CMS-HCA-Florida-Northside-Hospital

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review, observations and staff interview, it was determined the medical staff failed to ensure policies governing medical care provided in the Emergency Department (ED) were followed for continuous cardiac telemetry monitoring. The facility failed to ensure the provision of services, equipment, personnel and resources to ED patients was provided timely to protect the health and safety of all patients located in the hospital's ED for one (#3) of eight sampled patients. The facility failed to ensure policies governing medical care provided in the ED were followed for reassessment for four (#3, #5, #7, #8) of eight patients sampled.

Findings included:

Review of the medical record for patient #3 revealed on 3/10/2021 a [AGE]-year-old female with a recent diagnosis of COVID-19 presented to the facility ED at 1:33 PM via ambulance with complaints of shortness of breath, coughing and congestion. The patient's vital signs at the time of arrival were oxygen saturation of 78%, blood pressure of 117/44, respirations of 32 per minute, and heart rate of 107 beats per minute (bpm).

Review of the physician's evaluation, dated 3/10/2021 at 1:37 PM, revealed the patient's shortness of breath was worse on exertion and she had chest tightness. Physician documentation revealed EMS (Emergency Medical Services) personnel found the patient with oxygen saturation in the 40's which improved to the 70's with oxygen via face mask. EMS personnel noted the patient had one syncopal episode in route to the ED.

The physician reviewed the ECG (Electrocardiogram) and noted the patient's rhythm was Afib (Atrial Fibrillation) with RVR (Rapid Ventricular Response) and a rate of 133. The physician ordered continuous cardiac monitoring at 1:41 PM.

Review of the facility policy, Telemetry Monitoring (02/2020), NSH.PC.120, stated the purpose was to ensure patient safety and provide continuous cardiac monitoring and documentation guidelines for patients who have telemetry monitoring ordered. The policy stated, on page 5 of 10, (Q) areas where cardiac telemetry monitoring is not connected to centralized monitoring (i.e. ED) will (1) ensure appropriate continuous cardiac monitoring; (2) each area will ensure that arrhythmia competent staff are providing monitoring; and (3) guidelines related to protocols for cardiac monitoring, alarms, documentation, and competency of staff will be followed as per this policy.

Review of the medical record revealed at 1:45 PM on 3/10/2021 the RT (Respiratory Therapist) (Staff J) conducted an initial assessment of the patient and placed the patient on BiPAP (Bilevel Positive Airway Pressure). BiPAP is a treatment that uses air pressure to keep airways open. The RT (Staff J) documented the patient's pulse as 104 bpm, oxygen saturation of 94% on BiPAP, and respiratory rate 49 breaths per minute. At 2:03 PM the RT (Staff J) reassessed the patient and noted the patient's pulse as 107 bpm, oxygen saturation of 94%, and respiratory rate 53 breaths per minute.

RN (Registered Nurse) documentation at 2:25 PM on 3/10/2021 revealed an initial nursing assessment was performed. The RN noted the patient had BiPAP on and cardiac monitoring with a rhythm of ST (Sinus Tachycardia), no rate documented.

Review of the physician's re-evaluation, no time noted, revealed the patient was placed on a trial of BiPAP, received albuterol treatment and steroids. Her respiratory status improved significantly, and the patient stated she felt better and would like to continue the mask, refusing endotracheal intubation. Her respiratory rate and work of breathing had improved while on BiPAP.

Review of the medical record revealed a Code Blue was initiated on 3/10/2021 at 4:11 PM. Review of the physician's re-evaluation note revealed while the patient was waiting for admission, the RT (Staff J) notified the physician the patient was found unresponsive and disconnected from the BiPAP. The physician documented ACLS (Advanced Cardiac Life Support) resuscitation was initiated, the patient was in PEA (Pulseless Electrical Activity), then VFib (Ventricular Fibrillation), she received medications to aid in resuscitation, and was intubated endotracheally. The patient had ROSC (Return of Spontaneous Circulation) as a result of the treatment and transferred to ICU (Intensive Care Unit).

Review of the medical record for telemetry monitoring revealed no evidence a telemetry strip was in the medical record and the staff could not present one. Review of the facility policy, Telemetry Monitoring, (02/2020) stated (I) rhythm strips are printed for the following events: rhythm changes and during code blue; (L) in the event that a Code Blue is called on a monitored patient, the monitor technician will print telemetry rhythm to capture pre-code, during code, and post code events. The policy further states (II)(B) personnel in the role of monitor technicians will be responsible for monitoring cardiac telemetry, running documentation strips, and communicating to the nurse changes in the patient's rhythm.

Review of the medical record revealed a note by the RT (Staff J) which was documented on 3/10/2021 at 5:25 PM (post event). The RT note stated upon nearing the patient's room the BiPAP alarm could be heard alarming in the room (door was closed for isolation precautions). Upon entering the room, the BiPAP circuit was disconnected from the patient's mask. The circuit was immediately reconnected, the RT (Staff J) performed a sternal rub on the patient and verbally called the patient with no response. The RT (Staff J) noted the patient's heart rate on the monitor was in the 50's and immediately alerted the physician and resuscitation efforts began.

An interview was conducted on 4/14/2021 at 3:00 PM with the Charge Nurse (Staff E) for the day of the event. It was confirmed the Charge Nurse is responsible for monitoring the cardiac telemetry monitors of the patients in the ED. The Charge Nurse (Staff E) was asked if patient #3 had any changes in cardiac rhythm, rate or oxygen saturation while she was monitoring the patient on 3/10/2021. She stated there were no changes and there were no alarms on the telemetry monitor prior to the event.

An interview was conducted with the ED Medical Director (Staff I) (who was also the physician that provided care to patient #3 on 3/10/2021) on 4/15/2021 at 1:05 PM. The physician stated the patient's condition had improved and she responded well to the BiPAP, respiratory treatments, and steroids. The physician was asked to describe the current practice in the ED for when a patient is ordered continuous cardiac monitoring. He stated the cardiac monitors are located in the nursing station and clinical staff have access to view them. He stated the Charge Nurse monitors the cardiac monitors and alerts staff to alarms. The physician confirmed he was aware the Charge Nurse has other responsibilities and is not continuously watching the monitors. The physician confirmed this posed a risk in timely identifying a patient that is decompensating.

Observations and a tour were conducted in the ED on 4/14/2021 at 10:30 am. At the time of the tour there were currently four patients on continuous cardiac monitoring. There were two cardiac monitor screens observed in the nursing station. At the time of observation there was no staff member watching the monitors and the Charge Nurse was sitting with her back to the monitors. An interview was conducted with the Charge Nurse (Staff G) on 4/14/2021 at 10:45 am. The Charge Nurse confirmed there was not a dedicated staff member assigned to watch the monitors. She stated the Charge Nurse sits near the monitors and listens for audible alarms at which time she or another staff member would respond. She confirmed the monitor will alarm for a cardiac arrhythmia, oxygen saturation less than 90%, and hypotension per set parameters.

