Beaumont Hospital Royal Oak

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 45246 Based on interview and record review, the facility failed to provide a safe environment for one patient (P-1) with high suicidal risk score of five patients reviewed, resulting in adverse outcome for that patient and potential for adverse outcomes for all patients with high suicidal risk scores. Findings include: Review of the P-1 medical record on 12/22/25 revealed that patient was a 31-year-old female that was admitted to facility on 11/29/25 for evaluation of seizure-like activity. P-1 had a history of psychogenic nonepileptic seizures, gastroesophageal reflux disease, bulimia, polycystic ovarian syndrome, mood disorder, bipolar disorder, personality disorder, depression, post-traumatic stress disorder, multiple inpatient psychiatric admissions and suicidal behavior. During admission patient was consulted by neurology, gastroenterology, gynecology and psychiatry. On 12/22/25 at 1031, during the interview with Nurse manager of 8 Neuro unit, Staff I, she recalled the incident with P-1 on 12/7/25. She explained that patient got upset and agitated after the news of the upcoming transfer to GYN floor (female only unit). She became increasingly anxious and was saying to the nurse in care, Staff S, that she is having “thoughts”. Staff S assessed patient for suicidal ideation with Columbia Suicide assessment tool and patient scored “high risk”, however patient did not admit to having a plan. Staff S consulted with charge nurse and subsequently house supervisor. House supervisor suggested to monitor patient for an hour. Staff did not “secure” P-1 environment/room for any ligature risks. Later that night P-1 was found by Staff S with telemetry and cell phone cord wrapped around her neck, purple and with no pulse. Code blue (emergency response team) was activated, and CPR (cardiopulmonary resuscitation) was performed by staff. Patient was resuscitated and transferred to ICU (intensive care unit). There was a nursing note, Staff S, dated 12/7/25 0534. The note had the following documentation. MD (provider) placed an order for transfer the patient (P-1). Patient was assigned to bed on another unit, 6S gynecology. Patient was extremely upset and complained about not wanting to go to new floor and wanting to stay in the current room. Charge RN (registered nurse) talked to the patient and transfer was held for tonight due to patient’s emotional status. Patient then became severely anxious and hyper fixated on the transfer, even after transfer was postponed. Patient was telling RN that she was having thoughts of PTSD (post-traumatic stress disorder) but did not describe thoughts in detail. Suicide screening reassessed, patient denies having a plan to hurt herself at this time. Patient and RN completed intervention of 5 senses to decrease further anxiety with slight relief. Nursing documentation was reviewed on 12/22/25 and revealed C-SSRS assessment (Columbia Suicide Severity Rating Scale) dated 12/7/25 0100. Assessment had the following questions: 1) Wished to be dead (past 1 month). P-1 answered “yes”. 2) Non-specific active suicidal thoughts (past 1 month). Patient said “yes”. 3) Active suicidal ideation with any methods (not plan) without intent to act (past 1 month). Patient answered “yes”. 4) Active suicidal ideation with some intent to act, without specific plan (past 1 month). Patient said “yes”. 5) Active suicidal ideation with specific plan and intent (past 1 month). Patient answered “no”. Overall score was “High risk”. On 12/23/25 at 1033 during interview with a charge RN for unit 8 Neuro, Staff T, she recalled the events of that night (on 12/7/25). Staff T stated that nurse in care for P-1, Staff S, reported that patient had “thoughts” triggered by PTSD. Staff T recommended that nurse in care complete suicidal risk assessment. P-1 scored “high” on the assessment and Staff T contacted house supervisor to consult on further actions. House supervisor recommended to monitor the patient for 1 hour and see if P-1’s anxiety will resolve. When asked if patient’s room was “cleared” for safety and safety attendant was arranged at that time, Staff T said “no”. Provider note dated 12/7/25 0429 revealed: Patient was found unresponsive at 0251, and she was noted to be trying to strangle herself with TMS (telemonitoring system) cords. Code blue (emergency response team) was called on patient and