Memorial Mission Hospital and Asheville Surgery Ce

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 16369 Based on policy review, medical record review and staff and provider interviews, the hospital failed to provide an effective infection prevention and control program for oversight of infection prevention and control processes. The findings include: 1. The hospital’s Emergency Department (ED) staff failed to prevent exposure of infectious diseases by failing to implement timely isolation precautions for 3 of 18 ED patients reviewed (Patient #17, #40, #41) Cross refer to 482.42(a)(2) Infection Control Program, Tag A0749”

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 16369 Based on policy review, hospital document review, incident report review, hospital policy quality assurance and performance improvement plan, readmission data, medical record review and staff interview, the hospital failed to have a comprehensive discharge planning process in place to ensure the effective transition of patients from the hospital to post-discharge settings, and reduce the factors leading to preventable hospital readmissions. The findings include: 1. The hospital staff failed to coordinate and provide a safe and orderly discharge for 1 of 24 discharged patients reviewed (Patient #27). Cross refer to §482.43(a)(2) Discharge Planning, Tag A 0807. 2. The hospital staff failed to coordinate DME (Durable Medical Equipment) for the patient post discharge for 2 of 24 discharged patients review (Patient #35, Patient #36). Cross refer to §482.43(a)(3) Discharge Planning, Tag A 0808. 3. The hospital staff failed to monitor, analyze, track data and report opportunities for hospital readmissions, and failed to provide data to the appropriate leadership for improvement opportunities for the year 2025. Cross refer to §482.21(a)(b)(1)(b)(2)(i)(b)(3) QAPI, Tag A 0273.”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 41946 Based on policy review, observations, and staff interview, the hospital failed to provide patient privacy in the emergency department [ED] IPA [immediate patient access] and ED waiting room area for 3 of 3 observations. The findings include: Review on 01/09/2026 of the policy, Safeguarding Protected Health Information, effective date 09/23/2013 revealed “...Oral Communications involving PHI [protected health information] ...Facilities much ensure that reasonable safeguards are in place when workforce members verbally communicate PHI including: ...4. Workforce members must take reasonable safeguards and precautions when discussing PHI....In emergency situations, providers may engage in communications as required for quick, effective, and high-quality health care. When appropriate and practical, suggested safeguard examples include, but are not limited: i. using lowered voices;... iii. Speaking apart from others; iv. Refraining from discussing PHI in ...other public areas; ...” Observation during tour on 01/09/2026 at 1605 for approximately 40 minutes revealed more than 55 patients/visitors counted in all areas visible of the ED waiting room. Interview during tour with ED Nursing Leadership revealed that at 1630, approximately 11 patients were waiting and still pending for IPA. 1. Observation on 01/09/2026 at 1605 revealed a senior female patient who was walking with assistance in the entrance to the ED. The patient was placed in a wheelchair and directed to the ED waiting designated line. The Patient was wheeled to the front desk, close to the ED main entrance. Observation revealed the patient was placed in front and adjacent to the triage desk in the open. ED Triage RN #51 asked the patient why she was here, and the Patient replied, ‘shortness of breath, and chest pain.’ The ED Triage RN #51 placed a mask on the patient and proceeded to take her vital signs. The ED Physician’s Assistant [PA] #53 began asking medical history, ‘do you use oxygen at home, have you had a fever or cough, having any swelling in your legs? have you been exposed to the flu ...’, while auscultating the patients’ lungs, front and back, raising her pants legs to examine her lower legs, and explained to the patient ekg [elctrocardiogram], lab work, and x-rays would be ordered. 2. Observation on 01/09/2026 at 1609, revealed an adult male patient who walked up to the desk, after hearing his first name called out loud in the waiting room by ED Triage RN #52 who was at the opposite end of the triage desk. The patient was asked to sit down in a chair adjacent and in front of the triage desk in the open, and his vital signs were taken by the RN. ED Triage RN #52 proceeded to review discharge instructions. The patient signed his discharge paperwork and walked out of the ED main entrance. 3. Observation on 01/09/2026 at 1619 revealed, a young female in a wheelchair, who was audibly crying and restless. A male with the patient pushed her in front and adjacent to the Triage desk area. ED Triage RN #51 proceeded to ask her what was wrong. The male accompanying the patient responded ‘nausea/vomiting and abdominal pain for 2 days.’ Vital Signs were initiated by the RN. The observation revealed the patient being asked ‘could you be pregnant.’ The ED Triage PA #53 took the patient’s history from the male accompanying the Patient, while auscultating her abdomen, and lungs. The Patient was crying out in pain. The patient was taken directly to the IPA designated area. Interview during tour near the ED IPA area, on 01/09/2026 at 1624 with ED Nurse Manager #50, revealed that in relation to privacy, “We do the best we can.””

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 36956 Based on review of policy, the annual quality plan, readmission data and staff interviews the hospital staff failed to monitor, analyze, track data and report opportunities for hospital readmissions, and failed to provide data to the appropriate leadership for improvement opportunities for the year 2025. The findings include: Review of hospital policy titled “Quality Assurance and Performance Improvement Plan” dated 07/11/2025 revealed “Medical Director and Administrative Leaders are responsible for improving organizational performance by: ...1. Prioritizing performance improvement activities at the service line, department and unit level ...6. Reporting performance improvement activities to the designated committees including the Senior Leadership Team.” Review of quality construct data with graphs for hospital readmissions on 01/09/2026 at 1105 with COC #37 revealed data collected during the year 2025 for 30 day readmission goal was set at 11.6%. Review of the “30 Day Readmission All Payer” data revealed the following 2025 quarters were not within goal range and trended upward each quarter: Q1(January, February, March) was out of goal range at 12.75%, Q2 (April, May, June) was out of goal range at 12.96% and Q3 (July, August, September) were out of goal range at 13.57%. Interview on 01/09/2026 at 1105 with COC #37 and CMO #38 revealed the readmission data for all payers did trend upward and the red graph bars identified readmissions were out of goal range with opportunities for improvement. The COC #37 revealed the data was tracked by facility level not by unit level. CMO #38 revealed prior to November 2025 there had not been any analyzed data related to 30 day readmissions broken down or reported to the Medical Executive Committee.”

“WRITTEN DESCRIPTION OF SERVICES CFR(s): 482.27(a)(2) A written description of services provided must be available to the medical staff. This Standard is not met as evidenced by: 32003 Based on review of an abstract article from the Journal of the American Medical Association, Critical Tests and Critical Value Reporting policy review, medical record review and staff interviews, the facility staff failed to maintain the well-being of a patient by not following national guidelines for critical low hemoglobin level for 1 of 1 post-surgical orthopedic patient (Patient #19). The findings include: Review on January 9, 2025 of the Journal of the American Medical Association abstract published online October 12, 2023, Volume 330, Number 19, per the 2023 Association for the Advancement of Blood and Biotherapies (AABB) International Guidelines revealed, “the importance of red blood cell transfusion is a common medical intervention with benefits and harms. The findings for adults, 45 randomized controlled trials with 20,599 participants compared hemoglobin-based transfusion threshold, typically 7 to 8 g/dL (grams/deciliter). ...Recommendation 1: for hospitalized adult patient who are hemodynamically stable, the international panel recommends a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (strong recommendation, moderate certainty evidence). In accordance with the restrictive strategy threshold used in most trials, clinicians may choose a threshold of 7.5 g/dL for patient undergoing cardiac surgery and 8 g/dL for those undergoing orthopedic surgery or those with preexisting cardiovascular disease. ...” Review on January 9, 2026 of the facility’s policy, “Critical Tests & Critical Value Reporting, 1LAB.AD.0511.00” last approved May 27, 2025 revealed, “POLICY: All critical laboratory tests and critical laboratory test results require prompt notification to care providers ...SCOPE: ...DEFINITIONS: ...PROCEDURE: [space] Verification of Results: ...EXCEPTION: ...Attachments ...CRITICAL VALUE LIST ...Test [space] Hemoglobin [space] Critical Value Low ...? (less than equal to) 6.0 ...” Review revealed the policy was not following national guidelines for low hemoglobin levels. Closed medical record review on January 6, 2025 revealed on September 25, 2025, Patient #19, an 88-year-old Spanish-speaking female presented to the emergency department at 1:23 AM via ambulance due to a fall secondary to missing the last 2-steps of the staircase. Laboratory studies were ordered and at 1:44 AM, the hemoglobin level resulted as 11.0 g/dL (grams/deciliter - low). At 5:03AM, an orthopedic consult was ordered and completed at 5:06 AM. The risks and benefits of surgery was provided to the patient and daughter. The daughter was the surrogate decision-maker and consented to surgery/anesthesia for nail/screw implant of the left hip and the operative site was marked. A second hemoglobin laboratory specimen was collected and at 6:18 AM resulted as 10.8 g/dL (low). On September 26, 2025 at 7:57 AM, the dayshift hospitalist progress note revealed current interventions included transfuse red blood cells if hemoglobin less than 7 g/dL. At 12:12 PM, the hemoglobin resulted as 7.4 g/dL. At 8:57 PM, the hemoglobin level resulted as 6.8 g/dL. On September 27, 2025 at 8:03 AM, the dayshift hospitalist ordered to transfuse 1-unit of red blood cells for a hemoglobin less than 7 g/dL, for anemia. The glasses emoji icon, in the electronic medical record revealed, the blood transfusion order was not reviewed by a nurse. At 8:59 AM, a code blue was initiated. The initial condition of the patient was unconscious, not breathing, no pulse, and was no witnessed arrest. Five rounds of advanced cardiovascular life support was provided to the patient. The patient was asystole throughout the code blue event. The daughter was present at the bedside and at 9:13 AM, the daughter decided to call/end the code. Review revealed the patient had a low hemoglobin level of 6.8 g/dL that resulted 774-minutes before the dayshift hospitalist entered an order to transfuse red blood cells and 718-minutes before a code blue was called for the patient. Telephone interview on January 8, 2026 at with the day shift Hospitalist revealed, the doctor’s shift ended one hour prior to the last lab result-hemoglobin 6.8 g/dl, in which, the hemoglobin level was drawn after surgery and resulted as 7.4 g/dl. On September 27, 2025, dayshift hospitalist rounded on and interacted with the patient. The patient was not actively bleeding but was on Heparin (prevent blood clotting) and had a history of chronic kidney disease. Interview on January 8, 2026 at 5:05 PM with Medical Director of Internal Medicine/Hospitalist service line with a scribe present revealed, the night shift Hospitalist was on-call the night of September 26, 2025 and that the hospitalist was unavailable for interview because he probably would not remember the low hemoglobin incident involving Patient #19 since it had been a couple of months. Interview on January 9, 2026 at 10:25 with the Associate Chief Medical Officer for the hospital and the Chief Medical Officer for the Division revealed, the Medical Executive Committee met on the morning prior to this interview and a lot of discussion occurred surrounding the critical lab policy-as the policy is up for review this month and had been in place for a substantial period of time. Additionally, a subgroup committee, with a multidisciplinary approach, would be established and review the policy starting next month (February 2026).”

“DISCHARGE PLANNING-EVALUATION CFR(s): §482.43(a)(2) Standard: Discharge Planning Evaluation (2)A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-hospital services, including, but not limited to hospice care services, post-hospital extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services. This Standard is not met as evidenced by: 36956 Based on policy review, hospital document review, medical record review and staff interview, the hospital staff failed to coordinate and provide a safe and orderly discharge for 1 of 24 discharged patients reviewed (Patient #27). The findings include: A review of the hospital policy titled “Discharge Screening, Assessment, and Planning” with effective date 07/18/2023, revealed, “ ... A. CM (Case Manager) will ensure patients receive appropriate post hospital care by arranging referrals for follow up care ...2. DME (Durable Medical Equipment) ... B. Procedure: 1. Referral for home health, home infusion, and durable medical equipment and home hospice will be coordinated by CM Staff ... 9. CM staff will document all discharge planning discussion and interventions in the appropriate location within the EMR, provide clinical documents for continued care and assist with transportation arrangements if needed ...” Review of the RTS (Regional Transport Services - the hospital transport service) packet on 01/08/2026 revealed the RTS arrived at the hospital on 10/07/2025 at “1513” and departed the hospital to Shelter #1 at “1627.” Review of an email from the EMS (Emergency Medical Services) Manager #30 revealed “It was determined that the shelter was full so they (sic) patient agreed to go to October Road.” (Methadone Clinic) Medical record review on 01/06/2026 revealed Patient #27 arrived in the Emergency Department (ED) on 08/19/2025 at 2248 with a chief complaint of back pain that radiated down the patient’s left leg. The 49 year old female was alert and oriented with a history of Intravenous (IV) substance abuse. Review revealed prior to admission Patient #27 had difficulty walking, lived with a friend and did not provide a home address. The Discharge Planning Evalluation (DPE) was conducted on 08/20/2025 at 1133. Review revealed Patient #27 was admitted to inpatient status on 08/21/2025 at 1319 and transferred to a medical surgical complex unit. A Peripheral Insertion Central Catheter (PICC) line was inserted for antibiotic (abx) due to a diagnosis of an abscess to the patient’s left hip. Patient #27 had two discharge bed offers with a restorative facility (Critical Access Hospital) and the patient refused the bed offer twice. The discharge plan on 10/03/2025 was to discharge (dc) Patient #27 to a shelter. Review of the “CM (Case Management) Discharge Communication” note dated 10/03/2025 at 0905 by CM #20 revealed the patient had two shelter options for discharge. Continued review revealed the following for Shelter #1 the: “...pt (patient) will need to d/c (discharge) and drop in/check in between 12:00pm-2:00pm.” A “CM (Case Management) Discharge Communication” note dated 10/06/2025 at 1530 revealed the patient was to discharge on “Tuesday” 10/07/2025 with RTS pick up to be requested for 10 am. “CM (Case Management) Discharge Communication” note dated 10/07/2025 at 1100 by CM #20 revealed Patient #27’s Discharge Plan was to discharge to a shelter and “Check in for Shelter is between Noon - 2pm.” Review of the RTS Transport Request note dated 10/07/2025 revealed a request for a “Pick-up Date/Time: 10/7/2025 10:55 EDT (Eastern Daylight Time)” with a drop off destination to Shelter #1. Review of medical record revealed Patient #27 departed the hospital at 1610 via transport for Shelter #1 (2 hours after the end of check-in time). Interview on 01/08/2026 at 1854 with the RTS driver EMT #18 revealed he remembered the patient being discharged from the hospital to Shelter #1. EMT #18 stated Patient #27 “requested to go to the Methadone Clinic (MC) on October Road.” EMT #18 stated he “called his Team Leader (TL) and was told the patient was alert and oriented and she could go to the MC.” The EMT #18 stated they “did not go to” shelter #1. He stated, “he took her to the MC and helped her from the wheel chair onto the bench with her belongings.” Interview on 01/09/2026 at 0928 with CM #20 revealed the Case Management team communicated dc plan via notes and during huddles with the Nurses on the unit as to when patients were to discharge. CM #20 stated we work with the nurses and sometimes the discharge summary was not completed. CM #20 revealed if it was noted that the transport was to arrive after check in time “the patient would remain at the hospital and discharge the next day.” CM #20 was not sure regarding the discharge RTS pick up time and stated “I was not the discharge CM.” Interview on 01/09/2026 at 1525 with CM VP #21 revealed “we have opportunities regarding the pickup time process.” Interview via telephone call on 01/09/2026 at 1349 with the Director of Shelter #1 confirmed the shelter’s location address. He stated in October patients with referrals would not be accepted after check in time (2:00pm) because they were full. Interview revealed the Shelter “was first come first served after check in time.” Interview request on 01/09/2026 with EMS Manager #30 was not granted at time of survey exit.”

“DISCHARGE PLANNING EVALUATION CFR(s): The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). This Standard is not met as evidenced by: 50403 Based on policy and procedure review, medical record review, incident report review, and staff interviews, the hospital staff failed to coordinate DME (Durable Medical Equipment) for a patient post discharge for 2 of 24 discharged patients reviewed (Patient #35, Patient #36). The findings include: A review of the hospital policy titled “Discharge Screening, Assessment, and Planning” with effective date 07/18/2023, revealed, “... A. CM (Case Manager) will ensure patients receive appropriate post hospital care by arranging referrals for follow up care ...2. DME (Durable Medical Equipment) ... B. Procedure: 1. Referral for home health, home infusion, and durable medical equipment and home hospice will be coordinated by CM Staff ... 9. CM staff will document all discharge planning discussion and interventions in the appropriate location within the EMR, provide clinical documents for continued care and assist with transportation arrangements if needed ...” 1. Closed medical record review, on 01/09/2026, of Patient #35 revealed the patient was admitted on 01/03/2026 for leg pain and swelling. The review indicated the patient had a DVT (Deep Vein Thrombosis- serious condition where a blood clot forms in a deep vein, usually the leg, causing pain and swelling) and received treatment for the DVT. The review revealed the patient was stabilized and evaluated for discharge needs by CM. The review revealed Patient #35 needed the following DME: rolling wheelchair and a bedside commode. Medical record review revealed home health set up. Further review failed to reveal any documentation of DME set up or communication with patient/family at time of discharge. Medical record review revealed Pt #35 was discharged home with family on 01/09/2026. An interview with Case Manager #4 on 01/09/2026 at 1200 revealed home health with DME was the recommendation. CM stated “DME was refused by the patient”. A requested interview with the RN who discharged patient #35 (RN #7) on 01/09/2026 was not provided by the end of the survey. A follow-up interview with CM #4 on 01/09/2026 revealed CM #4 was not available. A request for medical documentation on 01/09/2026 of an offer and refusal of the DME was not produced by the end of the survey. 39307 2. Review on 01/09/2026 of the Hospital Incident Report #56770 revealed “ Event Notification date 10/07/2025...Provision of Care Event Inappropriate Discharge ...” Patient #36 was found to have discharge without home oxygen being arranged. The hospital report noted “ ...Primary Action to Prevent Recurrence Focused Professional Practice Evaluation ...” was initiated as a result of the event. Closed medical record review on 01/08/2026 revealed Patient #36 was a 90-year-old male with admitting diagnosis on 09/27/2025 of Pneumonia. Review of the documented Nursing Plan of Care revealed the patient had a risk of impaired gas exchange along with other focused issues for patient care. Review of the History and Physical (H&P) completed by the Medical Doctor (MD), on 09/27/2025 at 0126 revealed “...patient is alert oriented x4 (person, place, time, situation) ...” MD noted a discussion of goals of care with the patient and spouse at the bedside and all agreed with the goals of care. Review of Care Management Notes, Discharge Planning Evaluation on 09/29/2025 at 1340 revealed “Current Environment Durable Medical Equipment (DME) Benefits: Thinks they have Home O2 (oxygen) w/ (with) [Named Medical Equipment Company], but never had to use it per wife ...Discharge Needs ...Pt (Patient) goals/preferences at DC (discharge): 1) Home w/possible Home O2 and [Named] Home Health ...CM Narrative Note: ...Wife states he has an O2 tank @ home that he has never used ...” On 10/01/2025 at 1043 CM Discharge Communication Progress Note revealed “...Spoke with patient and spouse at bedside, wife states the plan is still for home as they have all needed DME to take care of him ...” On 10/02/2025 at 0807 CM Discharge Communication Progress Note revealed “...has tank at home he’s never used ...” On 10/03/2025 at 1119 CM Discharge Communication Progress Note revealed “...MSW met with patient and wife at bedside, Confirmed the D/C plan. Confirmed no DMW (sic) needs, possible need for home O2 pending weaning and sat levels at discharge.” At 1320 review of Physical Therapy Progress Note revealed “...Pt (patient) on 2L (liters, a measurement of level of oxygen administration) upon entry satting 82-84%. Pt requires additional O2 up to 4L in order to maintain > (greater than) 90% with cues for breathing ...Plan of Care ...DME Recommendations: Other: Oxygen Assessment Summary: ...Pt still requiring supplemental O2 which they would require in order to safely amb (ambulate) and complete ADLs (activities of daily living)...” On 10/05/2025 at 1316 the Discharge Summary completed by MD #2 revealed “...Hospital Course ...Patient is being discharged on supplemental oxygen, 2 L (Liters, a measure of gas) of nasal cannula continuously ...” On 10/06/2025 at 1417 CM Discharge Communication Progress Note by CM #3 revealed “...Spoke with patient and spouse at bedside, patient confirms he still wants to go home. Spouse feels like she can manage and provide transportation. RN updated.” Review of the Nursing Flowsheet on 10/06/2025 failed to reveal home oxygen in use for discharge transportation to home. Review failed to reveal evidence of the patient provided with DME education of use, ability to reorder oxygen or the request of the family to bring in portable oxygen tank for transportation to home for intended continued use. Patient #36 was discharged on 10/06/2025 at 1645 with Home Health Agency for Physical Therapy, Occupational Therapy and Registered Nursing services via private vehicle to home with family. Interview requested for the Discharge RN for Pt #36. RN was not available. Interview on 01/09/2026 at 1148 with CM #3 Social Worker revealed if a physician ordered home oxygen and a patient had oxygen already from a prior set up, the family would bring in a portable tank for transportation. Interview revealed the CM #3 involved with the Discharge Planning for Patient #36 had documented discussion with the patient and the spouse at bedside who reported having DME to care for the patient. CM verbalized that the department monitored DME needs through review of referrals for each patient and had staffing adequate to sufficiently provide for patient care needs. Interview on 01/09/2026 at 1455 with MD #2 revealed the MD stated due to the patient had oxygen at home there would be no need to enter an order for home oxygen. The MD stated during Multidisciplinary Rounds (MDR) meetings was where the clinical team would thoroughly cover discussion for patient needs. Based on the patient’s spouse stating ‘we do have the oxygen’ no order was placed. Interview revealed hospital staff go by what the patient & family make known to the staff to have already at home.”

“QUALIFIED EMERGENCY SERVICES PERSONNEL CFR(s): 482.55(b)(2) There must be adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility. This Standard is not met as evidenced by: 33790 Based on policy review, medical record review and staff interviews, Emergency Department [ED] staff failed to meet the needs of ED patients for 2 of 18 ED patients reviewed by failing to prevent delayed lab testing and aspirin administration [Pt #28] and to provide crutches and pain medication at discharge [Pt #2]. The findings include: 1.Review of the policy “Types of Orders...”, last approved 01/16/2025, revealed “...DEFINITIONS:...B. ‘Stat’ means within 30 minutes 1. Stat is utilized to designate orders that are to be expedited....3. For STAT medication orders, the medication should be administered as soon as possible with the highest priority. 4. Ancillary departments will respond within 30 minutes for STAT orders and results will be procedure specific... .” Medical record review on 01/09/2026 revealed Patient #28 arrived to the ED on 12/28/2025 at 1906 via private vehicle. Review of the Triage Note at 1906 revealed “...Pt [Patient] started having chest pain over the weekend and started again today. Pt is having mid sternal chest pain that is moving to his right shoulder. ...” An acuity of “2-Emergent” was assigned. Review of “Electronic Physician Orders” revealed an order for “aspirin (Baby Aspirin (Chewable)) Plan Name: ED Chest Pain Plan....Chest Pain Diagnostic Phase. Order Date/Time 12/28/2025 at 19:10... .” The “Order Details” revealed the order was written as “ONCE....STAT. ...” Review of the order revealed it was “Complete” at 2026, and review of the Medication Administration Report documented the aspirin was administered at 2026 [one hour 16 minutes after the stat order]. Further review of “Electronic Physician Orders” revealed “Order: Troponin I [blood test used in diagnosing for a heart attack]....Action Type: Order....Order Details: Stat, 12/28/25 19:10:00 EST [Eastern Standard Time]... .” Review revealed the blood for the Troponin was collected at 2035 [1 hour 25 minutes after the order]. Record review revealed the aspirin was not given and the blood for the troponin was not collected according the the 30 minute STAT definition. Interview with the Chief Operating Officer on 01/09/2026 at 2200 revealed the timing of the Troponin drawn on Patient #28 did not meet the standard for stat lab. Interview with the Chief Nursing Officer and Nurse Manager #19 on 01/09/2026 at 1935 revealed the aspirin should be given within 30 minutes of a STAT order. 41946 2. Review on 01/09/2026 of the policy EMERGENCY DEPARTMENT STANDARDS OF CARE GUIDELINES - NURSING 1PC.ED.0100., [no approved date ...”These Department Guidelines of Care are reviewed and revised as necessary.” Revealed “ ...Aspects of Care V. DISPOSITION ...Guidelines of Patient Care, Patient will be dispositioned according to their clinical needs. Guidelines of Nursing Practice ...A. Patient disposition will be determined by medical staff, facilitated by the interdisciplinary team, and documented in the EMR [electronic medical record]. Review on 01/07/2026 of the policy, Pain Assessment and Management, 1PC.ADM.0002, last approved 01/25/2024 revealed “ ...SCOPE: ...Emergency Departments (ED) ...POLICY: G. Patient ...are educated on discharge plans related to pain management included the following: 1. Information specific to discharge instructions will be provided to the individual or care provider responsible for continuing care of the patient, as appropriate ... c. ...barriers within the home environment that can affect the pain management plan of care; and the corresponding strategies to address these issues ...e. How to obtain further care, ...treatment to meet the patient’s identified needs. ...” Closed medical review on 01/06/2026 revealed Patient #2, a 59-year-old female patient who arrived to the emergency department by emergency services on 10/03/2025 at 2149 on transfer from another acute care hospital with complaints of a fall, and extreme lower leg pain. Patient #2 was given an Emergency Severity Index of 3-urgent by the Triage Registered Nurse [RN] #33, “ ...two falls, with a broken ankle.” The initial Numeric Pain Score was 3/10. Review of the ER Report dated 10/03/2025 at 2235 by ED Medical Doctor [MD] #37 revealed Patient #2 had a right bimalleolar [a severe ankle break involving three bony points; the medial malleolus, the lateral malleolus, and the posterior malleolus] ankle fracture dislocation “...sedated and reduced and splinted at the outside hospital ...Orthopedic surgery consulted anticipate they will admit ...” Review of the Physician Order dated 10/03/2025 at 2252 by ED MD #37 revealed, “Crutches. Bilateral.” Review of a second ER Report Note dated 10/03/2025 at 2319 by ED MD #35 revealed the patient had been signed out to him, and “ ...is currently being evaluated by the orthopedic associate, will follow-up on recommendations ...” Review of the ORTHO Consultation Note by Ortho PA #36 dated 10/03/2025 at 2348 revealed “...Perform [sic] a closed reduction and splinting of the patient’s right Tri malleolar ankle fracture dislocation. This was performed without the need for sedation [administering of a sedative drug to produce a state of sleep]. A closed reduction and posterior and stirrup splint was applied with the assistance of portable bedside x-ray. Near anatomic alignment was achieved. ...the [named ED MD] will provide the patient with a prescription for pain medication and discharge the patient home to follow-up with Dr. [named Ortho Surgeon] this coming Monday for surgical repair ...” The Discharge Order was written at 2319 by ED MD #35. The Discharge instructions were documented as given to Patient #2 by ED RN #34 at 2338 which included a new prescription for pain medication, “...Instructions From Your Doctor ... Strictly no weight-bearing in your right leg until cleared by the orthopedic surgeon. ...Use your normal pain medicines as needed. ...How can you care for yourself at home ...Discharge Instructions: ...Use crutches, ...to get around. ...Medications. New Medications to be take [sic] at home: Oxycodone [opioid pain medication used to treat moderate to severe pain] 1 tab, (5 mg) every 8 hours for pain for a quantity of 10 tablets ...” The Oxycodone was documented as being electronically routed to a local CVS Pharmacy store #4165 with address and phone number provided. Patient #2 was discharged from the emergency room on 10/04/2025 at 0009 and provided public transportation back home. Review of the medical record failed to reveal, Patient #2 received crutches at discharge. Further review revealed Patient #2 did not receive any pain management while in the ED on 10/03/2025 at 2149 through 10/04/2025 at 0009 and did not receive dispensed discharge pain medication from the ED. Patient #2 was discharged outside of retail pharmacy hours and would not have had access until the next day [9 hours later] to get her pain medication filled at the retail pharmacy. Review of the record revealed, Patient #2 returned to the ED on 10/04/2025. Review of the ER Report dated 10/04/2025 at 1600 by ED MD #48 revealed the Chief Complaint was Pain Lower Extremity, “ ...Stated Reason for Visit: Pt. presents to the ER [emergency room] via pov [private vehicle] with cc [chief complaint] of inability to perform adl’s [activities of daily living] d/t [due to] new right foot injury ...she returns today for hospitalization with orthopedic surgery reportedly scheduled for 6 October 2025. ...” Review revealed Patient #2 returned to the ED in less than 16 hours. In summary, Patient #2 had a physician orders for no weight bearing of the right leg, and Crutches, bilaterally. There was no evidence in the record, crutches were supplied to Patient #2 before being discharged 10/04/2025 at 0009. Furthermore, Patient #2’s pain medication was electronically sent to the local CVS Pharmacy, store number #4165. Patient #2 did not have access to obtain her prescribed pain medication from 10/04/2025 0009 until 10/04/2025 after 0900.[9 hours later]. Patient #2 returned to the ED within 16 hours of discharge, with chief complaint of the inability to perform activities of daily living, and pain in lower extremity, and was admitted pending surgery. Interview requested for ED MD #37 was not provided. Interview requested for ED MD #35 was not provided. Telephone interview on 01/08/2026 at 1635 with ED RN #34 revealed “ ...I do not recall this patient. I review discharge medication with discharge instructions. ...We do not provide medications in the middle of the night unfortunately. Our job is to assess and ensure they are comfortable, and notify the MD if reassessment is needed. ...” The interview revealed the RN did not recall if crutches were provided for Patient #2 prior to discharge. Interview on 01/09/2026 at 1430 with Ortho PA #36 revealed “ ...the tibia/talus [the bone that makes up the lower part of the ankle joint] ...Pain is individual. I don’t ask about pain. ...I can’t recall this patient specifically. ...If a patient asks, I have no problem giving pain medication. ...” The interview revealed, the Ortho PA does not admit or discharge patients but does make recommendations to the ED Provider. The interview revealed the Discharge Disposition and Discharge instructions/medications was per the ED Provider. NC00233751; NC00233767; NC00233823; NC00233931; NC00233932; NC00233948; NC00233951; NC00234147; NC00234148; NC00234160; NC00234151; NC00234186; NC00234289; NC00234320; NC00234461; NC00234483; NC00234603; NC00234633; NC00234663; NC00234750; NC00234907; NC00234910; NC00234937; NC00234919; NC00235050; NC00235171; NC00235173; NC00235170; NC00235166; NC00235167; NC00235168; NC00235162; NC00235243; NC00235401; NC00235379; NC00235351; NC00235317”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 33790 Based on policy review, observations, medical record review, CMU (Central Monitoring Unit) documentation, hospital document reviews and staff and provider interviews, the hospital’s governing body failed to provide oversight and have systems in place to ensure the protection and promotion of patient’s rights to receive care in a safe environment; failed to have an organized nursing service to meet patient care and safety needs and failed to meet the emergency needs of patients. The findings included: 1. Hospital staff failed to provide a safe environment for 3 of 32 patients reviewed by failing to ensure systems were in place and functioning for continuous pulse oximetry monitoring of a patient during transport (Patient #10), to provide timely response and patient evaluation to telemetry monitor alarms (Patient #14) and to provide accurate patient identification during initial quick registration and promptly correct the electronic misidentification and mitigate the associated risks (Patient #24). Cross refer to §482.13 Patient Rights’ Standard: Tag A 0144. 2. The hospital failed to ensure adequate staff was available to assess and respond to a monitored telemetry patient with leads off and the patient subsequently expired for 1 of 32 patients reviewed (Patient #14). Cross refer to 482.23 Nursing Standard: Tag A 0392. 3. Nursing staff failed to supervise and monitor care by failing to ensure safe and appropriate transport and continuous pulse oximetry monitoring for a patient during transport (Pt #10) and failing to prevent and control infections. Nursing staff failed to identify and communicate accurate and timely COVID precautions on an inpatient unit creating an unsafe environment for patient care (Pt #34). Cross refer to 482.23 Nursing Standard: Tag A 0395 4. Hospital nursing staff failed to follow policies to evaluate a patient’s change in condition requiring emergent treatment for 1 of 32 sampled patients (#17) and failed to follow post procedure guidelines following a heart catheterization for 2 of 32 sampled patients (#17, #15) Cross refer to 482.23 Nursing Standard: Tag A 0398 5. Emergency Department (ED) staff failed to ensure safe and appropriate transport and continuous pulse oximetry monitoring for a patient during transport from the ED to an inpatient unit for 1 of 12 emergency department patients reviewed (Patient #10). Cross refer to §482.55: Emergency Services Standard Tag A 1103.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 33790 Based on hospital policy review, medical record review, and staff and provider interviews, the hospital failed to protect and promote patients’ rights by failing to ensure care in a safe environment for 3 of 32 patients reviewed (Pt #10, #14, #24). The findings included: 1. Hospital staff failed to provide a safe environment for 3 of 32 patients reviewed by failing to ensure systems were in place and functioning for continuous pulse oximetry monitoring of a patient during transport (Patient #10), to provide timely response and patient evaluation to telemetry monitor alarms (Patient #14) and to provide accurate patient identification during initial quick registration and promptly correct the electronic misidentification and mitigate the associated risks (Patient #24). Cross refer to §482.13 Patient Rights’ Standard: Tag 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: 33790 Based on policy review, medical record review, video monitor review, CMU (Central Monitoring Unit) documentation, hospital documents and staff and provider interviews, the hospital’s nursing staff failed to have an effective nursing service providing oversight of day to day operations by failing to ensure systems were in place to supervise and provide safe delivery of care to patients for 5 of 32 records reviewed (Pts #14, #10, #34, #17, #15). . The findings included: 1. The hospital failed to ensure adequate staff was available to assess and respond to a monitored telemetry patient with leads off and the patient subsequently expired for 1 of 32 patients reviewed (Patient #14). Cross refer to 482.23 Nursing Standard: Tag A 0392. 2. Nursing staff failed to supervise and monitor care by failing to ensure safe and appropriate transport and continuous pulse oximetry monitoring for a patient during transport (Pt #10) and failing to prevent and control infections. Nursing staff failed to identify and communicate accurate and timely COVID precautions on an inpatient unit creating an unsafe environment for patient care (Pt #34) and exposure to COVID. Cross refer to 482.23 Nursing Standard: Tag A 0395 3. Hospital nursing staff failed to follow policies to evaluate a patient’s change in condition requiring emergent treatment for 1 of 32 sampled patients (#17) and failed to follow post procedure guidelines following a heart catheterization for 2 of 32 sampled patients (#17, #15) .. Cross refer to 482.23 Nursing Standard: Tag A 0398”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 16369 Based on policy review, internal document review, observation, closed medical record review, and staff interviews, the Emergency Department (ED) staff failed to have effective emergency services to meet the needs of patients that presented to the Emergency Department. The findings include: 1. The Emergency Department (ED) staff failed to ensure safe and appropriate transport and continuous pulse oximetry monitoring for a patient during transport from the ED to an inpatient unit for 1 of 12 ED patients reviewed (Patient #10). ~cross refer to 482.55 Emergency Services Standard: Tag 1103”

“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: 50318 Based on policy review, observation, medical record review and staff and physician interviews, the hospital staff failed to provide a safe environment for 3 of 32 patients reviewed by failing to ensure systems were in place and functioning for continuous pulse oximetry monitoring of a patient during transport (Patient #10), to provide timely response and patient evaluation to telemetry monitor alarms (Patient #14) and to provide accurate patient identification during initial quick registration and promptly correct the electronic misidentification and mitigate the associated risks (Patient #24). The findings include: 1. Review of hospital policy “Physiologic Monitoring - Cardiac Telemetry Monitoring, Continuous Pulse Oximetry Monitoring - 1PC.NRS.0001,” effective 08/19/2025, revealed, “ ... III. Transport of Monitored Patients. 1. Interruption in cardiac monitoring should not occur during transport for patients with active orders for telemetry monitoring. a. Patients with active monitoring orders should continue to be remotely monitored, and the Monitor/Telemetry Technician should be notified of unit travel, destination, primary contact for duration of travel, and anticipated time of return ... V. Telemetry Escalation Process ... 3. In the event a non-lethal arrhythmia is detected, pulse oximetry (SPO2) reading <87%, OR patient’s cardiac rhythm is not transmitting, the Monitor/Telemetry Technician will initiate the following procedure: a. The Monitor/Telemetry Technician will initiate a multi-level escalation process, requiring loop closure/alarm resolution within 5 minutes of the initial arrhythmia alarm ...” Review of hospital policy attachment “Example Telemetry Escalation Pathways,” effective 08/16/2025, revealed, “Immediate Escalation & 5 Minute Resolution: Non-lethal Rhythm, Loss of Signal (no transmission) or SPO2 <87%. TT (Telemetry Tech) immediately call Primary Nurse - Unable to reach Primary Nurse and/or issue not resolved within 2 minutes - TT to call Charge Nurse - Unable to reach Charge Nurse and/or issue not resolved within 3 minutes - Call overhead Telemetry Alert, repeat once per minute until resolved ...” Observation of the Emergency Department (ED) on 09/23/2025 at 1159 revealed a patient was switched from ED telemetry monitoring to the CMU (Central Monitoring Unit) for monitoring during transport to inpatient holding. Observation revealed the portable telemetry box did not display a visual or have an audible alarm for any changes during transport. Closed medical record review on 09/17/2025 for Patient #10 revealed a 48-year-old presented to the ED on 09/04/2025 at 1441 with complaints of chest pain and shortness of breath. The patient’s pain was documented at 1442 as 8 out of 10. The Provider’s MSE (Medical Screening Exam) Note at 1445 revealed, “Patient with chest pain and shortness of breath. On home oxygen normally. chest tube in place. Patient is alert, in no acute distress but is moaning in discomfort.” The patient’s oxygen saturation (O2 sat) at 1500 was 90%. The ED Provider’s Note at 1534 revealed the patient had a history of metastatic lung cancer with a chest tube on the right with “chronic pain at the tube site now with worsening shortness of breath for the past day.” The patient’s O2 sat at 1630 was 92%, and the patient was placed on 3 liters of oxygen via nasal cannula. The patient’s O2 sat at 1715 was 93%. An order for Morphine (a pain medication) 4 milligrams IV (intravenous) was placed at 1729. An order was placed at 1731 for continuous pulse oximetry (measures how much oxygen is in the blood for uninterrupted periods). The patient’s O2 sat at 1745 was 89% and at 1750 was 90%. A broadcast notification was sent to a Stepdown unit at 1803 with the room number the patient was assigned to and the box number for continuous pulse oximetry. The patient’s blood pressure at 1807 was 84/57 with a comment by the Nurse that the Provider was notified at that time. The patient’s pain was assessed at 1808 as 10 out of 10. A comment was documented on the MAR (Medication Administration Report) at 1809 that Morphine was not given as the patient’s blood pressure was “too low to administer,” and the Provider was notified. The patient’s oxygen was increased to 4 liters at 1820 with an O2 sat of 94%. ED Nurse Note at 1830 revealed the patient was transported by transport staff. The patient was on an “O2 monitor, awake and alert” with an O2 sat of 93% prior to transport. Record review failed to reveal documented evidence of the patient’s time of arrival to the unit and initial O2 sat on the unit. Review of a Code Record revealed a code blue (the initiation of resuscitative efforts in a cardiac or respiratory arrest) was called with initiation of CPR (cardiopulmonary resuscitation) at 1842 and initial ECG (electrocardiogram, a noninvasive test that records the electrical activity of the heart) rhythm of asystole (no heartbeat). The patient was intubated at 1853, and a rhythm of PEA (Pulseless Electrical Activity, a condition where the heart is still producing electrical signals, but there is no pulse or blood pressure) was noted at 1901. The patient expired at 1907. Record review failed to reveal evidence of continuous pulse oximetry monitoring during the patient’s transport and failed to reveal documented evidence of the patient’s heart rate and O2 sats during transport. Interview on 09/16/2025 at 1300 with RN #4 revealed the CMU monitored patients on continuous pulse oximetry (pulse ox), but they did not record the patients’ O2 sats. Telephone interview on 09/22/2025 at 1422 with Staff #7 revealed they were not aware of any alarm that could be heard with the telemetry box during a patient’s transport. Telephone interview on 09/23/2025 at 1313 with Tech #5 revealed they recalled RN #27 called to verify the pulse ox for Patient #10 could be visualized by the CMU prior to transport from the ED to a Stepdown unit. Interview revealed they were on the phone for a few minutes troubleshooting the pulse ox probe as there were issues with the signal going in and out. Interview revealed Wi-Fi connection issues, such as the signal cutting in and out, could occur when a patient was transported. Tech #5 revealed during Patient #10’s transport, the signal was again cutting in and out, and there was not a solid reading. Tech #5 revealed there were drops in Patient #10’s O2 sats, but they could not get a clear reading due to signal issues. Interview revealed the CMU pod was very busy that day as there were multiple patients being transferred and admitted, as well as multiple escalations at that time. Tech #5 revealed any time there were O2 sats dropping or signal loss, the monitor techs should notify the Nurse as soon as they see it with a resolution time of 5 minutes. Interview revealed the Stepdown unit was not notified that Patient #10’s pulse oximetry had signal issues, a loss of signal during transport, or drops in the patient’s O2 sats. Interview on 09/25/2025 at 0934 with Nursing Administrative Staff (AS) #6 revealed there was no action plan needed related to Patient #10 as the pulse oximetry signal could be intermittent while transporting patients in the elevator. The telemetry staff should follow the loss of signal pathway, which would give the staff time to contact the Nurse. Follow-up interview on 09/25/2025 at 1715 with AS #6 revealed there were potential opportunities for signal issues with telemetry during transport, but they were not aware that it was a “profuse issue.” 47421 2. Review of hospital policy titled “Physiologic Monitoring - Cardiac Telemetry Monitoring, Continuous Pulse Oximetry Monitoring” last approved 06/04/2025 revealed “ ...PURPOSE ... C. Identify which rhythms or arrhythmias require RN (registered nurse) notification/intervention and identification of proper escalation procedures ...ALARM RESPONSE AND ESCALATION PROCESS A. ...a defined escalation pathway is used to ensure timely notification and treatment ...II. Rhythm Transmitting with ...Leads Off ... A. First Escalation Attempt: 1. MTII (monitor tech) calls Primary Nurse. 2. Within 5 minutes the Primary Nurse will assess the patient and call the monitor tech and give an update ...4. The MTII records the notification ... B. Second Escalation Attempt: 1. If unable to reach Primary Nurse or unresolved within 5 minutes from the time of initial notification, the MTII call the Primary Nurse again and enter notification time ... C. Third Escalation Attempt: 1. If unable to reach Primary Nurse, or unresolved after 5 minutes, the MTII will call the CNC (clinical nurse coordinator)/Relief Charge Nurse. 2. If no resolution after 1 minute, send broadcast to unit. 3. If no resolution after 2 minutes, start escalation over until resolved. Review of hospital policy titled “Assessment and Reassessment” last approved 05/13/2025 revealed “Purpose The organization assesses and reassess the patient and the patient’s condition according to defined timeframes ... Policy ... C. The assessment process is a continuous, collaborative effort with departments functioning as an interdisciplinary team ... Assessment Framework A ...2. As individual patient condition changes ...” Review of hospital document titled “ADULT INTERMEDIATE CARE STANDARDS OF CARE GUIDELINES-NURSING”, revealed “ ...Reassessment intervals and parameters are presented as the minimum times, measurements, and evaluation criteria ... Patient Rounding A. Safety Rounds to occur as recommended - every 1-2 hours ... Safety A. The patient can expect appropriate safety precautions while in the hospital ...” Closed medical record review revealed Patient (Pt) #14 was a 72-year-old male readmitted on 07/23/2025 at 1715 for shortness of breath and chest pain. At 1742 there was an order for telemetry monitoring. Per documentation the patient was placed on telemetry and telemetry tech was notified. On 07/26/2025 at 0021 vital signs revealed temperature 98.1 (oral), heart rate (HR) 76, blood pressure (BP) 99/57, (oxygen saturation) SpO2 93% on 60L (liters) oxygen (O2) high flow humidified. At 0320 the RRT (registered respiratory therapist) documented the patients HR 78, respirations (RR) 18, SpO2 93% on 60L O2 high flow humidified. Review of a Provider Note at 0415 revealed “CODE BLUE called overhead on this patient ... Was not notified by staff of any issues overnight or notified of patient being found on the floor prior to CODE BLUE being called. CPR was in progress when I walked in the room. Per the patients nurse, he was found on the floor without his Vapotherm (high flow humidified O2) on and without telemetry on for an unknown period of time ... During discussion with Dr. (named) it was decided to stop the code as we never obtained a pulse. Time of death was called at 0403 ...” Review of the Code Blue documentation revealed code time started at 0347, the patient was intubated at 0354, and the code stopped at 0403. Record review did not reveal a bed/chair alarm was documented on the evening shift of 07/25/2025. Review of video footage dated 07/26/2025 revealed footage of unit 4 heart. Review revealed a view of the nursing station, a hallway view of Patient #14’s room (E433). From 0012 through 0024 staff were noted to be in Patient #14’s room and the 2 staff members exited at 0024. At 0231 a female staff (identified as CNC #14) was seen sitting at the nurse station computer. At 0305 a male staff (identified as [registered respiratory therapist] RRT #21) entered the patient’s room and was seen exiting the room also at 0305. At 0313 CNC #14 still observed at nurse station, observed answering the desk phone. At 0322 CNC #14 left the nurse station and walked to another patient’s room. At 0346 male staff (identified as unit PCT) entered Patient #14’s room. At 0348 the code team arrived via stairwell. Review did not reveal any nursing staff in Patient #14’s room between 0024 and 0346, only the Respiratory Therapist at 0305. Review of the facility investigation on 09/18/2025 at 1535 with Director #13, Director #9, and Nurse Administrative Staff (AS) #6 revealed a timeline of events. The timeline revealed on 07/25/2025 at 1900 an RN rounded on the patient and noted no distress. On 07/26/2025 at 0012 staff were in the patient’s room. At 0242 the RN was notified by the CMU tech (central monitoring unit technician) that the telemetry leads were off. At 0244 the RN was notified by the CMU tech again. At 0305 the RRT rounded on the patient and noted no distress. At 0309 the CMU tech sent a text to the RN. At 0312 the CMU tech notified the CNC to reinforce the leads. At 0317 the CMU tech called the RN but did not get an answer. At 0320 the RRT documented HR 78, RR 18, SpO2 93%, Vapotherm at 60L/minute. At 0326 CMU tech called the CNC. The CNC told the CMU tech they were in a rapid response and would get to the patient after they transferred the rapid response patient off the unit. At 0341 the CMU tech reached out to the PCT (patient care technician) asking for the telemetry leads to be checked. At 0345 the PCT entered the room and found the patient on the floor. At 0347 a Code Blue was initiated. At 0354 the patient was intubated. At 0403 the Code ended. Further interview revealed that the RRT was interviewed after the incident. The RRT entered the patient’s room at 0305 the RRT noted the patient was resting and did not have his telemetry leads on. The RRT used his pocket pulse oximetry to assess the patients SpO2 and noted the RRT had no issues and that he assumed the RN was aware of the leads being off and would get to them. Interview revealed that the CMU tech was interviewed after the incident. The CMU tech revealed that the RN stated someone would get to the patient, so the CMU tech was giving the RN the benefit of the doubt. The CMU tech revealed that it was a busy night, and multiple telemetry patients required his attention at that time. Also, the placement of each patient (patient in the upper right corner of screen vs patient in the left corner of the screen) on his telemetry monitor made it difficult to follow. Interview revealed that the Primary RN and CNC were dealing with another rapid response patient and transfer to the ICU (intensive care unit). Further interview revealed that the RRT and CMU tech were no longer employed at the facility. Review of CMU tech documentation on 07/26/2025 revealed at 0242 the RN was notified leads were off. At 0309 “called no answer left text”. At 0312 RN notified. At 0326 “called rn [sic] she said we will get pt we are transporting right now”. Per an interview with AS #6 the CMU tech did not write down all communication between the RN and CMU tech. Interview on 09/18/2025 at 0900 with AS #6 and Director #9 revealed that the CMU staff work 12-hour shifts (7am-7pm or 7pm to 7am), 3 days a week. The CMU has 10 pods and the staffing goal was to have 10 CMU techs, one for each pod, 2 rovers (staff available to assist), and a supervisor/team lead. Interview revealed that the CMU tech can monitor up to 45 telemetry and/or continuous pulse oximetry patients, but the average was 35 patients. Interview on 09/18/2025 at 1020 with AS #6 revealed that the CMU techs have different escalation pathways to follow depending on the situation. Interview revealed that when all the leads were off the patient needs to be evaluated by the primary RN/nursing staff. When there was no resolution by nursing staff the CMU tech should reach out to the CNC. If no resolution, then the CMU tech calls an overhead telemetry alert page throughout the specific unit. The escalation process should be repeated until there was a resolution. The expectation of the overhead call was for all staff to respond. Interview revealed that on 07/26/2025 the CMU tech reached out to the RN and CNC but they were busy with another rapid response patient. Interview revealed when there was no resolution the CMU tech did not follow the escalation pathway and call overhead, nor did the RN delegate the responsibility to get the patient assistance. Interview on 09/22/2025 at 1415 with CNC (Charge Nurse) #14 revealed the CNC recalled the patient and incident. Interview revealed that the CNC was not aware that the patient was off telemetry until CMU called the CNC and by that time the CNC was in the rapid response. The CNC stated that she informed CMU they were in a rapid response and to call overhead and CMU said ok, but the CNC did not recall if that happened. The CNC stated she was not aware that CMU had been calling the primary RN because the RN didn’t tell the CNC or delegate someone to check on the patient. Interview revealed that on the (named) unit all the RNs are paired with a buddy and that the primary RN should have called the buddy to check the patient. The CNC stated that the RN buddy was not in the rapid response and should have been available. Interview revealed that telemetry monitors can also be seen at the nurse station. The CNC did not recall any unit staff member on 07/26/2025 mention seeing the patient in E433 off of his telemetry monitor. Interview revealed that during the Code Blue debrief the RRT mentioned he told someone about the patient leads being off, but the CNC was not aware of the RRT alerting anyone. Further interview revealed that during the day shift rounding should take place every hour, and overnights between 10pm and 6am, the patient should be rounded on every two hours by either the RN or PCT. Interview revealed that the staffing ratio on the unit was one RN to five patients. On 07/26/2025 the CNC recalled that none of the RNs had more than five patients. Interview revealed that although the staff were within ratio the CNC felt the unit still had a staffing shortage and while staff do their best to provide care, it was not always safe care. 33790 3. Review of the policy titled “Patient Identification...”, last approved 08/09/2024, revealed “...POLICY: A. This policy establishes a mechanism to assure that all patients of (hospital) are positively identified using two patient-specific identifiers at every encounter. B. Name and date of birth....are the two preferred identifiers....C. Whenever possible, the patient should be asked to state name and date of birth. The patient may also be asked to spell the last name....F. The staff member placing the identification....bracelet on the patient will verify the identity of the patient or have the patient’s legal representative do so. ...” Review of a policy, reference number “PARA.HSC.FB.24”, effective 10/21/2024, revealed “...DEFINITION: TRUE OVERLAY/ PATIENT OVERLAY - One individual person/patient’s information is mixed in with or on top of another patient’s information. This occurs when a patient is registered for a visit or service on another patient’s medical record number. PURPOSE:....a standardized method of correcting patient medical records when an overlay has occurred.... The HIMD (Director Health Information Management) will notify.... to review the clinical information in the record on both records for accuracy.... must be remedied within 45 days of the EMPI (Combine) Team’s sending of the overlay notification... .” Medical record review on 09/18/2025 revealed Patient (Pt) #24, a 73-year-old, arrived to the hospital on 08/19/2025 at 0003 via EMS (Emergency Medical Services) as a transfer from an outside hospital. Pt #24 fell off a truck and sustained a pelvic fracture. Record review revealed a “COMBINE” note, signed on 08/20/2024 at 1443, that noted “...This patient had a duplicate Medical Record Number and/or Community Person ID number. A combine was done and the following was changed...._X_ Financial Number.... This patient’s encounter was moved.... Incorrect patient chosen during registration.” Review of an “ER Report” service date/time 08/19/2025 at 0018, revealed Pt #24 “...was on top of a barrel of hay and pulling a tarp on it, he lost his balance falling off the truck and landed on his right hip and back. He was taken to an outside hospital, had CT scan (Computed Tomography - type of imaging procedure) of the pelvis showing right pelvic fractures ....He has been unable to stand or bear weight.... Will admit to the hospitalist for pain control, PT/OT (Physical Therapy/Occupational Therapy) and potentially rehab placement. ...” Review of the “Hospital Medicine Admission H&P (History and Physical)”, service date 08/19/2025 at 0217, revealed addenda signed 09/10/2025 at 1011(22 days after arrival). The first addendum stated “...Correction to the H&P above: Patient has never smoked tobacco and the problem ‘former tobacco use’ should be removed from his social history and problem list above.” The second addendum noted “Please see corrections to the medical H&P below: Please note and remove the following from the H&P above. There is no prior history of coronary artery disease, no history of peripheral arterial (circulatory condition with narrowed blood vessels and reduced blood flow to the limbs); no history of tobacco use, and no history of hypothyroidism (thyroid gland does not produce enough thyroid hormone), and no history of BPH (Benign Prostatic Hyperplasia - enlarged prostate gland). [space] Past Medical History: Type 2 Diabetes mellitus (chronic disease when the body does not produce enough insulin or does not use insulin effectively resulting in elevated blood sugar), Hypercholesterolemia (elevated cholesterol), Hypertension (elevated blood pressure)... .” An “Orthopedic trauma consultation...” note, originally signed on 08/19/2025 at 1952, revealed an Addendum on 09/17/2025 at 1231 that stated “Please note that due to a clerical error at the time of the original date of service, a portion of the consultation note above contains inaccurate information. Specifically, I have just now been informed that a portion of the past medical history as documented above is inaccurate, and actually applicable to a separate patient of a similar nature. ...” On 08/19/2025 at 1727 an electronic system generated order was for “Order: Chart Merge Notification Order Date/Time 8/19/2025 17:27 EDT.... Order Comment: Immediate medication history and allergy review required due to patient chart merger. ...” The action was documented as complete 08/19/2025 at 2112 (21 hours after the patient’s arrival). Review of a “Progress Note”, dated 08/19/2025 at 2109 revealed “...Pt has remained in the ED throughout the day....Pt denies significant pain, no med changes or medical issues. Discussed plan of care ....all questions answered. ...” Review of “Allergies - Medications” revealed documentation that allergies were reviewed and validated by an RN on 08/19/2025 at 0013 and were again reviewed on 08/20/2025 at 0734. On 08/20/2025 at 0758, under “Notifications”, the note read “...Admission is complete. Med Rec was already done. Med Hx updated for you to review.... has an allergy to codeine. I’ve added that in. ...” Review of the Discharge Summary, service date/time 08/20/2025 at 1244, revealed an Addendum dated 09/12/2025 at 0229 that noted “Patient has no history of coronary artery disease, BPH, tobacco abuse, peripheral vascular disease. Patient has a history of T2DM (type 2 diabetes) hypertension (high blood pressure), hyperlipidemia presented with pelvic fracture.... fracture was closed by consulting orthopedics and recommended nonsurgical management. His home med list is inaccurate as well. Chart mixup happened at arrival. Patient’s med list is inaccurate except for pain medications. Updated medical conditions of her (sic) pelvic fracture, T2DM, HTN (hypertension, high blood pressure) and hypokalemia (low potassium).” Further review of Pt #24’s medical record revealed scanned documents from the transferring hospital which noted Pt #24’s full given name. It was unclear when these records were received. Patient #24 was discharged on 08/20/2025. The Triage Nurse was requested but was not available for interview. Interview with Registration Staff (Staff #34) on 09/19/2025 at 0935 revealed Patient #24 came through the ambulance entrance and was quick registered by the ED HUC (Health Unit Coordinator). Interview revealed “once the doctor has signed up for the patient we (registration staff) can register the patient (complete the registration process).” Interview revealed registration asked patient/family “is this (patient’s first name)” and the answer was no. Interview revealed Staff #34 verified that the patient name that was chosen in the system was not the same as the patient currently in the ED. Staff #34 went back out and explained to the HUC and Charge Nurse that the patient name in the system was not the patient in the ED. Staff #34 stated “I cannot register this patient due to this being someone else’s chart... last name and date of birth were correct, first name was not correct.” Interview revealed they discussed if there was identification that could confirm the correct name; the answer was yes and noted the patient was a transfer. Interview further revealed staff went to the patient’s family apologized that they could not register the patient now but would get it fixed. Staff #34 stated the patient’s correct name and the incorrect patient name both were listed on the “board”. Interview revealed they could not initially register Pt #24 with the patient’s correct name because labs and orders had already been recorded in the other record. Interview revealed they “can’t do anything, would lose everything.” Reg Staff #34 further indicated that Pt #24’s armband had the correct sticker placed on top of the armband that had incorrect information. Telephone interview on 09/19/2025 at 1130 with MD #36, revealed the MD was involved in the care of Pt #24. Interview revealed it was an overnight admission. Interview revealed MD #36 had no idea Pt #24 was registered under the wrong name. MD #36 stated s/he met with the patient only the one time, around 0200 for the admission H&P. Interview revealed physicians went in and did addendums to correct the medical record afterwards. Telephone Interview with MD #1(a physician leader), also at 1130 on 09/19/2025 revealed MD #1 was notified of the error and reached to MD #36 to discuss it. Interview with Registration Staff #35 on 09/19/2025 at 1155, revealed Staff #35 remembered another staff member had attempted to register the patient and learned the computer encounter in the system for Pt #24 was incorrect. Staff #35 pulled up the encounter and it was the wrong person. Orders had already been entered. Interview revealed “it is not something I can fix.” Staff #35 stated there was a combine team and noted “it’s an urgent thing but my only avenue to fix it was to reach out to the team.” Interview revealed it happens on a regular basis and “...if orders are already in, it is very difficult to correct. Before orders, the chart can be errored out...quick fix.... If beyond that....has to be dealt with by another group.” Telephone interview with HUC #37 on 09/19/2025 at 1220 revealed Pt #24 came through and EMS gave patient’s name and DOB. Interview revealed the HUC did not recall but did not think there was paperwork with the patient. Interview revealed the HUC mostly asked EMS and if unable to locate the name would then get more information. Interview revealed HUC #37 put in the patient’s last name, then stated a first name (incorrect first name) and they said yes so that record was selected. A few hours later, the HUC stated, family members came and said it was wrong and gave Pt #24’s ID. The patient received a new medical record number and a new bracelet and stickers, interview revealed. HUC #37 indicated the “Combine team” was e-mailed because “they are the ones who do changes.” Interview revealed the next day the patient still had two accounts. Interview further revealed tonight “...would still ask EMS ... if can’t find ask the patient.” Telephone interview with MD #38 on 09/19/2025 at 1300 revealed the physician recalled the patient and stated that issues like this do happen. The MD stated generally if no orders had been placed they can correct; in this case the issue wasn’t caught until a couple of hours later and the orders and consults were already in. Interview revealed MD #38 did not have any concerns related to the misidentification and care. About a week later, MD #38 stated, they received information on revising the record. Interview with Director #44 on 09/22/2025 at 1545 revealed the process to be followed when a patient was incorrectly registered was for whoever identified the error to send an email to EMPI/Combine team, a corporate team that managed these types of errors. Interview revealed the team was available from 0600 in the morning to about 0100 (unavailable approximately 5 hours each weeknight). Once the EMPI/Combine team got the notification email, they reviewed and would reach back out to the requestor with any questions. Interview revealed Director #44 did not receive e-mails sent to the Combine team. In this particular case the Director received a call from the patient’s family voicing concerns and Director #44 got involved. After the medical record was combined, Director #44 reached out to clinical leaders until all notes in the medical record had been reviewed and corrected. Interview on 09/23/2025 at 1425 with ED Manager #39 revealed that when the manager arrived to work around 0600 on 08/19/2025, and the issue related to the patient and misidentified name had not been corrected. Interview revealed a message had gone to the combine team earlier and the manager tried sending the information to them again. Later in the day it was still unresolved and Manager #39 escalated it, first to the House Supervisor, then the ED Director. At 1700, the VP was notified, who immediately escalated it farther and it got resolved. Manager #39 stated both charts were up and working, the charts just needed to be merged. Interview further revealed that Manager #39 did not know the processes that were being followed at the time. Telephone interview on 09/23/2025 at 1510 with RN #40 revealed when RN #40 came on duty at 1500, there was a patient with 2 charts, Pt #24. The orders and Medication Administration Record (MAR) remained in the incorrect record. There were no medication orders or MAR under the correct patient named record. The patient had a corrected ID bracelet on but could not scan the bracelet because the orders were in the incorrect record. RN #40 needed to give medications to Pt #24 so the nurse had a second RN verify the medication to ensure it was correct. Interview revealed RN #40 documented the medication in the MAR of the incorrect record with the note of a second verifier. In the correct patient record, interview revealed, the RN wrote a nursing note indicating medication was administered and called the hospitalists who said they would put orders in the correct chart.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 47421 Based on review of hospital policies and procedures, closed medical records, video review, the facility investigation, CMU (Central Monitoring Unit) documentation, and staff interviews, the hospital failed to ensure adequate staff was available to assess and respond to a monitored telemetry patient with leads off and the patient subsequently expired for 1 of 32 patients reviewed (Patient #14). The findings include: Review of hospital policy titled “Physiologic Monitoring - Cardiac Telemetry Monitoring, Continuous Pulse Oximetry Monitoring” last approved 06/04/2025 revealed “ ...PURPOSE ... C. Identify which rhythms or arrhythmias require RN (registered nurse) notification/intervention and identification of proper escalation procedures ...ALARM RESPONSE AND ESCALATION PROCESS A. ...a defined escalation pathway is used to ensure timely notification and treatment ...II. Rhythm Transmitting with ...Leads Off ... A. First Escalation Attempt: 1. MTII (monitor tech) calls Primary Nurse. 2. Within 5 minutes the Primary Nurse will assess the patient and call the monitor tech and give an update ...4. The MTII records the notification ... B. Second Escalation Attempt: 1. If unable to reach Primary Nurse or unresolved within 5 minutes from the time of initial notification, the MTII call the Primary Nurse again and enter notification time ... C. Third Escalation Attempt: 1. If unable to reach Primary Nurse, or unresolved after 5 minutes, the MTII will call the CNC (clinical nurse coordinator)/Relief Charge Nurse. 2. If no resolution after 1 minute, send broadcast to unit. 3. If no resolution after 2 minutes, start escalation over until resolved. Review of hospital policy titled “Assessment and Reassessment” last approved 05/13/2025 revealed “Purpose The organization assesses and reassess the patient and the patient’s condition according to defined timeframes ... Policy ... C. The assessment process is a continuous, collaborative effort with departments functioning as an interdisciplinary team ... Assessment Framework A ...2. As individual patient condition changes ... Interdisciplinary Plan of Care (IPOC) ...D. Nursing maintains the responsibility and accountability ...” Review of hospital document titled “ADULT INTERMEDIATE CARE STANDARDS OF CARE GUIDELINES-NURSING”, revealed “ ...Reassessment intervals and parameters are presented as the minimum times, measurements, and evaluation criteria ... Patient Rounding A. Safety Rounds to occur as recommended - every 1-2 hours ... Safety A. The patient can expect appropriate safety precautions while in the hospital ...” Closed medical record review revealed Patient (Pt) #14 was a 72-year-old male readmitted on 07/23/2025 at 1715 for shortness of breath and chest pain. At 1742 there was an order for telemetry monitoring. Per documentation the patient was placed on telemetry and telemetry tech was notified. On 07/26/2025 at 0021 vital signs revealed temperature 98.1 (oral), heart rate (HR) 76, blood pressure (BP) 99/57, (oxygen saturation) SpO2 93% on 60L (liters) oxygen (O2) high flow humidified. At 0320 the (registered respiratory therapist) RRT documented the patients HR 78, respirations (RR) 18, SpO2 93% on 60L O2 high flow humidified. Review of a Provider Note at 0415 revealed “CODE BLUE called overhead on this patient ... Was not notified by staff of any issues overnight or notified of patient being found on the floor prior to CODE BLUE being called. CPR was in progress when I walked in the room. Per the patients nurse, he was found on the floor without his Vapotherm (high flow humidified O2) on and without telemetry on for an unknown period of time ... During discussion with Dr. (named) it was decided to stop the code as we never obtained a pulse. Time of death was called at 0403 ...” Review of the Code Blue documentation revealed code time started at 0347, the patient was intubated at 0354, and the code stopped at 0403. Record review failed to reveal that a bed/chair alarm was documented on the evening shift of 07/25/2025. Review of video footage dated 07/26/2025 revealed footage of unit 4 heart. Review revealed a view of the nursing station, a hallway view of Patient #14’s room (E433). From 0012 through 0024 staff were noted to be in Patient #14’s room and the 2 staff members exited at 0024. At 0231 a female staff (identified as CNC #14) was seen sitting at the nurse station computer. At 0305 a male staff (identified as [registered respiratory therapist] RRT #21) entered the patient’s room and was seen exiting the room also at 0305. At 0313 CNC #14 still observed at nurse station, observed answering the desk phone. At 0322 CNC #14 left the nurse station and walked to another patient’s room. At 0346 male staff (identified as unit PCT) entered Patient #14’s room. At 0348 the code team arrived via stairwell. Review did not reveal any nursing staff in Patient #14’s room between 0024 and 0346, only the Respiratory Therapist at 0305. Review of the facility investigation on 09/18/2025 at 1535 with Director #13, Director #9, and Nurse Administrative Staff (AS) #6 revealed a timeline of events. The timeline revealed on 07/25/2025 at 1900 an RN rounded on the patient and noted no distress. On 07/26/2025 at 0012 staff were in the patient’s room. At 0242 the RN was notified by the CMU tech (central monitoring unit technician) that the telemetry leads were off. At 0244 the RN was notified by the CMU tech again. At 0305 the RRT rounded on the patient and noted no distress. At 0309 the CMU tech sent a text to the RN. At 0312 the CMU tech notified the CNC to reinforce the leads. At 0317 the CMU tech called the RN but did not get an answer. At 0320 the RRT documented HR 78, RR 18, SpO2 93%, Vapotherm at 60L/minute. At 0326 CMU tech called the CNC. The CNC told the CMU tech they were in a rapid response and would get to the patient after they transferred the rapid response patient off the unit. At 0341 the CMU tech reached out to the PCT (patient care technician) asking for the telemetry leads to be checked. At 0345 the PCT entered the room and found the patient on the floor. At 0347 a Code Blue was initiated. At 0354 the patient was intubated. At 0403 the Code ended. Further interview revealed that the RRT was interviewed after the incident. The RRT entered the patient’s room at 0305 the RRT noted the patient was resting and did not have his telemetry leads on. The RRT used his pocket pulse oximetry to assess the patients SpO2 and noted the RRT had no issues and that he assumed the RN was aware of the leads being off and would get to them. Interview revealed that the CMU tech was interviewed after the incident. The CMU tech revealed that the RN stated someone would get to the patient, so the CMU tech was giving the RN the benefit of the doubt. Review of CMU tech documentation on 07/26/2025 revealed at 0242 the RN was notified leads were off. At 0309 “called no answer left text”. At 0312 RN notified. At 0326 “called rn [sic] she said we will get pt we are transporting right now.” Per an interview with AS #6 the CMU tech did not write down all communication between the RN and CMU tech. Interview on 09/18/2025 at 1020 with AS #6 revealed that the CMU techs have different escalation pathways to follow depending on the situation. Interview revealed that when all the leads were off the patient needs to be evaluated by the primary RN/nursing staff. When there was no resolution by nursing staff the CMU tech should reach out to the CNC. If no resolution, then the CMU tech calls an overhead telemetry alert page throughout the specific unit. The escalation process should be repeated until there was a resolution. The expectation of the overhead call was for all staff to respond. Interview revealed that on 07/26/2025 the CMU tech reached out to the RN and CNC but they were busy with another rapid response patient. Interview revealed when there was no resolution the CMU tech did not follow the escalation pathway and call overhead, nor did the RN delegate the responsibility to get the patient assistance. Interview on 09/22/2025 at 1415 with CNC #14 revealed the CNC recalled the patient and incident. Interview revealed that the CNC was not aware that the patient was off telemetry until CMU called the CNC and by that time the CNC was in the rapid response. The CNC stated that she informed CMU they were in a rapid response and to call overhead and CMU said ok, but the CNC did not recall if that happened. The CNC stated she was not aware that CMU had been calling the primary RN because the RN didn’t tell the CNC or delegate someone to check on the patient. Interview revealed that on the (named) unit all the RNs are paired with a buddy and that the primary RN should have called the buddy to check the patient. The CNC stated that the RN buddy was not in the rapid response and should have been available. Interview revealed that telemetry monitors can also be seen at the nurse station. The CNC did not recall any unit staff member on 07/26/2025 mention seeing the patient in E433 off of his telemetry monitor. Interview revealed that during the Code Blue debrief the RRT mentioned he told someone about the patient leads being off, but the CNC was not aware of the RRT alerting anyone. Further interview revealed that during the day shift rounding should take place every hour, and overnights between 10pm and 6am, the patient should be rounded on every two hours by either the RN or PCT. Interview revealed that the staffing ratio on the unit was one RN to five patients. On 07/26/2025 the CNC recalled that none of the RNs had more than five patients. Interview revealed that although the staff were within ratio the CNC felt the unit still had a staffing shortage and while staff do their best to provide care, it was not always safe care.”

