Beaumont Hospital, Troy

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 50585 Based on interview and record review, the facility failed to obtain a completed and signed Important Message From Medicare (IMM) consent for 1 (P-1) of 3 patients reviewed for IMM consents resulting in the loss of patient’s rights for the patient. Findings include: On 2/11/2026 at 1236, P-1’s medical record was reviewed with Lead Clinical Compliance Specialist Staff F. P-1’s IMM consent form revealed documentation in the patient’s signature line, “letter @ bedside” on 10/5/2025 at 1429. A review of the IMM consent copy for P-1’s discharge revealed documentation “copy left in room” on “10/9/2025 (dated of discharge).” In both cases, there was no documentation of P-1 or P-1’s representative signature present on the IMM consent form. On 2/12/2026 at 1100, Director of Patient Registration Staff P reviewed P-1’s IMM consent and confirmed the staff “did not follow” procedures in obtaining a signature. For the copy of the consent provided at discharge, Staff P revealed the staff member “thought they had a signature and gave a copy to patient” and “letter at beside is not a signature.” On 2/12/2026 at 1330, the facility’s policy, “Important Message from Medicare (IM 1st Notice), dated 8/15/2023 was reviewed and the policy revealed: 4.1.1. The Medicare notice must be delivered to the beneficiary in person. 4.1.2. Contents of the notice must be explained to the patient. 5.1 When obtaining a signature, provide the following explanation of the notice with the following script: If patient is able to comprehend the notice explanation: 5.2.1. Provide an explanation of the notice following the script in 5.1.1. 5.2.2. Obtain the patient’s signature on the notice: 5.2.2.1. If the patient is able to comprehend, but is physically unable to sign, ask the patient if a representative may sign. 5.2.2.2. If a representative is not available, have the patient acknowledge receipt of the notice verbally. In front of the patient, print the patient’s name and add the reason why the patient is unable to sign, example: “verbal, patient unable to sign due to diagnosis”. It is required to have two staff sign as witnesses, print their name, date and time. 5.3. If patient is NOT able to comprehend the notice and a representative is present: 5.3.1. Give the notice to the representative and provide an explanation of notice using the script in section 5.1.1. 5.3.2. Obtain the representative’s signature on the notice: 5.3.2.1. Add the representative’s first and last name and the relationship to the patient. 5.3.2.2. Add staff signature, printed name, date and 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: 45246 Based on interview and record review, facility failed to properly assess and monitor 5 restrained patients (P-1, 2, 3, 5, and 6) of 10 reviewed patients resulting in the potential for adverse outcomes for all restrained patients. Findings include: See Specific Tags: A-166 Failure to document restraints in a plan of care A-168 Failure to obtain provider’s order for restraints A-175 Failure to assess and monitor patients in restraints. A-184 Failure to document face to face provider assessment in the patient’s record”

“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 interview and record review, the facility failed to document use of restraints in a plan of care for two patients (P-5 and P-6) of 10 patients reviewed, resulting in possible negative outcomes for these patients. Findings include: P-5 Record review for P-5 on 10/21/25 revealed the following documentation: P-5 was an 82-year-old female who was admitted to facility on 10/17/25 with a chief complaint of right hip, low back and left lower leg pain post syncopal fall and subsequent head injury shortly after she stood up out of bed in the morsing on 10/15/25. P-5 had a history of syncopal falls, hypertension (elevated blood pressure), hyperlipidemia, chronic hyponatremia (low sodium levels in blood), IBS (irritable bowel syndrome), anemia, chronic low back pain, osteoarthritis, vitamin D deficiency, restless leg syndrome and skin cancer. During the hospitalization P-5 experienced change in mental status on 10/18/25. There was a provider order for “Restraints non-violent or non-self-destructive” dated 10/18/25 1200 for soft restraints left and right wrist, restraint etiology- acute delirium. Order for restraints was discontinued on 10/19/25 1012. Further review of P-5 medical record did not reveal documentation for plan of care for restraints. P-6 Record review for P-6 on 10/21/25 revealed the following documentation: Patient was a 63-year-old male admitted to facility on 10/20/25 at 0329 with chief complaint of seizure and possible stroke. Patient had a medical history GERD (gastroesophageal reflux disease), hypercholesterolemia (high levels of cholesterol in the blood), hypertension, OSA (obstructive sleep apnea), and Raynaud disease (condition that causes spasms in small blood vessels in your fingers and toes). Nursing note dated 10/20/25 0550 revealed: Patient very agitated, threatening to staff, verbally abusive; imminent harm to self & staff. Patient shouting out to sitter at bedside and staff. Multiple RN & security at bedside attempting to redirect patient back in bed; patient agitation increased. Patient placed in 4-point leather restraints. Notified Dr. [name]. Orders placed for restraints. Further P-6 medical record review revealed that patient was in violent restraints on 10/20/25 from 0627 to 1640. Review of the emergency center nursing documentation did not reveal a care plan for restraints for P-6. On 10/21/25 at approximately 1000 during interview with Director of Nursing, Staff G, she stated that nurses are required to document restraints in patients’ plan of care. Facility’s policy titled “Restraints: Care of the Patients in Restraints”, dated 07/21/2024, was reviewed and revealed: “III. Use of Restraints A. Ordering Requirements 1. Non-Violent Restraints m. Restraints will be documented on the patient’s plan of care.” Facility policy “Patient Plan of Care”, effective 07/21/24, was reviewed and revealed: C. Inpatient and Inpatient Rehab Plan of Care: vi. Documentation of patient progress and an outcome/summary statement is recommended on change in patient condition and minimally twice per day for hospitalized patients.