Ascension St Vincent Hospital

“IC PROFESSIONAL ADHERENCE TO POLICIES CFR(s): [The infection preventionist(s)/infection control professional(s) is responsible for:] (v) The prevention and control of HAIs, including auditing of adherence to infection prevention and control policies and procedures by hospital personnel. This Standard is not met as evidenced by: 48061 Based on document review, observation, and interview, facility EVS (Environmental Services) failed to daily clean and discharge clean patient rooms per facility policy standard for 2 of 2 patient rooms observed. (4427/4403) Findings include: 1. Facility Policy titled, “Daily Patient Room Cleaning”, PolicyStat ID 5192770, last revised 07/2018, indicated under POLICY: 3. Utilize Clorox Bleach Wipes, sanitize all patient contact surfaces, including over bed table bedrails, bedside table phone nurse call button pad, chairs rails, and counters working out from the areas closest to the patient and then proceeding around the room in a counter clockwise circle. Sensitively, move the patient’s belongings where appropriate to disinfect surfaces. Clean high tough surfaces in the restroom (handles, faucets, light switch, toilet seat) last. 4. Use microfiber cloth and Virex disinfectant, damp high dust, beginning at the entranceway and working around the room in a counter clockwise circle. Damp high dust horizontal surfaces above should height starting opposite the restroom. Never dust above a patient/resident. Damp high dust surfaces in the restroom. 5. Spot clean and disinfect vertical surfaces including stains and spots from walls, light switches, door knobs and other relevant vertical surfaces using a microfiber cloth and Virex Disinfectant. 8. Use a microfiber cloth with Virex Disinfectant and sanitize the restroom. Clean the mirror, grab bars, dispensers, sink fixtures, basin, underside and pipes, shower fixtures, toilet fixtures, seat and base. Use bowl mop to sanitize the bowl rim and drain bowl. 9. Using dust pan and lobby brush, pick up debris on the floor including under the bed and furnishings and in the restroom. Place any debris collected in the trash collection bag on the housekeeping cart. 10. Inspect your work. 2. Facility Policy titled, “ Discharge Room Cleaning Procedure”, PolicyStat ID 7874810, last revised 04/2020, indicated under PROCEDURE: 3. High dist, beginning at the entranceway and work around the room in a counter clockwise circle. High dust horizontal surfaces above shoulder height starting as you enter the room. If patient is still present, never dust above the patient/resident. High dust surfaces in the restroom. Replace high duster after each rooms use. 6. Using Virex disinfectant and micro fiber clean cloth, sanitize all patient contact surfaces, starting with the bed. 7. Damp wipe stains and spots from walls and other vertical surfaces using Virex disinfectant and microfiber cloth. 9. Dampen clean microfiber cloth in Virex disinfectant solution and clean restroom beginning with the light over the sink, moving over the restroom downward. Clean ledge of the mirror. Use the window cleaning cloth with window cleaner, clean the bathroom mirror. Clean the sink, pipes under the sink, and spot clean walls around sink area. Clean shower and/or bathtub if applicable. Use the bowl mop and Virex disinfectant, clean under the rim of the toilet and all around the inside of the toilet in a circular motion. Dip the cloth and clean the top and bottom of toilet seat, then the outside if the toilet. Flush toilet. Leave toilet seat in a down position and apply toilet band if applicable. Restock any disposable supplies, cleaning dispensers as you go. 11. Using dust pan and lobby brush, pick up debris on the floor including under the bed and furnishings and in the restroom. Place any debris collected in the trash collection bag on the housekeeping cart. 3. Unit tour of the Multi Specialty Medical Surgical Unit (4 E/4W) on 6/17/26 at approximately 2:15 pm a clean room (4427/4W) was inspected and found to have dust on multiple surfaces including room walls, bathroom walls, and negative airflow vents. Various dried material orange, red, and brown in color was observed on multiple surfaces including bathroom walls, light switches, shower/potty chair, shower floor, and shower walls, window ledges, windows, and whiteboards. A second room (4403/4E) was inspected and the bathroom was found to have copious amounts of dust on the bathroom wall. The shower was found to have orange, brown, yellow, and red dried material located within the shower. Hair was located near the shower drain. 4. In interview on 6/17/26 at approximately 2:30 pm with EVS1 (Environmental Services Operational Manager) confirmed findings from toured rooms and confirmed the staff members that daily/discharge cleaned both room did not follow facility policy and procedure related to daily/discharge cleaning patient rooms but should have.”

