Excela Health Westmoreland Regional Hospital

“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: 50900 Based on a review of facility documents, security video footage, tour of the facility, medical records (MR), and employee interviews (EMP), it was determined that the facility failed to maintain a safe environment for psychiatric patients by permitting patient to use an unsecured courtyard, not securing access to remote control batteries, and not adhering to the policy for courtyard privileges for six of six medical records reviewed (MR1, MR2, MR3, MR4, MR5, MR6). Findings include: Review on November 21, 2025, of facility policy “Rights and Responsibilities of Patients”, last revised October 2024, revealed “You have the right to: ... Receive care in a safe setting free from any form of abuse, harassment, and neglect. ...”. Review on November 21, 2025, of facility policy “Behavioral Health Courtyard (Patient Recreation Area)”, established May 24, 2024, revealed, “Objective: To define the appropriate standards of which patients must meet to gain access and the privilege of attending the courtyard, describe authorized activities, and ensure safety of staff and patients in the courtyard. ... To provide an outdoor recreation area for patient activities. These activities may include individual and group discussion, group recreational activities, and activities designed to improve physical well-being. ... All policies applicable to patient care areas within the behavioral health service apply to the courtyard. ... Patients with a positive Broset assessment/score above 0 on most recent assessment must be reassessed prior to attending courtyard, unless otherwise authorized by attending psychiatrist. ... Patients with active, violent charges will not be permitted in the courtyard. ... Patients on a 1:1/sitter observation status for self-harm, suicide precautions, or any other behavioral health safety rationale are permitted in the courtyard, as long as the 1:1 remains with the patient at all times. ... Patients who are on self-harm precautions will only be permitted in the courtyard if they have a 1:1 staff with them in the courtyard. ... Patients with a history of becoming aggressive/violent or eloping in the courtyard must have approval to attend courtyard privileges by the attending psychiatrist before courtyard time. ...”. Review on November 21, 2025, of surveillance video from the behavioral health courtyard, dated November 13, 2025, revealed the footage of the courtyard elopement event. In the video, MR1 is seen sitting on a bench alone, drinking a beverage. MR1 walks away quickly from the bench and leaps over the vinyl fence, elopes from the patient courtyard, and sprints away through the parking lot. The elopement occurred on November 13, 2025 at 1:42 PM. Tour of the facility conducted on November 21, 2025, at 11:00 AM, revealed a fenced-in outdoor space, approximately 20 x 30 yards in size, used by behavioral health patients and staff. Observations include: There are three entry points to the courtyard, two gates at either side which provide access to a parking lot, and a sidewalk parallel to a two-way road. The third access point is through the behavioral health building, requiring interior badge clearance. To re-enter the building, one must use a key. Initial view of the space revealed several areas of patient safety concern. Within the perimeter of the courtyard is a volleyball net with hanging strings, a basketball hoop, several seating areas (benches and tables), a metal framed awning with torn/loose fabric, and approximately seven trees. Five of these trees are located within arm’s reach of the perimeter fence. There are portions of vinyl fencing which have gaps beneath, measuring eight to eleven inches from the ground. The height of vinyl fencing next to the storage shed is below the height of the surveyor (approximately 5 feet 9 inches with shoes on). EMP7 confirmed this section of fencing as the site of MR1’s elopement. During interview on November 21, 2025, at 11:15 AM, EMP7 confirmed the close proximity of trees and the height of the vinyl perimeter fence to be high elopement risks. Review on November 21, 2025, at 12:00 PM, of correspondence between the Facilities Director, Chief Nursing Officer, and Patient Safety Officers, included a courtyard perimeter assessment, conducted by EMP9 and EMP14. This document revealed the following environmental concerns related to patient safety: “The courtyard currently has three types of barriers to prevent elopement: a vinyl fence ... some aluminum fencing ... and a few spans of brick wall ... I have found numerous concerns with each type of barrier. The brick walls can be scaled with not much more than a running jump. There are also numerous trees near different parts of the wall as well as other grab-points that can assist with scaling. The aluminum fencing that has been added to the tops of some of the brick walls ... can possibly be used as an aid to scaling the wall. The vinyl fencing not only can be scaled with a running jump, but also has large gaps at the bottom of the fence that could allow for a smaller patient to crawl under with minimal effort. The vinyl fence is also the weakest of all fences and could possibly be broken through by a strong and determined patient. ... There are also numerous picnic tables and benches in the area that could aid with scaling any of the barriers. Additionally, the trees, the aluminum fencing, and the awning over the one picnic table ... present numerous ligature risks in the space. ...”