Additional observations were conducted in the ED on 4/16/2021 at 9:20 am. Upon arrival to the ED there was no staff observed at the cardiac telemetry monitor area. Interview with the ED Director (Staff E) stated the Charge Nurse was in a patient's room. At the time of the tour there were four patients with orders for continued cardiac monitoring. Staff were observed near the monitors but there was no visual monitoring of any of the patient's on cardiac monitoring. The Charge Nurse returned to the monitor area approximately five minutes later and was interviewed. The Charge Nurse (Staff M) was asked what her responsibilities were as the Charge Nurse. She stated providing resources to ED nurses and other staff, hands on tasks to ensure proper flow, timely placement of patients, ensure physicians evaluate patients in a timely manner, and assist in the monitoring of behavioral health patients. The Charge Nurse was asked if she was responsible to monitor the cardiac monitors. She confirmed it was her responsibility and stated it was all staff's responsibility to respond to the alarms.

The facility conducted a RCA (Root Cause Analysis) of the event but failed to identify the facility policy, Telemetry Monitoring, was not followed for patients located in the ED. Observation conducted on 4/14/20 at 10:30 am, 4/16/2021 at 9:20 am, and interviews conducted on 4/14/21 at 10:45 am, 4/14/2021 at 3:00 pm, 4/16/2021 at 9:20 am confirmed the facility's ED Charge Nurse is responsible for continuous cardiac monitoring of patients in the ED. Interviews on 4/14/2021 at 10:45 am and 4/16/2021 at 9:20 am confirmed the Charge Nurse has multiple tasks in the department and does not continuously view the telemetry monitors. Interviews on 4/14/2021 at 10:45 am and 4/16/2021 at 9:20 am confirmed the Charge Nurse relies on audible alarms to trigger a warning for the Charge Nurse or other staff in the area to assess the reason for the alarm. This jeopardizes the safety of patients located in the ED with orders for continuous cardiac monitoring and places patients at risk of serious adverse outcomes. Despite aggressive treatment for patient #3 the patient expired on [DATE].

Review of the facility policy, Assessment and Reassessment (12/2019), ##NSH.PC.009 page 36 of 39, Department Assessment and Reassessment, Table Emergency Department stated:

- Begin Initial Assessment within: Upon arrival, MSE [Medical Screening Examination] or Triage.

- Complete Initial assessment within: One [1] hour.

- Document Initial Assessment and Develop Plan of Care: During care episode.

- Reassessment Frequency:

Every 60 minutes until MSE complete, After MSE:

Level 1/Resuscitative will be performed continuously,

Level 2/Emergency will be performed every 60 minutes,

Level 3/Urgent will be performed every 4 hours,

Level 4/Less Urgent will be performed prior to disposition or every 4 hours,

Level 5/Non-Urgent will be performed prior to discharge.

Review of patient #3's medical record revealed the patient presented to ED on 3/10/2021 at 1:33 PM. The patient was triaged at 1:38 PM and had a chief complaint of shortness of breath, coughing and congestion. The patient's vital signs were Blood pressure 117/44, heart rate 107, respirations 32, temperature 98.6 degrees Fahrenheit, and oxygen saturation of 78% on room air. The patient's Acuity level was documented as 2/Emergent.

Review of the record revealed the RN reassessed the patient at 2:25 PM. The patient's pulse, oxygen saturation and respirations were reassessed by the RT (Staff J) at 1:45 PM and 2:03 PM. The RT (Staff J) discovered the patient unresponsive at 4:11 PM. There was no evidence the nurse reassessed the patient after 2:25 PM. Review of the record revealed the patient was not reassessed timely and per facility, Assessment and Reassessment, policy.

Review of the facility policy, Telemetry Monitoring (02/2020), NSH.PC.120, stated the purpose was to ensure patient safety and provide continuous cardiac monitoring and documentation guidelines for patients who have telemetry monitoring ordered. The policy stated, on page 2 of 10, POLICY (C) the cardiac telemetry monitoring alarms have been determined to be high-risk medical equipment where there is serious injury or death to a patient if the alarm/equipment were to fail; (D) the RN is ultimately responsible for the interpretation of cardiac monitoring. They may delegate this task to personnel who have completed an approved Basic Arrhythmia Interpretation class and have demonstrated competency.

Review of patient #5's medical record revealed the patient presented to ED on 2/09/2021 at 4:53 am. The patient was triaged at 5:00 am and had a chief complaint of nausea and vomiting for 4 days. The patient's vital signs were Blood pressure 143/82, heart rate 78, respirations 18, temperature 96.2 degrees Fahrenheit, and oxygen saturation of 100 % on 2 liters via nasal cannula. The patient's Acuity level was documented as 3/Urgent.

A detailed review of the medial record failed to show documentation of continuous cardiac monitoring. The patient's vital signs were reassessed at 10:36 am. Review of the record revealed no documentation found why facility policy for reassessment not followed and 5.36 hours elapsed before patient reassessed. Per facility policy, Assessment and Reassessment (12/2019), acuity level 3/urgent should be reassessed every 4 hours. Patient #5 should have reassed at 09:00 AM.

A review of patient #7's medical record revealed the patient presented to ED on 2/10/2021 at 8:30 am with complaint of headache and chest pain. Documentation revealed the patient was triaged at 8:47 am with vital signs showing Blood Pressure 129/73, Heart rate 88, Respirations 16 Temperature 36.7 degrees Celsius and oxygen saturation 96% on room air and acuity level 2/Emergent.

The patient's vital signs were reassessed at 9:28 am. Review of the record revealed the next reassessment was completed at 4:55 PM. Review of the record revealed no documentation found why facility policy for reassessment not followed and 7 hours elapsed before patient reassessed. Per facility policy, Assessment and Reassessment (12/2019), acuity level 2/emergent should be reassessed every 60 minutes. Patient # 7 should have been reassed at 10:28 AM, 11:28 AM, 12:28 PM, 1:28 PM, 2:28PM, 3:28 PM, and 4:28 PM

A review of patient #8's medical record revealed the patient presented to ED on 4/07/2021 at 5:17 PM with chief complaint of seizures. Documentation revealed the patient was triaged at 5:17 PM with vital signs documented as blood pressure 125/62, Heart rate 61, Respirations 16, Temperature 36.6 degrees Celsius, oxygen saturation 100% on room air, and acuity level 2/Emergent.

A detailed review of the record revealed the patient's vital signs were reassessed at 7:14 PM. Review of the record revealed no documentation found why facility policy for reassessment not followed and 2 hours elapsed before patient reassessed. Per facility policy, Assessment and Reassessment (12/2019), acuity level 2/emergent should be reassessed every 60 minutes. Patient # 8 should have been assessed at 6:17 PM, and 7:17 PM.

Interview with VP Quality & Patient Safety (Staff A) on 4/16/2021 at 2:00 PM confirmed the above findings.

Show Text of Violation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review, observations and staff interview, it was determined the facility failed to ensure an RN (Registered Nurse) supervised and evaluated the care, per facility policy, for four (#3, #5, #7, #8) of eight patients sampled.

