Duke Regional Hospital

“PATIENT RIGHTS:RESTRAINT/SECLUSION DEATH RPT CFR(s): 482.13(g)(1) & (3)(i) [Death Reporting Requirements: Hospitals must report deaths associated with the use of seclusion or restraint.] (1) With the exception of deaths described under paragraph (g)(2) of this section, the hospital must report the following information to CMS by telephone, facsimile, or electronically, as determined by CMS, no later than the close of business on the next business day following knowledge of the patient’s death: (i) Each death that occurs while a patient is in restraint or seclusion. (ii) Each death that occurs within 24 hours after the patient has been removed from restraint or seclusion. (iii) Each death known to the hospital that occurs within 1 week after restraint or seclusion where it is reasonable to assume that use of restraint or placement in seclusion contributed directly or indirectly to a patient’s death, regardless of the type(s) of restraint used on the patient during this time.”Reasonable to assume” in this context includes, but is not limited to, deaths related to restrictions of movement for prolonged periods of time, or death related to chest compression, restriction of breathing or asphyxiation.... (3) The staff must document in the patient’s medical record the date and time the death was: (i) Reported to CMS for deaths described in paragraph (g)(1) of this section; or .... This Standard is not met as evidenced by: 36956 Based on policy review, closed medical record review, and staff interviews the hospital staff failed to report the death of 3 of 10 sampled patients that died within 24 hours of being in restraints to CMS (Centers for Medicare and Medicaid) by the close of the next business day (Patients #35, #37, and #38) and failed to log 1 of 10 patients on the hospital’s internal log (Patient #36). The findings include: Review of hospital policy on 11/08/2024 titled “ ...Restraint Addendum E: Restraint Death Reporting Requirements with an effective date of 07/17/2023 revealed...Hospitals must report deaths associated with the use of restraint or seclusion to CMS (Centers for Medicare and Medicaid Services) and NC DHHS (North Carolina Department of Human and Health Services)....Reports to CMS...Deaths Associated with the Use of Restraint or Seclusion...Deaths associated with the use of restraint or seclusion are to be reported to CMS using the electronic form CMS-10455, no later than the close of the next business day following the day in which the hospital knows of the patient’s death. Such deaths must also be entered into the entity internal log. CMS considers the following deaths to be associated with the use of restraint or seclusion and thus reportable: i. Each death that occurs while a patient is in restraint or seclusion. ii. Each death that occurs within 24 hours after the patient has been removed from restraint or seclusion ....iii. Each death known to the hospital that occurs within 1 week after restraint or seclusion where it is reasonable to assume that use of restraint or placement in seclusion contributed directly or indirectly to a patient’s death, regardless of the type(s) of restraint used on the patient during this time....For any death falling under categories (i), (ii), or (iii)...b) The staff must document in the patient’s electronic health record the date and time the death was recorded in the internal log or other the system for deaths. c) Entries into the log or other system must be documented as follows: Each entry must be made no later than seven days after the date of death of the patient. Each entry must document the patient’s name, date of birth, date of death, name of attending physician or other licensed practitioner who is responsible for the care of the patient, electronic health record number, and primary diagnosis....Patient Deaths After Use of Soft Wrist Restraints...when the only restraints used on the patient are those applied exclusively to the patient’s wrist(s) and which are composed solely of soft, non-rigid, cloth-like materials, a report to CMS is not required. However, the hospital staff must record the...information in the entity’s internal log;” 1. Closed medical record review on 11/08/2024 of hospital documentation titled “DISCHARGE/DEATH SUMMARY” dated 02/22/2024 at 0625 revealed on 02/21/2024 Patient #35 was a 60 year old patient that arrived to named hospital from an outside hospital. “On arrival to ...” named hospital “ ...the patient was on 3 pressors (medication to maintain blood pressure). Family made Patient DNR ( Do Not Resuscitate) status with limited care and worked to transition patient to comfort care (a type of care to assist patients feel as comfortable as possible with the management of pain and symptoms)”. “Epinephrine (medication used to increase blood pressure and blood flow) and vasopressin (medication used for maintenance of blood pressure and kidney function) were stopped during the day. Overnight, the patient’s blood pressure continued to drop until she became asystolic (the stopping of the heartbeat and blood flow).” Review revealed on 02/22/2024 at 0611 Patient #35 expired. Interview at 1340 with PMQ (Program Manager for Quality) #6 revealed she worked for the corporate hospital since 07/15/2024 and was responsible for system wide quality management. Interview revealed on 11/06/2024 PMQ#6 ran the death reports, after the survey entrance and she became aware that there were not any restraint deaths in the named hospital reporting system. Interview revealed PMQ#6 ran the hospital’s death report and reviewed medical records for patients’ deaths that occurred while patients were in restraints. Interview revealed the report time frame was from 01/2024 to 11/06/2024, with the exception of March, May and June 2024. The PMQ#6 identified per the death report deaths that occurred while in restraints per CMS regulations. Interview revealed the medical records were reviewed for 4 of the 10 identified deaths. Continued interview revealed that Patient #35 was in 4 point restraints and patient expired 19 hours and 34 minutes after restraint application. Interview revealed that Patient #35 was admitted on 02/21/2024 at 0414, was placed in restraints and expired on 02/22/2024 at 0611. Interview revealed Patient #35’s death was not reported to CMS but should have been reported. On 11/08/2024 request made for patient timeline and restraint initiation information was not obtained prior to survey exit. 2. Closed medical record review on 11/08/2024 of hospital documentation titled “ED Provider Note History of Present Illness” dated “02/28/2024 at 1528” revealed on 02/28/2024 at 1513 Patient #37 was a 75 year old