Rockford Center

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 47821 Based on facility policy and document review, medical record review (MR), and staff interview (EMP), it was determined that the facility failed to identify a grievance for 1 (Patient #1) of 8 patients sampled, resulting in the loss of the right to have a grievance filed on behalf of the patient. Findings include: Facility policy “Patient and Family Grievances/The Role of the Patient Experience Specialist” issued June 1999, revised June 2021 and last reviewed December 2024 revealed, “...Rockford Center will provide an effective mechanism for handling patient...grievances and complaints as an important part of providing quality care...to our patients...It is the responsibility of each staff member to respond in a timely manner to any grievances or complaints voiced by patients...no matter how trivial the complaint may appear to be...A “patient grievance” is a written or verbal complaint that is made to the hospital by a patient...If a complaint cannot be resolved promptly by staff present...it is to be considered a grievance...The Director of Clinical Services or designee is made aware of all grievances and complaints...” Facility document “The Rockford Center Statement of Patient Rights” dated March 2024 revealed, “...You have the right to file grievances and have them heard by the facility in a fair and impartial manner...” Review of MR1 revealed: “Patient Observation Record” nursing progress note written by EMP12, RS (Recovery Specialist) on 1/28/25 at 3 PM stated, “... Patient struggled to stay on task most of shift. Patient share (sic) numerous complaints regarding medication an (sic) care. Needs prompting to participate in groups...discharged at 3:30 PM...” Interview conducted with EMP6, Director of Clinical Services, on 2/6/24 between 12:20 PM-12:20 PM. Surveyor inquired if Patient #1 had voiced any complaints or grievances to the staff. EMP6 replied that Patient #1 did not have any complaints or grievances during this admission.”

“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: 47821 Based on facility policy review, medical record review (MR), and staff interview (EMP), it was determined that for 1 out of 4 patients (Patient #3) sampled that were restrained, the hospital failed to modify the patient’s plan of care after a restraint episode. Findings include: Facility policy “Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion” issued December 1996, revised March 2024, revealed, “...Treatment Plan Review/Revision: When the patient has presented behavior that is dangerous to themselves or others so that restraint/seclusion were indicated, a review and modification of the treatment plan is indicated. Based upon the consultation with the attending physician...information gathered from the debriefing with the patient, and the face-to-face evaluation, the RN shall review and update the treatment plan within 8 hours. The updated treatment plan shall reflect...The identification of an assessed problem associated with the use of restraint/seclusion if problem has not been previously identified...Goals related to prevention of the further use of restraint/seclusion...Interventions which define alternative approaches to address the identified problem. Responsibility for each intervention is assigned...Review of the plan with the patient...” Review of MR3 revealed: Patient was physically restrained on 1/19/25 for 2 minutes. “Post Intervention Face to Face Evaluation” indicated that a treatment plan modification was indicated. No evidence noted of a modification to the treatment plan. This finding was confirmed with EMP6 on 2/6/25 at 2:44 PM.”

“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: 47821 Based on facility policy review, medical record review (MR), and staff interview (EMP), it was determined that the use of restraint was performed without a physician’s order and not in accordance with hospital policy for 3 out of 4 patients (Patient #3, #7, and #8) sampled that were restrained. Findings include: Facility policy “Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion” issued December 1996 and reviewed/revised March 2024, revealed, “...to support each patient’s right to be free from restraint...and therefore limit the use of these interventions...Any restraint...used...requires an order from a physician...The physician...must be contacted for an order either during the emergency initiation of the restraint/seclusion or immediately (within a few minutes) after the restraint/seclusion has been initiated...Telephone/verbal orders for restraint/seclusion may be received and recorded by an RN...The physician shall authenticate the telephone/verbal order within 24 hours...the physician’s order...will be recorded in the medical record and include...The nurse receiving the order, the physician giving the order, and the nurse transcribing the orders, with appropriate dates and times...” Facility policy “Verbal/Telephone Orders” issued March 2017 and reviewed February 2024, revealed, “.... Verbal/telephone orders are transcribed accurately inclusive of date, time and signature...Verbal/telephone orders should be noted timely...” Review of MR3 revealed: Patient was physically restrained on 1/19/25 for a total of 2 minutes. No evidence of a physician’s order for the restraint. This finding was confirmed with EMP6 on 2/6/25 at 2:44 PM. Review of MR7 revealed: A restraint order was received via telephone by the RN on 12/21/24. No time received recorded for the verbal/telephone order. A restraint order was received via telephone by the RN on 1/14/25. No physician name or time received recorded for the verbal/telephone order. These findings were confirmed with EMP6 on 2/6/25 at 4:46 PM. Review of MR8 revealed: A restraint order was received via telephone by the RN on 12/8/24 at 8:34 PM. No evidence of physician authentication of the verbal/telephone order. A restraint order was received via telephone by the RN on 12/16/24 at 2:00 PM. No evidence of physician authentication of the verbal/telephone order. These findings were confirmed with EMP6 on 2/6/25 at 4:49 PM.”

