Peninsula Medical Center

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 49264 Based on interview and record review, the facility failed to appropriately document a patient or patient’s representative’s informed consent for 1 out of 31 sampled patients when patient 19’s informed consent form for an Esophagogastroduodenoscopy (EGD, medical procedure where a doctor uses a special camera [endoscope] to view the lining of the esophagus, stomach, and the first part of the small intestine to diagnose or treat digestive issues) was undated and signed by two physicians rather than the patient’s representative and no documentation indicated it was an emergency procedure. This failure has the potential to violate a patient’s right to being informed of their health status, being involved in care planning and treatment, or being able to refuse treatment. Findings: 1. A review of facility policy and procedure (P&P) titled, “Informed Consent Discussion and Documentation”, last approved 09/26/22, indicated, “The goal of informed consent process is to allow each patient to fully participate in the decision about his/her care, treatment or service for the purpose of self-determination ...Procedures that require an Informed Consent are: any surgical procedures ...Any invasive procedure and certain non-invasive high risk procedures preformed outside surgery (including, but not limited to endoscopies ...) ... All pertinent medical records must contain a properly executed and completed written informed consent form for all procedures and treatments specified by the medical staff or state or federal law or regulation, except for those patients deemed emergent by the physician/surgeon ...Completing the Verification of Informed Consent to Surgery or Special Procedure Form: ... 4. Request the patient sign the Verification of Informed Consent to Surgery or Special Procedure form, including the date and time of signature.” A review of Patient 19’s informed consent form titled, “VERIFICATION OF INFORMED CONSENT TO SURGERY OR SPECIAL PROCEDURE”, dated 10/02/25, indicated the consent form was for a “BRONCHOSCOPY [a medical procedure where a doctor uses a special camera (bronchoscope) inserted through your nose or mouth down into your airways and lungs to visually inspect, diagnose, and sometimes treat lung conditions]”. The consent form was signed by the Patient 19’s son, witnessed by a nurse, and was signed and dated 10/02/25 at 12:00 PM. A review of progress note by Medical Doctor (MD) 1, signed 10/02/25 at 12:05 PM, indicated, “I spoke with patient’s son at bedside. He consented on her behalf for bronchoscopy with ... lavage and possible brush [a special way to collect specimens in the lungs to be used for testing]. We discussed the risks and benefits, and he agreed that I should proceed.” A review of a progress note by MD 2 titled, “HOSPITALIST PROGRESS NOTE”, signed 10/02/25 at 4:22 PM, indicated Patient 19 was transferred to the Intensive Care Unit (ICU, specialized hospital department for patients with severe illnesses or injuries needing constant, intensive monitoring and life support) where she was intubated (when a breathing tube is placed to assist someone with breathing). The progress note further indicated, “Surrogate Decision maker: son [name]” with a plan to “monitor for further improvement; plan for EGD today; spoke with son [name] and he agreed with the plan for EGD; also plan for ...bronchoscopy” A review of an operative report by MD 3 titled, “ESOPHAGOGASTRODUODENOSCOPY REPORT”, signed 10/02/25 at 5:27 PM, indicated Patient had an EGD procedure from “1639 (4:39 PM) to 1657 (4:57 PM)”. The report indicated that the reason for the procedure was due to Patient 19’s melena (blood in the stool). During a concurrent interview and record review on 12/18/25 at 9:01 AM with MD 3, Patient 19’s consent form for an EGD titled, “VERIFICATION OF INFORMED CONSENT TO SURGERY OR SPECIAL PROCEDURE”, undated, was reviewed. The consent form indicated that MD 3 was to perform an EGD “with control of bleeding using any method.” The consent form did not have a signature from the patient or the patient’s surrogate decision maker; instead of a patient signature, the form indicated, “unable to sign ...message left with son [name]”. The consent form further indicated it was signed by two different physicians, one of which was MD 3. MD 3 stated that he did preform the EGD for Patient 19 on 10/02/25. MD 3 stated for EGDs, “we have to try to attempt to get consent.” When asked why two physicians signed the consent form, MD 3 stated, “we needed to do the EGD urgently ...could not obtain consent from the patient ...we attempted to contact the immediate family”. When asked why the procedure wasn’t done earlier if the clinical team knew the EGD was necessary, MD 3 stated, “that’s when the anesthesiology staffing was available.” In addition, MD 3 was asked if the consent form was properly executed considering it was signed by two physicians and not dated, MD 3 stated “yes, I would think so.””

