St Joseph Regional Medical Center

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 49416 Based on interview and medical record review, the hospital failed to ensure that care was provided in a safe setting. The hospital failed to ensure care in a safe setting including appropriate assessment of behavioral health patients with risk for suicide. These failures placed all patients receiving medications or treatments at risk for serious harm or death. Findings include: 1. Refer to A144, as it relates to the failure of the hospital to ensure care was provided in a safe setting.”

“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: 49416 Based on record review and interview, the hospital failed to ensure care was provided in a safe setting for 1 of 1 sampled behavioral health patients (Patient #5) who was admitted following an intentional suicide attempt and subsequently completed suicide. Specifically, the hospital failed to ensure an accurate suicide risk assessment was completed and failed to ensure interventions and monitoring were consistent with Patient #5’s identified suicide risk status. These failures resulted in Patient #5 being inadequately assessed and monitored following admission to the BHU, after which experienced a Code Blue event after her suicide attempt on 3/20/26 and subsequently died following transfer to the ICU. Findings include: The facility policy titled, “Behavioral Health Level of Safety Systems” last revised 8/2025. The policy stated, “1. The [Facility] Behavioral Health Unit will use a system of observation and interventions in place to ensure the safety of all patients based on their individual needs and clinical presentation. A. Upon admission to the treatment unit, all inpatients will be assessed for safety risks and placed on a Level of Safety and/ or precautions appropriate for their needs. ... E. Levels of observation are: 1. Level I 1: 1 observation (arms length) 2. Level 1 1: 1 observation high risk (safe distance) 3. Level II line of sight 4. Level Ill standard q15min checks.” This policy was not followed examples include: Patient #5, a 62-year-old female, presented to the ED via ambulance on 3/18/26 following an intentional overdose with reported intent of “killing herself.” Patient #5 was placed on an involuntary hold in the ED on 3/18/26. Documentation indicated Patient #5 had recently experienced multiple psychiatric medication changes which she stated caused her to feel unwell and contributed to her overdose attempt. Review of the Columbia-Suicide Severity Rating Scale (C-SSRS) completed in the ED on 3/18/26 at 4:26 PM showed Patient #5: - wished she were dead within the past month, - had thoughts of killing herself, - had intention to act on suicidal thoughts, - had begun working out details of how to kill herself, - had prepared for suicide, and - had engaged in behavior intended to end her life. Patient #5 was admitted to the BHU on 3/19/26 for “treatment of major depression with a recent overdose.” The medical record documented Patient #5 had been safe since admission and was “appropriate for Level 3 precautions,” which, according to hospital policy, required patient safety checks every 15 minutes. Patient rounding checks were reviewed and documentation showed 15 min checks were completed. A subsequent C-SSRS completed on 3/19/26 at 2:43 PM documented contradictory findings and inaccurately reflected that during Patient #5’s lifetime she: - had not wished she were dead, - had not thought about killing herself, - had not thought about how she might kill herself, and - had not engaged in suicidal behavior. The C-SSRS specifically included the question: “Have you ever done anything, started to do anything, or prepared to do anything to end your life?” Examples included collecting pills or actually taking pills. Despite Patient #5’s documented overdose suicide attempt immediately preceding admission, the assessment reflected negative responses. Additionally, the assessment documented Patient #5’s “most severe ideation” as “non-applicable.” Review of the medical record showed nursing documentation entries on: - 3/19/26 at 2:52 PM, - 3/19/26 at 3:18 PM, - 3/20/26 at 1:43 AM, and - 3/20/26 at 4:05 AM. At 7:05 AM on 3/20/26, documentation reflected a Code Blue was initiated. Patient #5 achieved ROSC, was transferred to the ED and then ICU, where the family elected comfort care measures. Patient #5 subsequently died on 3/20/26. An Interview was conducted with the director of behavioral health services on 5/21/26 beginning at 9:00 AM. The Director confirmed outside information such as medical records were a necessary competent in completing the C-SSSR. The Director further confirmed there was a need for additional training on how to complete the C-SSSR correctly. An interview was conducted with a psychiatrist on staff at the facility on 5/20/26 beginning at 10:45 AM. The psychiatrist confirmed the assessment should be completed objectively and should include collateral information. The psychiatrist additionally confirmed, if a patient attempted suicide the previous day but denied the attempt during questioning, he would still answer “yes” to the suicide attempt questions because the assessment reflects objective findings rather than solely the patient’s statements. The psychiatrist stated, “It’s objective so I would put that yes they did attempt.” The hospital failed to ensure the suicide risk assessment accurately reflected Patient #5’s recent suicide attempt and current suicidal risk factors and failed to ensure patient monitoring and precautions were implemented consistent with Patient #5’s clinical presentation and suicide risk. These failures had the potential to put patients at serious risk of harm or death.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 39430 Based on document review, medical record review, and staff interview, the Governing Body failed to ensure that hospital services were provided in accordance with approved policies and procedures. The Governing Body did not ensure that policies governing the provision of Continuous Renal Replacement Therapy (CRRT) were developed, approved, and implemented prior to the initiation of CRRT services. This failure resulted in CRRT being performed in the hospital without any Governing Body-approved policies and procedures to guide safe practice, staff responsibilities, clinical parameters, or oversight mechanisms. This directly affected 1 of 1 patients (Patient #1) whose medical record was reviewed and had CRRT performed on them. Findings included: Hospital policies were requested that outlined the provision of CRRT in the hospital. A document titled “Sample Policies and Procedures for Using the NxStage System One for the Critical Care Environment: Hemofiltration, Hemodialysis, and Isolated Ultrafiltration” was provided. The first page of the document included the following statement: “Healthcare facilities are required to have written policies approved by their governing body concerning the services that they provide.” The next paragraph of the document stated: “NxStage Medical, Inc. has prepared this document to assist you in the preparation of policies and procedures for use with the NxStage System One. The information herein is intended as a guide for reference purposes only, and all providers are encouraged to modify these draft policies and procedures based on their own unique needs.” The document provided appeared to be an Instructions for Use for the NxStage System One machine, not a hospital approved policy. There was no documentation, through review of Governing Body meeting minutes or Medical Staff meeting minutes, that the hospital had created or implemented policies governing the use of CRRT in the hospital. Review of Patient #1’s medical record revealed that he was a 63 year old male who arrived at the hospital on 11/18/25 after being found down in his home for an extended period of time. Patient #1’s record included an Emergency Department physician’s note documenting that he was admitted with Acute Kidney Injury and Rhabdomyolysis. Patient #1’s medical record documented that he was started on hemodialysis on 11/19/25 at 3:48 PM. Documentation indicated that Patient #1 did not tolerate the dialysis treatment and his condition deteriorated. The record included a nursing entry at 5:45 PM stating, “Patient is tolerating treatment well. Sitting in chair with feet elevated and back of chair reclined.” A subsequent entry at 6:50 PM stated, “Patient is agitated, MD ordered restraints. Access visualized and no problems noted. Machine lines checked. Tx. ended, blood returned. Pt unresponsive. 40 min remaining.” Patient #1’s medical record included a physician order signed by the tele nephrologist on 11/19/25 at 11:29 PM for Patient #1 to start CRRT. The record documented that Patient #1 was started on CRRT on 11/20/25 at 1:00 AM. There was no documentation that all physicians involved in Patient #1’s care discussed or agreed upon the use of CRRT. Additionally, there was no documentation that pharmacy was involved in evaluating or adjusting Patient #1’s medications for renal dosing compatibility with CRRT therapy. A hospital pharmacist was interviewed on 2/11/25 beginning at 1:30 PM. When asked if he remembered this situation with Patient #1 he stated, “yes.” He stated the hospital on call pharmacy handles any necessary changes to patient meds or dose adjusting after hours. When asked if the on call pharmacy service was called for patient #1 on the night of 11/19/25 and morning of 11/20/25 he stated, “no.” He said when he arrived on the morning of 11/20/25 he was unaware Patient #1 had started on CRRT and was not consulted to establish if Patient #1 needed any dose adjustments for his medications. The Quality Director was interviewed on 2/11/25 beginning at 3:00 PM. She confirmed that there were no Governing Body-approved policies for CRRT. Additionally, she said the doctors have a system for collaboration with each other on complex cases but confirmed there was no documentation of communication. The absence of hospital approved CRRT policies meant there were no established clinical criteria, interdisciplinary communication requirements, or medication management standards to guide the decision making process for Patient #1. As a result, CRRT was initiated without documented coordination among treating physicians and without pharmacy involvement, during a period when Patient #1 was already clinically unstable following an unsuccessful hemodialysis attempt. The hospital failed to ensure that effective policies and procedures were developed, approved, and implemented to govern the provision of CRRT. By allowing CRRT to be performed without approved policies and procedures, the hospital failed to establish the clinical and operational standards necessary to provide safe and effective patient care. 2. Refer to TAG 0409 as it relates to the hospitals failure to ensure all medication orders were ordered and signed by a provider. 3. Refer to TAG 0576 as it relates to the hospitals failure to ensure laboratory services were provided in a timely manner and all labs ordered were completed.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 39430 Based on interview, hospital document review, and pharmacy record review, the hospital failed to ensure that care was provided in a safe setting. The hospital allowed treatments, services, and medications-including controlled substances-to be entered, ordered, and administered without Physician or Qualified Mid Level Practitioner involvement. The facility utilized an order source labeled “Per Pharmacy Protocol,” which permitted access to medications and treatments without a corresponding prescribing provider order. This failure created an environment in which medications, including narcotics, could be administered without documented authorization, clinical evaluation, or oversight by a licensed practitioner. These failures placed all patients receiving medications or treatments at risk for serious harm or death. Findings include: 1. Refer to A144, as it relates to the failure of the hospital to ensure care was provided in a safe setting. 2. Refer to A154, as it relates to the failure of the hospital to ensure restraints were discontinued at the earliest possible time.”

