Wayne Memorial Hospital

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 32692 Based on observation and interview, it was determined the facility failed to maintain doors required to be self or automatic closing on two of five floors. Findings include: 1. Observation on November 20, 2024, between 9:28 a.m., and 10:21 a.m., revealed the following; a. At 9:28 a.m., the smoke barrier doors at the 3rd floor maternity entrance failed to close smoke tight. b. At 10:21 a.m., the double doors into the cardio area on the 1st floor lack a required coordinating device, these doors are part of a horizontal exit. Interview at the time of the exit confrence with the Chief of Facilities Officer on November 20, 2024, at 11:30 a.m., confirmed the self closing door deficiencies.”

“Vertical Openings - Enclosure CFR(s): NFPA 101 Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box. This Standard is not met as evidenced by: 32692 Based on observation and interview, it was determined the facility failed to maintain the required fire resistance rating of stair tower doors in one of approximately seven exit stair towers. Findings include; 1. Observation on November 20, 2024, at 10:00 a.m., revealed the stair tower door in the administration area on the 3rd floor had a gap across the top in excess of required tolerance for a metal door. Interview at the time of the exit confrence with the Chief of Facilities Officer on November 20, 2024, at 11:30 a.m., confirmed the gap was in excess of 3/16 of an inch.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 32692 Based on observation and interview, it was determined the facility failed to maintian the sprinkler system on two of five floors. Findings include: 1. Observation on November 20, 2024, between 9:14 a.m., and 10:35 a.m., revealed the following; a. At 9:14 a.m., on the 3rd floor a sprinkler in the cath lab soiled utility room was missing an escutcheon. b. At 10:35 a.m., on the 1st floor several sprinklers in the main kitchen area were loaded with what appeared to be dust. Interview at the time of the exit confrence with the Chief of Facilities Officer on November 20, 2024, at 11:30 a.m., confirmed the sprinkler deficiencies.”

“Gas and Vacuum Piped Systems - Other CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Other List in the REMARKS section any NFPA 99 Chapter 5 Gas and Vacuum Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 5 (NFPA 99) This Standard is not met as evidenced by: 32692 Based on observation and interview, it was determined the facility failed to maintian medical as piping on one of five floors. Findings include: 1. Observation on November 20, 2024, at 8:51 a.m., revealed various steel components were in contact with the copper medical gas lines in the linen room corridor of the basement. Interview at the time of the exit confrence with the Chief of Facilities Officer on November 20, 2024, at 11:30 a.m., confirmed the dissimilar metals in contact with the copper medical gas lines.”

“UNUSABLE DRUGS NOT USED CFR(s): 482.25(b)(3) §482.25(b)(3) - Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use This Standard is not met as evidenced by: 21559 Based on review of facility documents, observation, and staff interview (EMP), it was determined the facility failed to ensure medications considered ready for patient administration were not outdated on the Intensive Care Unit (ICU) and the 4 West patient care unit. Findings include: Review on November 4, 2024, of the facility’s “Pharmacy Scope of Care & Services Policy #46,” last reviewed November 2023, revealed “Policy: It is the policy of Wayne Memorial hospital that the pharmacy provides care to our patients utilizing the following guidelines: Responsibility The Pharmacy manager is responsible for ensuring that all pharmacy services provided by the pharmacy department are of the highest possible quality ...” Review on November 4, 2024, of the facility’s “Inventory Control and Drug Accountability Policy #32,” last reviewed November 2023, revealed “Policy: It is the policy of Wayne Memorial Hospital Pharmacy to maintain a supply of drugs and devices adequate to meet the needs of the health professionals and the patients it is intended to serve. Purpose: The purpose of this policy is to establish a format for inventory control and drug accountability in order to maintain a supply of drugs and devices adequate to meet the needs of the health professionals and the patients it is intended to serve ...” Review on November 4, 2024, of the facility’s “Medication Area Inspection Policy #36,” last reviewed November 2023, revealed “Policy: 1. A pharmacist and a technician will conduct monthly inspections. The following medication preparation and storage areas will be inspected: ... ICU ...4 West ... 2. The Pharmacist will record the results of the inspection on the medication inspection record. A copy will be given to the unit supervisor when necessary and retain the original in the pharmacy. The Pharmacy team and unit supervisor will evaluate the findings and take action to correct the deficiencies and improve the system as soon as possible. Purpose: Periodic inspections of drug storage, administration and dispensing areas can identify most unusable medications. Inspections should focus on storage conditions ... security ...removal of outdated and other unusable medications and devices ...” Review on November 4, 2024, of the facility’s “Rotating Stock for Inventory Control Policy #58,” last reviewed November 2023, revealed “Policy: It is the policy of Wayne Memorial Hospital Pharmacy to rotate stock for better inventory control. Purpose: To maintain a format for rotating inventory. Procedure: 1. When an item is received from a supplier, the item will be placed on the shelf or on the bin with the shortest dated item in front of the unopened items ...” Observation on November 4, 2024, of the secured medication storage units in the Intensive Care Unit (ICU) revealed three intravenous (IV) bags of Clindamycin (an antibiotic) 300 milligrams (mg) in 50 milliliters (ml) of 5 % Dextrose. These three bags of IV Clindamycin expired on March 16, 2024. Interview with EMP6 and EMP10 on November 4, 2024, confirmed the above findings at the time of the observation. Observation on November 4, 2024, of the secured medication storage units on 4 West revealed five IV bags of Clindamycin 300 milligrams (mg) in 50 milliliters (ml) of 5 % Dextrose. These five bags of IV Clindamycin expired on March 16, 2024. Interview with EMP6 and EMP10 on November 4, 2024, confirmed the above findings at the time of the observation. Interview with EMP9 on November 4, 2024, revealed these secured medication storage units in the ICU and 4 West were reviewed monthly by EMP17, EMP18 and EMP19 from April through November 2024. Further interview revealed these employees did not identify the above medications as expired. EMP9 confirmed there was a potential for patients to receive a dose of the expired IV Clindamycin 300 mg in 50 ml of 5 % Dextrose.