Centracare - St. Cloud Hospital

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(7) The attending physician must be consulted as soon as possible if the attending physician did not order the restraint or seclusion. This Standard is not met as evidenced by: 47264 Based on interview and document review, the facility failed to obtain an order for restraints immediately, within minutes, for 1 of 7 patients (P9) reviewed for restraint use when P9 was placed in nonviolent restraints on 6/5/26 at 4:30 p.m., and the provider’s order indicated the restraint was ordered on 6/5/26 at 5:25 p.m. Findings include: P9 was a 90-year-old female who presented to the hospital emergency department (ED) on 6/4/26 at 3:31 a.m. for evaluation of abdominal pain and shortness of breath. P9’s relevant medical history included chronic obstructive pulmonary disease (COPD), coronary artery disease, diverticulitis, small bowel obstruction, and anxiety. A provider’s note dated 6/4/26 at 7:40 a.m. indicated P9 was assessed at bedside at 4:24 a.m. P9 reported a recent onset of upper left quadrant abdominal pain, bloating, and emesis with accompanying shortness of breath. Physical exam revealed P9 had an extended abdomen without tenderness. Imaging obtained at the hospital indicated P9 had multiple small lesions and cysts throughout her abdomen and pelvis, and multiple dilated loops of small bowel. General surgery was consulted and P9 was admitted to the hospital for further care. An operative report dated 6/5/26 at 5:31 p.m. indicted P9 underwent exploratory laparotomy at 1:39 p.m. The procedure revealed dilated and poorly perfused small bowel. Frank spillage of enteric contents throughout the abdomen was noted. The upper left quadrant, left abdominal sidewall, and interloop had multiple adhesions requiring extensive lysis of adhesions. The small bowel had multiple enterotomies from simple traction requiring sutures. Portions of the small bowel were nonviable, requiring resection. Due to extent of adhesions and clinical presentation, an open abdomen wound vacuum dressing was applied, and surgery was concluded. P9 was transferred to the intensive care unit (ICU) under intubation and sedation. Flowsheet entry titled “Restraints Non-violent, Non-Self-Destructive” dated 6/5/26 at 4:30 p.m. indicated bilateral soft wrist restraints were applied to P9 due to “unaware of potential harm by actions.” Prior to application, essential lines and tubes had been secured. The provider was notified. Restraints remained initiated from 6/5/26 at 4:30 p.m. through 6/7/26 at 6:00 p.m. An order dated 6/5/26 at 5:25 p.m. indicated a verbal order with read back was entered for “Restraint Non-Violent,” for the application of bilateral soft wrist restraints. Flowsheet entry titled “Restraints Non-violent, Non-Self-Destructive” dated 6/7/26 at 6:00 p.m. indicated P9’s bilateral wrist restraints were discontinued. A progress note dated 6/7/26 at 9:26 p.m. indicated P9’s family elected to transition to comfort cares with extubation. A discharge summary dated 6/6/26 at 11:30 p.m. indicated P9’s time of death was 9:47 p.m. During an interview on 6/22/26 at 1:36 p.m., registered nurse (RN)-B stated restraints may only be applied with an order from the provider. RN-B stated the order should be obtained and documented within 3-5 minutes of receiving the order. During an interview on 6/22/26 at 1:58 p.m., RN-C stated restraints require an order from the provider within an hour of application. RN-C stated staff should call the provider for an order immediately after applying the restraints. During an interview on 6/22/26 at 2:19 p.m., RN-D stated if staff apply restraints to a patient, they must contact the provider and obtain an order within 15 minutes of initiation. During an interview on 6/23/26 at 9:15 a.m., RN-E stated restraints require a provider’s order. Nursing staff must call immediately or as soon as possible to obtain a restraint order. During an interview on 6/23/26 at 3:04 p.m., the chief nurse executive stated that staff are expected to adhere to the facility’s restraint and seclusion policy. Staff need an order to apply restraints. For the application of restraints, nursing staff should enter the order as soon as possible, or preferably before initiation. A facility policy titled “Restraint and Seclusion” dated 05/2026, the policy indicated a provider’s order is required for each episode of restraint. The order for application must be obtained “as soon as safely possible.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 40945 Based on interview and document review, the hospital failed to ensure appropriate measures were implemented to ensure patient protection after an allegation of staff to patient physical abuse was verbalized by two of ten patients (P4, P5) reviewed who reported an allegation of physical abuse by staff during the provision of care. The facility failed to implement a thorough investigation into the allegation and the alleged perpetrators continued to provide unsupervised patient care. As a result, the hospital was found out of compliance with the Condition of Participation Patient Rights at 42 CFR 482.13. A condition level deficiency was issued at A-0115. See A-0145 for additional information.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 40945 Based on interview and document review, the hospital failed to ensure appropriate measures were implemented to ensure patient protection after an allegation of staff to patient physical abuse was verbalized by two of ten patients (P4, P5) reviewed who reported an allegation of physical abuse by staff during the provision of care. The facility failed to implement a thorough investigation into the allegation and the alleged perpetrators continued to provide unsupervised patient care. Findings include: P4’s admission record dated 5/31/26, indicated P4’s diagnoses included acute ischemic stroke. P4 was admitted to the neuroscience spine unit on 5/31/26 and discharged on 6/3/26. P4’s medical record dated 6/2/26, identified she was alert, oriented and follows all commands. Speech and weakness slightly improved from yesterday. P4’s provider orders dated 6/3/26, included Xray for left wrist due to left wrist pain, rule out fracture, likely a sprain. P4’s medical record included Xray study results dated 6/3/26, at 3:14 p.m. which included the following findings: possible nondisplaced scaphoid wrist fracture. Recommend ulnar deviated-navicular view radiograph. During an interview on 6/10/26 at 8:05 a.m. FM-A stated P4 could not be interviewed due to having pneumonia. FM-A stated on the morning of 6/2/26, P4 told FM-A that two male staff had been rough with her during the night and injured her left wrist. P4 reported this to the medical provider and a Xray was completed which indicated a possible fracture but required additional imaging. FM-A stated she had filed a grievance on 6/3/26. P4 was discharged from the hospital that same day on 6/3/26. FM-A stated the additional imaging may be completed today due to P4 currently in the emergency department with pneumonia. During an interview on 6/10/26, at 8:11 a.m. senior director of risk management (RM)-A stated FM-A had filed a grievance on 6/3/26 related to P4 reporting to the family that on the night of 6/1/26, two staff members had been rough with her during cares and injured her wrist. P4’s Xray results from imaging on 6/3/26, had indicated P4 sustained a possible left wrist fracture. RM-A stated video review of the unit was completed on 6/3/26, and based on the description provided by P4, video and units schedule it was determined the male staff providing care for P4 the night of 6/1/26, were registered nurse (RN)-A and nursing assistant (NA-A). RN-A was interviewed by hospital leadership and denied all allegations. NA-A was interviewed by hospital leadership and denied all allegations. No additional patients who received care by either RN-A or NA-A were interviewed. No additional staff members who work alongside either RN-A or NA-A were interviewed. The decision was made to allow both RN-A and NA-A to be allowed to continue to provide direct patient care. Leadership did not meet again to discuss further investigative steps until 6/9/26. RN-A was placed on leave as of 6/9/26, and NA-A was not on the current schedule. On 6/10/26, at 9:00 a.m. review of RN-A’s schedule revealed the following: -6/1/26, 7:00 p.m.- 11:30 p.m. neuro spine -6/2/26, 7:00 p.m. - 7 :30 a.m. adult behavioral health unit -6/3/26, 7:00 p.m.- 7:30 a.m. adult behavioral health unit -6/4/26, 7:00 p.m.- 7:30 a.m. adult behavioral health unit -6/6/26, 11:00 p.m.- 7:30 a.m. adult behavioral health unit -6/8/26, 7:00 p.m.- 7:30 a.m. adult behavioral health unit -6/9/26, 7:00 p.m.- 7:30 a.m. adult behavioral health unit On 6/10/26, at 9:00 a.m. review of NA-A’s schedule revealed the following: -6/1/26, 3:00 p.m.-11:30 p.m. neuro spine unit -6/2/26, 3:00 p.m.-7:30 p.m. neuro spine unit, 7:30 p.m.-11:30 p.m. peds sitter -6/4/26, 2:30 p.m.-11:30 p.m. intensive care unit -6/5/26, 7:00 a.m. -7:30 p.m. intensive care unit, 7:30 p.m.-11:30 p.m. oncology unit -6/6/26, 7:00 a.m.- 11:30 p.m. intensive care unit -6/7/26, 7:00 a.m.- 9:00 a.m. intensive care unit P5’s admission record dated 5/27/26, indicated P5’s diagnosis included post colectomy and recent shingles diagnosis. P5 was admitted to the neuroscience spine unit on 5/27/26 and discharged on 6/5/26. P5’s medical record dated 5/27/26, identified he was alert and somewhat restless. During an interview on 6/10/26 at 10:22 a.m. P5 was interviewed. P5 stated he had previously been a patient on the neuro spine unit. P5 stated his care had been good except for one night when two male staff members transferred him from the stretcher to the bed, they moved him so quickly he hit the side of the bed. P5 stated he told them they were rushing him, but they did not stop. P5 stated he reported this to his family member the next morning. During an interview on 6/10/26 at 10:26 a.m., P5’s FM-B stated it was the Monday or Tuesday of last week. P5 reported to her that two male staff members were rushing him during a transfer and caused him to hit the side of the bed during a transfer. FM-B stated she had reported this to the charge nurse at that time. FM-B stated no one had followed up with either P5 or FM-B about the incident. During an interview on 6/10/26 at 10:45 a.m., RN-B stated her current role was director of the neuro spine unit. She was made aware of the allegations of rough patient care resulting in a possible wrist fracture on 6/3/26. She had completed an interview with RN-A on 6/4/26. As a time with risk management involved, the decision was made to allow both RN-A and NA-A to continue to provide direct patient care. Leadership did not meet again to discuss further investigative steps until 6/9/26. To her knowledge no additional patients who received care by either RN-A or NA-A were interviewed. To her knowledge no additional staff members who work alongside either RN-A or NA-A were interviewed. Without additional interviews of both patients and staff members there would be no way to know if this was an isolated incident or if there were other allegations of rough patient care. During an interview on 6/10/26 at 11:24 a.m., RN-C stated her current role was supervisor for neuro spine unit. She had been made aware of the allegation of rough care by two male staff members on 6/3/26. She had interviewed NA-A on 6/4/26. The decision was made as a team, to allow both RN-A and NA-A to be allowed to continue to provide direct patient care. Leadership did not meet again to discuss further investigative steps until 6/9/26. To her knowledge no additional patients who received care by either RN-A or NA-A were interviewed. To her knowledge no additional staff members who work alongside either RN-A or NA-A were interviewed. Without additional interviews of both patients and staff members there would be no way to know if this was an isolated incident or if there were other allegations of rough patient care. During an interview on 6/10/26 at 12:07 p.m. RN-A stated he had been interviewed on 6/4/26 by leadership. RN-A was still allowed to provide care, and it was not until 6/10/26 when he was placed on administrative leave. RN-A denied all allegations of providing rough care. During an interview on 6/10/26 at 12:50 p.m. NA-A stated he had been interviewed by hospital leadership on 6/4/26. NA-A stated he denied all allegations at that time and had been allowed to still provide care on various medical units throughout the hospital. NA-A denied all allegations of providing rough care. During an interview on 6/10/26 at 3:21 p.m. medical doctor (MD)-A stated he had seen P4 on 6/3/26, the day she was discharged. P4 told MD-A when the nurses were moving her around, they injured her wrist. MD-A stated he did not ask for more details like when or what happened. MD-A did not ask any additional questions. Hospital’s Vulnerable Adult (VA) Maltreatment policy dated 2/2026 indicated it is the responsibility of CentraCare to report suspected or actual abuse, neglect, misappropriation of property/financial exploitation and injuries of unknown origin, suspicious in nature, of vulnerable adults immediately and as mandated by law. All personnel must comply with applicable state and local laws regarding incidents of actual or suspected maltreatment. Abuse included conduct which is not an accident or therapeutic conduct as defined in this section, which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to, the following: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult. Hospitals Rights and Responsibilities of Patients policy dated 3/2026, indicated the purpose of the policy is to ensure all staff respect, protect and promote patient rights. Patients have the right to be free from harassment, neglect, exploitation, and verbal, mental, physical, and sexual abuse.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 33925 Based on interview and document review, the hospital failed to ensure acts of potential non-therapeutic conduct and undignified treatment committed by a registered nurse (RN) in the operating room (OR) setting were reported, acted upon, and investigated to help prevent future incidents to other patients. The RN had been observed for several months to commit acts that were not in accordance with the standard of care for surgical preparation of a patient, but these concerns were not reported to appropriate leadership personnel timely nor investigated as potential acts of abuse and/or undignified treatment. The RN then committed more acts, including potential sexual assault, with two patients (P1, P2) on 5/8/26; however, this did not get reported to hospital leadership until several days later allowing the RN to remain working unsupervised with patients for multiple shifts despite these allegations. As a result, the hospital was found out of compliance with the Condition of Participation at CFR 482.13 - Patient’s Rights, and a condition-level deficiency was issued at A-0115. Refer to A-0145 for additional information. Based on interview and document review, the facility failed to obtain a non-violent restraint order, and comprehensively assess patient restraint needs, prior to restraint application for 1 of 4 patients (P7) reviewed for restraint use. Refer to A-0168 for additional information.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 33925 Based on interview and document review, the hospital failed to ensure acts of potential non-therapeutic conduct and undignified treatment committed by a registered nurse (RN) in the operating room (OR) setting were reported, acted upon, and investigated to help prevent future incidents to other patients. The RN had been observed for several months to commit acts that were not in accordance with the standard of care for surgical preparation of a patient, but these concerns were not reported to appropriate leadership personnel timely nor investigated as potential acts of abuse and/or undignified treatment. The RN then committed more acts, including potential sexual assault, with two patients (P1, P2) on 5/8/26; however, this did not get reported to hospital leadership until several days later allowing the RN to remain working unsupervised with patients for multiple shifts despite these allegations Findings include: A submitted Vulnerable Adult (VA) Maltreatment Report, dated 5/15/26, identified the hospital reported an allegation of sexual abuse towards P1. The report identified RN-E was accused by another staff member of using a surgical preparation stick beyond the normal field of preparation and into the genital area. Further, a subsequent VA Maltreatment Report, dated 5/18/26, identified the hospital reported an allegation of sexual abuse towards P2. The report identified the same RN-E as being accused of inserting a portion of their finger into the anus of the patient during surgical preparation for hemorrhoid surgery. On 5/19/26 at 2:06 p.m., RN-A was interviewed and stated they worked in the OR core. RN-A stated staff are provided education annually related to VA reporting and if they noticed a colleague does something concerning or non-therapeutic to a patient, they would report it to the supervisor and complete an online incident report called a “RL Solution.” RN-A stated if concerns about employee to patient care were seen, they should be reported right away adding, “As soon as you can.” RN-A explained the preparation procedure and stated a surgical prep-stick (i.e., chlor-a-prep) was used to clean the skin and each physician had a “preference card” for how big the prep-field should be made. There was also a hospital policy on it. RN-A stated they had participated in a hemorrhoid procedure previously and explained the patient would be positioned face down with their buttocks taped “slightly apart” and a betadine solution used on the area. RN-A stated the anal opening and inside should not be touched: “We don’t go in the rectum, just around the area.” When interviewed on 5/19/26 at 2:49 p.m., certified surgical technologist (CST)-A stated they worked with RN-E often and recalled being present for the hemorrhoid case on 5/8/26. CST-B was also present and worked with them routinely. CST-A stated they helped RN-E position the patient for the procedure and secured the buttocks open. As RN-E started to do the preparation, CST-A noticed RN-E inserted their finger into the patient’s anus up to “maybe fingernail length.” CST-A stated it made them pause and think, “That’s different.” CST-A stated they kept it in their mind until “later on” when they asked another nurse if that was normal preparation with a hemorrhoid case. The nurse identified it was not a normal part of the preparation, and it should be reported. CST-A stated they had never seen any other nurses insert their finger into the anus for preparation and then explained they had noticed several other concerning behaviors by RN-E, such as often leaving the patient “over-exposed” with breasts or genitals uncovered when not necessary for the procedures. CST-A stated they had provided several reminders to RN-E to keep patients covered, in which such behavior had been ongoing for multiple years now. CST-A stated they raised these concerns with their supervisor, RN-C, but the behavior never seemed to improve or change. CST-A reiterated they had not realized RN-E inserting their finger into the anus was concerning until they spoke to the nurse later, thus the reason they had not immediately reported it to the supervisor team. CST-A stated, since the incident on 5/8/26, she was given some informal coaching on reporting concerns but otherwise had not been given any other follow-up or re-education on reporting allegations or abuse or non-therapeutic conduct. When interviewed on 5/19/26 at 4:05 p.m., CST-C stated they, along with CST-B, worked on 5/8/26 with RN-E for an abdominal case with a female patient (P1). CST-C stated RN-E started the preparation using a chlor-a-prep stick on the skin and the patient was already under anesthesia. RN-E then removed the blanket covering the patient and moved it down past her knees. This exposed P1’s genital area, which was not required for the procedure. Next, RN-E started to use the preparation stick in and around the vaginal area. Upon seeing this, CST-C spoke up and said it was not needed. Despite this, RN-E just seemed to “shrug it off” and kept going. CST-C stated they had never seen RN-E do a preparation like that before but had observed RN-E “continuously” over-expose female breasts when it was not needed. CST-C stated they were encouraged by another staff member to report the concern which happened on 5/8/26, after-the-fact. This was the first time they had ever reported RN-E’s behaviors as previously they were unsure if just over-exposing the breasts was something to be concerned about or not. CST-C stated a meeting was held with their supervisor, RN-C, and employee relations on 5/14/26 to discuss the situation. CST-C stated they had never seen RN-E sexually assault anyone but then mentioned the way RN-E placed Foley catheters in a patient “also caught my attention.” CST-C stated RN-E seemed to use their hands and fingers in a way which “does not feel good” as RN-E seemed to almost “massage” the genital area at times. CST-C stated they had not seen other nurses do such actions when placing a Foley catheter. When interviewed on 5/19/26 at 4:19 p.m., RN-B verified they were the operating room (OR) charge nurse on 5/8/26. RN-B stated nobody had reported concerns to them about potentially non-therapeutic conduct, potential abuse, or over-exposing patients that day. The day went as scheduled and “pretty much as planned.” RN-B stated if someone had reported concerns, such as preparation of the genital area when it was not needed or inserting their finger into an anus, they would have reported to the director of surgical services (DSS) and the management team. RN-B stated they could maybe complete an online incident report; however, the managers usually would do that. On 5/20/26 at 8:33 a.m., RN-D was interviewed and explained they raised “some gray area” concerns about RN-E to RN-C several months ago, such as over-exposure and “unnecessary contact” with patients. RN-D stated they felt these things were “gray area” issues as, at times, blankets do need to be changed; however, RN-E seemed to have more of a pattern of this behavior versus other nurses. RN-D stated, on one occasion, they had observed RN-E feel a female breast prior to a lumpectomy case (surgical removal of a mass), which was “not our [RN] role.” RN-D stated they were unsure of the reason for this action. RN-D stated another observed concern happened when RN-E had positioned a female patient on their back in a “frog-leg position” prior to surgery and left them exposed while charting on the computer across the room. Then another incident happened when RN-E removed their cell phone to take a photo of the team schedule, in which the screen displayed pornography. RN-D stated the time of day this happened made them think RN-E may have possibly been watching the pornography while at work. RN-D stated during the week after 5/8/26, both CST-A and CST-C voiced to them RN-E went way over the usual preparation field on the female abdominal case and the finger being inserted into the anus of a male patient. RN-D stated they encouraged both CSTs to report their concerns to RN-C. On 5/11/26, they saw CST-C and inquired if they had reported the concerns to RN-C, to which CST-C responded, “Not yet.” RN-D stated they later ran into RN-C and told RN-C to find CST-C to speak with them about an issue. RN-D stated they did not report the finger insertion allegation themselves as they were unsure if CST-A had reported it or not. Further, RN-D stated there had been no further follow-up or education on reporting of the situation since it had been reported. When interviewed on 5/20/26 at 9:01 a.m., CST-B stated they were a newer employee to the hospital