Trinity Health Ann Arbor Hospital

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 29955 Based on interview and record review, the facility failed to ensure that 1 (P-1) of 10 patients reviewed was free from excessive force during behavior management, resulting in the loss of patient rights for P-1. Findings include: Review of the medical record revealed P-1 was a 22-year-old male with a history of ADHD (Attention Deficit Hyperactivity Disorder), depression, and developmental delay who was brought to the facility emergency room on 01/11/2026 at 08:26 PM via local police. P-1 had reportedly stood in the street hoping to be hit by a car and asked police to shoot him after they arrived on scene. P-1 was admitted to the facility Behavioral Health Unit on 01/14/2026 for suicidal ideation. A review of video footage from 01/14/2026 event was conducted on 06/03/2026. The footage revealed the following: 11:26 18 seconds PM - Facility security officers (staff J, K, S, T) followed P-1 into day room “lounge” 11:26 32 seconds PM - Nursing staff enter the room (staff N, O, P, Q - staff Q P-1’s nurse) 11:27 00 seconds PM - Staff started moving chairs and tables away from the area that was close to P-1 11:27 56 seconds PM - P-1 wrapped his arms and legs around the base of the table. 11:28 00 seconds PM - Security officers moved the table with P-1 wrapped around the base of the table. P-1 was surrounded by 5 staff members (Staff J, K, Q, S, T) 11:29 00 seconds PM - The table turned over and staff Q, RN, administered P-1 an injection 11:30 00 seconds PM - P-1 takes off socks and turns tables and chairs on their sides. P-1 did not attempt to physically strike any of the staff. 11:31 00 seconds PM - P-1 banged head on shatterproof glass leading to the courtyard 11:32 20 seconds PM - Staff K sprayed P-1 with pepper gel (first spray) P-1 continued to bang head on glass and could be seen shouting (no audio available) 11:32 35 seconds PM - Staff K sprayed P-1 with pepper gel (second spray). P-1 immediately started rubbing his eyes and pulling his T-shirt off 11:33 08 seconds PM - P-1 and staff exited the area - final film footage of the P-1 On 06/03/2026 at 03:50 PM an interview occurred with staff K, security officer, he explained that P-1 left the lounge area and went back to the seclusion room where P-1 was placed in restraints. Staff K stated that he requested that nursing staff bring a couple buckets of water to wash P-1’s face. Staff K stated that he advocated for P-1 to get a shower, and P-1 was released from the restraints and was taken to the shower. Staff K stated P-1 was restrained for several minutes before P-1 was taken to the shower room. On 06/03/2026 at 04:35 PM during an interview with staff Q, registered nurse, he explained that P-1 had been escalating earlier on the evening of 1/14/2026 at approximately 2000. Staff Q stated P-1 had been horsing around with another patient and had been offered PRN (as needed) medication Zyprexa to help calm P-1 down. Staff Q stated that when P-1 was offered the PRN medication Zyprexa that P-1 “really went off and became irate... He was threatening to harm me and other staff.” Staff Q further stated that when security was called P-1 escalated more and went into the patient lounge / activity room. Staff Q stated that P-1 swiped at him when he was trying to administer the PRN injection. Video review did not substantiate P-1 striking at staff Q while he was in the patient lounge / activity room. Further review of P-1’s medical record revealed documentation by staff P, Patient Care Assistant, revealed, “while pt was restrained this writer attempted to clean his face and eyes with soap and water. Writer then assisted pt in shower post seclusion, pt had a fall while this writer was out of the room due to not being able to see. Shower chair was offered and accepted. This writer assisted in bathing, room was changed after, and fresh clothes given. Pt had lots of redness on face and neck.” On 06/4/2026 at 09:20 AM during an interview with staff F, Director of Security, stated pepper gel was permitted to be used when security staff determined all efforts have been made to gain control of the patient. Staff F added that pepper gel was used in this instance due to the patient (P-1) banging his head on a glass door. Review of the policy titled, “Chemical Gel Irritant,” policy number 102, last reviewed on 6/2024, stated, “C. Use/Proper Use...2. Chemical gel restrictions of use:...b. The chemical gel will not be deployed on patients in the Behavior Health Unit unless the Security Police Officer responding has a good faith belief and can articulate there is an imminent threat of loss of life, great bodily harm, and the use of the chemical gel will preclude such loss from occurring...3. Once an offender, especially those with contact lenses, has been exposed to a chemical gel, the affected area, especially the eyes, should be flushed with water as soon as possible...