“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: 47821 Based on facility policy review, medical record review (MR), and staff interview (EMP), it was determined that for 1 out of 4 patients (Patient #3) sampled that were restrained, the facility failed to follow hospital policy regarding the monitoring of a restrained patient. Findings include: Facility policy “Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion” issued December 1996, revised March 2024, revealed, “...Patients in restraints/seclusion will be closely monitored and evaluated...Vital signs shall be taken upon initiation and as clinically indicated, but at least every 2 hours...Post-Restraint/Seclusion Debriefing: Debriefing following the use of restraint/seclusion is important in reducing the use of recurrent restraint/seclusion. The patient and staff participate in a debriefing session following the restraint/seclusion episode...The debriefing occurs as soon as possible, and as appropriate, but no longer than 24 hours after the episode...The debriefing is used to...Identify what led to the incident and what could have been managed differently...Ascertain that the individual’s physical well-being, psychological comfort, and right to privacy were addressed...Counsel the individual involved for any trauma that may have resulted from the incident...” Review of MR 3 revealed: Patient had a documented restraint episode on 1/19/25 which involved a 2-minute physical hold. No evidence that vital signs were obtained before, during, or after the restraint episode. The restraint packet included a form titled “Seclusion/Restraint/Emergency Medication Patient Debriefing”. The form was blank. No evidence that a debrief was completed following this episode of restraint use. These findings were confirmed with EMP6 on 2/6/25 at 1:34 PM.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(14) If the face-to-face evaluation specified in paragraph (e)(12) of this section is conducted by a trained registered nurse, the trained registered nurse must consult the attending physician or other licensed practitioner who is responsible for the care of the patient as soon as possible after the completion of the 1-hour face-to-face evaluation. This Standard is not met as evidenced by: 47821 Based on facility policy review, medical record review (MR), and staff interview (EMP), it was determined that the facility failed to ensure trained registered nurses, who completed the face-to-face evaluation after a restraint/seclusion episode, consulted with the attending physician as soon as possible for 2 out of 4 patients (Patients #2 and #7) sampled that were restrained. Findings include: Facility policy “Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion” issued December 1996 and reviewed/revised March 2024, revealed, “...Within one hour of the initiation of restraint or seclusion, the patient shall be evaluated in person by a physician...or trained RN...If a trained RN...conducts the evaluation, he/she must consult with the attending physician...as soon as possible (within 30 minutes) after the evaluation...” Review of MR2 revealed: Patient was physically restrained on 1/19/25 for a total of 2 minutes. The face-to-face evaluation was completed by the RN on 1/19/25 at 4:39 AM. No evidence that the physician was notified of the results of the evaluation. This finding was confirmed with EMP6 on 2/6/25 at 1:34 PM. Review of MR7 revealed: Patient was physically restrained on 12/21/24 for a total of 6 minutes. Patient was placed in seclusion for a total of 5 minutes. The face-to-face evaluation was completed by the RN on 12/21/24 at 1:40 PM. No evidence that the physician was notified of the results of the evaluation. Patient was physically restrained on 1/14/25 for a total of 1 minute. Patient was placed in seclusion for a total of 36 minutes. The face-to-face evaluation was completed by the RN on 1/14/25 at 5:48 AM. No time documented of when the physician was notified of the results of the evaluation. These findings were confirmed with EMP6 on 2/6/25 at 4:46 PM.