Franciscan Health Crown Point

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 35731 Based on document review and interview the registered nurse failed to assess a patient every two (2) hours while in non-violent restraints in one (1) of ten (10) medical records reviewed (Patient # 6). Findings include: 1. The facility policy titled, Restraint Policy, PolicyStat ID 15400263, indicated on page seven (7) - section - V - Non-Violent Restraint Procedure - letter D - Assess, assist, and document approximately every two (2) hours to determine the following - proper application - criteria for release - personal needs met - repositioning - vital signs obtained - skin integrity - physical / psychological status and comfort, patient rights dignity and safety maintained, and whether less restrictive methods are possible. This policy was last revised on 04/04/2024. 2. Patient # 6’s MR indicated the following: The patient was a 59 y/o (year/old) who was admitted to H # 2 (Acute Care Hospital) on 05/01/2025 with a diagnosis of atrial fibrillation (afib). The patient was placed in non-violent restraints on 05/01/2025 at 7:36 pm because he/she was pulling on lines/tubes. The MR lacked documentation the patient was monitored/reassessed every two (2) hours on 05/03/2025 at 2:00 am, 4:00 am, and 6:00 am. 3. In interview on 05/08/2025 at approximately 11:40 am, with administrative staff member A # 6 (Nursing Director, Critical Care Services), confirmed Patient # 6 should have been assessed every two (2) hours while in non-violent restraints.”

“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: 35731 Based on document review and interview, the registered nurse failed to reassess a patient within sixty (60) minutes after administering pain medication for two (2) of ten (10) medical records reviewed (Patient # 5 and Patient # 10), and failed to assess a patient’s pain every two (2) hours in one (1) of ten (10) medical records reviewed (Patient # 10). Findings include: 1. The facility policy titled, Assessment of Pain Guideline, PolicyStat ID 17232741, indicated on page four (4) - Reassessment of Pain (after PRN-as needed pain medication administration and/or one-time pain medication order administration) - letter B - Reassessment of the patient will be within 60 minutes (from time that the prn or one-time medication is given). This policy was last revised in 12/27/2024. 2. The facility policy titled, Vital Signs and Assessment in Critical Care, PolicyStat ID 11231832, indicated on page one (1) - section - Definitions - number 1 - Pain, temperature, pulse, respirations, oxygen level (Sp02), and blood pressure are basic vital signs - on page two (2) - section - Procedure - number 1 - In ICU (Intensive Care Unit) vital signs complete assessment every four (4) hours. This policy was last revised on 03/22/2022. 3. The facility policy titled, Vital Signs in the Emergency Department Guideline, PolicyStat ID 12033547, indicated on page one (1) - section - Definitions - Full set of vital signs includes blood pressure, pulse, respiratory rate, oxygen saturation, temperature, and pain rating - on page two (2) - section - Guidelines - number 4 - Repeat vital signs will be obtained on patients according to the following guidelines - letter C - ESI (Emergency Severity Index) - level 3 - every two (2) hours. This policy was last revised on 09/10/2019. 