Mercy Regional Medical Center

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 44763 Based on record review and interview, the hospital failed to have an effective infection prevention and control program. This deficient practice was evidenced by failure to ensure temperature and humidity were in appropriate range in the operating and procedure rooms. Findings: Review of the hospital’s policy titled “Environmental- Surgical Departmental Control”, last reviewed 08/2024, revealed in part, Policy: -All work areas should have a temperature between 68 - 74 degrees F and a relative humidity controlled between 30-60 percent. -The surgical department shall maintain a daily log with temperatures and humidity readings. -When adequate temperature and/or humidity range listed as acceptable ranges is not reached, notify Plant Ops and Manager (House Sup for after-hours) and document your actions. All elective surgery will be cancelled until the temperature and humidity are in acceptable ranges. Review of the surgery diversion documentation on 08/06/2026 provided by S4EDD revealed in part, the surgery department started diversion on 06/19/2026 at 2:12 PM and remained on diversion as of this review. Review of the Surgery Log Report revealed in part: On 06/29/2026- 1 procedure was performed in room ‘a’; On 07/02/2026- 1 procedure was performed in room ‘b’; On 07/13/2026- 2 procedures were performed in room ‘a’; On 07/22/2026- 2 procedures were performed in room ‘b’ and 1 procedure was performed in room ‘a’. Review of room ‘a’ temperature and humidity log dated 06/2026 revealed on 06/29/2026 the temperature was documented as 70 degrees F and humidity as 70%. Further review of the document revealed in part, 06/29/2026 action taken: dehumidifier brought into room ‘a’. Review of room ‘a’ temperature and humidity log dated 07/2026 revealed on 07/13/2026 the temperature was documented as 70 degrees F and humidity as 68%. Further review of the document revealed in part, 07/13/2026 action taken: maint (maintenance) aware. On 07/22/2026 the temperature was documented as 77 degrees F and humidity as 58%. Further review of the document failed to reveal an action taken on 07/22/2026. Review of room ‘b’ temperature and humidity log dated 07/2026 revealed on 07/02/2026 the temperature was documented as 68 degrees F and humidity as 64%. Further review of the document failed to reveal an action taken on 07/02/2026. On 07/22/2026 the temperature was documented as 73 degrees F and humidity as 72%. Further review of the document failed to reveal an action taken on 07/22/2026. Review of the Surgical Case Review Statistics 2026 revealed in part, there were 0 inpatient cases and 83 outpatient cases in July. In an interview on 08/06/2026 at 1:19 PM, S4EDD confirmed surgical diversion was due to air conditioning problems affecting temperature and/or humidity. In an interview on 08/06/2026 at 1:50 PM, S4EDD confirmed on 06/29/2026 humidity was out of range in room ‘a’ and on 07/02/2026 humidity was out of range in room ‘b’. In an interview on 08/10/2026 at 12:27 PM, S2CNO confirmed on 07/13/2026 humidity was out of range in room ‘a’, on 07/22/2026 humidity was out of range in room ‘b’, and on 07/22/2026 temperature was out of range in room ‘a’.”

