HCA-Healthone DBA Swedish Medical Center

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 52761 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.13 Patient’s Rights, was out of compliance. A-0144 The patient has the right to receive care in a safe setting. Based on interviews and document reviews, the facility failed to ensure a patient with complex medical and social needs was provided resources to meet their post-discharge needs in one of one patients reviewed who was discharged to the streets. (Patient #2) (Cross-reference A-0799)”

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 52761 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.43 Discharge Planning, was out of compliance. A-0799: The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers/support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to preventable hospital readmissions. Based on interviews and document reviews, the facility failed to ensure an effective transition of a patient with complex medical needs from hospital to post-discharge care in one of two patients reviewed who were ordered to discharge to a post-acute care facility. (Patient #2) Findings include: Facility policies: The Assessment and Reassessment policy read, the assessment process shall be a continuous, collaborative effort with all departments functioning as a team. The purpose shall be to ensure all patients receive the appropriate assessment, including reassessments. All patients receiving inpatient services shall have an initial assessment and appropriate follow-up assessments based upon their individual needs, including physical and social status. The data collected from each assessment shall identify the patient’s needs and the type of care to be provided. Decisions made regarding patient care shall be prioritized based on analysis of information collected. Assessments by the case manager (CM) shall address discharge planning needs and assessments for transfer to other levels of care. These assessments shall also focus on assisting with the discharge plan, and aim to promote quality of life and efficacy of the discharge plan. The Discharge Planning policy read, the purpose shall be to identify patients who have post-discharge needs in order to ensure adequate support is provided to meet such needs upon discharge. The discharge planning activities and care coordination shall be documented in the medical record. Alternatives to acute care, such as community resources, will be evaluated when appropriate to meet the needs of the patient. Patients discharged from the hospital who require nursing care shall receive instructions and individualized education prior to discharge or have home care set up. The Patient Rights and Responsibilities policy read, patients have the right to receive assistance from the physician and appropriate hospital staff in arranging for required follow-up care after discharge. 1. The facility failed to ensure an effective transition of a patient with complex medical needs from hospital to post-discharge care. A. Document Review i. Review of Patient #2’s medical record revealed Patient #2 presented to the facility on 3/18/26 for a headache caused by hypoxemia (low oxygen concentration in the bloodstream). Physician’s notes from 3/18/26 at 8:28 a.m., and 3:19 p.m., revealed Patient #2 was quadriplegic (when both arms and legs are paralyzed) and had a past medical history of a neurogenic bladder (loss of bladder control due to a spinal cord injury) requiring a suprapubic catheter (a hollow, flexible tube surgically inserted into the bladder to drain urine), neurogenic bowel (loss of bowel control due to a spinal cord injury), severe sleep apnea (breathing disorder characterized by brief interruptions of breathing during sleep) requiring a continuous positive airway pressure (CPAP) machine (a machine that uses air pressure to keep a person’s airway open), and pressure ulcers (areas of damaged skin and tissue caused by sustained pressure). A case management discharge planning evaluation from 3/18/26 at 3:10 p.m., revealed Patient #2 was living at a skilled nursing facility (SNF) (a temporary residence for patients who require continued medical care after discharge from the hospital) and required assistance with ambulation, bathing, dressing, medication management, meal preparation, shopping, toileting, transfers, and transportation. The SNF refused to re-accept Patient #2, therefore, Patient #2 required placement at a different facility to support their needs. On 3/20/26 at 5:07 p.m., a note by a CM revealed there were no accepting SNFs and Patient #2 would be discharged to a shelter or to the streets. On 3/21/26 at 12:47 p.m., a provider’s order was placed for an occupational therapist (OT) to evaluate Patient #2 to assist case management in identifying Patient #2’s post-discharge needs. The OT’s assessment from 3/22/26 at 4:09 p.m. revealed Patient #2 was dependent on assistance from others for their dressing, feeding, grooming, showering, toileting, and mobility needs, and with applying their orthotic wrist splints (specialized, custom-made devices designed to improve hand function by utilizing remaining wrist movement). The OT recommended Patient #2 be discharged to a long-term care facility (a residential setting that provides day and night medical, personal, and social support for individuals who are unable to live independently due to chronic illness or disability). The medical record failed to reveal evidence of attempts to find Patient #2 placement in a long-term care facility. Daily physician’s notes from 3/19/26 through 3/23/26 revealed Patient #2 was medically stable for discharge, however, they were not safe to discharge due to a lack of accepting post-discharge facilities. On 3/25/26 at 2:30 p.m., a provider’s order was placed for the case management discharge plan to include disposition to a SNF. At 3:31 p.m., an additional order was placed for Patient #2 to be discharged once a SNF bed was available. At 3:34 p.m., the physician signed Patient #2’s discharge summary, which revealed Patient #2 was to be discharged to a SNF. On 3/28/26 at 4:22 p.m., a physician’s note revealed Patient #2 was unable to empty their suprapubic catheter without assistance. A case management note from 3/30/26 at 4:51 p.m. revealed Patient #2 did not have family or friends to help them after discharge. Patient #2 was discharged to the streets on 3/31/26 at 2:43 p.m. This was in contrast to the provider’s order placed on 3/25/26 at 3:31 p.m., which revealed Patient #2 was to be discharged to a SNF. Patient #2’s discharge to the streets was also in contrast to the case management discharge planning evaluation from 3/18/26 at 3:10 p.m., and the occupational therapy evaluation from 3/22/26 at 4:09 p.m., which revealed Patient #2 required discharge to a facility for assistance with their feeding, hygiene, toileting, and mobility needs. Furthermore, the discharge instructions provided to Patient #2 on 3/31/26 failed to reveal evidence of resources provided to meet Patient #2’s continued care needs identified by the case management discharge planning evaluation and the occupational therapy evaluation. This was in contrast to the Discharge Planning policy, which revealed the purpose of discharge planning was to identify patients who had continued care needs in order to ensure adequate support was provided to meet such needs upon discharge. Discharge planning activities and care coordination should have been documented in the medical record. Alternatives to acute care, such as community resources, were evaluated when appropriate to meet the needs of the patient. Patients discharged from the hospital who required nursing care should have been provided instructions and individualized education prior to discharge. Additionally, the lack of resources provided to Patient #2 upon discharge was in contrast to the Assessment and Reassessment policy, which revealed all patients were assessed based on their individual needs. The data collected from these assessments was used to identify the patient’s needs and type of care to be provided. Decisions made regarding patient care were prioritized based on analysis of information collected. Assessments by the CM addressed discharge planning needs and assessments for transfer to other levels or care. These assessments also focused on assisting with the discharge plan, and aimed to promote quality of life and efficacy of the discharge plan. Patient #2’s discharge to the streets and lack of post-discharge resources was also in contrast to the Patient Rights and Responsibilities policy, which revealed patients had the right to receive assistance from the physician and appropriate hospital staff in arranging for required follow-up care after discharge. B. Interviews i. On 4/23/26 at 9:31 a.m., an interview was conducted with registered nurse (RN) #1. RN #1 stated they cared for Patient #2 in the days leading up to, and on the day of Patient #2’s discharge. RN #1 explained Patient #2 had limited ability to perform their activities of daily living (ADLs) (essential, routine self-care tasks such as bathing, dressing, eating, toileting, and mobilizing). RN #1 further explained two or three staff members were needed to assist Patient #2 with their toileting needs, however, Patient #2 did not have anyone who could have assisted them following discharge. RN #1 stated they were unaware of a plan developed to ensure Patient #2’s toileting needs were met following their discharge to the streets. This was in contrast to the Discharge Planning policy, which revealed the purpose of discharge planning was to ensure adequate support was provided to meet patients’ needs upon discharge. Patients discharged from the hospital who required nursing care should have received instructions and individualized education prior to discharge. This was also in contrast to the Patient Rights and Responsibilities policy, which revealed patients had the right to receive assistance from the physician and appropriate hospital staff in arranging for care after discharge. Additionally, RN #1 stated it was not safe to discharge Patient #2 because they did not have a safe place to go following discharge. ii. On 4/23/26 at 9:56 a.m., and interview was conducted with the RN CM manager (Manager) #2. Manager #2 stated a list of resources should have been provided to meet the needs of patients who were unable to care for themselves upon discharge. This was in contrast to the review of Patient #2’s medical record, which failed to reveal evidence of resources provided to ensure Patient #2’s needs were met after discharge. Manager #2 stated it was important to provide patients with resources to ensure they were equipped to manage their basic needs. iii. On 4/23/26 at 12:52 p.m., an interview was conducted with the social work CM manager (Manager) #3. Manager #3 stated the case management discharge plan was an order by the physician, which included the level of care to which a patient should be discharged. Manager #3 explained this plan should have been revised if the patient’s expected level of care changed in order to re-evaluate the patient’s post-discharge needs and to ensure the patient was safely discharged. This was in contrast to review of Patient #2’s case management discharge plan, which failed to reveal a plan for resources needed for Patient #2 to be safely discharged to the streets instead of being discharged to a SNF. iv. On 4/23/26 at 3:35 p.m., an interview was conducted with Physician #4. Physician #4 stated Patient #2 was expected to perform their ADLs following discharge in the same manner they performed their ADLs prior to admission. This was in contrast to the case management discharge planning evaluation from 3/18/26 at 3:10 p.m., which revealed Patient #2 was admitted from a SNF where they were dependent on staff to perform their ADLs.”

