Carepoint Health-Hoboken University Medical Center

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 48913 Based on staff interviews, review of facility documents, and review of three of three medical records (MR) (MR1, MR4 and MR5), it was determined that the facility failed to ensure that the quality assurance and performance improvement (QAPI) program analyzes the cause of medication errors and implements preventive actions, in accordance with the facility’s QAPI Plan. Findings include: Facility policy titled, “Hoboken University Medical Center Quality Assurance and Performance Improvement Plan (HUMC QAPI),” 2024-2025, stated, “...D. The Patient Safety Committee is a multidisciplinary forum to identify, review and analyze patient safety concerns. The Committee will provide a mechanism for a systemic approach to effective clinical error reduction, minimize injury, and reduce the potential for unsafe practice .... VIII. Data Collection/Reporting ... There is ongoing collection and evaluation of information related to key patient care priorities to identify opportunities of improvement and identify problems that have an impact on patient care, patient safety, and organization performance. Activities and results of all improvement initiatives will be communicated on a periodic scheduled basis to the Quality Assurance & Performance Improvement Committee as dictated ...” On 02/20/25 at 11:30 AM, P1’s medical record was reviewed in the presence of Staff (S) 1, Chief Nursing Officer, and S4, Risk Management Director. Patient (P)1 presented to the ED (Emergency Department) on 01/11/25 with a chief complaint of “High Fever.” P1 was triaged at 8:55 AM by S6, ED Nurse. The “Nursing Assessment/Treatments,” dated 01/11/25 at 8:55 AM, stated, “ ...Vital Signs Height 30 in [inches] Weight 19.8 kg [Kilograms] weight obtained by Baby Scale ...” P1’s order detail dated 01/11/25 at 09:19 [9:19 AM] stated, “... Order Ibuprofen Susp [Suspension] ...200 mg [milligrams] po [by mouth] STAT [immediately]...Last Administration 01/11/25 09:28 [9:28 AM] 200 mg...Dose Calculations Selected Dosing Set Ibuprofen 10 mg/kg ... Calculated dosing weight 19.8 kg ...Calculated Dose 198 mg ...Round to Nearest Dose 200 mg ...” Review of P1’s medication administration documentation dated 01/11/25 at 9:28 AM, indicated that P1 was administered one dose of 200 mg of Ibuprofen (a pain/fever medication). This dose was based on the weight of 19.8 kg documented during the triage. The “ED Additional Note” dated 01/11/25 at 13:44 [1:44 PM] and signed by S7, Physician Assistant, stated, “Patient’s [Parent] has called back, child’s weight was incorrectly entered as 19.8 kg, patient is 9.07 kilograms. Instructed to change cefdinir (an antibiotic) dose to 2.5 ml (milliliters), ibuprofen dose to 4.5 ml, Tylenol dose to 4 ml. All questions answered. Reiterated return precautions. (Parent) verbalized understanding ...” The “PHA (pharmacy) order” dated 01/11/25 at 9:19 AM, stated, “...Warnings Type: Single Dose Range: Ibuprofen (100 mg/5 ml) .... Daily Dose Dosing Range is 4 mg/kg/day- 10 mg/kg/day. Ordered dose of 10.1 mg/kg/day is above daily dose range ...” P1’s correct weight is 9.07 kg and maximum dosage for Ibuprofen should have been no more than 90.7 mg per dose. On 02/21/25 at 10:15 AM, S4 stated that Risk Management reviews and monitors all medication errors reported via Verge (internal incident reporting system) and reports the data to the Clinical Safety Committee (Formerly known as Patient Safety Committee). Review of the Clinical Safety Committee meeting minutes dated November 6, 2024, indicated that six events of improper medication dose were reported during the meeting. Two out of six events of improper medication dose were related to an inaccurate weight measurement documented in the medical records for P4 and P5. Review of P4’s Verge report dated 05/05/24 at 2:00 PM, stated, “ ... Factual description of the event: Patient received at 0830 [8:30 AM], patient’s weight was rechecked. Correct weight was 39.46 kg. Wrong dose of solumedrol was given in ER. ... Document any additional monitoring, treatment or intervention that have been taken as a result of this event: Comments: Not answered .... Manager Action Education ... “ The staff educated regarding this event was not indicated. On 2/21/25, the staff re-education regarding this event was requested. The facility failed to provide this documentation upon request. Review of P5 ‘s Verge report dated 05/20/24 at 5:14 AM, stated, “ ... Factual description of the event: I was doing the triage for the patient and was copying the weight from what was placed by the ER tech and have written the BMI which was 18.7 instead of the weight. Putting the weight at 18.7 instead of 10.87 as previously put by the ER tech. Weight was then changed now to 18.7. Initial dose of medication was based on the 10.8 kg weight which was 150 mg and an additional 120 mg was given. Weight was then confirmed by (parent), weight was changed to 10.7 kg as it was originally ...Document any additional monitoring, treatment or intervention that have been taken as a result of this event... ED Tech approached and educated on being careful in entering patients weights which is needed for proper dosing ...” On 02/21/25 at 2:30 PM, S4 stated as part of the corrective action, the ED technician, involved in the error with P5, was re-educated on entering patient weights accurately. On 02/21/25 at 2:45 PM, S4 stated that because the severity level of above reported events was a category D, meaning it reached the patient and required monitoring and intervention to confirm no patient harm, and category C, meaning it reached the patient but did not cause harm, respectively, the facility was not required to implement a systemic change.”

“REPORTING ADVERSE REACTIONS AND ERRORS CFR(s): §482.23(c)(5) - There must be a hospital procedure for reporting transfusion reactions, adverse drug reactions, and errors in administration of drugs. This Standard is not met as evidenced by: 48913 Based on staff interviews, review of facility documents, and review of one of three medical records (MR 1) that contained a medication administration error, it was determined that the facility failed to ensure the implementation of policies and procedures that address internal reporting of medication administration errors. Findings include: Facility policy titled, “Event Reporting,” last reviewed 05/24, stated, “...Staff should report events that occur on the hospital premises which are not consistent with routine operations or care for patient...2. Examples of events are...b. Medication administration Variances (wrong patient, wrong dose, wrong time, wrong route, wrong drug, dose omitted, extra dose...C. Event Report Completion... Enter an event report in the On-line Event Reporting System...Complete the report as soon as possible after the event and notify your supervisor....” Review of MR1 was conducted in the presence of Staff (S) 1, Chief Nursing Officer and S4, Risk Management Director. Patient (P)1 presented to the ED (Emergency Department) on 01/11/25 with a chief complaint of “High Fever.” P1 was triaged at 8:55 AM by S6, ED Nurse. The “Nursing Assessment/Treatments,” dated 01/11/25 at 8:55 AM, stated, “...Vital Signs Height 30 in [inches] Weight 19.8 kg [Kilograms] weight obtained by Baby Scale ...” P1’s order detail dated 01/11/25 at 09:19 [9:19 AM] stated, “... Order Ibuprofen Susp [Suspension]...200 mg [milligrams] po [by mouth] STAT [immediately]...Last Administration 01/11/25 09:28 [9:28 AM] 200 mg...Dose Calculations Selected Dosing Set Ibuprofen 10 mg/kg... Calculated dosing weight 19.8 kg...Calculated Dose 198 mg...Round to Nearest Dose 200 mg...” Review of P1’s medication administration documentation dated 01/11/25 at 9:28 AM, indicated that P1 was administered one dose of 200 mg of Ibuprofen (a pain/fever medication). This dose was based on the weight of 19.8 kg documented during the triage. The “ED Additional Note,” dated 01/11/25 at 13:44 [1:44 PM] and signed by S7, Physician Assistant, stated, “Patient’s [Parent] has called back, child’s weight was incorrectly entered as 19.8 kg, patient is 9.07 kilograms. Instructed to change cefdinir (an antibiotic) dose to 2.5 ml (milliliters), ibuprofen dose to 4.5 ml, Tylenol dose to 4 ml. All questions answered. Reiterated return precautions. (Parent) verbalized understanding ...” The “PHA (pharmacy) order” dated 01/11/25 at 9:19 AM, stated, “...Warnings Type: Single Dose Range: Ibuprofen (100 mg/5 ml).... Daily Dose Dosing Range is 4 mg/kg/day- 10 mg/kg/day. Ordered dose of 10.1 mg/kg/day is above daily dose range...” P1’s correct weight is 9.07 kg and maximum dosage for Ibuprofen should have been no more than 90.7 mg per dose. On 02/20/25 at 2:00 PM, S4 stated that all adverse drug events should be reported to Risk management via Verge, the online event reporting system. S4 confirmed that the facility was not aware of the event with P1, and a Verge report was not completed for this medication error event. During an interview on 02/21/25 at 10:25 AM, S6 confirmed that they were responsible for documenting P1’s weight in the medical record. S6 stated that he/she measured the patient weights in kilograms (kg) as the computer system requires weights to be documented in kg only. S6 stated that he/she has no knowledge as to how P1’s weight was measured incorrectly. S6 stated that sometimes when the ED is busy, an ER (Emergency Room) technician records patient vital signs, including weight and height, on a piece of paper. The nurses would then enter that information into the electronic medical record during the triage/assessment process. On 02/21/25 at 12:45 PM, during an interview, S7 stated that after P1’s discharge, P1’s parent called the ED from the outside retail pharmacy, where he/she was filling P1’s prescriptions that were prescribed at discharge. S7 stated that the outpatient retail pharmacist had some concerns about the high dose of antibiotics prescribed to P1. During that conversation, S7 realized that the wrong weight was entered during the triage process and a medication error occurred. S7 further stated that he/she informed the nurse on duty about this event to correct the weight in P1’s medical record and he/she thought that the nurse would report this event via Verge reporting system, however it was not done. On 02/21/25 at 1:00 PM, S4 confirmed the above findings and stated that a Verge report should have been completed.”

