29722 Based on observations, interviews and facility document review, the facility failed to ensure patient care in a safe setting as evidenced by the facility's lack of mechanisms in place to monitor persons entering the hospital after visiting hours, and failing to implement corrective action when internal threats were identified for 2 of 2 internal threat incidents, one of which being the fatal stabbing of patient #9. The findings include: Review of the hospital's risk management program revealed two internal threat incidents that had occurred at the hospital. Incident #1 occurred in the facility on 10/31/17 and involved a patient's report of a visitor with a gun. This incident was discovered during the review of the Risk Management Programs documentation which included a copy of Brief Bites, a newsletter that was disseminated to staff via e-mail. The November 2017 copy of Brief Bites included a full page statement from the Chief Operating Officer (COO) titled Code Lockdown Event 10/31. The statement included details of an incident that occurred in the facility on 10/31/17, in which a code lockdown was announced via the facility-wide paging system. The lockdown was the result of a patient's report of a visitor brandishing a gun. The facility was put on lockdown until the staff could ensure the visitor had left the building. Included in this statement, the COO identified that staff needed clarification of their roles when codes such as lockdown or silver were called. As a result, he offered a few key takeaways from the event in the newsletter, which stated, we will be developing an emergency preparedness practice schedule in 2018 so that we gain experience responding to such events in the safest possible way. This will include, but not be limited to, potential events such as mass casualty, active shooter, code pink, etc. Incident #2 occurred in the facility on 02/23/2018, and involved an incident where a visitor entered the hospital, after visiting hours, via the emergency department (ED) and made his way to the patient care floor where he then fatally stabbed his mother. This incident was discovered upon review of the Code 15 Report submitted to the Agency for Health Care Administration on February 27, 2018. On 02/27/2018 a Code 15 report was filed with the Agency for Healthcare Administration by the facility to report the fatal stabbing that occurred in the facility on 02/23/18. The Code 15 report indicated the facility had started a root cause analysis to investigate the events leading up to the incident, and to review the facility's processes to prevent or reduce possible reoccurrence. On 03/05/2018 beginning at approximately 11:40am, an interview was conducted with Staff J, a registered nurse (RN), regarding the facility's visitation policy. Staff J stated she didn't normally question family that came in after hours and that visitors were not required to sign-in when visiting after the 9:00pm, the time visitation hours ended. Staff J stated she did not remember the last time she had hospital codes training, but thought it was when she was hired. She indicated she had concerns for her safety. On 03/05/2018 beginning at approximately 11:50am, an interview was conducted with Staff K, a RN. Staff K stated that visiting hours ended at 9:30pm and that an announcement was made overhead, but that visiting hours were not enforced. Staff K stated she had found out about the incident that occurred on 2/23/18 two days after it occurred, when she came into work. She stated she had received no training since the incident, and couldn't remember when they had last had code training, but knew it was done upon hire and stated they had the codes listed on the back of their badges. On 03/05/2018 beginning at approximately 12:45pm, an interview was conducted with Staff E, the Director of Plant Operations. Staff E stated that visitors come through the emergency department after 9:00pm, and there was not a sign-in and out procedure, but that would be changing, though he was not sure when. He reported that security did sit with patients whenever there was a lack of sitters, but only for violent or security risk patients and for Baker Acted patients. On 03/05/2018 beginning at approximately 1:00pm, an interview was conducted with Staff L, a RN. Staff L stated that visiting hours stopped at 9:00pm and all doors were locked at that time except for in the emergency department. Staff L said that someone in the ED had to let visitors in after 9:00pm. Staff L stated she was made aware of the incident that occurred on 2/23/18 by a co-worker a couple of days following the incident. Staff L was asked if additional training or education was provided after the incident, and stated they had discussed the incident for about 30 minutes, but was not aware of any additional training or changes that were made. On 03/05/2018 beginning at approximately 1:15pm, an interview was conducted with Staff M, a RN. Staff M was informed of the incident that occurred on 2/23/18 by email, and there had been no additional training provided since the incident. Staff M indicated visiting hours were from 8am to 9pm, and when visiting hours were ending, an overhead announcement was made to inform visitors. Staff M stated that family members did stay overnight with patients frequently and could come and go through the ED after visiting hours. Staff M stated visitors were sometimes given stickers, but that didn't always happen, and that visitors didn't normally stop at the nurses' station, nor were they required to. On 03/05/2018 at approximately 1:45pm, an interview was conducted with patient #5. Patient #5 stated his brother was staying overnight with him and could come and go as he pleased with no interruptions from staff. He also stated he had a couple of buddies that had come in to visit the previous night (3/4/18) at 3:00am. The patient said they were not wearing visitor badges on when they came in, and that no one had stopped them or asked who they were coming to visit. They just came in through the emergency room . On 03/05/2018 beginning at approximately 2:00pm, an interview was conducted with Staff G, the Director of Oncology. Staff G was asked about the facility's visitation policy, and stated that around 9:00pm nightly, an announcement was made that visiting hours were ending. She also stated the hospital did not ask for identification and were not required to stop at any nursing stations. Staff G stated that the facility had increased security after the incident on 2/23/2018, and that security makes rounds 2 to 4 times a shift. She stated that each unit was equipped with a security button, that alerted there was an incident taking place and to come right away, but had not been used the night of 02/23/2018, and security had been contacted by telephone to respond to the incident. Staff G stated that no extra training had been provided for staff, and the facility had not addressed anything differently at that moment. On 03/05/2018 beginning at approximately 2:20pm, an interview was conducted with Staff N, a RN. Staff N stated visiting hours ended around 8:30pm, and an announcement was made to alert visitors that the main door would be closed at 9:00pm. When asked about the facility's afterhours procedure, staff N stated that if a family member wanted to visit after hours, they would come in through the ED. They would be asked who they were there to see, and then receive a badge to enter the hospital. The ED staff would then push a button for the visitor to enter the hospital through a locked door. Staff N also confirmed that elevators were accessible, even the service elevator. Staff N also stated that there had not been any training received by the staff in response to the incident. On 03/05/2018 beginning at approximately 4:00pm, hospital administrative staff, including the risk manager, were interviewed. The risk manager had no idea what the process was in the ED for visitors after hours and said there was no policy to address afterhours visitation. The COO, who was also responsible for direct oversight of the security department, was also unaware of any policies and procedures related to afterhours visitation for patients within the hospital. The risk manager was asked about what action had been taken by the facility, in which she stated they had started a root cause analysis and had increased security. She confirmed there had been no other action taken by the facility in regards to either of the internal threat incidents that had occurred on 10/31/17 or 2/23/18. The facility was not able to provide any additional documentation to determine where they were in the root cause analysis process. The COO indicated that the root cause analysis was a fluid analysis and was ever changing. The COO stated the administrators of the hospital