“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: 48061 Based on document review and interview, facility nursing staff failed to document hourly rounding, every 2-hour safety checks resulting in elopement of confused/hallucinating patient for 1 of 10 medical records reviewed (P1); and failed to complete an incident report related to patient (P1) elopement in one instance. The cumulative effects of these systemic problems resulted in the facility’s inability to provide nursing services 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: 48061 Based on document review and interview, facility nursing staff failed to document hourly rounding, every 2-hour safety checks resulting in elopement of confused/hallucinating patient for 1 of 10 medical records reviewed. (P1) Findings include: 1. Facility unit standards document titled,”Neurology Unit Standards and Documentation Requirements-RN”, no policy number, last updated 1/3/2025, indicated under PATIENT CARE: Initial Shift Assessment/Upon Admission. Safety Precautions, bed alarm/chair alarm, seizure precautions, activity positioning, SCDs. Q 1 hour. Hourly Rounding. Q 2 Hours. Safety Precautions, Activity, Positioning, Equipment, Self-Care Promotion, Venous Thromboembolism Prevention/Management. 2. Facility unit standards document titled,”Neurology Unit Standards and Documentation Requirements-PCT”, no policy number, last updated 1/3/2025, indicated under PATIENT CARE: Initial Shift Assessment/Upon Admission. Safety Precautions, bed alarm/chair alarm, seizure precautions, activity positioning, SCDs. Q 1 Hour. Hourly Rounding. Q 2 Hour. Safety Precautions, Activity, Positioning, Equipment, Self-Care Promotion, Venous Thromoembolism Prevention/Management. 3. Review of P1’s MR (Medical Record) indicated: a. MR lacked hourly rounding documentation on 2/12/26 for hours, including but not limited to: 9:00 am, 10:00 am, 12:00 pm, 1:00 pm, 2:00 pm, and/or 3:00 pm, lacked documentation of every 2 hour safety check and every 1 hour (hourly rounding) by facility nursing staff as indicated by unit documentation standards and requirements dates including by not limited to 2/3/26-2/12/26. b. MR noted indicated on 2/12/26 at 9:34 am, P1 was not found in room. Facility security brought P1 back to unit. Reported P1 was found in the parking lot trying to get into cars, disoriented to time and situation. 4. In interview on 4/2/26 at approximately 4:35 pm with A5 (Manager of Medical Surgery) confirmed the expectation is that a staff member should be laying eyes on the patient every hour and related hourly documentation can be listed under various types of documentation.”

“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: 48061 Based on document review and interview, facility staff failed to complete an incident report related to patient (P1) elopement in one instance. Findings include: 1. Facility policy titled, “Event Reporting (ERS) Policy”, PolicyStat ID 15464737, last revised 05/2024, indicated under PROCEDURE: Event Reporting (ERS) Entry. A. When an adverse event, error, harm, near miss, sentinel event, or serious reportable event occurs in the inpatient or ambulatory setting, the associate detecting the event is responsible for reporting the event via the hospital’s event reporting (ERS). 2. Review of P1’s MR (Medical Record) on 2/12/26 at 9:34 am indicated P1 was not found in room. Facility security brought P1 back to unit. Reported P1 was found in the parking lot trying to get into cars, disoriented to time and situation. 3. Review of Incident report log were reviewed for the months of 10/1/2025 - 4/2/2026. P1 was not listed, facility lacked documentation related to the elopement incident that occurred on 2/12/2026. 4. In interview on 4/2/26 at approximately 4:35 pm with A5 (Manager of Medical Surgery) confirmed P1’s elopement event on 2/12/26 should have been entered as an ERS by the nursing staff, but was not.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(ii) Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior. This Standard is not met as evidenced by: 48061 Based on document review and interview, facility staff failed to appropriately initiate seclusion of a patient for 1 of 10 patient medical records reviewed. (P1) Findings include: 1. Facility policy titled,”Restraint or Seclusion - Inpatient Behavioral Health”, Policy Stat ID 16364366, last revised 12/2024, indicated under POLICY: A. Restraint or seclusion will only be used to ensure the immediate physical safety of the patient, staff or others. At no time will the restraint or seclusion be used as a means of coercion, discipline, coercion, retaliation, or behavior modification. 2. Review of P1’s MR (Medical Record) on 2/5/26 at 9:30 pm indicated P1 was placed in seclusion. Description of events and behaviors prior to use of seclusion/restraint included P1 yelling and making loud inappropriate moaning sounds in his/her room. MR lacked evidence P1 was a threat to him/herself or others prior to being placed in seclusion and lacked evidence that P1 was banging and flailing his/her body against the head board. 