Uphs Marquette Dlp Hospital

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 36887 Based on interview and record review, the facility 1) failed to promote and protect patient rights by providing the Important Message from Medicare to 3 (P-15, P-16, P-17 ) of 6 patients; 2) failed to document the use of restraints in the patients plan of care of 2 (P-14, P-15) of 3 patients; 3) failed to ensure the restraint order was written according to facility policy for 1 (P-2) of 3 patients; 4) failed to renew a violent restraint order every 4 hours for 1 (P-2) of 2 patients in violent restraint; 5) failed to monitor 1 (P-2) of 2 patients in violent restraint; 6) failed to complete a timely 1 hour face-to-face assessment for 1 (P-15) of 2 patients resulting in the loss of patient rights and the potential for poor patient outcomes. Findings include: See Specific Tags: A-117 Failure to provide the Important Message from Medicare A-166 Failure to document the use of restraints in the patient’s care plan A-167 Failure to ensure order was written per the facility policy A-171 Failure to renew a violent restraint order every 4 hours A-175 Failure to monitor a patient in violent restraint every 15 minutes A-178 Failure to complete a face-to-face assessment within 1 hours of violent restraint application”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 53475 Based on interview and record review, the facility failed to present the Important Message from Medicare to 3 (P-15, 16, 17) of 6 patients (or their representative) whose chart was reviewed for the Important Message from Medicare, resulting in the failure to inform the patient or patient’s representative of the right to appeal discharge and potential loss of rights for the patient. Findings include: On 4/2/2026 at 1306, a targeted review of the medical record for P-15 revealed an admission date of 9/5/2025 and a discharged date of 9/12/2025. No Important Message from Medicare (IMM) was found within 48 hours of discharge. This information was confirmed with the Clinical Informaticist Staff N at 1325 who conducted the record review. On 4/2/2026 at 1350, a targeted review of the medical record for P-16 revealed an admission date of 12/26/2025 and a discharge date of 1/13/2026. No IMM was found on admission nor at discharge for this Medicare patient. This information was confirmed with Staff N at 1407 at the time of discovery. On 4/2/2026 at 1404, a targeted review of the medical record for P-17 revealed and admission date of 2/6/2026 and a discharge date on 2/12/2026. No IMM was found on admission nor at discharge for this Medicare patient. This information was confirmed with Staff N at 1419 at the time of discovery. Review of facility policy #13296912 titled “Important Message from Medicare/Discharge Rights, 100-227” effective 5/2024 stated, “As a condition of participation in the Medicare program, hospitals must notify Medicare beneficiaries who are hospital inpatients of their hospital discharge rights. The Centers for Medicare and Medicaid (CMS) mandates hospitals to issue a standardized letter, “An Important Message From Medicare About Your Rights” (OMB Approval No. 0938-0692) to any hospitalized impatient who is eligible for Original Medicare or a Medicare managed care plan whether Medicare is the primary payer or will pay any portion of the bill after the primary payer. All Medicare patients must receive the Important Message (IMM) each time they are admitted and in most cases before discharge. Federal regulation requires: o The issuance of the IMM within 2 calendar days of inpatient admissions. o Obtain the signature of the beneficiary or his or her representative and provide a copy at that time. o Deliver a copy of the signed notice as far in advance of discharge as possible, but not more than 48 hours or less than 4 hours before discharge. o If delivery of the original IMM is within 2 calendar days of the date of discharge, no follow-up notice is required.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 50585 Based on interview and record review, the facility failed to document the use of restraints in the patient’s plan of care for 2 (P-14, P-15) of 2 patients reviewed for restraint monitoring resulting in the loss of patient rights and increased likelihood of negative consequences for the patient. Findings include: On 4/2/2026 at 1305, P-14 and P-15’s medical record were reviewed with Clinical Informatics Staff N. On 8/31/2025 at 2115, P-14 had an order for nonviolent bilateral upper soft restraints for pulling at tubes and lines and the restraints were discontinued on 9/3/2025 at 1200. A review of P-14’s plan of care did not have any documentation on the use of restraints. On 9/5/2025 at 1305, P-15 had an order for a restraint chair for verbally/physically threatening behavior. P-15 was placed in a restraint chair on 9/5/2025 at 1438 and was completely out of the restraint chair on 9/5/2025 at 1623. A review of P-15’s plan or care did not have any documentation on the use of restraints. Staff N confirmed both findings at the time of discovery. On 4/2/2026 at 0935, Chief Nursing Officer Staff P was queried if they expected staff to follow the facility’s policy and procedures, Staff P revealed “absolutely.” According to the facility’s policies: “Restraints: Non-Violent and Violent/Self Destructive Behavior, dated 04/2024, “Restraint Documentation Includes: H. Modification of care plan to reflect the use and discontinuation of restraint.” “Violent Restraints,” dated 06/2024, “The use of Restraints must be in accordance with a written modification to the patient’s plan of care, Consideration of less restrictive measures shall be documented in the medical record.