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 28225 Based on observation, interview, and record review, the facility failed to ensure one (Patient 10) of 30 sampled patients had a formulated Advanced Directive (a “written” instruction for health care relating to provision of healthcare when a patient does not have the capacity or ability to make decisions for herself). The deficient practice resulted in patient’s rights to accept or refuse medical care needs not established. Findings: During a concurrent observation and interview on 12/15/25 at 11: 20 AM, escorted by Risk Manageent Staff (RMS) 1, Patient 10 was inside her room, in bed, awake but not responsive verbally. Visitor 1 stated she was Patient 10’s family member. Visitor 1 stated, Patient 10 only spoke (another language). Visitor 1 stated she and another family member were the decision maker for Patient 10’S medical care needs during Patient 10’s current hospital stay. During electronic health records (EHR) review of History and Physical, dated 12/5/25 at 2241 (10: 41 PM), for Patient 10 indicated, “ Per ED (emergency department) Triage: Patient presents with CVA (cerebral (brain) vascular accident, stroke -(when blood flow to part of the brain is cut off, causing brain cells to die from lack of oxygen) ... on the floor 2100 (9 PM) with right side deficit (impairment ) ... Plan: Admit to ICU (intensive care unit- specialized department for critically ill or injured patients needing constant, intensive monitoring and life support from a multidisciplinary team) ...” During a concurrent interview and EHR review on 12/16/25 at 9:33 AM, with Registered Nurse (RN)1, RN 1 stated, for Patient 10 the Advance Directive (Medical Healthcare section was not filled out. During an EHR review on 12/16/25 at 9:33 AM, with RN 1, Conditions of Admission And/Or Registration, dated 12/5/2025 at 10:16 PM, for Patient 10 indicated Family Member 1 signed/consented. During a review of paper copy of Conditions of Admission And/Or Registration, dated 12/5/2025 at 10:16 AM, for Patient 10 indicated the document was written in another language which the patient and family members spoke and understood. The paper document was signed by Family Member 1. During a review of facility document titled, Advanced Healthcare Directive Policy, dated 2025, indicated, “Purpose To obtain and record information from the patient regarding his/her Agent or surrogate to provide basic information about their advanced directive ... Through discussion and education, patients are encouraged to communicate their healthcare preferences and values ... Definitions Advance Health Care Directive (AHCD) or Advance Directive (AD) an individual’s health care instructions ... for health care ... Procedure ... only the patient with capacity may provide information about advanced directive. Capacity means a person’s ability to understand the nature and consequences of a decision and to make and communicate a decision, and includes in the case of proposed health care, the ability to understand its significant benefits, risk, and alternatives ... What if the person does not have an AHCD? If a person likes the capacity to make decisions, the physician and healthcare team will usually turn to the most appropriate decision maker from close family or friends at the person ... The most appropriate decision maker is that person who has a close, caring relationship with the person, is aware of the person’s values and beliefs, and is willing and able to make the needed decision ...””

