Foothill Regional Medical Center

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 29558 Based on interview and record review, the hospital failed to ensure nursing staff implemented the hospital’s P&Ps for assessment, reassessment and urinary catheter for one of two sampled patients (Patient 1) as evidenced by: 1. The nursing staff failed to document the Foley catheter assessment or the removal of the Foley catheter prior to discharge. 2. The nursing staff failed to document the least restrictive measures attempted prior to the use of restraints. This posted an increased risk of poor health outcomes to the patient. Findings: During a concurrent interview and record review of Patient 1 on 5/27/26 at 1312 hours with the CNO, the medical record showed Patient 1 was admitted on 1/20/26 and discharged home on 1/23/26 at 1840 hours. 1. Review of the hospital’s P&P titled “Assessment and Reassessment” dated 7/2024 showed: * Patients in Critical Care should be reassessed as needed and at least every two hours. * Reassessment may be problem-specific and is integrated into the patient’s medical record. Review of the hospital P&P titled “Catheter Associated Urinary Tract Infection (CAUTI) Elimination Policy” dated 7/2024 showed: * Urinary catheterization should only occur when medically necessary, with assessment each shift for continued need. * Catheters are to be removed if no longer needed unless exclusion criteria apply, and concerns about removal should prompt physician consultation. Review of the medical record showed a physician order for indwelling (Foley) catheter insertion on 1/22/26 at 1320 hours, with instruction to discontinue upon discharge. Review of the Nursing Narrative Note dated 1/22/26, showed that at 1200 hours the patient attempted voiding without output. A bladder scan showed 702 ml of urine retention, and the Foley catheter was placed at 1400 hours. At 1900 hours on 1/22/26, the patient was transferred to the ICU for a higher level of care. During a concurrent interview and record review on 5/27/26 at 1707 hours, the ICU Charge Nurse confirmed that the Foley catheter assessments were required every shift, and that, unless otherwise ordered, the catheter should be removed prior to discharge. The ICU Charge Nurse was unable to locate documentation of the Foley catheter assessment or documentation of Foley catheter removal during the 1/23/26 day shift (prior to discharge). 2. Review of the hospital’s P&P titled “Restraints” dated 7/2024 showed: * Restraints are only utilized when less restrictive interventions are ineffective. Nursing staff must document the rationale for both initiation and discontinuation, demonstrating attempts at less restrictive measures. Review of the Non-Violent/Behavioral Restraint Flowsheet dated 1/22/26, showed the “Upon Initial order, indicate less restrictive interactions tried or considered prior to restraints” section showing the box of “Family/companion/sitter” was left blank. During a concurrent interview and record review on 5/27/26 at 1543 hours, the Tele/Med/Surg Charge Nurse reviewed Patient 1’s restraint flowsheet and stated that least restrictive interventions should include family/companion/sitter involvement. The Tele/Med/Surg Charge Nurse confirmed that the flowsheet did not reflect family/companion/sitter interventions, and the charge nurse was unable to confirm the presence of a sitter prior to restraint use on 1/22/26.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 29558 Based on observation, interview, and record review, the GB failed to ensure the safe and effective operation of the hospital as evidenced by: 1. The hospital failed to ensure the medial staff was accountable to the GB for the use restraint when the medical staff did not review the hospital’s data related to the use of restraint for PI. Cross reference to A-049. 2. The hospital failed to ensure a hospital-wide, data-driven, effective QAPI program was implemented and maintained related to the use of restraint. Cross reference to A-263. 3. The hospital failed to protect and promote the rights of each patient. Cross reference A-115. The cumulative effect of these systematic practices resulted in the GB’s inability to provide high quality healthcare in a safe environment.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 29558 Based on observation, record review, and interview, the hospital failed to protect and promote the rights of each patient as evidenced by: 1. The hospital failed to ensure the informed consent was completed for one of 11 sampled patients (Patient 7). Cross reference to A-131. 2. The hospital failed to ensure the patient’s right to receive care in a safe setting for two of 11 sampled patients (Patients 7 and 11). Cross reference to A-144. 3. The hospital failed to ensure nursing staff followed the physician’s order for the use of a propofol drip (an intravenous general anesthetic and sedative-hypnotic agent used to induce and maintain anesthesia, as well as for sedation in critical care) for one of 11 sampled patients (Patient 10). Cross reference to A-160. 4. The hospital failed to ensure the nursing staff tried the less restrictive interventions and determined to be ineffective to protect the patient and staff member from harm prior to using four side rails of the bed and bilateral wrist restraints for six of 11 sampled patients (Patients 1, 3, 4, 6, 7 and 9). Cross reference to A-164. 5. The hospital failed to ensure nursing staff developed a plan of care for the use of restraints for seven of 11 sampled patients (Patients 1, 2, 6, 7, 8, 9, and 10). Cross reference to A-166. 6. The hospital failed to ensure the physician’s order for the application of the bilateral wrist restraints were obtained for four of 11 sampled patients (Patients 2, 5, 7, and 9). Cross reference to A-168. 7. The hospital failed to ensure seven of 11 sampled patients (Patients 1, 2, 5, 6, 7, 8, and 9) who were on restraints, were monitored by a trained staff. Cross reference to A-175. The cumulative effect of these systemic failures resulted in the hospital’s inability to provide quality healthcare in a safe environment to the patients.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 29558 Based on observation, interview, and record review, the hospital failed to ensure a hospital-wide, data-driven, effective QAPI program was implemented and maintained as evidenced by: 1. The hospital failed to ensure the QAPI program analyzed the reports for restraints use as part of the PI program of the hospital. Cross reference to A-273. 2. The hospital failed to ensure the QAPI program used the collected restraint data to identify opportunities for PI that affects health outcomes for patient safety and quality of care and measures success to ensure the improvements were sustained. Cross reference to A-283. 3. The hospital’s GB failed to ensure the hospital-wide QAPI program addressed the use of restraints for improvement of quality of care and patient safety. Cross reference to A-309. The cumulative effect of these failings meant the hospital did not implement and maintain a quality improvement program to ensure the safety and quality of the services provided.”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 37663 Based on observation, interview, and record review, the hospital failed to ensure the medial staff was accountable to the GB for the use restraint when the medical staff did not review the hospital’s data related to the use of restraint for PI. This failure posted an increased risk of restraints use inappropriately for the patients. Findings: Review of the hospital’s Quality Assessment and Performance Improvement Program Plan 2025 showed the following: - The Medical Staff shall oversee the safety and care, treatment and services provided to patients by practitioners privileged through the medical staff processes. - The Board shall receive reports from the Medical Staff and QAPI. The Board shall act as appropriate on the recommendations of those bodies and assure that effort undertaken are effective and appropriately prioritized . - The Board shall receive reports on the analysis and actions taken regarding various quality and utilization functions included in this plan and taken actions as needed. - The Board remains responsible for establishing clear expectations for safety allocating adequate resources for measuring, assessing, improving and sustaining hospital performance and reducing risk to patients, and enhancing the efficiency and quality of care through an appropriate number of performance improvement projects. - The Medical Staff is responsible for the PI and Quality Monitoring of its members including but not limited to: development and approval of Professional practice Evaluation indicators at least annual approval by appropriate medical staff bodies (departments, committees, etc.) During the Complaint Validation survey conducted from 4/22/26 to 4/28/26, the following deficient practices related to the use of restraint were identified: * The hospital failed to ensure the QAPI program analyzed the reports for restraints use as part of the PI program of the hospital. Cross reference to A-273. * The hospital failed to ensure the QAPI program used the collected restraint data to identify opportunities for PI that affects health outcomes for patient safety and quality of care. Cross reference to A-283. * The hospital’s GB failed to ensure the hospital-wide QAPI program addressed the use of restraints for improvement of quality of care and patient safety. Cross reference to A-309. On 4/28/26 at 1431 hours, interview and record review of the GB meeting minutes was conducted with the CNO. The CNO was asked about the GB meeting minutes. The CNO stated the GB meeting was done quarterly. For the discussion about the use of restraints, the MEC had a meeting on September 2025 for the 1st quarter. The hospital had a change of ownership that started in July 2025. The GB meeting was done on December 2025 for 2nd quarter, and the restraints report was for M/S only. The ICU and ED reports for the use of restraints had not been turned in to the Quality. The restraint data for the month of April, May, and June was not presented to medical staff and GB. The GB meeting on January 2026 for 3rd quarter did not have report on restraints for the month of July, August, and September. Director 1 should send data to the Medical Staff committee to record in the Medical Staff report and to be entered to the GB report. If the report was not sent, it would not be sent to the GB. The CNO was asked about the process for reviewing the restraints report with the GB. The CNO stated the Directors of the units submitted the restraints data to the Quality. The Director of the units attended the medicine meeting to discuss their restraints data. Then, restraints report was included in the meeting minutes and sent to the Medical Executives Committee for their PI. The CNO was asked where and who the restraints report would be discussed with. The CNO stated the Chief of Staff would include and present the PI project that was discussed in the Medical Executive Committee meeting during the GB meeting. The CNO stated the QAPI for acute or hospital for ICU, M/S and telemetry PI included restraints. Since there was no data reported for the use of restraint, there was none presented.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 37663 Based on interview and record review, the hospital failed to ensure the informed consent was completed for one of 11 sampled patients (Patient 7). This failure posted an increased risk of substandard health outcome for the patient. Findings: Review of the hospital’s General Medical Staff Rules and Regulations (undated) showed the following: * Who may give consent: - Non- emergency: Informed consent must be secured from competent patients. If a patient is incompetent by reason of age or condition, consent must be secured from a surrogate decision-maker. Surrogate decision-makers may be parents or guardians of minors, conservators, attorney-in-fact, the patient’s closest relative, the court, or the Bioethics Committee may, after review of the case, give consent (a telephone conference may be held with no less than two members of the Bioethics committee). - Emergency: Consent may be implied in an emergency. An emergency occurs when treatment is immediately necessary to prevent the patient’s death, severe impairment or deterioration, or to alleviate severe pain, and the patient is incompetent to give consent, or there is insufficient time to secure consent from the patient, or his or her surrogate decision-maker. The emergency exception applies only to the treatment which is immediately necessary and for which consent cannot be secured. In an emergency, the signature of the practitioner who is administering the treatment or performing the procedure is the only signature required for consent: * Complex procedure determined by medical staff are as follows: - Scope-related procedure: Bronchoscopy. * Documentation: The practitioner’s documentation for emergencies that should be entered in a progress note, must describe: the nature of the emergency, the reasons consent could not be secured from the patient or a surrogate decision-maker, and the probable results if treatment would have been delayed, or not provided. * Consents: - Informed consent is a process whereby the patient, his or her surrogate decision maker, is given information which will enable him or her to reach a meaningful, informed decision regarding whether to give consent. - Consent shall be obtained (and documented in writing) for all operations, before surgery and other complex medical procedure . No invasive procedures shall be performed without the written consent of the patient or his/her legal representatives except in an emergency. - The patient’s attending physician generally is responsible for giving the patient, or his/her surrogate decision-maker, the requisite information and securing consent. - Practitioners other than the patient’s attending physician(s) may have a duty to secure consent, when they will provide specialized procedures at the request of or together with the patient’s attending physician. The practitioner who will provide the specialized service (example, the radiology study or anesthesia), shall describe the nature of the procedure and its risks and associated complications. - The information that must be provided includes a description of the following: the nature of the recommended treatment; the expected benefits or effects; the associated risks and possible complications, and any alternative procedures and their expected benefits or effects and associated risks and possible complications. On 4/22/26 at 1045 hours, interview and concurrent review of Patient 7’s closed record review was conducted with RN 6 and Director 1. Patient 7’s medical record showed the patient was admitted to the hospital on 4/1/26 at 2025 hours. Review of the Nursing Narrative Note dated 4/9/26 at 0549 hours, showed Patient 7 was confused. The physician performed bronchoscopy at 0500 hours. The bronchoscopy was finished at 0540 hours. Review of the Physician Daily Progress Note dated 4/9/26 at 0711 hours, showed a Pulmonary Disease specialty documentation for bedside FOB (Fiberoptic bronchoscopy)/ lavage under conscious sedation/topical lidocaine (numbing medication). During the review of Patient 7’s medical record, Patient 7’s medical record physician signed the consent for bronchoscopy dated 4/9/26. However, Patient 7 signature was not documented on the consent form. RN 6 and Director 1 were asked about Patient 7’s consent for bronchoscopy. RN 6 stated the patient did not have a family and was oriented to name only. Director 1 stated they were getting conservators for the patient. During the review of Patient 7’s medical record with the CNO on 4/22/26 at 1420 hours, the CNO was asked for the documentation of the physician as required per Medical Rules and Regulation. The CNO could not provide the physician’s documentation the procedure was provided for emergency situation and reason why the consent could not be obtained. During the continued review of Patient 7’s record, the CNO could not provide the attending physician’s note secured a consent or documented the patient needing bronchoscopy on an emergent situation.”

