Ohiohealth Mansfield Hospital

“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 ensure patients’ pain was properly assessed and managed according to facility policy. This affected three patients (Patient #5, #7 and #8) of 10 patients reviewed for nursing care. Findings include: 1. The medical record for Patient #5 was reviewed on 08/14/24. Patient #5 was admitted to the emergency department (ED) on 06/19/24 at 8:00 AM with shortness of breath (SOB) and chest pain. The history and physical indicated this patient had hypertension, anemia and was receiving dialysis three times per week. Patient #5 stated the pain and SOB was similar to when she has fluid overload. Ativan 1 milligram (mg) was given by mouth at 8:22 AM for anxiety. A chest x-ray was completed which showed mild vascular congestion/edema with small bilateral pleural effusion. Facility policy titled, “Emergency Department Assessment and Reassessment Intervals” (9/2021) was reviewed on 08/15/24. This policy instructed staff to complete vital signs (VS) which include BP (blood pressure), pulse, respirations, temperature and pain scale as part of their initial assessment. This policy further instructed staff to complete a pain scale within 5 to 90 minutes after IV (intravenous), oral, intramuscular, or subcutaneous administration of medications. All abnormal VS the physician or their designee should be notified. The facility policy titled “Pain Management” (12/07/22) was reviewed on 08/15/24. This policy instructed staff to screen for the presence of pain during ED visits and at the time of admission. If pain was identified, perform a pain assessment which may include but is not limited to the following components as warranted by the patient’s condition and clinical setting to include location, pain intensity rating, description along with aggravating factors and alleviating factors. This policy further instructed staff to reassess and document after each pain management intervention in a timely and comprehensive manner. Review of Patient #5’s medical record revealed no pain score was completed in the emergency department from 8:00 AM to 2:30 PM on 06/19/24. Patient # 5 went to dialysis at 2:30 PM where the first documentation of pain was at 2:55 PM listing chest pain as 9 out of 10 with the patient being medicated with Oxycodone and dialysis treatment starting at 2:57 PM. Nursing notes at 5:54 PM revealed this patient insisted on coming off dialysis early due to cramping in her legs with a 300 milliliter (ml) bolus of normal saline given and the physician was notified. Notes further revealed Patient #5 refused the dressing change to her central line with education provided but still refused. A pre-dialysis weight was documented at 54.4 kg and post-dialysis weight of 52 kg. Patient #5 was transferred back to the ED at 6:20 PM. Nursing notes upon return to the ED indicated this patient was crying stating “my legs are cramping, and I need something for it”. The dialysis unit was contacted and informed to try Flexeril (muscle relaxer). Nursing notes stated Patient # 5’s mother called the ED at 6:23 PM stating “I’ve about had it with that place and am about to blow a gasket. My daughter was stuck in the ER all afternoon without a call light to let anyone know she needed help!”. This RN informed the mother this patient just returned from dialysis, and they would do all they could to get her comfortable with the mother verbalizing understanding. Patient #5 was medicated with Flexeril at 6:27 PM. No documentation was found in the medical record of a pain rating before or after being medicated for the cramping. This patient was transferred to a medical-surgical unit at 10:07 PM. Further review of the medical revealed vital signs were completed on 06/20/24 at 1:18 AM and 5:16 AM with no pain assessment documented. Flexeril 5 mg was given on 06/20/24 at 5:20 AM with no pain level documented. The first pain level documentated on the medical surgical unit was on 06/20/24 at 8:00 AM of of 0 out of 10. Patient #5 was discharged home on 06/20/24 at 12:54 P.M. Review of Patient #5 medical record revealed the patient returned to the ED on 07/10/24 at 10:20 AM stating their port was malfunctioning during dialysis on Monday and it was supposed to be replaced next week but now it felt like something was stabbing them. Physician notes stated this patient was complaining of a stabbing pain on the right side of the chest and she did not feel it was her heart. Orders were written on 07/10/24 at 12:17 PM to consult interventional radiologist due to a poorly functioning peripheral catheter. Patient #5’s medical record review revealed the first pain assessment was documented on 07/10/24 at 11:10 AM as a 8 out of 10 with no description of where the pain was. Patient #5 was medicated with .5 mg Dilaudid as a one time order with a 5 out 10 pain level recorded at 12:38 PM. Patient # 5 was medicated with 650 mg Tylenol at 9:47 PM with a pain level of 5 out 10 recorded then 0 out 10 at 10:47 PM. Review of Patient #5’s vital signs completed on 07/10/24 at 11:33 PM, 07/11/24 at 5:09 AM and 7:50 AM revealed the residents pain was not assessed with vitals. The next documentation of a pain assessment was at 8:25 AM on 07/11/24 of 10 out of 10. Patient # 5 was discharged home on 07/11/24 at 6:11 PM. The findings of not documenting a pain assessment upon admission, with vital signs, and with medication administration for Patient #5 as the facilities policies instruct was verified with the manager of the ED (Staff E) and Staff C through interview on 