Cooperman Barnabas Medical Center

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 51555 Based on medical record review, facility policy review, and staff interview, it was determined the facility failed to ensure documentation was completed in accordance with physician’s order and facility policy, in four of seven medical records reviewed (Patient (P)1, P4, P11, and P12). Findings include: Facility policy titled, “Initial and Subsequent Nursing Assessments in Patient Care Settings Procedure”, effective date, 8/21/25, stated, “... Nursing/Step-down Units/Intermediate Care Units... Re-Assessment - Every 12 hours; or as clinically indicated.” A review of P1’s medical record was conducted in the presence of Staff (S)3 and revealed the following: On 3/21/26 at 9:01 PM, P1 was admitted to the facility with a diagnosis of Cerebrovascular Accident (CVA, stroke). An order for “Neuro Checks... q2h [every two hours]” was entered on 3/21/26 at 10:00 PM. Review of the flowsheet section titled, “Neuro” revealed that on 3/22/26 from 7:30 PM to 10:00 PM, there was no evidence in the medical record of a neuro check being completed per order. This lack of a 2-hour neuro check was confirmed with S3 on 6/10/26 at 11:45 AM, S3 stated, “Yes, there should be neuro checks completed per the order.” P1 was discharged on 3/26/26. A review of P4’s medical record was conducted in the presence with S3 and revealed the following: P4 was admitted to the facility on 3/10/26 at 9:27 AM, with a diagnosis of leg swelling. On 3/18/26 at 1:04 PM, an order for “Neuro Checks... q4h” was placed. Review of the flowsheet section titled, “Neuro” revealed that on 3/23/26 from 12:00 AM to 8:00 AM, there is no evidence in the medical record on a neuro check being completed as ordered. On 3/18/26 at 1:02 PM, an order for “NIH Stroke Scale... Every shift and with any change in neuro status” was entered. This order was discontinued on 3/27/26 at 6:38 PM when P4 was discharged. Review of the flowsheet section titled, “NIH Stroke Scale” revealed that the NIH stroke scale was not completed in accordance with physicians order as follows: on 3/20/26 the stroke scale was documented once at 8:00 AM; on 3/21/26 the stroke scale was documented once at 8:00 PM; on 3/25/26 the stroke scale was documented once at 6:00 PM; and on 3/27/26 the stroke scale was documented once at 8:00 AM. The medical record lacked evidence that the NIH Stroke Scale was completed 3/22/26, 3/23/26, or 3/24/26. The lack of evidence of neuro checks and the lack of evidence of the NIH stroke scale being completed per shift was confirmed with S3 on 6/11/26 at 12:20 PM. A review of P11’s medical record was conducted in the presence of S3 and revealed the following: On 3/20/26 at 12:47 AM, P11 was admitted to the facility with acute renal failure. On 3/25/26 at 10:08 AM, an order for “Neuro Checks... every 15 minutes during code stroke only” was placed. Documented evidence in the medical record revealed a stroke code was activated on 3/25/26 at 10:06 AM and was completed at 10:58 AM. The medical record lacked evidence of every 15-minute neuro checks completed during the time of the stroke code. This was confirmed with S3 on 6/11/26 at 12:27 PM. A review of P12’s medical record was conducted in the presence of S3 and revealed the following: On 3/24/26 at 11:10 AM, P12 was admitted to the facility with a diagnosis of weakness and altered mental status. Documented evidence revealed a stroke code was activated in the emergency department on 3/24/26 at 11:01 AM and was completed at 11:34 AM. An order for “Neuro Checks... every 15 min x 1 hour until code stroke end, and then every 4 hr” was placed on 3/24/26 at 11:07 AM. There is no evidence in the medical record of every 15-minute neuro checks being completed during the stroke code. An order for “Neuro Checks... q4h” was placed on 3/24/36 at 11:34 AM. An order for “NIH stroke scale... every shift and with any change in neuro status” was ordered on 3/24/26 at 11:33 AM. Review of the flowsheet section titled, “NIH Stroke Scale,” revealed the NIH stroke scale was not completed on 3/25/26 from 7:00 PM to 7:00 AM. The lack of every 15-minute neuro checks during the stroke code, and the lack of NIH Stroke Scale documentation was confirmed with S3 on 6/11/26 at 12:02 PM. During interview on 6/11/26 at 10:38 AM, S16 stated, “the NIH frequency is dependent on the order. It [NIH scale] is done on every shift or if there is a significant change in neuro status.””

