Sinai-Grace Hospital

“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: 48772 Based on observation, interview and record review, the facility failed to provide a safe environment for one patient with a legal guardian who was determined to not have capacity for decision making (P-2) of 10 patients reviewed, who eloped from the facility. Findings include: P-2 is a 36-year-old male with a past medical history of alcohol use disorder, alcohol withdrawal seizures, and schizophrenia. P-2 presented to the emergency room on 4/5/26 with complaints of two weeks of constipation with abdominal pain and a wound on the left jaw from prior cyst excision. During record review on 4/10/26, it was noted that P-2 has a history of schizophrenia, treated with medication, but was not in acute psychosis on admission. A psychiatric consultation was ordered for capacity as P-2 refused colonoscopy. The consultation, documented on 4/6/26 at 1338, indicated that P-2 had a legal guardian. The record indicated a video monitoring system was initiated by a registered nurse on 4/6/26 at 1500 which indicated the reasons for monitoring as fall prevention and elopement. Video monitoring logs indicate P-2 was monitored hourly from 4/6/26 at 1500 until 4/8/26 at 0326. Record review indicated internal medicine progress note, dated 4/6/26 at 1805, indicated P-2 has a legal guardian and that, “Patient cannot leave AMA (against medical advice).” Record review indicated an antipsychotic medication used to treat schizophrenia, 4mg was ordered daily. On 4/7/26 at 0900, the record states, “patient/family refused” medication. A tour of cardiac telemetry unit was conducted on 4/10/26 from 0945 to 1030. P-2’s room was observed toward the end of the hallway, away from the nurses’ station, and near a stairwell. An interview was conducted with the cardiac telemetry nurse manager (Staff J) on 4/10/26 at 1025. Staff J stated that on 4/8/26, she received a call from the patient care coordinator (Staff T) that P-2 had eloped from the facility. Staff T followed the patient into the stairwell and out onto the hospital grounds and notified security. Record review indicates a nursing note, completed by Staff T on 4/8/26 at 0353 which stated, “Pt (patient) video monitor alarmed. Pt observed exiting unit and climbing under gate off hospital premise. Nurse followed patient while maintaining a safe distance. Security notified immediately. Pt verbalized, “ I am not going back inside.” and refused redirection despite education on need to remain in the hospital. Pt also verbalized that he snatch out his IV. Security currently maintaining visual observation and stated that patient is refusing to return. Guardian phoned with no answer, voicemail left on phone. (City) police contacted. Physician contacted. Pt remains outside of facility at this time in care/observation of security and law enforcement at this time.” [sic] An interview was conducted with security sergeant (Staff X) on 4/14/26 at 1410. Staff X stated that she received a call from a nurse (Staff U) on 4/8/26 at 0327 that P-2 was leaving the facility AMA. Staff X stated that officers were dispatched on foot and by mobile unit. Staff X stated that P-2 had refused to return to the facility. Staff X stated that the officers had left the patient when the nurse called back, after realizing that P-2 had a guardian. Staff X stated that the local police department was contacted at 0500 to locate the patient. An interview was conducted with the CNO (Staff B) and ACNO (Staff E) on 4/14/26 at 1434. Staff E confirmed that P-2 did not have an order for elopement precautions. Staff B was queried on the process if a patient who has a guardian elopes from the facility and replied, “we do everything in our power to keep them here. We work closely with our security staff and (local police department).” A request was made to review the facilities elopement and AMA policies and Staff E stated there are no policies for general admission patients (versus inpatient behavioral health). At 1753, Staff B phoned surveyor indicating an elopement policy was located. Policy - Patient Elopement Prevention - ECHO Alert (Effective 6/26/23). Elopement Prevention includes the following: 1. Constant Observer 2. Chart Flagging-at minimum, “elopement precautions” is added to the patient’s problem list in the electronic medical record. 3. Visual Cue-a sign identifying the patient is on elopement precautions is placed outside the patient’s doorframe and above the patient’s bed. 4. Clothing/Property-At-risk and vulnerable patients are instructed to change into green paper scrubs or green gowns. Policy - Constant Observer Patients Under Harm Precautions (Effective 8/15/24). Nurse Driven Interventions to Consider stated, “Relocate patient to a room close to nurses’ station.” The facility failed to provide a safe environment for P-2 by not instituting elopement prevention strategies per policy including chart flagging, visual cues, green scrubs, relocating patient room closer to nurses’ station, and by not clearly labelling the chart with guardianship status.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 50223 Based on interview and record review, the facility failed to provide nursing care in accordance with facility policy for pressure injury prevention and treatment for 1 of 10 sampled patients (P-1), resulting in the development of a hospital-acquired stage 2 pressure injury and delayed and inconsistent implementation of prevention and treatment interventions. Findings include: Record review revealed Patient #1 (P-1), was admitted to the Emergency Department (ED) on 2/20/26 at 1954 and remained in the ED until transfer to the stepdown unit on 2/25/26. Record review did not identify documentation of a pressure injury upon arrival to the ED. Review of ED documentation revealed a nursing note dated 2/25/26 documented the patient’s buttocks as reddened. No documentation of pressure injury prevention interventions, including repositioning/turning, offloading, or skin protection measures, was identified during the patient’s 5 day ED stay. During an interview conducted on 4/14/26 at 1148, the Associate Chief Nursing Officer (Staff E) confirmed that patients in the Emergency Department are expected to receive the same standard of nursing care as inpatient units, including skin assessment and implementation of pressure injury prevention interventions. Record review revealed that on 2/26/26 at approximately 0200 on arrival to the step down unit, the patient was documented to have a stage 2 pressure injury to the coccyx/bony prominence. Documentation indicated the wound was cleansed with saline, Triad cream was applied, and a foam dressing was placed. A pressure injury prevention order set was initiated on 2/26/26, including turning, positioning devices, and offloading interventions. An interview conducted on 4/14/26 at approximately 1029 with the nurse manager (Staff J) confirmed that nursing staff and patient care assistants are responsible for repositioning patients at least every two hours and documenting those interventions. Record review on 4/14/26 at 1029 with Nurse Manager Staff Z demonstrated inconsistent implementation and documentation of repositioning after identification of the pressure injury, including: 2/26/26 (day shift): no turning documented 2/27/26 (day shift): no turning documented 3/1/26 (night shift): no turning documented 3/3/26 (day shift): turning documented approximately every 4 hours rather than every 2 hours 3/4/26 (night shift): no turning documented Staff Z confirmed there were periods of 4-8 hours without documented repositioning, and confirmed there was no alternate location where repositioning was documented. Record review further demonstrated inconsistent wound assessment and treatment documentation after identification of the pressure injury, including: 2/28/26 (day shift): dressing change documented 3/1/26 (day and night shifts): no documented wound assessment 3/2/26 (day and night shifts): no documented wound assessment 3/3/26 (night shift): no documented wound assessment Staff Z explained that patients with wounds or at risk for developing wounds should be turned at least every 2 hours and the turns should be documented and that it is a shared responsibility between nurses and nurse aides. Staff Z also explained that a wound should be assessed by direct visualization every shift and that assessment should be documented. An interview conducted on 4/14/26 at 1351 with the wound care nurse (Staff AA) confirmed that nursing staff are responsible for ongoing assessment and treatment of stage 1 and stage 2 pressure injuries and that wound care consults are typically initiated for more advanced wounds or when additional concerns are identified. During an interview conducted on 4/14/26 at 1148, the Associate Chief Nursing Officer (Staff E) confirmed that nursing staff are expected to perform daily skin assessments and that pressure injury prevention interventions, including repositioning, must be implemented and followed. Staff E direct care nursing staff should be assessing skin and wounds daily and performing wound care daily and the clinical