Union Hospital Inc.

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 50584 Based on document review and interview, the facility failed to maintain documentation for consent to treat by a health care representative of an altered mental status patient in 1 of 10 MRs (Medical Records) reviewed (P5); and failed to renew restraint orders every calendar day for 1 of 10 MRs reviewed (P4). The cumulative effect of this systemic problem resulted in the facility’s inability to ensure that Patient Rights were promoted.”

“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: 50584 Based on document review and interview nursing services failed to inform a patients family of patient surgery and provide education regarding the procedure, risks, benefits, or alternatives and failed to document daily skin assessments of wounds for 1 of 10 MRs (Medical Records) reviewed (P4); and failed to ensure other departments involved in a patient’s care were included in an incident report for follow up of skin tears in 1 of 3 incident reports reviewed (P4). The cumulative effect of these systemic problem resulted in the facility’s inability to provide nursing care in a safe manner.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 50584 Based on document review and interview, the facility failed to maintain documentation for consent to treat by a health care representative of an altered mental status patient in 1 of 10 MRs (Medical Records) reviewed. (P5) Findings include: 1. Facility policy titled Consents, 348, PolicyStat ID: 17995423, Last Revised 4/2025, Page 1, under Purpose: To obtain written permission for treatment/procedure. Page 2, under Special Instructions: 1. Consent forms must be filled out completely prior to obtaining a signature. Page 3, 10. Persons authorized to consent for incapable parties: 3. An adult child. 2. Review of P5 MR indicated: a. P5 presented to Facility on 4/15/26 at 1151 hours with altered mental status. b. Consent to Treatment and Financial Responsibility for P5 on 4/15/26 indicated P5 had an altered mental status and gave verbal consent to treat. 3. In interview on 5/7/26 at 0925 hours with A5 (Director Clinical Education), he/she confirmed the consent for treatment form indicated P5 had an altered mental status and gave verbal consent to treat to the F1 staff. 4. In interview on 5/7/26 at 1130 hours with A7 (Director Patient Access), he/she confirmed that the Consent for Treatment form for P5 on 4/15/26 was filled out incorrectly. A patient with altered mental status cannot give verbal consent for treatment.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) [Unless superseded by State law that is more restrictive,] (iii) Each order for restraint used to ensure the physical safety of the non-violent or non-self-destructive patient may be renewed as authorized by hospital policy. This Standard is not met as evidenced by: 50584 Based on document review and interview facility failed to renew restraint orders every calendar day for 1 of 10 MRs (Medical Records reviewed. (P4) Findings include: 1. Facility policy titled Restraints, 4128, PolicyStat ID: 20211910, Last Revised: 03/2026, Page 9, under C. Use of Physical Restraints for Non-Violent Behavior, 2. ACHC 15.02.11 Obtain/Provide for a Non-Violent Restraint Order: c. Non-violent restraints require a new order each calendar day. 2. Review of P4 MR indicated: a. On 2/28/26 at 1430 hours soft restraints were ordered for P4 for non-violent behavior and were discontinued on 3/3/26 at 0100 hours. b. MR lacked documentation of a new restraint order on 3/1/26 per policy. 3. In interview on 5/7/26 at 0925 hours with A5 (Director Clinical Education), he/she confirmed P4 MR lacked documentation of an order for non-violent restraints on 3/1/26.”