female that arrived at the ED (Emergency Department) via EMS (Emergency Medical Service) with a chief complaint of abdominal pain and vomiting. Continued review revealed “ ...she was found to be lethargic (sluggish) and had diffused (pain to throughout the abdomen and not localized to a specific spot/area) abdominal tenderness with guarding (involuntary of tensing of abdominal muscles response to pain or inflammation within the abdomen).” Patient #37 had chest pain and ...patient could not follow directions to be able to take it safely” take an aspirin. Review revealed at 1804 “Patient climbing out of the bed, posing danger to herself. I have ordered for non-violent soft restraints.” Continued review revealed a late entry was entered at 2013 and documented Patient #37’s declining status. Patient #37 “was becoming more encephalopathic (disease affecting the brain function such as toxins and infections) and less responsive. The patient’s pulse “ ...was bradycardic (low heart rate) in the 40s and 50s ...” Patient #37 was bagged (air administered into a patient’s lungs via self-inflating bag) ventilation (air exchange into the lungs) and at 1943 she expired. Interview at 1340 with PMQ (Program Manager for Quality) #6 revealed she worked for the corporate hospital since 07/15/2024 and was responsible for system wide quality management. Interview revealed on 11/06/2024 PMQ#6 ran the death reports, after the survey entrance and she became aware that there were not any restraint deaths in the named hospital reporting system. Interview revealed PMQ#6 ran the hospital’s death report and reviewed medical records for patients’ deaths that occurred while patients were in restraints. Interview revealed the report time frame was from 01/2024 to 11/06/2024, with the exception of March, May and June 2024. The PMQ#6 identified per the death report deaths that occurred while in restraints per CMS regulations. Interview revealed the medical records were reviewed for 4 of the 10 identified deaths. Continued interview revealed Patient #37 was admitted on 02/28/2024 was placed in 4 point restraints and expired on 02/28/2024 at 1943. Interview revealed Patient #37’s death was not reported to CMS but should have been reported. On 11/08/2024 request made for patient timeline and restraint initiation information was not obtained prior to survey exit. 3. Closed medical record review for Patient #38 on 11/08/2024 of hospital documentation titled “ED Provider Note History of Present Illness” dated “02/24/2024 at 2047” revealed on 02/24/2024 Patient #38 was a 46 year old male arrived at the ED via EMS after cardiac arrest. “per EMS report he took an unknown substance possibly cocaine and was found in the bathroom by family. He was found pulseless. EMS performed CPR (Cardiopulmonary Resuscitation) and obtained ROSC (Return of spontaneous circulation). He was found to have pinpoint pupils and was given 4 mg of Narcan (medication used to reverse drug overdoses) with response. He was then combative and given a dose of benzodiazepine (medication used to treat anxiety) to help calm him. Review revealed that CPR was performed on Patient #38. During CPR, 6 rounds of epinephrine was administered. Review revealed during each round the monitor showed asystole and patient did not have a pulse. Review revealed on 02/24/2024 at 2011 Patient #38 expired. Interview at 1340 with PMQ (Program Manager for Quality) #6 revealed she worked for the corporate hospital since 07/15/2024 and was responsible for system wide quality management. Interview revealed on 11/06/2024 PMQ#6 ran the death reports, after the survey entrance and she became aware that there were not any restraint deaths in the named hospital reporting system. Interview revealed PMQ#6 ran the hospital’s death report and reviewed medical records for patients’ deaths that occurred while patients were in restraints. Interview revealed the report time frame was from 01/2024 to 11/06/2024, with the exception of March, May and June 2024. The PMQ#6 identified per the death report deaths that occurred while in restraints per CMS regulations. Interview revealed the medical records were reviewed for 4 of the 10 identified deaths. Interview revealed Patient #38 was admitted on 02/24/2024 at Interview revealed Patient #38’s death was not reported to CMS but should have been reported. On 11/08/2024 request made for patient timeline and restraint initiation information was not obtained prior to survey exit. 4. Closed medical record review on 11/08/2024 of hospital documentation titled “DISCHARGE/DEATH SUMMARY...H&P NOTES” dated 01/06/2024 at 1859 revealed on 01/06/2024 Patient #36 was a 94 year old female that arrived at the ED 0905 “ ...for an evaluation after weeks of increased weakness, dyspnea, poor appetite and general clinical worsening.” Review revealed Patient #36 was being treated for volume overload (too much fluid in the body) and possible community acquired pneumonia (patients that diagnosed with pneumonia that had not been recently hospitalized) when she experienced cardiac arrest (when a person’s heart stops). Patient #36 was coded (measures taken to restart a patient’s heart) for ten minutes and return of ROSC was achieved. Continued review revealed Patient #36 was transferred to ICU (Intensive Care Unit), was changed to DNAR (Do Not Attempt Resuscitation) status, extubated (the removal of a breathing tube from the throat) and placed on comfort care. Review revealed on 01/06/2024 at 1855 Patient #36 expired. Interview at 1340 with PMQ (Program Manager for Quality) #6 revealed she worked for the corporate hospital since 07/15/2024 and was responsible for system wide quality management. Interview revealed on 11/06/2024 PMQ#6 ran the death reports, after the survey entrance and she became aware that there were not any restraint deaths in the named hospital reporting system. Interview revealed PMQ#6 ran the hospital’s death report and reviewed medical records for patients’ deaths that occurred while patients were in restraints. Interview revealed the report time frame was from 01/2024 to 11/06/2024, with the exception of March, May and June 2024. The PMQ#6 identified per the death report deaths that occurred while in restraints per CMS regulations. Interview revealed the medical records were reviewed for 4 of the 10 identified deaths. Interview revealed Patient #36 was admitted on 01/06/2024 0905 and was placed into 2 point restraints and expired on 01/06/2024 at 1855. Interview revealed Patient #37’s death was not logged onto the hospital’s internal log. On 11/08/2024 request made for patient timeline and restraint initiation information was not obtained prior to survey exit. .”