coordinator on the skin team should be auditing and rounding weekly on skin and the unit leaders should be auditing daily in real time on skin and wounds. The facility policy titled “Skin and Wound Management” dated 4/15/2025 revealed the following: “I. POLICY A. RN is responsible for the assessment, planning, evaluation and documentation of skin and wound management. Wounds are assessed with each dressing change and characteristics documented in the medical record. B. Wound care is provided using DMC Wound and Skin Care Flow Charts as guidelines for the RN to independently make decisions and initiate orders for wound management until seen by WOCN/WOCC/APRN. C. Clean technique is used for wound care unless ordered otherwise by physician or APRN/WOCN/WOCC(c). D. Mechanical, chemical and sharp debridement may not be delegated to unlicensed personnel ...G. APRN/WOCN/WOCC(c) consults are placed when cytotoxic agents are ordered for wounds by another practitioner, e.g., Dakin’s. H. Any pressure injury that is identified on admission is defined as a community-acquired pressure injury (CAPI) and documented in the Adult or Pediatric Admission Assessment as present on admission (POA). I. RN staff members initiate EMR orders for pressure injury prevention and management based on patient risk assessment and/or presence of pressure injury (injuries). J. RN staff members document patient/family education regarding prevention strategies or wound care management on the adhoc Education Wound Care Form. Staff complete type of education patient received and need for further education. K. Any pressure injury that develops 24 hours after admission to the hospital or is not documented as present on admission within 24 hours is defined as a hospital-acquired pressure injury (HAPI). L. Patients are repositioned minimally every 2 hours. Able patients are taught to shift their body weight while in bed and chair sitting. EMR documentation of repositioning occurs in the Plan of Care under Comments. Additionally, repositioning may be documented in the activity section of the EMR.””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 50585 Based on interview and record review, the facility failed to assess and document a patient’s pressure injury according to the facility’s policy and procedure for 1 (P-1) of 3 patients reviewed with pressure injuries resulting in increased potential for harm and adverse outcomes for the patient. Findings include: On 3/11/2026 at 1345, P-1’s medical record was reviewed with Associate Chief Nursing Officer Staff E and revealed the following: On 1/12/2026 at 1800 and 1/13/2026 at 0900, P-1’s flow sheet documentation revealed P-1 had a documented “stage II” pressure injury on both the middle coccyx and left buttock areas of the skin. On 1/14/2026 through 1/17/2026, P-1’s flow sheet documentation revealed no pressure injury assessments on either the left coccyx or left buttock areas. However, P-1’s plan of care documentation on 1/14/2026 at 1328, 1/15/2026 at 0455, 1/15/2026 at 1400, 1/16/2026 at 0128, 1/17/2026 at 0233, and 1/17/2026 at 1050 revealed that P-1 had a “stage 2” pressure injury to left hip. Staff E was queried if they expected staff to document additional pressure injury assessments on 1/14/2026 for P-1’s pressure injuries previously identified on 1/12/2026, Staff E said “yes.” According to the facility’s policy “Skin and Wound Management,” dated 4/15/2025, “wound assessment and documentation include: “Location - Identify and list appropriately Wound Edges - Assess for undermining, tunneling, and condition of margin Size and depth - Measure or trace wound area, Measure length,, width and depth Wound Bed - Assess for necrotic and granulation tissue, fibrin slough, exudate and odor Periwound skin - Assess for color, denudation, fragility and moisture exposure””

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 50585 Based on interview and record review, the facility failed to document the goal of an infusion rate change for a sedation infusion as directed by a physician order for 1 (P-1) of 2 patients reviewed resulting in the potential for the patient not being maintained at the intended level of sedation and placed the patient at risk for adverse consequences. Findings include: On 3/11/2026 at 1345, P-1’s medical record was reviewed with Nurse Staff W. On 12/17/2025 at 1247, P-1 had an order for fentanyl 2,500 mCg/100 mL sodium chloride, titrate to goal “RASS (Richmond Agitation Sedation Score) to “0 to -1” or VAS (Visual Analogue Scale)/PABS (Pain Behavior Scale) < 5 if on concomitant sedation and “titrate up/down by 0.5 mCg/kg/hr increments every 10” minutes.” On 12/19/2025 at 1316, P-1’s documented fentanyl administration rate was 7.5 mCg/kg/hour. On 12/19/2025 at 1337, P-1’s physician progress note revealed “(P-1’s) blood pressure and heart rate have been good” and “Continue Fentanyl gtt (continuous infusion medication drip), titrate for RASS -1/0, wean off as tolerated.” On 12/19/2025 at 1400, Staff W documented a RASS score “+1 restless.” On 12/19/2025 at 1418, Staff W decreased the fentanyl administration rate to 0.2 mCg/kg/hour and there was no RASS score documented after the rate change. On 12/19/2025 at 1419, Staff W increased the fentanyl administration rate to 0.5 mCg/kg/hour and there was no RASS score documented after the rate change. On 12/19/2025 at 1506, Staff W increased the fentanyl administration rate to 7.5 mCg/kg/hour and there was no RASS score documented after the rate change. On 12/19/2025 at 1600, Staff W documented a RASS score “+1 restless” and RASS score after sedation awakening trial “4.” Staff W was queried about the fentanyl infusion rate change they performed on 12/19/2025 at 1418 and whether a RASS score should have been documented after the rate change, Staff W revealed “should have left a note.” According to the facility’s policy “Titration of Intravenous Medication Infusion,” dated 10/29/2019: -“Each titration change is entered into the EMR IVIEW. Documentation of titration of the medication infusion with dose/ rate and corresponding medication goal e.g., RASS, MAP, VAS/PABS pre and post infusion changes is recorded to evaluate cause and effect relationship of medication effectiveness.” -“For patients requiring a sedation vacation, medication infusions may be shut off instead of titrated down.” -For documentation “Vital signs and / or ordered scale used for titration pre and post change and for provider notification, “Provider informed of need to titrate titration outside of EMR orders.””

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 48772 Based on interview and record review, the facility failed to follow policy for the plan of care for 1 (P-2) of 10 records reviewed, resulting in the potential for poor patient outcomes and unmet care needs. Findings include: P-2 is a 66-year-old male with a past medical history of hypertension, type 2 diabetes mellitus, lung cancer, and paranoid schizophrenia. He was brought to the emergency department on petition for agitation, confusion, and a direct threat to self. He was admitted to the facility on 11/2/25. During record review, it was noted that the master treatment plan included behavioral health. The plan failed to include diabetes, blood glucose monitoring, or insulin use. This finding was reviewed and acknowledged by the RN Coordinator (Staff G) during interview on 11/13/25 at 1415. Policy 2PC 202: Nursing Plan of Care (effective date 3/16/25). The RN individualizes the pre-formatted plans of care to be reflective of the patient’s condition.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 48772 Based on interview and record review, the facility failed to provide the patient with the right to make informed decisions regarding care in 1 (P-5) of 10 records reviewed, resulting in the potential for unmet care needs. Findings include: P-5: This 40-year-old female has a prior history of schizophrenia and was voluntarily admitted to the facility on 11/4/25. P-5 was ordered and given Haldol 5mg twice daily, and Ativan 1mg at night. During record review, it was noted that the general consent for admission and treatment was not signed by the patient. It was also noted that the chart failed to include psychotropic medication consents. This finding was reviewed and acknowledged by the RN Coordinator (Staff G) during interview on 11/13/25 at 1415. Patient Rights and Responsibilities (dated August 2019): To receive adequate and appropriate care, and to receive from the appropriate individual within the health facility or agency, information about your medical condition, proposed course of treatment and prospects for recovery, in terms you can understand unless medically contracted as documented by the attending physician in the medical record. To refuse treatment to the extent provided by law and to be informed of the consequences of that refusal. Policy PMH 047: Use of Psychotropic Medications/Medication Procedures (Effective 2/20/2024). The indication for the initiation of the use of psychotropic medication will be noted in the clinical record with additional documentation which includes the following ...informed consent.”

