St Lukes Hospital

“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 licensed provider restraint order for 2 of 4 patients (P1, P7) prior to, or immediately after, the initiation of a physical/manual hold restraint. Findings include: P1’s electronic medical record (EMR) indicated P1 admitted on 10/01/25 to the behavioral health unit with a diagnosis of psychosis. P1’s nursing note indicated on 10/7/25 at 2:40 a.m. R1 was screaming, kicking, hitting a window, swearing and threatening staff. An oral medication was offered, but R1 refused. R1 yelled “Don’t you give me medication. Don’t f****** touch me.” Oral medication was again offered and refused. Security held P1’s arms while the nurse administered an intramuscular (IM) injection because R1 was going to “swing at” the nurse. P1’s security event note on 10/7/25 at 2:30 a.m. indicated security officers held P1 while a nurse administered an IM medication. P1’s violent restraint/Seclusion order set form indicated an initial order was obtained on 10/7/25 at 2:40 a.m., but did not indicate the type of intervention. P1’s provider face to face note dated 10/7/25 at 2:40 a.m., indicated the type of intervention was chemical. The face to face did not indicate a physical hold was utilized. P1’s violent restraint order was entered into the EMR on 10/7/25 at 3:26 a.m. for IM Haldol chemical restraint only. The EMR did not indicate an order for a physical hold. A security event note on 10/15/25 at 11:45 p.m., indicated security officers held P1’s arms while a nurse administered an IM medication. R1’s EMR did not contain a provider face-to-face note for the physical restraint event on 10/15/25 at 11:45 p.m. P1’s violent restraint/seclusion order set form indicated an initial order was obtained on 10/15/25 at 11:50 p.m. and the provider face-to -face was completed at 1:10 a.m., but did not indicate the intervention utilized that necessitated the order and face to face. P1’s violent restraint order was entered into the EMR on 10/16/25 at 12:32 a.m. for chemical restraint. The EMR did not indicate an order for a physical hold. P1’s nursing note dated 10/16/25 at 6:38 a.m., indicated R1 had been yelling and threatening staff safety. Security was called as R1 was not de-escalating. An IM medication was administered to P1 with the help/presence of security. After the injection, P1 agreed to walk to a less stimulating environment. P7’s EMR indicated P7 admitted to the behavioral health unit on 10/20/25 with a diagnosis of suicidal ideation. P7’s nursing note indicated on 11/9/25, P7 aggressively pushed into the nurse’s station requiring staff to assist in removing her. P7 was verbally and physically aggressive and not redirectable with verbal de-escalation, PRN use and decreased stimulation. A Disruptive Person code was called. P7 continued to yell threats and posture towards staff. P7 aggressively resisted while escorted by staff into the seclusion room. P7 was placed into the restraint chair at 4:15 p.m. P7 had a small laceration to her lip that occurred during the restraint episode. P7’s security event note dated 11/9/25, indicated at 4:02 p.m. security responded to the behavioral health unit. Security attempted to walk P7 to the seclusion room, but P7 stopped in the hallway and refused to go any further. Security utilized a resistive escort hold to walk P7 to the seclusion room. Once in the seclusion room, P7 began to fight and was taken to the ground by security and restrained there until she was placed in the restraint chair. P7 cut or bit her lip during the event. P7’s provider face to face note dated 11/9/25 at 4:20 p.m. indicated the type of intervention was physical, chemical, and seclusion. P7’s violent restraint order was entered into the EMR on 11/9/25 at 4:28 p.m. for seclusion. The EMR did not indicate an order for a physical hold nor for the restraint chair. P7’s nursing note indicated on 11/9/25, P7 was hitting the door to the nurse’s station, yelling, and threatening staff. De-escalation was unsuccessful. A disruptive person code was called at 7:45 p.m. and P7 was escorted to seclusion by security. P7’s security event note dated 11/9/25 indicated security responded to the behavioral health unit at 7:42 p.m. Security took control of P7’s left arm, a nurse took the right arm and P7 was escorted to seclusion with slight resistance. P7’s violent restraint order was entered into the EMR on 11/9/25 at 7:55 p.m. for seclusion. The EMR did not indicate an order for a physical hold. The provider face-to-face note dated 11/9/25 at 8:09 p.m. indicated type of intervention was seclusion. During an interview on 11/21/25 at 10:47 a.m., registered nurse (RN)-A stated a physical hold for IM medication administration, seclusion, restraint chair, and a