Mercy Medical Center

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 44104 Based on interview, review of medical record documentation for 5 of 7 patients (Patients 21, 22, 23, 24, and 25), and review of P&Ps it was determined that the hospital failed to fully develop and implement P&Ps that ensured each patient’s right to receive care in a safe setting. The hospital failed to fully investigate incidents and document follow up actions such as interviews, review of patient assessments, staff training, education provided, and/or corrective or remedial actions taken to prevent recurrence. The hospital failed to document whether abuse and/or neglect were ruled out. The Interpretive Guidelines reflect: * Investigate The hospital ensures, in a timely and thorough manner, objective investigation of all allegations of abuse, neglect or mistreatment. * Report/Respond. The hospital must assure that any incidents of abuse, neglect or harassment are reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State, or Federal law. Findings include: 1. The policy titled, “Adverse Event Management and Communication,” with an origination date of 07/01/2022 and last revised 05/30/2025 was reviewed and reflected: * “Supportive Data ... Event Reporting and Management Policy, Clinical A-023 ... CSH CANDOR Playbook 05-24-2024.” * “Attachments ... CSH CANDOR Playbook 05242024.pdf.” 2. The policy titled, “Event Reporting and Management Policy, Clinical A-023,” effective 10/24/2023 was reviewed and reflected: * “The documentation and reporting of patient safety events and incidents is a quality improvement effort. Reporting of events aids efforts to improve the culture of safety for patients and all CommonSpirit employees. Analysis of quality improvement efforts and promoting a culture of safety identify ways to mitigate risk and facilitate clinical quality care improvements.” 3. A document titled, “CANDOR Playbook” dated “May 24, 2024” was reviewed and reflected: * “Identification of CANDOR Events: Event Reporting is the foundation of the CANDOR process. The event reporting system becomes, not only where the event gets reported but is also the mechanism for identifying system issues that may lead to error and/or patient harm.” * “Investigation and Analysis: This is critical to understanding what happened, finding root causes and developing action plans and prevention strategies to prevent like events from recurring.” * “CANDOR Event Checklist ... Initial Event Review/Investigation” - “Schedule in-person interviews with key staff involved ...” - “Collect medical records and other documents/input to establish the timeline of the event.” - “Identify potential issues for peer review in accordance with Just Culture principles.” - “Develop the investigation strategy using evidence-based practices.” - “Identify policies and procedures that apply to the event. Determine if they were followed or are in need of revision.” - “Enter all information into IRIS.” 4.a. During an incident/adverse event review with the DQ on 07/17/2025 beginning at 1200, the following incidents were reviewed and reflected: 4.b. Regarding Patient 21: An Event form and investigation reflected Patient 21 experienced an unwitnessed fall incident on 05/21/2025. * IR documentation reflected the fall occurred at “10:15.” * “Reviewer Follow-Up” reflected the fall occurred at “10:15 ... Deviation Lead to Event? No ... Description of Deviation Fall precautions in use ... Dept Reviewer Comments Patient was more alert and able to answer some questions so restraints were removed. Patient attempted to get out of bed without help and fell to ... knees. Unable to state why ... was getting out of bed. No injury to patient. Bed alarm was in use and staff responded as soon as they heard the alarm, Continued fall precautions and use of virtual sitter.” * The “Preventability” section reflected “Not Preventable.” * The “Patient Safety Manager Comments” section was blank. * The “Event-Specific Information” section reflected “Post Fall Debrief Complete? No [and] Post Fall Debrief Attached? Yes.” * The “Post Fall Debrief Tool” attached to the IR reflected a fall occurred at “1040?” with the last rounding noted at “1035.” “Needs Addressed” had “No” noted. Under the “Determine the Type of Fall” section was a checked box next to “Anticipated Physiological fall due to known risk factors (Preventable)” and under “Proactive Strategies for Fall Prevention” was noted “none, patient already high fall risk ... bed alarm already in place.” The “Communication” section, “What was learned from this event/debrief that other units/departments/Virtual Companion could learn from?” was blank. The “Manager/Director or Designee Review” section was also blank. There was no form completion date noted. The