Wellstar Mcg Health, Affiliated With Med Col

“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: 47718 Based on the review of medical records, the facility’s policy/procedures, incident reports and staff interviews, it was determined that facility staff failed to ensure that an allegation of sexual abuse made by one patient (P) (P1) of three patients (P1, P2, and P3) reviewed was identified, documented, and processed per the facility’s grievance policy and procedures when it was determined that P1 had reported an allegation of sexual assault while hospitalized and facility staff failed to escalate the allegation due to P1’s mental status. Findings included: A review of the nursing flowsheets dated 06/10/2026 [LO1.1]at 1230 revealed that P1 was oriented to situation, time, and person, but disoriented to place. A review of the physician orders revealed a face-to-face sitter order on 06/11/2026 at 11:27 P.M. A continued review of the nursing notes on 06/13/2026 at 06:08 P.M. revealed that the medical doctor (MD) was made aware that P1 was confused and that P1 hit the sitter at bedside when P1 was being assisted to the bathroom. P1 claimed that the staff tried to give her poison and tried to kill her. A review of the physician’s progress notes on 06/14/2026 at 01:05 PM revealed that P1 had to have sitters due to sundowning/agitation (a pattern of confusion that spikes in the late afternoon or evening). A continued review of the physician’s progress notes on 06/15/2026 at 12:35 PM revealed that P1’s neurological examination and agitation had improved. A review of the care coordination notes on 06/15/26 at 05:22 PM revealed that P1 was approved for a Rehabilitation facility but was placed on hold because P1 required a sitter. Documentation revealed that P1 would have to be without any form of restraints/sitters for 24 hours in order to be discharged to the Rehabilitation facility. A continued review of the nursing flowsheets on 06/15/2026 at 08:00 P.M. revealed that P1 had impaired judgment, impaired safety awareness, and was disoriented to place. A continued review of the nursing flowsheets on 06/16/2026 at 08:00 A.M. revealed that P1 was oriented to person and situation and also followed commands. A continued review of the physician’s progress notes on 06/16/2026 at 02:14 P.M. revealed that P1 was pending bed availability at the Rehabilitation facility, and P1’s sitter was discharged earlier in the morning, as the Rehabilitation facility could only accept P1 when the sitter had been discharged 24 hours prior to discharge. A continued review of the nursing flowsheets on 06/17/2026 at 08:00 A.M. revealed that P1 was oriented to person, place, and situation. A review of the physician’s discharge summary on 06/17/2026 at 01:00 P.M. revealed that P1 was discharged in good condition to a rehabilitation facility. A review of P1’s medical record failed to reveal documentation that an allegation of sexual assault was made by P1. A review of the facility’s policy titled “Event Reporting,” policy #EC-60-01, published 07/09/2024, revealed that the purpose of the policy was to establish a mechanism and define responsibilities for reporting, investigating, studying, analyzing, and following-up on potential and actual safety events; to define a process for the identification, evaluation, trending, and reporting of patient safety event data to improve health care processes and aid in the mitigation and reduction of patient safety events. The facility believes that potential and actual safety events are often the result of latent and hidden causes within its systems and processes of care and are not usually the result of misconduct, inattention, or lack of skill. Events should be analyzed and trended in order to identify areas of focus and to uncover and correct latent issues in the systems of care. A review of the facility’s policy titled “Patient Rights and Responsibilities” policy #RI-01-01, published 07/15/2025, revealed that the facility is committed to providing safe, quality medical care to every patient. It is the policy of the facility to respect the individuality and dignity of every patient. Patients have the right to receive care in a safe environment while maintaining personal privacy, and to express concerns or grievances orally or in writing without fear of reprisal. A review of the facility’s policy titled “Mandatory Reporting of Child Abuse, NAS, Elder or Disabled Adult Abuse and Human Trafficking,” policy #6086-WMCG, last revised 12/08/2023, revealed that all healthcare providers are responsible for recognizing and reporting the signs of possible abuse and following guidelines for reporting any suspicion of possible abuse as outlined herein, including any mandated reporting that may be required by law. Any person required by Georgia law to report a suspected case of child abuse (e.g., physicians, nurses, psychologists, licensed professional counselors, among others) who knowingly and willfully fails to do so will be guilty of a misdemeanor. Disciplinary action will also result if a healthcare provider knowingly fails to report. A review of the SaFER (incident) report on the RCA documentation related to P1’s allegations revealed that on 06/16/2026 at: - 07:57 A.M., P1 was alert and oriented x3, but had intermittent confusion. - 08:33 A.M., the face-to-face sitter was discontinued, and at 11:30 A.M., the face-to-face sitter left the unit as per the staffing sheet. - 02:58 P.M., P1 was seen at the bedside for a speech and language treatment session; no family present, and P1 had asked the speech and language therapist (SLT) why she had come to her room and asked if the SLT knew that someone named “Chris” had sexually assaulted her twice since she was admitted. Documentation revealed that the SLT reported P1’s allegation to CN EE. P1 also agreed to sign the cognitive-linguistic assessment (an assessment to check how the brain processes language), and reported she was not crazy. Documentation also revealed that P1 was able to recall the reason for hospitalization but continued with poor insight regarding deficits. An interview was conducted in the facility’s board room on 06/30/2026 at 9:30 AM with Risk Manager (RM) AA, who stated that another facility had called her to report that P1 had indicated she had been sexually assaulted when she was admitted at this facility; however, P1 could not identify or describe the person who had sexually assaulted her. RM AA continued to state that she immediately initiated an investigation following the receipt of the allegation and interviewed the nurses and the sitters who had been involved in P1’s care, and the staff had described P1 to be alert and oriented at times, but intermittently disoriented. RM AA continued to state that during her investigation, she found out that P1 had reported to one of the staff members that someone by the name “Chris” had assaulted her, but she (RM AA) could not substantiate the allegation, as there was no evidence that the allegation occurred. An interview was conducted in the facility’s boardroom on 06/30/26 at 11:00 AM with Charge Nurse (CN) EE, who