Doctors Hospital

“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: 45841 Based on review of policy titled “Patient Restraint Policy,” record review and staff interviews, it was determined that the facility failed to ensure that restraints were only applied with a physician order for one patient (P) (P2) of three patients reviewed. Specifically, documentation revealed that restraints were in use on 2/18/26 from 4:00 PM through 7:30 PM without an active order. This failure had the potential to cause harm while being improperly restrained. Findings included: A facility policy titled “Patient Restraint Policy,” dated 05/2024, indicated, “a. An order for restraint or seclusion must be obtained from a physician or other licensed practitioner who is acting within their State Scope of Practice, authorized by State law as having authority for ordering restraints, and is responsible for the care of the patient prior to the application of restraint or seclusion.” A review of P2’s medical record revealed an order for restraints was entered on 02/17/2026 at 3:01 PM. The order revealed staff were to use soft bilateral upper extremity restraints due to the patient removing medical devices. Further review revealed that the order was for valid for 24 hours and expired on 02/18/2026 at 3:01 PM. A review of P2’s medical record revealed an order for restraints was entered on 02/18/2026 at 7:32 PM. The order revealed staff were to use soft bilateral upper extremity restraints due to the patient removing medical devices. Further review revealed that the order was valid for 24 hours and expired on 02/19/2026 at 7:32 PM. Review of P2’s medical record revealed that soft bilateral upper extremity restraints were initiated on 02/17/2026 at 3:30 PM and restraint checks were completed on 02/18/2026 at 4:00 PM, 6:00 PM, 8:00 PM. During an interview on 03/20/2026 at 10:35 AM, the Manager of Clinical Informatics (MCI) stated that each restraint order for P2 was ordered as an initial order, which was why they each expired after 24 hours. During a concurrent interview, the Vice President of Quality Management (VPQM) stated that there was a four-hour gap between the first restraint order and second restraint order for P2 but based on documentation, the patient was still in restraints at that time. During a telephone interview on 03/20/2026 at 3:17 PM, Registered Nurse (RN) #5 stated that there had to be an order for restraints, and the order needed to be renewed every 24 hours or discontinued if the patient did not need them anymore. She stated that the expectation was that when she took over care of a patient in restraints, she would check the order to see when the order needed to be renewed. She stated that it was the provider’s responsibility to reorder the restraints, but she could reach out to remind them. She stated that she did not remember what happened or why there was a lapse in P2’s order on 02/18/2026, while they were in restraints. During an interview on 03/20/2026 at 1:40 PM, RN #2 stated that restraints required an order. During a telephone interview on 03/20/2026 at 3:38 PM, RN #4 stated that the expectation was that an order was needed for restraints, and the restraints needed to be reordered every 24 hours if needed. During an interview on 03/20/2026 at 10:34 AM, the MCI stated that there was no electronic notification after an order expired (in the electronic health record). The MCI stated restraint orders was included in the orders to be reviewed daily tab, but there was no alert after an ordered expired. During an interview on 03/20/2026 at 5:00 PM, Nursing Director (ND) #6 stated that the expectation was that staff needed to have an order for restraints to place a patient in restraints. She stated orders for restraints were only active for 24 hours and had to be renewed daily.