“CHIEF EXECUTIVE OFFICER CFR(s): 482.12(b) The governing body must appoint a chief executive officer who is responsible for managing the hospital. This Standard is not met as evidenced by: 48050 Based on record review and interview, the CEO impeded the survey process and failed to provide requested documentation related to the management of the hospital. The deficient practice is evidenced by failure of the CEO to provide documentation the facility was current with payments of state employment taxes and federal employee Social Security and Medicare withholdings as required by state and federal laws. Findings: Review of the Governing Body Bylaws, no date of initiation or review, but provided to the surveyor as the current bylaws, revealed in part, “ The CEO shall be selected and employed by Corporation, after consultation with the Board, and shall be its direct executive representative in the management of the Hospital. The CEO shall have authority, and be held responsible for administering the Hospital in all of its activities, subject only to such policies as may be adopted and such or as may be issued by the Corporation, He/ She shall act as the authorized representative of the Board and Corporation if Corporation has not formally designated some other person for the specific purpose. Corporation, through the CEO, shall be solely responsible for the selection of key management personnel for the operation of the Hospital.” And “Chief Executive Officer’s Responsibility-6.3(g)-Supervising business affairs to ensure that funds are collected and expended to the best possible advantage.” During the entrance conference, the surveyor requested documentation to verify the facility was paying applicable state employment taxes and federal employee Social Security and Medicare withholdings as required by law. During tour of the facility, interviewed employees verified they were aware of financial issues related to the owner of the hospital and verified a few of the departments had experienced shortages of supplies which had not yet affected patient care. S2CNO verified there had been no problems with payment of the employees, but was unsure about the payment of unemployment taxes including Social Security and Medicare withholdings as well as contributions to the employee retirement plans. On 09/22/2025 at 12:00 PM, the surveyor reviewed the provided documents requested during the entrance conference. Review of the documents failed to reveal tax and withholding documents and the documents were request for a second time. At the time of the second request, S3CFO stated corporate office had that information, and she was not sure she could get this from corporate. On 09/22/2025 at 2:00 PM, an interview was conducted with S1CEO who requested a release of information to obtain the requested information of federal and state employment tax filings for 2025. Surveyor completed form and delivered to S1CEO to fax to corporate. On 09/22/2025 at 3:40 PM, an interview was conducted with S1CEO who reported the corporate office will not provided the requested information of federal and state employment tax filings for 2025. At the time of exit on09/22/2025 at 4:00 PM, the requested documents had not been provided and the surveyor was not provided alternative evidence of compliance with submission of state employment and federal employee Social Security and Medicare with holdings.”

“CARE OF PATIENTS CFR(s): 482.12(c) In accordance with hospital policy, the governing body must ensure that the following requirements are met: This Standard is not met as evidenced by: 48050 Based on record reviews and staff interviews, the facility failed to ensure the medical staff was accountable to the governing body for the quality of the medical care provided to patients. The deficient practice is evidenced by 1) failure to develop and implement a policy for special precautions used on the Behavioral Health Unit for 1 (#2) of 3 (#1-#3) sampled patients; 2) failure to ensure the availability of appropriate supplies for point or care testing for 1 (#3) of 3 (#1-#3) sampled patients; and 3)Failure to ensure the availability of appropriate equipment for elective surgeries performed at the hospital. Findings: 1) Failure to develop and implement a policy for special precautions used on the Behavioral Health Unit for 1 (#2) of 3 (#1-#3) sampled patients. Review of Patient #2’s medical record revealed Patient #2 was admitted to the BHU (Behavioral Health Unit) on 09/15/2025 for Impulse Control Disorder. Upon admission the provider ordered violence precautions for Patient #2. Further review of Patient #2’s medical record did not reveal any indications that violence precautions was being initiated/followed. In an interview on 09/18/2025 at 12:58 PM, S4QPR verified the facility did not have a policy on violence precautions. 2) Failure to ensure the availability of appropriate supplies for point or care testing for 1 (#3) of 3 (#1-#3) sampled patients Review of Patient #3’s medical record revealed Patient #3 has a history of Diabetes and provider ordered Accuchecks before meals. Further review of Patient #3’s nursing notes revealed on 09/15/2025 at 5:32 AM “Put in order for lab to come draw blood glucose due to limited test strips”. In an interview on 09/18/2025 at 3:07 PM, S4QPR verified the hospital had limited supplies of glucometer strips due to financial issues, and glucometer strips were only used for emergencies and quality controls. S4QPR revealed routine Accuchecks would be done by venipuncture lab analysis due to limited supplies from 09/09/2025 to 09/15/2025. 3)Failure to ensure the availability of appropriate equipment for elective surgeries performed at the hospital. During the tour of the facility on 09/22/2025 between 11:35 to 12:25 PM, S1CNO reported elective ophthalmology surgeries have been deferred to other facilities due to the hospital’s debt to Sightpath. S1CNO reported the facility did not schedule the elective ophthalmology surgeries for the month of September 2025, but Sightpath balance should be paid by October 2025 so ophthalmology surgeries can be scheduled. Review of the hospital’s financial statements for Sightpath dated 09/11/2025 revealed a balance of $64, 120.62 and was verified by C3CFO.”