“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: 48772 Based on observation, interview, and record review, the facility failed to label and monitor supplies used on patients, resulting in the increased likelihood of negative outcomes for all patients on the behavioral health unit. Findings include: During unit tour on 11/12/25 at 1210, on 5 South Behavioral Health Unit, in the medication room, the blood glucose monitoring system control solutions were observed with an expiration date of 8/2026 but failed to include an opened date. RN (Staff P) was queried if control solutions should be dated when opened and responded they are supposed to be dated. Policy 2POC PC 205-Blood Glucose Monitoring System Inform II (Effective 9/28/25). Storage and Handling: Glucose Control solutions are stable for three months after opening or until the expiration date, whichever comes first. The open date and expiration date must be recorded on the vials. 50585 On 11/12/2025 at 1210, during observation of the medication cupboard in the medication room on the behavioral health unit, three multiple dose vials of medications (Fluphenazine Decanoate, 125 milligram (mg) /5 mL, 5 mL Multiple Dose Vial x 2, Fluphenazine Hydrochloride 2.5 mg per mL, 10 mL Multiple Dose Vial x 1) were opened and punctured and there were no beyond use dates (BUD) noted on each of the three opened vials. One single dose vial of Sterile Water for Injection was observed with a puncture in the rubber stopper and stored on the shelf next to the multiple dose vials of injectable medications. Nurse Staff G confirmed the findings at the time of discovery. On 11/12/2025 at 1220, during observation of the clean supply room in the behavioral health unit, sixteen blood collection tubes used for type and screen blood collection were observed in the supply drawer and were expired. Seven collection tubes had an expiration date of 10/1/2025 and 9 collection tubes had an expiration date of 5/1/2024. Nurse Staff G confirmed the findings at the time of discovery. According to the facility’s policy, “Multi-Use Containers and Medication Packaging Available in Patient Care Areas,” dated 5/5/2024, The (Accreditation Body) requires that once a multi-dose pen or container of a medication for intravenous, intramuscular, subcutaneous, or intradermal injection is opened or puncture, organizations label the vials with a BUD (Beyond Use Date), as defined by the manufacturer or 28 days if no in use time is defined by the manufacturer.” The policy also reveals that “Single-dose/single use containers are only used for a single patent during the course of a single procedure. Discard the container after this single use; used containers should never be returned to stock or clinical units, drug carts, anesthesia carts, etc.” A policy was requested for the process to ensure expired medical supplies were removed from patient care areas, and the policy was not provided.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 50585 Based on observation, interview, and record review, the facility failed to accurately reflect the patient’s safety precautions in the medical record for 2 (P-2, P-4) of 10 patients reviewed resulting in the increased likelihood of negative consequences for these patient. Findings include: P-4 was admitted to the facility on 11/6/2025 with a diagnosis of schizophrenia spectrum and other related disorders. P-4 nursing’s note on 11/7/2205 at 2130 revealed “Patient sexually preoccupied with (their) (opposite sex) peers, patient trying to dress provocative, sitting in room with just panties covering (their) breast and wearing a pair of panties, and dancing in front of (opposite sex) peers (doing the stanky (sic) leg) patient re-directed and placed on sexual precautions.” On 11/7/2025 at 2346, P-4 had an order for “Sexual Precautions” and the order also had a stop date of 11/7/2025 at 2346. On 11/08/2025 at 1137, P-4’s physician progress note revealed “Per staff, patient sexually preoccupied with her male peers, trying to dress provocative sitting in room with just panties covering her breast and wearing a pair of panties and dancing in front of male peers, staff had to redirect patient several times, (they) was placed on sexual precautions. Discourage such behavior.” On 11/9/2025 at 2020, P-4’s physician progress note revealed “On sexual precautions.” P-4’s patient observation sheets on 11/7/2025, 11/8/2025, 11/9/2025, and 11/10/2025 (1200-2345), and 11/13/2025 did not have sexually acting out precautions checked. The facility daily census sheet used to communicate patient information including safety precautions each day revealed that P-4 did not have sexually acting out precautions noted on 11/8/2025, 11/9/2025, and 11/12/2025. Nurse Staff H confirmed the findings at the time of discovery. 48772 P-2 is a 66-year-old male with a past medical history of hypertension, type 2 diabetes mellitus, lung cancer, and paranoid schizophrenia. P-2 was brought to the emergency department on petition for agitation, confusion, and a direct threat to self and was admitted to the facility on 11/2/25. During record review on 11/13/25, it was noted that the safety precautions added on 11/1/25 at 1505 included elopement, homicide, and suicide. A progress note, completed by a mental health associate (MHA), dated 11/4/25, stated, “keeps reaching out to touch female staff/peers, gets upset easily when redirected.” On 11/7/25 at 0108, a nursing note indicated P-2 was placed on sexual precautions after an incident of genital exposure and agitation/aggression. The following The MHA frequent observation records indicated 15-minute checks and the following selected precautions: 11/2/25-no precautions selected 11/3/25-safety precautions 11/4/25-elopement precautions 11/5/25-no precautions selected 11/6/25-elopement precautions 11/7/25 & 11/8/25-safety precautions 11/9/25-elopement precautions 11/10/25 & 11/11/25-elopement and sexual precautions 11/12/25-elopement and safety precautions This finding was reviewed and acknowledged by the RN Coordinator (Staff G), who stated sexual precautions should have been started immediately, during an interview on 11/13/25 at 1415. According to the facility’s policy, “Precautions: Monitoring and Reporting,” (dated 7/12/2024), states “A patient may be placed on sexual precautions if there is a history or exhibit behaviors that are sexually inappropriate. The patient may be restricted from areas on the unit, be asked to remain in sight when not in a structure group. Or be placed on 1:1.” According to the facility’s policy “Sexual Incidents Between Patients: Guidelines and Reporting,” (dated 7/14/2024), states “1. Patients will be identified in the initial and ongoing psychiatric, social work, and/or nursing assessments if they are sexually dis-inhibited, have a history of sexual acting out, or are otherwise particularly vulnerable or aggressive. 2. Sexual precautions are instituted to alert staff to the possibility of sexual acting out.””

“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: 38269 Based on observation, interview, and record review, the facility failed to ensure nursing staff implemented interventions for prevention and treatment of changes in skin integrity for 2 (P-1, P-7) of 3 patients reviewed for skin integrity resulting in the potential for alterations in skin integrity for all patients at risk for pressure injury. Findings include: See tags: A-0395 Failure to document nursing assessments, including wound prevention measures.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 38269 Based on observation, interview, and record review, the facility failed to ensure patients were free from neglect for one (P-2) of seven patients reviewed for neglect from a total of 15 patients, resulting in poor outcomes for P-1. Findings include: On 8/20/2025 during document review of patients with extended length of stay, it was noted that P-2 was admitted on 01/18/2025 due to mental health concerns. P-1 was ambulatory at the time of admission and documented as being combative with staff requiring restraints. The patient has been in the facility for 211 days when he was observed on 08/20/2025 to be calm, malnourished, smelled of urine, and was in bilateral soft wrist restraints with a 1:1 safety sitter. Review of safety sitter documentation revealed during the last 5 days (8/21/2025 - 8/26/2025), P-2 had calm cooperative behavior with no evidence of restraint justification. Record review revealed the following: since admission to the facility on 1/18/2025, P-2 has had a 40lb weight loss. On admission P-2 had a documented weight of 64 kg (141 pounds) and on 03/06/2025 P-2 was documented as weighing 52.5 kg (116 pounds), decreased oral intake due to “tooth pain”, went from running in the halls to requiring 70% assistance for mobility and continued to remain in restraints without evidence of restraint justification.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(2) Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm. This Standard is not met as evidenced by: 38269 Based on record review, interview, and observation, the facility failed to use the least restrictive type of restraint for one (P-2) of three patients reviewed for restraint use, resulting in the loss of the patient’s right to be free from restraint at the earliest possible time. Findings include: On 08/21/2025 at 1400, a review occurred of P-2’s medical record. P-2 was described as a 48-year-old male that was cognitively impaired with a documented history of schizophrenia and acute psychosis. P-2 arrived at the emergency department (ED) on 01/18/2025 with a petition and was certified for aggressive behavior at the nursing home where he resided. P-2 was documented as having a history of psychosis, hypertension, schizophrenia, and brain injury. P-2 remained in the ED crisis center until 01/23/2025, when a psychiatric resident documented P-2 as not meeting the criteria for admission to the in-patient behavioral health unit. The psychiatric resident continued to document that P-2 did not meet in-patient behavioral health unit admission criteria. However, P-2’s documented diagnosis remained psychosis with history of schizophrenia. P-2 was located in the ED crisis center from 01/18/2025 to 01/24/2025. ED crisis center nursing progress notes described P-2 as “oriented x 4, siderails up, resting comfortably on stretcher.” The nursing progress note on 01/19/2025 documented the following: “The patient is resting comfortably on the stretcher, denies shortness of breath, denies distress, patient verbalizes understanding of treatment plan, including the use of restraints.” On the same date 01/19/2024, at 20:25, the ED physician placed an order for 2-point