Cooper University Hospital

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 51986 Based on medical record review, staff interview, and review of facility documents, it was determined the facility failed to ensure that the patient’s care plan concerning the specialty bed for the treatment of pressure wounds is plugged in and functioning at all times to deliver its intended therapeutic function. Findings include: Facility policy titled, “Skin Care to Reduce the Risk of Pressure Injury” (Reviewed: 02/14/2023) stated, “ ... I. Purpose: A. Provide guidance for appropriate skin assessment and use of nursing interventions to improve patient outcomes and reduce the risk of pressure injury in the adult and pediatric patient population. II. Scope: A. Members of the patient care team, including but not limited to RNs ... who are responsible to maintain a patient’s skin integrity and reduce the risk of pressure injury. III. Policy: A. The care of skin breakdown, including reducing the risk of pressure injury, skin tears ... is an interdisciplinary team approach ... D. Interventions are to be put into place to reduce the risk of Hospital Acquired Pressure Injuries ... IV. Policy Implementation: ... 7. Nursing Interventions: Implement ... Skin Care Bundle (See Appendix A) including measures to reduce risks of pressure injuries ... Appendix A ... IV. Bed/Chair Pressure Redistribution: ... Therapeutic: ... Dolphin Immersion mattress.” Facility policy titled, “Incoming Inspection of all New Leased or Rented Patient Care Equipment” (Reviewed: 12/12/2022) stated, “I. The purpose of this policy is to establish a system which provides medical equipment safety and an understanding for the approval and preventative maintenance inspection of newly acquired biomedical/clinical equipment ... III Procedure: ... B. Equipment maintained by the manufacturer/vendor under a service agreement will also be included in the equipment management program where services will be monitored and recorded. Facility policy titled, “Red Tag for Equipment Repair” (Reviewed: 01/05/2023) stated, “I. Purpose: A. To ensure accurate and timely repairs of all medical devices and to promote effective communications as it relates to the repair of medical devices ... II. Policy: A. All manufacturing medical device shall immediately be reported to the Clinical Engineering Department. B. Malfunctioning equipment shall be removed from service with a red tag attached to the equipment ...” On 04/02/25 at 11:44 AM, medical record review was conducted with Staff (S)3 (Senior Informatics Analyst) and revealed that Patient (P)1 had been placed on a Dolphin Immersion mattress [a specialty bed that simulates the effects of a body immersed in a fluid] for the treatment of a stage IV (four) pressure injury of the sacrum. On 11/04/2024 at 11:02 PM, a Nursing Note documented by S28 (Registered Nurse [RN]) revealed, “1930 [7:30 PM] Pt [patient] with visitor ([Complainant] and [Spouse]) at bedside. [Complainant] upset about pt [patient] bed being unplugged and states [he/she] had someone ... come check on [the patient] earlier in the day and they filed a maintenance request about the bed being unplugged for [him/her] ... This RN plugged the bed back [in] and left the room.” The duration for which the patient’s specialty bed failed to provide its intended therapeutic function due to being unplugged could not be determined. There was no documented evidence that the specialty bed was functioning after it was plugged in. S1 (Director of Relations and Affairs) confirmed that the Dolphin Immersion mattress is required to be plugged in to provide the prescribed therapy. Upon request, S1 was unable to provide a maintenance request. On 04/02/25 at 11:44 AM, upon interview, S1 confirmed the above findings and stated, “an unplugged bed would not have generated a maintenance request. For the bed to have been looked at, a red tag would have had to been placed on the bed with the reasoning and then removed from the patient’s room. A phone call would then be placed to our engineering department to make them aware of it. I do not see a red tag request was placed for this patient’s bed.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 49174 Based on review of medical records (MR), review of facility documents, and interview with the staff, it was determined the facility failed to: 1.) place a homicidal patient on a one-to-one observation (1:1) in one of two medical records of patients on 1:1 observation who eloped; (A0144) 2.) to provide a STAT psychiatric consultation to a homicidal patient in one of one medical chart reviewed. This failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to the patient and others. (A0144) On 10/31/24, at 12:17 PM, an IJ was identified. On 10/31/24 at 1:09 PM, the IJ template was presented to the administration and an acceptable removal plan was accepted on 10/31/24 at 3:39 PM. On 11/1/24, verification of the IJ removal plan was conducted and included the following: review of staff re-education sign in-sheets and staff interviews regarding the facility’s process for placing patients on 1:1 observation and implementing STAT consult orders. The IJ was lifted on 11/1/24 at 11:50 AM. Cross Reference: 482.13(c)(2) Patient Rights: Care in a Safe Setting”