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 21559 Based on review of facility documents, observation, and staff interview (EMP), it was determined the facility failed to ensure rooms considered ready for patient occupancy were clean in the Intensive Care Unit (ICU) and on 4 West; the facility failed to ensure durable medical equipment was cleaned prior to placing it in a plastic bag and storing in the clean storage room on the ICU unit and on 4 West; the facility failed to ensure the facility followed its policy regarding storage of commodes in the clean storage room on the ICU unit and 4 West; the facility failed to ensure cracks in a wall above a window was identified and repaired in a timely manner in the ICU unit, and the facility failed to ensure vegetation (plant growth) was not present on a roof outside the ICU unit. Findings include: Review on November 4, 2024, of the facility’s “Infection Prevention and Control Overview For Environmental Services (EVS) Reference #5010” policy, last revised August 2022, revealed “Purpose: To control the spread of infection, Wayne Memorial Hospital shall use evidence-based national guidelines, or in the absence of such guidelines, expert consensus to guide infection prevention and control practices throughout the organization. Policy: Environmental Service workers will consult the policy and procedure manual of Infection Control as well as the Environmental Services Manual that is maintained by the Director of Environmental Services for unit specific cleaning and disinfection policy and procedures as well as schedules for department cleaning procedures ... “ 1. Observation on November 4, 2024, of the facility’s Intensive Care Unit (ICU) revealed patient room 204 had a thermostat cover missing. Observation on November 4, 2024, of the facility’s 4 West patient care unit revealed the following: Room 427 - the cleaning card indicated this patient room was cleaned on November 3, 2024. Observation of this patient room revealed multiple areas of white debris and dust on the mattress, dried toilet paper on the commode bowl and dried urine stains on the floor in front of the commode. Room 429 - the cleaning card indicated this patient room was cleaned on October 17, 2024, and re-checked on October 22, 2024. Observation of this patient room revealed multiple areas of white debris and dust on the mattress. Room 430 - the cleaning card indicated this patient room was cleaned on November 2, 2024. Observation of this patient room revealed multiple areas of white debris and dust on the mattress. Room 431 - the cleaning card indicated no date this patient room was cleaned but the card indicated this room was rechecked on October 22, 2024. Observation of this patient room revealed multiple areas of white debris and dust on the mattress and an area of nasal discharge on the wall leading to the bathroom. Interview with EMP6 and EMP8 on November 4, 2024, confirmed the above findings at the time of the observation. 2. Observation on November 4, 2024, of the facility’s ICU clean storage room revealed a tube feeding pump in a clear plastic bag. This tube feeding pump had tape on the pump along with drops of dried tube feeding. Interview with EMP6 on November 4, 2024, confirmed the above findings at the time of the observation. EMP6 confirmed this tube feed pump was not appropriately cleaned and that it was identified as ready for patient use. Observation on November 4, 2024, of the facility’s 4 West clean storage room revealed a tube feeding pump in a clear plastic bag. This tube feed pump had dried tube feeding in the area where the tubing is secured to the pump, on the sides and bottom of the pump and on the back of the pump. Interview with EMP6 and EMP8 on November 4, 2024, confirmed the above findings at the time of the observation. EMP8 confirmed this tube feed pump was not appropriately cleaned and that it was identified as ready for patient use. 3. Observation on November 4, 2024, of the facility’s ICU clean storage room revealed three bedside commodes that did not have clear liners on the seat. Interview with EMP6 on November 4, 2024, confirmed the above findings at the time of the observation. EMP6 confirmed the commodes were not correctly identified as clean. Observation on November 4, 2024, of the facility’s 4 West clean storage room revealed three bedside commodes that did not have clear liners on the seat. Interview with EMP8 on November 4, 2024, confirmed the above findings at the time of the observation. EMP6 confirmed the commodes were not correctly identified as clean. 4. Observation on November 4, 2024, of the ICU revealed a window located in the area where the door opens into the stair way. The area had a vertical crack in the wall measuring approximately 12” long and one-eight inch wide above the window where the exterior wall and the interior wall meet. There was also a horizontal crack in the exterior wall directly above the window measuring approximately 8” long and one-eight inch wide. Interview with EMP7 on November 4, 2024, confirmed the above finding at the time of the observation. 5. Observation on November 4, 2024, of the roof area located outside the ICU revealed an area of vegetation (plant growth) on this roof. This vegetation measured approximately 8” by 6” and included a thick dense clumps and a mat of moss growth and several dried brown plants measuring approximately 15 inches high. Interview with EMP7 on November 4, 2024, confirmed the above finding at the time of the observation. EMP7 confirmed the vegetation and plant growth inhibits the structure of the roof and potentially can cause roof damage.”