documentation lacked a clear, complete and thorough investigation and follow up actions in accordance with hospital P&Ps. Information provided was not consistent. For example, the reviewer follow-up noted the fall occurred at 1015, however the Post Fall Debrief Tool noted that Patient 21 had been last rounded on at 1035, 20 minutes after Patient 21’s noted fall time. Additionally, the Post Fall Debrief Tool indicated that staff were unaware when the actual fall occurred as evidenced by the noted “1040?” documentation. Further, there was no indication that Patient 21’s fall risk had been reassessed when their restraints were removed, i.e., ability to get OOB safely, steady on feet, steady gait, provided education regarding fall risk, etc. The review of the incident indicated that no deviations occurred and that the fall was “Not Preventable,” however the Post Fall Debrief Tool noted that the fall was “Preventable” and that the patient’s needs had not been addressed. There were no notes in the investigation that indicated whether policy and procedures had been followed, or whether thorough staff interviews and debrief had been conducted in a timely manner as the debrief tool was undated. It was unclear whether precautions in place were reassessed as appropriate, or whether abuse and/or neglect were ruled out. 4.c. Regarding Patient 22: An Event form and investigation reflected Patient 22 was admitted for a hip fracture on 06/28/2024, surgery was recommended, but was cancelled twice due to anesthesiologist concerns. * IR documentation reflected that the Charge RN expressed concerns about the delayed procedure on 07/01/2024. * “Reviewer Follow-Up” reflected “Referred to MSQIC”. * “Deviation Lead to Event? ... No” * “Description of Deviation ... need to investigate to determine.” * “Classification ... Comments ... MSQI [sic] to investigate, however harm was ‘potential’ and it was RN opinion.” * The incident was closed on 07/07/2024 with no noted outcome nor determination of investigation outcome. The documentation lacked a clear, complete and thorough investigation and follow up actions in accordance with hospital P&Ps. Although the incident was referred to MSQIC for further investigation, there were no additional notes in the IR to indicate whether policy and procedures had been followed, or whether staff interviews had been conducted. It was unclear whether the concerns were appropriate, or whether abuse and/or neglect were ruled out. 4.d. Regarding Patient 23: An Event form and investigation reflected Patient 23 was admitted for myocardial infarction. On 07/05/2024, Patient 23’s family filed a grievance that the patient was not turned and patient care was not in accordance with hospital P&Ps. * The IR documentation initial report reflected, “Care of patient assumed by LPN ... at the start of night shift. Per report from family, [LPN] stated that moving patient at all would result in ‘imminent death.’ Therefore pt was not repositioned or changed after incontinence. Pt’s family members crying in the room when [staff] assumed care and complained that pt was afraid, painful and uncomfortable. No patient care charted for this patient from CNA. During bedside report between [staff] and [LPN], [LPN] stated that ‘turing [sic] the patient would mean imminent death sentence.’ while in front of the patient’s family.” * “Patient Harmed? (Reporter’s Assessment) ... Yes.” * “Event-Specific Information ... Reported Injuries ... Other (please specify) ... Other Injury Details ... pt afraid, in pain and sat in urine all night.” * “Contributing factors ... Staff - inattention ... Staff - Performance ... Patient Injury .. No Apparent Injury ... Reviewer Severity ... No Detectable Harm.” * “Did a deviation from performance standards by staff lead to this event? ... Yes ... Staff not following protocol and poor interaction with patient and family.” * “What universal skill(s) could have been used to prevent this incident from occurring?” This was blank. * “Department Reviewer Comments/Actions ... Discussion and follow up with staff member by ... director. Patient repositioned, cleaned, and comforted.” * “Safety First Review ... - Is this event related to patient care? ... Yes - Was there a deviation from generally accepted performance standards (GAPS)? ... Yes - Did the event reach the patient? ... Yes - Did the event cause moderate to severe harm or death? ... No - Patient Harm Determination ... Precursor Safety Event - Level of Severity ... Circumstances that reached the patient but did not cause harm - Preventability ... Likely & Clearly Preventable” * The incident was closed on 07/22/2024. The documentation lacked a clear, complete and thorough investigation and follow up actions in accordance with hospital P&Ps. For example, it