O U Medical Center

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 36712 Based on observation, record review and interview, the hospital failed to ensure: 1. patients and/or responsible persons had accurate notice of patient rights regarding the grievance and complaint processes for the facility (facility form, titled “Patient Rights and Responsibilities”) for all patients and; 2. signs posted in public viewing areas reflected accurate notice of patient rights regarding the grievance and complaint processes for the facility (facility poster, titled “Patient Rights and Responsibilities”) for all patients. The failed practice had the potential to affect the ability of all past and current patients to make a complaint and/or file a grievance. Findings: On 12/16/24 at 11:00 a.m., during a tour of the facility, the surveyor observed a poster (public signage). The facility poster titled, “Patient Rights and Responsibilities” showed incorrect information for patients on how to contact the Oklahoma State Department of Health or QIO for the resolution of complaints and grievances. The facility poster “Patient Rights and Responsibilities” documented the following. If you would like to bypass the hospitals complaint system, you can contact the: Oklahoma Department of Health Protective Health Services 1000 NE 10th Street Oklahoma City (405)271-6576 The poster documented a previous OSDH address and phone number that was obsolete for over four years. A Review of a facility form titled, “Patient Rights and Responsibilities” given to patients upon admission did not list current contact information for the Oklahoma State Department of Health and showed that the QIO was listed as KEPRO (an oversite organization) with a telephone number of (844)430-9504. The facility form did not show the correct contact information for the current QIO or the correct name. On 12/17/24 at 11:27 a.m., Staff #U reviewed current OSDH website information which stated: “Complaints against non-long term care facilities may be filed electronically by email: medfaccomplaints@health.ok.gov or by calling (405) 426-8470 or by written statements using the Medical Facilities complaint form and mailed to the mailing address listed below: Oklahoma State Department of Health Medical Facilities 123 Robert S. Kerr Ave., Suite 1702 Oklahoma City, OK 73102-6406” Staff #U stated: 1. “The “Patient Rights and Responsibilities” document given to patients on admission did not contain correct information on how to contact the Oklahoma State Department of Health to file a complaint and; 2. The poster titled, “Patient Rights and Responsibilities” did not list the correct contact information for patients to make a complaint or file a grievance with the Oklahoma State Department of Health or the current QIO. 39648”

“PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES CFR(s): 482.13(a)(2)(ii) At a minimum: The grievance process must specify time frames for review of the grievance and the provision of a response. This Standard is not met as evidenced by: 36712 Based on record review and interview, the hospital failed to ensure compliance of facility policy and procedures for resolution of a patient grievance for one (Patient 1) of 30 patients. The failed practice had the potential to impact the ability of patients and their representatives to make complaints and/or grievances. Findings: A facility policy titled, “Patient Complaint and/or Grievance Resolution” stated: “complaints from patients will be investigated promptly and resolution measures initiated. All grievances will be reviewed, and a written response given to the complainant within 7 days of receipt. (Facility name withheld) will inform the patient in writing that (Facility name withheld) is working on a resolution of the grievance and a written response will be given not to exceed 28 days.” Patient 1 Review of a patient grievance dated 08/28/24 showed a patient care and treatment complaint/grievance that occurred 03/24/24. Documentation showed an initial contact to the facility from the patient on 08/23/24 with an initial facility response letter dated 08/28/24. Follow up complaint/grievance letter dated 12/17/24 showed the complaint/grievance was reviewed, investigated, and resolved by the facility. On 12/18/24 at 2:30 p.m., Staff A stated the facility did not follow their complaint and grievance policy and procedures in the review, investigation, and follow up of the complainant.”

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 36712 Based on record review and interview, the hospital failed to ensure timely notice of decision related to a patient grievance for one (Patient #1) of 30 patients. The failed practice had the potential to affect the ability of patients and their representatives to have resolution of complaints and/or grievances. Findings: A facility policy titled, “Patient Complaint and/or Grievance Resolution” stated, “complaints from patients will be investigated promptly and resolution measures initiated. All grievances will be reviewed, and a written response given to the complainant within 7 days of receipt. (Facility name withheld) will inform the patient in writing that (Facility name withheld) is working on a resolution of the grievance and a written response will be given not to exceed 28 days.” Patient #1 Review of a patient grievance dated 08/28/24 showed a patient care and treatment related complaint/grievance that occurred 03/24/24. Documentation showed an initial contact to the facility from the patient on 08/23/24 with an initial facility response letter dated 08/28/24. Follow up complaint/grievance letter dated 12/17/24 (115 days from the date the complaint/grievance was reported) showed the complaint/grievance regarding patient care and treatment was reviewed, investigated, and resolved by the facility. On 12/18/24 at 2:30 p.m., Staff A stated the facility did not follow their complaint and grievance policy and procedures in the review, investigation, and follow up to the complainant.”

