Promedica Toledo Hospital

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 29000 Based on medical record review, staff interview, and policy review, the facility failed to follow complete pain assessments in the emergency department (ED) during triage, at admission, prior to medication administration, and following medication administration. Additionally, the facility failed to ensure intakes were monitored as ordered and failed to provide assistance with feeding and bathing for patient’s admitted. See A385”

“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: 29000 Based on record review, staff interview, and policy review, the facility failed to complete pain assessments in the emergency department (ED) during triage, at admission, prior to medication administration, and following medication administration for four (Patients #2, #19, #22 and #23) patients and failed to ensure oral intakes were monitored as ordered and assistance with feeding and bathing was provided for one (Patient #3) patient. 20 patient records were reviewed. Findings include: 1. Review of the medical record revealed Patient #2 arrived to the ED on 01/28/25 at 12:58 AM. Nursing notes documented the patient was unable to sit still stating “Pain is worse when sitting.” Triage was completed at 1:13 AM with notes stating this patient was complaining of abdominal pain with intermittent episodes of vaginal bleeding. No documentation was found of a pain level during triage. Nursing notes at 1:40 AM indicated security called the registered nurse (RN) due to this patient lying on the floor in the waiting room crying and stating she had left lower abdominal and rectal pain. The patient’s pain score was 10 out of 10 on a one to ten scale. Nursing notes at 2:33 AM documented the patient left without being seen by the physician. Patient #2 returned to the ED on 01/28/25 at 11:18 AM with complaints of vomiting. The notes referred to Patient #2 being in the ED earlier but left after triage and was not seen by a physician. This patient was complaining of diffuse abdominal pain and was actively vomiting. Physician notes at 1:01 PM by Staff I stated the patient presented with abdominal pain and vomiting with the pain becoming severe around 1:00 AM. Patient #2 stated she was nervous something was causing her symptoms and stated her pain was currently a ten out of ten on a one to ten scale. Physician orders were received and Patient #2 was given Morphine Sulfate four milligram (mg) intravenously (IV) at 1:19 PM due to complaints of abdominal pain. Patient #2 continued to complain of severe pain, rating it a nine on a one to ten scale and at 2:16 PM and was given Morphine two mg at 2:20 PM . A reassessment of pain was completed at 3:16 PM with Patient #2 stating the pain remained, rating a 10 out of 10 on a one to ten scale. A serum pregnancy test was ordered. The result was positive for pregnancy at 3:28 PM. At 4:00 PM, Patient #2 reported constant pain, rating it a ten on an one to ten scale. The pain was documented in the lower right and left side of the abdomen. Patient #2 received Tylenol 1000 mg via an IV infusion at 5:52 PM. Patient #2 continued to rate the pain a ten on a one to ten scale. A pain assessment was completed at 6:13 PM when the Tylenol was infused with abdominal pain rated as nine on a one to ten scale and stated the pain was unchanged. The record contained no further pain assessments. Review of the notes at 8:05 PM revealed the patient was requesting to leave after the urine results come back and the physician was informed. Nursing notes at 8:38 PM documented the patient left without receiving discharge instructions from the nurse. Review of the facility policy titled “#C113 Pain Assessment, Management and Re-assessment” stated the purpose was to provide defined criteria and standardized tools to screen for, assess, and reassess pain. This policy then refers to Lippincott which instructs staff to document a pain assessment before and after pain medication is given. This policy defines severe pain as a number from seven through ten. Pain is assessed upon presentation to the emergency department, at the time of admission and prior to administration of medications. This policy further instructs staff to continue pain monitoring and documentation at the intervals outlined in Corporate Clinical Policy “Documentation by Nursing, Acute Care,” which states pain should be monitored within one hour after pain intervention. Interview on 06/03/25 at 4:30 PM, Staff A verified no pain assessment was completed in triage for the first visit on 01/28/25 at 12:58 AM and no pain re-assessment was completed after the IV Tylenol was administered. 2. The medical record revealed on 03/10/25 at 5:38 PM Patient #19, Gravida 3 Para 2, at five weeks gestation came to the ED with complaints of abdominal pain and vaginal bleeding. Triage was completed at 5:52 PM with a pain assessment documented at 8/10. Patient #19 was examined and discharged home at 11:09 PM with instructions to return if increase in bleeding or if pain increases. No further pain assessments were documented after the triage. Interview on 6/10/25 at 5:00 PM, Staff A verified the findings of not completing a pain assessment upon admission to the ED. 3. The medical record revealed Patient #22 was admitted to the ED on 02/04/25 at 10:16 AM with complaints of right testicular pain and history of having groin surgery one week ago. Notes at 10:26 AM stated the patient was having right sided groin pain. No pain assessment of severity was completed. Physician orders were received for the nonsteroidal anti-inflammatory Toradol 5 mg. The Toradol was given via IV at 1:31 PM. No pain assessment was completed prior to the administration of the Toradol. The patient was discharged at 1:33 PM. Interview on 06/24/25 at 11:05 AM, Staff A verified the pain assessment at admission did not identify a severity rating and no assessment was completed prior to the administration of the Toradol. 4a. The medical record revealed Patient #23 came to the ED on 02/24/25 at 10:38 AM with complaints of sharp right groin pain since Friday night. Notes documented the patient had a history of lung cancer, which was in remission. Triage notes listed no pain. A provider assessed the patient at 11:58 AM and ordered pain medication. The pain medication Norco was given at 12:26 PM with no assessment of the patient’s pain scoring. The patient’s pain score was not assessed until 1:56 PM with a groin pain identified as 5/10. Interview on 6/25/25 at 11:57 AM, Staff A verified Patient #23 came in with groin pain at 10:38 AM, received pain medication at 12:26 PM, but did not have a pain score documented until 1:56 PM. b. Patient #23 returned to the ED on 03/26/25 at 3:28 PM complaining of pain under both sides of their ribs. On admission physician orders included to give pain medication. The muscle relaxant Zanaflex 4 mg and Tylenol were given at 6:51 PM. Toradol 15 mg was given intramuscularly (IM) at 6:53 PM. The patient was discharged home with a prescription for lidocaine patches at 8:11 PM. There was no documentation a pain assessment was completed during Patient #23’s stay in the ED. Interview on 6/25/25 at 11:57 AM, Staff A verified no documentation Patient #23 had a pain assessment was completed during his ED visit on 03/26/25. 