met on 02/27/2018 to begin implementation of the root cause analysis and had drafted a security action plan. None of the documents presented by the hospital were dated, and the COO admitted that some of the plan was added and implemented after the survey team entered the facility to conduct their review, including implementation of a stationed security guard in the ED to log and badge visitors after 9:00pm. A review of the security schedule was conducted to verify the facility's increase in security. Documentation identified that security was increased from 3 security guards to 5-7 guards for 2 days only, and then went back to 3 security guards. The facility's Risk Manager (RM), Staff A, was interviewed on 03/06/2018 at approximately 8:30am about the Code 15 report and where the facility was on their investigation and actions to reduce risk and increase patient safety. The RM reviewed a copy of the Code 15, which identified the facility's plan to double security officers onsite with continuous rounding throughout the hospital, review visitation policy and associated processes for visitation hours, and review of current code alerts and staff education. The RM stated the facility's investigation was ongoing, and that they had not put any formal corrective actions in place since either of the internal threat incidents (10/31/2017 and 02/23/2018). She was able to confirm that security had been temporarily increased in the hospital following the 02/23/2018 incident, but was not able to demonstrate that any of the other items listed on the Code 15 report had been looked at or addressed by the facility. On 03/06/2018 beginning at approximately 10:00am, the video surveillance footage from 02/23/2018 was reviewed. The surveillance video showed the patient's son entering the ED on 02/23/2018 at approximately 09:52pm, after visiting hours, and was wearing sunglasses, carrying rosary beads and was wearing a hospital identification (ID) bracelet. ED staff were witnessed on the video surveillance, but failed to acknowledge or question who the son was, or who he was there to see. He was able to access the hospital through a door in the ED that was opened by a visitor who was exiting the hospital via the same door. No staff identified that the son had entered the hospital. Once the son reached the 4th floor, he passed by the main nursing station before stopping at the nursing substation to retrieve some gloves, and then entering his mother's hospital room. None of the 4th floor staff, observed on the video, stopped the son or questioned the son, despite the fact he was wearing sunglasses, carrying rosary beads and was wearing a hospital ID bracelet. On 03/06/2018 beginning at approximately 6:40am, an interview was conducted with Staff O, a registered nurse (RN) who worked the 7pm-7am shift on the 4th floor. She stated that visiting hours were up until 9:00pm, but there were often visitors after 9:00pm. She stated she was not sure what the process for afterhours visitation was, but stated she knew the visitors had to come through the ED because the front door was locked at 9:00pm. She stated that she had been working at the hospital for about two years and that she believed she had received training on hospital codes at the time she was hired, but stated that the codes were listed on the back of their badges. On 03/06/2018 beginning at approximately 7:00am, an interview was conducted with Staff P, the charge nurse for 7pm-7am shift on the 4th floor. Staff P stated that the visiting hours were up until 9:00pm and that about 30 minutes before then, an announcement was made that visiting hours were ending at 9:00pm. Anyone entering or leaving the hospital after 9:00pm had to go through the ED. Staff P did not know what the process was for visitors who came in after hours, but stated that as a result of the incident on 2/23/18, the ED was checking in visitors and putting more focus on who is entering the building after hours. On 03/06/2018 beginning at approximately 7:15am, an interview was conducted with Staff Q, a RN who works the 7pm - 7am shift on the 4th floor. He stated that the mother, patient #9, had been a patient on the floor numerous times and was well known to staff. He stated he had seen the patient's son once before, on a previous admission. He said the night of the incident, the son came in and never made eye contact with anyone. He stopped and grabbed some gloves that were at the nursing substation, and then disappeared into this mother's hospital room. He stated he was in the nursing substation with Staff V, who was the nurse for patient #9 that night. He stated the patient's heart rate shot up to 170 beats per minute, and then went back to her normal 100. Staff V thought maybe the son had upset the patient and went to get her some medication and check on her. He stated that shortly after that, the medical emergency button for the room of patient #9 was activated, and he along with another nurse grabbed the crash cart and began heading towards the patient's room, while a certified nursing assistant (CNA) went to alert security. He said they got the crash cart to the patient's room when they realized they had passed the patient's son in the hallway. He stated there was no internal threat code called overhead. On 03/06/2018 beginning at approximately 1:10pm, a telephone interview was conducted with Staff R, the Security Guard who responded to the incident on 02/23/2018 at 10:00pm. Staff R stated her duties included watching Baker Act patients, locking up the lobby, monitoring the halls, lobby and stairways, and responding to emergencies and codes called. She stated that door checks were performed by scanning labels on the doors, that any occurrences were documented in an incident report, and any codes they respond to should be written-up. Staff R stated she was notified on 02/23/2018, by radio, that security was needed on the 4th floor immediately. She said she had no idea what the situation was and that when she arrived to the 4th floor, it looked like a patient trying to leave, as she saw the hospital wristband on the wrist of the son and he had on hospital socks. She stated she thought the son was a patient and that he was trying to leave after being under a Baker Act. She was informed of the situation once she encountered the son and staff members at the elevator. She then called for additional back-up, and another security guard and law enforcement arrived a few minutes later. She was asked about the different types of codes that were called in the facility, and stated we don't get training or review the codes very often. Staff R was asked about security in the ED, and how visitors were monitored after visiting hours. She stated that security really didn't have a role in the process for afterhours visiting, and she was not aware if afterhours visitation monitoring even occurred or who would be responsible for that. On 03/07/2018 beginning at approximately 3:45pm, a telephone interview was conducted with Staff V, the nurse caring for patient #9. Staff V had been off work following the incident and returned on 03/05/2018. She stated she had not met patient #9's son before, so she did not know who the son was when he came onto the floor, and stated he did not speak to anyone. She confirmed visitors were often on the floor after hours, and she was aware that visitors came through the ED. She stated that visitors after hours did not wear badges. She stated that the hospital's main doors were locked after hours; however, the doors from the ED into the admission area on the 2nd floor were not locked, and that her boyfriend had entered through those doors when he had brought her food during her shift many times. She reported that in the past, while visiting her mother at the hospital, she was able to enter the hospital after hours just by telling the staff at the desk that she was visiting her mom who was on the 8th floor and the employee just let her back. She stated she did not feel safe working at the hospital since the incident and that the only change that had been made was that security now sat in the ED and issued badges to visitors, which she discovered upon her return to work on 3/5/18. She stated she did not think a sign-in sheet would be effective and she had concerns. She stated she thought there needed to be more security guards at the hospital, as two was not enough, and she only sees security once a night, or maybe twice sometimes during her shift. She confirmed a code had not been called on the night of the incident. A follow-up interview was conducted with the COO on 03/09/2018 at approximately 12:45 PM. He was asked if the practice simulations he discussed in the Brief Bites Newsletter, after the October 2017 incident, had been put into place and stated, not at this time.