“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: 38289 Based on staff interviews and review of facility documents, it was determined that the facility failed to ensure 1). On-call coverage of a designated provider for services offered in the emergency department (ED) (Q2404); and 2). a process in place for timely care of an ED patient in the event there is not a physician on-call for the services needed (Q2404). Cross Reference: CFR 489.24(j) - Availability of On-call Physicians”

“ON CALL PHYSICIANS CFR(s): 489.20(r)(2) and 489.24(j)(1-2) §489.20(r)(2) [The hospital (including both the transferring and receiving hospitals), must maintain] a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. §489.24(j)(1) Each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital’s patients who are receiving services required under this section in accordance with the resources available to the hospital, including the availability of on-call physicians. §489.24(j)(2)(i) The hospital must have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician’s control. §489.24(j)(2)(ii) The hospital must have written policies and procedures in place to provide that emergency services are available to meet the needs of patients with emergency medical conditions if it elects to permit on-call physicians to schedule elective surgery during the time that they are on call or to permit on-call physicians to have simultaneous on-call duties. This Standard is not met as evidenced by: 38289 Based on staff interviews and review of facility documents, it was determined that the facility failed to ensure 1). On-call coverage of a designated provider for services offered in the emergency department (ED); and 2). a process in place for timely care of an ED patient in the event there is not a physician on-call for the services needed. Findings include: 1. On 2/12/25 at 1:30 PM, a review of the ED on-call list of specialty providers for the past three months (December 2024, January 2025, and February 2025), revealed the following: The group name “NJ [New Jersey] Cardiology” was designated on-call for the following dates: December 1-17, and 19-28, 2024 January 1-21, and 23-31, 2025 February 2-17, 21, 24-26, and 28, 2025 The group name “TPOC [an orthopedic group]” was designated on-call for December 2, 5-11, 13-15, 23-29, 2024 The group name “Dr. [Name of Physician] group (an infectious disease group)” was designated on-call for the following dates: December 16-22, 2024 January 1, 3-5, 2025 On the following dates, the on-call for the specialty “Infect Disease 24hr 8a-8a” stated, “consult provider of choice” for January 6-12, 2025. At 1:48 PM, upon interview, Staff (S) 3, Director of Accreditation and Licensure Quality and Standards, stated that the printed schedule did not best capture the on-call physicians. S3 stated that the facility uses an internet based on call schedule that can be accessed by all staff. S3 stated that eventhough the schedule that was provided to the surveyors may indicate group names, the online resource should designate the physician on-call name and not the group. For the above dates and names in questions, S3 logged in using the online on-call schedule and confirmed the dates and the listed group names, not an individual provider, from the above findings. On 2/12/25 at 2:45 PM, upon interview, S30, the Chief Medical Officer, stated that the oversight of maintaining the on-call schedule is the responsibility of the Department Chairs and Chiefs. The department Chairs and Chiefs assign the provider members to the call schedule. At 3:05 PM, the above findings were shared with S31, Vice President Quality and Patient Safety. S31 stated that he/she had issues with the on-call schedule in the past and the facility worked to mitigate the issue. S31 stated that he/she is aware that designated provider names should be on the on call schedule instead of groups and confirmed that the facility would work to ensure that current and future schedules would reflect a designated provider instead of a group or physician choice. 2. On 2/12/25 at 1:30 PM, a review of the ED on-call list of specialty providers for the past three months (December 2024, January 2025, and February 2025), revealed the following ED specialties did not have an on-call physician assigned: The specialty “ED Card [Cardiology] 24hr 8a-8a” was not assigned on: December 2024: 12/1, 12/3, 12/6, 12/17, 12/20, 12/22, 12/27; January 2025: 1/1, 1/2, 1/5, 1/21, 1/23-24, 1/26-27, 1/29-30; February 2025: 2/1, 2/3, 2/5, 2/7-9, 2/13, 2/15-16, 2/21, 2/24, 2/26, 2/28. The specialty “NJCA [New Jersey Cardiology Associates] On-Call Day 8a-5p” was not assigned on: December 2024: 12/7-8, 12/21-22, 12/28-29; January 2024: 1/4-5, 1/25-26; February 2024: 2/1-2, 2/8, 2/16-17. The specialty “NJCA [New Jersey Cardiology Associates] On-Call Night 5p-8a” was not assigned on: December 2024: 12/2, 12/4, 12/5, 12/7-11, 12/13-17, 12/19-29. The specialty “Peds [Pediatric] Ortho [Orthopedic] Att [Attending] 24hrs [hours] 7a-7a” was not assigned on: December 2024: 12/2, 12/7-11, 12/13-16, 12/23-29. The specialty “Infect [Infectious] Disease 24hr 8a-8a” was not assigned on: December 2024: 12/17-22; January 2025: 1/1-12, 1/27-31; February 2025: 2/1, 2/17-23. Upon request on 2/12/25 at 3:05 PM, to S3 and S30, was unable to provide a documented process or procedure concerning the protocol on how to care for an ED patient when the specialty on-call provider is not available.”

