Detroit Receiving Hospital

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 47415 Based on interview and record review, the facility failed to ensure that the registered nurse followed physician orders for wound care treatments and that registered nurses documented wound assessment and treatments per policy/protocol for 2 (P-1, P-8) of 5 patients reviewed for wound care resulting in the potential for unsatisfactory outcomes. Findings include: On 5/6/25 at approximately 1430, the medical record for P-1 was reviewed with the assistance of RN Director Staff F. The record review revealed that P-1 was assessed on admission (4/16/25) with wounds on left buttock, measuring 2 centimeters (cm) x 1.5 cm, left neck measuring 1 cm x 1 cm, right lateral knee measuring 3 cm x 2 cm, and right foot, no measurements found. An order to “irrigate wound bed with normal saline daily and as needed (PRN)” was written on 4/17/25 at 0559. No documentation that a daily wound irrigation was carried out found in the record (or refused) on any day from 4/17/25 (order date) through 4/22/25 (discharge date). Findings confirmed by Staff F during record review. On 5/7/25 at 1115, an interview with RN Staff M in a conference room revealed she was familiar with P-1, and described his behavior as aggressive, and noted he frequently refused care. Staff M asked what is done when patients refuse care and/or medications, and she stated the refusal is documented in the record, education is given, and the provider is notified. There was no evidence this was done for P-1. P-8 a 70-year-old man with history of chronic debility, cerebral vascular accident (CVA), Ethanol (EtOH) disorder, alcohol withdrawal seizures, and deep vein thrombosis was admitted with numerous areas of skin breakdown including unstageable wounds (documented by nursing) on left lower buttock, left foot and right heel. P-8 was an inpatient at the facility at the time of survey. Providers note dated 5/2/25 at 1207, revealed wound care was consulted. Wound care initiated prior to wound care consult being completed (between 5/2/25 -5/7/25) to unstageable areas by nursing, per plan of care, included: Turn every 2 hours, keep skin/dressing clean and dry. No documentation found that protocol for unstageable pressure ulcers was implemented, including application of hydrogel impregnated gauze/thera-honey gel, or foam dressings to unstageable areas, as applicable. Pressure Ulcer (Injury) Management Order set not initiated in the record per protocol. On 5/7/25 at 0906, a Pressure Ulcer/Wound/Ostomy Consult was documented by Staff I. Impression and plan of care for right heel, left heel, left foot, right butt, left ischium, and left hip included, topical wound care: Cleanse all wounds with normal saline with each dressing change, apply thera-honey sheet cut to fit to cover entire wound bed, cover left hip, left ischium, and right butt with foam dressing, and change dressing every 48 hours and as needed. Corresponding physician orders written on 5/7/25 at 0904. On 5/6/25 at approximately 1330, Interview with Wound Care Nurse Staff I revealed she is helping cover the facility as the wound care position has been vacant for 3 weeks. When asked about time frames to complete a wound care consult after an order for a consult is written, Staff I stated there is no time frame defined in policy, and that she prioritizes consult orders received, based severity and patient need. Nursing staff has wound care protocols and have been trained to initiate wound care for all levels of wounds before wound care consults are done. On 5/6/25 at 1500, an interview with CNO Staff B revealed it is her expectation that staff follow physicians orders and policies and procedures of the facility. Review of policy titled, “Pressure Injuries: Prevention and Care” (2 PC 5202), dated 8/10/21 revealed, “RN responsibilities ...Provide assessment, planning documentation and evaluation of skin, pressure injuries, and wound care with shift assessment ...Pressure injuries are measured on admission ...DOCUMENTATION I-View ...wound location ...length, width and depth in centimeters ...dressing type and treatment ...” Review of Nursing Wound Care Protocol revealed under the general care section: Cleanse open ulcers/wounds with normal saline ...turn & reposition, off load pressure, Initiate Pressure Ulcer (Injury) Management Order set ... (under Unstageable Pressure Injury) Refer to pressure injury general care section ...Apply hydrogel impregnated gauze/Thera honey ...If dry black/brown necrotic tissue ...on lower extremity ...cover with foam ...kerlix wrap.”

“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 document every 15-minute safety checks for 2 (P-2, P-8) of 13 patients reviewed resulting in the increased likelihood for negative outcomes for the patients. Findings include: Medical record review with Director of Nursing Staff G on 3/17/2025 at 1245 revealed P-2 was admitted to the facility’s Emergency Crisis Center on 2/4/2025 and was placed on constant observation. P-2’s frequency observation record checks for 2/5/2025 started at 1530 and were performed as documented through 2345. There were no times documented on 2/5/2025 from 1200 to 1515. Record review with Staff G of P-8 revealed P-8 was admitted to the facility’s on 1/19/2025 and was placed on constant observation for elopement precautions and being uncooperative. P-8’s constant observation logs revealed there was no documentation of every 15-minute safety checks performed when P-8 was on the medical surgical unit on 1/28/2025 from 0400 to 0530, on 1/31/2025 from 0930 to 1030, and 2/3/2025 from 1600 - 2300. Staff G confirmed the findings. According to the facility’s policy “Constant Observer for Patients Under Harm Precautions,” dated 6/15/22, the policy revealed that “The CCO (Competent Constant Observer) will document patient observations every 15 minutes on the designated flow sheet.” According to the facility’s policy “Utilization of Constant Observer for Non-Behavioral Health Patients,” dated 8/15/24, the policy revealed that “The Constant Observer will document patient observations every 15 minutes on the designated flow sheet as indicated, and as instructed by the nurse.””