“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: 36712 Based on record review and interview, the hospital failed to ensure medical and nursing surveillance was provided for timely recognition of early clinical deterioration and timely intervention for one (Patient #15) of 30 patients. Findings: Patient #15 A review of the clinical record showed the patient was admitted to the hospital 12/11/24 with orders to notify the physician if systolic BP was greater than 180 or less than 90 and a diastolic BP greater than 90 or less than 60. Documentation showed on 12/12/24 10:00 pm BP 125/99, 12/13/24 12:00 am BP 127/45, 1:00 am BP 123/98, 2:00 am BP 83/63, 3:34 am BP 156/58, 11:00 am 146/46, 1:00 pm 144/56, 3:00 pm BP 143/49, 8:17 pm BP 122/107, 12/14/24 12:00 am BP 134/49, 2:00 am BP 147/54, 5:00 am BP 146/54, 10:00 pm BP 126/49, 11:00 pm BP 131/48, 12/15/24 12:00 am BP 127/47, 10:00 am BP 147/51, and 12/16/24 2:02 am BP 142/58. Documentation showed no re-assessment of the patient or recheck of the blood pressure and showed no physician notification of the BP readings outside of the reporting parameters. On 12/18/24 at 8:31 a.m., Staff S stated: 1. The patient’s BP readings were outside of the ordered parameters and; 2. The nurse should have re-checked the BP’s and if the BP readings remained outside of the reporting parameters should have notified the physician. 39648”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 36712 Based on clinical record review and staff interview, the facility failed to ensure a medication was administered as ordered by the physician for one (Patients #19) of 30 patients. Findings: Patient #19 A review of the clinical record showed a physician’s order for Tenofovir Alafenamide 25 milligrams (a medication to treat systemic viral infection). On 11/28/24 at 8:00 a.m. Staff KK documented that Tenofovir Alafenamide 25 milligrams was not available on the unit, and the pharmacy was paged. Documentation showed the pharmacy sent the nurse a chat through Epic (clinical record documentation system) with the location of the medication on the unit (floor). Documentation showed no medication was administered, no physician notification and no changes in orders. On 12/18/24 at 11:01 a.m., Staff S stated: 1. The pharmacist instructed the nurse on the floor where on the floor to locate the medication and; 2. The nurse should have re-timed the medication and administered it. 39648”