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 45246 Based on interview and record review, the facility failed to ensure there was a provider order for the restraints for two patients (P-1 and P-3) of 10 patients reviewed, resulting in possible negative outcomes for these patients. Findings include: P-1 Record review for P-1 on 10/20/25 revealed the following documentation: P-1 was an 80-year-old female admitted to facility on 10/07/24 with chief complaint of vertigo. Patient had a history of chronic neck pain and hypertension (elevated blood pressure). There was a nursing note dated 10/07/24 2010: RN (registered nurse) at bedside to assess the patient. Patient became combative and paranoid feeling like she is going to “die” and wanting to call her family. RN wanted patient to be evaluated by physician due to sudden change in patient’s status, so RRT (rapid response team) was called and came to bedside. Patient combative with RRT, RN’s and confused. RRT PA (physician assistant) was called to bedside to also assess patient. Due to patient being combative and for safety reasons patient was placed in 4-point soft restraints so a full assessment could be completed. Epic camera was ordered for patient at this time as well for patient safety. Once cleared by RRT and PA patient was calm and RN left the patient resting in bed. Physician’s assistant (PA) note dated 10/7/2024 1735 revealed: RRT called to evaluate pt (patient) for suspected medication reaction. Pt admitted for BPPV (Benign paroxysmal positional vertigo- brief episodes of mild to intense dizziness that usually triggered by specific changes in the head’s position) which has responded to Benadryl gtt (drip) in the past. Pt was evaluated by neurology who ordered Benadryl 100 mg intended to be administered over 4 hours, however it was administered as an IVP (intravenous push). Pt subsequently became agitated, combative, and anxious after administration. She was attempting to bite and hit staff. RN notified Dr. [name] (Neurology) who recommended monitoring the patient and waiting for Benadryl to wear off. I arrived to bedside to find pt agitated, paranoid, and in restraints”. Further record review for P-1 revealed no provider orders for application or discontinue of 4-point soft restraints on 10/07/25. P-3 Record review for P-3 on 10/21/25 revealed the following documentation: Patient was a 21-year-old female admitted to facility on 8/20/25 with suicidal ideations and attempted self-injury. Patient had a history of schizoaffective disorder and autism. P-3 had intermittent and unpredictable instances of agitation and verbal and physical aggression towards facility staff. Patient was in violent restraints intermittently through her stay in the facility. There was a provider order for Violent 2-point keyed leather/fabric bilateral wrists restraints dated 09/01/25 1745 for 4 hours (till 2145). Next order for Violent 2-point keyed leather/fabric bilateral wrists restraints was dated 09/02/25 0708 for 4 hours (till 1108). There was no provider order for restraints between period of 09/01/25 2145 to 09/02/25 0708. Further record review revealed consistent nursing restraint assessment and documentation of P-3 who was continuing to be restrained for the above period of time (9 hours). On 10/20/25 at approximately 1350 during interview with director of nursing, Staff F, regarding restraints policy and provider’s orders he stated that restraints are initiated by the provider’s order. Facility policy “Restrains: Care of the Patient in Restraints”, effective 07/21/24, was reviewed and revealed: “II. Purpose of Restraints A. Non-Violent Restraint: Restraints are used when needed to manage non-violent behavior that jeopardizes the immediate physical safety of the patient. III. Use of Restraints. 1. Non-Violent Restraints a. Restraints may be initiated by the order of the physician, NP or PA (Provider) responsible for the patient’s care. When the order for restraints is initiated by a Resident, NP or PA, that provider will notify the Attending as soon as possible. b. The provider will complete a comprehensive patient assessment to identify medical problems that may be causing the behavior requiring restraint use. c. Restraint orders must include the type of restraint to be used and specify the location(s) that are to be restrained. d. In emergent situations, when the need for intervention occurs so quickly that an order cannot be obtained prior to application of physical restraints, an RN may initiate physical restraint based on assessment of the patient. The RN will notify the Provider within minutes of restraint application once the patient is safe and obtain the appropriate order. The assessment and restraint intervention must be documented by the RN. 2. Violent Restraints a. Restraints may be initiated by the order of the Physician, NP or PA (Provider) responsible for the patients care. When the order for restraints is initiated by a Resident, NP or PA, that provider will notify the Attending as soon as possible”.”