4. Patient # 5’s MR indicated the following: The patient was a 15 y/o (year/old) who arrived at H # 2 (Acute Care Hospital-Emergency Department) on 05/06/2025 with a diagnosis of right wrist open displaced fracture. The patient received pain medication (Toradol) on 05/07/2025 at 2:00 pm for a pain score of eight (8) out of ten (10). The patient’s pain was reassessed at 4:30 pm. The MR lacked documentation the patient’s pain was reassessed within sixty (60) minutes after receiving the pain medication. 5. Patient # 10’s MR indicated the following: a. The patient was a 33 y/o who arrived at H # 2’s ED on 01/20/2025 with a diagnosis of forearm fracture and was admitted. b. History and Physical indicated the patient fell on the ice injuring his/her left arm with no loss of consciousness. X-ray report indicated an acute fracture involving the distal third of the left radial and ulnar diaphyses with an angulation. c. The MR lacked documentation of a pain assessment on 01/20/2025 at 10:00 pm, 12:00 am, and on 01/21/2025 at 12:00 pm and 4:00 pm. d. The MR lacked documentation the patient was reassessed within sixty (60) minutes after receiving Morphine 5 mg injection on 01/21/2025 at 10:18 pm. e. Patient’s vital signs were taken on 01/21/2025 at 5:30 am. The MR lacked documentation the patient’s vital signs were taken on 01/21/2025 at 7:30 am. 6. In interview on 05/08/2025 at approximately 11:40 am, with administrative staff member A # 6 (Nursing Director, Critical Care Services), confirmed anytime a pain medication was administered there should be a sixty (60) minute pain reassessment of the patient (Patient # 5 & Patient # 10). Patient # 10’s pain and vital signs should have been assessed every two (2) hours while in the Emergency Department.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 35731 Based on document review and interview the registered nurse failed to ensure the patient’s care plan was updated per policy. (Patient # 10) Findings include: 1. The facility policy titled, Plan of Care Policy, PolicyStat ID 13636719, indicated on page two (2) - section - Procedure - letter B - Review - letter a - The care plan must be reviewed and progression toward goals documented at minimum once per calendar day - letter C - Progress Towards Goals - letter a. The RN (Registered Nurse) caring for the patient will update the Plan of Care in the EMR (Electronic Medical Record) by documenting the patient’s progress that occurred toward meeting the established goals - letter b. Document appropriate status: i. Progressing, ii. Not Progressing, iii. Adequate for Discharge, iv. Complete, v. Not Met - goal is no longer appropriate for patient, vi. Determine goals and appropriate goal date. This policy was last revised on 06/02/2023. 2. Patient # 10’s MR indicated the following: a. The patient was a 33 y/o (year/old) who arrived at H # 2 (Acute Care Hospital Emergency Department) on 01/20/2025 with a diagnosis of forearm fracture and was admitted. b. History and Physical indicated the patient fell on the ice injuring his/her left arm with no loss of consciousness. X-ray report indicated an acute fracture involving the distal third of the left radial and ulnar diaphyses with an angulation. c. The MR lacked updated appropriate status problem documentation and lacked the daily (01/22/2025) updated documentation problem list for anxiety, Fluid and Electrolyte Imbalance, Hemodynamic Status, Infection, Knowledge Deficit, Oxygenation/Respiratory Function, Pain, Psychosocial Needs, Universal Fall Precautions, and Risk for Impaired Skin Integrity. 3. In interview on 05/08/2025 at approximately 11:40 am, with administrative staff member A # 6 (Nursing Director, Critical Care Services), confirmed patient # 10’s Plan of Care was not updated daily and appropriately reflecting progress toward goals.”

