Thomas Jefferson University Hospital

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 38776 Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure adequate no smoking signage in patient rooms and areas oxygen was administered; failed to adequately assess and identify patients who smoke and the need to secure smoking materials; failed to educate patients regarding the dangers of smoking and oxygen use for one of one medical record reviewed (MR1); and failed to encourage patients who smoke alternatives to smoking while admitted to the facility (A0144). The failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to the patient. On January 24, 2025, the survey team toured the nursing units and conducted staff interviews regarding their education received about how patients will be educated regarding the dangers of smoking in a patient room with oxygen present or administered. The nursing units were toured; No Smoking signs were observed on patient units and in patient rooms. The immediate education that was provided to staff regarding patient no smoking education was reviewed. The survey team verified these immediate interventions were implemented and confirmed the facility’s IJ was removed on January 27, 2025. After secondary review the State Survey Agency returned onsite on February 5, 2025. The survey team toured the facility and observed No Smoking or use of smoking related paraphernalia at entrances throughout the facility. Staff were educated on policy changes implemented regarding assessing patients for smoking/tobacco use on admission; smoking materials will be considered contraband and will be secured from patients. Documentation for securing of contraband in the medical record was developed and validated. Staff were educated regarding providing smoking cessation, smoking alternatives to patients, and documentation in the medical record. Staff education was verified. In addition to drafting policy, and educating staff and patients, the facility identified the patients in house who smoke, and what they did for each patient, and provided it to the surveyor team. The survey team reviewed a sample of those records to verify implementation before lifting the IJ that same day. Cross reference 482.13(c)(2) Patient Rights: Care In Safe Setting”

“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: 38776 Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure adequate no smoking signage in patient rooms and areas oxygen was administered; failed to adequately assess and identify patients who smoke and the need to secure smoking materials; failed to educate patients regarding the dangers of smoking and oxygen use for one of one medical record reviewed (MR1); and failed to encourage patients who smoke alternatives to smoking while admitted to the facility (A0144). Findings: Review on January 24, 2025, of the facility policy, “Tobacco-Free Environment Policy, 200.88,” last reviewed February 2, 2023, revealed “... Purpose To set forth the policy for maintaining a tobacco-free environment to promote the safety, health, and wellness of all patients, employees, volunteers, faculty members, medical staff, students, vendors, and visitors of ... TJUH System and its Subsidiaries. ... Scope This policy applies to all Jefferson patients, visitors, vendors, students, volunteers, medical staff and employees within fifty (50) feet of the entryway to or exit from any property owned, rented or leased by Jefferson; ... Procedure I. Definitions A. Smoking is defined as the use of or carrying of a lighted cigarette, cigar, pipe, or other tobacco product. It means inhaling, exhaling, burning, or carrying any lighted or heated cigarette, cigar, or pipe. ... II. Tobacco-Free Environment A. Guidelines 1. Smoking of the use of tobacco products/smoking material is not permitted anywhere on the Jefferson Campus. 2. Patients are informed of this policy upon registration, arrival, or as soon thereafter as is reasonably possible. B. Notification 1. Signage prohibiting smoking shall be posted to notify individuals visiting the Jefferson Campus of this Tobacco-Free Environment Policy. ...” Review on January 24, 2025, of MR1 revealed the patient was admitted to the facility on January 21, 2025, for lower extremity numbness and weakness secondary to medistinal mass with adjacent destructive vertebral changes. There was documentation the patient reported smoking a few cigarettes a day. There was a physician order dated January 21, 2025, for Nicorette (a medicine used for nicotine replacement therapy) 2 milligrams lozenge by mouth as needed every two hours. There was no documentation MR1 was offered or administered the Nicorette lozenge. There was no documentation MR1 was assessed for having smoking materials on their person. There was no documentation MR1 ’ s smoking materials were secured by the facility. Continued review of MR1 revealed nursing documentation dated January 23, 2025, the nurse responded to MR1’s bed alarm, opened the door, and immediately smelled burning smoke in the room. There were burns/holes in the bed sheets. MR1’s nasal cannula was sitting on the patient’s lap. There was documentation half of the nasal cannula was burned off and a lighter was found in the patient’s bed. There was documentation MR1 admitted to attempting to light a cigarette, felt something catch on fire, and put it out with a pitcher of water. There were new burn marks to patient’s chest, upper lip, and nose. MR1’s vital signs were stable and there was no shortness of breath. There was documentation MR1’s primary care team was called to the bedside. There was documentation security completed a room search and all belongings were sent home with the patient’s brother who had arrived after the incident. Continued review of MR1 revealed physician documentation dated January 23, 2025, MR1 sustained first/second degree partial thickness burns to face and neck after MR1 attempted to smoke in the hospital while on six liters of oxygen via nasal cannula. There was documentation MR1 was evaluated. There was documentation there was no overt airway compromise and MR1 was transferred to the Surgical Intensive Care Unit (SICU) overnight for airway monitoring. There was documentation MR1’s burns were cleansed and Bacitracin and Silvadene were applied. Continued review of MR1 revealed there was no documentation MR1 was educated on the dangers of smoking while being administered oxygen prior to attempting to smoke while receiving oxygen on January 23, 2025. Interview on January 24, 2025, with EMP3, at approximately 1700 confirmed the above findings. An observation tour of the 9th floor Comprehensive Spine nursing unit was completed on January 24, 2025, at approximately 1700. There were no visible no smoking signs in the patient rooms where oxygen was accessible and administered. Interview on January 24, 2025, with EMP4, at approximately 1705 confirmed the above findings. On January 27, 2025, the State Survey agency confirmed the issue related to the posting of non-smoking signs was addressed, and on February 5, 2025, the facility identified patients in-house who smoke with interventions provided for each of these patients.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 34230 This Condition is not met as evidenced by: Based on review of facility documents, medical record (MR), camera video recording and interview with staff (EMP), it was determined that the hospital failed to ensure the safety and safe environment of a patient presenting to the emergency department transported by ambulance from a nursing home with Altered Change in Mental Status (A0144) and failed to ensure a documented reassessment of a patient triaged in the emergency department with an Emergency Severity Index Level 3 score presenting with Altered Change in Mental Status (1112). On January 26, 2024, at 3:40 PM, Immediate Jeopardy (IJ) was identified for 482.13: Patient Rights. The hospital implemented immediate interventions to include an additional Registered Nurse to be placed in the emergency department external waiting room triage to support the primary triage nurse and completing assessment of patients every 4 hours; education provided to the external waiting area triage nurse, medical staff providers, charge nurse. The State Agency verified the immediate interventions and the IJ was removed. Cross reference 482.13 (c)(2): Patient Rights: Care in Safe Setting 482.55 (b)(2): Qualified Emergency Services Personnel”

