Inspira Medical Center Vineland

“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: 43214 Based on medical record review, staff interview, and review of facility documents it was determined that the facility failed to ensure the effective implementation of its processes concerning monitoring patients assigned to tele-sitter for observation. Findings include: Facility policy titled, “Virtual Video Monitoring (Tele-Sitter)” (reviewed 08/25/2025), stated, “ ... V. PROCEDURE: ... B. Virtual Monitoring Technician ... 2. Procedure: i. Maintains virtual video observation at all times. ... iii. Immediately notifies nursing staff if the patient requires assistance. *If the virtual monitoring technician is unable to make contact with nursing staff, nursing leadership should be contacted. ...vii. Participates in collaborative identification and reporting of patient safety issues. Ix. Assures patient environment safety. ... x. Demonstrates safe work practices and attitudes, follows safety rules, works to prevent unsafe conditions and behaviors, and participates in organizational and department safety programs. ...” On 04/13/26 a review of Patient (P)1’s medical record revealed the following: P1 presented to the facility on 03/21/26 with a change in mental status. P1 was initially seen and cleared by Neurology and Psychology on 3/21/26. The Psychiatry Progress Note from 3/25/26 at 3:17 PM stated, “ ... Assessment: ... Reconsulted on 3/25 for hallucinations. ... Plan: Observation/Safety: -Recommend the following observation status: Safety sitter/ tele-sitter, although defer to nursing for order ...” Review of the tele-sitter initiation documentation retrieved from the virtual monitor technician/tele-sitter revealed that P1 was started on the tele sitter monitoring on 3/26/26 at 1:15 PM. The Progress Note from 04/01/26 at 8:08 PM stated, “ ... Updates for today: Nursing informed me that patient was having increased paranoia today, reportedly feeling that nursing was keeping [his/her] daughter captive. When I went to examine pt [patient] in late afternoon, pt had reportedly eloped from hospital. PD [Police Department]/daughter was contacted who located patient and brought pt back to ED voluntarily after daughter spoke with patient. ...” A review of the nursing documentation under “Environmental Safety Management Flowsheet” revealed that P1 was on tele monitoring at the time of the elopement from the facility on 04/01/26. Review of the “TELESITTER LOG” documentation from 04/01/26 revealed that the virtual monitor technician/tele-sitter reported calling the nurse and/or pressing the STAT button to alert the staff to P1 being in the doorway or being in the hallway on 04/01/26 at 7:25 AM; 9:23 AM; 10:47 AM; 11:04 AM; 2:16 PM and lastly at 3:26 PM which stated, “called nurse pt in hallway. No answer than [sic] called aide doesn’t have phone than [sic] called nurse again.” At 4:26 PM, the virtual monitor technician documented, “pt returned in room with nurse.” On 04/14/26 at 10:08 AM, during an interview with Staff (S)13, he/she denied receiving multiple calls from the virtual monitor technician on 04/01/26 regarding P1 being in the hallway or in the doorway. S13 stated that on 04/01/26, P1 was acting very paranoid and that he/she placed a call to P1’s psychiatrist regarding the paranoia and then spoke to P1 to update him/her. S13 stated that shortly after that conversation, the unit secretary informed him/her that P1 was not in his/her room, and he/she went to check and could not locate P1. S13 stated that he/she filled out the incident report based on the times that he/she made phone calls to security from his/her phone. S13 stated that the tele-sitter did call to report that the patient was not in the room, but the tele-sitter believed that P1 was walking around the unit with the PCT at the time. At 11:00 AM, an interview was conducted with S15, who spoke with the virtual monitoring technician/tele-sitter involved in the incident after it occurred. S15 explained that the tele-sitter reported that he/she witnessed S18 going into P1’s room and doing vital signs, but then the tele-sitter had to intervene on another patient who was trying to get out of bed, and that took some time. When the tele-sitter looked back P1 was not in the room, so he/she called into the room, received no response; then tried to call the nurse, did not get an answer; tried to call the tech, who didn’t have a phone; and then called the nurse again. The nurse answered the phone as the Unit Secretary was walking into P1’s room, and the nurse informed the tele-sitter that they were looking for P1. When asked if that was the usual process, S15 stated that it was not. He/she stated that the virtual monitor technician/tele-sitter should have called into the room, then called the nurse, then hit the STAT button, to alert the staff that help was needed in the room immediately. The above findings were confirmed with S15 on 4/14/26 at 11:10 AM.”