“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: 50318 Based on policy review, observation, medical record review and staff and provider interviews, nursing staff failed to supervise and monitor care for 2 of 32 patients reviewed by failing to ensure safe and appropriate transport and continuous pulse oximetry monitoring for a patient during transport (Pt #10) and failing to prevent and control infections. Nursing staff failed to identify and communicate accurate and timely COVID precautions on an inpatient unit creating an unsafe environment for patient care (Pt #34) and exposure to COVID. The findings include: 1. Review of hospital policy, “Physiologic Monitoring - Cardiac Telemetry Monitoring, Continuous Pulse Oximetry Monitoring - 1PC.NRS.0001,” effective 08/19/2025, revealed, “ ... III. Transport of Monitored Patients. 1. Interruption in cardiac monitoring should not occur during transport for patients with active orders for telemetry monitoring. a. Patients with active monitoring orders should continue to be remotely monitored, and the Monitor/Telemetry Technician should be notified of unit travel, destination, primary contact for duration of travel, and anticipated time of return ...” Review of hospital policy, “Assessment and Reassessment, 1PC.ADM.0013,” effective 05/13/2025, revealed, “ ... 6. The interdisciplinary team provides information concerning patient assessment relevant to their scope of care, as well as areas of concern or patient special needs. Further assessment and reassessment is based on their plan of care or changes in their condition ... Reassessment may be at specified/regular intervals, triggered by key decision points, and at any interval(s) specified by the departments/ancillary disciplines directly involved in providing patient treatment and/or care ...” Review of hospital Guidelines for Patient Transport revealed, “ ...If a patient’s condition appears to be questionable, always let the nurse know that you are non-clinical staff and ask if they feel that it is safe for you to transport the patient ...” Observation of a patient elevator from the Emergency Department (ED) to a Stepdown unit on 09/19/2025 at 1345 revealed an alarm button in the elevator which rang only in the immediate elevator area. Observation revealed a red phone button in the elevator; an operator answered after approximately 45 seconds and asked if assistance was needed. Observation of the Emergency Department (ED) on 09/23/2025 at 1159 revealed a patient was switched from ED telemetry monitoring to the CMU (Central Monitoring Unit) for monitoring during transport to inpatient holding. Observation revealed the portable telemetry box did not display a visual or have an audible alarm for any changes during transport. Closed medical record review on 09/17/2025 for Patient #10 revealed a 48-year-old presented to the Emergency Department (ED) on 09/04/2025 at 1441 with complaints of chest pain and shortness of breath. The patient’s pain was documented at 1442 as 8 out of 10. The Provider’s MSE (Medical Screening Exam) Note at 1445 revealed, “Patient with chest pain and shortness of breath. On home oxygen normally. chest tube in place. Patient is alert, in no acute distress but is moaning in discomfort.” The patient’s oxygen saturation (O2 sat) at 1446 was 97% and at 1500 was 90%. The ED Provider’s Note at 1534 revealed the patient had a history of metastatic lung cancer with a chest tube on the right with “chronic pain at the tube site now with worsening shortness of breath for the past day.” The patient’s O2 sat at 1630 was 92%, and the patient was placed on 3 liters of oxygen via nasal cannula. The patient’s O2 sat at 1715 was 93%. An order for Morphine (a pain medication) 4 milligrams IV (intravenous) was placed at 1729. An order was placed at 1731 for continuous pulse oximetry (measures how much oxygen is in the blood for uninterrupted periods). The patient’s O2 sat at 1745 was 89% and at 1750 was 90%. A broadcast notification was sent to the Stepdown unit at 1803 with the room number the patient was assigned to and the box number for continuous pulse oximetry. The patient’s blood pressure at 1807 was 84/57 with a comment by the Nurse that the Provider was notified at that time. The patient’s pain was assessed at 1808 as 10 out of 10. A comment was documented on the MAR (Medication Administration Report) at 1809 that Morphine was not given as the patient’s blood pressure was “too low to administer,” and the Provider was notified. The patient’s oxygen was increased to 4 liters at 1820 with an O2 sat of 94%. ED Nurse Note at 1830 revealed the patient was transported by transport staff. The patient was on an “O2 monitor, awake and alert. Prior to patient leaving emergency department this RN (Registered Nurse) spoke with transport leadership regarding blood pressure parameters for transport personnel. Transport leadership stated, ‘We do not have parameters for blood pressure as long as you feel patient is stable for transport’ ...” The patient’s O2 sat prior to transport at 1830 was 93%. Record review failed to reveal documented evidence of the patient’s heart rate and O2 sats during transport and failed to reveal documented evidence of the patient’s time of arrival to the unit and initial O2 saturation on the unit. Review of a Code Record revealed a code blue (the initiation of resuscitative efforts in a cardiac or respiratory arrest) was called with initiation of CPR (cardiopulmonary resuscitation) at 1842 and initial ECG (electrocardiogram, a noninvasive test that records the electrical activity of the heart) rhythm of asystole (no heartbeat). Check boxes for the initial condition were selected as “Yes” for conscious, breathing, and pulse, as well as “Witnessed Arrest.” A check box for “Monitored” was selected “No.” The patient was intubated at 1853, and a rhythm of PEA (Pulseless Electrical Activity, a condition where the heart is still producing electrical signals, but there is no pulse or blood pressure) was noted at 1901. Discharge Summary dated 09/06/2025 at 2226 revealed the patient was admitted to a medical floor for further evaluation and management of acute respiratory failure. The patient “coded as soon as she transferred to the medical floor ...” and was pronounced dead at 1907 on 09/04/2025. Interview on 09/18/2025 at 1335 with RN #26 revealed Patient #10 was transported from the ED and was brought to their assigned room. Interview revealed Staff #7 called for help, because “something did not look right.” A Nurse in the hallway responded and hit the Staff Assist button in the room, which sent an overhead alarm and blinked red outside the room. RN #26 responded at that time and observed the patient on the stretcher, and the patient appeared to be having seizure-like activity. The patient had their head back and was convulsing. RN #26 revealed the patient was moved to the bed, a code blue was called, and chest compressions were started immediately. Interview revealed Staff #7 reported the patient had been speaking to their family member in Spanish during transport, and when they arrived to the patient’s room on the Stepdown unit, the seizure-like event occurred. Telephone interview on 09/19/2025 at 0939 revealed nursing staff had “huge concerns” with signal loss in the elevators for their patients on remote telemetry. Interview on 09/19/2025 at 1713 with Director #8 revealed Staff #7 reported RN #27 called the transport dispatch to ask if there were blood pressure parameters for transport and was informed there were not parameters for blood pressure. Staff #7 then transported Patient #10 to the Stepdown unit. When Staff #7 arrived to the unit, the Nurse was not in the patient’s room, so Staff #7 pressed the call bell to alert the Nurse the patient had arrived. Interview revealed Patient #10 was in pain, so Staff #7 stepped out in the hallway to ask for help and a Nurse in the hallway responded. Staff #7 informed Director #8 that Patient #10’s family was present, and assisted with translation from Spanish that the patient was in pain during transport. Telephone interview on 09/22/2025 at 1422 with Staff #7 revealed Patient #10 had a family member with them at the bedside who assisted with translating from Spanish for Patient #10. Interview revealed Patient #10’s family verified the patient’s name and date of birth in English for Staff #7. Staff #7 revealed RN #27 asked if there were blood pressure parameters for transport, but Staff #7 was unaware of any parameters for blood pressure. Staff #7 called the transport dispatch, put them on speaker phone, and was informed there were not blood pressure parameters for transport. Transport dispatch informed RN #27 that the patient must be stable for non-clinical staff to transport; RN #27 checked the blood pressure again and signed off on Staff #7 transporting the patient. Staff #7 was not aware of any alarm that could be heard with the telemetry box during a patient’s transport. Staff #7 revealed when they were in the elevator, the patient was moaning in pain and spoke in Spanish to their family. The family then translated in English to Staff #7 that the patient was in pain; Staff #7 reassured the patient and family that Staff #7 would get the patient help. Interview revealed when they arrived to the Stepdown unit, the patient was still moaning in pain, and the family asked, “Can you please help? You’re a Nurse.” Staff #7 informed the family they were not a Nurse but would get the patient help. Staff #7 noticed the patient showed signs of a seizure, and the family was “frantic, asking for help.” Staff #7 pushed the Staff Assist button on the wall and stepped into the hallway for help. A Nurse approached and asked if they needed help, and then staff “were coming from everywhere into the room.” Staff #7 then stepped out into the hallway, the stretcher was pushed out of the room, and Staff #7 was informed that they could leave. Interview on 09/23/2025 at 0925 with RN #27 revealed Patient #10 had a significant other at the bedside, and RN #27 spoke in Spanish to them. RN #27 revealed the patient’s blood pressure had dropped a little, and MD #28 had ordered fluids. Interview revealed the patient’s blood pressure was not “at standard to give” Morphine. RN #27 revealed the patient was complaining of pain in the ED; RN #27 explained to the patient and their significant other that RN #27 could not give Morphine due to their blood pressure. Interview revealed the patient complained of generalized pain and stated, “everywhere hurts.” Interview revealed RN #27 called the CMU prior to Staff #7 transporting the patient to ensure the CMU could visualize Patient #10 on their O2 monitor. The CMU verified visualization and provided the patient’s heart rate and O2 sat. RN #27 did not recall the exact values but stated they were within normal limits. RN #27 revealed the telemetry boxes for transport did not have an alarm. Telephone interview on 09/23/2025 at 1313 with Tech #5 revealed they recalled RN #27 called to verify the pulse ox for Patient #10 could be visualized by the CMU prior to transport from the ED to a Stepdown unit. Interview revealed they were on the phone for a few minutes troubleshooting the pulse ox probe as there were issues with the signal going in and out. Interview revealed Wi-Fi connection issues, such as the signal cutting in and out, could occur when a patient was transported. Tech #5 revealed during Patient #10’s transport, the signal was again cutting in and out, and there was not a solid reading. Tech #5 revealed there were drops in Patient #10’s O2 sats, but they could not get a clear reading due to signal issues. Interview revealed the CMU pod was very busy that day as there were multiple patients being transferred and admitted, as well as multiple escalations at that time. Tech #5 revealed any time there were O2 sats dropping or signal loss, the monitor techs should notify the Nurse as soon as they see it with a resolution time of 5 minutes. Interview revealed the Stepdown unit was not notified that Patient #10’s pulse oximetry had signal issues, a loss of signal during transport, or drops in the patient’s O2 sats. 33790 2. A tour of the pulmonary medical unit was conducted 09/18/2025 at 1320. Prior to tour hospital staff noted the unit had served at one time as a COVID unit. The staff stated there were currently no (zero) COVID patients on the unit. Observation during the tour revealed some patient rooms were labelled with contact precaution signs, including Pt #34’s room. Observation did not reveal any signage for enhanced COVID precautions and hospital staff again indicated there were no current COVID patients on the area being toured. Medical record review for Patient #34, an inpatient on the unit during tour, revealed Patient #34 arrived to the ED and was admitted 09/16/2025. Medical record review revealed Pt #34 was tested for COVID, among other infectious diseases, and the COVID PCR resulted postitive on 09/16/2025. Review confimed Patient #34 was COVID positive on 09/18/2025 at the time of the tour. According to hospital data, fifteen staff were assigned or potentially exposed to COVID. Family interview 09/18/2025 indicated hospital staff failed to inform the family of a COVID positive PCR on 09/16/2025 and appropriate precautions until 09/18/2025. Interview on 09/19/2025 at 1425 with Director #47 revealed the enhanced precaution sign was in place until the morning of 09/18/2025 when the order was cancelled in error. Interview revealed enhanced COVID precautions included a N95 respirator (protective device designed to achieve a very close facial fit and efficient filtration of airborne particles) among other protective devices. Interview on 09/26/2025 at 1830 with Director #47 and Nursing Adminstrative Staff (AS) #46, revealed the signage error occurred due to a computer programming error where the isolation precautions were changed to contact based on a different positive result and overrode the enhanced isolation sign order. Interview revealed that should not have happened, the enhanced isolation precautions should have remained in place. The patient’s nurse, interview revealed, acknowledged the computer order for contact precautions and removed an enhanced precaution sign, replacing it with a contact isolation sign. Interview revealed an infectious disease doctor came in later that day, noticed the discrepancy and reordered and implemented the enhanced COVID precautions. In summary, there was no indication nursing staff were aware of a COVID positive patient on the unit before or during the observational tour since no one acknowledged a current COVID patient. There was no evidence nursing understood the need to question a change in the isolation precautions for a COVID positive patient. It was a physician who discovered and corrected the precautions.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 34065 Based on review of policy, medical records and staff and provider interviews, hospital nursing staff failed to follow policies to evaluate a patient’s change in condition requiring emergent treatment for 1 of 32 sampled patients (#17) and failed to follow post procedure guidelines following a heart catheterization for 2 of 32 sampled patients (#17, #15) The findings include: 1. Review of hospital policy titled “Assessment and Reassessment” last approved 05/13/2025 revealed “Purpose The organization assesses and reassess the patient and the patient’s condition ... Policy ... C. The assessment process is a continuous, collaborative effort ... Assessment Framework A ...2. As individual patient condition changes ...D. Nursing maintains the responsibility and accountability ...” Review of policy on 09/25/2025 titled “Clinical Documentation” with revision date of 07/26/2024, revealed “Purpose: A. Provides guidelines for documentation of patient care, patient data, and patient outcomes within the electronic medical record, by members of the clinical team as indicated.... Clinical documentation should be: 1. Completed during or immediately after care is provided, if possible, but not to exceed end of shift.... Documentation is: ...2. Based on professional observation and assessment. 3. Individualized to identify problems and actions taken. 4. Based on the patient’s current status....” Closed medical record review on 09/15/2025 of Patient #17 revealed a 69 year old female transferred from an outside facility on 06/07/2025 at 1752 via EMS to be evaluated for “NSTEMI (Non ST elevation Myocardial Infarction--possible heart attack without ST elevation of the ST waves on the heart monitor) and SEPSIS” Patient arrived at the ED (emergency department) with complaints of nausea after a fall 2 days prior. Patient #17’s past medical history included afib (atrial fibrillation--irregular rhythm of the heart with inadequate pumping) with ablation (procedure to attempt to place the heart in normal rhythm) and hypertension. Review of the patient’s medical record revealed on 06/09/2025 at 0740 vital signs were documented as HR 124 (elevated) Temperature 102 (elevated), oxygen at 2 liters with pulse Oximetry at 90% (normal is 90 or above). At 0743, an order for an EKG (Electrocardiogram--tracing of the heart rhythm) was received from MD #45. At 0750 Tylenol was administered for elevated temperature by RN #25. At 0753, the EKG was completed. The results of the EKG were: “ST elevation more prominent. Sinus tach (tachycardia--fast heart rate) with occasional PVCs (premature ventricular contractions--abnormal rhythm). Old MI (myocardial infarction--heart attack). Abnormal EKG.” Review of a communication from the Central Monitoring Unit (CMU) dated 06/09/2025 at 0758 revealed, “getting EKG per (RN #25). Freq (frequent) atrial and ventricular ectopy (irregular heart rhythm). The RN daily shift assessment was completed at 0800 by RN #25, noting “CV (cardiovascular) irregular. Diaphoretic.” Review of the record revealed no evidence of notification to the physician regarding the EKG results. Review of the medical record, timed at 0840, revealed a Rapid Response was called (Rapid Response--emergency team to assist with patient’s emergency). Review of a Rapid response note documented at 0840 stated: “Source of RRT (Rapid Response Team). Nurse request. Rapid response reason: Staff generalized concern. Husband requested the Rapid Response team be called. Increase in ST elevation. Noted elevated fevers decreasing plt (platelet) ct (count) down to 42 on a heparin (anticoagulant medication) gtt (drip) po (by mouth) ASA (Aspirin) given. Code STEMI (Process to alert emergency team to assist with heart attack patient.) ST elevation Myocardial infarction--heart attack with abnormal rhythm on the EKG) called and cath (Heart catheter department) lab at bedside to take pt (patient) to cath lab. We brought the husband to the cath lab waiting area.” Review of the provider orders revealed at 0842 (two minutes after the rapid response was called), a cardiac cath was ordered by the Nurse Practitioner (NP #3). Patient #17 was taken to the cath lab for a cardiac catherization. Review of the record (nursing or progress notes) revealed no assessment of the patient’s condition from the NP or nursing staff to describe the condition of the patient. The patient was taken to the cardiac cath lab at 0855. Review of the cardiac cath revealed “Pattern typical for Takotsubo cardiomyopathy (known as broken heart syndrome--a heart condition that causes a sudden weakening of the heart’s pumping function). Review revealed no evidence of an assessment of the patient’s change in condition or evaluation of the patient when the rapid response was called. Review revealed no notes from the nurses or provider during the rapid response. Interview on 09/17/2025 at 1545 with RN #25, the patient’s primary nurse, revealed there was no notification to the provider of the patient’s EKG results and no documentation of the patient’s change in condition. The nurse stated she would usually assess and document a patient’s change in condition and abnormal results. The nurse was unable to remember the patient. Interview on 09/18/2025 at 1115 with RN #2, Nursing Director, revealed no assessment or evaluation of the patient’s change in condition or notification to the provider regarding the EKG results. Interview revealed the hospital policy was not followed. Interview with NP #3 on 09/18/2025 at 1550 revealed NP #3 may have received a phone call for concerns about Patient #17, but did not recall. Interview revealed NP #3 did not have an explanation regarding the lack of documentation of assessment and treatment for Patient #17 during the Rapid Response. Interview on 09/18/2025 at 1600 with MD #1 revealed no assessment documentation from the NP was located in Patient #17’s medical record. Interview on 09/18/2025 at 1215 with RN #2 revealed vital signs were not taken per policy. Interview revealed no documentation of the occlusive dressing being placed on the puncture site. Interview revealed policy was not followed. 2. Review on 09/16/2025 of Guidelines titled “Radial Compression Band (TR Band) Radial Compression Device Removal Guidelines” with a “Created” Date of “Feb 2018” revealed “For Diagnostic cases, the TR band should be left on with appropriate compression for 1.5 hours post procedure or as ordered by Physician....Assess and document vital signs, site condition, pulse, color, temperature, sensation, capillary refill q (every) 15 x 4 (4 times), q 30 x 2 (2 times), q hr x 4 (4 times). NOTE*While the TR band is in place, an oxygen saturation probe must be placed on the patient’s thumb/pointer finger to monitor adequate hand perfusion .... REMOVAL PROCESS: 1. Once it is time to remove the TR Band, withdraw 3 ml (milliliter) of air over 1 minute observing for bleeding. Observe for additional 1 minute for bleeding after each 3 ml of air removed. Repeat every 10 minutes until band is fully deflated. Perform site condition, pulse, color, temperature sensation and capillary refill checks q 15 x 2. (In addition to post procedural vital signs) .... 2. Once TR band is completely deflated and homeostasis is maintained: Leave deflated band in place for 1 hour and continue to perform post procedure vital signs and site checks. Remove and discard TR band after 1 hour and place a protective covering (Tegaderm--clear occlusive dressing) over the radial percutaneous site. Inpatients: continue to evaluate the site for bleeding/hematoma q 15 x 4, then per unit routine. 3. The patient should be instructed not to manipulate the wrist for 48 hours.....” 2a. Closed medical record review on 09/15/2025 of Patient #17 revealed a 69-year-old female transferred from an outside facility on 06/07/2025 via EMS to be evaluated for “NSTEMI (Non ST elevation Myocardial Infarction--possible heart attack without ST elevation of the ST waves on the heart monitor) and SEPSIS.” Patient #17 was sent to the Cardiac Catheterization Lab on 06/09/2025 at 0855 and returned to the patient’s room at 0950. Review of documentation of the TR band revealed the TR band was placed on the patient at 0926. Vitals signs were documented every 15 minutes times 4 between 0945 and 1030. Assessment of the site condition, color, temperature, sensation and capillary refill was not documented every 15 minutes times four as the policy requires. Vitals signs were documented every 30 minutes times 2 at 1100 and 1130. Assessment of the site condition, color, temperature, sensation and capillary refill was not documented every 30 minutes times two as the policy requires. Vitals signs were not documented every one hour times 4 between 1230 and 1530. Vital signs due at 1330, 1430 and 1530 were not done as per the policy. Assessment of the site condition, color, temperature, sensation and capillary refill was not documented every one hour times four as the policy requires. The assessment was not documented at 1230, 1330, 1430 or 1530. Review of the removal of air from the TR Band started at 1200 with 4 milliliters (ml) of air removed (not consistent with the required 3 ml of air to be removed). There was no documentation of the observation for bleeding at the site for one minute after the air withdrawal. Three ml of air was due to be removed at 1210; however the air was removed at 1215 (not consistent with the policy); three ml of air was due to be removed at 1225; however no air was removed at 1225 (not consistent with the policy); three ml of air was due to be removed at 1235; however no air was removed at 1235 (not consistent with the policy); ); three ml of air was due to be removed at 1245; however no air was removed at 1245 (not consistent with the policy); ); three ml of air was due to be removed at 1255; however no air was removed at 1255 (not consistent with the policy); five ml of air was removed at 1300 (not consistent with the policy that requires only three ml of air to be removed). The TR Band was deflated at 1300. The policy requires the TR Band to remain in place for one hour after it is deflated with vital signs and site assessments to be assessed every 15 minutes times two. Vital signs and site checks were due at 1315 ad 1330. Review revealed the vital signs and site assessments were not done at 1315 and 1330 (not consistent with policy). Review of the record revealed no documentation of a site assessment through 2307 on 06/09/2025. Review of documentation of the TR Band revealed no documentation that an occlusive dressing on the puncture site was applied (not consistent with the policy). In summary, the vital signs and assessment of the puncture site were not completed as per policy. The TR Band was not deflated per policy. The occlusive dressing was not placed on the puncture site per policy. Interview on 09/18/2025 at 1215 with RN #2 revealed vital signs and site assessments were not done per policy. Interview revealed the deflation was not done according to the policy. Interview revealed no documentation of the occlusive dressing being placed on the puncture site. Interview revealed the policy was not followed. 2b. Open medical record review on 09/18/2025 of Patient #15 revealed a 45-year-old male admitted on 09/13/2025 for chest pain after a fall. Patient #15’s admitting diagnosis was NSTEMI, type I versus type II and ground level fall. Patient #15 was sent for a left heart cardiac catheterization on 09/15/2025 at 1508. Review of documentation of the TR band revealed the TR band was placed on the patient on 09/15/2025 at 1525. The TR Band was to remain in place one and one-half hours per policy before the air withdrawal process was to be started. The deflation was scheduled to start at 1655. Review of the record revealed the TR Band deflation was started at 1545 (20 minutes after the band was applied - not consistent with policy). Vital signs and site assessments were to be done every 15 minutes times four (due at 1525, 1540, 1555, and 1610). The patient’s vital signs were not done per policy between 1525 and 1610. The deflation started at 1545, and the patient was to have 3 ml of air removed every ten minutes until the TR Band was fully deflated per the policy. Three ml of air was due for removal at 1555, 1610 and 1620. Review revealed 3 ml of air was removed at 1600 (not consistent with policy), four ml of air was removed at 1615 (not consistent with policy). The TR Band was fully deflated at 1615. Per policy the TR Band should be left deflated for one hour (due to be removed at 1715). Per policy, vital sign assessments should be continued every 15 minutes times two. Vital signs were due at 1630 and 1645. Record review revealed vitals were documented at 1748 (not consistent with policy). The occlusive dressing was not placed on the puncture site per policy. Interview on 09/18/2025 at 1500 with RN #30 revealed the vital signs and deflation of the TR Band were not obtained according to policy. Interview revealed the occlusive dressing was not documented. Interview revealed the policy was not followed. An interview for the primary nurse was requested. An interview was not obtained.”

“CONTENT OF RECORD CFR(s): 482.24(c) The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and services. This Standard is not met as evidenced by: 34065 Based on review of policies, medical records, and interviews with staff, the provider and nursing staff failed to document during a patient’s change in condition for 1 of 1 patients who received a rapid response. (Patient #17). The findings include: Review of policy on 09/25/2025 titled “Clinical Documentation” with revision date of 07/26/2024, revealed “Purpose: A. Provides guidelines for documentation of patient care, patient data, and patient outcomes within the electronic medical record, by members of the clinical team as indicated by scope of practice....General Information: A. Clinical staff have a professional obligation to maintain documentation that is timely, clear, concise, comprehensive, and that is an accurate source of information. Clinical documentation should be: 1. Completed during or immediately after care is provided, if possible, but not to exceed end of shift. 2. Completed by the clinical team/caregivers evidenced by signature for paper documentation or login for electronic documentation. 3. Factual, accurate and objective. 4. Prefaced with date and time of care to include recording of late entries, corrections or additions. B. Documentation is patient-centered, focused, and appropriate to the setting in which care is provided. Documentation is: ...2. Based on professional observation and assessment. 3. Individualized to identify problems and actions taken. 4. Based on the patient’s current status and preferences....” Closed medical record review on 09/15/2025 of Patient #17 revealed a 69 year old female transferred from an outside facility on 06/07/2025 via EMS (Emergency Medical Services--ambulance) to be evaluated for “NSTEMI and SEPSIS (Non ST elevation Myocardial Infarction--possible heart attack without ST elevation of the ST waves on the heart monitor).” Patient arrived at ED (Emergency Department) at 1752 with complaints of nausea after a fall 2 days prior. Patient #17’s past medical history included afib (atrial fibrillation--irregular rhythm of the heart with inadequate pumping) with ablation (procedure to attempt to place the heart in normal rhythm) and hypertension. 1. Review of documentation of rapid response written by Rapid Response Nurse #29 on 06/09/2025 at 0840 revealed “Source of RRT (Rapid Response Team) Activation: Nurse request. Rapid Response Reason for Call: Staff generalized concern. Husband requested the Rapid Response team to be called--increase in ST elevation--Noted elevated fevers decreasing plt (platelet) ct (count) down to 42 on a heparin gtt (drip) po (by mouth) asa (aspirin) given..Code stemi (st elevated myocardial infarction--heart attack) called and cath Lab at bedside to take pt to cath lab--We brought the husband to the cath lab waiting area.” Review revealed no nurses notes of change in condition for Patient #17. Review revealed no nurses notes for rapid response team interventions. Interview on 09/17/2025 at 1545 with RN #25 revealed there was no documentation of change in condition or notification of the provider. Interview on 09/18/2025 at 1115 with RN #2 revealed no documentation of change in condition or notification of the provider. Interview revealed documentation was incomplete. 2. Review revealed an order written on 06/09/2025 at 0842 by NP (Nurse Practitioner) #3 for Cardiac Catheterization. Review revealed no provider notes or documentation of the change in condition of Patient #17. Review revealed no assessment from NP #3 of Patient #17. Interview on 09/18/2025 at 1550 with NP #3 revealed NP #3 may have received a phone call for concerns about the Patient #17. Interview revealed no NP documentation of the assessment of Patient #17. Interview on 09/18/2025 at 1600 with MD #1 revealed no assessment documentation from the NP was located in Patient #17’s medical record.”

“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: 50318 Based on policy review, internal document review, observation, closed medical record review, and staff interviews, the Emergency Department (ED) staff failed to ensure safe and appropriate transport and continuous pulse oximetry monitoring for a patient during transport from the ED to an inpatient unit for 1 of 12 ED patients reviewed (Patient #10). The findings include: Review of hospital policy, “Physiologic Monitoring - Cardiac Telemetry Monitoring, Continuous Pulse Oximetry Monitoring - 1PC.NRS.0001,” effective 08/19/2025, revealed, “ ... III. Transport of Monitored Patients. 1. Interruption in cardiac monitoring should not occur during transport for patients with active orders for telemetry monitoring. a. Patients with active monitoring orders should continue to be remotely monitored, and the Monitor/Telemetry Technician should be notified of unit travel, destination, primary contact for duration of travel, and anticipated time of return ...” Review of hospital policy, “Assessment and Reassessment, 1PC.ADM.0013,” effective 05/13/2025, revealed, “ ... 6. The interdisciplinary team provides information concerning patient assessment relevant to their scope of care, as well as areas of concern or patient special needs. Further assessment and reassessment is based on their plan of care or changes in their condition ... Reassessment may be at specified/regular intervals, triggered by key decision points, and at any interval(s) specified by the departments/ancillary disciplines directly involved in providing patient treatment and/or care ...” Review of hospital Guidelines for Patient Transport revealed, “ ...If a patient’s condition appears to be questionable, always let the nurse know that you are non-clinical staff and ask if they feel that it is safe for you to transport the patient ...” Observation of the ED on 09/23/2025 at 1159 revealed a patient was switched from ED telemetry monitoring to the CMU (Central Monitoring Unit) for monitoring during transport to inpatient holding. Observation revealed the portable telemetry box did not display a visual or have an audible alarm for any changes during transport. Closed medical record review on 09/17/2025 for Patient #10 revealed a 48-year-old presented to the Emergency Department (ED) on 09/04/2025 at 1441 with complaints of chest pain and shortness of breath. The patient’s pain was documented at 1442 as 8 out of 10. The Provider’s MSE (Medical Screening Exam) Note at 1445 revealed, “Patient with chest pain and shortness of breath. On home oxygen normally. chest tube in place. Patient is alert, in no acute distress but is moaning in discomfort.” The patient’s oxygen saturation (O2 sat) at 1446 was 97% and at 1500 was 90%. The ED Provider’s Note at 1534 revealed the patient had a history of metastatic lung cancer with a chest tube on the right with “chronic pain at the tube site now with worsening shortness of breath for the past day.” The patient’s O2 sat at 1630 was 92%, and the patient was placed on 3 liters of oxygen via nasal cannula. The patient’s O2 sat at 1715 was 93%. An order for Morphine (a pain medication) 4 milligrams IV (intravenous) was placed at 1729. An order was placed at 1731 for continuous pulse oximetry (measures how much oxygen is in the blood for uninterrupted periods). The patient’s O2 sat at 1745 was 89% and at 1750 was 90%. A broadcast notification was sent to the Stepdown unit at 1803 with the room number the patient was assigned to and the box number for continuous pulse oximetry. The patient’s blood pressure at 1807 was 84/57 with a comment by the Nurse that the Provider was notified at that time. The patient’s pain was assessed at 1808 as 10 out of 10. A comment was documented on the MAR (Medication Administration Report) at 1809 that Morphine was not given as the patient’s blood pressure was “too low to administer,” and the Provider was notified. The patient’s oxygen was increased to 4 liters at 1820 with an O2 sat of 94%. ED Nurse Note at 1830 revealed the patient was transported by non-clinical transport staff. The patient was on an “O2 monitor, awake and alert. Prior to patient leaving emergency department this RN (Registered Nurse) spoke with transport leadership regarding blood pressure parameters for transport personnel. Transport leadership stated, “We do not have parameters for blood pressure as long as you feel patient is stable for transport ...” The patient’s O2 sat prior to transport at 1830 was 93%. Record review failed to reveal documented evidence of the patient’s heart rate and O2 sats during transport. Record review failed to reveal documented evidence of the patient’s time of arrival to the unit and initial O2 sat. Review of a Code Record revealed a code blue (the initiation of resuscitative efforts in a cardiac or respiratory arrest) was called with initiation of CPR (cardiopulmonary resuscitation) at 1842 and initial ECG (electrocardiogram, a noninvasive test that records the electrical activity of the heart) rhythm of asystole (no heartbeat). Check boxes for the initial condition were selected as “Yes” for conscious, breathing, and pulse, as well as “Witnessed Arrest.” A check box for “Monitored” was selected “No.” The patient was intubated at 1853, and a rhythm of PEA (Pulseless Electrical Activity, a condition where the heart is still producing electrical signals, but there is no pulse or blood pressure) was noted at 1901. Discharge Summary dated 09/06/2025 at 2226 revealed the patient was admitted to a medical floor for further evaluation and management of acute respiratory failure. The patient “coded as soon as she transferred to the medical floor ...” and was pronounced dead at 1907 on 09/04/2025. Interview on 09/18/2025 at 1335 with RN #26 revealed Patient #10 was transported from the ED and was brought to their assigned room. Interview revealed Staff #7 called for help, because “something did not look right.” A Nurse in the hallway responded and hit the Staff Assist button in the room, which sent an overhead alarm and blinked red outside the room. RN #26 responded at that time and observed the patient on the stretcher, and the patient appeared to be having seizure-like activity. The patient had their head back and was convulsing. RN #26 revealed the patient was moved to the bed, a code blue was called, and chest compressions were started immediately. Interview revealed Staff #7 reported the patient had been speaking to their family member in Spanish during transport, and when they arrived to the patient’s room on the Stepdown unit, the seizure-like event occurred. Telephone interview on 09/19/2025 at 0939 revealed the Nursing staff had “huge concerns” with signal loss in the elevators for their patients on remote telemetry. Interview on 09/19/2025 at 1713 with Director #8 revealed Staff #7 reported RN #27 called the transport dispatch to ask if there were blood pressure parameters for transport and was informed there were not parameters for blood pressure. Staff #7 then transported Patient #10 to the Stepdown unit. When Staff #7 arrived to the unit, the Nurse was not in the patient’s room, so Staff #7 pressed the call bell to alert the Nurse the patient had arrived. Interview revealed Patient #10 was in pain, so Staff #7 stepped out in the hallway to ask for help and a Nurse in the hallway responded. Staff #7 informed Director #8 that Patient #10’s family was present and assisted with translation from Spanish that the patient was in pain during transport. Telephone interview on 09/22/2025 at 1422 with Staff #7 revealed Patient #10 had a family member with them at the bedside who assisted with translating from Spanish for Patient #10. Interview revealed Patient #10’s family verified the patient’s name and date of birth in English for Staff #7. Staff #7 revealed RN #27 asked if there were blood pressure parameters for transport, but Staff #7 was unaware of any parameters for blood pressure. Staff #7 called the transport dispatch, put them on speaker phone, and was informed there were not blood pressure parameters for transport. Transport dispatch informed RN #27 that the patient must be stable for non-clinical staff to transport; RN #27 checked the blood pressure again and signed off on Staff #7 transporting the patient. Staff #7 was not aware of any alarm that could be heard with the telemetry box during a patient’s transport. Staff #7 revealed when they were in the elevator, the patient was moaning in pain and spoke in Spanish to their family. The family then translated in English to Staff #7 that the patient was in pain; Staff #7 reassured the patient and family that Staff #7 would get the patient help. Interview revealed when they arrived to the Stepdown unit, the patient was still moaning in pain, and the family asked, “Can you please help? You’re a Nurse.” Staff #7 informed the family they were not a Nurse but would get the patient help. Staff #7 noticed the patient showed signs of a seizure, and the family was “frantic, asking for help.” Staff #7 pushed the Staff Assist button on the wall and stepped into the hallway for help. A Nurse approached and asked if they needed help, and then staff “were coming from everywhere into the room.” Staff #7 then stepped out into the hallway, the stretcher was pushed out of the room, and Staff #7 was informed that they could leave. Interview on 09/23/2025 at 0925 with RN #27 revealed Patient #10 had a significant other at the bedside, and RN #27 spoke in Spanish to them. RN #27 revealed the patient’s blood pressure had dropped a little, and MD #28 had ordered fluids. Interview revealed the patient’s blood pressure was not “at standard to give” Morphine. RN #27 revealed the patient was complaining of pain in the ED; RN #27 explained to the patient and their significant other that RN #27 could not give Morphine due to their blood pressure. Interview revealed the patient complained of generalized pain and stated, “everywhere hurts.” Interview revealed RN #27 called the CMU prior to Staff #7 transporting the patient to ensure the CMU could visualize Patient #10 on their O2 monitor. The CMU verified visualization and provided the patient’s heart rate and O2 sat. RN #27 did not recall the exact values but stated they were within normal limits. RN #27 revealed the telemetry boxes for transport did not have an alarm. Telephone interview on 09/23/2025 at 1313 with Tech #5 revealed they recalled RN #27 called to verify the pulse ox for Patient #10 could be visualized by the CMU prior to transport from the ED to a Stepdown unit. Interview revealed they were on the phone for a few minutes troubleshooting the pulse ox probe as there were issues with the signal going in and out. Interview revealed Wi-Fi connection issues, such as the signal cutting in and out, could occur when a patient was transported. Tech #5 revealed during Patient #10’s transport, the signal was again cutting in and out, and there was not a solid reading. Tech #5 revealed there were drops in Patient #10’s O2 sats, but they could not get a clear reading due to signal issues. Interview revealed the CMU pod was very busy that day as there were multiple patients being transferred and admitted, as well as multiple escalations at that time. Tech #5 revealed any time there were O2 sats dropping or signal loss, the monitor techs should notify the Nurse as soon as they see it with a resolution time of 5 minutes. Interview revealed the Stepdown unit was not notified that Patient #10’s pulse oximetry had signal issues, a loss of signal during transport, or drops in the patient’s O2 sats. In summary, Patient #10, a 48-year-old, presented to the Emergency Department (ED) on 09/04/2025 at 1441 with complaints of chest pain and shortness of breath. The patient experienced 10 out of 10 pain at 1808 and was unable to receive Morphine due to low blood pressure (84/57). The patient was admitted and transported to a Stepdown unit by a nonclinical transporter at 1830 with an order for continuous pulse oximeter. Findings revealed the pulse oximeter did not have continuous signal once the patient left the ED with a drop in oxygen saturation noted. The patient was moaning in pain and requesting nursing help during transport. The patient arrived to the unit, was transported to their room, observed to have seizure-like activity, and a code blue was called at 1842 (12 minutes after departing the ED). The patient expired at 1907. Emergency Department staff failed to ensure a patient with pain and shortness of breath was safe and appropriate for transport and continuously monitored prior to departing the ED. NC00233618, NC00233522, NC00233506, NC00233502, NC00233485, NC00233465, NC00233454, NC00233389, NC00233322, NC00233369, NC00233275, NC00233182, NC00233099, NC00233082, NC00233077, NC00232951, NC00231722, NC00231945, NC00231715, NC00231472”

“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: 33790 Based on policy reviews, medical record reviews, and staff and physician interviews, the hospital failed to comply with 42 CFR 489.20 and 489.24. The findings included: The hospital’s Dedicated Emergency Department (DED) failed to provide a timely appropriate Medical Screening Examination (MSE) within the capability of the hospital’s DED, including ancillary services routinely available to the DED, to prevent delay in determination of an Emergency Medical Condition (EMC) for one (1) of 21 sampled DED patients who presented to the hospital for evaluation and treatment, (Patient #41). ~ Cross refer to 489.24(a) and 489.24(c) Medical Screening Examination - Tag A 2406.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 33790 Based on policy review, medical record review, video footage review and staff interview the hospital’s DED (Dedicated Emergency Department) failed to provide a timely appropriate Medical Screening Examination (MSE) within the capability of the hospital’s DED, including ancillary services routinely available to the DED, to prevent determination of an Emergency Medical Condition (EMC) for one (1) of 21 sampled DED patients who presented to the hospital for evaluation and treatment, (Patient #41). The findings include: Review of the policy “EMTALA - Definitions and General Requirements”, effective 07/01/2024, revealed “...The hospital with an emergency department must provide to any individual....who ‘comes to the emergency department’ 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... .” Review of the DED medical record on 05/14/25 revealed Patient (Pt) # 41 was a 54 year-old male that presented to the Emergency Department on 02/10/2025 at 2250 with an arrival complaint of “SOB (shortness of breath)” Review of the Triage note at 2256 revealed “Pt presenting via EMS (emergency medical services) for COPD (chronic obstructive pulmonary disease - lung disease) exacerbation with increased work of breathing/SOB today - per EMS pt stated ‘the only thing that helps my COPD is 2 oxycodone (opioid pain medication) + (plus) 1 shot of dilaudid (opioid pain medication)’. VSS (vital signs stable). No O2 (oxygen) @ (at) baseline Hx: asthma COPD.... Ambulatory Status: Ambulatory; Triage appearance: Awake, Alert ... Triage Breathing: Unlabored; Other: tachypneic (fast breathing).... Acuity: 3-Urgent...” Vital Signs at 2258 revealed “...Temperature Fahrenheit: 97.3... Heart Rate: 164... Respiratory Rate: 28... Systolic Blood Pressure: 118... Diastolic Blood Pressure: 76...” Review of the Provider note dated 02/11/2025 at 0014 revealed “Chief Complaint: RESPIRATORY DIFFICULTY.... History of Present Illness 54-year-old with AML (acute myeloid leukemia -cancer that affects blood and bone marrow), non-Hodgkin’s lymphoma (cancer in the lymphatic system), COPD (chronic obstructive pulmonary disease) who presented with shortness of breath and went into cardiac arrest while in the ER waiting room. Per documentation the patient was triaged at 2256. While in the waiting room he went to the bathroom, subsequently was found unresponsive and pulseless in the bathroom.... He was brought back to the resuscitation area where I am working and at that point I assumed care of the patient at 2348....Medical Decision Making... 54-year-old ....who presented with shortness of breath by ambulance and was initially placed in the waiting room. I make note that the EMS run sheet recorded heart rate of 76, while the triage vital signs in the ER (emergency room) note heart rate 164 and respiratory rate 28. While in the waiting room the patient went to the bathroom and subsequently was found in cardiac arrest. CPR (cardiopulmonary resuscitation - emergency life saving procedure) was initiated and the patient was brought back to the ER critical care area... proceeded with standard ACLS (advanced cardiovascular life support)... patient was intubated for airway protection....He was given multiple rounds of epinephrine (medication to treat low blood pressure) as well as bicarb (medication used to regulate body acidity and basicity). Initial rhythm of asystole (complete cessation of electrical activity of the heart), subsequently PEA (pulseless electrical activity - abnormal heart rhythm where the electrical activity in the heart is too weak to maintain a heartbeat or pump blood through the body) and eventually ROSC (return of spontaneous circulation - return of a sustained heart rhythm that perfuses the body) was achieved several times. After his initial episode of ROSC he had several episodes of V-fib (ventricular fibrillation) and also ventricular tachycardia (abnormal heart rhythms).... ABG (arterial blood gas) demonstrated severely elevated potassium. He was given 2 g (grams) IV (intravenous) calcium, numerous boluses of bicarb. He was started on norepinephrine (used to treat life-threatening low blood pressure), amiodarone (medication that prevents and treats arrhythmia), Neo-Synephrine (drug used to treat low blood pressure). Ultimately after more than an hour of attempted resuscitation resulting in recurrent cardiac arrest the resuscitation was terminated at 0056.... Likely etiology of his arrest is multifactorial including hypoxic respiratory failure, hypokalemia.... Diagnosis/Disposition 1. Cardiac arrest 2. Hyperkalemia 3. Shortness of breath 4. Respiratory failure... “ Review of video footage from the ED waiting area on 05/15/2025 revealed on 02/10/2025 at 2301, Patient #41 was taken to the bathroom in the ED waiting room via wheelchair from the triage area (noted by staff during video review). At 2310, the bathroom light started blinking and at 2319, an Environmental Services (EVS) staff attempted to enter the bathroom, but did not appear to look up to see the blinking light or go inside the bathroom. An ED staff member was noted adjacent to the bathroom on a computer at 2325 but did not appear to acknowledge the blinking light. At 2329, another staff member took a different patient to a bathroom located beside the bathroom where the light was blinking. No acknowledgement of the blinking call light was observed. At 2333 an EVS staff member knocked on the door to the bathroom with the blinking light and appeared to attempt to open the door. At 2335, two staff members were observed in the area of the blinking light bathroom but did not appear to note or acknowledge the blinking light. At 2339 a female staff member knocked and opened the door of the bathroom with the blinking light. A male staff at the same bathroom runs out of the bathroom area. The female rolled the patient out of the bathroom into the IPA area via wheelchair and male staff brought a stretcher. Two other staff members presented and assisted with getting the patient placed on the stretcher and chest compressions were observed. At 2340, the patient was rolled out of the camera view. In summary, Patient #41 arrived to the hospital by EMS on 02/10/2025 at 2250 with a chief complaint of shortness of breath. Patient #41 was taken to triage. Triage vital signs at 2256 were temperature 97.3, heart rate 164, respirations 28 and blood pressure of 118/76. Although the heart rate was noted as 164 and respirations 28, documentation indicated “VSS” (vital signs stable) and Patient #41 was assigned an acuity of 3 (acuity range 1-5 with 1 being most severe). Per video review, Patient #41 was wheeled into a waiting room bathroom at 2301 and left alone. A call system inside the bathroom was activated at 2310 (per video observation of a blinking light above the bathroom door). No one entered the bathroom over the next 8 minutes. At 2319 per video a staff member, noted as EVS staff, opened the door, then closed it without entering the bathroom. Video review indicated at 2339 another staff member knocked, opened the bathroom door, entered, wheeled the patient out of the bathroom and into the IPA area where Patient #41 was placed on a stretcher and CPR began. Per video review and staff interview during the review, the bathroom was not entered until 29 minutes after the call light was activated, and when found the patient was slumped over in the wheelchair unresponsive. CPR was performed but the patient subsequently expired. Record and video review revealed the 50-year-old patient with a history of COPD and unstable vital signs (pulse 164, respirations 28) was placed in a waiting room bathroom unattended for 29 minutes and found unresponsive. Patient #41 needed continuous monitoring, an EKG within 10 minutes, evaluation by a clinician and blood work and chest x-ray shortly thereafter. Instead, Patient #41 was found unresponsive and in cardiac arrest in a waiting room bathroom at 2339. Review revealed a delay in medical screening. A meeting was held on 05/15/2025 at 1530 with hospital staff to discuss this event, the root cause analysis and actions taken. A review of the case indicated Patient #41 arrived via EMS to the ambulance bay and was determined stable enough to go to the triage area for triage. Per staff, vital signs from EMS included pulse of 74, respirations of 18. Hospital triage vital signs at 2254 included a pulse of 164 and respirations of 28. The patient’s chief complaint was noted as respiratory difficulty, with increased work of breathing and shortness of breath. A triage ESI (acuity) of 3 was assigned. The patient demanded to go to the bathroom before further care, including having the EKG, and was wheeled to the bathroom and then left alone. Review of the root cause analysis performed revealed concerns arose with delay in response and triage acuity designation. Per discussion, the hospital reported the event to the accrediting and state agencies. Action items around the level 3 ESI designation included additional triage education and monitoring of ESI designation for the triage nurse. Additionally, 70 audits of ESI levels per month were started and are ongoing across all staff to review ESI determinations; if or when a fall-out is found, real time education occurs. The root cause analysis also found delayed response to the call light. The hospital reviewed the video and interviewed involved staff. Issues were identified that included that the audible could not be heard in the waiting room bathroom vicinity, the call alarm was silenced at the remote call system location after it was initially answered, there was no clearly identified person who was to respond and the call light above the bathroom door was on but not noted by several staff. Multiple actions were taken. The staff member who answered the call button and silenced the alarm was disciplined and no longer works at the hospital. Changes were made that the remote alarm could not be silenced until a confirmed response was received that the patient’s light was answered. Audible alarms were added out front in the waiting room area. Additional lights were added for better visualization. A staff member is now formally assigned each shift to cover the waiting room bathrooms for clear designated responsibility. If that individual cannot immediately respond when a bathroom call light is triggered, they are to hand-off to another clearly designated person with required closed loop communication on who is responding. Discussion revealed a daily 9:00 am quality call to ensure oversight of the IPA (internal processing area in waiting room) bathrooms. Lastly, unannounced drills were put in place and are ongoing to ensure the changes have been consistently implemented and are working.”

“ORGANIZATION AND DIRECTION CFR(s): 482.55(a) Organization and Direction. If emergency services are provided at the hospital -- This Standard is not met as evidenced by: 33790 Based on policy reviews, medical record reviews and hospital interviews, the hospital failed to have organized emergency services by failing to have systems in place to prevent an IVC (Involuntary Committed) behavioral health inpatient transported to the emergency department from eloping for 1 of 32 ED records reviewed (Pt #7) The findings include: Review of the policy titled “Triage - Emergency Department...”, dated 07/05/2023, revealed “...The dynamic process of sorting, prioritizing, and assessing the patient...performed by a qualified RN (registered nurse) at the time of presentation....Reassessment - A process of periodic re-evaluation of the patient’s condition....Behavioral health patients: A comprehensive triage assessment should be completed after establishing safe environment for the patient. ...” . Review of the DED (dedicated emergency department) record for Patient #7, on 08/07/2024, revealed Patient #7 was transported from Hospital A’s inpatient behavioral health campus (Campus B) to the main campus (Campus A)’s DED. Review of the Transport Services Patient Care Record revealed they were dispatched for a patient with complaints of “breathing problem.” Review of the Transport Services Narrative noted “ ...When we arrived on scene ...nursing staff ...informed us that the pt was having difficulty breathing and needed to be placed on O2 (oxygen) to keep sats (oxygen saturation) up. Vitals were taken and were within normal range besides her SPO2 (oxygen saturation). Pt has behavioral health history and was taking medication for this ....Pt was transported w/o (without) incident. When we arrived at destination transfer of care was given to nursing staff at ED. ...” Review of Involuntary Commitment paperwork, dated 12/11/2024 at 1230, revealed a second examination which indicated Patient #7 needed inpatient commitment for 14 days due to “ ...suicidal ideation with a plan and means ....high risk of suicide w/out acute inpatient admission and has 3 previous attempts. ...” Review of the ED Triage Note performed 05/22/2024 at 1230 revealed Patient #7 received an acuity of 2 (on a scale of 1-5 with 1 being most severe). Vital signs were: Temperature 98.3, Pulse 84, Respirations 25, Blood Pressure 132/61, with an oxygen saturation of 98% on 3 liters oxygen and a pain score of 4. Triage Note review further revealed “ ...Mental Health Status - ED Triage ...Assess CSSRS (Columbia Scale Suicide Risk Screening - tool used for suicide screening)? : Patient with no chief BH complaint. ...” Review failed to reveal if the triage nurse was aware of Patient #7’s IVC status. Review of the provider’s “ER Report” note, dated 05/22/2024 at 1435, revealed “ ...This is a 58-year-old female who is brought into the emergency room via EMS secondary to nausea, vomiting and concern for possible aspiration pneumonia with report of O2 saturations being 84% on room air and increasing to 99% on 2 L (2 liters oxygen). The patient undergoes electronic shock therapy treatment and states she has tolerated well up until today. She states that she has felt nauseated and had intermittent episodes of vomiting today. She also reports a mild headache. She did not have symptoms like this after her other electronic shock therapy sessions. She has no complaints of photophobia, difficulty with speech or swallowing or difficulty with ambulating .... She does have behavioral health records which I have reviewed. On reviewing the patient’s ECT (electroconvulsive Therapy) procedure note, the patient apparently became very nauseous and vomited approximately 700 mL. The anesthesiologist decided to cancel the procedure and infused 1 L (liter) of lactated Ringer’s as well as 4 mg (milligrams) of IV (intravenous) Zofran (medication for nausea). Patient apparently did improve, but O2 sats were documented to be in the upper 70s .... upper 80s on room air. Patient was placed onto 2 L via nasal cannula and opt for sending the patient to the ER ....Here in the ED the patient stated that she just feels nauseated and not quite herself. She does confirm a mild headache as well .... Assessment/Plan ....concerned about possible aspiration pneumonia, given the report. I have requested for a portable chest x-ray, laboratory studies and I am going to get a CT scan of the head to evaluate her headache. Urinalysis and urine drug screen have both been ordered as well. Patient will receive antiemetics (medication for nausea) and fluids. Reexamination/ Reevaluation ....Patient’s laboratory studies showed a slightly low sodium at 132 and slightly elevated liver function tests, calcium corrected was just minimally low. CBC (complete blood count) is normal. CT scan of head showed no significant abnormality and our portable chest ray (sic x-ray) showed no significant abnormality. (space) I was made aware by nursing staff that the patient actually got up and left the emergency department with an IV in. I went out to the parking lot with nursing staff to try and convince the patient to come back in, she ripped her IV out and left. My recommendations are for the patient to be brought back into the emergency department for continued workup and evaluation. ...” A Nurses Note, at 1627, revealed “ ...The patient left ED room 54 with her husband by her side, (Nurse Name) RN and Doctor followed patient outside, IV was removed in the parking lot. The patient refused to come back into the ED, the patient and her spouse drove away in their private vehicle. ...” Another Nurse Note at 2013 indicated “This ED manager spoke with patient and her husband via phone call to follow up after they abruptly departed the ER this afternoon. Patient states she was well and had taken a shower and was relaxing on her couch. I expressed concern for patient not completing treatment and requested, if she was willing, we would like her to return to finish her workup. Patient stated that she would ‘never come back to this hospital because we never let patients leave.’ Patient continued to express that she was fine and if she needed treatment would seek it elsewhere.” A Mental Health Contact Note, on 05/22/2024 at 2158, revealed “ ...Received call from (Officer Name) @1800 who reports that she was informed by (Campus B) staff that pt had gone to ED due to medical issue and then left the ED without returning to (Campus B). She reports that they have said that the pt needs to return to (Campus B), but they are unsure regarding her IVC status. They are unable to determine from pt’s EMR (electronic medical record), and the paper chart was sent to ED with pt per protocol .... request assistance with locating pt’s paper chart in ED....Eventually spoke with EDMD (Name) @1945 and she was able to locate pt’s paper chart. Review of papers indicates that pt is on IVC.... Spoke with .... AOC (administrator on call at (Campus B) @2000 who reports that ....treating psychiatrist ....said that pt needs to be brought back under IVC. AOC requests that ....Magistrate be contacted for direction regarding how to proceed ... Contacted ....Sheriff Dept explaining the situation and requesting a return call from the magistrate .... Received call @2120 ....(Magistrate) directs me to fax all of the IVC to the ...County Detention Center and states....will contact the sheriff to have them pick up pt to return to (Hospital A Name) ....Spoke with Detention Center staff again @2230 and they report that deputy is on the way to pt’s residence at this time. ...” Review of a Mental Health Contact Note from 05/23/2024 at 0029 revealed “ ...Contacted .... Sheriff Dept for an update ....reports they went to pt’s home earlier and no one came to the door. He reports that they have not been able to check again as they have had other calls to work. ...” DED record review did not reveal any additional notes in the ED record related to Patient #7’s return. Telephone interview with MD #14, on 08/08/2024 at 1240, revealed MD #14 recalled the situation involving Patient #7 very well. Interview revealed the patient came in the low oxygen levels and they were concerned for possible aspiration pneumonia. Interview revealed MD #14 evaluated Patient #7. MD #14 stated when Patient #7 was evaluated, the MD could tell she was not feeling well and the patient was complaining of a headache. Interview revealed MD #14 got labs and a CT and then went to check on the patient. MD #14 indicated she was getting ready to go back into Pt #7’s room when the nursing staff stated the patient was not in the room. MD #14 stated “I said she can’t leave.” Interview revealed MD #14 literally ran to the parking lot to try and get the patient to come back in. Patient was there, tore out her IV, threw it on the ground and kept going. MD #14 said she tried to convince the patient to come back in and finish treatment, but Patient #7 said “no, you’re trying to kill me”, but then said “I know you’re not but its taking too long.” MD #14 said she explained to Patient #7, that they needed to observe her and check on some things. Interview revealed it was not working, the patient seemed determined to leave. MD #14 went back into the ED but explained to the Social Worker she couldn’t get Patient #7 to come back in but Pt#7 needed to stay, couldn’t leave. She had an abnormal workup and was sent from behavioral health. Interview revealed MD #14 knew Patient #14 arrived from Campus B, but did not recall knowing if there was an IVC. MD #14 said she was concerned for the patient medically, she had low sats and possible aspiration pneumonia and needed to complete the work-up. The Social Worker, per interview, said she would continue to investigate. MD #14 stated Patient #7 did not come back on her shift. Request to interview the nurse (RN #20) involved with Patient #7 in the ED, revealed the nurse was no longer at the hospital and thus not available. Interview on 08/08/2024 at 1645 with three leaders from Campus B, Administrative Staff (AS) #1, AS #2, and Supervisor#3, revealed that prior to transport of Patient #7 from Campus B to the ED at Campus A, Supervisor #3 called the Charge Nurse at the ED, explained there was concern for aspiration and the patient needed to be evaluated by a physician, then either be returned to Campus B or be admitted as an inpatient for medical care at Campus A. Interview revealed it was reported the patient was IVC. Interview revealed a call was later made from the ED to AS#1 that Patient #7 had eloped. AS#1, per interview, then called the Medical Director who indicated Patient #7 was not ok to be discharged. The patient’s home county magistrate was notified and Patient #7 was picked up. Interview revealed because Pt #7 lived in a different county the patient was taken to Hospital E for medical screening and clearance. Patient #7 then returned to Campus B and was later discharged home. Interview revealed that since this event there were actions taken to try and prevent this from occuring again. NC00220198, NC00220215, NC00220167, NC00220241”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 16369 Based on policy review, Quality Performance Improvement Plan review, medical record review, Emergency Medical Services (EMS) trip report review, incident report review, observations, environmental risk assessment review, pharmacy unit inspection review, personnel file review, hospital document review and staff and provider interviews, the hospital’s governing body failed to provide oversight and have systems in place to ensure the protection and promotion of patient’s rights to ensure a safe environment for emergency department patients; failed to maintain an organized and effective quality assessment and improvement program; failed to have an organized nursing service to meet patient care and safety needs and failed to meet the emergency needs of patients. The findings included: 1. The hospital’s leadership failed to ensure a medical provider was responsible for monitoring and ensuring the delivery of care to patients presenting to the emergency department. Nursing staff failed to provide care to emergency department (ED) patients by failing to triage upon arrival, assess, monitor, and provide care and treatment as ordered for 11 of 35 ED records reviewed (#92, #83, #43, #28, #27, #29, #6, #1, #2, #12 and #26). Cross refer to §482.12 Governing Body Standard: Tag A 0068. 2. The hospital’s leadership failed to ensure emergency care and services were provided according to policy and provider orders by failing to accept patients upon arrival to the emergency department, evaluate, monitor and provide treatment to emergency department patients to prevent delays and/or lack of triage, nursing assessment, and implementation of orders, including lab, telemetry and medication orders for 11 of 35 ED records reviewed (#92, #83, #43, #28, #27, #29, #6, #1, #2, #12 and #26). Cross refer to §482.12 Governing Body Standard: Tag A 0092. 3. The hospital staff failed to ensure a safe environment for behavioral health patients subject to self-harm in the ED by failing to limit environmental risks in the Emergency Room pods (cluster of rooms in a designated area) used to house Behavioral Health patients awaiting placement (Green Pod and Purple Pod). Cross refer to §482.13 Patient Rights’ Standard: Tag A 0144. 4. The hospital staff failed to ensure tracking and trending of medical errors by failing to document incidents for improvement opportunities and failing to investigate potential causes and identify corrective action for 7 of 94 sampled patients reviewed (#58, #27, #59, #50, #13, #50, #2). Cross refer to §482.21 Standard: QAPI Quality Improvement Activities, Tag A 0286. 5. The hospital’s leadership failed to provide oversight and responsibility of the quality improvement program to ensure medical errors were tracked and trended, failed to document incidents for improvement opportunities and failed to investigate potential causes and identify corrective action for 7 of 94 sampled patients reviewed. (#58, #27, #59, #50, #15, #13 and #2). Cross refer to §482.21 Standard: QAPI Standard: Tag A 0309. 6. The hospital’s emergency department staff failed to ensure adequate nursing staff was available to provide and monitor the delivery of assessments, care, and treatment in the emergency department for 4 of 35 sampled ED records reviewed (Patients #28, #43, #27, and #2). Cross refer to 482.23 Nursing Standard: Tag A 0392. 7. The hospital’s nursing leadership staff failed to ensure policies were implemented to evaluate, monitor and provide treatment for patients presenting to the emergency department resulting in delays and lack of triage, nursing assessment, monitoring, and implementation of lab, telemetry, medication and treatment orders for 11 of 35 ED records reviewed (#92, #83, #43, #28, #27, #29, #6, #1, #2, #12 and #26). Cross refer to §482.23 Nursing Standard: Tag A 0398. 8. The hospital nursing staff failed to administer medications and biologicals according to provider orders and standards of practice by failing to administer medications as ordered and evaluate and monitor the effects of the medication for 6 of 35 patients presenting to the emergency department (#92, #83, #43, #28, #27, and #26). Cross refer to §482.23 Nursing Standard: Tag A 0405. 9. The hospital staff failed to have available laboratory services to meet the identified turn around times for STAT results for 3 of 35 patients presenting to the hospital’s emergency department (#83, #27, #2), and failed to ensure timely laboratory results for 3 of 3 patients that had lab specimens sent to Hospital A’s lab from Hospital B (#11, #93 and #94). Cross refer to §482.27 Laboratory Services Standard: Tag A 0583. 10. Emergency department (ED) nursing staff failed to ensure emergency care and services were provided according to policy and provider orders by failing to accept patient upon arrival to the ED, evaluate, monitor and provide treatment to emergency department patients to prevent delays and/or lack of triage, nursing assessment, and implementation of orders, including lab, telemetry and medication orders for 11 of 35 ED records reviewed (#92, #83, #43, #28, #27, #29, #6, #1, #2, #12 and #26). Cross refer to §482.55: Emergency Services Standard Tag A 1101.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 16369 Based on policy review, medical record review, Emergency Medical Services (EMS) trip report review, incident report review, observations, environmental risk assessment review and staff and provider interviews, the hospital staff failed to promote and protect patient’s rights by failing to provide a safe environment to Emergency Department patients and failed to obtain authorization for psychotropic and nonpsychotropic medicinal interventions. The findings included: The hospital staff failed to ensure a safe environment for behavioral health patients subject to self-harm in the ED by failing to limit environmental risks in the Emergency Room pods (cluster of rooms in a designated area) used to house Behavioral Health patients awaiting placement (Green Pod and Purple Pod). Cross refer to 482.13 Patient Rights’ Standard: Tag A 0144. The hospital nursing staff failed to obtain authorization for psychotropic and nonpsychotropic medicinal interventions for 1 of 4 sampled pediatric behavioral health patient records reviewed (Patient #75). Cross refer to 482.13 Patient Rights’ Standard: Tag A 0131.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 16369 Based on policy review, Quality Performance Improvement Plan review, medical record review, incident report reviews, pharmacy unit inspection review, and staff interviews, hospital leadership failed to ensure adverse events were documented, tracked, trended, and analyzed in order to implement preventive actions and identify success of actions taken. The findings included: 1. The hospital staff failed to ensure tracking and trending of medical errors by failing to document incidents for improvement opportunities and failing to investigate potential causes and identify corrective action for seven (7) of 94 sampled patient records reviewed. (Patient #’s 58, 27, 59, 50, 15, 13, and 2). Cross refer to §482.21 Standard: QAPI Quality Improvement Activities: Tag A 0286. 2. The hospital’s leadership failed to provide oversight and responsibility of the quality improvement program to ensure medical errors were tracked and trended, failed to document incidents for improvement opportunities and failed to investigate potential causes and identify corrective action for 7 of 94 sampled patients reviewed. (Patient #’s 58, 27, 59, 50, 15, 13 and and 2). Cross refer to §482.21 Standard: QAPI Quality Improvement Activities: Tag A 0309.”

“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: 16369 Based on policy review, medical record review, incident report review, EMS trip report review, and staff and provider interviews, the hospital’s nursing staff failed to have an effective nursing service providing oversight of day to day operations by failing to ensure systems were in place to supervise and provide safe delivery of care to patients presenting to the emergency department (ED). The findings included: 1. The hospital’s emergency department staff failed to ensure adequate nursing staff was available to provide and monitor the delivery of assessments, care, and treatments in the emergency department for 4 of 35 sampled ED records reviewed (Patient #’s 28, 43, 27, and 2). Cross refer to 482.23 Nursing Standard: Tag A 0392. 1. The hospital nursing leadership staff failed to ensure policies were implemented to evaluate, monitor and provide treatment for patients presenting to the emergency department resulting in delays and lack of triage, nursing assessment, monitoring, and implementation of lab, telemetry, medication and treatment orders for 11 of 35 ED records reviewed (Patient #’s 92, 83, 43, 28, 27, 29, 6, 1, 2, 12 and 26). Cross refer to 482.23 Nursing Standard: Tag A 0398. 2. The hospital nursing staff failed to administer medications and biologicals according to provider orders and standards of practice by failing to administer medications as ordered and evaluate and monitor the effects of the medication for six (6) of 35 patients presenting to the emergency department (Patient #’s 92, 83, 43, 28, 27, and 26). Cross refer to 482.23 Nursing Standard: Tag A 0405.”

“LABORATORY SERVICES CFR(s): 482.27 The hospital must maintain, or have available, adequate laboratory services to meet the needs of its patients. The hospital must ensure that all laboratory services provided to its patients are performed in a facility certified in accordance with Part 493 of this chapter. This Condition is not met as evidenced by: 33790 Based on policy review, medical record reviews, and staff interviews the hospital failed to have available, adequate laboratory services to meet the needs of patients for three (3) of 35 patients presenting to the hospital’s Emergency Department (ED) (Patient #’s 83, 27 and 2) and failed to ensure laboratory results were timely for three (3) of three (3) patients (Patient #’s 11, 93, and 94). The findings included: The hospital failed to have available laboratory services to meet the identified turn around times for STAT results for three (3) of 35 patients presenting to the hospital’s emergency department (Patient #’s 83, 27, and 2), and failed to ensure timely laboratory results for three (3) of 3 patients that had lab specimens sent to Hospital A’s lab from Hospital B (Patient #’s 11, 93 and 94). Cross refer to §482.27 Laboratory Services Standard: Tag A 0583.”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 16369 Based on policy review, medical record review, incident report review, Emergency Medical Services (EMS) trip report review, and staff and provider interviews, the hospital staff failed to have effective emergency services to meet the needs of patients that presented to the Emergency Department. The findings included: Emergency Department (ED) nursing staff failed to ensure emergency care and services were provided according to policy and provider orders by failing to accept patient upon arrival to the ED, evaluate, monitor and provide treatment to emergency department patients to prevent delays and/or lack of triage, nursing assessment, and implementation of orders, including lab, telemetry and medication orders for eleven (11) of 35 patient records reviewed (Patient #’s 92, 83, 43, 28, 27, 29, 6, 1, 2, 12 and 26). Cross refer to §482.55 Emergency Services Standard: Tag 1101.”

