Henry Ford Macomb Hospital

“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: 50223 Based on interview and record review the facility failed to ensure nursing staff provided care in accordance with physician orders and facility policy and failed to ensure adequate supervision and evaluation of nursing care for 1 (P-2) of 10 sampled patients resulting in prolonged hyperglycemia and delayed recognition and treatment of hypoglycemia. Finding include: See tags: A-0397 Failure to follow policy and orders A-0398 Failure to supervise nursing care”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 50223 Based on interview and record review the facility failed to ensure its Quality Assessment and Performance Improvement (QAPI) program identified and analyzed a breakdown in the process for blood glucose monitoring and glucometer quality control for 1 of 10 sampled patients (P-2) receiving an insulin infusion resulting in delayed identification and treatment of critical hypoglycemia. Findings include: Record review revealed P-2 was admitted on 12/1/25 with diagnoses including sepsis and Type II diabetes mellitus. The patient underwent nephrectomy with inferior vena cava injury on 12/5/25 and was transferred post-operatively to the Intensive Care Unit. Record review showed the patient was started on a continuous insulin infusion on 12/5/25 at 1006. Facility policy titled Henry Ford Health Glycemic Control Intensive Care Protocol dated 7/1/25 indicated patients receiving insulin infusions require blood glucose monitoring every two hours. Record review showed blood glucose monitoring occurred at the following times: 12/5/25 1148 - glucose 244 12/5/25 1534 - glucose 227 12/5/25 1948 - glucose 141 12/5/25 2337 - glucose 161 Record review showed no further blood glucose monitoring occurred after 2337 on 12/5/25 while the patient remained on an insulin infusion. The next documented glucose result occurred from morning laboratory testing on 12/6/25, which resulted at 0831 with a critical glucose value of 48. Review of the facility adverse event log revealed P-2 appeared on the log twice for separate events dated 12/4/25 related to blood product and surgical/procedural issues. However, the adverse event log did not include the hypoglycemic event or the breakdown in glucose monitoring that occurred while the patient was receiving an insulin infusion. Review of the facility’s RL incident report (File ID 522931) dated 12/06/2025 documented that glucometer quality control checks had not been completed on four glucometers assigned to the Surgical Intensive Care Unit and that no additional glucose monitoring had been recorded after 2337 on 12/05/2025 for a patient receiving an insulin infusion prior to identification of a critical glucose result the following morning. Review of the manager follow-up documentation revealed the issue was addressed through staff discussion and verbal coaching of the night shift nursing assistant only. The RL investigation documentation failed to demonstrate that the facility conducted a broader analysis of the monitoring process, evaluated compliance with the insulin infusion protocol, reviewed overnight glucose monitoring intervals, evaluated the registered nurses supervision of delegated tasks or implemented system-level corrective actions or process improvements related to glucose monitoring or glucometer quality control. An interview conducted 3/11/26 at approximately 0930 with the ICU manager, Staff U confirmed patients receiving insulin infusions require blood glucose monitoring every two hours per policy. Staff U confirmed the documented monitoring intervals represented “a big gap in time.” An interview with Staff U further revealed that while the hypoglycemic event was discussed with the day shift nurse, earlier documentation related to blood glucose monitoring gaps was not reviewed, and the night shift registered nurse involved in the patient’s care was not interviewed as part of follow-up review. Review of glucometer quality control documentation for the ICU revealed multiple glucometers (devices 10, 11, 12, and 13) did not have documented quality control testing during the night shift on 12/6/25. Quality control checks had been documented on 12/5/25 at 0133 and were not performed again until the morning of 12/6/25 between approximately 0700 and 0900. Interview with the Chief Nursing Officer, Staff B on 3/11/26 at 1052 revealed leadership was not aware of the monitoring failure until it was identified during the survey. Staff B stated additional auditing would need to occur to determine whether the issue represented a broader pattern. A review of the facility’s policy titled “RL Feedback Reporting (Compliment, Comment, Complaint, Grievance”) revealed the following: “The tracking, investigation, and analysis of service failures develops a link between service recovery and process improvement initiatives to address the root causes of service failures, promote learning, and prevent recurring service failures.””

