Palos Community Hospital

“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: 36774 A. Based on document review and interview, the hospital failed to ensure that the RNs (registered nurses) followed the physician’s orders regarding completion of neurovascular and neurological checks (e.g., presence of pulse, level of consciousness, pupillary response, etc.) for 1 of 7 (Pt. #1) clinical records reviewed. Findings include: 1. The hospital’s policy titled, “Documentation (charting) Guidelines” (12/2022) included, “ ... IV. Clinical Guidelines ... 4. Documentation of Patient Assessments. Patient assessment will be documented, using (charting by exception) at minimum ...” 2. On 6/30/3035, the clinical record for Pt. #1 was reviewed. On 3/28/2025, Pt. #1 was admitted to the hospital due to left toe pain and underwent surgery on 4/2/2025 - Left femoral to anterior tibial bypass. Left great saphenous vein harvest (surgical procedure redirecting blood flow around a blockage in the leg and removal of a vein to replace or repair a blocked blood vessel). Pt #1 was transferred/admitted to the intensive care unit postoperatively. The clinical record indicated: - On 4/2/2025, Pt. #1 underwent left femoral to distal anterior tibial bypass with left greater saphenous vein (vascular surgery of left leg). On 4/2/2025 at 7:00 PM, a physician’s order indicated, “ ... check pedal doppler tones (neurovascular checks) ... every 1 hour ...” However, doppler/neurovascular checks were not documented on 4/3/2025 from 12:00 AM through 7:00 AM (7 hours). - On 4/03/2025 at 6:21 PM, a physician placed an order to perform neurological checks every one hour starting at 7:00 PM. However, hourly neurological assessments were not documented on 4/3/2025 from 8:01 PM through 11:59 PM (3 hours). 3. On 7/01/2025 at approximately 10:15 AM, findings were verified with E #8 (ICU Nurse Educator). E #8 validated that the doppler/neurovascular and neurological checks were not documented. E #8 stated that the RN should follow the physician’s order. B. Based on document review and interview, the hospital failed to follow their policy to ensure that the comprehensive pain assessment was completed for 1 of 3 (Pt. #1) clinical records reviewed. Findings include: 1. On 6/30/3035, the hospital’s policy titled, “ “Pain management” (5/2024) was reviewed and indicated, “I ... to provide standards for the appropriate management of the physical and psychological symptoms associated with pain ... Appendix A: Assessment/Reassessment and Documentation Guidelines ... Comprehensive Pain Assessments (an in-depth assessment that includes pain intensity rating score, quality, location, onset, and frequency of pain). When to use: 1. On admission ...” 2. On 6/30/3035, the clinical record for Pt. #1 was reviewed. On 3/28/2025, Pt. #1 was in the ED for evaluation of left toe pain. On 3/28/2025 at 4:54 PM, Pt. #1 was admitted to the hospital’s medical surgical unit. A nursing admission assessment was conducted; however, a comprehensive pain assessment was not completed. 3. On 7/01/2025 at approximately 10:15 AM, findings were discussed with E #8 (ICU Nurse Educator). E #8 validated that the comprehensive pain assessment was not documented. E #8 stated that a comprehensive pain assessment should be completed on admission.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 2 of 2 patients’ (Pt. #6 and Pt. #7) clinical records reviewed regarding use of restraints for violent or self-destructive behavior, the hospital failed to ensure that the care plan was modified to reflect use of restraint as an intervention. Findings include: 1. On 7/24/2024, the hospital’s policy titled, “Restraints” (effective 3/2023) was reviewed and included, “... II.A... 1. Restraint for violent or self-destructive behavior: Initiated in emergency or crisis situation if a patient’s behavior becomes aggressive or violent...” The policy did not include modification of care plan regarding use of restraints. 2. On 7/24/2024, the clinical record for Pt. #6 was reviewed. On 4/23/2024, Pt. #6 was admitted with a diagnosis of recurrent major depression. On 5/1/2024, Pt. #6 was placed on physical hold due to aggressive/violent behavior. The clinical record lacked documentation that the care plan was modified to reflect use of restraint as an intervention. 