Amita Health Resurrection Medical Center

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 40079 Based on document review, video surveillance review, and interview, it was determined that for 1 of 1 (Pt. #3) patient observed for privacy, the hospital failed to ensure the right to personal privacy for patients in the Emergency Department (ED) being disrobed in view of other patients and visitors. Findings include: 1. The hospital’s policy titled, “Patient Rights and Responsibilities” (revised 1/18/2024) was reviewed and required, “ ... 6. Expect privacy, confidentiality and dignity concerning your medical and/or psychiatric care.” 2. The clinical record of Pt.#3 was reviewed and indicated that Pt.#3 presented to the ED via EMS (Emergency Medical Services) on 11/18/2025 at 3:08 PM. The clinical record included the following: -Emergency Department Provider Note, dated 11/19/2025 at 12:10 AM, “HPI (History Present Illness) ... (Pt.#3) does not give any information regarding the accident ... is significantly agitated and aggressive with staff ... shouting and is a threat to self and others upon arrival to the ED requiring chemical and physical restraints.” 3. On 11/25/2025, video surveillance dated 11/18/2025 at 3:09 PM to 4:22 PM, of the ED was viewed along with the Manager of Performance Improvement (E#17), the Chief Nursing Officer (E#18), and Security Lead (E#19). The video surveillance showed the following: -At 3:09 PM to 3:17 PM, (Pt.#3) is observed being wheeled on a gurney by EMS (Emergency Medical Services), RN (E#16), and Security Officer (SO/E#11) and is placed in front of the nurse’s station across from patient rooms 6-9. During transport (Pt.#3) is observed to be flailing their arms and legs and attempting to get off the gurney. Additional SOs (E#13 and E#12) arrive to assist with (Pt.#3). E#16 is observed trying to place a mask on (Pt.#3) and (E#16) is hit by (Pt.#3) on the facial area. While the SOs (E#11, #12, and #13) are holding (Pt.#3’s) legs, arms and side of head to prevent (Pt.#3) from striking, E#16 and a PCT (Patient Care Technician) are observed removing (Pt.#3’s) clothing leaving (Pt.#3) fully unclothed and in view of other patients and visitors for approximately 6 seconds. A staff is observed covering (Pt.#3) with a sheet and putting scrubs on (Pt.#3). During this time (Pt.#2) was observed in the hallway while (Pt.#3’s) clothing was removed with a staff attempting to direct (Pt.#2) back to their room. 4. An interview was conducted with the CNO (E#18) on 11/25/2025 at approximately 12:25 PM. E#18 stated after the viewing the video that showed incidents involving (Pt.#3) it was not appropriate for staff to take off the patient’s clothing in the hallway. Patients have the right to privacy and dignity.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 40079 Based on document review, video surveillanc review, and interview, it was determined that for 1 of 3 violent restraints (Pt. #3) records reviewed, the hospital failed to ensure that restraints were discontinued at the earliest possible time. Findings include: 1. The hospital’s policy titled, “Restraint and Seclusion Management Policy” (revised 02/21/2024) was reviewed and required, “ ... E. Trained clinical staff must monitor and assess a patient’s condition on an ongoing basis to ensure that the patient is released from restraint or seclusion at the earliest possible time ... F. Once the unsafe situation ends, the use of restraint or seclusion must be discontinued ....” 2. The clinical record of Pt.#3 was reviewed and indicated that Pt.#3 presented to the ED (Emergency Department) via EMS (Emergnecy Medical Services) on 11/18/2025 at 3:08 PM. The clinical record included the following: -A Physician’s order dated 11/18/2025 at 3:51 PM, “Locked Restraint 4-Point; Imminent risk of harm to self and other; Discontinuation Criteria: Absence of behavior that required restraint; Monitor every 15-minutes.” -The 15-minute observation flow sheets were reviewed and included documentation that (Pt.#3) was placed in 4-point restraints at 3:49 PM and discontinued at 4:53 PM. At 3:55 PM, documentation included the following: “(Pt.#3) snoring and coughing, repositioned on cart.” At 4:03 PM, “(Pt.#3) sleeping on cart with HOB (head of bed) at 30 degrees.” (Pt.#3’s) restraints were not discontinued at 3:55 PM, when (Pt.#3) showed absence of behavior that required restraints. The restraints were discontinued 58 minutes after documentation indicated that Pt.#3 was asleep. -Emergency Department Provider Note, dated 11/19/2025 at 12:10 AM, “HPI (History Present Illness) ... (Pt.#3) does not give any information regarding the accident ... is significantly agitated and aggressive with staff ... shouting and is a threat to self and others upon arrival to the ED requiring chemical and physical restraints. (Pt.#3) was monitored for several hours and on reassessment is awake, alert, and able to tolerate p.o. (oral). Now calm and cooperative.” 3. On 11/25/2025, video surveillance dated 11/18/2025 at 3:09 PM to 4:22 PM, of the ED was viewed along with the Manager of Performance Improvement (E#17), the Chief Nursing Officer (E#18), and Security Lead (E#19). The video surveillance showed the following: -At 3:20 PM, restraints were applied to all limbs, at 3:24 PM (Pt.