Adventhealth Shawnee Mission

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 47233 Based on policy review, record review, and interview, the hospital failed to ensure that staff followed hospital policy and procedure in obtaining and completing the patient consent and treatment agreement for 2 of 9 (Patient 7 and 9) sampled patients. This deficient practice places any patient at risk of not understanding their individual rights. Findings Include: Review of a hospital policy titled “Patient Rights and Responsibilities,” dated 04/05/2025, showed that every patient has the right to receive information necessary to give informed consent prior to the start of any procedure or treatment and the right to refuse care, treatment, and services. Review of a hospital policy titled, “Consents-Admission and Informed,” dated 12/28/23, showed that if a patient cannot make or share decisions, a health care agent (a person legally designated by a patient to consent) or a court appointed guardian may give consent for treatment. If the patient lacks a health care agent or guardian, a patient family member or other adult that is involved and knowledgeable about the patient, may “assent” for treatment. The assent of the family member or other individual should be documented in the chart, along with an explanation that the patient is not competent, and that no health care agent, guardian or health care directive is available. A witness to the signed consent must be an associate that saw the patient or other individual or listened to the conversation to give consent. Patient 7 Review of Patient 7’s current medical record showed an 81-year-old admitted on 08/17/25 at 9:32 PM for altered mental status (confusion). Further review of the medical record showed past medical history that included advanced dementia (general term for loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life), and stroke. Review of Patient 7’s consent for treatment form showed that it was signed on 08/17/25 at 10:16 PM by an individual other than Patient 7. Further review of the form failed to identify the individual’s relationship to the patient, failed to identify the justification for the signature (patient unable/unwilling to sign), and failed to provide a hospital staff member as a witness to the signature as required per hospital policy. Patient 9 Review of Patient 9’s current medical record showed a 37-year-old admitted on 08/18/25 at 2:00 PM with a diagnosis of Bipolar affective disorder (extreme mood swings, including emotional highs and lows). Review of an undated document titled, “Letters of Guardianship and Conservatorship,” showed that Patient 9 had a guardian and conservator. During an interview on 08/26/25 at 9:45 AM, Staff A, Regulatory Manager, verified that Patient 9 had a guardian prior to the admission on 08/18/25 at 2:00 PM. Review of Patient 9’s, “Treatment and Consent Agreement,” showed the form was not signed until approximately 24 hours after admission. Further review of the consent showed the hospital allowed the patient to sign the consent. The hospital failed to ensure the consent was signed by the guardian as required per hospital policy. During an interview on 08/21/25 at 11:36 AM, Staff E3, Consumer Access Representative, stated that consents should be obtained on every patient visit. During an interview on 08/21/25 at 1:59 PM, Staff S2, Consumer Access Supervisor, stated that if a patient arrives with an altered mental status or is unable to sign a new consent, the system will automatically fill in a consent form using the patient’s signature, provided that the patient has visited this hospital system within the past calendar year. During an interview on 08/21/25 at 1:59 PM, Staff V2, Manager of Consumer Access, stated that if a caregiver or someone else with portal access is involved in a patient’s care, they may be able to sign the consent forms on behalf of the patient. In certain situations, especially for patients who do not have the capacity to consent, staff would need to review the emergency contacts to identify the legal guardian or decision-maker.”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 47233 Based on observation, record review, and interview, the hospital failed to ensure the patient’s right to personal privacy and failed to notify patients and/or patient representatives that video monitoring/surveillance and recording was taking place for 7 of 7 unidentified patients while in the hospital behavioral health area of the Emergency Department (ED). This deficient practice places any patient receiving care in the behavioral health area of the ED at risk for personal privacy violations. Findings Include: Review of a hospital policy titled, “Patient Rights and Responsibilities,” dated 04/05/2025, showed that patients have the right to be informed of policies and practices that relate to patient care and treatment responsibilities and the right to confidentiality, privacy, and security as well as an environment that preserves dignity and contributes to a positive self-image. Further review of the policy failed to show that patients would be notified if they required video monitoring/surveillance or that such monitoring may be recorded. An observation on 08/18/25 at 11:29 AM, showed that video monitoring of the behavioral health area of the ED was not protected in such a way as to prevent unauthorized persons from being able to view the occupied patient care areas. Observation also failed to show any type of notice, such as signage, that video monitoring and recording is in process. An observation on 08/21/25, at 11:40 AM, showed the BHAC area of the ED had seven patients present. During this observation, multiple visitors walked past the monitoring screens and had the potential to view the occupied patient care areas. During an interview on 08/14/25 at 4:19 PM, Staff Y, Security Manager, stated that cameras located in the Behavioral Health Assessment Center (BHAC) of the Emergency Department (ED) record and save video footage of patients in their personal care area. During observations from 08/18/25 at 11:30 AM through 08/21/25 at 12:20 PM, multiple patient care units were noted to have large monitors that were located at the main nursing station area that displayed patient identifying information. This information included the patient’s room number, initials, age, gender, attending physicians, and expected discharge date. The displayed health information was easily viewable by anyone walking past the nursing station areas.