Beaumont Hospital - Dearborn

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 47415 Based on interview and record review, the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to provide a complete medical screening exam (MSE) for 1 patient (P-1) of 21 patients reviewed, resulting in the potential for harm to P-1 and her fetus. Findings include: See tag 2406: Failure to provide a medical screening exam.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 47415 Based on interview and record review, the facility failed to ensure an appropriate medical screening exam was conducted for 1 (P-1) of 21 patients reviewed resulting in the potential for unrecognized, unmet patient needs and poor patient outcomes. Findings include: Record review on 4/14/2026 at 1300 revealed P-1 presented to the Emergency Department (ED) on 3/10/2026 at 0941 via private vehicle, with triage initiated at 0949. Provider documentation at 1002 indicated P-1’s chief complaints included shortness of breath (worsening in the supine position), chest pressure, and intermittent bilateral lower extremity swelling for three days. The patient reported she was 27 weeks pregnant. The ED evaluation included laboratory testing and an electrocardiogram. However, the medical record lacked evidence that the medical screening examination sufficiently addressed possible complications to the pregnancy and to the fetus. A provider order for fetal heart tones (FHT) was entered on 3/10/2026 at 1001 and acknowledged by nursing staff at 1131; however, there was no documentation that FHT assessment was performed, confirmed during record review and interview with Staff F on 04/15/26 at 1030. There was no documentation that obstetrical services were notified, consulted, or involved in the evaluation, monitoring, or plan of care for a patient at 27 weeks gestation presenting with cardiopulmonary symptoms. Laboratory results included an abnormal protein/creatinine ratio; however, there was no documentation that the result was reviewed, addressed, or communicated to the patient prior to discharge. P-1 was discharged from the ED with instructions to follow up with a primary care provider and obstetrician and to return if symptoms worsened. Discharged on 3/10/26 at 1335. Record review from a second facility revealed P-1 presented on 3/11/2026 at 0202 with abdominal pain radiating to the back and difficulty breathing when lying flat. The patient was diagnosed with chronic hypertension with superimposed preeclampsia and required transfer to a higher level of care on 3/11/26 at 0416 via advanced life support ambulance. Record reviews from a third facility revealed P-1 arrived on 3/11/2026 at 0516 and was treated for preeclampsia. When P-1 developed additional symptoms, and a decision was made to do a cesarean section, delivery time recorded as 3/11/2026 at 2141. Interviews conducted on 4/15/2026, in the administrative conference room revealed: ED Provider Staff O, interviewed at 1045, stated diagnostic testing was performed; however, he did not recall whether fetal heart tones were assessed and indicated the urine protein creatine ratio laboratory resulted close to or after discharge and was not addressed with the patient. Chief of Emergency Department Staff N, interviewed at 1120, stated expectations for evaluation of a pregnant patient with cardiopulmonary symptoms would include an assessment for pregnancy-related complications, including a fetal heart tone assessment, and if needed an obstetrical consultation for further management or monitoring. OB/GYN Staff CC, interviewed at 1330, by phone, stated an obstetrical consultation is expected for patients greater than 16 weeks gestation evaluated in the ED for shortness of breath and chest pressure, for the assessment of fetal health status (FHT/non stress test) and the development of a monitoring or disposition plan. Review of facility policy with Staff F, titled “Evaluation of Obstetrical Patients in the Emergency Department” dated 7/21/2024, patients greater than “16 weeks ...Medical issues/infectious process...ED Management is appropriate for non-obstetrical issues ...if greater than 23...Confirm viability and call OB senior for OB plan ...Complication of pregnancy ...Transfer to L&D”. Review of policy, with Staff G, titled, “Assessment Standards for Nursing: Emergency Services” dated 7/19/24, revealed on page 6, in table under the heading “Additional Assessments”, “The RN should complete additional assessment components ...Fetal Heart Tones: Assessed on gravida patients presenting at 12 weeks gestational age or greater”.