Vanderbilt Wilson County 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: 32777 Based on policy review, medical record review, and interview, the facility failed to ensure patients rights were protected and patients received care in a safe setting by failing to follow the hospital’s policy regarding proper labeling of chemicals when 1 of 3 (Patient #1) sampled patients reviewed, was given and ingested a cup of clear liquid poured from an unlabeled pitcher which was actually filled with a diluted chemical cleaning solution that Registered Nurse A mistook for water. The findings include: Patient #1 was seen in the Emergency Department (ED) on 3/26/2025 for an upper Gastrointestinal (GI) Bleed. Patient #1 was subsequently admitted to the Intensive Care Unit on 3/26/2025. On 3/28/2025 Patient #1 was assigned to Registered Nurse A. Registered Nurse A went into the nourishment room to get Patient #1 a cup of water. Registered Nurse A picked up an unmarked clear pitcher sitting on the counter, poured the liquid into a cup over ice and served it to Patient #1. Patient #1 drank the entire amount. Patient #1 subsequently required a second bronchoscopy due to ingesting a chemical substance with a GI Bleed. Refer to A-0144”

“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: 32777 Based on policy review, medical record review, review of a disclosure event note, and interview, the facility failed to ensure patients rights were protected, and the patients received care in a safe setting when 1 of 3 (Patient #1) sampled patients reviewed was given and ingested a cup of clear liquid poured from an unlabeled pitcher filled with a diluted chemical cleaning solution that Registered Nurse A mistook for water. The findings include: 1. Review of a policy titled, “Hazardous Chemical Right-to-Know/Hazard Communication” dated February, 2023, revealed, “...To provide a process by which chemicals stored or used... are identified and that information concerning the hazards are communicated to Workforce Members, non-employed medical providers with privileges, regulatory/accrediting agencies, and emergency responders, as required... Specific Education... New staff receive mandatory... training during general orientation...This training includes... Location and availability of this policy... Requirements for chemical container labels and SDS [Safety Data Sheet]... Physical and health hazards of hazardous chemicals... Protective measures staff use, which include work practices... Training is customized to address the hazardous chemicals maintained or utilized in individual areas and includes... Physical, health, and other hazards associated with exposure to chemicals in the work area... Labeling: Hazardous chemicals removed from original containers and placed into new containers are labeled with the hazard information consistent with that of the original container. Information on the new secondary container includes... Product identification or material name... Supplier identification (name of manufacturer or distributor, address, and emergency phone umber) and... A signal word, pictogram, hazard statement, and precautionary statement for each hazard class and category...” 2. Patient #1 was seen in the Emergency Department (ED) on 3/26/2025 reporting nausea and abdominal pain with Gastrointestinal (GI) Bleeding. Patient #1 was subsequently admitted to the Intensive Care Unit (ICU) on 3/26/2025 with diagnoses to include Esophageal Varices, and Gastroesophageal Reflux Disease (GERD). Review of a Disclosure Event Note dated 3/28/2025 signed by Advanced Practice Nurse C revealed, “...Date and Time of Disclosure Discussion: 3/28/2025 at approximately 10:45am... Location of Disclosure Discussion: Patient’s room ICU... Patient was present. No family members present. Date and Time of Event: 3/28/2025 at 10:15 [AM] Location of Event: ICU... I was approached by the task Nurse [named Registered Nurse A] who informed me that the patient had accidentally been given cleaning sanitizer that she retrieved from a drink pitched next to the water/ice machine in the ICU nourishment room. The patient drank the entire 8oz[ounces] cup of liquid. The Nurse then went back to the refreshment room to get water for another patient and saw that the maintenance staff member was pouring the liquid from the pitcher into the ice/water machine. The nurse asked the maintenance worker what was in the pitcher. He informed her that was a machine sanitizing solution. She informed him that she had given a patient this fluid. 1.6ml [milliliter]of solution was mixed in one gallon of water and 8oz [ounces] was given to the patient. [Named Nurse A] then approached me. I had just exited the patient’s room and he was not in any discomfort. I immediately called poison control. Given he had four esophageal varices banded yesterday and the caustic property of the solution, poison control recommended NGT [NasoGastric Tube - a tube inserted through the nose into the stomach to suction material a patient has ingested or the instill nutrition is a patient is unable to swallow] insertion, evacuation of the fluid from the stomach and repeat endoscopy in 12-24 hours while monitoring closely for bleeding...I entered the room with [Named Physician]...[Named Physician] and I informed the patient of his accidental ingestion of this cleaner. He was appropriately shocked. We told him that we believed that the nurse thought she was giving him water from a pitcher and found out it was diluted cleaner after the fact. He said that he did not tasted anything “off” with the fluid. He agreed to the NGT placement and asked for the smallest NGT possible. we offered an apology and said that we were continuing to investigate the cause of exactly how this happened, but didn’t have all the answers just yet but need to act urgently given the time sensitivity of evacuating the fluid from his stomach...NGT was placed without event with removal of approximately 200cc [cubic centimeter] clear fluid...I provided an update to his daughter...who was very understanding. Her biggest concern is her father’s discomfort coming off conscious sedation and she is worried about repeat endoscopy and further discomfort. I informed her that he would be monitored in the ICU