Munson Medical Center

“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: 27408 Based on record review and interview, it was determined that the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to initiate the triage process in a timely manner for 2 (P-1, 2) of 20 patients reviewed, resulting in the potential for poor patient outcomes. Findings include: See Tag A-2406: Failure to provide timely triage and medical screening examination”

“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: 27408 Based on interview and record review, the facility failed to initiate the triage process in a timely manner for 2 of 20 patients (P-1 and P-2) who presented to the Emergency Department (ED), resulting in delayed treatment and the potential for negative outcomes. Findings include: On 03/24/25 at 1300, during record review the following was noted for P-1: P-1 was a 65-year-old female with the history of metastatic stage 5 breast cancer. The patient also had a history of hyponatremia. For the past several days the patient had increased confusion, and she was so weak, she could not get up to go to the bathroom. She had been increasingly fatigued, with no urine output in the last 24 hours. She had not been eating and did not consume any type of fluids in the last 2 days. The patient denied any type of fevers, chills or coughing, but she does have chronic nausea. She is also on home oxygen at 3 liters per nasal cannula. On 03/25/25 at 1200, during review of the document titled “Patient Care Record” (EMS Run sheet) page 1 of 4, revealed: Patient Arrived at Destination (Date /Time):2025-02-16 at 20:56:14 Destination Patient Transfer (Date/Time): 2025-02-16 at 22:05:00 Review of document titled EMS Patient Care Report revealed, “Patient wanted to be transported to (the facility in question)... Delayed patient turnover due to (the facility of concern) being unable to accept the patient. Patient was taken to room and transferred to bed. Report given to nurse in charge of patient care.” Once the patient was triaged, she received an “Emergency Severity Index (ESI)” score of “2” High Risk, Potentially Unstable)”. On 03/24/25 at 1210, during an interview with Staff E, it was confirmed that the patient who came in by EMS was not triaged after arrival for 1 hour and 4 minutes. P-2 On 3/24/25 at 1400, during review of the medical record for patient #2 (P-2), it was noted that he was a 75-year-old male who was shoveling snow when he developed substernal chest pressure. He stated it lasted 60 to 120 minutes in duration before dissolving. His chest pain did not radiate from his chest. He denied any numbness, tingling, nausea, vomiting, lightheadedness, fever, chills or palpitations. On 03/25/25 at 1200 during review of the document titled “Patient Care Record” (EMS Run sheet) page 1 of 4, revealed: Patient Arrived at Destination (Date /Time):2025-02-16 at 2115 Destination Patient Transfer (Date/Time): 2025-02-16 at 2145 Once the patient was triaged, he received an “Emergency Severity Index (ESI)” score of “2” High Risk, Potentially Unstable)”. On 03/24/25 at 1210, during an interview with Staff E, it was confirmed that the patient who came in by EMS was not triaged after arrival for 30 minutes. On 03/24/25 at 1400, review of facility’s policy titled “(Facility Name) Healthcare EMTALA/Physician on Call Policy”, policy #15194754, last revised 8/14/2024 revealed: A. Hospital shall comply with emergency care obligations imposed by the Emergency Medical Treatment and Labor Act (EMTALA). These obligations include the following: #1. Medical Screening Examination: If a person comes to the hospital and a request is made...for their examination or treatment for a medical condition...then qualified medical personnel will, within hospital’s capability and capacity, conduct and document an appropriate medical screening examination reasonably calculated to identify an emergency medical condition... #8. “No Delay in Examination or Treatment. The hospital will not delay the emergency care described above to inquire about the individual’s method of payment or insurance status. Reasonable registration processes may be followed including asking for insurance information if they do not delay or discourage the person from receiving the emergency care described above. Preauthorization will not be sought from insurers or primary care physicians before providing the examination and, where necessary, initiating stabilizing treatment as described above.””

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 29955 Based on interview and record review, the facility failed to ensure nursing staff followed the individualized plan of care for 1 (P-24) of 30 patients reviewed, resulting in the patient acquiring a pressure sore. Findings include: A record review of P-24’s medical record on 12/11/2024 at 1215 revealed P-24 was admitted to the facility on 10/30/2024 and underwent emergent coronary artery bypass the same day. Records revealed the patient was intubated, sedated, and on strict bedrest with restrictions of turning from 10/30/2024 at 2000 to 10/31/2024 at 0400. P-24 was intubated from 10/30/2024 to 11/10/2024. P-24 activity level was noted to be complete bedrest until 11/10/2024. P-24 medical record revealed three new wounds documented on 11/2/2024 at 2005, “...right groin, scrotum, and buttock. The “buttock” wound was documented as “unable to visualize, dressing dry/intact, foam.” No documentation could be located for identification, description, or interventions of the “buttock” wound prior to 11/2/2024 at 2005. On 12/11/2024 at 1225 a review of P-24 “Plan of Care” revealed a “skin plan” was initiated on 10/31/2024 at 1500. On 11/4/2024 at 1354 a note from the Wound Ostomy Care Nurse, staff JJ revealed, “On 11/4/2024 at 1351 P-24 was evaluated by the staff JJ, WOCN (Wound Ostomy Continence Nurse) nurse. The note revealed, “Location: Coccyx, Type: DTI (deep tissue injury) open, with associated friction shear, Wound base: 25% purple, nonblanchable, 75% pink/moist, Periwound: friction shear, dry, Drainage (color/amount): scant, serous, Undermining/Tunneling: none, Photo: 11/4/24.” The documentation further described, “Dressing: Triad Cream, Frequency: TID & PRN, Present on Admission: no, Hospital Acquired: yes, Recommend frequent repositioning, wedge provided for this. Prafo boot in use. Toes discolored - left open to air.” Documentation continued, “Pt is ventilated, seen with RN. Ecchymosis/discolorations noted on backside. On 11/6/2024 at 2000 P-24 care plan documentation included, “Encourage self-repositioning” although P-24 remained sedated, intubated, and on continuous renal replacement therapy (dialysis). On 10/30/2024 at 1808 an order was placed to “Turn Patient, once stable side to side, q2h (every 2 hours)” and was marked as completed on 11/22/2024 at 0935. On 12/11/2024 at 1215 a record review occurred of P-24’s medical record and revealed under the subtitle “Position Documentation” P-24 was not repositioned on 10/31 at 1500 to 11/1 at 0800 (14 hours). Further record review revealed the following time lapses in documentation for repositioning for P-24: 11/9/2024 0746 to 2000 (8 hours) 11/9/2024 2000 to 11/10/2024 0400 (8 hours) 11/10/2024 0400 to 1000 (6 hours) 11/10/2024 1000 to 1400 (4 hours) 11/14/2024 2200 and 11/15/2024 0000 - patient remained in same position per footnotes T705 and T706 11/18/2024 1000 to 1700 (7 hours) 11/19/2024 from 0000 to 0400 (4 hours). 