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(A) Definitions. (i) A restraint is- (A) Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or This Standard is not met as evidenced by: 47233 Based on interview, record review, and facility policy review, the hospital failed to ensure that the use of restraints was in accordance with regulation and hospital policy when it utilized the use of four bed rails and/or lap belts as restraints to reduce the ability of a patient to move freely for 2 of 9 (Patient 8 and 12) sampled patients. This deficient practice violated the patient right to be free of restraint and places any patient receiving services at this hospital at risk of unauthorized use of restraints that may lead to serious injury and harm. Findings Include: Review of a hospital policy titled, “Patient Rights and Responsibilities,” reviewed 04/05/27, showed that patients have the right to be free from mental and physical abuse. Review of a hospital policy titled, “Restraints,” dated 05/01/25, defined a physical restraint as “ ...any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely ...” The purpose of the policy was stated as, “To protect the patient from physical and psychological harm, loss of dignity, violation of individual patient rights and even death ...” Additionally, the policy stated that restraint my never be used for the convenience of the caregiver or as a substitution for supervision, coercion, discipline, retaliation, or as punishment. Patient 8 Review of Patient 8’s current medical record showed a 68-year-old admitted on 08/15/25 at 1:36 PM with the diagnosis of psychosis (mental state that causes loss of reality) and schizophrenia (chronic mental condition that can result in hallucinations, confusion, delusions, and paranoia). An observation on 08/21/25 at 11:40 AM, showed Patient 8 in an Emergency Department (ED) psychiatric room bed with four bed rails up. Patient 8 was resting peacefully and showed no indication of behavior that would require the use of restraints. Review of Patient 8’s medical record failed to show documented evidence of an order for the use of restraints. During an interview on 08/21/25 at 11:45 AM, Staff D3, Safety Attendant, stated that the use of four bed rails would be considered restraint use and should not be utilized. Patient 12 Review of Patient 12’s current medical record showed an 87-year-old who was admitted on 08/18/25 at 9:53 PM with a diagnosis of hematuria (blood in urine). The past medical history included anxiety, depression, hypertension (high blood pressure), and dementia. An observation on 08/19/25 at 4:15 PM, showed Patient 12 sitting in a chair with a belt alarm around the waist. Patient 12 was unable to remove the belt and was observed leaning forward in a pulling motion, yelling out to the staff. An unidentified staff member explained that the use of the belt was to help keep the patient in the chair due to the patient’s increased confusion. Review of Patient 8’s medical record failed to show documented evidence of an order for the use of restraints. During an interview on 08/21/25 at 11:57 AM, Staff C3, Registered Nurse (RN), stated that a lap belt had been utilized on Patient 12. Staff C3 stated that Patient 12 had dementia and was unable to release the lap belt independently. Staff C3 acknowledged that because of Patient 12’s physical and mental status, the use of the lap belt was considered an inappropriate use of a restraint.”

“ORGANIZATION OF NURSING SERVICES CFR(s): 482.23(a) The hospital must have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The director of the nursing service must be a licensed registered nurse. He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. This Standard is not met as evidenced by: 47233 Based on document review, review of the hospital organizational chart, and interview, the hospital failed to ensure that it had only one nursing service under the direction of only one Registered Nurse (RN). This deficient practice poses a potential risk for inconsistency in the application of services and oversight of staff. Findings Include: Review the Hospital’s Database Worksheet, dated 08/11/25, showed another hospital (Hospital 2) providing inpatient services under the same Certification Number (CCN). During an interview on 08/11/25 at 11:30 AM, Staff D, Administrative Director, stated that another 96-bed hospital, Hospital 2 (H2), was opened under the same Certification Number (CCN) on 07/15/25. Review of the hospital’s organizational chart dated 07/25/25, showed that the hospital employed a different Chief Nursing Officer (CNO) for Hospital 2 (H2). During an interview on 08/19/25 at 12:48 PM, Staff A, Manager Regulatory Accreditation, confirmed the failure to have only one nursing service under the direction of a single CNO and acknowledged the employment of two CNOs, one at each hospital location.”