5a. The medical record revealed Patient #3 was admitted to the ED with shortness of breath. A computerized tomography (CT) scan revealed a small pulmonary emboli with orders received to start IV Heparin. On 03/05/25 at 6:50 PM Patient #3 was admitted to the sixth floor. A screening for activities of daily living (ADLs) was completed on 03/06/25 at 3:24 AM indicating the patient was dependent for care, listing maximum assistance was needed for feeding, dressing and grooming. The nursing care plan dated 03/07/25 identified Potential for compromised adequate intake. Interventions included full assist with meals, food selections and eating. Review of meal tickets showed Patient #3 received meals on 03/05/25 at 6:29 PM, 03/06/25 at 8:00 AM, 12:38 PM and 6:26 PM, and on 03/07/25 at 9:37 AM. Review of the flowsheet on 03/06/25 at 8:00 AM listed under feedings the patient took in 0%. There was no intake documented on the other days meals were provided. There was no documentation Patient #3 was fed these meals. The nursing care plan identified the patient was a full assist with bathing. There was no documentation of a bath offered or declined. Interview on 06/04/25 at 4:55 PM, Staff A verified no documentation was found to indicate Patient #3’s meal intakes or if the meals were fed to him. Staff A stated patients are to be offered a bath daily and this was to be documented on the flow sheets. Staff A verified there was no evidence Patient #3 was offered a bath during his stay. b. Patient #3 had orders for intake and output (I&O) per shift. The nursing care plan dated 03/07/25 lists potential for compromised adequate intake. The record contains no documentation of oral intake to ensure hydration needs were met. Review of the facility policy titled “Documentation by Nursing, Acute Care for Adult Medical/Surgical Units: Monitoring and Documentation Standards lists under I&O” reveals to monitor and document I&O per order every 12 hours. Interview on 06/04/25 at 4:55 PM, Staff A verified the findings of not recording I&O per order and policy.”

“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: 29000 Based on medical record review, policy review and staff interview, the facility failed to follow their policy to consult with an obstetrician based on the pregnant patient’s presenting symptoms. This affected one patient (Patient #2) who presented to the Emergency Department (ED) with severe abdominal pain, vomiting, and recent intermittent vaginal bleeding and one patient (Patient #19) who presented with complaints of abdominal pain and vaginal bleeding. This had the potential to affect all patients presenting to the ED of less than 20 weeks gestation with abdominal pain. Findings: 1.Review of the medical record revealed Patient #2 arrived to the ED on 01/28/254 at 12:58 AM. Nursing notes documented the patient was unable to sit still stating “Pain is worse when sitting.” Triage was completed at 1:13 AM with notes stating this patient was complaining of abdominal pain with intermittent episodes of vaginal bleeding. The patient reported she could be pregnant. No documentation was found of a pain level during triage. Nursing notes at 1:40 AM documented security called the registered nurse (RN) due to this patient lying on the floor in the waiting room crying and stating she had left lower abdominal and rectal pain. The patient’s pain score was 10/10. Nursing notes at 2:33 AM documented the patient left without being seen by the physician. Patient #2 returned to the ED on 01/28/25 at 11:18 AM with complaints of vomiting which started that day. These notes referred to Patient #2 being in the ED earlier however she left after triage and was not seen by a physician. The patient was complaining of diffuse abdominal pain and was actively vomiting. Physician notes on 01/28/25 at 1:01 PM by Physician Staff I revealed the patient presented with abdominal pain and vomiting. The pain became severe around 1:00 AM with associated vomiting. Patient stated she was nervous something was causing her symptoms and stated her pain was currently a 10/10. The patient denied fever, chills, urinary symptoms, or diarrhea. The patient’s last menstrual period was unknown but stated her periods are abnormal. Orders were received and the patient was given the opiod pain medication Morphine Sulfate (MS) 4 milligram (mg) intravenously (IV) at 1:19 PM due to complaints of abdominal pain of 10 out of 10. Patient #2 continued to complain of severe pain at a 9/10 at 2:16 PM and was given another dose of MS 2 mg at 2:20 PM . A re-assessment of pain was completed at 3:16 PM with the patient stating pain remained 10/10. A serum pregnancy test was ordered with results at 3:28 PM showing the patient was pregnant. A transvaginal ultrasound was ordered due to the patient being less than 14 weeks gestation. An assessment at 4:00 PM documented constant pain of 10/10 in the lower right and left side of the abdomen. The patient went for the ultrasound at 4:30 PM. The ultrasound report listed findings of a single live intrauterine pregnancy estimated gestational age eight weeks four days based on crown-rump length measurement. Fetal heart rate was 176 beats per minute and the gestational sac was grossly within normal limits. A large fluid collection likely adjacent to the gestational sac, measuring 4.9 centimeters (cm) by 6.8 cm by 2.2 cm, was noted. The ovaries were obscured by bowel gas artifact. Notes from the Radiology Technician Staff R documented limited transvaginal imagine due to patient cooperation, patient refusal to complete full exam, and limited field of view due to pain tolerance. Image quality is limited due to patient movement and pain tolerance. There was no documentation an attempt to alleviate the patient’s pain was provided. Discharge notes by the ED physician documented the patient had been advised to follow up with their specialist within one week and to return to the ED if their symptoms change, worsen, new symptoms arise or if they have additional concerns. No documentation was found a pelvic exam was completed. There was no documentation an obstetrician was consulted to assess the patient due to her symptoms. Notes at 8:05 PM revealed the patient was requesting to leave after the urine results come back and the physician was informed. Orders were placed for discharge by Physician Staff J at 8:14 PM. Nursing notes at 8:38 PM documented the patient left without receiving discharge instructions from the nurse. Review of the policy titled “Obstetrical Patients Who Present to the Emergency Department: Communication and Treatment,” dated 10/04/24, revealed women will receive obstetrical care based on the assessment of the needs and varying levels of gestational development. Staff will utilize the decision tree “OB Patient Presenting to the ED.” The decision tree revealed if the patient was greater than 20 weeks and having obstetrical issues the patient will be evaluated in the labor and delivery area. If the patient was less than 20 weeks with obstetrical complaints such as abdominal pain, cramping, and vaginal bleeding, the patient will be evaluated in the ED and the ED is to notify the obstetric provider. Interview with a Registered Nurse (RN) Staff Y on 06/02/25 at 4:00 PM revealed if a pregnant patient came to the ED greater than 20 weeks gestation and the reason was obstetrically related the patient would be transferred to the obstetric floor. If the patient was less than 20 weeks they will be assessed in the ED with the physician consulting with an obstetrician if needed. Physicians generally order a vaginal ultrasound after pregnancy is confirmed by a blood test to rule out ectopic pregnancy. Interview