stated that PCT JJ had yelled for help, and she (CN EE) and CN II had gone into P1’s room to see what was going on. CN EE stated that while in P1’s room, P1 had complained that she did not want “Chris” back in the room. CN EE continued to state that P1 had complained she smelled so bad but refused to have a shower as she complained someone had bothered her inappropriately and did not want any other staff member to touch her. CN EE continued to state that she told CN II, who also happened to be P1’s primary nurse, to take care of the situation, and she had expected that CN II would escalate P1’s allegations to the risk manager as per the facility’s protocol. CN EE further stated that CN II never came back to her, and she assumed CN II had taken care of the situation. An interview was conducted in the facility’s boardroom on 06/30/2026 at 12:00 PM with PCT JJ, who stated that P1 had a sitter, but the sitter was discontinued a day prior to discharge. PCT JJ stated that when she entered P1’s room, it appeared that P1 was upset because she wanted assistance with washing but did not want any staff member to touch her because she stated two male staff members had touched her inappropriately. PCT JJ stated that she immediately reported the allegations to P1’s primary nurse (CN II). PCT JJ continued to state that during a subsequent interaction with P1, P1 had repeated the same allegation, and she (PCT JJ) had to notify the Charge nurse (CN EE), and both CN EE and CN II had gone to P1’s room, but she (PCT JJ) was not aware of what was discussed as she had to leave the room to get wipes. A telephone interview was conducted in the facility’s boardroom on 06/30/2026 at 01:00 PM with CN II, who stated that she recalled she got a shift report where she had been informed to use caution because P1 had alleged that multiple staff members had touched her inappropriately. CN II continued to state that during a shift, PCT JJ had informed her that P1 made allegations of inappropriate touching. CN II stated that she went to P1’s room, accompanied by CN EE, and when they got into the room, P1 made complaints that she needed a wash, but did not want any staff members to touch her because she had been molested by some staff members. CN II further stated that she was not aware she needed to inform risk management because of P1’s clinical history of disorientation. An interview was conducted in the facility’s boardroom on 06/30/2026 at 04:00 PM with Vice President, Quality, who stated that the facility completed a Root Cause Analysis (RCA) regarding the allegations during the course of the internal investigation. VPQ KK stated that it was not a case of the staff not knowing what to report, but because of P1’s clinical condition. VPQ KK continued to state that the facility monitored all patients’ complaints and implemented education to increase staff awareness of reporting responsibilities. VPQ KK stated that moving forward, all staff are being trained to report any and all allegations or concerns, regardless of whether a patient was confused or cognitively impaired, and staff had been instructed not to make independent clinical determinations regarding the validity of a patient’s allegation. A telephone interview was conducted on 07/02/2026 at 02:30 PM with Speech and Language Therapist (SLT) LL, who stated that during her second encounter with P1 to conduct a further evaluation on language and cognition, P1 was speaking in full basic conversations with some confusion, but her language construction was intact. SLT LL stated that during the conversation, P1 had mentioned that she was sexually assaulted by someone named Chris. SLT LL continued to state that she immediately reported P1’s allegation to the charge nurse (CN EE). SLT LL further stated that in hindsight, she should have completed a SaFER (incident) report and informed the social worker in addition to reporting to the charge nurse.”

“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: 42305 Based on review of facility policy and procedures, medical records , and staff interviews, it was determined that the facility failed to ensure effective pain management measures were taken for four (P#1, P#2, P#3, and P#4) of four sampled patients. Specifically, nursing staff failed to: 1. Reassess pain after giving pain medications to determine if the medications were effective. 2. Failed to notify the provider when pain remained uncontrolled. 3. Failed to intervene when pain levels remained high enough to prevent therapy. 4. Failed to document alleviating factors or non-pharmacological techniques for pain relief. Findings included: Cross Reference to A-0144 as it relates to failure to provide care in a safe setting, Cross Reference A-0395 as it relates to nursing staff’s failure to evaluate and reassess pain after interventions.”

“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: 42305 Based on facility policy, medical record review, and staff interviews, the hospital failed to ensure patients received care in a safe setting for four Patient (P) (P#1, P#2, P#3, P#) of four patient records reviewed when patients reported severe pain over multiple shifts with minimal or no improvement after interventions. Follow up pain assessments were not documented and providers were not notified when interventions were ineffective as required by facility policies. Review of the facility’s policy titled, “Patients’ Rights and Responsibilities,” #RI-01-01, revised 11/1/22, revealed that patients had the right to request and receive medically appropriate treatment and services within the site’s capacity and capabilities. Patients had the right to care in a safe environment while maintaining their personal dignity. Review of the facility’s policy titled “Pain Assessment and Reassessment” RI-60-01, revised 5/10/22, revealed that it was the hospital’s policy to manage patient pain in collaboration with the patient and family. Pain would be assessed upon entry into the system, which included Emergency Room, Observation, Inpatient Admission, and Pre-procedure. A plan would be established for pain management to meet the patient’s stated goal. Interventions would be implemented according to the physician’s order or within the scope of practice; for example: medications and non-pharmacological therapies. Examples of alternative therapies included positioning, massage, heat/cold, music, distraction, etc. Pain would be reassessed at a minimum of one hour of an intervention, within one hour of patient refusal of intervention, minimum of each shift of patient care, following a procedure, and upon discharge. The physician would be notified when prescribed interventions did not achieve the patient’s stated pain goal. Pain assessment included intensity or pain score. Pain assessment/reassessment would be documented using approved tools. Review of an Operation Note (Op Note) by the Medical Doctor (AA) on 8/26/25 at 7:37 p.m. revealed that P#1 underwent a laminectomy for complaints of back and leg pain. The post-op plan was to admit P#1 to the hospital for antibiotics and pain control. P#1 would be discharged once stable for