29722 Based on interviews and facility record review, the facility failed to demonstrate a Quality Assurance and Performance Improvement (QAPI) program that included all services furnished under contract or arrangement, by failing to complete and analyze information from their contracted security company and include this information in their QAPI program to achieve the facility's 2018 quality goals. The findings include: The facility's performance improvement plan for 2018 was reviewed. The objectives in the plan included to provide a structure that supported the use of data in a planned and systematic manner to assess the effectiveness and safety of the care provided to the patients they serve; Facilitate the integration of safety and risk reduction to patient care, and into the design and redesign of all relevant organization process, functions, and services; Establish priorities for improvement work based on data, emerging trends and areas with high risk, high volume, or problem prone characteristics. The plan identified involvement from all departments of the hospital including the Environment of Care Committee (EOC), which reviews the management of the environment as defined by the Florida Department of Health (DOH) rules and regulations and utilizing the Joint Commissions/Centers for Medicare and Medicaid Services standards for important functions. On 03/09/2018 beginning at approximately 10:00am, an interview was conducted with the [NAME] President of Quality, Staff Y, regarding the QAPI program and how contracted services were evaluated for appropriateness, specifically related to security. Staff Y stated that contracted services would be evaluated monthly by the EOC (Environment of Care Committee) and security would fall under the environment of care plan. Staff Y stated that review of contracted security services was not a part of QAPI, and patient safety was discussed as part of the Patient Safety Committee. Staff Y stated the COO (Chief Operating Officer) was over the EOC Committee. A review of the EOC monthly meetings showed the facility did have a section for review of Quarterly Reporting - Safety Management; Security Management. The Quarterly report from the contracted security company identified the number of codes or calls that security responded to, with a break down to identify what the codes were. This information was produced from daily reports provided by security guards and then tallied. A review of several of the daily reports that were used to comprise this data were missing information with some blank shift reports. There were also identified inconsistencies within these monthly reports, including indication on the form for the month of October 2017 that security responded to zero (0) acts of violence or calls concerning weapons in the facility; however, previous review of risk management documents showed the facility did have an incident that month, on October 31, 2017 concerning a visitor with a handgun, resulting in the hospital being placed on lockdown. On 03/09/2018 beginning at approximately 11:00am, an interview was conducted with Staff E, the Director of Plant Operations, who was also over security. Staff E stated he gathered the information that was presented during the monthly Environment of Care Committee meetings. Included in the meetings, on a quarterly basis, was a report produced by the facility's contracted security vendor. The report provided an account of the number of incidents/actions taken by security, and were tallied by month and presented during the meeting. The Director of Plant Operations was not able to identify what was done with this information and the purpose of it, or if any actions had been implemented based on any of the data collected. On 03/09/2018 beginning at approximately 12:45pm, an interview was conducted with the Chief Operating Officer (COO), who was the lead on the EOC committee. When asked how contracted services, in particular security, were reviewed for appropriateness of services, he stated, we look at reliability of resources and availability of those resources. He further stated there was no documented evaluation of security that he was aware of, and would have to defer that to the Director of Plant Operations. On 03/09/2018 at approximately 1:15pm, a follow-up interview was conducted with the Director of Plant Operations regarding a review of the contracted services provided by the security vendor. He stated there was no information presented to QAPI on appropriateness of services provided, nor was he able to demonstrate this occurring in the EOC meetings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 26001 Based on review of Capital Regional Medical Center's written self-report letter of an Emergency Medical Treatment and Active Labor Act (EMTALA) violation, interviews with the hospital Risk Manager (RM), review of the central log, and review of the hospital EMTALA policies, the hospital failed to ensure that each individual seeking care from the emergency department was added to the central log for 1 of 21 sampled patients, #21. The findings: The facility submitted to the state survey agency the following potential violation self-report of an Emergency Medical Treatment and Active Labor Act (EMTALA) on [DATE]: On [DATE], at approximately 10:52 a.m., the patient (patient #21) entered the Walk-In entrance of our hospital which provides access to both the Emergency Department (ED) and other areas of the hospital. The patient proceeded to the patient and Visitor Waiting Area to the left of the entry door and then walked toward our Security Officer, who was sitting at the back area of the reception desk. The Security Officer is an off-duty Deputy with the County Sheriffs Office and employed by the contracted Security service to provide security at Capital Regional Medical Center. The reception desk is U-shaped with a Receptionist sitting in the center section. The Receptionist assists those coming through the entrance that may need assistance in initiating the ED (Emergency Department) process or directions to other areas of the facility. The Security Officer was sitting on the back left side of the U-shaped desk where there is a lower desk section for use by visitors or patients in wheelchairs. When the patient went to speak with the Security Officer the patient sat in a chair across from the Security Officer. The patient and Security Officer carried on a conversation for approximately 25 minutes. The Receptionist, when we interviewed her, said she did not see the patient enter the building but later saw him sitting in the chair talking with the Security Officer. She heard the patient say he was in fear for his life and the security guard explained the Baker Act to the patient. In addition, the Receptionist said she heard the patient state that he wanted to leave but she heard the Security Officer say he had to stay at the desk. Security video footage shows that a County Sheriffs Office Deputy entered the ED at 11:25 a.m., and the Security Officer, the patient, and the Deputy walked toward the entrance of the ED. They had a conversation by the entrance to the ED and at approximately 11:33 a.m., the patient exited the ED with the Deputy and the Security Officer. Approximately 30 minutes after the patient left, the Security Officer approached the Charge Nurse and explained that the patient walked up to him at the reception desk, stated that he needed help, someone was trying to kill him and he heard voices in his head. Because of this, the officer called a Sheriff cruiser to come get the patient and take him to a Baker Act Receiving facility. The 'Baker Act' is a Florida Statute designed to protect the rights of persons with mental illnesses, and allows the judicial system, law enforcement, and under certain circumstances, certain medical professionals to have a person involuntarily taken to a psychiatric receiving facility for evaluation and treatment of a suspected psychiatric condition. The central log was requested and reviewed. Patient #21 was not recorded on the central log at any time on [DATE]. No record existed for sample patient #21. A visit was made to the receiving facility (a psychiatric facility) for sample patient #21 on [DATE] at approximately 9:00 am. The receiving facility was able to confirm that patient #21 was admitted under the provisions of the Florida Baker Act on [DATE], by law enforcement, and identified the psychiatric diagnosis of the patient. The facility EMTALA - Florida Central Log Policy, dated ,d+[DATE], was reviewed. The policy stated, The hospital will maintain a Central Log containing information on each individual who comes on the hospital campus requesting assistance or whose appearance or behavior would cause a prudent layperson observer to believe the individual needed examination or treatment, whether he or she left before a medical screening examination could be performed, whether he or she refused treatment, whether he or she was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged . Under the Procedure section the document states, The Central Log, including all additional logs incorporated into the Central Log by reference, shall be maintained in the same manner and with the same central core of information. The logs must contain at a minimum, the name of the individual and whether the individual: refused treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred, was discharged , or expired. A log entry for all individuals who have come to the hospital seeking medical attention or who appeared to need medical attention must be made by the appropriate individual. At approximately 10:30 am on [DATE], and interview was conducted with the facility Risk Manager (RM). The RM confirmed the contents of the written self-report of emergency access violation, including the statements made from the receptionist, and from the security officer on duty at the time. The RM also stated that the security guards are provided by a contracted Security Agency, and the security guards are expected to follow all facility policies. Security has been retrained in hospital EMTALA policies. The RM confirmed that patient #21 was never added to the central log.