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 21559 Based on review of facility documents, observation, and staff interview (EMP), it was determined the facility failed to ensure operating room staff and Central Service Sterile Processing staff appropriately wore surgical scrub caps that covered all hair; the facility failed to ensure all facial hair was covered in the Central Service Sterile Processing area and the facility failed to ensure operating room staff did not wear jewelry while assisting in the operating room. Findings include: Review on November 5, 2024, of the facility’s “Dress Code Policy: D-4,” last revised April 2022, revealed “Purpose: All staff are expected to be professionally attired at all times. Policy ... Operating Room/PACU/Cardiac Cath Lab: ... Caps will be worn to cover the hair. Jewelry should not be worn, except a plain wedding band or other plain band with no stone ...Central Services: Hair ... Hair covers will also be worn ...” 1. Observation on November 5, 2024, of the operating room (OR) revealed EMP13 in the OR preparing for a surgical case. Further observation revealed EMP13’s hair on the top of the head and near the ears was not fully contained in the surgical scrub cap. Observation on November 5, 2024, of OTH1 revealed this surgeon was wearing a surgical cap with approximately 1” of hair showing below the surgical cap on each side of the head above the ears and approximately 2” of hair showing below the surgical scrub cap at the posterior neck area. Interview with EMP14 on November 5, 2024, at the time of the observation confirmed the above findings. 2. Observation on November 5, 2024, of the Central Service Sterile Processing area revealed EMP15 examining surgical equipment and preparing surgical instruments for sterilization. EMP15’s hair was not fully contained in the surgical cap. Observation on November 5, 2024, of the Central Service Sterile Processing area revealed EMP16 examining surgical equipment and preparing surgical instruments for sterilization. EMP16 had facial hair. Further observation of EMP16 revealed this employee’s facial hair was not fully contained in the facial covering. Interview with EMP14 on November 5, 2024, at the time of the observation confirmed the above findings. 3. Observation on November 5, 2024, of the OR revealed EMP13 in the OR preparing for a surgical case. Further observation revealed EMP11 and EMP12 were wearing necklaces with dangling pendants. Interview with EMP14 on November 5, 2024, at the time of the observation confirmed the above findings. EMP14 revealed necklaces are not to be worn by OR staff.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 21559 Based on review of facility documents, medical records (MR1), and staff interview (EMP), it was determined the facility failed to ensure a patient with suicidal thoughts was on a 1:1 direct visual observation by a facility staff member while using the bathroom in the Emergency Department (ED) and the facility failed to ensure a facility staff member maintained a 1:1 visual observation on a patient with suicidal thoughts while in a patient room in the ED (A0144). This failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to the patient. The IJ was identified on October 18, 2024, at 1:44 PM. On October 18, 2024, the survey team reviewed the revised policy #P6 was revised on 10/18/2024 at 0700 hours, to say “Patient will be directly observed as they change into disposable clothing and all belongings including sock, belt, under wear, cell phone/other devices, valuables, medications, and potentially dangerous equipment/items are removed from the room. Security will assist as required and patient will be scanned head to toe, for weapons with a metal detector and mouth inspected to objects. Toileting options will include use of bedside commode, urinal, bedpan, etc. if a restroom is utilized, the door latch is to be disabled and observer must position themselves in the doorway to avoid loss of visual contact with patient while positioning the door in a manner that provides privacy from passersby. Only bathrooms with disabling latches may be utilized. Signatures of all staff being educated will be obtained on education sheets starting on 10/18/2024. Staff that were educated on the evening and night of 10/17/2024 will be re-educated by reviewing the revised policy #P6 and confirming their understanding of these changes by signing by education sheets.” The immediate education sign-in sheets were reviewed on October 18, 2024, to determine compliance for the removal of the immediate jeopardy. The survey team verified these immediate interventions were implemented and confirmed the facility’s IJ was removed October 18, 2024, at 6:56 PM. Continuing deficiency October 17, 2024 Cross reference 482.13 (c)(2) -Patient Rights: Care In Safe Setting”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 21559 Based on review of facility documents, medical records (MR1), and staff interview (EMP), it was determined the facility failed to ensure a patient with suicidal thoughts was wanded and physically inspected for sharps; the facility failed to ensure all electronics were removed from a patient with suicidal thoughts (A1104) and the facility failed to ensure all clothing, including socks, were removed, and secured by staff and all patient belongings, including electronics, were secured while a patient is under 1:1 constant visual observation (A1112). This failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to the patient. The IJ was identified on October 18, 2024, at 1:44 PM. On October 18, 2024, the survey team reviewed the revised policy #P6 was revised on 10/18/2024 at 0700 hours, to say “Patient will be directly observed as they change into disposable clothing and all belongings including sock, belt, under wear, cell phone/other devices, valuables, medications, and potentially dangerous equipment/items are removed from the room. Security will assist as required and patient will be scanned head to toe, for weapons with a metal detector and mouth inspected to objects. At no time will a patient under a 1:1 observation be permitted to possess an electronic device. (cell phone, tablets, i-pod, kindle, etc.) If a patient requires a use of a phone, one will be provided and used only under the direct supervision of an observer. In these situations, the phone will be removed when call is complete. Signatures of all staff being educated will be obtained on education sheets starting on 10/18/2024. Staff that were educated on the evening and night of 10/17/2024 will be re-educated by reviewing the revised policy #P6 and confirming their understanding of these changes by signing by education sheets.” The immediate education sign-in sheets were reviewed on October 18, 2024, to determine compliance for the removal of the immediate jeopardy. The survey team verified these immediate interventions were implemented and confirmed the facility’s IJ was removed October 18, 2024, at 6:56 PM. Cross reference 482.55 (a)(3) Emergency Services Policies 482.55 (b)(2) Qualified Emergency Services Personnel”