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 49264 Based on interview and record review the facility failed administer medication according to a practitioner’s order for one of 31 sampled patients (Patient 19) when Patient 19’s norepinephrine (a strong medication used to treat dangerously low blood pressure) was not titrated (the process of gradually adjusting a drug’s dosage to achieve the optimal effect while minimizing side effects) in accordance with the practitioner’s order. This failure has the potential for a patient to receive an overdose (an excessive and dangerous amount of a drug) of the norepinephrine causing complications like severely high blood pressure, organ damage, or even death. Findings: A review of the facility’s policy and procedure (P&P) titled, “Medication Administration Policy”, last approved 02/19/25, indicated, “To ensure safe medication administration, the licensed personnel is responsible to: ... Check the prescriber’s order prior to administering the medication to verify it is complete ... The licensed personnel shall review and acknowledge the prescriber’s order for medications including the following parameters: ...Dose of medication ...Frequency of administration ...Licensed personnel administering medications shall always adhere to the ‘Six Rights’: ... The Right dose ...” A review of the facility’s P&P titled, “Titration of Continuous Infusions Policy”, last approved 02/20/25, indicated, “During administration of medication intended to be dosed via titration, doses may be titrated up and down in accordance with the specified dose, frequency, and clinical end point [specific goal of the medication] ...Medications may be titrated according to a ‘titration dose range’. A titration range refer to the titration of a medication by a pre-specified range of acceptable dose/rate changes ...Document each dose change of a titration medication in the EHR [electronic health record] and include the clinical indication for the dose change ....as specified in the medication order ... Document patient’s response to titration ...” A review of nursing documentation titled “Rapid Response Team Documentation”, dated 10/02/25, indicated that a Rapid Response Team (a specialized group of healthcare professionals [like critical care nurses, respiratory therapists, and doctors] who are called to a patient’s bedside in a hospital to quickly assess and treat signs of sudden, serious, and quickly worsening conditions) was called for Patient 19 due to a low blood pressure and Patient 19 was subsequently transferred to the Intensive Care Unit (ICU, specialized hospital department for patients with severe illnesses or injuries needing constant, intensive monitoring and life support). A review Patient 19’s critical care progress note, dated 10/02/25, indicated Patient 19 was in “Shock [life-threatening condition where the body lacks sufficient blood flow] on arrival in ICU” and was started on “norepinephrine”. During a concurrent interview and record review on 12/17/25 at 2:57 PM with the Assistant Nurse Manager of Critical Care (ANMCC), Patient 19’s norepinephrine administration record, dated 10/02/25 was reviewed. The administration record indicated norepinephrine was ordered at a starting dose of 5 micrograms/minute (mcg/min) and could be titrated up or down every minute by 1mcg to reach a desired goal for patient to maintain Mean Arterial Pressure (MAP, the average blood pressure within someone’s arteries, important in determining how well organs are receiving blood) greater than 65. The record indicated Patient 19 was receiving the medication at a rate of 3 mcg/min at 11:22 AM. The administration record further indicated that the rate was increased to 4 mcg/min at 11:37 AM. The ANMCC stated that per this order, norepinephrine should be increased within the parameters until the patient’s MAP maintains above 65 because “if a patient is consistently able to maintain that ...that is your lowest end threshold.” The ANMCC stated that on 10/02/25 at 11:37 AM, patient 19’s norepinephrine was increased (titrated up). During a concurrent interview and record review on 12/17/25 at 3:04 PM with the ANMCC, Patient’s 19’s vitals signs, dated 10/02/25, were reviewed. The vital sign record indicated the following times and vital signs documented on 10/02/25: - 11:00 AM, MAP of 72 - 11:40 AM, MAP of 71 When the ANMCC was asked if Patient 19’s norepinephrine was titrated per the provider order on 10/02/25, the ANMCC stated, “no ...it’s outside the MAP parameter ...something more should have been filed” to explain the increase in dose. During a concurrent interview and record review on 12/17/25 at 3:10 PM with the ANMCC, Patient 19’s norepinephrine administration record, dated 10/15/25, was reviewed. The administration record indicated norepinephrine was ordered at a starting dose of 3 mcg/min and could be titrated up or down every minute by 1mcg to reach a desired goal of a MAP greater than 60 or a systolic blood pressure (the top number in a blood pressure reading, it measures the pressure in your arteries when your heart beats and pushes blood out to the rest of the body) greater than or equal to 90. The record indicated Patient 19 was receiving the medication at a rate of 3 mg/ming at 8:39 PM. The administration record indicated that the rate was increased to 4 mcg/min at 8:46 PM. The ANMCC stated that per this order, norepinephrine should be increased in increments of 1 microgram within the parameters until the patient’s MAP maintains above 65 or a systolic of 90 or above is reached. During a concurrent interview and record review on 12/15/25 at 3:12 PM with the ANMCC, Patient’s 19’s vitals signs, dated 10/15/25, were reviewed. The vital sign record indicated the following times and vital signs documented on 10/15/25: - 8:00 PM, MAP 63 & systolic blood pressure 101 - 8:36 PM, MAP 61 & no documented blood pressure - 9:00 PM, MAP 69 & systolic blood pressure of 119. The ANMCC stated that a MAP of 61 is above the goal and therefore Patient 19 is “maintaining the appropriate MAP Goal.” When asked if Patient 19’s norepinephrine should have been titrated up around 8:36 PM, the ANMCC stated, “no.” When asked if titration was inappropriate based on the patient’s vitals and the order’s parameters, the ANMCC stated “correct [it is inappropriate].””