“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: 47233 Based on observation, policy review, and interview, the hospital failed to ensure nursing staff were responsible in securing a medication room that contained medications, biologicals, and supplies in a manner to prevent access by unauthorized individuals. This deficient practice has the potential for adverse outcomes that could negatively impact the health and well-being of any patient receiving services at this hospital. Findings Include: Review of a hospital policy titled, “Medication Administration,” effective 04/05/25, showed that medications must be kept in a secure area or taken immediately to the patient. An observation of the 5th floor on 08/20/25 at 3:40 PM showed that a medication room containing medication and medication supplies was not closed and locked securely to prevent access from unauthorized persons. An observation of the 5th floor on 08/20/25 at 3:40 PM and again on 08/21/25 at 12:01 PM, showed that an unlocked clean utility room that contained medication (normal saline used for IV administration) and medication supplies was not closed and locked securely to prevent access from unauthorized persons. During an interview on 08/20/25 at 3:45, an unidentified Registered Nurse (RN), stated that he/she was unaware that the medication room was open and confirmed that the medication room should not be accessible to unauthorized persons.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47233 Based on policy review, record review, and interview, the Hospital failed to ensure it met the requirements for Patient Rights Condition of Participation when the hospital failed to protect and promote each patient’s rights and failed to provide care in a safe setting. Findings Include: The hospital failed to ensure nursing staff followed the restraint policy and procedures and failed to follow fall prevention guidelines for high fall risk patients as stated in their policies for 2 of 9 Patients (Patients 6 and 9). (Refer to tag A-0144)”

“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: 47233 Based on policy review, record review, and interview, the Hospital failed to ensure that 1 (Staff K, Registered Nurse (RN) of 3 nursing personnel reviewed, had valid and current licensure. The hospital failed to ensure nursing staff effectively assessed and evaluated patient care for 5 (Patient 2, 3, 6, 8, and 9) of 9 sampled patients. This deficient practice places any patient receiving care at this hospital at risk for serious injury or harm. Findings Include: 1. The hospital failed to ensure that 1 (Staff K, RN) of 3 nursing personnel reviewed, had valid and current licensure that complies with Kansas State licensure law. (Refer to Tag A0394) 2. The hospital failed to ensure nursing care was evaluated by a registered nurse on an ongoing basis to ensure that staff were providing the appropriate assessment, care, and evaluation of patient’s response to interventions for 5 of 9 (Patient 2, 3, 6, 8, and 9) patient records reviewed. (Refer to Tag A0395)”

“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: 47233 Based on policy review, record review, and interview, the hospital failed to provide care in a safe setting by not following hospital policy for restraint procedures and by the failure to follow fall prevention guidelines for 2 of 9 patients (Patient 6 and 9) at high risk for falls. This deficient practice places any patient in restraints or at risk for falls at risk for serious harm or injury. Review of a hospital policy titled, “Patient Rights and Responsibilities,” revised 06/09/23, showed, “ ...Patients have the right to receive care in a safe setting ...” Review of a hospital policy titled, “Restraint Management for Non Violent Behavior,” revised 12/02/23, showed, “ ...Non-physical alternatives must be attempted before applying restraints. Restraints may not be used unless less restrictive interventions have been determined to be ineffective and the use is necessary to ensure the immediate physical safety of the patient, a staff member or others. Sensitivity to the impact on especially vulnerable patients such as ...cognitively or physically limited patients ...is clinically addressed and managed ...a. Obtain a Provider order for restraints ...ii. The Provider is notified of initiation immediately and an order obtained. b. Obtain new order for restraint each calendar day ...” Review of a hospital policy titled, “Restraints,” revised 12/02/23, showed, “ ...For non-violent patients’ restraint may only be used if needed to improve the patient’s well-being, and less restrictive, non-physical interventions have been determined to be ineffective to protect the patient from harm ...” Review of a document provided by the hospital titled, “Posey Bed 8070 User Manual,” dated 2017, showed, “ ...Because the bed is a restraint, its use must be prescribed by a licensed doctor. Anyone interacting with the bed must complete the Posey Bed 8070 In-Service Training Program which includes the ability to use this manual ... RISKS Improper use of the Posey Bed 8070 may lead to serious injury or death. Patient monitoring should be determined by hospital protocol, a doctor, and the patient care plan. As with any less restrictive restraint system, it is important to understand when the Posey Bed 8070 is needed, when it should not be used, and the dangers related to entrapment, suffocation, choking, and falls ... REDUCING THE RISK OF ENTRAPMENT To help reduce the risk of entrapment, adhere to the following guidelines: o Keep the mattress flat. - If you need to elevate the head or torso of an at-risk patient, keep the mattress flat and use a cushion to position the patient. - If you must leave the head of the bed up while an at-risk patient is alone, use the Posey Filler Cushions ... Warnings and Precautions ... Canopy gaps present an entrapment risk for certain at-risk patients. Raising the head of the Posey Bed creates “gaps” or “pockets” between the head of the bed and the canopy. These areas pose an extreme risk of serious injury or death from entrapment for certain at-risk patients. Keep the mattress flat with the head of the bed down when an at-risk patient is alone ...” Review of a policy titled, “Fall Risk and Injury Prevention,” dated 12/15/23 showed, “ ...4. Upon admission patients are assessed by nursing for risk of falls and prevention and reassessed every shift and with any change in condition using: A. The Hester Davis Scale (HDS) in adults over 17 years of age ... 