Findings included:

Review of the facility policy, Assessment and Reassessment, dated 12/2019 page 36 of 39, Department Assessment and Reassessment, Table Emergency Department, the policy stated:

- Begin Initial Assessment within: Upon arrival, MSE [Medical Screening Examination] or Triage.

- Complete Initial assessment within: One [1] hour.

- Document Initial Assessment and Develop Plan of Care: During care episode.

- Reassessment Frequency:

Every 60 minutes until MSE complete, After MSE:

Level 1/Resuscitative will be performed continuously,

Level 2/Emergency will be performed every 60 minutes,

Level 3/Urgent will be performed every 4 hours,

Level 4/Less Urgent will be performed prior to disposition or every 4 hours,

Level 5/Non Urgent will be performed prior to discharge.

Review of Patient #5's medical record revealed the patient presented to the ED (Emergency Department) on 2/09/2021 at 4:53 am. The patient was triaged at 5:00 am and had a chief complaint of nausea and vomiting for 4 days. The patient's vital signs were Blood pressure 143/82, heart rate 78, respirations 18, temperature 96.2 degrees Fahrenheit, and oxygen saturation of 100 % on 2 liters via nasal cannula. The patient's Acuity level was documented as 3/Urgent.

A detailed review of the medial record failed to show documentation of continuous cardiac monitoring. The patient's vital signs were reassessed at 10:36 am. Review of the record revealed no documentation found why facility policy for reassessment not followed and 5.36 hours elapsed before patient reassessed. Per facility policy, Assessment and Reassessment (12/2019), acuity level 3/urgent should be reassessed every 4 hours. Patient #5 should have reassessed at 09:00 AM.

A review of Patient #7's medical record revealed the patient presented to ED on 2/10/2021 at 8:30 am with complaint of headache and chest pain. Documentation revealed the patient was triaged at 8:47 am with vital signs showing Blood Pressure 129/73, Heart rate 88, Respirations 16 Temperature 36.7 degrees Celsius and oxygen saturation 96% on room air and acuity level 2/Emergent.

The patient's vital signs were reassessed at 9:28 am. Review of the record revealed the next reassessment was completed at 4:55 PM. Review of the record revealed no documentation found why facility policy for reassessment was not followed and 7 hours elapsed before the patient was reassessed. Per facility policy, Assessment and Reassessment (12/2019), acuity level 2/emergent should be reassessed every 60 minutes. Patient # 7 should have been reassessed at 10:28 AM, 11:28 AM, 12:28 PM, 1:28 PM, 2:28PM, 3:28 PM, and 4:28 PM.

A review of Patient #8's medical record revealed the patient presented to ED on 4/07/2021 at 5:17 PM with chief complaint of seizures. Documentation revealed the patient was triaged at 5:17 PM with vital signs documented as blood pressure 125/62, Heart rate 61, Respirations 16, Temperature 36.6 degrees Celsius, oxygen saturation 100% on room air, and acuity level 2/Emergent.

A detailed review of the record revealed the patient's vital signs were reassessed at 7:14 PM. Review of the record revealed no documentation found why facility policy for reassessment not followed and 2 hours elapsed before patient reassessed. Per facility policy, Assessment and Reassessment (12/2019), acuity level 2/emergent should be reassessed every 60 minutes. Patient # 8 should have been assessed at 6:17 PM, and 7:17 PM.

Interview with Vice President (VP) Quality & Patient Safety on 4/16/2021 at 2:00 PM confirmed the above findings.

Review of Patient #3's medical record revealed the patient presented to ED via ambulance on 3/10/2021 at 1:33 PM. The patient was triaged at 1:38 PM and had a chief complaint of shortness of breath, coughing and congestion. The patient's vital signs were blood pressure 117/44, heart rate 107, respirations 32, temperature 98.6 degrees Fahrenheit, and oxygen saturation of 78% on room air. The patient's Acuity level was documented as 2/Emergent.

Review of the record revealed at 1:45 PM the Respiratory Therapist (RT) (Staff J) completed an assessment of the patient and applied the BiPAP (Bilevel Positive Airway Pressure) to the patient. At 2:03 PM the RT (Staff J) reassessed the patient's pulse, oxygen saturation and respirations. The RN completed the initial assessment at 2:25 PM.

At 4:11 PM the RT (Staff J) approached the patient's room to reassess the patient and heard the BiPAP alarming inside the patient's room (door closed for isolation precautions). The RT (Staff J) entered the room and discovered the patient unresponsive and the BiPAP disconnected. The physician was called to the room and Code Blue initiated. The patient was resuscitated after 47 minutes, transferred to ICU (Intensive Care Unit), but expired on [DATE]. There was no evidence the nurse reassessed the patient after 2:25 PM. Review of the record revealed the patient was not reassessed the RN per facility policy. According to the Assessment and Reassessment policy (12/2019) a Level 2 should be reassessed every 60 minutes. Patient #3 should have been assessed no later than 3:25 pm by the RN.

An interview was conducted on 4/14/2021 at 2:45 PM with the VP of Quality & Patient Safety. The above findings were discussed and reviewed in detail and the VP of Quality & Patient Safety confirmed the findings.

Review of the facility policy, Telemetry Monitoring, dated 2/2020 - NSH.PC.120, stated the purpose was to ensure patient safety and provide continuous cardiac monitoring and documentation guidelines for patients who have telemetry monitoring ordered. The policy stated, on page 2 of 10, POLICY (D) the RN is ultimately responsible for the interpretation of cardiac monitoring. They may delegate this task to personnel who have completed an approved Basic Arrhythmia Interpretation class and have demonstrated competency.

On page 5 of 10 of the policy it stated (Q) Areas Where Cardiac Telemetry Monitoring is Not Connected to Centralized Monitoring (i.e. ED) will (1) ensure appropriate continuous cardiac monitoring; (2) each area will ensure that arrhythmia competent staff are providing monitoring; and (3) guidelines related to protocols for cardiac monitoring, alarms, documentation, and competency of staff will be followed as per this policy.

Review of the medical record revealed at 2:25 PM the RN (Registered Nurse) conducted an initial nursing assessment. The RN noted the patient had BiPAP on and cardiac monitoring with a rhythm of ST (Sinus Tachycardia), no rate documented. This rhythm was different than the documented rhythm by the physician's interpretation of the ECG (electrocardiogram) at 1:37 PM. The physician noted the patient's rhythm was Afib (Atrial Fibrillation) with RVR (Rapid Ventricular Response) and a rate of 133.

Review of the facility policy, Telemetry Monitoring, dated 2/2020, stated (I) rhythm strips are printed for the following events: rhythm changes and during code blue. There was no evidence the RN printed a telemetry strip of the patient's rhythm change or notified the physician of the change.

Observations and a tour were conducted in the ED on 4/14/2021 at 10:30 am. At the time of the tour there were currently four patients on continuous cardiac monitoring. There were two cardiac monitor screens observed in the nursing station. At the time of observation there was no staff member watching the monitors and the Charge Nurse (Staff G) was sitting with her back to the monitors.

