Hood Memorial Hospital

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Alarm Annunciator A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator. 6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99) This Standard is not met as evidenced by: 35367 Based on visual observation the facility is lacking a generator remote annunciator that is storage battery powered to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard wired to indicate alarm conditions of the emergency power source. A centralized computer system (e. g., building information system) is not to be substituted for the alarm annunciator. The deficiency has the potential to affect twelve of twenty five patients. Findings: During the facility tour March 23, 2026 between the hours of 7:30 a.m. to 10:30 a.m. the generator remote annunciator had a trouble alarm related to high water temperature and low water level. Additionally, a another generator annunciator was not energized. The interview with the Maintenance Director revealed the facility had defective sensors that were causing the annunciator to display alarms and the existing non energized generator annunciator would be removed.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 35367 Based on visual observation the facility failed to assure that the emergency generator was maintained and tested in accordance with NFPA 110. In cases of a power outage the emergency generator powers essential life safety equipment for the facility. The deficient practice had the potential to affect twelve of twenty five patients. Findings: During the facility tour on March 23, 2026 between the hours of 7:30 a.m. to 10:30 a.m. the two generators located outside shared a diesel tank and lacked a emergency stop with signage, lacked a no smoking sign, lacked a NFPA 704 emergency responders placard, lacked grounding of both generators and was missing a four hour load bank test. The interview with the Maintenance Director revealed the facility was unaware of the emergency stop, no smoking sign, NFPA 704 emergency responders placard. the grounding of both generators. But, was a aware a documented four hour generator load test was required. The Maintenance Director was in the process of remedying all the following items listed in the findings.”

“PATIENTS RIGHTS CFR(s): A CAH must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48050 Based on record reviews and interviews, the CAH failed to meet the requirements of the condition of participation of patient rights. This deficient practice was evidence by: 1) failure to provide nursing assessment and clinical justification for a patient in restraints per hospital policy (Tag C2540); 2) failure to ensure restraint and seclusion was used only when less restrictive interventions had been determined to be ineffective to protect the patient from harm (Tag C2551); and 3) failure to ensure documented completion of competency education of restraint usage by security staff members (Tag C2561).”

“LICENSURE, CERT., OR REG OF PERSONNEL CFR(s): Staff of the CAH are licensed, certified, or registered in accordance with applicable Federal, State, and local laws and regulations. This Standard is not met as evidenced by: 48050 Based on record review and interview, the CAH failed to ensure the contract staff met all applicable standards required by State or local law for CAH personnel. This deficient practice was evidenced by the CAH failing to ensure all security staff were trained, educated and evaluated on the CAH’s policies and procedures. Findings: Review of hospital security’s orientation education material revealed the following information: certification requirements, shift hours, security policy, contact information, parking, emergency codes, smoking policy, rounding requirements, emergency department duties, and PEC information. An interview on 03/11/2025 at 11:40 AM, S3RNEC revealed the hospital security orientation consisted of informational sheets/education left in a binder for the security officers to review and sign an attestation after reviewing the material. An interview on 03/11/2025 at 11:45 AM, S1QMD confirmed security officers do not have a job description and do not receive education on the CAH’s policies or procedures.”

“EQUIPMENT, SUPPLIES, AND MEDICATION CFR(s): Equipment, supplies, and medication used in treating emergency cases are kept at the CAH and are readily available for treating emergency cases. The items available must include the following: This Standard is not met as evidenced by: 50453 Based on observation and interview, the hospital failed to ensure facilities, supplies, and equipment were maintained to ensure an acceptable level of safety and quality. This deficient practice is evidenced by failing to ensure the glucometer Quality Control Solutions were properly labeled upon opening with an open date or beyond use date. Findings: Review of the Accu-Check Inform II Controls insert revealed in part the following: “Note: Write the discard date on the bottle label. The control solution is stable for 3 months after opening or until the Expiration date on the bottle label, whichever comes first.” Observations during a tour on 03/09/2026 from 9:37 AM - 10:33 AM revealed the glucometer Quality Control Solutions currently being used on Unit A were not labeled with an opening date or beyond use date. In an interview during the tour, S4CNO confirmed the above-mentioned findings. S4CNO confirmed the Quality Control Solutions should have been labeled upon opening.”