with the Director of the ED, Staff K, on 06/03/25 at 1:25 PM revealed when patients come in with abdominal pain or complaints of cramping the physicians will order a urine test for pregnancy. If the pregnancy test is positive they order an ultrasound. We now have order sets built in to rule out ovarian torsion, ectopic pregnancy and testicular torsion. Staff K stated if the patient is less than 20 weeks gestation they do not always consult with the obstetrician. If the patient has an obstetrician who works at the hospital the ED physicians may consult with them, otherwise they have the patient follow up with their obstetrician. While reviewing the OB Patient Presenting to the ED decision tree Staff K stated the ED physicians do not call the obstetrician routinely if the patient was less than 20 weeks unless the patient had an issue or the patient requested the staff to call. Interview with the Radiology Technician Staff R on 06/09/25 at 4:40 PM revealed Patient #2 was crying and moving a lot during the ultrasound. It was difficult to get good pictures. The patient initially refused transvaginal ultrasound and Radiology Technician Staff R explained the benefits with the patient agreeing to try it. Radiology Technician Staff R got a few images and took a few videos since she wasn’t getting good pictures due to the patient moving around in pain and asking Radiology Technician Staff R to stop. Radiology Technician Staff R called the reading room and was transferred to the radiologist. She explained she wasn’t getting good pictures to see the ovaries and if this was an ectopic pregnancy. The radiologist stated to attempt to get more pictures, but the patient refused and the exam ended. 2. The medical record revealed on 03/10/25 at 5:38 PM Patient #19, Gravida 3 Para 2, at five weeks gestation came to the ED with complaints of abdominal pain and vaginal bleeding. Triage was completed at 5:52 PM with a pain assessment documented pain at 8/10. Patient #19 was examined and discharged home at 11:09 PM with instructions to return if increase in bleeding or if pain increases. The record contained no evidence an obstetrician was consulted due to the patient’s symptoms.”

“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: 29000 Based on medical record review, staff interview, and policy review, the facility failed to provide effective pain management for ongoing pain levels described as in the severe pain category for a patient in the emergency department (ED). This affected one patient (Patient #2) out of 20 ED patients reviewed. Findings include: Review of the medical record revealed Patient #2 arrived to the ED on 01/28/254 at 12:58 AM. Nursing notes documented the patient was unable to sit still stating “Pain is worse when sitting.” Triage was completed at 1:13 AM with notes stating this patient was complaining of abdominal pain with intermittent episodes of vaginal bleeding. The patient reported she could be pregnant. No documentation was found of a pain level during triage. Nursing notes at 1:40 AM documented security called the registered nurse (RN) due to this patient lying on the floor in the waiting room crying and stating she had left lower abdominal and rectal pain. The patient’s pain score was 10/10. Nursing notes at 2:33 AM documented the patient left without being seen by the physician. Patient #2 returned to the ED on 01/28/25 at 11:18 AM with complaints of vomiting which started that day. These notes referred to Patient #2 being in the ED earlier however she left after triage and was not seen by a physician. The patient was complaining of diffuse abdominal pain and was actively vomiting. Physician notes on 01/28/25 at 1:01 PM by Physician Staff I revealed the patient presented with abdominal pain and vomiting. The pain became severe around 1:00 AM with associated vomiting. Patient stated she was nervous something was causing her symptoms and stated her pain was currently a 10/10 on the pain scale with 10 being the worst pain experienced. The patient denied fever, chills, urinary symptoms, or diarrhea. The patient’s last menstrual period was unknown but stated her periods are abnormal. Orders were received and the patient was given the opiod pain medication Morphine Sulfate (MS) 4 milligram (mg) intravenously (IV) at 1:19 PM due to complaints of abdominal pain of 10 out of 10. Patient #2 continued to complain of severe pain at a 9/10 at 2:16 PM and was given another dose of MS 2 mg at 2:20 PM . A re-assessment of pain was completed at 3:16 PM with the patient stating pain remained 10/10. No pain medication was administered. A serum pregnancy test was ordered with results at 3:28 PM showing the patient was pregnant. A transvaginal ultrasound was ordered due to the patient being less than 14 weeks gestation. Vital signs were completed at 4:00 PM with constant pain of 10/10 documented in the lower right and left side of the abdomen. No pain medication was administered at this time. The patient went for the ultrasound at 4:30 PM. The ultrasound report listed findings of a single live intrauterine pregnancy estimated gestational age eight weeks four days based on crown-rump length measurement. Fetal heart rate was 176 beats per minute and the gestational sac was grossly within normal limits. A large fluid collection likely adjacent to the gestational sac, measuring 4.9 centimeters (cm) by 6.8 cm by 2.2 cm, was noted. The ovaries were obscured by bowel gas artifact. Notes from the Ultrasound Technician Staff R documented limited transvaginal imagine due to patient cooperation, patient refusal to complete full exam, and limited field of view due to pain tolerance. Image quality was limited due to patient movement and pain tolerance. There was no documentation an attempt to alleviate the patient’s pain was provided Patient #2 returned to the ED from the ultrasound at 5:30 PM. The patient received Tylenol 1000 mg via an IV infusion at 5:52 PM with pain score of 10/10 continuing. A pain assessment was completed at 6:13 PM when the Tylenol was infused with abdominal pain rated as 9/10 and notes stating pain unchanged. The record contained no further pain assessments and no further pain medication was administered. Discharge notes by the ED physician documented the patient had been advised to follow up with their specialist within one week and to return to the ED if their symptoms change, worsen, new symptoms arise or if they have additional concerns. Orders were placed for discharge by Physician Staff J at 8:14 PM. Nursing notes at 8:38 PM documented the patient left without receiving discharge instructions from the nurse. Interview on 06/03/35 at 9:53 AM with Physician Staff J revealed he was Patient #2’s discharging physician. The patient came in with complaints of nausea/vomiting and severe abdominal pain. The patient was difficult to examine as she would push our hands away when we tried to examine her abdomen. Physician Staff J thought she was doing better and didn’t know she continued to have pain at a 9/10. Physician Staff J stated the resident physician had stated the patient was feeling better. The patient requested her IV be removed and left the hospital. She didn’t take her discharge paperwork. Physician Staff J stated he didn’t get a chance to see her again before she left. Interview with the Radiology Technician Staff R on 06/09/25 at 4:40 PM revealed Patient #2 was crying and moving a lot during the ultrasound. It was difficult to get good pictures. The patient initially refused