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 45246 Based on observation, interview, and record review, the facility failed to ensure that registered nurses supervised and evaluated the nursing care for 8 patients (P-1, 3, 4, 13 and 14, 15, 16, 17) of 18 patients reviewed for care supervised by registered nurses, resulting in negative outcomes to patients, including potential for harm and preventable physical decline. Findings include: See Specific Tags: A-395 Failure to ensure that nursing staff supervise and evaluates patients’ care, including ongoing assessments, evaluations and documentations. A-396 Failure to ensure that nursing staff developed patient centered individualized plan of care that meets patients’ needs.”

“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: 45246 Based on the interview and record review, the facility failed to provide three patients (P-4, 10 and 18) of five patients reviewed an Important Message from Medicare within 2 days of admission, resulting in patients not being informed of their rights and potential for patients not understanding their Medicare benefits. Findings include: During initial tour of the facility on 12/10/24 at 1130, random patient’s record (P-10) was chosen for a review on Unit 5M. Record revealed that patient was a 76-year-old male admitted to facility on 11/29/24. There was an IM (an Important Message from Medicare) form in the record. Form was dated 12/06/24. No patient’s or patient’s representative signature was evident on the form. Registered nurse, Staff I, was present during the review and was asked if the form needs to be signed by the patient or a responsible party. Staff I confirmed that the form needs to be signed. Further record review of a sample of inpatient medical records for Medicare beneficiaries, was conducted on 12/10/24 with Staff I. P-4’s medical record revealed that patient was an 85-yeal-old male admitted to facility on 9/2/24 and discharged on 9/12/24. Record did not contain a signed and dated IM form provided to the patient within 2 days of the admission. Staff I confirmed the above finding. On 12/11/24 P-18’s medical record was reviewed with Program Coordinator of patients’ services, Staff EE. Record revealed that patient was a 79-year-old male, admitted to facility on 8/1/24 and discharged on 8/10/24. Record did not contain a signed and dated IM (an Important Message from Medicare) provided to the patient within 2 days of the admission. Staff EE confirmed the above finding. Facility’s “Hospital Coverage Notices for Medicare Inpatients (including Important Message from Medicare)” policy was requested and reviewed. Policy, dated 04/14/20, indicated: B. Important Message from Medicare (IMFM) 1. The IMFM notice must be given to all beneficiaries in original Medicare fee-for-service program and to those in Medicare Advantage (MA) and other Medicare health plans subject to the MA regulations. 2. The Tenet Hospital must provide the IMFM to the beneficiary: a) Within two days of admission (this is known as the “admission/initial IMFM”); and b) Not more than two calendar days before the day of discharge. 4. The Tenet Hospital must obtain the signature of the beneficiary (or his/ her representative) on a copy of the IMFM and Follow-up Notice(s) and must retain the signed copies in the beneficiary’s 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 observation and record review, the facility failed to maintain and provide a safe and sanitary environment for all patients in the inpatient Behavioral Health Unit resulting in the potential for less-than-optimal outcomes for all 15 patients present on the unit. Findings include: During a tour of the inpatient behavioral health unit on 12/10/2024 at 1000: - Six blue blood vacutainer collection tubes with an expiration date 10/31/2024, two packages of electrodes with expiration date 3/25/22, and three individual 22-gauge needles with expiration dates 2/28/2022, 10/31/2021, and 6/30/2022 were observed on the shelf in the patient supply storage room. Nurse Manager Staff H confirmed the presence of the expired supplies at the time of discovery. - The facility’s patient seclusion room was observed to have a bolt and nut missing that attaches the bed to the floor. Rust including sprinkles of rust were present inside and around the slot where the bolt would be located. Additional rust was observed at the base of the flooring along both sides of the bed. Nurse Manager Staff H confirmed the presence of rust at the time of discovery. According to the facility’s policy “Checking Expiration Dates and Stock Rotation,” dated 2/22/2022, “Expiration dates stamped with month and year will be removed from the supply station at the first of each month (example 01/06). Products that have expiration dates of month, day, and year, will be removed from the supply station prior to that date (example 01/12/06).” According to the facility’s policy “Patient Rights and Responsibilities,” dated 2/10/2022, “Patient Rights” include “Patients will receive the same treatment and consideration as anyone else regardless of age, race, ethnicity, color , religion, culture, language ,martial status, physical or mental disability, sex, socioeconomic status, source of payment, sexual orientation and gender identify or expression” and Patient can expect their dignity as a human being to be recognized and respected.””