restraints due to P-2 being “unable to follow safety instructions.” P-2 remained in the ED crisis center until being transferred to the 5 W (medical surgical, telemetry unit) on 01/24/2025. While in the emergency department from 1/19 to 1/24, P-2 was documented as in restraints with no order for restraint found. Review of the medical record revealed that P-2 was placed in 2-point, 3-point, and 4-point restraints, as well as having a sitter 1:1 at the bedside during his 215-day hospitalization (to present 08/21/2025). On 08/21/2025 at 0900 during a tour of 5 W, P-2 was observed in room 521 with soft restraints on bilateral wrists. P-2 was smiling, grinding his teeth, and mumbling. At the time of observation, a safety attendant (sitter) Staff O, was observed in room 521 sitting in a chair. On 08/21/2025 at 0901, an interview was conducted with staff O. Staff O was asked to explain her role and responsibilities as a safety attendant. Staff O stated, “I fill out the form.” Staff O provided the document for review. The document was titled, “Constant Observer Flow Sheet.” The following categories were listed included activity, behavior, location codes, and initials for every entry point. The frequency of observations was marked constant and documented at a minimum of every 15 minutes. At the time of observation, the 08/21/2025 document was reviewed and revealed the following: “Activity: #1 - sleeping, and #4 - lying still or sitting,” ...”Behavior: #21 - quiet, #5 - mumbling incoherently, and #4 - cursing,” and “Location: #1 - patient room.” Staff O was queried why P-2 was in restraints, and if the restraints were removed when P-2 was documented as sleeping, quiet, and/or lying still. Staff O stated, “I don’t have anything to do with the restraints ...I just sit here and write down stuff every 15 minutes.” A review occurred of the “Constant Observer Flowsheets” from 08/18/2025 - 8/20/2025. The “constant observer” documents reviewed revealed similar results. Random reviews (admission to current) of the documents were conducted with the same outcome with an occasional #2 - screaming, #17 - confusion, #18 - agitation, 19 - impulsive, and #25 - spitting. Record review of P-2’s medical record revealed P-2 was receiving antipsychotics and antianxiety medications. P-2’s medical record revealed that upon admission P-2 was ambulating without assist, with the ability to “run in the halls.” P-2’s admission weight was documented as 141 pounds (64 kg), on 03/06/2025 documented as 116 pounds (52.5 kg). P-2 was also documented as having decreased oral intake since admission. Physical therapy progress notes dated 08/13/2025 revealed P-2 now required 70% assistance to ambulate 400 feet. On 08/21/2025 at 1510, review occurred of the facility’s policy titled, “Restraint or Seclusion in the non-psychiatric,” effective date 02/01/2024. According to section IV of the policy the following is revealed: “Based on an individualized patient assessment, the use of restraint or seclusion is limited to those situations where it is necessary to ensure the immediate physical safety of the patient, staff members, or others. The type of techniques of restraint or seclusion must be the least restrictive intervention that will be effective to protect the patient or others from harm. Restraint or seclusion is discontinued as soon as safely possible. A. 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, or convenience. For retaliation by staff, restraints or seclusion may only be imposed to ensure immediate physical safety of the patient or others with appropriate physical assessment and adequate clinical justification. To facilitate the discontinuation of restraint or seclusion as soon as possible based on an individualized patient assessment and reevaluation. B. As an adjunct to planned care, restraints may be used in response to unsafe behavior. The decision to use restraints is not driven by diagnosis or location, but by comprehensive individual patient assessment concluding that for this patient currently, the use of less restrictive measures poses a greater risk than the risk of using a restraint. Based on the patient’s clinical presentation, the physician makes the determination for use of restraints, including type of restraints. 1. Staff will apply restraint or seclusion only when less restrictive interventions are ineffective. 2. Staff will use the least restrictive form of restraint or seclusion that protects the physical safety of the patient, staff or others.””

“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: 38269 Based on observation, interview, and record review, the facility failed to ensure nursing staff implemented interventions for prevention and treatment of changes in skin integrity for 2 (P-1, P-7) of 3 patients reviewed for skin integrity resulting in the potential for alterations in skin integrity for all patients at risk for pressure injury. Findings include: On 8/20/2025 at 1425 a review occurred of P-1’s medical record. P-1’s initial nursing assessment on 07/08/2025 revealed that a “4-eyes” skin assessment was not completed. The initial nursing assessment included a Braden scale for P-1. P-1’s documented Braden score was 16, indicating P-1 was at risk for pressure injury. Further review of the medical record revealed that on 07/13/2025 orders were placed for pressure injury prevention and management per policy. On 08/20/2025 between 1000 and 1345, during a tour of the facility units of interest, registered nurses were asked if putting the EMR pressure injury prevention order set in place required a physician order. Nursing staff were aware of the prevention order sets and that they did not have to notify a physician prior to using the orders. Staff did admit that they don’t always use the available preventative measures as they could or should. On 08/20/2025 at 1555, P-7 was observed in a specialty bed in room 517. At the time of observation Patient Care Aide (PCA), Staff F was observed in room 517 conducting an accucheck (blood glucose monitoring test) on P-7. Staff F was asked to explain the purpose of P-7 being on a specialty bed, and if he assisted with every two-hour turns. Staff F stated, “is that a specialty bed? No, I haven’t turned him ...maybe the turn team does that.” On 08/20/2025 at 1607, just outside of room 517, an interview was conducted with Staff X, Registered Nurse. Staff X was queried regarding P-7 whom she stated was her assigned patient. Staff X was asked what time her shift started that day, if she knew why P-7 was on a specialty bed, and if P-7 had pressure wounds. Staff X stated, “My shift started at 0700 ...I am not sure why he has a specialty bed.” Staff X was unable to answer if P-7 had pressure wounds. Staff X scrolled through the Electronic Medical Record and was unable to locate a Braden scale and whether P-7 had any pressure wounds or why he was on a specialty bed. Staff X was then asked to show the documentation of every two-hour repositioning over the past 24 hours. Staff X was unable to find any documented turns for P-7 and stated, “maybe the turn team is turning him.” On 08/20/2025 at 1610, Staff C, the Director of Quality, was asked where the “turn team” documents patient turns in the EMR, and if she could show the turns completed for P-7 in the past 24 hours. Staff C went to the 5W nurses station and inquired as to where the documentation for turns completed by the turn team could be found. An RN at the nurses station stated P-7 is not on the turn team schedule for turning. Staff C stated, “it appears that P-7 has not been turned in the past 24 hours.” On 08/21/2025 a review occurred of the policy titled, “Pressure Injuries: Prevention and Management,” policy 2 PC 5202, dated 04/14/2025. The following was revealed: “A. RN assesses each patient admitted to an inpatient unit for risk pressure injury risk using the Braden Scale and performing the 4 ‘eyes’ assessment. 1.Braden Scale score of <18 or low subscale scores indicates that the patient is at risk for pressure injury development. Interventions targeting risk areas are implemented to prevent and manage pressure injuries. 2. Patients with actual or healed pressure injuries are considered high risk, especially if found on admission. B. RN’s use the policies for basic nursing interventions and enter EMR orders aimed at the prevention and management of pressure injuries. 1. Provide assessment, planning, documentation and evaluation of skin, pressure injuries, and wound management with shift assessment. Pressure injuries are measured on admission, every Monday, upon development, or deterioration. 4 ‘eyes’ assessment are performed on admission. 2. Assess patient by performing 4 ‘eyes’ upon admission and transfer. 3. Assess the patient ’ s risk using the Braden Scale. 4. Reposition patient to side lying position ensuring bony prominences are offloaded at least every 2 hours while in bed, unless contraindicated. 5. Initiate EMR orders for pressure injury prevention and management based on patient risk assessment and/or presence of pressure injuries directed toward specific subscale risk factors. 6. Identify and modify factors contributing to pressure injury development and/or delayed healing or worsening of existing pressure injuries. 8. Document, Altered Tissue Integrity as Plan of Care every shift for patients with pressure injuries, healed pressure injuries, or at risk for pressure injuries based on low subscales or Braden Scale Score < 18. 9. Consult dietitian for Braden Scale Score < 18 or Braden subscale nutrition score of < 2 or actual pressure injury. 10. Assess patient outcomes. Revise plan of care as needed. 11. Assure continuity of care through communication of plan to health care team members. 12. Consult the WOCC©/CWOCN/APRN/wound specialist for stage 3, stage 4, unstageable, deep tissue pressure injuries, medical device related pressure injuries or mucosal membrane pressure injuries pressure injuries and any hospital acquired injuries. 13. Enter hospital acquired pressure injuries into incident reporting database (MIDAS).””

“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: 45246 Based on interview and record review, the facility failed to ensure that registered nurses supervised and evaluated the nursing care for 3 patients (P-2, 4 and 5) of 19 patients reviewed and failed to develop comprehensive care plans for 2 patients (P-4, 5) of 19 patients reviewed, resulting in serious adverse outcomes to patients, including harm and physical decline. Findings include: See Specific Tags: A-395 Failure to ensure that nursing staff supervise and evaluates patients’ care. A-396 Failure to ensure that nursing staff develops patient centered individualized plan of care.”