3. In interview on 3/25/26 at 10:30 am with O1 (Officer) confirmed upon arrival, they could hear P1 banging on walls, shouting obscenities, debriefed with N1. N1 made the clinical decision to initiate restraints. O1 noted P1 banging and flailing his/her body against the head board. When O1 made contact with P1. P1 continued hurling profanities at the officers and nursing staff. P1 then crossed his/her arms. P1 then slammed his head against head board. P1 placed in escort position by officers. As P1 was being physically escorted seclusion room to be restrained. P1 began kicking. O1 confirmed P1 not carried by legs. P1 assisted into seclusion room with feet sliding on floor. 4. In interview on 3/25/26 at approximately 1:55 pm with O3 (Officer) called for staff assistance with P1. Officers talked with P1 for approximately 10 minutes attempting to verbal de-escalation but were unsuccessful. P1 was laying in bed, refused walk to seclusion room, cursing at clinical and security. Officers walked P1 towards seclusion room, P1 then went dead weight, P1 began kicking officers, officers walked P1 into seclusion room with an arm underneath each of the patients arms. P1’s face/head never pressed against floor, no injuries noted, was not carried by arms and legs, was not verbally abused, and/or was not treated unprofessionally.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(2) Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm. This Standard is not met as evidenced by: 48061 Based on document review and interview, facility staff failed to properly implement restraint/seclusion for a patient (P1) who was not a harm to themselves, staff members and/or other patients in 1 of 10 medical records reviewed. Findings include: 1. Facility policy titled,”Restraint or Seclusion - Inpatient Behavioral Health”, Policy Stat ID 16364366, last revised 12/2024, indicated under POLICY: A. Restraint or seclusion will only be used to ensure the immediate physical safety of the patient, staff or others. At no time will the restraint or seclusion be used as a means of coercion, discipline, coercion, retaliation, or behavior modification. 2. Review of P1’s MR (Medical Record) on 2/5/26 at 9:30 pm indicated P1 was placed in four point restraints. Description of events and behaviors prior to use of seclusion/restraint included P1 yelling and making loud inappropriate moaning sounds in his/her room. MR lacked evidence P1 was a threat to him/herself or others prior to being placed in seclusion, lacked evidence that P1 was banging and flailing his/her body against the head board, and lacked evidence P1 began kicking on the way to the seclusion room. 3. In interview on 3/25/26 at 10:30 am with O1 (Officer) confirmed upon arrival, they could hear P1 banging on walls, shouting obscenities, debriefed with N1. N1 made the clinical decision to initiate restraints. O1 noted P1 banging and flailing his body against the head board. When O1 made contact with P1. P1 continued hurling profanities at the officers and nursing staff. P1 then crossed his/her arms. P1 then slammed his head against head board. P1 placed in escort position by officers. As P1 was being physically escorted seclusion room to be restrained. P1 began kicking. P1 assisted into seclusion room with feet sliding on floor. N1 then advised officers that P1 needed to be placed in 4 point restraints. 4. In interview on 3/25/26 at approximately 1:55 pm with O3 (Officer) called for staff assistance with P1. Officers talked with P1 for approximately 10 minutes attempting to verbal de-escalation but were unsuccessful. P1 was laying in bed, refused walk to seclusion room, cursing at clinical and security. Officers walked P1 towards seclusion room, P1 then went dead weight, P1 began kicking officers, officers walked P1 into seclusion room with an arm underneath each of the patients arms. P1’s face/head never pressed against floor, no injuries noted, was not carried by arms and legs, was not verbally abused, and/or was not treated unprofessionally.”

“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: 48061 Based on document review and interview, facility nursing staff failed to apply SCDs (Sequential/Intermittent Compression Device) as ordered for 1 of 10 medical records reviewed. (P1) Findings Include: 1. Facility policy titled,”Sequential/Intermittent Compression Device (SCDs) & Anti-Embolism Stockings”, PolicyStat ID 11870252, last revised 07/2019, indicated under POLICY: Application of SCDs must be ordered by a LIP and may only be discontinued after receiving an order from the LIP. 2. Facility policy title,”Patient Assessment/Reassessment”, PolicyStat ID 14093069, last revised 10/2023, indicated under ASSESSMENT: PURPOSE: Time Frame for Initial Assessment: A Inpatient admissions/observation status: A patient assessment and plan of care will be initiated by the RN upon the patient’s arrival to the unit, and will be completed within 24 hours. 3. Review of P1’s MR (Medical Record) indicated on 10/7/25 at 10:54 am a provider order for bilateralSequential/Intermittent Compression Device was ordered for P1. MR for P1 lacked documentation of Intermittent compression device being applied by facility nursing staff on 10/7/25 and 10/8/25. 4. In interview on 11/18/25 at approximately 2:00 pm with A3 (Nursing Director) confirmed P1’s SCDs were not placed on the patient when admitted to the SO (Surgical Observation ) unit but should have been.”