“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 medical record reviews and staff interviews, the hospital staff failed to accurately monitor restraint deaths due to printer settings for 4 of 10 patients (Patient #35, #37, #38, #36). The findings include: 1. Closed medical record review on 11/08/2024 of hospital documentation titled “DISCHARGE/DEATH SUMMARY” dated 02/22/2024 at 0625 revealed on 02/21/2024 Patient #35 was a 60 year old patient that arrived to named hospital from an outside hospital. “On arrival to ...” named hospital “ ...the patient was on 3 pressors (medication to maintain blood pressure). Family made Patient DNR ( Do Not Resuscitate) status with limited care and worked to transition patient to comfort care (a type of care to assist patients feel as comfortable as possible with the management of pain and symptoms)”. “Epinephrine (medication used to increase blood pressure and blood flow) and vasopressin (medication used for maintenance of blood pressure and kidney function) were stopped during the day. Overnight, the patient’s blood pressure continued to drop until she became asystolic (the stopping of the heartbeat and blood flow).” Review revealed on 02/22/2024 at 0611 Patient #35 expired. Interview on 11/05/2020 1435 with PMR (Program Manager for Regulatory) #7 revealed when this surveyor requested CMS ((Centers for Medicare and Medicaid) restraint death log. PMR #7 reported there had not been any restraint deaths. This surveyor questioned if there had not been any reportable restraint deaths. PMR #7 stated “not since I’ve been here.” Surveyor asked how long you’ve been here and she stated, “since 2020.” Interview revealed there were not any restraint death reports. Interview on 11/08/2024 at 1340 with PMQ (Program Manager for Quality)#6 revealed she worked for the corporate hospital since 07/15/2024 and was responsible for system wide quality management. Interview revealed during the system wide Regulatory monthly meeting in July 2024 PMQ#6 identified and reported there was a system wide communication error regarding the CMS restraint death within the electronic HIM (Health Information Management-the oversight of protection, accuracy and availability of patient health information) reporting system. Interview revealed the HIM reporting error was corrected but the correction for the named hospital was never validated. Interview revealed the ongoing plan was to ensure the CMS restraint report was correct per HIM team. Interview on 11/08/2024 at 1340 with PMR #7 revealed PMR#7 had worked for hospital #1 since 2020 and was responsible for running the CMS death reports for the named hospital. Interview revealed she ran the CMS restraint death reports between 0730 and 0800 every Monday, Wednesday and Friday. Interview revealed PMR#7 attended the monthly corporate meetings held on Tuesday or Wednesday of the month. Continued review revealed PMR #7 was not aware there was a glitch in the report. 2. Closed medical record review on 11/08/2024 of hospital documentation titled “ED Provider Note History of Present Illness” dated “02/28/2024 at 1528” revealed on 02/28/2024 at 1513 Patient #37 was a 75 year old female that arrived at the ED (Emergency Department) via EMS (Emergency Medical Service) with a chief complaint of abdominal pain and vomiting. Continued review revealed “ ...she was found to be lethargic (sluggish) and had diffused (pain to throughout the abdomen and not localized to a specific spot/area) abdominal tenderness with guarding (involuntary of tensing of abdominal muscles response to pain or inflammation within the abdomen).” Patient #37 had chest pain and ...patient could not follow directions to be able to take it safely” take an aspirin. Review revealed at 1804 “Patient climbing out of the bed, posing danger to herself. I have ordered for non-violent soft restraints.” Continued review revealed a late entry was entered at 2013 and documented Patient #37’s declining status. Patient #37 “was becoming more encephalopathic (disease affecting the brain function such as toxins and infections) and less responsive. The patient’s pulse “ ...was bradycardic (low heart rate) in the 40s and 50s ...” Patient #37 was bagged (air administered into a patient’s lungs via self-inflating bag) ventilation (air exchange into the lungs) and at 1943 she expired. Interview on 11/05/2020 1435 with PMR (Program Manager for Regulatory) #7 revealed when this surveyor requested CMS ((Centers for Medicare and Medicaid) restraint death log. PMR #7 reported there had not been any restraint deaths. This surveyor questioned if there had not been any reportable restraint deaths. PMR #7 stated “not since I’ve been here.” Surveyor asked how long you’ve been here and she stated, “since 2020.” Interview revealed there were not any restraint death reports. Interview on 11/08/2024 at 1340 with PMQ (Program Manager for Quality)#6 revealed she worked for the corporate hospital since 07/15/2024 and was responsible for system wide quality management. Interview revealed during the system wide Regulatory monthly meeting in July 2024 PMQ#6 identified and reported there was a system wide communication error regarding the CMS restraint death within the electronic HIM (Health Information Management-the oversight of protection, accuracy and availability of patient health information) reporting system. Interview revealed the HIM reporting error was corrected but the correction for the named hospital was never validated. Interview revealed the ongoing plan was to ensure the CMS restraint report was correct per HIM team. Interview on 11/08/2024 at 1340 with PMR #7 revealed PMR#7 had worked for hospital #1 since 2020 and was responsible for running the CMS death reports for the named hospital. Interview revealed she ran the CMS restraint death reports between 0730 and 0800 every Monday, Wednesday and Friday. Interview revealed PMR#7 attended the monthly corporate meetings held on Tuesday or Wednesday of the month. Continued review revealed PMR #7 was not aware there was a glitch in the report. 