Raritan Bay Medical Center

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 46468 Based on review of medical records (MRs), review of facility documents and interview with facility staff (S) it was determined that the facility failed to ensure the privacy of all patients (0142); that all patients presenting to the Emergency Department (ED) are screened and assessed for suicide risk, and failed to implement their Suspected Victims of Abuse/Neglect/Exploitation policy by not notifying law enforcement about two minor patients that presented to the Emergency Department (ED) with suspected abuse (A0144). This failure resulted in an Immediate Jeopardy, posing a serious risk of harm to the patients. The Immediate Jeopardy (IJ) was identified on 12/4/23 at 5:10 PM. An acceptable removal plan was received on 12/5/23 at 11:51 AM. Verification of implementation of the removal plan was conducted to include: a tour of the ED to observe the updated algorithm and tool kit documents at the nurse’s station. Interviews with five registered nurses, two providers, and one social worker, confirmed staff education on the updated algorithm and tool kit documents. Facility staff were able to speak to the communication process for any suspected abuse, to include resource staff and materials.The IJ was lifted on 12/5/23 at 12:35 PM. Cross Reference: 482.13(c) Patient Rights: Privacy and Safety 482.13(c)(2) Patient Rights: Care in Safe Setting”

“PATIENT RIGHTS: PRIVACY AND SAFETY CFR(s): 482.13(c) Patient Rights: Privacy and Safety This Standard is not met as evidenced by: 48414 Based on medical record review, staff interviews, and review of facility documents, it was determined that the facility failed to ensure that privacy requirements were met for one patient (P9) in accordance with facility policy. Findings include: Facility policy titled, “Authorization for the Use of Photography, Videotaping & Audio Recording” effective date 3/23, stated, “ ...Workforce ...It is recognized that many mobile devices (i.e. cell phones, tablets, etc.) have photographic, video and audio recording capabilities, but the use of these features are prohibited by HMH team members unless authorization is granted and secured applications are embedded in a device. Note: Epic’s mobile apps Haiku ...provide secure access for clinicians to Epic’s electronic medical record. These applications can be utilized for secure capture of clinical images as outlined in the Documentation of Patient Care Section of this policy. ... Documentation of Patient Care. .... Photographs that are used to document in the patient’s medical record must be recorded on an approved device ...” On 12/4/23 at 10:45 AM, review of the Department of Emergency Medicine Quality Action Committee Meeting Minutes Date: November 16, 2023, revealed P9’s case was reviewed, and the facility identified, “Standard of Care: Not Met Review: ...Provider used personal phone to take pictures. ...Action: ED looking to obtain a HMH [Hackensack Meridian Health] issued device for taking pictures to upload to EPIC ....” On 12/4/23 at 11:45 AM, P9’s medical record review was conducted with S9, the ED (Emergency Department Clinical Nurse Educator and S10, a Quality Improvement Specialist, and revealed: P9 presented to the ED on 9/29/23 at 9:44 PM with a chief complaint of “Vaginal Bleeding- 7 Years or Less” and was assigned an ESI 3 (Emergency Severity Index) [an algorithm to categorize patients from level 1, the most critically ill to level 5, the least critically ill and the least resource intensive]. The ED Provider Note on 9/29/23 at 11:45 PM stated, “Spoke with parents about getting photos of the vulvar area to place on the chart. ... Difficult exam, as previously, as the patient