Mercy Medical Center Redding

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 41567 Based on observation, interview, and record review, the facility failed to develop and maintain a secure environment for its infant and pediatric patient population as evidenced by: 1. The attempted unauthorized removal of Patient 3, a newborn infant, from the Pediatric unit (a specialized department of a hospital for the care of infants, children and adolescents) by Patient 1 on 4/26/26, and the transfer of Patient 3, and family to a unit with a higher level of security. 2. The unobserved elopement of Patient 2, a 17-year-old who underwent substance abuse treatment, and a documented elopement risk, from the Pediatric unit on 4/16/26, leaving without necessary post-treatment prescriptions, without discharge education, and without the support of Social Services in living in a safe environment, and maintaining sobriety. These failings had the potential for harm and negative health outcomes to affect these vulnerable patient populations. Findings: A review, was made of the facility’s policy titled, Transfer of Mother/Infant Couplet to the Pediatric Department, effective date 2/3/23. This policy provided guidance on the criteria required before a couplet (mother and newborn infant) may be transferred from the Family Birth Center (FBC, a maternity unit that provides care during childbirth and the recovery period after birth) to the Pediatric unit. Infants must be at least two hours of age and physically stable; mothers must have had 2 hours of recovery from a normal vaginal birth, or 24 hours of recovery from a cesarean section (the delivery of a baby via an abdominal/uterine surgical incision), physically stable, and not a security risk. A review, was made of a facility’s policy titled, Infant/Child Safety and Security, effective date 9/21/22. This policy’s primary focus is within the Maternal Child Services (MCS) which includes the FBC, the Neonatal Intensive Care Unit (NICU, a specialized unit for premature, critically ill newborns), and Pediatrics. The stated purpose of the policy is to ensure the safety and security of infants and children at the facility and to prevent abductions through staff awareness and patient and family education. The policy provides instruction for staff on the prevention of infant/child abduction and the procedures to follow in the event of an abduction. Color-coded alerts are defined: code pink alerts are enacted for infants age 0 to one year of age who are missing or removed from the facility by an unauthorized person; code purple alerts are enacted for children aged one year to age 17 and 364 days who are removed from the facility by an unauthorized person. Upon admission to the FBC, NICU, or Pediatrics, patients and family are to be given education on, among other objectives, the banding of infants or children with the infant security system device. MCS Registered Nurses (RNs) are to verify infant security devices are activated in the infant security system each shift and when the infant or child is taken off the unit or returns and is to document each verification in the patient’s medical record. 1. Patient 3’s medical record was reviewed. Patient 3’s Newborn History, and Physical dated 4/24/26 at 9:04 pm, by Medical Doctor (MD) A indicated, that Patient 3 was born at 38 weeks gestation in the FBC on 4/24/26. Patient 3 was transferred to the Pediatric unit with her mother, Patient 1. Patient 3’s Physician Note, dated 4/26/26 at 4:34 am, by MD B was reviewed, which indicated, that nursing staff on the Pediatric unit had noted increasingly bizarre behavior from the mother of Patient 1 including hyper religiosity, agitation, accusing and firing a nurse for placing black oil on Patient 3’s head, writing nonsensical religious messages on notebooks and clothing items, and inappropriately euphoric affect (abnormal, intense excitement or happiness out of context to the given situation), and refusing standard nursing and medical interventions. On 4/26/26 at 2 am, Nursing observed Patient 1 “sneaking,” out the back exit of Pediatrics with Patient 3, and a packed bag while Patient 3’s father was asleep in the room and unaware. Patient 1 made it outside before she was stopped by hospital security. Upon returning to the hospital, the family was moved up to the obstetrics floor (the FBC) for closer monitoring and security. Patient 3’s Newborn Progress Note, dated 4/26/26 at 2:18 pm, by MD C was reviewed, it indicated that after Patient 3, and Patient 1 were returned to the Pediatric unit, the House Supervisor recommended they be moved “to the third floor” (the FBC). Patient 1’s medical record was reviewed. Patient 1’s Obstetrics Discharge Summary Note, dated 4/28/26, by MD D, was reviewed, which indicated, that Patient 1 was admitted for labor on 4/24/26, and delivered (Patient 3) via normal spontaneous vaginal delivery without complications. It was noted Patient 1 refused some standard interventions such as medication and was demonstrating signs of hyper religiosity when she made statements that she had asked Jesus three times if her baby should take antibiotics, and three times Jesus told her no, and that the blood of Jesus will protect her baby. On the night of 4/25/26, Nursing staff was concerned the patient was having visual hallucinations, and on 4/26/26 at 2 am, Patient 1 attempted to leave out the back door of Pediatrics with her newborn without notifying her husband, the nursing staff or placing the child in a car seat. An abduction alert was announced and Patient 1 was stopped. Patient 1 stated she left because Jesus told her to leave at 2 am. Patient 1’s husband informed staff that Patient 1 had abruptly stopped taking Prednisone (a steroidal medication used to reduce inflammation and calm the immune system), and that she had done the same previously which resulted in a psychotic/manic episode (a psychiatric emergency requiring interventions for a break from reality combined with extreme energy and elevated mood, with symptoms including hallucinations [the experience of visions or sounds that are not real], delusions [fixed and false beliefs], rapid racing thoughts and disorganized speech). Patient was diagnosed with steroid-induced psychosis and later on the same day exhibited behaviors such as chanting, holding her arms in the air and praying in the hallway. Patient was medicated with antipsychotics for acute agitation and reevaluated on 4/27/26, and the event was considered resolved. Patient 1’s Nursing Progress Note, dated 4/26/26 at 3:58 am, by Registered Nurse (RN) E, was reviewed which indicated RN E assumed care of Patient 1 mid-shift after Patient 1 “fired,” another nurse after claiming the nurse had put black oil on Patient 1’s head. Increasingly bizarre behaviors (Patient 1 sitting straight up in bed with “a very wide smile on her face and very wide eyes rapidly glancing around the room”) were noted, and the refusal of necessary nursing care for Patient 3. At 2:02 am, RN E observed, via security camera, Patient 1 run out the back exit of the Pediatric unit with Patient 3, and RN E ran after her while another nurse alerted staff of an abduction. RN E documented that Patient 1 almost dropped the baby and an unnamed staff member grabbed her and the baby to stop the fall. Security and the unnamed staff member stopped Patient 1 from going any further, and Patient 1 and Patient 3 were returned to the Pediatric unit, and shortly thereafter transferred “upstairs to the postpartum ward” (FBC). Patient 1’s Physician Note dated 4/25/26 at 11:42 pm, by MD F, was reviewed, which indicated Nursing contacted MD F over concerns that Patient 1 was having visual hallucinations, had fired nurses for rubbing black oil on her baby’s head, and Nursing was not sure if there was a psychiatric history involved. MD F documented, the decision was made that consulting social workers or psychiatric services in the morning “may be more appropriate in order to de-escalate the situation overnight.” 