“DRUGS AND BIOLOGICALS ARE APPROPRIATELY STORE CFR(s): (3) Drugs and biologicals are appropriately stored; This Standard is not met as evidenced by: 50453 Based on observation and interview, the Critical Access Hospital failed to ensure outdated or otherwise unusable drugs and biologicals were not available for patient use as evidence by failing to remove expired Xopenex. Findings: Observations during a tour on 03/09/2026 from 9:37 AM - 10:33 AM of the facility revealed: Room ‘a’: - Xopenex (Levalbuterol Inhalation) 0.63mg/3ml, expiration date 2/28/26, quantity 17, available for patient use. In an interview during the tour, S4CNO confirmed the above-mentioned findings.”

“PREMISES ARE CLEAN AND ORDERLY CFR(s): (4) The premises are clean and orderly; and This Standard is not met as evidenced by: 50453 Based on observation and interview, the hospital failed to ensure the premises were clean and orderly. The deficient practice is evidenced by a hole in the door of Room ‘b’. Findings: Observations during a tour on 03/09/2026 from 9:37 AM - 10:33 AM revealed the following: Room ‘b’ -Hole in the interior side of the door with exposed wood. In an interview during the tour, S4CNO confirmed the above-mentioned findings.”

“PATIENT CARE POLICIES CFR(s): (1) The CAH’s health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law. This Standard is not met as evidenced by: 48050 Based on record review and interview, the CAH failed to ensure health care services were provided in accordance with their written policy. This deficient practice was evident by failure to ensure the provision of safe, appropriate care for patients with psychiatric emergencies per policy. Findings: Review of the CAH’s policy titled, “Restraints”, effective date 05/2005 and last reviewed 10/2025 revealed in part: Purpose: The purpose is to define the essential elements of the appropriate use of restraint or seclusion and the management of restraints or seclusion. Policy: All patients have the right to be free from physical and 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. E. What is not considered a Restraint? The use of handcuffs, manacles, shackles, other chain-type restraint devices, or other restrictive devices applied by non-hospital employed or contracted law enforcement officials for custody, detention, and public safety reasons are not governed by this policy. The use of such devices are considered law enforcement restraint devices and would not be considered safe, appropriate health care restraint interventions for use by hospital staff to restrain patients. Reasons for Restraints: Restraints may only be imposed to ensure the physical safety of the patient, a staff member, or others from harm after less restrictive interventions have been determined to be effective through the individual patient assessment. Only personnel who have passed competency testing shall be authorized to apply, monitor, and/or discontinue restraints. Less Restrictive Alternatives: Less restrictive alternatives are those activities used, or evaluated for use, to prevent the use of restraint devices. These alternatives may include, but are not limited to the following: education of patient and family, attempt comfort measures, administered ordered medication(s), relocate patient to minimize external stimuli, allowing patient’s family members to assist in observing the patient and/or eliciting his/her cooperation, therapeutic communication or verbal de-escalation, having hospital appointed sitters to assist and observe the patient, setting verbal limits, reasoning with the patient, redirection or distraction, and toileting. Restraint Orders: the restraint order must specify the reason for the restraint, the type of restraint, the duration of the restraint and frequency of patient assessments. Review of Patient #21’s medical record revealed on 11/19/2025 Patient #21 presented to the ED for evaluation for homicidal ideations. The nursing documentation at 8:00 PM documented Patient #21 was anxious and got in verbal argument with S12HSO when S12HSO tased Patient #21 then placing her in handcuffs. Further review of Patient #21’s medical record failed to reveal an order by a physician for restraints and failed to reveal documentation of the use of restraints according to hospital policy/procedures. Review of Patient #22’s medical record revealed on 03/03/2025 at 3:35 PM Patient #22 presented to the ED for evaluation. After evaluation by the ED MD Patient #22 was placed under a legal protective custody at 4:15 PM. The nursing documentation Patient #22 was placed in handcuffs at 6:05 PM and leg shackles at 6:28 PM with removal of handcuffs at 7:34 PM. Further review of Patient #22’s medical record failed to reveal an order by a physician for restraints or and failed to reveal documentation of the use of restraints according to hospital policy/procedures. In an interview on 03/11/2025 at 2:18 PM, S11EDRN verified the restraint policy was not followed and the only restraints used were handcuffs and leg shackles in the above medical records reviewed.”