An interview was conducted with the Charge Nurse (Staff G) on 4/14/2021 at 10:45 am. The Charge Nurse confirmed there was not a dedicated staff member assigned to watch the monitors. She stated the Charge Nurse sits near the monitors and listens for audible alarms at which time she or another staff member would respond. She confirmed the monitor will alarm for a cardiac arrhythmia, oxygen saturation less than 90%, and hypotension per set parameters.

Additional observations were conducted in the ED on 4/16/2021 at 9:20 am. Upon arrival to the ED there was no staff observed at the cardiac telemetry monitor area. Interview with the ED Director stated the Charge Nurse was in a patient's room. At the time of the tour there were four patients with orders for continued cardiac monitoring. Staff were observed near the monitors but there was no visual monitoring of any of the patient's on cardiac monitoring. The Charge Nurse (Staff M) returned to the monitor area approximately five minutes later and was interviewed. The Charge Nurse was asked what her responsibilities were as the Charge Nurse. She stated providing resources to ED nurses and other staff, hands on tasks to ensure proper flow, timely placement of patients, ensure physicians evaluate patients in a timely manner, and assist in the monitoring of behavioral health patients. The Charge Nurse was asked if she was responsible to monitor the cardiac monitors. She confirmed it was her responsibility and stated it was all staff's responsibility to respond to the alarms.

The facility conducted a review of the Code Blue event for Patient #3 but failed to identify the facility policy, Telemetry Monitoring, (2/2020) was not followed for patients located in the ED. Observations and interviews confirmed the facility's ED Charge Nurse is responsible for continuous cardiac monitoring of patients in the ED. Interview confirmed the Charge Nurse has multiple tasks in the department and does not continuously view the telemetry monitors. Interview confirmed the Charge Nurse relies on audible alarms to trigger a warning for the Charge Nurse or other staff in the area to assess the reason for the alarm. This jeopardizes the safety of patients located in the ED with orders for continuous cardiac monitoring and places patients at risk of serious adverse outcomes. Interview with the ED Medical Director was conducted on 4/15/2021 at 1:05 PM and confirmed the above findings. The ED Medical Director reported that it was his expectation for the patient's cardiac rhythm to be monitored and addressed when necessary.

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, staff interview and review of Medical Staff Bylaws it was determined the medical staff failed to ensure medical staff were held accountable for their conduct for one (#2) of four patients sampled.

Findings included:

Review of the Medical Staff Bylaws, section 2.2 Purpose and Responsibilities; the purpose and responsibilities of the Medical Staff are: 2.2.1 to provide a formal organizational structure through which the Medical Staff shall carry out their responsibilities and govern the professional activities of its members...; 2.2.2 to provide patients with the quality of care that is commensurate with acceptable standards and available community resources; 2.2.3 to collaborate with the Hospital in providing for the uniform performance of patient care processes throughout the Hospital; and 2.2.4 Medical Staff serve as a primary means for accountability to the Board concerning professional performance of Practitioners and others with clinical privileges authorized to practice at the hospital with regard to the quality and appropriateness of health care.

Review of the record for patient #2 revealed the patient arrived to the facility via EMS (Emergency Medical Services) and was admitted to the ED (Emergency Department) on 3/4/2019 at 8:00 a.m. The patient's complaint was worsening dyspnea (shortness of breath) with onset of the night before (3/3/19). Review of the physician assessment revealed the ED physician evaluated the patient immediately upon arrival at 8:02 a.m. The patient reported his SOB (Shortness of Breath) began last night and he experienced a syncope (fainting) episode. He reported his SOB continued this morning and had rapidly worsened. Physician documentation stated EMS personnel reported the patient's BP (Blood Pressure) of 72 (not within normal limits - low systolic pressure) and heart rate in the 120's (normal limits 60-100). EMS reported upon arrival to the scene the patient was found to be on all fours trying to catch his breath. The physician noted the patient was a [AGE] year old male with no significant respiratory history. The physician noted the patient had an Achilles cast in place that was placed 1 week ago for a torn Achilles.

Review of the ED documentation revealed laboratory and radiographic imaging was completed timely. CT scan of the chest was completed at 8:20 a.m., and revealed extensive bilateral pulmonary emboli (blockage in the arterial or venous blood flow) with two saddle emboli (refers to a large pulmonary embolism that straddles the bifurcation of the pulmonary trunk, extending into the left and right pulmonary arteries) and right upper lobe/perihilar/peribronchial consolidation, suspicious for pulmonary infarct given the extensive pulmonary emboli. Review of the ED documentation revealed the patient was administered medication to treat his presenting systems timely. Documentation revealed admission for intervention and treatment was initiated at 9:07 a.m., by the ED physician.

Review of the physician's surgical procedure note and interventional radiology (IR) notes revealed the patient was brought to the room and prepped for pulmonary angiogram and placement of bilateral infusion catheters for pulmonary embolectomy. Consent was signed by the patient prior to the procedure. Review of the IR procedure notes revealed the physician entered the room at 10:35 a.m., and the procedure time-out was called at 10:35 am. Documentation revealed the patient went into cardiac/respiratory arrest at 10:37 a.m., at which time the patient was treated and resuscitated. Documentation revealed the procedure continued and the physician inserted the first catheter to the right common femoral vein and advanced it into the left and then right pulmonary arteries where a bolus of 4 mg (milligrams) of TPA (tissue plasminogen activator: a protein involved in the breakdown of blood clots) was injected into the right and left pulmonary arteries. Next, an infusion catheter was exchanged and left in place. A second infusion catheter was then placed across the left main [DIAGNOSES REDACTED]. The two infusion catheters were secured to the skin at the right groin.

Review of the Interventional Radiologist's documentation revealed chemical thrombectomy of the main and bilateral [DIAGNOSES REDACTED]'s using bolus of TPA as well as placement of infusion catheters with 0.5 mg/hour of tPA running through each catheter for at least 12 hours as well as 500 milligrams per hour of Heparin through the right common femoral sheath. The physician documented the patient would be assessed in approximately 12-24 hours for removal of the infusion catheters.

Review of the discharge summary revealed on 3/4/2019 at 7:08 p.m., the patient experienced cardiac arrest. Documentation stated ACLS (Advanced Cardiac Life Support) was immediately implemented. Physician documentation stated ACLS continued until the patient's time of death was called at 7:50 pm.

Review of the physician's orders revealed a verbal order was entered by nursing on 3/4/2019 at 1:19 p.m. The order read Heparin 500 ml (milliliters) per hr (hour), do not titrate. Documentation revealed the Heparin was premixed at a concentration of 25,000 units per 500 ml and was dispensed in a 500 ml bag. Documentation revealed the order was verbally read back and verified by the nurse. Review of the medication order revealed the ordering physician was the Interventional Radiologist that performed the procedure. Review of the medication order revealed the order was unsigned by the physician. Interview with the Director of Quality and Patient Safety at the time of the medical record review on 5/15/2019 at 9:45 a.m., stated the ordering physician refused to sign the verbal order entered into the patient's record and the IR stated to the Director of Quality and Patient Safety that is not what I ordered.