“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: 37663 Based on interview and record review, the hospital failed to ensure the patient’s right to receive care in a safe setting for two of 11 sampled patients (Patients 7 and 11) as evidenced by: 1. For Patient 7, the nursing staff failed to ensure the patient was monitored during bronchoscopy under conscious sedation as per the hospital’s P&P. 2. For Patient 11, the nursing staff failed to ensure the vital signs were obtained every two hours and the cardiac rhythm was monitored for chest pain with the pain level of 10 out of 10 (on the pain scale from zero to 10, zero = no pain and 10 = the worst pain) in the ED. These failures posed an increased risk of substandard health outcomes for the patients. Findings: 1. Review of the hospital’s P&P titled Moderate Sedation, Management of dated August 2025 showed the following: * Moderate Sedation /Analgesia (“Conscious Sedation”) is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required a patient airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. * Procedure: IV medications for the purpose of moderate sedation may be provided in .... ICU. * The nurse is responsible to: - Do pre-procedure Alderete Scoring assessment and record. - Sedation Drug: Versed (midazolam - a controlled medication used for sedation, anxiety relief and amnesia before or during surgical and diagnostic procedures). Dosing Guideline: Initial dose: 0.5 mg to 2.5 mg IV over 2 minutes, a total dose of 5 mg IV. - The nurse managing the care of the patient should have no other responsibilities that would leave the patient unattended or compromise continuous monitoring . If the physician needs someone to assist with the procedure, another RN or Technician shall be assigned with the procedure. - In addition, during and following administration of conscious sedation, the following requirements must be met: Continuous monitoring of physiological data ( BP, O2 saturation, Respiration, heart rate and rhythm. Vital sign documented every 5 minutes intervals during sedation. Cardiac rhythm strips pre and post procedure are to be included in documentation. Continuous monitoring of the patient for a minimum of 30 minutes after the procedure and documentation the physiological at every 10 minutes or more frequently as needed. Monitoring and documentation of neurologic status such as degree of sedation every 10 minutes for 30 minutes after last dosage of medication . The patient will not be returned to routine nursing care until they have attained a minimum of eight on Alderete Scale. Review of Patient 7’s medical record was conducted with RN 6 and Director 1 on 4/22/26 at 1045 hours. Patient 7’s medical record showed the patient was admitted to the hospital on 4/1/26. Review of the Physician Daily Progress Note dated 4/9/26 at 0711 hours, showed a Pulmonary Disease specialty documentation for bedside FOB (Fiberoptic bronchoscopy)/ lavage under conscious sedation/topical lidocaine (numbing medication). The patient was lethargic. Versed 2 mg IV was given for sedation, with topical anesthesia with lidocaine nebulization and 1 % solution. Patient 7 tolerated the procedure well. During the review of Patient 7’s medical record with RN 6 and Director 1 on 4/22/26 at 1045 hours, Director 1 was asked about Patient 7’s bronchoscopy procedure. Director 1 stated Patient 7 was given Versed IV for the procedure. However, Director 1 could not provide documentation for Patient’s 7 monitoring during and after the bronchoscopy procedure. During the interview and record review on 4/27/26 at 1711 hours, the CNO could not show documented evidence of Patient 7’s required monitoring during and after bronchoscopy procedure as per the hospital’s P&P. The CNO verified the findings. 2. Review of the hospital’s P&P titled Assessment and Reassessment dated June 2025 showed the following: * The Scope section showed Emergency Department Nursing Staff. * Vital signs are obtained on all patients and reassessed every two hours. Vital signs assessment includes temperature, pulse, pain, respiration, and blood pressure. The following parameters require immediate reassessment and intervention: - Blood pressure for adults greater than 140/90 or less than 90/50 mmHg. - Pulse in adult patients greater than 110 or less than 50 bpm. - Respirations greater than 32 or less than 14 breaths per minute. - Pulse oximetry less than 92%. * Cardiac monitoring is required with the following: - Profound bradycardia, - Shock ( as evidenced by cool, pale, diaphoretic, anxious, tachycardia, decreased pulse pressure, increased respiration and orthostatic changes), - Altered sensorium, - Cardiac related chest pain On 4/23/26 at 1550 hours, interview and concurrent review of Patient 11’s medical record was conducted with the CNO. Patient 11’s medical record showed Patient 11 arrived to the hospital ED on 2/26/26 at 1942 hours, ambulatory with a family member. Review of the ED Triage dated 2/26/26 at 2025 hours, showed Patient 11’s ESI was 3. The patient complained of aching chest pain with the pain level of 10 out of 10 that was radiating to left leg described as numbness. Patient 11’s vital signs were the oral temperature of 97.7 degrees Fahrenheit, the heart rate of 84 bpm, the RR of 16 breaths per minute, oxygen saturation of 96% on room air, and BP of 153/79 mmHg. Patient 11 was alert, oriented to person and place. Review of the Nursing Narrative Note dated 2/27/26 at 0018 hours, showed at 2231 hours, Patient 11’s family member called for help after witnessing the patient had a syncopal episode. The ED RN found the patient slumped over bedside after urinating in the urinal and leaning against the bed. Code was called at 2232 hours, and the patient was placed in bed and was non-arousable. Patient 11 had frothy sputum coming from the nose and mouth and grasping for air. The patient’s heart rate went down to 30’s; and the patient was diaphoretic and unresponsive. Patient 11 was placed on a defibrillator monitor. The patient was assisted with ventilation by Ambu bag, there was no rise and fall of the chest. During the review of Patient 11’s Code Blue Record dated 2/26/26 at 2231 hours, the Code Blue Record showed the patient was unconscious and had apnea. Pulse oximetry reading was 26%. The pulse was 40 bpm. The airway/ventilation was agonal. Ventilation was assisted with bag-valve-mask, and then the patient was intubated with ETT at 2339 hours (after 1 hour and 8 minutes with bag-valve-mask assisted ventilation). Review of Patient 11’s vital signs measurements documentation showed after the initial vital signs measured for Patient 11 at the triage that was 2/26/26 at 2025 hours, the next vital signs documented was on 2/26/26 at 2242 hours (after 2 hours and 17 minutes) when the patient had already coded. Director 1 was asked how often the vital signs were reassessed in the ED. Director 1 stated vital signs are reassessed every two hours. However, the vital signs were not reassessed in two hours as per the hospital’s P&P. During the review and concurrent interview of Patient 11’s medical record with the CNO and Director 1 on 4/28/26 at 1200 hours, the CNO was asked to show the cardiac monitoring during the time the patient was in the ED, before the code blue and during the code blue. The CNO could not show the cardiac monitoring documentation when the patient was admitted to the ED and when the code blue was called. On 4/28/26 at 1650 hours, the CNO verified there was no documented cardiac monitoring for Patient 11 and stated the cardiac monitors in the ED did not have capability to run rhythm strips and for the Zoll defibrillator monitor had no records of the cardiac rhythms.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(B) [A restraint is-] (B) A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. This Standard is not met as evidenced by: 37663 Based on observation, interview, and record review, the hospital failed to ensure nursing staff followed the physician’s order for the use of a propofol drip for one of 11 sampled patients (Patient 10). This failure increased the risk that propofol would be used to restrict the patient’s freedom of movement or for staff convenience, rather than as a standard treatment for a medical condition as per the hospital’s P&P. Findings: Review of the hospital’s P&P titled Restraints dated February 2025 showed: * Chemical restraints: any drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. Any drug that is used for discipline or convenience and not required to treat medical symptoms. Review of hospital’s P&P titled Propofol Titration Protocol dated October 2025 showed: * Policy: A Critical Care RN may titrate propofol per protocol when a physician’s order has been written. The physician must be notified if a maximum dose and unable to maintain titration protocol. The physician may override the protocol by providing specific elements of the order if he or she so chooses. Once the order for titration by protocol is received, the RN will place a copy of the dosing guideline in the patient’s medical record. * Definition: Propofol is an intravenous sedative-hypnotic agent for use in the maintenance of sedation. Intravenously....it works by slowing the brain wave activities accounting for the rapid onset of sedation. * Procedure: Dosing guideline: by Critical Care RN. Patient must be on a continuous cardiac monitor and ventilator. Vital signs - blood pressure should be monitored every 15 minutes while titration and every 15-60 minutes until discontinued. - Infusion: Change of rate recommendation is to increase by 5 mcg/kg/min every 5 minutes until desired effect is reached. Titrate to desired sedation level. On 4/27/26 at 1007 hours, an observation of Patient 10 was conducted with the CNO, Director 1, and RN 7. Patient 10 was observed orally intubated, connected to a ventilator, in a deep sleep state, with all four siderails raised and bilateral wrist restraints in place. RN 7 stated that the patient was on a propofol drip and that the bilateral wrist restraints had been reapplied that morning because the patient attempted to pull at medical devices when not sedated. RN 7 was asked how the propofol drip was being titrated to manage the patient’s sedation. RN 7 stated that the propofol drip was titrated to maintain a Glascow Coma Scale (GCS) score of 8. When asked about the physician’s order for propofol administration, RN 7 stated the order was to maintain the patient at a Richmond Agitation-Sedation Scale (RASS) score of -1. However, a review of the RN’s RASS assessments showed the patient remained at a RASS of -3 from 0500 to 0900 hours on 4/27/26 while receiving propofol at 10 mcg/kg/min. Review of Patient 10’s medical record showed a physician’s order dated 4/26/26 at 0637 hours, to start propofol at 5 mcg/kg/min and titrate 5 mcg/kg/min every 5 minutes to maintain a RASS of 0 to -2, with a maximum dose of 75 mcg/kg/min. RN 7 verified that there was no physician order directing the use of propofol to maintain the patient at a RASS of -3. On 4/27/26 at 1025 hours, a review of Patient 10’s medial record was conducted with Director 1. The documentation for propofol administration and RASS monitoring dated 4/26/26 showed the following: - At 0645 hours, dose was 5 mcg/kg/min; no RASS assessment documented. - At 0800 hours, dose was 5 mcg/kg/min; RASS -2 documented. - From 0900 to 1500 hours, dose remained at 5 mcg/kg/min; no RASS assessment documented. - From 1600 to 1800 hours, neither propofol dosing nor RASS assessments were documented. - At 1900 hours, dose was 5 mcg/kg/min; no RASS assessment documented. - At 2000 hours, dose was 10 mcg/kg/min; RASS -2 documented. - From 2100 to 2230 hours, dose remained at 10 mcg/kg/min; no RASS assessment documented. - From 2230 to 2300 hours, neither propofol dosing nor RASS assessments were documented. Documentation dated 4/27/26, showed: - From 0000 to 0400 hours, neither propofol dosing nor RASS assessments were documented. - From 0500 to 0900 hours, dose was 10 mcg/kg/min; RASS -3 documented. These findings were shared with Director 1 and the CNO.