CMS-North-Suburban-Medical-Center

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Based on observations, interviews and document review, the facility failed to employ methods to prevent and control the transmission of COVID-19 within the facility. Specifically, the facility did not ensure healthcare personnel (HCP) who were symptomatic for COVID-19 were excluded from work according to Centers for Disease Control (CDC) guidelines, public health orders (PHO) and facility policy, in order to prevent the transmission of COVID-19.

Findings include:

Facility policies and professional references in managing COVID-19:

1. The Employee Exposure and Return to Work Guidance During COVID-19 Response policy read, Any employee who is exposed to, has symptoms consistent with, or is positive for COVID-19 should immediately be evaluated to stay out of work and/or return to work using the approved healthcare guidance. The facility endorses the symptom-based strategy for assessing return to work for employees with symptoms of or confirmed COVID-19. The algorithm in Appendix 2 should be followed after an employee is out of work due to being COVID-19 symptomatic or found to be COVID-19 positive via test (symptomatic or asymptomatic).

Appendix 2 contained an algorithm titled Employee Return to Work Guidance for COVID-19: Symptom-Based Guidance for Symptomatic or Confirmed COVID-19 Employee. Employee reports/ screens with respiratory symptoms and/or fever greater than or equal to 101.4 and/or other known COVID-19 symptoms (i.e. loss of taste or smell, body aches, etc.) OR employee has confirmed positive COVID-19 test. Stay at or return home and self isolate. On day 10, evaluate for Return to Work Criteria: 10 days have passed since start of symptoms AND no fever for at least 24 hours without use of antipyretics AND improving symptoms. If all criteria met, work with employee health for return to work plan. If all criteria not met, repeat daily until all criteria met.

The CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 12/14/20, read, Properly manage anyone with suspected or confirmed SARS-CoV-2 (COVID-19) infection or who has had contact with someone with suspected or confirmed SARS-CoV-2 infection. Healthcare personnel (HCP) should be excluded from work and should notify occupational health services to arrange for further evaluation. For HCP, the potential for exposure to SARS-CoV-2 is not limited to direct patient care interactions. Transmission can also occur through unprotected exposures to asymptomatic or pre-symptomatic co-workers in breakrooms or co-workers or visitors in other common areas.

The CDC Criteria for Return to Work for Healthcare Personnel with SARS-CoV-2 Infection, updated 8/10/20 read, Symptom-based strategy for determining when HCP can return to work. HCP with mild to moderate illness who are not severely immunocompromised: At least 10 days have passed since symptoms first appeared and at least 24 hours have passed since last fever without the use of fever-reducing medications and symptoms (e.g., cough, shortness of breath) have improved.

In some instances, a test-based strategy could be considered to allow HCP to return to work earlier than if the symptom-based strategy were used. However, as described in the Decision Memo, many individuals will have prolonged viral shedding, limiting the utility of this approach. The criteria for the test-based strategy are HCP who are symptomatic: Resolution of fever without the use of fever-reducing medications and improvement in symptoms (e.g., cough, shortness of breath), and results are negative from at least two consecutive respiratory specimens collected at least 24 hours apart (total of two negative specimens) tested using an FDA-authorized molecular viral assay to detect SARS-CoV-2 RNA.

The CDC Interim U.S. Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to COVID-19, updated 12/14/20 read, Because of their often extensive and close contact with vulnerable individuals in healthcare settings, a conservative approach to HCP monitoring and work restrictions is recommended to prevent transmission from potentially contagious HCP to patients, other HCP and visitors.

The CDC Symptoms of Coronavirus, updated 12/22/20 read, people with COVID-19 have had a wide range of symptoms reported, ranging from mild symptoms to severe illness. People with these symptoms may have COVID-19: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea.

The Fourth Amended Public Health Order 20-36, updated 1/4/2021 read, Individuals who are sick or are experiencing flu-like symptoms should get tested for COVID-19. If an individual has tested positive for COVID-19 and/or has developed symptoms of COVID-19, including early or mild symptoms (such as cough and shortness of breath), they should be in isolation (staying away from others). In most cases, individuals are released from isolation when they are fever-free, without medication, for twenty-four (24) hours, other symptoms have improved, and at least ten (10) days have passed since symptoms first appeared. Disease Prevention Measures for Employees: Employers shall take all of the following measures regarding employees to minimize disease transmission: require employees to stay home when showing any symptoms or signs of sickness, which include fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and diarrhea.

The Ninth Amended Public Health Order 20-29, updated 1/12/2021, read Voluntary or Elective Surgeries and Procedures may be performed in hospitals, or any other setting where health care services are provided in accordance with the priorities, requirements, and specific criteria below. Exclude symptomatic employees from work activities according to the CDC ' s Criteria for Return to Work for Healthcare Personnel with SARS-CoV-2 Infection (Interim Guidance). In most cases, someone is released from isolation when they are fever-free, without medication, for 24-72 hours, other symptoms have improved and 10 days have passed since their first symptom.

1. The facility failed to ensure HCP who reported symptoms consistent with COVID-19 were excluded from work according to the CDC Return to Work criteria, PHO and facility policy, to prevent the spread of COVID-19.

a. According to the CDC Criteria for Return to Work for Healthcare Personnel with COVID-19 Infection, the symptom-based strategy for HCP to return to work included 10 days had passed since symptoms first appeared. The test-based strategy for HCP to return to work included negative results from at least two consecutive COVID-19 tests collected at least 24 hours apart.

According to PHO 20-29, symptomatic employees were to be excluded from work activities according to CDC Return to Work Guidance, which in most cases included when 10 days had passed since the employee's first symptom.

According to facility policy, the facility endorsed the symptom-based strategy for assessing return to work for employees with symptoms of or confirmed COVID-19.

b. The facility provided a line list, which was used by the facility Employee Health Nurse (Employee Health) #3 to monitor HCP who reported symptoms or tested positive for COVID-19.

i. Review of the line list revealed multiple instances in which HCP reported to work without fulfilling the CDC Return to Work criteria for HCP. Specifically, HCP were allowed to return to work on the basis of one negative test result, without observing either the symptom-based strategy which required 10 days from onset of symptoms, or test-based strategy which required two negative tests collected at least 24 hours apart. Examples included:

On 12/6/20 a HCP in environmental services (EVS) reported cough, congestion, low grade fever, headache and fatigue. The HCP was tested for COVID-19 with a single negative test result on 12/8/20. The HCP was allowed to return to work on 12/9/20, three days after the onset of symptoms.

On 12/18/20 a registered nurse (RN) on an inpatient unit reported symptoms of headache, fatigue, sore throat, runny nose and congestion. The RN was tested for COVID-19 with a single negative test result on 12/19/20. The RN was allowed to return to work on 12/21/20, three days after the onset of symptoms.

On 1/2/21 an RN in the Emergency Department reported symptoms of sore throat, congestion, chest heaviness and body aches. The RN was tested for COVID-19 with a single negative test result on 1/5/21. The RN was allowed to return to work on 1/8/21, six days after the onset of symptoms.

On 1/4/21 RN #1, who worked on the Intensive Care Unit (ICU) reported symptoms of headache, fatigue and sore throat. According to the line list, RN #1's spouse was positive for COVID-19. RN #1 was tested for COVID-19 with a single negative test and was allowed to return to work on 1/6/21, two days after the onset of symptoms.

c. Interviews with facility staff revealed HCP were allowed to return to work after they reported symptoms consistent with COVID-19 without fulfilling the CDC Return to Work criteria and the facility policy.

i. On 1/12/21 at 1:37 p.m., RN #1 was interviewed. RN #1 stated she communicated with Employee Health #2 when her husband tested positive for COVID-19. She stated she informed Employee Health #2 she went to an urgent care center for a rapid COVID-19 test. RN #1 stated she received a negative test result and was allowed to return to work three days later when she felt better.

RN #1 stated the symptoms she reported to Employee Health #2 were headache, sore throat and fatigue. She stated she attributed the symptoms to strep throat (a bacterial infection which causes sore or scratchy throat). However, RN #1 stated she was not tested or diagnosed for strep throat.

ii. On 1/12/21 at 4:24 p.m., Employee Health #2 was interviewed. Employee Health #2 stated she was responsible to oversee employee health for all HCP employed by the facility, and her role included to manage testing and return to work for staff who had COVID-19 or symptoms of COVID-19. Employee Health #2 stated the facility followed policies and standards provided by the facility's corporate system.

Employee Health #2 stated when a HCP reported symptoms, she would discuss the HCP's symptoms and potential exposure and would recommend the HCP be tested for COVID-19. She stated if a HCP's test results were negative, she would follow a return to work matrix for non-COVID-19 illness and allow the HCP to return to work when their symptoms improved. She stated this matrix was provided by the infection preventionist from another facility.

iii. The facility provided the Non-COVID Respiratory Viral Illness Matrix and Return to Work Guidelines for 2019-2020. According to the matrix, if a HCP had respiratory symptoms without fever, the HCP was allowed to return to work at least 24 hours after the start of signs or symptoms and when coughing, sneezing and nose blowing were less than four times per hour and would not interrupt patient care or work. HCP with respiratory symptoms and fever were allowed to return to work 6 days after the start of illness, when the HCP did not have fever for 24 hours, and coughing, sneezing and nose blowing were less than four times per hour.

The Non-COVID Respiratory Illness matrix did not align with the CDC Return to Work Guidance, which read HCP could return to work when 10 days had passed since the onset of symptoms, the HCP was fever-free for 24 hours without the use of fever-reducing medication, and the HCP's symptoms were improved.

Employee Health #2 stated the matrix was implemented and utilized prior to the beginning of the COVID-19 pandemic. She stated she did not know what guidelines were used to develop the matrix, or how it was determined the matrix remained appropriate to use during the COVID-19 pandemic.

Employee Health #2 stated any return-to-work protocols for HCP with symptoms of COVID-19 should be based on the CDC guidelines.

iv. On 1/13/21 at 3:32 p.m., Infection Preventionist #3 was interviewed. Infection Preventionist #3 stated one of her responsibilities was to provide guidance related to infection control to Employee Health #2. She stated her role in the facility's COVID-19 response was to ensure policies and procedures aligned with CDC guidelines and national standards for infection control.

Infection Preventionist #3 stated HCP reported any concerning symptoms for COVID-19 to Employee Health #2. She stated the HCP would then be tested for COVID-19, and if the HCP had a negative test result, they would return to work following the facility's normal return to work guidelines. She stated the facility's return to work guidance was developed through the facility's corporate system.

Infection Preventionist #3 stated the criteria outlined in the Non-COVID Respiratory Viral Illness matrix would apply to a HCP with a cold or influenza, and was implemented yearly during the respiratory illness season.

Infection Preventionist #3 stated the facility adhered to the CDC symptom-based strategy for HCP to return to work. However, she stated this was only utilized if a HCP was confirmed COVID-19 positive with a positive test result. She stated if a HCP reported symptoms of COVID-19, but had one negative test result and improved symptoms two days later, the HCP would return to work.

This was in contrast to the CDC return to work criteria for HCP, which read the symptom-based strategy for HCP to return to work required 10 days from the onset of symptoms, and the facility algorithm Employee Return to Work Guidance for COVID-19, which read for HCP who were symptomatic or positive for COVID-19 the HCP would isolate at home for 10 days before returning to work.

Violation Name: PATIENT RIGHTS(A-0115)

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Violation Name: PATIENT RIGHTS: CARE IN SAFE SETTING(A-0144)

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Based on observations, interviews, and document review, the facility failed to evaluate the number of patients telemetry technicians (tele techs) had to monitor and shift responsibilities of tele techs in order to ensure patients received care in a safe setting following a delay in care; specifically, one of one patient's (Patient #1's) continuous pulse oximeter remained off for approximately 47 minutes. The patient was unresponsive and expired shortly thereafter.

Findings include:

Facility policies:

The Centralized Telemetry Monitoring policy read, yellow alarms include a pulse oximetry probe off, a patient's oxygen level less than 86%, and the need for a battery change. In the situation where a pulse oximeter probe is off, the tele tech calls the assigned patient care technician (PCT) immediately and communicates the pulse oximetry probe is off. If unable to reach the PCT, the tele tech then immediately calls the registered nurse (RN). If unable to reach the RN, the tele tech then calls the charge nurse. In the event the tele tech is unable to reach the PCT, RN and the charge nurse within two minutes, the tele tech then escalates the concern to the nursing supervisor. Lastly, if unable to make contact with any of the staff members previously stated, the tele tech is to call a Clinical Assessment Team (CAT) response.

In the event contact has been made with staff but the pulse oximeter probe remains off, the tele tech re-contacts the staff member after five minutes from the initial call for an update. The tele tech repeats the escalation process previously stated as needed until there is a resolution.

The shift responsibilities of the tele tech include: ensuring alarms are on at all times, initiating telemetry monitoring by verifying patient information with the RN and validating waveforms; documenting communication with all nursing staff throughout the shift; printing, evaluating and delivering rhythm strips to appropriate units once a shift or PRN (as needed); notifying nursing staff of alarms for EKG and pulse oximetry readings; and documenting rhythm details on flow sheets every two hours.

The Pulse Oximetry policy read the purpose is to define guidelines and limitations of pulse oximetry to determine the need for oxygen in order to maintain a satisfactory oxygen saturation.

Reference:

According to the CDC, symptoms of the novel Coronavirus (COVID-19), a highly infectious disease, include but are not limited to cough, shortness of breath (SOB) or difficulty breathing, fever, chills, muscle aches, sore throat and the loss of taste and/or smell.

1. The facility failed to identify and evaluate the number of patients monitored by the tele tech along with the tele tech shift responsibilities as possible factors contributing to an incident involving Patient #1 and implement process changes to prevent a reoccurrence.

a. Patient #1's medical record was reviewed.

i. According to the Provider's Note on 5/22/20 at 5:45 p.m., Patient #1 had a history of chronic obstructive pulmonary disease (a chronic inflammatory lung disease which can cause obstructed airflow from the lungs), along with chronic respiratory failure. Patient #1 required four liters of oxygen prior to her hospital admission.

ii. According to the deceased Discharge Summary note written by the provider on 5/24/20 at 6:54 a.m., Patient #1 was requiring five to eight liters of supplemental oxygen during her hospital admission in order to maintain a pulse oximeter reading at or above 90%.

iii. On 5/23/20 at 6:22 p.m., Registered Nurse (RN #4) found Patient #1 with her pulse oximeter off and unresponsive. RN #4 initiated a code blue. On 5/23/20 at 7:09 p.m., Patient #1 expired.

b. A review of the telemetry communications log from 5/23/20 revealed the telemetry technician (tele tech #2) notified telemetry unit staff twice that Patient #1's pulse oximeter probe was off. The first notification from the tele tech to Patient #1's primary nurse, RN #4, was at 5:35 p.m. The second notification to RN #4 did not occur until 6:12 p.m. Tele tech #2 documented at 6:22 p.m. that a code blue was called for Patient #1.

c. A review of the telemetry monitoring room census for 5/23/20 revealed tele tech #2 was monitoring 47 patients on telemetry and/or continuous pulse oximeter monitors during her shift.

d. Interviews revealed the facility did not implement process changes following the incident involving Patient #1 in order to ensure the facility provided safe care to patients.

i. On 5/23/20 at 11:15 a.m., tele tech #2 was interviewed. Tele tech #2 stated there was only one telemetry monitoring technician scheduled for each shift. Tele tech #2 stated she typically monitored 40-60 patients on telemetry and/or pulse oximeter monitors and stated monitoring 50 patients was often difficult and hectic. Tele tech #2 stated since COVID-19, more patients had been on continuous pulse oximeter monitors. She stated the increase in patients on continuous pulse oximeter monitors had caused an increase in alarms due to pulse oximeter probes falling off patients.

The incident involving Patient #1 was reviewed with tele tech #2. Tele tech #2 confirmed that at the time of the event, she was monitoring 47 patients and there were several pulse oximeter probes off and alarming. Tele tech #2 stated when she initially spoke with RN #4 regarding Patient #1's pulse oximeter probe, RN #4 stated she would check on the patient soon. Tele tech #2 further explained, after the initial phone call with RN #4, she admitted two patients and had to print and evaluate telemetry monitoring strips for all the patients on telemetry monitors. Tele tech #2 said that due to these other tasks, she did not have time to escalate the call or to re-contact RN #4 within the five minute time period expected per the Centralized Telemetry Monitoring policy. Additionally, she stated she did not notify the charge nurse on duty about Patient #1's pulse oximeter probe remaining off because she had just spoken with the charge nurse and the charge nurse was addressing a different patient whose pulse oximeter probe was off.

Tele tech #2 stated she was not a part of the root cause analysis (RCA) meeting completed after the incident with Patient #1. She further stated she was not a part of any other additional review process. Tele tech #2 stated she received coaching to follow the Centralized Telemetry Monitoring policy and a telemetry technician meeting was held at which the policy was reviewed.

Tele tech #2 stated there had not been any changes implemented regarding tele tech staffing and tele tech job duties had remained unchanged.

ii. On 06/08/20 at 12:30 p.m., tele tech #14 was interviewed. Tele tech #14 stated the telemetry techs monitored anywhere from 30 to 50 patients at a time. Tele tech #14 stated when the number of patients monitored was in the high 40's to 50's, it was difficult to monitor patients effectively. She further stated when multiple patient monitors were alarming at the same time, it was difficult to prioritize the alarms. Tele tech #14 stated that due to the stressful environment, she often was afraid she was going to miss a lethal arrhythmia or oxygenation desaturation. Tele tech #14 stated monitoring 40 or more patients at a time can impact patient safety because when numerous alarms were alarming, it was easy to miss a change in a patient's rhythm or an oxygen desaturation.

Tele tech #14 stated she had recently brought up these concerns to the Director of Inpatient Services (Director #12). Tele tech #14 said she mentioned to Director #12 that monitoring 40 or more patients was difficult. Tele tech #14 stated, since that discussion with leadership, there had not been any staffing changes in the telemetry monitoring room or changes to tele tech shift responsibilities.

iii. On 06/08/20 at 11:58 a.m., charge nurse (RN #13) was interviewed. RN #13 stated her responsibility included providing support to the tele tech on duty and covering the telemetry monitoring room while the tele tech was on break. RN #13 stated it was difficult to monitor all the patients while covering the monitoring room, especially when two critical alarms were occurring at once. Additionally, RN #13 stated it was difficult to call two different nurses and appropriately communicate the status of the alarms when more than one patient was alarming.

iv. On 06/08/20 at 11:03 a.m., RN #15 was interviewed. RN #15 stated she worked on the telemetry floor and additionally worked in the telemetry monitoring room when there was not a tele tech scheduled to work the shift. RN #15 stated there had been a significant increase in the number of patients monitored on continuous pulse oximeter monitors since the COVID-19 pandemic began. RN #15 stated one of the tasks accomplished by tele techs was to print and evaluate telemetry rhythm strips. RN #15 stated strips were printed and evaluated twice a shift at 6 a.m. or 6 p.m. and 12 a.m. or 12 p.m.