An interview was conducted with the Director of Quality and Patient Safety on 5/15/2019 at 9:45 a.m. She stated when the Interventional Radiologist was interviewed she stated that it was her intention to infuse the Heparin at 500 units per hour and not 500 milliliters per hour. The Director of Quality and Patient Safety stated while the patient was in the procedure room a verbal order was given to the nurse for Heparin 500 per hour. The nurse verbally repeated the order back to the physician to confirm the dosage of Heparin 500 per hour at which time the physician verified the verbal order. The Director of Quality and Patient Safety confirmed no one stated the order was in units. The nurse initiated the Heparin and the patient was transported to the CVICU. The Director of Quality and Patient Safety stated the nurse in CVICU (Cardio Vascular Intensive Care Unit) and the primary care physician also confirmed the dosage for Heparin with the ordering physician. Review of the record did not reveal evidence of the primary care physician or CVICU nurse verification of the order with the interventional radiologist.

Review of the facility's corrective action plan revealed education to all clinical nursing staff facility wide was completed for utilizing the chain of command when nursing staff needed resolution to clinical patient care or patient safety issues which included dosing concerns for high risk/high alert medications. Education also included a Heparin Administration Safety Alert provided to all nursing staff. Review of the education revealed nursing was to confirm/clarify Heparin infusion rates in units, second independent nurse check at the time of administration or rate change, and no verbal orders are to be accepted for any high risk drugs unless it is an emergent situations where immediate electronic communication is not feasible. Review of the corrective action plan revealed no evidence education was provided to the medical staff regarding the same acceptable standards of care and quality of care for patient safety. Interview with the Director of Quality and Patient Safety on 5/15/2019 at 9:45 am confirmed the findings.

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review and interviews it was determined the registered nurse failed to supervise and evaluate care to ensure care was provided according to physician orders for three (#6, #7, #10) of 10 patient records sampled.

Findings included:

1. Patient #6 was admitted on [DATE]. Physician admission orders ordered telemetry. The patient was transferred from the emergency department to the nursing unit at 3:49 p.m. The documentation revealed the order for telemetry was acknowledged by the nurse at 4:10 p.m. No documentation was found indicating when the telemetry was initiated.

An interview with the director of the nursing unit on 05/03/2016 at 1:00 p.m. revealed a telemetry strip should have been ran and placed on the patient's chart on initiation of telemetry.

2. Patient #7 was admitted on [DATE]. Physician orders at 9:30 p.m. revealed an order for telemetry. The order was acknowledged by the nurse at 10:11 p.m. The documentation revealed the initiating telemetry strip was at 1:00 a.m. on 04/27/2016. No documentation was found indicating when the telemetry was initiated.

An interview with the director of the nursing unit on 05/03/2016 at 1:00 p.m. revealed a telemetry strip should have been ran and placed on patient's chart on initiation of telemetry.

3. Patient #10 was admitted on [DATE]. The review revealed admission orders to notify the physician if the oxygen saturation was less than 92 percent. A review of the nursing documentation revealed the patient's oxygen saturation was documented at 91 percent at 12:53 a.m. There was no documentation the patient care technician communicated the oxygen saturation level to the nurse. There was no nursing documentation showing the nurse was aware or physician notified of the 91 percent oxygen saturation level. There was no documentation of any nursing interventions. A physician order dated 04/28/2016 for incentive spirometry every one hour was documented on the physician orders The incentive spirometry was documented by respiratory therapy on April 30th and May 1st . There was no other documentation confirming every 1 hour incentive spirometry.

An interview with the director of the nursing unit and the director of risk management on 05/03/2016 at 9:50 a.m. confirmed there was no evidence of incentive spirometry, except as noted by respiratory therapy on 04/30/2016 and May 01/2016 was performed.

Show Text of Violation

Based on document review and staff interview it was determined the facility failed to implement corrective action related to identified problems by Health Information Management (HIM) for tracking of verbal and phone orders. This practice does not ensure identified problems are corrected.

Findings include:

Review of the quality indicators for the HIM department revealed monitoring of telephone and verbal orders for authentication within 48 hours, dating and timing. The goal of 90% compliance was set for the indicator. Overall compliance was consistently less than 50 % with trending downward since July, 2011, when overall compliance was 44 %.

The Director of HIM was interviewed on 3/2/11 at approximately 9:00 a.m. She indicated that the data was reported into the Utilization Review Committee meeting. Review of those minutes revealed no discussion of the data and no development and implementation of an action plan to address the low compliance.

The Interim Chief Nursing Officer provided information of the data provided to the Medical Executive Committee and Governing Body that indicated telephone and verbal orders compliance was 84.49%. The Director of HIM was asked to explain the discrepancy in the reports. She indicated the information given to the Medical Executive Committee and Governing Body was data collected by nursing regarding documenting the required read back by nursing when taking a verbal or phone order. She could provide no documentation of the HIM data being reported to the governing body. The only documentation of communication with the Governing Body was noted in the October 26, 2011 meeting minutes, which noted It was noted that a major issue with the Medical Staff is the timing, dating of their signature. It was noted that another issue was the authentication of verbal or telephone orders that has not been authenticated within 48 hours. There was no discussion of a plan of action to address the issue. The Chief Executive Officer (CEO) presented a copy of the news letter to hospital staff in November 2011 that included a message from the CEO that showed a report regarding the most recent survey by an accreditation organization. He listed the opportunities identified by the organization, which included the dating and timing of medical records entries and authentication of verbal and phone orders. Again, there was no documentation of a plan of action.

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Based on document review and staff interview it was determined the facility failed to implement corrective action related to identified problems by Health Information Management (HIM) for tracking of verbal and phone orders. This practice does not ensure identified problems are corrected.

Findings include:

Review of the quality indicators for the HIM department revealed monitoring of telephone and verbal orders for authentication within 48 hours, dating and timing. The goal of 90% compliance was set for the indicator. Overall compliance was consistently less than 50 % with trending downward since July, 2011, when overall compliance was 44 %.

The Director of HIM was interviewed on 3/2/11 at approximately 9:00 a.m. She indicated that the data was reported into the Utilization Review Committee meeting. Review of those minutes revealed no discussion of the data and no development and implementation of an action plan to address the low compliance.

The Interim Chief Nursing Officer provided information of the data provided to the Medical Executive Committee and Governing Body that indicated telephone and verbal orders compliance was 84.49%. The Director of HIM was asked to explain the discrepancy in the reports. She indicated the information given to the Medical Executive Committee and Governing Body was data collected by nursing regarding documenting the required read back by nursing when taking a verbal or phone order. She could provide no documentation of the HIM data being reported to the governing body. The only documentation of communication with the Governing Body was noted in the October 26, 2011 meeting minutes, which noted It was noted that a major issue with the Medical Staff is the timing, dating of their signature. It was noted that another issue was the authentication of verbal or telephone orders that has not been authenticated within 48 hours. There was no discussion of a plan of action to address the issue. The Chief Executive Officer (CEO) presented a copy of the news letter to hospital staff in November 2011 that included a message from the CEO that showed a report regarding the most recent survey by an accreditation organization. He listed the opportunities identified by the organization, which included the dating and timing of medical records entries and authentication of verbal and phone orders. Again, there was no documentation of a plan of action.

