Ascension Genesys Hospital

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(3) The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient or others from harm. This Standard is not met as evidenced by: 27408 Based on interview, and record review, the facility failed to ensure the provider order for restraints for 1(P-2) of 3 patients reviewed for restraints matched the type of restraint used, resulting in possible negative outcomes for the patient. Findings include: On 08/11/25 at 1016, during the initial tour it was noted P-2 was in his bed, sleeping with 4-point soft restraints applied to all 4 extremities. When the Nursing Manager of the 4th Floor, Staff R, was queried, she stated that that it was for medical reasons, even though the patient did not have any lines (heart monitor, oxygen, IV line). The patient’s most recent order was written 08/10/25 for soft restraints for “All extremities, soft restraints.” Also during the initial tour, 4 point locking restraints were on P-2’s bed frame. When Staff R was queried as to why there were 4 locking soft restraints hanging on the bed rail, located at each limb, Staff R stated,”Well sometimes we need them.” Further record review revealed on 08/10/25 between 0830 and 1030 it was documented that P-2 had 4 point locking restraints on all 4 limbs. The order was reviewed and was written for 4 point soft restraints, not the 4 point locking restraints. Further record review noted the last time a Physician/Advanced Practitioner, order for 4 point locking restraints was written on 07/31/25 at 2158. On 08/12/25 at 1530, during review of the document titled “Restraint Usage on Non-Behavioral Health Units (Policy),” dated 08/23/24, “10. New orders are required if: More restrictive restraints are required.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 27408 Based on observation, interview, and record review, the facility failed to remove 1(P-2) of 3 patients reviewed for restraints from restraints when restraint criteria was not met, resulting in risk for potential unnecessary restraint application. Findings include: On 08/11/25 at 1016, during the initial tour it was noted P-2 was in his bed, sleeping with 4-point soft restraints applied to all 4 extremities. When the Nursing Manager of the 4th Floor, Staff R, was queried, she stated that that it was for medical reasons, even though the patient did not have any lines (heart monitor, oxygen, IV line). The patient’s most recent order was written 08/10/25 at 0245 for 4 point soft restraints for “All extremities, soft restraints.” On 08/11/25 at 1030, during an interview with Nurse Manager, Staff R, regarding the restraint policy, assessments and orders, she stated that nursing assessments are “completed every hour for non-violent restraints, including the assessment for the need of restraints.” Documentation reflected that the patient was “quiet, calm, and resting”. Yet he remained in 4 point soft restraints. P-2 at the time of observation, 1016 appeared to be sleeping while in 4-point soft restraint. He did not have any type of medical lines (IV, heart monitor, urine catheter). Record review at that time, showed that P-2 was in 4-point restraint from on 08/11/25 at 0430 until the time of observation at 1016, and noted to be “quiet, calm,” or “appeared to be sleeping” for that entire time. On 08/12/25 at 0937, during observations, it was noted that P-2 was in bed, calm and quiet, using his phone and was in 4-point soft restraints. When the Manager of the 4th Floor, Staff R, was queried, she stated, “he was impulsive, and they (restraints) were for his behaviors.” He did not have any type of medical lines (IV, heart monitor, urine catheter). Record review at that time, 0937, showed that P-2 was in 4-point restraint from on 08/12/25 at 0345 until the time of observation at 0937, and noted to be “quiet, calm,” or “appeared to be sleeping” for that entire time. Yet he remained in 4-point soft restraints. On 08/12/25 at 1530, during review of the document titled “Restraint Usage on Non-Behavioral Health Units (Policy),” dated 08/23/24, “Non-Violent or Violent Restraints may only be imposed to ensure immediate physical safety of the patient or others and must be discontinued at the earliest possible time.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 50585 Based on observation, interview and record review, the facility failed to assess, monitor and provide care in a safe environment for 2 patients (P-1 and P-4) of 11 patients reviewed, resulting in an increased likelihood for adverse outcomes for all patients with high-risk for suicide at the facility and potential for negative outcomes for patients in restraints. Findings Include: See Specific Tags: A-130 Failure to implement a safety care plan for a patient with suicidal ideation. A-143 Failure to protect patients’ health and personal information A-144 Failure to provide patient care in a safe setting A-166 Failure to document a plan of care for a restrained patient A-175 Failure to assess and monitor patient in restraints.”