“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 interview and record review, the facility failed to properly assess and monitor two restrained patients (P-5 and P-6) of 10 reviewed patients resulting in possibility of patients’ physiological needs not being met, incomplete restraint assessments, and risk for negative outcomes for these patients. Findings include: P-5 Record review for P-5 on 10/21/25 revealed the following documentation: P-5 was an 82-year-old female who was admitted to facility on 10/17/25 with a chief complaint of right hip, low back and left lower leg pain post syncopal fall and subsequent head injury shortly after she stood up out of bed in the morning on 10/15/25. P-5 had a history of syncopal falls, hypertension (elevated blood pressure), hyperlipidemia, chronic hyponatremia (low sodium levels in blood), IBS (irritable bowel syndrome), anemia, chronic low back pain, osteoarthritis, vitamin D deficiency, restless leg syndrome and skin cancer. During the hospitalization P-5 experienced change in mental status on 10/18/25. There was a provider order for “Restraints non-violent or non-self-destructive” dated 10/18/25 1200 for soft restraints left and right wrist, restraint etiology- acute delirium. Order for restraints was discontinued on 10/19/25 1012. Further review of P-5 medical record revealed nursing restraint assessment documentation dated 10/18/25 1100. Next nursing restraint assessment was dated 10/18/25 1430 and had documentation that restraints were “discontinued”. No additional Q1h (every 1 hour) and Q2h (every 2 hours) restraint assessments were noted. P-6 Record review for P-5 on 10/21/25 revealed the following documentation: Patient was a 63-year-old male admitted to facility on 10/20/25 at 0329 with chief complaint of seizure and possible stroke. Patient had a medical history GERD (gastroesophageal reflux disease), hypercholesterolemia, hypertension, OSA (obstructive sleep apnea), and Raynaud disease (condition that causes spasms in small blood vessels in your fingers and toes). Nursing note dated 10/20/25 0550 revealed: Patient very agitated, threatening to staff, verbally abusive; imminent harm to self & staff. Patient shouting out to sitter at bedside and staff. Multiple RN & security at bedside attempting to redirect patient back in bed; patient agitation increased. Patient placed in 4-point leather restraints. Notified Dr. [name]. Orders placed for restraints. Further P-6 medical record review revealed the patient was in violent restraints on 10/20/25 from 0627 to 1640. Review of the emergency center nursing documentation revealed there was no Q1h (every one hour) violent restraint assessment for the time from 0627 to 0823, and from 1020 to 1220. On 10/21/25 at approximately 1000 during interview with Director of nursing, Staff G, she confirmed that nurses are required to document their restraint assessment every 2 hours while patient in restraints and every 1 hour for violent restraints assessment. Facility’s policy titled “Restraints: Care of the Patients in Restraints”, dated 07/21/2024, was reviewed and revealed: III. Use of Restraints B. Monitoring, Assessment, and Documentation of Patient Care. 1. General Standards a. Patients will be monitored and reassessed. Minimal standards for assessment, intervention, evaluation and re-intervention for non-violent restraints and violent restraints are listed below. It is expected that if the patient’s condition warrants, the monitoring will be more frequent or continuous. 2. Non-violent Restraint: Assessment and Documentation a. On initiation and discontinuation, the RN will document that the restraint used is the least restrictive restraint intervention and that it was applied properly and safely. b. Every 60 minutes, the RN will complete and document or delegate to an LPN or NSS. i. Patient observation to ensure that the patient’s safety is maintained c. Every 2 hours, the RN will complete and document (or delegate to an LPN or NSS the: i. Offering of nutrition, hydration, and toileting ii. Repositioning of the patient iii. Completion of range of motion as appropriate iv. Release/reapplication of physical restraints d. Every 2 hours, the RN will complete and document an assessment that includes: i. Patient behavior continues to require restraints ii. Current restraints continue to be appropriate for the behavior iii. Condition of restrained area including circulation, evidence of edema and skin condition iv. Patient’s