Jefferson Stratford Hospital

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 51986 Based on observation, medical record review, staff interview, review of video surveillance recording, and review of facility documents, it was determined that the facility failed to ensure that 1). patients on 1:1 observation are within direct visualization and continuous supervision at all times (A0144); 2.) a suicide risk assessment is provided for patients who are at risk for suicide or self-harm, in one of four medical records reviewed (A0144); 3). patients who are identified as high risk for suicide or harm (to self or others) are placed on 1:1 observation, in one of four medical records reviewed (A0144). This failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to patients. On 10/29/25 at 3:55 PM, an IJ was identified for the facility’s failure to ensure that patients on 1:1 observation are within direct visualization and continuous supervision at all times. On 10/29/25 at 4:45 PM, the IJ template was presented to Administration, and a removal plan was requested. On 10/30/25 an acceptable removal plan was received. The facility implemented the following to address the IJ: the current policy was revised to clearly outline the expectations of monitoring a patient who is ordered to be on a one-to-one observation and requests to use the restroom. An attestation was developed outlining the expectations for each therapeutic sitter to read and sign prior to initiating a one-to-one with a patient at risk for self-harm. A read-and-sign huddle was conducted for all Emergency Department nurses and therapeutic sitters. The huddle outlined the findings of the IJ, policy revisions, and the new attestation process for therapeutic sitters. The education and huddle is to continue each shift until all Emergency Department nurses and therapeutic sitters are educated prior to the start of their shift. An Emergency Department restroom was chosen and closed off as of 10/30/25 to begin immediate construction and modifications for the implementation of a behavioral health-safe restroom. The IJ was removed on 10/30/25 at 12:00 PM, after the State Agency verified implementation of the removal plan. Cross Reference: 482.13(c)(2) Patient Rights: Care in Safe Setting”

“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: 51986 Based on observation, medical record review, staff interview, review of video surveillance recording, and review of facility documents, it was determined the facility failed to ensure that 1). patients on one-to-one observation are within direct visualization and continuous supervision at all times; 2). a suicide risk assessment is conducted for patients who are at risk for suicide or self-harm, in one of four medical records reviewed; 3). patients who are identified as high risk for suicide or harm (to self or others) are placed on 1:1 observation, in one of four medical records reviewed. Findings include: 1. Facility policy titled, “Therapeutic Sitter (1:1) Observation, A138,” stated, “... Scope: 1. Responsibility... Emergency Department (ED) patients who require one-to-one (1:1) monitoring behaviors by staff ... d. Therapeutic Sitter One-to-one (1:1) Sitter: Continuous 1:1 monitoring ... for a patient who presents an immediate or actual threat of harm to themselves ... The patient remains within direct visualization and continuous supervision at all times ... Special Considerations for the Patient Requiring Continuous Monitoring 1. The patient must remain within direct visualization and continuous supervision at all times, including while in the bathroom ... the Therapeutic Sitter must accompany the patient at all times ...” On 10/29/25 at 10:38 AM, a tour of the Emergency Department (ED) was conducted in the presence of Staff (S)3 and S4. During the tour, S8 was observed conducting a therapeutic one-to-one observation with a patient of the opposite gender. At 10:46 AM, upon interview, S8 stated if the patient needed to use the restroom, S8 would ask another staff member who was of the same gender as the patient to accompany the patient to the restroom. S8 stated that with a therapeutic one-to-one level of observation, the patient must be visible at all times and the patient cannot be in the restroom alone or with the door closed. At 10:51 AM, during an interview, S9 confirmed that patients who have a one-to-one level of observation will always have a staff member with the patient and that the patient can never be left alone. S9 further stated that if a patient on a one-to-one need to use the restroom, a staff member must accompany the patient and have eyes on the patient at all times. On 10/29/25 at 2:27 PM, an ED restroom labeled “E1519A” was toured in the presence of S2, S4, and S5. Several ligature risks were identified in the restroom including a sink faucet, a toilet seat, a grab bar, a door handle, and a trash can with a plastic bag in it. On 10/29/25 at 2:31 PM, an ED restroom labeled “E1517A” was toured in the presence of S2, S4, and S5. Several ligature risks were identified in the including a sink faucet, a toilet seat, a grab bar, a door handle, and a trash can with a plastic bag in it. Upon interview, S4 confirmed that the ED restrooms E1519A and E1517A had potential ligature risks and presented a risk for harm of a patient if a suicidal patient was left unattended in these rooms. On 10/29/25 at 1:07 PM, P1’s medical record was reviewed in the presence of S12 and revealed the following: On 10/19/25 at 7:55 PM, P1 arrived in the ED for complaints of suicidal ideation (SI). At 8:09 PM, a Columbia Suicide Severity Rating Scale [C-SSRS] assessment was performed and revealed the following: 1. Wish to be Dead: Yes 2. Suicidal Thoughts: Yes 3. Suicidal Thoughts with Method Without Specific Plan or Intent to Act: No 4. Suicidal Intent Without Specific Plan: No 5. Suicide Intent with Specific Plan: Yes ... C-SSRS Risk Level: High ... On 10/19/25 at 8:09 PM, the ED triage notes documented by a Registered Nurse (RN) revealed that P1 had a plan to jump out of a second-floor window and had a previous suicide attempt in September 2025. On 10/20/25 at 12:57 PM, a physician documented in the “ED Course and MDM [Medical Decision Making]” log and revealed the following: “Patient was found with a part of top of cup in hand, was going to cut [self] but this was seen by a nurse and it was taken from [the patient] before [the patient] tried to cut [self] ... reports that if [the patient] went back to the group home, [the patient] ‘already has a plan’ for how [they] would kill [self] ...” On 10/22/25 at 5:18 PM, a physician documented in the “ED Course and MDM [Medical Decision Making]” log which stated, “Patient becoming agitated. Starting to take things off the walls in [his/her] room and threatening to hurt [self] ...” On 10/24/25 at 8:27 PM, a physician documented in the “ED Course and MDM [Medical Decision Making]” log which stated, “Just alerted that when the patient went to the restroom [the patient] cut [his/her] arms with a piece of plastic from the cup ...” On 10/24/25 at 8:37 PM, a nursing note documentation stated, “1:1 notified this RN that pt [patient] cut [himself/herself] in the bathroom. Pt with three new cuts to left