“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 Based on record review and interview, the hospital failed to ensure the registered nurse supervised and evaluated the nursing care of each patient as evidence by failing to ensure the provider was notified when patient had a change in condition for 1 (#3) of 3 (#1-#3) sampled patients reviewed. Finding: Review of Patient #3’s medical record revealed Patient #3 was admitted on 09/13/2025 with the following diagnosis: Altered Mental Status, Anxiety, and Self-Endangering Behavior. Further review of Patient #3’s nursing notes on 09/16/2025 at 11:12 PM revealed Patient #3 experienced increased agitation, violence, and delusional unable to redirect, so provider notified via communication applications which provider didn’t respond. In an interview on 09/18/2025 at 3:20 PM, S2CNO revealed the Behavioral Health Unit (BHU) staff communicate with providers via Netsphere, a communication application. S2CNO reports there was no policy/protocol for the use of Netsphere or provider response time. S2CNO verified that BHU staff should have called Patient #3’s provider to report exacerbated condition.”

“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: 48050 Based on record review and interview, the hospital failed to ensure 1 (#2) of 3 (#1-#3) client medical records contained a plan of care addressing all of the patient’s medical conditions as identified problems. Findings: Review of the hospital facility’s policy number AS-2021 titled “Admission/Assessment”, last reviewed 10/2024 revealed in part: “POLICY: Each patient admitted to the facility shall receive an initial comprehensive assessment by a qualified individual, as well as ongoing assessments throughout treatment, so that a plan of care can be developed to best meet their initial and ongoing care needs. PROCEDURE: The ongoing treatment need assessments shall be structured to identify facilitating factors and possible barriers to the patient reaching his/her goals including the presenting problems and needs.” Review of Patient #2’s medical record revealed Patient #2 was admitted to theBehavioral Health Unit (BHU) on 09/15/2024 for Impulse Control Disorder. Upon admission, the provider ordered aspirations precautions, bleeding precautions, and violence precautions. Further review of Patient #2’s nursing care plan did not reveal any nursing diagnosis or interventions which addressed the aspiration, choking, and violence precautions ordered by the provider. On 09/18/2025 at 12:58 PM, an interview was conducted with S4QPR who verified the above mentioned information.”

“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: 44763 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 the nursing staff to perform or assist in activities of daily living (ADLs) as per hospital policy for 2 of 2 (#2, #3) patients reviewed for ADLs from a total sample of 3 and failure of the RN to review and validate an initial admission assessment conducted by a LPN for 1 (#1) of 3 (#1, #2, #3) patients reviewed (see Findings in A-0395). 2) Failing to update a care plan after a fall for 1 (#1) of 3 (#1, #2, #3) patients reviewed and failing to create individualized care plans based on assessments for 1 (#2) of 3 (#1, #2, #3) patients reviewed (see Findings in A-0396).”

“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: 44763 Based on record reviews and interviews, the hospital failed to ensure care in a safe setting. This deficient practice was evidenced by a patient obtaining skin injuries of unknown origin while admitted for 1 (#2) of 3 (#1, #2, #3) patients reviewed. Findings: Review of Patient #2’s medical record revealed an admission date of 06/26/2024 and a discharge date of 07/08/2024. Review of the admission nursing assessment dated 06/26/2024 11:30 p.m. revealed in part: Integumentary (Integumentary Assessment within defined parameters = intact, color appropriate to ethnicity, warm and dry to touch.) - Within Define Parameters Sensory (ability to respond meaningfully to pressure-related discomfort) - Slightly Limited Moisture (Degree to which skin is exposed to moisture) - Rarely Moist Activity - Walks Occasionally Nutrition (Usual foot intake pattern) - Adequate Friction and Shear - Potential Problem Score Total of Skin Risk - 12.0 Level of Risk Indicated by Score - Score Total 10 to 12 = Level 3 (High Risk) Is there an indication of a pressure ulcer or other skin breakdown present on admission? - Yes Review of the Weekly Skin Assessment dated 06/27/2024 11:43 p.m. revealed in part, New Findings 1 - Location of Site - Back of Left Arm - Elbow Comment: skin tear Color of