“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: 52761 Based on interviews and document reviews, the facility failed to ensure a safe discharge for a vulnerable patient with complex medical and social needs in one of one patients reviewed who was discharged to the streets. (Patient #2) (Cross-reference A-0799) Findings include: Facility policies: The Patient Rights and Responsibilities policy read, patients have the right to receive assistance from the physician and appropriate hospital staff in arranging for required follow-up care after discharge. The Discharge Planning policy read, the purpose is to ensure adequate and accurate screening and follow-up on continued care needs for all patients. Patients meeting any of the following criteria will be screened for having continuing care needs and may be referred to the Department of Case Management for assessment and follow-up: A vulnerable adult, living alone, with no known support systems. In addition to the case manager’s identification of patients, any member of the multidisciplinary health care team, including the physician, may make a referral to case management. Reference: According to the Department of Human Services, Adult Protective Services, 12 Code of Colorado Regulations 2518-1, “At-Risk Adult” means an individual eighteen years of age or older who is susceptible to mistreatment because he/she is unable to perform or obtain services necessary for his/her health, safety, or welfare. 1. The facility failed to ensure a safe discharge for a vulnerable patient with complex medical and social needs. A. Document Review i. Review of Patient #2’s medical record revealed Patient #2 presented to the facility on 3/18/26 at 8:28 a.m. for a headache caused by hypoxemia (low oxygen concentration in the bloodstream). Physician’s notes from 3/18/26 at 8:28 a.m., and 3:19 p.m., revealed Patient #2 was quadriplegic (when both arms and legs are paralyzed) and had a past medical history of a neurogenic bladder (loss of bladder control due to a spinal cord injury) requiring a suprapubic catheter (a hollow, flexible tube surgically inserted into the bladder to drain urine), neurogenic bowel (loss of bowel control due to a spinal cord injury), severe sleep apnea (breathing disorder characterized by brief interruptions of breathing during sleep) requiring a continuous positive airway pressure (CPAP) machine (a machine that uses air pressure to keep a person’s airway open), and pressure ulcers (areas of damaged skin and tissue caused by sustained pressure). A case management discharge planning evaluation from 3/18/26 at 3:10 p.m., revealed Patient #2 was living at a skilled nursing facility (SNF) (a temporary residence for patients who require continued medical care after discharge from the hospital) and required assistance with ambulation, bathing, dressing, medication management, meal preparation, shopping, toileting, transfers, and transportation. The SNF refused to re-accept Patient #2, therefore, Patient #2 required placement at a different facility to support their needs. A case management note from 3/30/26 at 4:51 p.m. revealed Patient #2 did not have family or friends to help them after discharge. On 3/31/26 at 2:43 p.m., Patient #2 was discharged to the streets despite a provider’s order placed on 3/25/26 at 3:31 p.m., which revealed Patient #2 was to be discharged to a SNF. Additionally, Patient #2 was discharged to the streets despite the case management discharge planning evaluation from 3/18/26 at 3:10 p.m., and an occupational therapy evaluation from 3/22/26 at 4:09 p.m., which revealed Patient #2 required discharge to a facility for assistance with their feeding, hygiene, toileting, and mobility needs. (Cross-reference A-0799) ii. Additional medical record review revealed Patient #2 returned to the emergency department (ED) on 3/31/26 at 5:17 p.m. for chest pain, two hours and 34 minutes after they had been discharged. A physician’s note from 3/31/26 at 5:33 p.m. revealed Patient #2 had significant comorbidities (having two or more chronic health conditions at the same time), which included quadriplegia and homelessness, and had risk elements among Patient #2’s social determinants of health (nonmedical factors which influence health outcomes), which included homelessness. Patient #2 required placement at a post-acute facility, however, there was limited access to facility placement due to quadriplegia and behavioral issues. Patient #2’s chest pain resolved, and they were discharged to the streets on 3/31/26 at 8:00 p.m. Patient #2’s medical record failed to reveal a referral from the provider to case management for assessment and follow-up, or evidence of resources provided to Patient #2 to ensure a safe discharge. This was in contrast to the Patient Rights and Responsibilities policy, which read patients had the right to receive assistance from the physician and appropriate hospital staff in arranging for required follow-up care after discharge. This was also in contrast to the Discharge Planning policy which read, a vulnerable adult, living alone, with no known support systems would be screened for having continuing care needs and may be referred to the Department of Case Management for assessment and follow-up. In addition to the case manager’s identification of patients, any member of the multidisciplinary health care team, including the physician, could make a referral to case management. B. Interviews i. On 4/23/26 at 9:56 a.m., and interview was conducted with the RN CM manager (Manager) #2. Manager #2 stated patients were encouraged to reach out to friends and family for assistance with their post-discharge needs. If a patient did not have friends or family who were able to provide assistance, then they would be provided with resources to ensure their needs were met. This was in contrast to the review of Patient #2’s medical records, which failed to reveal evidence of resources provided to ensure Patient #2’s needs were met after discharge. Manager #2 stated it was important to provide patients with resources to ensure they were equipped to manage their basic needs. ii. On 4/20/26 at 10:30 a.m., an interview was conducted with ED director (Director) #5. Director #5 stated case management was consulted to assist with the discharge of patients in the ED who had complex medical needs. This was in contrast to review of Patient #2’s medical record, which failed to reveal evidence of case management involvement during Patient #2’s ED visit on 3/31/26. Additionally, Director #5 stated patients should not have been discharged from the ED if they required placement at a post-acute facility. This was in contrast to Patient #2’s discharge to the street on 3/31/26 at 8:00 p.m., despite the physician’s note from 3/31/26 at 5:33 p.m., which revealed Patient #2 required placement at a post-acute facility.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 52287 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.13, PATIENT RIGHTS, was out of compliance. A-202 The hospital must require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following: The safe application and use of all types of restraint or seclusion used in the hospital, including training in how to recognize and respond to signs of physical and psychological distress (for example, positional asphyxia). Based on interviews and document reviews, the facility failed to ensure staff obtained an order for the use of physical restraints before initiation, and before a chemical restraint (medication used to manage the patient’s behavior or restrict movement) was administered. Additionally, the facility failed to ensure the use of physical restraint occurred in accordance with facility policy. Furthermore, the facility failed to ensure staff recognized and responded to signs of physical distress in a restrained patient. This failure was identified in one of one medical records of patients who expired while restrained. (Patient #1)”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(2)(iv) [The hospital must require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following:] (iv) The safe application and use of all types of restraint or seclusion used in the hospital, including training in how to recognize and respond to signs of physical and psychological distress (for example, positional asphyxia). This Standard is not met as evidenced by: 52287 Based on interviews and document reviews, the facility failed to ensure staff obtained an order for the use of physical restraints before initiation, and before a chemical restraint (medication used to manage the patient’s behavior or restrict movement) was administered. Additionally, the facility failed to ensure the use of physical restraint occurred in accordance with facility policy. Furthermore, the facility failed to ensure staff recognized and responded to signs of physical distress in a restrained patient. This failure was identified in one of one medical records of patients who expired while restrained. (Patient #1) Findings include: Facility policies: The Seclusion/Restraint policy read, restraint use will be limited to clinically-justified situations, and the least restrictive restraint will be used. The facility provides leadership and organizational accountability for monitoring the safety, appropriateness and necessity of restraint use. Patients are to be assessed by a nurse immediately after restraints are initiated to assure the safe application of the restraint. The nursing assessment will include evaluation of the patient for signs of injury associated with restraint use, as well as a circulation assessment of any restrained extremities and an evaluation of the patient’s respiratory and cardiac status. When a physician or other licensed practitioner, authorized by State law to order restraints, is not available to issue a restraint or seclusion order, an regstered nurse (RN) with demonstrated competence may initiate restraint. In these emergency situations, the order must be obtained during the emergency application or immediately (within minutes) after the restraint or seclusion