University Medical Center New Orleans

“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: 50453 Based on record review and interview the hospital failed to ensure each patient or patient representative consented to treatment and was informed of his or her patient rights. This deficient practice is evidenced by failure to obtain signed consent for treatment or signed patient rights information form for 1 (#2) of 3 (#1-#3) records reviewed. Findings: Review of hospital policy # 04.01.010, titled “Patient Rights and Responsibilities,” effective date: 12/01/2024, revealed in part: “Purpose: To educate patients about their rights and responsibilities in their health care to engage them in the process and better meet their needs. Policy Statement: Whenever possible, this notice must be provided before providing or stopping care. All patients, inpatient or outpatient, must be informed of their rights as hospital patients. The patient’s rights should be provided and explained in a language or manner that the patient (or the patient’s representative) can understand. Definition: Patient Rights- 1. You have the right to receive considerate, respectful, and compassionate care in a safe setting regardless of your age, gender, race, national origin, religion, sexual orientation, gender identity, disabilities, handicap, diagnosis, or ability to pay or source of payment. 7. You have the right to be told by your doctor about your health status, diagnosis and possible prognosis, the benefits and risks of treatment, and the expected outcome of treatment, including unexpected outcomes. You or your representative (as allowed by state law) have the right to give written informed consent before any non-emergency procedures begins. 11. You, your family, and friends with your permission, have the right to participate in decisions about your care, your plan of care including its development and implementation, your treatment, and services provided, including the right to refuse treatment to the extent permitted by law.” Review of Patient #2’s medical record revealed Patient #2 was admitted from the ED on 07/01/2025 with a diagnosis of Encephalopathy. Further review of Patient #2’s medical record failed to reveal evidence that consents for patient rights or treatment were obtained prior to discharge from the hospital on 07/03/2025. In an interview on 07/08/2025 at 9:51 AM, S1RM confirmed there was no documented evidence that Patient #2 was notified of their patient rights or that a consent for treatment was obtained prior to discharge from the hospital.”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 50453 Based on record reviews and interview, the hospital failed to ensure patients in the hospital were informed of their right to be free from physical or mental abuse, and corporal punishment and to be free from restraint or seclusion of any form imposed as a means of coercion, discipline, convenience, or retaliation by staff. This deficient practice is evidenced by failing to provide nursing assessment and clinical justification for a patient in restraints per hospital policy. Findings: Review of hospital policy # 04.01.010, titled “Patient Rights and Responsibilities,” effective 12/01/2024, revealed in part: “ Definition: Patient Rights- 1. You have the right to receive considerate, respectful, and compassionate care in a safe setting regardless of your age, gender, race, national origin, religion, sexual orientation, gender identity, disabilities, handicap, diagnosis, or ability to pay or source of payment. 2. You have the right to receive care in a safe setting or environment free from all forms of abuse, neglect, harassment, or mistreatment. 9. You have the right to be free from restraints and seclusion in any form that is not medically required or that is used as a means of coercion, discipline, convenience, or retaliation by staff. In addition, any restrictions on your freedom must be kept to the minimum necessary to protect yourself or other people.” Review of hospital policy # Nursing 002, titled “Restraints and Seclusion,” effective 08/01/2024, revealed in part: “Definitions: Non-violent, Non-Self-Destructive, or Least Restrictive Restraint: A restraint that meets the safety needs of the patient, reduces the risk for dislodgment of tubes, lines, and catheters, and permits maximum freedom of movement. The use of non-violent restraints directly supports the medical healing of the patient and can be used in any unit of the hospital. Designated Staff: Describes staff roles involved in the application or monitoring or restraint or seclusion other than registered nurse (RN) but not limited to licensed practical nurse, certified nurse assistant, clinical nurse extern, clinical technician, public safety officer. Designated Staff are trained in de-escalation techniques, CPR/first aid, and restraint safety and may aid in the monitoring of patients placed in restraint or seclusion including providing fluids, nutrition, oral care, skin care, toileting, positioning, and range of motion. Responsibility: C. Nurses shall: 2. Initiate and discontinue restraint or seclusion based on the assessment of a patient’s need for restraint or seclusion with demonstrated and documented competency. 7. Perform ongoing assessments including: i. Need for the continuation of restraint or seclusion. ii. Re-evaluation of the patient’s response to the restraint or seclusion episode. 8. Educate the patient, as applicable, about behaviors leading to the initiation and discontinuation of restraint or seclusion. 9. Remove restraint or seclusion and discontinue the order as soon as safely possible, which may be before the time-limited order expires, if clinical justifications for restraint or seclusion are no longer met. Procedure: 4. Monitoring and Interventions: d. Non-Violent/Non-self-destructive Restraints will be assessed, monitored, and documented in the EMR every two (2) hours: i. The nurse’s assessment must include, but is not limited to: 1. Level of distress/Patient behavior/Visual check 2. Circulation 3. Range of motion 4. Fluids 5. Food/meal 6. Elimination 7. Respirations 8. Assessment and clinical justification for continued use of restraints ii. Vital signs per physician order. 5. Documentation: a. All required documentation is to be completed and documented in the EMR immediately following patient stabilization. b. Rationale for ongoing restraint usage must be documented. 7. Discontinuation of Restraint or Seclusion: a. The need for restraint or seclusion must be evaluated with every assessment/reassessment. b. Restraint or seclusion are discontinued as soon as safely possible and when the reason for implementation is resolved (i.e. when the patient’s behavior no longer threatens the physical safety of the patient, staff, or others).” A review of Patient #1’s medical record revealed Patient #1 to the ED on 05/07/2025 and was admitted to the hospital with a diagnosis of encephalopathy. On 05/20/2025 at 10:00 PM Patient #1 was placed in 4 point restraints after the patient became combative with staff. A review of Patient #1’s restraint documentation revealed in part the following: 05/20/2025 10:00 PM: 4 point soft restraints initiated, Patient agitated/restless, and circulation intact. Discontinuation Criteria: Absence of behavior that requires restraint, patient verbalized understanding and daughter notified. 05/21/2025 12:00 AM: “Patient Asleep” documented for the following: Visual Check, Range of Motion, Fluids, Food/Meal, and Elimination. Circulation intact. 4 point soft restraints continued. 05/21/2025 2:00 AM: “Patient Asleep” documented for the following: Visual Check, Range of Motion, Fluids, Food/Meal, and Elimination. Circulation intact. 4 point soft restraints continued. 05/21/2025 4:00 AM: “Patient Asleep” documented for the following: Visual Check, Range of Motion, Fluids, Food/Meal, and Elimination. Circulation intact. 4 point soft restraints continued. 05/21/2025 6:00 AM: “Patient Asleep” documented for the following: Visual Check, Range of Motion, Fluids, Food/Meal, and Elimination. Circulation intact. 4 point soft restraints continued. 05/21/2025 8:00 AM: Circulation: intact; Range of Motion: Performed; Fluids: Patient Accepted; Food/Meal: Patient Declined; Elimination: Incontinent/diapered/patient changed; RN Assessment Clinical Justification: Prevention of self-harm/Patient Safety. 4 point soft restraints continued. Review of Patient #1’s restraint documentation failed to reveal documentation by the nurse of an RN Assessment and clinical justification for continued use of 4 point restraints on 05/21/2025 at 12:00 AM, 2:00 AM, 4:00 AM, or 6:00 AM. Further review of Patient #1’s medical record revealed that Patient #1 remained in restraints until the patient was discharged home with family on 05/30/2025. In an interview on 07/07/2025 at 3:21 PM, S1RM and S4RN confirmed the above mentioned findings. S1RM also confirmed that S6RN did not perform restraint monitoring and assessment on Patient #1 every 2 hours per hospital policy.”

“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: 50453 Based on record review, policy review and interview, the hospital failed to ensure the nursing plan of care for each patient was kept current and reflected the patient’s goals and the nursing care to be provided to meet the patient’s needs. This deficient practice is evidenced by failure of the nursing staff to include existing and potential problems in the plan of care for 1 (#3) of 3 (#1-#3) patients reviewed. Findings: Review of hospital policy #5015, titled “Patient Screening, Assessment, Reassessment and Plan of Care,” last revised 07/2024, revealed in part: “Procedure: 2. Reassessment for Inpatients: a. Each patient is reassessed as necessary based on their identified problems, plan for care, changes in condition, changes in care setting, or as relevant. 3. Plan of Care for Inpatients: a. The patient’s plan of care is initiated within 24 hours of admission. b. Existing and potential problems, goals, and interventions are evaluated once in 24 hours and updated as clinically relevant.” Review of Patient #3’s medical record revealed Patient #3 was an 83 year old female who was admitted on 07/01/2025 for dysphagia. On 07/02/2025 Patient #3 had an EGD performed. Patient #3 was discharged home on 07/04/2025. Review of the Patient #3’s history and physical revealed in part the following Assessment/Plan: Dysphagia, Schatzki Ring, Abdominal Pain (GI consulted, EGD tomorrow), COPD, Anxiety (0.5mg Ativan IV once), Rheumatoid Arthritis, Hypertension, and Hyperlipidemia. Review of Patient #3’s nursing plan of care revealed in part: Problem: Gastrointestinal, Goals: Minimal or absence of nausea and vomiting, Maintains or returns to baseline bowel function, Maintains adequate nutritional intake, and establish and maintain optimal ostomy function. Further review of nursing plan of care failed to reveal the following existing problems: Dysphagia, Abdominal Pain, COPD, Anxiety, Rheumatoid Arthritis, Hypertension, or Hyperlipidemia. Further review failed to reveal that the nursing plan of care was updated after the EGD was performed. In an interview on 07/08/2025 at 10:40 AM, S1RM confirmed the above mentioned findings and verified the plan of care did not include all of Patient #3’s existing and potential problems.”

“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: 50453 Based on record review and interview, the hospital failed to ensure the patient’s right to be free from all forms of neglect. This deficient practice was evidenced by failing to monitor a patient on wandering precautions while being transported off the inpatient unit for procedure. Findings: Review of hospital policy number 5056, titled “Reporting Abuse and/or Neglect,” last reviewed 10/2023, revealed in part: “Scope: This policy applies to all health care providers. Purpose: The purpose of this policy is to: Protect patients whose physical or mental health and welfare are endangered by abuse and/or neglect and may be further threatened by the conduct of those responsible for their care and protection. Protect patients who cannot physically or mentally protect themselves and who are harmed or threatened with harm through action or inaction by themselves or by individuals responsible for their care.” Review of hospital policy number 5998, titled “Against Medical Advice, Wandering and Elopement,” effective date 04/2023, revealed in part: “Purpose: To provide guidelines for preventing and addressing a discharge against medical advice (AMA), and prevention of elopement and wandering within patient care areas. Definitions: Wandering - The act of a patient moving beyond the view of staff or out of the care area with or without the intention of leaving. The patient may not have a specific destination in mind and may be unaware of their surroundings or personal safety. This situation is generally encountered with patients who are temporarily or permanently cognitively impaired. Cognitively Impaired - A person who may have trouble remembering, learning new things, concentrating, or making decisions affecting their everyday life. A patient may become temporarily cognitively impaired as a result of the treatment. Policy: B. Patients recognized as potentially at risk of wandering (those who are cognitively impaired) will have safety precautions implemented. Procedure: 2. Patient Wandering: a. Wandering precautions will be initiated for patients at risk, particularly for those who are cognitively impaired. Wandering precautions consist of: i. if possible, patients will be placed in a room near the nurse’s station. ii. Bed alarms may be used. iii. Identify patient wandering risk during safety rounds. iv. Encourage family to stay with the patient. v. Assign a safety sitter as needed. b. In the event the patient is missing from the patient room/treatment area and suspected of wandering, begin a search of the unit immediately. e. If the wandering patient is not found on the unit, call for a Dr. Flight code and notify the following for immediate assistant in locating the patient: i. unit charge nurse/manager/director ii. House Supervisor iii. Public Safety iv. Resident/attending physician.” Patient #1 Review of Patient #1’s medical record revealed Patient #1 was admitted on 04/07/2025 with a diagnosis of Hypoxic Respiratory Failure and Severe Protein Malnutrition. Patient #1 had a history of Metastatic Cancer and a previous stroke. On 04/15/2025 the provider progress note revealed in part: Delirium/Agitation: Patient getting increasingly frustrated about staying in the hospital. Amenable to staying until imaging completed. On 04/15/2025 at 12:38 PM orders were placed for Wandering precautions and to Assign a virtual safety sitter. On 04/17/2025, self-report revealed in part: after completing radiation oncology testing Patient #1 was placed alone on a stretcher in the hallway to await transport back to his inpatient room. Prior to transport arriving to get Patient #1, Patient #1 walked out and exited the facility while he was unsupervised by staff. Review of Patient #1’s Physician Discharge Summary from 04/17/2025 at 9:46 AM, entered by S10RMD, revealed in part: Hospital Course: “During his stay, we were concerned about his full comprehension of the situation as well as whether he would follow-up outpatient for his treatments. Patient became increasingly agitated over staying in hospital, left AMA on 04/17/2025 morning.” Further review of the Physician Discharge Summary revealed an attestation by S11MD, entered on 04/23/3035 at 11:52 AM. This attestation revealed in part: Apparently patient frustrated and agitated because he’s still here in hospital. Notified by resident team that patient left AMA. We called patients neighbor who stated she can help patient sometime with his outpatient follow up appointments, but is unable to take patient to every appointment. Review of Patient #1’s nursing notes revealed in part the following: 04/17/2025 at 7:30 AM- Patient #1 attempted to leave room to walk to procedure. Received call from Tele-sitter of situation. RN attempted to redirect patient, patient continued to walk to elevator. Dr. Flight (elopement) called. Security met patient in elevator and was redirected back to his room where the MD met with patient. “Soon after transport took patient via stretcher off floor.” 04/17/2025 at 8:39 AM- Transport told me they were requested to pick Patient #1 up, but when they arrived Patient #1 was unable to be located. MD notified via phone. Dr. Flight (elopement) called over intercom. Notified charge nurse of situation. 04/17/2025 at 10:51 AM- “Therapist called me at approximately 9:30 AM to report Patient #1 had walked out after receiving treatment while waiting on stretcher for transport. Notified charge nurse.” Further review of nursing notes for Patient #1 failed to reveal documented evidence that the sending nurse communicated to the receiving nurse/staff in the cancer center clinic that Patient #1 was on wandering precautions or that Patient #1 attempted to leave the inpatient unit just prior to being transported. Patient #1’s medical record also failed to reveal documented evidence that Patient #1’s safety precautions were maintained while Patient #1 was off the inpatient unit for a procedure. In an interview on 05/20/2025 at 3:30 PM, S2RM and S9RN confirmed that there was no documentation that the sending nurse communicated to the receiving nurse/staff that Patient #1 was on wandering precautions. S2RM also confirmed that there is no documented evidence that Patient #1’s wandering precautions were maintained while Patient #1 was off the inpatient unit for a procedure.”

“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: 50453 Based on record review and interview, the hospital failed to ensure the registered nurse supervised and evaluated the care of each patient on an ongoing basis, in accordance with the accepted standards of nursing practice and hospital policy. This deficient practice is evidenced by failure of the registered nurse to supervise staff to ensure observations were being performed and documented hourly for 1 (#1) of 1 (#1) patients reviewed who had orders for a virtual safety sitter. Findings: Review of hospital policy number 6112, titled “Continuous Visual Monitoring Virtual Patient Sitter Policy,” last revised 02/2022, revealed in part: “Purpose: Initiation of continuous visual monitoring is a nursing intervention. It can be utilized to ensure patient safety as an additional tool in the plan of care for patients at high risk for falls, confusion, impaired mobility, etc. Procedure: Virtual Patient Observation (VPO) Inclusion Criteria: Patient warrants a closer level of observation, based on the clinical judgement of the primary care giver, but does not meet any of the exclusion criteria. Examples of inclusion criteria include: ii. Delirium/Restlessness iii. Confusion, acute or chronic v. Elopement risk. Primary Care Giver Responsibility: Notify patient and family that continuous visual monitoring will be implemented to promote patient safety. If the patient/family refuse telesitter monitoring, a patient sitter will be placed in the room. Reassess patient at least every four (4) hours for the need to continue VPO. Respond in a timely manner when notified by the Tele-monitor staff or the Stat Alarm. Notify Tele-monitor staff when patient is removed from room for test, therapy, walks, etc. Tele-Monitor Staff Responsibility: Receive report on VPO candidate from primary care giver. Record initiation of Telesitter on patient log and the reason for continuous visual monitoring. Monitor patients and attempt to verbally redirect patient when necessary. Call floor staff directly by phone if an issue arises with the patient that needs staff attention. Activate Stat Alarm when a patient is not following direction and/or situation is emergent. Document patient’s activities at least every two hours on the TeleSitter monitoring log if paper log is utilized. Perform hourly virtual rounds on patient. Rounds to include environmental check and verbal check-in if appropriate. Place status of patient when out of room (POOR) and follow up with expected return times. Provide report to oncoming staff regarding patient status and activity for the shift. Include notable behaviors or trends in overall patient activity.” Review of hospital policy number 5998, titled “Against Medical Advice, Wandering and Elopement,” effective date 04/2023, revealed in part: “Purpose: To provide guidelines for preventing and addressing a discharge against medical advice (AMA), and prevention of elopement and wandering within patient care areas. Definitions: Wandering - The act of a patient moving beyond the view of staff or out of the care area with or without the intention of leaving. The patient may not have a specific destination in mind and may be unaware of their surroundings or personal safety. This situation is generally encountered with patients who are temporarily or permanently cognitively impaired. Cognitively Impaired - A person who may have trouble remembering, learning new things, concentrating, or making decisions affecting their everyday life. A patient may become temporarily cognitively impaired as a result of the treatment. Policy: B. Patients recognized as potentially at risk of wandering (those who are cognitively impaired) will have safety precautions implemented. Procedure: 2. Patient Wandering: a. Wandering precautions will be initiated for patients at risk, particularly for those who are cognitively impaired. Wandering precautions consist of: i. if possible, patients will be placed in a room near the nurse’s station. ii. Bed alarms may be used. iii. Identify patient wandering risk during safety rounds. iv. Encourage family to stay with the patient. v. Assign a safety sitter as needed. b. In the event the patient is missing from the patient room/treatment area and suspected of wandering, begin a search of the unit immediately. e. If the wandering patient is not found on the unit, call for a Dr. Flight code and notify the following for immediate assistant in locating the patient: i. unit charge nurse/manager/director ii. House Supervisor iii. Public Safety iv. Resident/attending physician.” Patient #1 Review of Patient #1’s medical record revealed Patient #1 was admitted on 04/07/2025 with a diagnosis of Hypoxic Respiratory Failure and Severe Protein Malnutrition. Patient #1 had a history of Metastatic Cancer and a previous stroke. Review of Patient #1’s provider progress note on 04/15/2025 revealed in part: Assessment/Plan: Delirium/Agitation: “Patient getting increasingly frustrated about staying in the hospital. Amenable to staying until imaging completed. Wandering/Delirium precautions.” Review of Patient #1’s physician orders revealed on 04/15/2025 at 12:38 PM the following orders were placed: Wandering precautions Assign a virtual safety sitter Review of Patient #1’s medical record for virtual safety sitter observation/documentation revealed in part the following: 04/15/2025 at 4:29 PM- Virtual Patient Observation sitter initiated. Indication for sitter- patient safety. Patient Observation Assessment: Location- Room, Activity- Laying in bed, Behavior- Quiet. 04/15/2025 at 6:00 PM- Virtual Patient Observation sitter continued. Indication for sitter- patient safety. Patient Observation Assessment: Location- Room, Activity- Laying in bed, Behavior- Quiet. Review of Patient #1’s medical record failed to reveal documentation that hourly virtual rounds were performed after 04/15/2025 at 6:00 PM by the virtual safety sitter. Further review of Patient #1’s medical record revealed that on 04/17/2025 at 11:52 AM the virtual safety sitter order was automatically discontinued when Patient #1 was discharged AMA out the system. In an interview on 05/20/2025 at 3:45 PM, S2RM and S3DQPS confirmed that hourly virtual rounds were not documented after 04/15/2025 at 6:00 PM by the virtual safety sitter per hospital policy on Patient #1. S2RM and S9RN also confirmed at this time that the only 2 virtual safety sitter observations documented were on 04/15/2025 at 4:29 PM and 6:00 PM.”