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to ensure orders were properly written for 1 (P-2) of 2 violent patients reviewed resulting in the potential for poor patient outcomes. Findings include: Review of the medical record for P-2 revealed she was a 44-year-old female who was admitted as a trauma following an ATV (all-terrain vehicle) accident on 8/21/2025. Injuries included a traumatic brain injury, sub-arachnoid hemorrhage (bleeding in the space that surrounds the brain), transverse process fracture C-7 (break/crack in one of the wing-like sides of the cervical (neck) vertebra), hematoma around spinal cord at C-7, fractures to right ribs 5 and 6, Grade III liver laceration without bleeding, right and left humeral (upper arm) fractures, right orbital floor fracture with hemorrhage in the right maxillary sinus, right pneumothorax (collapsed lung by air requiring chest tube placement), and comminuted (splintered) fracture right nasal bone. On 8/31/2025 at 2001, a “Restraint Initiate Violent 18 Yrs (years) and more” order was placed for soft, bilateral lower restraint for violent/assaultive behavior. “Special Instructions” were given that the order was “valid for 4 hours. Evaluate patient and re-order Restraint Initiate Violent if indicated.” The order additionally had a comment which stated, “Spit mask needed as well even though upper extremities can’t be restrained.” This was confirmed by Staff M on 4/1/2025 at 1342 who additionally stated it was only for the lower extremities because of the injuries to P-2’s arms. The next order, dated 9/1/2025 at 1822 was labeled as a “Restraint Continue Non-Violent Behavior” for pulling at tubes and lines. They were soft limb restraints to “Bilateral Upper.” Special Instructions were “Order valid per episode, no matter the timeframe. Comments included “Completed due to continue restraint order. No order was found initiating the non-violent restraint. Review of nursing flow sheets revealed P-2 did have a saline lock to the left wrist and bilateral arm slings. No other tubes/wires were present between 8/31/2025-9/4/2025. Restraint documentation for 9/1/2025 revealed P-2 was oriented initially with agitation and physical aggression. On 9/1/2025 at 0800, she became disoriented and remained disoriented throughout the rest of the day with the agitation. Additionally, nursing documentation revealed it was the bilateral lower extremities that were being restrained. On 9/2/2025 at 1656, another “Restraint Continue Non-Violent Behavior” was given for “Pulling at tubes and lines.” This order was for bilateral lower soft limb restraints. The special instructions and comment were the same as the previous order on 9/1/2025 at 1822. Review of the nursing flow sheets revealed P-2 continued to be disoriented, agitated, and/or withdrawn. On 9/3/2025 at 1608, another “Restraint Continue Non-Violent Behavior” was given for “Pulling at tubes and lines.” This order was for bilateral upper soft limb restraints. The special instructions were the same as the previous order on 9/2/2025. There was no comment present. Review of the nursing flow sheets revealed P-2 had her lower extremities restrained and was agitated, angry and/or withdrawn. Restraints were discontinued on 9/4/2025 at 0700. Facility policy #15689871 titled “ Restraints: Non-Violent and Violent/Self-Destructive Behavior” effective 4/2024 states, “Reasons for Restraints: Non-Violent - When restraints are applied to directly support medical healing, such as a patient attempting to seriously interfere with a physical treatment or device, such as an IV [intravenous] line, other indwelling lines or catheters, respirator, dressing, and other less restrictive approaches are ineffective, the use of a restraint may be indicated... Violent - The use of restraint for management of violent or self destructive behavior applies to emergencies where the patient’s behavior is violent or aggressive and the behavior presents an immediate and serious danger to the safety of the patient, staff or others.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) Unless superseded by State law that is more restrictive-- (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1-hour for children under 9 years of age; This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to renew a violent restraint for 1 (P-2) of 2 patients reviewed for violent restraint resulting in the loss of patient rights. Findings include: Review of the medical record for P-2 revealed she was a 44-year-old female who was admitted as a trauma following an ATV (all-terrain vehicle) accident on 8/21/2025. Injuries included a traumatic brain injury, sub-arachnoid hemorrhage (bleeding in the space that surrounds the brain), transverse process fracture C-7 (break/crack in one of the wing-like sides of the cervical (neck) vertebra), hematoma around spinal cord at C-7, fractures to right ribs 5 and 6, Grade III liver laceration without bleeding, right and left humeral (upper arm) fractures, right orbital floor fracture with hemorrhage in the right maxillary sinus, right pneumothorax (collapsed lung by air requiring chest tube placement), and comminuted (splintered) fracture right nasal bone. On 8/31/2025 at 2001, an order was placed for soft, bilateral lower restraint for violent/assaultive behavior. The order indicated it was valid for 4 hours. This was confirmed by Staff M on 4/1/2025 at 1342 who additionally stated it was only for the lower extremities because of the injuries to P-2’s arms. Review of restraint monitoring revealed the patient was placed in restraint on 8/31/2025 at 2130. Documentation revealed P-2 was agitated. The face-to-face assessment on 8/31/2025 at 2018 indicated P-2 had “violent outbursts with aggression. Has struck sitter, PCT (patient care technician), nurse, and security guard. Has spit on these individuals as well...” P-2 remained in restraint until 9/4/2025 at 0700. Further review of provider orders revealed there was no renewal for the violent restraint. No other restraint orders were found until 9/1/2025 at 1822. Facility policy #15833525 titled “Violent Restraints” last revised 6/2024 states, “After personal examination made by a physician, restraints may be employed only for the length of time specified in the physician order, but not to exceed 4 hours for adults, 18 years of age or older... Prior to renewing an order for the use of restraints, a physician must see the patient in person and assess the patient not more than 30 minutes before the expiration of the previous restraint order...””