chest compressions were initiated by staff. The CPR (cardiopulmonary resuscitation) team responded and ACLS (advance cardiovascular life support) protocol was initiated. The patient received 2 min of CPR, after which pulse check showed she did have a pulse... The patient was noted to be shivering, and had her eyes rolled back. She did respond to name and looked around. She was noted to have reddish secretions on suctioning and had a strong cough. MICU (medical intensive care unit) resident was present at bedside and decision was made to admit to MICU for monitoring of patient’s airway. Psychiatry provider note dated 12/9/25 1415 indicated that “on 12/07 the patient (P-1) became distressed during a unit transfer, triggering PTSD flashbacks from past sexual trauma; she attempted self-strangulation using a phone cord and EKG leads and was found cyanotic. She currently endorses passive suicidal ideation but denies plan or intent. She reports three prior suicide attempts over five years and numerous psychiatric hospitalizations beginning at age 11. At this time patient continues to endorse depressive symptoms, sleep disturbance and passive suicidal ideations”. On 12/22/25 at 1403 during the interview with facility’s CNO, Staff B, it was identified that facility staff notified nursing leadership of the incident with P-1 on 12/8/25 and an incident report was filed. Facility investigated the incident, conducted interdisciplinary meetings, and identified opportunities for improvement. However, the facility did not re-educate all clinical staff on policy for safe environment for patients with moderate to high suicidal risk scores. When asked if patients with high suicidal risk can be admitted on any unit in a facility, Staff B stated yes. When asked if all facility staff should follow facility policies and procedures, Staff B said yes. Facility policy “Care of the Suicidal/Potentially Suicidal Patient” dated 7/19/24 was reviewed and revealed: “I. Purpose. To identify the process for maintaining the safety of patients who are expressing and/or demonstrating suicidal or potentially suicidal behavior. II. Responsibilities. Registered Nurse (RN), Physicians, Advanced Practice Provider (APP), Social Worker (SW), Safety Attendant (SA), Medical Assistant (MA), Any health care professional or care giver who may encounter a patient who expresses suicidal ideation and/or suicidal behaviors. VI. Policy: A. A patient at risk is identified by one or more of the following: 1. Completed risk screening 2. Presenting complaint/admitting diagnosis (i.e intentional overdose, self-inflicted injury) 3. Patient actions that are concerning for patient safety 4. Concerns or comments expressed by patient, family, friends, significant other(s), court order, law enforcement or community agencies. 5. SW and/or Provider assessment. Appendix B. Risk Stratification Table Inpatient & Emergency Department Interventions. High Risk: -Consult social work and order consult. -Initiate and order safety attendant at bedside. -Initiate and order secure environment precautions. Appendix H. Secured Environment Precautions. Secured Environment Precautions: -Environmental modifications made to the room to reduce the risk of harm to self or others. It is important to consider human rights in the initiation of this precaution outside of an evidence-based risk screening tool. Secured environment precautions may or may not include safety attendant (SA), see Safety Attendant Policy, or visual surveillance via clinical rounding or video monitoring, see Video Monitoring for Patient Safety Policy. -Secured environment precautions can be initiated by nursing or provider via an order and can be recommended by social worker. Indications to initiate Secured Environment Precautions. -Patient at risk for Suicide or Self-harm based on evidence-based risk screening tools or clinical assessment. Interventions. Key principles: -Patient will remain within the secured environment with the exception of medical necessity (tests/procedures) or with an exception deemed appropriate by social worker. -Secured environment precautions are implemented in their entirety until the patient is assessed by SW (social work). Key interventions: -Pre-existing medical devices should be addressed on an individual basis at the discretion of the provider. -Items that need to be removed from the room and bathroom: Any unnecessary cord like objects (room phone)”.”