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(2) Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm. This Standard is not met as evidenced by: 37663 Based on observation, interview, and record review, the hospital failed to ensure the nursing staff tried the less restrictive interventions and determined to be ineffective to protect the patient and staff member from harm prior to using four siderails of the bed and bilateral wrist restraints for six of 11 sampled patients (Patients 1, 3, 4, 6, 7 and 9). These failures posed an increased risk of using restraints inappropriately for the patients. Findings: Review of the hospital’s P&P titled Restraints dated February 2025 showed * Restraints may not be used unless the use of restraints is necessary to ensure the immediate physical safety of the patient, staff members and others. For a given patient at a particular point in time, this comprehensive individualized patient assessment is used to determine whether the use of less restrictive measures poses a greater risk than the risk of using restraints. * Less restrictive intervention: measures which modify the environment, enhance interpersonal interaction, or provide treatment so as to minimize or eliminate the problems or behaviors which place the patient at risk. Restraints or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member or others from harm. Examples of less restrictive measures include but are not limited to: - Verbal interventions such as talking quietly with the patient. - Environmental intervention through reduction of stimuli causing irritation. - Relaxation techniques. - Physical Activity - Psychoactive medications - Reality Orientation - Quiet times * The Procedure section showed - The use of restraints for the management of patient behavior should not be considered a routine part of patient care. - The use of restraints for prevention of falls should not be considered a routine part of a falls prevention program. On 4/22/26 at 1021 hours, an observation at the M/S Unit with the CNO was conducted. The following were observed: * Patient 3 was observed lying quietly in bed with four side rails raised up and * Patient 4 was observed lying quietly in bed with four side rails raised up. RN 5 was asked about the four siderails up for Patients 3 and 4. RN 5 stated Patients 3 and 4 had a sitter and four siderails up were not indicated for the patients. The CNO was asked for the use of four siderails. The CNO stated there was no P&P for the use of siderails for the patient. On 4/22/23 at 1035 hours, an observation in the ICU was conducted with the CNO. The following were observed: * Patient 6 was asleep in bed, on a bipap machine, had bilateral wrist restraints on with four side rails up. * Patient 7 was observed asleep in bed, on bipap machine, had bilateral wrist restraints. * Patient 9 was asleep, on room air, and had bilateral wrist restraints. 1. An interview and concurrent closed record review of Patient 1’s medical record conducted with the CNO on 4/22/26 at 1150 hours. Review of the order on 2/15/26 at 1152 hours showed bilateral soft wrist restraints to promote and support physical healing was ordered for Patient 1. Review of the Non-violent/Behavioral Restraint Flowsheet dated 2/15/26, showed the section of “Upon initial order, indicate less restrictive interactions tried or considered prior to restraints” were blank. The patient was restrained from 1130 to 1500 hours. The CNO was asked about Patient 1’s restraints monitoring form to show the RN’s least restrictive intervention tried prior to application of bilateral wrist restraints on 2/15/26. The CNO verified the restraints monitoring documentation was not completed. 2. During the interview and concurrent review of Patient 6’s medical record conducted with the CNO on 4/27/26 at 0930 hours, the CNO was asked about the Patient 6’s restraints monitoring form to show the RN’s least restrictive intervention tried prior to application of bilateral wrist restraints and four side rails on 4/18/26. The CNO verified the restraints monitoring documentation was not completed. 3. During the interview and concurrent review of Patient 7’s medical record conducted with the CNO on 4/23/26 at 0830 hours, the CNO was asked about the Patient 7’s restraints monitoring form to show the RN’s least restrictive intervention tried prior to application of bilateral wrist restraints and four side rails on 4/19/26. The CNO verified the restraints monitoring documentation was not completed. 4. During the interview and concurrent review of Patient 9’s medical record conducted with the CNO on 4/23/26 at 0900 hours, Patient 9’s medical record showed on 4/17/26 at 2114 hours, bilateral soft wrist restraints to promote and support physical healing was ordered for the patient. The CNO was asked about Patient 9’s restraints monitoring form to show the RN’s least restrictive intervention tried prior to application of bilateral wrist restraints on 4/17/26. The CNO verified the restraints monitoring documentation was not completed The CNO verified all the 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: 37663 Based on interview and record review, the hospital failed to ensure nursing staff developed a plan of care for the use of restraints for seven of 11 sampled patients (Patients 1, 2, 6, 7, 8, 9, and 10). These failures posed an increased risk of substandard health outcomes for patients. Findings: Review of hospital’s P&P titled Restraints dated February 2025 showed the Planning section showing the use of restraints will also include a written modification of the plan of care and the plan of care will be individualized to the patients assessed needs and goal of care. 1. On 4/22/26 at 0850 hours, an interview and concurrent review of Patient 1’s medical record was conducted with the CNO. Patient 1’s medical record showed the patient was admitted to the hospital on 2/14/26. Review of the orders showed the following: - From 2/15/26 at 1152 hours to 2/16/26 at 1200 hours, bilateral soft wrist restraints were ordered to support and promote physical healing. - From 2/16/26 at 1200 hours to 2/17/26 at 1530 hours, bilateral soft wrist restraints were ordered to support and promote physical healing. - From 2/17/26 at 1530 hours to 2/18/26 at 1530 hours, bilateral soft wrist restraints were ordered to support and promote physical healing. - From 2/18/26 at 1530 hours to 2/19/26 at 1530 hours, bilateral soft wrist restraints were ordered to support and promote physical healing. Review of the Non-violent/Behavioral Restraint Flowsheet showed the following: - From 2/15/26 at 1130 hours to 1500 hours, soft wrist restraints were applied and were discontinued at 1600 hours. - From 2/16/26 at 1200 hours to 2/17/26 at 0000 hours, soft wrist restraints were applied and were discontinued at 0200 hours. - From 2/17/26 at 1530 hours to 2/18/26 at 1230 hours, soft wrist restraints were applied. - From 2/18/26 at 1430 hours to 2/19/26 at 0800 hours, soft wrist restraints were applied. Review of Patient 1’s care plan did not show that a plan of care addressing the use of restraints was developed. The CNO verified the findings. 2. On 4/23/26 at 1023 hours, an interview and concurrent review of Patient 2’s medical record was conducted with the CNO. Patient 2’s medical record showed the patient was admitted to the hospital on 4/15/26. Review of the orders showed that from 4/17/26 at 1245 hours to 4/19/26, and from 4/20/26 at 2343 hours to 4/24/26, bilateral wrist restraints were ordered to support and promote physical healing. Review of the Non-violent/Behavioral Restraint Flowsheet showed the following: - On 4/17/26 at 1245 hours, and from 0245 hours to 2245 hours, soft wrist restraints were applied. - From 4/18/26 at 2000 hours to 4/19/26 at 0000 hours, soft wrist restraints were applied and were discontinued at 0050 hours. - From 4/20/26 at 2343 hours to 4/21/26 at 1900 hours, soft wrist restraints were applied and were discontinued at 2300 hours. - From 4/21/26 at 2100 hours to 4/22/26 at 1800 hours, soft wrist restraints were applied. - From 4/21/26 at 2000 hours to 4/22/26 at 1000 hours, soft wrist restraints were applied. Review of Patient 2’s care plan with the CNO showed that a plan of care addressing restraints was not developed until 4/22/26 at 1620 hours. The CNO verified the findings. 3. On 4/27/26 at 0930 hours, an interview and concurrent review of Patient 6’s medical record was conducted with the CNO. Patient 6’s medical record showed the patient was admitted to the hospital on 4/15/26. Review of the orders showed from 4/18/26 at 1200 hours, from 4/20/26 at 1200 hours to 4/23/26, bilateral soft wrist restraints were ordered to support and promote physical healing. Review of the Non-violent/Behavioral Restraint Flowsheet showed the following: - From 4/20/26 at 1200 hours to 4/21/26 at 1000 hours, soft wrist restraints were applied. - From 4/21/26 at 1200 hours to 4/22/26 at 1000 hours, soft wrist restraints were applied. Review of Patient 6’s care plan showed a plan of care related to restraints dated 4/22/26. The CNO verified that no care plan had been initiated at the start of the restraint order. 4. On 4/22/26 at 1045 hours, an interview and concurrent review of Patient 7’s medical record was conducted with Director 1. Patient 7’s medical record showed the patient was admitted to the hospital on 4/1/26. Review of the Non-violent/Behavioral Restraint Flowsheet showed the following: - From 4/10/26 at 0800 hours to 4/11/26 at 0600 hours, soft wrist restraints were applied. - From 4/12/26 at 0400 hours to 4/13/26 at 0200 hours, soft wrist restraints were applied. - From 4/13/26 at 1400 hours to 1000 hours, soft wrist restraints were applied and after 1000 hours was marked off. - From 4/19/26 at 0700 hours to 4/20/26 at 0600 hours, soft wrist restraints were applied. - From 4/21/26 at 0700 hours to 4/21/26 at 0500 hours, soft wrist restraints were applied. - From 4/21/26 at 0700 hours to 4/22/26 at 0500 hours, soft wrist restraints were applied. - From 4/22/26 at 0700 hours to 4/22/26 at 0900 hours, soft wrist restraints were applied. On 4/23/26 at 0830 hours, an interview and concurrent review of Patient 7’s medical record was conducted with the CNO. Review of the physician orders showed that on 4/5/26 at 1107 hours to 4/6/26, 4/10/26 at 1950 hours, 4/12/26 at 0309 hours to 4/13/26, 4/13/26 at 0303 hours to 4/14/26, and 4/19/26 at 0733 hours, bilateral soft wrist restraints were ordered to support and promote physical healing. Review of Patient 7’s care plan showed that a plan of care addressing restraints was not developed until 4/19/26 at 0732 hours. The CNO verified these findings. 5. On 4/23/26 at 1620 hours, an interview and concurrent review of Patient 8’s medical record was conducted with the CNO. Patient 8’s medical record showed the patient was admitted to the hospital on 4/15/26. Review of the orders showed that on 4/16/26 at 0817 hours, 4/17/26 at 0800 hours, 4/18/26 at 0800 hours, 4/19/26 at 0800 hours, 4/20/26 0800 hours, 4/21/26 0800 hours, and 4/22/26, bilateral wrist restraints were ordered to support and promote physical healing. Review of the Non-violent/Behavioral Restraint Flowsheet showed the following: - From 4/16/26 at 0800 hours to 4/17/26 at 0600 hours, soft wrist restraints were applied. - From 4/17/26 at 0800 hours to 4/18/26 at 0600 hours, soft wrist restraints were applied. - From 4/18/26 at 2000 hours to 4/19/26 at 0600 hours, soft wrist restraints were applied. - From 4/21/26 at 0000 hours to 2200 hours, soft wrist restraints were applied. - From 4/22/26 at 0000 hours to 2200 hours, soft wrist restraints were applied. Review of Patient 8’s care plan showed that a plan of care addressing restraints was not developed until 4/21/26 at 1514 hours. The CNO verified the findings. 6. On 4/23/26 at 0900 hours, an interview and concurrent review of Patient 9’s medical record was conducted with the CNO. Patient 9’s medical record showed the patient was admitted to the hospital on 4/16/26. Review of the physician’s orders showed that on 4/17/26 at 2114 hours, 4/18/26 at 1903 hours, 4/19/26 at 1524 hours, 4/21/26 at 0802 hours, and 4/23/26, bilateral soft wrists restraints were ordered to support and promote physical healing. Review of the Non-violent/Behavioral Restraint Flowsheet showed the following: - From 4/18/26 at 0800 hours to 4/19/26 at 0600 hours, soft wrist restraints were applied. - From 4/19/26 at 0800 to 4/20/26 0600 at hours, soft wrist restraints were applied. - From 4/21/26 at 0800 hours to 4/22/26 at 0600 hours, soft wrist restraints were applied. - From 4/22/26 at 0800 hours to 2200 hours, soft wrist restraints were applied. Review of Patient 9’s care plan showed that a plan of care addressing restraints was not developed until 4/22/26 at 1409 hours. The CNO verified the findings. 