Mercy Medical Center

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 31597 Based on record review, interview and policy review, the facility failed to ensure patients who presented to the emergency department received a timely medical screening and failed to ensure patients who reported pain were reassessed periodically. This affected six (Patients #3, #11, #14, #15, #17 and #20) patients, of 20 medical records reviewed. The average daily census of the emergency department from January 2024 through July 2024 was 146.29. See A1100 and A1112.”

“QUALIFIED EMERGENCY SERVICES PERSONNEL CFR(s): 482.55(b)(2) There must be adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility. This Standard is not met as evidenced by: 31597 Based on record review, interview and policy review, the facility failed to ensure patients who presented to the emergency department received a timely medical screening and failed to ensure patients who reported pain were reassessed periodically. This affected six (Patients #3, #11, #14, #15, #17 and #20) patients, of 20 medical records reviewed. The average daily census of the emergency department from January 2024 through July 2024 was 146.29. Findings include: 1. Patient #11 arrived at the facility’s emergency department on 07/19/24 at 11:08 PM with a chief complaint of elevated blood pressure. Vital signs were obtained on 07/19/24 at 11:36 PM during triage. The next set of vitals signs were not obtained until 07/20/24 at 5:22 AM. Patient #11 did not receive a medical screening exam until 8:06 AM. 2. Patient #14 arrived at the facility’s emergency department on 08/07/24 at 11:36 PM with a chief complaint of abdominal pain. The patient was triaged at 11:43 PM. Patient #14’s pain level was not assessed. Patient #14’s disposition was entered on 08/08/24 at 7:09 AM as left without being seen after triage. 3. Patient #15 arrived at the facility’s emergency department on 09/12/24 at 11:54 AM with a chief complaint of abdominal pain. On 09/12/24 at 12:02 AM, Patient #15’s pain level was rated a ten on a one to ten scale. Patient #15’s pain level was not documented any additional times during the visit. Patient #15 left the facility against medical advice (AMA) on 09/12/24 at 6:02 PM. 4. Patient #17 arrived at the facility’s emergency department on 09/17/24 at 7:50 PM with a chief complaint of abdominal pain. On 09/17/24 at 7:54 PM, Patient #17’s pain level was rated a ten on a one to ten scale. Patient #17’s pain level was not documented any additional times during the visit. Patient #17 left the facility AMA on 09/18/24 at 2:15 AM. 5. Patient #20 arrived at the facility’s emergency department on 08/24/24 at 3:54 AM with a chief complaint of abdominal pain. On 08/24/24 at 4:51 AM, Patient #20’s pain was rated a nine on a one to ten scale and on 08/24/24 at 6:01 AM, the pain was rated a ten. Patient #20’s pain level was not documented any additional times during the visit. Patient #20 was transferred on 08/24/24 at 6:49 PM. 6. Patient #3 arrived at the facility’s emergency department on 08/02/24 at 9:49 PM and was admitted to the facility on 08/03/25 at 8:05 AM. On 08/02/24 at 9:54 PM, Patient #3’s pain level was rated a ten on a one to ten scale. Patient #3 received Dilaudid 0.5 mg IV (intravenous) on 08/03/24 at 5:06 AM and 08/03/24 at 6:30 AM. Patient #3’s pain level was not reassessed while Patient #3 was in the emergency department. During an interview on 09/23/24 at 9:33 AM, Staff A verified the above findings. Review of the facility policy titled “Routine Care, Emergency Department Protocol”, effective date 03/11/24, stated A complete initial triage/assessment is performed by a registered nurse (RN) on arrival. A RN under the direction of an ED (emergency department) physician may delegate to an ED paramedic tasks allowed in the Emergency Department scope of a paramedic. Licensed practical nurses, paramedics, clinical technicians and /or nursing assistants may begin patient care, data collection and application of physiologic monitoring devices on arrival as directed by an RN. Measure and document vital signs a. Temperature (T), pulse (P), respirations (R), blood pressure (BP), pain level (using appropriate pain scale and SpO2 as indicated) during initial assessment. b. Recommendation in the electronic health record (EHR) for vital sign alert reminders are based on the following nursing/physician leadership recommendations which are based on the Emergency Severity Index (ESI) Score Emergency Severity Index (ESI) Scores: 1= 15 minutes 2= 30 minutes 3= 60 minutes 4= 240 minutes 5= 300 minutes Patient placement post triage a. Patients are assigned to exam spaces based on their assessed needs and the capabilities of areas within the ED (emergency department). When space is not immediately available, patients will be monitored in Intake/Triage area. Nurse initiated protocols may be ordered and the patient returned to lobby to wait for the next appropriate bed. b. Patients returned to the ED lobby will be instructed to notify caregivers of any change in condition (signs/symptoms) immediately. Patients will be reevaluated based on their initial acuity. A full set of vital signs should be taken on patients with an ESI (Emergency Severity Index) level of 2 every hour. ESI level 3, 4, and 5 should have a repeat set of vital signs every 2 hours. Any abnormal vital signs should be communicated to the triage or charge nurse. Patients should be communicated with frequently and kept informed of updates. Complete secondary assessment based on chief complaint. Measure pain severity using appropriate pain scale 1. Initial pain assessment 2. Provide nonpharmacological pain relief measures as indicated (i.e., ice, elevate). 