campus and recalled working the female abdominal case with CST-C on 5/8/26. During this case, they had their back to the patient but did hear CST-C say, “You don’t have to prep the vagina.” CST-B turned around and saw RN-E with a ChloraPrep stick down at the patient’s vaginal area which, “[I] thought was weird.” Additionally, RN-E had surgically prepared all the way down to the patient’s thighs for the abdominal case. CST-B stated they had never seen this done like that before. CST-B stated they didn’t even think ChloraPrep was even supposed to be used on the genital area as other hospitals usually used betadine. CST-B stated they also worked on the hemorrhoid case with CST-A on 5/8/26, however, did not recall seeing or hearing any concerns with that case. On 5/20/26 at 9:20 a.m., a group interview was held with RN-C, DSS, and the surgery manager (SM). RN-C stated they had received notification approximately “six to nine months ago” related to concerns about RN-E and situations which just “felt off.” These included feeling a female breast prior to the lumpectomy procedure and a nurse walking into the OR with RN-E at the computer while a female patient was in a “frog-leg position.” RN-C stated they shared these issues with SM but were unsure when. In follow up, observational audits of RN-E’s surgical preparations were completed; however, no concerns were witnessed. Then in March 2026, a nurse reported the incident with pornography being accidentally revealed on RN-E’s cell phone. RN-C stated they updated SM as they felt SM speaking to RN-E would be better for a “male to male conversation.” Then “early last week” RN-D approached RN-C and asked if CST-C had spoken to them yet, which they had not. RN-C stated they saw CST-C on 5/14/26 and asked if there was something they needed to discuss, which is when CST-C reported concerns of possible sexual harassment by RN-E and the over-exposure incident which happened on 5/8/26. This caused RN-C to alert SM and involve employee relations. RN-C stated 5/14/26 was the first time anyone had reported the concerns from 5/8/26 to them. SM stated their initial plan to address RN-E previously reported concerns, months earlier, was to increase the rounding with visual performance audits but when no concerns were directly seen, they “moved on.” SM stated they had not yet spoken to RN-E about the pornography incident despite it happening in March 2026. RN-C and SM both expressed that none of the incidents prior to 5/8/26 had been elevated beyond them to other leadership. This was due, at least in part, to them not being sure the reported situations rose to an allegation of abuse level which needed to be acted upon like that. RN-C and SM both verified despite employees bringing up concerns and potential work performance issues about RN-E, neither of them ever had a direct conversation with RN-E or provided any verbal coaching. They also did not visit with any other staff about RN-E’s work performance or potential observed concerns as they did not want to lead someone into thinking things which were not potentially accurate. SM stated they questioned why nobody else from the surgical team, such as the nurse anesthetists, ever reported similar situations were happening. RN-C stated providing dignity to patients was “something we commit to,” and SM stated they expected staff to work in a manner which respected that dignity. Both RN-C and SM stated no other staff members except RN-D had ever raised concerns about RN-E and these potentially abusive actions prior to 5/14/26, rather the voiced concerns were more about slow working and being on shift late. SM stated hearing other staff had seen actions which were concerning, like leaving female patients over-exposed and massaging the genitals with catheter insertion, was frustrating, questioning, “What’s the barrier [to report]?” SM stated if those things had been reported to them, it would have been investigated: “Knowing what I know now.” RN-C and SM both expressed that the staff who observed these behaviors could have completed an online incident report (RL Solution), which would have also caused a follow-up to happen. DSS stated staff were always able to report concerns to them, and hearing all these past allegations and the lack of in-the-moment action was hard to hear, questioning, “Why wasn’t it brought to me?!” If staff felt they reported something and no action had been taken on it, they could have gone up the chain to someone else too. RN-C and SM both expressed that neither of them was aware of the catheter observations staff voiced prior to this interview, but DSS stated it had been raised since the 5/8/26 incident(s) as someone finally reported it to them. DSS stated, “If [RN-E] had not brought this up, we [leadership] would not know [about it].” DSS stated the floor staff obviously felt they could discuss it amongst themselves and their peers but not with leadership, which was a concern. DSS stated all the employees were mandated reporters: however, they had not reported it despite seeing these acts being carried out. DSS verified there was no clinical reason or purpose to have a female’s genitals exposed or prepared for an abdominal procedure, nor was there any clinical reason to insert a finger into the anus of a hemorrhoid case for the surgical preparation. DSS stated maybe the fact the finger being inserted into the anus was more sexual-in-nature caused the CST to finally report it to someone else. SM verified a ChloraPrep stick should not have been used on the genital area as the solution can cause irritation and harm to the mucous membranes. DSS then explained the timeline of events for the 5/8/26 incidents in detail. This was first brought to their attention on the afternoon of 5/14/26, when SM asked about the following day’s schedule and identified RN-E would be removed from it due to some allegations from a staff member. During interviews with other staff, the 5/8/26 abdominal case incident was identified. In response, a meeting was arranged with RN-E; however, just prior to the meeting, the employee relations team stepped in and directed them to postpone it. RN-E was then contacted and removed from the schedule pending investigation. DSS was then asked to lead the investigation. This continued and remained in progress. The MAARC (VA maltreatment) reports were made as soon as they learned of the allegations, however, again reiterated the staff should have reported it right away when the incidents were initially observed. DSS stated RN-E had not yet been interviewed as involved law enforcement had directed them not to until they had a chance to meet with him. DSS verified if a MAARC was required due to an observed incident, it should be reported within 24 hours. Despite this, these incidents were not reported timely. DSS stated they had already started re-education to the leadership and supervisor level personnel as these staff were the level from whom direct care staff would receive a report. However, they had not yet started any re-education with the floor staff as they were directed by the regulatory team to wait until further notice. DSS added education for the direct care staff was likely to come soon. DSS verified RN-E had worked multiple shifts unsupervised after 5/8/26 and was not removed from the working schedule until after their shift on 5/14/26. This happened as, “We were not aware [of the incidents].” RN-E’s untitled working schedule, dated 4/26/26 to 6/6/26, identified RN-E worked on 5/8/26, 5/11/26, and 5/14/26. RN-E’s hospital training records identified RN-E was last educated on vulnerable adults and reporting allegations on 6/12/2025. On 5/19/26, correspondence with the local law enforcement was held and the surveyor was released to speak with RN-E about the allegations. On 5/20/26 at 11:20 a.m., RN-E was contacted and verbalized understanding they were free to decline the interview with the Minnesota Department of Health (MDH). RN-E agreed to speak and explained they had worked at the campus as an RN for approximately two years. RN-E verified they worked on 5/8/26 and recalled the case with the female abdominal procedure. RN-E stated “yes and no” sometimes the genital area needed to be prepared and explained they did prepare the area with a ChloraPrep stick but just did “one swipe” over the vaginal opening; however, they did not recall if anyone, such as the surgeon, had directed them to do that or not. RN-E stated most of the surgical preparation process was “at the nurses’ discretion.” RN-E stated they did recall someone else in the room saying, “We don’t need to go that low,” so RN-E stopped and covered the patient back up. RN-E reiterated, “I was told it’s fine to do that,” based on a prior case. RN-E then recalled the hemorrhoid case and stated they used betadine to prepare the area around the anus, which included using “a slight bit of the finger” inserted inside the anus. RN-E verified they inserted their finger into the patient’s anus and stated it was “just enough to have it cleaned.” RN-E stated they did this as this was what they had been told to do by another peer at the hospital but could not recall who. RN-E stated they then worked two more shifts until 5/14/26, when they were told they were being removed from the schedule for “improper touch.” RN-E stated this was the last they had heard from the hospital. RN-E stated if someone thought they had been massaging genital areas while inserting a catheter, then it would have been a male patient. RN-E stated they felt they needed to do this at times due to patients having a sometimes-enlarged prostate, and it made the catheter insert easier. RN-E denied any intentional wrong-doing and reiterated they were just doing what they felt was needed for the surgical preparation, adding, “Nothing was intentional for my pleasure at all.” Later at 2:36 p.m., RN-E contacted the surveyor and stated they thought more about the anal preparation. RN-E stated they had done the same thing, using a finger in the anus, to prepare a case “about two months ago” which caused some fluid to be released. Others in the room laughed at the time; however, nobody ever said not to insert a finger inside the anus. When interviewed on 5/20/26 at 11:42 a.m., P1 stated they were at the hospital on 5/8/26 for a procedure to remove a cyst from their abdomen. P1 recalled having a yellow-colored stain on their skin from the surgical preparation which went from “the high belly down to my mid-thighs.” To their recall, there was never rationale given to them why so much area was prepared. P1 stated someone from the hospital had just contacted them about the procedure on 5/8/26 and stated further they did not know how they felt about potentially being over-prepared using the wipe. A telephone interview was attempted with P2 on 5/20/26, however, they were unable to be reached. On 5/20/26 at 11:31 a.m., a group interview was held with the hospital chief operating officer (COO), vice president of operations (VPO) and regulatory manager (RM)-A. COO explained staff should report any witnessed concerns with staff actions to the level above them. From that, some “initial fact finding” happens and an outside report, like a MAARC, would be made if needed. VPO stated an RL Solution report could be completed by either the employee who witnessed the event or their leader which ensured all parties who needed to be notified would be notified. Also, there were incidents which could happen where follow-up would start before an RL report would be completed. VPO stated this investigation, which stemmed from the 5/8/26 incidents, was the first time the information had been raised to their level and part of the continued investigation included a review of what staff knew about this employee’s actions prior to the 5/8/26 incidents. VPO stated if concerns are witnessed or raised about an employee’s performance, especially with patient care, then it should be elevated using an RL report and acted upon, and stated, in hindsight, a formal investigation into RN-E’s actions which staff had observed prior to 5/8/26 would have been warranted. The group agreed that the employees who saw the concerns on 5/8/26 should have immediately reported them to the supervisor for action to be taken, which included a response plan being developed by employee relations and regulatory groups. RM-A stated the staff had resources available through a checklist, which could help guide them if needed. COO stated leaving patients over-exposed, preparing the genital areas when not needed, and inserting a finger into the anus could all be potential acts of abuse. At 12:23 p.m., senior director of risk management (SDRM) attended the interview. They verified there were no other RL reports made about RN-E’s behavior prior to the 5/8/26 incidents and employee relations was still trying to locate what, if any, coaching actions RN-E had in the past two years. SDRM verified the incidents on 5/8/26 were first reported to human resources (HR) on 5/14/26 and the first RL report was entered on 5/15/26. The local law enforcement was also first contacted on 5/15/26. SDRM stated the staff who witnessed these events on 5/8/26 should have immediately reported them so it could be acted on right then but that did not happen. SDRM stated once leadership was notified of the 5/8/26 incidents, quick actions were taken and things “started to fall into place.” SDRM stated the investigation remained ongoing and they were still gathering details to determine what education to provide the staff outside of those directly involved with the situation. COO stated they were looking into getting education rolled out to staff shortly but had paused some of their process to cooperate with law enforcement’s direction and the MDH investigation. A received e-mail correspondence, dated 5/20/26, identified the hospital’s HR was unable to locate any prior coaching or corrective action plans for RN-E prior to 5/20/26. The hospital Vulnerable Adult (VA) Maltreatment policy, dated 2/2026, identified the hospital as responsible for reporting suspected or actual abuse and neglect immediately as mandated by law. The policy identified all personnel must comply with applicable state and local laws regarding incidents of actual or suspected maltreatment, and directors and supervisors would review criteria for reporting or not reporting errors in the provision of therapeutic conduct. The policy listed definitions which included abuse as being assault in the 1st to 5th degree(s) or criminal sexual conduct in the 1st through 5th degree(s) adding, “A violation includes any action that meets the elements of the crime, regardless of whether here is a criminal proceeding or conviction.” The policy defined, “Immediately means as soon as possible, but no longer than 24 hours from the time initial knowledge that the incident occurred has been received,” and MDH was listed as the lead investigative agency for entities licensed as a hospital campus. The policy defined, “Therapeutic conduct means the provision of program services, health care, or other personal care services done in good faith in the interests of the vulnerable adult by ... [the] employee or person providing services in a facility .... or ... a caregiver.” The policy continued and directed all instances of abuse, including actual or just an allegation, needed to be reported. All employees were expected to report concerns or allegations, and licensed personnel were expected to report to MAARC. The policy identified upon identification or suspected abuse, the hospital would provide protection which could include moving an affected patient, providing 1:1 monitoring as needed and removing the alleged perpetrator (AP) from patient contact. An internal investigation would then happen, which could include interviews with patients involved, staff involved, witnesses to the event, and review of applicable documentation.”

“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: 48300 Based on interview and document review, the facility failed to obtain a non-violent restraint order, and comprehensively assess patient restraint needs, prior to restraint application for 1 of 4 patients (P7) reviewed for restraint use. Findings include: P7’s medical record identified admission to the inpatient intensive care unit (ICU) from an outside hospital on 5/18/26 at 10:36 p.m. P7’s admission history and physical dated 5/18/26 at 11:45 p.m., identified P7 was intubated (breathing tube) and sedated (calm, relaxed state due to effects of medication). P7 had been intubated at the outside hospital due to restlessness and agitation. The note lacked evidence P7 attempted to remove and/or interfere with ventilator equipment and/or any other utilized medical equipment, nor did the note identify soft restraints had been applied, or the reason for their use. P7’s nursing note date of service 5/18/26 at 10:45 p.m. indicated P7 had arrived to the ICU, vital signs were stable, propofol (a sedating medication) was infusing and a doctor was at bedside. The note lacked evidence P7 attempted to remove and/or interfere with ventilator equipment and/or any other utilized medical equipment, nor did the note identify soft restraints had been applied. P7’s Restraint Non-Violent flowsheet identified right and left soft restraints were applied on 5/18/26 at 10:45 p.m. for “pulling at lines/tubes” and the provider had been notified. P7’s Flowsheet section dated 5/18/26 at 10:48 p.m. identified P7 aroused only with vigorous tactile stimulus, did not open his eyes, and his motor strength to all extremities was a “Flicker/trace of contraction (not enough muscle contraction to produce meaningful movement)”. Additionally, P7’s Glasgow Coma Scale total was 6 (deep state of coma). P7’s medical record identified a verbal order read back (VORB) for non-violent restraints was entered by registered nurse (RN)-F on 5/19/26 at 3:42 a.m., approximately five hours after the restraints were applied. The order identified right, and left wrist soft restraints were utilized for “lack of awareness to harm self by actions”. Order comments included: “Provider signature verifies assessment has determined the risk associated with restraint use is outweighed by the risk of not using restraint. This order is for calendar day 5/18. Verbal order received from Dr. [name]. Patient arrived shortly before 2300 (11:00 p.m.)”. P7’s nursing note date of service 5/19/26 at 8:16 a.m., indicated restraint use was required for lack of safety awareness. The note lacked additional information related to the restraint use and/or any behaviors/attempts to interfere with medical equipment P7’s medical record lacked evidence he was assessed for restraint use, based on his specific needs, prior to the application of non-violent restraints to ensure the restraint use was the less restrictive measure to ensure P7’s safety. On 5/20/25 at 3:29 p.m., a message was left for RN-F requesting a return call with no return call received. During an interview on 5/18/2026 at 9:42 a.m., RN-G stated patient behaviors and interventions like de-escalation, repositioning, food, and distraction should be attempted and documented prior to restraint use. RN-G explained a provider order for restraints should be obtained prior to placing any type of restraint, if possible, in which the provider should enter the order into the medical record when present for the application. If the provider was not present, a verbal order should be obtained and entered into the medical record as soon as possible. During an interview on 5/18/26 at 2:01 p.m., medical doctor (MD)-A stated all restraints needed an order before, or as soon as possible after application and the provider should enter the order into the patient’s medical record if the provider was present during application or if a nurse requested a restraint order. When restraint orders required renewals, this process was based on restraint type, and facility policy, in which she inquired about the patient’s behaviors, what the staff had attempted prior to restraint use, and then completed a face-to-face within an hour. MD-A stated staff should attempt interventions like repositioning and de-escalation prior to restraint use and document if the interventions were effective or not. All patient behaviors necessitating restraint use should also be clearly documented. During an interview on 5/20/2026 at 2:42 p.m., director of ICU (ICU-D) stated that when a patient is pulling at critical lines and tubes, staff should attempt other interventions prior to soft restraint placement. Such interventions, along with the patient’s displayed behaviors necessitating the restraint use, should be documented. ICU-D stated soft restraint orders need to be obtained every calendar day and should be entered as soon as possible if a verbal order is received from a provider. ICU-D stated she did not see an order for soft restraints on 5/18/26 for P7 prior to their application and did not find a note in P7’s medical record to provide insight into the lateness of the verbal order. ICU-D stated she would have expected the provider to put the restraint order into P7’s medical record or the nurse should have entered a verbal order as soon as possible and the nurse should not have waited five hours to enter the order. The Restraint and Seclusion policy dated 5/2026 instructed patients will be assessed and the least restrictive interventions will be attempted prior to use of restraints. An RN may initiate restraint application if the patient continues to demonstrate actions/movements potentially resulting in negative clinical outcomes such as dislodgement of a device resulting in increased risk of infection, pain, or trauma. The provider is notified of the situation, and an order is obtained as soon as safely possible after the restraint device has been applied. A new order is required by the end of the next calendar day for patients continuing to meet the requirements for restraint use.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 43080 Based on interview and document review, the facility failed to provide a face-to-face evaluation (a physical and behavioral assessment of the patient by a qualified practitioner), and/or a comprehensive review of the patients status at the time of the face-to-face evaluation, within an hour of restraint and/or seclusion initiation, for 4 of 5 emergency department (ED) patients (P7, P11, P12, P13) who were physically restrained, and/or placed in seclusion. In addition, the facility failed to obtain a physician or licensed practitioner order prior to, during, or immediately, and develop a restraint and seclusion policy that was directed, by regulations, when an order for restraint(s)/seclusion was to be obtained, and discontinue restraint and/or seclusion orders at the earliest possible time once restraints were released, and/or the patient was removed from seclusion. As a result, the hospital was found out of compliance with the Condition of Participation: Patient Rights at 42 CFR 482.13. For additional information see A-0168, A-0174, and A-0179.”

“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: 43080 Based on interview and document review, the hospital failed to deliver adequate nursing care based on patient needs in response to changes in condition for 1 of 10 patients reviewed (P4) when the patient experienced a deterioration in their surgical incision, and an elevated blood pressure (BP). Nursing staff failed to reassess P4’s blood pressure and failed to notify the appropriate medical provider for additional follow up prior to P4’s discharge. This resulted in an immediate Jeopardy (IJ) finding. In addition, the facility failed to utilize restraint and/or seclusion verbal orders (VO) infrequently in the emergency department (ED). The deficient practice resulted in an immediate jeopardy. The hospital was found out of compliance with the Condition of Participation Nursing Services at 42 CFR 482.23. For additional information see A-0395 and A-407.”