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 50223 Based on interview and record review the facility failed to ensure nursing staff provided care in accordance with physician orders and facility policy for blood glucose monitoring and intravenous insulin for 1 (P-2) of 10 sampled patients resulting in prolonged hyperglycemia and delayed recognition and treatment of hypoglycemia. Findings include: Record review revealed P-2 was admitted on 12/1/25 with diagnoses including sepsis, renal abscess, and Type II diabetes mellitus. Record review revealed the patient underwent nephrectomy with inferior vena cava injury on 12/5/25 at 0238 and was transferred post-operatively to the Intensive Care Unit (ICU). Review of P-2s order revealed “Order: Ordered On: 12/05/25 0806 Starts/Ends: 12/05/25 0900 - 12/06/25 0933 Ordered Dose (Remaining/Total): 0.5-22 units/hr (hour). Route: Intravenous; Frequency: Continuous; Ordered Rate/Order Duration: 0.5-2 units/hr; Admin Instructions: INITIATION Infusion Rate: Blood glucose (mg/dL) at time of INITIATION 181-219=2 units/hr 220 or greater=4 units/hr TITRATION per STANDARD dosing nomogram to keep glucose levels between 140-180 mg/dL Blood glucose (mg/dL) at time of TITRATION Glucose less than 70 -- initiate hypoglycemic treatment Check glucose at 15 min & every hr after dextrose given. Resume every 2 hour glucose checks when glucose greater than 100 mg/dL and restart drip at 50% previous rate when glucose greater than 140 mg/dL. (If rate is less than 0.5 units/hr, turn off drip & restart protocol from beginning. 70-139=No bolus. Reduce drip rate by 50%. Turn off drip if rate less than 0.5 units/hr-restart protocol from beginning 140-180=No Change 181-200=2 unit Reg Insulin IVP & increase drip rate by 1 un/hr 201-250=4 unit Reg Insulin IVP & increase drip rate by 1 un/hr 251-300=6 unit Reg Insulin IVP & increase drip rate by 2 un/hr 301-400=8 unit Reg Insulin IVP & increase drip rate by 2 un/hr Greater than 400=Call provider for new order HIGH ALERT Medication. Look Alike/Sound Alike Medication” Medication Administration Record (MAR) review revealed the following: 12/05/25 1006 New Bag 4 Units/hr 4 mL/hr Intravenous Performed by: Staff II Scanned Package: 0002-8215-01, 0338- 0049-38 12/05/25 1538 New Bag 5 Units/hr 5 mL/hr Intravenous Performed by: Staff II Scanned Package: 0002-8215-01, 0338- 0049-38 12/06/25 0749 Stopped 0 Units/hr 0 mL/hr Intravenous Performed by: Staff CC Review of blood glucose documentation during the insulin infusion revealed the following results: 12/5/25 1148 - Blood glucose 244 12/5/25 1534 - Blood glucose 227 12/5/25 1948 - Blood glucose 141 12/5/25 2337 - Blood glucose 161 12/6/25 0630 - Laboratory glucose 48 (critical value) 12/6/25 0748 - Glucometer recheck 50 12/6/25 0843 - Glucose 94 following treatment A review of the facility Policy titled “Henry Ford Health Glycemic Control Intensive Care Protocol” dated 7/1/25 indicated that patients receiving an insulin infusion require blood glucose monitoring every two hours. The “Surgical Standard IV insulin Nomogram” revealed that blood sugars 201-250 should be treated with 4 units bolus insulin and then increase the insulin infusion by 1 units per hour. Interview conducted on 3/11/26 at approximately 0930 with the ICU manager, Staff U confirmed that patients receiving insulin infusions are expected to have blood glucose monitored every two hours per policy. During review of the record, Staff U identified monitoring intervals greater than two hours, including: 1534 to 1948 (over four hours) 1948 to 2337 (approximately four hours) 2337 with no rechecks until morning labs result. Staff U stated these intervals were inconsistent with policy and stated “that is a big gap in time.” Staff U explained that it is her expectation that nurses follow physician orders and protocols and that if they have any questions or concerns they can reference the policies, contact the ICU educators, managers, and physicians. Record review showed failure to document required insulin infusion titration adjustments. On 3/10/26 at 1505 during review of P-2s record the ICU educator, Staff Y explained that the blood glucose level should have been checked every 2 hours and explained that per protocol the blood glucose level of 244 at 1148 should have been treated with a bolus of insulin and the insulin infusion should have been increased by 1 unit per hour and confirmed that those interventions were not documented. Staff Y explained that the blood glucose level should then be checked again at 1400 and confirmed that it was not documented. Staff Y also confirmed that the blood glucose level was not checked for an extended period over night resulting in critical hypoglycemia. Review of the facility’s internal RL event report (File ID 522931) confirmed the last documented glucose monitoring occurred at 2337 on 12/05/2025 with a result of 161 mg/dL and no additional glucose monitoring was recorded overnight prior to identification of a critical glucose value the following morning. The RL report further documented the patient was receiving an insulin infusion during this time period. An interview conducted on 3/11/26 at 1052 with the Chief Nursing Officer, Staff B confirmed that the registered nurse has ultimate responsibility to ensure blood glucose monitoring occurs per physician orders and facility policy. A review of the facility’s policy titled, “IPD Nursing Document: Nursing Process” revealed the following: “The Registered Nurses (RN) will document all phases of the nursing process in the electronic Health Record (EHR) ...Interventions will be documented in the EHR.””

