Mount Carmel East & West

“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: 32088 Based on medical record review, staff interview, policy review, and review of the hospital Rules and Regulations, it was determined the hospital failed to ensure an immediate (STAT) psychiatric consult was completed timely for a patient experiencing psychiatric symptoms. This affected one patient (Patient #1) out of ten patients reviewed. The census was 165. Findings include: Review of Patient #1’s medical record revealed the patient arrived to the emergency department (ED) on 01/14/26 at 10:20 AM after being found in a farmer’s field making odd noises, banging their head, and rolling around on the ground. The patient had been administered Ketamine (anesthetic) 300 milligram (mg) intramuscularly (IM) by Emergency Medical Services (EMS). The patient signed the consent to treat voluntarily on 01/14/26 at 1:39 PM. Review of the ED Provider note dated 01/14/26 at 10:20 AM revealed the patient received Ketamine 300 mg by EMS. In the ED the patient was administered Zofran (anti-nausea). The provider noted as the patient became more alert and interactive she would answer some questions. She denied drug use, suicidal ideations, homicidal ideation, and pain but stated the officers were rough. A computed tomography (CT) of the head, spine and face was obtained on 01/14/26 revealing no acute findings. The patient was calm on multiple re-assessment and could not recall much from the interaction with officers earlier. The patient reported she was homeless, living out of a hotel and wanted to be discharged. A social services consult was placed. The provider discussed with the patient they wanted social services to see her before she was discharged. The provider noted “suddenly” they were notified the patient ran out into the parking lot, was not able to be redirected and had to be brought back in by security. The patient was medicated with IM Benadryl, Haldol and Ativan. She threw a tray of food and hit staff. The patient was trying to hit her head on the bedrails so pads were placed for safety. The provider noted she did not feel she could medically clear the patient for discharge and the patient would benefit from an observational stay and an inpatient psychiatric consult. A stat consult was placed with psychiatry and internal medicine admitted Patient #1. On 01/14/26 at 1:53 PM the provider pink slipped the patient related to immediate concerns for the patient’s safety after she ran out. The provider also noted the patient was as acting like she was on a stimulant and had been given Ketamine prior to arrival to the ED. Review of the orders revealed a STAT psychiatric consult was placed on 01/14/26 at 1:45 PM. The consult was completed on 01/15/26 at 9:04 AM. Review of the Psychiatry Consult dated 01/15/26 at 9:04 AM for SP #1 revealed the patient had a history of attention deficit hyperactivity disease (ADHD) and anxiety. The urinalysis was positive for marijuana usage. The patient presented with altered mental status and severe agitation after being found in a field behaving “aggressively and bizarre.” In the ED the patient remained altered, agitated, and combative requiring chemical sedation and four point restraints. Later she transitioned to soft restraints, was able to free herself, and attempted to leave against medical advice. The patient ran towards the exit, engaged in a physical altercation with security, and during the altercation she was able to place her finger inside the gun holster which resulted in accidental discharge of the weapon through the holster. The patient was subdued and placed in bed in four point hard restraints. Zyprexa 50 mg IM was administered. On 01/15/26 the patient was in a room on the 7th floor with two police officers and a sitter in four point restraints. The patient was sedated but able to awaken. She was oriented to person, place and time. The patient stated she was in an altercation with the police and brought to the hospital. She denied suicidal ideation and would not comment on homocidal ideation. She refused to discuss her psychiatric history and denied any psychosis in the past. She refused to answer specific questions but stated she was not in a psychiatric crisis. The provider noted the patient was calm and guarded. Her speech and volume was low. Her affect was blunt. Her thought process was linear when she answered. She was not fully oriented to the situation, asking to leave and pay for the hospital stay. Her judgement was slightly impaired, as evidenced by recent violent behaviors. The patient denied past psychiatric history but the provider noted that she saw in the system the patient had a dispense history of Adderal, lorazepam, Vyvanse and Strattera. The provider noted the patient’s mother was bipolar, with anxiety and ADHD. Her brother had a substance abuse disorder. The patient stated she was currently unemployed and lived with her parents. The provider noted an impression of mood disorder, ADHD, and to rule out substance induced