Mercy St Vincent Medical Center

“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 record review, interview and policy review, the facility failed to ensure a patient received appropriate treatment for a hip fracture. This affected one (Patient #11) of three patients reviewed for fractures. The census was 73. Findings include: Record review revealed Patient #11 arrived to the emergency department (ED) on 03/14/25 at 5:13 AM via emergency medical services (EMS). EMS reported the patient was picked up from home with an altered mental status, a history of seizures and body jerking. EMS reported the patient was home with a relative and the home was poorly kept. Patient #11 was found on the floor at home, unresponsive for an unknown length of time. The patient presented uncooperative, intermittently arousable with sluggish pupils, a Glasgow Coma Scale (GCS) of seven out of 15 and a history of several abdominal surgeries. At 10:26 AM, after being stabilized in the ED, the patient was admitted to the Medical Intensive Care Unit (MICU). Pain assessment flow sheets were reviewed and staff was using the Critical Care Pain Observation Tool (CPOT) to assess Patient #11’s pain as the patient was intubated. The highest pain score was four, with eight being the highest level of pain based on facial expressions, body movements, muscle tension and ventilator compliance. Pain assessment flow sheets were reviewed for the stay and there was no mention of hip pain during this encounter in the pain flow sheets. On 03/31/25 the patient had an X-ray of the pelvis and right hip and due to Patient #11 complaining of pain. The results at 4:57 PM revealed there was an intertrochanteric fracture of the right hip. The fracture was angulated. There were no notes indicating care was provided for this fracture prior to discharge. The patient was discharged home in stable condition on 03/31/25 at 4:46 PM. On 04/04/25 at 1:52 PM, Patient #11 returned to the ED, complaining hip pain and urinary frequency. Review of the ED nursing notes at 2:05 PM revealed the patient reported to the nurse that she had a fall a couple of days ago and has not been ambulating on her own. She also reported having pain where her sacral ulcer was and rated the pain to her right hip a nine on a one to ten scale. Imaging of the right knee, hip and femur was ordered at 2:12 PM and results revealed a right interochaneric femur fracture. At 2:15 PM, Patient #11 was administered Morphine 4 milligrams (mg) intramuscularly (IM) for pain and at 2:18 PM, Patient #11 denied pain. Consults with trauma surgery, orthopedic surgery and Internal medicine were placed. At 4:54 PM Rocephin (Antibiotic) intravenous was ordered. The patient was admitted on 04/04/25 at 4:50 PM. Review of the orthopedic provider note, dated 04/04/25 revealed Patient #11 was recently admitted for encephalopathy as well as a fall on 03/14/25. On arrival the patient was intubated for respiratory protection. She stated that she had complaints regarding her right hip pain throughout her stay previous stay. On 03/31/25 X-rays of the right hip were taken which demonstrated a right hip fracture. The patient was discharged the same day without an orthopedic consult. The patient returned on 04/04/25 due to continued right hip pain and she denied pain elsewhere at this time. The provider noted the patient had previously had a left femur fracture status post intramedullary nailing in 2024. On 04/04/25 at 3:30 PM the patient was evaluated by the Orthopedic Surgeon who noted Patient #11 had been admitted on 03/14/25 and was discharged on 03/31/25 after being found down for an unknown amount of time. She stated that she fell out of her bed onto the concrete floor. She does not remember the details of the event. She stated that she fell prior to her admission on 03/14/25 and had hip pain and after that she did not remember anything. During her hospital stay physical therapy worked with her and patient had right hip pain that continued during this time frame. No radiographic images were taken until 03/31/25, the day of her discharge and at that time the X-ray demonstrated a right intertrochanteric femur fracture. It is unclear why the patient was discharged that same day without any orthopedic evaluation. Surgery was sent for 04/05/25 to repair the fracture. Review of the Operative Note dated 04/05/25 at 6:47 PM revealed the surgery was completed due to a displaced right subacute intertrochanteric femur fracture. A cephalomedullary nail was placed and there were no complications noted. The wound was irrigated with normal saline and there was no infection noted to the site by the surgeon. Patient #11 was discharged in stable condition to a skilled nursing facility on 04/10/25 at 5:29 PM. During an interview on 06/26/25 at 12:40 PM, the Director of Quality stated the resident physician that ordered the X-ray did not view the results timely as the results went to their email inbox without timely recognition, review and/or action. Review of the policy titled “Individuals Rights and Responsibilities”, effective 05/15/25, revealed patients have the right to receive prompt, considerate, compassionate, dignified, and respectful care provided by qualified health care professionals. Patients also have the right to receive care in a safe and secure setting free from all forms of abuse, neglect, exploitation, or harassment. Patients also have the right to receive appropriate assessment and management of pain.”

