St Catherine Hospital Inc.

“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: 26641 Based on document review and interview, nursing staff failed to complete required information on Patient’s Medicine Inventory Bag, place copy in chart, and return to patient at discharge; and failed to ensure a physician order for surgical dressing changes and/or nursing staff failed to document surgical dressing changes and wound characteristics in patient’s electronic medical record for one of ten patients (patient 3). Findings include: 1. The hospital policy titled, Storage of Home Medications, Policy/Procedure: MED 15.25, last revised March 2023, indicated on page one, section 1.0, upon admission patients will surrender all medications brought from home to nursing personnel; section 1.2, the medications will be placed in a security sealed bag...The patient or representative and the admitting nurse signs the sealed bag. The sealed bag will be returned to the patient upon discharge. On page two, section 3.5, Remove receipt from the top of the bag and make a copy. Give original portion to patient if appropriate and keep copy for chart. The copy on the chart is to indicate that the patient has home medications in storage; section 4.0, upon discharge return medication storage bag to patient after verifying serial number from storage bag with patient receipt. 2. The hospital policy titled, Discharge of Patients, Policy/Procedure: SCH.BC.9.04, last revised January 2025, indicated on page two, section 17.1, assure...any stored home medications are sent home with the patient. 3. The hospital policy titled, Dressing Changes, Surgical Dressing Guideline, Policy/Procedure: SCH.INT.8.01, last revised March 2025, indicated on page one, under General Information, section 1.0, The initial surgical dressing is changed by the physician, unless otherwise ordered by the physician; section 5.0, Documentation of the dressing change and the condition of the wound will be placed in the patient’s electronic medical record and may include the following: 5.1 Location of the wound; 5.2 Size of wound; 5.3 Appearance of wound; 5.4 Presence or absence of drainage; 5.5 Amount, color, and odor of drainage if present; 5.6 Condition of sutures/staples if present; 5.7 Condition of incision line if present; 5.8 Type, number, and adherence of drain(s) and packing if present; 5.9 Photograph of wound if indicated; 5.10 Pain at wound or incision site; 5.11 Type of dressing(s) applied. On page two, under Surgical Dressings, section 9.1.17, Document wound characteristics as listed in 5.0 of this policy in the electronic medical; section 10.0, Nursing to do initial wound assessment and dressing application per physician order on patient admission. 4. Medical record review for patient 3 on 8/7/2026 at approximately 11:45 am, indicated: a. Patient 3 was admitted at 10:44 am on 6/15/2026 for elective right knee total arthroplasty completed on this date. b. Nurse’s Note by P12 (Registered Nurse) on 6/16/2026 at 11:03 am, patient 3 had nasal diazepam in purse. Package was unopened and taken to pharmacy. c. Discharge Orders on 6/17/2026 at 3:55 pm of Diazepam 5 mg/0.1 ml nasal spray be resumed upon discharge. d. After Visit Summary (AVS) that included discharge instructions and printed on 6/17/2026 at 5:21 pm, indicated patient 3 signed and dated on 6/17/2026 receipt of the printed copy of discharge instructions that stated, “including all medications brought from home”, and that patient/significant other demonstrated/verbalized understanding of discharge instructions. e. Lacked a copy in patient’s chart of the receipt from the top of the medication storage bag for this medication patient brought from home. f. Post Op Progress Note by P17 (Physician Assistant [PA]) on 6/16/2026 at 7:49 am, indicated on exam of right knee, wound dry, continue current wound care/dressing changes [not specified]. g. Physical Therapy Note by P10 (Physical Therapist [PT]) on 6/17/2026 at 2:09 pm, indicated patient 3’s surgical wound dressing on right knee noted to be bleeding and a new dressing was placed by P10. h. Wound Care Flowsheet lacked documentation by P10 on 6/17/2026 at 2:09 pm, of surgical dressing change and assessment and wound characteristics in electronic medical record. i. Home Medications List dated 6/15/2026 at 10:18 am, indicated Diazepam 5 mg (milligrams)/0.1 ml (milliliters) nasal spray. j. Discharge Summary indicated patient was discharged home in good condition on 6/17/2026 at 6:27 pm. 5. Copy of Security Bag for Patient’s Medicine Inventory for patient 3 was reviewed on 8/7/2026 at approximately 12:25 pm, that indicated patient 3’s home medication of Diazepam 5 mg/0.1 ml nasal spray was still in this bag and originally was placed into the medication storage bag on 6/16/2026 (no time listed). The bag lacked the signature of patient 3 and/or their representative and the admitting nurse’s signature. 6. Interview on 8/7/2026 at approximately 3:01 pm with P12 (Registered Nurse), confirmed patient 3 brought their Diazepam 5 mg/0.1 ml nasal spray from home on admission and it was placed in a medication storage bag, the bag should have been signed by the patient or their representative and the admitting nurse, it was not. A copy of the receipt from the top of the bag should have been placed in the chart but wasn’t. The home medication should have been returned to the patient on discharge and even though the patient signed the AVS indicating the medication was returned, it wasn’t returned to the patient on discharge. This is known because the medication was still in the pharmacy in the medication storage bag on 8/7/2026. Do not know whether or not the patient received the original receipt from the top of the bag. 7. Interview on 8/7/2026 at approximately 4:29 pm with P10 (PT), confirmed right knee surgical dressing had bloody discharge on 6/17/2026 during PT session and P10 changed the dressing. There were no physician orders for dressing changes, only the note from P17 (PA) on 6/16/2026 at 7:49 am stating on exam wound dry, continue current wound care/dressing changes. P10 did not document on 6/17/2026 at 2:09 pm the right knee surgical dressing change and wound characteristics in patient 3’s electronic medical record.”