transvaginal ultrasound and Radiology Technician Staff R explained the benefits with the patient agreeing to try it. Radiology Technician Staff R got a few images and took a few videos since she wasn’t getting good pictures due to the patient moving around in pain and asking Radiology Technician Staff R to stop. Radiology Technician Staff R called the reading room and was transferred to the radiologist. She explained she wasn’t getting good pictures to see the ovaries and if this was an ectopic pregnancy. The radiologist stated to attempt to get more pictures, but the patient refused and the exam ended. Interview with Resident Physician Staff U on 06/10/25 4:00 PM revealed initially they gave Patient #2 MS which helped her pain earlier. Last time Resident Physician Staff U checked on Patient #2 she was getting the IV Tylenol and she verbalized she was a little more comfortable. This is what was reported to Physician Staff J. When Patient #2 was discharged Resident Physician Staff U was off shift. Interview on 06/26/25 at 3:15 PM with RN Staff S revealed she took care of Patient #2 prior to her leaving. RN Staff S stated she assessed the patient and she was not writhing in the bed in pain. She complained of nausea and vomited on the floor at 7:00 PM. The staff were waiting on a urine sample and Patient #2 wasn’t able to urinate. RN Staff S gave the patient options since the urine was needed to rule out a urinary tract infection. The patient asked to be catheterized. After being catheterized the patient called out saying she wanted to leave. She was informed of the need to stay until her urine results were back. RN Staff S let the physician know the patient was waiting for the urine results to leave. Once the discharge was ordered RN Staff S went to the patient’s room and the patient had gone. The patient was given pain medication prior to RN Staff S’s first seeing the patient. The patient kept saying she was uncomfortable but her vital signs did not indicate she was in pain. By the time RN Staff S went into reassess Patient #2 she was gone. Review of the facility policy titled “Pain Assessment, Management and Re-assessment” stated the purpose was to provide defined criteria and standardized tools to screen for, assess, and reassess pain. This policy defines severe pain as a number from seven through ten. This policy then refers to Lippincott which instructs staff to document a pain assessment before and after pain medication is given. Pain is assessed upon presentation to the emergency department, at the time of admission and prior to administration of medications. Implement interventions, such as medication administration, emotional support, comfort measures, and complementary and alternative therapies as ordered/indicated based upon the resulting patient reported pain score. This policy further instructs staff to continue pain monitoring and documentation at the intervals outlined in Corporate Clinical Policy “Documentation by Nursing, Acute Care,” which states pain should be monitored within one hour after pain intervention.”

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 29000 Based on medical record review, policy review and staff interview, the facility failed to ensure a supply of tube feeding formula and supplies were available to a patient upon discharge. This affected one patient (Patient #2) with the potential to affect all patients needing supplies at discharge. Findings include: The medical record revealed Patient #2 was admitted on 03/28/24. Primary diagnoses included failure to thrive, severe malnutrition with history of not eating or drinking for the past three days, Type II diabetes with altered mental status, and dementia. The patient had an infected percutaneous endoscopic gastrostomy (PEG) tube which was removed. A swallow test was attempted on 03/29/24 under fluoroscopy, which was unsuccessful due to this patient unable to cooperate. A new PEG tube was placed on 04/01/24 with tube feeds initiated on 04/02/24. Review of the enteral nutrition notes revealed on 04/05/24 Patient #2 was to receive Osmolite 1.5 formula, 250 milliliters (ml) bolus feeds four times a day. The patient was also to receive 60 ml water flush before and after each feeding. Review of the Careport notes for Patient #2 on 04/03/24 at 11:01 AM asked the Medical Service Company (MSC) if they could provide Osmolite 1.5 for bolus feedings at home upon discarge. The MSC’s response was they can provide the formula they just need the prescription. Careport notes on 04/04/23 at 12:21 PM stated the hospital anticipated a weekend discharge. Notes from the MSC on 04/05/24 at 11:00 AM stated they are waiting for the prescription and will drop ship to the patient’s home as long as the hospital can provide the patient with a three day supply at discharge. On 04/06/24 at 10:31 AM the MSC asked when the patient will they be discharged and was informed discharge was scheduled for that day. The next note was on 04/08/24 from the MSC stating they still need the physician to sign off on the order to deliver the formula. Review of a progress note dated 04/06/24 at 10:05 AM revealed the social worker informed the nurse the patient was awaiting tube feeding supplies to be delivered to the patient’s home. Review of a discharge planning note by a licensed social worker (LSW), Staff R, on 04/06/24 at 1:31 PM stated after discussion with this patient’s nurse the family will be coming in for tube feed education. The medical record documented the family completed education related to tube feedings and care of the gastrostomy tube site prior to discharge on 04/06/24. Review of the discharge instructions dated 04/06/24 revealed Patient #2 was to have no food or liquid orally due to a high risk of aspiration. The patient was to receive Osmolite 1.5, one carton four times a day. The medical record contained no evidence any tube feeding formula or supplies were sent home with Patient #2 upon discharge on 04/06/24 at 9:30 PM. Interview with the registered dietician (RD), Staff O, on 07/02/24 at 10:00 AM revealed upon discharge the dieticians will work with the Care Navigators, who work with the infusion company to get everything set up. Interview with an available care coordinator, Staff P, on 07/02/24 at 11:38 AM revealed upon discharge the process is they work with the RD, physician, and supply company to have everything ready at discharge. They will then confirm the date and time supplies will be delivered and let the family know. Staff P further stated all these communication notes get written in Careport. Interview with the Manager for the Care Navigators, Staff Q, on 07/02/24 at 12:10 PM revealed Careport is where the navigators document communications with other providers such as home health and equipment companies. Staff Q reviewed Patient #2’s Careport notes and stated she hoped the nurse sent the patient home with a three day supply of tube feeding formula. Staff Q stated nursing staff do not see these communication notes in Careport, only the Care Navigators can see this information. Interview with Staff S, who was one of the discharge nurses, on 07/03/24 at 8:22 at AM revealed they gave discharged instructions to who they believed was Patient #2’s daughter. Staff S stated she wasn’t sure she sent the patient home with a three day supply of tube feeding formula, but she would have sent her home with whatever she had left in the room. Staff S stated she had double checked with the social worker to make sure everything