Inspira Medical Center Mullica Hill

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 51555 Based on medical record review, review of facility policies, and staff interview, it was determined the facility failed to ensure staff was completing pain re-assessments within one hour of pain medication administration, as indicated in facility policy, in four of four medical records reviewed (Patient (P)1, P5, P9, and P10). Findings include: Facility policy titled, “Rights, Patient’s Bill of,” last reviewed, 3/9/23, stated, “... [Facility Name]... (a) Every New Jersey hospital patient shall have the following rights... These rights shall include at least the following:... 31. To expect and receive appropriate assessment, management, and treatment of pain as an integral component of that person’s care.” Facility policy titled, “Pain Management,” last reviewed, 6/18/25, stated, “... V. Procedures:... C. Interventions... 3. Pharmacological methods:... d. Reassessment within 1 (one) hour of pain medication administration and [reassessment] must be documented in the medical record.” A review of P1’s medical record was conducted in the presence of S3 and revealed the following: On 12/6/25 at 10:42 PM, P1 arrived at the ED (Emergency Department) with complaints of chest pain. At 3:27 AM, an order for ketorolac (Toradol) (NSAID, non-steroid anti-inflammatory drug) 15 mg, IV [intravenous] push, once, was ordered by S21, and administered by S23. A pain assessment was documented by S23 at the time of administration; “Pain score: 4 = moderate pain.” At 5:28 AM, a pain assessment was documented, by S23, and stated, “Pain score: 3 = mild pain.” This was two hours and one minute after medication was administered for pain. There is no evidence of a pain reassessment within one hour, as indicated in facility policy, after the administration of IV Toradol at 3:27 AM. The lack of pain reassessment after pain medication administration for P1 was confirmed with S3 on 1/7/26 at 11:10 AM. A review of P5’s medical record was conducted in the presence of S3 and revealed the following: On 12/6/25 at 12:02 AM, P5 arrived at the ED with complaints of chest pain. At 12:06 AM, a note titled, “ED Triage Adult” was documented by S24, and stated, “... Chief complaint: L [left] side CP [chest pain] when taking a deep breath since yesterday... Pain Assessment Adult:... Numeric Pain Scale: 7 = Moderate pain.” At 1:38 AM, an order for oxycodone 5 mg, oral, tab, once, was placed by S25. At 1:52 AM, the oxycodone 5 mg was administered by S26 as ordered. At 6:00 AM, a pain assessment was documented by S26, and stated, “Pain Present: no.” This was four hours and eight minutes after medication was administered for pain. There is no evidence within P5’s medical record of a pain assessment within one hour, as indicated in facility policy, after the oxycodone administration. The lack of pain reassessment after pain medication administration for P5 was confirmed with S3 on 1/7/26 at 11:20 AM. A review of P9’s medical record was conducted in the presence of S3 and revealed the following: On 12/7/25 at 7:41 AM, P9 arrived at the ED with complaints of left flank (side of torso, between the ribs and the hip) pain. At 7:48 AM, a note titled, “ED Triage Note,” documented by S27, stated, “Chief Complaint: pt experiencing left flank pain for the past couple days. Denies NVD [nausea, vomiting, diarrhea] ... Pain assessment adult: ... Numeric Pain Scale: 7 = Moderate pain.” At 8:47 AM, an order for ketorolac (Toradol) 15 mg, IV push, injection, once, was placed by S28. At 8:54 AM, the IV Toradol 15 mg, was administered by S30. At 12:01 PM, a pain assessment was documented by S30, and stated, “Pain Present: No.” This was three hours and seven minutes after medication was administered for pain. There is no evidence within P9’s medical record of a pain assessment within one hour, as indicated in facility policy, after the IV Toradol administration. The lack of pain reassessment after pain medication administration for P9 was confirmed with S3 on 1/7/26 at 11:32 AM. A review of P10’s medical record was conducted in the presence of S3 and revealed the following: On 12/7/25 at 12:37 AM, P10 arrived at the ED with complaints of abdominal pain. At 12:48 AM, a note titled, “ED Triage Adult” was documented by S31, and stated, “... Chief Complaint: pt c/o LLQ [left lower quadrant] pain x couple hours. Endorses nausea, denies V/D/C [vomiting, diarrhea, cramping]. Pt denies an abdominal surgeries... Pain Assessment Adult... Numeric Pain Scale: 9 = Severe pain.” At 1:28 AM, an order was placed for ketorolac (Toradol) 15 mg, IV push, injection, once, by