3. Post-fall assessment will be conducted to identify patient injury and immediate care needs. a. Consider calling Rapid Response Team for additional resources to assist patient assessment and/or meeting immediate patient care needs. b. Notify provider, as appropriate to the care setting. c. Reassess fall risk and implement additional safety measures, as appropriate. d. Conduct post-fall huddle/evaluation. Post-fall evaluation shall be completed by the patient care team to include at a minimum the primary care nurse, charge nurse and Nurse Leader. e. Discuss fall in safety huddles for one week after fall or until patient discharges ... B. Prevention 1. Evaluate at a minimum once a shift to determine if expected outcome is being met ... c. Interventions are tailored to the specific identified risk factors. 1. Activate the Fall Injury Risk Care Plan Guide for patients at moderate or high risk for fall and select appropriate interventions: Low Risk= 7-10 Moderate Risk= 11-14 High Risk= 15 ...Nurse’s judgement as indicated based on risk factors (physiological functioning and ABCS factors) signs and symptoms of altered mental status impaired judgement e.g. confusion, dementia, forgetfulness, impulsive, overestimates or forgets limitations ...” Patient 6 Review of Patient 6’s medical record showed a 73-year-old admitted on 10/13/24 at 11:58 AM with a diagnosis of weakness, blurred vision and fall with closed head injury. Past medical history includes depression; diabetes; high cholesterol and heart failure. Review of a document titled, “Fall Assessment Scale,” dated 10/13/24 at 1:00 PM, showed, “ ...Hester Davis Fall Risk Assessment ... Hester Davis Fall Risk Total: 10 Hester Davis Fall Risk Level: Low ...” The admitting diagnosis of weakness, blurred vision and fall with closed head injury should have resulted in a fall risk level of “High”. Review of a document titled, “ED [Emergency Department] Provider Notes,” dated 10/13/24 at 3:23 PM, showed, “Patient was in the bathroom. She did have a very large bowel movement and fell off the toilet. I reassessed the patient [sic] is brought back to her room states she potentially hit her head she was also very shaky rechecked her temperature and she was febrile ... I did order repeat head CTs patient fell no other injury was noted. Charge nurse was present and assess the patient after fall. Likely patient has a vagal response codes the bowel movement she was will extremely large and was on the floor plus a toilet and patient did fall no other injury was noted ...” The medical record failed to show a documented post fall assessment was completed at time Patient 6 fell. Patient 9 Review of Patient 9’s medical record showed a 91-year-old admitted inpatient on 11/03/24 at 1:21 AM with a diagnosis of altered mental status; unwitnessed fall and metabolic encephalopathy (condition in which brain function is disturbed due to underlying diseases or toxins in the body). Past medical history includes atrial fibrillation (irregular heart rhythm); Benign Prostatic Hyperplasia (BPH) (noncancerous enlargement of the prostate gland). Review of the medical record showed that Patient 9 fell while in the hospital as indicated by a document titled, “Post Fall Assessment,” dated 11/07/24 at 6:45 PM, showed, “Fall Date 11/07/24 Fall Time 1645 [4:45 PM] Notification Time 1840 [6:40 PM] ...” The medical record showed that Patient 9 was placed in restraints after the fall, specifically an enclosure bed, as evidenced by a document titled, “Nursing Assessments,” dated 11/07/24 at 7:50 PM, that showed, “ ...Restraint Order Length of Order 24 hours ... Less Restrictive Alternative Verbal redirection; Increased frequency of nursing rounds; Diversionary activities; Reorientation to surroundings; Decreased stimulation; Alarm; Pain management; Reevaluate equipment;Repositioning ...Clinical Justification Removal of dressing; Pulling tubes; Removal of equipment Impulsive, high fall risk, fall on current hospitalization ... Restraint Monitoring Every 2 Hours.. Start Enclosure bed ...” Review of the medical record for 11/07/24 failed to showed documented evidence that hospital staff notified a provider of behaviors leading to the use of an enclosure bed restraint for Patient 9. Staff failed to follow Posey Bed manufacturer guidelines to prevent patient entrapment as evidenced by Patient 9’s “Daily Cares/Safety” chart on 11/10/24 at 8:00 AM that showed, “ ...HOB [head of bed] at 30-35 degrees ...” and “Daily Cares/Safety” chart on 11/09/24 at 11:00 AM that showed, “ ...HOB at 30 degrees ...” During an interview on 12/09/24 at 3:27 PM Staff Q, RN stated that restraint training is not specific to enclosure beds and that hands on training for use of a Posey Bed was not provided. During an interview on 12/09/24 at 4:07 PM Staff R, RN stated that training on enclosure beds is done upon hire and that the beds are self-explanatory so hands on training is not provided. During an interview on 12/09/2024 at 3:00 PM Staff O, Regulatory Compliance, stated, “ ...there is not specific training on enclosure beds and no hands-on restraint training ...” . Review of Patient 9’s medical record showed from 11/10/24 at 