“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: 48704 Based on document review and interview, nursing services failed to document dietary intake in 1 of 10 (Patient 3) medical records reviewed. Findings include: 1. Facility document titled Neurology Unit Standards and Documentation Requirements - PCT, updated 01/03/2025, indicated under Intake and Output, Dietary Intake, every meal (to be documented in room before tray is removed). 2. Review of patient 3’s medical record indicated the following: a. On 10/11/2025 patient 3 was admitted for a cerebrovascular accident (CVA). b. On 10/17/2029 provider ordered a chopped diet. c. On 10/19/2025, 10/20/2025, and 10/21/2025 medical record lacked documentation for 1 of 3 dietary intake entries. d. On 10/23/2025 the medical record lacked documentation for 2 of 3 dietary intake entries. e. On 10/24/2025, 10/25/2025, and 10/26/2025 the medical record lacked documentation for 3 of 3 dietary intake entries. f. On 10/27/2025 and 10/28/2025 the medical record lacked documentation for 2 of 3 dietary intake entries. g. On 10/29/2025 the medical record lacked documentation for 3 of 3 dietary intake entries. h. On 10/30/2025 and 10/31/2025 the medical record lacked documentation for 2 of 3 dietary intake entries. i. On 11/01/2025 and 11/02/2025 the medical record lacked documentation for 3 of 3 dietary intake entries. j. On 11/03/2025 the medical record lacked documentation for 1 of 3 dietary intake entries. k. On 11/04/2025 and 11/05/2025 the medical record lacked documentation for 3 of 3 dietary intake entries. l. On 11/06/2025 and 11/07/2025 the medical record lacked documentation for 1 of 3 dietary intake entries. m. On 11/08/2025 and 11/09/2025 the medical record lacked documentation for 3 of 3 dietary intake entries. 3. Interview with A8 (Clinical Supervisor) on 11/12/2024 at approximately 4:10 p.m. confirmed that patient care technicians (PCT) and nursing staff are to document dietary intake for all meals daily. 4. Interview with A4 (Accreditation) on 11/12/2025 at approximately 4:23 p.m. confirmed patient 3’s medical record lacked documentation of patient meals as indicated above.”

“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: 48061 Based on document review and interview, facility staff failed to ensure all patients were free from sexual abuse in 1 of 10 medical records reviewed. (P1) Findings include: 1. Facility policy titled,”Patient Rights and Responsibilities”, PolicyStat ID 10309215, last revised 05/2022, indicated under Patient Rights: You have the right to receive care free from all forms of neglect, abuse, harassment, and exploitation. 2. Review of P1’s MR (Medical Record) at H1 (Psychiatric Hospital) indicated progress note documentation dated 9/20/25 at 11:15 am indicated MD1 (Medical Doctor) was conducting his/her session with P1. At the end of the session P1 requested to change rooms. P1 believed his/her roommate (P2) was touching them inappropriately during the night of 9/19/25. 3. Review of P1’s MR at H2 (Acute Care Hospital) indicated sexual assault examination documentation dated 9/20/25, no time documented, indicated P1 named his/her attacker as P2 by name, location of attack as H1, time of attack as 9:30 pm to an unknown time. P1 indicated his/her anus was penetrated by P2’s finger and penis, P1’s anus was contacted orally by P2, P1 was made to make oral contact with P2’s penis. Ejaculation of P2 was indicated, no lubrication was indicated, no method of protection was indicated. P1 indicated P2 pushed him/her to the floor, restrained him/her on the floor, strangulation was used. Physical examination indicated pertinent findings to P1’s body. Multiple small abrasions on the right anterior neck, a small abrasion on the left side of the neck, and anal tear. 4. In interview on 9/30/25 at approximately 11:00 am with MD1 (Medical Doctor) confirmed he/she was apologetic, regretful, that the allegations happened.”

“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: 48061 Based on document review and interview, facility nursing staff failed to inform a patient and/or patients parent on services provided related to sexual assault prior to discharge for 1 of 10 medical records reviewed. (P1) Findings include: 1. Facility policy titled,”Patient Rights And Responsibilities”, PolicyStat ID 12352151, last revised 12/2022, indicated under Discharge: You have the right to know what care you should seek after discharge from the hospital. 2. In interview on 9/30/25 at approximately 11:25 am with N4 (Registered Nurse) confirmed N4 did not discuss and/or offer the sexual assault examination services of H1 to P1’s parent prior to discharge. Instructions were given on the services over the phone after requested by P1’s parent shortly after discharge.”