“PATIENT CARE POLICIES CFR(s): (i) A description of the services the CAH furnishes, including those furnished through agreement or arrangement. This Standard is not met as evidenced by: 50453 Based on policy review and interview, the hospital failed to have written patient care policies that identified and described healthcare services provided through telemedicine. Findings: Review of the policies provided failed to reveal a written policy that identified the services provided through telemedicine. In an interview on 03/09/2025 at 12:50 PM, S1QMD confirmed the hospital does not have a policy for telemedicine.”

“AGREEMENTS AND ARRANGEMENTS CFR(s): §485.635(c)(4) The person principally responsible for the operation of the CAH under §485.627(b)(2) of this chapter is also responsible for the following: (i) Services furnished in the CAH whether or not they are furnished under arrangements or agreements. (ii) Ensuring that a contractor of services (including one for shared services and joint ventures) furnishes services that enable the CAH to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 14442 Based on observation, policy review, and interview, the hospital failed to ensure expired supplies were not available for use in the contracted dialysis service equipment storage room. Findings: Observation of the hospital dialysis equipment storage room with S1QMD on 03/09/2026 at 10:03 AM revealed the following expired supplies: One Statlock Catheter Stabilization Device expired 08/28/2025. One Monoject Hypodermic Safety needle expired 10/25/2025. Two BD Eclipse Needles expired 02/02/2026. One Clearlink System Secondary Medication Set expired 02/2026. Review of the hospital policy “Title: Expired Supplies. Effective Date: 04/01/2022” revealed, in part: “Purpose: To ensure not to use out of date items. Policy: It is the policy of Hood Memorial Hospital to monitor expiration dates on a regular basis and use items nearing the expiration date first whenever possible. Procedure: An integral part of maintaining a closed inventory control is the process of monitoring expired supply items. As new items are received the Materials Management employee will check expiration date and the ones expiring sooner will be placed to the front to be used first. By the last day of each month, the employee will pull supplies in Materials Management and ER that are expiring and properly dispose of that item.” In an interview on 03/09/2026 at 10:08 AM, S1QMD confirmed supplies found in dialysis equipment storage room expired. S1QMD confirmed dialysis was a contracted service and hospital responsible for contracted services.”