“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: 48913 Based on a review of three of three medical records (MR) (MR1, MR4, and MR5) and staff interviews, it was determined that the facility failed to ensure that the documentation in medical records is accurate in accordance with facility policy. Findings include: Facility policy titled, “Scope of Service, Unit Description,” last reviewed 04/24, states, “ ...All assessments, interventions, diagnostic testing and results, patients’ responses and outcomes are documented in the ED medical record ...Department goals include: 1. To provide a rapid, skilled and accurate triage assessment for every patient entering the department seeking care.” Medical records (MR) review was conducted in the presence of Staff (S)1, Chief Nursing Officer and S4, Risk Management Director, and revealed the following: Patient (P)1 presented to the ED (Emergency Department) on 01/11/25 with a chief complaint of “High Fever.” P1 was triaged at 8:55 AM by S6, ED Nurse. The “Nursing Assessment/Treatments,” dated 01/11/25 at 8:55 AM, stated, “...Vital Signs Height 30 in [inches] Weight 19.8 kg [Kilograms] weight obtained by Baby Scale ...” P1’s order detail dated 01/11/25 at 09:19 [9:19 AM] stated, “... Order Ibuprofen Susp [Suspension]...200 mg [milligrams] po [by mouth] STAT [immediately]...Last Administration 01/11/25 09:28 [9:28 AM] 200 mg...Dose Calculations Selected Dosing Set Ibuprofen 10 mg/kg... Calculated dosing weight 19.8 kg...Calculated Dose 198 mg...Round to Nearest Dose 200 mg...” Review of P1’s medication administration documentation dated 01/11/25 at 9:28 AM, indicated that P1 was administered one dose of 200 mg of Ibuprofen (a pain/fever medication). This dose was based on the weight of 19.8 kg documented during the triage. The “ED Additional Note,” dated 01/11/25 at 13:44 [1:44 PM] and signed by S7, Physician Assistant, stated, “Patient’s [Parent] has called back, child’s weight was incorrectly entered as 19.8 kg, patient is 9.07 kilograms. Instructed to change cefdinir (an antibiotic) dose to 2.5 ml (milliliters), ibuprofen dose to 4.5 ml, Tylenol dose to 4 ml. All questions answered. Reiterated return precautions. (Parent) verbalized understanding ...” The “PHA (pharmacy) order” dated 01/11/25 at 9:19 AM, stated, “...Warnings Type: Single Dose Range: Ibuprofen (100 mg/5 ml).... Daily Dose Dosing Range is 4 mg/kg/day- 10 mg/kg/day. Ordered dose of 10.1 mg/kg/day is above daily dose range...” P1’s correct weight is 9.07 kg and maximum dosage for Ibuprofen should have been no more than 90.7 mg per dose. P4 presented to the ED on 05/05/24 with a chief complaint of “Shortness of Breath.” P4 was triaged at 4:50 AM by S20, ED Nurse. The “Nursing Assessment/Treatments,” dated 05/05/24 at 4:40 AM, stated, “... Weight 89 kg weight obtained by Standing Scale ...” A second “Nursing Assessment/Treatments,” dated 05/05/24 at 5:01 AM, stated, “Vital Signs Weight 89 kg Weight Obtained by Standing Scale ...” Review of P4’s Verge Report [an electronic incident reporting system] on 05/05/24 at 2:00 PM, stated, “...Factual description of the event: Patient received at 0830 [8:30 AM], patient’s weight was rechecked. Correct weight was 39.46 kg. Wrong dose of solumedrol was given in ER (Emergency room).” P5 presented to the ED on 05/20/24 with a chief complaint of “Fever.” P5 was triaged at 4:09 AM by S19, ED Nurse. The “Nursing Assessment/Treatments,” dated 05/20/24 at 4:19 AM, stated, “... Vital Signs 18.7 kg (Kilograms) Weight Obtained by Baby Scale ...” The “ED Physician Documentation,” dated 05/20/24 at 0443 [4:43 AM] stated, “...Medical Decision Making ...weight was incorrectly entered: patient given slightly more Tylenol than recommended dosage ...” On 02/21/25 at 2:00 PM, S1 and S4 confirmed the above findings. S1 stated that the ED nurses were responsible for ensuring patient vital signs, including patient weights, were documented accurately in the medical records.”

“PHARMACY ADMINISTRATION CFR(s): 482.25(a) [§482.25 Condition of Participation: Pharmaceutical Services .....The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital’s organized pharmaceutical service.] §482.25(a) Standard: Pharmacy Management and Administration The pharmacy or drug storage area must be administered in accordance with accepted professional principles. This Standard is not met as evidenced by: 48913 Based on medical record review, review of facility documents, and staff interviews, it was determined the facility failed to ensure that adverse drug events are reported to and reviewed at the Pharmacy and Therapeutic (P&T) Committee. Findings include: Facility policy titled, “Pharmacy: Adverse Drug Reactions,” last reviewed 04/24, stated, “...5. The Pharmacy Department will report ADR (Adverse drug reactions) data to Pharmacy and Therapeutics Committee on a regular basis for review and recommendations...10. The pharmacist-in-charge shall be responsible for maintaining a system by which all reported adverse drug reactions are recorded and reviewed by the Pharmacy and Therapeutics Committee...” On 02/20/25 at 1:30 PM, the facility’s Pharmacy and Therapeutics Committee (P&T) meeting minutes for year 2024 were reviewed and the following was identified: The P&T Committee meeting minutes dated 03/14/24, stated, “...Adverse Drug Events... Unable to report...” The P&T Committee meeting minutes dated 04/25/24, stated, “...Adverse Drug Reactions...NO AVAILABLE REPORTING ...” The P&T Committee meeting minutes dated 06/20/24 and 08/29/24 indicated that no adverse drug events data was reported. The P&T Committee meeting minutes dated 10/30/24 at 10:00 AM, stated, “...Medication Incident Policy Update- Title Change to Medication Safety Committee. Policy to remain the same, only changes made to the title to include the words medication safety as required by Joint commission. Medication Safety Committee is an interdisciplinary team including Pharmacy, Nursing, Risk Management and the Medical Staff working in cooperation to identify, classify reports in VERGE and minimize the occurrence of medication incidents. Committee meets quarterly to discuss and resolve any medication related incidents such as delays, adverse events, errors in administration etc., and consider implementation plans...” The meeting minutes lacked documentation that medication incidents were reviewed during this meeting. On 02/21/25 at 11:50 AM, Staff (S) 5, the Director of Pharmacy, provided a Pharmacy Dashboard for the year 2024 that indicated that the facility was tracking adverse drug reactions and medication errors, however, the P&T meeting minutes lacked documentation that the adverse drug reactions and medication errors data was reviewed. Upon interview, S5 stated that she/he was assigned to this role recently and was not sure why data from adverse drug events was not reported to the P&T committee. On 02/21/25 at 1:10 PM, S5 confirmed the above findings.”