“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: 43080 Based on interview and document review, the facility failed to obtain a physician or licensed practitioner order prior to, during, or immediately (within a few minutes) following, restraint or seclusion initiation for 4 of 5 emergency department (ED) patients (P7, P11, P13, P14) reviewed for violent restraint and seclusion use. In addition, the facility failed to develop a restraint and seclusion policy that was directed, by regulations, when an order for restraint(s)/seclusion was to be obtained. Findings include: P7’s presented to the ED on 3/6/26, at 8:41 p.m., for a mental health evaluation in the setting of severe bipolar disorder with a current manic episode and agitation and aggressive behaviors at home. She arrived with police escort in a “restraint wrap” due to behavioral dysregulation. P7’s Restraint Monitoring Flowsheets and Order’s section identified: -3/6/26, at 8:55 p.m., double Velcro restraint to her right wrist, left wrist, right ankle, and left ankle were placed. At 9:11 p.m. (16 minutes later), the verbal order (VO) was entered into the medical record. -3/7/26, at 3:55 a.m., P7 was placed in a restraint chair. P7’s record lacked an order for a restraint chair; however, at 3:58 a.m., a VO was entered into the medical record for seclusion. The record lacked evidence P7 was placed in seclusion at this time. -3/8/26, at 10:30 a.m., P7 was placed in seclusion. At 10:41 a.m. (11 minutes later), the VO was entered into the medical record. P11 presented to the ED on 3/8/26, at 12:53 p.m., related to chemical dependency in the setting of methamphetamine intoxication. P11’s Restraint Monitoring Flowsheets and Order’s section identified: -3/8/26, at 1:20 p.m., a physical hold was utilized for intramuscular (IM) medication administration. At 4:56 p.m. (approximately 3.5 hours later), the VO was entered into the medical record. -3/8/26, at 1:28 p.m., P11 was placed in seclusion. At 4:57 p.m., (approximately 3.5 hours later), the VO was entered into the medical record. -3/8/26, at 6:00 p.m., double Velcro restraints to his right wrist, left wrist, right ankle, and left ankle were placed. At 6:08 p.m. (eight minutes later), the VO was entered into the medical record. -3/9/26, at 9:30 a.m., P11 was placed in seclusion. At 11:20 a.m. (approximately two hours later), the VO was entered into the medical record. P13 presented to the ED on 3/17/26, at 10:35 a.m., via law enforcement for aggressive behavior in the community. P13’s Restraint Monitoring Flowsheets and Order’s section identified: -3/17/26, at 2:00 p.m., P13 was placed in seclusion. At 2:23 p.m. (23 minutes later), a VO was entered into the medical record. -3/17/26, at 2:10 p.m., P13 was placed in the restraint chair. At 2:23 p.m., (13 minutes later), a VO was entered into the medical record. -3/17/26, at 2:10 p.m., P13 had a spit hood placed over his head. At 2:23 p.m., (13 minutes later), a VO was entered into the medical record. P14 presented to the ED on 3/18/26, at 7:03 p.m., for a mental health evaluation in the setting of schizophrenia and not having took his medication for a couple of days where he was noted to talk to himself. During the ED encounter, P14 punched multiple staff. P14’s Restraint Monitoring Flowsheets and Order’s section identified: -3/18/26, at 12:30 a.m., P14 was placed in the restraint chair. At 12:37 a.m. (seven minutes later), a VO was entered into the medical record. A Violent Restraint and Seclusion auditing flowsheet, dated 3/6/26, through 3/19/26, identified a column labeled, “Was a provider order obtained within one hour of initiation of restraint? (Y/N).” The indicated “Percent Compliance” for this column was 8 “Yes” and 4 “No” for a total of “67% (percent).” The following entries were identified: -P11’s 3/8/26, 1:20 p.m., physical hold was a “No.” -P11’s 3/8/26, 1:28 p.m. seclusion was a “No.” -P11’s 3/9/26, 9:30 a.m. seclusion was a “No.” -P7’s and P13’s audits all identified as “Yes.” -18 additional patient restraint encounters were audited and seven of them were identified to not have an order within one hour. When interviewed on 3/31/26, at 10:41 a.m., RN-D stated she was responsible for ED restraint and seclusion auditing which she conducted every 24-48 hours. Quarterly, her audits were presented at a restraint committee meeting - last held in January 2026. When asked about any recent trends related to restraint concerns, she stated, “we are not perfect ...there are always going to be concerns.” “We miss things here and there,” especially as patient care came first, and charting second. RN-D explained that she had not identified any significant concerns during her audits lately; however, she did note “missed” items, or concerns where the “times were funky,” but the date was on. In response to noted errors, she provided a monthly report to the ED director and brought provider concerns to the ED medical director (MD)-D as she did not manage provider education. Initially, she was without recollection as to the last time she had updated MD-D related to any restraint concerns; however, later in the interview she indicated she had such communication in the past three weeks or so. RN-D identified restraint orders were expected to be obtained within “60 minutes,” as staff could not do things without an order - “They cannot practice out of their scope.” She felt staff were “good” at entering orders within the 60 minutes if patient care did not come first. RN-D stated nursing staff were educated yearly on restraints and seclusion; however, she was unsure when and with what information the providers were educated. When RN-D was updated on the concerns surrounding P7, P11, P13, and P14, she stated, “That is a lot. We usually do better than this.” She further stated all restraint/seclusion orders were expected to be correct. If an order for seclusion was put in, that was what she expected to see during her audits. RN-D felt that over the last few weeks she had to question staff related to such concerns and indicated staff could go back and “fix” the documentation; however, she did not go back and ensure such concerns were fixed. RN-D expressed no overall concern about the orders not being completed as expected, as staff were doing the right thing for the patients, but their documentation, and processes, could be improved. RN-D verbalized the concerns brought forth to her on this day were overall not a concern as the ED staff did right things for the patients in practice, it was only the documentation that could be improved. When interviewed on 3/31/26, at 11:28 a.m., medical doctor (MD)-B stated that when she was present during restraint initiation, which she was much of the time, the orders were usually given in real time and per a verbal order to the nursing staff who initiated the process. She identified, if she was not present during application and/or initiation, nursing staff were good at updating her. MD-B stated the order was to be placed as soon as possible as the order process triggered a mental reminder for her that the face-to-face was also due within an hour of the application/initiation. MD-B explained, when a nurse entered a VO, it flowed to her inbox that was housed in the medical record system. She was expected to verify the orders and acknowledge them. She was unaware of any concerns related to staff not placing a correct order during her verification process. When interviewed on 3/31/26, at 11:45 a.m., MD-C stated his recent experience with such orders was that the nurses updated him and he provided a verbal order “most of the time.” If a VO was provided, he was expected to verify the order. He had until the end of his shift to perform this expectation. MD-C was unsure whether he had recently been updated on any restraint process concerns, and if so, if he had followed through on any education. He stated he was in the middle of a lot of things at times and such may not be on his priority list. MD-C explained, if a wrong order was identified, he expected it to be changed to the right order. As he was unaware of the details surrounding such a situation, he was unable to comment further. He was unsure how often he was provided restraint/seclusion education. Due to MD-C’s chief of staff role, when questioned on provider concerns related to restraints, such as order entry, he indicated he was unfamiliar with any concerns. When interviewed on 3/31/26, at 12:03 p.m., MD-D stated RN-D audited restraint use and was good at letting him know when there were provider mistakes. He felt RN-D had not updated him related to any recent order concerns; however, he was aware of some provider misses with other things. MD-D stated it was expected the order was documented within an hour of application. The providers “usually” placed the orders, otherwise they cosigned the VO that was provided and were expected at that time to make sure the order was correct in relation to what they verbally ordered. When interviewed on 3/31/26, at 12:44 p.m., MD-E stated the providers attempted to place their own restraint orders more often, which was expected to be completed within one hour of initiation. If a VO was provided, he was expected to verify the orders as soon as possible but hopefully within the first hour. If a patient required a restraint chair, and that was what staff were required to do, he expected the order to reflect that, not something such as seclusion. For his assessment processes and documentation, he needed to know exactly what restraint was utilized, especially when patient safety was a factor. When interviewed on 3/31/26, at 1:07 p.m., RN-E stated a restraint order was ideally expected to be placed as soon as possible, “but the computer will let you go back within the hour.” She stated there were “times” when the VO was placed after the one-hour mark. With the VO process, she was expected to ensure the order was correct, thus the need for a readback of the order to ensure accuracy. RN-E explained the restraint process required extensive charting and with this, and other restraint processes, order entry was the last thing on her mind at times. RN-E remembered the situation with P11. She identified she was “very busy” at that time, and she placed the order when she realized she had missed it. RN-E stated no one had spoken to her recently about any restraint process concerns, but she did mention these processes were audited. When interviewed on 3/31/26, at 1:28 p.m., RN-F stated restraint orders were to be processed right away or within the first hour of initiation. She identified the VO practice was to get a verbal order, clarify it with the provider for accuracy, and then place it into the orders. She stated the system would not allow you to “back time” if outside of the one hour. Additionally, she stated no one has spoken to her recently related to any restraint related concerns. When interviewed on 3/31/26, at 1:50 p.m., RN-G stated providers ideally put in their own restraint orders; however, if they were unable to, a VO was utilized which she expected to be processed within an hour as the medical record system did not allow them to put the order in after an hour. Additionally, when a VO was utilized, she was expected to read back the order to verify accuracy as this ensured patient safety. Typically, the VOs were placed once she ensured the patient was safe. RN-G explained, when questioned on P11’s seclusion order, P11’s care was “busy,” and she probably just forgot to put the order in at the time and placed it when she remembered. RN-G stated no one had spoken to her recently related to any restraint related concerns. When interviewed on 3/31/25, at 2:10 p.m., MD-F stated that at times it was very hard to place the restraint orders herself, and/or to ensure they were entered timely, due to her workload; however, it was important for this to be done as soon as possible, or at least within the hour, as the nurses’ required the orders. MD-F stated no one had spoken to her recently related to any restraint related concerns. When interviewed on 3/31/26, at 2:33 p.m., RN-H, the ED manager, stated that nursing staff could enact a restraint order; however, the provider was expected to be updated as the provider was expected to write the order. He expected this ideally to be as soon as possible but no later than one hour after initiation and he expected the restraint order and the restraint utilization matched as the nurse was expected to follow the order and could not do something independently of what was ordered. RN-H did not do restraint auditing and thus was not aware of what was audited. He explained that RN-D was very transparent and if any concerns were identified by RN-D, RN-D would have updated him and/or the ED director. He identified the ED director had not brought any concerns to him related to the restraint order process. After he was updated on the restraint concerns for P7, P11, P13, and P14, he stated he was unaware of the increased concern related to the order process and verbalized, “Looks like we have some work on this.” When interviewed on 3/31/26, at 4:13 p.m., the chief nursing officer (CNO) stated the provider was expected to enter the restraint orders as soon as possible; however, at times, such as emergency situations, a VO process was utilized, and the nurse was then expected to place the order as soon as possible. The CNO indicated she expected staff to follow the hospital’s policies and procedures. She stated, prior to the survey, she was unaware of the concerns that surrounded order entry related to following such policies and practices. A facility Restraint Education module transcript, dated 2025, identified RN training and a Clinical Partner Annual Education module transcript, dated 2025, identified provider education. Both transcripts, directed an order must be obtained from the provider immediately and no later than one hour from the time the violent restraints or seclusion were initiated. The education lacked direction for the requirement that a restraint/seclusion order was expected to be obtained prior to, during, or immediately (within a few minutes) following restraint application based on the presented situation. A Restraint and Seclusion policy, dated 8/2025, identified a provider order was needed for each episode of restraint use and/or seclusion and restraints and/or seclusion are initiated under the direction of the registered nurse (RN). The policy directed that the RN could initiate the restraint or seclusion if the patient continued to demonstrate aggressive/violent and behaviors/actions, which were not controlled immediately and that may result in serious injury to self, staff, or others. In such situations, the RN was to notify the provider and obtained an order “as soon as safely able to complete within the first hour.” The provider order must include the type of restraint or seclusion. If there was a change in the need for restraint/seclusion, the RN was to notify the provider and obtain a new order. The restraint type was to be determined based on the behavior, clinical indication, and provider orders where the RN was to use critical thinking when the restraint type was determined. The policy lacked direction for the requirement that a restraint/seclusion order was expected to be obtained prior to, during, or immediately (within a few minutes) following restraint application based on the presented situation.”

“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: 43080 Based on interview and document review, the facility failed to discontinue restraint and/or seclusion orders at the earliest possible time once restraints were released, and/or the patient was removed from seclusion, for 5 of 5 emergency department (ED) patients (P7, P11, P12, P13, P14) reviewed for violent restraint and seclusion use. This resulted in active restraint orders being in effect up to approximately three and a half hours after the restraints were removed once criteria for discontinuation met. Findings include: P7’s presented to the ED on 3/6/26, at 8:41 p.m., for a mental health evaluation in the setting of severe bipolar disorder with a current manic episode and agitation and aggressive behaviors at home. She arrived with police escort in a “restraint wrap” due to behavioral dysregulation. P7’s Restraint Monitoring Flowsheets and Order’s section identified: -3/6/26, from 8:55 p.m. to 9:55 p.m., P7 was in double Velcro restraint to her right wrist, left wrist, right ankle, and left ankle. The order was discontinued by the system “[Automatically discontinued after expiring],” on 3/7/26, at 1:10 a.m. (approximately three hours later). -3/7/26, from 3:55 a.m. to 5:05 a.m., P7 was in the restraint chair based on the restraint monitoring flowsheets; however, at 3:58 a.m., a VO was entered into the medical record for seclusion. The record lacked evidence P7 was placed in seclusion at this time. The seclusion order was discontinued by the system “[Automatically discontinued after expiring],” on 3/7/26, at 7:58 a.m. (approximately three hours later). -3/7/26, from 2:45 p.m. to 4:15 p.m., P7 was in seclusion. The order was discontinued by the system “[Automatically discontinued after expiring],” on 3/7/26, at 6:48 p.m. (approximately two and a half hours later). -3/8/26, from 10:30 a.m. to 12:00 p.m., P7 was in seclusion. The order was discontinued by the system “[Automatically discontinued after expiring],” on 3/8/26, at 2:41 p.m. (approximately two and a half hours later). -3/8/26, from 1:45 p.m. to 4:00 p.m., P7 was in seclusion. The order was discontinued by the system “[Automatically discontinued after expiring],” on 3/8/26, at 5:50 p.m. (approximately two hours later). P11 presented to the ED on 3/8/26, at 12:53 p.m., related to chemical dependency in the setting of methamphetamine intoxication. P11’s Restraint Monitoring Flowsheets and Order’s section identified: -3/8/26, from 1:20 p.m. to 1:21 p.m., a physical hold was utilized for intramuscular (IM) medication administration. The order was discontinued by the system “[Automatically discontinued after expiring],” on 3/8/26, at 8:55 p.m. (approximately seven and a half hours later). -3/8/26, from 1:28 p.m. to 1:56 p.m., P11 was in seclusion. The order was discontinued by the system “[Automatically discontinued after expiring],” on 3/8/26, at 8:56 p.m. (approximately seven hours later). -3/8/26, from 6:00 p.m. to 8:45 p.m., P11 was in double Velcro restraints to his right wrist, left wrist, right ankle, and left ankle. The order was discontinued by the system “[Automatically discontinued after expiring],” on 3/8/26, at 9:59 p.m. (approximately one hour later). -3/9/26, from 9:30 a.m. to 9:45 a.m., P11 was in seclusion. The order was discontinued by the system “[Automatically discontinued after expiring],” on 3/9/26, at 1:20 p.m. (approximately three and a half hours later). P12 presented to the ED on 3/11/26, at 3:53 p.m., via law enforcement in “4-point-restraints,”, related to aggressive behavior at school that caused significant damage to a classroom. P12’s Restraint Monitoring Flowsheets and Order’s section identified: -3/11/26, from 4:15 p.m. to 4:38 p.m., P12 was in seclusion. The order was discontinued by a registered nurse (RN) on 3/11/26 at 5:48 p.m. (approximately an hour later.) P13 presented to the ED on 3/17/26, at 10:35 a.m., via law enforcement for aggressive behavior in the community. P13’s Restraint Monitoring Flowsheets and Order’s section identified: -3/17/26, from 2:00 p.m. to 2:10 p.m., P13 was in seclusion. The nurse discontinued the on 3/17/26 at 2:43 p.m. (approximately a half hour later.) -3/17/26, from 2:10 p.m. to 2:50 p.m., P13 was in the restraint chair. The order was discontinued by the system “[Automatically discontinued after expiring],” on 3/17/26, at 6:09 p.m. (approximately three hours later). -3/17/26, from 2:10 p.m. to 2:50 p.m., P13 had a spit hood placed over his head. The order was discontinued by the system “[Automatically discontinued after expiring],” on 3/17/26, at 6:09 p.m. (approximately three hours later). P14 presented to the ED on 3/18/26, at 7:03 p.m., for a mental health evaluation in the setting of schizophrenia and not having took his medication for a couple of days where he was noted to talk to himself. During the ED encounter, P14 punched multiple staff. P14’s Restraint Monitoring Flowsheets and Order’s section identified: -3/18/26, from 12:30 a.m. to 1:17 a.m., P14 was in the restraint chair. The order was discontinued by the system “[Automatically discontinued after expiring],” on 3/19/26, at 4:29 a.m. (approximately three hours later). A Violent Restraint and Seclusion auditing flowsheet, dated 3/6/26, through 3/19/26, lacked information related to order discontinuation timing. All P7’s, P11’s, P12’s, P13’s, and P14’s restraint and seclusion orders identified a “Scheduling instructions” section that directed “RN may attempt discontinuation of restraint in absence of behavior(s) previously noted.” When interviewed on 3/31/26, at 10:41 a.m., RN-D stated she was responsible for ED restraint and seclusion auditing which she conducted every 24-48 hours. Quarterly, her audits were presented at a restraint committee meeting - last held in January 2026. When asked about any recent trends related to restraint concerns, she stated, “we are not perfect ...there are always going to be concerns.” “We miss things here and there,” especially as patient care came first, and charting second. RN-D explained that she had not identified any significant concerns during her audits lately; however, she did note “missed” items, or concerns where the “times were funky,” but the date was on. In response to noted errors, she provided a monthly report to the ED director and brought provider concerns to the ED medical director (MD)-D as she did not manage provider education. Initially, she was without recollection as to the last time she had updated MD-D related to any restraint order concerns. RN-D identified the facility did not have a timeline when staff were expected to discontinue the order and she was unaware the order system automatically discontinued the orders, based on the order frequency. They just tried to remove the restraint as quickly as able. Even if a patient had the restraints removed, even if they were on for 15 minutes, staff were expected to get a new order if restraints were required again: even if the initial order was still active. RN-D stated nursing staff were educated yearly on restraints and seclusion; however, she was unsure when and with what information the providers were educated. When RN-D was updated on the concerns surrounding P7, P11, P12, P13, and P14, she stated this process was not an overall concern as the ED staff did right things for the patients in practice, it was only the documentation that could be improved. When interviewed on 3/31/26, at 11:45 a.m., MD-C stated discontinuation of restraint orders were driven by nursing most of the time as they constantly supervise the patient. He verbalized it was ideal if the order was discontinued at the same time as the restraint was removed/stopped; however, he was not overly concerned as once the restraint was removed/stopped, the active order would no longer be an implied order and thus did not impact patient safety going forward. When interviewed on 3/31/26, at 12:03 p.m., MD-D stated he expected restraint orders to be discontinued when the restraint/seclusion was removed/stopped. He was unaware of concerns related to order discontinuations. When interviewed on 3/31/26, at 12:44 p.m., MD-E stated a restraint order should be discontinued by the nurse at the same time the restraint was removed, or the patient taken out of seclusion. When interviewed on 3/31/26, at 1:07 p.m., RN-E stated the restraint order should be discontinued immediately after the restraint was removed, or at the next available opportunity to chart, as patient care came first. This was important as they could not use that order again once it was removed/stopped, and if again needed, they were expected to get a new order. When interviewed on 3/31/26, at 1:28 p.m., RN-F stated she did not discontinue the restraint orders after the restraints were removed as, “It expires.” For pediatrics this was after two hours and for adults this was after four hours. When interviewed on 3/31/26, at 1:50 p.m., RN-G stated she never thought of discontinuing a restraint order after the restraint was removed as the order was only used once and she would need to procure a new order if restraints were again needed. When interviewed on 3/31/26, at 2:10 p.m., MD-F stated she did not personally discontinue a restraint order once the nurse informed her the restraint was removed. She explained she “probably” would allow it to expire. When interviewed on 3/31/26, at 2:33 p.m., RN-H, the ED manager, stated he was unsure what the standard of practice for restraint order discontinuation was. He thought this was in the policy and stated the order should be discontinued once the restraint was removed. If a restraint order was not discontinued, and remained an active order, he verbalized there was a risk of someone trying to enact an order that was not needed. When interviewed on 3/31/26, at 4;13 p.m., the chief nursing officer (CNO) stated she expected the facility’s policies and procedures to be following in which an assessment process occurred, along with shared decision making to ensure restraints were safely removed at the right time. Once removed, she stated the providers should discontinue their own orders. She expected this discontinuation to occur timely and for the orders not to be allowed to discontinue automatically. An Orders: Entry and Management policy, dated 12/2024, identified the policy was in place to provide evidence of provider orders guiding the care and treatment of patients. The policy defined discontinued orders as orders that were no longer used, or applied, to the patient situation. Despite this definition, the policy lacked additional information related to discontinued orders. A Restraint and Seclusion policy, dated 8/2025, directed the use of restraints or seclusion must be limited to the duration of the safety event (aggressive behavior/action by the patient) and discontinued (see above policy) at the earliest possible time, regardless of the length of the initial order. Additionally, the RN could discontinue the order, when there was no longer a clinic need for the intervention, without a new provider order.