7. On 4/27/26 at 1025 hours, an interview and concurrent review of Patient 10’s medical record was conducted with Director 1. Patient 10’s medical record showed the patient was admitted to the hospital on 4/20/26. Review of the physician’s orders showed that on 4/23/26 at 0925 hours, 4/23/26 at 1040 hours, 4/24/26 at 1024 hours, and 4/26/26 at 1315 hours, bilateral wrists soft restraints were ordered to support and promote physical healing. Review of the Non-violent/Behavioral Restraint Flowsheet showed the following: - From 4/22/26 at 1052 hours to 2200 hours, soft wrist restraints were applied. - From 4/23/26 at 0000 hours to 4/24/26 at 2200 hours, soft wrist restraints were applied. - From 4/24/26 at 0000 hours to 1800 hours, soft wrist restraints were applied and were discontinued per the RN note showing the patient was sedated. Review of Patient 10’s care plan conducted with the CNO on 4/27/26 at 1630 hours. Patient 10’s plan of care showed that a plan of care addressing restraints was not developed until 4/24/26 at 1137 hours. The CNO verified the findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 37663 Based on interview and record review, the hospital failed to ensure the physician’s order for the application of the bilateral wrist restraints were obtained for four of 11 sampled patients (Patients 2, 5, 7, and 9). These failures posed an increased risk of violating patient rights. Findings: Review of the hospital’s P&P titled Restraints dated February 2025 showed the Physician Orders section showing: * Restraints order will be obtained from the physician licensed independent practitioner who is responsible for the care of the patient and who is authorized to order restraints by the hospital policy in accordance with the State Law. * The physician must specify the need for restraints, the type of restraints to be used and the duration of the restraints use. * Non-Violent/Non-Self Destructive: - Each order for restraint used to ensure the physical safety of the non-violent or non-self- destructive patient is renewed per MD order each calendar day. - A new or renewal order is requested based on the nurses and physician ’ s examination of the patient. A MD order must be obtained for new or renewal orders. - If restraints are removed (as opposed to release for patient care needs) and then are needed again to maintain safety, another MD order must be obtained from the physician. 1. On 4/22/26 at 0956 hours, an interview and concurrent record review for Patient 2 was conducted with RN 3. Patient 2’s medical record showed the patient was admitted to the hospital on 4/15/26. Review of the order showed physician ordered bilateral soft wrist restraints to support and promote physical healing on 4/17/26 at 1245 hours to 4/18/26. However, review of the Non-violent/Behavioral Restraint Flowsheet dated 4/17/26, showed the soft wrist restraints monitoring was started on 4/17/26 at 1245 hours; and was then noted that the monitoring documentation was changed to 0245 hours and every 2 hours until 2245 hours. RN 3 stated that the RN documented incorrectly for 1245 hours. RN 3 verified the physician’s order was placed 12 hours after the restraints were started for Patient 2. 2. On 11/23/26 at 1400 hours, interview and concurrent record review for Patient 5 was conducted with the CNO. Patient 5’s medical record showed the patient was admitted to the hospital on 3/30/26. Review of the Non-Violent/Behavioral Restraint Flowsheet dated 4/18/26, showed the restraints were applied for Patient 5 on 4/18/26 at 2000 hours until 4/19/26 at 1000 hours. However, review of the order for bilateral wrist restraints showed the physician’s order was entered on 4/18/26 at 1147 hours, to start the bilateral soft wrist restraint on 4/18/26 at 1146 hours; and on 4/19/26 at 1112 hours, to start the bilateral soft wrist restraint on 4/19/26 at 1100 hours. The CNO stated the RN should have obtained another physician’s order for the application of the bilateral wrist restraints that started on 4/18/26 2000 hours to 4/19/26 at 1000 hours. 3. On 4/22/26 at 1045 hours, an interview and concurrent record review of Patient 7’s medical record was conducted with Director 1. Patient 7’s medical record showed the patient was admitted to the hospital on 4/1/26. Review of the Non-Violent/Behavioral Restraint Flowsheet showed the restraints monitoring every two hours for the following dates: - 4/10/26 at 0800 hours to 4/11/26 at 0600 hours - 4/12/26 at 0400 hours to 4/13/26 at 0200 hours. On 4/23/26 at 0830 hours, interview and record review of Patient 7’s order for bilateral wrist restraint was conducted with the CNO. Review of the orders showed the bilateral wrist restraints order with an entry date of 4/10/26 at 1950 hours. However, the RN documented on the restraints flow sheet monitoring that the application of bilateral wrist restraints was on 4/10/26 at 0800 hours, or 11 hours and 50 minutes before the order was obtained from a physician). The CNO verified the order was obtained or entered late. 4. On 4/23/26 at 0900 hours, an interview and concurrent record review of Patient 9’s medical record was conducted with the CNO. Patient 9’s medical record showed the patient was admitted to the hospital on 4/16/26. Review of the order showed physician’s order for bilateral wrists restraints on the following dates: - 4/18/26 at 1903 hours, restraints non-behavioral with the start date as of 4/18/26 at 0800 hours and end date 4/19/26. - 4/19/26 at 1524 hours, restraints non-behavioral with the start date as of 4/20/26 at 0800 hours and end date 4/21/26. Review of the Non-Violent/Behavioral Restraint Flowsheet documents showed the soft wrist restraints monitoring every two hours for the following dates: - On 4/18/26 at 0800 hours to 4/19/26 at 0600 hours. - On 4/19/26 at 0800 to 4/20/26 at 0600 hours. - On 4/21/26 at 0800 hours to 4/22/26 at 0600 hour The CNO verified the order for the 4/19/26 application of restraints was not obtained for Patient 9.”

“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: 37663 Based on observation, interview, and record review, the hospital failed to ensure seven of 11 sampled patients (Patients 1, 2, 5, 6, 7, 8, and 9) who were on restraints, were monitored by a trained staff. These failures posed an increased risk of substandard health outcomes for the patients not being monitored while the patients were on non-behavioral bilateral wrist restraints. Findings: Review of the hospital’s P&P titled Restraints dated February 2025 showed the section of Ongoing Monitoring/Nursing Documentation showing: * The condition of the patient who is restrained must be monitored by a physician, other licensed independent practitioner or trained staff that have completed the training criteria specified at an interval determined by the hospital policy. * It is the responsibility of the nursing to clearly document specific patient behavior to justify both the application and discontinuation of restraints use, include documentation that demonstrates that the lesser restrictive measures were tried before the use of restraints and the patient’s response to the interventions. - Patients who are placed in nonviolent or non-behavioral restraints will be monitored by the RN/assigned trained staff a minimum of every two hours and have the following documented: evaluation for continued use, vital signs stable (such as respirations, pulse if on monitor), range of motion offered/provided, food/fluids offered/provided, toileting offered/provided, dignity/comfort maintained, skin integrity unchanged, any injury to the patient . * The selection of an intervention and determination of the frequency of the assessment and monitoring needs to take into consideration the patient’s condition, cognition status, and risks associated with the use of the chosen intervention. 1. On 4/22/26 at 0850 hours, an interview and concurrent record review of Patient 1’s medical record was conducted with the CNO. Patient 1’s medical record showed the patient came to the hospital on 2/14/26. Review of the Patient Orders showed the following: - On 2/15/26 at 1152 hours to 2/16/26 at 1200 hours, bilateral soft wrist restraints to support and promote physical healing. - On 2/16/26 1200 hours to 2/17/26 at 1530 hours, bilateral soft wrist restraints to support and promote physical healing. Review of the Non-violent/Behavioral Restraint Flowsheet dated 2/15/26, showed the monitoring every two hours, from 1130 hours to 1500 hours. The restraint was discontinued at 1600 hours. However, the documentation did not show the reason for discontinuation of the restraint for Patient 1. On 4/22/26 at 1150 hours, an interview and concurrent review of Patient 1’s medical record was conducted with the CNO. The CNO verified the above findings. 2. On 4/22/26 at 0940 hours, Patient 2 was observed in the presence of RN 3 and RN 4. Patient 2 was asleep and calm. Four side rails were all up. The patient was on bilateral wrist restraints. The patient had bilateral lower extremity amputee. RN 4 was asked about the restraint renewal order. RN 4 stated the renewal order for soft wrist restraints was obtained when needed. However, the restraints order or renewal might not be authorized as needed. On 4/23/26 at 1023 hours, an interview and concurrent record review of Patient 2’s medical record was conducted with the CNO. Patient 2’s medical record showed the patient was admitted to the hospital on 4/15/26, to telemetry unit. Review of the orders showed physician’s order for bilateral soft wrist restraints to support and promote physical healing as follows: - On 4/17/26 at 1245 hours to 4/18/26; - On 4/18/26 at 0045 hours to 4/19/26; - On 4/20/26 at 2343 hours to 4/21/26; - On 4/21/26 at 2343 hours to 4/22/26; - On 4/22/26 with the start time as “Routine” to 4/23/26 - On 4/23/26 with the start time as “Routine” to 4/24/26. Review of the Non-violent/Behavioral Restraint Flowsheet documents showed the restraints monitoring every two hours was performed on the following dates and times: - On 4/17/26 at 1245 hours, and from 0245 hours to 2245 hours. The soft wrist restraints were discontinued on 4/18/26 at 0040 hours; however, the reason for discontinuation of the restraints was not documented. - On 4/18/26 at 2000 hours to 4/19/26 at 0000 hours. The soft wrist restraints were discontinued on 4/19/26 at 0050 hours. However, there was no documentation of the reason for discontinuation. - On 4/20/26 at 2343 hours to 4/21/26 at 1900 hours. The soft wrist restraints were discontinued at 2300 hours. However, there was no documentation of the reason for discontinuation. - On 4/21/26 at 2100 hours to 4/22/26 at 1800 hours. - On 4/22/26 at 2000 hours to 4/23/26 at 1000 hours. The section of “Restrains discontinue at:” was left blank. There was no documented evidence showing the soft wrist restraints monitoring every 2 hours from 1200 hours to 1800 hours while the patient was on bilateral wrist restraints. The CNO verified the findings. 3. On 11/23/26 at 1400 hours, interview and concurrent record review for Patient 5 was conducted with the CNO. Patient 5’s medical record showed the patient was admitted to the hospital on 3/30/26. Review of the Non-Violent/Behavioral Restraint Flowsheet documents showed the following: - On 4/15/26 at 0800 hours to 1800 hours, the boxes of the patient’s “Psychological status...See key below” were checked. The section of Psychological Status/Behavior” showed the list of behaviors for the staff to choose for documentation. However, the staff failed to list the patient’s behavior while the patient was on bilateral wrist restraints on 4/15/26 from 0800 to 1800 hours. - On 4/16/26, the boxes of the patient’s “Psychological status...See key below” were checked from 0800 hours to 1800 hours and were left blank from 4/16/26 at 2000 hours to 4/17/26 at 0600 hours. The staff failed to document specific behavior or psychological status of the patient while the restraints were applied. - On 4/22/26 from 0800 to 2200 hours, the patient was restrained. At 2230 hours, the restraint was discontinued; however, the reason for discontinuation of restraints was not documented. The CNO verified the findings. 4. On 4/27/26 at 0930 hours, an interview and concurrent record review of Patient 6’s medical record was conducted with the CNO. Patient 6’s medical record showed the patient was admitted to the hospital on 4/15/26. Review of the order showed the order for bilateral soft wrist restraints to support and promote physical healing on the following dates: - On 4/18/26 start at 1200 hours to 4/19/26. - On 4/20/26 start at 1200 hours to 4/21/26. - On 4/21/26 start at 1200 hours to 4/22/26. - On 4/22/26 start at 1200 hours to 4/23/26. Review of the Non-Violent/Behavioral Restraint Flowsheet documents showed the following restraints monitoring every two hours: - On 4/20/26 at 1200 hours to 4/21/26 1000 hours - On 4/21/26 at 1200 hours to 4/22/26 at 0800 hours. The section of “Restraint discontinued at:” was left blank. However, the CNO failed to show documented evidence that the RN performed non-violent restraints monitoring while the wrist restraints were applied on the patient on 4/18 to 4/19/26 and from 4/22/26 at 1200 hours to 4/23/26 at 1200 hours. 