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 26001 Based on review of Capital Regional Medical Center's written self-report of an Emergency Medical Treatment and Active Labor Act (EMTALA) violation, interviews with the hospital Risk Manager (RM), Emergency Department (ED) Director, and other ED staff members, and review of the hospital EMTALA policies, the hospital failed to provide a Medical Screening Exam (MSE) for 1 of 21 patients in the sample (#21). The findings are: The facility submitted to the state survey agency the following potential violation self-report of an Emergency Medical Treatment and Active Labor Act (EMTALA) on 3/18/2015: On 03/05/2015, at approximately 10:52 a.m., the patient (patient #21) entered the Walk-In entrance of our hospital which provides access to both the Emergency Department (ED) and other areas of the hospital. The patient proceeded to the patient and Visitor Waiting Area to the left of the entry door and then walked toward our Security Officer, who was sitting at the back area of the reception desk. The Security Officer is an off-duty Deputy with the County Sheriffs Office and employed by [NAME] Security to provide security at Capital Regional Medical Center. The reception desk is U-shaped with a Receptionist sitting in the center section. The Receptionist assists those coming through the entrance that may need assistance in initiating the ED (Emergency Department) process or directions to other areas of the facility. The Security Officer was sitting on the back left side of the U-shaped desk where there is a lower desk section for use by visitors or patients in wheelchairs. When the patient went to speak with the Security Officer the patient sat in a chair across from the Security Officer. The patient and Security Officer carried on a conversation for approximately 25 minutes. The Receptionist, when we interviewed her, said she did not see the patient enter the building but later saw him sitting in the chair talking with the Security Officer. She heard the patient say he was in fear for his life and the security guard explained the Baker Act to the patient. In addition, the Receptionist said she heard the patient state that he wanted to leave but she heard the Security Officer say he had to stay at the desk. Security video footage shows that a County Sheriffs Office Deputy entered the ED at 11:25 a.m., and the Security Officer, the patient, and the Deputy walked toward the entrance of the ED. They had a conversation by the entrance to the ED and at approximately 11:33 a.m., the patient exited the ED with the Deputy and the Security Officer. Approximately 30 minutes after the patient left, the Security Officer approached the Charge Nurse and explained that the patient walked up to him at the reception desk, stated that he needed help, someone was trying to kill him and he heard voices in his head. Because of this, the officer called a Sheriff cruiser to come get the patient and take him to a Baker Act Receiving facility. The 'Baker Act' is a Florida Statute designed to protect the rights of persons with mental illnesses, and allows the judicial system, law enforcement, and under certain circumstances, certain medical professionals to have a person involuntarily taken to a psychiatric receiving facility for evaluation and treatment of a suspected psychiatric condition. The facility EMTALA - Florida Medical Screening Examination and Stabilization Policy, effective 3/1/13 was reviewed. The policy states: an EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED) and: the individual or representative acting on the individual's behalf requests an examination or treatment for a medical condition, or a prudent layperson observer would conclude from the individual's appearance or behavior that the individual needs an examination or treatment of a medical condition. The policy continues to state, and provide an example as follows: the individual arrives on hospital property either in the DED or property other than the DED, and no request is made for evaluation or treatment, but the appearance or behavior of the individual would cause a prudent layperson observer to believe that the individual needed such examination or treatment. On 3/26/15 at approximately 3:25 pm, an interview was conducted with the ED Receptionist. The receptionist stated that on 3/5/15 she was on shift at the reception desk. She heard a man state that somebody was after him and he was in fear for his life (to the security guard). She stated it was pretty busy that day, and she was probably 20 feet away from them. She did not hear what the officer said to him. The officer did not address her at all about the incident. On 3/26/15 at approximately 3:50pm, an interview with was conducted with the ED Charge Nurse on duty on the day shift on 3/5/15. The charge nurse stated the security officer was at the nursing desk, and informed him that he had taken care of one patient for him. The charge nurse stated the security officer explained what he had done. The charge nurse stated he sent an email to the ED Director about it, and also did an occurrence report which went to the risk manager the next day. He then stated he discussed it with ED Director. He also stated that the ED does morning huddles to talk about previous days events, and to put out new information to staff. Security is not involved in those huddles. The huddles were used to review EMTALA requirements with clinical staff after the event. A handout has been given out to all employees with EMTALA updates. We also have Annual EMTALA training. On 3/27/15 at approximately 12:15am, a telephone interview was conducted with the security officer on duty in the ED on the date of the incident. The officer confirmed that he was on duty that day at his part time security job with the hospital, and that he was a full time county deputy sheriff. The officer stated he was seated when a man entered the reception area. The man sat in a chair for a while, and then got up, and down a couple of times. He stated the man eventually asked him if he could help him. The officer stated he asked the man if he needed to see a doctor, and the man replied No, he needed his help because people were trying to kill him. The officer further stated the man made comments about the people that were in his head and trying to kill him. The officer states he noticed what looked like healed cuts on the man's wrists. When he asked about the cuts, the man replied that he had to cut himself sometimes so the people would go away. The officer stated he called the county sheriff's office dispatch, and asked for a car to be sent to the hospital. The car arrived with 2 other officers. One officer came into the reception area, and after discussing the situation with the officer and the man, it was decided the man was a harm to himself, and he was taken to a local Baker Act receiving facility, under the Florida Baker Act law. The officer stated that he was given a pamphlet about EMTALA upon hire, approximately 2 months ago. He states he honestly just glanced at the pamphlet, not really reading it. He stated that when he saw the man exhibit what he thought was clear suicidal and paranoid behavior, he just did what he would normally do in his role as a county deputy sheriff, and he had the man taken by law enforcement for transport to a psychiatric receiving facility. He only later, after the man was escorted from the building by other officers, informed the charge nurse. That was when he was informed that he had made a mistake, and should not have done that. The officer states he has now been trained, and fully understands the requirements for the hospital when anyone comes to the hospital property, and asks for treatment, or is observed to possibly need treatment. A further review of the hospital written policy reveals a bold font paragraph, with the title Baker Act Patients, which is underlined. The paragraph states: With respect to the provision of emergency services and care to patients who are being involuntarily examined under Chapter 393, Florida Statutes (the Baker Act), facility shall adhere to the requirements of Chapter 394, Florida Statutes, regarding patient rights and involuntary examination procedures, regardless of whether facility is designated as a receiving facility under the Baker Act. Facility shall adhere to, and maintain in the Emergency Department, copies of the provisions of the Baker Act which govern Baker Act patient rights and the involuntary examination process. To the extent that the Baker Act conflicts with EMTALA, facility shall comply with EMTALA. At approximately 10:30 am on 3/25/15, and interview was conducted with the facility Risk Manager (RM). The RM confirmed the contents of the written self-report of emergency access violation, including the statements made from the receptionist, and from the security officer on duty at the time. The RM also stated that the security guards are provided by a contracted Security Agency, and the security guards are expected to follow all facility policies. On 3/26/15 at approximately 4:00 pm an interview was conducted with the ED Director. The ED Director stated that during orientation to the facility, all staff, including contracted security guards are provided an EMTALA pamphlet. The pamphlet provides the basic guidelines for compliance with EMTALA requirements, emphasizing the medical screening examination. Since the incident occurred on 3/5/15, 100% of security officers have been re-trained on EMTALA, and a copy of the EMTALA pamphlet has been placed in a required daily reading book for security officers working in the ED. (The ED Director provided a list of all security employees with signatures attesting to receiving the EMTALA training). The other ED staff, have been required to read the EMTALA pamphlet again, and retake the Electronic EMTALA training prior to 3/30/15. The ED Director was able to account for the completion of the training requirement through an electronic report. While not all ED staff have completed the training, those who have not, have not been back to work since the incident occurred, due to leave of absence, vacation, sick leave, or as needed work status. On 3/27/15 at approximately 10:30 a.m., and interview was conducted with ED registered nurse A. Nurse A was able to verbalize appropriate knowledge of EMTALA requirements, and stated she receives annual training on EMTALA, and also had EMTALA training as recently as one week ago. On 3/27/15 at approximately 10:40 am, an interview was conducted with ED registered nurse B. Nurse B was able to verbalize EMTALA requirements, stated EMTALA training is required annually, and had EMTALA training last week. On 3/27/15 at approximately 10:37 am, and interview was conducted with ED registered nurse C. Nurse C was able to verbalize EMTALA requirements, stated he is trained annually on EMTALA, and most recently he received EMTALA training within the past 2 weeks. Record reviews of 20 sampled ED patients were selected from the ED control log, based upon sample selection of similar diagnosis and patients transferred to another level of care. The review did not reveal any patients in the sample who did not receive the appropriate medical screening exam (MSE). No record existed for sample patient #21. A visit was made to the receiving facility (a psychiatric facility) for sample patient #21 on 3/26/15 at approximately 9:00 am. The receiving facility was able to confirm that patient #21 was admitted under the provisions of the Florida Baker Act on 3/5/15, by law enforcement, and identified the psychiatric diagnosis of the patient.