“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: 34230 This Condition is not met as evidenced by: Based on review of facility documents, medical record (MR), camera video recording and interview with staff (EMP), it was determined that the hospital failed to ensure a documented reassessment of a patient triaged in the emergency department with a Emergency Severity Index Level 3 score presenting with Altered Change in Mental Status (1112) and failed to ensure the safety and safe environment of a patient presenting to the emergency department transported by ambulance from a nursing home with Altered Change in Mental Status (A0144). On January 26, 2024, at 3:40 PM, Immediate Jeopardy (IJ) was identified for 482.55: Emergency Services. The hospital implemented immediate interventions to include revision in the provider workflow for dispositioning a patient arriving via EMS/Ambulance to the external waiting room, treatment space and internal waiting room area; ambulance patients will be assigned to internal waiting room or treatment room; patient care technician assigned to the external waiting room 24/7 to round on patients every 2 hours and document in the electronic medical records the rounds completed. Rounding audits performed by the patient care technician will be audited by the Nurse Supervisor. The State Agency verified the immediate interventions and the IJ was removed. Cross Reference: 482.55 (b)(2): Qualified Emergency Services Personnel 482.13 (c)(2): Patient Rights: Care in Safe Setting”

“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: 34230 Based on review of facility policy, security camera footage, medical record (MR) and interview with staff (EMP), it was determined that the facility failed to provided a safe environment in the emergency department (ED) by failing to ensure that a patient presenting to the emergency department with an Altered Change in Mental Status was in a safe location within the ED waiting room for one of one medical record reviewed (MR1). Findings Include: Review of facility policy “Patient Rights and Responsiblities, 112.09”, last revised October 2023 revealed “...Each patient’s personal dignity and self-worth are important to Thomas Jefferson University Hospital (TJUH). Patients have the right to be treated in a dignified and respectful manner by all TJUH personnel. This policy reflects TJUH’s consideration of all patients cultural and personal values, beliefs and preferences and is designed to optimize their comfort and dignity. Patients have the right to be cared for by staff educated about patient rights and their role in supporting those rights....To Receive Quality Health Care: Patients have the right to excellent quality health care, maintained to the highest professional standards. In furtherance of that goal, TJUH continually monitors and reviews care rendered to patients and seeks ways to improve performance and quality. Review of MR1 revealed the patient arrived to the Emergency Department via ambulance at the ambulance entrance on January 23, 2024, at 10:54 AM and was triage by a registered nurse on January 23, 2024, at 10:57 AM .Further review revealed the patient arrived from a nursing home presenting to the emergency department with Altered Mental Status, Urinary Track Infection (UTI) and Aggressive Behavior. Review of MR1 revealed a progress note authored by EMP14,registered nurse on January 23, 2024, at 11:10 AM revealed “Altered Mental Status reported from Nursing Home. Nursing Home reports patient displays aggression.” Review of MR1 revealed a progress note authored by OTH1, physician assistant, on January 23, 2024, at 11:51 AM revealed “ Patient presenting with change in Mental Status, aggressive behavior, “he/she” is not sure why “he/she” is in the emergency department...”he/she” states “he/she” is hungry.” Review of MR1 revealed documentation of a blood glucose test result dated January 23, 2024, at 12:05 PM. Further review of MR1 revealed the patient was assigned and seated in the external waiting room location at 12:05 PM in the emergency department. Review of the facility’s security camera footage received from the facility on January 27, 2024, to the survey team revealed the patient (MR1) exiting the emergency department external waiting room unassisted on January 24, 2024, at 12:11 AM. An interview conducted on January 26, 2024, at 11:15 AM with EMP1 confirmed the medical record of MR1 contained no documentation of the patient’s care and treatment after the blood glucose lab test resulted at 12:05 PM on January 23, 2024. An interview conducted on January 26, 2024, at 11:52 AM with EMP15 confirmed an internal incident report was filed on January 24, 2024, at 2:57 AM reporting MR1 as a missing person. Further interview confirmed the emergency department staff was not aware as to when MR1 had exited the facility’s emergency department waiting room and the patient’s location after exiting. EMP15 confirmed the police and the patient’s family member was notified of the patient’s elopement from the emergency department external waiting room.”