11/19/2024 2000 to 11/20/2024 0514 (9 hours). 11/21/2024 0800 to 11/21/2024 1230 (4.5 hours) 11/21/2024 2000 to 11/22/2024 0800 (12 hours) 11/23/2024 0600 to 11/24/2024 2100 (41 hours) 11/24/2024 2100 to 11/25/2024 0354 (7 hours ) 11/25/2024 0354 to 11/25/2024 0800 (4 hours) 11/25/2024 0800 to 11/25/2024 2000 (12 hours) 11/25/2024 2300 to 11/26/2024 0800 (9 hours) 11/26/2024 0800 to 11/26/2024 2011 (12 hours) 11/27/2024 1200 to 11/27/1800 (6 hours) 11/28/2024 0000 to 11/28/2024 0520 (5 hours) 11/28/2024 0520 to 11/28/2024 1945 (14 hours) 11/28/2024 1945 to 11/29/2024 0200 (6 hours) 11/29/2024 0200 to 11/29/2024 1500 (13 hours) 11/29/2024 1500 to 11/29/2024 2100 (6 hours) 11/29/2024 2100 to 12/1/2024 0346 (6.5 hours) 12/1/2024 0346 to 12/1/2024 2000, (16 hours) 12/2/2024 0600 to 12/2/2024 2100 (15 hours) 12/3/2024 0500 to 12/3/2024 2000 (15 hours) 12/3/2024 2100 to 12/4/2024 0300 (6 hours) 12/5/2024 0245 to 12/6/2024 0903 (6 hours) Record review revealed the patient was not turned as recommended and as ordered. On 12/11/2025 at 1230 during an interview with staff C, it was confirmed P-24 was not turned as ordered. According to the policy titled, “Inpatient Skin Assessment and Intervention Guidelines,” dated 3/16/2021, policy ID#15415942, under “Assessment Standards, the following is documented, “F. Major Risk Factors for Pressure Injury/Skin Breakdown: 1. Anticipated bedrest for over 24 hours 2. Vasopressor therapy 3. Sepsis or suspected sepsis 4. Mechanical ventilation 5. Compromised nutrition (low serum albumin) 6. Restraints 7. Dialysis 8. Procedures lasting 3 hours or more 9. Compromised tissue viability (severe bruising, edema, vascular deficiency, high doses of steroids, anticoagulation) 10. History of pressure injures 11. Other risk factors per nursing judgement.” The guidelines continue with, “When risk areas are identified, select individualized interventions to meet patient skin outcome goals. The plan of care shall be based on the specific areas of risk, as well as the total risk assessment score,” and “H. When risk areas are identified, select individualized interventions to meet patient skin outcome goals. The plan of care shall be based on the specific areas of risk, as well as the total risk assessment score...I. Refer to Appendix A: Braden Risk Assessment and Nursing Interventions for specific interventions that can be incorporated into the plan of care.” Review of “Appendix A: Braden Risk Assessment and Nursing Interventions,” dated 6/25/2020, occurred on 12/11/2025 at 1310. Under the subtitle, “Braden Subscale: Sensory Perception...Nursing Interventions,” the following is documented, “Establish turning / repositioning schedule (timing based on patient ’ s needs). Minimally q2hrs (every 2 hours) while in bed and q1hr while in chair.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 28042 Based on observation, interview and record review, the facility failed to honor a patient’s code status for one of one patients (P-1), failed to provide care to 2 of 4 patients (P-3 and P-11), and failed to protect patient rights for 2 of 4 patients (P-2 and P-11) reviewed for restraints, from a total of sample of 14, placing all 346 current inpatients at risk for the loss of their rights and the potential for poor outcomes up to death. Findings include: A-132: Failure to honor code status. A-145: Failure to ensure patients were free from neglect. A-167: Failure to ensure that an order for a physical restraint was written per the facility policy. A-171: Failure to obtain a new physician order after four hours for renewal of four-point violent restraints. A-179: Failure to document physician’s face to face assessments within one hour for patients in violent restraints.”

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 29955 Based on interview and record review the facility failed to comply with one of one patients (P-1) code status resulting in the potential for poor patient outcomes including death. Findings include: Document review of P-1 revealed she was a 83 year old woman admitted on 11/5/2023 for a fractured femur. The patient was a DNR/DNI on admission. However, P-1’s code status was changed to a full code on 11/5/2024 for surgery. P-1 underwent surgery on 11/6/2023 at 0920 for “open treatment of left intertrochanteric femur fracture with intramedullary implant.” According to the progress note on 11/6/2023 at 1352 by staff T, Anesthesiologist, “Patient (P-1) did reasonably well in OR (Operating Room) requiring three 100 mcg doses of phenylephrine. However, first blood pressure upon PACU (Post-Anesthesia Care Unit) arrival was systolic in 50’s with little response to escalating doses of phenylephrine, ephedrine, vasopressin, and levophed. (Staff I) from cardiology arranged a stat echo (echocardiogram) which showed some poor lateral wall motion, no indication of a PE (pulmonary embolism), and he arranged for a STEMI (ST elevation Myocardial Infarction) protocol. (Staff L, Orthopedic Surgeon) was able initially to reach her daughter who supported full resuscitation measures, and subsequently her husband who supported taking her to the Cath (catheterization) lab (she was a DNR/DNI - do not resuscitate / do not intubate patient who chose full code in OR in our preop discussion). She passed away on the elevator ride to A6 (Cardiac Catheterization Lab location).” On 5/9/2024 at 1215 an interview was conducted with staff I, Cardiologist for P-1. A review of the events on 11/6/2023 occurred with staff I. Staff I was queried if P-1 had been coded during transport to the Cath Lab when the patient went asystole. Staff I stated, “No ...there was nothing further that we could do for the patient.” On 5/9/2024 at 1330 an interview was conducted with staff R, PACU RN. Staff R was queried if she cared for P-1 on 11/06/2023. Staff R stated, “Yes ...I was her nurse in the PACU....” Staff R stated, “I know she had switched her code status to full code in order to have the surgery ... She was a full code in the PACU.” On 5/9/2024 at 1345 an interview was conducted with staff S, PACU nurse tech for P-1 on 11/06/2023. Staff S stated, “A Cath Lab nurse was actually in the bed with the patient (P-1) ...the elevator doors opened and as soon as we got the bed in the elevator the patient flat lined (Asystole is also known as flatline. It is a state of cardiac standstill with no cardiac output and no ventricular depolarization, it eventually occurs in all dying patients.)” Staff S was asked if any CPR (Cardiac Pulmonary Resuscitation) took place when the patient flat lined.” Staff S stated, “No ...the doctor said she was dead and not to do anything more.” On 5/9/2024 a document review occurred of the policy titled, “Resuscitation Policy: Code Status in a Hospital Setting,” policy number 14051291, effective date 10/24/2023. According to the policy it states under subtitle, ‘Code Status Order per Patient Population,’ ‘Adult, A. 1. Full: In the event of cardiac arrest or severe respiratory failure, CPR will be attempted and endotracheal intubation with mechanical ventilation will be performed. a. Staff should initiate a CODE BLUE in the event of cardiopulmonary arrest per ACLS (Advanced Cardiovascular Life Support).’””