is initiated. The Physical Holding for Forced Medications section read, use of force to physically hold a patient to administer a medication against the patient ’ s wishes is considered restraint. The patient has the right to be free from restraint and also has the right to refuse medication. Healthcare staff are expected to use the least restrictive method of administering the medication to avoid or reduce the use of force, when possible. Use of force in order to medicate a patient, as with other restraints, must have a physician’s order prior to the application of the restraint (use of force). Appendix A, Training Requirements read, staff will demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion. Training will be provided to all staff designated as having direct patient care responsibilities (as listed by the facility), including contract or agency personnel. In addition, if hospital/ASC security guards or other non-healthcare staff (the facility to list) assist direct care staff, when requested, in the application of restraint or seclusion, the security guards, or other non-healthcare staff (as defined by the facility) are also expected to be trained and able to demonstrate competency in the safe application of restraint and seclusion. Before applying restraints, monitoring, assessing, or providing care for a restrained patient, staff must first demonstrate the necessary knowledge and skills to do so safely. This competency should be confirmed during orientation and reviewed in accordance with the regulations. Staff will be trained and able to demonstrate competency and training to recognize and respond to signs of physical and psychological distress (e.g., positional asphyxia). Staff will be trained and able to demonstrate competency in monitoring the physical and psychological well-being of patients who are restrained. This training will include, but will not be limited to, respiratory and circulatory status, skin integrity, and vital signs. Appendix D, Definitions read, a physical restraint is any manual method or device, such as material or equipment, attached to a patient that they cannot easily remove, and that restricts their freedom of movement or access to their own body. This includes any measure that immobilizes or limits the patient ’ s ability to move their arms, legs, body, or head freely. The policy further defines a drug or medication, when used 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, as a type of restraint. When medications are used as a restraint, it’s important to understand that whether they are considered a restraint depends not on the treatment setting, but on the specific situation being addressed. A medication is considered a chemical restraint if it is not being used as a standard treatment for the patient’s medical or psychiatric condition, or if it is used in a dosage outside the normal range, and its effect is to control the patient’s behavior or restrict their freedom of movement. The Use of Force policy defines Passive/Verbal Resistance as an event in which the subject verbally states their intention of non-compliance or engages in argumentative behavior. This includes being deliberately non-compliant with facility colleagues to ensure their safety and well-being. Colleagues should allow the Subject to de-escalate and calm down on their own. Provide space, back away, or place safe barriers between themselves and the Subject. The policy further defines Active Resistance as the Subject using verbal threats or vulgarity, pulling away, or fleeing without attempting to cause injury to another. If the Subject is free to leave the facility voluntarily, colleagues should implement de-escalation techniques. Provide loud and clear verbal commands to the individual, indicating the action they should follow, and attempts to apprehend the individual will be avoided. Active Physical Aggression is defined as a subject actively exhibiting physical violence towards other individuals in the moment. A continuum of force may be applied to defend oneself or another against imminent bodily harm or death. The level of force used depends upon the degree of the physical attack and the reasonable perception of the threat of injury. Colleagues should attempt to retreat and/or back away from the physical attack for their safety and continue using de-escalation techniques to prevent further escalation. Additionally, Colleagues should contact law enforcement officials to further manage the event. The policy further read that for Subjects who are pushing, slapping, biting, spitting, pinching, or throwing objects, empty-hand control techniques may be used. Use of force examples (for empty-hand control techniques) include empty-hand/pressure point escort, and clinical medication/behavioral restraints. Colleagues who use any level of force in an incident will complete a Use of Force Report, accurately detailing the Subject’s actions that necessitated force as well as the colleague’s actions and all circumstances relevant to the event. The report should articulate the factors perceived and the reason the colleague believed the use of force was necessary under the circumstances. 1. The facility failed to ensure security staff did not initiate the use of manual holds, and bodily force (physical take-down and physical hold) to restrain patients. Nursing staff also failed to obtain a provider order before administering a chemical restraint. Additionally, security staff failed to use verbal de-escalation techniques on a patient who was not immediately posing a threat to self or others. A. Document Review i. Medical record review revealed on 11/28/24 at 2:49 p.m., Patient #1 was admitted with acute pancreatitis (inflammation of the pancreas). On 11/29/24, Patient #1 developed progressive shock (a life-threatening condition where the internal organs begin to fail due to a lack of blood and oxygen) and was transferred to the Burn Intensive Care Unit (ICU). Further, medical record review revealed, on the evening of 12/5/24, Patient #1 developed severe agitation, acute progressive encephalopathy (a medical illness causing progressive brain dysfunction), and respiratory failure (the lungs cannot get enough oxygen into the blood). Additionally, Patient #1 removed their nasal feeding tube several times. Medical provider (Provider) #17 prescribed Haldol to be administered as needed and ordered the application of non-violent medical restraints (non-behavioral restraints used to restrict a patient’s movement for medical reasons) on both of Patient #1 ’ s wrists to prevent them from removing medical devices necessary to treat the patient’s medical condition. a. Review of the nursing documentation entered on 12/6/24 at 6:14 p.m. revealed Patient #1 became agitated, removed the non-violent restraints on both of their wrists, and disconnected all medical devices from their body. Patient #1 also removed their soiled disposable adult brief, took out feces, and smeared it on their body and the surrounding area. Afterward, Patient #1 ran out of their ICU room and through the emergency exit door into the parking lot. Further nursing documentation review revealed at 4:34 p.m., while in the parking lot, Patient #1 experienced respiratory arrest (breathing completely stopped), and a code blue (emergency code for when a patient’s heart stops beating) was called. The code blue lasted 48 minutes, and at 5:22 p.m., Patient #1 expired. ii. A review of the Use of Force report completed by security officer (Officer) #3 on 12/6/24 at 10:41 p.m., revealed nursing staff had alerted security assistance was needed on the ICU, and both Officer #2 and Officer #3 responded to the alert. Upon their arrival, they were informed Patient #1 eloped and was in the adjacent parking lot. Both Officer #2 and Officer #3 went to the parking lot to assess the situation. According to Officer #3’s use of force report, once in the parking lot, they saw Patient #1 walking around unclothed and covered in feces. Officer #3 approached Patient #1, who then wiped feces on the officer. Officer #3 backed away from the patient, and as Officer #3 moved back, Patient #1 began to run. Officer #3 responded by using a one-arm takedown (a type of physical restraint used to force a person to the ground) to bring Patient #1 to the ground. Once Patient #1 was on the ground, Officer #2 approached and grabbed Patient #1’s other arm. Together, both officers physically held Patient #1 face down on the ground while Patient #1 continued to struggle. At 4:30 p.m., registered nurse (RN) #13 administered 5 milligrams (mg) of Haldol (a medication used to chemically restrain a patient and limit movement) intramuscularly to Patient #1 while Officers #2 and #3 physically held and restrained the patient. At 4:32 p.m., Patient #1 stopped breathing, did not have a pulse, and was cyanotic (blue around the face and chest from lack of oxygen). While in the parking lot, nursing staff started cardiopulmonary resuscitation (CPR). Upon request, the facility was unable to provide evidence that a provider had ordered violent physical restraints or a chemical restraint for Patient #1. Although Officers #2 and #3 submitted a use of force report, the facility was unable to provide evidence Patient #1 posed an imminent threat to themselves or others or that the patient’s behavior warranted the use of physical restraint. Additionally, the use of force reports completed by Officers #2 and #3 contrasted with the Use of Force policy. According to the Use of Force policy, the use of force may be applied to defend oneself or another against imminent bodily harm or death. Physical force should have only been used when necessary and only when patients attempted to harm themselves or others. Security officers should have retreated or backed away from patients who attempted to physically engage, and continued using de-escalation techniques to prevent the situation from further escalating. Lastly, the officers’ actions during the event resulted in unnecessary harm to Patient #1. According to Patient #1’s autopsy report provided by the facility