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 47821 Based on facility policy and document review, medical record review (MR), and staff interview, it was determined that the facility failed to obtain consent from the patient or the patient’s representative before the administration of psychotropic medication in 5 of 5 adolescent patients (Patient #1, #2, #3, #4, #5) sampled. Findings include: Facility policy “Informed Consent for Psychotropic Medications” issued January 2019 and reviewed January 2024, revealed, “...Informed consent must be obtained by the physician...Consent will be documented on a medication consent form with signatures of both the patient/guardian, the physician or in the electronic HCS [electronic health system] system...No medication can be administered without consent...” Review of MR1 revealed: “Physician Medication Orders” documents the following psychotropic medications were ordered on 9/16/24: - divalproex sodium DRT [delayed release tablet] 500 mg (milligrams) by mouth at bedtime for mood stabilization. - hydroxyzine pamoate 25 mg by mouth four times a days needed for anxiety. - trazodone 50 mg by mouth at bedtime as needed for sleep. - divalproex 250 mg DR [delayed release] by mouth every morning for mood stabilization. “Medication Administration Record” revealed patient received: - divalproex sodium DRT 500 mg on 9/16/24 at 10:08 PM. - hydroxyzine pamoate 25 mg on 9/19/24 at 5:30 PM. - trazodone 50 mg on 9/17/24 at 10:43 PM. - divalproex 250 mg DR on 9/17/24 at 8:51 AM. There was no evidence of patient consent for these psychotropic medications. Interview with EMP4 on 9/24/24 revealed there was no evidence of patient consent for these psychotropic medications in the MR or the HCS (Electronic health system). These findings were confirmed with EMP4 on 9/24/24 at 10:39 AM. Review of MR2 revealed: “Physician Medication Orders” documents the following psychotropic medications were ordered on 5/16/24: - lamotrigine 200 mg by mouth daily for mood stabilization. - fluoxetine 40 mg by mouth daily for mood stabilization. - hydroxyzine pamoate 25 mg by mouth 4 times a day as needed for anxiety. - guanfacine extended release 2 mg by mouth daily at bedtime for mood stabilization. “Medication Administration Record” revealed patient received: - lamotrigine 200 mg on 5/19/24 at 9:49 AM. - fluoxetine 40 mg on 5/18/24 at 12:29 PM. - hydroxyzine pamoate 25 mg on 5/19/24 at 00:10 AM. - guanfacine extended release 2 mg on 5/17/24 at 9:33 PM. Interview with EMP4 on 9/23/24 revealed there was no evidence of patient consent for these psychotropic medications in the MR or the HCS. These findings were confirmed with EMP4 on 9/23/24 at 1:45 PM. Review of MR3 revealed: “Physician Medication Orders” documents the following psychotropic medications were ordered on 9/10/24: - hydroxyzine pamoate 25 mg by mouth 4 times a day as needed for anxiety. - guanfacine extended release 1 mg by mouth daily for mood stabilization. “Medication Administration Record” patient received: - hydroxyzine pamoate 25 mg on 9/10/24 at 8:01 PM. - guanfacine extended release 1 mg on 9/11/24 at 8:36 AM. Interview with EMP4 on 9/23/24 revealed there was no evidence of patient consent for these psychotropic medications in the MR or the HCS. These findings were confirmed with EMP4 on 9/23/24 at 1:45 PM. Review of MR4 revealed: “Physician Medication Orders” documents the following psychotropic medications were ordered on 8/8/24: - hydroxyzine pamoate 25 mg by mouth 4 times a day as needed for anxiety. “Physician Medication Orders” documents the following psychotropic medications were ordered on 8/12/24: - guanfacine extended release 2 mg by mouth daily for mood stabilization. - risperidone 1 mg by mouth twice a day for mood stabilization. “Physician Medication Orders” documents the following psychotropic medications were ordered on 8/16/24: - chloropromazine 50 mg by mouth every 6 hours as needed for agitation. “Medication Administration Record” patient received: - hydroxyzine pamoate 25 mg on 8/8/24 at 8:25 PM. - guanfacine extended release 2 mg on 8/13/24 at 9:17 AM. - risperidone 1 mg on 8/12/24 at 5:24 PM. - chloropromazine 50 mg on 8/16/24 at 1:39 PM. Interview with EMP4 on 9/24/24 revealed there was no evidence of patient consent for these psychotropic medications in the MR or the HCS. These findings were confirmed with EMP4 on 9/24/24 at 10:30 AM. Review of MR5 revealed: “Physician Medication Orders” documents the following psychotropic medications were ordered on 7/16/24: - hydroxyzine pamoate 25 mg by mouth 4 times a day as needed for anxiety. “Physician Medication Orders” documents the following psychotropic medications were ordered on 7/24/24: - chloropromazine 50 mg by mouth every 6 hours as needed for agitation. - diphenhydramine 50 mg by mouth every 6 hours as needed for aggression. “Physician Medication Orders” documents the following psychotropic medications were ordered on 7/28/24: - quetiapine 50 mg by mouth twice a day for mood stabilization. “Medication Administration Record” patient received: - hydroxyzine pamoate 25 mg on 8/3/24 at 8:08 PM. - chloropromazine 50 mg on 8/9/24 at 1:52 PM. - diphenhydramine 50 mg on 8/2/24 at 4:52 PM. - quetiapine 100 mg on 8/2/24 at 12:58 PM Interview with EMP4 on 9/24/24 revealed there was no evidence of patient consent for these psychotropic medications in the MR or the HCS. These findings were confirmed with EMP4 on 9/24/24 at 10:37 AM.”