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 42140 Based on record review and interview, the hospital failed to ensure dated and timed consents for one (Patient #14) of thirty patients. Findings: Patient #14 Review of a blood consent showed no documentation of the date and time of the patient’s signature. Review of a document titled “Important Message from Medicare” showed no documentation of the time of the patient’s signature. On 12/16/24 at approximately 3:00 PM, Staff H reviewed the blood consent and “Important Message from Medicare” documents and stated the patient’s signatures were not dated and timed and should have been.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 36712 Based on observation, record review and interview, the hospital failed to ensure the development and adherence of a clear patient food storage protocol for one (7 North Tower) of two units. This failed practice had the likelihood to result in process confusion and placed all patients at risk for spoilage of food items and the risk of infection. Review of a sign posted on the 7 North Tower west nutrition room refrigerator on 12/16/24 at 10:30 AM read in part, “FAMILIES PLEASE REMEMBER TO LABEL YOUR CONTAINERS WITH OUR FOOD STORAGE TAGS (Last name and Room Number).” Affixed to the sign was an orange label that read, “FOOD STORAGE TAG” with a line for “ITEM,” a line for “DATE,” and a line for “TIME.” Review of a sign posted on the 7 North Tower west nutrition room refrigerator on 12/16/24 at 10:30 AM read in part, “Any food MORE THAN 48H will be thrown away.” Review of a sign posted on the 7 North Tower west nutrition room refrigerator on 12/16/24 at 10:30 AM read in part, “ATTENTION FAMILY/PATIENT TAKE YOUR FOOD TO THE STAFF TO BE LABELED BEFORE YOU PLACE IN THE FRIDGE.” Findings: During a tour of 7 North Tower on 12/16/24 at 10:30 AM, the following was observed in the west nutrition room freezer: 1. A clear plastic cup with frozen pink ice cream and no lid bearing an orange label that read, “shake, 12-3, Rm 128 [Patient Name], 6:08” (11 days past due) 2. A pint container of Haagen Dazs ice cream bearing an orange label that read, “[Patient Name], 3-12-24” (277 days past due) On 12/16/24 at 9:51 AM, Staff #C stated they were not sure who was responsible to discard food older than 48 hours. On 12/16/24 at 10:15 AM, Staff #D stated the Health Unit Coordinators discard old food and try to do it every week. On 12/16/24 at 10:30 AM, Staff #E stated the following: 1. The shake and pint of ice cream were older than 48 hours. 2. The shake should have been covered. On 12/16/24 at 10:49 AM, Staff F stated the following: 1. Nourishment people as well as charge nurses discard old food. 2. Patients and families label their food (in contradiction to one of the posted signs) Administrative policy and procedure for patient use food storage and infection prevention was requested. No documentation was provided.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 36712 Based on record review and interview, the facility failed to ensure services were provided in compliance with the requirements of EMTALA (Emergency Medical Treatment and Labor Act) for one (Patient #1) of 30 patients reviewed. This failed practice had the potential to place hospital staff, including medical staff, at risk of failure to uphold responsibilities under the EMTALA requirements. Cross-referenced: See tag A2407”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 36712 Based on record review and interviews, the hospital failed to ensure stabilizing treatment for one (patient #1) of 30 patients reviewed. The deficient practice placed the patient and unborn child at risk of a threat to their health and safety. Findings: Patient #1 A review of the clinical record showed the patient was seen in the obstetrical emergency department on 03/16/24 for complaints of contractions, was diagnosed with latent phase labor and admitted to inpatient hospital services from 03/16/24 to 03/19/24. The patient returned to the hospital obstetrical emergency department on 03/22/24 and again on 03/24/24 for complaints of increased contractions and spontaneous rupture of membranes. Documentation dated 03/22/24 showed a medical screening examination (MSE) began at 11:01 a.m. The examination showed the patient was 37 weeks in pregnancy development, five centimeters (cm) widening of the cervix and the cervix was 80% (percent) thinned at a station of -2 (negative two), with an active diagnosis of ongoing latent phase labor. At 12:38 p.m., the patient was rechecked which documented no changes. At 2:11 p.m., the patient was discharged home with instructions to follow up with the obsterical primary care physician in clinic. There was no documentation if the contractions had ceased, if patient needed pain management or if all management options for her latent phase labor were discussed. Documentation dated 03/24/24 showed an MSE began at 6:05 p.m. The examination showed the patient was at 37 weeks and four days in pregnancy development, 5 (five) cm widening of the cervix and the cervix was and was 80% thinned at a station of -2 (higher in the pelvis), with an active diagnosis of ongoing latent phase labor. At 8:57 p.m., the patient was rechecked, which documented no changes. At 10:17 p.m ., the patient was discharged home with instructions to follow up with the obsterical primary care physician in clinic on 3/25/24. There was no documentation if the contractions had ceased, if patient needed pain management or if all management options for her latent phase labor were discussed. the MSE ended documentation showed the labor had not progressed, contractions remained intermittent and variable, and the patient continued to complain of pain. The patient was not admitted to observation status and was discharged home with instructions to follow up with the obstetrical primary care physician in clinic and showed no medical determination the patient required pain management. Documentation showed no shared decision making between the obstetrical staff and the patient for management of latent phase labor and showed no medical determination the patient required pain management. A review of an ambulance run report dated 03/25/24 at approximately 3:45 a.m., showed the patient had experienced an unattended birth at home and was transferred to Hospital B for obstetrical and pediatric post-natal evaluation and follow up care. The documentation showed the patient and newborn were admitted to in-patient care services for observation at Hospital B from 03/25/24 to 03/27/24. On 12/17/24 at 2:00 p.m., Staff O and Staff R were interviewed and stated: 1. The decision to admit patients to observation status is determined depending on signs of active labor or if an obstetrical problem is identified during the MSE. 2. After the obstetrical examination begins the nurse will do a maternal fetal assessment and assign a score. 3. When a patient is in the obstetrical emergency department, their attending obstetrical physician is notified after the patients are fully evaluated as a part of the decision-making process. 4. We attempt to resolve complaints or problems with the patients when they are happening. A ‘code help’ is a bedside meeting with the patient by the doctor on duty and the nursing staff to resolve patient complaints about care. Staff O further stated the patient wanted an induction, she was informed the hospital utilized the national standard of 39 weeks in pregnancy development for routine inductions and that she was at 37 weeks in pregnancy development so that was not an option at that time. Administrative policy and procedure for treatment of latent phase labor and admission for in-patient care service protocols were requested. No documentation was provided On 12/18/24 at 1:20 p.m., Staff KK was interviewed and stated: 1. When patients present to the obstetrical emergency department they are given a manual exam, hooked up to a contraction and fetal heart monitor, and lab and other diagnostic testing are done on a case-by-case basis as needed. 2. Patients are admitted to observation or full in-patient status if signs of active labor progress or when there is a problem. Some patients are admitted to observation status if progress is slowed with active signs of labor. 2. The patient’s own physician is notified if a patient needs to be admitted for treatment or observation status. They are then admitted under their own obstetrical physician. 3. Patient #1 had been in to the obstetrical emergency department (OB ED) several times over the course of a week or so. She was admitted to an in-patient stay for observation and monitoring but failed to progress and was discharged home. 4. Patient #1 requested an induction to speed up the labor and delivery during the last visit to the OB ED. She was informed that routine inductions were only done after the 39th week of pregnancy development and she was at 37 weeks of pregnancy development. She was discharged home with instructions to return to the OB ED if contractions progressed or with any problems. Staff KK further stated she was not aware the patient continued to have contractions and delivered at home in the early morning hours 03/25/24.”