on 4/14/25, the use of physical force and the administration of Haldol when Patient #1 was physically restrained contributed to their death. Additionally, Patient #1 had blunt force injuries present on their head, bleeding within their eyes, and bruising across their chest, back, and abdomen, which were a direct result of excessive pressure being applied while Patient #1 was physically held face-down on the ground. This prevented Patient #1 from breathing and caused the patient to become unresponsive. Furthermore, the autopsy report stated, Patient #1’s manner of death was homicide. B. Interviews i. During a discussion with facility leadership, on 4/15/25 at 5:01 p.m., chief medical officer (CMO) #16 stated they conducted a review of Patient #1’s medical record. CMO #16 stated on 12/5/24 at 11:02 p.m., an order for Patient #1 to receive Haldol as needed (PRN) for agitation was entered by Provider #17. CMO #16 further stated Haldol was not administered to Patient #1 as a chemical restraint since the medication was administered to treat the agitation resulting from their encephalopathy. CMO #16’s interview was in contrast to the medication order for Haldol, which directed it to be given intravenously to treat agitation. However, Patient #1’s medical record revealed that the Haldol was administered intramuscularly while the patient was physically restrained face down on the ground. CMO #16’s interview also contrasted with the Restraint/Seclusion policy, which stated medications were intended to enable, not disable patients. The administration of a medication to reduce the patient’s ability to effectively or appropriately interact with the world around them was a restraint. ii. On 4/9/25 at 2:11 p.m., RN #1 was interviewed and stated they were the primary nurse for Patient #1 on the day the patient eloped. RN #1 stated they informed Provider #17 of Patient #1’s elopement. However, RN #1 further stated that they did not obtain a provider order to physically restrain Patietn #1 or to administer a chemical restraint to the patient. RN #1’s interview contrasted with the Restraint/Seclusion policy, which stated when a provider was not immediately available, an RN with demonstrated competency could initiate the use of physical restraint. However, an order for physical restraint should be obtained from a provider immediately (within minutes) after initiating the physical restraint. iii. On 4/10/25 at 11:16 a.m., Officer #6 was interviewed and stated security officers attempted verbal de-escalation with patients who attempted to elope. Officer #6 stated this was the first step before any physical intervention. However, Officer #6 also stated security officers initiated manual holds, physically engaged patients, and used force to prevent elopement. Officer #6 further stated a physician’s order was not needed when patients were physically restrained or when officers used force to take a patient to the ground. Officer #6’s interview contrasted with the facility’s Restraint/Seclusion policy, which defined physically holding a patient to restrict movement against their will as a restraint and warned that physical holds posed a risk of patient death, including from complications such as positional asphyxia. Additionally, the policy stated that to ensure the safety of the patient when physical and chemical restraints were initiated, only an RN who had been deemed competent was permitted to initiate the use of physical restraint before a provider order was obtained. Furthermore, a provider order for chemical restraint was required before staff physically held a patient down to administer a medication to the patient. 2. The facility failed to ensure that contracted security officers were deemed competent to apply restraints and in recognizing and responding to signs of physical and psychological distress in accordance with facility policies. A. Document Review i. A review of personnel records for Officer #2, Officer #3, and Officer #6 revealed no evidence that the security officers had been deemed competent to apply restraints and in recognizing and responding to the signs of physical distress in patients who were restrained. This contrasted with the Restraint/Seclusion policy, which stated security officers will be trained and able to demonstrate competency in the safe application of all types of restraints used at the facility, including training to recognize and respond to signs of physical and psychological distress, such as positional asphyxia. B. Interviews i. On 4/10/25 at 11:16 a.m., Officer #6 was interviewed and stated that security officers were required to complete Crisis Prevention Institute (CPI) training, which focused on preventing, de-escalating, and managing hostile or escalated situations. Officer #6 stated they were given facility policies to review upon hire and had not been required to complete facility-specific training or competencies during their four years of employment, as they were contracted staff. ii. On 4/10/25 12:18 p.m., an interview was conducted with director of security (Director) #10. Director #10 stated that since security was contracted, the security company followed its own policies and did not use facility-specific training or procedures. Upon request, the was unable to provide evidence security officers had been educated, trained, and deemed competent in the application of restraints or in recognizing and responding to signs of positional asphyxia when physical force was used as a restraint. Additionally, the facility was unable to provide evidence of preventative measures implemented after use of force by security officers resulted in Patient #1’s death. Despite the findings in Patient #1’s autopsy report, which indicated the use of physical force as a form of restraint, along with the administration of Haldol while the patient was physically restrained contributed to Patient #1’s death, the facility was unable to provide evidence it had implemented measures to mitigate risk or prevent a similar event from occurring in the future. This lack of follow-up conflicted with the Restraint/Seclusion policy, which required the review of restraint-related events, the implementation of preventive measures, and organizational accountability to ensure that restraints were used only when clinically justified and in the least restrictive manner.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48269 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.13, PATIENT RIGHTS, was out of compliance. A-0154 USE OF RESTRAINT OR SECLUSION Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. Based on interviews and record review, the facility failed to use restraints in accordance with facility policy and the restraint manufacturer’s instructions for use (IFU). This failure included lack of provider orders for restraint use, lack of assessment and monitoring of patients when in restraints, and the use of restraints as a fall precaution. The failure was identified in one of two records reviewed of patients who were restrained (Patient #3).”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 48269 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.23 NURSING SERVICES was out of compliance. A-0395 - A registered nurse must supervise and evaluate the nursing care for each patient. Based on interviews and document reviews, the facility failed to provide nursing services within recognized standards. Specifically, the facility failed to monitor a tracheostomy patient with continuous pulse oximetry in accordance with facility policy in one of one medical record reviews of patients with a tracheostomy (a curved tube inserted into an opening made in the neck and windpipe to allow air to pass through) (Patient #4). Additionally, the facility failed to ensure staff notified the provider of a change in patient condition in one of six medical records reviewed (Patient #6). In addition, the facility failed to provide assistance with activities of daily living (ADLs) in four of six medical records reviewed (Patients #1, #2, #3, and #4).”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 48269 Based on interviews and record review, the facility failed to use restraints in accordance with facility policy and the restraint manufacturer’s instructions for use (IFU). This failure included lack of provider orders for restraint use, lack of assessment and monitoring of patients when in restraints, and the use of restraints as a fall precaution. The failure was identified in one of two records reviewed of patients who were restrained (Patient #3). Findings include: Facility Policy: The facility Restraint/Seclusion policy read, use will be limited to clinically-justified situations, and the least restrictive restraint will be used with the goal of reducing, and ultimately eliminating, the use of restraints. There must be a provider order for restraint with non-violent or non-self-destructive behavior that must specify clinical justification for the restraint, the date and time ordered, the duration of the use, the type of restraint and behavior-based criteria for release. Staff must assess, monitor, and re-evaluate the patient regularly and release the patient from restraint when criteria for release are met. A physical restraint is defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the patient’s body that he or she cannot easily remove that restricts freedom of movement or normal access to one’s body to include immobilization or reduction of the ability of a patient to move his or her arms, legs, body, or head freely is considered a physical restraint. An object may be a restraint by functional definition, which is when an object restricts the patient’s movement or access to his or her body. Under this definition, many commonly used facility devices and practices could meet this definition of a restraint (e.g., tucking in sheets very tightly, use of side rails to prevent a patient from voluntarily getting out of bed, holding a patient to prevent movement, pinning of mitts on infants, arm restraints and other wrappings that prevent infants, children and/or adults from removing invasive lines or reopening surgical sites, etc.) Reference: The Posey Self-Releasing Roll Belt instructions for use (IFU) read, the indications for use are for patients needing a reminder to call for assistance before exiting a bed, and are able to follow instructions. Rx (medical prescription) only. The product is designed for self-release. If the patient is not able to easily self-release, it is considered a restraint and must be prescribed by a physician. Contraindications state do not use on a patient who is or becomes highly aggressive, combative, agitated, or suicidal; and do not use on a patient who is unwilling or unable to follow instructions, and is at risk of a fall or re-injury from self-release. Additional warnings include constant monitoring may be required for aggressive or agitated patients. Always monitor patients per facility policy. Improper application or use of any restraint may result in serious injury or death. 