psychosis. The provider changed her medications from Depakote to 250 mg intravenous (IV) three times a day to 500 mg twice a day, and to switch to oral form upon discharge. She also ordered for the patient to start Zyprexa 5 mg and continue every eight hours for agitation, a 1:1 sitter, four point violent restraints, and strict elopement precautions. The medical record documented Patient #1 was discharged on 01/15/26 at 5:11 PM in stable improved condition to jail. Review of the Mount Carmel Security Incident Report dated 01/14/26 at 11:56 PM revealed the security officer, Staff K, noted on 01/14/26 at approximately 11:51 PM security received a call from the 7th floor charge nurse, Staff F, stating Patient #1 had gotten out of the restraints and was walking towards the stairwell. Staff K dispatched security officers Staff D and Staff L. Staff K went to the stairwell and waited in case the patient ran down the stairwell. Staff K then heard on the radio the patient was running around the 7th floor looking for an exit. Staff K went up the stairwell and when he arrived on the 7th floor he opened the door and noticed another officer, Staff L, getting off of the elevator and heard a loud “pop.” He then saw Staff L throw his coat and start sprinting forward. Staff K started to turn the corner and notices Staff D and Staff L were on the ground engaged in a physical altercation with Patient #1. While engaged in the physical altercation Staff D stated something regarding a firearm being shot. Despite numerous commands the patient continued to engage in the physical altercation. Officers were able to gain control of Patient #1 and nursing staff were directed to bring the bed and hard restraints to where the altercation had occurred. Once the bed and restraints arrived the officers placed the patient in the bed and the four point hard restraints were applied to the patients limbs. Shortly after placing Patient #1 in the bed Grove City Police Officers arrived and began to assist. The patient was taken back to Room 7011 under law enforcement observation. Staff K noted as things began to settle it was found that a single entry gun shot was found to the left facing wall next to elevator 5/6, directly right of the 7th floor data room. The Grove City Police Department began investigating the scene and requested witness statements from all parties directly involved. Interview on 01/21/26 at 12:00 PM with Staff F revealed she was the 7th floor Medical/Surgical charge nurse the night Patient #1 discharged the security officer’s weapon. She stated the patient arrived on the unit in four point violent restraints. At around 11:00 PM the Resident Physicians came to assess the patient and determined the patient was cooperative so they were going to remove the violent restraints and replace them with soft wrist restraints. The patient’s nurse voiced concern because the patient had not been evaluated by psychiatry yet and was just waking up from the previous incident in the emergency department. Staff F stated within 15 minutes of removal of the violent restraints the patient had pulled free from the soft wrist restraints and ran out of the room towards the stairs. The nurse and the nurse manager followed the patient and were talking to her to get her to calm down. Staff F stated she called security. She stated the patient ran towards the elevator and she went after the patient pleading with the patient to go back to the room. When one of the elevator doors opened the patient listened to her and did not get on the elevator. She stated they were coming down the hallway with the patient when the officer arrived. We all were walking back towards the main nursing station and the patient seemed to be cooperating and then the patient charged the officer. The officer tackled the patient to the floor and the firearm discharged. She stated at this time other officers arrived to help detain the patient. The nursing supervisor brought a hospital bed to the patient and the officers placed the patient in the bed and the four point violent restraints were applied to the patient’s limbs. Grove City Police arrived and completed an investigation. A code silver was called after the incident because when she first called security there was no firearm involved. Grove City Police had two officers guard the patient and the hospital had a sitter for the remainder of her stay. Interview on 01/21/26 at 10:32 AM with Staff E revealed she was the nurse who cared for Patient #1 in the ED when she first attempted to elope. She stated the patient arrived via EMS and the police after wrecking their car and being found laying in a farmer’s field, banging her head on the ground, and making weird noises. She stated the patient had bruises and was covered with dirt and mulch. She stated the patient was sweet and thankful at first. She stated she went to see another patient and left Patient #1 with a sitter and when she came back staff told her the patient was ready to leave. She went in the room to talk to the patient and the