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 45841 Based on review of policy titled “Assessment/Reassessment (Collaborative),” record review, and staff interviews, it was determined that the facility failed to ensure that nursing care plans included goals and reflected the nursing care to be provided for three patients (P) (P1, P2, and P3) of three patients reviewed. Findings included: A facility policy titled “Assessment/Reassessment (Collaborative),” dated 06/2023, indicated, “4. Interventions are identified in the Patient’s Plan of Care based on the diagnoses and location of the patient. The Plan of Care will reflect expected outcomes in the restoration of health or peaceful death during the hospitalization.” A review of P1’s medical record “Plan of Care” failed to reveal goals and nursing care required to meet the patient’s needs and goals. A review of P2’s medical record “Plan of Care” failed to reveal goals and nursing care required to meet the patient’s needs and goals. A review of P3’s medical record “Plan of Care” failed to reveal goals and nursing care required to meet the patient’s needs and goals. During an interview on 03/20/2026 at 1:10 PM, Registered Nurse (RN) #3 stated that the care plans included why a patient was in the hospital, but staff did not include goals in the care plans. During an interview on 03/20/2026 at 1:40 PM, RN #2 stated that nursing care plans were based on the reason a patient was in the hospital or problems the patient developed while at the hospital. RN #2 stated that care plans were meant to guide staff on patient education. She did not think care plans included goals but provided the opportunity to document when patients’ issues were improved, maintained, or deteriorating. During a telephone interview on 03/20/2026 at 3:17 PM, RN #5 stated that facility staff completed care plans for the patients. RN #5 stated that the care plans went along with the teaching provided to the patients. Care plans were based on the patient’s problems. RN #5 stated that care plans were updated each shift. RN #5 explained that documentation options included problem maintained, problem improved or problem resolved. She was not certain if goals could be added to the care plan. During a telephone interview on 03/20/2026 at 3:38 PM, RN #4 stated that the care plans included different topics to help guide education for the patient but did not include goals RN #4 explained that care plans were individualized to each patient’s admission diagnosis and problems.. During an interview on 03/20/2026 at 5:00 PM, Nursing Director (ND) #6 stated that nursing care plans were expected to be documented under the plan of care and they were based on the patient’s admission and education needs. ND #6 stated that she knew the plan of care asked if the patient was improving or stabilizing, but she did not think it triggered goals and interventions.”

“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: 45841 Based on review of policies and procedures, record review, and staff interviews, it was determined that the facility failed to ensure that staff adhered to facility policies and procedures for skin assessments, pressure injury prevention, and hygiene for three patients (P) (P1, P 2, and P3) of three patients reviewed. This failure had the potential of a patient developing skin breakdown due to not having their hygiene maintained. Findings included: Review of policy titled “Clinical Documentation,” dated 12/2023, indicated, “Documentation in the electronic health record is focused on patient care activities, clinical decisions and patient response to care.” The policy revealed, “Key elements of the patient-centered electronic health record are A. History B. Screening and risk assessment C. Individual considerations for care D. Assessment E. Plan of care F. Care Activities.” The policy revealed, “Interventions that must be documented every shift: A. Plan of Care B. Vital Signs C. Admission/Shift Assessment D. Safety/Risk/Regulatory E. Lines/Drains/Airway F. Routine Daily Care G. RASS/CAM [Richmond Agitation Sedation Scale/Confusion Assessment Method] (for Critical Care areas) H. PEWS [pediatric early warning score] (per unit requirement) I. Pain Assessment.” The policy also indicated that routine care interventions included, “10. Activities of Daily Living (ADL): hygiene care/meals/ambulation (repositioning).” Review of policy titled “Pressure Injury Prevention,” dated 11/2024, revealed, “Skin Risk and Physical Skin Assessment: All Age Groups” included, “3. Skin risk and physical assessment will occur at the following intervals: a. Upon admission; b. Once per shift; c. Following a change in medical condition or level of care; and d. Upon transfer.” The policy also revealed, “Procedure Statements” included, “1. Skin risk assessment will be documented in the