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) [the patient must be seen face-to-face within 1 hour after the initiation of the intervention -- ] §482.13(e)(12)(ii)To evaluate - 1. The patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. This Standard is not met as evidenced by: 43080 Based on interview and document review, the facility failed to provide a face-to-face evaluation (a physical and behavioral assessment of the patient by a qualified practitioner), and/or a comprehensive review of the patients status at the time of the face-to-face evaluation, within an hour of restraint and/or seclusion initiation, for 4 of 5 emergency department (ED) patients (P7, P11, P12, P13) who were physically restrained, and/or placed in seclusion. This had the potential to affect all future patients who came to the ED and required restraints and/or seclusion. Findings include: P7’s presented to the ED on 3/6/26, at 8:41 p.m., for a mental health evaluation in the setting of severe bipolar disorder with a current manic episode and agitation and aggressive behaviors at home. She arrived with police escort in a “restraint wrap” due to behavioral dysregulation. P7’s Restraint Monitoring Flowsheets and medical records identified: -3/6/26, from 8:55 p.m. to 9:55 p.m., P7 was in double Velcro restraint to her right wrist, left wrist, right ankle, and left ankle. From 8:55 p.m. to 9:55 p.m., the record lacked evidence a 1-hour face-to-face evaluation was completed. -3/7/26, from 3:55 a.m. to 5:05 a.m., P7 was in the restraint chair. From 3:55 a.m. to 4:55 a.m., the record lacked evidence a 1-hour face-to-face evaluation was completed. -3/7/26, from 2:45 p.m. to 4:15 p.m., P7 was in seclusion. From 2:45 p.m. to 3:45 p.m., the record lacked evidence a 1-hour face-to-face evaluation was completed. -3/8/26, from 10:30 a.m. to 12:00 p.m., P7 was in seclusion. From 10:30 a.m. to 11:30 a.m., the record lacked evidence a 1-hour face-to-face evaluation was completed; however, the record identified a “Provider Restraint Assessment Criteria for Violent Behavior Face to Face Evaluation, dated 3/8/26, and signed/filed at 12:14 p.m., that a 1-hour face-to-face was completed at 12:01 p.m. (one and a half hours later). -3/8/26, from 1:45 p.m. to 4:00 p.m., P7 was in seclusion. From 1:45 p.m. to 2:45 p.m., the record lacked documentation a 1-hour face-to-face evaluation was completed. A Violent Restraint and Seclusion auditing flowsheet, dated 3/6/26, through 3/19/26, identified a column labeled, “Is there evidence that the face-to-face assessment is completed within 1 hour (Y/N).” The indicated “Percent Compliance” for this column was 6 “Yes” and 5 “No” for a total of “55% (percent).” The following entries were identified for P7: -3/6/26 8:55 p.m. Velcro restraints: Yes. A comment section indicated the face to face was in the arrival note. -3/7/26 3:55 a.m. restraint chair: No. -3/7/26 2:45 p.m. seclusion: No. -3/8/26 10:30 a.m. seclusion: No. -3/8/36 1:45 p.m. seclusion: Yes. P7’s provider History of Present Illness, dated 3/7/26, at 12:57 a.m., identified the P7 was initially examined by the provider at 8:42 p.m. and the restraint wrap P11 arrived in; however, the note lacked documentation related to the restraints placed by the ED staff. P11 presented to the ED on 3/8/26, at 12:53 p.m., related to chemical dependency in the setting of methamphetamine intoxication. P11’s Restraint Monitoring Flowsheets and medical record identified: -3/8/26, from 1:20 p.m. to 1:21 p.m., a physical hold was utilized for intramuscular (IM) medication administration. From 1:20 p.m. to 2:20 p.m., the record lacked documentation that a 1-hour face-to-face evaluation was completed. -3/8/26, from 1:28 p.m. to 1:56 p.m., P11 was in seclusion. From 1:28 p.m. to 2:28 p.m., the record lacked documentation that a 1-hour face-to-face evaluation was completed. -3/8/26, from 6:00 p.m. to 8:45 p.m., P11 was in double Velcro restraints to his right wrist, left wrist, right ankle, and left ankle. The record identified a progress note, dated 3/8/26, signed/filed at 8:51 p.m., labeled MD Restraint for Violent Behavior Face to Face Evaluation, that documented the following: The evaluation occurred at 6:07 p.m.; Patient’s “Immediate Situation: Patient demonstrated the following behaviors (describe): “Aggression, not redirectable at this time;” Patient’s Reaction to the Intervention: Does the patient understand the reason for restraint/seclusion?” “Pt altered due to methamphetamine intoxication;” Medical Condition: Compromises to skin integrity, respiratory, cardiovascular, musculoskeletal, and hydration all identified a “No” response.; Behavioral Condition: At the time of the face-to-face evaluation noted above, is there a need to continue restraints? “Yes;” “See Restraint Flowsheet for complete restraint documentation and assessment.” The face-to-face note lacked evidence of which restraint the evaluation was for i.e., Velcro restraints and did not provide a comprehensive review of the patient’s condition in relation to the restraint application and continued need. -3/9/26, from 9:30 a.m. to 9:45 a.m., P11 was in seclusion. From 9:30 a.m. to 10:30 a.m., the record lacked documentation a 1-hour face-to-face evaluation was completed. The Violent Restraint and Seclusion auditing flowsheet, dated 3/6/26, through 3/19/26, “Is there evidence that the face-to-face assessment is completed within 1 hour (Y/N),” identified the following for P11: -3/8/26 1:20 p.m. physical hold: Yes. The comment section indicated the face-to-face was in the note ‘with assistance of security meds given.’ -3/8/26 1:28 p.m. seclusion: No. -3/8/36 6:00 p.m. Velcro restraints: Yes. The comment section indicated the face-to-face was completed at 6:05 p.m. [See additional information above.] -3/9/26 9:30 a.m. seclusion: No. P11’s provider History of Present Illness progress note, dated 3/8/26, signed/filed at 5:52 p.m., identified the initial history and physical exam was completed at 1:14 p.m. The Medical Decision Making section identified, “With the assistance of security IM Zyprexa was administered and patient did start to have some improvement in his mental status and agitation.” The note lacked identification when the face-to-face was completed or if the provider was present at the time of administration or if this documentation was reflective of the face-to-face process or just representative of the history and physical process. P12 presented to the ED on 3/11/26, at 3:53 p.m., via law enforcement in “4-point-restraints,”, related to aggressive behavior at school that caused significant damage to a classroom. P12’s Restraint Monitoring Flowsheets and medical record identified the following: -3/11/26, from 4:15 p.m. to 4:38 p.m., P12 was in seclusion. From 4:15 p.m. to 5:15 p.m., the record lacked documentation a 1-hour face-to-face evaluation was completed. The Violent Restraint and Seclusion auditing flowsheet, dated 3/6/26, through 3/19/26, “Is there evidence that the face-to-face assessment is completed within 1 hour (Y/N),” identified the following for P12: -P12: 3/11/26 4:15 p.m. seclusion: Yes. The comment section indicated the face-to-face was in the arrival note at 3:53 p.m. [time of ED presentation]. P12’s History of Present Illness progress note, dated 3/11/26, signed/filed at 5:57 p.m., identified P12 was currently in law enforcement-initiated restraints that he came in with. The Medical Decision Making section indicated P12 was provided with an IM medication and then was able to be taken out of restraints and out of seclusion. The note lacked additional information related to the restraint use. The note lacked identification when the face-to-face was completed or that a comprehensive review was completed at the time of, or within one hour of the seclusion initiation. P13 presented to the ED on 3/17/26, at 10:35 a.m., via law enforcement for aggressive behavior in the community. P13’s Restraint Monitoring Flowsheets identified the following: -3/17/26, from 2:00 p.m. to 2:10 p.m., P13 was in seclusion. -3/17/26, from 2:10 p.m. to 2:50 p.m., P13 was in the restraint chair. -3/17/26, from 2:10 p.m. to 2:50 p.m., P13 had a spit hood placed over his head. The Violent Restraint and Seclusion auditing flowsheet, dated 3/6/26, through, 3/19/26, “Is there evidence that the face-to-face assessment is completed within 1 hour (Y/N),” identified the following for P13: -3/17/26 2:00 p.m. seclusion: No. -3/17/26 2:10 p.m. restraint chair: No -3/17/26 2:10 p.m. spit hood: No P13’s medical record identified the following: -A provider History of Present Illness progress note, dated 3/17/26, signed/filed at 3:49 p.m., identified the initial history and physical exam was conducted at 10:58 a.m. The Medical Decision Making section indicated at the time of discharge, P13 started to “get wrapped up here in the ER and agitated, punching the glass windows and doors, screaming. Security called. When they entered the room, the patient fought with security. He is placed in the restraint chair. Embedded in the progress note was a section labeled “Physician Restraint for Violent Behavior Face to Face Evaluation.” This section identified the following: -The evaluation occurred at “2210:2210.” [Record review with registered nurse (RN)-C identified this embedded note was initiated by a scribe at 2:12 p.m.] -Patient’s “Immediate Situation: lacked a response. -Patient demonstrated the following behaviors (describe): “Aggression.” -Does the patient understand the reason for restraint/seclusion? “NO.” -Medical Condition: Compromises to skin integrity, respiratory, cardiovascular, musculoskeletal, and hydration all identified a “No” response. -Behavioral Condition: Is there a need to continue this restraint or seclusion? “YES.” -“See Restraint Flowsheet for complete restraint documentation and assessment.” -The face-to-face note lacked evidence which restraint the evaluation was for i.e., seclusion, spit hood, restraint chair, and did not provide a comprehensive review of the patient’s condition at the time of, or within one-hour of the restraint ’ s applications. Additionally, the record lacked evidence a separate face-to-face was conducted for each restraint application. The Violent Restraint and Seclusion auditing flowsheet, dated 3/6/26, through 3/19/26, identified that 18 additional patients ‘restraint and/or seclusion encounters were audited for face-to face evaluation completion. Six identified a “No” in the designated face-to-face column. Two encounters lacked a response to the question. When interviewed on 3/31/26, at 10:41 a.m., RN-D stated she was responsible for ED restraint and seclusion auditing which she conducted every 24-48 hours. Quarterly, her audits were presented at a restraint committee meeting - last held in January 2026. When asked about any recent trends related to restraint concerns, she stated, “we are not perfect ...there are always going to be concerns.” “We miss things here and there,” especially as patient care came first and charting second. RN-D explained that she had not identified any significant concerns during her audits lately; however, she did note “missed” items, or concerns where the “times were funky,” but the date was on. RN-D stated there was a face-to-face component to her audits. In response to noted errors, she provided a monthly report to the ED director and brought provider concerns to the ED medical director (MD)-D as she did not manage provider education. Initially, she was without recollection as to the last time she had updated MD-D related to any restraint concerns; however, later in the interview she indicated she had such communication in the past three weeks or so. RN-D identified the providers performed the face-to-face evaluation, at which time the provider assessed the patient, and she indicated the expectation was within 60 minutes. Despite the frequency of her audits, she stated she did not have the required components for this memorized, but felt it was “time, rationale, and assessment.” RN-D commented, there were times when she completed her audit, and she noted the provider assessed the patient prior to the restraint application, she counted that assessment as the required face-to-face. With clarification, she provided an example: If the provider saw the patient at 1:10 p.m., and the restraint was applied at 1:20 p.m., she still counted that as the evaluation. RN-D stated nursing staff were educated yearly on restraints and seclusion; however, she was unsure when and with what information the providers were educated. When RN-D was updated on the concerns surrounding P7, P11, P12, and P13, she stated, “That is a lot. We usually do better than this.” She stated that their processes could be improved. RN-D expressed no overall concerns about the face-to-face evaluations not being completed, as staff were doing the right thing for the patients, but their documentation could be improved. When interviewed on 3/31/26, at 11:28 a.m., MD-B stated that when she was present during restraint initiation, which she was much of the time, she immediately assessed the patient for such things as airway, skin compromises, and to ensure patient safety. If she was not present, she assessed them at the “soonest opportunity,” but was expected to do this within one hour. MD-B indicated the face-to-face documentation required a summary of the exam and the need for the restraint(s)/seclusion. When questioned about P7’s face-to-face, MD-B explained this may have been related to a recent event when the nurse placed a comment onto the track board that a patient was placed in seclusion, but she was away from the area with a critical patient and did not see the nurse ’ s comment within the hour time frame. She indicated this was an anomaly and no one had reached out to her related to the late face-to-face. When interviewed on 3/31/26, at 11:45 a.m., MD-C stated the face-to-face was expected to be done “as soon as possible” with an ideal within 10 minutes; however, she was unsure what the facility expectation was. He just knew one needed to be done. MD-C explained the face-to-face documentation needed to show patient understanding why restrained, the time the patient was restrained, how the patient was restrained, a physical assessment, and the continued restraint need. When questioned on processes to ensure the face-to-face was completed timely, MD-C stated typically the nurse called him that someone was restrained, at which time, he then verified the order and made sure the patient was okay. MD-C was unsure whether he had recently been updated on any restraint process concerns, and if so, if he had followed through on any education. He stated he was in the middle of a lot of things at times and such may not be on his priority list. He was unsure how often he was provided restraint/seclusion education. MD-C stated he remembered P7. He explained her initial restraint application occurred during his initial evaluation and associated documentation; however, he stated he still should have documented the face-to-face properly. Additionally, he explained that most of the time he had to reassess the patients during their stay, but with P7, he did not think he had to do this for her. Due to MD-C’s chief of staff role, when questioned on provider concerns related to restraints, he indicated he was unfamiliar with any concerns. When interviewed on 3/31/26, at 12:03 p.m., MD-D stated RN-D audited restraint use and was good at letting him know when there were mistakes. He felt RN-D had updated him about face-to-face concerns in January, and about a month ago. He was aware of frequent provider misses. He explained the providers completed the evaluation, which he expected to be done within an hour of the restraint; however, he identified they just failed to document it. There was no excuse for this, but he felt providers thought the order was the required face-to-face and no matter how often they were reminded, such as during monthly meetings, there were still possibilities for errors. When questioned on the use of scribes for documentation, he explained, when they worked with him, and the face-to-face documentation was needed after his evaluation, the scribe “cued up” the evaluation text script into the patient’s medical record. Then, once he logged into the record, he completed the sections and signed it. This process documented the patient’s understanding, skin issues, any identified cardiovascular/neurological compromises, the reason for the restraints, etc. If the evaluation was not completed, the patient was at risk for injury, cardiovascular compromise, and the patient not understanding why the restraints were needed. MD-D stated the ED providers were initially trained on facility restraint expectations during their orientation and then again only when needed, such as with policy changes. Despite being aware of the identified concerns for the past month or so, MD-D stated he had not completed any deep dives into the concerns, and he had not followed up with any of the providers individually. After he was updated on the concerns for P7, P11, P12, and P13, he stated this was bad leadership on his part despite “these providers [knowing] better.” He again mentioned the order for the restraint was not the required face-to-face - one was the order, and the other was clinical documentation where he expected them to be separate entries. Additionally, MD-D stated, “The process is correct, but the follow-through is not.” When interviewed on 3/31/26, at 12:44 p.m., MD-E stated he typically documented his face-to-face evaluation once he entered the restraint order which he attempted to complete as soon as possible; however, he indicated this needed to be completed at least within 1-hour of the application to ensure patient understanding, assurances there were no health compromises, and to reassess to ensure there are no injuries. Often, he was right there when it occurred, and he hoped the team got their documentation time stamps right. MD-E explained, if more than one restraint happened close to another, the face-to-face documentation was only needed once as it would be the same. He stated if the evaluation was not completed, the patient may not be safe, but if the evaluation was completed, and only the documentation was not completed, then there was no risk other than they were unable to show they mitigated any risks. MD-E stated the facility had done a lot of work on restraint processes over the years and currently he mainly saw errors related to documentation. He identified that he received annual restraint training and restraint use was brought up occasionally at monthly meeting; however, was unable to remember any real specifics over the past few months. When interviewed on 3/31/26, at 2:10 p.m., MD-F stated she attempted to be present when the restraint/seclusion was utilized, or to response right away once initiated; however, it was hard to do the face-to-face documentation right away at times, especially when she was already behind on other things: “This is how we miss things.” She stated she tried to do the assessment within five minutes but was unaware of the facility expectation. Additionally, she was unaware when the facility expected the documentation to be signed as completed. Her typical practice was to start the documentation when she did the evaluation but then she officially signed it at the end of her shift. MD-F explained that it would be weird to have any signs of concern identified after the restraint/seclusion was initiated, “unless they were not responding well.” MD-F explained the components of the face-to-face without concern and indicated the scribes, depending on “how seasoned” they were, opened the note in the medical record which then pulled to her inbox. If the scribe did not do this, that may be how the documentation for the evaluations was missed. MD-F was confident that she completed her face-to-face evaluations; however, because of the nature of getting pulled into these violent scenarios and how taxed their workload was, the documentation may not be completed. MD-F was updated on P11 and P12’s missed face-to-face and stated, in relation to P11, due to how complex his care was, the missed documentation was on her. She identified she had not received a formal re-education recently on restraints and stated, “We need to be more consistent with our processes.” When interviewed on 3/31/26, at 2:33 p.m., RN-H, the ED manager, stated he did not do restraint auditing and thus was not aware of what was audited. He explained that RN-D was very transparent and if any concerns were identified by RN-D, RN-D would have updated him and/or the ED director. He identified the ED director had not brought any concerns to him related to the restraint process, but he was aware that the face-to-face evaluations were occasionally later than expected to be. RN-H stated the providers were very aware they needed to perform the face-to-face evaluations within one hour of initiation. He expected the evaluation to be documented in the medical record at least by the end of the provider’s shift. If the evaluation was not completed, he felt there was absolute risk to the patients as the provider was expected to make sure the patients were safe, and the restraints were utilized appropriately. RN-H was unaware of any recent education outside of their standard annual education. After he was updated on the restraint concerns for P7, P11, P12, and P13, he stated he was unaware of the increased concern related to the completion of the evaluations and verbalized, “Looks like we have some work on this.” When interviewed on 3/31/26, at 4:13 p.m., the chief nursing officer (CNO) stated the face-to-face evaluation was expected to be completed as instructed by the facility policy to keep the staff and the patients safe. If the evaluation were not completed, the risks to the patient, such as limb circulation, skin integrity, joint concerns, etc., could be compromised. She stated, prior to the survey, she was unaware of the concerns that surrounded these evaluations. A Restraint and Seclusion policy, dated 8/2025, directed a face-to-face evaluation by a provider was required within 1-hour of the application of the restraint or initiation of seclusion. This was to be performed regardless of whether the restraint or seclusion was discontinued within the 1-hour of initiation. The face-to-face was to include an evaluation of the patient’s immediate situation including an assessment of the incident/situation that led to the intervention, the patient’s reaction to the intervention, the patient’s physiological and psychological condition, and the need to continue or terminate the restraint or seclusion.”

