Mercy Health Saint Mary’s

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 53475 Based on interview and record review, the facility failed to ensure that nursing staff adhered to a documented allergy for 1 (P-1) of 10 patients reviewed, resulting in the potential for adverse patient outcomes. Findings include: On 07/23/2026 at 1:35 PM, during the medical record review with the Clinical Nurse Leader (CNL) Staff B, it was noted that P-1, a 58 year old female, presented to the Emergency Department (ED) on 05/12/2026 at 12:22 PM with the arrival complaint of “hard time breathing/cough.” P-1 was triaged with an Emergency Severity Index (ESI - a standardized five level triage tool indicating clinical acuity and anticipated resource needs) of 2 (emergent). P-1’s allergies were reviewed at 12:26 PM. An existing adhesive tape-silicones allergy had been previously documented in the medical record since 02/12/2014. P-1 was transferred to a third floor inpatient unit on 05/12/2026 at 8:43 PM with a diagnosis of “sepsis (systemic infection) with acute organ dysfunction without septic shock, due to unspecified organism, unspecified organ dysfunction.” On 07/23/2026 at 1:30 PM, the Clinical Nurse Leader (CNL) ED Staff B and the Director of Critical Care and Emergency Services Staff D confirmed that no information was charted in the ED regarding the nature or severity of the allergic reaction, nor was there documentation showing that an allergic reaction had occurred during this time. On 07/23/2026 at 1:35 PM, during the medical record review with the Clinical Nurse Leader (CNL) ED Staff B and the Director of Critical Care and Emergency Services Staff D, the medical record was searched for: 1. One-time medication orders related to allergic reactions; one incident was documented. 2. Allergic reactions to tape; one incident was documented. Regarding 1- One-time medication orders related to allergic reactions: It was identified that a one- time medication order was associated with a tape related incident that had been documented only in the medication administration record. On 05/14/2026 at 8:25 AM, Unit RN Staff Y documented that P-1 was experiencing anxiety overnight due to the “night team putting a piece of plastic tape on her skin.” Staff Y requested a one-time order for either an antihistamine (Benadryl) or an anxiolytic (Atarax). A 10 milligram (mg) dose of the anxiety medication was prescribed on 05/14/2026 at 9:07 AM and administered at 9:12 AM. These findings were acknowledged by Staff B and Staff D. Regarding 2 - Allergic reaction to tape: One documented tape related incident was found. On 05/15/2026 at 4:51 PM, Hospitalist Staff X stated that P-1 reported “exposure to tape,” which resulted in an allergic reaction described as “throat being dry and itching.” Provider Notification Communication dated 05/15/2026 at 2:30 AM, initiated by Unit Registered Nurse (RN) Staff N, confirmed the reported tape-related incident. Staff N documented that P-1 was feeling anxious, had an elevated heart rate ranging from 116 to 128 beats per minute, and was experiencing shortness of breath, with an oxygen saturation of 93% (percent). On 05/15/2026 at 2:38 AM, a second Provider Notification Communication, initiated by Staff N, indicated a change in P-1’s condition. P-1 reported throat itchiness, dry mouth, a sensation of throat narrowing, and slight chest discomfort associated with coughing. Staff N stated: “Patient has a (sic) adhesive allergy (sic) tape was place (sic) on hand by PCA (Patient Care Assistant). patient (sic) feel (sic) like she is (sic) having a reaction. Please advise. bp (sic - blood pressure) 167/95.” The provider ordered an antihistamine (Benadryl) and a secretion reduction agent (Pepcid) to alleviate the symptoms of the allergic reaction. On 07/24/2026 at 7:37 AM, Unit Staff N was queried regarding the tape related incident that occurred on 05/15/2026 at 2:38 AM. Staff N reported that the tape had been applied by the Unit Patient Care Assistant (PCA) Staff O. Staff N stated that in-the -moment-education regarding allergies and related reactions was provided to Staff O on the same day. When asked whether other tape-related incidents had occurred previously, Staff N responded with “Yes” but could not recall details. No nursing documentation regarding these could be located in the medical record. Staff N was also asked how Staff O would have been aware of the patient’s allergy. Staff N explained that the medical record contained allergy information and that this information was communicated during patient handoff between PCAs and RNs to PCAs. Staff N added that a sign was placed above the patient’s bed headboard to further alert caregivers to the tape related allergy. On 07/24/2026 at 8:47 AM, Quality Improvement Accreditation Lead Staff F stated that Staff O was not available for interview at the time of survey. On 07/23/2026 at 1:35 PM, during P-1’s medical record review, the Director of Critical Care and Emergency Services Staff D, confirmed that no rapid responses had been initiated, nor had any other rescue medications been administered to address allergic reactions. A Rapid Response System or Rapid Response Team would have been activated when a hospitalized patient showed early signs of clinical deterioration. On 07/24/2026 at 9:47 AM, the Chief Nursing Officer (CNO) Staff E was queried regarding training and expectations of adhering to allergies in the medical record. Staff E confirmed that it was a nursing expectation for both licensed and unlicensed nursing staff to understand the allergies a patient presented with and how these could impact a patient’s condition. Staff E further confirmed that this training was provided during orientation. Review of the policy titled “Nursing Clinical Documentation” revised on 11/01/2024 states: “It is the policy of ...that clinical documentation consistently reflects the patient’s condition, situation, progress, and the provision of care through quality, accuracy, and clarity of a timely clinical record ... Initial admission assessment data, including safety, allergy, and encounter-specific information, is required for all patients.””