chemical restraint all need a provider. An escort hold with a staff person on each arm to assist an unwilling patient to seclusion was not considered a restraint and did not need a provider order. During an interview on 11/24/25 at 1:18 p.m., RN-B stated a restraint was anything that impairs a patient’s ability to freely use their body and included a chemical restraint, restraint chair, seclusion, 4-point restraints, holding a patient for medication administration, and going “hands on” to walk a patient to the seclusion room. A separate provider order was required for each restraint type before the restraint was utilized or as soon as possible after the restraint event. All provider orders needed to be entered into the EMR as soon as possible after the order was received. When entering an order into the computer, each type of restraint was entered into the notes section of the order. During an interview on 11/21/25 at 11:45 a.m., advance practice registered nurse (APRN) stated a hold for medication administration, locked seclusion, the restraint chair, and a chemical restraint are all considered restraints would need a provider order. If a patient’s arms are held to assist them into seclusion, a provider order is needed only for the locked seclusion. During an interview on 11/24/25 at 12:52 p.m., RN-C stated a restraint was any time a patient was physically or chemically prevented from doing something and included the restraint chair, restraint straps on a bed, physically holding a patient down, physically holding a patient for forced medication administration, and locked seclusion. Each restraint type used in an event needed a separate provider order. RN-C would need to look in the restraint policy or ask another nurse if an order was needed to physically hold a patient’s arms to walk them to seclusion. During an interview on 11/24/25 at 1:47 p.m., RN nurse manager (RN-NM) stated a restraint was any time a patient was held or restrained against their will and included the restraint chair, locked seclusion room, physically holding a patient for medication administration, bed restraints and chemical restraints. Each restraint type used in an event needed a separate provider order. However, if multiple restraints were utilized in a single event (for example the restraint chair was used in locked seclusion) then one order would be entered into the computer and each restraint ordered would be documented in the notes section of the order. After review of P1’s restraint event on 10/7/25, RN-NM stated a provider order was not needed for the hold to escort P1 to the seclusion room. A provider order was not needed for a physical escort if staff were escorting a patient to a restraint/seclusion. For example, if staff had physically escorted a patient to locked seclusion, then a provider order was needed only for the locked seclusion. If security took a patient to the floor, then placed the patient in the restraint chair, an order was needed for the restraint chair only. How staff got the patient to the restraint was part of the restraint process and did not need a separate provider order. During an interview on 11/25/25 at 10:14 a.m., Doctor of Osteopathic Medicine (DO) (a fully licensed physician who uses a whole-person approach to healthcare) stated a restraint was when a patient’s ability to move about freely was limited by staff and included locked seclusion, chemical restraint, restraint chair, when staff need to have hands on a patient to physically move an unwilling patient into the seclusion room and when staff needed to hold a patient for medication administration. A provider order was needed for each type of restraint utilized in an event. A provider order was needed if staff needed to go hands on to physically hold a patient for an IM medication administration and/or to move a patient who was not willing to move voluntarily into the seclusion room. Anything the patient is not doing willingly is a restraint. After review of P7’s restraint event on 11/9/25 4:02 p.m., DO confirmed a provider order for a physical hold and the restraint chair should have been obtained but the orders were not in R7’s EMR. The Restraints policy dated 9/2025 defined a physical restraint as any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move their arms, legs, body, or head freely. Examples of physical restraints included but not limited to four-way locking chair and physical hold. A provider order needs to be obtained prior to or as soon as possible after application of a restraint. If a physical hold was required to administer a forced medication, a separate order for a physical hold was required in addition to the medication order. The policy does not address the use of a physical hold to escort a patient to seclusion.”