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 38612 Based on observation, interview, and record review, the facility failed to provide the standardized notice, titled “Important Message from Medicare (IM - describes Medicare beneficiaries’ rights to receive necessary care, their financial responsibility, rights to appeal to discharge, and how to appeal a hospital discharge)” within two days of admission to three of 23 sampled patients with Medicare benefits (Patient 4, 17, and 22) and/or their legal representatives when: 1. For Patient 4, the IM notice was provided three days after admission; 2. For Patient 22, the IM notice was provided eight days after admission; and 3. For Patient 17, the IM notice was provided three days after admission. This failure had the potential for Medicare beneficiary patients and/or their legal representatives to not understand their rights as a hospital inpatient which could result to their inability to effectively make decisions regarding their treatment or care. Findings: 1. Review of Patient 4’s admission records indicated Patient 4 was admitted on 1/29/25 at 6:04 PM. During an interview on 2/5/25 at 9:34 AM, Case Management Supervisor (CMS) 1 stated the IM is given to patients admitted to the hospital with Medicare benefits “within the first two days” of admission “to ensure patients are aware of appeal rights, in case they disagree with the decision for discharge.” During a concurrent interview and record review on 2/5/25 at 11:35 AM with Patient Advocate (PA) 1, Patient 4’s IM, dated 2/1/25, with no time recorded, indicated on the signature line, “telephone consent.” The IM did not indicate who provided the telephone consent. PA 1 stated, “Sometimes if unable to go to the patient, we call to get their consent.” PA 1 verified Patient 4’s IM was given three days after admission, adding it should have been provided “by the 31st (referring to 1/31/25).” 2. Review of Patient 22’s admission records indicated Patient 22 was admitted on 12/16/24 at 1:15 AM. During a concurrent interview and record review on 2/5/25 at 11:56 AM with PA 1, Patient 22’s IM was reviewed. Patient 22’s IM, dated 12/24/24 at 10:45 AM, indicated on the signature line, “verbal given by (Patient 22’s family member).” PA 1 verified the IM was not given until eight days after admission. 31794 3. In an interview on 2/5/25, at 11:13 AM, with PA 1, PA 1 stated, when patients checked in the Registration on admission, the staff would have the patients sign the letter called “Important Message from Medicare” within “48 hours” of admission. The PA 1 stated, the staff would go over the patient’s rights and their rights to “appeal” on discharge and if patient was unable to sign, the staff would reach out to the family or the person assigned as DPOA (Durable Power of Attorney, a legal document that allows someone to manage your finances and property if you are unable to do so). Review of the History and Physical (H&P), dated 1/20/25 at 5:43 PM indicated, Patient 17 presented with the chief complaint of abdominal pain and the Physical Examination section of the H & P indicated, patient was awake, alert and oriented x 3, admitted for “Bowel perforation (a hole in the wall of the small or large intestine) on 1/20/25. In concurrent record review and interview on 2/5/25, at 11:15 AM, with PA 1, the facility’s document titled, “Important Message from Medicare,” was reviewed. PA 1 stated, Patient 1 was admitted on 1/20/25, the IM, dated 1/23/25 at 2:26 PM was not signed by the patient, instead there was a written word “Verbal” on the line that asked for “Signature of patient or representative”, it was “three (3) days” after admission, it should be signed by the patient within 48 hours of admission. Review of the facility’s Policy and Procedure titled, “Registration Accountability Policy” with the Effective date of 6/4/24 indicated, “Procedure: ... C. In addition ... 1. ... 5. Upon inpatient admission of a Medicare beneficiary patient, patient must be provided a copy of Notice called “An Important Message from Medicare about Your Rights”. Staff are responsible for obtaining patient’s or patient representative’s signature to acknowledge receipt of notification upon admission. ... .””

