Mount Sinai Beth Israel

“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: 48940 . Based on medical record review, document review, video surveillance review, and interview, in one (1) of five (5) medical records reviewed, the facility failed to ensure that a patient received continuous cardiac and oxygen saturation monitoring as ordered by the provider and according to the facility’s policy and procedure on continuous cardiac monitoring. Findings include: The Emergency Department staff failed to continuously monitor Patient #1, who had an order for continuous cardiac monitoring and continuous pulse oximetry. The patient was transported to the computed tomography (CT) scan (a non invasive medical imaging procedure) without a portable monitor and an appropriate staff member to monitor the patient. When the patient returned from the CT scan and was reconnected to the cardiac monitor, the patient was found to be bradycardic (low heart rate); the patient decompensated and was pronounced dead. The patient had orders not to be resuscitated. See Tag A-1104. .”

“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: 48940 . Based on medical record review, document review, video surveillance review, and interview, the facility failed to ensure that Patient #1 received continuous cardiac and pulse oximetry monitoring as ordered by the provider and according to the facility’s policy and procedure on continuous cardiac monitoring. This failure was identified in one (1) of five (5) medical records reviewed. Findings include: The facility’s policy and procedure titled “MSH ED Guideline on the Use of Continuous Cardiac Monitoring and Pulse Oximetry in the ED” effective 12/7/2022 states: “a. Patients ordered for cardiac monitoring must remain connected to a monitor with a clinical staff member (Registered Nurse (RN), Physician Assistant (PA), Nurse Practitioner (NP), or Doctor of medicine (MD) close enough to hear alarms. b. Patients leaving the department for radiology studies should be accompanied by a clinical staff member and connected to a portable monitor ... ii. Cardiac monitoring should not be “suspended” for transport to a study outside the ED.” Medical record review identified Patient #1 presented to the Emergency Department (ED) on 9/3/2024 at 11:36 AM for vomiting blood and shortness of breath. The patient had a past medical history of liver cancer, diabetes, hypertension (high blood pressure), and a gastric ulcer. The patient had an order not to be resuscitated. On 9/3/2024 at 11:41 AM, Patient #1 had an order placed for continuous cardiac monitoring and continuous pulse oximetry (measuring oxygen saturation). At 5:16 PM, while undergoing treatment and awaiting transfer to another facility, the patient had a CT scan ordered. At 5:46 PM, the CT scan was in progress. At 6:07 PM, the registered nurse (RN) documented that the patient had returned from CT scan and when being reconnected to the cardiac monitor, the patient was found to be bradycardic. At 6:20 PM, the patient was pronounced dead. A review of video surveillance revealed that on 9/3/2024 at 5:33 PM, Staff L [Patient Care Associate (PCA)] was in the room with the patient, and Staff D (CT Technologist) took the patient out of the room on a stretcher. No cardiac monitor is seen attached to the patient, nor is the patient accompanied by a staff member who could appropriately monitor the patient. During an interview with Staff L on 10/24/2024 at 2:05 PM, Staff L stated that she could not recall informing the nurse that the patient was being taken for a CT scan. Staff L also stated that they were unaware the patient had an order for continuous cardiac monitoring. Staff L stated that patients from the resuscitation rooms typically are taken to radiology with a monitor, but the patients in the regular ED rooms are not. She believed the patient had been downgraded to a regular room and did not require cardiac monitoring. During an interview with Staff E [RN] on 10/23/2024 at 12:18 PM, Staff E stated that she was covering the patient for another nurse. After receiving the handoff, she noticed that the patient had medications ordered, so she went to the medication room to get the medications and prepare them for administration. When she went to administer the medications, she saw that the patient was no longer in the room. She said she was not informed that the patient was being taken for a CT scan. During an interview with Staff G [Attending Physician] on 10/23/2024 at 1:48 PM, Staff G stated that when she orders patients to be on continuous cardiac monitoring, she expects them to be connected to the cardiac monitors in their assigned rooms. If they need to be disconnected from the monitors in the rooms, she expects them to be transported on portable monitors