“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: 48061 Based on document review and interview, facility nursing staff failed to obtain documentation of venipuncture training & competency for 1 of 5 personnel files reviewed. (PCT1, Patient Care Technician) Findings include: 1. Facility policy titled,”Blood Specimen Collection (Venipuncture, Capillary and Heel Stick)”, PolicyStat ID 15597655, last revised 10/2024, indicated under POLICY: Procedure Notes: F. Venipunctures are performed by persons who have been trained and passed competency testing in phlebotomy. 2. Review of PCT1 (Patient Care Technician) personnel file indicated PCT1’s new PCT Associate Orientation Competency Assessment packet lacked documented competency for venipuncture. 3. In interview on 4/3/25 at approximately 2:33 pm A6 (Nurse Manager) confirmed PCT1 did not have required documented venipuncture competency but should have.”

“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: 49709 Based on document review and interview, nursing services failed to ensure call lights were answered in a timely manner in 2 of 3 patient rooms reviewed (rooms 4225 and 4226); failed to document patient repositioning every 2 hours for 1 of 10 patient medical records (MRs) reviewed (P6); failed to document every four-hour entries for patient vital signs for 1 of 10 patient MRs reviewed (P6); and failed to document daily patient personal hygiene for 1 of 10 patient MRs reviewed (P6). Findings include: 1. The facility policy/procedure titled, “Skin Care Policy: Pressure Injury Prevention and Wound Management,” PolicyStat ID: 13405907, last approved 12/2023; indicated under Pressure Injury Prevention/Interventions: 2. Interventions include but are not limited to: j. When in bed: iii. Reposition or if patient able, encourage/educate patient to reposition every 2 hours as appropriate and safe for medical condition. (minimum every two-hour turns). 2. The facility policy/procedure titled, “Patient Personal Hygiene: Guidelines For Providing Care (CHG Bathing),” PolicyStat ID: 15745546, last approved 07/2024; indicated under Policy Statement: Personal Hygiene (including washing hair) is to be offered to all in-patients at least daily and documented as completed or refused in the patient’s medical record. 3. Review of Nurse Call Detail Report for dates from 03/09/25 - 03/10/25 indicated patient call lights were not answered timely 20 times the call light was activated out of 91 call light activations. The report indicated the following: a. Room 4225 call light report indicated the call light was not answered timely 14 out of 66 times the call light was activated. These include but are not limited to 03/09/25 - 7 minutes 29 seconds, 20 minutes 55 seconds, 17 minutes 27 seconds, 18 minutes 32 seconds, 11 minutes 48 seconds, 51 minutes 14 seconds, and 10 minutes 42 seconds. On 03/10/25 - 28 minutes 43 seconds, 36 minutes 45 seconds, 10 minutes 13 seconds, 44 minutes 07 seconds, 7 minutes 48 seconds, and 14 minutes 12 seconds. b. Room 4226, P6’s room, call light report indicated the call light was not answered timely 7 out of 43 times the call light was activated. These include but are not limited to 03/09/25 - 26 minutes 44 seconds, 7 minutes 21 seconds, and minutes 14 seconds. On 03/10/25 - 7 minutes 51 seconds, 33 minutes 16 seconds, 43 minutes 16 seconds, and 59 minutes 47 seconds. 4. Review of MR for P6 indicated the following: a. Patient Care Flow sheet lacked every two-hour entries for turns on the following dates: 03/03/25, 03/04/25, 03/05/25, 03/06/25, 03/07/25, 03/08/25, 03/09/25, 03/10/25, 03/11/25, 03/12/25, 03/13/25, 03/14/25, and 03/15/25. b. P6 lacked daily documentation of receiving personal hygiene on the following dates: 03/03/25, 03/04/25, 03/05/25, 03/06/25, 03/07/25, 03/08/25, and 03/11/25. c. Physician order on 03/02/25 indicated vital signs assessed every four hours. d. Vital Signs - Adult sheet, lacked every four-hour entries for vital signs on the following dates: 03/03/25, 03/04/25, 03/05/25, 03/06/25, 03/07/25, 03/08/25, 03/09/25, 03/10/25, 03/12/25, 03/13/25, 03/14/25, and 03/15/25. 5. On 04/02/25 at approximately 4:55 p.m., an interview with A4 (RN) confirmed patients get a chlorhexidine bath daily. The unit has a monitor technician, they will answer call lights and notify the nurse or Patient Care Technician (PCT), it depends on the need of the patient. 6. On 04/03/2025 at approximately 10:05 a.m., an interview with A6 (Nursing Manager) and A7 (Nursing Director), confirmed the nurses on their units follow the physician order for patient assessment including vital signs.”