2. Patient 2’s medical record was reviewed. Patient 2’s Discharge Summary dated 4/16/26 at 12:44 pm, by MD G, was reviewed, which indicated that Patient 2 was a 17-year-old who presented to the Emergency Department with a history of homelessness, polysubstance abuse (the use of two or more drugs or medications within a short period of time), prior sexual assault, and sexually transmitted diseases. Patient 2 was accompanied by her Social Worker, seeking assistance with detoxification (medical treatment to assist with the symptoms that accompany substance withdrawal) and initiation of substance use treatment; additionally, diagnostics indicated a urinary tract infection (UTI). Patient 2 reported that she had been living on the street for several years and had intermittently engaged with Social Services but often left care prematurely. In the course of treatment, Patient 2 had cardiac (heart) abnormalities and irregularities noted for which a Pediatric Cardiologist was consulted who recommended that Patient 2 may need a Holter monitor (a diagnostic test involving a wearable device that continually records the heart’s electrical activity) on an outpatient basis “within a few months.” Patient 2 was to be discharged back to Child & Family Services (CFS) with prescriptions to treat addiction, and antibiotics to treat the UTI, however, on 4/16/26 it was discovered that she had eloped from the hospital, leaving her possessions. During an observation, made of the Pediatric unit on 7/7/26 at 11:45 am, the following was noted. The unit was located on the ground floor and stood out from the main campus of the hospital, connected by breezeways to other adjacent departments. Sidewalks and a small grassy area connected the unit to the physicians’ parking lot, which was connected to other designated parking lots and the main hospital entrance. Emergency doors were found to be locked and prevented entrance from the outside. Entrance through the front double doors into the Pediatric unit required utilizing a phone system to request entrance, or to be escorted in by an employee using their badge; once in the unit, one is able to leave the unit by pushing against the entrance doors which open without alarming or otherwise signaling egress. The nurses’ station was positioned opposite the entrance doors. A CCTV (closed-circuit television video surveillance system that transmits signals from cameras) monitor was installed at the station, with a 4-view grid format on a single display and continuous stationary views of points of ingress/egress. At 12:05 pm, the west facing emergency exit door was tested by being pushed open; an alarm sounded as the door swung open freely, allowing egress directly onto sidewalks that led to the physician’s parking lot; this was the route Patient 1 had used to attempt to leave the unit with Patient 3 on 4/26/26. During an interview, conducted on 7/7/26 at 12 pm, the Director of Maternal Child Services, NICU, Pediatrics, Labor and Delivery and Postpartum (DMCS) confirmed that the current Pediatric census was six, four of which were couplets transferred from the FBC after delivery. When asked about staffing numbers, she stated usually two RNs were assigned to the unit each shift. When asked about security measures to prevent infant abduction on the Pediatric unit, she stated newborns are banded with an identification band that pairs with their parent(s) and/or other trusted adults. She indicated the CCTV monitoring system and stated nurses monitored the cameras from the station. At 12:07 pm, she stated people could not enter the unit without either badging in or being allowed entrance by nursing. Patients and family are taught to look for a pink stripe across staff ID badges and are cautioned against turning care of infants over to anyone without the pink stripe. She confirmed that the FBC unit did have electronic security measures and when asked why there was no electronic security system on Pediatrics, she stated that the roof in Pediatrics would have to be redesigned. During an interview, conducted on 7/7/26 at 12:10 pm, RN H was asked how soon newborns and their mothers transfer from the FBC to Pediatrics; she stated, usually after the two-hour recovery period (indicating, two hours after delivery). When asked about security measures on the Pediatrics unit to prevent infant abduction, she replied, the security officers visit the unit three to five times per shift and sometimes performed a walk-through of the unit. Visitors check in with security in the hospital’s main lobby before walking over to the Pediatric unit; once at Pediatrics, they check in with Nursing, so staff know who is seeing which patient. When asked if these bands were electronic (as part of an electronic security system) RN H stated that they were not. She pointed out the CCTV monitoring system as another security feature and stated the goal was to always have a nurse present at the station to monitor the cameras but when asked, did state that there were times when all nurses would be busy with patient care and away from the station. During a continuance of the interview, with DMCS on 7/7/26 at 12:55 pm, DMCS was asked if nurses had brought up security concerns on the Pediatric unit at recent meetings and she stated that they had and stated, they feel like there’s a lack of security. She confirmed that in April 2026, a patient (Patient 1) had attempted to elope from the unit with her newborn (Patient 3) and was diagnosed with psychosis. The patient had been in the FBC and had refused a lot of interventions for herself and her baby after delivery. She passed the criteria for transfer and the couplet was sent to Pediatrics. When Patient 1 started making statements that the nurses were putting black oil on the baby, the Residents were notified but did not evaluate the patient. At 2 am, Patient 1 picked up the baby and headed out the back door and the alarm sounded. Staff called an infant abduction alert overhead and an Environmental Services (EVS) worker and a nurse tried to stop her. Patient 