“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: 44819 Based on review of facility policies and medical records (MR), it was determined that for 1 of 7 patients (Patient #3) sampled, the facility failed to provide proper staff supervision as evidenced by missed safety observation checks. Findings include: Review of facility policy “Patient Observation” issued on 3/3/08 and revised 3/24 revealed, “To ensure patient safety ...observe each patient, a minimum within every 15 minutes ...Document patient location and behavior ...” Review of MR3’s “Ancillary Orders” dated 9/10/24 at 11:24 AM documented an order for every 15-minute level of observations. Review of MR3’s “Patient Observation Record” revealed no evidence patient was observed on 9/10/24 from 12:00 midnight to 11:30 AM for 47 missed safety checks. EMP12 confirmed this finding on 9/23/24 at 2:40 PM.”

“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: 47821 Based on medical record review (MR), policy review, and staff interview, it was determined that for 5 of 7 (Patient #2, #3, #4, #5, and #6) patients, the facility failed to ensure nursing staff followed facility policies as evidenced by failure to completed blood glucose checks as ordered, failure to report abnormal blood sugar readings to the physician/designee or licensed independent practitioner, and failure to sign medical record entries. Findings include: I. Blood sugar monitoring Review of facility policy “Diabetic Care” revised January 2019 and reviewed January 2024, revealed, “...Blood glucose levels will be tested at the frequency ordered by the physician...The level will be recorded in the patient’s medical record...” Review of facility job description “Registered Nurse” job code 650 revealed, “...Responsibilities...Performs treatments...as ordered by physician...” Review of MR6 medical record revealed: “Final Ancillary Orders (non-med)” dated 8/12/24 at 4:30 PM documented an order for blood glucose (sugar) monitoring before meals and at bedtime. “All Observations Recorded During the Stay” revealed no evidence of documentation of 12 out of 29 blood sugar monitoring scheduled from 8/12/24 to 8/19/24. EMP3 confirmed the finding on 9/23/24 at 1:36 PM. II. Nursing progress notes Review of facility policy “Medical Record Documentation Requirements” issued 12/96 revealed, “Documentation of patient care...Entries shall be dated, timed, and signed...” a. Review of MR2’s nursing progress notes revealed a typed note dated 9/7/24 at 6:00 PM and without a signature and a note dated 9/19/24 without a time or signature. EMP4 confirmed the finding on 9/23/24 at 3:25 PM. b. Review of MR3’s nursing progress notes revealed a typed note dated 9/19/24 without a time or signature. EMP4 confirmed this finding on 9/23/24 at 1:45 PM. c. Review of MR4’s nursing progress notes revealed a typed note dated 9/19/24 without a time or signature. EMP4 confirmed this finding on 9/24/24 at 10:30 AM. d. Review of MR5’s nursing progress notes revealed a typed note dated 9/19/24 without a time or signature. EMP4 confirmed this finding on 9/24/24 at 10:37 AM.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 45764 Based on medical record review, document review, and staff interview, it was determined that the facility failed to obtain informed consent from 1 out of 4 patients in the sample (Patient #1). Findings include: “Medication Administration for Nursing” policy: “ ...The MD ordering medications is responsible for obtaining the necessary consents prior to administration of the first dose of psychiatric medications, and for documenting such in the notes section of HCS or on the consent form. The nurse administering the first dose of new psychiatric medication must witness consents for patients and or guardians ...” Psychiatric Evaluation dated 11/17/2023 stated, “ ...Denies being on any current medications ...” Physician Medication Orders shows orders placed for the following psychotropic medications on 11/16/23: -divalproex sodium ERT oral 500 mg tablet twice a day (Depakote - a mood stabilizer) -olanzapine oral 10 mg tablet twice a day (Zyprexa - an antipsychotic) There was no evidence of a signed patient consent for psychotropic medications. In an interview with Employee #6 there was no evidence of consent in HCS [Electronic health system]. These findings were confirmed with Employee #6 on 12/1/23 at 10:45 AM.