Capital Health Medical Center - Hopewell

“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: 51986 Based on facility document review and staff interviews, it was determined the facility failed to ensure 1) that medical screening exams are documented in accordance with facility policy in three of four medical records reviewed (Patient (P)1, P3, and P5); and 2) reassessment of patients in the emergency department per facility policy in four of four medical records reviewed (Patient (P)1, P3, P4, and P5). Findings include: 1. Facility policy titled, “Medical Screening Examinations in Dedicated Emergency Departments” (last approved August 2025), stated, “ ... V. Procedure: A. Dedicated Emergency Departments ... 1. A Medical Screening Examination is an examination conducted by a Qualified Medical Person that is sufficient to determine, with reasonable clinical confidence, whether a medical emergency exists. ... C. Documentation of Medical Screening Examination 1. The examiner performing the Medical Screening Examination documents in the medical record: a. A statement of history; b. A physical examination; and c. If the patient is determined to be stable, a notation certifying this, with additional evaluation as dictated by the patient’s condition.” Facility policy titled, “Emergency Care” (Revised 04/2025) stated, “ ... 3. Documentation ... The Qualified Medical Person performing the Medical Screening Examination records in the medical record: a. a statement of history; b. A physical examination, appropriate to the patient’s condition; d. If the patient is determined to be stable, a notation certifying this ...” Facility policy titled, “Documentation in the Emergency Department: Guidelines” (Revised 01/2023) stated, “ ... Procedure: ... B. After the initial triage assessment, a more thorough evaluation, either focused or complete, will be documented for each patient and will include the following components: ... 4. Physical Exam (focused-complete) 5. Intervention(s)/outcome ...” A review of medical records for P1, P3, and P5, in the presence of S1, S3, S5, S12, S13, and S15. revealed the following: P1’s ED Triage note on 12/28/25 at 6:27 PM, indicated a chief complaint of sinus congestion and vomiting twice, suspects from swallowing mucus/phlegm. P1 was 16 weeks pregnant and denied abdominal pain or vaginal discharge/bleeding. On 12/28/25 at 21:22:01 [9:21 PM], the medical screening exam documented stated, “History was obtained by to expedite treatment with expectation that patient will be seen by another provider for a complete history and physical ... Vital signs reviewed by me ... Focused physical exam was performed by me ...” P3’s ED Triage note on 12/28/25 at 6:30PM, indicated a chief complaint of fever, HA [headache], cough, sore throat, and pain of 8/10 [eight out of 10 pain level]. P3 was eight months pregnant. The triage note further stated, “HR [heart rate] 116, ekg done in triage.” On 12/28/25 at 21:22:47 [9:22 PM], the medical screening exam documentation stated, “History was obtained by to expedite treatment with expectation that patient will be seen by another provider for a complete history and physical ... Vital signs reviewed by me ... Focused physical exam was performed by me ...” P5’s ED Triage note on 12/29/25 at 10:36 PM indicated a chief complaint of back pain radiating to the chest for two days. The medical record lacked documented evidence of a focused or complete MSE. On 12/30/25 at 1:50 AM, the ED Triage Reassessment nurse documentation on the ED WR Triage Status, stated, “Unchanged & appropriate to return to WR.” On 12/30/25 at 6:12 AM, P5’s ED disposition was documented as “Left without being seen.” On 12/30/25, documentation under section titled, ED Called to Triage/Treatment Area, indicated that the patient was called three times at 5:15 AM, 5:40 AM, and 6:13 AM, with no answer. On 03/23/26 at 1:42 PM, S14 stated an MSE is utilized to provide an “initial evaluation” of a patient and is done to “confirm vitals and the triage notes.” When asked what focused exam was performed for P1, P3, and P5. S14 stated it would be “assumed” the focused exam was “based off the triaging note.” S14 confirmed the MSE evaluation notes for P1 and P3 contained “sparse” information. S14 stated a focused exam would have occurred with these patients based on whatever was triaged. When S14 was asked how would he/she know what type of focus exam occurred, he/she stated the focused exam would be based on the triage note. When asked if the providers should be documenting the focused exam somewhere, S14 said “no, that information would be documented in the H&P [history and physical] once another physician saw the patient.” The findings were presented to S14 and when asked about the patient’s medical stabilization, S14 stated the above patients were not fully evaluated and a full evaluation would be contained in the H&P. On 3/24/26 at 10:44 AM, upon interview, S19 stated, “there is no “standard” as to what should be performed when conducting a medical screening exam (MSE) on a patient.” S19 stated that the MSE documentation should include documentation of what exam was performed. S19 stated,”providers should be documenting what is done to care for the patient.” When questioned if the MSE documention note “history was obtained to expedite treatment” was the expected documentation for providers, S19 stated that it was. When asked if documenting in an MSE note “vital signs