physical therapy and pain was well-controlled. A physician’s order for oxycodone included instructions to assess pain before and after administering the medication . Review of the Care Plan on 8/27/25 at 12:08 p.m. revealed that the problem identified was pain. Interventions included monitoring pain, assessing pain with the pain scale, administering analgesics as ordered based on the type and severity of pain, and evaluating response within the approved timeframe. Non-pharmacological measures would be implemented as appropriate and response evaluated. The provider would be notified if interventions were unsuccessful or the patient reported new pain. Review of Occupational Therapist (OT) KK’s Clinical Impression on 8/27/25 at 12:09 p.m. revealed that P#1 had pain that significantly impacted mobility, activity tolerance, and participation in activities of daily living. Review of a consult note by Physical Therapist (PT) BB on 8/27/25 at 1:35 p.m. revealed that P#1 exhibited decreased activity tolerance due to pain and fatigue. Functional mobility was severely limited by pain. Review of Physical Therapist (PT)’s Clinical Impression on 8/27/25 at 3:32 p.m. revealed that P#1 exhibited decreased activity tolerance due to pain and fatigue. P#1 required minimal assistance overall for functional mobility but was severely limited by pain. A review of the “Pain Assessment” flow sheet for a sample of 12 pain intervention encounters for P#1 revealed: P#1 reported moderate (scale 4-6) pain after pain interventions for 5 of 12 sampled interventions. P#1 reported severe (scale 7-10) pain after pain interventions for 1 of 12 sampled interventions. Documentation failed to reveal post intervention assessments for 3 of 12 sampled interventions Documentation failed to reveal additional interventions, provider notifications or additional pain assessments for 9 of 12 sampled interventions, all which revealed a post intervention pain score of moderate to severe. Patient #2 was admitted to the hospital 10/14/25 and had an open reduction (surgical repair) of a spinal fracture on 10/17/25 at 11:45 a.m. A review of the ‘Pain Assessment’ flow sheets revealed that P#2 reported moderate (scale 4-6) post intervention pain for 1 of 6 sampled pain interventions. P#2 reported severe post intervention pain (scale 7-10) for 4 of 6 sampled pain interventions. There were no post intervention assessments for 1 of 6 sampled pain interventions with a reported pain scale of 8/10. There were no additional assessments, interventions, or physician notifications documented for 6 of 6 samples pain interventions where the pain was reported to be moderate to severe. Patient (P) 3 was admitted to the hospital on 10/28/25 at 10:03 a.m. A laminectomy was performed on 10/28/25 at 3:46 p.m. Review of the ‘Pain Assessment’ flow sheets revealed that P#3 reported severe post intervention pain (scale 7-10) for 5 of 6 sampled pain interventions. There were no post intervention assessments for 1 of 6 sampled with a reported pain scale of 8/10. There were no additional assessments, interventions, or physician notifications documented for 5 of 6 samples where the pain was reported to be severe. Patient (P) 4 was admitted to the hospital on 9/14/25 at 5:13 p.m. after a hip dislocation caused by a motor vehicle collision. P#4 had a closed reduction (bone reset without surgery) on 9/14/25. P#4 was admitted for pain control and to work with physical and occupational therapy. Review of the ‘Pain Assessment’ flow sheets revealed that P#4 reported moderate (scale 4-6) post intervention pain scores for 3 of 7 sampled pain interventions. P#1 reported severe post intervention pain (scale 7-10) for 2 of 7 sampled pain interventions. There were no post intervention assessments for 2 of 7 sampled pain interventions with a reported pain scale of 8/10 and 9/10. There were no additional assessments, interventions, or physician notifications documented for 6 of 7 samples where the pain was reported to be moderate to severe. An interview took place with Patient Advocate (PA) NN, on 12/1/25 at 1:49 p.m. in the Workroom. PA NN said P#1’s family member reported that P#1 should not be discharged. P#1 had too much pain to walk. An interview took place with the Nurse Manager (NM) QQ on 12/2/25 at 2:39 p.m. NM QQ remembered a complaint where P#1 was not getting pain medication. NM QQ went to see the patient and family member on the second day of admission. By this time, the pain had been managed. NM QQ said the nurses would ask patients how they were feeling. If the patient said the pain had decreased to something like a six, the staff would offer something additional to help with pain. Refusal of additional pain medication was not usually documented. If the medication was not adequate, additional pain medication could be given according to the doctor’s order. Doctors could be contacted for additional orders. An interview took place with Registered Nurse (RN) LL on 12/3/25 at 9:34 a.m. RN LL said she had given P#1 pain medication and P#1 said patients would be rechecked around 30 minutes after receiving pain medication. If a patient only got down to a scale of 6, RN LL would ask if 6 was okay. If not, RN LL would try to escalate to the breakthrough pain medication if the patient was not comfortable at 6. RN LL said P#1 was in too much pain to get up and walk. P#1 and a family member said PT had tried to get him up, and P#1 could not stand it. RN LL did not recall speaking to the doctor that night. An interview took place with Occupational Therapist (OT) KK on 12/3/25 at 2:19 p.m. in the Workroom. OT KK said sometimes patients could not participate in OT because of pain. If a patient could not participate, OT would check back later to see if the pain was manageable. OT’s role was to communicate with the care team if the medications were not working. An interview took place with Physical Therapist (PT) BB on 12/3/25 at 2:25 p.m. in the Workroom. PT BB said if pain was uncontrolled and severe to the point where PT could not do anything, PT would reach out to the doctor. PT reported that they could not do therapy because the pain was out of control. If patients complained that medications were needed more frequently, the complaints would be communicated to the nurses or providers. Sometimes a different medication may be needed instead of an increased dosage. An interview took place with Licensed Practical Nurse (LPN) TT on 12/3/25 at 2:33 p.m. in the Workroom. LPN TT said P#1’s family member was his advocate and was very adamant about managing P#1’s pain. The family members felt the hospital could have done more for pain. P#1 did not feel like doing PT. A telephone interview took place with the Medical Doctor (MD) AA on 12/5/25 at 8:12 a.m. MD AA said the nursing staff were expected to notify MD AA whenever pain remained above the expected range or if interventions were not effective. MD AA also stated that sometimes nursing staff became busy and fell behind with pain medication timing, but MD AA expected the nurses to contact him if the pain was not controlled so that MD AA could adjust the treatment plan.”