forearm ...” On 10/29/25 at 3:22 PM, the ED surveillance video recording was reviewed in the presence of S2 and S15 and revealed the following: On 10/24/25 at 7:51:45 PM, P1 was observed standing up from the hospital stretcher and walked toward the staff member conducting the 1:1 observation. S15 identified the staff member S26 present in the video footage as the patient’s assigned therapeutic 1:1 observer, and that the patient present in the video footage was P1. At 7:53:08 PM, S26 was observed opening the ED restroom door and waved P1 into the restroom. P1 entered the restroom and closed the door after entering. The therapeutic 1:1 observer was observed standing outside of the restroom. During the video surveillance review, S26 was not observed to perform a safety check of the environment prior to P1 entering the restroom. At 7:56:37 PM, P1 exited the ED restroom. P1 was in the restroom for three minutes and 29 seconds without direct observation of the therapeutic sitter. On 10/29/25 at 3:51 PM, upon interview, S15 confirmed the above findings at the time of discovery and stated the patient should not have been left alone and out of sight in the restroom because of their level of observation and high risk of suicide. 2. Facility policy titled, “Suicide Risk Assessment & Prevention, S-8,” stated, “ ... Purpose: ... 1. The identification of patients who are at risk for suicide or self-harm ... Policy: Risk factors that may increase the likelihood of patient self-harm include ... a. Verbalization of clear intent to harm self or expresses suicidal thoughts, plans, or plans for final arrangements ... 2. The Columbia Suicide Severity Rating Scale (C-SSRS) is utilized to screen for a patient’s risk for suicide upon arrival to the ED ... 5. The clinical nurse implements 1:1 patient observation (therapeutic sitter) upon identification of a patient at a high level of risk until the provider determines clinical management and interventions ...” On 10/29/25 at 12:14 PM, a review of P3’s medical record revealed the following: On 10/15/25 at 3:43 PM, P3 arrived in the ED accompanied by police officers and reported they “didn’t want to live anymore,” per the nursing ED triage note. The patient’s chief complaint was documented as “suicidal.” The medical record lacked evidence that a Columbia Suicide Severity Rating Scale [C-SSRS] assessment was performed during triage. 10/29/25 at 2:39 PM, upon interview, S5 confirmed the above findings and stated that the C-SSRS should have been completed during triage and that the patient was at risk of self-harm. S5 stated a therapeutic one-to-one observer should have been implemented immediately. 3. Facility policy titled, “Therapeutic Sitter (1:1) Observation, A138,” stated, “... Scope: ... 2. Definition of Terms: ... d. Therapeutic Sitter One-to-one (1:1) Sitter: Continuous 1:1 monitoring by a qualified staff member for a patient who presents as an immediate or actual threat of harm to themselves ...” On 10/29/25 at 12:14 PM, a review of P3’s medical record revealed the following: On 10/15/25 at 3:43 PM, P3 arrived in the ED with a chief complaint documented as “suicidal.” On 10/15/25 at 4:18 PM, a Nursing ED Note indicated the patient was changed into scrubs and that security was called for “wanding” and a belongings search. The nurse documented that a police officer was at the bedside with P3. On 10/29/25 at 12:44 PM, during an interview with S11 and S12, S11 was asked if a police officer qualifies as a 1:1 therapeutic observer for suicidal patients. S11 stated that a police officer does not count as a patient’s 1:1 observer and that it must be a staff member. S12 agreed with S11’s statement. On 10/29/25 at 2:39 PM, P3’s medical record was reviewed with S5. During the review, S5 stated the C-SSRS should have been conducted on this patient and that a police officer did not qualify as a patient’s 1:1 observer. On 10/29/25 at 2:40 PM, upon interview, S5 confirmed the above findings at the time of discovery and stated that only qualified staff members may act as a therapeutic one-to-one observer for patients who require 1:1 observation.”

“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 staff interview, medical record review, and review of facility documents, it was determined the facility failed to ensure: 1.) policies and procedures for incident reporting are followed by all staff; and 2.) a suicide screening is completed accurately for all patients in the ED in one of seven medical records reviewed (Patient (P) 1). Findings include: 1. Facility policy titled, “Incident Investigation Reports” (Last Revised 06/2024) stated, “Policy: Reporting is essential to the identification and evaluation of incidents for the purpose of improving processes, patient care and safety issues. The purpose of such documentation is to identify patterns of risk to patients, visitors, and/or the organization, conduct further investigations as needed, and provide a foundation for education to reduce risks. incidents involving patients and visitors are documented according to the procedure specified below. ... Definition: .. .b. Near Miss: an occurrence that could have resulted in an adverse event, but the adverse event was prevented. ... Procedure: 1. The person discovering the error/near miss communicates the incident to the supervisor for the purpose of taking action to mitigate harm to involved parties. 2. The person discovering the incident completes a Healthcare Event Report, no later than by the end of their shift, using the electronic tool located on the [name of facility] Intranet. ... c. Provide a brief, objective, factual narrative description of the event. d. Review all information and submit. ... When notified of an error or near miss in their area, the manager/supervisor is responsible for performing an investigation and documenting follow-up and corrective action in the electronic reporting system ...” Facility document titled, “Behavioral Health: [Name of facility] ED Environmental Assessment (May-August 2024),” stated, “ ... This Self-Assessment Questionnaire (SAQ) highlights areas of risk management and patient safety unique to behavioral health treatment facilities or units, with particular emphasis on policies and procedures for the safe environment of care, use of restraints and seclusion, and suicide risk assessment and prevention ...” An incident report was requested for the 08/08/24 incident, when P1 attempted to jump over the rail outside the ED. The facility failed to provide an Incident Report from the event on 08/08/24, when security officers de-escalated P1 from the railing and brought him/her into the ED for a psychiatric evaluation. Review of an email titled, “[Name of facility] Last 24 hr (hour) Incident Reports” that was sent to facility administration on 08/09/24, stated, “Statistics from Occurred Date 8/8/24 6:00 am to 8/9/24 6:00 am ... 6 Searches; 6 Returns; 1 Room Search---3rd floor; 1 Fire Drill; No other Issues.” This document did not contain evidence of P1 attempting to jump over the rail. On 08/30/24 at 12:45 PM, S3 confirmed an incident should have been generated and that no incident report was filed for the ‘near miss’ event that occurred at the ED railing on 08/08/24 as per facility policy. 