was in place for discharge and te social worker stated it was. Staff S stated she received a call a couple days later from the patient’s daughter who said they were trying to get in touch with the home health agency because they still have not received the tube feedings or supplies. Staff S went to the care navigator who informed her to call MSC. MSC was asking questions Staff S could not answer so she gave the phone to the care navigator. Staff S stated if there were no supplies or formula available for home use at discharge they nurses would call the physician and hold the discharge. But in this case the care navigator told Staff S the discharge was all set. Staff S stated she wasn’t aware of any Careport notes to send the patient home with three days worth of Osmolite. Review of the facility policy titled “Multidisciplinary Discharge Planning,” dated 09/06/23, identifies the policy purpose was to ensure smooth and safe transition for post-hospital care. This policy states discharge planning starts at the time of admission. Staff are to document in the medical record the patient’s needs, goals for care, treatment preferences, and the selected agencies have the capability to provided the care needed. The staff should verify the patient, or guardian, understand the discharge instructions as well as medications and referrals. Interview with Staff B on 07/03/24 at 3:00 PM verified the medical record did not identify if a three day supply of tube feeding formula and supplies was sent home with Patient #2.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 29000 Based on record review, interview and policy review, the facility failed to ensure a patient was provided a Medicare notification to appeal a discharge from the hospital. This affected one (Patient #21) of two patients reviewed for Medicare benefits. Findings include: Patient #21 was admitted to the emergency department (ED) on 9/02/23 at 2:20 PM after being found unresponsive at his rehabilitation center. Physician notes listed this patient had a history of substance abuse presenting from a recovery center due to concerns for possible overdose. Emergency room notes stated this patient’s glasgow coma scale (GCS) ranged between three and 11 (15 is fully awake) and was not responding to questions. This patient was intubated in the ED and transferred to the intensive care unit (ICU) at 5:55 PM. This patient was taken off the ventilator on 09/04/23 at 11:06 AM. A fasciotomy was completed on 9/05/23. A debridement and application of a wound vac was completed on 09/07/23 in the operating room. Discharge planning began on 9/06/23 by the discharge coordinator (Staff Y). Plan at this time was to find an in-patient acute rehabilitation closer to his home out of state per patient and his father’s request. Discharge coordinator notes dated 09/25/23 at 3:12 PM documented during discharge rounds, multiple inpatient rehab facilities are denying to accept Patient #21 due to the substance abuse history. Care navigation following up on several skilled nursing facilities (SNF) referrals that were sent on 09/22/23. Initiated discussion with patient and father in reference to discharging home with home care and outpatient therapy. A note dated 09/26/23 at 2:03 PM documented there were continuing barriers to discharge and discussed with medical staff. The discharging physician (Staff X) progress note dated 09/27/23 at 2:40 PM stated the hospital was still working on disposition for inpatient rehab versus skilled nursing facility placement close to home but patient had refusal from multiple facilities. This Patient’s father was again frustrated this morning that he is not clear about the timeline when he is should expect healing of wounds, wound care following from here. Appropriate support provided to father and he was reassured that every loose end will be addressed prior to discharge. He is also given tentative date for discharge for 09/29/23 to either an inpatient rehab or home with home health. The surgeon’s (Staff W) progress note dated 09/27/23 stated they feel this patient can convert to a different dressing and discontinue the wound vacuum. Discharge planning and care navigation can continue to work towards potentially discharge to home and follow up with the wound care clinic near home. Discharge Planning notes dated 09/29/23 documented Patient #21 was being discharged home with home health care, wound care and physical therapy. Home care to start on 10/01/23 or 10/02/23. Planning discharge later today, patient and his father verbalized understanding. Review of the discharge nursing notes dated 09/29/23 by Staff AA documented the discharge paperwork was reviewed with patient and their family. Patient agrees with plan of care, although the father does not. Supplied patient and father with information on discharge, bandages, and appointment information. Left leg wrapped with an ace wrap per patients request, then walking boot was placed. Patient was able to dress himself independently and walk to the wheelchair with a walker without difficultly. Patient left unit in wheelchair to private car. Discharged home with a seven day supply of Oxycodone 20 milligrams (mg) every four hours. Review of the record revealed Patient #21 was not provided the Important Message from Medicare (IMM) 48 hours prior to discharge. During an interview on 03/21/24 at 4:00 PM, Staff B verified Patient #21 was not provided the IMM to have an opportunity to appeal the discharge. The facility policy titled “Assisting Patients with Discharge Appeal”, dated 03/17/22, documented the purpose was to ensure that Medicare beneficiaries an exercise their rights to have their hospital stay reviewed if they believe they are being discharged too soon. Every Medicare beneficiary who is admitted to inpatient status, is given the Important Message from Medicare (IMM) upon admission and 48 hours prior to discharge. If a patient chooses to exercise their discharge appeal rights with the Quality Improvement Organization (QIO), ProMedica Health System staff assists the patient with this appeal. If a patient wishes to appeal a discharge, the QIO is contacted before the patient leaves the hospital. If the QIO is contacted, the patient is not financially responsible for services they received during the appeal process except for co-pays and deductibles.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 21893 Based on record review and interview, the facility failed to provide an appropriate medical screening examination, stabilizing treatment or an appropriate transfer for one patient who presented to the emergency department’s ambulance bay (Patient #2). A total of 78,581 patients were seen and 205 patients were transferred to other facilities in the last six months. Findings include: Review of the medical record revealed Patient #2, who was unnamed, arrived to the emergency department (ED) on 01/26/24 of 6:39 PM via ambulance and was discharged one minute later at 6:40 PM. The ED physician note dated 01/26/24 at 8:35 PM, a late entry, documented Patient #2 was in full arrest with return of spontaneous curculation that was brought in by ambulance and was diverted from another hospital due to loss of vital signs. The ambulance did not call report prior to arrival. The ED was notified that the patient may be coming by the other hospital’s nursing staff at about 8:00 PM. The ambulance staff stated the patient had return of spontaneous circulation prior to arrival to the ED. The circumstances of