Regency Hospital of Cleveland East

“DISCHARGE PLANNING - PAC PROVIDER DATA CFR(s): The hospital must assist patients, their families, or the patient’s representative in selecting a post-acute care provider by using and sharing data that includes, but not limited to, HHA, SNF, IRF, or LTCH data on quality measures and data on resource use on measures. The hospital must ensure that the post-acute care data on quality measures and data on resource measures is relevant and applicable to the patient’s goals and treatment preferences. This Standard is not met as evidenced by: 42015 Based on medical record review, interview, and policy review, the facility failed to ensure Patient #3’s family were involved in her discharge planning and failed to notify family prior to discharging Patient #3 to a different hospital. This affected one (Patient #3) out 10 records reviewed for discharge planning. The facility census was 33. Findings include: Review of the medical record for Patient #3 revealed an admission date of 02/01/25 and discharge date of 02/22/25. The patient was admitted with respiratory failure, from an acute care intensive care unit (ICU). Review of the Nursing Practitioner Note dated 02/20/25 at 2:21 P.M. revealed Advanced Practice Registered Nurse (APRN) Staff DD examined clinical and laboratory results. She discussed the results with Advanced Practitioner at bedside that the patient has acute on chronic hypnotic respiratory failure due to usual interstitial pneumonia (UIP) and progressive fibrotic pattern of interstitial lung disease (ILD). She is currently on 100 percent Fraction of Inspired Oxygen (FI02), there are no further options. The patient is on a steroid taper, diuresis, Pneumocystis jirovecii pneumonia (pjp), bronchodilators, (has) concomitant aspiration through no evidence of new worsening infiltrates and no signs of new pneumonia. No role at this time for transfer to intensive care unit (ICU) as there is no additional treatments that can be offered unless family are considering intubation and tracheotomy which she would be unlikely be a candidate for. Review of Patient #3’s Pulmonary Progress note dated 02/21/25 at 10:20 A.M. revealed the patient’s status was discussed with her daughter and husband (POA). Ultimately, they want her closer to home. They were enroute and would be at the hospital in about an hour and will continue this conversation about her progress and goals of care in person. Plan was to discuss palliative measures as she was end stage. Discussed that she would need to be intubated prior to transfer to an acute care hospital, the treatment would not be different, and she would be unable to wean. Review of Patient #3’s Nursing Progress Note dated 02/22/25 at 10:31 A.M. revealed critical care transport was here to take Patient #3 to Local Acute Hospital A. (This nurse) attempted to call nurse report three times and was placed on hold. The charge nurse is aware and will reach out to Local Acute Hospital A and also contact family to inform them of the transport. Review of Patient #3’s Discharge Summery dated 02/22/25 at 10:50 A.M. revealed the patient had a planned discharge to Local Acute Hospital A. Interview on 03/17/26 at 8:48 A.M. Chief Nursing Officer Staff C revealed she was asked to contact Patient #3’s family and get in touch with Local Acute Hospital A. She reported she was attempting to give report to the hospital when Patient #3’s family arrived. She stated the patient had just left when they arrived and were made aware of the transfer. Interview on 03/17/26 at 8:56 A.M. Director of Quality Staff D revealed originally the family had requested the patient be transferred to a closer hospital. Local Acute Hospital A stated they would take Patient #3 when a bed became available. Later Pulmonary spoke with the family and it was agreed upon that she would remain at her current hospital. This was not communicated to her providers and when a bed became available she was discharged to Local Acute Hospital A without the family’s knowledge. Review of the facility policy, “Discharge, Discharge Planning and Instruction Form,” revised 01/01/25 revealed the policy is to plan and provide a smooth and efficient transition which ensures that each patient is referred to the proper environment to maintain safety and continuity of care. This environment shall be able to meet the patient with the ability to reach his/her optimal level of care. Hospital staff are responsible for notifying the patient’s family of the name and address of the receiving institution and approximate time of arrival. This deficiency represents non-compliance investigated under Complaint Number OH00163857.”

“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: 21893 Based on medical record review and staff interview, the facility failed to ensure restraint use was in accordance with the physician’s order. This affected one (Patient #3) of two patients reviewed for restraints. The facility’s census was 68. Findings include: Review of the medical record for Patient #3 revealed orders dated 11/06/24 at 10:33 AM for bilateral soft wrist restraints. The medical record documentation on 11/06/24 at 2:29 PM revealed bilateral secured mittens were in use until 8:00 PM when the restraints changed to a left secured mitten and a right soft wrist restraint. On 11/25/24 at 6:57 AM bilateral unsecured mittens were ordered. The medical record contained documentation of a left unsecured mitten only on 11/25/24 at 6:58 AM. On 11/28/24 at 7:59 AM bilateral unsecured mittens were ordered. The medical record contained documentation of bilateral soft wrist restraints on 11/28/24 from 6:00 AM until discontinued at 8:00 PM. The medical record lacked additional restraint orders on these dates. Interview on 02/06/25 at 3:05 PM, Staff E verified the above findings.”