“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: 29955 Based on observation, interview, and record review the facility failed to provide a ligature free room and observation for 1 (P-1) of 4 patients reviewed for suicidal ideation resulting in death. Findings include: Review of the medical record for P-1 revealed he was a 30-year-old male who presented to the ED (Emergency Department) on 06/07/2026 at 02:13 PM for acute psychosis with claims of being followed by multiple people. He was assigned an acuity level 2 on the emergency severity index (ESI-a scale based on the severity of the patient ’ s medical condition and the anticipated number of resources the hospital will use for that patient’s care). A level 2 acuity, according to the ESI, is a patient who is considered stable but faces a high risk of deterioration or have a time-critical problem, and needs to be seen by a provider within typically 15 minutes of presenting to the ED. P-1 was seen by ED provider, staff L at Facility A and determined to have a mental health emergency and was transferred to Facility B. On 06/07/2026 at 03:56 PM, P-1 was assessed at Facility B ED and remained at ESI level 2. P-1 was evaluated on 06/07/2026 at 04:13 PM by staff R, social worker for a mental health evaluation (MHE). Staff R determined that P-1 needed inpatient hospitalization because of the MHE. According to the MHE under the subtitle, “Suicidal Behavior, History of prior attempt(s),” it included the following, “Patient reports he has had 3 attempts however did not want to go into full detail regarding methods. Per chart review, patient had an admission on 03/14/2026 for a [SIC] intentional drug overdose. Patient was at (hospital). At that time patient had ingested an unknown amount of (over the counter pain medication) and bottles of (cold medicine) and a suicide attempt. He had also admitted to drinking and using cocaine that same night.” Additional documentation by staff R in the MHE, under the subtitle, “Current/Past Mental Illness, Mental health diagnosis, No current medication use for mental health dx (diagnosis), and No current treatment for mental illness. Comment: Patient reports having a diagnosis for ADHD (Attention Deficit Hyperactivity Disorder), depression and anxiety. Patient states he was on (antidepressant) medication. However, patient stated he has not been taking the medication for about a month as he [SIC - stated] “did not think I needed it.” Patient has a long history of suicidal ideation. Patient presents guarded, avoiding eye contact and taking long pauses after personal questions are asked. Patient reports having SI (suicidal ideation) thoughts for years. Patient reports no plan or intent however patient seems to be a poor historian. Due to patient being guarded, it is possible that patient is not reporting all information.” Continuation of the MHE review revealed staff R documented under “Suicide Inquiry, Ideation - Current ideation (frequency, intensity, duration): Patient reports having long history of suicidal thoughts. Plan - No current plan; patient denied having a plan, however stated ‘I would do it in the quickest way possible. It would be nothing that would hurt me.’ (Staff R) inquired if patient had written a letter or said goodbye to people and patient stated, ‘I thought about writing a letter in my head.’ He then shook his head and stated, ‘I did not write a letter.’ Intent- No current intent.” Risk level was documented as “moderate.” Staff O, ED physician ordered psychiatric placement for P-1. Staff R was able to secure placement for P-1 at a psychiatric hospital but transfer of P-1 could not occur until 06/08/2026 at 1230. P-1 was admitted by staff S, Hospitalist Internal Medicine, as an observation patient until transfer could occur. P-1 was transferred to 7M inpatient medical/surgical/orthopedic/oncology unit on 06/08/2026 at 12:07 AM. Review of P-1’s medical record included documentation that P-1 was rounded on at the following times on 06/08/2026: 12:26 AM, 02:00 AM, 02:50 AM, 04:53 AM, 06:16 AM, 09:19 AM, and 10:06 AM. A tour of the 7M unit bed 723 occurred on 06/11/2026 at 02:45 PM where P-1 was located on 06/08/2026. Ligature risks were observed throughout the main patient room including and not limited to: overhead patient lift system, television wall mount with connection cords, wall coat hooks, closet handles, reclining chair control cord, open wall mount for blood pressures, medical bed with openings located throughout frame, headboard, and footboard, open handrail, sink faucet handles, gooseneck faucet, and fixed glove box holder. Further observation of the patient bathroom identified ligature risks of open plumbing under the sink and connections to the toilet, 3 open handrails located near the toilet, and walls, fixed and attached shower curtain rod, 3 open handrails in the shower, shower head, mobile shower wand, and shower fixed seating. On 06/11/2026 at 02:59 PM staff C was queried about how a room is made safe for a suicidal patient with multiple ligature risks. Staff C responded that a “sweep” of the room is made and all items that are considered a high ligature risk and are mobile are removed. Staff C was then asked about the multiple items observed in the patient room and bathroom. Staff C stated that a “high” risk patient would have a sitter assigned for continual observation of the patient. Staff C was then queried about other non-high risk “psychiatric” patients who are placed in a medical/surgical room. Staff C stated that the room would be considered safe for patients determined to be moderate to low risk for suicide after a room had been swept prior to patient being placed in the room. Staff C stated that P-1 had been assessed as a “moderate” suicide risk. Review of video documentation on the day of 06/08/2026, revealed staff V, patient care assistant (PCA) entered P-1’s room at 10:41 AM and left the room and closed the P-1’s room door at 10:42 AM. P-1’s door remained closed from 10:42 AM to 12:32 PM. EMS arrived for transport of P-1 to the accepting psychiatric facility. Staff W was observed giving report to EMS outside of P-1’s room. EMS was then observed entering the room. P-1 was found in his room by the EMS staff member at 12:32 PM. P-1 was suspended by a ligature attached to the ceiling lift device (used to move patients) and had also cut his wrists. The EMS staff member quickly returned to P-1’s RN, staff W, to get assistance. A code was called at 12:33 PM. Staff were observed bringing the crash cart into P-1’s room at 12:34 PM. Code efforts were stopped at 01:00 PM according to staff U, Internal Medicine Hospitalist, P-1 was pronounced deceased by staff Y, Physician (code team) after multiple rounds of ACLS/CPR (Advanced Cardiovascular Life Support/Cardiopulmonary Resuscitation) at 01:22 