. During an interview on November 21, 2025, at 1:30 PM, EMP14 confirmed the above to be safety hazards in this patient setting. On November 21, 2025, at 11:25 AM, a tour of two patient lounges on the behavioral health unit was conducted. The lounges included seating, reading material, and a television. At 11:25 AM, the second-floor lounge revealed a television remote with removable back plate, and two AA batteries inside. At 11:30 AM, the third-floor lounge revealed two television remotes, with removable back plates, each with two AAA batteries inside. During interview on November 21, 2025, at 11:31 AM, EMP7 confirmed the above to be safety hazards in this patient setting. Review on November 21, 2025, of MR1 revealed a 23-year-old male patient admitted to the hospital on November 3, 2025, as a 201 voluntary commitment to the psychiatric unit. MR1 was admitted to the hospital with a diagnosis of Schizophrenia and the initial Broset score on admission was 1. On November 3, 2025, an order was placed by the physician in the medical record for the active self-harm protocol. MR1 chose not to participate in group therapy and was expressing an interest in leaving the hospital for several days. The medical care team documentation revealed that MR1 became a 302 involuntary commitment to promote safety on November 7, 2025. MR1 was in the patient courtyard on November 13, 2025, and the medical record does not reveal documentation of 1:1 staff-to-patient ratio during this time. During an interview on November 21, 2025, at 1:15 PM, EMP3 confirmed the above. Review on November 24, 2025, of MR2 revealed that the patient was a 78-year-old male admitted to the hospital on October 17, 2025, as a 302 involuntary commitment to the psychiatric unit. MR2 was admitted to the hospital with a diagnosis of Psychosis, and PTSD. The initial Broset score on admission was 0. On October 31, 2025, the Broset score was a 3. On November 1, 2025, the Broset score was a 2. On November 2, 2025, the Broset score was a 3 and on November 3, 2025, the Broset score was a 3. An order was placed by the physician in the medical record for the active self-harm protocol. MR2 also had an order for Courtyard/Smoking Privileges. Documentation in the medical record reveals that MR2 had a history of elopements but privileges were present in the medical record as evidenced by the admission orders on October 17, 2025. Review on November 24, 2025, of MR3 revealed that the patient was a 55-year-old female admitted to the hospital on July 26, 2025, as a 302 involuntary commitment to the psychiatric unit. MR3 was admitted to the hospital with a diagnosis of Alcoholism. The initial Broset score on admission was 0. On July 26, 2025, the Broset score was a 0. On July 27, 2025, the Broset score was a 0. On July 28, 2025, the Broset score was a 0 and on July 29, 2025, the Broset score was not completed. An order was placed by the physician in the medical record for the active self-harm protocol. MR3 also had an order for Courtyard/Smoking Privileges. Documentation in the medical record reveals that MR3 had privileges were present in the medical record as evidenced by the admission orders on July 26, 2025, and documentation revealed lack of Broset scale for July 29, 2025. Review on November 24, 2025, of MR4 revealed that the patient was a 43-year-old male admitted to the hospital on October 21, 2025, as a 302 involuntary commitment to the psychiatric unit. MR4 was admitted to the hospital with a diagnosis of Bipolar and Substance Abuse. The initial Broset score on admission was 0. On October 22, 2025, the Broset score was a 5. On October 23, 2025, the Broset score was a 0. On October 24, 2025, the Broset score was a 3 and on October , 2025, the Broset score was a 1. An order was placed by the physician in the medical record for the active self-harm protocol. MR4 also had an order for Courtyard/Smoking Privileges. Documentation in the medical record reveals that MR4 had privileges were present in the medical record as evidenced by the admission orders. Review on November 24, 2025, of MR5 revealed that the patient was a 47-year-old male admitted to the hospital on September 3, 2025, as a 302 involuntary commitment to the psychiatric unit. MR5 was admitted to the hospital with a diagnosis of Alcohol withdrawal. The initial Broset score on admission was 1. Documentation does not reveal another Broset score. An order was placed by the physician in the medical record for the active self-harm protocol. MR5 also had an order for Courtyard/Smoking Privileges. Documentation in the medical record reveals that MR5 had privileges were present in the medical