“NURSING SERVICES CFR(s): A nursing care plan must be developed and kept current for each inpatient. This Standard is not met as evidenced by: 48050 Based on record review and interview, the CAH failed to ensure the nursing staff developed, and kept current, a comprehensive nursing care plan based upon ongoing assessments of patients’ needs. This deficient practice was evidenced by failure to ensure patient care plans were inclusive of all medical diagnoses for 5 (#16, #17, #18, #19, #20) of 5 (#16, #17, #18, #19, #20) sampled patients reviewed for care plans. Findings: Review of the CAH’s policy titled, “Nursing Documentation Requirements”, effective date 09/30/2025 revealed in part: Purpose: To establish a policy for nursing documentation. Nursing documentation is intended to give a complete picture of patient’s status and activity. Policy: B. Care plans: Identify two or more nursing diagnosis driven plans of care. The attending nurse on each shift will review, address or resolve items on the plan of care. Review of the CAH’s policy titled, “Standards of Practice General Nursing”, last reviewed 10/2025 revealed in part: Policy: The emphasis is based on the process of assessment and problem identification. The standards are divided into assessment, diagnosis, outcomes identification, planning, implementation and evaluation. Standard I: comprehensive patient history and physical. Standard II: formation of nursing diagnosis. Standard III: identification of patient outcomes. Standard IV: development of nursing care plan. Standard V: implementation of nursing care plan. Standard VI: evaluation of the nursing process. Review of the CAH’s policy titled, “Initial Physical Assessment and Reassessment” effective date 09/30/2025 revealed in part: Policy: The assessment of the care or treatment required to meet the needs of the patient will be ongoing throughout the patient’s hospital stay, with the assessment process individualized to meet the needs of the patient population. Procedure: 5. Any change in the patient’s condition shall require an immediate reassessment with changes in the plan of care reflecting the change in condition. 6. The plan of care will be reviewed regularly in consultation with the patient/significant other and revised as patient’s condition or diagnosis changes. Review of Patient #16’s medical record revealed Patient #16 was admitted on 02/10/2026 with Influenza and Hypoxia. Further review of Patient #16’s care plan revealed the following nursing diagnosis: discharge planning, falls risk, and activity intolerance. Further review failed to reveal nursing diagnosis related to Patient #16’s admit diagnosis or interventions/goals/updates. Review of Patient #17’s medical record revealed Patient #17 was admitted on 12/05/2025 with the following diagnoses: Malaise, Polydipsia, Hyperglycemia, Lactic Acidosis, Hypomagnesemia, and Uncontrolled Diabetes. Further review of Patient #17’s medical record review did not reveal a care plan, but a problem list was found with the following problems: discharge planning, fall at risk, and risk for unstable blood glucose. Patient #17’s problem list failed to reveal documented evidence of interventions, goals, or updates. Review of Patient #18’s medical record revealed Patient #18 was admitted on 11/01/2025 for wounds, UTI, AKI, and Hyperglycemia. Further review of Patient #18’s care plan revealed the following nursing diagnosis: discharge planning, fall risk, and alteration in comfort. Further review failed to reveal nursing diagnosis related to Patient #18’s admit diagnosis or interventions/goals/updates. Review of Patient #19’s medical record revealed Patient #19 was admitted on 03/17/2025 for CHF, COPD, Hepatic Cirrhosis, Seizures, and Throat Cancer. Further review of Patient #19’s medical record did not reveal a care plan, but a problem list was found with the following problems: impaired physical mobility, fall at risk, and discharge planning. Patient #19’s problem list failed to reveal documented evidence of interventions, goals, or updates. Review of Patient #20’s medical record revealed Patient #20 was admitted on 03/05/2025 for multiple wounds, Dementia, CAD, COPD, CVA, and HTN. Further review of Patient #20’s medical record did not reveal a care plan, but a problem list was found with the following problems: discharge planning, impaired swallowing, activity intolerance, and alteration in comfort. Patient #20’s problem list failed to reveal documented evidence of interventions, goals, or updates. In an interview on 3/11/2026 at 9:45 a.m., S21LPN showed a computer screen by S1QMD which revealed the patient’s medical records titled Care Plans, S21LPN said that she did not know how to get to that screen in the computer charting system. After reviewing the care plans for Patient #1, Patient #2 and Patient #2, S1QMD verified the care plans on that screen were computer generated and had not been individualized by the nursing staff. In an interview on 03/11/2026 at 11:30 AM, S3RNEC verified the above mentioned information.”