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 31794 Based on interview and record review the facility failed to ensure patients participated in the development of their Plan of Care (a written plan of care outlining individual patient’s mental and physical needs for recovery) for one of 30 sampled patients (Patient 27) when, the Care Plan for Pain was not developed to address the pain issue. This deficient practice had the potential to violate patient’s right to participate in the development, implementation and re-evaluation of all aspects of the plan of care related to her pain. Findings: Review of undated “ADT (Admission, Discharge, Transfer) Event” indicated, Patient 27 was admitted to the facility on 2/2/25 at 9:35 PM. Review of the admission History and Physical (H&P) dated 2/2/25 indicated, Patient 1 was brought in by the ambulance from home to the Emergency Room (ER, area in the hospital staffed and equipped to provide immediate medical care to patients with sudden, serious illnesses or injuries that require life-saving interventions) with the complaint of “worsening abdominal pain”, and was prescribed OxyContin (strong pain medication) following a biopsy (a procedure to remove a piece of tissue or a sample of cells from the body) two days ago in another hospital. The Assessment/ Plan section of the H&P indicated, the diagnoses that included pancreatic mass (lump in the pancreas that can be cancerous or noncancerous) status post biopsy, “now with abdominal pain”, uncontrolled diabetes mellitus (high blood sugar), and chronic pain syndrome. In a concurrent record review and interview on 2/5/25, at 2:14 PM, with the Nurse Manager (NM 1) in the presence of the Director of Risk Management (DRM), the Pain Assessment Flowsheet dated 2/2/25, was reviewed. The Pain Assessment Flowsheet indicated, on 2/2/25 at 9:42 PM, the Numeric Pain Scale (NPS, is a tool for the self-reporting of pain level for use in cognitively functioning verbal adults, as define in the facility policy. The NPS of 0/10 means no pain and the NPS of 10/10 is severe pain) was 2/10 on 2/2/25 at 9:42 PM and the NPS was 8/10 on 2/2/25 at 11:22 PM. Further review of the Pain Assessment Flowsheet indicated the following: the type of pain was “acute pain”, pain location was “abdomen”, pain description was “aching”, pain frequency was “constant”, and the pain onset was “ongoing”. The NM 1 stated, patient had pancreatic mass with recent biopsy and was given pain medication in the ER prior to the admission in the Nursing Unit. The NPS on admission was assessed as 2/10 at 9:42 PM, the NPS went up to 8/10 at 11:22 PM, and Dilaudid (opioid medication that treats severe pain) was administered to the patient for pain control. Record review of the Medication Administration Record (MAR) dated 2/2/25 indicated, “Hydromorphone (Dilaudid) Inj (injectable) 0.25 mg (milligrams)” was administered on 2/2/25 at 11:22 PM. In a concurrent record review and interview on 2/5/25, at 2:17 PM, with the NM 1 in the presence of the DRM, NM 1 searched the list of Care Plans and stated, “I don’t see” the Care Plan for pain. The NM 1 stated, the staff should develop Care Plan for pain because patient came in with pancreatic mass and ongoing pain, it’s “patient’s rights” and the patient has the “right to be humanly be free from pain.” Review of the facility’s Policy and Procedure (P&P) titled, Pain Management Procedure, with the last revised date of 2/22/24 indicated, “Policy: It is the policy ... to respect the patient’s right to pain management ... Procedure, ... B. Pain Management Plan, 1. The patient experiencing pain should have a pain treatment plan developed ... 3. The pain management plan maybe documented in the care plan and/or interdisciplinary. C. Pain Intervention, 1. Pain is treated in accordance with the plan based on an assessment. ... .” Review of the facility’s P&P titled “Policy on Patient Rights” with the last effective date of 4/20/23 indicated, “Procedure: ... Patient Rights: ... 9. Appropriate assessment and management of your pain, ... and to participate in pain management decisions. ... .””