PM. On 06/12/2026 at 09:55 AM staff Z, security officer confirmed that P-1’s door to his room remained closed from 10:42 AM to 12:32 PM. Review of the policy titled, “Suicide and Self Harm Assessment and Prevention,” version number 4, dated 8/27/2024, “Appendix A, Suicide Guideline” establishes the following for “Moderate” risk patients when located in the inpatient units: “Physical Environment - Dietary precaution: Patient safety tray, Suicide Prevention Strategies; Patient Belongings: Place in gown/appropriate scrubs pajama bottoms (remove clothing), Remove hazardous personal belongings, Screen visitors & belongings; Communication: Notify SW (social worker), Educate visitors on precautions, Handoffs (RN, Patient Care Assistant (PCA), Provider) included risk level; Observation: Standard observation; Documentation: Document Safety Intervention in the EHR (electronic health record), Assessment; Reassessment: Suicide Risk Assessment.” Suicide prevention strategies are described as, “if possible, eliminate structures of supporting a hanging object and objects that might be used for strangulation.” Appendix B, “Suicide Prevention Strategies for Moderate and High-Risk Patients” included under the subtitle “Self-Injury...Open room doors/curtains/hall window blinds to allow observation of patient.””

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 48030 Based on interview and record review, the facility failed to ensure an appropriate medical screening exam was conducted for 1 (P-1) of 20 patients reviewed resulting in the potential for unrecognized, unmet patient needs and poor patient outcomes. Findings include: Record review from Facility-A was conducted for P-1 on 3/4/2026 at 1140 and reveals P-1 arrived at the facility ED on 1/9/2026 at 1209 and triage began at 1212. The chief complaint reveals, “Suicidal (Pt states that she is coming in from her PCP office today where she expressed suicidal ideations to them. She states she has thoughts and desires of running into traffic to kill herself. She was recently discharged from [inpatient psychiatric facility] on 12/31.)” An ESI (emergency severity index score) of 2 was assigned and a Columbia Suicide Severity Risk was completed at 1213 and calculated as High Risk. At 1335 record review reveals P-1 was moved to triage room 3 and was evaluated by Social Work. At 1454 a nursing reveals, “After being told pt did not meet inpatient criteria, pt ran out of ED to try to run into the street; Pt unable to be verbally redirected; MSW and provider aware. Security and PD outside managing pt”. Review of the ED Timeline in P-1’s record reveals the first provider evaluation at 1524 and P-1 was discharged at 1530 (after P-1 eloped from the ED). Review of the Social Work note from 1450 reveals the ED provider met with P-1 in triage room 3 to go over discharge to the residential treatment facility and safety plan, prior to P-1 exiting the ED. Review of the Social Worker note from 1450 reveals attempts were made by the residential treatment worker to provide timely transportation back to the facility and the Social Worker called the local Behavioral Health Team transportation to assist with transporting P-1 without success. The local police could not transport P-1 back to the residential facility, and therefore the representative accompanying P-1 to the ED from the residential treatment facility and the local police, “determined that the patient would be transported to another hospital to determine next step.” Discharge documents were not found in the medical record. Review of the Departure Condition from 1549 reveals the “Departure Condition: Stable, Patient Teaching: Discharge instructions reviewed; Follow-up care reviewed. Case manager verbalized understanding. Pt upset about discharge.” On 3/19/2026 record review from Facility-B was conducted and revealed a Social Work note from 1/9/2026 at 1616 which reveals, “[P-1] arrived to ED via [police] co-response team. [P-1] was picked up outside of [Facility-A]. Per [police social worker], the [police] co-response team happened to be at [Facility-A] as they were just dropping off another patient there, and they were flagged down to assist with this [P-1]. It is reported that [P-1] was discharged from [behavioral health facility] recently on 1/30/26. [P-1] was following up with their PCP today (accompanied by [direct support specialist/caregiver] from residential facility) where they endorsed SI and were advised to go to the nearest ED, [Facility-A]. At [Facility-A], [P-1] was told they would not be pursuing inpatient psychiatric treatment at this time, then [P-1] eloped from their ED and attempted to run into traffic. [P-1] had to be restrained by [director support specialist/caregiver from residential facility] and then security. It is reported by [police] that [Facility-A] refused to readmit this PT to their ED, therefore they brought [P-1] to this ED. [Police] reports that [P-1] was also banging his head throughout this.” An interview was conducted on 3/4/2026 at 1335 with the nurse (Staff N) working as the patient sorter in triage area on 1/9/2026 when P-1 was brought in for evaluation. Staff N revealed that she remembered P-1 and that she was working in the triage area as the patient sorter when they ran out of the front entrance of the Emergency Department (ED) with the residential treatment team member following behind. Staff N recalled that the ED social worker (Staff Q) came to her and told her that P-1 was not happy that they would not seek inpatient treatment and asked her to notify the provider (Staff T) that they had left the building. Staff N shared that she observed that the residential treatment team member stopped P-1 in front of the ED in the circle drive. When queried if she notified Staff T that P-1 had left the facility, Staff N responded, she spoke with Staff T and he responded, “ok”. Staff N explained that was when she put a note in P-1’s chart. Staff N recalled that the police were present and assisting Security with P-1 and “normally police would bring a patient back to our ED if they are involuntary.” On 3/5/2026 at 0915 an interview with the ED Social Worker (Staff Q) was conducted. Staff Q revealed she remembered P-1 and that she was notified via page by the nurse sorter in triage that a behavioral health evaluation needed to be completed, Staff Q explained that the facility pages social work for this because they want behavioral health evaluations completed within 30 minutes of arrival. Staff Q revealed she completed her assessment in triage room 3 in the presence of the residential treatment team member where P-1 was currently living. Staff Q explained that when she asked P-1 “what was going on tonight”, P-1 shared a desire to run away from home and did not want to live anymore and wanted to “run into