Wound- Red Color of Drainage at Site - None Dressing - Other Comment: tegaderm Type of Finding - Skin Tear Color of the skin around the wound - Red 2 - Location of Site - Back of Left Arm - Back of Upper Arm Color of Wound - Red Color of Drainage at Site - None Dressing - Other Comment: tegaderm Type of Finding - Skin Tear Color of skin around the wound - Red Review of the Weekly Skin Assessment dated 06/29/2024 9:14 a.m. revealed in part, No New Findings 1 - Location of Site - Back of Left Arm - Elbow Comment: skin tear Color of Wound- Red Color of Drainage at Site - None Dressing - Other Comment: tegaderm Type of Finding - Skin Tear Color of the skin around the wound - Red 2 - Location of Site - Back of Left Arm - Back of Upper Arm Color of Wound - Red Color of Drainage at Site - None Dressing - Other Comment: tegaderm Type of Finding - Skin Tear Color of skin around the wound - Red 3 - Location of Site - Front of Right Leg - Front of Lower Leg Type of Finding: Bruise Color of Wound - Bruised Color of the skin around the wound - Bruised Odor from Site - None Dressing - Dry and Intact Review of the Weekly Skin Assessment dated 07/06/2024 1:16 p.m. revealed in part, Wound to back of left hand and multiple scabs on lower and upper extremities with bruises. 1 - Location of Site - Back of Left Arm - Elbow Comment: skin tear Color of Wound- Red Color of Drainage at Site - None Dressing - Other Comment: tegaderm Type of Finding - Skin Tear Color of the skin around the wound - Red 2 - Location of Site - Back of Left Arm - Back of Upper Arm Color of Wound - Red Color of Drainage at Site - None Dressing - Other Comment: tegaderm Type of Finding - Skin Tear Color of skin around the wound - Red 3 - Location of Site - Front of Right Leg - Front of Lower Leg Type of Finding: Bruise Color of Wound - Bruised Color of the skin around the wound - Bruised Odor from Site - None Dressing - Dry and Intact 4 - Location of Site - Back of Left Hand - Back of Hand Type of Finding - Open Wound Color of Wound - Yellow Color of the skin around the wound - Pink Color of Drainage at Site - None Odor from Site - None Dressing - Dry and Intact 5 - Location of Site - Front of Left Leg - Front of Lower Leg Type of Finding - Skin Tear Comment: multiple skin tears Color of Wound - Black Color of skin around the wound - Pink Color of Drainage at Site - None Odor from Site - None Dressing - None Applied 6 - Location of Site - Back of Right Arm - Back of Lower Arm Type of Finding - Scab Comment: multiple scabs to back of lower arm Color of Wound - Black Color of the skin around the wound - Pink Color of Drainage at Site - None Odor from Site - None Dressing - None Applied 7 - Location of Site - On Back - Spine Comment: redness to both sides of back Type of Finding - Other Comment: Redness Color of Wound - Red Color of skin around the wound - Pink Color Drainage at Site - None Odor from Site - None Dressing - None Applied 8 - Location of Site - Back of Left Arm - Back of Lower Arm Color of Wound - Black Color of Drainage at Site - None Dressing - Dry and Intact Odor from Site - None Type of Finding - Scab Comment: multiple scabs Color of the skin around the wound - Pink Review of the nursing note dated 07/02/2024 6:35 a.m. revealed in part, Patient #2 sitting in geri chair picking skin to bilateral upper extremities noted by MHT and LPN. In a phone interview on 08/21/2024 at 2:16 p.m. S5LPN stated Patient #2 had a lot of bruising at admission. S5LPN stated Patient #2 did have a skin tear to the left arm. S5LPN stated Patient #2 had a skin tear to his left hand. S5LPN stated when they would draw blood Patient #2 would bruise easily. S5LPN stated she did not know how Patient #2 got the skin tears. In an interview on 08/21/2024 at 2:51 p.m. S1CNO and S2DQ stated it appeared from the documentation and pictures that Patient #2 inquired these skin injuries during his psychiatric admission. S2DQ stated there was documentation that Patient #2 would “pick” himself. S2DQ stated the LPN from the psychiatric unit reported the scratches were self-inflicted by Patient #2. S2DQ stated S4DON reported she did a chart check and the areas of concern were not reported to the inpatient medical unit upon transfer but were documented on the skin assessment on 07/01/2024 and 07/06/2024. In an interview on 08/21/2024 at 3:07 p.m. S6RN stated he did not know how Patient #2 got the skin tears or bruising. S6RN stated he was not at the hospital when it happened. S6RN stated he was off and when he came back, he found the wounds. S6RN stated Patient #2’s hand was bandaged. S6RN stated S7LPN and S8NP were rounding together and removed the