Christus Santa Rosa Hospital-San Marcos

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 51738 Based on a review of patient records, facility documents, and interviews, the facility failed to ensure that nursing notes, reports of treatment, and other information needed to monitor the condition of patients were appropriately documented. Findings were: A review of the Facility Policy Titled “Nursing Process - CO-OM-07-49 - Last Approved Date: 04/23”, addresses the facility’s requirements for documentation in patients’ medical records. See relevant excerpt below: 1.”Nursing documentation reflects the elements of the nursing process. electronic documentation system allows for charting by exception with a focus on abnormal or significant findings ... 2.Documentation is completed in the electronic medical record. In cases in which electronic documentation is not available, the appropriate paper form(s) is/are used and is placed in the permanent medical record. 3. Scope of practice dictates the appropriateness and completion of documentation by RN’s, LVN’s and unlicensed personnel.” Review of the “Job Description” for the “Job Title: Registered Nurse” states in part: “MAJOR JOB RESPONSIBILITIES *Documents patient history, symptoms, medication, and care given.” Review of the “Job Description” for the “Job Title: Certified Nursing Assistant” states in part: “MAJOR JOB RESPONSIBILITIES “Completes pertinent documents... “...Perform unit specific patient care tasks in accordance with skills checklist and documents on the flowsheet” A review of medical records for 2 of 2 patients (#1, #11) with orders to be turned every 2 hours (Q2h) revealed missing documentation from the mobility flowsheet for several dates during each patient’s admission. A review of patient #1’s medical record revealed missing documentation from the Mobility Flowsheet for 0700 to 1900 on four of the four dates (12/31/24, 01/07/25, 01/21/25, 01/28/25) chosen as a sample from her extended stay from 12/29/24 to 02/05/25: *12/31/24 - 0800 - “lying on right side”, next documentation 2000 - “pillow support”, “lying on right side”. No other repositioning documented. * 01/07/25 - 1100 - “lying on left side”, next documentation 2000 - “pillow support”. No other repositioning documented. * 01/14/25 - 0600 - “lying on left side”, next documentation 2026 - “lying on right side”. No other repositioning documented. * 01/21/25 - 0805 - no documentation under “Repositioned” or “Positioning Frequency”; next documentation 2000 - “pillow support”, “semi fowlers”, “lying on right side”. No other repositioning documented. * 01/28/25 - 0816 - “pillow support”; next documentation 2020 - “pillow support”. No other repositioning documented. * 02/04/25 0906 - “pillow support”, “high fowlers”; next documentation 1600 - “activity completed”, “other”, “repositioned”; 1830 - “pillow support”, “semi fowlers”. No other repositioning documented. A review of patient #11’s medical record revealed a similar lack of documentation on the Mobility Flowsheet for 0700 to 1900 on 1/24/25, 1/25/25, and 1/26/25 related to her admission from 01/16/25 to 01/27/25: * 01/24/25 - 0735 - “semi fowlers, pillow support,”; next documentation 1700 - “semi fowlers”. No other repositioning documented. * 01/25/25 - 0800 - “repositioned left side”. No other repositioning documented. * 01/26/25 - 0800 - “left side”; next documentation 1957 - “lying on side”. No other repositioning documented. In an interview with Staff #6, they stated “All staff should document patient care.” They also shared there are times the documentation is not recorded even though the care was provided.” In an interview with Staff #7, they stated “...everyone can document but the nurse [helping the CNA] is normally the one that does it.” In an interview with Staff #8, they shared that all staff are required to document patient care when performed; and that if the nurse is assisting, the nurse will normally document.” In an interview on 3/25/25 with staff # 3 & #4 the above findings were confirmed.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 43999 Based on interviews, a review of facility policies, and guidelines from the Centers for Disease Control (CDC), the facility failed to avoid potential sources of infection by not maintaining a clean and sanitary environment. Findings were: Review of the Facility Policy Titled “Standard Precautions - CO-ICP-04-06 - Last Approved Date: 11/17”, addresses associates’ responsibility for disinfecting equipment. See relevant excerpt below: “8. Reusable EQUIPMENT/DEVICES: All reusable equipment/devices will be appropriately disinfected or sterilized before patient use ... c. Equipment and devices that do not touch the patient or that only touch intact skin of the patient will be cleaned with a detergent or disinfectant as indicated by the manufacturer ....” A Review of the Center for Disease Control’s (CDC’s) Healthcare Infection Control Practices Advisory Committee “Guidelines for Disinfection and Sterilization in Healthcare Facilities. 2008;” last updated June 2024, found at: https://www.cdc.gov/infectioncontrol/pdf/guidelines/disinfection-guidelines-H.pdf - stated in part, “3. Indications for Sterilization, High-Level Disinfection, and Low-Level Disinfection c. Perform low-level disinfection for noncritical patient-care surfaces (e.g., bedrails, over-the-bed table) and equipment (e.g., blood pressure cuff) that touch intact skin.” In an interview with Staff #7, they stated “We wipe them [portable vital signs machine] down with bleach wipes if we have to use them on a patient in isolation, but not when taking vital signs moving from room to room.” In an interview with Staff #8, they stated “We disinfect when the equipment [portable vital signs machine] is used on isolation patients, with the bleach wipes. We don’t disinfect with the bleach wipes between other patients.” In an interview with Staff #3 & #4 on 3/25/25 it was confirmed the staff did not follow policy for disinfection of shared equipment.”