“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: 43080 Based on interview and document review, the hospital failed to deliver adequate nursing care based on patient needs in response to changes in condition for 1 of 10 patients reviewed (P4) when the patient experienced a deterioration in their surgical incision, and an elevated blood pressure (BP). Nursing staff failed to reassess P4’s blood pressure and failed to notify the appropriate medical provider for additional follow up prior to P4’s discharge. This resulted in an immediate Jeopardy (IJ) finding. The IJ began on 2/1/26, when nursing staff failed to notify the appropriate medical provider of P4’s surgical incision deteriorations, and failed to reassess and notify the appropriate provider of P4’s abnormal blood pressure reading of 219/114 the following day. This resulted in P4 being discharged on 2/2/26 in an unstable condition. Subsequently, P4 required re-hospitalization that same day, and was diagnosed with an infection that required surgical intervention on 2/3/26. P4 passed away due to septic shock on 2/3/26, at 10:29 p.m. The chief nursing officer (CNO), vice president of medical affairs (VPMA), senior director of hospital and critical care, and two system regulatory and accreditation program managers were notified of the IJ on 3/27/26, at 3:15 p.m. The IJ was removed on 3/30/26, at 11:17 a.m., after verification of an acceptable removal plan but noncompliance remained at a condition level. Findings include: P4’s Podiatry History and Physical progress note, dated 1/15/26, completed by Doctor of Podiatry Medicine (DPM)-A, identified P4 admitted on 1/14/26 for evaluation and management of a somewhat rapid onset of tissue breakdown and gangrene of the second, third, and fourth toes of his right foot. Arterial Doppler ultrasound identified significant peripheral arterial disease (PAD). Due to the limb threatening gangrene with severe PAD, P4 likely needed transmetatarsal amputation. He was at high risk of further complications which included more proximal amputation depending on the outcome of vascular evaluation and intervention. P4’s additional diagnoses included: hypertension, hyperlipidemia, type 2 diabetes with peripheral neuropathy and minimal foot sensation, end stage renal disease with peritoneal dialysis, atrial fibrillation with use of blood thinners. P4 ’ s provider progress note, dated 1/21/26, signed at 2:47 p.m., identified P4 underwent a right transmetatarsal amputation by DPM-A that morning in response to a diabetic right foot infection and critical limb ischemia that posed threat to his life and limb. P4 ’ s right foot was wrapped with a pressure dressing. P4 ’ s provider progress note, dated 1/22/26, signed at 3:06 p.m., by DPM-A, identified P4 ’ s surgical dressing was changed that day. The incision was well joined together with intact sutures, there was no draining on the dressings, and there was no evidence of pallor (unusually light skin color) or necrosis (dead tissue). It was free of malodor, rubor (reddish discoloration of the skin), or signs of infection. Daily dressing changes were ordered until P4 discharged and podiatry signed off with instructions to re-consult if needed. P4 ’ s provider (hospitalist) progress notes, dated 1/23/26, through 1/31/26, lacked evidence the providers visually assessed P4 ’ s surgical incision. Documentation identified that on each day, during the physical exam, the right foot was wrapped, or there was a dressing in place. P4 ’ s Surgical Incision Right Foot nursing assessment documentation flow sheet, dated 1/31/26, at 8:06 a.m., identified the dressing was changed. The sutures remained and the dressing was clean, dry, and intact. The wound site was “Red” and there was a scant amount of serosanguineous (serous fluid or blood indicative of early healing) drainage. P4 ’ s hospitalist progress note, dated 2/1/26, signed 10:57 a.m. by medical doctor (MD)-A, identified P4 as “stable for discharge.” The exam section of the note indicated P4 ’ s right foot was wrapped and there was no significant peripheral edema. P4 ’ s last BP reading was 98/70. The note indicated P4 ’ s hospital course was complicated by acute on chronic hypotension. In response to the hypotension, P4, over the course of his hospital stay, required medication adjustments, thigh-high compression socks to his left leg and abdominal binder when up out of bed. P4 ’ s Surgical Incision Right Foot nursing assessment documentation flow sheet, dated 2/1/26, at 11:02 a.m., identified the dressing was changed. The documentation lacked the state of the removed dressing. The sutures remained and the wound bed showed eschar (dead tissue), the peri-wound was boggy (soft, spongy, or mushy texture indicative of underlying inflammation, tissue damage, or infection) and macerated (skin damage due to excessive moisture), and there was a small amount of purulent drainage (thick, pus-like fluid indicative of infection). This documentation reflected P4 ’ s incision had deteriorated in status since the 1/31/26 nursing assessment. P4 ’ s medical record lacked evidence that the hospitalist, i.e., MD-A, and/or the podiatrist, i.e., DPM-A, were updated about the incisional deteriorations. P4 ’ s Surgical Incision Right Foot nursing assessment documentation flow sheet, dated 2/2/26, at 7:51 a.m., identified the dressing was changed. The documentation lacked the state of the removed dressing. The sutures remained and the wound bed showed eschar, the peri-wound showed blanchable erythema (redness), and there was a small amount of purulent drainage. P4 ’ s medical record lacked evidence that the hospitalist and/or the podiatrist were updated on the status of the incision. P4 ’ s Discharge Summary, dated 2/2/26, signed at 10:57 a.m. by MD-A, identified P4 ’ s most recent BP reading was 108/47 and provided one of his discharge diagnoses as chronic hypotension which complicated P4 ’ s postoperative course. The summary indicated a day of discharge exam; however, this section lacked information related to the incision. P4 was in no distress, and his physical condition was good for discharge. The note lacked evidence that MD-A was updated by the nurse on P4 ’ s 7:51 a.m. incisional assessment and deteriortion. P4 ’ s Vital Sign flow sheet documentation identified the following BPs: -1/31/26, at 8:17 a.m.: 95/77. -1/31/26, at 11:40 a.m.: 82/69. -1/31/26, at 3:25 p.m.: 93/65. -1/31/26, at 7:11 p.m.: 111/98. -2/1/26, at 8:12 a.m.: 98/70. -2/1/26, at 11:02 a.m.: 103/41. -2/1/26, at 3:51 a.m.: 118/105. -2/1/26, at 8:30 a.m.: 95/77. -2/2/26, at 1:00 a.m.: 95/44. -2/2/26, at 1:09 a.m. (recheck): 116/38. The provider was updated - no interventions ordered. -2/2/26, at 7:40 a.m.: 108/47. -2/2/26, at 12:00 p.m.: vitals taken; however, a BP was not documented as part of the vital set. -2/2/26, at 12:13 p.m. (13 minutes later): BP was 219/114. The flow sheet identified this was an abnormal BP and the documentation lacked evidence the nurse and/or the provider were updated. P4 ’ s medical record identified he discharged the facility on 2/2/26, at 3:41 p.m. The record lacked evidence that the 12:13 p.m. BP was rechecked, or that the hospitalist was updated on the abnormally elevated reading. P4 ’ s Nursing Care Plan Note, dated 2/2/26, signed at 3:51 p.m., by RN-B, identified P4 ’ s vital signs were stable on room air and right lower extremity dressing was changed. A “Problem: Infection,” indicated its goal was to be free of infection signs and symptoms, and was documented as completed. A “Tissue Perfusion, Peripheral- Altered,” indicated its goal was to have adequate tissue perfusion, was documented as completed. The note lacked references to P4 ’ s incisional status, any identified incision concerns, P4 ’ s 219/114 BP, a BP recheck, or that the provider(s) were updated in relation to the incisional assessment and the BP. P4 presented to another the emergency department (ED) the evening of 2/2/26 and admitted to telemetry during the morning hours of 2/3/26. The following hospital record indicated: -On admission, white blood cell count (WBC - produced to fight infection and respond to inflammation) was 11.1 (mildly elevated) and on 2/3/26 by 9:33 p.m. had increased to 17.7, c-reactive provide (CRP - indicating presence of inflammation such as infection) was elevated at 150 mg (milligrams)/L (liter). -While in the ED and during the morning of 2/3/26, P4 became tachycardic and hypotensive with BPs 70/50s. -A Provider note, dated 2/3/26, entered at 2:08 p.m., identified P4’s amputation site showed the site to be black, with necrotic appearing tissue and bloody drainage oozing from the incision. Erythema (redness) tracked along with dorsum foot and plantar aspect with exquisite tenderness to palpation. The assessment indicated severe sepsis with septic shock - likely source was the right foot. The exam showed concerns for a severe soft tissue infection with gangrene. The provider also questioned necrotizing fasciitis. An order was placed for P4 to be transferred to the intensive care unit (ICU). Hypotension continued to be monitored. -Surgery Operative Note, dated 2/3/26, entered at 3:49 p.m., indicated P4 underwent a right sided guillotine below the knee amputation after he was evaluated by podiatry and determined his prior amputation was not salvageable, along with his hemodynamic status at that time, and thus emergent surgery was required. -Post-op Pathology Report, signed 2/6/26, indicated the below the knee amputation specimen was microscopically examined. The report diagnosed gangrenous necrosis and acute osteomyelitis. -The Discharge Summary, entered 2/10/26, identified a primary diagnosis of severe refractory septic shock with secondary diagnoses of gangrene of the right foot, acute stress induced cardiomyopathy, PAD, end stage renal disease, and diabetes. After emergency surgery, P4’s shock continued to worsen despite aggressive medical efforts, and he passed away. P4’s Minnesota Documentation of Death record, identified P4 passed away on 2/3/26 at 10:29 p.m. due to septic shock and PAD. On 3/26/26, during an abbreviated review of P4 ’ s medical record with RN-C, the record identified RN-A documented the 2/1/26 11:02 a.m. incision assessment, RN-B documented the 2/2/26 7:51 a.m. incision assessment and the 12:00 p.m. vitals, and nursing assistant (NA)-A documented the 2/2/26 12:13 p.m. BP. When interviewed on 3/26/26, at 2:57 p.m., RN-B stated P4 showed periods of unstable and inconsistent BPs; however, the BP was “consistently a little lower.” RN-B identified P4 received medications to elevate his BP. RN-B was unable to recollect why the documentation lacked a 12:00 p.m. BP entry, or that P4 ’ s 210/114 BP was reported to her. RN-B explained, if she were updated, she would have rechecked the BP and updated the appropriate provider if still high. RN-B stated she had concerns related to the nursing assistants updating her on abnormal vitals, thus the reason why she often checked the vital documentation. Despite this concern and practice, there were times when this review could not be completed as she liked. RN-B stated with P4 ’ s BPs being “all over the place,” along with him being a dialysis patient, he was at increased risk for complications such as a stroke. When questioned on incision assessments, RN-B stated if deteriorations were observed, she reviewed prior RN assessments for comparisons. She explained signs and symptoms of incisional infection ranged from redness, increased drainage, odor, peri-wound irritation, and abnormal vitals. If such were identified, she was expected to update the provider. RN-B lacked remembrance of P4 ’ s incision; however, if she were concerned, she would have updated the provider. She explained that P4 ’ s wife was present for the dressing change on 2/2/26 and she did not recollect if the wife expressed any concerns. When interviewed on 3/26/26, at 3:26 p.m., NA-A stated she ensured patients had their vitals checked every four hours and as directed by the nurse. NA-A explained, when she obtained a patient ’ s vitals, and the value turned “red [indicating abnormal value]” once the value was placed in the flow sheets, she was expected to update the nurse “immediately.” When questioned on P4 ’ s 219/114 BP, her response was one of significant concern and “that is high.” NA-A was unable to recollect P4; however, she remembered a BP this high “in the last month or so.” She stated she immediately updated the nurse. She was unable to remember whether she rechecked the BP or not after the initial high reading. When interviewed on 3/26/26, at 4;15 p.m., MD-A identified she recalled P4; however, she was unable to recollect the last time she had assessed the surgical incision, or if she had assessed it post-op. She explained that her typical practice for incisional assessments depended on the post-op/operating surgeon’s ‘involvement as some of these providers changed the patient’s incisions while hospitalized, while others left it to the nurses to manage. It was not her typical practice to review the documentation in the nursing flow sheets, as when nurses assessed and performed the daily dressing changes, she relied on them to update her if there were any incisional concerns. MD-A lacked remembrance that staff updated her on any changes to P4 ’ s incision. When updated on the incision documentation from 1/31/26 to 2/1/26, she stated this was “concerning.” If updated, she would have assessed the incision as there was a potential for ischemia and lack of blood supply to the area which would have prompted additional evaluation, consulting, and testing, and she would not have allowed P4 to be discharged on 2/2/26. When questioned on the elevated BP, this again concerned MD-A and she stated staff had not updated her on this; however, she stated this reading was “probably inaccurate,” given P4 ’ s hypotension trending. Despite this, she would have expected a manual BP recheck and if the recheck again showed similar readings, she expected to be updated as such a reading required additional follow up, and again, she expected such follow up processes to be completed prior to discharge. When interviewed on 3/26/26, at 4:45 p.m., RN-A stated if concerns were identified during a dressing change, she looked at previous photos and/or prior incision documentation. She preferred to look at prior photos as pictures were “much better,” as every nurse had a different way of charting. RN-A remembered P4 and felt her 2/1/26 incision assessment lacked alarming concerns and if there was increased drainage, maybe P4 had moved from bed to chair just prior to that. When reminded of her assessment documentation from 2/1/26, she stated such an assessment possibly indicated a “deeper infection in the foot,” and she should have consulted a wound care nurse (WOC) or updated the provider to “figure out what was doing on.” She was unable to recollect if she updated the provider; however, if she had, her documentation would have reflected that. Additionally, with such presentation, she would have advocated for P4 to remain in the hospital versus discharging the next day. When interviewed on 3/27/26, at 8:16 a.m., the CNO stated she expected documentation, and notification to the provider, of any identified skin assessment deteriorations, as deteriorations were potential concerns for infection. If a patient’s BP was out of range for them, she expected the nurse and/or the provider to be updated. In a perfect world, there would then be documentation of the nurse being updated, if applicable, and/or the provider being notified. The CNO identified the inpatient policies did not reflect expectations for how soon such a BP was to be re-checked but did explain another policy referenced abnormalities were to be reassessed within 12 to 16 hours. The CNO stated the BP of 219/114 concerned her as this possibly indicated pain, anxiety, infection, etc., and she expected P4 ’ s chart referenced a recheck and provider notification. After being updated on P4 ’ s discharge day status, she stated she would have hoped the provider would have been called to the bedside to talk about the situation. After the provider assessed P4, P4 ’ s discharge may have still been appropriate; however, provider input after they reviewed the BP and assessed the incision would have been needed first. When interviewed on 3/27/26, at 9:46 a.m., P4 ’ s family member (FM)-A stated he was there on 2/2/26 and did not remember staff updating her on P4 ’ s BP. She stated she was present when the nurse changed the dressing. The incision was “bright red and oozing,” and there were “black areas” present. She was unsure what the oozing was and stated the nurse did not appear concerned about the state of the incision. She did not question this as “a couple days prior to that,” the incision was also bright red with “scabbing” where the stitches were. FM-A thought the incision appeared a little worse on discharge; however, was not one hundred percent sure. After about two hours at home, P4 screamed about his foot hurting, and he wanted to go to another hospital. P4 was admitted to another hospital that same evening and the next day required surgery as the “infection had spread.” FM-A stated P4 came out of surgery but “never woke up,” in which he passed away later that evening. FM-A denied she visualized the incision after he discharged on 2/2/26. FM-A was significantly concerned why the hospital discharged P4 “when he had sepsis.” FM-A explained the providers at the outside hospital informed her that P4 would have had signs and symptoms of this at least seven days prior to discharge, and that they questioned her on why P4 was discharged. When interviewed on 3/27/26, at 12:33 p.m., DPM-A stated he assessed P4 ’ s incision “a day to a few days” post-op and it was without concerns. Due to that, he left the incision management to the hospitalists and nursing. He expected if concerns were identified, he would be updated. If updated, he would have looked at the documentation and the photos to help determine next steps. DPM-A reviewed P4 ’ s incision photos from 2/1/26 and stated P4 had extremely poor vascularity and low capillary flow where hopes for healing and the incision to remain closed was “not great.” The incision looked “like a possibly deteriorating wound.” DPM-A explained, if staff had updated him, he would have reviewed the photos and personally assessed the incision. DPM-A was unable to find a photo of the incision from 2/2/26. DPM-A stated that he lacked knowledge on how to review nursing documentation in the flow sheets and that he received information from his review of the nursing notes. He reviewed P4 ’ s nursing notes and identified there was nothing of concern documented that reflected incisional concerns. DPM-A identified P4 ’ s only other option was a below the knee amputation; but, prior to that, as P4 did not have a “terrible infection prior,” as it was “more vascular gangrene,” he would have most likely have started with antibiotic therapy once lab work returned, as there was a potential for sepsis, before P4 was brought back to the operating room. Despite this, he was unsure whether that would have changed anything due to P4 ’ s impaired circulation and ability for the antibiotics to reach the foot. When questioned on the elevated BP, he felt that was “high,” and assumed staff had contacted the hospitalist. A Patient Outcome Standards: Medical 1 ...surgical Care 1, and Surgical Care 2 Units, dated 6/2025, directed when abnormalities in assessments were identified, reassessment was to occur within 12-16 hours, or more frequently at the discretion of the nurse or as indicated in other parts of the policy. A section labeled absence of infection, directed that if during required assessments, fever, redness, warmth, and/or purulent drainage were identified, the provider was to be updated. A Provider Notification policy, dated 9/2025, directed the appropriate provider was to be updated, in a timely manner, when significant changes in a patient’s condition were identified, such as a significant change in vital signs or mentation and acute physical changes. After the notification, the policy directed the notification, and the change in the patient’s condition was to be documented. A Skin: Assessment, Prediction, and Prevention - Inpatient policy, dated 11/2025, directed that during the skin assessment, the wound would be assessed for deterioration or improvements with routine dressing changes, dressing changes based on wound care recommendations and/or provider order. Skin changes were to be observed such as color, temperature, firmness/fogginess, pulses, and turgor. If there were significant changes in the wound, the WOC nurse was to be consulted. The policy lacked direction to contact the provider when wound changes were identified. A policy related to vital signs was requested; however, none was provided. The IJ was removed on 3/30/26, at 11:17 a.m., after the following actions were completed: comprehensive chart review for Surgical Care units inpatients on 3/27/26 that focused on abnormal surgical incisions, abnormal vital signs, and evidence of appropriate provider notification; escalation of any identified audit concerns to the unit’s nursing supervisor, who verified patient stability, appropriate follow-up actions, and timely provider notification; continued chart review on 3/28/26 and 3/29/26; surgical units, staff specific, in-person, coaching/education related to reassessment of abnormal observations, escalation of abnormal vital signs, and the provider communication policy; policy and competency review; and verification, that included interviews and document review, that the removal plan was implemented.”

“VERBAL ORDERS FOR DRUGS CFR(s): 482.23(c)(3)(i) If verbal orders are used, they are to be used infrequently. This Standard is not met as evidenced by: 43080 Based on interview and document review, the facility failed to utilize restraint and/or seclusion verbal orders (VO) infrequently in the emergency department (ED) for 5 of 5 patients (P7, P11, P12, P13, P14) who were provided VOs for restraints and/or seclusion in response to behavioral events, even at times when the provider was present during the event. Findings include: P7’s medical record indicated P7 presented to the ED on 3/6/26, at 8:41 p.m., for a mental health evaluation in the setting of severe bipolar disorder with a current manic episode and agitation and aggressive behaviors at home. She arrived with police escort in a “restraint wrap” due to behavioral dysregulation. P7’s Restraint Monitoring Flowsheets, Order’s section and medical record identified: -3/6/26, at 8:55 p.m., double Velcro restraints to her right wrist, left wrist, right ankle, and left ankle were placed after law enforcement restraints were removed and P7 continued to show behavioral dysregulation. P7 was assessed by the provider for her initial history and physical exam at 8:42 p.m. Nursing flow sheets, at 8:55 p.m., identified the provider was notified. At 9:11 p.m. (16 minutes after the restraint change over), an RN entered the order into the medical record for the Velcro restraints with a “Mode” identified as “Ordering in Emergency mode”, which means orders implemented when the patient’s condition requires immediate action for example a stroke, code blue, hypoglycemia, emergency department/emergency trauma center. At 1:39 a.m., the order was acknowledged by the provider (approximately four hours after the restraint was applied). -3/7/26, at 3:55 a.m., after P7 continued to escalate over the prior one and a half hours, she was placed in a restraint chair after she began to demonstrate additional behaviors (banging on windows, verbally threatened staff, and attacked security). Nursing flow sheets, at 3:55 a.m., identified the provider was notified. P7’s record lacked an order for the restraint chair; however, at 3:58 a.m., an RN entered a VO defined as an order verbally given by an by an authorized provider to a qualified personnel to be entered into the electronic health record by that person, into the medical record for seclusion. The record lacked evidence P7 was placed in seclusion at this time. The record lacked evidence that the provider acknowledged the order. -3/7/26, at 2:45 p.m., P7 was placed in seclusion due to striking out and threatening the safety of others. Nursing flow sheets, at 2:45 p.m., identified the provider was notified. At 2:49 p.m., an RN entered the order into the medical record with an identified “Mode” as “Ordering in Emergent mode.” At 7:52 p.m., the order was acknowledged by the provider (approximately five hours after seclusion was initiated). -3/8/26, at 10:30 a.m., P7 was placed in seclusion due to threatening the safety of others, extreme agitation, and disruptive to the milieu. At 10:41 a.m. (11 minutes later), an RN entered a VO into the medical record. Other than the VO being entered, the record around the restraint initiation does not identify the provider was updated. At 11:45 a.m., the order was acknowledged by the provider (approximately one hour after the seclusion was initiated). -3/8/26, at 1:45 p.m., P7 was placed in seclusion due to extreme agitation, disruptive to the milieu and threatening the safety of others. At 1:49 p.m., an RN entered a VO into the medical record. Other than the VO being entered, the record around the restraint initiation does not identify the provider was updated. At 7:39 p.m., the order was acknowledged by the provider (approximately six hours after the seclusion was initiated). P7’s medical record lacked information to support why nursing VOs were initiated versus provider entered restraint orders after the providers were provided status notifications. P11 presented to the ED on 3/8/26, at 12:53 p.m., related to chemical dependency in the setting of methamphetamine intoxication. P11’s Restraint Monitoring Flowsheets, Order’s section and medical record identified: -3/8/26, at 1:20 p.m., a physical hold was utilized for intramuscular (IM) medication administration after P11 was agitated and demonstrating threatening behavior. At 1:20 p.m., the provider was notified, in which the nursing progress note, timed at 2:15 p.m., identified P11’s behaviors, in which the provider was called to the room and ordered the medication. At 4:56 p.m. (approximately 3.5 hours later), an RN entered a VO. At 6:13 p.m., the order was acknowledged by the provider (approximately five hours after the hold was initiated). -3/8/26, at 1:28 p.m., P11 was placed in seclusion. At 1:28 p.m., the provider was notified. At 4:57 p.m., (approximately 3.5 hours later), an RN entered a VO. At 6:13 p.m., the order was acknowledged by the provider (approximately five hours after the seclusion was initiated). -3/8/26, at 6:00 p.m., double Velcro restraints to his right wrist, left wrist, right ankle, and left ankle were placed. At 6:00 p.m., the provider was notified. At 6:07 p.m., a face-to-face evaluation was performed. At 6:08 p.m., an RN entered a VO. At 6:13 p.m., the provider acknowledged the order. -3/9/26, at 9:30 a.m., P11 was placed in seclusion. At 11:20 a.m. (approximately two hours later), an RN entered a VO. Other than the VO being entered, the record around the restraint initiation does not identify the provider was updated. At 1:47 p.m., the order was acknowledged by the provider (approximately four hours after the seclusion was initiated). P11’s medical record lacked information to support why nursing, versus the provider, entered the VOs after the providers were notified at the times of the restraint and seclusion initiation and was documented to be present in relation to the physical hold. P12 presented to the ED on 3/11/26, at 3:53 p.m., via law enforcement in “4-point-restraints,”, related to aggressive behavior at school that caused significant damage to a classroom. P12’s Restraint Monitoring Flowsheets, Order’s section and medical record identified: -3/11/26, at 4:15 p.m., P12 was placed in seclusion due to extreme agitation, being disruptive to the milieu, threatening the safety of others, and striking out. At 4:15 p.m., the provider was updated. At 4:20 p.m., (five minutes later), an RN entered a VO. At 8:59 p.m., the order was acknowledged by the provider (approximately five hours after the seclusion was initiated. P12’s medical record lacked information to support why nursing, versus the provider, entered a VO despite the provider being notified at the time of the seclusion initiation. P13 presented to the ED on 3/17/26, at 10:35 a.m., via law enforcement for aggressive behavior in the community. P13’s Restraint Monitoring Flowsheets, Order’s section and medical record identified: -3/17/26, at 2:00 p.m., P13 was placed in seclusion due to threatening the safety of others. At 2:00 p.m., the provider was updated. -3/17/26, at 2:10 p.m., P13 was placed in the restraint chair due to verbalizing and demonstrating harm to others. At 2:00 p.m., the provider was updated. -3/17/26, at 2:10 p.m., P13 had a spit hood placed over his head due to verbalizing and demonstrating harm to others. At 2:00 p.m., the provider was updated. -3/17/26, at 2:10 p.m., P13 had a face-to-face evaluation performed. -For all three restraint episodes, at 2:23 p.m. (13 minutes after the face-to-face), an RN entered the orders with a “Mode” that identified “Ordering in Emergency mode.” At 2:38 p.m., the provider acknowledged all three orders. P13’s record lacked information to support why nursing, versus the provider, entered the orders into the medical record in emergent mode 13 minutes after the provider performed a face-to-face evaluation at the same time P13 was placed in the restraint chair with a spit hood. P14 presented to the ED on 3/18/26, at 7:03 p.m., for a mental health evaluation in the setting of schizophrenia and not having took his medication for a couple of days where he was noted to talk to himself. During the ED encounter, P14 punched multiple staff. P14’s Restraint Monitoring Flowsheets, Order’s section and medical record identified: -3/18/26, at 12:30 a.m., P14 was placed in the restraint chair due to verbalizing and demonstrating harm to others. -3/18/26, at 12:34 a.m., P14 had a face-to-face evaluation performed. -3/18/26, at 12:37 a.m. (three minutes after the face-to-face), an RN entered the order with the “Mode” identified as “Ordering in Emergent mode.” -3/18/26, at 6:19 a.m., the order was acknowledged by the provider (approximately six hours after the restraint chair was initiated). P14’s record lacked information to support why nursing, versus the provider, entered the order in emergent mode after the face-to-face was completed within minutes of the restraint initiation. When interviewed on 3/25/26, at 12:00 p.m., RN- I, the ED director, stated that the ED did not utilize telephone orders, but did utilize VOs in emergency situations only. These orders were not expected to be the norm. When interviewed on 3/31/26, at 10:41 a.m., RN-D stated she conducted ED restraint audits and verbalized she does not audit who puts in the order, only that the order was entered. She explained that nursing staff monitored to ensure the providers placed the restraint orders; however, if they noticed this process was not completed in one hour of the restraints and/or seclusion being initiated, then they placed a VO. RN-D stated nursing did a better job of placing restraint orders versus the providers. When interviewed on 3/31/26, at 11:28 a.m., MD-B stated she provided the nurse with a VO “in real time” of restraint initiation, or she herself initiated the order “as soon as possible,” but within the first hour after initiation. MD-B explained, “at least 75 percent of the time” she was present when restraints were needed. She identified she acknowledged a VO anytime a nurse placed a VO, as the system sent a VO notification to her inbox. She assumed this acknowledgement process was expected to be completed within an hour of the VO. When interviewed on 3/31/26, at 11:45 a.m., MD-C stated he “usually” was present during restraint initiation events. Despite this, MD-C explained, “most of the time,” his current process was to provide a VO for the restraint(s) at that time. He stated his VO acknowledgements may not be completed until the end of his shift. When interviewed on 3/31/26, at 12:03 p.m., the ED medical director (MD)-D stated he usually placed his own restraint orders, otherwise he acknowledged them if the situation prompted a VO - such as an emergency where he was otherwise occupied and the order was needed before he was able to enter. He expected the VO acknowledgement to occur within the hour of restraint application. MD-D stated he was unaware there was a potential concern related to increased VOs surrounding restraints at that time. When interviewed on 3/31/26, at 12:44 p.m., MD-E stated, “We have gone to the provider trying to put in the [restraint] order more often.” He explained he tried to put in his own orders, but there were situations where it was quicker for the nurse to put them in. MD-E stated VO notifications come to his inbox where he acknowledged them as soon as he could, based on facility recommendations within the hour of application, but then he stated he was required to make sure they were all signed by the end of his shift. MD-E stated when he entered P14’s ED room, P14 was on the floor with security and brought them to the restraint chair. He was unsure why he did not enter the restraint chair order when he was present for the event. When interviewed on 3/31/26, at 1:07 p.m., RN-E stated she attempted to ensure the provider was updated on patient behaviors so that the provider could be involved before the restraint was needed; however, at times things happened quickly. When such quickness occurred, she notified the provider as soon as possible. RN-E stated VOs were expected to be infrequent; however, “Ninety percent of the time” she entered a VO when it came to restraints. This VO was to be entered within an hour of the restraint initiation but at times, due to workload, order entry was the last thing on her mind, especially when patient care came first. RN-E explained she entered the VO most of the time, so she knew it was done and missed communication did not occur. When interviewed on 3/31/26, at 1:50 p.m., RN-G stated “ideally” she wanted the providers to enter their own restraint orders; however, if not, she then entered them. She stated she “often” entered the restraint orders and was expected to make sure these VOs were entered within the hour of initiation. One the patient was safe, then it was her typical practice to enter the VO. When interviewed on 3/31/26, at 2;10 p.m., MD-F stated restraint order placement was “very hard” as it took time away from what she was doing when nursing updated her, especially if she was already behind in her other work. She attempted to do this as quickly as she could, when able, “as the nurse needs that,” but explained she had up to an hour to enter the order. Additionally, the nurses entered a VO when she was “slammed with strokes and codes.” If a VO was placed, she then went into the system and acknowledged the order. MD-F identified she was in P11’s room “all day,” where during one of his behavioral episodes she was present when a restraint was initiated. She was unable to remember the reason she did not enter the restraint order. When interviewed on 3/31/26, at 2:33 p.m., RN-H, the ED manager, stated nursing staff were allowed to enact a restraint and then update the provider. After, the provider was expected to place the order as soon as possible, but no later than an hour after initiation, to decrease the risk of incorrect orders. RN-H stated he did not personally conduct ED restraint audits and relied on RN-D to alert him if there were any identified concerns. He was unaware as to the degree of nursing versus provider entered restraint orders but felt this should be infrequent. RN-D stated he expected the providers to acknowledge any VO by the end of their shift. When interviewed on 3/31/26, at 4:13 p.m., the chief nursing officer (CNO) stated the provider was expected to enter their own orders as soon as possible. There were some urgent situations, such as emergency moments when the provider was unable to enter them, thus, there were situations where a VO was applicable. This, however, was expected to be infrequent. If a VO was entered, she expected the provider to acknowledge that as soon as possible. The CNO stated restraints were a special breed of order. She was unaware of how often nurses, versus the providers, entered restraint orders and she identified no one had brought such concerns to her. An Orders: Entry and Management policy, dated 12/2024, identified computerized provider order entry as the preferred method of order placement. It defined a verbal order as an order that was verbalized by an authorized provider to qualified staff who then entered the order into the electronic medical record. A telephone order was defined as an order given over the phone by an authorized provider to qualified personnel to be entered in the electronic health record by that person. The policy directed that orders were to be accurately processed as soon as possible, and “Stat” orders were to be processed within 30 minutes. The policy lacked direction related to a one-hour processing time. When a VO was received, the order was to be entered directly into the electronic medical record. In certain “Emergency situations,” the orders could be written on paper. A mode section labeled Verbal Order Read Back Telephone Order Read Back identified its intended use was for when a provider was not available to place the order and the patient needed an immediate order. One provided example identified when a patient was in the ED and there was an identified need in triage that required a provider order. The policy does not specifically call out restraint and/or seclusion use. A facility Clinical Partner Annual Education module transcript, dated 2025, identified provider education. The transcript educated providers that restraint orders must be provided who was responsible for the care of the patient. In relation to violent restraints/seclusion, and in an emergency, the RN was allowed to apply the restraints, but an order was to be obtained as soon as possible or within one hour after application. The education did not reflect how the order was to be obtained i.e., provider entered, verbal order, telephone order, etc. A Restraint and Seclusion policy, dated 8/2025, directed that an RN may initiate a restraint or seclusion if a patient continued to demonstrate aggressive/violent, behaviors/actions, which when not controlled immediately, may result in serious injury to self, staff, or others. The nurse then notified the provider and obtained an order as soon as safety allowed, within the first hour. This allowed the restraints to be initiated prior to a provider notification. The policy directed steps when a restraint order required renewal/continuation and adjustments but lacked direction related to expectations on how the order was expected to be obtained - only that it was to be obtained.”