“PHARMACY: REPORTING ADVERSE EVENTS CFR(s): 482.25(b)(6) Drug administration errors, adverse drug reactions, and incompatibilities must be immediately reported to the attending physician and, if appropriate, to the hospital’ s quality assessment and performance improvement program. This Standard is not met as evidenced by: 48913 Based on staff interviews and facility document review, it was determined that the facility failed to ensure that medication errors are reported to and reviewed by the hospital’s Quality Assurance Performance Improvement (QAPI) program. Findings include: The Hoboken Univeristy Medical Center [HUMC] QAPI Plan stated, “.... D. The Patient Safety Committee is a multidisciplinary forum to identify, review and analyze patient safety concerns. The Committee will provide a mechanism for a systemic approach to effective clinical error reduction, minimize injury, and reduce the potential for unsafe practice. ... F. The Pharmacy and Therapeutics [P&T] Committee will serve an advisory group to the Medical Board in all matters relating to the use of pharmaceuticals... The committee will also be responsible for the review of all adverse drug reactions and perform criteria -based drug usage evaluation on an on-going basis ...VIII. Data Collection/Reporting ... There is ongoing collection and evaluation of information related to key patient care priorities to identify opportunities of improvement and identify problems that have an impact on patient care, patient safety, and organization performance. Activities and results of all improvement initiatives will be communicated on a periodic scheduled basis to the QAPI committee ... “ The P&T Committee meeting minutes dated 10/30/24 at 10:00 AM, stated, “...Medication Incident Policy Update- Title Change to Medication Safety Committee. Policy to remain the same, only changes made to the title to include the words medication safety as required by Joint commission. Medication Safety Committee is an interdisciplinary team including Pharmacy, Nursing, Risk Management and the Medical Staff working in cooperation to identify, classify reports in VERGE and minimize the occurrence of medication incidents. Committee meets quarterly to discuss and resolve any medication related incidents such as delays, adverse events, errors in administration etc., and consider implementation plans...” On 02/20/25 at 2:00 PM, the facility’s Medication Safety Committee meeting minutes mentioned in the P&T Committee meeting minutes above, were requested. The facility failed to provide meeting minutes from the Medication Safety Committee. Upon interview, Staff (S) 4, Risk Managment Director, stated that all medication errors should be reported to Risk Management via Verge, the online event reporting system. On 02/21/25 at 10:15 AM, S4 stated that Risk Management reviews and monitors medication errors and reports the data to the Clinical Safety Committee (Formerly known as Patient Safety Committee). He/she was not aware of the Medication Safety Committee. The Clinical Safety Committee meeting minutes for the year 2024 was requested and reviewed. The Clinical Safety Committee meeting minutes indicated that medication errors were reported to this committee, however the meeting minutes lacked documentation of corrective actions developed and implemented to ensure patient safety. On 02/21/25 at 11:50 AM, S5, the Director of Pharmacy, provided a Pharmacy Dashboard for the year 2024 that indicated that the facility was tracking adverse drug reactions and medication errors. S5 provided the Pharmacy and Therapeutic (P&T) Committee meeting minutes for year 2024. The meeting minutes were reviewed and lacked evidence that the data collected from the monitoring of adverse drug events was reviewed at P&T committee. Upon interview, S5 stated that she/he was assigned to this role recently and was not sure why the data was not reviewed at the P&T committee meeting. The HUMC QAPI meeting minutes for 2024, were reviewed and lacked evidence that adverse drug events were reported to the hospital QAPI committee. On 02/21/25 at 3:00 PM, during an interview, S9, the QAPI Director, stated that he/she was assigned to this role recently and was not aware of reporting requirements of adverse drug events to the hospital QAPI committee and stated, “this will be on his/her to do list for year 2025.” S9 confirmed that adverse drug events were not reported to the hospital QAPI committee. It could not be determined what corrective actions were implemented to minimize medication errors and adverse drug events to improve patient safety. On 02/21/25 at 3:55 PM, S1, Chief Nursing Officer and S4 confirmed the above findings.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 38289 Based on medical record review, staff interviews, and review of facility documents, it was determined that the facility failed to ensure: 1). the protection and promotion of patient rights; and 2). the hospital meets the emergency needs of patients in accordance with acceptable standards of practice. Cross Reference: 482.13: Condition: Patient Rights 482.55: Condition: Emergency Services”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 38289 Based on review of medical records (MR), review of video surveillance, staff interviews, and review of facility documents, it was determined that the facility failed to ensure: 1). that the elopement protocol is implemented for a patient determined to be at high-risk for elopement, per facility policy (A0144); 2). that policies and procedures for the care of patients at risk for suicide are implemented (A0144); 3). to ensure the mechanisms in place are implemented, to keep patients safe from abuse (A0145). These failures resulted in Immediate Jeopardys (IJ), posing a serious risk of harm to the patients. Cross Reference: 482.13(c)(2) Patient Rights: Care in Safe Setting 482.13(c)(3) Patient Rights: Patient has the right to be free from all forms of abuse or harassment On 12/11/24 at 1:52 PM, an Immediate Jeopardy (IJ) was identified due to the facility’s failure to ensure the policy and procedure was implemented for a patient determined to be at high-risk for elopement (A0144). On 12/11/24 at 2:06 PM, the IJ template was presented to the administration and a removal plan was requested. On 12/12/24 at 10:13 AM, an acceptable removal plan was received. The facility implemented the following to address the IJ: The policy related to elopement was reviewed for the protocol associated with a patient identified to be at risk for elopement. Education to all emergency department (ED) patient care staff, ED administration, and security was provided regarding the policy and their particular roles when a patient is identified to be at risk for elopement. The IJ removed on 12/12/24 at 2:49 PM after the State Survey Agency verified full implementation of the removal plan, and Condition Level non-compliance remains (A0144). On 12/13/24 at 3:51 PM, a second IJ was identified for the facility’s failure to implement mechanisms in place to keep patient’s safe from abuse. On 12/13/24 at 4:30 PM, the IJ template was presented to the administration and a removal plan was requested. On 12/16/24 at 10:22 AM, an acceptable removal plan was received. The facility implemented the following to address the IJ: The policy related to abuse and suspected abuse was reviewed. Education to all ED patient care staff, ED administration, ED Psychiatric Screeners, and security was provided regarding the policy and their particular roles when a patient has been identified as a victim of abuse or suspected abuse. The IJ was removed on 12/16/24 at 2:44 PM, after the State Survey Agency verified full implementation of the removal plan, and Condition Level non-compliance remains (A0145). On 12/16/24 at 3:05 PM, a third IJ was identified for the facility’s failure to implement facility policy and ensure orders for one-to-one (1:1) monitoring and a psychiatric evaluation were implemented for a patient determined to be at moderate risk for suicide (A0144). On 12/16/24 at 3:20 PM, the IJ template was presented to the administration and a removal plan was requested. On 12/17/24 at 1:09 PM, an acceptable removal plan was received. The facility implemented the following to address the IJ: The policy related to patients determined to be at risk for suicide was reviewed. Education to all ED patient care staff, ED administration, and security was provided regarding the policy and their particular roles when a patient has been identified at risk for suicide. The IJ was removed on 12/18/24 at 11:31 AM, after the State Survey Agency verified full implementation of the removal plan, and Condition Level non-compliance remains (A0144).”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 38289 Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to ensure: 1). notification to social work for emergency department (ED) patients that meet high-risk criteria (A-1103); 2). all patients seeking emergency treatment received a medical screening examination (MSE) from a qualified provider (A-1104); 3). a complete psychiatric evaluation for patients requiring a crisis Psych Emergency Services (PES) screening prior to the patient leaving the ED (A-1104); and 4). all patients discharged from the ED receive a discharge order (A-1104). Cross Reference: 482.55(a): The services must be integrated with other parts of the hospital 482.55(a): The policies and procedures governing medical care provided in the emergency department are established by and are a continuing responsibility of the medical staff”