“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: 50584 Based on document review and interview nursing services failed to inform a patients family of patient surgery and provide education regarding the procedure, risks, benefits, or alternatives and failed to document daily skin assessments of wounds for 1 of 10 MRs (Medical Records) reviewed. (P4) Findings include: 1. Facility policy titled Consents, 348, PolicyStat ID: 17995423, Last Revised 4/2025, Page 1, under Purpose: To inform the patient/patient’s family/significant other concerning procedures/surgery and answer any questions. To provide education to patient/family/significant other concerning the procedure and any risks, benefits, and alternatives by the provider. 2. Facility policy titled Documentation and Assessment Guidelines, 3095, PolicyStat ID: 19943337, Last Revised 2/2026, Page 7, under Daily assessment and Care Guidelines: h. Complete an assessment of the integumentary system, including by but not excluding description of an anomaly, defining characteristics, type of tissue in wound bed, exudate, condition of surrounding skin and any interventions in place to prevent pressure ulcers and other types of skin breakdown. 3. Review of P4 MR indicated: a. On 2/28/26 at 1245 hours Operative Note indicated P4 underwent an exploratory laparotomy, incarcerated ventral hernia repair, 4 cm (centimeter) lysis of adhesions, with release of small bowel obstruction, small bowel resection with anastomosis. b. MR lacked documentation P4’s family was notified of P4’s surgery prior to the procedure on 2/28/26. c. MR lacked documentation of initial assessment of skin tears to the base of P4’s left thumb and left medial wrist on 2/28/26. d. MR lacked documentation of skin tears to base of P4’s base of left thumb and left medial wrist from 2/28/26 through 3/3/26. 4. Review of facility Incident Reports form indicated the following incident involving P4: a. On 2/28/26 incident report indicated P4 was found to have a skin tear to the base of his/her left thumb and medial left wrist in PACU (Post Anesthesia Care Unit). 5. In interview on 5/7/26 at 0925 hours with A5 (Director Clinical Education), he/she confirmed P4 MR lacked documentation of daily skin care assessments to include skin tears to P4’s base of left thumb and medial left wrist from 2/28/26 through 3/3/26. A5 also confirmed P4 MR lacked documentation of P4’s family being notified P4 was going to surgery on 2/28/26,”

“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: 50584 Based on document review and interview, facility failed to ensure other departments involved in a patient’s care were included in an incident report for follow up of skin tears in 1 of 3 incident reports reviewed. (P4) Findings include: 1. Facility policy titled Patient/Visitor Incident, Adverse Event, Good Catch (Near Miss) Reporting, 330, PolicyStat ID: 20504384, Effective: 05/2026, Page 2, under Procedure: 3. It is the responsibility of the involved supervisor/manager/director to review the report for completion and to take any necessary actions. Actions may include but are not limited to the following: d. Ensure other departments/locations involved are included in report for necessary follow up. 2. Review of P4 MR indicated: a. MR lacked documentation of skin tears to base of P4’s left thumb and left medial wrist from 2/28/26 through 3/3/26. 3. Review of facility Incident Reports from 11/6/25 through 5/6/26 indicated the following incident regarding P4: a. On 2/28/26 incident report indicated P4 was found to have a skin tear to the base of his/her left thumb and medial left wrist in PACU. b. Incident lacked documentation to other departments involved in P4s care to ensure follow up of skin tears. 4. In interview on 5/7/26 at 0918 hours with A1 (Director of Quality), he/she confirmed the incident report on 2/28/26 involving P4 did not include notification to the ICU (Intensive Care Unit) to follow up on wounds.”

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 44532 Based on document review, the facility failed to provide a patient/patient family, a written response from grievance submitted to facility in one instance. (P1) Findings include: 1. Review of the Policy titled “Patient Grievance/ Complaint Procedure, 340”, PolicyStat ID: 18398064, last revised 08/2025, indicated to provide a mechanism by which a patient or patient’s representative will be able to voice complaints regarding the quality of care or services received or a premature discharge. Procedure 8. F1 will address the substance of each patient grievance through the patient/complaint process as soon as possible. In any case, a written response will be provided to the patient or patient representative within seven (7) days from the date of receipt of a Patient Grievance. 2. Review of a grievance form titled “Complaint and Grievance Report” related to patient P1 on 01/20/26, indicated a grievance was received on 09/18/2025 from P1 family regarding quality of care, P1 was restrained in bed with food tray sitting open on bedside table and was cold. Grievance indicated that the nurse manager was notified of this incident on 09/18/2025. Report lacked any correspondence verbal or written was given to the complainant post investigation of the grievance. 3. In interview with A1 (Quality Manager) on 01/20/2026 at 1445 hours confirmed that the complaint/grievance record did not reflect that P1 family had any written and/or verbal response following the complaint/grievance that was received on 09/18/2025 from P1 family.”

