Trinity Health Muskegon Hospital

“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 follow nursing policy and acceptable standards of practice for managing skin wounds for 2 (P-1, P-3) of 2 patients reviewed resulting in the increased likelihood of negative outcomes for the patients. Findings include: On 08/11/2026 at 2:55 PM, P-1’s medical record was reviewed with Clinical Nurse Specialist Staff X. On 06/22/2026 at 5:27 AM, P-1’s initial inpatient skin assessment revealed a Braden scale score of 12 (high risk for developing a skin wound) and that P-1 had “very limited mobility”. On 08/12/2026 at 11:25 AM, Staff X confirmed there was no documentation in P-1’s initial skin assessment that another staff member witnessed P-1’s initial inpatient head to toe skin assessment. Staff X was queried on 08/11/2026 how often would P-1 be turned or repositioned based on a Braden score of 12, Staff X revealed minimally “every 2 hours”. A review of P-1’s turning and repositioning documentation revealed that P-1 was not turned or repositioned between the following dates and times: - 06/23/2026 at 2:55 PM through 06/24/2026 at 9:16 AM - 06/25/2026 at 5:57 PM through 06/25/2026 at 9:01 PM Staff X confirmed that P-1’s turning and repositioning was not performed during the dates and times noted. On 06/23/2026 at 2:55 PM, P-1’s initial Care Plan revealed two problems were recorded: - “Cognitive deficit/Change in mental status” - “Swallowing” Staff X was queried if P-1’s high risk for developing skin wounds should be documented as a problem in P-1’s Care Plan, Staff X revealed “yes” and confirmed P-1’s Care Plan did not have the skin wound problem recorded. On 08/11/2026 at 2:55 PM, P-3’s medical record was reviewed with Staff X. On 08/09/2026 at 5:00 PM, P-3’s inpatient nursing skin assessment revealed “wounds to right hip/heels”. A review of P-3’s turning and repositioning documentation revealed that P-1 was not turned or repositioned between the following dates and times: - 08/10/2026 at 5:29 AM to 08/10/2026 at 9:37 PM - 08/11/2026 at 12:07 AM to 08/11/2026 at 4:25 AM - 08/11/2026 at 6:32 AM to 08/11/2026 at 10:00 AM On 08/10/2026 at 6:09 PM, P-3’s Care Plan revealed the following goals: - “Identify possible barriers to meeting goals/advancing plan of care: condition” - “Stability of the patient: Unstable - High likelihood or risk of patient condition declining or worsening” - “End of Shift Summary: alert-unable to understand verbal noises” Staff X confirmed that P-3’s turn and reposition documentation was not performed every 2 hours and that P-3’s Care Plan did not include P-3’s skin wounds as a problem to improve. On 08/12/2026 at 2:02 PM, Chief Nursing Officer Staff B was queried if they expected staff to follow the facility’s policies and procedures, Staff B revealed “yes”. According to the facility’s policy “Skin Integrity,” dated 06/02/2026, “A. Upon admission all patients shall be assessed using the Braden Risk Assessment Scale. Thereafter, patients shall be assessed daily or and (sic) whenever there is a change/decline in patient status. - A score of 19 or greater: low risk for developing a pressure injury. - A score of 15-18: mild risk for developing a pressure injury. - A score of 13-14: moderate risk for developing a pressure injury. - A score of 10-12: high risk for developing a pressure injury. - A score of < 9 or less: very high risk for developing a pressure injury. B. If an at-risk patient has a score of 18 or less, has a score of one (1) in any of the six (6) specific risk categories, or has a history of a pressure injury, “At-risk for impaired skin integrity” may be manually added to the Problem List in the patient’s electronic health record (EHR).” C. The bedside RN shall implement the “Pressure Injury Actual or At-Risk Care Plan” in the patient’s EHR and initiate all appropriate interventions. Head-to-Toe Skin Assessment: A. All patients shall receive a head-to-toe skin assessment by two (2) trained bedside medical associates, one of which must be a Registered Nurse, within the first four (4) hours of admission/unit transfer. Thereafter, a head-to-toe assessment shall be performed by a Licensed Nurse every shift AND when there is a change/decline in patient status; or after procedures lasting four (4) hours or longer (ensure the head to-toe skin assessment incudes (sic) looking above, below, and around medical devices). - If a patient refuses the skin assessment, report refusal to provider and unit manager. Document refusal in the EHR on a Significant Events Progress Note. - The head-to-toe assessment and presence of pressure injuries shall be documented in the patient’s EHR by the RN performing the assessment before the end of his/her shift.” The policy revealed for “Pressure-Related Skin Injuries”, - Implement pressure injury prevention measures/interventions. - Reposition every two (2) hours or more frequently. Avoid positioning patient on affected area.”