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Based on review of (5) physician credentialing files, interview of the Chief of Staff and interview of medical records staff and credentialing staff the hospital failed to provide for quality appraisals for reappointment. This practice does not ensure safe quality care is delivered to patients.

Findings Include:

1. Five of the (5) physician files reviewed, with the Medical Staff Coordinator and Credentialing staff, on 3/2/12 at 9:30 a.m. did not contain evidence of data or performance reviews for the reappointment.

Interview of the credentialing staff revealed the information was kept at the corporate office, if present. The surveyor asked that quality, performance reviews that was conducted for the reappointments be made available. Three of the five physician reappointment profiles were presented for review. None of the three profiles reviewed were evident of the number of records reviewed or percentage of cases and expected outcomes for performance.

2. Physician #1 was reappointed November 2010 for a two year period. A review of the credentialing and additional information for performance reviews was conducted. Information on the March 2012 reappointment profile contained the physician had 1 under behavior. The credential staff stated that was for a 1 time/incident were the physician wrote orders while suspended from writing orders.

Patients #34, #35, and #36's medical records contain 9 orders written by physician #1, while on administrative suspension.

Interview of the medical records staff on 3/2/12 revealed the physician was placed on suspension 8/30/11 and remains on suspension for incomplete medical records.

3. Physician #2 was originally appointed 12/10 for a period of one year. There was no reappointment checklist or performance review evident. Information presented by medical records revealed that the physician was suspended for incomplete medical records on August 30, 2011 until January 12, 2012.

Patients #37 and #38's physician orders reveal the physician gave orders during December 2011, while on suspension.

4. Physician #3 was reappointed on February 2011 for a two year period. No quality data or performance was present in file or available. The medical records staff presented that the physician had been on suspension for incomplete medical records since 12/19/2011. The physician file and reappointment profile did not contain any information regarding numbers of records for the physician reappointment.

A review of the medical staff by-laws, 2012, for suspension stated that the suspended physician would not be allowed to admit, round, order, write progress notes, or consult. The exception was for patients that were being attended or consulted for by the physician at the time the suspension was placed.

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record review and staff interview it was determined registered nurse (RN) failed to supervise the nursing care to ensure the care was in accordance with physician's orders for 2 (#4, #13) of 38 sampled patients. This practice does not ensure patient goals are met and may lengthen a hospital stay.

Findings Include:

1. Patient #4's history and physical revealed the patient was admitted to the facility on [DATE] with a positive blood culture and bacteremia.

Review of physician's admission orders dated 2/27/12 at 10:00 a.m. revealed an order for a urine culture that day before antibiotics. The order included Vancomycin intravenously (IV), give dose STAT after blood cultures are drawn. The nurse noted the orders had been faxed 2/27/12 at 1:20 p.m., approximately three and half hours later.

Review of laboratory entry and results revealed the blood cultures were collected 2/27/12 at 1:55 p.m. The urine culture were collected 2/28/12 at 9:00 a.m.

Review of the medication administration record (MAR) revealed Vancomycin was profiled by the pharmacy on 2/27/12 at 1:22 p.m. Nursing documented Vancomycin was administered on 2/27/12 at 3:22 p.m., which was more than 5 hours after the physician's STAT order was written and 23 hours before the urine culture was collected.

Interviews were conducted on 3/2/12 at 3:01 p.m. with staff RN #1. The interview revealed when a STAT order was received, it should be carried out immediately. An interview at 3::15 p.m. with RN #2 revealed a STAT order means to do it now. An interview at 3:25 p.m. with RN #3 revealed a STAT order should be called to the pharmacy and the laboratory to let them know that the order was STAT.

The Director of the Progressive Care Unit and the Quality Management Coordinator confirmed there was a order for a urine culture to be completed on 2/27/12 and Vancomycin to be given STAT. They also confirmed nursing did not follow the physician's order and the antibiotic should not have been given prior to collecting the urine culture. The Assistant Chief Nursing Officer confirmed that STAT on a physician's order means it should be done right away.

2. Patient #13's physician signed and dated an order protocol for Intravenous (IV) Access/Maintenance/

Flushing Orders. It was not specific to the patient. The order contained multiple selections for the physician to mark for the order. None were selected for Type of Catheter, Reason for Insertion, Reason for Femoral Insertion, Medications, Flush selections ranged from 3 to 10 milliliters (ml).

Interview with the charge nurse on 3/1/12 at 2:00 p.m. revealed that the order sets usually are checked specific to the type of IV line, medications and flushes for each patient.

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Based on record review and staff interview it was determined the facility failed to ensure that orders for medications are only accepted from physicians authorized to provide them for 2 (#34, #38) of 38 sampled patients. This practice does not ensure safe administration of medications.

Findings Include:

1. Review of patient #34's medical record revealed on 12/31/11 at 7:43 p.m. a physician's telephone order was received from physician #1 for 20 milli equivalents (meq) of potassium by mouth now and 20 meq by mouth in the morning. Physician's order dated 12/31/11 at 3:20 p.m. instructed for Ambien 5 milligram (mg) at bedtime as needed, discontinue intravenous fluids, and Lisinopril 10 mg orally for systolic blood pressure greater than 170 daily. Review of the pharmacy order entry of the medications revealed the medication orders had been entered under another physician and not the ordering physician.

2. Review of patient# 38 medical record revealed on 12/30/11 at 6:00 p.m. a physician's order from physician #2 for Librium 50 mg by mouth every 6 hours, hold for sedation and Procardia XL 60 mg by mouth daily, change Lisinopril to 40 mg by mouth two times a day, change Lopressor to 25 mg twice a day, and clonidine 0.1 mg three times a day. Review of the pharmacy order entry of the medications revealed the medication orders had been entered under another physician and not the ordering physician.

An interview conducted on 3/2/12 at approximately 6:00 p.m. with the pharmacist revealed physician's orders for medications are scanned to pharmacy from all units of the hospital. The pharmacist checks the order and enters the medications into the patient's medication profile. He indicated the pharmacist would have a list of suspended physician's in the pharmacy that would be used to verify the physician was not suspended and the orders could be entered into the computer. He indicated a memo was sent from medical records every day to all units to notify staff of physician's who have suspended privileges and are not allowed to write orders for patients. He indicated the memo was usually on the bulletin board, but it could not be found at the time of the interview. The pharmacist indicated there was no stop in the pharmacy order entry software that would prevent a medication ordered by a suspended physician from being entered into a patient's medication profile.

