Methodist Hospitals Inc.

“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: 44532 Based on document review and interview, nursing staff failed to ensure all high fall precautions were in place at all times and failed to document fall precautions accurately for 1 of 10 patient Medical Records reviewed (P1) . The cumulative effects of these systemic problems resulted in the facility’s inability to provide nursing care in a safe manner.”

“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: 44532 Based on document review and interview, nursing staff failed to ensure all high fall precautions were in place at all times and failed to document fall precautions accurately for 1 of 10 patient Medical Records reviewed (P1) . Findings Include: 1. The policy titled “Risk for Fall and/or Entrapment Guidelines”, last revised: 05/2025, PolicyStat ID: 17699367 indicated the under I. policy: Indication of Risk guidelines are provided to identify patients at risk for falling and/or entrapment and to implement strategies for fall and/or entrapment prevention. All patients need to be assessed using the Morse Fall Risk Scale at the time of admission, daily and when patients condition changes. III. Procedure: Once the patient is identified as being medium or high risk for fall per Morse Fall Risk Scale, additional interventions specific to the needs of the patient can be initiated to improve patient safety. These may include but not limited to if possible place patient close to nurses station, check patient every 1-2 hours and assess for reorienting patient, toileting needs . food/fluid needs, check tubing, close curtain at night, implement bed/chair alarm, implement bed/chair alarm for patients with medium or high fall risk. 2. Review of P1’s medical record (MR) indicated the following: a. Morse fall risk assessment on 04/29/2025 at 2300 hours indicated a total score of 80 points (High fall is 45 points or above). b. Fall risk interventions dated 05/05/2025 at 1900 in place pre fall for P1 included, nonskid footwear, bedside commode in place, require moderate assist when out of bed, 2 side rails up on bed, bed alarm on, bed wheels locked, and room door open. c. Review of Nurse progress note dated 05/05/2025 at 1935 hours N2 (Registered Nurse) indicated that P1 was found on the floor. Post fall wound documentation dated 05/05/2025 at 1935 hours indicated P1 had a laceration above the left eyebrow. d. Review of the computed tomography (CT) of the head without intravenous therapy (IV) dated 05/05/2025 at 2027 hours indicated a large left frontal and forehead soft tissue hematoma, moderate chronic small vessel ischemic disease evidenced by periventricular white matter hypodensities. and mild diffuse volume loss with associated ventricular and sulcal prominence. 3. Review of Post Fall Huddle Review Form dated 05/05/2025 at 1935 hours indicated that P1 had a fall with a head laceration to the left forehead. Huddle report indicated the fall was preventable due to F1 failed to put the bed alarm on while he/she was in bed. 4. In interview on 07/07/2025 at approximately 1530 hours with staff member A3 (Director of Acute Care) indicated that P1 did not have his/her bed alarm on at the time of P1 fall and that MR indicated at 1900 hours F1 staff had documented bed alarm on.”

“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: 14445 Based on document review and interview, nursing services failed to follow facility Fall guidelines for fall risk patients in the utilization of patient bed siderails; and failed to accurately document in MR event related to a patient’s fall for 1 of 10 patient MR’s (Medical Records) reviewed (Patient # 4). The cumulative effects of these systemic problems resulted in the facility’s inability to ensure that quality Nursing Services were provided.”