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 42587 Based on interview and document review, the hospital failed to ensure post-operative vital sign monitoring were performed and documented as ordered by the provider or as indicated in the hospital policy titled Patient Outcome Standard for 5 of 10 patients (P33, P35, P36, P37, P38) who were reviewed for post-operative care following a surgery or procedure. Findings include: P33’s medical record review indicated P33 was admitted on 6/2/25, with concerns of incarcerated ventral umbilical hernias. On 6/2/25, P33 underwent an exploratory laparotomy, right hemicolectomy with ileotransverse anastomosis, strangulated hernia repair with Vicryl mesh underlay. P33’s medical record revealed P33 had orders for standard post-operative vital signs and left the post-acute recovery unit (PACU) on 6/2/25 at 6:53 p.m. P33’s vital signs were documented as follows: -6/2/25 at 7:02 p.m., blood pressure 99/57, heart rate 96, respirations 16, oxygen saturation 98% -6/2/25 at 7:06 p.m., blood pressure 93/72, no heart rate, respiration, or oxygen saturation were documented -6/2/25 at 8:43 p.m., blood pressure 92/66, heart rate 95, respiration 16, oxygen saturation 98% On 9/17/25 at 4:03 p.m., RN-B verified P33’s the post-operative vital sign monitoring was not completed and verified documentation of the 15-minute vital signs were missing as well as the hourly vital signs. RN-B stated the documentation showed P33 was hypotensive, and she would have expected more frequent vital sign monitoring. On 9/17/25 at 4:43 p.m., RN-C verified they would have expected the nurse to follow the standard for post-operative vital sign monitoring for P33 and stated close post-operative vital sign monitoring was important to watch for complications, for example post-operative bleeding. RN-C stated the goal was to intervene before an emergency occurred. RN-C verified respirations were part of post-operative vital sign monitoring. P37’s medical record review indicated P37 was admitted on 9/3/25 with malignant neoplasm of the ascending colon and right renal mass for a planned surgery. On 9/3/25, P37 underwent laparoscopic assisted ascending colectomy and right robotic assisted laparoscopic radical nephrectomy with adrenal sparing. P37’s medical record identified they arrived on the nursing unit at 8:09 p.m., with orders for standard post-operative vital signs. P37’s vital signs were documented as follows: -9/3/27 at 8:09 p.m., blood pressure 123/71, heart rate 87, respirations 18, oxygen saturation 89% -9/3/27 at 8:30 p.m., blood pressure 132/70, heart rate 89, respirations were not documented, oxygen saturation was not documented -9/3/25 at 8:45 p.m., blood pressure 113/66, heart rate 87, respirations were not documented, oxygen saturation 96% -9/3/25 at 9:00 p.m., blood pressure 112/68, heart rate 85, respirations were not documented, oxygen saturation 97% -9/4/25 at 3:06 a.m., blood pressure 136/69, heart rate 82, respirations 14, oxygen saturation 95% On 9/17/25 at 3:35 p.m., RN-B verified the standards for post-operative vital sign documentation was not followed for P37. RN-B verified documenting respirations was important to ensure the patient was oxygenating properly. RN-B verified there was not follow up for an oxygen saturation that was low at 89%. On 9/17/25 at 4:52 p.m., RN-C verified P37’s the documentation did not meet the standard of care for post-operative vital sign monitoring. P38’s medical record review indicated P38 was admitted on 9/5/25 with symptoms of small bowel obstruction such as abdominal pain, distention, nausea. On 9/5/25, P38 underwent laparoscopic assisted small bowel resection. P38 arrived on the post-operative nursing unit on 9/5/25 at 8:57 p.m., with orders for standard post-operative vital signs. P38’s vital signs were documented as follows: -9/5/25 at 9:15 p.m., blood pressure 153/67, heart rate 65, respirations were not documented, oxygen saturation 97%. -9/5/25 at 9:30 p.m., blood pressure 136/122, heart rate 62, respirations 18, oxygen saturation 95% -9/5/25 at 9:45 p.m., blood pressure 149/60, heart rate 67, respirations were not documented, oxygen saturation 97%. -9/5/25 at 11:37 p.m., blood pressure 128/60, heart rate 71, respirations 16, oxygen saturation 98% -9/6/25 at 4:22 a.m., blood pressure 148/58, heart rate 68, respirations 16, oxygen saturation 96% On 9/17/25 at 3:53 p.m., RN-B verified the documentation for P38 did not meet the standard of care for post-operative vital sign monitoring, and stated the documentation was missing respiration rates, missing hourly checks, and did not have documentation for an elevated blood pressure re-check. On 9/17/25 at 4:53 p.m., RN-C verified the documentation for P38 did not meet the standard of care for post-operative vital sign monitoring. RN-C stated there seemed to be a gap in knowledge and stated if documentation was not documented it was considered “not done”. P35’s medical record review indicated P35 was admitted on 9/6/25 with right upper quadrant abdominal pain was diagnosed with cholelithiasis, elevated LFTs (liver function tests), and dilated bile duct concerning for possible choledocholithiasis. On 9/7/25, P35 was taken to surgery for laparoscopic cholecystectomy with intraoperative cholangiogram. P35 arrived on the post-operative nursing unit on 9/7/25 at 5:16 a.m., with orders with orders for standard post-operative vital signs. P35’s vital signs were documented as follows: -9/7/25 at 5:16 a.m., blood pressure 149/107, heart rate 72, respirations 18, oxygen saturation 100% -9/7/25 at 6:00 a.m., blood pressure 141/103, heart rate 72, respirations were not documented, oxygen saturation 98%. -9/7/25 at 3:20 p.m., blood pressure 148/92, heart rate 70, respirations were not documented, oxygen saturation 98%. On 9/18/25 at 3:11 p.m., RN-B verified the post-operative vital sign standard was not followed for P35. RN-B verified she would have expected follow up on the blood pressures and a documented call to the provider if the blood pressures did not improve. On 9/18/25 at 4:49 p.m., RN-C verified the post-operative vital sign standard was not followed for P35. RN-C stated they would have expected more frequent monitoring of the blood pressure based on what had been documented. P36’s medical record review indicated P36 was admitted on 9/11/25 for a planned surgery for laparoscopy-assisted abdominal wall hernia repair with mesh. On 9/11/25 at 10:06 a.m., P36 left the PACU. P36 had orders for standard post-operative vital signs. P36’s vital signs were documented as follows: -9/11/25 at 10:15 a.m., blood pressure 116/76, heart rate 93, respirations were not documented, oxygen saturation 91%. -9/11/25 at 10:30 a.m., blood pressure 108/84, heart rate 87, respirations were not documented, oxygen saturation 93%. -9/11/25 at 10:45 a.m., blood pressure 115/80, heart rate 86, respirations were not documented, oxygen saturation 91%. -9/11/25 at 3:50 p.m., blood pressure 101/69, heart rate 91, respirations 18, oxygen saturation 95% On 9/18/25 at 2:52 p.m., RN-B verified the standard for post-operative vital sign monitoring for P36 had not been followed. RN-B verified the potential was there to miss an opportunity to intervene. On 9/16/25 at 3:58 p.m., Doctor of Osteopathic Medicine (DO)-A stated it was important to monitor vital signs after a procedure or surgery because might see changes in the vital signs to indicate post-operative complications for example bleeding. On 9/17/25 at 9:10 a.m., RN-D stated the standard for post-operative vital sign monitoring was every 15 minutes times four, every 30 minutes for one hour, and then every four hours. On 9/17/25 at 9:27 a.m., RN-E stated the standard for post-operative vital sign monitoring was every 15 minutes times four, every 30 minutes times two, then every hour. On 9/17/25 at 9:53 a.m., RN-F stated she was not sure what the standard for post-operative vital sign monitoring was but stated it was “programmed into the machine”. Not able to state the frequency to check and validate the readings. On 9/17/25 at 10:00 a.m., RN-G stated the standard for post-operative vital sign monitoring was every 15 minutes times three, every 30 minutes times two, every hour once or twice. On 9/17/25 at 10:07 a.m., RN-H stated the standard for post-operative vital sign monitoring was “in the computer”. Not able to state the frequency to check and validate the readings. On 9/17/25 at 10:20 a.m., RN-I stated the standard for post-operative vital sign monitoring was programed into the “monitor”. RN-I was not able to state the frequency to check and validate the readings. RN-I stated it was their understanding the machine measured the vital signs and the vital sign readings would flow into the medical record whether they were “validated” or not. On 9/17/25 at 11:15 a.m., RN-B stated there was a concern when a machine was doing the work (measuring the vital signs), the nurses might not be reviewing the vital signs in real-time, although she verified it was her expectation they would review the vital signs in real-time to see complications and act on them timely. On 9/18/25 at 2:12 p.m., the chief nursing officer (CNO) verified she would expect nurses to document in real time as much as possible. The CNO verified this was important to monitor for potential complications following the surgery or procedure. The director of nursing (DN) verified monitoring post-operative vital signs was important to look for trends, detect deterioration, and to be able to intervene as soon as possible. On 9/18/25 at 4:51 p.m., RN-C verified the standard for post-operative vital sign monitoring had not been followed reviewing what had been documented in the electronic medical records. The hospital policy titled Patient Outcome Standards: Medical 1, Medical 2, Medical Oncology, Neuroscience/Spine, Orthopedics, Surgical Care 1, and Surgical Care 2 Units dated 6/2025, indicated the purpose of the policy was to identify outcome standards (goals) and process standards (interventions) for patients. Patients outcomes/goals included the ability for patients to maintain hemodynamic and respiratory stability and afebrile. Process standards/interventions included a full set of vital signs which included blood pressure with mean arterial pressure (MAP), pulse, respiratory rate (RR), oxygen saturation including oxygen source and amount (O2 saturation), and temperature is measured on arrival and every 4 hours for the first 24 hours (0400, 0800, 1200, 1600, 2000 and 2400). Then if stable four times daily or more often as clinically indicated. Post invasive procedure without sedation vital signs (procedures can include chest tube insertion, liver biopsy, thoracentesis, paracentesis): On arrival to unit: full set; Every 15 minutes x 3, every 30 minutes x 2, every 60 minutes x 1: BP with MAP, pulse, O2 saturation.Every 4 hours: full set; or per provider order then every 4 hours. Post-op (following discharge from PACU or Phase 2 recovery) vital signs: On arrival to unit: full set; Every 15 minutes x 2, then every 60 minutes x 2: BP with MAP, RR, pulse, O2 saturation; every 4 hours: full set x 24 hours. Assess rate and regulatory of pulse on arrival and twice per day and as clinically indicated. Assess regularity, effort, and lung sounds on arrival, twice per day and as clinically indicated. Attempt to wean oxygen every 4 hours, while awake and more often as clinically indicated. Patients will be encouraged to cough and deep breathe every 2 hours while awake. Clinical Documentation dated 8/2025, identified “A comprehensive accurate EHR (electronic health record) will be maintained” and “Documentation will be done concurrently or as soon as possible (recommended within 60 minutes).””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48040 Based on interview and document review, the hospital failed to ensure appropriate measures were implemented to ensure patient protection after an allegation of staff to patient sexual abuse was verbalized by 1 of 1 patient (P1) who reported sexual abuse by staff during the provision of care. The facility failed to implement a thorough investigation into the allegation and the alleged perpetrator continued to provide unsupervised patient care. As a result, the hospital was found out of compliance with the Condition of Participation Patient Rights at 42 CFR 482.13. An immediate jeopardy was issued at A-0145. See A-0145 for additional information.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 48040 Based on interview and document review, the hospital failed to ensure appropriate measures were implemented to ensure patient protection after an allegation of staff to patient sexual abuse was verbalized by 1 of 1 patient (P1) who reported sexual abuse by staff during the provision of care. The facility failed to implement a thorough investigation into the allegation and the alleged perpetrator continued to provide unsupervised patient care. This had the potential to affect all patients receiving care within the hospital. The immediate jeopardy began on 8/18/25, when P1 reported to her day shift registered nurse (RN) that a nurse had touched her vagina overnight, the hospital failed to protect patients after the allegation was made. The incident was not thoroughly investigated and the alleged staff member continued working on the unit without supervision, placing other patients at risk for sexual abuse. The Regulatory and Accreditation Officer, Inpatient Nursing Practice Director, and Saint Cloud Hospital President were informed of the immediate jeopardy on 9/4/25 at 4:15 p.m. The immediate jeopardy was removed on 9/9/25 at 2:43 p.m. but the hospital remained out of compliance with the COP of Patient’s Rights at 42 CFR 483.13. Findings include: P1’s admission record dated 8/15/25, indicated P1’s diagnoses included acute spontaneous subarachnoid, intracranial hemorrhage due to cerebral aneurysm (HCC), and cerebral artery vasospasm. P1 was treated, stabilized, and was discharged home on 8/30/25. On 8/15/25, P1’s medical record indicated P1 arrived at the emergency department (ED) via emergency medical services (EMS) and was subsequently transferred to intensive care unit (ICU) for further evaluation. During an interview on 9/2/25 at 2:38 p.m. P1 stated she was sexually abused by the male night nurse, on the night of 8/17/25 into 8/18/25. P1 recalled AP coming into her room, started asking “weird” questions and wanted to rub her back. AP then put his thumb/finger inside her vagina. P1 indicated she did not say anything to AP because she did not know what to do. P1 described the alleged perpetrator (AP) as an African American. P1 explained it was dark in the room so she could not provide any further description of the AP and was not aware of the exact time of occurrence because she had not looked at the clock. P1 reported the incident to the registered nurse (RN)-A on the morning of 8/18/25. P1 explained after a couple of days the incident still bothered her so she talked to another nurse (not identified) who would try and find more information. The nurse came back and reported no one knew anything about her report of sexual assault, so P1 called the police. P1 stated no one offered her a SANE (sexual assault nurse examination) after she had reported. The police officer told her the exam needed to be done within 12 hours, so she declined the exam when offered days later. P1 stated no one from the hospital interviewed her after RN-AC nor after she reported to the police. P1’s Flowsheet dated 8/18/25 included (but not limited to) at 12:00 a.m. indicated R1 was repositioned in bed. At 2:00 a.m. indicated R1 was in bed, foley catheter had 150 ml (milliliters) of urine. At 4:00 a.m. indicated R1 was alert and orientated, had mild/moderate pain, R1 was repositioned, room was darkened, wet to cold cloth to head; and “Back rub”. Additional documentation at 4:00 a.m. included foley catheter was in place draining clear/yellow/straw colored urine- Urinary containment device;Absorbent chux in place;Limit use of briefs; Linens clean dry, wrinkle free; Stabilize tubes;Skin folds clean and dry was documented. During an interview on 9/3/25 at 11:30 a.m. RN-A stated on 8/18/25 P1 reported to her she was sexually abused by the male night nurse. P1 reported AP rubbed her back first then put his finger into her vagina. RN-A stated she reported the incident to her charge nurse, RN-B, immediately and did not report to the State Agency or law enforcement. During an interview on 9/3/25 at 9:33 a.m., RN-B stated RN-A reported P1’s sexual abuse allegation to her on 8/18/25. On the same day RN-B then followed-up with P1 who reported the same allegations, however, RN-B did not remove the AP who she described as “Middle Eastern” from the schedule that evening and reassigned the AP to care for different patients on the same unit but restricted the AP from providing care to P1. RN-B explained when P1 required personal hygiene, staff were to use the “buddy system” after the allegation was made. RN-B stated on 8/19/25, the following day, she reported the allegation to RN-C the director of the ICU. RN-B did not report it to the State Agency on 8/18/25 nor call the police to file a criminal report. During an interview on 9/3/25 at 11:58 a.m. RN-C stated RN-B told her on 8/19/25 about P1’s sexual abuse allegation. RN-C stated she attempted to talk to P1 on 8/19/25 and 8/20/25 but she was sleeping on both occasions. On 8/21/25, 3 days after the allegation, she was able to talk to P1 who stated the male night nurse, who P1 described as an African American, had sexually assaulted her on 8/18/25 by rubbing her back and putting his thumb into her vagina. RN-C updated P1’s care plan to reflect two staff at all times during cares. RN-C did not file a report to the State Agency on 8/21/25. Further explaining during an interdisciplinary meeting on 8/25/25, the team realized the incident should have been reported to the State Agency, so RN-C directed RN-B to make the report. RN-C stated the AP was not suspended; he was still working in the ICU but not caring for P1 anymore. RN-C reported no education was provided to the staff pertaining to timely reporting nor was there education provided for protocols on immediately implementing patient protections after an allegation of abuse was made. P1’s Patient Protection Event Summary that was entered on 8/22/25 included an event identified as staff to patient “sexual criminal” with no detectable harm. The description of the event indicated on 8/22/25 the writer became aware that St. Cloud Police were on site to take a report from P1 who was reporting a sexual assault that she states occurred while admitted to the ICU. This incident reportedly occurred this past weekend (8/16/25-8/1725). Because an exact date and time are not known, the date and time are approximate. P1 reports that either a nurse or doctor assaulted her. Further identified the writer reached out to the on-duty nursing supervisor and asked her if she could ensure that the patient is offered a SANE examination. She stated that she would reach out to ETC define ETC to facilitate this. Additionally indicated the writer was not a licensed staff member so a vulnerable adult report was not submitted. During an interview on 9/4/25 at 3:24 p.m. a security officer (SO)-A stated a police officer came to the hospital on 8/22/25 per P1’s request to investigate P1’s alleged sexual assault by a staff member in the ICU. SO-A stated he went to the unit to make sure the charge nurse was aware of the allegation and to see if P1 had received an examination which the charge nurse did not know. SO-A stated he requested VA to be filed and it was not filed until 8/25/25. P1’s Patient Protection Event Summary Follow-Up Actions dated 8/25/25 included, “”pt reported “a male nurse “put a finger in her vagina”. Pt added that she already reported the incident to ICU staff. Pt unable to recall when the incident occurred and name of staff involved. Pt stated that she feels uncomfortable sleeping in a different room by herself and would like for her partner/boyfriend to stay with her.” Further identifying P1 had a history of hallucinations. The follow-up also included interviews from the nurses that P1 had reported the allegations to. The actions identified the team reviewed the facts of case which included: discussed allegation, timeline of events, no clinical management, no video footage needed due to no specific timeframe, determined no additional staff/pt interview needs, and male nurses removed from care team. A Vulnerable Adult Maltreatment Report dated 8/26/25 received by the state agency from the hospital indicated on 8/18/25, P1 reported to staff member she was sexually assaulted by the male night nurse. The probable AP was removed from caring for P1. However, the AP remained providing patient care to others in the unit. During an interview on 9/3/25 at 12:52 p.m. AP stated he provided care to P1 the night of 8/17/25. AP explained on 8/17/25 when he had administered P1 pain medication, P1 had told him that rubbing her back would help too, so he rubbed her back as requested. AP stated rubbing patient’s back was part of nursing practices to alleviate pain and was a nonpharmacological intervention. Further explaining P1 had a Foley catheter and could not recall providing peri care to P1. AP stated he did not put his finger into her vagina. AP was reassigned to care for different patients on 8/18/25 in ICU. RN-B was the only person who talked to him on 8/18/25 about the allegation. AP confirmed he was not suspended but continued to work in the ICU on 8/18/25, 8/19/25, 8/20/25 and was off and came back on 8/26/25. AP stated he had not received any education since the allegation was made. During an interview on 9/4/25 at 10:58 a.m. director of risk management (RM)-A stated she was made aware of the allegation on 8/25/25 after police came onsite to talk to P1. RM-A’s team initiated the internal investigation and had determined P1’s description of African American male did not fit the description of any staff who worked on the night shift that evening. RM-A stated AP was the only mail nurse assigned to care for P1 on 8/17/25, but there was not enough information to suspend any staff based on P1’s description (African American), however, no attempt was made to re-interview P1 to obtain additional information about the AP (such as skin tone, defining characteristic, height, weight). RM-A stated the allegation was unsubstantiated because there was no AP that matched the description of “African America”. RM-A stated there were some learning opportunities for ICU staff pertaining to reporting an allegation on time and ensuring education was provided however this has not been completed. On 9/4/25 at 3:35 p.m. a voicemail was left for the lead investigating law enforcement officer requesting a return call; however the call was not returned. Hospital’s Vulnerable Adult (VA) Maltreatment policy dated 2/2025 indicated the responsibility of CentraCare to report suspected or actual abuse, neglect, misappropriation of property/financial exploitation and injuries of unknown origin, suspicious in nature, of vulnerable adults immediately but no longer than 2 hours from the time initial knowledge that the incident occurred has been received and thoroughly investigated as mandated by law. Hospitals Rights and Responsibilities of Patients policy dated 11/2022, indicated patients shall be free from maltreatment as defined in the Vulnerable Adult Protection Act. “Maltreatment” means conduct described in Section 626.5572, Subdivision 15, or the intentional and nontherapeutic infliction of physical pain or injury, or any persistent course of conduct intended to produce mental or emotional distress. The immediate jeopardy that began on 8/18/25, was removed on 9/9/25, when it was verified by interview, and document review the hospital completed review of the Vulnerable Adult policy by adding a clear definition of “allegation” and “alleged perpetrator”, adding the hospital allegation workflow for team members and leadership to reference when an allegation is made as well as providing the allegation resource guide for leaders to aid in conducting thorough investigations. Also, the hospital provided educational handouts to be reviewed and signed off by nursing and security staff within a tracking log before their next scheduled shift. Practice changes include Vulnerable Adult (VA) & Child Maltreatment reports of abuse need to be filed immediately following the event or within 24 hours. Staff to initiate immediate protection measures such as ensuring immediate safety of the patient, suspending suspected team member, interviewing and assessing the patient (consider SANE). Also, staff have to file VA or Child Maltreatment, notify team members and/or patient representative if needed, and reassess all patients in contact with suspected team member.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 40945 Based on observation, interview, and record review, the hospital failed to keep patients safe from abuse for of 2 of 18 patients (P16, P18) reviewed for abuse when interventions were not initiated to prevent physical aggression. P18 attacked P16 on 5/25/25 and on 5/31/25. In addition, the hospital failed to timely report the allegations to the state agency when the incident of 5/25/25 was not reported until 5/28/25 and the 5/31/25 incident was not reported until 6/2/25. As a result, the hospital was found out of compliance with the Condition of Participation Patient Rights at 42 CFR 482.13. An immediate jeopardy was issued at A-0145. See A-0145 for additional information. A condition level deficiency was issued at A-0144. See A-0144 for additional information. A standard level deficiency was issued at A-0143. See A-0143 for additional information.”

