Saint 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: 35731 Based on document review, observation and interview, the facility failed to ensure patient # 10 received care in a safe setting by assuring a staff member had current education related to CPI - Crisis Prevention Intervention training and Patient Rights (Tag 144), and failed to ensure patient # 10 was free from abuse during an altercation with a staff member (Tag 145). The cumulative effect of this systemic problem resulted in the facility’s inability to ensure that Patient Rights were promoted.”

“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: 35731 Based on document review, observation and interview the facility failed to ensure a staff member was current with required education/competency in one (1) instance. (Security Officer-SO # 2) Findings include: 1. Review of the surveillance video dated 10/21/2025, indicated a staff member SO # 2 struck patient # 10 with a closed fist during an altercation. 2. Review of SO # 2’s employee file indicated he/she had expired annual Patient Rights competency (date last completed 04/03/2025) and had expired bi-annual CPI training (date last completed 04/24/2023). 3. In interview on 04/09/2026 at approximately 10:02 am with security member SO # 2, confirmed he/she was making rounds and heard patient # 10 yelling at staff in the ED (Emergency Department). Patient # 10 had already been discharged and was yelling at SO # 3 (SO) about picking up his/her clip board (which had the patient’s Against Medical Advice form on it). Patient # 10 indicated that he/she may have a gun - at that point SO # 2 went to grab his/her arm and the patient punched SO # 2 twice in his/her face. Then both SO # 3 and SO # 2 were attempting to hold the patient against the wall and properly contain his/her hands. The patient was grabbing at something so “I struck” him/her. 4. In interview with administrative staff member AS # 1 (Director of Security) on 04/10/2026 at approximately 9:48 am, confirmed the hospital follows “best practice” related to CPI education, which is recertification every two years. SO # 2 should have been recertified. It should have been completed every two (2) years. Confirmed SO # 2’s CPI and Patient Rights training/competency were expired. Punching a patient was not part of the CPI training/competency.”

“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, observation and interview the facility failed to ensure a patient was free from abuse in one (1) of ten (10) medical records (MR’s) reviewed. (Patient # 10) Findings include: 1.The facility policy titled, Patient Rights and Responsibilities, Version # 4, no policy number, indicated the patient’s right to care that is considerate and respectful of his or her personal values and beliefs. This policy was approved on 01/31/2022. 2. The facility policy titled, Disruptive Combative Behavior - H # 2 (Acute Care Hospital), version # 6, no policy number, page one (1) - section Procedure - number one (1) - letter (C) - At no time will any associate do any physical harm to a patient, visitor or guest. This policy was last approved on 12/05/2023. 3. Review of the surveillance video dated 10/21/2025, indicated a staff member SO # 2 (Security Officer-SO) struck patient # 10 with a closed fist during an altercation. 4. In interview on 04/09/2026 at approximately 10:02 am with staff member SO # 2, confirmed he/she was making rounds and heard patient # 10 yelling at staff in the ED. Patient # 10 had already been discharged and was yelling at SO # 3 (SO) about picking up his/her clip board (which had the patient’s Against Medical Advice form document on it). Patient # 10 indicated that he/she may have a gun - at that point SO # 2 went to grab his/her arm and the patient punched SO # 2 in his/her face twice. Then both SO # 3 and SO # 2 were attempting to hold the patient against the wall and properly contain his/her hands. The patient was grabbing at something so “I struck” him/her. SO #2 was asked if patient had a gun and he/she indicated that no, the police never found a gun. 5. In interview with administrative staff member AS # 1 (Director of Security) on 04/10/2026 at approximately 9:48 am, confirmed SO # 2 should not have punched patient # 10.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 35731 Based on document review, and interview the facility failed to ensure an incident/event report was completed in one instance. (Patient # 10) Findings include: 1. The hospital policy titled, Online Incident Reporting, version # 5, no policy number, indicated page one (1) - Policy - number six (6) - It shall be the responsibility of each associate to report all incidents/events at the time they are encountered, page two (2) - Definitions - Incident/Event - An incident/event is any event or situation which is inconsistent with standards of care or routine, or which has significant positive or negative impact upon the safety, security, or satisfaction of a patient. 2. Review of the Incident/Event Log dated 10/01/2025 through 04/01/2026, lacked documented incident/event report related to patient # 10. 3. Review of the surveillance video dated 10/21/2025, indicated a staff member SO # 2 (Security Officer-SO) struck patient # 10 with a closed fist during an altercation. 4. In interview on 04/09/2026 at approximately 3:05 pm with staff member A # 2 (Risk Manager), confirmed he/she did not have an incident report from 10/21/2025 related to patient # 10. 5. In interview on 04/10/2026 at approximately 9:48 am with staff member AS # 1 (Director of Security), confirmed the senior officer SO # 3 (SO) should have completed an incident report.”