“CARE OF PATIENTS - RESPONSIBILITY FOR CARE CFR(s): 482.12(c)(4) [ ...the governing body must ensure that the following requirements are met:] A doctor of medicine or osteopathy is responsible for the care of each Medicare patient with respect to any medical or psychiatric problem that-- (i) Is present on admission or develops during hospitalization; and (ii) Is not specifically within the scope of practice of a doctor of dental surgery, dental medicine, podiatric medicine, or optometry; a chiropractor; or clinical psychologist, as that scope is-- (A) Defined by the medical staff; (B) Permitted by State law; and (C) Limited, under paragraph (c)(1)(v) of this section, with respect to chiropractors. This Standard is not met as evidenced by: 16369 Based on policy review, medical record review, Emergency Medical Services (EMS) trip report review, incident report review, and staff and provider interviews, the hospital’s leadership failed to ensure a medical provider was responsible for monitoring and ensuring the delivery of care to patients presenting to the emergency department. Nursing staff failed to provide care to emergency department (ED) patients by failing to triage upon arrival, assess, monitor, and provide care and treatment as ordered for 11 of 35 ED records reviewed (#92, #83, #43, #28, #27, #29, #6, #1, #2, #12 and #26). The findings included: Review of the Quality Improvement Plan approved by the hospital Chief Executive Officer (CEO), Board of Trustees Chair and Chief Medical Officer (CMO) on 04/24/2023 revealed, “ ...The hospital-wide Performance Improvement Plan is designed to improve quality performance and patient safety, ultimately reducing the risk to patients. ... ACCOUNTABILITY ... The following individual and/or committees are accountable for setting expectations, developing plans, and implementing procedures to assess, improve quality, and measure performance improvement within the organization. ... Medical Executive Committee ... Medical Staff / Medical Staff Department Chairman. The Medical staff shall be responsible to participate in the Performance Improvement Plan to the degree necessary and appropriate to achieve the purpose of the plan. Medical Staff members will be appointed to various Medical Staff Committees. These committees shall be responsible for implementing and maintaining an effective system to monitor and evaluate the quality and appropriateness of care ... The medical staff department chairs will participate in the Campus Executive Committee or Medical Executive Committee, as applicable. Participation will include monitoring metrics, developing criteria, evaluating results, ensuring resolution, and reporting findings to the appropriate medical staff department. ...” Review on 12/06/2023 of the hospital policy “Triage - Emergency Department 1PC.ED.0401” revised 07/2023 revealed, “...DEFINITIONS: ... A. Triage Assessment: The dynamic process of sorting, prioritizing, and assessing the patient and is performed by a qualified RN (Registered Nurse) at the time of presentation and before registration. This is a focused assessment based on the patient’s chief complaint and consists of information, which is obtained that would enable the Triage RN to determine minimal acuity. A rapid or comprehensive triage assessment is completed, with a goal of 10 minutes, on arrival to the emergency department. 1. A rapid triage assessment is composed of airway, breathing, circulation and disability, general appearance, eliciting symptom driven presenting complaint(s), and any pertinent objective and subjective data/assessment from the patient or parent or caregiver. 2. A comprehensive assessment, performed on each patient that presents to the emergency department, is a focused physical assessment including vital signs, pain scale, allergy, history of current complaint, current medications, exposure to infectious disease, and pertinent past medical/surgical history. ... B. Triage Acuity Level - The Emergency Severity Index (ESI) is a five level emergency department (ED) triage algorithm that provides clinically relevant stratification of patients into five groups from 1 (most urgent) to 5 (least urgent) on the basis of acuity and resource needs. C. Reassessment - A process of periodic re-evaluation of the patient’s condition and symptoms prior to and during the initiation of treatment. Reassessment components may include some or all of the following: vital signs, a focused physical assessment, pain assessment, general appearance, and/or responses to interventions and treatments. Reassessment after the medical screening exam are performed by RN’s (Registered Nurses) according to acuity or change in patient’s condition. D. Vital Signs - Helps nursing personnel determine the stability of patients and acuity of those that are that are presenting with life-threatening situations or who are in high-risk categories. Usually refers to temperature, pulse rate, respiratory rate, and blood pressure. May include pulse oximetry for patients presenting with respiratory and/or hemodynamic compromise, and pain scale for those patients with pain as a component to their presenting complaint...PROCEDURE: ...B. All patients presenting for care will be evaluated by an RN. This RN should complete a brief evaluation of the patient, including immediate compromise to a patient’s airway, breathing, or circulation.... H. If there is no bed available, the patient will need to wait in the lobby. While in the lobby, patient reassessment and vital signs should be documented in the health record in accordance with documentation guidelines. ...” Review on 12/09/2023 of the “Assessment and Reassessment” policy revised 06/2021 revealed, “... PURPOSE: A. The goal of the assessment/reassessment is to provide the patient the best care and treatment possible ... The nursing process is utilized in order to achieve this goal. This process includes assessing, analyzing, planning, implementing, and evaluating patient care or treatment. ... DEFINITIONS: A. Assessment: The multidisciplinary assessment process for each patient begins at the point where the patient enters a (facility name) facility for care, and in response to changes in the patient’s condition. ... The assessment will include systematic collection and review of patient-specific data necessary to determine patient care and treatment needs. B. Reassessment: The reassessment process is ongoing and is also performed when there is a significant change in the patient’s condition or diagnosis and in response to care. ... SECTION VI: EMERGENCY DEPARTMENT: A. Patients should be triaged following guidelines set forth in the system Triage Policy (1PC.ED.0401), including documentation of required elements within the electronic medical record (e.g. Vital signs, Glasgow Coma Scale (GCS)). B. The priority of data is determined by the patient’s immediate condition. On arrival to unit, an initial assessment is initiated, and immediate life-threatening needs are determined with appropriate interventions implemented. C. Patient assessment should be performed based on the developmental, psychosocial, physiological, and age-specific needs of the individual. D. Focused patient history and physical assessment are based on patient’s presenting problem(s) including individual indicators of vulnerability. E. Reassessment: 1. Reassessment is ongoing and may be triggered by key decision points and at intervals based on the needs of the patients. Additional assessment/reassessment elements and frequency are based upon patient condition or change in condition, diagnosis, and/or patient history, not to exceed four hours. Interventions may warrant more frequent assessments....” 1. Closed medical record review on 12/09/2023 of Patient #92 revealed a 69 year-old male that presented to the emergency department on 11/09/2023 at 1149 via private vehicle with a chief complaint of chest pain. The patient was triaged at 1155 with a chief complaint of “Woken from sleep at 0400 with midsternal chest pain, described as sharp and pressure. No SOB (shortness of breath), arm/jaw/back pain, or diaphoresis (sweating). H/o (history of) colon CA (cancer) with mets (metastasis) to the lung, currently on chemotherapy....” Review revealed vital signs of blood pressure (BP) 125/60, pulse (P) 57, temperature (T) 97.4 degrees Fahrenheit, oxygen saturation (O2 Sat) 97% and a pain level reported as 2 (scale 1-10 with 10 the worst). Review revealed a triage level of 2 (level 1 most urgent). Review revealed a Medical Screening Examination by a physician was started in the waiting room area at 1209. Review of the physician’s notes recorded the patient’s chest pain had been waxing and waning, coming in waves and lasting about five minutes at a time. Review revealed a plan to conduct an ED chest pain work-up including a chest x-ray, EKG and labs including CBC, chemistry, lipase and troponin, and administer a dose of aspirin. Review recorded a differential diagnosis of GERD (gastroesophageal reflux disease), referred abdominal pain, musculoskeletal chest pain, ACS (acute coronary syndrome), with lower suspicion for PE (pulmonary embolus) given no tachycardia, hypotension, or evidence of DVT (deep vein thrombosis) on exam. Review revealed the ED physician recommended admission for further chest pain workup based on risk factors. Review of physician’s orders revealed labs were ordered at 1218, collected at 1320 and resulted at 1332. Review revealed a troponin result of 0.013 (normal). Review revealed a physician’s order placed at 1218 for continuous ECG (telemetry) monitoring in the ED. Review of the ED record revealed no evidence that continuous ECG monitoring was initiated in the ED. A chest x-ray was ordered at 1220 and resulted at 1246 with normal results. An EKG was completed at 1224 which showed sinus rhythm with premature atrial complexes (PACs), with no changes when compared with a prior EKG done in 2022 per the physician’s read. A troponin resulted at 1320 as 0.013 (normal) and a baby aspirin was administered as ordered at 1334. A second troponin ordered at 1607 and resulted at 1704 as 0.014 (normal). Review of a second EKG completed at 1628 revealed “Sinus rhythm with premature atrial complexes (PACs). Otherwise normal ECG. When compared with ECG of 09-Nov-2023 12:24, Non-specific change in ST segment in inferior leads. ST elevation now present in Lateral leads.” Review recorded the ECG was confirmed by a physician on 11/09/2023 at 1821. Review revealed a physician’s order at 1659 for nitroglycerine 0.4 milligrams (mg) sublingual every five minutes times three as needed (prn) chest pain. Record review revealed no nursing assessment/reassessment documented after the patient’s triage was recorded at 1155. The patient was administered Morphine (narcotic pain medication) 2 milligrams intravenously (IV) at 1703 by a medic for a pain level of 4. There was no reassessment of the patient’s pain and no documentation of the patient’s condition by a nurse. The patient was moved from the waiting room to a bed in the orange pod (admission holding area of the ED) at 1937. Nitroglycerine 0.4 milligrams sublingual was administered by a nurse times one for a pain level of 10 at 2013. Review revealed no reassessment of the patient’s response to the medication intervention and no nursing assessment of the patient’s condition was documented. The patient was transported from the ED to a medical surgical floor on 11/09/2023 at 2054. The patient was placed on continuous telemetry at 2111 when he was noted to be in Atrial Fibrillation with Rapid Ventricular Rate (abnormal heart rhythm). Review of the ECG completed at 2110 recorded an “ST elevation consider lateral injury or acute infarct ** ** ACUTE MI / STEMI (myocardial infarction or heart attack) ** ** ...”. Review of a Cardiovascular Consult History and Physical documented on 11/10/2023 at 0020 as an Addendum revealed the patient “... went into AF/RVR (Atrial Fibrillation with Rapid Ventricular Rate) at 2110 hrs this evening with ECG demonstrating evolving high lateral STEMI (l, aVL) which was more pronounced on follow-up ECG at 2210 hrs prompting formal STEMI activation for emergent cardiac catheterization. ...” Review of a Discharge Summary dated 11/13/2023 at 1211 revealed the patient was discharged home on 11/13/2023 with a diagnosis of STEMI (ST elevation myocardial infarction), Coronary Artery Disease, Hypertension, and Atrial Fibrillation with RVR. Interview on 12/09/2023 at 1210 with ADON #17 revealed Patient #92 was identified as a level 2 triage and should have been assessed every four hours at a minimum, every two hours for a level two and with any change in the patient’s condition. Interview revealed the patient developed chest pain and required interventions and no nursing assessments or reassessments were documented in the ED record. Interview revealed continuous telemetry was ordered for the patient at 1218 and telemetry was not placed on the patient in the ED. Interview revealed the telemetry was placed on the patient at 2111 once the patient transferred to the medical floor. Patient #92 presented to the ED with chest pain on 11/09/2023 at 1149. The patient was not assessed by a nurse after triage was completed at 1155, or with a change in condition, or after pain medication was administered at 1703. The patient was never placed on continuous telemetry in the ED as ordered by a physician at 1218. The patient was transferred to a medical floor and placed on telemetry at 2111 when he was found to be in atrial fibrillation with rapid ventricular rate, prompting a STEMI Code Activation. The patient underwent an emergency cardiac catheterization at 2249. ED nursing staff failed to ensure a safe environment for the delivery of care to Patient #92 by failing to provide ongoing assessment of the patient’s condition and follow physician’s orders for application of continuous telemetry. 41946 2. Review on 11/17/2023 of the hospital policy Turn Around Time, last revised 11/17/2021 revealed “...PURPOSE: To provide timely and efficient testing services for routine, critical and high-risk situations. DEFINITIONS: Turn Around Time (TAT): the time elapsed from order placement to result reporting. Categorized as: Pre-analytical Phase: the period between test order entry by the caregiver and specimen receipt in the Laboratory. May be influenced, but not controlled by the Laboratory. Analytical Phase: the period between specimen receipt in the Laboratory and result reporting. Controlled by the Laboratory...STAT: an emergent, potentially life-threatening request. NOW: as soon as possible. Synonymous with ASAP. POLICY: All tests will be performed without delay to maximize specimen quality and integrity. STAT, NOW ... requests will be managed as priority situations. First-in, First-out (FIFO) processes are utilized to facilitate rapid and efficient movement of specimens through the system. Requests are also prioritized based on the following criteria to meet defined turn-around times: ...Response to STAT requests: ...STATS take priority over other specimens and should be managed from time of receipt until result reporting with no interruption in handling or testing. In general, the maximum TAT for most tests is 45-50 minutes from order receipt.... Response to NOW/ASAP requests: ...Staff will immediately process the specimen, perform testing, and verify results. Results should be available within (1) one hour from specimen receipt.... TAT Summary (Inpatient): STAT, Time from ORDER Receipt 45-50 minutes. NOW, Time from SPECIMEN receipt 1 hour...” Closed medical record review on 12/06/2023 revealed Patient #83, a 74-year-old female patient who arrived at the emergency department (ED) via emergency medical services (EMS) on 11/28/2023 at 1216 with a chief complaint of dizziness from her doctor’s office. Patient #83 was seen by an ED MD #1 on arrival and at 1218 a comprehensive metabolic panel (CMP) [includes serum glucose] was included in laboratory tests ordered as STAT (an emergent, potentially life-threatening request) with continuous ECG monitoring. At 1259 Patient #83 was placed in Red Pod (for the most acute patients) Hallway Bed-17. At 1309 the first set of vital signs was recorded by RN #2 as temperature 98.7, heart rate 84, respirations 19, blood pressure 225/88, and oxygen saturation of 93 percent on room air. At 1316 RN #3 completed a nursing triage assessment and Patient #83 was given an emergency severity index (ESI) [level 1 as the most urgent and 5 as the least urgent] of 3-urgent. Review of the CMP history revealed the STAT lab was collected at 1358 by RN #3 (1 hour and 40 minutes after the order was placed), the blood specimen arrived at the laboratory at 1412, and resulted at 1532 (3 hours and 14 minutes after the STAT order was placed) with a serum glucose resulted of 1137 (high normal range 120). Review of the Physician’s Order on 11/28/2023 at 1626 by ED Nurse Practitioner (NP) #5 revealed a new order for an Insulin (IV medication to reduce serum glucose) IV infusion to be started (54 minutes after the glucose had resulted). At 1709 an Insulin drip was initiated for Patient #83 by the RN #3. At 1739, the Hospitalist NP #6 placed a continuous telemetry monitoring order for 48 hours for Patient #83, with vital signs every 2 hours while in the ED. At 1908 ED MD #14 ordered a Glycosylated Hemoglobin NOW that was collected at 2128 (2 hours after ordered). At 2109 Patient #83 was moved to the ED Holding-Orange Pod-Room-2 awaiting an inpatient bed. At 2329 Hospitalist MD #9 ordered an IV infusion of D51/2 NS with KCL (Dextrose, Normal Saline, and Potassium Chloride Solution). On 11/29/2023 at 0127 MD #9 ordered a Lactic Acid (carries oxygen from your blood to other parts of your body) level to be drawn “NOW” for “nurse collect” for Patient #83. At 0153 MD #9 ordered to suspend the insulin IV. An addendum was made to the History and Physical at approximately 0200 by MD #9 which revealed “...Unfortunately patient has been on insulin drip since 5pm without continuous fluid administration or repeat blood work, it is currently 2 am, Nursing staff was previously contacted requesting these, later on did let provider know there was difficulty obtaining blood work as well as delay in obtaining D51/2NS KCL fluid from pharmacy. Given we have no blood work, no fluids, for the safety of the patient will suspend insulin drip at this time, until blood work is back to ensure appropriateness of insulin drip infusion...” 0157 RN #10 documented the IV with D51/2NS KCL as started (2 hours and 27 minutes after ordered). At 0200 Patient #83’s Insulin IV was suspended by RN #10. At 0256 Patient #83’s Insulin IV was reordered and was resumed (56 minutes after it was stopped). On 11/29/2023 at 0514 Patient #83 was transported to a Stepdown Unit. Review of the ED record revealed no evidence that continuous telemetry monitoring or vital signs every 2 hours were initiated in the ED by a nurse, further the NOW Lactic Acid “nurse collect” order at 0127 was never drawn while the patient was in the ED. On the inpatient floor, at 0529, RN #11 cancelled the 0127 NOW Lactic Acid order “nurse collect” from the ED and reordered the NOW Lactic Acid order “lab collect”. The Glycosylated Hemoglobin NOW that was ordered 11/28/2023 at 1908 resulted on 11/29/2023 at 0743 (12 hours and 35 minutes after ordered) with result of 12.3 (normal high range 6.3). At 0844 the Lactic Acid was drawn (3 hours and 15 minutes after it was ordered), was in the lab for processing at 0907, and resulted at 1108 (5 hours and 39 minutes after ordered) as “7.48” (high normal for lactic acid was 2.1). The computer system automatically reordered an additional Lactic Acid order by default and was collected at 1119 and was in the lab to be processed at 1148. At 1146 RN #12 documented a blood pressure of 141/67 with respirations of 36. At 1158 Rapid Response was called for Patient #83. At 1206 blood pressure was 65/40. At 1213 blood pressure was recorded at 68/40. At 1225 a Levophed (medication used to increase blood pressure) IV infusion was initiated via interosseous to increase her blood pressure. At 1245 the blood pressure was 126/84 at 98 percent oxygen saturation while the patient was being mechanically bagged at the bedside. At 1247 Patient #83 was intubated (mechanical ventilation), at 1250 Patient #83 was transferred to the medical intensive care unit. At 1256 the second Lactic Acid resulted as critically high “11.96”. After discussion with the family, Hospitalist MD #16 changed Patient #83 Full Resuscitation status to Limited Resuscitation with no cardiopulmonary resuscitation (CPR). Patient #83 expired on 11/30/2023 at 1337. Review on 12/06/2023 of a Patient Safety Analysis (Incident Report) completed by RN #12 on 12/01/2023 at 1917 revealed this Care Event was a “Delay in Care” and the issue was “Lack of timely response to Order”, for Patient #83. A description “A NOW LA (lactic acid) order was placed at 0529. Lab wasn’t drawn until 0844, and in lab at 0907. Critical results of lactic acid 7.48 reported at 1108. MD at 1114...Shortly after this (within the hour), the patient took a turn and had to be intubated at bedside and sent to ICU (intensive care unit) ...Solution to Prevent this from Recurring? Promptly follow orders...” This Patient Safety Report was still in process. Review of the report revealed Patient #83 had a delay in lab work. Request to interview MD #9 revealed she was unavailable for interview. Request to interview MD #16 revealed he was unavailable for interview. Telephone interview on 12/07/2023 at 1632 with RN #10 who cared for Patient #83 in the Orange Pod (location in the ED for pending admissions) revealed “...I work on an inpatient unit and was pulled to the ED that day. It’s a revolving door, I don’t recall this patient in particular. If I can’t get the labs, I would call a phlebotomist after 3 tries to get the labs if I couldn’t...” Interview revealed she could not remember why the NOW lactic acid order was not collected. Interview revealed physician orders for Patient #83 were not followed. Interview on 12/08/2023 at 0915 with RN #11 revealed she did remember Patient #83 and worked night shift. “...I did not receive a report on this patient from the ED. You have to look up the medical record number and sometimes the charge nurse gets an alert that the patient is coming and will print the face sheet. I had to piece it together and go through the orders. I reordered the lab work when I saw it was pending. My concern is we have had trouble getting in contact with the phlebotomist. That morning they were not logged into to their imobile device. I called the general lab number, and no one answered. I then contacted my house supervisor, and he told me ‘we don’t have another option right now.’ I can’t recall if she was on a telemetry box or not, I was only with her over an hour...” Interview revealed not being able to reach a phlebotomist during night shift had happened before. Interview revealed RN #11 had called multiple times to reach the lab phlebotomist to draw NOW blood orders without reaching someone. Interview revealed lab Turn Around Time for NOW lab orders was not followed for Patient #83. Interview on 12/08/2023 at 1309 with Laboratory Phlebotomist Supervisor #17 revealed “...the phlebotomists do not collect in the ED; we will help if called. All labs ordered in the ED default to “nurse collect”. The expectation was for STAT and NOW orders to be from order to collection in 15 minutes and to be resulted in an hour from order...” Interview revealed lab collection for STAT and NOW orders for Patient #83 did not follow hospital policy for lab turnaround times. Interview on 12/08/2023 at 1414 with NP #6 revealed her expectation for Patient #83, was for her to have continuous ECG monitoring and vital signs every 2 hours while in the ED. Interview revealed physician orders were not followed for Patient #83. Interview on12/08/2023 at 1425 with RN #3 who cared for Patient #83 in the Hallway Bed 17 on 11/28/2023 revealed “...I remember her. It was an extremely busy day...she was a hard stick; I used an ultrasound to start her IV. The problem with hallway beds is they have no dedicated monitor. She had a monitor and vital signs ordered. I strongly advocated for her to get moved into a bed with the CNC (clinical nurse coordinator), and it didn’t happen. She didn’t think it was a big deal. We don’t have the capability to link the patient to a monitor in a hallway bed. She wasn’t on a monitor; I spent the afternoon telling the CNC and MD. The doctors don’t have any say, it’s up to the CNC where patients are roomed. I sat behind her all day, ...I was extremely frustrated...” Interview revealed Patient #83 was not placed on continuous ECG monitoring, nor were vital signs monitored every 2 hours. Interview revealed physician orders were not followed for Patient #83. Interview on 12/08/2023 at 1230 with Nursing VP of ED Services, VPED #20 revealed she could not explain the lack of telemetry monitoring or vital signs for Patient #83 while in the ED. Interview revealed the ED nurse should elevate to the ED Charge Nurse for the need to continuously monitor a patient in a hallway bed if one was not available. Further interview revealed the ED Provider and ED Nurse were responsible for monitoring lab results via electronic medical record in the ED. Interview revealed hospital policy was not followed for Patient #83. Interview on 12/09/2023 at 1159 with Lab Director #18 revealed “...I do know we had a call out that day. The lactic acid was available for the lab tech to see at 1016 but wasn’t called to the floor until 1108. I don’t know what the delay was. The expectation was to call as soon as the result was available. The expectation for lab collection and processing was to follow the policy guidelines, and for STAT and NOW results to be completed within an hour...” Interview revealed lab collection and processing did not follow hospital policy for Patient #83. Patient #83 was presented to the ED with dizziness on 11/28/2023 at 1216. The patient had STAT lab work ordered at 1218 with continuous ECG monitoring. Labs were drawn at 1358 (1 hour and 40 minutes after ordered). Labs arrived at the lab at 1412 and resulted at 1532 (3 hours and 14 minutes after ordered). The blood glucose was 1137 (critically high). Insulin IV infusion was ordered at 1626 and initiated at 1709 (1 hour and 13 minutes after ordered and 1 hour and 37 minutes after the glucose resulted). Orders for continuous ECG monitoring placed at 1218, and vital signs every 2 hours were never initiated in the ED. At 2349 an IV infusion of D51/2 KCL was ordered that was not completed until 0157 (2 hours. and 8 minutes after ordered). Lactic acid was ordered NOW at 0127 for nurse collect in the ED. At 0200 a physician wrote there was a delay in labs and fluids so stopped the insulin IV infusion. The lactic acid was not collected in the ED. At 0529 the original lactic acid NOW, order was cancelled and reordered as lab collect NOW on the floor. It was collected at 0844 (3 hours and 15 minutes after ordered at 0529) and resulted at 1108 (9 hours and 41 minutes after originally ordered at 0127) with a result of 7.48 critical high. A second lactic acid was reordered at 1108 and resulted at 1256 (1 hr. and 36 minutes after ordered) with a result of 11.96 critically high. A rapid response was called previously at 1158, the patient was intubated at 1247, and ultimately expired on 11/30/2023. 3. Review of the CIWA (Clinical Institute Withdrawal Assessment for Alcohol) /Alcohol Withdrawal Plan, effective date 07/20/2022 revealed “...Monitoring Phase ...Now ONCE, when plan is initiated with goal CIWA < (less than) 15...” The CIWA/Alcohol Withdrawal Plan Reference Information included 10 questions, questions 1-9 can score between 0 and 7 points each question, question 10, can score 0 to 4 points, depending on severity of symptoms for each question. Score range 0-68. Questions with observations: 1. Nausea/Vomiting? 2. Paroxysmal sweats? 3. Agitation? Headache, fullness in head? 5. Anxiety? 6. Tremor? 7. Visual disturbances? 8. Tactile disturbances? 9. Auditory disturbances? 10.Orientation and clouding of sensorium -Ask what day it is? “...CIWA Management Communication If CIWA > 15 for four consecutive hours, contact provider to initiate Severe Withdrawal Phase and/or to consider transfer to higher level of care...” Closed medical record review on 11/16/2023 revealed Patient #43, a 39-year-old who presented to the emergency department (ED) by private vehicle on 08/14/2023 at 1603 with complaints of “...chest pain, nausea, clammy, lightheaded, and right-side tingling for several week. Drinks 12 beers a day....” At 1603 triage by Registered Nurse (RN) #21 with vital signs: temperature 98.5, heart rate 97, respirations 18, blood pressure141/89, oxygen saturation of 96 percent on room air, and pain of 4/10 (1 being least pain, and 10 being most pain) and was assigned an emergency severity index [ESI] (level 1 as the most urgent and 5 as the least urgent) of 2. Patient #43 was then moved to the ED waiting room IPA (Internal Processing Area) area and was seen by Nurse Practitioner (NP) #22. At 1650 initial labs, ekg, and chest Xray were completed, and Patient #43 was assigned to ED Medical Doctor (MD) #23. Review of the ER Physician Note from 08/14/2023 at 1727 by MD #23 revealed a review of lab, ekg and chest Xray results from 08/14/2023 did not show any critical results. At 1732 MD #23 ordered a GI cocktail (oral combination of medications given for indigestion), Zofran 4mg orally (medication given for nausea and vomiting). An addendum to MD #23’s ER Report Note revealed “...On reassessment patient and his mom who is now accompanying him are updated on his results. He is still in the waiting room unfortunately. I have ordered IV (intravenous) fluids, CIWA protocol and 1mg of Ativan (a sedative given for anxiety and seizures) as he is slightly tremulous (shaking) and diaphoretic (sweating) my reassessment [sic]...Hospitalist has been consulted for admission...” At 1841 MD #23 placed orders for IV (intravenous) fluids-NS NOW, thiamine (dietary supplement/nutrient) 100 milligrams (mg) orally STAT (immediately), and CIWA scale/protocol (alcohol withdrawal plan/protocol). At 1851 vital signs were rechecked by IPA ED RN #24 temperature 98.3, heart rate of 103, blood pressure 132/82, and oxygen saturation of 92 percent on room air, the GI Cocktail, and Zofran were administered in the ED waiting room. At 1947 MD #23 ordered Ativan 1mg IV push NOW (urgent). Per the CIWA plan at 2100 a multivitamin orally was ordered and CIWA Scale assessment. The History and Physical was initiated on 08/14/2023 at 2229 by Hospitalist MD #25 while in the ED waiting room, and new orders were placed for aspirin orally NOW, Lopressor (medication given in treatment of alcohol withdrawal) 12.5 mg orally, and again IV access at 2226. At 2305 MD #25 ordered Patient #43 phenobarbital (medication given to prevent seizure) 60 mg orally three times a day STAT and a CIWA Scale reassessment was due to be completed per protocol. No nursing reassessments, medication administrations, IV access/fluids, or physician orders were completed after 1851 for Patient #43 while in the ED waiting room. On 08/15/2023 at 0057 Patient #43 was moved to the Red Pod (ED area for the most acute patients) room 11. At 0105 MD #25 ordered Patient #43 to have Ativan 4mg IV STAT and was given at 0106 by RN #27. Review of the ER Report Note on 08/15/2023 at 0107 by MD #26 revealed “...I became involved in the patient’s care after he apparently left the waiting room where he was awaiting admission and then had a seizure and struck his head on the sidewalk outside of the ER (emergency room) entrance. On my evaluation, the patient seems postictal (the period following a seizure, disorienting symptoms, confusion, and drowsiness), he is not actively seizing. He does have a history of heavy alcohol use, drinks about 12 beers a daily. He has been in the emergency department waiting room for 9 hours and has not received any Ativan or Phenobarbital. I suspect that he seized due to alcohol withdrawal. Will obtain head CT (cat scan) given the patient did strike his head, he also has a small laceration that will require repair....” Record review revealed the ED waiting room orders for IV fluids NOW on 08/14/2023 at 1841 to 08/15/2023 at 0106 (5 hrs. and 25 min), Ativan IV NOW ordered on 08/14/2023 at 1947 to administered on 08/15/2023 at 0106 (5 hours 19 min), and Phenobarbital STAT ordered on 08/14/2023 at 2305 to administered on 08/15/2023 at 0150 (2 hours and 45 min) for Patient #43 were delayed and no CIWA score/assessment was completed until 08/15/2023 at 0437 (9 hours and 56 minutes after ordered). No CIWA score/assessment was documented before the patient had a seizure event with sustained head injury. There was no nursing reassessment, or nursing care after 08/14/2023 at 1851 by RN #22 until 08/15/2023 at 0057 (6 hours and 1 minute). Patient #43 was admitted to an inpatient room on 08/15/2023 at 0334 from the ED. Patient #43 was discharged home on 08/17/2023. Review of the Patient Care Analysis (Incident) report submitted by MD #25 on 08/15/2023 at 0443 revealed the date of event was 08/15/2023 at 0000. Brief description revealed “...patient was in waiting room for 9 hours, did not receive any medications for alcohol withdrawal, then had a seizure and sustained a head injury...” Investigator #28 Notes revealed: We continue to work through ways to provide care to patients in the waiting room during peak times of surge and limited staffing...” Further comments were reviewed by the hospital Pharmacy, dated 11/17/2023 (3 months after the event) that revealed “...Suggest education to sent out of CIWA precautions...Nurse could have clarified with provider about the CIWA order and administered medication...” Level of Harm was documented as “Harm-required intervention” and Primary Action to Prevent Recurrence: “Increase in Staffing/Decrease in Workload.” Request to interview MD #23 revealed she declined the interview. Interview on 11/15/2023 at 1414 with MD #26 revealed “...With the current process it’s still difficult to treat patients in the ED waiting room. The goal was for delays in care to not happen, but especially at night it occurs. I have concerns with delays in patient care. The patient was better off in a more clinical area where they can be monitored ...” Interview revealed MD #26 had concerns for patient safety in the ED waiting room due to delays in patient monitoring. Interview on 11/15/2023 at 1615 with NP #36 revealed “...it does happen occasionally that orders in the ED waiting room are on hold until the patient can be roomed. I do have concerns about it. The new waiting room flow is not better...” Interview revealed NP #36 had concerns provider orders were not completed timely in the ED waiting room. Interview on 11/16/2023 with ED IPA Day RN #22 revealed she did not remember Patient #43. Interview revealed “...best practice was to go back to see if patients’ meds (medication) were helpful. I must have left before I was able to put in a reassessment...I work IPA and the waiting room. There are multiple nurses and nurse techs (technicians) who get vital signs in the lobby and the techs notify us if abnormal. We escalate patient concerns with the charge nurse and the doctors do the same...” Interview revealed RN #22 cared for Patient #43 until 1900 and did not remember doing a reassessment after medication administration. Interview on 11/28/2023 at 1639 with ED IPA Night RN #28 revealed she did not remember Patient #43. Interview revealed “NOW orders in the IPA area go by priority and ESI, we are not always able to do them. The CNC (clinical nurse coordinator) should be informed...If you are the only IPA nurse and the doctor says ‘this has to happen now’ then it’s the next on my list. There was no protocol for who was actually assigned patients in the waiting room. Reassessments for ED patients who are waiting in the lobby would fall under the IPA nurse tasks but they are doing other patient’s needs and medications as well. There were only two ways to know if additional orders are placed on a patient after IPA, the doctor tells you, or on the tracking board, you might see “repeat troponin”, the CNC was supposed to help with that. If I gave controlled medication in the waiting room, I am responsible for the reassessment. If we are caught up it is a part of our duties to reassess...” Interview revealed patients in the ED waiting room are not assigned a nurse for reassessment and monitoring. Interview revealed hospital policy for reassessment in the ED was not followed for Patient #43. Interview on 12/01/2023 at 1130 with ED IPA RN #35 revealed “...The IPA nurse continues to be responsible for patients in the waiting room, after initial orders were completed...” Interview revealed the IPA nurse should continue to reassess patients in the ED waiting room. Interview revealed hospital policy for reassessment was not followed for Patient #43. Interview on 12/08/2023 at 1230 with Nursing VP of ED Services, VPED #20 revealed she could not explain the lack of monitoring or completion of provider orders in the ED waiting room. Interview revealed any new outstanding provider orders for patients in the ED waiting room would be elevated to the CNC. Further there was a WebEx huddle (meeting virtually for many hospital departments to discuss and prioritize patient needs) held every 2 hours and any outstanding provider orders would be delegated to be completed. Interview revealed RN #20 could not explain why Patient #43’s reassessments and providers orders had not been completed. Patient #43, a 39-year-old who presented to the emergency department (ED) by private vehicle on 08/14/2023 at 1603 with complaints of chest pain, nausea, clammy, lightheaded, right-side tingling for several weeks, with a reported history of drinks 12 beers a day. Review revealed the patient was located in the waiting room area and was observed by a physician to be diaphoretic. The physician ordered intravenous (IV) fluids and CIWA protocol (assessment tool used for alcohol withdrawal) at 1841, and Ativan (medication for anxiety) was ordered at 1947. These orders were not implemented. Multivitamin was ordered at 2100. Another order was placed at 2226 for IV fluids and Lopressor. Aspirin was ordered at 2229. None of these orders were implemented. An order written at 2305 for Phenobarbital administration was not implemented. At 0107, a physician’s note referenced the patient had a seizure and fall with a head injury outside the ED waiting room area. Findings revealed the patient had delays with nursing assessments, and failure to implement orders, including medication administration, and following the CIWA protocol. The patient subsequently had a seizure and fall with a resulting head injury. 4. Closed medical record review on 11/14/2023 revealed Patient #28, a 48-year-old male patient who arrived at the emergency department (ED) by emergency medical services (EMS) on 07/05/2022 at 0947 with headache x 2 weeks, altered mental status, fall, and was combative. He was triaged at 0950 by RN #57 with vital signs temperature 97.8, pulse 79, respirations 24, blood pressure 175/86, oxygen saturation of 94 percent on room air, a pain scale of 0 and an emergency severity index (ESI) of 1-Resusicitation. At 0955 Medical Doctor (MD) #59 initiated orders for EKG, lab work, chest Xray and CT (cat scan) of the head. At 1005 Haldol (given to treat severe behavior) 10 mg Intravenous was ordered by MD #59 and given due to combativeness. Review of the ER Note by MD #59 dated 07/05/2023 at 1002 revealed “.... history unable to be obtained from the patient...he was combative with EMS requiring 5 mg (milligrams) of Versed (given for sedation) given IV. He is only slightly sedated right now, ...pulling at lines, not answering questions, and not following commands...” At 1005 the complete blood count resulted with a white blood cell count of critical high- 32.4 (normal high 11). At 1029 Normal Saline 1 liter IV bolus was given and Rocephin (antibiotic) 1 gram IV was administered. At 1045 vital signs were pulse 78, blood pressure 226/107, oxygen saturation 98 percent on room air. At 1050 Patient #28 was intubated (mechanical ventilation) with standard IV sedation protocols. At 1054 vital signs pulse 76, blood pressure 211/91, and ventilated at 98 percent oxygen saturation. At 1236-1311 Patient #28 went into ventricular tachycardia (lethal heart rhythm) and was coded (resuscitated by staff), defibrillated, and had a central line placed. At 1322 a lumbar puncture was completed by MD #59 and a meningitis panel was ordered. At 1322 the cerebrospinal fluid (CSF) white blood count (WBC) resulted high at 94000 (normal high range 5 WBC’s per mm3 [million cubic meters]. At 1324 more antibiotics were given IV. Review of the ER Report Reexamination/Reevaluation (not timed) by MD #59 revealed “...the patient ultimately did require intubation for sedation and airway protection, his mental status continued to worsen despite Haldol and Versed...The Head CT was negative...Once back from CT the patient became profoundly hypotensive and at 1 point lost pulses requiring CPR, total time roughly 5 to 10 minutes...We have been running norepinephrine (given to sustain blood pressure) through this...ICU (intensive care unit) has been consulted. Family additionally has been updated...” At 1409 Pulmonologist/ICU MD #60 ordered Levophed (used to treat life-threatening low blood pressure) 4mg/ in 250 milliliters (ml) to titrate to 30 micrograms (mcg)/per minute and was initiated by RN #56 at 1514 (1 hour and 5 minutes after ordered), and at 1655 this drip rate was adjusted to 20mcg/min. At 1740 blood pressure was 137/79, at 1750 blood pressure was 73/42, at 1800 blood pressure was 33/18. Review of the Medication Administration Record revealed at 1801 RN #68 initiated a bag of Levophed at 30 mcg/min for Patient #28. At 1803 a code was initiated, and Patient #28 was in asystole (no heart rhythm). The code ended at 1807 with the return of blood pressure. At 1814 blood pressure was 249/118 with a pulse of 145. At 1816 an addendum to the ER Report by MD #62 revealed “...At 1803 I was called to the patient’s room, who had gone asystole. I was notified of the patient’s diagnosis of meningitis and hypotension. CPR was in progress on my arrival...I was notified that the patient’s Levophed had run dry, and that the patient had been hypotensive (low blood pressure) sometime before coding...Shortly after the epi (epinephrine-used to return pulse) and bicarb (bicarbonate improves outcomes in cardiac arrest), (1807) we had return of pulses. Patient’s blood pressure high. ICU attending entered shortly after the code finished.” At 1940 Patient #28 was transferred to the medical ICU for admission. Patient #28 continued to decline and showed no signs of improvement. Review of the Discharge Summary date 07/15/2022 at 1525 by Doctor of Osteopathic Medicine, DO #63 revealed “...There was no change in neurology exam, and it was explained to the family that there were no signs of meaningful improvement. At this time the family changed its code status to DNR (do not resuscitate) ...at this time the family was amenable...for organ procurement. He was brought to the OR (operating room) this morning where he was extubated (removal of mechanical ventilation), and time of death was 1040. On 07/15/2022 at 0931 Patient #28 had his kidneys harvested and was pronounced dead at 1040. Review on 11/28/2023 of the Patient Safety (Incident) Report for Patient #28 revealed it was reported by: (named RN #57) on 07/05/2022 at 1930. Event #: 6858. Event time was 07/05/2022 at 1803 with brief description “...assigned 5 patients, pt. (patient) coded due to unsafe staffing ratio...additional comments ...NUS (nursing unit supervisor RN #74) and Director (named, RN #75) notified of unsafe assignment at approx. 1730. RN (named RN #56) responded to assigned Trauma Alert which arrived at 1748. Pt. coded at 1803, 1 round of CPR, epi, sodium bicarb, ROSC (return of spontaneous circulation). Pt’s levophed emptied due to unsafe staffing assingment [sic]which was reported to NUS and Director prior to event...” Review on 07/06/2022 by Investigator and Director of ED Services (named RN #76) revealed one of the ED managers had spoken to Patient #28’s family member. The family was upset because they had “...asked for help at the doorway of the patient’s room when she noted alarms going off in the room. A PA (PA#77) was at the nurse’s station from a different service line that reportedly did not respond to her request...” Further the CNC, RN #74 reported she was only notified RN #56 needed assistance when the patient was coding. Patient #28 did code 2 times during his ER stay and had a length of stay of 9:52 (9 hours and 52 minutes) in the ER. RN #56’s patient assignment was broken down by RN #76 in the report as two stable patients awaiting admission to step down units (2), one patient who had been moved to the hallway (1), a new Trauma Alert patient (1), and Patient #28, an ICU patient (1). (RN #56 was assigned and responsible for 5 patients during Patient #28’s code/event). RN #76 discussed collateral staff available in the ED to support RN #56. “...Background information: The House was unable to provide staffing support for the admit holds in the ER on this date. There was an ER census of 295 on this date...” On 07/07/2022, Vice President (VP) of ED Services, VPED #48 reviewed this Patient Safety Report. Her investigation revealed there was an additional Patient Safety Report for this same event “...Indicating that the ER Director was informed of an alleged unsafe patient assignment. This notification to the Director was not substantiated...” Additionally, VPED #48 agreed RN #56’s assignment was safe due to collateral staffing in the ED. And did mention Patient #28’s family had voiced concerns who did not respond to their request for help for alarms in the room with (named, PA #77). The Primary Contributing Factor was “Human Factors/Staff Factors...Competing priorities...Level of Harm Harm-intervention to sustain life...” In summary, Patient #28’s levophed IV infusion sustaining his blood pressure was allowed to run dry, his blood pressure dropped, he was coded for 7 minutes until the infusion was reinstated. RN #56 had a patient assignment of 5 patients. Review on 11/28/2023 of the Patient Safety Analysis report, Event #6856, referencing Patient #28 dated 07/05/2022 at 1843 by ED Clinical Pharmacist, ED RPH #78 revealed the event date was 07/05/2022 at 1800 with a brief description of “...Patient required CPR (cardio-pulmonary resuscitation) due to levophed running dry while RN was attending to other patients (RN had 5 pts), including two traumas and this ICU patient...additional comments...making this report on behalf of (named RN #56) as he does not have time to make report. (Named) had 5 patients: the patient from this report (named) intubated, ICU), a trauma alert, a trauma transfer-a comfort care patient in the hall, and two other admitted patients. While he was in one of the traumas, this patient’s norepinephrine infusion ran dry-the patient became hypotensive. The family of the patient was monitoring the BP (blood pressure) and tried to get help from a non-ER provider who was sitting at a computer outside the room and this provider told the family that he could not help them because it was not his patient. Family is irate about this. A few minutes later, another RN came into the room and was able to switch out the levophed, but by this point the pt’s SBP (systolic blood pressure) was in the 30’s. He then became aystolic and required a round of CPR. (Named RN #56) alerted the ER NUS throughout the day that his assignment was unsafe. This patient coding was a direct result of an unsafe and unreasonable assignment...” This Report was investigated by ED Director, RN #76 on 07/06/2022 without any new findings from previous Event #6858. Additionally, on 07/21/2022 Doctor of Pharmacy, PharmD #79 added investigator notes to this report. The leading description of harm cited by PharmD #79 was “Human Factors/Staff Factors...Level of Harm...Harm-intervention to sustain life...” A summary of her report revealed that a bag of levophed was pulled for Patient #28 on 07/05/2022 at 1511 by RN #56 and was documented on the Medication Administration Record as given on 07/05/2022 at 1514, and per her estimation of the rates of infusion, the bag of levophed “...would have likely run out 1745...” The next bag of levophed was pulled on 07/05/2022 at 1757 by ED RN #68 and was started at 1801 for Patient #28. Review revealed Patient #28’s levophed IV infusion was interrupted for 16 minutes; he was coded from 1803 to 1810 before returning to spontaneous circulation. Request to interview ED RN #68 revealed she was not available for interview. Request to interview ED RPH #78 revealed she was unavailable for interview. Request to interview ED Manager RN #75 revealed he was unavailable for interview. Request to interview ED Director, RN #76 revealed she was unavailable for interview. Interview on 11/15/2023 at 1014 with RN #56 revealed he remembered Patient #28 and had worked in the ED for 5 years. Interview revealed “...I had trauma bay 11, and rooms 10, 9, 8 initially. The patient in room 10 was combative, intubated and a danger to himself and was receiving the maximum dose of levophed to keep his blood pressure elevated. I had him around 10 hours of my day. I got a trauma patient, and they were going to assign me another new trauma patient. Around 1730 I went to CNC (named RN #74) to discuss my assignment and the acuity of my already 4 patients, she put my dying trauma patient in the hallway, to make room for the new trauma patient even when I explained I felt my assignment was unsafe. I had already approached her that morning after 0800 to explain the acuity of my patients. So, then I went to my Nurse Manager (named, RN #75) to discuss my assignment and was assigned the new trauma anyway. My new trauma patient had just arrived after 1730, I was working with them and didn’t realize a code had been called for my intubated patient. When I arrived in the room (named RN #68), the person who was assisting me while I was caring for the new trauma patient, had already hung a new bag of levophed, and the code was in progress. I was very upset. I voiced my concerns, I talked to the administration, to the ethics and compliance committee and filed a complaint with HR (human resources). I tried to document this the best I could...” Interview revealed RN #56 had gone to the CNC, RN #74 at 0800 and again before new assigned trauma patient to voice his concerns with his high patient acuity assignment. Interview revealed RN #56 was caring for another patient, when the levophed IV infusion ran out, causing Patient #28’s blood pressure to drop, and a code was initiated. The interview revealed reassessment and monitoring of Patient #28 did not follow hospital policy. (request for all documents filed by RN #56 administration, ethics committee and HR were not made available for this surveyor). Interview on 11/16/2023 at 1128 with CNC, RN #74 revealed RN #56 approached her one time, and said ‘I need help’. CNC RN #74 stated she got RN #56 help by calling on the trauma team nurses who support trauma patients in the ED, but were not assigned patients in the ED. Interview revealed “...If we need help, we pull resources...” Further interview with CNC RN #74 revealed “...she had no concerns with nursing reassessments in the ED... that nursing assignments in the Red Pod (where the most acute patients are assigned) were 1 RN to 4 patients...” The interview revealed CNC #74 added trauma team nurses to assist RN #56 and stated she and the CNC’s filled in themselves when needed to support patient care. Interview on 11/15/2023 at 1637 with VPED #20 during tour of the ED revealed the Red Pod in the ED was assigned the most acute ED patients. The interview revealed nursing assignments were 1 nurse to 4 patients, and RNs are expected to communicate with the CNC’s any concerns or delays with patient care. “...starting in 2023 we have Webex huddles with nursing, providers, and other hospital departments every 2 hours to discuss delays in care and appoint resources where they are needed...” Interview revealed the expectation for reassessment and monitoring patients were for all staff to follow hospital policy. Interview revealed hospital policy for Patient #28 was not followed. Telephone interview on 12/01/2023 at 1209 with Director of the Trauma Team, MD #80 revealed he was aware of the case with Patient #28 and was the Medical Supervisor for PA #77 in 2022 and currently. Interview revealed “...when a Trauma Team member was in the ED it was to care for a specific consulted trauma patient, however a Trauma Team member if clearly evident could assist any patient in a life sustaining emergency...” The interview revealed PA #77 would not be allowed to touch an IV drip or alarming IV pump of a patient they were not consulted on. Interview revealed PA #77 notified a person who could adjust the drip for Patient #28. Further interview revealed he had no concerns with PA #77’s patient care, and the Trauma Team Supervisor, RN #81 had communicated with PA #77 “...we should always respond with compassion to family...” regarding this event. Interview revealed MD #80 had not followed up with PA #77, the Trauma Team Director had talked with PA #77. Interview revealed PA #77 did not know Patient #28’s blood pressure was low or the levophed had run out but had communicated to ED nursing staff who could attend the alarms when family asked him. Telephone interview on 12/01/2023 at 1241 with Trauma Team PA #77 revealed he had been employed for 8 years. Interview revealed “...I am only in the ED when called/consulted for a specific trauma patient. The family came to the desk, I told them I can get your nurse, and I did. The family was asking about an IV beeping. If I thought he was coding, I would have made sure he was OK. I did not have that information. I only learned about the IV levophed today. Of course, I would respond to help a patient coding. I would not ‘shirk’ a patient needing help...” Interview revealed PA #77 recalled the family asking for help with an IV alarm. He told the family he would find the nurse, and he did. Patient #28 presented to the ED on 07/05/2022, was critically ill, intubated and diagnosed with bacterial meningitis. The patient developed a low blood pressure and a Levophed IV drip was started. Findings revealed the Levophed IV drip was allowed to run dry and the patient’s blood pressure dropped to 33/18. A trauma PA was requested by the family for help related to alarms and the patient’s condition and the PA indicated the patient was not the PAs assigned patient. The patient arrested. A new Levophed bag was hung. The patient and IV were not monitored and the bag ran dry with subsequent cardiac arrest. 5. Closed medical record review on 11/14/2023 revealed Patient #27, a 66-year-old female who arrived at the emergency department (ED) on 07/04/2022 at 0025 by private vehicle with abdominal pain, nausea, and vomiting. Patient #27 was triaged at 0025 by RN #38 vital signs: temperature 97.2, respirations 20, heart rate 107, blood pressure 169/93, and oxygen saturation of 94 percent on room air, a pain score of 10 (1 least pain and 10 being the most pain) and was assigned an emergency severity index (ESI) of 3 (urgent). At 0028 Nurse Practitioner (NP) #39 wrote orders for Lipase (a digestive enzyme) STAT, CMP (comprehensive metabolic panel) STAT, Lactic Acid (carries oxygen from your blood to other parts of your body) STAT, CBC (complete blood count) STAT, Urinalysis (Urine test) STAT, and CT (cat scan) of the Abdomen/Pelvis STAT, an IV (intravenous) of Normal Saline to be started and Ondansetron (medication for nausea) 4 milligrams (mg) IV to be given. Record review did not reveal lab work, nursing reassessment, or physician orders for IV and medications were implemented for Patient #27 while in the ED waiting room (6 hours and 3 min). At 0631 Patient #27 was moved to Red Pod (for highest acuity patients) room 20. Patient #27 was seen by MD #26 at 0656 and orders were placed for ondansetron 4 mg, and Dilaudid (narcotic pain medication) 0.5 mg for pain. At 0734 lab work resulted (7 hours and 6 minutes after ordered). At 0739 Patient #27 had an IV started of NS (7 hours and 11 minutes after ordered), and medications for pain (7 hours and 14 minutes after identified pain level of 10, and 43 minutes after pain medication ordered) and nausea (7 hours and 11 minutes after original order) were administered by RN #40. At 0742 vital signs were documented as heart rate 85, respirations 16, blood pressure 174/89, oxygen saturation of 93 percent on room air (no temperature), with a pain score of 10/10 by RN #40. At 0755 the CT of Abdomen and Pelvis (6 hours) resulted (7 hours and 27 minutes after ordered) positive for a small bowel obstruction. Review of the ER Note Reevaluation (not timed) by MD #26 revealed Labs were reviewed without critical results, and the CT scan was consistent with a small bowel obstruction. Surgery was consulted for further evaluation and management by MD #26. At 0839 repeat pain assessment was 1/10 by RN 40. On 07/04/2022 at 1316 Hospitalist #41 saw the patient, set for admission. At 1319 Patient #27 had a pain score of 10/10, vital signs heart rate 83, respirations 17, blood pressure 147/96, oxygen saturation of 93 percent on room air, and was given Dilaudid 0.5mg IV for pain relief by RN #40. Review of the Surgical Consult Physician Note by MD #42 dated 07/04/2022 at 1543, Patient #27 was scheduled for a Laparoscopy, Possible Exploratory Laparotomy with Possible Bowel Resection. At 1620 a repeat pain assessment was completed for a pain score of 3/10. At 1600 Patient #27 left the ED for the operating room for surgery. Patient #27 completed surgery without complications and was discharged home on 07/06/2022 at 1136. Request for a Patient Safety Report (Incident Report) revealed there was not one available. Interview on 11/15/2023 at 1350 with ED RN #38 who triaged Patient #27 revealed “...in 2022 no patients were checked on in the ED waiting room, some changes were made, and there are some improvements. It’s very possible that this patient waited without any labs or orders completed. At that time there was one nurse in the waiting room to triage patients. There was no way to complete orders...” Interview revealed nursing reassessments and physician orders were not completed in the ED waiting room in 2022. Interview on 11/17/2023 at 1102 with NP #39 revealed “...the IPA (Internal Processing Area area in the ED waiting room) did not exist then. Now if patients need to move to the back, I tell the CNC (clinical nurse coordinator), we call and we call. I personally have been pulled to do patient reassessments when there was a change in condition. One hundred percent, patients are not safe, orders are not completed, and staffing is a concern. There is one nurse with a line out the door, I can put orders in, but it is not going to get done because of the volume of patients and minimal staff...” Interview revealed NP #39 had current concerns with waiting room patients not getting orders completed in the ED waiting room. Interview on 11/15/2023 at 1414 with ED MD #26 revealed “...I saw the patient after she was roomed.... There is not always a person to get labs and orders done. No staff to do orders. With the new process the goal is for that not to happen, but at night I suspect it does. As far as care in the waiting room, this patient didn’t get vital signs, or overall assessments and no meds...things are not happening on a timely basis...” Interview revealed Patient #27 did not get vital signs, assessments, or medications as prescribed. Interview revealed hospital policy was not followed for Patient #27. Patient #27 arrived in the ED on 07/04/2022 at 0025 with a reported pain level of 10 of 10. The patient had a STAT CT of the abdomen and pelvis ordered at 0027 that was not completed until 0755 (7 hours, 27 minutes later) resulted and signed at 0825. The patient had pain reported as 10 of 10, with nausea and vomiting with vital signs at arrival at 0025 and was medicated with Dilaudid (narcotic pain medication) at 0739 (7 hours and 14 minutes after arrival). The patient was diagnosed with a small bowel obstruction and had surgery that day. The patient had a delay with STAT lab work, STAT CT, nursing reassessment and pain management. 6. Closed medical record review on 11/14/2023 revealed Patient #29, a 78-year-old female who presented to the emergency department (ED) via emergency medical services (EMS) on 04/05/2022 at 1451 with complaint of falling at home with a laceration to the right lower extremity. The EMS report dated 04/05/2022 at 1342 revealed the patient had fallen from the toilet at home, was on oxygen 3 liters by nasal cannula “comments: baseline for patient”, had an Intravenous (IV) line in her left forearm #20 gauge and had received Normal Saline 700 milliliters. Review of an EMS narrative note revealed “she does have significant bleeding from her right lower leg...bleeding is controlled...the leg is splinted...”, was on a ECG (heart monitor) showing a heart rhythm of atrial fibrillation (irregular heart beat) with a pulse of 88. At 1503 a Physician’s Assistant (PA) #45 was assigned and a review of his ER Report Note at 1510 revealed “...High suspicion for open fracture to right anterior shin...”, with plans to order CT (cat scan) of the head and neck, pain medication, antibiotics, and lab work.” PA #45 ordered X-rays/CT at 1508. At 1514 Patient #29 was moved to Red Pod (for most acute patients) Hallway Bed 7. At 1517 Patient #29 was triaged by RN #43 “...subjective rapid assessment: fell in the bathroom at home. On Eliquis (blood thinning medication) and a pain score of 0. Open Tib Fib started earlier unseen...Pre-hospital treatments: oxygen, other: 3-liter O2. 20g Left arm...Acuity 5-non-urgent...”, an emergency severity index (ESI) was assigned of 5 (Non-Urgent). At 1536 lab work was ordered. At 1537 the CNC (clinical nurse coordinator), RN #44 documented a change in patient ESI to 3-urgent. 1559 lab work had resulted. At 1618 PA #45 ordered Hydromorphone (narcotic pain medication for severe pain) 0.5 mg IV push every 15 minutes duration 3 doses for pain for Patient #29 and Zofran 4mg IV for nausea. At 1630 (one hour and 39 minutes after arrival) vital signs were documented as pulse 88, blood pressure 161/79, oxygen saturation of 90 percent (no oxygen was documented), 1639 respirations of 22, and temperature of 98.4. By 1627 all radiology had resulted, and a review of the ER Report Reexamination/Reevaluation (not timed) by PA #45 revealed “...On my read it appears the patient has a rather significant tib-fib (tibia/fibula) fracture. I do believe this is an open fracture. She has already received Ancef (antibiotic), and I have already spoken to orthopedic surgery. They will come and speak with the patient...” At 1636 Ancef 1 gram IV, a Tetanus (infectious disease that can occur from an unclean wound) booster intramuscular, Hydromorphone 0.5mg IV for a pain score of 10/10 and Zofran 4mg IV were administered by RN #43(no evidence of an oxygen assessment). At 1736 a pain reassessment was charted as 9/10 (no evidence of an oxygen reassessment). At 1748 the Orthopedic Consult and History and Physical was completed by MD #52 with diagnosis of “Open tibial shaft fracture...” with plan for surgery to repair fracture. Review of the ER Report addendum by PA #45 (not timed) revealed “...Orthopedic surgery agrees this appears to be open fracture and recommends a room for splinting and simple reduction before surgery tomorrow am...” At 1816 Patient #29 was given Dilaudid 0.5mg IV for a pain score of 9/10 by RN #43 (no evidence of oxygen assessment). Review of the Patient Summary Report revealed Patient #29 was moved to room 11 at 1915. Review of an addendum to the ER Report by PA #45 (not timed) revealed “...As I was handing off the patient to ... I was told by nursing staff that the patient was unresponsive. Upon arrival at the bedside, the patient is unresponsive. She does have DNR (no evidence of this in the record). She is moved into room 11 where Dr. (MD #46), my attending physician was kind enough to evaluate the patient and call time of death...” Review of the ER Report 04/05/2022 at 1947 by MD #46 revealed “...78-year-old female past medical history of atrial fibrillation currently anticoagulated on Eliquis. She fell and had an open fracture of the tibia/fibula. Patient has been admitted to the orthopedic service. I was called to the patient’s bedside at 7 PM as nursing found her pulseless and apneic (no respiration). After 60 seconds, the patient has no cardiac activity, she is in asystole (no heart rhythm) on the monitor. Her pupils are fixed and dilated. No spontaneous respirations, no cardiac sounds and she is pulseless. Official time of death was called at 709 PM ...” Patient #29 was pronounced dead in the ED on 04/05/2022 at 1909. Review of the Patient Event Record dated 04/06/2022 at 0341 by Nursing/Surgical Services #54 revealed the event was “unexpected death” date of event “04/05/2022 at 1903” with narrative “...pt came to ER (emergency room) c/o (complaint) fall with fracture. pt placed in the hall bed. pt found unresponsive in hall...House Supervisor (RN #55) notified at 1905...”, the description of harm and action to prevent reoccurrence was documented as “monitor trends and patterns”. There was no witness to event per report. Request to interview Trauma Nurse, RN #56 revealed she was unavailable for interview. Interview on 11/16/2023 at 1204 with ED RN #43 who cared for Patient #29 revealed “...I was checking on the patient, she was responding, her daughter was there. I was charting and could see her. She was full code, her daughter ran over to me and asked me what I was doing, as I was pulling the stretcher away from the wall and replied ‘CPR’ and the daughter said, ‘please don’t do that’. The trauma nurse that day, (named RN #56) took the patient to room 11. I reported it to my charge nurse (named RN #57), and I went to report off on my other patients because it was the end of the shift. I didn’t see her again...you’ll have to go by my charting, I don’t remember if she was on oxygen...” A further interview revealed “...I should have charted she expired, that was an error...” The interview revealed RN #43 did not recall if Patient #29 received oxygen in the ED, did not recall if an oxygen reassessment was completed and did not get vital signs or reassess a change in condition. Interview revealed hospital policy for reassessment was not followed for Patient #29. Telephone interview on 11/16/2023 at 1324 with MD #46 revealed she did not recall Patient #29. Interview revealed “...monitoring of patients in hallway beds are a concern. Ideally every patient in the Red Pod should be on some sort of a monitor with a pulse oximeter. More monitoring is always better...” Interview revealed when MD #46 arrived at the patient’s bedside she was in asystole, and she pronounced the patient with daughter at the bedside. Interview on 11/16/2023 at 1747 with CNC, RN #44 revealed “...I do remember she was in a hallway bed, and (named RN #43) said she had passed. I had checked on her. (Named RN #43) told me the daughter came to her and said, ‘somethings wrong with my mom’. I don’t remember if she had oxygen or was being monitored. I would expect the ED nurse to complete assessments and document them in the chart...Staffing was 4:1 in the Red Pod, If a nurse tells me I’m overwhelmed, I will ask another nurse to assist with patient care...” Interview revealed RN #44 did not know why oxygen reassessments or changes in conditions were not completed for Patient #29. Interview revealed hospital policy for reassessment for a change of condition was not followed for Patient #29. Interview on 11/28/2023 at 1433 with Assistant Director of Nursing, RN #15 to review the internal investigation following Patient #29’s death in the ED “...Per the ED Manager (not identified) the patient’s family called staff over to the patient because ‘she didn’t look good’. She was unresponsive and was taken to room 11 to be placed on a cardiac monitor which showed asystole. At 1909 was the time of death pronounced with her daughter at the bedside. Interview revealed this event was reviewed by the Mortality and Morbidity which was comprised of multiple providers and the MD who had completed the report dated 07/11/2022 the internal investigation of Patient #29’s death revealed the patient was under triaged, the door to antibiotics was greater than 1 hour, and needed closer monitoring. (note: this surveyor was not allowed to hold or view documents during this interview.) Patient #29 arrived on 04/05/2022 at 1451 via EMS and had atrial fibrillation (abnormal heart rhythm) on arrival. The patient had a recent fall with fracture prior to arrival. Pulse Oximetry was 94% prior to arrival. 1630 pulse oximetry was 90% (1 hour and 39 minutes after arrival) with no evidence of oxygen administration at hospital. Dilaudid 0.5 milligrams (mg) IV was administered at 1630 and at 1816. No vital sign or oxygen assessment on an elderly patient was assessed on the patient with a prior pulse oxygen of 90% after the administration of Dilaudid. The patient was subsequently asystole at 1909 and expired. Patient #29 had one set of vital signs from 1451 until time of death at 1909 (5 hours and 18 minutes). Nursing staff failed to reassess the patient after narcotic administration. Nursing staff failed to reassess the patient for a change in condition (not breathing). 33790 7. Medical Record review, on 12/14/2023, revealed Patient #6 arrived to Hospital B via EMS on 10/03/2023. Review of the Triage Note at 1723 revealed “ ...Reason for Visit: Pt (patient) at 2 started having left sided arm and leg muscle weakness and left sided diminished sensation on leg. Facial drooping noted in lower face. No blood thinners and 10 days post partum. What aspect of reason for visit is concerning to patient? : Stroke symptoms. ... “ Review of a MD “ER Report”, service date/time 10/03/2023 at 1714, revealed “ ... History of Present Illness 22-year-old female with a past medical history of vaginal delivery 10 days prior ....who presents to the emergency department with left-sided weakness. Patient states that she felt normal when she went to take a nap at approximately 2 (2:00), when she woke up at 330 (3:30) she noticed that she had weakness on the left side of her face and is developing weakness in the left side of her body. She notes that she was unable to smile fully. States that she has never had any symptoms like this in the past. She notes that last night she had an episode of epigastric pain, but that has gone away since fully. States that the developing left-sided weakness has been ongoing since that time and called EMS for evaluation. Pregnancy was uncomplicated ....Initial Vitals T: 98.9 F Oral HR: 65 RR: 20 BP: 170/97 SpO2: 87%.... Medical Decision Making ....22-year-old female presenting to the emergency department secondary to onset of neurologic deficit with last known normal of approximately 2:00 PM. On exam, I initially had concern for Bell’s palsy given her age and demographic info, but on my physical examination I noted appreciable weakness on the left side of the body with regards to motor function. I would not expect Bell’s palsy to cause the symptoms, in addition to this she was able to raise both eyebrows equally. Although there can be varying degrees of eyebrow raise or inability to thereof with Bell’s palsy, I would not expect the left-sided sensory subjective deficit and motor deficit as noted. Therefore I did initiate a code stroke procedure. This is also complicated by the fact the patient is 10 days postpartum which does place her at an elevated risk for ischemic CVA (stroke). Differential at this point would also include complex migraine, preeclampsia/eclampsia (serious pregnancy complication characterized by high blood pressure), or complex partial seizure, though she did not report any seizure-like activity .... Ultimately, the decision was made in concert with the stroke neurologist at (Hospital A) not to provide thrombolytics at this point in time .... However, patient will require transport to (Hospital A) for further close work-up and likely MRI (Magnetic Resonance Imaging- type of diagnostic testing). Ultimately my concern for eclampsia (serious pregnancy complication) is certainly present given her elevated blood pressure and abnormal neurologic exam. I did order 20 mg of IV labetalol (to treat BP) to be given as a stat dose in addition to 4 mg of magnesium as a bolus with a 2g/h (grams per hour) infusion thereafter. I did reach out to and speak with the OB/GYN on-call ....who agreed with this management plan and possible diagnosis of eclampsia given her blood pressure and symptoms. Patient was transferred to (Hospital A) emergently for further care. ... Diagnosis/ Disposition Postpartum eclampsia/stroke. ...” Review of the EMS (Emergency Medical Services) Patient Care Record, dated 10/03/2023, revealed EMS transported Patient #6 from Hospital B to Hospital A. The EMS record indicated they arrived to Hospital A at 1938. Review of the EMS Narrative note revealed “(EMS) on scene at (Hospital B) and was informed of a Red Transport (red is the most urgent transport) .... Arrived to find the pt (patient) in room 3, alert to EMS presence and in no obvious distress....report is as follows: ....Dx (Diagnosis): HTN (hypertension) crisis, Preeclampsia Stroke HPI (History/Physical): Came in with EMS for L (left) sided drooping and weakness and tingling onset....10 days postpartum....CT Head clear for bleed and clots ‘Preeclampsia Stroke’ Meds: Mag (Magnesium) 4 g (gram) Bolus with 2 gm/hr infusion, Labetalol 10 mg (milligrams) ....Vitals: 172/98 .... Pt states that she feels fine just feels super weak but denies any pain or N/V (Nausea/Vomiting). Due to the importance of medication, (EMS) waited for nurses to retrieve and start a magnesium (Mag) drip before departing. In the meantime, secondary IV access obtained by Paramedic (name) and pt is moved over to the stretcher, placed on all monitoring ....Pt was placed on capnography (carbon dioxide monitoring) noting elevated rate and borderline hypocapnia (decrease in carbon dioxide levels below normal) with normal appearing waveform ....Once all paperwork is obtained and Mag is started pt is moved out to the truck and transport is initiated to (Hospital A) Emergency. Enroute pt is monitored with no new complaints....While waiting on a bed at (Hospital A) pt was monitored with minimal changes to her BP. Repeat neuro checks were completed periodically....Pt began to complain of a mild headache and posterior neck pain similar to how she felt before she delivered. Pt report and care given to RN (Name) bedside ....Arrived: 19:40 .... Transferred Care 22:24 (2 hours 44 minutes after EMS arrived to the hospital). Review of the EMS Record revealed EMS staff continued to monitor the patient, including ongoing vital signs. An EKG was performed at 2016. An EMS assessment was completed at 2121 which indicated slight yellowing of the skin, right upper quadrant tenderness and left arm and leg weakness along with a facial droop and neck pain. Vital signs continued approximately every 5 minutes, with the last recorded blood pressure 147/90 at 2215. Emergency Department record review revealed Patient #6 arrived to Hospital A on 10/03/2023 at 1942. An “ED Triage” performed on 10/03/2023 at 2227 (2 hours 45 minutes after arrival) revealed “...Subjective Rapid Assessment Stated Reason for Visit : Brought by EMs (sic) team from (Hospital B) due to stroke like symptoms, left facial droop and left sided weakness, last known normal was 1400H (hours) and onset of symptoms at 1530H ....ED Full Triage Arrival Mode - ED (Emergent) : EMS ....Pre-Hospital Treatments : IV Access, Other: Magnesium sulfate at 2g/hr ....Arrived From: Hospital. ...” Review of vital signs revealed a heart rate of 82, respiratory rate of 18, BP of 168/96, oxygen saturation of 93% on room air and a pain score of 4. Record review revealed an “ED Medical Screen Exam Form.... Entered on 10/03/23 22:23 EDT” which noted “...MSE Comments : tx (Transfer) from (Hospital B) for MRI brain, concern for ecclampsia. Appears admit bed is already ordered.” Review of the “ER Report”, service date/time, 10/03/2023 at 2310, revealed “...Patient presents as a transfer from outside hospital for concern of strokelike symptoms. She presented to (Hospital B) today with left facial droop that she noticed when she woke up from her nap around 3:30 PM. Her last known well was around 2 PM. At (Hospital B), she was noted to have left facial droop as well as some left arm and leg weakness. Stroke consult was called and the patient was seen in concert with telemetry neurologist decision was made against using tPA (breaks down blood clots). She was transferred here for further stroke eval and MRI (magnetic resonance imaging). She was also notably hypertensive at outside hospital with blood pressure 160s systolic. She has also had some headaches recently, did have a headache at the time of her delivery. She denies any chest pain or shortness of breath currently.... Physical Exam ....Initial Vitals HR: 82 RR: 19 BP: 168/96 SpO2: 93% ....Neurological: Alert and oriented to person, place, time. Patient does have left facial droop with left eyebrow droop as well. Has very mild drift on the left as compared to right. Has difficulty lifting left leg up against gravity .... Medical Decision Making ....Differential Diagnosis.... Stroke, eclampsia less likely given no seizures, preeclampsia, Bell’s palsy although this is less likely given her symptoms in the left arm and leg ....Treatment and Disposition .... Patient presents the emergency department with left sided weakness and left facial droop. Chart reviewed from outside hospital as she is a transfer from (Hospital B). Discussed with neurologist who will admit to their service. MRI and MRV (magnetic resonance venography-imaging that focuses on the veins) have been ordered. Patient continues to have left facial droop on exam, does seem to have eyebrow sparing as she is able to lift her left eyebrow. She also does have some very mild pronator drift on the left side as compared to the right as well as difficulty lifting up her left leg .... Concern remains for stroke. MRI has been ordered and MRV as well as ordered by neurology. I did discuss the case with OB given her hypertension here. I have ordered the magnesium infusion at 2 g/h as well as a 10 mg dose of IV labetalol given her systolic of 168 here. Patient admitted to neurology .... Diagnosis/Disposition Left-sided facial droop Preeclampsia. ...” Record review failed to reveal acceptance and monitoring of Patient #6 by nursing until triage at 2227 (~2 hours 45 minutes after arrival). Record review did not reveal documentation of a physician evaluation until 2310. Record review revealed the only documented evaluation and monitoring of Patient #6 during the time period from arrival to triage was from EMS staff. Patient #6 was moved from the initial ED room to a holding unit and later to a maternal fetal medicine unit. The patient was discharged home on 10/06/2023. Telephone interview with EMS #63, on 11/14/2023 at 1430, revealed the EMS team was at Hospital B dropping off another patient and were notified of a “red” transfer of a patient who was 10 days postpartum with a hypertensive crisis and preeclampsia or stroke. Interview revealed they were notified that Neurology wanted the patient transferred emergently. Medications were started and the patient immediately transferred. Patient #6, per interview, was still having symptoms and waited at Hospital A for a “2 hour 46 minute wait time on the wall” (location where EMS waits in the ED with patients who are awaiting an available bed). Interview revealed EMS continued to monitor the patient closely as Patient #6 had right upper quadrant pain and was on a Mag Drip. Interview revealed that EMS waiting and patients holding for a bed had been an ongoing issue for 3 ½ years and seemed to be getting worse. Interview revealed the EMS staff member did not feel the patient’s care was met in the ED as Patient #6 required neuro checks, vital signs and close monitoring. Interview with RN #64 during observation on 11/13/2023 around 1030 revealed that when EMS arrives with patients and there are no beds available then EMS stays “on the wall” with the patient until a bed is available. They do not hand-off the patient until patients get to an assigned bed. Physicians may see patients on the wall, but “EMS can only hand-off to a RN.” Follow-up telephone interview on 11/15/2023 at 1430 revealed that in relation to patients arriving with EMS, ED nurses do not “triage patients until ...taking ownership of the patient. Interview revealed that if the CNC in the EMS arrival area was to triage the patient, then the RN was “taking ownership of the patient.” The RN stated they could not do that as CNC and still meet all the expectations of the role. Interview revealed that in this ED, “EMS is still responsible.” Telephone interview on 11/15/2023 at 1410 with DO #65 revealed the DO went to assess Patient #6 when she was in a bed in the ED. Interview revealed the DO signed up for Patient #6 as soon as her name popped up on the ED tracking board. Before that time, the DO was not aware the patient was in the department. Interview revealed that technically the patient was already admitted, having been accepted by neurology, but was an ED to ED transfer. ED physicians still did a full medical screening on transferred patients, the DO stated. Interview revealed Patient #6 was on a Mag infusion and was hypertensive. Interview revealed DO #65 called the accepting Neurologist and also called an Obstetric Resident since the patient was postpartum and hypertensive and there were concerns for preeclampsia. Telephone interview with Patient #6’s Triage Nurse, RN #66, on 11/17/2023 at 0932, revealed the nurse did not recall Patient #6 or the situation. Interview revealed the EMS team was responsible for any patient they brought in until the patient got a room assignment and was moved to a room in the ED. Once the patient was in a room, the ED RN triaged the patient and there was a proper hand-off between EMS and the RN. Telephone interview on 11/17/2023 at 1205 with MD #67, the accepting neurologist for Patient #6, revealed they were concerned enough to transfer the patient to Hospital A even though they decided not give thrombolytics. Interview revealed obstetrics was called since the patient recently delivered and Mag was given more often by obstetrics. Interview revealed the time until the patient was triaged was “a long time.” Interview revealed the patient should have received frequent vital signs by staff. The MD stated they often do ED to ED transfers. Interview revealed MD #67 thought he saw the patient when she was in an ED room and that the accepting physicians would not know a patient had arrived to the ED until a call was received from the ED that the patient was there. Interview revealed if they had a room the patient would have gone to Neuro. Ultimately, the MD stated, it was determined Patient #6 was hypertensive related to pregnancy and it was better for her to be admitted to obstetrics. Patient #6 arrived to Hospital B with strokelike symptoms at 10 days postpartum. She was accepted for transfer to Hospital A as an ED to ED transfer. Patient #6 arrived to the hospital via EMS on 10/03/2023 at 1942. The patient waited in the ED for a bed and continued to be managed by EMS. No documentation was noted by a medical provider until 2223 and Patient #6 was not triaged or assessed by hospital nursing staff until 2227 (approximately 2 hours 45 minutes after arrival by EMS). There was a delay in accepting the patient and a delay in triage, assessment and monitoring. 8. Hospital B Medical Record review on 12/16/2023 revealed Patient #1, a 64-year-old, arrived to Hospital B on 10/31/2023 at 2203. Review of the ED Triage, at 2203, revealed “...Subjective Rapid Assessment Stated Reason for Visit : 2130 onset slurred and right sided weakness with facial droop; no thinners (blood thinning medications) ....CODE STROKE. ED Full Triage ....Acuity : 1 (highest acuity). ...” Review of the “ER Report” by a physician, at 2212, revealed “ ...History of Present Illness This patient is a 64-year-old woman....here with neurologic symptoms. Independent history is obtained from the patient’s husband, who is here with her. He said that at approximately 9:30 PM, she called out to him that something was wrong. He looked over and saw that she was having difficulty walking and seemed to be slumping to the side. Her speech was noted to be slurred.... She is weak on the right side. Physical Exam ....Initial Vitals .... BP: 204/100....VITAL SIGNS: Triage vital signs are reviewed and show elevated blood pressure approximately 204/100, otherwise normal. GENERAL: Patient is well-developed, well-nourished, and clearly with facial asymmetry and slurred speech .... NEURO: The patient has paralysis of the right lower face.... She has moderate dysarthria (slurred speech).... Level of consciousness seems normal. She does have drift of the right arm without hitting bed ....Medical Decision Making This patient presents with neurologic symptoms concerning for acute ischemic stroke ....I think she will likely be a candidate for thrombolytics assuming that we can get her blood pressure down. She is going to CAT (computerized axial tomography - type of diagnostic imaging) scan right now. We are giving labetalol IV (medication for blood pressure given intravenously). [space] 10/31/23 23:00:55.... I reviewed CT scan .... Showing left basal ganglia hemorrhage (hemorrhagic [bleed] stroke in a part of the brain] ....I did discuss the patient with the neurologist, who accepts the patient in transfer for treatment of acute atraumatic hemorrhage. The patient did receive a dose of labetalol, and her blood pressure dropped below 160 briefly but then went back up over 170, so nicardipine infusion was started. Diagnosis/Disposition Acute atraumatic intraparenchymal hemorrhage (bleeding into the brain) [space] Acute hypertensive emergency (acute marked elevation in BP associated with signs of damage) [space] Right-sided weakness. ...” Review of the Transfer Form revealed Patient #1 was accepted for transfer at 2225. Review of the Physician’s Certification for Medical Transport form revealed “ ...Medical Condition at the Time of Transport : Patient requires neurological, cardiac, and hemodynamic monitoring and a nicardipine drip by a medical attendant throughout transport. ...” Review revealed Patient #1 was transferred out at 2233 as a “Red” priority. Review of the EMS Patient Care Record revealed EMS transferred Patient #1 as an emergency “red” transfer. Review of the “Narrative” documentation revealed “(EMS) WAS ISSUED A RED TRANSPORT TO (Hospital A). ....THE PT WAS BEING TRANSPORTED TO (Hospital A) DUE TO INTRACRANIAL HEMORRHAGE. THE PT WAS PLACED ON THE CARDIAC MONITOR, 12 LEAD ESTABLISHED ....THE PHYSICIAN ADVISED TARGET BLOOD PRESSURE IS 140/90 AND ADVISED TO MONITOR BLOOD PRESSURE DURING TRANSPORT. NICARDIPINE WAS ADMINISTERED AND MAINTAINED THROUGHOUT ROUTE .... EMERGENCY TRAFFIC. THE PT WAS REASSESSED EVERY 5 MINUTES DURING TRANSPORT.... PT REMAINED ALERT, ORIENTED, SLURRED SPEECH WAS NOTED. PT CARE .... UPON ARRIVAL, THE PT WAS REGISTERED, AND EMS WAITED ON ROOM ASSIGNMENTS. VITAL SIGNS WERE CONTINUOUSLY MONITORED. A PHYSICIAN STATED, ‘WHAT DO YOU HAVE?’. THE PHYSICAN (sic) WAS ADVISED RED TRANSPORT FROM (Hospital B) ER TO (Hospital A) WITH AN INTRACRANIAL HEMORRHAGE. THE PHYSICIAN ASKED FOR PAPERWORK AND THEN STATED ‘NEVER MIND.’ THE PT REMAINED STABLE WITH ONLY COMPLIANT (sic) OF A HEADACHE. THE NEUROLOGIST (Name of accepting physician) ADVISED THE PT WOULD MOVE TO THE ICU ONCE A BED WAS AVAILABLE. THE PT REMAINED IN THE HALLWAY AND WAS CONTINUOUSLY MONITORED AND ASSESSED. (EMS) WAS ADVISED THE PT WOULD BE TRANSFERRED TO THE NEUROLOGY ICU. PT CARE REPORT WAS GIVEN TO THE ATTENDING NURSE .... PT CARE WAS TRANSFERRED. ...” Review revealed the EMS unit arrived to Hospital A at 2312 and Patient #1’s care was handed-off to hospital staff at 0106 (1 hour 54 minutes after arrival to the hospital). Review revealed EMS completed vital signs every 5 minutes to 10 minutes throughout the wait time for a bed and hand-off to the hospital. Review of the Hospital A medical record for Patient #1, on 11/14/2023, revealed the patient arrived as a transfer via EMS at 2314. Review of the “ED Report” by an ED physician, at 2351, revealed “... 64-year-old female who presents as a transfer due to intracranial hemorrhage. Was taken to an outside hospital due to concern unilateral (one-sided) weakness and speech difficulty at roughly 2130. At that time had a head CT which showed an intracranial bleed and thus the patient was transferred here. At the outside hospital she was noted to have fairly profound hypertension was given IV Lopressor (treats elevated BP). Plan is for neurology admission however they would like angiography of the head and neck prior to getting a bed. Nicardipine was also initiated for blood pressure management....Physical Exam .... Initial Vitals No Data Available ...Neuro: Right-sided facial droop with loss of nasolabial fold as well as dysarthria noted. Weakness of the right arm over relatively normal left arm and lower extremities. Medical Decision Making ....Patient presents as a transfer due to intracranial hemorrhage. Working with nursing staff in order to have this patient placed in a room. Neurology is already consulted on this patient, will follow-up with their requested CT angiography. We will also needs (sic) very close blood pressure monitoring. ...” Review also revealed a Neurology “History and Physical”, service date/time 10/31/2023 2347, which indicated “...Impression and Plan: ....#ICH (Intracranial Hemorrhage): hypertensive etiology suspected ....#HTN (hypertension) urgency: no prior hx (history) of HTN, treat >160/90 with goal towards normotension. #dysarthria, right hemiparesis (weakness or partial paralysis on one side of the body). Plan: admit to ICU for close neurologic monitoring. ...” Review of the ED record failed to reveal any vital signs or assessments by nursing. Review revealed “Nurse Notes” on 11/01/2023 at 0051 that stated “RN gave heads up to NSICU (Neurosurgery ICU) by (Name), RN. ED CNC (Clinical Nurse Coordinator) aware that (Name), RN is not assuming care of patient and only transporting PT (patient) upstairs. Pt has been with EMS in hallway for approx. (approximately) 2 hours and now has bed assignment upstairs. RN only transporting from EMS to NSICU.” Record review failed to reveal an ED RN ever accepted, triaged, assessed or did vital signs on Patient #1 while the patient was in the Emergency Department. The first documented vital signs were at 0110, once Patient #1 arrived to NSICU. The patient’s blood pressure at 0110 was documented as 162/85. Telephone interview with EMS #73 on 11/30/2023 at 1415 revealed the paramedic was involved in the transfer of Patient #1. Interview revealed it was a “red” transfer. Interview revealed on arrival to the hospital they gave the paperwork to hospital staff and then “sat on the wall.” The neurologist came to evaluate the patient and said she would move as soon as a bed was available. EMS, interview revealed, continue to monitor Patient #1. The patient was on IV medications for blood pressure and EMS staff had to “fluctuate the meds to keep the blood pressure where it needed to be.” Interview revealed no nurse evaluated Patient #1 while she was in the ED. Interview with MD #69 the accepting neurologist, revealed it was not uncommon to do ED to ED transfers, that it was good to have them in the ED for emergent evaluation when there was a concern for a patient’s stability on arrival. Interview revealed MD # 69 came to see patients in the ED as soon as they were notified of the patient’s arrival. Interview revealed it was “surprising” not to have vital signs completed in the ED and stated it did not meet expectations for care - patients needed hourly neuro checks and vital signs with provider updates on changes. Interview with RN #64 during observation 11/13/2023 around 1030 revealed that when EMS arrives with patients and there are no beds available then EMS stays “on the wall” with the patient until a bed is available. They do not hand-off the patient until patients get to an assigned bed. Physicians may see patients on the wall, but “EMS can only hand-off to a RN.” Follow-up telephone interview on 11/15/2023 at 1430 revealed that in relation to patients arriving with EMS, ED nurses do not “triage patients until ...taking ownership of the patient. Interview revealed that if the CNC in the EMS arrival area was to triage the patient, then the RN was “taking ownership of the patient.” The RN stated they could not do that as CNC and still meet all the expectations of the role. Interview revealed that in this ED, “EMS is still responsible.” Telephone interview with RN #66, on 11/17/2023 at 0932, revealed the EMS team was responsible for any patients they brought in until a room was assigned and the patient moved to a room in the ED. Once the patient was in a room, the ED RN triaged the patient and there was a proper hand-off between EMS and the RN. Patient #1 arrived as a transfer on 10/31/2023 at 2314 by EMS. No triage, nursing assessment or evaluation was completed in the ED. The patient was transported to the NSICU (Neurosciences Intensive Care Unit) on 11/01/2023 at 0105. A nursing note was written that stated the nurse was only transporting the patient to the inpatient unit and had not assumed care of the patient. The first nursing vitals or assessment were done at 0110 in NSICU. EMS monitored Patient #1 in the ED and nursing failed to accept, triage and provide care to a patient in the ED. 9. Review of the EMS Patient Care Record, on 11/14/2023, revealed EMS was called to Patient #2’s home on 10/17/2023. The EMS record revealed the call came in at 1654, EMS reached the patient at 1702, departed the scene at 1720 and reached the Hospital at 1748. The Patient Care Record noted the patient’s medical history was “Cirrhosis of Liver, Diabetes, Infectious disease, Neuropathy, Other-Infection of foot - amputation schedule for 10/21.” Review of the Narrative Note revealed “(EMS) DISPATCHED EMERGENCY TRAFFIC TO LISTED ADDRESS REFERENCE SYNCOPAL EPISODE WITH CHEST PAIN AND SHORTNESS OF BREATH ...ARRIVED ON SCENT TO FIND A 66-YEAR-OLD MALE, A&Ox4, SKIN PALE, WARM, AND DRY, SITTING UPRIGHT IN A RECLINER IN THE LIVING ROOM. PT ADVISED HE HAD BEEN HAVING CHEST PAIN AND SHORTNESS OF BREATH FOR THE LAST WEEK ....ADMINISTERED ASPIRIN ...PT ADVISED THAT HE AND HIS FRIEND HAD BEEN WORKING AROUND THE HOUSE AND ALL OF A SUDDEN HE DID NOT FEEL GOOD AND PASSED OUT. PT’S FRIEND ADVISED PT DID NOT FALL, ‘I CAUGHT HIM ON THE WAY DOWN.’ .... PT ADVISED HE RECENTLY HAD SURGERY ON HIS FOOT AND IT HAD GOT AN INFECTION AND WAS TAKING ANTIBIOTICS FOR SAME. PT ADVISED HE WAS GOING TO NEED ANOTHER SURGERY TO REMOVE THE BIG TOE OF HIS LEFT FOOT. IT WAS NOW NOTED THAT PT’S EKG WAS SHOWING ....ALSO SHORT RUNS OF A WIDE COMPLEX TACHYCARDIA. PT REMAINED COMPLETELY A&Ox4 ....PT WAS PLACED ON SUPPLEMENTAL OXYGEN WITH NOTED IMPROVEMENT IN BREATHING, ACCORDING TO THE PT. PT WAS TRANSPORTED ROUTINE TRAFFIC TO (Hospital) ....WHILE ENROUTE PT’S VITALS WERE CONTINUALLY ASSESSED ...IV ACCESS WAS OBTAINED ...PT WAS FOUND TO HYPERGLYCEMIC (high blood sugar). PT ADVISED HE HAD NOT BEEN ABLE TO TAKE HIS INSULIN YET TODAY ....PT WAS ADMINISTERED FLUID AS RECORDED ....PT ADVISED HIS CHEST PAIN WAS A 6/10 AND THAT TAKING A DEEP BREATH HURT. PT ADVISED THIS HAS BEEN GOING ON ALL WEEK AND HAS NOT CHANGED. (Hospital) WAS CONTACTED FOR PT NOTIFICATION. UPON ARRIVAL AT (Hospital) PT WAS TAKEN TO ER ROOM, WHERE (EMS) WAITED FOR ER PERSONNEL TO COME FOR THE HANDOFF REPORT WHILE BEING CONTINUALLY MONITORED. A FACILITY RN FINALLY ARRIVED AND A FULL REPORT WAS GIVEN AND PT CARE WAS TRANSFERRED TO THE RECEIVING RN. ...” EMS record review revealed the team arrived to the hospital with Patient #2 at 1748 and care was transferred to hospital staff at 1907 (1 hour, 19 minutes after arrival). Review revealed EMS staff continued monitoring Patient #2 after arrival with vital signs generally taken every 5-6 minutes. The last recorded EMS vital signs were at 1858 with BP noted as 104/61, pulse 70, respirations 15, 99% pulse ox and a pain score of 6. A note was made on “Turn Around Delays” that indicated “ED Overcrowding/ Transfer of Care. ...” Review of the medical record, on 11/14/2023, revealed Patient #2 arrived to the hospital on 10/17/2023 at 1753 via EMS. Review of “ED Triage”, performed 10/17/2023, at 1900 (1 hour and 7 minutes after arrival) revealed a pre-hospital blood glucose of 459 and an acuity of “3-urgent”. Vital signs were: Temperature 97.9, Pulse 72, Respirations 20, blood pressure 106/69 and oxygen saturation of 100% on 4 liters oxygen. Patient #2’s pain score was 7. Review of the “ER Report” by a Physician Assistant, on 10/17/2023 at 1845, revealed “... 66-year-old male patient .... presents.... (to the) emergency department today via EMS for chief complaint of chest pain and shortness of breath. Patient reports that he has had chest pain and shortness of breath ongoing over the past week and reports that these symptoms are aggravated with exertion. He also reports aggravation to shortness of breath with lying supine and he states that today he had acute worsening to his symptoms and also had a syncopal episode earlier today. He reports pain and shortness of breath are still present. He states that he also has bilateral lower extremity swelling which has been ongoing over the past couple of weeks....He states that he has ulcer to the first metatarsal of his left foot and this extends to his bone. He states that he has planned to have amputation of the first digit of his left foot this coming Friday patient currently taking ciprofloxacin (antibiotic, Diflucan (antifungal), and Duricef (antibiotic)....Medical Decision Making ... EMS reports that they gave patient 324 mg aspirin....blood pressure was approximately 96 mmHg. They gave one L (liter) of normal saline IV blood pressure is 105/66 now. EMS also reports that patient had 7 beat run of V tach on their EKG tracing in route with patient now in sinus rhythm and occasional bigeminy. Ordered EKG and for patient to be on telemetry....Point-of-care CBG (blood sugar), CMP (comprehensive metabolic panel), CBC (complete blood count), troponin, proBNP, D-dimer, lactic acid, and portable 1 view chest x-ray ordered. EKG obtained and notes sinus rhythm with PVCs and 4 beat run of V tach....1953 Dr. (Name) called to patients bedside for cardiac arrest and assumed care of patient. CPR initiated ....2017 ....Called lab to request results of chemistries be available as soon as possible. Labs resulted after arrest ....Resuscitation attempt failed. Patient deceased. Suspect etiology to cardiac arrest related to MI (Myocardial infarction- heart attack). Review revealed a Stat order for an EKG at 1841. Review did not reveal an EKG was completed until 1905 (24 minutes after ordered and 1 hour and 12 minutes after arrival). Review of lab orders revealed the following lab tests were ordered in the ED stat at 1841 (48 minutes after Patient #2 arrived): Lactic Acid, CMP (comprehensive metabolic panel), Troponin, D-Dimer, Pro B-Type Natriuretic Peptide (ProBNP) and CBC with Differential. Review of orders revealed the labs were collected as Nurse collects at 1920 (39 minutes after the lab orders). Patient #2 experienced cardiac arrest at 1953, 2 hours after arrival. The CBC resulted at 2002 and the CMP resulted at 2012. The D-Dimer resulted as 824 (high) at 2006. The Pro BNP resulted as 9690 (High - reference range 5-125) at 2023 and the Troponin resulted as 0.460 (High - reference range 0.000-0.034) at 2039 (1 hour 19 minutes after the lab was collected; 1 hour, 58 minutes after it was ordered). The physician was notified. Review revealed the physician was notified 2 hours, 46 minutes after Patient #2 arrived to the ED and 15 minutes after the patient expired). Review revealed delays in ordering, collecting and resulting the labs and a delay in obtaining an EKG. Review of the “ER Report”, service date/time 10/17/2023 at 2030, revealed “ ...The patient was initially evaluated by the emergency department physician assistant .... Work-up for chest pain and syncope were underway. I was called to the patient’s bedside at 1953 for cardiac arrest. Staff reports that only moments before the patient had been alert and talking. CPR (cardia pulmonary resuscitation) was initiated. The patient was placed on a monitor and defibrillator. Initial rhythm revealed ventricular tachycardia (fast heart rhythm). He received electrical therapy and CPR was resumed. Patient received high-quality chest compressions. He would briefly show signs consciousness indicating adequate cerebral perfusion (blood to the brain) with chest compressions, but remained without an organized rhythm ....required continuation of CPR. He received multiple doses of electrical therapy ....He received magnesium as well as amiodarone (medication for irregular heart rhythm) for shock refractory ventricular tachycardia. Ventricular tachycardia progressed to ventricular fibrillation (life threatening arrhythmia). He also received multiple doses of epinephrine (emergency medication) per ACLS (advanced cardiac life support) protocol for pulseless arrest. He was intubated ....I called the physician assistant to the bedside to brief me on the details of the initial presentation. During the resuscitation I took the opportunity to review the available work-up. The EKG was brought to me for review at 2002 ....For this patient who presented with chest pain, syncope, and suffered cardiac arrest has either suffered an MI or rhythm disturbance ....I reviewed his medications ....I made attempts to address ....reversible causes of cardiac arrest. As resuscitation proceeded the rhythm progressed ....to asystole ....After 30 minutes of resuscitation he remained in asystole. All team members agreed that further resuscitative efforts were futile ....the patient was pronounced dead at 8:24 PM ....10/17/23 20:38:56 I received a (sic) from the chemistry lab. Troponin is 0.46 ....Diagnosis/Disposition Chest pain Syncope Ventricular tachycardia Cardiopulmonary arrest. ...” Telephone interview on 11/20/2023 at 1415 with EMS #70 revealed they responded to a call for a patient with chest pain and shortness of breath. Interview revealed on EKG the heart was very irritated, throwing PVCs (arrhythmias), PACs (arrhythmias) and then short runs of wide complex tachycardia (rapid heart rate). Interview revealed there was potential for things to turn unstable quickly. By the time they got to the hospital there were just a few PVCs. EMS #70 stated they arrived to the hospital at 1750 and were assigned a room at 1756 but they got to the room and there was a patient in the room which caused the wait. EMS #70 stated at some point the patient started to get hypotensive and the fluids had emptied, so the other EMS staff gathered another bag of fluids. Patient #2, per EMS, was on supplemental oxygen and had no complaints at the time. Interview revealed they got the patient into an ED bed at 1845 but there was no nurse for report. At 1907 (1 hours, 17 minutes after arrival), per interview, EMS was able to give hand-off report to a nurse. Interview revealed waits had gotten more common recently and it seemed like a staffing issue. Telephone interview with PA #71, on 11/15/2023 at 1600, revealed the patient came into the ED with EMS and there were no rooms available. PA #71 stated he saw the patient while in the hallway and placed orders. Interview revealed the patient had not been triaged, he was still in the hall. Interview revealed prior to arrival the patient had “a few runs, approximately 8 beats”, of V tach. PA #71 stated the patient was given a liter of fluids and the rhythm improved. Patient #2 remained on the EMS monitor prior to getting a formal EKG in the ED, the PA stated. Interview revealed there were another 4 beats of V tach but it was not sustained; the patient appeared stable. PA #71 moved to another patient and did not see Patient #2 after he got in an ED room until the PA heard the code and responded. Interview revealed these patients should be closely monitored. Interview revealed the goal for the screening evaluation was 20 minutes from arrival. Telephone interview with RN #66, on 11/16/2023 at 0938, revealed the nurse assigned to Patient #2’s room was busy and not able to triage the patient, so a radio request for help was made and RN #66 responded, did the hand-off with EMS and triaged Patient #2. The patient had been placed on a monitor by the Certified Nursing Assistant (CNA). RN #66 then received report from EMS. Interview revealed there was no bed available when Patient #2 first arrived by EMS. When RN #66 went to triage the patient, Patient #2 had just been put in a room and was stable, alert and talking. RN #66 stated that after Patient #2 was triaged, RN #66 drew blood for labs; labs were not drawn until after the patient was accepted and in a room. Until the patients were in a room and care handed-off from EMS, interview revealed, they were “counting on EMS to care for (the patients). ...” Telephone interview on 11/16/2023 at 1100 with MD #72 revealed he heard the overhead page for Patient #2 and immediately responded. Interview revealed the expectation for chest pain patients was an EKG within 10 minutes and to be seen by a provider within 10 minutes. Interview revealed there is a chest pain protocol, but the protocol had to be activated by a provider. MD #72 acknowledged there was a delay for Patient #2. Interview revealed in an ideal situation the patient would have gone straight back to a room and care started. Patient #2 was brought to the ED by EMS from home. The patient arrived on 10/17/2023 at 1753 with chest pain and a syncopal episode at home. The provider ordered labs at 1841 (48 minutes after Patient #2 arrived), and the labs were not collected by nursing staff until 1920 (39 minutes after orders), after the patient was triaged at 1900 (1 hour and 7 minutes after arrival). The patient was on a cardiac monitor and received vital signs by EMS until triage at 1900. No hospital EKG was completed until 1905 (24 minutes after order and 1 hour 12 minutes after arrival). The elevated D-Dimer did not result until 2006, the elevated Pro BNP did not result until 2023 and the elevated Troponin did not result until 2039. At 1953 a physician responded to the patient’s bedside due to a cardiac arrest. CPR was started and the patient expired. The hospital staff failed to accept the patient upon arrival to the ED, resulting in delayed triage, care and treatment. 47421 10. Closed medical record review of Patient #12 revealed a 41 year old female transferred to the ED (emergency department) on 07/18/2023 at 1623 via EMS (emergency medical service) for abdominal pain, nausea, chills, and evaluation by general surgery for concerns of appendicitis. No past medical history. Review of EMS run report revealed vital signs were taken at 1526 and 1555 via EMS. Review of ED record revealed a Medical Screening Examination (MSE) was performed at 1653. Further review of MSE revealed the CT (computed tomography) was consistent with appendicitis and general surgery consult placed at 1652. Review of physician orders revealed an order for q4h (every 4 hours) vital signs at 1729. An order for Dilaudid 0.25mg (milligram) Inj. Q3h, PRN (as needed), pain (refractory) at 1729. An order for Dilaudid 0.5mg Inj. Q15min, PRN, pain, at 1734. Review of ED record revealed the patient was assigned to RPOD-Hall 18 at 1756. Review of ED record revealed a pain assessment of 10 at 1759. Review of MAR (medication administration record) revealed the patient was given Zofran 4mg at 1757 and Dilaudid 0.5mg at 1759. Review of the General Surgery History and Physical at 1820 revealed a plan to proceed with laparoscopic appendectomy. Pain control and antiemetics as needed. Review of ED record revealed the patient was transferred to preop at 1830. Review of ED record revealed triage time at 1832 and vital signs documented at 1832 (2 hours and 9 minutes after the patient’s arrival). Interview on 11/14/2023 at 1153 with RN #91 revealed when patients are “on the wall” they are waiting to be assigned an RN (registered nurse) and put in a room. EMS stays with the patient in case they need any medical attention. Interview revealed it is typically not a long wait but can be up to an hour. Interview revealed patients can be seen by providers and prescribed medications while “on the wall” but can not get them because no RN has been assigned. 49480 11. Review on 11/16/2023 of “Nursing Management of Wounds and Alterations of Skin” policy revised 11/2021 revealed, “POLICY: Patients are assessed on admission and once every 12-hour shift for alterations in skin integrity and/or wounds. SCOPE:...Inpatient, acute care services, critical access hospitals, and other related services. Emergency Department (ED)...DOCUMENTATION: Document wound details: type, bed color, odor, drainage (color and amount), undermining/tunneling, induration, and erythema. Document intervention”. Review on 11/16/2023 of the “Assessment and Reassessment” policy revised 06/2021 revealed: “...PURPOSE: A. The goal of the assessment/reassessment is to provide the patient the best care and treatment possible...The nursing process is utilized in order to achieve this goal. This process includes assessing, analyzing, planning, implementing, and evaluating patient care or treatment...”. Closed medical record review on 11/14/23 of Patient #26 revealed a 22-year-old patient that presented to the Emergency Department (ED) via EMS (Emergency Management Services) on 09/01/2022 at 1845 for complaints of abdominal pain, decreased appetite, watery non-bloody diarrhea, and right-calf burn. Review of an ED Note dated 09/01/2022 at 2130 per medical provider indicated: “Assessment/Plan...Burn. I ordered bacitracin and instructed the nurse to apply a Xeroform dressing”. Review of Patient #26’s closed medical record lacked documentation that an ED nurse assessed and applied bacitracin and a Xeroform dressing to the patient’s right-calf burn. Review revealed the patient was transferred to inpatient room #566 A5-West on 09/03/2022 at 1357. Review revealed a nursing wound consultation was completed on 09/04/2022 at 1024. Review of Inpatient Wound/Ostomy Documentation Note dated 09/04/2022 at 1024 indicated: “Wound care consult received for calf burn...wound is pink, red wound bed, superficial. Communicated with RN (Registered Nurse) that wound team will not be able to prioritize this patient today. Would recommend provider place order for bacitracin to be applied generously, cover with xeroform gauze, then dry gauze and gauze roll, daily. Will only follow if wound worsend with appropriate treament-please reconsult if this occurs”. Review of a physician’s order dated 09/04/2022 at 2100 indicated: “Bactroban topical 2% cream to be applied three times daily at 0900, 1500, and 2100 for 7 days to right-calf wound”. Review revealed a lack of documentation related to the application of the aforementioned wound treatment per nursing. Review of the patient’s closed medical record lacked nursing documentation related to the assessment and treatment of the patient’s right calf wound from presentation in the ED on 09/01/2022 through discharge on 09/07/2022.”