1:39 PM through 11/10/24 at 7:16 PM, Patient 9 was sleeping for approximately 6 hours without removing restraint. Further review of the medical record showed Patient 9 remained in the enclosure bed restraint without a physician’s order every 24 hours as required per policy from 11/10/24 at 7:50 PM through 11/11/24 when Patient 9 was found deceased. Review of a document titled, “Asset History,” showed, “ ...Period: 11/11/24 5:05:00 PM - 11/12/24 6:05:00 AM ...Asset: [Staff R, Registered Nurse (RN)] ...” last documented entry into Patient 9’s room prior to his death at 4:30 AM was on 11/12/24 at 2:39AM. Review of a document titled, “Asset History” showed, “ ...Period: 11/11/24 5:05:00 PM - 11/12/24 6:05:00 AM ...Asset: [Staff P, Clinical Associates (CA)] ...” last documented entry into Patient 9’s room prior to his death at 4:30 AM was on 11/12/24 at 2:39 AM. Review of a document titled, “REPORT OF A HOSPITAL DEATH ASSOCIATED WITH THE USE OF RESTRAINT OR SECLUSION” dated 11/12/2024 at 3:34 PM showed, “ ...Date and Time of Death 11/12/2024 0430 [4:30 AM] ... Date Patient Last Monitored 11/12/2024 Time Patient Last Monitored 04:00 [4:00 AM] ...” The “REPORT OF A HOSPITAL DEATH ASSOCIATED WITH THE USE OF RESTRAINT OR SECLUSION” showed Patient 9 was last assessed on 11/12/24 at 4:00 AM before his death on 11/12/24 at 4:30 AM even though the tracer activity of Staff R, RN and Staff P, CA showed the last documented time Patient 9 was monitored was on 11/12/24 at 2:39 AM. During an interview on 12/06/24 at 10:55 AM Staff A, RN stated that staff had been in Patient 9’s room at 4:00 AM and then staff found Patient 9 deceased at 4:30 AM. Review of Patient 9’s “Restraint Monitoring,” on 11/12/24 at 4:00 AM showed that a visual check was completed, and that Patient 9 was asleep with no sign of injury. Further review showed that Staff R, RN charted the 4:00 AM visual check at 7:07 AM. Review of Staff R’s location tracking on 11/12/24 showed that Staff R did not enter Patient 9’s room between 2:39 AM and 4:39 AM. Review of a nurses note with a date of service on 11/12/24 at 7:00 AM was filed and signed by Staff R, RN on 11/23/24 at 1:17 AM (11 days after Patient 9’s death.) The note stated, “Patient was rounded on every hour until 2200 [10:00 PM] and then every 2 hours beginning at 0000 [12:00 AM]. Patient slept all night with occasional groaning. At 0200 [2:00 AM] visit CA [Staff P] and I changed his purewick and brief and repositioned patient to right side. Patient moaned and tried to move our hands out of the way. At 0430 [4:30 AM] check, CA [Staff P] found patient without a pulse and called me in bed briefing. I immediately returned to floor to assess situation. Patient had passed.””

“LICENSURE OF NURSING STAFF CFR(s): 482.23(b)(2) The nursing service must have a procedure in place to ensure that hospital nursing personnel for whom current licensure is required have a valid and current licensure. This Standard is not met as evidenced by: 47233 Based on policy review, personnel record review, and interview, the hospital failed to ensure that 1 (Staff K, Registered Nurse (RN) of 3 nursing personnel reviewed had valid and current licensure that complies with Kansas State licensure laws. This deficient practice places any patient receiving care at risk for serious injury or harm. Review of a hospital policy titled, “License, Certification, Registration Requirements,” dated 12/13/2023 showed, “ ...PURPOSE: To establish requirements for the verification, monitoring, and tracking of licenses, certifications, and registrations of all team members who are required by federal, state, and local laws, job description or as deemed required to perform the essential functions of the role, to possess a valid and current license, certification, and/or registration. POLICY: Team members must maintain required current and active licenses, certifications, and/or registrations, as required in their job description. This policy also establishes the requirement that all team members are to function within the limits of their scope of practice as defined by their professional practice act, Federal and State laws, and job description ... Team members must submit a copy of their renewed professional licenses, certifications, and/or registrations to their local human resources department not completed seven (7) days prior to the expiration date of such license or certification. Upon receipt (thereafter), a primary source verification will be run, ensuring it is in a clear and active status ...” Review of a document titled, “Job Description,” dated 10/2021 showed, “ ...Title ...Registered Nurse ... LICENSURE, CERTIFICATION OR REGISTRATION REQUIRED: Kansas Registered Nurse License ...” During an interview on 12/05/24 at 1:23 PM, Staff K, RN, stated that she had been working at the hospital for a year and currently works Monday through Friday. Review of Staff K, RN, personnel record on 12/06/24 showed Staff K’s RN license expired 11/30/24. Review of a document titled, “QuickConfirm License Verification Report,” dated 12/06/24 at 1:11 PM, showed the status of Staff K’s license as non-active and “ ...License Status EXPIRED ...License Expiration Date 11/30/24 ...” Review of a document titled, “List of Patients,” showed that from 12/02/24 through 12/06/24 Staff K, RN had 24 encounters with patients. Review of a document titled, “[Staff K] Notification Timeline] showed, “Timeline of Events on 12/5/24 RE: [Staff K]: 11:35 [11:35 AM]-15:03 [3:03 PM] Hours worked by [Staff K] on 12/5 [12/05/24] 14:58 [2:58 PM]- HR [Human Resources] called Quality to notify it appeared that [Staff K] license expired 11/30 [11/30/24]...” During an interview on 12/06/24 at 10:42 AM, Staff L, Human Resources, stated that Staff K, RN, was put on administrative leave when the hospital became aware of the lapse in nursing license.”