“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: 33326 Based on record review, and interview, the facility failed to conduct a complete medical examination, to determine whether an emergency medical condition exits for (1) one (Patient #1) out of (21) twenty-one medical records reviewed of patients having arrived at the facility’s emergency department seeking treatment. The facility failed to assess Patient #1’s left shoulder resulting in a 3-day delay of a diagnosis of a fractured clavicle, this delay placed Patient #1 in continued pain, at risk of worsening symptoms and permanent deformity. Findings include: Review of the Christus Hospital Physician’s notes dated 10/25/24 reflected, “Physical Exam Musculoskeletal: No edema in the lower extremities bilaterally, no stigmata of DVT (signs/symptoms of deep vein thrombosis) Medical Decision-Making Differential diagnosis: Seizure, intracranial hemorrhage, cervical spine fracture. This is a patient with a seizure disorder who takes valproic acid and clonazepam when he has a Seizure. Today had a seizure which was witnessed. He fell and hit his head. He had a small amount of bleeding over the right left eyebrow. No significant laceration. CT (computed tomography) the brain ordered which was unremarkable. CT of the cervical spine from interpretation shows no evidence of acute fracture.” Review of the Clinic Physician’s notes dated 10/27/24 reflected, “Chief complaint of Left trauma/injury. Pt (patient) has developmental delay. Pt is with mother. Pt had a seizure and fell Weds. Pt went to the ER and had a CT of the neck and head. Mother states no one look at his shoulder and he is having problems putting on his shirt. Physical Exam Musculoskeletal: Motor Strength and Tone: abnormal motor strength; left arm and shoulder. Joints, Bones, and Muscles: limited ROM (Range of Motion); left shoulder, deformity of left distal clavicle with mild tenting, no redness or significant pressure to skin... FINDINGS: Bones are diffusely demineralized. There is displaced mildly comminuted distal clavicular fracture with greater than one full shaft elevation of the major proximal fragment in relation to the major distal fragment. AC joint appears intact. Coracoclavicular interval may be widened. Left-sided implanted electronic device and leads are in place. *** IMPRESSION ***: Distal clavicular fracture.” During a telephone interview 12/18/23 at 12:10 pm, Patient #1’s mother stated in part, “My husband and I were called by the facility, Patient #1 had a seizure and had fallen, he and was taken to the emergency room. We went to the emergency room; Patient #1 was already being treated by the emergency room. Patient #1 is non-verbal I took him home for a few days, when I took him back to the residential home the staff noticed the bruising to his upper shoulder and arm pit. He also winced when they put his shirt on. I told them he needed to get an x-ray. I took him to the clinic; they took x-rays and said he had a non-union break of his left clavicle. He kept a sling on that arm for 6-weeks.” During an interview on 12/18/23 at 11:00 am in an admin office, Staff #3, Emergency room director stated in part, “We don’t automatically take x-rays for all falls, it would depend on the mechanism of the fall and the injuries, each case is different. Usually, the patients from the group homes will come by ambulance, we use the information provided by the ambulance to help determine the course of treatment. We will call the group home to get additional information if needed.””