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 28042 Based on interview and record review, the facility failed to ensure patients were free from neglect for two (P-3 and P-11) of 4 patients reviewed for patient rights from a total of 14 patients, resulting in potential for poor outcomes . Findings include: Review of P-11’s medical record on 05/09/2024 at 0930 revealed he was a 58-year-old man who presented on 02/05/24 with dizziness. Review of radiographs for P-11 demonstrated a CT (cat scan) of head was negative for acute process. Review of discharge summary dated 02/28/2024 for P-11 indicated P-11 was a 58-year-old male with history including bipolar, hypertension, diabetes, who originally presented with complaints of dizziness and a fall on 2/5/2024, eventually noted to have central cervical stenosis and expired on 02/18/2024. He was taken for multilevel anterior cervical discectomy and decompression on 2/13/2024. The discharge summary indicated psychiatry was consulted for P-11’s bipolar disorder as he was having increased mania symptoms and episodes of intermittent agitation. The note indicated on 2/15/2024 P-11 had a “code gray” and was placed in 4-point twice as tough restraints (hard locking), with psychiatric medication changes made. On 2/18/2024, P-11 was found unresponsive with no pulse. On cardio-respiratory resuscitation, he was noted to have copious amount of frothy tan secretions in his respiratory tract, making it difficult to use assistive breathing device. P-11 received 20 minutes of ACLS resuscitation prior to ROSC (return of spontaneous circulation) and was transferred to the ICU. The discharge summary documented that P-11 had two subsequent cardiac arrests and per discussion with family, decision was made to change code status to DNR (do not resuscitate). P-11 passed on full mechanical ventilatory support with vasopressors active. Review of physician orders for P-11 revealed violent restraint order dated 02/15/2024 at 1521 for 4 point twice as tough. Comment: Every 4 hours a provider must decide whether to discontinue or reorder “Restraints Violent.” Physician orders for P-11 revealed system discontinued violent restraint order dated 02/16/2024 at 0726 and new violent restraint order dated 02/16/2024 at 0726 for 4 point twice as tough. Comment: Every 4 hours a provider must decide whether to discontinue or reorder “Restraints Violent.” Physician orders for P-11 revealed system discontinued violent restraint order dated 02/17/2024 at 0802 and new violent restraint order dated 02/17/2024 at 0802 for 4 point twice as tough. Comment: Every 4 hours a provider must decide whether to discontinue or reorder “Restraints Violent.” Physician orders for P-11 revealed new violent restraint order dated 02/17/2024 at 1129 for 4 point twice as tough. Comment: Every 4 hours a provider must decide whether to discontinue or reorder “Restraints Violent.” Physician orders for P-11 revealed new non-violent restraint order dated 02/17/2024 at 1710 for 4-point soft restraints, with cancellation order on 02/17/2024 at 1934. Speech therapy note dated 02/15/2024 at 1109 indicated P-11 unable to tolerate mildly nectar thickened liquid or moist pureed consistency. His cough was strong, productive. P-11 appeared to be producing mass amounts of clear secretions into emesis bag, likely secondary suspected prevertebral swelling. The note recommended NPO, medications via IV, ice chips sparingly after oral care, may need to consider NG (nasogastric) tube placement for nutrition. The note indicated provider and patient aware and in agreement with plan. Speech therapy note dated 02/16/2024 indicated P-11 continued to be in 4-point restraints. Attempted a swallow eval with patient in restraints may cause an increase in anxiety/aggravation at that time. RN to page Speech Therapy if eval became appropriate. Physical Therapy noted dated 02/16/2024 documented per RN, hold PT. P-11 is in 4-point restraints. Psychiatric consult note dated 02/16/2024 at 0819 documented P-11 is acutely confused with abrupt onset. The note indicated high likelihood that current symptoms are a result of delirium rather than underlying psychiatric disorder. The note indicated treatment of delirium including identification and treatment of underlying medical/neurological causes as well as supportive care and allow time for cognition to clear. The progress note recommended continued re-orientation, promotion of good sleep/wake cycles, optimizing pain management strategies, ensuring good nutrition/hydration, encouraging use of sensory aids when needed, and fostering physical therapy/early mobilization when appropriate. The provider documented to attempt to get out of restraints as soon as it is deemed safe. Routine labs had not been done since 2/12/2024, consider checking again that day, 02/16/2024 along with EKG (electrocardiogram). The consulting provider note indicated starting Zyprexa 5 mg BID, particularly when P-11 was not able to take the PO Tegretol due to NPO status. If swallowing deemed unsafe even for zydis formulation, switch to IV (intravenous route). The note indicated Zyprexa would be helpful for both underlying bipolar symptoms as well as agitation associated with current delirium. Once P-11’s delirium improved, the note indicated to taper off the Zyprexa and maintain on Tegretol monotherapy. Due to lack of suicidal ideation the provider discontinued safety companion/suicide precautions. Neurosurgery Progress note dated 02/16/2024 at 1036 indicated physical exam: drowsy, pleasant, in 4-point restraints. Plan: Dysphagia post-op likely to improve. Continue mobilizing with nursing staff and physical therapy, goal to ambulate at least once daily. Okay to remove collar for meals and showering. Hospitalist (Staff N) progress note dated 02/16/2024 at 1832 documented total intake of 0ml for 02/16/2024 with P-11 still in 4-point restraints. Hospitalist (Staff N) progress note dated 02/17/2024 at 0907 documented total intake of 0ml and total output 0ml for 02/17/2024 with P-11 still in 4-point restraints, with physical exam documented as calmer in 4-point twice as tuffs, not grimacing face or puling at restraints, lungs clear bilaterally, good air movement, and psych: good affect. Review of intake and output for P-11 revealed: 02/13/2024 to 02/14/2024: Intake total 947.92ml (milliliters) (IV fluids, IV antibiotics) Output total 800ml Urinary catheter 02/14/2024 to 02/15/2024: Intake total 1003.33ml (IV fluids, IV Antibiotics) Output total 1725ml Urine voided 02/15/2024 to 02/16/2024: Intake total 150ml (IF fluids, IV Antibiotics) Prior to restraint application; Output total 750ml Urine voided 02/16/2024 to 02/17/2024: Intake total 0ml; Output total 200ml Urine voided 02/17/2024 to 02/18/2024: Intake total 0ml; Output total 4ml Urine voided Review of nursing documentation for P-11 revealed nursing assessment and