“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: 36887 Based on interview and record review, the facility failed to properly monitor 1 (P-2) of 2 patients placed in violent restraints resulting in the loss of patient rights and the potential for poor patient outcomes. Findings include: Review of the medical record for P-2 revealed she was a 44-year-old female who was admitted as a trauma following an ATV (all-terrain vehicle) accident on 8/21/2025. Injuries included a traumatic brain injury, sub-arachnoid hemorrhage (bleeding in the space that surrounds the brain), transverse process fracture C-7 (break/crack in one of the wing-like sides of the cervical (neck) vertebra), hematoma around spinal cord at C-7, fractures to right ribs 5 and 6, Grade III liver laceration without bleeding, right and left humeral (upper arm) fractures, right orbital floor fracture with hemorrhage in the right maxillary sinus, right pneumothorax (collapsed lung by air requiring chest tube placement), and comminuted (splintered) fracture right nasal bone. On 8/31/2025 at 2001, an order was placed for soft, bilateral lower restraint for violent/assaultive behavior. The order indicated it was valid for 4 hours. This was confirmed by Staff M on 4/1/2025 at 1342 who additionally stated it was only for the lower extremities because of the injuries to P-2’s arms. Review of nursing documentation revealed monitoring was done every 2 hours throughout the duration of restraint from 8/31/2025 at 2001-9/4/2025 at 0700 and was documented under the non-violent restraint area of the electronic medical record (EMR). Clinical Educator Staff M was queried on 4/1/2026 at 1342 as to if the documentation was accurate for the type of restraint documentation present. Staff M quickly looked in the EMR to see if there was documentation of restraint under the violent restraint section in the EMR, then said, “Nope there’s nothing there. The information should have been in the violent restraint area and they should have been doing checks every 15 minutes.” Facility policy #15689871 titled “Restraints: Non-Violent and Violent/Self-Destructive Behavior” effective 4/2024 states, “ Patient monitoring... Violent Restraint Track Documentation Monitoring of restrained adults and children ages 9-17 occurs at least every 15 minutes by a trained and competent staff member...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 50585 Based on interview and record review, the facility failed to perform a face-to-face evaluation within the proper time frame according to the facility’s policy and procedure following the application of restraints for 1 (P-15) of 3 patients reviewed for restraint monitoring resulting in the loss of patient rights and increased likelihood of negative outcomes for the patient. Findings include: On 4/2/2026 at 1305, P-15’s medical record was reviewed with Clinical Informatics Staff N. On 9/5/2025 at 1308, P-15 had an order for a violent restraint for a restraint chair for verbally/physically threatening behaviors. On 9/5/2025 at 1438, P-15’s violent/self-destructive restraint monitoring form revealed P-15 was placed in a restraint chair and P-15 was completely out of the restraint chair on 9/5/2025 at 1623. On 9/5/2025 at 1559, P-15’s face-to-face physician evaluation was completed (1 hour and 21 minutes after P-15 was placed in a chair restraint). Staff N when queried confirmed the findings at the time of discovery. According to the facility’s policy “Violent Restraints,” dated 06/2024, the physician responsibility included “Perform an in-person evaluation of the patient in restraint within 1 hour after the initiation of restraint by a physician to evaluate at a minimum: This evaluation will include the patient’s : - Immediate situation - Reaction to the intervention - Medial and behavioral condition AND the need to continue or discontinue the restraint - The patient’s physical and psychological status - The patients behavior that warranted the intervention, the intervention used; - Alternative or less restrictive measure attempted d(of applicable and the appropriateness of the intervention measures - The patient’s response to the intervention used, including rationale for continued use; (v) any complications resulting from, the intervention.”

“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: 53475 Based on record review, and interview, the facility failed to ensure nursing staff maintained an updated plan of care for 2 (P-16, 17) of 6 patient charts reviewed for plans of care resulting in the potential for unidentified patient needs and ineffective patient care. Findings include: On 4/2/2026 at 1350, a targeted review of the medical record for P-16 revealed that P-16 was admitted to the facility on 12/26/2025 and discharged on 1/13/2026. No nursing care plan documentation could be located in the medical record. This information was confirmed with Staff N at 1407 at the time of discovery. On 4/2/2026 at 1404, a targeted review of the medical record for P-17 revealed P-17 was admitted to the facility on 2/6/2026 and discharged on 2/12/2026. No nursing care plan documentation could be located in the medical record. This information was confirmed with Staff N at 1419 at the time of discovery. Review of facility policy #16404157 titled “Patient Plan of Care: Nursing” effective 04/2024 states, “Plan of Care - The registered nurse will initiate the nursing plan of care within the first 8 hours of admission integrating the initial assessment, significant medical history affecting the patients current health, significant co-morbidities and patient problem specific plan of care. Review/Revision of Plan of Care: All plans of care will be reviewed as follows: A. The RN will review/revise problem as needed or a minimum of every 24 hours. Consideration of the patient’s progress, or lack of progress, toward meeting the expected goals, the effectiveness of interventions and the continued needs of the patient. B. Plan of Care will be reviewed in the patients record by oncoming and off going RN’s during bedside shift report. C. Plans of Care will be re-assessed with any change in patient status or condition with input from the multidisciplinary team. All members of the multidisciplinary team are repsonsible (sic) for communicated changing patient needs determined by daily assessments and evaluations. 1. A change in patient condition may impact the discharge of a patient. Discharge plan of care must be re-evaluated with the change in patient condition. Notification to the receiving facility, family, home health agency, etc. must occur prior to the patient discharging when a status or condition change has occurred.””