“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 ensure adequate supervision and evaluation of nursing care related to blood glucose monitoring and glucometer quality control processes in 1 patient (P-2) of 10 sampled patients resulting in delayed identification and treatment of critical hypoglycemia. Findings include: Record review showed the patient was started on a continuous insulin infusion on 12/5/25 at 1006. Facility policy titled (Facility name) Glycemic Control Intensive Care Protocol indicated that patients receiving insulin infusions require blood glucose monitoring every two hours. Record review showed blood glucose monitoring occurred at the following times: 12/5/25 1148 - 244 12/5/25 1534 - 227 12/5/25 1948 - 141 12/5/25 2337 - 161 Record review showed no additional blood glucose monitoring was documented after 2337 on 12/5/25 while the patient remained on the insulin infusion. The next documented glucose value occurred from laboratory testing drawn the morning of 12/6/25, which resulted at 0831 with a critical glucose value of 48. An Interview conducted on 3/11/26 at 1052 with the intensive care manager, Staff U confirmed that blood glucose monitoring should occur every two hours for patients receiving insulin infusions and that failure to obtain timely blood glucose checks can result in delayed identification and treatment of hypoglycemia and adverse events. Staff U further confirmed she had discussed the hypoglycemic event with the 12/6/25 day shift nurse, Staff CC but had not reviewed earlier documentation for monitoring gaps and had not spoken with the night shift registered nurse involved in the patient’s care. A review of an internal incident report RL solution revealed documentation of missed blood glucose monitoring and missed glucometer quality control checks. Review of glucometer quality control audit documentation for the ICU revealed that glucometers numbered 10, 11, 12, and 13 did not have documented quality control testing during the night shift on 12/6/25. Quality control testing had been documented on 12/5/25 at 0133 and was not performed again until between approximately 0700 and 0900 on 12/6/25. Review of the Nursing Assistant job description revealed nursing assistants may perform blood glucose testing using a glucometer and are required to communicate patient care findings to the responsible registered nurse. Interview conducted 3/11/26 with Staff B (Chief Nursing Officer) confirmed that the registered nurse has ultimate responsibility for ensuring blood glucose monitoring is completed and reviewed and is responsible for communicating and delegating to assistive personnel. Personnel file review revealed the nursing assistant involved in the care of P-2, Staff EE had previously received verbal coaching related to performance and the interview with Staff U confirmed that Staff EE previously had issues completing delegated tasks including glucometer quality control testing. Review of the manager follow-up documentation associated with the RL report dated 1/2/26 1254 indicated that ensuring glucose monitoring occurs for patients receiving insulin infusions is a nursing responsibility. Despite this expectation, overnight glucose monitoring was not completed and the registered nurse did not ensure delegated tasks were performed. Despite these concerns, record review showed no evidence the registered nurse ensured delegated blood glucose monitoring tasks were completed or addressed the missed monitoring intervals overnight. Interview with Staff U on 3/11/26 at 0930 confirmed that failure to obtain blood glucose monitoring while a patient is receiving an insulin infusion may result in delayed identification of hypoglycemia and delay in patient care. Interview with Staff U further confirmed that blood glucose monitoring may be delegated to nursing assistants, however the registered nurse remains responsible for supervision and ensuring the monitoring occurs according to physician orders and policy. An interview with the ICU manager, Staff U, confirmed that failure to perform glucometer quality control checks could delay the ability to obtain accurate blood glucose results. A review of the facility’s policy titled “IPD Nursing Document: Nursing Process” dated 2/25/25 revealed the following: “Assistive personnel will document data collected and interventions performed that have been delegated to them by an RN in the electronic health record (EHR) ...Other healthcare providers may complete portions of the assessment process, however it is the responsibility of the RN assigned to the patient to review assessment information, use the data to initiate the interdisciplinary plan of care, and take appropriate interventions and actions.””

“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 follow policy in obtaining consent for treatment in 2 (P-8 and P- 9) of 12 records reviewed, resulting in the potential loss of making informed decisions regarding care. Findings include: P-8: This 75-year-old male presented to the emergency room with complaints of fever and shortness of breath on 12/6/25 and was admitted to the facility. P-8 has a medical history of acute respiratory failure secondary to community acquired pneumonia, hypercapnic respiratory failure, chronic obstructive pulmonary disease, pulmonary hypertension, hypertension, hyperlipidemia, type 2 diabetes mellitus, and stage 3 chronic kidney disease. During record review, it was noted that P-8 speaks Arabic and limited English, and the consent for treatment was written in English and Arabic. In the patient signature box, it states, “verbal by patient used interpreter services.” The date documented on the consent is 12/6/25 at 1124. It was noted that the check box and “Print Name & Company if Interpreter Used” was blank. P-9: This 76-year-old female presented to the emergency room via ambulance on 12/5/25 after a fall at home, accompanied with generalized weakness, confusion, and decreased oral intake. P-9 has a medical history of paroxysmal atrial fibrillation, hypertension, hyperlipidemia, type 2 diabetes mellitus, chronic obstructive pulmonary disease, and chronic pain with opioid use. In the ED, P-9 became less responsive, was hypoxic and was intubated for airway protection. During record review, it was noted that the history was provided by the patient’s son as the patient was lethargic and unable to provide history. It was also noted that the consent for treatment was signed on 12/5/25 at 0423. The printed name of signer and relationship to the patient were blank. These findings were reviewed and acknowledged by the Chief Nursing Officer (Staff C) during an interview on 12/10/25 at 1430. Staff C stated staff should have listed the interpreting service utilized and should have listed the name and relationship of the family member who signed the consent. Policy 19260635 - General Consent Policy (effective 11/8/25). The following fields should be completed by the employee who is checking in, arriving, and registering the patient: Signature, Printed Name, Date/Time, Relationship to patient, Interpreter Information when available. If the form cannot be signed by the patient and or a designated advocate signing on that patient’s behalf the following terminology is acceptable for use: unable to sign, patient is physically not capable of signing or providing verbal consent for treatment. If the patient later is in a better state to consent, staff should give the general consent form again for signature.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 53399 Based on interview and record review, the facility failed to renew a restraint order for 1 (P-5) of 5 patients reviewed for restraints resulting in the increased likelihood of poor outcomes and loss of patient rights for the patient. The findings include: On 12/09/2025 at 1311, a review of P-5’s medical record with Clinical Nurse Specialist Staff G revealed: On 11/26/2025 at 0921, P-5 was admitted to the facility’s Emergency Department (ED). On 11/26/2025 at 1410, Nurse Staff T documented “at approximately 1350, patient became extremely combative and agitated. Patient was trying to fight (Family members), remove (Their) line, and was threatening to hurt staff. RN called security and placed patient in 4-point soft restraints.” On 11/26/2025 at 1438, ED Physician Staff U ordered “Restraints violent or self-destructive adult (age 18 and older),” “Locking Left wrist, Right wrist, Right ankle Left ankle” for “danger to self.” The order also identified that the restraint order was “automatically discontinued after expiring on 11/26/2025 at 1837.” On 11/26/2025 at 1854 (17 minutes after the violent restraint order was automatically discontinued) the restraint monitoring flowsheet revealed that the nurse documented “yes” to “continued criteria to remain restraint” and “Yes” to “restraint device as ordered and applied correctly.” According to the facility’s policy, “Restraint Management for Acute Care Hospital and Ambulatory Setting,” dated 03/06/2025. Restraint Orders for Nonviolent, Non-Self- Destructive and Violent Self-Destructive Restraints: 1. All restraint orders must be entered into the electronic health record. 2. A provider’s order for restraint is required for each restraint episode.”