flushing of peripheral IV line on 2/15/2024, 02/16/2024 and 02/17/2024. Review of entire medical record with Staff A and Staff Q on 05/09/2024 at 0900 for documentation of care of P-11 while in restraints from 02/15/2024 at 1521 until discontinued on 02/17/2024 at 1934 revealed P-11 had an order for nothing by mouth (NPO) starting 02/15/2024. Review of the record revealed P-11 did not receive any IV fluids or nutrition during the time he was in restraints. The care documented in P-11’s records was oral care documented on 02/16/2024 at 0800, Oral swab on 02/17/2024 at 1452, Partial peri-care completed on 02/17/2024 at 0842, and partial linen change on 02/17/2024. Review of the record did reveal nursing documentation that the restraint was still needed every 15 minutes. However, review of the record for P-11, did not reveal any documented repositioning, circulation checks, release from the restraints at any time, range of motion, hygiene, labs to assess hydration or nutrition status while P-11 was NPO and in restraints. Review of vital signs for P-11 revealed on 02/15/2024 at 0558 temperature (T) 37.1, heart rate (HR) 106, respiratory rate (R) 20; on 02/15/2024 at 1515 T 37.4, HR 110, R 21; on 02/16/2024 at 2123, T 37.8, HR 118, R 18; on 02/17/2024 at 0938 T 37.3, HR 128, R 19; on 02/17/2024 at 1428 T 37.9, HR 127, R 18; on 02/17/2024 at 2133 T 37.1 HR 133, R 20; on 02/18/2024 at 0649 T 37.1, HR 132, R 18; on 02/18/2024 at 1318 T 38, HR 132, R 32;on 02/18/2024 at 1323 HR 144; and on 02/18/2024 T 39.8. Review of documented weights for P-11 revealed his weight on 02/05/2024 at 1531 was 191.4 pounds. On 02/17/2024 at 0940 his documented weight was 149.6 pounds. Review of laboratory results for P-11 revealed on 2/12/2024 P-11 had a Sodium of 134, Potassium of 3.8, Magnesium of 1.9. On 02/18/2024, P-11’s labs were: sodium 149, potassium 3.0, magnesium 2.7, BUN 45, Creatinine 1.82 and AST 54. Hospital (Staff N) progress note dated 02/18/2024 at 1550 indicated code blue called for P-11 at 1407 for unresponsiveness. P-11 did not have pulse and was not breathing. P-11 was still in 4-point restraints and became unresponsive. CPR started immediately. ACLS medications given. P-11’s rhythm remained PEA with no pulse on repeated pulse checks. P-11 intubated by intensivist and continuously bagged by respiratory therapy. Suction after intubation revealed very thick mucous like material. The note indicated aspiration suspected to be cause of hypoxia leading to pulseless electrical activity. The progress note documented after approximately 15 minutes, return of spontaneous circulation was achieved and P-11 had an irregular wide-complex rhythm but was maintaining pulse. P-11 transferred to ICU, did briefly code again but spontaneous circulation was achieved. P-11’s care was transferred to intensivist service. Facility record of death for P-11 dated 2/18/2024 documented no autopsy was requested. In an interview on 05/09/2024 at 1243, Unit A7 RN Staff U confirmed they had taken care of P-1 during his 02/05/2024 admission and stated P-11 was hallucinating, spitting and kicking at staff. Staff U stated P-11 was in 4-point hard leather restraints and was not able to kick at staff while in restraints. P-11 was consistently calm on the last day in restraints. When queried as to whether P-11 was ever removed from his restraints for range of motion or repositioning, Staff U stated, “you would have to refer to my documentation.” When asked how P-11’s hydration was ensured, Staff U stated IV fluids. In an interview on 05/09/2024 at 1110, Staff X stated she was P-11’s nurse on night shift with P-11. and during the first two nights he was making statements about want to kill everyone and their family. On the third night, P-11 was calmer and let her suction him. Staff X stated P-11 had been having thick secretions that had required suctioning and he could not clear his airway. She had notified the provider and P-11 was on oxygen. Staff X said she was told P-11 was known to be violent and that was why on the third night he still could not come out of restraints even though he was more calm. When queried how she ensured hydration/nutrition status for P-11 with his NPO (nothing by mouth) status. Staff X status she used mouth swabs and would document if she did that. In an interview on 05/09/2024 at 1145, Staff O stated she was the nurse working when P-11 initially went into restraints. He charged security and was aggressive. P-11 was cooperative once he was in restraints. He made bizarre, delusional statements. Staff O stated when P-11 was in restraints he could not move his arms and legs, he had a saline lock which was working, but no fluids were ordered. In an interview on 05/09/2024 at 1345, Staff P stated he was the RN working with P-11 on 02/18/2024 when a nurse tech reported his oxygen levels were low. Staff P said he went in P-11’s room and observed his oxygen tubing out of place. When returned, his oxygen came up, but his heart rate dropped quickly. Staff P gave a sternal rub, but P-11 then coded at the same time a second nurse entered the room. CPR was initiated and code team responded. Staff P said P-11 had been full of mucous for 3-4 days, requiring suctioning and supplemental oxygen. The nurse in report had told him she had notified several providers. In an interview on 05/09/2024 at 1130, Staff N (Hospitalist) said he was the provider for P-11 during his stay. When queried if he had been the provider who wrote the orders for P-11’s violent restraints from 02/15/2024 through 02/17/204 and the non-violent 4-point restraints on 02/17/2024, Staff N answered yes. When the surveyor stated upon document review no face-to-face assessments could be located after violent restraint orders were initiated, Staff N stated none could be found because it wasn’t done. He said he wasn’t aware of that policy. When queried if he had been educated on the restraint policy during his credentialing process or annually, Staff O stated he may have been educated, but he forgot. When asked how he addressed P-11’s hydration or nutrition status while being NPO and in restraints, Staff O stated he would normally use IV fluids, but P-11 was too aggressive to risk having nursing staff go near him with needles to start an IV. Staff N stated P-11 was not safe to swallow pills, yet they were giving him oral Zyprexa, and nobody addressed that. When queried as to whether he addressed P-11 getting oral medication while being NPO, Staff N stated, “No, that would be a nursing thing.” Staff N stated he believed P-11 aspirated due to the large amount of thick secretions observed and removed during his code. On 05/09/2024 at 1410, Review of facility Policy, “Use of Physical Restraints: Ordering, Monitoring and Documentation Requirements”, dated 06/22/2022 revealed for Violent or Self-Destructive Patient, Section F. In addition, for the duration of