“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: 50453 Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation (CoP) for Nursing Services. The deficient practice was evidenced by: 1) failure of nursing staff to document vital signs as ordered by the physician and/or hospital policy for 3 (#1-#3) of 3 (#1-#3) patient medical records reviewed (see findings in A0395); 2) failure of nursing staff to document hourly neuro checks as ordered by the physician for 1 (#2) of 3 (#1-#3) patient medical records reviewed (see findings in A0395); 3) failure to document hourly level of consciousness for 2 (#1, #3) of 2 (#1, #3) patient’s reviewed receiving Continuous Renal Replacement Therapy (CRRT) per hospital policy (see findings in A0398); and 4) failure of nursing staff to document a physician notification for alterations in vital signs that represent a deteriorating patient condition for 2 (#2, #3) of 3 (#1-#3) patient medical records reviewed per hospital policy (see findings in A0398).”

“CONTRACTED SERVICES CFR(s): 482.12(e)(1) The governing body must ensure that the services performed under a contract are provided in a safe and effective manner. This Standard is not met as evidenced by: 48050 50453 Based on record review and interview, the governing body failed to ensure contracted services were provided in a safe and effective manner. This deficient practice is evidenced by failing to ensure contracted services are following hospital policy for the services provided in 2 (#1, #3) of 2 (#1, #3) patient records reviewed who received Continuous Renal Replacement Therapy (CRRT). Findings: Review of hospital policy # Critical Care 12, titled, “Critical Care Continuous Renal Replacement Therapy,” last revised: 09/2021, revealed in part: “STANDARD OF PROFESSIONAL PRACTICE: Both the Critical Care Registered Nurse and the Dialysis/Renal Registered Nurse are responsible to monitor the patient’s vital signs and mechanical operation of the CRRT machine during the first hour of CRRT therapy. Thereafter, it is the responsibility of the Critical Care Registered Nurse to monitor the patient, the CRRT machine and efficacy of CRRT treatment. Procedures: PRETREATMENT: The Critical Care Nurse and Dialysis/Renal Nurse are responsible for the following: iv. Hemodynamically assess patient: vital signs, fluid status, level of consciousness, and weight of patient before treatment. INITIATING THERAPY: iv. Both the Critical Care Registered Nurse and the Dialysis/Renal Registered Nurse are responsible for monitoring the patient’s vital signs during the first hour of therapy. DURING THERAPY: i. Hemodynamically monitor patient - vital signs, fluid status, and level of consciousness on an hourly basis. v. Calculate I&O’s each hour and set the ultrafiltration rate on the CRRT machine to meet the UF goal of the patient. Documentation: Documentation of CRRT is performed hourly in the EMR. The following parameters must be documented every hour: Arterial Pressure, Venous Pressure, Effluent Pressure, UF Rate, Therapy Fluid Potassium Bath, Blood Flow Rate, All I&O’s are documented under the Input and Output Flowsheet. Based upon the I&O’s that hour the nurse calculates the goal UF to program on the CRRT machine.” Review of Patient #1’s CRRT Initiation Therapy Report revealed in part the following documentation by the dialysis nurse: Arrival Date/Time: 05/01/2025 at 11:30 PM. Timeout Date/Time: 05/01/2025 at 11:30 PM. Pre-Therapy Vitals Date/Time: 05/01/2025 at 11:30 PM. Therapy Start Date/Time: 05/01/2025 at 11:30 PM. Post Report Date/Time: 05/01/2025 at 11:30 PM, report given to critical care nurse. Departure Date/Time: 05/02/2025 at 12:30 AM. In an interview on 05/07/2025 at 3:36 PM, S11DN confirmed he was able to recall initiating CRRT on Patient #1. S11DN further verbalized that he stayed with this patient for 20-30 minutes and then reported care off to the critical care nurse. S11DN stated that when he initiates CRRT on a patient that vital signs are obtained every 15 minutes. In an interview on 05/08/2025 at 9:28 AM, S3RM confirmed the policy states the dialysis nurse and Critical Care nurse should remain with the patient for the first hour of CRRT after initiation. S3RM confirmed that S11DN documented he stayed with Patient #1 for the first hour of CRRT. S3RN further confirmed that during the interview with S11DN, S11DN verbalized he only remained with the Patient #1 for 20-30 minutes. Review of Patient #3’s CRRT Initiation Therapy Report revealed in part the following documentation by the dialysis nurse: Arrival Date/Time: 05/03/2025 at 6:27AM. Timeout Date/Time: 05/03/2025 at 6:27AM. Pre-Therapy Vitals Date/Time: 05/03/2025 at 6:27AM. Therapy Start Date/Time: 05/03/2025 at 6:27AM. Post Report Date/Time: 05/03/2025 at 6:27AM, report given to critical care nurse. Departure Date/Time: 05/03/2025 at 7:00 AM. Further review revealed documentation that the dialysis nurse only remained with Patient #3 for 33 minutes after initiating CRRT. In an interview on 05/08/2025 at 1:39 PM, S7CSM confirmed that the dialysis nurse did not remain with Patient #3 for the entire first hour after initiating CRRT per policy.”

“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: 48050 50453 Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by: 1) failure of nursing staff to document vital signs as ordered by the physician and/or hospital policy for 3 (#1-#3) of 3 (#1-#3) patient medical records reviewed; and 2) failure of nursing staff to document hourly neuro checks as ordered by the physician for 1 (#2) of 3 (#1-#3) patient medical records reviewed. Findings: 1) Failure of nursing staff to document vital signs as ordered by the physician for 3 (#1-#3) of 3 (#1-#3) patient medical records reviewed. Review of hospital policy number Critical Care 13, titled “Critical Care General Nursing Care,” last reviewed 10/2024, revealed in part: “Purpose: This policy is intended to outline how general nursing care will be delivered to all patients within critical care units. The outcome of this policy will be delivery of excellent nursing care to all patients within critical care units. Procedure: VITAL SIGNS: blood pressure, pulse, respiratory rate, and O2 saturation will be taken and documented on admission, then every hour for at least 24 hours. Temperatures will be taken on admission, and then every four hours. Hourly temperatures are required for patients with a temperature less than 36C or greater than 38C and for those on cooling blankets or warming devices.” Patient #1 Review of Patient #1’s medical record revealed Patient #1 was a 52 year old male admitted to ICU on 04/30/2025 at 3:16 PM for Post-Cardiac Arrest Management. Review of Patient #1’s vital signs revealed the following: 04/30/2025 4:00 PM: HR 122, RR 15, 97% O2, no BP or temperature documented. 5:00 PM: HR 126, RR 24, Temperature 93.6F (34.2C), no BP or O2 documented. 6:00 PM: HR 121, RR 24, Temperature 93.2F (34C), no BP or O2 documented. 7:00 PM: HR 118, RR 24, Temperature 93F (33.9C), BP 104/90, no O2 documented 8:00 PM: HR 114, RR 24, Temperature 91.4F (33C), BP 108/97, no O2 documented 9:00 PM: HR 108, RR 24, Temperature 90.5F (32.5C), BP 123/106, no O2 documented 05/01/2025 12:00 AM: HR 111, RR 23, Temperature 92.7F (33.7C), BP 151/100, no O2 documented 3:00 AM: HR 113, R 24, Temperature 95.4F (35.2C), BP 105/88, no O2 documented 4:00 AM: HR 110, RR 24, Temperature 96.1F (35.6C), BP 97/58, no O2 documented 5:00 AM: HR 110, RR 24, Temperature 96.4F (35.8C), BP 94/79, no O2 documented 6:00 AM: HR 97, RR 24, Temperature 97.2F (36.2C), BP 101/74, no O2 documented 7:00 AM: HR 95, RR 24, Temperature 97.5F (36.4C), BP 98/67, no O2 documented 8:00 AM: HR 96, RR 24, Temperature 97.7F (36.5C), no BP or O2 documented 9:00 AM: HR110, RR 24, Temperature 97.7F (36.5C), BP 84/29, no O2 documented 10:00 AM: HR 104, RR 24, Temperature 97.7F (36.5C), no BP or O2 documented 11:00 AM: HR 106, RR 24, Temperature 97.7F (36.5C), BP 94/77, no O2 documented 12:00 PM: HR 98, RR 24, Temperature 97.5F (36.4C), BP 110/79, no O2 documented 1:00 PM: HR111, RR 24, Temperature 96.8F (36C), no BP or O2 documented 2:00 PM: HR 112, RR 24, Temperature 97.2F (36.2C), BP 95/59, no O2 documented 3:00 PM: HR 108, RR 24, Temperature 95.9F (35.5C), BP 94/71, no O2 documented 4:00 PM: HR 105, RR 24, Temperature 97F (36.1C), BP 98/85, no O2 documented 5:00 PM: HR 105, RR 24, Temperature 97F (36.1C), BP 82/31, no O2 documented 6:00 PM: HR 107, RR 24, Temperature 96.8F (36C), BP 88/53, no O2 documented 7:00 PM: HR 109, RR 24, Temperature 96.8F (36C), no BP or O2 documented 9:00 PM: HR 112, RR 24, BP 119/90, O2 95%, no temperature documented 10:00 PM: HR 115, RR 28, O2 95%, no BP or temperature documented 11:00 PM: HR 97, RR 22, BP 104/78, O2 95%, no temperature documented 05/02/2025 12:00 AM: HR 86, RR 24, Temperature 95F (35C), O2 92%, no BP documented 1:00 AM: HR 93, RR 24, Temperature 95.1F (35.1C), O2 90%, no BP documented 2:00 AM: HR 92, RR 28, BP 101/63, O2 90%, no temperature documented 3:00 AM: HR 97, RR 28, no BP, O2, or temperature documented 4:00 AM: HR 87, RR 28, Temperature 95.2F (35.1C), O2 90%, no BP documented 5:00 AM: HR 41, RR 0, no BP, O2, or temperature documented Further review of Patient #1’s medical record revealed documentation by provider at 1:33 AM on 05/02/2025 a code blue was called a response to Patient #1’s cardiac arrest. Patient #1 underwent manual CPR compressions until 1:39 AM, when a pulse check revealed a sinus rhythm of 94 beats per minute and return to spontaneous circulation was declared. Patient #1 was given 3 rounds of epinephrine at 1:34 AM, 1:36 AM, 1:39 AM. Patient was provided with 2 amps of Bicarb at 1:35 AM, 1:36 AM, Calcium chloride was given at 1:37 AM. On 05/02/2025 at 4:02 AM Patient #1 was palliatively extubated and subsequently expired at 5:45 AM. In an interview on 05/08/2025 at 11:15 AM, S7CSM confirmed the above mentioned findings. S7CSM also verified that blood pressure, pulse, respiratory rate, and O2 saturation should be documented each hour when obtaining vital signs. Patient #2 Review of Patient #2’s medical record revealed Patient #2 was a 37 year old male admitted to ICU on 05/02/2025 at 8:41 PM for Sepsis with Acute Organ Dysfunction and Encephalopathy. A physician order to start Q1H vital signs was entered on 05/02/2025 at 8:00 PM. Review of Patient #2’s vital signs revealed the following: 05/02/2025 9:00 PM: BP 93/57, HR 104, RR 18, 100% O2, temperature 95F (35C). 10:00 PM: BP 78/58, HR 105, RR 18, 99% O2, no temperature documented. 11:00 PM: BP 95/51, HR 108, RR 22, 100% O2, no temperature documented. 05/03/2025 12:00 AM: BP 107/50, HR 109, RR 19, 100% O2, no temperature documented. 1:00 AM: BP 74/44, HR 112, RR 19, 100% O2, no temperature documented. 2:00 AM: BP 79/43, HR 119, RR 21, 100% O2, no temperature documented. 3:15 AM: BP 123/96, HR 122, RR 28, no O2 saturation or temperature documented. 4:00 AM: BP 94/69, HR 137, RR 26, 100% O2, no temperature documented. 5:00 AM: BP 96/77, HR 147, RR 26, no O2 saturation or temperature documented. Further review of Patient #2’s medical record revealed documentation by the provider that a rapid response was called 05/03/2025 at 5:35 AM. Patient #2 received CPR and 2 rounds of epinephrine. Time of Death was called on 05/03/2025 at 5:49 AM. Review of Patient #2’s vital signs failed to reveal that a repeat temperature was obtained or documented after 9:00 PM on 05/02/2025. The last O2 saturation documented on Patient #2 was 05/03/2025 at 4:00 AM. Further review failed to reveal that a complete set of vital signs were obtained per physician order and policy. In an interview on 05/08/2025 at 11:54 PM, S7CSM confirmed the above mentioned findings. S7CSM also verified that blood pressure, pulse, respiratory rate, and O2 saturation should be documented each hour when obtaining vital signs. Patient #3 Review of Patient #3’s medical record revealed Patient #3 was a 65 year old male who was admitted for a Pulmonary Embolism on 04/29/2025. Patient #3 was moved to ICU on 05/02/2025 at 10:00 PM and was intubated and placed on vasoactive IV medication for hypotension and elevated lactic acidosis. On 05/03/2025 at 6:27 AM CRRT was initiated on Patient #3. Review of Patient #3’s vital signs revealed the following: 05/05/2025: 12:00 AM: BP 76/54, HR 90, RR 31, 95% O2, 96.3F (35.7C) temperature. 1:00 AM: BP 96/75, HR 97, RR 31, 93% O2, 95.7F (35.4C) temperature. 2:00 AM: no BP documented 3:00 AM: no BP documented 4:00 AM: BP 63/15, HR 89, RR 25, 93.7F (34.3C) temperature, no O2 saturation documented. Further review of Patient #3’s vital signs failed to reveal a repeat documented blood pressure after 4:00 AM on 05/05/2025 or a repeat O2 saturation after 3:00 AM on 05/05/2025. Patient #3’s medical record revealed on 05/05/2025 at 8:13 AM that the patient went into cardiac arrest and CPR was initiated. Patient #3 expired on 05/05/2025 at 8:42 AM. In an interview on 05/08/2025 at 2:25 PM, S7CSM confirmed the above mentioned findings. S7CSM also verified that blood pressure, pulse, respiratory rate, and O2 saturation should be documented when obtaining vital signs. 2) Failure of nursing staff to document hourly neuro checks as ordered by the physician for 1 (#2) of 3 (#1-#3) patient medical records reviewed. Patient #2 Review of Patient #2’s medical record revealed Patient #2 was admitted to ICU on 05/02/2025 at 8:41 PM. Further review of Patient #2’s medical record revealed a physician order for Q1H Neuro checks entered on 05/02/2025 at 9:00 PM. Review of Patient #2’s nursing assessments revealed the following documented neurological assessments: 05/02/2025 at 9:00 PM. 05/03/2025 at 12:00 AM and 4:00 AM. Further review failed reveal a neurological assessment documented on Patient #2 for the following times: 05/02/2025 at 10:00 PM or 11:00 PM. 05/03/2025 at 1:00 AM, 2:00 AM, 3:00 AM, or 5:00 AM. In an interview on 05/08/2025 at 11:50 AM, S7CSM confirmed the above mentioned findings. S7CSM also confirmed neurological checks were not obtained every hour per physician order for Patient #2.”