“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 adhere to the facility’s policies and procedures for assessing pain response and administering pain medications for 2 (P-1, P-7) of 4 patients reviewed for pain management resulting in the increased likelihood of negative consequences for the patients. Findings include: On 4/1/2026 at 1005, P-1’s medical record was reviewed with Director of Heart & Vascular Imaging Staff PP. On 7/7/2025 at 1647, P-1’s physician orders included “cholangiogram with possible tube removal or exchange” and the procedure was performed on 7/10/2025. A review of P-1’s pre-procedure pain assessment on 7/10/2025 at 0915 revealed P-1 had a numeric pain score of 3 in the right upper laterality of the abdomen. P-1’s post-procedure documentation did not reveal any documentation of pain assessment or scoring. On 4/1/2026 at 1020, Staff PP was queried and verified there should be a pain assessment documented after the procedure. On 4/2/2026 at 1430, Staff PP revealed additional information about P-1’s pain score documentation. Staff PP revealed staff would have charted “if having pain” and reconfirmed that “pain” would be expected to be documented after the procedure. On 4/1/2026 at 1300, P-7’s medical record was reviewed with Clinical Educator, Peri-Operative Services Staff BB. On 3/3/2026 at 1138, P-7 had an order for oxycodone 5 mg tablet orally every 4 hour as needed for moderate (4 to 6 pain scale) pain. According to P-7’s medication administration record, P-7 received oxycodone doses on: - 3/4/2026 at 1435 with no reason or pain score documented - 3/4/2026 at 1510 with no reason or pain score documented - 3/5/2026 at 1724 with no reason or pain score documented - 3/5/2026 at 1724 with no reason or pain score documented On 2/26/2026 at 2355, P-7 had an order for morphine 4 mg IV to push every 3 hours as needed for moderate pain (4 to 6 pain scale). According to P-7’s medication administration record, P-7 received morphine doses on: - 3/4/2026 at 1510 with no reason or pain score documented - 3/5/2026 at 1941 with no reason or pain score documented Staff BB confirmed the findings at the time of discovery. On 4/2/2026 at 0935, CNO Staff P was queried if they expected staff to follow the facility’s policies and procedures, Staff P revealed “absolutely.” According to the facility’s policy “Post Procedure Monitoring,” dated 02/2024, “Purpose: Define the minimum documentation and required monitoring of patients post procedure in the CID (Cardiac Imaging) department. 1. Vital signs including pulse oximetry 3. Patient’s response to procedure 10. Monitor level of discomfort at end of procedure.” According to the facility’s policy “Pain Management,” dated 6/2025, “Pain medication will be administered occording (sic) to provider order based on pain scale.””

“THERAPEUTIC DIETS CFR(s): 482.28(b), (b)(1) §482.28(b) Menus must meet the needs of patients. (1) Individual patient nutritional needs must be met in accordance with recognized dietary practices. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to keep food allergens off meal trays for 1 (P-2) of 19 patients reviewed resulting in an allergic reaction and the potential for poor patient outcomes. Findings include: Review of the medical record for P-2 revealed she had allergies listed for “melons” since the beginning of her admission on 8/21/2025. A nursing note dated 9/11/2025 indicated P-2’s lunch tray came up with melon on it. It stated, “Patient states she ate it anyway just to see if something would happen. Patient had 3 pieces of cantaloupe before stopping and alerting nurse to her allergy... patient stated nose and throat felt a little itch...” Review of the MAR confirmed that Benadryl 50 mg was given for “anaphylaxis.” On 9/24/2025, a progress note was found from the dietician stating P-2 “was sent melons for lunch today and Pt took a bite of it. Pt is allergic to melons, however the Kitchen was not aware of allergy prior to sending the melon. Melon is listed in EMR (electronic medical record) as an allergy however was not specified as a food allergy therefore it does not show up for the Kitchen...” The dietician further stated she ensured the melon was listed as a food allergy and was unsure of any reaction the patient may have had. No nursing notes were found regarding this incident. On 4/2/2026 at 1410, review of facility incident report dated 9/24/2025 stated an order had come in from the unit for a tray for P-2 on 9/24/2025. The kitchen was not given any information that the patient had an allergy to melon. The tray did go to the patient with melon on it. That same day (9/24/2025) it was discovered that the allergy was not placed under food allergies, so it did not populate on the allergy log and melon went up on the tray again (separate incident). On 4/2/2026 at 1302, Dietary Manager Staff W stated she could not recall the incidents listed above; however, she stated a process was in place was for an ambassador to get patient choices off the menu based on their diet order from the provider and submit it to the kitchen. The in-patient census populated in the kitchen had the diet order on it and any allergies. An allergy log could also be pulled from the EMR (electronic medical record). Trays got checked prior to going to the unit and were checked again prior to passing it to the patient. A red dot was placed on the tray, or a red placemat was present to indicate that was a specialty tray because of allergies. Staff W stated that sometimes a food allergy item can be sent inadvertently and the kitchen was usually notified when that occurred. Policies were requested regarding dietary food allergies; however, none of the policies provided contained information on identification of patient allergies and/or prevention from food allergens reaching patients.”