was unclear whether the patient was assessed for skin integrity issues such as maceration as Patient 23 “sat in urine all night.” There was no documentation of staff interviews other than “Discussion and follow up with staff member by ... director.” It was unclear what the discussion included or whether the staff received additional education and training. There was no documentation whether abuse and/or neglect were ruled out. 4.e. Regarding Patient 24: An Event form and investigation reflected that on 07/09/2024, Patient 24 needed assistance to use the restroom. An Radiology technician offered to assist the ED technician with the patient and the patient “ended up on the floor.” * The IR documentation initial report reflected, “Pt needed to use the restroom. Rad tech ... came to take the patient to imaging. Ed tech ... was at bedside and due to the patient’s body habitus was looking for additional staff to assist in getting patient up. [Radiology tech] claimed [they] were able to help [the ED tech] and the patient ended up on the floor. [ED Tech] reports assisting the patient to the floor.” * Immediate Actions Reported were “I came to the room to assist in getting the patient up and found [patient] to be sitting on the ground in the middle of the room. With the assistance of additional staff: [Staff 1, Staff 2 & Staff 3] and [ED Tech], we placed a Hoyer sling under the patient and raised [them] into the air. Placed [them] on a stretcher. [Radiology Tech] able to take the patient to imaging. [Staff name], Charge Nurse, was notified and upon return to department patient was moved to the main department ... No injuries were reported by patient.” * “Patient Harmed? (Reporter’s Assessment) ... No.” * “Event-Specific Information ... Patient’s activity prior to fall ... Changing position ...” * “Anyone attempt to minimize fall? ... Assisted by staff.” * “Contributing Factors ... Transfer Technique-Lifting/assistive devices not utilized.” * “Patient Injury ... No Apparent Injury.” * “Did a deviation from performance standards by staff lead to this event? ... Yes.” * “Additional details regarding deviation ... Use of transfer tools and or additional help.” * “What universal skill(s) could have been used to prevent this incident from occurring? ... Stop, Think, Act, Review (S.T.A.R.)” * “Department Reviewer Comments/Actions ... IRIS should be reviewed by imaging ... Reviewed with [Radiology Tech].” * “Safety First Review ... - Is this event related to patient care? ... Yes - Was there a deviation from generally accepted performance standards (GAPS)? ... Yes - Did the event reach the patient? ... Yes - Did the event cause moderate to severe harm or death? ... No - Patient Harm Determination ... Precursor Safety Event - Level of Severity ... Circumstances that reached the patient but did not cause harm - Preventability ... Likely & Clearly Preventable” * The incident was closed on 07/26/2024. * The “Post Fall Debrief Tool” attached to the IR reflected a fall occurred on 07/09/2024 at 2150. “Needs Addressed” had “Bathroom” noted. Participants included the patient, primary RN, and ED Tech. “Immediate Cause of the Fall: Ask the patient and write down the answer in the Patient’s own words” noted the following, “’Moving to go with [staff member] over there’ (pointing at [Radiology Tech] from Radiology). ‘My foot hurts more.’” Under the “Determine the Type of Fall” section was a checked box next to “Anticipated Physiological fall due to known risk factors (Preventable)” and under “Proactive Strategies for Fall Prevention” was noted “Pt is being moved from Rm ... to Rm ... in [their] main department ... Radiology staff should not insist on getting large pts up when nursing staff say no wait for additional help.” The “Communication” section was blank. The “Manager/Director or Designee Review” section noted “other departmental staff not listening to ED techs/not feeling they are heard.” The manager or designee signed and dated the form on 07/09/2024. The documentation lacked a clear, complete and thorough investigation and follow up actions in accordance with hospital P&Ps. For example, it was unclear whether the patient was thoroughly assessed for injury as the investigation report reflected, “Patient Harmed? (Reporter’s Assessment) ... No.” However, the Fall Debrief included a patient statement that reflected, “My foot hurts more.” There was no documentation that an assessment of the patient’s foot was completed. Additionally, the proactive strategies noted that “Radiology staff should not insist on getting large pts up when nursing staff say no wait for additional help.” However, the investigative report did not reflect that nursing staff were present and only indicated that the Radiology tech and the ED tech were present