Baptist Health Floyd

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 50584 Based on document review and interview, facility failed to adhere to their policy by applying handcuffs as a healthcare restraint in 1 of 10 MRs (Medical Records) reviewed. (P8) Findings include: 1. Facility policy titled Security Department Use of Handcuffs, Policy #: 13240.1, Original Effective Date: 10.09.2024, page 1, under Policy, Handcuff Use, The use of handcuffs is considered a law enforcement restraint. Handcuffs are not considered a safe or appropriate healthcare restraint intervention. 2. Review of P8 MR indicated: a. P8 presented to the ED (Emergency Department) on 9/29/25 with chief complaint of left knee pain. b.On 10/1/25 at 0140 hours Nursing Note indicated P8 came back from CT (computed tomography) at midnight. Technicians attempted to get vital signs from P8 and he/she was attempting to call 911 multiple times. N1 (LPN [Licensed Practical Nurse), attempted to given P8 medication, P8 was on the phone with a friend, took medication back to the omnicell, another nurse that admitted P8 indicated he/she was not acting right. N1 attempted to reorientate P8, pull patient up in bed and turn the bed alarm on for P8s safety. P8 then starting taking pictures of N1, was trying to ambulate, stumbled, grabbed the IV (Intravenous) pole, N1 repeatedly tried to reorientate P8 as he/she walked out of his/her room continuing to take pictures of the staff. N1 continued to talk to P8 to calm him/her, P8 slapped N1’s hand, Security was called, two security guards and N8 (off-duty police officer) who works with security responded. P8 was agitated and telling N8 he/she was not a real officer, N1 and security were attempting to speak with P8, multiple attempts were made to calm P8, P8 continued to be agitated and called a family member to come and get him/her. P8 then called 911, house supervisor was called, more attempts were made to calm P8, P8 stated he would not go back to the room, they would have to physically make him/her, security then handcuffed P8 and placed P8 back into the room. Family member called P8s room and N1 told FM1 (P8 sibling) P8 could not leave due to his/her altered status, FM1 stated he/she would come to see P8. Physician order was received to place P8 in restraints and handcuffs were removed replaced by restraints. 3. In phone interview on 12/22/25 at approximately at 1502 hours with N8 (Off-duty Officer), he/she indicated security was called to assist with P8 on Unit 3C. P8 was wanting to leave, confused, yelling with signs of violence that the staff was trying to kill him/her. P8 was asked several times to return to his/her room, N8 told P8 they would ask P8 one more time to return to his/her room or they would carry him/her back to the room. N8 reached for P8s arm and he/she jerked away, N8 handcuffed P8 and carried P8 back to the room. 4. In interview on 12/22/25 at approximately 1520 hours with N3 (security officer), he/she indicated that P8 was aggressive and trying to leave the unit. The house manager indicated that P8 was not coherent, unsteady with recent knee surgery and pain, and P8 was not free to leave at that point. P8 was mad and yelling in the hallway, calling N8 a fake cop, N8 reached for P8, P8 tensed up, was not swinging or coming at anyone, and P8 instinctively placed handcuffs on P8. 5. In phone interview on 12/22/25 at approximately 1931 hours with N1, he/she indicated that N8 told P8 he would have to cuff him/her if he/she did not return to his/her room, P8 told N8 to go ahead, he/she would call his/her lawyer friend, N8 reached out to touch P8, and at some point the handcuffs were used to get P8 back into his/her room. N1 is unsure at what point the handcuffs were removed.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f) Restraint or Seclusion: Staff Training Requirements. The patient has the right to safe implementation of restraint or seclusion by trained staff. This Standard is not met as evidenced by: 50584 Based on document review and interview, facility failed to maintain documentation of competency to apply restraints and/or handcuffs in 1 of 8 personnel records reviewed. (N8, Off-duty Officer) Findings include: 1. Facility policy titled Security Department Use of Handcuffs, Policy #: 13240.1, Original Effective Date: 10.09.2024, page 2, under Procedure, Certification and Recertification Training, Initial Certification: Officers must successfully complete the mandatory handcuff training certification prior to being issued handcuff equipment. An officer who fails to complete the initial handcuff certification will not be issued, nor permitted to carry, handcuff equipment. Page 3, Recertification: Officers must successfully complete recertification on an annual basis for continued carry of handcuff equipment. 