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 22432 Based on medical record review, facility documentation, staff interview, and facility policy review, the facility failed to ensure staff properly verified patients’ identities at the bedside prior to blood transfusions. This affected two patients (Patient #1 and Patient #2) in a sample of nine patients reviewed for blood administration. This deficient practice had the potential to affect any patient who required blood administration at the facility. The facility census was 68. Findings include: Review of the medical record revealed Patient (Pt) #1 was admitted to the facility’s West campus on 01/18/25. Diagnoses included history of a motor vehicle accident with traumatic chest injury, multiple rib and sternal fractures, respiratory failure which required intubation, anemia, thoracic and lumbar spine fractures, liver injury, and multiple abdominal injuries. The physician’s progress note dated 01/23/25 documented the patient’s red blood cell count (RBC) was normal at 2.2 cells/microliter (c/mcL) (normal 4.7 to 6.1 c/mcL), hemoglobin was 7.0 grams/decliter (g/dL) (normal was 13.5 to 17.5 g/dL), and hematocrit was 22.5% (normal 38% to 48%). The progress note documented the hemoglobin was borderline at 7.0 g/dL and transfuse if it goes lower. The laboratory tests dated 01/24/25 documented Pt #1’s hemoglobin was 6.6 g/dL and the physician ordered the patient to have a blood transfusion. The patient was blood typed and screened and found to have ABO blood group type O positive blood. The medical record documented on 01/24/25 at approximately 7:00 PM Pt #1’s unit of O positive blood arrived at the facility. Pt #1’s blood transfusion was initiated at approximately 7:19 PM. The Single Transfusion Record form documented Supervisory Staff Nurse F and Staff Nurse H both attested on 01/24/25 the following: “I am currently at the bedside with the nurse who will complete Dual Signoff and we have validated the patient’s identity with two forms of identification.” The nurses’ notes dated 01/24/25 at 11:18 PM documented the patient received wrong unit of blood which was mixed up with neighbor’s blood. Transfusion started at 7:14 PM and was stopped at 7:42 PM after receiving 41 milliliters (ml). The physician was notified, ordered a bolus of normal saline (NS) intravenous (IV), and to follow up with blood bank protocol. Suggested to be transported to the nearest hospital. The patient was transported to the hospital at 8:55 PM for further observation. Review of the acute care hospital’s post transfusion laboratory analysis by the acute care hospital pathologist documented impressions included there was an evidence of mild acute hemolytic transfusion reaction. No further blood transfusions are recommended for this patient. Review of the medical record revealed Pt #2 was admitted to the facility’s West campus on 01/20/25. Diagnoses included respiratory failure, circulatory shock, gastrointestinal (GI) bleeding, large B-cell lymphoma with mediastinal lymphadenopathy, history of deep vein thrombus, pulmonary emboli, and history of tumor lysis syndrome. The patient has aggressive B-cell lymphoma with metastasis and hemorrhagic effusion. Review of the patient’s 01/24/25 complete blood count (CBC) documented the patient with a RBC count of 2.32 c/mcL, hemoglobin of 6.9 g/dL, and a hematocrit of 22.8%. The medical record documented the patient was ordered a blood transfusion on 01/23/25. The patient was typed and screened and found to have ABO blood group type A negative blood. The medical record documented on 01/24/25 at approximately 6:59 PM Pt #2’s A negative unit of blood arrived at the facility. Pt #2’s blood transfusion was initiated at approximately 7:20 PM. The Single Transfusion Record form documented Supervisory Nurse G and Staff Nurse I both attested on 01/24/25 the following: “I am currently at the bedside with the nurse who will complete Dual Signoff and we have validated the patient’s identity with two forms of identification.” Review of the PT #2’s physician’s Significant Event Progress note dated 01/24/25 at 11:19 PM documented the physician was contacted by the charge nurse regarding Pt #2 was supposed to receive blood this evening. Instead of getting the blood intended for him (A negative) he received the blood intended for his neighbor. Patient received what was reported to be roughly 50 mls of Type O positive blood. Upon discovery of the mismatch the blood transfusion was stopped immediately. The physician advised the charge nurse to contact the blood bank and to follow the protocols they outline for incorrect transfusion as well as hospital policies of contacting family and leadership, all while monitoring patient for reaction and maintaining stable vitals. Review of the facility’s adverse event documentation revealed the facility’s West campus administrative staff received a report that on the evening of 01/24/25 two patients (Pt #1 and Pt #2) received the wrong ABO type blood. The adverse event report documented “Found the nurses failed to follow the facility’s Blood Administration Policy (B04-N) by ensuring the use of two patient identifiers which resulted in the incorrect blood administered to two patients.” The investigation documentation revealed there were multiple deviations from the policy which included two units of blood were verified at the nurses’ station against the paperwork and physician orders. The two units of blood were never checked at the bedside against the patients’ wrist bands thereby Pt #1 received Pt #2’s intended unit of blood and Pt #2 received Pt #1’s intended unit of blood. Four nurses failed to verify the patients with their names on the units of blood and the patients’ wrist identification bracelets at the bedside. This adverse event was documented as having the potential to affect all patients. Review of the West campus Patient Safety Huddle forms used during nursing shift report documented immediate re-education of Staff F, Staff G, Staff H and Staff I was initiated on 01/25/25. The re-education directed nurses must complete the mandatory verification using two nursing staff and two patient identifiers with the verification performed at the bedside. Documentation revealed Staff F, Staff G, Staff H and Staff I received written disciplinary action. Review of the facility’s policy and procedure titled “Blood/Blood Components Administration (Packed Cells, Plasma, Platelets Cryoprecipitate),” revised 07/01/24, revealed the purpose was to establish a policy and procedures for the safe administration of blood and/or blood components. Under the heading of Procedure Item 5 states Perform dual verification of blood products at the bedside as follows: a. Two registered nurses (RN), one of whom must be the Chief Nursing Officer (CNO), House Supervisor (HS), Nurse Manager (NM) or Clinical Coordinator (CC), and the other must be the RN initiating the transfusion and h. Spell aloud and verify the patient’s name and hospital number on crossmatch tag and match the patient’s ID bracelet. NOTE: Patient Identifiers and labeling requirements must match that of the issuing blood bank. NOTE: If there are any discrepancies, do not start the transfusion and immediately contact the contracted blood bank. Interview with Director of Quality Management, Nurse C, on 02/05/25 at 11:31 AM revealed there had been an adverse event on 01/24/25 in regard to blood administration. The facility had conducted a Root Cause Analysis (RCA). The RCA had identified multiple errors related to the adverse event on 01/24/25 related to the administration of the wrong blood to two patients. Staff C verbalized blood transfusions were currently being administered by facility nursing staff per physician orders. Staff C verbalized each facility campus was responsible for re-educating their own nursing staff. Staff C verbalized staff had until 02/08/25 to complete the facility’s blood administration re-education. Interview on 02/12/25 at 11:23 AM Staff A confirmed East campus nurses had administered blood transfusions to four patients (Patient #11, Patient #12, Patient #13, and Patient #14) after 01/24/25 and prior to nurse’s re-education for blood product patient verification at the bedside.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 31597 Based on medical record review, policy review, and interview, the facility failed to ensure nursing provided Foley catheter care in accordance with the facility’s policy for one (Patient #5) of six medical records reviewed for Foley catheter care. The facility identified 13 patients with Foley catheters. The facility census was 50. Findings include: Review of the facility’s Urinary Catheter Management policy revised 01/01/24 revealed the facility would clean around the area where the catheter enters urethral meatus and the catheter every shift with care wipes. Patient #5 was admitted to the facility on 02/12/24 and discharged to an acute care hospital on 02/26/24. Patient #5 had a Foley catheter in place at admission. Further review of the medical record revealed Patient #5 catheter care was provided on 02/19/24 at 8:00 PM. There was no documentation to show catheter care was completed during the morning of 02/19/24. Further review revealed catheter care was provided on 02/20/24 at 4:37 AM and 8:00 AM. There was no documentation to show catheter care was completed during the evening of 02/20/24. Interview on 03/13/24 at 2:18 PM with Staff A verified there was no documentation to show catheter care was completed during the morning of 02/19/24 or the evening of 02/20/24. This deficiency represents non-compliance investigated under Complaint Number OH00151662.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 31597 Based on medical record review and interview, the facility failed to ensure the care plan for one (Patient #3), of 10 patients reviewed, was followed regarding the removal of an Intravenous (IV) site at discharge. The facility’s active census at the time of the survey was 50. Findings include: Patient #3 was admitted to the facility on 01/04/24 and discharged on 01/24/24. Patient #3 had a 22 gauge peripheral IV site placed on 01/18/24 at 7:30 PM by Staff K. The IV site was removed automatically from the medical record at discharge on 01/24/24 at 4:33 PM. There was no documentation showing the IV had been removed from Patient #5 upon discharge. Review of Patient #3’s care plan revealed interventions in place to monitor all insertions sites, indwelling lines, tubes, and drains and obtain an order to remove device when no longer clinically necessary. Interview on 03/12/24 at 3:19 PM with Staff I revealed Staff I was unable to recall Patient #3’s discharge and was unable to recall if Patient #3’s IV had been removed prior to discharge. Interview on 03/12/24 at 11:30 AM Staff A verified there was no documentation contained in Patient #3’s medical record to show Patient #3’s IV was removed prior to discharge. This deficiency represents non-compliance investigated under Complaint Number OH00150580.”