“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: 38289 Based on medical record review, review of video surveillance, staff interview, and review of facility documents, it was determined that the facility failed to: 1). implement interventions for patients determined to be at risk for elopement in two of 22 medical records reviewed (Patient (P)1 and P6); 2). implement policies and procedures for the care of suicidal patients in the Emergency Department (ED) in two of 22 medical records reviewed (P17 and P21). Findings include: Facility policy titled, “Elopement (Prevention and Response)” revised 4/24, stated, “... Strategies to Prevent Elopement: 1. Communicate to the health care team members that the patient is an elopement risk. 2. Remove outdoor clothing and other articles which would facilitate the patient’s elopement and secure them out of the patient’s sight ... 4. Place the patient in a room near the nursing station. 5. Place on frequent monitoring via hourly rounding and every 15-minute quick visual checks. 6. Notify Security Officers that the patient is at risk to elope so that the ED exits can be monitored ... Response to Patient Elopement Nursing Unit Staff Response/Actions: 1. Notify the operator of Code Gray/Elopement ... 3. Notify the nurse in charge and appropriate administrative personnel. 4. Search the medical area, unit, and adjacent area ... 6. Notify the [local police department] if patient is a risk of harm to self or others ... Physician Response/Action: 1. Determine if the patient has the capacity to make decisions for his/her own healthcare. 2. ... For patients who cannot make decisions or attend to their own safety, or who pose a risk to the safety of others, the response is geared to returning the patient to a safe environment as quickly as possible ... Documentation: 1. The patient progress notes must be updated by the RN [registered nurse] and the physician and should relate: a. Time/date the patient was noted to be missing b. All actions taken ... d. Police Department notification 2. The Security Department will record time of notification and all actions taken, including hospital, environmental searches and Police Department Notification ...” 1. On 12/10/24 at 11:10 AM, a review of P1’s medical record (MR) revealed the following: On 12/9/24 at 12:19 AM, P1 presented to the ED by ambulance with behavioral complaints. The triage nurse assessment at 12:27 AM indicated that P1 refused to speak with the triage nurse and refused vital signs assessment. The triage nurse documentation indicated that P1 was a high elopement risk, and the nurse documented that the following interventions were to be put into place for the elopement risk: place the patient in a room near the nurse’s station; frequent hourly monitoring and every 15-minute visual checks; removal of shoes/clothing and secure belongings where the patient cannot access them; and placing the patient in a color identifiable gown. There was no documented evidence that Q 15 minute visual checks were completed, the patient was placed in a gown or that a belongings checklist was completed. A psychiatric screening completed at 12:58 AM, indicated the patient had homicidal ideation (HI) with a plan. In an interview with Staff (S)1, the Director of Risk Management, and S3, the Chief Nursing Officer on 12/11/24 at 11:11 AM, S1 and S3 confirmed that the patient should have been placed on one-to-one observation for the HI. The medical record lacked documentation that P1 was placed on a one-to-one observation. Further review of the medical record indicated on 12/9/24 at 1:30 AM, the ED Provider Note documented that the patient absconded from the ED. At 2:22 AM, the Psychiatric Screener Note stated, “Confirmed P1 left the hospital declining treatment ... Contacted [On call psychiatrist] to provide update, left voicemail.” Multiple attempts were made to interview both the Psychiatric screener and the ED provider, However, niether were available at the time of the survey. The medical record lacked documentation of attempts to locate the patient including notification to security, phone calls to patient, and notification to the local police department per facility policy. On 12/11/24 at 10:45 AM, a review of the video surveillance, in the presence of S1, S3, and S16, the Security Supervisor, revealed the following: On 12/9/24 at approximately 12:13 AM, P1 was brought into ED Room 7, located across the nurse’s station. Staff were observed removing items such as chairs, garbage cans, and other equipment from the room as the patient was placed in the room. The ED provider entered the patient’s room at 12:38 AM, and left at 12:40 AM. At 12:57 AM, the patient exited the room, walked to the bathroom, and returned to Room 7 at 12:58 AM. It was observed that the patient was still wearing the clothes that he/she came to the ED with. At 12:59 AM, the Psychiatric Screener entered Room 7 and left the room at 1:06 AM. At 1:07 AM, P1 exited Room 7, walked past the nurse’s station and exited the ED via the ambulance doors. Staff interviews were conducted after review of the video surveillance. Upon interview, S3 confirmed that the doors from which P1 eloped was the ambulance bay exit. S3 further stated that there is a security desk located at this exit, but it is not staffed during low volumes and confirmed it was not staffed at the time of P1’s elopement. During the interview, S1 and S3 confirmed that the elopement policy was not followed to included, the lack of a one-to-one (1:1) sitter, the removal of outside clothes and changing into a hospital gown, and the lack of documentation of visual checks. S16 confirmed that the security department was not notified of a high-risk elopement patient, a code gray was not called and the local police were not notified. On 12/12/24 at 10:39 AM, a review of P6’s medical record revealed the following: On 12/8/24 at 2:16 AM, P6 presented to the ED via ambulance with a chief complaint of alcohol ingestion. At 2:39 AM, the triage assessment identified P6 as an elopement risk. The medical record lacked documented evidence of elopement risk interventions as required per policy. On 12/13/24 at 10:58 AM, S18, the Nursing Informaticist, confirmed that the medical record for P6 lacked evidence of elopement risk interventions. S18 verified that the medical record did not have a continuous observation order, belongings checklist, or the observation checklist. 48965 2). Facility policy titled, “Suicide Assessment and Prevention,” last revised 1/24, stated, “ ...Procedure: A. Assessment of Suicide Risk: Emergency Department... If the patient shows signs/symptoms of being a self-harm risk through a positive suicide screening using the Columbia Suicide Severity Rating Scale (C-SSRS), the nursing staff will place the constant observation by staff acting in the sitter role... Levels of Risk and Intervention using the C-SSRS... Low Suicide Risk: Initiate patient search procedures, place patient in a gown, separate patient from belongings and store in a separate area. Initiate safe room protocols or place in Psych room ... ED- Refer patient to Psychiatric Emergency Services (if medically cleared) and alert Medical units ... Moderate Suicide Risk: Initiate patient search procedures, place patient in a gown, separate patient from belongings and store in a separate area. Initiate safe room protocols or place in Psych room...Emergency Department - Refer patient to Psychiatric Emergency Services (if medically cleared) and alert Medical units...Do not leave patient unattended and place on 1:1... High Suicide Risk: Initiate patient search procedures, place patient in a gown, separate patient from belongings and store in a separate area. Initiate safe room protocols or place in Psych room ...Emergency Department - Refer patient to Psychiatric Emergency Services (if medically cleared) and alert Medical units...Do not leave unattended and placed on 1:1...D. Patient Monitoring...An increased observation level may be initiated by a registered nurse in an emergency and an order obtained by an LIP [Licensed Independent Practioner]...” Facility policy titled, “General