“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: 48061 Based on document review and interview, the facility failed to ensure care in a safe setting for 1 of 10 patient (P1) medical records reviewed. Findings include: 1. The facility algorithm titled, “Patient Allegation of Caregiver Misconduct against a Care Provider to be facilitated by Risk Management”, last revised 08/19/2021, indicated Per CMS regulation 482.13(c) 3 The hospital must protect patients from abuse during investigations of any allegation of abuse, neglect, or harassment. Department Leader or Administrator on Call must take necessary action to prevent patient from abuse during investigation. 2. Review of facility incident log for dates 3/17/24-9/17/24 indicated P1 was listed twice on 8/27/24. No times were recorded for the submission of these incident reports. The details of the incident report filed by unit staff details an account of P1 grabbing at RN1’s (Registered Nurse) wrist during the morning of 8/27/24 and being uncooperative with medications and wearing his/her nasal cannula. The incident report then describes the incident between PCT1 (Patient Care Tech) and P1 regarding the blood sugar check and notes Q2 (Witness) stated that PCT1 hit P1. A second was initiated by an unknown provider, made aware by Q1 of his/her concern about the patient being hit. A provider called Q1 to update on the patient’s status, Q1 (Complainant) voiced concerns that the patient was hit after noncompliance with medications, the provider was unaware of the incident until Q1 voiced his/her concerns. Pt is demented, cannot describe incident. Family reported that family friend was present in room. The provider discussed that he/she would escalate concerns. The provider notified the abuse concern to the charge nurse and attending. Both incident reports were unresolved at the time of survey. 3. Associate timecard documentation for PCT1 indicated that he/she worked the following shifts during the investigation of abuse. 8/27/24, 8/30/24, 9/4/24, 9/7/24, 9/8/24, 9/9/24, 9/14/24, & 9/15/24. 4. In telephone interview on 9/19/24 at approximately 1:45 pm with A10 (Unit Manager) confirmed notifying Risk Management by email of the incident and requesting next steps, Confirms PCT1 was removed from P1’s care and reassigned to a different patient care assignment. 5. In virtual interview on 9/17/24 at approximately 1:15 pm with A7 (Risk Manager) confirmed PCT1 was not removed from patient care during the investigation of alleged abuse but rather reassigned to a different patient care assignment.”

“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: 48061 Based on document review and interview, the facility failed to keep patient free from abuse for 1 of 10 patient (P1) medical records reviewed. Findings Include: 1. The facility algorithm titled, “Patient Allegation of Caregiver Misconduct against a Care Provider to be facilitated by Risk Management”, last revised 08/19/2021, indicated under Risk Management: Triages concern with AR (Administrative Representative), LC (Legal Counsel) within 24-48 hours. 2. Review of facility incident log for dates 3/17/24-9/17/24 indicated P1 was listed twice on 8/27/24. No times were recorded for the submission of these incident reports. The details of the incident report filed by unit staff details an account of P1 grabbing at RN1’s (Registered Nurse) wrist during the morning of 8/27/24 and being uncooperative with medications and wearing his/her nasal cannula. The incident report then described the incident between PCT1 (Patient Care Tech) and P1 regarding the blood sugar check and notes Q2 (Witness) stated that PCT1 hit P1. A second was initiated by an unknown provider, made aware by Q1 of his/her concern about the patient being hit. A provider called Q1 to update on the patient’s status, Q1 (Complainant) voiced concerns that the patient was hit after noncompliance with medications, the provider was unaware of the incident until Q1 voiced his/her concerns. Pt is demented, cannot describe incident. Family reported that family friend was present in room. The provider discussed that he/she would escalate concerns. The provider notified the abuse concern to the charge nurse and attending. Both incident reports were unresolved at the time of survey. 