“RECORDS SYSTEM CFR(s): The records are legible, complete, accurately documented, readily accessible, and systematically organized. This Standard is not met as evidenced by: 48050 Based on record review and interview, the CAH failed to ensure the provider documented all orders provided in patient care. The deficient was practice is evidenced by failure to document an order for a DNR in 1(#20) of 1(#20) medical records reviewed for life sustaining measures. Findings: Review of the CAH’s policy titled, “Withholding or Withdrawal of Life Sustaining Measures”, revealed in part: PROCEDURE: When a decision to place limits on the resuscitative efforts performed on a patient has been reached: An order for “No Code” or “Do Not Resuscitate” or an order to with draw a specific supportive measure(s), will be written by a physician caring for the patient and communicated to the nursing staff. Review of Patient #20’s medical record revealed Patient #20 was admitted on 03/05/2025 for wound care and therapy. Further review of Patient #20’s medical record revealed on 04/10/2025 Patient #20 became unresponsive with low blood pressure and a rapid response code was called by staff. At this time S9NP contacted Patient #20’s two daughters to discuss code status which Patient #20’s 2 daughters agreed to intubation but did not wish for chest compression in the event that Patient #20 went into cardiopulmonary arrest. In Patient #20’s medical record was a form dated 04/10/2025 that documented a telephone consent from Patient #20’s two daughters that “ok intubation, no chest compressions” signed by S10CN and S9NP. Further review failed to reveal an order for the DNR. In an interview on 03/11/2025 at 11:20 AM, S8MRT confirmed the above mentioned information.”

“QAPI CFR(s): (b) Standard: QAPI Program Design and scope. The CAH’s QAPI program must: (5) Address outcome indicators related to improved health outcomes and the prevention and reduction of medical errors, adverse events, CAH acquired conditions, and transitions of care, including readmissions. This Standard is not met as evidenced by: 48050 Based on record review and interview, the CAH failed to ensure the Quality Assessment Performance Improvement program addressed outcome indicators related to improved health outcomes and the prevention and reduction of adverse events. This deficient practice was evidenced by failing to ensure recommendations were completed following a RCA of an identified issue with an incident of a patient (#21) being tazed by hospital security. Findings: Review of the CAH’s policy titled, “Safety Event Recognition and Incident Reporting”, effective date 12/2021 and last reviewed 10/2025 revealed in part: Purpose: To define safety events and describe the process of reporting these. Event category and severity definitions: Temporary Harm: F. Event contributed or resulted in temporary harm AND required additional intervention or care. 1. Procedure: c. Trending and Continued Improvement: Safety Events will be trended to ensure that the actions developed at the time were implemented, tested, and revised as needed for continued compliance with the policy, process and education intended to prevent recurrence. Information is reported through Quality Committee, Leadership, and Board Reports. Review of the CAH’s policy titled, “Quality Assessment and Performance Improvement (QAPI) Plan”, effective date 11/2022 and last reviewed 10/2025 revealed in part: Procedure: The QAPI program responsibilities include monitoring, evaluating, and improving the quality of services provided. The goal is to identify problems, potential problems, and failures in systems or processes that involve the patients’ health and safety to initiate plans of correction. A. Governance & Oversight: b. Quality Committee- The Quality Committee is responsible for monitoring and improving the quality of care, safety, and service provided by staff. E. Improving Performance: d. Patient Safety and Event Learning- Activities track medical errors and adverse patient events, analyze causes, implement preventive actions, and create feedback and learning loops throughout the organization. Success is measured by post-implementation, with continued monitoring to ensure gains are sustained. Additional action is taken when improvements are not achieved or maintained. Review of the CAH’s incident report log revealed a submission ID #A25-000207; date of incident 11/19/2025; described as an unanticipated event related issue in the emergency room with an OPC/PEC patient. Review of the Submission ID #A25-000207 Occurrence Reporting revealed on 11/19/2025 at 8:00 PM Patient #21 was a PEC patient who was tased by hospital security. The final investigation revealed severity of outcome was documented as temporary harm- category F. The following recommendations were made from the final investigations: 1. Provide more expectations for the Code White policy, which was completed 12/2025, 2. Review expectations of security guard for PEC patients scheduled to be completed 03/2026, 3. Review and update PEC patient policy for the ED which was not done, 4. Expand Centrak to downstairs so that the panic button and tracker could be used which was completed 12/2025, and 5. Quality Director to schedule follow up meeting to determine progress made on these recommendations from the team which is unknown. An interview on 03/11/2026 at 1:16 PM, S1QMD reported all recommendations had been completed, but upon request of verification, S1QMD confirmed the PEC Policy for the ED had not been reviewed/updated and the ED staff had not been educated.”