“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: 40945 49618 Based on interview and record review, the facility failed to protect a patient’s personal information for 1 of 18 (P12) patients when hospital staff informed law enforcement of the patient’s presence in the hospital. Hospital staff informed law enforcement of P12’s presence in the hospital after being notified that he had an active warrant out for his arrest. Findings include: P12’s medical record was reviewed. P12 was admitted to the hospital on 12/29/23 due to stroke symptoms. P12 was diagnosed with an acute ischemic left middle cerebral artery stroke with moderate expressive aphasia and severe receptive language impairment and resolved right hemiparesis. P12’s additional diagnoses included cerebral edema and asymptomatic petechial hemorrhages, hypotension, ischemic cardiomyopathy, diabetes mellitus, methamphetamine abuse, suicidal ideation and depression, homelessness, and history of noncompliance with medications. P12 was discharged from the hospital on 1/18/24 when he transferred to the county jail. P12’s progress note dated 1/10/24 indicated P12’s transitional barrier was placement in an assisted living facility. P12’s progress note dated 1/11/24 indicated P12’s transitional barrier was placement in an assisted living facility. P12’s progress note dated 1/12/24 indicated P12’s transitional barrier was placement in an assisted living facility. P12’s progress note dated 1/15/24 indicated P12’s transitional barrier was placement in an assisted living facility. P12’s progress note dated 1/17/24 indicated P12’s transitional barrier was placement due to P12’s criminal history. P12’s progress note dated 1/18/24 indicated on 1/18/24, case management was made aware that P12 had a warrant out for his arrest in the county. P12 was released to custody of the police department on 1/18/24. P12’s progress note dated 1/18/24 indicated P12 was medically ready for discharge since 1/11/24. After a discussion with care management leadership and law enforcement personnel, the patient would be released with law enforcement who was at P12’s bedside. P12’s progress note dated 1/18/24 indicated social services (SS)-A had noted P12’s transitional barriers included placement. SS-A had followed up with pending long term care referrals and was awaiting responses back. SS-A consulted with law enforcement to coordinate the P12’s discharge to law enforcement custody. P12 was discharged to law enforcement custody. During an interview on 6/4/25 at 11:23 a.m., registered nurse (RN)-D stated case management was attempting to find placement into an assisted living facility for P12. Case management would send referrals out to facilities and the facilities would review the referral. One of the facilities reported back to her that they ran a criminal background check on P12, and it came back that P12 had an active warrant for his arrest. P12’s active warrant was a barrier to finding long term care placement. RN-D stated the facilities wanted the hospital “to explore the warrant”. RN-D spoke with the hospital security guards to identify what steps to take, what information they should share, and what information they could not share. The hospital security guard could not be identified. The security guard recommended to call the county law enforcement to see if they could drop the criminal charge so P12 could find placement, and the county law enforcement stated they would not drop the criminal charge. RN-D stated she could not recall if she called the county law enforcement or if the social worker did. RN-D stated when it comes to Health Information Portability and Accountability Act (HIPAA), the hospital does not give patient’s identifying information out to people who are not involved in the care with that patient. The county law enforcement was not involved in P12’s medical care. RN-D stated if law enforcement is not involved in a patient’s medical care, the patient’s information should not be shared with them. During an interview on 6/4/25 at 1:03 p.m., security officer (SO)-B stated if a patient has an active search warrant, law enforcement should not be called while the patient is receiving care in the hospital. If the hospital is attempting to find long term care placement for the patient, the patient is still receiving care in the hospital. During an interview on 6/4/25 at 1:20 p.m., Regulatory and Accreditation Program Manager (RAPM) stated legal or criminal information should not apply when a patient is receiving medical care in the hospital. During an interview on 6/4/25 at 3:15 p.m., Regulatory and Accreditation Officer (RAO) stated criminal or legal information should not be shared with law enforcement while a patient is receiving medical care in the hospital. During an interview on 6/5/25 at 7:27 a.m., RN-H stated two law enforcement officers came to the unit P12 was on and asked if P12 was in his room. RN-H stated she could not give that information to law enforcement. Law enforcement stated P12 had a warrant out for his arrest, and they had to take P12 into custody. RN-H talked to case management but could not recall the specific case management staff she talked to. Case management stated P12’s discharge plan was being changed from long term care placement to law enforcement custody. Once RN-H was told P12 was being discharged to law enforcement custody, she brought the law enforcement personnel to P12’s room. RN-H printed off P12’s after visit summary and gave it to the patient, and then the patient gave the packet to the law enforcement personnel. RN-H stated it is not “appropriate” for hospital staff to disclose patient information specific to the care they receive, and diagnosis, or if the patient is in the hospital. RN-H stated when it comes to HIPAA, it is not appropriate for hospital staff to contact law enforcement about a patient’s who has an active warrant. During an interview on 6/5/25 at 10:39 a.m., SS-A during P12’s admission, SS-A and his care team would send out referrals to facilities for long term care placement. SS-A would get refusals back from facilities because P12 had an active warrant out for his arrest. RN-D called the county law enforcement, and the county law enforcement stated they were going to “book” P12 and follow up on his warrant. SS-A stated that because P12’s warrant was in another county, the local county law enforcement was going to pick up P12 from the hospital. SS-A stated she did not know the policy on HIPAA and patients with active warrants. The hospital’s Release of Information policy dated 6/2023 indicated a permitted release of information disclosure was civil, administrative, or criminal proceedings or actions. The hospital’s Patient Privacy and Confidentiality policy dated 3/2025 indicated hospital employees, clinical partners, students, and volunteers would maintain privacy and confidentiality for all patients and would agree to reasonably cooperate with the hospital regarding any issues related to patient privacy and confidentiality. Protected Health Information included all information regarding patients; their presence in the facility if requested, their condition, care, or treatment, whether in the medical record, in computer files, transmitting or receiving data via the e-health exchange, or other related types of data. Protected Health Information about patients which is obtained by hospital employees, clinical partners, volunteers, or students is presumed to be private and is shared only for appropriate professional purposes, only at the time it is needed and with those who have a legitimate need to know.”

“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: 40945 Based on interview and document review, the hospital failed to provide adequate monitoring and supervision to prevent 1 of 1 patient reviewed (P4) from self-injurious behavior and ingesting foreign objects when the implementation of interventions were not successful. P4 had three instances of ingesting of foreign object which required surgical interventions. Findings include: P4’s medical record was reviewed. P4 was admitted to the medical unit on 5/15/25 for evaluation of self-inflicted abdominal wound. P4’s diagnosis included significant psychiatric history, including borderline personality, polysubstance abuse, suicidal ideation, and self-harming behavior. P4 was admitted to the facility on 5/15/25, for medical treatment of self-inflicted abdominal wound. P4’s diagnosis at admission included suicide and self-inflicted injury by cutting and piercing instrument, borderline personality disorder and history of swallowed foreign body. Admitting provider notes included the following, review of P4’s treatment plan with no male caregivers. P4 had a long history of swallowing objects and a suicide attempt to hang herself in the hospital. The provider discussed with psychiatry and did not order one-to-one or suicide precautions at the time of review. P4 denied suicide ideation and requested a 72-hour hold, which was deferred to psychiatry. A Vulnerable Adult Maltreatment Report dated 5/15/25 was submitted by the hospital outlined P4 admitted 5/15/2025 following multiple admissions for open wound of abdomen. Patient being evaluate for decision-making capacity by psychiatry. Patient was seen by psychiatry at 12:20 p.m. Psychiatry exited the room to speak with nursing. Decision was made to place patient on suicide precautions including 1:1 sitter observation. Staff returned to room within 5 minutes of provider leaving to begin removal of items, environment of care check and 1:1 nursing. Patient told nursing to check something on counter in room. When nursing turned back on patient, patient swallowed two AA batteries from bedside remote control. Actions taken to protect the vulnerable adult from further harm included additional environment of care check to remove all items that have potential to swallow, and modification of 1:1 always includes eyes on patient. Seeking emergency guardianship. An Esophagogastroduodenoscopy (EGD) report dated 5/16/25, at 4:06 p.m. indicated after obtaining informed consent from P4, the endoscope was passed under direct vision two AAA batteries were found in the gastric fundus. Removal was successful. Pt transported to the ICU for sedation. The upper GI endoscopy was accomplished without difficulty. The patient tolerated the procedure well. A facility incident report dated 5/16/25, indicated P4 admitted 5/15/2025 following multiple admissions for open wound of abdomen. Patient being evaluate for decision making capacity by psychiatry. Patient was seen by psychiatry at 12:20 p.m. Psychiatry exited the room to speak with nursing. Decision was made to place patient on suicide precautions including 1:1 sitter observation. Staff returned to room within 5 minutes of provider leaving to begin removal of items, environment of care check and 1:1 nursing. Patient told nursing to check something on counter in room. When nursing turned back on patient, patient swallowed two AAA batteries from bedside remote control. A nursing note dated 5/27/25, at 10:37 p.m., indicated P4 reported abdominal pain because she swallowed metal wire earlier this AM as she was “frustrated at the time.” P4 also notified staff that she had multiple screws in pillowcase. She attempted to remove metal objects from couch first, was unsuccessful so then moved to chair to find metal objects to remove, which was done “a couple of days ago”. P4’s pillowcase was removed, and she voluntarily provided the screws. Room stripped of all additional removable objects/pieces by charge RN. Explained to P4 and 1:1 sitter that hands must always be visible. Notified cross-cover MD of above information. Ordered abdominal CT, completed this evening. CT completed with writer, 1:1, and house float RN for support. Report given to oncoming RN. A nursing note dated 5/28/25, at 3:46 a.m. indicated P4 had just received a CT scan due to ingesting a foreign metal object. Writer communicated with patient that she would not be allowed to leave her room overnight due to her ingesting the foreign object. Explained to patient that room restriction would be further discussed with the care team in the morning. P4 agreed to these boundaries. Charger nurse present when conversation occurred as well as 1:1. Charge nurse communicated to the surgical care unit director. GI was consulted for EGD in the morning to remove the foreign body from stomach. P4 was alert and oriented to person, place, time, and event. Staff 1:1 remains in place due to risk for self-harm and elopement. P4 did have complaints of abdominal pain. An Esophagogastroduodenoscopy (EGD) report dated 5/28/25, at 10:19 a.m. indicated after obtaining informed consent, the endoscope was passed under direct vision. A longitudinal piece of twist ties extending into the bulb was found in the gastric antrum. Removal was accomplished with a snare. The upper GI endoscopy was accomplished without difficulty. The patient tolerated the procedure well. A facility incident report dated 5/28/25, indicated P4 Patient w/significant psych history including swallowing metal objects with 1:1 sitter present in room reported that she swallowed a metal wire earlier in the day, believes it was sometime between 0700-0900, because she was frustrated. Reports that she got the wire from the chair while 1:1 sitter was in the room, as well as swallowing it while sitter in the room. At that time also reported that she had screws hiding inside her pillowcase, reports all objects were obtained 2 days prior to event happening. Disclosed that she was able to get objects by hiding hands behind a pillow while sitting in chair and unscrewing from wall/chair/nearby objects. Notes that all of this was done while 1:1 was present in room. CT obtained confirmed that metal object was in her stomach, GI consult placed for removal. A Vulnerable Adult Maltreatment Report dated 5/28/25 was submitted by the hospital outlined P4 admitted 5/15/2025 following multiple admissions for open wound of abdomen. Upon evening assessment on 5/27/25, patient endorsed pain and reported that pain is because she swallowed metal wire earlier this AM., she did this because she was “frustrated at the time.” Per patient report, all of this was done “a couple of days ago”. Imaging confirmed foreign object. Foreign object obtained via endoscopy 5/28/25. Actions taken to protect the vulnerable adult from further harm included room stripped of all additional removable objects. Maintenance completed additional environmental check. Modification to unique treatment plan for out of room activity. Explanation to patient and 1:1 sitter that hands must always be visible. Seeking emergency guardianship. A nursing note date 5/30/25, at 11:56 a.m. indicated P4 extubated as ordered after afebrile and all tests showed no infection at this time. P4 to room air. Instantly accusing staff of trying to kill her and watch her choke. P4 was fighting the ventilator and coughing as the sedation was weaned waiting until extubation. P4 consistently asking for court decisions and guardianship and demanding staff be fired. P4 demanding to be left restrained while in the hospital, soft wrist restraints in place for safety at this time until transferred out of ICU to a safer environment and two available sitters. A nursing note dated 5/30/25, at 3:53 p.m. indicated P4 would be transferred back to the medical surgical unit with two nursing assistant (NA) sitters present for safety. Both were given report previously by charge nurse. Behavioral Access RN present on the unit for transfer along with nursing supervisor. A nursing note dated 6/1/25, at 7:49 a.m. indicated P4 swallowed a wire and some water. Situation explained and both sitters that were present. They stated P4 was getting frustrated that the staff wanted to measure the water that she was allowed to swish and spit and was upset about needing some lights on to observe her. She started raising her voice and becoming more agitated, so one sitter went to open the room door and put the assistance light on, while the other sitter observed her walk to the bathroom and drink the water while she was scratching at her breast. Then P4 stated she hid the wire underneath her breast fold. P4 did not disclose where she got the wire. She laughed at the situation and wondered if she told us where she got it, she could have more privileges. Security called to complete a room search. Primary RN called provider. Completed environmental checklist more frequently. Removed items sitting outside of room that could be snatched easily. During the search, P4 was hyperactive and making sexual comments- inquiring if we would search her body. Stated “I’d love to strip for you, you can search me all you want” and proceeded to pull pants down and cough and flashed her breast folds and abdominal folds. P4 was told “That is inappropriate, please stop, but at some point, a search may be necessary for your safety.” Sitters re-educated on close, careful observation, and always both keeping eyes on pt and staying in the room. Educated them that they could use the staff assist, or personal alarm. Updated director and nurse supervisor. An Esophagogastroduodenoscopy (EGD) report dated 6/1/25, at 10:27 a.m. indicated after obtaining informed consent from P4, the endoscope was passed under direct vision. A long piece of a metal wire (extracted from a surgical mask per patient) was found in the stomach, and extracted. The upper GI endoscopy was accomplished without difficulty. The patient tolerated the procedure well. A provider note dated 6/1/25, 1:09 p.m. provided P4’s history. P4 left against medical advice (AMA) on 05/04/2025 afternoon but returned several hours later with profuse drainage and food coming out from the abdominal wound. Per surgical team, patient’s abdomen was inoperable. Patient on strict nothing by mouth (NPO) (okay for medications), started on total parenteral nutrition (TPN) nutrition. Patient left AMA again on 5/14/2025 after she was refused IV Dilaudid and returned few hours later and admitted on 5/15/2025. Patient was intubated after the procedure and observed in ICU, successfully extubated on 5/17/2025 and monitored at surgical progressive care unit (SPCU). Guardianship was being pursued to help make decisions regarding her care and find compliance with the necessary interventions for her safety. On 5/28/2025 patient ingested twisted tie, requiring removal via EGD. Intentional foreign objects ingestions included patient ingested 2 AAA batteries from remote on 5/16/2025, requiring EGD removal, ingested twisted tie on 5/28/2025, removed per EGD, and ingested twisted tie on 06/01/25, removed per EGD. A nursing note dated 6/1/25, at 1:14 p.m. indicated P4’s endoscopy had been completed at 10:30 a.m. for foreign body removal. P4’s behavior was acceptable prior to procedure. Remains on 2:1 nursing at all times. Procedure was successfully completed. P4 threatened to dismantle computer and did attempt to pull cords out of the wall. Security and behavioral health arrived to redirect. Several methods were used to calm patient down. She then removed her port access. P4 then placed herself on the floor. She banged herself, her head on the floor, bed, and cupboards. Order obtained for physical restraints. P4 was placed on the bed by staff. Security, nursing staff, and behavioral health remained in room to try to calm patient down verbally. P4 redirection of behavior became unsuccessful. Placed in 4-point restraints. 2:1 nursing remains present. Will remain closely monitored. A Vulnerable Adult Maltreatment Report dated 6/1/25 was submitted by the hospital outlined P4 swallowed a piece of metal that she took from a surgical mask that was laying in the garbage. Actions taken to protect the vulnerable adult from further harm included patient room has been stripped of all harmful objects. 