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 45246 Based on observation, interview, and record review, the facility failed to ensure that registered nurses supervised and evaluated the nursing care for 5 patients (P-1, 3, 4, 13 and 14) of 18 patients reviewed for care supervised by registered nurses, resulting in negative outcomes to patients, including potential for adverse outcomes and preventable physical decline. Findings include: During initial tour of the facility on 12/10/2024, medical surgical unit (4L) was observed for patient care and environment from 1048 to approximately 1125. During the tour, unit Nurse manager, Staff Y, and clinical nurse coordinator, Staff Z, were interviewed regarding wound management, patients’ assessment and repositioning. Staff Y was asked how often nurses do patients’ skin assessments. She stated that skin assessments are done every shift (day and night). Staff Z stated that facility had a mobility team that helps staff with repositioning patients who are on every 2 hours repositioning schedule. Nurse added that mobility team coordinates care with nurses on the unit, however it was nurses’ (or nursing assistants’) responsibility to document the activity. When asked if there were any patients with compromised skin integrity or pressure injuries, Staff Z, provided information for P-13 and P-14. P-13 On 12/11/2024 at 1035 nurse in care for P-13, Staff CC, was interviewed. She stated that she did not complete patient’s shift skin assessment yet, however per report from the night shift nurse, patient had a pressure injury. Staff CC was asked if she does daily skin and wound assessments, care plan updates and education. Nurse stated yes. Following the interview with Staff CC, at 1040, P-13 was interviewed in his room. Patient was noted sitting in his bed with his legs positioned directly on the bed. No foam positioning devices were observed in the patient’s bed. Patient was asked if he needs assistance with repositioning. Patient stated that he can roll from side to side but he needs assistance with prepping the pillow, so he doesn’t roll back. When asked if staff repositioned him every 2 hours he said “no”. Patient proceeded to share that some nursing staff doesn’t come for long periods of time when he calls the call light. P-13 added that day shift nurses are better with providing care, at night though it was difficult to get staff’s attention. P-13 was asked if his roommate, P-14 (who was sleeping), was repositioned every 2 hours. P-13 said that “the guy was sleeping all morning, and no one touched him yet”. Record review for P-13 revealed that patient was a 31-year-old male who was admitted to facility on 12/01/24 with chief complaint of chronic generalized pain and testicular swelling. Physician’s examination dated 12/1/2024 0814 revealed that P-13 had a past medical history of T7 paraplegia (causes complete paralysis of the hips and legs, loss of bladder and bowel control, and no feeling in the abdominal muscles) secondary to GSW (gun shot wound), neurogenic bladder requiring straight catheterization, and colostomy dependence. Provider’s History and physical assessment for P-13 dated 12/01/2024 1504 revealed: “well healed wounds at the buttocks area with scab formation”. Nursing assessment of P-13 dated 12/02/2024 2100 revealed Braden score of 14 (tool for risk assessment of pressure injury development that range from 6 to 23 with a lower score indicating high risk). Wound assessment documentation dated 12/03/2024 0900 indicated P-13 had left hip pressure injury stage 3 present on admission. Further review of the nursing documentation revealed no other wounds or skin impairment documentation. Wound care nurse note dated 12/03/2024 1112 revealed the following wound assessment: resurfaced stage 3 pressure injury, left lateral hip, size 2 x 2 cm (centimeters), full thickness. Under the plan there were instructions “to be completed daily”: 4. Assess skin, wound, and all bony prominences every shift and document. 6. Turn and reposition q2 (every 2) hours with assistance of foam wedge, pillows, or turn assist feature on specialty bed and document each shift in Plan of Care and Q2h in Activity & Intervention. 7. Offload heels with use of heel lift boots or pillows placed under patient’s calves. Nursing wound assessments documentation review revealed missing assessments on 12/06/2024- night shift and 12/07/2024- day shift. Also, no repositioning every 2 hours were documented on 12/04/2024 (from 12/03/2024 at 1700 to 12/05/2024 at 0700). Provider’s orders review revealed order for heel lift boots, dated 12/03/2024 at 0903. There was also a provider’s order for “Reposition patient” dated 12/03/2024 at 0903. Order details indicated: “Q 15 min -1 hour if in chair or wheelchair and unable to shift weight independently. Turn q2 (every 2) hours when patient is in bed. Head of bed not greater than 30 degrees if tolerated. Avoid side-lying on trochanter. 