Electronic Health Record (EHR) for each patient;” “3. Skin assessment changes and presence of any skin alterations or wounds will be documented in the EHR for all patients;” and “7. Pressure Injury interventions and an individualized plan of care, including education, will be implemented and documented in the EHR, for all AT RISK patients.” The policy continued, “a. Pressure injury interventions will be applied in accordance with precipitating risk factors identified via the skin risk assessment (refer to Appendix for guidance).” Review of the medical records “Skin Risk,” assessment dated 03/15/2026 at 8:00 AM for P1 revealed the patient was occasionally moist, was bedfast, and had slightly limited mobility. The record revealed the patient’s pressure injury risk score was 17, which indicated the patient was at risk for pressure injury. Continued review of P1’s record for 03/15/2026 under “Routine Daily Care” revealed skin breakdown interventions of a low air loss mattress at 8:00 AM and turning every two hours from 8:00 AM to 4:00 PM. The record failed to reveal documentation of hygiene care on 03/16/2026 or 03/17/2026. During a concurrent record review and interview on 03/20/2026 at 10:27 AM, the Manager of Clinical Informatics (MCI) stated that the only skin interventions she saw documented for P1 on 03/15/2026, were the use of a low air loss mattress at 8:00 AM and turning at 8:00 AM, 10:00 AM, and 12:00 PM. In addition, MCI acknowledged that she did not see hygiene documentation for 03/16/2026 or 03/17/2026 including free text notes. A review of P2’s medical record failed to reveal evidence of skin risk assessments for day shift on 02/17/2026 or 02/19/2026. Continued review revealed failed to reveal evidence of an integumentary assessment on 02/19/2026 during the day shift. Record review for P2 failed to reveal hygiene care on 02/17/2026 or 02/20/2026. Continued review revealed skin breakdown interventions documented under ‘Routine Daily Care” included: On 02/17/2026 at 8:10 PM, a low air loss mattress and head of bed at 30 degrees; on 02/18/2026 at 7:15 AM, an air fluidized mattress and the head of the bed at 30 degrees; and on 02/19/2026 at 8:59 PM, P2 was turned. During a concurrent record review and interview on 03/20/2026 at 10:42 AM, the MCI stated that the only skin risk assessments she saw documented for P2 were on night shifts for 02/17/2026 and 02/19/2026. These skin risk assessments were not documented under the integumentary assessments and she did not see any free text notes. MCI acknowledged that the only skin interventions documented for P2 from 02/17/2026 to 02/20/2026 were a low air loss mattress on 02/17/2026 at 8:10 PM, an air fluidizer mattress on 02/18/2026 at 7:15 AM, turning on 02/19/2026 at 8:59 PM, and the head of bed at 30 degrees on 02/17/2026 at 8:10 PM and 02/18/2026 at 7:15 AM. During an interview on 03/20/2026 at 10:48 AM, the Manager of Clinical Informatics (MCI) stated that P2 did not have an integumentary assessment completed on 02/19/2026 during the day shift. MCI further stated that there was no hygiene documentation for P2 on 02/17/2026 or 02/20/2026. There was nothing documented under hygiene care or in the notes. A medical record review for P3 failed to reveal “Skin Risk” assessments documented during the night shift on 03/04/2026, 03/10/2026, and 03/11/2026 and during the day shift on 03/06/2026 and 03/13/2026. Further review of the medical record for P3 failed to reveal integumentary assessments conducted during the night shift on 03/03/2026 and 03/04/2026, and during the day shift on 03/06/2026 and 03/13/2026. Record review of “Hygiene Care” flowsheet dated 03/11/2026 at 10:37 AM, revealed the patient had already received a bath that day, but oral care was provided at that time. The medical record failed to reveal documented evidence of a bath earlier in the day. A medical record review for P3 further revealed no evidence of skin breakdown interventions documented under “Routine Daily Care” for the day shift on 03/03/2026, 03/05/2026, 03/06/2026, 03/10/2026, 03/11/2026, and 03/12/2026, 03/13/2026 and the night shift on 03/04/2026, 03/05/2026, 03/13/2026 During an interview on 03/18/2026 at 4:31 PM, the Vice President of Quality Management (VPQM) stated that there was no policy on patient baths and hygiene; it was only referenced