“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: 45751 Based on record review, interview, and policy review, the facility failed to ensure the medical record contained documentation regarding two falls. This affected one (Resident #9) of four records reviewed for falls. The facility census was 50. Findings include: Review of medical record for Patient #9 revealed admission diagnoses of altered mental status, urinary tract infection (UTI), acute metabolic encephalopathy secondary to UTI, dislocated left shoulder, and hypotension. Review of fall risk/interventions assessment completed on 04/17/25 revealed a score of 79.61 which indicated a high fall risk. Interventions on 04/17/25 included standard measures along with fall sign, socks, door open, bed alarm, and hourly visual checks. Patient had falls on 04/19/25 at 10:28 A.M. and 03:00 P.M. Review of physician note dated 04/19/25 at 11:02 A.M. revealed the physician was asked to see the patient due to a fall. The patient was trying to get up from his chair and fell. Apparently he hit his head against the wall. The patient did have a bump at the back of his head. The patient’s mental state appeared similar to what it was when seen earlier in the day. The patient was moving all four limbs. The physician wrote and order to check computerized tomography (CT) scan of head and X-ray of ribs emergently. Review of CT scan of the head without contrast completed on 04/19/25 at 12:31 P.M. revealed head injury and patient on Eliquis (blood thinner) due to fall. CT scan revealed no acute intracranial abnormality. Review of two view X-ray of the bilateral ribs on 04/19/25 at 12:35 P.M. revealed no evident displaced bilateral rib fractures. Review of CT scan completed on 04/19/25 at 05:19 P.M. noted it was completed due to second fall with head injury today. CT scan revealed no acute intracranial abnormality. Review of charting for 04/19/25 revealed no nursing note regarding the fall at 10:28 A.M. or any mention of the fall at 03:00 P.M. Interview on 06/16/25 at 10:45 A.M. with Quality Specialist #200 revealed the facility could not locate any documentation in the medical record regarding the fall on 04/19/25 at 03:00 P.M. Quality Specialist #200 also verified the fall at 10:28 A.M. was only documented by the physician at 11:02 A.M. Review of the policy titled “Falls Prevention Policy,” dated 11/25/24, revealed when a patient experiences a fall the facility will complete a post fall assessment including vital signs and neuro checks and document description of the fall in the progress notes.”

“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: 32088 Based on record review, interview and policy review, the facility failed to ensure an appropriate medical screening exam was provided to a patient. This affected one (Patient #5) of four pregnant patients whose records were sampled. Findings include: Review of the medical record for Patient #5 revealed she presented to the Emergency Department (ED) on 01/29/25 at 12:48 AM via emergency medical services (EMS) complaining of vaginal bleeding while pregnant, vomiting, and abdominal and back pain. She rated the pain a nine on a one to ten scale. The patient was triaged at an acuity level of four meaning “less urgent.” The triage note completed on 01/29/25 at 12:52 AM documented Patient #5 was eight weeks pregnant with abdominal pain, vaginal pain, and vaginal bleeding. At 12:53 AM, Patient #5’s vital signs were temperature of 98.3 degrees Fahrenheit (F), pulse of 105, blood pressure 101/68, respirations of 18 and oxygen saturation of 100 percent on room air. Patient #5 rated her pain a nine on a one to ten scale. Review of the ED provider notes revealed Physician A assessed the patient at 12:54 AM and noted Patient #5 was eight weeks pregnant with a subchorionic hemorrhage, nausea, difficulty urinating and severe pain and tenderness in her abdomen (right lower and left lower quadrant and supra pubic areas) and low back. The provider documented “Patient states that it is hard for her to sit up because of pain.” He documented Patient #5 was seen at another hospital a few hours prior but did not stay for laboratory or imaging results. Physician A documented Patient #5 was in acute distress. At 12:56 AM, Physician A documented “all labs and everything that was done” at the prior hospital was reviewed. Physician A’s documenation of “medical decision making: included “[At] this point in time, there is really nothing further to do for her; since she is pregnant, we ncannot really do a whole lot of medications and we cannot do a CT scan....”