“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: 21559 Based on review of facility documents, medical records (MR), observation, and staff interview (EMP), it was determined the facility failed to ensure a patient with suicidal thoughts was on a 1:1 direct visual observation by a facility staff member while using the bathroom in the Emergency Department (ED) for one of one applicable medical record reviewed (MR1) and the facility failed to ensure a facility staff member maintained a 1:1 visual observation on a patient with suicidal thoughts while in a patient room in the ED for one of one applicable medical record reviewed (MR2). Findings include: Review on October 18, 2024, of the facility policy, “Patient’s Rights and Responsibilities,” reviewed November 28, 2023, revealed “Policy: It is the policy of Wayne Memorial Hospital to inform each patient (inpatient and outpatient), or when appropriate, the patient’s representative, of their rights and responsibilities, in advance of furnishing or discontinuing patient care, whenever possible ...Your Rights...As our patient, you have the right to safe, respectful and dignified care at all times. You will receive services and care that are medically suggested and within the hospital’s services, its stated mission, and required law and regulation .... “ Review on October 18, 2024, of facility, “Standard Of Care Violence, Potential For, Self-Directed Or Directed At Others (Suicidal Or Homicidal)” revised October 2018, revealed “...Nursing Directives Emergency Department Management...Continuous Observations-Requires a staff/patient ratio where one person can continuously view a patient, or group of patients and alert staff if patient(s) in danger. 1:1/Arm’s length observation-(for immediate violent/self-destructive behavior)-Requires 1 to 1 staff to patient ratio where the staff person is at the bedside (or just outside the room) and is only monitoring 1 patient....Special Circumstances: One to One (1:1) observation may be implemented in situations where there is no immediate violent/self-destructive behavior identified, but neither close or continuous observation are adequate to protect the patient from harm. Examples may include, but are not limited to, high fall risk, at risk to wander, disorientation, etc. ...” Review on October 19, 2024, of the facility’s “Chief Of Patient Care Services” job description, last revised July 2009, revealed “Primary Purpose Of The Position: Organizes the Department of Nursing in such a way that its policies and procedures assure that quality nursing care is delivered to patients in a safe, effective and consistent manner...Responsibilities...Make nursing rounds to assess the quality of patient care and to identify problems and needs...Maintains compliance with nursing care standards, hospital policies and procedures and regulatory agency requirements...continually evaluates the care delivered by regular review of management reports, direct observation and patient rounds, results for quality assurance studies, review charts...” Review on October 19, 2024, of the facility’s “Nurse Manger II” job description, last revised November 8, 2022, revealed “...Responsibilities...Assesses all departmental activities, identifies problems and any need for improvement...Implementation:...Ensures that the Emergency Room Standards of Nursing Practice are implemented and assists in monitoring those standards as necessary. Holds self and staff accountable for the delivery of quality nursing care. Acts rapidly and effectively, follows hospital policies and procedures, and utilizes principles of management in any emergency situation...” Review on October 18, 2024, of the facility’s “Psychiatric Emergencies: Voluntary/Involuntary Commitment 201/302 Policy: P-6”, last revised September 2024, revealed “Policy: It is the policy of Wayne Memorial Hospital to evaluate and stabilize patients suffering from a psychiatric emergency by addressing immediate medical needs and providing a safe environment that reduces potential harm to both the patient and others in conjunction with available county resources...Purpose: To ensure a safe and secure environment for patient, staff and visitors...Definitions:...Voluntary Commitment (201): Agreement by patient to consent to inpatient psychiatric care. Involuntary Commitment (302): Completion of warrant for patient in crisis who does not voluntarily consent to treatment... Guidelines of Practice For Emergency Department Care of Patients With Psychiatric Disorders And / Or Behavioral Issues: At the time of triage, if the patient is found to be a threat to themselves or others, or is under a 302 warrant, the patient will be placed in a designated area in ED where he/she can be continually observed...Patients will change into disposable clothing and all clothing (including socks, belt, underwear, and cell phone) valuables, medications and potentially dangerous equipment/items are removed from the room...” Observation of the ED bathroom on October 18, 2024, revealed the following: A rigid trash can measuring 20 inches high, A clear plastic bag lining the rigid trash can, A wall mounted light measuring 48 inches long with a gap between the light and the wall, A wall mounted paper towel holder, Two open back wall mounted handrails, one measuring 53 inches and the second one measuring 36 inches, A glass mirror, A wall mounted soap dispenser A louvered vent directly above the commode, A goose neck faucet with louvered handles for the hot and cold water. EMP1 and EMP2 on October 18, 2024, revealed this bathroom is utilized by ED patients. Interview with EMP1 and EMP2 on October 18, 2024, confirmed the above findings in the ED bathroom. EMP1 and EMP2 confirmed the above items pose a risk of hanging or harm to a patient with suicidal thoughts. EMP1 confirmed this bathroom is used for all patients in the ED including those admitted for mental health evaluations related to suicidal thoughts. 1. Review of MR1 on October 18, 2024, revealed this patient presented to the ED on October 17, 2024, at 1126, for a mental health evaluation due to cutting self and having suicidal thoughts for the past couple of days. MR1’s nursing documentation revealed this patient had multiple lacerations on the left arm in varying stages of healing; this patient had a history of harming self and has had multiple previous admissions for attempts of harming self. The facility assessed MR1 and determined this patient met the criteria for an ESI level of 2 and a 1:1 direct observation sitter was assigned to this patient. Review of MR1 on October 18, 2024, dated October 17, 2024, revealed the following timeline: 1214 - EMP8 documented the facility wanded this patient upon arrival to the ED; MR1 was changed into paper scrubs, given a pair of non-skid socks and all belongings including electronics, personal supplies and jewelry were placed in a bag and secured. 