“POST-ANESTHESIA EVALUATION CFR(s): 482.52(b)(3) [The policies must ensure that the following are provided for each patient:] A post-anesthesia evaluation completed and documented by an individual qualified to administer anesthesia, as specified in paragraph (a) of this section, no later than 48 hours after surgery or a procedure requiring anesthesia services. The post-anesthesia evaluation for anesthesia recovery must be completed in accordance with State law and with hospital policies and procedures, which have been approved by the medical staff and which reflect current standards of anesthesia care. This Standard is not met as evidenced by: 50585 Based on interview and record review, the facility failed to document vital signs, and the time the post anesthesia evaluation was performed for 1 (P-18) of 5 patients reviewed for sedation evaluation resulting in the increased likelihood of negative outcomes for the patient. Findings include: On 4/3/2026 at 1005, P-18’s anesthesia evaluation documentation was reviewed with Clinical Informatics Staff DD. P-18’s post-anesthesia evaluation record from 1/21/2026 revealed that vital signs section including blood pressure, heart rate, rhythm, respiratory rate, blood oxygen level, and temperature and the time the evaluation was performed were blank. Staff DD confirmed the findings at the time of discovery. On 4/3/2026 at 1540, the Director of Risk Management and Compliance, Staff A, was asked if they expected the vital signs section to be complete at the time of evaluation on P 18’s post anesthesia evaluation record, Staff A responded, “Yes.” Staff A was then queried for the facility’s policy for a post-anesthesia evaluation, Staff A revealed there was no policy and that the facility followed a frequently asked questions document from an outside accreditation organization. A review of the accreditation document revealed that for “Post anesthesia (deep sedation, regional and general anesthesia) assessments: “Completion of the post- anesthesia assessment for both inpatient and outpatient must be completed within 48 hours by an anesthesia practitioner or credentialed LP” and “The calculation of the 48-hour timeframe begins at the point the patient is moved into the designated recovery area. The evaluation generally should not be performed immediately at the point of movement from the operative area to the recovery area.” The guidelines also revealed “Components of the evaluation may include, but are not limited to: respiratory function, including respiratory rate, airway patency and oxygen saturation; cardiovascular function, including pulse rate and blood pressure; mental status; temperature; presence of nausea and/or vomiting; pain’ and post operative hydration. Depending on the specific surgery or procedure performed, additional types of monitoring and assessment may be necessary.””

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 48030 Based on record review and interview, the facility failed to provide the Important Message from Medicare to 2 (P-1, P-2) of 10 patients whose medical records were reviewed for provision of the Important Message from Medicare, resulting in the failure to inform the patient or patient’s representative of the right to appeal discharge and potential loss of rights for the patient. Findings include: On 6/24/2025 at 1340, review of the medical record for P-1 revealed he was admitted to the facility from 3/28/2025-4/25/2025. Review of insurance information revealed he did have Medicare. An Important Message from Medicare (IMM) document was not found in the record. On 6/25/2025 at 0930, review of the medical record for P-2 revealed she was admitted to the facility on 6/8/2025 and a current patient in the facility at the time of survey. Review of the insurance information revealed she did have Medicare. An Important Message from Medicare was no found in the record. On 6/25/2025 at 1255, Facility Lead Registration (Staff P) and the Regional Lead Registration (Staff Q) were queried if it is an expectation that the Important Message from Medicare (IMM) be signed at the time of admission by the patient or their representative, Staff Q responded, “yes”. Staff P revealed the facility had recently changed the process for obtaining consents for admitted patients and the Admitting Department will get the consents signed moving forward. Review of facility policy titled, “Important Message from Medicare/Discharge Rights, 100-227”, policy #13296912, last revised #10/2019 under section titled “Purpose - As a condition of participation in the Medicare program, hospitals must notify Medicare beneficiaries who are hospital inpatients of their hospital discharge rights. The Centers for Medicare and Medicaid (CMS) mandates hospitals to issue a standardized letter, “An Important Message From Medicare About Your Rights” (OMB Approval No. 0938-0692) to any hospitalized inpatient who is eligible for Original Medicare or a Medicare managed care plan whether Medicare is the primary payer or will pay any portion of the bill after the primary payer. All Medicare patients must receive the Important Message (IMM) each time they are admitted and in most cases before discharge. Federal regulation requires: The issuance of the IMM within 2 calendar days of inpatient admissions.””