“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: 53399 Based on interview and record review, the facility failed to complete a face-to-face patient assessment within 1 hour of initiation of patient restraints for 1 (P-5) of 5 patients reviewed for restraints resulting in the increased likelihood of poor outcomes and loss of patient rights for the patient. Findings include: On 12/09/2025 at 1311, a review of P-5’s medical record with Clinical Nurse Specialist Staff G revealed: On 11/26/2025 at 0921, P-5 was admitted to the facility’s Emergency Department (ED). On 11/26/2025 at 1410, Registered Nurse Staff T documented, “At approximately 1350 patient became extremely combative and agitated. Patients were trying to fight (Family members), remove (their) line, and were threatening to hurt staff. RN called security and placed patients in 4-point soft restraints.” On 11/26/2025 at 1438, ED Physician Staff U ordered “Restraints violent or self-destructive adult (age 18 and older),” “Locking Left wrist, Right wrist, Right ankle Left ankle” for “danger to self.” On 11/26/2025 at 1601, Staff U documented a Face-to-Face assessment for P-5’s restraint application. The restraint application was applied on 11/26/2025 at 1355. (2 hours and 6 minutes after the violent restraint order was initiated). According to the facility’s policy, “Restraint Management for Acute Care Hospital and Ambulatory Setting,” dated 03/06/2025 responsible for the patient’s care must perform a face-to-face evaluation of the patient within one hour of restraint application. Restraint Orders Specific to Violent Self-Destructive (VSD) Behavior: Provider primarily responsible for the patient’s care must perform a face-to-face evaluation of the patient within one hour of restraint application.””

“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: 45245 Based on observation, interview, and record review, the facility failed to monitor 1 (P-1) of 10 patients reviewed, resulting in a delayed response to patient decline. Findings include: Review of “Chief Complaint for P-1,” dated 02/18/25 revealed, “Patient presents with shortness of breath, and cough. (P-1) is a 95-year-old female presenting with upper respiratory symptoms, cough, fever, and increased oxygen requirements. Patient reports for the past 4 days, she has had upper respiratory symptoms, such as a hoarse voice, cough, and congestion. Today they noticed a fever of 100.6. They also noticed that her SpO2 (oxygenation) was low, to the 80s.” Review of triage record dated 02/18/25 revealed that P-1 presented with the following vital signs: Blood pressure (BP) 142/72, Heart Rate (HR) 103, Respiratory rate (RR) 22, Oxygen saturation (O2) of 93% on 4 liters (L) via nasal cannula. An interview with confidential informant 11 (CI-11) on 03/27/25 at 1022 revealed, (P-1) was triaged and placed into an exam room at 1609 on 02/18/25 and moved into hall bed “CCH-20” after approximately 10 minutes. CI-11 stated that the ED was full, and the staff were very busy. P-1 began to have more breathing distress, despite being placed on 4 liters of oxygen. CI-11 stated that they tried to get the attention of staff to re-examine P-1’s condition. CI-11 spoke with an ED Technician and requested the physician to come. CI-11 stated they were told that P-1 had been admitted to an inpatient bed and that no ED doctor was “staffed” to her (P-1). CI-11 stated that they called a sibling and requested her to bring a portable pulse oxygenation detector (pulse ox) from home, so she could at least monitor P-1’s oxygenation status. CI-11 stated that when P-1 was moved to the hall, there was no monitoring equipment available. CI-11 requested a “pulse-ox” and was told one was not available because the ED was so busy. After CI-11’s sister arrived with her personal pulse-ox, CI-11 took a reading on P-1 and found her (P-1) to be oxygenating at 70%. CI-11 again requested a doctor and “Someone must have heard me; they moved P- into a room with three beds and then placed P-1 on a cardiac monitor, a BiPAP (non-invasive ventilator) and continuous pulse ox. Review of “Patient Care Timeline,” dated 02/18/25 at 2250 revealed P-1’s vital signs recorded as BP 101/53, HR 81, RR 39 (2x normal), O2 95% on non-rebreather. Review of “ED Notes,” dated 02/18/25 at 2302 revealed, “Rapid response called due to patient desaturation to 85%. Patient moved to a room and rapid called. Rapid response came to bedside.” The next note at 2316 revealed, “Patient’s arterial blood gas requires bipap (bi-level positive airway pressure). Respiratory at bedside.” A tour of the Emergency Department was conducted on 03/26/25 at 0930 with ED manager (Staff H). Staff H was questioned how many patients can be boarded in the halls? Staff H stated that he had 19 hallcarts in Critical Care and 30 in Acute Care. Staff H stated that the department has 5 telemetry (heart monitoring) packs available for hallcart patients. Staff H was then requested to demonstrate the equipment available to monitor the patients placed in halls. After a quick tour of the ED and Acute care areas, 3 portable pulse oximeter machines, and 4 ‘Dynamaps’ (blood pressure, pulse ox and heart rate) monitoring machines were observed and available for the 67 beds in Critical care, and 3 Dynamaps were available for Acute Care, with 24 beds and an additional 30 hall beds. Staff H was next questioned how often patients are ‘boarded’ (no inpatient bed available so the patient remains in the ED) overnight? Staff H replied, “Every day.” Staff H was next questioned if the unit has enough equipment to monitor cardiac or respiratory patients when the boarding beds are full? Staff H replied, “There is not enough. If we had a lot of telemetry (patients requiring heart monitoring), we would have a shortage. We currently have to swap patients rooms or equipment to manage.””