“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: 47131 Based on review of medical records (MR), staff interviews, and review of facility documents, it was determined that the facility failed to ensure: 1.) individuals who present to the Emergency Department (ED) are triaged to receive immediate and appropriate assessment and identify any life-threatening conditions, in accordance with facility policy in three of 10 medical records reviewed (MR1, MR6, and MR10) [A-1104]; 2.) patients in the ED waiting area are reassessed for a change in condition and that reassessments are documented in accordance with facility policy in two of 10 medical records reviewed (MR1 and MR6) [A-1104]; and 3.) an appropriate medical screening evaluation to identify whether an Emergency Medical Condition exists in two of 20 medical records reviewed (MR1 and MR4). Cross Reference: 482.55(a)(3) Emergency Services: Emergency Services Policies”

“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: 47131 Based on medical record review, staff interviews, and review of facility policies and procedures, it was determined the facility failed to ensure that: 1) individuals who present to the Emergency Department (ED) are triaged to receive immediate and appropriate assessment and identify any life-threatening conditions, in accordance with facility policy in three of 10 medical records reviewed (MR1, MR6, and MR10); 2.) patients in the ED waiting area are reassessed for a change in condition and that reassessments are documented in accordance with facility policy in two of 10 medical records reviewed (MR1 and MR6); and 3.) an appropriate medical screening evaluation to identify whether an Emergency Medical Condition exists in two of 20 medical records reviewed (MR1 and MR4). Findings include: 1.) Policy titled, “ED Triage” (Effective August 2010) stated, “ ...PURPOSE: The purpose of triage is to: Provide immediate and appropriate assessment and intervention to all patients in the Emergency Department; Rapidly identify patients with life threatening conditions and to determine the most appropriate treatment area for patients presenting to the department; Oversee the activity of the waiting area in times of high volume; ...Constantly reassess patients as waiting times increase. ...This change in acuity must be reflected in the EDIMS documentation progress note. ... PROCEDURE: All patients arriving to the ED through the walk in area will be seen by the Greeter Nurse. The Greeter Nurse obtains basic information about the patient as well as the reason for their visit. ID band is placed on patient and Greeter Nurse will: ... At times of high volume, patients are called into triage area based on complaint and history as Greeter Nurse. ... Triage Acuities: ... Level 2: Patients presenting problems require rapid evaluation and either stabilization or treatment which is related to critical time factor and are hemodynamically unstable. This includes but is not limited to chest pain, stroke, ...acute pain, ...neurological deficits ...Level 2 patients are high risk and require rapid intervention and evaluation. Failure to act can potentially result in the loss of life, limb, or organ. Level 3: ... require diagnostic evaluation and treatment in the ED. VS (vital signs) are stable and condition is not likely to deteriorate or require time sensitive treatment. These patients present with but are not limited to moderate pain ... Level 3 patients require multiple resources to determine illness. ... Special triage considerations: ... 3. Presumed cardiac chest pain patients are to have an EKG (electrocardiogram) done upon arrival and read by an MD. Any unstable patient is to be brought directly to a bed. ...” On 02/10/25 at 10:25 AM, during a tour of the Emergency Department (ED), an interview was conducted with Staff (S)5. When questioned on the process for patients who arrive complaining of chest pain, S5 stated that the patient’s symptoms are assessed, a cardiac alert is announced, and the patient is taken to a room where an EKG (electrocardiogram) is performed and given to a provider for evaluation. During the interview, S5 stated, “I don’t triage patients, they are triaged at the bedside.” At 10:59 AM, during an interview, S7 stated, “A patient with chest pain is taken to a room for an EKG (electrocardiogram) and it should be read by a provider within 10 minutes and a cardiac alert is announced overhead.” This was confirmed by S8 at 11:05 AM. On 02/10/25 at 12:55 PM, during an interview with S4, [he/she] explained that individuals that arrive to the ED are met by an “ED Greeter Nurse” who obtains the chief complaint and determines if the individual needs to be seen immediately by the Triage Nurse for Direct Bedding. S4 confirmed that the ED Greeter Nurse does not complete the patient’s ESI or