“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: 42305 Based on review of facility policy and procedures, medical records , and staff interviews, it was determined that the facility failed to ensure that nursing staff effectively evaluate pain interventions for four (P#1, P#2, P#3, and P#4) of four patients reviewed when post intervention assessments failed to reveal additional interventions, provider notifications or additional assessments. Findings included: Review of the facility’s policy titled “Pain Assessment and Reassessment” RI-60-01, revised 5/10/22, revealed that it was the hospital’s policy to manage patient pain in collaboration with the patient and family. Pain was whatever the person experiencing said it was, existing whenever the person said it did. The patient’s self-report of pain was the primary source of assessment. Continued review of the policy revealed that comprehensive assessments included onset/duration, location, intensity, quality, aggravating factors, alleviating factors, pain goal, previous experiences with pain, and prior methods of pain management. A plan would be established for pain management to meet the patient’s stated goal. Interventions would be implemented according to the physician’s order or within the scope of practice. Examples of alternative therapies included positioning, massage, heat/cold, music, distraction, etc. Pain would be reassessed at a minimum of one hour of an intervention, within one hour of patient refusal of intervention, minimum of each shift of patient care, following a procedure, and upon discharge. The physician would be notified when prescribed interventions did not achieve the patient’s stated pain goal. Pain assessment included intensity or pain score. Pain assessment/reassessment would be documented using approved tools. Review of the facility’s policy titled “Medication Administration Policy” 920-WMCG, reviewed 9/23/24, revealed that education and training regarding medication administration was included in hospital orientation or other continuing education for nursing staff. Education included safe handling and preparation of medication, specific drug information, and techniques required for administration. Medications could only be administered with a legal medical order. Scheduled medications were administered as close to the scheduled time as possible. All documentation occurred on the medication administration record or appropriate procedural flowsheet. The patient’s response to medications would be monitored according to the clinical needs of the patient. Documentation of additional data would be included in the administrative documentation. This included the pain score. Review of pre-operative History and Physical (H&P) on 7/31/25 at 9:30 a.m. by Physician Assistant (PA) MM revealed that Patient (P) 1 had complaints of lower back pain with severe leg pain and cramping. Review of an Operation Note (Op Note) by the Medical Doctor (AA) on 8/26/25 at 7:37 p.m. revealed that P#1 underwent a laminectomy. The post-op plan was to admit P#1 to the hospital for IV antibiotics and pain control. P#1 would be discharged once stable for physical therapy and pain was well-controlled. Review of a Nursing Note by Registered Nurse (RN) LL on 8/27/25 at 3:21 a.m. revealed that P#1 was received from the PACU (recovery unit) around 10:30 p.m. P#1 complained of nerve pain radiating down both legs. The Medical Doctor (MD) was notified. As-needed pain medications were administered. Continued review of “Nursing notes” failed to reveal further notes regarding pain, notification of the MD, or administration of additional pain medications. A physician’s order for Oxycodone (narcotic used for pain, given by mouth) included instructions to assess pain before and after administering the medication. Review of the Care Plan on 8/27/25 at 12:08 p.m. revealed that the problem identified was pain. Interventions included monitoring pain, assessing pain with the pain scale, administering analgesics as ordered based on the type and severity of pain, and evaluating response within the approved timeframe. Non-pharmacological measures would be implemented as appropriate and response evaluated. The provider would be notified if interventions were unsuccessful or the patient reported new pain. Review of Occupational Therapist (OT) KK’s Clinical Impression on 8/27/25 at 12:09 p.m. revealed that P#1 had pain that significantly impacted mobility, activity tolerance, and participation in activities of daily living. Review of a consult note by Physical Therapist (PT) BB on 8/27/25 at 1:35 p.m. revealed that P#1 exhibited decreased activity tolerance due to pain and fatigue. Functional mobility was severely limited by pain. P#1 initially stated that he was in too much pain to participate in PT, but after education, P#1 agreed to participate as able. Review of Physical Therapist (PT)’s Clinical Impression on 8/27/25 at 3:32 p.m. revealed that P#1 exhibited decreased activity tolerance due to pain and fatigue. P#1 required minimal assistance overall for functional mobility but was severely limited by pain. P#1 agreed to participate as able. Review of a consult by Physical Therapist (PT) CC on 8/28/25 at 10:57 p.m. revealed that P#1 completed all mobility despite reported 9/10 back pain and was able to ambulate further than a previous session. A review ‘Medication Administration’ records, ‘Alleviating Factors’ flowsheets, nursing notes, and the ‘Numeric Pain Intensity Scale’ flowsheets revealed the following pain intervention samples for P#1: 1) 8/27/25 1:14 a.m. - pain score: 9 (scale used to assess pain with 0 being no pain and 10 being the worst pain), intervention: Oxycodone 5 mg, reassessment 1:51 a.m.:pain score 9. Alleviating factors -1:58 a.m.: medication, decreased movement, positioning. No further assessment or physician notification documented. 2) 8/27/25 6:53 p.m. - pain score: 8, intervention: Oxycodone 10 mg, reassessment: 7:14 a.m. -pain score: 5. No further assessment, alleviating factors, or physician notification documented. 3) 8/27/25 8:27 p.m. - pain score: 8, interventions: Morphine (narcotic given for severe pain) injection 2mg/ml, Lyrica (medication used for nerve pain) 25 mg, Robaxin (muscle relaxant) 1500 mg. Reassessed 8:57 p.m. - pain score: 6. No further assessment, alleviating factors, or physician notification documented. 4) 8/27/25 10:47 p.m. - pain score: 7, reassessed 11:17 p.m. - resting quietly, pain score: 2. 5) 8/28/25 12:58 a.m. - pain score: 8, intervention: Morphine 2mg/ml injection. No further assessment, alleviating factors, or physician notification observed. 6) 8/28/25 3:35 a.m. - pain score: 9, intervention: Oxycodone 10mg, reassessment 4:29 a.m.- pain score: 6. No further assessment, alleviating factors, or physician notification observed. 