“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: 14445 Based on document review and interview, nursing services failed to follow facility Fall guidelines for fall risk patients in the utilization of patient bed siderails; and failed to accurately document in MR event related to a patient’s fall for 1 of 10 patient MR’s (Medical Records) reviewed (Patient # 4). Findings include: 1. Facility policy titled: “Risk for Fall and/or Entrapment Guidelines”, Policy Stat ID 12014203, indicated on page 2, under PROCEDURE, Action, the following can assist in providing a safe environment for patients; 8th point; ... in locked position, 11th point: Utilize two side rails as applicable for positioning and bed controls, and on page 4, under Fall Actions, if fall should occur, the nurse must take the following actions, 7th point; Document objective findings related to patient fall. Last revised 4/2022. 2. Review of Patient # 4 MR, indicated, the following: (a). Nursing flowsheets on admission reflected the following: Morse fall risk - (scores included, but not limited to): on admission = 80 (high risk). (b). Plan of care on admission reflected patient safety; falls. Fall preventions (included: call light, bed low position, side rails up x [times] 2, staff rounding, non-skid socks, alarms {bed & chair}, fall risk band). (c). Nurse note on 10/8/2024 at 2:45 am, by N # 20 (RN {Registered Nurse} - 5W-2 - IMCU {Intermediate Care Unit} - staff), reflected nurse was called to patient room where patient was found on the floor nearby bed and commode. Patient was placed on commode and instructed to call for assistance with call light in reach prior to incident. Patient has small laceration to right eyebrow. Patient was assisted back to bed by staff. (d). MR documentation for fall by nursing staff is not consistent with incident/event report findings. 3. Review of Incident/event report for Patient # 4, dated 10/8/2024 at 2:30 am for an unwitnessed fall (patient’s room), indicated the following: (a). Patient was found on floor near commode. Patient had bruise to right eyebrow. (b). Event was reviewed by A # 4 (Unit Manager - 5W-2), with additional information. Event date: 10/8/2024 at 2:30 am, for an unwitnessed fall (patient’s room), indicated that patient was found on floor near commode - in regards to patient was assisted to BSC (bedside commode), NA (nursing assistant) remained with patient and assisted patient back to bed; bed alarm in place. NA in rush and thought that side rail of bed was latched and left room. Side rail found not to be latched. Patient was found on floor by primary RN. (c). Incident/event review is not consistent with MR documentation for fall. 4. In interview on 11/12/2024 at approximately 12:00 pm, with A # 4, confirmed the following: a. Three side rails up, for patients on fall risk; rails would be locked/latched in place. b. NA assisted patient # 4 from bedside commode back to bed; in incident investigation, NA was unsure if she/he heard click for right side rail once patient was in bed. Call light in place and bed alarm was on.”

“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: 35731 Based on document review and interview, the Registered Nurse (RN) failed to ensure a patient was moved from the Emergency Department (ED) cart to an inpatient bed once admitted in one (1) instance, failed to ensure a patient was turned every two (2) hours (Q2h) in seventy (70) instances, and failed to ensure a risk report was completed/evaluated for a patient who had developed new wounds during the patient’s length of stay. (Patient # 10) The cumulative effects of these systemic problems resulted in the facility’s inability to provide nursing care in a safe manner.”