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 31794 Based on interviews and record reviews the facility failed to ensure patients were provided information to formulate their Advance Directive (AD, an individual’s health care instruction or power-of-attorney for health care, as define in the facility policy) upon admission for two patients (Patients 15 and 27) when: 1. For Patient 15, there was no documented evidence the copy of the Advance Directive (AD) was placed in the medical record. 2. For Patient 27, the AD section on the Flowsheet was not completed. These deficient practices resulted in the potential for patient’s inability to exercise their rights to make decisions concerning their medical care including the right to accept or refuse medical care. Findings: 1. Review of the undated “ADT (Admission Discharge Transfer) Event” indicated, Patient 15 was admitted to the facility on 1/29/25. In an interview on 2/5/25, at 1:42 PM, with the Nurse Manager (NM 1) in the presence of the Director of Risk Management (DRM), NM 1 explained, the staff would ask whether the patient has Advance Directive (AD) or not on admission and they would mark the question with a “yes” or “no” answer on the Flowsheet. The NM 1 stated, if the patient has a signed Advance Health Care Directives (AHCD) or signed “POLST (stands for Physician Orders for Life-Sustaining Treatment, it is a medical form that documents a patient’s wishes regarding end-of-life care)” in the past, it would be scanned and placed in the medical record. In a concurrent record review and interview on 2/5/25, at 1:45 PM, with the NM 1 in the presence of the DRM, the “Advance Directive (Medical Healthcare)” section of the Flowsheet dated 1/29/25 for Patient 15, was reviewed. The AD section of the Flowsheet indicated, the box for the AD was marked “yes”, the box that stated, AD information given was marked, “yes”, and the box that stated, patient request assistance was marked, “no”. The NM 1 searched the entire Electronic Health Record (EHR) and stated, “I don’t see” the AD on file and did not see a signed copy of POLST on file. 2. Review of the undated ADT Event indicated, Patient 27 was admitted to the facility on 2/2/25 at 9:35 PM. In a concurrent record review and interview on 2/5/25, at 1:57 PM with the NM 1 in the presence of the DRM, the Flowsheet on Advance Directive dated 2/2/25, was reviewed. The NM 1 searched the “Advance Directives, Medical Healthcare” section of the Flowsheet and stated, “I can’t find the Advance Directives.” The NM 1 stated, the Licensed Nurse (LN) should be completing the information that was asked on the AD such as: Does patient has AD on file? Did the patient request assistance with the AD? Was AD information given? The NM 1 stated, the Flowsheet on AD did not have an answer to the questions asked, it was not completed by the LN on admission. After searching the entire EHR, the NM verified, there was no documentation the staff spoke to patient /or surrogate to determine whether the patient has AD or not and there was no signed AD Health Care Directive or POLST on file. When asked why AD was important to verify when patients were admitted, the NM 1 stated, it was important to be able to follow patient’s wishes when providing medical care. Review of the facility’s Policy and Procedure (P&P) titled, Advance Healthcare Directive Policy, with the last revised date of 8/2/23 indicated, “Policy: ... When a patient has an advance directive the staff will ask for and make an effort to secure a copy to be included in the patient’s medical record so that the patient’s wishes are known and the patient’s agent is identified. ... Procedure: A. Department Responsibilities: Inpatient Setting, 1. The nurse/social worker will fill out the Advance Directive portion of the Electronic Health Record (EHR). ... .” Review of the facility’s P&P titled “Patient Rights”, with the effective date of 4/20/23 indicated, “Purpose: The purpose of this policy is to provide guidance and mechanism by which Patient Rights are protected and exercised ... Procedure: ... Patient Rights: ... 