patient ripped off her equipment and ran out of the room. Staff E stated the patient ran back into the ED and out of the squad bay doors. When the patient was brought back in by security she asked the patient why they did that and the patient replied, “I don’t want to be here. I just want to pay and leave.” Staff E stated she then realized there was something “off” with the patient mentally. She stated after the patient was brought back into the ED she asked the patient to get into the bed as the doctor had pink slipped the patient when she ran out. The patient would not get into the bed so they gave emergency medications (Haldol, Benadryl and Ativan) and the patient was placed in four point hard restraints. She stated the patient remained in the restraints for the remainder of her stay in the ED. Interview on 02/04/26 at 1:27 PM with Licensed Social Worker, Staff Q, revealed she received a consult in the queue for Patient #1 on 01/14/26. She stated she was going to provide resources for housing, outpatient mental health and substance abuse since the patient reported homelessness and providers were suspicious of illegal drug usage. She stated she went to the ED to complete the consult with the patient and prior to arriving to the patient’s room she witnessed the patient run out of her room and continue to run through the ED. Staff Q stated she informed the bedside nurse. Staff Q stated at this time she was told by a provider to call psychiatry to give the verbal order for a STAT psychiatry consult. She stated she does not remember what provider asked her to call the psychiatric call center to relay the STAT verbal order. She also saw the STAT order in the electronic medical record. She stated she called and spoke with a male at the psychiatric call center and provided the order for a STAT consult. Staff Q stated based of of her observation of the patient it was appropriate for the provider to order a STAT psychiatric consultation. Staff Q stated the providers can call the psychiatric provider themselves, but since she was already involved in the case it was her responsibility to make the verbal referral. She stated usually psychiatric patients stay in the ED until they transfer out, unless they have a medical need, then they may be admitted to the medical floor. She stated she usually does not know if the consults are completed on time. She stated when she returned to work the next day she was informed a Code Silver for firearm discharge was called the previous night for Patient #1. Interview on 02/04/26 at 4:04 PM with Psychiatrist, Staff N, revealed the practitioner (Staff O) who completed Patient #1’s psychiatric consult on 01/15/26 was currently unavailable. He stated he was peripherally aware of the patient because he was assigned with Staff O to this hospital on 01/15/26. Staff O had contacted him to discuss the case. He stated they have a small department and they provide services for four hospitals in the area and they are assigned one of the four each day. He stated they have a third party answering service that has their schedules and know what hospitals each staff member is assigned to. He stated each morning at approximately 8:05 AM they receive a text saying these are the consults for your assigned hospital for the day. If consults come in throughout the day the answering service will send them via text message at 2:00 PM. If a consult comes later in the day the answering service will send the consult in the morning at approximately 8:05 AM. He stated they have 24 hours to fulfill a regular consult order. He stated if the consult is STAT the referring provider puts in the order and they have a drop down where they can click routine or STAT. He stated the answering service asks whether the consult is routine or STAT. He stated it was their standard of care to see the patient within 24 hours whether it’s marked routine or STAT. He added the standard of care for the hospital is if the physician wants a truly STAT consult they call him personally to present the emergent crisis situation. He stated he speaks with the provider and asks questions about medications, laboratory results, and heart rhythm. He will give a treatment plan and orders over the phone. He stated for a patient who arrives to the ED exhibiting unsafe behaviors or becoming a danger to self or others, they are immediately pink slipped by the ED providers. He stated ED providers can pink slip patient’s which legally holds the patient for 72 hours. A patient then can wait to be seen psychiatry. He stated the ED physicians never call to pink slip a patient or to give emergent medication. He stated the ED doctors are trained on administering emergency medications for agitation and they rarely call psychiatry for this. They may call if what they are using is not working or they want additional advice. Usually when they call psychiatry the psychiatrist just orders more of the already scheduled medications. When they do get a STAT order for a consult they may be at another hospital for the day, which