Providence St. Jude Medical Center

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital 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. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the hospital’s P&P for the grievance process was followed with a written notice of its decisions. This failure resulted in the increased risk of a failed grievance process. Findings: Review of the hospital’s P&P titled Patient/Family Compliant and Grievance Process dated 4/2025, showed the following: * The patient or patient representative will receive verbal or written acknowledgement of receipt of the grievance and information regarding the process for investigating and responding to grievances within seven days of receipt. Once a concern or complaint has been identified as a grievance, every attempt will be to made to resolve the grievance within seven working days or as soon as possible. * A grievance is considered resolved when the patient is satisfied with the actions taken on their behalf. In situations where the organization has taken appropriate and reasonable actions on the patient’s behalf in order to resolve the grievance and the patient or the patient’s representative remains unsatisfied with the actions taken, the organization will consider the grievance closed. On 8/6/26, list of grievance was requested. The random grievance was selected to review. Review of grievance log showed #23 grievance was filed on 6/22/26. When requested for documentation of grievance letter, the copy of e-mail was provided. Review of the e-mail the hospital provided dated 6/25/26 at 1626 hours, showed “this email is in response to your online submission we received on June 18, 2026. We understand your concerns were addressed. Please contact us if you have any additional concerns.” However, further record review failed to show the follow- up letter including if the grievance was resolved and what had taken appropriate and reasonable actions. On 8/7/26 at 0845 hours, the Director of Risk Management and Regulatory verified the above findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the care plan was updated to reflect the use of violent restraints for one of seven sampled patients (Patient 5). This failure created the risk of substandard outcomes to the patient. Findings: Review of the hospital’s P&P titled Restraints dated May 2024 showed the use of restraint or seclusion (including drugs or medications used as restraint as well as physical restraint) must be documented in the patient’s plan of care or treatment plan. On 8/7/26, Patient 5’s open medical record was reviewed. Patient 5’s medical record showed Patient 5 was admitted to the hospital on 8/2/26. Review of the physician’s order dated 8/2/26 at 1422 hours, showed to apply hard restraints to all four extremities. Review of the Flowsheet dated 8/2/26, showed the restraints were initiated at 1315 hours and were discontinued at 1500 hours. However, further review of Patient 1’s medical record failed to show the care plan for the use of restraints. On 8/7/26 at 1330 hours, the Director of Risk Management and Regulatory and ED Nurse Manager verified the above findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the monitoring for violent restraint was consistently performed as per the hospital’s P&P for one of seven sampled patients (Patient 6). This failure posed the risk of substandard outcomes to the patients. Findings: Review of the hospital’s P&P titled Restraint for Violent/Seclusion/Self-Destructive Behavior dated 5/2025, showed the following: * Monitoring/assessing the patient after administration of the chemical restraint is ongoing and will include but is not limited to: - Vital signs (VS) including pulse, blood pressure, and respirations. - VS measurements must occur every 15 minutes for the first hour after administration of the chemical restraint. - If there is no notable change from the patient’s baseline, the VS frequency may return to the unit’s protocol. On 8/7/26, Patient 6’s closed medical record was reviewed. Review of Patient 6’s medical record showed Patient 6 was admitted to the hospital on 6/14/26 and was discharged on 6/15/26. Review of Order dated 6/15/26 at 0212 hours, showed to apply soft restraints to right and left upper extremities for violent behavior. Review of Care Plan Notes dated 6/15/26 at 0738 hours, showed at 0300 hours, Patient 6 was slightly more alert and attempted to kick a nurse. Patient 6 ripped out IV with her teeth, and security was called. Haldol (an antipsychotic medication) IM was given. Review of the Medication showed Haldol 5 mg IM as needed every six hours for agitation was ordered on 6/14/26 at 1803 hours, and the Haldol was administered to Patient 6 on 6/15/26 at 0311 hours. Review of Flowsheet History dated 6/15/26, showed Patient 6’s VS were measured at 0238 and 0835 hours. Further review of Patient 6’s medical record failed to show VS were measured every 15 minutes for first hour after Haldol was administered. On 8/10/26 at 0930 hours, the Accreditation Program Manager verified the above findings.