“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: 45245 Based on observation and interview, the facility failed to ensure that nursing personnel adhered to the facility’s policy and procedure regarding the placement of colored “fall risk” identification bands on 4 ( P-4, P-5, P-6, P-7) of 4 patients assessed for increased fall risk, resulting in the increased potential for patient falls for all patients screened for risk, and the facility failed to ensure that nursing personnel performed daily CHG (chlorhexidine gluconate) baths for 1 (P-2) of 10 patients reviewed for nursing care, resulting in the potential for negative outcomes for patients receiving nursing services. Findings include: During bedside interview on 03/26/25 at 1110 with the daughter of (P-4), the daughter stated that P-4 had an “assisted fall” hours earlier that day. P-4 was noted to not be wearing a wrist band colored to indicate risk of falls. An interview was conducted with P-4’s nurse, (Staff N) on 03/26/25 at 1120. Staff N was questioned if her patients, wear wrist bands to communicate fall risks? Staff N replied, “Yes.” Staff N was next asked to verify that P-4 was at risk for falls, and if they should have a fall-band in place? Staff N verified the fall risk status and absence of the fall band. She then placed a fall risk ID band on P-4. During tour of the Oncology (4300) unit on 04/27/25 at approximately 1243, patient rooms for P-5,P-6, and P-7 were observed to have magnetic signs on the door frames. An interview was conducted with RN (Staff O) at 1245 on 04/27/25. Staff O was questioned about the magnetic signage and she stated that the magnets communicate fall risks to staff. Yellow socks and wrist bands are also used. Staff O was next asked to verify that current patients (P-5, P-6, and P-7) were wearing fall bands. Staff O assessed the three patients and stated that all three had been identified as a fall risk and required fall bands. None of the three patients were were identified by Staff O as wearing colored fall risk identification bands. Review of “Protocol/Care Plan for the Management of The Patient at Risk for Falls, (no date, no rev.) revealed that all patients, (low, moderate or high risk) are to wear bands. The procedure states under “Low Risk (score 7-10) 1. Initiate universal fall precautions (UFPs). 2. Individualize Fall protocol. 3. Place FALL RISK patient ID band on Patient. “Moderate” and “High” risk patients have additional precautions in addition to the low risk measures. All levels of fall risk wear the same fall risk band. Review of “Orders,” demonstrated that P-2 was ordered to receive daily baths using chlorhexidine gluconate (CHG/antimicrobial) wipes on 02/24/25 at 2111. Medical record review for P-2 did not have documentation of a daily CHG bath as ordered for 02/27/25, 02/28/25, 03/01/25, 03/02/25 and 03/03/25.”

“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 assess and monitor 3 restrained patients (P-1, 2 and 13) of 13 patients reviewed, resulting in the potential for adverse outcomes for all patients in restraints. Findings include: P-1 P-1 was a 90-year-old male who was brought to Emergency department of the facility on 7/15/23 at 1120 with chief complaint of confusion and right-sided facial pain. P-1 had a past medical history of 2-vessel coronary artery disease, anemia, ankle fracture, arthritis, BPH (benign prostatic hyperplasia), cardiomyopathy (an acquired or inherited disease of the heart muscle which makes it difficult for the heart to pump blood to other parts of the body), carotid arterial disease, cataract, chronic obstructive pulmonary disease, chronic renal insufficiency, glaucoma, hyperlipidemia, hypertension, Inflammatory bowel disease, and LBBB (left bundle branch block). Emergency medicine provider note dated 7/15/23 1355 indicated: This is a 90-year-old male who presents with altered mental status and right ear pain. Brought in by family for worsening confusion according to his partner at home. Three days ago, patient was seen for a right ear infection and given Amoxicillin for 10 days. He just started his third day today but has been complaining of worsening ear pain that now radiates to his right face/jaw. It is painful for him to chew as well. Family member also reports he had an episode of slurred/garbled speech yesterday AM and today AM for a brief period of time. They thought it was because he was sleepy but then today, when patient was unsteady on his feet, family brought him to the ED (emergency department). Patient has a hx (history) of dementia, A&Ox1 (alert and oriented to himself) at baseline and so most of history is provided by family. Further in the note, Mental Status: He is alert. Gait abnormal. Comments: Patient is very unsteady on his feet. No other neurologic deficits. Record review revealed ED registered nurse (RN) Admission note dated 07/15/23 1910 had the following documentation: The following information is reflective of patient’s condition within 1 hour of transferring to an observation or inpatient unit. Is assistance required to ambulate? Yes. If assistance is required 1 or 2 person? One. Diet: No diet orders on file. P-1 was admitted to the observation unit on 7/15/23 at 2117. There was a nursing admission (to the observation unit) assessment dated 07/15/23 2157: Diet/Nutrition Received- regular. Diet order was identified as: Diet- Regular; thin liquids, soft and bite sized. Ordering user: Staff W, RN 07/16/23 1435. Electronically signed by: (physician’s name), MD on 07/18/23 1234. There was a documented order for restraints, non-violent or non-self-destructive. Ordering user: (provider’s name) on 07/16/23 0833. Restraint reason: Interference with medical treatment. Alternatives found ineffective: Comfort, Therapeutic, Environmental, Diversionary. Select a Restraint