at the time of the fall. It was unclear what the discussion included or whether the staff received additional education and training. Department Reviewer Comments reflected that “IRIS should be reviewed by imaging ... Reviewed with [Radiology Tech].” It was not clear what exactly was reviewed with the Radiology Tech. There was no documentation whether abuse and/or neglect were ruled out. 4.f. Regarding Patient 25: An Event form and investigation reflected that on 08/20/2024 a contracted RN administered a medication to Patient 25 that had been prescribed to another patient. * The IR documentation initial report reflected, “Pt had order for home med: Trelegy Ellipta Inhaler (... RN to administer instead of RT). Inhaler was pulled from patient lockbox by NOC RN and administered at 2219 ... Wrong medication which was previously administered to patient [name] was administered to wrong patient [Patient 25]. Patient verified that Dulera ‘blue inhaler’ was what she received by NOC RN.” * “Immediate Actions Reported” - “Primary RN notified CN” - “Primary RN had pt visually verify medication received.” - “Primary RN verified w/pharmacy that Trelegy is not medication carried by hospital and patient verified home inhaler was not brought in.” - “Isolation precautions from previous patient were assessed to determine possible risk to current patient.” - “Previous patient had no current isolation precautions though a hx of MRSA nares and Candida Albicans.” - “Dulera clearly labelled [sic] on box and medication with previous patient label x3.” * “Patient Harmed? (Reporter’s Assessment) ... No.” * “Event-Specific Information ... Incident Subtype ... Incorrect patient ... Medication Mode ... Administering ... High Alert Med ... No ... Brand ... Dulera ... Drug Class ... Asthma/COPD Therapy Combinations ... Tier 1 Drug Class ... Respiratory Therapy Agents.” * “Reviewer Follow-Up ... Patient/Family Informed Date ... 08/21/2024 ... Patient Injury ... No harm, reached patient.” * “Contributing Factors ... - “Failure to Validate &/or Verify” - “Fatigue or Lack of Sleep” - “Lack of Critical Thinking or Situational Awareness” * “Did a deviation from performance standards by staff lead to this event? ... Yes.” * “Additional details regarding deviation ... See narrative.” * “What universal skill(s) could have been used to prevent this incident from occurring? ... Ask Clarifying Questions ... Crosscheck & Coach ... Stop, Think, Act, Review (S.T.A.R.)” * “Department Reviewer Comments/Actions ... New Contract RN [name] gave medication-was in patient’s locked drawer. This medication was not scanned but manually entered. Medication was labeled x3 with a different patient’s name. Medication is not what is ordered on the chart so Dulera was given but home medication was ordered-patient had not brought in as of this writing; patient reported [they] did get the ‘Blue inhaler’ which is the incorrect medication. Will follow up with this contract RN.” * “Special Reviewer Comments/Actions ... Lapse in medication verification and bypass of the ... system, exacerbated by presence of discontinued medications from a prior patient in the care area, in violation of discharge routines.” * “Feedback for Additional Reviewer ... Please review for consideration for Nursing QI.” * “Safety First Review ... - Is this event related to patient care? ... Yes - Was there a deviation from generally accepted performance standards (GAPS)? ... Yes - Did the event cause moderate to severe harm or death? ... No - Patient Harm Determination ... Precursor Safety Event - Level of Severity ... Circumstances that reached the patient but did not cause harm - Preventability ... Likely & Clearly Preventable” * The incident was closed on 08/26/2024. The documentation lacked a clear, complete and thorough investigation and follow up actions in accordance with hospital P&Ps. For example, “Department Reviewer Comments/Actions” reflected “New Contract RN [name] gave medication-was in patient’s locked drawer.” The investigation did not note whether there were interviews conducted regarding the process of discharging patients or whether the medication had been returned to the previous patient. Additionally, the reviewer noted, “This medication was not scanned but manually entered ... Medication was labeled x3 with a different patient’s name. Medication is not what is ordered on the chart ...” There were no notes regarding whether additional training regarding medication administration was provided to the contract RN. The reviewer noted “Will follow up with this contract RN,” however, it was unclear what the follow up encompassed and therefore there was no assurance similar incidents/events involving other patients would not recur. 5. During the incident/adverse event review with the DQ on 07/17/2025 beginning at 1200, the DQ confirmed Findings 4.b. - 4.f. The DQ confirmed that the investigations lacked documented actions and follow up in accordance with hospital P&Ps. For Finding 4.c. the DQ stated that there was “not much on this.” For Finding 4.d, the DQ stated there’s “not a lot of information.” Additionally, the DQ acknowledged that it was not clear what was reviewed with the “Radiology Tech” in Finding 4.e.”