1215 - EMP8 documented MR1 kept belongings at the bedside which included kindle, chap stick, paper with phone numbers and insurance card. Items labeled and moved by security to valuable room. 1803 - EMP9 documented MR1 requested and was escorted to the restroom. While using the restroom MR1 took a razor that was taped to the bottom of the foot and cut their left forearm. 1820 - EMP8 documented a microblade was confiscated from MR1. MR1 reported the microblade was kept in the back case of the kindle when they arrived in the ED. 1820 - EMP10 documented MR1 informed this staff person the microblade was hidden in the kindle case when they arrived in the ED then placed into the sock before being escorted to the bathroom. Review of MR1 on October 18, 2024, dated October 17, 2024, at 1820 revealed this patient requested to use the bathroom; was taken to the bathroom by nursing staff and the bathroom door was closed behind the patient leaving MR1 out of direct 1:1 observation. When MR1 opened the bathroom door, MR1 had blood coming from new superficial lacerations to this patient’s left upper arm. Interview with EMP1, EMP2 and EMP3 on October 18, 2024, confirmed the above findings. EMP1, EMP2 and EMP3 confirmed MR1 was taken to the ED bathroom by EMP8; EMP8 closed the bathroom door and allowed MR1 to be behind a closed bathroom door and EMP8 did not maintain 1:1 direct observation of MR1 while in the bathroom. 2. Review of MR2 on October 18, 2024, revealed this patient was admitted to the ED on October 18, 2024, at 2051 with suicidal thoughts and wanting to kill self. MR2 had a history of suicidal attempts. The facility assessed MR2 and determined this patient met the criteria for an ESI level of 2 and a 1:1 direct observation sitter was assigned to this patient. EMP11 was assigned to MR2 for 1:1 direct observation. Observation on October 18, 2024, at 0910 revealed EMP11 sitting in the doorway of MR2’s room facing the hallway and having a conversation with EMP12. Interview with EMP1, EMP2 and EMP3 on October 18, 2024, confirmed the above finding at the time of the observation. EMP2 and EMP3 confirmed MR2 was not under the constant 1:1 visual observation to protect this patient from potential self-harm. Further interview with EMP2 and EMP3 revealed EMP11 received training on the requirement of maintaining a 1:1 direct visual observation of patients with suicidal thoughts at the beginning of this employees shift on October 18, 2024. Continuing deficiency October 17, 2024 Cross reference 482.13 Patient Rights”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 21559 Based on review of facility documents, personnel files (PF) and staff interview (EMP), it was determined the facility failed to ensure a security office received training regarding the use of a metal detector to scan patients, belongings, and visitors for metal objects that could potentially be used by patients with suicidal thoughts for one of one applicable personnel files reviewed (PF2). Findings include: Review on October 19, 2024, of the “Security In-Service Training PN-01” policy, last revised May 2024, revealed “Training: Development of training of Security Department Personnel must be a continuing process. Development in security is largely accomplished by a thorough training program to improve the Security Officer’s skills and knowledge and to keep him/her current in the field. The merits of training will be reflected in his/her attitude, better morale and increased incentive. Training provides a better understanding of his/her relationship to management and the objectives of his/her job...” Review on October 19, 2024, of the facility’s “Detection Principles and Capabilities of the [Name of metal detector]” manual, no date, revealed “...The [name of metal detector] is an active hand-held metal detector with very high sensitivity to all metals including ferrous, non-ferrous and stainless steel. Detection and alarming takes place when the instrument is passed in close proximity to metal objects. Detection range is dependent upon the size and conductivity of the metal object. The larger the object, the greater the detection distance. The [name of metal detector] is factory preset to nominal sensitivity with no operator adjustments required. This ensures that the detector will be used at the proper operating level established for the particular security need...When metal objects are encountered, the red LED is activated along with an audible alarm or the vibration alarm...Recommended Body Scanning Procedure double check pocket areas.” The diagram illustrates front scanning beginning at the right shoulder proceeding down the right arm to the right leg and top of the right foot to the top of the left foot to the left leg then the left arm and ending at the left shoulder. The diagram illustrates back scanning beginning at the back of the head proceeding down the right arm to the right leg to the left leg to the left arm then down the middle of the back...” A request was made of EMP1 and EMP5 on October 19, 2024, for PF2’s training regarding the use of the facility’s metal detector. None was provided. Interview with EMP1 and EMP5 on October 19, 2024, revealed PF2 did not receive training on the facility’s metal detector. Cross reference 482.55 Emergency Services 482.55 (b)(2) Qualified Emergency Services Personnel”

“QUALIFIED EMERGENCY SERVICES PERSONNEL CFR(s): 482.55(b)(2) There must be adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility. This Standard is not met as evidenced by: 21559 Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to prevent self-harm of a patient with suicidal thoughts while in their care for one of one applicable medical record reviewed (MR1). Findings include: Review on October 19, 2024, of the “Chief Facilities Officer” job description, revised July 2009, revealed “Primary Purpose Of The Position: Administers and directs programs to maintain the buildings, grounds and equipment and procure or generate all utilities and their distribution systems. Has administrative responsibility for Maintenance, Environmental Services, Security, Bio-medical, Food and Nutrition Services and Materials Management Departments...Responsibilities... Assures that departmental employees are adequately trained to properly perform assigned responsibilities...Competency Assessment The process of ensuring that each employee demonstrates continued ability to perform the tasks, duties, and responsibilities of his/her position in a competent fashion. Following are the competency standards for the position...Effectively encourages and promotes staff education, develops training needs assessments for staff, maintains employee training records, communicates mandatory training requirements...” Review of MR1 on October 18, 2024, revealed this patient presented to the Emergency Department (ED) on October 17, 2024, at 1126, for a mental health evaluation due to cutting self and having suicidal thoughts for the past couple of days. MR1’s nursing documentation revealed this patient had multiple lacerations on the left arm in varying stages of healing; this patient had a history of harming self and has had multiple previous admissions for attempts of harming self. The facility assessed MR1 and determined this patient met the criteria for an ESI level of 2 and a 1:1 direct observation sitter was assigned to this patient. Review of MR1 on October 18, 2024, dated October 17, 2024, revealed the following timeline: 1214 - EMP8 documented the facility wanded this patient upon arrival to the ED; MR1 was changed into paper scrubs, given a pair of non-skid socks and all belongings including electronics, personal supplies and jewelry were placed in a bag and secured. 