“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, the facility failed to ensure that meal intake/meal percentage was recorded for 2 (P1 and P2) of 10 patients medical record (MR) reviewed. Findings include: 1. Policy titled “Documentation and Assessment Guidelines”, PolicyStat ID: 19530238, last revised 12/2025, indicated provides standards to guide documentation for inpatients of all ages. Daily Assessment and Care Guidelines: 3. Intake and output will be completed every 4 (four) hours, unless ordered more frequently by a physician. Measure and record all sources of intake and output, including meals, on all patients with an order for intake and output, or as appropriate. 2. Review of patient P1 MR indicated the patient was admitted to F1 (Acute Care Hospital) on 09/11/2025 with a diagnosis of declining mental status. MR review indicated P1 was ordered a regular diet on 09/11/2025. Review of P1 Nutritional Service Flowsheet indicated recorded meal consumption of having 7 (seven) documented meal intakes during his/her stay 09/11/2025 through 09/16/2025. Lacked documentation of 12 (twelve) recorded oral meal intake. Review of nutrition service flowsheet for 09/17/2025 through 09/19/2025 while P1 had non-violent restraints applied lacked documentation meal intakes. Unable to verify that P1 had been offered or helped with meals during his/her stay. 3. Review of patient P2, medical record (MR) indicated the patient was admitted to F1 on 09/12/2025 with a diagnosis of altered mental status. He/She was placed in non-violent restraints from dates 09/15/2025 at 0025 hours and removed on 09/15/2025 at 1530 hours. P2 was back in non-violent restraints on 09/17/2025 until 09/19/2025. Review on MR indicated P2 had an ordered diet of a dysphasia diet with bite size level 6. Review of P2 Nutrition Service Flowsheet indicated documentation of P2 having 15 (fifteen) documented meal intakes during his/her stay 09/12/2025 through 09/19/2025. Lacked documentation of 9 (nine) recorded meal intakes. P2 was discharged from F1 on 09/19/2025. 4. In interview on 01/20/2025, at approximately 1150 hours with N10 (Patient Care Technician) confirmed that we are supposed to chart meal intakes on all patients. 5. In an interview on 01/20/2025, beginning at approximately 1450 hours, A4 (Quality Specialist) indicated that she/he could not obtain any more oral meal intake recorded for P1 and P2 from MR reviewed.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 44532 Based on document review and interview, the registered nurse failed to ensure patients medication was given as ordered by the physician for 1 of 11 patients (P#2). Findings include: 1. Review of the policy titled “Medication and Intravenous Therapy Administration Documentation (D), 3075”, PolicyStat ID: 12583523, last revised 06/2022 indicated the purpose to provide an accurate daily permanent record of medication and intravenous therapy administration, medications are documented by using bedside computer documentation with barcoding. Page 2. 4. Administer medications utilizing 5 rights. a. Right Patient b. Right Medication c. Right dose d. Right time e. Right route Page 3. 1. Medications may have one or both of the following barcodes: b. Scanning the patient’s armband will verify the patient. Scanning the manufacturer barcode will verify the correct medication, as an error could occur in the process of pharmacy labeling. If the medication barcode will not scan, contact pharmacy. 2. Review of medical record for P#2 medical indicated the patient had a order written on 01/01/2024 at 0453 for norepinephrine additive 8 mg (milligram) plus sodium chloride 250 ml (milliliter), Intravenous (IV). The MR indicated that norepinephrine was administered to P#2 on 01/01/2024 at 0512 hours. 3. Review of the Override Medication Scan Reason Report dated 01/01/2024 indicated when attempting to administer P#2 medications, the medication that was scanned by N2 (Registered Nurse) with the barcode was nicardipine 50 mg and sodium chloride 0.9% 250 ml on 01/01/2024 at 0512 hours producing an error code. N2 overrode this error message by selecting norepinephrine from the P#2 ordered medication list on the computer screen. N2 proceeded by administering the incorrect medication without a provider’s order. 4. Interview on 03/13/2024 with A1 (Chief Nursing Officer) at 0915 hours, confirmed that the facility failed to administer the correct medication as ordered (Norepinephrine) and the incorrect medication (Nicardipine) was administered to P#2.”