2. Facility policy titled, “Suicide Risk Assessment & Prevention, S-8” (Last Revised: 02/2024) stated, “ ... Policy: ... 2. The Columbia Suicide Severity Rating Scale (C-SSRS) is utilized to screen for a patient’s risk for suicide upon arrival to the ED [emergency department] ... The determined level of risk identified through screening aids the licensed provider and clinical nurse in determining clinical management and interventions to prevent patient self-harm (see Appendix A). ... 4. The provider, clinical nurse, and other members of the health care team utilize the C-SSRS identified levels of risk ... to make clinical decisions when addressing the care needs of the patient. Documentation of such clinical decision making must be documented in the patient’s medical record ... Appendix A: Columbia-Suicide Severity Rating Scale Screen Version-Recent ... Suicide Ideation Definitions and Prompts ... Past Month ... Ask questions 1 and 2. 1) Have you wished you were dead or wished you could go to sleep and not wake up? Yes (Yellow)/ No (Blank) ... 2) Have you actually had any thoughts of killing yourself? Yes (Yellow)/ No (Blank) ... If YES to 2, ask questions 3, 4, 5, and 6. If NO to 2, go directly to question 6) ... 3) Have you been thinking about how you might do this? Yes (Orange)/ No (Blank) ... 4) Have you had these thoughts and had some intention of acting on them? Yes (Red)/ No (Blank) ... 5) Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? Yes (Red)/ No (Blank) ...6) Have you ever done anything, started to do anything, or prepared to do anything to end your life? If yes, ask: ‘Was this in the past three months?’: Yes (Red)/ No (Orange) ... Key: Low Risk (Yellow); Moderate Risk (Orange); High Risk (Red) ... .” Upon review of the medical record for P1 on 08/28/24, the following was noted: P1 arrived at the ED on 08/20/24 at 3:24 AM with complaints of suicidal ideation and shoulder pain. The triage note written by S32, an RN, at 3:25 AM, stated, “Pt arrives ambulatory c/o [complaint of] SI [suicidal ideation]. States ‘the only reason I didn’t do it was because I didn’t have anything sharp.’ 1:1 maintained ...” Review of the patient’s Columbia Severity Rating Scale (C-SSRS Short Version) completed 8/20/24 at 3:28 AM, indicated that for Question #1: ‘Wish to be dead’, the nurse documented “No”; Question #2: ‘Suicidal thoughts’, the nurse documented “No”; Question #6: ‘Suicide Behavior Question’, the nurse documented “No.” The C-SSRS Risk Level indicated there was ‘No Risk identified.’ The nurse’s documentation on the C-SSRS did not indicate that the patient had presented to the ED with a chief complaint of suicidal ideation, as per facility policy.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 37432 Based on observation of Emergency Department (ED) video footage, staff interview, review of the medical record (MR) of Patient #1 (P1), and review of facility documents, it was determined the facility failed to ensure the safety of a patient presenting to the ED with severe abdominal pain and back pain, as evidenced by: failing to perform a pain assessment on a patient presenting to the ED with abdominal pain and back pain, and failing to reassess a patient in the ED waiting area who was observed lying on the floor in the fetal position for nine minutes (A0144). This failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to patients. The IJ was identified on 5/17/24 at 10:00 AM. The IJ template was provided to the facility on 5/17/24 at 12:00 PM and an acceptable IJ removal plan was received at 2:30 PM. On 5/20/24, verification of the IJ removal plan was conducted during an on-site visit and included the following: a tour of the ED, review of staff re-education sign-in sheets, and staff interviews regarding the facility’s process for performing pain assessments and re-assessment of patients in the ED waiting area. The IJ was lifted on 5/20/24 at 2:15 PM, however, Condition level non compliance remains. Cross Reference: 482.13(c)(2) - Patient Rights: Care in a Safe Setting”

“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: 37432 Based on review of 2 medical records (Patient (P) 1 and P20), observation of video footage of the Emergency Department (ED) waiting area, staff interview, and review of facility policies and procedures, it was determined that the facility failed to ensure that: 1) patients in the ED waiting area are kept safe by reassessing their clinical status after a change in their condition; and 2) patients presenting with pain have their pain assessed and managed. Findings include: 1) Reference #1: Facility policy titled, “Assessment/Reassessment” (last reviewed 6/2021) states, “ ... Procedure: ... Key Points ... Patient assessment and reassessment (including frequency of vital signs) should be based upon factors including, but not limited to, patient acuity, complaint, presentation, changes in condition.” Reference #2: Facility policy titled, “Emergency Department Triage Process” (last reviewed 5/2024) states, “ ... Policy: ... 4. Reassessment of the patient in the ED lobby is dependent upon the patient acuity level, and or change in patient condition. ... Procedure: ... If a patient or visitor waiting in the ED lobby notifies the registration and/or security staff of ... uncontrolled pain ... or a reported significant concern about another patient’s condition, the registrar and/or security staff will inform the triage nurse.” On 5/15/24 at 1:35 PM, review of video footage from the ED waiting room on 4/29/24 was conducted in the presence of Staff (S)1 (Regulatory Coordinator), S2 (Associate Chief Nurse), S3 (VP of Operations), S4 (AVP Quality, Safety, and Accreditation), S5 (ED Nurse Manager), and S28 (Assistant Chief Medical Officer). The video footage revealed the following: At 1:09 PM, P1 entered the ED with a family member and walked up to the ED registration counter. While the family member spoke to S31 (Registrar), P1 leaned over the registration desk and placed his/her head on his/her arm. P1 was grimacing as if uncomfortable. At 1:11 PM, a staff member brought P1 a wheelchair and blanket. At 1:13 PM, P1’s family member wheeled P1 away from the registration desk and into the ED waiting area. At 1:15 PM, P1 was observed “heaving” into a blue bag as if he/she was going to vomit. At 1:18 PM, P1 leaned forward in the wheelchair and held his/her head in his/her hands. At 1:19 PM, P1 leaned back in the wheelchair and began grimacing, as if he/she was uncomfortable. At 1:21 PM, P1 began “heaving” into the blue bag. The family member then begins wheeling P1 into Triage Room 1. At 1:27 PM, P1 exits Triage Room 1 with his/her family member, S29 (Triage Nurse) and S30 (Medical Resident), then enters Triage Room 2. At 1:32 PM, P1 exits Triage Room 2 and is wheeled back into the ED waiting area. P1’s family member is with him/her. At 1:36 PM, P1 begins “heaving” into blue bag. At 1:38 PM, P1 begins looking around and grimacing as if uncomfortable. At 1:40 PM, P1 is sitting in the wheelchair with his/her head in his/her hands. P1’s family member goes over to the registration desk and begins speaking with S31. S31 then goes into Triage Room 1. S31 exits Triage Room 1, speaks to the