“QAPI CFR(s): (d) Standard: Program activities. For each of the areas listed in paragraph (b) of this section, the CAH must:] (2) Use the measures to analyze and track its performance. This Standard is not met as evidenced by: 48050 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 identify and investigate potential allegations of abuse. Findings: Review of the CAH’s policy titled, “Safety Event Recognition and Incident Reporting”, effective date 12/2021 and last reviewed 10/2025 revealed in part: Purpose: To define safety events and describe the process of reporting these. Event category and severity definitions: No Harm: D. Event increased the need for monitoring or evaluation but caused no harm. 1. Procedure: c. Trending and Continued Improvement: Safety Events will be trended to ensure that the actions developed at the time were implemented, tested, and revised as needed for continued compliance with the policy, process and education intended to prevent recurrence. Information is reported through Quality Committee, Leadership, and Board Reports. 2. Evaluation to determine designation of serious safety events will include, preventability, detectability, deviation from policy/procedure. Review of the CAH’s policy titled, “Restraints”, effective date 05/2005 and last reviewed 10/2025 revealed in part: Purpose: The purpose is to define the essential elements of the appropriate use of restraint or seclusion and the management of restraints or seclusion. Policy: All patients have the right to be free from physical and 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. E. What is not considered a Restraint? The use of handcuffs, manacles, shackles, other chain-type restraint devices, or other restrictive devices applied by non-hospital employed or contracted law enforcement officials for custody, detention, and public safety reasons are not governed by this policy. The use of such devices are considered law enforcement restraint devices and would not be considered safe, appropriate health care restraint interventions for use by hospital staff to restrain patients. Reasons for Restraints: Restraints may only be imposed to ensure the physical safety of the patient, a staff member, or others from harm after less restrictive interventions have been determined to be effective through the individual patient assessment. Only personnel who have passed competency testing shall be authorized to apply, monitor, and/or discontinue restraints. Review of the CAH’s incident report log revealed a submission ID #A25-000041; date of incident 03/03/2025; described as a behavioral health related issue in the emergency room with an OPC/PEC patient. Review of the Submission ID #A25-000041, “Occurrence Reporting,” revealed on 03/03/2025 at 6:00 PM, Patient #22 was a PEC patient who hospital security attempted to tase then placed in handcuffs and leg shackles. The final investigation revealed the severity of outcome was documented as no harm (category D), and no recommendations noted or further actions required. In an interview on 03/11/2026 at 12:20 PM, S1QMD verified that the above safety event was not reported or analyzed by the Quality Committee. In an interview on 03/11/2026 at 1:25 PM, S12HSO confirmed he had tased patients in the past while working security at the hospital.”

“ORGAN, TISSUE, & EYE PROCUREMENT CFR(s): Ensure that the CAH works cooperatively with the designated OPO, tissue bank and eye bank in educating staff on donation issues, reviewing death records to improve identification of potential donors, and maintaining potential donors while necessary testing and placement of potential donated organs, tissues, and eyes takes place. §485.643(f) For purpose of these standards, the term “organ” means a human kidney, liver, heart, lung, pancreas, or intestines (or multivisceral organs). This Standard is not met as evidenced by: 50453 Based on policy review and interview, the hospital failed to have written policies and procedures in place to address its organ procurement responsibilities. Findings: Review of the hospital policies and procedures provided failed to reveal a written policy for organ procurement responsibilities. In an interview on 03/10/2026 at 9:41 AM, S1QMD confirmed the hospital does not have a written policy for its organ procurement responsibilities.”