the use of the restraint or seclusion, the patient must be assessed every fifteen minutes or more frequently by bedside caregivers for the following: signs of injury associated with restraint/seclusion, nutrition and hydration status, circulation and ROM, vital signs (as appropriate), hygiene and elimination, physical and psychologic status and comfort, readiness for discontinuation of restraint or seclusion. Documentation must occur in the patient’s electronic health record. Section, Discontinuing a Restraint, A. A restraint should be discontinued at the earliest possible time, regardless of the length of time identified in the order. On 05/09/2024 at 1440, review of facility Policy, “Patient Abuse and Neglect - Inpatient Services” dated 12/06/2021, revealed People have the right to be free from abuse, neglect, mistreatment, and misappropriation of their property. Definitions 1.e. Neglect: means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. There is a presumption that neglect has occurred whenever a facility or individual fails to provide a treatment or service to a patient which is necessary for a patient’s health or safety, and the failure to provide that treatment or service results in a deterioration of the resident’s physical, mental, or emotional condition. 29955 On 5/9/2024 a record review was conducted of the medical record of P-3. P-3 was seen at the facility Emergency Room on 4/25/2024. She was documented as, “a 48-year-old female who presents emergency room today with complaints of abdominal pain. Patient states that this has been ongoing for approximate 2 weeks. She has been recently seen and evaluated here in the emergency department for similar complaints and undergone laboratory studies along with CT (computed tomography) imaging. States that she is nauseous however not experiencing any vomiting she denies diarrhea. She states that her primary care provider has arranged for her to follow-up with the general surgeon, she states that she is on the schedule for evaluation anticipating having a an EGD (esophagogastroduodenoscopy - upper scope of esophagus and stomach) along with colonoscopy done. She denies any fevers or chills, dysuria, hematuria or any malodorous urine. Patient states that she is currently taking omeprazole along with Carafate as previously recommended.” P-3 reported 10 of 10 for pain. Abnormal findings for physical exam included, “Gastrointestinal: soft, non-distended, there is diffuse abdominal tenderness, no guarding no CVA tenderness percussion of the bilateral flanks.” Lab Results on 4/25/2024 for P-3 included the following abnormal results, “WBC 11.00, Neutrophils 8.41, Sodium 135.” Urinalysis abnormal results, “Protein in Urine, 50 mg/dl, Blood Large, WBC 6 (high), and RBC 51 (high).” On 5/9/2024 at 1210 an interview occurred with staff G, the Physician Assistant who cared for P-3 on 04/25/2024. Staff G was queried what the course of treatment was for P-3. Staff G stated, “You can read my notes ...it’s all in there.” Staff G was then queried what concerns P-3 presented with to the ED on 4/25/2024. Staff G stated P-3 presented with abdominal pain and nausea. Staff G was then asked what medications are commonly used to address pain and nausea. Staff G stated, “Antiemetics and pain medications ...It’s dependent on the patient.” Staff G was then asked if P-3 received anything other than normal saline during her stay. Staff G stated, “I told the patient to go back to the current plan she had with her physician.” Staff G was queried if a re-assessment of P-3 pain level was done prior to discharge. Staff G stated, “No ...that is not required.” On 5/9/2024 at 1300 an interview was conducted with staff E, the Nursing Manager for the ED. Staff E was queried about the re-assessment of a patient’s pain level prior to discharge. Staff E responded, “It is not a requirement to reassess a patient’s pain level prior to discharge from the ED ...the only requirement is to go over discharge instructions from the provider and document if the patient understands discharge instructions.” Based on record review, P-3 vital signs upon entry to the emergency department were, “T (temperature) 36.4 degrees Celsius oral (97.5 degrees Fahrenheit), HR (heart rate) 58 (monitored), RR (respiratory rate) 16, BP (blood pressure) 110/77, SpO2 (pulse oxygenation) 96%, HT (height) 175 cm (5’7”), WT: 117 kg (258 lbs).” P-3 reported 10 of 10 for pain. Abnormal findings for physical exam included, “Gastrointestinal: soft, non-distended, there is diffuse abdominal tenderness, no guarding no CVA tenderness percussion of the bilateral flanks.” Medications given to P-3 during her emergency visit included Normal Saline 0.9% IV Bolus at 1203. No further medications were ordered or given during P-3 ED visit. On 5/9/2024 at 1210 an interview occurred with staff G, the Physician Assistant who cared for P-3 on 04/25/2024. Staff G was queried what the course of treatment was for P-3. Staff G stated, “You can read my notes ...it’s all in there.” Staff G was then queried what concerns P-3 presented with to the ED on 4/25/2024. Staff G stated P-3 presented with abdominal pain and nausea. Staff G was then asked what medications are commonly used to address pain and nausea. Staff G stated, “Antiemetics and pain medications ...It’s dependent on the patient.” Staff G was then asked if P-3 received anything other than normal saline during her stay. Staff G stated, “I told the patient to go back to the current plan she had with her physician.” Staff G was queried if a re-assessment of P-3 pain level was done prior to discharge. Staff G stated, “No ...that is not required.” A record review of the P-3 medical record on 5/8/2024, revealed the Attending Physician’s note dated 4/25/2024 at 1144 stated, “I discussed the case with (staff G, the Physician’s Assistant) and agree with the care plan and disposition by the APP (Advanced Practice Practitioner). I have personally performed a face-to-face diagnostic evaluation on this patient. My findings are as follows: Patient’s laboratory evaluation is unremarkable. Patient will be given a liter of normal saline. Patient was reassured and discharged. Arrange for follow-up with gastroenteritis.” A record review of the P-3 medical record on 5/8/2024, revealed the Attending Physician’s note dated 4/25/2024 at 1144 stated, “I discussed the case with (staff G, the Physician’s Assistant) and agree with the care plan and disposition by the APP (Advanced Practice Practitioner). I have personally performed a face-to-face diagnostic evaluation on this patient. My findings are as follows: Patient’s laboratory evaluation is unremarkable. Patient will be given a liter of normal saline. Patient was reassured and discharged. Arrange for follow-up with gastroenterology.” P-3’s medical record also failed to show any medications administered for nausea or pain management.”