S32. At 2:42 AM, the IV Toradol was administered by S33. At 5:08 AM, a pain assessment was documented by S33 and stated, “Pain Present: No.” This was two hours and 26 minutes after Toradol was administered for pain. There is no evidence within P10’s medical record of a pain assessment within one hour, as indicated in facility policy, after the IV Toradol administration. The lack of pain reassessment after pain medication administration for P10 was confirmed with S3 on 1/7/26 at 11:50 AM. On 1/7/26 at 12:35 PM, when asked regarding the process of a pain reassessment in the ED, S3 explained, that after pain medication is administered, nurses are required to reassess the patient’s pain. S3 further explained, if the patient is given IV push medications, the nurse should reassess within 30-minutes of administration and if the patient is given PO (oral/by mouth) pain medication, the nurse should reassess the patients pain level within an hour of administration.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47131 Based on review of one of one medical records (MR1), staff interviews, video surveillance review, and review of facility documents, it was determined the facility failed to ensure orders for one-to-one (1:1) monitoring were implemented in accordance with facility policy, resulting in the elopement of a patient who was waiting for a psychiatric crisis screening (A-0144). This failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to patients. Cross Reference: 482.13(c)(2) Patient Rights: Care in Safe Setting On March 21, 2025 at 2:57 PM, an IJ was identified for the facility’s failure to appropriately monitor a patient on one-to-one monitoring for safety (A-0144). On March 21, 2025, at 3:34 PM, the IJ template was presented to the administration and a removal plan was requested. On March 24, 2025 at 11:17 AM, an acceptable removal plan was received. The facility implemented the following to address the IJ: Staff re-education which included: 1) appropriate position of staff in the room when a patient is on one-to-one monitoring; 2) escalation to registered nurse (RN) and provider when a patient reports the desire to leave the hospital; and 3) education on the debriefing process after an elopement was provided to Sitters, Nurses, Technicians, Unit Secretaries, and Security Officers. The IJ was removed on March 24, 2025 at 2:20 PM, after the State Survey Agency verified the full implementation of the removal plan, and Condition Level non-compliance remains (A0144).”

“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: 47131 Based on the review of one of one medical record (MR1), staff interviews, video surveillance review, and review of facility documents, it was determined the facility failed to ensure that orders for one-to-one (1:1) monitoring were implemented in accordance with facility policy, resulting in the elopement of a patient who was waiting for a psychiatric crisis screening. Findings include: Facility policy titled, “One to One (1:1) Criteria” (Review Date: 07/06/2023) stated, “1. POLICY: A. To provide guidelines for the assessment and use of one to one (1:1) intervention for patients on suicide/behavioral health precautions. ... IV. Procedure: ... D. Staff members must complete a training and competency program prior to assignment of a 1:1. E. Training and competency program will be provided by the Education Department with annual competencies via Health Stream; and will review the expectations and obligations of any staff members providing 1:1 intervention, including appropriate psychological interactions with the patient, therapeutic boundaries, the need to observe the patient continuously at arm’s length ...” Facility training document titled, “1:1 (One-to-One) Observer Role” (Reviewed/Updated 2024) stated, “What to do ... Basics: ... Place yourself in the room between the patient and the door (and keep a distance of at least arm’s length + (plus) ten inches). You should NEVER be on the opposite side of the room from the door ... Report concerning conversations to the RN (Registered Nurse) immediately ... Report to RN immediately: ... The patient talks about leaving ...” On 03/21/25 at 10:00 AM, during the entrance conference conducted with Staff (S)1 (Vice President of Nursing) and S2 (System Director of Regulatory Compliance), S1 confirmed that Patient (P)1 came to the ED on 02/27/25 via EMS for psychiatric crisis screening, then eloped from the ED prior to receiving psychiatric clearance. At 10:05 AM, S1 stated,”[P1] called State Police after feeling that someone was following [him/her]. County crisis evaluated the patient and brought [him/her] to