the road” and “just saying anything that is coming to mind”. Staff Q shared that she has done a lot of evaluations and did not feel P-1 had a specific plan and discussion with the team member from the residential care facility revealed there was a of “secondary gain” with being admitted to the behavioral health facility. Staff Q explained that P-1 was not having suicidal ideation earlier in the day and the only reason for the ED visit was because P-1 answered certain questions to the primary care physician (PCP) that would trigger an evaluation in the ED and P-1 frequently attempts to run away from the treatment facility, and they have been working on a treatment plan. Staff Q revealed after assessing P-1 she felt like inpatient admission was not required and that doing so would “start a cycle of frequent admission” and she shared her findings with the provider (Staff T). Staff Q added that she had created a safety plan with P-1 and the residential care facility staff member and that they already had a safety plan in place at the residential facility. Staff Q revealed that she was notified that P-1 became upset and left the ED after learning an inpatient admission would not be required. Staff Q explained that she went out to the front of the ED to find the residential facility staff had restrained P-1 and Security and the local police were present. Staff Q told them P-1, “was in the care of [the residential care staff] and ED staff (Security) should not lay hands on the patient”. Staff Q added she tried to notify the provider at the time this was occurring but was unable to discuss the case with them and another social worker came outside to assist. Staff Q revealed the police were “very anxious and not willing to transport patient back to home”, and took P-1 to another ED. When queried if the patient ever asked to go back into the ED, Staff Q revealed she did not remember. When queried why P-1 was not brought back into the ED, Staff Q explained that a treatment plan was agreed upon and a Safety Plan was made and no further treatment was required as P-1 was discharged. During an interview with Security Sergeant (Staff U) on 3/5/2026 at 1150 it was revealed he remembered the incident involving P-1 and had completed a Security Incident Report. Staff U explained he was sitting in the office near the front entrance of the ED when he saw 2 females grabbing P-1 to prevent the patient from leaving. Staff U revealed he asked the facility social worker if P-1 was allowed to leave and was told “yes”, so he did not attempt to stop the patient. Staff U explained that he observed the residential care facility staff bring P-1 down to the ground and another Security Officer flagged the police (who were dropping another patient off in the ED) to assist them. Staff U revealed P-1 was escorted to a bench located outside of the ED and began banging his head against the wall, so he put his hand in the way to prevent injury and the social worker and the resident care facility staff member were trying to arrange transportation back to the facility. Staff U revealed that transportation and additional help were unable to be secured and the police officer that was present decided to bring P-1 to another ED for evaluation. Staff U added that he asked if P-1 should be brought back into the ED and the social worker did not think that anything else needed to be done for P-1. Staff U added that he recalled the residential facility worker asking if they could bring P-1 back into the facility ED and police said it was outside of their jurisdiction. Review of the Security Incident Report dated 1/9/2026 at 1436, reported by Staff U was conducted on 3/5/2026 and revealed in section titled, “Report Synopsis/Overview-Patient from [residential treatment program] ran out of the ED with a staff member from [residential treatment program] going hands on with [P-1]. Social work advised they were free to leave. [Local police] assisted and eventually brought the patient to [Facility-B] hospital.” Review of paragraph 1 of the Narrative text reveals, “I observed a female who I later identified as [P-1] run out of the Emergency Department vestibule with another female who I later identified as [residential care team member] going hands on to slow [P-1] down from running. I thought [P-1] may be attempting to elope, so I went to the vestibule and saw [facility social worker Staff Q] and asked her if [P-1] was allowed to leave and [Staff Q] stated [P-1] was allowed to leave. [P-1] continued to run out of the ED vestibule with [residential care team member] still going hands on to slow [P-1] down from running. Eventually [residential care team member] was able to slow [P-1] down and they both ended up on the ground by the island in the middle of the ED drive circle. Security assisted with directing incoming vehicles that were dropping off patients to be seen.” Review of the Narrative text, paragraph 3 reveals, a local police department officer was flagged down by Security to assist with P-1, and the officer helped the residential care member with P-1 who slipped away. Security suggested P-1 be moved to a bench outside of the ED vestibule to prevent them from continuing to block traffic. Security and the police walked P-1 to the bench, and [P-1] began to bang their head against the wall. Security put a hand behind P-1’s head and the wall to prevent self-arm. Paragraph 4 reveals the residential care member was speaking with her supervisors and stated that her supervisors wanted [P-1] to be reevaluated and the Social Worker (Staff Q) advised that P-1 was behavioral and would not be going inpatient at which time the police officer decided to take P-1 to Facility-B for evaluation. Review of facility policy titled, “Emergency Medical Treatment and Labor (EMTALA), version 7, approved 9/15/2025, page 2, “Procedure: 1. The Hospital ’ s emergency department staff will provide a medical screening examination of anyone who comes to the emergency department and requests examination or treatment of what may be an emergency medical condition. 2. An individual “comes to the emergency department” of the Hospital if he or she: c. Presents on the Hospital property and appears to a reasonable person to be suffering from an emergency medical condition.” Review of page 8, number 5 reveals, “An individual is considered stable and ready for discharge with follow-up instructions when the Qualified Medical Person determines that the individual has reached a point where his or her continued care, including diagnostic work-up and/or treatment, could be reasonably performed as an outpatient, or later as an inpatient, provided the individual is given a plan for appropriate follow-up care to prevent relapse or worsening of the medical condition as part of his or her discharge instructions.””