“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: 49416 Based on record review, policy review, and staff interview, it was determined the hospital failed to ensure nursing staff met the needs of patients in accordance with standards of care established by hospital policy and expectation. This had the potential to result in unmet patient needs and affect all patients receiving care at the hospital. Findings include: Refer to A- 395 as it relates to the hospital’s failure to ensure nursing leadership for the specialized units was qualified to provide the necessary clinical supervision, direction, and evaluation of nursing care. Refer to A-396 as it relates to the hospital’s failure to ensure nursing staff provided ongoing assessment, monitoring, and timely interventions. These systemic failures significantly impeded the ability of the hospital to provide safe nursing care.”

“LABORATORY SERVICES CFR(s): 482.27 The hospital must maintain, or have available, adequate laboratory services to meet the needs of its patients. The hospital must ensure that all laboratory services provided to its patients are performed in a facility certified in accordance with Part 493 of this chapter. This Condition is not met as evidenced by: 39430 Based on interviews, document review, and medical record review, the hospital failed to ensure that all laboratory services provided under arrangement were adequately supervised, integrated into the hospital’s quality assessment and performance improvement (QAPI) program, and or into the hospitals governance and Medical staff leadership meetings and managed in a manner that ensured timely and reliable diagnostic services for patients. This directly affected 1 of 18 patients whose record was reviewed (Patient #18). This failure resulted in a systemic lack of oversight of the contracted off site laboratory and a lack of awareness of “TNP” (test not performed) results, placing patients at risk for delays in diagnosis and treatment. Medical record review identified multiple instances in which laboratory results were reported as “TNP.” The records did not clearly indicate whether the tests were redrawn, completed, or followed up in a timely manner. 1. Patient #18 was a 68-year-old male admitted on 2/02/26 from an outside facility with a primary diagnosis of osteomyelitis of the right foot and additional diagnoses including severe peripheral arterial disease (PAD), chronic normocytic anemia, type 2 diabetes mellitus (T2DM), hypertension (HTN), and stable chronic kidney disease (CKD). Patient #18’s medical record included: On 2/07/26, 49 labs were ordered that were documented as TNP. It is unclear in the medical record if these results were ever provided or reordered for Patient #18. This patient had a complicated hospital course which did involve a cardiac arrest and code being called, although ROSC was obtained, and Patient #18 was discharged on 2/17/26. Hospital Governing Body meeting minutes and Medical Executive meeting minutes were requested. There was no indication that the TNP issue on the labs was disccused. During an interview with the Laboratory Director on 2/18/26 at 2:45 PM, she stated that the in house laboratory is not notified when the contracted laboratory issues a TNP result. She explained that the contracted laboratory communicates directly with individual nursing units to request redraws, and that new orders are entered at the unit level without involvement or awareness of the in house laboratory. She confirmed that the hospital does not conduct routine monitoring of TNP occurrences, does not track TNP trends, and does not include TNP data in the hospital wide QAPI program. She further acknowledged that the hospital does not hold regular meetings with the contracted laboratory and agreed that such communication would be beneficial. The hospital Quality and Patient Saftey Manager was interviewed on 2/18/26 beginning at 9:30 AM. she stated there was no current tracking or project in the hospitals quality system based on the TNP labs. The hospital failed to ensure that laboratory services provided under contract were integrated into the hospital’s laboratory oversight structure and QAPI program, as required. The hospital did not maintain effective systems to monitor the performance of the contracted laboratory, including the tracking and follow up of TNP results. 2. Refer to A 0583 as it relates to the hospital’s failure to ensure emergency lab services were provided onsite 24/7. The cumulative effect of these systemic failures resulted in the hospital’s inability to ensure the safe provision of laboratory services.”

“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: 39430 1. Based on interview, hospital document review, and pharmacy record review, the hospital failed to ensure that care was provided in a safe setting. The hospital allowed treatments, services, and medications-including controlled substances-to be entered, ordered, and administered without Physician or qualified Mid Level Practitioner involvement. The facility utilized an order source labeled “Per Pharmacy Protocol,” which permitted access to medications and treatments without a corresponding prescribing provider order. This failure created an environment in which medications, including narcotics, could be administered without documented authorization, clinical evaluation, or oversight by a licensed practitioner. These failures placed all patients receiving medications or treatments at risk for serious harm or death. Findings include: During the course of a complaint investigation, a review of the facility’s electronic medical record system and medication ordering system showed an order source titled “Per Pharmacy Protocol.” This designation allowed staff to enter and administer medications and treatments without a corresponding signed order from a Physician or Mid Level Practitioner. The process permitted access to medications-including controlled substances-without documented practitioner authorization. The Director of Pharmacy and the Director of Quality and Patient Safety were interviewed together on 2/12/26 beginning at 11:15 AM. When asked if a nurse could enter an order into the system and retrieve that medication from the Automated Dispensing Cabinet without a Physician order, the Director of Pharmacy answered, “yes.” When asked about the “Per Pharmacy Protocol” order source, this surveyor asked whether this order source would trigger a provider to sign the order in the hospital’s EMR. The Director of Pharmacy stated that a Physician would not be notified and that there was no way a provider could sign or co sign a “Per Pharmacy Protocol” order. When asked if the hospital leadership was aware of this, he stated yes, it had been discussed in leadership meetings and during the course of potential diversion investigations, starting in July of 2025, and ongoing when a hospital employee was potentially diverting medications and this was the staff member’s primary order source. When asked if the pharmacy had the ability to verify that every “Per Pharmacy Protocol” medication order in the hospital had been ordered by a practitioner authorized to order medications, he stated, “no.” Pharmacy orders were reviewed in the presence of the Hospital Pharmacy Director and the Director of Quality and Patient Safety at the time of the interview. When asked how many “Per Pharmacy Protocol” orders were input and administered in the month of December 2025, the Director of Pharmacy stated there were 288 individual orders. When asked if there was a way to see if these 288 orders were signed or ordered by a provider, he stated there was not. Hospital Medical Executive Meeting and Governing Body minutes were requested. There was no documented discussion of the “Per Pharmacy Protocol” order source and its potential to allow the diversion of medications. Review of medication administration records classified as “per pharmacy protocol” for December 2025 identified more than 188 instances in which IV medications were administered under the designation “Per Pharmacy Protocol” without a corresponding practitioner order. Additionally, the records indicated over 120 instances in which a PO medication listed as “misc med” was administered under the designation “per pharmacy Protocol without a corresponding practitioner order. The Hospital CEO was interviewed on 2/17/25 beginning at 2:45 PM. When asked about the usage of the “Per Pharmacy Protocol” order source and the knowledge of hospital leadership about this order source, the CEO stated that he became aware of the issue during the survey. He stated that there were significant leadership changes recently, and that there was a leader who did not see urgency in some items, and that some things may have “gone to leadership but not been recognized appropriately.” The absence of practitioner oversight placed patients at risk for serious harm. Without a Physician or Qualified Practitioner order, medications-including high risk or controlled substances-could be administered without verification of medical necessity, appropriate dosage, route, or frequency. The hospital failed to safeguard patients from harm by enabling medication administration without documented authorization, assessment, or oversight by a licensed practitioner. 2. Based on document review and staff interviews, the hospital failed to ensure patients received care in a safe setting. The hospital did not have a comprehensive policy and procedure that addressed how patient safety was maintained during investigations of potential medication diversion by staff. Specifically, what actions would be taken regarding the staff member under investigation. This failure had the potential to place all patients at risk for harm during periods when staff were under investigation for suspected diversion. Findings include: The hospital provided a list of potential medication diversion cases that had been investigated. When the policy and procedure for medication diversion investigations were requested, the hospital submitted a flow sheet that outlined steps for leadership notification and internal discussion. The flow sheet did not describe what actions were taken regarding the staff member under investigation, did not address whether access to medications was restricted or supervised, and did not outline any process for assessing or mitigating patient safety risks during an active investigation. During interviews with leadership and clinical staff, it was unclear how the hospital ensured patient safety while an employee was being investigated for possible diversion. Staff were unable to describe whether the employee under investigation continued to have access to controlled substances, whether patients assigned to that employee received additional monitoring, or whether any standardized protective measures were implemented. The Director of Quality and Patient Safety was interviewed on 2/11/26 beginning at 1:30 PM. She confirmed that the outlined process did not describe what actions were to be taken regarding the employee who was being investigated for potential diversion. The hospital was unable to provide documentation showing how patient safety was evaluated or maintained during any of the diversion investigations reviewed. No evidence was provided showing temporary reassignment, suspension, enhanced oversight, or other actions taken immediately upon notification of potential medication diversion to protect patients during the investigation period. The hospital failed to maintain a clear, comprehensive process to ensure patient safety during medication diversion investigations. This created the potential for ongoing patient exposure to unsafe care, including the risk of inadequate medication administration, impaired staff performance, or continued diversion of medications intended for patient treatment. The facility was notified of an Immediate Jeopardy finding at A 0144 on 2/12/26 at 1:55 PM. A plan of correction was submitted and accepted on 2/17/26 at 2:55 PM. The facility was notified the Immediate Jeopardy was removed at 2/17/26 at 3:07 PM.”