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) [the patient must be seen face-to-face within 1 hour after the initiation of the intervention -- ] §482.13(e)(12)(ii)To evaluate - 1. The patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. This Standard is not met as evidenced by: 50585 Based on interview and record review, the facility failed to document the completion of a face-to-face medical evaluation for a patient placed in four-point violent restraints for 1 (P-7) of 3 patients reviewed for restraint monitoring, resulting in the increased likelihood of negative consequences and a loss of patient rights for the patient. Findings include: On 12/1/2025 at 1400, P-7’s medical record was reviewed with Accreditation Specialist Lead Staff F and Chief Nursing Officer Staff C. On 8/13/2025 at 0140, P-7 arrived at the facility’s Emergency Department and was immediately placed in four-point violent restraints. On 8/13/2025 at 0225, P-7’s nursing note revealed “Pt was placed in 4-point restraints on arrival due to harm to self and others. (Physician) at bedside trying to explain to patient proper behavior to get out of restraints. PT then stated, “get me out so I can punch you in the fucking face”.” P-7’s four-point violent restraints were discontinued on 8/13/2025 at 0240. A review of the medical record revealed that a face-to-face evaluation was not documented as being performed. Staff F confirmed the findings at the time of discovery. According to the facility’s policy “Restraints: Care of the Patient in Restraints,” dated 7/21/2024, under “Violent Restraints, A face-to-face assessment is required by a Provider within one hour after restraint initiation.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 45246 Based on interview and record review, the facility failed to ensure restraint care plans and orders were complete for 2 (P-1, 4) of 2 patients reviewed for restraints and failed to complete restraint monitoring documentation for 1 (P-1) of 2 patients reviewed for restraints, resulting in the potential for unrecognized care needs and the potential for harm. Findings include: See tags: A-0166 Failure to complete restraint care plan A-0173 Failure to obtain order for restraints A-0175 Failure to complete restraint monitoring documentation”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 45246 Based on interview and record review, the facility failed to consistently document use of restraints in a plan of care for two restrained patients (P-1 and 4) of 2 patients reviewed for restraints, resulting in possible negative outcomes for the patients. Findings include: P-1 Record review for P-1 on 3/03/25 revealed the following documentation: Physician order- non-violent 2-point soft restraints on 09/25/24 1113, discontinued on 09/26/24 at 0318. No nursing documented care plan for restraints was identified for a day shift on 09/25/24. P-4 P-4 medical record was reviewed on 3/04/25 and revealed: Patient was placed in 2-point soft restraints (per provider’s order) on 2/25/25 at 2054. Restraints were discontinued on 03/02/25 at 2122. Review of nursing plan of care for restraints revealed that no updates to care plan were documented on 2/26/25 night shift, 2/27/25 day and night shift, 2/28/25 day and night shift, and 3/01/25 night shift. On 3/04/25 at 1200 nurse educator, Staff V, was asked how often nurses should document plan of care for patients in restraints. Staff V stated that nurses need to update plan of care every shift. Facility policy “Restrains: Care of the Patient in Restraints”, effective 07/21/24, was reviewed and revealed: “III. Use of Restraints A. Ordering Requirements 1. Non-Violent Restraints m. Restraints will be documented on the patient’s plan of care.” Facility policy “Patient Plan of Care”, effective 07/21/24, was reviewed and revealed: C. Inpatient and Inpatient Rehab Plan of Care: vi. Documentation of patient progress and an outcome/summary statement is recommended on change in patient condition and minimally twice per day for hospitalized patients.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) [Unless superseded by State law that is more restrictive,] (iii) Each order for restraint used to ensure the physical safety of the non-violent or non-self-destructive patient may be renewed as authorized by hospital policy. This Standard is not met as evidenced by: 45246 Based on interview and record review, the facility failed to assure there was a provider order for the restraints for two restrained patients (P-1 and 4) of 2 patients reviewed for restraints, resulting in possible negative outcomes for the patients. Findings include: P-1 Record review for P-1 on 3/03/25 revealed the following documentation: There was a nursing note dated 9/24/24 1819: “Patient verbalized behaviors needed to remain out of restraints. Restraints initiated at 1345 and discontinued 