1. The facility failed to ensure staff followed facility policies and processes for patients who were restrained. A. Medical Record Review i. On 2/26/24, Patient #3 was admitted to the facility with sepsis (a serious condition in which the body responds improperly to an infection) and severe progressive dementia (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life). Medical record review revealed Patient #3 had a suprapubic catheter (a tube used to drain urine from the bladder through a cut in the abdomen) and had been taking antibiotics for a urinary tract infection (UTI). Provider notes stated Patient #3 was not oriented to name, place, or time. Provider notes also stated Patient #3 was agitated with episodes of combative behavior which were refractory (resistant) to medications. The medical record revealed the patient had both neurology and psychiatry consultations which concluded Patient #3’s behavior was consistent with dementia. The nursing flow sheets revealed Patient #3 was placed in a roll belt (a belt used to remind a patient to call for assistance before getting out of bed) on 2/26/24 at 11:52 a.m. The initial provider order for restraint use was written on 2/26/24 at 8:34 p.m., more than eight hours after the roll belt was applied. Additionally, the final order for restraint use for Patient #3 expired on 3/8/24 at 11:59 p.m. However, documentation in the medical record revealed Patient #3 continued to be restrained with a roll belt and at times mitts until discharge from the facility on 3/15/24, which was seven days after the last order for restraints. Nursing staff did not document use of restraints or frequent checks of Patient #3 according to facility policy during this time period. This was in contrast to the facility Restraint/Seclusion policy which read, there must be a provider order for restraint with non-violent or non-self-destructive behavior that must specify clinical justification for the restraint, the date and time ordered, the duration of the use, the type of restraint and behavior-based criteria for release. Also, the policy read, staff must assess, monitor, and re-evaluate the patient regularly and release the patient from restraint when criteria for release were met. Physical therapy, occupational therapy, and case management notes reviewed in the medical record revealed Patient #3 continued to be in a roll belt, and at times mitts, days after the last restraint order expired on 3/8/24. On 3/11/24, the provider documented a conversation with the charge nurse about a request for an in-person sitter for Patient #3 to alleviate the need for restraints. The provider was informed there was no staff available to provide a sitter. Case management notes about discharge planning described difficulty finding placement for Patient #3 in a skilled nursing facility due to the use of the roll belt. According to the case management notes, outside facilities required patients to be free from restraint use for 24 hours prior to admission, and due to Patient #3’s need for the roll belt facilities would not accept them for admission. B. Interviews revealed inconsistencies between staff practices, facility policies, facility leadership expectations, and the Posey self-releasing roll belt IFUs. i. On 3/20/24 at 11:32 a.m., an interview was conducted with patient care technician (PCT) #1. PCT #1 stated a roll belt was used for patients who tried to get out of bed. They explained it was used especially for patients who were disoriented so they would not try to get out of bed alone and hurt themselves. Further, PCT #1 said if a roll belt was used alone it was not considered a restraint, but if the roll belt was used along with mitts then it would be considered a restraint. This was in contrast to the facility’s Restraint/Seclusion policy which read, the definition of a physical restraint was any manual method or physical or mechanical device, material, or equipment attached or adjacent to the patient’s body that he or she could not easily remove that restricted freedom of movement or normal access to one’s body to include immobilization or reduction of the ability of a patient to move his or her arms, legs, body, or head freely was considered a physical restraint. An object may be a restraint by functional definition, which is when an object restricts the patient’s movement or access to his or her body. Under this definition, many commonly used facility devices and practices could meet this definition of a restraint. This was also in contrast to the roll belt IFU which stated the roll belt should have only been used on patients who were able to follow instructions. The product IFU cautioned if the patient was not able to easily self-release, it was considered a restraint and must have been prescribed by a physician. Also, the roll belt contraindications stated not to use it on a patient who was or became highly aggressive, combative, agitated, or suicidal. Furthermore, the contraindications stated not to use the roll belt on a patient who was unwilling or unable to follow instructions and was at risk of a fall. According to the medical record review, Patient #3, who was disoriented (altered mental state in which the person did not know name, time, date, or location) and had severe dementia, was placed in a roll belt and at times in both a roll belt and mitts. Provider orders for restraints were missing from 3/9/24 through the patient’s discharge on 3/15/24. ii. On 3/20/24 at 12:05 p.m., an interview was conducted with registered nurse (RN) #2. RN #2 stated a roll belt was a belt placed around the patient’s waist that could be unclipped by the patient. They said the roll belt was something they used on patients instead of a restraint. They explained the roll belt was a reminder to patients not to get up without help. RN#2 was not sure if a provider order was needed to apply a roll belt to a patient. iii. On 3/21/24 at 9:13 a.m., an interview was conducted with clinical nurse coordinator (CNC) #3. CNC #3 said a roll belt by itself was not a restraint. They explained a provider order was not needed before they applied the roll belt when it was used alone. CNC #3 said if a roll belt was used with mitts and/or soft wrist restraints then the roll belt would be considered a restraint and a provider order would be needed. Also, they said frequent checks of patients who were restrained were important to ensure the patient got food, water, toileting, and basic needs met. Furthermore, they said patients in roll belts needed frequent checks because they could be at risk of dehydration, pressure injuries, or getting tied up in the roll belt. CNC #3 said they would be difficult if someone tied them to the bed. iv. On 3/26/24 at 1:02 p.m., an interview was conducted with nurse manager (Manager) #4. Manager #4 stated they had been educated that a roll belt was not a restraint because the patient could remove it. They said if a patient had a roll belt with mitts, the roll belt would be considered a restraint. They said the roll belt would not be considered a restraint if used on a patient with dementia. Manager #4 said staff were educated on how to use roll belts in orientation. Also, they explained the importance of ensuring staff followed IFUs was to be sure they used the product properly. Furthermore, Manager #4 stated incorrect use of any product could harm the patient; for example, if the roll belt were applied too tight, it could harm the skin and any tubes across the patient’s midsection. v. On 3/26/24 at 1:38 p.m., an interview was conducted with the director of acute care (Director) #5. Director #5 stated roll belts were used for patients who were impulsive and at risk of falling. They explained if the patient could demonstrate the ability to remove the roll belt themselves, then it was not considered a restraint. They also said a provider order was not needed. Additionally, Director #5 said in practice they were not considering roll belts a restraint unless the patient had mitts on too. They said the main use for roll belts was for fall prevention. Director #5 stated at some point, they learned a roll belt was a restraint if the patient could not remove it by themselves. Director #5 said other facilities considered a roll belt a restraint because they required the patient to be out of it for 24 hours before they would accept the patient. Furthermore, Director #5 stated it was important for patient safety to follow the IFU. They stated if the roll belt product was not used as intended the risk to patients could be any event up to death. These interviews were in contrast to the roll belt IFU which stated the device should be used for patients who were able to follow instructions. Additionally, the IFU said if the patient was not able to easily self-release the roll belt it was considered a restraint and must be ordered by a provider. Furthermore, contraindications stated the device should not be used on a patient who was highly aggressive, combative, or agitated; unwilling or unable to follow instructions; and warnings included that constant monitoring would be required for aggressive or agitated patients.”