30-degree side lying position produces lower interface pressures. Use pillows or foam positioning devices. Provide foam positioning wedge to maintain body position. Protect bony prominences and heels.” Further, there was an order for “Suspend heels off bed” dated 12/03/2024 at 0903. P-14 On 12/11/2024 at 1020 P-14 was observed sleeping in bed. Patient was positioned on his back with a pillow lying next to his right hip and another pillow tucked under his left hip. No foam positioning devices were observed in the patient’s bed. Patients’ heels were positioned directly on the bed. No protective boots were noted on patient’s feet. Following this observation, at 1025, P-14’s nurse in care, Staff BB, was interviewed regarding patient’s status. He stated that patient had multiple pressure injuries. He was provided a specialty bed to relieve the pressure. When asked if nurse did his assessments yet, he stated that patient had been sleeping all morning and nurse did not want to disturb him. Medical record for P-14 was reviewed and revealed that patient was a 44-year-old male admitted to facility on 11/29/2024 with complaint of abdominal pain and leakage around SPT (suprapubic urinary catheter) site. Patient had a past medical history of T6 paraplegia following gunshot wound, neurogenic bladder with SPT, left hip osteomyelitis (infection in a bone) and recurrent UTIs (urinary tract infection). Nursing wound assessment documentation dated 11/30/2024 0700 revealed the following wound documentation: coccyx pressure ulcer, stage 3 present on admission, hip right lateral pressure ulcer stage 3 present on admission, hip left lateral pressure ulcer stage 3 present on admission, buttock left pressure ulcer stage 3 present on admission. Wound care nurse note dated 12/03/2024 1039 revealed: “healing stage 4 pressure injury to Sacro coccyx, 2cm x 1cm x 1cm (length x width x depth); healing stage 4 pressure injury to right hip, 3cm x 8cm; healing stage 4 pressure injury to left hip, 3cm x 2cm; healing stage 4 pressure injury to left ischium, 1.5cm x 1cm x 1cm. Healed pressure injuries present to bilateral heels.” Under the plan there were instructions “to be completed daily”: 4. Assess skin, wound, and all bony prominences every shift and document. 6. Turn and reposition q2 hours with assistance of foam wedge, pillows, or Turn Assist feature on specialty bed and document each shift in Plan of Care and Q2h in Activity & Intervention. 7. Offload heels with use of heel lift boots or pillows placed under pt’s calves. Nursing wound assessments documentation review revealed missing assessments on 12/01/2024 for day and night shift, on 12/02/2024 for night shift, on 12/03/2024 for night shift, on 12/04/2024 for day shift, on 12/07/2024 for day shift. Facility’s wound care nurse, Staff K, was interviewed on 12/11/2024 at 1130. She was asked if her expectations were that facility staff nurses follow her wound care recommendations and skin deterioration preventive measures. Staff K stated yes. Facility’s “Pressure injuries: Prevention and Care” policy was requested and reviewed. Policy 2PC 5202, dated 8/10/21, revealed: A. An RN assesses each patient admitted to [facility] inpatient unit for risk pressure injury risk using the Braden scale. 1. Braden scale score of less or equal 18 or low subscale scores indicates that the patient is at risk for pressure injury development. Interventions targeting risk areas are implemented to prevent and manage pressure injuries. 2. Patients with actual or healed pressure injuries are considered high risk. C. RN responsibilities: 1. Provide assessment, planning, documentation and evaluation of skin, pressure injuries, and wound care with shift assessment. Pressure injuries are measured on admission, every Monday, upon development or deterioration. 2. Assess the patient’s risk using the Braden scale. 3. Reposition patient to 30-degree side lying position ensuring sacrum/ coccyx and heels are offloaded at least every two hours while in bed, unless contraindicated. 11. Consult the APRN/CWOCN (wound care) for stage 3, stage 4, unstageable, deep tissue pressure injuries, or mucosal membrane pressure injuries.” P-3 P-3 was admitted to the facility on 12/09/2023 with a pressure wound described as “unstageable (with slough/or eschar) pressure injury to coccyx...Measurements dated 12/11/2023 at 2000 were 12 X 6.5cm (centimeters). Wound care nurse was not consulted until 01/04/2024 (26 days after admission). Wound care nurse note dated 01/04/2024 at 1316 revealed “patient has unstageable pressure injury that evolved from deep tissue pressure injury, present on admission. Location: Coccyx, length x width: 13cm x 11cm, depth: full thickness. Wound bed color/necrotic tissue (%): 90% black/yellow and 10% dull pink wound bed.” Nursing documentation on 01/08/2024, the day prior to discharge, noted P-3’s wound had increased in size to 15 X 9.5cm. P-4 P-4’s medical record was reviewed and revealed that patient was an 85-year-old male admitted to facility on 09/02/2024 at 1521 with chief complaint of back pain post fall a week prior. Patient was diagnosed with vertebral compression fractures and unstable T10 fracture. There were the following providers’ orders: 1) MRI- Request dated 9/2/2024 1840, order status: Discontinued on 9/3/2024 1013 (not completed). 2) MRI- Request dated 9/3/2024 1013, order status: Discontinued on 9/4/2024 0717 (not completed). 3) MRI- Request dated 9/4/2024 0716. Order status- completed (P-4 had an MRI test on 9/4/2024). 4) Nothing By Mouth (procedure, NPO-nothing by mouth, except for medications) dated 9/2/2024 1845, order status: Discontinued on 9/6/2024 0815. 