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 45764 Based on medical record review, policy review and staff interview, it was determined that for one (1) of two (2) (50%) restrained patients (Patient #4) in the sample, the restraint order failed to specify the information required by hospital policy. Findings include: The hospital policy titled “Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion” revised 8/2020 states, “The physician’s order for use of restraint or seclusion will be recorded in the medical record and include ... time limits not to exceed 4 hours for adults ...behavioral criteria for discontinuation of/release from physical restraint/seclusion ...staff shall assist the patient to meet the behavioral criteria for release ...use of restraint/seclusion shall be terminated as soon as criteria for release have been met.” Medical record review revealed: Patient #4 1. “Seclusion/Restraint Order” for date 2/1/23 is missing: a. “Date/Time of Intervention” b. “Criteria for Release” These findings were confirmed by Employee #6 on 12/1/23 at 11:05 AM.”

“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: 45764 Based on medical record review, policy review, and staff interview, it was determined that for two (2) of two (2) (100%) restrained or secluded patients in the sample (Patients #1 and #4), a restraint and/or seclusion intervention was utilized without a physician’s order. Findings include: The hospital policy titled “Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion” revised 3/2023 states, “...to support each patient’s right to be free from restraint ...and therefore limit the use of these interventions...requires an order from a physician...physician/LIP must be contacted for an order either during the emergency initiation of the restraint/seclusion or immediately (within a few minutes) after the restraint has been initiated...The physician shall authenticate the telephone/verbal order within 24 hours... A physician’s order is required for each separate restraint and seclusion episode that is not considered one continuous episode...’Trial releases’ ...are not allowed...If the patient is released from restraint...behaviors again become dangerous to themselves or others, a new order must be obtained...” Medical record review revealed: Patient #1: 1. “Seclusion/Restraint Order” for date 11/19/23 at 4:30 AM was blank for the “Practitioner’s Signature” and “Date/Time”[of signature] 2. “Seclusion/Restraint Order” for date 11/23/23 at 11:15 AM was blank for the “Practitioner’s Signature” and “Date/Time”[of signature] 3. “Seclusion/Restraint Order” for date 11/30/23 at 3:27 AM was blank for the “Practitioner’s Signature” and “Date/Time”[of signature] This finding was confirmed by Employee #6 on 12/1/23 at 11:05 AM. Medical record review revealed: Patient #4: 1. “Seclusion/Restraint Order” for seclusion dated 1/20/23 at 11:20 PM shows two (2) “Date/Time of Interventions” including: a. 1/20/23 at 11:20 PM b. 1/21/23 at 1:20 AM 2. “Seclusion/Restraint Order” for seclusion date 1/20/23 at 11:20 PM shows “Practitioner’s Signature” and “Date/Time” with one (1) signature and one (1) date: a. 1/23/23 at 11:20 PM This finding was confirmed by Employee #6 on 12/1/23 at 11:05 AM.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) Unless superseded by State law that is more restrictive-- (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1-hour for children under 9 years of age; This Standard is not met as evidenced by: 45764 Based on medical record review, policy review, and staff interview, it was determined that the physician’s orders for one (1) of two (2) (50%) restrained patients (Patient #4) in the sample, failed to include a time limit for restraint use. Findings include: The hospital policy titled “Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion” revised 8/2020 states, “The physician’s order for use of restraint/seclusion will be recorded in the medical record and include...Time limits...If the attending physician did not order the restraint/seclusion...must be consulted as soon as possible - in most cases within 4 hours, but no longer than 12 hours...” Patient #4 medical record review revealed: 1. “Seclusion/Restraint Order” for date 2/1/23 at 1350 is missing a time limit for restraint use a. “Duration of Order” was left blank by the physician. This finding was confirmed by Employee #6 on 12/1/23 at 11:05 AM.”