in the clinical documentation policy. During a concurrent record review and interview on 03/20/2026 at 11:08 AM, the MCI stated that there was no skin risk assessments documented for P3 for the night shift on 03/04/2026, 03/10/2026, and 03/11/2026 and during the day shift on 03/06/2026 and 03/13/2026. During a concurrent record review and interview on 03/20/2026 at 11:14 AM, the MCI stated that there were no skin breakdown interventions documented on P3 for the day shift on. 03/03/2026, 03/05/2026, 03/06/2026, 03/10/2026, 03/11/2026, and 03/12/2026, 03/13/2026 and the night shift on 03/04/2026, 03/05/2026, 03/13/2026. The notes fail to reveal interventions. During an interview on 03/20/2026 at 11:20 AM, the MCI stated that there were no integumentary assessments documented for P3 for the night shift on 03/03/2026 and 03/04/2026, and the day shift on 03/06/2026 and 03/13/2026. The MCI stated that she did not see documentation for the previous bath that was mentioned for P3 on 03/11/2026 at 10:37 AM. During an interview on 03/20/2026 at 1:10 PM, Registered Nurse (RN) #3 stated that skin assessments were to be completed on the patients each shift. If the patient was at risk for skin breakdown, they would place a clear Mepilex on the site at risk for breakdown and turn the patient. She stated interventions for wounds were documented under the wound section in the chart; if the interventions were only preventative, they were not documented. During an interview on 03/20/2026 at 1:40 PM, RN #2 stated that the expectation for skin assessments was that they were completed per shift. She stated if a patient was at risk, interventions could include Mepilex dressings, heel supports, pillows, and other positioning devices. RN #2 stated that the expectation was that patients be provided with hygiene care at least daily, if not per shift, and as needed throughout. There was a specific hygiene care section for documentation, or it could be documented under daily care as well. During a telephone interview on 03/20/2026 at 3:17 PM, RN #5 stated that skin assessments were completed every day. She stated skin breakdown prevention included things such as different mattress types, turning a patient every two hours if needed, checking them more frequently if they were incontinent, or floating their heels. If interventions were put into place, they would be documented under the integumentary section. RN #5 stated that the expectation for patient hygiene was that they received a chlorhexidine gluconate (CHG) bath if they had a central line as well as a regular bath unless the patient refused. She stated it did not matter which shift completed the bath, as each patient had their own preference. She stated that baths and hygiene were documented under hygiene, and there was a personal care tab to document under as well. During a telephone interview on 03/20/2026 at 3:38 PM, RN #4 stated that skin assessments were completed every shift. She stated that she did a complete skin assessment when doing a head-to-toe assessment or every two hours if the patient was a total care patient who was turned every two hours. She stated if the Braden Scale (standardized tool used to assess and document a patient’s risk for developing pressure injuries) showed the patient was at risk for skin breakdown, then interventions would be documented under the wound section of the medical record. RN #4 stated that patients should be bathed daily, if not a full bath, then cleansed with wipes, their linens changed, oral care performed, and perineal care performed. During an interview on 03/20/2026 at 5:00 PM, Nursing Director (ND) #6 stated that the expectation for skin assessments was that they were completed every shift and the expectation for risk assessments or Braden Scales was that they were completed every shift. She stated that the expectation was if the Braden Scale showed a patient was at risk for skin breakdown, then interventions would be put into place. She stated that a downfall of Meditech [electronic medical record] was that interventions were not populated for the staff to choose from, so it needed to be documented in a note, so the interventions were difficult to document. ND #6 stated that the expectation was for hygiene to be offered daily to patients and could be documented under hygiene or daily care.”