family member, then walks behind the registration desk. The family member returns to the ED waiting area. At 1:45 PM, the family member again walks toward the registration desk and is speaking to S31. S31 remains behind the registration desk. At 1:46 PM, P1 stands up from the wheelchair, walks toward the registration desk while “hunched over,” then lays on the floor in a corner between the side of the registration desk and Triage Room 1. P1 is laying in a fetal position. At 1:47 PM, P1’s family member is speaking with S31 and S31 is looking in the direction of where P1 is lying on the floor. At 1:48 PM, P1’s family member knocks on the door of Triage Room 1. The door opens and S33 (Patient Care Technician) is partially present in the doorway conversing with P1’s family member. S33 does not come out of Triage Room 1 nor engage with the patient, who continues to lie on the floor in a fetal position. At 1:49 PM, P1’s family member crouches down to speak with P1 while talking on a cell phone. At 1:52 PM, S32 (Physician’s Assistant) exits Triage Room 2, enters the ED waiting area (and is briefly out of the camera’s view), then returns to Triage Room 2. S32 does not have any interaction with the patient, who continues to lie on the floor in a fetal position. At 1:53 PM, P1’s family member exits the ED while talking on his/her cell phone. At 1:55 PM, P1’s family member returns to the ED, then walks over to P1 and assists him/her to his/her feet. Both P1 and the family member walk out of the ED. At 2:20 PM, S1, S2, S3, S4, S5, and S28 confirmed that P1 laid on the floor of the ED in a fetal position for nine minutes without having a clinical staff member re-assess his/her condition. Upon interview at 2:31 PM, S5 was asked what the expectation was, of the registrar, when a patient has a change in their condition while waiting in the ED waiting area. S5 stated, “The expectation is that the registrar notifies a clinical person, like the triage nurse.” S5 was then asked what the expectation was, of the clinical person, when they are informed of a patient’s change in condition. S5 stated, “The expectation is that they respond.” An interview was conducted with S31 at 3:06 PM, in the presence of S1. S31 stated that he/she remembered when P1 arrived to the ED on 4/29/24. S31 stated, “The patient came in with abdominal pain and back pain. I remember [P1’s family member] was upset that [P1] was not being seen as soon as possible. [He/she] was being rude and said [P1] was here a long time and needs to be seen. [He/she] was going to go somewhere else and called an ambulance. [He/she] was not having it.” S31 was asked if he/she notified anyone about P1. S31 stated, “I told the triage nurse.” When asked the name of the triage nurse he/she notified about P1, S31 stated, “I don’t remember who I spoke with.” S31 was asked what he/she told the triage nurse. S31 stated, “I told [him/her] that [P1] was in a lot of pain and the [family member] was upset. I told the triage nurse that [P1] was laying on the floor. They said the patient was triaged already and that the patient would have to wait for a bed.” S31 then stated, “I told my supervisor also, that the patient was laying on the floor. My supervisor asked me if I told triage and I said yes.” When asked, S31 denied receiving training on what to do for patient emergencies when a patient is in the ED waiting area. Upon review of S31’s education file it was determined that S31 received training on how to notify licensed personnel [nurses, doctors, technicians] if a medical emergency takes places, but because S31 is not licensed personnel he/she does not receive hands on training in responding to medical emergencies. On 5/16/24 at 11:14 AM, an interview was conducted with S32 (Physician’s Assistant) in the presence of S4. S32 confirmed that when he/she was returning to Triage Room 2, he/she saw P1 lying on the floor in the fetal position. S32 stated, “I saw [him/her] on the floor. [He/She] was angry because [he/she] wanted a bed.” S32 was asked if he/she notified anyone that P1 was lying on the floor in the fetal position. S32 stated, “I remember telling either [S30] or the attending that the patient was laying on the floor. They said the plan was to get the patient back shortly.” S32 was asked why he/she didn’t assess P1 to make sure he/she was okay. S32 stated, “I saw the patient but I decided not to go over there because I heard the patient was angry and just wanted to go back to a room.” When asked when he/she was told this information about the patient, S32 indicated that he/she remembers being told the patient was angry but could not recall when he/she was told that information. At 11:27 AM, S32 stated that when a patient sitting in the ED waiting area has a change in their condition, he/she was trained to “let the charge nurse and attending (physician) know.” S32 confirmed he/she did not notify the charge nurse that P1 was lying on the floor in the fetal position. When asked, S32 stated he/she “did not recall” if he/she notified the medical resident or the attending physician that P1 was lying on the floor. A telephone interview with S30 was conducted at 12:06 PM, in the presence of S28. S30 was asked if he/she was made aware that P1 was lying on the floor of the ED waiting area in a fetal position. S30 stated, “No. I don’t recall that. It doesn’t sound familiar.” Upon interview at 12:29 PM, S18 (ED Attending Physician) stated that if a patient in the ED waiting room has a change in their clinical status, the charge nurse and the attending “should be notified.” S18 stated the patient would then be “immediately brought back into the ED.” S18 was asked if he/she was made aware that on 4/29/24, P1 was lying on the floor in the ED waiting area in a fetal position. S18 stated, “I was not aware that [P1] was lying on the floor.” A telephone interview was conducted with S29 (Triage Nurse) at 2:04 PM, in the presence of S1. S29 stated he/she remembered P1 coming to the ED on 4/29/24. S29 stated P1 came into the ED with “10 out of 10 abdominal pain” and “looked super uncomfortable.” S29 stated, “We didn’t have any beds that day. We were jamb packed in the back. I say the same thing to all my patients that I have to put back in the waiting room - if anything changes let me know.” S29 was asked if anyone notified him/her that P1 was in a lot of pain. S29 stated, “I don’t remember if anyone told me [P1] was still in pain.” S29 was asked if the registrar notified him/her that P1 was lying on the floor in the ED waiting area. S29 stated, “I don’t remember that at all. I never spoke to the registrar after triaging the patient. I would have definitely gone out to see the patient.” S29 was asked what he/she is required to do if there is a change in the patient’s condition while they are in the ED waiting area. S29 stated, “We are required to assess the patient. I would pull the patient back into triage or I would have to bring them in the back.” 2) Reference #1: Facility policy titled, “Patient Rights and Responsibilities” (last reviewed June 2021) states, “ ... As a patient at [name of facility], you have the following rights: ... The right to receive pain relief. The right to an appropriate assessment and management of your pain. You have a right to be educated about pain, pain relief measures, and to be included in setting goals for relieving identified pain.” Reference #2: Facility policy titled, “Emergency Department Triage Process” (last reviewed May 2024) states, “ ... 