is 45 minutes from this hospital. They may not be able to show up STAT, but they have STAT protocol. He stated the protocol is if the consult is needed emergent or urgent the ED providers call him and they speak right away. He stated he hopes when he sees the patient they have awoken from the emergency medications they were given for a situation., then they can be assessed. He stated the ED provider is trained to handle STAT psychiatric situations and expecting a provider to materialize STAT when they are not in the building is unsafe. So the physician calls ensure they are available immediately for the ED providers via phone. Review of the hospitals Rules and Regulations revealed a STAT consultation shall be seen within one hour. Interview on 01/21/26 at 10:40 AM Staff A verified Patient #1’s medical record revealed the ED provider ordered a STAT psychiatric consultation for the patient on 01/14/26 at 1:45 PM and it was not completed until 01/15/26 at 9:04 AM. Staff A verified a STAT consult shall be completed within one hour.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 28999 Based on record review, interview and policy review, the facility failed to ensure the physician was notified when a patient’s heart rate remained above normal. This affected Patient #1. Findings include: Review of the medical record of Patient #1, a Gravida 2 Para 0 at 39 weeks gestation, revealed the patient was admitted to Labor and Delivery on 11/21/24 at 12:07 AM for a scheduled induction of labor due to a diagnosis of preeclampsia without severe features. Two doses of Cytotec were administered to induce the patient’s labor. By 7:49 PM, the labor flow sheet revealed the patient’s heart rate was elevated at 122 beats per minute. The patient’s heart rate remained elevated and at 8:25 PM, it was 132 beats per minute. At 8:45 PM, the labor flow sheet revealed a Category II fetal heart tracing as late decelerations in the fetal heart rate were occurring. The patient’s heart rate remained elevated at 123 beats per minute at this time. On 11/21/24 at 9:45 PM, the fetal heart baseline was elevated at 160 beats per minute. At 10:22 PM, the patient was four centimeters dilated and at 10:31 PM, the patient’s heart rate remained elevated at 134 beats per minute. The elevated heart rate continued throughout the night and into the morning of 11/22/24. On 11/22/24 at 2:46 AM, the patient’s heart rate remained elevated at 139 beats per minute. At 4:31 AM, the patient’s heart rage was climbing at 149 beats per minute. At 5:16 AM, the patient’s heart rate was very elevated at 158 beats per minute. There was no documentation the obstetric physician was notified of the increase in the patient’s heart rate at any time from 11/21/24 at 7:49 PM until 11/22/24 at 5:16 AM. On 11/22/24, the decision was made to perform an unscheduled cesarean section due to non-reassuring fetal heart tones. The Delivery Summary revealed the infant was delivered on 11/22/24 at 5:41 AM. The Operative Note revealed that the patient was diagnosed with intrapartum hemorrhage as the estimated blood loss was 1265 mL. Although a massive transfusion protocol was not activated, the patient was medicated with Hemabate, TXA, and rectal Cytotec. During an interview on 03/04/25 at 2:40 PM, the Labor and Delivery Nurse Manager, Staff B, confirmed that Patient #1 maintained a heart rate greater than 120 beats per minute for an entire shift on 11/21/24 and the medical record lacked documentation an obstetric provider was notified. The facility policy titled “Laboring Patient Care”, effective April 2019, stated registered nurses are instructed to notify an OB provider in the event a patient has a pulse greater than 120 beats per minute upon repeat evaluation.”

“INTEGRATION OF EMERGENCY SERVICES CFR(s): 482.55(a)(2) [If emergency services are provided at the hospital --] (2) The services must be integrated with other departments of the hospital. This Standard is not met as evidenced by: 28999 Based on record review, interview and policy review, the facility failed to provide balanced blood component therapy, in accordance with acceptable standards of practice and the hospital’s policies in place at the time. This affected two (Patients #2 and #7) level II obstetric patients. The hospital averages approximately 1000 deliveries annually. Findings include: 1. Record review revealed Patient #2, Gravida 2 Para 1 at 37.4 weeks gestation, was admitted on 12/09/24 at 2:04 PM after serial blood pressures were elevated and a maternal fetal medicine physician recommended the patient’s labor be induced. After the induction of labor was initiated, the patient experienced non-reassuring fetal heart tones and an emergency cesarean section was performed. The Delivery Summary revealed the infant was delivered at 9:37 AM on 12/10/24. The estimated blood loss was 1055 mL. The patient recovered and was transported to the Mother Infant unit at 12:50 PM. On 12/10/24 at 6:15 PM, through a Spanish interpreter, the patient complained of severe upper abdominal