Nursing - Observation Levels” last revised 1/24, stated, “ ...Procedure ...Constant Observation or one to one (1:1) Procedure: ...Criteria: Patients who currently present an acute risk to harm self or others will be assigned to one dedicated staff member for a 1:1 observation. Criteria for this level of observation include: Suicidal/Homicidal Ideation ...Patients exhibiting acute signs and symptoms of psychosis and are not in control of their symptoms ...Elopement precautions for confused patients without decision making capacity and who do not respond to limit setting ...Staff role and responsibility ...a. The staff member continuously assess the patient’s status and documents at least every 15 minutes on the Patient Monitoring Form ...” On 12/13/24 at 1:00 PM, a review of P21’s medical records, for the ED visits 12/4/24 and 12/5/24, revealed the following: On 12/4/24 at 1:46 AM, P21 presented to the ED requesting a psychiatric evaluation. P21 reported hearing voices telling him/her to hurt [him/her]self. P21 was triaged on 12/4/24 at 1:52 AM, by an RN, and was assessed with a C-SSRS score of zero or “no risk.” On 12/4/24 at 3:00 AM, a Crisis Evaluation was ordered for P21. The Crisis Evaluation was completed on 12/4/24 at 3:49 AM. The crisis screener completed a CSSR assessment on P21 which revealed a numerical score of 4, indicating “low risk” on the C-SSRS rating scale. The crisis screener discussed P21’s evaluation with the on-call Psychiatrist on 12/4/24 at 4:06 AM, and P21 was cleared for discharge with outpatient Psychiatric follow-up. On 12/4/24 at 5:42 AM, the ED Physician documentation stated, “ ...Review of Symptoms: ...Psych: Positive for: Psychosis ...Physical Exam: ...Psychological: Positive for: Responding to Internal Stimuli, Suicidal Verbalizations (denies SI [suicidal ideation], however, stating voices are telling [him/her] to hurt [him/herself]) ...” Upon review, P21’s medical record lacked evidence of suicide precautions and safety interventions in place per facility policy. On 12/5/24 at 3:00 AM, P21 presented to the ED via ambulance with SI. P21 was triaged on 12/5/24 at 3:01 AM by an RN and was assessed with a C-SSRS score of two or “low risk.” On 12/5/24 at 3:14 AM, a physician’s order was placed for a Crisis Evaluation and 1:1 continuous evaluation. On 12/5/24 at 3:33 AM, the nursing assessment indicated that P21 had a 1:1 sitter at bedside for SI and patient safety. During the medical record review, P21’s record lacked documented evidence of 1:1 sitter observation sheet and other safety interventions, such as: patient search, safe room protocols and removal of belongings, per facility policy. On 12/13/24 at 2:45 PM, the above findings were reviewed and confirmed with S1, the Director of Risk Management. S1 stated that safety interventions should have been implemented for P21. 49174 On 12/16/24, a review of P17’s medical record revealed the following: On 10/12/24 at 4:15 PM, P17 arrived at the facility’s ED with complaints of Suicidal Ideation (SI). On 10/12/24 at 4:19 PM, P17 was triaged and was assessed as “high risk” on the Columbia Suicide Severity Rating Scale (C-SSRS) screening. On 10/12/24 at 4:45 PM, a physician’s order was placed for P17 to be on 1:1 observation. On 10/12/24 at 5:10 PM, the first documented observation on the “Patient Monitoring Form” was completed. On 10/12/24 at 9:27 PM, P17’s crisis PES (Psychiatric Emergency Service) screening was conducted. The Behavioral Health Intake/Inquiry Form completed by the PES screener revealed that under section, “Part C: Disposition and Status” it stated, “Admitted: yes/no. If no, why Check all box(es) that apply.” The PES screener documented “No” and the applicable boxes were left blank. There was no documentation why P17 was not admitted. On 10/13/24 at 3:00 AM, P17 was discharged from the ED with his/her condition listed as “improved.” The MR lacked documented evidence that P17 was on 1:1 observation between 4:19 PM and 5:10 PM, 51 minutes. During an interview with S1, the Director of Management, on 12/16/24 at 12:08 PM, S1 stated, “a nurse would document in the notes section if [he/she] was with [P17].” Upon request S1 was unable to provide documented evidence that P17 was placed on 1:1 observation. S1 further stated that placing a patient on 1:1 observation is a nurse driven protocol and could be initiated without an order. An interview with S31, the PES Coordinator, was conducted on 12/16/24 at 12:39 PM. P17’s “Behavioral Health Intake/Inquiry Form” was presented to S31 who stated, “the form needs to say why [the patient wasn’t admitted] and I don’t know why it doesn’t.””

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 38289 Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to ensure the implementation of the policy and protocol for the care of a patient with suspected abuse. Findings include: Facility policy titled, “High Risk Screening Criteria” revised 01/24, stated, “... The Case Manager, Nurse, Physician, Family or other members of the interdisciplinary healthcare team may refer a patient to the Social Work Department ... In addition, the Social Worker will review each admission by the first business day on the assigned unit for patients meeting high-risk criteria ... Special emphasis is placed on identifying children and adults ‘at risk’ for neglect/abuse ... The following are considered High Risk Screening Categories ... -Suspicion of abuse/neglect (ADULT AND CHILD) ...” Facility policy titled, “Discharge Criteria for ED Patients” revised 4/24, stated, “... At any time if there is a concern about the appropriateness of discharge or the patient’s safety, that patient is to be held and the physician and appropriate administrative personnel be notified ...” Facility policy titled, “[Facility] Identification and Reporting of Abuse and Neglect” revised 8/30/23, stated, “... It is the policy of [Facility] personnel to identify and assess suspected or alleged victims of abuse using established criteria, so to arrange follow-up, care and intervention ... NJS [New Jersey Statute] 9:6-8.16 The Child Abuse and Neglect law states: ’ Any physician examining or treating any child ... is empowered to take said child into protective custody when the child has suffered serious physical injury or injuries, and the most probably inference from the medical and factual information supplied upon the child by another person by other that accidental means and the person suspected of inflicting, or permitting to be inflicted, the said injury upon the child is a person into whose custody the child would be normally returned’ ... “ During the review of P15’s medical record the following was revealed: P15 is a 15-year-old minor who presented to the Emergency Department (ED) by ambulance on 8/22/24 at 9:37 PM, with complaints of anxiety and feeling unsafe at home, accompanied by his/her mother. During the triage assessment at 9:45 PM, P15 stated that he/she feels threatened in the home. A psychiatric evaluation was ordered. Staff (S)37, the psychiatric screener, obtained collateral information from the patient’s mother and documented, “Mother minimized pt’s [patient’s] concerns.” S37 documented at 10:00 PM, that P15’s mother reluctantly allowed the psychiatric screener to evaluate P15 in private. S37 documented that the patient reported his/her mother is frequently verbally abusive towards the patient; in addition, it was documented that P15 admitted to the mother being physically abusive towards him/her. P15’s case was reviewed by the on-call psychiatrist and the patient was referred for outpatient services. On 8/22/24 at 11:19 PM, S37 reported the alleged physical abuse to DCPP (Division of Child Protection and Permanency) hotline per facility policy and protocol, and documentation noted that someone would respond within 24 hours. At 11:19 PM, S37 documented that P15 and P15’s friends did not feel that the patient was safe to return home. S37 documented that this information was relayed to S13, the ED provider. On 8/23/24 at 12:22 AM, S13 discharged P15 to home with his/her mother, and potential abuser, prior to being seen by DCPP and without a social work referral as per facility policy. On 12/13/24 at 2:06 PM, during an interview, S31, the Psychiatric Evaluation Screener Coordinator, stated that the facility needed to ensure the safety of the patient. He/She stated that if DCPP could not respond right away even after call backs then the psychiatric screener should have updated the on-call psychiatrist to keep the patient until DCPP arrived and it was determined that the patient was safe to return home. S31 confirmed that the medical record lacked documentation that S37 updated the on-call psychiatrist after it was learned that DCPP might not be at the facility immediately and that the patient stated that they did not feel safe to go home.”