“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: 51906 Based on record review, policy review, observation, and staff interview, the hospital failed to ensure that 2 of 2 patients (Patient #1 and #18) who had restraints applied and whose records were reviewed, were free from use of restraints imposed as a means of coercion, discipline, convenience, or retaliation by staff. The hospital also failed to ensure that restraints or seclusion was discontinued at the earliest possible time. Failing to follow established restraint and seclusion policies and to implement less restrictive interventions prior to and during the use of restraints placed patients at risk for physical and psychological harm, violated their rights to be free from unnecessary restraint, and did not ensure care was provided in a safe and therapeutic manner in accordance with regulatory requirements. A hospital policy titled “Restraint and Seclusion” dated 09/2024 was reviewed. Under the title “DEFINITIONS:” was listed “II. Restraints for Nonviolent, Non Self Harm: The use of restraints to protect a patient from harm for reasons unrelated to behavior (pulling tubes, drug-induced delirium) in which there is a risk to the health of the patient with the use of restraint and alternative interventions to restraints would not be effective.” Under the title “POLICY:” was listed “II. Restraint or seclusion use will be limited to clinically justified situations, and the least restrictive restraint will be used with the goal of reducing, and ultimately eliminating, the use of restraints.” Under the title, “PROCEDURE:” the following was listed, “1. Assessment for Risk for Restraint I. When the patient displays behavior(s) that place him/her at risk for harm, the RN will perform a safety assessment. The assessment would also include patient (sic) who arrive in restraint and Patients in a restraint who have recovered from the effects of anesthesia and are awaiting transfer to a bed. This assessment includes: i. Does the patient have a medical device? ii. Does the patient understand the need to not remove the device? iii. Is the patient required to be immobile? iv. Does the patient understand the need to remain immobile? v. Is the patient exhibiting aggressive, combative or destructive behavior? vi. Does this behavior place the patient /staff/others in immediate danger? vii. Consideration for physical or behavioral conditions such as PTSD for which restraints would be contraindicated. 2. Alternative to Restraints: Alternatives approaches to managing a patient’s behavior, base (sic) on the patients age or developmental age are considered or attempted prior to attempting restraints or seclusion. These include but not (sic) limit to: I. Psychosocial Alternatives: i. Diversion, family interaction, orientation, pastoral visit, reassurance, reading, relaxation techniques, interpreter services, personal possessions available, quiet area, one-on-one discussion, decreased stimulation, change in environment, re-establishing communication, setting limits II. Environmental Alternatives: i. Commode at bedside, decreased noise, music/TV, night light, room close to nursing station, call light within reach, bed alarm in use, specialty low bed, sensory aids available (glasses, hearing aid), decreased stimulation, providing a quiet area, physical activity, orientation Ill. Physiological Alternatives: i. Toileting, fluids/nutrition/snack, pain intervention, assisted ambulation, re-positioning, rest/sleep, providing assistance, additional warmth, decreased temperature, check lab values, pharmacy consult. 3. Initiation of Restraints or/and Seclusion: The RN determines that alternatives to restraint have failed and that the patient will be safer in restraints than continuing without restraints. I. Order for Restraint I. An order for restraint must be obtained from an LIP/physician who is responsible for the care of the patient prior to the application of the restraint. The order must specify clinical justification for the restraint, the date and time ordered, the duration of use, the type of restraint to be used and behavior-based criteria for release.” This policy was not followed. Examples included: 1. Patient #1 was a 63 year old male who was admitted to the hospital after arriving to the emergency department via ambulance. He was found to have an AKI (acute kidney injury) and admitted to the hospital for treatment. Patient #1’s medical records were reviewed. A form titled “RESTRAINT ORDER” was found in Patient #1’s chart. On the form was a check next to “wrist” and a check next to “L”, and “R” indicating that Patient #1 was placed in wrist restraints and they were applied to his left and right wrists. There was an “x” next to “Violent Restraint use for this patient limited to ___ hours (must be less than 4 hrs for adults; 2 hrs for adolescents.” Indicating that the restraints are for violent behavior. The blank in the sentence was not filled in, indicating the limit of how many hours the restraints can remain on. The order was signed on 11/19/25 at 10:25 PM. A form titled, “Continuation of Restraint Episode Order” was found in Patient #1’s medical record. The form was signed on 11/19/25 at 6:28 PM. There was an “x” next to a selection option under a title of, “Non-Violent Restraints:” stating, “Continue original order up to an additional 24 hours” “Behavior necessitating restraint/seclusion use: Interfering with medical devices purposely (applied to support medical healing / non-biolent (sic), example tubes & lines). It was unclear, from reviewing these forms, if the restraints were for violent or non-violent behaviors for Patient #1. Additionally, the “Restraint Order” form did not indicate a time limit for the restraints, the clinical justification for the restraints, nor the behavior based criteria for release. Restraint monitoring logs found in Patient #’1 medical records were reviewed. A restraint monitoring form dated 11/19/25 at 10:25 PM lists the reason for the restraints as “Tubes/Lines Maintenance” with the restraints being “Wrist Soft, Both”, indicating the restraints are soft restraints and applied to both wrists. Under the prompt: “Describe behaviors/ symptoms for restraint use: HIGH RISK FOR SELF EXTUBATION” is listed. The form lists “Patients behavioral response to restraints or titration++ Calm Relaxed” “Readiness for discontinuation of restraint/seclusion++ Continue.” A restraint monitoring form dated 11/20/25 at 12:00 AM lists the reason for the restraints as “Tubes/Lines Maintenance” with the restraints being “Wrist Soft, Both”, indicating the restraints are soft restraints and applied to both wrists. Under the prompt: “Describe behaviors/ symptoms for restraint use: HIGH RISK FOR SELF EXTUBATION” is listed. The form lists “Patients behavioral response to restraints or titration++ Calm Relaxed” “Readiness for discontinuation of restraint/seclusion++ Continue.” Under the prompt “Interventions tried before restraints used++” nothing is listed. It was unclear if interventions were tried to be able to remove Patient #1 from restraints, making it unclear if restraints were the least restrictive intervention. Further, it was unclear why restraints were continued as Patient #18 was not documented as reaching for tubes/lines, being agitated, being a danger to self or others, and was documented as calm and relaxed. A restraint monitoring form dated 11/20/25 at 2:00 AM lists the reason for the restraints as “Tubes/Lines Maintenance” with the restraints being “Wrist Soft, Both”, indicating the restraints are soft restraints and applied to both wrists. Under the prompt: “Describe behaviors/ symptoms for restraint use: HIGH RISK FOR SELF EXTUBATION” is listed. The form lists “Patients behavioral response to restraints or titration++ Calm Relaxed” “Readiness for discontinuation of restraint/seclusion++ Continue.” Under the prompt “Interventions tried before restraints used++” nothing is listed. It was unclear if interventions were tried to be able to remove Patient #1 from restraints, making it unclear if restraints were the least restrictive intervention. Further, it was unclear why restraints were continued as Patient #18 was not documented as reaching for tubes/lines, being agitated, being a danger to self or others, and was documented as calm and relaxed. A restraint monitoring form dated 11/20/25 at 4:00 AM lists the reason for the restraints as “Tubes/Lines Maintenance” with the restraints being “Wrist Soft, Both”, indicating the restraints are soft restraints and applied to both wrists. Under the prompt: “Describe behaviors/ symptoms for restraint use: HIGH RISK FOR SELF EXTUBATION” is listed. The form lists “Patients behavioral response to restraints or titration++ Calm Relaxed” “Readiness for discontinuation of restraint/seclusion++ Continue.” Under the prompt “Interventions tried before restraints used++” nothing is listed. It was unclear if interventions were tried to be able to remove Patient #1 from restraints, making it unclear if restraints were the least restrictive intervention. Further, it was unclear why restraints were continued as Patient #18 was not documented as reaching for tubes/lines, being agitated, being a danger to self or others, and was documented as calm and relaxed. A restraint monitoring form dated 11/20/25 at 6:00 AM lists the reason for the restraints as “Tubes/Lines Maintenance” with the restraints being “Wrist Soft, Both”, indicating the restraints are soft restraints and applied to both wrists. Under the prompt: “Describe behaviors/ symptoms for restraint use: HIGH RISK FOR SELF EXTUBATION” is listed. The form lists “Patients behavioral response to restraints or titration++ Calm Relaxed” “Readiness for discontinuation of restraint/seclusion++ Continue.” Under the prompt “Interventions tried before restraints used++” nothing is listed. It was unclear if interventions were tried to be able to remove Patient #1 from restraints, making it unclear if restraints were the least restrictive intervention. Further, it was unclear why restraints were continued as Patient #18 was not documented as reaching for tubes/lines, being agitated, being a danger to self or others, and was documented as calm and relaxed. A restraint monitoring form dated 11/20/25 at 8:00 AM lists the reason for the restraints as “Tubes/Lines Maintenance” with the restraints being “Wrist Soft, Both”, indicating the restraints are soft restraints and applied to both wrists. Under the prompt: “Describe behaviors/ symptoms for restraint use: HIGH RISK FOR SELF EXTUBATION” is listed. The form lists “Patients behavioral response to restraints or titration++ Calm Relaxed” “Readiness for discontinuation of restraint/seclusion++ Continue.” Under the prompt “Interventions tried before restraints used++” “N/A” is listed. It was unclear if interventions were tried to be able to remove Patient #1 from restraints, making it unclear if restraints were the least restrictive intervention. Further, it was unclear why restraints were continued as Patient #18 was not documented as reaching for tubes/lines, being agitated, being a danger to self or others, and was documented as calm and relaxed. A restraint monitoring form dated 11/20/25 at 10:00 AM lists the reason for the restraints as “Tubes/Lines Maintenance” with the restraints being “Wrist Soft, Both”, indicating the restraints are soft restraints and applied to both wrists. Under the prompt: “Describe behaviors/ symptoms for restraint use: HIGH RISK FOR SELF EXTUBATION” is listed. The form lists “Patients behavioral response to restraints or titration++ Calm Relaxed” “Readiness for discontinuation of restraint/seclusion++ Continue.” Under the prompt “Interventions tried before restraints used++” “N/A” is listed. It was unclear if interventions were tried to be able to remove Patient #1 from restraints, making it unclear if restraints were the least restrictive intervention. Further, it was unclear why restraints were continued as Patient #18 was not documented as reaching for tubes/lines, being agitated, being a danger to self or others, and was documented as calm and relaxed. A restraint monitoring form dated 11/20/25 at 12:00 PM lists the reason for the restraints as “Tubes/Lines Maintenance” with