enters any documentation in the patient’s electronic medical record (EMR.) During times of ED surge [a high volume of people arriving to the ED], S4 confirmed that the Triage nurse is responsible for assessing the patient’s acuity and documenting the patient’s ESI in the patient’s electronic medical record (EMR) at the time it’s completed. Review of medical record (MR)1 on 02/10/25 revealed the patient arrived at the ED on 01/03/25 at 2:49 AM, with chief complaint of “CP” (Chest Pain). An EKG was completed at 3:24 AM and read by a medical provider at 7:54 AM, five hours and five minutes after the patient’s arrival to the ED. The medical record lacked documentation that the patient’s vital signs and pain were assessed at the time of the patient’s arrival despite the patient’s complaint of chest pain. Patient (P)1 was moved into a room in the ED at 6:44 AM. The patient was triaged by a Registered Nurse (RN) at 7:03 AM and was assigned an ESI level of three. The medical record indicated that the patient’s triage was completed four hours and 14 minutes after P1’s arrival to the ED. A Medical Screening Exam (MSE) was completed by a provider at 7:09 AM. Review of MR6 on 02/10/25 revealed the patient arrived at the ED on 01/03/25 at 3:05 AM, with complaint of abdominal pain and vomiting. The patient was moved into a room in the ED at 6:44 AM and was evaluated by a provider at 6:55 AM. The medical record lacked documentation that the patient’s vital signs and pain level were assessed at the time of the patient’s arrival. The triage was completed by a RN at 7:07 AM, four hours and two minutes after the patient’s arrival to the ED, the patient was assigned and ESI level of three. Review of MR10 on 02/10/25 revealed the patient arrived at the ED on 01/03/25 at 4:54 AM, with a chief complaint of chest pain, shortness of breath, and productive cough. An EKG was completed at 5:02 AM. Vital signs were completed at 5:27 AM as follows: Blood Pressure: 169/103, Heart Rate: 97 BPM (beats per minute), Temperature: 98.9, Oxygen Saturation: 98%. The medical record lacked evidence that the patient’s pain was assessed at the time of the patient’s arrival despite the patient’s complaint of chest pain. P10 was moved into a room in the ED at 6:44 AM and evaluated by a provider at 6:55 AM. The patient was triaged at 7:21 AM and assigned an ESI level of two. The patient’s vital signs at the time of triage were as follows: Blood Pressure: 179/112, Heart Rate: 97, Respiratory Rate: 30, Oxygen saturation: 93%. A pain assessment was completed at 7:49 AM, and the patient reported pain rated 10 out of 10. On 2/10/25 at 2:25 PM, S4 confirmed that the patients’ ESI were not completed at the time of patient arrival to rule out life threatening emergency, in accordance with facility policy and procedures. 2.) Policy titled, “Initial and Subsequent Nursing Assessments in Patient Care Settings” (Effective 2/18/22) stated, “...1. Purpose Statement: Assessing and reassessing provides the foundation to determine the appropriate care, treatment, and services to meet the patient’s changing needs ... 3. Procedure: ... Nursing/Emergency Department ... Initial Assessment-Upon Arrival; Re-Assessment-Based on Triage Category; as clinically indicated ...” Policy titled, “ED Triage” (Effective August 2010) stated, “ ... Oversee the activity of the waiting area in times of high volume; ...Constantly reassess patients as waiting times increase. ...This change in acuity must be reflected in the EDIMS documentation progress note. ...” On 2/10/25 at 12:55 PM, upon interview, S4 stated, “ ...when a patient arrives to the ED, a Greeter Nurse meets with the patient and gets their chief complaint. The Greeter Nurse is responsible for the patient flow and determines whether the patient can wait or needs to go directly to the Triage Nurse to be assessed. If there is a Cardiac Alert, there is an overhead page.” During the interview, S4 stated that patients seated in the waiting room are monitored by the Triage Nurse or “PIT” (Provider in Triage) and are reassessed every 30 minutes. S4 confirmed that the Triage Nurse is responsible for documenting each reassessment in the patient’s medical record. During times of ED surge [a high volume of people arriving to the ED], S4 confirmed that the Triage nurse is responsible for reassessing patients every 30 minutes to determine if there has been any change in condition while the patient is in the waiting room. S4 explained that the average wait time in the ED is “usually under an hour” and confirmed that there was a ‘Surge’ overnight on 01/03/25. S4 reported that the average number of patients in 24 hours in the ED is 270, and on 01/03/25, 330 patients came to the ED. Review of medical record (MR)1 on 02/10/25 revealed the patient arrived at the ED on 01/03/25 at 2:49 AM with chief