the ED. The patient was triaged, changed into a grey gown, [his/her] belongings were secured in a locker, and the patient was placed on one-to-one (1:1) monitoring with a safety sitter.” S1 stated the patient presented as “calm and cooperative, not resisting.” S1 confirmed the patient was medically cleared by a provider and was awaiting crisis screening onsite with [name of county crisis screening services.] At 11:34 AM, a review of the video surveillance footage was conducted in the presence of S1, S2, S10 (ED Nurse Manager), S11 (Quality and Patient Safety), and S13 (Security Supervisor). Video #1 - Time stamp: 02/27/25 at 16:15:02 [4:15 PM], hallway view outside of Room 18, identified by S1 and S10: P1 was observed standing in the doorway of Room 18. The 1:1 sitter was not observed in view of camera. P1 was observed wearing a hospital gown while holding a hospital blanket with one hand over [his/her] head. P1 then turn [his/her] head to the right and appeared to look down the hallway. Upon interview, S13 stated P1 appeared to be looking in the direction of the ED exit. P1 ran out of the room and down the hallway in the direction of the ED exit doors. S21 (ED Sitter) ran out of Room 18 in the same direction as P1 and followed by S29 (ED RN) who was observed to be running from a different direction [not in view of camera footage] in same path as P1 and S21. Video #2 - Time stamp: 02/27/25 at 16:15:11, hallway view towards Ambulance Bay exit doors: S14 (Security Officer) was observed sitting at the security desk next to the ambulance bay exit. P1 was observed wearing a hospital gown and socks, running in the hallway towards the ambulance bay exit doors. S14 got up and moved towards P1 as the patient ran towards the exit doors. P1 was observed running past S14 and through the ambulance bay exit doors into the parking lot. S21 and S29 were observed running behind P1 through the doors behind S14 into the ambulance bay. S21 and S29 was then observed walking back into the ED. Video #3 - Time stamp: 02/27/25 at 16:15:17, parking lot view from the ambulance bay (towards the street): P1 was observed running directly across the parking lot and turned left onto a sidewalk next to a main road. P1 continued running on the sidewalk next to the main road while wearing only a hospital gown with [his/her] back exposed and socks. S14 was observed running behind P1 until P1 and S14 were out of view of the video camera. During an interview conducted with S21 (ED sitter) on 03/21/25 at 1:55 PM, it was confirmed that S21 was the sitter assigned to P1 on 02/27/25. S21 stated that P1 was “compliant” and “not agitated”. S21 stated that P1 was “paranoid and asked me to shut the door to the exam room and for me to sit next to the door.” When asked if [he/she] closed the door to the room, S21 stated, “Yes. After about 20 minutes, P1 asked me to move away from the door and next to the counter. The patient was laying in the bed. Then the patient got up from the bed and was standing in the room. [He/She] kept asking for the doctor. [P1] kept saying [he/she] wanted to leave and when could [he/she] leave.” When asked if S21 reported to the nurse or physician that P1 expressed wanting to leave, S21 said “No.” When asked where S21 was positioned when P1 ran from the exam room, S21 stated, “The patient was standing in the doorway and I was inside the room, behind [P1] ... I probably should have not been standing behind the patient with the patient in the doorway. I should have told the nurse or doctor that P1 said [he/she] wanted to leave.” During the interview, S21 confirmed that [he/she] did not notify P1’s nurse when the patient expressed [he/she] wanted to leave; that [he/she] was positioned behind P1 in the exam room as the patient was standing in the doorway at the time [he/she] ran out of the room, down the hallway, and eloped from the ED; and that [he/she] was not positioned in front of P1 in the exam room, in accordance with facility 1:1 observer role training. On 03/21/25, a review of the medical record for Patient (P)1 revealed the following: P1 was a 21-year-old who arrived at the Emergency Department (ED) on 02/27/25 at 13:42 (1:42 PM) via EMS (Emergency Medical Services). The ED Nurse Documentation section of the medical record dated 02/27/25 at 13:44 (1:44 PM) stated, “Presenting complaint: EMS states: sent here by [name of county psychiatric crisis screening service] for screening. Per EMS they were called out for [the patient] twice r/t (related to) [the patient] feeling like someone was following [him/her]. ...” The patient’s ESI (emergency severity index) acuity was assessed as Level 2. At 