“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 failed to protect and promote the rights of 3 (P-1, P-3, P-4) of 10 patients reviewed resulting in the loss of patient rights and the potential for unidentified, unmet patient needs and poor patient outcomes. Findings include: See Specific Tags: A-154 Failure to restrain without use of a weapon A-167 Failure to follow policy for restraint documentation A-178 Failure to conduct a face-to-face assessment within 1 hour of restraint initiation”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 53475 Based on interview and record review, the facility failed to ensure that 1 (P-1) of 10 patients reviewed was free from abuse resulting in the loss of patient rights for P-1. Findings include: The review of the medical record for P-1, a 30-year-old male, who was brought to the Emergency Department (ED) by the police on 10/22/2025 at 1210, showed a petition for psychological evaluation. Once other medical concerns were ruled out and arrangements for discharge were put in place by 20:02:08, P-1 was told that he would be admitted to an inpatient psych unit on 10/23/2025. A video review on 1/27/2026 at 1415 of events from 10/22/2025 around 20:30 did not include time stamps nor sound but detailed the following events over the course of about 16 minutes. However, the “Security Department Memorandum” dated 10/31/2025, identified the following timeline: 20:08:00 P-1 wore paper scrubs, was walking in the hallway near ED 45. 20:10:10 P-1 opened wrong door (next door - ED 46). 20:10:45 P-1 was inside the doorway of his room. 20:11:31 P-1 was back in the hallway outside his room, watched staff passing by, walked back, looked at documents posted to the glass door of ED 45. 20:17:13 P-1 was seated in a chair across the hall from his room. 20:17:24 Security Sergeant Staff-J approached P-1 and they communicated. Shortly after, Security Officer Staff-I washed hands and joined the conversation. 20:18:12 Staff-J opened the door to P-1’s room, Staff-I placed his hands on the back of the chair to wheel P-1 back to the room. 20:18:17 P-1 stood up swinging a fist at Staff-I. 20:18:21 P-1 was backed up against ED 46 door with both Staff-J and Staff-I attempting to corner P-1 using their hands and physical weight to control P-1. The Taser electrical discharge to gain patient corporation could not be witnessed; the event was out of camera view. The “Taser 7 Log” on 1/28/2026 at 0905 from 10/22/2025 identified the following: 20:18:24:136 Safety OFF 20:18:24:287 Bay 1: Taser 7, Live 12 Cartridge status: Ready 20:18:24:325 Bay 2: Taser 7, Live 12 Cartridge status: Ready 20:18:24:348 Taser Battery detected: 86% 20:18:55:901 Right arc button pressed 20:18:55:913 Electrically discharged 20:18:56:987 Right arc button pressed 20:18:56:993 Electrically discharged 20:19:53:860 Safety ON, Disarmed P-1 continued to resist, and additional staff member joined to lower P-1 to the floor. 