bandage from Patient #2’s hand. In an interview on 08/21/2024 at 3:17 p.m. S7LPN stated when she got off of shift on Thursday Patient #2 had the skin tears to upper arm. S7LPN stated Patient #2 did not have the bruising and skin tears to the hand. S7LPN stated when she returned to shift on Monday the bruising and skin tears were a new concern with Patient #2. In a phone interview on 08/22/2024 at 10:19 a.m. S9LPN stated she remembered Patient #2 had bruises. S9LPN stated she did not know if anything happened to Patient #2’s left hand. S9LPN stated if she remembered correctly Patient #2 had a tegaderm on the back of his hand. S9LPN stated it did not happen on her shift. S9LPN stated she did not know what happened to Patient #2’s left hand. S9LPN stated Patient #2’s skin was really thin. S9LPN stated she didn’t know if Patient #2 got the skin tear from having thin skin. S9LPN stated she didn’t know how Patient #2 got the skin tear. In a phone interview on 08/22/2024 at 1:44 p.m. S10CNA stated she did not know where the skin tears or skin issues came from. S10CNA stated she remembered when she left Patient #2 had nothing. S10CNA stated when she came back Patient #2’s hand was wrapped. S10CNA stated she didn’t quite remember how many days in between but does remember nothing was wrong when she took care of Patient #2 and then when she returned to work Patient #2’s hand was wrapped. S10CNA stated she didn’t remember Patient #2 having any skin tears to his legs. S10CNA stated maybe he moved around and maybe bumped his arm on a chair or something. S10CNA stated when people have fragile skin it could have happened that way. S10CNA stated she wasn’t certain how Patient #2 got the skin tears to his arm. In an interview on 08/22/2024 at 3:47 p.m. S1CNO stated drawing blood could have caused the bruising to Patient #2’s hand. S1CNO stated Patient #2’s skin was very thin. S1CNO stated she could not determine for certain what caused the skin injuries to Patient #2’s hand.”

“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: 44763 Based on record reviews 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 nursing staff to perform or assist in activities of daily living (ADLs) as per hospital policy for 2 of 2 (#2, #3) patients reviewed for ADLs from a total sample of 3; and 2.) failure of the RN to review and validate an initial admission assessment conducted by a LPN for 1 (#1) of 3 (#1, #2, #3) patients reviewed. Findings: 1.) Failure of the nursing staff to perform or assist in activities of daily living (ADLs) as per hospital policy for 2 of 2 (#2, #3) patients reviewed for ADLs from a total sample of 3. Review of the hospital’s policy titled “Personal Hygiene” effective date 09/21/2021, revealed in part, all patients shall be encouraged or assisted in grooming daily or more often as needed. Grooming articles such as bath soap dispenser, shampoo, body powder, shaving equipment, etc., are available per patient need. Shower or sponge bath to be provided with staff supervision and/or assistance. Patient #2 Review of Patient #2’s medical record revealed an admission date of 06/26/2024. Review of the skin assessment photographs revealed Patient #2 wearing the same clothes on 06/26/2024, 06/27/2024, and 06/29/2024. Review of the daily skin audit and bath sheets presented by S4DON and S3ADQ revealed the following: 06/26/2024- No bath given / Other: scabbed area 06/27/2024- No bath given 06/27/2024- Bath given / bed bath 06/28/2024- No bath given 06/29/2024- No bath given 06/30/2024- No bath given 07/01/2024- Bath given 07/01/2024- No bath given 07/02/2024- No bath given 07/02/2024- No bath given; date of last bath: 07/01/2024 / no findings 07/03/2024- No bath given 07/04/2024- Bath given / no findings 07/04/2024- No bath given 07/05/2024- No bath given 07/05/2024- No bath given 07/06/2024- Bath given / sponge bath / no findings No documentation for 07/07/2024 Review of the daily skin audit and bath sheets there was no documentation of Patient #2 having a bath on the following dates: 06/28/2024; 06/29/2024; 7/2/2024; 7/3/2024; 7/5/2024; and 7/7/2024. In an interview on 08/22/2024 at 9:52 a.m. S1CNO verified the expectation is daily bath/shower for patients. In an interview on 08/22/2024 at 9:55 a.m. while reviewing the skin assessment photographs, S2DQ verified Patient #2 was wearing the same clothes on 06/26/2024, 06/27/2024, and 06/29/2024. In an interview on 08/22/2024 at 12:25 p.m. S1CNO verified there was no documentation of Patient #2 having a bath on the above stated dates. Patient #3 Review of Patient #3’s medical record revealed an admission date of 08/10/2024. Review of the ADL documentation that was included in Patient #3’s medical record revealed on 08/10/2024 10:34 p.m. assisted with bath; 08/14/2024 10:43 p.m. bathed self; and 08/21/2024 12:02 a.m. complete (total) bath performed, hair shampoo, bathed self. There was no documentation of Patient #3 having a bath on the following dates: 08/11/2024; 08/12/2024; 08/13/2024; 08/15/2024; 08/16/2024; 08/17/2024; 08/18/2024; 08/19/2024; and 08/20/2024. In an interview on 08/22/2024 at 3:15 p.m. S1CNO verified there was no documentation of Patient #3 having a bath on the above stated dates. 