record as evidenced by the admission orders. Review on November 24, 2025, of MR6 revealed that the patient was a 49-year-old female admitted to the hospital on May 15, 2025, as a 302, as an involuntary commitment to the psychiatric unit. MR6 was admitted to the hospital with a diagnosis of Intentional Overdose, Bipolar, and Anxiety. The initial Broset score on admission was 0. An order was placed by the physician in the medical record for the active self-harm protocol. MR6 also had an order for Courtyard/Smoking Privileges. Documentation in the medical record reveals that MR6 had privileges were present in the medical record as evidenced by the admission orders on May 15, 2025. During medical record review on November 24, 2025, at approximately 12:00 PM, EMP22 confirmed the above medical record findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 45574 Based on a review of facility documents, medical records (MR) and employee interview (EMP), it was determined that the facility failed to obtain an order to continue seclusion in one of four restraint medical records reviewed (MR7). Findings include: On November 25, 2025, a review of “Policy and Procedure for Patient Restraint and Seclusion” (Last Revised: 02/2024) was completed and revealed the following: “Section IV. Guidelines for Restraint and Seclusion Use: D. Restraints for violent, self-destructive behavior: These standards apply to Emergency or crisis management situations, where a patient’s behavior becomes self-destructive or violent, presenting an immediate serious danger to his/her safety or that of others regardless of clinical setting. Restraints may be physical, chemical and/or seclusion ...Orders for Physical/Chemical Restraint for the Violent Self-destructive Patient: ...2. The physician order must be obtained as soon as possible ...8. Orders for restraint/seclusion must include: Date and Time of application/Clinical Application/Type of restraints .../Time limited order ... Callout Box: Up to 4 hours for individuals 18 years and older.” On November 25, 2025, a review of MR7 revealed that the patient was placed in seclusion for violent, self-destructive behavior on September 10, 2025, at 2:25 AM. MR7 remained in seclusion until 4:38 PM on September 10, 2025. The second order for continuing restraint was due, per policy, at 6:25 AM and not obtained until 10:18 AM, 7 hours and 53 minutes after the first order at 2:25 AM. Thus, exceeding the 4 hour time limit for violent, self-destructive restraints. On November 24, 2025, at 11:14 AM, EMP6 confirmed that the order due at 6:25 AM was not completed per policy.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 45574 Based on a review of facility documents, medical records (MR), and employee interview (EMP), it was determined that the facility failed to document a face to face evaluation/assessment completed by a licensed practitioner, certified nurse practitioner, or physician assistant, for seclusion of the violent, self-destructive patient in four of four seclusion records reviewed (MR7, MR8, MR9, and MR10). Findings include: On November 24, 2025, a review of “Policy and Procedure for Patient Restraint and Seclusion” (Last Revised: 02/2024) was completed and revealed the following: “Section IV. Guidelines for Restraint and Seclusion Use: D. Restraints for violent, self-destructive behavior: ...9. Face to Face Evaluation- One Hour and Eight Hour Assessments: The in person evaluation, conducted by a licensed practitioner, a certified nurse practitioner, or a physician assistant must be completed within one hour of the initiation of restraint or seclusion for the management of violent or self-destructive behavior that jeopardizes the physical safety of the patient, staff, or others ... “. On November 24, 2025, a review of MR7 revealed that the patient was placed in seclusion on September 10, 2025, at 02:25 AM. The face to face assessment was completed at 2:30 AM by EMP17, a registered nurse. A second, time limited order was obtained on September 10, 2025, at 10:18 AM, with the face to face assessment occurring at 11:15 AM by EMP18, a registered nurse. On November 24, 2025, a review of MR8 revealed that the patient was placed in seclusion on September 11, 2025, at 2:30 PM. The face to face assessment was completed at 2:50 PM by EMP19, a registered nurse. On November 24, 2025, a review of MR9 revealed that MR9 was placed in seclusion on October 29, 2025, at 01:36 PM. The face to face assessment was completed at 2:00 PM by EMP9, a registered nurse. On November 24, 2025, a review of MR10 revealed that MR10 was placed in seclusion on September 2, 2025, at 01:13 PM. The face to face assessment was completed at 1:15 PM by EMP18, a registered nurse. The above findings were confirmed on November 24, 2025, at 12:00 PM by EMP6. At approximately 1:00 PM, EMP5 confirmed that the facility policy stated that only licensed practitioners, certified registered nurse practitioners, or physician assistants were permitted, by policy, to perform the face to face evaluation.