1215 - EMP8 documented MR1 kept belongings at the bedside which included kindle, chap stick, paper with phone numbers and insurance card. Items labeled and moved by security to valuable room. 1803 - EMP9 documented MR1 requested and was escorted to the restroom. While using restroom took a razor that was taped to the bottom of the foot and cut left forearm. 1820 - EMP8 documented a microblade was confiscated from MR1. MR1 reported the microblade was kept in the back case of the kindle when they arrived in the ED. 1820 - EMP10 documented MR1 informed this staff person the microblade was hidden in the kindle case when they arrived in the ED then placed into the sock before being escorted to the bathroom. Review of MR1 on October 18, 2024, dated October 17, 2024, at 1820 revealed this patient requested to use the bathroom; was taken to the bathroom by nursing staff and the bathroom door was closed behind the patient leaving MR1 out of direct 1:1 observation. When MR1 opened the bathroom door, MR1 had blood coming from new superficial lacerations to this patient’s left upper arm. Interview with EMP5 on October 18, 2024, revealed it is the security officer that is responsible for completing the metal detection on patients, on patient’s belongings, and on visitors. There was no documentation in MR1 indicating the security officer completed metal detection of MR1’s feet or MR1’s belongings. Interview with EMP1 and EMP5 on October 18, 2024, confirmed the above findings at the time of the review. Cross reference 482.55 Emergency Services 482.55 (a)(3) Emergency Services Policies”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 36696 Based on review of facility documents, medical records (MR1), and staff interview (EMP), it was determined that the facility failed to ensure the Emergency Department (ED) physician ordered a continuous 1:1 sitter after discussing the recommendations with the tele-health psychiatrist after consultation was completed (A0144). This failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to the patient. The IJ was identified on October 16, 2024, at 2:03 PM. On October 16, 2024, the survey team reviewed that all staff in the ED, ED providers, Nursing Supervisors, Nursing Managers, and Senior administration were immediately educated when a Tele-psych consult is performed and recommendations are communicated verbally and/or in writing, the recommendations will be immediately communicated by the receiver to the care team (Physicians, Mid-level provider, Primary nurse, etc.) Orders will be entered into the Medical Record based on the Attending Provider’s discretion. If there is a disagreement between the tele-psych Provider and the Attending Provider, the Attending Provider shall immediately address, document in the Medical Record and communicate to care team the reasons why he/she is choosing not to follow the tele-psych recommendation(s). The immediate education sign-in sheets were reviewed to determine compliance for the removal of the immediate jeopardy. The survey team verified these immediate interventions were implemented and confirmed the facility’s IJ was removed October 16, 2024, at 6:18 PM. Cross reference 482.13(b)-Exercise Use Of Rights 482.13 (c)(2)-The patient has the right to receive care in a safe setting 482.13(e)-Use of Restraint Or Seclusion”

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 21559 Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure adequate nutrition to patients who are in the Emergency Department (ED) for a prolonged period of time for four of 11 applicable medical records reviewed (MR4, MR5, MR6 and MR11). Findings include: A request was made of EMP1, EMP2 and EMP3 on October 17, 2024, for a facility policy / procedure / protocol / guideline facility staff follow regarding ensuring patients who are in the ED for a prolonged period of time are provided with adequate nutrition. None was provided. Interview with EMP1, EMP2 and EMP3 revealed the facility does not have a policy / procedure / protocol / guideline for facility staff to follow regarding ensuring patients who are in the ED for a prolonged period of time are provided with adequate nutrition. Review of MR4 on October 17, 2024, revealed this patient presented to the ED on October 4, 2024, at 12:13 PM for evaluation and treatment of a psychiatric disorder and was discharged to an inpatient psychiatric facility on October 5, 2024, at 5:35 PM. There was no documentation in MR4 indicating the facility provided this patient with a meal tray or any nutrition on October 4, 2024, for the lunch meal or on October 5, 2024, for the breakfast, lunch, and evening meal. Review of MR5 on October 17, 2024, revealed this patient presented to the ED on September 30, 2024, at 11:23 AM for evaluation and treatment of a psychiatric disorder and was discharged to an inpatient psychiatric facility on October 1, 2024, at 12:46 PM. There was no documentation in MR5 indicating the facility provided this patient with a meal tray or any nutrition on September 30, 2024, for the lunch and dinner meals. Review of MR6 on October 17, 2024, revealed this patient presented to the ED on October 1, 2024, at 3:03 PM for evaluation and treatment of a psychiatric disorder and was discharged to an inpatient psychiatric facility on October 3, 2024, at 7:51 AM. There was no documentation in MR6 indicating the facility provided this patient with a meal tray or any nutrition on October 1, 2024, for the lunch meal; on October 2, 2024, for the lunch meal or on October 3, 2024, for the breakfast meal. Review of MR11 on October 17, 2024, revealed this patient presented to the ED on September 14, 2024, at 00:29 AM for evaluation and treatment of a psychiatric disorder and was discharged to an inpatient psychiatric facility on September 16, 2024, at 9:07 PM. There was no documentation in MR11 indicating the facility provided this patient with a meal tray or any nutrition on September 14 and 16, 2024, for the breakfast or lunch meals or on September 16, 2024, for the breakfast meal. Interview with EMP2 and EMP3 on October 17, 2024 confirmed the above findings.”