2.) Failure of the RN to review and validate an initial admission assessment conducted by a LPN for 1 (#1) of 3 (#1, #2, #3) patients reviewed. Review of the hospital’s policy titled “Admission/Assessment” effective date 09/21/2021, revealed in part, at the time of admission each patient shall have an initial physical and psychological assessment completed by a registered nurse (RN). A licensed practical/vocational nurse (LPN or LVN) may conduct basic elements of the assessment under the direct supervision of a RN, and report these on the nursing assessment and to the RN. The RN will sign-off on any assessments performed by the LPN or LVN under the RN’s supervision. Review of Patient #1’s medical record revealed an admission date of 06/21/2024. Review of the initial admission assessment revealed the assessment was conducted on 06/21/2024 at 9:01 p.m. by S5LPN. Further review revealed no documentation of the assessment being reviewed and validated by a registered nurse. In an interview on 08/20/2024 at 2:54 p.m. S4DON verified S5LPN is a licensed practical nurse. S4DON stated an RN should have reviewed, verified, and signed the initial admission assessment. In an interview on 08/20/2024 at 2:56 p.m. S2DQ verified there was no documentation that a RN reviewed, verified, and signed Patient #1’s initial admission assessment.”

“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: 44763 Based on record reviews and interviews, the hospital failed to ensure that the nursing staff developed, and kept a current, and individualized nursing care plan for each patient that reflected the patient’s goals and the nursing care expected to meet the patient’s needs. This deficient practice was evidenced by: 1.) failing to update a care plan after a fall for 1 (#1) of 3 (#1, #2, #3) patients reviewed; and 2.) failing to create individualized care plans based on assessments for 1 (#2) of 3 (#1, #2, #3) patients reviewed. Findings: 1.) Failing to update a care plan after a fall for 1 (#1) of 3 (#1, #2, #3) patients reviewed. Review of the hospital’s policy titled “Master Treatment Plan, Treatment Team, Treatment Plan Updates” effective date 09/21/2021, revealed in part, the master treatment plan is continuously reviewed and updated for effectiveness. The plan is updated with findings and results from ongoing evaluations, assessments, and diagnostic testing. Each member of the interdisciplinary team contributes findings and updates in the treatment team process. The master treatment plan is kept current with these updates. Review of Patient #1’s medical record revealed an admission date of 06/21/2024 and a discharge date of 07/03/2024. Review of the nursing notes revealed in part, 07/03/2024 12:25 a.m.: 12:25 a.m.- notified by roommate that resident fell on buttocks coming from bathroom. Upon entering room resident was noted on floor near bed in sitting position. Complete head to toe assessment done. Bruise noted under right eye. Patient #1 was asked what happened “patient stated I don’t know” assisted to bed x2 staff members. Neuro checks initiated. Notified house supervisor, physician and family. No c/o pain or discomfort. Intervention to prevent future falls, maintain adequate lighting. There was no documentation of the care plan being updated after Patient #1’s fall and prior to Patient #1 being discharged the same day. In an interview on 08/21/2024 at 10:15 a.m. S1CNO verified the care plan should have been updated after Patient #1’s fall. 2.) Failing to create individualized care plans based on assessments for 1 (#2) of 3 (#1, #2, #3) patients reviewed. Review of the hospital’s policy titled “Master Treatment Plan, Treatment Team, Treatment Plan Updates” effective date 09/21/2021, revealed in part, C. Admitting Nurse/Charge Nurse: opens initial care plans for nursing services in the Master Treatment Plan, including the preliminary plans of care addressing psychiatric and non-psychiatric conditions, within eight (8) hours of admission. Opens the problem list of needs based on medical and psychiatric diagnoses