3. Event Timeline provided by facility’s Risk Management team: 8/27/24: Risk Management notified of event. Event investigation started. Unit Manager to pt bedside for event review. OUTCOME: pt unable to participate. Unit Manager talked to PCT1 involved about involvement with event. OUTCOME: PCT assignment changed while further review. Unit Manager talked to family friend: OUTCOME: No concerns shared with him/her at this time. Unit Manager talked to primary RN regarding patient’s condition and event. OUTCOME: Continued to review. Unit Manager called patient’s child regarding event. OUTCOME: Discussed possible delirium for patient, Avasys (Video Monitor) being placed and PCT1 being changed. Family was polite. 8/28/24: Patient condition unchanged, no new concerns. 8/29/24: Patient discharged, no new concerns. 9/11/24: Interviewed: PCT, Interviewed: Primary RN, OUTCOME: No additional findings. 9/13/24: Met with legal. Discussed all information obtained from collaboration with unit leadership and interviews. OUTCOME: Unsubstantiated Claim. 4. In telephone interview on 9/19/24 at approximately 1:45 pm with A10 (Unit Manager) confirmed notifying Risk Management by email of the incident and requesting next steps, Confirms PCT1 was removed from P1’s care and reassigned to a different patient care assignment. 5. In virtual interview on 9/17/24 at approximately 1:15 pm with A7 (Risk Manager) confirmed he/she was the investigator of the alleged abuse claim that occurred on 8/27/24 on P1 by PCT1, P1 was not interviewed d/t (due/to)cognitive status in medical record. No contact was made with the patient after incident by A7, Q2 (Witness) was not interviewed d/t direction of H1’s legal counsel, PCA1 and RN1 were not interviewed until 9/13/24, facility legal counsel advised A7 there were no further actions to be taken after the interviews of the associates and chart review, and that H1 Legal counsel was not notified of incident within 24-48 hours, PCT1 was not removed from patient care during the investigation of alleged abuse but rather reassigned to a different patient care assignment.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 48704 Based on document review and interview, the facility failed to inspect surgical instruments and segregate broken, stained, or rusted instruments for 9 of 15 surgical sets to be used in surgery for the month of July 2024. Findings include: 1. Facility Policy titled, Assembly - Surgical Sterile Processing, PolicyStat ID 14494787, last approved 08/2024, indicated under POLICY, Prior to sterilization, all instrumentation should be inspected for cleanliness and functionality. Instruments must be clean in order for sterility to be achieved, and to assist in preventing infection. Instruments should function properly in order to prevent actual or potential patient injury. Instrument trays and sets should be assembled using standardized procedures to ensure best practices are learned and followed consistently. Instrument inspection should be performed: 1. After each use. 2. To ensure cleanliness and proper functionality. 3. To identify missing parts. 4. Using a lighted magnifying glass. 5. To identify and segregate broken, stained, or rusted instruments. 6. When new instruments are received. 2. Review Infection Control data for July 2024 indicated that there was 1 case of bioburden from EP Lab on 07/19/2024. Review of Sterile Central Electrophysiology Lab sets returned to Central Sterile for processing indicated the following: a. On 07/12/2024, 1 surgical case was performed, 1 case was cancelled due to surgical instrument contamination and 4 surgical sets from Electrophysiology Lab were sent to Central Sterile for processing. b. On 07/19/2024, 5 surgical cases were performed, 8 surgical sets from Electrophysiology Lab were sent to Central Sterile for processing including 1 surgical set with bioburden. c. On 07/31/2024, 1 surgical case was performed, 4 surgical sets from Electrophysiology Lab were sent to Central Sterile for processing. 3. Interview with A7 (Manager of Electrophysiology Lab) on 08/19/2024 at approximately 2:50 p.m. confirmed that a surgical case was canceled due to surgical instrument contamination on 07/12/2024 and indicated they did not have any documentation of the quality improvement plan for cleaning and repairing of the surgical Electrophysiology Lab instruments.”