his arrest, age or history was limited to this information. The patient was intubated, unresponsive, and being bagged by ambulance personnel. An advanced airway was in place. Return of spontaneous circulation was confirmed by ambulance personnel. The ED was free standing and had exceptionally limited resources, including oxygen for maintenance of a ventilated patient, no cardiac catheterization lab, no cardiologist, and no inpatient facility. Given the circumstances, the need for emergent percutaneous coronary intervention was warranted and recommended if available. Based on visual evaluation in the ambulance bay, the physician thought this patient would be better served by diversion to a cardiac catheterization capable facility. The ED was having prolonged transportation times for an advanced cardiovascular life support rig in this county. With the free-standing ED limitations and the patient was as stable as could be achieved at this facility, his only chance for a positive outcome was to be seen by a hospital based ED for possible cardiac catheterization and admission. The closest cardiac catheterization capable facility would be notified. The ambulance rig was agreeable to take the patient there. The patient was left in the rig and sent to the hospital based ED. Review of the ambulance run sheet for Patient #2 revealed the ambulance was dispatched on 01/26/24 at 5:40 PM for unresponsive patient in the middle of the roadway. While en route, the ambulance crew was advised Patient #2 was now in cardiac arrest by another ambulance medic. Upon arrival cardiopulmonary resuscitation (CPR) was initiated using a Lucas device, a mechanical chest compression device. Intubation was completed. Intravenous (IV) access established. Advanced Cardiac Life Support (ACLS) protocol was started. A normal saline IV was started. Epinephrine was given. Pulse check at 6:02 PM and Patient #2 is now in ventricular tachycardia. One shock given. CPR resumed. At 6:06 PM, pulse check showed asystole. Epinephrine given. Patient #2 moved to ACLS ambulance and secured. Yellow IV placed in left humeral head. Patient #2 was placed on ventilator. Curculation 1 at 6:10 PM. Twelve lead cardiac monitoring obtained and showed atrial fibrillation with anterior wall myocardial infarction. IV saline with pressure infuser started. Transport to hospital. At 6:20 PM, Patient #2 went back into cardiac arrest. At 6:21 PM, Epinephrine given. At 6:24 PM, the rhythm check was pulseless electrical activity. At 6:25 PM, Epinephrine given. At 6:27 PM, curculation obtained. Twelve lead cardiac monitor still showed atrial fibrillation with anterior wall myocardial infarction. At 6:34 PM, Patient #2 was back in cardiac arrest. At 6:35 PM, Epinephrine given. At 6:37 PM, pulse check was asystole. At 6:41 PM, arrived at free-standing ED. As doors opened, circulation obtained. ED physician refused patient and told ambulance to go elsewhere where cath center was. At 6:43 PM, transported to another ED. Told the free-standing ED to call to let them know they were coming to them. Twelve lead cardiac monitoring showed atrial fibrillation. At 6:47 PM, Patient #2 back in cardiac arrest. Arrived at ED at 6:48 PM. Patient #2 moved to ED room and ED bed by backboard. Report given to ED staff. Care transferred to ED staff. On 03/19/24 at 10:32 AM, one of the two named witnesses, Paramedic #1, was interviewed by phone. Paramedic #1 stated that on a recent cardiac arrest call the patient was transported without return of spontaneous circulation. Circulation was achieved so they headed toward a ST-Segment Elevation Myocardial Infarction (STEMI) facility. Circulation was lost and then obtained again, so they headed to this facility’s free-standing emergency department . Circulation was lost again, and obtained as the ambulance pulled into the hospital’s ambulance bay. The doctor came out and asked if there was circulation and stated they could not stay here and would have to go to another facility with a cardiac catheterization lab. The doctor lectured the ambulance staff on why they could not be there and they left to go to the next facility. They lost circulation during transport again. They arrived at the next ED and they handed off the patient and gave report. The patient did pass away a few days later. Paramedic #1 stated that this is the only time he is aware of this happening.. There were two additional staff in the ambulance at the time who witnessed this. On 03/19/24 from 2:55 PM to 3:30 PM, the free-standing ED was toured. The free-standing ED had 10 beds, a small lab for point of care testing, and radiology services were available. At most they received 30 to 50 ambulances per month. Most patients came by private vehicle or walk in. During the tour, Staff J stated that she was present on the night of the incident but not part of the decision making. Another hospital called to inform the free-standing ED that an ambulance was being diverted to them. The ED staff was not able to talk to the ambulance directly, they just showed up. The patient had circulation on arrival. The physician made the decision to send the patient on to a cardiac catheterization lab and the patient was not brought into the ED. Staff J stated this was a “gray area” and if the squad had called ahead they would have never been on site. Staff J understands the physician did what was best for the patient, as the other ED in the area had a catheterization lab. During an interview on 03/19/24 at 5:26 PM, Staff E stated he was not here the night of the incident, as he had just left prior to the ambulance arrival. There was an ambulance from another county that was headed to another hospital. The ambulance was diverted to this hospital due to the patient being in cardiac arrest. Circulation was obtained on arrival to the parking lot. The other hospital had called to give the ED a heads up and there was no direct communication with the ambulance. The ambulance was not on the Lucas County radio. The ambulance pulled in and the provider met the crew at the ambulance. The Lucas device was in place but not active. There was no cardiac catheterization lab at this facility. The provider directed the ambulance to the facility with a cardiac catheterization lab. The patient did not leave the ambulance. The provider “eye balled” the patient due to return of circulation. Patient #2 was added to the ED Log as “John Doe” and the electronic medical record system assigned an Alpha Numeric name. The provider put a note in the electronic medical record system. During an interview on 03/20/24 at 1:40 PM, Staff A stated that education on Emergency Medical Treatment and Labor Act (EMTALA) was emailed to the staff and providers for review. They followed their normal quality processes which included peer review. The physician who was involved in the incident at the free-standing ED was part of a contracted group, was no longer coming to this facility, and was unavailable for interview.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 29000 Based on medical record review, review of manufacturer’s guidelines, staff interview, review of video footage, and review of facility policy, the facility failed to follow their policies and manufacturer’s guidelines to ensure staff provided repositioning, bathing, changing of external urinary devices and appropriate pain assessments. (A395). The cumulative effects of these systemic practices resulted in the agency’s inability to ensure patient care needs would be met.”