7) 8/28/25 5:39 a.m. - pain score: 8, intervention: Robaxin 1500 mg, reassessment 6:10 a.m. - pain score faces: 2, resting quietly. 8) 8/28/25 9:37 a.m. - pain score: 9, interventions: Morphine 2mg/ml injection, Oxycodone 10mg, Lyrica 25mg, reassessment 10:10 a.m. -at pain goal, faces: zero, no hurt, resting quietly. 9) 8/28/25 8:25 p.m. - pain score: 7, intervention: Oxycodone 10 mg, Lyrica 25mg, reassessment 8:55 p.m. - pain score: 6. No further assessment, alleviating factors, or physician notification documented. 10) 8/29/25 10:10 a.m. - pain score: 8, interventions: Morphine 2mg/ml injection, Lyrica 25mg. No further assessment, alleviating factors, or physician notification documented. 11) 8/29/25 11:48 a.m. - pain score: 9, intervention: Oxycodone 10mg, reassessment 12:41 p.m. - pain score: 4. No further assessment, alleviating factors, or physician notification documented. 12) 8/29/25 3:21 p.m. - pain score: 8, intervention: Oxycodone 10mg. No further assessment, alleviating factors, or physician notification documented. Review of the “Pain Assessment” flow sheets revealed that P#1 reported moderate (scale 4-6) post intervention pain for 5 of 12 sampled interventions. P#1 reported severe post intervention pain (scale 7-10) for 1 of 12 sampled. There were no post intervention assessments for 3 of 12 sampled with a reported pain scale of 8/10 for all three. There were no additional assessments, interventions, or physician notifications observed for 9 out of 12 samples where the pain was reported to be moderate to severe. Review of the “Discharge Summary” by MD JJ on 8/29/25 at 7:37 p.m. revealed that P#1 was discharged at 7:37 p.m. in good condition. Patient #2 was admitted to the hospital 10/14/25 and had an open reduction (surgical repair) of a spinal fracture on 10/17/25 at 11:45 a.m. A review ‘Medication Administration’ records, ‘Alleviating Factors’ flowsheets, nursing notes, and the ‘Numeric Pain Intensity Scale’ flowsheets revealed the following samples of pain management interventions for P#2: 1) 10/17/25 9:02 p.m. - pain score: 8, intervention: Toradol 30 mg, Oxycodone 10mg, reassessment 9:36 p.m. - pain score: 8. No further assessment, alleviating factors, or physician notification documented. 2) 10/18/25 4:36 a.m. - pain score: 9, intervention: Oxycodone 10 mg, reassessment 5:22 a.m. - pain score: 8, intervention: Toradol. No further assessment, alleviating factors, or physician notification observed. 3) 10/18/25 9:40 a.m. - pain score: 8, intervention: Oxycodone 10 mg, reassessment (no time noted) - pain score: 6. No further assessment, alleviating factors, or physician notification observed. 4) 10/19/25 5:51 a.m. - pain score: 8, intervention: Toradol. No further assessment, alleviating factors, or physician notification observed. 5) 10/19/25 9:41 a.m. - pain score: 8, intervention Oxycodone 10 mg, reassessment (no time noted) pain score 8. No further assessment, alleviating factors, or physician notification observed. 6) 10/19/25 2:35 p.m. - pain score: 10, intervention Oxycodone 10 mg, reassessment 3:08 p.m. - pain score: 7. No further assessment, alleviating factors, or physician notification observed. A review of the ‘Pain Assessment’ flow sheets revealed that P#2 reported moderate (scale 4-6) post intervention pain for 1 of 6 sampled pain interventions. P#2 reported severe post intervention pain (scale 7-10) for 4 of 6 sampled pain interventions. There were no post intervention assessments for 1 of 6 sampled pain interventions with a reported pain scale of 8/10. There were no additional assessments, interventions, or physician notifications documented for 6 of 6 samples pain interventions where the pain was reported to be moderate to severe. Patient (P) 3 was admitted to the hospital on 10/28/25 at 10:03 a.m. A laminectomy was performed on 10/28/25 at 3:46 p.m. A review ‘Medication Administration’ records, ‘Alleviating Factors’ flowsheets, nursing notes, and the ’ Numeric Pain Intensity Scale’ flowsheets revealed the following samples of pain management for P#3: 1) 10/28/25 8:52 p.m. - pain score: 9, intervention: Oxycodone 5mg, reassessment 9:12 p.m. - pain score: 8. No documentation of further assessment, alleviating factors, or physician notification observed. 2) 10/29/25 12:34 a.m. - pain score: 10, intervention: Morphine 2mg, reassessment 1:04 a.m. - pain score: 8. No documentation of further assessment, alleviating factors, or physician notification observed. 3) 10/19/25 3:42 a.m. - pain score: 10, intervention: Morphine 2mg, reassessment 4:12 a.m. - pain score: 8. No documentation of further assessment, alleviating factors, or physician notification observed. 4) 10/19/25 6:24 a.m. - pain score: 10, intervention: Oxycodone 5mg, reassessment 6:54 a.m. - pain score: 8. No documentation of further assessment, alleviating factors, or physician notification observed. 5) 10/19/25 7:49 a.m. - pain score: 10, intervention: Morphine 2mg, reassessment 8:19 a.m. - pain score: 3. 6) 10/29/25 10:44 a.m. - pain score: 8, intervention: Oxycodone 5mg. No documentation of further assessment, alleviating factors, or physician notification observed. Review of the ‘Pain Assessment’ flow sheets revealed that P#3 reported severe post intervention pain (scale 7-10) for 5 of 6 sampled pain interventions. There were no post intervention assessments for 1 of 6 sampled with a reported pain scale of 8/10. There were no additional assessments, interventions, or physician notifications documented for 5 of 6 samples where the pain was reported to be severe. Patient (P) 4 was admitted to the hospital on 9/14/25 at 5:13 p.m. after a hip dislocation caused by a motor vehicle collision. P#4 had a closed reduction (bone reset without surgery) on 9/14/25. P#4 was admitted for pain control and to work with physical and occupational therapy. A review ‘Medication Administration’ records, ‘Alleviating Factors’ flowsheets, nursing notes, and the ’ Numeric Pain Intensity Scale’ flowsheets revealed the following samples of pain management for P#4: 1) 9/14/25 11:42 p.m. - pain score: 7, intervention: Oxycodone 5mg, reassessment 9/15/25 12:12 a.m. - pain score: 4. No documentation of further assessment, alleviating factors, or physician notification observed. 2) 9/15/25 4:28 a.m. - pain score: 8, intervention: Oxycodone 5mg, reassessment 4:58 a.m. - pain score: 8. No documentation of further assessment, alleviating factors, or physician notification observed. 3) 9/15/25 12:22 p.m. - pain score: 10, interventions: Toradol, Ultram. No documentation of further assessment, alleviating factors, or physician notification observed. 4) 9/17/25 11:08 a.m. - pain score: 9, intervention: Oxycodone 10mg, reassessment 11:38 a.m. - pain score: 5. No documentation of further assessment, alleviating factors, or physician notification observed. 5) 9/18/25 2:38 a.m. - pain score 8, intervention: Oxycodone 10mg, reassessment 3:09 a.m.