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 48030 Based on observation, interview and record review, the facility failed to have medical personnel immediately available to meet the emergency needs for (P-1) of 20 patients reviewed resulting in the potential for poor patient outcomes up to and including death. Findings include: On 10/13/2025 at 1226 record review for P-1 was conducted and revealed he was a 53-year-old who presented to the facility Emergency Department (ED) on 9/19/2025 at 1803 for a complaint of chest pain. Review of the ED provider note reveals P-1’s significant other reported he was complaining of chest pain, had taken nitroglycerine for the pain and requested she come pick him up and bring him to the ED. P-1 arrived at the facility by private vehicle, was assisted into a wheelchair and was wheeled into the facility. At the time of arrival P-1 was awake and alert but slumped over in the wheelchair, became unresponsive, and had agonal respirations in front of the registration desk. The ED provider was summoned to the registration area by Security personnel. Upon arrival the ED physician assessed the patient and found he did not have a pulse and attempted to bring him into the treatment area but realized he would need a stretcher and additional staff for assistance. Leaving P-1 in registration area the ED provider opened the treatment door area and summoned staff for assistance and returned to P-1 and began CPR. While performing CPR in the wheelchair P-1 was wheeled back into the treatment area by Security personnel and taken to a stretcher in the hallway, where other ED nurses had arrived to assist. P-1 was moved into a patient care room and chest compressions continued and ACLS protocols were initiated and cardiac monitoring revealed PEA (pulseless electrical activity). During the resuscitation effort P-1 was intermittently in ventricular-fibrillation and defibrillations (use of an electric current to help heart return to normal rhythm) were administered. P-1 received Narcan, Epinephrine every 3 minutes, glucose, Amiodarone, Lidocaine during the resuscitative efforts. An ultrasound of the heart at 1843 revealed no cardiac activity. After 45-minutes of CPR, P-1’s family members were brought to the bedside and requested resuscitative efforts be stopped and he was pronounced deceased at 1846. On 10/13/2025 at 1045 a tour of the facility Emergency Department (ED) was conducted and revealed an 8-bed stand-alone ED with a current patient census of 7. At the time of the tour there were 3 nurses caring for patients, with a 4th nurse added at 1100, one ED physician and one physician assistant. The ED is staffed with 2 nurses from 0300-0700 and no additional support staff in the ED throughout the day. During the tour it was observed that the ED is located within a building that shares its entrance with other outpatient services provided at the facility. Upon entry patients are greeted by Security who assists patients with exiting their vehicle and obtaining a wheelchair and a Patient Access Representative who is responsible for obtaining the patient’s chief complaint, demographic information and consent for treatment. Patient Access Representatives are instructed to call the nurses station if a patient needs “emergent intervention” and a list of chief complaints and observations are available for them to use as a “guide to determine when to notify a nurse”. ED nurses are able to view the waiting area by video at the nurse’s station. On 10/13/2025 at 1345 review of video from 9/19/2025 at 1755 of the facility ED entrance, ED registration area and ED treatment area was conducted with the Security Liaison (Staff L) and the ED Manager (Staff E). The video reveals P-1’s arrival to the facility and subsequent observations following his arrival as listed below: 1755 - P-1 arrives to the facility front entrance as a passenger of a private vehicle. The passenger door slightly ajar while the vehicle is observed pulling up to the facility. 1757 - Security Officer observed walking out towards the vehicle, speaking with the driver and passenger and then heading back into the facility and into the treatment area. The Security Officer is observed to look towards the nurse’s station, which is vacant and then towards the provider charting station and walking back out into the registration area. 1759 - Security Officer is then observed walking back out towards the vehicle and finding P-1 is being assisted into a wheelchair by his significant other. P-1 is then wheeled into the ED entrance and towards the Patient Access Representative desk and while speaking with them P-1 leans back into wheelchair and becomes unresponsive. Patient Access Representative is observed picking up the phone to call into the main ED to the nurse’s station. Security Officer is observed walking back into the ED treatment area and the ED physician is following behind him (the nurse station is unoccupied). 1800 - Physician presents to registration area and attempts to push his wheelchair back into the treatment area and then leaves P-1 to go back into the treatment area and appears to be requesting assistance. The ED provider is then observed to return to P-1 in the lobby area. 1801 - P-1 is brought back into the treatment area by the Security Officer while the ED physician performs CPR in wheelchair. 1803 - A empty stretcher is observed to be in the entryway of the treatment area and P-1 is transferred from the wheelchair to the stretcher by the ED provider, Security and nursing staff. CPR is observed to continue while P-1 is transported into a patient room. On 10/13/2025 at 1406 an interview with the Security Officer (Staff M) was conducted and reveals he remembered when P-1 arrived at the facility. Staff M explained he was working out in the Emergency Department (ED) entrance area when he saw a car pulling up with the passenger door slightly open and he was worried the person may fall out so he went out right away to see what was happening. Staff M revealed when he got to the vehicle a woman was driving, and a man was in the passenger seat, and she stated that P-1 thought he was having a heart attack. Staff M explained that P-1 had vomited in the vehicle on the way to the ED and that was why the car door open. Staff M revealed that when he first arrived at the ED P-1 was awake and answering questions. Staff M explained that he went back into the ED to alert the nursing staff that a patient with chest pain had arrived and to get something to help clean up the vehicle. Staff M revealed that when he went back to the treatment area to alert nursing staff, the nurses ’ station was empty, so he notified the ED physician that a patient had arrived that reported he was “having a heart attack”. When queried if the ED physician came out to the ED entrance, Staff M revealed he did not come out at that time. Staff M explained that after he had returned to the vehicle, he assisted P-1 into a wheelchair, and he was brought into the facility. Staff M revealed that P-1 went unresponsive while speaking with the Admitting Representative, and he