5) Diet order- cardiac, dated 9/4/24 1950. Further record review with Program Coordinator of patients’ services, Staff EE, revealed the following documentation. On 9/2/24 and 9/3/24 no oral intake was documented for entire day for P-4. On 9/4/24 patient had an MRI test. At 2000 there was a documentation of 75% of dinner consumed by P-4. On 9/5/24 there was a documentation of graham crackers consumed at 0000 and 0300. At 2000- apple juice x 2 and graham crackers were documented. On 9/7/24, 9/8/24 and 9/9/24- there was no documentation of any food consumed by P-4. On 9/10/24 patient had a surgery for his thoracic compression fracture (T10 and L3 kyphoplasty). There was a documentation of 50% breakfast consumed at 0800 and “all lunch” at 1200 (noon). On 9/11/24 and 9/12/24- there was no documentation of any food consumed by P-4. Patient was discharged home on 9/12/24 at 1726. Staff EE confirmed the findings. On 12/11/24 at 1330 Chief Nursing Officer, Staff B, was interviewed. She was asked if her expectations were that registered nurses and clinical staff were following facility’s procedures and policies. Staff B stated “yes”. Facility’s “Patient assessment and Documentation” policy was requested and reviewed. Policy 2 PC 201 dated 2/23/22, revealed: B. The RN (registered nurse) documents patient information in the electronic medical record (EMR) except when such documentation is outside the scope of existing electronic forms or during system downtime when downtime procedures will be followed. C. The RN documents admission and on-going and focused assessments, patient/ family teaching, plan of care, interventions and patient response in the medical record. The RN documents all pertinent patient data, including but not limited to designated required fields. D. The RN is responsible for patient assessment, data interpretation, determination of patient needs, establishment of nursing intervention priorities, and evaluating effectiveness of the plan of care. G. The RN may delegate data collection tasks to other nursing team members. H. RNs verify all data documented and co-sign documentation of selected data collected by Licensed Practical Nurses, Student Nurses Associates, Nurse Associates, Patient Care Associates, Constant Observers, Mental Health Techs, and ED Techs.” 50585 P-1 On 10/16/2024 at 2000 (day of admission), the nurse documentation revealed that P-1 had a Braden score (scaled used to determine risk for patients developing pressure injuries) of 13. According to the facility’s policy “Pressure Injury, Prevention and Care,” dated 8/10/2021, “Braden Scale score of </= 18 or low subscale scores indicates that the patient is a risk for pressure injury development.” The nursing note on 10/17/2024 at 2000 revealed that P-1 had a pressure injury classified as Stage I on the sacrum present on admission and the medical record revealed there were no other pressure injuries present. Five days later, the nurses note on 10/22/2024 at 2300 revealed the sacrum pressure injury was classified as Stage II. P-1 had additional pressure injuries identified on 10/24/2024 (right heel that measured 3 cm x 2 cm) and on 10/29/2024 at 1000 (Stage II pressure ulcer on the left buttock). According to P-1’s medical record, the facility staff did not reposition P-1 at the following dates and times: 10/18/2024 at 0700 0900, 1300 1500, 1700, and 1900 and on 10/19/2024 at 1800, 2000, 2200 and on 10/20/2024 at 0200, 0400, 0600, 2000, 2200.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 47415 Based on interview and record review, the facility failed to develop care plans for 3 of 3 patients in isolation (P-15, P-16, P-17) and failed to initiate a care plan timely for 1 of 1 patient with a high risk for developing pressure injuries (P-1), resulting in a potential risk for the transmission of infection and less than optimal outcomes. Findings include: On 12/11/24, assisted by RN Staff G, 3 medical records were reviewed of patients selected from unit 5M (P-15, P-16, P-17) revealed all 3 patients were admitted with a known history of Candida Auris (C. Auris). All 3 records had an order for contact isolation, but none of the 3 records had a care plan open addressing infection risk. None of the 3 records contained documentation that isolation was implemented or maintained. Only 1 of the 3 records (P -15) contained patient/family education documentation on C. Auris. Staff G confirmed the findings during chart review, and confirmed the education on C. Auris should have been charted. On 12/11/24 at approximately 1330, an interview with CNO Staff B revealed that it is her expectation that staff follow policy and procedures of the hospital. On 12/11/24 record review of policy titled, “Nursing Plan of Care” dated 3/16/22, revealed: “Objective: To document the plan of care required to meet the admitted patient’s needs through the episode of care ... The RN collaborates with the patient, family ... to formulate the Plan of Care ... The RN individualizes ...plans of care to be reflective of the patient’s condition ...The RN is responsible for reviewing, evaluating, and documenting the progress toward established plan of care goals and updates the plan of care accordingly ...every 12 hours”. 50585 P-1 On 10/16/2024 at 2000 (day of admission), the nurse documentation revealed that P-1 had a Braden score (scaled used to determine risk for patients developing pressure injuries) of 13. According to the facility’s policy “Pressure Injury, Prevention and Care,” dated 8/10/2021, “Braden Scale score of </= 18 or low subscale scores indicates that the patient is a risk for pressure injury development.” The nursing note on 10/17/2024 at 2000 revealed that P-1 had a pressure injury classified as Stage I on the sacrum present on admission and the medical record revealed there were no other pressure injuries present. Five days later, the nurses note on 10/22/2024 at 2300 revealed the sacrum pressure injury was classified as Stage II. P-1 had additional pressure injuries identified on 10/24/2024 (right heel that measured 3 cm x 2 cm) and on 10/29/2024 at 1000 (Stage II pressure ulcer on the left buttock). P-1’s nursing plan of care for integumentary (body’s outside layer e.g., skin) impaired tissue was not initiated until 10/23/2024.”