“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 observation, interview, and document review, the hospital failed to ensure staff implemented policies and procedures in a timely manner to provide immediate protection from potential abuse for 1 of 10 patients (P1) reviewed. P1 reported being sexually assaulted by a member of the medical staff and this allegation was not reported to the proper leadership channels timely to determine what, if any, actions needed to be done to ensure P1 and other patients’ safety from the alleged perpetrator (AP) resulting in the AP having unsupervised access to other patients within the hospital campus for a period of time. Findings include: A received Vulnerable Adult Maltreatment Report, dated 11/11/25 at 5:04 p.m., identified the hospital reported an allegation which read, “VA [vulnerable adult; P1] claims AP touched both of VA’s breasts and VA’s crotch.” The report listed a date of incident as 11/11/25, however, did not list a time of the incident. The section labeled, “F. Allegations,” identified P1 had alleged sexual abuse and listed nurse practitioner (NP)-A as the AP. On 11/14/25 at 10:52 a.m., the hospital “Inpatient Behavioral Health” unit was toured with the registered nurse manager (RN)-A present. The unit consisted of a central nursing station with hallways off each side leading to patient rooms, conference rooms, and staff meeting areas (i.e., exam rooms). The unit had a capacity of 23 beds with patients having mental health diagnoses including schizophrenia, suicidal ideation, and bipolar disorder being common per RN-A. A sample of other patients was interviewed at this time and none expressed concerns about abuse or being mistreated by staff or medical providers. Further, the hallways of the unit had visible camera systems installed. P1’s Clinical Note, dated 11/3/25, identified P1 admitted to the unit with a diagnosis of psychosis. P1’s Clinical Note, dated 11/9/25, identified P1 had been asking repeatedly for water and was found to have filled up her trash can with water and food items. P1 was told this was unsafe and responded, “I’m a healer, I know what I’m doing.” The note recorded P1 as being disorganized and unable to follow instructions. P1’s Progress Note, dated 11/11/25 at 3:36 p.m., was authored by NP-A and outlined P1 was seen. NP-A recorded, “She informed me that she believes I am a pervert and wants another provider ... [P1] spoke over me with a loud voice and repeatedly stated, ‘The God of Abraham hates you,’ She then left the assessment room ... later approached me with a Bible and asked, ‘Does this scare you.” NP-A then made medication adjustments. P1’s corresponding Clinical Note, dated 11/11/25 at 4:16 p.m., identified P1 was pacing the hallways during the shift hours and looking into the cameras. P1 was provided as-needed (PRN) medication at 4:15 p.m., and the note outlined, “[P1] was making accusations that staff sexually assaulted her reporting that they grabbed her breast and vagina ... Writer and Charge Nurse talked w/ [P1] and had her go to her room. [P1] was yelling on the way top [sic] her room that staff was a sexual predator. Charge Nurse followed policy and procedure regarding allegations.” An additional Clinical Note, dated 11/11/25, was authored by RN-D and outlined P1 had been increasingly agitated throughout the shift and yelling she had been “ ... touched on her breast and crotch” by staff. The note identified, “Policy and procedure followed.” P1’s Clinical Note, dated 11/13/25, identified P1 reported having anxiety and depression while appearing preoccupied and disorganized. P1 was provided her medications and the note recorded P1 as voicing, “ ... she does not want to see ‘that sick sexual predator,’ insinuating [NP-A] seeing her.” However, all the completed note(s) lacked any information on what, if any, actions were taken with NP-A despite being accused of potential sexual abuse. When interviewed on 11/14/25 at 11:08 a.m., RN-B explained they had worked at the hospital for several years and were often the charge nurse assigned to P1’s unit. RN-B stated the hospital provided staff education on abuse reporting annually, and if a patient reported an allegation of abuse, then they would contact the medical provider and social worker (SW) with the information. If the allegation happened after-hours, then they would contact the “house supervisor” and seek input from them. RN-B stated if an allegation was made with another staff members as the AP, then they would suggest to the AP that they “not have any contact with this person [patient who accused].” RN-B stated they had never been involved with a situation where a staff member needed to be supervised due to allegations against them adding, “I