. Physician A did not believe this to be an acute intra-abdominal issue. Physician A documented they would check for COVID and flu and then try to symptomatically help her and discharge her back home. Physician A documneted the medical screening examination for Patient #5 considered “Problem List This Visit: Abdominal pain, vaginal bleeding, back pain, nausea, difficulty urinating[.] Differential Diagnosis: Viral illness, threatened miscarriage[.] Diagnoses Considered but Do Not Suspect: None[.] Pertinent Comorbid Conditions: None.” At 12:58 AM. the COVID/influenza testing returned a positive result for COVID-19. Between 1:00 AM and 1:05 AM, Patient #5 was administered acetaminophen, Reglan (treats GERD) and metaclopramide, an anti-nausea medication. The medical record reflected that Patient #5 was discharged home on 01/29/25 at 1:52 AM with prescriptions for cough medication and muscle relaxing medication. The medical record did not contain documentation of further reassessment of Patient #5’s abdominal pain or abnormal vital signs, nor did the record contain documentation of consultation with the on-call OB/GYN physician or further diagnostic testing pertaining to her complaints of vaginal bleeding and abdominal pain associated with early pregnancy. Within 12 hours of discharge, on 01/29/25, Patient #5 called EMS for ongoing abdominal pain and went into cardiac arrest enroute to the hospital. Patient #5 underwent an emergent exploratory laparotomy with evacuation of hemoperitoneum and evidence of a left ruptured ectopic pregnancy. She had a.ruptured ectopic pregnancy requiring massive transfusion and was sent to the intensive care unit (ICU) for stabilization. On day four post-op, Patient #5 suffered a cerebellar herniation and had cessation of reflexes. Patient #5 did not regain neurologic function and was sent to a skilled nursing facility. Patient #5 was subsequently transferred to another hospital where she was declared brain dead and eventually died on 04/20/25. During an interview on 06/12/25 at 12:00 PM, the ED Nurse Manager verified the medical record lacked documentation of any further treatment prior to the discharge of Patient #5. During an interview on 06/12/25 at 12:26 PM, the Director of Quality stated Physician A declined to answer questions of the State Agency on advice of his legal counsel. Review of the policy titled “Emergency Medical Treatment & Active Labor Act (EMTALA)”, effective 03/21/24, revealed the policy applies to all Medicare-participating Bon Secours Mercy Health (BSMH) hospitals that have an emergency department on or off of the hospital’s main campus, and any hospital-based urgent care center that qualifies as a Dedicated Emergency Department (DED). The policy ensures that individuals seeking examination and/or treatment will receive a Medical Screening Examination (MSE) by a physician or qualified medical personnel to determine if the patient has an emergency medical condition (EMC) and if so provide stabilizing treatment and/or an appropriate transfer to another facility. An appropriate MSE is one that is sufficient to determine with reasonable clinical confidence whether a patient has an EMC. A patient has an EMC if their medical condition manifests itself by acute symptoms of sufficient severity (severe pain) such that the absence of immediate medical attention could be expected to result in placing the health of the individual in serious jeopardy. An individual with an EMC is considered stabilized when no material deterioration of the individuals condition is likely, within reasonable medical probability. Review of the policy titled “Obstetrical Patient Flow for Pregnant Women Presenting for Care in the Emergency or OB Department”, effective 04/28/25, revealed for pregnant patients presenting at a BSMH location without Obstetrical Services with an obstetrical complaint and delivery is not imminent, they should transfer the patient to an appropriate facility as directed by patient’s obstetrician or an accepting facility. The policy directed that patients less than 20 weeks gestation be evaluated in the ED, and the ED provider may consult the OB provider to evaluate the obstetrical concern.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 29000 Based on record review, staff interview, and policy review, the facility failed to ensure the patient representative was informed of health changes for one (#2) of 10 patients reviewed for notification. The facility census was 128. Findings include: Review of medical record for Patient #1 revealed the patient was admitted on 02/11/25 for mania and symptomatic anemia to the medical floor. On 02/14/25 the patient was transferred from the medical floor to the Behavioral Unit. On 02/17/25 the patient was febrile and tachycardic. Blood cultures and chest x-rays were obtained. On 02/18/25 the patient was observed with a change in condition which included intermittent catatonia, drooling, and tachycardia. The physician was notified and order was obtained to send the patient to the Emergency Room (ER) as there were no beds available in the Intensive Care Unit (ICU) at the time. Patient #1 was transferred to the ER on 02/18/25 2:15 A.M. On 02/18/25 at 4:05 A.M. the