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the nursing staff provided the necessary care to three of seven sampled patients (Patients 1, 3 and 4) in the ED as evidenced by: 1. The nursing staff failed to measure the vital signs for Patients 3 and 4 as per the physician’s order. 2. The nursing staff failed to perform the pain assessment/reassessment for Patients 1 and 3, as per the hospital’s P&P. These failures had the potential to result in substandard care to the patients. Findings: 1. a. On 8/6/26, Patient 3’s closed medical record was reviewed. Patient 3’s medical record showed Patient 3 arrived in the ED on 5/26/26 at 1509 hours. Patient 3 was admitted to the unit on 5/27/26 at 1622 hours and was discharged on 6/3/26. Review of the Patient Care Timeline for Patient 3 dated 5/26/26 at 1531 hours, showed an order to measure vital signs every hour four times and every four hours five times. Review of the Patient Care Timeline for Patient 3 dated 5/27/26 at 0600 hours, showed Patient 3’s vital signs were measured. Further review of Patient 3’s medical record failed to show Patient 3’s VS was measured every hour four times as physician’s order. b. On 8/6/26, Patient 4’s closed medical record was reviewed. Patient 4’s medical record showed Patient 4 arrived in the ED on 6/7/26 at 0724 hours. Patient 4 was admitted to the unit on 6/7/26 and was discharged on 6/16/26. Review of the Patient Care Timeline for Patient 4 dated 6/7/26 at 0734 hours, showed an order to measure vital signs every hour four times and every four hours five times. Review of the Patient Care Timeline for Patient 4 dated 6/7/26, showed Patient 4’s vital signs were measured at 0828, 0830, 0847, 0900, and 1000 hours. Further medical record review failed to show the last set of hourly VS. 2. Review of the hospital’s P&P titled Pain Assessment and Intervention dated 5/2026, showed the following: * Initial pain assessment includes onset, duration, location(s), quality, intensity, variation and patterns, aggravating/relieving factors, and comfort goal. * Patients must be asked about the presence of pain when routine vital signs are taken. Pain is assessed and documented by licensed personnel. * Patient with identified pain will be assessed and documented a minimum of every four hours. * Pain will be reassessed after interventions to evaluate their effectiveness. a. On 8/6/26, Patient 1’s closed medical record was reviewed. Patient 1’s medical record showed Patient 1 arrived in the ED on 3/31/26 at 1648 hours. Patient 1 was admitted to the unit on 4/1/26 at 0111 hours and was discharged on 4/13/26. Review of the Patient Care Timeline for Patient 1 dated 3/31/26 at 1649 hours, showed Patient 1’s arrival complaint was leg pain. Review of the Patient Care Timeline for Patient 1 dated 4/1/26 at 0035 hours, showed Patient 1 reported four out of 10 pain (zero being no pain and 10 being the worst pain) level to right leg. However, further review of Patient 1’s medical record failed to show complete pain assessment including onset, duration, location(s), quality, intensity, variation and patterns, aggravating/relieving factors, and comfort goal. b. On 8/6/26, Patient 3’s closed medical record was reviewed. Patient 3’s medical record showed Patient 3 arrived in the ED on 5/26/26 at 1509 hours. Patient 3 was admitted to the unit on 5/27/26 at 1622 hours and was discharged on 6/3/26. Review of the Patient Care Timeline for Patient 3 dated 5/26/26 at 1509 hours, showed Patient 3’s arrival complaint was abdominal pain. Review of the Patient Care Timeline for Patient 3 dated 5/26/26, showed the following: * At 1524 hours, Patient 3 reported 10 out of 10 pain to abdomen. However, further review of Patient 3’s medical record failed to show complete pain assessment including onset, duration, location(s), quality, intensity, variation and patterns, aggravating/relieving factors, and comfort goal. * At 1807 hours, Dilaudid (a pain medication) 0.5 mg IV was ordered. * At 1824 hours, Dilaudid 0.5 mg was administered. * At 2049 hours, Dilaudid 1 mg IV was ordered. * At 2110 hours, Dilaudid 1 mg was administered for pain level nine out of 10. (Further medical record review failed to show the effectiveness of the medication given at 1824 hours prior to the 2nd dose of the medication. In addition, the pain assessment did not include pain location). * At 2237 hours, Dilaudid 1 mg IV was ordered. * At 2250 hours, Dilaudid 1 mg was administered. However, there was no documentation of pain level and location for this pain medication. * On 5/27/26 at 0942 hours, Patient 3 reported nine out of 10 pain to abdomen. However, further medical record review failed to show the effectiveness of the medication given on 5/26/26 at 2250 hours. On 8/7/26 at 1330 hours, the Director of Risk Management and Regulatory and ED Nurse Manager verified the above findings.”