the restraints being “Wrist Soft, Both”, indicating the restraints are soft restraints and applied to both wrists. Under the prompt: “Describe behaviors/ symptoms for restraint use: HIGH RISK FOR SELF EXTUBATION” is listed. The form lists “Patients behavioral response to restraints or titration++ Calm Relaxed” “Readiness for discontinuation of restraint/seclusion++ Continue.” Under the prompt “Interventions tried before restraints used++” “N/A” is listed. It was unclear if interventions were tried to be able to remove Patient #1 from restraints, making it unclear if restraints were the least restrictive intervention. Further, it was unclear why restraints were continued as Patient #18 was not documented as reaching for tubes/lines, being agitated, being a danger to self or others, and was documented as calm and relaxed. A restraint monitoring form dated 11/20/25 at 2:00 PM indicates Patient #1 is not restrained and the restraints are discontinued. Listed in comments are “EXTUBATED, COMFORT CARE.” 2. Patient #18 was a 68 year old male who presented to the ED on 02/02/26 with concern for osteomyelitis and worsening cellulitis. He was admitted to the hospital on 02/02/26 for treatment. Patient #18’s medical record was reviewed. A form titled “RESTRAINT ORDER” was found in Patient # 18’s medical record. This form was blank and did not specify the medical necessity for the restraints, the alternatives attempted, or a time limit for the restraints. In Patient #18’s medical record was a form titled “Continuation of Restraint Episode Order.” At the top of this form was noted, “Initial Restraints Ordered: Date 2/10/26 Time 8:25 AM.” This form was reviewed further and noted to have been first signed on 02/10/26 at 8:25 AM with a check mark next to the option of “Non-Violent Restraints.” It was unclear if an initial order for restraints was placed for Patient #18. The restraint log for Patient #18 was reviewed. A restraint monitoring form dated 2/10/26 at 8:00 PM lists the reason for the restraints as “Tubes/Lines Maintenance” with the restraints being “Wrist Soft, Both”, indicating the restraints are soft restraints and applied to both wrists. Under the prompt: “Describe behaviors/ symptoms for restraint use: HIGH RISK FOR SELF EXTUBATION” is listed. The form lists “Patients behavioral response to restraints or titration++ Calm Relaxed” “Readiness for discontinuation of restraint/seclusion++ Continue.” Under the prompt “Interventions tried before restraints used++” no interventions are listed. It was unclear if interventions were tried to be able to remove Patient #1 from restraints, making it unclear if restraints were the least restrictive intervention. Further, it was unclear why restraints were continued as Patient #18 was not documented as reaching for tubes/lines, being agitated, being a danger to self or others, and was documented as calm and relaxed. A restraint monitoring form dated 2/10/26 at 10:00 PM lists the reason for the restraints as “Tubes/Lines Maintenance” with the restraints being “Wrist Soft, Both”, indicating the restraints are soft restraints and applied to both wrists. Under the prompt: “Describe behaviors/ symptoms for restraint use: HIGH RISK FOR SELF EXTUBATION” is listed. The form lists “Patients behavioral response to restraints or titration++ Calm Relaxed” “Readiness for discontinuation of restraint/seclusion++ Continue.” Under the prompt “Interventions tried before restraints used++” no interventions are listed. It was unclear if interventions were tried to be able to remove Patient #1 from restraints, making it unclear if restraints were the least restrictive intervention. Further, it was unclear why restraints were continued as Patient #18 was not documented as reaching for tubes/lines, being agitated, being a danger to self or others, and was documented as calm and relaxed. A restraint monitoring form dated 2/11/26 at 12:00 AM lists the reason for the restraints as “Tubes/Lines Maintenance” with the restraints being “Wrist Soft, Both”, indicating the restraints are soft restraints and applied to both wrists. Under the prompt: “Describe behaviors/ symptoms for restraint use: HIGH RISK FOR SELF EXTUBATION” is listed. The form lists “Patients behavioral response to restraints or titration++ Calm Relaxed” “Readiness for discontinuation of restraint/seclusion++ Continue.” Under the prompt “Interventions tried before restraints used++” no interventions are listed. It was unclear if interventions were tried to be able to remove Patient #1 from restraints, making it unclear if restraints were the least restrictive intervention. Further, it was unclear why restraints were continued as Patient #18 was not documented as reaching for tubes/lines, being agitated, being a danger to self or others, and was documented as calm and relaxed. A restraint monitoring form dated 2/11/26 at 2:00 AM lists the reason for the restraints as “Tubes/Lines Maintenance” with the restraints being “Wrist Soft, Both”, indicating the restraints are soft restraints and applied to both wrists. Under the prompt: “Describe behaviors/ symptoms for restraint use: HIGH RISK FOR SELF EXTUBATION” is listed. The form lists “Patients behavioral response to restraints or titration++ Calm Relaxed” “Readiness for discontinuation of restraint/seclusion++ Continue.” Under the prompt “Interventions tried before restraints used++” no interventions are listed. It was unclear if interventions were tried to be able to remove Patient #1 from restraints, making it unclear if restraints were the least restrictive intervention. Further, it was unclear why restraints were continued as Patient #18 was not documented as reaching for tubes/lines, being agitated, being a danger to self or others, and was documented as calm and relaxed. A restraint monitoring form dated 2/11/26 at 4:00 AM lists the reason for the restraints as “Tubes/Lines Maintenance” with the restraints being “Wrist Soft, Both”, indicating the restraints are soft restraints and applied to both wrists. Under the prompt: “Describe behaviors/ symptoms for restraint use: HIGH RISK FOR SELF EXTUBATION” is listed. The form lists “Patients behavioral response to restraints or titration++ Calm Relaxed” “Readiness for discontinuation of restraint/seclusion++ Continue.” Under the prompt “Interventions tried before restraints used++” no interventions are listed. It was unclear if interventions were tried to be able to remove Patient #1 from restraints, making it unclear if restraints were the least restrictive intervention. Further, it was unclear why restraints were continued as Patient #18 was not documented as reaching for tubes/lines, being agitated, being a danger to self or others, and was documented as calm and relaxed. A restraint monitoring form dated 2/11/26 at 6:00 AM lists the reason for the restraints as “Tubes/Lines Maintenance” with the restraints being “Wrist Soft, Both”, indicating the restraints are soft restraints and applied to both wrists. Under the prompt: “Describe behaviors/ symptoms for restraint use: HIGH RISK FOR SELF EXTUBATION” is listed. The form lists “Patients behavioral response to restraints or titration++ Calm Relaxed” “Readiness for discontinuation of restraint/seclusion++ Continue.” Under the prompt “Interventions tried before restraints used++” no interventions are listed. It was unclear if interventions were tried to be able to remove Patient #1 from restraints, making it unclear if restraints were the least restrictive intervention. Further, it was unclear why restraints were continued as Patient #18 was not documented as reaching for tubes/lines, being agitated, being a danger to self or others, and was documented as calm and relaxed. A restraint monitoring form dated 2/11/26 at 2:00 AM lists the reason for the restraints as “Tubes/Lines Maintenance” with the restraints being “Wrist Soft, Both”, indicating the restraints are soft restraints and applied to both wrists. Under the prompt: “Describe behaviors/ symptoms for restraint use: HIGH RISK FOR SELF EXTUBATION” is listed. The form lists “Patients behavioral response to restraints or titration++ Calm Relaxed” “Readiness for discontinuation of restraint/seclusion++ Continue.” It was unclear why restraints were continued as Patient #18 was not documented as reaching for tubes/lines, being agitated, being a danger to self or others, and was documented as calm and relaxed. A restraint monitoring form dated 2/11/26 at 10:00 AM lists the reason for the restraints as “Tubes/Lines Maintenance” with the restraints being “Wrist Soft, Both”, indicating the restraints are soft restraints and applied to both wrists. Under the prompt: “Describe behaviors/ symptoms for restraint use: HIGH RISK FOR SELF EXTUBATION” is listed. The form lists “Patients behavioral response to restraints or titration++ Calm Relaxed” “Readiness for discontinuation of restraint/seclusion++ Continue.” It was unclear why restraints were continued as Patient #18 was not documented as reaching for tubes/lines, being agitated, being a danger to self or others, and was documented as calm and relaxed. A restraint monitoring form dated 2/11/26 at 12:00 PM lists the reason for the restraints as “Tubes/Lines Maintenance” with the restraints being “Wrist Soft, Both”, indicating the restraints are soft restraints and applied to both wrists. Under the prompt: “Describe behaviors/ symptoms for restraint use: HIGH RISK FOR SELF EXTUBATION” is listed. The form lists “Patients behavioral response to restraints or titration++ Calm Relaxed” “Readiness for discontinuation of restraint/seclusion++ Continue.” It was unclear why restraints were continued as Patient #18 was not documented as reaching for tubes/lines, being agitated, being a danger to self or others, and was documented as calm and relaxed. A restraint monitoring form dated 2/11/26 at 2:00 PM lists the reason for the restraints as “Tubes/Lines Maintenance” with the restraints being “Wrist Soft, Both”, indicating the restraints are soft restraints and applied to both wrists. Under the prompt: “Describe behaviors/ symptoms for restraint use: HIGH RISK FOR SELF EXTUBATION” is listed. The form lists “Patients behavioral response to restraints or titration++ Calm Relaxed” “Readiness for discontinuation of restraint/seclusion++ Continue.” It was unclear why restraints were continued as Patient #18 was not documented as reaching for tubes/lines, being agitated, being a danger to self or others, and was documented as calm and relaxed. A restraint monitoring form dated 2/11/26 at 4:00 PM lists the reason for the restraints as “Tubes/Lines Maintenance” with the restraints being “Wrist Soft, Both”, indicating the restraints are soft restraints and applied to both wrists. Under the prompt: “Describe behaviors/ symptoms for restraint use: HIGH RISK FOR SELF EXTUBATION” is listed. The form lists “Patients behavioral response to restraints or titration++ Calm Relaxed” “Readiness for discontinuation of restraint/seclusion++ Continue.” It was unclear why restraints were continued as Patient #18 was not documented as reaching for tubes/lines, being agitated, being a danger to self or others, and was documented as calm and relaxed. A restraint monitoring form dated 2/11/26 at 6:00 PM lists the reason for the restraints as “Tubes/Lines Maintenance” with the restraints being “Wrist Soft, Both”, indicating the restraints are soft restraints and applied to both wrists. Under the prompt: “Describe behaviors/ symptoms for restraint use: HIGH RISK FOR SELF EXTUBATION” is listed. The form lists “Patients behavioral response to restraints or titration++ Calm Relaxed” “Readiness for discontinuation of restraint/seclusion++ Continue.” It was unclear why restraints were continued as Patient #18 was not documented as reaching for tubes/lines, being agitated, being a danger to self or others, and was documented as calm and relaxed. A restraint monitoring form dated 2/11/26 at 8:00 PM lists the reason for the restraints as “Tubes/Lines Maintenance” with the restraints being “Wrist Soft, Both”, indicating the restraints are soft restraints and applied to both wrists. Under the prompt: “Describe behaviors/ symptoms for restraint use: HIGH RISK FOR SELF EXTUBATION” is listed. The form lists “Patients