1435.” Further review of the nursing documentation indicated that P-1 was placed in 4-point soft restraints. Internal medicine note dated 9/25/2024 1121 revealed: under “assessment and plan- Acute agitation, Possible Delirium. - Patient has fluctuating cognition and has had multiple episodes of aggressive and agitated behavior. - 9/24: removed foley catheter and IV lines. Had to be placed on soft restraints for a few hours - 9/25: In morning was pleasant and understandable to plan, later in day was attempting to remove NG (nasogastric tube) tube and IV (intravenous) lines. Plan- Placed on soft restraints again.” Further record review for P-1 revealed no provider order for application or discontinue of 4-point soft restraints on 9/24/24. P-4 P-4’s medical record was reviewed on 3/04/25 and revealed the following: P-4 had nursing Q2h (every 2 hours) non-violent restraints assessments documented consistently on 02/28/25. No provider order for 2-point restraints were found for 02/28/25. On 03/03/25 at 1206 during interview with nurse manager, Staff L, regarding restraints policy and provider’s orders he stated that provider has to re-new restraints orders daily and assess the patients. Facility policy “Restraints: Care of the Patient in Restraints”, effective 07/21/24, was reviewed and revealed: “II. Purpose of Restraints A. Non-Violent Restraint: Restraints are used when needed to manage non-violent behavior that jeopardizes the immediate physical safety of the patient. III. Use of Restraints. A. Ordering Requirements a. Restraints may be initiated by the order of the physician, NP or PA (Provider) responsible for the patient’s care. d. In emergent situations, when the need for intervention occurs so quickly that an order cannot be obtained prior to application of physical restraints, an RN may initiate physical restraint based on assessment of the patient. The RN will notify the Provider within minutes of restraint application once the patient is safe and obtain the appropriate order. The assessment and restraint intervention must be documented by the RN. f. A daily evaluation of the patient by a Provider is required. l. Orders must be renewed daily.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 45246 Based on interview and record review, the facility failed to consistently assess and monitor 1 restrained patient (P-1) of 2 patients reviewed for restraints, resulting in risk for patients’ physiological needs not being met, potentially unnecessary restraints, and incomplete restraint assessments. Findings include: Record review for P-1 revealed the following documentation: Physician order- non-violent 2-point soft restraints on 09/25/24 1113, discontinued on 09/26/24 at 0318. Nursing note dated 09/25/24 1431 indicated: “1105 am TMS (telemonitoring system) alarming. RN walked into room. Leads off. Found patient (P-1) getting out of bed again. Pulling on NG (nasogastric tube). Patient redirected back to bed and bilateral soft wrist restraints applied, Dr. [name] notified. Received order for bilateral soft wrist restraints. Order placed.” Further record review revealed nursing Q2h (every 2 hours) non-violent restraints assessment completed on 09/25/24 at 1112 and next on 09/25/24 at 1714 (with 2 assessments missing). Physician order for P-1 for non-violent 2-point soft restraints was placed on 09/26/24 0319, discontinued on 09/26/24 at 2246. Nursing Q2h (every 2 hours) non-violent restraints assessment review revealed the last assessment was completed on 09/26/24 at 1600. No assessments were documented for 1800, 2000 and 2200 before restraints were removed at 2247. On 03/03/25 at 1206 during interview with nurse manager, Staff L, regarding restraints policy, assessments and orders he stated that nursing assessments are completed Q2h for non-violent restraints, including the assessment for the need of the restraints. Facility policy “Restraints: Care of the Patient in Restraints”, effective 07/21/24, was reviewed and revealed: “2. Non-violent Restraint: Assessment and Documentation c. Every 2 hours, the RN will complete and document (or delegate to an LPN or NSS the: i. Offering of nutrition, hydration, and toileting ii. Repositioning of the patient iii. Completion of range of motion as appropriate iv. Release/reapplication of physical restraints d. Every 2 hours, the RN will complete and document an assessment that includes: i. Patient behavior continues to require restraints ii. Current restraints continue to be appropriate for the behavior iii. Condition of restrained area including circulation, evidence of edema and skin condition iv. Patient’s behavior that places the patient or others at risk v. Physical and psychological status vi. Comfort.””