“INTEGRATION OF EMERGENCY SERVICES CFR(s): 482.55(a)(2) [If emergency services are provided at the hospital --] (2) The services must be integrated with other departments of the hospital. This Standard is not met as evidenced by: 38289 Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to ensure that social work is notified of Emergency Department (ED) patients that meet high-risk criteria for a social work referral in three of 22 medical records reviewed (Patient (P)1, P5, and P14). Findings include: Facility policy titled, “High Risk Screening Criteria” Revised 01/24, stated, “... The Case Manager, Nurse, Physician, Family or other members of the interdisciplinary healthcare team may refer a patient to the Social Work Department ... In addition, the Social Worker will review each admission by the first business day on the assigned unit for patients meeting high-risk criteria ... Special emphasis is placed on identifying children and adults ‘at risk’ for neglect/abuse ... The following are considered High Risk Screening Categories ... -Suspicion of abuse/neglect (ADULT AND CHILD) -Self neglect, unable to care for self -Homeless - No Next of Kin, disoriented and/or without identity -Change in Mental Status ... -Multiple, frequent admissions -Frequent emergency room visits ...” During the review of Patient (P)1’s medical record review for visit dates: 12/6/24, 12/7/24, 12/8/24, and 12/9/24, the following was revealed: On 12/6/24, P1 presented to the ED with a complaint of anxiety. The ED Provider evaluated the patient and noted that the patient was “ ...internally preoccupied, concern for SI [suicidal ideation] ...” and a crisis evaluation was ordered. The psychiatric screener identified that P1 had not been seen at the facility’s ED prior to this date, and collateral information was collected from the county psychiatric screening center which identified that the patient had been seen as an outpatient for behavioral health at another facility. P1’s affect was documented as flat, with a derealization perception, tangential thought process, and abnormal thought content. The psychiatric screener, in collaboration with the psychologist, determined that P1 was at no risk for self-harm or hurting others and provided psychiatric clearance and gave P1 information for follow-up post-discharge with an outpatient mental health and addiction services center. P1 was diagnosed with generalized anxiety disorder and was discharged. The medical record did not contain documentation of a next of kin, emergency contact, or home address for the patient. The medical record lacked evidence of a social work referral for P1. On 12/7/24, P1 presented to the ED with complaints of possible HIV (human immunodeficiency virus), bloating, and constipation. P1 was also noted to be seeking referrals for shelter due to homelessness. The ED Provider conducted a medical screening exam and noted that the exam was unremarkable. The patient was discharged with a prescription for the medication Colace (to treat constipation), referrals to two local clinics, and to follow-up with his/her primary care physician in four to six weeks for a follow-up HIV test if still concerned. The medical record did not contain documentation of a next of kin, or emergency contact for the patient. The medical record lacked evidence of resources provided to assist with homelessness and a social work referral for the patient’s recent homelessness. On 12/8/24, P1 returned to the ED by ambulance for complaints of anxiety and a panic attack. The triage nurse assessment noted that P1 had no pertinent psychiatric history. The ED Provider note stated that the patient relayed that he/she became anxious after he/she got lost as he/she was new to the area. The ED provider also noted that the patient was seen in the ED approximately 24 hours prior for vague similar complaints. The ED Provider noted that P1 declined Anxiolytic treatment and that the provider suspects a malingering component to the patient’s presentation. P1 was discharged after a brief respite in the ED with information on managing anxiety. The medical record did not contain documentation of a next of kin, or emergency contact for the patient. The medical record lacked evidence of a social work referral for the patient’s recent homelessness. On 12/9/24, P1 presented to the ED by ambulance with behavioral complaints. The Triage Nurse assessment stated that P1 refused to speak with the Triage Nurse and was refusing vital signs. The Columbia Suicide Severity Rating (CSSR) and homicidal risk assessment was not completed. A psychiatric screening conducted identified the patient has homicidal ideation (HI) with a plan. The psychiatric screening also notes that P1 had a history of suicidal ideation and currently demonstrated a lack of insight regarding care and internal preoccupation and irritability. The psychiatric screener documented that P1 continued to acute psychiatric dangerousness and P1’s case was referred to a local facility for evaluation for inpatient services. The medical record did not contain documentation of a next of kin, or emergency contact for the patient. The medical record lacked evidence of a social work referral for the patient’s recent homelessness and change in mental status. During a review of P5’s medical record, it was revealed the patient presented to the ED on 12/6/24 and twice on 12/8/24. The ED Provider identified P5 as being homeless on each presentation to the ED. The medical records lacked evidence of a social work referral for the patient’s homelessness. A review of P14’s medical record revealed that on 8/22/24 at 1:42 PM, P14 presented to the facility ED for complaints of SI. The ED Triage Nurse indicated in the Nursing Assessments/Treatments note that P14 was homeless. P14 was discharged on 8/22/24 at 2:21 PM with a referral for community resources. The medical record lacked evidence of a referral to social work due to P14’s homelessness. On 12/11/24 at 10:10 AM, during a tour of the facility’s ED, S2, Nurse Manager of the ED, S3, Chief Nursing Officer, and S12, Chief Medical Officer, were asked about the diagnosis of malingering and how the ED providers come to that particular diagnosis. S12 explained that malingering is a diagnosis of exclusion, not one of presumption. S12 stated that there is a large population of homeless, many with behavioral health issues, in the area that come to ED often for medical complaints and sometimes seek respite from the extremes of the environment. S12 stated that this population that returns frequently are known as high utilizers and states that they are monitored. S12 noted that the ED clinician should assess risk and err on the side of caution treating each visit as individual and unique, but there is some “clinician fatigue” with the high utilizers. S2 stated that he/she will work with registration to identify the high utilizers when they come to the facility ED to determine if they have a medical complaint or not. S2 stated that registration would notify him/her if a high utilizer comes to the ED and then S2 would ask the patients if there was a medical concern, and if not she would “send them on their way.” On 12/13/24 at 10:00 AM, the ED high utilizer list was provided for review. The high utilizer list is a list of patients with multiple admissions/presentations to ED that is monitored by the facility. This list is reviewed and discussed in the monthly utilization review meetings. Specific patient cases are discussed at meetings on how the facility can assist the high utilizers better in the community. On 12/16/24 at 11:05 AM, S12 stated that the facility used to have a “Transitions of Care” program that would monitor and track the high utilizers when they came to the facility and in the ED. The facility paused the program and the responsibilities were integrated into the roles of the social worker and the behavioral health crisis management team. S12 confirmed that even though the responsibilities are integrated into other departments, the other departments were not specifically made aware of the specific responsibilities after the Transitions of Care program was paused. On 12/13/24 at 2:36 PM, during an interview with S38, Director of Case Management, it was stated that there is a social worker assigned to the ED Monday through Friday from 7:30 AM to 5:30 PM. S38 stated that after hours and on weekends, a social worker is on call for the unit’s needs. S38 stated that social work only sees a patient if they receive a consult from the provider in the ED. When questioned concerning the ED high utilizer patients and if he/she monitored and tracked these cases, S38 stated that he/she would only know those patients if the social worker was consulted. S38 stated that social work does not keep files on the high utilizers and therefore does not monitor or track the patients. 49174”