never came across that.” RN-B stated they could not recall any training or direction on how to handle the AP following an accusation of abuse adding, “What we do with that staff is not a training, if that makes sense.” RN-B stated they had heard about P1 accusing NP-A of abuse just that morning while in report and expressed they had never seen or suspected NP-A of inappropriate behavior with a patient prior. RN-B stated nobody had been directed or told to monitor NP-A thus far, either, but expressed staff had started doing two people with all interactions due to the allegation. On 11/14/25 at 11:25 a.m., P1 was observed on the unit in a special area by herself watching television with a blanket pulled over half of her face. P1 stated the hospital was “really [explicative] up” and voiced frustration about having to be there due to an involuntary commitment order. P1 made several allegations about her care including that she had been “sexually attacked” by NP-A when they (NP) grabbed her breasts and crotch area without warning or permission. P1 stated this happened in the examination room and staff, at least to her knowledge, had “done nothing” so far about it and NP-A continued to work on the unit. P1 voiced the situation was upsetting adding aloud, “I don’t wanna have to see a sexual predator!” P1 stated after she reported the incident that two nurses, including RN-C, had interviewed her about it but added, “It’s hard to remember sometimes.” Following, on 11/14/25 at 11:39 a.m., P1’s medical record was reviewed with RN-A and the chief nursing officer (CNO) present. RN-A explained P1 admitted to the hospital on 10/31/25 through the emergency department (ED) with a Jarvis in place and transferred to the inpatient unit on 11/3/25. RN-A stated P1 had a history of making false accusations in previous documentation from other hospitalizations and past jailings. RN-A acknowledged the time when NP-A entered the first note about the incident (3:36 p.m.) and explained they had just learned of the accusations the day prior (11/13) when they came into work after being off. CNO explained a “safety zone” report and the MAARC had been filed or started on 11/11/25 to their understanding. CNO explained another supervisor, RN-C, helped to spearhead the situation since some of the upper management staff were offsite those days for various reasons. It was RN-C who then determined the allegations needed to be reviewed and initiated the human resources (HR) contact since the allegation was against a provider. CNO verified that, at least to their understanding of the situation, that leadership was “not made aware” of the incident on 11/11/25 adding “[their] assumption is he [NP-A] was still allowed to work” after the allegation was made due to the overlap of time. RN-A and CNO both acknowledged that staff should have reported the incident to the house supervisor who then would be responsible to ensure the AP was not left with seeing patients, either P1 or others, without immediate supervision. At 12:04 p.m., RN-C joined the interview. RN-C explained they first learned of the allegation on 11/12/25 at “like 9:30 [a.m.]” when another staff had asked about it. RN-C stated it was reported to them that P1 alleged a provider had “inappropriately grabber her.” RN-C stated that a meeting was then held with several roles present and notification to HR was done as they make the decision on how to handle the AP when it is a medical provider. RN-C stated they expected staff to “immediately notify their supervisor” with allegations like that, and expressed the supervisor for that evening was RN-E. RN-C stated they followed up with RN-E since the allegation was voiced, and RN-E had reported to them that he was not aware of the allegation on 11/11/25 adding, “His answer was no.” RN-C stated aloud, “There was clearly a breakdown in the process.” RN-A stated that upon checking his emails, RN-D had notified him on 11/11/25 at 5:01 p.m., however, the message was not received since RN-A was offsite on leave. RN-A and RN-C both verified the allegation and situation surrounding it were still being investigated at the time of survey. Following this interview, at 12:29 p.m., RN-C approached the surveyor and expressed they had some additional communication with RN-E about the incident. RN-C stated that RN-E recalled the unit contacting them on 11/11/25 in the evening hours but had merely expressed there was “a patient issue” and RN-E did not “understand the severity of the situation” due to staff reporting it being “kinda vague” with details. On 11/14/25 at 12:37 p.m., RN-D was interviewed. RN-D recalled the incident involving P1 from 11/11/25, and explained P1 had reported to the social worker that NP-A had “touched her breast and