“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: 28042 Based on document review and interview, the facility failed to ensure that an order for a physical restraint was written per the facility policy identifying the least restrictive type, length of time and reason for 2 (P-2 and P-11) of 4 patients reviewed for restraints, from a total of 14 sampled patients, resulting in the potential for less than optimal patient outcomes. Findings include: On 05/08/2024 at 1400 review of P-2’s medical record revealed he was a 90-year-old male with a medical history significant for cognitive impairment, hemorrhagic stroke, and COPD (chronic obstructive pulmonary disease), with stroke resulting in vision changes, and speech abnormalities (expressive aphasia). P-2 was admitted to the facility on 02/12/2024 and discharged on 02/26/2024 with diagnoses to include altered mental status, garbled speech with cognitive impairment status post hemorrhagic stroke, acute anemia, UTI secondary to benign prostatic hypertrophy causing obstruction, myocardial injury secondary to dehydration, cough, and bradycardia (slow heart rate). Review of physician orders for P-2 revealed order for non-violent restraints on 02/14/2024 at 0106 for 4-point Twice as Tuff restraints (hard, locking restraints). Physician order 2/17/2024 at 0002 for non-violent 4-point soft restraints. Physician order 02/20/2024 at 0301 for non-violent 4-point soft restraints. Physician order 02/20/2024 at 2325 for non-violent 4-point soft restraints. Physician order 02/21/2024 at 1619 for non-violent 4-point soft restraints. Review of nursing restraint initiation notes for P-2 dated 02/14/2024 at 0106 indicated use behaviors to be: Challenging alarms multiple times, inability to redirect, resistive to staff attempts to assist. Nursing restraint initiation dated 02/16/2024 at 2317 indicates use behaviors to be: P-2 continued to climb out of bed, verbal threats, swinging at staff, scratched staff. Nursing restraint initiation dated 02/20/2024 at 0301 indicates use behaviors to be: P-2 frequently trying to get out of bed, cussing and swearing at staff, attempted to hit staff. Review of P-11’s medical record on 05/09/2024 at 0930 revealed he was a 58-year-old man who presented on 02/05/24 with dizziness. P-11 reported onset around 1300 on 02/04/2024 with a fall, without head injury and no loss of conscious, no headache. Review of radiographs for P-11 demonstrated: evidence of hypoperfusion in the left cerebellum and evidence of high-grade stenosis of the left vertebral artery. CT (cat scan) head was negative for acute process. Review of discharge summary dated 02/28/2024 for P-11 indicated P-11 was a 58-year-old male with history including bipolar, hypertension, diabetes, who originally presented with complaints of dizziness and a fall on 2/5/2024, eventually noted to have central cervical stenosis and expired on 02/18/2024. He was taken for multilevel anterior cervical discectomy and decompression on 2/13/2024. The discharge summary indicated psychiatry was consulted for P-11’s bipolar disorder as he was having increased mania symptoms and episodes of intermittent agitation. The note indicated on 2/15/2024 P-11 had a “code gray” and was placed in 4-point twice as tough restraints (hard locking), with psychiatric medication changes made. On 2/18/2024, P-11 was found unresponsive with no pulse. On cardio-respiratory resuscitation, he was noted to have copious amount of frothy tan secretions in his respiratory tract, making it difficult to bag him. P-11 received 20 minutes of ACLS resuscitation prior to ROSC (return of spontaneous circulation) and was transferred to the ICU. The discharge summary documented that shortly after transfer, he had another arrest, with two minutes of chest compressions and resuscitation. Post-resuscitation, P-11 was then stabilized for several hours, on epinephrine, Levophed, and vasopressin drips. The discharge summary indicated per discussion with family, decision was made to change code status to DNR (do not resuscitate). P-11 had another cardiac arrest at 2023 and passed on full mechanical ventilatory support with vasopressors active. Review of physician orders for P-11 revealed violent restraint order dated 02/15/2024 at 1521 for 4 point twice as tough. Comment: Every 4 hours a provider must decide whether to discontinue or reorder “Restraints Violent.” Physician orders for P-11 revealed system discontinued violent restraint order dated 02/16/2024 at 0726 and new violent restraint order dated 02/16/2024 at 0726 for 4 point twice as tough. Comment: Every 4 hours a provider must decide whether to discontinue or reorder “Restraints Violent.” Physician orders for P-11 revealed system discontinued violent restraint order dated 02/17/2024 at 0802 and new violent restraint order dated 02/17/2024 at 0802 for 4 point twice as tough. Comment: Every 4 hours a provider must decide whether to discontinue or reorder “Restraints Violent.” Physician orders for P-11 revealed new violent restraint order dated 02/17/2024 at 1129 for 4 point twice as tough. Comment: Every 4 hours a provider must decide whether to discontinue or reorder “Restraints Violent.” Physician orders for P-11 revealed new non-violent restraint order dated 02/17/2024 at 1710 for 4-point soft restraints, with cancellation order on 02/17/2024 at 1934. The orders failed to note the reason for continuation. The orders were not renewed every four hours per policy. Psychiatric consult note dated 02/16/2024 at 0819 documented P-11 is acutely confused with abrupt onset. The note indicated high likelihood that current symptoms are a result of delirium rather than underlying psychiatric disorder. The note indicated treatment of delirium including identification and treatment of underlying medical/neurological causes as well as supportive care and allow time for cognition to clear. The progress note recommended continued re-orientation, promotion of good sleep/wake cycles, optimizing pain management strategies, ensuring good nutrition/hydration, encouraging use of sensory aids when needed, and fostering physical therapy/early mobilization when appropriate. The provider documented to attempt to get out of restraints as soon as it is deemed safe. Hospitalist (Staff N) progress note dated 02/17/2024 at 0907 documented total intake of 0 ml and total output 0 ml for 02/17/2024 with P-11 still in 4-point restraints, with physical exam documented as calmer in 4-point twice as tuffs, not grimacing face or puling at restraints, lungs clear bilaterally, good air movement, and psych: good affect. In an interview on 05/09/2024 at 1110, Staff X stated she worked night shift with P-11 and during the first two nights he was making statements about want to kill everyone and their family. On the third night, P-11 was calmer and let her suction him. Staff X said she was told P-11 was known to be violent and that was why on the third night he still could not come out of restraints even though he was calmer. In an interview with Staff Q on 05/09/2024 at 1000, she stated nursing staff had been incorrectly choosing “Violent” versus “Non-Violent” restraints when initiating restraint orders in the electronic medical record. As the Nurse Educator she had been initiating education on this topic, but the education was not yet implemented through their system. Staff Q stated per the policy, restraints should be classified by the reason for the restraint, not the type of restraint. In an interview on 05/09/2024 at 1145, when queried as to what constitutes a violent versus a non-violent restraint, Staff O stated a violent restraint is the Twice as Tuff hard leather restraint and a non-violent restraint is a soft restraint. In an interview on 05/09/2024 at 1300, Unit A7 RN, Staff J was queried as to restraint choices and when to use a restraint. Staff J stated, “Hard restraints are used for violence and soft restraints are used for non-violent.” Staff J continued by stating, “It really depends on the patient... I think that twice as tough restraints are actually better for a patient because it provides soft foam around the extremity which does not cause any skin issues versus soft restraints.” On 05/09/2024 at 1410, Review of facility Policy, “Use of Physical Restraints: Ordering, Monitoring and Documentation Requirements”, dated 06/22/2022 revealed for Non-Violent or Non-Self-Destructive Patient, Section A. This type of restraint would be used for a primary medical problem or to enable medical interventions. Section C. Examples of situations where this type of restraint may be ordered include: patients who are at risk of dislodging lines, tubes, drains, or other medical equipment; patients who are at risk for significant injury due to an underlying medical condition, where other interventions have failed to protect the patient from injury. The policy indicated... for Violent or Self-Destructive Patient - A. In addition to the requirements for Non-Violent Restraints, the following requirements also exist: B... used for restraint or seclusion episodes that are initiated to manage violent or self-destructive behavior that jeopardizes the immediate safety of the patient, staff, or others. This type of restraint/seclusion would be initiated in an emergency situation only and would be used primarily for a behavioral health problem. C. A face-to-face assessment of the patient must occur within one (1) hour of the intervention. 1. The patient ’ s immediate situation; 2. The patient ’ s reaction to the intervention; 3. The patient ’ s medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. D. For the duration of the time restraint/seclusion is used to manage a violent or self-destructive patient, a new order must occur in accordance with the following for a maximum of 24 hours: 1. Every 4 hours for adults 18 years of age or older. 2. Every 2 hours for children and adolescents 9-17 years of age; or 3. Every 1-hour for children under 9 years of age. Section, Discontinuing a Restraint, A. A restraint should be discontinued at the earliest possible time, regardless of the length of time identified in the order.”