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) Unless superseded by State law that is more restrictive-- (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1-hour for children under 9 years of age; This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to renew a violent restraint order every four hours while the patient was in restraint for 2 (P-4, P-25) of 5 patients reviewed for restraint resulting in the loss of patient rights. Findings include: Review of the medical record for P-4 revealed he was a 61-year-old male who presented to the Emergency Department (ED) 2/6/2025 at 1457 for alcohol intoxication. P-1 was highly agitated and was “swinging at security.” As a result, an order was given for violent/behavioral 4-point locked restraint on 2/6/2025 at 1500 with a duration of four hours and the restraints were applied on 2/6/2025 at 1501. The restraints were discontinued 2/6/2025 at 2047, 5 hours and 47 minutes after the first order. There was no renewal of the order for the restraints. This was confirmed by Staff G 8/25/2025 at 1345. Review of the medical record for P-25 revealed he was a 44-year-old male who presented to the ED 4/25/2025 at 1620 with paranoia and agitation. On 4/26/2025 at 0511, an order was given for violent restraint of the right wrist and left ankle. This order was modified 4/26/2025 at 0624 and 0629 to having all extremities restrained with a duration of 4 hours. A “reorder” of restraint was given on 4/26/2025 at 1104, 4 hours and 35 minutes after the modification order at 0629. This was confirmed by Staff G on 8/26/2025 at 1117. Facility policy “Restraint (Non-violent and Violent)” last revised 2/2025 states, “A physician/LIP [licensed independent practitioner] restraint order to manage a patient’s violent or self-destructive behavior must be renewed on the following scheduled [sic]: i. Adults 18 and older: every four (4) hours...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(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: 36887 Based on interview and record review, the facility failed to conduct a face-to-face assessment within one hour of initiation of violent/behavioral restraint for 3 (P-4, P-20, P-25) of 5 patients reviewed for restraint resulting in the potential for unidentified, unmet patient needs and poor patient outcomes. Findings include: Review of the medical record for P-4 revealed he was a 61-year-old male who presented to the Emergency Department (ED) 2/6/2025 at 1457 with alcoholic intoxication and agitation. An order was given on 2/6/2025 at 1500 for P-4 to be placed in four-point locked restraint. The restraints were initiated at 1501. The face-to-face-evaluation was conducted at 1500. This was confirmed by Staff E on 8/25/2025 at 1345. Review of the medical record for P-20 revealed he was a 30-year-old male who presented to the ED 7/30/2025 at 1142 with a drug overdose and agitation. An order was given 7/31/2025 at 0117 for 2-point locked restraint of the left wrist and right ankle. Restraint was initiated 7/31/2025 at 0105 and the face-to-face assessment was conducted at 0105. This was confirmed by Staff E on 8/26/2025 at 1042. Review of the medical record for P-25 revealed he was a 44-year-old male who presented to the ED 4/25/2025 at 1620 with paranoia and agitation. On 4/25/2025 at physical hold was done at 1621 followed by P-25 being placed in four-point locked restraints at 1623. The face-to-face assessment was done 4/25/2025 at 1620. Additionally, on 4/26/2025 at 0511, an order was placed violent/behavioral restraint of the right wrist and left ankle. AT 0624 and 0629 the order was modified to include all extremities. The face-to-face assessment was conducted at 0529. Facility policy “Restraint (Non-violent and Violent) last revised 2/2025 states, “For violent of self-destructive behavior, a face-to-face evaluation between the physician/LIP [licensed independent practitioner] and the patient will need to occur within one hour of the initiation of the restraint. The physician/LIP conducting a required evaluation must include an assessment of the following issues and document the evaluation findings in the patient’s medical record: i. The patient’s immediate situation ii. The patient’s reaction to the intervention iii. The pateint’s medical and behavioral condition iv. The need to continue or terminate the restraint or seclusion.””