“INTEGRATION OF EMERGENCY SERVICES CFR(s): 482.55(a)(2) [If emergency services are provided at the hospital --] (2) The services must be integrated with other departments of the hospital. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the admission assessment was performed for one of five sampled patients (Patient 2) after Patient 2’s level of care was changed to the telemetry care level while boarded in the ED. This failure had the potential to result in substandard care for the patient. Findings: Review of the hospital’s P&P titled Assessment and Documentation dated March 2025 showed the following: * The admission document criteria should be completed. * Complete Physical Assessment - An assessment is done by an RN on admission and will be reassessed throughout the hospital. Assessment is to include consideration of age, psychosocial, environmental, cultural factors and pregnancy status, ability to do self-care, educational needs, and discharge planning factors. On 5/23/25, Patient 2’s open medical record was reviewed. Patient 2’s medical record showed Patient 2 arrived at the ED on 5/22/25 at 1733 hours. Review of the physician’s order dated 5/22/25 at 2054 hours, showed to admit Patient 2 to cardiac telemetry level of care. Review of the ED Provider Notes dated 5/22/25, showed at 2130 hours, based on the patient’s condition and test results, the patient will be admitted at this time. At this time, the care of the patient will be transferred to the admitting service. Review of Patient 2’s medical record dated 5/23/25 at 0800 hours, showed Patient 2’s head to toe assessment was performed (approximately 11 hours and 30 minutes after the admission order). On 5/23/25 at 1042 hours, an interview and concurrent review of Patient 2’s medical record was conducted with RN 5 in the presence of the Director of Risk Management and Executive Director of Critical Case Services. When asked, RN 5 stated the head-to-toe assessment and admission criteria documentation should be completed within 4 hours of the admission. RN 5 stated the electronic medical record showed the items to be completed under “Admit-Arrival.” RN 5 stated the green color next to the items was meaning that it had been completed, and the red color next to the items was meaning that it was incomplete. The incomplete items showed C. Auris Screen, Admit Notification, VS and Pain, Latex Screening, OB Gyn status, Directives, D/C planning, Blood Avoidance, Braden, Skin, Psychosocial, Nutrition, Immunizations, ADL, Care Plan, and Education. On 5/23/25 at 1330 hours, the Director of Risk Management and Accreditation Program Manager verified the above findings.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the nursing staff provided the necessary care to two of five sampled patients (Patients 1 and 5) in the ED as evidenced by: 1. The nursing staff failed to administer the pain medication in a timely manner for Patient 1. 2. The nursing staff failed to perform the pain assessment/reassessment as per the hospital’s P&P for Patients 1 and 5. These failures had the potential to result in substandard care to the patients. Findings: 1. Review of the hospital’s P&P titled Medication Administration and Documentation dated March 2025 showed medications shall be administered in a timely manner. Depending on a variety of factors, including but not limited to the pharmacokinetics of the prescribed medication; specific clinical applications; and patient risk factors, medications (unless otherwise noted) shall be administered at scheduled dosing times. On 5/5/25, Patient 1’s closed medical record was reviewed. Patient 1’s closed medical record showed Patient 1 arrived in the ED on 5/5/25 at 1358 hours and discharged from the ED at 2103 hours. Review of the Patient Care Timeline for Patient 1 dated 5/5/25, showed the following: * At 1429 hours, Patient 1’s chief complaint was right flank pain. * At 1431 hours, Patient 1 complained of pain to the right flank with the pain level of one out of 10 (0 being no pain and 10 being the worst pain). * At 1641 hours, Patient 1 complained of pain to the right flank with the pain level of eight out of 10. * At 1915 hours, Patient 1 received morphine (a pain medication) 4 mg IV. Review of the physician’s order for medication dated 5/5/25 at 1519 hours, showed to administer morphine injection 4 mg scheduled on 5/5/25 at 1525 hours. However, Patient 1 received morphine 4 mg at 1915 hours (three hours and 50 minutes later). On 5/23/25 at 1330 hours, the Director of Risk Management and Accreditation Program Manager verified the above findings. 