1 had called her sister and arranged to be picked up outside. Her husband had been sleeping in the room and he came out and coaxed her back in. She added that abduction alerts are more of a stranger abduction situation, and this was more of an elopement, since she was the infant’s mother and legal guardian. When moved back to the post-partum unit, a psychiatric evaluation was done, a safety sitter was placed at her door, and Patient 1 ended up needing to be placed in restraints. DMCS was asked about elopements and stated that a 16-year-old foster child was a patient in Pediatrics in March or April 2026 (Patient 2), and when her case worker and a Resident were involved in discussion, she snuck out the front door which did not sound, and she was not found. DMCS confirmed that an electronic security system would have sounded, had it been in place. She stated, Patient 2 had a history of being a flight risk. When asked if she could, would she have an electronic security system installed in Pediatrics she stated there are advantages but there was a lot to figure like up to what age do you apply the system. When asked why there was an electronic security system in labor delivery and postpartum (FBC) she stated there’s a higher risk of infant abduction than of child abduction; there is a risk with infants in Pediatrics but it’s less of a risk than on the true postpartum unit. Unless you knew the hospital uses the Pediatric unit as an overflow, you know postpartum has the newborn infants, and Pediatrics is not a unit one would think of to go to abduct an infant. During an interview, conducted 7/7/26 at 2:25 pm, RN I was asked if she had security concerns on the Pediatric unit. RN I stated, I do wish we had the infant security tags because if it’s important upstairs it should be important downstairs. Infants are easier to sneak out than a full-sized person. I love that our Pediatric unit has secured doors and cameras so we always know who’s coming in though but not necessarily knowing who’s leaving. There’s no less likelihood that an infant would be abducted downstairs (Pediatrics) than upstairs (FBC). During an interview, conducted 7/7/26 at 3:10 pm, the Emergency Preparedness Program Manager (EPPM) stated the Pediatric unit is a locked unit that you have to badge in and badge out of and has limited access. When asked if Pediatrics does not require electronic security systems when there are newborn patients, why does the Family Birth Center require such security measures, EPPM stated the FBC is where a greater percentage of that population is. She stated a risk assessment tool scored the risk of infant abduction at 18%, a low risk because of the systems in place; camera systems and administrative controls, staff are educated to maintain a secure environment, and specific badging staff wear to indicate they are safe to interact with. During a concurrent interview, and record review, on 7/7/26 at 3:20 pm, regarding the facility’s policy titled, Infant/Child Safety and Security, effective date 9/21/22, DMCS was asked about passages in the policy on electronic security systems that included the Pediatric unit which indicated that upon admission to the FBC, NICU, or Pediatrics, patients and family are to be given an orientation to safety and security of their infant/child on the banding of infants or children with the infant security system device; “importance of banding will be reinforced.” Maternal Child Primary Registered Nurses are to verify infant security devices are activated in the infant security system each shift and when the infant or child is taken off the unit or returns and is to document each verification in the patient’s medical record. DMCS stated the policy was not accurate, that Pediatrics and NICU do not use electronic infant security devices. During an interview, conducted on 7/8/26 at 10 am, RN J stated she had been Patient 2’s nurse for a couple of days during her admission to the Pediatric unit and was the charge nurse on the day Patient 2 eloped from the unit. RN J stated, Patient 2 wasn’t observed leaving. Patient 2 was expected to be discharged into the care of her Social Worker and the Social Worker and a Resident were in another room discussing Patient 2’s medication for discharge. When RN J returned from lunch break, she was informed Patient 2 had eloped from the building. RN J stated, I went looking around the parking lot trying to locate her. She was never located. We were not aware she was an elopement risk. I was dumbfounded when she left. When asked if she had security concerns about the Pediatric unit, RN J stated we are secure in not letting people in, but there’s no way to keep people from leaving out the door. We have a lot of adults as visitors. Also, we are a backup unit for adult patients who overflow to our unit, they get lot of visitors. She stated, infants in the FBC have an alarm on them and if they get near the doors the doors automatically lock, but there’s no way to keep them from being taken out of our (Pediatrics) unit. It’s impossible to be constantly monitoring the CCTV, there’s always at least two nurses on the unit, you try to keep a nurse at the station but sometimes we both get called away. I want a way to secure patients, so they and we feel safe. We’ve all asked about security and were told the system wasn’t able to be put on Pediatrics. During an interview, conducted on 7/8/26 at 10:30 am, RN K affirmed she was Patient 1’s nurse on 4/26/26 and confirmed details of her Nursing Progress Note of the same date. RN K stated, when Patient 1 attempted to leave we called DMCS and we were told parents cannot kidnap their own kids and they can leave whenever they chose to, and I said not when there’s a medical issue no they can’t. She stated she recalled a meeting approximately a year ago with DMCS when there was discussion of the Pediatric unit taking more adults patients as overflow from other units; RN K stated she said, we have kids people could just walk out with. You can just walk out our front doors, and we aren’t at the front all the time. There’s one nurse who’s a TL (Team Leader, or Charge Nurse) who takes patients, and if both nurses are busy, this is a safety issue. It could be an adult patient, it could be a visitor, it could be a custody issue with a parent. They could walk out any time, and we wouldn’t know without an alarm. There are two doors to the outside world, getting out is extremely accessible. With Patient 1, we’re lucky I was at the nursing station and saw it on the CCTV monitor, we could have been busy in rooms or away from the station. It’s a huge issue that kids and people can leave the unit whenever they want to. There’s no cameras on the inside of the unit. RN X stated she also worked in the FBC, stating, upstairs there’s an electronic security system, the baby is banded on the leg with an electronic security device. At the station there is someone sitting watching monitoring system at all times. If the electronic device gets within a certain distance of a door, the