“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: 48050 50453 Based on record review and interview, the hospital failed to ensure licensed nurses adhered to policies and procedures of the hospital as evidenced by: 1) failure to document hourly level of consciousness for 2 (#1, #3) of 2 (#1, #3) patient’s reviewed receiving Continuous Renal Replacement Therapy (CRRT) per hospital policy; and 2) failure of nursing staff to document a physician notification for alterations in vital signs that represent a deteriorating patient condition for 2 (#2, #3) of 3 (#1-#3) patient medical records reviewed per hospital policy. Findings: 1) Failure to document hourly level of consciousness for 2 (#1, #3) of 2 (#1, #3) patient’s reviewed receiving Continuous Renal Replacement Therapy (CRRT) per hospital policy. Review of hospital policy # Critical Care 12, titled, “Critical Care Continuous Renal Replacement Therapy,” last revised: 09/2021, revealed in part: “STANDARD OF PROFESSIONAL PRACTICE: Both the Critical Care Registered Nurse and the Dialysis/Renal Registered Nurse are responsible to monitor the patient’s vital signs and mechanical operation of the CRRT machine during the first hour of CRRT therapy. Thereafter, it is the responsibility of the Critical Care Registered Nurse to monitor the patient, the CRRT machine and efficacy of CRRT treatment. Procedures: PATIENT ASSESSMENT AND MONITORING: The standard nurse to patient ration for patients receiving CRRT will be 1 nurse to 1 patient. This ratio can only be altered by the ICU nurse director based on patient safety considerations. PRETREATMENT: The Critical Care Nurse and Dialysis/Renal Nurse are responsible for the following: iv. Hemodynamically assess patient: vital signs, fluid status, level of consciousness, and weight of patient before treatment. INITIATING THERAPY: iv. Both the Critical Care Registered Nurse and the Dialysis/Renal Registered Nurse are responsible for monitoring the patient’s vital signs during the first hour of therapy. DURING THERAPY: i. Hemodynamically monitor patient - vital signs, fluid status, and level of consciousness on an hourly basis. v. Calculate I&O’s each hour and set the ultrafiltration rate on the CRRT machine to meet the UF goal of the patient. Documentation: Documentation of CRRT is performed hourly in the EMR. The following parameters must be documented every hour: Arterial Pressure, Venous Pressure, Effluent Pressure, UF Rate, Therapy Fluid Potassium Bath, Blood Flow Rate, All I&O’s are documented under the Input and Output Flowsheet. Based upon the I&O’s that hour the nurse calculates the goal UF to program on the CRRT machine.” Patient #1 Review of Patient #1’s medical record revealed Patient #1 was a 52 year old male who was admitted to ICU on 04/30/2025 with a diagnosis of cardiac arrest. Patient #1 was intubated and on multiple vasoactive IV medications. On 05/01/2025 at 11:30 PM CRRT was initiated on Patient #1. Review of Patient #1’s nursing assessments revealed documented levels of consciousness for the following times during CRRT: 05/02/2025 at 12:00 AM. Review of Patient #1’s nursing assessments failed to reveal documented levels of consciousness for the following times: 05/01/2025 at 11:00 PM prior to initiating CRRT. 05/02/2025 at 1:00 AM during CRRT. Further review of Patient #1’s medical record revealed on 05/02/2025 at 1:33 AM that the patient went into cardiac arrest and CPR was initiated and ROSC (return of spontaneous circulation) was obtained at 1:39 AM. Patient #1 was made a DNR (do not resuscitate) and expired on 05/02/2025 at 5:45 AM. In an interview on 05/08/2025 at 10:52 AM, S3RM and S7CSM confirmed that the nurse did not document the level of consciousness on Patient #1 prior to initiating CRRT or hourly per hospital policy. In an interview on 05/08/2025 at 11:15 AM, S1CVP confirmed that the CRRT policy states the level of consciousness is part of the required documentation for patients receiving CRRT. Patient #3 Review of Patient #3’s medical record revealed Patient #3 was a 65 year old male who was admitted for a Pulmonary Embolism on 04/29/2025. Patient #3 was moved to ICU (intensive care unit) on 05/02/2025 at 10:00 PM and was intubated and placed on vasoactive IV medication for hypotension and elevated lactic acidosis. On 05/03/2025 at 6:27 AM CRRT was initiated on Patient #3. Review of Patient #3’s nursing assessments revealed documented levels of consciousness for the following times during CRRT: 05/03/2025: 8:00 AM, 12:00 PM, 4:00 PM, 8:00 PM. 05/04/2025: 12:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, 8:00 PM. Review of Patient #3’s nursing assessments failed to reveal hourly documented levels of consciousness for the following times during CRRT: 05/03/2025: 9:00 AM, 10:00 AM, 11:00 AM, 1:00 PM, 2:00 PM, 3:00 PM, 5:00 PM, 6:00 PM, 7:00 PM, 9:00 PM, 10:00 PM, or 11:00 PM. 05/04/2025: 1:00 AM, 2:00 AM, 3:00 AM, 5:00 AM, 6:00 AM, 7:00 AM, 9:00 AM, 10:00 AM, 11:00 AM, 1:00 PM, 2:00 PM, 3:00 PM, 5:00 PM, 6:00 PM, 7:00 PM, 9:00 PM, 10:00 PM, or 11:00 PM. 05/05/2025: 1:00 AM, 2:00 AM, 3:00 AM, 5:00 AM, 6:00 AM, 7:00 AM. Further review of Patient #3’s medical record revealed on 05/05/2025 at 8:13 AM that the patient went into cardiac arrest and CPR(cardiopulmonary resuscitation) was initiated. Patient #3 expired on 05/05/2025 at 8:42 AM. In an interview on 05/08/2025 at 2:23 PM, S7CSM confirmed the above mentioned findings on Patient #3. S7CSM also verified that during CRRT the level of consciousness should be documented hourly by the nurse per policy. 2) Failure of nursing staff to document a physician notification for alterations in vital signs that represent a deteriorating patient condition for 2 (#2, #3) of 3 (#1-#3) patient medical records reviewed per hospital policy. Review of hospital policy number Critical Care 13, titled “Critical Care General Nursing Care,” last reviewed 10/2024, revealed in part: “Purpose: This policy is intended to outline how general nursing care will be delivered to all patients within critical care units. The outcome of this policy will be delivery of excellent nursing care to all patients within critical care units. Procedure: VITAL SIGNS: blood pressure, pulse, respiratory rate, and O2 saturation will be taken and documented on admission, then every hour for at least 24 hours. Unstable patients: vital signs will be taken relative to the patient’s condition and nursing interventions such as manipulation of vasoactive drips, fluid and blood replacement, etc. Documentation of frequent vital signs (such as every 15 minutes, etc.) will occur via electronic health record (EHR). When titrating drips, continuous assessment of every 5-minute vital signs is needed to determine patient reaction and stabilization. Physician notification is required for altercations in vital signs that represent a deteriorating patient condition. Documentation of physician notification must be included in the EHR. INTAKE and OUTPUT: Accurate intake & output will be maintained on all critical care patients. IV infusion pumps will have “volume infused” cleared every 12 hours at 6 PM and 6 AM. Urine outputs will be monitored and recorded every hour. Daily weights will be done at the same time each day between 4 and 6 AM and recorded in the patient’s EHR.” Patient #2 Review of Patient #2’s medical record revealed documentation by the provider that a rapid response (an activation team who responds when called for any significant change in the assessment, including but not limited to significant changes in vital signs, respiratory status and/or mental status) was called 05/03/2025 at 5:35 AM. Patient #2 received CPR and 2 rounds of epinephrine. Patient #2 expired on 05/03/2025 at 5:49 AM. Review of nursing documentation failed to reveal documented evidence that the physician was notified by the nurse of an alteration in vital signs or that Patient #2 was deteriorating prior to the event on 05/03/2025 at 5:35 AM. . In an interview on 05/08/2025 at 11:54 AM, S7CSM confirmed that there was no nursing documentation that the provider was notified for alterations in vital signs per hospital policy on Patient #2. Patient #3 Review of Patient #3’s medical record revealed on 05/05/2025 at 8:13 AM that the patient went into cardiac arrest and CPR was initiated. Patient #3 expired on 05/05/2025 at 8:42 AM. Review of nursing documentation failed to reveal documented evidence that the physician was notified by the nurse of an alteration in vital signs or that Patient #3 was deteriorating prior to the event on 05/05/2025 at 8:13 AM. In an interview on 05/08/2025 at 2:25 PM, S7CSM confirmed that there was no nursing documentation that the provider was notified for alterations in vital signs per hospital policy on Patient #3.”

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 48050 50453 Based on record review and interview, the facility failed to ensure medical records contained documentation of all procedures performed. The deficient practice is evidenced by failure to document the entire Code Blue event for 1 (#2) of 2 (#1, #2) reviewed records of a patient who experienced cardiopulmonary arrest. Findings: Review of hospital policy # 5026, titled, “Clinical Emergency Activations (Code Blue, Rapid Response, Stroke Activation, and Code AMI),” last revised 04/2024, revealed in part: “Policy Statement: III. Documentation of all Clinical Emergency Activations (Code Blue, Rapid Response, Stroke Activation, and Code AMI) events should be completed in the patient’s EHR. During EHR Down time, the nurse shall document interventions and outcomes in the EHR on the appropriate down time form electronically linked to this policy. Once completed and signed by members of the “Activation Team” the form will be scanned into the patient’s EHR. Procedure: I. It is the responsibility of the designated nursing staff to document each “Code Blue” occurrence, on the Code Blue Flow Sheet or in the electronic health record (EHR) under the Code Narrator/Navigator. Any paper document including the Code Blue Flow Sheet and EKG strips must be scanned into the EHR. If the Code Blue Flow Sheet is utilized instead of the Code Narrator in the EHR, the flowsheet must be transcribed into the Narrator upon completion of the event. The name and signature of the “Code Blue” Team Leader and nurse recorder is required.” Review of Patient #2’s medical record revealed a death summary that was completed by the physician on 05/03/2025 at 6:31 AM. The death summary for Patient #2 revealed in part: Patient admitted overnight for acute encephalopathy. Despite aggressive interventions, patient went into cardiac arrest at 5:44 AM on 05/03/2025. After 2 rounds of CPR and Epinephrine, family decided to cease interventions, so CPR was stopped. Time of death 5:49 AM. Further review of Patient #2’s medical record, failed to reveal documentation by nursing staff of the code blue. In an interview on 05/08/2025 at 11:56 AM, S7CSM confirmed there was no code blue nursing documentation in Patient #2’s medical record. S7CSM also confirmed that the only documentation that Patient #2 was a code blue was by the provider.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47397 Based on record review, and interview, the hospital failed to meet the requirements of the Condition of Participation in Patient Rights. The hospital failed to protect and promote each patient’s rights as evidenced by failure to ensure care in a safe setting. This deficient practice is evidenced by failure to ensure the emergency system used to call a code related to an elopement was available and functioning at all times potentially leading to injuries in Patient #4. This resulted in an Immediate Jeopardy Situation. S1CVP, S2SD, and S3RM were notified on 04/30/2025 at 2:05 PM. The hospital provided the following plan of removal for the Immediate jeopardy situation on 05/01/2025: “Date Notified of Immediate Jeopardy: 04/30/2025 Date Removal Plan Developed: 04/30/2025 Date Removal Plan Initiated: 04/30/2025 Date Removal Plan Fully Implemented or Planned to be Fully Implemented: All operators will be trained to answer the emergency call line (2-5000) immediately per Dr. Flight (Elopement) policy. Each person will be trained prior to their next shift and will not be allowed to work until trained. The entity’s removal plan must: Identify those who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Any PEC/CEC patient attempting to elope. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete or was taken. Immediately a plan was developed by the Chief Operating Officer, the Senior Director of Facilities, Nursing Leadership, and Quality/Patient Safety Leadership on 4/30/2025 to retrain all Operators immediately, and prior to starting their next shift. The senior director of facilities, who oversees the Operators, provided the training as described in the University Medical Center policy Emergency Management 15004 Dr. Flight (Elopement). The Chief Operating Officer is ultimately responsible for the implementation of the training. The Senior Director of Facilities, or his leadership designee, will monitor the training daily. 1. All operators will be trained to answer the emergency call line (2-5000), immediately. Each person will be trained before their next shift and will not be allowed to work until trained. 2. The emergency communication system will be evaluated to ensure proper functionality immediately. 3. The emergency communication system will be reprogrammed so that the 2-5000 emergency line does not roll into a queue. It will ring until answered. This re-programming will be completed immediately. Process/ System Involved: Maintain a safe environment by ensuring the safety of all patients who are PEC/CEC’d to prevent a potential delay in the communication of the emergency system for calling all codes and auditing compliance. Factors Involved: Equipment and Human Other: Individual error/potential delay in answering the 2-5000 line within the first two rings/calls. Potential emergency communications system programming error. Action(s) Taken/ Planned to be Taken: See above action plan above. The operator on shift will have verbal coaching. Date Action(s) Taken/ Planned to be Taken: 4/30/2025 at 5:30 pm Staff Education Plan: Who: Facilities Leadership When: IJ received at 2:00 PM; training started at 5:30 PM. What: In person- Red Huddle format to train on policy, procedure, and auditing of compliance with signatures of the staff who were educated. Mode of Education: daily huddle ( X ) Monitoring of Implemented Action(s): Monitoring of answering 2-5000; monitoring to ensure 2-5000 is no longer rolling into the queue. What will be monitored: Compliance of answering 2-5000; compliance of re-educating operators prior to the next shift. How long will it be monitored? For three months at 100% compliance; then via the incident reporting process. Who / What Committee will receive reports - Patient Safety & Quality Committee and the Quality sub committee of the hospital board, who will then report it to the full hospital board. What is the plan if the action does not meet expectations? If noncompliance is found, the disciplinary policy Health Human Resources will be followed titled HR 404 Code of Conduct. RCA: Yes.” On 05/01/2025 at 10:30 AM, the Immediate Jeopardy Situation was lifted but there was not enough evidence to determine sustainability of compliance for the Condition of Patient Rights to be cleared therefore the deficiencies remain at Condition levels (See findings in A-0144).”