and presenting symptomatology. Problem needs are listed and addressed in order of severity, beginning with psychiatric needs. Revises and develops the medical components of the master treatment plan based on ongoing assessment findings and physician’s orders. Review of Patient #2’s medical record revealed an admission date of 06/26/2024. Review of the weekly skin assessment dated 06/27/2024 at 11:43 p.m. revealed skin tear to back of left arm elbow and skin tear to back of upper left arm. Review of the weekly skin assessment dated 06/29/2024 at 9:14 a.m. revealed skin tear to back of left arm elbow, skin tear to back of upper left arm, and bruise to front of lower right leg. Review of the weekly skin assessment dated 07/06/2024 at 1:16 p.m. revealed skin tear to back of left arm elbow, skin tear to back of upper left arm, bruise to front of lower right leg, open wound to back of left hand, multiple skin tears to front of lower left leg, multiple scabs to back of lower right arm, redness to both sides of back and multiple scabs to back of lower left arm. Review of the treatment plan failed to reveal a plan related to skin integrity. Review of the progress note dated 07/08/2024 at 8:10 a.m. revealed in part, Medical F/U 07/03/2024- not eating or drinking much, 07/02/2024 IV fluid for hydration. Medical F/U today- Patient #2 with continued decline, likely aspirating with food. Patient with continued decline over the weekend - today not eating or drinking, on IV fluid for hydration. Review of the treatment plan failed to reveal a plan related to nutrition. In an interview on 08/22/2024 at 4:15 p.m. S1CNO verified skin integrity and nutrition were not addressed in Patient #2’s care plan. She stated skin integrity and nutrition should have been included in Patient #2’s care plan.”

“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: 44763 Based on record reviews and interviews, the hospital failed to ensure all practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, vital signs, and other information necessary to monitor the patient’s condition were contained in patients’ medical records. This deficient practice was evidenced by: 1.) failing to ensure an observation order for patients in a psychiatric unit was included in the medical record for 3 of 3 (#1, #2, #3) medical records reviewed; 2.) failing to ensure documentation of activities of daily living (ADLs) were included in the medical record for 1 (#2) of 2 (#2, #3) medical records reviewed for ADLs from a total sample of 3. Findings: 1.) Failing to ensure an observation order for patients in a psychiatric unit was included in the medical record for 3 of 3 (#1, #2, #3) medical records reviewed. Patient #1 Review of Patient #1’s medical record revealed an admission date of 06/21/2024. Review of the physician orders failed to reveal an order for observation for patients in a psychiatric unit. In an interview on 08/22/2024 at 4:00 p.m. S2DQ verified there was no documentation of an observation order in Patient #1’s medical record. Patient #2 Review of Patient #2’s medical record revealed an admission date of 06/26/2024. Review of the physician orders failed to reveal an order for observation for patients in a psychiatric unit. In an interview on 08/22/2024 at 10:13 a.m. S1CNO verified there was no documentation of an observation order in Patient #2’s medical record. She stated observation order is included in the order set but was not selected for Patient #2. Patient #3 Review of Patient #3’s medical record revealed an admission date of 08/10/2024. Review of the physician orders failed to reveal an order for observation for patients in a psychiatric unit. In an interview on 08/22/2024 at 2:20 p.m. S2DQ verified there was no documentation of an observation order included in Patient #3’s medical record. 2.) Failing to ensure documentation of activities of daily living (ADLs) were included in the medical record for 1 (#2) of 2 (#2, #3) medical records reviewed for ADLs from a total sample of 3. Review of Patient #2’s medical record revealed an admission date of 06/26/2024. Further review revealed ADLs were not documented in Patient #2’s medical record. The daily skin audit and bath sheets that were presented by S4DON and S3ADQ were kept on the unit. In an interview on 08/22/2024 at 9:44 a.m. S2DQ verified there was no documentation of ADLs, shower/bath, etc. included in Patient #2’s medical record. In an interview on 08/22/2024 at 11:02 a.m. S1CNO verified the daily skin audit and bath sheets were not part of Patient #2’s medical record. S1CNO stated ADLs should have been documented in Patient #2’s medical record.”