patient was intubated to protect the airway. On 02/18/25 discharge paperwork from the Behavioral Unit to the ER revealed no documentation Patient #1’s family was notified of the transfer or the change in health status of the patient. Interview on 04/22/25 at 3:03 P.M. with Registered Nurse (RN) A revealed they took over care for Patient #1 at 11:00 P.M. on 02/18/25. RN A stated the patient had a change in condition and required the transfer to the ER. RN A verified she did not call the family to inform them of the transfer as she thought the ER would. Review of facility policy titled “Transfers,for “ reviewed 09/19/22, revealed transfers within the hospital the family, the physician, and the consultants are to be notified when patients are transferred to a higher level of care.”

“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, policy review and staff interview, the facility failed to follow physician orders to turn patients to prevent the development of new skin breakdown and to promote healing for two patients (#2 and #4) and failed to provide any evidence of assistance with feeding and acceptance of meals for one patient (#4). These deficient practices affected two patients (Patient #2 and #4). Findings include: 1. The medical record for Patient #4 revealed an admission on 11/15/24 after a fall. A nursing skin assessment was completed on admission 11/15/24 at 4:00 PM, listing scattered abrasion and bruising noted on the back with preventative foam placed to the sacrum. Nursing notes further stated this patient was unable to move either leg and was positioned with assistance. Orders were placed to turn this patient every two hours and to float heels. Review of the flowsheets revealed Patient #4 was turned to the right side on 11/16/24 at 8:00 AM and was not turned to the left side until 6:00 PM. On 11/18/24 at 6:00 PM Patient #4 was turned to the right side until 11/19/24 at 6:00 AM when the patient was turned to the back. The next documentation found in the medical record was on 11/20/24 at 8:00 PM indicating this patient was turned to the right side. Notes on 11/21/24 at 8:00 PM stated this patient was sitting upright with no documentation of turning again until 8:00 AM, when she was turned to the left side. Notes on 11/23/24 at 8:00 PM stated this patient turned themselves, with the next documentation of positioning on 11/24/24 at 8:00 AM showing the patient was turned onto the back. The next documentation of re-positioning was recorded on 11/26/24 at 10:00 AM stating the patient was up in the chair. Review of the wound care notes dated 11/25/24 revealed Patient #4 had a documented a deep tissue injury to the sacrum with measurements of 7 centimeters (cm) by 5 cm and 0 for depth. Notes further stated this deep tissue injury was not present on admission. Review of the facility policy titled “Pressure Injury Prevention Clinical Practice Guidelines,” dated 07/05/24, revealed a risk assessment should be completed upon admission to identify patients at risk for developing pressure injuries. Reposition for optimal offloading/pressure redistribution of bony prominence and reduce time in a sitting position. Clean skin routinely ad promptly after incontinence and protect with appropriate moisture-barrier product. Document interventions taken to prevent pressure injury in the electronic medical record and if the patient refuses. Interview on 12/04/24 at 3:00 PM staff A verified the finding of not turning this patient every two hours per order with the development of a sacral wound. 2. The medical record for Patient #2 was reviewed on 12/04/24. Patient #2 was admitted on 09/24/24 at 5:23 AM per squad due to altered mental status and elevated blood sugars. The history and physical documented this patient had a history of chronic obstructive pulmonary disease (COPD), Type II diabetes and left sided residual paralysis from a stroke which occurred in 2020. This patient was admitted to the Intensive Care Unit (ICU) on an insulin drip with blood glucose levels in the 400s. Patient #2 was assessed by the wound care nurse on 09/25/24 at 9:50 AM. Notes listed a Stage 3 wound to the sacrum, which was present on admission measuring 4.4 cm by 1.8 cm by 0.3 depth. Orders were received to cleanse with soap and water, apply Hydrofiber silver foam, and to change every other day and as needed for soiling. Orders were written on 09/25/24 at 11:47 AM to turn every two hours, cleanse skin after soiling and to maintain heels off the bed. The medical record revealed on 09/25/25 at 8:00 AM Patient #2 was turned to the right side with the next documentation of turning to the left side occurring 14 hour later at 10:00 PM. The patient remained on the left side until 4:00 AM on 09/26/24, six hours after turning. On 09/27/24 at 2:00 PM this patient was turned to the right then to the left at 5:00 PM. No documentation was found this patient was turned