doors lock. That keeps them from walking out with the baby. The elevators up there lock too. There is no electronic infant security system on the Pediatric unit and never has been. Not for newborns, not for couplets, not for peds (Pediatric patients), nothing whatsoever. We brought up these safety concerns to management, they said they would look into it, I don’t know if they did or not. During an interview, conducted on 7/8/26 at 11:08 am, RN L stated she had concerns about security on Pediatrics, that her patient (Patient 2) had eloped. She stated she was in the float pool on 4/16/26 and was giving Patient 2’s primary nurse a break and was busy helping another nurse when Patient 2 eloped. RN K stated, I didn’t know she left until the Social Worker and Residents were looking for her, she snuck out through front door where there is no alarm when you leave. That’s my concern. We screen people coming in but not those leaving. Most of the time there’s only two nurses on duty, sometimes we are in isolation rooms or otherwise caring for patients so we can’t always be out front to monitor that door. When we have overflow patients and couplets, we don’t know how these adult patient will be, or their visitors. In a perfect world there will be another nurse watching. Those are my main concern, someone exiting when we have limited staff. During an interview, conducted 7/8/26 at 1:15 pm, the Facility Director/Plant Manager (FDPM) stated that the facility had been looking at the feasibility of installation of an electronic security system in Pediatrics, and the issue discussed in Environment of Care meetings but that due to construction of the Pediatric building, the system could not be installed. He stated, this issue is not closed, I’m not sure where it’s at now but we are looking into delayed egress and audible alarms systems. When asked if there had been an actual evaluation looking into installation FDPM stated he had not seen a report but believed that there was. At 1:35 pm, a concurrent observation, and continued interview, was made with FDPM in the Pediatric unit. He explained that one of the electronic systems, Totguard (a location system designed to prevent newborn abductions by the attachment of a tag to the newborn’s leg which sends continuous signals to sensors in a building) relies on RFID (Radio Frequency Identification, a wireless technology utilizing radio waves to track objects) and that the shape of the ceiling is disruptive to the signal. During a concurrent observation, and interview, on 7/8/26 at 2:05 pm, in the FBC, DMCS was informed of this Surveyor’s intention to test the electronic security systems. DMCS retrieved a Totguard sensor device from a supply box and approached an emergency exit door to demonstrate; the alarm sounded, but the door did not lock and could be opened. DMCS then had the sensor device registered and tested another emergency exit door which sounded an alarm and locked, preventing egress, as did the next exit tested. DMCS explained during the demonstration that the TotGuard system establishes a perimeter and that transgressing the perimeter sets off an alarm. During a concurrent observation, and interview, on 7/8/26 at 2:30 pm, in the FBC, Director of Security (DS) pointed out parts of the electronic security systems and stated the Totguard is a separate system from the maglock (electromagnetic locking egress delay system secures perimeter doors against unauthorized egress as an infant abduction prevention measure) system installed above doors on the unit, which lock for a pre-determined period of time to allow staff time to respond to the alarm. During an interview, conducted on 7/8/26 at 2:38 pm, the Market Director for Planning Designing Construction (MDPDC) stated TotGuard was doable but there were challenges. The facility had done a study on installing electronic security systems in Pediatrics and concluded it was not feasible due to construction limitations of the building which would require significant work to the fire and alarm systems involving not just Pediatrics but adjacent departments. The facility again assessed the possibility of installation in Pediatrics in 2023 when they planned an upgrade from the previous system in the FBC to TotGuard but corporate did not approve the funding. When asked for documentation he stated he would contact the engineering firm. A record review, was made of a Project Status Report titled, Facility X Infant Security, Project no. 20-4080, with a series of planned actions with a start date of 2/2/22, to 8/8/24. An entry dated 2/2/23, indicated that the facility was working on an “Add Service” to add Pediatrics to the scope of work which would require a fire alarm contractor to update the system in the Pediatric building. An entry dated 5/1/23 indicated that a proposal to add Pediatrics had been sent to MDPDC An entry dated 5/31/23 indicated, “Per MDPDC the decision has been made to not add PEDs into the scope of work. Project is gearing up for a July start date for the approved work on the 3rd floor.” The remainder of the document outlined project steps in various stages of approval and/or completion. A record review, of the facility’s 2026 Hazard Vulnerability Analysis, dated 1/20/26, indicated that infant abduction was listed as a moderate probability, with an 18% risk. A record review, was made of the facility’s 2025 Environment of Care, Program & Management Plans. An overview of the program indicated that it provides the framework by which environment of care processes are managed within the organization. Goals and objectives of the program include, to provide a safe, secure and effective environment through activities supportive of reducing risk of injury for patients, visitors, employees, and other individuals providing care or services. Under the section, Security Sensitive Areas, is written, “the organization will control access to and egress from the following security-sensitive areas.” Among areas identified were Newborn Nursery/Postpartum, and Pediatrics; in both identified areas, the reason given that they were identified as Security-sensitive areas was, “Abduction.” A record review, of the facility’s Emergency Management After Action Report Disaster Critique, dated 4/26/26, was an analysis of the event, “Attempted Elopement from Pediatric Department (couplet). The critique identified that on 4/26/26 at 2:03 am, “attempted Elopement mom with baby.” Section 5, Safety & Security, noted the following concerns: “Lockdown procedures - there is no delayed egress out of the back of the pediatric department. The door is alarmed, however it doesn’t have a delay in opening. Also, there isn’t an infant/child security system installed in the pediatric department.” Section 10, Improvement Plan, identified corrective actions: “Evaluate rear exterior door for ability to install delayed egress feature,” and, “evaluate department for installation of an infant child security system.” A record review, was made of An Environment Of Care Committee Meeting Minutes, dated 7/1/26. New business covered included the following: “Attempted elopement- mom left with baby out back door at 2 am. Code purple was called, EVs employee caught her. Baby was recovered; mom is doing better. Peds (Pediatrics) doesn’t have delayed egress on back door. No infant/child security in peds. Will need further evaluation. A Critical Care Debrief was done, some nurses were upset. This was brought to Patient Safety Round Table.””