2. Facility policy titled Restraints, Policy # 600.0406, Revised & Effective Date 7.2025, page 5, under Safe Application of Restraints, 1) Restraints will be applied correctly and appropriately by competent, trained staff. 3. Review of Contract Service Agreement with F2 (security contractor), page7, under Exihibit A, Services To Be Provided, 5. Contractor shall require Officer to participate in Hospital’s orientation process, clinical health requirements (including immunizations and vaccinations required of staff) and department specific education and training, as identified and requested by Hospital. 4. Review of P8 MR indicated: a. P8 presented to the ED (Emergency Department) on 9/29/25 with chief complaint of left knee pain. b.On 10/1/25 at 0140 hours Nursing Note indicated P8 came back from CT (computed tomography) at midnight. Security was called, two security guards and N8 who works with security responded. P8 was agitated and telling N8 he/she was not a real officer, N1 and security were attempting to speak with P8, multiple attempts were made to calm P8, P8 continued to be agitated and called a family member to come and get him/her. P8 then called 911, house supervisor was called, more attempts were made to calm P8, P8 stated he would not go back to the room, they would have to physically make him/her, security then handcuffed P8 and placed P8 back into the room. 5. In phone interview on 12/22/25 at approximately at 1502 hours with N8, he/she indicated security was called to assist with P8 on Unit 3C. P8 was wanting to leave, confused, yelling with signs of violence that the staff was trying to kill him/her. P8 was asked several times to return to his/her room, N8 told P8 they would ask P8 one more time to return to his/her room or they would carry him/her back to the room. N8 reached for P8s arm and he/she jerked away, N8 handcuffed P8 and carried P8 back to the room. 6. In interview on 12/22/25 at approximately 1530 hours A9 (Safety and Security Manager), he/she confirmed N8 did not have orientation to the facility and job specific to include training related to the application of restraints and/or use of handcuffs.”

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 50584 Based on document review and interview, facility failed to maintain complete and accurate documentation in 1 of 10 History and Physical reviewed. (P8) 1. Review of P8 History and Physical indicated P11 was listed in P8 History and Physical file reflecting information for both patients, therefore the History and Physical did not reflect accurate documentation regarding P8 in the Medical Record. 2. Email dated 12/29/25 at 1445 hours from A1 (Accreditation Coordinator) confirmed that the History and Physical for P8 contained incorrect information.”

“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: 47685 Based on document review and interview, nursing services failed to complete daily patient hygiene and daily linen change per policy for 4 of 10 medical records reviewed. (P1, P3, P6 & P7); failed to initiate wound care/treatment for wound discovered on initial skin assessment for 1 of 10 MRs reviewed (P7); failed to assess wound dressing every 4 hours per policy for 2 of 10 MRs reviewed (P2, P3); failed to assess patient pain level every 4 hours per policy for 3 of 10 patient medical records reviewed (P3, P6, P10); and failed to re-assess pain 30-60 minutes after interventions per policy for 2 of 10 patient MRs reviewed. (P7, P10) Findings Include: 1. Policy titled Inpatient Nursing Unit Standards of Care, no policy #, indicated Hygiene: Daily Bath all patients, CHG (chlorhexidine) bath daily for central lines; linen change daily and PRN (as needed). Pain: Q (every) 4 hours or presence of any S/S (signs/symptoms) discomfort. Following any alleviation intervention. Incisions/Dressings, Drains: Q4 hours. Skin: On admit, during bedside change of shift, and Q shift. 2. Policy titled Pain Management and Narcotic Usage, no policy #, last revised 3/2024, indicated after the medication is administered, follow-up of its effectiveness should be assessed and documented within 30-60 minutes. Procedure 6. Chart narcotic, when given, why, route, use pain scale prior to giving, and then chart the response to pain medication with pain scale within 30-60 minutes. 