“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: 44532 Based on document review and interview, the hospital failed to ensure 1 of 10 patients (P5) was provided the opportunity to take part in his/her care by means of informed decisions to request or refuse treatment; and failed to ensure the patient/POA was informed of his/her wound. Findings include: 1. Policy and Procedure review: The policy titled “F1 Alliance Patient’s Rights Policy”, Last Approved 10/21/2022, indicated the following: (The Hospital) identifies specific Patient’s Rights and Responsibilities based upon the following processes and activities: 2. To participate in the development and implementation of your plan of care. 3. To have you representative make informed decisions regarding your care under state law, to be informed of your health status, be involved in care planning and treatment being able to request or refuse treatment. 2. Medical record (MR) review for patient P5 indicated the following: MR indicated on 09/03/2024 that P5 had a deep tissue injury to the sacrum measuring length 3 cm (centimeters), width 12.5 cm, and depth 0.2 cm. Wound Consult was completed on 09/03/2024 at 0038 hours. MR indicated wound dressing orders received as followed cleanse with normal saline, pat dry apply cavilion to peri wound every other day, allow to dry then cover with xeroform and then secure with an abdominal pad. Wound to the left posterior thigh and left lower inner gluteal and left heel treatments ordered were to cleanse with soap and water as needed pat dry, apply venelex bid (two times daily. The patient’s MR lacked documentation that the patient and or the patient’s power of attorney was notified of this new development. 3. On 09/23/2024 between approximately 1400 hours and 1500 hours., A1, Quality Director, confirmed MR findings for patient P5, including lack of documentation as noted.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 44532 Based on document review, nursing administration failed to provide adequate staffing for 5 (five) of 7 (seven) days reviewed on Medical Surgical Unit (MS). Findings Include: 1. Review of policy “Staffing Plan- Implementation & Assignments”, last reviewed 09/19/2024. PolicyStat ID: 16351934. This policy indicated to ensure a sufficient number of qualified nurses are on duty at all times. 2. Review of the Medical Surgical staffing matrix indicated: a. 22 (twenty-two) patients on the day shift requires 4 (four) Registered Nurse (RN) and 3 (three) Patient Care Assistant (PCA). 22 (twenty-two) patients on the night shift requires 4 (four) Registered Nurse and 3 (three) Patient Care Assistant. b. 23 (twenty-three) patients on the day shift requires 5 (five) Registered Nurse and 3 (three) Patient Care Assistant. 23 (twenty-three) patients on the night shift requires 4 (four) Registered Nurse and 3 (three) Patient Care Assistant. c. 24 (twenty-four) patients on the day shift requires 5 (five) Registered Nurse and 3 (three) Patient Care Assistant. 23 (twenty-four) patients on the night shift requires 5 (five) Registered Nurse and 3 (three) Patient Care Assistant. d. 25 (twenty-five) patients on the day shift requires 5 (five) Registered Nurse and 3 (three) Patient Care Assistant. 23 (twenty-five) patients on the night shift requires 5 (five) Registered Nurse and 3 (three) Patient Care Assistant. 3. Nursing and/or Staffing Review: The Staffing Pattern Worksheets were reviewed for F1 MS unit for the dates 08/30/2024 - 09/05/2024 and indicated the MS unit was not appropriately staffed per facility policy and/or matrix as follows: a. MS Unit: 08/30/2024 short 2 clinical staff member from 1900 hours - 0700 hours with a patient census of 23 (twenty-three). 7 (seven) clinical staff members needed but only 5 (five) clinical staff members were present. 09/02/2024 short 1 clinical staff member from 1900 hours - 0700 hours with a patient census of 25 (twenty-five). 8 (eight) clinical staff members needed but only 7 (seven) clinical staff members were present. 09/04/2024 short 1 clinical staff member from 1900 hours - 0700 hours with a patient census of 25 (twenty-five). 8 (eight) clinical staff members needed but only 7 (seven) clinical staff members were present. 09/05/2024 short 1 clinical staff member from 0700 hours - 1900 hours with a patient census of 22 (twenty-two) 7 (seven) staff members were needed but only 6 (six) were present. 09/05/2024 short 1 clinical staff member from 1900 hours - 0700 hours with a patient census of 24 (twenty-four). 8 (eight) clinical staff members needed but only 7 (seven) clinical staff members were present. 3. On 09/23/2024 N2 (Chief Nursing Officer) completed and signed “The Staffing Pattern Worksheets” provided by this surveyor as to all information provided accurately reflected the staffing for the Medical Surgical Unit on dates 08/30/2024 through 09/05/2024.”