pain, feeling sick, sweaty, and dizzy. At 6:19 PM, the patient was passing clots vaginally. Obstetric resident physicians were at the bedside of the patient at 6:21 PM. At 6:24 PM, the patient was hypotensive with a blood pressure of 75/48 millimeters of mercury (mmHg). The attending obstetric physician was at the bedside of the patient at 6:29 PM and a massive transfusion protocol (MTP) was activated at 6:40 PM. Review of the MTP blood bank notes revealed the first cooler, released at 6:45 PM, contained four units of packed red blood cells and two units of fresh frozen plasma. At 6:50 PM, the patient was transported to the Operating Room. Platelets were not stored in the blood bank, therefore, a STAT order for platelets was placed by a blood bank staff member at 6:55 PM. The patient underwent an exploratory laparotomy and was actively bleeding. An emergent hysterectomy was performed. The second cooler, released at 7:20 PM, contained four units of packed red blood cells only as the fresh frozen plasma continued to thaw. Two units of fresh frozen plasma was released 10 minutes later, at 7:30 PM. The third cooler contained four units of packed red blood cells only and was released at 7:41 PM. A blood bank note stated that staff rotated two to four units of packed red blood cells and thawed plasma every 10-15 minutes. During the procedure, the patient went into pulseless ventricular tachycardia arrest and a code blue was initiated. She underwent multiple rounds of cardiopulmonary resuscitation (CPR). During this time, general surgery was consulted for assistance, a left thoracotomy (a surgical procedure that involves making an incision in the left chest wall to access the organs and structures within the thoracic cavity) was performed. In all, 16 rounds of epinephrine were administered, 26 units of packed red blood cells and 10 units of fresh frozen plasma were transfused. The ordered unit of pooled platelets did not arrive to hospital until 8:20 PM. The platelets were transfused at 8:23 PM. Despite these aggressive resuscitative measures, the patient died at 8:40 PM. 2. Record review revealed Patient #7, Gravida 1 Para 0 at 41.3 weeks gestation, presented to Obstetric Triage on 10/29/23 at 5:36 PM with complaints of contractions. With the use of a Spanish interpreter, the patient stated contractions had become more painful. The decision was made to perform a cesarean section due to non-reassuring fetal heart tones and patient request. The Delivery Summary revealed the infant was delivered at 1:21 AM. Brisk bleeding from the incision was noted. Brisk atony (lack of normal tone or tension in muscles) was also noted. The estimated blood loss was 4250 milliliters (ml). MTP was activated at 1:43 AM. There were no platelets available in the blood bank. A blood bank note revealed the first cooler containing four units of packed red blood cells was released at 1:50 AM. Two units of fresh frozen plasma was released at 1:58 AM. The second cooler containing four units of packed red blood cells was released at 2:16 AM. A unit of pooled platelets was not ordered by a blood bank staff member until 2:26 AM. At 2:42 AM, the blood bank released four units of packed red blood cells and two units of fresh frozen plasma. Review of a progress note at 2:43 AM by the Certified Registered Nurse Anesthetist (CRNA) he and his attending anesthesiologist noticed a sudden drop in the ETCO2 (end-tidal carbon dioxide) and the attending anesthesiologist was unable to palpate a pulse. A code blue was called and chest compressions were initiated. As compressions were initiated, frank red blood was coming from the endotracheal tube. Despite continued aggressive resuscitative measures, compressions were stopped, the code was terminated and the patient was pronounced dead at 3:52 AM. According to the Operative Report, 12 units of packed red blood cells, and three units of fresh frozen plasma were transfused, however, no platelets were infused as the platelets did not arrive until 4:07 AM, 15 minutes after the patient was pronounced dead. Review of a letter titled “Mount Carmel Health System Blood Bank System Update”, undated stated due to the system’s increase in wastage of platelet products, fiscal year total in 2019 $63,914 and fiscal year total in 2020 $153,452, facility Blood Bank needed to reduce the amount of stock platelets kept on site 24/7. With this update, it was recognized that the request for platelets during surgeries will be accepted. It will be up to each site to monitor these requests and make sure that one platelet is kept in-house until after the patient’s surgery. As of 11/03/20, Mount Carmel Grove city would not longer keep stock platelets. During an interview on 03/17/25 at 4:45 PM, Blood Bank technician, Staff E, stated there is typically one technician working in the Blood Bank 24/7. She stated in the event of an activation of MTP, if there is a technician in the lab that is trained in the blood bank, he/she may step in to assist. She stated that the blood bank keeps two