14:00 (2:00 PM), the ED Nurse Documentation section of the medical record stated, “One-on-one care: Initiated continuous observation, based on the suicide risk/behavioral disorder assessment. ...” The triage assessment completed at 14:20 (2:20 PM) stated, “ ...General: Appears in no apparent distress, Behavior is agitated. ...” A review of the Two-Hour Assessment documentation entry completed at 16:00 (4:00 PM) by S29 (RN) stated, “ ... Mental Status Assessment: rapid speech, mood agitated, anxious, judgement impaired ... Patient Behavior: Standing in room.” The ED Physician Documentation Note completed at 14:19 (2:19 PM) by S32 (a Physician Assistant (PA)) stated, “Differential diagnosis: acute psychotic break, Acute anxiety disorder, depression, Manic disorder.” The patient was cleared for psychiatric crisis screening at 15:46 (3:46 PM). In an ED Nurse Documentation Outcome Note completed at 18:35 (6:35 PM) it stated, “Patient left without treatment, Reason for leaving-patient here for paranoia, ran out of ER. In grey gown. Security has patients phone and patients clothing in ER (Emergency Room) psych (psychiatric) locker.” At 16:56 (4:56 PM), in an assessment entry it stated, “General: pt (patient) ran from ER. Security attempted to stop patient. State police notified.” Review of P1’s Observation Record indicated the reason P1 was placed on 1:1 observation as “Elopement Risk” and “Hyperactivity”. One-to-One (1:1) monitoring was documented every fifteen minutes by S21, beginning at 1400 (2:00 PM) and the last entry was at 1615 (4:15 PM). On 03/21/25 at 2:05 PM, S2 confirmed the above findings.”

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 48060 Based on medical record review, staff interview, and review of facility documents, it was determined the facility failed to ensure that: 1) the patient’s right to have pain managed and treated is performed in accordance with facility policy; and 2) pain assessments include pain level in accordance with facility policy. Findings include: 1. Facility policy titled, “Rights, Patient’s Bill of ADM.044 *IHN*” REVIEW Date: 03/09/2023 states, “ ...III. Procedure [:] ...(a) Every New Jersey hospital patient shall have the following rights ...These rights shall include at least the following: ...31. To expect and receive appropriate assessment, management and treatment of pain as an integral component of that person’s care, in accordance with N.J.A.C. 8.43E-6. ...” On 12/10/24 at 2:02 PM, Patient (P)1’s medical record was reviewed with Staff (S)10, a Registered Nurse, and revealed the following: On 10/22/24 at 18:13 (6:13 PM), P1 arrived at the Emergency Department (ED). He/she was triaged at 18:21 (6:21 PM) with a Chief Complaint of “right sided flank pain” and assigned an ESI (Emergency Severity Index) level (triage level) of 3H. During triage, an initial pain assessment was obtained, with a numerical pain score of 10/10 (10 out of 10). On 10/22/24 at 21:34 (9:34 PM), an “ED Note Physician Note” by S11 (Physician Assistant) documented the following: “ ... Treatment and Disposition [:] ...Patient ...coming to the ER [emergency room] complaining of severe right upper abdominal pain that started at noon today. No trauma injury. States that [he/she] feels 5 out of 10 pain worse with deep breathing and palpitation. ... I went out to the waiting room evaluated patient in the triage room, ordered labs [laboratory studies] imaging IV [intravenous] medication. ... went out and told the front desk that I do believe [he/she] needs an IV and medication for [his/her] symptoms they did tell me that IV placement cannot be done in the waiting room therefore I told them to please bring [him/her] back as soon as possible. ...” P1 was brought back from the waiting room into room ED26 at 22:29 (10:29 PM), 4 hours and 1 minute after first report of pain, and 55 minutes after S11’s assessment. The “ED Physician Note” on 10/22/24 by S11 further stated, “ ...Treatment and Disposition [:] ... Patient was brought back into the room and I was called immediately by the nursing that patient is angry and does not want the IV placed. I go to the room [he/she] states that Motrin is not going to help [him/her]. I told [him/her] that I did order Toradol but we can change the medication to something stronger, at this time [he/she] was refusing the imaging and IV. Patient asks me multiple times what [his/her] diagnosis is I do explain to [him/her] that I do not have a diagnosis as of yet I do go over the ultrasound results with [him/her] saying that ...I do need further imaging ... [He/She] is very upset that [he/she] believes we brought back other people into the