the rest of their stay, with a discharge home on 10/07/24. Review of progress notes from the wound care nurse on 09/30/24 at 12:16 PM revealed the dressing was changed with measurements of 4.4 cm by 3 cm by 0.3 cm. Patient #2 returned to the hospital on 10/17/24 at 8:23 PM with a diagnosis of left sided facial drop with a Stroke alert called. This record revealed on 10/18/24 at 5:30 AM Patient #2 was turned to the left side and then to the right side at 10:00 AM, where they remained until 4:00 PM. On 10/19/24 at 4:00 AM Patient #2 was turned to the left side on with the next documentation of turning 14 hour later when the patient was turned to the left. On 10/20/24 at 6:00 PM Patient #2 was turned to the right side and not repositioned again until 10:00 AM on 10/21/24, 16 hours later. Interview on on 12/04/24 at 3:00 PM Staff A verified the Patient #2 was not turned every two hours. Additionally, Patient #2 had orders dated on 10/01/24 for Patient #2 to have a dysphasia pureed moderately thick diet and for a total assist with feeds. On 10/02/24 the record contained no intake amounts or any documentation to identify this patient ate. Notes on 10/03/24 stated the patient completed 51-75% of the meal at 9:38 AM and 12:41 PM. No other documentation was found in the medical record of any oral intake amounts or assistance with eating. The patient discharged home on 10/07/24. Patient #2 was re-admitted on 10/17/24 with a pureed moderately thick diet reordered on 10/18/24. Feedings were recorded on 10/18/24 at 9:15 AM and 12:50 PM showing intake of diet was 76-100 %. There was no documentation of the dinner meal intake on 10/18/24. On 10/19/24 there was no documentation of any oral intake. No oral intake or assistance provided with meals was documented on 10/21/24 or 10/23/24, with this patient discharged home on 10/24/24 with family. Interview on 12/05/24 at 3:55 PM per phone call with a resident physician revealed they spoke with Patient #2’s family on 10/24/24 at approximately 4:15 PM. The family was very upset, stating when they came to visit the food tray was cold in the room and no one ever fed their mother. Interview on 12/05/24 at 4:30 PM the Registered Dietician (RD) stated the patient’s history tells staff if the patient needs assistance with meals. The RD stated this facility does not have a policy related to feeding patients further stating it’s in the orders. Interview on 12/04/24 at 3:00 PM, Staff A verified the findings of no evidence Patient #2 was provided an oral intake and assisted with eating was not identifiable in the medical record. Staff A stated this facility does not have a policy in place it’s just a given and should be documented.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 45445 Based on medical record review, staff interview, and review of facility policies, the facility failed to ensure patients had a comprehensive plan of care at discharge. This affected two (#6 and #3) patients of three patients reviewed for discharge with wounds and an implantable device. The facility census was 59. Findings include: 1. Review of the medical record for Patient #6 revealed an admission date and time of 07/08/24 at 7:41 A.M. Patient #6 was an elective admission for cardiology services to place a cardiac pacemaker due to Patient #6 suffering from sinus pauses. Diagnoses included bradycardia and vasovagal and deglutition syncope. Patient #6 had a history of type 2 diabetes mellitus with long term use of insulin, hypertension, obstructive sleep apnea, morbid obesity, gastroesophageal reflux disease, hyperlipidemia, and vitamin D deficiency. Review of the history and physical completed on 07/08/24, timed 7:41 A.M., revealed Patient #6 had a loop recorder implanted 06/19/24 with near syncopal episodes noted, mostly with swallowing. Two of the episodes were associated with bradycardia with pauses in the range of five seconds. Physical examination was unremarkable. The plan to proceed, agreed upon by the patient and the patient’s wife, was to have an implantation of dual chamber pacemaker placed. Review of the brief postoperative note dated 07/08/24 and timed 3:11 P.M. completed by Cardiologist D revealed , Patient #6 experienced no complications with all lead impedances and thresholds stable. The plan for Patient #6 was bedrest overnight, with chest x-ray and pacemaker evaluation in the then morning and then discharge to home if no complications. Follow up for staple removal on 07/16/24 at the cardiology office. Review of the discharge note, dated 07/09/24 completed at 11:42 A.M., revealed Patient #6 had a permanent pacemaker placed with recommended follow ups in one week with primary care and in four weeks with cardiology. Review of the discharge paperwork printed on 07/09/24 at 2:24 P.M. revealed Patient #6 received educational information on COVID, stroke, warning signs of a heart attack and the use of opioids. Patient #6 was scheduled for a wound check on 07/17/24 at 11:30 A.M. and a device check on 07/20/24 at 9:30 A.M. There were no instructions for wound care or any information on the pacemaker. Interview on 08/13/24 at 10:30 A.M. with Registered Nurse (RN) K verified Patient #6 had not received discharge instructions for wound care or any information on the pacemaker. 