“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: 47233 Based on policy review, record review, and interview, the hospital failed to ensure nursing care was evaluated by a registered nurse (RN) on an ongoing basis, specifically, providing an appropriate assessment, care, and evaluation of patient response to interventions for 5 of 9 (Patient 2, 3, 6, 8, and 9) patient records reviewed. This deficient practice places patients at risk for deterioration of current illness, and adverse outcomes. Findings Include: Review of a policy titled, “Wound and Skin Care,” dated 07/26/2024 stated that it’s electronic charting system “EPIC” utilized a tool named, “Non-Surgical Wound and Skin Nurse Panel”. This panel defined the Braden Score (tool used in healthcare to assess a patient’s risk for developing pressure injuries) as follows: 19-23 without wounds; 6-18 without a wound; 6-23 with a wound. These scores as written in the policy fail to show the risk level for developing pressure injuries as low risk; moderate risk; high risk; or very high risk. The policy stated that patients are required to be repositioned every 2-3 hours. Review of an article titled, “Understanding the Braden Scale Assessment” dated 01/18/24 showed, “ ...Interpreting Braden Scale scores: A total Braden Scale score ranges from 6 to 23, with lower scores indicating higher susceptibility to pressure ulcers. Healthcare professionals interpret the Braden Scale ranges as follows:18 or higher Low risk; 15-17 Moderate risk; 13-14 High risk; 12 or lower Very high risk ...” Review of a policy titled, “Fall Risk and Injury Prevention,” dated 12/15/23 showed, “ ...4. Upon admission patients are assessed by nursing for risk of falls and prevention and reassessed every shift and with any change in condition using: A. The Hester Davis Scale (HDS) in adults over 17 years of age ... 3. Post-fall assessment will be conducted to identify patient injury and immediate care needs. a. Consider calling Rapid Response Team for additional resources to assist patient assessment and/or meeting immediate patient care needs. b. Notify provider, as appropriate to the care setting. c. Reassess fall risk and implement additional safety measures, as appropriate. d. Conduct post-fall huddle/evaluation. Post-fall evaluation shall be completed by the patient care team to include at a minimum the primary care nurse, charge nurse and Nurse Leader. e. Discuss fall in safety huddles for one week after fall or until patient discharges ... B. Prevention 1. Evaluate at a minimum once a shift to determine if expected outcome is being met ... c. Interventions are tailored to the specific identified risk factors. 1. Activate the Fall Injury Risk Care Plan Guide for patients at moderate or high risk for fall and select appropriate interventions: Low Risk=7-10; Moderate Risk=11-14; High Risk=15 ...Nurse’s judgement as indicated based on risk factors (physiological functioning and ABCS factors) signs and symptoms of altered mental status impaired judgement e.g. confusion, dementia, forgetfulness, impulsive, overestimates or forgets limitations ...” Review of a policy titled, “Care of the Deceased Patient,” dated 04/25/24 showed, “ ...1. Pronouncing Death ... notification that two RNs confirmed the patient is unresponsive with no pulse, respirations, blood pressure, and pupils fixed and dilated ...3. All providers and consultants will be notified of the patient death ...g. The patient’s assigned RN is responsible for completion of the Release of Body Authorization and the expiration record. The Chaplain is called to fill out the Release of Body Authorization and obtain needed signatures, particularly in the event of an unexpected death ...” The policy also showed that at the time of death the expiration record is required to state by whom and when the pronouncement of death was made. Review of document provided by the hospital titled, “Posey Bed 8070 User Manual” dated 2017, showed, “ ...Because the bed is a restraint, its use must be prescribed by a licensed doctor. Anyone interacting with the bed must complete the Posey Bed 8070 In-Service Training Program which includes the ability to use this manual ... RISKS Improper use of the Posey Bed 8070 may lead to serious injury or death. Patient monitoring should be determined by hospital protocol, a doctor, and the patient care plan. As with any less restrictive restraint system, it is important to understand when the Posey Bed 8070 is needed, when it should not be used, and the dangers related to entrapment, suffocation, choking, and falls ... REDUCING THE RISK OF ENTRAPMENT To help reduce the risk of entrapment, adhere to the following guidelines: o Keep the mattress flat. - If you need to