“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: 48772 Based on interview and record review, the facility failed to follow policy for intake monitoring for 2 (P-1, P-2) of 10 patients reviewed, resulting in the potential for unmet patient needs and adverse outcomes. Findings include: P-1: This 31-year-old female arrived at the emergency department (ED) via ambulance from a subacute rehabilitation facility post inpatient psychiatric hospitalization on 11/29/25 at 0159 for evaluation of seizure-like activity. P-1 has a history of bipolar affective disorder, personality disorder, bulimia, psychogenic nonepileptic seizures, gastroesophageal reflux disease, mood disorder, polycystic ovarian syndrome, and post-traumatic stress disorder. During record review, it was noted a general diet was ordered on 11/29/25 at 0803, which was changed to upper GI soft diet on 11/29/25 at 1354. In addition, a speech-language pathology consultation for swallow evaluation was documented on 12/6/25 at 0855, which indicated close supervision needed for intake. P-1 was also ordered intravenous fluids of 0.9% sodium chloride 1,000 ml bolus on 11/30/25 at 1830 and 12/3/25 at 1600 as well as a continuous infusion at 100 ml/hr from 12/4/25 0003 to 12/6/25 at 1127 and on 12/6/25 at 2050 to 12/7/25 at 1148. On 12/7/25 at 1515, intravenous fluids were changed to a continuous infusion of 5% dextrose in lactated ringers at 75 ml/hr. Meal intake was documented on three of the 14 days: 12/1/25 at 1000, 10% of breakfast, 12/9/25 at 1200, 0% of breakfast, and 12/10/25 at 1200, 100% of lunch. Oral intake was documented on three of the 14 days on 11/30/25 (360 ml), 12/1/25 (560 ml) and 12/3/25 (960 ml). P-2: This 59-year-old female was admitted to the facility on 11/29/25 for an intraparenchymal hemorrhage (bleeding directly into the brain’s functional tissue). P-2 has a history of coronary artery disease, Barrett esophagus, hyperlipidemia, hypertension, obstructive sleep apnea, and Grave’s disease. P-2 underwent a right sided craniectomy on 12/10/25 at 0634. During record review, it was noted that I&O (intake and output) monitoring was ordered every 4 hours on 12/16/25 at 0843. Nursing flowsheets indicate gaps in oral intake documentation on 12/16/25 from 1800 until 12/17/25 at 0800, on 12/18/25 from 1200 until 12/19/25 at 0815, on 12/19/25 at 1344 until 12/20/25 at 0948, and on 12/20/25 at 1818 until 12/22/25 at 0927. These findings were reviewed and acknowledged by the regional compliance specialist (Staff E) at the time of discovery. Policy 21728-Vital Signs and I & O Monitoring (effective date 7/21/24). Frequency of vital sign monitoring and I&O monitoring are not scheduled times and should be bundled with other nursing care. It is intended to be an approximated frequency to maintain a cadence of monitoring. Documentation of vital signs and I&O should be completed as soon as possible to ensure accurate trending in electronic medical record.”

“THERAPEUTIC DIETS CFR(s): 482.28(b), (b)(1) §482.28(b) Menus must meet the needs of patients. (1) Individual patient nutritional needs must be met in accordance with recognized dietary practices. This Standard is not met as evidenced by: 45246 Based on observation, interview and record review, the facility failed to provide one patient (P-1) of 2 patients reviewed for dependency on tube feedings with comprehensive nutritional support resulting in P-1 not receiving adequate nutritional support and less than optimal outcomes for the patient. Findings include: On 04/30/25 at approximately 1600 P-1 was observed and interviewed in her room. Patient’s GJ tube (Gastrojejunostomy tube- is a soft, narrow tube that enters the stomach in the upper part of the abdomen and is threaded into the small intestine) was observed connected to the bottle with tube feeding formula and was infusing at 10 ml/h (milliliters in hour). Patient stated that on her admission to the facility she experienced pain with tube feeding and at the site of its insertion. She added that the balloon that holds tube in place was partially visible when she was admitted and at some point during her stay here it “popped out” and was sitting on her skin. She said that bile was leaking all over her stomach area and she experienced great deal of pain and discomfort, not to mention that her medications and feeding was paused till GI (Gastroenterology) service “fixed” the balloon issue. P-1 added that all this time since admission she was unable to tolerate feeding infusion higher than 10 ml/h no matter what formula was running. “I am in pain when it runs