2. Review of the medical record for Patient #3 revealed an elective admission date of 07/29/24 for an implantable cardioverter-defibrillator replacement. Patient #3 diagnoses included legal blindness, coronary artery disease, with a history of coronary bypass surgery, congestive heart failure, sleep apnea, hyperlipidemia, type 2 diabetes mellitus, and hypertension. Patient #3 was care planned on 07/29/24 for discharge planning with a goal to discharge home with appropriate resources. Review of the social Case Management Assessment and Initial Evaluation dated 07/29/24 and timed 3:35 P.M. revealed Patient #3 lived at home with spouse, planned to return to home, and was independent with activities of daily living. Review of the procedure note dated 07/31/24 and timed 5:14 P.M. revealed Patient #3 had a new pulse generator placed in the left upper chest on 07/29/24 without complication due to defibrillator battery depletion. Review of the Occupational Therapy note dated 07/31/24 revealed Patient #3 would benefit from continued therapy at discharge with a plan for Occupational Therapy two to three times a week for self-care needs, home management training and safety education due to position restrictions as result of the pacemaker. Review of the discharge paperwork printed on 07/31/24 at 12:22 P.M. revealed Patient #3 received discharge education on stroke, heart attack, heart failure, and COVID. Patient #3 was provided continuation of care documents that included medications, follow up appointments and home health services that had been arranged. There were no instructions for wound care or any information on the pacemaker. Interview on 08/12/24 at 1:30 P.M. with RN K verified Patient #3 had not received discharge instructions for wound care or any information on the implanted device, further stating the information was sent to the home health agency. Interview on 08/13/24 at 2:00 P.M. with Nurse Manager S verified patients who have received implantable devices have inconsistent discharge instructions, furthering verifying all patients should receive information on wound management and device information. Review of the facility policy titled “Individual Rights and Responsibilities,” dated 05/05/23, stated all healthcare providers have the responsibility to assure that patients receive care and consideration in accordance with the mission and values of the organization. Patients have the right to be informed, be involved in decision making, be provided with furnishings and equipment that are safe and fit their needs, and have the right to receive information regarding care, proposed treatments or procedures and or healthcare services. Review of the facility policy titled “Discharge Planning,” dated 03/25/24, revealed discharge is a multidisciplinary process by which healthcare professionals collaborate with the patient and caregiver to identify what the patient needs for a smooth, safe transition to the next level of care. The discharge plan will be made after identifying discharge planning needs so that appropriate arrangements for post-hospital care are made timely and to avoid unnecessary delays. Documentation of the communication about discharge evaluation must be included in the medical record. Review of the facility policy titled “Nursing Documentation Requirements,” dated 05/27/24, stated discharge documentation requirement includes signs and symptoms to report with contact information for reporting, any activity restrictions, post discharge education including treatment prescribed.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 29000 Based on medical record review and staff interview, the facility failed to implement an appropriate discharge plan which met all the medical needs of a resident when ordered medications were omitted from the discharge orders. This affected one patient (Patient #4) with the potential to affect all patients cared for at this facility. The facility census was 219. Findings: The medical record revealed Patient #4 was admitted on 1/27/24 at 12:58 AM to the medical surgery floor from the emergency room. The physician history listed positive for Covid-19 on 01/08/24, chronic obstructive pulmonary disease (COPD) and concerns for congestive heart failure (CHF) with swelling noted to bilateral legs. Internal medicine physician notes on 02/02/24 at 2:18 PM stated potential discharge in one to two days. Review of the nursing notes on 02/05/24 at 1:30 PM revealed a respiratory panel was ordered and a nasopharyngeal swab was obtained. This panel