“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, nursing services failed to ensure that the Skin Assessment and Management Procedure policy was implemented for 1 of 10 patient medical records reviewed. (P5) Findings: 1. Review of policy “Skin Assessment and Management Procedure” last reviewed 08/29/2024. PolicyStat ID: 16130084. To outline Nursing responsibilities in the protection and promotion of skin integrity by utilizing the Braden Scale to identify those patients at risk and implement focused interventions for those who may need preventive measures. a. Braden Scale will be utilized as evidence-based tool to assess the severity of skin integrity risk. 1. 19 to 23 = No Risk 2. 15 to 18 = Mild Risk 3. 13 to 14 = Moderate Risk 4. 10 to 12 = High Risk 5. 9 or below = Very High Risk b. Every patient will be assessed for skin integrity risk by utilizing the Braden Scale upon admission, every shift and as patient condition warrants. 2. Review of medical records for P5 indicated: a. Initial Nurse Admission assessment dated 8/30/2024 indicated that the Braden scale tool was used for predicting pressure risk, P5 scored a 16 (sixteen) (mild risk). Shift assessment on 08/31/2024 indicated P5 was a 1 (one) bed mobility (for rolling, scooting, and boost), friction and shear indicated potential problem, and nutrition was adequate. Skin assessment dated 09/01/2024 on the skin care flow sheet indicated that P5 had redness to his/her buttocks. Skin assessment dated 09/02/2024 indicated that P5 had bruising non-blanchable area noted to the buttocks, sacrum and that there was a fluid filled area to the right foot. Skin assessment dated 09/03/2024 indicated that P5 had a deep tissue injury to the sacrum measuring length 3 cm (centimeters), width 12.5 cm, and depth 0.2 cm. There was a lack of documentation of reevaluation by nursing staff of P5’s Braden Scale, and/or implementation of new measures to help prevent further skin pressure area breakdown throughout P5 stay.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 35731 Based on document review, the facility failed to provide a complete medical screening exam for 1 of 20 patients (patient #20). Findings include; 1. Facility policy titled Emergency Medical Treatment Medical Screening Exam (MSE) and Transfer Following MSE Policy last reviewed 5/11/23 indicates under purpose statement on page 1 that all persons seeking emergency treatment at the hospital shall receive an appropriate medical screening exam. 2. Review of the closed MR for Patient # 20 indicated the patient arrived at H # 2’s (Acute Care Hospital) ED on 01/11/2024 at approximately 10:16 am. The Patient Care Timeline, indicated triage started at 10:19 am. Triage notes dated 01/11/2024 indicated patient stated he/she was getting hooked up to dialysis and staff told him/her that he/she blacked out. Triage plan, vital signs (blood pressure 123/65, pulse 63, respirations 16, temperature 97.5, oxygen saturation 97%), assessment, and triage screening completed by 10:28 am. Patient was seen by MS # 1 (Doctor of Osteopathy-DO/ED) at 10:29 am. Orders (laboratory tests, medications, Electrocardiogram, and chest x-ray) were placed by MS # 1 at 10:30 am. Medication administered to patient at 10:36 am (Zofran-nausea) and 10:38 am (Toradol-pain). Labs completed at 10:42 am. Electrocardiogram resulted normal sinus rhythm at 10:48 am. Chest x-ray performed 10:43 am - completed at 10:58 am resulted normal. ED Provider Notes dated 01/11/2024 at approximately 10:31 am, indicated - physical exam - vital signs and nursing note were reviewed. Patient was not in any acute distress and/or diaphoretic. The patient left before treatment was completed. 3. Review of incident reports indicated S # 3 (Security) completed an incident report related to an altercation between patient #20 and a family member with other family in the emergency department waiting room. Patient # 20 was asked by S # 3 to refrain from profane language. Patient # 20 continued to use profanity at which time S # 3 advised patient # 20 and family member that further disruption would be cause for S # 3 to ask patient # 20/family member to leave the facility (H # 2). Patient # 20 aggressively got close to S # 3’s face and clenched his/her fists in a threatening manner which at that time they both (patient # 20/family member) were advised to leave. Patient # 20 refused and indicated that they would have to physically remove him/her. S # 3 requested S # 2 to notify the police department. The family member went to get the car while patient # 20 continued to repeatedly threaten S # 3 with physical violence and then death. Once PD # 1 arrived the patient began to leave. 4. Patient #20 left the facility without a completed medical screening exam and treatment.”