reviewed by me” was the expected documentation for providers, S19 stated that it was. When asked if documenting in an MSE note “focused physical exam was performed by me” was the expected documentation for providers, S19 stated that it was. When asked if the MSE note documented in the medical record should include what history was obtained, what vital signs were reviewed, and what type of focused exam was performed, S19 stated “not necessarily.” S19 stated this information would be documented later when the history and physical (H&P) note was written. When asked if a patient left the ED prior to having a full H&P conducted if there should be any further documentation from a provider, S19 stated “no,” as the patient did not have a full exam or workup by the provider. When asked if there was a way to see what “focused exam” was performed on a patient during an MSE, S19 stated, “no, but it would be assumed the MSE would be focused on the triage information collected.” At 11:00 AM, upon interview, S20 stated, “an MSE is done after a patient is triaged and is utilized to ensure a patient is stable enough to be in the waiting room.” S20 further stated an MSE note that is documented would include a review of vital signs and that the patient was seen and examined by a provider. When asked if documenting in an MSE note “history was obtained to expedite treatment” was the expected documentation for providers, S20 stated that it was. When asked if documenting in an MSE note “vital signs reviewed by me” was the expected documentation for providers, S20 stated that it was. When asked if documenting in an MSE note “focused physical exam was performed by me” was the expected documentation for providers, S20 stated that it was. When asked if the MSE note documented in the medical record should include what history was obtained, what vital signs were reviewed, and what type of focused exam was performed, S20 stated, “no, because all of that information would be included in the H&P once the patient has been fully evaluated.” When asked if a patient left the ED prior to having a full H&P conducted if there should be any further documentation from a provider, S20 stated “no,” as the patient did not have a full exam or workup by the provider. When asked if there was a way to see what “focused exam” was performed on a patient during an MSE, S20 stated, “no,” and that whatever issue was addressed in triage would be the what was assessed in the focused exam. 2. Facility policy titled, “Triage Policy” (Revised 05/2024) stated, “V. Procedure: 5. V. All Level 3 (Urgent) patients are given priority ... A Level 3 patient is defined as a patient with significant medical problems ... 1. Level 3 patients remaining in the waiting room are reassessed every 90-105 minutes to determine if the patient’s condition has changed, warranting a change in the level of acuity. Findings are documented in the patient’s chart ... “ On 03/24/26 at 11:44 AM, medical record review was conducted in the presence of Staff (S)3, S4, S5, S12 S13, and S15 that revealed the following: On 12/28/25 at 6:27 PM, Patient (P)1 was triaged in the Emergency Department (ED) as a level three ESI (Emergency Severity Index) indicating his/her level of care was “urgent,” and his/her vital signs (VS) were assessed. At 10:51 PM (264 minutes after initial VS), P1’s reassessment was documented which included P1’s blood pressure, oral temperature, peripheral pulse (heart rate) rate, and his/her respiratory rate. On 12/29/25 at 4:00 AM, 4:08 AM, and 4:40 AM, the facility attempted to contact P1. P1’s disposition was documented as “eloped,” in P1’s medical record. At the time of discovery, S13 confirmed there were no further reassessments after 10:51 PM and that P1 should have been reassessed more frequently per the facility’s policy. On 12/28/25 at 6:30 PM, P3 was triaged in the ED as a level three ESI indicating his/her level of care was “urgent,” and his/her vital signs were assessed. At 11:13 PM (283 minutes after initial VS), P3’s reassessment was documented which included P3’s blood pressure, oral temperature, peripheral pulse (heart rate) rate, and his/her respiratory rate. On 12/29/25 at 12:03 AM, vital signs were documented in P3’s medical record which included P3’s blood pressure, oral temperature, peripheral pulse (heart rate) rate, and his/her respiratory rate. On 12/29/25 at 5:00 AM, 5:15 AM, and 5:28 AM, the facility attempted to contact P3. P3’s disposition was documented as “eloped.” At the time of discovery, S13 confirmed there were no further reassessments after 12:03 AM and that P3 should have been reassessed more frequently per the facility’s policy. On 12/27/25 at 7:41 PM, P4 was triaged in the ED as a level three ESI indicating his/her level of care was “urgent,” and his/her vital signs were assessed which included P4’s blood pressure, oral temperature, peripheral pulse (heart rate) rate, and his/her respiratory rate. On 12/29/25 at 12:07 AM (266 minutes after initial VS), reassessment vital signs were documented in P4’s medical record which included blood pressure, oral temperature, peripheral pulse (heart rate) rate, and his/her respiratory rate. On 12/29/25 at 3:07 AM, a Registered Nurse (RN) documented an ED nursing note that stated P4 wanted to go home. P4’s disposition was documented as “eloped.” At the time of discovery, S13 confirmed there were no further reassessments after 12:07 AM and that P4 should have been