10. Formulate advance directives. This includes designating a decision maker if you become incapable of understanding a proposed treatment ... .””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 31794 Based on interviews and record review the facility failed to ensure the use of restraint (any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely and is not a normal part of treatment, as per facility policy) was discontinued at the earliest possible time for one of 30 sampled patients (Patient 1) when, the bilateral (means both) mittens (a type of restraint, which are soft, padded gloves worn on one or both hands to prevent patients from harming themselves or others, or from disrupting medical treatment), applied for “pulling lines/tubes”, were not discontinued when the patient developed altered level of consciousness (change in the person’s level of alertness and arousal), became “unresponsive (no reaction to stimulation, such as touch, sound, or activity)” and “obtunded (difficult to arouse)” following a Rapid Response Team (RRT, a group of healthcare professionals, typically including nurse(s) and a physician, who are called to a patient’s bedside when their condition is rapidly deteriorating) interventions on 1/24/25 at 12:18 PM. The bilateral mittens were re-started/re-applied on 1/24/25 at 3:00 PM and continued until 1/25/25 at 5:00 AM. The patient was placed on “Comfort Care (type of medical care that focuses on relieving pain and other symptoms for patients who are near the end of their life)” and passed away on 1/25/25 at 12:52 PM. This deficient practice had resulted in the potential to negatively affect the patient’s physical and emotional well-being as well as the patient’s dignity and safety. Findings: In a concurrent record review and interview on 1/30/25, at 1:20 PM, with the Nurse Manager (NM 1) in the presence of the Clinical Effectiveness Consultant (CEC 1), the undated “ADT (Admission Discharge Transfer) Event” was reviewed. The NM 1 stated, Patient 1 was admitted on 1/1/25 at 6:47 PM. Review of the Admission History & Physical (H &P), dated 1/1/25 indicated, patient presented with the chief complaint of “slurred speech” and right sided weakness. The Assessment/Plan section of the H &P indicated, the diagnoses that included right sided hemiparesis (weakness or an inability to move on the right side of the body), dysarthria (speech disorder), and dysphagia (swallowing difficulties) presumed secondary to “CVA (cerebrovascular accident means stroke)”, hypertension (abnormally high blood pressure), and carotid artery disease (arteries in the neck become blocked or narrowed). In a concurrent record review and interview on 1/30/25, at 2:01 PM, the NM 1 and 2, in the presence of the CEC 1, NM 1 stated, restraints were used due to non-violent behavior, four types of restraints were used on the patient, and discontinued at different times such as: bilateral mittens and bilateral soft wrist restraint (medical device where soft, fabric-like restraints are applied to both wrists of a patient, limiting their arm movement due to “pulling lines/tube” and a “vest” (a sleeveless garment that’s placed over a patient’s clothing to prevent them from falling or climbing out of bed or a chair) and raising the four (4) bed side rails up, due to patient “climbing out of the bed”. In a concurrent record review and interview on 2/5/25, at 10:05 AM, with the NM 1 and 2 in the presence of the Director of Risk Management (DRM) and the Quality Specialist (QS 1), the Flowsheet for Restraints dated 1/24/25 and 1/25/25, were reviewed. The Flow sheet dated 1/24/25 at 3:00 PM, indicated, Restraint Type: Mitts, Bilateral ... Start, ... Continued ... Restraint order Before Application: yes, ... Restraint Monitoring Q (every) 2 (two) Hours, Visual Check: patient asleep, ... .” The NM 2 stated, on 1/24/25 at 3:00 PM, the