“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: 28042 Based on interview and record review the facility failed to obtain a new physician order after four hours for renewal of four-point violent restraints for one (P-11) of 4 patients reviewed for restraints form a total of 14 sampled patients, resulting in the potential for unmet needs and injury. Findings include: Review of P-11’s medical record on 05/09/2024 at 0930 revealed he was a 58-year-old man who presented on 02/05/24 with dizziness. P-11 reported onset around 1300 on 02/04/2024 with a fall, without head injury and no loss of conscious, no headache. Review of radiographs for P-11 demonstrated: evidence of hypoperfusion in the left cerebellum and evidence of high-grade stenosis of the left vertebral artery. CT (cat scan) head was negative for acute process. Review of discharge summary dated 02/28/2024 for P-11 indicated P-11 was a 58-year-old male with history including bipolar, hypertension, diabetes, who originally presented with complaints of dizziness and a fall on 2/5/2024, eventually noted to have central cervical stenosis and expired on 02/18/2024. He was taken for multilevel anterior cervical discectomy and decompression on 2/13/2024. The discharge summary indicated psychiatry was consulted for P-11’s bipolar disorder as he was having increased mania symptoms and episodes of intermittent agitation. The note indicated on 2/15/2024 P-11 had a “code gray” and was placed in 4-point twice as tough restraints (hard locking), with psychiatric medication changes made. On 2/18/2024, P-11 was found unresponsive with no pulse. On cardio-respiratory resuscitation, he was noted to have copious amount of frothy tan secretions in his respiratory tract, making it difficult to bag him. P-11 received 20 minutes of ACLS resuscitation prior to ROSC (return of spontaneous circulation) and was transferred to the ICU. The discharge summary documented that shortly after transfer, he had another arrest, with two minutes of chest compressions and resuscitation. Post-resuscitation, P-11 was then stabilized for several hours, on epinephrine, Levophed, and vasopressin drips. The discharge summary indicated per discussion with family, decision was made to change code status to DNR (do not resuscitate). P-11 had another cardiac arrest at 2023 and passed on full mechanical ventilatory support with vasopressors active. Review of physician orders for P-11 revealed violent restraint order dated 02/15/2024 at 1521 for 4 point twice as tough. Comment: Every 4 hours a provider must decide whether to discontinue or reorder “Restraints Violent.” Physician orders for P-11 revealed system discontinued violent restraint order dated 02/16/2024 at 0726 and new violent restraint order dated 02/16/2024 at 0726 for 4 point twice as tough. Comment: Every 4 hours a provider must decide whether to discontinue or reorder “Restraints Violent.” Physician orders for P-11 revealed system discontinued violent restraint order dated 02/17/2024 at 0802 and new violent restraint order dated 02/17/2024 at 0802 for 4 point twice as tough. Comment: Every 4 hours a provider must decide whether to discontinue or reorder “Restraints Violent.” Physician orders for P-11 revealed new violent restraint order dated 02/17/2024 at 1129 for 4 point twice as tough. Comment: Every 4 hours a provider must decide whether to discontinue or reorder “Restraints Violent.” In an interview on 05/09/2024 at 1130, Staff N (Hospitalist) said he was the provider for P-11 during his stay. When queried if he had been the provider who wrote the orders for P-11’s violent restraints from 02/15/2024 through 02/17/204 and the non-violent 4-point restraints on 02/17/2024, Staff N answered yes. He said he wasn ’ t aware of the restraint policy. When queried if he had been educated on the restraint policy during his credentialing process or annually, Staff O stated he may have been educated, but he forgot. In an interview with the Manager of Accreditation, Staff A on 05/09/2024 at 1100, she stated it was the facility restraint policy for a physician to review and discontinue or reorder violent restraints every 4 hours. On 05/09/2024 at 1410, Review of facility Policy, “Use of Physical Restraints: Ordering, Monitoring and Documentation Requirements”, dated 06/22/2022 revealed for Violent or Self-Destructive Patient - A. In addition to the requirements for Non-Violent Restraints, the following requirements also exist: B... used for restraint or seclusion episodes that are initiated to manage violent or self-destructive behavior that jeopardizes the immediate safety of the patient, staff, or others. This type of restraint/seclusion would be initiated in an emergency situation only and would be used primarily for a behavioral health problem. C. A face-to-face assessment of the patient must occur within one (1) hour of the intervention. 1. The patient ’ s immediate situation; 2. The patient ’ s reaction to the intervention; 3. The patient ’ s medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. D. For the duration of the time restraint/seclusion is used to manage a violent or self-destructive patient, a new order must occur in accordance with the following for a maximum of 24 hours: 1. Every 4 hours for adults 18 years of age or older. 2. Every 2 hours for children and adolescents 9-17 years of age; or 3. Every 1-hour for children under 9 years of age. Section, Discontinuing a Restraint, A. A restraint should be discontinued at the earliest possible time, regardless of the length of time identified in the order.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) [the patient must be seen face-to-face within 1 hour after the initiation of the intervention -- ] §482.13(e)(12)(ii)To evaluate - 1. The patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. This Standard is not met as evidenced by: 28042 Based on record review and interview the facility failed to document physician face to face assessments within one hour for patients in violent restraints for one (P-11) of 4 patients reviewed for restraints from a total sample of 14 patients, resulting in the potential for loss of patient rights, risk of injury and risk for negative outcomes. Findings include: Review of P-11’s medical record on 05/09/2024 at 0930 revealed he was a 58-year-old man who presented on 02/05/24 with dizziness. P-11 reported onset around 1300 on 02/04/2024 with a fall, without head injury and no loss of conscious, no headache. Review of discharge summary dated 02/28/2024 for P-11 indicated P-11 was a 58-year-old male with history including bipolar, hypertension, diabetes, who originally presented with complaints of dizziness and a fall on 2/5/2024, eventually noted to have central cervical stenosis and expired on 02/18/2024. He was taken for multilevel anterior cervical discectomy and decompression on 2/13/2024. The discharge summary indicated psychiatry was consulted for P-11’s bipolar disorder as he was having increased mania symptoms and episodes of intermittent agitation. The