26001 Based on review of Capital Regional Medical Center's written self-report of Emergency Medical Treatment and Active Labor Act (EMTALA) violation, interviews with the hospital Risk Manager (RM), Emergency Department (ED) Director, and other ED staff members, and review of the hospital EMTALA policies, the hospital failed to provide Stabilizing Treatment for 1 of 21 patients in the sample (#21). The findings are: The facility submitted to the state survey agency the following potential violation self-report of the Emergency Medical Treatment and Active Labor Act (EMTALA) on 3/18/2015: On 03/05/2015, at approximately 10:52 a.m., the patient entered the Walk-In entrance of our hospital which provides access to both the Emergency Department (ED) and other areas of the hospital. The patient proceeded to the patient and Visitor Waiting Area to the left of the entry door and then walked toward our Security Officer, who was sitting at the back area of the reception desk. The Security Officer is an off-duty Deputy with the County Sheriffs Office and employed by the contracted Security service to provide security at Capital Regional Medical Center. The reception desk is U-shaped with a Receptionist sitting in the center section. The Receptionist assists those coming through the entrance that may need assistance in initiating the ED (Emergency Department) process or directions to other areas of the facility. The Security Officer was sitting on the back left side of the U-shaped desk where there is a lower desk section for use by visitors or patients in wheelchairs. When the patient went to speak with the Security Officer the patient sat in a chair across from the Security Officer. The patient and Security Officer carried on a conversation for approximately 25 minutes. The Receptionist, when we interviewed her, said she did not see the patient enter the building but later saw him sitting in the chair talking with the Security Officer. She heard the patient say he was in fear for his life and the security guard explained the Baker Act to the patient. In addition, the Receptionist said she heard the patient state that he wanted to leave but she heard the Security Officer say he had to stay at the desk. Security video footage shows that a County Sheriffs Office Deputy entered the ED at 11:25 a.m., and the Security Officer, the patient, and the Deputy walked toward the entrance of the ED. They had a conversation by the entrance to the ED and at approximately 11:33 a.m., the patient exited the ED with the Deputy and the Security Officer. Approximately 30 minutes after the patient left, the Security Officer approached the Charge Nurse and explained that the patient walked up to him at the reception desk, stated that he needed help, someone was trying to kill him and he heard voices in his head. Because of this, the officer called a Sheriff cruiser to come get the patient and take him to a Baker Act Receiving facility. The Baker Act is a Florida Statute designed to protect the rights of persons with mental illnesses, and allows the judicial system, law enforcement, and under certain circumstances, certain medical professionals to have a person involuntarily taken to a psychiatric receiving facility for evaluation and treatment of a suspected psychiatric condition. The facility EMTALA - Florida Medical Screening Examination and Stabilization Policy, effective 3/1/13 was reviewed. The policy states: an EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED) and: the individual or representative acting on the individual's behalf requests an examination or treatment for a medical condition, or a prudent layperson observer would conclude from the individual's appearance or behavior that the individual needs an examination or treatment of a medical condition. The policy continues to state, and provide an example as follows: the individual arrives on hospital property either in the DED or property other than the DED, and no request is made for evaluation or treatment, but the appearance or behavior of the individual would cause a prudent layperson observer to believe that the individual needed such examination or treatment. On 3/26/15 at approximately 3:25 pm, an interview was conducted with the ED Receptionist. The receptionist stated that on 3/5/15 she was on shift at the reception desk. She heard a man state that somebody was after him and he was in fear for his life (to the security guard). She stated it was pretty busy that day, and she was probably 20 feet away from them. She did not hear what the officer said to him. The officer did not address her at all about the incident. On 3/26/15 at approximately 3:50 pm, an interview with was conducted with the ED Charge Nurse on duty on the day shift on 3/5/15. The charge nurse stated the security officer was at the nursing desk, and informed him that he had taken care of one patient for him. The charge nurse stated the security officer explained what he had done. The charge nurse stated he sent an email to the ED Director about it, and also did an occurrence report which went to the risk manager the next day. He then stated he discussed it with ED Director. He also stated that the ED does morning huddles to talk about previous days events, and to put out new information to staff. Security is not involved in those huddles. The huddles were used to review EMTALA requirements with clinical staff after the event. A handout has been given out to all employees with EMTALA updates. We also have Annual EMTALA training. On 3/27/15 at approximately 12:15am, a telephone interview was conducted with the security officer on duty in the ED on the date of the incident. The officer confirmed that he was on duty that day at his part time security job with the hospital, and that he was a full time county deputy sheriff. The officer stated he was seated when a man entered the reception area. The man sat in a chair for a while, and then got up, and down a couple of times. He stated the man eventually asked him if he could help him. The officer stated he asked the man if he needed to see a doctor, and the man replied No, he needed his help because people were trying to kill him. The officer further stated the man made comments about the people that were in his head and trying to kill him. The officer states he noticed what looked like healed cuts on the man's wrists. When he asked about the cuts, the man replied that he had to cut himself sometimes so the people would go away. The officer stated he called the county sheriff's office dispatch, and asked for a car to be sent to the hospital. The car arrived with 2 other officers. One officer came into the reception area, and after discussing the situation with the officer and the man, it was decided the man was a harm to himself, and he was taken to a local Baker Act receiving facility, under the Florida Baker Act law. The officer stated that he was given a pamphlet about EMTALA upon hire, approximately 2 months ago. He states he honestly just glanced at the pamphlet, not really reading it. He stated that when he saw the man exhibit what he thought was clear suicidal and paranoid behavior, he just did what he would normally do in his role as a county deputy sheriff, and he had the man taken by law enforcement for transport to a psychiatric receiving facility. He only later, after the man was escorted from the building by other officers, informed the charge nurse. That was when he was informed that he had made a mistake, and should not have done that. The officer states he has now been trained, and fully understands the requirements for the hospital when anyone comes to the hospital property, and asks for treatment, or is observed to possibly need treatment. A further review of the hospital written policy reveals a bold font paragraph, with the title Baker Act Patients, which is underlined. The paragraph states: With respect to the provision of emergency services and care to patients who are being involuntarily examined under Chapter 393, Florida Statutes (the Baker Act), facility shall adhere to the requirements of Chapter 394, Florida Statutes, regarding patient rights and involuntary examination procedures, regardless of whether facility is designated as a receiving facility under the Baker Act. Facility shall adhere to, and maintain in the Emergency Department, copies of the provisions of the Baker Act which govern Baker Act patient rights and the involuntary examination process. To the extent that the Baker Act conflicts with EMTALA, facility shall comply with EMTALA. At approximately 10:30 am on 3/25/15, and interview was conducted with the facility Risk Manager (RM). The RM confirmed the contents of the written self-report of emergency access violation, including the statements made from the receptionist, and from the security officer on duty at the time. The RM also stated that the security guards are provided by a contracted Security Agency, and the security guards are expected to follow all facility policies. On 3/26/15 at approximately 4:00 pm an interview was conducted with the ED Director. The ED Director stated that during orientation to the facility, all staff, including contracted security guards are provided an EMTALA pamphlet. The pamphlet provides the basic guidelines for compliance with EMTALA requirements, emphasizing stabilizing treatment. Since the incident occurred on 3/5/15, 100% of security officers have been re-trained on EMTALA, and a copy of the EMTALA pamphlet has been placed in a required daily reading book for security officers working in the ED. (The ED Director provided a list of all security employees with signatures attesting to receiving the EMTALA training). The other ED staff, have been required to read the EMTALA pamphlet again, and retake the Electronic EMTALA training prior to 3/30/15. The ED Director was able to account for the completion of the training requirement through an electronic report. While not all ED staff have completed the training, those who have not, have not been back to work since the incident occurred, due to leave of absence, vacation, sick leave, or as needed work status. On 3/27/15 at approximately 10:30 a.m., and interview was conducted with ED registered nurse A. Nurse A was able to verbalize appropriate knowledge of EMTALA requirements, and stated she receives annual training on EMTALA, and also had EMTALA training as recently as one week ago. Record reviews of 20 sampled ED patients were selected from the ED control log, based upon sample selection of similar diagnosis and patients transferred to another level of care. The review did not reveal any patients in the sample who did not receive stabilizing treatment. No record existed for sample patient #21. A visit was made to the receiving facility (a psychiatric facility) for sample patient #21 on 3/26/15 at approximately 9:00 am. The receiving facility was able to confirm that patient #21 was admitted under the provisions of the Florida Baker Act on 3/5/15, by law enforcement, and identified the psychiatric diagnosis of the patient.