5. On 4/23/26 at 0830 hours, interview and concurrent record review for Patient 7 was conducted with the CNO. Patient 7’s medical record showed Patient 7 was admitted to the hospital on 4/1/26. Review of the Non-Violent/Behavioral Restraint Flowsheet dated 4/12/26, showed Patient 7 was on soft wrist restraints on 4/12/26. The staff documented that the patient was monitored every 2 hours from 4/12/26 at 0400 hours to 4/13/26 at 0200 hours. However, on 4/12/26 2000 hours to 4/13/26 at 0200 hours, the staff marked a check for the patient’s behavior or psychological status; and failed to indicate the patient’s specific behavior or psychological status while the soft wrist restraints were applied on the patient. Review of the Non-Violent/Behavioral Restraint Flowsheet dated 4/13/26, showed the patient was on soft wrist restraints on 4/13/26 at 0400 hours to 1000 hours. The soft wrist restraints monitoring was marked off after 1000 hours. The form showed the restraint was discontinued on 4/13/26 at 1200 hours. However, there was no documentation for the reason the restraints were discontinued. Review of the Non-Violent/Behavioral Restraint Flowsheet dated 4/19/26, showed the patient was on wrist restraints on 4/19/26 from 0700 hours to 4/20/26 0600 hours. However, the staff marked check on the patient’s behavior or psychological status and failed to document the specific behavior or psychological status of the patient. On 4/23/26 at 0845 hours, the findings were shared with the CNO. 6. On 4/27/26 at 1505 hours, interview and concurrent record review for Patient 8’s was conducted with the CNO. Patient 8’s medical record showed the patient was admitted to the hospital on 4/15/26. Review of the orders showed bilateral soft wrist restraints to support and promote physical healing on the following dates: - On 4/16/26 at 0817 hours, - On 4/17/26 at 0800 hours, - On 4/18/26 at 0800 hours, - On 4/19/26 at 0800 hours, - On 4/20/26 at 0800 hours, - On 4/21/26 at 0800 hours, - On 4/22/26 at 0800 hours, and - On 4/23/26 at 0700 hours. Review of the Non-Violent/Behavioral Restraint Flowsheet for monitoring every 2 hours showed the following: - On 4/18/26 at 0800 hours to 1800 hours, failed to show staff documented evidence of Patient 8’s monitoring every 2 hours while the soft wrist restraints were applied to the patient. - On 4/19/26 at 0800 hours to 2200 hours, failed to show staff’s documented evidence of Patient 8’s monitoring every 2 hours while the soft wrist restraints were applied on the patient. - On 4/20/26 at 0000 hours to 2200 hours, failed to show staff’s documented evidence of Patient 8’s monitoring every 2 hours while the soft wrist restraints were applied on the patient. - On 4/21/26 at 0000 hours to 0600 hours, the staff marked the behavior or psychological status of the patient. However, the staff failed to document the specific behavior or psychological status of the patient while the soft wrist restraints were applied on the patient. - On 4/22/26 at 0000 hours to 0600 hours, the staff marked the behavior or psychological status of the patient. However, the staff failed to document the specific behavior or psychological status of the patient while the soft wrist restraints were applied on the patient. The CNO acknowledged the findings. 7. On 4/23/26 at 0900 hours, an interview and concurrent record review of Patient 9’s medical record was conducted with the CNO. Patient 9’s medical record showed the patient was admitted to the hospital on 4/16/26. Review of the order showed physician’s order for bilateral wrists restraints on the following dates: - 4/18/26 at 1903 hours, restraints non-behavioral start on 4/18/26 at 0800 hours and end date 4/19/26. - 4/19/26 at 1524 hours, restraints non-behavioral start on 4/20/26 at 0800 hours, and end date 4/21/26. Review of the Non-Violent/Behavioral Restraint Flowsheet for the soft wrist restraints monitoring every two hours showed the following: - On 4/18/26 at 0800 hours to 4/19/26 at 1800 hour, the patient’s psychological status or behavior was marked. However, the staff failed to document Patient 9’s specific behavior or psychological status while the soft wrist restraints were applied on the patient. The CNO verified the findings.”

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 37663 Based on observation, interview, and record review, the hospital failed to ensure the QAPI program analyzed the reports for restraints use as part of the PI program of the hospital. This failure increased the risk of substandard health outcomes for the patients. Findings: Review of the hospital’s Quality Assessment and Performance Improvement Program Plan 2025 showed the following: * The Organizational Leaders (including the Board, Medical Staff Leaders, and Senior Hospital Leaders) are responsible to: - Create and maintain a culture of safety and quality throughout the organization. - Use data and information in decision making that supports and/or improves the safety and/or quality of care, treatment, and services. * Quality Indicators: QAPI shall oversee measurement, and shall analyze and track quality indicators, including adverse patient events and other aspects of performance. * Prioritization: QAPI shall prioritize performance improvement activities to assure that they are focused on high-risk, high volume, or problem prone areas. It shall focus on issues of known frequency, prevalence or severity and shall give precedence to issues that affect health outcomes, quality of care and patient safety. * The organization’s leaders ensure that the hospital uses data and information as a guide in decision-making and to understand variation in the performance of processes that support safety and quality of care, treatment and services including, but not limited to the collection and aggregation of the following data measures: - Restraint usage. * The quality/performance indicators, including adverse patient events, will be measured, analyzed, and tracked to ensure that date is collection on an ongoing basis as outlined in this plan and the department and/or services QAPI plan. * This data is analyzed to identify patterns and trends and to monitor the effectiveness of services. During the Complaint Validation survey conducted from 4/22/26 to 4/28/26, the following deficient practices related to the use of restraint were identified: * The nursing staff did not follow the physician’s order for the use of a propofol drip for one of 11 sampled patients (Patient 10). Cross reference to A-160. * The nursing staff did not try the less restrictive interventions and determined it to be ineffective to protect the patient and staff member from harm prior to using four side rails of the bed and bilateral wrist restraints for six of 11 sampled patients (Patients 1, 3, 4, 6, 7 and 9). Cross reference to A-164. * The nursing staff did not develop a plan of care for the use of restraints for seven of 11 sampled patients (Patients 1, 2, 6, 7, 8, 9, and 10). Cross reference to A-166. * The nursing staff did not ensure the physician’s order for the application of the bilateral wrist restraints were obtained for four of 11 sampled patients (Patients 2, 5, 7, and 9). Cross reference to A-168. * The nursing staff failed to ensure seven of 11 sampled patients (Patients 1, 2, 5, 6, 7, 8, and 9) who were on restraints, were monitored by a trained staff. Cross reference to A-175. On 4/28/26 at 1250 hours, review of the 2025 and 2026 QAPI Department Dashboard for ICU and Medical Surgical Telemetry showed the following: Review of the 2026 QAPI Department Dashboard for ICU showed the Restraints Utilization section showing: - For January: 65% restraint utilization, 17 restraint episodes, and 55 restraint days - For February: 52% restraint utilization, 14 restraint episodes, and 37 restraint days - For March: 32% restraint utilization, 10 restraint episodes, and 45 restraint days Review of the 2026 QAPI Department Dashboard for Medical Surgical Telemetry showed the Restraints Utilization section showing: - For January: 7% restraint utilization, 34 restraint episodes, and 130 restraint days - For February: 5% restraint utilization, 18 restraint episodes, and 47 restraint days - For March: 7% restraint utilization, 35 restraint episodes, and 617 restraint days Review of the 2025 QAPI Department Dashboard for ICU showed the Restraints Utilization section showing: - For September: 24% restraint utilization, 7 restraint episodes, and 27 restraint days. - For October: 50% restraint utilization, 14 restraint episodes, and 35 restraint days. - For November: 48% restraint utilization, 14 restraint episodes, and 48 restraint days. - For December: 53% restraint utilization, 8 restraint episodes, and 42 restraint days Review of the 2025 QAPI Department Dashboard for Medical Surgical Telemetry showed the Restraints Utilization section showing: - For October: 5% restraint utilization, 22 restraint episodes, and 72 restraint days. - For November: 6% restraint utilization, 28 restraint episodes, and 102 restraint days. - For December: 5% restraint utilization, 23 restraint episodes, and 93 restraint days Review of the hospital’s QAPI Committee Meeting Minutes showed the following: - The January 2026 meeting minute for December 2025 data collected showed the use of restraints in ICU on December 2025 were 8 episodes of restraints, 42 restraint days, and the restraint utilization was 53%; and the use of restraint in medical surgical telemetry for December 2025 were 23 episodes of restraints, 93 restraint days, and the restraint utilization was 5%. - The February 2026 meeting minute for January 2026 data collected, showed there was no restraints use data reported in ICU. Therefore, there was no action, or the restraints utilization was addressed . However, the data collected for restraints utilization in ICU showed an increase of restraints utilization to 65% in January. - The March 2026 meeting minute for February 2026 data collected showed the restraint utilization rate in ICU for the month of February was 52%. However, there was no action discussed for PI or to reduce rate of the restraints use. During the interview with the CNO, Director 1, and Director 4 on 4/28/26 at 1320 hours, Director 4 was asked about the data reported to the Quality for actions taken, with the use of restraints and other data related to the use of restraints. Director 4 stated the Quality kept an eye for the usage of the restraints but did not collect other data related to the use of restraints. Director 4 stated we should have looked deeper into it.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 37663 Based on observation, interview, and record review, the hospital failed to ensure the QAPI program used the collected restraint data to identify opportunities for PI that affects health outcomes for patient safety and quality of care and measures success to ensure the improvements were sustained. This failure posed an increased risk of patient safety and poor quality of care. Findings: Review of the hospital’s Quality Assessment and Performance Improvement Program Plan 2025 showed the following: * Follow up: QAPI shall assure that steps taken to improve performance and enhance safety are appropriately implemented, measured, and tracked to determine that the steps have achieved and sustained the intended effect. * Performance Improvement Projects: QAPI shall oversee PI projects, the number and scope of which shall be proportional to the scope and complexity of the hospital’s services and operations. QAPI must also ensure there is documentation of what the quality improvement projects are being conducted, the reason for conducting the projects, and the measurable progress achieved on the projects. Review of hospital’s P&P titled Restraints dated February 2025 showed the Quality & Performance Improvement section showing: - The facility measures and assess restraints use to identify opportunities to introduce preventive strategies, alternatives to use, and process improvements to reduce the risk associated with restraints use. Reports will include collected data and will be used in conjunction with PI initiatives. - The organization will collect restraints data to assess and monitor the use of restraints in their facility; implement actions to ensure the restraints are used only to ensure the physical safety of patients, staff and visitors; identify opportunities to decrease the frequency and increase the safety of restraint use; identify any need to redesign care processes. During the Complaint Validation survey conducted from 4/22/26 to 4/28/26, the following deficient practices related to the use of restraint were identified: * The nursing staff did not follow the physician’s order for the use of a propofol drip for one of 11 sampled patients (Patient 10). Cross reference to A-160. * The nursing staff did not try the less restrictive interventions and determined it to be ineffective to protect the patient and staff member from harm prior to using four side rails of the bed and bilateral wrist restraints for six of 11 sampled patients (Patients 1, 3, 4, 6, 7 and 9). Cross reference to A-164. * The nursing staff did not develop a plan of care for the use of restraints for seven of 11 sampled patients (Patients 1, 2, 6, 7, 8, 9, and 10). Cross reference to A-166. * The nursing staff did not ensure the physician’s order for the application of the bilateral wrist restraints were obtained for four of 11 sampled patients (Patients 2, 5, 7, and 9). Cross reference to A-168. * The nursing staff failed to ensure seven of 11 sampled patients (Patients 1, 2, 5, 6, 7, 8, and 9) who were on restraints, were monitored by a trained staff. Cross reference to A-175. During the interview and record review was conducted with the CNO, Director 1 and 4 on 4/28/26 at 1320 hours, Director 4 was asked for the PI project related to restraints to decrease frequency of use. Director 4 stated there was no PI project related to restraints use; we only monitored the utilization.”