bilateral mittens were re-started and continued until 1/25/25. Review of the Physician’s Order, dated 1/24/25 at 3:12 PM indicated, “Type of restraint: Mitts (mittens) Bilateral, Reason(s) for restraint: pulling lines, pulling tubes”. In a concurrent record review and interview on 2/5/25, at 1:32 PM, with the NM 1 and 2 in the presence of the DRM and the QS 1, the Rapid Response Team (RRT) Documentation dated 1/24/25, was reviewed. The RRT Documentation dated 1/24/25 at 12:18 PM indicated, “RRT was called for AMS (altered mental status, means change in mental functioning) ... Assessment: ... unresponsive despite painful stimuli ... patient con’t (continued) to be unresponsive. ... .” The NM 2 stated, Ativan (prescription medication that produces calming effect) IV (intravenously) was administered prior to the RRT being called on 1/24/25 at 12:18 PM and the RRT was called due to altered mental status and “unresponsive.” Review of the Medication Administration Record (MAR) dated 1/24/25 indicated, four (4) milligrams of Ativan (also known as Lorazepam) was administered intravenously at 11:59 AM on 1/24/25. In a concurrent record review and an interview on 2/5/25, at 1:38 PM, with the NM 1 and 2, in the presence of the DRM and the QS 1, the RRT Documentation dated 1/24/25 at 4:50 PM and 1/25/25 at 3:15 AM were reviewed. The RRT Documentation dated 1/24/25 at 4:50 PM indicated, “RRT was called for prolonged ALOC (Altered Loss of Consciousness), obtundation (dulled or blunted sensitivity). Assessment: flexion (bending an arm or leg) to deep painful stimuli in BLE (bilateral lower extremity, means both legs), nothing in the upper extremity (both arms). ... .” The NM 2 stated, another RRT was called at 4:50 PM due to “prolonged altered mental status and “obtundation.” Review of the RRT Documentation dated 1/25/25 at 3:15 AM indicated, “RRT called for altered level of consciousness and increase o2 (oxygen) requirement ... Assessment: Pt (Patient) obtunded ... not responding to pain or vigorous stimuli. ... .” The NM 2 stated, another RRT was called on 1/25/25 at 3:15 AM, due to altered loss of consciousness and prolonged oxygen requirement, from oxygen use at 2 liters (L)/ min (per minute) using nasal cannula to 15 L/min using a non-rebreather mask (NRB, a breathing device use to provide high concentrations of oxygen) and the patient was “intubated (tube is inserted through the mouth or nose into the trachea (windpipe), a form of life support)”. The NM 2 further stated, the patient was transferred to the Intensive Care Unit (ICU, area in the hospital that provides specialized care for patients who are critically ill or injured) on 1/25/25 at 4:10 AM, was placed on Comfort Care, and passed away on 1/25/25 at 12:52 PM. When asked when the bilateral mittens should had been discontinued, the NM 1 stated, there was a change in the level of consciousness on 1/24/25 at 12:18 PM, the bilateral mittens should had been discontinued and not re-started at 3:00 PM on 1/24/25. The NM 2 stated, the bilateral mittens were discontinued on 1/25/25 at 5:00 AM. Review of the Discharge Summary, dated 1/25/25 indicated, the Discharge Diagnoses that included, left temporal (side of the skull behind the ears) brain tumor due to glioblastoma (brain cancer), right sided weakness and expressive aphasia (difficulty in producing speech or forming words). Review of the facility’s Policy and Procedure titled, “Restraint Use and Management” with the last revised date of 8/18/22 indicated, “Procedure: (non-Violent and Violent). ... B. Orders for Restraints 1. Non-violent (Non-Self-Destructive) Restraint Orders: ... c. Implementation of a time-limited order for restraint does not require application of the restraint for the entire period. If the patient demonstrates reduction in the activity/behavior that led to the restraint, restraint or seclusion must be discontinued at the earliest possible time. Regardless of the length of time identified in the order. ... .””