“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: 32952 Based on document review and interview, the facility failed to ensure a Registered Nurse followed facility policy related to nasogastric tube assessments for 1 of 10 patient medical records reviewed. (Patient #1) Findings include: 1. Facility policy titled “Assessment and Reassessment” with an approval date of 5/3/23, indicated the following: POLICY: 1. To ensure that the needs and problems of each patient are identified and assessed upon admission and throughout the patient’s hospital stay, a Registered Nurse shall identify patient needs and determine their priority by interpreting patient data that is collected continuously. 2. A. Best practice is to document assessment, interventions, purposeful rounding, and vital signs in real time. Attachment A. Scope of Assessment and Reassessment by Patient Care Unit. Medical Surgical. Elements Assessed: 3. IV Lines, tubes and drains. Time Frame: 3. IV heplock, lines, drains and tubes every 4 hours/IV infusing every 2 hours. 2. Facility procedure titled “Nasogastric or orogastric tube irrigation”, revised 12/11/23, indicated the following: Implementation: Confirm proper placement of the NG (nasogastric) or OG (orogastric) tube using at least two bedside techniques: * Observe the incremental marking on the tube at the exit site or measure the external tube length and compare it with the incremental marking or external length documented in the medical record at the time of insertion to assess for tube migration. * Review chest X-ray reports for notations about the tube’s location. *Inspect the visual characteristics of the tube aspirate. Fasting gastric secretions commonly appear grassy green, brown or clear and colorless. *If tube placement remains uncertain, notify the practitioner and arrange for an X-ray as ordered. 3. Review of Patient #1’s medical record indicated the following: (A) The patient was admitted inpatient on 9/10/24 at 2:00 p.m. with a diagnosis of ventral hernia and discharged on 9/15/24 at 5:00 p.m. (B) The patient had a nasogastric tube placed in the right nostril on 9/11/24 at 8:04 p.m. and it was discontinued on 9/14/24 at 5:16 p.m. per physician order. Patient #1’s medical record lacked documentation of a nasogastric tube assessment and/or placement verification every four hours per facility policy on the following dates and times: 9/12/24 at 4:05 a.m., 8:05 a.m., 11:14 a.m., 3:14 p.m., 7:14 p.m., 8:05 p.m., 9/13/24 at 12:00 a.m., 4:05 a.m., 8:05 a.m., 12:05 p.m., 4:05 p.m., 8:00 p.m., 9/14/24 at 12:00 a.m., 4:00 a.m., 8:00 a.m., 11:00 a.m. 3:00 p.m. 4. During an interview with A3 (5 Orthopedic Unit Supervisor) and A5 (Clinical Informatics) on 10/16/24 at 2:00 p.m., they verified the medical record information for Patient #1 and the lack of NG assessment documentation and/or NG placement verification every 4 hours. 5. During an interview with A1 (Director of Accreditation) on 10/16/24 at 3:30 p.m., A1 indicated that NG placement verification should be completed with NG assessments and documented in the patient’s medical record.”