“QAPI EXECUTIVE RESPONSIBILITIES CFR(s): 482.21(e)(1), (e)(2), (e)(5) The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: 1) That an ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained . (2) That the hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated. (5) That the determination of the number of distinct improvement projects is conducted annually. This Standard is not met as evidenced by: 37663 Based on observation, interview, and record review, the hospital’s GB failed to ensure the hospital-wide QAPI program addressed the use of restraints for improvement of quality of care and patient safety. This failure posed an increased risk for the safety of the patients with the use of non-violent or violent restraints. Findings: Review of the hospital’s Quality Assessment and Performance Improvement Program Plan 2025 showed: * The Organizational Leaders (including the Board, Medical Staff Leaders, and Senior Hospital Leaders) are responsible to use data and information in decision making that supports and/or improves the safety and/or quality of care, treatment, and services. * Medical Staff: - The Medical Staff, in accordance with currently approved Medical Staff Bylaws, shall be accountable for the quality and safety of patient care. - The Medical Staff has leadership role in the organization’s performance improvement activities and is accountable to Board for the overall safety and quality of patient care, treatment, and service. * QAPI Framework and Methodology: - The organization’s leaders ensure that the hospital uses data and information as a guide in decision-making and to understand variation in the performance of processes that support safety and quality of care, treatment and services including, but not limited to the collection and aggregation of the following measures: .... Restraints usage. - The quality or performance indicators, including adverse patient events will be measured, analyzed, and tracked to ensure that data collected on an ongoing basis as outlined in this plan and department and/or service QAPI plans. - This data is analyzed to identify patterns and trends and to monitor the effectiveness of services provided. During the Complaint Validation survey conducted from 4/22/26 to 4/28/26, the following deficient practices related to the use of restraint were identified: * The hospital failed to ensure the QAPI program analyzed the reports for restraints use as part of the PI program of the hospital. Cross reference to A-273. * The hospital failed to ensure the QAPI program used the collected restraint data to identify opportunities for PI that affects health outcomes for patient safety and quality of care. Cross reference to A-283. On 4/28/26 at 1431 hours, interview and record review was conducted with the CNO. The CNO was asked how the Medical Staff were involved with the QAPI regarding the use of restraints. The CNO stated that for the discussion about the use of restraints, the MEC had a meeting on September 2025 for the 1st quarter. The hospital had a change of ownership that started in July 2025. The GB meeting was done on December 2025 for 2nd quarter, and the restraints report was for M/S only. The ICU and ED report for the use of restraint had not been turned in to the Quality. The restraint data for the month of April, May, June was not presented to the medical staff and GB. The GB meeting on January 2026, for 3rd quarter did not have report on restraints for the month of July, August, and September. Director 1 should send the restraint data to the Medical Staff committee to record in the Medical Staff report and to be entered to GB report. If the report was not sent, it would not be sent to the GB. The CNO was asked about the process for reviewing the restraints report with the GB. The CNO stated the Directors of the units submitted the restraints data to the Quality. The Directors of the units attended the medicine meeting to discuss their restraints data. Then, restraints report was included in the meeting minutes and sent to the Medical Executive Committee for their PI. The CNO was asked where and who the restraints report would be discussed with. The CNO stated the Chief of Staff would include and present the PI project that were discussed in the Medical Executive Committee meeting during the GB meeting. The CNO stated the QAPI for acute or hospital for ICU, M/S and telemetry PI included restraints. According to the meeting minutes, there was no data for the use of restraint reported during the medicine meeting.”

“MEDICAL STAFF BYLAWS CFR(s): 482.22(c) The medical staff must adopt and enforce bylaws to carry out its responsibilities. The bylaws must: This Standard is not met as evidenced by: 22553 Based on interview and record review, the hospital failed to ensure its P&P was implemented as evidenced by: 1. The hospital did not ensure two physicians (Physicians 3 and 4) submitted the required annual TB screening. 2. Physician 1 did not complete two informed consent forms prior to performing the medical procedures as per the hospital’s P&P for one of four sampled patient (Patient 1). These failures posed the potential risk to patient safety and unsafe hospital environment. Findings: Review of the hospital’s General Medical Staff Rules and Regulations showed medical staff members are responsible for abiding by the Medical Staff Bylaws, Rules and Regulations of their assigned department, as well as other relevant standards and hospital policies. 1. Review of the hospital’s P&P titled Tuberculosis Screening for Physicians and/or Allied Health Professional Staff reviewed February 2024 showed the following: * TB screening is essential to detect latent or active tuberculosis and ensure treatment and follow-up as per CDC’s guidelines. * The screening program applies to all members of the AHP staff. * All medical staff and AHP members must provide documentation of TB screening upon appointment and must complete an annual TB symptom screening (Attestation). * Practitioners who fail to provide TB screening evidence may face referral to the Medical Staff committee and suspension of clinical privileges until compliance is demonstrated. a. On 6/5/25 at 0931 hours, an interview and concurrent review of credential files for Physicians 3 and 4 were conducted with the Director of Medical Staff Services and the Medical Staff Coordinator. Review of Physician 3’s credential file showed the physician signed an Information Release/Acknowledgment form on 2/13/25, agreeing to abide by Medical Staff Bylaws and Regulations. The credential file included documented evidence of a TB skin test from December 17, 2023. However, the 2024 annual TB attestation was missing. The Medical Staff Coordinator provided the email records showing multiple requests Physician 3 to submit the required attestation on 2/3/25 at 1502 hours, 2/10/25 at 1222 hours, 3/10/25 at 1005 hours, and 4/24/25 at 1230 hours. As of 6/5/25 at 0931 hours, the hospital had not received Physician 3’s TB attestation. The Director of Medical Staff Services confirmed the above findings and stated it would be presented for review at the next MEC meeting. b. Review of Physician 4’s credential file showed the completion of an Annual TB Screening Questionnaire on 2/21/24. However, the required TB attestation was not found. The Medical Staff Coordinator provided email correspondence showing the follow-up attempts on 2/3/25 at 1502 hours, 2/10/25 at 1228 hours, 3/10/25 at 1010 hours, 4/24/25 at 1210 hours, and 5/26/25 at 1206 hours. As of June 5, 2025, the attestation remained outstanding. The Director of Medical Staff confirmed the issue and planned to bring it to the next MEC meeting for review. 2. Review of the hospital’s P&P titled Informed Consent last reviewed June 2024 showed the following: * Informed consent must be documented in the patient’s chart before a medical procedure. * There must be evidence of appropriate informed consent for any procedure or treatment, including documentation of the date, the practitioner who informed the patient, and the signature of the individual obtaining consent. On 6/4/25 at 0910 hours, review of Patient 1’s closed medical record was conducted with the CNO. Patient 1’s closed medical record showed Patient 1 underwent the paracentesis procedures on 3/12 and 3/26/25, performed by Physician 1. Review of Patient 1’s informed consent showed two informed consent forms titled Consent to Surgical or Special Procedures did not meet the documentation requirements with the hospital’s P&P as follows: * The Consent to Surgical or Special Procedures dated 3/12/25, showed the consent form lacked Physician 1’s signature, date, and time. * The Consent to Surgical or Special Procedures dated 3/26/25, showed the consent form lacked Physician 1’s printed name, date, and time. The CNO confirmed both forms lacked the necessary elements and did not meet policy standards.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 22553 Based on interview and record review, the hospital failed to ensure RN 2 followed the hospital’s P&P for administering the oral medication for one of four sampled patient (Patient 1) despite the patient’s NPO status. This failure created the risk of patient safety. Findings: Review of the hospital’s P&P titled Medication Administration, General Guidelines reviewed in July 2024 showed all medication orders must specify the exact route of administration. Nurses are responsible for contacting the physician if an order appears unclear or inappropriate. On 6/4/25 at 0910 hours, an interview and concurrent review of Patient 1’s closed medical record was conducted with CNO. Patient 1’s closed medical record showed Patient 1 was admitted to the hospital on 3/10/25, due to abdominal pain, gastrointestinal bleeding, and hematemesis. Patient 1’s closed medical record showed on 3/15/25 at 0953 hours, RN 2 entered the physician’s order for NPO status for Patient 1. Review of the MAR dated 3/17/25 at 1600 hours, showed RN 2 administered duloxetine (an antidepressant) 20 mg by mouth to Patient 1. On 6/5/25 at 1226 hours, an interview was conducted with the Director of Quality and Risk. The Director of Quality and Risk confirmed for the patient who had an NPO order and received oral medication, the physician’s order must explicitly state, “NPO except meds.” In the absence of such instructions, nurses were required to contact and verify the order with the physician before administering any oral medications. There was no documented evidence RN 2 consulted the ordering physician to determine whether the oral medication administration was appropriate for Patient 1 who was in NPO status.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 29558 Based on interview and record review, the hospital failed to comply with the 24 CFR 489.24, special responsibilities of Medicare hospitals in emergency cases. This failure had the potential to result in poor health outcomes and serious adverse events to the patients receiving the ED services. Findings: 1. The hospital failed to ensure the provision of on-call coverage to provide further evaluation and/or treatment necessary to stabilize an individual with an EMC. Cross reference to A2404. 2. The hospital failed to ensure the nursing staff failed to perform an accurate and thorough triage assessment upon arrival to the ED for one of 20 sampled patients (Patient 1). Cross reference to A2406. 3. The hospital failed to ensure the necessary stabilizing treatments were provided within the capabilities of the hospital for two of 20 sampled patients (Patients 1 and 14). Cross reference to A2407.”