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 41567 Based on interview, and record review, the facility failed to implement their policy for one (Patient 3) of six sampled patients, when Patient 3 was transferred to another facility: 1. without a signed consent for transfer, and, 2. without discharge education prior to transfer. These failures resulted in ambiguity as to whether Patient 3 was aware of the risks/benefits of transfer and fully consented to transfer, and whether she was provided education at the time of discharge which could have resulted in negative clinical outcomes. Findings: A review, of the facility’s policy titled, “Core Nursing Standards of Practice - Medical/Surgical, Orthopedics, Oncology, IMCU (Intermediate Care Unit), and 4West,” dated 4/24/25, indicated that the facility developed this policy as a guideline for the provision of nursing care and professional performance expectations, and that these standards of practice do not replace clinical judgment but represent minimal, safe standards. Among practices outlined in the policy, is guidance that nursing is to ensure consents are completed in paper form and placed in the medical chart, and nursing is to complete the depart process upon transfer to another acute care facility. A review, of the facility’s policy titled, “Patients Rights,” effective 8/2/22, indicated that patients have the right to make decisions regarding medical care and receive as much information about any proposed treatment or procedure as needed in order to give informed consent, and the right to be involved in the development and implementation of their discharge plan. Patient 3’s medical record was reviewed. Patient 3’s Discharge Summary, dated 5/9/25, prepared by Medical Doctor (MD) A indicated that Patient 3 was admitted for worsening breathing, with a medical history of chronic obstructive pulmonary disease (COPD, a group of inflammatory lung conditions that obstruct airflow and make it hard to breathe). Patient 3 was found to have a pulmonary embolism (a condition where a clot blocks an artery and prevents blood from reaching the affected part of the lungs), and a cancerous mass obstructing her airway. Treatment involved blood thinning medications, and a tracheotomy (a surgically-created opening in the neck leading to the windpipe, with a tube placed into the opening to allow air to enter the lungs directly, bypassing the mouth, nose and throat). At discharge, Patient 3 was transferred to a long-term acute care facility (a hospital for those with complex medical conditions who require specialized extended care but no longer need the intensive level care of a general hospital). Patient 3’s Transfer Certification, and Patient Request/Refusal/Consent To Transfer Under EMTALA form, dated 5/9/25, indicated on the top portion of the document - to be completed by the medical doctor - was mostly completed with the patient condition, the reason for transfer, the benefits of transfer, and the name and signature of the ordering provider, MD A; the risks of transfer were not addressed. The middle portion of the document - to be completed by nursing - had a checkmark by the box, “Receiving facility has capacity to treat and agrees to accept the transfer,” but the name of the receiving facility and the contact, time of contact, and phone number were not completed. Other unaddressed items; patient belongings, vital signs (measurements indicating a patient’s system functions) to be completed within 30-minutes of transfer, and the date and time of transfer. There is no Registered Nurse signature on the form. The bottom portion of the document - to be completed by the patient - is where the patient acknowledges they were informed of the risks and benefits of transferring, and either requests or refuses to transfer. There was no patient signature, nor witness signatures, on this portion of the form. During an interview, on 4/3/26 at 2:49 pm, the Director of Care Coordination (DCC), stated that completing the transfer consent form is a shared responsibility with nursing which can be completed by nursing, or by CCRNs (Care Coordination RNs, a.k.a. Discharge Planning), but it is ultimately the responsibility of the staff discharging the patient, which is bedside nursing. DCC stated, that the patient’s verbal consent in medical documentation (provider’s notes, nursing notes) is in lieu of the written consent. During an interview, on 4/3/26 at 2:55 pm, the Director of Critical Care Services (DCCS), indicated that she was surprised that bedside nursing was to complete consent to transfer forms and stated, that’s different to me, if CCRN weren’t there then they could pass that responsibility to nursing. Care Coordination sets up the transfer, and make the packet that goes with the patient (to the receiving facility), and nursing does the instruction. A review, of a facility’s policy titled, “Care Coordination Discharge Planning,” dated 11/21/22, indicated that bedside nursing is responsible for completing discharge instructions, providing written discharge instructions and reconciled medication list, and documenting the discharge in the medical record. During a concurrent interview, and record review, on 4/2/26 at 1:14 pm, the Quality Patient Safety Program Manager (QPSPM) confirmed, that there were no documented discharge instructions in Patient 3’s medical record prior to her discharge, and transfer on 5/9/25. During an interview, on 4/3/26 at 2:30 pm, the Director of Critical Care Services, confirmed that the nurse who discharged Patient 3 on 5/9/25, did not complete the discharge instructions. When asked her expectation of her nurse’s regarding patient education on discharge, she stated, that all discharge instructions and actions should be completed and documented prior to discharge.”