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(2)(iv) [The hospital must require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following:] (iv) The safe application and use of all types of restraint or seclusion used in the hospital, including training in how to recognize and respond to signs of physical and psychological distress (for example, positional asphyxia). This Standard is not met as evidenced by: 45574 Based on a review of facility documents, personnel files (PF), and employee interviews (EMP), it was determined that the facility failed to provide evidence of training regarding the use of restraints and seclusion for violent and/or self-destructive patients for two of two agency registered nurses reviewed and assigned to the behavioral health unit (PF13 and PF14). Findings Include: On November 24, 2025, a review of “Policy and Procedure for Patient Restraint and Seclusion” (Last Revised: 02/2024) was completed and revealed the following: “ Section VI. Education and Training: ...Staff Education and Training: 1. Orientation to this policy will be provided to all newly hired staff and agency personnel that have direct patient care responsibilities, responsibilities for the application of restraint or the monitoring or assessment of patients in restraint. At the end of orientation, the staff should be able to demonstrate competency in the application of restraint, implementation of seclusion if applicable, monitoring, assessment and providing care for a patient in restraint or seclusion.” On November 24, 2025, a review of the “Behavioral Health Nursing Learning Objectives “ (competency checklist) (Last Updated: 5/24/2023) was completed and revealed, “In the Competency section, where this is an option, to choose either V, O, or D in the key: Circle O if the orientee observed the preceptor doing the procedure; Circle D if the nurse demonstrated the skill associated with that specific competency. If only D is available in the key section, the nurse must demonstrate the skill in order to be deemed competent ...” The Restraint and Seclusion section, on page 2, of the “Behavioral Health Nursing Learning Objectives” requires demonstrated skills. On November 24, 2025, a review of PF13, agency registered nurse, revealed no documentation of completed restraint/or seclusion training/competency. On November 24, 2025, a review of PF14, agency registered nurse, revealed no documentation of completed restraint/or seclusion training/competency. On November 24, 2025, at approximately 1:15PM, EMP5 confirmed that PF13 and PF14 had no documentation of completed restraint/or seclusion training/competency.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 27429 Based on a review of facility documents, medical records (MR), employee interviews (EMP), it was determined that the facility failed to have safety measures in place to reduce the risk of psychiatric patient elopements (A0142), and failed to following the patient sitter policy which resulted in an elopement of a psychiatric patient (A0144). This failure resulted in an Immediate Jeopardy, posing a serious risk of harm to the patients. Cross reference: 482.13(c)Patient Rights: Privacy and Safety 482.13(c)(2) Patient Rights: Care in Safe Setting”

“PATIENT RIGHTS: PRIVACY AND SAFETY CFR(s): 482.13(c) Patient Rights: Privacy and Safety This Standard is not met as evidenced by: 27429 Based on a review of facility documents, medical records (MR), and employee interviews (EMP), it was determined that the facility failed to ensure safety measures were in place to reduce the risk of psychiatric patient elopements for eight of ten medical records reviewed (MR1, MR2, MR5, MR6, MR7, MR8, MR9, and MR10). Finding include: On August 8, 2024, a review of the Psychiatric Patients in the Emergency Department Policy revealed, “To ensure the safety and appropriate plan of care of the psychiatric patient presenting to the Emergency Department. 5. Security or a Sitter will be requested to observe any patient that presents as homicidal. suicidal, or exhibiting impaired judgment for personal and or other’s safety, or as deemed necessary by the ED nurse, or physician....10. Patients for mental health (MH) evaluation are not permitted to leave the ED. 11. In the event that a situation escalates that cannot be safely managed, security will collaborate with ED staff to determine if assistance is required from the local police department...”. On August 8, 2024, review of the Patient Sitter Policy revealed, “The policy of Excela Health to utilize patient sitters in accordance with established standards to minimize the safety risk to the patient or another individual. This policy applies to all employees or Contractor employees working in a sitter position or capacity within Excela Health. E. Patient sitter responsibilities include but are not limited to: 1. Sitting with patient in view 2. Providing protection to keep a patient from harming themselves or others...5. Patient sitters must remain in the patient room with the patient at all times. ...7. The use of radios, headphones and any other other electrical devices by sitters for personal use is prohibited...”