RN #15 stated when she was covering the telemetry monitoring room and more than one critical alarm was sounding, she evaluated the alarms and called the RN responsible for the most lethal alarm first. RN #15 stated if there was a delay in notification to a RN regarding a patient, the patient could go into cardiac arrest, respiratory arrest or even die.

v. On 6/4/20 at 12:59 p.m., RN #4 was interviewed. RN #4 stated she primarily worked on the telemetry unit as a RN. RN #4 explained since the COVID-19 pandemic began, the telemetry unit admitted all COVID-19 rule out and COVID-19 positive acute care patients. RN #4 stated all COVID rule out patients and COVID positive patients were monitored on a continuous pulse oximeter in order to continuously monitor the patient's oxygenation needs.

vi. On 6/8/20 at 1:00 p.m., the Director of Inpatient Services (Director #12) was interviewed. Director #12 stated she had oversight of the acute care units, the telemetry monitoring unit, and the telemetry monitoring room. Director #12 confirmed only one tele tech was staffed per shift. She further stated one tele tech was able to monitor up to 50 patients at one time. Director #12 explained the ratio of 50 patients monitored by one tele tech had always been the facility's practice. Director #12 stated the staffing ratio had not been re-evaluated recently or after the events on 5/23/20, involving Patient #1. Director #12 stated she had not heard of incidents where the telemetry tech was too overwhelmed and could not effectively monitor patients and perform required tasks.

Director #12 stated if a tele tech was unable to complete expected tasks, that would raise a concern the tele tech would not be able to monitor patients effectively; the tele tech might miss a de-saturation or heart rate parameter. Director #12 stated she would expect tele techs to escalate to her or the leader on call if the tech had concerns with the number of patients she or he was monitoring or with completing assigned tasks. Director #12 stated the telemetry monitoring census had not been above 50 patients that she could recall.

e. A document provided by the facility on 6/8/20 revealed the telemetry monitor room census. It read, since 3/20/20, there were 17 shifts when the census was greater than 50 patients being monitored on telemetry and/or continuous pulse oximeter monitors.

f. Documentation in regard to the incident involving Patient #1 was requested from the facility. The facility was unable to provide evidence telemetry monitoring room staffing and tele tech shift responsibilities were reviewed as possible factors in Patient #1's pulse oximeter probe remaining off for 47 minutes. Furthermore, the facility failed to provide evidence that concerns brought to leadership about tele tech staffing due to the increased number of patients monitored since the start of the COVID-19 pandemic were considered and addressed.

Violation Name: QAPI(A-0263)

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Violation Name: PATIENT SAFETY(A-0286)

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

Based on interviews, document review and record review, the facility's quality management committee failed to analyze adverse patient events per facility policy in order to identify contributing factors and implement preventive actions in one of four medication events, two of eight delay in care events, and one of one sentinel events reviewed. Furthermore, the facility failed to perform tracking and trending of adverse patient events in order to implement process changes to reduce the risk of future patient harm.

Findings include:

Facility Policies:

The Performance Improvement, Risk Management and Patient Safety Plan 2020 read: Through the implementation of processes and measurable goals outlined in this plan, the facility will achieve the following objectives: target high risk, high volume, problem prone conditions activities for proactive review to reduce likelihood of future and recurring errors; collaborate with all individuals within the organization to improve processes and performances; identify organization changes that result in improved health outcomes, risk reductions, safety, and prevention of sentinel events.

Definitions

Sentinel Event: An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.

Root Cause Analysis (RCA): A process for identifying the basic or causal factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event, near miss, or medical error.

The Quality Management Committee is responsible for the following: monitor and analyze data used to make decisions for improvement of performance improvement, risk management, and patient safety activities.

Patient Safety/ Risk Management at the facility is an integral part of the quality monitoring process. The Risk Manager oversees the day-to-day operations and is responsible for ensuring the effectiveness of the plan. The Risk Manager shall ensure that a timely flow of pertinent information is directed internally as well as externally for appropriate action.

Data are collected in the following areas: Patient safety activities including but not limited to sentinel events, medical errors, and adverse patient events, root causes analysis done and actions taken; ongoing proactive identification and reduction of anticipated adverse events and safety risks. The facility will utilize information from ongoing data analysis to make changes that will improve performance and patient safety, and reduce the risk of sentinel and other adverse events.

The Serious Safety Events policy read: Patient Safety Event: An event, incident, or condition that could have resulted or did result in harm to a patient. A patient safety event can be, but is not necessarily, the result of a defective system or process design, a system breakdown, equipment failure, or human error. Patient safety events also include adverse events, no-harm events, close calls, and hazardous conditions.

The Sentinel Event policy read: Investigation - when a determination is made that a sentinel event has occurred, the following people will participate in the investigation and the formulation of a root cause analysis: Person with technical knowledge of event as determined by team members. A root cause analysis focuses primarily on systems and processes, not individual performance.

To be thorough, the root cause analysis must include: a determination of the human and other factors most directly associated with the event; analysis of the underlying systems and processes; identification of risk points and their potential contributions to this type of event; a determination of potential improvements in processes or systems that would tend to decrease the likelihood of such events in the future. To be credible, the root cause analysis must include participation by the organization's leadership and by the individuals most closely involved in the processes and systems under review.

1. The facility failed to identify staffing of telemetry technicians and telemetry unit nurses as a possible contributing factor to a sentinel event resulting in a patient's death. (Cross-reference A-0144, A-0392)

a. Review of the facility's occurrence log revealed a death that occurred on 5/23/20 on the 2 South Telemetry unit.

b. Patient #1's medical record was reviewed. On 5/23/20 at 6:22 p.m., Registered Nurse (RN #4) found Patient #1 with her pulse oximeter off and the resident unresponsive. RN #4 initiated a code blue. On 5/23/20 at 7:09 p.m., Patient #1 expired.

c. A review of the telemetry communications log from 5/23/20 revealed the telemetry technician (tele tech #2) notified telemetry unit staff twice that Patient #1's pulse oximeter probe was off. The first notification from the tele tech to Patient #1's primary nurse, RN #4, was at 5:35 p.m. The second notification to RN #4 did not occur until 6:12 p.m. Tele tech #2 documented at 6:22 p.m., a code blue was called for Patient #1.

d. A review of the telemetry monitoring room census for 5/23/20 revealed the tele tech was monitoring 47 patients on telemetry and/or continuous pulse oximeter monitors during her shift.

e. Interviews revealed the facility did not ensure that input from staff involved in the 5/23/20 incident was incorporated into the investigation of the event, and therefore, the facility did not evaluate staffing as a factor contributing to the event.

i. On 5/23/20 at 11:15 a.m., Tele tech #2 was interviewed. Tele tech #2 stated there was only one telemetry monitoring technician scheduled for each shift. Tele tech #2 stated she typically monitored 40 to 60 patients on telemetry and/or pulse oximeter monitors and stated monitoring 50 patients was often difficult and hectic.

The incident involving Patient #1 was reviewed with Tele tech #2 who confirmed that at the time of the incident, she was monitoring 47 patients and there were several pulse oximeter probes off and alarming. Tele tech #2 stated when she initially spoke with RN #4 regarding Patient #1's pulse oximeter probe, RN #4 stated she would check on the patient soon. Tele Tech #2 further explained that after the initial phone call with RN #4, she admitted two patients and had to print and evaluate telemetry monitoring strips for all the patients on telemetry monitors. Tele tech #2 explained that due to these other tasks, she did not have time to escalate the call or to re-contact RN #4 within the five minute time period as expected per the facility's Centralized Telemetry Monitoring policy. Additionally, she stated she did not notify the charge nurse on duty that Patient #1's pulse oximeter probe remained off because she had just spoken with the charge nurse and the charge nurse was addressing a different patient whose pulse oximeter probe was off.

Tele tech #2 stated she was not a part of the root cause analysis (RCA) meeting completed after the incident involving Patient #1. She further stated she was not a part of any other review process related to the incident. Tele tech #2 stated she received coaching to follow the Centralized Telemetry Monitoring policy and a telemetry technician meeting was held at which the policy was reviewed.

Tele tech #2 stated there had not been any changes implemented regarding tele tech staffing and tele tech job duties had remained unchanged.

ii. On 6/4/20 at 12:59 p.m., RN #4 was interviewed. Patient #1's record was reviewed with RN #4 who stated on the day the incident occurred with Patient #1, she had a busy patient load. RN #4 stated the telemetry unit was not staffed appropriately when the incident with Patient #1 occurred. Besides herself, she stated the unit had only one patient care technician (PCT) staffed and the charge nurse had to perform extra duties such as assist the PCT in completing vital signs on the unit.

RN #4 stated she was a part of the RCA meeting that took place after the incident involving Patient #1. RN #4 stated she had mentioned staffing on the unit as a potential factor that led to the incident; however, she had not heard a response on the matter and there had not been any changes implemented to staffing on the unit.

iii. On 6/8/20 at 1:00 p.m., the Director of Inpatient Services (Director #12) was interviewed. Director #12 stated she had oversight of the acute care units, the telemetry unit, and the telemetry monitoring room. Director #12 stated she was present during the RCA for Patient #1. Director #12 confirmed staff brought up the concern of not having adequate staff to care for patient's needs as a possible factor when the incident occurred. Director #12 stated staffing for that day was reviewed and although the unit only had one PCT, it was felt the charge nurse was available for staff assistance since she did not have patients assigned to her. Director #12 stated the staffing matrix was determined and utilized at a division and corporate level and confirmed that despite the concern raised about staffing, there had not been a review of the staffing matrix since January of 2020.

Director #12 also confirmed only one tele tech was staffed per shift. She further stated one tele tech was able to monitor up to 50 patients at one time. Director #12 explained the ratio of 50 patients monitored by one tele tech had always been the facility's practice. Director #12 also confirmed the staffing ratio in the telemetry monitoring room had not been re-evaluated recently or after the incident involving Patient #1. Director #12 stated the telemetry monitoring census had not been above 50 patients.

f. A document provided by the facility on 6/8/20 revealed the telemetry monitoring room census. It read, since 3/20/20, there were 17 shifts where the census was greater than 50 patients being monitored on telemetry and/or continuous pulse oximeter monitors.

g. Documentation in regard to the sentinel event in which Patient #1 died was requested from the facility. The facility was unable to provide evidence protocols for telemetry monitoring room and telemetry unit staffing were reviewed as potential factors contributing to the sentinel event involving Patient #1's death. Furthermore, the facility failed to provide evidence the concerns raised by RN #4 during the RCA related to staffing of the telemetry unit were addressed during the investigation of the event.

2. The facility failed to investigate adverse patient safety events according to facility protocol. Record review and interview revealed facility investigation of adverse events did not include identification of causes and contributing factors, and ongoing communication and monitoring did not occur to ensure preventive actions were implemented to prevent reoccurrence.

a. Review of the facility's occurrence log revealed a medication event, which occurred on 3/20/20 on the 2 South Telemetry unit. The report read, No drugs in code blue cart 2S. Code blue resuscitation: transfer to ICU (intensive care unit).

A description of the event provided by the Director of Patient Safety and Risk Management (Director #18) read, Attended code blue on 2S in 209. Crash cart had 2 black locks and no drugs inside. RN grabbed crash cart from ICUB and able to use meds from the cart.

i. The facility provided documentation of actions taken in response to the event. A staff coaching log revealed on 3/21/20, nursing staff were coached on crash cart checks at a huddle. The coaching log did not specify which staff attended or what information was reviewed. In addition, a note was entered in the facility's event reporting system on 4/21/20, one month after the event occurred. The note read, Recently we had a crash cart with black locks and no drug trays. Although we don't know where in the process this went wrong we need to make sure we aren't the failure point in the process. If we have a cart that needs trays, please do it right away. If the cart is sitting in the pharmacy for a while for whatever reason please verify everything is done prior to that cart leaving the pharmacy.

There was no documentation provided to indicate how the event was reviewed whether causes or contributing factors were identified, or if process changes were implemented in order to prevent reoccurrence of the event.

ii. On 6/10/20 at 2:30 p.m. an interview was conducted with the Director of Pharmacy (Director #8). Director #8 stated the process for stocking crash carts was multidisciplinary, involving central supply, pharmacy and the house supervisor. Director #8 described a system of color-coded locks which indicated whether the cart had been stocked with supplies and medications and was ready to return to the unit. She stated the black locks, which were unnumbered, indicated a cart had not yet been stocked with medications. She stated the absence of numbers on the black locks was intended to alert nursing staff the cart was not stocked with medications when nursing staff conducted a check of the crash cart.

Director #8 stated the process was monitored by the patient safety and medication safety team, and she was a participant on the team. She stated if there was an issue with a crash cart, an occurrence would be entered, and the team would review the report to determine if human error or system error contributed to the event, and whether the process needed to be changed.

Director #8 stated she was aware of the event involving a crash cart with no drug trays. However, Director #8 stated she did not remember whether it was discussed at a patient safety committee meeting. She reviewed the note entered in the event reporting system and stated the note referenced an email sent to pharmacy staff as follow-up to the event. She stated she did not know where in the process the error occurred, and she did not know if any action was taken, aside from the email to pharmacy staff to prevent the error from happening again.

Director #8 stated having medications readily available in a crash cart was considered best practice and ensured staff would be able to get the medications more quickly during a code. She stated the risk of a crash cart not being stocked with medications was not having what was needed in time.

iii. The daily crash cart check log for the 2 South Telemetry unit was reviewed. On each day from 3/4/20 to 3/20/20, the day the cart was opened for a code and was found to be missing medications, multiple staff recorded two numbers as corresponding to the two intact locks on the cart. This was in contrast to Director #8's statement the presence of unnumbered black locks on a crash cart would alert nursing staff the cart did not have medications. The facility did not provide evidence the crash cart check logs were reviewed as part of the investigation of the event.

iv. Interviews conducted with nursing staff on the unit where the incident occurred revealed staff lacked understanding of the process for re-stocking and checking the crash carts.

On 6/11/20 at 10:29 a.m. Registered Nurse (RN #16) was interviewed on the 2 South unit. RN #16 stated the purpose of a crash cart was to have tools and medications readily available in case a patient's heart stopped beating or the patient stopped breathing. He stated if there were no drugs in the crash cart, it would be a problem because staff would have to go somewhere else to get needed medications. RN #16 stated he understood the house supervisor was responsible for re-stocking the crash carts, and the charge nurses were responsible for checking them.

On 6/11/20 at 11:09 a.m. the 2 South unit Charge Nurse (Charge RN #7) was interviewed. Charge RN #7 stated it was important to have medications like epinephrine (a hormone used to treat allergic reactions in an emergency situation) and sodium bicarb (used to combat acidosis during periods of inadequate oxygenation, such as shock or cardiac arrest) available because they were important to sustain life. She stated she did not know what the black tags were or what they meant.

b. Review of the facility's occurrence log revealed a delay in care event which occurred on 3/18/20 on ICU Pod A. The corrective action documented on the report read, Refer to Peer Review.

A description of the event provided by the Director of Patient Safety and Risk Management (Director #18) read, Patient transferred to ICU (intensive care unit) without order for admit to ICU and order to discontinue A Line (arterial line, a catheter inserted into an artery).

i. The facility provided documentation of actions taken in response to the event. An email sent to Director #18 on 6/9/20 at 9:31 a.m. read, I have no emails for this incident. I only updated the incident in this case as it was only sent to me as FYI (for your information) only. Here is what was put in OPPE. An entry in OPPE (a database used to track communication with physicians) dated 3/18/20 read, Failure to respond to calls or pages. Patient transferred to ICU without order by (provider), ortho was primary. ICU provider and nurse attempted to call provider several times without success, resulted in delay of care.

ii. On 6/11/20 at 1:47 p.m. the event was reviewed with Director #18. Director #18 stated the event was reviewed by the peer review quality coordinator, the director of the medical staff office, and the ICU director. Director #18 stated she closed the event on 5/12/20 assuming communication would occur with the provider who did not provide ICU orders for the patient, but she did not confirm at the time whether this communication had occurred.

Director #18 stated the director of the medical staff office reviewed the event on 3/28/20 but did not initiate communication with the provider involved in the event until 6/10/20, 84 days after the event occurred. She stated the event was addressed and closed late per facility protocol, which called for follow-up to be completed and events to be closed within 60 days of being reported.

Director #18 stated the ICU director had signed off on the event, and she believed there had been actions implemented on the unit level in response to the event. However, she was not able to provide documentation verifying actions had occurred and this was not included in the documentation provided by the facility.

c. Review of the facility's occurrence log revealed a delay in care event that occurred on 4/30/20 on ICU Pod A. The report read, VTACH ([DIAGNOSES REDACTED], an abnormal, fast heart rate). The corrective action documented on the report read, Refer to Peer Review.

A description of the event provided by Director #18 read, Patient admitted to ICU post cath (catheterization). Patient started to become more diaphoretic and increase in oxygen demands. Patient became agitated and anxious. Cardiology contacted via phone and change in patient condition reported. RN requested cardiology consult intensivist. Updates given to cardiology with no response. All concerns and changes reported to intensivist on call.

i. Patient #4's medical record was reviewed. On 5/1/20 at 7:40 a.m., a nurse note read, Patient admitted to ICU post cath. Patient arrived cold, pale and diaphoretic. Patient became more agitated throughout the evening and increased oxygen demands noted. Patient placed on 15L (liters) non-rebreather (a mask used to assist in the delivery of oxygen). Cardiology notified of patient condition change. 80 mg Lasix (a medication used to treat fluid retention) and PRN (pro re nata, to be given as needed) .5 mg Ativan (a medication used to treat anxiety) and EKG (electrocardiogram, a recording of the electrical signals of the heart) ordered. Both administered, EKG and patient update sent to cardiology. No response.

The nurse went on to document in the note she requested the intensivist be consulted. Shortly thereafter, the patient became extremely agitated, and developed dry heaving and abdominal pain. The intensivist was consulted and placed orders for medication, imaging, and a urinary catheter. Throughout the night, the patient continued to decline, and eventually lost pulses, went into [DIAGNOSES REDACTED], and required resuscitation and intubation (insertion of an endotracheal tube into the airway so a patient can be placed on a ventilator). Patient #4 died on [DATE].

ii. The facility provided documentation of actions taken in response to the event. A staff coaching log revealed on 5/10/20, the nurse who entered the adverse event report was coached on documenting in the patient's medical record when she called physicians for changes in condition. In addition, meeting minutes were provided of a cardiovascular care committee meeting on 5/19/20. The meeting minutes read, Patient fall-out review: Cath PCI fall outs reviewed, 1 mortality. The facility also provided documentation of a routine facility mortality review conducted on 5/4/20, which reviewed Patient #4's hospitalization but did not address the delay in care occurrence the nurse entered on 5/1/20.