is fighting with the staff and trying to keep her legs closed.” The medical record revealed four photographs of P9’s vulvar and anus area were scanned into the medical record on 9/29/23: Photo Number 1 at 11:46 PM; Photo Number 2 at 11:47 PM; Photo Number 3 at 11:49 PM; and Photo Number 4 at 11:50 PM. On 12/4/23 at 12:11 PM, upon interview with S9, he/she stated that the facility uses the “Haiku app [application]” that allows providers to take pictures that do not violate HIPPA (Health Insurance Portability and Accountability Act). S9 and S10 both confirmed they were unsure if the app is utilized from a provider’s personal phone or from a facility phone. On 12/4/23 at 1:42 PM, upon interview with S1, the Director of Patient Safety and Quality, he/she indicated that Haiku is an Epic [electronic medical record system] app [application] that directly uploads pictures within the app and does not save to the user’s phone. S1 confirmed that the pictures taken in P9’s medical record were uploaded from the Haiku app, however the app was utilized from the provider’s personal cellphone. S1 stated, “now there are facility phones to take patient pictures with, there is one in the ED, one in the nursing supervisors’ office and the wound care team has one.” A tour of the ED was conducted on 12/4/23 at 1:55 PM, with S7, the ED Nurse Manager, and S1. At 2:12 PM, an interview was conducted with S16, Psychiatric Advanced Practice Nurse (APN), that indicated that he/she hasn’t taken any patient pictures, however was unaware of an app to use or a facility phone. At 2:16 PM, an interview was conducted with S17, an ED physician, who indicated that if a picture of a patient needs to be documented he/she uses the Haiku app on his/her personal phone. He/She was able to verbalize the process using Haiku. At 2:24 PM, S9 indicated that he/she was unaware of a facility phone in the ED for obtaining patient pictures. At 2:55 PM, an interview was conducted with S22, an ED Provider, who indicated that he/she takes patient photographs on the Epic Haiku app on his/her personal phone. On 12/4/23 at 3:05 PM, S1 stated, “All providers were notified by email from the Chairman and Medical Director of the ED to not use personal phones for pictures of patients.” A request was made for the email from the Medical Director to the ED providers. The email was received and reviewed. S1, also explained that a facility issued cell phone was allocated to the ED, to obtain photos of patients, if necessary. On 12/5/23 at 11:01 AM, S1 confirmed that staff should only be using the facility phone to obtain photographs of patients. S1 also confirmed that the photographs obtained of P9 were from the ED providers personal phone through the “Epic Haiku app”. S1 provided an email dated 12/4/23 at 8:03 PM from the Chair and Medical Director that stated, “If you are using the Epic Haiku app to take and upload pictures, that is an encrypted app that will not save the pictures onto your phone. That is an acceptable way to take pictures. Do no take pictures with your camera app and then upload the pictures.” At 12:15 PM, the Chair and Medical Director sent another email to all the facility providers that stated, “ ...The only way to use a phone to take pictures of a patient’s physical finding to upload to Epic or to send to a consultant, is to use the Epic Haiku app on an HMH approved phone. We have one of these phones in the ANMs [Assistant Nurse Manager] office at each campus. If you need to take a picture of the patient, aske [sic] the ANM for this phone. Do not use your personal phone even if you have the Epic Haiku app on it. The HMH policy on this states that the phone must be an approved device and that is why this has been provided.””