behavior that places the patient or others at risk v. Physical and psychological status vi. Comfort 3. Violent Restraint: Assessment and Documentation c. Patients will be continuously observed by a trained staff member, staff will notify the RN immediately if there are any safety concerns. d. On initiation and discontinuation, the RN will document that the restraint used is the least restrictive restraint intervention and that it was applied properly and safely. e. Every 60 minutes, the RN will complete and document an assessment to ensure the patient’s safety is maintained. The assessment will include the following as appropriate. i. Patient behavior continues to require restraints ii. Current restraints continue to be appropriate for the behavior iii. Condition of restrained area including circulation, evidence of edema and skin condition iv. Physical and psychological status v. Comfort vi. Readiness for discontinuation of restraint vii. Range of motion in the extremities (release and reapply wrist/ankle restraints every two (2) hours) viii. Nutrition, hydration, and toileting (minimally every 2 hours) ix. Vital signs are obtained based on department assessment standards and provider orders. f. An LPN or NSS may assist with care activities”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 45246 Based on interview and record review, the facility failed to ensure there was a provider face to face assessment and documentation for violent restraints for two restrained patients (P-2 and P-6) of 10 patients reviewed, resulting in possible negative outcomes to these patients. Findings include: P-2 Record review for P-2 on 10/20/25 revealed the following documentation: P-2 was a 65-year-old female admitted to facility on 10/18/25 with chief complaint of shortness of breath, cough and nausea. Patient had a medical history of atrial fibrillation, anemia, chronic back pain, drug-seeking behavior, diabetes mellitus, chronic obstructive pulmonary disease, essential hypertension, dyslipidemia, peripheral neuropathy, spinal stenosis and severe recurrent major depression with suicidal ideations. There was a provider order for initiation of violent 4-point restraints dated 10/19/25 1621 and discontinued at 1921. There was a nursing note dated 10/19/25 1915: Patient in 4-point lockable restraints and sitter now at the bedside. At 1800, restraints removed, patient calm and cooperative. Further review of P-2 record revealed no ordering provider violent restraint face to face assessment and documentation in flowsheets. P-6 Record review for P-5 on 10/21/25 revealed the following documentation: Patient was a 63-year-old male admitted to facility on 10/20/25 at 0329 with chief complaint of seizure and possible stroke. Patient had a medical history GERD (gastroesophageal reflux disease), hypercholesterolemia, hypertension, OSA (obstructive sleep apnea), and Raynaud disease (condition that causes spasms in small blood vessels in your fingers and toes). Nursing note dated 10/20/25 0550 revealed: Patient very agitated, threatening to staff, verbally abusive; imminent harm to self & staff. Pt shouting out to sitter at bedside and staff. Multiple RN & security at bedside attempting to redirect patient back in bed; patient agitation increased. Patient placed in 4-point leather restraints. Notified Dr. [name]. Orders placed for restraints. Further P-6 medical record review revealed the patient was in violent restraints on 10/20/25 from 0627 to 1640. Review of the emergency center documentation did not reveal provider face to face violent restraint assessment and documentation for the initial order for violent restraints on 10/20/25 0627. On 10/20/25 at approximately 1350 during interview with director of nursing, Staff F, regarding restraints policy and provider’s orders he stated that restraints are initiated by the provider’s order and face to face assessment needs to be completed by providers within 1 hour after initiation of violent restraints. Facility’s policy titled “Restraints: Care of the Patients in Restraints”, dated 07/21/2024, was reviewed and revealed: “2. Violent Restraints a. Restraints may be initiated by the order of the Physician, NP or PA (Provider) responsible for the patient’s care. When the order for restraints is initiated by a Resident, NP or PA, that provider will notify the Attending as soon as possible. d. A face-to-face assessment is required by a Provider within one hour after restraint initiation.””