“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: 48269 Based on interviews and document reviews, the facility failed to provide nursing services within recognized standards. Specifically, the facility failed to monitor a tracheostomy patient with continuous pulse oximetry in accordance with facility policy in one of one medical record reviews of patients with a tracheostomy (a curved tube inserted into an opening made in the neck and windpipe to allow air to pass through) (Patient #4). Additionally, the facility failed to ensure staff notified the provider of a change in patient condition in one of six medical records reviewed (Patient #6). In addition, the facility failed to provide assistance with activities of daily living (ADLs) in four of six medical records reviewed (Patients #1, #2, #3, and #4). Findings include: Facility policies: The Tracheostomy policy read, the purpose was to establish a protocol for the care of tracheostomy patients. The procedure stated continuous pulse oximetry will be used on all trach patients. The Assessment and Reassessment policy read, the nurse will notify the provider of change in condition. The Urinary Catheter (Foley) Insertion and Management policy read, its purpose was to define the indication and care of an indwelling urinary catheter, and to provide a guideline for the removal of indwelling urinary catheters when no longer clinically indicated. See the EBSCO Nursing Procedures and Skills for detailed indwelling urinary catheter care and management. Perineal/indwelling urinary catheter care must be performed at least once a shift, during daily bath, and as needed (e.g. after episodes of fecal incontinence). References: The Resource Guidebook for New Hire Nurses read, the frequency for patient care routines such as urinary catheter care should be every shift and as needed, a full bath should be daily and as needed, oral care should be every shift and as needed, and for pressure ulcer prevention turning should be every two hours. The owner for each of these interventions is listed as the RN. The documentation checklist read, routine care should be documented every shift, Activities of Daily Living (ADL) should be documented at the end of the shift, and CHG baths should be documented twice each day for patients with central lines or a foley. The EBSCO Pressure Injury Prevention guidelines read, relieve/redistribute pressure with frequent position changes. Avoid positioning on erythemic areas. The EBSCO Oral Care guidelines read, providing oral hygiene improves oral health, overall health, and comfort. Consistent oral hygiene prevents the proliferation and spread of oral microbes which cause oral disease and other complications. Educate the patient about the need for brushing at least twice per day and flossing once per day. The EBSCO Bathing guidelines read, bathing on a regular basis is a necessary part of personal hygiene and is a method of preventing body odor and infection. The EBSCO Urinary Catheter Care guidelines read, providing urinary catheter care involves regular cleaning. Encourage patient to clean their established urinary catheter using clean technique with warm soapy water, usually twice daily. 1. The facility failed to ensure a patient with a tracheostomy (trach) was monitored in accordance with the facility’s expectations. A. Medical Record Review i. On 12/15/23, Patient #4 was admitted to the facility with a history of agitation and a tracheostomy and they remained hospitalized until 2/18/24 when they died after a cardiorespiratory arrest (the cessation of effective ventilation and circulation). Provider notes read on 2/18/24 the patient was found with an oxygen saturation level (the amount of oxygen circulating in the blood) of 4% (normal range is above 94%) and the tracheostomy tube (a tube inserted into the windpipe to allow ventilation) was dislodged. A code blue was called at 6:52 a.m. All pulse checks showed asystole. After 20 minutes of asystole and attempts to revive the patient, resuscitative efforts were stopped and the patient died at 7:12 a.m. Patient #4’s past medical history was significant for a stroke (occurred when the blood supply to part of the brain was blocked or when a blood vessel in the brain burst) with left-sided weakness. On their previous admission, Patient #4 had also had a tracheostomy placed, had increased oxygen needs, and struggled with mucus plugging in their airway. After prolonged hospitalization Patient #4 was discharged to a skilled nursing facility but returned to the hospital due to agitation which required a right-hand mitt to decrease the risk of removing the tracheostomy tube. Medical record review revealed when Patient #4 was readmitted for agitation there was an initial telemetry order placed by the provider on 12/15/23. This provider order was from the tracheostomy protocol and specified the patient may not be off telemetry monitoring. This order was stopped on 2/13/24. No order was written for continuous pulse oximetry throughout Patient #4’s admission. This was in contrast to the facility’s tracheostomy policy which read, continuous pulse oximetry would be used on all tracheostomy patients. According to the medical record, trach care had been provided by respiratory therapy (RT) on 2/17/24 at 7:45 a.m., 2:38 p.m., 8:07 p.m., and on 2/18/24 at 3:12 a.m. At 3:12 a.m. the RT documented the patient was combative but tolerated the trach care and the trach was secure. Further documentation revealed Patient #4 was found by nursing staff at 6:52 a.m. in complete cardiorespiratory arrest with the trach tube dislodged and a code blue was called. B. Interviews i. On 3/27/24 at 12:15 p.m., an interview was conducted with the clinical coordinator of respiratory care (CCRC) #10. CCRC #10 stated all patients with a tracheostomy should have been placed on continuous pulse oximetry. They said the risk to the tracheostomy patient of no continuous pulse oximetry monitoring would be delayed notification to staff if oxygen levels and heart rate were out of normal range. ii. On 3/27/24 at 12:15 p.m., an interview was conducted with registered nurse (RN) #11. RN #11 stated a patient with a tracheostomy would be continuously monitored with pulse oximetry. Also, they said they would ensure there was another trach tube, a cleaning kit, and suctioning equipment at the patient’s bedside. They said they would contact respiratory therapy (RT) if deep suctioning was needed. They stated VS were checked every four hours and patients would be monitored either by the VS machine in the patient’s room or remotely by centralized telemetry monitoring. RN #11 explained if an alarm sounded they would go straight to the patient’s room to check on the patient first. If the monitor was being remotely monitored and it alarmed the monitor technicians would call the RN first. RN #11 said it was important to continuously monitor trach patients because they were on continuous oxygen and their airway was compromised. They said they would need to know if the trach had been removed or dislodged. Further, they said the risk to the patient of not continuously monitoring with pulse oximetry and the airway was dislodged the patient could code or or die. iii. On 3/27/24 at 12:34 p.m., an interview was conducted with RN #8. They said for trach patients there was supposed to be a black box with emergency supplies that RT set up at the bedside. Also, they said continuous pulse oximetry would be in place on all trach patients remotely and at the nursing stations. RN #8 explained if the monitor alarmed, the techs would call the RN and then they would page overhead if there was no response from the call. They said nurses needed a provider order for continuously monitoring pulse oximetry. They also said there were capnography (monitoring of the carbon dioxide levels in respiratory gasses) machines that could be used until the nurse obtained a provider order. RN #8 said patients were not monitored if their trach was capped. They said it was important to monitor trach patients because they need to be suctioned frequently. They said if the trach patient’s airway were blocked or would decannulate (removal of the trach tube), they would need to know immediately because the risk to the patient would be that their oxygen level would drop too low and could cause brain damage or death. iv. On 3/27/24 at 12:53 p.m., an interview was conducted with RN #12. They said trach care was not done very often in the medical acute care unit. They said continuous pulse oximetry monitoring would be used for all trached patients. RN #12 stated the staff was supposed to respond to alarms within two minutes. They said the risk of not monitoring a trach patient would be a