The facility did not provide documentation revealing how the facility investigated the nurse's concerns for a delay in care when she attempted to notify the cardiologist a second time of the patient's condition and did not receive a response. There was no evidence to demonstrate the causes or contributing factors of the event were identified or measures were implemented in order to prevent reoccurrence of the event.

iii. On 6/11/20 at 1:47 p.m. the event was reviewed with Director #18. Director #18 stated the delay in care coding on the event report was used to describe the delay in getting a response from cardiology. She did not know whether there was an identified delay in treatment to the patient as a result.

Director #18 stated the coaching provided to the nurse who reported the event was in relation to documenting orders for an EKG, which was a secondary learning opportunity from the event. She stated there would have been discussion with the nurse and the ICU director regarding computer processes and the provider's response to Patient #4's change in condition. However, she was not able to provide documentation verifying the discussion had occurred and this was not included in the documentation provided by the facility.

Director #18 stated there should have been communication with the provider involved in the event, or communication with the Chief Medical Officer, but she could not recall whether the communication occurred or if it was documented.

3. The facility failed to conduct tracking and trending of adverse patient safety events, in order to identify high-risk or problem-prone areas and to evaluate the need for and effectiveness of preventive actions.

a. On 6/11/2020 at 10:42 a.m. documentation of the tracking and trending of adverse patient safety events for 2019 was requested. At 11:47 a.m. Vice-President of Quality (Vice-President #10) stated tracking and trending data for patient safety events was considered Patient Safety Work Product and could not be provided. The facility was not able to provide alternative documentation to verify tracking and trending of adverse patient safety events for 2019.

Violation Name: NURSING SERVICES(A-0385)

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Violation Name: STAFFING AND DELIVERY OF CARE(A-0392)

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Based on interviews and document review, the facility failed to ensure there was an adequate number of nursing staff to meet the needs of the patients. Specifically, the facility failed to evaluate and implement process changes to ensure the telemetry unit was adequately staffed to provide care to patients, following an incident of a patient (Patient #1) remained off her continuous pulse oximeter (a devices used to measure the saturation of oxygen carried in red blood cells) for 47 minutes. The resident was unresponsive and died shortly thereafter.

Findings include:

Facility policy:

The Telemetry Scope of Services read, the mission of the unit is to provide high quality patient care that meets the expectations of the patients. The services provided on the telemetry unit include monitoring patients through equipment such as EKG, pulse oximetry, and non-invasive blood pressure. Minimum staffing for the unit consists of two registered nurses. Additional staff is added based on the increase of patient needs and census. The Director is responsible for staffing the unit appropriately according to census, acuity and patient care needs as well as the staffing matrix. Every effort will be made to contact off duty staff and the staffing office if staffing is inadequate.

1. The facility failed to identify, evaluate staffing in the telemetry unit and implement process changes after an adverse event involving Patient #1 occurred.

a. Patient #1's medical record was reviewed.

i. According to the Provider's Note on 5/22/20 at 5:45 p.m., Patient #1 had a history of chronic obstructive pulmonary disease (a chronic inflammatory lung disease which can cause obstructed airflow from the lungs) along with chronic respiratory failure. Patient #1 required four liters of oxygen prior to hospital admission.

ii. According to the deceased Discharge Summary note written by the provider on 5/24/20 at 6:54 a.m., Patient #1 was requiring five to eight liters of supplemental oxygen during her admission in order to maintain a pulse oximeter reading at or above 90%.

iii. On 5/23/20 at 6:22 p.m., Registered Nurse (RN #4) found Patient #1 with her pulse oximeter probe off and unresponsive. RN #4 initiated a code blue. On 5/23/20 at 7:09 p.m., Patient #1 expired.

b. Interviews revealed process changes in the telemetry unit related to staffing had not been identified and addressed in order to ensure appropriate patient care was provided.

i. On 6/4/20 at 12:59 p.m., RN #4 was interviewed and Patient #1's record was reviewed. RN #4 stated on the day the incident involving Patient #1, she had a busy patient load. RN #4 explained when she had received the first phone call from telemetry technician (tele tech #2) at 5:35 p.m., she had just received a new patient who transferred to the telemetry floor with orders for the Clinical Institute Withdrawal Assessment for Alcohol (CIWA), a tool used to assess and manage alcohol withdrawal in patients. Additionally, RN #4 stated her new patient was on isolation precautions due to a possible diagnosis of COVID-19.

RN #4 explained she was unable to check Patient #1's pulse oximeter probe after receiving the notification from tele tech #2 that the patient's pulse oximeter probe was off because she was occupied in her new patient's room, ensuring he did not fall on the way to the bathroom. RN #4 further explained she was unable to see anyone outside of the room to ask help check Patient #1's pulse oximeter probe. She further explained she was unable to use her phone to contact staff for help since she was in a COVID-19 isolation room. RN #4 stated once her new patient was back in bed, she went to check on Patient #1 which was when she found Patient #1 unresponsive and with her pulse oximeter probe off.

RN #4 stated since the COVID-19 pandemic began, tasks took longer to perform due to the need to don and doff personal protective equipment (PPE) when going into COVID-19 positive or COVID-19 rule out patient rooms.

RN #4 stated the telemetry unit was not staffed adequately when the incident involving Patient #1 occurred. She stated the unit had only one patient care technician (PCT) staffed (contrary to the staffing matrix - see below) and the charge nurse had to assist the PCT in completing vital signs on the unit.

RN #4 stated she was a part of the root cause analysis (RCA) meeting that took place after the incident involving Patient #1. RN #4 stated she had mentioned staffing on the unit as a potential factor contributing to the incident; however, she had not received a response about her concern. She confirmed there had not been any changes in staffing implemented to ensure the unit was adequately staffed.

ii. On 6/4/20 at 11:15 a.m. tele tech (tele tech #2) was interviewed and the incident involving Patient #1's was reviewed. Tele tech #2 stated she called RN #4 regarding Patient #1's pulse oximeter being off and at that time, there were several other pulse oximeters off. Tele tech #2 stated she did not escalate the concern with Patient #1's pulse oximeter probe to the charge nurse on the unit (per facility monitoring policy expectations) because she had just spoken to the charge nurse and she was addressing another patient whose pulse oximeter probe was off at the time.

iii. On 6/8/20 at 1:00 p.m., an interview with the Director of Inpatient Services (Director #12) was conducted. Director #12 stated she was present during the RCA of the incident involving Patient #1. Director #12 stated staff brought up the concern of having inadequate staff to care for patient's needs as a possible factor when the incident occurred. Director #12 stated staffing for that day was reviewed and although the unit only had one PCT, it was felt the charge nurse was available for staff assistance since she did not have patients assigned to her.

iv. On 6/11/20 at 11:09 am, charge nurse (RN #7) was interviewed. RN #7 stated the telemetry unit staffing was based off the patient census (the number of patients admitted to the unit). RN #7 stated acuity was defined as the amount of time it took to provide care to a patient and how difficult or how many tasks the RN had to complete for the patient. RN #7 stated acuity was determined by the nurse caring for the patient. RN #7 stated she had not received any training on how to determine acuity. RN #7 stated the acuity of the unit had increased due to COVID-19; however, the staffing matrix had not been evaluated or adjusted since the increase began.

v. On 6/10/20 at 1:01 p.m. RN #9 was interviewed. RN #9 stated each RN on the telemetry unit typically had four to five patients assigned to them. RN #9 stated she was unsure how the staffing ratio was determined. RN #9 stated the acuity of a patient was determined by the charge nurse, communicating with the RNs regarding their patients. RN #9 stated staffing assignments based on acuity were important because it enabled the nurse to provide the best care to all of their patients.

RN #9 stated COVID-19 was an extremely contagious respiratory illness. RN #9 stated the acuity of a patient with COVID-19 depended on what stage the patient was in during the disease process. RN #9 explained that at the beginning of the disease process, a patient may only need one to two liters of supplemental oxygen. However, a patient with COVID-19 may deteriorate rapidly and may then need to be transferred to the ICU for intubation (a procedure where a tube was inserted in the patient's airway in order to be hooked to a ventilator to assist the patient to breathe).

vi. On 6/11/20 at 9:55 a.m., Patient Care Technician (PCT#17) was interviewed. PCT #17 stated her duties included: getting patient supplies, change the batteries in telemetry boxes, replacing leads and pulse oximeter probes that were off, turning patients, blood glucose monitoring, answering call lights and take vital signs every four hours. Additionally, she stated she assisted patients to the restroom, shower, change clothing, change bed linen, assisted incontinent patients and provided patients with water and meal trays. She stated the number of PCTs assigned to the unit was based on the census of the unit. The patients would then be split evenly among PCTs assigned. PCT #17 stated there had been times when there was only one PCT working on the telemetry unit and the primary nurses had to assist the PCT with all their duties listed above since the PCT would only be able to answer call lights and take some vital signs. She stated the charge nurse answered call lights and would take half the patients vital signs when there was only one PCT assigned to the unit.

vii. On 6/11/20 at 10:29 a.m., RN #16 was interviewed. RN #16 was assigned to four patients on the day of the interview; however, he was unable to identify the acuities of his patients. RN #16 stated there was not a rating system to determine the acuity of the patients; rather, acuity was determined based on the report each RN provides to the charge nurse about the patient.

viii. On 6/11/20 at 3:05 p.m., Director #12 was interviewed again. Director #12 stated she defined acuity as the complexity of a patient, determined by the charge nurse after discussing the patient workloads with the RNs. Director #12 stated an acuity tool was not used to determine patient acuity and determine staffing needs of the unit. Director #12 stated the staffing matrix was determined and utilized at a division and corporate level. Director #12 stated there had not been a review of the staffing matrix since the telemetry unit began caring for COVID-19 patients. Director # 12 stated if there were not enough staff members to care for all patients, there were numerous risks to the patient including missed orders and delay in medication administration.

c. According to the telemetry unit census provided by the facility, there were 21 patients on the telemetry unit on the day of the incident involving Patient #1. According to the staff assignment sheet on 5/23/20, the telemetry unit had one charge nurse, four RNs, one PCT sitting with a patient and one PCT working on the floor. The number of staff scheduled and assigned to work on the telemetry unit did not correlate with the facility's staffing matrix. Specifically, according to the facility's staffing matrix, for a census of 21 patients, an adequate number of staff for the unit was one charge nurse, four RNs, two PCT and a unit secretary. The staffing matrix did not consider the need for a one-to-one sitter.

The facility failed to ensure there was an adequate number of staff working according to the facility's staffing matrix in order to provide safe patient care on the day of the incident Involving Patient #1.

d. Documentation in regard to the incident involving Patient #1's was requested from the facility. The facility was unable to provide evidence the number of staff members assigned to the telemetry unit was identified and evaluated as a possible factor that contributed to the incident involving Patient #1. Furthermore, the facility failed to provide evidence the staffing matrix had been evaluated since the increased number of patients monitored due to COVID-19.

Violation Name: INFECTION PREVENTION CONTROL ABX STEWARDSHIP(A-0747)

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Violation Name: INFECTION CONTROL PROGRAM(A-0749)

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Based on observations, interviews and document reviews, the facility failed to ensure staff actively screened employees for signs and symptoms of the novel Coronavirus (COVID-19), a highly infectious disease, and prior to the start of their shift in accordance with the Center for Disease Control (CDC) infection control guidelines. Additionally, the facility did not document the absence of COVID-19 symptoms or elevated temperature in staff upon arriving to work.

Findings include:

Facility policy:

According to the Protecting Colleagues Flyer, to reduce the spread of respiratory illnesses, we are continuing to follow the CDC guidelines to better protect our patients, colleagues and you. Colleagues who report to work, by entering the facility, are attesting that they do not have symptoms of a contagious illness (e.g. fever with coughing, etc.) and that they have self-screened by answering the following: Do you have symptoms of COVID-19, which include fever, cough or shortness of breath?

References:

According to the CDC, symptoms of COVID-19 include but are not limited to cough, shortness of breath (SOB) or difficulty breathing, fever, chills, muscle aches, sore throat and the loss of taste and/or smell.

According to the CDC's Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Health Care Settings, updated May 18, 2020, a facility should actively screen anyone entering the health facility for fever or symptoms of COVID-19. All healthcare personnel should be screened at the beginning of their shift by actively checking their temperature for the absence of fever and documenting the absence of symptoms consistent with COVID-19.

According to the CDC's Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease 2019 (COVID-19), updated April 15, 2020, healthcare facilities should consider foregoing contact tracing for exposures in a healthcare setting in favor of universal source control for healthcare personnel (HCP) and screening for fever and symptoms of COVID-19 before every shift.

According to the QSO 20-20 CMS Memo dated March 23, 2020, state surveyors are to use a streamlined review checklist to ensure providers are implementing actions to protect the health and safety of individuals during the COVID-19 pandemic.

According to COVID-19 Focused Infection Control Survey: Acute and Continuing Care (attached to the QSO 20-20 CMS Memo), facilities are expected to be in compliance with CMS guidance that is in effect at the time of the survey.

According to the Summary of the COVID-19 Focused Survey for Acute and Continuing Care Providers (page 27 of the QSO 20-20 memo), surveyors should review the Focused Infection Control Survey tool in light of the established State Operations Manual Survey Protocol for more detailed information. Facilities can review the Focused Survey to determine CMS's expectations for an infection prevention and control program during the COVID-19 pandemic. Facilities should utilize the COVID-19 Focused Survey as a self-assessment tool. Priority areas for self- assessment include education, monitoring, and screening of staff.

According to the COVID-19 Focused Infection Control Survey: Acute and Continuing Care, (page 24 of the QSO memo), surveyors are to investigate if the facility is screening all staff at the beginning of their shift for fever and signs and symptoms of illness. Is the facility actively taking their temperature and documenting absence of illness. If the facility did not provide appropriate education, monitoring, and screening of staff, the appropriate IPC tag is to be cited for the provider/supplier type.

1. The facility failed to ensure healthcare personnel (HCP) were actively screened prior to their shift to include active symptom assessment. Additionally, the facility failed to document the absence of elevated temperature and staff symptoms consistent with COVID-19 in order to prevent the spread of COVID-19.

a. On 6/3/20 at 9:45 a.m., an observation was conducted of Paramedic #1 screening staff upon entry to the facility. Paramedic #1 actively screened a HCP's temperature and provided her with a mask. Paramedic #1 did not ask the HCP if she was experiencing COVID-19 symptoms. Paramedic #1 was observed screening a total of three HCP in which the temperature was the only active screening assessment performed. Additionally, Paramedic #1 did not document the absence of COVID-19 symptoms for any HCP screened.

b. During the HCP screening observation, an interview was conducted with Paramedic #1. Paramedic #1 stated she was the staff screener for the day. She stated all staff were required to enter the facility through the one location to be screened for a temperature. Paramedic #1 stated she assessed staff temperatures only when they entered the facility, but did not assess if staff had symptoms of COVID-19. She stated when staff entered the badge entry door, they were attesting they did not have symptoms of COVID-19. Paramedic #1 stated she did not document if staff had a normal temperature or symptoms of COVID-19. Paramedic #1 stated she only documented staff temperature if it was above 99.0 degrees. She stated if staff had a temperature of 100.4 degrees or above, they would not be allowed to report to work and would be given information to contact employee health.

c. Interviews conducted with front line staff members revealed CDC guidelines referenced above were not followed, as staff were not assessed for the absence of COVID-19 symptoms and the absence of symptoms was not documented prior to the start of their shift.

i. On 5/23/20 at 11:15 a.m., an interview with telemetry technician (tele tech #2) was conducted. Tele tech #2 stated the screener at the staff entrance assessed her temperature and provided her with a facemask each time she reported to work. Tele tech #2 stated the screener did not ask her if she had any COVID-19 related symptoms.

ii. On 6/04/20 at 12:00 p.m., an interview with Registered Nurse (RN #3) was conducted. RN #3 stated she was only screened with temperature assessment when she arrived at work. RN #3 stated the screener did not ask her if she had COVID-19 symptoms. She stated she signed an attestation which stated when she used her employee badge to enter the building to report to work, she was attesting she did not have COVID-19 symptoms.

iii. On 6/11/20 at 10:29 a.m., an interview with RN #16 was conducted. RN #16 stated when he arrived for work, the screener assessed his temperature only and provided him with a facemask for the day. He stated he was not assessed for symptoms of COVID-19. RN #16 stated he signed an attestation to report fever, chills, cough, and shortness of breath, nausea, vomiting or diarrhea to his supervisor and charge nurse and not report for work. He stated all employees were sent a link to a symptom monitoring app for their phones so they could fill in their symptoms. He stated he had the app on his phone but had since removed it and no longer screened for symptoms through the app.

iv. On 6/11/20 at 11:09 a.m., an interview with Charge RN #7 was conducted. Charge RN #7 stated staff were instructed to call out from work and to notify employee health for any symptoms of COVID-19. She stated employees were screened for an elevated temperature when they entered the facility. RN #7 stated it was each employee's responsibility to identify if they had COVID-19 symptoms. She stated staff had been good at self-monitoring because she had not sent any employees home for COVID-19 symptoms.

d. Further interviews were conducted with various leadership staff members who had oversight over front line staff.

i. On 6/10/20 at 9:59 a.m., Infection Prevention Manager (IP Manager #5) was interviewed. She stated her role was the surveillance, management and investigation of communicable diseases. IP Manager #5 stated the pandemic was caused by COVID-19, which was an emerging infectious disease pathogen. She stated the signs and symptoms of COVID-19 were cough, fever, lethargy (lack of energy), myalgia (muscle pain), loss of taste or smell, nausea and vomiting. She stated it was important to screen for symptoms of COVID-19 so prompt isolation procedures could be put in place to prevent the spread of COVID-19 to patients, visitors and staff. IP Manager #5 stated if an employee went to work with COVID-19 symptoms, they could spread the virus to everyone they had contact with, including patients, visitors and other HCP. She stated staff had been educated to stay home if they felt ill and would not be allowed to work if they had a fever or gastrointestinal symptoms.

IP Manager #5 stated staff were required to enter the facility through one badge access door. She stated the staff screener actively assessed each employee's temperature when the employee entered the facility. IP Manager #5 stated each employee attested she or he did not have COVID-19 symptoms when they used their employee badge to enter the facility. She stated the staff screeners physically assessed staff as they entered the facility for cough, sneezing or just appearing ill. This was in contrast to Paramedic #1's interview in which she stated she only actively assessed staff temperatures.

IP Manager #5 stated staff were the primary people who monitored themselves and had the responsibility to not report to work when sick. She stated leadership additionally monitored employees and would send staff home if they were sick. She stated all employees could seek an employee health evaluation if they desired.

IP Manager #5 stated the process to screen employees was created at the corporate level. She stated the facility used the CDC for their infection prevention guidelines and would not want to deviate from the CDC guidance for disease control measures.