“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: 46468 Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to 1.) ensure that all patients that enter the Emergency Department (ED) are screened and assessed for suicide risk for one pediatric patient (#11); and 2.) implement their Suspected Victims of Abuse/Neglect/Exploitation policy by failing to notify law enforcement concerning two minor patients (#9 and #11) that presented to the Emergency Department (ED) with suspected abuse. Findings include: 1. On 12/4/23 at 11:52 AM, upon review of Patient 11’s (P11) medical record, in the presence of Staff 7 (S7), the ED Manager, it was revealed that each of these patients did not receive suicide screening during triage in the ED. The facility policy titled, “Suicide Risk Screening, Assessment and Prevention Process” (dated 1/22) stated, “ ... D. Procedure: 1. Emergency Department All patients eight years old and above presenting to the Emergency Department or Pediatric Emergency Department will be screened and assessed for suicide risk ... A. ADULT ... All patients 18 years old and greater after arrival to emergency department will be screened for suicide using the Patient Safety Screener 3 (PSS3) [a validated tool used to screen adult patients for suicide, and determine the need for further mental health evaluation, age 18 years and older] .... All patients 8 thru 17 years old after arrival to emergency department will be screened for suicide using the Ask Suicide-Screening Questions (ASQ [a validated tool used to screen pediatric patients for suicide, and determine the need for further mental health evaluation, age 8-17].” On 12/4/23 at 11:25 AM, upon interview, S9 (ED Clinical Nurse Educator) indicated that every patient between the ages of 8 and 17 presenting to the ED receives an ASQ, and confirmed that P11 (fifteen-years-old) did not have the ASQ documented in the medical record. On 12/4/23 at 11:56 AM, upon interview with S7 it was stated that every adult patient gets screened using the PSS3, and the pediatric patients are screened using the ASQ. At 1:55 PM, upon interview with S11, the ED EPS (Emergency Psychiatric Services) Manager, he/she confirmed that all patients, no matter the complaint, physical or psychosocial should have a suicide screening during triage. 2. On 12/4/23 at 11:11 AM, upon review of P9 and P11’s medical records, in the presence of S9 (ED Clinical Nurse Educator), and S10 (Quality Improvement Specialist), it was revealed that the police department was not contacted for each of these suspected cases of abuse, as follows: On 9/29/23 at 9:44 PM, P9 (five-years-old), presented in the ED accompanied by his/her parents with a chief complaint of vaginal bleeding. The nursing assessment was completed, the provider was notified, and the Registered Nurse (RN) S12 notified DCP&P (Division of Child Protection and Permanency). The ED Note dated 9/30/23 at 12:04 AM, indicated that “CPS (Child Protective Services, a.k.a. DCP&P) did not advise to not discharge the patient.... Due to the nature of the injury, child protective services was notified of the incident, and they will investigate further. ...” P9 was discharged home on 9/30/23 at 12:28 AM with parents. At 5:54 AM, S12 documented, “CPS to do further investigation.” P9’s medical record lacked documentation of police notification. On 11/29/23 at 1:16 PM, P11 (fifteen-years-old) presented to the ED via ambulance with a chief complaint of Suicidal Ideation. The EMS (Emergency Medical Services) report noted that 911 call was initiated by an anonymous caller, indicating P11 was being abused by his/her mother. The provider was notified, and DCP&P was notified. At 8:56 PM, the ED Note documented by S13, indicated “waiting for CPS.” P11’s Discharge Disposition dated 11/29/23 at 10:20 PM stated, “Discharge to mom, follow up with DCP&P tomorrow.” The minor was discharged to home with mother. P11’s medical record lacked documentation of police notification. Review of facility policy titled, “Suspected Victims of Abuse/Neglect/Exploitation, 1510” dated 7/20, stated, “ ... A person having reasonable cause to believe that a child has been subjected to abuse or acts of abuse should immediately report this information to the State Central Registry (SCR) at [phone number]. If the child is in immediate danger, call 911 ...” On 12/4/23 at 12:11 PM, upon interview with S9, he/she indicated that if a child presents with suspected physical or sexual abuse, under 18 years old, DCP&P would be notified, also the police department in the town that the incident occurred. On 12/4/23 at 2:15 PM, upon interview with S19 (ED RN), it was stated that for suspected physical or sexual abuse on a child, first, they would let a provider know. S19 further stated that both physicians and nurses may call, however the police department and DCP&P will be notified.