Device (s): Soft R Wrist (NV), Soft L Wrist (NV), Soft R Ankle (NV), Soft L Ankle (NV) (4-points restraints). Restraints were initiated at 0836 and discontinued at 1646 on 07/16/23 by Staff W, RN. Nursing restraint Q2H (every 2 hours) monitoring documentation reflected that P-2 was NPO (nothing by mouth) at 0838. At 1000, 1047, 1200 and 1407 documentation was as following: food- “offered, snack”, fluids- “offered”. No documentation regarding patient accepting food or drink was noted. At 1446 the following was documented: food- “offered”, fluids- “offered”. No documentation regarding patient accepting food or drink was noted. No documentation was evident regarding P-1 food or fluids intake on 7/16/23. No record of consuming/declining breakfast or lunch while in 4-point restraints from 0836 till 1446. Review of the P-1 record revealed pain assessment performed on 7/16/23 at 1100 and documented on 7/16/23 at 1126 by Staff W, nurse in care. Painad (pain behavior tool that is used to assess pain in older adults who have dementia or other cognitive impairment and are unable to reliably communicate their pain) score was documented as 4 (on the 1-10 scale) which indicated mild to moderate pain. Further review indicated that patient’s pain was not addressed by the nurse after the pain assessment with prescribed/available medication (Tylenol) while patient was in 4-point restraints. Next pain assessment documented by Staff W at 1450 had a score of 4. Tylenol was given to P-1 on 07/16/23 at 1420 (3 hours later after first pain score of 4). There was Acetaminophen (TYLENOL) order: tablet 325-650 mg, oral, as needed for mild pain (1-3 on a scale 1-10). Ordered on 07/15/23 2112, discontinued on 07/18/23 1836. Nursing note signed 07/16/23 1434 revealed: Patient daughter expressing frustration with plan of care. Patient had no diet order in upon start of shift, nurse has been attempting to contact attending and teaching team since am (morning)- phones will not connect to any of teams’ phones (IT was notified). Direct page to a physician was never read. In afternoon physician was changed to (a different name), situation was forwarded to that physician. Patient has been in restraints throughout day due to previous notes [sic] behavior. Daughter has been administering oral medications under supervision of nurse due to patient refusing medications from staff. On 04/24/24 at 1403 Staff W, registered nurse in care on 07/16/23, was interviewed. She was asked if she remembered when patient’s family arrived to the facility on 07/16/23. Staff W stated it was in afternoon, approximately around 1 or 2 pm. She was asked why Tylenol was not given to P-1 after his pain assessment of score 4 at 1100. Staff W said that it was possible that patient refused to take it. When asked about food order for the patient, nurse stated that when she found out about the situation with the diet, she initiated communication with providers. However, providers did not respond to her inquiries timely. Staff W was asked about her restraint documentation on 7/16/23 with “offered” snack and fluids to the P-1 while there was no diet order in place. She said she was offering it anyway. When queried if patient consumed any fluids or food offered by her, she could not recall. On 07/16/23 1032 Staff W documented following drug administration: Carbamide peroxide (DEBROX) 6.5 % otic [sic] solution 5 drops. Given 5 drops to right ear. Performed by: [Staff W], RN. Comments: patient family administered. (Suggesting that family member was with the patient on 07/16/23 at 1032 and was available to give pain medications and food). No food or fluid intake documentation was identified in P-1’s record during his time in 4-point restraints, resulting in incomplete assessment/monitoring of restrained patient regarding his nutritional/ nourishment needs. P-2 P-2 was a 78-year-old female who was brought to Emergency Department (ED) by family member on 10/23/23 at 1800. ED physician note dated 10/23/23 1829 revealed: Patient presents to emergency department due to aggressive behavior. Patient this time is a poor historian due to her dementia. Psychiatric recommendations reviewed. They recommended inpatient psychiatric placement. Given patient’s need for dialysis, rapid placement to a psychiatric facility will be difficult. We will place patient in the hospital for further management and evaluation by Internal Medicine as well as Psychiatry. I discussed the case with Internal Medicine Service (IM), and they have accepted patient. A consult to Nephrology has been placed as well. Patient is currently hemodynamically stable. Admitting diagnoses for P-2 were listed as Acute psychosis, Paranoid delusion, ESRD (end stage renal disease). Patient had a past medical history of AKI (acute kidney injury), carpal tunnel syndrome, cervical spondylosis, congestive heart failure, hyperlipidemia, hypertension, kidney stone, dementia and venous insufficiency. P-2 was admitted to observation unit on 10/25/23 at 1230 and was transferred to a regular medical telemetry unit on 10/25/23 at 2127. Review of P-2 medical record revealed the following documentation. There was an ED (emergency department) RN Admit (admission) note dated 10/25/23 1216: Diet-Thin Liquids, Regular. P-2 had a scheduled CT (computed tomography) guided kidney biopsy on 10/30/23 for which she was made NPO (nothing by mouth) starting midnight 10/30/23. This order had not been changed after P-2’s attempted procedure and patient continued with the order for nothing by mouth till her discharge on 11/01/23. There was a nursing note dated 11/01/23 1804: Patient (P-2) cleaned and dressed for discharge. Patient’s daughter given discharge instructions. Questions answered. Patient given by mouth meds with pudding. No swallowing deficit noted. Patient’s daughter upset