“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: 36696 Based on review of facility documents, medical records (MR), observation, security footage and staff interview (EMP), it was determined the facility failed to ensure the Emergency Department (ED) physician ordered a continuous 1:1 sitter after discussing the recommendations with the tele-health psychiatrist after consultation was completed for one of one medical records reviewed (MR1); failed to ensure a patient admitted for a psychiatric evaluation was placed in paper scrubs as per hospital policy for 2 of 12 applicable medical records reviewed (MR1 and MR2) and the facility failed to identify a 25 second delay in the first set of ED exit doors contributing to an ED patient admitted for a psychiatric evaluation to elope from the ED (MR1). Findings include: Review on October 16, 2024, of the facility policy, “Patient’s Rights and Responsibilities,” reviewed November 28, 2023, revealed “Policy: It is the policy of Wayne Memorial Hospital to inform each patient (inpatient and outpatient), or when appropriate, the patient’s representative, of their rights and responsibilities, in advance of furnishing or discontinuing patient care, whenever possible. ...Your Rights ...As our patient, you have the right to safe, respectful and dignified care at all times. You will receive services and care that are medically suggested and within the hospital’s services, its stated mission, and required law and regulation .... “ Review on October 16, 2024, of the facility’s “Psychiatric Emergencies: Voluntary/Involuntary Commitment 201/302 Policy: P6” , last revised September 2024, revealed “Policy: it is the policy of Wayne Memorial Hospital to evaluate and stabilize patients suffering from a psychiatric emergency by addressing immediate medical needs and providing a safe environment that reduces potential harm to both the patient and others in conjunction with available county resources ...Purpose: To ensure a safe and secure environment for patient, staff and visitors ...Definitions: ...Voluntary Commitment (201): Agreement by patient to consent to inpatient psychiatric care. Involuntary Commitment (302): Completion of warrant for patient in crisis who does not voluntarily consent to treatment ... Guidelines of Practice For Emergency Department Care of Patients With Psychiatric Disorders And/Or Behavioral Issues: At the time of triage, if the patient is found to be a threat to themselves or others, or is under a 302 warrant, the patient will be placed in a designated area in ED where he/she can be continually observed ...Patients will change into disposable clothing and all clothing (including socks, belt, underwear, and cell phone) valuables, medications and potentially dangerous equipment/items are removed from the room ...” Review on October 16, 2024, of facility, “Standard Of Care Violence, Potential For, Self-Directed Or Directed At Others (Suicidal Or Homicidal)” revised October 2018, revealed “ ...Nursing Directives Emergency Department Management ...Continuous Observations-Requires a staff/patient ratio where one person can continuously view a patient, or group of patients and alert staff if patient(s) in danger. 1:1/Arm’s length observation-(for immediate violent/self-destructive behavior)-Requires 1 to 1 staff to patient ratio where the staff person is at the bedside (or just outside the room) and is only monitoring 1 patient. ...Special Circumstances: One to One (1:1) observation may be implemented in situations where there is no immediate violent/self-destructive behavior identified, but neither close or continuous observation are adequate to protect the patient from harm. Examples may include, but are not limited to, high fall risk, at risk to wander, disorientation, etc. ...” 1.Review on October 16, 2024, of MR1, revealed MR1 presented to the Emergency Department (ED) on October 12, 2024, at 12:20 PM, for a mental health examination. MR1 revealed a tele-psychiatry consult note dated October 13, 2024, at 3:44 AM from CF1 that revealed history of anxiety disorder, TBI, cluster B personality disorder, bipolar disorder, schizophrenia, depressive disorder, schizoaffective disorder, ADHD, current cannabis use, history of suicide attempt(s), disruptive behavior, poor self-care, history of psychiatric hospitalization, self-referred via walk-in for psychosis. Clearly psychotic and in need of inpatient psychatric admission again for safety and stabilization.-unclear if patient has been compliant with medications or not, talking about wanting/needing to die, and maintains no insight into severity of mental illness or need for treatment. Though patient intermittently agreeable to voluntary admission, recommend involuntary admission on the grounds of gravely poor insight/judgment that is impairing MR1’s capacity to make decisions about treatment (unable to maintain a consistent decision). Patient is at elevated risk of danger to self, danger due to grave disability/poor self-care. Patient presently meets criteria for inpatient psychiatric hospitalization. Plan disposition: Involuntary admission when medically stable. Observation level - Psychiatric 1:1 needed. Continue psych 1:1. Discussed plan with onsite team member: Yes-OTH2. Interview with EMP2 on October 16, 2024, confirmed the above findings. Continued review on October 16, 2024, of MR1, revealed there was no documentation from OTH2 that a continuous 1:1 sitter was ordered after discussing the consultation with CF1. Nursing documentation revealed MR1 eloped (unauthorized leaving of the hospital’s emergency department independently and without notifying staff) on October 13, 2024, at 5:09 AM. MR1 was returned to the ED on October 13, 2024, at 8:25 AM via state police. Interview with EMP 2 on October 16, 2024, confirmed the above findings. Review on October 16, 2024, of the facility provided security footage dated October 13, 2024, at 5:09 AM revealed MR1 exiting the ambulance entrance doors wearing a dark t-shirt, paper scrub bottoms and socks. Interview with EMP2, EMP4 and EMP5 on October 16, 2024, at the time of review confirmed MR1 eloped from the ED though the ambulance entrance doors wearing a dark t-shirt, paper scrub bottoms and socks. EMP2 and EMP4 confirmed MR1 was not wearing a required hospital paper scrub top as per hospital policy. 