26001 1. Based on review of Capital Regional Medical Center's written self-report of an Emergency Medical Treatment and Active Labor Act (EMTALA) violation, interviews with the hospital Risk Manager (RM), Emergency Department (ED) Director, and other ED staff members, and review of the hospital EMTALA policies, the hospital failed to provide a Medical Screening Exam (MSE) for 1 of 21 patients in the sample (#21). Refer to finding in Tag A-2406. B. Based on review of Capital Regional Medical Center's written self-report of Emergency Medical Treatment and Active Labor Act (EMTALA) violation, interviews with the hospital Risk Manager (RM), Emergency Department (ED) Director, and other ED staff members, and review of the hospital EMTALA policies, the hospital failed to provide Stabilizing Treatment for 1 of 21 patients in the sample (#21). Refer to findings in Tag A-2407. C. Based on review of Capital Regional Medical Center's written self-report of Emergency Medical Treatment and Active Labor Act (EMTALA) violation, interviews with the hospital Risk Manager (RM), Emergency Department (ED) Director, and other ED staff members, and review of the hospital EMTALA policies, the hospital failed to provide an appropriate transfer of a patient with a reported unstable emergency medical condition for 1 of 21 sampled patients (#21). Refer to findings in Tag A-2409.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 25370 Based on reviews of Capitol Regional medical Center ' s written self-pf EMTALA violation, policies and procedures and the ED control log the facility failed to maintain a medical record or other related records for 1 (#21) of 21 sampled patients. The Findings: The facility submitted to the state survey agency the following potential violation self-report of an Emergency Medical Treatment and Active Labor Act (EMTALA) on 3/18/2015: On 03/05/2015, at approximately 10:52 a.m., the patient (patient #21) entered the Walk-In entrance of our hospital which provides access to both the Emergency Department (ED) and other areas of the hospital. The policy titled EMTALA Definitions and General Requirements Reference Number LL.EM.001, Effective March 2, 2013 was reviewed. The policy specified in part, When the Individual Leaves Before the EMTALA obligations is Met .a. Purpose of the Sign-In sheet- For those individual who present to the DED who are not immediately placed in a bed, the Sign-In Sheet must be completed. The Sign-In Sheet is used to document the date and time of request for medical screening, pre-registration information .d. The Sign-In Sheet is to be placed in the permanent medical record or scanned or stored in the electronic Horizon Patient Folder or notebook .Logistics .b. Open a medical record. Record reviews of 20 sampled ED patients were selected from the ED control log. No medical record existed for sample patient #21 when he presented to the facility on [DATE]. The facility failed to ensure that their Policy and Procedure was followed as evidenced by failing to ensure that a medical record or other related records were maintained for Patient #21 on 3/5/2015.

26001 Based on review of Capital Regional Medical Center's written self-report of Emergency Medical Treatment and Active Labor Act (EMTALA) violation, interviews with the hospital Risk Manager (RM), Emergency Department (ED) Director, and other ED staff members, and review of the hospital EMTALA policies, the hospital failed to provide an appropriate transfer of a patient with a reported unstable emergency medical condition for 1 of 21 sampled patients (#21). The findings are: The facility EMTALA - Florida Transfer Policy, dated 3/1/13, was reviewed. The policy stated, Any transfer of an individual with an EMC (emergency medical condition) must be initiated either by a written request for transfer from the individual or the legally responsible person acting on the individual ' s behalf or by a physician order with the appropriate physician certification as required under EMTALA. A transfer will be an appropriate transfer if: i. The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual ' s health . ii. The receiving facility has available space and qualified personnel for the treatment of the individual and has agreed to accept the transfer and to provide appropriate medical treatment; iii. The transferring hospital sends the receiving hospital copies of all medical records related to the EMC for which the individual presented that are available at the time of transfer . iv. The transfer is effected through qualified personnel and transportation equipment as required including the use of necessary and medically appropriate life support measures during the transport. On 3/26/15 at approximately 4:00 pm an interview was conducted with the ED Director. The ED Director stated that during orientation to the facility, all staff, including contracted security guards are provided an EMTALA pamphlet. The pamphlet provides the basic guidelines for compliance with EMTALA requirements, regarding appropriate transfers. Record reviews of 20 sampled ED patients were selected from the ED control log, based upon sample selection of similar diagnosis and patients transferred to another level of care. The review did not reveal any patients in the sample who were inappropriately transferred to another (appropriate) facility for treatment beyond the capacity of the facility. No record existed for sample patient #21. A visit was made to the receiving facility (a psychiatric facility) for sample patient #21 on 3/26/15 at approximately 9:00 am. The receiving facility was able to confirm that patient #21 was admitted under the provisions of the Florida Baker Act on 3/5/15, by law enforcement, and identified the psychiatric diagnosis of the patient.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33394 Based on staff interviews, patient record reviews and review of the facility's policies and procedures, the facility failed to ensure that patient care provided by certified nursing assistants (CNAs) was supervised and evaluated to ensure that the CNAs were operating within their scope of practice as regulated by the State of Florida Administrative Code Law 64B9-15.002; failed to ensure a complete admission assessment of the patient's current physical status following surgery and failed to perform an accurate reassessment for a change in patient's condition for three of four open/closed medical records reviewed. (#1, #2 and #3) The findings include: 1. On 04/02/2014 at 1:37pm an interview was conducted with certified nursing assistant (CNA) B who was working on the progressive care unit. The staff member was asked about any special training she had received in regard to her job duties or any special care tasks that she performed for her patients. CNA B stated that she had received specialized training to perform finger stick blood sugar testing but stated that the hospital had changed that policy about three months ago and now the nurses were responsible for doing that testing. CNA B then stated that sometimes she would suction the patients' tracheostomies. She stated that when she noticed the patients making sounds that indicated they may have stuff in their tracheostomy she would suction them to clear the tracheostomy out. She explained that she was a CNA and a medical assistant (MA) and that she was currently in nursing school. CNA B was then asked if the hospital had provided her with any training in regards to tracheostomy suctioning and she stated that No they had not. She stated that she had a daughter with a tracheostomy and that was where she had learned to perform suctioning and care for the tracheostomy and so if she has a patient that needs suctioning or if the patient needs a new water bottle then she would just go ahead and do it for them. CNA B was then asked if she felt as if she had adequate training to perform her job and she stated that she felt as if she was really over qualified . Review of the State of Florida Administrative Code Law 64B9-15.002, which contains the authorized duties allowed for certified nursing assistants, showed that A certified nursing assistant shall not perform any task which requires specialized nursing knowledge, judgment, or skills, and a certified nursing assistant shall not work independently without the supervision of a registered nurse or a licensed practical nurse. Specific Authority 464.202, 464.203 FS. Law Implemented 464.203, 464.2085 FS. History-New 9-21-06. 