20:21:31 Several staff and security assisted to move P-1 onto a stretcher, and four-point leather restraints were applied to P-1’s arms and legs. 20:22:00 P-1 was moved to ED 37; a psych-safe room in POD C. During the course of P-1s stay, 2 ECG’s were completed: 13:50:49 Admit to ED: P-1 had a “Normal sinus rhythm with sinus arrythmia. Normal ECG.” 20:34:53 After Taser electricity discharge: P-1 was “in atrial fibrillation with rapid ventricular response - abnormal rhythm ECG.” The ED Physician Staff-R stated during an interview on 1/27/2026 at 1442 that it was a “challenging case.” P-1 “needed admission.” He had completed a clinical certificate (legal document indicating need for inpatient admission), and he had told the patient about the admission. Staff-R was unsure why security was present other than the patient was a potential “flight risk... Everything happened so fast. It was right outside the window where I was documenting and I saw everything. There was a small scuffle and then the patient was tased. When asked why the patient was placed in restraints, Staff-R hesitated, then stated he felt “the whole thing just snowballed.” He thought at the time something else must have happened such as an assault or attempted assault on staff and that was the reason for the restraints. The review of the “Use of Force Report” on 1/27/2026 at 1450 from 10/22/2025 indicated that the encounter between P-1 and security began at 20:18 and ended at 20:28. The report stated that the Security Sergeant Staff-I “applied a dry stun lasting 0.525 seconds to the patient’s right toros area ...The patient was medically assessed and transferred without further assistance.” Under section “VII. Injuries/Medical Review” the injury was described as “Localized redness at dry stun site; no further injury.” A review of the “Security Department Taser Deployment Policy” effective 2/2/5/2025, states, “Tasers shall only be used by trained and authorized hospital security personnel in situations where the use of force is necessary to prevent serious harm. The use of Tasers must comply with all applicable federal, state, and local laws, and must prioritize the safety and well-being of all individuals on hospital premises. When feasible, security personnel must attempt verbal de-escalation techniques before deploying a Taser.” The policy states also under “4. Medical Evaluation and Care that o All individuals subjected to a Taser deployment shall be evaluated by medical personnel immediately. o If probes are embedded in sensitive areas (face, neck, groin, or breast), removal must only be performed by medical personnel. o Subjects shall be monitored for signs of medical distress and transported to the Emergency Department if required.” The policy did not include any guidance for when a Taser should be used. Facility policy “Rules of Engagement & Use of Force,” approved on 04/01/2025, states, “It ensures that all security personnel understand when and how to respond to threats involving patients, visitors, and other individuals on hospital property. The policy prioritizes verbal de-escalation and outlines circumstances under which physical force may be used, following nationally recognized standards and healthcare security best practices...” It also states under “Flight Risk Patients” that “Patients under legal holds or emergency mental health detention (e.g., involuntary psychiatric admissions) who attempt to leave peacefully shall not be physically restrained. o Security shall not engage beyond verbal redirection. o The Muskegon Police Department will be notified immediately, and all available identifying and situational information will be shared with law enforcement. If such individuals attempt to flee violently or unpredictably, posing a clear risk to themselves or others, proportional force may be used to prevent eloping in line with this policy.” There was no involvement of local police following the Taser electricity discharge.”