“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: 45764 Based on medical record review, staff interview, and review of hospital policy, the hospital failed to ensure patients placed in physical restraint were monitored for respiratory rate and/or circulation checks for one (1) of two (2) restrained patients (50%) in the sample (Patient #4). Findings include: The hospital policy titled “Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion”...revised 8/2020...states, “The patient shall be assessed...while in restraint/seclusion by trained staff...monitoring needs to take into consideration the patient’s condition... including...circulation...vital signs shall be taken upon initiation and as clinically indicated...” Patient #4 medical record review revealed: “Post Intervention Face to Face Evaluation” for restraint order 2/1/23 at 1350 missing vital signs. This finding was confirmed by Employee #6 on 12/1/23 at 11:05 AM.”

“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: 45764 Based on policy review, document review, and interview with staff, it was determined that for 14 out of 14 patients assigned to the Middle Unit, and 2 out of 4 patients sampled (Patients #1 and #4), the hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient. Findings include: I. Patient Observations Policy titled “Patient Observation Policy” revised 3/2023 stated “ ... Charge Nurse/Nursing Supervisor/Team Leader ...ensures the patient observation rounds are occurring as ordered, 24 hours per day, seven days a week with reviewing the rounding sheet every four hours and the sign, date, and time ...” During a unit tour of the Middle Unit on 11/30/23 between 11:08 AM and 11:20 AM, a review of patients forms titled “Patient Observation Record” revealed that charge nurse checks for the time frame between 04:00 AM and 08:00 AM on 11/20/23 were missing a charge nurse signature for all 14 patients on the unit. During an interview on 11/20/23 at 11:15 AM with Employee #3, this finding was confirmed. Medical record review for Patient #1 revealed: Patient Observation Records showed nursing supervision of observations was missing for the following dates and times: 11/19/23 from 8:00 PM - 12:00 AM (1 supervision) 11/20/23 from 8:00 AM - 12:00 AM (4 supervisions) 11/21/23 from 4:00 AM - 8:00 AM (1 supervision) 11/22/23 from 8:00 PM - 12:00 AM (1 supervision) 11/23/23 from 4:00 PM - 12:00 AM (2 supervisions) 11/25/23 from 8:00 AM - 4:00 PM (2 supervisions) 11/27/23 from 12:00 PM - 4:00 PM (1 supervision) 11/29/23 from 8:00 PM - 12:00 AM (1 supervision) The Patient Observation Record dated 11/30/23 was provided to surveyors after the discharge of Patient #1 on 11/30/23 at 2:54 PM. Observations were done from 12:00 AM - 11:00 AM. (no observations done from 11:00 AM - 2:54PM (15 observations). There was no nursing supervision signature for 4:00 AM - 8:00 AM and 12:00 PM - 4:00 PM. Upon chart review on 12/1/23 the Patient Observation Record for 11/30/23 was discovered to have observations recorded until 3:00 PM. There was a signature for nursing supervision of observations from 12:00 PM - 4:00 PM that is timed for 12:15PM. In an interview with Employee #6 on 12/1/23 that the record appeared to be backfilled and that there was no procedure or documentation that would explain the discrepancy. The employees who documented the added observations were unavailable for interview. These findings were confirmed with Employee #6 on 12/1/23 at 11:27AM. Patient #4 medical record review revealed: Patient Observation Records showed nursing supervision of observations was missing for the following dates and times: 1/18/23 from 12:00 AM - 8:00 AM; 9:00 PM -12:00 PM (3 supervisions) 1/19/23 from 4:00 PM - 12:00 PM (2 supervisions) 1/20/23 from 12:00 PM - 4:00 PM (1 supervision) 1/23/23 from 