3. Policy titled Skin Assessment/Braden Scale Guidelines/Pressure Ulcer/Injury, Policy # 11998.3, last revised 9/1/2021, indicated Policy: On admission, nurse should assess patient and document assessment. Nurse should also complete skin assessment every shift throughout hospital stay. I. At Time of Admission - Interventions addressing care should be developed by the nursing staff and incorporated into the patient’s plan of care, as appropriate. 4. Policy procedure titled Clinical Nursing Skills & Techniques (10th. Ed.), no procedure #. no revision date, indicated 5. Assess the location of the stoma, the type of stoma, and the characteristics of the patient’s abdomen to determine the best type of pouching system. Consider the abdominal contour and the presence of scars or incisions. 5. P1 Medical Record (MR) review completed on 4/30/2024 indicated: a. Patient was admitted on 3/27/2024 with chief complaint of mechanical fall. b. MR lacked documentation of patient daily bathing and daily linen change completed on 3/28/2024 and 3/29/2024. c. Patient was discharged home on 3/31/2024. 6. P2 MR review completed on 4/30/2024 indicated: a. Patient was admitted on 3/27/2024 with pain to the back post lateral fusion procedure. b. MR lacked documentation of nursing assessing PICO (wound care system that provides suction) dressing, according to policy, every 4 hours, from 1959 hours on 3/28/2024 through 0739 hours on 3/29/2024. c. Patient was discharged home on 4/4/2024. 7. P3 MR review completed on 4/30/2024 indicated: a. Patient History and Physical dated 3/27/2024 at 1844 hours indicated patient was admitted on 3/27/2024 with chief complaint of abdominal pain. b. MR lacked documentation of inguinal hernia dressing and site assessment completed every 4 hours, per policy, from 1959 hours on 3/28/2024 through 0739 hours on 3/29/2024. c. MR lacked pain assessment every 4 hours, per policy, from 0859 hours on 3/30/2024 through 2001 hours on 3/30/2024. d. MR lacked documentation of midline abdominal wound dressing and site assessment completed every 4 hours per policy, from 1913 hours on 4/11/2024 through 1634 hours on 4/12/2024. e. MR lacked documentation of colostomy site dressing and site assessment completed every 4 hours, per policy, from 0424 hours on 4/13/2024 through 1148 hours on 4/13/2024, and from 1148 hours on 4/13/2024 through 2203 hours on 4/13/2024. f. MR lacked documentation of daily patient bathing and linen change 3/28/2024, 3/29/2024, 3/31/2024 and 4/1/2024. g. Patient was discharged home on 4/16/2024 in stable condition. 8. P6 MR review completed on 4/30/2024 indicated: a. Patient was admitted on 3/28/2024 with chief complaint of dyspnea. b. MR lacked documentation of pain assessment every 4 hours, per policy, on from 0800 hours on 4/1/2024 until 2000 hours on 4/1/2024. c. MR lacked documentation of daily patient bathing and linen change on 4/1/2024. d. Patient was discharged home on 4/3/2024. 9. P7 MR review completed on 4/30/2024 indicated: a. Patient was admitted on 3/28/2024 with chief complaint of left knee pain. b. Initial nursing assessment dated 3/28/2024 indicated a wound was found on patient left knee; no further documentation/description or interventions were noted. No further documentation until assessment on 3/31/2024. b. MR indicated pain intervention was administered on 3/28/2024 at approximately 2131 hours, pain was not reassessed within 30-60 minutes per policy; pain was reassessed on 3/29/2024 at 0032 hours. c. MR lacked documentation of daily patient bathing and linen change on 3/30/2024. d. MR indicated pain intervention was administered on 4/1/2024 at approximately 0830 hours, pain was not reassessed within 30-60 minutes per policy; pain was reassessed on 4/1/2024 at 1200 hours. e. Patient was discharged home on 4/1/2024. 10. P10 MR indicated: a. Patient was admitted on 4/23/2024 with chief complaint of right flank pain. b. MR lacked documentation of pain assessment from 2004 hours on 4/23/2024 through 0700 hours on 4/24/2024. c. MR lacked documentation of daily patient bathing and daily linen change on 4/24/2024. d. Patient was administered pain intervention on 4/28/2024 at approximately 0421 hours, MR indicated intervention was not reassessed in 30-60 minutes per policy, pain was reassessed at 0424 hours on 4/28/2024. e. P10 is currently inpatient on SIPS unit. 11. In interview on 4/30/2024 at approximately 1500 hours with A4 (Accreditation Coordinator), he/she confirmed MR findings of lack of pain management and reassessment documentation, lack of hygiene and linen change, lack of dressing and wound assessments and interventions as appropriate for MRs reviewed (P1, P2, P3, P6, P7, and P10).”