3. Reassess patient’s pain score (refer to pain management protocols). Review of the facility policy titled “Pain Management of the Adult Patient Protocol”, effective 04/12/22, stated to perform pain assessments for every patient: - On admission - Per routine care protocol - With change in caregiver - As needed or indicated Interventions 1. Develop attainable goals in collaboration with the patient/family focusing on comfort and function as well as based on severity and duration of pain. 2. Develop a multimodal integrative pain management plan in collaboration with the patient, family, and healthcare team using both non-pharmacologic and pharmacologic interventions. - Administer analgesics as ordered to prevent/minimize recurrence of pain. - Administer adjuvant medications as ordered per physician/LIP. - Implement non-pharmacologic interventions as available - Nonpharmacologic Pain Management Care Path. (See Appendix D for additional recommendations) Reassessment, Monitoring, and Readjustments of Interventions 2. Reassess pain (duration, description, and location) at the timeframes listed below: - Within 60 minutes after the administration of any type and/or route of a needed analgesic medication (consider route, onset & duration of pharmacological agent being used). - When a clinician dose is given or basal rate increased in a Patient Controlled Analgesic (PCA) device (peripheral or epidural). - After providing a non-pharmacological pain intervention. - As determined by patient clinical status.”

“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: 45753 Based on medical record review, grievance review, staff interview, and policy review, the facility failed to ensure a registered nurse supervises and evaluates the nursing care for each patient (A395). The facility failed to ensure that the nursing staff develops a nursing care plan that reflects the nursing care to be provided to meet the patient’s needs (A396).”

“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: 45753 Based on medical record review, grievance review, staff interview, and policy review, the facility failed to ensure a registered nurse supervised and evaluated the nursing care of one of ten patients reviewed (Patient #4). The census was 244. Findings include: Review of Patient #4’s medical record revealed the patient had arrived in the Emergency Department (ED) on 10/21/23 at 9:46 AM with a chief complaint of nausea and vomiting with abdominal pain. Diagnosis included small bowel obstruction. Past medical history included quadriplegia C5-C7 level spinal cord injury, severe protein-calorie malnutrition, osteoarthritis of left shoulder, chronic osteomyelitis of left hip, muscular atrophy, contracture of muscle of left upper arm, chronic pain syndrome, neurogenic bladder, and osteoporosis (2012). Review of the Functional Assessment completed on 10/21/23 revealed the Patient #4 was totally dependent for transfers and required total assistance for activities of daily living (ADL). The patient’s fall risk assessment indicated he was a high risk for falls. Review of the Patient #4’s care plan dated 10/21/23 revealed the plan did not address the individual needs related to transfer assistance for a total dependent with high risk factors. Review of a portable Xray dated 10/25/23 revealed an impacted fracture of the left humeral head and neck. Review of the computed tomography (CT) scan of the left shoulder revealed an impacted left humeral neck fracture with extension to greater and lesser tuberosity, no displacement. Review of the Orthopedic Nurse Practitioner assessment dated 10/25/23 revealed the patient suffered severe pain and fracture of the left shoulder. Review of the Physical Therapy (PT) evaluation dated 10/31/23 at 10:24 AM and post incident, revealed the Patient #4 was not seen due to clinical appropriateness (does not require a PT eval as he is dependent care and unable to participate in therapy). The patient requires a Hoyer (mechanical) lift pad that wraps around upper extremity as opposed to underneath the arm. Review of the Occupational Therapy (OT) evaluation on 11/01/23 and post incident, revealed the patient required assistance with meals, medication management, safety, self-care, wheelchair mobility, transportation, transfers, cleaning, and laundry. Prior Functional Level revealed the patietn was diagnosed with quadriplegia since 2006 and reported home care staff assists with activities of daily living. The patient reported on “bedrest” for past year and use of a home Hoyer lift ceiling system for transfers and power wheelchair for mobility. Review of a Grievance filed on 10/26/23 revealed the patient reported the following concern: The patient contacted the Ombudsman Office with concern that during his inpatient stay on 10/25/23 proper steps were not