“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: 45246 Based on observation, interview and record review, the facility failed to maintain a clean sanitary environment and timely meet the individual basic care needs for 2 patients (P-5 and 15) of 19 patients reviewed for basic care, resulting in an unclean and unmonitored environment, potential for unrecognized safety events, increased patient dissatisfaction, and denial of patient rights to patient centered and dignified care in a safe setting. Findings include: On 10/15/24 at 1155, during the tour of Medical Surgical unit (2 West) with Clinical Improvement Coordinator, Staff Y, and Nurse Manager, Staff M, the clean storage room was observed on the unit. The floor in the room looked worn, covered with dark gray and black stains, and residue. Multiple paper and plastic debris, supplies packages, vacutainers, and tape rolls were found under the storage shelves. When asked how often this room was cleaned Staff M stated that is supposed to be done daily. When asked why the floor was so dirty and unsanitary appearing, Staff Y stated that it was clean, but old and needed a replacement. “Infection Control in the Environment of Care Attachment Cleaning Grid” (Policy # 2 IC 033) was reviewed on 10/16/24 and revealed: “Clean utility room- locker shelves. Responsible group or person- EVS high dusting and exterior. Frequency- visibly dusty or soiled.” Cleaning grid attachment provided by facility did not have clean utility/storage room floors cleaning frequency and responsible group mentioned in it. 50585 On 10/15/2024 at 1040, during a tour of the medication room in the Medical Intensive Care Unit, the thermometer attached to the medication refrigerator was observed to contain a label with a calibration due date of January 2024. An emergency eyewash bottle with an expiration date of 10/2021 was observed in the corner of the countertop and available for use. Clinical Improvement Coordinator Staff E was queried and confirmed the findings at the time of discovery. 47415 On 10/15/2024 at 1040, during a tour of the medication room on 4 West Medical Surgical Unit, review of the medication refrigerator temperature logs for October 2024, revealed that no daily temperature was recorded on October 3, 4, 5, 6, 10, 11, and 12, 2024. RN staff X was queried and confirmed findings at the time of discovery. Unit Manager Staff T was asked whose responsibility it was to record refrigerator temperatures in the medication room, and she responded she was responsible and accountable to make sure the temperatures are logged. On 10/15/24 at 0914, a conversation with the caregiver (complainant), by phone, revealed P-5 called her many times stating his call light was on to request help with toileting, but no staff were coming to help. She (the complainant) had to call the nursing desk to tell someone to go to the room to help him. During his stay, he fell getting up unassisted to toilet. On 10/16/24 at 1400, medical record review revealed P-5 had an unwitnessed fall on 6/5/24. (found on floor by RN), An assessment post fall included a computerized tomography of head (negative for intracranial hemorrhage) and a left pelvis X-ray, that noted an acute left intertrochanteric fracture. P-5 went to surgery for a left intramedullary nail (IMN) procedure on 6/6/24. On 10/16/24 at 1430, the fall event and incident logs were reviewed, no entry was found on these logs for P-5. Interview with Staff B at the time of this event log review, confirmed there were no event reports or follow up documentation available regarding P-5’s fall. Review of facility policy titled. “Event Reporting”, dated 1/3/20 revealed, “A reportable event means an event that is not consistent with the routine operation of the Hospital or the routine care of a patient or patients ... “Patient Safety Reporting System” or “PSRS” is the mechanism for the Hospital Staff Member to complete an Event Report for patient safety events ... Hospital Staff Members must complete and submit an Event Report as soon as possible ... “Event Manager” means the role typically assigned to a subject matter expert who is the Hospital’s identified authority on the event type(s) assigned. This individual sees all events of their assigned event type(s) - regardless of where the events occur ... Examples ...falls champion as falls event manager.” On 10/16/24 at 1400, review of record for P-5 revealed, on 6/5/2024 at 0649, Clinical Nurse Practitioner (CNP) was paged to assess P-5 after a fall event. Patient was assessed at bedside. P-5 stated he fell when he attempted to get up to urinate. P-5 assessed as alert and orientated x 4. Review of nursing note of 6/11/24 at 0323, revealed that patient was found with stool on him, the bed and the floor. On 10/15/24 at 1030 during facility tour, an interview was conducted with P-15 in room 4091, who stated he is blind, and it takes a long time for staff to answer the call light every time he puts it on, and sometimes the response time is more than an hour. There have been delays in setting him up for meals and the food gets cold, delays with repositioning, and delays with toileting requests. When he asks about the delays in answering the light, he said the staff replies they are busy. On 10/16/24 at 1500, review of policy titled, “Patient Rights and Responsibilities” dated 2/10/22 revealed that, “Patients will receive the same treatment and consideration as anyone else regardless of age... status...physical or mental disability ... Patients can expect their dignity as a human being to be recognized and respected.””

“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: 47415 Based on interview and record review, the facility failed to ensure that registered nurses supervised and evaluated the nursing care for 3 patients (P-2, 4 and 5) of 19 patients reviewed, resulting in facility acquired unstageable pressure injuries, patients’ deterioration in health status and preventable decline. Findings include: On 10/16/24 at 1400, record review revealed P-5 presented to the emergency department (ED) on 4/27/24 at 1904, with chief complaint of increasing fatigue, loss of appetite, and weight loss (15 pounds in past 2 weeks). Admitting diagnosis was failure to thrive and acute kidney injury. Review of progress notes of 5/30/24 revealed a plan to monitor strict intake and outputs, and daily weights for P-5. Based on record review, weights for P-5 were only recorded three times during stay, from 4/24/24 - 6/12/24. Weights were recorded on 4/27/24- 45 kg, 5/27/24 - 45 kg, and 6/11/24 - 45 kg. The three (3) weights were recorded as “estimated”. Nutritional consult dated 5/7/24 revealed, P-5 had a low fiber, double portion diet ordered with high protein supplement three times daily. Nutritional Assessment on 5/27/24 revealed, P-5 had no documentation of oral meal intake in the record. Review of record for oral meal consumption for P-5, revealed no documentation for any meal (breakfast, lunch, dinner) intake on the following dates: 4/28/24, 4/29/24, 4/30/24. No meal entries recorded on any day in May 2024, and no meal entries documented in the record on 6/1/24, 6/2/24, 6/7/24, 6/8/24, 6/9/24, 6/10/24, 6/11/24, or 6/12/24. Supplement intake not documented in the record. On 10/16/24 at 1300, interview with CNO Staff A revealed that it is her expectation that nursing staff follow policy and procedures, and standards of practice for nursing. On 10/16/24 at 1530, review of facility policy titled, “Assessment Monitoring Guidelines Acute Care”, dated 2/16/19, revealed, “OBJECTIVE/PURPOSE: To provide guidelines for routine monitoring and assessment of general acute care (medical-surgical) adult patient population ... Intake includes all fluids delivered orally, parenterally, and via irrigation or feeding tubes ... This policy sets minimal guidelines for the Acute Care (medical-surgical) adult patient. These standards do not preclude clinical judgment”. 