“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: 43214 Based on a review of four of 10 medical records (Patients (P)1, P8, P9 and P10), staff interviews, review of facility documents, and review of accepted standards of nursing practice, it was determined that the facility failed to assess, monitor, and document patient status in accordance American Nurses Association Standards of Practice and facility policy. Findings include: Facility policy titled, “Documentation Policy” (reviewed 4/14/2026), stated, “ ... I. PURPOSE: The purpose of this policy is to outline the expectations that nursing documentation must be accurate, timely, complete, readable, secure, and clinically meaningful. ... V. PROCEDURES: RN Documentation. A. RN documentation must include assessments, care plans, interventions and outcomes, medications and treatments, provider communication, care coordination, patient/family education, and discharge documentation as close to real-time as feasible and always within unit-defined standards. ... PCT/MHT Documentation. A. The PCT/MHT documents data collected into the patient’s medical record (e.g., vital signs, intake and output, weights) and Activities of Daily Living (i.e., nutrition, hygiene, activity). ... VII. REFERENCES & STANDARDS ... American Nurses Association (ANA). (2021). Standards of practice. Nursing: Scope and Standards of Practice (3rd ed.) (pp. 53 - 66). Silver Spring, MD: ANA ...” Reference: American Nurses Association (ANA). (2021). Standards of practice. Nursing: Scope and Standards of Practice (3rd ed.) (pp. 53 - 66). Silver Spring, MD: ANA, stated, “... Standards of Practice: Standard 1. Assessment. The registered nurse collects pertinent data and information relative to the healthcare consumer’s health or the situation. ... Documents relevant data accurately and in a manner accessible to the interprofessional team. ...” On 04/13/26, a review of Patient (P)1’s medical record conducted in the presence of S9, revealed the following: P1 presented to the facility on 03/21/26 with a change in mental status. P1 was initially seen and cleared by Neurology and Psychology on 03/21/26. The Psychiatry Progress Note from 03/25/26 at 3:17 PM stated, “... Assessment: ... Reconsulted on 3/25 for hallucinations. ... Plan: Observation/Safety: -Recommend the following observation status: Safety sitter/ tele-sitter, although defer to nursing for order ...” The tele sitter (camera placed in room monitored by a technician for patients at risk for falls, restless behavior, wandering, etc.) was initiated on P1 on 03/26/26 at 1:15 PM and continued until 04/01/26 when P1 eloped and was placed on 1:1 observation upon his/her return to the facility. On 04/14/26 at 10:47 AM, during an interview Staff (S)18 stated that patients on tele-sitters will still have hourly rounding completed by the nurses and technicians. S18 indicated that on 04/01/26 he/she was performing hourly rounding and had just finished observing P1 prior to him/her eloping from the facility. At 1:30 PM, the Caregiver Hourly Rounding documentation for P1 was reviewed with S9. P1’s medical record lacked documented evidence of hourly rounding from 4:00 AM on 03/28/26 until 8:00 PM on 4/5/26. During an interview, S9 stated, “the hourly rounding responsibility was a shared responsibility between nursing and the PCTs [patient care technician]. I don’t think the PCTs have access to this though, I don’t know if they know this band [part of the medical record for documentation] exists. It was an upgrade, but I had to manually put it in, they [PCTs] may not know how to do it.” The above findings were confirmed by S9. On 04/14/26 at 12:15 PM, a review of P8’s medical record conducted in the presence of S9, revealed the following: P8 was admitted to the facility on 01/19/26 with a diagnosis of NSTEMI (non-ST Elevated Myocardial Infarction). During the admission, P8 was documented as oriented to self with confusion. P8 was placed on a tele-sitter for “wandering risk.” The medical record lacked evidence of a “Caregiver Hourly Rounding” documentation, this was confirmed with S9 on 04/14/26 at 1:42 PM. At 12:30 PM, a review of P9’s medical record was conducted in the presence of S9, which revealed the following: P9 was admitted to the facility on 04/11/26 with a diagnosis of altered mental status and a fall at home. P9 was documented as confused and was placed on a tele-sitter for “fall risk.” The tele-sitter log documentation stated, “Start Date: 4/11/26 at 8:32 AM.” The medical record lacked evidence of “Care Giver Hourly Rounding” documentation, this was confirmed with S9 on 4/14/26 at 1:50 PM. At 12:35 PM, a review of P10’s medical record conducted in the presence of S9, revealed