“RESTRAINT AND SECLUSION CFR(s): 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: 48050 Based on record reviews and interview, the CAH failed to ensure patients 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 the CAH’s policy titled, “Restraints”, effective date 05/2005 and last reviewed 10/2025 revealed in part: Purpose: The purpose is to define the essential elements of the appropriate use of restraint or seclusion and the management of restraints or seclusion. Policy: All patients have the right to be free from physical and 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. A. What is a Restraint? A restraint is any manual method, physical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. E. What is not considered a Restraint? The use of handcuffs, manacles, shackles, other chain-type restraint devices, or other restrictive devices applied by non-hospital employed or contracted law enforcement officials for custody, detention, and public safety reasons are not governed by this policy. The use of such devices are considered law enforcement restraint devices and would not be considered safe, appropriate health care restraint interventions for use by hospital staff to restrain patients. Reasons for Restraints: Restraints may only be imposed to ensure the physical safety of the patient, a staff member, or others from harm after less restrictive interventions have been determined to be effective through the individual patient assessment. A comprehensive assessment of the patient must determine that the risk associated with the use of restraints is outweighed by the risk of not using the restraint. Restraint Orders: The restraint order must specify the reason for the restraint, the type of restraint, and duration of the restraint and frequency of patient assessments. Review of Patient #21’s medical record revealed on 11/19/2025 Patient #21 presented to the ED for evaluation for homicidal ideations. The nursing documentation at 8:00 PM documented Patient #21 was anxious and got in verbal argument with S12HSO when S12HSO tased Patient #21 then placing her in handcuffs. Further review of Patient #21’s medical record did not reveal documented evidence of a nursing assessment or clinical justification related to restraints. Review of Patient #22’s medical record revealed on 03/03/2025 at 3:35 PM Patient #22 presented to the ED for evaluation. After evaluation by the ED MD Patient #22 was placed under a legal protective custody at 4:15 PM. The nursing documentation revealed the following: 6:00 PM: Patient #22 became aggressive attempting to run down ED hallway so S13HSO tased Patient #22. 6:05 PM: Patient #22 placed in handcuffs by S13HSO. 6:28 PM: Patient #22 attempted to run through ED doors, so S13HSO placed leg shackles on Patient #22. 7:34PM: Patient #22 sleeping on stretcher, calm; so handcuffs removed. Further review of Patient #22’s medical record failed to reveal documented evidence of a nursing assessment or clinical justification related to restraints. Review of the CAH’s security personnel sign in sheets revealed S12HSO was working on 11/19/2025 as hospital security and S13HSO was working on 03/03/2025 as hospital security. In an interview on 03/11/2025 at 2:15 PM, S11EDRN confirmed the above mentioned information.”