IP Manager #5 stated she considered assessing staff temperatures active screening. When asked how the facility was actively screening for symptoms of COVID-19, IP Manager #5 stated each staff member signed an attestation, which stated when they reported to work they were symptom free. She stated it was very difficult for screeners to determine if staff had a cough or were ill as the reason for the staff attestation. She stated she did not know how screeners or leadership staff were trained to assess employees for illness.

ii. On 6/10/20 at 1:38 p.m., an interview with Employee Health RN (RN #6) was conducted. RN #6 stated employee health was the centralized resource area for employees to have a contained screening process for COVID-19. She stated all employees who reported symptoms were referred to her and were told to stay at home to isolate. She stated she monitored employees who had symptoms of COVID-19. She stated she learned of employee symptoms from either the employee or their supervisor. RN #6 stated she would contact the employee and obtain their symptoms and temperature reading.

RN #6 stated the symptoms of COVID-19 were fever, respiratory illness such as a cough, loss of taste and smell, chest tightness and discomfort. She stated it was important to screen for COVID-19 symptoms because if employees were sick with symptoms, they could have COVID-19, a highly contagious disease. She stated if employees reported to work with COVID-19 symptoms, there was a high probability they could spread the germ to other people and contaminate the facility since COVID-19 was not easily contained and could cause an outbreak.

RN #6 stated there have been a couple employees who tested positive for COVID-19 whose only symptoms were loss of taste and smell. She stated at least one case was identified by the employee's supervisor while the employee was at work. RN #6 stated the staff member was screened for an elevated temperature when she reported to work. She stated once an employee had to self-isolate, they were sent an invite for an app in which they entered their symptoms and temperature two times a day. The employee would then self-monitor symptoms at home until they met the criteria to return to work.

RN #6 stated employees were only allowed to enter the facility through one door. At the employee entrance there was a screener who assessed the employee's temperature. She stated the screener recorded everyone's temperature on a log. This was in contrast to the observation and interview performed on Paramedic #1 screening employees on 6/3/20. RN #6 stated if an employee had a temperature of 99.0 to 100.3 degrees, the employee would monitor their temperature mid-shift and do a self-evaluation. If an employee had a temperature of 100.4 degrees or greater, they would be sent home and instructed to follow up with employee health. She stated the screeners were then supposed to notify her of any employees whose temperature was not within the normal range. RN #6 stated employees attested they did not have COVID-19 symptoms by reporting to work and using their badge to enter the facility.

RN #6 stated the facility's COVID-19 policies were created by the corporate office and all facilities in the health system were required to abide by the corporate policies. She stated the policies used the CDC for guidance to create the COVID-19 policies.

RN #6 stated the process for the facility to take an employee's temperature was active screening. She stated employee's attesting they were symptoms free was passive screening. RN #6 stated screeners were only actively assessing employee's temperature when they reported to work.

e. The facility was unable to provide employee screening logs or policies and procedures related to staff screening for COVID-19.

Violation Name: PATIENT RIGHTS(A-0115)

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Violation Name: PATIENT RIGHTS: INFORMED CONSENT(A-0131)

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

Based on interviews and record review, the facility failed to ensure patients with limited English proficiency were able to make informed decisions regarding their care in 1 of 3 medical records reviewed for patients with limited English proficiency (Patient #3). Specifically, the facility failed to provide oral and written language assistance services according to facility policy. The facility further failed to ensure general consents were completed according to facility protocol in 3 of 13 medical records reviewed (Patient #5, #10 and #11).

Findings include:

Facility policies:

The Limited English, Accommodating Patients With Limited English Proficiency read, Definitions: Effective Communication is communication sufficient to provide the individual with limited English proficiency the same level of services received by individuals who are not limited in English proficiency. LEP limited English proficiency is a patient's self-assessed ability to speak English less than very well and encompasses individuals who do not speak English as the primary (or preferred) language and who have limited ability to read, write, speak or understand English. Language Assistance Services are oral and written language services needed to assist individuals with LEP to communicate effectively with staff.

Identification of Persons who may be LEP: As soon as facility becomes aware of language and communication needs of a person with LEP, staff will use the form Notice of Language Assistance Services to inform such persons of service and determine what language services may be needed. If language services are declined, staff will then use the Waiver of Language Assistance to document the refusal. The forms Notice of Language Assistance Services and Waive of Language Assistance will be included in the patient's medical record.

Area staff are responsible for obtaining a qualified interpreter when needed to ensure effective communication. Family members or friends will not be used for language assistance except when the individual specifically requests that the accompanying adult interpreter facilitate communication and reliance on that adult is appropriate under the circumstances.

Any and all contacts with interpreting agencies must be documented in patient records. The staff member will document in the medical record that assistance has been provided, offered or refused.

The Informed Consent to or Refusal of Medical Treatment by Patient or Substitute Decision Maker policy read, all patients shall have the right to participate actively in decisions regarding the patient's care and to receive the information necessary to enable informed consent to or refusal or a particular treatment, surgery, procedure or plan of care. To obtain informed consent, the physician informs the patient or appropriate decision maker, in language geared to the level of understanding of the patient or decision maker, of the patient's medical status and diagnosis, and an explanation of the consequences if no treatment is pursued.

The Conditions of Admission and Consent for Outpatient Care document read, Consent to Treatment: I consent to the procedures that may be performed during this hospitalization , including but not limited to emergency treatment, diagnostic procedures, medical nursing or surgical treatment, or hospital services rendered as ordered by the Physician. Release of Information: I authorize my healthcare information to be disclosed for purposes of communicating results, findings and care decisions. I consent to Providers using and disclosing healthcare information about me for purposes of treatment, payment and healthcare operations. Acknowledgement of Notice of Patient Rights and Responsibilities: I have been furnished with a Statement of Patient Rights and Responsibilities, ensuring that I am treated with respect and dignity and without discrimination or distinction.

1. The facility failed to provide available language assistance services, including interpreter services and informed consent documents in the patient's primary language, in order to ensure patients with limited English proficiency were able to participate in and make informed decisions regarding their care.

a. Patient #3's medical record was reviewed. Review of the history and physical (H&P) completed on 8/2/19 at 7:59 p.m. revealed Patient #3 was admitted for a worsening great toe infection and osteo[DIAGNOSES REDACTED] (an inflammation of the bone due to infection). The H&P noted Patient #3 was Spanish-speaking only.

i. Review of the medical record revealed inconsistent utilization and documentation of language assistance services during physician interactions with Patient #3 and family members.

As examples:

On 10/15/19 a hospitalist progress note documented Patient #3 was reporting chest pain and dyspnea (difficult or labored breathing). The note documented cardiology was consulted and planned to start a heparin (a blood-thinner medication used to prevent blood clots) drip and take the patient for a heart catheterization (the insertion of a thin tube called a catheter into a chamber or vessel of the heart) the following day. The patient and daughter were updated of the findings and plan.

On 10/27/19 a nephrology progress note documented the daughter at bedside spoke some English and wanted to make sure water comes off.

On 10/30/19 a hospitalist progress note documented Patient #3 was Spanish-speaking only. The physician discussed with the daughter at bedside who helped to translate.

On 11/1/19 a hospitalist progress note documented the physician appreciated podiatry's impression whether the foot was salvageable, and cited High Medical Complexity. The note documented the plan of care was discussed with the patient.

On 11/2/19 a hospitalist progress note documented Patient #3 reported shortness of breath and nausea, and denied chest pain.

On 11/7/19 a nephrology progress note documented the patient was Spanish-speaking. The note read, the patient refused to stay and was leaving AMA, and understood the risks including life-threatening complications.

There was no documentation in these physician notes of how the provider communicated with Patient #3 and family members, or whether interpretation services were utilized or offered, in order to ensure the patient and family understood her health status and plan of care.

ii. The medical record further revealed multiple instances in which informed consent for medical procedures was not completed in the patient's primary language and without evidence of interpretation services being utilized.

As example:

On 10/15/19 at 5:00 p.m. a consent form in English was completed by Physician #21 for a left heart catheterization.

On 10/17/19 at 1:45 p.m. a consent form in English was completed for a blood transfusion.

On 10/22/19 at 8:10 a.m. a consent form in English was completed for an angiography (an imaging procedure to visualize the inside of blood vessels or chambers of the heart).

On 10/30/19 at 3:00 p.m. a consent form in English was completed for a second angiography.

Review of the informed consents revealed no evidence interpretation services were utilized or offered to ensure Patient #3 understood the forms and procedures referenced.

b. On 1/20/20 at 12:01 p.m., an interview was conducted with Physician #20. Physician #20 stated when a patient was identified as primarily Spanish-speaking, any staff member who spoke Spanish or any family member who spoke English could provide interpretation. She stated she would have staff or family interpret discussions with patients because it was easier than using the virtual interpretation services.

Physician #20 stated she did not document in the medical record when she used interpretation services, or how she communicated with a patient who did not primarily speak English. She stated she did use consent forms in a different language if needed, and she would have a nurse, staff member or family member interpret the discussion of the consent form. She stated she did not recall having used interpreter services during the time she cared for Patient #3.

Physician #20 stated interpretation was important when treating patients with limited English proficiency because it ensured the correct history and diagnosis were obtained. She further stated if patients or family members did not understand the care they received, they might go home from the hospital and not follow the instructions they were given.

Physician #20 stated she did not recall having recently received education or training regarding use of language assistance services.

c. On 1/20/20 at 12:58 p.m., an interview was conducted with Physician #21. Physician #21 reviewed the surgical consent completed for Patient #3 on 10/15/19 and acknowledged he was the physician who completed this consent. He stated if a patient's primary language was Spanish, providers should make an effort to get the consent signed in Spanish, and stated a patient who does not speak English should not sign a consent in English. He stated the consent form completed for Patient #3 was available in Spanish and he did not know why the Spanish-language form was not used.

Physician #20 stated it was important to complete informed consent so a patient understood what was going on with them and the results of any testing done. He stated it was also important to ensure a patient understood the procedure, why it was needed, and the risks and benefits associated with the procedure.

Physician #20 stated he had not received education or training regarding language assistance services in the past two years. He stated he wished physicians received more education and resources regarding caring for patients with limited English proficiency.

d. On 1/20/20 at 2:13 p.m., an interview was conducted with Patient Access Manager (Manager) #22. Manager #22 stated video interpretation was available for patients in the emergency department and main hospital. She stated video interpretation was the best resource to interview patients, discuss consents and inform patients of their rights.

Manager #22 stated staff should always use a certified interpreter because family may not be able to interpret the medical language used by a doctor or in a consent form. She stated if a patient preferred for a family member to interpret, they would sign the language assistance waiver.

e. On 1/20/20 at 9:51 a.m., an interview was conducted with Manager #23. He stated he reviewed the informed consent forms completed for Patient #3, and he was unable to provide evidence the physicians utilized interpretation services when completing consents in English.

Manager #23 stated physicians had not been included in any recent education or training regarding language assistance services for patients with limited English proficiency.

2. The facility failed to ensure admission consents and documentation informing patients of their rights was completed according to facility protocol.

a. The medical records for Patients #5, #10 and #11 were reviewed.

Patient #5 was admitted on [DATE] for postpartum hemorrhage.

Patient #10 was admitted on [DATE] for labor and delivery via Caesarean-section.

Patient #11 was admitted on [DATE] for newborn feeding concerns and failure to thrive.

The medical records revealed no evidence general consents for admission were completed or signed, and did not reveal documentation of any efforts to obtain consent for admission and treatment.

b. On 1/20/20 at 2:13 p.m., an interview was conducted with Patient Access Manager (Manager) #22. Manager #22 stated every patient signed a general consent form for admission and outpatient care. She stated the form explained importation information to the patient including patient rights and responsibilities, consent to treatment, the facility financial agreement, and consent to professional services.

Manager #22 stated the form was usually completed in the emergency department when a patient was first admitted . She stated if a patient could not sign consents immediately then facility staff were responsible for seeing the patient at a later time to review and sign the forms.

Manager #22 stated it was important to complete general consents with patients because consent allowed the facility to legally treat the patient. She stated if consents were not completed with every patient the facility was not in compliance with the requirements for informed consent.

c. On 1/20/20 at 4:13 p.m., an interview was conducted with Manager of Quality and Regulatory Compliance (Manager) #23. Manager #23 stated there was no evidence of general consents having been completed for Patients #5, #10 or #11.

Violation Name: PATIENT RIGHTS: CARE IN SAFE SETTING(A-0144)

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Based on observations, interviews and record review, the facility failed to ensure at-risk patients were monitored and treated according to facility policy and physician orders in two of two patient records reviewed for at-risk patients and one of one observations for patients requiring a 1:1 Patient Safety Attendant (Patient #7 and #9). Additionally, the facility failed to ensure an action plan was implemented to prevent re-occurrence in one of one safety events reviewed involving a patient requiring monitoring for alcohol withdrawal (Patient #7).

Findings include:

Facility Policy:

The At Risk Patients policy read, Definitions: At Risk Patient: Patient has been placed on a mental health or drug/ alcohol (ETOH) emergency commitment; Patient suffering from acute drug/ ETOH intoxication or withdrawal; Patient's behavior presents a danger to self or others; Patient's presentation and/or history indicates the need for further safety assessment. Patient Assist: The utilization of a security officer or safety attendant to protect a patient from harming themselves or others. Policy: These guidelines are intended to help clinical staff implement appropriate interventions to reduce the risk of patients harming themselves or others when they recognize an At Risk Patient. Any patient on a Patient Assist is the direct responsibility of the assigned RN.

The security officer or safety attendant assigned to a Patient Assist is required to stay at the door of the room, or as close as possible without causing an adverse effect on the patient. Security officers or safety attendants assigned to patients on the medical floors will typically be inside the room and will maintain a distance from the patient that promotes their safety and the safety of the patient. The security officer or safety attendant will keep the patient in line-of-sight. When the patient is being monitored by a safety attendant, safety attendant documentation needs to be completed, including the Safety Attendant Flowsheet.

All At Risk Patients will have their belongings inventoried by the admitting RN and a second staff member. The belongings will be secured and any items deemed unsafe will be made inaccessible to the patient. Remove all items identified as potentially injurious from the patient's room. All reasonable efforts will be made to remove the following items not necessary for ongoing patient care, including but not limited to: medications, intoxicating beverages or substances, breakables, sharps, appliances with electrical cords, items that can be used to strangle such as cords, rope, dental floss, yarn, belts, extra tubing, and trash can liners, matches and lighters, any non-essential items. Searches of belongings and person shall be documented by the clinical staff in the patient's medical record.

The Safety Attendant policy read, 1:1 Patient Safety Attendant (PSA) - An individual assigned and responsible for participation in the care of a patient requiring continuous observation at the bedside with a focus on patient safety. Protective observation is provided for patients who meet certain behavioral, environmental, or medical criteria. The PSA will document continuous observation on the Protective Observation Tool. The patient is in direct view of the safety attendant at all times. The patient is continually visualized by the PSA at the bedside. Document observed safety check every 15 minutes on Protective Observation Tool.

The Alcohol Research Foundation Clinical Institute Withdrawal Assessment (CIWA) and Alcohol Withdrawal Monitoring Flow Sheet read, Total score and refer to Alcohol Withdrawal Orders for assessment parameters and medication orders. For last CIWA score 0-4, monitor every 4 hours while awake. For last CIWA score 5-10, monitor every 4 hours. For last CIWA score 11-19, monitor every 2 hours. For last CIWA score 20 or greater, monitor every 1 hour.

The physician order for Lorazepam Tab (Ativan Tab) and Lorazepam Inj (Ativan Inj) Administration Criteria read, PRN Reason: Withdrawal Symptoms. CIWA-Ar Level and dose to give: Less than 5- Give no dose. Level 5 - 8- Give 1mg PO (1st choice) or IV (2nd choice) every 2 hours PRN. Level 9 - 11- Give 2mg PO or IV every 2 hours PRN. Level 12 or greater- 4mg IV every 1 hour PRN. After 2 consecutive doses of 4mg and CIWA-Ar still 12 or greater- Give 6mg IV every 30 minutes PRN. After 3 consecutive doses of 6 MG and CIWA-Ar isn't 8 or less notify MD for further orders.

The Error and Incident Reporting- Quality Improvement policy read, The purpose of this policy is to detect, document, investigate, evaluate, correct, and prevent errors. Internal occurrence report forms are completed by staff to document errors that have occurred in any phase of patient testing. The error may then be further investigated with details documented in the Risk Management Notification Module. These are then referred to any manager whose department was impacted by the error as well as the facility Risk Manager. Corrective actions are taken to improve processes when necessary to reduce the frequency of such errors. Under the direction of the Risk Manager and hospital administration, any error that has caused a serious adverse effect to a patient will be investigated by a multidisciplinary team using Root Cause Analysis. Strategies will be developed to prevent reoccurrence of the event.

1. Facility staff failed to ensure a safe environment for an at risk patient on a mental health hold was monitored according to facility policies and protocols.

a. On 1/15/20 at 5:05 a.m. an interview was conducted with the Medical/Surgical Charge Nurse (Charge RN) #17. Charge RN #17 stated Patient #9 was considered an at risk patient as she was on a mental health hold and required a Patient Safety Attendant (PSA).

b. An observation was conducted on 1/15/20 at 5:40 a.m. of Patient #9. Observations revealed Certified Nursing Assistant (CNA) #16, who was the PSA assigned to monitor Patient #9, located outside the second door to the patient's room. The patient was not initially in view of CNA #16 from where he was located. There were no lights on in the hallway, the ante room and the patient's room. Patient #9 was not visible to the surveyor until the patient moved towards the foot of the bed in the room.

When asked, CNA #16 stated he was watching the patient for self-harm. According to the Protective Observation Tool used by CNA #16 to document safety checks and observations of the patient, the documented precautions were Suicide and Other- Patient Safety.

Observations of the inside of Patient #9's room revealed the following items: a phone with cords, monitor cords, pants with draw-strings on the patient and in the room, pencils, a call light with cords, shoes with shoe strings on the patient, computer cords, and bed cords. These items were found during surveyor observation, even though staff interviews reported the patient was previously searched last night. According to the At Risk Patient policy, these items would be considered potentially injurious to an at risk patient.

The Protective Observation Tool for Patient #9 was reviewed at 5:45 a.m. Review revealed CNA #16 was not documenting patient observations and safety checks in real time, and had documented observations which had not yet occurred. The Observation Tool had already been completed for the observations due to occur at 6:00 a.m. and 6:15 a.m. CNA #16 did not respond when asked why those observations had already been completed.

c. Review of Patient #9's medical record revealed an At Risk Patient Environmental Checklist was completed on 1/14/20. The checklist documented the patient was identified as High Risk and 1:1 Patient Safety Attendant required.