“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: 47397 Based on record review, and interview, the hospital failed to ensure care in a safe setting as evidenced by failure to ensure the emergency system used to call a code related to an elopement was available and functioning at all times potentially leading to traumatic injuries in Patient #4. Findings: Review of hospital policy titled “Emergency Management” last revised 09/2023, revealed in part: “Policy Statement: It is the policy of University Medical Center Management Corporation, doing business as University Medical Center New Orleans (UMCNO) to take all appropriate measures necessary to prevent patients committed via a Formal Voluntary Admission (FVA), Physician’s Emergency Commitment (PEC), Coroner’s Emergency Commitment (CEC) or Judicial Commitment (JC) from leaving the hospital without authorization and to ensure the safe and timely return of patients who leave without authorization. Procedure, in part: Elopement from Hospital: When a patient elopes or cannot be found from a unit/department, the originating unit/department shall initiate the following step and place the patient on an elopement status: i. The staff member with the patient shall call for immediate assistance of co-workers by pressing the “Staff Assist” button on the inpatient bed control panel or verbally alert all staff in the area that the patient has left the assigned area. The staff member shall not physically attempt to detain the patient from leaving but can attempt to verbally redirect the patient. The staff member shall call Communications via 2-5000 and state the following: i. The unit the patient eloped from ii. The description of the patient including: iii. Race iv. Features (age, sex, height, weight, color of hair) V. Clothing vi. Direction of flight vii.Was the patient dangerous to himself/herself or others. Elopement Status Notification: When a patient elopes, the following departments will be notified and shall follow the procedure described below: i. Communications a. It is the responsibility of Communications to overhead page the following information: Calling Dr. Flight to (give originating location). ii. Hospital Public Safety a. It is the responsibility of Hospital Public Safety (HPS) to: Notify all HPS officers via radio; Disperse to areas surrounding the originating location as well as exits and entrances throughout the facility; Conduct a full search of the hospital premises; Follow HPS policy regarding notification of local law enforcement, if unable to locate the patient. All UMCNO Staff: a. It is the responsibility of all UMCNO staff to: Monitor all pathways and areas; Attempt to locate any patient that is outside of the patient care area and appears to be fleeing the building; If the patient is identified, call 2-5000 and provide the patient description and location; Do not attempt to engage unless you have completed the Crisis Prevention Intervention (CP|) training and can attempt to de-escalate or redirect patient verbally; and Do not attempt to physically restrain the patient.” Review of hospital document titled “Hospital / Licensed Provider Abuse/Neglect Initial Report” dated 4/15/2025 and documented “Final Report”, revealed in part: “Patient #4 was admitted on 04/02/2025 diagnosed with suicide attempt-drug ingestion and eloped from the Cardiology Unit, room ‘a’, on 04/06/2025 at 12:34 PM. Patient was a 1:1 with an assigned sitter and was CEC’d.” Following was the description of the incident: “Patient became verbally aggressive with S10PCT. Patient stated to the PCT that she could not keep him here. Sitter along with another PCT followed the patient encouraging him to return to his room. Charge nurse was notified. Staff members kept line of sight with the patient as he ran out of the Galvez Exit. Further review of the incident report revealed at 4:03 PM the patient presented to the ED via NOPD due to being found walking along the side of the road with facial bleeding. He was evaluated and treated for his injuries. The patient was PEC’d, assigned a sitter for 1:1 observation, and admitted to TICU for further evaluation and care. Injuries listed on report included open skull fracture, right pneumothorax, minimally displaced fracture of the right 1st, 2nd, 3rd , 5th, and 10th ribs, displaced fracture of the right mid clavicle, right scapular, fracture of the right transverse process of T6-T8, 2nd - 4th transverse process fractures of L2 - L4. Initial actions taken: Two staff members maintained a visual on the patient from his room to the Galvez exit. They were unable to return the patient to his room. NOPD and family were notified. Upon patient’s return to UMC, the patient was PEC’d, assigned a sitter for 1:1 observation, and admitted to TICU for further evaluation and care. Additionally, a RCA was immediately triggered.” Following was video observation: “Video revealed at 12:33 PM Patient #4 exited the room with the PCT and walked down the hallway. He attempted to open a door and was unsuccessful. He began to walk down the hallway. An additional PCT and a nurse presented and appeared to de-escalate but were unsuccessful. Patient #4 continued to walk down the hallway with the two PCTs following closely behind him. He exited the unit and attempted to open double doors leading to Tower ‘T’ but was unsuccessful. He turned around and took the elevator. The two PCTs remained with him. At 12:35 PM, he exited the elevator on the first floor. Patient #4 walked down the hallway and turned right toward street ‘G’. The patient began to run down the hallway toward street ‘G’ with the PCTs following him. He exited the street ‘G’ entrance. Patient #4 then ran out the door toward street ‘C’. Two PCTs and an Allied Officer exit and stop at the entrance, maintaining visual contact. Notifications: Police agency ‘N’ notified at 12:45 PM. Mother notified at 1:00 PM and physician notified at 1:06 PM. Further notifications in part: On 4/6/25 at 12:34 PM S12CN; 12:36 PM S13HS; and 1:09 PM S15ND. Comments: On 4/2/2025, patient presented to the ED via EMS with a potential intentional overdose. The patient was intubated and sedated. He was transferred to MICU. He had a history of Bipolar Disorder, anxiety, and panic disorder. On 4/4/2025 he was extubated and placed on a PEC at 11:09 AM. On 4/4/2025 Psychiatry completed their consult and noted once patient is medically cleared he would need psychiatric admission for suicide attempt. On 4/5/2025 psychiatry noted that patient understands he may need inpatient admission after he is medically stable. The patient denied suicide ideation. On 4/6/2025 patient was placed on a lower aquity level of care and assigned a sitter for 1:1 observation. On 4/6/2025 at 9:50 AM, S12CN noted that the patient stated, “he doesn’t want to go to jail because he has done horrible things.” S12CN was able to de-escalate and reassure the patient that they are here to help him. He appeared to be reassured. On 4/6/2025 at 10:40 AM, per physician order, patient was given Vistaril. On 4/6/2025 at 11:40 AM, psychiatry was at the bedside and noted the patient stated he has trouble focusing and concentrating. On 4/6/2025 at approximately 12:35 PM, as stated previously, he eloped. On 4/6/2025 at 4:02 PM patient presented to UMC via EMS. Agency “N” found the patient walking along the side the road with facial bleeding. He was evaluated and treated for his injuries. The patient was PEC’d, assigned a sitter for 1:1 observation, and admitted to TICU for further evaluation and care.” The report documented that upon investigation, it was determined that “staff reacted appropriately by maintaining a visual and following the patient closely. Once the patient exited the elevator, he began running toward the street ‘G’ entrance. Hospital Police Security (HPS) and the House Supervisor were notified. HPS notified agency ‘N’. The Quality Department will continue to investigate this matter in order to identify whether there are opportunities for improvement.” Investigation Results concluded: “We do not substantiate the allegation. We consider this our final report.” Review of S12CN’s Nursing Note Addendum for Patient #4, dated 4/6/2025 at 12:33 PM, revealed the following: “Patient #4 expressed to the sitter at the doorway if he could leave. She explained that he couldn’t and he pushed past her and went down the hall to the right looking for the elevator. S12CN attempted to call a doctor flight (Elopement) using the emergency number 2-5000. There was no answer after 2 calls. On the 3rd call the phone rolled over to the operator, S14OP, and he called a doctor flight (Elopement). The patient then circled back and went past his room and kept going with the sitter and PCT following him. As stated by the sitter, the patient got on the elevator to the first floor, he headed to the street ‘G’ entrance and took off running. S12CN met hospital police and the house supervisor at the entrance to the unit and told them that the sitter had informed that the patient was headed to the street ‘G’ entrance. Both left the unit to assess situation. 12:45 PM-Attempted to contact primary team. No answer. 12:55 PM-Attempted to contact primary team. No answer. 1:06 PM-Notified S16MD via secure chat that patient had eloped. 1:06 PM- S16MD responded via secure chat, ‘Wow, thanks for letting me know’.” Review of Patient #4’s trauma note dated 4/6/2025 at 4:02 PM (the elopement occured on 04/06/2025 at approximately 12:35 PM) revealed: “Patient #4 presented to emergency room found by agency ‘N’ walking along the side of the road with facial bleeding. Per report, Patient escaped from UMC behavioral health earlier today and was trying to jump in front of cars. Patient arrived with dried blood around avulsion to right forehead. Found to have right clavicle fracture, possible bowel contusion, right 2nd through 4th transverse process fractures. Right hemopneumothorax, pulmonary contusions, fracture of the right scapular, fractures of the right 2nd, 3rd, and left ribs and displaced fractures of right 5th through 10th ribs and right transverse processes of T6-T8. Right anterior frontal/temporal bone fracture extending into the skull base. Comminuted right lateral orbital wall fracture with proptosis. Right anterior frontal/temporal bone fracture extending the skull base with hemorrhage. Found to have skull fracture and intracranial findings.” Review of ED Trauma Activation Note dated 4/6/2025 at 4:29 PM (the elopement occured on 04/06/2025 at approximately 12:35 PM) revealed: “Patient #4 presented to the emergency department via EMS after being found on the streets with concerns for blunt trauma. EMS reports that patient was found near the hospital with obvious wound to his head, was confused and there was concern for blunt trauma. Presented with obvious head trauma and decreased mental status. Patient was found wandering around by police and noted to have obvious laceration to forehead, was brought to ED as trauma activation. Large right-sided scalp laceration with exposed skull. Patient agitated and requiring both chemical and physical restraints in order to facility necessary care and prevent self-harm and harm to others.” Review of Patient #4’s Neurosurgery consult note dated 4/6/2025 at 6:13 PM (the elopement occured on 04/06/2025 at approximately 12:35 PM) revealed: “Patient #4 presented to emergency department after jumping in front of a car. He escaped from UMC’s behavioral health unit earlier today.” Review of Psychiatry Consult for Patient #4 dated 04/06/2025 at 7:20 PM (the elopement occured on 04/06/2025 at approximately 12:35 PM) revealed: “adult with past psychiatric history of anxiety and bipolar disorder who presents after jumping in front of car. Patient most recently eloped from UMC while on a PEC. Per S12CN at 12:33 PM on 4/6/2025 she attempted to call a doctor flight (Elopement) using the emergency number 2-5000. There was no answer after 2 calls. On the 3rd call, the phone rolled over to the operator who called a doctor flight (Elopement).” During an interview on 04/30/2025 at 8:53 AM, S12CN stated she was Patient #4’s nurse on 04/06/2025 starting at 7:00 AM. He had come to unit ‘A’ sometime between 12:00 AM and 6:00 AM, probably around 2:00 AM. He was sent to unit ‘A’ because there was an open bed, not because he was a cardiology patient. S12CN reported Patient #4 would not speak at first then he started talking. He had locked himself in bathroom on the morning of the 6th and was asking to see psychiatry. He was CEC’d around 11:33 AM. He did not come out of his room until 12:33 PM. Patient #4 asked the sitter if he tried to leave would she stop him. The sitter told him he could not leave. S12CN then tried to call the emergency line and no one answered until the 3rd time when the call rolled over to the operator. By the time of the third call, he was already on the elevator. During an interview on 04/30/2025 at 10:31 AM, S2SD reported the staff should call dispatch and not the emergency number but the process was not yet implemented. During an interview on 05/01/2025 between 9:52 AM-10:02 AM, S17SG with agency ‘S’ stated the doctor flight (Elopement) call was late and she saw the patient in purple scrubs running towards the street ‘G’ entrance before the call came through. She could hear staff running behind the patient trying to stop him and knew it was an elopement. She reported she then got up from her chair near the door but he was already going out the door. She stated her walkie-talkie was not working that day and she had to use the phone to call it in to headquarters. She said as she was on the phone with them she could hear a lady in the background trying to get the doctor flight (Elopement) called. She said she had to decide if she was going to follow him or call it in but they had been trained not to chase the eloping patients because they could run out into traffic and get hit so she went to the house phone to call it in. In interview on 04/30/2025 at 11:45 AM, S3RM verified that the facility had just finished its root cause analysis and had not implimented any changes as a result of the investigation into the event. S3RM also verified their investigation revealed only one call was made to the operator. In interview on 04/30/2025 at 2:00 PM, S1CVP stated that there was no delay in the hospital’s response to the elopment. In interview on 05/01/2025 at 9:42 AM, S1CVP verified the facility did not have a record of calls missed by operator, and it was not possible to know how many calls were made if the nurse hung up after 2 rings because she did not want the call to go to the bottom of the operator call que. In interview on 04/30/2025 at 10:35 AM, S3RM verified that she had spoken to the security supervisor and he indicated that the walkie talkie was working properly, but that S17SG need to be educated on areas of the hospital where the walkie talkies do not work.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to recognize factors related to patient safety and quality improvement. This deficient practice was evidenced by failure to accurately document, fully investigate and identify safety issues related to the emergency call system following the elopement of suicidal Patient #4 that potentially led to traumatic injuries. Findings: Review of hospital document titled “Hospital / Licensed Provider Abuse/Neglect Initial Report” dated 4/15/2025 and documented “Final Report”, revealed in part: “Patient #4 was admitted on 04/02/2025 diagnosed with suicide attempt-drug ingestion and eloped from unit ‘A’, room ‘a’ on 04/06/2025 at 12:34 PM. Patient was a 1:1 with an assigned sitter and was CEC’d.” Following was the description of the incident: “Patient became verbally aggressive with S10PCT. Patient stated to the PCT that she could not keep him here. Sitter along with another PCT followed the patient encouraging him to return to his room. Charge nurse was notified. Staff members kept line of sight with the patient as he ran out of the Galvez Exit. On 04/06/2025 at 4:03 PM, the patient presented to the ED via NOPD due to being found walking along the side of the road with facial bleeding. He was evaluated and treated for his injuries. The patient was PEC’d, assigned a sitter for 1:1 observation, and admitted to TICU for further evaluation and care.” Injuries listed on report: “Open skull fracture, right pneumothorax, minimally displaced fracture of the right 1st, 2nd, 3rd , 5th, and 10th ribs, displaced fracture of the right mid clavicle, right scapular, fracture of the right transverse process of T6-T8, 2nd - 4th transverse process fractures of L2 - L4.” Following were the initial actions taken: “Two staff members maintained a visual on the patient from his room to the Galvez exit. They were unable to return the patient to his room. NOPD and family were notified. Upon patient’s return to UMC, the patient was PEC’d, assigned a sitter for 1:1 observation, and admitted to TICU for further evaluation and care. Additionally, a RCA was immediately triggered.” Following was video observation: “Video revealed at 12:33 PM the patient exited the room with the PCT and walked down the hallway. He attempted to open a door and was unsuccessful. He began to walk down the hallway. An additional PCT and a nurse presented and appeared to de-escalate but were unsuccessful. The patient continued to walk down the hallway with the two PCTs following closely behind him. He exited the unit and attempted to open double doors leading to Tower ‘T’ but was unsuccessful. He turned around and took the elevator. The two PCTs remained with him. At 12:35 PM, he exited the elevator on the first floor. He walked down the hallway and turned right toward street ‘G’. The patient began to run down the hallway toward street ‘G’ with the PCTs following him. He exited the street ‘G’ entrance. He then ran out the door toward street ‘C’. Two PCTs and an Allied Officer exit and stop at the entrance, maintaining visual contact.” Notifications: “Police agency ‘N’ notified at 12:45 PM. Mother notified at 1:00 PM and physician notified at 1:06 PM. Further notifications in part: On 4/6/25 at 12:34 PM S12CN; 12:36 PM S13HS; and 1:09 PM S15ND.” Comments: “On 4/2/2025, patient presented to the ED via EMS with a potential intentional overdose. The patient was intubated and sedated. He was transferred to MICU. He had a history of Bipolar Disorder, anxiety, and panic disorder. On 4/4/2025 he was extubated and placed on a PEC at 11:09 AM. On 4/4/2025 Psychiatry completed their consult and noted once patient is medically cleared he would need psychiatric admission for suicide attempt. On 4/5/2025 psychiatry noted that patient understands he may need inpatient admission after he is medically stable. The patient denied suicide ideation. On 4/6/2025 patient was stepped down and assigned a sitter for 1:1 observation. On 4/6/2025 at 9:50 AM, S12CN noted that the patient stated, “he doesn’t want to go to jail because he has done horrible things.” S12CN was able to de-escalate and reassure the patient that they are here to help him. He appeared to be reassured. On 4/6/2025 at 10:40 AM, per physician order, patient was given Vistaril. On 4/6/2025 at 11:40 AM, psychiatry was at the bedside and noted the patient stated he has trouble focusing and concentrating. On 4/6/2025 at approximately 12:35 PM, as stated previously, he eloped. On 4/6/2025 at 4:02 PM patient presented to UMC via EMS. Agency “N” found the patient walking along the side the road with facial bleeding. He was evaluated and treated for his injuries. The patient was PEC’d, assigned a sitter for 1:1 observation, and admitted to TICU for further evaluation and care.” Further review of the report revealed upon investigation, it was determined that “staff reacted appropriately by maintaining a visual and following the patient closely. Once the patient exited the elevator, he began running toward the street ‘G’ entrance. Hospital Police Security (HPS) and the House Supervisor were notified. HPS notified agency ‘N’. The Quality Department will continue to investigate this matter in order to identify whether there are opportunities for improvement.” Investigation Results revealed the following: “We do not substantiate the allegation. We consider this our final report.” Review of S12CN’s Nursing Note Addendum for Patient #4 , dated 4/6/2025 at 12:33 PM, revealed the following in part: “Patient #4 expressed to the sitter at the doorway if he could leave. She explained that he couldn’t and he pushed past her and went down the hall to the right looking for the elevator. S12CN attempted to call a doctor flight using the emergency number 2-5000. There was no answer after 2 calls. On the 3rd call the phone rolled over to the operator, S14OP, and he called a doctor flight. 12:45 PM-Attempted to contact primary team. No answer. 12:55 PM-Attempted to contact primary team. No answer.” During an interview on 04/30/2025 at 8:53 AM, S12CN stated in part: Patient #4 asked the sitter if he tried to leave would she stop him. The sitter told him he could not leave. S12CN then tried to call the emergency line and no one answered until the 3rd time when the call rolled over to the operator. By the time of the third call, he was already on the elevator. During an interview on 05/01/2025 between 9:52 AM-10:02 AM, S17SG with agency ‘S’ stated the doctor flight call was late and that she saw the patient in purple scrubs running towards the street ‘G’ entrance before the call came through. She could hear staff running behind the patient trying to stop him and knew it was an elopement. She reported she then got up from her chair near the door but he was already going out the door. She stated her walkie-talkie was not working that day and she had to use the phone to call it in to headquarters. She said as she was on the phone with them, she could hear a lady in the background trying to get the doctor flight called. She indicated she had to decide if she was going to follow him or call it in but they had been trained not to chase the eloping patients because they could run out into traffic and get hit so she went to the house phone to call it in. After review of the medical record, interviewing S12CN and S17SG, and review of “Hospital / Licensed Provider Abuse/Neglect Initial Report” dated 4/15/2025 and documented “Final Report”, it was determined that the report failed to reveal the nurse had documented in the medical record she had difficulty contacting comunications or the primary team. The report failed to reveal the security officer had a malfunctioning walkie-talkie system. The report failed to reveal the hospital investigated and identified safety issues related to the emergency call system following the elopement of suicidal Patient #4 that potentially led to his traumatic injuries. In interview on 04/30/2025 at 11:45 AM, S3RM verified that the facility had just finished its root cause analysis and had not implimented any changes as a result of the investigation into the event. S3RM also verified their investigation revealed only one call was made to the operator. In interview on 04/30/2025 at 2:00 PM, S1CVP stated that there was no delay in the hospital’s response to the elopment. In interview on 05/01/2025 at 9:42 AM, S1CVP verified the facility did not have a record of calls missed by operator, and it was not possible to know how many calls were made if the nurse hung up after 2 rings because she did not want the call to go to the bottom of the operator call que. In interview on 04/30/2025 at 10:35 AM, S3RM verified that she had spoken to the security supervisor and he indicated that the walkie talkie was working properly , but that S17SG need to be educated on areas of the hospital where the walkie talkies do not work.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 50453 Based on record review, video review, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. The hospital failed to protect and promote each patient’s rights as evidenced by: 1) failure to provide nursing assessments per hospital policy of a patient who was found deceased in restraints which resulted in an Immediate Jeopardy. On 01/29/2025 at 4:30 PM, S3RM and S5CVP were notified of the Immediate Jeopardy . On 01/30/2025 at 9:35 AM, S5CVP presented the plan for lifting the immediacy of the IJ situation and the plan included the following: - 1. All nursing staff including PCT’s will be educated prior to starting their next shift starting from 01/29/2025 until all nurses have received training or no later than 02/14/2025, when they will be removed from the schedule and not allowed to work until training has occurred. - 2. The entity’s removal plan must: Identify those who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Individuals in restraints. Immediately reviewed all current patients in restraints house-wide via observation and documentation audits and addressed any and all patient needs and ensured appropriate documentation. Immediately a plan was developed by Nursing Leadership and Quality/Patient Safety Leadership on 01/29/2025 to retrain all nursing staff including PCTs prior to starting their next shift. The nursing education and nursing informatics leaders overseen by the CNO provided the training on restraints and assessing, monitoring, and documenting every 2 hours including the assessment points as described in LCMC Health policy Nursing 002 Restraints and following physician’s orders. The Nursing Leadership team is responsible for implementing the training. Nursing leadership will monitor the training daily. A report from the EHR will be run to identify all patients in restraints. Once a shift the charge nurse will conduct observational/face to face audits to ensure restraint compliance and patient safety. A review of the required documentation per hospital policy will occur and feedback will be delivered to the nursing staff timely. If noncompliance is found, the disciplinary policy LCMC Health Human Resources titled HR 404 Code of Conduct will be followed. Investigating if EHR automation and reminders are feasible. - 3. Process/System involved: Maintain a safe environment by consistent application of the restraint policy including proper monitoring of patients in restraints and per physician orders and auditing of compliance. - 4. Action(s) Taken/Planned to be Taken: See above action plan above. The nurse caring for Patient #1 has been immediately placed on leave and will be terminated and reported to the State Board of Nursing. - 5. Date Action(s) Taken/Planned to be Taken: Initiated at 7:00 PM 01/29/2025-02/14/2025; Nurses who have not completed the training as of this date will be removed from the schedule until training obtained. - 6. Staff Education Plan: Nursing staff including PCTs will be trained in person during daily shift huddle by nursing leaders on restraints including patient assessment, monitoring, and documentation AND on implementing physician orders. Nursing staff will be retrained on the restraint module in the electronic education system and this will be completed by 02/14/2025. - 7. Who: Nursing Leaders and Educators. When: IJ received at 4:30 PM; Training started at 7:00 PM What: In person - (Red) Huddle format to train on policy, procedure, documentation and auditing of compliance of restraints and physician orders with signatures of the staff who were educated. - 8. Mode of Education: Daily huddle and CBL - 9. Monitoring of Implemented Action(s): Monitoring daily of restraint monitoring and documentation compliance and the education which includes daily monitoring of in person huddle and weekly of completion of CBL training. - 10. What will be monitored: Restraint documentation and compliance of following physician orders for vital signs; Once a shift the charge nurse will conduct observational/face to face audits to ensure restraint compliance and patient safety. - 11. How long will it be monitored: For three months at 100% compliance and monthly thereafter. - 12. Who/What Committee will receive reports: Patient Safety and Quality Committee and the Quality sub-committee of the UMC board who will then report it to the full UMC board. - 13. What is the plan if the action does not meet expectations: If noncompliance is found, the disciplinary policy LCMC Health Human Resources will be followed titled HR 404 Code of Conduct. The Immediacy was lifted on 01/30/2025 at 11:50 AM by the survey team. Noncompliance remains at the Condition Level. (See findings in A0144); and 2) failure to document patients were informed of their rights in 2 (#1, #3) of 3 (#1- #3) records reviewed for notification of patient rights (See findings in A0117); and 3) failure of the hospital to ensure a translator or interpreter was used to facilitate communication with hearing impaired patients in 1(#1) of 1 (#1) reviewed patients with a hearing impairment (See findings in A0131); and 4) failure of the hospital to witness Patient #1’s signature on a Formal Voluntary Admission form per hospital policy (See findings in A0131); and 5) failure to have documented evidence that a translator or interpreter was utilized to inform Patient #1, who was hearing impaired, of the reasons for the use of restraint/seclusion and to confirm his understanding before he was placed in restraints (See findings in A0154).”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 47397 Based on record reviews and interview, the hospital failed to meet the requirements of the Condition of Participation for Quality Assessment and Performance Improvement (QAPI) as evidenced by failing to ensure the Quality Assurance/Performance Improvement program measured, analyzed and tracked quality indicators to monitor the safety and effectiveness of services and quality of care. This deficient practice is evidenced by failure to accurately document, fully investigate and identify neglect in the death of Patient #1 who was found deceased while in restraints (See findings in A0286).”