“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: 50585 Based on interview and record review, the facility failed to ensure the implementation of a care plan for suicidal ideation for 1 (P-1) of 11 patients reviewed, resulting in the potential for less-than-optimal outcomes for the patient. Findings include: According to P-1’s medical record, P-1’s suicidal ideation was confirmed on 1/18/2025 at 2130 while P-1 was in the Emergency Department. On 1/19/2025 at 2030, P-1 was transferred to the inpatient unit and the initial care plan documented as “Care Plan Essentials” did not reveal anything about safety for suicidal ideation. On 1/23/2025 at 1100, Nurse Manager Staff K was queried if there was a care plan for P-1’s suicide ideation and they said “no.” When queried if there should be a care plan essential for suicidal ideation and Staff K said “yes.” According to the facility’s policy “Patient Care Planning and Implementation.” dated 3/2024, “Each patient’s care is based on identified needs and established care standards consistent with a multi-disciplinary approach” and “Reasonable patient outcomes are established and evaluated as to progress throughout the patient’s contact with or system and should be modified/updated twice within a 24 hour period and/or as condition changes.” According to the facility’s policy “Suicide Risk Screening, Assessment & Response Policy - Emergency Department and Acute Care,” dated 6/2023, under documentation, “The appropriate Patient Centered Plan of Care will be initiated and updated at least daily.””

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 45246 Based on observation, interview and record review, the facility failed to ensure that patients’ health and personal information was protected in the clinical setting for 2 of 2 mobile workstation observations, resulting in the potential for unauthorized access to confidential patient data. Findings include: On 01/21/25 from 0955 to approximately 1110 initial tour of the facility was conducted. During the tour of the Medical intensive care unit (MICU) at 1035 with facility’s Director of Nursing, Staff E, a “computer on wheels” station was observed in a hallway, next to the patient’s room, unattended, and positioned with computer monitor facing the wall. Upon further observation, the computer screen was visible from the side with a patient’s personal and healthcare related information displayed on it. No staff was noted in attendance. Several minutes later, respiratory therapist, Staff II, approached the computer. Staff II was queried if she was using this computer station. She stated “yes”. Further, Staff II was asked if she left the computer unattended with patient information on it. Staff II stated that she left “for couple minutes only to get treatment medications” for this patient and she turned the computer towards the wall to protect patient’s information. On 01/21/25 at 1055, during the tour of the facility’s medical surgical unit (2 South) with Staff E, an unattended “computer on wheels” station was observed in a hallway. No staff was observed in attendance or monitoring. When approached by surveyor, computer screen had a patient’s information displayed on it, and it was visible to anyone who would pass by. Additionally, there was paper documentation lying on the top of the station with the other patient’s information (medical record and treatment orders) visible. Staff E was present during the observation and was asked if this was a common practice to leave patients’ information open to view and unattended. Staff E stated “no”, staff are required to secure the computer (log out) prior to leaving it. In addition, the medication cart, attached to the station was unlocked and had medications visible and easily accessible. Approximately 5 minutes later respiratory therapist, Staff JJ approached the computer station. Staff JJ was queried if she was using this computer. She stated “yes”. Further, Staff JJ was asked if she left the computer unattended, unlocked and with patient information visible on it. Staff JJ stated that she went “to get medication for the patient and she needs to administer it right now”. Facility’s policy “Patient Rights and Responsibilities”, approved 01/2025, was reviewed and revealed: Purpose. To define and distribute rights and responsibilities for patients. Policy. A patient has the right: O. To confidentiality of his/her legal medical record.”