vaginal area.” P1 then reported the same allegation to them (nursing) so they completed a MAARC (Minnesota Abuse Report) and notified RN-A via e-mail. RN-D stated a “safety zone” was then started, too. RN-D recalled this happening “between 4 and 4:30 [p.m.]” on 11/11/25. RN-D stated they contacted RN-E who was the house supervisor with the information P1 had been “making allegations against a provider” but expressed they did not recall what exact verbiage was reported to RN-E. RN-D stated RN-E then directed them to do a MAARC report and start the “safety zone” report which they did. RN-D stated they had “never been a part of that scenario” prior and were unsure how or what actions needed to happen to the AP in that case. Further, RN-D stated RN-E gave them no verbal instructions or directions on how to address NP-A since they were the identified AP (i.e., supervision, removed from care) adding, “No, not that I can recall.” When interviewed on 11/14/25 at 12:51 p.m., RN-E recalled working on 11/11/25 as the house supervisor. RN-E stated that role, as supervisor, had a “main focus” of ensuring staffing levels were met and helping to be an “initial point of contact” for nurses with questions or help. RN-E explained they had received a call from RN-D on 11/11/25 around “5 or 6 p.m.” where RN-D reported an allegation against the provider but added, “I don’t remember her exact words [used].” RN-E stated they directed RN-D to “follow the process” then adding the whole event had been “kinda weird to me” due to a compliance person calling them the next morning saying we should have contacted them first instead of doing a MAARC report. RN-E stated that did not seem right to their understanding. RN-E explained they had directed RN-D to ensure the AP was “not ever alone” with P1 again, too. RN-E stated they were unsure what else they could do with the AP adding, “I didn’t think I had the power [to suspend them from campus].” RN-E verified they did not contact HR with the allegation and explained the idea to supervise the AP had not been taught to them by the hospital but rather it was just something they had seen done “throughout my career.” Further, RN-E verified they did not speak with NP-A about the incident on 11/11/25. On 11/14/25 at 1:27 p.m., the camera footage from the hallway outside the examination room was viewed with quality management partner (QMP)-A present. The footage identified the following: - 2:33:06 p.m., various patients are seen walking the hallway. P1 was not immediately visible in this shot. - 2:34:06 p.m., NP-A leaves the examination room with another patient. NP-A and P1 walk into the examination room a few moments later and the door is closed. P1 walked in the room under her own power. - 2:39:10 p.m., the examination room door opens. P1 walks out of the room and is drinking a beverage in her hand. P1 turned down the hallway and walked into her room. NP-A left the examination room a few moments later and walked the same direction towards P1’s room. P1 then walked back into the hallway from her room holding up a dark-colored object (i.e., Bible) in her hands at NP-A. No physical contact between them was observed. When interviewed on 11/14/25 at 1:37 p.m., NP-A recalled the allegation from 11/11/25, and he explained P1 met with him in the examination room and was upset about not being discharged to an IRTF program. P1 alleged staff were “targeting her” and that she “didn’t believe me” with information about her condition she was being told so she stood up and told me, “The God of Abraham hate you.” NP-A verified there was no camera installed in the examination rooms, and he explained P1 never accused him of sexually assaulting her during that examination but rather afterwards. NP-A stated being accused of that by a patient was “a difficult situation” but not uncommon, either. NP-A denied ever physically touching P1 while in the examination room and expressed they would no longer meet with P1 alone due to the allegation. NP-A verified following the interaction with P1 on 11/11/25, they did see other patients without supervision present adding they had worked “throughout the hospital.” NP-A stated nobody, either RN-E or from HR, had contacted him about the allegation on 11/11/25. NP-A stated the following day, on 11/12/25, some from “compliance” contacted him about the event, however, reiterated there was no supervision implemented for all the other patients seen aside from P1. Further, NP-A stated they had “not specifically” been provided education on whom to report an allegation of abuse to and explained they would “not necessarily” report such an allegation to compliance or leadership unless they could determine if the allegation was not illness or behavioral-related. The unit