emergency room before [him/her], I do apologize and explained that I did try to get things started earlier in the waiting room, I did speak to the nurses about bringing [him/her] back sooner. Patient states that [he/she] does not want the IV [he/she] is just going to pull without [sic] [it out] [and] go to another hospital. I do try to alleviate the situation I do offer to give [him/her] a dose of morphine for [his/her] pain as well as the nurses at bedside attempting to put the IV line as we speak however [he/she] refuses. I did leave the room and [he/she] told the nurse [he/she] went [sic] to leave, refuses to sign any AMA [Against Medical Advice] forms. ...” “ED Note Nursing,” dated 10/22/24 at 23:23 (11:23 PM) stated, “ ...Pt [patient] was just brought back from the waiting room about 15 minutes prior when [husband/wife] came to this RN to speak with Manager. ...Told I would come to get an IV started, draw blood and give Toradol. ... Patient asked what pain meds [medications] I was giving and told [him/her] Toradol. Patient refused and said [he/she] needed to speak with the PA. Told PA [S11] who came and explained to patient that we need to get IV and do the scans to figure out what is causing [his/her] flank pain. PA left and then the patient stated [he/she] is leaving AMA with [husband/wife]. Did not want to speak with PA or doctor again nor sign any AMA forms ...” The medical record lacked documentation that P1’s pain was managed and treated for over four hours after assessment. These findings were confirmed with S10 on 12/10/24 at 2:24 PM. 49510 2. Facility policy titled “Vital Signs,” last reviewed 10/04/2021, states, “ ...Procedure: A. All patients presenting to the Emergency Department/S.E.D. [satellite emergency department] will have vital signs taken as part of the triage assessment. Additional vital signs will be taken for re-assessment at a minimum of four (4) hours and at time of discharge. ... F. Abnormal vital signs including pain level, will be rechecked at intervals appropriate to the abnormality and the patient condition as determined by the Triage/Primary nurse or the responsible physician. G. Complete vital signs will include temperature, pulse, respiration, blood pressure, pulse ox, and pain assessment ...” On 12/10/24 at 2:37 PM, medical record review of P6 was conducted with S5, Regional Manager of Accreditation and Regulatory Affairs, and revealed the following: On 9/12/24 at 6:27 PM, P6 presented to the ED with a chief complaint of right lower back pain that radiates to the hip. At 6:30 PM, P6 was triaged. The RN documented “yes” next to “pain present” in the triage assessment. No pain rating scale or level was documented. At 10:56 PM, P6 received Toradol 30mg IV (30 milligrams intravenous) for pain, with a documented pain level of 7 out of 10. At 1:56 AM, when P6 was discharged to home, the RN documented “yes” next to “pain present.” No pain rating scale or level was documented following the patient’s reported pain level of 7 out of 10, or as part of a complete set of vital signs, at the time of discharge. On 12/10/24 at 2:34 PM, medical record review of P10 was conducted with S6, and revealed the following: On 11/24/24 at 2:03 PM, P10 arrived at the ED with a complaint of right upper quadrant abdominal pain. At 2:04 PM, P10 was triaged by a RN with a pain assessment documented as “10 = Worst possible pain/Severe.” At 3:54 AM, P10 was administered 4mg IV morphine (a narcotic) for pain. At 6:15 PM, an RN documented P10 had “pain present,” and at 6:16 PM, P10 was discharged to home. No pain rating scale or level was documented as part of a complete set of vital signs, at the time of discharge. On 12/10/24 at 3:38 PM, findings for P6 and P10 were confirmed by S3, System Director of Regulatory and Accreditation”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 41646 Based on staff interviews, medical record review, and review of facility policies and procedures, it was determined that the facility was not in compliance with §489.24 as evidenced by failure to ensure: 1.) a medical screening examination is conducted and a triage level is assigned as per facility policy on a patient presenting to the Emergency Department (ED) with documented symptoms of a stroke (A-2406); and 2.) a suicidal or psychological assessment is completed in accordance with facility policy for patients who exhibit self-injurious behaviors (A-2406). Cross Reference: 489.24(a)(1)(i) - Medical Screening Exam”