“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 follow hospital policy regarding restraint for 1 (P-1) of 3 patients reviewed for restraint resulting in the loss of patient rights and the potential for poor patient outcomes. Findings include: Review of the provider notes dated 10/22/2025 for P-1 revealed he was a 30-year-old male who was placed in violent 4-point restraints on 10/22/2025 at approximately 2020 after he had been tased by security. Review of restraint documentation revealed there was no initiation or discontinuation times and no monitoring of the patient while in restraint. On 1/27/2026 at 1005, Registered Nurse (RN) Staff O stated when P-1 was moved into his care, P-1 was already in restraint. At the time, there was no order for restraint. He stated he and Charge Nurse Staff EE went in to speak with the patient and they took P-1 out of restraint. When queried as to why he didn’t chart P-1 was in restraint upon transfer to his care or when the restraints were removed, Staff O stated, “There was no charting of restraint because there was no order for restraint.” Charge Nurse Staff EE was unavailable for interview. Attempts were made to identify who was responsible for documenting restraint application, but were unsuccessful. Facility policy titled Restraint (Non-violent and Violent)” last revised 9/2025 states, “The RN shall complete the initial assessment upon initiation of restraints... For violent or self-destructive behavior, patients need to be monitored continuously. This is required regardless of the number of limbs restrained (2,3, or 4), the type of limb restraint (soft or locked*) or the patient’s location (inpatient versus ED). All elements on the Restraints (violent) Flow Sheet must be completed when the restraints are initiation [sic] and for all subsequent reassessments until discontinuation... Documentation requirements upon Initiation of restraint-completed by RN. Patient Behaviors leading up to restraint application... Restraint Education ... Apply Care Plan template appropriate to the intervention Initiate Restraints (Work List task) Restraint Order; Assessment; Justification; Restraint Monitoring; Restraint Monitoring Care; Restraint Type Documentation requirements every 15 minutes-completed by either RN, LPN [licensed practical nurse], PCT [patient care technician], or other clinician with Basic Life Support (BLS) certification Restraint Monitoring Psychosocial Status; Physical Comfort; Circulation; Continuous Observation Documentation requirements every 2 hours-completed by RN, or LPN. Clinical Justification; Restraint Monitoring Psychosocial Status; Physical Comfort; Circulation; Continuous Observation Restraint Monitoring Care Range of Motion; Fluids; Food/Meal; Elimination Restraint Type... Monitoring and reassessment may permit the early termination of restraint. The RN may release restraint before the time limit based on reassessment. Restraints are discontinued when the patient can cooperate, is no longer a harm risk to self or others, is no longer interfering with the treatment sites, can ambulate safely without assistance or request assistance. Document discontinuation of restraints and rationale.””

“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: 36887 Based on interview and record review, the facility failed to conduct a face-to-face assessment within one hour of initiation of restraint for 3 (P-1, P-3, P-4) of 3 patients reviewed for restraint resulting in the loss of patient rights and the potential for unidentified, unmet patient needs and poor patient outcomes. Findings include: Review of the medical record for P-1 revealed he was a 30-year-old male brought to the Emergency Department (ED) on 10/22/2025 at 1210 by police for a psychological evaluation. Review of restraint documentation revealed orders for violent 4 point restraints at 2040. There was no documentation for when the restraints were initiated. The face-to-face assessment was done 10/22/2025 at 2010. On 1/27/2026 at 1400, review of the security report dated 10/31/2025 which detailed the events leading up to P-1’s restraint on 10/22/2025 revealed P-1 was placed into restraint at sometime after 20:19:56. During interview on 1/27/2026 at 1442, Physician Staff R confirmed the time of the face-to-face assessment as 2010 and stated confusion as to why he had done it that way. Review of the medical record for P-3 revealed he was placed into 4-point violent restraints on 1/23/2026 at 1650. The face-to-face assessment was done 1/23/2026 at 1650. Review of the medical record for P-4 revealed he was placed into 4-point violent restraints on 1/22/2026 at 0830. The face-to-face assessment was done 1/22/2025 at 0827. Facility policy titled “Restraint (Non-violent and Violent)” last revised 9/2025 states, “For violent or self-destructive behavior, a face-to-face evaluation between the physician/LIP [licensed independent practitioner] and the patient will need to occur within one hour after the initiation of the restraint.””