“PHARMACIST SUPERVISION OF SERVICES CFR(s): 482.25(b)(1) §482.25(b)(1) - All compounding, packaging, and dispensing of drugs and biologicals must be under the supervision of a pharmacist and performed consistent with State and Federal laws. This Standard is not met as evidenced by: 39942 Based on interview, and record review, the facility failed to safely prepare intravenous (directly into a vein) medications to two of four sampled patients (Patients 1, and 3) when the medications were inaccurately labeled and dispensed by pharmacy staff. This failure had the potential to cause life-threatening sensitivity reactions in the patients, as well as disrupt their prescribed treatment regimens, which could have led to negative clinical outcomes. Findings: The facility’s policy, titled, “Compounding Sterile Preparation (CSP) USP 797,” effective 4/16/25, was reviewed and indicated that the pharmacist performing or supervising compounding (mixing of medications) was responsible for the integrity, potency, quality and labeled strength of a CSP until the beyond-use-date (BUD) indicated on the label, so long as label instructions for storage and handling were followed after the preparation was dispensed. CSPs must have been labeled with legible identifying information to prevent errors during storage, dispensing and use. Information must have been displayed prominently and legibly on the label of each immediate container of the CSP included active ingredients and their amounts, activities or concentrations; the solution utilized, for CSPs administered by infusion; route of intended administration; instructions for administration, and any warning statements. The facility’s policy titled, “Medication Management - Labeling,” approved 12/9/19, was reviewed and indicated that that all medications and solutions are labeled whenever medications are prepared but not immediately administered. When individualized medication is prepared by someone other than the person administering the medication, the label is to include the patient’s name, and directions for use and applicable accessory and cautionary instructions. No more than one medication, or solution is to been labeled at one time. A document, titled, “Highlights of Prescribing Information,” for the medication Sarclisa ® (isatuximab-irfc), revised 6/1/25, was reviewed. This document indicated that Sarclisa was used to treat adult patients who had multiple myeloma (a blood cancer arising from bone marrow cells). Among the warnings listed in the prescribing information was the potential for infusion-related reactions, including life-threatening anaphylaxis (a severe, rapid and potentially fatal systemic allergic reaction), and cardiac arrest (heart stopping). A medication package insert, titled, “Leucovorin Calcium for Injection, USP (United States Pharmacopeia),” dated 1/1/24, was reviewed. This document indicated that Leucovorin was derived from folic acid (vitamin B9, found naturally in leafy greens and beans). One of the uses of Leucovorin was to prolong survival in the palliative (management of pain and symptoms) treatment of patients with advanced colon (large intestine), and rectal cancer. Patient 1’s medical record was reviewed. Patient 1’s clinical record indicated a medical history that included heart disease, high blood pressure, and colon and rectal cancer that had spread to their liver. Patient 1 received regularly scheduled treatments at the Outpatient Oncology (cancer treatment) Center. On 2/25/26, Patient 1 came to the Oncology Center for a Leucovorin infusion. A record review, of Patient 1’s Rapid Response Team (RRT) Activation and Response Note, dated 2/25/26 at 12:33 pm, by Registered Nurse (RN) A, indicated that RN A documented that a Code Blue was activated in the Outpatient Chemotherapy unit at 9:43 am. The Outpatient Oncology RN informed RN A, that Patient 1 was alert and oriented upon arrival for treatment. After receiving Leucovorin, and Zofran (nausea medication), Patient 1 became unresponsive and started drooling. Found to be pulseless (no heartbeat) when assessed, and Code Blue was activated. Chest compressions and bagging (ventilating) with bag-valve mask began at 9:44 am. At 9:45 am, RN A arrived to find active cardiopulmonary resuscitation in progress with an automated external defibrillator (AED) attached to Patient 1, and an intensive care doctor directing care. Staff transported Patient 1 to the Emergency Department (ED). A record review, of an Patient 1’s ED Physician Note, dated 2/25/26 at 2:51 pm, by Medical Doctor (MD) B, indicated that Patient 1 was brought in for a cardiac arrest. Patient 1 regained consciousness and circulation and was able to open their eyes, and obey simple commands after receiving epinephrine (adrenaline). A record review, of Patient 1’s Physician Note, dated 3/2/26 at 8:28 pm, by MD C, indicated a description of a discussion held with Patient 1. MD C documented that there was a labeling error of the Leucovorin that Patient 1 was intended to receive, and Patient 1 had received a different medication in error. Patient 3’s medical record was reviewed. A review, of Patient 3’s clinical record indicated a medical history of osteoporosis (fragile bones), anemia (low red blood cells), and multiple myeloma. Patient 3 received regularly scheduled treatments at the Outpatient Oncology Center. On 2/25/26, Patient 3 came to the Oncology Center for a Sarclisa® infusion. A record review, of a Patient 3’s Progress Note, dated 3/2/26 at 4:34 pm, by MD D, documented a description of Patient 3’s treatment. MD D documented, “Incidence [sic] reported by [Facility] pharmacist that [Patient 3] did not receive scheduled medication last week instead by mistake [Patient 3] had Leucovorin instead. [Patient 3] will be starting her first dose this week.” During an interview, on 3/10/26 at 8:37 am, the Pharmacy Technician (PT) described how they had prepared the ordered solutions for Patients 1, and 3 on 2/25/26. PT had been working at the facility and compounding medications for approximately three and one-half years. PT stated that both solutions were prepared using a 250 milliliter (ml, a unit of volume) bag of normal saline (NS -- 0.9% sodium chloride; salt water). Both required removal of 35 ml of fluid to be replaced with the medication volume of 35 ml. The Leucovorin required mixing into sterile water before being added to the bag of NS. The Sarclisa® was drawn directly out of a vial and added to the bag of NS. Both solutions were clear. PT prepared one item at a time, and brought them both out of the sterile compounding area. The product labels had been printed beforehand by the pharmacist. PT stated they labeled the Leucovorin first, and the Sarclisa® second. The Registered Pharmacist (RPH) asked PT, if they were sure they had labeled the two solutions correctly, and PT was certain that they had. It was only later, after twice reviewing camera footage of their preparation of the two bags, that PT discovered they had inadvertently misapplied the medication labels. During an interview, on 3/10/26 at 8:43 am, the Pharmacy Director (PD) described RPH’s role in completing the final check of compounded medications on 2/25/26. RPH had been a pharmacist at the facility for approximately 33 years. Anything used to compound medication, such as syringes and vials of medication, were placed in a bin with the bag of solution, and label by the person who compounded the medication. The final step after compounding was for the compounding staff to bring all equipment out of the compounding area for the pharmacist to check. RPH questioned the labeling based on visual inspection of the materials, and verified with PT that the bags had been labeled correctly.