. On August 8, 2024, review of Infant/Child Abduction and Missing Person Policy - Code Amber, Policy 4-11-214, revealed, “the purpose is to establish guidelines for the prevention of infant/child abduction and/or missing person, and prompt recognition and response to any abduction and/or missing person in the Acute Care and Outpatient settings on the Westmoreland premises. ...Missing person may be an infant/child/adult. ...The person who first becomes aware of the abduction or missing person immediately notifies the hospital operator at extension 1111 and then Security at extension 2222, providing all available information to both parties need to ensure a full description is provided...When code Amber Adult is announced via overhead paging, all employees are alerted to observe for any person matching the description. ...The employee should attempt to delay the person by questioning the suspected missing person until a Security of Police respond. Nursing should be available to identify the person if needed. ...Upon receiving a report of a missing person...the Security Officer shall, verify that all closed caption television are being monitored, obtain as much information from the caller as possible, notify all security officers and Greensburg and State Police if warranted....Upon receiving notification of the missing person...the switchboard operator shall page the following, Safety Manager, Patient Safety, Risk Manager, Administrator on Call, Security Supervisor, Nursing Supervisor...”. Review of MR1, on August 8, 2024, revealed that the patient was a 28 year old male with a history of psychiatric disorders, arrived in the Emergency Department for a psychiatric evaluation because patient was off all medication for two weeks with a suicide attempt. On the morning of August 2, 2024, MR1 attempted to slit his wrists at 08:42 AM, MR1 was placed in a patient room and a patient sitter was order due to the Columbia Suicide Severity Rating Scale. MR1 had positive thoughts for suicide and a psychiatric consultation to see the patient. MR1 had a history of psychiatric admissions in the past and the most recent was in July of 2024, at 11:08 AM, the determination was made to admit the patient to the inpatient psych unit as and a COVID test was requested prior to moving the patient to the unit. At 14:07, MR1 eloped from the Emergency Department. The medical record revealed that the patient eloped from the Emergency Department on August 2, 2024. Further review revealed that the sitter policy and missing person’s policy were not followed, per policy. A review of MR2 on August 8, 2024, revealed the patient presented to the Emergency Department on August 6, 2024, for a psychiatric evaluation and 201, after attempting to cut his arms with a knife when the police arrived. A sitter was ordered by the physician. The medical record revealed that the patient eloped from the Emergency Department on August 8, 2024. A review of MR5 on August 8, 2024, revealed the patient presented to the Emergency Department on March 14, 2024, for a psychiatric evaluation after threatening suicide after fighting with the mother and sister. The medical record revealed that the patient eloped from the Emergency Department prior to assessment and evaluation on March 14, 2024. A review of MR6 on August 8, 2024, revealed the patient presented to the Emergency Department on July 15, 2024, for a psychiatric evaluation with the police. Documentation reveals the patient was loud and disruptive while in the Emergency Department and security was requested to assist and the patient eloped from the Emergency Department prior to assessment and evaluation on July 15, 2024. A review of MR7 on August 8, 2024, revealed the patient presented to the Emergency Department on August 2, 2024, for a psychiatric evaluation with the police. Documentation revealed patient was unkept, loud, had an odor of alcohol and security was requested to assist. The patient eloped from the Emergency Department prior to assessment and evaluation on August 2, 2024. A review of MR8 on August 8, 2024, revealed the patient presented to the Emergency Department on June 19, 2024, for a psychiatric evaluation with the police. Documentation reveals the patient was angry, loud, demanded to see psych. Security was requested to assist and a sitter was ordered, however the patient eloped. A review of MR9 on August 8, 2024, revealed the patient presented to the Emergency Department with police on February 8, 2024, for a psychiatric evaluation. Documentation revealed the patient was paranoid and hallucinating upon arrival and requested help. Documentation revealed that the patient was not seen by a provider and eloped. A review of MR10 on August 8, 2024, revealed the patient presented to the Emergency Department on April 10, 2024, for a psychiatric evaluation with the police. Documentation reveals the patient was found on a local college campus after falling out of a moving car. The patient was rambling and pacing. Documentation reveals the patient was not seen by a provider and eloped. On August 8, 2024, at 11:55, EMP3 confirmed the above.”