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to provide written notice of grievance investigation and closure for 1 (P-13) of 3 patients reviewed for complaints and grievances resulting in the loss of the patient’s right to the grievance process. Findings include: On 7/28/2025 at 1330, review of the Complaint and Grievance Log for the past six months revealed an entry for P-13 regarding his care. On 7/29/2025 at 1049, the complaint regarding P-13 was reviewed with Patient Relations Staff CC who stated the patient’s daughter had emailed the complaint to the chief nursing officer regarding provision of care, call light availability, and concerns regarding a potential bedsore being “dismissed.” On 7/29/2025 at 1049, Staff CC was asked to provide letters of acknowledgement and closure. Staff CC stated the facility had identified this as a complaint, so no letters had been sent. When queried as to the difference between a complaint and grievance, she stated a complaint was if the patient was an inpatient and it was resolved before discharge. A grievance was anything needing follow-up or in writing. Facility policy titled “Patient Complaint and Grievance Policy” last revised 10/28/2024 states, “DEFINITIONS Complaint: 1. A verbal expression of dissatisfaction with patient care or service made by a patient or patient’s representative during the time of service that can be resolved at the time by staff present. 2. A verbal communication received after the time of service that could have been handled by staff present if communication had occurred at that time or is resolved to the patient’s satisfaction at the time of initial contact. *Becomes a grievance if patient is requesting follow up or if not resolved to their satisfaction. Grievance: A complaint is considered a grievance when it meets one of the following criteria: 1. A verbal complaint that is not resolvable by staff present at the time the complaint is made because it requires further investigation, and/or actions for resolution. 2. A verbal complaint made after the time of service when patient requests follow up. 3. Any written expression of dissatisfaction by a patient or patient’s representative, directed to this organization. This may include a written letter, email, fax, letter attached to a satisfaction survey or a survey comment requesting a resolution...””

“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 orders for violent/behavioral restraint for 1 (P-7) of 4 patients reviewed for violent restraint resulting in the loss of patient rights. Findings include: Review of the medical record for P-7 revealed he was a 34-year-old male who presented to the Emergency Department (ED) on 7/10/2025 with altered mental status and polysubstance abuse. Review of physician orders revealed orders on 7/10/2025 at 0313 for 4-point locking restraints continuously for 4 hours due to P-7 being a danger to himself and others. P-7 was placed in restraint at 0321. Restraints were released one limb at a time until the release of the left wrist at 0918. On 7/29/2025 at 1451, Staff A confirmed there were no renewal orders present for P-7. Facility policy titled “Restraint (Non-violent and Violent)” last revised 2/2025 states, “A physician/LIP (Licensed Independent Practitioner) restraint order to manage a patient’s violent or self-destructive behavior must be renewed on the following scheduled (sic): i. Adults 18 and older: every four (4) hours...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) [Unless superseded by State law that is more restrictive,] (iii) Each order for restraint used to ensure the physical safety of the non-violent or non-self-destructive patient may be renewed as authorized by hospital policy. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to renew orders for non-violent/non-destructive behavior restraint for 1 (P-5) of 2 patients reviewed for non-violent restraint resulting in the loss of patient rights. Findings include: Review of the medical record for P-5 revealed she was a 70-year-old female who was admitted for acute on chronic exacerbation of severe COPD (chronic obstructive pulmonary disease) on 7/16/2025. Review of restraints revealed orders were placed on 7/17/2025 at 0319 for bilateral soft wrist restraints. The order was updated 7/17/2025 at 1330 for 4-point soft restraints. No order for renewal was present on 7/18/2025 until 2018. On 7/29/2025 at 1405, Staff A confirmed there was no renewal order for restraints on 7/18/2025 until 2018 and that it should have been ordered earlier. Facility policy titled “Restraint (Non-violent and Violent)” last revised 2/2025 states, “Non-violent, non-destructive restraint orders will need to be renewed every 24 hours after an evaluation of the patient by a physician/LIP (Licensed Independent Practitioner).””

“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: 28042 Based on interview and record review, the facility failed to assess discharge needs and ensure discharge to a safe environment for one (P-1) of 10 vulnerable Emergency Department patients reviewed for discharge planning, resulting in a poor outcome for P-1 and the potential for poor outcomes for all patients discharged from the emergency department. Findings include: A - 0800 Failure to follow discharge process.”