“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: 48704 Based on document review and interview, nursing services failed to document medication administration in 1 of 10 patient (Patient #7) medical records reviewed; failed to complete fall risk shift assessments in 2 of 10 patient (Patients #3 and #6) medical records reviewed; failed to complete neurological checks in 3 of 10 patient (Patients #4, #8, and #9) medical records reviewed; and failed to document activity and position change every 2 hours per policy in 2 of 10 patient (Patients #8 and #9) medical records reviewed. Findings include: 1. Facility policy titled, Fall Prevention, PolicyStat ID 9099224, last approved 01/2021, indicated, under Policy, D. Assessment/Reassessment, 1. Will be completed upon admission, each shift, with any change in patient condition and with transfer from or to a higher/lower level of care; or at the frequency defined by the approved evidence-based fall risk tool. Safety interventions will be implemented according to identified levels of risk. Patient’s scoring low fall risk will have all Basic Safety Needs interventions in place. 2. Facility policy titled, Medication Administration by Nursing Associates, PolicyStat ID 13606967, last approved 05/2023, indicated under Policy/Procedure, K., Record administration given or not given on MAR (Medication Administration Record). 3. Review of document titled Exhibit F Performance Standards indicated the key laboratory metrics that will be reported (including targeted performance) are noted in the following chart (the “Key Metrics”). Table 1: Metric, STAT testing turn-around-time (in patient locations not including ED/NICU/PICU/ICU) (measured from receipt in laboratory as evidenced by the time-stamp for entry into the system); Target 95% of STAT tests completed and resulted < 60 minutes. 4. Review of document titled Neuro Standard of Care and Documentation - RN indicated a. Minimum Frequencies; Q4H, Vital signs & neuro checks unless ordered more frequently b. Minimum Frequencies: Q2H, Position change, Activity, Safety Precautions, IV site for medicated drips i.e. cardizem, heparin, insulin, IVIG, blood 5. Review of Patient 1’s medical record indicated a STAT urinalysis was ordered on 05/13/2024, no time documented, urine specimen collected at 11:37 a.m. on 05/13/2024; specimen received in the lab at 2:20 p.m.; urinalysis results were completed at 2:31 p.m. Medical record lacked documentation of why specimen was not taken to lab after collected. 6. Review of Patient 2’s medical record lacked documentation of a fall risk shift assessment for the following shifts: a. Day shift on 05/13/2024, 05/14/2024, 05/15/2024, 05/16/2024, 05/17/2024, and 05/18/2024, 05/20/2024, 05/21/2024, 05/24/2024, and 05/25/2024. b. Night shift on 05/13/2024, 05/14/2024, 05/15/2024, 05/16/2024, 05/17/2024, and 05/18/2024, 05/19/2024, 05/20/2024, 05/21/2024, 05/22/2024, 05/23/2024, and 05/24/2024. 7. Review of Patient 3’s medical record lacked documentation of a fall risk shift assessment for the following shifts: a. Day shift on 05/13/2024, 05/14/2024, 05/15/2024, 05/18/2024, 05/19/2024, 05/20/2024, 05/21/2024, 05/22/24, 05/23/2024, 05/24/2024, 05/25/2024, 05/26/2024, 05/27/2024, and 05/28/2024. b. Night shift on 05/13/2024, 05/14/2024, 05/15/2024, 05/16/2024, 05/17/2024, 05/18/2024, 05/19/2024, 05/20/2024, 05/21/2024, 05/22/24, 05/23/2024, 05/24/2024, 05/25/2024, 05/26/2024, and 05/27/2024. 8. Review of Patient 4’s medical record lacked documentation of 4-hour neurological checks per Neuro Standard of Care and Documentation on 05/13/2024. 9. Review of Patient 5’s medical record indicated a complete blood count (CBC) without differential was ordered STAT on 05/11/2024 at 11:40 a.m.; order noted on 05/11/2024 at 12:00 p.m. by a registered nurse (RN); lab resulted on 05/11/2024 at 2:21 p.m. Medical record lacked documentation of when lab was drawn, when specimen was taken to lab, or why it was not collected and resulted in less than 60 minutes. 10. Review of Patient 6’s medical record lacked documentation of a fall risk shift assessment for the following shifts: a. Day shift: 05/13/2024, 05/14/2024, 05/15/2024, 05/16/2024, 05/18/2024, 05/19/2024 b. Night shift 05/13/2024, 05/14/2024, 05/15/2024, 05/16/2024, 05/17/2024, 05/19/2024, 05/20/2024 and 05/21/2024. c. Medical record lacked documentation of 1 of 6 neurological checks on 05/16/2024. 11. Review of Patient 7’s medical record indicated that on 04/19/2024, the patient was ordered Amantadine 100 milligrams (mg) by mouth (PO) to be given at 09:00 a.m. and 1:00 p.m. daily. Medication administration records lacked documentation of the medication being administered or held on 05/11/2024. 12. Review of Patient 8’s medical record lacked documentation of 1 of 3 neuro checks on 05/16/2024 per Neuro Standard of Care and Documentation and lacked documentation of patient’s activity and position change every two hours on 05/16/2024 per Neuro Standard of Care and Documentation. 13. Review of Patient 9’s medical record lacked documentation of patient’s activity and position change every two hours on 05/18/2024 per Neuro Standard of Care and Documentation. 14. Interview with A1 (Director of Quality and Patient Safety) and A2 (Director of Accreditation) on 06/17/2024 at approximately 4:20 p.m. confirmed the information above for patients 1, 2, 7, and 9’s medical record lacked the documentation as indicated above. 15 Interview with A1 on 06/18/2024 at approximately 4:00 p.m. confirmed the information above for patients 3, 4, 5, 6, and 8’s medical record lacked the documentation as indicated above.”