that patient has not had anything to eat since Sunday (10/29/23). Writer received in report that patient was on a regular diet. Upon checking the orders, patient was nothing by mouth. Writer investigated why patient was nothing by mouth. Patient was made nothing by mouth 10/30/2023 12:01 am for renal biopsy that was performed on Monday. Diet was never resumed. Writer informed unit 3100 manager [name] of situation. Writer notified Dr. [name] that patient is being discharged home. Registered Dietitian note was found in the record dated 11/01/23 1426: Patient (P-2) interview in room with sitter, not able to provide nutrition history, no family present. Spoke with nursing related to nothing by mouth diet order. Nursing aware, reported potential discharge today on 11/1/23. Further in the note under Nutrition Diagnosis was the following documented: Problem: Inadequate oral intake with increased energy/protein needs; Signs/Symptoms: charted meal acceptance on 10/26- zero acceptance. 10/30-NPO. Medical history of dementia with charted aggravation (wrist restraints present). Hemodialysis, charted anasarca (general swelling of the whole body). Intervention: 1. Continue with nothing by mouth as prescribed, oral diet advance at discretion of medical (provider). 1. Discussed with nursing-nothing by mouth status. 2. With nothing by mouth status consider alternate nutrition support. 5. With oral diet advance, please provide total meal assistance. 6. With oral diet advance recommend oral nutrition supplement. 7. Nephro supplement at lunch. 8. High protein gelatin at breakfast. During interview with Staff O, registered dietitian who wrote the above-mentioned note, on 4/24/24 at 1220, she stated that she did not remember what exactly she discussed with nursing staff regarding P-2’s diet. When asked if Staff O could place patient on a specific diet or change the current diet order, she said “no”. She explained that physicians or midlevel providers only can prescribe diet orders; dietitians can only recommend the diet or prescribe supplements. When asked if she was able to contact providers with concerns or recommendation, Staff O answered “yes”. When clarified if she did contact a provider after assessing P-2, she could not recall. On 04/24/24 at approximately 1000 Staff GG, registered nurse in care of P-2 on 10/30/23, 10/31/23 and 11/1/23, was interviewed over the phone. Staff GG was asked if he remembered P-2 and details of care. He stated that he did not remember the patient. When asked if diet status would be given in nursing reports between shifts. Staff GG stated that usually it is a part of the report along with the other pertinent information. Further review of P-2 record revealed no documentation of intake of breakfast, lunch or dinner from 10/30/23 till 11/1/23. No documentation of patient’s fluid intake was noted in the record for the period from 10/30/23 till 11/1/23. No IV (intravenous) fluids were administered, except during dialysis treatments. Nephrology consulting physician’ note dated 10/30/23 1053 indicated: No intake/output data recorded (in patient’s record). P-2 Care plans were reviewed. Interventions (for skin integrity) dated 10/27/23 had the following: Perform a nutrition assessment that includes a nutrition-focused physical exam; identify malnutrition risk. Assess for adequate oral intake; if inadequate, offer oral supplemental food or drinks to enhance calorie and protein intake. Assess for vitamin and mineral deficiencies, supplement if depleted. Assess need and assist with meal set-up and feeding. Adjust diet or meal schedule based on preferences and tolerance. Minimize unnecessary dietary restrictions to increase oral intake. Establish bowel elimination program to increase comfort and appetite. Provide and encourage oral hygiene to enhance desire to eat. Consider enteral nutrition support if oral intake remains inadequate; provide parenteral nutrition if enteral is contraindicated. Nursing assessment every shift documentation had the following: 10/30/23 1347- diet regular (P-2 was NPO for procedure on 10/30/23 midnight) 10/30/23 2135- diet regular (P-2 still had NPO order active and not changed) 10/31/23 1251- diet regular (P-2 still had NPO order active and not changed) On 10/31/23 at 1922 nursing documentation indicated: under Diet/Feeding assistance- “tray set up”, “refused”. On 11/01/23 0955- diet regular, “tray set up”, “refused”. P-2 had nothing by mouth (NPO) order since 10/30/23 midnight and was in 4-point restraints on: 10/30/23 from 0536- till 10/31/23 0548 10/31/23 from 0548 till 0540 11/1/23 from 0541 till 1031. Nursing restraint monitoring Q2H (every 2 hours) had this documentation: On 10/30/23 at 0000- fluids, food/meal offered (P-2 was NPO for the procedure); at 0200- fluids, food/meal offered (P-2 was NPO for the procedure); at 0400- NPO; at 0600- NPO; at 0800, 1000 and 1200- patient declined food and fluids. No restraint assessment was recorded on 10/30/23 at 1400. P-2 was in dialysis treatment from 1529 till 1730. The rest of the restraint assessments for 10/30/23 indicated fluids, food/meal offered to P-2 at 1800, 2000, 2135 and 2335 with no record of acceptance/decline by patient. On 10/31/23 restraint assessment had documentation of fluids, food/meal as “offered” at 1000, 1200, 1600, 1738, 2000 and 2200. No documentation of patient acceptance or decline of food was noted (except at 1922 it was documented that patient refused food). On 11/1/23 restraint assessment had documentation of fluids, food/meal as “offered” at 0000, 0200, 0400 and 0554. No record of acceptance or decline form the patient. On 11/1/23 at 0554 a 4-point restraint order was renewed and discontinued later at 1031. No nursing Q2h assessment were found for this period of over 4 hours in patient’s record. Palliative Medicine physician’s