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 50585 Based on interview and record review, the facility failed to document the patient’s communication preferences in a timely manner for 1 (P-1) of 2 patients reviewed requiring translation services resulting in the loss of patient rights and the increased likelihood of negative consequences for the patient. Findings include: On 3/15/2025 at 1039, P-1 was admitted to the facility’s Emergency Department. On 3/15/2025 at 1128, P-1 signed their general consent and there was no documentation whether any interpreter was used. On 3/16/2025 at 0215, P-1 was provided information on advanced directives and there was no documentation that an interpreter was used. On 3/17/2025 at 1622, P-1’s language status was changed in the medical record from English to Korean. On 3/17/2025 at 1649, P-1’s language preference for “written” was changed from English to Korean. On 3/17/2025 at 1741, P-1 was discharged from the facility with after care instruction documentation in the Korean language. On 3/20/2025 at 1106, three days after discharge, P-1’s medical record was updated to reflect P-1’s language for “spoken” was English. On 4/16/2025 at 1645, Nurse Staff O was queried why they used an interpreter when discharging P-1, and they revealed that P-1 “spoke Korean.” When queried if P-1 spoke English, Staff O revealed that they didn’t “know how much” and “could say a few words.” Staff O revealed that a family member shared that P-1 “doesn’t understand English.” Staff O proceeded to update P-1’s medical record with P-1 requiring interpreter services. According to the facility’s policy “Patients - Communication Assistance (Limited English Proficiency (EP) , Sight, Impairment and Hearing Impairment.), dated 2/24, “Every attempt will be made during the admission process to determine the communication assistance needs of each patient. This need will be documented in the medical record. Documentation will include, as applicable, the patient’s language and communication needs and authorized representative, if any. During high-risk communication, the presence of any interpreter must be documented in the medical record. The type of interpretation used as well as if the patient declines language interpretation services must be documented in the medical record. The policy also revealed “The following are examples, but not an all-inclusive list, of high-risk communications: providing information about advanced directives, obtaining informed consent or permission for treatment or surgery.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) [Unless superseded by State law that is more restrictive,] (iii) Each order for restraint used to ensure the physical safety of the non-violent or non-self-destructive patient may be renewed as authorized by hospital policy. This Standard is not met as evidenced by: 50585 Based on interview and record review, the facility failed to ensure an order for a restraint was initiated in a timely manner for 1 (P-5) of 4 patients reviewed for restraints resulting in the potential for negative consequences for the patient. Findings include: On 4/17/2025 at 1100, during P-5’s medical record review with Accreditation and Regulatory Program Leader Staff C, P-5 was placed in left and right wrist soft restraints on 4/13/2025 at 0000 for pulling lines and tubes. P-5’s order for the restraint occurred on 4/13/2025 at 0814, over 8 hours after soft restraints were initiated on P-5. Staff C confirmed the findings at the time of discovery. On 4/17/2025 at 1115, when queried how would you define as soon as possible for obtaining an order for restraints, Staff C revealed “one hour.” According to the facility’s policy “Restraint Non-violent and Violent), dated 2/25, “Physician/LIP or Registered Nurse if the physician/LIP is not available, a registered nurse may initiate restraint in advance of a physician/LIP order. If the restraint was due to a significant change in the patient’s condition, the physician shall be contacted as soon as possible for an order. If initiated by RN, notify physician/LIP to obtain an order as soon as possible.””