- pain score: 4. No documentation of further assessment, alleviating factors, or physician notification observed. 6) 9/18/25 9:08 a.m. - pain score: 8, no interventions, reassessment 9:22 a.m. - pain scale: 8, interventions: Ultram, Toradol, Oxycodone 10mg. No documentation of further assessment, alleviating factors, or physician notification observed. 7) 9/18/25 2:41 p.m. - pain score: 9, intervention: Oxycodone 5mg. No documentation of further assessment, alleviating factors, or physician notification observed. Review of the ‘Pain Assessment’ flow sheets revealed that P#4 reported moderate (scale 4-6) post intervention pain scores for 3 of 7 sampled pain interventions. P#1 reported severe post intervention pain (scale 7-10) for 2 of 7 sampled pain interventions. There were no post intervention assessments for 2 of 7 sampled pain interventions with a reported pain scale of 8/10 and 9/10. There were no additional assessments, interventions, or physician notifications documented for 6 of 7 samples where the pain was reported to be moderate to severe. An interview took place with Patient Advocate (PA) NN, on 12/1/25 at 1:49 p.m. in the Workroom. P#1’s family member called in a complaint to the hospital system that was assigned to PA NN. The family member asked PA NN to meet in the room with P#1. P#1 said pain management had gotten good, but P#1 had not been able to walk a lot. A family said P#1 should not be discharged. P#1 had too much pain to walk and felt that he was behind. An interview took place with the Nurse Manager (NM) QQ on 12/2/25 at 2:39 p.m. NM QQ remembered a complaint where P#1 was not getting pain medication. NM QQ went to see the patient and family member on the second day of admission. NM QQ said the nurses would ask patients how they were feeling. If the patient said the pain had decreased to something like a six, the staff would offer something additional to help with pain. The staff may have waited to see if the medication given would continue to work. It was up to the patient if they wanted something else. The nurses could put the pain scale at six then add a comment. Refusal of additional pain medication was not usually documented. If the medication was not adequate, doctors could be contacted for additional orders. NM QQ further said that if a patient could not participate in PT because of pain, the expectation would be to contact the doctor to see what additional medication could be gotten to relieve pain. An interview took place with Registered Nurse (RN) LL on 12/3/25 at 9:34 a.m. RN LL said oxycodone 10 was for pain scale 8-10. Morphine was used for breakthrough pain between oxycodone doses. Patients would be rechecked around 30 minutes after receiving pain medication. If a patient only got down to a scale of 6, RN LL would ask if 6 was okay. If not, RN LL would try to escalate to the breakthrough pain medication. RN LL said P#1 was in too much pain to get up and walk. P#1 and a family member said PT had tried to get him up, and P#1 could not stand it. RN LL did not recall speaking to the doctor that night. An interview took place with Occupational Therapist (OT) KK on 12/3/25 at 2:19 p.m. in the Workroom. OT KK said sometimes patients could not participate in OT because of pain. An interview took place with Physical Therapist (PT) BB on 12/3/25 at 2:25 p.m. in the Workroom. PT BB said If patients complained that medications were needed more frequently, the complaints would be communicated to the nurses or providers. Sometimes a different medication may be needed instead of the amount. An interview took place with Licensed Practical Nurse (LPN) TT on 12/3/25 at 2:33 p.m. in the Workroom. LPN TT said P#1’s family member was his advocate and was very adamant about managing P#1’s pain. The family members felt the hospital could have done more for pain. P#1 did not feel like doing PT. LPN TT would document the pain scale on reassessment. If a patient said 7/10 was unbearable and there was no medication already for breakthrough pain, the nurses would ask for something additional. It was not documented when a patient declined additional medications. A telephone interview took place with the Medical Doctor (MD) AA on 12/5/25 at 8:12 a.m. MD AA said the nurses were expected to notify the physician if interventions were not effective.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 46188 Based on a review of policy and procedures, medical records, and interviews with staff, it was determined that the facility failed to provide five (P#6, P#10, P#11, P#14, P#15) patients out of 25 sampled records documentation related to informed refusal of treatment or sign a refusal document. Findings Included: One (P#6) patient record failed to have a completed leave against medical advice (AMA) form signed by the provider and witnessed by clinical staff. Four (P#10, P#11, P#14, P#15) patient records failed to include a refusal for treatment document or documentation that attempts were made to have the patient review and sign a refusal document. Cross Refer to A-2407.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 46188 Based on a review of policy and procedures, medical records, and interviews with staff, , it was determined that the facility failed to ensure that an appropriate and ongoing medical screening examination was conducted for five (P#6, P#10, P#11, P#14, P#15) patients out of 25 patients. Specifically, the medical record reviews failed to reveal that the facility documented steps to discourage an individual from leaving the facility or document that attempts were made to locate the individual prior to setting a disposition of leaving the facility without being seen (LWBS), left after seeing the provider (LASP), and left against medical advice (AMA). Findings Included: Review of Emergency Department (ED) policies and procedures title “Completion of AMA Form’ last reviewed 3/27/2023 revealed the purpose was to provide guidelines for the completion of the AMA form for patients who choose to leave Against Medical Advice (AMA). Procedures: Whenever possible, an AMA form will be completed by the patient’s EM or service physician on patients who elect to leave Against Medical Advice. A. Only those patients who choose to leave after physician contact has been established will need to have an AMA form completed. B. Patients who choose to leave prior to establishing physician contact are classified as “leaving without being seen”. C. The physician is responsible for completing all portions of the AMA form. D. The nurse may witness the patient’s signature on the AMA form. E. If the patient refuses to sign the AMA form, the physician shall document that decision appropriately on the form and the nurse shall co-sign. F. The EM attending, and the Charge Nurse shall be informed of