“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: 50585 Based on interview and record review, the facility failed to ensure a patient with suicidal ideation was directly monitored and placed in a safe room for 1 (P-1) of 11 patients reviewed, resulting in increased likelihood for adverse outcomes for the patient. Findings include: On 1/18/2025 at 1946, P-1’s Emergency Department (ED) Nurse Staff R completed the suicide assessment screen at triage, and the results indicated there was no risk for suicide. On 1/18/2025 at 2130, after obtaining additional patient (P-1) information from a family member, ED Physician Staff DD ordered “Sitter (Pt Care Order) Suicide watch until Psych Eval done.” Upon review of P-1’s medical record, there were no patient sitter observations documented in the ED on 1/18/2025 at 2145, 2200, 2215, 2230, 2245, 2300, 2315, 2330, 2345 and on 1/19/2025 at 0000, 0015, 0030, and 0045.” Also, there was no documentation that P-1’s ED room was confirmed as a safe room (removing objects that patient can harm themselves with). On 1/19/2025 at 1625, P-1’s “Consult Note- Behavioral Health - Psychology” revealed that “Recommend sitter remain for the duration of the hospital stay, as P-1’s impulsivity can come and go with little provocation.” On 1/19/2025 at 1959, P-1 was transported to the inpatient unit. According to the medical record, there was no documentation that P-1’s patient sitter performed safety checks on 1/20/2025 at 0300, 0315, 0330, 0345, and 0400 and there was no documentation prior to or immediately after P-1 arrived at the inpatient unit that the inpatient room was prepared as a safer room. During the period of the missing safety checks, both Nurse Assistants Staff M (primary) and Staff CC (provided coverage for Staff M) cared for P-1. On 1/23/2025 at 1645, ED Nurse Staff R was queried if they received an order for suicide precautions for P-1. Staff R revealed that they completed P-1’s suicide screening assessment and later had to go to x-ray with another patient and Staff R “missed” seeing the order (from ED Physician Staff DD at 2130) for a patient sitter). When queried if they recalled whether the room was set up as a safer room, they did not remember. When queried if they received the order for a sitter for suicide ideation, then would that initiate the room to be modified as a safer room and they said “yes.” On 1/24/2025 at 1415, interviewed Nursing Manager Staff K. Staff K contacted Nurse Assistant Staff M and provided the missing safety checks that were performed by Staff M on 1/20/2025. Staff K revealed that Staff M placed their safety check documentation on their clipboard and therefore the safety checks were not available for review. When queried if Staff K expected the covering Nurse Assistant Staff CC to obtain a new “Suicide Sitter Frequent Observation Documentation” form to document safety checks and they said “yes.” According to the facility’s policy “Suicide Risk Screening, Assessment & Response Policy - Emergency Department and Acute Care,” dated 6/2023, for a “high risk” patient: “1:1 PSA (patient safety attendant) at bedside within arm’s reach with full visual eye contact at all times. DO NOT leave unless another trained PSA present.” The policy also revealed for documentation, the “trained sitter or Nurse/Designee will complete the appropriate documentation for one-to-one or for visual surveillance video monitoring and for activities of daily living in the medical record.” “A safer room is a room where items that a patient could use to harm or kill themselves are removed or minimized. There are two different types of safer room: a room that has been constructed specifically to be a safer room, and a regular room where a process and guideline are utilized to remove items that could be used for lethal means” and for “high-risk” patient, “Place patient in safer room with guidelines completed, put in gown and remove belongings.” Under documentation, “Preparation of the Safer Room is documented in the patient’s medical record.” According to the facility’s policy “(Facility) Patient Safety Attendant (PSA) Policy,” dated 4/2023, “The trained PSA observer or nurse designee will complete all the appropriate documentation needed for 1:1 safety monitoring, and for activities of daily living on the Frequent Observation Documentation Form” and “The tool is used to record observation of the patient’s behavior and interventions attempted every 30 minutes. This tool should be used in communication of pertinent information in all hand-offs from the PSA-PSA and PSA-nurse.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 45246 Based on observation, interview and record review, the facility failed to consistently document use of restraints in a plan of care for one patient (P-4) of 2 patients reviewed for restraint care plans, resulting in possible negative outcomes to the patient. Findings include: On 01/21/25 at 1120, during the tour of facility, P-4 was observed in his room, sitting in bed, with bilateral soft restraints on his wrists. Nurse Manager, Staff I, was present during the observation and was asked what care and documentation regarding restraints staff nurses complete. She stated that nurses complete and document their daily assessments of patients in restraints (for soft non-violent restraints every 2 hours). P-4 medical record review revealed that patient was a 55-year-old male admitted to facility on 01/15/25 with diagnosis of severe colitis. Patient’s