“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: 29955 Based on interview and record review, the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to identify a patient as unstable before transfer for 1 patient (P-1) of 20 patients reviewed, resulting in the potential for unrecognized needs for all unstable patients requiring transfer. Findings include: See tag 2409: Failure to properly transfer.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 29955 Based on record review, the facility failed to identify 1 (P-1) of 20 emergency department patients reviewed as having an unstabilized emergency medical condition (EMC) before transfer to a receiving facility, resulting in the failure to identify a patient as unstable and the potential for misunderstanding of the seriousness of the patient’s EMC. Findings include: Review of P-1’s medical record dated 07-13-2023 revealed that P-1 was a 54-year-old male who presented to facility A with chest pain and left leg pain/weakness with an onset immediately after feeling a sudden pop in his back. A computed tomographic angiography (CTA) scan showed type A dissection from the aortic root through the right iliac artery. Plan was for the patient to have emergent surgical repair of the dissection at the facility of concern (facility B). However, the vascular surgeon at facility B had to attend to his current surgical case who unexpectedly became acutely ill during surgery, leaving the vascular surgeon unavailable. P-1 was transferred to another facility in critical condition. The required stabilization for an aortic dissection is surgical repair. Since surgery was not available at facility B, the aortic dissection was not stabilized prior to the transfer of P-1 to receiving facility C. Material deterioration of type A dissection is not only reasonably medically probable without surgical repair; it is fully expected. Record review of facility B’s document titled “Emergency Transfer Record” dated 07/13/2023 for P-1 revealed under Section A, 2. “I hereby certify that the patient’s emergency medical condition has been stabilized such that, within reasonable medical probability, no material deterioration of the patient’s condition is likely to result or occur during transfer ...Physician signature on the form dated and timed 07/13/2023 at 1745. The transfer record from facility B erroneously reported the patient as stable. Review of policy “Patients-Screening, Stabilization and Transfer” dated 11/21 revealed under Definitions ...5. Emergency Medial Condition: A medical condition manifesting itself by acute symptoms of sufficient severity ...such that the absence of immediate medical attention could reasonably be expected to result in placing the health of an individual ...in serious jeopardy ... 10. Stabilized: A patient with an Emergency Medical Condition is considered stabilized such that the Hospital may effectuate a transfer ...if the treating physician attending to the individual determines with reasonable clinical confidence that the Emergency Medical Condition is resolved and/or no material deterioration of the individual’s condition is likely to result from or occur during transfer of the individual ...Main Campus Procedure. 2.B. (4) The receiving facility is provided with relevant records ...including; (b) applicable transfer forms, including the Emergency Transfer Record ...”

“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: 36887 Based on record review and interview, nursing staff failed to follow facility policy/guidelines and acceptable standards of practice regarding turning and repositioning of 1 (#9) of 2 patients reviewed for pressure injury wound care resulting in the potential for worsening wounds and poor patient outcomes. Findings include: On 3/12/2024 at 1404, review of the medical record for P-9 revealed he was a 78-year-old male who was admitted to MICU (medical intensive care unit) on 7/27/2023 for continuous EEG (electroencephalogram-test to measure the electrical activity of the brain). Past medical history included a meningioma (a usually noncancerous tumor that arises from the membranes surrounding the brain and spinal cord), seizures, chronic kidney disease Stage V, Type II diabetes, hypertension (high blood pressure), and hyperlipidemia (high fat content in the blood). P-9 remained in MICU until 7/31/2023 when he was transferred to a stepdown unit. He remained on stepdown until 10/15/2023 with a slow overall decline of health. Palliative care was consulted and recommended hospice; however, the family chose to continue with aggressive treatment. He was moved back to MICU on 10/15/2023 