“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: 45245 Based on interview, observation and record review, the facility failed to ensure a safe environment for one (P-1) of fifteen patients reviewed for patient rights, resulting in the death of P-1, and potentially resulting in the loss of patient rights for all 220 patients being served at the facility. Findings include: Review of document “History of Present Illness,” dated 06/12/24 revealed that P-1 was a 21-year-old female with a history of bipolar disorder, attention-deficit hyper-activity disorder (ADHD) and traumatic brain injury (TBI). P-1 was admitted to a local psychiatric hospital in April of 2024 and was discharged to home on long-acting forms of Haldol (anti-psychotic medication) and Abilify (antipsychotic medication). P-1 reported symptoms of medication side-effects and was placed on cogentin. She presented to the facility of concern on 06/11/24 after being found unresponsive in a vehicle on the freeway. Police noted an empty bottle of Cogentin on P-1’s lap when she was found, with approximately 75 pills unaccounted for. This record review also revealed that P-1 was transported to the facility’s Emergency Department, where she was intubated (breathing tube placed). P-1 was admitted to the facility’s medical intensive care unit (MICU) on 06/11/24. Following extubation (breathing tube removed) on 06/13/24, she stated that she took 75 pills in an attempt to “get some sleep.” P-1 was assessed by psychiatry and placed in 1:1 close observation while in the MICU. P-1’s recovery from the overdose was expected to take 7-8 days. P-1 was transferred to a general medical unit on 06/15/24, where she remained on 1:1 close observation. Once medically cleared, she was transferred to the facility’s psychiatric unit (3Q) on 06/19/24. P-1’s physician ordered safety precautions of “every 15-minute safety observations.” On 06/22/24 at 1704, P-1 was found unresponsive, hanging from the bathroom door, with bed linens wrapped around her neck. A tour of the behavioral unit 3Q, room 10A-10B, was conducted at approximately 1140 on 07/02/24 with ACNO Staff S. Observations of the room demonstrated that the bathroom door was not square at its top edge, as the room entry door was. During this tour, an interview was conducted with ACNO Staff S. Staff S was questioned why the top of the bathroom doors were angled. Staff S stated that the top of the bathroom door was anti-ligature (designed to prevent hanging/suicide). Staff S stated, “She was able to fix the ligature between the bathroom door and the door frame, at the non-hinged side.” Staff S also stated that she herself attempted to replicate P-1’s actions by attempting to secure a similar (bed sheet) ligature at the door and frame junction. Staff S stated that she too was able to secure the ligature and it was able to support her full weight. Review of document titled “15-minute Safety Check Rounding” dated 06/22/24 revealed that Mental Health Tech (MHT) Staff Y did not document safety checks as ordered, after 1630 on 06/22/24. An interview was conducted with CNO Staff B and ACNO Staff S at 1353 on 07/02/24. Staff S stated that video review confirmed that MHT Staff Y did not do safety checks after 1630 on 06/22/24. Staff S stated that P-1 was discovered after her roommate approached the nursing station.”