behavioral response to restraints or titration++ Calm Relaxed” “Readiness for discontinuation of restraint/seclusion++ Continue.” Under the prompt “Interventions tried before restraints used++” no interventions are listed. It was unclear if interventions were tried to be able to remove Patient #18 from restraints, making it unclear if restraints were the least restrictive intervention. Further, it was unclear why restraints were continued as Patient #18 was not documented as reaching for tubes/lines, being agitated, being a danger to self or others, and was documented as calm and relaxed. A restraint monitoring form dated 2/11/26 at 10:00 PM lists the reason for the restraints as “Tubes/Lines Maintenance” with the restraints being “Wrist Soft, Both”, indicating the restraints are soft restraints and applied to both wrists. Under the prompt: “Describe behaviors/ symptoms for restraint use: HIGH RISK FOR SELF EXTUBATION” is listed. The form lists “Patients behavioral response to restraints or titration++ Calm Relaxed” “Readiness for discontinuation of restraint/seclusion++ Continue.” Under the prompt “Interventions tried before restraints used++” no interventions are listed. It was unclear if interventions were tried to be able to remove Patient #18 from restraints, making it unclear if restraints were the least restrictive intervention. Further, it was unclear why restraints were continued as Patient #18 was not documented as reaching for tubes/lines, being agitated, being a danger to self or others, and was documented as calm and relaxed. A restraint monitoring form dated 2/12/26 at 12:00 AM lists the reason for the restraints as “Tubes/Lines Maintenance” with the restraints being “Wrist Soft, Both”, indicating the restraints are soft restraints and applied to both wrists. Under the prompt: “Describe behaviors/ symptoms for restraint use: HIGH RISK FOR SELF EXTUBATION” is listed. The form lists “Patients behavioral response to restraints or titration++ Calm Relaxed” “Readiness for discontinuation of restraint/seclusion++ Continue.” Under the prompt “Interventions tried before restraints used++” no interventions are listed. It was unclear if interventions were tried to be able to remove Patient #18 from restraints, making it unclear if restraints were the least restrictive intervention. Further, it was unclear why restraints were continued as Patient #18 was not documented as reaching for tubes/lines, being agitated, being a danger to self or others, and was documented as calm and relaxed. A restraint monitoring form dated 2/12/26 at 2:00 AM lists the reason for the restraints as “Tubes/Lines Maintenance” with the restraints being “Wrist Soft, Both”, indicating the restraints are soft restraints and applied to both wrists. Under the prompt: “Describe behaviors/ symptoms for restraint use: HIGH RISK FOR SELF EXTUBATION” is listed. The form lists “Patients behavioral response to restraints or titration++ Calm Relaxed” “Readiness for discontinuation of restraint/seclusion++ Continue.” Under the prompt “Interventions tried before restraints used++” no interventions are listed. It was unclear if interventions were tried to be able to remove Patient #18 from restraints, making it unclear if restraints were the least restrictive intervention. Further, it was unclear why restraints were continued as Patient #18 was not documented as reaching for tubes/lines, being agitated, being a danger to self or others, and was documented as calm and relaxed. A restraint monitoring form dated 2/12/26 at 4:00 AM lists the reason for the restraints as “Tubes/Lines Maintenance” with the restraints being “Wrist Soft, Both”, indicating the restraints are soft restraints and applied to both wrists. Under the prompt: “Describe behaviors/ symptoms for restraint use: HIGH RISK FOR SELF EXTUBATION” is listed. The form lists “Patients behavioral response to restraints or titration++ Calm Relaxed” “Readiness for discontinuation of restraint/seclusion++ Continue.” Under the prompt “Interventions tried before restraints used++” no interventions are listed. It was unclear if interventions were tried to be able to remove Patient #18 from restraints, making it unclear if restraints were the least restrictive intervention. Further, it was unclear why restraints were continued as Patient #18 was not documented as reaching for tubes/lines, being agitated, being a danger to self or others, and was documented as calm and relaxed. A restraint monitoring form dated 2/11/26 at 6:00 AM lists the reason for the restraints as “Tubes/Lines Maintenance” with the restraints being “Wrist Soft, Both”, indicating the restraints are soft restraints and applied to both wrists. Under the prompt: “Describe behaviors/ symptoms for restraint use: HIGH RISK FOR SELF EXTUBATION” is listed. The form lists “Patients behavioral response to restraints or titration++ Calm Relaxed” “Readiness for discontinuation of restraint/seclusion++ Continue.” Under the prompt “Interventions tried before restraints used++” no interventions are listed. It was unclear if interventions were tried to be able to remove Patient #18 from restraints, making it unclear if restraints were the least restrictive intervention. Further, it was unclear why restraints were continued as Patient #18 was not documented as reaching for tubes/lines, being agitated, being a danger to self or others, and was documented as calm and relaxed. A restraint monitoring form dated 2/12/26 at 7:49 AM lists the reason for the restraints as “Tubes/Lines Maintenance” with the restraints being “Wrist Soft, Both”, indicating the restraints are soft restraints and applied to both wrists. Under the prompt: “Describe behaviors/ symptoms for restraint use: HIGH RISK FOR SELF EXTUBATION” is listed. The form lists “Patients behavioral response to restraints or titration++ Calm Relaxed” “Readiness for discontinuation of restraint/seclusion++ Continue.” It was unclear why restraints were continued as Patient #18 was not documented as reaching for tubes/lines, being agitated, being a danger to self or others, and was documented as calm and relaxed. A restraint monitoring form dated 2/12/26 at 10:00 AM lists the reason for the restraints as “Tubes/Lines Maintenance” with the restraints being “Wrist Soft, Both”, indicating the restraints are soft restraints and applied to both wrists. Under the prompt: “Describe behaviors/ symptoms for restraint use: HIGH RISK FOR SELF EXTUBATION” is listed. The form lists “Patients behavioral response to restraints or titration++ Calm Relaxed” “Readiness for discontinuation of restraint/seclusion++ Continue.” It was unclear why restraints were continued as Patient #18 was not documented as reaching for tubes/lines, being agitated, being a danger to self or others, and was documented as calm and relaxed. A restraint monitoring form dated 2/12/26 at 12:00 PM lists the reason for the restraints as “Tubes/Lines Maintenance” with the restraints being “Wrist Soft, Both”, indicating the restraints are soft restraints and applied to both wrists. Under the prompt: “Describe behaviors/ symptoms for restraint use: HIGH RISK FOR SELF EXTUBATION” is listed. The form lists “Patients behavioral response to restraints or titration++ Calm Relaxed” “Readiness for discontinuation of restraint/seclusion++ Continue.” It was unclear why restraints were continued as Patient #18 was not documented as reaching for tubes/lines, being agitated, being a danger to self or others, and was documented as calm and relaxed. A restraint monitoring form dated 2/12/26 at 2:00 PM lists the reason for the restraints as “Tubes/Lines Maintenance” with the restraints being “Wrist Soft, Both”, indicating the restraints are soft restraints and applied to both wrists. Under the prompt: “Describe behaviors/ symptoms for restraint use: HIGH RISK FOR SELF EXTUBATION” is listed. The form lists “Patients behavioral response to restraints or titration++ Calm Relaxed” “Readiness for discontinuation of restraint/seclusion++ Continue.” It was unclear why restraints were continued as Patient #18 was not documented as reaching for tubes/lines, being agitated, being a danger to self or others, and was documented as calm and relaxed. A restraint monitoring form dated 2/12/26 at 2:54 PM lists that Patient #18 is ready for discontinuation of restraints and notes “EXTUBATED.” On 2/11/26 at 9:28 AM and observation of Patient #18 was completed by surveyors. Patient #18 was observed to being sift writs restraints that were applied to both his left and right wrists. Patient #18 was observed during medication administration and during an echocardiogram. The observation of Patient #18 lasted for 21 minutes. At no time during the surveyors’ observations did the surveyors observe any meaningful or unmeaningful movement from Patient #18. The Quality Director was interviewed on 2/11/26 beginning at11:00 AM. The observation from the surveyors were shared with her. Patient #1 and Patient #18’s charts were reviewed in her presence. She acknowledged the lack of accurate documentation for the restraint orders and ongoing documentation of restraints and interventions attempted. The hospital failed to ensure that least restrictive interventions were continually attempted to ensure that the least restrictive intervention was used and that the restraints were discontinued at the earliest possible time and not used for convenience.”

“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: 49416 Based on policy review and staff interview, the hospital failed to ensure nursing leadership for the specialized units was qualified to provide the necessary clinical supervision, direction, and evaluation of nursing care for critically ill patients. Specifically, the hospital failed to ensure 1 of 1 Nurse Directors, whose training files was reviewed, possessed the specialized competencies and clinical experience required to oversee the high-acuity interventions unique to an intensive care environment. The hospital had a position description titled, “Position Description and Analysis” for the Department Director Position, dated revised 7/18. The position description stated in part, “Under the direction and supervision of the CNO, [the Nurse Director] has line and functional responsibility for departmental management. Responsibilities shall include but, not necessarily limited to: Direct supervision of the function and activities in the department: interpreting polices, standard and regulations of the Division of Nursing to department personnel, patient, medical staff and public and responsibility for patient care on a 24-hour basis.” The hospital failed to ensure these responsibilities were implemented as written. Findings included: The Nurse Director was interviewed on 2/18/26 beginning at 9:40 AM. The Nurse Director confirmed she has never worked in a high-acuity or intensive care setting and would not accept an ICU patient assignment due to lack of competency and comfort with high-acuity patient care requirements. She stated her assistance on the unit is limited to basic nursing tasks such as medication administration, assisting with routine patient care, witnessing medication administration, and obtaining supplies. The Nurse Director confirmed she does not perform or maintain competency in high-acuity interventions including ventilator management, titration of vasoactive or other continuous intravenous infusions, or management of critically ill patients. She further stated she relied on charge nurses to oversee staff competencies, evaluation, and training related to high-acuity care. The hospital failed to ensure the Nurse Director maintained the clinical competence necessary to provide supervision, direction, and evaluation of nursing care in accordance with the position description and the expectations for 24-hour responsibility for patient care. This created a supervisory gap in which the individual responsible for oversight of clinical standards in a critical care environment was unable to directly supervise, support, or evaluate life-sustaining interventions, including emergency response and management of complex, high-risk therapies. The failure has the potential to affect all critically ill patients requiring intensive nursing care services. .”