3. Closed medical record review for Patient #38 on 11/08/2024 of hospital documentation titled “ED Provider Note History of Present Illness” dated “02/24/2024 at 2047” revealed on 02/24/2024 Patient #38 was a 46 year old male arrived at the ED via EMS after cardiac arrest. “per EMS report he took an unknown substance possibly cocaine and was found in the bathroom by family. He was found pulseless. EMS performed CPR (Cardiopulmonary Resuscitation) and obtained ROSC (Return of spontaneous circulation). He was found to have pinpoint pupils and was given 4 mg of Narcan (medication used to reverse drug overdoses) with response. He was then combative and given a dose of benzodiazepine (medication used to treat anxiety) to help calm him. Review revealed that CPR was performed on Patient #38. During CPR, 6 rounds of epinephrine was administered. Review revealed during each round the monitor showed asystole and patient did not have a pulse. Review revealed on 02/24/2024 at 2011 Patient #38 expired. Interview on 11/05/2020 1435 with PMR (Program Manager for Regulatory) #7 revealed when this surveyor requested CMS ((Centers for Medicare and Medicaid) restraint death log. PMR #7 reported there had not been any restraint deaths. This surveyor questioned if there had not been any reportable restraint deaths. PMR #7 stated “not since I’ve been here.” Surveyor asked how long you’ve been here and she stated, “since 2020.” Interview revealed there were not any restraint death reports. Interview on 11/08/2024 at 1340 with PMQ (Program Manager for Quality)#6 revealed she worked for the corporate hospital since 07/15/2024 and was responsible for system wide quality management. Interview revealed during the system wide Regulatory monthly meeting in July 2024 PMQ#6 identified and reported there was a system wide communication error regarding the CMS restraint death within the electronic HIM (Health Information Management-the oversight of protection, accuracy and availability of patient health information) reporting system. Interview revealed the HIM reporting error was corrected but the correction for the named hospital was never validated. Interview revealed the ongoing plan was to ensure the CMS restraint report was correct per HIM team. Interview on 11/08/2024 at 1340 with PMR #7 revealed PMR#7 had worked for hospital #1 since 2020 and was responsible for running the CMS death reports for the named hospital. Interview revealed she ran the CMS restraint death reports between 0730 and 0800 every Monday, Wednesday and Friday. Interview revealed PMR#7 attended the monthly corporate meetings held on Tuesday or Wednesday of the month. Continued review revealed PMR #7 was not aware there was a glitch in the report. 4. Closed medical record review on 11/08/2024 of hospital documentation titled “DISCHARGE/DEATH SUMMARY...H&P NOTES” dated 01/06/2024 at 1859 revealed on 01/06/2024 Patient #36 was a 94 year old female that arrived at the ED 0905 “ ...for an evaluation after weeks of increased weakness, dyspnea, poor appetite and general clinical worsening.” Review revealed Patient #36 was being treated for volume overload (too much fluid in the body) and possible community acquired pneumonia (patients that diagnosed with pneumonia that had not been recently hospitalized) when she experienced cardiac arrest (when a person’s heart stops). Patient #36 was coded (measures taken to restart a patient’s heart) for ten minutes and return of ROSC was achieved. Continued review revealed Patient #36 was transferred to ICU (Intensive Care Unit), was changed to DNAR (Do Not Attempt Resuscitation) status, extubated (the removal of a breathing tube from the throat) and placed on comfort care. Review revealed on 01/06/2024 at 1855 Patient #36 expired. Interview on 11/05/2020 1435 with PMR (Program Manager for Regulatory) #7 revealed when this surveyor requested CMS ((Centers for Medicare and Medicaid) restraint death log. PMR #7 reported there had not been any restraint deaths. This surveyor questioned if there had not been any reportable restraint deaths. PMR #7 stated “not since I’ve been here.” Surveyor asked how long you’ve been here and she stated, “since 2020.” Interview revealed there were not any restraint death reports. Interview on 11/08/2024 at 1340 with PMQ (Program Manager for Quality)#6 revealed she worked for the corporate hospital since 07/15/2024 and was responsible for system wide quality management. Interview revealed during the system wide Regulatory monthly meeting in July 2024 PMQ#6 identified and reported there was a system wide communication error regarding the CMS restraint death within the electronic HIM (Health Information Management-the oversight of protection, accuracy and availability of patient health information) reporting system. Interview revealed the HIM reporting error was corrected but the correction for the named hospital was never validated. Interview revealed the ongoing plan was to ensure the CMS restraint report was correct per HIM team. Interview on 11/08/2024 at 1340 with PMR #7 revealed PMR#7 had worked for hospital #1 since 2020 and was responsible for running the CMS death reports for the named hospital. Interview revealed she ran the CMS restraint death reports between 0730 and 0800 every Monday, Wednesday and Friday. Interview revealed PMR#7 attended the monthly corporate meetings held on Tuesday or Wednesday of the month. Continued review revealed PMR #7 was not aware there was a glitch in the report.”