went back into the treatment area to notify the doctor. Staff M explained the ED physician followed him out to the registration area and examined P-1 and found him unresponsive and attempted to bring him back to the treatment area but then realized he would need a stretcher and additional nursing staff assistance so he went back to get help because all of the nursing staff were in rooms with other patients. Staff M revealed when the doctor came back, he began CPR while P-1 was in the wheelchair and he assisted by pushing the wheelchair back into the treatment area and transferring P-1 onto a stretcher. When queried what type of medical training he has received, Staff M explained he has basic life support (BLS) training, but he has been instructed that he should go get help from the nursing staff if a patient is experiencing an emergent medical condition. Staff M shared that he felt the admitting personnel did not pay close attention when a patient presents with a serious medical condition and they are responsible for calling the nurse for help when needed. On 10/13/2025 at 1600 an interview was conducted with the Patient Access Representative (Staff N) that was working in the registration area the evening P-1 presented to the facility. Staff N explained she remembered P-1 and that he came in as a new patient to the facility, was initially speaking with her and answering questions but then became unresponsive. Staff N explained that she was attempting to get P-1’s name and driver’s license when he went unresponsive and that his significant other was very distraught saying he was having a heart attack. Staff N revealed she tried calling the nurses station right when P-1 arrived, but her call was not answered. Staff N explained she either called the nurses station a couple times or let it ring a long time, she could not recall. Staff N explained that when P-1 first arrived “he didn’t seem to be in bad shape” and was talking and that he went downhill rapidly. When queried if she has basic life support (BLS) training, Staff N revealed, no she did not and she has been trained to call the nurses station for patients that present with certain medical conditions and they have a list of emergent conditions to use as a guide. On 10/13/2025 at 1500 an interview with the Emergency Department (ED) physician (Staff I) who was the attending ED provider when P-1 arrived on 9/19/2025 was conducted. Staff I revealed he remembered P-1 and that he recalls the ED was full at the time of his arrival and all of the nursing staff was busy in other patient rooms. Staff I explained he was looking into the past medical history for another patient that had just arrived in atrial fibrillation with RVR when the Security Officer came to tell him that a patient with chest pain had just arrived in registration area. Staff I revealed he went out to the registration area when the Security Officer came back a second time to alert him that the patient was unresponsive. Staff I explained that when he went out to the registration area, he found P-1 unresponsive in the wheelchair and attempted to wheel him back into the treatment area but his foot was catching and dragging in the wheelchair so he went to get additional staff to assist. After alerting nursing staff that he needed a stretcher and help, he immediately returned to P-1 in the registration area and found he did not have a pulse and began CPR in the wheelchair. P-1 was wheeled into the treatment area, transferred to a stretcher and moved to room 3 where staff continued with ACLS protocol which was not successful in resuscitating him. Staff I explained that he did have a debrief with the ED staff following the code, because this type of event does not occur frequently in this small stand-alone ED. During an interview on 10/14/2025 at 0840 with the Emergency Department (ED) nurse (Staff P) it was revealed that he remembered the night P-1 came to the ED. Staff P explained that he was in a room with a patient when he heard the ED physician (Staff I) yelling through the door that he needed a stretcher. Staff P revealed he went and retrieved a stretcher and observed that Staff I was already performing CPR on P-1 while he was in the wheelchair. Staff P explained he assisted with transferring P-1 onto the stretcher and wheeled into room 3 where the crash cart was brought to the bedside and ACLS protocol was initiated, which were unsuccessful. When queried how ED nurses are alerted when a new patient has arrived, Staff P explained that their name will “pop up” on the tracking board and depending on what their chief complaint is, the Patient Access Representative may call the nurses station if they need a nurse right away. When queried what happens if the nurse’s station is empty and if nobody answers their call, Staff P explained that either Security or the Patient Access Representative will come back into the treatment area to get them. Staff P revealed there is always a charge/triage nurse assigned and that nurse is responsible for monitoring the patients in the waiting area when the ED is full. When queried how the patients are monitored, Staff P explained nurses “visually monitor” on the video at the nurse’s station or when they go into the lobby to get another patient. On 10/13/2025 at 1518 an interview with the charge/triage nurse (Staff J) that was working the night P-1 came to the Emergency Department (ED) was conducted. Staff J revealed she remembered P-1 and was in another patient room triaging at the time of his arrival. Staff J explained that all of the patient rooms were full at that time and all of the nurses were busy taking care of other patients when she heard the ED physician (Staff I) yell into the ED requesting a stretcher. When queried how Security/Patient Care Representatives staff alert nursing staff that a patient with an emergent medical condition has arrived or that a nurse is needed in the waiting area, Staff J explained that they typically will come back into the treatment area, call the nurse’s station to notify them or call charge/triage nurse phone. When queried if she recalls being notified that P-1 had arrived and that staff needed immediate assistance, Staff J explained no, she did not remember being notified and she was in a patient room at the time. When queried if they called the charge/triage phone, Staff J revealed she was not carrying the phone at the time of the incident and they usually just call the nurse’s station. Review of facility policy titled “Triage Nurse Role and Initiation of Diagnostic Tests by Emergency Department RN-Emergency Services Guideline #23”, version #2, approved on 10/20/2023 revealed under section titled, “Responsibilities, #9. Escorts (or delegates) acutely ill patients to treatment area and initiates assessment and/or resuscitation measures until relieved by the nurse assigned to that room or designee.”... “#13. Assists security in removing patients from vehicles as needed.”...”#16. Ensures that waiting room patients are rounded on hourly, have repeat vital signs documented, and maintain accountability for waiting room patients.””

