Atrium Health Navicent the Medical Center

“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: 46188 Based on a review of medical records, policies and procedures, and staff interviews, it was determined that the facility failed to provide care in a safe setting when one patient (P) (P#1) of five (P#1, P#2, P#3, P#4, P#5) patients failed to have head of bed elevated at 45 degree angle following cervical spine surgery as ordered. This failure had the potential to negatively impact the health outcomes during hospitalization of P#1. Findings included: A review of P#1’s medical record revealed that on 8/19/25 at 10:46 a.m., Physician Assistant (PA) DD ordered for P#1 to have an elevated head of bed (HOB) at 45 degrees at all times. A review of P#1’s medical record revealed that on 8/19/25 at 8:00 p.m. to 10:00 p.m., Nurse Technician (NT) HH noted P#1’s HOB was at 30 degrees. A review of P#1’s medical record revealed that on 8/20/25 at 12:00 a.m. to 6:00 p.m., clinical staff noted P#1’s HOB was at 30 degrees. A review of P#1’s medical record revealed that on 8/20/25 at 7:45 p.m. to 8/21/25 at 6:00 a.m., clinical staff noted P#1’s HOB was at 30 degrees. A review of P#1’s medical record revealed that on 8/24/25 at 1:43 p.m., a physician ordered to elevate the head of bed (HOB) 45 degrees unless contraindicated by surgical orders. A review of P#1’s medical record revealed that on 8/25/25 at 1:00 p.m. P#1 had a HOB elevated at 30 degrees. A review of P#1’s medical record revealed that on 8/25/25 at 3:00 p.m. P#1 had a HOB elevated at 30 degrees. A review of P#1’s medical record revealed that on 8/25/25 at 10:00 p.m. P#1 had a HOB elevated at 30 degrees. A review of P#1’s medical record revealed that on 8/26/25 at 7:00 a.m. P#1 had a HOB elevated at 30 degrees. A review of P#1’s medical record revealed that on 8/26/25 at 10:00 a.m. P#1 had a HOB elevated at 30 degrees. A review of “Progress Note,” dated 8/26/25 at 11:02 a.m., by PA DD noted orders for P#1 to have a strict head of bed (HOB) elevation of 45 degrees or above for three weeks. A review of a “Progress Note”, dated 8/27/25 at 7:49 a.m., by PA DD repeated orders for strict HOB elevation of 45 degrees or above for three weeks. A review of the facility ’ s policy titled “Patient Rights WI AHNMC,” last revised 7/24/23, revealed that the purpose of the policy was to establish a consistent method for addressing patients ’ rights and responsibilities and provide guidelines for providing medical and nursing care for all patients and safeguard their right to privacy regardless of their race, gender, age, religion, sexual preference, disability, or ability to pay. Continued review revealed, 4.0., Process Flow Diagram, every patient at the facility has the right to: ·Safety - The right of the patient to protection from the risks of the hospital environment will be honored through the hospital ‘s safety committee, hospital ’ s infection control committee/program, and risk management program. A review of the facility ’ s policy titled “Plan for Provision of Care AHNMC,” last revised 9/8/25, revealed that the purpose of the policy was to delineate the plan for the provision of interdisciplinary patient care across the continuum including pre-admission, acute care and discharge/follow-up and community care. Various health care disciplines communicate and collaborate to meet the identified needs and follow the physician’s orders to provide patient and family centered care. A telephone interview was conducted with Registered Nurse (RN) BB on 12/17/25 at 2:00 p.m. RN BB reported that her responsibilities included providing post-operative care, carrying out physicians ‘orders, administering medications and managing pain. RN BB said that nurses are not allowed to discontinue any medications and that a physician must do it. RN BB said that if a physician places an order, the nurse should follow it unless there is a concern and if there is then the nurse should contact the ordering provider for further orders. An interview was conducted with Licensed Practical Nurse (LPN) AA on 12/18/25 at 9:25 a.m. LPN AA explained that her responsibilities included providing care to assigned patients, communicating with providers, and following provider orders. A telephone interview was conducted with Physician Assistant (PA) DD on 12/18/25 at 11:52 a.m. PA DD said that it is important to maintain a 45-degree elevation after cervical surgery because it helps with reducing inflammation and assist with recovering faster. PA DD said that the order is always put in when a patient receives cervical spine surgery.”