“COMPETENT DIETARY STAFF CFR(s): 482.28(a)(3) There must be administrative and technical personnel competent in their respective duties. This Standard is not met as evidenced by: 34065 Based on policy review, observations, and staff interviews, the hospital’s dietary staff failed to carry out duties in a competent manner to ensure the correct concentration of the dishwashing soap in the dishwater of the compartment sink; failed to date and label open containers of food; failed to remove expired food items from the refrigerator units, and failed to secure hair and beards in proper restraints for 1 of 1 kitchen toured. The findings include: Review on 11/5/2024 of policy titled “Safe Standards and Procedures: Cleaning and Sanitation-Food Safety” with revision date of 07/17/2024, revealed “...Sanitizer Test Procedures: Verify that sanitizer solution is at the proper concentration daily, testing and recording results...Follow quat sanitizer testing instructions below: Ensure the test paper is clean and dry. Remove 1.5 inches of the test paper. Dip the test strip into the solution (not the foam) for 10 seconds. Do not shake the test strip. Compare test strip color to wall charts or strip dispenser to verify sanitizer concentration. If test strips turn dark quickly, retest....” Review of policy on 11/05/2024 titled “Storage Standards and Procedures” with revision date of 07/05/2019 revealed “Label foods clearly and correctly with use-by-date information....” Review of policy on 11/05/2024 titled “Receiving & Storage: Standards and Procedures” with revision date of 07/05/2019 revealed “5.1. Storage Standards and Procedures...Discard out-of-date products.... After opening, store all ‘in-use’ foods or products in the original packaging when possible...and properly labeled....” Review of policy on 11/05/2024 titled “TCS Food Labeling Guide” with 2024 date revealed “Temperature Control for Safety (TCS) foods are more perishable than others and must be kept hot or cold to stay safe. Labeling and storing TCS foods correctly ensure our ingredients are safe to use in food served to customers. All TCS food we prepare and keep for over 24 hours must be labeled and used within 7 days. TCS food labels must include these 4 things: 1. Item 2. Prep Date 3. Use by Date 4. Your initials.” Review of policy on 11/6/2024 titled “Uniform and Personal Appearance” with revision date of March 2019 revealed “All Food Service Employees shall wear clean uniforms, maintain a high degree of personal cleanliness and conform to hygienic practices while on duty....6. All food service employees must wear hair restraints to meet health and food code standards at all times while working. Hair styles must be neat and well kept. Hair restraints must completely enclose all hair. Long hair (shoulder length or longer) must be pulled back and should be worn inside the hair restraint. Approved hair coverings include hairnet, approved baker’s cap... alternative baseball caps, bandanas, and other head wraps are not permitted....8. Beards and mustaches must be neatly trimmed and clean at all times.... Employees with facial hair longer than 1/4 inch working in food production and/or serving areas with facial hair are required to wear a beard guard....” 1. Observation on 11/6/2024 at 1400 revealed Dishwasher #1 was standing at the three-compartment sink. Dishwasher #1 demonstrated the technique for verifying the sanitizer strength of the dish water by allowing the test strip paper to stay submerged in the dish water more than 10 seconds, shaking the test strip after submersion into the water, and not using a time clock to verify the time. Observation revealed the pots and pans of the dish sink were not covered with soapy water. Interview on 11/6/2024 at 1400 with Dishwasher #1 revealed the correct time for the test strip to be submerged in the water was 30 seconds. The interview revealed the Dishwasher #1 was unable to tell the surveyor of the correct result of the test strip. The interview revealed the sink was not holding water to cover the dishes for the past 2 days. Interview on 11/6/2024 at 1400 with Director #2 revealed the process was not followed to check the concentration of the dish water. The interview revealed the administration and facility staff was not aware that the sink was not working properly. 2. Observation during tour on 11/5/2024 from approximately 1315 to 1430 revealed an 8 ounce jar of Italian pasta salad with use by date of 10/30/2024 (6 days past due); blue cheese dressing with use by date of 11/1/2024 (3 days past due); cellophane wrapped food bag with colors of red and green visible through the cellophane without a label of contents or use by date; One third of a gallon plastic container of Classic Caesar Dressing without a label indicating open date or use by date; Full jar of banana peppers with expiration date of 11/3/2024 at 2 pm, (24 hours past expiration date); Bottle of teriyaki glaze with use by date of 11/2/2024 at 1238, (48 hours past expiration date), Two-thirds gallon of orange juice without open date or expiration date; 5 lbs. (pounds) mozzarella cheese with 1/2 bag remaining without a sticker indicating open date or expiration date; bag of tortilla chips with use by date of 09/20/2024 (46 days past due); two bags of brown sugar wrapped in cellophane without a label indicating open or expiration date; and 21 facility prepared dessert cups of vanilla pudding with use by date of 11/4/2024 (one day past due). Interview on 11/5/2024 during tour with Director #2 revealed “all foods should have a label of open date and expiration date.” The interview revealed “Production leadership is responsible for daily rounds and removing expired foods.” Interview revealed the Production Leadership staff had left for the day. The interview revealed policy has not been followed. 