“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: 48030 Based on observation, interview, and record review, the facility failed to accurately track the release of a deceased patient’s body taken from the morgue for 1 (P-1) of 10 patients reviewed secondary to a failed system for monitoring the removal of deceased patient bodies from the facility morgue which could increase the potential for loss of dignity and respect for the deceased patient and their families. Findings include: On 6/24/2025 at 1527 an interview with the Director of Risk Management (Staff C) and the Patient Advocate (Staff R) was conducted and reveals Staff C was notified on 4/29/2025 by the house supervisor that P-1’s sister called the facility and was very concerned because when she called to make arrangements to pick up her brother’s belongings and the nursing house supervisor told her that he did not know where her brother’s body was located because he was no longer in the morgue. Staff C revealed she began to investigate the concern immediately and was able to determine that a local funeral home had mistakenly removed P-1’s body without following the proper procedures. Staff C explained P-1’s body was returned to the facility’s morgue with his belongings, which were returned to his sister. Staff C explained that P-1’s sister had requested the medical examiner consider performing an autopsy on P-1 due to the circumstances surrounding his death and his body should have been on “hold”. However, due to a miscommunication the funeral home staff thought they could remove him from the morgue to assist with transporting him to another funeral home about 2 hours away. During an interview with the Executive Director of Nursing (Staff E) it was revealed an Root Cause Analysis (RCA) was held on 5/19/2025 with the 6th Floor Medical/Surgical Unit Manager (Staff L), Chief Nursing Officer (Staff B), the Director of Risk Management (Staff C), the Supervisor of Patient Experience, and the Chief Medical Officer (Staff F) to review the morgue process. Staff E revealed during the meeting it was determined that the facility’s electronic tracking system, “Morgue Manager” did not show all staff which patient bodies have been archived and nobody at the facility was responsible for managing the Morgue Manager system. Staff E also explained that historically the facility allowed local funeral home staff to have badge access to the facility and the morgue to be able to pick up bodies without supervision and the expectation was they were to use Morgue Manager to sign patient bodies out. During the RCA the group decided to no longer allow funeral home staff to have this access and they could no longer remove patient bodies without supervision by facility staff. Staff E revealed the funeral home badge access was removed and the local funeral homes were notified about the change in process by Staff A (Vice President of Operations). The house supervisors and Security staff were educated about the change in process by Staff B. When queried if the facility policy had been updated to reflect these changes, Staff E revealed that these changes had not been finalized in the policy. When queried which staff were educated about the process changes and the dates of the education, Staff E revealed the conversations were verbal and they were unable to provide a list of employees that were educated or the date of the education. On 6/25/2025 at 0950 an interview with the Chief Nursing Officer (Staff B) was conducted and revealed the access to Morgue Manager has been updated and funeral homes no longer have badge access to the facility. Staff B explained that the house supervisors were notified of the change in process in monthly team meetings, but additional education will be provided to the house supervisors and Security after the policy has been finalized. Review of facility policy titled “Releasing Bodies to Funeral Homes”, policy #16489961, last revised 1/2017 was conducted and revealed in the section titled “Purpose - To establish policy and procedure to be followed in the event of death...to maintain the individual’s dignity after death, to provide appropriate documentation of death and to prepare the body for expedient release to the funeral home.””

“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: 48030 Based on record review and interview, nursing staff failed to follow facility policy/guidelines and acceptable standards of practice regarding Code Blue documentation for 2 (P-1, P-8) of 2 patients reviewed for Code Blue documentation resulting in the potential for increased risk of harm for all patients experiencing a Code Blue at the facility. Findings include: On 6/24/2025 at 1340 record review was conducted for P-1 and revealed a Code Blue Summary was not found in the medical record. On 6/25/2025 at 1223 record review was conducted for P-8 and revealed a Code Blue Summary was not found in the medical record. During an interview with the Executive Director of Nursing (Staff E) on 6/25/2025 at 1230 it was revealed she was aware that the facility had previously identified that Code Blue Summary documentation has not been making it into patient medical records. Staff E explained in the April 2025 Emergency Response Work Group Meeting the topic of adding Code Blue documentation in the electronic medical record was discussed because the team had identified the paper Code Blue Summary was not making it into the electronic medical record. When queried if if is an expectation that the Code Blue Summary become part of the patient’s permanent record, Staff E replied “yes we are working on developing a process to document in the medical record electronically because the paper Code Blue forms were not making it into the record”. On 6/25/2025 at 1230 an interview with the ICU/Cardiac Unit Manager (Staff G) was conducted and reveals she is responsible for reviewing the Code Blue Summary documentation. When queried if she was able to review the Code Blue Summary for P-1 and P-8, Staff G said yes and was able to produce a paper copy of the Code Record Summary for P-1. When queried why the summary was not part of the permanent medical record, Staff G said staff was supposed to send a copy to medical records and put one in her mailbox for review, but the copies are not making it to medical record all of the time. When queried if she audits medical records to make sure the documentation in the record is present, Staff G responded she is currently not auditing for that but the Emergency Response Work Group is aware it is a problem and they are working on having the Code Blue Summary information be documented electronically. Review of Facility PowerPoint presentation from the Emergency Response Workgroup for April 2025 reveals an action plan dated 3/2025 that states “Add Code Blue documentation in (name of electronic medical record)”, due date 6/30/2025, in progress. Review of facility policy titled, “Code Blue Cardiac/Respiratory Arrest in the Hospital/Procedure/Assignments”, policy #12850958, last revised 12/2022 reveals in the section, “Responsibilities of Code Team Personnel - Upon termination of a Code Blue, will complete Code Blue Summary, Adult or Pediatric Code Blue orders, and Code Blue Evaluation Sheet, and document positive/negative aspects of the Code. The Cardiac Arrest Record becomes part of the chart and will be completed immediately after the Code.””