through the weekend...Copy of this note provided to his daughter and former wife, at their request...” Review of the upper GI endoscopy results dated 3/30/2025 revealed, “Preoperative Diagnosis: Exclusion of esophageal injury due to caustic ingestion...Postoperative Diagnosis...Esophageal ulcers with no stigmata of recent bleeding...Findings...Three superficial esophageal ulcers with no stigmat [a specific diagnostic sign of a disease] of recent bleeding were found in the lower third of the esophagus....The upper third of the esophagus and middle third of the esophagus were normal. No evidence of caustic esophagitis or esophageal mucosal necrosis...Signed by Physician B on 3/30/2025 at 10:47:43 AM...” Review of Physician’s Assessment dated 3/30/2025 at 10:50 AM revealed, “Condition: In stable condition. Unchanged. (Upper GI bleeding-post banding x4. Caustic ingestion noted. Repeat upper endoscopy today with no bands in place...No evidence of esophageal necrosis related to caustic ingestion)...” Review of the Discharge Summary dated 4/2/2025 revealed, “...Primary Diagnosis: GI bleed... Additional discharge Diagnoses...Accidental ingestion of cleaning solution...HOSPITAL COURSE...Notably, on 3/28 [2025] a disclosure event had occurred and patient had accidentally been given cleaning sanitizer that nursing staff had received from a drink picture [pitcher] next to the water/ice machine...Patient had consumed 8 ounces of a cup of liquid. Poison control was immediately contacted and NG [NasoGastric tube] was placed for evacuation of fluid from the stomach. A repeat endoscopy was performed 3/30 [2025] that showed no evidence of caustic injury prior esophageal varices without stigmat of recent bleeding...was ultimately transferred out of the ICU on 3/30 [2025]...” During a telephone interview on 5/1/2025 beginning at 11:57 AM, Registered Nurse (RN) A was asked what happened when Patient #1 was given a chemical solution by mistake. RN A stated, she went into the nourishment room to get a cup of ice water for a patient. She stated there was a maintenance man in the room on a ladder doing maintenance on the water/ice dispensing machine. She stated she poured the water from an unmarked clear pitcher that was on the counter and gave it to Patient #1. She stated he drank all of it which was in an 8 oz cup. She stated she went back into the nourishment room to get another cup of water for another patient and saw the maintenance man pouring the liquid from the pitcher into the water/ice dispensing machine. She stated the maintenance man told her it was a sanitizing chemical solution in the pitcher. She stated she immediately notified the Nurse Practitioner and the poison control center was called. During an interview on 5/1/2025 beginning at 12:04 PM, the Heating, Ventilation and Air Conditioning (HVAC) Mechanic was asked what he was doing in the nutrition room when Patient #1 was given the chemical solution by mistake. The HVAC Mechanic stated he was in the nourishment room in the ICU doing preventative maintenance on the water/ice dispensing machine. He confirmed there was no signage posted on the doors to the nourishment room notifying staff. He confirmed RN A came into the nourishment room. He stated he did not see RN A pour any liquid into the cup. During an interview on 5/1/2025 beginning at 12:53 PM, The Chief Nursing Officer and the Director of Plant Operations were asked if an Ad Hoc (for this situation) Quality Assurance Process Improvement (QAPI) meeting and Governing Body meeting was held and if so, what was the outcome of the meetings. The Chief Nursing Officer stated they call QAPI a “Safety Event Analysis” meeting. The first debriefing meeting date was 3/28/2025 and also included ICU staff on site that day. They had a second meeting on 4/4/2025 and a third meeting on 4/15/2025. They constructed a plan of correction immediately which was documented and a copy was provided. The Director of Plant Operations stated some of the immediate interventions would be all maintenance personnel will provide purchased water bottles to any area when the water/ice machine is taking down for maintenance. The maintenance personnel will communicate with the Charge Nurse and notify them of the preventative maintenance to be done. The plan also included making laminated signs to put outside the doors when maintenance was being done. A sign was provided and read, “Preventative maintenance in progress. If there are questions, please see Charge Nurse.” Education was provided beginning on 3/28/2025 for the maintenance staff and continued to expand the education to the Lab personnel. Nursing staff education was ongoing. The Chief Nursing Officer stated their policy was reviewed and no changes were made to the policy. She stated the policy review was part of the education. The Chief Nursing Officer also stated, the computer training was reviewed and provided a copy of a slide that documented, “If you move a chemical to a new container, you must copy what was listed on the first container onto a label for the new container. This lets everyone know if the chemical might be dangerous. The Office of Clinical and Research Safety (OCRS) website has resources to help you make your own labels that comply with the regulations.” The Chief Nursing Officer stated the Governing Body was notified regarding the incident. During a telephone interview on 5/20/2025 beginning at 11:41 AM, Patient #1 stated, “...No one expected that to happen with the cleaning solution...That put me over the edge. I was extremely nervous and kind of anxious about the whole thing. I see a counselor, and that’s been the only thing we’ve talked about since I’ve left that hospital...Now, I’m a little more terrified of that thinking about how easily something went wrong...They put a tube up my nose down into my stomach to pump...out...But how I felt after that was panic. I was shaking all the time...” Patient #1 was asked if a representative from the hospital did any follow up after discharge. Patient #1 stated, “...I got a call from administration at the [Named Hospital] telling me...they were really sorry to hear that happened and they were looking into it...So I had to have a second endoscopy within a couple days of being there...””