would make that decision’ interdisciplinary team (IDT) at the following morning’ meeting. On 11/14/25 at 2:29 p.m., the CNO, RN-A, and chief compliance officer (CCO) were interviewed. CCO explained when an allegation is made, then a group of people assembles to determine what, if any, action towards the AP would be such as suspension or supervision adding that happened “typically when we’re put on noticed [notified].” COO stated notification of the allegation to their team happens “a number of ways” including a “safety zone” being done or telephone notification. COO verified if an allegation is made after-hours, then the house supervisor would be the resource to address it in the immediate timeframe. At 2:38 p.m., senior compliance specialist (SCS) joined the interview. They explained staff are told to report allegations of abuse “immediately” to their department so a review of it can begin. SCS stated that in “this situation [P1]” the house supervisor was notified, however, the “other leadership” who needed to be was not adding there “was a delay.” SCS verified if their office had been notified of the allegation on 11/11/25, including in the later afternoon hours, it would have been addressed that day and a decision about immediate protection needs would have been made then. CNO stated it was important to ensure these items were handled quickly and appropriately as “we want to make sure the patient, and other patients potentially, are protected.” Further, the SCS verified the allegation, and its surrounding circumstances were still being investigated by the hospital. A provided Enrollments & Completions listing, dated 11/17/25, identified RN-D, RN-E, and NP-A, had all completed and passed the required mandated reporter training within the past 8 months. The hospital Reporting and Investigating Caregiver Misconduct policy, dated 7/2025, identified several definitions which included, “Misconduct [bolded] means abuse or neglect of a patient ...” The policy outlined a process which included, “ 1. Immediately upon learning of any allegations ... staff must take the necessary steps to protect all patients from possible subsequent incidents of mistreatment or injury by taking the following steps,” and a sub-headed direction, “A. Take steps necessary to ensure the safety of patients. Notify your immediate leader, using the chain of command. Leader is to immediately reach out to HR to consult regarding investigative leave for the accused employee from patient contact or responsibility.” The policy continued and outlined after those actions are completed, then the supervising authority should then notify risk management or the compliance team to receive direction on the next steps.”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 40945 Based on interview and document review, the facility failed to maintain an accurate and complete medical record for 1 of 30 patient records (P1) reviewed for medical records content. Findings include: P1’s medical records indicated P1 arrived at the emergency department (ED) on 7/30/25 at 11:52 a.m., via ambulance from a local health care crisis facility for complaints of suicidal ideation. P1 was assessed and determined to be medically stable, placed on a 72 hour hold and transferred to the adult mental health unit for further monitoring and treatment of suicidal ideation. A provider note dated 7/30/25 at 12:34 p.m., indicated P1 currently lacks capacity in her own decision making and her health care directive (HCD) is to be activated. The plan is to communicate with her brother about the need for activated HCD as he is the assigned decision maker, power of attorney (POA). On 9/4/25 at 12:58 p.m., health information management manager (HIMM)-A stated in an interview HIM did not have any information which reflects P1’s HCD has been activated. P1’s POA has made multiple requests for copies of P1’s medical record, however because P1’s medical record did not indicate an activation of the HCD no medical records have been provided to POA. On 9/4/25 at 1:19 p.m., social worker (SW)-A stated in an interview the provider had activated P1’s health care directive on 7/30/25. The process is when a medical provider activity a patients HCD, it is the case manager and or SW’s responsibility to ensure this information is sent to the health information management (HIM) department. This is important to ensure a patient’s medical record reflects accurate information. On 7/30/25, HIM was not informed of the change to P1’s HCD. Because of this failure, P1’s POA has not been provided P1’s medical record despite POA’s multiple requests. On 9/4/25 at 2:01 p.m., care coordinator manager (CCM)-A stated in an interview HIM should have received the information related to P1’s HCD being active