#3) was moved to the other side of the nurse’s station, where several staff are observed to be at. At 3:35 PM, (Pt.#3) appears to be asleep. At 4:14 PM, (Pt.#3) is moved into a room. At 4:44 PM, staff are observed removing restraints. The video footage did not show that staff restrained (Pt.#3) inappropriately, however, the footage shows that (Pt.#3’s) rights were not removed when (Pt.#3) no longer displayed behaviors that warranted restraints. 4. An interview was conducted with the CNO (E#18) on 11/25/2025 at approximately 12:25 PM. E#18 stated after the viewing the video of incident involving (Pt.#3), that restraints should be discontinued as soon as the patient is no longer showing signs of aggressiveness or is able to contract for safety to self and others. E#18 confirmed that (Pt.#3) was asleep during the video review.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 36774 Based on document review and interview, for 4 of 24 patients (Pt. #1, Pt. #5, Pt. #6, and Pt. #14) clinical records reviewed in the ED (emergency department), the hospital failed to ensure that pain intervention or assessment/reassessments were conducted, as required by policy. 1. On 11/24/2025, the hospital’s policy titled, “Pain Management” (3/2024) was reviewed and indicated, “ ... II. Procedure ... 4 ... d. Severity of pain will be categorized as the following values on the 0-10 pain scale ... iv. Severe pain: 7-10 ... B. Pain Management Plan ... 2. Elements of Pain Management Plan ... b. Based upon pain assessment; the pain management plan shall address the patient’s pain employing ... interventions ... i. Pharmacologic strategies ... ii. Non-pharmacologic strategies ... c. Assessment and reassessment ... i. Evaluation and documentation of response to pain ...” 2. On 11/24/2025, the clinical record for Pt. #1 was reviewed. On 8/14/2025, Pt. #1 was brought to the hospital’s ED due to alcohol intoxication and body pain. The clinical record indicated: - On 8/14/2025 at 2:00 AM, the clinical record indicated that Pt. #1 had a pain rating of 10 (severe pain). At 9:10 AM, Pt. #1 was given Tylenol for severe pain. - On 8/14/2025 at 1:30 PM, the clinical record indicated that Pt. #1 was having severe pain (pain rating of 7/10). - The clinical record lacked documentation that pain intervention was provided when Pt. #1 was having severe pain at 2:00 AM and at 1:30 PM. There was also no pain reassessment after administration of Tylenol at 9:10 AM. 3. On 11/24/2025, the clinical record for Pt. #5 was reviewed. On 8/14/2025 at 12:40 AM, Pt. #5 was brought to the hospital’s ED due to shoulder injury. There was no pain assessment from 12:40 AM through Pt. #5’s discharge at 2:11 AM. 4. On 11/24/2025, the clinical record for Pt. #6 was reviewed. On 8/31/2025 at 8:31 PM, Pt. #6 was brought to the hospital’s ED due to abdominal pain. There was no pain assessment from 8:31 PM through Pt. #6’s discharge at 11:55 PM. 5. On 11/24/2025, the clinical record for Pt. #14 was reviewed. On 11/18/2025, Pt. #14 was brought to the hospital’s ED due to chest pain. At 10:29 AM, Pt. #14 was given pain medication (nitroglycerin). There was no pain reassessment following administration of nitroglycerin. 6. On 11/24/2025 at approximately 1:30 PM, findings were discussed with E #10 (Critical Care Director). E #10 validated the above information. E #10 stated that non-pharmacologic or pharmacologic intervention/s should be provided when a patient is complaining of severe pain. E #10 stated that pain assessments and reassessments should be performed on all patients after provision/administration of pain intervention.”

“CONTENT OF RECORD: FINAL DIAGNOSIS CFR(s): 482.24(c)(4)(viii) [All records must document the following, as appropriate:] Final diagnosis with completion of medical records within 30 days following discharge This Standard is not met as evidenced by: 40079 Based on document review and interview, it was determined that the hospital failed to ensure the completion of medical records within 30 days of patient discharge. Findings include: 1. On 07/02/2025, the hospital’s policy titled, “Medical Staff Suspensions, HIM (Health Information Management)” (revised 04/28/23) was reviewed and included, “Medical Staff Bylaws states a Physician who fails to complete available medical records within fourteen (14) days of a patient’s discharge shall be subject to suspension... C. 1. Physicians are expected to complete all incomplete records and may be subject to suspension if he/she does not complete all delinquent records which include: History and Physical ... ED provider notes ... Consult notes ... verbal orders not signed within 48 hours ...” 2. On 07/02/2025, the hospital’s Supervisor of Health Information Management (E #7) provided a Delinquent Record log dated June 2025 to current and indicated that there were a total of six (6) delinquent records for (the hospital). 3. On 07/02/2025 at approximately 9:40 AM, an interview was conducted with the Supervisor of HIM (E #7). E #7 stated, “Records are considered delinquent if not completed within 30 days, including history & physical and discharge summary. Currently there are six delinquent records or incomplete history and physical and the discharge summary. I reach out the providers to remind them of the requirements.””