“EMERGENCY SERVICES CFR(s): 482.12(f)(1) If emergency services are provided at the hospital, the hospital must comply with the requirements of §482.55. This Standard is not met as evidenced by: 16369 Based on policy review, medical record review, incident report review, Emergency Medical Services (EMS) trip report review, and staff and provider interviews, hospital leadership failed to ensure emergency care and services were provided according to policy and provider orders by failing to accept patient upon arrival to the emergency department, evaluate, monitor and provide treatment to emergency department patients to prevent delays and/or lack of triage, nursing assessment, and implementation of orders, including lab, telemetry and medication orders for eleven (11) of 35 ED records reviewed (#92, #83, #43, #28, #27, #29, #6, #1, #2, #12 and #26). The findings included: Cross refer to all findings at §482.55: Emergency Services A 1100. Emergency Department (ED) nursing staff failed to ensure emergency care and services were provided according to policy and provider orders by failing to accept patient upon arrival to the ED, evaluate, monitor and provide treatment to emergency department patients to prevent delays and/or lack of triage, nursing assessment, and implementation of orders, including lab, telemetry and medication orders for eleven (11) of 35 patient records reviewed (Patient #’s 92, 83, 43, 28, 27, 29, 6, 1, 2, 12 and 26). 1. Patient #92 presented to the ED with chest pain on 11/09/2023 at 1149. The patient was not assessed by a nurse after triage was completed at 1155, or with a change in condition, or after pain medication was administered at 1703. The patient was never placed on continuous telemetry in the ED as ordered by a physician at 1218. The patient was transferred to a medical floor and placed on telemetry at 2111 when he was found to be in atrial fibrillation with rapid ventricular rate, prompting a STEMI Code Activation. The patient underwent an emergency cardiac catheterization at 2249. ED nursing staff failed to provide ongoing assessment of the patient’s condition and follow physician’s orders for application of continuous telemetry. Nursing staff failed to ensure policies and provider orders were implemented. 2. Patient #83 was presented to the ED with dizziness on 11/28/2023 at 1216. The patient had STAT (immediate) lab work ordered at 1218 with continuous ECG monitoring. Labs were drawn at 1358 (1 hour and 40 minutes after ordered). Labs arrived at the lab at 1412 and resulted at 1532 (3 hours and 14 minutes after ordered). The blood glucose was 1137 (critically high). Insulin IV infusion was ordered at 1626 and initiated at 1709 (1 hour and 13 minutes after ordered and 1 hour and 37 minutes after the glucose resulted). Orders for continuous ECG monitoring placed at 1218, and vital signs every 2 hours were never initiated in the ED. At 2349 an IV infusion of D51/2 KCL was ordered that was not completed until 0157 (2 hours. and 8 minutes after ordered). Lactic acid was ordered NOW at 0127 for nurse collect in the ED. At 0200 a physician wrote there was a delay in labs and fluids so stopped the insulin IV infusion. The lactic acid was not collected in the ED. At 0529 the original lactic acid NOW, order was cancelled and reordered as lab collect NOW on the floor. It was collected at 0844 (3 hours and 15 minutes after ordered at 0529) and resulted at 1108 (9 hours and 41 minutes after originally ordered at 0127) with a result of 7.48 critical high. A second lactic acid was reordered at 1108 and resulted at 1256 (1 hr. and 36 minutes after ordered) with a result of 11.96 critically high. A rapid response was called previously at 1158, the patient was intubated at 1247, and ultimately expired on 11/30/2023. 3. Patient #43, a 39-year-old who presented to the emergency department (ED) by private vehicle on 08/14/2023 at 1603 with complaints of chest pain, nausea, clammy, lightheaded, right-side tingling for several weeks, with a reported history of drinks 12 beers a day. Review revealed the patient was located in the waiting room area and was observed by a physician to be diaphoretic. The physician ordered intravenous (IV) fluids and CIWA protocol (assessment tool used for alcohol withdrawal) at 1841, and Ativan (medication for anxiety) was ordered at 1947. These orders were not implemented. Multivitamin was ordered at 2100. Another order was placed at 2226 for IV fluids and Lopressor. Aspirin was ordered at 2229. None of these orders were implemented. An order written at 2305 for Phenobarbital administration was not implemented. At 0107, a physician’s note referenced the patient had a seizure and fall with a head injury outside the ED waiting room area. Findings revealed the patient had delays with nursing assessments, and failure to implement orders, including medication administration, and following the CIWA protocol. The patient subsequently had a seizure and fall with a resulting head injury. 4. Patient #28 presented to the ED on 07/05/2022, was critically ill, intubated and diagnosed with bacterial meningitis. The patient developed a low blood pressure and a Levophed IV drip was started. Findings revealed the Levophed IV drip was allowed to run dry and the patient’s blood pressure dropped to 33/18. A trauma PA was requested by the family for help related to alarms and the patient’s condition and the PA indicated the patient was not the PAs assigned patient. The patient arrested. A new Levophed bag was hung. The patient and IV were not monitored and the bag ran dry with subsequent cardiac arrest. 5. Patient #27 arrived in the ED on 07/04/2022 at 0025 with a reported pain level of 10 of 10. The patient had a STAT CT of the abdomen and pelvis ordered at 0027 that was not completed until 0755 (7 hours, 27 minutes later) resulted and signed at 0825. The patient had pain reported as 10 of 10, with nausea and vomiting with vital signs at arrival at 0025 and was medicated with Dilaudid (narcotic pain medication) at 0739 (7 hours and 14 minutes after arrival). The patient was diagnosed with a small bowel obstruction and had surgery that day. The patient had a delay with STAT lab work, STAT CT, nursing reassessment and pain management. 6. Patient #29 arrived on 04/05/2022 at 1451 via EMS and had atrial fibrillation (abnormal heart rhythm) on arrival. The patient had a recent fall with fracture prior to arrival. Pulse Oximetry was 94% prior to arrival. 1630 pulse oximetry was 90% (1 hour and 39 minutes after arrival) with no evidence of oxygen administration at hospital. Dilaudid 0.5 milligrams (mg) IV was administered at 1630 and at 1816. No vital sign or oxygen assessment on an elderly patient was assessed on the patient with a prior pulse oxygen of 90% after the administration of Dilaudid. The patient was subsequently asystole at 1909 and expired. Patient #29 had one set of vital signs from 1451 until time of death at 1909 (5 hours and 18 minutes). Nursing staff failed to reassess the patient after narcotic administration. Nursing staff failed to reassess the patient for a change in condition (not breathing). 7. Patient #6 arrived to Hospital B with strokelike symptoms at 10 days postpartum. She was accepted for transfer to Hospital A as an ED to ED transfer. Patient #6 arrived to the hospital via EMS on 10/03/2023 at 1942. The patient waited in the ED for a bed and continued to be managed by EMS. No documentation was noted by a medical provider until 2223 and Patient #6 was not triaged or assessed by hospital nursing staff until 2227 (approximately 2 hours 45 minutes after arrival by EMS). There was a delay in accepting the patient and a delay in triage, assessment and monitoring by nursing staff. 8. Patient #1 arrived as a transfer on 10/31/2023 at 2314 by EMS. No triage, nursing assessment or evaluation was completed in the ED. The patient was transported to the NSICU (Neurosciences Intensive Care Unit) on 11/01/2023 at 0105. A nursing note was written that stated the nurse was only transporting the patient to the inpatient unit and had not assumed care of the patient. The first nursing vitals or assessment were done at 0110 in NSICU. EMS monitored Patient #1 in the ED and nursing failed to accept, triage and provide care to a patient in the ED. 9. Patient #2 was brought to the ED by EMS from home. The patient arrived on 10/17/2023 at 1753 with chest pain and a syncopal episode at home. The provider ordered labs at 1841 (48 minutes after Patient #2 arrived), and the labs were not collected by nursing staff until 1920 (39 minutes after orders), after the patient was triaged at 1900 (1 hour and 7 minutes after arrival). The patient was on a cardiac monitor and received vital signs by EMS until triage at 1900. No hospital EKG was completed until 1905 (24 minutes after order and 1 hour 12 minutes after arrival). The elevated D-Dimer did not result until 2006, the elevated Pro BNP did not result until 2023 and the elevated Troponin did not result until 2039. At 1953 a physician responded to the patient’s bedside due to a cardiac arrest. CPR was started and the patient expired. Nursing staff failed to accept the patient upon arrival to the ED, resulting in delayed triage, care and treatment. 10. Patient #26 presented to the ED via EMS on 09/01/2022 at 1845 for complaints of abdominal pain, decreased appetite, watery non-bloody diarrhea, and right-calf burn. Review of the patient’s closed medical record lacked nursing documentation related to the assessment and treatment of the patient’s right calf wound from presentation in the ED on 09/01/2022 through discharge on 09/07/2022. 11. Closed medical record review of Patient #12 revealed a 41 year old female transferred to the ED (emergency department) on 07/18/2023 at 1623 via EMS (emergency medical service) for abdominal pain, nausea, chills, and evaluation by general surgery for concerns of appendicitis. Record review revealed the patient did not have her vital signs monitored and had no nurse assigned to monitor status or provide care. 41946 33790 47421 49480”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 26622 Based on review of the “Authorization for Nonpsychotropic Medicinal Intervention” form, medical record review and interview, the nursing staff failed to obtain authorization for psychotropic and nonpsychotropic medicinal interventions for one (1) of four (4) sampled pediatric behavioral health patient record reviewed. (Patient #75). The findings included: Request for policy revealed the hospital staff advised there was no policy available. The hospital provided a consent form titled “Authorization for Nonpsychotropic Medicinal Intervention” which stated “By signing below I, as the Legally Responsible Person for the minor, _________, do hereby give my consent for the physician to perform medicinal intervention as related to the aforementioned minor. I understand that the physician will be using _______ as medication for the purpose of treating the minor for ________. I also understand that I can revoke this consent at any time” and “Authorization for Psychotropic Medicinal Intervention” which stated “By signing below I, as the Legally Responsible Person for the minor, _________, do hereby give my consent for the physician to perform psychotropic medicinal intervention as related to the aforementioned minor. I understand that the physician will be using _______ as medication for the purpose of treating the minor for ________. I also understand that I can revoke this consent at any time.” The forms provided spaces for date/time, legally responsible person signature, relationship, and witness signatures. Review on 12/04/2023 of the closed medical record for Patient #75 revealed a 12-year-old female that presented to the Emergency Department on 06/30/2023 at 2251 by law enforcement with Involuntary Commitment (IVC) paper for assault on therapist and mother. Patient #75 was admitted to inpatient behavioral health services on 07/01/2023 at 2027. Review of the Medication Administration Record (MAR) showed that Patient #75 was administered Zyprexa on 07/01/2023 at 0018, Melatonin and Trazodone at 0045, Prozac, Guanfacine, Lamictal and Quetiapine at 0817, Tylenol at 0913, Benadryl and Zyprexa at 1006 and Sarna Topical Lotion at 1035. Review of the medical record revealed a signed authorization/consent form dated 07/01/2023 at 1614 for the following psychotropic medicinal interventions: Zyprexa (15 hours and 56 minutes after administered), Trazodone (15 hours and 29 minutes after administered), Prozac, Guanfacine, Lamictal and Quetiapine (7 hours and 57 minutes after administered) Zyprexa (6 hours and 8 minutes after administration). Review of the MAR revealed that Patient #75 was administered Benadryl on 07/01/2023 at 1006 with no evidence of a signed authorization/consent form from the parent/guardian. Review of the medical record revealed a signed authorization/consent form dated 07/01/2023 at 1614 for the following non-psychotropic medicinal interventions: Melatonin (15 hours and 29 minutes after administered), Tylenol (7 hours and 1 minute after administered), and Sarna Topical Lotion (5 hours and 39 minutes after administered). Interview on 12/06/2023 at 1520 with RN #84 revealed that consent forms should be obtained from the parent/legal guardian prior to administration of psychotropic and/or non-psychotropic medications to a minor.”

“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: 16369 Based on observations, review of the “Environmental Risk Assessment for Suicide Prevention” form, and staff and provider interviews, the hospital failed to ensure a safe environment for behavioral health patients subject to self-harm in the Emergency Department (ED) Pods (cluster of rooms in a designated area), and identify and/or remove potential environmental hazards that were located in the designated behavioral health area. The findings included: 41946 33790 47421 49480 40299 Observation on 11/13/2023 at 1150 during tour of the emergency department (ED) revealed Green Pod had twelve patient care rooms, eight of which had adolescent behavioral health patients in them. Three of the eight patients had a sitter at the doorway of their room (Room 78, 80, and 83). Observation revealed all eight behavioral health patients had a corded call bell. Tour of the Purple Pod revealed a twelve-patient care room unit with eleven behavioral health adult patients in them. Observation revealed all eleven patients had corded call bells. There were two sitters for two of the eleven patients (Room 44 and 48). There were three rooms in the Purple Pod that had Hoyer lifts (device to assist with moving and lifting a patient who cannot move themselves) on the ceiling (Rooms 37, 42, and 45). The twelve rooms and the bathrooms in the Purple Pod had rectangle shaped hook(s) behind the door that were not breakaway hooks. Staffing consisted of two Registered Nurses and a Rover (a Patient Safety Attendant assigned to round every fifteen minutes on the patients in the unit). Observation on 11/15/2023 at 1315 in the Purple Pod revealed eight behavioral health adult patients. The Rover (Patient Safety Attendant assigned to perform every fifteen-minute checks) took a corded telephone into Room 46 and left the room. The patient in the room did not have a virtual sitter nor a one-to-one sitter while having the corded telephone. Observation on 11/30/2023 at 0947 during tour revealed there were four patients in the Green Pod with corded call bells. There were no sitters with the four patients. The patient in room 77 had a hospital bed with a fitted sheet on the bed instead of the behavioral health safe sheets (linen that is designed to not hold tied knots). Observation revealed Rooms 73 and 82 had bathrooms within the patient rooms. Each bathroom contained safety handrails that you could tie something completely around the rail, normal toilets, regular faucets on the sinks, and regular mirrors. Observation during tour of the Purple Pod revealed the Pod had been “flipped” back for non-behavioral health patients. On 11/30/2023 a review of the “Environmental Risk Assessment for Suicide Prevention” performed on 09/08/2023 revealed any ligature risk identified were listed as being mitigated by monitoring needs that were put in place as identified by the suicide risk scores. Interview on 11/27/2023 at 1500 with Acting Chief Nursing Officer (ACNO) #47 revealed that all the rooms are ED rooms and all the Pods in the ED were used for any type of ED patients. A behavioral health patient could be placed anywhere in the ED not only in the Blue Pod, or the current overflow Pods, Green and Purple, that were currently used to house overflow behavioral health patients. ACNO #47 stated that all behavioral health patients get a C-SSRS (Columbia Suicide Severity Rating Scale- assessment tool used to evaluate a patient’s suicidal ideation and behavior) score performed by a nurse. The C-SSRS score was used to determine if a patient was low, moderate, or high risk (a yes answer on key questions within the assessment would increase the score from low to moderate or high risk). Interview revealed a medical provider would perform their assessment and their determination trumps the score of the nurse. Interview revealed the risk of self-harm was mitigated based on the patients’ C-SSRS score, if a patient was Low risk, they were rounded on every fifteen minutes by the Rounder, if the patient was Moderate risk, they got a virtual sitter, and if the patient was High risk, they got a one-to-one sitter. Interview on 11/27/2023 at 1504 with Nurse Vice President for ED Services #20 revealed the risk of self-harm were mitigated based on the patients’ C-SSRS score. Interview revealed if a patient was Low risk, they were rounded on every fifteen minutes by the Rounder, if the patient was Moderate risk, they got a virtual sitter, and if the patient was High risk, they got a one-to-one sitter. The nurse would check on the patient as they deem appropriate and perform safety checks on every patient in the Pod every hour. Interview on 11/28/2023 at 1306 with COO (Chief Operating Officer) #50 and ACNO #47 revealed nursing took safety steps for overflow areas of behavioral health patients in the Green and Purple Pods. The staff members reported that nursing checked off in the electronic medical record that they have validated the rooms were safe for the patient. The hospital saw an increase in the number of behavioral health patients, so when the new Pediatric ED area opened in September of 2023, the space that was previously used for pediatrics (identified as the Purple Pod) became an overflow/holding area for behavioral health patients. Interview revealed the last known time a medical ED patient was in the Purple Pod (a pediatric patient) was September 26, 2023 (after the environmental risk assessment for suicide prevention was performed on September 8, 2023). Interview revealed safety for behavioral health patients in the Green Pod based on their C-SSRS score would be every fifteen-minute check by the Rounder or the virtual sitter, or the one-to-one sitter. Depending on the volume of patients and their acuity (high risk, elopement risk, patients that wander) there would be either one or two Rounders in the Pod. Interview revealed if the volume was low, the hospital may need to and can put an adult patient in the Green Pod with the adolescent behavioral health patients. Interview revealed that based on the C-SSRS score, they would put in place mitigators (staff to monitor) to assure safety for patients. The staff member stated they do not monitor and cannot pull the data to determine the last time there were both pediatric/adolescent and adult patients in the Green Pod at the same time. Interview revealed the staff do not monitor when the Pods are used as behavioral health only patients versus medical ED patients, nor how frequently they are being flipped back and forth. It was reported that the staff mitigate the risk of harm in the room space down to what is deemed appropriate by removing trash cans, suction, cords, and make sure the beds have a behavioral health approved sheet on it. Interview revealed the corded call bell was not removed from the room as it is the patient’s way of calling staff if they need something and it operates the television in the room. Mitigating factors (every fifteen-minute check, virtual sitter, or one-to-one sitter) are put in place based on the C-SSRS score. The staff member reported corded telephones are used if the patient wants to make a telephone call, and that it was a patient’s right to make telephone calls. If the patient was high risk, have a one-to-one sitter with them when they have the telephone, if they were a moderate risk they have a virtual sitter with them, and the low risk has an every fifteen-minute check done by the Rounder. The “nurses are really in tune with the patients” in behavioral health. Interview revealed the nurses rotate throughout the ED and were not always working in the pods that have behavioral health only patients in them. Interview revealed the Green Pod and Purple Pods were not psych friendly. Mitigating factors were put in place such as every fifteen-minute check, virtual sitters, or one-to-one sitters based off the patients C-SSRS score. Interview on 11/30/2023 at 1532 with Manager #51 and Manager #49, that performed the Suicide Risk Environmental Assessment on 09/08/2023, revealed the Green Pod and Purple Pod areas were a medical ED and not a Behavioral Health unit. Behavioral Health patients could be in any area of the ED. The staff reported that all risks for behavioral patients in the ED could be mitigated by every fifteen-minute observation, a virtual sitter, or a one-to-one sitter. The staff stated, the call bell cords break away from the wall if, for instance, someone pulled on it or put too much pressure on it. It was stated that they did not look at the cord itself as a risk used for hanging or self-harm, just that it could break away from the wall. Telephone cords were not evaluated on the risk assessment that was performed, and staff reported they were not aware that Behavioral Health patients were given a telephone with cords in their rooms. The interview revealed that a risk assessment was done for the entire ED on September 08, 2023. Interview revealed the staff conducting the assessment did not go in every room in the ED when they did the Environmental Risk Assessment for Suicidal Prevention. The staff members stated that they did not go back and look at the Purple Pod that was converted over to behavioral health holding/overflow after the pediatric patients were moved to the new pediatric ED.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 41946 Based on policy review, medical record review, incident report review, pharmacy unit inspection review, personnel file review, hospital document review and staff and physician interviews, the hospital staff failed to ensure tracking and trending of medical errors by failing to document incidents for improvement opportunities and failing to investigate potential causes and identify corrective action for seven (7) of 94 sampled patients reviewed (Patient #’s 58, 27, 59, 50, 15, 13 and 2) The findings included: Review of the hospital policy titled “Event and Close Call Reporting” revised 10/13/2022 revealed “... Facility risk management personnel have the affirmative duty to oversee timely and thorough reporting within the designated systems ... Facility risk management personnel have the affirmative duty to oversee timely and thorough reporting within the designated systems... This policy applies to services provided by (Hospital Corporate Name) staff members in each of these settings: ... *Inpatient services, including acute care and behavioral health, critical access hospitals, and other related services * Emergency Departments (ED) * Hospital-based outpatient department or ambulatory services, including but not limited to behavioral health services and Independent Diagnostic Testing Facilities ... *Physician practices or clinics that may include rural health clinics or federally qualified health care centers ... NC Division Clarification ... In addition to the roles listed in the policy, the Directors of Quality and Patient Safety and/or Administrative Quality Directors are also responsible for oversight of this process ... Escalation to Leadership ...” 1. Medical record review revealed Patient #58 had a witnessed fall on 04/26/2023 following abdominal surgery for a gun shot wound. A CT (cat scan) of the Abdomen and Liver on 04/26/2023 showed changes to a liver hematoma (clotted blood within the tissues) from the previous CT study on 04/25/2023. Patient #58 was moved to ICU (intensive care unit) for closer monitoring, and Interventional Radiology was consulted to rule out active bleeding. On 04/27/2023 Patient #58’s hemoglobin dropped from 13.2 to 7.3 [6.0] and he received 2 units of red blood cells, and he underwent CT Angiogram and found no active bleed. Request for an event report on 12/05/2023 revealed there was not one available for Patient #58 after a witnessed fall, that required interventions. Telephone interview on 12/06/2023 at 1332 with RN #95 revealed she remembered the patient. Interview revealed “...he said he was going to pass out. We assisted him back to the bed after the fall and called a rapid response. I called the doctor. I didn’t remember to complete a report, it was not quite a fall. I guided him to the bed, and another nurse picked his legs up onto the bed...” Interview revealed Patient #58 had a witnessed fall, and an event report was not completed for Patient #58. Interview revealed hospital policy was not followed for Patient #58. Interview on 12/06/2023 at 1409 with the Charge Nurse, RN #96 revealed “...if a patient falls, we complete a (named) an incident report...” Interview revealed for witnessed falls an incident report should be completed. Interview revealed an event report should have been completed for Patient #58. Interview revealed hospital policy was not followed for Patient #58. Telephone interview on 12/07/2023 at 0906 with MD #94 revealed he remembered the patient. Interview revealed “...he had a traumatic liver injury it would not be surprising to have a re-bleed, it required packing, and hemorrhage control. He did get an CT and have an interventional radiology angiography procedure after the event to ensure he didn’t have an active bleed...It’s impossible to tell...the fall did not extend an injury or stay at the hospital...” Interview revealed Patient #58 did have interventions after the fall on 04/26/2023 to ensure he had no active bleeding. Interview revealed hospital policy was not followed for event reporting for Patient #58 after a witnessed fall. 2. Review on 12/05/2023 of the policy Facility Event and Close Call Reporting Policy and Procedure, with effective date 04/01/2022 revealed “...PURPOSE: This policy is intended to minimize risks to patients, ...through the development and implementation of an event and close call reporting system based upon the affirmative duty of all health care providers and all agents and employees of the licensed health care facility to report events and close calls to the Patient Safety Director, Risk Manager, or designee. Furthermore, this policy is intended to mitigate risks and improve quality of services by outlining the processes for factual reporting of events, close calls, and unsafe situations. POLICY: Facility staff will provide the needed data elements through a formal, documented event reporting system. Event reports should be completed as soon as possible after the event, but no later than the end of the shift...X. Fair and Accountable Reporting Culture...B. The responsibility for reporting an event or close call rests with any person who witnesses, discovers, or has direct knowledge of that event or close call...” Medical record review revealed Patient #27 arrived in the ED on 07/04/2022 at 0025 with a reported abdominal pain level of 10 of 10, and nausea and vomiting. The patient had a STAT CT of the abdomen and pelvis ordered at 0027 that was not completed until 0755 (7 hours, 27 minutes later) resulted and signed at 0825. The patient had pain reported as 10 of 10, with nausea and vomiting with vital signs at arrival at 0025 and was not medicated with Dilaudid (narcotic pain medication) at 0739 (7 hours and 14 minutes after arrival). The patient was diagnosed with a small bowel obstruction and had surgery that day. The patient had a delay in pain management, STAT lab work, STAT CT, and physician orders as prescribed. Request for a Patient Safety Report (Event Report) revealed there was not one available. Interview on 11/15/2023 at 1350 with ED RN #38 who triaged Patient #27 revealed patients had delays in receiving pain management, STAT lab work and completion of physician orders in the ED waiting room. Interview revealed an event report was not completed for Patient #27. Interview on 11/17/2023 at 1102 with NP #39 revealed she had current concerns with waiting room patients not getting orders completed in the ED waiting room. Interview revealed an incident report should have been completed for Patient #27. Interview on 11/15/2023 at 1414 with ED MD #26 revealed “...I saw the patient after she was roomed.... There is not always a person to get labs and orders done. No staff to place orders. With the new process the goal is for that not to happen, but at night I suspect it does. As far as care in the waiting room, this patient didn’t get vital signs, or overall assessments and no meds...things are not happening on a timely basis...” Interview revealed Patient #27 did not receive pain management, STAT lab work, STAT CT, and physician orders as prescribed. Interview revealed an incident report should have been completed for Patient #27. 32003 3. Closed medical record review revealed on 3/4/2023, Patient #59 was admitted to the oncology unit and received a diagnosis of acute myeloid leukemia. Per physician orders, treatment for acute myeloid leukemia included Dacogen (intravenous chemotherapy medication) and Venetoclax (oral oncology medication). On 3/17/2023, the patient was infused Dacogen after two (2) [oncology nurses] verified the medication. Further review revealed on 3/18/2023, an Oncologist documented that the patient received an expired dose of Dacogen. The incident report for Patient #59’s medication administration of the expired dose of Dacogen, was requested on 12/7/2023 at 11:00 AM from the Director of Quality. No incident report was provided. Upon inquiry for pharmacy unit inspections from March 2023 through November 2023 revealed there had only been one inspection documented on 5/16/2023. Interview on 12/6/2023 at approximately 8:45 AM with the oncology pharmacist revealed oncology patients could be located on any unit within the hospital, in which case, the oncology medication would be delivered from outpatient infusion pharmacy to the oncology unit. The oncology nurse(s) would be responsible for going to the perspective unit(s) for the administration (intravenous and/or oral) of the medication. The pharmacist was unaware that an oncology patient was administered an expired dose of Dacogen. Interview on 12/7/2023 at approximately 10:30 AM with oncology staff revealed that Patient #59 declined the first dose of Dacogen, which could have resulted in the administration of an expired medication. Interview on 12/7/2023 at 11:00 AM with the Director of Quality revealed the Oncologist failed to enter an incident report and/or failed to speak to anyone regarding the administration of an expired dose of Dacogen to Patient #59 that occurred 3/17/2023. Interview on 12/7/2023 at 1:51 PM with the Oncology Unit Manager (OUM) revealed in April 2023 the oncology unit adopted a more detailed treatment administration checklist to assist the oncology nurses and the pharmacy department. The OUM further indicated she could not speak to the effectiveness of the updated checklist because no audits had been performed. Telephone interview on 12/8/2023 at 3:00 PM with the Oncologist revealed providers were made aware after-the-fact of any problems or concerns. As related to the administration of expired medication to a patient, the oncologist revealed, efficacy should be the main concern which falls upon the pharmacy department and was pretty sure this was what happened in the case of Patient #59. Further inquiry revealed that since the hospital joined [name of organization], the oncology unit lost valuable nurses which led to the hiring of new/inexperienced staff, and increased use of travel staff. The changes in staff led to an increase in errors, especially with neutropenic patients, which resulted in a degradation in care. Additionally, in the past oncology patients were directly admitted to the oncology unit without emergency department presentation. Now, oncology patients were admitted through the emergency department secondary to closure of transfers, which put the oncology patients at an increased risk for infection. Additionally, the unit no longer admitted complex cases of oncology patients because those cases were referred to other hospitals. Further interview revealed pharmacy errors increased secondary to the loss of experienced oncologist pharmacists. The interview concluded with the aforementioned concerns were voiced to the Medical Director for the oncology service line in which there were no notifications or any observations of changes. 40299 4. Review of the closed medical record for Patient #50 revealed a 21-year-old female presented to the Emergency Department (ED) via law enforcement under IVC (involuntary commitment) for a “Psychiatric screening exam; Behavioral health concern.” Review of the Provider Note dated 05/04/2023 at 1640 revealed “... patient presents with IVC paperwork and recent behavior concerning for danger to others in particular ... I will have behavioral health services see the patient ...” Review of the Initial Psychiatric Evaluation dated 05/06/2023 at 0531 revealed “The patient is a 21 yo (year old) female with h/o (history of) autism and mild intellectual disability, who was brought to the ED under IVC due to increasingly aggressive behavior. The IVC paperwork reports (sic) that the patient has been going around the neighborhood with a hammer. She has done thoughtless things such as covering her father’s eyes with his hat while driving and then kicking him. The (sic) patient’s behavior has been escalating since she could no longer participate in her programs during COVID 19 (pandemic). Instead of going to a group home, she was d/c (discharged) home from her last program. She has been increasingly irritable since she is swinging to calm herself down and has demonstarted (sic) dangerous behaviors ... Nursing reports pt (patient) became unexpectedly agitated this AM (morning), pulled nurse and sitter’s hair after being asked if her ears hurt (she was pulling at them). She received 5 mg (milligrams) Versed (medication to help you relax) at time of arrival to the ED yesteay (sic) afternoon, but otherwise no PRN (as needed) medication. She has not required restraint ... She is mostly mute (refraining from speech), although sometimes echolalic (repeat others) and echopraxic (involuntary copying of another person’s actions or movements). She waves when I wave. Says ‘hello’ when I say hello, and ‘happy’ when I ask if she is happy’(sic) ... Suggested plan; Uphold the IVC for now; observe the patient for the next 24-48 hours (sic); if the patient is stabilized, she can be discharged home or to a new placement, if one is available.” Review of the Mental Health Contact Note dated 05/08/2023 at 1017 revealed “... reached out to Pt’s mother, ..., and informed her that Pt was seen by Psychiatrist who is recommending discharge due to concerns of Pt safety on this unit, her aggressive behaviors w/ (with) other Pt’s ...” Review of the Nurse Note dated 05/29/2023 at 0855 revealed “... This was the third time pt had attacked the hair of a sitter.” Review of the Provider Note dated 05/29/2023 at 1007 revealed “...Patient was triggered by her sitter and attacked her this morning jumping on top of her and grabbing her hair ... Nursing staff reports this is the third sitter she is intact (sic) in the past 2 days ...” Review of the Nurse Note dated 06/10/2023 at 1920 revealed “Earlier today ... had multiple aggressive acts towards me, the first was when she spit on me as I was handing her a snack in the BHU (behavioral health unit) ... The second aggressive act came hours later when she saw me in the hall and came towards me. I attempted to walk away but she ran towards me, screaming and reaching for my face. She was able to pull the mask off my face but I restrained her hands and took several steps back, when she came after me again screaming and tearing at my head and face. I restrained her hands again and walked her back into her room towards her bed. As I let go and backed up ... leaned on her bed and kicked me in the chest with all her force ... I don’t intend to escalate this matter any further and have explained the entire situation to the psych clinician.” Mental Health Contact Note dated 06/18/2023 at 2100 revealed “... sitting in BHU intake office and heard yelling. Pt seen ... on camera gripping a male pt hair in ... hallway bed. Pt was standing over male pt’s hallbed (sic), hand in male pt’s hair shaking pt’s head around. Male pt was yelling ... immediately came out of BHU intake office, pt ran back towards her room into her bed. Male pt was visibly upset and yelling at pt in her room ...” Nurse Note dated 06/18/2023 at 2130 revealed “Pt. ran out of her room and pulled hair/hit another pt who was in a hall bed. After getting loose the pt. ran after her back in to her room, a BERT (behavioral health emergency) was called, physician, RNs, psych clinicians, and security all responded. The pt who was attacked aggressively was shouting, punching the walls, and hitting her bed. We were able to de-escalate the situation and both pts. We moved the second pt. to a differed pod in his own room so he would feel safe. It is unsure if (Patient #50) was hit while he was hitting her bed, physician did an assessment and she has no obvious injuries or marks. Pts are both settled in separate areas now.” Review of the medical record revealed Patient #50 was discharged to a facility on 06/20/2023 at 1659. Review on 12/05/2023 of the incident/variance reports provided regarding Patient #50 revealed there were no incident/variance reports for the incident on 05/29/2023 nor on 06/10/2023 to correspond with the incidents described in the medical record notes. There were incidents dated 05/27/2023 and 06/18/2023. Telephone interview on 12/06/2023 at 1400 with PSA #48 revealed she remembered Patient #50 and had to push her distress alarm button when caring for Patient #50. Interview revealed there had been several incidents involving Patient #50 pulling staff hair, attacking staff or other patients. Interview revealed PSA #18 had submitted incident/variance reports herself regarding more than one incident with Patient #50. Interview revealed there was a male patient in her room one time. PSA #18 could not remember the details about this incident, however confirmed she had filled out an incident report. PSA #18 stated there was a time when Patient #50 kissed another patient and an incident report should have been filled out about that. Interview on 12/06/2023 at 1500 with Director #82 revealed she only had four incidents/variances for Patient #50. Three of the four were dated 2022 and only one from 2023. Director #82 did not have the incident/variance provided to this surveyor dated 05/27/2023. Interview revealed the person entering the incident/variance did not enter the medical record number and Director #20 searched by the medical record number. Interview revealed it is hard to find incidents/variances if the medical record number is not entered so the information will pull across the system and make it easier to find. Interview revealed they can search by name however if the name is misspelled there would be problems finding any incidents/variances that were entered. Director #82 requested more time to research to see if there were more incidents/variances. At time of exit from facility on 12/09/2023 at 1600, Director #82 had not provided any additional information to this surveyor regarding additional incidents/variances for Patient #50. 47421 5. Closed medical record review of Patient #15 revealed a 21 year old male admitted on 08/14/2023 with abdominal pain. Record review revealed the patient had laparoscopic converted to open total abdominal colectomy (remove all or part of colon) with end ileostomy (stoma-opening in abdomen surgically created) on 08/27/2023 for ulcerative colitis. Record review revealed on 08/27/2023 at 1117 a ketamine drip was ordered stat (urgent). Record review revealed the patient arrived in PACU (post anesthesia care unit) at 1120. Patient transferred to floor (unit) at 1420. Record review revealed ketamine was started at 1448 on the unit. Patient returned to PACU at 1515 for ketamine drip. Review of nursing note on 08/27/2023 at 1526 revealed “Ketamine gtt (drip) sent to floor from pharmacy rather than to PACU. Patient arrived on the unit from PACU without ketamine gtt started. Notified (named) CNC (clinical nurse coordinator) and called to PACU nurse for patient to be transferred back to PACU for ketamine gtt initiation and required monitoring.” Review of nursing note on 08/27/2023 at 1656 revealed “Pt (patient) transferred to floor after report called to RN (registered nurse). PT was ordered Ketamine and the pharmacy sent the medication to the nursing unit instead of PACU. RN agreed in report to start ketamine on pt arrival to floor, since the ketamine was on the unit. Pt later brought back to pacu when nurse became aware that she was not cleared by hospital regulations to start the ketamine gtt.” Review of a ketamine drip timeline document revealed Ketamine drip ordered at 1117. The order was verified by pharmacy at 1140, but the label was not printed. Missing medication request sent by the RN at 1228, high priority with comment “please bring to PACU pod 2 bay 9”. Medication request was accepted by pharmacy at 1243 and label was printed. Label stated A3W/A336 as location. Medication hand delivered to staff and signed as received by the named RN. Ketamine drip documented as initiated at 1448. Review of ketamine delivery signature sheet revealed no time of acceptance documented. Review of the incident/variance reports provided regarding Patient #15 revealed there were no incident/variance reports for the incident on 08/27/2023 to correspond with the incident described in the medical record notes. Interview on 11/16/2023 at 1045 with RPH #87 revealed medications are sent to locations based on the patient’s location in the medical record. Interview revealed when patients are in PACU the pharmacy staff rely on nursing to put in a missing medication request in order to get the drug to the correct location. Interview on 11/16/2023 at 1230 with PA #90 who ordered the drip revealed the drip was supposed to be initiated as soon as possible. Interview revealed the ketamine drip should have been started before the patient went to the floor. Interview revealed “the periop phase can be tricky and the patient’s location does not populate automatically.” Interview on 11/16/2023 at 1421 with RN #88 revealed the PACU staff had waited for hours for the pharmacy to fill the order. Interview revealed the medication had been delivered to the floor and not to PACU. Interview revealed pharmacy was called several times to inquire about medication, “so we thought they knew that the patient was in PACU since we kept calling.” Interview on 11/17/2023 with NM #89 revealed ketamine drips are not done on the unit, they should be initiated on a higher level of care unit. Interview revealed the unit and pharmacy staff received education on which units can not initiate the ketamine drip. Interview revealed the education was in 12/2022. Interview revealed more education would be given to staff. Interview on 11/27/2023 at 1540 with RPH #79 revealed the nursing staff would put in a medication request when they are ready for the medication to be prepared. The RN has to put in the location of the patient with the medication request. Interview revealed the pharmacy staff that processed the label may not be the same staff member that delivered the order, and the patient’s location may not have been communicated to the delivery technician. Interview revealed the delivery technician would then go by the location that was printed on the label. Request to interview a floor nurse revealed not available for interview. Request to interview the unit CNC revealed not available for interview. 34065 6. Review of a policy titled “Physiologic Monitoring-Cardiac Telemetry Monitoring...” with a revision date of 08/14/2023, revealed “Internal (lateral) transfers within the (named hospital). C. Patients transferring to non-ICU (Intensive care unit) units with continuous ECG (Electrocardiogram) orders will transport on continuous ECG. 2. The receiving RN will notify CMU (cardiac monitoring unit) with patient name/MRN (medical record number), room being transferred to and telemetry box being assigned.” Closed medical review on of Patient #13 revealed a 76 year old male admitted on 08/19/2023 at 1430 for hypertension (high blood pressure) and Intracranial hemorrhage (brain bleed). Review of RN #53’s note written on 08/25/2023 at 1750 revealed “Transferred to Floor. Transfer Report Given to (RN #54). Transport equipment: Monitor. Mode: Wheelchair.” On 08/25/2023 at 1934, Patient #13 was transferred to a stepdown unit. Review on 11/15/2023 of an incident report written by CMU supervisor #52 revealed (Patient #13)” had active 48 hr (hour) tele (telemetry) orders from 08.24.2023 at 1348 but were (sic) not being monitored.” Review of telemetry strips failed to reveal a telemetry strip for evening hours of 08/25/2023. Review revealed Patient #13 was not monitored by telemetry for 6 hours. Review of a Safety Event Timeline dated 08/29/2023 at 1408 from Manager #56 from Floor A revealed “Status: Assigned to Manager #55, Manager of Floor B (sending floor manager).” Review revealed on “08/31/2023 at 1234, Status: Assigned. Closed.” Review revealed no further documentation from Manager #55. Review revealed no documentation of the investigation of the Patient #13 without telemetry monitoring. Interview on 11/15/2023 at 1605 with CMU supervisor #52 revealed a daily audit is conducted at 0100 and 1300 of telemetry patients to ensure patients are being monitored as ordered. Interview revealed Patient #13 was found to have an order for telemetry but was not being monitored. Patient #13 had not been monitored since transfer to another floor on 08/25/2023 at 1934. Interview revealed Patient #13 was placed on telemetry on 08/26/2023 at 0139, 6 hours and 5 minutes after transfer to the floor. Interview on 11/28/2023 at 1234 of RN #54 revealed no recollection of Patient #13 or details of the transfer. Interview revealed RN #54 had not been interviewed regarding the incident of Patient #13. Interview on 11/28/2023 at 1633 of RN #53 revealed no recollection of Patient #13 or details of the transfer. Interview on 11/30/2023 at 1645 with Risk Manager #58 revealed “incidents should be reviewed and escalated to the department leaders. There should be notes from the manager.” Interview of Manager #55 was not obtained due to no longer employed. Patient #13 was transferred to Floor B with telemetry orders. After 6 hours, Patient #13 was discovered without telemetry. There was no review of the incident from the management of the sending floor or risk management. 33790 7. Medical record review on 11/14/2023 of Patient #2 revealed the patient arrived to the Emergency Department on 10/17/2023. Review of the EMS Patient Care Record revealed EMS received a call at 1654, arrived to Patient #2’s home at 1720 and transported the patient to the hospital, arriving at 1748. EMS documented they transferred care of the patient to the hospital at 1907, 1 hour 19 minutes later. Prior to the transfer of care, review revealed EMS continued monitoring Patient #2. A note in the EMS record indicated “Turn Around Delays ....ED Overcrowding/ Transfer of Care. ...” The hospital ED record review revealed the patient arrived at 1753 via EMS, with complaints of chest pain, shortness of breath, and syncope. Patient #2 was noted as evaluated by a provider at 1845 (52 minutes after arrival) and triaged by a RN at 1900 (1 hour, 7 minutes after arrival). An EKG was completed at 1905 (1 hour 12 minutes after arrival) and labs, including troponin, were drawn at 1920 (1 hour 27 minutes after arrival). Record review revealed a delay in the hospital accepting the patient from EMS, triaging and initiating care to the patient, including an EKG and labs. Patient #2 went into cardiac arrest at 1953 (2 hours after arrival) and subsequently expired after failed resuscitation attempts. Review of a document received from the hospital related to this patient, on 11/16/2023, revealed it was not dated or timed and was not signed. Document review revealed the following statement: “I have reviewed this case and the initial presentation, the timing on the workup, the findings and escalation were all appropriate and met standard of care. The patient arrived at 1753, was roomed at 1830 and was seen by a clinician at 1845 the patient coded at 19:53 and had a time of death at 22024 (sic) all of which occurred while in a room. The EKG was reviewed by the initial clinician and reported in the chart. The patient coded at 1953 and Dr. (Name) was called to the Code. During the code Dr. (Name) has documented that the patient had brief return of consciousness with the ongoing CPR. During this time he began reviewing the workup and the EKG, which was handed to him at 2002. It was read as sinus rhythm with a PVC and a 4 beat run of non-sustained ventricular tachycardia. He signed this EKG at this time 2002, the code was continued for another 22 minutes before time of death.” There were no other notations on the received document including no identification of who completed it or when. The document did not identify any areas of concern. There was no documented review of the timing of triage or implementation of orders. Additional information on the document was requested on 11/17/2023. No updated information was received. Telephone interview on 11/20/2023 at 1415 with EMS #70 revealed EMS was able to given hand-off report to a nurse at 1907 (over an hour after arrival). Interview revealed wait times for EMS to hand-off patients had recently gotten more common. Telephone interview with RN #66, on 11/16/2023 at 0938, revealed that until patients were in a room and care handed-off from EMS, they were “counting on EMS to care for (the patients). ...” Telephone interview with PA #71, on 11/15/2023 at 1600, revealed the goal for screening evaluations was 20 minutes from arrival. Telephone interview on 11/16/2023 at 1100 with MD #72 revealed the expectation for chest pain patients was an EKG within 10 minutes and to be seen by a provider within 10 minutes. MD #72 acknowledged a delay with Patient #2. Interview revealed the physician was not aware if there was a review of the case. Review of documents received did not reveal an incident report. Review of findings and document provided revealed the hospital failed to identify and evaluate delays in accepting, triaging and initiating care and treatment for a patient presenting via EMS with chest pain.”