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to fulfill transfer requirements for 5 patients (P-11, 12, 16, 21, 30) of 5 patients reviewed for transfer, resulting in the potential for less than optimal outcomes for all patients requiring transfer to another facility from the emergency department. Findings include: See tag 2409: Failure to fulfill transfer requirements.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 36887 Based on record review and interview, the facility failed to have transfer documents present and/or designate resources needed during transfer for 5 (#11, 12, 16, 21, 30) of 5 patients reviewed for transfer according to facility policy resulting in the potential for unrecognized, unmet patient needs and poor patient outcomes. Findings include: Review of the medical record for P-11 revealed he was a 5-year-old male who presented to the ED 5/17/2024 at 1512 and was diagnosed with febrile hyperbilirubinemia. Physician note indicated patient needed to go to a Children’s hospital ICU and was at high risk for decompensation. It was determined flight transport was required. Review of the EMTALA (emergency medical treatment and labor act) transfer form revealed section 4, “Mode/Support During Transfer as Determined by Physician” was left blank. A form titled “Physician Medical Necessity Statement Supporting Ambulance Transport” was present which indicated the date, patient name, sending physician, sending and receiving facility, the need for cardiac monitoring or IV (intravenous) maintenance, and the reason for transfer. Following the above listed information was a statement reading as follows: “In my professional opinion, this patient requires transport by ambulance and should not be transported by other means. The patient’s condition is such that transportation by medically trained personnel is required. I certify that the above information is true and correct based on my evaluation of this patient, to the best of my knowledge. I understand that this information will be used by the Centers for Medicare and Medicaid and/or its agents to support the determination of medical necessity for ambulance services.” Under the statement were listed options, physician, physician assistant, nurse practitioner, registered nurse, and discharge planner. The line for registered nurse (RN) was marked and the printed name and signature of the nurse was present with her credentials and the date. No time of signature was present. There was no acknowledgement or signature present by a physician or provider. Review of the medical record for P-12 revealed she was a 9-year-old female who presented to the ED on 5/17/2024 at 2128 and was diagnosed with status asthmaticus. Review of the EMTALA transfer form revealed section 4, “Mode/Support During Transfer as Determined by Physician” was left blank. The “Physician Medical Necessity Statement Supporting Ambulance Transport” was present and was found to have been completed and signed by the RN. No acknowledgement or signature was present by the physician or provider. Physician note indicated the patient needed a pediatric ICU and that the patient required continuous nebulizers during transport. Review of the medical record for P-16 revealed she was a 41-year-old female who presented to the ED on 6/2/2024 at 2043 and was diagnosed with a food bolus impaction. No transfer documents or evidence of transferred records were found. Review of physician documentation on 6/3/2024 at 1250 stated, “Spoke to Dr. (physician name) at (accepting facility name) who accepted patient for transfer. Patient is stable. She will go via private vehicle to be driven by her husband.” On 10/1/2024 at 1500, Emergency Department Clinical Director Staff B, who was present during chart review, was queried as to why there were no transfer documents present to which he stated it was because the patient had been sent by private car. The facility failed to identify P-16 as a transfer and follow EMTALA transfer requirements. Review of the medical record for P-21 revealed she was a 42-year-old female who presented to the ED on 6/11/2024 at 1137 and was diagnosed with being bipolar. Physician note indicated the patient had a petition and certification stating she had unresolved psychiatric symptoms and required inpatient psychiatric care. Review of the EMTALA transfer form revealed section 4, “Mode/Support During Transfer as Determined by Physician” was left blank. The “Physician Medical Necessity Statement Supporting Ambulance Transport” was present and was found to have been completed and signed by the RN. No acknowledgement or signature was present by the physician or provider. Review of the medical record for P-30 revealed she was a 40-year-old female who presented to the ED on 8/13/2024 at 1557 and was diagnosed with a post-operative abscess. Physician note indicated the patient was having post op surgical complications and needed to see specialist surgeon at another facility. It was determined flight transportation would be needed due to delays in ground transportation. The EMTALA transfer form was not present in the medical record. Discharge information revealed she was being transferred to another acute care facility and P-25 left the ED 8/13/2024 at 2023. Physician documentation dated 8/13/2024 at 1631 stated, “I did discuss the case with Dr. (physician name) from Urology in Traverse City Michigan at (hospital name)...He is accepted (sic) the patient in transfer...Patient has been accepted by Dr. (physician name) in the ER (emergency room) at (hospital name). Working on arranging transfer now.” The “Physician Medical Necessity Statement Supporting Ambulance Transport” was present and was found to have been completed and signed by the RN. No acknowledgement or signature was present by the physician or provider. Review of patient transfer form did not have a way for providers to note if the patient was stable or unstable. Review of documentation revealed no physician certification statements regarding transfer details and no clear indication if patient was stable or unstable upon transfer. Facility policy #14334383 titled “EMTALA Transfers To Other Acute Care Facilities 100-210” last revised 9/2023 states, “EMTALA forms are required when transferring a patient to another acute care facility....The transfer from (hospital name) will be affected through qualified personnel and equipment. The patient’s attending physician has the responsibility to determine the appropriate mode of transportation (air or ground), equipment, and attendants needed for the transfer. Completion of the EMTALA Transfer Record is required (TR-0015)...The attending physician must complete the Physician Medical Necessity Statement Supporting Ambulance Transport form (EMS-0001).””

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 48030 Based on record review and interview, the facility failed to follow their policy by not updating one patient’s (P-1) plan of care after a change in the patient’s condition for 1 (P-1) of 10 patients reviewed, resulting in the requirement for rehospitalization and inadequate preparation for care at home. Findings include: See tag A-0802: Failure to re-evaluate a discharge plan after a change in condition.”