reassessed more frequently per the facility’s policy. On 12/29/25 at 10:39 PM, P5 was triaged in the ED as a level three ESI indicating his/her level of care was “urgent,” and his/her vital signs were assessed. On 12/30/25 at 1:50 AM (191 minutes after initial VS), P5’s reassessment was documented which included blood pressure, oral temperature, peripheral pulse (heart rate) rate, and his/her respiratory rate. Documentation in the medical record under ED Called to Triage/Treatment Area indicated that at 5:15 AM, 5:40 AM, and 6:13 AM, the facility attempted to contact P5. At 6:13 AM, P5’s disposition was documented as “eloped.” At the time of discovery, S13 confirmed there were no further reassessments after 1:50 AM and that P4 should have been reassessed more frequently per the facility’s policy. On 03/24/26 at 12:20 PM, during an interview, S13 stated that a patient who was triaged at a level three ESI must have a reassessment conducted every 90 to 105 minutes to determine if the patient’s condition has changed. S13 confirmed P1, P3, P4, and P5 should have been reassessed more frequently.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48965 Based on staff interview, medical record review, and review of facility documents, it was determined the facility failed to ensure all patients’ cardiac monitors, pain, and vital signs, were assessed and reassessed by nursing staff according to facility policy. (Patient (P)1). Findings include: Facility policy titled, “Multidisciplinary Patient Assessment and Reassessment” last revised March 2024 states, “ ...IV. Policy: ...E. The content of the initial assessment and ongoing reassessment is specific to the patient diagnosis and the complexity of care needs of the patient. F. Reassessment ensures that the treatment is dynamic, appropriate, and effective for the patient. G. Each patient is reassessed at regular intervals in the course of treatment to determine their response to care. In addition, patients are reassessed when there is a change in the level of care or a significant change in condition or diagnosis. Reassessment of patients with a change in level of care is provided by staff competent to provided that level of care .... Nursing Assessment and Reassessment Grid: ... Cardiac/Neuro Telemetry: Assessed by RN [registered nurse] immediately upon arrival .... Reassessment: Focused, problem-oriented reassessment every 12 hours or more frequently as indicted by the patient’s condition. Continuous cardiac monitoring ...Vital Signs assessment/reassessment Schedule: ...Cardiac Telemetry: Upon admission; BP/P/R [Blood Pressure/Pulse/Respiratory Rate]: q4hr [every 4 hours]; temp [temperature]: q4hr; O2 Sat [Oxygen Saturation]: q4hr; Pain: At the time of Vital Signs and within 1 hour after intervention; Additional: Monitor rhythm strips on admission and every shift (8 hours) with written interpretation and RN initials ...” On 1/14/25 at 11:48 AM, a review of P1’s medical record took place in the conference room in the presence of Staff (S)7, Emergency Department (ED) Manager and S8, Pediatric ED Manager. On 1/2/25, P1 presented to the ED at 12:06 PM with a chief complaint of upper abdominal pain radiating to chest and bilateral arms for two days. P1 was triaged at 12:07 PM by the triage nurse and assessed as an ESI (Emergency Severity Index) level 3. During triage, the nurse assessed P1’s pain at a level 8 out of 10 in his/her upper abdomen. At 2:07 PM, a triage reassessment was completed by the triage nurse and no change in condition was identified. P1 reported his/her pain to be 7 out of 10. No pain interventions were documented in the medical record at this time. P1 had no change on ESI level or condition. At 2:17 PM, P1 was placed in a hallway bed. At 2:33 PM, P1 was seen by an ED provider and a full MSE was performed. On 1/2/25 at 5:17 PM, an inpatient bed request was placed and at 6:44 PM an order for telemetry was placed. On 1/2/25 at 6:52 PM, a nurse acknowledged this telemetry order. The medical record lacked documentation of placement of a telemetry monitor on the patient. S7 explained that when a nurse acknowledges an order, that means he/she completed the task. The medical record also lacked printed rhythm strips from admission, and every 8 hours, with the nurse’s initials and interpretation of the rhythm. On 1/14/25 at 2:57 PM, S7 confirmed that no strips were found in the medical record as required per facility policy. P1’s pain was assessed every four hours, per facility policy, until 1/3/25 at 6:00 PM. After 6:00 PM, there are no further nursing assessments of P1’s pain. P1’s medical record also revealed that vital signs were not completed every four hours, as per facility policy for cardiac telemetry. Vital signs for P1 were documented on 1/2/25 at 6:29 PM and 1/3/25 at 12:00 AM. There are 5 hours and 31 minutes between the documented vital signs. Another set of vital signs were documented on 1/3/25 at 12:00 PM and the next set was not documented until 1/4/24 at 4:17 AM. There are 16 hours and 17 minutes between documented vital signs. On 1/14/25 at 12:15 PM, the facility policy titled, “Multidisciplinary Patient Assessment and Reassessment” was reviewed with S3, Director of Regulatory Affairs, and S7. S3 and S7 confirmed that the facility policy dictates that P1’s vital signs should have been completed every four hours. S7 confirmed P1’s vital signs were not completed every four hours as indicated in facility policy.”