“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: 44104 Based on interview, and review of medical record documentation for 4 of 14 patients (Patients 2, 7, 8, and 9), and review of P&Ps it was determined that the hospital failed to fully develop and implement P&Ps that ensured each patient’s right to receive care in a safe setting. The hospital failed to complete and document admission medication reconciliation assessments in accordance with hospital policies related to the nursing standard of care, and admission protocols. Findings include: 1. The policy titled, “Medication Reconciliation” dated as effective on 12/07/2023 was reviewed and reflected: * Purpose: “To obtain a patient’s current medication list since the last provided, allowing for a way of reconciling medication information from the time of admission throughout the hospital stay, and at the time of discharge.” * “Medication Reconciliation: Medication reconciliation is the ongoing process of comparing the medications that the patient has been taking ‘prior to arrival’ ... with the medication that the organization is about to provide. The process requires patient/caregiver involvement in obtaining and/or verifying a complete list of the patient’s current medications upon the patient’s admission to the organization to which medication orders can be compared. Medication Reconciliation includes medication reconciliation of all active medication orders as part of the workflow when there is a change in level of care, including postoperative, or discharge.” * “Patient Medication List ... The first step of the medication reconciliation process is to collect a complete list of current medications for each patient ... A current medication list is obtained as part of the initial assessment in the inpatient acute setting ... A good faith effort will be made to obtain a home medication list ... If a list of the patient’s medication cannot be obtained from the patient ... documentation of why this list could not be obtained should occur.” * “Reconcile Medications ... Medication Reconciliation is the responsibility of the provider ... Reconciliation occurs on admission ... Where multiple providers are involved in the care of the patient, the Attending is responsible for the initial medication reconciliation.” 2. The policy titled, “Admission Assessment & Screening of Patients” dated as effective on 09/14/2022 was reviewed and reflected: * “It is the policy of Mercy Medical Center that all patients admitted to the facility will receive a complete head-to-toe assessment ... Within the scope of care of each patient care unit; time frames are established for completion of the patient admission assessment along with criteria on what will be included in the assessment/reassessment process.” * “Admission Assessment and Time Frames[:]” - “Medical/Surgical/Pediatrics ... Target ... 30 minutes ... Completion ... 12 hours...” - “ICU ... Target ... 5 minutes ... Completion ... 12 hours...” * “As part of the admission assessment each patient will be screened for additional care needs or support as identified by developed criteria of patient care support services. This screening will include an assessment of patients [sic] ... Medication reconciliation.” 3. The policy titled, “Nursing/Pharmacy Relationship” dated as effective on 12/07/2023 was reviewed and reflected: * “To provide maximum benefits of pharmaceutical therapy for patient care, Nursing Department and Pharmacy will acknowledge the following responsibilities ... Nursing Department will ... Notify Pharmacy of medication error and adverse drug reactions ... See information from Pharmacist on new drugs ...” * “Pharmacy will ... Maintain patient profile ... Cross check for order accuracy ... “ The policy failed to address how the Pharmacy would prevent potential adverse drug reactions when a patient’s home medications were unknown or when a medication reconciliation had not been completed within the 12 hour timeframe as specified in the P&P, “Admission Assessment & Screening of Patients.” The P&P failed to mention that Pharmacy would verify and reconcile the patient’s home medications prior to initiating medications ordered by the patient’s physician. 