consult note dated 10/31/23 1355 revealed: Patient (P-2) seen and examined this pm (afternoon). Notes reviewed. Still in restraints. Under Assessment and Plan: Acute confusional state. Delirium, superimposed on dementia. Patient without own decision-making capacity. Agree with Zyprexa/Depakote. Attempt to discontinue restraints as able. To avoid worsening delirium: Redirect patient as first line treatment for any behavior issues, use medications as second line treatment only when patient’s behavior is negatively impacting care. Encourage family visits to help with orientation. Keep the patient hydrated, and correct electrolyte abnormalities. Optimize nutrition. Have patient sit up in chair for several times during the day. Recommend early mobilization with PT (physical therapy). Avoid restraints. P-3 Patient was a 92-year-old female who was brought to Emergency department of the facility on 4/15/24 at 1255 with a chief complaint of the unwitnessed fall at home with 4 cm (centimeters) laceration to her left eyebrow. Patient was placed in observation for fall after syncopal episode. There was a 2-point non-violent restraint order dated 4/16/24 at 2024. Restraints were applied on 4/16/24 at 2147. Restraints order (non-violent 2-point) was renewed on 4/17/24 at 0547. Full every 2 hours (Q2h) nursing assessment was completed and documented at 0400 before renewal. At 0548 there was documentation of renewal justification and less restrictive alternatives with no full nursing assessment documented till 0800. Last full Q2h restraints assessment was completed at 1400. Restraints were discontinued by nurse on 04/17/24 at 1843. No restraints nursing assessments were found for 1600 and 1800. On 04/24/24 at 1107 during interview with clinical nurse specialist and facility’s restraint specialist, Staff BB, she was asked if the expectation for staff nurses to know and follow facility’s policy for restraints. She stated yes. Staff BB was asked how often nursing assessments need to be performed for non-violent restrained patients. Nurse said the assessments had to be done every 2 hours with specific documentation outlined in facility’s policy. Facility’s Restraint Management for Acute Care Hospital and Ambulatory Setting policy was requested and reviewed on 04/24/24. Policy dated 2/23/22 indicated: “This policy is a combined effort on the parts of all system hospitals represented with adherence to the current CMS regulations. Definitions: Alternatives - Restraints should only be used when other appropriate alternatives have been exhausted and ineffective, including but not limited to de-escalation, re-orientation, pain relief, repositioning, sleep, food, increased or decreased lighting / stimulation, ambulation with assistance, occupational therapies, TV or music, etc. Comprehensive Individual Patient Assessment - This assessment includes physical assessment to identify medical problems that may be causing behavioral changes in the patient. Examples include temperature elevations, pain, hypoxia, hypoglycemia, electrolyte imbalances, drug interactions, and drug side effects that may cause confusion, agitation, and combative behaviors. The overriding goal is to maximize mobility and freedom of movement and preserve the patient’s right to be free from all forms of abuse or harassment while utilizing the least restrictive method possible to protect patients and others. Monitoring - Monitoring is intended to evaluate the physical and emotional well-being of the patient and the continued protection of his or her rights and dignity throughout the restraint process. Monitoring is accomplished by observation and interaction with the patient or related direct visual observation by qualified staff. Thus, monitoring would evaluate whether the patient’s mental status is stable, respirations are even and regular and circulation is jeopardized, i.e. constricted in any restrained extremity. It also includes whether the patient is comfortable, too warm, or too cold, need fluids or food, use of the restroom, need for exercise or support for diagnostic or treatment procedures, and whether his/her restraint device is need to be continued or removed. Policy: C. Patients have the right to be free from restraints of any form that are imposed for coercion, discipline, convenience, or retaliation by staff, including medications that are used as restraints. G. Whenever possible and appropriate, alternative less restrictive measures or interventions will be tried or considered prior to use of restraint or seclusion. These include a variety of modalities, both physical and non-physical, that may serve as distractions or reminders to the patient. H. When used, restraint must be the least restrictive intervention that protects the safety of the patient and others after alternatives have been tried or considered and found to be ineffective. I. Restraint must be discontinued at the earliest possible time based on clinical assessment of the patient’s behavior. Procedures: B. Ordering/ Renewal 5. The ordering provider will notify the service/provider of the restraint order. D. Observation, Monitoring and Documentation 1. The RN performs and documents in the EHR a nursing assessment every two (2) hours which consists of: skin integrity, psychological and medical status, physical comfort, and circulation status and vital signs when available. This also includes an evaluation of criteria for continuation or removal of the restraint. This assessment is documented in the HER. 2. Assistive staff monitors and documents in the EHR the patient every to (2) hours for nourishment, hygiene, elimination necessities, and range of motion. If any change in the patient’s condition occurs the RN is immediately notified and the RN takes appropriate action including notification of the provider.””