“QAPI EXECUTIVE RESPONSIBILITIES CFR(s): 482.21(e)(1), (e)(2), (e)(5) The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: 1) That an ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained . (2) That the hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated. (5) That the determination of the number of distinct improvement projects is conducted annually. This Standard is not met as evidenced by: 41946 Based on policy review, Quality Improvement Performance Plan review, medical record review, incident report review, pharmacy unit inspection review, personnel file review, hospital document review and staff and physician interviews, the hospital’s leadership failed to provide oversight and responsibility of the quality improvement program to ensure medical errors were tracked and trended, failed to document incidents for improvement opportunities and failed to investigate potential causes and identify corrective action for seven (7) of 94 sampled patients reviewed (Patient#’s 58, 27, 59, 50, 15, 13 and 2). The findings included: Review of the Quality Improvement Plan approved by the hospital Chief Executive Officer (CEO), Board of Trustees Chair and Chief Medical Officer (CMO) on 04/24/2023 revealed, “ ...The hospital-wide Performance Improvement Plan is designed to improve quality performance and patient safety, ultimately reducing the risk to patients. ... ACCOUNTABILITY ... The following individual and/or committees are accountable for setting expectations, developing plans, and implementing procedures to assess, improve quality, and measure performance improvement within the organization. ... Board of Trustees ... The Board of Trustees delegates the responsibility for implementing this plan to the Medical Staff, through its Medical Staff committees and the hospital through its Quality, patient safety, and Performance Improvement Committees and leadership team. ... The (hospital name) Quality Council was organized as an interdisciplinary team with representation of Department Directors/Managers, hospital leadership, and key staff members with input from the Chief Medical Officer. The functions of the committee include but are not limited to: ... 2. Review data including continuous measurement activities of important functions. 3. Identify of (sic) problems/opportunities for improvement. 4. Review of actions planned or completed. 5. Evaluate of (sic) the effectiveness of actions completed. ... Staff will be accountable to: 1. Detect adverse events and near-misses. 2. Report events or near-misses via the incident reporting system. 3. Comply with all policies and procedures to mitigate risk and loss to the facility. ... Aggregation and analysis of performance data is used to compare internal performance with industry standards, comparable organizations, and best practices. ... Data is collected in a systemic manner to: a Establish a performance baseline and compare to national benchmarks ... d) Identify areas of opportunity for more focused data abstraction/reviews ... Data analysis is performed to identify processes to be targeted for change or improvement. The intent is to reduce the probability of adverse outcomes and eliminate patient harm events. The following events or outcomes require data analysis: ... b) Performance measurements that reveal significant undesirable variation from recognized standards ...h) Patterns of frequent event reporting (i.e. patient injury, including near misses) ... Patient Safety/ Risk Management is responsible for ensuring a culture of safety while promoting safe, error-free care, and a safe environment for our patients, staff and visitors. Patient Safety/ Risk Management works collaboratively with hospital personnel as they review and triage all reported events and create detailed analysis of the causes of events. ...” Review of the hospital policy titled “Event and Close Call Reporting” revised 10/13/2022 revealed “... Facility risk management personnel have the affirmative duty to oversee timely and thorough reporting within the designated systems ... Facility risk management personnel have the affirmative duty to oversee timely and thorough reporting within the designated systems... This policy applies to services provided by (Hospital Corporate Name) staff members in each of these settings: ... *Inpatient services, including acute care and behavioral health, critical access hospitals, and other related services * Emergency Departments (ED) * Hospital-based outpatient department or ambulatory services, including but not limited to behavioral health services and Independent Diagnostic Testing Facilities ... *Physician practices or clinics that may include rural health clinics or federally qualified health care centers ... NC Division Clarification ... In addition to the roles listed in the policy, the Directors of Quality and Patient Safety and/or Administrative Quality Directors are also responsible for oversight of this process ... Escalation to Leadership ...” 1. Medical record review revealed Patient #58 had a witnessed fall on 04/26/2023 following abdominal surgery for a gun shot wound. A CT (cat scan) of the Abdomen and Liver on 04/26/2023 showed changes to a liver hematoma (clotted blood within the tissues) from the previous CT study on 04/25/2023. Patient #58 was moved to ICU (intensive care unit) for closer monitoring, and Interventional Radiology was consulted to rule out active bleeding. On 04/27/2023 Patient #58’s hemoglobin dropped from 13.2 to 7.3 [6.0] and he received 2 units of red blood cells, and he underwent CT Angiogram and found no active bleed. Request for an event report on 12/05/2023 revealed there was not one available for Patient #58 after a witnessed fall, that required interventions. Telephone interview on 12/06/2023 at 1332 with RN #95 revealed she remembered the patient. Interview revealed “...he said he was going to pass out. We assisted him back to the bed after the fall and called a rapid response. I called the doctor. I didn’t remember to complete a report, it was not quite a fall. I guided him to the bed, and another nurse picked his legs up onto the bed...” Interview revealed Patient #58 had a witnessed fall, and an event report was not completed for Patient #58. Interview revealed hospital policy was not followed for Patient #58. Interview on 12/06/2023 at 1409 with the Charge Nurse, RN #96 revealed “...if a patient falls, we complete a (named) an incident report...” Interview revealed for witnessed falls an incident report should be completed. Interview revealed an event report should have been completed for Patient #58. Interview revealed hospital policy was not followed for Patient #58. Telephone interview on 12/07/2023 at 0906 with MD #94 revealed he remembered the patient. Interview revealed “...he had a traumatic liver injury it would not be surprising to have a rebleed, it required packing, and hemorrhage control. He did get an CT and have an interventional radiology angiography procedure after the event to ensure he didn’t have an active bleed...It’s impossible to tell...the fall did not extend an injury or stay at the hospital...” Interview revealed Patient #58 did have interventions after the fall on 04/26/2023 to ensure he had no active bleeding. Interview revealed hospital policy was not followed for event reporting for Patient #58 after a witnessed fall. 2. Review on 12/05/2023 of the policy Facility Event and Close Call Reporting Policy and Procedure, with effective date 04/01/2022 revealed “...PURPOSE: This policy is intended to minimize risks to patients, ...through the development and implementation of an event and close call reporting system based upon the affirmative duty of all health care providers and all agents and employees of the licensed health care facility to report events and close calls to the Patient Safety Director, Risk Manager, or designee. Furthermore, this policy is intended to mitigate risks and improve quality of services by outlining the processes for factual reporting of events, close calls, and unsafe situations. POLICY: Facility staff will provide the needed data elements through a formal, documented event reporting system. Event reports should be completed as soon as possible after the event, but no later than the end of the shift...X. Fair and Accountable Reporting Culture...B. The responsibility for reporting an event or close call rests with any person who witnesses, discovers, or has direct knowledge of that event or close call...” Medical record review revealed Patient #27 arrived in the ED on 07/04/2022 at 0025 with a reported abdominal pain level of 10 of 10, and nausea and vomiting. The patient had a STAT CT of the abdomen and pelvis ordered at 0027 that was not completed until 0755 (7 hours, 27 minutes later) resulted and signed at 0825. The patient had pain reported as 10 of 10, with nausea and vomiting with vital signs at arrival at 0025 and was not medicated with Dilaudid (narcotic pain medication) at 0739 (7 hours and 14 minutes after arrival). The patient was diagnosed with a small bowel obstruction and had surgery that day. The patient had a delay in pain management, STAT lab work, STAT CT, and physician orders as prescribed. Request for a Patient Safety Report (Event Report) revealed there was not one available. Interview on 11/15/2023 at 1350 with ED RN #38 who triaged Patient #27 revealed patients had delays in receiving pain management, STAT lab work and completion of physician orders in the ED waiting room. Interview revealed an event report was not completed for Patient #27. Interview on 11/17/2023 at 1102 with NP #39 revealed she had current concerns with waiting room patients not getting orders completed in the ED waiting room. Interview revealed an incident report should have been completed for Patient #27. Interview on 11/15/2023 at 1414 with ED MD #26 revealed “...I saw the patient after she was roomed.... There is not always a person to get labs and orders done. No staff to place orders. With the new process the goal is for that not to happen, but at night I suspect it does. As far as care in the waiting room, this patient didn’t get vital signs, or overall assessments and no meds...things are not happening on a timely basis...” Interview revealed Patient #27 did not receive pain management, STAT lab work, STAT CT, and physician orders as prescribed. Interview revealed an incident report should have been completed for Patient #27. 32003 3. Closed medical record review revealed on 3/4/2023, Patient #59 was admitted to the oncology unit and received a diagnosis of acute myeloid leukemia. Per physician orders, treatment for acute myeloid leukemia included Dacogen (intravenous chemotherapy medication) and Venetoclax (oral oncology medication). On 3/17/2023, the patient was infused Dacogen after two (2) [oncology nurses] verified the medication. Further review revealed on 3/18/2023, an Oncologist documented that the patient received an expired dose of Dacogen. The incident report for Patient #59’s medication administration of the expired dose of Dacogen, was requested on 12/7/2023 at 11:00 AM from the Director of Quality. No incident report was provided. Upon inquiry for pharmacy unit inspections from March 2023 through November 2023 revealed there had only been one inspection documented on 5/16/2023. Interview on 12/6/2023 at approximately 8:45 AM with the oncology pharmacist revealed oncology patients could be located on any unit within the hospital, in which case, the oncology medication would be delivered from outpatient infusion pharmacy to the oncology unit. The oncology nurse(s) would be responsible for going to the perspective unit(s) for the administration (intravenous and/or oral) of the medication. The pharmacist was unaware that an oncology patient was administered an expired dose of Dacogen. Interview on 12/7/2023 at approximately 10:30 AM with oncology staff revealed that Patient #59 declined the first dose of Dacogen, which could have resulted in the administration of an expired medication. Interview on 12/7/2023 at 11:00 AM with the Director of Quality revealed the Oncologist failed to enter an incident report and/or failed to speak to anyone regarding the administration of an expired dose of Dacogen to Patient #59 that occurred 3/17/2023. Interview on 12/7/2023 at 1:51 PM with the Oncology Unit Manager (OUM) revealed in April 2023 the oncology unit adopted a more detailed treatment administration checklist to assist the oncology nurses and the pharmacy department. The OUM further indicated she could not speak to the effectiveness of the updated checklist because no audits had been performed. Telephone interview on 12/8/2023 at 3:00 PM with the Oncologist revealed providers were made aware after-the-fact of any problems or concerns. As related to the administration of expired medication to a patient, the oncologist revealed, efficacy should be the main concern which falls upon the pharmacy department and was pretty sure this was what happened in the case of Patient #59. Further inquiry revealed that since the hospital joined [name of organization], the oncology unit lost valuable nurses which led to the hiring of new/inexperienced staff, and increased use of travel staff. The changes in staff led to an increase in errors, especially with neutropenic patients, which resulted in a degradation in care. Additionally, in the past oncology patients were directly admitted to the oncology unit without emergency department presentation. Now, oncology patients were admitted through the emergency department secondary to closure of transfers, which put the oncology patients at an increased risk for infection. Additionally, the unit no longer admitted complex cases of oncology patients because those cases were referred to other hospitals. Further interview revealed pharmacy errors increased secondary to the loss of experienced oncologist pharmacists. The interview concluded with the aforementioned concerns were voiced to the Medical Director for the oncology service line in which there were no notifications or any observations of changes. 40299 4. Review of the closed medical record for Patient #50 revealed a 21-year-old female presented to the Emergency Department (ED) via law enforcement under IVC (involuntary commitment) for a “Psychiatric screening exam; Behavioral health concern.” Review of the Provider Note dated 05/04/2023 at 1640 revealed “... patient presents with IVC paperwork and recent behavior concerning for danger to others in particular ... I will have behavioral health services see the patient ...” Review of the Initial Psychiatric Evaluation dated 05/06/2023 at 0531 revealed “The patient is a 21 yo (year old) female with h/o (history of) autism and mild intellectual disability, who was brought to the ED under VC due to increasingly aggressive behavior. The IVC paperwork reports (sic) that the patient has been going around the neighborhood with a hammer. She has done thoughtless things such as covering her father’s eyes with his hat while driving and then kicking him. THe (sic) patient’s behavior has been escalating since she could no longer participate in her programs during COVID 19 (pandemic). Instead of going to a group home, she was d/c (discharged) home from her last program. She has been increasingly irritable since she is swinging to calm herself down and has demonstarted (sic) dangerous behaviors ... Nursing reports pt (patient) became unexpectedly agitated this AM (morning), pulled nurse and sitter’s hair after being asked if her ears hurt (she was pulling at them). She received 5 mg (milligrams) Versed (medication to help you relax) at time of arrival to the ED yesteay (sic) afternoon, but otherwise no PRN (as needed) medication. She has not required restraint ... She is mostly mute (refraining from speech), although sometimes echolalic (repeat others) and echopraxic (involuntary copying of another person’s actions or movements). She waves when I wave. Says ‘hello’ when I say hello, and ‘happy’ when I ask if she is happy’(sic) ... Suggested plan; Uphold the IVC for now; observe the patient for the next 24-48 hours (sic); if the patient is stabilized, she can be discharged home or to a new placement, if one is available.” Review of the Mental Health Contact Note dated 05/08/2023 at 1017 revealed “... reached out to Pt’s mother, ..., and informed her that Pt was seen by Psychiatrist who is recommending discharge due to concerns of Pt safety on this unit, her aggressive behaviors w/ (with) other Pt’s ...” Review of the Nurse Note dated 05/29/2023 at 0855 revealed “... This was the third time pt had attacked the hair of a sitter.” Review of the Provider Note dated 05/29/2023 at 1007 revealed “...Patient was triggered by her sitter and attacked her this morning jumping on top of her and grabbing her hair ... Nursing staff reports this is the third sitter she is intact (sic) in the past 2 days ...” Review of the Nurse Note dated 06/10/2023 at 1920 revealed “Earlier today ... had multiple aggressive acts towards me, the first was when she spit on me as I was handing her a snack in the BHU (behavioral health unit) ... The second aggressive act came hours later when she saw me in the hall and came towards me. I attempted to walk away but she ran towards me, screaming and reaching for my face. She was able to pull the mask off my face but I restrained her hands and took several steps back, when she came after me again screaming and tearing at my head and face. I restrained her hands again and walked her back into her room towards her bed. As I let go and backed up ... leaned on her bed and kicked me in the chest with all her force ... I don’t intend to escalate this matter any further and have explained the entire situation to the psych clinician.” Mental Health Contact Note dated 06/18/2023 at 2100 revealed “... sitting in BHU intake office and heard yelling. Pt seen ... on camera gripping a male pt hair in ... hallway bed. Pt was standing over male pt’s hallbed (sic), hand in male pt’s hair shaking pt’s head around. Male pt was yelling ... immediately came out of BHU intake office, pt ran back towards her room into her bed. Male pt was visibly upset and yelling at pt in her room ...” Nurse Note dated 06/18/2023 at 2130 revealed “Pt. ran out of her room and pulled hair/hit another pt who was in a hall bed. After getting loose the pt. ran after her back in to her room, a BERT (behavioral health emergency) was called, physician, RNs, psych clinicians, and security all responded. The pt who was attacked aggressively was shouting, punching the walls, and hitting her bed. We were able to de-escalate the situation and both pts. We moved the second pt. to a differed pod in his own room so he would feel safe. It is unsure if (Patient #50) was hit while he was hitting her bed, physician did an assessment and she has no obvious injuries or marks. Pts are both settled in separate areas now.” Review of the medical record revealed Patient #50 was discharged to a facility on 06/20/2023 at 1659. Review on 12/05/2023 of the incident/variance reports provided regarding Patient #50 revealed there were no incident/variance reports for the incident on 05/29/2023 nor on 06/10/2023 to correspond with the incidents described in the medical record notes. There were incidents dated 05/27/2023 and 06/18/2023. Telephone interview on 12/06/2023 at 1400 with PSA #48 revealed she remembered Patient #50 and had to push her distress alarm button when caring for Patient #50. Interview revealed there had been several incidents involving Patient #50 pulling staff hair, attacking staff or other patients. Interview revealed PSA #18 had submitted incident/variance reports herself regarding more than one incident with Patient #50. Interview revealed there was a male patient in her room one time. PSA #18 could not remember the details about this incident, however confirmed she had filled out an incident report. PSA #18 stated there was a time when Patient #50 kissed another patient and an incident report should have been filled out about that. Interview on 12/06/2023 at 1500 with Director #82 revealed she only had four incidents/variances for Patient #50. Three of the four were dated 2022 and only one from 2023. Director #82 did not have the incident/variance provided to this surveyor dated 05/27/2023. Interview revealed the person entering the incident/variance did not enter the medical record number and Director #20 searched by the medical record number. Interview revealed it is hard to find incidents/variances if the medical record number is not entered so the information will pull across the system and make it easier to find. Interview revealed they can search by name however if the name is misspelled there would be problems finding any incidents/variances that were entered. Director #82 requested more time to research to see if there were more incidents/variances. At time of exit from facility on 12/09/2023 at 1600, Director #82 had not provided any additional information to this surveyor regarding additional incidents/variances for Patient #50. 47421 5. Closed medical record review of Patient #15 revealed a 21 year old male admitted on 08/14/2023 with abdominal pain. Record review revealed the patient had laparoscopic converted to open total abdominal colectomy (remove all or part of colon) with end ileostomy (stoma-opening in abdomen surgically created) on 08/27/2023 for ulcerative colitis. Record review revealed on 08/27/2023 at 1117 a ketamine drip was ordered stat (urgent). Record review revealed the patient arrived in PACU (post anesthesia care unit) at 1120. Patient transferred to floor (unit) at 1420. Record review revealed ketamine was started at 1448 on the unit. Patient returned to PACU at 1515 for ketamine drip. Review of nursing note on 08/27/2023 at 1526 revealed “Ketamine gtt (drip) sent to floor from pharmacy rather than to PACU. Patient arrived on the unit from PACU without ketamine gtt started. Notified (named) CNC (clinical nurse coordinator) and called to PACU nurse for patient to be transferred back to PACU for ketamine gtt initiation and required monitoring.” Review of nursing note on 08/27/2023 at 1656 revealed “Pt (patient) transferred to floor after report called to RN (registered nurse). PT was ordered Ketamine and the pharmacy sent the medication to the nursing unit instead of PACU. RN agreed in report to start ketamine on pt arrival to floor, since the ketamine was on the unit. Pt later brought back to pacu when nurse became aware that she was not cleared by hospital regulations to start the ketamine gtt.” Review of a ketamine drip timeline document revealed Ketamine drip ordered at 1117. The order was verified by pharmacy at 1140, but the label was not printed. Missing medication request sent by the RN at 1228, high priority with comment “please bring to PACU pod 2 bay 9”. Medication request was accepted by pharmacy at 1243 and label was printed. Label stated A3W/A336 as location. Medication hand delivered to staff and signed as received by the named RN. Ketamine drip documented as initiated at 1448. Review of ketamine delivery signature sheet revealed no time of acceptance documented. Review of the incident/variance reports provided regarding Patient #15 revealed there were no incident/variance reports for the incident on 08/27/2023 to correspond with the incident described in the medical record notes. Interview on 11/16/2023 at 1045 with RPH #87 revealed medications are sent to locations based on the patient’s location in the medical record. Interview revealed when patients are in PACU the pharmacy staff rely on nursing to put in a missing medication request in order to get the drug to the correct location. Interview on 11/16/2023 at 1230 with PA #90 who ordered the drip revealed the drip was supposed to be initiated as soon as possible. Interview revealed the ketamine drip should have been started before the patient went to the floor. Interview revealed “the periop phase can be tricky and the patient’s location does not populate automatically.” Interview on 11/16/2023 at 1421 with RN #88 revealed the PACU staff had waited for hours for the pharmacy to fill the order. Interview revealed the medication had been delivered to the floor and not to PACU. Interview revealed pharmacy was called several times to inquire about medication, “So we thought they knew that the patient was in PACU since we kept calling.” Interview on 11/17/2023 with Nurse Manager (NM) #89 revealed ketamine drips are not done on the unit, they should be initiated on a higher level of care unit. Interview revealed the unit and pharmacy staff received education on which units can not initiate the ketamine drip. Interview revealed the education was in 12/2022. Interview revealed more education would be given to staff. Interview on 11/27/2023 at 1540 with RPH #79 revealed the nursing staff would put in a medication request when they are ready for the medication to be prepared. The RN has to put in the location of the patient with the medication request. Interview revealed the pharmacy staff that processed the label may not be the same staff member that delivered the order, and the patient’s location may not have been communicated to the delivery technician. Interview revealed the delivery technician would then go by the location that was printed on the label. Request to interview a floor nurse revealed not available for interview. Request to interview the unit CNC revealed not available for interview. 34065 6. Review of a policy titled “Physiologic Monitoring-Cardiac Telemetry Monitoring...” with a revision date of 08/14/2023, revealed “Internal (lateral) transfers within the (named hospital). C. Patients transferring to non-ICU (Intensive care unit) units with continuous ECG (Electrocardiogram) orders will transport on continuous ECG. 2. The receiving RN will notify CMU (cardiac monitoring unit) with patient name/MRN (medical record number), room being transferred to and telemetry box being assigned.” Closed medical review on of Patient #13 revealed a 76 year old male admitted on 08/19/2023 at 1430 for hypertension (high blood pressure) and Intracranial hemorrhage (brain bleed). Review of RN #53’s note written on 08/25/2023 at 1750 revealed “Transferred to Floor. Transfer Report Given to (RN #54). Transport equipment: Monitor. Mode: Wheelchair.” On 08/25/2023 at 1934, Patient #13 was transferred to a stepdown unit. Review on 11/15/2023 of an incident report written by CMU supervisor #52 revealed (Patient #13)” had active 48 hr (hour) tele (telemetry) orders from 08.24.2023 at 1348 but were (sic) not being monitored.” Review of telemetry strips failed to reveal a telemetry strip for evening hours of 08/25/2023. Review revealed Patient #13 was not monitored by telemetry for 6 hours. Review of a Safety Event Timeline dated 08/29/2023 at 1408 from Manager #56 from Floor A revealed “Status: Assigned to Manager #55, Manager of Floor B (sending floor manager).” Review revealed on “08/31/2023 at 1234, Status: Assigned. Closed.” Review revealed no further documentation from Manager #55. Review revealed no documentation of the investigation of the Patient #13 without telemetry monitoring. Interview on 11/15/2023 at 1605 with CMU supervisor #52 revealed a daily audit is conducted at 0100 and 1300 of telemetry patients to ensure patients are being monitored as ordered. Interview revealed Patient #13 was found to have an order for telemetry but was not being monitored. Patient #13 had not been monitored since transfer to another floor on 08/25/2023 at 1934. Interview revealed Patient #13 was placed on telemetry on 08/26/2023 at 0139, 6 hours and 5 minutes after transfer to the floor. Interview on 11/28/2023 at 1234 of RN #54 revealed no recollection of Patient #13 or details of the transfer. Interview revealed RN #54 had not been interviewed regarding the incident of Patient #13. Interview on 11/28/2023 at 1633 of RN #53 revealed no recollection of Patient #13 or details of the transfer. Interview on 11/30/2023 at 1645 with Risk Manager #58 revealed “incidents should be reviewed and escalated to the department leaders. There should be notes from the manager.” Interview of Manager #55 was not obtained due to no longer employed. In summary, Patient #13 was transferred to Floor B with telemetry orders. After 6 hours, Patient #13 was discovered without telemetry. There was no review of the incident from the management of the sending floor or risk management. 33790 7. Medical record review on 11/14/2023 of Patient #2 revealed the patient arrived to the Emergency Department (ED) on 10/17/2023. Review of the EMS Patient Care Record revealed EMS received a call at 1654, arrived to Patient #2’s home at 1720 and transported the patient to the hospital, arriving at 1748. EMS documented they transferred care of the patient to the hospital at 1907, 1 hour 19 minutes later. Prior to the transfer of care, review revealed EMS continued monitoring Patient #2. A note in the EMS record indicated “Turn Around Delays ....ED Overcrowding/ Transfer of Care. ...” The hospital emergency department record review revealed the patient arrived at 1753 via EMS, with complaints of chest pain, shortness of breath, and syncope. Patient #2 was noted as evaluated by a provider at 1845 (52 minutes after arrival) and triaged by a RN at 1900 (1 hour, 7 minutes after arrival). An EKG was completed at 1905 (1 hour 12 minutes after arrival) and labs, including troponin, were drawn at 1920 (1 hour 27 minutes after arrival). Record review revealed a delay in the hospital accepting the patient from EMS, triaging and initiating care to the patient, including an EKG and labs. Patient #2 went into cardiac arrest at 1953 (2 hours after arrival) and subsequently expired after failed resuscitation attempts. Review of a document received from the hospital related to this patient, on 11/16/2023, revealed it was not dated or timed and was not signed. Document review revealed the following statement: “I have reviewed this case and the initial presentation, the timing on the workup, the findings and escalation were all appropriate and met standard of care. The patient arrived at 1753, was roomed at 1830 and was seen by a clinician at 1845 the patient coded at 19:53 and had a time of death at 22024 (sic) all of which occurred while in a room. The EKG was reviewed by the initial clinician and reported in the chart. The patient coded at 1953 and Dr. (Name) was called to the Code. During the code Dr. (Name) has documented that the patient had brief return of consciousness with the ongoing CPR. During this time he began reviewing the workup and the EKG, which was handed to him at 2002. It was read as sinus rhythm with a PVC and a 4 beat run of non-sustained ventricular tachycardia. He signed this EKG at this time 2002, the code was continued for another 22 minutes before time of death.” There were no other notations on the received document including no identification of who completed it or when. The document did not identify any areas of concern. There was no documented review of the timing of triage or implementation of orders. Additional information on the document was requested on 11/17/2023. No updated information was received. Telephone interview on 11/20/2023 at 1415 with EMS #70 revealed EMS was able to give hand-off report to a nurse at 1907 (over an hour after arrival). Interview revealed wait times for EMS to hand-off patients had recently gotten more common. Telephone interview with RN #66, on 11/16/2023 at 0938, revealed that until patients were in a room and care handed-off from EMS, they were “counting on EMS to care for (the patients). ...” Telephone interview with PA #71, on 11/15/2023 at 1600, revealed the goal for screening evaluations was 20 minutes from arrival. Telephone interview on 11/16/2023 at 1100 with MD #72 revealed the expectation for chest pain patients was an EKG within 10 minutes and to be seen by a provider within 10 minutes. MD #72 acknowledged a delay with Patient #2. Interview revealed the physician was not aware if there was a review of the case. Review of documents received did not reveal an incident report. Review of findings and document provided revealed the hospital failed to identify and evaluate delays in accepting, triaging and initiating care and treatment for a patient presenting via EMS with chest pain.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 41946 Based on policy, medical record review, incident report review, and staff and provider interviews, the hospital’s emergency department staff failed to ensure adequate nursing staff was available to provide and monitor the delivery of assessments, care, and treatments in the Emergency Department (ED) for eleven (11) of 35 patient records reviewed (Patient #’s 92, 83, 43, 28, 27, 29, 6, 1, 2, 12 and 26). The findings included: Cross refer to §482.55 Emergency Services Standard: Tag 1101. The ED nursing staff failed to ensure emergency care and services were provided according to policy and provider orders. Patients were not accepted upon arrival to the ED, evaluated, monitored and provided treatment to prevent delays and/or lack of triage, nursing assessment, and implementation of orders, including lab, telemetry and medication orders Patient #’s 92, 83, 43, 28, 27, 29, 6, 1, 2, 12 and 26. 1. Patient #92 presented to the ED with chest pain on 11/09/2023 at 1149. The patient was not assessed by a nurse after triage was completed at 1155, or with a change in condition, or after pain medication was administered at 1703. The patient was never placed on continuous telemetry in the ED as ordered by a physician at 1218. The patient was transferred to a medical floor and placed on telemetry at 2111 when he was found to be in atrial fibrillation with rapid ventricular rate, prompting a STEMI Code Activation. The patient underwent an emergency cardiac catheterization at 2249. ED nursing staff failed to provide ongoing assessment of the patient’s condition and follow physician’s orders for application of continuous telemetry. Nursing staff failed to ensure policies and provider orders were implemented. 2. Patient #83 was presented to the ED with dizziness on 11/28/2023 at 1216. The patient had STAT (immediate) lab work ordered at 1218 with continuous ECG monitoring. Labs were drawn at 1358 (1 hour and 40 minutes after ordered). Labs arrived at the lab at 1412 and resulted at 1532 (3 hours and 14 minutes after ordered). The blood glucose was 1137 (critically high). Insulin IV infusion was ordered at 1626 and initiated at 1709 (1 hour and 13 minutes after ordered and 1 hour and 37 minutes after the glucose resulted). Orders for continuous ECG monitoring placed at 1218, and vital signs every 2 hours were never initiated in the ED. At 2349 an IV infusion of D51/2 KCL was ordered that was not completed until 0157 (2 hours. and 8 minutes after ordered). Lactic acid was ordered NOW at 0127 for nurse collect in the ED. At 0200 a physician wrote there was a delay in labs and fluids so stopped the insulin IV infusion. The lactic acid was not collected in the ED. At 0529 the original lactic acid NOW, order was cancelled and reordered as lab collect NOW on the floor. It was collected at 0844 (3 hours and 15 minutes after ordered at 0529) and resulted at 1108 (9 hours and 41 minutes after originally ordered at 0127) with a result of 7.48 critical high. A second lactic acid was reordered at 1108 and resulted at 1256 (1 hr. and 36 minutes after ordered) with a result of 11.96 critically high. A rapid response was called previously at 1158, the patient was intubated at 1247, and ultimately expired on 11/30/2023. 3. Patient #43, a 39-year-old who presented to the emergency department (ED) by private vehicle on 08/14/2023 at 1603 with complaints of chest pain, nausea, clammy, lightheaded, right-side tingling for several weeks, with a reported history of drinks 12 beers a day. Review revealed the patient was located in the waiting room area and was observed by a physician to be diaphoretic. The physician ordered intravenous (IV) fluids and CIWA protocol (assessment tool used for alcohol withdrawal) at 1841, and Ativan (medication for anxiety) was ordered at 1947. These orders were not implemented. Multivitamin was ordered at 2100. Another order was placed at 2226 for IV fluids and Lopressor. Aspirin was ordered at 2229. None of these orders were implemented. An order written at 2305 for Phenobarbital administration was not implemented. At 0107, a physician’s note referenced the patient had a seizure and fall with a head injury outside the ED waiting room area. Findings revealed the patient had delays with nursing assessments, and failure to implement orders, including medication administration, and following the CIWA protocol. The patient subsequently had a seizure and fall with a resulting head injury. 4. Patient #28 presented to the ED on 07/05/2022, was critically ill, intubated and diagnosed with bacterial meningitis. The patient developed a low blood pressure and a Levophed IV drip was started. Findings revealed the Levophed IV drip was allowed to run dry and the patient’s blood pressure dropped to 33/18. A trauma PA was requested by the family for help related to alarms and the patient’s condition and the PA indicated the patient was not the PAs assigned patient. The patient arrested. A new Levophed bag was hung. The patient and IV were not monitored and the bag ran dry with subsequent cardiac arrest. 5. Patient #27 arrived in the ED on 07/04/2022 at 0025 with a reported pain level of 10 of 10. The patient had a STAT CT of the abdomen and pelvis ordered at 0027 that was not completed until 0755 (7 hours, 27 minutes later) resulted and signed at 0825. The patient had pain reported as 10 of 10, with nausea and vomiting with vital signs at arrival at 0025 and was medicated with Dilaudid (narcotic pain medication) at 0739 (7 hours and 14 minutes after arrival). The patient was diagnosed with a small bowel obstruction and had surgery that day. The patient had a delay with STAT lab work, STAT CT, nursing reassessment and pain management. 6. Patient #29 arrived on 04/05/2022 at 1451 via EMS and had atrial fibrillation (abnormal heart rhythm) on arrival. The patient had a recent fall with fracture prior to arrival. Pulse Oximetry was 94% prior to arrival. 1630 pulse oximetry was 90% (1 hour and 39 minutes after arrival) with no evidence of oxygen administration at hospital. Dilaudid 0.5 milligrams (mg) IV was administered at 1630 and at 1816. No vital sign or oxygen assessment on an elderly patient was assessed on the patient with a prior pulse oxygen of 90% after the administration of Dilaudid. The patient was subsequently asystole at 1909 and expired. Patient #29 had one set of vital signs from 1451 until time of death at 1909 (5 hours and 18 minutes). Nursing staff failed to reassess the patient after narcotic administration. Nursing staff failed to reassess the patient for a change in condition (not breathing). 7. Patient #6 arrived to Hospital B with strokelike symptoms at 10 days postpartum. She was accepted for transfer to Hospital A as an ED to ED transfer. Patient #6 arrived to the hospital via EMS on 10/03/2023 at 1942. The patient waited in the ED for a bed and continued to be managed by EMS. No documentation was noted by a medical provider until 2223 and Patient #6 was not triaged or assessed by hospital nursing staff until 2227 (approximately 2 hours 45 minutes after arrival by EMS). There was a delay in accepting the patient and a delay in triage, assessment and monitoring by nursing staff. 8. Patient #1 arrived as a transfer on 10/31/2023 at 2314 by EMS. No triage, nursing assessment or evaluation was completed in the ED. The patient was transported to the NSICU (Neurosciences Intensive Care Unit) on 11/01/2023 at 0105. A nursing note was written that stated the nurse was only transporting the patient to the inpatient unit and had not assumed care of the patient. The first nursing vitals or assessment were done at 0110 in NSICU. EMS monitored Patient #1 in the ED and nursing failed to accept, triage and provide care to a patient in the ED. 9. Patient #2 was brought to the ED by EMS from home. The patient arrived on 10/17/2023 at 1753 with chest pain and a syncopal episode at home. The provider ordered labs at 1841 (48 minutes after Patient #2 arrived), and the labs were not collected by nursing staff until 1920 (39 minutes after orders), after the patient was triaged at 1900 (1 hour and 7 minutes after arrival). The patient was on a cardiac monitor and received vital signs by EMS until triage at 1900. No hospital EKG was completed until 1905 (24 minutes after order and 1 hour 12 minutes after arrival). The elevated D-Dimer did not result until 2006, the elevated Pro BNP did not result until 2023 and the elevated Troponin did not result until 2039. At 1953 a physician responded to the patient’s bedside due to a cardiac arrest. CPR was started and the patient expired. Nursing staff failed to accept the patient upon arrival to the ED, resulting in delayed triage, care and treatment. 10. Patient #26 presented to the ED via EMS on 09/01/2022 at 1845 for complaints of abdominal pain, decreased appetite, watery non-bloody diarrhea, and right-calf burn. Review of the patient’s closed medical record lacked nursing documentation related to the assessment and treatment of the patient’s right calf wound from presentation in the ED on 09/01/2022 through discharge on 09/07/2022. 11. Closed medical record review of Patient #12 revealed a 41 year old female transferred to the ED (emergency department) on 07/18/2023 at 1623 via EMS (emergency medical service) for abdominal pain, nausea, chills, and evaluation by general surgery for concerns of appendicitis. Record review revealed the patient did not have her vital signs monitored and had no nurse assigned to monitor status or provide care.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 16369 Based on policy review, medical record review, incident report review, Emergency Medical Services (EMS) trip report review, and staff and provider interviews, hospital nursing leadership staff failed to ensure policies were implemented to evaluate, monitor and provide treatment for patients presenting to the emergency department resulting in delays and lack of triage, nursing assessment, monitoring, and implementation of lab, telemetry, medication and treatment orders for eleven (11) of 35 patients records reviewed (Patient #’s 92, 83, 43, 28, 27, 29, 6, 1, 2, 12 and 26). The findings included: Review on 12/06/2023 of the hospital policy “Triage - Emergency Department 1PC.ED.0401” revised 07/2023 revealed, “...DEFINITIONS: ... A. Triage Assessment: The dynamic process of sorting, prioritizing, and assessing the patient and is performed by a qualified RN (Registered Nurse) at the time of presentation and before registration. This is a focused assessment based on the patient’s chief complaint and consists of information, which is obtained that would enable the Triage RN to determine minimal acuity. A rapid or comprehensive triage assessment is completed, with a goal of 10 minutes, on arrival to the emergency department. 1. A rapid triage assessment is composed of airway, breathing, circulation and disability, general appearance, eliciting symptom driven presenting complaint(s), and any pertinent objective and subjective data/assessment from the patient or parent or caregiver. 2. A comprehensive assessment, performed on each patient that presents to the emergency department, is a focused physical assessment including vital signs, pain scale, allergy, history of current complaint, current medications, exposure to infectious disease, and pertinent past medical/surgical history. ... B. Triage Acuity Level - The Emergency Severity Index (ESI) is a five level emergency department (ED) triage algorithm that provides clinically relevant stratification of patients into five groups from 1 (most urgent) to 5 (least urgent) on the basis of acuity and resource needs. C. Reassessment - A process of periodic re-evaluation of the patient’s condition and symptoms prior to and during the initiation of treatment. Reassessment components may include some or all of the following: vital signs, a focused physical assessment, pain assessment, general appearance, and/or responses to interventions and treatments. Reassessment after the medical screening exam are performed by RN’s (Registered Nurses) according to acuity or change in patient’s condition. D. Vital Signs - Helps nursing personnel determine the stability of patients and acuity of those that are that are presenting with life-threatening situations or who are in high-risk categories. Usually refers to temperature, pulse rate, respiratory rate, and blood pressure. May include pulse oximetry for patients presenting with respiratory and/or hemodynamic compromise, and pain scale for those patients with pain as a component to their presenting complaint...PROCEDURE: ...B. All patients presenting for care will be evaluated by an RN. This RN should complete a brief evaluation of the patient, including immediate compromise to a patient’s airway, breathing, or circulation.... H. If there is no bed available, the patient will need to wait in the lobby. While in the lobby, patient reassessment and vital signs should be documented in the health record in accordance with documentation guidelines. ...” Review on 12/09/2023 of the “Assessment and Reassessment” policy revised 06/2021 revealed, “... PURPOSE: A. The goal of the assessment/reassessment is to provide the patient the best care and treatment possible ... The nursing process is utilized in order to achieve this goal. This process includes assessing, analyzing, planning, implementing and evaluating patient care or treatment. ... DEFINITIONS: A. Assessment: The multidisciplinary assessment process for each patient begins at the point where the patient enters a (facility name) facility for care, and in response to changes in the patient’s condition. ... The assessment will include systematic collection and review of patient-specific data necessary to determine patient care and treatment needs. B. Reassessment: The reassessment process is ongoing and is also performed when there is a significant change in the patient’s condition or diagnosis and in response to care. ... SECTION VI: EMERGENCY DEPARTMENT: A. Patients should be triaged following guidelines set forth in the system Triage Policy (1PC.ED.0401), including documentation of required elements within the electronic medical record (e.g. Vital signs, Glasgow Coma Scale (GCS)). B. The priority of data is determined by the patient’s immediate condition. On arrival to unit, an initial assessment is initiated and immediate life-threatening needs are determined with appropriate interventions implemented. C. Patient assessment should be performed based on the developmental, psychosocial, physiological, and age-specific needs of the individual. D. Focused patient history and physical assessment are based on patient’s presenting problem(s) including individual indicators of vulnerability. E. Reassessment: 1. Reassessment is ongoing and may be triggered by key decision points and at intervals based on the needs of the patients. Additional assessment/reassessment elements and frequency are based upon patient condition or change in condition, diagnosis, and/or patient history, not to exceed four hours. Interventions may warrant more frequent assessments....” 1. Closed medical record review on 12/09/2023 of Patient #92 revealed a 69 year-old male that presented to the emergency department on 11/09/2023 at 1149 via private vehicle with a chief complaint of chest pain. The patient was triaged at 1155 with a chief complaint of “Woken from sleep at 0400 with midsternal chest pain, described as sharp and pressure. No SOB (shortness of breath), arm/jaw/back pain, or diaphoresis (sweating). H/o (history of) colon CA (cancer) with mets (metastasis) to the lung, currently on chemotherapy....” Review revealed vital signs of blood pressure (BP) 125/60, pulse (P) 57, temperature (T) 97.4 degrees Fahrenheit, oxygen saturation (O2 Sat) 97% and a pain level reported as 2 (scale 1-10 with 10 the worst). Review revealed a triage level of 2 (level 1 most urgent). Review revealed a Medical Screening Examination by a physician was started in the waiting room area at 1209. Review of the physician’s notes recorded the patient’s chest pain had been waxing and waning, coming in waves and lasting about five minutes at a time. Review revealed a plan to conduct an ED chest pain work-up including a chest x-ray, EKG and labs including CBC, chemistry, lipase and troponin, and administer a dose of aspirin. Review recorded a differential diagnosis of GERD (gastroesophageal reflux disease), referred abdominal pain, musculoskeletal chest pain, ACS (acute coronary syndrome), with lower suspicion for PE (pulmonary embolus) given no tachycardia, hypotension, or evidence of DVT (deep vein thrombosis) on exam. Review revealed the ED physician recommended admission for further chest pain workup based on risk factors. Review of physician’s orders revealed labs were ordered at 1218, collected at 1320 and resulted at 1332. Review revealed a troponin result of 0.013 (normal). Review revealed a physician’s order placed at 1218 for continuous ECG (telemetry) monitoring in the ED. Review of the ED record revealed no evidence that continuous ECG monitoring was initiated in the ED. A chest x-ray was ordered at 1220 and resulted at 1246 with normal results. An EKG was completed at 1224 which showed sinus rhythm with premature atrial complexes (PACs), with no changes when compared with a prior EKG done in 2022 per the physician’s read. A troponin resulted at 1320 as 0.013 (normal) and a baby aspirin was administered as ordered at 1334. A second troponin ordered at 1607 and resulted at 1704 as 0.014 (normal). Review of a second EKG completed at 1628 revealed “Sinus rhythm with premature atrial complexes (PACs). Otherwise normal ECG. When compared with ECG of 09-Nov-2023 12:24, Non-specific change in ST segment in inferior leads. ST elevation now present in Lateral leads.” Review recorded the ECG was confirmed by a physician on 11/09/2023 at 1821. Review revealed a physician’s order at 1659 for nitroglycerine 0.4 milligrams (mg) sublingual every five minutes times three as needed (prn) chest pain. Record review revealed no nursing assessment/reassessment documented after the patient’s triage was recorded at 1155. The patient was administered Morphine (narcotic pain medication) 2 milligrams intravenously (IV) at 1703 by a medic for a pain level of 4. There was no reassessment of the patient’s pain and no documentation of the patient’s condition by a nurse. The patient was moved from the waiting room to a bed in the orange pod (admission holding area of the ED) at 1937. Nitroglycerine 0.4 milligrams sublingual was administered by a nurse times one for a pain level of 10 at 2013. Review revealed no reassessment of the patient’s response to the medication intervention and no nursing assessment of the patient’s condition was documented. The patient was transported from the ED to a medical surgical floor on 11/09/2023 at 2054. The patient was placed on continuous telemetry at 2111 when he was noted to be in Atrial Fibrillation with Rapid Ventricular Rate (abnormal heart rhythm). Review of the ECG completed at 2110 recorded an “ST elevation consider lateral injury or acute infarct ** ** ACUTE MI / STEMI (myocardial infarction or heart attack) ** ** ...”. Review of a Cardiovascular Consult History and Physical documented on 11/10/2023 at 0020 as an Addendum revealed the patient “... went into AF/RVR (Atrial Fibrillation with Rapid Ventricular Rate) at 2110 hrs this evening with ECG demonstrating evolving high lateral STEMI (l, aVL) which was more pronounced on follow-up ECG at 2210 hrs prompting formal STEMI activation for emergent cardiac catheterization. ...” Review of a Discharge Summary dated 11/13/2023 at 1211 revealed the patient was discharged home on 11/13/2023 with a diagnosis of STEMI (ST elevation myocardial infarction), Coronary Artery Disease, Hypertension, and Atrial Fibrillation with RVR. Interview on 12/09/2023 at 1210 with Assistant Director of Nursing (ADON) #17 revealed Patient #92 was identified as a level 2 triage and should have been assessed every four hours at a minimum, every two hours for a level two and with any change in the patient’s condition. Interview revealed the patient developed chest pain and required interventions and no nursing assessments or reassessments were documented in the ED record. Interview revealed continuous telemetry was ordered for the patient at 1218 and telemetry was not placed on the patient in the ED. Interview revealed the telemetry was placed on the patient at 2111 once the patient transferred to the medical floor. In summary, Patient #92 presented to the ED with chest pain on 11/09/2023 at 1149. The patient was not assessed by a nurse after triage was completed at 1155, or with a change in condition, or after pain medication was administered at 1703. The patient was transferred to a medical floor and placed on telemetry at 2111 when he was found to be in atrial fibrillation with rapid ventricular rate. Findings of an EKG at 2110 showed ST elevation, **ACUTE MI/STEMI**. A STEMI Code Activation was initiated for an evolving lateral STEMI. The patient underwent an emergency cardiac catheterization at 2249. ED nursing staff failed to provide ongoing assessment of the patient’s condition and follow physician’s orders for application of continuous telemetry. 41946 2. Review on 11/17/2023 of the hospital policy Turn Around Time, last revised 11/17/2021 revealed “...PURPOSE: To provide timely and efficient testing services for routine, critical and high-risk situations. DEFINITIONS: Turn Around Time (TAT): the time elapsed from order placement to result reporting. Categorized as: Pre-analytical Phase: the period between test order entry by the caregiver and specimen receipt in the Laboratory. May be influenced, but not controlled by the Laboratory. Analytical Phase: the period between specimen receipt in the Laboratory and result reporting. Controlled by the Laboratory...STAT: an emergent, potentially life-threatening request. NOW: as soon as possible. Synonymous with ASAP. POLICY: All tests will be performed without delay to maximize specimen quality and integrity. STAT, NOW ... requests will be managed as priority situations. First-in, First-out (FIFO) processes are utilized to facilitate rapid and efficient movement of specimens through the system. Requests are also prioritized based on the following criteria to meet defined turn-around times: ...Response to STAT requests: ...STATS take priority over other specimens and should be managed from time of receipt until result reporting with no interruption in handling or testing. In general, the maximum TAT for most tests is 45-50 minutes from order receipt.... Response to NOW/ASAP requests: ...Staff will immediately process the specimen, perform testing, and verify results. Results should be available within (1) one hour from specimen receipt.... TAT Summary (Inpatient): STAT, Time from ORDER Receipt 45-50 minutes. NOW, Time from SPECIMEN receipt 1 hour...” Closed medical record review on 12/06/2023 revealed Patient #83, a 74-year-old female patient who arrived at the emergency department (ED) via emergency medical services (EMS) on 11/28/2023 at 1216 with a chief complaint of dizziness from her doctor’s office. Patient #83 was seen by an ED Medical Doctor (MD) #1 on arrival and at 1218 a comprehensive metabolic panel (CMP) [includes serum glucose] was included in laboratory tests ordered as STAT (an emergent, potentially life-threatening request) with continuous ECG monitoring. At 1259 Patient #83 was placed in Red Pod (for the most acute patients) Hallway Bed-17. At 1309 the first set of vital signs was recorded by RN #2 as temperature 98.7, heart rate 84, respirations 19, blood pressure 225/88, and oxygen saturation of 93 percent on room air. At 1316 Registered Nurse (RN) #3 completed a nursing triage assessment and Patient #83 was given an emergency severity index (ESI) [level 1 as the most urgent and 5 as the least urgent] of 3-urgent. Review of the CMP history revealed the STAT lab was collected at 1358 by RN #3 (1 hour and 40 minutes after the order was placed), the blood specimen arrived at the laboratory at 1412, and resulted at 1532 (3 hours and 14 minutes after the STAT order was placed) with a serum glucose resulted of 1137 (high normal range 120). Review of the Physician’s Order on 11/28/2023 at 1626 by ED Nurse Practitioner (NP) #5 revealed a new order for an Insulin (IV medication to reduce serum glucose) IV infusion to be started (54 minutes after the glucose had resulted). At 1709 an Insulin drip was initiated for Patient #83 by the RN #3. At 1739, the Hospitalist NP #6 placed a continuous telemetry monitoring order for 48 hours for Patient #83, with vital signs every 2 hours while in the ED. At 1908 ED MD #14 ordered a Glycosylated Hemoglobin NOW that was collected at 2128 (2 hours after ordered). At 2109 Patient #83 was moved to the ED Holding-Orange Pod-Room-2 awaiting an inpatient bed. At 2329 Hospitalist MD #9 ordered an IV infusion of D51/2 NS with KCL (Dextrose, Normal Saline, and Potassium Chloride Solution). On 11/29/2023 at 0127 MD #9 ordered a Lactic Acid (carries oxygen from your blood to other parts of your body) level to be drawn “NOW” for “nurse collect” for Patient #83. At 0153 MD #9 ordered to suspend the insulin IV. An addendum was made to the History and Physical at approximately 0200 by MD #9 which revealed “...Unfortunately patient has been on insulin drip since 5pm without continuous fluid administration or repeat blood work, it is currently 2 am, Nursing staff was previously contacted requesting these, later on did let provider know there was difficulty obtaining blood work as well as delay in obtaining D51/2NS KCL fluid from pharmacy. Given we have no blood work, no fluids, for the safety of the patient will suspend insulin drip at this time, until blood work is back to ensure appropriateness of insulin drip infusion...” 0157 RN #10 documented the IV with D51/2NS KCL as started (2 hours and 27 minutes after ordered). At 0200 Patient #83’s Insulin IV was suspended by RN #10. At 0256 Patient #83’s Insulin IV was reordered and was resumed (56 minutes after it was stopped). On 11/29/2023 at 0514 Patient #83 was transported to a Stepdown Unit. Review of the ED record revealed no evidence that continuous telemetry monitoring or vital signs every 2 hours were initiated in the ED by a nurse, further the NOW Lactic Acid “nurse collect” order at 0127 was never drawn while the patient was in the ED. On the inpatient floor, at 0529, RN #11 canceled the 0127 NOW Lactic Acid order “nurse collect” from the ED and reordered the NOW Lactic Acid order “lab collect”. The Glycosylated Hemoglobin NOW that was ordered 11/28/2023 at 1908 resulted on 11/29/2023 at 0743 (12 hours and 35 minutes after ordered) with result of 12.3 (normal high range 6.3). At 0844 the Lactic Acid was drawn (3 hours and 15 minutes after it was ordered), was in the lab for processing at 0907, and resulted at 1108 (5 hours and 39 minutes after ordered) as “7.48” (high normal for lactic acid was 2.1). The computer system automatically reordered an additional Lactic Acid order by default and was collected at 1119 and was in the lab to be processed at 1148. At 1146 RN #12 documented a blood pressure of 141/67 with respirations of 36. At 1158 Rapid Response was called for Patient #83. At 1206 blood pressure was 65/40. At 1213 blood pressure was recorded at 68/40. At 1225 a Levophed (medication used to increase blood pressure) IV infusion was initiated via interosseous to increase her blood pressure. At 1245 the blood pressure was 126/84 at 98 percent oxygen saturation while the patient was being mechanically bagged at the bedside. At 1247 Patient #83 was intubated (mechanical ventilation), at 1250 Patient #83 was transferred to the medical intensive care unit. At 1256 the second Lactic Acid resulted as critically high “11.96”. After discussion with the family, Hospitalist MD #16 changed Patient #83 Full Resuscitation status to Limited Resuscitation with no cardiopulmonary resuscitation (CPR). Patient #83 expired on 11/30/2023 at 1337. Review on 12/06/2023 of a Patient Safety Analysis (Incident Report) completed by RN #12 on 12/01/2023 at 1917 revealed this Care Event was a “Delay in Care” and the issue was “Lack of timely response to Order”, for Patient #83. A description “A NOW LA (lactic acid) order was placed at 0529. Lab wasn’t drawn until 0844, and in lab at 0907. Critical results of lactic acid 7.48 reported at 1108. MD at 1114...Shortly after this (within the hour), the patient took a turn and had to be intubated at bedside and sent to ICU (intensive care unit) ...Solution to Prevent this from Recurring? Promptly follow orders...” This Patient Safety Report was still in process. Review of the report revealed Patient #83 had a delay in lab work. MD #9 was unavailable for interview. MD #16 was unavailable for interview. Telephone interview on 12/07/2023 at 1632 with RN #10 who cared for Patient #83 in the Orange Pod (location in the ED for pending admissions) revealed “...I work on an inpatient unit and was pulled to the ED that day. It’s a revolving door, I don’t recall this patient in particular. If I can’t get the labs, I would call a phlebotomist after 3 tries to get the labs if I couldn’t...” Interview revealed she could not remember why the NOW lactic acid order was not collected. Interview revealed physician orders for Patient #83 were not followed. Interview on 12/08/2023 at 0915 with RN #11 revealed she did remember Patient #83 and worked night shift. “...I did not receive a report on this patient from the ED. You have to look up the medical record number and sometimes the charge nurse gets an alert that the patient is coming and will print the face sheet. I had to piece it together and go through the orders. I reordered the lab work when I saw it was pending. My concern is we have had trouble getting in contact with the phlebotomist. That morning they were not logged into to their imobile device. I called the general lab number, and no one answered. I then contacted my house supervisor, and he told me ‘we don’t have another option right now.’ I can’t recall if she was on a telemetry box or not, I was only with her over an hour...” Interview revealed not being able to reach a phlebotomist during night shift had happened before. Interview revealed RN #11 had called multiple times to reach the lab phlebotomist to draw NOW blood orders without reaching someone. Interview revealed lab Turn Around Time for NOW lab orders was not followed for Patient #83. Interview on 12/08/2023 at 1309 with Laboratory Phlebotomist Supervisor #17 revealed “...the phlebotomists do not collect in the ED; we will help if called. All labs ordered in the ED default to “nurse collect”. The expectation was for STAT and NOW orders to be from order to collection in 15 minutes and to be resulted in an hour from order...” Interview revealed lab collection for STAT and NOW orders for Patient #83 did not follow hospital policy for lab turnaround times. Interview on 12/08/2023 at 1414 with NP #6 revealed her expectation for Patient #83, was for her to have continuous ECG monitoring and vital signs every 2 hours while in the ED. Interview revealed physician orders were not followed for Patient #83. Interview on 12/08/2023 at 1425 with RN #3 who cared for Patient #83 in the Hallway Bed 17 on 11/28/2023 revealed “...I remember her. It was an extremely busy day...she was a hard stick; I used an ultrasound to start her IV. The problem with hallway beds is they have no dedicated monitor. She had a monitor and vital signs ordered. I strongly advocated for her to get moved into a bed with the CNC (clinical nurse coordinator), and it didn’t happen. She didn’t think it was a big deal. We don’t have the capability to link the patient to a monitor in a hallway bed. She wasn’t on a monitor; I spent the afternoon telling the CNC and MD. The doctors don’t have any say, it’s up to the CNC where patients are roomed. I sat behind her all day, ...I was extremely frustrated...” Interview revealed Patient #83 was not placed on continuous ECG monitoring, nor were vital signs monitored every 2 hours. Interview revealed physician orders were not followed for Patient #83. Interview on 12/08/2023 at 1230 with Nursing VP of ED Services, RN #20 revealed she could not explain the lack of telemetry monitoring or vital signs for Patient #83 while in the ED. Interview revealed the ED nurse should elevate to the ED Charge Nurse for the need to continuously monitor a patient in a hallway bed if one was not available. Further interview revealed the ED Provider and ED Nurse were responsible for monitoring lab results via electronic medical record in the ED. Interview revealed hospital policy was not followed for Patient #83. Interview on 12/09/2023 at 1159 with Lab Director #18 revealed “...I do know we had a call out that day. The lactic acid was available for the lab tech to see at 1016 but wasn’t called to the floor until 1108. I don’t know what the delay was. The expectation was to call as soon as the result was available. The expectation for lab collection and processing was to follow the policy guidelines, and for STAT and NOW results to be completed within an hour...” Interview revealed lab collection and processing did not follow hospital policy for Patient #83. Patient #83 was presented to the ED with dizziness on 11/28/2023 at 1216. The patient had STAT lab work ordered at 1218 with continuous ECG monitoring. Labs were drawn at 1358 (1 hour and 40 minutes after ordered). Labs arrived at the lab at 1412 and resulted at 1532 (3 hours and 14 minutes after ordered). The blood glucose was 1137 (critically high). Insulin IV infusion was ordered at 1626 and initiated at 1709 (1 hour and 13 minutes after ordered and 1 hour and 37 minutes after the glucose resulted). Orders for continuous ECG monitoring placed at 1218, and vital signs every 2 hours were never initiated in the ED. At 2349 an IV infusion of D51/2 KCL was ordered that was not completed until 0157 (2 hours. and 8 minutes after ordered). Lactic acid was ordered NOW at 0127 for nurse collect in the ED. At 0200 a physician wrote there was a delay in labs and fluids so stopped the insulin IV infusion. The lactic acid was not collected in the ED. At 0529 the original lactic acid NOW, order was canceled and reordered as lab collect NOW on the floor. It was collected at 0844 (3 hours and 15 minutes after ordered at 0529) and resulted at 1108 (9 hours and 41 minutes after originally ordered at 0127) with a result of 7.48 critical high. A second lactic acid was reordered at 1108 and resulted at 1256 (1 hr. and 36 minutes after ordered) with a result of 11.96 critically high. A rapid response was called previously at 1158, the patient was intubated at 1247, and ultimately expired on 11/30/2023. 3. Review of the CIWA (Clinical Institute Withdrawal Assessment for Alcohol) /Alcohol Withdrawal Plan, effective date 07/20/2022 revealed “...Monitoring Phase ...Now ONCE, when plan is initiated with goal CIWA < (less than) 15...” The CIWA/Alcohol Withdrawal Plan Reference Information included 10 questions, questions 1-9 can score between 0 and 7 points each question, question 10, can score 0 to 4 points, depending on severity of symptoms for each question. Score range 0-68. Questions with observations: 1. Nausea/Vomiting? 2. Paroxysmal sweats? 3. Agitation? Headache, fullness in head? 5. Anxiety? 6. Tremor? 7. Visual disturbances? 8. Tactile disturbances? 9. Auditory disturbances? 10. Orientation and clouding of sensorium -Ask what day it is? “...CIWA Management Communication If CIWA > 15 for four consecutive hours, contact provider to initiate Severe Withdrawal Phase and/or to consider transfer to higher level of care...” Closed medical record review on 11/16/2023 revealed Patient #43, a 39-year-old who presented to the emergency department (ED) by private vehicle on 08/14/2023 at 1603 with complaints of “...chest pain, nausea, clammy, lightheaded, and right-side tingling for several week. Drinks 12 beers a day....” At 1603 triage by Registered Nurse (RN) #21 with vital signs: temperature 98.5, heart rate 97, respirations 18, blood pressure 141/89, oxygen saturation of 96 percent on room air, and pain of 4/10 (1 being least pain, and 10 being most pain) and was assigned an emergency severity index [ESI] (level 1 as the most urgent and 5 as the least urgent) of 2. Patient #43 was then moved to the ED waiting room IPA (Internal Processing Area) area and was seen by Nurse Practitioner (NP) #22. At 1650 initial labs, EKG, and chest X-ray were completed, and Patient #43 was assigned to ED Medical Doctor (MD) #23. Review of the ER Physician Note from 08/14/2023 at 1727 by MD #23 revealed a review of lab, EKG and chest X-ray results from 08/14/2023 did not show any critical results. At 1732 MD #23 ordered a GI cocktail (oral combination of medications given for indigestion), Zofran 4 mg orally (medication given for nausea and vomiting). An addendum to MD #23’s ER Report Note revealed “...On reassessment patient and his mom who is now accompanying him are updated on his results. He is still in the waiting room unfortunately. I have ordered IV (intravenous) fluids, CIWA protocol and 1 mg of Ativan (a sedative given for anxiety and seizures) as he is slightly tremulous (shaking) and diaphoretic (sweating) my reassessment [sic]...Hospitalist has been consulted for admission...” At 1841 MD #23 placed orders for IV (intravenous) fluids-NS NOW, thiamine (dietary supplement/nutrient) 100 milligrams (mg) orally STAT (immediately), and CIWA scale/protocol (alcohol withdrawal plan/protocol). At 1851 vital signs were rechecked by IPA ED RN #24 temperature 98.3, heart rate of 103, blood pressure 132/82, and oxygen saturation of 92 percent on room air, the GI Cocktail, and Zofran were administered in the ED waiting room. At 1947 MD #23 ordered Ativan 1 mg IV push NOW (urgent). Per the CIWA plan at 2100 a multivitamin orally was ordered and CIWA Scale assessment. The History and Physical was initiated on 08/14/2023 at 2229 by Hospitalist MD #25 while in the ED waiting room, and new orders were placed for aspirin orally NOW, Lopressor (medication given in treatment of alcohol withdrawal) 12.5 mg orally, and again IV access at 2226. At 2305 MD #25 ordered Patient #43 phenobarbital (medication given to prevent seizure) 60 mg orally three times a day STAT and a CIWA Scale reassessment was due to be completed per protocol. No nursing reassessments, medication administrations, IV access/fluids, or physician orders were completed after 1851 for Patient #43 while in the ED waiting room. On 08/15/2023 at 0057 Patient #43 was moved to the Red Pod (ED area for the most acute patients) room 11. At 0105 MD #25 ordered Patient #43 to have Ativan 4 mg IV STAT and was given at 0106 by RN #27. Review of the ER Report Note on 08/15/2023 at 0107 by MD #26 revealed “...I became involved in the patient’s care after he apparently left the waiting room where he was awaiting admission and then had a seizure and struck his head on the sidewalk outside of the ER (emergency room) entrance. On my evaluation, the patient seems postictal (the period following a seizure, disorienting symptoms, confusion, and drowsiness), he is not actively seizing. He does have a history of heavy alcohol use, drinks about 12 beers a daily. He has been in the emergency department waiting room for 9 hours and has not received any Ativan or Phenobarbital. I suspect that he seized due to alcohol withdrawal. Will obtain head CT (cat scan) given the patient did strike his head, he also has a small laceration that will require repair....” Record review revealed the ED waiting room orders for IV fluids NOW on 08/14/2023 at 1841 to 08/15/2023 at 0106 (5 hrs. and 25 min), Ativan IV NOW ordered on 08/14/2023 at 1947 to administered on 08/15/2023 at 0106 (5 hours 19 min), and Phenobarbital STAT ordered on 08/14/2023 at 2305 to administered on 08/15/2023 at 0150 (2 hours and 45 min) for Patient #43 were delayed and no CIWA score/assessment was completed until 08/15/2023 at 0437 (9 hours and 56 minutes after ordered). No CIWA score/assessment was documented before the patient had a seizure event with sustained head injury. There was no nursing reassessment, or nursing care after 08/14/2023 at 1851 by RN #22 until 08/15/2023 at 0057 (6 hours and 1 minute). Patient #43 was admitted to an inpatient room on 08/15/2023 at 0334 from the ED. Patient #43 was discharged home on 08/17/2023. Review of the Patient Care Analysis (Incident) report submitted by MD #25 on 08/15/2023 at 0443 revealed the date of event was 08/15/2023 at 0000. Brief description revealed “...patient was in waiting room for 9 hours, did not receive any medications for alcohol withdrawal, then had a seizure and sustained a head injury...” Investigator #28 Notes revealed: We continue to work through ways to provide care to patients in the waiting room during peak times of surge and limited staffing...” Further comments were reviewed by the hospital Pharmacy, dated 11/17/2023 (3 months after the event) that revealed “...Suggest education to sent out of CIWA precautions...Nurse could have clarified with provider about the CIWA order and administered medication...” Level of Harm was documented as “Harm-required intervention” and Primary Action to Prevent Recurrence: “Increase in Staffing/Decrease in Workload.” MD #23 declined to be interviewed. Interview on 11/15/2023 at 1414 with MD #26 revealed “...With the current process it’s still difficult to treat patients in the ED waiting room. The goal was for delays in care to not happen, but especially at night it occurs. I have concerns with delays in patient care. The patient was better off in a more clinical area where they can be monitored ...” Interview revealed MD #26 had concerns for patient safety in the ED waiting room due to delays in patient monitoring. Interview on 11/15/2023 at 1615 with Nurse Practioner (NP) #36 revealed “...it does happen occasionally that orders in the ED waiting room are on hold until the patient can be roomed. I do have concerns about it. The new waiting room flow is not better...” Interview revealed NP #36 had concerns provider orders were not completed timely in the ED waiting room. Interview on 11/16/2023 with ED IPA Day RN #22 revealed she did not remember Patient #43. Interview revealed “...best practice was to go back to see if patients’ meds (medication) were helpful. I must have left before I was able to put in a reassessment...I work IPA and the waiting room. There are multiple nurses and nurse techs (technicians) who get vital signs in the lobby and the techs notify us if abnormal. We escalate patient concerns with the charge nurse and the doctors do the same...” Interview revealed RN #22 cared for Patient #43 until 1900 and did not remember doing a reassessment after medication administration. Interview on 11/28/2023 at 1639 with ED IPA Night RN #28 revealed she did not remember Patient #43. Interview revealed “NOW orders in the IPA area go by priority and ESI, we are not always able to do them. The CNC (clinical nurse coordinator) should be informed...If you are the only IPA nurse and the doctor says ‘this has to happen now’ then it’s the next on my list. There was no protocol for who was actually assigned patients in the waiting room. Reassessments for ED patients who are waiting in the lobby would fall under the IPA nurse tasks but they are doing other patient’s needs and medications as well. There were only two ways to know if additional orders are placed on a patient after IPA, the doctor tells you, or on the tracking board, you might see “repeat troponin”, the CNC was supposed to help with that. If I gave controlled medication in the waiting room, I am responsible for the reassessment. If we are caught up it is a part of our duties to reassess...” Interview revealed patients in the ED waiting room are not assigned a nurse for reassessment and monitoring. Interview revealed hospital policy for reassessment in the ED was not followed for Patient #43. Interview on 12/01/2023 at 1130 with ED IPA RN #35 revealed “...The IPA nurse continues to be responsible for patients in the waiting room, after initial orders were completed...” Interview revealed the IPA nurse should continue to reassess patients in the ED waiting room. Interview revealed hospital policy for reassessment was not followed for Patient #43. Interview on 12/08/2023 at 1230 with Nursing Vice President of ED Services (VPED) #20 revealed she could not explain the lack of monitoring or completion of provider orders in the ED waiting room. Interview revealed any new outstanding provider orders for patients in the ED waiting room would be elevated to the CNC. Further there was a WebEx huddle (meeting virtually for many hospital departments to discuss and prioritize patient needs) held every 2 hours and any outstanding provider orders would be delegated to be completed. Interview revealed RN #20 could not explain why Patient #43’s reassessments and providers orders had not been completed. Patient #43, a 39-year-old who presented to the emergency department (ED) by private vehicle on 08/14/2023 at 1603 with complaints of chest pain, nausea, clammy, lightheaded, right-side tingling for several weeks, with a reported history of drinks 12 beers a day. Review revealed the patient was located in the waiting room area and was observed by a physician to be diaphoretic. The physician ordered intravenous (IV) fluids and CIWA protocol (assessment tool used for alcohol withdrawal) at 1841, and Ativan (medication for anxiety) was ordered at 1947. These orders were not implemented. Multivitamin was ordered at 2100. Another order was placed at 2226 for IV fluids and Lopressor. Aspirin was ordered at 2229. None of these orders were implemented. An order written at 2305 for Phenobarbital administration was not implemented. At 0107, a physician’s note referenced the patient had a seizure and fall with a head injury outside the ED waiting room area. Findings revealed the patient had delays with nursing assessments, and failure to implement orders, including medication administration, and following the CIWA protocol. The patient subsequently had a seizure and fall with a resulting head injury. 4. Closed medical record review on 11/14/2023 revealed Patient #28, a 48-year-old male patient who arrived at the emergency department (ED) by emergency medical services (EMS) on 07/05/2022 at 0947 with headache x 2 weeks, altered mental status, fall, and was combative. He was triaged at 0950 by RN #57 with vital signs temperature 97.8, pulse 79, respirations 24, blood pressure 175/86, oxygen saturation of 94 percent on room air, a pain scale of 0 and an emergency severity index (ESI) of 1-Resuscitation. At 0955 Medical Doctor (MD) #59 initiated orders for EKG, lab work, chest X-ray and CT (cat scan) of the head. At 1005 Haldol (given to treat severe behavior) 10 mg Intravenous was ordered by MD #59 and given due to combativeness. Review of the ER Note by MD #59 dated 07/05/2023 at 1002 revealed “.... history unable to be obtained from the patient...he was combative with EMS requiring 5 mg (milligrams) of Versed (given for sedation) given IV. He is only slightly sedated right now, ...pulling at lines, not answering questions, and not following commands...” At 1005 the complete blood count resulted with a white blood cell count of critical high- 32.4 (normal high 11). At 1029 Normal Saline 1 liter IV bolus was given and Rocephin (antibiotic) 1 gram IV was administered. At 1045 vital signs were pulse 78, blood pressure 226/107, oxygen saturation 98 percent on room air. At 1050 Patient #28 was intubated (mechanical ventilation) with standard IV sedation protocols. At 1054 vital signs pulse 76, blood pressure 211/91, and ventilated at 98 percent oxygen saturation. At 1236-1311 Patient #28 went into ventricular tachycardia (lethal heart rhythm) and was coded (resuscitated by staff), defibrillated, and had a central line placed. At 1322 a lumbar puncture was completed by MD #59 and a meningitis panel was ordered. At 1322 the cerebrospinal fluid (CSF) white blood count (WBC) resulted high at 94000 (normal high range 5 WBC’s per mm 3 [million cubic meters]. At 1324 more antibiotics were given IV. Review of the ER Report Reexamination/Reevaluation (not timed) by MD #59 revealed “...the patient ultimately did require intubation for sedation and airway protection, his mental status continued to worsen despite Haldol and Versed...The Head CT was negative...Once back from CT the patient became profoundly hypotensive and at 1 point lost pulses requiring CPR, total time roughly 5 to 10 minutes...We have been running norepinephrine (given to sustain blood pressure) through this...ICU (intensive care unit) has been consulted. Family additionally has been updated...” At 1409 Pulmonologist/ICU MD #60 ordered Levophed (used to treat life-threatening low blood pressure) 4 mg/ in 250 milliliters (ml) to titrate to 30 micrograms (mcg)/per minute and was initiated by RN #56 at 1514 (1 hour and 5 minutes after ordered), and at 1655 this drip rate was adjusted to 20 mcg/min. At 1740 blood pressure was 137/79, at 1750 blood pressure was 73/42, at 1800 blood pressure was 33/18. Review of the Medication Administration Record revealed at 1801 RN #68 initiated a bag of Levophed at 30 mcg/min for Patient #28. At 1803 a code was initiated, and Patient #28 was in asystole (no heart rhythm). The code ended at 1807 with the return of blood pressure. At 1814 blood pressure was 249/118 with a pulse of 145. At 1816 an addendum to the ER Report by MD #62 revealed “...At 1803 I was called to the patient’s room, who had gone asystole. I was notified of the patient’s diagnosis of meningitis and hypotension. CPR was in progress on my arrival...I was notified that the patient’s Levophed had run dry, and that the patient had been hypotensive (low blood pressure) sometime before coding...Shortly after the epi (epinephrine-used to return pulse) and bicarb (bicarbonate improves outcomes in cardiac arrest), (1807) we had return of pulses. Patient’s blood pressure high. ICU attending entered shortly after the code finished.” At 1940 Patient #28 was transferred to the medical ICU for admission. Patient #28 continued to decline and showed no signs of improvement. Review of the Discharge Summary date 07/15/2022 at 1525 by Doctor of Osteopathic Medicine, DO #63 revealed “...There was no change in neurology exam, and it was explained to the family that there were no signs of meaningful improvement. At this time the family changed its code status to DNR (do not resuscitate) ...at this time the family was amenable...for organ procurement. He was brought to the OR (operating room) this morning where he was extubated (removal of mechanical ventilation), and time of death was 1040. On 07/15/2022 at 0931 Patient #28 had his kidneys harvested and was pronounced dead at 1040. Review on 11/28/2023 of the Patient Safety (Incident) Report for Patient #28 revealed it was reported by: (named RN #57) on 07/05/2022 at 1930. Event #: 6858. Event time was 07/05/2022 at 1803 with brief description “...assigned 5 patients, pt. (patient) coded due to unsafe staffing ratio...additional comments ...NUS (nursing unit supervisor RN #74) and Director (named, RN #75) notified of unsafe assignment at approx. 1730. RN (named RN #56) responded to assigned Trauma Alert which arrived at 1748. Pt. coded at 1803, 1 round of CPR, epi, sodium bicarb, ROSC (return of spontaneous circulation). Pt’s levophed emptied due to unsafe staffing assignment [sic]which was reported to NUS and Director prior to event...” Review on 07/06/2022 by Investigator and Director of ED Services (named RN #76) revealed one of the ED managers had spoken to Patient #28’s family member. The family was upset because they had “...asked for help at the doorway of the patient’s room when she noted alarms going off in the room. A PA (PA#77) was at the nurse’s station from a different service line that reportedly did not respond to her request...” Further the CNC, RN #74 reported she was only notified RN #56 needed assistance when the patient was coding. Patient #28 did code 2 times during his ER stay and had a length of stay of 9:52 (9 hours and 52 minutes) in the ER. RN #56’s patient assignment was broken down by RN #76 in the report as two stable patients awaiting admission to step down units (2), one patient who had been moved to the hallway (1), a new Trauma Alert patient (1), and Patient #28, an ICU patient (1). (RN #56 was assigned and responsible for 5 patients during Patient #28’s code/event). RN #76 discussed collateral staff available in the ED to support RN #56. “...Background information: The House was unable to provide staffing support for the admit holds in the ER on this date. There was an ER census of 295 on this date...” On 07/07/2022, Vice President (VP) of ED Services, VPED #48 reviewed this Patient Safety Report. Her investigation revealed there was an additional Patient Safety Report for this same event “...Indicating that the ER Director was informed of an alleged unsafe patient assignment. This notification to the Director was not substantiated...” Additionally, VPED #48 agreed RN #56’s assignment was safe due to collateral staffing in the ED. And did mention Patient #28’s family had voiced concerns who did not respond to their request for help for alarms in the room with (named, PA #77). The Primary Contributing Factor was “Human Factors/Staff Factors...Competing priorities...Level of Harm Harm-intervention to sustain life...” In summary, Patient #28’s levophed IV infusion sustaining his blood pressure was allowed to run dry, his blood pressure dropped, he was coded for 7 minutes until the infusion was reinstated. RN #56 had a patient assignment of 5 patients. Review on 11/28/2023 of the Patient Safety Analysis report, Event #6856, referencing Patient #28 dated 07/05/2022 at 1843 by ED Clinical Pharmacist, ED RPH #78 revealed the event date was 07/05/2022 at 1800 with a brief description of “...Patient required CPR (cardio-pulmonary resuscitation) due to levophed running dry while RN was attending to other patients (RN had 5 pts), including two traumas and this ICU patient...additional comments...making this report on behalf of (named RN #56) as he does not have time to make report. (Named) had 5 patients: the patient from this report (named) intubated, ICU), a trauma alert, a trauma transfer-a comfort care patient in the hall, and two other admitted patients. While he was in one of the traumas, this patient’s norepinephrine infusion ran dry-the patient became hypotensive. The family of the patient was monitoring the BP (blood pressure) and tried to get help from a non-ER provider who was sitting at a computer outside the room and this provider told the family that he could not help them because it was not his patient. Family is irate about this. A few minutes later, another RN came into the room and was able to switch out the levophed, but by this point the pt’s SBP (systolic blood pressure) was in the 30’s. He then became aystolic and required a round of CPR. (Named RN #56) alerted the ER NUS throughout the day that his assignment was unsafe. This patient coding was a direct result of an unsafe and unreasonable assignment...” This Report was investigated by ED Director, RN #76 on 07/06/2022 without any new findings from previous Event #6858. Additionally, on 07/21/2022 Doctor of Pharmacy, PharmD #79 added investigator notes to this report. The leading description of harm cited by PharmD #79 was “Human Factors/Staff Factors...Level of Harm...Harm-intervention to sustain life...” A summary of her report revealed that a bag of levophed was pulled for Patient #28 on 07/05/2022 at 1511 by RN #56 and was documented on the Medication Administration Record as given on 07/05/2022 at 1514, and per her estimation of the rates of infusion, the bag of levophed “...would have likely run out 1745...” The next bag of levophed was pulled on 07/05/2022 at 1757 by ED RN #68 and was started at 1801 for Patient #28. Review revealed Patient #28’s levophed IV infusion was interrupted for 16 minutes; he was coded from 1803 to 1810 before returning to spontaneous circulation. ED RN #68 was not available for interview. ED RPH #78 was unavailable for interview. ED Manager RN #75 was unavailable for interview. ED Director, RN #76 was unavailable for interview. Interview on 11/15/2023 at 1014 with RN #56 revealed he remembered Patient #28 and had worked in the ED for 5 years. Interview revealed “...I had trauma bay 11, and rooms 10, 9, 8 initially. The patient in room 10 was combative, intubated and a danger to himself and was receiving the maximum dose of levophed to keep his blood pressure elevated. I had him around 10 hours of my day. I got a trauma patient, and they were going to assign me another new trauma patient. Around 1730 I went to CNC (named RN #74) to discuss my assignment and the acuity of my already 4 patients, she put my dying trauma patient in the hallway, to make room for the new trauma patient even when I explained I felt my assignment was unsafe. I had already approached her that morning after 0800 to explain the acuity of my patients. So, then I went to my Nurse Manager (named, RN #75) to discuss my assignment and was assigned the new trauma anyway. My new trauma patient had just arrived after 1730, I was working with them and didn’t realize a code had been called for my intubated patient. When I arrived in the room (named RN #68), the person who was assisting me while I was caring for the new trauma patient, had already hung a new bag of levophed, and the code was in progress. I was very upset. I voiced my concerns, I talked to the administration, to the ethics and compliance committee and filed a complaint with HR (human resources). I tried to document this the best I could...” Interview revealed RN #56 had gone to the CNC, RN #74 at 0800 and again before new assigned trauma patient to voice his concerns with his high patient acuity assignment. Interview revealed RN #56 was caring for another patient, when the levophed IV infusion ran out, causing Patient #28’s blood pressure to drop, and a code was initiated. The interview revealed reassessment and monitoring of Patient #28 did not follow hospital policy. (request for all documents filed by RN #56 administration, ethics committee and HR were not made available). Interview on 11/16/2023 at 1128 with CNC, RN #74 revealed RN #56 approached her one time, and said ‘I need help’. CNC RN #74 stated she got RN #56 help by calling on the trauma team nurses who support trauma patients in the ED, but were not assigned patients in the ED. Interview revealed “...If we need help, we pull resources...” Further interview with CNC RN #74 revealed “...she had no concerns with nursing reassessments in the ED... that nursing assignments in the Red Pod (where the most acute patients are assigned) were 1 RN to 4 patients...” The interview revealed CNC #74 added trauma team nurses to assist RN #56 and stated she and the CNC’s filled in themselves when needed to support patient care. Interview on 11/15/2023 at 1637 VPED #20 during tour of the ED revealed the Red Pod in the ED was assigned the most acute ED patients. The interview revealed nursing assignments were 1 nurse to 4 patients, and RNs are expected to communicate with the CNC’s any concerns or delays with patient care. “...starting in 2023 we have Webex huddles with nursing, providers, and other hospital departments every 2 hours to discuss delays in care and appoint resources where they are needed...” Interview revealed the expectation for reassessment and monitoring patients were for all staff to follow hospital policy. Interview revealed hospital policy for Patient #28 was not followed. Telephone interview on 12/01/2023 at 1209 with Director of the Trauma Team, MD #80 revealed he was aware of the case with Patient #28 and was the Medical Supervisor for PA #77 in 2022 and currently. Interview revealed “...when a Trauma Team member was in the ED it was to care for a specific consulted trauma patient, however a Trauma Team member if clearly evident could assist any patient in a life sustaining emergency...” The interview revealed PA #77 would not be allowed to touch an IV drip or alarming IV pump of a patient they were not consulted on. Interview revealed PA #77 notified a person who could adjust the drip for Patient #28. Further interview revealed he had no concerns with PA #77’s patient care, and the Trauma Team Supervisor, RN #81 had communicated with PA #77 “...we should always respond with compassion to family...” regarding this event. Interview revealed MD #80 had not followed up with PA #77, the Trauma Team Director had talked with PA #77. Interview revealed PA #77 did not know Patient #28’s blood pressure was low or the levophed had run out but had communicated to ED nursing staff who could attend the alarms when family asked him. Telephone interview on 12/01/2023 at 1241 with Trauma Team PA #77 revealed he had been employed for 8 years. Interview revealed “...I am only in the ED when called/consulted for a specific trauma patient. The family came to the desk, I told them I can get your nurse, and I did. The family was asking about an IV beeping. If I thought he was coding, I would have made sure he was OK. I did not have that information. I only learned about the IV levophed today. Of course, I would respond to help a patient coding. I would not ‘shirk’ a patient needing help...” Interview revealed PA #77 recalled the family asking for help with an IV alarm. He told the family he would find the nurse, and he did. Patient #28 presented to the ED on 07/05/2022, was critically ill, intubated and diagnosed with bacterial meningitis. The patient developed a low blood pressure and a Levophed IV drip was started. Findings revealed the Levophed IV drip was allowed to run dry and the patient’s blood pressure dropped to 33/18. A trauma PA was requested by the family for help related to alarms and the patient’s condition and the PA indicated the patient was not the PA’s assigned patient. The patient arrested. A new Levophed bag was hung. The patient and IV were not monitored and the bag ran dry with subsequent cardiac arrest. 5. Closed medical record review on 11/14/2023 revealed Patient #27, a 66-year-old female who arrived at the emergency department (ED) on 07/04/2022 at 0025 by private vehicle with abdominal pain, nausea, and vomiting. Patient #27 was triaged at 0025 by RN #38 vital signs: temperature 97.2, respirations 20, heart rate 107, blood pressure 169/93, and oxygen saturation of 94 percent on room air, a pain score of 10 (1 least pain and 10 being the most pain) and was assigned an emergency severity index (ESI) of 3 (urgent). At 0028 Nurse Practitioner (NP) #39 wrote orders for Lipase (a digestive enzyme) STAT, CMP (comprehensive metabolic panel) STAT, Lactic Acid (carries oxygen from your blood to other parts of your body) STAT, CBC (complete blood count) STAT, Urinalysis (Urine test) STAT, and CT (cat scan) of the Abdomen/Pelvis STAT, an IV (intravenous) of Normal Saline to be started and Ondansetron (medication for nausea) 4 milligrams (mg) IV to be given. Record review did not reveal lab work, nursing reassessment, or physician orders for IV and medications were implemented for Patient #27 while in the ED waiting room (6 hours and 3 min). At 0631 Patient #27 was moved to Red Pod (for highest acuity patients) room 20. Patient #27 was seen by MD #26 at 0656 and orders were placed for ondansetron 4 mg, and Dilaudid (narcotic pain medication) 0.5 mg for pain. At 0734 lab work resulted (7 hours and 6 minutes after ordered). At 0739 Patient #27 had an IV started of NS (7 hours and 11 minutes after ordered), and medications for pain (7 hours and 14 minutes after identified pain level of 10, and 43 minutes after pain medication ordered) and nausea (7 hours and 11 minutes after original order) were administered by RN #40. At 0742 vital signs were documented as heart rate 85, respirations 16, blood pressure 174/89, oxygen saturation of 93 percent on room air (no temperature), with a pain score of 10/10 by RN #40. At 0755 the CT of Abdomen and Pelvis (6 hours) resulted (7 hours and 27 minutes after ordered) positive for a small bowel obstruction. Review of the ER Note Reevaluation (not timed) by MD #26 revealed Labs were reviewed without critical results, and the CT scan was consistent with a small bowel obstruction. Surgery was consulted for further evaluation and management by MD #26. At 0839 repeat pain assessment was 1/10 by RN 40. On 07/04/2022 at 1316 Hospitalist #41 saw the patient, set for admission. At 1319 Patient #27 had a pain score of 10/10, vital signs heart rate 83, respirations 17, blood pressure 147/96, oxygen saturation of 93 percent on room air, and was given Dilaudid 0.5 mg IV for pain relief by RN #40. Review of the Surgical Consult Physician Note by MD #42 dated 07/04/2022 at 1543, Patient #27 was scheduled for a Laparoscopy, Possible Exploratory Laparotomy with Possible Bowel Resection. At 1620 a repeat pain assessment was completed for a pain score of 3/10. At 1600 Patient #27 left the ED for the operating room for surgery. Patient #27 completed surgery without complications and was discharged home on 07/06/2022 at 1136. Request for a Patient Safety Report (Incident Report) revealed there was not one available. Interview on 11/15/2023 at 1350 with ED RN #38 who triaged Patient #27 revealed “...in 2022 no patients were checked on in the ED waiting room, some changes were made, and there are some improvements. It’s very possible that this patient waited without any labs or orders completed. At that time there was one nurse in the waiting room to triage patients. There was no way to complete orders...” Interview revealed nursing reassessments and physician orders were not completed in the ED waiting room in 2022. Interview on 11/17/2023 at 1102 with NP #39 revealed “...the IPA (Internal Processing Area area in the ED waiting room) did not exist then. Now if patients need to move to the back, I tell the CNC (clinical nurse coordinator), we call and we call. I personally have been pulled to do patient reassessments when there was a change in condition. One hundred percent, patients are not safe, orders are not completed, and staffing is a concern. There is one nurse with a line out the door, I can put orders in, but it is not going to get done because of the volume of patients and minimal staff...” Interview revealed NP #39 had current concerns with waiting room patients not getting orders completed in the ED waiting room. Interview on 11/15/2023 at 1414 with ED MD #26 revealed “...I saw the patient after she was roomed.... There is not always a person to get labs and orders done. No staff to do orders. With the new process the goal is for that not to happen, but at night I suspect it does. As far as care in the waiting room, this patient didn’t get vital signs, or overall assessments and no meds...things are not happening on a timely basis...” Interview revealed Patient #27 did not get vital signs, assessments, or medications as prescribed. Interview revealed hospital policy was not followed for Patient #27. Patient #27 arrived in the ED on 07/04/2022 at 0025 with a reported pain level of 10 of 10. The patient had a STAT CT of the abdomen and pelvis ordered at 0027 that was not completed until 0755 (7 hours, 27 minutes later) resulted and signed at 0825. The patient had pain reported as 10 of 10, with nausea and vomiting with vital signs at arrival at 0025 and was medicated with Dilaudid (narcotic pain medication) at 0739 (7 hours and 14 minutes after arrival). The patient was diagnosed with a small bowel obstruction and had surgery that day. The patient had a delay with STAT lab work, STAT CT, nursing reassessment and pain management. 6. Closed medical record review on 11/14/2023 revealed Patient #29, a 78-year-old female who presented to the emergency department (ED) via emergency medical services (EMS) on 04/05/2022 at 1451 with complaint of falling at home with a laceration to the right lower extremity. The EMS report dated 04/05/2022 at 1342 revealed the patient had fallen from the toilet at home, was on oxygen 3 liters by nasal cannula “comments: baseline for patient”, had an Intravenous (IV) line in her left forearm #20 gauge and had received Normal Saline 700 milliliters (ml). Review of an EMS narrative note revealed “she does have significant bleeding from her right lower leg...bleeding is controlled...the leg is splinted...”, was on a ECG (heart monitor) showing a heart rhythm of atrial fibrillation (irregular heart beat) with a pulse of 88. At 1503 a Physician’s Assistant (PA) #45 was assigned and a review of his ER (emergency room) Report Note at 1510 revealed “...High suspicion for open fracture to right anterior shin...”, with plans to order CT (cat scan) of the head and neck, pain medication, antibiotics, and lab work.” PA #45 ordered X-rays/CT at 1508. At 1514 Patient #29 was moved to Red Pod (for most acute patients) Hallway Bed 7. At 1517 Patient #29 was triaged by RN #43 “...subjective rapid assessment: fell in the bathroom at home. On Eliquis (blood thinning medication) and a pain score of 0. Open Tib Fib started earlier unseen...Pre-hospital treatments: oxygen, other: 3-liter O2 (oxygen) 20g (gauge) Left arm...Acuity 5-non-urgent...”, an emergency severity index (ESI) was assigned of 5 (Non-Urgent). At 1536 lab work was ordered. At 1537 the CNC (clinical nurse coordinator), Registered Nurse, (RN) #44 documented a change in patient ESI to 3-urgent. 1559 lab work had resulted. At 1618 PA #45 ordered Hydromorphone (narcotic pain medication for severe pain) 0.5 mg IV push every 15 minutes duration 3 doses for pain for Patient #29 and Zofran 4 mg IV for nausea. At 1630 (one hour and 39 minutes after arrival) vital signs were documented as pulse 88, blood pressure 161/79, oxygen saturation of 90 percent (no oxygen was documented), 1639 respirations of 22, and temperature of 98.4. By 1627 all radiology had resulted, and a review of the ER Report Reexamination/Reevaluation (not timed) by PA #45 revealed “...On my read it appears the patient has a rather significant tib-fib (tibia/fibula) fracture. I do believe this is an open fracture. She has already received Ancef (antibiotic), and I have already spoken to orthopedic surgery. They will come and speak with the patient...” At 1636 Ancef 1 gram IV, a Tetanus (infectious disease that can occur from an unclean wound) booster intramuscular, Hydromorphone 0.5 mg IV for a pain score of 10/10 and Zofran 4 mg IV were administered by RN #43(no evidence of an oxygen assessment). At 1736 a pain reassessment was charted as 9/10 (no evidence of an oxygen reassessment). At 1748 the Orthopedic Consult and History and Physical was completed by MD #52 with diagnosis of “Open tibial shaft fracture...” with plan for surgery to repair fracture. Review of the ER Report addendum by PA #45 (not timed) revealed “...Orthopedic surgery agrees this appears to be open fracture and recommends a room for splinting and simple reduction before surgery tomorrow am...” At 1816 Patient #29 was given Dilaudid 0.5 mg IV for a pain score of 9/10 by RN #43 (no evidence of oxygen assessment). Review of the Patient Summary Report revealed Patient #29 was moved to room 11 at 1915. Review of an addendum to the ER Report by PA #45 (not timed) revealed “...As I was handing off the patient to ... I was told by nursing staff that the patient was unresponsive. Upon arrival at the bedside, the patient is unresponsive. She does have DNR (do not resuscitate) [no evidence of this in the record]. She is moved into room 11 where Dr. (MD #46), my attending physician was kind enough to evaluate the patient and call time of death...” Review of the ER Report 04/05/2022 at 1947 by MD #46 revealed “...78-year-old female past medical history of atrial fibrillation currently anticoagulated on Eliquis. She fell and had an open fracture of the tibia/fibula. Patient has been admitted to the orthopedic service. I was called to the patient’s bedside at 7 PM as nursing found her pulseless and apneic (no respiration). After 60 seconds, the patient has no cardiac activity, she is in asystole (no heart rhythm) on the monitor. Her pupils are fixed and dilated. No spontaneous respirations, no cardiac sounds and she is pulseless. Official time of death was called at 709 PM ...” Patient #29 was pronounced dead in the ED on 04/05/2022 at 1909. Review of the Patient Event Record dated 04/06/2022 at 0341 by Nursing/Surgical Services #54 revealed the event was “unexpected death” date of event “04/05/2022 at 1903” with narrative “...pt came to ER (emergency room) c/o (complaint) fall with fracture. pt placed in the hall bed. pt found unresponsive in hall...House Supervisor (RN #55) notified at 1905...”, the description of harm and action to prevent reoccurrence was documented as “monitor trends and patterns”. There was no witness to event per report. Trauma Nurse, RN #56 was unavailable for interview. Interview on 11/16/2023 at 1204 with ED RN #43 who cared for Patient #29 revealed “...I was checking on the patient, she was responding, her daughter was there. I was charting and could see her. She was full code, her daughter ran over to me and asked me what I was doing, as I was pulling the stretcher away from the wall and replied ‘CPR’ and the daughter said, ‘please don’t do that’. The trauma nurse that day, (named RN #56) took the patient to room 11. I reported it to my charge nurse (named RN #57), and I went to report off on my other patients because it was the end of the shift. I didn’t see her again...you’ll have to go by my charting, I don’t remember if she was on oxygen...” A further interview revealed “...I should have charted she expired, that was an error...” The interview revealed RN #43 did not recall if Patient #29 received oxygen in the ED, did not recall if an oxygen reassessment was completed and did not get vital signs or reassess a change in condition. Interview revealed hospital policy for reassessment was not followed for Patient #29. Telephone interview on 11/16/2023 at 1324 with MD #46 revealed she did not recall Patient #29. Interview revealed “...monitoring of patients in hallway beds are a concern. Ideally every patient in the Red Pod should be on some sort of a monitor with a pulse oximeter (oxygen monitor). More monitoring is always better...” Interview revealed when MD #46 arrived at the patient’s bedside she was in asystole, and she pronounced the patient with daughter at the bedside. Interview on 11/16/2023 at 1747 with CNC, RN #44 revealed “...I do remember she was in a hallway bed, and (named RN #43) said she had passed. I had checked on her. (Named RN #43) told me the daughter came to her and said, ‘somethings wrong with my mom’. I don’t remember if she had oxygen or was being monitored. I would expect the ED nurse to complete assessments and document them in the chart...Staffing was 4:1 in the Red Pod, If a nurse tells me I’m overwhelmed, I will ask another nurse to assist with patient care...” Interview revealed RN #44 did not know why oxygen reassessments or changes in conditions were not completed for Patient #29. Interview revealed hospital policy for reassessment for a change of condition was not followed for Patient #29. Interview on 11/28/2023 at 1433 with Assistant Director of Nursing, RN #15 to review the internal investigation following Patient #29’s death in the ED “...Per the ED Manager (not identified) the patient’s family called staff over to the patient because ‘she didn’t look good’. She was unresponsive and was taken to room 11 to be placed on a cardiac monitor which showed asystole. At 1909 was the time of death pronounced with her daughter at the bedside. Interview revealed this event was reviewed by the Mortality and Morbidity which was comprised of multiple providers and the MD who had completed the report dated 07/11/2022 the internal investigation of Patient #29’s death revealed the patient was under triaged, the door to antibiotics was greater than 1 hour, and needed closer monitoring. (note: this surveyor was not allowed to hold or view documents during this interview.) Patient #29 arrived on 04/05/2022 at 1451 via EMS and had atrial fibrillation (abnormal heart rhythm) on arrival. The patient had a recent fall with fracture prior to arrival. Pulse Oximetry was 94% prior to arrival. 1630 pulse oximetry was 90% (1 hour and 39 minutes after arrival) with no evidence of oxygen administration at hospital. Dilaudid 0.5 milligrams (mg) IV was administered at 1630 and again at 1816. No vital sign or oxygen assessment on an elderly patient was assessed on the patient with a prior pulse oxygen of 90% after the administration of Dilaudid. The patient was subsequently asystole at 1909 and expired. Patient #29 had one set of vital signs from 1451 until time of death at 1909 (5 hours and 18 minutes). Nursing staff failed to reassess the patient after narcotic administration. Nursing staff failed to reassess the patient for a change in condition (not breathing). 33790 7. Medical Record review, on 12/14/2023, revealed Patient #6 arrived to Hospital B via EMS on 10/03/2023. Review of the Triage Note at 1723 revealed “ ...Reason for Visit: Pt (patient) at 2 started having left sided arm and leg muscle weakness and left sided diminished sensation on leg. Facial drooping noted in lower face. No blood thinners and 10 days post partum. What aspect of reason for visit is concerning to patient? : Stroke symptoms. ... “ Review of a MD “ER Report”, service date/time 10/03/2023 at 1714, revealed “ ... History of Present Illness 22-year-old female with a past medical history of vaginal delivery 10 days prior ....who presents to the emergency department with left-sided weakness. Patient states that she felt normal when she went to take a nap at approximately 2 (2:00), when she woke up at 330 (3:30) she noticed that she had weakness on the left side of her face and is developing weakness in the left side of her body. She notes that she was unable to smile fully. States that she has never had any symptoms like this in the past. She notes that last night she had an episode of epigastric pain, but that has gone away since fully. States that the developing left-sided weakness has been ongoing since that time and called EMS for evaluation. Pregnancy was uncomplicated ....Initial Vitals T: 98.9 F Oral HR: 65 RR: 20 BP: 170/97 SpO2: 87%.... Medical Decision Making ....22-year-old female presenting to the emergency department secondary to onset of neurologic deficit with last known normal of approximately 2:00 PM. On exam, I initially had concern for Bell’s palsy given her age and demographic info, but on my physical examination I noted appreciable weakness on the left side of the body with regards to motor function. I would not expect Bell’s palsy to cause the symptoms, in addition to this she was able to raise both eyebrows equally. Although there can be varying degrees of eyebrow raise or inability to thereof with Bell’s palsy, I would not expect the left-sided sensory subjective deficit and motor deficit as noted. Therefore I did initiate a code stroke procedure. This is also complicated by the fact the patient is 10 days postpartum which does place her at an elevated risk for ischemic CVA (stroke). Differential at this point would also include complex migraine, preeclampsia/eclampsia (serious pregnancy complication characterized by high blood pressure), or complex partial seizure, though she did not report any seizure-like activity .... Ultimately, the decision was made in concert with the stroke neurologist at (Hospital A) not to provide thrombolytics at this point in time .... However, patient will require transport to (Hospital A) for further close work-up and likely MRI (Magnetic Resonance Imaging- type of diagnostic testing). Ultimately my concern for eclampsia (serious pregnancy complication) is certainly present given her elevated blood pressure and abnormal neurologic exam. I did order 20 mg of IV labetalol (to treat BP) to be given as a stat dose in addition to 4 mg of magnesium as a bolus with a 2g/h (grams per hour) infusion thereafter. I did reach out to and speak with the OB/GYN on-call ....who agreed with this management plan and possible diagnosis of eclampsia given her blood pressure and symptoms. Patient was transferred to (Hospital A) emergently for further care. ... Diagnosis/ Disposition Postpartum eclampsia/stroke. ...” Review of the EMS (Emergency Medical Services) Patient Care Record, dated 10/03/2023, revealed EMS transported Patient #6 from Hospital B to Hospital A. The EMS record indicated they arrived to Hospital A at 1938. Review of the EMS Narrative note revealed “(EMS) on scene at (Hospital B) and was informed of a Red Transport (red is the most urgent transport) .... Arrived to find the pt (patient) in room 3, alert to EMS presence and in no obvious distress....report is as follows: ....Dx (Diagnosis): HTN (hypertension) crisis, Preeclampsia Stroke HPI (History/Physical): Came in with EMS for L (left) sided drooping and weakness and tingling onset....10 days postpartum....CT Head clear for bleed and clots ‘Preeclampsia Stroke’ Meds: Mag (Magnesium) 4 g (gram) Bolus with 2 gm/hr infusion, Labetalol 10 mg (milligrams) ....Vitals: 172/98 .... Pt states that she feels fine just feels super weak but denies any pain or N/V (Nausea/Vomiting). Due to the importance of medication, (EMS) waited for nurses to retrieve and start a magnesium (Mag) drip before departing. In the meantime, secondary IV access obtained by Paramedic (name) and pt is moved over to the stretcher, placed on all monitoring ....Pt was placed on capnography (carbon dioxide monitoring) noting elevated rate and borderline hypocapnia (decrease in carbon dioxide levels below normal) with normal appearing waveform ....Once all paperwork is obtained and Mag is started pt is moved out to the truck and transport is initiated to (Hospital A) Emergency. Enroute pt is monitored with no new complaints....While waiting on a bed at (Hospital A) pt was monitored with minimal changes to her BP. Repeat neuro checks were completed periodically....Pt began to complain of a mild headache and posterior neck pain similar to how she felt before she delivered. Pt report and care given to RN (Name) bedside ....Arrived: 19:40 .... Transferred Care 22:24 (2 hours 44 minutes after EMS arrived to the hospital). Review of the EMS Record revealed EMS staff continued to monitor the patient, including ongoing vital signs. An EKG was performed at 2016. An EMS assessment was completed at 2121 which indicated slight yellowing of the skin, right upper quadrant tenderness and left arm and leg weakness along with a facial droop and neck pain. Vital signs continued approximately every 5 minutes, with the last recorded blood pressure 147/90 at 2215. Emergency Department record review revealed Patient #6 arrived to Hospital A on 10/03/2023 at 1942. An “ED Triage” performed on 10/03/2023 at 2227 (2 hours 45 minutes after arrival) revealed “...Subjective Rapid Assessment Stated Reason for Visit : Brought by EMs (sic) team from (Hospital B) due to stroke like symptoms, left facial droop and left sided weakness, last known normal was 1400H (hours) and onset of symptoms at 1530H ....ED Full Triage Arrival Mode - ED (Emergent) : EMS ....Pre-Hospital Treatments : IV Access, Other: Magnesium sulfate at 2g/hr ....Arrived From: Hospital. ...” Review of vital signs revealed a heart rate of 82, respiratory rate of 18, BP of 168/96, oxygen saturation of 93% on room air and a pain score of 4. Record review revealed an “ED Medical Screen Exam Form.... Entered on 10/03/23 22:23 EDT” which noted “...MSE Comments : tx (Transfer) from (Hospital B) for MRI brain, concern for ecclampsia. Appears admit bed is already ordered.” Review of the “ER Report”, service date/time, 10/03/2023 at 2310, revealed “...Patient presents as a transfer from outside hospital for concern of strokelike symptoms. She presented to (Hospital B) today with left facial droop that she noticed when she woke up from her nap around 3:30 PM. Her last known well was around 2 PM. At (Hospital B), she was noted to have left facial droop as well as some left arm and leg weakness. Stroke consult was called and the patient was seen in concert with telemetry neurologist decision was made against using tPA (breaks down blood clots). She was transferred here for further stroke eval and MRI (magnetic resonance imaging). She was also notably hypertensive at outside hospital with blood pressure 160s systolic. She has also had some headaches recently, did have a headache at the time of her delivery. She denies any chest pain or shortness of breath currently.... Physical Exam ....Initial Vitals HR: 82 RR: 19 BP: 168/96 SpO2: 93% ....Neurological: Alert and oriented to person, place, time. Patient does have left facial droop with left eyebrow droop as well. Has very mild drift on the left as compared to right. Has difficulty lifting left leg up against gravity .... Medical Decision Making ....Differential Diagnosis.... Stroke, eclampsia less likely given no seizures, preeclampsia, Bell’s palsy although this is less likely given her symptoms in the left arm and leg ....Treatment and Disposition .... Patient presents the emergency department with left sided weakness and left facial droop. Chart reviewed from outside hospital as she is a transfer from (Hospital B). Discussed with neurologist who will admit to their service. MRI and MRV (magnetic resonance venography-imaging that focuses on the veins) have been ordered. Patient continues to have left facial droop on exam, does seem to have eyebrow sparing as she is able to lift her left eyebrow. She also does have some very mild pronator drift on the left side as compared to the right as well as difficulty lifting up her left leg .... Concern remains for stroke. MRI has been ordered and MRV as well as ordered by neurology. I did discuss the case with OB given her hypertension here. I have ordered the magnesium infusion at 2 g/h as well as a 10 mg dose of IV labetalol given her systolic of 168 here. Patient admitted to neurology .... Diagnosis/Disposition Left-sided facial droop Preeclampsia. ...” Record review failed to reveal acceptance and monitoring of Patient #6 by nursing until triage at 2227 (~2 hours 45 minutes after arrival). Record review did not reveal documentation of a physician evaluation until 2310. Record review revealed the only documented evaluation and monitoring of Patient #6 during the time period from arrival to triage was from EMS staff. Patient #6 was moved from the initial ED room to a holding unit and later to a maternal fetal medicine unit. The patient was discharged home on 10/06/2023. Telephone interview with EMS #63, on 11/14/2023 at 1430, revealed the EMS team was at Hospital B dropping off another patient and were notified of a “red” transfer of a patient who was 10 days postpartum with a hypertensive crisis and preeclampsia or stroke. Interview revealed they were notified that Neurology wanted the patient transferred emergently. Medications were started and the patient immediately transferred. Patient #6, per interview, was still having symptoms and waited at Hospital A for a “2 hour 46 minute wait time on the wall” (location where EMS waits in the ED with patients who are awaiting an available bed). Interview revealed EMS continued to monitor the patient closely as Patient #6 had right upper quadrant pain and was on a Mag Drip. Interview revealed that EMS waiting and patients holding for a bed had been an ongoing issue for 3 ½ years and seemed to be getting worse. Interview revealed the EMS staff member did not feel the patient’s care was met in the ED as Patient #6 required neuro checks, vital signs and close monitoring. Interview with RN #64 during observation on 11/13/2023 around 1030 revealed that when EMS arrives with patients and there are no beds available then EMS stays “on the wall” with the patient until a bed is available. They do not hand-off the patient until patients get to an assigned bed. Physicians may see patients on the wall, but “EMS can only hand-off to a RN.” Follow-up telephone interview on 11/15/2023 at 1430 revealed that in relation to patients arriving with EMS, ED nurses do not “triage patients until ...taking ownership of the patient. Interview revealed that if the CNC in the EMS arrival area was to triage the patient, then the RN was “taking ownership of the patient.” The RN stated they could not do that as CNC and still meet all the expectations of the role. Interview revealed that in this ED, “EMS is still responsible.” Telephone interview on 11/15/2023 at 1410 with DO #65 revealed the DO went to assess Patient #6 when she was in a bed in the ED. Interview revealed the DO signed up for Patient #6 as soon as her name popped up on the ED tracking board. Before that time, the DO was not aware the patient was in the department. Interview revealed that technically the patient was already admitted, having been accepted by neurology, but was an ED to ED transfer. ED physicians still did a full medical screening on transferred patients, the DO stated. Interview revealed Patient #6 was on a Mag infusion and was hypertensive. Interview revealed DO #65 called the accepting Neurologist and also called an Obstetric Resident since the patient was postpartum and hypertensive and there were concerns for preeclampsia. Telephone interview with Patient #6’s Triage Nurse, RN #66, on 11/17/2023 at 0932, revealed the nurse did not recall Patient #6 or the situation. Interview revealed the EMS team was responsible for any patient they brought in until the patient got a room assignment and was moved to a room in the ED. Once the patient was in a room, the ED RN triaged the patient and there was a proper hand-off between EMS and the RN. Telephone interview on 11/17/2023 at 1205 with MD #67, the accepting neurologist for Patient #6, revealed they were concerned enough to transfer the patient to Hospital A even though they decided not give thrombolytics. Interview revealed obstetrics was called since the patient recently delivered and Mag was given more often by obstetrics. Interview revealed the time until the patient was triaged was “a long time.” Interview revealed the patient should have received frequent vital signs by staff. The MD stated they often do ED to ED transfers. Interview revealed MD #67 thought he saw the patient when she was in an ED room and that the accepting physicians would not know a patient had arrived to the ED until a call was received from the ED that the patient was there. Interview revealed if they had a room the patient would have gone to Neuro. Ultimately, the MD stated, it was determined Patient #6 was hypertensive related to pregnancy and it was better for her to be admitted to obstetrics. In summary, Patient #6 arrived to Hospital B with strokelike symptoms at 10 days postpartum. She was accepted for transfer to Hospital A as an ED to ED transfer. Patient #6 arrived to the hospital via EMS on 10/03/2023 at 1942. The patient waited in the ED for a bed and continued to be managed by EMS. No documentation was noted by a medical provider until 2223 and Patient #6 was not triaged or assessed by hospital nursing staff until 2227 (approximately 2 hours 45 minutes after arrival by EMS). There was a delay in accepting the patient and a delay in triage, assessment and monitoring by nursing staff. 8. Hospital B Medical Record review on 12/16/2023 revealed Patient #1, a 64-year-old, arrived to Hospital B on 10/31/2023 at 2203. Review of the ED Triage, at 2203, revealed “ ...Subjective Rapid Assessment Stated Reason for Visit : 2130 onset slurred and right sided weakness with facial droop; no thinners (blood thinning medications) ....CODE STROKE. ED Full Triage ....Acuity : 1 (highest acuity). ...” Review of the “ER Report” by a physician, at 2212, revealed “ ...History of Present Illness This patient is a 64-year-old woman....here with neurologic symptoms. Independent history is obtained from the patient’s husband, who is here with her. He said that at approximately 9:30 PM, she called out to him that something was wrong. He looked over and saw that she was having difficulty walking and seemed to be slumping to the side. Her speech was noted to be slurred.... She is weak on the right side. Physical Exam ....Initial Vitals .... BP: 204/100....VITAL SIGNS: Triage vital signs are reviewed and show elevated blood pressure approximately 204/100, otherwise normal. GENERAL: Patient is well-developed, well-nourished, and clearly with facial asymmetry and slurred speech .... NEURO: The patient has paralysis of the right lower face.... She has moderate dysarthria (slurred speech).... Level of consciousness seems normal. She does have drift of the right arm without hitting bed ....Medical Decision Making This patient presents with neurologic symptoms concerning for acute ischemic stroke ....I think she will likely be a candidate for thrombolytics assuming that we can get her blood pressure down. She is going to CAT (computerized axial tomography - type of diagnostic imaging) scan right now. We are giving labetalol IV (medication for blood pressure given intravenously). [space] 10/31/23 23:00:55.... I reviewed CT scan .... Showing left basal ganglia hemorrhage (hemorrhagic [bleed] stroke in a part of the brain] ....I did discuss the patient with the neurologist, who accepts the patient in transfer for treatment of acute atraumatic hemorrhage. The patient did receive a dose of labetalol, and her blood pressure dropped below 160 briefly but then went back up over 170, so nicardipine infusion was started. Diagnosis/Disposition Acute atraumatic intraparenchymal hemorrhage (bleeding into the brain) [space] Acute hypertensive emergency (acute marked elevation in BP associated with signs of damage) [space] Right-sided weakness. ...” Review of the Transfer Form revealed Patient #1 was accepted for transfer at 2225. Review of the Physician’s Certification for Medical Transport form revealed “ ...Medical Condition at the Time of Transport : Patient requires neurological, cardiac, and hemodynamic monitoring and a nicardipine drip by a medical attendant throughout transport. ...” Review revealed Patient #1 was transferred out at 2233 as a “Red” priority. Review of the EMS Patient Care Record revealed EMS transferred Patient #1 as an emergency “red” transfer. Review of the “Narrative” documentation revealed “(EMS) WAS ISSUED A RED TRANSPORT TO (Hospital A). ....THE PT WAS BEING TRANSPORTED TO (Hospital A) DUE TO INTRACRANIAL HEMORRHAGE. THE PT WAS PLACED ON THE CARDIAC MONITOR, 12 LEAD ESTABLISHED ....THE PHYSICIAN ADVISED TARGET BLOOD PRESSURE IS 140/90 AND ADVISED TO MONITOR BLOOD PRESSURE DURING TRANSPORT. NICARDIPINE WAS ADMINISTERED AND MAINTAINED THROUGHOUT ROUTE .... EMERGENCY TRAFFIC. THE PT WAS REASSESSED EVERY 5 MINUTES DURING TRANSPORT.... PT REMAINED ALERT, ORIENTED, SLURRED SPEECH WAS NOTED. PT CARE .... UPON ARRIVAL, THE PT WAS REGISTERED, AND EMS WAITED ON ROOM ASSIGNMENTS. VITAL SIGNS WERE CONTINUOUSLY MONITORED. A PHYSICIAN STATED, ‘WHAT DO YOU HAVE?’. THE PHYSICAN (sic) WAS ADVISED RED TRANSPORT FROM (Hospital B) ER TO (Hospital A) WITH AN INTRACRANIAL HEMORRHAGE. THE PHYSICIAN ASKED FOR PAPERWORK AND THEN STATED ‘NEVER MIND.’ THE PT REMAINED STABLE WITH ONLY COMPLIANT (sic) OF A HEADACHE. THE NEUROLOGIST (Name of accepting physician) ADVISED THE PT WOULD MOVE TO THE ICU ONCE A BED WAS AVAILABLE. THE PT REMAINED IN THE HALLWAY AND WAS CONTINUOUSLY MONITORED AND ASSESSED. (EMS) WAS ADVISED THE PT WOULD BE TRANSFERRED TO THE NEUROLOGY ICU. PT CARE REPORT WAS GIVEN TO THE ATTENDING NURSE .... PT CARE WAS TRANSFERRED. ...” Review revealed the EMS unit arrived to Hospital A at 2312 and Patient #1’s care was handed-off to hospital staff at 0106 (1 hour 54 minutes after arrival to the hospital). Review revealed EMS completed vital signs every 5 minutes to 10 minutes throughout the wait time for a bed and hand-off to the hospital. Review of the Hospital A medical record for Patient #1, on 11/14/2023, revealed the patient arrived as a transfer via EMS at 2314. Review of the “ED Report” by an ED physician, at 2351, revealed “ ... 64-year-old female who presents as a transfer due to intracranial hemorrhage. Was taken to an outside hospital due to concern unilateral (one-sided) weakness and speech difficulty at roughly 2130. At that time had a head CT which showed an intracranial bleed and thus the patient was transferred here. At the outside hospital she was noted to have fairly profound hypertension was given IV Lopressor (treats elevated BP). Plan is for neurology admission however they would like angiography of the head and neck prior to getting a bed. Nicardipine was also initiated for blood pressure management ....Physical Exam .... Initial Vitals No Data Available ...Neuro: Right-sided facial droop with loss of nasolabial fold as well as dysarthria noted. Weakness of the right arm over relatively normal left arm and lower extremities. Medical Decision Making ....Patient presents as a transfer due to intracranial hemorrhage. Working with nursing staff in order to have this patient placed in a room. Neurology is already consulted on this patient, will follow-up with their requested CT angiography. We will also needs (sic) very close blood pressure monitoring. ...” Review also revealed a Neurology “History and Physical”, service date/time 10/31/2023 2347, which indicated “ ...Impression and Plan: ....#ICH (Intracranial Hemorrhage): hypertensive etiology suspected ....#HTN (hypertension) urgency: no prior hx (history) of HTN, treat >160/90 with goal towards normotension. #dysarthria, right hemiparesis (weakness or partial paralysis on one side of the body). Plan: admit to ICU for close neurologic monitoring. ...” Review of the ED record failed to reveal any vital signs or assessments by nursing. Review revealed “Nurse Notes” on 11/01/2023 at 0051 that stated “RN gave heads up to NSICU (Neurosurgery ICU) by (Name), RN. ED CNC (Clinical Nurse Coordinator) aware that (Name), RN is not assuming care of patient and only transporting PT (patient) upstairs. Pt has been with EMS in hallway for approx. (approximately) 2 hours and now has bed assignment upstairs. RN only transporting from EMS to NSICU.” Record review failed to reveal an ED RN ever accepted, triaged, assessed or did vital signs on Patient #1 while the patient was in the Emergency Department. The first documented vital signs were at 0110, once Patient #1 arrived to NSICU. The patient’s blood pressure at 0110 was documented as 162/85. Telephone interview with EMS #73 on 11/30/2023 at 1415 revealed the paramedic was involved in the transfer of Patient #1. Interview revealed it was a “red” transfer. Interview revealed on arrival to the hospital they gave the paperwork to hospital staff and then “sat on the wall.” The neurologist came to evaluate the patient and said she would move as soon as a bed was available. EMS, interview revealed, continue to monitor Patient #1. The patient was on IV medications for blood pressure and EMS staff had to “fluctuate the meds to keep the blood pressure where it needed to be.” Interview revealed no nurse evaluated Patient #1 while she was in the ED. Interview with MD #69 the accepting neurologist, revealed it was not uncommon to do ED to ED transfers, that it was good to have them in the ED for emergent evaluation when there was a concern for a patient’s stability on arrival. Interview revealed MD # 69 came to see patients in the ED as soon as they were notified of the patient’s arrival. Interview revealed it was “surprising” not to have vital signs completed in the ED and stated it did not meet expectations for care - patients needed hourly neuro checks and vital signs with provider updates on changes. Interview with RN #64 during observation 11/13/2023 around 1030 revealed that when EMS arrives with patients and there are no beds available then EMS stays “on the wall” with the patient until a bed is available. They do not hand-off the patient until patients get to an assigned bed. Physicians may see patients on the wall, but “EMS can only hand-off to a RN.” Follow-up telephone interview on 11/15/2023 at 1430 revealed that in relation to patients arriving with EMS, ED nurses do not “triage patients until ...taking ownership of the patient. Interview revealed that if the CNC in the EMS arrival area was to triage the patient, then the RN was “taking ownership of the patient.” The RN stated they could not do that as CNC and still meet all the expectations of the role. Interview revealed that in this ED, “EMS is still responsible.” Telephone interview with RN #66, on 11/17/2023 at 0932, revealed the EMS team was responsible for any patients they brought in until a room was assigned and the patient moved to a room in the ED. Once the patient was in a room, the ED RN triaged the patient and there was a proper hand-off between EMS and the RN. Patient #1 arrived as a transfer on 10/31/2023 at 2314 by EMS. No triage, nursing assessment or evaluation was completed in the ED. The patient was transported to the NSICU (Neurosciences Intensive Care Unit) on 11/01/2023 at 0105. A nursing note was written that stated the nurse was only transporting the patient to the inpatient unit and had not assumed care of the patient. The first nursing vitals or assessment were done at 0110 in NSICU. EMS monitored Patient #1 in the ED and nursing failed to accept, triage and provide care to a patient in the ED. 9. Review of the EMS Patient Care Record, on 11/14/2023, revealed EMS was called to Patient #2’s home on 10/17/2023. The EMS record revealed the call came in at 1654, EMS reached the patient at 1702, departed the scene at 1720 and reached the Hospital at 1748. The Patient Care Record noted the patient’s medical history was “Cirrhosis of Liver, Diabetes, Infectious disease, Neuropathy, Other-Infection of foot - amputation schedule for 10/21.” Review of the Narrative Note revealed “(EMS) DISPATCHED EMERGENCY TRAFFIC TO LISTED ADDRESS REFERENCE SYNCOPAL EPISODE WITH CHEST PAIN AND SHORTNESS OF BREATH ...ARRIVED ON SCENT TO FIND A 66-YEAR-OLD MALE, A&Ox4, SKIN PALE, WARM, AND DRY, SITTING UPRIGHT IN A RECLINER IN THE LIVING ROOM. PT ADVISED HE HAD BEEN HAVING CHEST PAIN AND SHORTNESS OF BREATH FOR THE LAST WEEK ....ADMINISTERED ASPIRIN ...PT ADVISED THAT HE AND HIS FRIEND HAD BEEN WORKING AROUND THE HOUSE AND ALL OF A SUDDEN HE DID NOT FEEL GOOD AND PASSED OUT. PT’S FRIEND ADVISED PT DID NOT FALL, ‘I CAUGHT HIM ON THE WAY DOWN.’ .... PT ADVISED HE RECENTLY HAD SURGERY ON HIS FOOT AND IT HAD GOT AN INFECTION AND WAS TAKING ANTIBIOTICS FOR SAME. PT ADVISED HE WAS GOING TO NEED ANOTHER SURGERY TO REMOVE THE BIG TOE OF HIS LEFT FOOT. IT WAS NOW NOTED THAT PT’S EKG WAS SHOWING ....ALSO SHORT RUNS OF A WIDE COMPLEX TACHYCARDIA. PT REMAINED COMPLETELY A&Ox4 ....PT WAS PLACED ON SUPPLEMENTAL OXYGEN WITH NOTED IMPROVEMENT IN BREATHING, ACCORDING TO THE PT. PT WAS TRANSPORTED ROUTINE TRAFFIC TO (Hospital) ....WHILE ENROUTE PT’S VITALS WERE CONTINUALLY ASSESSED ...IV ACCESS WAS OBTAINED ...PT WAS FOUND TO HYPERGLYCEMIC (high blood sugar). PT ADVISED HE HAD NOT BEEN ABLE TO TAKE HIS INSULIN YET TODAY ....PT WAS ADMINISTERED FLUID AS RECORDED ....PT ADVISED HIS CHEST PAIN WAS A 6/10 AND THAT TAKING A DEEP BREATH HURT. PT ADVISED THIS HAS BEEN GOING ON ALL WEEK AND HAS NOT CHANGED. (Hospital) WAS CONTACTED FOR PT NOTIFICATION. UPON ARRIVAL AT (Hospital) PT WAS TAKEN TO ER ROOM, WHERE (EMS) WAITED FOR ER PERSONNEL TO COME FOR THE HANDOFF REPORT WHILE BEING CONTINUALLY MONITORED. A FACILITY RN FINALLY ARRIVED AND A FULL REPORT WAS GIVEN AND PT CARE WAS TRANSFERRED TO THE RECEIVING RN. ...” EMS record review revealed the team arrived to the hospital with Patient #2 at 1748 and care was transferred to hospital staff at 1907 (1 hour, 19 minutes after arrival). Review revealed EMS staff continued monitoring Patient #2 after arrival with vital signs generally taken every 5-6 minutes. The last recorded EMS vital signs were at 1858 with BP noted as 104/61, pulse 70, respirations 15, 99% pulse ox and a pain score of 6. A note was made on “Turn Around Delays” that indicated “ED Overcrowding/ Transfer of Care. ...” Review of the medical record, on 11/14/2023, revealed Patient #2 arrived to the hospital on 10/17/2023 at 1753 via EMS. Review of “ED Triage”, performed 10/17/2023, at 1900 (1 hour and 7 minutes after arrival) revealed a pre-hospital blood glucose of 459 and an acuity of “3-urgent”. Vital signs were: Temperature 97.9, Pulse 72, Respirations 20, blood pressure 106/69 and oxygen saturation of 100% on 4 liters oxygen. Patient #2’s pain score was 7. Review of the “ER Report” by a Physician Assistant, on 10/17/2023 at 1845, revealed “ ... 66-year-old male patient .... presents.... (to the) emergency department today via EMS for chief complaint of chest pain and shortness of breath. Patient reports that he has had chest pain and shortness of breath ongoing over the past week and reports that these symptoms are aggravated with exertion. He also reports aggravation to shortness of breath with lying supine and he states that today he had acute worsening to his symptoms and also had a syncopal episode earlier today. He reports pain and shortness of breath are still present. He states that he also has bilateral lower extremity swelling which has been ongoing over the past couple of weeks ....He states that he has ulcer to the first metatarsal of his left foot and this extends to his bone. He states that he has planned to have amputation of the first digit of his left foot this coming Friday patient currently taking ciprofloxacin (antibiotic , Diflucan (antifungal), and Duricef (antibiotic). ....Medical Decision Making ... EMS reports that they gave patient 324 mg aspirin ....blood pressure was approximately 96 mmHg. They gave one L (liter) of normal saline IV blood pressure is 105/66 now. EMS also reports that patient had 7 beat run of V tach on their EKG tracing in route with patient now in sinus rhythm and occasional bigeminy. Ordered EKG and for patient to be on telemetry ....Point-of-care CBG (blood sugar), CMP (comprehensive metabolic panel), CBC (complete blood count), troponin, proBNP, D-dimer, lactic acid, and portable 1 view chest x-ray ordered. EKG obtained and notes sinus rhythm with PVCs and 4 beat run of V tach ....1953 Dr. (Name) called to patients bedside for cardiac arrest and assumed care of patient. CPR initiated ....2017 ....Called lab to request results of chemistries be available as soon as possible. Labs resulted after arrest ....Resuscitation attempt failed. Patient deceased. Suspect etiology to cardiac arrest related to MI (Myocardial infarction- heart attack). Review revealed a Stat order for an EKG at 1841. Review did not reveal an EKG was completed until 1905 (24 minutes after ordered and 1 hour and 12 minutes after arrival). Review of lab orders revealed the following lab tests were ordered in the ED stat at 1841 (48 minutes after Patient #2 arrived): Lactic Acid, CMP (comprehensive metabolic panel), Troponin, D-Dimer, Pro B-Type Natriuretic Peptide (ProBNP) and CBC with Differential. Review of orders revealed the labs were collected as Nurse collects at 1920 (39 minutes after the lab orders). Patient #2 experienced cardiac arrest at 1953, 2 hours after arrival. The CBC resulted at 2002 and the CMP resulted at 2012. The D-Dimer resulted as 824 (high) at 2006. The Pro BNP resulted as 9690 (High - reference range 5-125) at 2023 and the Troponin resulted as 0.460 (High - reference range 0.000-0.034) at 2039 (1 hour 19 minutes after the lab was collected; 1 hour, 58 minutes after it was ordered). The physician was notified. Review revealed the physician was notified 2 hours, 46 minutes after Patient #2 arrived to the ED and 15 minutes after the patient expired). Review revealed delays in ordering, collecting and resulting the labs and a delay in obtaining an EKG. Review of the “ER Report”, service date/time 10/17/2023 at 2030, revealed “ ...The patient was initially evaluated by the emergency department physician assistant .... Work-up for chest pain and syncope were underway. I was called to the patient’s bedside at 1953 for cardiac arrest. Staff reports that only moments before the patient had been alert and talking. CPR (cardia pulmonary resuscitation) was initiated. The patient was placed on a monitor and defibrillator. Initial rhythm revealed ventricular tachycardia (fast heart rhythm). He received electrical therapy and CPR was resumed. Patient received high-quality chest compressions. He would briefly show signs consciousness indicating adequate cerebral perfusion (blood to the brain) with chest compressions, but remained without an organized rhythm ....required continuation of CPR. He received multiple doses of electrical therapy ....He received magnesium as well as amiodarone (medication for irregular heart rhythm) for shock refractory ventricular tachycardia. Ventricular tachycardia progressed to ventricular fibrillation (life threatening arrhythmia). He also received multiple doses of epinephrine (emergency medication) per ACLS (advanced cardiac life support) protocol for pulseless arrest. He was intubated ....I called the physician assistant to the bedside to brief me on the details of the initial presentation. During the resuscitation I took the opportunity to review the available work-up. The EKG was brought to me for review at 2002 ....For this patient who presented with chest pain, syncope, and suffered cardiac arrest has either suffered an MI or rhythm disturbance ....I reviewed his medications ....I made attempts to address ....reversible causes of cardiac arrest. As resuscitation proceeded the rhythm progressed ....to asystole ....After 30 minutes of resuscitation he remained in asystole. All team members agreed that further resuscitative efforts were futile ....the patient was pronounced dead at 8:24 PM ....10/17/23 20:38:56 I received a (sic) from the chemistry lab. Troponin is 0.46 ....Diagnosis/Disposition Chest pain Syncope Ventricular tachycardia Cardiopulmonary arrest. ...” Telephone interview on 11/20/2023 at 1415 with EMS #70 revealed they responded to a call for a patient with chest pain and shortness of breath. Interview revealed on EKG the heart was very irritated, throwing PVCs (arrhythmias), PACs (arrhythmias) and then short runs of wide complex tachycardia (rapid heart rate). Interview revealed there was potential for things to turn unstable quickly. By the time they got to the hospital there were just a few PVCs. EMS #70 stated they arrived to the hospital at 1750 and were assigned a room at 1756 but they got to the room and there was a patient in the room which caused the wait. EMS #70 stated at some point the patient started to get hypotensive and the fluids had emptied, so the other EMS staff gathered another bag of fluids. Patient #2, per EMS, was on supplemental oxygen and had no complaints at the time. Interview revealed they got the patient into an ED bed at 1845 but there was no nurse for report. At 1907 (1 hours, 17 minutes after arrival), per interview, EMS was able to give hand-off report to a nurse. Interview revealed waits had gotten more common recently and it seemed like a staffing issue. Telephone interview with PA #71, on 11/15/2023 at 1600, revealed the patient came into the ED with EMS and there were no rooms available. PA #71 stated he saw the patient while in the hallway and placed orders. Interview revealed the patient had not been triaged, he was still in the hall. Interview revealed prior to arrival the patient had “a few runs, approximately 8 beats”, of V tach. PA #71 stated the patient was given a liter of fluids and the rhythm improved. Patient #2 remained on the EMS monitor prior to getting a formal EKG in the ED, the PA stated. Interview revealed there were another 4 beats of V tach but it was not sustained; the patient appeared stable. PA #71 moved to another patient and did not see Patient #2 after he got in an ED room until the PA heard the code and responded. Interview revealed these patients should be closely monitored. Interview revealed the goal for the screening evaluation was 20 minutes from arrival. Telephone interview with RN #66, on 11/16/2023 at 0938, revealed the nurse assigned to Patient #2’s room was busy and not able to triage the patient, so a radio request for help was made and RN #66 responded, did the hand-off with EMS and triaged Patient #2. The patient had been placed on a monitor by the Certified Nursing Assistant (CNA). RN #66 then received report from EMS. Interview revealed there was no bed available when Patient #2 first arrived by EMS. When RN #66 went to triage the patient, Patient #2 had just been put in a room and was stable, alert and talking. RN #66 stated that after Patient #2 was triaged, RN #66 drew blood for labs; labs were not drawn until after the patient was accepted and in a room. Until the patients were in a room and care handed-off from EMS, interview revealed, they were “counting on EMS to care for (the patients). ...” Telephone interview on 11/16/2023 at 1100 with MD #72 revealed he heard the overhead page for Patient #2 and immediately responded. Interview revealed the expectation for chest pain patients was an EKG within 10 minutes and to be seen by a provider within 10 minutes. Interview revealed there is a chest pain protocol but the protocol had to be activated by a provider. MD #72 acknowledged there was a delay for Patient #2. Interview revealed in an ideal situation the patient would have gone straight back to a room and care started. Patient #2 was brought to the ED by EMS from home. The patient arrived on 10/17/2023 at 1753 with chest pain and a syncopal episode at home. The provider ordered labs at 1841 (48 minutes after Patient #2 arrived), and the labs were not collected by nursing staff until 1920 (39 minutes after orders), after the patient was triaged at 1900 (1 hour and 7 minutes after arrival). The patient was on a cardiac monitor and received vital signs by EMS until triage at 1900. No hospital EKG was completed until 1905 (24 minutes after order and 1 hour 12 minutes after arrival). The elevated D-Dimer did not result until 2006, the elevated Pro BNP did not result until 2023 and the elevated Troponin did not result until 2039. At 1953 a physician responded to the patient’s bedside due to a cardiac arrest. CPR was started and the patient expired. Nursing staff failed to accept the patient upon arrival to the ED, resulting in delayed triage, care and treatment. 47421 10. Closed medical record review of Patient #12 revealed a 41 year old female transferred to the ED (emergency department) on 07/18/2023 at 1623 via EMS (emergency medical service) for abdominal pain, nausea, chills, and evaluation by general surgery for concerns of appendicitis. No past medical history. Review of EMS run report revealed vital signs were taken at 1526 and 1555 via EMS. Review of ED record revealed a Medical Screening Examination (MSE) was performed at 1653. Further review of MSE revealed the CT (computed tomography) was consistent with appendicitis and general surgery consult placed at 1652. Review of physician orders revealed an order for q4h (every 4 hours) vital signs at 1729. An order for Dilaudid 0.25mg (milligram) Inj. Q3h, PRN (as needed), pain (refractory) at 1729. An order for Dilaudid 0.5mg Inj. Q15min, PRN, pain, at 1734. Review of ED record revealed the patient was assigned to RPOD-Hall 18 at 1756. Review of ED record revealed a pain assessment of 10 at 1759. Review of MAR (medication administration record) revealed the patient was given Zofran 4mg at 1757 and Dilaudid 0.5mg at 1759. Review of the General Surgery History and Physical at 1820 revealed a plan to proceed with laparoscopic appendectomy. Pain control and antiemetics as needed. Review of ED record revealed the patient was transferred to preop at 1830. Review of ED record revealed triage time at 1832 and vital signs documented at 1832 (2 hours and 9 minutes after the patient’s arrival). Interview on 11/14/2023 at 1153 with RN #91 revealed when patients are “on the wall” they are waiting to be assigned an RN (registered nurse) and put in a room. EMS stays with the patient in case they need any medical attention. Interview revealed it is typically not a long wait but can be up to an hour. Interview revealed patients can be seen by providers and prescribed medications while “on the wall” but can not get them because no RN has been assigned. 49480 11. Review on 11/16/2023 of “Nursing Management of Wounds and Alterations of Skin” policy revised 11/2021 revealed, “POLICY: Patients are assessed on admission and once every 12-hour shift for alterations in skin integrity and/or wounds. SCOPE:...Inpatient, acute care services, critical access hospitals, and other related services. Emergency Department (ED)...DOCUMENTATION: Document wound details: type, bed color, odor, drainage (color and amount), undermining/tunneling, induration, and erythema. Document intervention”. Review on 11/16/2023 of the “Assessment and Reassessment” policy revised 06/2021 revealed: “...PURPOSE: A. The goal of the assessment/reassessment is to provide the patient the best care and treatment possible...The nursing process is utilized in order to achieve this goal. This process includes assessing, analyzing, planning, implementing, and evaluating patient care or treatment...” Closed medical record review on 11/14/23 of Patient #26 revealed a 22-year-old patient that presented to the Emergency Department (ED) via EMS (Emergency Management Services) on 09/01/2022 at 1845 for complaints of abdominal pain, decreased appetite, watery non-bloody diarrhea, and right-calf burn. Review of an ED Note dated 09/01/2022 at 2130 per medical provider indicated: “Assessment/Plan...Burn. I ordered bacitracin and instructed the nurse to apply a Xeroform dressing”. Review of Patient #26’s closed medical record lacked documentation that an ED nurse assessed and applied bacitracin and a Xeroform dressing to the patient’s right-calf burn. Review revealed the patient was transferred to inpatient room #566 A5-West on 09/03/2022 at 1357. Review revealed a nursing wound consultation was completed on 09/04/2022 at 1024. Review of Inpatient Wound/Ostomy Documentation Note dated 09/04/2022 at 1024 indicated: “Wound care consult received for calf burn...wound is pink, red wound bed, superficial. Communicated with RN (Registered Nurse) that wound team will not be able to prioritize this patient today. Would recommend provider place order for bacitracin to be applied generously, cover with xeroform gauze, then dry gauze and gauze roll, daily. Will only follow if wound worsend with appropriate treament-please reconsult if this occurs”. Review of a physician’s order dated 09/04/2022 at 2100 indicated: “Bactroban topical 2% cream to be applied three times daily at 0900, 1500, and 2100 for 7 days to right-calf wound”. Review revealed a lack of documentation related to the application of the aforementioned wound treatment per nursing. Review of the patient’s closed medical record lacked nursing documentation related to the assessment and treatment of the patient’s right calf wound from presentation in the ED on 09/01/2022 through discharge on 09/07/2022.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 16369 Based on policy review, medical record review, incident report review, EMS trip report review, and staff and provider interviews, hospital nursing staff failed to administer medications and biologicals according to provider orders and standards of practice by failing to administer medications as ordered, and evaluate and monitor the effects of the medication for 6 of 35 patients presenting to the emergency department (#92, #83, #43, #28, #27, and #26). The findings included: Cross refer to A-0398 for all examples. Review of a “Pain Assessment and Management” policy revised 01/05/2022 revealed, “ ... Each patient is screened for the presence of pain in all settings where treatment is provided. ... 3. For emergency departments (ED), patients will be screened for pain during each ED visit. ... The frequency of pain assessment is based on patient symptoms, interventions, and progress towards goals. ... Interventions are provided based on the patient’s treatment plan for pain. ... The pain management/treatment plan is evaluated on an ongoing basis and is revised to facilitate achievement of pain goals based on best practices, patient’s clinical condition, past medical history, and pain goals. ... Pain rating must be documented prior to the administration of PRN pain medication. If opioids are administered, sedation level must also be documented. Pain rating and sedation levels are reassessed within 1 hour after PRN pain administration by any route. If opioids are administered, sedation is evaluated to assess for opioid-induced respiratory depression using one of the following sedation scales: 1. For the non-ICU, non-intubated patient (adult and pediatric), the Pasero Opioid-Induced Sedation Scale (POSS) should be used. ... The pain/treatment plan is evaluated on an ongoing basis and is revised to facilitate achievement of pain goals. ...” Review of a “Medication Administration” policy revised 03/20/2023 revealed, “ ... Pain medications may be administered to treat or prevent pain. Proactive pain management is preferred to reactive. ...For opioid medications ordered “as needed for pain” the level of pain for administration must be specified in the order. 1. If the patient’s symptom is unrelieved, the nurse may administer additional doses of PRN (as needed) medications ordered, not to exceed the maximum dose within the prescribed frequency. 2. Subsequent doses are based on the nurse’s assessment, the patient’s response to the previous dose, absence of adverse effects, and symptom severity. ... Monitor the patient’s response. ...” 1. Closed medical record review on 12/09/2023 of Patient #92 revealed a 69 year-old male that presented to the emergency department on 11/09/2023 at 1149 with a chief complaint of chest pain. The patient was triaged at 1155 with a chief complaint of “Woken from sleep at 0400 with midsternal chest pain, described as sharp and pressure. No SOB (shortness of breath), arm/jaw/back pain, or diaphoresis (sweating). H/o (history of) colon CA (cancer) with mets (metastasis) to the lung, currently on chemotherapy....” Review revealed a pain level reported as 2 (scale 1-10 with 10 the worst). Review of the physician’s notes recorded the patient’s chest pain had been waxing and waning, coming in waves and lasting about five minutes at a time. Review revealed a plan to administer a dose of aspirin. A baby aspirin was administered as ordered at 1334. Review revealed a physician’s order at 1659 for nitroglycerine 0.4 milligrams (mg) sublingual every five minutes times three as needed (prn) chest pain. Record review revealed no nursing assessment/reassessment documented after the patient’s triage was recorded at 1155. The patient was administered Morphine (narcotic pain medication) 2 milligrams intravenously (IV) at 1703 by a medic for a pain level of 4. There was no reassessment of the patient’s pain. Nitroglycerine 0.4 milligrams sublingual was administered by a nurse times one for a pain level of 10 at 2013. Review revealed no reassessment of the patient’s response to the medication intervention and no nursing assessment of the patient’s condition was documented. Interview on 12/09/2023 at 1210 with Assistant Director of Nursing (ADON) #17 revealed no nursing assessments or reassessments were documented in the ED record. 41946 2. Closed medical record review on 12/06/2023 revealed Patient #83, a 74-year-old female patient who arrived at the emergency department (ED) via emergency medical services (EMS) on 11/28/2023 at 1216 with a chief complaint of dizziness. Review revealed a serum glucose resulted of 1137 (high normal range 120). Review of the Physician’s Order on 11/28/2023 at 1626 by ED Nurse Practitioner (NP) #5 revealed a new order for an Insulin (IV medication to reduce serum glucose) IV infusion to be started (54 minutes after the glucose had resulted). At 1709 an Insulin drip was initiated for Patient #83 by the Registered Nurse (RN) #3 (1 hour and 13 minutes after ordered and 1 hour and 37 minutes after the glucose resulted). At 2329 Hospitalist Medical Doctor (MD) #9 ordered an IV infusion of D5 1/2 NS with KCL (Dextrose, Normal Saline, and Potassium Chloride Solution). At 0157 RN #10 documented the IV with D5 1/2 NS KCL as started (2 hours and 27 minutes after ordered). Interview on 12/08/2023 at 1425 with RN #3 who cared for Patient #83 on 11/28/2023 revealed physician orders were not followed for Patient #83. Interview on 12/08/2023 at 1230 with Nursing Vice President (VP) of ED Services, VPED #20 revealed hospital policy was not followed for Patient #83. 3. Closed medical record review on 11/16/2023 revealed Patient #43, a 39-year-old who presented to the emergency department (ED) by private vehicle on 08/14/2023 at 1603 with complaints of “...chest pain, nausea, clammy, lightheaded, and right-side tingling for several week. Drinks 12 beers a day....” Patient #43 was assigned to ED Medical Doctor (MD) #23. At 1732 MD #23 ordered a GI cocktail (oral combination of medications given for indigestion), Zofran 4 mg orally (medication given for nausea and vomiting). An addendum to MD #23’s ER Report Note revealed “...I have ordered IV (intravenous) fluids...1 mg of Ativan (a sedative given for anxiety and seizures) as he is slightly tremulous (shaking) and diaphoretic (sweating)...Hospitalist has been consulted for admission...” At 1841 MD #23 placed orders for IV (intravenous) fluids-NS NOW, and thiamine (dietary supplement/nutrient) 100 milligrams (mg) orally STAT (immediately). At 1851 the GI Cocktail and Zofran were administered. At 1947 MD #23 ordered Ativan 1 mg IV push NOW (urgent). At 2100 a multivitamin orally was ordered. The History and Physical was initiated on 08/14/2023 at 2229 by Hospitalist MD #25 while in the ED waiting room, and new orders were placed for aspirin orally NOW, Lopressor (medication given in treatment of alcohol withdrawal) 12.5 mg orally, and again IV access at 2226. At 2305 MD #25 ordered Patient #43 phenobarbital (medication given to prevent seizure) 60 mg orally three times a day STAT. No medication administrations, IV access/fluids, or physician orders were completed after 1851 (when the GI Cocktail and Zofran was administered) for Patient #43 while in the ED waiting room. At 0105 MD #25 ordered Patient #43 to have Ativan 4 mg IV STAT and was given at 0106 by RN #27. Review of the ER Report Note on 08/15/2023 at 0107 by MD #26 revealed “...I became involved in the patient’s care after he apparently left the waiting room where he was awaiting admission and then had a seizure and struck his head on the sidewalk outside of the ER (emergency room) entrance. On my evaluation, the patient seems postictal (the period following a seizure, disorienting symptoms, confusion, and drowsiness), he is not actively seizing. He does have a history of heavy alcohol use, drinks about 12 beers a daily. He has been in the emergency department waiting room for 9 hours and has not received any Ativan or Phenobarbital. I suspect that he seized due to alcohol withdrawal. Will obtain head CT (cat scan) given the patient did strike his head, he also has a small laceration that will require repair....” Record review revealed the ED waiting room orders for IV fluids NOW on 08/14/2023 at 1841, Ativan IV NOW ordered on 08/14/2023 at 1947, and Phenobarbital STAT ordered on 08/14/2023 at 2305 for Patient #43 were delayed. Interview on 11/15/2023 at 1615 with NP #36 revealed “...it does happen occasionally that orders in the ED waiting room are on hold until the patient can be roomed. I do have concerns about it...” Interview revealed NP #36 had concerns provider orders were not completed timely in the ED waiting room. Interview on 11/16/2023 with ED Internal Processing Area (IPA) Day RN #22 revealed she did not remember Patient #43. Interview revealed “...best practice was to go back to see if patients’ meds (medication) were helpful. I must have left before I was able to put in a reassessment...” Interview revealed RN #22 cared for Patient #43 until 1900 and did not remember doing a reassessment after medication administration. Interview on 11/28/2023 at 1639 with ED IPA Night RN #28 revealed she did not remember Patient #43. Interview revealed “NOW orders in the IPA area go by priority and ESI (Emergency Severity Index ESI - score to determine patients with most to least urgent needs), we are not always able to do them. The CNC (Clinical Nurse Coordinator should be informed...If you are the only IPA nurse and the doctor says ‘this has to happen now’ then it’s the next on my list. There was no protocol for who was actually assigned patients in the waiting room. Reassessments for ED patients who are waiting in the lobby would fall under the IPA nurse tasks but they are doing other patient’s needs and medications as well. There were only two ways to know if additional orders are placed on a patient after IPA, the doctor tells you, or on the tracking board, you might see “repeat troponin”, the CNC was supposed to help with that. If I gave controlled medication in the waiting room, I am responsible for the reassessment. If we are caught up it is a part of our duties to reassess...” Interview revealed patients in the ED waiting room are not assigned a nurse for reassessment and monitoring. Interview revealed hospital policy for reassessment in the ED was not followed for Patient #43. Interview on 12/08/2023 at 1230 with Nursing VP of ED Services, VPED #20 revealed she could not explain the lack of completion of provider orders in the ED waiting room. Interview revealed any new outstanding provider orders for patients in the ED waiting room would be elevated to the CNC. Further there was a WebEx huddle (meeting virtually for many hospital departments to discuss and prioritize patient needs) held every 2 hours and any outstanding provider orders would be delegated to be completed. Interview revealed RN #20 could not explain why Patient #43’s providers orders had not been completed. 4. Closed medical record review on 11/14/2023 revealed Patient #28, a 48-year-old male patient who arrived at the emergency department (ED) by emergency medical services (EMS) on 07/05/2022 at 0947 with headache x 2 weeks, altered mental status, fall, and was combative. At 1050 Patient #28 was intubated (mechanical ventilation) with standard IV sedation protocols. At 1236-1311 Patient #28 went into ventricular tachycardia (lethal heart rhythm) and was coded (resuscitated by staff), defibrillated, and had a central line placed. Review of the ER Report Reexamination/Reevaluation (not timed) by MD #59 revealed “...the patient ultimately did require intubation for sedation and airway protection, his mental status continued to worsen despite Haldol and Versed...The Head CT was negative...Once back from CT the patient became profoundly hypotensive and at 1 point lost pulses requiring CPR, total time roughly 5 to 10 minutes...We have been running norepinephrine (given to sustain blood pressure) through this...ICU (intensive care unit) has been consulted....” At 1409 Pulmonologist/ICU MD #60 ordered Levophed (used to treat life-threatening low blood pressure) 4 mg in 250 milliliters (ml) to titrate to 30 micrograms (mcg)/per minute and was initiated by RN #56 at 1514 (1 hour and 5 minutes after ordered), and at 1655 this drip rate was adjusted to 20 mcg/min. At 1740 blood pressure was 137/79, at 1750 blood pressure was 73/42, at 1800 blood pressure was 33/18. Review of the Medication Administration Record revealed at 1801 RN #68 initiated a bag of Levophed at 30 mcg/min for Patient #28. At 1803 a code was initiated, and Patient #28 was in asystole (no heart rhythm). The code ended at 1807 with the return of blood pressure. At 1814 blood pressure was 249/118 with a pulse of 145. At 1816 an addendum to the ER Report by MD #62 revealed “...At 1803 I was called to the patient’s room, who had gone asystole. I was notified of the patient’s diagnosis of meningitis and hypotension. CPR was in progress on my arrival...I was notified that the patient’s Levophed had run dry, and that the patient had been hypotensive (low blood pressure) sometime before coding...Shortly after the epi (epinephrine-used to return pulse) and bicarb (bicarbonate improves outcomes in cardiac arrest), (1807) we had return of pulses. Patient’s blood pressure high. ICU attending entered shortly after the code finished.” At 1940 Patient #28 was transferred to the medical ICU for admission. Patient #28 continued to decline and showed no signs of improvement. Review of the Discharge Summary date 07/15/2022 at 1525 by Doctor of Osteopathic Medicine, DO #63 revealed “...There was no change in neurology exam, and it was explained to the family that there were no signs of meaningful improvement. At this time the family changed its code status to DNR (do not resuscitate)...at this time the family was amenable...for organ procurement. He was brought to the OR (operating room) this morning where he was extubated (removal of mechanical ventilation), and time of death was 1040...” Review on 11/28/2023 of the Patient Safety (Incident) Report for Patient #28 revealed it was reported by: (named RN #57) on 07/05/2022 at 1930. Event #: 6858. Event time was 07/05/2022 at 1803 with brief description “...assigned 5 patients, pt. (patient) coded due to unsafe staffing ratio...additional comments ...NUS (nursing unit supervisor RN #74) and Director (named, RN #75) notified of unsafe assignment at approx. 1730. RN (named RN #56) responded to assigned Trauma Alert which arrived at 1748. Pt. coded at 1803, 1 round of CPR, epi, sodium bicarb, ROSC (return of spontaneous circulation). Pt’s levophed emptied due to unsafe staffing assingment [sic]which was reported to NUS and Director prior to event...” Review on 07/06/2022 by Investigator and Director of ED Services (named RN #76) revealed one of the ED managers had spoken to Patient #28’s family member. The family was upset because they had “...asked for help at the doorway of the patient’s room when she noted alarms going off in the room. A PA (Physician’s Assistant PA #77) was at the nurse’s station from a different service line that reportedly did not respond to her request...” Further the CNC, RN #74 reported she was only notified RN #56 needed assistance when the patient was coding. Patient #28 did code 2 times during his ER stay and had a length of stay of 9:52 (9 hours and 52 minutes) in the ER. RN #56’s patient assignment was broken down by RN #76 in the report as two stable patients awaiting admission to step down units (2), one patient who had been moved to the hallway (1), a new Trauma Alert patient (1), and Patient #28, an ICU patient (1). (RN #56 was assigned and responsible for 5 patients during Patient #28’s code/event). RN #76 discussed collateral staff available in the ED to support RN #56. “...Background information: The House was unable to provide staffing support for the admit holds in the ER on this date. There was an ER census of 295 on this date...” On 07/07/2022, Vice President (VP) of ED Services, VPED #48 reviewed this Patient Safety Report. Her investigation revealed there was an additional Patient Safety Report for this same event “...Indicating that the ER Director was informed of an alleged unsafe patient assignment. This notification to the Director was not substantiated...” Additionally, VPED #48 agreed RN #56’s assignment was safe due to collateral staffing in the ED. And did mention Patient #28’s family had voiced concerns who did not respond to their request for help for alarms in the room with (named, PA #77). The Primary Contributing Factor was “Human Factors/Staff Factors...Competing priorities...Level of Harm Harm-intervention to sustain life...” In summary, Patient #28’s levophed IV infusion sustaining his blood pressure was allowed to run dry, his blood pressure dropped, he was coded for 7 minutes until the infusion was reinstated. RN #56 had a patient assignment of 5 patients. Review on 11/28/2023 of the Patient Safety Analysis report, Event #6856, referencing Patient #28 dated 07/05/2022 at 1843 by ED Clinical Pharmacist, ED RPH #78 revealed the event date was 07/05/2022 at 1800 with a brief description of “...Patient required CPR (cardio-pulmonary resuscitation) due to levophed running dry while RN was attending to other patients (RN had 5 pts), including two traumas and this ICU patient...additional comments...making this report on behalf of (named RN #56) as he does not have time to make report. (Named) had 5 patients: the patient from this report (named) intubated, ICU, a trauma alert, a trauma transfer-a comfort care patient in the hall, and two other admitted patients. While he was in one of the traumas, this patient’s norepinephrine infusion ran dry-the patient became hypotensive. The family of the patient was monitoring the BP (blood pressure) and tried to get help from a non-ER provider who was sitting at a computer outside the room and this provider told the family that he could not help them because it was not his patient. Family is irate about this. A few minutes later, another RN came into the room and was able to switch out the levophed, but by this point the pt’s SBP (systolic blood pressure) was in the 30’s. He then became aystolic and required a round of CPR. (Named RN #56) alerted the ER NUS throughout the day that his assignment was unsafe. This patient coding was a direct result of an unsafe and unreasonable assignment...” This Report was investigated by ED Director, RN #76 on 07/06/2022 without any new findings from previous Event #6858. Additionally, on 07/21/2022 Doctor of Pharmacy, PharmD #79 added investigator notes to this report. The leading description of harm cited by PharmD #79 was “Human Factors/Staff Factors...Level of Harm...Harm-intervention to sustain life...” A summary of her report revealed that a bag of levophed was pulled for Patient #28 on 07/05/2022 at 1511 by RN #56 and was documented on the Medication Administration Record as given on 07/05/2022 at 1514, and per her estimation of the rates of infusion, the bag of levophed “...would have likely run out 1745...” The next bag of levophed was pulled on 07/05/2022 at 1757 by ED RN #68 and was started at 1801 for Patient #28. Review revealed Patient #28’s levophed IV infusion was interrupted for 16 minutes; he was coded from 1803 to 1810 before returning to spontaneous circulation. Request to interview ED RN #68 revealed she was not available for interview. Request to interview ED RPH #78 revealed she was unavailable for interview. Request to interview ED Manager RN #75 revealed he was unavailable for interview. Request to interview ED Director, RN #76 revealed she was unavailable for interview. Interview on 11/15/2023 at 1014 with RN #56 revealed he remembered Patient #28 and had worked in the ED for 5 years. Interview revealed “...I had trauma bay 11, and rooms 10, 9, 8 initially. The patient in room 10 was combative, intubated and a danger to himself and was receiving the maximum dose of levophed to keep his blood pressure elevated. I had him around 10 hours of my day. I got a trauma patient, and they were going to assign me another new trauma patient. Around 1730 I went to CNC (named RN #74) to discuss my assignment and the acuity of my already 4 patients, she put my dying trauma patient in the hallway, to make room for the new trauma patient even when I explained I felt my assignment was unsafe. I had already approached her that morning after 0800 to explain the acuity of my patients. So, then I went to my Nurse Manager (named, RN #75) to discuss my assignment and was assigned the new trauma anyway. My new trauma patient had just arrived after 1730, I was working with them and didn’t realize a code had been called for my intubated patient. When I arrived in the room (named RN #68), the person who was assisting me while I was caring for the new trauma patient, had already hung a new bag of levophed, and the code was in progress. I was very upset. I voiced my concerns, I talked to the administration, to the ethics and compliance committee and filed a complaint with HR (human resources). I tried to document this the best I could...” Interview revealed RN #56 had gone to the CNC, RN #74 at 0800 and again before new assigned trauma patient to voice his concerns with his high patient acuity assignment. Interview revealed RN #56 was caring for another patient, when the levophed IV infusion ran out, causing Patient #28’s blood pressure to drop, and a code was initiated. (request for all documents filed by RN #56 administration, ethics committee and HR were not made available for this surveyor). Interview on 11/15/2023 at 1637 with VPED #20 revealed hospital policy for Patient #28 was not followed. Telephone interview on 12/01/2023 at 1209 with Director of the Trauma Team, MD #80 revealed he was aware of the case with Patient #28 and was the Medical Supervisor for PA #77 in 2022 and currently. Interview revealed “...when a Trauma Team member was in the ED it was to care for a specific consulted trauma patient, however a Trauma Team member if clearly evident could assist any patient in a life sustaining emergency...” The interview revealed PA #77 would not be allowed to touch an IV drip or alarming IV pump of a patient they were not consulted on. Interview revealed PA #77 notified a person who could adjust the drip for Patient #28. Further interview revealed he had no concerns with PA #77’s patient care, and the Trauma Team Supervisor, RN #81 had communicated with PA #77 “...we should always respond with compassion to family...” regarding this event. Interview revealed MD #80 had not followed up with PA #77, the Trauma Team Director had talked with PA #77. Interview revealed PA #77 did not know Patient #28’s blood pressure was low or the levophed had run out but had communicated to ED nursing staff who could attend the alarms when family asked him. Telephone interview on 12/01/2023 at 1241 with Trauma Team PA #77 revealed he had been employed for 8 years. Interview revealed “...I am only in the ED when called/consulted for a specific trauma patient. The family came to the desk, I told them I can get your nurse, and I did. The family was asking about an IV beeping. If I thought he was coding, I would have made sure he was OK. I did not have that information. I only learned about the IV levophed today. Of course, I would respond to help a patient coding. I would not ‘shirk’ a patient needing help...” Interview revealed PA #77 recalled the family asking for help with an IV alarm. He told the family he would find the nurse, and he did. 5. Closed medical record review on 11/14/2023 revealed Patient #27, a 66-year-old female who arrived at the emergency department (ED) on 07/04/2022 at 0025 by private vehicle with abdominal pain, nausea, and vomiting. Patient #27 was triaged at 0025 by RN #38 with a pain score of 10 (1 least pain and 10 being the most pain). At 0028 Nurse Practitioner (NP) #39 wrote orders for an IV (intravenous) of Normal Saline to be started and Ondansetron (medication for nausea) 4 milligrams (mg) IV to be given. Record review did not reveal physician orders for IV and medications were implemented for Patient #27 while in the ED waiting room (6 hours and 3 min). Patient #27 was seen by MD #26 at 0656 and orders were placed for ondansetron 4 mg, and Dilaudid (narcotic pain medication) 0.5 mg for pain. At 0739 Patient #27 had an IV started of NS (7 hours and 11 minutes after ordered), and medications for pain (7 hours and 14 minutes after identified pain level of 10, and 43 minutes after pain medication ordered) and nausea (7 hours and 11 minutes after original order) were administered by RN #40. At 0742 vital signs were documented as heart rate 85, respirations 16, blood pressure 174/89, oxygen saturation of 93 percent on room air (no temperature), with a pain score of 10/10 by RN #40. At 0755 the CT of Abdomen and Pelvis (6 hours) resulted (7 hours and 27 minutes after ordered) positive for a small bowel obstruction. Interview on 11/15/2023 at 1350 with ED RN #38 who triaged Patient #27 revealed “...in 2022 no patients were checked on in the ED waiting room, some changes were made, and there are some improvements. It’s very possible that this patient waited without any completed. At that time there was one nurse in the waiting room to triage patients. There was no way to complete orders...” Interview revealed physician orders were not completed in the ED waiting room in 2022. Interview on 11/15/2023 at 1414 with ED MD #26 revealed “...I saw the patient after she was roomed...There is not always a person to get labs and orders done. No staff to do orders. With the new process the goal is for that not to happen, but at night I suspect it does. As far as care in the waiting room, this patient didn’t get vital signs, or overall assessments and no meds...things are not happening on a timely basis...” Interview revealed Patient #27 did not get medications as prescribed. Interview revealed hospital policy was not followed for Patient #27. 49480 6. Review on 11/16/2023 of “Nursing Management of Wounds and Alterations of Skin” policy revised 11/2021 revealed, “POLICY: Patients are assessed on admission and once every 12-hour shift for alterations in skin integrity and/or wounds. SCOPE:...Inpatient, acute care services, critical access hospitals, and other related services. Emergency Department (ED)...DOCUMENTATION: Document wound details: type, bed color, odor, drainage (color and amount), undermining/tunneling, induration, and erythema. Document intervention”. Review on 11/16/2023 of the “Assessment and Reassessment” policy revised 06/2021 revealed: “...PURPOSE: A. The goal of the assessment/reassessment is to provide the patient the best care and treatment possible...The nursing process is utilized in order to achieve this goal. This process includes assessing, analyzing, planning, implementing, and evaluating patient care or treatment...”. Closed medical record review on 11/14/23 of Patient #26 revealed a 22-year-old patient that presented to the Emergency Department (ED) via EMS (Emergency Management Services) on 09/01/2022 at 1845 for complaints of abdominal pain, decreased appetite, watery non-bloody diarrhea, and right-calf burn. Review of an ED Note dated 09/01/2022 at 2130 per medical provider indicated: “Assessment/Plan...Burn. I ordered bacitracin and instructed the nurse to apply a Xeroform dressing”. Review of Patient #26’s closed medical record lacked documentation that an ED nurse assessed and applied bacitracin and a Xeroform dressing to the patient’s right-calf burn. Review revealed the patient was transferred to inpatient room #566 A5-West on 09/03/2022 at 1357. Review revealed a nursing wound consultation was completed on 09/04/2022 at 1024. Review of Inpatient Wound/Ostomy Documentation Note dated 09/04/2022 at 1024 indicated: “Wound care consult received for calf burn...wound is pink, red wound bed, superficial. Communicated with RN (Registered Nurse) that wound team will not be able to prioritize this patient today. Would recommend provider place order for bacitracin to be applied generously, cover with xeroform gauze, then dry gauze and gauze roll, daily. Will only follow if wound worsend with appropriate treament-please reconsult if this occurs”. Review of a physician’s order dated 09/04/2022 at 2100 indicated: “Bactroban topical 2% cream to be applied three times daily at 0900, 1500, and 2100 for 7 days to right-calf wound”. Review revealed a lack of documentation related to the application of the aforementioned wound treatment per nursing. Review of the patient’s closed medical record lacked nursing documentation related to the assessment and treatment of the patient’s right calf wound from presentation in the ED on 09/01/2022 through discharge on 09/07/2022.”