“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: 50453 Based on record review and interview, the hospital failed to ensure each patient was notified of their rights. This deficient practice is evidenced by failing to document patients were informed of their rights in 2 (#1, #3) of 3 (#1- #3) records reviewed for notification of patient rights. Findings: Review of hospital policy # 04.01.010, titled “Patient Rights and Responsibilities,” effective date: 12/01/2024, revealed in part: “Purpose: To educate patients about their rights and responsibilities in their health care to engage them in the process and better meet their needs. Policy Statement: Whenever possible, this notice must be provided before providing or stopping care. All patients, inpatient or outpatient, must be informed of their rights as hospital patients. The patient’s rights should be provided and explained in a language or manner that the patient (or the patient’s representative) can understand. Definition: Patient Rights- 1. You have the right to receive considerate, respectful, and compassionate care in a safe setting regardless of your age, gender, race, national origin, religion, sexual orientation, gender identity, disabilities, handicap, diagnosis, or ability to pay or source of payment. 2. You have the right to receive care in a safe setting or environment free from all forms of abuse, neglect, harassment, or mistreatment. 7. You have the right to be told by your doctor about your health status, diagnosis and possible prognosis, the benefits and risks of treatment, and the expected outcome of treatment, including unexpected outcomes. You or your representative (as allowed by state law) have the right to give written informed consent before any non-emergency procedures begins. 9. You have the right to be free from restraints and seclusion in any form that is not medically required or that is used as a means of coercion, discipline, convenience, or retaliation by staff. In addition, any restrictions on your freedom must be kept to the minimum necessary to protect yourself or other people. 14. You have the right to communication that you can understand. The hospital will provide sign language and foreign language interpreters as needed as soon as possible and at no cost to you. Information given will be appropriate to your age, understanding, and language. If you have vision, speech, hearing, and/or other impairments, you will receive additional aids to ensure your care needs are met. 22. You have the right, if applicable and requested, to a statement of your legal rights and responsibilities under the Louisiana Mental Health Law and information about available advocacy services at the time that the Order of Authorization for Temporary Admission.” A review of policy # 0121, titled “Interpreter Services and Communication Services for Hearing-Impaired Patients or Their Companions,” last reviewed 03/2021, revealed in part: “Policy Statement: Provide appropriate communication assistance free of charge to assure that patients’ needs are met effectively. Ensure that all patients and companions are able to understand medical conditions and treatment options and to provide quality patient care through effective communication to and with its patients and companions. Provide appropriate auxiliary aids and services, including qualified interpreters, where such aids and services are necessary to ensure effective communication with patients and companions who are deaf or hard-of-hearing. Provide deaf and hard-of-hearing patients and companions with the full and equal enjoyment of the services, privileges, facilities, advantages, and accommodations of the hospital as required by the Americans with Disabilities Act (ADA). Definitions: Auxiliary Aids and Services: may include, but not be limited to the following: Qualified interpreters provided either on-site or through video remote interpreting services, Note takers, Real-time computer-aided transcription services, Written materials, Exchange of written notes, Telephone handset amplifiers, Assistive listening devices, Assistive listening systems, Telephones compatible with hearing aids, Closed caption decoders, Open and closed captioning, Video text displays, and Accessible electronic and information technology or other effective methods of making aurally delivered information available to individuals who are deaf or hard-of-hearing. Deaf- refers to persons who are deaf, late-deafened, or hard-of-hearing. The term “hard-of-hearing” includes persons who have a hearing deficit and who may or may not primarily use visual aids for communication and may or may not use auxiliary aides. Qualified Interpreter- means an interpreter who via VRI service or on-site, is able to interpret effectively, accurately, and impartially, both receptively and expressively, using any necessary specialized vocabulary. Qualified interpreters include, for example, sign language interpreters, oral translators, and cued-language translators. Procedure: UMCNO will provide to deaf or hard-of hearing patients and companions any appropriate auxiliary aids and services that are necessary for effective communication. Appropriate auxiliary aids and services will be provided as soon as practicable and reasonable without compromising patient care. UMCNO will advise patients and companions who require auxiliary aids or services that these will be made available as required by ADA. Hospital personnel are responsible for assessing/determining whether and what type(s) auxiliary aids should be used to effect effective communication with deaf patients and/or their companions. Obtaining A Sign Language Interpreter: Designated computers with “face time” capability are available via the Department of Communications. An in-person sign language interpreter is available 24 hours a day, seven (7) days a week. It is the responsibility of the Hospital personnel coordinating the use of the sign language interpreter to document the use of the sign language interpreter within the patient’s medical record. Patient #1 A review of Patient #1’s medical record revealed an admission date of 12/28/2024 with a diagnosis of trauma with an open fracture of the right side of the mandibular body. Patient #1’s medical record also revealed patient was developmentally disabled with a hearing impairment and did not have documentation of a Medical Power of Attorney. Further review of Patient #1’s medical record failed to reveal that the patient was informed of their patient rights. In an interview on 01/16/2025 at 2:25 PM, S3RM and S5CVP confirmed that there was no documented evidence that Patient #1 was notified of their patient rights. S3RM and S5CVP also confirmed that Patient #1 did not have documentation of a Medical Power of Attorney in their medical record. Patient #3 A review of Patient #3’s medical record revealed an admission date of 12/31/2024 with a diagnosis of penetrating trauma and suicidal attempt. Patient #3’s medical record also revealed that Patient #3 had a Medical Power of Attorney scanned into the chart on 01/01/2025. Further review of Patient #3’s medical record failed to reveal that Patient #3 and/or their Medical Power of Attorney were informed of their patient rights. In an interview on 01/28/2025 at 2:43 PM, S3RM and S5CVP confirmed that there was no documented evidence Patient #3 and/or their Medical Power of Attorney were notified of their patient rights.”

“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: 50453 Based on record review and interview, the hospital failed to ensure patients/representatives had the right to make informed decisions regarding care. This is evidenced by: 1) failure of the hospital to witness Patient #1’s signature on a Formal Voluntary Admission form per hospital policy; and 2) failure of the hospital to ensure a translator or interpreter was used to facilitate communication with hearing impaired patients in 1(#1) of 3 (#1- #3) reviewed patients with a hearing impairment. Findings: Review of policy # 5016, titled “Informed Consent,” last revised 04/2024, revealed in part: Definitions: Decision-Making Capacity- The ability to understand and appreciate the nature and consequences of a decision regarding medical treatment and the ability to reach and communicate and informed decision in the matter. Disclosure- In the context of Informed Consent, means communicating the risk, benefits, and alternatives to medical treatment. The act of making someone known. Informed Consent- The permission given by a patient or surrogate decision-maker, to perform a medical treatment or surgical procedure after he/she has been advised of and fully understands the risks, benefits and alternatives or hazards that could influence a reasonable person in deciding whether or not to consent, the patient or surrogate decision-maker needs information from the provider about the treatment or procedure, including risks, benefits, and alternatives, in a language or means of communication he/she understands. Procedure: 2. What is the Method for Documenting Informed Consent? e. Witness Requirement of Patient’s Signature: i. It is mandatory to have the signature of a witness who observed the patient sign the Informed Consent. ii. The signature of the witness attests to the validity of the signature of the patient (or Surrogate Decision Maker) and not to the quality, relevance, or thoroughness of the discussion that led to the consent. Witnessing a consent does not indicate or imply responsibility for the Informed Consent. iii. The Witness should sign, date and time in the presence of the patient, immediately after the patient (or Surrogate Decision Maker) signs the Informed Consent form. 8. What if there is an Issue Regarding Communication (ESL, hearing or sight impairment, or difficulty reading)? b. Obtaining consent from a patient (or Surrogate Decision Maker) who is hearing impaired shall be secured per Policy 0121 - Interpreter Services and Communication Services for Hearing-Impaired Patients or their companions. A review of policy # 0121, titled “Interpreter Services and Communication Services for Hearing-Impaired Patients or Their Companions,” last reviewed 03/2021, revealed in part: “Policy Statement: Provide appropriate communication assistance free of charge to assure that patients’ needs are met effectively. Ensure that all patients and companions are able to understand medical conditions and treatment options and to provide quality patient care through effective communication to and with its patients and companions. Provide appropriate auxiliary aids and services, including qualified interpreters, where such aids and services are necessary to ensure effective communication with patients and companions who are deaf or hard-of-hearing. Provide deaf and hard-of-hearing patients and companions with the full and equal enjoyment of the services, privileges, facilities, advantages, and accommodations of the hospital as required by the Americans with Disabilities Act (ADA). Definitions: Auxiliary Aids and Services: may include, but not be limited to the following: Qualified interpreters provided either on-site or through video remote interpreting services, Note takers, Real-time computer-aided transcription services, Written materials, Exchange of written notes, Telephone handset amplifiers, Assistive listening devices, Assistive listening systems, Telephones compatible with hearing aids, Closed caption decoders, Open and closed captioning, Video text displays, and Accessible electronic and information technology or other effective methods of making aurally delivered information available to individuals who are deaf or hard-of-hearing. Deaf- refers to persons who are deaf, late-deafened, or hard-of-hearing. The term “hard-of-hearing” includes persons who have a hearing deficit and who may or may not primarily use visual aids for communication and may or may not use auxiliary aides. Qualified Interpreter- means an interpreter who via VRI service or on-site, is able to interpret effectively, accurately, and impartially, both receptively and expressively, using any necessary specialized vocabulary. Qualified interpreters include, for example, sign language interpreters, oral translators, and cued-language translators. Procedure: UMCNO will provide to deaf or hard-of hearing patients and companions any appropriate auxiliary aids and services that are necessary for effective communication. Appropriate auxiliary aids and services will be provided as soon as practicable and reasonable without compromising patient care. UMCNO will advise patients and companions who require auxiliary aids or services that these will be made available as required by ADA. Hospital personnel are responsible for assessing/determining whether and what type(s) auxiliary aids should be used to effect effective communication with deaf patients and/or their companions. Obtaining A Sign Language Interpreter: Designated computers with “face time” capability are available via the Department of Communications. An in-person sign language interpreter is available 24 hours a day, seven (7) days a week. It is the responsibility of the Hospital personnel coordinating the use of the sign language interpreter to document the use of the sign language interpreter within the patient’s medical record. 1) Failure of the hospital to witness Patient #1’s signature on a Formal Voluntary Admission form per hospital policy. A review of Patient #1’s medical record revealed a Formal Voluntary Admission (FVA) form signed on 01/03/2025 at 2:27 PM by the patient and physician, and signed by S7RN as a witness to the FVA. In an interview on 01/16/2025 at 3:20 PM, S7RN confirmed that she was the witness for the Formal Voluntary Admission (FVA) form signed by Patient #1. When S7RN was asked if Patient #1 understood what the FVA was when he signed it, S7RN stated she assumed Patient #1 was able to understand it since he signed it. S7RN then stated she was not present in the room when the physician had Patient #1 sign the FVA form, stating she was standing outside the room. S7RN further confirmed that she did not visualized the patient sign the form. In an interview on 01/16/2025 at 2:45 PM, S3RM and S8ND verified that S7RN stated she was not present in Patient #1’s room when he signed his FVA form. S3RM and S8ND also confirmed that S7RN stated she signed her name as a witness on the form although she did not witness Patient #1’s signature. In an interview on 01/27/2025 at 3:14 PM, S3RM and S5CVP confirmed that the only time an interpreter service was used to assist Patient #1 was on 01/02/2025 at 6:37 PM. S3RM and S5CVP further confirmed that there is no further documentation by hospital staff that an interpreter was provided to Patient #1. 2) Failure of the hospital to ensure a translator or interpreter was used to facilitate communication with hearing impaired patients in 1(#1) of 3 (#1- #3) reviewed patients with a hearing impairment. A review of Patient #1’s medical record revealed an admission date of 12/28/2024 with a diagnosis of Facial Trauma with an Open Fracture of the right side of the Mandibular Body. A review of Psychiatry Consult note dated 12/31/2024 revealed Patient #1 had a past history of Intellectual Disability. Describes Patient #1’s speech as difficult to understand due to facial swelling and patient’s difficulty hearing/understanding questioning. Collateral obtained revealing Patient #1 wears a hearing aid, which has been lost and he knows sign language and how to read lips. Social History: Source of Income: on disability. Special Ed: yes. Assessment: Intellectual Disability. Patient with history of “bipolar schizophrenia” however, suspect intellectual disability to be the main driver in patient’s similar presentations. A review of Psychiatry Progress note dated 01/03/2025 at 7:48 AM revealed Interval events: Per nursing note, patient unable to be redirected last night despite attempts at verbal de-escalation. Soft restraints ordered for 1 day. Patient #1 is hard of hearing and has trouble communicating. Further review of the plan for Patient #1 revealed -Please allow patient to have dry erase board and marker in his room to assist with communication. Further review of Patient #1’s medical record failed to reveal documentation that the hospital used an interpreter/translator to assist with Patient #1’s understanding and agreement of his patient care during his admission. In an interview on 01/16/2025 at 3:20 PM, S7RN confirmed that she was the primary nurse for Patient #1 on day shift on 01/02/2025 and 01/03/2025. S7RN stated Patient #1 was confused at times and had a developmental delay. S7RN stated the patient knew some sign language. S7RN confirmed that staff would yell in Patient #1’s ear to communicate and that the patient could read lips. S7RN stated that she attempted to use the interpreter ipad once to communicate with Patient #1. S7RN confirmed that she did not document the use of the ipad because the interpreter would say Patient #1 wasn’t making sense, and that he wasn’t using proper ASL. S7RN confirmed this was the only time she attempted to use an interpreter service while providing care for Patient #1. In an interview on 01/16/2025 at 2:17 PM, S3RM and S5CVP confirmed the use of an interpreter service was not documented as being used on Patient #1 by a provider.”