and accompanied by staff who can monitor them. On 10/25/2024 at 2:53 PM, an Immediate Jeopardy (IJ) situation was announced due to the facility’s failure to provide continuous cardiac monitoring and continuous pulse oximetry, resulting in the decompensation of the patient. On 10/28/2024 at 11:11 AM, the facility provided an IJ Removal Plan to survey staff. The plan included: (1) Re-education of ED staff to the facility’s policy and procedure titled “MSHS 191 Intra-Hospital Patient Transportation and Clinical Accompaniment,” last revised 5/6/2024, which states “active ED patients requiring care in the Resuscitation Area (RESUS) require the continuous presence of an RN and a cardiac monitor, +/- Licensed Provider, for round transport to Radiology and Non-admitted patients may be handed off to a clinical team in a procedural area only if the receiving unit staff assume responsibility for an equivalent level of monitoring.” Staff to be trained included PCAs, PAs, Physicians, RNs, and CT Technologists. (2) Nursing verification of continuous cardiac monitoring and oxygen saturation monitoring during patient transport. From 10/25/2024 to 10/29/2024, the ED nursing staff was required to conduct dual nurse verification of continuous cardiac monitoring and oxygen saturation monitoring for any patient with active orders who required transport to radiology imaging in the ED to ensure 100% compliance. The IJ was removed on 10/28/2024 at 3:09 PM based on onsite verification of the implementation of the IJ removal plan. Surveyors conducted tours and interviews with ED staff on 10/28/2024 to verify staff re-education and observe continuous cardiac and oxygen saturation monitoring during transport to radiology. Based on interviews with ED staff on duty, 100% of staff reported they had been re-educated regarding the implementation of the existing policy. A review of the training log revealed that 77% of all staff working in the Emergency Department had been trained. Interviews with senior leadership confirmed that staff members who have not been trained will be trained before the start of their shift and before providing patient care.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 35161 . Based on medical record review, document review, and interview, in one (1) of ten (10) medical records review, the facility failed to follow their process for grievance resolution. Findings: A review of the facility’s policy titled “Response to Allegations of Assault against a Patient (Including Sexual Assault and/or Misconduct),” Revised in June 2017, revealed investigation guidelines: (a) Initial Steps: i. Risk Management and Patient Safety will conduct an evaluation of the allegation(s) and direct the investigation with the assistance of other departments ... (b) Follow-up Steps: i. The Leadership Representative will determine how investigative interviews will be conducted and who will perform them ... (c) A report of the investigation will be made by the Leadership Representative. The report will include: i. A summary of the investigation findings, including a list of all interviews and any conclusions and recommendations that were agreed upon by the involved departments ... ii. Supporting documentation described above ... (d) Risk Management and Patient Safety will maintain the report and ensure that the appropriate parties are notified of the findings of the investigation report ...” A review of the grievance report revealed that patient #1 complained on 2/20/2024 and 2/26/2024 that they were sexually assaulted by hospital staff during their admission in December 2023. The facility initiated an investigation on 2/21/2024. The facility documented the status of the investigation as “Resolved,” and the Date closed/Date of Resolution and Letter to the complainant was dated 2/27/2024. The response letter to the patient indicated that the facility could not validate the patient’s complaint. There was no documentation of the investigation findings, including a list of all interviews and any conclusions as per the facility’s policy “Response to Allegations of Assault against a Patient (Including Sexual Assault and/or Misconduct).” On 06/12/2024, at approximately 12:00 p.m., during an interview with Staff B (Director of Patient Services), they provided a list of staff members interviewed and confirmed that the interviews were not documented. During an interview with Staff G, Chief Nursing Officer, on 6/13/2024 at approximately 1:10 p.m., they acknowledged the lack of a summary of investigation findings, including staff interviews. These findings were brought to the attention of the facility’s administrative personnel, Staff D (MD., CMO) and Staff G (Chief Nursing Officer), during the survey exit conference on 06/13/2024 at about 4:00 p.m.”