3. Vital Signs: Vital signs shall include blood pressure, heart rate, temperature, pulse oximetry, respiratory rate, and pain. ... Procedure: ... 2. Upon arrival, the triage nurse will conduct a quick triage assessment consisting of a full set of vital signs and evaluation of the patient’s chief complaint and focused physical assessment. ... .” Reference #3: Facility policy titled, “Pain Management,” (last reviewed December 2022) states, “ ... Procedure: ... 4. If the patient complains of pain, the RN will document in the electronic medical record the assigned pain score AND conduct a detailed comprehensive pain assessment (CPA) which includes all of the following characteristics: a. Comfort/acceptable pain level[,] b. Body location[,] c. Pain rating[,] d. Frequency[,] e. Quality[,] f. Pain onset/duration[,] g. Pain management intervention[.] 5. The RN will complete a CPA with any new identified site of pain. ... “ Review of P1’s medical record on 5/15/24 indicated P1 arrived to the ED on 4/29/24 with a chief complaint of abdominal pain and back pain. The triage note entered by Staff (S) 29 (Triage Nurse) at 1:17 PM states “ HPI [History of Present Illness] Stated Reason for Visit: pt [patient] states right sided abd [abdominal] pain radiating to right lower/ mid back since this morning, pt reports n/v [nausea/vomiting], vomiting in the lobby, pt reports having a meal with butter yesterday, pt reports allergic to dairy, pt presents agitated and restless in triage. ...” There was no evidence of a pain assessment documented in P1’s medical record. S29 was asked why he/she did not document a pain assessment in P1’s medical record. S29 stated, “We’re required to document in the pain assessment portion of the chart. I’m confused why it’s not there. I know that [he/she] had 10 out of 10 pain. I would have had no other reason to make [him/her] a level 2.” S29 was asked if anyone notified him/her that P1 was in a lot of pain. S29 stated, “I don’t remember if anyone told me [P1] was still in pain.” S29 was asked if the registrar notified him/her that P1 was lying on the floor in the ED waiting area. S29 stated, “I don’t remember that at all. I never spoke to the registrar after triaging the patient. I would have definitely gone out to see the patient.” During a telephone interview on 5/16/24 at 12:06 PM, S30 stated, “I recall seeing the patient that day. I thought [he/she] had mild to moderate pain, but nothing emergent.” S30 was asked why he/she did not document his/her assessment of P1, specifically P1’s pain assessment, in the medical record. S30 stated, “I am a resident. Technically, residents don’t do medical screening exams (MSEs). We do a brief history and a brief physical - just an overview. I opened the template, but I wasn’t able to complete it because the patient left, so I just deleted it.” There was no evidence in the medical record S30 performed a pain assessment for P1. On 5/16/24 at 11:14 AM, an interview was conducted with S32 in the presence of S4. S32 confirmed that on 4/29/24, he/she was returning to Triage Room 2 and saw P1 lying on the floor in a fetal position. S32 stated, “I saw [him/her] on the floor. [He/She] was angry because [he/she] wanted a bed.” S32 was asked if he/she notified anyone that P1 was lying on the floor in the fetal position. S32 stated, “I remember telling either [S30] or the attending that the patient was laying on the floor. They said the plan was to get the patient back shortly.” S32 was asked why he/she didn’t assess P1 to make sure he/she was okay. S32 stated, “I saw the patient, but I decided not to go over there because I heard the patient was angry and just wanted to go back to a room.” Review of Patient (P)20’s medical record on 5/15/2024 revealed that on 2/3/2024 at 1:32 PM, P20 arrived at the Emergency Department (ED) via EMS (Emergency Medical Services) with a chief complaint of “Abdominal Pain.” The patient was triaged at 1:33 PM. Vital signs were obtained which included temperature, heart rate, respiratory rate, blood pressure, pulse oximetry, and height and weight. At 1:58 PM, an RN documented, “No available beds in ED, VSS [Vital Signs Stable], pt [patient] sent to WR [Waiting Room] in WC [wheelchair].” At 3:30 PM, documentation states, “Triage call 3x [three times].” ED disposition set to Left Without Treatment After RN Triage at 3:31 PM. There was no evidence of a pain assessment documented in P20’s medical record. These findings were reviewed with and confirmed by S1 (Regulatory Coordinator) on 5/16/2024 at 11:17 AM.”

“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: 37432 Based on observation of video footage of the ED waiting area, staff interview, review of the medical record of P1, and review of ED policy and procedure, it was determined the facility failed to ensure patients in the ED waiting area are kept safe, by reassessing their clinical status after a change in their condition. Findings include: Reference: Facility policy titled, “Emergency Department Triage Process” (last reviewed 5/2024) states, “ ... Policy: ... 4. Reassessment of the patient in the ED lobby is dependent upon the patient acuity level, and or change in patient condition. ... Procedure: ... If a patient or visitor waiting in the ED lobby notifies the registration and/or security staff of ... uncontrolled pain ... or a reported significant concern about another patient’s condition, the registrar and/or security staff will inform the triage nurse.” On 5/15/24 at 1:35 PM, review of video footage from the ED waiting room on 4/29/24 was conducted in the presence of Staff (S)1 (Regulatory Coordinator), S2 (Associate Chief Nurse), S3 (VP of Operations), S4 (AVP Quality, Safety, and Accreditation), S5 (ED Nurse Manager), and S28 (Assistant Chief Medical Officer). The video footage revealed the following: At 1:09 PM, P1 entered the ED with a family member and walked up to the ED registration counter. While the family member spoke to S31 (Registrar), P1 leaned over the registration desk and placed his/her head on his/her arm. P1 was grimacing as if uncomfortable. At 1:11 PM, a staff member brought P1 a wheelchair and blanket. At 1:13 PM, P1’s family member wheeled P1 away from the registration desk and into the ED waiting area. At 1:15 PM, P1 was observed “heaving” into a blue bag as if he/she was going to vomit. At 1:18 PM, P1 leaned forward in the wheelchair and held his/her head in his/her hands. At 1:19 PM, P1 leaned back in the wheelchair and began grimacing, as if he/she was uncomfortable. At 1:21 PM, P1 began “heaving” into the blue bag. The family member then begins wheeling P1 into Triage Room 1. At 1:27 PM, P1 exits Triage Room 1 with his/her family member, S29 (Triage Nurse) and S30 (Medical Resident), then enters Triage Room 2. At 1:32 PM, P1 exits Triage Room 2 and is wheeled back into the ED waiting area. P1’s family member is with him/her. At 1:36 PM, P1 begins “heaving” into the blue bag. At 1:38 PM, P1 begins looking