higher than 10, and I can feel the same discomfort and nausea when nurses give me meds and flushes”, she said. She stated that she feels dizzy, weak and lightheaded. P-1’s medical record was reviewed on 04/30/25 and revealed: General medicine physician note dated 4/24/25 0815: “Patient states that her pain started one day prior to presentation, she also noted that the site of the tube is more red than usual. Pain at the GJ tube site worsens with moving the tube or administering any tube feeds or medications through her tube, this patient has not been able to get any feeds or take any of her medications since yesterday which prompted her to present to emergency department. Appropriate GJ tube positioning was confirmed on Xray (PEGogram)”. Gastroenterology provider note dated 4/24/25 1217 indicated: “Ok for clears. Ok to use J portion for feeds. Would benefit from an EGD as outpatient to evaluate if she continues to have epigastric pain”. Weight on admission (04/23/25 at 2031) was recorded as 61.2 kg, method- estimated/emergent, height 5’8” (172.7 cm). Registered dietitian (RD) note dated 4/25/25 1046 revealed: “Nutrition interventions/recommendations: Jevity 1.5 (nutritional tube feeding formula) with fiber initiate at 10 ml/h, advance as tolerated to goal of 50 ml/h x 24 hrs via J tube to provide: 1800 kcal/day, 77 gram/day protein, 259 gram/day (10.8 g/hr) carbohydrates, 25 gram fiber, 912 ml/day free water. Flushes 30 ml every 4 hrs for patency. Home TF (tube feeding) regimen: Jevity 1.5 at 50 ml/hr. Malnutrition criteria met? No”. There was a provider order dated 04/25/25 1102: Tube feed Jevity 1.5, route PGJ, continuous, goal as tolerated 50 ml/hr. Discontinued 04/29/25 1030. Wound care consult note dated 04/28/25 0856 revealed: consulted for help with G tube that is leaking enteric contents and causing the patient pain. Gastroenterology consulting physician note dated 04/29/25 1648 had the following documented: pain and redness at the site of PEG J probably related to skin irritation from bile leakage from displaced and deflated ballon. Status post repositioning. Upon evaluation erythema was noted around the PEG site and the balloon was noted to be outside the ostomy. The ballon was completely deflated and repositioned with subsequent inflation of the ballon with 10 ml of sterile saline. Recommendations: hold tube feeds for another 5-6 hours and then restart with minimal manipulation of the tube. If symptoms of pain do not improve, we will consider scheduling patient for an EGD (esophagogastroduodenoscopy or upper endoscopy that examines esophagus, stomach and duodenum with scope). Registered dietitian (RD) note dated 4/30/25 1354 revealed: “Malnutrition criteria met? Yes. Malnutrition diagnosis: moderate protein-calorie malnutrition. Acute illness of injury: enteral access complication. Subcutaneous body fat loss acute illness: mild. Muscle mass loss acute illness: mild. Energy intake: less than 75% for greater than 7 days (patient states she has not had tube feeding at goal for > 7 days. Weight loss: patient states she has lost weight, unsure of amount, bed scale on admission possibly discrepancies [sic]. Intervention: Trial GI product Peptamen 1.5, follow up tolerance”. There was a provider order dated 04/30/25 1400: Tube feed Peptamen 1.5, route PGJ, continuous, start at 10 ml/h via pump to J port, increase rate by 10 ml every 12 hours or per patient preference, eventual goal rate 50 ml/hr x 24 hrs/day. There was no record of the RD follow up notes regarding P-1 tolerance of the ordered tube feeding formula, rate or any complications between 04/25/25 and 04/30/25. Further record review revealed that P-1 received total of 420 ml of intermittent tube feeding during her admission from 04/23/25 until 04/30/25 at approximately 1600. As per RD recommendations the goal for the patient was “50 ml/h x 24 hours via J tube to provide: 1800 kcal/day”. That would be a goal of 1200 ml a day and a total of 7200 ml for 6 days. No orders for additional nutritional supplements were identified during record review. Also, there was no accurate (only estimated) weight recording for P-1 on admission and throughout patient’s stay, therefore, no accurate determination could be made if patient lost weight and how much. On 05/01/25 at 1040 P-1 internal medicine physician, Staff DD, was interviewed. During the interview he stated that he was communicating the plan of care for P-1 with the patient and her mother/guardian. He added that appropriate consultations were placed on admission, including GI and registered dietitian. When asked