taken to ensure his safety when five nursing caregivers attempted to transfer him from his bed to a chair. The patient expressed that during the transfer they lost control of him, and in doing so they caused him to fracture his shoulder. Review of a Grievance resolution letter dated 11/15/23 revealed Staff L acknowledged the patient’s concern, reviewed the medical record, and shared the experience with the Clinical Risk Department who investigated the concern. After review, it was determined that there were no concerns with the transfer of the patient from the bed to the chair, and that use of a mechanical lift would not be considered the standard of care in this situation. Further, a safe plan was in place to have a team of caregivers transfer the patient upon request of the physician, and unfortunately the patient had an underlying condition which contributed to the injury. Interview on 02/06/24 at 11:20 AM with Staff H revealed she filed a report on 10/26/23 regarding Patient #4’s incident dated 10/25/23. Staff H stated a surgeon gave staff a verbal order during rounds for the patient to be out of bed and up to a chair. Staff H stated four or five staff went to the patient’s room to assist with transfer (Staff N, Staff O, Staff X, and two unnamed staff available for additional standby assistance). Staff H stated the patient had never been transferred by staff before. Staff H stated she spoke with Staff N and Staff O who reported the patient’s bottom had come off the bed during the transfer and the weight shift from bed to the chair caused Staff O to feel the left shoulder crack. Staff N, Staff O, and Staff X lowered the patient to the recliner. The staff proceeded to call the physician who placed an order for a portable Xray of the left shoulder. Staff H stated the patient was alert and oriented and was able to make his own medical decisions and he did not object to the plan of transfer. Staff H further stated immediate one on one education was provided to Staff N, Staff O, and Staff X regarding transfer assistance and techniques, however the education provided had not been documented. Staff H verified the step-down unit had no specific transfer policy and transfer assistance was at the discretion of the nurse’s judgement. Interview on 02/06/24 at 2:42 PM with Staff Y stated a therapy consult was not ordered for the patient prior to the incident and the patient was unable to help due to limited mobility and risk factor of osteoporosis. The Staff Y confirmed the appropriate transfer for a total dependent with risk factors was a Hoyer lift. Interview on 02/07/24 at 3:01 PM with Staff N revealed on 10/25/23 she was unable to use a Hoyer lift or assistive device to assist Patient #4 with a safe transfer due to none being available on the floor. Staff N stated during Patient #4’s transfer, Staff O proceeded to lift the patient from the edge of the bed and the patient was sliding through Staff O’s arm. Staff N confirmed the patient’s transfer had initially been a one assist transfer by Staff O. Staff N confirmed the patient was at minimum a two-person transfer and Staff N was unable to articulate the process. Interview on 02/07/24 at 3:13 PM with Staff O revealed on 10/25/23 the plan for transfer of the patient was to sit the patient on the edge of bed, stand and pivot the patient utilizing a “bear hug” transfer technique. Staff O confirmed he was unaware the patient was unable to stand and stated post incident that a Hoyer lift should have been used. Staff O was unable to articulate a two-person transfer assist. Interview conducted on 02/08/24 at 10:34 AM with Staff Q confirmed no specific transfer criteria was listed in the care plan for Patient #4. Staff Q stated the nurse and experienced care team was to use clinical judgement for safe transfers and used online Lippincott application for reference. Staff Q stated PT/OT was to be on board for dependent patients and nursing was responsible to ask the physician to place an order. Staff Q was unable to provide access to Lippincott for review and was unable to demonstrate use of the Lippincott application per request. Interview on 02/08/24 at 10:38 AM with Staff P revealed she was unable to demonstrate the Lippincott application for transfer assistance. The Staff P stated she used Lippincott for patient education and patient handouts. Staff P stated she assessed patients for transfer by interview, asking the patient about strengths and weakness, reviewing mobility scores, functional assessments, and then utilized nursing judgment to develop a plan for safe transfer. Staff P verified PT/OT may be used to consult on mobility and transfers but would need to contact the doctor for an order. Interviews conducted on 02/08/24 between 11:05 AM through 11:50 AM via zoom meeting with Staff Q revealed the goal for patient transfer was a safe patient transfer. Staff Q stated a Hoyer lift was designed to mobilize patients and Staff Q would not consider that an option. Staff Q stated no policy or procedures stated a Hoyer lift was to be used for standard operating procedures. Staff Q stated a Hoyer lift transfer would be appropriate if it was the patient’s preferred way to transfer and the patient did not object to being manually transferred. Interviews