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 30553 Based on review of facility policy, review of Emergency Department (ED) Central Logs, medical record review and interviews, the facility failed to ensure an accurate ED Central Log and failed to provided a medical screening examination for 1 patient (#19) who presented to the ED for evaluation of 21 patients reviewed. The findings include: Patient #19 presented to Facility A’s ED on 2/28/2024. The patient had a right knee arthroplasty (knee replacement) 9 days prior to arriving at the ED. The patient had been evaluated by her surgeon the same day and an ultrasound was performed to rule out a blood clot. The ultrasound was inconclusive. The patient’s provider had sent the patient an electronic media (email) stating she needed to go to a facility and have another ultrasound. The patient arrived at the ED and showed the email to the registration clerk. The registration clerk advised the patient they did not schedule outpatient ultrasounds and the patient’s provider was not a credentialed provider at the facility. The registration clerk advised the patient she could be registered as an ED Patient, the provider could see her and make a plan of care. The patient stated she did not want to sign into the ED. The patient was not registered as a patient into the ED, there was no medical record for the patient, and the patient was not listed on the ED central log. On 2/28/2024 at 7:30 PM the patient presented to Facility B where the patient was evaluated, treated. Cross Refer A-2405 and A-2406”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 30553 Based on review of a facility investigation, review of Emergency Department (ED) Central Logs and interviews, the facility failed to ensure an accurate ED Central Log for one patient (#19) who presented to the ED for evaluation of 21 patients reviewed. The findings include: Patient #19’s family contacted the facility on 3/4/2024 and alleged the patient presented to the ED on 2/28/2024 somewhere around 6:00 PM. The patient’s primary care physician had told the patient to go to the ED for an ultrasound of the right lower extremity. The son alleged the patient had a ‘prescription for an ultrasound’ but she was told the ultrasound had to be scheduled and could not be performed. The patient was turned away and not medically evaluated or treated. The patient left the ED and went to Facility B where the patient was evaluated, and an ultrasound was performed. The facility contacted the patent on 3/4/2024. The patient stated her provider had sent her an email and told her to go to a facility to get an ultrasound performed. The patient did not have a written prescription for the procedure but she had an email. She had presented to the facility and showed the admission clerk the email. The registration clerk stated she told the patient ultrasounds were normally scheduled under outpatient status. The admission clerk asked the patient if she wanted to register as a patient into the ED and they could evaluate the patient. The patient stated she did not want to register and left the ED. Review of the ED Central Logs showed the patient was not listed on the log for 2/28/2024. During an interview on 4/10/2024 at 1:45 PM, the Director of Quality Management confirmed the patient presented to the ED on 2/28/2024. She confirmed the patient was not registered in the ED and was not placed on the ED Central Logs. The ED admission clerk did not register the patient and did not ask the nursing staff for assistance. The patient left the ED on 2/28/2024. During an interview on 4/10/2024 at 2:20 PM, the Director of Patient Access stated the patient presented to the ED on 2/28/2024 around 6:00 PM. The Registration Clerk did not register the patient when the patient stated she did not want to sign in. The patient left the ED. Cross Refer to 2406.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 30553 Based on review of facility policy, review of Emergency Department (ED) Central Logs, medical record review and interviews, the facility failed to provide a medical screening examination for 1 patient (#19) who presented to the ED for evaluation of 21 patients reviewed. The findings include: Review of facility policy, “Emergency Screening, Stabilization, and Transfer” dated 1/2022, showed “...[A] state and federal regulations, including EMTALA, federal statute 42 CFR 489.24 mandate that whenever an individual comes to the hospital’s ED when QMP [qualified medical provider] present, requesting or requiring an examination or treatment, the individual shall receive a medical screening examination [MSE], to determine whether an EMC [emergency medical condition] exits...