“PHARMACY ADMINISTRATION CFR(s): 482.25(a) [§482.25 Condition of Participation: Pharmaceutical Services .....The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital’s organized pharmaceutical service.] §482.25(a) Standard: Pharmacy Management and Administration The pharmacy or drug storage area must be administered in accordance with accepted professional principles. This Standard is not met as evidenced by: 26641 Based on document review, interview, and observation, the facility failed to destroy a medication per policy in one instance. Findings include: 1. The hospital policy titled, Storage of Home Medications, Policy/Procedure: MED 15.25, last revised March 2023, indicated on page one, section 1.0, upon admission patients will surrender all medications brought from home to nursing personnel; section 1.2, the medications will be placed in a security sealed bag...The patient or representative and the admitting nurse signs the sealed bag. The sealed bag will be returned to the patient upon discharge; section 1.3, Any medications remaining in the pharmacy/unit for longer than 30 days following discharge will be destroyed per the Pharmacy Department standard policy and procedure; on page two, section 3.5, Remove receipt from the top of the bag and make a copy. Give original portion to patient if appropriate and keep copy for chart. The copy on the chart is to indicate that the patient has home medications in storage; section 4.0, upon discharge return medication storage bag to patient after verifying serial number from storage bag with patient receipt. 2. Medical record review for patient 3 on 8/7/2026 at approximately 11:45 am, indicated: a. Patient 3 was admitted at 10:44 am on 6/15/2026 for elective right knee total arthroplasty completed on this date. b. Home Medications List dated 6/15/2026 at 10:18 am, indicated Diazepam 5 mg (milligrams)/0.1 ml (milliliters) nasal spray. c. Nurse’s Note by P12 (Registered Nurse) on 6/16/2026 at 11:03 am, patient 3 had nasal diazepam in purse. Package was unopened and taken to pharmacy. d. Discharge Summary indicated patient was discharged home in good condition on 6/17/2026 at 6:27 pm. 3. Copy of Security Bag for Patient’s Medicine Inventory for patient 3 was reviewed on 8/7/2026 at approximately 12:25 pm, that indicated patient 3’s home medication of Diazepam 5 mg/0.1 ml nasal spray was still in this bag and originally was placed into the medication storage bag on 6/16/2026 (no time listed). 4. Interview on 8/7/2026 at approximately 12:23 pm with P4 (Associate Director of Pharmacy), confirmed patient 3 brought to the facility their home medication of Diazepam 5 mg/0.1 ml nasal spray and it was placed into a medication storage bag and sealed on 6/16/2026 (no time listed). An attempt to contact the patient via phone was done, but not documented and the patient did not answer the call. The medication should have been returned to the patient upon discharge on 6/17/2026, but it wasn’t so it should have been destroyed after 7/17/2026. This sealed medication storage bag was still in pharmacy storage on 8/7/2026. 5. Interview on 8/7/2026 at approximately 3:01 pm with P12 (Registered Nurse), confirmed patient 3 brought their Diazepam 5 mg/0.1 ml nasal spray from home on admission and it was placed in a medication storage bag, the bag should have been signed by the patient or their representative and the admitting nurse, it was not. The home medication should have been returned to the patient on discharge and even though the patient signed the AVS indicating the medication was returned, it wasn’t returned to the patient on discharge. This is known because the medication was still in the pharmacy in the medication storage bag on 8/7/2026. Do not know whether or not the patient received the original receipt from the top of the bag.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 35731 Based on document review and interview the facility failed to ensure safety requirements were met during an altercation between a staff member and patient in one (1) instance. (Patient # 10) Findings include: 1. The hospital policy titled, Patient Rights Statement, Policy Number: BE 3, indicated on page two (2) - section - Policy Statement/Purpose - The patient had the right to - number thirteen (13) - Receive every consideration of safety in their surroundings. This policy was last revised on 05/2023. 