the following: P10 was admitted with a diagnosis of acute infectious encephalopathy. P10 was documented as confused and was placed on a tele-sitter for “fall-risk and confusion.” The tele-sitter log documentation stated, “Start Date: 4/11/26 at 9:22 AM.” The medical record lacked evidence of “Caregiver Hourly Rounding” documentation, this was confirmed with S9 on 04/14/26 at 1:58 PM. 51555”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 50124 Based on staff interviews and review of facility documents, it was determined that the facility failed to ensure that: 1) the response process for “grievances” is implemented in accordance with facility policy; and 2) grievances are investigated in accordance with facility policy. Findings include: 1. The facility’s policy titled “Patient/Visitor Complaint and Grievance,” last reviewed 11/25/25, stated “...C. Grievance ...If the grievance can be investigated and resolved within 7 calendar days of the initial receipt, the patient or representative will receive a final letter detailing the investigation and the measures taken to address the concerns. If the grievance cannot be resolved within 7 calendar days, an acknowledgement letter will be sent to the patient or representative, informing them of the current status and providing an estimated timeline for completion. The hospital aims to ensure that a final letter is sent to the patient or representative within 37 days of the initial receipt of the grievance ...If it becomes apparent that the grievance cannot be resolved within the 37-day period, an interim letter will be issued to detail the progress of the investigation and provide an anticipated completion date ...” On 12/31/25 during the review of facility documents, an electronic mail (email) dated 11/12/25 at 3:17 PM, sent by Patient (P)1’s family member to the facility contained a written complaint with multiple concerns. An email reply sent by the facility to P1’s family member dated 11/12/25 at 9:29 PM, was reviewed. The email stated, “We have received your report regarding [P1’s] care and will review it promptly in accordance with [facility] policy and our grievance procedure ...If you have additional details or documentation, please send them to ...” On 12/31/25 at 12:16 PM, Staff (S) 15 stated that this email was the “acknowledgement” letter sent within 7 days of the initial receipt of P1’s grievances. No other correspondence was provided acknowledging the finalization or continuation of the investigation by the facility as required by facility policy. The facility’s “Grievance” Report for P1 dated of 11/12/25, was reviewed. The “File State” for this report noted “Closed.” The “Resolution Date,” noted 11/13/25, with “Manager” as the Reviewer. The manager, under “Situation” noted the concerns mentioned by P1’s family member; under “Background” noted interviews with staff involved; under “Feedback Assessment” stated, “Issues in Concern not Substantiated;” and under “Recommendation...” noted the summary of findings and recommendations for patient care. However, on 12/31/25 at 11:45 AM, S15 stated that this investigation was still ongoing, not closed. On 12/31/25 at 12:01 PM, S15 stated an acknowledgement letter should be sent to the complainant within 7 days from the initial receipt of the grievance, a letter should be sent if the grievance was resolved, and if the investigation was ongoing and not resolved a letter should be sent within 37 days from the initial receipt of the grievance. S15 stated that the facility should send an official “paper” letter for the acknowledgement and resolution of the investigation. The initial date of receipt of the P1’s grievances was 11/12/25. S15 confirmed that a letter should have been sent to the complainant within 7 days, which would have been by 11/19/25, and a second letter within 37 days, which would have been by 12/19/25, if the grievance was still under investigation. On 12/31/25 at 12:13 PM, documentation detailing the investigation and the measures taken to address the grievance, such as the letters sent to P1’s family member were requested. On 12/31/25 at 12:15 PM, S15 corresponded with S16 via phone and confirmed that an official letter was not sent to P1’s family member concerning the investigation of the grievances. S15 stated that the facility usually sends an official “paper” letter, however this case was different, and the facility was communicating with P1’s family member via email. This process was not included in the facility’s policy. On 12/31/25 at 12:18 PM, S15 stated that an official “paper” letter would only be sent to P1’s address or to P1’s designated representative. S15 confirmed that P1’s family member that initiated the “grievances” was not P1’s designated representative, therefore no “official” paper letters were sent to him/her. This process was not included in the facility’s policy. On 12/31/25 at 12:19 PM, this finding was confirmed by S15. S15 could not provide the official “paper” notification letters that addressed the status or outcome of the grievance filed on P1’s behalf as required by facility policy. 