The Director of Pharmacy and the Chief Operating Officer confirmed the orders were not entered under the ordering physician. They also confirmed it was the pharmacist entering the medication orders responsibility to confirm the ordering physician was not on the medical records suspension list that was distributed daily to all departments. There was no explanation of how or why the orders were entered under another physician's name.

3. Interview with the Director of Health Information Management on 3/2/12 at approximately 9:00 a.m. revealed that physicians #1 and #2 were under suspension when the orders were written and were not authorized to write or give verbal or phone orders.

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Based on observation, interview with dietary staff, and review of cleaning schedules, the facility failed to ensure that the main kitchen was maintained in sanitary order to prevent transmission of food borne illness, and physical contamination.

Findings include:

During a tour of the main kitchen, on 02/29/12 beginning at 10:00 a.m. , with the Director of Food Service, the following was noted:

+ Along the bottom edge of the right side of the ventilation hood, drips were noted at an interval of an inch or two. When the edge was wiped with a paper towel, the drips appeared to be grease. The grease collection container, located in the back right side of the hood, was noted to be full of liquid grease. The Director of Food Service reported, at that time, that the hood and grease trap were to be cleaned weekly on Sundays, but someone must had missed cleaning it.

+ The tray return/conveyor track leaving the clean side of the dish machine was noted, on 02/29/12 at 1:40 p.m. . to have food (penne pasta) and an unknown substance on the rack. The unknown substance was slippery feeling and looked like small clumps of oatmeal .

+ Several ceiling tiles throughout the kitchen, including ceiling vents and lattice coverings over vents, were noted to be coated with a dust like debris, indicating air flow.

+ The wall behind the slicer was noted to be splattered with bits of an orange substance, that was hard and dried onto the wall.

+ A tall open metal cart located in the cold reach in, holding meals for same day surgery, was noted to be soiled with a beige crusty substance on the horizontal and vertical supports. A tall open metal cart located in the heated reach in, was noted to be soiled with a beige crusty substance on the horizontal and vertical supports.

+ Clean wet steam table pans were noted to be stacked together on a drying storage rack, located across from the 3-compartment sink. The drying storage rack was noted to be encrusted with beige debris and a dust like substance. The steam table pans were noted to have standing water in the lips of the pans and were wet inside and out.

+ The Robot-Coupe was pushed against the back wall of the cook's prep table and the lid was on and secured. Upon request the robot coupe was opened and noted to be wet inside. The staff member reported that the equipment had been used for lunch service and cleaned for later use. He confirmed that the inside was wet and the lid should not have been secured as the inside would not have air dried.

+ The Dairy walk in shelving was noted to have dried white and black debris in the corners on the shelving.

+ The lattice fan cover in the produce walk in was noted to be wet with a black substance caught in the lattice work.

+ In the walk in freezer two bags of a battered food were noted to be open to the air. A bag of frozen vegetables was noted to be ripped, exposing the vegetables to the air.

+ The inside of the door to the ice machine was noted to have a thin black coating of a substance.

+ Extension cords hanging down from the ceiling, coiled and secured to be hanging 3-4 feet from the ceiling, were noted to be dusty.

Interview with the Food Service Director on 03/02/12 at 10:30 a.m. revealed that cleaning assignments were in place specific for job assignments and for bigger cleaning (ceilings, equipment) the department had a cleaner three times a week. She reported that the assignment for this cleaner was based on a walk through sanitation checklist and was not a formal assignment that would be written and signed off.

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility documentation, policy, procedure and clinical records and staff interviews it was determined the risk manager failed to investigate and analyze the cause of specific types of adverse incidents for three (#1, #3, #7) of five sampled records. This practice does not allow for tracking and trending of specific adverse incidents to promote patient safety and improved care.

Findings include:

1. Patient #1 was admitted on [DATE] from the Emergency Department (ED). Review of the ED record did not show a history of seizures. Review of the physician History and Physical revealed no history of seizures. The patient was admitted to the Progressive Care Unit (PCU) on 11/5/11 at 9:40 p.m. Review of Licensed Practical Nurse (LPN) documentation dated 11/6/11 at 1:08 a.m. revealed the patient complained of limited range of motion with pain to both arms. The documentation noted the patient had a seizure yesterday that was unwitnessed.

There was no documentation of where the unwitnessed seizure had occurred, the patient being placed on seizure precautions or the physician being notified of the allegation of an unwitnessed seizure or bilateral decreased range of motion to the arms.

Interview on 12/22/11 at approximately 2:30 p.m. with Registered Nurse (RN) on Neuroscience Unit revealed when a patient is admitted to the unit with a history of seizures, they are placed on seizure precautions, which would include padded side rails.

On 11/7/11 at 4:10 a.m. a rapid response was called. Review of the Rapid Response Team documentation indicated the patient was found unresponsive. Review of the neurology consult dated 11/7/11 at 8:05 a.m. revealed the impression was a probable seizure.

Nursing documentation revealed the pain in both arms was reported to the Advanced Registered Nurse Practitioner (ARNP) on 11/9/11 at 9:05 a.m. An orthopedic consult was completed on 11/10/11 at 11:03 a.m. It was discovered the patient had bilateral fractures of right and left shoulders. The consult indicated the fractures were presumed to be caused by the unwitnessed seizure on 11/7/11.

Interview on 12/22/11 at approximately 2:00 p.m. with the PCU Nurse Manager and the Risk Manager confirmed there was no documentation in the medical record related to the unwitnessed seizure while the patient was in PCU or seizure precautions being implemented after the patient had stated she had an unwitnessed seizure the day prior. The interviews revealed no further investigation was completed since the physician indicated the fractures were presumed to be from an unwitnessed seizure. The review by the facility did not show evidence of the investigation as to why the information from 1/6/11 was not reported to the physician, the lack of documentation of the unwitnessed seizure by the nursing staff or other possibilities for the bilateral shoulder fractures.

2. Patient #7 was admitted on [DATE]. The physician's History and Physical dated 10/12/11 revealed a history of recurrent falls. She was placed with a 1:1 sitter in the Neuroscience Unit.

Interview with the Risk Manager on 12/22/11 at 11:30 a.m. revealed on 10/13/11, exact time unknown, the patient was in the Neuroscience Unit with a 1:1 sitter. The patient was swinging her arms at staff. The sitter grabbed the patient's arms. The Nursing Supervisor went into the patient's room and talked with the patient. The patient stated she broke my arm and pointed to the sitter.

A physician's order dated 10/13/11, no time, ordered an x-ray of the left forearm and wrist. The x-ray was completed on 10/14/11 at 10:28 a.m. The result showed a fracture of the distal ulna.

Interview on 12/22/11 at approximately 11:30 a.m. with Risk Manager revealed security responded to a code gray in the patient's room on 10/14/11 at 12:10 p.m. (the day after the alleged wrist fracture being caused by the sitter and the physician's order for the x-ray).The patient was combative and uncooperative. The interview revealed she threw herself to the floor. She was kicking and swinging her arms.