“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: 48965 Based on medical record review, staff interviews, and review of facility documents, it was determined that the facility failed to ensure: 1). all patients seeking emergency treatment received a medical screening examination (MSE) from a qualified provider in two of 22 medical records reviewed (Patient (P) 2 and P13); 2). a complete psychiatric evaluation for patients requiring a crisis Psych Emergency Services (PES) screening prior to the patient leaving the Emergency Department (ED) one of 22 medical records reviewed (P17); 3). all patients discharged from the ED receive a discharge order in six of 22 medical records (Patient (P)2, P3, P7, P16, P19, P21); and 4). interventions in place to prevent a patient from eloping from the facility in one of 22 medical records reviewed (P1). Findings include: 1). Facility policy titled, “Emergency Medical Treatment and Active Labor Act” last revised January 2024, states, “ ...Procedure ...3. Medical Screening Examination (MSE) A. ...staff will provide all patients with a Medical Screening Examination. This examination shall be performed by a physician or other practitioner (e.g., Nurse Practitioner, Physician’s Assistant) deemed qualified to perform such examination pursuant to state law and the acute care hospitals Rules and Regulations ... C. Staff will ensure that the Medical Screening Examination is performed in accordance with the patient’s identified needs and with the acute care hospital’s capabilities ...D. All mental health patients will first receive a medical examination to sufficiently rule out organic, toxic, or traumatic causes for the observed condition, and if necessary, receive stabilizing treatment. Upon completion of the medical examination, the mental health patient will receive a mental health assessment. Data may be gathered by non-physicians (crisis workers) but the finale [sic] evaluation will be performed by the Emergency Department physician in consultation with the on-call Psychiatrist. ...” Facility policy titled, “Patient Refusing Treatment or Leaving Against Medical Advice” last revised January 2024, states, “Policy: A competent patient has the right to refuse treatment, including the right to leave the hospital against medical advice (AMA) at any time, for any reason...” On 12/11/24 at 11:25 AM, a review of P2’s medical records for ED visits from 12/7/24 to 12/9/24 revealed the following: On 12/7/24 at 12:10 AM, P2 presented to the ED with a chief complaint of foot pain. The medical record indicated that P2 was seen by a provider on 12/7/24 at 1:59 AM. P2’s medical record lacked evidence of an MSE, or a provider note. This finding was confirmed with Staff (S)18, the Nursing Informaticist, on 12/13/24 at 10:44 AM. On 12/7/24 at 9:29 AM, P2 returned to the ED with a chief complaint of “tongue/feet problems.” The triage nurse documented that P2 reported “mouth blisters” with no other medical complaints. The provider note dated 12/7/24 at 9:50 AM stated that P2 presented to the ED with a history of malingering behavior requesting respite. The physical exam in this note stated, “ENT: Positive for Normal ENT inspection, Moist Mucous Membranes...Extremity: Normal ROM [Range of Motion], Capillary refill < 2 seconds.” This MSE did not address P2 initial presenting chief complaint of foot problem. On 12/9/24 at 2:30 AM, P2 presented to the ED via ambulance. The triage note by the nurse stated that P2 complained of chronic foot pain secondary to being homeless. The provider note from 12/9/24 at 2:41 AM stated P2 presented to the ED for nonspecific complaint of “feeling tired.” The clinical impression documented by the provider was listed as: fatigue, weakness, homeless, malingering. This MSE did not address P2’s initial presenting chief complaint of foot pain. On 12/13/24 at 12:30 PM, the above findings were reviewed and confirmed with S1, the Director of Risk Management. On 12/13/24 at 1:00 PM, the medical record of P13 was reviewed. On 7/19/24 at 8:59 AM, P13 arrived at the ED via ambulance with a chief complaint of “odd behavior.” The triage note completed at 9:12 AM, stated that P13 was not taking his/her Psychiatric (Psych) medications for the past six months and has not been sleeping well. The triage note also stated that P13 denied suicidal or homicidal ideation (SI/HI) and he/she was in a nearby ED the day prior and was diagnosed with a urinary tract infection (UTI). On 7/19/24 at 9:22 AM, an ED provider ordered a PES (Psychiatric Emergency Services) Crisis Evaluation for P13. The ED Provider Note completed by a Physician’s Assistant (PA), indicated that outside ED visit records were “not available/not reviewed.” The provider note also contained a reassessment timed for 9:20 AM which stated, “Crisis c/s [consult], aware of patient but understaffed - warned assessment may take a while.” An updated documentation by the PA at 11:00 AM stated, “Patient requesting d/c [discharge]. Discussed with ER attending physician, patient AOx3 [alert and oriented to person, place, and time], denying SI/HI/hallucinations and has outpt [outpatient] psychiatric care. Patient seen and cleared yesterday at [facility name]. Due to these reasons, attending physician comfortable with AMA [against medical advice]. All risks/benefits of care dsicussed [sic] with the patient, verbalized understanding. Patient signed AMA paperwork.” On 7/19/24 at 11:04 AM, P13 signed out AMA without clearance from the PES Screeners. P13 was notified of the risks of leaving AMA by the PA and P13 and the PA signed the AMA paperwork. On 12/16/24 at 2:50 PM, during an interview with S24, Crisis Intervention Specialist, and S25, the Crisis Intervention Specialist, both S24 and S25 confirmed that once a patient has a referral to the crisis screeners, the patient cannot sign out AMA. Both S24 and S25 confirmed that a patient needs to be cleared by the Psychiatrist before signing out AMA. On 12/16/24 at 2:57 PM, during an interview with S20, the Physician’s Assistant, it was stated that the decision to allow the patient to leave AMA would be patient specific and would require a thorough evaluation and a consultation with the attending physician. S20 further stated that if a patient meets the criteria for a crisis evaluation, they likely do not have the capacity to sign out AMA. On 12/16/24 at 3:00 PM, an interview was conducted with S33, a Registered Nurse (RN). S33 indicated that if a patient was pending a crisis evaluation, he/she cannot leave AMA, they have to wait for clearance from Psychiatry. This was confirmed by S21, an RN, on 12/16/24 at 3:06 PM and S36, the ED Physician on 12/18/24 at 10:46 AM. 49174 2). Facility policy titled, “Suicide Assessment and Prevention” last revised 1/24, states, “... A full suicide assessment will be completed by a Licensed Independent Practitioner (LIP-MD/DO, PA, APN) or Psych Emergency Services (PES). If the assessment is performed by PES [Psychiatric Emergency Services], the results will be communicated to the LIP. The assessment completed by the LIP or PES will determine the level of risk and interventions and monitoring necessary to maintain patient safety. PES and the Psychiatrist will determine disposition and referrals as indicated.” On 12/16/24, a review of P17’s medical record revealed the following: On 10/12/24 at 4:15 PM, P17 arrived at the facility’s ED with complaints of Suicidal Ideation (SI). At 4:19 PM, P17 was triaged and scored “high risk” on the Columbia Suicide Severity Rating Scale (C-SSRS) screening. The triage nurse documented interventions to be implemented for a high risk suicidal patient. Interventions included a patient search, placing the patient in a room near the nurse’s station, initiating the safe room protocols, not leaving the patient unattended, and placing the patient on 1:1 observation. The medical record lacked documentation that these interventions were put into place per facility policy. On 10/12/24 at 9:15 PM, P17 was medically cleared for a crisis evaluation by the ED physician. On 10/12/24 at 9:27 PM, P17’s crisis PES screening was conducted. The Behavioral