2. The facility’s policy titled “Patient/Visitor Complaint and Grievance,” last reviewed 11/25/25, stated “ ...I. Purpose: The purpose of the Patient and Visitor Complaint and Grievance is to outline the procedure to address concerns raised by patients, their representatives, or visitors and to ensure they are addressed in a fair, respectful, and timely manner. II. Policy Statement(s): ...if a complaint remains unresolved, it escalates to a formal grievance, as overseen by the Grievance Committee, ensuring compliance with hospital polices and regulatory requirements ...” An initial complaint submitted by P1’s family member, dated 11/12/25, to the facility was reviewed. The document included a grievance that a staff member hung up the telephone on the complainant while he/she was talking to P1. The facility’s “Grievance Report” for P1, dated 11/12/25, was reviewed. P1’s “Grievance Report” lacked documentation of the investigation that addressed the complainant’s grievance concerning the phone being hung up on him/her. It could not be determined if the facility investigated this complaint. On 12/30/25 at 12:39 PM, S7 stated that he/she was aware of an incident that occurred when the complainant was on a Facetime call with P1. S7 explained that they were trying to get P1 ready for dialysis and P1’s family member would not let the staff turn the phone off. S7 stated he/she hung up the phone on P1’s family member, after explaining several times that they needed him/her to get off the phone due to privacy concerns, related to getting P1 washed up. S7 stated that he/she could not remember the exact date of occurrence, and just remembered it was on P1’s dialysis day. On 12/31/25 at 12:03 PM, S15 stated that there were no additional complaint or grievance reports filed for P1, on or after 11/12/25, concerning this reported grievance for P1. On 12/31/25 at 12:04 PM, this finding was confirmed by S4 and S15.”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 39724 Based on the review of one medical record (MR) MR1, facility document review, and staff interviews, it was determined that the facility failed to ensure that documentation in the medical record is accurate. Findings include: Facility policy titled, “Documentation (ER26) IHN [Name of facility],” last reviewed 12/07/22, stated, “... The patient record is initiated upon the patient’s arrival ... All documentation should be complete and legible...” During review of MR1, with Staff (S) 13 (Director of Social Work) and S15 (Director of Care Coordinators), the following was identified: The “ED [Emergency Department] Nursing Note,” dated 12/24/24 at 00:25 (12:25 AM), stated, “pt [patient] discharged home.” MR1 lacked documentation of a discharge summary or an order for discharge for P1. S13 and S15 explained that the original plan was to discharge P1 to home, however that plan was changed. S13 and S15 confirmed that the nurse note documented in MR1 was inaccurate. The “Discharge Planning Initial Assessment” written by S14 (ED social worker), dated 12/24/25 at 9:36 AM, stated, “ ... Patient was brought in by EMS [emergency medical services] and dc’d [discharged] home. Subsequently, EMS brought patient back to ER [emergency room] due to poor living conditions at home ...” The transport log dated 12/24/24 -12/25/24 was reviewed and it lacked documentation that P1 was transported home on 12/24/24. The facility provided a copy of the communication with the transport company. The “Trip Details” report for the transport called for P1 dated 12/24/24 at 1:28 AM, stated, “ ... per [staff name] cancel trip. Pt [patient] is being admitted ...” On 03/06/25 at 2:00 PM, during an interview conducted in the presence of S13 and S15, S14 stated that the information documented in the “Discharge Planning Initial Assessment” found in MR 1 dated 12/24/24 at 9:36 AM, was based on information verbally provided to S14 by another staff member. S14 stated that based on what he/she knows now, the note is inaccurate, and the patient did not leave the facility on 12/24/24. S13 confirmed that the original plan was to discharge P1 to home, however that plan was changed and P1 was held in the Emergency Department overnight until the social work evaluation was conducted. This finding was confirmed by S13, S14, and S15 on 3/6/25 at 2:10 PM.”