3. On 7/24/2024, the clinical record for Pt. #7 was reviewed. On 3/19/2024, Pt. #7 was admitted with dementia with behavioral disturbance. On 4/17/2023, Pt. #7 was placed in 4-point restraints due to aggressive/violent behavior. The clinical record lacked documentation that the care plan was modified to reflect use of restraint as an intervention. 4. On 7/24/2024 at approximately 1:30 PM, findings were discussed with E #8 (Education Coordinator). E #8 confirmed that Pt. #6 and Pt. #7’s care plan was not modified reflecting the use of restraints for violent behavior. E #8 did not provide explanation whether use of restraint should be documented in the plan of care.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 40079 Based on document review and interview, it was determined that for 1 of 3 patients’ (Pt.#1) clinical records reviewed regarding use of restraints, the hospital failed to ensure that the staff documented the required assessments/reassessments while patient wwas in non-violent restraints. Findings include: 1. On 01/30/24, the hospital’s policy titled, “Restraints” (revised 09/03/20) was reviewed and required, “Observation/Monitoring: Acute Medical and Surgical Care (non-violent or non-self-destructive behavior) ... At a minimum of every two Hours: Monitor circulation, movement, and sensation (CMS) - Skin integrity, Condition or symptoms that warranted use of restraint ... Documentation of the above observation and monitoring will be reflected on the appropriate flowsheet ...” 2. On 01/30/24, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted to the hospital on 10/23/23 with diagnosis of acute UTI (urinary tract infection). On 10/24/23 through 11/06/23, Pt.#1 was placed on soft restraints to bilateral wrists due to interference with medical treatment. The Non-violent Restraint Q2H (every 2 hour) Observation flow sheets dated 10/23/23 through 11/06/23 were reviewed and indicated that for the following dates the clinical record lacked documentation that assessments for circulation, movement, sensation, and skin integrity were completed every 2 hours as required: -10/26/23 from 6:00 PM to 10/27/23 at 2:00 AM (8 hours) -10/27/23 from 10:00 AM to 12:00 PM (2 hours) -10/29/23 from 10:00 AM to 10/30/23 at 2:00 AM (16 hours). -10/30/23 from 10:00 PM to 10/31/23 a 8:00 AM (10 hours). 3. On 01/30/24 at approximately 11:30 AM, an interview was conducted with the Nursing Director (E #8). E #8 confirmed that for the above dates, the clinical record lacked documentation of every 2-hour assessments for (Pt.#1). E #8 stated that staff are required to complete and document an assessment for circulation, movement, and sensation while patients are on non-violent restraints.”

“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: 40079 Based on document review and interview, it was determined that for 1 of 5 (Pt.#1) clinical records reviewed for post fall assessment, the hospital failed to ensure that a registered nurse completed vital signs and neurological checks, as required. Findings include: 1. On 01/30/24, the hospital’s policy titled, “Fall Prevention/Post Fall Assessment” (effective date 02/07/23) was reviewed and required, “ ... V. C. In case of a fall, the following post-fall management should be followed ... 4. RN to take full set of vitals, as well as neurological checks every 2 hours x 3 occurrences...” 2. On 01/30/24, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted to the hospital on 10/23/23 with diagnosis of acute UTI (urinary tract infection). -The Physician Hospitalist note dated 11/08/23 at 9:35 PM, included, “I was called to evaluate (Pt.#1) status post unwitnessed fall. Reportedly (Pt.#1) fell off his bed ... is noted to have small laceration above (Pt. #1) left eyebrow. CT brain, cervical spine were negative for acute finding. Skin laceration was managed with Dermabond ... Sitter at the bedside.” -The Vital Signs flow sheets dated 10/23/23 through 11/20/23 were reviewed. The flow sheets indicated that on 11/08/23 after (Pt.#1’s) fall (at 7:15 PM), the first set of vital signs were done at 10:51 PM (3 hours and 31 minutes post fall). The neuro checks every 2 hours x 3 post-fall were not completed as required. 3. On 01/31/24 at 11:40 AM, an interview was conducted with the Nursing director (E#8). E#8 confirmed that after an unwitnessed fall, the nurse is required to complete a set of vital signs and neurological assessments every 2 hours three times. E#8 confirmed that staff failed to complete the required post fall assessments.”