29722 On 04/03/2014 at 9:44am an interview was conducted with the Unit Director of the Progressive Care Unit. The unit director was asked to explain what role CNAs play in the care of tracheostomies and she stated that CNAs are there to assist the nurse as needed. The unit director was then asked if CNAs were allowed to perform tracheostomy suctioning and she stated No, CNAs are not allowed to suction a tracheostomy under any circumstances. She went on to explain that CNAs are not even allowed to change the tracheostomy ties. The unit director was also asked if CNAs are allowed to change the fluid bottles for patients with humidified tracheostomies and she stated that No either respiratory or the nurse would be responsible for changing the water bottles for humidified tracheostomies. 2. On 04/02/2014 a closed record review was conducted for patient #1, who underwent a vaginal hysterectomy on 04/01/2014. There was a pre-admission assessment performed on 03/31/2014, prior to the patient's surgical procedure. The patient was admitted on to the facility's Family Care Unit on 04/01/2014 at 16:25 (4:25pm). The admission assessment was incomplete. The Electronic Medical Record (EMR) revealed Neurologic Assessment and Genitourinary Assessment as N which means not within defined parameters. The patient's pain level was rated a 7 and indicated medicated for breakthrough pain, but failed to identify current use of a Patient Controlled Analgesia Unit (PCA pump- pain pump) or an intravenous (I.V.) site. The record did identify the presence of a urinary catheter - indication as detail peri-op use. There was was no assessment to identify the presence or absence of vaginal bleeding - or identification of the presence of a perineal pad. The nurse currently caring for patient #1 identified that the patient came to the unit with a pain pump system and peri-pad in place. 3. On 04/03/2014 a closed record review was conducted for Patient #2. Patient #2 was admitted through the ED (Emergency Dept.) to the Critical Care Unit (CCU) on 02/05/2014. There was a physician order written at 20:34 (8:34pm) for nasal cannula 2 liter/minute. Titrate O2(oxygen) up to 4 liters per minutes to maintain O2 saturation > 92%. Notify attending physician if O2 requirement exceed 4 liter/nasal cannula. Nurse note indicates 1900 report received care assumed. Dr. __ in on rounds, new order to decrease IVF (IV fluids) rate to 75ml/hr. Call in am for possible transfer orders to PCU (progressive care unit) pending how patient does tonight per physician. 1915 (7:15pm) vital signs reveal heart rate (HR) 75, respirations (R) 22, blood pressure (BP) 92/45 and an oxygen saturation(O2 sat) of 91% [below physician prescribed parameter]. 1946 (7:46pm) oxygen saturation 100%. The medical record identifies an initial assessment completed by the RN at 20:00 (8:00pm) that reveals Oxygen at 2.0 L via nasal cannula (nc). No acute resp distress noted. Heart Rhythm: paced. 20:00 (8:00pm) P - 76, R 19 , BP 86/40 - No acute respiratory distress noted. - mod[erate] edema. [no oxygen saturation level noted]. 02/06/2014 - 2100 (9:00pm) HR 76 - R 19 - BP 88/52. Next nursing assessment performed at 02/06/2014 2333 (11:33pm) under Reassessment Comment (page 14), Assessment findings unchanged since last assessment. There was no other documentation including no vital signs, no oxygen saturation levels noted. There was a BP recorded at 11:00pm 99/56. At 0002 ( 12:02am, now 02/17/2014 - the patient's HR 75 - R 27 - BP 92/52. There was a respiratory therapy note that indicated at 0027 (12:27am) patient's oxygen saturation 98% on 2 liters of oxygen [no other information documented]. 1:00am - HR 75, R 24, 87/48 [no oxygen saturation noted]. 02/07 0115 (1:15am) R 27; 02/07 0130 (1:30am) R 29; 02/07 0145 (1:45am) R 30. [The 0115, 0130, 0145 entries were all acknowledged and entered into the medical record after 0300 - late entries]. The patient respiratory rate was noted to increase, beginning at 1:00am to 1:45am - but there was nothing in the patient's record to identify nursing interventions, or the condition of the patient. Interview on 04/03/2014 at approximately 2:30pm with the Director of CCU (critical care unit) indicates respiratory alarms are set based on manufacturer's recommendation - the parameters can be narrowed, but cannot be expanded. The Director of CCU indicated the respiratory rate alarm parameters are set at 5 to 30 per minutes and nurse to patient staffing ratios are usually 2 patient to 1 nurse. It was not identified in the medical record if Patient #2's alarms sounded. There was Nursing documentation at 03:48am that indicated 0150 (1:50am) change in resp[iration] pattern noted, daughter at bedside states mother breathing is different, noted decreased breath sound, daughter questioned how much O2 (oxygen) pt (patient) was on, informed 2L/min nc, daughter states uses 3-4L/min nc at home, increased O2 to 3L/2L/min nc. Left room to page physician and resp[iratory]. While paging physician, charge nurse called to room by daughter, writer returned to bedside, charge nurse and writer noted patients resp[irations] become agonal (gasps) and code blue was called. (2:00am) Patient subsequently intubated and placed on mechanical ventilator. New orders were obtained. Post code nursing assessment - none noted. Nursing Assessment documented on 02/07/2014 at 0400 (4:00am) - under Reassessment Comment (page 14), Assessment findings unchanged since last assessment. Nursing assessment fails to accurately assess Patient #2's current physical condition; patient now on ventilator. Patient #2's medical record failed to indicate the assessment of oxygen saturation rates to ensure, per physician orders - that the patient's oxygen saturation level was maintained at or above 92%. The record fails to identify the condition of the patient or nursing interventions when a change in the patient condition were identified. Post resuscitative procedure -the record fails to identify a nursing assessment and fails to reflect an accurate, complete assessment at 0400, as per the facility's policy and procedure, in a Unit in which the patient requires a higher level of care and monitoring. This writer was unable to ascertain patient's respiratory effectiveness and whether current oxygen administration dose were adequate to sustain the patient's oxygen saturation at or above 92% due to lack of documentation. 4. On 04/03/2014 a closed record review was conducted for Patient #3. Patient #3 was admitted to the facility on [DATE] through the Emergency Department with a diagnosis of Respiratory failure. She was admitted to CCU at approximately 17:51 (5:51pm) with an admission nursing assessment conducted at 17:59. Physician order written at 17:06 (5:05pm) indicates oxygen therapy - titrate to keep oxygen saturation greater than 91%. A review of the record, with the assistance of the Risk Manager, vital signs recorded at 20:30 (8:30pm) heart rate (HR) 123, blood pressure (BP) 107/69 and respirations (R) 13. Unable to locate patient's oxygen saturation level. There was a nursing assessment performed at 20:00 (8:00pm) Additional entries in the record record vital signs at 20:45 (8:45p) - P 119. 