“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: 49174 Based on review of medical records (MR), review of facility documents, and staff interviews, it was determined the facility failed to 1.) place a homicidal patient on a one-to-one observation (1:1) in one of two medical records of patients on 1:1 observation who eloped; 2.) provide a STAT psychiatric consultation to a homicidal patient in one of one medical record reviewed. Findings include: 1. Facility policy titled, “Emergency Department Suicide Risk Assessment” (Reviewed 10/25/2022) stated, “... III. DEFINITIONS: A. TYPES OF OBSERVATION STATUS, commonly referred to colloquially as level of observation, a ‘one to one,’ or ‘1:1’ status in the ED 1. Constant observation - One designated clinical staff member remains within arm’s reach continuously with 1 patient and completes observation documentation every 15 minutes. 2. Close Observation - One designated staff member may monitor patient(s) in an open area with direct line of sight and with unobstructed view of thepatient(s). ... 3. Continuous Observation encompasses both constant and close observation. Patients with SI [suicidal ideation] or HI [homicidal ideation] are designated as Level I. Patients may also be designated for Level I when exhibiting concerning behaviors such as self-injury, elopement attempts, ... or other signs of risk for harming self or others, even if they do not explicitly verbalize SI or HI.” Facility policy titled, “Appendix A: Emergency Department Safe Environment Guidelines’ (Reviewed 10/25/22) states, “ I. Purpose: A. To provide guidelines to staff observing patients posing a safety risk to themselves or others while in the Emergency Department. ... III., Procedure: A. Safety: 1. Patients shall be placed into hospital paper scrubs. 2. Patient belongings shall be placed in a patient belonging bag, labeled, and stored with security during ED visit. ...” On 10/29/24 at 12:03 PM, during a review of the medical record (MR) for Patient (P)2, in the presence of Staff (S)1 (Director of Regulatory Affairs), S2 (Interim Clinical Director of the Emergency Department), S3(AVP Regulatory and Patient Safety), S4 (AVP Nursing Operations), S5 (Medical Informatics), and S6 (Medical Informatics) the following was revealed: On 8/27/24, at 3:45 PM, P2 arrived at the facility’s Emergency Department (ED) with complaints of aggressive behavior. On 8/27/24 at 4:39 PM, P2 was examined by S18, an ED Resident. A review of the ED Provider Notes documented by S18 stated, “... [the patient] tried to cut [his/her] wrists with glass shards ... denying SI [suicidal ideation] now, stating [he/she] wants to hurt someone but does not state who ...” On 8/27/24 at 4:51 PM, S18 placed an order for STAT continuous 1:1 observation, with an Observation Level 1 indicating “SI/HI precautions or ED behavior risk” and a STAT psychiatric consultation. MR2 lacked evidence that P2 was placed on a 1:1 observation. MR2 lacked evidence that P2 was changed into paper scrubs and had his/her belongings taken and placed with security. On 8/27/24 at 5:02 PM, P2 was moved from a hallway bed to a room in the ED at 5:02 PM. MR2 lacked evidence that P2 was on a 1:1 observation at this time. On 8/27/24 at 5:29 PM, P2’s vitals were obtained. On 8/27/24 at 5:30 PM, ED Notes documentation by S16, a Registered Nurse, stated, “17-25- [5:25 PM] patient brought to ER [Emergency Room] from home, patient became aggressive after talking to [his/her] therapist [outpatient - confirmed with S2], vitals stable [blood pressure, pulse, respirations], A&O x4 [alert and oriented to person, place, time, situation], patient has superficial cuts to [his/her] Lt [left] and Rt [right] forearms, will continue to monitor.” P2’s medical record lacked documentation that P2 was placed on a continuous observation prior to P2’s elopement. On 8/27/24 at 6:46 PM, S16’s documentation in the “ED Notes” stated, “18:15- patient eloped, walked out the back door by [his/her] mother. 18:35- writer called mom, left a voice message. 18:40- writer called patient. Left a voice message.” On 8/27/24 at 6:55 PM, S19’s, a Registered Nurse, documentation in the “ED Notes” stated, “1850-called [city] county police dispatch at this time per physician request to go to patient residence for wellness check, to return to ED for psychiatric evaluation.” There was no documented evidence that P2 returned to the Emergency Department. On 10/29/24 at 12:12 PM, upon interview, S2 confirmed that P2 was not placed on a 1:1 per the physician’s order and stated that P2 should have been placed on a 1:1 for homicidal ideation after the physician evaluation since the patient was considered high risk. On 10/30/24 at 11:41 AM, an interview with S2 was conducted to discuss the process of placing a patient on 1:1 observation. S2 explained that after a physician evaluates the patient and determines the need, the physician would communicate that with the nurse. The nurse then calls the flow manager who calls staffing to send someone to observe the patient. The ED technician will be pulled off the floor to sit with the 1:1 until someone else is available. When asked how long that process should take, S2 stated, “I can’t put a time on that, my hope is that it is immediate.” On 10/31/24 at 10:00 AM an interview was conducted with S16, ED Registered Nurse, P2’s nurse. When asked about the process for ordering a 1:1, S16 stated, “I am notified of a one-to-one order through the computer tracking system.” S16 also stated, “I’ve had two incidences where I didn’t see a 1:1 entered into the system until later.” When asked if notification through the computer system is the primary method of notifying the nurse of a one-to-one order, S16 stated, “correct.” S16 confirmed that a 1:1 order should be implemented immediately for patient safety. 2. Facility document titled, “Rules and Regulations of the Medical Staff” (Revised 9/9/24, Approved 10/22/2024) stated, “ ... J. The attending practitioner is primarily responsible, for requesting consultation when indicated and for calling in a qualified Consultant. EMERGENCY DEPARTMENT AND INPATIENT CONSULTATION: 1. Emergent - ... since patient outcome in emergent cases may be directly related to care provided by the on-call physician, that physician shall respond by telephone within 20 minutes of receiving a call from hospital clinical staff. ...” A review of P2’s medical record on On 10/29/24 at 12:03 PM, revealed that on 8/27/24 at 4:51 PM, a STAT consult to Psychiatry was placed by S18. Upon further review, MR2 lacked evidence that the on-call psychiatrist was notified of the STAT consultation.”