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 41567 Based on interview, and record review, Registered Nurse (RN) A failed to follow their facility’s policy titled, “Leaving the Hospital Against Medical Advice,” when one patient (Patient 8) of two patients sampled with a discharge disposition of leaving Against Medical Advice (AMA), left the facility without being offered the AMA form for signature. This failure resulted in uncertainty as to the events surrounding Patient 8’s departure, and an incomplete medical record, which is a legal document. Findings: A review, was made of a facility’s policy titled, “Leaving the Hospital Against Medical Advice,” dated 1/10/19, which indicated the importance of documentation of the facts surrounding a patient’s departure and the actions taken to assure the patient’s safety. Staff is to complete the Leaving Hospital Against Medical Advice form, and offer it to the patient for signature, and the original form will be placed into the medical chart. A review, was made of Patient 8’s Emergency Department (ED) Provider’s Note, dated 11/19/25 at 3:21 pm. Physician’s Assistant (PA) B diagnosed Patient 8 with nausea/vomiting during pregnancy. Under decision-making, PA B documented, Patient had some improvement after IV fluids (fluids that were infused via a tube into a patient’s bloodstream, to provide hydration and some mineral content) but while waiting for her workup to be completed, she wanted to leave. Nursing staff had her sign the AMA form, and the patient left this against medical advice. A review, of Patient 8’s ED Discharge Notes, dated 11/19/25 at 11:32 am, by RN A, indicated Patient 8 left against medical advice. On 2/10/26, a review, of Patient 8’s medical records, dated 11/19/25, was made and the Patient 8’s AMA form was not found in the record; the AMA form was requested from the Quality Patient Safety Program Manager (QPSPM). During an interview, on 2/10/26 at 2:40 pm, the QPSPM stated, that could did not find the AMA form in Patient 8’s medical record. During a concurrent interview, and record review, on 2/11/26 at 12:15 pm, RN A stated, that she did not specifically recall Patient 8, and explained how she handles the situation when a patient expresses the intention to leave the hospital before being discharged by the provider. RN A stated, if they want to leave AMA I ask them if they will wait to talk with the provider, so they can explain why we need them to stay, and then the patient makes their own decision from there. If the patient does not want to wait for the provider, I let them know it’s not in their best interest to leave at this time depending on their results, and I ask if they can wait to sign the AMA form, it lists out the risks of what can happen to them when they are outside of this hospital and not under our care. RN A reviewed, Patient 8’s ED Discharge Note, dated 11/19/25 at 11:32 am, and stated, so then I would grab an AMA paper and document that the patient did not want to sign. RN A could not explain why there was no signed AMA form in Patient 8’s medical record. During an interview, on 2/11/26 at 12:30 pm, the ED Manager stated, in the case of Patient 8, she would have expected an AMA form to have been completed.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 41567 Based on interview, and record review, the facility failed to comply with the Emergency Medical Treatment and Active Labor Act (EMTALA) when one of 22 sampled patients (Patient 2), was not provided with a Medical Screening Examination (MSE) upon presenting to the Emergency Department (ED). This failure had the potential to delay necessary medical care which could cause negative clinical outcomes to occur. Findings: A review, of the facility’s policy titled, “Emergency Medical Treatment and Labor Act (EMTALA),” effective date 12/11/24, indicated that the emergency medical screening and stabilizing treatment will be provided to all individuals requesting, or requiring examination or treatment of a medical condition, and to individuals presenting on the hospital property including parking lots, sidewalks, driveways within 250-yards of the hospital. A review, of the facility’s policy titled, “Ambulance Diversion (the redirection of an ambulance to a different medical facility than the one originally intended),” effective date 10/8/20, which defined diversion as the closure of a hospital’s emergency department (ED) from receiving patients arriving by ambulance including any specialty services. The policy outlines the procedure for STEMI (ST-Elevated Myocardial Infarction, a severe type of heart attack) diversion: EMResource is to be updated with the status “Advisory,” and indicate that STEMI services are unavailable, and completion of the Ambulance Patient Diversion Form 508-A. A review, the facility’s policy titled, “Code STEMI,” effective date 11/19/24, and lists the policy “Ambulance Diversion,” as an associated document. The policy indicates that when emergency medical services (EMS) calls with a field identified (a term indicating EMS services, before a patient arrives to a hospital) STEMI, the EKG (electrocardiogram, a diagnostic test of the electrical activity of the heart) will be transmitted to the ED from the field, and the ED physician will confirm the diagnosis. If an EKG cannot be transmitted but it is called a STEMI by EMS, the cardiac catheterization lab (CCL, a specialized unit or department in a hospital where cardiologists [a medical doctor specializing in diagnosing and treating diseases of the heart and blood vessels] and specialized staff perform cardiac procedures) team will be activated; the patient will not go to the CCL until the EKG has been reviewed by the ED physician and the cardiologist and STEMI has been confirmed. If there is an unavoidable delay in patient care, for example simultaneous STEMI patients, or the cardiologist is in another case already in progress in the CCL, the ED physician will collaborate with the cardiologist to determine if thrombolytic therapy (medications that dissolve blood clots blocking blood vessels) should be administered. Patient 2’s medical record was reviewed. An ambulance trip report, incident # 206857, indicated that emergency medical services (EMS) responded to Patient 2’s private residence for a complaint of chest pain on 7/2/25 at 11:36 am. In the narrative, documented by Paramedic (a trained healthcare professional that provides emergency medical care outside of the hospital setting) A, Patient 2 stated he was having difficulty breathing and stated, “I’m going to have a heart attack, I’m going to die,” and that he had had MI’s (myocardial infarctions, or heart attacks) twice this year with a total of 4 stents placed (a reference to a cardiac procedure in which stents, or tubes, are inserted into narrowed or blocked arteries in order to keep blood flowing to the heart). An EKG performed indicated Patient 2 had a STEMI. EMS contacted Facility A’s ED and activated a STEMI alert (a process that informs staff that the incoming patient has a STEMI and requires specialized medical care). Upon arriving to Facility A’s