Masonicare Health Center

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 32738 Based on a review of clinical records, hospital documentation, and staff interviews, for one (1) of four (4) patients, (Patient #20) reviewed for a change in condition, the hospital failed to notify Patient #20’s family that the patient was abused by a staff member and failed to notify the patient’s family that the patient was transferred to an acute care hospital for evaluation. The finding includes: Review of Patient #20’s clinical record identified s/he was admitted to the hospital with a diagnosis of dementia with extreme aggression and agitation. A nursing note dated 05/25/2026 at 11:57 PM identified that Patient #20 was found to have a black and blue raised bump with a small laceration on his/her left eye, of unknown origin, during 10:00 PM checks. The nursing supervisor, administrator on call, and medical provider were notified and neurological checks were initiated. Patient #20 was sent to Hospital #21 for an evaluation. The note further identified that Patient #20’s family would be called in the morning by the day nurse. Review of the Hospital’s investigation on 06/25/2026 identified that on 05/25/2026 at approximately 10:30 PM CNA #20 punched Patient #20 in the face five (5) to six (6) times and held his/her head and arm down due to Patient #20’s aggressive behavior. The investigation determined that Patient #20 had injuries to his/her left eye and was transferred to Hospital #21 for evaluation of his/her injuries. Patient #20 was transferred back to the Hospital on 05/26/2026 after it was determined s/he had no serious injuries. Review of the hospital’s documentation dated 06/02/2026 indicated Patient #20’s family was not notified the patient was transferred to Hospital #21, and that Hospital #21 notified Patient #20’s family of the transfer. Interview with ED #20 (Executive Director) on 06/24/2026 at 10:20 AM identified that either the nurse caring for Patient #20 or the Nursing Supervisor should have contacted the patient’s family to make them aware of the injury and of the transfer to a higher level of care at the time the patient was injured and transferred. ED #20 identified that staff did not notify Patient #20’s family of the injury or of the transfer until eleven hours (11) after the injury. Interview with RN #22 (nursing supervisor) on 6/24/26 at 10:30 AM identified s/he was assigned to care for Patient #20 and was involved in the decision to send Patient #20 to a higher level of care for evaluation. RN #22 indicated they were aware that the family should have been notified at the time of incident and transferred to a higher level of care but made the decision to defer it to the morning because s/he did not want to wake up the family. Review of Behavioral Health Hospital Change in Condition and Communication dated 05/18/2021, directed, in part, that when a change in condition from baseline is observed and reported, the nurse is responsible to evaluate the patient’s condition and the patients’ family/guardian are to be notified, and the contact will be documented in the Nursing Flow Sheet form.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(2)(vii) [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:] (vii) The use of first aid techniques and certification in the use of cardiopulmonary resuscitation, including required periodic recertification. This Standard is not met as evidenced by: 48336 Based on a review of hospital documents and staff interviews, for twenty-seven (27) of nine-seven (97) staff members reviewed for Basic Life Support (BLS) and forty-nine (49) of ninety-six (96) staff members reviewed for Crisis Prevention Institute (CPI) Certifications, the hospital failed to ensure staff obtained and or maintained their required BLS and/or CPI Certification in accordance with the hospital practice. The findings include: a. Review of the Hospital’s investigation on 06/25/2026 identified that on 05/25/2026 at approximately 10:30 PM CNA #20 punched Patient #20 in the face five (5) to six (6) times and held his/her head and arm down due to Patient #20’s aggressive behavior. The investigation determined that Patient #20 had injuries to his/her left eye and was transferred to Hospital #21 for evaluation of his/her injuries. Patient #20 was transferred back to the Hospital on 05/26/2026 after it was determined s/he had no serious injuries. Review of staff Crisis Prevention Institute (CPI) (teaches crisis response and de-escalation techniques) certifications identified that CNA #20 was never CPI certified and RN #20’s (assigned to patient #20 on the day of the incident) CPI certification expired on 05/10/2026. Further review of the hospital’s list of staff who were required to be CPI certified on 06/25/2026 revealed that 49 of 96 staff members were not CPI certified (required to be completed within 90 days of hire). Review of the hospital’s CPI expiration dates document identified that all 49 staff that were not CPI certified were hired between the dates of 09/28/1998 through 10/14/2024. b. Review of staff Basic Life Support (BLS, a course that teaches life-saving techniques in emergencies) staff training identified that RN #21’s (working on the unit at the time of the incident) BLS certification expired on 12/2025. Further Review of the list of staff required to be BLS certified on 06/25/2026 revealed that twenty-seven (27) out of ninety-seven (97) staff members were not BLS certified (required to be completed within ninety (90) days of hire). Review of the hospital s CPR expiration dates document identified that all 27 staff that were not CPR certified were hired between the dates of 09/28/1998 through 03/03/2026. Interview with Executive Director #20, Manager #20, and Manager #21 on 06/25/2026 at 9:30AM indicated that staff are required to complete BLS and CPI training and become certified within 90 days of hire to the facility and that there is no formal process in place to monitor staff certifications. In addition, staff are required to maintain BLS certification, which needs to be renewed every two years, and CPI certification, which needs to be renewed annually. According to ED #20, Manager #20, and Manager #21, it is the responsibility of each unit manager to ensure staff maintain required certifications but there is no specific process in place to complete the certification. Interview with Manager #22 (Human Resources) indicated that certain staff are required to maintain BLS and/or CPI certification, but there is no formal process in place to ensure staff are required to maintain their certifications. Manager #22 said that in the past if a staff member did not maintain the required certification, they were taken off the schedule, put out on leave, and given two (2) weeks to acquire their required certification and if not completed, the employee was terminated. Manager #22 identified that due to the high number of staff presently not maintaining their certifications, the hospital was in the process of determining how to ensure everyone was certified in BLS and CPI and to ensure a plan was in placed to provide safe patient care. Subsequent to this investigation, the facility created and implemented policies that outline the requirements for CPI and CPR Certification.”