2:1 sitter in place. Frequent environmental checks. During an interview on 5/29/25 at 10:94 a.m., RN-B stated P4 had a history of self- injurious behavior and ingestion of foreign objects which required staff to always be in the room with P4. P4 required 1:1 staffing for her safety. P4 swallowed a wire on 5/27/25, which was removed successfully thru a surgical procedure. Staff were to always have eyes on P4; however, staff had no knowledge that P4 swallowed anything until P4 reported this to staff. P4 was currently in ICU intubated and sedated for her safety. During an interview on 5/29/25 at 12:21 a.m., medical doctor (MD)-A stated she was very familiar with P4’s medical diagnosis and conditions. Provider orders had been in pace which included 1:1 sitter for P4’s safety. Her expectation was staff always had eyes on P4. She was not surprised P4 continued to ingest foreign object, however she would still expect staff to follow all provider orders for P4’s safety. MD-A stated P4’s case of self- injurious behavior and ingestion of foreign objects behaviors is the most severe case she has treated. During an interview on 6/2/25, at 8:41 a.m. Chief Nursing Officer (CNO) stated P4 had again ingested a piece of metal from a medical face mask that required surgical removal. At the time of the third ingestion incident P4 had two sitters in the room with her. CNO stated the hospital was still investigating the incident. During an interview on 6/2/25 at 9:18 a.m., NA-C stated she was assigned as 1 of the 1:1 sitters for P4, always having eyes on P4. It was important to always watch P4 and make sure they are staying safe. She was assigned as P4’s 1:1 prior to the ingestion on 5/27/25, and many times P4 would be laying on the couch where you could not see her hands and face. NA-C stated nursing staff did not share a lot of information or give instruction for performing the 1:1 prior to the incident on 5/27/25, including that you had to always see P4’s hands and face. During an interview on 6/2/25, at 10:34 a.m. RN-B stated P4 transferred back to the surgical unit on 5/30/25. Interventions were in place to include all items removed from the room that could be removed and possibly ingested. P4 was also always assigned two staff in the room with her. Staff were to always have eyes on P4, including a visual of P4’s face and hands. P4 disclosed to staff she took a face mask out of the garbage which had been thrown away by the IV access team. There was a failure of something because no one saw P4 take the mask from the garbage. Staff should have seen P4 remove the mask from the garbage. After the incident, all garbage is to be taken out with the staff after the care has been performed. The entire team met including the behavioral nurse, primary medical doctor, charge nurse, and psychiatric team to review P4’s orders and care plan. RN-B stated immediately after the incident re- education all staff on the importance of eyes on at all times, no garbage or items are to be left in the room and environmental room checks were initiated. P4 has not had any additional ingestion incidents since. The hospital policy titled Sitter and Video Observation, dated 2/2025, indicated a Sitters responsibility included the remain with patient and always ensure visibility and patients on suicide precautions will have head and hands visible. Sitter is staff trained to observe for real or potential threats to patient and staff safety. Hospital’s Vulnerable Adult (VA) Maltreatment policy dated 2/2025 indicated caregiver neglect means the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, healthcare or supervision which is reasonable and necessary to obtain or maintain the vulnerable adults’ s physical or mental health or safety.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 40945 49618 Based on observation, interview, and record review, the hospital failed to keep patients safe from abuse for of 2 of 18 patients (P16, P18) reviewed for abuse when interventions were not initiated to prevent physical aggression. P18 attacked P16 on 5/25/25 and on 5/31/25. In addition, the hospital failed to timely report the allegations to the state agency when the incident of 5/25/25 was not reported until 5/28/25 and the 5/31/25 incident was not reported until 6/2/25. The immediate jeopardy began on 5/25/25, when P18 physically attacked P16, and the facility failed to ensure intervention were in place to prevent further physical aggression towards P16 or other patients on the mental health unit. Then again, P18 physically attacked P16 on 5/31/25. The Regulatory and Accreditation System Program Manager and Chief Nursing Officer was informed of the immediate jeopardy on 6/3/25 at 4:31 p.m. The immediate jeopardy was removed on 6/5/25 at 10:09 a.m. but noncompliance remained at a condition level. Findings include: A Vulnerable Adult Maltreatment Report dated 5/28/25, was submitted by the hospital. The report outlined on 5/25/25, at 7:43 p.m. P-16 was seen in the dining room in a headlock by P18. Staff guided P18 away from P16, but P18 attempted to go towards P16 again, grabbing and attempting to punch P16. Staff guided P16 to her room. Per P16 report, the attack was unprovoked and has no idea why she was attacked by P18. P16 reported she and P18 had been arguing over the remote, and P16 stated “beat me up”. P16 was bitten by P18; suffered a laceration on right side of forehead. Wound was cleaned and image was uploaded to P16’s medical chart. After wound was cleaned P16 requested to go back to the dining room to finish coloring. Security came onto unit to interview with P16 and inquire if she wanted to press charges against P18. On 6/3/25, during video review with security guard (SG) on 5/25/31, at 7:42 p.m. P16 was seen seated at a table in the dining room of the mental health unit. P18 approached P16 while she was seated at the table and began striking P16 multiple times in the face and head and pulling P16’s hair. P18 bit P16 on the right forehead causing a laceration. No staff was present in the dining room at the initial time of the attack. P18 and P16 were separated by staff, however they remined in the same area on the mental health unit (MHU). A facility report dated 5/25/25, indicated on 5/25/25, at 7:43 p.m., P16 was seen in the dining room in a headlock by P18. Staff guided P18 away from P16, but P18 attempted to go towards P16 again, grabbing and attempting to punch P16. The report lacked interventions to prevent further incidents of physical violence and aggression. A Vulnerable Adult Maltreatment Report dated 6/2/25, was submitted by the hospital. The report outlined on 5/31/25, at 5:55 p.m. P16 had been showing signs of agitation such as irritability throughout the day as evidenced by door slamming and notes including the progress note from the physician earlier that day. At 5:50 p.m. P16 barricaded herself and another patient in the dining room at 5:52 p.m. P16 did open the doors and walked back to her room prior to returning to the dining room with her meal tray. At 5:55 p.m. P18 entered the dining room walking directly towards P16, grabbed P16 by the hair with bilateral hands and brought P16 to the floor. P18 did hit P16 in the head 3-5 times before being pushed back against the wall. At 5:55 p.m. staff were hands on. The behavioral alarm was initiated, and security contacted. At 5:55 p.m. security officers were on site in the dining room. P16 was accepting of oral Zyprexa. P18 verbally redirected successfully. Staff will continue to assess and monitor all patients for changes in risk level. On 6/3/25, during video review with security guard (SG) from 5/31/31, at 5:50 p.m., P16 had physically barricaded herself and 2 other patients in the dining room. No staff was present in the dining room, and no staff member entered the dining room to redirect or remove P16 from the situation. At 5:55 p.m. P18 entered the unit dining room and walked directly towards P16 who had been seated at a table. P18 grabbed P16 by her hair with both hands and threw P16 to the floor. P18 violently struck P16 with both her fists striking her head and face at least five times before staff pulled P18 off P16 who was lying on the floor during the entire physical attack. No staff was present in the dining room at the initial time of the attack. Staff verbally redirected P18 successfully. P16 was transferred onto the BICU for safety. A facility report dated 6/3/25, indicated on 5/31/25, at 5:50 p.m., P16 had physically barricaded herself and 2 other patients in the dining room. At 5:55 p.m. P18 entered the units dining room and walked directly towards P16 who had been seated at a table. P18 grabbed P16 by her hair with both hands and brought P16 to the floor. P18 struck P16 in the head 3-5 times before being pushed back against the wall. P16 was moved to onto the BICU for safety. P16’s medical record was reviewed. P16 was admitted to the mental health unit (MHU) from the hospital’s emergency department on 5/23/25. P16’s diagnosis included suicidal ideation, schizoaffective disorder, and antisocial personality disorder. Care/treatment plan included risk of violence towards self/other, and cognitive perceptual pattern impaired. P16’s behaviorally anchored rating scale (BARS) assessment dated 5/23/25, indicated P16 scored a four, indicating quiet and awake and was determined to be a low-risk violence. The assessment also indicated to consider assault precautions and aggression prevention protocol. Assault precautions were initiated, however P16 remained on routine (15 min) safety checks. A nursing note dated 5/25/25, at 11:02 p.m. indicated P16 was seen in the dining room in a headlock by a peer. Staff guided peer away from patient, but peer attempted to go towards patient again, grabbing and attempting to punch patient. Staff guided patient to her room. Patient states that the attack was unprovoked and has no idea why she was attacked by her peer. Per spell out (BHT) report, patient and peer were arguing over the remote, and patient stated, “beat me up”. Patient was bitten by peer; had laceration on right side of forehead. Wound was cleaned and image was uploaded to patient chart. No changes were made to P16’s observation level and or interventions. P16 remained on routine (15 min) safety checks. P16’s provider note dated 5/27/25, at 5:46 p.m. at 7:35 p.m. indicated there were concerns known for violence towards others, including violence in a healthcare setting. P16 remained on routine (15 min) safety checks. P16’s nursing note dated 5/28/25, at 3:05 p.m. indicated P16 walking very close to other patients and making comments as she goes by. Patient stated, she is agitated. P16 remained on routine (15 min) safety checks. A nursing note dated 5/28/25, at 4:45 p.m. indicated P16 became agitated and began screaming in dining room. Security called for show of support. Intramuscular (IM) Zyprexa administered in left arm at 3:50 p.m. Patient was asked to remove the 10+ pens from her hair and pockets. She continued to scream but ultimately gave them up to staff. Paced around milieu uttering “you don’t want to f*ck with me” and screamed through the BICU doors to the other patients. Eventually returned to dining room to isolate with doors closed. Security remained on unit until 4:45 p.m. No changes made to P16’s care/treatment plan, P16 remained on routine (15 min) safety checks. A nursing note date 5/29/25, at 12:38 p.m. indicated P16 isolating to self, requiring intermittent reminders from staff to have appropriate physical boundaries with peers on the unit. Patient was overall redirectable. Patient remained free from violence this shift, occasionally yelling out to peers and staff from room. Remained on the adult mental health unit for further monitoring and stabilization. P16 remained on routine (15 min) safety checks. A nursing note date 5/29/25, at 5:10 p.m. indicated P16 walked past peer and raised middle finger at another patient, staff told patient that was not nice. P16 walked past peer again and flicked peer in the forehead, attempted to flick another peer and staff. P16 was told they were not allowed to touch peers. P16 slammed door, went into dining room, and shut dining room doors. P16 remained on routine (15 min) safety checks. A nursing note dated 5/29/25, at 5:24 p.m. indicated P16 walked past peers and flicked them off. P16 then went into the dining room and closed both doors. P16 remained on routine (15 min) safety checks. A nursing note dated 5/29/25, at 10:09 p.m. indicated P16 was flat and agitated. Occasionally yelling out, had poor boundaries with peers that required intermittent reminders from staff to have appropriate physical boundaries with peers on the unit. Patient took markers from another peer, was dismissive, and denied psych questions. Possibly responding to some internal stimuli. P16 remained on routine (15 min) safety checks. A nursing note dated 5/30/25, at 8:53 a.m. indicated P16 was observed yelling out with all interactions this AM. Pacing and slamming room door. No changes to P16’s observation level or care plan made. P16 remained on routine (15 min) safety checks. A nursing note dated 5/31/25, at 7:47 p.m. indicated P16 barricaded herself and another patient in the dining room. Later, P16 ate dinner at dining room table. Patient was on the floor on her back after another patient pulled her hair and punched her in the face. The two patients were separated, removing P16 from the room. P16 went to her room, vitals were taken, a small bump to left outer eyebrow was present. Police department contacted and she was interviewed. Security present for show of support. Patient escorted back to BICU with security present. P16 took her personal belongings and went back to the BICU without difficulty. P18’s medical record was reviewed. P18 was admitted to the MHU from the hospitals Empath (Emergency Psychiatric Assessment, Treatment and Healing) unit on 5/20/25. P18’s diagnosis included history of schizoaffective disorder, bipolar type, borderline personality disorder, and alcohol use disorder. P18’s care/treatment plan included risk of violence towards self/other, and cognitive perceptual pattern impaired. A nursing note dated 5/24/25, at 9:59 p.m. indicated P18 stated she was hearing voices that are threatening to harm her, was feeling anxious and afraid. She did not want to be in her room alone. P18 remained on routine (15 min) safety checks. A nursing note dated 5/25/24, at 9:47 p.m. indicated at 7:43 p.m. P18 was observed in the dining room getting up and putting peer in a headlock, trying to hit peer. Staff guided patient away from peer. Patient did not resist staff but attempted to go towards peer again and grabbed peer. Staff guided patient to her room. P18 remained on routine (15 min) safety checks. A provider note dated 5/26/25, at 7:56 a.m. indicated P18 physically assaulted a peer after getting into an argument about the TV remote. She put the peer in a headlock, attempted to punch her and bit her. She reported that she was experiencing auditory hallucinations that were “egging” her on. P18 remained on routine (15 min) safety checks. A provider note dated 5/27/25, at 4:03 p.m. indicated P18 had significant volatility and significant physical aggression with another patient over the weekend biting this patient on the head breaking the skin. This was over a fight over the remote control. Patient later told staff that she was having auditory hallucinations although this is somewhat unclear and there were concerns about this being behavioral and part of the patient’s personality style. P18 remained on routine (15 min) safety checks. A provider note dated 5/30/25, at 3:33 p.m. indicated P18 endorsed ongoing struggles with auditory hallucinations, particularly at night, reporting the voices “come out for me at night” and she has to “fight for [her] sanity.” She described the voices as severe last night, contributing to a disrupted sleep schedule. P18 remained on routine (15 min) safety checks. A nursing note dated 5/31/25 at 6:26 p.m. indicated P18 abruptly went into the dining room and pulled the hair of another peer. While pulling the peers hair she brought her to the ground. Once on the ground she started punching her in the face/head approximately four to five times. At this time, another peer intervened and pushed and pulled her off the other peer. P18 said when she saw this peer it was an “impulse.” She said she grabbed her hair and felt like she “blacked out.” P18’s BARS assessment dated 5/31/25, indicated P18 scored a seven-meaning violent, requires restraint. The assessment also indicated high aggression risk and were to consider assault precautions and aggression prevention protocol. Assault precautions were initiated, however P18 remained on routine (15 min) safety checks. A provider note dated 6/1/25, at 11:01 p.m. indicated P18 was involved in a physical altercation yesterday after another patient accused her of stealing a notebook. She acknowledged they fought in the past but believed the issue resolved. When the accusation was made again, she became upset and responded by pulling the other patient’s ponytail and punching her in the face. She denied any command auditory hallucinations directing her to act violently and expressed remorse for the incident afterward. During an interview on 6/3/25 at 1:12 p.m., Registered (RN)-A stated there had been two sperate incidents of physical aggression/assault involving P16 and P18 on the inpatient Mental Health Unit. He had not reviewed video footage of either incident until 6/3/25. Both incidents occurred in the dining room, with no staff present. Video review of the incident revealed P18 approached P16 while she was seated at the table and began striking P16 multiple times in the face and head as well as pulling P16’s hair. P18 bit P16 on the right forehead causing a laceration. RN-A stated after the incident occurred on 5/25/25, no changes to either P16 or P18’s observation level had been made and they both remained on the same unit with routine 15 min safety checks. RN-A stated on 5/31/25, P16 had barricaded herself and two other patients in the dining room prior to the assault incident between P18 and P16. No staff was in the dining room while P16 barricaded herself and two other patients in the dining room. The assault on 5/31/25, involving P18 and P16 was very rough and physically aggressive. The video had revealed P18 entered the unit dining room and walked directly towards P16 who had been seated at a table. P18 grabbed P16 by her hair with both hands and threw P16 to the floor. P18 violently struck P16 with both her fists striking her head and face at least 5 times before staff pulled P18 off P16 who was lying on the floor during the entire physical attack. No staff was present in the dining room at the initial time of the attack. RN-A stated after P18 had physically assaulted P16, P16 was moved onto the BICU. P18’s treatment /care plan upon admission identified patient care area concerns, which included behavior altered, ineffective coping, and violence/self/others. During an interview on 6/4/25, at 1:35 p.m. RN-F stated if there was an incident of patient-to-patient physical aggression assault we would want to separate and obtain and order for a sitter for 1:1 observation. If able to only get one staff for the 1:1 the aggressor is the one who would be assigned a sitter for that patient and or removed from the unit and placed on the BICU. It was important to separate and increase the observation level to prevent further altercations not only for that patient’s safety if they are being targeted, but also for the other patients on the unit. After the initial incident which occurred between P18 and P16 on 5/25/25, no changes to either patients’ observation level were put in place for patients’ safety. During an interview on 6/4/25, at 2:18 p.m. RN-A stated the first incident of patient-to-patient aggression between P16 and P18 had occurred on 5/25/25, at 7:43 a.m. however it was not reported to the state agency until 5/28/25, at 6:20 p.m. RN-A stated the second incident of patient-to-patient aggression between P16 and P18 had occurred on 5/31/25, at 5:55 p.m. however it was not reported to the state agency until 6/2/25, at 10:00 a.m. RN-A stated anyone of the staff are able to file the required repot and education for all staff was needed to ensure the hospital met the timelines and guideline for reporting. Hospital Inpatient Mental Health Units Patient Outcome Standards policy dated 10/2024, indicated patients on the MHU can expect the following outcomes, to remain physically and emotionally safe, behavioral complications to be monitored and intervention provided as indicated, to remain physically and emotionally safe. Hospitals MHUs Safety and Security policy dated 3/2024, indicated the purpose of the policy is to ensure a safe, secure environment for all patients and staff. Patients who are in imminent danger to themselves or others will be protected by appropriate interventions. Hospital’s Vulnerable Adult (VA) Maltreatment policy dated 2/2025 indicated caregiver neglect means the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, healthcare or supervision which is reasonable and necessary to obtain or maintain the vulnerable adults’ s physical or mental health or safety. Hospitals Rights and Responsibilities of Patients policy dated 11/2022, indicated patients shall be free from maltreatment as defined in the Vulnerable Adult Protection Act. “Maltreatment” means conduct described in Section 626 .5572, Subdivision 15, or the intentional and nontherapeutic infliction of physical pain or injury, or any persistent course of conduct intended to produce mental or emotional distress. The immediate jeopardy that began on 5/25/25, was removed on 6/3/25/25, when it was verified by interview, and document review the facility completed review of the Behavioral Health Person to Person Assault Procedure policy which included clarity on roles of the team for aggressor and assaulted persons, and decision making for team on behavioral management & safety of all patients. Hospitals MHUs - Safety & Security policy document review was completed, and changes included a Pathway which determines if immediate action is required, continually assess with care team, and if warranted, implement 5-minute safety round or inline of sight monitoring. Practice changes also included Vulnerable Adult (VA) & Child Maltreatment reports of abuse need to be filed immediately following the event or within 24 hours. Staff presence is required in the dining room when patients are present to observe, listen and monitor interactions. Staff to intervene and communicate to care team when boundary issues are present. Immediately following a patient-to-patient assault, nursing staff to consider location change, increased patient monitoring, close observation/sitter, or BICU placement If implementing 5-minute safety rounds - place a notify nursing order prior to initiating this increased level of observation.”