“DISCHARGE PLANNING - EARLY IDENTIFICATION CFR(s): 482.43(a) The hospital’s discharge planning process must identify at an early stage of hospitalization those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient’s representative, or patient’s physician. This Standard is not met as evidenced by: 28042 Based on interview and record review, the facility failed to accurately assess discharge needs for one (P-1) vulnerable Emergency Department (ED) patient out of total sample of 10 patients reviewed for discharge planning, resulting in the facility’s failure to identify the correct discharge location for P-1 and the potential for harm. Findings include: On 07/18/2024 at 1200, review of medical record for P-1 revealed she was a 71-year-old female who presented to the emergency department via ambulance at 1529 on 05/28/2024. Her chief complaint is documented as black or bloody stool. Providers note documented active problem list to include altered mental status, superficial thrombophlebitis (inflammation in a vein caused by a blood clot) left upper extremity, chronic hypoxic respiratory failure, spinal stenosis of lumbar region with neurogenic claudication (narrowing of space around lower spine, putting pressure on spinal cord and can compress blood vessels around spine causing weakness, numbness, tingling in feet and legs and loss of bowel/bladder control), vulvar ulceration, paresthesia (numbness) both feet, wound left buttock, rectal bleeding, urinary incontinence, and cognitive impairment. P-1 resided at a skilled nursing facility, used a Hoyer lift and was unable to stand at all. P-1’s baseline oxygen of 2 liters (L), alert and oriented x2, not to situation or place. Physical exam documented P-1 to be chronically ill in appearance, irregularly irregular heart rate, 2-3+ significant pitting edema to bilateral lower extremities, alert and oriented to self only. P-1 received treatment for a urinary tract infection. She continued to complain of rectal pain which the provider documented was due to chronic wounds and skin breakdown she had from laying and wearing a diaper. The note indicated P-1 lived in a skilled nursing facility and was stable to be discharged back to home. Supervising physician note dated 05/28/2024 indicated P-1 was stable and to be discharged back to the nursing home with a prescription for Macrobid. Review of nursing note for ED visit #1 dated 05/29/2024 at 0159 indicated report called to RN (name listed) at the skilled nursing facility. The note documented that P-1 did not live at her previous apartment. Emergency Department (ED) visit #2 05/29/2024: Provider note dated 05/29/2024 at 1525 indicated P-1 is a 71-year-old female who was a poor historian and does not appear to have capacity to make her own decisions. P-1 was currently residing at a subacute rehab (SAR) and on 05/28/2024 had an appointment with a physician where there was concern for possible GI bleed and was sent to the ED. P-1 was evaluated, found to have a UTI and was discharged back to the SAR. The provider note documented that P-1 was taken back to her apartment and placed on an air mattress which was on the floor. Provider note indicated P-1 had a signed document as of 5/22/2024 by a physician and psychologist that stated that she did not have capacity to make her own decisions. On 05/29/2024 there was concern when the P-1 did not return to the subacute rehab so the police, Emergency Medical Services (EMS) and fire department were contacted to do a well check. They did find her where EMS left her last night (05/28/2024) on her air mattress. They brought her to the emergency department for evaluation. Providers note at 1652 revealed provider was made aware of this patient by social work, who received a phone call from P-1’s power of attorney discussing the concerns with admitting labs and the mix up with transporting the patient back to her apartment instead of the subacute rehab last night. RN triage note for ED visit #2 dated 05/29/2024 at 1541 revealed P-1 arrived via EMS from home after being found on the ground, “presumably there all night”. P-1 was seen in this ED yesterday and diagnosed with urinary tract infection. P-1 was discharged home to her apartment when pt had been living at a subacute rehab facility. After EMS dropped P-1 off “last night” pt slid on to the ground from her bed to pick something up and was unable to get up. Family friend called 911 to go check on P-1. Reports back/butt pain from being on the ground throughout the night. Patient demographic information and certification of medical necessity for transport for the ED visit of 05/28/2024 for P-1 was provided to the surveyor by Staff A on 07/18/2024 at 1340. Review of the patient demographic information for P-1 revealed her address to be her