and was there until 10/25/2023 when he transferred to a long-term acute care hospital (LTACH). Physician notes dated 7/27/2023 revealed P-9 was “obtunded (state similar to lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states) and unresponsive on arrival.” GCS (Glasgow Coma Scale - a clinical scale used to reliably measure a person ’ s level of consciousness after a brain injury by measuring eye opening, verbal responses, and motor responses. Scoring 13-15: mild; 9-12: moderate; 3-8: severe; and <3: vegetative state) score was 6 with response to pain. A 24-hour continuous EEG was consistent with a “mild to moderate degree of diffuse encephalopathy...” P-9 had wounds noted to be in the coccyx area on admission. The initial nursing assessment dated 7/27/2023 revealed Braden score (assessment tool used to document patient risk for developing pressure injuries-very high risk <10, high risk 10-12, moderate risk 13-14, mild risk 15-18) was 10. Review of the Braden scores revealed his scores remained between 9-13 throughout the entire hospitalization. On 7/28/2023 at 0339, the physician ordered a wound consult “for multiple possible stage 2 wounds on coccyx.” The consult occurred later that same day at 1226. It described a 10 cm (centimeter) x 10 cm area over the coccyx. The consult stated. “He has a large evolving DTI (deep tissue injury) on his buttocks to open pink wounds scant to no drainage... A plan of care was discussed with the nurse.” The plan of care included a specialized bed, turning/repositioning the patient every two hours, floating the heels, frequent position changes, daily cleansing of the area with cleansers and wipes, and use of a lotion. When interviewed on 3/12/2024 at 1615, Wound Care Nurse Staff EE stated when she saw the wound on 7/28/2023, it was “an evolving deep tissue injury” which “always evolves into an open wound. Once it starts, there is no turning it around when it is that extensive. It just keeps getting worse and worse.” Staff EE stated the recommended treatment was the standard treatment per facility guidelines. Further review of the medical record revealed there were multiple gaps of 4+ hours between repositioning interventions throughout P-9’s hospitalization. Some of the larger gaps were as follows: -7/27/2023 from 0704 to 7/28/2023 at 0052 (17 hours, 48 minutes). It was 12 hours and 27 minutes from the time of the wound consult. -8/2/2023 from 1816 to 8/3/2023 at 0057 (6 hours, 41 minutes) -8/10/2023 from 1836 to 8/11/2023 at 0246 (8 hours, 10 minutes) -8/14/2023 from 2201 to 8/15/2023 at 0802 (10 hours, 1 minute) -8/17/2023 from 2052 to 8/18/2023 at 0814 (11 hours, 22 minutes) -8/18/2023 from 0814 to 8/18/2023 at 1830 (10 hours, 16 minutes) -8/18/2023 from 1830 to 8/19/2023 at 0224 (7 hours, 54 minutes) -8/20/2023 from 0805 to 8/21/2023 at 0108 (17 hours, 3 minutes) -8/21/2023 from 0108 to 8/21/2023 at 2051 (19 hours, 43 minutes) -8/23/2023 from 1850 to 8/24/2023 at 1058 (16 hours, 8 minutes) -9/3/2023 from 2221 to 9/5/2023 at 0015 (25 hours, 54 minutes) -9/6/2023 from 2214 to 9/7/2023 at 1020 (12 hours, 6 minutes) -9/14/2023 from 1453 to 9/15/2023 at 0107 (10 hours 14 minutes) -9/16/2023 from 1704 to 9/17/2023 at 0038 (7 hours, 34 minutes) -9/17/2023 from 0621 to 9/17/2023 at 2306 (16 hours, 15 minutes) -9/18/2023 from 0700 to 9/18/2023 at 1854 (11 hours, 54 minutes) -9/23/2023 from 0633 to 9/24/2023 at 0109 (18 hours, 36 minutes) -9/24/2023 from 0633 to 9/25/2023 at 0819 (25 hours, 46 minutes) -10/1/2023 from 1844 to 10/2/2023 at 0910 (14 hours, 26 minutes) -10/4/2023 from 1659 to 10/5/2023 at 0143 (9 hours, 42 minutes) -10/5/2023 from 2215 to 10/6/2023 at 1446 (16 hours, 31 minutes) -10/6/2023 from 1446 to 10/7/2023 at 2308 (32 hours, 22 minutes) -10/9/2023 from 2249 to 10/10/2023 at 1429 (15 hours, 40 minutes) -10/27/2023 from 2220 to 10/28/2023 at 1058 (12 hours, 38 minutes) During the record review on 3/12/2024 at 1430, Staff B acknowledged there were large gaps of time in which repositioning was not done or was not documented. Review of facility guidelines titled “Skin Assessment Bundle” effective July 2021 revealed based on P-9’s assessment, he should have received the following interventions: reposition every hour while sitting up; turn every 2 hours while resting in bed; off-load/elevate heels; place pillows between the knees and bony prominences to avoid direct contact; and avoid positioning individuals directly onto medical devices such as drainage tubes. Staff B stated on 3/13/2024 at 0925 the “Skin Assessment Bundle” was available for all staff to access and could be implemented without physician order.”