50585 According to the medical record, P-2 was admitted on 4/15/2024 and was discharged on 6/1/2024. P-2’s had an order on 4/18/2024 for a daily CHG bath. There was no documentation of P-2 receiving a CHG bath on 4/23/2024, 5/03/2024, and 5/7/2024. Clinical Improvement Coordinator Staff E confirmed the findings at the time of discovery. On 10/15/2024 at 1020, Physician Staff K was interviewed and was queried if a chlorhexidine gluconate (CHG) bath required an order and they said “yes”, and the order was usually “daily.” On 10/15/2024 at 1025, Medical Intensive Care Unit Nurse Staff D was interviewed and was asked what CHG baths were used for and they said to “disinfect patient” and the frequency was normally “daily” sometimes “every shift.” P-2’s chart review revealed that “peri-care” was not documented as performed on 4/23/2024, 4/24/2024, 4/28/2024, 5/3/2024, 5/7/2024 and 5/12/2024 and “oral hygiene” was not documented as performed on 4/23/2024 through 4/28/2024, 5/2/2024 through 5/4/2024, 5/7/2024, 5/8/2024, 5/10/2024 through 5/16/2024, 5/19/2024, 5/21/2024, 5/22/2024, 5/25/2024 through 5/27/2024, and 5/29/2024. On 10/16/2024 at 1100, Wound Care Nurse Staff HH was interviewed and was asked if a patient’s pressure injury was documented in the Facility Acquired Pressure Injury log, does that mean the pressure injury was acquired at the facility, and they said “yes.” Staff HH was asked about frequency of repositioning the patient, and they revealed that the patient turn documentation was “every two hours” and “every Monday” the pressure injury was measured. According to the facility’s Facility Acquired Pressure Injury log for May 2024, P-2 had a reported facility acquired pressure injury on the right ankle, Stage II. According to the medical record, the Medical Care Intensive Care Unit note on 4/15/2024 at 2047 (date of admission) revealed that P-2 had Stage II pressure injuries on both left and right buttock as well as Stage I lower lumbar decubitus ulcer. On 4/17/2024 at 1700, a pressure injury on the sacrum midline was recorded for P-2 and the injury measured 5 centimeters (cm) x 8 centimeters (cm). On 4/19/2024 at 1600, the pressure injury was recorded as stage III. On 5/16/2024 at 1400, the pressure injury was recorded as stage IV. On 4/20/2024 at 1600, a pressure injury on the lateral back was recorded. On 4/26/2024 at 1600, the pressure injury was recorded as stage I. On 5/9/2024 at 0300, the pressure injury was recorded as stage III. On 4/22/2024 at 1200, a pressure injury (facility acquired) on the right lateral ankle was recorded without a stage status. On 5/6/2024 at 0445, the pressure injury was recorded as stage II and the pressure injury measured 3 cm x 3 cm. According to P-2’s medical record, documentation revealed that P-2 was not repositioned every 2 hours on the following dates and times: 4/18/2024 at 2000, 2200, 4/19/2024 at 0000, 0200, 0400, 1800, 4/20/2024 at 2200, 4/21/2024 at 0000, 0200, 0400, 4/22/2024 at 0200, 0400, 1400, 1600, 1800, 2000, 2200, 4/23/2024 at 0000, 0200, 0400, 1600, 4/24/2024 at 0400, 4/25/2024 at 0200, 0400, 1000, 1200, 1400, 1600, 1800, 2000, 2200, and 4/26/204 at 0000, 0200, 0400. 45246 P-4 record review on 10/16/24 revealed that he was admitted to facility on 3/5/2024 for urgent evaluation following a motor vehicle collision as a pedestrian. On 3/8/24, he underwent cervical spine surgery (C7-T1 Anterior Cervical Discectomy and Fusion) with significant blood loss that was managed with transfusions and fluid replacements. Postoperatively, he was started on tube feeds. By 3/10/24, he remained intubated and sedated. Plans were made for a tracheostomy and Percutaneous Endoscopic Gastrostomy (PEG) tube placement. Carotid angiogram and stenting were performed on 3/12/24 and a retrograde left femur intramedullary nail surgery was performed on 3/14/24 to repair his broken hip. On 3/19/24 MRI revealed diffuse axonal injury (traumatic brain injury that can lead to a coma and/or physical and cognitive impairment), contributing to a poor neurological prognosis. By 4/8/24, after detailed discussions with family, a consensus was reached to transition patient to a hospice care. By 4/9/24, a referral to hospice care was initiated. On 4/10/24 P-4 was taken off the ventilator and transferred to a medical surgical unit in the same facility. Case Management reassessment note dated 4/14/24 1526 revealed: “Patient is signed with [name] Hospice”. Next Case Management reassessment note dated 4/20/24 0932 indicated that P-4 was “disenrolled from inpatient hospice care” by his sister. Palliative care provider note dated 5/31/24 1231 revealed that provider spoke to a Hospice Director, Staff EE, who stated that patient was enrolled with Hospice up until 4/18/24. Per patient’s sister P-4 wanted to live and she wanted him to be removed from the hospice. Internal Medicine Discharge Summary note dated 6/11/2024 2142 revealed the following: “patient’s sister would like to speak with hospice team directly as she is requesting inpatient hospice. Disposition: Patient is not GIP (general inpatient) hospice appropriate. Guardian (sister) no longer wants hospice care. LTAC (long term acute care facility) was requested, and patient was transferred to [facility name].” Patient was discharged from facility on 6/12/24. Based on above findings, P-4 was admitted to facility from 3/5/24 to 6/12/24 with a hospice care enrollment from 4/10/24 to 4/18/24. Review of nursing admission skin assessment documented on 3/5/24 2300 (after his admission to facility on 3/5/24) did not reveal any pressure injuries present on admission. There was a nursing assessment documentation dated 3/16/24 2000: “Coccyx Medial pressure ulcer- Unstageable, deep tissue injury, evolving, measurements 0.5 x 0.5 cm, intact and discolored, wound status- deteriorating.” Nursing assessment documentation dated 3/25/24 0800: “Coccyx Medial pressure ulcer- Stage II, measurements 1.5 x 1 cm, wound status- deteriorating.” Nursing assessment documentation dated 04/06/24 0800: “Coccyx Medial pressure ulcer- Stage I, improving.” Record review did not reveal nursing Plan of Care for risk for impaired tissue integrity after identifying deep tissue injury on 3/16/24. No Plan of Care was initiated by nursing for impaired skin integrity after P-4 pressure injury deteriorated to Stage II and until patient was transferred to a different unit on 4/10/24. Further nursing skin assessment documentation review revealed the following data: On 4/27/2024 19:00 “Coccyx pressure ulcer, Unstageable - deep tissue injury evolving. No nursing plan of care for skin impairment was initiated after this assessment.” On 4/30/24 1800 “Coccyx pressure ulcer, Unstageable - deep tissue injury evolving, present on arrival to unit, silicone border foam dressing.” On 5/06/24 0200 “Coccyx pressure ulcer, Stage II ...” On 5/10/2024 1100 “Coccyx pressure ulcer, Unstageable- slough and/or eschar, wound bed- necrotic tissue, slough; wound exudate- sanguineous...” On 5/13/2024 0600 “Coccyx pressure ulcer, Stage III, wound status- deteriorating...” No wound care consult was initiated after this nursing skin assessment. On 5/27/2024 1700 “Coccyx pressure ulcer, Stage IV, wound bed- necrotic tissue, eschar, wound exudate- sanguineous, moderate...” On 5/29/2024 1000 “Coccyx pressure ulcer, measurements 18 x 24 cm, wound status- unchanged. Further record review revealed the following nursing skin assessments and documentations.” On 4/30/24 1800 “Back right lateral pressure ulcer, Stage II ...” No nursing assessments were documented for this pressure injury to the right lateral back from 5/02/24 to 5/29/24. On 5/29/2024 1000 “Back right lateral pressure ulcer, unstageable - deep tissue injury evolving, measurements 9.5 x 3 cm...” On 5/27/24 1700: 1) “Right scapula pressure ulcer, Stage III, wound exudate- sanguineous, moderate...” 2) “Left lateral knee pressure ulcer, Stage II, wound exudate- sanguineous, moderate, wound status- unchanged.” On 5/29/2024 1000: 1) “Right scapula pressure ulcer, measurements 5 x 9 cm.” 2) “Left lateral knee pressure ulcer, Stage III, measurements 9.5 x 3 cm.” No wound consult was placed after identifying above two pressure ulcers on 5/27/24. No nursing plan of care for skin impairment was initiated after this assessment. On 5/29/24 1743: 1) “Left posterior thigh pressure ulcer, Stage III, measurements 5 x 5 cm, wound status- deteriorating...” 2) “Right gluteal pressure ulcer, Stage III, measurements 7.5 x 7.5 cm.” No wound consult was placed after identifying above two pressure ulcers on 5/29/24. No nursing plan of care for skin impairment was initiated after this assessment. Further record review for this encounter from 4/10/24 to 5/30/24 did not reveal any provider notes regarding the wounds. There was a provider order dated 4/12/24 1519 and discontinued on 5/31/24 0102 for Nutrition and food services consult. Wound management consult note signed by Staff HH, wound care nurse, and dated 6/3/24 0930 indicated the following. Wound assessment: “1) Sacral unstageable pressure injury, 19.5 x 14 x 0.2 cm (length/width/depth), wound bed- dry black necrotic tissue. 2) Right trochanter unstageable pressure injury, 5 x 5 x 0.2 cm, wound bed- dry black necrotic tissue. 3) Right proximal scapula unstageable pressure injury, 7 x 11 x 0.2 cm, wound bed- moist necrotic tissue. 4) Right distal scapula unstageable pressure injury, 6 x 11 x 0.2 cm, wound bed- dry black necrotic tissue. 5) Left lateral thigh unstageable pressure injury, 1.5 x 2.5 cm, wound bed- dry black necrotic tissue. 6) Left lateral knee unstageable pressure injury, 6.5 x 1 x 0.2 cm, wound bed- dry black necrotic tissue. 7) Left medial knee unstageable pressure injury, 5 x 3 cm, wound bed- dry black necrotic tissue. 8) Left anterior knee unstageable pressure injury, 5 x 1 cm, wound bed- dark flattened intact. Spoke with staff to have patient scheduled for q2 (every 2 hours) turning ... Bedside nurses to complete dressing changes as ordered. If deterioration or development of wounds occurs, please reconsult. Sacro-coccyx, Right Trochanter, Right Distal & Proximal Scapula, Left Lateral Thigh, Left knee pressure injury: 1. Clean and soak wounds for 5-10 minutes with Vashe (topical super-oxidized solution specifically formulated to combat bacteria and facilitate wound healing) soaked gauze and pat dry with gauze. 