if he knew how much total feeding patient received during her stay in the facility, Staff DD said that he was not aware of the total amount. He stated that the treating team’s goal was to advance patient’s feeding rate gradually over time and see if she would tolerate that. When queried what the current rate of the patient’s tube feed infusion was, he referred to his colleague, an internal medicine physician who took over the case, Staff CC. She stated that as of today, 05/01/25, the rate was still at 10 ml/h. Facility policy “Protocol Medical Nutrition Therapy: Nutrition Orders Protocol, effective 07/21/24, was reviewed on 05/01/25 and revealed: “4.2. Protocolized Other Orders: 4.2.1. Enteral Feeding/ Tube Feeding Orders: Order, Modify, Discontinue. 4.2.2. Water flushes: Order, Modify, Discontinue. 4.2.3. Nutrition Supplements: Order, Modify, Discontinue. 4.2.5. Weigh Patient: Order, Modify Discontinue 4.2.5.1. Indicate equipment to be used (bed, floor, or chair scale) 6. Inclusion Criteria 6.2. Criteria 6.2.3. Presence of one or more of the following nutrition risk factors: 6.2.2. All bedded patients, inpatient and observation status. Malnutrition Screening Tool (MST) score of 2 or greater Weight loss Decreased nutritional intake or decreased appetite Muscle wasting or fat wasting Dysphagia Parenteral or enteral nutrition Nutritional Therapy Protocol- Tube Feeding Adjustment Guidelines. Based on nutrition assessment, when nutrition therapy protocol is ordered- the RDN may adjust tube feeding and additive according to the following guidelines. Tube feeding product selection. Clinical scenario indicates patient needs. Dietitian will select the following formula type (genetic name). Comments: See Enteral and Oral Supplement Formulary, document order, include follow-up date for monitoring (tolerance and complications). Tube feeding- rate and or product change. If GI intolerance persists- consider product change. Weigh patient. If patient accurate weight needed for provision of care, then weigh patient now and every day, indicate equipment to be used (bed, floor or chair scale).””

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 50223 Based on observation, interview, and record review, the facility failed to ensure staff followed procedures for transmission-based precautions (TBP) for one patient (P-1) out of one reviewed for infection control practices, resulting in possible spread of infection to all patients on the unit. Findings include: A review of P-1’s medical record revealed that they were admitted to the facility on 4/23/25 with a chief complaint of GJ tube (feeding tube) site pain. Patient had a history of autism spectrum disorder, chronic suprapubic (urinary) catheter, gastroesophageal reflux, gastroparesis, inflammatory bowel diseases, moderate protein-calorie malnutrition, psychogenic nonepileptic seizures, seizure-like activity, POTS (postural orthostatic tachycardia syndrome), Conversion disorder (a psychological condition that causes symptoms that appear to be neurological, such as paralysis, speech impairment, or tremors, but with no obvious or known organic causes), and depression. On 4/30/25 at 1545, Nursing Assistant (NA), Staff R, and NA Staff Q were observed in P-1’s room providing care without wearing gowns. On 4/30/25 at 1600, P-1 was observed in their room. A Contact Precaution sign was observed on P-1’s door. P-1 explained that they are on contact precautions for an infection. On 4/30/25 at 1601, During an interview, Registered Nurse (RN), Staff P, was asked if wearing PPE was required to enter P1’s room. Staff P explained that PPE is only required when providing care. On 4/30/25 at 1602, Staff R was observed in P-1’s room checking vital signs on the bedside monitor without wearing a gown. Staff R was observed to remove a pen and paper from their pocket while wearing gloves and then place the pen and paper back into their pocket. Staff R then removed one glove and repositioned P-1’s over-bed table with their bare hand. Staff R then exited the room. No hand hygiene was observed prior to exiting the room. On 4/30/25 at 1645, during an interview, the unit Clinical Nurse Manager, Staff N, explained that all staff and visitors should wear appropriate PPE when entering the room of a patient on contact precautions. A review of the facility’s policy titled “Isolation - Transmission Based Precautions” effective 7/21/2024 revealed the following: “1. Purpose. To outline the process for the use of transmission-based precautions, also known as isolation precautions and proper use of personal protective