“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: 45246 Based on observation, interview and record review, the facility failed to ensure that registered nurses adhered to facility’s policy and procedures regarding patients’ timely initiation and documentation of the plan of care for three patients (P-1, 2 and 3) of 3 patients reviewed, resulting in possible unidentified patient care needs for these patients. Findings include: P-1 Review of the P-1 medical record revealed that patient was an 88-year-old female presented to facility’s emergency department (ED) on 03/11/25 at 1840 with a chief complaint of weakness. On 03/11/25 at 1842 a fall risk assessment was completed with a total Kinder score of 1 (The Kinder Falls Risk Assessment Tool utilizes five screening questions to identify those at risk of falling. A positive response to any of the questions denotes the requirement for risk reduction interventions to be implemented). On 03/11/25 at 1938 patient was “roomed” in RD401H. At approximately 2245 on 03/11/25 P-1 suffered a fall in the bathroom. P-1 was assigned a room RD 407 at 2246. On 03/11/25 at 2255 she was placed in observation status. On 03/12/25 at 0322 P-1’s status was changed to inpatient, and she was transferred to an inpatient unit. Further review of the record indicated that no nursing-initiated Care Plan Guide (CPG) was documented for P-1 during her stay in the facility’s ED and further, patient’s care plan was not evaluated by ED nursing staff at disposition/departure from the ED considering she suffered a fall with a hip fracture while in the facility’s ED. P-2 Review of the P-2 medical record revealed that P-2 was a 66-year-old female who arrived at facility’s ED on 05/06/25 at 1642 with a chief complaint of shortness of breath (wears 3L (liters of Oxygen) at baseline SpO2 86% (Oxygen saturation), now on 6L SpO2 94%, positive for cough and lower left extremity cellulitis. Symptoms worse with movement, patient was treated for pneumonia a week prior). Fall risk assessment was completed on 05/06/25 at 1652 with a Kinder score of 2. Physician’s note dated 05/06/25 2146 revealed: “Interventions initiated while patient (P-2) was in the ED (emergency department) included Cefazolin, Vancomycin, Zithromax, Ceftriaxone (antibiotics). Patient’s lab and imaging findings significant for pneumonia. Unlikely CHF (congestive heart failure) exacerbation as BNP negative (B-type natriuretic peptide is a diagnostic blood test that can indicate worsening heart failure). Discussed case with admitting physician who agreed with plan of admission to progressive care unit for further care and evaluation. Consults to Cardiology and Pulmonology were placed. Lasix was not ordered in the setting of possible AKI (acute kidney injury) which is likely from over diuresis.” On 05/06/25 at 1707 patient was assigned room BL508 and a nurse was assigned as well. On 05/06/25 at 2126 order was placed to admit P-1 to inpatient. On 05/07/25 at 0913 Shortness of breath assessments were completed by the nurse, and at 0914 “Asthma Exacerbation CPG Interventions” were initiated. At 0915 “General Emergency Care CPG Interventions”, “Dyspnea or Respiratory Distress CPG Interventions” and “COPD Exacerbation CPG Interventions” were added (16 hours after P-1 was assigned the bed in ED). P-3 Review of the P-3 medical record revealed that P-3 was an 83-year-old male presented to facility’s emergency department (ED) on 05/07/25 at 0908 with a chief complaint of “knee pain (Fall from standing. Was standing at sink washing hands when he states [sic] “my knees just gave out” denies any lightheadedness, dizziness, syncope, LOC (loss of consciousness). Complaints of left knee pain. Pain controlled at rest, significant with movement)”. P-3 was observed on 05/07/25 at 1000 lying on a stretcher in ED. His wife was sitting at the bedside. P-3 was interviewed during observation and stated that he was just admitted here because he fell at home. Patient was asked if staff nurses educated him to call for help when needed and not to get up on his own. P-3 stated that “they don’t need to remind me, I know that”. Registered nurse assigned to care for P-3, Staff K, approached the stretcher and applied yellow socks and a yellow wrist band to the patient. No education/reminder was provided to the patient and the family while she was doing that why he needed to wear those. Further review of the P-3 medical record on 05/07/25 at approximately 1430 revealed that a fall risk assessment was completed on 05/07/25 at 0921 with a Kinder score of 3. Patient was assigned room RD406H on 05/07/25 at 0933. Patient’s status changed to “ED observation patient” at 1218. At 1238 he was transferred to room RD403. “Lower Extremity Injury CPG Interventions” were initiated by the nurse, Staff K, on 05/07/25 at 1510. On 05/07/25 at 1512 during the interview with ED Nurse Manager, Staff J, she was asked about her expectations on how soon nurses need to chart on the patients’ assessments and plan of care. She stated that nurses need to provide patients’ assessments and care first, address any emergency needs, IV (peripheral intravenous access) starts, labs, tests, orders and then timely document the tasks completed including the care plan (CPG). Facility’s policy “Patient Plan of Care”, effective 07/21/24, was reviewed on 05/07/25 and revealed: “I. Purpose To establish guidelines to provide an individualized plan of care for each patient that is interprofessional, coordinated, high quality, and both patient and family-centered within the acute care setting (inpatient, ED and surgical/procedural care spaces). III. Policy A. Plan of Care Principles: i. Each patient will have a plan of care that is appropriate to their unique needs. It begins on arrival in the Emergency Department (ED), admission to the hospital and/or surgical/procedural setting. iii. Planning care starts with learning the patient’s chief complaint or medical diagnosis, assessment findings, and results of diagnostic testing to determine their individual needs. iv. Evidence-based Care Plan Guides (CPG(s)) and supportive documentation tools are designed for specific care settings and formulate the patient plan of care. CPGs support the associated professional processes of care (e.g., focused, and ongoing assessments, implementation of interventions to prevent/manage potential problems, goal/outcome evaluation, suggested patient education topics). Alterations or deviations from the evidence-based CPGs may be appropriate according to patient preference, provider order(s) or facility policy/procedure. v. The patient plan of care is individualized/revised based on ongoing assessment findings, the patient’s response to treatment/interventions and evaluation of progress toward goals/outcomes. B. Emergency Department Plan of Care: i. The patient care plan is initiated as soon as enough information is available to select appropriate Care Plan Guide (CPG), and within thirty minutes of ED bed assignment. a. A “rule-out” diagnosis may be used as the basis for selecting CPGs. ii. The patient’s care plan is evaluated at disposition/departure from the ED.””

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 19647 Based upon observation, and interview, the facility failed to maintain the hospital kitchen environment in a safe and sanitary condition. Food packages and items that have fallen and been left on the floor, present both a hazard for slips and falls, as well as create unsanitary conditions with potential for attracting pests and spread of harmful diseases to all staff and patients. Findings include: 1. On March 26, 2024 between 12:45 - 1:45 PM, during a tour of the main hospital kitchen, observation revealed food packages and food debris that had fallen onto the floor in the walk-in coolers # 1, 3, 4, 5, and 7, including butter packets, yogurt containers, pasta, French fries, and food crumbs. These conditions were confirmed by staff EE, and staff FF at the time of the sighting. At approximately 1:00 PM, Staff FF was asked how often they clean the kitchen floors. He responded that the kitchen staff sweep and mop the floors at least daily and often twice daily.”