units of thawed plasma as it takes 30-35 minutes to thaw fresh frozen plasma. Staff E confirmed there were currently no platelets in the blood bank. She further stated when an MTP is activated, the technician working in the Blood Bank electronically orders a unit of platelets STAT from the American Red Cross. Staff E stated it typically takes one hour to receive the platelets but can take longer depending on traffic. During an interview on 03/19/25 at 11:00 AM, the System Lab Director, Staff D stated platelets aren’t kept in the blood bank and have to be ordered at the American Red Cross. Staff D stated that platelets used to be available in the blood bank but the decision was made to discontinue this practice due to the cost. During an interview on 03/18/25 at 1:49 PM and on 03/20/25 at 8:19 AM, the anesthesiologist, Staff G stated that Patient #2 was a complicated case. He stated that during an activation of MTP, blood products should be administered in a one to one to one ratio of packed red blood cells, fresh frozen plasma, and platelets to ensure balanced resuscitation and prevent dilutional coagulopathy (occurs when blood volume is rapidly replaced with fluids that lack clotting factors). This ratio mimics the composition of whole blood. Platelets are essential for blood clotting and are often depleted in patients that are hemorrhaging. Staff G stated a the one to one to one ratio is ideal. He stated that there were some limitations of platelets during the MTP of Patient #2. Staff G stated that he could think of numerous clinical scenarios where the presence of platelets was the difference between life and death. He stated that if he had to vote, he would vote to keep platelets stored in the blood bank 24/7. During an interview on 03/18/25 at 1:11 PM, Rapid Response Registered Nurse, Staff H, stated that she ran the Belmont rapid infuser during the activation of MTP and subsequent code of Patient #2. She stated that Patient #2 was losing blood really fast. A ratio of one to one to one is ideal to get as close to whole blood as possible. Platelets are essential for blood clotting. She stated that without administration of platelets as a clotting factor, the patient’s blood was pouring out as fast as they could transfuse it. Staff H stated that they’re at the mercy of the American Red Cross when platelets aren’t stored in the blood bank 24/7. During an interview on 03/20/25 at 4:45 PM, the Regional Director of Regulatory and Accreditation Services, Staff A stated the standard of care calls for a one to one to one ratio of packed red blood cells, fresh frozen plasma, and platelets, mimicking whole blood during activation of MTP. And currently, there are no platelets stored in the blood bank. It was confirmed that the STAT order for platelets for Patient #7 wasn’t placed until 43 minutes after activation of MTP when the facility policy requires for platelets to be ordered upon activation of MTP. It was further confirmed that the facility discontinued keeping stock platelets due to the cost. In a scholarly article titled “The Society for Academic Specialists in General Obstetrics and Gynecology” dated 11/05/24, stated obstetric patients that experience severe hemorrhage may necessitate massive transfusion, defined as transfusion of 4 or more units of packed red blood cells within one hour with ongoing bleeding, transfusion of 10 or more units of packed red blood cells within 24 hours, or replacement of the patient’s entire blood volume. Once these criteria are met, fixed ratios of blood products are transfused in a 1:1:1 ratio of packed red blood cells, fresh frozen plasma, and platelets, mimicking whole blood. Blood banks store and release platelets in pooled units equivalent to 6 individual units. The facility policy titled “Massive Transfusion Protocol Management”, issued April 2019, stated the massive transfusion system standard facilitates the rapid availability and delivery of blood and blood products when a massive hemorrhage situation occurs. The goal of massive blood transfusion is to restore blood volume and components rapidly during a massive hemorrhage to maintain hemodynamic stability, homeostasis, oxygen-carrying capacity, oncotic pressure, and chemical balance. The MTP is designed to ensure continuous and timely access to blood components for use in resuscitating patients with massive traumatic hemorrhage. Patients who experience massive hemorrhage will develop severe hematological derangements if prompt blood product replacement is not delivered. Facility staff is instructed that the first container/cooler should contain four units of packed red blood cells, two units of fresh frozen plasma, and no platelets. The second container/cooler should contain four units of packed red blood cells, 2 units of fresh frozen plasma, and one unit of pooled platelets. Subsequent containers/coolers will be provided as products become available. The policy further states platelet products will be ordered STAT from the American Red Cross upon activation of the MTP.”