“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: 49416 Based on record review and interview, the hospital failed to ensure nursing staff provided ongoing assessment, monitoring, and timely intervention in response to abnormal vital signs and changes in patient condition for 1 of 1 sampled patient (Patient #18), who subsequently experienced a cardiopulmonary arrest requiring intubation and transfer to the ICU. Findings included: Patient #18 was a 68-year-old male admitted on 2/02/26 from an outside facility with a primary diagnosis of osteomyelitis of the right foot and additional diagnoses including severe PAD, chronic normocytic anemia, T2DM, HTN, and stable CKD. Patient #18’s Medical record included that on 2/10/26 at 12:11 AM, Patient #18’s oxygen saturation was documented at 84% while receiving oxygen at 5 LPM. The record indicated the nurse was notified. There was no documented nursing assessment, reassessment of respiratory status, adjustment of oxygen flow rate, notification of the provider, notification of respiratory therapy, initiation of rapid response, or other intervention in response to the abnormal oxygen saturation. At 5:37 AM on 2/10/26, the provider was notified of a blood pressure of 170/90 and nasal blood clots. There was no documented nursing follow-up, reassessment, or intervention related to these findings for Patient #18’s . On 2/10/26 at 7:40 AM, Patient #18’s medical record documented a cardiopulmonary arrest/coded, was intubated, and transferred to the ICU. On 2/18/26 at 10:23 AM, Med/Surg Nurse Manager was interviewed. Med/Surg Nurse Manager stated she would expect the CNA to notify the registered nurse of abnormal findings, and the registered nurse to complete an assessment and follow up with the provider or respiratory therapy as indicated. Med/Surg Nurse Manager confirmed there were areas for improvement in the care of Patient #18, including failure to perform a respiratory assessment, failure to provide follow-up for the documented oxygen saturation of 84% on 5 LPM, and failure to adjust oxygen therapy. Med/Surg Nurse Manager stated, “I would be calling a rapid response if I could not maintain oxygen level at 5 LPM.” The hospital’s failure to ensure timely nursing assessment, intervention, and escalation of care in response to documented hypoxia and other abnormal clinical findings resulted in a lack of appropriate monitoring and treatment of a deteriorating patient condition prior to cardiopulmonary arrest.”

“ORDERS FOR DRUGS AND BIOLOGICALS CFR(s): Orders for drugs and biologicals may be documented and signed by other practitioners, not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. This Standard is not met as evidenced by: 39430 Based on interview, Idaho Code board of medicine rules, hospital document review, and pharmacy record review, the hospital failed to ensure that all orders for drugs and biologicals were documented and signed by a practitioner responsible for the care of the patient or otherwise authorized under hospital policy, medical staff bylaws, and Idaho State law. The hospital permitted nursing and other staff to initiate, enter, retrieve, and administer medications-including controlled substances-under an internal order source labeled “Per Pharmacy Protocol” without a practitioner oversite or order. This practice did not comply with the Idaho Board of Medicine statutes governing prescribing and the practice of medicine, including: - Idaho Code §37 2722 (Board of Medicine), which stated: “Issuing, distributing, and dispensing of controlled substances. No person shall issue or dispense a prescription drug order for a controlled substance unless it is in compliance with applicable state and federal law and rules of the board... Be dispensed only pursuant to a valid prescription drug order, except when dispensed directly by a prescriber.” This authority prohibit nurses and other licensed individuals not licensed under the Idaho Board of medicine from independently prescribing, ordering, initiating, or entering medication orders without a licensed practitioner’s authorization or a lawful standing order. This had the potential for medications-including narcotics- to be available for administration without required practitioner oversight, clinical evaluation, or authentication in the medical record, placing patients at risk for serious harm or death. Findings included: A review of the electronic medical record and medication ordering system showed an order source titled “Per Pharmacy Protocol.” This order source allowed staff to enter and administer medications without a corresponding Physician or Mid Level Practitioner order. The Director of Pharmacy and the Director of Quality and Patient Safety were interviewed on 2/12/26 at 11:15 AM. The Pharmacy Director confirmed that nurses could enter orders and obtain medications from the Automated Dispensing Cabinet without a practitioner order. He stated the EMR did not notify any practitioner of the order, and practitioner authentication was not possible for “Per Pharmacy Protocol” orders. He stated leadership had been aware of issues related to this order source as early as July 2025, including during diversion investigations, and confirmed that pharmacy had no means of verifying whether these orders had practitioner authorization. Pharmacy records showed over 250 “Per Pharmacy Protocol” orders in December 2025, with no method to determine whether any were signed or ordered by an authorized practitioner. Review of medication administration records for December 2025 identified: - 188 IV medications administered under “Per Pharmacy Protocal” as the order source. - Over 120 PO medications listed as “misc med” administered under “Per Pharmacy Protocal” as the order source. Review of Hospital Medical Executive Committee and Governing Body minutes revealed no documentation of discussion or oversight of the “Per Pharmacy Protocol” order source. The Hospital CEO was interviewed on 2/17/25 at 2:45 PM and stated he became aware of the issue during the survey. He referenced leadership turnover and stated some issues may have “gone to leadership but not been recognized appropriately.” The hospital failed to safeguard patients from harm by enabling medication order and administration without practitioner authorization, assessment, or oversight. This had the potential to expose patients to unsafe medication administration without verification of medical necessity, dose, route, frequency, or contraindications.”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 49416 Based on interview and medical record review, the hospital failed to ensure all medical records were accurate for 3 of 3 patients (Patient #12, #16, and #17) whose surgeries were observed and records reviewed. Patient #12 was a 26 year old male who was scheduled for “venaseal right leg great saphenous vein” and had surgery on 2/10/26 per medical record review. The procedure was performed by Provider A. Patient #12 ’ s medical record documented “ASA and Mallampati assessed and documented by MD in patient chart” at 11:50 AM on 2/10/26. Patient #12 ’ s medical record contained the completed ASA and Mallampati score form which was signed by Provider A at 12:10 PM on 2/10/26. Patient #12 ’ s medical record documented the procedure was completed and the patient was transferred to OPHV at 12:25 PM on 2/10/26. The pre-operative course and procedure was observed for Patient #12. This surveyor did not observe Provider A assess Patient #12 prior to the procedure, including once in the procedure room. This surveyor did not observe Provider A assess current vital signs or assess inside Patient #12 ’ s mouth to determine the Mallampati score. Patient #16 was a 52 year old female who was scheduled for “diagnostic cerebral angiogram” and had the procedure on 2/11/26 per medical record review. The procedure was performed by Provider A. Patient #16 ’ s medical record documented “ASA and Mallampati assessed and documented by MD in patient chart” at 9:40 AM on 2/11/26. “Physician Arrived” is documented in the procedure notes of Patient #16 ’ s medical at 9:49 AM on 2/11/26. Patient #16 ’ s medical record contained the completed ASA and Mallampati score form which was signed by Provider A at 10:12 AM on 2/11/26. Patient #16 ’ s medical record documented the procedure was completed and the patient was transferred to OPHV at 10:13 AM on 2/11/26. The procedure was observed for Patient #16. This surveyor did not observe Provider A assess Patient #16 in the procedure room. This surveyor did not observe Provider A assess or review current vital signs or assess inside Patient #16 ’ s mouth to determine the Mallampati score. Patient #17 was an 84 year old male who was scheduled for “prostate artery embolization” and had the procedure on 2/11/26 per medical record review. The procedure was performed by Provider A. Patient #17’s medical record documented “ASA and Mallampati assessed and documented by MD in patient chart” at 10:21 AM on 2/11/26. Patient #17 ’ s medical record contained the completed ASA and Mallampati score form signed by Provider A at 11:12 AM on 2/11/26. Patient #17 ’ s medical record documented the procedure was completed and the patient was transferred to OPHV at 11:18 AM on 2/11/26. The procedure was observed for Patient #17. This surveyor did not observe Provider A assess Patient #17 in the procedure room. This surveyor did not observe Provider A assess or review current vital signs or assess inside Patient #17 mouth to determine the Mallampati score. The nurse manager of the Cath Lab PACU was interviewed on 2/18/26 beginning at 9:20 AM. The Nurse manager confirmed Provider A does not, as normal practice, enter the pre or post operative area to assess the patient. The nurse manager confirmed the Cath lab RN, as normal practice, completes the pre procedure assessment. The nurse present during the procedure was interviewed on 2/19/26 beginning at 9:10 AM. The nurse confirmed nurses prep the patient prior to procedure and get baseline vitals pre procedure. When asked if Provider A looked in the patients’ mouths prior to surgery, the nurse reported they did not observe that. When asked if Provider A assesses the patient prior to surgery, the nurse reported he documents a reassessment. The failure of the facility to ensure all medical records are accurate represents a potential risk and affects ongoing care for all patients.”