The checklist read, Nursing staff or security staff shall search and remove/ secure items deemed hazardous per facility's search policy, please check all that apply. The checklist item Ligature risks, including tubing, wires/ string, cords was marked Yes. However, the observation of Patient #9's room on 1/15/20 revealed multiple items consistent with the definition of a ligature risk remained in the patient's room.

d. On 1/15/20 at 8:39 a.m. an interview was conducted with the Medical/Surgical Nurse Manager (Manager) #12 who was present during the observations conducted for Patient #9 and the surveyor. Manager #12 stated charge nurses were responsible for doing shift audits and safe room checks for at risk patients. She stated Patient #9 required 1:1 monitoring for hallucinations, erratic behavior, and wandering. She stated it was the nurse's responsibility to ensure the patient was safe.

Manager #12 stated during the observation of Patient #9 she reviewed the Protective Observation Tool which had been completed. She stated she was concerned the observations had been pre-marked on the tool. Manager #12 stated the expectation was for observations to be documented in real-time, and the purpose of the observation tool was to document what was happening in the moment.

Manager #12 stated the expectations for a CNA who was acting as a patient safety attendant were to be alert and have eyes on the patient at all times and verified this had not occurred during the observation of Patient #9.

Manager #18 stated when a patient was on precautions for suicide, the patient's room must be free of ligature risks including machines with cords. She stated the safety attendant should be within arm's reach of a patient on precautions for suicide. Manager #12 stated if the safety attendant for Patient #9 believed the patient was on precautions for suicide, she would question why there were items considered ligature risks in the patient's room. Manger #12 was unsure why this had not occurred for Patient #9.

2. Facility staff did not monitor, re-evaluate, or provide ordered medications per facility protocols and physician orders for an at-risk patient who experienced alcohol withdrawal.

a. A Patient Event Record for Patient #7 entered on 8/4/19 at 7:01 a.m. and appended at 7:29 a.m. by Registered Nurse (RN) #2 was reviewed. The record revealed on 8/3/19 at 11:00 p.m. RN #2 notified Physician #3 of concerns with Patient #7, which included unsafe mobile events, disorientation, setting off the bed alarm, pulling out IVs, and unsteadiness. The report read, orders were received from Physician #3 for an enclosure bed, and Patient #7 was safely transferred to a Posey bed (an enclosed hospital bed designed to help provide a safe environment for patients at risk for fall or unassisted bed exit).

The record further read, at 2:30 a.m. RN #2 heard Patient #7 scream from his room, and upon entering the room RN #2 smelled smoke and burning plastic. RN #2 found Patient #7 hanging head first out of the Posey bed, with his head on the ground and his arms out. RN #2 saw a lighter in Patient #7's hand, even though Patient #7 had been searched previously by security. The record read, Patient #7 sustained a skin tear, first degree burn, and hit his head. Physician #3 was notified and orders were received for soft wrist restraints in addition to the Posey bed.

b. Patient #7's medical record was reviewed. Review of the history and physical (H&P) completed on 8/2/19 at 7:59 p.m. revealed Patient #7 was admitted for acute chest pain and alcohol withdrawal. The assessment and plan read, CIWA (Clinical Institute Withdrawal Assessment, a scale used for assessment and management of alcohol withdrawal) protocol would be initiated for alcohol withdrawal.

The attending physician placed an order for CIWA monitoring on 8/2/19 at 3:49 a.m. The physician placed additional orders for intravenous (IV) and oral Lorazepam (a sedative medication used to treat drug and alcohol withdrawal, also referred to as Ativan) with specific Administration Criteria on 8/2/19 at 4:00 a.m.

A scanned Alcohol and Withdrawal Monitoring Flow Sheet, completed by the Registered Nurse (RN) assigned to care for Patient #7, was reviewed. The flow sheet documented Patient #7's CIWA scores and administrations of medication between 4:00 a.m. on 8/2/19 and 6:00 a.m. on 8/4/20.

i. The flow sheet revealed multiple instances in which Patient #7 was not assessed in the appropriate time frames based on the patient's documented CIWA scores.

According to the CIWA protocol, for a score of 11-19 the patient should have been monitored and re-evaluated every two hours for vital signs, nausea and vomiting, sweats and any disturbances, tremors, orientation, anxiety, headaches and agitation.

On 8/3/19 at 9:30 a.m. RN #1 documented Patient #7 had a CIWA score of 11. Patient #7 was not re-evaluated until three hours later at 12:37 p.m. when RN #1 documented the score for Patient #7 remained at 11. The next evaluation did not occur until three hours and 23 minutes later at 4:00 p.m. when RN #1 documented the score for Patient #7 remained at 11 with no improvement.

On 8/3/19 at 6:00 p.m. RN #1 documented Patient #7 had a score of 11. Patient #7 was not re-evaluated until three hours later at 9:00 p.m.

According to the CIWA protocol, for a score of 20 or greater, the patient should have been monitored and re-evaluated every hour.

At 9:00 p.m. RN #2 documented Patient #7 had a CIWA score of 20. Patient #7 was not re-evaluated until two hours later on 8/4/19 at 12:00 a.m. when RN #2 documented the score for Patient #7 increased to 23. The next two evaluations did not occur until two hours later at 2:00 a.m, when RN #2 documented Patient #7's score was 21, and subsequently 1.5 hours later at 3:30 a.m., when RN #2 documented Patient #7's score was 19.

ii. The flow sheet further revealed multiple instances in which Patient #7 was not given the appropriate amount of medication based on the patient's documented CIWA scores and per physician orders.

On 8/3/19 at 9:00 p.m., when RN #2 documented Patient #7 had a CIWA score of 20 the patient was given 2 mg of IV Ativan. At 10:00 p.m., when RN #2 documented the score for Patient #7 increased to 21 the patient was again given 2 mg of IV Ativan. According to physician orders, the patient should have received 4 mg of IV Ativan on both of these occasions for a CIWA score of 12 or greater.

At 12:00 a.m. when RN #2 documented Patient #7 had a score of 23, and again at 2:00 a.m. when RN #2 documented the score was 21 the patient was given 4 mg of IV Ativan. At 3:30 a.m. when RN #2 documented Patient #7's score was 19 the patient was given 2 mg of IV Ativan. According to physician orders, the patient should have received 6 mg of IV Ativan on all of these occasions for a CIWA score remaining greater than 12.

Had Patient #7 received the correct amounts of medication during this time frame without improvement in his CIWA scores, the physician orders would have called for the nurse to notify the physician for further orders. Review of Patient #7's medical record revealed no evidence the RN contacted the physician to report the patient's elevated CIWA scores.

iii. Review of nursing documentation entered revealed additional evidence Patient #7 exhibited escalating symptoms related to alcohol withdrawal, and was not demonstrating improvement in response to administered medications.

A nurse note entered by RN #1 at 7:00 p.m. revealed Patient #7 was experiencing confusion, and was up and dressed in his street clothes. RN #1 documented the patient removed his telemetry monitoring, stated he was going home, and stated he was told he was going home. RN #1 documented when she informed Patient #7 he was not yet discharged he admitted his thinking may have been muddled.

A Restraint Documentation entered by RN #2 at 11:11 p.m. revealed Patient #7 was displaying symptoms of agitation, altered consciousness, and confusion, and required the initiation of an enclosure restraint device at 11:06 p.m. The clinical justification for initiation of the restraint was documented as unsafe mobile attempts and attempts to remove a device.

On 8/4/19 at 6:46 a.m. Physician #3 entered an addendum to a clinical note. The addendum read, the patient had to be placed in a Posey bed due to unsafe mobile attempts. The physician documented per update by the RN, the patient was found later after she smelled smoke. Physician #3 documented Patient #7 had a lighter on him, lit the Posey bed on fire and crawled out through the hole he made. The patient fell out and hit his head on the floor as he was exiting head first.

The note entered by Physician #3 did not indicate he had been notified of Patient #7's elevated CIWA scores at the time this event occurred.

c. On 1/14/20 at 3:43 p.m. an interview was conducted with RN #13. RN #13 stated the CIWA scoring and assessment were based on a patient's symptoms and the scores determined how much medication to give to a patient experiencing alcohol withdrawal. She stated nurses assessed patients for symptoms of anxiety, hallucinations, and nausea or vomiting.

RN #13 stated nurses assessed patients every four hours if the patient was not scoring or requiring medication, and would assess more frequently depending on the score and amount of medication the patient required. She stated the nurse would refer to the physician order in the Electronic Medication Administration Record (EMAR) to determine the appropriate medication dosage and frequency.

RN #13 stated if a patient's withdrawal symptoms were not controlled, it was part of the CIWA protocol to notify the physician and discuss a possible transfer to the intensive care unit (ICU). RN #13 stated it was important to notify the physician when a patient's withdrawal symptoms were not managed on the medical-surgical unit because the ICU could provide an increased level of medication the patient may need.

RN #13 stated it was important to keep patients experiencing alcohol withdrawal comfortable and safe, as these patients could hallucinate, attempt to get out of bed, or display unsteadiness.

d. On 1/14/20 at 4:39 p.m. an interview was conducted with the Medical/Surgical Charge Nurse (Charge RN) #15. Charge RN #15 stated the CIWA protocol was used to score a patient's signs and symptoms of withdrawal, and would indicate how much medication should be administered. She stated if a patient required two administrations of 4 mg or 6 mg of Ativan, there were specific instructions in the EMAR for the physician to be contacted and the patient required a higher level of care.

e. On 1/15/20 at 5:05 a.m. an interview was conducted with the night-shift Medical/Surgical Charge Nurse (Charge RN) #17. Charge RN #17 stated the CIWA protocol was in place to determine how much Ativan to give based on a patient's symptoms. She stated Ativan was administered to patients for alcohol withdrawal because it calmed the patient and helped with withdrawal symptoms and seizures.

Charge RN #17 stated if a patient's CIWA scores were high enough on three assessments, the patient would advance to a higher level of care because the patient may need a different medication if Ativan was not helping, and the patient's withdrawal symptoms may need to be managed more closely. She stated the risks of alcohol withdrawal included behaviors which could harm the patient, disorientation, seizures and death.

f. On 1/15/20 at 8:39 a.m. an interview was conducted with the Medical/Surgical Nurse Manager (Manager) #12. Managers #12 reviewed the medical record and Alcohol Withdrawal Monitoring Flow Sheet for Patient #7.

Managers #12 and #18 stated on 8/3/19 at 9:30 a.m. when Patient #7 had a CIWA score of 11 the patient should have been monitored every two hours. Managers #12 and #18 stated she was concerned the patient was not re-evaluated for up to three hours because the nurse did not follow the physician's orders. Manager #12 stated it was important to follow physician orders for Ativan and alcohol withdrawal monitoring because it ensured patient safety and prevented further escalation of a patient's symptoms.

Manager #12 stated at 9:00 p.m. when Patient #7's CIWA score increased to 20 the patient should have been re-evaluated every hour and the amount of medication given should have increased to 4 mg of Ativan. She stated she could see from the medical record 4 mg of Ativan was the ordered dose for this score, but was not the amount administered.

Manager #12 stated at 12:00 a.m., when Patient #7 had a CIWA score of 23, the amount of medication given should have increased to 6 mg of Ativan. She stated by this point the physician should have been notified. She stated a CIWA score of 23 was high enough to be concerning. Manager #12 was unable to locate evidence in Patient #7's medical record the nurse notified the physician of the patient's increasing CIWA scores.

Manager #12 stated the safety concerns related to alcohol withdrawal which needed to be monitored were impulsive behaviors, seizures, injuries, and abnormal heart rhythms which could become lethal.

g. On 1/20/20 at 12:31 p.m. an interview was conducted with Physician #3. Physician #3 stated the two most important elements of the CIWA protocol were the administration of oral and IV Ativan, which were given based on the patient's CIWA score as assessed by the nurse. Physician #3 stated he did not typically see the scores documented by the nurse for a patient, and stated a physician treating a patient for alcohol withdrawal would use the EMAR to monitor the amount of Ativan administered in a 24 hour period. The physician would use this information to determine whether a patient's symptoms withdrawal symptoms were controlled.

Physician #3 reviewed Patient #7's Alcohol Withdrawal Monitoring Flow Sheet completed by RN #1 and RN #2. Physician #3 stated the scores and medications documented for Patient #7 were not correct according to the CIWA protocol, and specifically administering 2 mg of Ativan for a score of 21 was not correct. He stated he could immediately see the amounts of medication given to the patient were not correct, because at one time the patient received 2 mg of Ativan for a score of 21 and at a later time received 4 mg of Ativan for the same score of 21.

Physician #3 stated the amounts of medication administered to Patient #7 were relatively low and would indicate the patient's symptoms were controlled. However Physician #3 stated upon review of the CIWA scores documented for Patient #7, he would be concerned the patient's symptoms were actually not controlled.

Physician #3 stated he would expect to be notified by the nurse of the scores documented for Patient #7, and stated he was surprised the physician caring for Patient #7 on the night of 8/3/19 and morning of 8/4/19 was not contacted. He stated there was no excuse for giving a patient less medication than the amount ordered, or for failing to notify a physician of the patient's scores.

Physician #7 stated prior to this interview he was not aware of the scores documented on the monitoring flow sheet for Patient #7 and further stated the patient's hospital course made more sense to him after reviewing the monitoring flow sheet and the patient's documented CIWA scores. He stated the behaviors Patient #7 exhibited, including unsafe mobile events, agitation, and attempting to get out of bed, were associated with the patient withdrawing. He stated the patient become more agitated and needed to be put into a Posey bed likely occurred because his CIWA scores and withdrawal symptoms were untreated.

3. The facility failed to ensure an action plan was implemented to prevent reoccurrence of a safety event involving a serious adverse effect to an at risk patient.

The record further read, at 2:30 a.m. RN #2 heard Patient #7 scream from his room, and upon entering the room RN #2 smelled smoke and burning plastic. RN #2 found Patient #7 hanging head first out of the Posey bed, with his head on the ground and his arms out. RN #2 saw a lighter in Patient #7's hand, despite having been searched previously by security. The record read, Patient #7 sustained a skin tear, first degree burn, and hit his head. Physician #3 was notified and orders were received for soft wrist restraints in addition to the Posey bed.

Follow-up documentation for the patient event was reviewed. The event was classified as a Sentinel Event because it involved fire, flame or smoke. A manager note entered by Director of Patient Safety (Director) #19 read, will need to conduct RCA (Root Cause Analysis)- event sentinel in nature.

b. The Summary of Root Cause Analysis, completed on 8/16/19 by the Clinical Patient Safety and Quality Committee of the Board, was reviewed. The Identified Root Cause read, the patient was not placed on the At Risk Protocol for alcohol withdrawal upon admission to the unit, and personal belongings and clothing were not checked for unsafe items. A second Identified Root Cause read, security did not conduct a search of the patient's clothing.

The Risk Reduction Strategies read, Interim Director of 5 South (Medical/ Surgical Unit) was to pilot a checklist and handoff for nursing to utilize for at risk patients. The checklist was created and vetted by 9/30/19, and the pilot was determined unsuccessful according to the Chief Nursing Officer.

A second Risk Reduction Strategy read, the Program Manager of Security was to review expectations with the team regarding conducting room and belongings searches. The training was documented as having been due and completed 8/30/19. 100% compliance with safety checks was to be monitored by auditing through 11/3/19.

The Summary of Root Cause Analysis did not indicate Patient #7's medical record was reviewed as part of the investigation. It did not identify lapses in compliance with CIWA monitoring protocol or medication orders as relevant findings or root causes for the patient event.

c. Document review and interviews revealed the facility did not ensure the Risk Reduction Strategies identified in the RCA were implemented.

i. On 1/14/20 at 5:25 p.m. an interview was conducted with Director #19. Director #19 stated the action plan identified as part of the RCA was to create a handoff for nurses to utilize when caring for at risk patients. She stated the handoff was piloted but was determined to be unsuccessful, and the subsequent action plan was to conduct drills with security regarding searches of at risk patients. Director #19 was unable to provide any documentation the actions from the RCA had been completed to include any drills had been completed.

Director #19 stated security did a staff training in follow-up to Patient #7's event, and security was also to provide auditing of safety checklists completed for patients. Director #19 stated she did not have evidence of staff training or auditing conducted by security.

Director #19 stated a bulletin was sent to HSS (the security agency contracted with the facility) as part of the action plan identified by the RCA. A Security Training Bulletin dated September 19 was provided, which outlined security responsibilities during the search of a psychiatric patient. There was no documentation regarding which staff received or reviewed the bulletin.

ii. On 1/15/20 at 8:39 a.m. an interview was conducted with the Medical/Surgical Nurse Manager (Manager) #12. RN Manager #12 stated she believed the previous nurse manager participated in conversations regarding the patient safety event involving Patient #7, but she had not received any report from the previous manager regarding this event.

Manager #12 stated she was aware of the concerns and action plans identified as part of the RCA, but did not have documentation regarding her implementation of the action plans. She stated the primary opportunity identified for nursing related to collection of patient belongings for at risk patients. Manager #12 stated the action plan was to create an at risk/ high risk tool for nursing to utilize when caring for at risk patients, but the tool was quickly determined to be unsuccessful. Manager #12 stated there had been no other action plans identified and could not state what was in place to prevent a similar incident which had occurred with Patient #7 from occurring again at the facility.

d. Document reviews and interviews revealed the investigation and RCA for the patient safety event did not identify lapses in compliance with the CIWA protocol as a contributing factor to the patient safety event, and as such did not implement measures to prevent reoccurrence of these lapses.

i. Interviews revealed staff had not received any recent education or training regarding the CIWA monitoring protocol and administration of medications ordered for alcohol withdrawal.

During an interview conducted on 1/14/20 at 4:08 p.m. RN #14 stated she could not recall having been provided with training or education specific to the CIWA protocol. During an interview conducted on 1/14/20 at 4:39 p.m. Charge RN #15 stated staff had not received any recent education or training specific to the CIWA protocol, nor could she remember the last time staff had received education on this topic.

Review of documentation of nursing huddles from 8/1/19 to 1/13/20 for the Medical-Surgical Unit revealed no evidence of discussion or education related to CIWA protocol monitoring or medications.

ii. During the interview on 1/14/20, Director #19 stated she interviewed the nurse involved in the patient safety event, and she and the nurse manager had reviewed the medical record for Patient #7. She stated processes for CIWA monitoring appeared to have been followed appropriately. She stated concerns regarding compliance with the CIWA protocol were not identified as part of the RCA, nor were any process changes implemented regarding CIWA monitoring in response to the RCA.

iii. During the interview conducted on 1/15/20, Manager #12 stated she had not interviewed any staff regarding the event involving Patient #7. She stated prior to this interview she had not reviewed the medical record for Patient #7.

iv. On 1/20/20 at 12:31 p.m. an interview was conducted with Physician #3. Physician #3 stated he had not have the opportunity to review the medical record for Patient #7. He stated as chief of medical staff he was very aware of the safety event related to Patient #7, and stated the event was reviewed by leadership, department heads, and the nurse leader on the medical-surgical unit.