result was positive for Influenza A. The internal medicine physician was notified at 3:37 PM and orders received to start Tamiflu. A chest xray was completed at 6:50 PM which showed bilateral patchy lower lobe opacities, concerning for pneumonia. Tamiflu was given on 02/05/24 at 8:00 PM and again on 02/06/24 at 8:00 AM. Notes from the internal medicine physician, Staff F on 02/06/24 at 12:08 PM revealed pulmonary medicine cleared this patient for discharge and orders were received to discharge home. Patient #4 was discharged home on 02/06/24 at 1:23 PM. Review of the discharge summary revealed the Tamiflu was not ordered by either internal medicine physician (Staff E or Staff F) upon discharge. Interview with Staff B on 02/29/24 at 10:55 AM stated the discharge orders were placed the day prior to Patient #4 starting on the Tamiflu and no physician caught it to add it on the discharge medications. Interview with the pulmonologist (Staff G) on 02/29/24 at 9:30 AM verified the discharge instructions did not contain an order for the Tamiflu. Staff G stated it should have been given for five days.”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 38624 Based on observation and staff interviews the facility failed to provide accurate evacuation diagrams per NFPA 101-2012 Edition, Section 19.2.10.1, NFPA 101-2012 Edition, Section 7.10.8.5*, NFPA 101-2012 Edition, Section 7.10.3.2*, and NFPA 170-09 Edition, Section 9.4*. This had the potential to affect all the patients, staff, and visitors at the time of the survey. Findings include: An observation during a tour of the facility with Plant Operations on 02/28/24 at approximately 1:28 P.M. revealed there was no evacuation map displayed on the 3rd floor B-side. Also, the evacuation maps displayed on the C-side, B-side, and Oncology of the building did not display floor arrangement that included primary and secondary exits, YOU ARE HERE symbols, the location of pull stations, and fire extinguishers like the arrangement in the Emergency Departments (ED). An interview with Plant Operations on 02/28/24 at approximately 1:28 P.M. verified the finding by stating that the building was built at different times, and at one point the 3rd floor was closed off. The Plan Operation Personnel stated, “it appears not to be in public site”. NFPA 101-2012 Edition, Section 19.2.10.1 Means of egress shall have signs in accordance with Section 7.10 unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4. NFPA 101-2012 Edition, Section 7.10.8.5* states, that where a posted floor evacuation diagram is required in Chapters 11 through 43, floor evacuation diagrams reflecting the actual floor arrangement and exit locations shall be posted and oriented in a location and manner acceptable to the authority having jurisdiction. A.7.10.8.5 Egress paths with multiple turns can often be confusing with respect to which exit route will lead to the closest exit door. Floor evacuation diagrams can eliminate the guesswork by giving the occupant a point of reference with the YOU ARE HERE symbol. The entire floor plan should be shown with the primary and secondary exit routes, exit stairs, and elevators identified. For further information see ASTM E 2238, Standard Guide for Evacuation Route Diagrams. NFPA 101-2012 Edition, Section 7.10.3.2* Where approved by the authority having jurisdiction, pictograms in compliance with NFPA 170, Standard for Fire Safety and Emergency Symbols, shall be permitted. NFPA 170-09 Edition, Section 9.4 Information Shown. NFPA 170-09 Edition, Section 9.4.1 The information in 9.4.1.1 and 9.4.1.2 shall be shown on the plan area of the diagram or plan. Additional information shall be permitted to be added if it does not confuse the viewer during an emergency. NFPA 170-09 Edition, Section 9.4.1.1 The means of egress from the viewers’ location shall be shown. This shall include all exit locations, exit access paths, stairways, elevators, elevator lobbies, areas of refuge, areas of rescue assistance, shelter areas, and exterior outside assembly areas. NFPA 170-09 Edition, Section 9.4.1.2 The equipment used during an emergency shall be shown in a key or legend. This key or legend shall include fire alarm pull stations, emergency phones, defibrillators (AED), fire extinguishers (if trained to use properly), or any other building-specific emergency equipment. NFPA 170-09 Edition, Section 9.4.2 The diagram or plan shall provide emergency phone numbers. NFPA 170-09 Edition, Section 9.4.3 The diagram or plan shall provide emergency evacuation guidelines describing the emergency alert signals and when and what to do when the signals are sounded. If there are not any signals, the guidelines shall describe how the occupants will be instructed what to do in case of an emergency. NFPA 170-09 Edition, Section 9.5 Construction. The diagram shall be constructed with materials that protect it from fading and wear.”