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 46468 Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to ensure that the facility policy and procedure was implemented for Medical Screening Exams (MSEs) for one patient (#1). Findings include: On 12/4/23 at 10:05 AM, a review of Patient 1 (P1) medical record was conducted in the presence of Staff 4 (S4) (ED Assistant Nurse Manager), and revealed that on 11/29/23: At 11:48 PM, P1 arrived at the facility ED with a Chief Complaint of “Homeless, Denies chest pain. Verbalizes [he/she] is tired. No shortness of breath. At 11:56 PM, P1’s vital signs were taken. At 11:57 PM, P1 was screened for Suicidal Ideation (SI) with the PSS3 (Patient Safety Screener 3). P1 was screened with three questions: “1. In the past two weeks, have you felt down, depressed, or hopeless? No. 2. In the past two weeks, have you had thoughts of killing yourself? No. In your lifetime, have you ever attempted to kill yourself? No.” The bottom of the PSS3 flowsheet indicated “Suicide Screening Status: NEGATIVE SCREEN.” At 11:58 PM, P1 was assigned an Emergency Severity Index (ESI) 5 [on a scale of 1 to 5, ESI 1 is the most emergent level, requiring life-saving interventions]. At 12:10 AM, P1 was placed in an ED room. At 1:29 AM, Registration was completed. At 3:10 AM, Medical Screening Exam (MSE) was completed. Review of the facility policy titled, “Emergency Medical Treatment And Labor Act (EMTALA) Policy” (dated 2/23) state, “ ... The hospital shall not seek, or ask the patient to seek, authorization from the patient’s insurance company for screening or stabilizing purposes until after the Hospital has provided an appropriate Medical Screening Examination ... “”

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 48614 Based on review of medical records, staff interviews, patient interviews, and review of facility policy and procedures, it was determined that the facility failed to ensure: 1) pain is assessed and treated for one of 10 medical records (#1); 2) pain reassessments are completed in accordance with facility policy and procedure for six of 10 medical records (#2, #3, #4, #6, #8, and #9). Findings include: 1. On 11/22/2023 at 10:00 AM, during medical record review for Patient (P)1 with Staff (S)4 (Emergency Department Manager), in the presence of S1, (Quality Improvement Specialist), S2, (Quality Improvement Specialist), and S3, (Chief Nursing Officer), the following was revealed: On 11/06/2023 at 01:08 [1:08 AM], P1 presented to the ED [Emergency Department] with complaints of chest pain, left sided (below the breast area) pain, and lower back pain that radiates down to the left leg. At 1:14 AM, P1’s triage was started. There was no documented pain assessment. At 2:26 AM, a MSE (Medical Screening Exam) was completed by the ED provider. The chief complaint documented was “chest pain and back pain.” Review of the ED Provider Examination of P1 stated, “Review Of Systems ... Respiratory: Positive for shortness of breath. Negative for cough ...Cardiovascular: Positive for chest pain and leg swelling ... .” Documentation from the ED Provider identified P1 was positive for pain. There was no documented measurement of P1’s pain level throughout his/her course in the ED, as outlined in the facilities “Pain Management” policy. The Facility policy, “Pain Management” (10/2021) states, “ ...when it has been determined that a patient is experiencing pain; a clinician further assesses factors impacting that pain experience. This includes the following:..Pain intensity is assessed...utilizing a validated assessment scale...a simple verbal scale of 0 to 10...0 is defined as “no pain” and 10 is defined as “sever pain...”. The facility “Nursing Documentation” (04/2022) policy states, “ ...All assessments shall be available to all healthcare personnel involved in the care of the patient...Documentation in the EMR is performed by the appropriate disciplines involved in the patient’s care...”