around and grimacing as if uncomfortable. At 1:40 PM, P1 is sitting in the wheelchair with his/her head in his/her hands. P1’s family member goes over to the registration desk and begins speaking with S31. S31 then goes into Triage Room 1. S31 exits Triage Room 1, speaks to the family member, then walks behind the registration desk. The family member returns to the ED waiting area. At 1:45 PM, the family member again walks toward the registration desk and is speaking to S31. S31 remains behind the registration desk. At 1:46 PM, P1 stands up from the wheelchair, walks toward the registration desk while “hunched over,” then lays on the floor in a corner between the side of the registration desk and Triage Room 1. P1 is lying in a fetal position. At 1:47 PM, P1’s family member is speaking with S31 and S31 is looking in the direction of where P1 is lying on the floor. At 1:48 PM, P1’s family member knocks on the door of Triage Room 1. The door opens and S33 (Patient Care Technician) is partially present in the doorway conversing with P1’s family member. S33 does not come out of Triage Room 1 nor engage with the patient, who continues to lie on the floor in a fetal position. At 1:49 PM, P1’s family member crouches down to speak with P1 while talking on a cellphone. At 1:52 PM, S32 (Physician’s Assistant) exits Triage Room 2, enters the ED waiting area (and is briefly out of the camera’s view), then returns to Triage Room 2. S32 does not have any interaction with the patient, who continues to lie on the floor in a fetal position. At 1:53 PM, P1’s family member exits the ED while talking on his/her cellphone. At 1:55 PM, P1’s family member returns to the ED, then walks over to P1 and assists him/her to his/her feet. Both P1 and the family member walk out of the ED. At 2:20 PM, S1, S2, S3, S4, S5, and S28 confirmed that P1 laid on the floor of the ED in a fetal position for nine minutes without having a clinical staff member re-assess his/her condition. Upon interview at 2:31 PM, S5 was asked what the expectation was, of the registrar, when a patient has a change in their condition while waiting in the ED waiting area. S5 stated, “The expectation is that the registrar notifies a clinical person, like the triage nurse.” S5 was then asked what the expectation was, of the clinical person, when they are informed of a patient’s change in condition. S5 stated, “The expectation is that they respond.” An interview was conducted with S31 at 3:06 PM, in the presence of S1. S31 stated he/she remembered when P1 arrived to the ED on 4/29/24. S31 stated, “The patient came in with abdominal pain and back pain. I remember [P1’s family member] was upset that [P1] was not being seen as soon as possible. [He/she] was being rude and said [P1] was here a long time and needs to be seen. [He/she] was going to go somewhere else and called an ambulance. [He/she] was not having it.” S31 was asked if he/she notified anyone about P1. S31 stated, “I told the triage nurse.” When asked the name of the triage nurse he/she notified about P1, S31 stated, “I don’t remember who I spoke with.” S31 was asked what he/she told the triage nurse. S31 stated, “I told [him/her] that [P1] was in a lot of pain and the [family member] was upset. I told the triage nurse that [P1] was laying on the floor. They said the patient was triaged already and that the patient would have to wait for a bed.” S31 then stated, “I told my supervisor also that the patient was laying on the floor. My supervisor asked me if I told triage and I said yes.” When asked, S31 denied receiving training on what to do for patient emergencies when a patient is in the ED waiting area. Upon review of S31’s education file it was determined that S31 received training on how to notify licensed personnel [nurses, doctors, technicians] if a medical emergency takes places, but because S31 is not licensed personnel he/she does not receive hands on training in responding to medical emergencies. On 5/16/24 at 11:14 AM, an interview was conducted with S32 (Physician’s Assistant) in the presence of S4. S32 confirmed that when he/she was returning to Triage Room 2, he/she saw P1 lying on the floor in the fetal position. S32 stated, “I saw [him/her] on the floor. [He/She] was angry because [he/she] wanted a bed.” S32 was asked if he/she notified anyone that P1 was lying on the floor in the fetal position. S32 stated, “I remember telling either [S30] or the attending, that the patient was laying on the floor. They said the plan was to get the patient back shortly.” S32 was asked why he/she didn’t assess P1 to make sure he/she was okay. S32 stated, “I saw the patient, but I decided not to go over there because I heard the patient was angry and just wanted to go back to a room.” When asked when he/she was told this information about the patient, S32 indicated that he/she remembers being told the patient was angry but could not recall when he/she was told that information. At 11:27 AM, S32 stated that when a patient sitting in the ED waiting area has a change in their condition, he/she was trained to “let the charge nurse and attending (physician) know.” S32 confirmed he/she did not notify the charge nurse that P1 was lying on the floor in the fetal position. When asked, S32 stated he/she “did not recall” if he/she notified the medical resident or the attending physician that P1 was lying on the floor. A telephone interview with S30 was conducted at 12:06 PM, in the presence of S28. S30 was asked if he/she was made aware that P1 was lying on the floor of the ED waiting area in a fetal position. S30 stated, “No. I don’t recall that. It doesn’t sound familiar.” Upon interview at 12:29 PM, S18 (ED Attending Physician) stated that if a patient in the ED waiting room has a change in their clinical status, the charge nurse and the attending “should be notified.” S18 stated the patient would then be “immediately brought back into the ED.” S18 was asked if he/she was made aware that on 4/29/24, P1 was lying on the floor in the ED waiting area in a fetal position. S18 stated, “I was not aware that [P1] was lying on the floor.” A telephone interview was conducted with S29 (Triage Nurse) at 2:04 PM, in the presence of S1. S29 stated he/she remembered P1 coming to the ED on 4/29/24. S29 stated P1 came into the ED with “10 out of 10 abdominal pain” and “looked super uncomfortable.” S29 stated, “We didn’t have any beds that day. We were jamb packed in the back. I say the same thing to all my patients that I have to put back in the waiting room - if anything changes let me know.” S29 was asked if anyone notified him/her that P1 was in a lot of pain. S29 stated, “I don’t remember if anyone told me [P1] was still in pain.” S29 was asked if the registrar notified him/her that P1 was lying on the floor in the ED waiting area. S29 stated, “I don’t remember that at all. I never spoke to the registrar after triaging the patient. I would have definitely gone out to see the patient.” S29 was asked what he/she is required to do if there is a change in the patient’s condition while they are in the ED waiting area. S29 stated, “We are required to assess the patient. I would pull the patient back into triage or I would have to bring them in the back.””