2. Review of the hospital’s P&P titled Pain Assessment and Intervention dated March 2025 showed the following: * Initial pain assessment includes onset, duration, location(s), quality, intensity, variation and patterns, aggravating/relieving factors, and comfort goal. * Pain will be reassessed after interventions to evaluate their effectiveness. a. On 5/5/25, Patient 1’s closed medical record was reviewed. Patient 1’s medical record showed Patient 1 arrived in the ED on 5/5/25 at 1358 hours and discharged from the ED at 2103 hours. Review of the Patient Care Timeline for Patient 1 dated 5/5/25, showed the following: * At 1429 hours, Patient 1’s chief complaint was right flank pain. * At 1431 hours, Patient 1 complained of pain to the right flank with the pain level of one out of 10. * At 1641 hours, Patient 1 complained of pain to the right flank with the pain level of eight out of 10. * At 1915 hours, Patient 1 received morphine 4 mg IV. * At 2045 hours, Patient 1 reported no pain. However, further review of Patient 1’s medical record failed to show a complete pain assessment including onset, duration, quality, variation and patterns, aggravating/relieving factors, and comfort goal as per the hospital’s P&P. On 5/23/25 at 1330 hours, the Director of Risk Management and Accreditation Program Manager verified the above findings. 36703 b. On 5/5/25, Patient 5’s closed medical record was reviewed. Patient 5’s medical record showed the patient arrived in the ED on 5/23/25 at 0647 hours and discharged from the ED at 0859 hours. Review of the Patient Care Timeline for Patient 5 dated 5/23/25, showed the following: * At 0650 hours, Patient 5’s complained of head pain with the pain level of four out of 10. * At 0656 hours, Patient 5’s chief complaint was updated to show head injury without loss of consciousness after a fall. * At 0857 hours, Patient 5 was assessed by the RN to be in no distress. However, further review of Patient 5’s medical record failed to show complete pain assessment including onset, duration, quality, variation and patterns, aggravating/relieving factors, and comfort goal as per the hospital’s P&P. On 5/23/25 at 1330 hours, the Director of Risk Management and Accreditation Program Manager verified the above findings.”

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 39199 Based on interview and record review, the hospital failed to ensure the nursing staff followed the hospital’s P&P for the administration of blood and blood products for three of four sampled patients (Patients 1, 2, and 3) as evidenced by: 1. For Patient 1, the physician’s order to transfuse Red Blood Cells (PRBC) over one hour was not followed, and complete vital signs were not assessed and documented during the blood transfusion. 2. For Patient 2, there was no documentation to show if the patient had any suspected transfusion reaction, and complete vital signs were not assessed and documented during the blood transfusion. 3. For Patient 3, the transfusion was not started within 30 minutes from the time the unit of blood was issued from the blood bank. This posed the risk of potential complications, including undetected changes in the patient’s condition, delayed interventions, and overall compromised patient safety during the blood transfusion process. Findings: Review of the hospital’s P&P titled Transfusion Reaction dated April 2024 showed patients are to be observed frequently during the transfusion, including monitoring of vital signs and temperature. Vital signs should be taken prior to starting the transfusion, 15 minutes after starting the transfusion, every hour thereafter and at the end of the transfusion, and documented on the transfusion record. Signs or symptoms of a possible adverse effect include fever (rise of 1 degree Celsius or 2 degrees Fahrenheit). Review of the hospital’s P&P titled Transfusion Therapy dated April 2025 showed transfusion must be started within 30 minutes from the time the unit of blood was issued from the blood bank. Review of the hospital’s Transfusion Service Scope of Practice and Clinical Service Agreement showed the blood bank provides optimal storage conditions for each type of blood component, according to regulatory requirements. Prolonged storage outside of these limitations compromises the safety, purity, and the potency of the blood product. A transfusion must either be started, or the blood returned to the blood bank within 30 minutes of issue. 1a. On 5/15/25 at 1022 hours, medical record review for Patient 1 was conducted with the Accreditation Program Manager. Patient 1’s medical record showed the patient was admitted to the hospital on 2/7/25. Review of the physician’s order dated 5/8/25 at 0751 hours, showed to transfuse one unit of PRBC over one hour. However, review of Patient 1’s Blood Administration Flowsheet showed the one unit of PRBC was transfused on 5/8/25 at 1048 hours and completed at 1342 hours, over approximately three hours instead of the rate ordered by the physician. b. Further review of Patient 1’s medical record showed there was no documented evidence Patient 1’s temperature was assessed on 5/8/25 at 1300 hours. On 5/15/25, during the interview and concurrent record review, the Accreditation Program Manager verified the findings. 