“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: 38269 Based on interview and record review, the facility failed to provide care in a safe setting for two (P-1 and P-16) of two patients reviewed for one-on-one observation in restraints, resulting in patient-to-patient sexual abuse. Findings include: On 06/04/2024 at 1115, interviews with staff in the Crisis Care Unit (CCU) revealed staff knowledge of an incident of “patient-to-patient” sexual abuse. The charge nurse, Staff R, when interviewed stated, “There was an incident a few months ago, one of the male patients tried to pull down the pants of a female patient in restraints. The female patient (P-1) had written orders to be watched at all times (one-to-one observation). The RN stepped away leaving the Mental Health Tech (MHT) to monitor, but she (Staff MM - the MHT) was not watching. Finally, a nurse came in and saw what was going on. The MHT (Staff MM) was fired.” On 06/04/2024 at 1120, the Director of the CCU Staff Q, was interviewed and confirmed the patient-to-patient abuse and added, “We have done training for all staff, and created new assignment sheets, partner care teams have been created...Where staff never leave the view of patients without letting your partner know.” Staff Q further stated, “Staff must ensure their partner is monitoring before leaving the area. All staff on 04/09/2024 were taken off duty during the investigative period. After the video of the incident that occurred on 04/09/2024 was viewed, ultimately the MHT was terminated. We have done a lot of work and have a binder with a record of the action plan related to this incident. We are still tightening up the process.” On 06/05/2024 at 1130, the Chief Nursing Officer (CNO) Staff B, and Staff Q were interviewed, and the action plan related to the confirmed incident involving P-1 was discussed. Record review of the video was completed at the time of this interview. The video of 04/09/2024 revealed P-1 lying on a stretcher and initially no additional patients were observed in the video. P-1 was in 4 point restraints as ordered; A male patient was viewed entering the view on the video footage. The male patient was observed walking to the side of the stretcher where P-1 was located. He was then observed trying to remove P-1’s slacks. The male patient was unable to remove the slacks and was then seen throwing a blanket off P-1. The male patient then tried to straddle the stretcher where P-1 was restrained but was unsuccessful. As the male patient continued to try multiple maneuvers to lower P-1’s slacks, a staff member (identified by the CNO as MHT Staff MM) was observed in the nurse’s station (also known as the fishbowl) with her head down, not facing the direction of P-1. Another staff member (identified by the CNO as a Registered Nurse) was viewed in the video footage. It appeared as though the RN was saying something to the male patient, at which point the staff member (Staff MM) looked up. Neither of the staff were observed leaving the fishbowl area. The male patient was seen walking away from P-1. The video footage ended prior to any staff member being observed to assist P-1. On 06/05/24 at 1145, Staff B confirmed the above findings and stated staff did not go to assist P-1 due to feeling the area was unsafe until security had arrived. Staff B identified the person with her head down, “Not monitoring the patients as assigned,” was MHT Staff MM. Staff B stated Staff MM was no longer employed by the facility. On 06/05/2024 at 1430, while reviewing requested security records, it was revealed that a similar sexual abuse incident had been reported to a security officer on 06/03/2024. On 06/05/2024 at 1438, a request to review the video dated 06/02/2024 was made. This review confirmed a second case of “patient-to-patient” sexual abuse had occurred. The Director of CCU, Staff Q, and the CNO, Staff B, were aware of the incident and confirmed the incident had occurred two days prior on 06/02/2024 but had failed to include the incident on the incident report provided on 6/4/2024. Record review of the video dated 06/02/2024 revealed a male patient (P-10) entered the quiet room where P-16 was seen on a stretcher in four point restraints. The male patient enters the room and hands a styrofoam cup with a straw in it to P-16. The male, P-10 proceeds to the side of the stretcher where he is seen touching P-16’s breasts and her vaginal area. P-10 is then seen trying to get on top of P-16, he gets off the stretcher and P-10 puts his head between P-16’s legs, then puts his hand between her legs and penetrates the vaginal area with his fingers. When queried regarding this second incident the CNO stated that the Director was doing her audits of reviewing video recordings, as part of the action plan secondary to the incident on 04/09/2024, and this second incident was identified. The CNO stated they were in the process of investigating and she confirmed she did not see the video until after 2100 on 06/02/2024. The facility failed to disclose the 06/02/2024 incident during the tour conducted on 06/04/2024 and during the extensive above interview conducted on 06/05/2024. After the interview of staff and record review of the video, an Immediate Jeopardy was identified. A record review occurred of the facility’s policy titled, “Constant Observer for patients under harm precautions,” policy # CLN 02.07, last review date 6/10/22. According to the policy it revealed, under the subtitle “Definitions...Line of Sight Observation: One CCO in direct line of sight with one or more patients...One to One Observation: One CCO to one patient within line of sight, in proximity with no physical barriers in the same room/area unless there exists a risk to the CCO.” This policy further revealed under subtitle, “Policy: Facilities will use Competent Constant Observers (CCOs) to provide continuous observation of a patient under suicide/self-harm and harm to other precautions to support safety.” This policy further revealed, “Procedure: Implementation of CCO, The nurse assigned to the patient remains responsible for the nursing care throughout the shift regardless of the presence of a CCO....The nurse assigned to the patient will document the assessments and observations relative to the continued need for CCO use per unit assessment frequency protocols, and report findings to the Clinical Coordinator (or comparable role), who will relay the information to the House Supervisor (or comparable role). The Clinical Coordinator/Manager/Director/House Supervisor will round at the start of each shift with the nurse on all patients with a CCO to assess process and care. The nurse will provide a complete report to the CCO at the beginning of each shift.... The CCO will: Document patient observations every 15 minutes on the designated flow sheet. Review and sign the guidelines for the roles and responsibilities of the CCO provided by the nurse each shift. Provide a complete report to the on-coming CCO. Enforcement: All employees whose responsibilities are affected by this policy are expected to be familiar with the basic procedures and responsibilities created by this policy. Failure to comply with this policy will be subject to appropriate performance management pursuant to all applicable policies and procedures, up to and including termination. Such performance management may also include modification of compensation, including any merit or discretionary compensation awards, as allowed by applicable law.””