all patients desiring to leave Against Medical Advice. G. The AMA form will become a part of the patient’s permanent medical record. A review of the facility’s policy titled, “ED: Management of patients who leave before triage or without being seen policy”, policy #4251, last revised 3/16/23, revealed that the purpose of the policy was to establish guidelines for managing patients who wish to leave the ED prior to formal triage or leave without being seen by a physician. Any patient indicating that they will be leaving before formal triage or prior to being seen by a physician and/or advanced practice provider (APP) will be encouraged to stay and complete their ED evaluation and treatment. If the patient has decision making capacity and still insists on leaving, a “Patient Refusal of care” form will be completed, this form will become part of the permanent medical record. Patients leaving before triage and/or prior to being seen and evaluated will be brought to the attention of a physician and Charge Nurse. A review of the facility’s policy titled, “Nursing Documentation Policy”, policy #3299, last revised 1/25/22, revealed that the purpose of the policy was to detail that the following nursing care documentation guidelines will be adhered to in order to assure care is provided to and documented for each patient based on a nursing assessment. D. Emergency Department 14. ED Discharge/Left before completing visit/AMA process: “ Documentation of patient leaving AMA and patient leaving before visit completion can be completed by the nurse, EMT, or paramedic. “ Discharge order/instruction summary will be completed by the physician. During an interview on 10/30/24 at 3:24 p.m., Emergency Department (ED) Nurse Manager (NM) FF said that she has been the ED NM for 10 years, and a Registered Nurse (RN) at the facility for 30 years. ED NM FF said that when a patient is listed as leaving against medical advice (AMA), it means that the patient has already been evaluated by the provider and chooses to leave without treatment and has had the risks and benefits discussed by the provider. ED NM FF said that nursing staff are to have the patient sign the AMA form, but if they do not or if they walk out, then staff are to sign it and notate that the patient left and then get the form witnessed by another staff member. ED NM FF said that when a patient is listed as left without being seen (LWBS), it means that the patient has not been seen by a provider and has chosen to leave the facility prior to this. ED NM FF said that sometimes patients will inform nursing staff they are choosing to LWBS and that staff are to encourage the patient to stay and have them sign a refusal of care form in the event they choose to still leave. ED NM FF said that the expectation is that nursing staff are to still make three attempted calls to the patient and document it in the electronic medical record (EMR). ED NM FF said that when a patient is listed as left after seeing a provider (LASP), it means that the patient has seen the provider and agreed to the treatment plan but then decided to leave without telling staff or elope. ED NM FF said that an example of this is when patients are waiting for discharge paperwork and they choose to leave prior to receiving it but they have already gotten treatment and been stabilized. ED NM FF said that nursing staff are expected to make three attempted calls to locate the patient and document it in the EMR. ED NM FF said that depending on the situation of the patient, staff may have to get security involved and that would require an incident report. A review of P#6’s medical record revealed that P#6 left against medical advice (AMA). An AMA form was on file and signed by P#6, however it was not signed by a physician or witnessed by clinical staff. A review of P#10’s medical record revealed that P#10 left the facility without being seen (LWBS). Continued review of P#10’s medical record failed to reveal any documented calls and attempts to locate P#10 when the facility realized that P#10 LWBS. A review of P#11’s medical record revealed that P#11 left the facility after seeing the provider (LASP). Continued review of P#11’s medical record failed to reveal any documented calls and attempts to locate P#11 when the facility realized that P#11 LASP. A review of P#14’s medical record revealed that P#14 left the facility after seeing the provider (LASP). Continued review of P#14’s medical record failed to reveal any documented calls and attempts to locate P#14 when the facility realized that P#14 LASP. A review of P#15’s medical record revealed that P#15 left the facility after seeing the provider (LASP). Continued review of P#15’s medical record failed to reveal any documented calls and attempts to locate P#15 when the facility realized that P#15 LASP.”

“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: 46188 Based on review of medical records, staff interviews, and facility policies, it was determined that the facility failed to appropriately monitor and document on patients while in restraints for three patients (P) (P#1, P#4, P#5) of five (P#1, P#2, P#3, P#4, P#5) sampled patients. Specifically, the facility failed to reveal either documentation of restraint charting for the time interval per the type of restraint, circulation assessment charting, assessment of needs by clinical staff, such as hygiene, elimination, or food and fluids, or documentation and assessment for the discontinuation of restraints. Findings Included: 1. A review of the medical record revealed that P#1 was ordered non-violent restraints for 8/20/24 at 6:35 a.m., 8/20/24 at 8:41 a.m., and 8/21/24 at 8:23 a.m. A review of “Flowsheet - Restraints Information” dated 8/20/24 through 8/21/24 failed to reveal that P#1 was offered food or fluids, hygiene care, and assistance with elimination needs. Continued review failed to reveal documentation that restraints were discontinued by staff. 2. A review of P#4’s medical record revealed that P#4 presented to the facility’s ED on 8/20/24 due to suicidal ideations (SI) and paranoia. Continued review of the medical record revealed that violent restraints were ordered for P#4 on 8/20/24 at 7:55 a.m., 3:24 p.m., 4:36 p.m. A review of “Flowsheets - Restraints Information” dated 8/20/24 through 8/20/24 failed to reveal documentation of the discontinuation of restraints. 