4. The policy titled, “Nursing Department Standards” dated as effective on 09/12/2022 was reviewed and reflected: * It is the policy of Mercy Medical Center that the Nursing Department will be responsible for nursing care throughout the facility under the direction of the Vice President of Nursing Services.” * “To accomplish this goal, Mercy Medical Center provides ... nursing/patient care staff members to ... Assess the patient’s nursing needs ... Prevent complications and promote improvement in the patient’s condition and wellness ... Alert other care professionals to the patient’s condition as appropriate.” * “Nursing Staff Communication Responsibilities ... Staff RN’s direct ... questions of physician practice standards to the Unit Director and/or the Nursing Coordinator whom [sic] will assist in the process clarification.” * “Nursing staff coordinates ... multidisciplinary team coordination of ongoing patient care...” * “Patient safety and protection needs are safeguarded by adherence to patient care standards ...” 5. The policy titled, “Standards of Nursing Practice” dated as effective on 09/12/2022 was reviewed and reflected: * “It is the policy of Mercy Medical Center to ensure that patient care standards are in place and consistent with established nursing process standards.” * Quality, productivity, and responsiveness to the needs of patients, physicians and staff are the foundation of care delivery.” * “Nursing care provided demonstrates evidence of professional responsibility and accountability. This includes ongoing collaboration with interdisciplinary team members ... This is evidenced by... Coordination of other disciplines in the patient’s assessment ...” 6. The policy titled, “Care Coordination Discharge Planning Policy, Clinical A-016” dated as effective on 09/12/2022 was reviewed and reflected: * “The purpose of this Policy is to provide and operational definition of discharge planning ...” * “Discharge planning is a collaborative process that includes the ... attending physician, nursing and other member(s) of the multidisciplinary care team ...” * “... discharge needs are identified during the first stage screening ...” * “All activities related to discharge planning ... are documented in the medical record, including screenings, assessments ... “ * “Roles & Responsibilities ...” - “Attending Physician or Provider ... Responsible for ... performing medication reconciliation ...” - “Nursing ... The bedside nurse is responsible for completing the discharge screening of all patients upon admission, so that all necessary patient or caregiver/representative teaching has occurred, completing discharge instructions providing written discharge instructions ... and reconciled medication list ... The bedside nurse will collaborate with other members of the multidisciplinary team as needed for successful patient discharges.” 7. During a medical record review with the QD and CIS on 07/16/2025 beginning at 0930, the following patient records were reviewed and reflected: * Patient 2 was admitted in July 2024 for approximately 9 days with a diagnosis of Menubrium Fracture and Chronic Dementia. The record reflected that an Admission Medication Reconciliation had not been completed per hospital policy. * Patient 7 was admitted in August 2024 for approximately 16 days with a diagnosis of DKA. The record reflected that an Admission Medication Reconciliation had not been completed per hospital policy. * Patient 8 was admitted in July 2024 for approximately 6 days with a diagnosis of DKA. The record reflected that an Admission Medication Reconciliation had not been completed per hospital policy. * Patient 9 was admitted in August 2024 for approximately 3 days with a diagnosis of DKA. The record reflected that an Admission Medication Reconciliation had not been completed per hospital policy. The hospital failed to fully implement its policies and failed to obtain and document patients’ current medications and reconcile those medications as required by hospital policies, refer to Findings 1, 2, and 6. The hospital failed to provide safe nursing care and complete a full nursing care assessment of patients 2, 7, 8 and 9 within defined timelines as required by the policy “Admission Assessment & Screening of Patients,” and did not complete an Admission Medication Reconciliation as part of the patients’ admission assessments. The hospital failed to fully implement nursing care standards, collaborate with the multidisciplinary team, and implement a thorough discharge planning assessment as required in hospital policies, refer to Findings 4, 5, and 6. It was unclear whether the potential for “adverse drug reactions” was fully assessed or whether nursing staff communicated to the pharmacist “new drugs” in accordance with hospital policy, refer to Finding 3. 8. The QD and the CIS confirmed Finding 7 at the time of the medical record review.”