equipment (PPE). Transmission-based precautions are infection control and prevention measures used in addition to standard precautions to protect against exposure to a suspected or identified pathogen. These precautions are specific and based on the way the pathogen is transmitted. The guidelines follow the recommendations from the Centers for Disease Control and Prevention (CDC). Contact Precautions 6.1.1. Contact Precautions are designed to reduce the risk of transmission of epidemiologically important microorganisms by direct or indirect contact (e.g., multi-drug resistant organisms, lice). PPE is to be worn by all team members entering the patient room. 6.1.7. Hand Hygiene must be performed prior to donning PPE and upon entering the patient’s room ...6.1.8. Gloves and gowns must be worn at all times for Contact Precautions.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47415 Based on interview and record review, the facility failed to supervise intake and provide thickened liquids to P-1 resulting in injury; and failed to document corrective actions/education provided to staff regarding the level of assistance P-1 needed with meals, following diet orders, and implementing speech language pathology recommendations, resulting in the potential of reoccurrence and the potential of a missed opportunity to improve patient safety. Findings include: See tag A-0144: Failure to provide care in a safe setting.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 47415 Based on interview and record review, the facility failed to supervise intake and provide thickened liquids to P-1 resulting in injury; and failed to document corrective actions/education provided to staff regarding the level of assistance P-1 needed with meals, following diet orders, and implementing speech language pathology recommendations, resulting in the potential of reoccurrence and the potential of a missed opportunity to improve patient safety. Findings include: P-1 was a 92-year-old male was admitted to facility on 12/6/24 with confusion and a history of dementia, dysphagia (difficulty swallowing), and limited mobility. A diet order was placed on 12/6/25 at 1520 for a dental soft, dysphagia diet with nectar thick liquids. Occupational Therapy (OT) notes of 12/6/2024 revealed: P-1 at time of the initial OT assessment could not follow instructions, was orientated to person, impulsive, and needed maximum assist with upper body skills. Speech Language Pathologist (SLP) consult of 12/8/24 at 1204, recommended to continue dysphagia, dental soft diet with nectar thick liquids, 1:1 feed assist, sit fully upright with all oral intake, small bites, sips at a slow rate. Notes also indicate these recommendations were discussed with nurse. Review of incident report revealed on 12/9/24 between 0800 and 0900, hot coffee, not thickened to nectar thick consistency, was given to P-1 by a nursing assistant, and P-1 was left unattended during oral intake. P-1 sustained second degree burns, due to spilling coffee on his left abdomen and upper hip. On 3/25/25 at 1323 an interview with Nursing Manager Staff R on 3/25/25 at 1323 revealed that an investigation was conducted, and it was determined that that coffee was served to P-1 as a “thin liquid”, by the nursing assistant assigned to P-1 (per P-1’s request for a cup of coffee). Coffee was served in a styrofoam cup with a lid, and it was confirmed a microwave was not used to heat up coffee. Record review revealed corrective actions/education to nursing staff post investigation was not documented nor was it included in the risk investigation report. On 3/26/25, review of policy titled, “Patient Safety and Precautions” dated 7/9/24 revealed, “Precautions are bundles of assessment and prevention steps for high-risk clinical conditions ...Each individual patient’s Precautions are clearly identified in the Electronic Health Record (EHR)... which displays the specific Precaution title in the patient header for easy identification ... by all care team members. Some precautions have routine, clearly outlined steps, others require individualization ...Indications to Initiate Aspiration Precautions ...High risk patients include: any degenerative neurological disease (...dementia, Alzheimer’s, etc.), stroke... history of dysphagia/on dysphagia diet prior to admission .... Aspiration precautions should be followed on all high-risk patients during meals regardless of swallow screen outcome ... Interventions ... Refer to patient specific instructions in diet order comments provided by Speech Language Pathology evaluation.””