Health Intake/Inquiry Form completed by the PES (Psychiatric Emergency Service) screener revealed that under section, “Part C: Disposition and Status” it stated, “Admitted: yes/no. If no, why Check all box(es) that apply.” The PES screener documented “No” and the applicable boxes were left blank. The medical record lacked the documented reason why the patient was not admitted. On 10/12/24 at 11:23 PM, the ED Physician Documentation note stated, “crisis called to inform me that the patient will be discharged by [psychiatrist] with diagnosis of MDD (Major Depressive Disorder).” On 10/13/24 at 3:00 AM, P17 was discharged from the ED with his/her condition listed as “improved.” On 12/16/24 at 12:39 PM, during an interview with S31, the PES Coordinator, P17’s “Behavioral Health Intake/Inquiry Form” was presented to S31 who stated the form, “needs to say why [the patient wasn’t admitted] and I don’t know why it doesn’t.” 3). A review of the Medical Staff Rules and Regulations approved by the Board of Directors on June 23, 2022, states, “ ...11. Patient Discharge: A. Patients shall be discharged only on written or telephone order of the attending practitioner. The attending practitioner shall make every effort to discharge the patient as soon as possible within the dictates of reasonably proper care and treatment of the patient. Should a patient leave the hospital against the advice of the attending practitioner, or without proper discharge, a notation of the incident shall be made on the patient’s medical record and, where possible, the patient shall sign a release. ...” On 12/11/24 at 11:25 AM, a review of medical records revealed the following: On 12/7/24 at 12:10 AM, P2 presented to the ED with a chief complaint of foot pain. P2 was discharged on 12/7/24 at 6:16 AM. This medical record lacked evidence of a discharge order from an ED provider. On 12/13/24 at 10:44 AM, S18, the Nursing Informaticist, confirmed P2’s medical record from 12/7/24 at 12:10 AM did not have a discharge order. On 12/6/24 at 2:43 PM, P3 presented to the ED with a chief complaint of “ETOH” (alcohol). P3 was discharged home on 12/7/24 at 4:32 AM. The medical record lacked evidence of a discharge order from an ED provider. On 12/13/24 at 10:54 AM, S18 confirmed P3’s medical record from 12/7/24 at 2:43 PM did not have a discharge order. On 12/8/24 at 5:56 AM, P7 presented to the ED with a chief complaint of “anxiety.” P7 was discharged home on 12/8/24 at 12:24 PM. The medical record lacked evidence of a discharge order from an ED provider. On 12/13/24 at 11:04 AM, S18 confirmed P7’s medical record from 12/8/24 at 5:56 AM did not have a discharge order. On 10/12/24 at 3:52 AM, P16 presented to the ED with a chief complaint of “anxiety.” P16 was discharged home on 10/12/24 at 6:25 AM. The medical record lacked evidence of a discharge order from an ED provider. On 11/24/24 at 1:24 AM, P19 presented to the ED with a chief complaint of “abd pain” (abdominal pain). P19 was discharged home on 11/24/24 at 6:00 AM. The medical record lacked evidence of a discharge order from an ED provider. On 11/20/24 at 7:54 PM, P21 presented to the ED with a chief complaint of a headache. P21 was discharged home on 11/20/24 11:10 PM. The medical record lacked evidence of a discharge order from an ED provider. On 12/5/24 at 3:00 AM, P21 presented to the ED with a chief complaint of “SI per EMT” (suicidal ideations per emergency medical technicians). P21 was discharged home on 12/5/24 at 7:01 AM. The medical record lacked evidence of a discharge order from an ED provider. On 12/13/24 at 11:04 AM, S18 explained that the ED has a patient tracker with a status column. According to S18, the ED provider can change the patient status to ready for discharge, but he/she explained that this is not a discharge order. S18 reported that the nurse still needs to obtain a discharge order and instructions from a provider before a patient is to be discharged. On 12/13/24 at 12:30 PM, the above findings were reviewed and confirmed with S1, Director of Risk Management. 4). Facility policy, titled, “Elopement (Prevention and Response)”, revised 04/2024, states, “ ... Strategies to Prevent Elopement: 1. Communicate to the Health Care Team Members that the patient is a high elopement risk. 2. Remove outdoor clothing and other articles which would facilitate the patient’s elopement and secure them out of the patient’s sight ... 6. Notify security officers that the patient is at risk to elope so that the ED exits can be monitored. 7. Use bed exit alarm if available; if the patient exits the bed while unattended, the staff will be alerted ... 12. When possible, the patient will be informed of the staff’s concern about possible elopement, and the fact that special precautions to provide for his/her safety are being implemented ... Documentation: 1. The patient progress notes must be update by the RN and the physician and should relate: a. Time/Date the patient was noted to be missing. b. All actions taken. c. Family/guardian notification d. Police Department notification 2. The Security Department will record the time of notification and all actions taken, including hospital, environmental searches, and Police Department notification ...” On 12/9/24 at 12:19 AM, P1 presented to the ED by ambulance with behavioral complaints. The Triage nurse assessment at 12:27 AM indicated that P1 refused to speak with the triage nurse and refused vital signs assessment. The triage nurse was unable to complete the Columbia Suicide Severity Rating (CSSR) and homicidal risk assessment. The triage nurse identified P1 as a high elopement risk, and documented interventions to be implemented for a high elopement risk patient. Interventions included placing the patient in a room near the nurse’s station; frequent hourly monitoring and every 15-minute visual checks; removal of shoes/clothing and secure belongings where the patient cannot access them; and placing the patient in a color identifiable gown. The medical record lacked documentation that these interventions were put into place per facility policy. A psychiatric screening completed at 12:58 AM identified the patient with homicidal ideation (HI) with a plan. In an interview with Staff (S)1, Director of Risk Management, and S3, Chief Nursing Officer on 12/11/24 at 11:11 AM, S1 and S3 confirmed that the patient should have been placed on one-to-one observation for the HI. The medical record lacked documentation that P1 was placed on a one-to-one observation. An ED Provider Note at 1:30 AM indicated that the patient absconded from the ED. The Psychiatric Screener Note at 2:22 AM stated that it was confirmed P1 left the hospital declining treatment. The medical record lacked documentation of attempts to locate the patient including notification to security, phone calls to patient, and notification to the local police department per facility policy.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 48965 Based on medical record review, staff interviews, and review of facility documents, it was determined the facility failed to ensure that all patients seeking emergency treatment received a medical screening examination (MSE) from a qualified provider in one of 22 medical records reviewed (Patient (P)2). Findings include: Facility policy titled, “Emergency Medical Treatment and Active Labor Act” last revised January 2024 stated, “ ...Procedure ... 3. Medical Screening Examination (MSE) A. ...staff will provide all patients with a Medical Screening Examination. This examination shall be performed by a physician or other practitioner (e.g., Nurse Practitioner, Physician’s Assistant) deemed qualified to perform such examination pursuant to state law and the acute care hospitals Rules and Regulations .... C. Staff will ensure that the Medical Screening Examination is performed in accordance with the patient’s identified needs and with the acute care hospital’s capabilities ...” On 12/11/24 at 11:25 AM, a review of P2’s medical record for an Emergency Department (ED) visit from 12/7/24 was reviewed. On 12/7/24 at 12:10 AM, P2 presented to the ED with a chief complaint of foot pain. The medical record indicated that P2 was seen by a provider on 12/7/24 at 1:59 AM. P2’s medical record lacked evidence of an MSE, or a provider note. This finding was confirmed with Staff (S)18, Nursing Informaticist, on 12/13/24 at 10:44 AM. On 12/13/24 at 12:30 PM, the above findings were reviewed and confirmed with S1, Director of Risk Management.”