“Evacuation and Relocation Plan CFR(s): NFPA 101 Evacuation and Relocation Plan There is a written plan for the protection of all patients and for their evacuation in the event of an emergency. Employees are periodically instructed and kept informed with their duties under the plan, and a copy of the plan is readily available with telephone operator or with security. The plan addresses the basic response required of staff per 18/19.7.2.1.2 and provides for all of the fire safety plan components per 18/19.2.2. 18.7.1.1 through 18.7.1.3, 18.7.2.1.2, 18.7.2.2, 18.7.2.3, 19.7.1.1 through 19.7.1.3, 19.7.2.1.2, 19.7.2.2, 19.7.2.3 This Standard is not met as evidenced by: 38624 Based on record review, observation, and interview the facility failed to provide an accurate location of a code red announcement per NFPA 101-2012 Edition, Section 19.7.2.1*. This had the potential to affect all patients, employees, and visitors. Findings include: Record review of the Mercy Health - Toledo Metro / CODE RED - Fire Plan effective date 01/1968 under the announcement section it stated, “When a pull station or a smoke detector has gone into alarm, the Campus Police Dispatch Center will initiate the Public Address System to state, “Attention all personnel, Code Red Fire, and fire location”. This announcement will be repeated three times. A record review of the licensed contractor pulls station report dated 01/20/24 on 02/28/24 at approximately 1:00 P.M. revealed the location of the pull stations N2-L2-M008 in the café building C, and L1-M015 was located by 3rd floor elevator. An observation during a test of the fire alarm, using the pull station labeled N2-L2-M008 on 02/28/24 at approximately 1:38 P.M. by the Outpatient Pharmacy revealed an announcement was made over the intercom that there was a Code Red located in the Oncology Lobby. Also, during a second test of the fire alarm using the pull station L1-M015 located on the 1st-floor lobby, near the chapel on the C-side of the building, a Code Red announcement stated the emergency was in oncology. Resulting in an inaccurate description of where the Code Red was located. An interview with Plant Operations on 02/28/24 at approximately 1:38 P.M. after a test of the fire alarm verified the finding by stating, “Good question” and again after a second test of the fire alarm in a different location at approximately 1:28 P.M. by stating, “Because it is in building B”. NFPA 101-2012 Edition, Section 19.7.2.1* Protection of Patients. NFPA 101-2012 Edition, Section 19.7.2.1.1 For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. NFPA 101-2012 Edition, Section 19.7.2.1.2 The basic response required of staff shall include the following: (1) Removal of all occupants directly involved with the fire emergency (2) Transmission of an appropriate fire alarm signal to warn other building occupants and summon staff (3) Confinement of the effects of the fire by closing doors to isolate the fire area (4) Relocation of patients as detailed in the health care occupancy’s fire safety plan NFPA 101-2012 Edition, Section 19.7.2.2 Fire Safety Plan. A written health care occupancy fire safety plan shall provide for all of the following: (1) Use of alarms (2) Transmission of alarms to the fire department (3) Emergency phone call to the fire department (4) Response to alarms (5) Isolation of fire (6) Evacuation of immediate area (7) Evacuation of smoke compartment (8) Preparation of floors and building for evacuation (9) Extinguishment of fire”