“CONTENT OF RECORD CFR(s): 482.24(c) The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and services. This Standard is not met as evidenced by: 36956 Based on review of hospital staff orientation/competency training, medical record review, and staff interviews, hospital staff failed to document baths and/ or linen changes had been performed to meet patient activity of daily living needs in seven (7) of 56 sampled inpatient patient records reviewed (Patient #’s 55, 64, 90, 81, 60, 40, and 26). The findings included: On 12/08/2023 at 0911 review of hospital documentation titled “Preceptor Guide Patient Care Tech (PCT) Staged Orientation” last updated 04/15/2022 revealed the “Preceptor Guide Provides detailed instructions for what the orientee must do for items to be checked off as ‘met.’” Further review revealed the orientation stages ranged from 0 through 2. Stage 1 focused on basic patient care and procedures which included documentation. Stage 2 focused on “Routine Application: Provision of Patient Care” which included “Safely and reliably performs routine daily care for a variety of patient populations” and “Anticipates basic potential patient needs.” Review revealed in stage 1 of orientation the orientee was expected to meet the following objectives: “Objective that needs to be Met ...Contributes to a healing environment ...Changes linen as indicated (includes occupied / unoccupied bed changes) ...” The orientee expected to meet “Documents activities / care in the EHR (Electronic Health Record) with preceptor assistance” which included “ADL (Activity of Daily Living”. Stage 2 for routine application included “providing information related to ADLs and other care to patient ...Prepares in advance to answer questions about topics such as ADLs” Review revealed the skills with “(**)” indicated the skills “are essential items to onboarding and should be completed with orientee to successfully prepare them in patient care.” Further review revealed the orientee assisted with ADLs which included “Hygiene Care** ...Bed bath, Shower and linen change.” On 12/08/2023 at 0911 review of hospital documentation titled “Preceptor Guide Medical Surgical RN Staged Orientation” last updated 04/15/2022 revealed the staged orientation grid was divided into stages 0 through 4. Stage 4 “Preceptor Guide Provides detailed instruction for what the orientee must do for items to be checked off as ‘met’” Further review revealed in the “Stage 1 - SKILL BUILDING” the preceptor was to “show” the orientee “how to document routine Activities of Daily Living (ADLs) in the EHR.” On 12/08/2023 at 0911 review of hospital documentation titled “New Employee Orientation” module revealed “Cerner (hospital electronic system) Training for the PCT included “Documenting ADL’s” 1. Closed medical record review on 12/05/2023 for Patient #55 revealed on 05/17/2023 at 1638 a 74 year old male arrived in the ED with SOB (shortness of breath). The admission H&P dated 05/17/2023 at 2100 by NP #29 revealed Patient #55 was seen earlier the same day at an outside hospital. The H&P included sarcoidosis diagnosed two years ago and during the last 3-4 days Patient #55 experienced a productive cough with increased SOB. The patient was transferred from the ED to a Medical Surgical Unit room 445 and remained assigned to the room until discharge on 06/06/2023 at 1115. Review revealed there was no documentation that Patient #55 was provided, offered or refused a bath for 16 days or that Patient #55 was provided, offered or refused linen changes x 14 days. On 12/05/2023 request made to interview CNA that provided care for Patient #55. On 12/06/2023 at 1115 it was revealed the CNA was not available. Interview on 12/06/2023 at 1320 with Nurse Manager (NM) #32 revealed staff were expected to offer baths every twenty-four hours, per patient’s request and as needed. Interview revealed staff was expected “to document” performed ADLs. Interview on 12/08/2023 at 1403 with (Certified Nurse Aide) CNA #33 revealed she offered baths every day and as needed. She stated “especially” if the patient was able to take a shower. CNA #33 revealed she charted when the task was done. Interview on 12/08/23 at 1448 with CNA #34 revealed patient baths can be given day or night shift. She revealed she checked the chart at the beginning of her day shift to see the number of patients that needed baths. Interview revealed that CNA #34 documented baths right away once done but if she did not have time, she would write the task down on paper and document the task later. Interview on 12/08/2023 at 0911 with the Director of Clinical Education (DCE) #36 revealed PCT was the same as CNA. She revealed there was not a policy regarding when baths or a change of linen was offered. She revealed that upon hire PCTs were oriented by preceptors which included baths, linen change and documentation once the task was completed. The orientation continued on the assigned unit and a face-to-face with the hospital EMR (Electronic Medical Record) system. DCE #36 stated “the annual competencies may not be the same for each unit because it depends on the needs of that unit.” 2. Closed medical record review on 12/06/2023 for Patient #64 revealed on 08/30/22 at 1547 a 36 year old male arrived in the ED with upper back pain. Review of a progress note dated 08/31/2023 at 1240 by PA #31 revealed per a Radiologist Patient #64 had osteomyelitis to C6-C7 with discitis (inflammation to the disc between the spinal vertebrae - bones). An epidural abscess was present with spinal cord compression that extended from CT to T1 (pressure to the top of the neck-cervical segment to the thoracic segment - chest portion of the spinal cord). A neurosurgery consultation was made for likely urgent surgical intervention. Further review revealed on 08/31/2022 Patient #64 had an emergency “Anterior Cervical Discectomy” spinal surgical procedure. Review of a progress note dated 12/12/2022 at 1419 by an ID (infectious disease) MD revealed Patient #64 remained “profoundly debilitated and with neurologic deficits; he is currently paraplegic but also has upper extremity strength issues.” Patient # 64 was assigned to the Pulmonary unit Date: 10/09-15/2022. Review revealed there was no documentation the patient was offered or refused linen changes x 6 days. Patient #64 was assigned to the K-Spine unit, Date: 10/19-26/2022. Review revealed there was no documentation that Patient #64 was provided, offered or refused a bath x 6 days or that Patient #64 was provide, offered or refused a linen change x 5 days for sample week. Patient #64 was assigned to a Med Surg/Telemetry unit, Date: (11/13-19/2022) and (12/25-31/2023) and the patient required total assistance. Review revealed there was no documentation that Patient #64 was provided, offered, or refused baths x 6 days or was provided, offered or refused a linen change x 4 days for the first sample week. Review revealed there was no documentation that Patient #64 was provided, offered or refused baths x 5 days or was provided, offered or refused linen change x seven days for the second week. Patient #64 was assigned to the Neuro unit, Room A611, Dates: 01/06-31/2023 and 02/19-25/2023. Review revealed there was no documentation that Patient #64 was provided, offered or refused a bath x 23 days or provided, offered or refused linen changes x 5 days for the first sample week. Review revealed there was no documentation that Patient #64 was provided, offered or refused baths x 5 days or provided, offered or refused linen changes for the second sample week. Interview on 12/06/2023 at 1320 with Nurse Manager (NM) #32 revealed staff were expected to offer baths every twenty-four hours, per patient’s request and as needed. Interview revealed staff was expected “to document” performed ADLs. Interview on 12/08/2023 at 1403 with (Certified Nurse Aide) CNA #33 revealed she offered baths every day and as needed. She stated “especially” if the patient was able to take a shower. CNA #33 revealed she charted when the task was done. Interview on 12/08/23 at 1448 with CNA #34 revealed patient baths can be given day or night shift. She revealed she checked the chart at the beginning of her day shift to see the number of patients that needed baths. Interview revealed that CNA #34 documented baths right away once done but if she did not have time, she would write the task down on paper and document the task later. Interview on 12/08/2023 at 0911 with the Director of Clinical Education (DCE) #36 revealed PCT was the same as CNA. She revealed there was not a policy regarding when baths or a change of linen was offered. She revealed that upon hire PCTs were oriented by preceptors which included baths, linen change and documentation once the task was completed. The orientation continued on the assigned unit and a face-to-face with the hospital EMR (Electronic Medical Record) system. DCE #36 stated “the annual competencies may not be the same for each unit because it depends on the needs of that unit.” 34065 3. Review of closed medical record revealed Patient #90, a 57 year old female arrived to the hospital on 07/05/2022 for a scheduled surgical total hip arthroplasty (total hip surgical replacement) for continued failed treatment for hip osteoarthritis (degeneration of cartilage and the underlying bone). Review of physician post-surgical orders revealed Patient #90 could shower after surgery. Review of documentation of baths revealed Patient #90 did not receive a bath or shower on 07/06/2022, 07/07/2022, 07/08/2022, 07/09/2022, 07/10/2022, and 07/11/2022, a total of 6 days. Patient #90 was discharged on 07/13/2022. Interview on 12/06/2023 at 1320 with Nurse Manager (NM) #32 revealed staff were expected to offer baths every twenty-four hours, per patient’s request and as needed. Interview revealed staff were expected “to document” performed ADLs (activities of daily living--baths or showers). 39307 4. Closed medical record review revealed Patient #81 was admitted on 09/20/2023 at 1445 with a presenting chief complaint of shortness of breath. Review of the Nursing Flowsheet, revealed on 09/20/2023 no evidence of assistance with activities of daily living on the Medical Cardiology Stepdown unit when patient arrived onto the unit at 2144. On 09/21/2023 review failed to reveal evidence of a bath offer/decline or linens changed. On 09/22/2023 review failed to reveal evidence of a bath offer/decline or linens changed. On 09/23/2023 review failed to reveal evidence of a bath offer/decline or linens changed. On 09/24/2023, 0700 through 1900 (12 hours), RN #4 provided primary nursing care to Patient #81, which failed to reveal evidence of a bath offer/decline or linens changed. On 09/26/2023 review failed to reveal evidence of a bath offer/decline or linens changed. Patient #81 was discharged on 09/26/2023 at 0759 to the skilled nursing facility. Interview with an RN #82 on 12/05/2023 at 1115 revealed, it was the expectation of the facility staff to document that patients were offered or declined daily hygiene opportunities and linen changes in the medical record every 24 hours. Interview with RN #4 on 12/07/2023 at 0955 revealed, it was the expectation of the facility staff that patients were to be offered and documented daily hygiene opportunities and linen changes in the medical record every 24 hours. Interview revealed it was the Registered Nurse to oversee the completion of the task of bathing opportunities, linens changed as part of activities of daily living. 26622 5. Review on 11/28/2023 of the closed medical record for Patient #60 revealed a 63-year-old female that presented to the Emergency Department on 10/31/2022 at 1101 with a chief complaint of chest pain. Patient #60 was admitted to inpatient services on 10/31/2022 at 1646 and discharged on 11/18/2022 at 1556. Review of the nursing notes from 10/31/2022 through 11/18/2022 revealed that Patient #60 was assisted with a bath on 11/03/2022, refused bath on 11/04/2022 and 11/15/2022, basin wipes bath on 11/16/2022 and performed bath independently on 11/17/2022. Documentation failed to reveal evidence that Patient #60 received a bath on 11/01, 11/02, 11/05, 11/06, 11/07, 11/08, 11/09, 11/10, 11/11, 11/12, 11/13, 11/14 and 11/18/2022 (13 of 18 days with no documented bath). Interview on 12/01/2023 at 0945 with NM #85 and NM #86 revealed the staff were expected to document that patients were offered or refused a daily bath in the medical record every 24 hours. 49480 7. Review on 11/16/2023 of the “Staffing Responsibilities and Procedure” policy revised 02/10/2015 revealed, “Policy: Mission Hospital will maintain staffing to meet patient care needs on all nursing units...”. Closed medical record review on 11/14/23 of Patient #26 revealed a 22-year-old patient presented to the Emergency Department (ED) via EMS (Emergency Management Services) on 09/01/2022 at 1845 for complaints of abdominal pain, decreased appetite, watery non-bloody diarrhea, and right-calf burn. Review revealed the patient was transferred from the ED to unit B3-South (3rd floor holding area) on 09/02/2022 at 1915. Review of closed medical record lacked nursing documentation related to patient assistance with toileting while located on unit B3-South from 09/02/2022 through 09/03/2022. Review revealed the patient was transferred from unit B3-South to unit A5-West room #566 on 09/03/2022 at 1357. Review of closed medical record lacked nursing documentation related to patient assistance with bathing (shower/bath) and hygiene needs from 09/03/2022 through 09/07/2022. Interview on 11/14/2023 at 1545 with RN #101 revealed unit B3-South (3rd floor holding area) is currently not being utilized as a patient care unit. RN #98 revealed during Patient #26’s hospital admission starting on 09/02/2022, unit B3-South was a “holding unit” for patients between the ED and admission to an inpatient bed. RN #98 revealed patient rooms on the unit did not have bathrooms in the rooms and patients would have to walk to a bathroom located in the hallway. RN #98 revealed nursing staff should have assisted patients with toileting and/or ambulating to the hallway bathroom. Interview on 11/16/2023 at 1130 with PCT #99 (Patient Care Technician) while on tour of unit A5-West indicated that he/she assists patients with ADL’s (Activities of Daily Living) such as bathing, toileting, and oral care. PCT #99 stated that patients located in even room numbers are assisted with bathing on the dayshift and patients located in odd room numbers are assisted with bathing on the nightshift. PCT #99 stated the unit is often staffed with 1 PCT for up to 36 patients making it difficult to provide care in a safe and timely manner to all patients. Interview on 11/16/2023 at 1200 with RN #97 (Director) indicated unit A5-West has 36 patient beds which ideally was staffed with 7 RN’s, 2 PCT’s and 1 unit clerk. RN #97 revealed fully staffing the unit was often a challenge. 49003 6. Closed medical record review on 11/14/23 for Patient #40 revealed on 3/4/2023 at 1747 an 84 year old male with a history of Alzheimer’s presented with increasing weakness and confusion. Patient #40 remained in the Emergency Department (ED) until being admitted from 3/5/23 at 0216 until discharge to a nursing facility on 3/8/23 at 1722. There was no documentation to reflect an offer/decline of a bath during this 4-day time period. Closed medical record review on 11/14/23 for Patient #40 revealed on 4/28/23 at 0226 the 84-year-old male with a history of Alzheimer’s was transported to the ED via ambulance after falling at a local pharmacy. Patient #40 was diagnosed with COVID requiring supplemental oxygen then admitted to the facility on 4/29/23 at 0709. Patient #40 remained in the facility until discharge to a nursing facility on 5/9/23 at 1021. There was no documentation to reflect an offer/decline of a bath for the 11-day admission. During the same 11-day admission, there were no documented linen changes with the exception of “no” being documented on 5/5/23 at 0442 and 2000. Interview with RN #81 on 11/14/23 at 1200 confirmed the expectation for nursing to offer and document bathing and linen changes in the medical record. .”