21:45 (9:45pm) P 126 - resp 25; 2200 (10:00pm) - P 118, R 9; 2215 (10:15pm) P 123, R19. An additional nursing assessment (per facility policy - every 4 hours), performed at 2356 (11:56pm) indicates Assessment unchanged. Last oxygen saturation level located in the record was performed at 17:36 (5:36pm), which was 95% on a 35% Oxygen flow rate. Record entry on 02/23/2014 at 12:00am - the patient's oxygen saturation was record at 77%, BP obtained at 12:36pm was 115/72. There was no documented intervention in the record to address the patient's decrease in oxygen level or was there an indication the physician was notified. On 04/03/2014 at approximately 3:30pm, an interview was conducted with the Director of CCU, she indicated she would have expected that someone with a low oxygen saturation - to notify the physician, get respiratory therapy involved and would expect an assessment of the patient's condition. Additional review of the record, revealed an additional nursing assessment performed on 02/23/2014 at 3:34 am, Assessment findings unchanged since last assessment. A review of the facility's policy and procedure entitled Patient Assessment and Reassessment - Policy number: NUR-035, indicates A. Initial Screening Assessment. The comprehensiveness and frequency of screening and assessments will be dependent upon a number of factors, including patient needs, program goals, and the care, treatment and services provided as well as patient response. Initial screening and assessments may indicate the need for further data collection or a more intensive or specialized assessment. At a minimum, the need for further assessment is determined by the care, treatment and services and any significant changes in patient condition. In addition to the assessment factors listed above, an initial assessment, will include: 1. Assessment of the patient's current physical condition. C. Reassessment: 3. Reassessment may be specified/regular intervals related to: a. The patient's response to care, treatment & services b. The patient's response to a significant change in status or diagnosis/condition c. To satisfy legal or regulatory requirements d. To satisfy pre-determined intervals specified by organizational policy or protocol e. To meet time intervals determined by the course of care, treatment and services provided to the patient f. To meet changing discharge planning needs when appropriate in the scope of care of the department involved

14762 Based on interview and record review it was determined that the hospital failed to ensure a qualified Registered Nurse was provided to meet patient care needs for 1 of 7 current patients. (#4) Findings include: 1) On 3/17/2011 a complaint investigation was conducted and patient #4 was interviewed at approximately 12:30 PM. He stated he was moved from the Intensive Care Unit (ICU) on 3/16/2011 around mid-day and that the nursing staff had failed to provide him with medications. He stated that he and his full time caregiver had requested pain medications and antianxiety medications several times, but it was not until close to midnight before he received something for pain. Patient #4's caregiver was also interviewed at this time and she stated the nurse assigned to him on the evening shift on 3/16/2011 appeared overwhelmed, and was unable to provide the patient with his medications. 2) A review of the medication orders and Medication Administration Records (MARs) revealed the patient did not receive any medications by the Registered Nurse (RN) initially assigned to the patient on the 7 P- 7 A shift. A review of the nursing notes revealed no nursing assessment or notes entered by the evening RN. 3) On 3/17/2011 at approximately 2:30 PM and interview was conducted with the 3rd Floor Unit Manager. She stated it is a standard for each shift to perform a nursing assessment. 3) On 3/18/2011 at approximately 7:50 AM, an interview was conducted with the RN assigned to patient #4 on 3/16/2011 evening shift. She stated she had never worked the 3rd floor unit and had a total 6 patients to care for. She stated she was busy with other patients and did not provide patient #4 with his medications and did not conduct a nursing assessment. The RN also stated she did not receive any orientation or training specific to the 3rd floor which contained medical type patients and that her primary work location was the post partum area. She stated when she reported for work on 3/16/2011, her supervisor told her to she was being assigned to the 3rd floor.

14762 Based on on interview and record review was determined that the hospital failed to ensure medications were administered in a safe and efficient manner for 2 of 7 current patients. (#1 and #4) Findings include: 1) On 03/17/2011 during a medical record review for patient #1, who was admitted on the evening of 03/15/2011, the eMar (Electronic Medication Administration Record) listed the patient's physician ordered intravenous and as needed medications and their administration times, but did not show the oral medications that were to be continued as listed on the Home Medication Continuation Form. The Home Medication Continuation Form was stamped that it was faxed to the pharmacy on 03/16/2011 at 6:20 PM. However, the Pharmacy Department failed to receive the faxed order. A 24 hour chart check was completed by the RN on the 7 P to 7 A shift on 03/17/2011, but failed to identify that the oral medications were not on the eMAR. Therefore, patient #1 failed to receive her oral medications during this time. On 03/17/2011 at approximately 2:00 PM an interview was conducted with Patient #1. She stated she has only received IV (intravenous) medication (points to IV bag) since she has been here. She states she has not received any oral medications. On 03/18/2011 at 07:55 am an interview was conducted with the RN assigned to patient #1 during the evening shift 7 P-7 A on 03/16-17/2011. She confirmed that she did do the 24 hour Chart Check for the patient, but did not remember seeing the Home Medication Continuation Form. She verified that the 24 hour chart check is done to ensure that the physician orders previously written have been carried out. A review of the hospital's policy for Medication Reconciliation (effective 6/2/2010) revealed nursing staff are to ensure the home medications are reviewed and compare to the medications ordered. 2) On 3/17/2011 at approximately 12:30 PM and interview was conducted with patient #4. He stated he was moved from the Intensive Care Unit (ICU) on 3/16/2011 around mid-day and that the nursing staff had failed to provide him with medications. He stated that he and his full time caregiver had requested pain medications and antianxiety medications several times, but it was not until close to midnight before he received something for pain. Patient #4's caregiver was also interviewed at this time and she stated the nurse assigned to him on the evening shift on 3/16/2011 appeared overwhelmed, and was unable to provide the patient with his medications. The caregiver stated something was wrong with all of the computers and nursing staff told us they could not give medications while they were down. A review of the medication orders and Medication Administration Records (MARs) revealed the patient did not receive any medications by the Registered Nurse (RN) initially assigned to the patient on the 7 P- 7 A shift. The MAR revealed a second RN did finally provide the patient with Dilaudid for pain control at approximately 11:45 PM on 3/16/2011. On 3/18/2011 at approximately 7:50 AM, an interview was conducted with the RN assigned to patient #4 on 3/16/2011 evening shift. She stated she had never worked the 3rd floor unit and had a total 6 patients to care for. She stated she was busy with other patients and did not provide patient #4 with his medications and did not conduct a nursing assessment. On 3/18/2011 at approximately 9:30 AM, an interview was conducted with the Director of Information Technology and Services. He stated a planned downtime for the RIS (nursing documentation system) was performed on 3/16/2011 at 2230 EDT for approximately 30 minutes, however the email notification to the staff contained a typo and indicated the downtime would be at 2330. Therefore nursing staff were caught off guard by the early system interruption