“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: 52673 Based on review of medical records, policies and procedures, and staff interviews, it was determined that the facility failed to ensure that there was adequate Registered Nurse (RN) supervision for one patient (P) (P#1) of five sampled patients (P#1, P#2, P#3, P#4, P#5) had an admission assessment initiated and completed by an Licensed Practical Nurse (LPN) without RN supervision. Additionally, on 8/20/25, P #1 experienced an unwitnessed fall and the records failed to reveal a post-fall assessment or an RN supervision of patient care/treatment following the fall incident. This failure resulted in the potential for patient harm and care in a safe setting. Findings Include: A review of P#1’s medical record revealed that LPN AA completed an admission assessment on 8/19/25 at 2:54 p.m. Continued review failed to reveal an RN co -review signature or an RN assessment. A review of “Clinical Notes,” dated 8/20/25 at 1:40 p.m., revealed that P#1 reported that he had a fall. Continued review revealed that LPN AA assessed P#1, vital signs were taken, and assessment showed that P#1 did not have any injuries, as he stated, “I stood up from the bedside commode, turned around, and fell, but I got myself off the floor and got back in bed. A review of P#1’s medical record failed to reveal a post fall assessment by an RN. A review of the facility’s policy titled “Plan for Provision of Care AHNMC,” revision date 09/08/2025, revealed that the purpose of the policy was to delineate the plan for the provision of interdisciplinary patient care across the continuum including pre-admission, acute care and discharge/follow-up and community care. 1. A basic nursing assessment is initiated by an RN and includes evaluation of physical and psychological status sufficient to develop an initial plan of care within the first 12 hours after admission. Continued review revealed, reassessments will also occur whenever another nurse assumes care. RNs and LPNs with documented competency may perform ongoing reassessments. Reassessment after the initial nursing assessment occurs approximately every 12 hours on all patients and more frequently if indicated by the patient’s condition. A review of the facility ’ s policy titled “ Fall Prevention Hester Davis Assessment, Interventions, “ last revised 4/11/22, revealed the following: 4. Post Fall Care/assessment: · Take care of patient · Notify provider, nursing manager, nursing administrative · Fall CQIR (Incident reporting) · Quick Nursing note to reflect any procedures done or family notification · Complete fall risk assessment · Complete fall risk interventions · Complete post fall assessment · Update Safe Environment to include mat and alarm · Document any wounds · Update plan of care (POC) to include fall prevention · Complete debrief/huddle · Assure preventive interventions in place to prevent another fall A review of the facility’s document titled “Licensed Practical Nurse JC305745,” last date of change was 12/5/25, revealed that the job profile summary of the Licensed Practical Nurse (LPN) was under direct supervision of the Registered Nurse (RN) with standards and policies within scope of practice. Major responsibilities include, but are not limited to: Assists with assessment by collecting and documenting data, actions, and responses including biological, psychological social and cultural factors. Detects significant changes in patient condition and report these to the RN. A telephone interview was conducted with RN BB on 12/17/25 at 2:00 p.m. RN BB explained that patient admissions were completed by the primary nurses, who could be either an RN or a LPN. RN BB stated that when LPNs admitted patients, they initiated and completed patient assessments. RN BB further explained that patient assessments were completed every shift and whenever there was a change in the patient’s condition. During a telephone interview on 12/18/25 at 12:08 p.m., Nurse Manager (NM) II said that LPNs are not supposed to conduct the initial admission assessment for when a patient arrives at the unit, it must be an RN. NM II said that LPNs may conduct and document on-going assessments. NM II said that the LPN may document the admission assessment in the electronic medical record (EMR) but an RN must still physically assess the patient and then electronically sign-off on the assessment by the LPN. NM II said that if the patient experiences a change in condition or unexpected event occurs, then an RN must assess the patient. An interview was conducted with LPN AA on 12/18/25 at 9:25 a.m. in the facility conference room. LPN AA stated that she admitted patients by receiving report and coordinating care with technicians. LPN AA explained that she completed admission assessments and documented them per policy. LPN AA stated that admission assessments completed by LPNs were required to be co-signed by Registered Nurses (RNs). LPN AA stated that when a patient experienced a change in condition or a fall, particularly an unwitnessed fall, staff were required to obtain vital signs, complete post-fall assessments, and notify the provider and family while anticipating further orders. LPN AA explained that assessments related to changes in condition or post-fall events were completed by LPNs and co-signed by RNs. LPN AA stated that P#1 informed her that he had fallen but was able to get up and return to bed independently. LPN AA further explained that a technician had assisted P#1 to the bedside commode and left the patient unattended. LPN AA stated that P#1 attempted to return to bed, had a fall, got up and then returned to bed by himself. LPN AA stated that P#1 did not have a bed alarm in place despite being identified as a fall risk. LPN AA acknowledged that P#1 was considered a fall-risk patient.”