“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] regarding appropriate transfers for 2 (P-1, P-20) of 20 patients reviewed for EMTALA requirements resulting in the lack of information and identification of resources required for appropriate transfer. Findings include: See Specific Tags: A-2409 Lack of information regarding EMTALA requirements for appropriate transfer”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 36887 Based on observation and interview, the facility failed to provide signage pursuant to EMTALA (emergency medical treatment and labor act) in 5 of 7 waiting areas for the emergency department resulting in the potential for all emergency department patients using the waiting areas to not be informed of their rights to have a medical screening exam and stabilizing treatment. Findings include: On 5/7/2025 at 1004 during the initial tour of the main facility, Triage Nurse Staff F stated there were two other overflow waiting areas for patients who wanted to be seen in the ED (Emergency Department). On 5/7/2025 at 1018, Waiting Room #2 was entered and found to have 7 chairs present; however, no EMTALA signs were found in the room. This was confirmed by Staff F at the time of discovery. On 5/7/2025 at 1020, Waiting Room #3 was entered and found to have 11 chairs present. No EMTALA signs were found in the room. This was confirmed by Staff F at the time of discovery. On 5/7/2025 at 1021, ED Manager Staff A was informed of the findings and steps were retraced back to both waiting rooms. Staff A stated she knows that signs had been present and was surprised they were not there. On 5/8/2025 at 0830, the lobby of child facility Free-standing ED #1 was entered. It was noted there was seating on either side of the entrance door from the outside of the building which was shared with other medical offices. No EMTALA signage was visualized in either waiting area. Additionally, during the tour of the facility on 5/8/2025 at approximately 0840, another small waiting area was present in front of the triage room which also had no EMTALA signage present. Both of these findings were confirmed by Regulatory/Compliance Staff N at their respective times of discovery. Facility policy, Version Number 6, titled “Emergency Medical Treatment and Labor (EMTALA) approved 4/23/2024 states, “A sign will be posted in a conspicuous location, and in places likely to be noticed by individuals entering and waiting for examination, in each dedicated emergency department (including any off campus departments where medical screening examinations must be performed, such a s Labor and Delivery), specifying in clear and simple terms the rights of individuals under EMTALA with respect to examination and treatment for an emergency medical condition and of women in labor, and whether the Hospital participates in the Medicaid program.””

“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 interview and record review, the facility failed to document requirements for appropriate transfer for 2 (P-1, P-20) of 6 patients reviewed for transfer resulting in the lack of information and identification of resources needed for appropriate transfer. Findings include: Review of the medical record for P-1 revealed he was a 13-year-old male who presented to the Emergency Department (ED) on 2/24/2025 at 0131 for a headache after being seen twice (2/19/2025, 2/21/2025) at a nearby children’s hospital and another time at another nearby acute care hospital (2/22/2025) for the same issue. Following evaluation in the ED and consults with pediatric providers, it was determined P-1 required transfer to the nearby children’s hospital for further treatment and care. Review of the “Emergency Medical Treatment and Transfer (EMTALA [Emergency Medical Treatment and Labor Act]) Form” revealed there were no risks or benefits of transfer present. This was confirmed by Staff B 5/7/2025 at 1310. Review of the medical record for P-20 revealed he was a 39-year-old male who presented to the ED on 12/23/2025 at 1624 for suicidal ideation (SI) with a plan to cut his neck that day. P-20 was requesting admission for medication adjustment as he felt his anti-psychotic medication was not working. Past medical history included ADHD (attention deficit hyperactivity disorder), anxiety, depression, and schizophrenia. C-SSRS (Columbia Suicide Severity Rating Scale - assessment tool used to assess suicide risk) indicated he was high risk for suicide. Social work notes indicated P-20 was displaying current symptoms of anxiety and command hallucinations. P-20 indicated he had a plan to cut his neck and had access to kitchen knives in order to do it. His intent showed he would carry out his plan. Social work placed him at moderate risk for suicide. Social work notes further indicated P-20 was supposed to have his injection for his anti-psychotic that day; however, he decided not to go because it was cold outside. When trying to obtain placement at the crisis center, it was discovered the injection was court-ordered, so the patient would be on a notification of non-compliance and would need in-patient hospitalization. Due to the notification of non-compliance, P-20 was made an involuntary admission. Social work indicated the facility for placement, accepting physician, admission status, transportation plan, and indicated that nurse report was completed. P-20 was diagnosed with SI, schizophrenia, and severe episode of recurrent major depressive disorder with psychotic features. He was transferred via ambulance to a local psychiatric facility. No EMTALA paperwork was found present in the medical record indicating the risks/benefits of transfer, physician certification that the benefits outweighed the risks, resources needed for transfer or that the medical record had been sent to the receiving facility. Facility policy, Version Number 6, titled “Emergency Medical Treatment and Labor (EMTALA) approved 4/23/2024 states, “Transfer: The movement (including the discharge of an inpatient) of an individual outside the Hospital’s property at the direction of any person employed by (or affiliated or associated, directly or indirectly