. On 11/22/2023 at 10:05 AM, during an interview, S4 (ED Nurse Manager) stated, “when vital signs are done in the ED, the pain assessment is done at the same time.” S4 confirmed that there was no documented evidence that a pain assessment was done in the ED for P1. On 11/06/2023 at 05:29 [5:29 AM], P1 was admitted to the 5th floor nursing unit. P1’s first pain assessment was not documented until 8:00 AM, at a 0/10 on the numeric pain rating scale. At 9:50 AM, P1’s pain score was documented as a 7/10; “pain location: back, radiating towards the leg”; was described as “constant” and “aching, cramping, crushing, penetrating, nagging.” Review of the prescribed medications revealed an order for lidocaine (Lidoderm) 5% 1 Patch with a start date of 11/06/23 0515 [5:15 AM]. There was no documentation that P1 received the Lidocaine Patch ordered. A nurse to doctor communication under the section titled, “Registered Nurse Progress Notes,” dated 11/6/23 at 2:00 PM stated,” ... PATIENT COMPLAIN OF RIB PAIN RADIATING TO THE LEFT LEG. DR. (NAME) NOTIFIED, WILL SEE THE PATIENT ...on 11/06/2023 at 15:50 [3:50 PM], it stated,” ...DR. (NAME) CAME AND SPEAK TO THE PATIENT, THEN THE PATIENT GET UPSET [sic]. DO NOT WANT ANY DISCHARGEINSTRUCTION [sic] The SALINE LOCK REMOVED AND MONITOR. DO NOT ANY PAIN MEDICATIONS [sic]. LEFT AMBULATORY BY THE RN. NOT IN ACUTE DISTRESS ...” P1 was discharged on 11/6/23 at 4:18 PM. An order was documented for oxycodone-acetaminophen (PERCOCET) 5-325 MG (milligrams) per tablet, 1 tablet, with a start date of 11/06/23 15:30 [3:30 PM]. There was no documention that P1 received the Percocet ordered. There was no documentation that P1 was provided any other pain medication during his/her hospital course. On 11/22/23 at 11:55 AM, during an interview with S12 (Registered Nurse, 5th floor), he/she stated, “When a patient comes from the ER (Emergency Room), the process of admission to the unit starts with an overall assessment.” S12 further stated, “an overall assessment consist of vital signs, pain assessment, body assessment, and identification of patient needs.” S12 also stated, “if a patient is experiencing a pain level of seven (7), I would contact the doctor. If the primary is not available, we can call a resident for a one time order.” S12 stated, “documentation on patients’ charts are done throughout the shift. Every patient gets a pain assessment, every four hours for the Telemetry Unit.” The Facility policy, “Pain Management” (10/2021) states, “ ...requires that pain be assessed in all locations where care is provided ...Pain is... personal... influenced to varying degrees by biological, psychological, and social factors ...A person’s report of... pain should be respected ...pain is contingent upon appropriate pain assessment ...is subjective ...the patient is the best judge of the intensity and relief of pain ... ...presence of severe pain requires immediate attention and intervention...” The Facility policy, “Patient Rights” (3/2023) states, “ ...Every New Jersey hospital patient shall have the following rights...to appropriate assessment and treatment for pain ...” The facility policy, “Nursing Documentation” (04/2022) states, “ ...Required Documentation ...Vital signs and Pain Assessment ...assessed by the registered nurse, based on the patient’s chief complaint ... .” 2. On 11/22/2023 at 11:45 AM, Medical Records (MR) two through 10, reviewed with S8 (Professional Development Department Specialist), revealed the following: MR #2: Primary Problem: Closed Fracture of right hip, initial encounter. P2 had a pain assessment on 11/21/2023 at 20:00 [8:00 PM] with a reported pain level of 2/10. P2 was given acetaminophen extra strength 1000mg at 21:53 [9:53 PM]; no pain re-assessment done 1 hour post medication administration in accordance with facility policy. MR #3: Primary Problem: Acute knee pain. P3 had a pain assessment on 11/21/2023 at 4:45 AM, with a reported pain level of 10/10. Morphine 6 mg IV (intravenous) Push given at 6:15 AM, Morphine 4 mg IV Push given at 7:25 AM; no pain re-assessment documented 1 hour post medication administrations in accordance with facility policy. MR #4: Primary Problem: Osteomyelitis of left foot, unspecified type. P4 had a pain assessment on 11/20/2023 at 00:41 [12:41 AM], with a reported pain level of 4/10. Oxycodone 5 mg by mouth was given at 00:41 [12:41 AM]; no pain re-assessment