12:00 PM - 4:00 PM (1 supervision) 1/27/23 from 4:00 PM - 12:00 AM (2 supervisions) 1/29/23 from 4:00 AM - 12:00 AM (2 supervisions) 1/30/23 from 9:00 PM - 12:00 PM (1 supervision) 2/21/23 from 12:00 AM - 8:00 AM (2 supervisions) This finding was confirmed by Employee #6 on 12/1/23 at 11:05 AM. II. Vital Signs The hospital policy titled “Medical Record Documentation Requirements” issued 12/1996 states, “Documentation of patient care must be performed to communicate the treatment provided and its results. This documentation is to be timely...complete...” Patient #1 medical record review revealed: Orders placed on 11/16/23 at 8:33 AM for vital signs to be done twice a day for 3 days. Orders placed on 11/16/23 at 8:33 AM for vital signs to be done daily after 3 days. In an interview with Employee #6 on 12/1/23 at 11:45 AM it was verified that after taking vital signs twice a day on 11/16/23, 11/17/23, and 11/18/23 that vital signs would be done daily, per orders. Vital signs were done once on 11/16/23 (missing 1 set). Vital signs were done once on 11/18/23 (missing 1 set). Vital signs were not done on 11/21/23 (missing 1 set) These findings were confirmed with Employee #6 on 12/1/23 at 11:45 AM. Patient #4 medical record review revealed: Orders placed on 1/18/23 at 5:00 PM for vital signs to be done twice a day for 3 days. Vital signs were done once on 1/19/23 (missing 1 set). Vital signs were done once on 1/21/23 (missing 1 set). This finding was confirmed by Employee #6 on 12/1/23 at 11:05 AM.”

“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: 48349 Based on policy review, patient chart review, and interview with staff, it was determined that for 1 out of 1 patient (Patient #3) on increased level of observation in the sample, the hospital failed to ensure that all licensed nurses who provide services in the hospital adhered to the policies and procedures of the hospital. Findings include: Agency policy titled “Special Precautions and Patient Level of Observation” reviewed 2/2023 stated, “ ...A progress note entry by nursing staff should be documented in the medical record at least every hour, reflecting the patient’s behavior, condition, mood and conversation. There must be a progress note entry by an RN every four (4) hours ...” Review of patient record revealed: Patient #3 “Final Ancillary Orders” indicated an order for “Level of Observation One on One While Awake” with a start date and time of 2/6/23 at 2:57 PM was placed by provider. “Nursing Progress Note” dated 2/06/23 at 01:00 AM stated, “Pt [Patient] is constantly agitated, trying to go into other patient’s rooms, pulling down notices, constantly pulling on the glass panes of the nursing station...” “Psychiatrist Treatment Planning Progress Note” dated and timed 2/6/23 at 10:15 AM indicated that patient attitude was uncooperative and agitated. Note stated, “ pt ... withdrawn...agitated, needed PRN med and frequent redirection...will need 1:1 ...” “Psychiatrist Treatment Planning Progress Note” dated and timed 2/7/23 at 11:00 AM indicated that patients attitude was cooperative. Note stated, “ ...D/C 1:1 level of observation ...” “Patient observation records” dated 12/6/23 and 12/7/23 indicated that Patient #3 was awake from 3:00 PM to 11:00 PM on 12/6/23 and from 7:00 AM to 11:00AM on 12/7/23 (patient was awake for 12 hours during the time the 1:1 level of observation order was active). “Nursing progress note” form dated 2/6/23 contained 1 hourly RS (Recovery Specialist) note (out of the required 12), and 0 RN progress notes (out of the required 3). “Daily Nurse Progress Note” dated 12/6/23 indicated that no nursing assessment was completed for the 7:00 PM to 07:00 AM shift. During an interview on 12/01/23 between 10:45 AM and 11:05 AM with Employee #6, this finding was confirmed.”