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 15195 Based on interview and record review, the facility failed to ensure implementation of the pain management plan of care for 1 (#2) of 4 patients, resulting in less than optimal outcomes. Findings include: On 12/2/24 at 1700, phone interview with patient #2’s sister revealed that the patient had excruciating pain that was not managed during the end of her life. The sister had agreed to signing on to hospice in the hospital, provided that the Physician Pain Management Consultant FF continue to follow the patient for the pain management plan of care due to success in pain management for patient #2. This had not been done. The patient’s sister was a physician with hospice experience. Medical record review revealed that patient #2 was 64-year-old female admitted to the hospital on 6/8/24 for pain crisis of abdominal and back pain related to metastatic colon cancer (initially diagnosed 1/18/23). She had pathologic vertebral fractures and wounds which required interventions. The patient was placed on multiple pain medications, including a continuous intravenous solution of Dilaudid. The plan was to get pain under control then transfer to hospice. Continued medical record review revealed that on 6/21/24 at 1505, the patient was signed on to inpatient hospice. The hospice nurse met with the sister to clarify that hospice in the hospital was for the patient who required symptom management that could not be managed in less than acute care setting. The hospital and hospice agency had an agreement that clarified that hospital staff provided direct patient care with the oversight of the hospice staff/agency. The medical record documented that patient’s representative (sister) requested the Pain Management/Palliative Care Physician FF to be on board to continue to manage the patient’s pain. The Hospice Nurse HH documented in the “Hospice Inpatient Admission Coordination Note dated 6/21/24 at 1420” to consult this physician if needed and Attending Physician CC agreed. The patient was transferred from the oncology unit (8 South) to the medical unit with hospice patients (6 Center) on 6/21/24 at 2245. Review of pain level scores revealed that on on 6/21/24 at 2245 the patient’s pain score was 0-none (0-10 pain scale). On 6/22/24 at 1545, patient #2’s pain had spiked up to 7-severe, medications were adjusted. On 6/22/24 at 1733 patient’s pain level was 5-moderate. Medications continued to be adjusted by the Attending Physician CC and Physician Assistant DD (PA). No other pain levels were recorded after the level 5. Medications were adjusted and the patient expired at 1926. On 12/4/24 at approximately 1230, interview with Physician CC revealed that he was the attending physician (internal medicine/geriatrics), but not a hospice/palliative care physician. He stated that he and his PA have taken care of end of life patients with input from the hospice team. The requested Pain Management/Palliative Care Physician FF had not continued to follow and manage the patient’s pain. The patient’s right to develop and implement the pain management plan of care had not been honored.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 15195 Based on record review and interview, the facility failed to follow triage policies for 1 (#9) of 1 patients with an emergency acuity level of 2 (ESI 2), resulting in the potential for less than optimal outcomes. Findings include: Record review with the Emergency Center Nurse Director (Staff E) revealed that patient #9 was a 38-year-old male who had presented to the emergency center (EC) by car on 9/12/24 at 2146 with altered mental status. He was assessed (vital signs and questions) by the triage nurse at 2148 and assigned an acuity or emergency severity index (ESI) of 2 (a triage level assigned to patients who need emergency care and should be seen by a physician promptly). On 9/13/24 at 0104 (three hours and 16 minutes later), the patient was called back to an EC room, but had left without being seen by a physician or provider. On 10/16/24 at 1330, phone interview with the Triage Nurse (Staff Q), who worked on the date and time of the occurrence, revealed that she did not recall the patient. After review of her notes, Triage Nurse Q stated that on that evening they were very busy, the patient was younger, was stable, and that there were sicker patients in the EC. When the Triage Nurse was queried about additional assessments or vital signs, she stated that was done in the back when the patient was placed in an EC room. Interview with the EC Nursing Director E, on 10/16/24 at approximately 1400, verified that reassessment with vital signs should have been done after two hours by the triage nurse. Review of the EC policy and procedure titled “Assessment Standards For Nursing: Emergency Services, dated 7/19/24” documented, “Nursing Reassessment ESI level 1 & 2: Minimally every 1-hour while patient unstable (refer to ESI criteria), then every 2 hours once the patient’s acuity becomes more stable based on ESI level criteria.” This had not been done.”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 15195 Based on observation and interview, the facility failed to post Emergency Medical Treatment and Labor Act (EMTALA) signs in areas likely to be noticed by all individuals waiting for examination and treatment in the emergency center (EC), resulting in the potential for all EC patients to not be informed of their rights to have a medical screening exam and stabilizing treatment. Findings include: During the observational tour of the EC, on 10/15/24 at approximately 1030 - 1200, it was noted that there was only one EMTALA sign to the left and below eye level right next to the patient walk-in doorway and one sign in the ambulance entrance. The EC was a large 144 room facility with four triage rooms and a large waiting area. These signs were not visible to patients waiting for examination or treatment. There were no signs posted in the Waiting Area, none in the Triage Rooms, and none in the Treatment Rooms/Areas. On 10/15/24 at approximately 1120, EC Nurse Director E was queried about the lack of EMTALA signs and she stated that they only had EMTALA signs at the emergency entrances.”