[B] an EMTALA obligation arises if an individual presents to a [named facility]...campus, [parking lots, including sidewalks, driveways, or within 250 yards of the main hospital entrance] and a request is made by the individual or on the patient’s behalf, for evaluation or treatment of the potential EMC...if the individual does not have a medical record, staff open a new medical record for documentation purposes...an MSE is performed on all patients presenting to an ED...requesting or requiring an examination or treatment...if the patient refuses examination and/or treatment, a reasonable effort is made to inform the patient of risks, benefits, alternatives, and consequences of no treatment regarding the offered examination and treatment. The refusal of screening and/or treatment is documented in writing, and if possible signed by the patient or the patient’s legal representative...” Patient #19 presented to Facility A’s ED on 2/28/2024 around 6:00 PM, after her primary care physician told the patient to go to the ED for an ultrasound of the right lower extremity. The patient had a right knee replacement in February 2024. The patient had an initial ultrasound earlier on 2/28/2024 which was inconclusive and the patient continued to complain of right leg pain. The patient’s surgeon sent the patient an electronic media (email) message to go to the nearest facility and have an ultrasound performed. She presented to Facility A and showed the admission clerk the email. The registration clerk stated she told the patient ultrasounds were normally scheduled under outpatient status. The admission clerk asked the patient if she wanted to register as a patient into the ED and they could evaluate the patient. The patient stated she did not want to register. The patient left the ED. On 2/28/2024 at 7:39 PM, the patient presented to Facility B where she was evaluated and an ultrasound was performed. Review of Facility A’s ED Central Logs showed the patient was not listed on the log for 2/28/2024. Review of the facility A’s Electronic Medical Record showed no record for the patient on 2/28/2024. Medical record review showed the patient presented to Facility B on 2/28/2024 at 7:43 PM, for an examination related to a possible blood clot. During an interview on 4/10/2024 at 1:45 PM the Director of Quality Management stated the patient presented the ED admission area at Facility A on 2/28/2024 for evaluation and an ultrasound of the right lower extremity. The patient stated she was told by her primary care physician to go to the ED and get a repeat ultrasound. The patient had an email from her provider which stated she needed an ultrasound of the lower extremity but there was no written order for the procedure. The patient had presented around 6:00 PM, ultrasound staff were not in the facility, and the patient was not scheduled for an ultrasound. The admission clerk told the patient she could not schedule the ultrasound but told the patient she could register into the ED and be evaluated for possible ultrasound if needed. The patient stated she did not want to register into the ED. The ED admission clerk did not register the patient and did not ask the nursing staff for assistance. The patient left the ED on 2/28/2024. During an interview on 4/10/2024 at 2:20 PM, the Director of Patient Access stated the patient presented to the ED on 2/28/2024 around 6:00 PM. The patient showed the registration clerk an email from her primary care provider which told the patient to go an ED for a radiology examination. The patient told the clerk she needed an ultrasound performed to her right leg. The registration clerk told the patient ultrasounds would have to be scheduled related to the technicians were not in the facility after hours. The registration clerk offered to sign the patient into the ED for evaluation and the ED Physician would make the decision if the ultrasound needed to be performed. The registration clerk again ask the patient if she wanted to sign into the ED. The patient stated she only wanted an ultrasound and did not want to sign in. The patient was given the number to schedule the ultrasound and the patient left the ED. She confirmed if a patient comes to the ED, there should be a ‘quick registration’ for the patient and a medical record generated for the patient, but this was not done. If there were concerns, the ED Charge Nurse or House Supervisor were available to assist as needed. She stated “...the clerk did not register the patient as the patient stated she did not want to sign in...The house supervisor or the ED triage nurse was not involved with the patient..” During a telephone interview on 4/10/2024 at 3:20 PM, Registration Clerk #1 stated the patient presented to the ED on 2/28/2024 around 6:00 PM. The outpatient department was closed for the day and there were no orders by a physician for the ultrasound. The patient had an email from her provider which stated the patient needed to go to an ED and have a repeat ultrasound performed. The patient left the ED. Registration Clerk #1 confirmed the patient was not registered and there was no medical record for the patient. During a telephone interview on 4/11/2024 at 9:15 AM the ED Medical Director stated any patient who presented to the ED for a medical screening should be evaluated and treated by a medical provider.”