“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: 34230 Based on review of facility policy, security camera footage, medical record (MR) and interview with staff (EMP), it was determined that the facility failed to ensure the clinical healthcare staff performed a reassessment for care delivery according to the facility’s policy as a standard of care for a patient in the emergency department with an Emergency Severity Index (ESI) Score: Level 3 presenting with Altered Change in Mental Status for one of one medical record reviewed (MR1). Findings include: Review of facility policy “Plan for Patient Assessment and Reassessment, 113.35” last revised December 2023 revealed “VIII. ASSESSMENT/REASSESSMENT CRITERIA revealed “ The patient’s diagnoses-treatment setting (ED, Intensive Care, OR, Med/Surg..... etc.) duration of care of length of stay, age and developmental needs, patient’s desire for treatment and response to treatment all serve to direct the process of assessment and reassessment by members of the healthcare team. Criteria defining guidelines for admission to, transfer to and discharge or transfer from all hospital-based units have been developed through criteria approved by the Medical Staff,,, to assist in appropriate placement within the facility.... Each patient is reassessed at points designated in department specific policy. This includes but is not limited to reassessment: Occurring at regular intervals in the course of care (consistent with standard of care). Based on the patient’s response to care. ...Assessment and reassessment data is utilized to develop the interprofessional plan of care and to revise this plan throughout the course of care: [UNIT: Emergency Dept. PERSON ASSESSING: RN & ED Physician, INITIAL TIME FRAME: Based on Intake assessment, RE-ASSESSMENT: Every 2 hrs. (hours) or change in condition]...A. Emergency Department(ED). An RN and ED provider assess all patient arriving for treatment in the Emergency Department. Patient seeking medical care are seen by the ED provider in order of priority based upon their condition or change in condition. Priority is determined by an RN based on the following criteria: Emergency Severity Index: 5 Level Triage System: Level 3-Urgent-Conditions that could potentially progress to a serious problem requiring emergency intervention. May be associated with significant discomfort or affecting ability to function at work or activities of daily living....The ED provider assesses and evaluate each patient to diagnose, treat and form a discharge plan prior to making a referral or decision regarding disposition. Reassessments are performed by RNs and physicians when: A minimum of every 2 hours for ESI level 3 or above. Level 4 and 5 patient will have vital signs reassessed every 4 hours. Review of MR1 revealed a progress note authored by EMP14 dated January 23, 2024, at 11:10 AM with a triage assigned Emergency Severity Index (ESI) Level 3 score: (Urgent-Conditions that could potentially progress to a serious problem requiring emergency intervention. May be associated with significant discomfort or affecting ability to function at work or activities of daily living). An interview conducted on January 26, 2024, at 1:45 PM with EMP1 confirmed MR1 (patient) was triaged as a ESI Level 3 scored patient. Further interview confirmed there was no documentation in MR1 of a reassessment by the healthcare clinical staff as required by the facility’s policy for a ESI Level 3 scored patient. EMP1 stated “The medical record should have contained progress note documentation of reassessments completed by the staff as to the patient’s status while in the ED external waiting room. The patient should have been given something to eat as there was a compliant by the patient (MR1) of being hungry upon arrival to the emergency department.””