3. Observation on 11/6/2024 at 1300 during tour of the kitchen revealed FN (Food and Nutrition) worker #3 washing dishes at the three-compartment sink. Observation revealed FN #3 was wearing a baseball style cap with braids extending past the jaw line. Observation revealed FN #3 was not wearing a hair net. Interview on 11/6/2024 at 1330 with Director #5 revealed employees should wear hair nets at all times during the day and all hair should be contained. The interview revealed the beards should be covered with a beard guard per policy. The interview revealed policy was not followed. 4. Observation on 11/6/2024 at 1100 of tray building line in the kitchen revealed FN #4 was placing food on the tray line. Observation revealed FN #4 had facial hair extending longer than ¼ inches. Observation revealed FN #4 was not wearing a beard guard. Interview on 11/6/2024 at 1330 with Director #5 revealed employees should wear hair nets at all times during the day and all hair should be contained. The interview revealed the beards should be covered with a beard guard per policy. The interview revealed policy was not followed. Observation during tour on 11/5/2024 from approximately 1315 to 1430 revealed an 8 ounce jar of Italian pasta salad with use by date of 10/30/2024 (6 days past due); blue cheese dressing with use by date of 11/1/2024 (3 days past due); cellophane wrapped food bag with colors of red and green visible through the cellophane without a label of contents or use by date; One third of a gallon plastic container of Classic Caesar Dressing without a label indicating open date or use by date; Full jar of banana peppers with expiration date of 11/3/2024 at 2 pm, (24 hours past expiration date); Bottle of teriyaki glaze with use by date of 11/2/2024 at 1238, (48 hours past expiration date), Two-thirds gallon of orange juice without open date or expiration date; 5 lbs. (pounds) mozzarella cheese with 1/2 bag remaining without a sticker indicating open date or expiration date; bag of tortilla chips with use by date of 09/20/2024 (46 days past due); two bags of brown sugar wrapped in cellophane without a label indicating open or expiration date; and 21 facility prepared dessert cups of vanilla pudding with use by date of 11/4/2024 (one day past due). Interview on 11/5/2024 during tour with Director #2 revealed “all foods should have a label of open date and expiration date.” The interview revealed “Production leadership is responsible for daily rounds and removing expired foods.” Interview revealed the Production Leadership staff had left for the day. The interview revealed policy has not been followed.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 36956 Based on observations and staff interviews, the hospital staff failed to ensure patient belongings were labeled and stored in a secure area. The findings include: 1. Observation during tour on 11/05/2024 1040 and 11/07/2024 at 1124 of the BHU located on named hospital’s campus revealed on the 3400 hall, clean patient equipment was stored in the clean equipment storage room where 5 plastic bags, without names which were identified by Mgr #8 as BH patient belongings. Continued observations revealed CPAP (Continuous Positive Airway Pressure - treatment for apnea - stop interrupted breathing) machine, walker and loose clothes not contained in bags on a shelf and not labeled with the patient’s names to which they belonged. Interview on 11/07/2024 with Mgr#8 revealed on the 3500 hall clean equipment room there was Christmas decorations hanging out of the box touching patient’s belongings and patient belongings were draped over the clean equipment that should not have been. Mgr #8 stated she understood and would fix the problem. Interview on 11/08/2024 at 1037 with BH Mgr#8 revealed there was not a policy and procedure regarding placement of BH patient belongings but was considered a standard of work process. Interview revealed the process was patient belongings over three outfits was to be placed in the clean equipment room in a bag and labeled. Interview revealed the bags were located on the BHU. Interview on 11/07/2024 at 1325 with IP (Infection Preventionist ) revealed she was unsure of the overall BH process for patient belongings. IP stated from an infection control standpoint “patient belongings should be bagged and secured, separated, not mixed with other patient’s, not with equipment used for different patients.” 2. Observation during tour on 11/07/2024 at 1124 of the BHU located on named hospital’s campus revealed on the 3500 hall, clean patient equipment was stored in the clean equipment storage room. Observation revealed clean patient equipment with sweatpants draped across a Geri-chair, Christmas decorations in a box with Christmas items hung over the top of the box that touched loose patient’s belongings and clothes. Observation revealed on the same shelf piles of loose patient items to include a bra, tennis shoes, a jacket, a gallon container of distilled water dated 6/25/24 were not labeled with the patient’s names to which they belonged. Interview on 11/07/2024 with Mgr#8 revealed on the 3500 hall clean equipment room there was Christmas decorations hanging out of the box touching patient’s belongings and patient belongings were draped over the clean equipment that should not have been. Mgr #8 stated she understood and would fix the problem. Interview on 11/08/2024 at 1037 with BH Mgr#8 revealed there was not a policy and procedure regarding placement of BH patient belongings but was considered a standard of work process. Interview revealed the process was patient belongings over three outfits was to be placed in the clean equipment room in a bag and labeled. Interview revealed the bags were located on the BHU. Interview on 11/07/2024 at 1325 with IP (Infection Preventionist ) revealed she was unsure of the overall BH process for patient belongings. IP stated from an infection control standpoint “patient belongings should be bagged and secured, separated, not mixed with other patient’s, not with equipment used for different patients.” NC00220136 NC00217092 NC00216576 NC00214275 NC00214128 NC00204128 NC00200064 NC00200627 NC00200950 NC00197840 NC00197063”