on 7/30/25, however this was not completed. Because of this failure, P1’s medical record still reflected an inactive HCD, causing P1’s POA multiple requests for medical records not being honored. She can understand why P1’s POA is frustrated. There are currently ongoing issues with the facilities current process for managing changes in-patient decision-making capacity. The facility policy Documentation in Patient’s Medical Record policy - Use and Disclosure of PHI With Authorization policy reviewed 9/2014, directed every patient that is registered has a medical record that includes identification data and clinically pertinent information appropriate to the type of encounter. The information accurately reflects the services provided. Medical records are legal documents are used for a variety of purposes. To ensure legal and clinical integrity, charting must be accurate, complete, and legible.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47264 Based on observation, interview, and document review, the facility failed to ensure freedom from restraints for one of ten patients (P1) reviewed for use of restraints when P1 who was not on a peace officer hold or an emergency 72-hour hold, was barred from exiting the emergency department (ED) through verbal direction, physical positioning, and use of restraints. 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 A0154. See A0154 for additonal information. A standard level deficiencies was issued at A0168.”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 47264 Based on observation, interview, and document review, the facility failed to ensure freedom from restraints for one of ten patients (P1) reviewed for use of restraints when P1 who was not on a peace officer hold or an emergency 72-hour hold, was barred from exiting the emergency department (ED) through verbal direction, physical positioning, and use of restraints. Findings include: During an observation on 7/21/25 at 12:45 p.m., footage of the ED hallway on 7/7/25 at 6:19 p.m. was reviewed with the security manager. In the footage, P1 was seen exiting ED room 5 and walking around the nursing station. Family member (FM)-A and FM-B exited ED room 5 and walked after P1. Registered nurse (RN)-A and other staff members in the nurses station immediately began to follow P1. P1, FM-A and FM-B exited the frame. Shortly afterwards, P1 returned and walked towards ED room 5, followed by RN-A, security guard (SG)-A and SG-B, FM-A and FM-B. P1 then quickly walked past ED room 5, down another hallway, and out of frame. SG-A responded by running behind the nursing station as RN-A and SG-B followed P1. At 6:22 p.m., P1, FM-A, and FM-B returned to ED room. SG-A and SG-B stayed in the hallway. RN-A entered ED room 5, with nursing assistant (NAR)-A and began removing supplies from the room. As supplies were removed, SG-C arrived and spoke with SG-A and SG-B in the hallway. RN-A left ED room 5, then returned with a folded set of teal scrubs as NAR-A left the room. After a few moments, SG-A, SG-B and SG-C walked into ED room 5. The privacy curtain in ED room 5 moved erratically and FM-B exited the room to stand in the doorway. NAR-A reentered room 5. FM-A left ED room 5 and stood in the hallway with FM-B. More nursing staff ran into ED room 5, one of which was holding a green bag. FM-A and FM-B reentered the room but exited with NAR-A shortly afterwards to stand in the hallway. Room 5’s privacy curtain was then drawn. FM-A and FM-B reentered the room, and SG-D arrived. Shortly afterwards, FM-A left the room with an unknown nursing staff and SG-D. At approximately 6:28 p.m., multiple nursing staff and security staff exited the room and were discussing in the hallway. Medical doctor (MD)-A entered the hallway and was seen speaking with RN-A and security staff. MD-A then entered the room for a few minutes before going back to RN-A. At 6:45 p.m., RN-A and multiple staff reentered ED room 5. P1 was a 39-year-old male who presented to the ED on 7/7/25 at 5:49 p.m. via private car for suicidal ideation. A triage note dated 7/7/25 at 5:59 p.m. indicated P1 had presented from the local jail with suicidal thoughts for several years. The triage note indicated P1 was accompanied by FM-A and FM-B. P1’s suicide screening dated 7/7/25 at 6:02 p.m. indicated P1 was a high risk for suicide, and a provider was notified. P1 was roomed in ED room 5 at 6:03 p.m. A nursing note dated 7/7/25 at 7:04 p.m. indicated at 6:30 p.m. P1 attempted to elope from the emergency department and was brought back to his room. P1 refused to change into provided hospital scrubs and began to elope. P1 then postured and pushed staff. The note indicated security was notified and assisted in placing P1 into restraints to keep himself and staff