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 47415 Based on interview and record review, the facility failed to ensure ongoing assessment and care of a tracheostomy was performed according to facility policy and procedure for one (P-3) of one patient reviewed for tracheostomy care resulting in the potential for unidentified and unmet patient needs. Findings include: A record review of P-3’s medical record on 6/3/24 at 1400 revealed P-3 was a 67-year-old female with past medical history of ischemic stroke with residual right sided hemiplegia, chronic respiratory failure and ventilator dependent with tracheostomy. Review of assessment and care of tracheostomy documentation revealed no documentation between the dates of 10/8/23 through 10/11/23. On 6/5/24 at 1000 an interview was conducted with Registered Nurse (RN) Staff II who stated that the tracheostomy inner cannula is to be cleaned or changed (depending on type) every twelve hours, along with an assessment of the tracheostomy site, including the dressing around the tracheostomy. The dressing ties are changed more often if needed. RN II stated that documentation of this assessment and interventions are done in the “Quick View” section of the medical record under artificial airways. On 6/6/24 the facility’s policy titled “Tracheostomy Care” dated 11/23/23 revealed “Tracheostomy care is performed every 12 hours at least and PRN...Tracheostomy care includes: Assessing skin and tissues under the tracheostomy dressing,...Cleaning outer cannula...Changing tracheostomy dressing...Changing soiled tracheostomy ties from twill to padded commercial tracheostomy holder. Commercial tracheostomy holder is changed every 72 hours and PRN soiling...Cleaning inner cannula or changing disposable inner cannula every 12 hours and PRN ... Documentation...EMR...Quick View, artificial airway subset, trach care...”.”

“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: 50585 Based on interview and record review, the facility failed to provide adequate and appropriate care to prevent and/or treat bedsores by not following policy and physician orders for one (P-2) of one patient reviewed for treatment of bedsores, resulting in the potential for unidentified and unmet care needs. Findings include: A review of P-2’s medical record revealed the following: P-2 was admitted on 10/12/2023 for a burn to her left foot attributed to her foot touching a radiator at home. The initial skin assessment of P-2 dated 10/12/2023 at 1800 revealed P-2 had bedsores on the tail bone, right shoulder and left buttock prior to coming to the facility. The physician ordered interventions to manage and prevent additional bedsores from occurring. The interventions included repositioning the patient while in bed every two hours, providing patient education, applying a heel protector to the patient’s feet, and performing a skin assessment to monitor for bed sores. Additional record review revealed by 10/26/2023 P-2 had two additional bed sores, one on the right hip and the other on the right foot. Also, this record review of P-2’s medical record indicated staff did not always complete the physician ordered interventions to prevent or to heal bed sores. A review of P-2’s medical record revealed a physician order dated 10/12/2023 for daily skin assessments to be performed. The nurse failed to document a skin assessment in the plan of care between the hours of 2213 on 10/29/2023 to 0200 on 11/1/2023. Additionally, on 10/12/2023 at 1831, the physician ordered the use of heel protectors on the feet, however, from 10/22/23 at 2000 to 11/1/2023 at 0800, there was no documentation that this intervention was used. On 6/6/2024 at 0910, during a review of the P-2’s medical record with the Administrative Director of the Intensive Care Unit (ICU) Staff G, it revealed repositioning of the patient only occurred two times on 10/30/2023 at 2000 and 2200. When asked, Staff G acknowledged the missing documentation of skin breakdown interventions during this record review. On 6/6/2024 at 1400, a record review occurred of the facility’s policy titled “Skin and Wound Care,” dated 7/21/2021. According to the policy “Any pressure injury that develops 24 hours after admission to the hospital and is not documented as present on admission within 24 hours is defined as a hospital-acquired pressure injury.” The policy also states that “Patients are repositioned minimally every 2 hours.” On 6/6/2024 at 1415, a record review occurred of the policy titled “Patient Assessment and Documentation”, dated 2/23/2022. According to the policy “An Ongoing Assessment is conducted minimally once every 12 hours and includes but is not limited to fall risk, self-harm risk, need for restraints and need for continuous observation. The Physical Assessment includes a core assessment of all systems with consideration to deviation from normal and special attention to new onset variance or change in degree of variance.” On 6/6/2024 at 1420, a record review occurred of the policy entitled “Nursing Plan of Care,” dated 3/16/2022. According to the policy “The RN is responsible for reviewing, evaluating, and documenting the progress toward established plan of care goals and updates the plan of care accordingly, minimally every twelve hours. Documentation is reflective of findings from: On-going and focused assessments plus additional updates to be completed to address new findings or Change in the patient’s condition (e.g., post-op, change in hemodynamic state, change in level of consciousness (LOC), invasive procedures).” On 6/6/2024 at 1530, during an interview, CNO Staff B stated she expects nurses to follow all policies and procedures, including the ones noted above.”