“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: 29000 Based on medical record review, review of manufacturer’s guidelines, staff interview, review of video footage, and review of facility policy, the facility failed to follow their policies and manufacturer’s guidelines to ensure staff provided repositioning, bathing, changing of external urinary devices and appropriate pain assessments. This affected Patient #2, Patient #5, Patient #11, Patient #14 and Patient #18 with the potential to affect all patients cared for in this facility. The facility’s current census was 402. Findings include: 1a) The medical record for Patient #18 was reviewed on 02/02/24. On 12/12/23 at 5:00 PM Patient #18 was a direct admit to the neurological intensive care unit (ICU). Patient #18 had a history of a ischemic stroke on 09/28/23 with a stent completed and atrial fibrillation. The history stated this patient was admitted with left sided weakness. An electroencephalogram (EEG) was completed on 12/12/23 with abnormal findings listed. Orders were received on 12/13/23 for a continuous video EEG due to possible seizure activity. Review of the Braden score (prediction of pressure score risk) on 12/12/23 revealed a score of 14. On 12/13/23 at 11:35 AM the Braden score was 12. Review of the Adult Skin and Wound Care form revealed when a Braden score is 18 or less a skin assessment should be completed every eight hours of all bony prominence and areas of pressure. Turn and reposition the patient at least every two hours at minimum 20 degrees. Notes on 12/12/23 at 11:00 PM revealed staff applied a preventive cushion foam dressing to the coccyx and the patient was placed on a low air loss bed to prevent skin breakdown. Interview with Staff E on 01/30/24 at 2:40 PM revealed all bed bound patients are turned every two hours. Bathing is completed by the nursing assistant (NA) or RN with some getting bathed on days and others at night. Staff E further stated hourly rounding is completed to check if the patient needs anything or needs to use the bathroom. The medical record revealed Patient #18 was transferred from the ICU to the ninth floor on 12/13/23 at 9:46 AM. A Braden score of 12 was listed upon transfer. The medical record revealed repositioning was completed every two hours daily. Documentation in the medical record on 12/13/23 at 11:35 AM listing this patient was positioned on his/her left side, notes at 3:54 PM revealed this patient continued on her left side. Review of the record revealed skin breakdown was documented on 12/18/23 at 8:10 PM identified as bruising and excoriation noted on the buttocks and coccyx. Orders were placed for wound therapy to see. Review of the wound care nurse documentation dated 12/20/23 at 11:07 AM revealed the presence of an acute and pressure injury likely from friction/moisture limited to breakdown of skin which was not present on admission. Location is left ischium measuring 2 centimeters (cm) by 1 cm and and left buttocks measuring 0.5 cm by 1 cm. Orders were received to cleanse skin with soap and water, pat dry, apply Cavilon (barrier film) to sacral wound and to left ischial area on Tuesday and Friday and as needed. Review of the video EEG was completed on 02/02/24 at 3:25 PM with Staff A. This review revealed Patient #18 was in a semi-fowlers (SF) position (lying on back with head of bed half way up) on 12/13/23 at 11:35 AM with visitors at the bedside. The video at 3:34 PM showed this patient continued to be in a SF with no one in the room until 7:38 PM when a staff member came in to complete vital signs (VS) then left the room without turning or re-positioning the patient. Video surveillance on 12/14/23 at 1:00 AM showed this patient remained in this SF position. A staff member was in the room at 4:10 AM, appeared to open the adult diaper then re-taped it with this patient remaining in the same SF position and no repositioning done. A staff member came into the room at 4:35 AM and appeared to be flushing the intravenous (IV), but when checking the medication record Labetolol (BP medicine) was given at this time. Vital signs were completed at 4:47 AM, Oxygen was applied by nasal cannula and this patient remained in the same SF position. The video at 5:57 AM showed staff in the room talking with this patient, scanned the name band and gave medication in what appeared to be applesauce with a spoon. Vital signs were again completed at 8:15 AM with a male visitor present having a conversation with Patient #18. Visitors were present at 9:47 AM and were assisting this patient with eating breakfast. On 12/14/23 at 12:17 PM staff were at the bedside to change Patient #18’s adult diaper, change the external catheter and repositioned this patient onto the left side. This was the first observed repositioning of the patient in 24 hours and 17 minutes. An interview with Staff A at the time of the video review verified after observing the video for the 24 hour time period Patient #18 was turned only once and had the adult diaper changed one time. Staff A further verified the medical record had documented the patient had been turned and repositioned every two hours, but the video lacked evidence that this was completed. The findings of not turning this Patient #18 every two hours as ordered was verified with Staff A, Staff B, and Staff D on 02/02/24 at 5:30 PM. 1b) The medical record documented under activities of daily living (ADL) Patient #18 was a total care for a bath. A complete bed bath, back rub and oral care was documented as completed in the ICU on 12/13/23 prior to transferring to the step down unit. No documentation was found of a bath being completed again until 12/22/23 at 7:00 PM by Staff C. Interview with Staff C was completed on 02/02/24 at 1:45 PM. Staff C stated they remember this patient stating she hadn’t had a bath since she was admitted to the hospital so they stayed and gave her a bath. Staff C further stated the nursing assistants usually bath the patients. Interview with the facility nurse educator Staff F on 02/02/24 at 2:00 PM revealed all patients should be offered a bath daily. The nursing assistants will get vital signs first, set up for breakfast, then start the baths. Staff F further stated the daily bath is an expectation which should be offered and documented if refused. The findings of not offering a daily bath for nine days was verified with Staff A and Staff B on 02/02/34 at 3:00 PM. 1c) The medical record revealed Patient #18 had a external female urinary collection