“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: 10723 Based on medical record (MR) review, document review, and interview, the hospital failed to comply with the Emergency Medical Treatment and Active Labor Act (EMTALA). Findings: The hospital failed to ensure that “The Physician Certification Consent To Transfer” form, documented the benefits and/or risks associated with the patient’s transfer and were specific to the patient’s medical condition. See Tag A-2409”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 10723 Based on medical record (MR) review, document review, and interview, in six (6) of six (6) medical records MRs reviewed, the hospital failed to ensure that The “Physician Certification Consent To Transfer” form, documented the benefits and/or risks associated with the patient’s transfer and were specific to the patient’s medical condition. (Patients #1, 13, 33, 37, 38, and 44) Findings include: Review of the hospital’s policy and procedure (P&P) titled, “Emergency Treatment, Stabilization, Transfer of Patients and EMTALA (Emergency Medical Treatment and Labor Act),” reviewed 11/2022, stated: “Staff arranging transfers will follow these requirements: (d) Document all of the following in the patient’s medical record in accordance with the hospital’s standard descriptions of patients requiring specialized emergency care, triage protocols, and formal written transfer agreements: ... (iii) specific risks and benefits of the proposed transfer.” Review of Patient #1’s MR identified: On 12/28/23, the patient was brought to the Emergency Department with a chief complaint of unresponsiveness. The patient was diagnosed with Intracerebral Hemorrhage and the physician determined that the patient needed to be transferred to another hospital. The “Physician Certification Consent To Transfer” form, dated 12/28/23, stated the following: “I certify that I have discussed with the patient and/or his/her representative the following risks and benefits of the proposed transfer to... Hospital, Neurology Intensive Care Unit (receiving facility): for further treatment and stabilization.” The benefits and risks associated with the transfer and specific to the patient’s medical condition were not documented. Review of Patient #13’s MR identified: On 1/23/24, the patient was transferred from MSQ Hospital to MSBI Emergency Department with a chief complaint of upper respiratory infection with respiratory distress and hypoxia. The patient was diagnosed with Multifocal Pneumonia and the physician determined that the patient needed to be transferred to another hospital. The “Physician Certification Consent To Transfer” form, dated 1/24/24, stated the following: “I certify that I have discussed with the patient and/or his/her representative the following risks and benefits of the proposed transfer to, (receiving facility): risk of decompensation, requiring higher respiratory support.” The benefits associated with the transfer and specific to the patient’s medical condition were not documented. Review of Patient #33’s MR identified: On 1/22/24, the patient was brought to the Emergency Department with a chief complaint of unresponsiveness. The patient was diagnosed with Septic Shock secondary to Pneumonia and the physician determined that the patient needed to be transferred to another hospital. The “Physician Certification Consent To Transfer” form, dated 1/22/24, stated the following: “I certify that I have discussed with the patient and/or his/her representative the following risks and benefits of the proposed transfer to MSW Hospital, (receiving facility): informed patient representative that patient requires ICU level care and requires transfer due to space limitation and staff limitation at current hospital.” The benefits and risks associated with the transfer and specific to the patient’s medical condition were not documented. Review of Patient #37’s MR identified: On 1/8/24, the patient presented to the Emergency Department with a chief complaint of cardiac workup and clearance for a procedure. The patient was diagnosed with Atrial Fibrillation and the physician determined that the patient needed to be transferred to another hospital. The “Physician Certification Consent To Transfer” form, dated 1/8/24, stated the following: “I certify that I have discussed with the patient and/or his/her representative the following risks and benefits of the proposed transfer to MSH, (receiving facility): benefits is specialty care; risk is atrial fibrillation with rapid ventricular rate (RVR), hypotension and death.” The benefits associated with the transfer and specific to the patient’s medical condition were not documented. Review of Patient #38’s MR identified: On 1/7/24 the patient was brought to the Emergency Department with a chief complaint of slurred speech and weakness. The patient was diagnosed with Stroke and the physician determined that the patient needed to be transferred to another hospital. The “Physician Certification Consent To Transfer” form, dated 1/7/24, stated the following: “I certify that I have discussed with the patient and/or his/her representative the following risks and benefits of the proposed transfer to MSH, (receiving facility): decompensation, worsening of symptoms, delay care to medical facility.” The benefits associated with the transfer and specific to the patient’s medical condition were not documented. Review of Patient #44’s MR identified: On 1/13/24 the patient was brought to the Emergency Department with a chief complaint of slurred speech and weakness. The patient was diagnosed with Large Vessel Obstruction (LVO)-Ischemic Stroke and the physician determined that the patient needed to be transferred to another hospital. The “Physician Certification Consent To Transfer” form, dated 1/13/24, stated the following: “I certify that I have discussed with the patient and/or his/her representative the following risks and benefits of the proposed transfer to MSW Hospital, (receiving facility): further treatment and stabilization.” The benefits and risks associated with the transfer and specific to the patient’s medical condition were not documented. Per interviews of Staff C, (President/Chief Operating Officer), Staff HH (Deputy Chief Operating Officer) and Staff II (Physician) on 1/31/2024 at 3:00 PM, the “Patient Transfer Summary” form for Patient #33 was reviewed and documented the following: “Risks and benefits have been reviewed with the patient and the patient/guardian accepts the transfer.” They confirmed the form does not include the risks and benefits associated with the transfer and specific to the patient’s medical condition. Staff HH stated the doctor reviews the risks and benefits of the transfer with the patient. They could not provide documentation that the risks and benefits were specific to the patient’s medical condition.”