“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: 27429 Based on a review of facility documents, medical records (MR), a hospital surveillance video and employee interviews (EMP), it was determined that the facility failed to following the patient sitter policy which resulted in an elopement of a psychiatric patient for one of 20 medical records reviewed (MR1). Finding include: On August 8, 2024, a review of the facility’s Patient Sitter Policy revealed, “The policy of Excela Health to utilize patient sitters in accordance with established standards to minimize the safety risk to the patient or another individual. This policy applies to all employees or Contractor employees working in a sitter position or capacity within Excela Health. E. Patient sitter responsibilities include but are not limited to: 1. Sitting with patient in view 2. Providing protection to keep a patient from harming themselves or others...5. Patient sitters must remain in the patient room with the patient at all times. ...7. The use of radios, headphones and any other other electrical devices by sitters for personal use is prohibited...”. Review of MR1 on August 8, 2024, revealed that the patient was a 28 year old with a history of psychiatric disorders and arrived in the facility’s Emergency Department (ED) for a psychiatric evaluation. The patient had been off all medication for two weeks and attempted suicide. MR1 had a history of psychiatric admissions in the past and the most recent in July of 2024. Further review of the medical record revealed that the patient was placed in a patient room and a patient sitter was order due to the Columbia Suicide Severity Rating Scale. MR1 had positive thoughts for suicide and after a psychiatric consultation a determination was made to admit the patient to the inpatient psych unit as a Covid test was requested prior to moving the patient to the unit. On August 2, 2024, at 14:07, MR1 eloped from the Emergency Department. On August 7, 2024, a review of a surveillance video in the ED and and interview with EMP1 at 12:15 PM, provided the following chronological summary of the events that occurred on August 2, 2024. · 2:06:17: MR1 was seen stepping out of room 18. A security guard in the hall was looking at their phone while reportedly directly observing a patient in room 20. MR1’s sitter was sitting in the hallway across from room 18, looking to the right (away from room 18) and appeared not to notice MR1. There did not appear to be any interaction at this time between the security guard, sitter, and patient. · 2:06:28 the patient’s sitter continues looking in the opposite direction of the patient and room 18. · 2:06:47 MR1 exits through the the non-restricted doorway into the hall. Security guard turns but does not respond and removes radio from his back pocket and returns it without use. · 2:07:09 MR1 exits at a fast pace through the ambulance bay doors. · 2:07:24 MR1 observed in parking lot walking at a normal pace and crosses the street and no longer able to be viewed by video surveillance. On August 8, 2024, at 9:11 AM, EMP3 confirmed the above.”

“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: 46390 Based on a review of facility documents, medical records (MR), observation, and staff interview(EMP), it was determined that the facility failed to supervise the patient’s care to ensure the patient’s cardiac status was being monitored at all times for one of 20 medical records reviewed (MR1), failed to follow the cardiac standards of care for two of 20 medical records reviewed (MR1 and MR2), and failed to ensure that a registered nurse (RN) supervised and evaluated patients under the care of a licensed practical nurse (LPN) consistent with professionally recognized standards of nursing practice for two of two medical records reviewed (MR21 and MR22). Findings include: On July 29, 2024, a review of the facility’s Protocol for Patient Management, last reviewed July 17, 2024, revealed, “...Excela Health has created this policy in order to facilitate appropriate alarm management and decrease instances of alarm fatigue and alarm nuisance. ...ALARM RESPONSE. Patient care staff must respond to alarms immediately. ...Patient care staff identifies the reason for the alarm the reason for the alarm, corrects the issue or notifies the appropriate individual when patient monitoring issues arise that are outside the clinicians’ scope of practice. ... DOCUMENTATION in EMR: All assessment and reassessment findings, Interpretation of the rhythm strips on admission, every 8 hours, and as needed. Alarms are functional, Any changes made to alarms, Any changes inpatient’s vital signs or cardiac rhythm...”. On July 29, 2024, a review of the facility’s Registered Nurse Standard Work, dated June 2020, revealed, “Primary RN will give verbal delegation and report to LPN and TP (technical partner) for appropriate patient needs and task completion...”