“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: 49174 Based on staff interviews, medical record review, and review of facility policies and procedures, it was determined that the facility failed to ensure that 1.) a medical screening examination is conducted and a triage level is assigned as per facility policy on a patient presenting to the Emergency Department (ED) with documented symptoms of a stroke; and 2.) a suicidal or psychological assessment is completed in accordance with facility policy for patients who exhibit self-injurious behaviors. Findings include: 1.) Facility policy titled, “Stroke, Treatment of Acute Ischemic,” last reviewed 5/6/24, states, “IV. Identification. 1. Stroke and stroke-like symptoms may (SLS) include, but are not limited to, sudden onset of: 1. Focal weakness ...7. Dizziness ...V. Response ...a) Emergency Department ...1) Patients arriving with stroke-like symptoms will be triaged as per triage policy. a) Patient assigned a bed as soon as possible b) Notify the ED Physician/Resident/Advanced Practice Clinician immediately c) Stroke order sets utilized d) STAT blood glucose and CT head obtained e) Appropriate labs obtained f) Tele Neurology consult initiated as needed if within the 24-hour window of onset of symptoms g) Appropriate disposition made for admission/Transfer ...” On 6/9/24 at 6:33 PM, P15 arrived in the ED. At 6:39 PM, S33 (ED RN) documented in the “ED Triage” the patient, “arrives for generalized weakness and dizziness x [times] 2 hours - pt [patient] states went to bathroom for bowel movement and was dizzy before and after.” Vital signs were documented, and an EKG (Electrocardiogram) was performed at 6:46 PM. A “General Assessment” was completed, and the triage nurse documented “Yes” to “Does the patient have any stroke symptom.” At 10:38 PM, a registered nurse documented for P15, under “Waiting Room Patient” that the “Waiting Room [was] checked. Patient called x3” with the first time called listed as 2229 [10:29 PM], three hours and fifty-six minutes after P15 arrived in the ED. At 10:38 PM, the nurse entered the patient’s ED disposition as “Left without being seen.” An interview was conducted on 9/25/24 at 2:29 PM with S32, Stroke Coordinator. S32 discussed signs and symptoms of a stroke and stated, “early signs would be balance issues, dizziness, weakness, vision changes, and speech difficulties.” S32 explained the protocol for caring for a stroke patient, stating, “the triage nurse, who is NIH [National Institute of Health] certified, will bring back the patient to the doc bubble immediately for rapid assessment with the physician. An initial NIH score will be documented, and this process only takes a few minutes. A CAT [Computerized Axial Tomography] Scan and neurology consult would be ordered, vital signs would be taken every 15 minutes, and lab work including an INR [International Normalized Ratio] would be completed and resulted within 45 minutes.” S32 confirmed that a patient who exhibited signs and symptoms of a stroke would be assigned an acuity level of 2 or higher. P15’s chart was reviewed in the presence of S32, who confirmed that the patient should have immediately been brought back to the “physician bubble” to be assessed. The medical record lacked documentation that the facility’s stroke policy was followed. 2.) Facility policy titled, “Suicide Risk Assessment (Pt. Safety),” last reviewed 12/04/2023, states, “ ...RN [Registered Nurse] screens all patients age 12 and above for suicidal ideation during triage. The Columbia Suicide Severity Rating Scale (C-SSRS) is completed for every patient with suicidal ideation. In situations where the patient is unable to respond to questions and has exhibited self-injurious behavior such as drug overdose, RN initiates 1:1 Observation until suicide attempt and/or suicidal ideation can be ruled out ...” On 6/1/24 at 11:31 AM, P20 was brought to the ED by ambulance. At 11:34 AM, S47 (ED RN) documented in the “ED Triage, ...pt found on steps of doctors office with empty bottle of rubbing alcohol next to [him/her] ...” Vital signs were documented, and an EKG was performed. A “General Assessment” was completed by the triage RN who documented “unable to obtain” to the question, “do you want to hurt yourself.” P20 was assigned an acuity level of “2”. P20 was examined by the physician (S46) at 11:37 AM and diagnosed with “altered mental state; isopropyl alcohol poisoning.” A CT (Computed Tomography) of the face, spine, brain, and head were completed, an IV (intravenous) catheter was placed, fluids were administered, ABGs (Arterial Blood Gas) taken, and a chest x-ray was completed. The patient was placed on “1:1 observation Non-Suicidal” at 12:06 PM. A “Psychosocial Assessment” completed by the ED RN at 12:00, showed the patient as having a “flat, impulsive, restless” affect, “disheveled” appearance, and “not coping.” A physician note, written at 5:39 PM by S31 (ED Physician), states, “ ...Patient has significant improvement in [his/her] mental status. [He/She] is fully alert and oriented ...I anticipate that the patient will likely elope or sign out AGAINST MEDICAL ADVICE from this emergency department. Patient has capacity to do so on my assessment. Another note, written by the physician at 7:53 PM, states, “Patient has achieved clinical sobriety. [His/Her] withdrawal symptoms are adequately controlled. I strongly encouraged [him/her] to stay for discussion with the recovery coach and detoxification. However, patient adamant declines ...” The patient signed “Against Medical Advice” (AMA) paperwork and left the ED at 7:57 PM. P20’s medical record was reviewed in the presence of S6, Director of the ED, and an interview was conducted on 9/26/24 at 10:08 AM. S6 stated he/she would consider ingesting rubbing alcohol as “probably a self-injurious behavior” and “we would contact our behavior health.” S6 confirmed that the physician did not perform a psychological or suicidal assessment. The medical record lacked documentation that the physician performed a suicidal or psychological assessment in accordance with facility policy for patients who exhibit self-injurious behaviors.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 48965 Based on staff interviews, medical record review, and review of facility documents, it was determined that the facility failed to ensure an organized nursing service, where staff were properly trained prior to performing an invasive procedure in one of 10 Medical Records (Patient (P) 1) reviewed (A-0397). Cross Reference: 482.23(b)(5) Nursing Services: Patient Care Assignments”

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 48414 Based on review of facility documents and staff interview, it was determined that the facility failed to implement its “Patient Grievances and Complaints” policy, in one of one complaint and grievances reviewed (Patient (P) 1). Findings include: On 1/22/24 review of the facility document “Clinical Incident” for P1 stated “Comments Complaint-phone call received by patients [son/daughter] regarding the care of her mother while at [facility name] ...” Upon interview with Staff (S) 1, the Vice President of Nursing, on 1/22/24 at 1:20 PM, he/she indicated the Clinical Incident was considered a complaint and was “resolved in house.” S1 confirmed according to the facility policy, the telephone verbal complaint would be considered a grievance. Facility policy titled, “Patient Grievances and Complaints” (effective 11/2019), stated, “ ...3. Grievance: A written or verbal complaint (when the verbal complaint is not resolved at the time of the complaint by the staff present) by a patient or the patient ’ s representative regarding the patient ’ s care ...4. Examples of Patient Grievances: ...Patient complaints that are considered grievances also include situations where a patient or a patient ’ s representative telephones the hospital with a complaint regarding the patient ’ s care ...Procedure for using the Event Report-Complaint and Grievance From or online reporting in the event reporting system ...6. The complaint or grievance form is forwarded to the applicable Department Manager immediately for review and action ....7. The Department Manger completes any investigation, identifying if the issue has been resolved or not resolved, corrective actions taken and any needed notifications of other personnel for follow up. ...12. The CEO is responsible for completing and sending a letter to the complainant in response to a complaint/grievance. The letter shall include the name of the Hospital contact person, steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of the completion. ...14. Verbal or written response shall be forwarded to the patient or patient representative no later than 7 business days after receipt of the grievance ...” The facility was unable to provide any documentation of an investigation or follow up response to the grievance.