2. Patient care security video from 02/05/2025 from approximately 11:03:40 am through 11:04:49 am was observed with A # 1 (Quality Director). The video showed patient # 10 walking in the hall with other patients and staff. Patient # 10 on three (3) different occasions went at M # 1 (Mental Health Worker III) by trying to initiate physical contact. Patient # 10 went toward M # 1 from the front at 11:03:40 am and again at 11:04:03 am. At approximately 11:04:44 am patient # 10 quickly ran up behind M # 1 who spun around and physically redirected (hands on patient’s chest) patient # 10 up against a wall. At approximately 11:04:49 am the video showed M # 1 shoving patient # 10 in the chest again to direct patient # 10 toward the entrance of the patient # 10’s room. 3. Behavioral Health Services - Mental Health Worker III - Job Description - indicated on page three (3) - main section - Job Responsibilities - number six (6) - Job Specific - number 6.9 - Regularly assesses and implements non-violent crisis intervention strategies for each patient on the psychiatric units. 4. In interview on 03/05/2025 at approximately 10:30 am with administrative staff member A # 1, confirmed the patient care security video was stored for up to forty-five (45) days. 5. In interview on 03/05/2025 at approximately 12:35 pm with patient care staff member R # 1 (Recreation Therapist), confirmed M # 1 turned around, grabbed patient # 10’s shirt, and pushed patient # 10 up against the wall.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 35731 Based on document review and interview the registered nurse failed to ensure an event/occurrence report was completed related to an altercation between a staff member and patient in one (1) instance. (Patient # 10) Findings include: 1. The hospital policy titled, Patient Safety and Risk Management Program, Policy Number: QAI 6.25, indicated on page one (1), Guiding Principles - number 3.2 - Individuals are still held accountable for compliance with patient safety and risk management practices. On page two (2), Definitions - number 1 - Adverse event or incident: An undesired outcome or occurrence, not expected within the normal course of care or treatment, disease process, condition of the patient, or delivery of services. This policy was last revised on 07/2019. 2. Patient care security video from 02/05/2025 from approximately 11:03:40 am through 11:04:49 am was observed with A # 1 (Quality Director). The video showed patient # 10 walking in the hall with other patients and staff. Patient # 10 on three (3) different occasions went at M # 1 (Mental Health Worker III) by trying to initiate physical contact. Patient # 10 went toward M # 1 from the front at 11:03:40 am and again at 11:04:03 am. At approximately 11:04:44 am patient # 10 quickly ran up behind M # 1 who spun around and physically redirected (hands on patient’s chest) patient # 10 up against a wall. At approximately 11:04:49 am the video showed M # 1 shoving patient # 10 in the chest again to direct patient # 10 toward the entrance of the patient # 10’s room. 3. Incident Report Log was reviewed for the months of January and February 2025. The log lacked an Occurrence/Event Report related to patient # 10 and/or his/her representative for 02/05/2025. 4. In interview on 03/05/2025 at approximately 11:50 am with nursing staff member CN # 1 (Registered Nurse-RN/Charge), confirmed M # 1 told CN # 1 that patient # 10 ran up on him/her, more than once, during the hallway walking group. The patient’s nurse would be the one responsible for completing an event report related to staff to patient altercation. If M # 1 pushed patient # 10 then yes, the nurse should have completed an event report. 5. In interview on 03/05/2025 at approximately 12:35 pm with patient care staff member R # 1 (Recreation Therapist), confirmed M # 1 turned around, grabbed patient # 10’s shirt, and pushed patient # 10 up against the wall. 6. In interview on 03/05/2025 at approximately 1:45 pm with B # 1 (Behavioral Health Services-BHS/Nurse Manager), confirmed N # 2 should have completed an occurrence/event report related to M # 1 physically redirecting patient # 10 on 02/05/2025.”