3. A review of P#5’s medical record revealed that P#5 presented to the facility and was admitted on 8/20/24 at 8:19 p.m. Continued review of the medical record revealed that non-violent restraints were ordered for P#5 on 8/21/24 at 12:09 a.m., 8/21/24 at 1:36 p.m., 8/22/24 at 7:40 a.m., 8/23/24 at 6:53 a.m., 8/24/24 at 12:02 p.m., 8/25/24 at 1:29 p.m., 8/26/24 at 12:19 p.m., 8.27/24 at 11:57 a.m., 8/28/24 at 4:14 p.m.,8/29/24 at 6:39 p.m., 8/30/24 at 7:09 p.m., 9/2/24 at 2:30 p.m., and 9/2/24 at 2:55 a.m. Continued review of P#5’s “Flowsheets - Restraints Information” dated 8/20/24 through 9/3/24 failed to reveal appropriate two-hour restraint documentation from 8/23/24 at 8:00 p.m. through 8/24/24 at 12:00 a.m., 8/24/25 at 4:00 a.m. through 8/24/25 at 12:15 p.m., 8/25/24 at 7:00 a.m. through 8/25/24 at 7:00 p.m., 8/26/24 at 4:00 p.m. through 8/26/24 at 7:00 p.m., 8/27/24 at 5:00 a.m. through 8/27/24 at 8:00 a.m., 8/28/24 at 7:00 a.m. through 8/28/24 at 10:00 a.m., 8/28/24 at 6:00 p.m. through 8/28/24 at 8:15 p.m., 8/29/24 at 8:00 p.m. through 8/30/24 at 6:16 p.m., 8/31/24 at 7:00 a.m. through 9/1/24 at 1:00 p.m., and 9/1/24 3:00 p.m. through 9/2/24 at 8:00 a.m. Continued review of the medical record failed to reveal appropriate documentation of offering fluids, food, hygiene care, and elimination needs at appropriate intervals for P#5. A review of the facility’s policy titled “Acute Care Restraint and Seclusion Policy,” policy #942, last reviewed 10/25/22, revealed that the purpose of the policy was to detail that all patients have the right to be free from physical or mental abuse, and corporal punishment. Continued review revealed, II, Restraint of The Non-Violent/Non-Self-Destructive Patient: a. Monitoring and documentation of monitoring and interventions will occur at least every two hours and may include but is not limited to: i. Patient’s behavior, mental status with reorientation as needed ii. Restraint observations and interventions iii. Decrease in sensory stimuli iv. Placement of call light and personal items within reach/remove unsafe objects from reach v. Readiness for release from restraints whenever possible. vi. Temperature, pulse, respiration, and blood pressure checks as ordered or clinically indicated vii. Skin condition and reposition checks if needed to prevent skin breakdown viii. Circulation, motor, and sensory function checks below the level of restraint. ix. Needs: 1. Nutritional 2. Hydration 3. Elimination 4. Hygiene 5. Exercise and Range of Motion x. Reinforcement of teaching of behaviors needed for early release I. Requirements of documentation for when the restraints are released: 4. Associated interventions, patient’s condition, changes in the patient’s condition, and removal of the devices must be documented in the medical record. 5. Document the time when the patient met release criteria and was released from restraints. 6. Update plan of care to reflect restraints are removed. Continued review revealed, III, Restraint or Seclusion of The Violent/Self Destructive Patient: B. Requirements of documentation for the restraint or seclusion event: 1. The care plan must be individualized to address the restraint or seclusion usage. 4. Documentation by the physician includes the one-hour face-to-face medical and behavioral evaluation. 6. Monitor and document a minimum of every 15 minutes: a. Patients’ behavior, mental status, and readiness for release b. Reinforcement of teaching of behaviors needed for early release as applicable and if practical and safe to do so. c. Check circulation, motor, and sensory function below the level of restraint. 2. Information that should be documented approximately every two hours: a. If deemed unsafe to be up and about, then each individual limb is released from restraint and active or passive range of motion is given. b. Airway and respiratory status c. Check of Circulation, motor, and sensory function below the level of the restraint as applicable. d. Check of skin condition and any skin care provided. e. Needs assessed: i. Hydration ii. Elimination iii. Hygiene 8. Food should be offered to the patient at least every four hours or sooner when requested by the patient. During a telephone interview on 9/4/24 at 9:07 a.m., Registered Nurse (RN) FF said that documentation by nursing staff included indications for the restraint usage, alternative measures taken aside from the restraint, how long the patient has been in restraint for, and the patient’s response while in restraints. RN FF said that staff chart on non-violent restraints every two hours, and for violent restraints every 15 minutes. RN FF said that staff also chart that the patient was offered fluids, hygiene care, assistance with elimination, and nutrition for the patient. During a telephone interview on 9/4/24 at 10:05 a.m., RN GG said that before a patient is placed in any type of restraints, staff should ensure that alternative methods have been attempted. RN GG said that if a non-violent restraint is applied, then staff should chart every two hours versus charting every 15 minutes for a violent restraint. RN GG said that while a patient is in restraints, she would assess the patient’s need to be in it, circulation, range of motion, and if the patient has received food/fluids, and toileting. During a telephone interview on 9/4/24 at 1:18 p.m., RN DD said that the commonly used restraint is the non-violent soft restraint that requires documentation every two hours. RN DD explained that patients in restraints are assessed for skin integrity, alternative measures to restraints and behavior. RN DD said that she was not sure if fluid, foods, and elimination had to be charted for a patient in restraints. RN DD said that when a patient is ready to come out of restraints, staff should document the time it was removed and how the patient tolerated it.”

“CONTENT OF RECORD: INFORMED CONSENT CFR(s): 482.24(c)(4)(v) [All records must document the following, as appropriate:] Properly executed informed consent forms for procedures and treatments specified by the medical staff, or by Federal or State law if applicable, to require written patient consent. This Standard is not met as evidenced by: 46188 Based on a review of medical record, policies and procedures, and staff interview, it was determined that the facility failed to ensure that patient’s rights were promoted and protected when one patient (P) (P#1) of four (P#1, P#2, P#3, P#4) patients reviewed failed to have a consent for medical treatment documented in the electronic medical record. Findings Included: A review of the medical record for P#1 revealed that no consent for treatment was on file. A review of the facility’s policy titled, “General Consent Policy,” policy #387, last reviewed 10/6/24, revealed that the purpose of the policy was to detail that the facility will ensure that consent for treatment is obtained on every patient and documented appropriately in the medical record. During an interview on 7/17/2024 at 10:15 a.m. in a conference suite, Manager of Regulatory Affairs (MRA) AA revealed that every patient should have a consent form for treatment signed and in each patient’s chart upon admission, as appropriate. MRA AA said that she and other members of the team could not locate a consent for treatment on file for P#1.”