“DELIVERY OF DRUGS CFR(s): 482.25(b) §482.25(b) Standard: Delivery of Services In order to provide patient safety, drugs and biologicals must be controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law. This Standard is not met as evidenced by: 39724 Based on medical record review, facility document review, and staff interview, it was determined the facility failed to ensure policies and procedures that address the 1) wasting and the documentation of the waste of IV (intravenous) infusions of Controlled Dangerous Substances (CDS); and 2) the monitoring of CDS accountability for IV infusions of CDS, dispensed from the pharmacy department to the patient care units, are developed and implemented. Findings include: 1. Four of six medical records (MR), MR1, MR4, MR5, and MR 8, that contained documentation of CDS infusion administration, reviewed on 4/17/24 and 4/18/24, lacked documentation that the disposal of partial doses of CDS infusions were completed in a timely manner. During an interview on 4/18/24 at 4:15 PM, S5, the Director of Pharmacy, stated that partial doses of CDS that need to be wasted should be done “promptly.” S5 stated that the benchmark for “promptly” would be within 60 minutes of discontinuing the infusion. During an interview on 4/17/24 at 12:30 PM, S16, the ICU (intensive care unit) clinical coordinator, stated that the wasting of partial doses of CDS infusions, such as Dilaudid and Morphine, should be documented on the I&O Flow Sheet found in the medical record, in accordance with facility policy below. The following was identified during medical record review: On 4/17/24 at 11:45 AM, MR1 was reviewed with S15, the ICU manager, and S16. The Resident Death Exam Note note dated 4/13/24 at 6:11 AM stated, “...Patient was pronounced at 5:52 AM...” The I&O Flow Sheet dated 4/13/24 at 5:50 AM indicates that 43.25 ml (milliliters) of Dilaudid 20 mg (milligrams)/ 100 ml infused. Therefore 56.75 ml of Dilaudid infusion was remaining. The I&O Flow Sheet lacked documentation that the Dilaudid was wasted. This was confirmed with S15 and S16 on 4/17/24 at 12:00PM. On 4/17/24 at 3:29 PM during an interview, S8, an ICU RN (registered nurse), explained that he/she was P1’s nurse on 4/13/24. S8 stated that his/her shift started at 7:00 AM and the Dilaudid infusion was still in P1’s room because P1’s family was present. S8 explained that he/she was going to waste the remaining Dilaudid infusion around 12:30 PM on 4/13/24, approximately six and a half hours after the infusion was discontinued, and discovered that the IV (intravenous) tubing was cut and the Dilaudid was missing. Review of the facility’s investigation, and interview with S18, an environmental services staff member, on 4/18/24 at 12:35 PM, confirmed that S18 cut the IV line while cleaning the room, the Dilaudid leaked onto the floor, and CDS diversion did not occur. However, the facility failed to ensure the CDS was wasted in a timely manner and the Dilaudid was available for diversion. On 4/18/24 at 10:30 AM, MR4 was reviewed with S15. The Resident Death Exam Note dated 4/10/24 at 4:18 PM stated, “...Patient was pronounced at 16:09 (4:09 PM).” S15 confirmed that the Flow Sheet found in MR4 lacked documentation that the Morphine 100 mg/ 100 ml infusion, that was discontinued on 4/10/24, was wasted as required by facility policy. Review of the Pyxis, “Returns and Wastes” report, contained documentation that 85 mg of Morphine dispensed to P4 was wasted on 4/10/24 at 17:24 (5:24 PM). On 4/18/24 at 11:00 AM, S5 confirmed the CDS was wasted more than an hour after is was discontinued. On 4/18/24 at 11:05 AM, MR5 was reviewed with S15. MR5 contained documentation that P5 was pronounced on 4/10/24 at 23:20 (11:20PM). The I&O Flow Sheet found in MR5 lacked documentation that the remaining Morphine 100 mg/100 ml that was administered to P5 was wasted, as required by facility policy. With further review of MR5, S15 identified a Nurse Progress Note dated 4/11/24 at 2:56 AM that stated, “...Wasted 60 cc (cubic centimeters) of morphine drip with [nurse’s name] RN.” The note was written approximately three and half hours after the Morphine infusion was stopped. It could not be determined when the Morphine was wasted. This finding was confirmed by S5 and S15 on 4/18/24 at 12:00 PM. On 4/18/24 at 11:40 AM, MR8 was reviewed with S15. MR8 contained documentation the P8 was pronounced on 3/23/24 at 2:49 AM. The I&O Flow Sheet, dated 3/23/24 at 6:00 AM, indicated the Morphine 100 mg/ 100 ml administered to P8, was wasted. This is approximately three hours and ten minutes after the infusion was discontinued. S15 confirmed the CDS infusion was wasted late on 4/18/24 at 11:47 AM. Facility policy titled “Medication Administration Record (MAR)” dated 10/23, states, “...Documentation of Large Volume Controlled Substance Waste... The waste is documented on the I&O (in and out) flow sheet for the medication being wasted. The RN (registered nurse) requests a ‘Cosign’ and enters the 2nd RNs name...” During an interview conducted in 4/17/24 at 3:15 PM, S9, an ICU RN, explained that CDS infusions should be wasted as soon as they are discontinued and if a patient is deceased, the CDS should be removed from the patient room and wasted before the family members enter the room. S9 confirmed that CDS infusion waste should be documented on the I&O Flow Sheet. On 4/17/24, the facility policy that addressed the wasting of partial doses of CDS, including CDS infusions, was requested. The facility provided multiple policies including “Pain Management,” dated 12/22, “Controlled Substance Procurement, Storage, and Distribution,” dated 8/23, and “Continuous Critical Care Intravenous Medication Infusions(s) Titration Protocol,” dated 2/24. On 4/17/24 at 4:15PM, these were reviewed with S5, and S5 confirmed the polices do not indicate that the CDS waste should be completed as soon as possible or within a timely manner. 2. During an interview on 4/18/24 at 11:52 AM, the above findings were reviewed with S5, the Director of Pharmacy. It was determined that the software system utilized to monitor CDS administration and waste in the facility, called Bluesight, collected data for CDS removed from the Pyxis, an automated drug cabinet, and reconciled it with data found in the electronic medical records. Bluesight did not collect data for patient specific CDS distributed from the pharmacy directly to the patient care area, such as the Dilaudid infusion. Therefore, CDS infusions distributed directly to patient care areas were not included in the data monitored by Bluesight. When questioned about the processes in place to ensure the accountability of patient specific CDS dispensed directly from the pharmacy, and not stored in the Pyxis, S5 stated “... good question... .” S5 confirmed the facility did not have a process to monitor the CDS infusions distributed from the pharmacy to the patient care area, and that those CDS were not captured in the monitoring conducted by Bluesight on 4/18/24 at 11:56 AM.”