Physician #3 stated prior to this interview he had not reviewed the CIWA scores documented on the Alcohol Withdrawal Monitoring Flow Sheet for Patient #7. He stated he was not aware of the lapses in compliance with CIWA monitoring and administration of ordered medications which occurred prior to the safety event involving Patient #7.

Violation Name: NURSING SERVICES(A-0385)

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Violation Name: STAFFING AND DELIVERY OF CARE(A-0392)

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Based on interviews and document reviews, the facility failed to ensure there was an adequate number of nursing staff to meet the needs of patients. Specifically, nursing staff did not respond to patient call lights in a timely manner in 2 of 2 patient call light logs reviewed (Patients #3 and #6). Nursing staff failed to ensure patients were offered hygiene care according to unit standards in 1 of 11 adult patient medical records reviewed (Patient #6).

Findings include:

Facility policy:

The Scope of Service -Medical/Surgical read, the unit is staffed based on each shift's patient census and patient acuity.

The Scope of Service -Telemetry read, a charge nurse is responsible for, and supervises the care delivered each shift. Minimum staffing for the unit consists of 2 Registered Nurses (RN) on duty. Additional staff will be added based on an increase on the census and according to patient care needs. Patient care is provided as a partnership, patient-focused care model using the established staffing matrix. The Director is ultimately responsible for staffing the unit appropriately for census, acuity and patient needs.

1. Patient call lights were not answered in a timely manner to address the patients' needs.

a. On 1/13/20 at 9:11 a.m., an interview was conducted with Patient #6 who was receiving care on the 5th floor medical surgical unit. Patient #6 stated sometimes she waited forever for staff to come in to help her. When asked how long staff would take to respond to her call light, she said an hour or more. Patient #6 said she would wait, wait, wait when she thought staff were supposed to respond right away. Patient #6 said there might be a lack of staffing but was unsure as to why there was a delayed response to the call lights.

Review of Patient #6's call light logs from 12/25/19 through 1/13/20 showed multiple days where the patient's call light was not answered in a timely manner to address the patient's needs.

From 12/28/19 through 1/13/20, Patient #6 was in two different rooms on the Medical/Surgical unit. Review of the detailed call report log showed, on 1/3/20 a call was placed at 12:16 p.m. and responded to 75 minutes and 25 seconds later. At 6:08 p.m., a call was placed and not canceled until 54 minutes and 27 seconds time frame lapsed. On 1/4/20 at 8:16 a.m., a call was placed and not canceled until 52 minutes and 50 seconds later. Later the same day, at 10:58 a.m., another call was placed where nursing staff did not answer until almost an hour later.

Review of the patient's call report log for the second room, from 1/5/20 through 1/13/20, showed continued delays throughout the days when the call light was not answered in a timely manner.

As example,

On 1/5/20, Patient #6 used her call light at 7:01 a.m.. The call was not canceled until 25 minutes and 18 seconds later.

On 1/6/20, a call was placed at 5:57 a.m. and canceled 28 minutes and 11 seconds later.

On 1/8/20, the patient used her call light at 3:21 p.m.. The call was not canceled until 46 minutes and 36 seconds after it was placed.

On 1/9/20, there were three separate occasions when Patient #6's call light was not answered for over 25 minutes: 10:58 a.m., 3:32 a.m., and 7:02 p.m.

On 1/12/20, the patient placed a call at 11:12 a.m. The call was not answered for 42 minutes and 18 seconds.

Additionally, upon review of Patient #6's call light log while she was on the Telemetry unit, showed on 12/27/19 at 3:23 p.m., the call light was not canceled until 34 minutes and 54 seconds after the call was placed.

i. On 1/20/20 at 2:13 p.m., an interview was conducted RN #6 and RN #7.

RN #6 stated she tried to answer a patients' call light within a couple of minutes. RN #6 reviewed Patient #6's call light log, for 1/9/20, the day she was assigned to the patient. She said she did not remember that specific day but stated on some days patient call lights were definitely affected when there was a low number of staff. RN #6 stated a reasonable time to answer call lights was under five minutes.

RN #6 stated sometimes the unit would have 29 patients with only one CNA (certified nursing assistant) which left the RNs with a heavier workload. She said the CNAs were overloaded. RN #6 said patients would not get the best care if nursing staff could not get to them in a timely manner..

RN #6 stated she felt the Medical/Surgical unit had more short days than being adequately staffed. She said unless the call light was answered, nursing staff would not know what was going on with the patient and there could be a delay in patient care. She said a patient could be having chest pain, trying to get out of bed to go to the bathroom or the patient may need water. RN #6 stated if nursing staff did not get there quick enough, the patient could try to get out of bed without assistance and be at risk of falling.

RN #7 stated if a unit was short a CNA or if the charge nurse had patients, the resources for the nurses would be unavailable. She said this happened more often than it did in the past on both the Medical/Surgical unit and the Telemetry unit. RN #7 said even if the nurse had five patients a CAN could get pulled to provide one on one monitoring for a patient. RN #7 said she felt the units had been short staff at times over the last four months. After review of Patient #6's call light log for 1/3/20, RN #7 stated 75 minutes was a long time for a patient's call light to be answered.

According to the staffing matrix provided by the facility, for 33 patients, the Medical/Surgical unit should have one charge nurse, seven RN's and three Cans. Review of the unit's staffing assignment sheet, dated 1/3/20, showed the unit had one less RN and CAN than the matrix called for. Further, the charge nurse was assigned three patients which according to the RN interviews above, limited resources for the other nurses on the unit if help was needed.

c. Review of Patient #3's call log report, revealed on 11/4/19 and 11/5/19, the patient's call light was not answered in a timely manner. On 11/4/19 at 12:11 p.m., the patients call light was answered after a duration of 34 minutes and 21 seconds. On 11/5/19 at 1:15 a.m., the call light was canceled 24 minutes and 28 seconds after the call was placed.

Review of the Telemetry unit's staffing assignment sheet, dated 11/4/19, showed the unit had 30 patients and was staffed with one charge nurse, six RN's and two Cans. According to the staffing matrix for the unit, the Telemetry unit called for one more CAN for a census of 30.

The 11/4/19 night shift staffing assignment sheet showed the unit had a census of 28 patients with one charge nurse, five RN's and two Cans. The Telemetry unit's staffing matrix for 28 patients, called for one more RN and one additional CAN.

Both 11/4/19 day shift and night shift charge nurses were assigned patients.

d. On 1/20/20 at 12:18 p.m., RN #4 and RN #5 were interviewed. Both nurses provided care to Patient #3 during her 10/8/19 admission on the Telemetry unit.

Both RN's reviewed the 11/4/19 call light log. RN #4 stated 34 minutes was a long time for a patient call light to be answered. RN #5 stated 34 minutes was concerning because the patient may have needed something like pain medicine or assistance to the bathroom. RN #5 stated the purpose of the call light system was to inform nursing staff the patient needs something. RN #4 stated the goal was to answer a patient's call light as soon as you could.

RN #5 stated there had been days in the past where the unit was short staffed or did not have enough Cans. She said staff were stretched thin with answering all the patient call lights and providing their care.

e. Additional nursing staff who worked both the Medical/Surgical and Telemetry units were interviewed. All three nurses expressed concerns with staffing.

On 1/14/20 at 3:43 p.m., RN #13, who floated to both the Medical/Surgical and Telemetry units, stated there were times the units were short staffed. She said although the nurses would not be assigned over five patients, the charge nurse, at times,would have to take patients. She reported the Cans would be assigned more than they could handle. RN #13 said staffing like this affected the nurses' workload. RN #13 stated the Cans have told leadership about their concerns.

On 1/14/20 at 4:08 p.m., RN #14 stated there were times the Medical/Surgical unit would need an additional CAN or one more nurse. She said sometimes agency staff could be requested but if they were not available, then the RN's would have to assist the Cans with patient care, including ADLs (activities of daily living) and hygiene care. RN #14 stated nursing staff could utilize the charge nurse for assistance if they do not have patients themselves.

On 1/14/20 at 4:39 p.m., Charge Nurse #15 was interviewed and stated since the unit was no longer using the pediatric side for overflow of patients, staffing had improved. However, she then stated, prior to the closing of the pediatric unit a few weeks prior to the survey, she had concerns about staffing. Charge Nurse #15 stated at that time, charge nurses were taking a full load of patients. Charge Nurse #15, as a charge nurse, she could be a resource to the nurses and assist with patient care but when she had patients herself and along with her other charge duties, she was unable to help.

Charge Nurse #15 stated sometimes it was a challenge to meet the demands of patient safety when assuming care of patients. She stated staffing had been brought up to leadership multiple times by nurses and Cans.

f. On 1/20/20 at 3:06 p.m., an interview was conducted with Chief Nursing Officer (CNO) #10, Medical/Surgical Nurse Manager (Manager) #12 and Telemetry Nurse Manager (Manager #11).

A review of the call light logs and unit assignments sheets, along with the corresponding matrices, was conducted for both Patient #6 and Patient #3. CNO #10 stated delayed response times on the call light logs was concerning, however, she did not feel there was a correlation with staffing. CNO #10 stated the staffing matrices were not set in stone and were inaccurate. When asked if the staffing matrices took in consideration of the charge nurse taking patients, CNO #10 stated it did not.

CNO #10 stated the typical patient to nurse ratio on the Telemetry unit was five patients to one nurse and for the Medical/Surgical unit, five or six to one. When asked if the facility could provide these guidelines, CNO #10 stated there were no facility guidelines for the ratios, but the facility was meeting the general benchmarks for the Denver market.

2. Facility failed to ensure patients' hygiene needs were met according to unit standards. .

a. On 1/13/20 at 9:11 a.m., an interview was conducted with Patient #6 who was receiving care on the Medical/Surgical unit. Patient #6 expressed concerns about nursing being understaffed. She said she just started to get washed up and her teeth brushed, although she had been in the hospital since December.

b. On 1/20/20 at 2:13 p.m., interviews were conducted with RN #6 and RN #7 who both had worked on the Medical/Surgical unit. RN #6 stated patients should be offered hygiene at least daily to prevent further infections, improve patient's sleep and to make patient's feel better during their stay.

RN #6 reviewed Patient #6's electronic medical record and provided the documentation for days the patient did receive hygiene care. However, there was no documentation to show the patient was offered a bath or shower and oral care on 12/28/19, 12/29/19, 12/30/19, 1/1/19 and 1/6/19.

c. On 1/20/20 at 12:18 p.m., two additional nurses (RN #4 & RN #5) were interviewed regarding the process for hygiene care. RN #4 stated hygiene care starts with Cans and was included in a patient's care plan. She stated RN's could also document in the medical record about hygiene or in a nurse's note. RN #4 stated the standard of care was for hygiene to be offered to patients on a daily basis, including showers, baths, peri care and assistance with oral care. She said linen change was included when hygiene was done.

Review Patient #6's nurse notes showed no evidence RN's documented hygiene care on the identified gaps above.

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

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Based on interviews and document reviews, nursing staff failed to evaluate patients' wounds in a consistent manner according to standards of practice in one of three medical records reviewed for wound care (Patient #3).

Findings include:

Facility policy:

The Wound Care Guidelines for Nursing policy read, nursing management of wounds included: wound assessment, dressing and wound care and documentation of wound care. Wound assessment includes: location and type of wound (e.g. surgical, pressure, trauma, etc); how long the wound has been present; measurement if indicated; description of wound and current wound treatment. Wound assessment are to be documented in the Skin Assessment (admission assessment followed by shift assessments ) and include all elements noted in Wound Assessment above. Dressing changes will be documented in Nursing Notes and include type of dressing applied and any wounds products utilized.

1. Nursing staff failed to assess patients wounds in accordance with unit standards.

a. Review of Patient #3's nursing admission assessment, dated 10/8/19 at 8:11 p.m., revealed the patient had a procedure related wound located at the anterior right big toe. Nursing staff also documented an abrasion to the anterior right foot related to the patient's diabetes and two closed wounds located on the patient's left foot.

Review of Patient #3's nursing shift assessments, from 10/8/19 through 11/7/19, revealed a lack of nursing assessments on Patient #3's wounds which were identified on admission and throughout her stay.

As example,

On 10/12/19 at 2:27 a.m., the nursing shift assessment showed no evidence the patient's wound was assessed.

On 10/16/19 at 8:10 a.m., nursing staff did not document a wound assessment.

On 10/18/19 at 9:30 a.m., Patient #3's day nursing assessments lacked evidence which showed the condition of the patient's right big toe's dressing. Patient #3's had surgery on her toe eight days prior.

On 10/20/19 at 8:48 a.m. and 8:00 p.m., there was no evidence of a nursing assessment of the patient's right big toe amputation.

On 10/24/19 at 9:00 a.m., nursing staff documented the patient had no skin alterations which contradict daily physician notes.

Similar findings for lack of documented nursing wounds assessments, specifically for Patient #3's right big toe surgical wound, were found on 10/26/19, 10/27/19,10/28/19, 10/29/19, and 10/31/19.

On 11/7/19 at 12:17 p.m., the nursing shift assessment showed no evidence the patient's nurse evaluated the right big toe surgical wound. Patient #3's nurse documented the patient had no skin alterations/procedure sites which contradicted the discharge summary dated the same day.

b. On 1/20/20 at 11:36 a.m., an interview was conducted with Wound Care RN #8 and Float Pool RN (RN #9).

RN #9 stated she works multiple inpatient units and skin assessments were required every shift.

She said documented wounds trigger nursing to perform additional assessments of the patient.

RN #8 reviewed Patient #3's medical record and stated she was admitted to the hospital for an amputation. Dressing changes to the wound were done by himself or the podiatrist. RN #8 stated nursing staff should look at the dressing for any strike through (the point at which absorbed fluid reaches the outer surface or edge of a dressing).

RN #9 stated there was a place in the nursing assessment to document the skin assessment and each wound present. She stated the assessment was required to be done and then documented. RN #9 stated skin alteration assessments needed to be thorough to establish a baseline for the patient and for nursing staff to recognize any changes in the patient's condition. She said then the nurse could consult resources such as the wound nurse or notify changes to the physician.

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

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

Based on document reviews and interviews, nursing staff failed to ensure pain evaluations, re-evaluations and interventions were completed according to standards of practice, in three of ten patient records reviewed (Patients #3, #6 and #10).

Findings include:

Facility policy:

The Pain Management policy read, all patients have the right to an accurate assessment and management of their pain. The caregiver assures that patients who experience pain, or at risk for pain are reassessed and treated appropriately and quickly. The patient may be monitored for pain: during hourly rounding; whenever an intervention or treatment is provided to relieve pain.

Pain reassessment is individualized to occur at the time that caregivers expect the intervention to begin relieving the patient's pain and discomfort. In general, reassessment is expected approximately 30 minutes after an injectable pain medication is administered, and 60 minutes after an oral pain medication is administered.

Pain is assessed and treated throughout the patient's course of treatment and stay in the facility.

General guidelines for interpretation of patient's pain level (0-10), and treatment per physician orders, as follows:

0 = no pain

1-3 = mild pain

4-6 = moderate pain

7-10 = severe pain

The policy also read, to consider non-pharmacological pain interventions, such as distraction, relaxation techniques, massage, positioning, and heat/cold for patient. Pain reassessment is based on the expected time of medication peak effect and route administered.

The Patient Assessment and Reassessment policy read, all patients will receive an initial nursing assessment and subsequent reassessment, based on individual needs including physical status. The assessment process determines the need for care and/or treatment, they type of care to be provided, and the patient's needs through the continuum of care. Reassessment for inpatients will include the following information: for nursing, patient reassessment or data collection will occur at a minimum of every shift. Reassessment must occur by an RN every shift or more frequently as indicated by the patient's condition.

1. Nursing staff did not ensure patients' pain was assessed and treated according to standards of care.

a. Review of Patient #3's medical record revealed the patient was admitted on [DATE]. According to the History and Physical, dated 12/7/18, Physician #8 documented the plan for the patient's alcohol pancreatitis (pancreas inflammation), was intravenous fluids and pain management.

On 12/8/19 at 8:00 a.m., Registered Nurse (RN) #7 documented the patient's pain goal was a zero.

On 12/8/19 at 8:45 p.m., RN #9 documented in the nursing notes, the patient's pain level was reported as a five out of ten on a numeric pain scale and the patient's pain goal was zero. According to policy, a five pain level was considered to be moderate pain.

There was no evidence documented in RN #9's nursing assessment and the patient's medication administration record (MAR) which showed the nurse offered or provided interventions to relieve Patient #3's reported pain.

b. Review of Patient #6's medical record revealed the patient was admitted for right hip pain after a fall. Review of the patient's History and Physical, dated 3/1/19, showed the patient had a right introchanteric (femur) fracture. Patient #6 had surgery to repair the fracture the same day.

On 3/3/19 at 8:00 p.m., RN #10 documented Patient #6's pain intensity was at a six out of ten on the numeric scale. According to policy, the patient had a moderate level of pain. The patient's nurse documented the patient's right hip was aching and cramping. RN #10 documented interventions used to manage the patient's pain were dimming the lights, cold therapy, relaxation techniques and repositioning. The next pain reassessment was not documented until three hours later. RN #10 documented the patient's pain intensity was a 6; the same intensity as the patient's 8:00 p.m. assessment.

From 8:00 p.m. until 11:06 p.m., there was no evidence in the medical record, which showed the patient was reassessed to see if the non pharmacological interventions were effective at treating the patient's moderate pain.

c. Review of Patient #10's Discharge Summary, dated 3/18/19, revealed the patient was admitted on [DATE] after a motor vehicle accident. Patient #10 had left anterior rib fractures.

Review of the History and Physical, dated 3/16/19, revealed the physician's plan for the rib fractures included pain control.

On 3/16/19, Patient #10 was administered 10 milligrams of Oxycontin (a narcotic pain reliever) for a pain intensity of seven, which the patient reported to her nurse at 9:20 p.m. The patient's goal was two out of ten on the numeric pain scale. According to the pain assessment documented, the patient's pain was located at her left side, ribs. There was no evidence in the medical record which showed the patient was reassessed to see if the Oxycontin was effective. The next pain assessment was not documented until three hours later, at 1:31 a.m. the next day. The patient's reported pain was documented at a five, which was still not at her goal of two.

d. On 3/21/19 at 2:09 p.m., RN #5 was interviewed and stated she worked throughout the hospital. RN #5 said pain assessments were done with shift assessments. She also said patients were assessed throughout the day during hourly rounding. RN #5 said she would chart when she gave as needed pain medications and then conduct a follow up assessment within one hour to see if the medication was working.

RN #5 stated other interventions could be offered for pain, including: ice, heat and repositioning. She stated she would have to reassess the patient to see if the intervention was working.