. On July 30, 2024, a review of the facility’s Registered Nurse job description, dated April 28, 2022, revealed, “Assure quality of care by adhering to therapeutic standards ...following system/hospital and nursing division’s philosophies and standards of care set by state board of nursing, nurse practice act, and other governing agency regulations.... Document patient care services by charting in patient records ... Identify patient care requirements by establishing a personal rapport with potential and actuals patients, and other persons in a position to understand care requirements...”. On July 30, 2024, a review of the facility’s Licensed Practical Nurse job description dated January 19, 2023, revealed, “Essential Job Functions- Assists the RN in collecting patient health care data on admission by completing a focused assessment.” On July 29, 2024, a review of MR1 revealed the patient was a 76-year-old female with a history of coronary artery disease, gout and diabetes and presented to the hospital on July 2, 2024, due to decreased urine output, urinary retention, an elevated troponin, a urinary tract infection, chest tightness, and short of breath. Cardiology was consulted and patient was admitted with hypoxia and a STEMI. MR1 had a stress test and was not medically stable to have a left heart catheterization at this time due to Chronic Renal Failure. On July 8, 2024, at 4:04 AM, Monitor tech alerted staff via text that the cardiac monitor came off. The charge nurse responded that they would let primary nurse know. Facility documents showed a call was made to the unit at 4:16 AM. At 4:32 AM, the monitor tech texted the charge nurse again that the monitor leads continued to read leads off without a change. At 4:46 AM, the tech went in to check the patient, found patient unresponsive and called out for help. A code blue was called. Staff initiated CPR immediately and on arrival of the Code team, underlying rhythm was asystole. After ten rounds of epinepherine and Bicarb, the patient was transferred to ICU for further management. There, the intensivist had multiple conversations with the family including the possibility of inadequate brain perfusion after a cardiac arrest and CPR for forty minutes. Family was notified that patient’s neurological exam was poor. Later in the afternoon, the patient experienced seizure like activity. Another discussion with the family resulted in the decision to proceed with Comfort Measures Only. The patient passed away on July 8, 2024. On July 29, 2024, a review of MR2, revealed that the 68 year old patient was admitted on July 26, 2024, via the Emergency Department with shortness of breath, chest pain, a recent weitght gain of 17 pounds and a valve replacement to a cardiac monitor unit. The patient had a history of hypertension, Supraventricular Tachycardia (SVT) and Sleep Apnea. Further review revealed that MR2 was ordered a Trans-Esophageal Echocardiogram (TEE) to rule out cardiac tamponade and the nurse obtained an order for the patient to go for testing off the the cardiac monitor on July 29, 2024. On July 29, 2024 at 10:01 AM, MR2 was observed from the monitor room, returning to the nursing unit,off the cardiac monitor. At 10:06 AM, EMP9 placed a call to call to the third floor telemetry unit to place the patient back on the monitor. EMP9 stated that the nurse has five minutes to place the patient back on the monitor. The patient was observed being off the monitor until 10:13 AM. On July 29, 2024, at 10:13 AM, EMP3 confirmed the above. On July 30, 2024, during a review of assignment sheets while on tour, the following verbiage was noted on the standardized facility assignment sheet, “MUST indicate RN that is covering the LPN...”. On July 30, 2024, at 09:50 AM, during a tour of the first floor telemetry unit, nursing patient assignment sheets were reviewed. It was noted that the titles of registered nurse and licensed practical nurse were not delineated on the assignment sheets for six of six assignment sheets reviewed. It was also noted that LPN coverage by a RN was not delineated on the assignment sheet for six of six assignment sheets reviewed. On July 30, 2024, at 10:00 AM, EMP15 described that the LPN was covered by the charge nurse or clinical nurse coordinator. On July 30, 2024, a review of MR21 revealed that the patient was cared for by LPN EMP16 between July 27, 2024, at 7:00 PM, and July 28, 2024, at 7:00 AM. Further review of MR21 revealed no documentation to support that an RN supervised nursing care or evaluated the patient during this shift. On July 30, 2024, a review of MR22 revealed that the patient was cared for by LPN EMP17 between July 27, 2024, at 7:00 PM, and July 27, 2024, at 3:00 PM. Further review of MR22 revealed no documentation to support that an RN supervised nursing care or evaluated the patient during this shift. On July 30, 2024, at approximately 12:15 pm, EMP1 and EMP12 confirmed the above.