“EMERGENCY LABORATORY SERVICES CFR(s): 482.27(a)(1) Emergency laboratory services must be available 24 hours a day. This Standard is not met as evidenced by: 41946 Based on policy review, medical record review, incident report review, laboratory logs, documents and staff interview, the hospital failed to have available laboratory services to meet the identified turn around times for STAT (immediate) results for three (3) of 35 patients presenting to the hospital’s Emergency Department (ED) (Patient #’s 83, 27, and 2), and failed to ensure timely laboratory results for three (3) of three (3) patients that had lab specimens sent to Hospital A’s lab from Hospital B (Patient #’s 11, 93 and 94). The findings included: A. Review on 11/17/2023 of the hospital policy Turn Around Time, last revised 11/17/2021 revealed “...PURPOSE: To provide timely and efficient testing services for routine, critical and high-risk situations. DEFINITIONS: Turn Around Time (TAT): the time elapsed from order placement to result reporting. Categorized as: Pre-analytical Phase: the period between test order entry by the caregiver and specimen receipt in the Laboratory. May be influenced, but not controlled by the Laboratory. Analytical Phase: the period between specimen receipt in the Laboratory and result reporting. Controlled by the Laboratory...STAT: an emergent, potentially life-threatening request. NOW: as soon as possible. Synonymous with ASAP. POLICY: All tests will be performed without delay to maximize specimen quality and integrity. STAT, NOW ... requests will be managed as priority situations. First-in, First-out (FIFO) processes are utilized to facilitate rapid and efficient movement of specimens through the system. Requests are also prioritized based on the following criteria to meet defined turn-around times: ...Response to STAT requests: ...STATS take priority over other specimens and should be managed from time of receipt until result reporting with no interruption in handling or testing. In general, the maximum TAT for most tests is 45-50 minutes from order receipt.... Response to NOW/ASAP requests: ...Staff will immediately process the specimen, perform testing, and verify results. Results should be available within (1) one hour from specimen receipt.... TAT Summary (Inpatient): STAT, Time from ORDER Receipt 45-50 minutes. NOW, Time from SPECIMEN receipt 1 hour...” 1. Closed medical record review on 12/06/2023 revealed Patient #83, a 74-year-old female patient who arrived at the emergency department (ED) with dizziness on 11/28/2023 at 1216. The patient had STAT lab work ordered at 1218. Labs were drawn at 1358. Labs arrived at the lab at 1412 and resulted at 1532 (1 hour and 20 minutes after arriving to lab, 3 hours and 14 minutes after ordered). The blood glucose was 1137 (critically high). Lactic acid was ordered NOW at 0127 for nurse collect in the ED. At 0200 a physician wrote there was a delay in labs and fluids so stopped the insulin IV infusion. At 0529 the original lactic acid NOW, order was canceled and reordered as lab collect NOW on the floor. It was collected at 0844 (3 hours and 15 minutes after ordered at 0529) and resulted at 1108 (9 hours and 41 minutes after originally ordered at 0127) with a result of 7.48 critical high. A second lactic acid was reordered at 1108 and resulted at 1256 (1 hr. and 36 after ordered) with a result of 11.96 critically high. A rapid response was called previously at 1158, the patient was intubated at 1247, and ultimately expired on 11/30/2023. Review of Patient Safety Analysis completed by RN #12 on 12/01/2023 at 1917 revealed this Care Event was a “Delay in Care” and the issue was “Lack of timely response to Order”, for Patient #83. A description “A NOW LA (lactic acid) order was placed at 0529. Lab wasn’t drawn until 0844, and in lab at 0907. Critical results of lactic acid 7.48 reported at 1108. MD at 1114...Shortly after this (within the hour), the patient took a turn and had to be intubated at bedside and sent to ICU (intensive care unit) ...Solution to Prevent this from Recurring? Promptly follow orders...” This Patient Safety Report was still in process. Review of the report revealed Patient #83 had a delay in lab work. Telephone interview on 12/07/2023 at 1632 with RN #10 who cared for Patient #83 in the Orange Pod revealed “...I work on an inpatient unit and was pulled to the ED that day. It’s a revolving door, I don’t recall this patient in particular. If I can’t get the labs, I would call a phlebotomist after 3 tries to get the labs if I couldn’t...” Interview revealed she could not remember why the NOW lactic acid order was not collected. Interview revealed physician orders for Patient #83 were not followed. Interview on 12/08/2023 at 0915 with RN #11 revealed she did remember Patient #83 and worked night shift. “...I did not receive a report on this patient from the ED. You have to look up the medical record number and sometimes the charge nurse gets an alert that the patient is coming and will print the face sheet. I had to piece it together and go through the orders. I reordered the lab work when I saw it was pending. My concern is we have trouble getting in contact with the phlebotomist. That morning they were not logged into to their IMobile device. I called the general lab number, and no one answered. I then contacted my house supervisor, and he told me ‘we don’t have another option right now.’ I can’t recall if she was on a telemetry box or not, I was only with her over an hour...” Interview revealed not being able to reach a phlebotomist during night shift had happened before. Interview revealed RN #11 had called multiple times to reach the lab phlebotomist to draw NOW blood orders without reaching someone. Interview revealed lab Turn Around Time for NOW lab orders was not followed for Patient #83. Interview on 12/08/2023 at 1309 with Laboratory Phlebotomist Supervisor #17 revealed “...the phlebotomists do not collect in the ED; we will help if called. All labs ordered in the ED default to “nurse collect”. The expectation was for STAT and NOW orders to be from order to collection in 15 minutes and to be resulted in an hour from order...” Interview revealed lab collection for STAT and NOW orders for Patient #83 did not follow hospital policy. Interview on 12/09/2023 at 1159 with Lab Director #18 revealed “...I do know we had a call out that day. The lactic acid was available for the lab tech to see at 1016 but wasn’t called to the floor until 1108. I don’t know what the delay was. The expectation was to call as soon as the result was available. The expectation for lab collection and processing was to follow the policy guidelines, and for STAT and NOW results to be completed within an hour...” Interview revealed lab collection and processing did not follow hospital policy for Patient #83. 2. Closed medical record review revealed Patient #27 arrived in the ED on 07/04/2022 at 0025 with abdominal pain reported as a pain level of 10 of 10. Orders for STAT lab work were placed at 0028. Lab results were completed at 0734 (7 hours and 6 minutes after ordered). The patient was diagnosed with a small bowel obstruction and had surgery that day. The patient had a delay with STAT lab work. Interview on 11/15/2023 at 1350 with ED Registered Nurse (RN) #38 who triaged Patient #27 revealed “... It’s very possible that this patient waited without any labs or orders completed. At that time there was one nurse in the waiting room to triage patients. There was no way to complete orders...” Interview revealed physician orders were not completed in the ED waiting room. Interview on 11/15/2023 at 1414 with ED Medical Doctor (MD) #26 revealed “...I saw the patient after she was roomed.... There is not always a person to get labs and orders done. No staff to do orders. With the new process the goal is for that not to happen, but at night I suspect it does. ... things are not happening on a timely basis...” Interview revealed hospital policy was not followed for Patient #27. 33790 3. Review of the medical record, on 11/14/2023, revealed Patient #2 arrived to the hospital on 10/17/2023 at 1753 via EMS. Review of “ED Triage”, performed 10/17/2023, at 1900 (1 hour and 7 minutes after arrival) revealed a pre-hospital blood glucose of 459 and an acuity of “3-urgent”. Review of the “ER Report” by a Physician Assistant, on 10/17/2023 at 1845, revealed “... 66-year-old male patient .... presents.... (to the) emergency department today via EMS for chief complaint of chest pain and shortness of breath. ED record review revealed the following lab tests were ordered in the ED stat at 1841 (48 minutes after Patient #2 arrived): Lactic Acid, CMP (comprehensive metabolic panel), Troponin, D-Dimer, Pro B-Type Natriuretic Peptide (ProBNP) and CBC with Differential. Review of orders revealed the labs were collected as Nurse collects at 1920 (39 minutes after the lab orders). Patient #2 experienced cardiac arrest at 1953, 2 hours after arrival. The CBC resulted at 2002 and the CMP resulted at 2012. The D-Dimer resulted as 824 (high) at 2006. The Pro BNP resulted as 9690 (High - reference range 5-125) at 2023 and the Troponin resulted as 0.460 (High - reference range 0.000-0.034) at 2039 (1 hour 19 minutes after the lab was collected; 1 hour, 58 minutes after it was ordered). The physician was notified. Review revealed the physician was notified 2 hours, 46 minutes after Patient #2 arrived to the ED and 15 minutes after the patient expired). Review revealed delays in ordering, collecting and resulting the labs. Interview on 12/08/2023 at 1309 with Laboratory Phlebotomist Supervisor #17 revealed “...the phlebotomists do not collect in the ED; we will help if called. All labs ordered in the ED default to “nurse collect”. The expectation was for STAT and NOW orders to be from order to collection in 15 minutes and to be resulted in an hour from order...” Interview on 12/09/2023 at 1159 with Lab Director #18 revealed “...The expectation for lab collection and processing was to follow the policy guidelines, and for STAT and NOW results to be completed within an hour...” 47420 B. Review of policy Microbiology Turn Around Times, Effective 05/30/2023, revealed “...III. POLICY A. Microbiology services are available 24/7. B. Specimens are received and processed on all 3 shifts. Microbiology Department: Test menu and turnaround time information...17. Urine Culture a. Negative Culture: i. Non-invasive (i.e. clean catch & indwelling cath): 18-24 hours ii. Invasive: 48 hours b. Positive Culture: 24-48 hours ...” Review on 11/15/2023 of lab work sent to Hospital A from Hospital B as an outpatient lab service for Patient #11 revealed that a urine culture was submitted on 09/14/2023. The positive results were released on 09/19/2023 (four days after the specimen was received in the lab). Review on 11/15/2023 of lab work sent to Hospital A from Hospital B as an outpatient lab service for Patient #94 revealed that a urine culture was submitted on 09/06/2023. The positive results were released on 09/12/2023 (six days after the specimen was received in the lab). Review on 11/15/2023 of lab work sent to Hospital A from Hospital B as an outpatient lab service for Patient #93 revealed that a urine culture was submitted on 09/18/2023. The positive results were released 09/23/2023 (five days after the specimen was received in the lab). Review on 11/16/2023 of a log of all urine cultures processed by the Microbiology section from 09/23/2023 through 09/30/2023 revealed that 14 of 29 cultures, or 48%, were resulted at greater than 48 hours. Review of an email from a Laboratory Microbiology Manager on 11/15/2023 at 1121 revealed “...There were delays in getting these finalized due to critical staffing in Microbiology. The decision was made on 09/19/2023 to start sending all of (named Hospital) to (Named outpatient Laboratory Company) since we didn’t have the staff to read all cultures. The staff had to prioritize cultures. Outpatients were not looked at on a daily basis. They had to prioritize inpatients and critical specimen types such as blood cultures. However, they did sub the organisms each day to make sure they were viable to do identification and susceptibility testing.” Request for interview with the Laboratory Microbiology Manager revealed they were unavailable. Telephone interview on 11/17/2023 at 0959 with the North Carolina Division Director of Laboratory revealed that during September 2023, the hospital microbiology department was experiencing critical staffing problems due to vacancies and staff on medical leave. The Director stated that on 10/02/2023, it was decided to use an outside Laboratory company to handle microbiology cultures. The Director also stated that at the same time, the department focused on staffing, hiring travelers and training on new processes. The Director stated that on November 6th, 2023, the hospital inpatient cultures were returned to in-house processing. The Director stated the Quality dashboards were being created to monitor turnaround times for cultures going forward.”