rapid decline in the patient’s condition that could go unnoticed. v. On 3/27/24 at 1:41 p.m., an interview was conducted with patient safety manager (Manager) #13. Manager #13 stated there had been a review of Patient #4’s unexpected death. They said the review of this incident had determined the code blue response was appropriate and the patient monitoring had been appropriate for a medical-surgical level of care. Manager #15 explained there was no specific provider order for continuous pulse oximetry so by default the nurses would follow unit standards for tracheostomy care. For the nursing unit where Patient #4 was located, they said it would have been nursing protocol for the patient to have continuous pulse oximetry in place. They said for Patient #4 the staff was following the trach policy. They said the policy did not differentiate between a new trach or one that was in place for a while. Manager #13 said they were unsure what determined whether a trach patient would have continuous pulse oximetry in the patient’s room or remote monitoring. They said they would defer to the nursing unit for that decision. This interview was in contrast with the Tracheostomy policy which instructed that continuous pulse oximetry would be used on all trach patients. vi. On 3/28/24 at 8:52 a.m., an interview was conducted with the interim hospitalist medical director (MD #14). When asked about Patient #4, MD #14 said they had been waiting for skilled nursing facility (SNF) placement for several days and that Patient #4 was medically stable. They said the trach was pre-established and secured and the patient had no respiratory distress. They said RT was doing daily suctioning. MD #14 said when Patient #4 was first admitted, at least the first 48 hours, was when they would have needed monitoring. They said the decision to place patients on continuous pulse oximetry came down to provider practice. They said when the intensivist went to the code it was unclear whether the trach came out prior to the code or during resuscitation efforts. They said Patient #4 was a very sick patient and a number of things could have caused their cardiopulmonary arrest. MD #14 stated since Patient #4 was going to a SNF, they would have taken care of the immediate needs and then taken her off monitoring to get her ready for discharge to the SNF which would not have had continuous monitoring capability. This was in contrast to facility policy which stated continuous pulse oximetry will be used on all trach patients. 2. The facility failed to ensure staff notified the provider of a change in condition. A. Medical Record Review i. On 2/8/24, Patient #6 was admitted to the facility with sepsis (a serious condition in which the body responded improperly to infection) and pneumonia (an infection in the lungs). Medical record review revealed on the evening of 2/14/24 Patient #6 experienced a marked increase in oxygen needs. They were emergently transferred to the ICU for bedside bronchoscopy (a procedure to look directly at the airways in the lungs using a thin, lighted tube) and intubation (a tube inserted through the nose or mouth into the trachea so air can get through) to clear an obstruction of the lung. A review of Patient #6’s medical record revealed in the hours leading up to the respiratory crisis on 2/14/24 the patient had diminished lung sounds on the morning of 2/13/24 and at 9:24 a.m. the provider ordered a chest CT (diagnostic imaging technique used to get internal images of the body). The chest CT was not completed until 2/14/24 at 9:21 p.m., which was 36 hours after the order was written. There was no evidence in the medical record to explain why there was a delay in completing the provider order. On 2/14/24 at 10:34 a.m., nursing documentation reported Patient #6’s lung sounds were clear. At 3:54 p.m. that afternoon, Patient #6 had a respiratory rate of 18 on one liter of oxygen and had an oxygen saturation of 92%. At 8:15 p.m., the medical record revealed Patient #6 had increased respiratory effort with the use of accessory muscles. The documentation stated lung sounds were absent in the left upper and lower lobes of the lung and diminished on the right side. Patient #6’s oxygen had been increased to five liters via nasal cannula. There was no evidence in the medical record the provider had been notified of the patient’s change in condition. On 2/14/24 at 9:21 p.m., the chest CT which had been ordered 36 hours prior on 2/13/24 at 9:24 a.m. was completed on Patient #6. At 9:42 p.m. the report read, complete collapse of the left lung, likely secondary to mucus plugging. There was no evidence in the medical record this imaging result had been called to the care team in accordance with facility policy. On 2/14/24 at 11:47 p.m., two hours after the chest CT was completed, medical record documentation revealed respiratory therapy (RT) placed Patient #6 on 45 liters of heated high-flow oxygen at 65% and notified the nurse and provider. On 2/15/24 at 1:00 a.m., Patient #6 was transferred to ICU for intubation and bronchoscopy. At 2:10 a.m. bedside bronchoscopy was completed and at 2:15 a.m. Patient #6 was intubated. B. Interviews i. On 3/27/24 at 12:15 p.m., an interview was conducted with the clinical coordinator of respiratory care (CCRC) #10. CCRC #10 explained a respiratory therapist (RT) would notify the nurse and provider of a patient’s change in condition. They stated if the patient’s condition were emergent the RT would hit the rapid response button. If the patient had increased oxygen needs, RT would communicate directly with the bedside nurse and when appropriate let the rapid response nurse know too. CCRC #10 stated depending on the situation either RT or the nurse would contact the provider about an acute change in condition. ii. On 3/27/24 at 2:34 p.m., an interview was conducted with the manager of medical imaging (Manager) #15. Manager #15 stated there were a variety of reasons why a delay in completing a routine CT test could occur. They said the healthcare standard most hospitals abided by was usually within 12 to 24 hours of the provider order being placed for inpatient care. They said the timeframe to report a critical test result was 30 minutes. Manager #15 explained a critical result was anything seen on imaging that the provider deemed critical. They said a new collapsed lung finding would be considered a critical result. Manager #15 reviewed the PACS (computerized system for imaging communications) notes for Patient #6’s chest CT procedure to understand why there was a 36-hour delay in completing the chest CT. Manager #15 explained on 2/13/24, the date of the chest CT order, there were texts exchanged between imaging and the primary nurse at 6:48 p.m., 8:26 p.m. and 11:00 p.m. At 11:00 p.m. a note was made in PACS which stated the test would be done in the morning per the charge nurse. Manager #15 said on 2/14/24, there were texts exchanged between imaging and nursing at 6:14 p.m., 7:31 p.m., and 8:19 p.m. The 8:19 p.m. text was when transport was requested to bring Patient #6 to radiology for the chest CT. Manager #15 said there were no notes in PACS that indicated there was a critical finding. They also said there was no documentation the radiologist had notified the ordering provider or care team. iii. On 3/27/24 at 12:31 p.m., an interview was conducted with nurse manager (Manager) #16. Manager #16 said they were involved with the review of the incident regarding Patient #6’s collapsed lung. Manager #16 reviewed the incident follow-up documentation which read, the critical results list was reviewed, the exam was read promptly by the care team, and the care was appropriate. Manager #16 said they debriefed Patient #6’s collapsed lung incident the morning after it occurred with the charge nurse who had been working at the time of the incident. Manager #16 stated the expectation for notifying a provider of a change in patient condition was based on nursing critical thinking and best judgment. They said any time there was a change in the patient’s condition the nurse would have been expected to notify the provider. They said the nursing staff used their best judgment on what would have been the best way to do that. For example, if a change in patient condition occurred in the middle of the night, the nurse would have needed to use their best judgment whether to text or call the provider. Manager #16 stated they were unsure why the chest CT that had been ordered on 2/13/24 had not been completed until 36 hours later. They said some causes for the delay could have been CT equipment out of service or the imaging team had prioritized other imaging tests ahead of Patient #6. Manager #16 said nurse staffing would