“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: 50453 Based on record review, video review, and interview the hospital failed to ensure the patients received care in a safe setting. This deficient practice is evidenced by failing to provide nursing assessment of a patient in restraints per hospital policy. Findings: Review of hospital policy # 04.01.010, titled “Patient Rights and Responsibilities,” effective 12/01/2024, revealed in part: “ Definition: Patient Rights- 1. You have the right to receive considerate, respectful, and compassionate care in a safe setting regardless of your age, gender, race, national origin, religion, sexual orientation, gender identity, disabilities, handicap, diagnosis, or ability to pay or source of payment. 2. You have the right to receive care in a safe setting or environment free from all forms of abuse, neglect, harassment, or mistreatment. 9. You have the right to be free from restraints and seclusion in any form that is not medically required or that is used as a means of coercion, discipline, convenience, or retaliation by staff. In addition, any restrictions on your freedom must be kept to the minimum necessary to protect yourself or other people.” Review of hospital policy # Nursing 002, titled “Restraints and Seclusion,” effective 08/01/2024, revealed in part: “Definitions: Designated Staff: Describes staff roles involved in the application or monitoring or restraint or seclusion other than registered nurse (RN) but not limited to licensed practical nurse, certified nurse assistant, clinical nurse extern, clinical technician, public safety officer. Designated Staff are trained in de-escalation techniques, CPR/first aid, and restraint safety and may aid in the monitoring of patients placed in restraint or seclusion including providing fluids, nutrition, oral care, skin care, toileting, positioning, and range of motion. Responsibility: C. Nurses shall: 7. Perform ongoing assessments including: i. Need for the continuation of restraint or seclusion. ii. Re-evaluation of the patient’s response to the restraint or seclusion episode. 8. Educate the patient, as applicable, about behaviors leading to the initiation and discontinuation of restraint or seclusion. Procedure: 4. Monitoring and Interventions: d. Non-Violent/Non-self-destructive Restraints will be assessed, monitored, and documented in the EMR every two (2) hours: i. The nurse’s assessment must include, but is not limited to: 1. Level of distress/Patient behavior/Visual check 2. Circulation 3. Range of motion 4. Fluids 5. Food/meal 6. Elimination 7. Respirations 8. Assessment and clinical justification for continued use of restraints ii. Vital signs per physician order. 5. Documentation: a. All required documentation is to be completed and documented in the EMR immediately following patient stabilization. b. Rationale for ongoing restraint usage must be documented. 7. Discontinuation of Restraint or Seclusion: a. The need for restraint or seclusion must be evaluated with every assessment/reassessment. b. Restraint or seclusion are discontinued as soon as safely possible and when the reason for implementation is resolved (i.e. when the patient’s behavior no longer threatens the physical safety of the patient, staff, or others).” Review of policy #5015, titled “Patient Screening, Assessment, Reassessment and Plan of Care,” last revised 07/2024, revealed in part: “Definitions: Assessment: an objective evaluation of appraisal of an individual’s health status, including acute and chronic conditions. The assessment gathers information through collection of data, observation, and physical examination. Reassessment: Ongoing data collection, which begins on initial assessment, comparing the most recent data with the data collected at earlier assessments. Procedure: 1. Initial Screening and/or Assessment: b. The extent of the screening, assessment, and reassessment is based on the patient’s current condition, age, and treatment setting. 2. Reassessments for Inpatients: a. Each patient is reassessed as necessary based on their identified problems, plan for care, changes in condition, changes in care setting, or as clinically relevant. i. Reassessment may also be based on the patient’s diagnosis; desire for care, treatment, and services; response to previous care, treatment, and services; discharge planning needs; and/or setting requirements. b. Specific assessments related to patient diagnosis or procedure are completed per licensed practitioner order or as clinically relevant. c. Reconciliation of lines, drains, and airways is performed by tracing lines, drains, and airways from the patient to the point of origin at the following times: i. Every change in caregiver. ii. Change in care setting. iii. Change in level of care. iv. Before connecting to or reconnecting any device or infusion. d. .Ongoing assessment is the responsibility of direct caregivers and consultants and may include: i. Current physical, social, and psychological status of the patient. ii. Evaluation of diagnoses considering input from patient/family, consultants, and results of diagnostic testing. iii. Patient reports and physiologic responses related to medical, nursing, and other interventions.” A review of Patient #1’s medical record revealed an admission date of 12/28/2024 with a diagnosis of trauma with an open fracture of the right side of the mandibular body. Patient #1’s medical record also revealed the patient was developmentally disabled and had a hearing impairment. On 12/29/2024 at 5:38 AM Patient #1 was placed in wrist restraints and a 1:1 sitter was ordered to bedside to monitor the patient. On 01/03/2025 Patient #1 was taken to surgery and an open reduction with internal fixation of the mandibular fracture and extraction of tooth #30 was performed. Vital signs were obtained prior to leaving Post Anesthesia Care Unit [PACU] at 8:57 PM on 01/03/2025 and returning to the floor. The next set of vital signs were documented at 11:00 PM on 01/03/2025. Further review of Patient #1’s medical record failed to reveal documented vital signs after 11:00 PM on 01/03/2025. Nursing documentation revealed the following nursing notes: On 01/03/2025 at 9:45 PM - S11RN documented she attempted to take Patient #1 out of restraints and patient started pulling at dressing on his face/head and we were not able to redirect. On 01/03/2025 at 10:10 PM - S11RN called provider to obtain order to resume oral medications. 01/03/2025 at 11:00 PM - S11RN documented restraint monitoring/assessment performed. 01/03/2025 at 11:09 PM - S11RN administered Oxycodone (Roxicodone) 10mg oral solution for pain to Patient #1. 01/03/2025 at 11:54 PM - S11RN administered Olanzapine (Zyprexa) 10mg IM for agitation to Patient #1. 01/04/2025 at 1:00 AM - S11RN documented restraint monitoring/assessment performed. 01/04/2025 at 3:00 AM - S11RN documented restraint monitoring/assessment performed. 01/04/2025 at 5:00 AM - S11RN documented restraint monitoring/assessment performed. 01/04/2025 at 5:51 AM - S11RN documented a nurse note stating phlebotomist in patient’s room drawing labs and when S11RN approached the patient to hang his antibiotic, noticed that patient was not breathing. Immediately chest compressions were initiated and a code blue was called. 01/04/2025 at 6:17 AM - TOD [time of death] called by physician. On 01/29/2025 from 11:30 AM - 2:30 PM, a review of video footage navigated by S2DPS, S3RM, and S5CVP of hallway outside room a on 01/03/2025 at 11:56 PM through 01/04/2025 at 5:57 AM revealed the following: 01/03/2024 11:58 PM - S11RN enters room a. 11:59 PM - S11RN exits room a. 01/04/2025 12:28 AM - S11RN enters room a. 12:29 AM - S11RN exits room a. 1:04 AM - S12PS enters room a, and relieves previous sitter at bedside. 2:29 AM - PCT enters room a. 3:30 AM - PCT exits room a. 3:41 AM - PCT enters, then exits room a. 4:10 AM - S12PS exits room a, and goes back in room a. 4:34 AM - S11RN enters room a. 4:35 AM - S11RN exits room a. 5:39 AM - PCT enters room a. 5:43 AM - S17PHL enters room a. 5:46 AM - PCT exits room a with soiled linen bag and trash bag. 5:50 AM - S11RN enters room a. 5:51:43 AM - S12PS exits room a to get Phillips vital sign machine and goes back in room. 5:53 AM - S11RN exits room a and activates code. 5:54 AM - S11RN brings crash cart to room a. Code team arriving room a. 5:57 AM - Video footage ends. Review of video failed to reveal entry into the room a by S11RN for the assessments, as required by hospital policy and documented in her notes, between 12:29 AM and 4:34 AM. Further review of video failed to reveal a PCT or nurse entering room a to obtain vital signs on 01/04/2025 between 12:29 AM and 4:34 AM per provider order. In an interview on 01/28/2025 at 12:26 PM, S3RM and S5CVP confirmed that there was no documented re-evaluations of the effectiveness of the medications administered by S11RN on 01/03/2025 at 11:09 PM and 11:53 PM. In an interview on 01/29/2025 at 2:30 PM, S3RM confirmed that the documented monitoring and assessment of restraints by S11RN in the medical record at 1:00AM, 3:00 AM and 5:00 AM did not match the video evidence. In an interview on 01/29/2025 at 2:34 PM, S2DPS and S3RM confirmed that S11RN did not perform restraint monitoring and assessment every 2 hours per hospital policy. At this time S2DPS, S3RM, and S5CVP also confirmed that based on the video review, S11RN was in Patient #1’s room a total of 3 minutes from 01/03/2025 at 11:58 PM until finding the patient unresponsive and initiating a code on 01/04/2025 at 5:53 AM. In an interview on 01/30/2025 at 11:25 AM, S11RN confirmed that she was the primary nurse for Patient #1 on the night of 01/03/2025 through the morning of 01/04/2025. Per S11RN around midnight, Patient #1 started settling down. S11RN stated at this time she attempted to release the restraint but Patient #1 immediately attempted to pull at facial dressings. S11RN stated she could hear the patient talking at the nurse station which was located directly across the hallway from room a. S11RN stated she would ask the sitter from the nurse station what the patient was doing and was told the patient was talking in his sleep. S11RN stated that the PCT told her around 4:00 AM that they would get vital signs on Patient #1 in a little while when they change the patient linens since he was sleeping. S11RN also stated when she went in Patient #1’s room around 4:00 AM (4:34 AM per the video) to check on the patient, she put her hand on his chest to count his respirations and the patient startled when she touched him. When asked why she documented performing assessments during times the video revealed she did not go into the room, S11RN explained she entered her documentation at the end of the shift and, she was so busy on the unit as charge nurse, that she thought she had been in the room at the times she was supposed to check on Patient #1.”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 50453 Based on record reviews and interview, the hospital failed to ensure patients in the hospital were informed of their right to be free from physical or mental abuse, and corporal punishment and to be free from restraint or seclusion of any form imposed as a means of coercion, discipline, convenience, or retaliation by staff. This deficient practice is evidenced by failing to have documented evidence that a translator or interpreter was utilized to inform Patient #1, who was hearing impaired, of the reasons for the use of restraint/seclusion and to confirm his understanding before he was placed in restraints. Findings: Review of hospital policy # 04.01.010, titled “Patient Rights and Responsibilities,” effective date: 12/01/2024, revealed in part: “Purpose: To educate patients about their rights and responsibilities in their health care to engage them in the process and better meet their needs. Definition: Patient Rights- 1. You have the right to receive considerate, respectful, and compassionate care in a safe setting regardless of your age, gender, race, national origin, religion, sexual orientation, gender identity, disabilities, handicap, diagnosis, or ability to pay or source of payment. 9. You have the right to be free from restraints and seclusion in any form that is not medically required or that is used as a means of coercion, discipline, convenience, or retaliation by staff. In addition, any restrictions on your freedom must be kept to the minimum necessary to protect yourself or other people. 14. You have the right to communication that you can understand. The hospital will provide sign language and foreign language interpreters as needed as soon as possible and at no cost to you. Information given will be appropriate to your age, understanding, and language. If you have vision, speech, hearing, and/or other impairments, you will receive additional aids to ensure your care needs are met.” Review of hospital policy # Nursing 002, titled “Restraints and Seclusion,” effective date: 08/01/2024, revealed in part: “Policy Statement: A. Restraints and/or seclusion are only used when they are clinically justified, when less restrictive interventions are ineffective, and with the least restrictive means of restraint or seclusion to ensure patient safety. B. When restraints and/or seclusion are used, the patient’s rights, dignity, and well-being shall be preserved. Restraints and seclusion are not to be used as a means of coercion, discipline, corporal punishment, convenience, or retaliation. Discontinuation of restraint and seclusion must occur as soon as possible, based on an individualized patient assessment and reevaluation, regardless of the scheduled expiration of the order. D. Documentation in the EMR must justify each type of restraint or seclusion used, the patient’s response, plan of care, observation, and assessment. Responsibility: C. Nurses shall: 7. Perform ongoing assessments including: i. Need for the continuation of restraint or seclusion. ii. Re-evaluation of the patient’s response to the restraint or seclusion episode. 8. Educate the patient, as applicable, about behaviors leading to the initiation and discontinuation of restraint or seclusion. Procedure: 2. Initiation or Restraint and/or Seclusion: c. Restraint Application: i. Explain to the patient the reason for restraint, the criteria for discontinuation, and the process for frequent reassessments to assure safety and discontinuation of restraints as soon as possible. 4. Monitoring and Interventions: b. A means of communication with staff should always be provided to the patient. 5. Documentation: a. All required documentation is to be completed and documented in the EMR immediately following patient stabilization. b. Rationale for ongoing restraint usage must be documented. 7. Discontinuation of Restraint or Seclusion: a. The need for restraint or seclusion must be evaluated with every assessment/reassessment. b. Restraint or seclusion are discontinued as soon as safely possible and when the reason for implementation is resolved (i.e. when the patient’s behavior no longer threatens the physical safety of the patient, staff, or others).” Patient #1 A review of Patient #1’s medical record revealed an admission date of 12/28/2024 with a diagnosis of trauma with an open fracture of the right side of the mandibular body. Patient #1’s medical record also revealed patient was developmentally disabled and had a hearing impairment. On 12/29/2024 at 5:38 AM, Patient #1 was placed in 2 point soft wrist restraints. Nursing documentation describes Patient #1 at this time as restless, agitated, and confused. Education documented as complete with a note stating the following: Yes - patient with AMS, sedated, and/or no family present. Patient #1’s response to the restraint education stated no evidence of learning. Discontinuation criteria for restraints was documented as absence of behavior that requires the restraint. Patient #1 remained in wrist restraints from 12/29/2024 at 5:38 AM until the restraints were discontinued on 01/02/2025 at 12:00 PM with a RN Assessment/Clinical Justification stating the patient no longer meets criteria - restraints removed. On 01/02/2025 at 11:43 PM Patient #1 was placed back in restraints. Nursing documentation describes Patient #1 at this time as restless and agitated. Education documented as complete with a note stating the following: Yes - patient with AMS, sedated, and/or no family present. Patient #1’s response to the restraint education stated no evidence of learning and needs reinforcement. Discontinuation criteria for restraints was documented as absence of behavior that requires the restraint. Review of Patient #1’s medical record revealed that the patient remained in restraints from 01/02/2025 at 11:43 PM until the patient was found without a pulse on 01/04/2025 at 5:53 AM and CPR was initiated. Patient #1’s medical record failed to reveal documentation that a translator or interpreter was used to inform Patient #1 about the reasons for the use of the restraints or that he expressed understanding prior to restraint placement. In an interview on 01/27/2025 at 3:14 PM, S3RM and S5CVP confirmed that the only time an interpreter service was used on Patient #1 was on 01/02/2025 at 6:37 PM. S3RM and S5CVP confirmed at this time that there is no documentation by hospital staff that an interpreter was provided to Patient #1 prior to restraint application. In an interview on 01/27/2025 at 3:40 PM, S3RM and S5CVP were unable to confirm if Patient #1 expressed understanding of why the restraints were being used.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to recognize factors related to patient safety and quality improvement. This deficient practice was evidenced by failure to accurately document, fully investigate and identify neglect in the death of Patient #1 who was found deceased while in restraints. Findings: Review of the Hospital / Licensed Provider Abuse/ Neglect Initial Report submitted on 01/05/2025 and finalized on 01/10/2025 revealed an anonymous report involving a patient death that occurred on 01/04/2025 at 5:51 AM. The document revealed the following: Patient #1, identified as the victim, was in restraints following an open reduction internal fixation mandibular fracture surgery and extraction of tooth 01/03/2025. The report indicated Patient #1 was placed under an FVA on 01/03/2025 at 2:27 PM and one-to-one sitter was at the bedside. Placed in restraints due to agitation and pulling at lines at10:44 PM. Spiked a temperature of 100.4 at 11:00 PM. Administered oxycodone 5mg/5ml orally at 11:09 PM. Administered Zyprexa 10mg IM at 11:54 PM. CT scan was ordered to assess for reduction and cancelled by S11RN because the patient was in restraints, and would need to be accompanied to CT. CT was not completed after medication administration and Patient #1 was calm. S11RN discovered Patient #1 unresponsive at 5:51 AM on 01/04/2025, while hanging antibiotics, called Code Blue, initiated ACLS. Time of death was called at 6:17 AM by S18MD. Continued review of the Hospital / Licensed Provider Abuse/ Neglect Initial Report submitted finalized on 01/10/2025 revealed the following documentation: Video Review information documented on report included: No Video surveillance at incident site. No video in patient rooms. What was revealed on video? Answer: N/A Names/titles/positions of ALL video reviewers: N/A Incident details included the following: Name of the first employee aware of allegation and how they became aware of allegation:-Answer: The alleged allegation was submitted anonymously. Comments-Answer: A full investigation had been completed and included interviews and statements from staff involved. Patient #1 arrived to the ED on 12/28/2024 as a trauma activation due to blunt force trauma to the face with altered mental status. OMFS was consulted due to initial findings of multiple facial fractures. Investigation revealed Patient #1 was placed in non-violent restraints for safety measures in the ED, with a sitter at the bedside, due to altered mental status and attempting to pull at lines and dressings. Inpatient consult to psychiatry was ordered for evaluation of mental status on 12/31/24. It was noted throughout his admission that re-direction was unsuccessful due to Patient #1’s continued confusion and lack of safety awareness. On 01/03/24 at 6:57 PM, following an open reduction internal fixation mandibular fracture and dental extraction, Patient #1 met criteria for discharge from the PACU. Discharge criteria included stable vital signs and Aldrete score between 8-10. Patient #1 had arch bars in place and was not wired shut. On 01/03/25 at 9:45 PM, S11RN attempted to take the patient out of restraints; however, patient started pulling at the dressing on his face/head and was not able to be redirected. At 11:00 PM, it was noted the head of the bed was elevated to 45 degrees. S11RN documented restraint monitoring every two hours, per protocol, including visual check, circulation, range of motion, fluids, food/meal, elimination, respiration and clinical justification for continued restraints until 5:00 AM on 01/04/25. At 1:00 AM and 3:00 AM, it was noted by S11RN the patient continued to pull at lines and dressing with altered mental status with no signs of injury and normal respirations with circulation throughout the shift. A sitter remained at bedside for safety observation with documentation at least every 30 minutes, including the patient location, activity and behavior. At 5:51 AM, per S11RN, S17PHL was in Patient #1’s room to draw routine lab orders. S11RN approached the patient to start his IV antibiotics. Patient #1 was noted to be unresponsive. S11RN stated she immediately started chest compressions and called a “Code Blue.” The “Code Blue” team arrived and ACLS continued until the time of death called at 6:17 AM. Per the anesthesiology note, the intubation during the Code Blue was successful and only one attempt was necessary, with no other remarkable findings. After thorough review of Patient #1’s medical record, including physician orders, nursing assessments and documentation, including sitter observations, the hospital did not substantiate the allegation of neglect. The hospital stated on the report that this was the final report and the allegation was not substantiated. The report failed to reveal Patient #1 was diagnosed with Intellectual Disability and hearing impairment requiring the use of hearing aid and sign language as stated in Psychiatric Consult dated 12/31/2024 and Psychiatric Progress notes dated 01/01/2025, 1/02/2025, and 01/03/2024. The report failed to reveal the results of the available video surveillance in the hallway outside of room a. (“No Video surveillance at incident site. No video in patient rooms”). Review of video showing the hallway outside of room a failed to reveal entry into the room a by S11RN for the assessments, as required by hospital policy and documented in her notes, between 12:29 AM and 4:34 AM. Further review of video failed to reveal a PCT or nurse entering room ‘a’ to obtain vital signs on 01/04/2025 between 12:29 AM and 4:34 AM per provider order. In an interview on 01/29/2025 at 2:34 PM, S2DPS and S3RM confirmed that S11RN did not perform restraint monitoring and assessment every 2 hours per hospital policy. At this time S2DPS, S3RM, and S5CVP also confirmed that based on the video review, S11RN was in Patient #1’s room a total of 3 minutes from 01/03/2025 at 11:58 PM until finding the patient unresponsive and initiating a code on 01/04/2025 at 5:53 AM. In an interview on 01/29/2025 at 2:30 PM, S3RM confirmed that the documented monitoring and assessment of restraints by S11RN in the medical record at 1:00AM, 3:00 AM and 5:00 AM did not match the video evidence. The report failed to reveal S11RN did not documented requisite re-evaluations of the effectiveness of the medications administered on 01/03/2025 at 11:09 PM and 11:53 PM. In an interview on 01/28/2025 at 12:26 PM, S3RM and S5CVP confirmed that there was no documented re-evaluations of the effectiveness of the medications administered by S11RN on 01/03/2025 at 11:09 PM and 11:53 PM. The report failed to reveal that S17PHL began chest compressions. The report stated S11RN “immediately started chest compressions”. In an interview on 01/30/2025 at 12:35 PM, S17PHL confirmed she went into Patient #1’s room on 01/04/2025 between 5:00 AM and 6:00 AM to draw labs. S17PHL stated Patient #1 was on his back in restraints and did not respond to his name when called. S17PHL proceeded to draw assuming he was asleep. While she was drawing the 2nd tube, S11RN walked in and turned the lights on, called Patient #1’s name and he did not respond. S11RN asked S17PHL if Patient #1 was breathing and S17PHL touched his chest and put her hand over his nose and said “I don’t think so”. S11RN instructed S17PHL to start compressions while S11RN left to get the code cart. The report failed to reveal the CT order was written as a STAT order. Furthermore, the report did not include evidence that the STAT CT had been rescheduled or discontinued. In an interview on 01/30/2025 at 11:52 AM, S3RM confirmed that the stat CT order was never modified or discontinued from the original order placed on 01/03/2025 at 7:00 PM until it was automatically discontinued upon discharge from the system. 50453”

“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: 50453 Based on record review and interviews, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by: 1) failure of the staff to document 1:1 continuous visual observations for 1 (#1) of 3 (#1-#3) patient medical records reviewed; 2) failure of the nursing staff to document vital signs as ordered by the physician for 1 (#1) of 3 (#1-#3) patient medical records reviewed; and 3) failure of the nursing staff to complete a stat CT as ordered by the physician for 1 (#1) of 3 (#1-#3) patient medical records reviewed. Findings: Review of hospital policy #5003, titled “Patient Care Technician Safety Assistant Policy,” last revised 02/2022, revealed in part: “The assigned Patient Care Technician Safety Assistant (PCTSA) will always maintain visual contact of the patient to prevent harm with unpredictable behavior and intervene immediately when necessary. Documentation: The PCTSA will document patient observations (location, activity, behavior) in the “Daily Cares” section in the electronic medical record (EMR). i. Documentation will be determined by the patient’s physician and/or the Registered Nurse. ii. The registered nurse will document patient observations every 2 hours in the EMR (Daily Cares, Observation Monitoring and/or Shift Assessment). a. Document initiation, changes and stopping of observation. b. In Daily Cares, document Safe Environment, Communication Need, Comfort and Environment Interventions and Entertainment/Diversion activities. c. Note the patient’s behavior, mental status, appetite, energy levels and sleep patterns. d. Document refusal to accept treatments which are life sustaining or for which refusal may cause danger to health status or recovery. e. Describe progress or lack of progress in resolving problems identified in the plan of care. f. Document and report attempts by the patient to harm him/herself or others.” 1) Failure of the staff to document 1:1 continuous visual observations for 1 (#1) of 3 (#1-#3) patient medical records reviewed. A review of Patient #1’s medical record revealed an admission date of 12/28/2024. On 12/29/2024 Patient #1 was placed in 2 point soft wrist restraints and had a 1:1 sitter ordered for bedside. Further review of Patient #1’s medical record failed to reveal continuous visual observation documentation by a sitter or staff member on 01/01/2025 from 2:30 PM to 7:00 PM. In an interview on 01/27/2025 at 11:58 AM, S8ND confirmed that a patient with an order for 1:1 sitter for continuous observations are documented on every 30 minutes in the medical record. S8ND also confirmed that the 1:1 sitter documentation includes the location, activity, and behavior of the patient being observed. In an interview on 01/28/2025 at 11:00 AM, S3RM and S5CVP confirmed that Patient #1 did not have continuous visual observations documented on 01/01/2025 from 2:30 PM to 7:00 PM. S3RM and S5CVP also confirmed that during this time, Patient #1 had orders for a sitter at bedside. 2) Failure of the nursing staff to document vital signs as ordered by the physician for 1 (#1) of 3 (#1-#3) patient medical records reviewed. A review of Patient #1’s medical record revealed an order for vital signs every 4 hours. A review of Patient #1’s documented vital signs revealed the following: On 01/02/2025 vital signs were obtained at the following times: 4:00 AM, 1:00 PM, and 7:32 PM. At 11:00 PM on 01/02/2025 the vital signs were documented as patient refused. The next set of vital signs were obtained on 01/03/2025 at 4:30 AM. On 01/03/2025 Patient #1 went to the operating room for an Open Reduction Internal Fixation Mandibular Fracture and Extraction of Tooth #30. Vital signs were obtained prior to leaving PACU at 8:57 PM on 01/03/2025. The next set of vital signs were documented at 11:00 PM on 01/03/2025. Further review of Patient #1’s medical record failed to reveal documented vital signs after 11:00 PM on 01/03/2025. Patient #1’s medical record failed to reveal documentation for not completing the order for vital signs every 4 hours. There was also no order from the provider to discontinue obtaining vital signs every 4 hours. Further review failed to reveal that vital signs were obtained every 4 hours as per provider order. In an interview on 01/27/2025 at 1:03 PM, S3RM and S8ND confirmed that vital signs were not obtained on Patient #1 as per provider order. S3RM and S8ND also confirmed there was no provider notification about why the vital signs were not obtained as per provider order. In an interview on 01/29/2025 at 11:23 AM, S5CVP confirmed there is no documentation from the nurse for Patient #1 regarding not obtaining vital signs at 3:00 AM on 01/04/2025. S5CVP also stated that the nurse told her she used her judgement since the patient had previously been agitated. 3) Failure of the nursing staff to complete a stat CT as ordered by the physician for 1 (#1) of 3 (#1-#3) patient medical records reviewed. A review of Patient #1’s medical record revealed that on 01/03/2025 an Open Reduction Internal Fixation Mandibular Fracture and Extraction of Tooth #30 was performed in the operating room. On 01/03/2025 at 7:00 PM a one-time order for a CT Maxillofacial without Contrast was entered with a priority level of stat. The order was entered by the surgeon post-op to assess the reduction of the procedure. On 01/03/2025 at 9:59 PM, an additional note was entered in Patient #1’s medical record by the radiology tech stating the following: Per patient nurse, patient is in restraints and will not follow commands. Patient will have to come out of restraints to have scan done. Someone will have to come to CT with patient and remove restraints for patient to have CT done tonight. On 01/03/2025 at 10:10 PM, an additional note was entered in Patient #1’s medical record by S11RN stating the following: Informed radiology tech that patient was being very combative and in 2 patient restraints and we will not be able to take the patient out of restraints for the test. Doctor notified patient not able to go for the CT. Review of Patient #1’s medical record failed to reveal that the order for the stat CT was changed or discontinued. Further review of the medical record failed to reveal that the stat CT order was completed as ordered. Patient #1’s medical record also failed to reveal a documentation by S11RN from the physician in response to not completing the stat CT order. In an interview on 01/30/2025 at 11:25 AM, S11RN confirmed that she was the primary nurse for Patient #1 on the night of 01/03/2025 through the morning of 01/04/2025. S11RN stated that the radiology tech called her about getting Patient #1 for the stat CT that was ordered and at the time the patient was uncooperative. Per S11RN, the radiology tech told her that they couldn’t take the patient because he was in restraints. S11RN was asked if she made an additional attempt to get the patient to CT to complete the stat order. S11RN also stated that no one ever called about the CT being done or not, and stated OMFS didn’t ask for it, so the patient probably would have just gone in the morning when they had time. In an interview on 01/27/2025 at 12:55 PM, S3RM and S8ND confirmed that there is no documentation about the response from the physician regarding completing the stat CT order. At this time S3RM and S8ND verified that the stat CT order was never completed. In an interview on 01/30/2025 at 11:38 AM, S5CVP confirmed that there is no hospital policy that states a patient cannot have a CT if they are in restraints. In an interview on 01/30/2025 at 11:52 AM, S3RM confirmed that the stat CT order was never modified or discontinued from the original order placed on 01/03/2025 at 7:00 PM until it was automatically discontinued upon discharge from the system.”