note indicated on 2/15/2024 P-11 had a “code gray” and was placed in 4-point twice as tough restraints (hard locking), with psychiatric medication changes made. On 2/18/2024, P-11 was found unresponsive with no pulse. On cardio-respiratory resuscitation, he was noted to have copious amount of frothy tan secretions in his respiratory tract, making it difficult to bag him. P-11 received 20 minutes of ACLS resuscitation prior to ROSC (return of spontaneous circulation) and was transferred to the ICU. The discharge summary documented that shortly after transfer, he had another arrest, with two minutes of chest compressions and resuscitation. Post-resuscitation, P-11 was then stabilized for several hours, on epinephrine, Levophed, and vasopressin drips. The discharge summary indicated per discussion with family, decision was made to change code status to DNR (do not resuscitate). P-11 had another cardiac arrest at 2023 and passed on full mechanical ventilatory support with vasopressors active. Review of physician orders for P-11 revealed violent restraint order dated 02/15/2024 at 1521 for 4 point twice as tough. Comment: Every 4 hours a provider must decide whether to discontinue or reorder “Restraints Violent.” Physician orders for P-11 revealed system discontinued violent restraint order dated 02/16/2024 at 0726 and new violent restraint order dated 02/16/2024 at 0726 for 4 point twice as tough. Comment: Every 4 hours a provider must decide whether to discontinue or reorder “Restraints Violent.” Physician orders for P-11 revealed system discontinued violent restraint order dated 02/17/2024 at 0802 and new violent restraint order dated 02/17/2024 at 0802 for 4 point twice as tough. Comment: Every 4 hours a provider must decide whether to discontinue or reorder “Restraints Violent.” Physician orders for P-11 revealed new violent restraint order dated 02/17/2024 at 1129 for 4 point twice as tough. Comment: Every 4 hours a provider must decide whether to discontinue or reorder “Restraints Violent.” Review of entire medical record did not reveal a face-to-face evaluation after any of the violent restraint physician orders. In an interview on 05/09/2024 at 1130, Staff N (Hospitalist) said he was the provider for P-11 during his stay. When queried if he had been the provider who wrote the orders for P-11’s violent restraints from 02/15/2024 through 02/17/204 and the non-violent 4-point restraints on 02/17/2024, Staff N answered yes. When the surveyor stated upon document review no face-to-face assessments could be located after violent restraint orders were initiated. Staff N stated none could be found because it wasn’t done. He said he wasn’t aware of that policy. When queried if he had been educated on the restraint policy during his credentialing process or annually, Staff O stated he may have been educated, but he forgot. On 05/09/2024 at 1410, Review of facility Policy, “Use of Physical Restraints: Ordering, Monitoring and Documentation Requirements”, dated 06/22/2022 revealed for Violent or Self-Destructive Patient - A. In addition to the requirements for Non-Violent Restraints, the following requirements also exist: B... used for restraint or seclusion episodes that are initiated to manage violent or self-destructive behavior that jeopardizes the immediate safety of the patient, staff, or others. This type of restraint/seclusion would be initiated in an emergency situation only and would be used primarily for a behavioral health problem. C. A face-to-face assessment of the patient must occur within one (1) hour of the intervention. 1. The patient ’ s immediate situation; 2. The patient ’ s reaction to the intervention; 3. The patient ’ s medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. D. For the duration of the time restraint/seclusion is used to manage a violent or self-destructive patient, a new order must occur in accordance with the following for a maximum of 24 hours: 1. Every 4 hours for adults 18 years of age or older. 2. Every 2 hours for children and adolescents 9-17 years of age; or 3. Every 1-hour for children under 9 years of age. Section, Discontinuing a Restraint, A. A restraint should be discontinued at the earliest possible time, regardless of the length of time identified in the order.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 29955 Based on interview and record review the facility failed to have the Emergency Department (ED) Triage conducted by a registered nurse (RN) in one of four patients (P-3) resulting in the potential for poor patient outcomes. Findings include: On 5/8/2024 at 0930 during tour of the facility ED it was revealed the facility utilizes paramedics to triage patients from the hours of 0100 to 0700. On 5/8/2024 at 0935 an interview occurred with staff E, the Nursing Manager of the ED. Staff E was queried if triage was within the scope of practice for a paramedic. Staff E stated, “Paramedics can do triage and if they have any concerns there is an RN available as a resource.” On 5/9/2024 a record review occurred of the job description titled, “Advanced Emeg [SIC] Tech-Paramedic,” dated 5/26/2022. According to the description it states,”Paramedic in Emergency Department setting that assists the health care team in the delivery of patient care under the supervision/delegation of a physician/APP (Advanced Practice Practitioner).” Under the subtitle “Essential Duties” it states the following: -Demonstrates ability to effectively communicate and interact with the general public as well as with emotionally distraught patients, family members and visitors. -Works within the guidelines of nursing and hospital standards of practice, policies and procedures. -Maintain current knowledge in clinical practice, attends in-services as appropriate. -Performs direct patient care activities within scope of practice and under the supervision of a Registered Nurse. -Recognizes and reports pertinent change in health care status of patients to a Registered Nurse or Physician. -Specific patient care duties, including, but not limited to: -Vital signs -Monitoring of patient condition -Splinting, fracture care -Cardiac monitoring -Transport -12 Lead EKGs -Wound care -Specimen collection -Foley placement -Decontamination -Application of restraints -Assist with procedures -Apply oxygen by appropriate delivery system. -Peripheral IV cannulation and maintenance of IV lines (within scope of practice). -Cardiac defibrillation and cardioversion. Review of the Emergency Nurses Association “Position Statement” from 2018 revealed the following: “It is the position of the Emergency Nurses Association (ENA) that: 1. Triage is a critical assessment process performed by a registered nurse or nurse practitioner with a minimum of one-year of emergency nursing experience, as well as appropriate additional credentials and education that may include certification in emergency nursing and continuing education in trauma, pediatrics, and cardiac care, with verification or certification in those subspecialties as appropriate.””