documented 1 hour post medication administration in accordance with facility policy. MR #6: Primary Problem: Numbness of both lower extremities. P6 had a pain assessment on 11/22/2023 at 10:36 [10:36 AM], with a reported pain level of 5/10. P6 was given acetaminophen 650 mg at 10:36 [10:36 AM]; no pain re-assessment documented 1 hour post medication administration in accordance with facility policy. MR #8: Primary Problem: Acute pancreatitis, unspecified complication status, unspecified pancreatitis type. P8 had a pain assessment done on 11/20/2023 at 14:53 [2:53 PM], with a pain level of 8/10. P8 was given Fioricet, ESGIC 50-325-40 mg tablet at 17:42 [5:42 PM]. No pain re-assessment documented 1 hour post pain medication administration in accordance with facility policy. MR #9: Primary Problem: Intractable headache. P9 had a pain assessment on 11/21/2023 at 09:36 [9:36 AM], with a pain level of 8/10. P9 was given Toradol injection 30 mg IV Push at 10:54 [10:54 AM]. No pain re-assessment done 1 hour post pain medication administration in accordance with facility policy. The facility “Pain Management” (10/2021) policy states, “...Once an intervention is instituted to address pain needs, appropriate follow-up assessment is required...Pain reassessment is completed within a maximum of one hour following pain medication administration and is documented...”. The facility “Nursing Documentation” (04/2022) policy states, “ ...Reassessment can be based on any of the following: their individualized need...plan of care...change in the patient’s condition...the patient’s diagnosis...desire for care, treatment, and services...”.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 48614 Based on medical record review, staff interviews, review of policy and procedure, it was determined that the facility failed to ensure that patients participate in the development and implementation of his/her care plan. Findings include: On 11/22/2023 at 10:00 AM, during medical record review for Patient (P)1 with Staff (S)4 (Emergency Department Manager), in the presence of S1, (Quality Improvement Specialist), S2, (Quality Improvement Specialist), and S3, (Chief Nursing Officer), the following was revealed: On 11/06/2023 at 01:08 [1:08 AM], Patient (P)1 presented to the Emergency Department (ED). with a chief complaint, documented in the “ED-specific reports” as the following: “ ...Chief Complaint ...Chest pain ... Left side below breast area, started 11/04/2023, pain increased 11/05/2023 ...Lower Back Pain ...Radiates down left leg ...Patient roomed in ED ... To room C1-03 ... 01:14 [1:14 AM] ...”. On the ED Provider Examination Note of P1, on 11/06/2023 at 2:26 AM, while in the ED, it was identified in S17, the Medical Doctor-ED Provider, under documentation of, “Review of Systems” that P1’s, “ ...Respiratory: Positive for shortness of breath. Negative for cough ...Cardiovascular: Positive for chest pain and leg swelling ...”. At 1:25 [1:25 AM], S16 (ED Registered Nurse) documented in the ED Triage Notes “ ... c/o L [left] sided chest and back pain ...reports pain when taking a deep breath ... .” A review of P1’s Care Plan, generated on 11/06/ 2023 at 1221 [12:21 PM] by the interdisciplinary team, revealed implementation for problems associated with, “ ...Mobility -Impaired ... .” There was no documented care plan generated during P1’s stay for his/her chief complaints of shortness of breath, chest pain, or lower back pain radiating down his/her leg. Review of P1’s discharge education and instructions provided by the discharging nurse, revealed instructions for, “ ...Mobility ...ambulation safety ...bed mobility ... .” There was no documentation of patient education for reported and documented problems of shortness of breath, chest pain, or lower back pain radiating down to his/her leg. These findings were confirmed at 2:26 PM with S1, S2, S3, and S15 [via telephone], (Director of Patient Safety and Quality). Facility policy, “Interdisciplinary Plan of Care” (11/2022) states, “ ...Within 24 hours of admission, an individualized plan of care is designed ...The plan of care provides a mechanism for monitoring a patients progress ...The RN will initiate ...and work in collaboration with the multidisciplinary team, the patient, and ...utilizing information from the patient’s admission history, physical assessment, the patient’s admitting diagnosis, and physician orders ... .””