“EMERGENCY LABORATORY SERVICES CFR(s): 482.27(a)(1) Emergency laboratory services must be available 24 hours a day. This Standard is not met as evidenced by: 39430 Based on interview and document review, the hospital failed to ensure that onsite emergency laboratory services were organized, defined, and available 24 hours a day, 7 days a week as required. The hospital had no policies, no Medical Staff-approved emergency laboratory test menu, no master list of onsite emergency laboratory testing, and no leadership oversight ensuring that all hospital units’ emergency testing needs-including Emergency Department, trauma, stroke, ICU, obstetrics, and cardiac catheterization services-were identified and supported. These failures had the potential to affect all patients requiring emergency or time sensitive laboratory testing. Findings include: The hospital was asked to provide a list of laboratory services offered onsite 24/7. Surveyors were given a document titled “[Hospital] STAT Laboratory Testing Menu.” The document listed the following tests: - Amnisure ROM - Qualitative urine hCG - Rapid strep A - Mononucleosis screen - Rapid HIV - CBC with differential - Urinalysis - Urine drug screen - Basic blood bank functions The STAT menu did not include chemistry testing, coagulation studies, cardiac biomarkers, metabolic panels, lactate, or arterial blood gases, all of which are standard emergency laboratory tests necessary for the hospital’s level of services. The Quality Director was interviewed on 2/17/26 at 3:30 PM. She stated that the facility used the “i STAT” device for certain tests, but there was no hospital policy or governing document identifying iSTAT testing as part of the emergency laboratory services menu. The Lab Director was interviewed on 2/18/26 beginning at 2:30 PM. When asked whether the iSTAT laboratory menu represented all tests provided in the laboratory, she stated yes. When asked whether other tests were performed in the hospital, she stated yes, and identified Point of Care Testing (POCT) such as arterial blood gases and metabolic panels. She acknowledged that the hospital had not developed or implemented a master list of emergency laboratory tests, and that it was unclear which tests were performed onsite versus which were sent to the contracted offsite laboratory. The hospital could not demonstrate that all hospital units’ emergency testing needs-including ED, trauma, stroke, ICU, OB, and cardiac catheterization-had been assessed or considered when determining emergency laboratory services. Review of Medical Staff meeting minutes revealed no evidence that the Medical Staff had reviewed, determined, or approved an emergency laboratory test menu. There was no documentation that the Medical Staff had verified the adequacy of onsite emergency lab testing for services the hospital provided. The hospital failed to maintain clear, defined, and Medical Staff-approved emergency laboratory services, and failed to ensure leadership oversight of emergency testing available onsite 24/7.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 49416 Based on observation, interview, and record review, the hospital failed to ensure adherence to infection prevention and control practices related to hand hygiene and appropriate glove use during an invasive procedure for 1 of 3 patients observed (Patient #16). Patient #17 was an 84-year-old male scheduled for a prostate artery embolization on 2/11/26. Medical record review confirmed the procedure was performed on 2/11/26 by Provider A. The surveyor observed the procedure on 2/11/26. During the procedure, the circulating RN was observed to leave the procedure room wearing gloves, retrieve an item, and return to the procedure room without removing or changing gloves and without performing hand hygiene. Upon re-entering the room, the circulating RN was observed touching the patient and then touching additional items in the room without changing gloves or performing hand hygiene. The circulating RN was then observed administering medication into the patient’s IV without gloves and without performing hand hygiene before or after the task. On 2/11/26 at 11:30 AM, the circulating RN was interviewed and confirmed hand hygiene and glove changes are expected in the procedure room between tasks and upon leaving and re-entering the room. The hospital’s failure to ensure staff adhered to established hand hygiene and glove use practices during an invasive procedure has the potential to place patients at risk for transmission of infectious agents and procedure-related infections.”

“UPDATED EXAM CFR(s): Prior to surgery or a procedure requiring anesthesia services and except in the case of emergencies: (ii) An updated examination of the patient, including any changes in the patient’s condition, must be completed and documented within 24 hours after admission or registration when the medical history and physical examination are completed within 30 days before admission or registration and except as provided under paragraph (b)(1)(iii) of this section. This Standard is not met as evidenced by: 49416 Based on staff interview, observation, policy review, medical bylaws review, and record review, the facility failed to ensure a comprehensive physical examination was conducted by a physician prior to a surgical procedure for 3 of 3 patients whose surgeries were observed (Patient #12, #16, and #17). Findings include: The hospital medical staff bylaw included and undated article titled: Article 3.4 “History and Physical examinations and initial assessment.” The bylaws stated “When the history and physical examination is conducted within thirty (30) days before admission or registration, an update must be completed or certified and documented by a qualified practitioner or AHP who is credentialed and privileged by the Hospital’s medical staff to perform a history and physical examination. An updated examination of the patient, including any changes in the patient’s condition, must be completed and documented within twenty-four (24) hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services.” These bylaws were not followed, Examples included: Patient #12 was a 26-year-old male who was scheduled for “venaseal right leg great saphenous vein” and had surgery on 2/10/26 per medical record review. The procedure was performed by Provider A. The medical record contained a History and Physical (H&P) dated 2/04/26, signed by FNP-C, which was performed six days prior to the surgery. Further review of the surgical pre-operative notes and the physician’s progress notes failed to provide evidence Provider A personally assessed or examined the patient on the day of the procedure to validate the findings of the previous H&P. Patient #12’s medical record documented “ASA and Mallampati assessed and documented by MD in patient chart” at 11:50 AM on 2/10/26. Patient #12’s medical record contained the completed ASA and Mallampati score form which was signed by Provider A at 12:10 PM on 2/10/26. Patient #12’s medical record documented the procedure was completed and the patient was transferred to OPHV at 12:25 PM on 2/10/26. The pre-operative course and procedure was observed for Patient #12. This surveyor did not observe Provider A assess Patient #12 prior to the procedure, including once in the procedure room. This surveyor did not observe Provider A assess current vital signs or assess inside Patient #12 ’ s mouth to determine the Mallampati score. It was unclear how Provider A documented a current ASA and Mallampati score. Patient #16 was a 52-year-old female who was scheduled for “diagnostic cerebral angiogram” and had the procedure on 2/11/26 per medical record review. The procedure was performed by Provider A. Patient #16’s medical record contained a History and Physical (H&P) dated 1/29/26, signed by Provider A, which was performed twelve days prior to the surgery. Further review of the surgical pre-operative notes and the physician’s progress notes failed to provide evidence Provider A personally assessed or examined the patient on the day of the procedure to validate the findings of the previous H&P. Patient #16 ’ s medical record documented “ASA and Mallampati assessed and documented by MD in patient chart” at 9:40 AM on 2/11/26. “Physician Arrived” is documented in the procedure notes of Patient #16 ’ s medical at 9:49 AM on 2/11/26. Patient #16 ’ s medical record contained the completed ASA and Mallampati score form which was signed by Provider A at 10:12 AM on 2/11/26. Patient #16 ’ s medical record documented the procedure was completed and the patient was transferred to OPHV at 10:13 AM on 2/11/26. The procedure was observed for Patient #16. This surveyor did not observe Provider A assess Patient #16 in the procedure room. This surveyor did not observe Provider A assess or review current vital signs or assess inside Patient #16’ s mouth to determine the Mallampati score. Patient #17 was an 84-year-old male who was scheduled for “prostate artery embolization” and had the procedure on 2/11/26 per medical record review. The procedure was performed by Provider A. Patient #17 ’ s medical record contained a History and Physical (H&P) dated 2/04/26, signed by Provider A, which was performed seven days prior to the surgery. Further review of the surgical pre-operative notes and the physician’s progress notes failed to provide evidence Provider A personally assessed or examined the patient on the day of the procedure to validate the findings of the previous H&P. Patient #17 medical record documented “ASA and Mallampati assessed and documented by MD in patient chart” at 10:21 AM on 2/11/26. Patient #17’s medical record contained the completed ASA and Mallampati score form which was signed by Provider A at 11:12 AM on 2/11/26. Patient #17 ‘s medical record documented the procedure was completed and the patient was transferred to OPHV at 11:18 AM on 2/11/26. The procedure was observed for Patient #17. This surveyor did not observe Provider A assess Patient #17 in the procedure room. This surveyor did not observe Provider A assess or review current vital signs or assess inside Patient #17 mouth to determine the Mallampati score. The nurse manager of the Cath Lab PACU was interviewed on 2/18/26 beginning at 9:20 AM. The Nurse manager confirmed Provider A does not, as normal practice, enter the pre or post operative area to assess the patient. The nurse manager confirmed the Cath lab RN, as normal practice, completes the pre procedure assessment. The nurse present during the above procedures was interviewed on 2/19/26 beginning at 9:10 AM. The nurse confirmed the nurses prep the patient prior to procedure and get baseline vitals pre procedure. The nurse confirmed Provider A is provided with the H&P but does not routinely look at baseline vitals or pre surgery paperwork prior to initiating the procedure. When asked if Provider A looked in the patients’ mouths prior to surgery, the nurse reported they did not observe that. When asked if Provider A assesses the patient prior to surgery, the nurse reported he documents a reassessment. The failure of the facility to ensure all patients receive an updated assessment to assess patient ’ s condition prior to receiving treatment and/or anesthesia represents a possible risk to all surgical patients.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 39430 Based on observation, staff interview, and review of medical records, bylaws, and hospital documents it was determined the hospital failed to ensure the Governing Body was effective and assumed responsibility for the conduct of the hospital staff. This resulted in the inability of the Governing Body to direct staff in the provision of patient care. It had the potential to impact all patients who received care at the hospital. Findings include: on record review, hospital document review, staff bylaws review, and staff interviews 1. Refer to A - 0049 as it relates to the failure of the governing body to ensure medical staff were accountable to the Governing Body for the quality of patient care. 2. Refer to A - 0405 as it relates to the failure of hospital staff to administer medications as ordered by a physician. 3. Refer to A - 0407 as it relates to the failure of hospital staff including physicians’ over-utilization verbal orders. These systemic failures significantly impeded the ability of the hospital to provide safe patient care.”