“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: 48414 Based on medical record review, staff interviews, review of facility documents, and review of video surveillance, it was determined that the facility failed to ensure that a facility approved personal protective equipment is available and utilized as referenced in the “Handle with Care Instructor Manual” to protect staff and patients from bodily fluids (i.e. sputum). Findings include: On 1/3/24 at 1:36 PM, time stamped ED hallway video surveillance review for P1, was conducted in the presence of S6, the Security Manager, S5, and S12, the Assistant Vice President of Quality. The video surveillance reviewed did not have any audio recording. The video surveillance began in “Hallway 24” in the ED as confirmed by S6, and it revealed the following: At 7:16 PM: P1 appeared to spit and verbally communicate in what appeared to be an aggressive manner at facility staff and then began to punch the wall next to the stretcher with the side of his/hers arm. Multiple staff members (RNs and Security officers) were observed to respond and began to lay P1 down onto his/her stretcher in a supine (lying horizontally with face and torso facing up) position in a controlled manner. The staff members were observed to place themselves around the stretcher and physically hold P1, restraining P1 to the stretcher. Staff members were observed physically holding P1’s B/L (bilateral) arms and B/L legs. At 7:17 PM: S10 (Security Officer) was observed to place his/her hand on the top portion of P1’s forehead and side of face, however exact hand placement on side of face was difficult to assess due to the angle of the camera. Multiple staff members continued to physically hold P1 restraining him/her to stretcher. S24 (RN) was observed to place a surgical mask on to P1. On 1/3/24 at 1:40 PM, upon interview with S6, he/she indicated after video surveillance review, he/she “did not see any excessive force and no disciplinary actions were taken.” S6 indicated that P1’s head was physically secured to the stretcher to prevent P1 from biting or spiting on staff. S6 indicated that this technique was appropriate to keep staff and the patient safe. On 1/3/24 at 1:53 PM, S5 stated, “we do not use spit shields, a surgical mask was used because the patient was spitting and biting.” S5 indicated that each situation when a patient becomes agitated is very individualized but verbal de-escalation is always the first step and that the facility provides Handle with Care training yearly that includes de-escalation. S5 indicated that if a patient begins to spit, surgical masks are applied to the patient to prevent staff from being spat on. On 1/3/24 at 3:00 PM, an interview was conducted with S10. S10 confirmed he/she was present when the event occurred with P1 on 12/2/23. S10 indicated he/she received a call to retrieve P1 belongings for discharge. S10 stated, “[P1] was freaking out.” S10 stated that he/she held patients head while on the stretcher because P1 was trying to spit and bite the staff. Once the surgical mask was on the patient, S10 indicated that he/she was holding P1’s ear so that P1 he could not remove the mask. S10 indicated that P1 was still attempting to spit and moving head to attempt to remove the mask. On 1/4/24 at 1:53 PM, upon interview with S12, he/she stated that surgical masks were appropriate for spitting patients and the facility does not use spit shields, though staff have requested spit shields. Upon request, S12 was unable to provide documentation related to the acceptable use of surgical masks for patients that are spitting. The facility provided the Handle with Care training which referenced the use of an appropriate cushion like spitguard in the event of a patient spitting at staff. Review of the facility document titled, “Handle with Care ...Instruction Manual” it stated, “ ...Once oriented, stabilize the head (to prevent head butting, spitting, or biting) ...Watch for spitting. An appropriate cushion like CerviPro SpitGuard can also be used.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 48414 Based on medical record review, staff interview, review of facility documents, and review of video surveillance, it was determined that the facility failed to implement the facility’s policy to ensure that a documented evidence of a physician order was obtained and documented upon initiation of restraints, for one of 10 patients (#1). Findings Include: On 1/3/23 at 10:30 AM, a medical record review of P1 was conducted with Staff 3 (S3), the ED Coordinator of Patient Services, and S5, the ED Manager. P1 arrived at the ED (emergency department) via EMS (Emergency Medical Services) on 12/2/23 at 3:02 PM, with a chief complaint of SI (Suicidal Ideation). An ED Provider Note on 12/2/23 at 7:19 PM stated, “Delayed charting: Patient was seen and evaluated by Behavioral Health and deemed stable for discharge. Diagnosis schizophrenia and autism. Upon being formed [sic] of being discharged, the patient became irate stating [he/she] does not want to go back to [his/her] group home. [He/she] then proceeded to have a agitated outburst where [he/she] threw [his/her] try a [sic] food on the ground and started screaming at staff and having a temper tantrum. ... 2000 [8:00 PM] Delayed charting: After being medicated, patient continued to escalate and become extremely agitated and combative. Security was at bedside helping try to control the patient has [sic] [he/she] was attempting to hit staff as well as harm [him/herself].” A “Nursing Note” on 12/2/23 at 7:21 PM, stated, “ ...Patient agitated, Dr. [name] at bedside and orders placed for medication administration.” During the medical record review, it was reavealed that on 12/2/23 at 7:18 PM, Haldol 10mg IM (intramuscular) and Ativan 2 mg IM was administered to P1 as ordered. On 1/3/23 a review of the “Safety/Security Event” report from 12/2/23 revealed, “ ... On December 2nd, 2023, at 1915 [7:15 PM] HRS [hours]. Officers received a Strongline Activation to assist ED Clinical Staff of Patient of ED Hall 24. ...Patient was trying to bite [him/herself] and started to hit the wall. Officers then grab Patient by the arms and then started to get Patient onto the stretcher. Clinical Staff then assisted by getting Patient on the Stretcher and started to use Handle with Care until other officers arrived on scene to assist. ED Clinical Staff then got medication as Officer had Patient left Leg. Officer also assisted with holding Patient left leg. Officer [name] had both Patient [P1 name] legs, Officer had Patient right Arm, ED Clinical Staff RN [name] had patient left Arm, Officer had Patient right Knee and leg, and Officer had Patient face. ...ED Clinical Staff gave Patient his medication ...” On 1/3/24 at 1:36 PM, a review of the time ED hallway video surveillance surrounding the event involving P1 was conducted in the presence of S6, the Security Manager, S5, and S12, the Assistant Vice President of Quality. The video surveillance reviewed did not have any audio recording. The video surveillance began in “Hallway 24” in the ED as confirmed by S6, and it revealed the following: At 7:16 PM: P1 appeared to spit and verbally communicate in what appeared to be an aggressive manner at facility staff and then began to punch the wall next to the stretcher with the side of his/hers arm. Multiple staff members (RNs and Security officers) were observed to respond and began to lay P1 down onto the stretcher in a supine (lying horizontally with face and torso facing up) position in a controlled manner. The staff members were observed to place themselves around the stretcher, physically hold P1, restraining P1 to the stretcher. Staff members were observed physically holding P1’s B/L (bilateral) arms and B/L legs. At 7:17 PM: S10 (Security Officer) was observed to place his/her hand on the top portion of P1’s forehead and side of face, however exact hand placement on side of face was difficult to view due to the angle of the camera. Multiple staff members continued to physically hold P1 restraining him/her to stretcher. At 7:18 PM: S21 (RN) and S22 (RN) were observed administering IM medications. At 7:20 PM: P1 was observed to be physically restrained by staff members holding P1’s B/L arms, B/L legs and S10 restraining P1’s forehead to the stretcher in supine position as he/she was being transported on the stretcher through the ED hallway. At 7:21 PM: P1 was observed to be transported to Room 9, which S6 and S10 confirmed was the Behavioral Health Room, all medical equipment was removed from this room. Once P1 was transported to Room 9 the visual observation was limited due to no video surveillance in Room 9. On 1/4/24 at 10:00 AM, a review of P1’s medical record review was conducted with S3 and S5, for the ED visit on 11/29/23 and 7/14/23. S5 confirmed that there was no order for restraints for P1 related to the physical hold on 12/2/23. The facility policy titled, “Restraints and Seclusion” (reviewed 2/23) states, “PURPOSE: ...d. ensure the appropriate ordering of restraint or seclusion. ...B. Definitions of Terms: ...4. Physical Holding: Holding a patient in a manner that restricts the patient’s movement against the patient’s will is considered a restraint including physically holding a patient in order to administer a medication against his or her wishes. Also known as a “therapeutic hold.” ...D. Order Requirement: An order by the licensed provider is required to apply any type of restraint including physical, chemical, seclusion, or physical hold. ...PROCEDURE: ...II. Use of Restraints and Seclusion for Violent or Self Destructive Patients (Behavioral Management) ...C. ...3. A LP [licensed provider] order is issued on initiation of restraints or seclusion 4. Orders are entered into the electronic medical record. ...6. All orders must include the following information: That restraint use is clinically justified. The type of restraint to be used. The time limit for use of restraints according to the age of the patient. ... The date, time and physician or advance practice practitioner signature. ...””