RN #5 stated documentation included: the type of pain scale used; where the pain was located, if the pain radiated; and what interventions were done.

e. On 3/21/19 at 3:01 p.m., an interview was conducted with RN #7 and RN #6. RN #7 provided care to Patient #3 on 12/8/19 and 12/9/19, during the day shift.

RN #7 reviewed Patient #3's pain assessment documented by the night nurse on 12/8/18 at 8:45 p.m. RN #7 stated, the pain assessment documented was a pain level of five. RN #6 who navigated the electronic medical record during the interview, was not able to find any documented evidence which would show Patient #3's pain was addressed by nursing staff throughout the night shift beginning 12/8/18.

RN #7 stated pain management was important to promote the patient's healing and comfort. She said other interventions, in addition to medication, which could be provided to the patient were ice packs, repositioning and ambulation in the halls. She said documentation should be in the nursing notes.

f. On 3/21/19 at 4:37 p.m., an interview was conducted with Ortho/Trauma Nurse Manager (Manager) #3, Vice President of Quality & Patient Safety (VP) #4, Manager of Quality and Regulatory Compliance (Manager) #2 and Chief Nursing Officer (CNO) #1.

CNO #1 stated pain assessments were done with the morning assessment and at hourly rounding. She stated the hourly rounding assessments were documented on the whiteboard and were not part of the patient's medical record. CNO #1 stated the facility had a pain policy to address what actions were required for pain management. She stated she would refer to policy for the requirements.

Review of Patient #3's pain assessment documented on 12/8/19 at 8:45 p.m. was conducted. CNO #1 stated if the patient reported a pain level of five, she would ask the patient if he wanted medications or any other interventions. She said if there was no documentation in the medical record, the conclusion would be the patient did not want any interventions done and staff would continue to monitor.

Manager #3, who managed the unit Patient #3 and Patient #6 were admitted to, stated if a medication was administered, the assessment should be documented on the MAR. She stated if the patient was offered an option of ice, the care was assumed to be done.

Violation Name: DISCHARGE PLANNING(A-0799)

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Violation Name: DISCHARGE PLANNING EVALUATION(A-0806)

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Based on interviews and document review, the facility failed to provide a discharge evaluation to meet the needs of the patient in 1 of 7 discharged patient medical records reviewed (Patient #2).

Findings include:

Policies

The policy Discharge Planning/Continued Care Process read, the nurse will utilize various sections of the nursing admission form to identify high risk discharge planning patients, e.g. skin assessment, psychosocial assessment, patient risk to fall, restraint prevention/alternative measures, specific barriers to learning, functional assessment/discharge planning. It further read, patients with an admission as a result of drug or alcohol abuse would be given an Intensive Psychosocial Assessment by social work.

The policy Suicidal Patients, Evaluation and Treatment of, read All patients admitted to North Suburban shall have a nursing assessment completed which includes suicide risk screening.

The policy Patient Assessment and Reassessment read, all patients will have the following data collected/addressed in their initial screening (based on the patient's condition) including screening for educational needs and barriers, abuse and neglect, pain, functional status, nutritional status, psychological, social, spiritual/cultural needs, and suicide risk assessment. The policy further read, reassessment and/or data collection are to be ongoing and may be triggered by key decision points including significant change in condition or diagnosis.

1. The facility failed to provide a discharge evaluation to meet the needs of Patient #2, including suicide risk screening and social work evaluation for a high risk admission.

a. Review of the Emergency Provider Report, dated 11/16/17, showed Patient #2 presented to the emergency department (ED) on 11/16/17 at 3:06 p.m. On arrival to the ED, Patient #2 was deeply sedated due to an elevated blood alcohol level (BAL). Patient #2 was intubated for respiratory failure to protect his airway on 11/16/17 at 3:20 p.m. and subsequently admitted to the intensive care unit.

Registered Nurse (RN) #1 documented Patient #2's ED admission assessment on 11/16/17 at 4:37 p.m. She documented she was unable to complete the suicide ideation assessment due to the patient's condition.

An interview was conducted with RN #1 on 2/27/18 at 10:19 a.m., in which she stated while a patient was intubated, their suicide risk could not be assessed.

According to ED nursing notes, Patient #2 transferred to the intensive care unit (ICU) on 11/16/17 at 5:27 p.m. At 7:00 p.m., RN #3 documented Patient #2's ICU admission assessment. She documented she assessed Patient #2 for suicide risk, and he had no current suicidal thoughts. However, the RN noted she was Unable to assess if the patient was at risk for suicide. Additionally, the nursing assessment noted Patient #2 was not alert and oriented. She also documented she was unable to assess recent attempts at self harm, and recent stressful events. RN #3 noted Patient #2 was still intubated on 11/16/17 at 7:00 p.m.

A review of nursing notes revealed Patient #2 was extubated on 11/17/17 at 8:05 a.m. On 11/17/17 at 10:19, Physician #5 documented, in his discharge summary, Patient #2 was awake and alert, and walking around the unit independently. Despite Patient #2 being awake and alert, no further attempts were made to assess Patient #2's suicide risk.

Review of Case Manager (CM) #11's discharge summary revealed that she met with Patient #2 prior to discharge. CM #11 stated Patient #2 had no discharge needs and would walk home.

An interview with CM #11 was conducted on 2/26/18 at 3:37 p.m. CM #11 stated she had a questionnaire for patients with alcohol related admissions. She stated if the patient scored high, she would utilize a social worker with the patient. Review of Patient #2's medical record revealed the assessment was not done for Patient #2, and a social worker did not see this patient. This was in contrast to the facility's policy regarding discharge planning for high risk admissions.

During an interview with RN #1 on 2/17/18 at 10:19 a.m., RN #1 reviewed Patient #2's medical record. She stated a complete suicide risk assessment was not completed by nursing staff in the ED. RN #1 stated suicide risk should be assessed prior to discharge. RN #1 stated screening all patients for suicide risk was important because it allowed the facility to weed out those who need more support. Those who are saying they have stomach pain, but are really coming in because they need more help. RN #1 stated she was unaware of any triggers to reassess a patient once the patient's condition changed. She stated the only way she was aware of to communicate the need to reassess suicide risk after extubation was direct communication during shift report. There was no documentation this communication occurred in Patient #2's record.

An interview with ICU RN #2 was conducted on 2/17/18 at 1:59 p.m. RN #2 reviewed her documentation and confirmed she had not documented a suicide risk assessment for Patient #2 after he was extubated. RN #2 confirmed that there was not a complete suicide risk assessment charted by nursing throughout his entire stay.

b. Three weeks prior, on 10/21/17, Patient #2 was brought to the facility's ED for trauma. According to the discharge summary, dated 10/22/17 at 10:25 a.m., Patient #2 had been seen lunging at cars by the police earlier that evening. When the police returned later, Patient #2 was found unconscious with a laceration on his scalp. Patient #2 was released by the ED pending a ride home; however, he became tachycardic (fast heart rate) and began to display symptoms of alcohol withdrawal. Patient #2 was then admitted for withdrawal symptoms management.

There was no documentation Patient #2 received an intensive psychosocial assessment by social work prior to discharge pursuant to the facility's policy.

c. An interview with Physician #5 was conducted on 2/17/18 at 3:05 p.m. Physician #5 stated during Patient #2's November 2017 admission, he assumed he screened Patient #2 for suicide risk. However, he stated he could not find the assessment in his documentation. A review of Physician #5's discharge note revealed no documentation of suicide risk screening. Physician #5 stated Patient #2 should have been assessed for suicide risk prior to discharge.

d. An interview was conducted with Social Worker (SW) #4 on 2/27/18 at 11:18 a.m. She stated the initial suicide risk assessment should be done by nursing staff. She also stated the case manager would review this nursing assessment during the process of discharge planning. She stated the case manager would also review the physician's history and physical for indications of suicide risk.

SW #4 stated high risk case management screens were for more complex patients and included patients with frequent admissions for substance abuse and mental health. SW #4 stated Patient #2 met this criteria and it would have been appropriate for social work to have been consulted and evaluate Patient #2 during his November 2017 admission due to his multiple ED visits and inpatient stays related to alcohol.

Violation Name: NURSING SERVICES(A-0385)

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Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

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

Based on interviews and document review, the facility failed to assess patients in accordance with physician orders and facility policy. In addition, the facility failed to ensure patient weights were measured and documented as ordered in 4 of 11 medical records reviewed (Patient #2, #4, #10 and #11).

This failure created the potential for the patient's medical needs to not be addressed. In addition, this failure resulted in a longer than expected patient hospitalization and emergent dialysis for 1 of 11 patients (Patient #4).

FINDINGS

POLICY

According to the policy, Patient Assessment and Reassessment, the Registered Nurse (RN) will perform a physical assessment including weight. Physical reassessment will be conducted at a minimum every shift and will include vital signs, diagnosis or signs/symptoms, and a review of systems including renal.

According to policy, Pre and Post Treatment Assessment and Data Collection, pre and post dialysis treatment data collection includes a weight.

According to policy, Dialysis Performed on a Nursing Unit, the unit nurse assesses the patient prior to the start of the scheduled dialysis. Weigh and record weight prior to dialysis.

REFERENCE

According to the contracted dialysis company's policy, Dialysis Performed on a Nursing Unit, obtain pre treatment hand off report from the patient's primary nurse to include but not limited to vital signs, including weight, scale type and time obtained. Post treatment vital signs to include weight (if ordered by the nephrologist).

1. Nursing staff failed to identify and alert medical providers in regards to Patient #4's chronic medical condition and hemodialysis needs.

a) Review of a Consultation Note on 02/05/17 at 3:32 p.m. revealed Patient #4 (MDS) dated [DATE] for a procedure to place an Implantable Cardioverter Defibrillator (ICD), a small device placed in the chest or abdomen used to treat abnormal heartrate. The procedure was delayed until 02/02/17. Documentation stated the procedure went well but the patient was unable to leave the facility due to other issues of concern, specifically related to the patient's history of end stage renal disease (ESRD) and the need for hemodialysis.

Review of the patient's medical record showed the following documentation:

On 02/01/17 at 3:35 p.m., a Nursing Admission History documented Patient #4 had a history of kidney failure and received hemodialysis on Mondays, Wednesdays and Fridays. At 4:05 p.m., the patient's weight was documented at 70.94 kilograms (kg) or 156 pounds (lbs). At 6:31 p.m., nursing documentation noted Patient #4's ICD placement procedure was delayed to the next morning due to 2 emergencies. Documentation further stated the patient was on a renal diet.

On 2/01/17 at 11:39 p.m., nursing documentation revealed an assessment of Patient #4's fistula (access for dialysis) located in the right upper extremity. Documentation further stated Patient #4 last received dialysis on 1/31/17, one day prior to presenting for the outpatient procedure.

A review of the Medication Discharge Summary revealed Patient #4 was receiving Renvela (a medication used by dialysis patients to lower phosphorus levels in the blood) beginning on 02/02/17. According to the Discharge Report, Renvela was ordered on [DATE] at 8:45 a.m.

On 02/02/17 at 9:00 a.m., nursing documentation revealed Patient #4 was a dialysis patient and an assessment of the patient's fistula was conducted.

On 02/03/17 at 1:25 a.m., nursing documentation revealed Patient #4 was a dialysis patient and an assessment of the patient's fistula was conducted. The patient's blood pressure was assessed in his/her right arm, which was the same arm the fistula was located at. Additionally, the RN documented the patient received dialysis one-day prior, which indicated 02/02/17. This was in contrast to the nursing admission history on 2/01/17, which stated the patient last received dialysis on 01/31/17.

On 02/03/17 at 10:00 a.m. and at 8:00 p.m., as well as on 02/04/17 at 8:30 a.m., nursing documentation revealed Patient #4 was a dialysis patient and an assessment of the patient's fistula was conducted. However, there was no documentation the facility identified Patient #4 was not receiving his/her routine dialysis treatments.

On 02/04/17 at 10:18 a.m., a Cardiology Progress note documented Patient #4 was weak and that the patient did not feel ready for discharge. Physician documentation noted the plan for the patient's weakness was for physical therapy and case management to see the patient. Patient #4's documented intake was noted on 02/03/17 at 7:00 p.m. to be 1260 ml's and zero mls of fluid output. Further review of the Progress Note revealed no indication the patient had ESRD or was a hemodialysis patient.

On 02/04/17 at 8:00 p.m., nursing documentation revealed Patient #4 was a dialysis patient, 3 days after the patients admission to the facility. There was no documentation the facility identified the patient had not received dialysis since 01/31/17.

On 02/05/17 at 10:28 a.m., nursing documentation revealed Patient #4 was a dialysis patient and an assessment of the patient's fistula was conducted.

On 02/05/17 at 2:45 p.m., the RN documented s/he notified the patient's cardiologist that the patient was a chronic dialysis patient and had not had dialysis since before admission. The RN further documented the patient appeared to be jaundiced (yellow in color) and had not been feeling well. Per the documentation, the physician ordered immediate lab work and a nephrology consultation (a physician who specialized in patients with ESRD). At 5:12 p.m., the Patient #4's weight was documented at 79.9 kg (176.5 lbs). This was a 20.5 lb weight increase from Patient #4's weight of 156 lbs documented on 02/01/17.

A review of the Lab Discharge Summary Report documented the laboratory results from tests drawn on 02/01/17 at 10:45 a.m. and repeated on 02/05/17 at 2:58 p.m. Results from the tests revealed critical levels including the potassium level increased from 4.3 to 6.8 (normal range 3.5-5.0), the blood urea nitrogen (BUN) level increased from 31 to 122 (normal range 7-18), and the creatinine level increased from 4.5 to 14.1 (normal range 0.6-1.1).

On 02/05/17 at 7:47 p.m., a Nephrology Progress Note documented the patient had a history of receiving dialysis treatments at an out patient dialysis center on Mondays, Wednesdays and Fridays with the last dialysis treatment on 01/31/17. Patient #4's plan was to receive emergent dialysis on 02/05/17, (6 days after the patient's last documented dialysis treatment). The physician additionally planned for Patient #4 to receive emergent dialysis again the next morning. The physician noted the patient to have a weight increase and requested to have the patient always admit to medicine on future admissions.

A physician order was placed for Patient #4 to receive hemodialysis on 02/05/17 at 8:28 p.m. Patient #4 received 2 hours of dialysis beginning at 8:08 p.m. on 02/05/17.

On 02/06/17 at 4:02 p.m., a Pulmonary Consultation Note documented Patient #4 was admitted on [DATE] for a placement of an automatic implantable cardioverter-defibrillator (AICD) which was delayed until 02/02/17. The physician noted during this time noted the patient had progressive weakness, shortness of breath and was noted to have an enlarging left sided pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest). During the hospitalization Patient #4 had gained about 9 kilograms (kg) (19.8 pounds). Further documentation revealed the physician suspected the buildup of fluid on the patient lungs, the patient weight gain and slow appearance of pleural effusion (buildup of fluid between the lungs and the chest) over subsequent days were due to missing several sessions of hemodialysis.

Review of a Bedside Post Procedure Report revealed on 02/06/17 at 7:10 p.m., Patient #4 underwent a thoracentesis (insertion of a needle in the space between the lungs and the chest in order to remove excess fluid). The report documented a total of 1.2 Liters of fluid was removed during the procedure.

b) On 04/26/17 at 2:27 p.m., an interview was conducted with Registered Nurse (RN) #8 who stated s/he cared for ESRD patients on the Telemetry Unit. RN # 8 verified the medication Renvela was administered to dialysis patients in order to lower the amount of phosphorus levels in the blood. RN #8 stated the risk of taking a blood pressure on an arm with a fistula present could result in damage or the need to replace the fistula. RN #8 further stated the risk of missing dialysis treatments could result in confusion, swelling, and cardiac issues.

c) On 04/26/17 at 5:05 p.m., an interview with RN #3 was conducted. RN #3 stated s/he was notified of a patient's history of requiring hemodialysis either during report from the patient's previous nurse, by looking at the medical record for the patient's history, or from assessing the patient to see if a fistula was present.

d) On 04/27/17 at 11:11 a.m., an interview was conducted with Nurse Manager of the Intensive Care Unit and the Telemetry Unit (Manager #5). Manager #5 stated s/he was familiar with Patient #4 and confirmed dialysis was not conducted on the patient for several days after s/he presented to the facility. Manager #5 stated the patient was transferred from an observation status to an inpatient status and was planned to be discharged earlier; however, the patient was not feeling well so s/he stayed in the unit for a longer amount of time than planned. This resulted in the patient missing orders for hemodialysis.

Manager #5 then stated the facility sent letters to the RNs involved in Patient #4's care discussing the importance of communication between staff regarding patient care needs. Manager #5 stated s/he had not conducted any further education with the rest of the nursing staff or implemented any practice changes to avoid similar outcomes because s/he was waiting for results from an internal analysis of the incident.

e) On 04/27/17 at 10:20 a.m., an interview was conducted with Physician #6, a nephrologist who specialized in renal patients. Physician # 6 stated hemodialysis was used when patients' kidneys were not working. Dialysis took over and got rid of fluid and waste products. Dialysis was important because the waste products would build up and become life threatening if not removed.

2. Nursing staff failed to obtain patient weights as ordered by the physician.

a) On review of Patient #2's History and Physical, dated on 03/06/17 at 9:09 a.m., Patient #2 presented to the Emergency Department (ED) for emergent dialysis.

On 03/06/17 at 11:30 a.m., an order was placed by the physician to obtain the patient's weight prior to each procedure and at the completion of dialysis. The patient's weight was documented in the Nursing Admission Assessment note at 12:25 p.m. at 53.97 kg (118.73 lb) and on the Acute Hemodialysis Flow Sheet (flow sheet) as pre weight of 54.0 kg and post weight of 51 kg.

The patient received dialysis again on 03/07/17 at 7:05 a.m. On review of the nursing documentation and the Hemodialysis Flow Sheet, there was no further documentation of the patient's weight prior to or at the completion of the dialysis treatment.

b) Review of a Consultation Note on 02/05/17 at 3:32 p.m. revealed Patient #4 (MDS) dated [DATE] for a procedure to place an Implantable Cardioverter Defibrillator (ICD), a small device placed in the chest or abdomen used to help treat an abnormal heartrate. The procedure was delayed until 02/02/17.

Admission orders dated 02/02/17 at 7:38 a.m., instructed nursing staff to obtain Patient #4's daily weights. Nursing documentation on 02/01/17 at 4:05 p.m. revealed the patient's weight was 70.94 kg (156 lbs). The next weight was documented 4 days later on 02/05/17 at 5:12 p.m. at 79.9 kg (176.5 lbs), which was a 20.5 lb increase.