“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: 50453 Based on record review and interview, the hospital nursing staff failed to follow hospital policy and standard of care for medication administration. This deficient practice is evidenced by failure of the nursing staff to monitor the therapeutic effectiveness of pain medications in 1 (#1) of 3 (#1-#3) patients reviewed. Findings: Review of hospital policy #5052 titled, “Pain Management,” last revised 11/2024, revealed in part: “P. Pain management interventions should be evaluated for effectiveness. a. reassessment should occur within 90 minutes after an IV pain medication has been administered. b. Within 90 minutes after oral pain medication administration. c. Within 90 minutes of any reporting of pain and use of non-pharmacological pain intervention. Q. Assessment and Reassessment of pain management effectiveness must be documented within the patient’s medical record.” Patient #1 Review of Patient #1’s medication administration record revealed the following pain medications were administered: 01/02/2025 at 12:10 AM - Acetaminophen, 650 mg/20.3ml oral solution, Dose: 650 mg, every 6 hours for pain. 01/02/2025 at 5:44 AM - Acetaminophen, 650 mg/20.3ml oral solution, Dose: 650 mg, every 6 hours for pain. 01/03/2025 at 7:59 PM - Hydromorphone, 0.5mg IV, every 3 minutes, PRN for pain. 01/03/2025 at 11:09 PM - Oxycodone, 5mg/5ml oral solution, Dose: 5 mg, every 4 hours PRN for pain. Further review of Patient #1’s medical record and medication administration record failed to reveal a re-evaluation of the effectiveness of the medications listed above. In an interview on 01/28/2025 at 12:26 PM, S3RM and S5CVP confirmed the above mentioned findings and verified that there were no documented re-evaluations of the effectiveness of the pain medications listed 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: 44495 Based on record review and interview the hospital failed to report all cases of possible abuse and neglect to the licensing authority within 24 hours of awareness of the allegation. The deficient practice is evidenced by failure of the hospital to notify the Louisiana Department of Health of an attempted suicide in the Behavioral Health Emergency Department. Findings: Review of Policy #5228, “Management of High-Risk Patients Levels of Observation,” last reviewed 02/2022, revealed in part, “Policy Statement: . . .Patients who are identified as high risk due to behaviors, diagnosis, and/or physical conditions, or are being held without consent on an Emergency Certificate or Judicial Commitment shall be placed on levels of observation appropriate to maintain their safety. One example of a patient that is identified as high-risk would be an individual that has attempted or expressed the desire to commit suicide or to self-inflict injury. As indicated by physician’ orders, these patients shall be monitored closely by an assigned staff member to ensure the patient’s safety and security. Although a physician’s order is required, specifying the level of observation, a registered nurse may increase a level of observation to ensure patient safety, pending an order.” Review of the medical record for Patient #1 revealed she was brought to the hospital on 09/21/2024 at 6:11 a.m. by police after calling 911 after endorsing suicidal ideations with an attempt. The patient attempted to slit her wrists and was noted to have bilateral superficial wrist lacerations with no active bleeding at the time of presentation. The Chief Complaint was listed as “Suicidal.” An initial suicide screen was performed on 09/21/2024 at 6:13 a.m. revealed the patient answered yes to the following questions from the Columbia Suicide Severity Rating Scale: 1) “Have you wished you were dead or would go to sleep and not wake up; 2) Are you had any thoughts about killing yourself; 3) Have you thought about how you might do this? Further review of the medical record revealed she was initially evaluated in the emergency department by a physician at 6:22 a.m. who documented at 6:28 a.m., “Patient #1 is a 38 year old with past medical history of schizoaffective disorder here with chief complaint of suicidal ideations. Patient reports plan to hang herself. She reports that she witnessed a murder and no one believes her. Reports auditory hallucinations. Also reports homicidal ideations towards, ‘those bitches who were doing the killing.’ She reports she has been off her medication for the last few days.” The physical examination documented, “Thought Content: thought content is delusional. Thought content includes homicidal and suicidal ideation. Thought content includes suicidal plan.” After Patient #1 was medically cleared, she was sent to the Behavioral Health Emergency Room on 09/21/2024 at 6:23 a.m. The Columbia Suicide Severity Rating Scale was repeated at 6:31 a.m. and Patient #1 responded “No” to Question #1, “Have you wished you were dead or would go to sleep and not wake up; and she responded “No” to Question #6, “Have you done anything, started to do anything or prepared to do anything to end your life?” Review of the nursing note from 09/21/2024 at 6:31 a.m., revealed “Patient arrives to the unit. Calm and cooperative. Flat and withdrawn. Upon her arrival the patient states, ‘A boy was murdered and no one believes me.’ Patient appears paranoid. Speaks at a low whisper and stares intensely at hospital police. Patient has limited engagement with nursing staff. Just stares towards the wall when questions are asked.” Review of the nursing note from 09/21/2024 at 11:21 a.m. revealed, “Patient attempting to wrap her socks and other clothing around her neck. Patient given a PRN medication. And now in direct observation.” Review of the orders revealed no order for level of observation was placed at the time of transfer to the Behavioral Health Emergency Department. After the incident, an order was placed for one-to one observation. In interview during the record review on 10/21/2024 between 2:20 p.m. and 3:30 p.m., S5RN verified there were no orders for level of observation at the time she was brought on the unit for evaluation and explained that routine level of observation was every 15 minutes and orders were only placed if the patient required a higher level of observation. The surveyor questioned why a patient who had slit her wrists in a reported suicide attempt at home would not have been considered high risk for suicide and placed on line of sight or one-to-one observation at the time she was admitted. S5RN and S3DPSQ both verified Patient #1 was not considered high risk by the staff at that time and routine observation was appropriate and followed hospital policy. Review of the incident report revealed a statement a provided by the behavioral health tech assigned to Patient #1. The tech documented she was working with another patient when she was notified by security that Patient #1 was shirtless in her room. The tech returned to the room to find the patient sitting on the floor with yellow hospital socks tied around her neck loosely. The tech tried to remove the socks, the patient resisted, but with the help of security the socks were removed. The patient was examined and found to be unharmed and was placed on one-to-one observation at that point. Further review of the incident report revealed the first Follow-Up Action documented was a chart review by S6RN on 09/22/2024 at 3:57 p.m. The next documented Follow-Up Actions were a sign-off by S5RN on 09/23/2024 at 8:28 a.m., “work done on file” by S6RN on 09/23/2024 at 1:52 p.m. and then her sign-off on 09/23/2024 at 1:56 p.m., and a sign-off by S4RN on 09/30/2024 at 11:45 a.m. In interview on 10/22/2024 at 11:09 a.m., S10RM verified the incident was not reported to the licensing authority within 24 hours of awareness, as required for all possible cases of neglect or abuse, because it was determined that there was never any concern about the quality of care provided. S10RM verified that she had consulted with nursing and legal staff and they determined it did not meet the requirement for reporting because all hospital processes were performed according to hospital policy. S10RM verified the investigation documented in the incident report, which began on 09/22/2024 at 3:57 p.m., was only performed because reviews are required for all incidents.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 44495 Based on record review and interview, the hospital failed to recognize opportunities for improvement and initiate changes to ensure compliance. The deficient practice is evidenced by failure of the hospital to initiate changes and monitor for compliance after staff failed to immediately initiate an incident report after an allegation of sexual abuse was made against a member of the Behavioral Health Emergency Room staff. Findings: Review of Policy #5999, “Communication for Patient Safety Events,” last reviewed 12/2021, revealed in part, “B. Sentinel Event: A “sentinel event” defined by The Joint Commission as a patient safety event (not primarily related to the natural course of the [patient’s] illness or underlying condition) that reaches a [patient] and results in death, severe harm (regardless of duration of harm), or permanent harm (regardless of severity of harm). . . An event is also considered sentinel if it is one of the following: . . . 8. Sexual abuse/assault of any patient while receiving care, treatment, and services while on site at the organization/ facility or while under the supervision/care of the organization. . . . C. Never Events or Serious Reportable Events . . . C. vii. Criminal Events . . . 3. Sexual abuse/assault on a patient within or on the grounds of a health care setting.” Further review revealed, “SECTION III: RESPONSE TO A PATIENT SAFETY EVENT . . . 1. Any potential sentinel event, never event, or serious safety event shall be immediately reported to the designated person or person(s) within the hospital in accordance with that Hospital’s policies and procedures. 2. The designated person or person(s) within the Hospital who was originally alerted to the incident or his/her designee is responsible for immediately notifying the following via telephone within twenty-four (24) hours of the discovery of the event: 1) Hospital’s President & CEO and 2) LCMC Health’s President of Clinical and System Operations.” Review of the incident initially reported to Louisiana Department of Health on 09/04/2024, and the final report which was submitted on 09/18/2024, revealed S13RN reported to S6RN on 08/14/2024 that she saw S14RN grab a patient by the genitals in an effort to subdue the patient. S13RN was unable to provide S6RN with the date of the incident or the name of the patient who was abused. Both S13RN and S6RN failed to start formal report of the accusations in the BSafe reporting system at that time. S6RN began an investigation and on 09/04/2024, S8HRD became aware of the investigation and immediately initiated documentation and began a proper investigation of the allegation including the notification of Louisiana Department of Health. In interview on 10/21/2024 between 1:38 p.m. and 1:57 p.m., S8HRD verified that hospital policy for reporting had not been followed. S8HRD said she was never given a clear explanation as to why the incident was not immediately reported in the BSafe system (the system used by the hospital to report patient safety issues or concerns), but said that during her interviews with S13RN, S6RN, S11RN, S12RN and S15UC she emphasized that the system should be used and would result in thorough and fair investigations. S8HRD verified she was not aware of any formal re-education after the incident and was not aware of any monitoring for compliance. In interview on 10/21/2024 at 2:07 p.m., S4RN verified S6RN came to him with the allegations but he did not know the date, only that it was sometime before 09/04/2024, because that is the date he went out on a vacation. S4RN verified he did not feel it was right to initiate a BSafe report at that point because there were no facts to support the allegation. S4RN informed the surveyor that S6RN was out of the country and not available for interview. S4RN verified there had been no re-education on the reporting of allegations of abuse or neglect since he was back and stated he was not sure if the staff had been re-educated while he was out. S4RN explained he returned from vacation on 09/26/2024 and S6RN went out shortly after he got back, and they never really had time to discuss the matter. S4RN was informed that the surveyor would be onsite another day and he was encouraged to bring any information related to education after the event. There was no additional information provided to the surveyor prior to the exit conference on 10/22/2024 at 11:40 p.m.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 44495 Based on record review and interview, the hospital failed to recognize patient safety issues through the Quality Assurance and Performance Improvement (QAPI) review process. The deficient practice is evidenced by failure of hospital to identify deviations from hospital policy for reporting safety events and deviations from CMS guidelines after deployment of pepper gel to detain an eloped patient on a public sidewalk. Findings: Review of Policy Number 10.01, “Public Safety: Use of Control,” last reviewed 09/2024, revealed in part: Types of Control/Applications 1. Warning- whenever possible members shall exercise persuasion, advice, and/or warning of impending use of control. Warnings need not specify the type or amount of control to be applied and need only indicate that appropriate control will be utilized if compliance is not obtained. However, members are not expected to place themselves or others in jeopardy in order to deliver such warnings, and if a warning is ineffective, appropriate control should be used to effect the arrest. 2. Weaponless Control Techniques: a) Non-Impact Methods- firm grip and pain compliance techniques designed for subject come-a-longs. When verbalization proves ineffective, a firm grip and/or pain compliance control methods may be all that is necessary to overcome a subject’s resistance. b) Oleoresin Capsicum [pepper gel] to stop aggressive or combative behavior. Further review of policy Number 10.01 revealed in part: Levels of Control . . . . 5. Level 2 uses of control include use of Oleoresin Capsicum; . . . [and] Use of Control Investigations . . . 3. For all level 2 and 3 uses of control, the investigating supervisor shall: a. Respond to the scene, examine the subject of the control for injury, interview the subject for complaints of pain after advising the subject of his/her rights, and ensure that the subject receives appropriate medical attention. b. Notify the Operations Commander, and Deputy Director of Public Safety immediately. . . . Review of Policy #5999, “Communication for Patient Safety Events,” last reviewed and revised 12/2021, revealed in part, “Policy: Section I: . . .B. Sentinel Event: A “sentinel event” defined by the Joint Commission as a patient safety event (not primarily related to the natural course of the [patient’s] illness or underlying condition) that reaches a [patient] and results in death, severe harm (regardless of the duration of harm), or permanent harm (regardless of severity of harm) . . .An event is also considered sentinel if it is one of the following: . . .6. An elopement (that is, unauthorized departure) of a patient from a staffed around-the-clock setting (including the ED), leading to death, permanent harm or severe temporary harm to the patient.” Further review of Policy #5999 revealed, “Section II: Comprehensive Systemic Analysis, Corrective Action Plan and Staff Recovery- LCMC is expected to identify and respond appropriately to all sentinel events occurring in its Hospitals . . . appropriate response to a sentinel event, never event, and an HPI classified Serious Safety Event includes completion of a comprehensive systemic analysis for identifying the causal and contributory factors. . . . Each hospital shall prepare a through and credible comprehensive systemic analysis and corrective action plan within forty-five (45) business days of the event or of becoming aware of the event.” Review of the medical record for Patient #2 revealed he presented to the emergency department on 09/23/2024 at 4:06 a.m. with complaints of auditory hallucinations telling him to harm himself but he denied suicidal ideation. Patient #2 reported that he had been recently discharged from a local inpatient psychiatric facility. At 4:26 a.m., after being informed that he would be placed under a Physicians Emergency Certificate (PEC), the patient grabbed his luggage and proceeded to leave. He could not be stopped by medical staff, and he was closely followed by staff as he exited the emergency department. The patient was intercepted outside of the hospital, sprayed with pepper gel and returned to the emergency department. Patient #2 was medically cleared and then observed for several hours. The patient was seen by a psychiatrist on 09/23/2024 at 11:55 a.m. The psychiatrist recommended that the PEC be rescinded. Patient #2 was determined to not be a danger to self, nor to others, and was not gravely disabled. Patient #2 was discharged on 09/23/2024 at 11:58 a.m. Review of the report submitted to the licensing authority on 09/24/2024, as the initial and final investigation report, revealed on 09/23/2024 at 4:58 a.m. Patient #2 eloped from the hospital as medical staff were in the process of initiating a Physicians Emergency Certificate (PEC). The nurse who was assigned to the patient did try to block the triage exit, but the patient threatened her stating, “move out of my fucking way before I beat your ass up.” The nurse then followed him out and notified police. Video review confirmed the patient was seen exiting the emergency department with his suitcase followed by two nurses, a contracted security officer and a directly employed security officer. The video also showed the patient being intercepted by a hospital patrol car which pulled up at the base of the ramp. The report then documented, “De-escalation efforts by hospital security officers were unsuccessful and the patient began to threaten the officers. The officers deployed pepper gel. The patient was then escorted back to the emergency department.” The investigation concluded, “. . . the staff reacted quickly and appropriately. There were no processes broken and the patient was escorted back to the emergency department and was transferred to the behavioral health emergency room for further evaluation.” In interview on 10/22/2024 at 8:20 a.m., the surveyor discussed with S3DPSQ the use of the pepper spray and the position of CMS as stated in the guidance under Resident/ Patient/ Client Rights. The guidance clearly indicates that if the use of pepper spray is necessary, it is best practice to involve local police. S3DPSQ verified she was not aware of the guidance. The Security Report was then provided to the surveyor. Review of the security incident report prepared by the designated Supervisor on Duty revealed the following narrative: On 09/23/2024, I, S17SC, was on duty as Shift Commander from 5:45 p.m. until 6:15 a.m. When at 4:38 a.m., Officer S18SO initiated a Dr. Flight for Patient #2 in triage room 5. Upon being informed he would be placed under PEC (Physicians Emergency Certificate) Patient #2 grabbed his rolling luggage and was attempting to leave UMCNO property while the Dr. was writing the PEC order. Responding officers S19SO, S20SO, and S21AO intercepted the patient on S. Roman Street. SO20 stated he gave loud and clear verbal commands for Patient #2 to stop and that he was not free to go. Patient #2 became combative and attempted to strike S20SO with a closed fist. According to all three responding officers, this took place at the bottom of the ED ramp, in the grassy area prior to re-entering S. Roman Street (see attached statements). Patient #2 allegedly stated to S20SO that his “whole family was dead” at this time. S20SO gave one more loud verbal command to stop before deploying his duty issued OC gel. The patient was escorted by Charge Nurse to the decontamination room and back to room 2501 for further treatment under the care of S22MD. S20SO did not pursue charges for the attempted strike. CCTV footage was reviewed, provided to House Supervisor, and attached to this report. Further review of the provided documentation revealed the report did contain statements from S19SO, S20SO, and S21AO, but none of the responders mentioned where the interaction took place as stated in the narrative by S17SC. The two officers in the patrol car were not identified. The review of the CCTV footage was not included as a part of the report. The report did not contain statements from S18SO, who initiated the Dr. Flight, and S23SO, who was also documented as dispatched to the incident. The report did not document that Patient #2 was examined and advised of his rights by S17SC as required in the policy. The report did not contain documentation of an interview by S17SC with Patient #2 after the incident as required by the policy. There was no documentation of notification of the Operations Commander, and Deputy Director of Public Safety. On 10/22/2024 at 8:55 a.m., S16DCPS was interviewed. S16DCPS verified he was familiar with the investigation into the incident and was interviewed between 8:55 a.m. and 8:59 a.m. S16DCPS verified Patient #2 was on the sidewalk on South Roman Street heading towards Tulane Avenue when he was intercepted. S16DCPS verified the sidewalk is public property and Patient #2 was not on hospital property when the pepper gel was deployed. S16DCPS verified the security officers had authority to detain the patient on public property because it was to ensure the safety of the patient and the public. S16DCPS verified the use of the pepper gel was warranted after Patient #2 tried to hit the officers and made threats. When asked if he was aware of the CMS position on the use of pepper gel, he verified it did not apply to the situation because they were not trying to put the patient in restraints, they were trying to detain him. S16DCPS verified New Orleans Police Department was not notified of the incident. S16DCPS verified the use of the pepper gel was justified, and the incident was properly reviewed and documented, and all hospital security policies were followed.”

“PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES CFR(s): 482.13(a)(2)(ii) At a minimum: The grievance process must specify time frames for review of the grievance and the provision of a response. This Standard is not met as evidenced by: 44495 48050 Based on record review and interview, the hospital failed to ensure grievances were resolved in a timely fashion and following established timelines. The deficient practice is evidenced by failure of the hospital representative to send a letter explaining that it would take longer than 7 days to resolve a grievance for 1 (#4) of 9 (#2, #4-#11) reviewed grievances. Findings: Review of Policy 0111, “Process for Acknowledging and Resolving Patient Complaints and Grievances,” revised 12/2020, revealed in part, “If a grievance will not be resolved, or if the investigation is not or will not be completed within 7 days, the Department of Patient Experience will inform the patient or the patient representative that the hospital is still working to resolve the grievance and that the hospital will follow-up with a written response with 15 days.” Review of the report of the incident submitted to the licensing authority revealed on 05/14/2024 Patient #4 reported that security had physically abused her after an attempted elopement causing pain in her arm. Further review of the report revealed that the grievance was not substantiated and was closed on 05/21/2024. In interview on 05/10/2024 at 2:53 p.m., S9RM verified that a letter had not been sent because the parties involved were trying to decide which investigator would be listed as the contact in the letter. S9RM verified it had been 20 days since the grievance was closed. In interview on 06/11/2024 at 12:28 p.m., S3DS and S4MRA verified there was no documented contact or letter sent to the patient when it was determined that the grievance could not be thoroughly investigated within 7 days as per the policy.”

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 44495 48050 Based on record review and interview, the hospital failed to ensure all grievances were investigated and resolved according to hospital policy. The deficient practice is evidenced by: 1) failure to include the steps taken on behalf of the patient to investigate the grievance and the results of the grievance process in the written notice sent to 6 (#5, #7, #8, #9, #10, #11) of 6 (#5, #7, #8, #9, #10, #11) reviewed letters sent after closure of a grievance; and 2) failure to document that a letter was sent after closure of a grievance to 1 (#2) of 3 (#2, #5, #6) reviewed grievances involving sexually inappropriate behavior by a member of hospital staff. Findings: Review of Policy 0111, “Process for Acknowledging and Resolving Patient Complaints and Grievances,” revised 12/2020, revealed in part, “Grievance: is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient’s representative, regarding the patient’s care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital’s compliance with CMS Hospital Conditions of Participation, or Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489. . . . In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains: the name of the hospital contact person; the steps taken on behalf of the patient to investigate the grievance; the results of the grievance process; and the date of completion.” 1) Failure to include the steps taken on behalf of the patient to investigate the grievance and the results of the grievance process in the written notice. Review of the grievance letters for Patients #5, #7, #8, #9, #10, and #11 revealed the same grievance letters sent to all patients which did not include steps taken on behalf of the patients or the results of the investigation. In an interview on 06/11/2024 at 12:30 p.m. S15ELPE verified that the hospital does not include the steps on behalf of the patient in the grievance investigation or the results of the investigation in the letter that is sent to the patient. Furthermore, S15ELPE verified that all patients receive the same generic letter after the investigation is complete. 2) Failure to document that a letter was sent after closure of a grievance involving sexually inappropriate behavior. Review of the report sent to the state licensing agency revealed Patient #2 reported on 04/30/2024 that she felt she was inappropriately touched by S10CT during a study for evaluation of segmental pressures of the lower extremities. The report documented that an investigation was completed and the accusation was not substantiated. Further review of the provided documentation failed to reveal a letter was sent to Patient #2 explaining how the grievance was investigated and the results of the investigation. In interview on 06/11/2024 at 2:03 p.m., S3DS verified a letter was not sent to Patient #2 after the grievance was closed.”

“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: 44495 Based on record review and interview, the facility failed to provide care in a safe setting. The deficient practice is evidenced by failure to provide documentation of education for contracted security staff on hire and after an elopement. Findings: Review of the elopement of Patient #1 on 05/12/2024 revealed a contracted security person, S12AS, was assigned to monitor the traffic in and out of the door where Patient #1 exited, but failed to alert hospital police when a patient in paper scrubs exited the building through the door he/she was monitoring. On 06/10/2024 the surveyor requested verification that the contracted security personnel were re-educated. The documentation provided on 06/11/2024 had no date on it and only 7 from a total of 36 employees had reviewed the educational information. Further review revealed S12AS had not been re-educated after the incident. On 06/11/2024 at 9:40 a.m., the surveyor requested to review the personnel file for S12AS In interview on 06/11/2024 at 10:59 a.m., S4MRA verified they did not have complete records for the contracted security and were waiting for them to be sent from the agency. In interview on 06/11/2024 at 1:27 p.m., S6DHR stated that the contracted agency was responsible for the credentialing and education of its employees and, per the contract, the documentation was to be made available to the hospital as needed. In interview on 06/11/2024 at 2:30 p.m., S4MRA verified Agency A had only documented the education of 7 from a total of 36 employees and S12AS had not received the education. At the time of exit at 3:20 p.m., the personnel file with education and orientation for S12AS still had not been provided. S4MRA and S6DQIC verified the facility had not provided any proof S12AS was ever educated on his/her duties at the hospital.”

“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: 44495 48050 Based on record review and interview, the hospital failed to protect patients from possible abuse and/or neglect. The deficient practice is evidenced by the failure of individual departments to submit information about disciplinary actions to the human resources department for documentation in the official personnel file for 2 (S10CT and S11EDC) of 2 reviewed personnel with disciplinary actions. Findings: S10CT Review of the reported incident from 1/27/2021 revealed Patient #6 complained that she had been inappropriately touched by S10CT while he performed a transthoracic echocardiogram. The hospital investigation determined the accusation could not be substantiated. Further review of the document revealed the report was prepared by S9RM and S13NMIC, the manager over S10CT, was listed as a participant in the investigation. Review of the reported incident from 03/22/2022 revealed Patient #5 complained that she had been inappropriately touched by S10CT while he performed and echocardiogram. The hospital investigation revealed the accusation could not be substantiated. The document was prepared by S9RM and documented “NA” after Question #12 which asked, “Did the aggressor have a history of this behavior? If yes, what interventions related to the behavior were in place at the time of the incident?” Further review of the report revealed S10CT was immediately pulled from his duties to speak with S13NMIC. Education and training was provided to S10CT and S10CT was required to have a chaperone when performing echocardiograms or document verbal consent from the patient that a chaperone was not necessary. Review of the reported incident from 04/30/2024 revealed Patient #2 reported she was inappropriately touched by S10CT during a study for evaluation of segmental pressures of the lower extremities. The hospital investigation revealed the accusation could not be substantiated. The document was prepared by S9RM and there was no answer after Question #12 which asked, “Did the aggressor have a history of this behavior? If yes, what interventions related to the behavior were in place at the time of the incident?” Further review of the report revealed S10CT was immediately pulled from his duties to speak with S13MNIC and S6DHR. S10CT was suspended from his duties pending the completion of the investigation. Under the Comments Section of the form the facility documented, “The complaint will be documented in the employee’s file to monitor for trends. [S10CT] will receive counseling on maintaining body awareness and ensuring our patients receive safe and comfortable care.” On 06/11/2024 at 9:40 a.m., the surveyor requested copies of the investigation into Patient #2’s grievance and was later provide with documentation of the disciplinary actions for S10CT from 03/22/2022 and 04/10/2024. In the verbal counseling from 05/10/2024 it stated that S10CT had no prior incidents documented. In interview on 06/11/2024 at 11:30 a.m., S13MNIC was questioned why the documentation of the disciplinary action from 05/10/2024 documented that there had been no prior similar incidents with S10CT. S13MNIC verified that she had not written the letter, only signed it. S13MNIC verified S6DHR wrote the letter. In interview on 06/12/2024 between 1:14 p.m. and 1:30 p.m., S6DHR verified the complaints and disciplinary actions for S10CT were not documented in the file maintained by the Human Resources Department. The documents were maintained in the file held by the department where each worked by the director of the department. S6DHR was questioned about the documented disciplinary action from 05/01/2024 and why it stated there were no other similar incidents. She stated that she called and asked S13MNIC if there had been any prior incidents involving S10CT before writing the letter, and S13MNIC verified that there were no other incidents. S11EDC Review of the report sent to the licensing agency revealed Patient #1 was admitted on 05/10/2024 under a Physician’s Emergency Certificate (PEC) and was placed on one to one observation with a sitter. On 05/12/2024 around 11:02 a.m., Patient #1 eloped from the ED and exited the hospital through a door with assigned security personnel. An alert for the elopement (Dr. Fight) was announced when the assigned sitter realized Patient #1 was missing. The report documented that S11EDC had turned away from her one to one assignment to scan documents, and was negligent in her duties as a one to one sitter. Review of the personnel file for S11EDC on 06/11/2024 failed to reveal the employee had any disciplinary actions. In interview on 06/11/2024 between 11:14 p.m. and 1:30 p.m., S6DHR verified there was no disciplinary action in the personnel file. S6DHR suggested that S5EDD be contacted for the documentation. In interview on 06/11/2024 at 1:53 p.m., S5EDD presented the documentation of the disciplinary action signed by S5EDD and S11EDC on 05/10/2024. S5EDD verified he should have sent the documentation to Human Resources but failed to send it.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 44495 48050 Based on record review and interview, the facility failed to ensure the accuracy of data collected as part of the quality improvement process. The deficient practice is evidenced by failure to identify significant errors or omissions in the documentation for 4 (#1, #2, #4, #5) of 5 (#1, #2, #4, #5, #6) reviewed records with investigations involving allegations of possible abuse or neglect. Findings: Patient #1 Review of the medical record for Patient #1 revealed admission on 05/10/2024 for altered mental status and electrolyte imbalances. Patient #1 eloped from the ED on 05/12/2024 when the sitter assigned to the one to one observation turned her back on the patient’s room to scan documents. Review of the report sent to the licensing authority revealed the specific location of the event was documented as ED Room 2567. During the tour of the ED on 06/11/2024 between 2:30 p.m. and 2:50 p.m., the surveyors asked to see ED Room 2567 to understand its proximity to the nursing station and the scanner. S5EDD was guiding the tour and expressed doubt that the room number in the report was right, because the scanner was on the end of nursing station other side of the room in all the pods. S5EDD verified that all the pods were parallel and identically arranged. S4MRA called to have the medical record reviewed and it was verified that Patient #1 was in ED Room 2553, which was in a different pod and situated near the end of the nursing station where the scanner was also located. Patient #2 Review of the clinic record for Patient #2 revealed she was an outpatient in the clinic who presented to Non-Invasive Cardiology for bilateral segmental pressures of the lower extremities on 04/30/2024. Review of the report provided to the licensing authority revealed Patient #2 reported she was inappropriately touched by S10CT while he performed the study. The investigation documented that the accusation could not be substantiated. The report was prepared by S9RM who had prepared two previous reports involving accusations of sexually inappropriate touching by S10CT. S9RM failed to provide an answer after Question #12 which asked, “Did the aggressor have a history of this behavior? If yes, what interventions related to the behavior were in place at the time of the incident?” In interview on 06/11/2024 at 12:09 p.m., S14FN verified that she had spoken to Patient #2 after the event. She said Patient #2 was not comfortable with the way S10CT tucked the towel in her underwear and that S10CT had raised the level of the bed to a point where Patient #2’s hands grazed his genitals. In interview on 06/11/2024 between 1:14 p.m. and 1:30 p.m., S6DHR verified she met with S10CT immediately after the event as part of the investigation. S6DHR read the report provided to the licensing agency and verified the report did no document that S10CT had tucked a towel in the underwear of Patient #2 as part of the procedure or that he raised the level of the table to comfortable work height which might have been at the level of his genitals. Patient #4 Review of the medical record for Patient #4 revealed she presented to the Emergency Department on 05/13/2024 with a diagnosis of suicidal ideation. Review of the report provided to the licensing authority revealed on 05/13/2024 Patient #3 tried to elope but the officer “places a hand on her back and her right arm to usher her back into her room.” During the next shift Patient #2 reported to the nurse that she had pain in the right forearm “from when the officer grabbed her earlier.” Further review of the document revealed the date of the incident listed at the top of pages 2, 3, 4, and 5 is reported as 04/26/2024. In interview on 06/10/2024 at 2:53 p.m., S9RM verified she had prepared the document and that the incident had occurred on 05/13/2024 and the investigation was closed on 05/21/2024. Patient #5 Review of the medical record for Patient #5 revealed admission on 03/22/2022 for surgical repair of a right femoral neck fracture. Review of the report provided to the licensing authority revealed on 03/22/2022, Patient #5 had an echocardiogram performed by S10CT and reported that S10CT had touched her inappropriately. The investigation documented that the accusation could not be substantiated. The report was prepared by S9RM who had prepared one previous report involving accusations of sexually inappropriate touching by S10CT 2 months prior. S9RM answered NA to Question #12 which asked, “Did the aggressor have a history of this behavior? If yes, what interventions related to the behavior were in place at the time of the incident?” In interview on 06/11/2024 at 2:46 p.m., S4MRA verified S9RM had prepared the reports for the incidents on 01/27/2022, 03/22/2022, and 04/30/2024 involving accusations of inappropriate touching by S10CT and should have documented the previous accusation in the report for the incidents on 03/22/2022 and 04/30/2024.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 44495 48050 Based on record review and interview, the facility failed to take preventative action after an elopement from the emergency department (ED). The deficient practice is evidenced by failure to document re-education of all emergency department staff and security personnel after negligence in performance of duty was determined in the investigation of the event. Findings: Review of the report sent to the licensing agency revealed Patient #1 was admitted on 05/10/2024 under a Physician’s Emergency Certificate (PEC) and was placed on one to one observation with a sitter. On 05/12/2024 around 11:02 a.m., Patient #1 eloped from the ED and exited the hospital through a door with assigned security personnel. An alert for the elopement (Dr. Fight) was announced when the assigned sitter realized Patient #1 was missing. The report documented that S11EDC had turned away from her one to one assignment to scan documents. In interview on 06/10/2024 at 2:28 p.m., S4MRA verified there was a security person assigned to door where Patient #1 exited. S4MRA verified the security person should have called for help if he/she saw someone leaving the hospital in purple scrubs. In interview on 06/10/2024 at 2:32 p.m., S3DS verified they did not know the name of the security person who was assigned to the door where Patient #1 exited. S3DS also verified the contracted agency was supposed to re-educate the security personnel and the contact person was not available to provide the information. S3DS verified she did not know any details about the education and did not know if the hospital had provided the educational material. In interview on 06/10/2024 between 2: 54 p.m. and 2:58 p.m., S5EDD verified there was no documentation for the education provided to the ED staff after the event. In interview on 06/10/2024 at 3:13 p.m., S4MRA verified the security person assigned to the exit where Patient #1 eloped was S12AS. On 06/11/2024, the documentation of the re-education of the security personnel was provided. The educational material had no date for the education and read as follows: This encompasses multiple policies here at the hospital. Below is what [Agency A] staff need to be trained in concerning the use of purple scrubs within the hospital. Patients wearing purple scrubs indicates that the patient is a psych hold patient. If an [Agency A] officer assigned to the hospital observes a patient wearing purple scrubs who is not being escorted by medical/ hospital staff, they should inquire and contact DPS Dispatch immediately via their post issued radio or their cell phone. DPS Dispatch will then advise or start the process of identifying the status of the patient and attempt to stop their departure from hospital property. Further review of the documentation of the education provided to the security personnel from Agency A revealed that only 7 from a total of 26 employees had reviewed the information, and S12AS had not been re-educated. During an interview on 06/11/2024 at 1:53 a.m., S5EDD provided documentation of the warning given to S11EDC. S5EDD again verified he had no documentation to prove the rest of the ED staff had been educated after the elopement. In interview on 06/11/2024 at 2:30 p.m., S4MRA verified Agency A had only documented the education of 7 from a total of 26 employees and S12AS had not received the education.”

“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: 44495 48050 Based on record review and interview, the hospital failed to ensure the Registered Nurse (RN) performed assessments according to hospital policy. The deficient practice is evidenced by failure of the registered nurse to perform the admission assessment within 8 hours of admission for 1 (#1) of 4 (#1, #3, #5, #6) reviewed records of patients admitted to the facility. Findings: Review of the policy “Screening, Assessment, and Reassessment,” reviewed 12/2021, revealed in part, “ Policy:- Assessments- For additional unit specific documentation requirements, refer to unit specific protocols in Appendix B.- Each patient will have an initial nursing assessment completed upon admission.” Review of Appendix B revealed the time frame for the initial nursing assessments for admitted patients ranged from within the first hour for intensive care units to within 8 hours for regular units. Review of the medical record for Patient #1 navigated by S7RN revealed admission on 05/10/2024 at 11:09 p.m. Further review of the medical record revealed the admission nursing assessment was initiated on 05/12/2024 at 10:23 a.m. In interview on 06/10/2024 at 1:59 p.m., S7RN verified the admission assessment was not performed within the timeframe specified by the hospital policy.”