“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: 49003 Based on facility policy review, medical record review, and staff interviews, the facility failed to provide patient assessments and reassessments of vital signs and pain per facility policies in 5 of 23 patient records sampled (Patient #’s 22, 6, 8, 14, 21). The findings included: Review on 03/07/2024 of the facility policy “DRH ED Documentation Policy Emergency Department Nursing ID:8245,” revised 09/01/2023, “... Procedure: A. Basic Triage Documentation - Adult ... g. Vital signs will include temperature noting modality, heart rate, respiration rate, blood pressure and pain level h. Pulse oximetry when appropriate ... C. Documentation of Triage Status Re-Checks of Waiting Patients a. Vital signs, observations, and patient condition updates are to be performed at a minimum ... based on initial ESI level as follows: i. ESI Level 2-every 2 hours ii. ESI Level 3-every 3 hours iii. ESI Level 4, 5-Every 4 hours ... D. Documentation of Ongoing Assessments While in Patient Treatment Area ... a ... vii. Vital signs, observations, and patient condition updates are to be performed based on initial ESI level as follows: 1. ESI Level 1-every 15 minutes until condition stabilizes, then every hour 2. ESI Level 2-every 2 hours 3. ESI Level 3-every 3 hours 4. ESI Level 4, 5-every 4 hours ... E. Documentation of Discharged Patients (Treated and Released) a. Vital signs including pain level within last hour ... I. Documentation for Patients Requiring a Psychiatric Evaluation ... h. Vital signs every 6 hours or more frequently based on patient clinical status ... J. Documentation for Admissions Holding Patient ... b ... iii. Vital signs every 4 hours ...” Review on 03/07/2024 of the hospital policy “DUHS Pain Management Policy” ID 2330, revised 11/18/2020, “... Procedure: A. Initial Assessment: (see sections L. & M. for ambulatory and ED requirements) ... M. Emergency Department Nursing- 1. Pain Assessment and Documentation a. ... all patients will be screened for the presence/absence of pain at that time of presentation for care or with any new complaint of pain by patient/family or caregiver. b. Pain will be initially assessed at time of triage and both pharmaceutical and non-pharmacologic interventions, if administered, to address pain will be documented in the patient EMR. c. Reassessment of pain will occur within one hour as required following any pain intervention.” 1. Closed medical record review completed 03/06/2024 revealed Patient #22 (Pt#22) a 44-year-old presented to the Emergency Department (ED) on 12/09/2023 at 1023 with altered mental status and a headache at the back base of the head and was assigned a patient acuity score (ESI) of 2 (reflects the urgency of care with 1 being the greatest need and 5 being the least). The Patient Care Timeline revealed the initial triage vital signs at 1024 as temperature 36.6, heart rate 85, respiratory rate 18, blood pressure 154/82, and a room air pulse ox of 97%. There was no pain assessment documented. The Patient Care Timeline revealed on 12/09/2023 at 1152 Pt#22 was medicated with Toradol (non-narcotic pain medication) 15mg (milligrams) and Zofran (antinausea medicine) 4mg IV (intravenous) for pain and nausea. There was no reassessment of pain within one hour of medication administration. At 1402 a pain scale of 2/10 (0/10 is no pain and 10/10 is the worst pain) was documented on the Patient Care Timeline. The next set of vital signs documented on 12/09/2023 at 1820 revealed a temperature of 36.8, heart rate 86, respiratory rate 19, and blood pressure 139/78, and room air pulse ox of 97%. Vital signs at 1848 were documented as temperature 36.7, heart rate 77, blood pressure 149/78, and a room air pulse ox of 96%. Vital signs documented at 2042 revealed a heart rate of 84, blood pressure 141/82, and a room air pulse ox of 95%. There was no temperature or respiratory rate documented. A pain assessment was documented at 2045 revealing a rating of 5/10 and Pt#22 was given Motrin (non-narcotic pain medicine) 400mg orally. There was no reassessment of pain completed within one hour of the medication administration. The Patient Care Timeline revealed Pt#22 was admitted to observation status on 12/10/23 at 0052. A final set of vital signs was documented at 0848 and revealed temperature 36.7, blood pressure 133/84, heart rate 79, respiratory rate of 16, and room air pulse ox of 96% with the discharge diagnosis of acute encephalopathy. The medical record review failed to reveal a complete set of initial vital signs according to facility policy. Record review failed to reveal a pain assessment with pharmacological intervention and a follow-up reassessment within one hour of medication administration. Record review failed to reveal ongoing documentation of vital signs according to ESI level or according to the holding guidelines. Interview on 03/07/2024 at 1715 with the Clinical Director (CD#2) revealed the expectation for staff to follow written policy. CD#2 revealed that vital signs should be completed as per policy and a pain assessment should be completed upon arrival, a reassessment after medication administration, and based upon policy as it relates to the patient acuity score. 