A physician order for Patient #4 to receive hemodialysis was placed on 02/05/17 at 8:28 p.m. An additional order at 8:28 p.m. instructed staff to measure the patient's weight prior to each procedure and at the completion of dialysis. The patient underwent dialysis treatment on 02/05/17 at 8:08 p.m.; however, there was no documented patient weight at the completion of the treatment.

c) Review of Patient #10's Emergency Provider Report revealed the patient (MDS) dated [DATE] at 10:00 a.m. after the patient's spouse found the patient on the floor unarousable. A physician order dated 01/10/17 at 2:57 p.m., instructed nursing staff to obtain daily weights on the patient.

On 01/10/17 at 4:03 p.m., Patient #10's weight was documented at 80.29 kg (177 lbs). The weight source was documented as reported by the patient.

On 01/11/17 at 5:42 a.m., the patients weight was documented at 85.72 kg and the weight source was documented as obtained by the patient's bed scale. This was 5 kg (11 lbs) higher than the previous day.

On review of documentation for 01/12/17, 01/13/17 and 01/14/17 (the date of discharge), there was no documentation of the patient's weight, which was in contrast to the physician's order for daily weights.

d) Review of Patient #11's Emergency Provider Report revealed the patient (MDS) dated [DATE] at 3:26 p.m. with a chief complaint of general malaise and a history of chronic kidney disease. A review of Patient #11's orders for 01/11/17 at 10:30 p.m. revealed a physician order to obtain daily weights for the patient. The patient's weight was documented in a Rapid Assessment Note at 3:30 p.m. at 89.81 kg and then again in a Clinical Documentation note at 10:54 p.m. at 98.70 kg (a difference of 8.89 kg). This was the only documented patient weight, although the patient was in the facility until 01/16/17.

e) On 4/26/17 at 1:54 p.m., an interview was conducted with RN #1, who revealed s/he was contracted with the facility to conduct dialysis treatments for patients. RN #1 explained all patients receiving dialysis were expected to have weights obtained and documented prior to and after each treatment. RN #1 stated s/he would obtain patient weights either from the patient's bed scale, from the medical record or on a scale located in the dialysis unit. RN #1 then stated the scale used for patients in the dialysis unit was currently broken s/he and was unsure how long the scale had been broken. RN # 1 stated s/he had been getting weights from the patients' medical record in the computer.

f) On 04/27/17 at 11:11 a.m., an interview was conducted with Nurse Manager #5 who stated monitoring patient weights was an important assessment for many types of diagnoses and that RN's were expected to follow physician orders with weighing patients. Manger #5 also identified a 2-pound weight change in a 24-hour period would be important to notify a physician due to possible fluid overload.

g) 04/26/17 2:11 p.m., an interview was conducted with Clinical Education Specialist (CES #4), who was in charge of staff education for the hospital units for the facility. CES #4 stated daily weights in renal patients were important to monitor for fluid retention and anything over 5-8 pounds was a significant weight gain for a renal patient. CES #4 further stated s/he was unsure if staff had access to a policy offering guidance on obtaining patient weights and notifying physicians of abnormal weight findings.

Violation Name: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION(A-0123)

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Based on interviews and document review, the facility failed to ensure patients or their representatives who reported grievances were provided written responses of the findings from the facility's investigation of the issues reported by the complainant in 2 of 3 grievance documentation records reviewed (Patients #2 and #10).

This failure resulted in a deviation from the facility's approved grievance process and the potential for patients or their representatives to be unaware of the outcome of their grievance.

FINDINGS

POLICY

According to Patient Grievance Mechanism Plan, in the resolution of the grievance, the facility will provide the patient with a written response of its decision that will contain: the facility's contact person; the steps taken on behalf of the patient to investigate the grievance; the results of the grievance process; and the date of completion. Contact information for other individuals or entities the patient may contact, if they are not satisfied with the Patient Advocate's response, will be provided in the written response.

1. The facility failed to send written responses regarding the facility's contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion in accordance with the facility's policy.

a) Review of the Patient Experience Coordinator's (PEC #1) grievance documentation revealed Patient #2 and his/her nephew called on 09/27/16 and spoke with PEC #1 regarding the care of Patient #2. Care concerns included the patient receiving medication s/he was allergic to and the patient's blood pressure on discharge was elevated and not addressed appropriately by staff.

A letter dated 09/28/16, one day after Patient #2 called PEC #1 with concerns, was addressed to Patient #2. The letter thanked him/her for sharing concerns and stated the concerns were being investigated by the Quality Outcomes Department. No further documentation was found notifying Patient #2 or his/her family of the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion of the investigation. This was in contrast with the facility's Grievance Mechanism Plan.

b) Review of PEC #1's grievance documentation revealed Patient #10 called on 09/13/16 and spoke with PEC #1 regarding concerns from a recent hospital visit regarding Patient #10 receiving narcotic pain medications after s/he requested none be given due to severe allergies and sensitivities to these medications in the past.

A letter dated 09/13/16, the same day Patient #10 called PEC #1 with concerns, was addressed to Patient #10. The letter thanked the patient for sharing concerns and stated the concerns were being investigated by the Quality Outcomes Department. No further documentation was found notifying Patient #10 of the steps take on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion of the investigation.

c) On 01/05/17 at 1:36 p.m., an interview was conducted with PEC #1 and the Vice President of Quality (VP #2). PEC #1 stated his/her role included documenting and taking care of grievances received at the facility. PEC #1 stated s/he did not send written documentation to complaints after the investigation was completed notifying them of the results of the investigation.

During the same interview, VP #2, revealed s/he was previously in charge of the grievance process for the facility. VP #2 stated s/he was not aware that sending written notification of the results of grievance investigations to complainants was required.

Violation Name: PATIENT RIGHTS: RESTRAINT OR SECLUSION(A-0168)

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Based on interviews and document review, the facility failed to ensure an order was obtained from a physician or Licensed Independent Practitioner (LIP) prior to the initiation of physical restraints in 1 of 4 medical records reviewed of patients with documented use of physical restraints (Patient # 2).

This failure created the potential for an unsafe patient care environment in which the responsible attending physicians or practitioners were not aware of patients' medical needs and current health status.

FINDINGS:

POLICY

According to Patient Restraint/Seclusion, an order for restraints or seclusion must be obtained from a LIP/physician who is responsible for the care of the patient prior to the application of restraint or seclusion. When a LIP/physician is not available to issue a restraint or seclusion order, a RN with demonstrated competence may initiate restraint or seclusion use based upon face-to-face assessment of the patient. In these emergency situations, the order must be obtained during the emergency application or immediately (within minutes) after the restraint or seclusion is initiated.

1. The facility did not ensure restraint orders were obtained prior to or immediately after placing patients in physical restraints.

a) Review of the Clinical Documentation record, dated 07/02/16, revealed Patient #2 was in non-violent physical restraints on 07/02/16 at 10:00 p.m.; however, there was no order for restraints until 07/03/16 at 2:45 p.m. (16 hours and 45 minutes after the restraints had been initiated). This was in contrast to the policy which stated to notify a practitioner immediately, within a few minutes, to obtain an order.

b) On 01/05/17 10:10 a.m., an interview was conducted with Registered Nurse (RN #3), who recalled caring for Patient #2 on the night shift of 07/02/16. RN #3 stated s/he would typically obtain a verbal order from a physician to initiate restraints and then s/he would enter the order in the electronic order system. RN #3 stated s/he thought s/he had entered the physician's order for initiating restraints for Patient #2; however, after reviewing the medical record with RN #3, no documentation regarding restraints was found. RN#3 stated the facility's expectation was for staff to obtain a doctor's order within the hour of initiation of physical restraints.

c) On 01/04/17 at 2:50 p.m., an interview was conducted with the Chief Nursing Officer (CNO #7). After reviewing the Medical Record of Patient #2, CNO #7 confirmed restraints were initiated on 07/02/16 at 10:00 p.m. and there was no order to initiate restraints until 07/03/16 at 2:45 p.m. CNO #7 stated this was outside of the expectation and policy of the facility for restraints.

Violation Name: ADMINISTRATION OF DRUGS(A-0405)

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

Based on interviews and document reviews, the facility failed to ensure patients with allergies did not receive medications they were documented to be allergic to in 1 of 10 medical records reviewed (Patient #2).

This failure resulted in a patient receiving a medication s/he was allergic to.

FINDINGS

POLICY

According to Patient Assessment and Reassessment, all admitted patients will have the following data collected/addressed in their initial screening (based on the patient's condition): Allergies.

According to Medication Errors, medication errors, including errors that do not reach the patient must be reported promptly and accurately via the Clinical Patient Care System Occurrence Reporting process in an effort to identify opportunities to improve the medication use process.

Types of errors include, but are not limited to: contraindication/allergy: Administration of a medication that has contraindications with the patient's current regimen or disease state or the patient has a stated allergy to the medication.

1. Facility staff administered two doses of morphine to a patient with a documented allergy to the medication.

a) Review of Patient #2's Emergency Patient Record (EPR) revealed the patient presented to the Emergency Department (ED) on 07/02/16 at 6:43 p.m. with a chief complaint of vertigo and dizziness. The only allergy listed on the Allergies section of the EPR was sulfonamide antibiotics (Sulfa) with an unknown reaction, which was verified on 07/02/16.

Review of Patient #2's History and Physical (H&P) on 07/02/16 at 9:57 p.m. revealed the patient (MDS) dated [DATE] with a chief complaint of syncope. Patient #2's care plan included a referral to a cardiology physician with plans to urgently take the patient to the catheterization laboratory for placement of a temporary pacemaker. Sulfonamide antibiotic (Sulfa) was the only allergy documented under the Coded Allergies section of the H&P.

Patient #2's medical record revealed faxed documents were received from a separate health care facility on 07/02/16 at 7:49 p.m. The documents included information of Patient #2's medical history, including current medications and allergies. Patient #2 was listed as having 4 allergies under the Allergies section of the document. Allergies listed included Morphine Sulfate, which was noted on 02/05/02 with reactions documented as skin rash and/or hives, other.

Patient #2's Emergency Patient Record showed documentation from RN #2 on 07/02/16 at 8:24 p.m., which stated the patient's nephew asked if Patient #2's medication list from a separate health care facility was seen by anyone. The physician stated yes, I physically saw it and reviewed all of his/her medications.

According to Patient #2's physician orders, on 07/02/16 at 9:45 p.m., Morphine, 2 milligrams (mg) via intravenous (IV) route every four hours as needed for pain was ordered. The order was discontinued on 07/03/16 at 9:35 a.m.

Review of Patient #2's Medical Administration Record (MAR) revealed the patient received 2 doses of Morphine by Registered Nurse (RN #1); the first dose given on 07/03/16 at 12:40 a.m. and the second dose given on 07/03/16 at 6:22 a.m.

Review of Patient #2's Allergy History revealed Morphine was added to the patient's allergy list on 07/05/16 at 12:07 p.m. by Pharmacist #3, which was 3 days after the documented receipt of the fax stating the patient was allergic to Morphine.

b) On 01/05/17 at 10:59 a.m., and interview was conducted with RN #4 who revealed s/he worked as a nurse in the ED. RN #4 stated typically allergies were assessed and documented by the ED nurse during the initial triage process. If documents from an outside facility containing patient medical information were received by the ED nurse, the expectation was for the nurse to make a photo copy of the document, label the document with the patient's identification information and place the document in the medical record. RN #4 stated allergy information could be updated at any time during the patient's visit.

RN #4 recalled caring for Patient #2 in the ED on 07/02/16. RN #4 stated s/he remembered Patient #2's family asking if staff had received the patient's medication list. RN #4 further recalled Patient #2's physician discussing the patient's medication list with the family. However, RN #4 stated s/he did not recall if allergies were discussed at this time. RN #2 further stated s/he never saw the medication list from the outside facility.

c) On 01/05/17 at 10:10 a.m., in interview was conducted with RN #3 who revealed s/he worked in the ICU. RN #3 stated when receiving a new patient s/he would typically verify the patient's allergies and reactions with the patient. RN #3 then recalled caring for Patient #2 on the night shift of 07/02/16. RN #3 stated s/he did not remember seeing a faxed document with Patient #2's allergies listed before s/he administered Morphine to the patient. RN #3 stated s/he did recall Patient #2 telling him/her about having nausea after receiving morphine a long time ago. RN #3 further stated s/he thought s/he had documented the morphine in the sensitivities section of the medical record; however, after reviewing the medical record with RN #3, no documentation regarding morphine sensitivity was found.

d) On 01/15/17 at 9:49 a.m., an interview with Pharmacist #5 was conducted. Pharmacist #5 stated the process for assessing and documenting patient allergies began when the patient arrived at the facility. The patient's nurse or physician was expected to ask the patient about allergies and enter them into the medical record. The pharmacist would then clarify any missing allergy information with either the patient or the patient's nurse.

After reviewing the allergy section of Patient #2's medical record, Pharmacist #5 verified that s/he had entered the patient's allergy information on 07/05/16 from the document received on 07/02/16 from a separate health care facility. Pharmacist #5 stated s/he could not remember how s/he had received the faxed document or why the allergy information had not been entered into Patient #2's medical upon receipt of the document.

Pharmacist #5 stated if s/he had known Patient #2 had received Morphine and Benadryl, s/he would have entered the incident as an occurrence. Pharmacist #5 further stated anyone could have entered the incident into the occurrence system in order for the incident to be looked at more closely by the facility.

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

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Based on facility policy/procedure, review of medical records, review of personnel files, and staff interviews, the facility failed to ensure a Registered Nurse (RN) supervised and evaluated the care for each patient on an ongoing basis. Instead, the facility allowed patient care to be provided independently by Licensed Practical Nurses (LPN). Specifically, one LPN (#12) within the facility routinely provided care to patients without supervision, assistance, or collaboration with an RN, despite the facility's policy and procedure to do so. This failure created the potential for a negative patient outcome and did not ensure all patients were provided care by a Registered Nurse.

Findings:

1. Staff member #12, an LPN, routinely provided independent care, including physical assessments, to patients without oversight or evaluation by an RN.

a. Staff member #12's job description stated the following: The LPN performs delegated duties consistent with his/her scope of practice and functions within the philosophy and overall plan of care delivery at NSMC.

b. The facility's policy titled Patient Assessment and Reassessment, issued 2/11, stated the following: Reassessment must occur by an RN every shift or more frequently as indicated by the patient's condition or by physician order as otherwise defined in specific setting.

c. Review of sample medical record #3 revealed that, on 3/27/13 day shift, the patient was exclusively assessed and cared for by an LPN. No other record of an RN assessment of the patient or care during that shift was found.

d. An interview was conducted with the Medical Surgical Unit's charge nurse on 4/8/13 at approximately 9:15 a.m. When asked if any LPNs worked on the unit, the charge nurse stated one. When asked if the LPN was paired with an RN or had oversight by an RN, the charge nurse stated the LPN did not get paired with an RN. The charge nurse was asked who conducts the physical assessments of patients assigned to the LPN. S/he stated, [S/he] does not do the initial [admission assessment and history] but does all those after that.

e. An interview with the Director of Nursing was conducted on 4/8/13 at approximately 11:00 a.m. When asked about the LPN conducting assessments, s/he stated LPNs could not give intravenous push medications or blood, but they could do all other care and assessments but the initial admission assessment.

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North Suburban Medical Center

26 CMS Violations since 2013-04-11

Non Immediate Jeopardy Violations

Violation Name: None(None-None)

Violation Name: INFECTION PREVENTION CONTROL ABX STEWARDSHIP(A-0747)

Violation Name: INFECTION CONTROL PROGRAM(A-0749)

Violation Name: PATIENT RIGHTS(A-0115)

Violation Name: PATIENT RIGHTS: CARE IN SAFE SETTING(A-0144)

Violation Name: QAPI(A-0263)

Violation Name: PATIENT SAFETY(A-0286)

Violation Name: NURSING SERVICES(A-0385)

Violation Name: STAFFING AND DELIVERY OF CARE(A-0392)

Violation Name: INFECTION PREVENTION CONTROL ABX STEWARDSHIP(A-0747)

Violation Name: INFECTION CONTROL PROGRAM(A-0749)

Violation Name: PATIENT RIGHTS(A-0115)

Violation Name: PATIENT RIGHTS: INFORMED CONSENT(A-0131)

Violation Name: PATIENT RIGHTS: CARE IN SAFE SETTING(A-0144)

Violation Name: NURSING SERVICES(A-0385)

Violation Name: STAFFING AND DELIVERY OF CARE(A-0392)

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

Violation Name: DISCHARGE PLANNING(A-0799)

Violation Name: DISCHARGE PLANNING EVALUATION(A-0806)

Violation Name: NURSING SERVICES(A-0385)

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

Violation Name: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION(A-0123)

Violation Name: PATIENT RIGHTS: RESTRAINT OR SECLUSION(A-0168)

Violation Name: ADMINISTRATION OF DRUGS(A-0405)

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

Respect us. Protect us. Pay us!

North Suburban Medical Center

26 CMS Violations since 2013-04-11

Non Immediate Jeopardy Violations

Violation Name: None(None-None) toolTips('.tooltip_post_id_custom_b7074d39ec1ecb860ff7456715af8952','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>None');

Violation Name: PATIENT RIGHTS(A-0115) toolTips('.tooltip_post_id_custom_3a6c2b9af7e55c24eca88ab1e95a5655','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>A hospital must protect and promote each patients rights\.');

Violation Name: PATIENT RIGHTS: CARE IN SAFE SETTING(A-0144) toolTips('.tooltip_post_id_custom_da1d6a817249f966fe6668118761d60f','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>The patient has the right to receive care in a safe setting\.');

Violation Name: PATIENT RIGHTS(A-0115) toolTips('.tooltip_post_id_custom_541b90d578517a54d9898feaf495aefd','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>A hospital must protect and promote each patients rights\.');

Violation Name: PATIENT RIGHTS: CARE IN SAFE SETTING(A-0144) toolTips('.tooltip_post_id_custom_e0e11bb1dc2f36ca29df6932783497ad','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>The patient has the right to receive care in a safe setting\.');

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395) toolTips('.tooltip_post_id_custom_f9078bc6bd23a937c5c531b40009c8af','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>A registered nurse must supervise and evaluate the nursing care for each patient\.');

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395) toolTips('.tooltip_post_id_custom_9e55215f342731640f3319efb55f9e97','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>A registered nurse must supervise and evaluate the nursing care for each patient\.');

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395) toolTips('.tooltip_post_id_custom_c10a49063612a8b56d8bc31d668f272c','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>A registered nurse must supervise and evaluate the nursing care for each patient\.');

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395) toolTips('.tooltip_post_id_custom_b6457f1dd4817789f1725dc7a81b358a','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>A registered nurse must supervise and evaluate the nursing care for each patient\.');

Violation Name: None(None-None)

Violation Name: PATIENT RIGHTS(A-0115)

Violation Name: PATIENT RIGHTS: CARE IN SAFE SETTING(A-0144)

Violation Name: PATIENT RIGHTS(A-0115)

Violation Name: PATIENT RIGHTS: CARE IN SAFE SETTING(A-0144)

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)