2a. On 5/15/25 at 1117 hours, medical record review for Patient 2 was conducted with the Accreditation Program Manager. Patient 2’s medical record showed the patient was admitted to the hospital on 5/7/25. Review of the physician’s order dated 5/8/25 at 0352 hours, showed to transfuse two units of PRBC to Patient 2. Review of Patient 2’s Blood Administration Flowsheet showed the first unit of PRBC was transfused from 5/8/25 at 0445 hours to 0759 hours, with no suspected transfusion reaction. The second unit of PRBC was transfused from 5/8/25 at 1115 hours to 1323 hours; however, there was no documentation to show if the patient had any suspected transfusion reaction. On 5/15/25 at 1411 hours, an interview was conducted with Nurse Manager 1 who stated the nurses were supposed to document whether or not the patient had a suspected reaction to the blood transfusion at the end of the transfusion. b. Further review of Patient 2’s medical record showed that there was no documented evidence Patient 2’s temperature was assessed on 5/8/25 at 0700 (hourly) and 0759 hours (at the end of the transfusion of the first unit), and vital signs were not assessed and documented on 5/8/25 at 1323 hours, at the end of the transfusion of the second unit. On 5/15/25, during the interview and concurrent record review, the Accreditation Program Manager verified the findings. 3. On 5/15/25 at 1303 hours, medical record review for Patient 3 was conducted with the Accreditation Program Manager. Patient 3’s medical record showed the patient was admitted to the hospital on 5/11/25. On 5/15/25 at 1055 hours, an interview was conducted with the Blood Bank Supervisor who stated once a type and screen then crossmatch was completed, the unit of blood was released to the nurse who signed a copy of the order, and that order or requisition form was time stamped by the blood bank to indicate the date and time the blood was released to the nurse. Review of the physician’s order dated 5/11/25 at 2105 hours, showed to transfuse one unit of PRBC to Patient 3. Review of the copy of the blood transfusion order signed by the nurse showed the unit of PRBC was released to the nurse on 5/11/25 at 2242 hours. However, review of Patient 3’s Blood Administration Flowsheet showed the unit of PRBC was started on 5/11/25 at 2325 hours, not within 30 minutes of issuance by the blood bank. On 5/15/25 at 1411 hours, an interview was conducted with Nurse Manger 1 who stated blood transfusion must be started within 30 minutes from the time the unit of blood was issued from the blood bank, and the nurse must contact the blood bank for further instructions if they were unable to start the transfusion within the 30 minutes. On 5/15/25, during the interview and concurrent record review, the Accreditation Program Manager verified the findings.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 45560 Based on observation, interview, and record review, the hospital failed to ensure two of six sampled patients (Patients 1 and 2) received care in a safe setting as evidenced by: 1. For Patient 1, Patient 1’s temperature was not rechecked after administering acetaminophen (a medication used to treat pain and reduce fever) as per the hospital’s P&P. In addition, Patient 1’s provider was not notified when Patient 1’s oxygen saturation level was below 93% as per the physician’s order. 2. For Patient 2, the Anesthesiologist did not perform lung auscultation to verify the anesthesia airway placement. These failures had the potential to result in the unsafe care and poor clinical outcomes for the patients. Findings: 1. On 12/3/24, Patient 1’s medical record was reviewed with the Accreditation Program Manager. Patient 1’s medical record showed Patient 1 was admitted to the hospital on 9/13/2024. a. Review of hospital’s P&P titled Range Orders and Multiple PRN Medication Order of Use dated October 2023 showed to reassess the patient when the drug approximately reaches peak effect: 45-75 minutes after PO/Rectal administration. Review of Patient 1’s Flowsheet History from 9/22/24 at 0000 hours to 9/23/24 at 0700 hours, showed on 9/22/24 at 0433 hours, Patient 1 had a temperature of 100.9 °F (normal body temperature: 97 °F to 99 °F). Review of Patient 1’s MAR dated 9/22/24, showed 650 mg suppository acetaminophen was administered rectally to Patient 1 at 0444 hours for fever. Review of Patient 1’s Flowsheet History from 9/22/24 at 0000 hours to 9/23/24 at 0700 hours, showed Patient 1’s body’s temperature was not rechecked until 9/22/24 at 0755 hours, or approximately three hours later. On 12/3/24 at 1244 hours, an interview and concurrent record review was conducted with the