“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: 45246 Based on observation, interview and record review, the facility failed to maintain a clean and sanitary environment as part of Infection Prevention and Control program, and failed to ensure Infection Prevention and Control standards of practice and facility’s policies were followed for Transmission Based Precautions and Standard Precautions, resulting in the potential for the spread of infection to all patients. Findings include: Initial facility tour was conducted on 03/26/24 at 0930 with Staff B, Staff G and Staff H. Tour began in facility’s Emergency Department (ED). During observation, staff nurse, Staff I, was noted handling patient’s blood specimen in a vacutainer tube at the computer station, while wearing blue gloves. Staff I hand specimen at the computer station, used computer keyboard, printed label, placed it on the tube and proceeded to a different room with a specimen tube in hand (no biohazard plastic bag was observed in use at this moment or prior). Staff I returned to the computer station without a specimen. When asked about the process of specimen collection, Staff I stated that she always puts clean gloves on after collecting specimen from the patient. When asked if the tube came from a patient bedside area, she stated yes. She explained that she collected a specimen, and came to the nurses’ station to print a label for it. When asked if she was planning to clean computer station, Staff I stated “absolutely, I have my sanitary wipes ready right here”. Further, a roll of white tape was observed taped to a glass edge of the nurses’ station about 7 feet high from the floor. Staff could not speak to why the roll was placed there. Patient triage examination room was observed and had a brown shipping box with supplies placed on a floor in a corner, with shipping label visible and hand-written instructions not to remove the box. Patients’ public bathroom was observed next. There were two metal shelves with clean supplies stored in plastic bins about 2-3 feet away from the toilet. Supplies were not secured/locked and could be accessed/touched by anyone who used the bathroom. Patient bay #12 was observed next. It had a floor sideboard of approximately 3 feet in length missing. Side chair in a bay was noted to have tears with white material visible and exposed. Bay #14 was observed to have a hole through the drywall atop of the mounting board (headboard area) approximately 1- 1 1/2 inch in diameter. Multiple areas with paint missing and drywall exposed were observed throughout the tour of the ED. Staff B stated that all areas that need attention (patching and repainting) will be addressed with workorders immediately. Also, multiple areas with tape or tape residue were observed in ED on work surfaces, walls, and equipment. This was acknowledged by Staff G and Staff H at the time of observation. Pediatric ED area was toured at 1025 on 3/26/24. Room #109 was empty and available for observation. White debris and dust collection was observed on the floor next to patient headboard area. Blue rubber tourniquet (from intravenous access start kit) was observed on the ceiling light holding two light arms together. Staff G could not explain the reason for its use on the light. Further, a sink was observed across nurses’ station that had a step stool placed on top of it. After inquiring with nurses, Staff G said that it was used for pediatric patients to help step up and wash their hands at the sink. Next, patients’ public bathroom located across from room #102 was observed. There were metal shelves with clean supplies stored in plastic bins about 2-3 feet away from the toilet. Supplies were not secured/locked and could be accessed/touched by anyone who used the bathroom. Further observation of ED confirmed that majority of the bathrooms had similar set up. Staff G and Staff H acknowledged it. Family area was observed at the end of the hall with two white privacy screens stored in it. Screens were connected together at 3 points of contact with Coban (self-adherent elastic wrap that is used for strain and sprain support and secure dressing or devices without the need to for adhesives, pins, clips, or tape). Ambulance nurses’ station was toured next. There was a copious amount of dark gray dust found on the top of the blanket warmer. This was acknowledged by Staff G and Staff H at the time of observation. Clinical staff member was observed in the same area with a face mask worn below her chin. Staff G was asked if this was appropriate wear of the PPE. She responded “no”. On 3/26/24 at 1140 Staff Z, facility’s Infection prevention specialist joined the team on the facility tour. Staff Z was asked if he was aware of the scope and prevalence of tape use on surfaces, equipment and tape residue identified in ED areas. Staff Z shared that facility Infection control department was aware of “tape issue” and was working on implementing strategies to minimize it’s use on surfaces in patient care areas. On 3/26/24 at 1450 tour of 4 West Unit was conducted with Staff B, Staff L, and Staff J. Room #4925 was observed to have a contact isolation precaution sign on with PPE supplies bin placed outside of the room. Staff was observed exiting the isolation room wearing mask and blue gloves, holding clipboard and a pen. Staff was not noted to have a gown while in a room with a patient. Staff proceeded to walk the hall. Staff B stepped in with immediate correction and education. Next patient room had a bedside commode placed in a corner with 2 blue positioning assistive devices placed on it. Staff L was asked what those blue devices were used for. He stated that staff use them for keeping patient’s feet off the bed (pressure injury prevention). When asked if storing these devices on a bedside commode was appropriate, Staff L stated that it was not. Family area was observed to have chair and a love seat with tears and underlayment material visible and exposed. Tape and tape residue was observed on surfaces and patient equipment (bedside commode). This was acknowledged by Staff B and Staff L. On 03/27/24 