record review revealed soft bilateral restraints order dated 01/16/25 at 1200 (noon). Restraints were re-ordered by physician every day until patient’s discharge on 01/22/25. Restraints were applied on 01/16/25 1500 and discontinued on 01/22/25 1545 at discharge. Review of care plans for P-4 did not reveal a care plan for restraints. No plan of care or treatment was established for P-4 that reflected a process of assessment, interventions, and evaluation for use of restraints. Further, there was a flowsheet restraints assessment documentation with the column “Safety: restraints care plan (each shift)” for staff documentation. The following shifts were missing this documentation: 01/16/25- night shift, 01/17/25- day and night shift, 01/20/25- day and night shift, 01/21/25- night shift. During P-4’s record review on 01/21/25 at 1330 Director of Nursing, Staff D, was asked how often staff nurses update patients’ care plans. Staff D stated that plans of care have to be updated by nurses every shift. Facility policy “Patient Care Planning and Implementation”, approved 03/2024, was reviewed and indicated: “Policy statement. Each patient’s care based on identified needs and established care standards consistent with multi-disciplinary approach. Policy detail. A. 1. The appropriate setting and service is identified and provided to meet each patient’s unique care goals. 4. Reasonable patient’s outcomes are established and evaluated as to progress throughout the patient’s contact with our system and should be modified/updated twice within a 24 hour period and/or as condition changes.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 45246 Based on observation, interview and record review, the facility failed to consistently assess and monitor 1 restrained patient (P-4) of 2 patients reviewed for restraints, resulting in the patient’s physiological needs not being met, incomplete restraint assessments, and risk for negative outcomes for the patient. Findings include: On 01/21/25 at 1120, during the tour of facility, P-4 was observed in his room, sitting in bed, with bilateral soft restraints on his wrists. Nurse Manager, Staff I, was present during the observation and was asked what care and documentation regarding restraints staff nurses complete. She stated that nurses complete and document their daily assessments of patients in restraints (for soft non-violent restraints every 2 hours). P-4 medical record review revealed that patient was a 55-year-old male admitted to facility on 01/15/25 at 2037 with diagnosis of rectal discharge and severe colitis. Patient had a past medical history of Down syndrome with developmental delay, CHF (congestive heart failure), hypothyroidism, GERD (Gastroesophageal reflux disease is a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach), depression, DVT (deep vein thrombosis), pulmonary embolism, compartment syndrome, chronic anemia, benign prostatic hypertrophy, neurogenic bladder (with suprapubic catheter), and necrotizing fasciitis in 2024 (serious bacterial infection that results in the death of the body’s soft tissue). There was a documented order for restraints, dated 01/16/25 1200, type- Med-Surg (medical-surgical) 24 hour/calendar day renewal, restraint type: soft- both wrist; behavior required for release: no longer threat to self or others. Restraints were applied by the nurse on 01/16/25 1500 and discontinued on 01/22/25 1545 upon patient’s discharge. Nursing restraint Q2h (every 2 hours) monitoring documentation reflected that P-4 was assessed on 01/16/25 at 1500. Next assessments were documented on 01/16/25 at 2000 and 2200. There were no documented Q2h nursing restraint assessments from 01/17/25 0554 until 01/17/25 2000 (total of 14 hours). No Q2h restraint assessment was documented on 01/18/25 from 1600 to 2000, and on 01/18/25 from 2000 to 01/19/25 0000. On 01/23/25 at 1050, during interview with Nurse Manager, Staff I, she was asked how often staff nurses need to document assessments for non-violent soft restraints. Staff I confirmed that assessments must be done every 2 hours. Facility policy “Restraint Usage on Non Behavioral Health Units”, approved 08/2024, was reviewed and revealed: “I. General Statement and Implementation B. Key Tasks 4. The nurse is responsible for overseeing the care of the patient as well as educating the patient and notifying next of kin or designee as applicable regarding the reason for the use of restraint. 10. Initiation, ongoing monitoring and discontinuation of restraints are documented on the appropriate forms (electronic where available). II. Non-Violent Restraints B. Monitoring 1. Patients should have/be offered the following a minimum of every two-hours unless a patient’s condition warrants otherwise: -Opportunity to toilet/elimination -Range of motion -Assessment of physical, emotional, and mental status -Privacy/modesty -Circulation to extremities -Skin care -Evaluation to determine if criteria are met for restraint discontinuation 2. Document patient’s response to the use of restraints. Documentation. Every 2 hours, the following must be documented: -Assessment of need for restraints (readiness for discontinuation of use of restraint) - Psychosocial interventions - Nursing interventions - Environmental interventions - Patient behaviors - Type and location of restraints - Patient restraints assessment - Patient response to restraints - Time and reason restraints should continue or be removed/discontinued.””