previous apartment and not the skilled nursing facility where she was currently living. Review of the certificate of medical necessity form revealed “destination” was documented as the address of her previous apartment and not the skilled nursing facility. In an interview on 07/18/2024 at 1230, Staff J (Experience of Care) stated a grievance was received on 05/29/2024 from the friend of P-1. She was concerned about how P-1 was taken to her old apartment instead of back to the subacute nursing home where she was living when she was discharged from the emergency department. Staff J stated the ambulance service is owned by the hospital, so she reached out to the manager of the EMS service, who told her they take the patients where they are told to take them. Staff J stated the ED Manager investigated and found the hospital had P-1’s old address in their system and had not updated her information with her new subacute facility address as her new address. Because the ambulance service is owned by the hospital, the information on their transfer forms comes directly from P-1’s medical records, which was her old address. Staff J stated they determined the mix up happened due to P-1’s address not being updated in their system, and when P-1 was returned to her apartment, she wanted to stay there and not return to the subacute rehab. Staff J said P-1 was her own decision maker, so she was allowed to stay in her apartment. In an interview on 07/18/2024 at 1430, Staff K (Director of EMS (Emergency Medical Services) stated the ambulance staff took P-1 back to her apartment, which is where P-1 requested to go and where the transfer paperwork listed as the destination. When queried as to whether his expectation for leaving P-1 on an air mattress on the floor of her apartment, when she was not able to stand or move was a safe situation, Staff J stated no, that was not a safe way to leave P-1. In an interview on 07/18/2024 at 1350, Staff F stated she did not have any involvement with P-1 until her second visit to the emergency department on 05/29/2024 when her advocate/power of attorney called with concerns about how P-1 ended up at her apartment instead of the subacute rehab facility where she had been for quite some time. Staff F said she did not know how that happened, and the hospital did not obtain the documents that P-1 wasn’t her own decision maker until her second ED visit on 05/29/2024. Review of facility Utilization Management Process, Annual Plan dated “2023”, revealed V. Discharge Planning (42 CFR 482.43) The purpose of Discharge Planning is to ensure the gains achieve from hospitalization can be maintained following hospital transition thus promoting optimal patient outcomes. The inter professional team that includes the physician, registered nurse, care manager, and social worker, together with other members of the health care team shall assess each patient ’ s unique actual and potential transition planning needs, collaborate with the patient/pt. Representative create transition planning goals and develop a plan to meet identified needs/goals.”

“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: 48030 Based on document review and interview, the facility failed to ensure that a physician performed a face to face assessment within one hour of the initiation of a physical restraint for 2 (P-10, P-11) of 2 patients reviewed for behavioral (violent) restraints resulting in the potential for violation of patient rights and the potential for adverse patient outcomes. Findings include: On 4/17/2024 at 1253, P-10’s medical record was reviewed, and the patient was found to have been placed in behavior restraints on 1/2/2024 at 1648. The one-hour face to face assessment was not found to have been completed. On 4/17/2024 at 1545, P-11’s medical record was reviewed, and the patient was found to have been placed in behavioral restraints and a one hour face-to-face assessment was not found to have been completed Staff Q was queried on 4/17/2024 at 1555 whether a face-to face was documented for P-10 or P-11 and he responded that “after reviewing the medical record” the face-to-face was not documented. Staff Q was further queried as to when the physician assessment was to be performed with behavioral restraints to which he replied, “The assessment should be done within an hour.” Facility policy titled “Restraints Use (Violent and Non-Violent) and Seclusion”, Version 2, effective 3/5/2024 was reviewed on 4/17/20 at 1600. Physicial Face-to-Face Assessment, page 9 states, “Within 1 hour of initiation of violent restraint, or within 24 hours of initiation of non-violent restraint, the physician will perform a face-to-face clinical assessment of the patient.” and “The clinical assessment will be documented in the medical record”.”