have been reviewed as part of the incident follow-up and they were unaware if nurse staffing was a causative factor in the delayed chest CT. Nursing assignment sheets for 2/13/24, the day the chest CT was ordered, were reviewed and revealed, the nursing unit was short an RN and the charge nurse had a five-patient assignment on that day shift. On 2/13/24, the night shift assignment sheet was not available and the daily roster revealed the unit was short two RNs for that shift. On 2/14/24, the night of Patient #6’s collapsed lung, the night shift assignment sheet was not available and the daily roster revealed the unit was short one RN. 3. The facility failed to ensure patients received assistance with activities of daily living (ADLs) in accordance with the facility’s expectations. A. Record review i. Review of Patient #1’s medical record revealed the patient was admitted to the facility 12/19/23 for sepsis and anemia. Patient #1 had a stage 4 sacral decubitus ulcer on admission. A Plastic surgery consultation on 2/20/24 recommended wound care evaluation and treatment, antibiotics, a specialty offloading mattress, a dietitian consult for nutritional optimization, and routine nursing care. A review of the nursing documentation for turning Patient #1 every two hours throughout this hospital admission revealed turning and repositioning every two hours was not performed in nine of the nineteen shifts (47%) shifts reviewed. This was in contrast to the Resource Guidebook for New Hire Nurses which read, for pressure ulcer prevention turning should have occurred every two hours. ii. Review of Patient #2’s medical record revealed the patient was admitted to the facility on 1/11/24 for treatment of a subdural hematoma (bleeding between the brain and its outermost covering). A review of the nursing documentation for Patient #2’s ADLs revealed oral care was not provided in 49 of 149 (33%) of shifts reviewed. This was in contrast to the Resource Guidebook for New Hire Nurses and the EBSCO Oral Care guideline which read, the frequency of oral care should have occurred every shift or twice daily and as needed. iii. Review of Patient #3’s medical record revealed the patient was admitted to the facility on 2/26/24 for sepsis (a serious condition in which the body responded improperly to an infection) and dementia (loss of memory, language, problem-solving, and other thinking abilities that were severe enough to interfere with daily life). A review of the nursing documentation for Patient #3’s ADLs revealed oral care was not provided in 13 of 38 (34%) shifts during hospital admission. This was in contrast to the Resource Guidebook for New Hire Nurses and the EBSCO Oral Care guideline which read, the frequency of oral care should have occurred every shift or twice daily and as needed. iv. Review of Patient #4’s medical record revealed the patient was admitted to the facility 12/15/23 for agitation with recent past medical history of stroke (loss of blood flow to part of the brain which damaged brain tissue) and a tracheostomy (incision in the throat for placement of a breathing tube). A review of the nursing documentation for Patient #4’s ADLs revealed oral care was not provided on 20 of 34 (59%) shifts reviewed and CHG urinary catheter care was not provided on 18 of 34 (53%) shifts reviewed. This was in contrast to the Resource Guidebook for New Hire Nurses and the EBSCO Oral Care guideline which read, the frequency of oral care should have occurred every shift or twice daily and as needed. Also, this was in contrast to the facility’s Urinary Catheter (Foley) Insertion and Management policy which read, perineal/indwelling urinary catheter care must be performed at least once a shift, during daily bath and as needed (e.g. after episodes of fecal incontinence). Additionally, the facility Resource Guidebook for New Hire Nurses read, urinary catheter/CHG care/Foley Care should have been completed every shift and as needed. Further, the EBSCO Urinary Catheter Care guidelines read, providing urinary catheter care involved regular cleaning using clean technique, usually twice daily. B. Interviews revealed inconsistencies between staff practices, facility policy and guidelines, and facility leadership expectations. i. On 3/18/24 at 10:25 a.m., an interview was conducted with patient care technician (PCT) #6. When asked about the frequency of ADLs on their unit, PCT #6 stated they offered patients a bath or shower and oral care daily. ii. On 3/18/24 at 10:41 a.m., an interview was conducted with licensed practical nurse (LPN) #7. When asked about ADLs in their unit, LPN #7 stated they offered patients at least one shower in 48 hours. They stated the frequency of showering and bathing patients had just been discussed in a recent staff meeting. This was in contrast to the Resource Guidebook for New Hire Nurses which read, the frequency for a full bath should have occurred daily and as needed. iii. On 3/20/24 at 12:05 p.m., an interview was conducted with registered nurse (RN) #2. When asked about ADLs on their unit, RN #2 stated they offered a daily bath. For any patient with a central line, foley catheter, or any tubes in the body, they said those patients were to get a daily chlorhexidine (CHG) (wipes with antiseptic antibacterial agent used to clean the skin after an injury, before surgery, or before an injection) bath. They said personal hygiene care was important to prevent infection because over time skin and the bed sheets would get dirty and feel sticky. RN #2 said it was basic human decency to provide daily hygiene care to patients. iv. On 3/26/24 at 11:32 a.m., an interview was conducted with registered nurse (RN) #8. When asked about ADLs, RN #8 stated CHG baths were done daily or more often. They also said they did not know what the expected frequency for hygiene, perineal care, or oral care was and these were the PCT’s responsibilities. RN #8 said the nurses did not check up on the LPNs and PCTs on their team to ensure ADLs were completed. Furthermore, she stated they always had some PCTs but when they were short staffed and had so many patients to provide care, it could be very overwhelming for the PCTs, and, depending on the acuity of the patient assignment, ADLs would get missed. v. On 3/21/24 at 9:13 a.m., an interview was conducted with clinical nurse coordinator (CNC) #3. When asked about ADLs on their unit, CNC #3 stated the expectation was to offer daily bed bath or shower and to offer oral care once each shift. They also said it was important to have enough staff, and if the ratios were too high, the staff would not have the time to check on their patients as often as needed. Further, CNC #3 said if staffing ratios were too high, things like 1:1 feedings were rushed, baths would be rushed or not done, and patients were only getting the bare minimum to keep them alive. They said this made it hard for the dependent patients or the patients with no family to receive the ADL care needed. CNC #3 said the risk to patients if there was not enough staff was patients not getting turned, skin breakdown, not getting showers, and the PCTs would not have enough time to feed full meals to patients. vi. On 3/26/24 at 1:02 p.m., an interview was conducted with nurse manager (Manager) #4. When asked about the expectations for ADLs on the Medical Acute Care unit, Manager #4 stated their unit expectation was a CHG bath to be done every shift but the hospital policy was a CHG bath every 24 hours. Manager #4 said, ideally, oral care, showers, and baths would be done daily, but they tried for a goal of bathing every 2-3 days. They also said the expectation for perineal care would be done each time the patient was dirty. Further, Manager #4 stated the risks to patients of not getting ADLs completed could be skin breakdown, pressure injury, pneumonia, and weakness if not moving around enough. This was in contrast to the Resource Guidebook for New Hire Nurses which read, the frequency for a full bath should have occurred daily and as needed, and oral care should have occurred every shift and as needed. vii. On 3/21/24 at 9;38 a.m., an interview was conducted with director of acute care (Director) #9. When asked about the facility’s expectations for ADLs, Director #9 stated staff RNs partnered with PCTs to ensure all ADLs were completed for a given patient assignment. They said ADLs included daily bathing, oral care, linen changes, ordering meals, and feeding. Director #9 said RNs, LPNs, and PCTs were each given access to the fields in the EMR so they could document ADLs after they were completed. This was in contrast to the interview with RN#8 who stated the RNs did not check with LPNs and PCTs to ensure ADLs were completed.”