2. Interview with EMP2 and EMP4 on October 16, 2024, revealed disposable clothing included paper scrub tops and pants. Review of MR1 on October 16, 2024, revealed this patient was admitted to the ED on October 12, 2024, for evaluation and treatment of a psychiatric disorder and was discharged to an inpatient psychiatric facility on October 13, 2024. During MR1’s ED admission, the facility initiated a 302 (Involuntary Commitment) warrant on MR1 after consultation with the Tele-Psychiatrist who determined this patient had gravely poor insight and judgement that was impairing the capacity to make decisions about treatment and was unable to maintain a consistent decision. Review on October 16, 2024, of MR1’s nursing documentation dated October 12, 2024, at 1248 revealed EMP7 documented this patient changed into paper scrubs and non-skid socks. Further review on October 16, 2024, of MR1 revealed this patient eloped from the ED on October 13, 2024, through the side hallway doors of the ED and through the ambulance entrance doors. Review on October 16, 2024, of the facility provided security footage dated October 13, 2024, at 0509 revealed MR1 exiting the ambulance entrance doors wearing a dark t-shirt, paper scrub bottoms and socks. Interview with EMP2, EMP4 and EMP5 on October 16, 2024, at the time of review confirmed MR1 eloped from the ED though the ambulance entrance doors wearing a dark t-shirt, paper scrub bottoms and socks. EMP2 and EMP4 confirmed MR1 was not wearing a required hospital paper scrub top as per hospital policy. Review of MR2 on October 16, 2024, revealed this patient was admitted to the ED on October 7, 2024, for evaluation and treatment of a psychiatric disorder. MR2 was brought to the ED accompanied by police and on a 302 warrant. Review of MR2 on October 16, 2024, revealed no documentation nursing staff provided this patient with paper scrubs and non-skid socks on admission to the ED. Interview with EMP2 on October 16, 2024, confirmed the above findings at the time of the medical record review. 3. Observation tour on October 16, 2024, revealed a set of doors that were employee only badge activated to exit from the ED to a second set of doors leading to the ambulance bay. EMP2 activated these doors with the employee badge; this surveyor, EMP2 and EMP5 exited through the first set of doors and proceeded to the second set of doors to the ambulance bay. It was noted there was a 25 second delay in the closure and securing of the first set of doors. Interview with EMP2 and EMP5 on October 16, 2024, confirmed the above findings. EMP2 revealed this was not reviewed as part of MR1’s elopement investigation.”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 21559 Based on review of facility documents, observation, and staff interview (EMP), it was determined the facility failed to ensure a staff member maintained constant one-to-one visual observation of a pediatric patient (MR3) and the facility failed to ensure staff assigned to function as a one-to-one sitter for behavioral health patients had training for seven of 14 personnel files reviewed (PF1, PF2, PF3, PF4, PF6, PF7 and PF10). Findings include: Review on October 16, 2024, of the facility’s “Behavioral Health Emergency Care Competency” last reviewed September 2024, revealed “Wayne Memorial Hospital (WMH) routinely provides services to those in the community in need of mental health crisis services. Those that have been identified as an increased risk for potential harm to self (Moderate / high risk) or others require a care provider with a specific skill set to ensure safety. Though training, established policies, standards of care, guidance, and educational materials staff are able to provide safe, quality care for those with behavioral health needs. [space for the name of the employee], has shown the ability to: Maintain the dignity and respect of the patient at all times. Follow Primary nurses [sic] direction for level of observation required for each patient. Can differentiate between the variation of 1:1 observation: 1 to 1 observation - (for immediate violent/self-destructive behavior) - Requires 1 to 1 staff to patient ratio where the staff person is in close proximity and facing the patient at all times and is only monitoring 1 patient. This level of observation is also required (regardless of order) when the patients is: Secluded and restrained. Exhibiting immediate violent or self-destructive behavior until behavior is controlled ...Ordered by the Provider regardless of risk assessment, that must be maintained until discontinued by Provider ...Exhibiting no immediate violent/self-destructive behavior identified but neither close or continuous observation are adequate to protect the patient from harm ...Requiring arm’s length 1:1. This is when the patient requires protection from injury that cannot be done from a distance ...Understands the Importance / rational of maintaining a one to one observation of a patient. Ensure for room safety (free from any potentially harmful objects such as but not limited to): sharp, heavy objects, cords, wires, medications, clothing, cleaning solutions, or contraband (which includes cell phones) etc. Focus is on patient and free of distraction such as cell phone, games, electronics, etc. Recognizes that the patient is never to be left unattended (this includes bathroom use). Implements appropriate safety precautions with meals: finger food only, paper or foam dinnerware, no plastic ware, not water bottles, or any drinks in plastic bottles. Communicate using nonjudgemental words and behaviors. Maintains appropriate boundaries with patient at all times. [space for Employee Signature and date] [space for Primary Nurse/instructor signature and date] [space for Education Manager Signature and date].” 1. Review of MR3 on October 16, 2024, revealed this patient presented to the Emergency Department (ED) on October 15, 2024, for evaluation of behavioral problems. Interview with EMP4 on October 16, 2024, revealed MR3 required a 1 to 1 sitter as this patient was pediatric. Observation of the ED on October 16, 2024, at approximately 10:50 AM revealed PF1 sitting in MR3’s room. Further observation revealed MR3, and this patient’s parent, reclined in the recliner next to the bed with their eyes closed. PF1 was facing away from MR3; PF1 was facing the wall with the wall mounted television and watching the Tom and Jerry cartoon show. PF1’s vision and attention were on the television and not on MR3. Interview with EMP2 and EMP4 on October 16, 2024, confirmed the findings noted above at the time of the observation. 2. A request was made of EMP2, EMP3 and EMP4 on October 16, 2024, for PF1’s Behavioral Health Emergency Care Competency. None was provided. Interview with EMP2, EMP3 and EMP4 on October 16, 2024, revealed PF1 did not receive the required Behavioral Health Emergency Care Competency prior to performing this job. A request was made of EMP2, EMP3 and EMP4 on October 16, 2024, for PF2, PF3, PF4, PF6, PF7 and PF10’s Behavioral Health Emergency Care Competency. None was provided. Interview with EMP2, EMP3 and EMP4 on October 16, 2024, revealed PF2, PF3, PF4, PF6, PF7 and PF10 did not receive the required Behavioral Health Emergency Care Competency. Interview with EMP2 on October 16, 2024, revealed any staff member can function as a 1:1 sitter and must have the Behavioral Health Emergency Care Competency completed in order to perform this job.”