with) the Hospital, but does not include such a movement of an individual who (a) has been declared dead, or (b) leaves the Hospital without the permission of any such person...If after examination it is determined that an a {sic} individual has an emergency medical condition, the Hospital will provide, within the staff and facilities’ capacity, capability and availability at the Hospital, for such further medical examination and treatment as may be required to stabilize the medical condition, or else provide for the transfer of the individual to another medical facility... An individual with an emergency medical condition may not be transferred until he or she is stabilized, unless: a. A physician or qualified medical personnel (as defined by the Medical Staff Bylaws) in consultation with a physician makes a determination that the medical benefits reasonably expected from treatment at another facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or her unborn child, from being transferred, and the physician or other qualified medical person signs the Physician Certification of Transfer form (Appendix A)...Transfer of an individual with an emergency medical condition to a medical facility is appropriate only where: a. The risks to the individual’s health and, in the case of the woman in labor, the health of the unborn child, of the transfer are first minimized, to the extent possible within the capabilities of the staff and facilities available at the Hospital. b. The receiving facility has available space and qualified personnel for treatment of the individual and has given its consent to the transfer of the individual and to provide appropriate medical treatment. Acceptance of the transfer by receiving facility must be documented in writing. c. The transfer is effected through qualified personnel and proper transportation equipment, including the use of necessary medically appropriate life support measures during the transfer; and d. The receiving facility is provided with copies of all medical records related to the emergency medical condition available at the time of transfer, including: I. available history, records relating to the individual’s emergency medical condition, observations of signs and symptoms, preliminary diagnosis, the results of diagnostic studies (or telephone reports of the same), test results, and treatment provided. ii. applicable transfer forms, including any informed written consents and the Physician Certification of Transfer form; and iii. the name and address of any on-call physician who was requested to come to the emergency department and refused or failed to appear within a reasonable amount of time to provide stabilizing treatment. Note: Other records and the results of tests not completed by the time of transfer must be sent to the receiving medical facility when available.””

“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 record review and interview, the facility failed to renew a violent restraint order after four hours for 1 (#5) of 3 patients reviewed for restraint and seclusion resulting in the loss of patient rights. Findings include: Review of the medical record for P-5 revealed he was a 34-year-old male who presented to the Emergency Department (ED) 8/2/2024 for evaluation following an assault on family members and police. During his ED visit, an order was given on 8/2/2024 at 1708 for 4-point violent restraints. The restraints were applied on 8/2/2024 at 1708, the same time the order was given. The restraints were not discontinued until 8/2/2024 at 2228. The total time of restraint was 5 hours and 20 minutes. On 1/27/2025 at 1605, Staff M was queried as to if there was a renewal order for the restraint to which she stated there was not. Facility policy titled “Use of Restraint” approved 7/15/2024 states, “Authorized restraint may not continue for more than 4 hours...An order for restraint must continue only for that period of time specified in the order or for up to the following limits, whichever is less: i. 4 hours for adults 18 years of age or older...A physician who orders or reorders restraint shall do so in accordance with sections 740(5) of the act...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 36887 Based on record review and interview, the facility failed to release 1 (#5) of 3 patients reviewed for violent restraints and/or seclusion at the earliest possible time resulting in the loss of patient rights. Findings include: Review of the medical record for P-5 revealed he was a 34-year-old male who presented to the Emergency Department (ED) 8/2/2024 for evaluation following an assault on family members and police. He had no documented psychiatric history. ED physician notes dated 8/2/2024 revealed the patient was “confused, altered, aggressive...was inconsolable and unable to be verbally de-escalated calmly.” P-5 attempted multiple times to “strike staff.” As a result, an order was given on 8/2/2024 at 1708 for 4-point violent restraints as the patient was at risk of harming himself and/or others. The restraints were applied on 8/2/2024 at 1708, the same time the order was given. While in restraint, the patient continued to “lash out at staff.” Medications were given for anxiety and “to help calm patient down although multiple attempts were administered without success.” Physician notes continue to document a limited exam due to the patients behaviors. It was determined a lumbar puncture was needed to rule out meningitis. Sedation was administered on 8/2/2024 at 2121 and P-5 was intubated 2130. Further review of restraint documentation revealed the 4-point violent restraints were not discontinued until 8/2/2024 at 2228. On 1/27/2025 at 1610, Staff A agreed the 4-point violent restraints should have been released shortly after intubation. Facility policy titled “Use of Restraint” approved 7/15/2024 states, “Restraint: the use of a physical device to restrict an individual’s movement... Restraints may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm... Restraint must be discontinued at the earliest possible time, regardless of the length of time identified in the order.””