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 48965 Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to ensure staff were properly trained prior to performing an invasive procedure in one of 10 Medical Records (Patient (P) 1) reviewed. Findings Include: On 1/3/23 at 11:10 AM, P1 presented to the Emergency Department (ED) via ambulance for increased shortness of breath over a period of two days. P1 was admitted to a telemetry bed on 1/3/23 at 1:50 PM for Chronic Obstructive Pulmonary Disease (COPD, a group of progressive lung diseases) exacerbation, acute respiratory failure with hypoxia (a serious condition when the lungs cannot release enough oxygen), and influenza A (a type of virus that causes the flu). On 1/8/23 at 7:59 AM, P1 was transferred to the Intensive Care Unit (ICU) after a rapid response was called for hypoxia (a condition in which the tissues are deprived of oxygen). On 1/23/24, review of P1’s medical record was conducted in the presence of S4, a Nurse Educator. On 1/10/23 at 11:00 AM, P1’s provider placed a nursing communication order for the nurse to insert a Dobhoff tube (a small lumen feeding tube advanced into the duodenum) for feeding. The medical record lacked documented evidence of the time the Dobhoff tube was inserted. An order for a STAT x-ray to confirm Dobhoff tube placement was placed on 1/10/23 at 1:28 PM. Findings for this x-ray were initially read by the Radiologist on 1/10/23 at 2:54 PM. The initial reading did not acknowledge the Dobhoff tube placement. An addendum was added on 1/10/23 at 3:02 PM which stated, “ ...Correction. Current film was reviewed. The feeding tube extends into the right lower lung. ICU notified by telephone ...” The medical record does not indicate if the Dobhoff tube was used prior to x-ray results. An order for STAT x-ray for examination after removal of Dobhoff tube was placed on 1/10/23 at 3:03 PM. Findings for this x-ray on 1/10/23 at 6:24 PM showed a moderate right pneumothorax. The report indicates that the radiologist notified the Advanced Practice Nurse (APN) of results at the time of dictation. An ICU nursing note dated 1/10/23 at 6:30 PM stated, “ ... [Radiologist name] will call [APN name] to inform [him or her] that there is a moderate pneumothorax in the right lung from dobhoff insertion - dobhoff pulled and repeat chest x-ray done ...” Based on nursing documentation, it was unclear at what time the Dobhoff tube was removed and S4 was unable to clarify the time during medical record review. On 1/11/23 at 12:17 AM, a nursing note stated, “21:30 [9:30 PM]: patient was intubated, chest tube placed, and femoral line inserted. ...” On 1/12/23 at 1:23 AM, a nursing note stated, “Approximately around midnight patient was oxygen saturation was noted to drop to 83% and tachycardiac, respiratory therapist was called. ...Around 00.15 [12:15 AM] patient pulse was not palpable. Chest compression was started and code blue called. Completed multiple rounds of chest compression. Patient was pronounced dead at 00:35 [12:35 AM] ...” An interview was conducted with S15, ICU Nurse, on 1/23/24 at 2:45 PM. S15 explained that he/she has been a nurse for 28 years and has placed Dobhoff tubes at other hospitals but had never received competencies or performed the procedure at this facility. S15 stated that prior to inserting the Dobhoff tube, he/she asked the supervisor if it was ok to insert the Dobhoff tube into P1. According to S15, the supervisor consulted with the nurse educator, and they ultimately approved the insertion. S15 stated that he/she inserted the Dobhoff tube and then P1 had the STAT x-ray to confirm placement of the tube. On 1/23/24 at 1:15 PM, S15’s personnel file was reviewed. The personnel file lacked evidence of training, education, or competency in inserting a Dobhoff tube. The facility identified the above incident as a safety concern and developed an action plan. The action plan stated that education would be provided to nurses regarding a revised policy and a Dobhoff competency would be developed for (Advanced Practice Nurses) APNs and Physicians. This will be checked yearly during credentialing. Only APNs, Physician Assistants (PA) and physicians are permitted to insert a Dobhoff tube. Nurses are not allowed to insert a Dobhoff tube. The education provided to staff was requested and not received. On 1/23/24 at 1:58 PM, S1, the Vice President of Nursing, stated that the facility was unable to locate a record of education provided to nurses and providers regarding the new policy on Dobhoff tube insertion. The Dobhoff tube policy that was in place at the time of the incident and the revised policy were requested from S1. The facility was unable to provide these policies. S1 confirmed that education was not provided to nurses and providers and there are no policies regarding Dobhoff tube insertion. A list of patients with Dobhoff tubes in the last 3 months was requested of S1. S1 confirmed that there were no patients with Dobhoff tubes in the last 3 months. On 1/23/24, interviews with S10, S12, S16 and S17, Registered Nurses (RNs) and S11, a physician, confirmed that Dobhoff tubes are only to be inserted by a physician, APN, or PA.”