2. Closed medical record review completed 03/06/2024 revealed Patient #6 (Pt#6) a 65-year-old presented to the Emergency Department (ED) on 08/09/2023 at 1224 via ambulance with complaints of altered mental status and assigned a patient acuity score (ESI) of 3 (reflects the urgency of care with 1 being the greatest need and 5 being the least). The Patient Care Timeline revealed that the initial triage vital signs completed at 1226 were temperature 36.6, heart rate 98, respiratory rate 18, blood pressure 125/87, pulse ox 98% on room air, and pain rated 0/10 (0/10 is no pain and 10/10 is the worst pain). At 1444 the Patient Care Timeline revealed temperature of 36.6, heart rate 98, respiratory rate 18, blood pressure 125/87. Pt#6 was discharged at 2157 with a final diagnosis of altered mental status and seizure with no other vital signs recorded. During Pt#6’s hospitalization, staff failed to provide vital signs according to ESI and within one hour of discharge. Interview on 03/07/2024 at 1715 with the Clinical Director (CD#2) revealed the expectation for staff to follow written policy. CD#2 revealed that vital signs should be completed as per policy and a pain assessment should be completed upon arrival and based upon policy as it relates to the patient acuity score. CD#2 revealed that vital signs should be completed within one hour of discharge. 3. Closed medical record review completed 03/06/2024 revealed Patient #8 (Pt#8) a 33-year-old presented to the Emergency Department (ED) on 02/24/2024 at 0738 with complaints of needing a psychiatric evaluation with a history of drinking, doing drugs, and hearing voices and assigned a patient acuity score (ESI) of 2 (reflects the urgency of care with 1 being the greatest need and 5 being the least). The Patient Care Timeline revealed the initial triage vital signs from 0753 as temperature 36.7, heart rate 93, respiratory rate 18, blood pressure 118/63, and pulse ox 98% on room air. There was no pain assessment documented. Pt#8 was then discharged at 1629 with no other vital signs documented. During Pt#8’s hospitalization, staff failed to provide complete vital signs and pain assessments according to the psychiatric hold guidelines in the documentation policy. Interview on 03/06/2024 at approximately 1000 with the Assistant Chief Nurse of Psychiatry revealed that the expectation was that nurses followed the documentation policy related to vital signs for psychiatric evaluation as well as upon discharge from the facility. Interview on 03/07/2024 at 1715 with the Clinical Director (CD#2) revealed the expectation for staff to follow written policy. CD#2 revealed that vital signs should be completed as per policy, including a pain assessment upon arrival and within one hour of discharge. 50111 4. Closed medical record review completed on 03/06/2024 revealed Patient #14 (Pt#14), a 44-year-old female, presented to the Emergency Department (ED) on 01/13/2024 at 1803 with a chief complaint of back and abdominal pain. Medical record review revealed Pt#14 presented to triage on 01/13/2024 at 1809 and was assigned an ESI level of 3. Triage vital signs at 1809 were temperature 36.9, heart rate 102 (normal heart rate range is 60-100), respirations 16, blood pressure 162/125 (high blood pressure is considered 140/90 or higher), a pulse oximetry level 97% on room air and a pain level 6/10. Record review revealed that Pt#14 received 0.5 milligrams of intravenous Dilaudid for pain level 8/10 (0/10 is no pain and 10/10 is the worst pain) at 1925. Review failed to reveal a reassessment of pain within one hour after Dilaudid was administered. At 2117, P#14 was medicated with a second dose of 0.5 milligrams intravenous Dilaudid with no documented pain assessment or reassessment within one hour after administration. Review revealed Pt#14 was discharged at 2252 on 01/13/2024. Review failed to reveal vital signs within one hour of discharge. Interview with a Clinical Director (CD#2) on 03/07/2024 at 1715 revealed that staff was expected to follow written policy for documentation of vital signs and pain assessment. Interview revealed policy was not followed for documentation of vital signs and pain assessment for Pt#14. 5. Closed medical record review completed on 03/06/2024 revealed Patient #21 (Pt#21), a 37-year-old female, presented to the Emergency Department (ED) on 01/10/2024 at 1023 with a chief complaint of back pain. Medical record review revealed Pt#21 presented to triage on 01/10/2024 at 1037 and was assigned an ESI level of 4. Triage vital signs at 1039 were temperature 37, heart rate 70, respirations 16, blood pressure 133/79 and pulse oximetry level 100% on room air. Review revealed Pt#21 was given 15 milligrams of intravenous Toradol at 1149 and 0.5 milligrams of intravenous Dilaudid at 1150 with no documented pain assessment. Review failed to reveal a reassessment of pain within one hour after Toradol and Dilaudid were administered. Pt#21 was discharged on 01/10/2024 at 1611. Review failed to reveal vital signs and pain assessment within one hour of discharge. Interview with a Clinical Director (CD#2) on 03/07/2024 at 1715 revealed that staff was expected to follow written policy for documentation of vital signs and pain assessment. Interview revealed policy was not followed for documentation of vital signs and pain assessment for Pt#21.”