“RESTRAINT AND SECLUSION CFR(s): The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient, a staff member, or others from harm. This Standard is not met as evidenced by: 48050 Based on observation, record review and interview, the CAH failed to ensure restraint and seclusion was used only when less restrictive interventions had been determined to be ineffective to protect the patient from harm for 2 (#21, #22) of 2 (#21-#22) sampled patients reviewed for restraint and seclusion. Findings: Review of the CAH’s policy titled, “Restraints”, effective date 05/2005 and last reviewed 10/2025 revealed in part: Purpose: The purpose is to define the essential elements of the appropriate use of restraint or seclusion and the management of restraints or seclusion. Policy: All patients have the right to be free from physical and 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. A. What is a Restraint? A restraint is any manual method, physical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. E. What is not considered a Restraint? The use of handcuffs, manacles, shackles, other chain-type restraint devices, or other restrictive devices applied by non-hospital employed or contracted law enforcement officials for custody, detention, and public safety reasons are not governed by this policy. The use of such devices are considered law enforcement restraint devices and would not be considered safe, appropriate health care restraint interventions for use by hospital staff to restrain patients. Reasons for Restraints: Restraints may only be imposed to ensure the physical safety of the patient, a staff member, or others from harm after less restrictive interventions have been determined to be effective through the individual patient assessment. Less Restrictive Alternatives: Less restrictive alternatives are those activities used, or evaluated for use, to prevent the use of restraint devices. These alternatives may include, but are not limited to the following: education of patient and family, attempt comfort measures, administered ordered medication(s), relocate patient to minimize external stimuli, allowing patient’s family members to assist in observing the patient and/or eliciting his/her cooperation, therapeutic communication or verbal de-escalation, having hospital appointed sitters to assist and observe the patient, setting verbal limits, reasoning with the patient, redirection or distraction, and toileting. Review of Patient #21’s medical record revealed on 11/19/2025 Patient #21 presented to the ED for evaluation for homicidal ideations. The nursing documentation at 8:00 PM documented Patient #21 was anxious and got in verbal argument with S12HSO when S12HSO tased Patient #21 then placing her in handcuffs. Review of Patient #22’s medical record revealed on 03/03/2025 at 3:35 PM Patient #22 presented to the ED for evaluation. After evaluation by the ED MD Patient #22 was placed under a legal protective custody at 4:15 PM. The nursing documentation revealed the following: 6:00 PM: Patient #22 became aggressive attempting to run down ED hallway so S13HSO tased Patient #22. 6:05 PM: Patient #22 placed in handcuffs by S13HSO. 6:28 PM: Patient #22 attempted to run through ED doors, so S13HSO placed leg shackles on Patient #22. 7:34PM: Patient #22 sleeping on stretcher, calm; so handcuffs removed. In an interview on 03/11/2025 at 2:20 PM, S11EDRN verified that less restrictive alternatives were not used or documented in the ED medical record of Patient #21 and Patient #22.”

“RESTRAINT AND SECLUSION CFR(s): The CAH must provide patient- centered, trauma informed competency- based training and education of CAH personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the CAH, on the use of restraint and seclusion. This Standard is not met as evidenced by: 48050 Based on observation, record review, and interview the CAH failed to ensure contracted staff were trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion. This deficient practice was evidenced by the failure to ensure documented completion of competency education of restraint usage by 7 (S12HSO, S13HSO, S14HSO, S15HSO, S16HSO, S17HSO, S18HSO, S19HSO, S20HSO) of 7 security staff members. Findings: Review of the CAH’s policy titled, “Emergency Department Security”, effective date 03/15/2025 and last reviewed 10/2025 last revealed in part: Policy: Procedures which address the safety and security of patients, personnel and visitors will be followed by all personnel working in the Emergency Department. Procedure: All Emergency Department/and hospital staff in direct patient care will receive training on management of aggressive behaviors or similar training provided. Training on handling disruptive and violent persons will be implemented during orientation and annually thereafter. Education: *Principles, techniques, and skills used to recognize, reduce, and manage anxious, aggressive, and violent behavior. * HMH will provide training under the direct supervision of a qualified instructor in a classroom. Contacted security companies will provide evidence of appropriate aggressive management training provided by the contractor’s company. *Restraining techniques. *Proper care of the psychiatric patient. Review of hospital security’s orientation education material revealed the following information: certification requirements, shift hours, security policy, contact information, parking, emergency codes, smoking policy, rounding requirements, emergency department duties, and PEC information. An interview on 03/11/2025 at 11:40 AM, S3RNEC revealed hospital security orientation consisted of informational sheet/education left in a binder for the security officers to review and sign an attestation after reviewing the material. In an interview on 03/11/2025 at 11:45 AM, S1QMD confirmed security officers do not receive restraint/seclusion education. In an interview on 03/11/2026 at 1:25 PM, S12HSO confirmed he had not received any training.”