conducted on 02/08/24 between 11:05 AM through 11:50 AM via zoom meeting with Staff U confirmed the clinical team or witnesses had not been interviewed regarding the patient’s incident on 10/25/23. Staff U stated she relied on Staff H for the details. Staff U further explained she was unaware of safe transfer techniques and how the patient was transferred from bed to chair. Follow up interview conducted on 02/08/24 at 3:08 PM with Staff H revealed a thorough investigation had not been completed regarding Patient #4’s incident on 10/25/23. Staff H stated she was unaware of the transfer technique used for transfer and confirmed the “bear hug” technique was not appropriate for patient transfers. Staff H stated she did not document the witness statements or interviews and received miscommunication regarding how many staff assisted “hands on” with the patient’s transfer. Staff H confirmed the patient did not have an individualized care plan related to the mode of transfer for a total dependent patient and stated staff was responsible for formulating a safe transfer plan. Review of the facility policy titled, “Fall Minimization and Post Fall Care, Adult Protocol,” dated 06/14/23 revealed the purpose is to define nursing’s role in the management of adult patients at risk for falls and post fall care. This document provides a universal protocol that applies to all patients. Universal Moderate/High Risk Interventions include implementing individualized plan of care and consult resources as needed/as available (e.g., Physical/Occupational Therapy - requires order, Pharmacy, Social Work, etc.). The facility failed to implement the policy. Review of the facility policy titled, “Safe handling policy SOP,” dated 05/12/21 revealed the registered nurse (RN) is responsible for the assessment, planning and implementation of the progressive mobility plan. The RN may delegate select interventions to unlicensed personnel. The caregiver team will aid the patient in achieving progressive mobility providing physical assistance and/or the use of mobility assist device as indicated to safely accomplish the mobility tasks. The facility failed to implement the policy. Review of the facility policy titled, “Lippincott Nursing Online Resource Policy,” dated 05/31/22, revealed Lippincott Nursing Online Resource is used as a reference for nursing practice when a written documentation covering the same information is not available. The facility failed to implement the policy. This deficiency represents non-compliance investigated under Substantial Allegation OH00150528.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 45753 Based on medical record review, grievance review, staff interview, and policy review, the facility failed to ensure nursing staff developed a nursing care plan that reflects the nursing care to be provided to meet the patient’s needs for one of ten patients reviewed (Patient #4). The census was 244. Findings include: Review of the Patient #4’s medical record revealed the patient had arrived in the Emergency Department (ED) on 10/21/23 at 9:46 AM with a chief complaint of nausea and vomiting with abdominal pain. Diagnosis included small bowel obstruction. Past medical history included quadriplegia C5-C7 level spinal cord injury, severe protein-calorie malnutrition, osteoarthritis of left shoulder, chronic osteomyelitis of left hip, muscular atrophy, contracture of muscle of left upper arm, chronic pain syndrome, neurogenic bladder, and osteoporosis (2012). Review of the Functional Assessment completed on 10/21/23 revealed the Patient #4 was a total dependent for transfers and required total assistance for activities of daily living (ADL). The SP’s fall risk assessment indicated high risk for falls. Review of the Patient #4’s care plan dated 10/21/23 revealed the plan did not address the individual needs related to transfer assistance for a total dependent with high risk factors. Occupational and Physical therapy were not consulted upon admission. Review of a portable Xray dated 10/25/23 revealed an impacted fracture of the left humeral head and neck. Review of the computed tomography (CT) scan of the left shoulder revealed an impacted left humeral neck fracture with extension to greater and lesser tuberosity, no displacement. Review of the Orthopedic Nurse Practitioner assessment dated 10/25/23 revealed Patient #4 suffered severe pain and fracture of the left shoulder. Review of a grievance filed on 10/26/23 revealed the patient reported the following concern: Patient #4 contacted the Ombudsman Office with concern that during his inpatient stay on 10/25/23 proper steps were not taken to ensure his safety when five nursing caregivers attempted to transfer him from his bed to a chair. The patient expressed that during the transfer they lost control of him, and in doing so they caused him to fracture his shoulder. Review of the Physical Therapy (PT) evaluation dated 10/31/23 at 10:24 AM and post incident, revealed Patient #4 was not seen due to clinical appropriateness (does not require a PT eval as he is dependent care and unable to participate in therapy). Patient #4 requires a Hoyer (mechanical) lift pad that wraps around upper extremity as opposed to underneath the arm. Review of the Occupational