“ORGANIZATION AND DIRECTION CFR(s): 482.55(a) Organization and Direction. If emergency services are provided at the hospital -- This Standard is not met as evidenced by: 16369 Based on policy review, medical record review, incident report review, EMS trip report review, and staff and provider interviews, Emergency Department (ED) nursing staff failed to ensure emergency care and services were provided according to policy and provider orders by failing to accept patients upon arrival to the ED, evaluate, monitor and provide treatment to emergency department patients to prevent delays and/or lack of triage, nursing assessment, and implementation of orders, including lab, telemetry and medication orders for eleven (11) of 35 patient records reviewed (Patient #’s 92, 83, 43, 28, 27, 29, 6, 1, 2, 12 and 26). The findings included: Review on 12/06/2023 of the hospital policy “Triage - Emergency Department 1PC.ED.0401” revised 07/2023 revealed, “...DEFINITIONS: ... A. Triage Assessment: The dynamic process of sorting, prioritizing, and assessing the patient and is performed by a qualified RN (Registered Nurse) at the time of presentation and before registration. This is a focused assessment based on the patient’s chief complaint and consists of information, which is obtained that would enable the Triage RN to determine minimal acuity. A rapid or comprehensive triage assessment is completed, with a goal of 10 minutes, on arrival to the emergency department. 1. A rapid triage assessment is composed of airway, breathing, circulation and disability, general appearance, eliciting symptom driven presenting complaint(s), and any pertinent objective and subjective data/assessment from the patient or parent or caregiver. 2. A comprehensive assessment, performed on each patient that presents to the emergency department, is a focused physical assessment including vital signs, pain scale, allergy, history of current complaint, current medications, exposure to infectious disease, and pertinent past medical/surgical history. ... B. Triage Acuity Level - The Emergency Severity Index (ESI) is a five level emergency department (ED) triage algorithm that provides clinically relevant stratification of patients into five groups from 1 (most urgent) to 5 (least urgent) on the basis of acuity and resource needs. C. Reassessment - A process of periodic re-evaluation of the patient’s condition and symptoms prior to and during the initiation of treatment. Reassessment components may include some or all of the following: vital signs, a focused physical assessment, pain assessment, general appearance, and/or responses to interventions and treatments. Reassessment after the medical screening exam are performed by RN’s (Registered Nurses) according to acuity or change in patient’s condition. D. Vital Signs - Helps nursing personnel determine the stability of patients and acuity of those that are that are presenting with life-threatening situations or who are in high-risk categories. Usually refers to temperature, pulse rate, respiratory rate, and blood pressure. May include pulse oximetry for patients presenting with respiratory and/or hemodynamic compromise, and pain scale for those patients with pain as a component to their presenting complaint...PROCEDURE: ...B. All patients presenting for care will be evaluated by an RN. This RN should complete a brief evaluation of the patient, including immediate compromise to a patient’s airway, breathing, or circulation.... H. If there is no bed available, the patient will need to wait in the lobby. While in the lobby, patient reassessment and vital signs should be documented in the health record in accordance with documentation guidelines. ...” Review on 12/09/2023 of the “Assessment and Reassessment” policy revised 06/2021 revealed, “... PURPOSE: A. The goal of the assessment/reassessment is to provide the patient the best care and treatment possible ... The nursing process is utilized in order to achieve this goal. This process includes assessing, analyzing, planning, implementing and evaluating patient care or treatment. ... DEFINITIONS: A. Assessment: The multidisciplinary assessment process for each patient begins at the point where the patient enters a (facility name) facility for care, and in response to changes in the patient’s condition. ... The assessment will include systematic collection and review of patient-specific data necessary to determine patient care and treatment needs. B. Reassessment: The reassessment process is ongoing and is also performed when there is a significant change in the patient’s condition or diagnosis and in response to care. ... SECTION VI: EMERGENCY DEPARTMENT: A. Patients should be triaged following guidelines set forth in the system Triage Policy (1PC.ED.0401), including documentation of required elements within the electronic medical record (e.g. Vital signs, Glasgow Coma Scale (GCS)). B. The priority of data is determined by the patient’s immediate condition. On arrival to unit, an initial assessment is initiated and immediate life-threatening needs are determined with appropriate interventions implemented. C. Patient assessment should be performed based on the developmental, psychosocial, physiological, and age-specific needs of the individual. D. Focused patient history and physical assessment are based on patient’s presenting problem(s) including individual indicators of vulnerability. E. Reassessment: 1. Reassessment is ongoing and may be triggered by key decision points and at intervals based on the needs of the patients. Additional assessment/reassessment elements and frequency are based upon patient condition or change in condition, diagnosis, and/or patient history, not to exceed four hours. Interventions may warrant more frequent assessments....” 1. Closed medical record review on 12/09/2023 of Patient #92 revealed a 69 year-old male that presented to the emergency department on 11/09/2023 at 1149 via private vehicle with a chief complaint of chest pain. The patient was triaged at 1155 with a chief complaint of “Woken from sleep at 0400 with midsternal chest pain, described as sharp and pressure. No SOB (shortness of breath), arm/jaw/back pain, or diaphoresis (sweating). H/o (history of) colon CA (cancer) with mets (metastasis) to the lung, currently on chemotherapy....” Review revealed vital signs of blood pressure (BP) 125/60, pulse (P) 57, temperature (T) 97.4 degrees Fahrenheit, oxygen saturation (O2 Sat) 97% and a pain level reported as 2 (scale 1-10 with 10 the worst). Review revealed a triage level of 2 (level 1 most urgent). Review revealed a Medical Screening Examination by a physician was started in the waiting room area at 1209. Review of the physician’s notes recorded the patient’s chest pain had been waxing and waning, coming in waves and lasting about five minutes at a time. Review revealed a plan to conduct an ED chest pain work-up including a chest x-ray, EKG and labs including CBC, chemistry, lipase and troponin, and administer a dose of aspirin. Review recorded a differential diagnosis of GERD (gastroesophageal reflux disease), referred abdominal pain, musculoskeletal chest pain, ACS (acute coronary syndrome), with lower suspicion for PE (pulmonary embolus) given no tachycardia, hypotension, or evidence of DVT (deep vein thrombosis) on exam. Review revealed the ED physician recommended admission for further chest pain workup based on risk factors. Review of physician’s orders revealed labs were ordered at 1218, collected at 1320 and resulted at 1332. Review revealed a troponin result of 0.013 (normal). Review revealed a physician’s order placed at 1218 for continuous ECG (telemetry) monitoring in the ED. Review of the ED record revealed no evidence that continuous ECG monitoring was initiated in the ED. A chest x-ray was ordered at 1220 and resulted at 1246 with normal results. An EKG was completed at 1224 which showed sinus rhythm with premature atrial complexes (PACs), with no changes when compared with a prior EKG done in 2022 per the physician’s read. A troponin resulted at 1320 as 0.013 (normal) and a baby aspirin was administered as ordered at 1334. A second troponin ordered at 1607 and resulted at 1704 as 0.014 (normal). Review of a second EKG completed at 1628 revealed “Sinus rhythm with premature atrial complexes (PACs). Otherwise normal ECG. When compared with ECG of 09-Nov-2023 12:24, Non-specific change in ST segment in inferior leads. ST elevation now present in Lateral leads.” Review recorded the ECG was confirmed by a physician on 11/09/2023 at 1821. Review revealed a physician’s order at 1659 for nitroglycerine 0.4 milligrams (mg) sublingual every five minutes times three as needed (prn) chest pain. Record review revealed no nursing assessment/reassessment documented after the patient’s triage was recorded at 1155. The patient was administered Morphine (narcotic pain medication) 2 milligrams intravenously (IV) at 1703 by a medic for a pain level of 4. There was no reassessment of the patient’s pain and no documentation of the patient’s condition by a nurse. The patient was moved from the waiting room to a bed in the orange pod (admission holding area of the ED) at 1937. Nitroglycerine 0.4 milligrams sublingual was administered by a nurse times one for a pain level of 10 at 2013. Review revealed no reassessment of the patient’s response to the medication intervention and no nursing assessment of the patient’s condition was documented. The patient was transported from the ED to a medical surgical floor on 11/09/2023 at 2054. The patient was placed on continuous telemetry at 2111 when he was noted to be in Atrial Fibrillation with Rapid Ventricular Rate (abnormal heart rhythm). Review of the ECG completed at 2110 recorded an “ST elevation consider lateral injury or acute infarct ** ** ACUTE MI / STEMI (myocardial infarction or heart attack) ** ** ...”. Review of a Cardiovascular Consult History and Physical documented on 11/10/2023 at 0020 as an Addendum revealed the patient “... went into AF/RVR (Atrial Fibrillation with Rapid Ventricular Rate) at 2110 hrs this evening with ECG demonstrating evolving high lateral STEMI (l, aVL) which was more pronounced on follow-up ECG at 2210 hrs prompting formal STEMI activation for emergent cardiac catheterization. ...” Review of a Discharge Summary dated 11/13/2023 at 1211 revealed the patient was discharged home on 11/13/2023 with a diagnosis of STEMI (ST elevation myocardial infarction), Coronary Artery Disease, Hypertension, and Atrial Fibrillation with RVR. Interview on 12/09/2023 at 1210 with ADON #17 revealed Patient #92 was identified as a level 2 triage and should have been assessed every four hours at a minimum, every two hours for a level two and with any change in the patient’s condition. Interview revealed the patient developed chest pain and required interventions and no nursing assessments or reassessments were documented in the ED record. Interview revealed continuous telemetry was ordered for the patient at 1218 and telemetry was not placed on the patient in the ED. Interview revealed the telemetry was placed on the patient at 2111 once the patient transferred to the medical floor. Patient #92 presented to the ED with chest pain on 11/09/2023 at 1149. The patient was not assessed by a nurse after triage was completed at 1155, or with a change in condition, or after pain medication was administered at 1703. The patient was never placed on continuous telemetry in the ED as ordered by a physician at 1218. The patient was transferred to a medical floor and placed on telemetry at 2111 when he was found to be in atrial fibrillation with rapid ventricular rate, prompting a STEMI Code Activation. The patient underwent an emergency cardiac catheterization at 2249. ED nursing staff failed to provide ongoing assessment of the patient’s condition and follow physician’s orders for application of continuous telemetry. Nursing staff failed to ensure policies and provider orders were implemented. 41946 2. Review on 11/17/2023 of the hospital policy Turn Around Time, last revised 11/17/2021 revealed “...PURPOSE: To provide timely and efficient testing services for routine, critical and high-risk situations. DEFINITIONS: Turn Around Time (TAT): the time elapsed from order placement to result reporting. Categorized as: Pre-analytical Phase: the period between test order entry by the caregiver and specimen receipt in the Laboratory. May be influenced, but not controlled by the Laboratory. Analytical Phase: the period between specimen receipt in the Laboratory and result reporting. Controlled by the Laboratory...STAT: an emergent, potentially life-threatening request. NOW: as soon as possible. Synonymous with ASAP. POLICY: All tests will be performed without delay to maximize specimen quality and integrity. STAT, NOW ... requests will be managed as priority situations. First-in, First-out (FIFO) processes are utilized to facilitate rapid and efficient movement of specimens through the system. Requests are also prioritized based on the following criteria to meet defined turn-around times: ...Response to STAT requests: ...STATS take priority over other specimens and should be managed from time of receipt until result reporting with no interruption in handling or testing. In general, the maximum TAT for most tests is 45-50 minutes from order receipt.... Response to NOW/ASAP requests: ...Staff will immediately process the specimen, perform testing, and verify results. Results should be available within (1) one hour from specimen receipt.... TAT Summary (Inpatient): STAT, Time from ORDER Receipt 45-50 minutes. NOW, Time from SPECIMEN receipt 1 hour...” Closed medical record review on 12/06/2023 revealed Patient #83, a 74-year-old female patient who arrived at the emergency department (ED) via emergency medical services (EMS) on 11/28/2023 at 1216 with a chief complaint of dizziness from her doctor’s office. Patient #83 was seen by an ED MD #1 on arrival and at 1218 a comprehensive metabolic panel (CMP) [includes serum glucose] was included in laboratory tests ordered as STAT (an emergent, potentially life-threatening request) with continuous ECG monitoring. At 1259 Patient #83 was placed in Red Pod (for the most acute patients) Hallway Bed-17. At 1309 the first set of vital signs was recorded by RN #2 as temperature 98.7, heart rate 84, respirations 19, blood pressure 225/88, and oxygen saturation of 93 percent on room air. At 1316 RN #3 completed a nursing triage assessment and Patient #83 was given an emergency severity index (ESI) [level 1 as the most urgent and 5 as the least urgent] of 3-urgent. Review of the CMP history revealed the STAT lab was collected at 1358 by RN #3 (1 hour and 40 minutes after the order was placed), the blood specimen arrived at the laboratory at 1412, and resulted at 1532 (3 hours and 14 minutes after the STAT order was placed) with a serum glucose resulted of 1137 (high normal range 120). Review of the Physician’s Order on 11/28/2023 at 1626 by ED Nurse Practitioner (NP) #5 revealed a new order for an Insulin (IV medication to reduce serum glucose) IV infusion to be started (54 minutes after the glucose had resulted). At 1709 an Insulin drip was initiated for Patient #83 by the RN #3. At 1739, the Hospitalist NP #6 placed a continuous telemetry monitoring order for 48 hours for Patient #83, with vital signs every 2 hours while in the ED. At 1908 ED MD #14 ordered a Glycosylated Hemoglobin NOW that was collected at 2128 (2 hours after ordered). At 2109 Patient #83 was moved to the ED Holding-Orange Pod-Room-2 awaiting an inpatient bed. At 2329 Hospitalist MD #9 ordered an IV infusion of D51/2 NS with KCL (Dextrose, Normal Saline, and Potassium Chloride Solution). On 11/29/2023 at 0127 MD #9 ordered a Lactic Acid (carries oxygen from your blood to other parts of your body) level to be drawn “NOW” for “nurse collect” for Patient #83. At 0153 MD #9 ordered to suspend the insulin IV. An addendum was made to the History and Physical at approximately 0200 by MD #9 which revealed “...Unfortunately patient has been on insulin drip since 5pm without continuous fluid administration or repeat blood work, it is currently 2 am, Nursing staff was previously contacted requesting these, later on did let provider know there was difficulty obtaining blood work as well as delay in obtaining D51/2NS KCL fluid from pharmacy. Given we have no blood work, no fluids, for the safety of the patient will suspend insulin drip at this time, until blood work is back to ensure appropriateness of insulin drip infusion...” 0157 RN #10 documented the IV with D51/2NS KCL as started (2 hours and 27 minutes after ordered). At 0200 Patient #83’s Insulin IV was suspended by RN #10. At 0256 Patient #83’s Insulin IV was reordered and was resumed (56 minutes after it was stopped). On 11/29/2023 at 0514 Patient #83 was transported to a Stepdown Unit. Review of the ED record revealed no evidence that continuous telemetry monitoring or vital signs every 2 hours were initiated in the ED by a nurse, further the NOW Lactic Acid “nurse collect” order at 0127 was never drawn while the patient was in the ED. On the inpatient floor, at 0529, RN #11 cancelled the 0127 NOW Lactic Acid order “nurse collect” from the ED and reordered the NOW Lactic Acid order “lab collect”. The Glycosylated Hemoglobin NOW that was ordered 11/28/2023 at 1908 resulted on 11/29/2023 at 0743 (12 hours and 35 minutes after ordered) with result of 12.3 (normal high range 6.3). At 0844 the Lactic Acid was drawn (3 hours and 15 minutes after it was ordered), was in the lab for processing at 0907, and resulted at 1108 (5 hours and 39 minutes after ordered) as “7.48” (high normal for lactic acid was 2.1). The computer system automatically reordered an additional Lactic Acid order by default and was collected at 1119 and was in the lab to be processed at 1148. At 1146 RN #12 documented a blood pressure of 141/67 with respirations of 36. At 1158 Rapid Response was called for Patient #83. At 1206 blood pressure was 65/40. At 1213 blood pressure was recorded at 68/40. At 1225 a Levophed (medication used to increase blood pressure) IV infusion was initiated via interosseous to increase her blood pressure. At 1245 the blood pressure was 126/84 at 98 percent oxygen saturation while the patient was being mechanically bagged at the bedside. At 1247 Patient #83 was intubated (mechanical ventilation), at 1250 Patient #83 was transferred to the medical intensive care unit. At 1256 the second Lactic Acid resulted as critically high “11.96”. After discussion with the family, Hospitalist MD #16 changed Patient #83 Full Resuscitation status to Limited Resuscitation with no cardiopulmonary resuscitation (CPR). Patient #83 expired on 11/30/2023 at 1337. Review on 12/06/2023 of a Patient Safety Analysis (Incident Report) completed by RN #12 on 12/01/2023 at 1917 revealed this Care Event was a “Delay in Care” and the issue was “Lack of timely response to Order”, for Patient #83. A description “A NOW LA (lactic acid) order was placed at 0529. Lab wasn’t drawn until 0844, and in lab at 0907. Critical results of lactic acid 7.48 reported at 1108. MD at 1114...Shortly after this (within the hour), the patient took a turn and had to be intubated at bedside and sent to ICU (intensive care unit) ...Solution to Prevent this from Recurring? Promptly follow orders...” This Patient Safety Report was still in process. Review of the report revealed Patient #83 had a delay in lab work. Request to interview MD #9 revealed she was unavailable for interview. Request to interview MD #16 revealed he was unavailable for interview. Telephone interview on 12/07/2023 at 1632 with RN #10 who cared for Patient #83 in the Orange Pod (location in the ED for pending admissions) revealed “...I work on an inpatient unit and was pulled to the ED that day. It’s a revolving door, I don’t recall this patient in particular. If I can’t get the labs, I would call a phlebotomist after 3 tries to get the labs if I couldn’t...” Interview revealed she could not remember why the NOW lactic acid order was not collected. Interview revealed physician orders for Patient #83 were not followed. Interview on 12/08/2023 at 0915 with RN #11 revealed she did remember Patient #83 and worked night shift. “...I did not receive a report on this patient from the ED. You have to look up the medical record number and sometimes the charge nurse gets an alert that the patient is coming and will print the face sheet. I had to piece it together and go through the orders. I reordered the lab work when I saw it was pending. My concern is we have had trouble getting in contact with the phlebotomist. That morning they were not logged into to their imobile device. I called the general lab number, and no one answered. I then contacted my house supervisor, and he told me ‘we don’t have another option right now.’ I can’t recall if she was on a telemetry box or not, I was only with her over an hour...” Interview revealed not being able to reach a phlebotomist during night shift had happened before. Interview revealed RN #11 had called multiple times to reach the lab phlebotomist to draw NOW blood orders without reaching someone. Interview revealed lab Turn Around Time for NOW lab orders was not followed for Patient #83. Interview on 12/08/2023 at 1309 with Laboratory Phlebotomist Supervisor #17 revealed “...the phlebotomists do not collect in the ED; we will help if called. All labs ordered in the ED default to “nurse collect”. The expectation was for STAT and NOW orders to be from order to collection in 15 minutes and to be resulted in an hour from order...” Interview revealed lab collection for STAT and NOW orders for Patient #83 did not follow hospital policy for lab turnaround times. Interview on 12/08/2023 at 1414 with NP #6 revealed her expectation for Patient #83, was for her to have continuous ECG monitoring and vital signs every 2 hours while in the ED. Interview revealed physician orders were not followed for Patient #83. Interview on12/08/2023 at 1425 with RN #3 who cared for Patient #83 in the Hallway Bed 17 on 11/28/2023 revealed “...I remember her. It was an extremely busy day...she was a hard stick; I used an ultrasound to start her IV. The problem with hallway beds is they have no dedicated monitor. She had a monitor and vital signs ordered. I strongly advocated for her to get moved into a bed with the CNC (clinical nurse coordinator), and it didn’t happen. She didn’t think it was a big deal. We don’t have the capability to link the patient to a monitor in a hallway bed. She wasn’t on a monitor; I spent the afternoon telling the CNC and MD. The doctors don’t have any say, it’s up to the CNC where patients are roomed. I sat behind her all day, ...I was extremely frustrated...” Interview revealed Patient #83 was not placed on continuous ECG monitoring, nor were vital signs monitored every 2 hours. Interview revealed physician orders were not followed for Patient #83. Interview on 12/08/2023 at 1230 with Nursing Vice President of ED Services, RN #20 revealed she could not explain the lack of telemetry monitoring or vital signs for Patient #83 while in the ED. Interview revealed the ED nurse should elevate to the ED Charge Nurse for the need to continuously monitor a patient in a hallway bed if one was not available. Further interview revealed the ED Provider and ED Nurse were responsible for monitoring lab results via electronic medical record in the ED. Interview revealed hospital policy was not followed for Patient #83. Interview on 12/09/2023 at 1159 with Lab Director #18 revealed “...I do know we had a call out that day. The lactic acid was available for the lab tech to see at 1016 but wasn’t called to the floor until 1108. I don’t know what the delay was. The expectation was to call as soon as the result was available. The expectation for lab collection and processing was to follow the policy guidelines, and for STAT and NOW results to be completed within an hour...” Interview revealed lab collection and processing did not follow hospital policy for Patient #83. Patient #83 was presented to the ED with dizziness on 11/28/2023 at 1216. The patient had STAT (immediate) lab work ordered at 1218 with continuous ECG monitoring. Labs were drawn at 1358 (1 hour and 40 minutes after ordered). Labs arrived at the lab at 1412 and resulted at 1532 (3 hours and 14 minutes after ordered). The blood glucose was 1137 (critically high). Insulin IV infusion was ordered at 1626 and initiated at 1709 (1 hour and 13 minutes after ordered and 1 hour and 37 minutes after the glucose resulted). Orders for continuous ECG monitoring placed at 1218, and vital signs every 2 hours were never initiated in the ED. At 2349 an IV infusion of D51/2 KCL was ordered that was not completed until 0157 (2 hours. and 8 minutes after ordered). Lactic acid was ordered NOW at 0127 for nurse collect in the ED. At 0200 a physician wrote there was a delay in labs and fluids so stopped the insulin IV infusion. The lactic acid was not collected in the ED. At 0529 the original lactic acid NOW, order was cancelled and reordered as lab collect NOW on the floor. It was collected at 0844 (3 hours and 15 minutes after ordered at 0529) and resulted at 1108 (9 hours and 41 minutes after originally ordered at 0127) with a result of 7.48 critical high. A second lactic acid was reordered at 1108 and resulted at 1256 (1 hr. and 36 minutes after ordered) with a result of 11.96 critically high. A rapid response was called previously at 1158, the patient was intubated at 1247, and ultimately expired on 11/30/2023. 3. Review of the CIWA (Clinical Institute Withdrawal Assessment for Alcohol) /Alcohol Withdrawal Plan, effective date 07/20/2022 revealed “...Monitoring Phase ...Now ONCE, when plan is initiated with goal CIWA < (less than) 15...” The CIWA/Alcohol Withdrawal Plan Reference Information included 10 questions, questions 1-9 can score between 0 and 7 points each question, question 10, can score 0 to 4 points, depending on severity of symptoms for each question. Score range 0-68. Questions with observations: 1. Nausea/Vomiting? 2. Paroxysmal sweats? 3. Agitation? Headache, fullness in head? 5. Anxiety? 6. Tremor? 7. Visual disturbances? 8. Tactile disturbances? 9. Auditory disturbances? 10.Orientation and clouding of sensorium -Ask what day it is? “...CIWA Management Communication If CIWA > 15 for four consecutive hours, contact provider to initiate Severe Withdrawal Phase and/or to consider transfer to higher level of care...” Closed medical record review on 11/16/2023 revealed Patient #43, a 39-year-old who presented to the emergency department (ED) by private vehicle on 08/14/2023 at 1603 with complaints of “...chest pain, nausea, clammy, lightheaded, and right-side tingling for several week. Drinks 12 beers a day....” At 1603 triage by Registered Nurse (RN) #21 with vital signs: temperature 98.5, heart rate 97, respirations 18, blood pressure141/89, oxygen saturation of 96 percent on room air, and pain of 4/10 (1 being least pain, and 10 being most pain) and was assigned an emergency severity index [ESI] (level 1 as the most urgent and 5 as the least urgent) of 2. Patient #43 was then moved to the ED waiting room IPA (Internal Processing Area) area and was seen by Nurse Practitioner (NP) #22. At 1650 initial labs, ekg, and chest Xray were completed, and Patient #43 was assigned to ED Medical Doctor (MD) #23. Review of the ER Physician Note from 08/14/2023 at 1727 by MD #23 revealed a review of lab, ekg and chest Xray results from 08/14/2023 did not show any critical results. At 1732 MD #23 ordered a GI cocktail (oral combination of medications given for indigestion), Zofran 4mg orally (medication given for nausea and vomiting). An addendum to MD #23’s ER Report Note revealed “...On reassessment patient and his mom who is now accompanying him are updated on his results. He is still in the waiting room unfortunately. I have ordered IV (intravenous) fluids, CIWA protocol and 1mg of Ativan (a sedative given for anxiety and seizures) as he is slightly tremulous (shaking) and diaphoretic (sweating) my reassessment [sic]...Hospitalist has been consulted for admission...” At 1841 MD #23 placed orders for IV (intravenous) fluids-NS NOW, thiamine (dietary supplement/nutrient) 100 milligrams (mg) orally STAT (immediately), and CIWA scale/protocol (alcohol withdrawal plan/protocol). At 1851 vital signs were rechecked by IPA ED RN #24 temperature 98.3, heart rate of 103, blood pressure 132/82, and oxygen saturation of 92 percent on room air, the GI Cocktail, and Zofran were administered in the ED waiting room. At 1947 MD #23 ordered Ativan 1mg IV push NOW (urgent). Per the CIWA plan at 2100 a multivitamin orally was ordered and CIWA Scale assessment. The History and Physical was initiated on 08/14/2023 at 2229 by Hospitalist MD #25 while in the ED waiting room, and new orders were placed for aspirin orally NOW, Lopressor (medication given in treatment of alcohol withdrawal) 12.5 mg orally, and again IV access at 2226. At 2305 MD #25 ordered Patient #43 phenobarbital (medication given to prevent seizure) 60 mg orally three times a day STAT and a CIWA Scale reassessment was due to be completed per protocol. No nursing reassessments, medication administrations, IV access/fluids, or physician orders were completed after 1851 for Patient #43 while in the ED waiting room. On 08/15/2023 at 0057 Patient #43 was moved to the Red Pod (ED area for the most acute patients) room 11. At 0105 MD #25 ordered Patient #43 to have Ativan 4mg IV STAT and was given at 0106 by RN #27. Review of the ER Report Note on 08/15/2023 at 0107 by MD #26 revealed “...I became involved in the patient’s care after he apparently left the waiting room where he was awaiting admission and then had a seizure and struck his head on the sidewalk outside of the ER (emergency room) entrance. On my evaluation, the patient seems postictal (the period following a seizure, disorienting symptoms, confusion, and drowsiness), he is not actively seizing. He does have a history of heavy alcohol use, drinks about 12 beers a daily. He has been in the emergency department waiting room for 9 hours and has not received any Ativan or Phenobarbital. I suspect that he seized due to alcohol withdrawal. Will obtain head CT (cat scan) given the patient did strike his head, he also has a small laceration that will require repair....” Record review revealed the ED waiting room orders for IV fluids NOW on 08/14/2023 at 1841 to 08/15/2023 at 0106 (5 hrs. and 25 min), Ativan IV NOW ordered on 08/14/2023 at 1947 to administered on 08/15/2023 at 0106 (5 hours 19 min), and Phenobarbital STAT ordered on 08/14/2023 at 2305 to administered on 08/15/2023 at 0150 (2 hours and 45 min) for Patient #43 were delayed and no CIWA score/assessment was completed until 08/15/2023 at 0437 (9 hours and 56 minutes after ordered). No CIWA score/assessment was documented before the patient had a seizure event with sustained head injury. There was no nursing reassessment, or nursing care after 08/14/2023 at 1851 by RN #22 until 08/15/2023 at 0057 (6 hours and 1 minute). Patient #43 was admitted to an inpatient room on 08/15/2023 at 0334 from the ED. Patient #43 was discharged home on 08/17/2023. Review of the Patient Care Analysis (Incident) report submitted by MD #25 on 08/15/2023 at 0443 revealed the date of event was 08/15/2023 at 0000. Brief description revealed “...patient was in waiting room for 9 hours, did not receive any medications for alcohol withdrawal, then had a seizure and sustained a head injury...” Investigator #28 Notes revealed: We continue to work through ways to provide care to patients in the waiting room during peak times of surge and limited staffing...” Further comments were reviewed by the hospital Pharmacy, dated 11/17/2023 (3 months after the event) that revealed “...Suggest education to send out of CIWA precautions...Nurse could have clarified with provider about the CIWA order and administered medication...” Level of Harm was documented as “Harm-required intervention” and Primary Action to Prevent Recurrence: “Increase in Staffing/Decrease in Workload.” MD #23 declined to be interviewed. Interview on 11/15/2023 at 1414 with MD #26 revealed “...With the current process it’s still difficult to treat patients in the ED waiting room. The goal was for delays in care to not happen, but especially at night it occurs. I have concerns with delays in patient care. The patient was better off in a more clinical area where they can be monitored ...” Interview revealed MD #26 had concerns for patient safety in the ED waiting room due to delays in patient monitoring. Interview on 11/15/2023 at 1615 with NP #36 revealed “...it does happen occasionally that orders in the ED waiting room are on hold until the patient can be roomed. I do have concerns about it. The new waiting room flow is not better...” Interview revealed NP #36 had concerns provider orders were not completed timely in the ED waiting room. Interview on 11/16/2023 with ED IPA Day RN #22 revealed she did not remember Patient #43. Interview revealed “...best practice was to go back to see if patients’ meds (medication) were helpful. I must have left before I was able to put in a reassessment...I work IPA and the waiting room. There are multiple nurses and nurse techs (technicians) who get vital signs in the lobby and the techs notify us if abnormal. We escalate patient concerns with the charge nurse and the doctors do the same...” Interview revealed RN #22 cared for Patient #43 until 1900 and did not remember doing a reassessment after medication administration. Interview on 11/28/2023 at 1639 with ED IPA Night RN #28 revealed she did not remember Patient #43. Interview revealed “NOW orders in the IPA area go by priority and ESI, we are not always able to do them. The CNC (clinical nurse coordinator) should be informed...If you are the only IPA nurse and the doctor says ‘this has to happen now’ then it’s the next on my list. There was no protocol for who was actually assigned patients in the waiting room. Reassessments for ED patients who are waiting in the lobby would fall under the IPA nurse tasks but they are doing other patient’s needs and medications as well. There were only two ways to know if additional orders are placed on a patient after IPA, the doctor tells you, or on the tracking board, you might see “repeat troponin”, the CNC was supposed to help with that. If I gave controlled medication in the waiting room, I am responsible for the reassessment. If we are caught up it is a part of our duties to reassess...” Interview revealed patients in the ED waiting room are not assigned a nurse for reassessment and monitoring. Interview revealed hospital policy for reassessment in the ED was not followed for Patient #43. Interview on 12/01/2023 at 1130 with ED IPA RN #35 revealed “...The IPA nurse continues to be responsible for patients in the waiting room, after initial orders were completed...” Interview revealed the IPA nurse should continue to reassess patients in the ED waiting room. Interview revealed hospital policy for reassessment was not followed for Patient #43. Interview on 12/08/2023 at 1230 with Nursing VP of ED Services, VPED #20 revealed she could not explain the lack of monitoring or completion of provider orders in the ED waiting room. Interview revealed any new outstanding provider orders for patients in the ED waiting room would be elevated to the CNC. Further there was a WebEx huddle (meeting virtually for many hospital departments to discuss and prioritize patient needs) held every 2 hours and any outstanding provider orders would be delegated to be completed. Interview revealed RN #20 could not explain why Patient #43’s reassessments and providers orders had not been completed. Patient #43, a 39-year-old who presented to the emergency department (ED) by private vehicle on 08/14/2023 at 1603 with complaints of chest pain, nausea, clammy, lightheaded, right-side tingling for several weeks, with a reported history of drinks 12 beers a day. Review revealed the patient was located in the waiting room area and was observed by a physician to be diaphoretic. The physician ordered intravenous (IV) fluids and CIWA protocol (assessment tool used for alcohol withdrawal) at 1841, and Ativan (medication for anxiety) was ordered at 1947. These orders were not implemented. Multivitamin was ordered at 2100. Another order was placed at 2226 for IV fluids and Lopressor. Aspirin was ordered at 2229. None of these orders were implemented. An order written at 2305 for Phenobarbital administration was not implemented. At 0107, a physician’s note referenced the patient had a seizure and fall with a head injury outside the ED waiting room area. Findings revealed the patient had delays with nursing assessments, and failure to implement orders, including medication administration, and following the CIWA protocol. The patient subsequently had a seizure and fall with a resulting head injury. 4. Closed medical record review on 11/14/2023 revealed Patient #28, a 48-year-old male patient who arrived at the emergency department (ED) by emergency medical services (EMS) on 07/05/2022 at 0947 with headache x 2 weeks, altered mental status, fall, and was combative. He was triaged at 0950 by RN #57 with vital signs temperature 97.8, pulse 79, respirations 24, blood pressure 175/86, oxygen saturation of 94 percent on room air, a pain scale of 0 and an emergency severity index (ESI) of 1-Resusicitation. At 0955 Medical Doctor (MD) #59 initiated orders for EKG, lab work, chest Xray and CT (cat scan) of the head. At 1005 Haldol (given to treat severe behavior) 10 mg Intravenous was ordered by MD #59 and given due to combativeness. Review of the ER Note by MD #59 dated 07/05/2023 at 1002 revealed “.... history unable to be obtained from the patient...he was combative with EMS requiring 5 mg (milligrams) of Versed (given for sedation) given IV. He is only slightly sedated right now, ...pulling at lines, not answering questions, and not following commands...” At 1005 the complete blood count resulted with a white blood cell count of critical high- 32.4 (normal high 11). At 1029 Normal Saline 1 liter IV bolus was given and Rocephin (antibiotic) 1 gram IV was administered. At 1045 vital signs were pulse 78, blood pressure 226/107, oxygen saturation 98 percent on room air. At 1050 Patient #28 was intubated (mechanical ventilation) with standard IV sedation protocols. At 1054 vital signs pulse 76, blood pressure 211/91, and ventilated at 98 percent oxygen saturation. At 1236-1311 Patient #28 went into ventricular tachycardia (lethal heart rhythm) and was coded (resuscitated by staff), defibrillated, and had a central line placed. At 1322 a lumbar puncture was completed by MD #59 and a meningitis panel was ordered. At 1322 the cerebrospinal fluid (CSF) white blood count (WBC) resulted high at 94000 (normal high range 5 WBC’s per mm3 [million cubic meters]. At 1324 more antibiotics were given IV. Review of the ER Report Reexamination/Reevaluation (not timed) by MD #59 revealed “...the patient ultimately did require intubation for sedation and airway protection, his mental status continued to worsen despite Haldol and Versed...The Head CT was negative...Once back from CT the patient became profoundly hypotensive and at 1 point lost pulses requiring CPR, total time roughly 5 to 10 minutes...We have been running norepinephrine (given to sustain blood pressure) through this...ICU (intensive care unit) has been consulted. Family additionally has been updated...” At 1409 Pulmonologist/ICU MD #60 ordered Levophed (used to treat life-threatening low blood pressure) 4mg/ in 250 milliliters (ml) to titrate to 30 micrograms (mcg)/per minute and was initiated by RN #56 at 1514 (1 hour and 5 minutes after ordered), and at 1655 this drip rate was adjusted to 20mcg/min. At 1740 blood pressure was 137/79, at 1750 blood pressure was 73/42, at 1800 blood pressure was 33/18. Review of the Medication Administration Record revealed at 1801 RN #68 initiated a bag of Levophed at 30 mcg/min for Patient #28. At 1803 a code was initiated, and Patient #28 was in asystole (no heart rhythm). The code ended at 1807 with the return of blood pressure. At 1814 blood pressure was 249/118 with a pulse of 145. At 1816 an addendum to the ER Report by MD #62 revealed “...At 1803 I was called to the patient’s room, who had gone asystole. I was notified of the patient’s diagnosis of meningitis and hypotension. CPR was in progress on my arrival...I was notified that the patient’s Levophed had run dry, and that the patient had been hypotensive (low blood pressure) sometime before coding...Shortly after the epi (epinephrine-used to return pulse) and bicarb (bicarbonate improves outcomes in cardiac arrest), (1807) we had return of pulses. Patient’s blood pressure high. ICU attending entered shortly after the code finished.” At 1940 Patient #28 was transferred to the medical ICU for admission. Patient #28 continued to decline and showed no signs of improvement. Review of the Discharge Summary date 07/15/2022 at 1525 by Doctor of Osteopathic Medicine, DO #63 revealed “...There was no change in neurology exam, and it was explained to the family that there were no signs of meaningful improvement. At this time the family changed its code status to DNR (do not resuscitate) ...at this time the family was amenable...for organ procurement. He was brought to the OR (operating room) this morning where he was extubated (removal of mechanical ventilation), and time of death was 1040. On 07/15/2022 at 0931 Patient #28 had his kidneys harvested and was pronounced dead at 1040. Review on 11/28/2023 of the Patient Safety (Incident) Report for Patient #28 revealed it was reported by: (named RN #57) on 07/05/2022 at 1930. Event #: 6858. Event time was 07/05/2022 at 1803 with brief description “...assigned 5 patients, pt. (patient) coded due to unsafe staffing ratio...additional comments ...NUS (nursing unit supervisor RN #74) and Director (named, RN #75) notified of unsafe assignment at approx. 1730. RN (named RN #56) responded to assigned Trauma Alert which arrived at 1748. Pt. coded at 1803, 1 round of CPR, epi, sodium bicarb, ROSC (return of spontaneous circulation). Pt’s levophed emptied due to unsafe staffing assingment [sic]which was reported to NUS and Director prior to event...” Review on 07/06/2022 by Investigator and Director of ED Services (named RN #76) revealed one of the ED managers had spoken to Patient #28’s family member. The family was upset because they had “...asked for help at the doorway of the patient’s room when she noted alarms going off in the room. A PA (PA#77) was at the nurse’s station from a different service line that reportedly did not respond to her request...” Further the CNC, RN #74 reported she was only notified RN #56 needed assistance when the patient was coding. Patient #28 did code 2 times during his ER stay and had a length of stay of 9:52 (9 hours and 52 minutes) in the ER. RN #56’s patient assignment was broken down by RN #76 in the report as two stable patients awaiting admission to step down units (2), one patient who had been moved to the hallway (1), a new Trauma Alert patient (1), and Patient #28, an ICU patient (1). (RN #56 was assigned and responsible for 5 patients during Patient #28’s code/event). RN #76 discussed collateral staff available in the ED to support RN #56. “...Background information: The House was unable to provide staffing support for the admit holds in the ER on this date. There was an ER census of 295 on this date...” On 07/07/2022, Vice President (VP) of ED Services, VPED #48 reviewed this Patient Safety Report. Her investigation revealed there was an additional Patient Safety Report for this same event “...Indicating that the ER Director was informed of an alleged unsafe patient assignment. This notification to the Director was not substantiated...” Additionally, VPED #48 agreed RN #56’s assignment was safe due to collateral staffing in the ED. And did mention Patient #28’s family had voiced concerns who did not respond to their request for help for alarms in the room with (named, PA #77). The Primary Contributing Factor was “Human Factors/Staff Factors...Competing priorities...Level of Harm Harm-intervention to sustain life...” In summary, Patient #28’s levophed IV infusion sustaining his blood pressure was allowed to run dry, his blood pressure dropped, he was coded for 7 minutes until the infusion was reinstated. RN #56 had a patient assignment of 5 patients. Review on 11/28/2023 of the Patient Safety Analysis report, Event #6856, referencing Patient #28 dated 07/05/2022 at 1843 by ED Clinical Pharmacist, ED RPH #78 revealed the event date was 07/05/2022 at 1800 with a brief description of “...Patient required CPR (cardio-pulmonary resuscitation) due to levophed running dry while RN was attending to other patients (RN had 5 pts), including two traumas and this ICU patient...additional comments...making this report on behalf of (named RN #56) as he does not have time to make report. (Named) had 5 patients: the patient from this report (named) intubated, ICU), a trauma alert, a trauma transfer-a comfort care patient in the hall, and two other admitted patients. While he was in one of the traumas, this patient’s norepinephrine infusion ran dry-the patient became hypotensive. The family of the patient was monitoring the BP (blood pressure) and tried to get help from a non-ER provider who was sitting at a computer outside the room and this provider told the family that he could not help them because it was not his patient. Family is irate about this. A few minutes later, another RN came into the room and was able to switch out the levophed, but by this point the pt’s SBP (systolic blood pressure) was in the 30’s. He then became aystolic and required a round of CPR. (Named RN #56) alerted the ER NUS throughout the day that his assignment was unsafe. This patient coding was a direct result of an unsafe and unreasonable assignment...” This Report was investigated by ED Director, RN #76 on 07/06/2022 without any new findings from previous Event #6858. Additionally, on 07/21/2022 Doctor of Pharmacy, PharmD #79 added investigator notes to this report. The leading description of harm cited by PharmD #79 was “Human Factors/Staff Factors...Level of Harm...Harm-intervention to sustain life...” A summary of her report revealed that a bag of levophed was pulled for Patient #28 on 07/05/2022 at 1511 by RN #56 and was documented on the Medication Administration Record as given on 07/05/2022 at 1514, and per her estimation of the rates of infusion, the bag of levophed “...would have likely run out 1745...” The next bag of levophed was pulled on 07/05/2022 at 1757 by ED RN #68 and was started at 1801 for Patient #28. Review revealed Patient #28’s levophed IV infusion was interrupted for 16 minutes; he was coded from 1803 to 1810 before returning to spontaneous circulation. Request to interview ED RN #68 revealed she was not available for interview. Request to interview ED RPH #78 revealed she was unavailable for interview. Request to interview ED Manager RN #75 revealed he was unavailable for interview. Request to interview ED Director, RN #76 revealed she was unavailable for interview. Interview on 11/15/2023 at 1014 with RN #56 revealed he remembered Patient #28 and had worked in the ED for 5 years. Interview revealed “...I had trauma bay 11, and rooms 10, 9, 8 initially. The patient in room 10 was combative, intubated and a danger to himself and was receiving the maximum dose of levophed to keep his blood pressure elevated. I had him around 10 hours of my day. I got a trauma patient, and they were going to assign me another new trauma patient. Around 1730 I went to CNC (named RN #74) to discuss my assignment and the acuity of my already 4 patients, she put my dying trauma patient in the hallway, to make room for the new trauma patient even when I explained I felt my assignment was unsafe. I had already approached her that morning after 0800 to explain the acuity of my patients. So, then I went to my Nurse Manager (named, RN #75) to discuss my assignment and was assigned the new trauma anyway. My new trauma patient had just arrived after 1730, I was working with them and didn’t realize a code had been called for my intubated patient. When I arrived in the room (named RN #68), the person who was assisting me while I was caring for the new trauma patient, had already hung a new bag of levophed, and the code was in progress. I was very upset. I voiced my concerns, I talked to the administration, to the ethics and compliance committee and filed a complaint with HR (human resources). I tried to document this the best I could...” Interview revealed RN #56 had gone to the CNC, RN #74 at 0800 and again before new assigned trauma patient to voice his concerns with his high patient acuity assignment. Interview revealed RN #56 was caring for another patient, when the levophed IV infusion ran out, causing Patient #28’s blood pressure to drop, and a code was initiated. The interview revealed reassessment and monitoring of Patient #28 did not follow hospital policy. (request for all documents filed by RN #56 administration, ethics committee and HR were not made available during the survey). Interview on 11/16/2023 at 1128 with CNC, RN #74 revealed RN #56 approached her one time, and said, ‘I need help’. CNC RN #74 stated she got RN #56 help by calling on the trauma team nurses who support trauma patients in the ED, but were not assigned patients in the ED. Interview revealed “...If we need help, we pull resources...” Further interview with CNC RN #74 revealed “...she had no concerns with nursing reassessments in the ED... that nursing assignments in the Red Pod (where the most acute patients are assigned) were 1 RN to 4 patients...” The interview revealed CNC #74 added trauma team nurses to assist RN #56 and stated she and the CNC’s filled in themselves when needed to support patient care. Interview on 11/15/2023 at 1637 VPED #20 during tour of the ED revealed the Red Pod in the ED was assigned the most acute ED patients. The interview revealed nursing assignments were 1 nurse to 4 patients, and RNs are expected to communicate with the CNC’s any concerns or delays with patient care. “...starting in 2023 we have Webex huddles with nursing, providers, and other hospital departments every 2 hours to discuss delays in care and appoint resources where they are needed...” Interview revealed the expectation for reassessment and monitoring patients were for all staff to follow hospital policy. Interview revealed hospital policy for Patient #28 was not followed. Telephone interview on 12/01/2023 at 1209 with Director of the Trauma Team, MD #80 revealed he was aware of the case with Patient #28 and was the Medical Supervisor for PA #77 in 2022 and currently. Interview revealed “...when a Trauma Team member was in the ED it was to care for a specific consulted trauma patient, however a Trauma Team member if clearly evident could assist any patient in a life sustaining emergency...” The interview revealed PA #77 would not be allowed to touch an IV drip or alarming IV pump of a patient they were not consulted on. Interview revealed PA #77 notified a person who could adjust the drip for Patient #28. Further interview revealed he had no concerns with PA #77’s patient care, and the Trauma Team Supervisor, RN #81 had communicated with PA #77 “...we should always respond with compassion to family...” regarding this event. Interview revealed MD #80 had not followed up with PA #77, the Trauma Team Director had talked with PA #77. Interview revealed PA #77 did not know Patient #28’s blood pressure was low or the levophed had run out but had communicated to ED nursing staff who could attend the alarms when family asked him. Telephone interview on 12/01/2023 at 1241 with Trauma Team PA #77 revealed he had been employed for 8 years. Interview revealed “...I am only in the ED when called/consulted for a specific trauma patient. The family came to the desk, I told them I can get your nurse, and I did. The family was asking about an IV beeping. If I thought he was coding, I would have made sure he was OK. I did not have that information. I only learned about the IV levophed today. Of course, I would respond to help a patient coding. I would not ‘shirk’ a patient needing help...” Interview revealed PA #77 recalled the family asking for help with an IV alarm. He told the family he would find the nurse, and he did. Patient #28 presented to the ED on 07/05/2022, was critically ill, intubated and diagnosed with bacterial meningitis. The patient developed a low blood pressure and a Levophed IV drip was started. Findings revealed the Levophed IV drip was allowed to run dry and the patient’s blood pressure dropped to 33/18. A trauma PA was requested by the family for help related to alarms and the patient’s condition and the PA indicated the patient was not the PAs assigned patient. The patient arrested. A new Levophed bag was hung. The patient and IV were not monitored and the bag ran dry with subsequent cardiac arrest. 5. Closed medical record review on 11/14/2023 revealed Patient #27, a 66-year-old female who arrived at the emergency department (ED) on 07/04/2022 at 0025 by private vehicle with abdominal pain, nausea, and vomiting. Patient #27 was triaged at 0025 by RN #38 vital signs: temperature 97.2, respirations 20, heart rate 107, blood pressure 169/93, and oxygen saturation of 94 percent on room air, a pain score of 10 (1 least pain and 10 being the most pain) and was assigned an emergency severity index (ESI) of 3 (urgent). At 0028 Nurse Practitioner (NP) #39 wrote orders for Lipase (a digestive enzyme) STAT, CMP (comprehensive metabolic panel) STAT, Lactic Acid (carries oxygen from your blood to other parts of your body) STAT, CBC (complete blood count) STAT, Urinalysis (Urine test) STAT, and CT (cat scan) of the Abdomen/Pelvis STAT, an IV (intravenous) of Normal Saline to be started and Ondansetron (medication for nausea) 4 milligrams (mg) IV to be given. Record review did not reveal lab work, nursing reassessment, or physician orders for IV and medications were implemented for Patient #27 while in the ED waiting room (6 hours and 3 min). At 0631 Patient #27 was moved to Red Pod (for highest acuity patients) room 20. Patient #27 was seen by MD #26 at 0656 and orders were placed for ondansetron 4 mg, and Dilaudid (narcotic pain medication) 0.5 mg for pain. At 0734 lab work resulted (7 hours and 6 minutes after ordered). At 0739 Patient #27 had an IV started of NS (7 hours and 11 minutes after ordered), and medications for pain (7 hours and 14 minutes after identified pain level of 10, and 43 minutes after pain medication ordered) and nausea (7 hours and 11 minutes after original order) were administered by RN #40. At 0742 vital signs were documented as heart rate 85, respirations 16, blood pressure 174/89, oxygen saturation of 93 percent on room air (no temperature), with a pain score of 10/10 by RN #40. At 0755 the CT of Abdomen and Pelvis (6 hours) resulted (7 hours and 27 minutes after ordered) positive for a small bowel obstruction. Review of the ER Note Reevaluation (not timed) by MD #26 revealed Labs were reviewed without critical results, and the CT scan was consistent with a small bowel obstruction. Surgery was consulted for further evaluation and management by MD #26. At 0839 repeat pain assessment was 1/10 by RN 40. On 07/04/2022 at 1316 Hospitalist #41 saw the patient, set for admission. At 1319 Patient #27 had a pain score of 10/10, vital signs heart rate 83, respirations 17, blood pressure 147/96, oxygen saturation of 93 percent on room air, and was given Dilaudid 0.5mg IV for pain relief by RN #40. Review of the Surgical Consult Physician Note by MD #42 dated 07/04/2022 at 1543, Patient #27 was scheduled for a Laparoscopy, Possible Exploratory Laparotomy with Possible Bowel Resection. At 1620 a repeat pain assessment was completed for a pain score of 3/10. At 1600 Patient #27 left the ED for the operating room for surgery. Patient #27 completed surgery without complications and was discharged home on 07/06/2022 at 1136. Request for a Patient Safety Report (Incident Report) revealed there was not one available. Interview on 11/15/2023 at 1350 with ED RN #38 who triaged Patient #27 revealed “...in 2022 no patients were checked on in the ED waiting room, some changes were made, and there are some improvements. It’s very possible that this patient waited without any labs or orders completed. At that time there was one nurse in the waiting room to triage patients. There was no way to complete orders...” Interview revealed nursing reassessments and physician orders were not completed in the ED waiting room in 2022. Interview on 11/17/2023 at 1102 with NP #39 revealed “...the IPA (Internal Processing Area area in the ED waiting room) did not exist then. Now if patients need to move to the back, I tell the CNC (clinical nurse coordinator), we call and we call. I personally have been pulled to do patient reassessments when there was a change in condition. One hundred percent, patients are not safe, orders are not completed, and staffing is a concern. There is one nurse with a line out the door, I can put orders in, but it is not going to get done because of the volume of patients and minimal staff...” Interview revealed NP #39 had current concerns with waiting room patients not getting orders completed in the ED waiting room. Interview on 11/15/2023 at 1414 with ED MD #26 revealed “...I saw the patient after she was roomed.... There is not always a person to get labs and orders done. No staff to do orders. With the new process the goal is for that not to happen, but at night I suspect it does. As far as care in the waiting room, this patient didn’t get vital signs, or overall assessments and no meds...things are not happening on a timely basis...” Interview revealed Patient #27 did not get vital signs, assessments, or medications as prescribed. Interview revealed hospital policy was not followed for Patient #27. Patient #27 arrived in the ED on 07/04/2022 at 0025 with a reported pain level of 10 of 10. The patient had a STAT CT of the abdomen and pelvis ordered at 0027 that was not completed until 0755 (7 hours, 27 minutes later) resulted and signed at 0825. The patient had pain reported as 10 of 10, with nausea and vomiting with vital signs at arrival at 0025 and was medicated with Dilaudid (narcotic pain medication) at 0739 (7 hours and 14 minutes after arrival). The patient was diagnosed with a small bowel obstruction and had surgery that day. The patient had a delay with STAT lab work, STAT CT, nursing reassessment and pain management. 6. Closed medical record review on 11/14/2023 revealed Patient #29, a 78-year-old female who presented to the emergency department (ED) via emergency medical services (EMS) on 04/05/2022 at 1451 with complaint of falling at home with a laceration to the right lower extremity. The EMS report dated 04/05/2022 at 1342 revealed the patient had fallen from the toilet at home, was on oxygen 3 liters by nasal cannula “comments: baseline for patient”, had an Intravenous (IV) line in her left forearm #20 gauge and had received Normal Saline 700 milliliters. Review of an EMS narrative note revealed “she does have significant bleeding from her right lower leg...bleeding is controlled...the leg is splinted...”, was on a ECG (heart monitor) showing a heart rhythm of atrial fibrillation (irregular heart beat) with a pulse of 88. At 1503 a Physician’s Assistant (PA) #45 was assigned and a review of his ER Report Note at 1510 revealed “...High suspicion for open fracture to right anterior shin...”, with plans to order CT (cat scan) of the head and neck, pain medication, antibiotics, and lab work.” PA #45 ordered X-rays/CT at 1508. At 1514 Patient #29 was moved to Red Pod (for most acute patients) Hallway Bed 7. At 1517 Patient #29 was triaged by RN #43 “...subjective rapid assessment: fell in the bathroom at home. On Eliquis (blood thinning medication) and a pain score of 0. Open Tib Fib started earlier unseen...Pre-hospital treatments: oxygen, other: 3-liter O2. 20g Left arm...Acuity 5-non-urgent...”, an emergency severity index (ESI) was assigned of 5 (Non-Urgent). At 1536 lab work was ordered. At 1537 the CNC (clinical nurse coordinator), RN #44 documented a change in patient ESI to 3-urgent. 1559 lab work had resulted. At 1618 PA #45 ordered Hydromorphone (narcotic pain medication for severe pain) 0.5 mg IV push every 15 minutes duration 3 doses for pain for Patient #29 and Zofran 4mg IV for nausea. At 1630 (one hour and 39 minutes after arrival) vital signs were documented as pulse 88, blood pressure 161/79, oxygen saturation of 90 percent (no oxygen was documented), 1639 respirations of 22, and temperature of 98.4. By 1627 all radiology had resulted, and a review of the ER Report Reexamination/Reevaluation (not timed) by PA #45 revealed “...On my read it appears the patient has a rather significant tib-fib (tibia/fibula) fracture. I do believe this is an open fracture. She has already received Ancef (antibiotic), and I have already spoken to orthopedic surgery. They will come and speak with the patient...” At 1636 Ancef 1 gram IV, a Tetanus (infectious disease that can occur from an unclean wound) booster intramuscular, Hydromorphone 0.5mg IV for a pain score of 10/10 and Zofran 4mg IV were administered by RN #43(no evidence of an oxygen assessment). At 1736 a pain reassessment was charted as 9/10 (no evidence of an oxygen reassessment). At 1748 the Orthopedic Consult and History and Physical was completed by MD #52 with diagnosis of “Open tibial shaft fracture...” with plan for surgery to repair fracture. Review of the ER Report addendum by PA #45 (not timed) revealed “...Orthopedic surgery agrees this appears to be open fracture and recommends a room for splinting and simple reduction before surgery tomorrow am...” At 1816 Patient #29 was given Dilaudid 0.5mg IV for a pain score of 9/10 by RN #43 (no evidence of oxygen assessment). Review of the Patient Summary Report revealed Patient #29 was moved to room 11 at 1915. Review of an addendum to the ER Report by PA #45 (not timed) revealed “...As I was handing off the patient to ... I was told by nursing staff that the patient was unresponsive. Upon arrival at the bedside, the patient is unresponsive. She does have DNR (no evidence of this in the record). She is moved into room 11 where Dr. (MD #46), my attending physician was kind enough to evaluate the patient and call time of death...” Review of the ER Report 04/05/2022 at 1947 by MD #46 revealed “...78-year-old female past medical history of atrial fibrillation currently anticoagulated on Eliquis. She fell and had an open fracture of the tibia/fibula. Patient has been admitted to the orthopedic service. I was called to the patient’s bedside at 7 PM as nursing found her pulseless and apneic (no respiration). After 60 seconds, the patient has no cardiac activity, she is in asystole (no heart rhythm) on the monitor. Her pupils are fixed and dilated. No spontaneous respirations, no cardiac sounds and she is pulseless. Official time of death was called at 709 PM ...” Patient #29 was pronounced dead in the ED on 04/05/2022 at 1909. Review of the Patient Event Record dated 04/06/2022 at 0341 by Nursing/Surgical Services #54 revealed the event was “unexpected death” date of event “04/05/2022 at 1903” with narrative “...pt came to ER (emergency room) c/o (complaint) fall with fracture. pt placed in the hall bed. pt found unresponsive in hall...House Supervisor (RN #55) notified at 1905...”, the description of harm and action to prevent reoccurrence was documented as “monitor trends and patterns”. There was no witness to the event per the report. Trauma Nurse, RN #56 as unavailable for interview. Interview on 11/16/2023 at 1204 with ED RN #43 who cared for Patient #29 revealed “...I was checking on the patient, she was responding, her daughter was there. I was charting and could see her. She was full code, her daughter ran over to me and asked me what I was doing, as I was pulling the stretcher away from the wall and replied ‘CPR’ and the daughter said, ‘please don’t do that’. The trauma nurse that day, (named RN #56) took the patient to room 11. I reported it to my charge nurse (named RN #57), and I went to report off on my other patients because it was the end of the shift. I didn’t see her again...you’ll have to go by my charting, I don’t remember if she was on oxygen...” A further interview revealed “...I should have charted she expired, that was an error...” The interview revealed RN #43 did not recall if Patient #29 received oxygen in the ED, did not recall if an oxygen reassessment was completed and did not get vital signs or reassess a change in condition. Interview revealed hospital policy for reassessment was not followed for Patient #29. Telephone interview on 11/16/2023 at 1324 with MD #46 revealed she did not recall Patient #29. Interview revealed “...monitoring of patients in hallway beds are a concern. Ideally every patient in the Red Pod should be on some sort of a monitor with a pulse oximeter. More monitoring is always better...” Interview revealed when MD #46 arrived at the patient’s bedside she was in asystole, and she pronounced the patient with daughter at the bedside. Interview on 11/16/2023 at 1747 with CNC, RN #44 revealed “...I do remember she was in a hallway bed, and (named RN #43) said she had passed. I had checked on her. (Named RN #43) told me the daughter came to her and said, ‘somethings wrong with my mom’. I don’t remember if she had oxygen or was being monitored. I would expect the ED nurse to complete assessments and document them in the chart...Staffing was 4:1 in the Red Pod, If a nurse tells me I’m overwhelmed, I will ask another nurse to assist with patient care...” Interview revealed RN #44 did not know why oxygen reassessments or changes in conditions were not completed for Patient #29. Interview revealed hospital policy for reassessment for a change of condition was not followed for Patient #29. Interview on 11/28/2023 at 1433 with Assistant Director of Nursing, RN #15 to review the internal investigation following Patient #29’s death in the ED “...Per the ED Manager (not identified) the patient’s family called staff over to the patient because ‘she didn’t look good’. She was unresponsive and was taken to room 11 to be placed on a cardiac monitor which showed asystole. At 1909 was the time of death pronounced with her daughter at the bedside. Interview revealed this event was reviewed by the Mortality and Morbidity which was comprised of multiple providers and the MD who had completed the report dated 07/11/2022 the internal investigation of Patient #29’s death revealed the patient was under triaged, the door to antibiotics was greater than 1 hour, and needed closer monitoring. (note: this surveyor was not allowed to hold or view documents during this interview.) Patient #29 arrived on 04/05/2022 at 1451 via EMS and had atrial fibrillation (abnormal heart rhythm) on arrival. The patient had a recent fall with fracture prior to arrival. Pulse Oximetry was 94% prior to arrival. 1630 pulse oximetry was 90% (1 hour and 39 minutes after arrival) with no evidence of oxygen administration at hospital. Dilaudid 0.5 milligrams (mg) IV was administered at 1630 and at 1816. No vital sign or oxygen assessment on an elderly patient was assessed on the patient with a prior pulse oxygen of 90% after the administration of Dilaudid. The patient was subsequently asystole at 1909 and expired. Patient #29 had one set of vital signs from 1451 until time of death at 1909 (5 hours and 18 minutes). Nursing staff failed to reassess the patient after narcotic administration. Nursing staff failed to reassess the patient for a change in condition (not breathing). 33790 7. Medical Record review, on 12/14/2023, revealed Patient #6 arrived to Hospital B via EMS on 10/03/2023. Review of the Triage Note at 1723 revealed “ ...Reason for Visit: Pt (patient) at 2 started having left sided arm and leg muscle weakness and left sided diminished sensation on leg. Facial drooping noted in lower face. No blood thinners and 10 days post partum. What aspect of reason for visit is concerning to patient? : Stroke symptoms. ... “ Review of a MD “ER Report”, service date/time 10/03/2023 at 1714, revealed “ ... History of Present Illness 22-year-old female with a past medical history of vaginal delivery 10 days prior ....who presents to the emergency department with left-sided weakness. Patient states that she felt normal when she went to take a nap at approximately 2 (2:00), when she woke up at 330 (3:30) she noticed that she had weakness on the left side of her face and is developing weakness in the left side of her body. She notes that she was unable to smile fully. States that she has never had any symptoms like this in the past. She notes that last night she had an episode of epigastric pain, but that has gone away since fully. States that the developing left-sided weakness has been ongoing since that time and called EMS for evaluation. Pregnancy was uncomplicated ....Initial Vitals T: 98.9 F Oral HR: 65 RR: 20 BP: 170/97 SpO2: 87%.... Medical Decision Making ....22-year-old female presenting to the emergency department secondary to onset of neurologic deficit with last known normal of approximately 2:00 PM. On exam, I initially had concern for Bell’s palsy given her age and demographic info, but on my physical examination I noted appreciable weakness on the left side of the body with regards to motor function. I would not expect Bell’s palsy to cause the symptoms, in addition to this she was able to raise both eyebrows equally. Although there can be varying degrees of eyebrow raise or inability to thereof with Bell’s palsy, I would not expect the left-sided sensory subjective deficit and motor deficit as noted. Therefore I did initiate a code stroke procedure. This is also complicated by the fact the patient is 10 days postpartum which does place her at an elevated risk for ischemic CVA (stroke). Differential at this point would also include complex migraine, preeclampsia/eclampsia (serious pregnancy complication characterized by high blood pressure), or complex partial seizure, though she did not report any seizure-like activity .... Ultimately, the decision was made in concert with the stroke neurologist at (Hospital A) not to provide thrombolytics at this point in time .... However, patient will require transport to (Hospital A) for further close work-up and likely MRI (Magnetic Resonance Imaging- type of diagnostic testing). Ultimately my concern for eclampsia (serious pregnancy complication) is certainly present given her elevated blood pressure and abnormal neurologic exam. I did order 20 mg of IV labetalol (to treat BP) to be given as a stat dose in addition to 4 mg of magnesium as a bolus with a 2g/h (grams per hour) infusion thereafter. I did reach out to and speak with the OB/GYN on-call ....who agreed with this management plan and possible diagnosis of eclampsia given her blood pressure and symptoms. Patient was transferred to (Hospital A) emergently for further care. ... Diagnosis/ Disposition Postpartum eclampsia/stroke. ...” Review of the EMS (Emergency Medical Services) Patient Care Record, dated 10/03/2023, revealed EMS transported Patient #6 from Hospital B to Hospital A. The EMS record indicated they arrived to Hospital A at 1938. Review of the EMS Narrative note revealed “(EMS) on scene at (Hospital B) and was informed of a Red Transport (red is the most urgent transport) .... Arrived to find the pt (patient) in room 3, alert to EMS presence and in no obvious distress....report is as follows: ....Dx (Diagnosis): HTN (hypertension) crisis, Preeclampsia Stroke HPI (History/Physical): Came in with EMS for L (left) sided drooping and weakness and tingling onset....10 days postpartum....CT Head clear for bleed and clots ‘Preeclampsia Stroke’ Meds: Mag (Magnesium) 4 g (gram) Bolus with 2 gm/hr infusion, Labetalol 10 mg (milligrams) ....Vitals: 172/98 .... Pt states that she feels fine just feels super weak but denies any pain or N/V (Nausea/Vomiting). Due to the importance of medication, (EMS) waited for nurses to retrieve and start a magnesium (Mag) drip before departing. In the meantime, secondary IV access obtained by Paramedic (name) and pt is moved over to the stretcher, placed on all monitoring ....Pt was placed on capnography (carbon dioxide monitoring) noting elevated rate and borderline hypocapnia (decrease in carbon dioxide levels below normal) with normal appearing waveform ....Once all paperwork is obtained and Mag is started pt is moved out to the truck and transport is initiated to (Hospital A) Emergency. Enroute pt is monitored with no new complaints....While waiting on a bed at (Hospital A) pt was monitored with minimal changes to her BP. Repeat neuro checks were completed periodically....Pt began to complain of a mild headache and posterior neck pain similar to how she felt before she delivered. Pt report and care given to RN (Name) bedside ....Arrived: 19:40 .... Transferred Care 22:24 (2 hours 44 minutes after EMS arrived to the hospital). Review of the EMS Record revealed EMS staff continued to monitor the patient, including ongoing vital signs. An EKG was performed at 2016. An EMS assessment was completed at 2121 which indicated slight yellowing of the skin, right upper quadrant tenderness and left arm and leg weakness along with a facial droop and neck pain. Vital signs continued approximately every 5 minutes, with the last recorded blood pressure 147/90 at 2215. Emergency Department record review revealed Patient #6 arrived to Hospital A on 10/03/2023 at 1942. An “ED Triage” performed on 10/03/2023 at 2227 (2 hours 45 minutes after arrival) revealed “...Subjective Rapid Assessment Stated Reason for Visit : Brought by EMs (sic) team from (Hospital B) due to stroke like symptoms, left facial droop and left sided weakness, last known normal was 1400H (hours) and onset of symptoms at 1530H ....ED Full Triage Arrival Mode - ED (Emergent) : EMS ....Pre-Hospital Treatments : IV Access, Other: Magnesium sulfate at 2g/hr ....Arrived From: Hospital. ...” Review of vital signs revealed a heart rate of 82, respiratory rate of 18, BP of 168/96, oxygen saturation of 93% on room air and a pain score of 4. Record review revealed an “ED Medical Screen Exam Form.... Entered on 10/03/23 22:23 EDT” which noted “...MSE Comments : tx (Transfer) from (Hospital B) for MRI brain, concern for ecclampsia. Appears admit bed is already ordered.” Review of the “ER Report”, service date/time, 10/03/2023 at 2310, revealed “...Patient presents as a transfer from outside hospital for concern of strokelike symptoms. She presented to (Hospital B) today with left facial droop that she noticed when she woke up from her nap around 3:30 PM. Her last known well was around 2 PM. At (Hospital B), she was noted to have left facial droop as well as some left arm and leg weakness. Stroke consult was called and the patient was seen in concert with telemetry neurologist decision was made against using tPA (breaks down blood clots). She was transferred here for further stroke eval and MRI (magnetic resonance imaging). She was also notably hypertensive at outside hospital with blood pressure 160s systolic. She has also had some headaches recently, did have a headache at the time of her delivery. She denies any chest pain or shortness of breath currently.... Physical Exam ....Initial Vitals HR: 82 RR: 19 BP: 168/96 SpO2: 93% ....Neurological: Alert and oriented to person, place, time. Patient does have left facial droop with left eyebrow droop as well. Has very mild drift on the left as compared to right. Has difficulty lifting left leg up against gravity .... Medical Decision Making ....Differential Diagnosis.... Stroke, eclampsia less likely given no seizures, preeclampsia, Bell’s palsy although this is less likely given her symptoms in the left arm and leg ....Treatment and Disposition .... Patient presents the emergency department with left sided weakness and left facial droop. Chart reviewed from outside hospital as she is a transfer from (Hospital B). Discussed with neurologist who will admit to their service. MRI and MRV (magnetic resonance venography-imaging that focuses on the veins) have been ordered. Patient continues to have left facial droop on exam, does seem to have eyebrow sparing as she is able to lift her left eyebrow. She also does have some very mild pronator drift on the left side as compared to the right as well as difficulty lifting up her left leg .... Concern remains for stroke. MRI has been ordered and MRV as well as ordered by neurology. I did discuss the case with OB given her hypertension here. I have ordered the magnesium infusion at 2 g/h as well as a 10 mg dose of IV labetalol given her systolic of 168 here. Patient admitted to neurology .... Diagnosis/Disposition Left-sided facial droop Preeclampsia. ...” Record review failed to reveal acceptance and monitoring of Patient #6 by nursing until triage at 2227 (~2 hours 45 minutes after arrival). Record review did not reveal documentation of a physician evaluation until 2310. Record review revealed the only documented evaluation and monitoring of Patient #6 during the time period from arrival to triage was from EMS staff. Patient #6 was moved from the initial ED room to a holding unit and later to a maternal fetal medicine unit. The patient was discharged home on 10/06/2023. Telephone interview with EMS #63, on 11/14/2023 at 1430, revealed the EMS team was at Hospital B dropping off another patient and were notified of a “red” transfer of a patient who was 10 days postpartum with a hypertensive crisis and preeclampsia or stroke. Interview revealed they were notified that Neurology wanted the patient transferred emergently. Medications were started and the patient immediately transferred. Patient #6, per interview, was still having symptoms and waited at Hospital A for a “2 hour 46 minute wait time on the wall” (location where EMS waits in the ED with patients who are awaiting an available bed). Interview revealed EMS continued to monitor the patient closely as Patient #6 had right upper quadrant pain and was on a Mag Drip. Interview revealed that EMS waiting and patients holding for a bed had been an ongoing issue for 3 ½ years and seemed to be getting worse. Interview revealed the EMS staff member did not feel the patient’s care was met in the ED as Patient #6 required neuro checks, vital signs and close monitoring. Interview with RN #64 during observation on 11/13/2023 around 1030 revealed that when EMS arrives with patients and there are no beds available then EMS stays “on the wall” with the patient until a bed is available. They do not hand-off the patient until patients get to an assigned bed. Physicians may see patients on the wall, but “EMS can only hand-off to a RN.” Follow-up telephone interview on 11/15/2023 at 1430 revealed that in relation to patients arriving with EMS, ED nurses do not “triage patients until ...taking ownership of the patient. Interview revealed that if the CNC in the EMS arrival area was to triage the patient, then the RN was “taking ownership of the patient.” The RN stated they could not do that as CNC and still meet all the expectations of the role. Interview revealed that in this ED, “EMS is still responsible.” Telephone interview on 11/15/2023 at 1410 with DO #65 revealed the DO went to assess Patient #6 when she was in a bed in the ED. Interview revealed the DO signed up for Patient #6 as soon as her name popped up on the ED tracking board. Before that time, the DO was not aware the patient was in the department. Interview revealed that technically the patient was already admitted, having been accepted by neurology, but was an ED to ED transfer. ED physicians still did a full medical screening on transferred patients, the DO stated. Interview revealed Patient #6 was on a Mag infusion and was hypertensive. Interview revealed DO #65 called the accepting Neurologist and also called an Obstetric Resident since the patient was postpartum and hypertensive and there were concerns for preeclampsia. Telephone interview with Patient #6’s Triage Nurse, RN #66, on 11/17/2023 at 0932, revealed the nurse did not recall Patient #6 or the situation. Interview revealed the EMS team was responsible for any patient they brought in until the patient got a room assignment and was moved to a room in the ED. Once the patient was in a room, the ED RN triaged the patient and there was a proper hand-off between EMS and the RN. Telephone interview on 11/17/2023 at 1205 with Medical Doctor (MD) #67, the accepting neurologist for Patient #6, revealed they were concerned enough to transfer the patient to Hospital A even though they decided not give thrombolytics. Interview revealed obstetrics was called since the patient recently delivered and Mag was given more often by obstetrics. Interview revealed the time until the patient was triaged was “a long time.” Interview revealed the patient should have received frequent vital signs by staff. The MD stated they often do ED to ED transfers. Interview revealed MD #67 thought he saw the patient when she was in an ED room and that the accepting physicians would not know a patient had arrived to the ED until a call was received from the ED that the patient was there. Interview revealed if they had a room the patient would have gone to Neuro. Ultimately, the MD stated, it was determined Patient #6 was hypertensive related to pregnancy and it was better for her to be admitted to obstetrics. Patient #6 arrived to Hospital B with strokelike symptoms at 10 days postpartum. She was accepted for transfer to Hospital A as an ED to ED transfer. Patient #6 arrived to the hospital via EMS on 10/03/2023 at 1942. The patient waited in the ED for a bed and continued to be managed by EMS. No documentation was noted by a medical provider until 2223 and Patient #6 was not triaged or assessed by hospital nursing staff until 2227 (approximately 2 hours 45 minutes after arrival by EMS). There was a delay in accepting the patient and a delay in triage, assessment and monitoring by nursing staff. 8. Hospital B Medical Record review on 12/16/2023 revealed Patient #1, a 64-year-old, arrived to Hospital B on 10/31/2023 at 2203. Review of the ED Triage, at 2203, revealed “ ...Subjective Rapid Assessment Stated Reason for Visit : 2130 onset slurred and right sided weakness with facial droop; no thinners (blood thinning medications) ....CODE STROKE. ED Full Triage ....Acuity : 1 (highest acuity). ...” Review of the “ER Report” by a physician, at 2212, revealed “ ...History of Present Illness This patient is a 64-year-old woman....here with neurologic symptoms. Independent history is obtained from the patient’s husband, who is here with her. He said that at approximately 9:30 PM, she called out to him that something was wrong. He looked over and saw that she was having difficulty walking and seemed to be slumping to the side. Her speech was noted to be slurred.... She is weak on the right side. Physical Exam ....Initial Vitals .... BP: 204/100....VITAL SIGNS: Triage vital signs are reviewed and show elevated blood pressure approximately 204/100, otherwise normal. GENERAL: Patient is well-developed, well-nourished, and clearly with facial asymmetry and slurred speech .... NEURO: The patient has paralysis of the right lower face.... She has moderate dysarthria (slurred speech).... Level of consciousness seems normal. She does have drift of the right arm without hitting bed ....Medical Decision Making This patient presents with neurologic symptoms concerning for acute ischemic stroke ....I think she will likely be a candidate for thrombolytics assuming that we can get her blood pressure down. She is going to CAT (computerized axial tomography - type of diagnostic imaging) scan right now. We are giving labetalol IV (medication for blood pressure given intravenously). [space] 10/31/23 23:00:55.... I reviewed CT scan .... Showing left basal ganglia hemorrhage (hemorrhagic [bleed] stroke in a part of the brain] ....I did discuss the patient with the neurologist, who accepts the patient in transfer for treatment of acute atraumatic hemorrhage. The patient did receive a dose of labetalol, and her blood pressure dropped below 160 briefly but then went back up over 170, so nicardipine infusion was started. Diagnosis/Disposition Acute atraumatic intraparenchymal hemorrhage (bleeding into the brain) [space] Acute hypertensive emergency (acute marked elevation in BP associated with signs of damage) [space] Right-sided weakness. ...” Review of the Transfer Form revealed Patient #1 was accepted for transfer at 2225. Review of the Physician’s Certification for Medical Transport form revealed “ ...Medical Condition at the Time of Transport : Patient requires neurological, cardiac, and hemodynamic monitoring and a nicardipine drip by a medical attendant throughout transport. ...” Review revealed Patient #1 was transferred out at 2233 as a “Red” priority. Review of the EMS Patient Care Record revealed EMS transferred Patient #1 as an emergency “red” transfer. Review of the “Narrative” documentation revealed “(EMS) WAS ISSUED A RED TRANSPORT TO (Hospital A). ....THE PT WAS BEING TRANSPORTED TO (Hospital A) DUE TO INTRACRANIAL HEMORRHAGE. THE PT WAS PLACED ON THE CARDIAC MONITOR, 12 LEAD ESTABLISHED ....THE PHYSICIAN ADVISED TARGET BLOOD PRESSURE IS 140/90 AND ADVISED TO MONITOR BLOOD PRESSURE DURING TRANSPORT. NICARDIPINE WAS ADMINISTERED AND MAINTAINED THROUGHOUT ROUTE .... EMERGENCY TRAFFIC. THE PT WAS REASSESSED EVERY 5 MINUTES DURING TRANSPORT.... PT REMAINED ALERT, ORIENTED, SLURRED SPEECH WAS NOTED. PT CARE .... UPON ARRIVAL, THE PT WAS REGISTERED, AND EMS WAITED ON ROOM ASSIGNMENTS. VITAL SIGNS WERE CONTINUOUSLY MONITORED. A PHYSICIAN STATED, ‘WHAT DO YOU HAVE?’. THE PHYSICAN (sic) WAS ADVISED RED TRANSPORT FROM (Hospital B) ER TO (Hospital A) WITH AN INTRACRANIAL HEMORRHAGE. THE PHYSICIAN ASKED FOR PAPERWORK AND THEN STATED ‘NEVER MIND.’ THE PT REMAINED STABLE WITH ONLY COMPLIANT (sic) OF A HEADACHE. THE NEUROLOGIST (Name of accepting physician) ADVISED THE PT WOULD MOVE TO THE ICU ONCE A BED WAS AVAILABLE. THE PT REMAINED IN THE HALLWAY AND WAS CONTINUOUSLY MONITORED AND ASSESSED. (EMS) WAS ADVISED THE PT WOULD BE TRANSFERRED TO THE NEUROLOGY ICU. PT CARE REPORT WAS GIVEN TO THE ATTENDING NURSE .... PT CARE WAS TRANSFERRED...” Review revealed the EMS unit arrived to Hospital A at 2312 and Patient #1’s care was handed-off to hospital staff at 0106 (1 hour 54 minutes after arrival to the hospital). Review revealed EMS completed vital signs every 5 minutes to 10 minutes throughout the wait time for a bed and hand-off to the hospital. Review of the Hospital A medical record for Patient #1 revealed the patient arrived as a transfer via EMS at 2314. Review of the “ED Report” by an ED physician, at 2351, revealed “ ... 64-year-old female who presents as a transfer due to intracranial hemorrhage. Was taken to an outside hospital due to concern unilateral (one-sided) weakness and speech difficulty at roughly 2130. At that time had a head CT which showed an intracranial bleed and thus the patient was transferred here. At the outside hospital she was noted to have fairly profound hypertension was given IV Lopressor (treats elevated BP). Plan is for neurology admission however they would like angiography of the head and neck prior to getting a bed. Nicardipine was also initiated for blood pressure management ....Physical Exam .... Initial Vitals No Data Available ...Neuro: Right-sided facial droop with loss of nasolabial fold as well as dysarthria noted. Weakness of the right arm over relatively normal left arm and lower extremities. Medical Decision Making ....Patient presents as a transfer due to intracranial hemorrhage. Working with nursing staff in order to have this patient placed in a room. Neurology is already consulted on this patient, will follow-up with their requested CT angiography. We will also needs (sic) very close blood pressure monitoring. ...” Review also revealed a Neurology “History and Physical”, service date/time 10/31/2023 2347, which indicated “ ...Impression and Plan: ....#ICH (Intracranial Hemorrhage): hypertensive etiology suspected ....#HTN (hypertension) urgency: no prior hx (history) of HTN, treat >160/90 with goal towards normotension. #dysarthria, right hemiparesis (weakness or partial paralysis on one side of the body). Plan: admit to ICU for close neurologic monitoring. ...” Review of the ED record failed to reveal any vital signs or assessments by nursing. Review revealed “Nurse Notes” on 11/01/2023 at 0051 that stated “RN gave heads up to NSICU (Neurosurgery ICU) by (Name), RN. ED CNC (Clinical Nurse Coordinator) aware that (Name), RN is not assuming care of patient and only transporting PT (patient) upstairs. Pt has been with EMS in hallway for approx. (approximately) 2 hours and now has bed assignment upstairs. RN only transporting from EMS to NSICU.” Record review failed to reveal an ED RN ever accepted, triaged, assessed or did vital signs on Patient #1 while the patient was in the Emergency Department. The first documented vital signs were at 0110, once Patient #1 arrived to NSICU. The patient’s blood pressure at 0110 was documented as 162/85. Telephone interview with EMS #73 on 11/30/2023 at 1415 revealed the paramedic was involved in the transfer of Patient #1. Interview revealed it was a “red” transfer. Interview revealed on arrival to the hospital they gave the paperwork to hospital staff and then “sat on the wall.” The neurologist came to evaluate the patient and said she would move as soon as a bed was available. EMS, interview revealed, continue to monitor Patient #1. The patient was on IV medications for blood pressure and EMS staff had to “fluctuate the meds to keep the blood pressure where it needed to be.” Interview revealed no nurse evaluated Patient #1 while she was in the ED. Interview with MD #69 the accepting neurologist, revealed it was not uncommon to do ED to ED transfers, that it was good to have them in the ED for emergent evaluation when there was a concern for a patient’s stability on arrival. Interview revealed MD # 69 came to see patients in the ED as soon as they were notified of the patient’s arrival. Interview revealed it was “surprising” not to have vital signs completed in the ED and stated it did not meet expectations for care - patients needed hourly neuro checks and vital signs with provider updates on changes. Interview with RN #64 during observation 11/13/2023 around 1030 revealed that when EMS arrives with patients and there are no beds available then EMS stays “on the wall” with the patient until a bed is available. They do not hand-off the patient until patients get to an assigned bed. Physicians may see patients on the wall, but “EMS can only hand-off to a RN.” Follow-up telephone interview on 11/15/2023 at 1430 revealed that in relation to patients arriving with EMS, ED nurses do not “triage patients until ...taking ownership of the patient. Interview revealed that if the CNC in the EMS arrival area was to triage the patient, then the RN was “taking ownership of the patient.” The RN stated they could not do that as CNC and still meet all the expectations of the role. Interview revealed that in this ED, “EMS is still responsible.” Telephone interview with RN #66, on 11/17/2023 at 0932, revealed the EMS team was responsible for any patients they brought in until a room was assigned and the patient moved to a room in the ED. Once the patient was in a room, the ED RN triaged the patient and there was a proper hand-off between EMS and the RN. Patient #1 arrived as a transfer on 10/31/2023 at 2314 by EMS. No triage, nursing assessment or evaluation was completed in the ED. The patient was transported to the NSICU (Neurosciences Intensive Care Unit) on 11/01/2023 at 0105. A nursing note was written that stated the nurse was only transporting the patient to the inpatient unit and had not assumed care of the patient. The first nursing vitals or assessment were done at 0110 in NSICU. EMS monitored Patient #1 in the ED and nursing failed to accept, triage and provide care to a patient in the ED. 9. Review of the EMS Patient Care Record, on 11/14/2023, revealed EMS was called to Patient #2’s home on 10/17/2023. The EMS record revealed the call came in at 1654, EMS reached the patient at 1702, departed the scene at 1720 and reached the Hospital at 1748. The Patient Care Record noted the patient’s medical history was “Cirrhosis of Liver, Diabetes, Infectious disease, Neuropathy, Other-Infection of foot - amputation schedule for 10/21.” Review of the Narrative Note revealed “(EMS) DISPATCHED EMERGENCY TRAFFIC TO LISTED ADDRESS REFERENCE SYNCOPAL EPISODE WITH CHEST PAIN AND SHORTNESS OF BREATH ...ARRIVED ON SCENT TO FIND A 66-YEAR-OLD MALE, A&Ox4, SKIN PALE, WARM, AND DRY, SITTING UPRIGHT IN A RECLINER IN THE LIVING ROOM. PT ADVISED HE HAD BEEN HAVING CHEST PAIN AND SHORTNESS OF BREATH FOR THE LAST WEEK ....ADMINISTERED ASPIRIN ...PT ADVISED THAT HE AND HIS FRIEND HAD BEEN WORKING AROUND THE HOUSE AND ALL OF A SUDDEN HE DID NOT FEEL GOOD AND PASSED OUT. PT’S FRIEND ADVISED PT DID NOT FALL, ‘I CAUGHT HIM ON THE WAY DOWN.’ .... PT ADVISED HE RECENTLY HAD SURGERY ON HIS FOOT AND IT HAD GOT AN INFECTION AND WAS TAKING ANTIBIOTICS FOR SAME. PT ADVISED HE WAS GOING TO NEED ANOTHER SURGERY TO REMOVE THE BIG TOE OF HIS LEFT FOOT. IT WAS NOW NOTED THAT PT’S EKG WAS SHOWING ....ALSO SHORT RUNS OF A WIDE COMPLEX TACHYCARDIA. PT REMAINED COMPLETELY A&Ox4 ....PT WAS PLACED ON SUPPLEMENTAL OXYGEN WITH NOTED IMPROVEMENT IN BREATHING, ACCORDING TO THE PT. PT WAS TRANSPORTED ROUTINE TRAFFIC TO (Hospital) ....WHILE ENROUTE PT’S VITALS WERE CONTINUALLY ASSESSED ...IV ACCESS WAS OBTAINED ...PT WAS FOUND TO HYPERGLYCEMIC (high blood sugar). PT ADVISED HE HAD NOT BEEN ABLE TO TAKE HIS INSULIN YET TODAY ....PT WAS ADMINISTERED FLUID AS RECORDED ....PT ADVISED HIS CHEST PAIN WAS A 6/10 AND THAT TAKING A DEEP BREATH HURT. PT ADVISED THIS HAS BEEN GOING ON ALL WEEK AND HAS NOT CHANGED. (Hospital) WAS CONTACTED FOR PT NOTIFICATION. UPON ARRIVAL AT (Hospital) PT WAS TAKEN TO ER ROOM, WHERE (EMS) WAITED FOR ER PERSONNEL TO COME FOR THE HANDOFF REPORT WHILE BEING CONTINUALLY MONITORED. A FACILITY RN FINALLY ARRIVED AND A FULL REPORT WAS GIVEN AND PT CARE WAS TRANSFERRED TO THE RECEIVING RN. ...” EMS record review revealed the team arrived to the hospital with Patient #2 at 1748 and care was transferred to hospital staff at 1907 (1 hour, 19 minutes after arrival). Review revealed EMS staff continued monitoring Patient #2 after arrival with vital signs generally taken every 5-6 minutes. The last recorded EMS vital signs were at 1858 with BP noted as 104/61, pulse 70, respirations 15, 99% pulse ox and a pain score of 6. A note was made on “Turn Around Delays” that indicated “ED Overcrowding/ Transfer of Care. ...” Review of the medical record, on 11/14/2023, revealed Patient #2 arrived to the hospital on 10/17/2023 at 1753 via EMS. Review of “ED Triage”, performed 10/17/2023, at 1900 (1 hour and 7 minutes after arrival) revealed a pre-hospital blood glucose of 459 and an acuity of “3-urgent”. Vital signs were: Temperature 97.9, Pulse 72, Respirations 20, blood pressure 106/69 and oxygen saturation of 100% on 4 liters oxygen. Patient #2’s pain score was 7. Review of the “ER Report” by a Physician Assistant, on 10/17/2023 at 1845, revealed “ ... 66-year-old male patient .... presents.... (to the) emergency department today via EMS for chief complaint of chest pain and shortness of breath. Patient reports that he has had chest pain and shortness of breath ongoing over the past week and reports that these symptoms are aggravated with exertion. He also reports aggravation to shortness of breath with lying supine and he states that today he had acute worsening to his symptoms and also had a syncopal episode earlier today. He reports pain and shortness of breath are still present. He states that he also has bilateral lower extremity swelling which has been ongoing over the past couple of weeks ....He states that he has ulcer to the first metatarsal of his left foot and this extends to his bone. He states that he has planned to have amputation of the first digit of his left foot this coming Friday patient currently taking ciprofloxacin (antibiotic , Diflucan (antifungal), and Duricef (antibiotic). ....Medical Decision Making ... EMS reports that they gave patient 324 mg aspirin ....blood pressure was approximately 96 mmHg. They gave one L (liter) of normal saline IV blood pressure is 105/66 now. EMS also reports that patient had 7 beat run of V tach on their EKG tracing in route with patient now in sinus rhythm and occasional bigeminy. Ordered EKG and for patient to be on telemetry ....Point-of-care CBG (blood sugar), CMP (comprehensive metabolic panel), CBC (complete blood count), troponin, proBNP, D-dimer, lactic acid, and portable 1 view chest x-ray ordered. EKG obtained and notes sinus rhythm with PVCs and 4 beat run of V tach ....1953 Dr. (Name) called to patients bedside for cardiac arrest and assumed care of patient. CPR initiated ....2017 ....Called lab to request results of chemistries be available as soon as possible. Labs resulted after arrest ....Resuscitation attempt failed. Patient deceased. Suspect etiology to cardiac arrest related to MI (Myocardial infarction- heart attack). Review revealed a Stat order for an EKG at 1841. Review did not reveal an EKG was completed until 1905 (24 minutes after ordered and 1 hour and 12 minutes after arrival). Review of lab orders revealed the following lab tests were ordered in the ED stat at 1841 (48 minutes after Patient #2 arrived): Lactic Acid, CMP (comprehensive metabolic panel), Troponin, D-Dimer, Pro B-Type Natriuretic Peptide (ProBNP) and CBC with Differential. Review of orders revealed the labs were collected as Nurse collects at 1920 (39 minutes after the lab orders). Patient #2 experienced cardiac arrest at 1953, 2 hours after arrival. The CBC resulted at 2002 and the CMP resulted at 2012. The D-Dimer resulted as 824 (high) at 2006. The Pro BNP resulted as 9690 (High - reference range 5-125) at 2023 and the Troponin resulted as 0.460 (High - reference range 0.000-0.034) at 2039 (1 hour 19 minutes after the lab was collected; 1 hour, 58 minutes after it was ordered). The physician was notified. Review revealed the physician was notified 2 hours, 46 minutes after Patient #2 arrived to the ED and 15 minutes after the patient expired). Review revealed delays in ordering, collecting and resulting the labs and a delay in obtaining an EKG. Review of the “ER Report”, service date/time 10/17/2023 at 2030, revealed “ ...The patient was initially evaluated by the emergency department physician assistant .... Work-up for chest pain and syncope were underway. I was called to the patient’s bedside at 1953 for cardiac arrest. Staff reports that only moments before the patient had been alert and talking. CPR (cardia pulmonary resuscitation) was initiated. The patient was placed on a monitor and defibrillator. Initial rhythm revealed ventricular tachycardia (fast heart rhythm). He received electrical therapy and CPR was resumed. Patient received high-quality chest compressions. He would briefly show signs consciousness indicating adequate cerebral perfusion (blood to the brain) with chest compressions, but remained without an organized rhythm ....required continuation of CPR. He received multiple doses of electrical therapy ....He received magnesium as well as amiodarone (medication for irregular heart rhythm) for shock refractory ventricular tachycardia. Ventricular tachycardia progressed to ventricular fibrillation (life threatening arrhythmia). He also received multiple doses of epinephrine (emergency medication) per ACLS (advanced cardiac life support) protocol for pulseless arrest. He was intubated ....I called the physician assistant to the bedside to brief me on the details of the initial presentation. During the resuscitation I took the opportunity to review the available work-up. The EKG was brought to me for review at 2002 ....For this patient who presented with chest pain, syncope, and suffered cardiac arrest has either suffered an MI or rhythm disturbance ....I reviewed his medications ....I made attempts to address ....reversible causes of cardiac arrest. As resuscitation proceeded the rhythm progressed ....to asystole ....After 30 minutes of resuscitation he remained in asystole. All team members agreed that further resuscitative efforts were futile ....the patient was pronounced dead at 8:24 PM ....10/17/23 20:38:56 I received a (sic) from the chemistry lab. Troponin is 0.46 ....Diagnosis/Disposition Chest pain Syncope Ventricular tachycardia Cardiopulmonary arrest...” Telephone interview on 11/20/2023 at 1415 with EMS #70 revealed they responded to a call for a patient with chest pain and shortness of breath. Interview revealed on EKG the heart was very irritated, throwing PVCs (arrhythmias), PACs (arrhythmias) and then short runs of wide complex tachycardia (rapid heart rate). Interview revealed there was potential for things to turn unstable quickly. By the time they got to the hospital there were just a few PVCs. EMS #70 stated they arrived to the hospital at 1750 and were assigned a room at 1756 but they got to the room and there was a patient in the room which caused the wait. EMS #70 stated at some point the patient started to get hypotensive and the fluids had emptied, so the other EMS staff gathered another bag of fluids. Patient #2, per EMS, was on supplemental oxygen and had no complaints at the time. Interview revealed they got the patient into an ED bed at 1845 but there was no nurse for report. At 1907 (1 hours, 17 minutes after arrival), per interview, EMS was able to give hand-off report to a nurse. Interview revealed waits had gotten more common recently and it seemed like a staffing issue. Telephone interview with PA #71, on 11/15/2023 at 1600, revealed the patient came into the ED with EMS and there were no rooms available. PA #71 stated he saw the patient while in the hallway and placed orders. Interview revealed the patient had not been triaged, he was still in the hall. Interview revealed prior to arrival the patient had “a few runs, approximately 8 beats”, of V tach. PA #71 stated the patient was given a liter of fluids and the rhythm improved. Patient #2 remained on the EMS monitor prior to getting a formal EKG in the ED, the PA stated. Interview revealed there were another 4 beats of V tach but it was not sustained; the patient appeared stable. PA #71 moved to another patient and did not see Patient #2 after he got in an ED room until the PA heard the code and responded. Interview revealed these patients should be closely monitored. Interview revealed the goal for the screening evaluation was 20 minutes from arrival. Telephone interview with RN #66, on 11/16/2023 at 0938, revealed the nurse assigned to Patient #2’s room was busy and not able to triage the patient, so a radio request for help was made and RN #66 responded, did the hand-off with EMS and triaged Patient #2. The patient had been placed on a monitor by the Certified Nursing Assistant (CNA). RN #66 then received report from EMS. Interview revealed there was no bed available when Patient #2 first arrived by EMS. When RN #66 went to triage the patient, Patient #2 had just been put in a room and was stable, alert and talking. RN #66 stated that after Patient #2 was triaged, RN #66 drew blood for labs; labs were not drawn until after the patient was accepted and in a room. Until the patients were in a room and care handed-off from EMS, interview revealed, they were “counting on EMS to care for (the patients)...” Telephone interview on 11/16/2023 at 1100 with MD #72 revealed he heard the overhead page for Patient #2 and immediately responded. Interview revealed the expectation for chest pain patients was an EKG within 10 minutes and to be seen by a provider within 10 minutes. Interview revealed there is a chest pain protocol but the protocol had to be activated by a provider. MD #72 acknowledged there was a delay for Patient #2. Interview revealed in an ideal situation the patient would have gone straight back to a room and care started. Patient #2 was brought to the ED by EMS from home. The patient arrived on 10/17/2023 at 1753 with chest pain and a syncopal episode at home. The provider ordered labs at 1841 (48 minutes after Patient #2 arrived), and the labs were not collected by nursing staff until 1920 (39 minutes after orders), after the patient was triaged at 1900 (1 hour and 7 minutes after arrival). The patient was on a cardiac monitor and received vital signs by EMS until triage at 1900. No hospital EKG was completed until 1905 (24 minutes after order and 1 hour 12 minutes after arrival). The elevated D-Dimer did not result until 2006, the elevated Pro BNP did not result until 2023 and the elevated Troponin did not result until 2039. At 1953 a physician responded to the patient’s bedside due to a cardiac arrest. CPR was started and the patient expired. Nursing staff failed to accept the patient upon arrival to the ED, resulting in delayed triage, care and treatment. 47421 10. Closed medical record review of Patient #12 revealed a 41 year old female transferred to the ED (emergency department) on 07/18/2023 at 1623 via EMS (emergency medical service) for abdominal pain, nausea, chills, and evaluation by general surgery for concerns of appendicitis. No past medical history. Review of EMS run report revealed vital signs were taken at 1526 and 1555 via EMS. Review of ED record revealed a Medical Screening Examination (MSE) was performed at 1653. Further review of MSE revealed the CT (computed tomography) was consistent with appendicitis and general surgery consult placed at 1652. Review of physician orders revealed an order for q4h (every 4 hours) vital signs at 1729. An order for Dilaudid 0.25mg (milligram) Inj. Q3h, PRN (as needed), pain (refractory) at 1729. An order for Dilaudid 0.5mg Inj. Q15min, PRN, pain, at 1734. Review of ED record revealed the patient was assigned to RPOD-Hall 18 at 1756. Review of ED record revealed a pain assessment of 10 at 1759. Review of MAR (medication administration record) revealed the patient was given Zofran 4mg at 1757 and Dilaudid 0.5mg at 1759. Review of the General Surgery History and Physical at 1820 revealed a plan to proceed with laparoscopic appendectomy. Pain control and antiemetics as needed. Review of ED record revealed the patient was transferred to preop at 1830. Review of ED record revealed triage time at 1832 and vital signs documented at 1832 (2 hours and 9 minutes after the patient’s arrival). Interview on 11/14/2023 at 1153 with RN #91 revealed when patients are “on the wall” they are waiting to be assigned an RN (registered nurse) and put in a room. EMS stays with the patient in case they need any medical attention. Interview revealed it is typically not a long wait but can be up to an hour. Interview revealed patients can be seen by providers and prescribed medications while “on the wall” but can not get them because no RN has been assigned. 49480 11. Review on 11/16/2023 of “Nursing Management of Wounds and Alterations of Skin” policy revised 11/2021 revealed, “POLICY: Patients are assessed on admission and once every 12-hour shift for alterations in skin integrity and/or wounds. SCOPE:...Inpatient, acute care services, critical access hospitals, and other related services. Emergency Department (ED)...DOCUMENTATION: Document wound details: type, bed color, odor, drainage (color and amount), undermining/tunneling, induration, and erythema. Document intervention”. Review on 11/16/2023 of the “Assessment and Reassessment” policy revised 06/2021 revealed: “...PURPOSE: A. The goal of the assessment/reassessment is to provide the patient the best care and treatment possible...The nursing process is utilized in order to achieve this goal. This process includes assessing, analyzing, planning, implementing, and evaluating patient care or treatment...”. Closed medical record review on 11/14/23 of Patient #26 revealed a 22-year-old patient that presented to the Emergency Department (ED) via EMS (Emergency Management Services) on 09/01/2022 at 1845 for complaints of abdominal pain, decreased appetite, watery non-bloody diarrhea, and right-calf burn. Review of an ED Note dated 09/01/2022 at 2130 per medical provider indicated: “Assessment/Plan...Burn. I ordered bacitracin and instructed the nurse to apply a Xeroform dressing”. Review of Patient #26’s closed medical record lacked documentation that an ED nurse assessed and applied bacitracin and a Xeroform dressing to the patient’s right-calf burn. Review revealed the patient was transferred to inpatient room #566 A5-West on 09/03/2022 at 1357. Review revealed a nursing wound consultation was completed on 09/04/2022 at 1024. Review of Inpatient Wound/Ostomy Documentation Note dated 09/04/2022 at 1024 indicated: “Wound care consult received for calf burn...wound is pink, red wound bed, superficial. Communicated with RN (Registered Nurse) that wound team will not be able to prioritize this patient today. Would recommend provider place order for bacitracin to be applied generously, cover with xeroform gauze, then dry gauze and gauze roll, daily. Will only follow if wound worsend with appropriate treament-please reconsult if this occurs”. Review of a physician’s order dated 09/04/2022 at 2100 indicated: “Bactroban topical 2% cream to be applied three times daily at 0900, 1500, and 2100 for 7 days to right-calf wound”. Record review revealed a lack of documentation related to the application of the aforementioned wound treatment per nursing. Review of the patient’s closed medical record lacked nursing documentation related to the assessment and treatment of the patient’s right calf wound from presentation in the ED on 09/01/2022 through discharge on 09/07/2022.”

“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: 33790 Based on policy reviews, medical record reviews, and staff and physician interviews, the hospital failed to comply with 42 CFR 489.20 and 489.24. The findings included: The hospital’s Dedicated Emergency Department (DED) failed to provide a timely appropriate Medical Screening Examination (MSE) within the capability of the hospital’s DED, including ancillary services routinely available to the DED, to determine whether an Emergency Medical Condition (EMC) existed for one (1) of 38 sampled DED patients who presented to the hospital for evaluation and treatment, (Patient #2). ~ Cross refer to 489.24(a) and 489.24(c) Medical Screening Examination - Tag A 2406.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 33790 Based on policy and procedure reviews, medical record reviews and staff and physician interviews the hospital’s Dedicated Emergency Department (DED) failed to provide a timely appropriate Medical Screening Examination (MSE) within the capability of the hospital’s DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for one (1) of 38 sampled DED patients who presented to the hospital for evaluation and treatment, (Patient #2). The findings included: Review of the policy “EMTALA (Emergency Medical Treatment and Labor Act) - Medical Screening and Stabilization...”, last approved 12/13/2021, revealed “...3. Extent of the MSE (Medical Screening Examination) a. Determine if an EMC (Emergency Medical Condition) exists. The hospital must perform an MSE to determine if an EMC exists...b. Definition of MSE. An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. It is not an isolated event. The MSE must be appropriate to the individual’s presenting signs and symptoms and the capability and capacity of the hospital. c. An on-going process. The individual shall be continuously monitored according to the individual’s needs until it is determined whether or not the individual has an EMC, and if he or she does, until he or she is stabilized or appropriately admitted or transferred. The medical record shall reflect the amount and extent of monitoring that was provided prior to the completion of the MSE and until discharge or transfer....5. No Delay in Medical Screening or Examination .... c. EMS. A hospital has an obligation to see the individual once the individual presents to the DED whether by EMS or otherwise. A hospital that delays the MSE or stabilizing treatment of any individual who arrives via transfer from another facility, by not allowing EMS to leave the individual, could be in violation of EMTALA.... Even if the hospital cannot immediately complete an appropriate MSE, the hospital must assess the individual’s condition upon arrival of the EMS service to ensure that the individual is appropriately prioritized based on his or her presenting signs and symptoms to be seen for completion of the MSE. ...” Review of the EMS (Emergency Medical Services) Patient Care Record, on 11/14/2023, revealed EMS was called to Patient #2’s home on 10/17/2023. The record noted the patient’s medical history was “Cirrhosis of Liver, Diabetes, Infectious disease, Neuropathy, Other-Infection of foot - amputation schedule for 10/21.” Review of the Narrative Note revealed “(EMS) DISPATCHED EMERGENCY TRAFFIC.... SYNCOPAL EPISODE (episode of unconsciousness with recovery) WITH CHEST PAIN AND SHORTNESS OF BREATH ...ARRIVED....TO FIND A 66-YEAR-OLD MALE, A&Ox4 (alert and oriented to person, place, time, situation), SKIN PALE, WARM, AND DRY.... PT ADVISED HE HAD BEEN HAVING CHEST PAIN AND SHORTNESS OF BREATH FOR THE LAST WEEK.... ADVISED THAT HE .... HAD BEEN WORKING AROUND THE HOUSE AND ALL OF A SUDDEN HE DID NOT FEEL GOOD AND PASSED OUT.... PT ADVISED HE RECENTLY HAD SURGERY ON HIS FOOT AND IT....GOT AN INFECTION AND WAS TAKING ANTIBIOTICS FOR SAME. PT ADVISED HE WAS GOING TO NEED ANOTHER SURGERY.... IT WAS NOW NOTED THAT PT’S EKG WAS SHOWING.... ALSO SHORT RUNS OF A WIDE COMPLEX TACHYCARDIA. PT REMAINED COMPLETELY A&Ox4 .... PT WAS PLACED ON SUPPLEMENTAL OXYGEN WITH NOTED IMPROVEMENT IN BREATHING....PT WAS FOUND .... HYPERGLYCEMIC (high blood sugar) .... HAD NOT BEEN ABLE TO TAKE HIS INSULIN YET TODAY....PT WAS ADMINISTERED FLUID AS RECORDED ....PT ADVISED HIS CHEST PAIN WAS A 6/10 (on a scale of 0-10 with 0 being no pain and 10 being the worst pain) AND THAT TAKING A DEEP BREATH HURT....THIS HAS BEEN GOING ON ALL WEEK AND HAS NOT CHANGED.... UPON ARRIVAL AT (Hospital) PT WAS TAKEN TO ER ROOM, WHERE (EMS) WAITED FOR ER PERSONNEL TO COME FOR THE HANDOFF REPORT WHILE BEING CONTINUALLY MONITORED. A FACILITY RN FINALLY ARRIVED AND A FULL REPORT WAS GIVEN AND PT CARE WAS TRANSFERRED TO THE RECEIVING RN. ...” EMS record review revealed the team arrived at the hospital with Patient #2 at 1748 and care was transferred to hospital staff at 1907 (1 hour, 19 minutes after arrival). Review revealed EMS staff continued monitoring Patient #2 after arrival to the hospital’s ED. The last recorded EMS vital signs were at 1858 with BP 104/61, pulse 70, respirations 15, 99% pulse ox and a pain score of 6. Review of the Dedicated Emergency Department (DED) medical record, on 11/14/2023, revealed Patient #2 arrived by EMS to the hospital on 10/17/2023 at 1753. Review of the “ER Report” by a Physician Assistant (PA), at 1845, revealed “...66-year-old male patient.... presents.... (to the) emergency department today via EMS for chief complaint of chest pain and shortness of breath. Patient reports that he has had chest pain and shortness of breath ongoing over the past week and reports that these symptoms are aggravated with exertion.... he states that today he had acute worsening to his symptoms .... had a syncopal episode earlier today. He reports pain and shortness of breath are still present. He states that he also has bilateral lower extremity swelling which has been ongoing over the past couple of weeks .... He states that he has ulcer to the first metatarsal of his left foot and this extends to his bone. He states that he has planned to have amputation of the first digit of his left foot this coming Friday patient currently taking ciprofloxacin (antibiotic), Diflucan (antifungal), and Duricef (antibiotic).... Medical Decision Making.... EMS reports that they gave patient 324 mg aspirin.... blood pressure was approximately 96 mmHg. They gave one L (liter) of normal saline IV blood pressure is 105/66 now. EMS also reports that patient had 7 beat run of V tach on their EKG tracing in route with patient now in sinus rhythm and occasional bigeminy. Ordered EKG and for patient to be on telemetry.... Point-of-care CBG (blood sugar), CMP (comprehensive metabolic panel), CBC (complete blood count), troponin, proBNP, D-dimer, lactic acid, and portable 1 view chest x-ray ordered. EKG obtained and notes sinus rhythm with PVCs and 4 beat run of V tach (ventricular tachycardia - where lower chambers of the heart beat very quickly). ...” Review of the “ED Triage”, performed 10/17/2023 at 1900 (1 hour and 7 minutes after EMS arrival) revealed a pre-hospital blood glucose of 459 and an acuity of “3-urgent”. Vital signs were recorded as: Temperature 97.9, Pulse 72, Respirations 20, blood pressure 106/69 and oxygen saturation of 100% on 4 liters oxygen. Patient #2’s pain score was noted as seven (7). Further review of the PA’s “ER Report” note revealed “...1953 Dr. (Name) called to patients bedside for cardiac arrest and assumed care of patient. CPR initiated.... 2017....Called lab to request results of chemistries be available as soon as possible. Labs resulted after arrest .... Resuscitation attempt failed. Patient deceased. Suspect etiology to cardiac arrest related to MI (Myocardial infarction- heart attack). Review of orders revealed a stat order for an EKG at 1841 (48 minutes after Patient #2 arrived to the ED). Review revealed a hospital EKG was completed at 1905 (24 minutes after order and 1 hour 12 minutes after arrival). Review of lab orders revealed the following lab tests were ordered stat at 1841: Lactic Acid, CMP (comprehensive metabolic panel), Troponin, D-Dimer, Pro B-Type Natriuretic Peptide (ProBNP) and CBC with Differential. Review of orders revealed the labs were collected as Nurse collects at 1920 (39 minutes after the stat orders). Patient #2 experienced cardiac arrest at 1953, 2 hours after arrival. The labs resulted later, the CBC at 2002 and the CMP at 2012. The D-Dimer resulted at 2006 as 824 (high). The Pro BNP resulted at 2023 as 9690 (High - reference range 5-125) and the Troponin resulted at 2039 as 0.460 (High - reference range 0.000-0.034). The physician was notified. Review of the “ER Report”, service date/time 10/17/2023 at 2030, revealed a note by a physician that indicated “...I was called to the patient’s bedside at 1953 for cardiac arrest. Staff reports that only moments before the patient had been alert and talking. CPR (cardio- pulmonary resuscitation) was initiated. The patient was placed on a monitor and defibrillator. Initial rhythm revealed ventricular tachycardia (fast heart rhythm). He received electrical therapy and CPR was resumed. Patient received high-quality chest compressions. He would briefly show signs consciousness indicating adequate cerebral perfusion (blood to the brain) with chest compressions, but remained without an organized rhythm .... required continuation of CPR. He received multiple doses of electrical therapy.... He received magnesium as well as amiodarone (medication for irregular heart rhythm) for shock refractory ventricular tachycardia. Ventricular tachycardia progressed to ventricular fibrillation (life threatening arrhythmia). He also received multiple doses of epinephrine (emergency medication) per ACLS (advanced cardiac life support) protocol for pulseless arrest. He was intubated.... I called the physician assistant to the bedside to brief me on the details of the initial presentation. During the resuscitation I took the opportunity to review the available work-up. The EKG was brought to me for review at 2002 .... For this patient who presented with chest pain, syncope, and suffered cardiac arrest has either suffered an MI or rhythm disturbance .... I reviewed his medications.... I made attempts to address....reversible causes of cardiac arrest. As resuscitation proceeded the rhythm progressed ....to asystole .... After 30 minutes of resuscitation he remained in asystole. All team members agreed that further resuscitative efforts were futile.... the patient was pronounced dead at 8:24 PM (2024) ....10/17/23 20:38:56 I received a (sic) from the chemistry lab. Troponin is 0.46 .... Diagnosis/Disposition Chest pain Syncope Ventricular tachycardia Cardiopulmonary arrest. ...” Telephone interview on 11/20/2023 at 1415 with EMS #70 revealed EMS responded to a call for a patient with chest pain and shortness of breath. Interview revealed on EKG the heart was very irritated, throwing PVCs, PACs (arrhythmias) and then short runs of wide complex tachycardia (rapid heart rate). Interview revealed there was potential for things to turn unstable quickly. By the time they got to the hospital there were just a few PVCs. EMS #70 stated at some point the patient started to get hypotensive and the fluids had emptied, so the other EMS staff gathered another bag of fluids. Patient #2, per EMS, was on supplemental oxygen and had no complaints at the time. Interview revealed they got the patient into an ED bed at 1845 but there was no nurse for report. At 1907 (1 hours, 17 minutes after arrival), per interview, EMS was able to give hand-off report to a nurse. Interview revealed waits had gotten more common recently and it seemed like a staffing issue. Telephone interview with PA #71, on 11/15/2023 at 1600, revealed the patient came into the ED with EMS and there were no rooms available. PA #71 stated he saw the patient while in the hallway and placed orders. Interview revealed the patient had not been triaged, he was still in the hall. Interview revealed prior to arrival the patient had “a few runs, approximately 8 beats”, of V tach. PA #71 stated the patient was given a liter of fluids and the rhythm improved. Patient #2 remained on the EMS monitor prior to getting a formal EKG in the ED, the PA stated. Interview revealed there were another 4 beats of V tach but it was not sustained; the patient appeared stable. PA #71 moved on to another patient and did not see Patient #2 after he got in an ED room until the PA heard the code and responded. Interview revealed these type patients should be closely monitored. Interview revealed the goal for the screening evaluation was 20 minutes from arrival. Telephone interview with RN #66, on 11/16/2023 at 0938, revealed the nurse assigned to Patient #2’s room was busy and not able to triage the patient, so RN #66 responded, did the hand-off with EMS and triaged Patient #2. The patient had been placed on a monitor by the Certified Nursing Assistant (CNA). RN #66 then received report from EMS. Interview revealed there was not a bed available when Patient #2 first arrived by EMS. When RN #66 went to triage the patient, Patient #2 had just been put in a room and was stable, alert and talking. RN #66 stated that after Patient #2 was triaged, RN #66 drew blood for labs. The RN stated labs were not drawn until after the patient was accepted and in a room. Until patients were in a room and care handed-off from EMS, interview revealed, they were “counting on EMS to care for (the patients). ...” Telephone interview on 11/16/2023 at 1100 with MD #72 revealed he heard the overhead page for Patient #2 and immediately responded. Interview revealed the expectation for chest pain patients was an EKG within 10 minutes and to be seen by a provider within 10 minutes. Interview revealed there is a chest pain protocol, but the protocol had to be activated by a provider. MD #72 acknowledged there was a delay for Patient #2. In summary, Patient #2 was brought to the ED by EMS from home. The patient arrived on 10/17/2023 at 1753 with chest pain after a syncopal episode at home. The provider ordered labs at 1841 (48 minutes after Patient #2 arrived). The patient was triaged at 1900 and labs were collected at 1920 by nursing staff. Patient #2 was on a cardiac monitor and received vital signs by EMS until triage at 1900. No hospital EKG was completed until 1905 (1 hour 12 minutes after arrival). The D-Dimer, Pro BNP and Troponin all resulted after 2000 and all resulted abnormally high. Patient #2 experienced cardiac arrest around 1953 (2 hours after arrival to the DED). CPR was initiated but was not successful and Patient #2 expired. There was a delay in triage, medical screening and interventions, including hospital EKG and labs for a patient who arrived at the hospital via EMS for chest pain and syncope.”