at 1430 interview was conducted with Staff B, Staff Y, Manager of Infection Prevention department and Infection Control specialists, Staff Z, Staff AA, Staff BB, Staff CC and Staff DD. Facility’s infection Prevention and Control Program was discussed in detail with pertinent documentation reviewed. Process of auditing and observing staff for compliance with Infection Prevention policies and procedures was identified. Staff was asked if issues identified during the tour of the ED department was known to the Infection Prevention department. Staff Y shared that the clean supplies storage in public/patients’ bathrooms was not a prior identified issue. Prevalence of tape use was known to all staff present in the meeting. On 3/27/24 at 1600 interview with CNO, Staff B, was conducted. Staff B stated that facility identified opportunities for improvement in ED and had already interventions in place to address the issues. Facility’s policies for Infection Prevention and Control, as well as policy for Infection Prevention and Control program were requested and reviewed on 3/27/24. Standard Precautions Policy, effective and revised 4/18/23, indicated: Purpose and Objective. Standard precautions are meant to reduce the risk of transmission of bloodborne and other pathogens from both recognized and unrecognized sources. They are the basic level of infection control precautions which are to be used as a minimum in the care of all patients. Policy statement: A. All patients are considered to be potentially infected with pathogenic microorganism. Standard precautions are a concept that emphasizes protection against direct or indirect contact with infectious agents that maybe found in blood, body fluids, other potentially infectious material (OPIM) or contaminated surfaces. D. Standard precautions should be used consistently in the care of all patients in all patient care settings. These measures are to be used when providing care to all individuals, whether or not they appear infectious or symptomatic. Handling of Specimens, linen, and equipment: A. Laboratory Specimens 1. Each specimen should be placed in a container with a secure lid to prevent leakage during transport. Care should be taken when collecting specimens to avoid contamination of the outside of the container. The container must be labeled prior to placing a specimen in it. 2. It is unacceptable to send non intact or leak in specimen containers to the laboratory. All laboratory specimens are considered to be contaminated and should be placed in the leak-proof, labeled biohazard bags at point of use. 3. Vacutainer specimens that are transported in a specimen rack need not be placed in a leak-proof bag. Those vacutainer specimens that are transported by hand should be placed in the leak-proof biohazard bags at a site of use. D. Storage of clean and sterile equipment and supplies 3. Medical and surgical items must not be stored under sinks, under exposed water or sewer pipes, or in any location where they could become wet. a. Medications should not be prepared, and clean/sterile patient supplies should not be stored near areas of splashing water (i.e., within 3 feet/36 inches of a sink). 6. Outside shipping containers should be examined for obvious signs of damage and if damage is found it is advisable to unpack contents in the loading dock area. a. Whenever possible shipping boxes should be unpacked and broken down in an area designated for this purpose; this should not be done in any area designated as “sterile”, “semi-sterile” or clean. Isolation Practices Policy, effective and revised 4/25/24, revealed: II. Policy Statement: 3. Healthcare personnel (HCP) should always follow Standard Precautions in addition to transmission-based precautions to reduce the risk of cross contamination and microbial transmission. HCP includes all clinical and support staff, doctors, licensed mid-level providers, volunteers, students, etc. 7. Ensure isolation signs are posted clearly so that anyone entering the patient room is alerted to the precaution requirements to reduce transmission. 8. Educate all guests for the need to adhere to precautions prior to entering patient room. III. Responsibilities for Isolation Management: A. All healthcare workers are responsible for complying with all posted isolation precautions. Proper Use of Personal Protective Equipment (PPE) 3. Removing (Doffing) PPE: a. When removing PPE, care must be taken to avoid self-contamination and potential exposure to infectious materials. b. PPE should be removed in the room or other patient environment in this order: i. Slowly and carefully remove gloves; most contaminated piece of PPE. ii. Remove googles or face shield. iii. Remove gown. iv. Remove mask or N-95 respirator or PAPR v. Perform hand hygiene immediately after removing all PPE. Facility’s Infection Control Plan effective 2023 indicated: EP 3: The hospital assigns responsibility for the daily management of infection prevention and control activities. a. The daily management of infection prevention activities is given to the department of Infection Prevention & Epidemiology. c. The Infection Prevention & Epidemiology staff and Committee will focus resources and attention on specific goals, e.g., respiratory education, (COVID-19, influenza), patient isolation, removing patient isolations, staff safety, patient and visitor safety, proper use of PPE, etc. e. Continue to focus on hospital cleanliness via rounding and audits to ensure appropriate cleanliness is being done. Low Level Cleaning and Disinfection of Surfaces and Patient Care Equipment Policy, effective and revised 3/1/24, indicated: I. Purpose and Objective: to provide information about best practice recommendations for the selection and use of cleaning and disinfecting products. II. Policy Statement: Proper cleaning and disinfection of environmental services and patient care equipment is vital to protect patients and staff from infection. IV. Procedure for cleaning and disinfection: Non-critical care items: Patient care equipment or environmental surfaces which only come in contact with intact skin. Low level disinfection.”