08/14/24 at 3:00 PM. 2. The medical record for Patient #7 was reviewed on 08/14/24. Patient # 7 was admitted to the emergency department (ED) on 08/08/24 at 5:14 PM after a fall at home. Nursing notes on admission listed a pain of 5 out of 10 on their right side and back at 5:17 PM. The physician ordered a CT scan of the abdomen, pelvis and chest with results showing fractured ribs. Plan was written to admit for observation due to multiple rib fractures and increased pain. Review of Patient #7’s medical record revealed Tylenol was given at 11:17 PM and the patient was transferred to the oncology floor on 08/09/24 at 12:28 AM. Vital signs were completed at 12:36 AM, 7:19 AM and 11:35 AM but no pain assessment was documented during these times. Patient #7 was discharged home on 08/09/24 at 1:30 PM with discharge instructions. The findings of not following the facility policies in regards to completing a pain assessment for Patient #7 when vital signs were completed was verified with Staff C through interview on 08/14/24 at 5:10 PM. 3. The medical record for Patient #8 was reviewed on 08/14/24. Patient #8 was admitted to the emergency department (ED) on 08/11/24 at 1:41 PM with an inguinal hernia which was enlarged and painful. Review of Patient #8’s medical record revealed no pain assessment was completed on admission or the entire time in the ED. Patient # 8 went to the operating room at 4:57 PM for hernia repair. Patient #8’s medical record revealed the first pain assessment was documented at 8:11 PM of 0 out of 10 and hourly in recovery. This patient was transferred to the intermediate care unit on 08/11/24 at 9:15 PM with the first documentation of pain at 10:11 PM of 4 out of 10. Patient #8 was medicated with .5 mcg of Dilaudid at 10:15 PM. No re-assessment of pain was completed with the next pain assessment documented of 4 out of 10 on 08/12/24 at 2:12 AM and again medicated with .5 mcg of Dilaudid. The record did not include a description of where the pain was located. The findings of no evidence Patient #8’s pain assessment was completed upon admission or when pain medication was administered were verified with Staff C through interview on 08/14/24 at 5:10 PM. .”

“MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY CFR(s): 482.22(b)(1), (2), (3) The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. (1) The medical staff must be organized in a manner approved by the governing body. (2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy. (3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: (i) An individual doctor of medicine or osteopathy. (ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located. (iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located. This Standard is not met as evidenced by: 21893 Based on staff interview and document review, the facility failed to ensure the medical staff were accountable to the governing body for the quality of the medical care provided to the patients for one of 10 patient records reviewed (Patient #1). This had the potential to affect all patients presenting to the cath lab. The cath lab performed 736 diagnostic and 536 non-surgical coronary revascularizations in the cath lab in the last 12 months. Findings include: Review of the medical record for Patient #1 revealed arrival on 12/04/23 to the emergency department (ED) at 11:11 AM by ambulance. The patient was breathing and unresponsive. The patient lost pulses as he was transferred from the ambulance cot to the ED cot. A STEMI (ST-elevation myocardial infarction) alert and Code Blue were called and CPR (cardiopulmonary resuscitation) was started at 11:13 AM. Chest compressions were done manually at first and then a Lucas Device (automatic chest compression device) was placed and took over all chest compressions. ROSC (return of spontaneous circulation) was achieved but the patient lost pulses again and CPR was reinitiated. At 11:24 AM, a foley catheter was placed and the patient was intubated. At 11:37 AM, Patient #1 was taken to the cath lab emergently with the Lucas Device doing chest compressions. At 11:53 AM, ECMO (extracorporeal membrane oxygenation) was initiated. At 12:03 PM, the CPR ended. Patient #1 was transferred to another facility for additional care later that day. Review of the staff list for the cath lab revealed there were six Registered Nurses (RN) and five Radiologic Technologists (Rad Techs) in the cath lab. On 01/23/24 from 1:18 PM to 3:20 PM, seven cath lab staff (Staff F, G, H, I, J, K, and L) were interviewed individually. The staff collectively stated that training could be better, and that it was not well defined. The staff stated there had only been one instance of a Lucas Device in the cath lab so far. They stated they had not worked with the Lucas Device before and had not had any training on it. They all stated they had not had education on the ECMO process as to what their role was, what to monitor for specifically, how to provide care, and what to document. They reported there had been a few ECMO cases in the cath lab lately. Personnel files were reviewed for Staff G, H, J, and S. The personnel files lacked documentation of any education on Lucas Devices or ECMO. On 01/24/24 at 2:00 PM, Staff O verified the cath lab staff had not received education on the Lucas Device. Staff O stated that last year the staff had attended a Cardiogenic Shock lecture which included information on ECMO in general, but not specific to their position. This deficiency represents non-compliance investigated under Substantial Allegation OH00149142.”