Therapy (OT) evaluation on 11/01/23 and post incident, revealed Patient #4 required assistance with meals, medication management, safety, self-care, wheelchair mobility, transportation, transfers, cleaning, and laundry. Prior Functional Level revealed the Patient #4 was diagnosed with quadriplegia since 2006 and reported home care staff assists with activities of daily living. The Patient #4 reported on “bedrest” for past year and use of a home Hoyer lift ceiling system for transfers and power wheelchair for mobility. Interview on 02/06/24 at 11:20 AM with Staff H revealed she filed a report on 10/26/23 regarding the patient’s incident dated 10/25/23. Staff H stated a surgeon gave staff a verbal order during rounds for the patient to be out of bed and up to a chair. Staff H stated four or five staff went to the patient’s room to assist with transfer (Staff N, Staff O, Staff X, and two unnamed staff available for additional standby assistance). Staff H stated the patient had never been transferred by staff before. Staff H stated she spoke with Staff N and Staff O who reported the patient’s bottom had come off the bed during the transfer and the weight shift from bed to the chair caused Staff O to feel the left shoulder crack. Staff N, Staff O, and Staff X lowered the patient to the recliner. The staff proceeded to call the physician who placed an order for a portable Xray of the left shoulder. Staff H stated the patient was alert and oriented and was able to make his own medical decisions and the patient did not object to the plan of transfer. Staff H further stated immediate one on one education was provided to Staff N, Staff O, and Staff X regarding transfer assistance and techniques, however the education provided had not been documented. Staff H verified the step-down unit had no specific transfer policy and transfer assistance was at the discretion of the nurse’s judgement. Interview on 02/06/24 at 2:42 PM of Staff Y stated a therapy consult was not ordered for the Patient #4 prior to the incident and the Patient #4 was unable to help due to limited mobility and risk factor of osteoporosis. Staff Y confirmed the appropriate transfer for a total dependent with risk factors was a Hoyer lift. Interview conducted on 02/08/24 at 10:34 AM with Staff Q confirmed no specific transfer criteria was listed in the care plan for Patient #4. Staff Q stated the nurse and experienced care team was to use clinical judgement for safe transfers and utilize online Lippincott application for reference. Staff Q stated PT/OT was to be on board for dependent patients and nursing was responsible to ask the physician to place an order. Staff Q was unable to provide access to Lippincott for review and was unable to demonstrate use of the Lippincott application per request. Interview on 02/08/24 at 10:38 AM with Staff P revealed she was unable to demonstrate the Lippincott application for transfer assistance. Staff P stated she used Lippincott for patient education and handouts. Staff P stated she assessed patients for transfer by interview, asking the patient about strengths and weakness, reviewing mobility scores, functional assessments, and then utilized nursing judgment to develop a plan for safe transfer. Staff P verified PT/OT may be used to consult on mobility and transfers but would need to contact the doctor for an order. Follow up interview conducted on 02/08/24 at 3:08 PM of Staff H stated she was unaware of the transfer technique utilized for transfer and confirmed the “bear hug” technique was not appropriate for patient transfers. Staff H confirmed Patient #4 did not have an individualized care plan related to the mode of transfer for a total dependent and stated staff was responsible for formulating a safe transfer plan. Review of the facility policy titled, “Fall Minimization and Post Fall Care, Adult Protocol,” dated 06/14/23, revealed the purpose is to define nursing’s role in the management of adult patients at risk for falls and post fall care. This document provides a universal protocol that applies to all patients. Universal Moderate/High Risk Interventions include implementing individualized plan of care and consult resources as needed/as available (e.g., Physical/Occupational Therapy - requires order, Pharmacy, Social Work, etc.). The facility failed to implement the policy. Review of the facility policy titled, “Safe handling policy SOP,” dated 05/12/21, revealed the registered nurse (RN) is responsible for the assessment, planning and implementation of the progressive mobility plan. The RN may delegate select interventions to unlicensed personnel. The caregiver team will aid the patient in achieving progressive mobility providing physical assistance and/or the use of mobility assist device as indicated to safely accomplish the mobility tasks. The facility failed to implement the policy. Review of the facility policy titled, “Lippincott Nursing Online Resource Policy,” dated 05/31/22, revealed Lippincott Nursing Online Resource is used as a reference for nursing practice when a written documentation covering the same information is not available. The facility failed to implement the policy. This deficiency represents non-compliance investigated under Substantial Allegation OH00150528.”