elevate the head or torso of an at-risk patient, keep the mattress flat and use a cushion to position the patient. - If you must leave the head of the bed up while an at-risk patient is alone, use the Posey Filler Cushions ... Warnings and Precautions ... Canopy gaps present an entrapment risk for certain at-risk patients. Raising the head of the Posey Bed creates “gaps” or “pockets” between the head of the bed and the canopy. These areas pose an extreme risk of serious injury or death from entrapment for certain at-risk patients. Keep the mattress flat with the head of the bed down when an at-risk patient is alone ...” Patient 2 Review of Patient 2’s medical record showed a 53-year-old that admitted to the Emergency Department (ED) on 07/04/24 at 10:02 PM and transferred to the Intensive Care Unit (ICU) on 07/05/24 at 12:29 AM with a diagnosis of respiratory failure with hypoxia (lack of oxygen in the blood.) Past medical history included diabetes melitus Type 2 (chronic high blood sugar). Patient 2 discharged home on 07/18/24 at 10:47 AM. Patient 2 returned to the ED on 07/19/2024 at 11:39 AM and was transferred to inpatient status 07/19/2024 at 4:50 PM with a diagnosis of generalized weakness and inability to care for self at home. Patient 2 discharged to an inpatient rehab facility on 07/23/24 at 1:00 PM. Concerns with medical record included a lack of repositioning and lack of glucose monitoring prior to medication administration. 1. Lack of repositioning: Review of Patient 2’s medical record showed the patient at high risk for skin breakdown as indicated by a “Braden Scale Assessment” dated 07/05/24 at 3:05 AM that showed, “ ...Sensory Perceptions Completely limited ... Activity Bedfast ... Braden Scale Score 11[very high risk] ...” Review of Patient 2’s medical record failed to show documented evidence that the patient was turned or repositioned every two hours as recommended for a patient at very high risk for skin break down from 07/04/24 at 10:02 PM through 07/18/24 at 10:47 AM. Review of Patient 2’s, “Braden Scale Assessment” dated 07/20/24 at 1:20 AM showed, “ ...Sensory Perceptions Completely limited ... Activity Bedfast ... Braden Scale Score 11 [very high risk] ...” Review of Patient 2’s medical record from 07/19/24 at 4:02 PM through 07/23/24 at 1:00 PM failed to show documented evidence that Patient 2 was turned or repositioned every two hours as recommended for a patient at high risk for skin break down. 2. Medication Administration Review of Patient 2’s medication orders dated 07/06/24 showed orders to have blood glucose levels checked within 30 minutes of breakfast, lunch, dinner, bedtime and 2:00 AM. The patient was to receive 2 units of insulin lispro (a rapid acting medication used to lower blood sugar levels) 5 times daily: with breakfast, lunch, and dinner if blood glucose results were 150-199. The 2:00 AM dose was only to be given for blood glucose levels > 199. Review of Patient 2’s “Medication Administration Record,” dated 07/08/24 at 1:54 AM, showed a blood glucose of 33. At 2:28 AM there was a blood glucose of 158. The administration record at 2:40 AM showed 2 units of insulin lispro was administered despite Patient 2’s blood sugar being below prescribed parameters. At 8:17 PM the record showed that 2 units of insulin lispro was administered without evidence that a blood glucose level was obtained within 30 minutes of administration as ordered. The facility failed to ensure that nursing staff followed orders for the administration of insulin for Patient 2. Patient 3 Review of Patient 3’s inpatient medical record showed an 89-year-old admitted to the Emergency Department on 11/22/24 at 3:55 PM. Patient 3 was admitted to inpatient status on 11/23/24 at 12:28 AM with a diagnosis of altered mental status. Patient 3 was inpatient at the time of record review. Concerns with this medical record included turning and repositioning. Review of Patient 3’s, “Braden Scale Assessment” dated 11/23/24 at 2:31 AM showed the patient at a high risk for developing pressure ulcers, “ ...Sensory Perceptions Slightly limited ... Activity Bedfast ... Braden Scale Score 13 ...” Review of Patient 3’s medical record failed to show documented evidence of repositioning every two hours as recommended for a patient at high risk for skin break down from 11/23/24 at 3:55 PM through 12/04/24 at time of chart review. Patient 6 Review of Patient 6’s medical record showed a 73-year-old admitted on 10/13/24 at 11:58 AM with complaints of weakness, falls, blurred vision, and reported cognitive decline. Concern with this medical record includes the missing post fall assessment. Review of an ED provider noted dated 10/13/24 at 3:23 PM showed that Patient 6 fell off the