Review of the medical record revealed physician's order for a right shoulder and elbow x-ray dated 10/13/11 at 6:45 p.m. and was completed at 10:55 p.m.. Radiology report dated 10/14/11 at 10:48 a.m. revealed no fractures.

A phone interview was conducted on 12/22/11 with the attending physician at approximately 9:30 a.m. She stated I documented in the progress note patient was walking in hallway and threw herself to floor. I do not remember who informed me of this event. She also stated It happened in the evening, so I was not in hospital. The physician indicated she believed the wrist fracture occurred when the patient fell in the hallway.

Review of the Discharge Summary dictated on 10/16/11 noted the patient sustained a wrist fracture after falling in the hallway.

The interview with the Risk Manager on 12/22/11 at approximately 11:30 a.m. revealed there was no investigation concerning the contradicting information between the physician and medical record documentation on how and when the fracture occurred .

3. Patient #3's triage record revealed the patient presented via ambulance from a Skilled Nursing Facility (SNF) on 11/12/11 at 3:26 p.m. with a chief complaint of a right leg Deep Vein Thrombosis (DVT). The documentation noted the patient was oriented to person only with a history of dementia. Review of ED nursing initial assessment documentation at 3:28 p.m. revealed the patient was oriented to person only and with a history of dementia. The documentation showed the skin was within normal parameters. ED nursing notes at 7:30 p.m. indicated the patient was found on the floor. There were no reports of injuries.

Review of the medical surgical unit nursing documentation noted the patient arrived from the ED on 11/12/11 at 10:52 p.m. Review of the initial assessment dated [DATE] at 11:12 p.m. revealed the skin assessment was Within Normal Parameters (WNP) and the patient did not have a urinary catheter. Nursing documentation dated 11/13/11 at 6:10 a.m. noted a bath was given. Documentation at 6:24 a.m. showed the adult brief was changed and peri care provided. Shift evaluation dated 11/13/11 at 8:01 a.m. revealed the skin was not WNP. The documentation noted redness on the coccyx. Nursing shift evaluation dated 11/13/11 at 9:22 p.m. noted the skin was not WNP. The area noted was described as redness on the coccyx. The wound bed was red and the surrounding tissue was pink. The patient used adult brief for toileting. Nursing documentation dated 11/14/11 at 6:16 a.m. noted a complete bath was given. Shift evaluation dated 11/14/11 at 8:00 a.m. revealed the skin was not WNP. The documentation noted redness on the coccyx. Nursing documentation showed the patient was discharged on [DATE] at 2:39 p.m. to the SNF.

Hand written on the computer form dated 11/13/11 was a late entry dated 11/18/11 at 12:10 p.m. by a registered nurse that stated at 2:00 p.m. the nurse went into change the adult brief and noted a small pencil width two inch bruise in the peri anal area. No other skin discoloration noted after assessing the vaginal and upper thigh area. Hand written on the computer form dated 11/12/11 was a late entry dated 11/17/11 at 3:55 p.m. by a different registered nurse that noted a hematoma located in the rear peri area and both legs. The area was not opened, the wound bed was purple and the surrounding tissue was pink.

Review of the physician ' s History and Physical revealed no evidence of bruising. Physician progress notes dated 11/13-11/14/11 revealed no evidence of the peri area bruising .

Review of the discharge summary dictated 12/6/11 revealed no mention of the bruising in the peri area.

Interview with the wound care nurse on 12/22/11 at approximately 10:50 a.m. and review of the wound care referral form dated 11/13/11 at 11:31 p.m. revealed a request for the skin care person to visit. There was no reason documented for the wound care referral. Wound care nurse referral form dated 11/14/11 at 10:57 a.m. noted a request for the wound care nurse to visit for a red bottom and bruising on the peri area. The interview revealed she received the referral via computer at approximately 11:00 a.m. while making her wound care rounds. She stated when she actually viewed the referral the patient had already been discharged . The patient was never seen by a wound care nurse.

Review of the transfer out form dated 11/12/11 from the SNF revealed no evidence of bruising or a urinary catheter prior to transfer from the SNF to the ED

Interview with a Licensed Practical Nurse (LPN) on 3 East on 12/22/11 at approximately 10:15 a.m. revealed given a scenario of bruising in the peri area the LPN would document the findings, take pictures, and notify the resource nurse, unit charge nurse, and physician.

Interview with the 3 East unit manager on 12/22/11 at approximately 10:25 noted pictures would be taken of bruising in the peri area. She did not recall if pictures were taken of the patient. The interview revealed the findings must be documented when found. The interview revealed the facility thought the bruises were related to the fall in the ED.

Interview with one of the nurses who wrote the late entry on 12/22/11 at approximately 9:00 a.m. revealed she just forgot to document the findings of the bruises in the peri area.

Review of facility documentation dated 11/17/11 at 2:27 p.m. revealed a patient complaint was received from a family member on 11/15/11. The family member stated the SNF informed her that the patient had bruising in the outer vaginal area and inner thigh. The documentation noted the patient had fallen in the ED on 11/12/11. There was no documentation of the bruising in the nursing assessments. The documentation noted when asked all staff remembered the bruising.

Interview with the Vice President (VP) of Quality and Risk and the Assistant Chief Nursing Officer on 12/21/11 at approximately 4:00 p.m. revealed on 11/15/11 a call was received from the family member. She told her the SNF informed her that the patient had bruising in the groin area. The Sheriff department requested information from the facility on 11/15/11. The interview revealed the Unit Director had done a chart review. Late entries were made. The interview revealed the abuse registry was called by the hospital on [DATE]. The risk manager delayed in calling the abuse registry until the investigation was done. The interview noted the SNF facility thought the bruising was due to a urinary catheter from the hospital. There was no documentation of bruising in the record or of a urinary catheter being used.

The interview revealed there was no documentation of how the patient was when she was found on the floor in the ED. The interview with the VP of Quality and Risk confirmed there were discrepancies between the two late entries' documentation by the registered nurses, the physician was not notified of the bruising nor were pictures taken of the bruising.

Review of policy and procedure Victims of Domestic Violence/Abuse/Neglect #NPE-06 dated 6/10 indicated under Checklist-Recognition of Abuse under the heading of sexual abuse signs included bruises in the perineal area.

The clinical record, facility documentation and interviews revealed the bruises were noted on 11/13/11 by at least two registered nurses. The patient had been assessed on each shift evaluation, had baths and adult brief changes, and was seen by the physician service from 11/12/11 to 11/14/11 with no documentation of bruises in the peri area. The late entry had conflicting descriptions that were written three and four days after discharge. The patient was discharged before the wound care nurse could perform her assessment of the findings on 11/14/11. A call was received from a family member on 11/15/11 that the receiving SNF informed her bruises were found near the vaginal area, facility documentation was not written until 11/17/11. The abuse registry was not notified until 11/17/11. There was no evidence of an investigation or results of the chart review that was conducted or the rationale in the delay of investugating or reporting to rule out potential abuse.

There was no evidence of the facility analyzing adverse patient events and other aspects of performance that assess processes of care for three of three patients reviewed with an adverse event.