Accreditation Program Manager. The Accreditation Program Manager acknowledged Patient 1’s body’s temperature was not rechecked after the administration of acetaminophen as per the hospital’s P&P. b. Review of the physician’s order dated 9/14/24 at 1613 hours, showed the order for notification parameters for surgical vitals. The nurse would notify the provider of significant changes to vital signs or other clinical deterioration. Provider to indicate below if they would like to be notified OUTSIDE of this usual routine. The order indicated that the provider wanted to be notified if Patient 1’s oxygen saturation level dropped below 93%. Review of Patient 1’s Flowsheet History from 9/22/24 at 0000 hours to 9/23/24 at 0700 hours, showed the following: - On 9/22/24 at 0035 hours, Patient 1’s oxygen saturation level was 91%. - On 9/22/24 at 0433 hours Patient 1’s oxygen saturation level was 90%. - On 9/22/24 at 1617 hours Patient 1’s oxygen saturation level was 89%. - On 9/22/24 at 1916 hours Patient 1’s oxygen saturation level was 92%. - On 9/22/24 at 2106 hours Patient 1’s oxygen saturation level was 90%. On 12/3/24 at 1244 hours, an interview and concurrent record review was conducted was conducted with the Accreditation Program Manager. The Accreditation Program Manager acknowledged Patient 1’s provider was not notified of the low oxygen saturation levels as ordered. On 12/4/24 at 1308 hours, the Director of Risk Management and Accreditation Program Manager were notified of the above findings. 35310 2. On 12/4/24 at 1050 hours, during an observation of the surgical area with the Accreditation Program Manager, Patient 2 was observed transferring to OR 3. The Anesthesiologist was observed to performing airway placement with a video laryngoscope. The Anesthesiologist was observed not auscultating the patient’s bilateral lungs after the airway placement. On 12/4/24, Patient 2’s medical record was reviewed. Patient 2’s medical record showed Patient 2 had an outpatient surgical procedure. Review of the Anesthesia Airway Placement dated 12/4/24 at 1111 hours, showed the airway type used for Patient 2 was endotracheal. The Anesthesia Airway Placement also showed the tube placement was verified by bilateral chest rise, carbon dioxide detection, video laryngoscope, and equal bilateral breath sounds. On 12/4/24 at 1308 hours, the Director of Risk Management, Accreditation Program Manager, and Executive Director of Surgical Services confirmed the Anesthesiologist did not auscultate Patient 2’s lung sounds.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the nursing staff monitored and assessed the patient’s status and response to restraints for one of six sampled patients (Patient 3) as per the hospital’s P&P. This failure posed the risk of substandard outcomes to the patient. Findings: Review of the hospital’s P&P titled Restraint for Non-Violent/Non-Self-Destructive Behavior dated May 2022 showed to ensure the well-being of the patient and the continued needs for restraints, an ongoing process including assessment, intervention, evaluation, and re-intervention will be carried out. The RN assesses on initiation and reassesses the patient’s status and response to restraints at intervals not greater than two hours. The RN: * Assesses neurologic: level of consciousness, orientation, and emotional status to determine if the clinical justification continues or there is potential for reduction or early termination of restraint. * Assesses proper application of restraints. * Assesses circulation, joint mobility, and sensation of affected limb, if applicable. * Assesses skin integrity under the restraint. * Assesses physical needs, exercise, elimination, nutrition, and hydration. * Provides range of motion * Repositions to prevent pressure ulcers. * The RN or other member of the health care team meets the physical needs identified. On 12/3/24, Patient 3’s closed medical record was reviewed with the Accreditation Program Manager. Patient 3’s closed medical record showed Patient 3 was admitted to the hospital on 8/29/24 and discharged on 10/5/24. Review of the physician’s order dated 9/1/24 at 0641 hours, showed to apply non-violent soft restraints to the waist, right and left upper extremities. Review of the Flowsheet dated 9/1/24, showed the restraints were initiated for Patient 3 at 0641 hours; and the restraint type, current mental status, response to restraints, peripheral neurovascular, skin, hydration, nutrition, elimination, range of motion, repositioning, and signs of injury were assessed for the patient on 9/1/24 at 0641 hours. Further review of Patient 3’s medical record failed to show the monitoring and assessment until the restraint was discontinued at 1112 hours (for four hours and 31 minutes). On 12/3/24 at 1400 hours, the Accreditation Program Manager verified the above findings.”