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 48030 Based on record review and interview, the facility failed to follow their policy by not updating one patient’s (P-1) plan of care after a change in the patient’s condition for 1 (P-1) of 10 patients reviewed, resulting in the requirement for rehospitalization and inadequate preparation for care at home. Findings include: On 5/30/2024 at 1401 record review of the History and Physical for P-1 revealed she was an 89-year-old female who was transferred to the facility on 11/14/2023 after a 4-day admission at a smaller affiliated facility for sepsis associated with possible pneumonia, left lower extremity osteomyelitis and infected diabetic foot wound. P-1 was alert and oriented to person and place and GCS (Glasgow Coma Scale - tool used to measure the consciousness of patients) during admission was 13-14 with episodes of confusion and disorientation. After an extended stay, the daughter decided the patient should return home with home care. On 05/30/2024 at 1400 record review revealed a group note from therapy dated 12/5/2023 at 0858 in which it was documented, “pt with change in participatory status today due extreme [sic] lethargy/somnolent being.” A note from nursing dated 12/6/2023 at 1024 reveals “At bedside shift report, patient was barely responsive to painful stimulus. She was not opening her eyes or speaking at all. Vitals were stable in the morning and her sugar was within normal limits. We completed her discharge and EMS came to pick her up at 10:05. I attempted to give her a medication before she left and was unable to get her to respond. I continued to take her vitals which were normal. I called a rapid response to ensure discharge was still appropriate” ...the provider came to the room and the nurse documented she was told “to alert the family, but that there was nothing more we could do for her”. I attempted to call the daughter twice and she did not respond either time.” On 05/30/2024 record review of documentation from Case Manager (CM) dated 12/6/2023 at 1514 reveals “Confirmed pt ready to DC (discharge) w/provider & DC orders placed. PCS already on the chart. Updated bedside RN of plan of to DC at 0900. EMS delayed d/t 911 traffic. Then pt had rapid response (was then cancelled) around 0945. When CM was able to make it to the floor around 1100 bedside RN stated pt had been unresponsive but still able to be discharged home via EMS. Called and l/m message for daughter...that pt DC home late & scripts sent to Apothecary. Pt DC home w/home health via EMS today.” Further review of documentation from case management notes dated 12/6/2023 at 1546 reveals “Received call...patient’s daughter refused to take her once EMS arrived”. Review of case management documentation did not reveal the patient’s home and daughter were ready to care for an unresponsive patient. On 5/30/2024 at 1400 review of the EMS documentation “Prehospital Care Report” dated 12/6/2023 reveals EMS arrived at the facility for transport to patient’s home at 0945 and left with P-1 at 1039. Narrative History Text reveals “Arrived to find an 89-year-old female unresponsive mouth open, eyes closed, shallow breathing at a rate of 28.” and “Our delay on scene was due to ...staff calling rapid response to her room because she was unresponsive and making sure we could do the transfer and tried to get a hold of family to let them know her current condition. Family did not answer the phone. Nurse stated the physician signed off and was ok for her to be transferred.” and “Upon arrival to patients’ residence, daughter met us outside and we told her the patient is unresponsive. Daughter now wants her brought to the hospital because she doesn’t want to feel responsible for an unresponsive person.” Further review of EMS notes reveled P-1 was unresponsive during transfer with a GCS of 3. P-1 was transported to another hospital and expired within 24 hours. On 5/30/2024 at 1603 an interview with the Director of Quality/Patient Safety Officer (Staff B) was conducted and revealed an incident report was filed on 12/8/2023 by Staff J regarding the Rapid Response that was cancelled for P-1. Staff B stated follow-up was requested by Staff J and “nothing further was done”. On 5/31/2024 at 0929 an interview with the Director of Case Management (Staff F) was conducted and revealed she did not see P-1 during her admission but was made aware of the case because of the issues related to the son and daughter’s difference in opinion. Staff F revealed she did review the case of P-1 and it was her understanding that the family would not accept Hospice Care but wanted Home Health Care. Staff F revealed “our rule of thumb is if a patient looks like they are going to die within 24-48 hours we won’t let them go unless family says to take her home.” On 5/31/2024 at 1126 an interview with the 6th Floor Manager (Staff J) was conducted. Staff J revealed she did remember P-1 and that there was a Rapid Response called on her unit with EMS at the bedside. The nurse called the Rapid Response because P-1 was not responsive, and she wanted to make sure the discharge was still appropriate. Staff J revealed the Internal Medicine physician was at the bedside of P-1 and cancelled the Rapid Response secondary to the discharge plan and DNR/DNI status. Staff J revealed the RN at the beside was concerned because P-1 was obtunded, which was a change in her status. Staff J revealed she filed an incident report in the facility’s incident reporting system, Company T, because “it seemed strange”. Staff J revealed the RN tried to call the family and contacted Case Management about the change in status and questioning if the transfer should continue. Staff J revealed there were issues regarding concerns with the family between the son and the daughter and P-1’s level of consciousness did “go in and out” but the daughter had not come to the facility throughout the admission and may not have been aware of this change. On 5/31/2024 at 1350 during review of policy, Discharge Planning, last revision date of 11/2020 revealed on page 2, paragraph 5, under Procedure, “...may have a change in condition and a discharge planning evaluation requested. Reassessments are made. Discharge plans are modified as needed. ’ “ and paragraph 6 states, “Follow-up/transfer/other referrals for continuity of care will be based on the patient’s assessed needs at the time of discharge.””