“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 review of policies and procedures, video surveillance, incident report logs, and staff interviews, it was determined that the facility failed to ensure patient rights for one patient (P) (P1) of five patient charts reviewed (P1, P2, P3, P4, P5) when a Patient Safety Assistant (PSA) witnessed a security officer drag a patient across the floor by one arm. Findings included: A review of policy titled “Patient Rights and Responsibilities,” policy number 15362056, approved 03/2024, revealed that patients had the right to receive individualized care that was delivered in a setting that was free from abuse, discrimination and harassment. A review of policy titled “Facility Event and Close Call Reporting,” policy number 14998769, last reviewed 07/2024, revealed that facility staff must report events promptly, ideally within the shift, with reports accessible to leaders for immediate review. A review of policy titled “Use of Force,” policy number EOG.SS.009, effective April 1, 2021, revealed that colleagues that use any level of force in an incident will complete a Use of Force Report accurately detailing the subjects’ actions that necessitated force as well as the colleagues’ actions and all circumstances relevant to the event. The report should articulate the factors perceived and reason the colleague believed use of force was necessary under the circumstances. All witnesses will provide a written summary of what they observed when possible. Review of the Emergency Department (ED) Central Log revealed that P1 came to the ED on 10/4/25 0402 with paranoia (feeling of being threatened or harmed even though there is no proof). Review of video surveillance of the ED’s behavioral health unit (BHU) took place in the Azalea Room with the Chief of Security (CS) JJ on 3/10/2026 at 11:50 AM. Video revealed that on 10/04/2025 at 2:11:25 PM, P1 was seated in a recliner furthest from the nurses’ station (9D) wearing a blue scrub top and burgundy scrubs. Staff present in the BHU at that time were identified by CS JJ as Security Officer (SO) FF and Patient Safety Attendant (PSA) DD. PSA DD was seated behind the nurses’ station. SO FF stood facing the nurses’ station. At 211:24.004, P1 arose from the recliner, crossed the black and yellow line, and stood beside SO FF at the nurses’ station. The following events were observed via video: “ 2:11:34.419, SO FF’s right hand was observed in contact with P1’s upper right arm as P1 pulled away and began falling to the floor. “ 2:11:34.887 OC FF attempted to secure P1’s right sleeve. “ 2:11:35.054 P1 fell to the floor on her left side. “ 2:11:36.357 PSA DD stood up from behind the nurse’s station and walked toward the garbage can. “ 2:11:36.739 PSA DD tossed an item in the garbage, faced P1 and OC FF, then returned to her seat where she remained standing behind the nurses’ station. There was approximately 10 feet between PSA DD and OC FF. PSA DD was not observed leaving the BHU to ask for help, making a phone call, nor assisting OC FF during the event. “ 2:11:36.832 OC FF took hold of P1’s right upper arm with his right hand and held P1’s elbow with his left hand. OC FF attempted to pull P1 up from the floor. “ 2:11:39.468 P1 began falling back toward the floor. “ 2:11:39.107 OC FF released his left grip and began moving forward while continuing to grasp P1’s right upper arm with his right hand. P1 was facing upward while being pulled across the floor and bracing herself with her left hand on the floor. OC FF took two to three steps toward the recliner where P1 was previously seated. “ 2:11:41.208 PSA DD was observed standing behind the nurse’s station. “ 2:11:41.841 OC FF turned toward P1 and secured her back against his chest in a cradle position while lifting P1 onto the recliner. “ 2:11:44.909 OC FF proceeded to walk back to the nurse’s station. P1 remained in the recliner. Review of the Incident Logs and Security Logs from 10/04/2025 and 10/05/2025 failed to reveal reports related to the incident with P1. There was no security documentation regarding the use of force or restraint when escorting P1 across the room to her seat. An interview took place with Risk Management (RM) on 03/10/2026 at 3:17 PM in the Azalea Room. RM said P1 called the hospital in February 2026. At the time, P1’s story was vague without details. There were no staff reports at the time of the incident. Camera footage was reviewed with the Chief of Security (CS) JJ. Some of the allegations were founded. There was no documentation about the incident. Self-reporting would have been a way the incident could have been addressed in real time. Anyone could report an incident in the incident reporting system. There would have been an immediate report on the computer. Nobody reported the incident with P1. An interview took place with the Chief of Security (CS) JJ on 03/10/2026 at 3:38 PM in the Conference Room. CS JJ said there was no specific policy about how to get people off the floor. That would be considered soft empty hands use of force. The security contract company reviewed the video and thought it was excessive. SO FF was terminated by the security company. CS JJ said SO FF should have done an incident report because he put his hands on someone. There was no incident report. All staff had been notified to put in a report if they touched a patient.