2. Apply dime thick layer of Triad (Zinc-oxide based hydrophilic paste) to wound. 3. Cover with Allevyn (multi-layered dressing with adhesive boarders). 4. Provide surface cleansing after incontinence episode and reapply Triad if needed. 5. Completely remove Triad with mild soap and lukewarm water and replace Q72H. To be completed daily: 1. Complete daily/PRN (as needed) bathing using lukewarm water and pH-balanced skin cleanser or CHG solution. 2. Avoid use of incontinence brief and use single white Ultrasorb pad for proper moisture-wicking, especially on specialty beds (allows for proper microclimate). 3. Apply barrier cream to bilateral buttock/perineum if excessive moisture is noted. 4. Assess skin, wound, and all bony prominences every shift and document. 5. Protect bony prominences with use of foam wedge, pillows, or Allevyn. 6. Turn and reposition every 2 hours with assistance of foam wedge, pillows, or Turn Assist feature on specialty bed and document each shift in Plan of Care and Q2H (every 2 hours) in Activity & Intervention. 7. Offload heels with use of heel lift boots or pillows placed under patient’s calves. 8. Start Pressure Injury Management Order set and complete Patient Education/Plan of Care forms each shift. 9. Consult Nutrition for Pressure Injury.” Review of the nursing documented skin assessments for P-4 revealed missing nursing wound assessments on 5/31/24, 6/01/24, 6/02/24, 6/04/24, 6/05/24, 6/07/24, 6/08/24, 6/09/24, and 6/11/24 6/10/24 (as per wound care nurse, Staff HH, recommendations above). Documentation regarding repositioning patient every 2 hours and consistent offloading heels was not evident in a provided medical record. On 10/15/24 at 1020 during the tour of Medical intensive Care unit (MICU) nurse manager, Staff C, was interviewed regarding nurses’ clinical responsibilities and documentation. Staff C stated that all nurses are responsible for their shift assessments, including skin and wounds, and appropriate documentation. When asked about initial admission assessment, Staff C said that it is expected to be completed and documented withing 24 hours period. Furthermore, if any skin conditions were identified during nursing assessments, they need to be documented with plan of care initiated as well. On 10/16/24 at 1058 facility wound care nurse, Staff HH, was interviewed. She was asked what the process was for initiating wound consult for patients. Staff HH stated that wound consult was warranted with complex, Stage 3 and 4 wound management. For pressure injuries Stage 1 and 2 management there were binders available on each unit. They contain the wound care assessment, information and references for nurses. Staff HH also added that nursing staff can reach out to her at any time with questions related to skin or wound assessment and/or management. When asked if the expectations were for staff nurses to assess patients’ skin daily and document any new findings, Staff HH stated yes. Facility Skin and Wound Care Policy was reviewed on 10/16/24. Policy effective 7/21/21 revealed: “I. OBJECTIVE To provide guidelines for skin and wound care III. POLICY A. The RN (registered nurse) is responsible for the assessment, planning, evaluation and documentation of skin and wound care. Wounds are assessed with each dressing change and characteristics documented in the medical record. B. Wound care is provided using [facility name] Wound and Skin Care Flow Charts as guidelines for the RN to independently make decisions and initiate orders for wound care. I. RN staff members initiate EMR (electronic medical record) orders for pressure injury prevention and management based on patient risk assessment and/or presence of pressure injury (injuries). K. Any pressure injury that develops 24 hours after admission to the hospital or is not documented as present on admission within 24 hours is defined as a hospital-acquired pressure injury (HAPI). M. Patients are repositioned minimally every 2 hours. Able patients are taught to shift their body weight while in bed and chair sitting. EMR documentation of repositioning occurs in the Plan of Care under Comments. Additionally, repositioning may be documented in the activity section of the EMR.””

“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: 47415 Based on interview and record review, the facility failed to establish an individualized plan of care for two patients (P-4 and 5) of 4 patients reviewed resulting in negative outcomes for the patient. Review of the medical record revealed that P-5 had an admitting diagnosis of failure to thrive with chief complaint of recent weight loss, greater than 15 pounds in 2 weeks. No nursing care plan was open for imbalanced nutrition to address P-5’s recent weight loss, decreased appetite, or low BMI. A nutritional note entered on 5/23/24, revealed oral meal intake was not documented in the record. Nutritional Problem recorded by dietitian was underweight, evidenced by a BMI of 15.2 Nutritionist recommendations and plan of care included: “continue double portion, high protein diet, which provided 350 calories and 20 grams of protein each, and encourage oral meal/supplement intake, and monitor weight, RN to document and trend weights.” Review of record for oral meal intake/meal consumption for P-5 revealed no documentation for meal intake on the following dates: 4/28/24, 4/29/24, 4/30/24. No entries recorded on any day in May 2024, 6/1/24, 6/2/24, 6/7/24, 6/8/24, 6/9/24, 6/10/24, 6/11/24, or 6/12/24. Supplement intake not documented. Three entries of “estimated” weight documented in the record, 4/27/24 at 45.0 kilograms (kg), 5/27/24 - 45.0 kg, and 6/11/24 - 45.0 kg On 10/16/24 an interview with CNO Staff A revealed that it is her expectations that nursing staff follow policy and procedures, and standards of practice for nursing. 45246 On 10/15/24 at 1020 during the tour of Medical intensive Care unit (MICU), nurse manager, Staff C, was interviewed regarding nurses’ clinical responsibilities and documentation. Staff C stated that all nurses are responsible for their shift assessments, including skin and wounds, and appropriate documentation. Staff C added that if any skin conditions were identified during nursing assessment, on admission or later during hospitalization, they need to be documented with the plan of care initiated as well. On 10/16/24 P-4’s record was reviewed and revealed the following documentation. P-4 was a 73-year-old male admitted to facility on 03/05/24 at 1906 post MVA (moto-vehicle incident) with multiple traumas. P-4 underwent several surgical procedures, was admitted to a Surgical Intensive Care Unit (SICU) and on 4/10/24 was transferred to a medical surgical unit after family agreed to hospice care. Initial nursing admission skin assessment documented on 3/5/24 2300 (after his admission to facility on 3/5/24) did not reveal any pressure injuries present on admission. There was a nursing assessment documentation dated 3/16/24 2000: “Coccyx Medial pressure ulcer- Unstageable, deep tissue injury, evolving, measurements 0.5 x 0.5 cm, intact and discolored, wound status- deteriorating.” Nursing assessment documentation dated 3/25/24 0800: “Coccyx Medial pressure ulcer- Stage II, measurements 1.5 x 1 cm, wound status- deteriorating.” Nursing assessment documentation dated 04/06/24 0800: “Coccyx Medial pressure ulcer- Stage I, improving.” Record review did not reveal a nursing Plan of Care for risk for impaired tissue integrity after identifying deep tissue injury on 3/16/24. No Plan of Care was initiated for P-4 for impaired skin integrity after the wound was assessed on 3/25/24 and evolved to Stage II. No Plan of Care for skin impairment was developed for P-4 until patient’s transfer to a different unit on 4/10/24. Nursing Plan of Care Policy was requested and reviewed on 10/16/24. Policy, Effective 3/16/22, indicated: “I. Objective. To document the plan of care required to meet the admitted patient’s needs. II. Scope. Registered Nurse (RN) IV. Policy. The RN develops, documents and updates the patient’s Plan of Care, which includes problems and goals as identified through the episode of care. V. Provisions. A. The Plan of Care is initiated with the patient and is documented within the first twelve hours of patient admission. B. The RN integrates data obtained through objective and subjective means (e.g. Admission History and Assessments) to identify patient needs and care priorities. C. The RN collaborates with the patient, family and/or significant other to formulate the Plan of Care. D. The RN individualizes the pre-formatted plans of care to be reflective of the patient’s condition E. The RN is responsible for reviewing, evaluating, and documenting the progress toward established plan of care goals and updates the plan of care accordingly, minimally every twelve hours. Documentation is reflective of findings from: F. On-going and focused assessments plus additional updates to be completed to address new findings or G. Change in the patient’s condition (e.g., post-op, change in hemodynamic state, change in level of consciousness (LOC), invasive procedures).””