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 46390 Based on a review of facility documentation, medical record (MR), and staff interview (EMP), it was determined the facility failed to ensure staff adhered to the policies and procedures of the hospital for the cardiac monitor standard of care in two of two medical records (MR1 and MR2), and failed to ensure that the standard for assessment/reassessment was met in one of two medical records reviewed (MR21). Findings include: On July 29, 2024, a review of the facility’s Protocol for Patient Management, last reviewed July 17, 2024, revealed, “Excela Health has created this policy in order to facilitate appropriate alarm management and decrease instances of alarm fatigue and alarm nuisance. ...ALARM RESPONSE. Patient care staff must respond to alarms immediately. ...Patient care staff identifies the reason for the alarm the reason for the alarm, corrects the issue or notifies the appropriate individual when patient monitoring issues arise that are outside the clinicians’ scope of practice, ... DOCUMENTATION in EMR: All assessment and reassessment findings, Interpretation of the rhythm strips on admission, every 8 hours, and as needed. Alarms are functional, Any changes made to alarms, Any changes inpatient’s vital signs or cardiac rhythm...”. On July 30, 2024, a review of the policy, “Assessment/Reassessment of the Patient” (Last Reviewed/Revised: January 2024) revealed, “... A head to toe re-assessment will be completed and documented by an RN/GN a minimum of every 12 hours, with change in patient condition, and when responsibility for a patient’s care changes from one nurse to another.” On July 29, 2024, a review of MR1 revealed the patient was a 76-year-old female with a history of coronary artery disease, gout and diabetes and presented to the hospital on July 2, 2024, due to decreased urine output, urinary retention, an elevated troponin, a urinary tract infection, chest tightness, and short of breath. Cardiology was consulted and patient was admitted with hypoxia and a STEMI. MR1 had a stress test and was not medically stable to have a left heart catheterization at this time due to Chronic Renal Failure. On July 8, 2024, at 4:04 AM, Monitor tech alerted staff via text that the cardiac monitor came off. The charge nurse responded that they would let primary nurse know. Facility documents showed a call was made to the unit at 4:16 AM. At 4:32 AM, the monitor tech texted the charge nurse again that the monitor leads continued to read leads off without a change. At 4:46 AM, the tech went in to check the patient, found patient unresponsive and called out for help. A code blue was called. Staff initiated CPR immediately and on arrival of the Code team, underlying rhythm was asystole. After ten rounds of epinepherine and Bicarb, the patient was transferred to ICU for further management. There, the intensivist had multiple conversations with the family including the possibility of inadequate brain perfusion after a cardiac arrest and CPR for forty minutes. Family was notified that patient’s neurological exam was poor. Later in the afternoon, the patient experienced seizure like activity. Another discussion with the family resulted in the decision to proceed with Comfort Measures Only. The patient passed away on July 8, 2024. On July 29, 2024, a review of MR2, revealed that the 68 year old patient was admitted on July 26, 2024, via the Emergency Department with shortness of breath, chest pain, a recent weitght gain of 17 pounds and a valve replacement to a cardiac monitor unit. The patient had a history of hypertension, Supraventricular Tachycardia (SVT) and Sleep Apnea. Further review revealed that MR2 was ordered a Trans-Esophageal Echocardiogram (TEE) to rule out cardiac tamponade and the nurse obtained an order for the patient to go for testing off the the cardiac monitor on July 29, 2024. On July 29, 2024 at 10:01 AM, MR2 was observed from the monitor room, returning to the nursing unit,off the cardiac monitor. At 10:06 AM, EMP9 placed a call to call to the third floor telemetry unit to place the patient back on the monitor. EMP9 stated that the nurse has five minutes to place the patient back on the monitor. The patient was observed being off the monitor until 10:13 AM. On July 29, 2024, at 10:13 AM, EMP3 confirmed the above. On July 30, 2024, at 12:00 PM, a review of MR21 was completed. On 7/27/2024, at 07:00PM, the responsibility for MR21 was assumed by another nurse. There was no documented patient assessment with the change of patient responsibility from one nurse to another. On July 30, 2024, at approximately 12:10 PM, EMP1 and EMP12 confirmed this finding.”