“ON CALL PHYSICIANS CFR(s): 489.20(r)(2) and 489.24(j)(1-2) §489.20(r)(2) [The hospital (including both the transferring and receiving hospitals), must maintain] a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. §489.24(j)(1) Each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital’s patients who are receiving services required under this section in accordance with the resources available to the hospital, including the availability of on-call physicians. §489.24(j)(2)(i) The hospital must have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician’s control. §489.24(j)(2)(ii) The hospital must have written policies and procedures in place to provide that emergency services are available to meet the needs of patients with emergency medical conditions if it elects to permit on-call physicians to schedule elective surgery during the time that they are on call or to permit on-call physicians to have simultaneous on-call duties. This Standard is not met as evidenced by: 37548 Based on interview and record review, the hospital failed to ensure the provision of on-call coverage to provide further evaluation and/or treatment necessary to stabilize an individual with an EMC as evidenced by: 1. The Anesthesia Call Panel did not include the individual physician’s contact information. 2. The Gynecology Call Panel did not clearly identify the on-call physician by including the individual physician’s name and their contact information. These failures could result in the delay in the stabilizing treatments and substandard health outcomes to the patients. Findings: Review of the hospital’s General Rules & Regulations of the Medical Staff, subsection of Emergency Medicine with a review date of November 2020 showed the hospital shall maintain a daily roster of the following physician specialist who must be on-call at all times and available to come into the hospital. The required Back-Up Panel coverage includes the following specialists: anesthesiologist and gynecologist. On 10/16/24 at 1009 hours, an interview and concurrent review the General Rules & Regulations of the Medical Staff, Subsection of Emergency Medicine and the 2024 Anesthesia and Gynecology Call Panel was conducted with the Director of Medical Staff Services. The Director of Medical Staff Services stated the ED required the back-up panel coverage included Anesthesia and Gynecology. 1. Review of the Anesthesia Call Panel showed the following: - For May 2024, the direct telephone numbers of Anesthesiologists 1, 2, 3, 4, and 5 were not available. - For June 2024, the direct telephone numbers of Anesthesiologists 1, 2, 3, and 4 were not available. - For July 2024, the direct telephone numbers of Anesthesiologists 1, 2, 3, and 4 were not available. - For August 2024, the direct telephone numbers of Anesthesiologists 1, 2, 3, 4, and 5 were not available. - For September 2024, the direct telephone numbers of Anesthesiologists 1, 2, 3, and 4 were not available. - For October 2024, the direct telephone numbers of Anesthesiologists 1, 2, 3, and 4 were not available. The Director of Medical Staff Services confirmed the Anesthesia Call Panel did not include the individual physician’s contact information. 2. Review of the Gynecology Call Panel showed the following: - For May 12, 2024, the Gynecology Call Panel did not identify the physician by including the individual physician’s name and their contact information. - For August 15, 16, and 18, 2024, the Gynecology Call Panel did not identify the physician by including the individual physician’s name and their contact information. - For September 12, 13, 18, and 19, 2024, the Gynecology Call Panel did not identify the physician by including the individual physician’s name and their contact information. - For October 6, 10, and 11, 2024, the Gynecology Call Panel did not identify the physician by including the individual physician’s name and their contact information. The Director of Medical Staff Services confirmed the Gynecology Call Panel did not show there was an on-call physician for May 12; August 15, 16, and 18; September 12, 13, 18, and 19; and October 6, 10, and 11, 2024. The Gynecology Call Panel did not identify the individual physician’s name and their contact information. On 10/16/24 at 1218 hours, the CNO was interviewed about the Anesthesia and Gynecology Call Panel. The CNO confirmed the Anesthesia Call Panel did not include the individual physician’s contact information. The CNO stated the ED nurses did not have access to the direct telephone number of the physicians on the Anesthesia Call Panel and only the House Supervisor had access. The CNO acknowledged the Gynecology Call Panel did not show there was an on-call physician for May 12; August 15, 16, and 18; September 12, 13, 18, and 19; and October 6, 10, and 11, 2024. The Gynecology Call Panel did not identify the individual physician’s name and their contact information.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 29798 Based on interview and record review, the hospital failed to ensure the ED Central Log was accurately maintained for 14 of 20 sampled patients (Patients 1, 2, 3, 4, 8, 10, 11, 14, 15, 16, 17, 18, 19, and 20). This failure had the potential to result in the hospital not being able to accurately track the care provided to the individuals who presented to the ED for the treatments of their emergency medical conditions. Findings: Review of the hospital’s P&P titled Log, Emergency Department dated June 2022 showed in part: * Purpose: To provide method of documentation of all patients presented to the Emergency Department (ED) seeking care. * Scope: Emergency Department Nursing Staff. * Policy: It is the policy of this hospital that all patients that come seeking care will be documented in the ED patient log, as well as those patients that are dead on arrival shall be entered in the log, to comply with the state and county requirements. * Procedure: An ED Central Log shall be maintained by the Emergency Department. It shall contain at least the following information on each patient who presents seeking care to the hospital ED. - Name - Arrival date - Arrival time - Means of arrival - Age - Sex - Medical Record/Account number - Nature of presenting complaint - Disposition - Time of departure - Treating physician The log will also detail whether the patient: - Refused treatment - Was refused treatment by the hospital - Was transferred or stabilized and transferred - Was admitted and treated - Was discharged 1. On 10/14/24 at 1105 hours, an interview and concurrent review of Patient 1’s medical record was conducted with the CNO. Patient 1’s medical record showed Patient 1 was brought to the ED on 9/13/24 due to a thumb fracture. On 9/14/24, Patient 1 was admitted to the Medical Surgical Unit for further treatment and discharged home later that day. Review of the ED Central Log dated 9/13/24 did not show Patient 1’s means of arrival, disposition, time of departure, and the treating physician. The above findings were verified by the CNO. 2. On 10/14/24 at 1605 hours, an interview and concurrent review of Patient 2’s medical record was conducted with the CNO. Patient 2’s medical record showed Patient 2 presented to the ED on 10/11/24 for abdominal pain, nausea and vomiting for 5 days. Review of the ED Central Log dated 10/11/24 did not show Patient 2’s means of arrival, disposition, time of departure, and the treating physician. The above findings were verified by the CNO. 3. On 10/16/24 at 1435 hours, an interview and concurrent review of Patient 3’s medical record was conducted with the House Supervisor. Patient 3’s medical record showed the patient was seen in the ED on 6/4/24, due to chest pain with shortness of breath. Review of the ED Central Log showed Patient 3 was transferred to a higher level of care. The ED Central Log did not show the patient’s arrival date, means of arrival, age, sex, time of departure, the treating physician, and if the patient was transferred or stabilized and transferred. The above findings were verified by the House Supervisor. 37548 4. On 10/15/24 at 1409 hours, an interview and concurrent review of Patient 14’s medical record was conducted with the CNO. Patient 14’s medical record showed Patient 14 presented to the ED on 10/14/24, for abdominal pain and left AMA. Review of the ED Central Log dated October 2024 did not show the patient’s means of arrival or time of departure. The CNO acknowledged the above findings. 5. On 10/14/24 at 1416 hours, an interview and concurrent review of Patient 15’s medical record was conducted with the CNO. Patient 15’s medical record showed Patient 15 presented to the ED on 10/13/24. The Emergency Services Pre-Screening Information form showed the reason for the visit was “Don’t feel good.” Patient 15’s medical record showed the patient left without being seen. Review of the ED Central Log dated October 2024 did not show the patient’s date and time of arrival, means of arrival, chief complaint, and time of departure. The log showed the patient eloped. The findings were shared with the CNO. 6. On 10/15/24 at 1353 hours, an interview and concurrent review of Patient 16’s medical record was conducted with the CNO. Patient 16’s medical record showed Patient 16 presented to the ED on 6/25/24. The patient was admitted to the telemetry unit on 6/26/24. Review of the ED Central Log dated June 2024 did not show the patient’s arrival time, means of arrival, and time of departure. The findings were shared with the CNO. 7. On 10/15/24 at 1403 hours, an interview and concurrent review of Patient 17’s medical record was conducted with the CNO. Patient 17’s medical record showed Patient 17 presented to the ED on 6/18/24. The patient was discharged on 6/18/24. Review of the ED Central Log dated June 2024 did not show the patient’s departure time. The findings were shared with the CNO. 8. On 10/15/24 at 1148 hours, an interview and concurrent review for Patient 18 ‘d medical records was conducted with the CNO. Patient 18’s medical record showed Patient 18 presented to the ED on 7/27/24. The patient was admitted to the telemetry unit on 7/27/24. Review of the ED Central Log dated July 2024 did not show the patient’s mode of arrival, patient’s disposition, and time of departure. The findings were shared with the CNO. 9. On 10/15/24 at 1136 hours, an interview and concurrent review for Patient 19’s medical records was conducted with the CNO. Patient 19’s medical record showed Patient 19 presented to the ED on 7/26/24, and left AMA. Review of the ED Central Log dated July 2024 did not show the patient’s mode of arrival and time of departure. The findings were shared with the CNO. 10. On 10/15/24 at 1447 hours, an interview and concurrent review for Patient 20’s medical record was conducted with the CNO. Patient 20’s medical record showed Patient 20 presented to the ED on 9/23/24, and the patient left without being seen. Review of the ED Central Log dated September 2024 did not show the patient’s date and time of arrival, means of arrival, chief complaint, and time of departure. The log showed the patient eloped. The findings were shared with the CNO. 38660 11. On 10/14/24, at 1545 hours, an interview and concurrent review of Patient 8’s medical record was conducted with the House Supervisor. Patient 8’s medical record showed Patient 8 was brought to the ED on 8/31/24, for right leg pain and the patient was admitted on 9/1/24. Review of the ED Central Log dated 8/21/24 did not show the patient’s disposition, means of arrival, and time of departure. The House Supervisor acknowledged the above findings. 12. On 10/15/24, at 1056 hours, an interview and concurrent review of Patient 10’s medical record was conducted with the House Supervisor. Patient 10’s medical record showed Patient 10 was brought to the ED on 7/8/24, for left shoulder pain after a fall and was admitted on 7/8/24. Review of the ED Central Log dated 7/8/24 did not show the patient’s disposition, means of arrival, and time of departure. The House Supervisor acknowledged the above findings. 13. On 10/15/24 at 1128 hours, an interview and concurrent review of Patient 4’s medical record was conducted with the House Supervisor. Patient 4’s medical record showed Patient 4 was brought to the ED on 7/10/24, for an overdose and was transferred to higher level of care on 7/10/24 at 1813 hours. Review of the ED Central Log dated 7/10/24 did not show the patient’s admitting physician, transfer time, disposition, means of arrival, and time of departure. The House Supervisor acknowledged the above findings. 14. On 10/15/24, at 1318 hours, an interview and concurrent review of Patient 11’s medical record was conducted with the House Supervisor. Patient 11’s medical record showed Patient 11 was brought to the ED on 7/13/24, for failure to thrive and was admitted on 7/14/24. Review of ED Central Log dated 7/13/24 did not show the patient’s means of arrival and time of departure. The House Supervisor acknowledged the above findings.”