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 50585 Based on observation, interview, and record review, the facility failed to ensure that clinical staff followed established processes and methods for preventing and controlling the transmission of infections for 1 patient (P-8) of 1 patient observed, resulting in the potential for transmission of infection and less-than-optimal outcomes for the patient. Findings include: On 10/15/2024 at 1100, in the presence of Clinical Improvement Coordinator Staff E, Nurse Staff G was observed outside a room (P-8) that was listed as isolation precautions. Staff G gathered medications and supplies and placed the items on the surface of the computer-on-wheels device. Staff G put one glove on and proceeded to the patient care unit desk to obtain a glucometer, then put the other glove on and proceeded to open the isolation room door and enter P-8’s room. Without performing additional hand wash, Staff G was observed performing the following tasks using the same pair of gloves that were put on prior to entering P-8’s isolation room and without additional hand wash. Staff G scanned all the medications at one time before administering any medication. Staff G opened P-8’s isolation room door twice, once to ask for assistance for the Mobility Technician to reposition P-8 and again to announce that they were going to close the curtain to reposition P-8. Staff G spiked a medication vial. Staff G pressed buttons on the intravenous pump, moved the curtain to reposition P-8, and reopened the curtain. Staff G administered an intravenous (IV) piggyback, then placed the used IV piggyback in the trash can that was near capacity with trash. Staff G used a pencil to document information on paper and pressed keys on the keyboard to enter information into the computer. Clinical Improvement Coordinator Staff E confirmed the observations and findings. According to the facility’s policy “Facility Isolation Policy,” dated 11/1/2023, the policy revealed that “Hand hygiene will be performed according to the facility’s Epidemiology Hand Hygiene Policy” and that “Hand hygiene is performed before and after patient contact, contact with patient environment, between patients and before and after gloving.” According to the facility’s policy “Hand Hygiene Policy,” dated 11/1/2023, the policy revealed that indications for hand hygiene are “Between clean and contaminated tasks on the same patient “and “After contact with equipment or surfaces likely to be contaminated, including bed rails, bedside trays, telephones, and other objects in the patient’s immediate environment.” The policy also revealed that “Gloves are never a substitute for hand hygiene” and “Gloves are changed after each task.””

“IC PROFESSIONAL TRAINING CFR(s): [The infection preventionist(s)/infection control professional(s) is responsible for:] (iv) Competency-based training and education of hospital personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the hospital, on the practical applications of infection prevention and control guidelines, policies, and procedures. This Standard is not met as evidenced by: 45246 Based on observation, interview and record review, the facility failed to ensure the facility staff disposed of bodily fluids according to policy for one patient (P-15) of 24 patients sampled, resulting in the potential for adverse patient outcomes from improper handling of biohazardous fluids. Findings include: During initial facility tour on 03/05/24 at 1048 medical surgical unit was observed with Staff P, Staff Q and Staff R. P-15 was observed lying in bed in his room. Two clear plastic bottles were noted sitting on a windowsill next to the patient’s bed. One bottle was filled to the top with a red fluid. Second bottle had approximately 50 ml of red fluid in it. Both bottles were not covered and were visible form the hallway. Staff nurse in care of P-15, Staff S, was asked regarding the bottles. Nurse S stated that it was a bladder irrigation fluid that was collected by urology residents this morning and residents left it there, on the window. Staff S was not sure what has to be done with the fluid since he did not receive any instructions from the urology residents regarding collection of any specimens for laboratory analysis and he was not sure if it was ok to discard the fluid. Staff nurses, Staff T and Staff U were called into the room to see if they had any knowledge of the bottles. Both nurses looked at the bottles and Staff T said that urology residents do that sometimes- they collect the bladder irrigation and leave the fluid behind so “nurses clean after them”. Staff T and Staff U were asked if they educate residents on proper disposal of bloody bodily fluids. Nurses responded that they do it “all the time”. Both nurses were asked what an appropriate place would be to discard the bloody fluid. Staff responded that they always do it into the patient’s bathroom, into the toilet. During this conversation Staff S was observed collecting more irrigation fluid from P-15’s catheter into a plastic container. He asked his peers where he should dispose it. Both nurses responded that it needs to be flushed down into the toilet in patient’s bathroom. During collection of the bladder irrigation Staff R noted not to wear eye protection. Staff T and Staff U were asked if they do wear eye protection while collecting bladder irrigation. Staff T said that they usually don’t, and they (staff) just look away, so it won’t splash in the eyes. Unit Nurse Manager, Staff R, who was present during the conversation with the staff, was asked if the bloody irrigation fluid should be removed from the window and discarded at this point. She stated yes. When asked where it should be discarded, Staff R responded that it should go “into the hopper in soiled utility room”. Infection Control Nurse, Staff P, was present during the conversation with nursing staff and unit manager. She was asked if medical staff, including residents, have a designated infection prevention educator. Staff P stated that she was not sure. When asked how residents can be educated on appropriate and timely bodily fluid disposal, Staff P said it would be communicated through medical leadership. On 03/06/24 at 1026, during interview with Staff P and Staff B, facility’s Infection control prevention practices and policies were discussed in detail. Staff P shared the description of her responsibilities as an Infection Control Nurse. Part of Staff P’s role was clinical staff education on facility’s infection prevention and control guidelines, policies, and procedures. She stated that clinical applications of the policies and guidelines are discussed in huddles with clinical staff regularly. When asked about bloody fluids sitting on the windowsill as being an appropriate practice, Staff P indicated “absolutely not”, and reassured that all the clinical staff who was involved will be re-educated. When asked if staff needs to follow facility’s policy for personal protective equipment when working with biohazard materials, Staff P stated “yes”. Facility’s Infection control and prevention policies were requested and reviewed on 03/06/24. Medical Waste Plan Policy, effective date: 05/09/23, indicated the following: Objective To provide an effective medical waste management program for the (facility’s name) to protect human health and the environment from exposure to the hazards posed by regulated medical waste. 2. Medical Waste Management-General F. Medical waste is stored in such a manner that putrefaction will not occur and infectious agents will not come in contact with air or individuals. E. Human blood, blood products and body fluids shall be flushed into designated sanitary sewers located throughout each facility. 4. Protective Measures A. Appropriate personal protective equipment (PPE) must be worn when handling, packaging, and transporting medical waste as well as for management of general waste. Isolation Policy, effective and revised 11/01/2023, indicated the following: Objective/Purpose: To prevent the spread of communicable and other infectious diseases between patients, personnel, and visitors. To improve the safety of the (facility’s name) healthcare delivery system by reducing the rates of healthcare associated infections. A. Standard Precautions by the Centers for Disease Control and Prevention includes the practice of Universal Precautions for blood and body fluids in the care of all patients in accordance with the OSHA Bloodborne Pathogens rule. I. Standard precautions Standard Precautions presumes that all patients may be harboring an infectious agent, does not rely upon specific diagnosis or culture results for implementation and applies to all blood and bodily fluids. 3. Gloves are worn for anticipated contact with blood or body fluids, mucous membranes, or non-intact skin. Gloves are worn when handling items or surfaces soiled with blood or body fluids. Gloves are changed after each task and after contact with each patient; hand hygiene is performed between glove changes. 4. Masks and protective eyewear are used during procedures likely to generate splashes of blood or body fluids to prevent exposure to mucous membranes of the mouth, nose, and eyes. 6. Gowns are not routinely necessary. Gowns are used during procedures likely to generate splashes of blood or body fluids or when soiling of clothing is likely.”