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 42305 Based on review of policies and procedures, video reviews, and staff interviews, it was determined that the facility failed to protect a patient’s right to be free from abuse by revealing inappropriate use of force for one patient (P) (P1) of four sampled patients. Findings included: A review of the policy titled “Patient Rights and Responsibilities,” policy number 15362056, approved 03/2024, revealed that patients had the right to receive individualized care that fosters the patient’s comfort and dignity and is delivered in a setting that is free from abuse, discrimination and harassment. A review of the policy titled “Use of Force,” policy number EOG.SS.009, effective date April 1, 2021, revealed that colleagues are expected to use de-escalation training and verbal skills to defuse behavioral/crisis situations when feasible. Colleagues will only use the necessary force to defend themselves or others from injury against a combative subject and will immediately cease to use force when the subject is no longer causing physical harm to themselves or others. Level Two Use of Force included Empty Hand Control (Soft)- (grabs, holds, joint locks), assisted escort, clinical medication/behavioral restraints. Review of the Emergency Department (ED) Central Log revealed that P1 came to the ED on 10/4/25 0402 with paranoia (feeling of being threatened or harmed even though there is no proof) and was transferred to a behavioral health hospital on 10/05/2025 at 8:37 AM. Review of video surveillance of the Emergency Department’s (ED’s) behavioral health unit (BHU) took place in the Azalea Room with the Chief of Security (CS) JJ on 3/10/2026 at 11:50 AM. Video review beginning on 10/4/2025 at 2:11:25 PM revealed that P1 was seated in the recliner furthest from the nurses’ station (9D) wearing a blue scrub top and burgundy pants. Staff present in the BHU at that time were identified by CS JJ as Security Officer (SO) FF and Patient Safety Attendant (PSA) DD. SO FF stood facing the nurses’ station. At 2:11:24.004, P1 rose from the recliner, crossed the black and yellow line, and stood beside SO FF at the nurses’ station. The following events observed via video: “ 2:11:34.419, SO FF’s right hand was observed in contact with P1’s upper right arm. P1 pulled away and began falling to the floor. “ 2:11:35.054 P1 fell to the floor on her left side. “ 2:11:36.832 OC FF took hold of P1’s right upper arm with his right hand and held P1’s inner elbow with his left hand. OC FF attempted to pull P1 up from the floor. “ 2:11:39.468 P1 began falling back toward the floor. “ 2:11:39.107 OC FF released his left grip and began moving forward while continuing to grasp P1’s right upper arm with his right hand. OC FF took two to three steps toward the recliner where P1 was previously seated. “ 2:11:41.841 OC FF turned toward P1 and secured her back against his chest in a cradle position while lifting P1 onto the recliner. “ 2:11:44.909 OC FF proceeded to walk back to the nurse’s station. P1 remained in the recliner. An interview took place with Risk Management (RM) on 3/10/2026 at 3:17 PM in the Azalea Room. RN said P1 called the hospital in February 2026. At the time, P1’s story was vague without details. P1 described a security guard, but RM did not get a clear picture. RM explained the grievance process to P1. P1 chose to file a police report instead of a grievance. RM heard from P1 nine days later. P1 had a photograph of the security guard and was able to give a closer range of dates. There was enough information to start an investigation. There were no staff reports at the time of the incident. RM stated that camera footage was reviewed with the Chief of Security (CS) JJ. Some of the allegations were founded. An interview took place with the Chief of Security (CS) JJ on 3/10/2026 at 3:38 PM in the Conference Room. CS JJ said once P1 was on the ground, SO FF could have let her sit while talking to her and trying to get her to willingly get up. In that situation, CS JJ would have asked for backup with someone on each side of the patient. There was no specific policy about how to get people off the floor. That would be considered soft empty hands use of force. The security contract company reviewed the video and thought it was excessive. SO FF was terminated by the security company.”