“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: 29798 Based on interview and record review, the hospital failed to ensure the nursing staff failed to perform an accurate and thorough triage assessment upon arrival to the ED for one of 20 sampled patients (Patient 1). This failure had the potential to result in poor clinical outcomes and serious adverse events to the patients receiving the ED services in the hospital. Findings: Review of the hospital’s P&P titled Triage dated June 2022 showed in part: * Policy Purpose: To systematically and logically assign priorities of care to patients as they arrive to the Emergency Department. To ensure that every patient receives high quality, efficient and appropriate medical care based on medical need utilizing and established triage process. * Scope: Emergency Department Registered Nurses. * Policy: Triage will be involving a rapid, directed patient assessment, which provides an assignment of an acuity level for each patient presenting to the emergency department. The triage category is designed to minimize morbidity, disfigurement, pain, emotional distress, and client dissatisfaction with their emergency care. * Triage assessment and documentation: A RN will interview and assess each patient upon arrival to prioritize incoming patients and to identify those who must be seen immediately. * Triage Procedure...The Triage Nurse and/or the Charge Nurse are responsible to see that all ambulance patients are triaged to include vital signs and have the MD assess them as quickly as possible. The Triage Nurse will be responsible to provide immediate first aid to minor injuries as necessary, e.g. splinting, cool packs, control of bleeding. Review of the hospital’s P&P titled Standard of Practice for Emergency Services dated June 2022, showed in part: * Policy Purpose: This policy is to define the standards of practice for the Emergency Department. * Scope: Emergency Department Nursing Staff. * Policy: The Standards of Practice based on competent nursing care as demonstrated by the nursing process. The Standards of Practice addresses the role and boundaries of practice for acute care nursing. The professional practice of nursing is characterized by the application of relevant theories, research and evidenced based guidelines. * Procedure: - Standard I. Assessment: Data is collected from the patient, support person, family to develop a holistic picture of the patient’s needs. Decisions are made matching knowledge with clinical findings. Relevant data is communicated to other healthcare providers. - Standard II. Diagnosis: Diagnosis and care issues are derived from the assessment data. Diagnosis and care issues are prioritized and documented in a manner that facilitates outcomes. - Standard III: Outcome Identification: Outcomes are derived from actual or potential diagnosis and care issues. Outcomes provide direction for continuity of care. - Standard IV: Planning: The plan is individualized and considers patient characteristics and the situation. The plan reflects current best evidence. The plan establishes priorities of care. - Standard V: Implementation: Interventions are delivered in a manner that minimizes complication and life-threatening situations. The implemented plan and modifications are documented. Collaboration to implement the plan occur with the patient, family, healthcare provider and the healthcare system. - Standard VI: Evaluation: Evaluation is systemic and ongoing using evidenced based techniques and instruments. The evaluation of the effectiveness of interventions towards achieving the desired outcomes occurs. Results of the evaluation are documented. Review of the hospital’s P&P titled Assessment and Reassessment dated June 2022, showed in part: * Policy Purpose: To establish guidelines for patient assessment and reassessment in the Emergency Department. * Scope: Emergency Department Nursing Staff. * Policy: It is the policy of this hospital that the Emergency Department incorporates an interdisciplinary approach to meet the physical, emotional, spiritual and health education needs of the patient and family. * Procedure: Physical assessments are completed by a RN caring for the patient within one (1) hour or sooner of admission to the ED. Assessment includes patient’s subjective statement, pertinent medical history, physical observation and/or examination to include appropriate disrobing. On 10/14/24 at 1105 hours, a concurrent interview and review of Patient 1’s medical record was conducted with the CNO. The ED Triage documentation dated 9/13/24 at 2016, showed Patient 1 was brought in by ambulance on 9/13/24 at 1955 hours, with a chief complaint of thumb fracture. The triage documentation did not show if the injury was on the right or left thumb. The pain assessment section showed the patient’s pain was present upon triage; however, there was no documentation of the level of pain. On 10/15/24 at 1252 hours, an interview and concurrent review of Patient 1’s medical record was conducted with RN 1. RN 1 stated RN 1 did not ask the patient about the level of pain or location of the injury when triaged. RN 1 could not recall if the EMS report included the location of patient’s injury. The findings were verified by the CNO.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 29798 Based on interview and record review, the hospital failed to ensure the necessary stabilizing treatments were provided within the capabilities of the hospital for two of 20 sampled patients (Patients 1 and 14) as evidenced by: 1. The ED staff did not ensure the pain management for Patient 1 as per the hospital’s P&P. 2. The P&P for leaving AMA was not implemented for Patient 14. These failures had the potential to result in poor health outcomes and serious adverse events to the patients receiving the ED services. Findings: 1. Review of the hospital’s P&P titled Pain Assessment, Intervention and Management of dated February 2022 showed in part: * Policy Purpose: To define the process for nursing in assessing, intervening, and managing a patients concern of pain. * Scope: Nursing * Policy: - The hospital strives to achieve patient pain relief in a timely manner provided by concerned and committed staff that is trained to recognize varied expression of pain. - The goal is to control patients’ pain, to provide pain relief, reassessment of pain interventions in a timely manner, to educate both patient/family and staff to effective pain management methods and refer the patient for treatment of pain when appropriate. - The presence and absence of pain is assessed in all patients. The pain management process will be carried out by interdisciplinary team which includes the patient and representative. The process includes pain assessment, planning and intervention, reassessment of patient responses to pain management measures, education of patient and family, and documentation. - Both pharmacologic and nonpharmocologic strategies (i.e. relaxation exercises, distraction...) will be reviewed for appropriate utilization in management of pain. * Procedure: - On admission and each time vital signs are taken, the patient will be asked if they are experiencing pain. If yes, they will be asked to define location and type of pain, specify their pain score utilizing the pain scale, and establish current pain goal. - The Universal Pain Assessment Tool is a series of pain intensity rating scales used. It offers five options of describing pain including 0 to 10 scale. - Assessment: An admission assessment for pain will be done on all patients. Elements for pain assessment may include pain intensity (utilizing the universal pain assessment tool appropriate for the patient, location (ask patient to point to the site or sites of pain), and quality and character of pain (aching, burning, throbbing or sharp) - Reassessment: Pain will be reassessed with each set of vital signs, with the change of care giver and with each new report of pain. Consider pain level as the fifth vital sign. Reassess patient for pain at the time vital signs are taken for pain intensity, location, quality and character of pain. - Documentation: Pain management, intervention, education may be documented in the following areas: Care and assessment tab in Electronic Medical Record (EMR) - pain management Review of the hospital’s P&P titled Triage dated June 2022 showed in part: * Policy Purpose: To systematically and logically assign priorities of care to patients as they arrive to the Emergency Department. To ensure that every patient receives high quality, efficient and appropriate medical care based on medical need utilizing and established triage process. * Scope: Emergency Department Registered Nurses. * Policy: Triage will be involving a rapid, directed patient assessment, which provides an assignment of an acuity level for each patient presenting to the emergency department. The triage category is designed to minimize morbidity, disfigurement, pain, emotional distress, and client dissatisfaction with their emergency care. * Procedure: Triage will be completed using the Emergency Severity Index (ESI) version 4 methodology. - ESI Level 4: Semi-Urgent: The patient presents with a condition that has a low potential for deterioration or complications. One resource is respected [SIC] to treat this patient. Vital signs will be taken at a minimum of every 2 hours until seen by the MD. * Triage assessment and documentation: A RN will interview and assess each patient upon arrival to prioritize incoming patients and to identify those who must be seen immediately. * Triage Procedure...The Triage Nurse and/or the Charge Nurse are responsible to see that all ambulance patients are triaged to include vital signs and have the MD assess them as quickly as possible. The Triage Nurse will be responsible to provide immediate first aid to minor injuries as necessary, e.g. splinting, cool packs, control of bleeding. On 10/14/24 at 1105 hours, a concurrent interview and review of Patient 1’s medical record was conducted with the CNO. The ED Triage documentation dated 9/13/24 at 2016, showed the patient was brought in by ambulance on 9/13/24 at 1955 hours, with a chief complaint of thumb fracture. The ESI level was documented as level 4. The triage documentation did not show if the injury was on the right or left thumb. The pain assessment section showed the patient’s pain was present upon triage; however, there was no documentation of the level of pain, pain related interventions, and reassessment of pain of the injured hand. The findings were verified with the CNO. On 10/15/24 at 1252 hours, an interview and concurrent review of Patient 1’s medical record was conducted with RN 1. RN 1 stated RN 1 did not ask the patient about the level of pain or location of the injury when triaged. 37548 2. Review of the hospital’s P&P titled Patient Detainment: Against Medical Advice (AMA) dated February 2023 showed all risks of leaving facility against medical advice shall be given to the patient and documented in the medical record. On 10/15/24 at 1337 hours, an interview and concurrent review of Patient 14’s medical record was conducted with the CNO. Patient 14’s medical record showed Patient 14 presented to the ED on 10/14/24, with a chief complaint of abdominal pain. The ED physician documentation dated 10/14/24 at 0702 hours, showed Patient 14 had a history of Crohn’s disease with one week of abdominal pain associated with nausea, vomiting and diarrhea. The patient was offered nonnarcotic pain medications, antiemetics, and diagnostic workup including CT but declined. The documentation showed patient “Will leave AMA in favor of going home and taking her own meds.” The Medical Decision-Making documentation dated 10/14/24 at 0720 hours, showed the patient “Has capacity to AMA, pt left without signing AMA form.” Review of the Nursing Narrative Note dated 10/14/24 at 0723 showed, “Left AMA refused to sign form...Ambulated out of ED.” There was no documentation to show all risks of leaving hospital AMA were given to the patient as per the hospital’s P&P. In a concurrent interview, the CNO confirmed the findings.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 38492 Based on interview and record review, the hospital failed to ensure the informed consent was obtained prior to performing the surgical procedure for one of four sampled patients (Patient 4). This failure had the potential for the patient to not be fully informed of the risks and benefits prior to the surgery. Findings: Review of the hospital’s P&P titled Informed Consent dated 6/26/22, showed the hospital will not perform any medical or surgical procedure without the risk of liability unless the patient or person legally authorized to act in the patient’s behalf, has consented to the treatment. Consents must be witnessed by licensed hospital personnel. The witness should be present with the form is signed by the patient or the patient’s legal representative, and should state that they witnessed the signing in the designated place on the form. On 8/14/24 at 0920 hours, an interview and concurrent review of Patient 4’s medical record was conducted with the CNO. Patient 4’s medical record showed Patient 4 was admitted to the hospital on 8/13/24. Review of the Physician Operative Procedure Report showed Patient 4 had a surgical procedure on 8/13/24 at 1346 hours. Review of the Consent to Surgery or Special Procedures form showed the procedure to be done and the name of the practitioner who would perform the procedure. However, the signature section to show the patient authorized and consented to the performance of the operation or procedure was left blank. The CNO stated the informed consent should be obtained and signed prior to performng the surgical procedure and verified the above findings.”

“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: 38492 Based on interview and record review, the hospital failed to ensure the nursing staff followed the hospital’s P&P for medication reconciliation for one of four sampled patients (Patient 1). This failure put the patient at risk of not receiving the medications based on the most current information. Findings: Review of the hospital’s P&P titled Medication Reconciliation dated February 2022 showed all patients admitted to the hospital with be asked what home medications they are on. If patient is unable to provide, a good faith effort will be attempted by contacting family, support person, sending facility to see if they could provide the information. On 8/14/24 at 0920 hours, an interview and concurrent review of Patient 1’s closed medical record was conducted with the CNO. Patient 1’s medical record showed Patient 1 was transferred to the hospital from Facility A on 7/10/24, and discharged on 7/14/24. Review of the physician H&P dated 7/11/24 at 1145 hours, showed Patient 1 was not alert and oriented so no reliable history was available. Review of Patient 1’s Facesheet showed Patient 1 had a Power of Attorney (POA). The CNO was asked to show documented evidence the medication reconciliation was done as per the hospital’s P&P. The CNO stated Facility A did not send the current medications list when Patient 1 was transferred to the hospital. The CNO was unable to show documented evidence the hospital had contacted the POA or Facility A for the current medication list. When asked how the medication list was obtained, the CNO stated the hospital used the medication list from the previous hospital admission from March 2024. The CNO verified the above findings.”