device. The medical record was reviewed with Staff B. No documentation was found this device was changed on 12/13/23, 12/15/23 and 12/17/23. Interview with Staff A revealed the facility does not have a policy to change the external catheter and would follow the manufacturer guidelines. Review of the manufacturer guidelines titled “Sage Primafit External Urine Management for the Female Anatomy” instruct staff to change the device every 12-24 hours. The findings of not changing the urinary management device per the manufacturer guidelines was verified with Staff A and Staff B on 02/02/24 at 3:00 PM. 1d) The medical record for Patient #18 revealed she was a direct admit on 12/12/23 at 5:00 PM and taken directly to the neurological intensive care unit (ICU). The first documentation of a pain for Patient #18 was on 12/13/23 at 5:10 AM scored an 8/10 (scale to rate pain severity with a score of seven to ten being the most severe) in her shoulder and occurring with repositioning. Pain medication was administered. Pain was documented on 12/16/23 at 6:07 PM as a 2/10 but no description of where it was located or any alleviating measures being administered. On 12/17/23 at 1:03 PM pain was reported as 4/10 with no description of where the pain was. Nursing notes on 12/18/23 at 1:12 PM listed a pain of 10/10 with no description of where the pain was located. The patient was medicated with Tylenol 650 milligrams (mg). Review of the policy titled “Pain Assessment, Management, and Reassessment,” reviewed 12/08/23, revealed the patient’s pain experience is assessed on an ongoing basis in all patient care settings. Emergency center and in-patient patients are routinely assessed for pain A pain assessment should be included on admission and with any new onset of pain. This assessment should include pain location, intensity, quality, onset, duration and what makes the pain feel better or worse. A numeric pain score is used for patients who are verbal and able to self report. The score identifies zero is no pain, 1-3 is mild pain, 4-6 is moderate pain, and 7-10 is severe pain. If the patient is non-verbal a FACES score should be used with descriptions of smiling for no pain to crying for severe pain. The findings of not following the facility policy for completing an appropriate pain assessment for Patient #18 was verified with Staff A on 02/02/24 at 11:50 AM. 2) The medical record for Patient #2 was reviewed on 01/31/24. Patient #2 was admitted to the emergency department (ED) on 12/31/23 at 2:57 PM with complaints of right lower quadrant abdominal pain. This patient complained of nausea and vomiting with pain which started two days prior. Vital signs were completed at 3:13 PM and documented within normal range. Laboratory (lab) work was ordered along with a ultrasound of the pelvis. No documentation of a pain assessment using a numerical rating to assess pain severity was completed upon admission for Patient #2. This patient was discharged home on 12/31/23 at 6:53 PM. The findings of not following the facility policy for completing an appropriate pain assessment on admission to the ED for Patient #2 was verified with Staff A on 02/02/24 at 11:50 AM 3) The medical record for Patient #5 was reviewed on 01/31/24. Patient #5 came to the ED on 01/21/24 at 6:45 PM with complaints of left shoulder pain, chest pain and bright red blood in her stool. Vital signs at 6:49 PM were recorded as temperature (T) 36.7 degrees Celsius, blood pressure of 120/71, heart rate of 77, respirations of 18, and oxygen saturation of 97%. Lab work was ordered by the physician with results documented as within normal limits (WNL). A 12-lead electro cardiogram (ECG) was completed at 6:54 PM and documented the patient with normal sinus rhythm with a heart rate of 73. A urine specimen reported back at 7:45 PM as within normal limits and a negative pregnancy test. Physician notes documented a review of all the ordered tests and no need for interventions. Patient #5 was discharged from the ED at 8:50 PM with no documentation of a numeric score to assess pain severity being completed from admission to discharge. Interview with Staff A on 02/01/24 at 10:00 AM verified the findings of not following the policy for an appropriate pain assessment upon admission to the ED. 4) The medical record for Patient #11 was reviewed on 02/01/24. Patient #11 was admitted to the ED on 12/03/23 at 10:40 AM with complaints of left sided rib pain from a fall two weeks prior. Vital signs were completed at 11:20 AM with a heart rate of 100 and blood pressure of 147/87, which were both slightly elevated. The physician was into see this patient at 11:51 AM with orders for lab work. Physician notes stated the testing and imaging from previous ED visit was reviewed and interpreted. This patient was offered muscle relaxers and non-narcotic pain medication in the ED, which she refused. No documentation was found Patient #11’s pain was assessed for severity using a numeric scale. Discharge instructions were provided at 2:52 PM with this patient becoming angry and refusing to sign the paperwork due to requesting narcotics even after talking with the charge nurse and physician. Patient #11 was discharged home at 3:01 PM with instructions in hand. The findings of not following the facility policy for completing an appropriate pain assessment on admission to the ED for Patient #11 was verified with Staff A on 02/02/24 at 11:50 AM. 5) The medical record for Patient #14 was reviewed on 02/01/24. Patient #14 was admitted to the ED on 01/23/24 at 1:21 PM with complaints of chest pain and shortness of breath (SOB). A ECG was ordered and completed at 1:28 PM along with lab work and chest xray. A physician assistant (PA) was into see the patient at 3:35 PM with an assessment completed. Notes from the PA revealed based on patients history, physical exam, labs, and imaging results, no evidence of acute condition needing immediate intervention or admission today. Patient complained of sporadic chest pain for three months that can sometimes cause SOB. There were no current symptoms. This note stated the attending physician agreed with the findings and this patient would be discharged home. No documentation was found Patient #14’s pain was assessed for severity using a numeric scale. The findings of not following the facility policy for completing an appropriate pain assessment in regards to completing a pain assessment on admission to the ED for Patient #14 was verified with Staff A on 02/02/24 at 11:50 AM.”