complaint of “CP” (Chest Pain). An EKG (electrocardiogram) was completed at 3:24 AM and read by a medical provider at 7:54 AM, five hours and five minutes after the patient’s arrival to the ED. The medical record lacked documentation that the patient’s vital signs and pain were assessed at the time of the patient’s arrival. Patient (P)1 was moved into a room in the ED at 6:44 AM. The patient was triaged by a Registered Nurse (RN) at 7:03 AM and assigned an ESI level of three (3). The medical record indicated that the patient’s Triage was completed four hours and 14 minutes after P1’s arrival to the ED and lacked documentation that [his/her] condition was reassessed by the Triage Nurse between 3:30 AM and 6:30 AM, while the patient was in the waiting room. Review of MR6 on 02/10/25 revealed the patient arrived at the ED on 01/03/25 at 3:05 AM with complaint of abdominal pain and vomiting. The patient was moved into a room in the ED at 6:44 AM and was evaluated by a provider at 6:55 AM. The medical record lacked documentation that the patient’s vital signs and pain level were assessed at the time of the patient’s arrival. The patient was triaged by a RN at 7:07 AM, four hours and two minutes after the patient’s arrival to the ED and lacked documentation that [his/her] condition was reassessed by the Triage Nurse between 3:35 AM and 6:35 AM, while the patient was in the waiting room. On 2/10/25 at 2:35 PM, S4 and S11 confirmed the above findings. 3.) Policy titled, “Transfer of Patient, Acute (E.M.T.A.L.A.) (Last reviewed 9/27/2017) stated, “ ... Definitions: ... Emergency Medical Condition: a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, ...) such that the absence of immediate medical attention could reasonably be expected to result in: placing the health of the individual ( ...) in serious jeopardy ... Triage: Triage entails the clinical assessment of the individual’s presenting signs and symptoms at the time of arrival at the hospital, in order to prioritize when the individual will be seen by a physician or other qualified medical personnel. ... Medical Screening Examination: is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist ... PROCEDURE: 1. Medical Screening Examination: The hospital must provide an appropriate Medical Screening Examination within the capability of its ED (Emergency Department), including ancillary services routinely available at the hospital, to determine whether an emergency medical condition exists ... .” Review of medical record MR1 on 2/10/25, revealed the following: The patient arrived at the ED on 1/03/25 at 2:49 AM, with chief complaint of “CP” (Chest Pain). An EKG (electrocardiogram) was completed at 3:24 AM. The medical record lacked evidence that vital signs and pain level were assessed at the time of the patient’s arrival. The medical record indicated that the EKG was read by a medical provider at 7:54 AM, five hours and five minutes after the patient’s arrival to the ED. The patient was moved from the waiting room to room MED048 at 6:44 AM. The medical record lacked evidence that the patient’s condition was reassessed for the three hours and 20 minutes the patient was in the waiting room from 3:24 AM until 6:44 AM. The Patient Care Timeline indicated that at 6:49 AM the First Provider Evaluation was completed. The MR lacked documentation of the provider’s evaluation. Triage was completed at 7:03 AM and the patient was assigned an ESI level of three. Triage was completed four hours and 14 minutes after the patient’s arrival to the ED. A Medical Screening Exam (MSE) was marked completed at 7:09 AM, however the medical record lacked documentation of the provider’s assessment of the patient’s emergency medical condition. At 9:52 AM, P1 was discharged. The medical record lacked documentation of the patient’s condition upon discharge. A review of MR4 on 2/10/25, revealed the following: The patient arrived at the ED on 1/3/2025 at 2:04 AM, with chief complaint of “Left arm weakness” that began at 2:00 AM. An EKG was completed at 2:50 AM. The medical record lacked evidence that vital signs were assessed at the time of the patient’s arrival. Triage was completed at 4:46 AM and the patient was assigned an ESI level of three. Triage was completed two hours and forty-two minutes after the patient’s arrival to the ED with [his/her] chief complaint of left arm weakness. The medical record lacked evidence that the patient’s condition was reassessed while the patient was in the waiting room from 2:04 AM to 4:42 AM. The patient was moved from the waiting room to room MED014 at 6:44 AM. The MR indicated that an MSE was completed at 6:52 AM, however the medical record lacked documentation of the provider’s assessment of the patient’s emergency medical condition. The above findings were confirmed by S7 on 02/10/25 at 2:25 PM.”