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 39430 Based on record review, hospital document review, staff bylaws review, and staff interviews, it was determined the hospital failed to ensure its medical staff was accountable to the governing body for the quality of care provided to patients. This caused verbal orders to be over utilized. This resulted in controlled substances administered to 3 of 8 patients whose records were reviewed (Patients #1-3) without the order of a physician. Additionally, this had the potential to affect all patients receiving care in the hospital. Findings include: 1. Patient #1 was an 82 year old male who presented to the ED on 4/27/25 with the chief complaint of left knee pain. Patient #1 was subsequently admitted to the hospital and discharged on 5/01/25. Patient #1 received an ultrasound, CT scan, x-ray, and arthrocentesis. Patient #1’s record showed 5 verbal orders and one of unclear origin. Two verbal orders for conscious sedation were not signed by the ordering provider. A review of Patient #1 ‘s medical record revealed that two controlled substances, Hydromorphone and Midazolam, were administered on 4/29/25 at 11:22 AM by an RN. The record indicated a verbal order had been given by a physician; however, there was no signature or authentication from the physician. The facility provided a medication cabinet override list, detailing instances where medications were retrieved from cabinets without a physician order. This list included Patient #1’s RN accessed Hydromorphone and Midazolam via an override. An interview was conducted with the listed ordering physician 5/21/25 at 2:40 PM, and Patient #1’s medical record was reviewed in his presence. When asked whether he had ordered Midazolam and Hydromorphone for Patient #1, he denied providing any verbal orders and stated he had no communication with the dayshift nurses regarding Patient #1. He further stated he did not know how his name became associated with the medication orders. An interview with the Director of Quality was conducted on 5/21/25 at 10:30 AM, during which Patient #1’s medical record was reviewed. She confirmed the missing provider authentication. She stated she had investigated the orders and based on her investigation, suggested that the medication order may have been verbally given to a nightshift RN by the provider but was not entered into the EMR. The nightshift RN then relayed the verbal order to the dayshift RN, who subsequently retrieved the medication via override. The Director of Quality confirmed this practice was not permitted at the facility. 2. Patient #2 was an 82 year old male who presented to the ED on 4/21/25 with the chief complaint of acute bilateral embolism. Patient #2 was admitted to the hospital and discharged on 4/24/25. Patient #2 received an x-ray, ultrasound, CT scan, and thrombectomy. Patient #2’s medical records were reviewed. Patient #2’s record showed 9 verbal orders. Additionally, 10 orders were not signed by a provider. The unsigned physician verbal orders included, but were not limited to midazolam, fentanyl, and lidocaine. 3. Patient #3 was a 67 year old female who presented to the ED on 4/27/25 with chief complaint of cardiac arrest. Patient #2 was admitted and died on 5/1/25. Patient #3 was intubated and received an EEG, CT scan, cardiac catheterization, and an MRI. Patient #3’s medical records were reviewed. Patient #3’s record showed 38 verbal orders. Sixteen of the verbal orders were signed 5 days after the verbal order and one day after the patient had died. Additionally, 10 orders were not signed by a provider. Patient#1, #2, and #3’s medical records were reviewed with the Patient Safety Coordinator on 5/21/25 at 1:30 PM. She confirmed the missing provider authentication of the above verbal orders. She stated all verbal orders needed to be signed by the ordering provider. The Director of Pharmacy was interviewed on 5/21/25 at 9:00 AM. When asked about the overutilization of verbal orders and medication overrides, where medications were accessed from cabinets without a physician-entered order in the hospital’s EMR, he stated the issue had existed prior to his tenure and continued currently, due to procedural drift among physicians and nurses. He acknowledged the problem and had sent a memo outlining new procedures for verbal order usage; however, a new governing-body-approved policy had not been finalized at the time of the survey. A hospital memo sent on 5/09/25 to staff and physicians outlined procedures for utilizing verbal orders, but no formal governing-body-approved policy was in place to ensure compliance. The Chief of Staff was interviewed on 5/21/25 at 2:30 PM. When asked about his role, he stated that he runs meetings and helps coordinate hospital matters. When asked how he oversees physician quality of care throughout the hospital, he stated he does not oversee individual physicians directly. Regarding verbal order overutilization, he indicated that he had only been made aware of the issue the previous week, acknowledging that a memo had been sent but stating, “I may have been CC’ d on it.” There was no indication from the interview that the Chief of Staff had oversight of physician verbal order usage throughout the hospital. Hospital staff bylaws were reviewed. Under the section titled “Chief of Staff” stated the Chief of Staff was responsible to the board, in conjunction with the Medical Executive Committee, for the quality and efficiency of clinical services and professional performance within the hospital. However, interviews revealed a lack of oversight in fulfilling this responsibility The hospital Quality Director was interviewed on 5/21/25 at 3:15 PM. When asked who was appointed by the governing body to oversee medical staff conduct and quality of care, she stated that responsibility belonged to the Chief of Staff. The hospital failed to ensure medical staff were accountable to the governing body regarding the overutilization of verbal orders.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 39430 Based on review of medical records and staff interview, it was determined the hospital failed to ensure orders for the administration of medications were administered under the order of the practitioner or practitioners responsible for the patient’s care for 3 of 7 patients (Patient #1, #2, #3) whose records were reviewed. Additionally, this had the potential to create unsafe medication administration with no physician or provider involvement. Findings include: Patient medical records were reviewed. The medical records reviewed showed frequent usage of verbal orders with no authentication or follow up by the ordering provider making it unclear if the provider had ordered the medication. Examples included but were not limited to: 1. Patient #1 was an 82 year old male who presented to the ED on 4/27/25 with the chief complaint of left knee pain. Patient #1 was subsequently admitted to the hospital and discharged on 5/1/25. Patient #1 received an ultrasound, CT scan, x-ray, and arthrocentesis. Patient #1’s medical records were reviewed. Patient #1’s record showed 4 verbal medication orders and one of unclear origin with no physician signature. A review of Patient #1’s medical record revealed that two controlled substances, Hydromorphone and Midazolam, were administered on 4/29/25, at 11:22 AM by an RN. The record indicated a verbal order had been given by a physician; however, there was no signature or authentication from the ordering physician. The facility provided a medication cabinet override list, detailing instances where medications were retrieved from cabinets without a physician-entered order in the hospital’s EMR. This list confirmed Patient #1’s nurse accessed Hydromorphone and Midazolam via an override. An interview was conducted with the ordering physician 5/21/25 at 2:40 PM, and Patient #1’s medical record was reviewed in his presence. When asked whether he had ordered Midazolam and Hydromorphone for Patient #1, he denied providing any verbal orders and stated he had no communication with the dayshift nurses regarding Patient #1. He further stated he did not know how his name became associated with the medication orders. 2. Patient #2 was an 82 year old male who presented to the ED with chief complaint of acute bilateral embolism on 4/21/25. Patient #2 was admitted to the hospital and discharged on 4/24/25. Patient #2 received an x-ray, ultrasound, CT scan, and thrombectomy. Patient #2’s medical records were reviewed. Patient #2’s record showed 4 verbal medication orders of with no physician signature. The unsigned physician verbal orders included, but were not limited to, midazolam, fentanyl, and lidocaine. 3. Patient #3 was a 67 year old female who presented to the ED with chief complaint of cardiac arrest on 4/27/25. Patient #2 was admitted and died on 5/1/25. Patient #3 was intubated and received EEG, CT scan, cardiac catheterization, and an MRI. Patient #3’s medical records were reviewed. Patient #3’s record showed 4 verbal medication orders. The 4 verbal medication orders were not signed by a provider. Patient#1, #2, and #3’s medical records were reviewed with the Patient Safety Coordinator on 5/21/25 at 1:30 PM. She confirmed the missing provider authentication of the above verbal orders. She stated all verbal orders needed to be signed by the ordering provider. It was unclear why the above patients’ verbal orders were not authenticated by the ordering providers in a timely manner. The hospital failed to ensure all orders were signed by the ordering provider.”

“VERBAL ORDERS FOR DRUGS CFR(s): 482.23(c)(3)(i) If verbal orders are used, they are to be used infrequently. This Standard is not met as evidenced by: 49416 Based on record review and staff interview, it was determined the facility failed to ensure the use of verbal orders was not a common practice and was not used for the convenience of the ordering practitioner. This failure directly impacted 3 of 7 patients (Patients #1, #2, and #3) whose written physician orders were reviewed, and had the potential to impact all patients receiving care at the facility. Additionally, this resulted in the administration of controlled substances to a patient without a medication order from a provider. This failure increased the risk of miscommunication or error resulting in an adverse patient event. The findings include: Examples of frequent use of verbal physician orders included, but were not limited to: Patient medical records were reviewed for Patients #1, #2, and #3. The medical records showed usage of frequent verbal orders with no authentication or follow up by the ordering provider. Examples included: 1. Patient #1 was an 82-year-old male who presented to the ED on 4/27/25 with the chief left knee pain. Patient #1 was subsequently admitted to the hospital and discharged on 5/1/25. Patient #1 received an ultrasound, CT scan, x-ray, and arthrocentesis. Patient #1’s medical records were reviewed. Patient #1’s record showed 4 verbal medication orders and one of unclear origin with no physician signature. 2. Patient #2 was an 82-year-old male who presented to the ED with chief complaint of acute bilateral embolism on 4/21/25. Patient #2 was admitted to the hospital and discharged on 4/24/25. Patient #2 received an x-ray, ultrasound, CT scan, and thrombectomy. Patient #2’s medical records were reviewed. Patient #2’s record showed 4 verbal medication orders of with no physician signature. The unsigned physician verbal orders included, but were not limited to midazolam, fentanyl, and lidocaine. 3. Patient #3 was a 67-year-old female who presented to the ED with chief complaint of cardiac arrest on 4/27/25. Patient #2 was admitted and died on 5/1/25. Patient #3 was intubated and received EEG, CT scan, cardiac catheterization, and an MRI. Patient #3’s medical records were reviewed. Patient #3’s record showed 4 verbal medication orders. The 4 verbal medication orders were not signed by a provider. Patient #1, #2 and #3’s medical records were reviewed with the Patient Safety Coordinator on 5/21/25 at 1:30 PM. She confirmed the missing provider authentication of the verbal orders. She stated all verbal orders need to be signed by the ordering provider. The Director of Pharmacy was interviewed 5/21/25 beginning at 9 AM. When asked, “Is the culture allowing convenience-based verbal orders?” he replied “Yes, historically. But that’s no longer acceptable. We presented this to the medical executive team, and they approved new standards. Verbal orders must now follow strict criteria-emergency, off-hours, etc.-not convenience.” Through medical record review and staff interview, it was determined verbal orders were being over utilized for the convenience of providers. It was unclear why the above patients’ verbal orders were not authenticated by the ordering providers in a timely manner. The hospital failed to ensure verbal orders by physicians were not a common practice throughout the hospital.”