ambulance bay at 12:20 pm, Paramedic A documented being met by ED Medical Doctor (ED MD) B and being informed Patient 2 needed to be diverted to Facility B due to, “no cardiologist in house.” EMS contacted Facility B and issued the STEMI alert, and diverted Patient 2 to Facility B. A review, was made of a compilation of Patient 2’s encounters at Facility A (document untitled). There was an encounter documented on 7/2/25 between 11:17 am to 12:20 pm, with Patient 2 arriving via ambulance. A review, was made of Facility A’s Cardiology call schedule for the month of July, 2025. Dr Cardiologist C was on call on 7/2/25. A review, was made of Facility A’s list of cardiac catheterization procedures performed on 7/2/25. Cardiologist C performed procedures from 9:20 am to 10:06 am, and 11:38 pm to 2:43 am. A review, was made of Facility A’s Ambulance Patient Diversion Form 508-A, from 2/1/25 through 7/29/25. In a total of nine diversions, there were none listed for 7/2/25. During a concurrent observation, and interview, on 7/29/25 from 10:15 to 11:15 am, the Chief Nursing Officer (CNO) was asked for information on the processing of STEMI patients in the ED. The CNO stated, that EMS usually sends an EKG which the provider looks at. If there is a confirmed STEMI, the STEMI crew is called in, consisting of the cardiac catheterization lab crew, and one of two interventional cardiologists (a cardiologist who specializes in using catheter-based procedures to diagnose and treat heart and blood vessel conditions), and the house supervisor is contacted. The CNO indicated that STEMI (along with two other specialty treatment areas) are never diverted. During a concurrent interview, and record review, on 7/31/25 at 12:21 pm, of a Radio/audio recording with the Manager of Emergency Preparedness (MEP). EMS was heard to inform Facility A’s ED staff of Patient 2’s impending arrival, his current heart rate and blood pressure, the EKG findings, medications given, signs and symptoms, and some background information. Hospital staff asked for transmission of EKGs; EMS stated they “will attempt to, but monitor is having some issues.” At this time, MEP confirmed that the Patient Diversion Forms 508-A provided were complete, containing all diversions in the previous six months. During an interview, on 7/31/25 at 3:25 pm, Cardiovascular Nurse Coordinator (CNC) was asked for the process involving incoming STEMI patients, in particular if more than one patient arrives. CNC stated, I’m not sure of the policy, so I don’t want to speak out of turn. When asked how this situation would be managed, the CNC stated there was one interventional cardiologist on duty at a time, and when a second patient needing their services arrives to the facility, the cardiologist would speak with the ED provider, decide if the patient can be accommodated, see if the patient is stable and give TNK (Tenecteplase, a medication used to treat blood clots in cases of acute myocardial infarction) if needed. CNC stated, if a STEMI was identified in the field, we would try to stop them in the field before they arrive. When asked for more information, CNC stated, all EMS services call ahead to notify of STEMI in the field. We are a primary receiving center for outlying counties in this area. Our process should be if we are busy, they would divert the ambulance before they arrive here. If patients are diverted, we place an advisory. The ED handles those notifications. CNC stated, “one concern we had, we had a patient called a STEMI in the field, they arrived to the ambulance bay.” CNC identified Patient 2 by surname, and stated the facility started an investigation because the case was unusual in that Patient 2 was diverted without a diversion notification being placed, there was miscommunication between the ED provider and the cardiologist, and the ambulance trip report indicated the cardiologist wasn’t present when they actually were present. The fault was that they were diverted without a diversion being in place. During an interview, on 7/31/25 at 4:18 pm, ED MD B stated, that Patient 2 came in as a STEMI-alert on 7/2/25, and the EKG could not be transmitted from the ambulance. The cardiologist was in a complicated procedure; when ED MD B spoke with the cardiologist, ED MD B was told “it would be OK to give TNK,” but the cardiologist could not accommodate the patient at this time and suggested diverting. ED MD B stated, that while speaking with EMS, “the radio died, and I couldn’t reach the ambulance to divert. I took 10 to 15 minutes to trying to reach them and then the ambulance arrived.” ED MD B informed Patient 2 and EMS they had been trying to divert but could not reach them, that if Patient 2 needed a cardiac catheterization the facility could not provide that due to the lack of provider. ED MD B gave Patient 2 the options that he could remain in the ED and wait for a cardiac catheterization procedure, or go to Facility B, and Patient 2 opted to go to facility B. ED MD B stated, that she did not speak with Facility B about the transfer and was told by her superiors that she should have registered the patient and should have spoken with Facility B to assure their cardiologist was available. When asked if communication was the issue, ED MD B stated, other than the equipment failure when the radio died, yes, that was the issue.”

“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: 41567 Based on interview, and record review, the facility failed to include restraint use in one of two sampled patient’s nursing plan of care (Patient 1). This failure had the potential for missed interventions, and assessments that could have resulted in negative health outcomes for Patient 1. Findings: The facility’s policy titled, “Use of Restraint or Seclusion (Nursing),” effective date 4/15/22, was reviewed, and indicated that the use of restraints must be documented in the patient’s plan of care, or treatment plan. Patient 1’s medical record was reviewed. Patient 1 was admitted with diagnoses including chronic lymphocytic leukemia (a type of cancer of the blood and bone marrow) and COVID-19 (a contagious respiratory virus). A review, of Patient 1’s physician’s orders indicated that on 11/3/23 at 10:45 am, that he had been ordered soft wrist restraints for to both wrists for pulling on lines, tubing or dressings. On 11/4/23 at 5:38 am, this order had been discontinued. A review, of Patient 1’s nursing assessments indicated that on 11/3/23, the 7 am - 7 pm assessment was completed by Registered Nurse (RN) 1. On 11/3/23, the 7 pm - 7 am assessment was completed by RN 2. On 11/4/23, the 7am - 7 pm assessment was completed by RN 3. In a concurrent interview, and record review, with the Patient Safety Manager (PSM) on 11/15/23 at 11:30 am, a review of Patient 1’s plans of care indicated that there was no plan for restraint use, which the PSM confirmed. In an interview, on 11/17/23 at 12:20 pm, the Senior Director of Nursing (SDN) stated, that she would think there should be a nursing plan of care for restraints.”