“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: 35731 Based on document review and interview, the Registered Nurse (RN) failed to ensure a patient was moved from the Emergency Department (ED) cart to an inpatient bed once admitted in one (1) instance, failed to ensure a patient was turned every two (2) hours (Q2h) in seventy (70) instances, and failed to ensure a risk report was completed/evaluated for a patient who had developed new wounds during the patient’s length of stay. (Patient # 10) . Findings include: 1. The hospital policy titled, Skin and Tissue Inspection, Assessment and Management Procedure, PolicyStat ID 12484038, indicated to turn and reposition the patient at least every two (2) hours, and complete a risk control report and forward to Risk Management when patients are admitted with pressure injuries/wounds and/or patients develop pressure injuries/wounds during their length of stay. This policy was last revised in 10/2022. 2. The facility policy titled, Event Reporting of Patient/Visitor Incidents, PolicyStat ID 11064742, indicated to maintain a safe environment issues and events representing risks to the institiution are to be reported. The reports will be reviewed each business day. This policy was last revised in 10/2020. 3. Review of patient # 10’s medical record indicated the following: a. Emergency Department (ED) note dated 11/11/2023, indicated patient arrived with right lower leg wound. b. The patient arrived at the ED on 11/11/2023 and remained on the cart until moved to the inpatient unit on 11/14/2023. Patient # 10’s MR lacked documentation related to the patient being moved from an ED cart/gurney to an inpatient bed while waiting for an inpatient room. The MR lacked documentation the patient was turned/repositioned Q2h’s on the following dates/times: 11/12/2023 at 0000, 0200, 0400, 0600, 0800, 1000, 1200, 1400, 1600, 1800, 2000, 2200; 11/13/2023 at 0000, 0200, 0400, 0600, 0800, 1000, 1200, 1400, 1600, 1800, 2000, 2200; 11/18/2023 at 0200, 0400, 0600; 11/21/2023 0800, 1000, 1200, 1400; 11/21/2023 2000, 2200; 11/22/2023 0000, 0200, 0400, 0600, 0800, 1000, 1200, 1400, 1600, 1800, 2000, 2200; 11/23/2023 0000, 0200, 0400, 0600; 11/24/2023 2000, 2200; 11/25/2023 0000, 0200, 0400, 0600; 11/27/2023 1400, 1600, 1800, 2000, 2200; and 11/28/2023 0000, 0200, 0400, 0600, 0800, 1000, 1200, 1400, 1600, 1800. c. Wound Care note dated 11/14/2023 indicated the patient had a venous ulcer on his/her right medial lower leg, pressure ulcer left buttock, pressure ulcer sacrum, pressure ulcer left lower posterior leg calf proximal/distal, pressure ulcer right lateral lower leg calf proximal, and pressure ulcer right lower leg distal. 4. In interview on 01/10/2024 at approximately 12:30 pm with staff member S # 3 (ED RN), confirmed once we know the patient has been admitted we move them from the ED cart to a inpatient hospital bed. Everything should be documented. 5. In interview on 01/11/2024 at approximately 9:00 am with administrative staff member A # 1 (Assistant Vice President Patient Care Services), confirmed the ED did not have a policy related to boarding inpatients and/or moving the patient from the cart to an inpatient bed. 6. In interview on 01/11/2024 with administrative staff member A # 2 (Director of Critical Care), confirmed the patient should have been moved from the ED cart to an inpatient bed and turned Q2h’s while an inpatient. He/she also confirmed there should have been a risk report completed related to the patients new wounds. 7. In interview on 01/11/2024 at approximately 1:45 pm with staff member S # 4 (Wound Care Registered Nurse), confirmed he/she evaluated the patient on 11/14/2023 and the patient had eight (8) wounds and an area of hyperpigmentation. 8. In interview on 01/11/2024 at approximately 2:15 pm with administrative staff member A # 4 (Regulatory Specialist), confirmed he/she had not received/reviewed any risk reports for the patient related to wounds.”

“DIETS CFR(s): 482.28(b)(2) All patient diets, including therapeutic diets, must be ordered by a practitioner responsible for the care of the patient, or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff and in accordance with State law governing dietitians and nutrition professionals. This Standard is not met as evidenced by: 35731 Based on document review and interview the Registered Dietitian failed to ensure a nutritional supplement was ordered for one (1) of ten (10) medical records (MR’s) reviewed. (Patient # 10) Findings include: 1. The facility policy titled, Skin and Tissue Inspection, Assessment and Management Procedure, PolicyStat ID 12484038, indicated nutritional support interventions should be implemented as recommended by the dietary consult. This policy was last revised in 10/2022. 2. Review of patient # 10’s MR indicated the following: a. Medical Nutrition - Inpatient Follow-up Assessment note, dated 11/22/2023 by P # 1 (Registered Dietitian), indicated to continue current diet order per physician and initiate orders for vanilla Boost Plus one (1) times daily. Patient # 10 was considered High nutritional risk. b. The MR lacked the order to initiate vanilla Boost Plus. 3. In interview on 1/11/2024 at approximately 2:30 pm with administrative staff member A # 1 (Assistant Vice President Patient Care Services-AVP SLPCS), confirmed the MR lacked the order from the RD.”