toilet while in the ED. A Computed Tomography (CT) [type of medical imaging technique] was ordered to rule out a head injury with no other injuries noted. Provider documented that the Charge Nurse was present and assessed Patient 6 after the fall. The medical record failed to show documented evidence that a post fall physical assessment was completed on Patient 6 by the Charge Nurse or any nursing staff at time of fall. Patient 8 Review of Patient 8’s medical record showed a 99-year-old male admitted on 11/26/2024 at 4:50 PM with a diagnosis of Acute renal failure secondary to ureteral obstruction secondary to bladder mass, bilateral hydronephrosis. Past medical history includes hypertension (elevated blood pressure) and bladder cancer. Review of a document titled, “Nursing Assessments” dated 11/26/24 at 8:02 PM showed, “Vital Signs Temp ...94.7 °F ...” Review of a document titled, “Nursing Assessments” dated 11/27/24 at 12:33 AM showed, “Vital Signs Temp ...96.1 °F ...” (4 hours after low temperature reading) Review of a document titled, “Nursing Assessments” dated 11/27/24 at 5:00 AM showed, “Vital Signs Temp ...95.5 °F ...” Review of a document titled, “Nursing Assessments” dated 11/27/24 at 7:45 AM showed, “Vital Signs Temp ...95.1 °F ...” Review of a document titled, “Nursing Assessments” dated 11/27/24 at 5:30 PM showed, “Vital Signs Temp ...85.7 °F ...” The medical record failed to show documentation of interventions or provider notification for a low temperature. Patient 9 Review of Patient 9’s medical record showed a 91-year-old admitted to inpatient status on 11/03/24 at 1:21 AM with a diagnosis of acute encephalopathy (condition in which brain function is disturbed due to underlying diseases or toxins in the body) urinary tract infection (UTI). Review of a document titled “Nursing Assessments (Flowsheets)” dated 11/07/24 at 7:50 PM showed that an order for an enclosure bed [Posey bed] (a restraint device used to protect patients at risk of injury from falling out of bed) was initiated with clinical justification documented as impulsiveness, high fall risk, and recent fall during hospitalization after Patient 9 sustained a fall. Review of Patient 9’s medical record and document review showed that Staff R, RN, falsified nursing assessment times that were provided on 11/11/24 - 11/12/24 as evidenced by “Nursing Assessments (Flowsheet)” and staff “Asset History” records (staff location tracking record) as follows: 1. Staff R, RN documented the completion of non-violent restraint assessments as performed at 10:00 PM. The location tracking record showed Staff R did not enter Patient 9’s room until 10:33 PM. Staff R did not enter the assessment into the medical record until 3:29 AM. 2. Staff R, RN documented the completion of non-violent restraint assessments as performed on 11/12/24 at 2:00 AM. The location tracking record showed Staff R did not enter Patient 9’s room until 2:10 AM. Staff R did not enter the assessment into the medical record until 3:32 AM. 3. Staff R, RN documented the completion of non-violent restraint assessments as performed on 11/12/24 at 4:00 AM. The location tracking record showed Staff R did not enter Patient 9’s room until 4:29 AM. Staff R did not enter the assessment into the medical record until 7:07 AM. Review of Patient 9’s medical record showed that Patient 9 was found deceased in the Posey bed on the morning of 11/12/24 at 4:30 AM as indicated by a document titled, “REPORT OF A HOSPITAL DEATH ASSOCIATED WITH THE USE OF RESTRAINT OR SECLUSION,” dated 11/12/2024 at 3:34 PM that showed, “ ...Date and Time of Death 11/12/2024 0430 [4:30 AM] ... Date Patient Last Monitored 11/12/2024 Time Patient Last Monitored 04:00 [4:00 AM] ...” The facility’s staff location tracking records showed that no staff entered Patient 9’s room for monitoring at 4:00 AM. No staff entered Patient 9’s room between 2:39 AM and 4:29 AM. During an interview on 12/06/24 at 10:55 AM Staff A, RN stated that staff had been in Patient 9’s room at 4:00 AM and then staff found Patient 9 deceased at 4:30 AM. Review of the medical record showed staff failed to obtain vital signs every four hours as required as indicated by “Vital Signs” document review. Vitals were not obtained between 11/11/24 at 8:52 PM and 11/12/24 at 4:30 AM when patient was found deceased. During an interview on 12/09/24 at 3:27 PM Staff Q, Registered Nurse (RN) stated that vital signs should be obtained every four hours unless otherwise ordered. During an interview on 12/09/24 at 3:51 PM Staff S, RN stated that vitals should be obtained a minimum of every four hours. During an interview on 12/09/24 at 4:07 PM Staff R, RN stated that vitals should be obtained a minimum of every four hours.”