safe. At 6:45 p.m., P1 was removed from violent restraints per provider request. A care coordination note dated 7/7/25 at 7:04 p.m. indicated P1 was given information about local mental health resources. A provider note dated 7/7/25 at 9:39 p.m. indicated P1 was assessed by MD-A at 6:40 p.m. The note indicated P1 presented to the ED following release from jail with a bail condition to seek mental health services in the community due to P1’s suicidal statements. P1 attempted to elope from the ED due to long wait times and was successfully verbally redirected back to his room. P1 became physically aggressive with staff and was placed in four-point restraints. P1 had chronic thoughts of suicide but verbalized them in the setting of an acute life stressor of being in jail over the weekend. The note indicated P1 did not have a history of suicide attempts or previous psychiatric hospitalization. P1 did not have suicidal intent or a plan. The note indicated P1 was to be discharged home. There was no order submitted for placement of four-point restraints. P1 was discharged from the emergency room to the community on 7/7/25 at 7:05 p.m. During an interview on 7/21/25 at 9:43 a.m., RN-B restraints may only be used on patients if they are a danger to self or others. RN-B stated other methods must be attempted prior to resorting to restraints. If a patient screened as a high suicide risk, they would page the provider and have them assess the patient at the bedside. RN-B stated a provider must initiate a 72-hour hold; a nurse cannot initiate a 72-hour hold. If a patient is brought in by law enforcement, they are on a peace officer hold and cannot leave until a provider is able to assess if they are appropriate for a 72-hour hold. RN-B stated it is protocol to have all mental health patients change into hospital scrubs when they come to the emergency department. If a patient refuses to change, security staff are requested and will then use a hand-held metal detector to manually wand them as part of a security screening. During an interview on 7/7/25 at 10:06 a.m., RN-C stated if a patient is in the ED voluntarily and wants to leave, nursing staff should attempt to educate them on the risks of leaving, inform the provider, and attempt to have the patient sign against medical advice (AMA) paperwork. RN-C stated restraints can only be used on patients if they want to hurt themselves or others. RN-C stated a provider is the only staff who can place a patient on a 72-hour hold. It is their policy to change mental health patients into hospital scrubs. RN-C stated if a patient refuses to change, reeducate them on the policy and how it keeps patients and staff safe. If a patient refuses to change, document their refusal in the medical record and inform the rest of the healthcare team. RN-C stated they would then call security to come and complete a security screening with the metal-detecting wand. During an interview on 7/21/25 at 10:26 a.m., the emergency department (ED) clinical supervisor stated four-point restraints may only be used if there is a risk of harming the patient or others. Security had informed her P1 was placed into restraints because he had tried to leave the emergency department. If a non-suicidal patient wanted to leave against medical advice, the nursing staff must attempt to educate the patient on the risks of leaving prior to receiving appropriate medical care, but they cannot prevent the patient from leaving. If a patient screens as a high suicide risk, the patient is continuously monitored until a provider sees them. If the patient wanted to leave prior to a provider’s evaluating them, the nurse should activate their duress button to have a provider come to them immediately. The clinical supervisor stated in a scenario where a provider does not immediately come to them, the nurse should avoid going “hands on” with the patient but may if it prevents the patient from leaving. The clinical supervisor stated it is their practice to have all mental health patients change into hospital scrubs. If a patient refused to change into scrubs, the nurse should redirect and reeducate the patient to the goal of maintaining patient safety. If the patient continued to escalate, the nurse should activate their duress button to have a provider involved as soon as possible. If a provider is not available, the nursing staff cannot force the patient to change their clothes. The clinical supervisor stated she was aware of the incident involving P1 on 7/7/25 through a conversation with security. The clinical supervisor stated after P1 had attempted to elope, RN-A had requested he change into scrubs per the policy. P1 stood up suddenly and tried to walk away, prompting security staff to place him in a manual hold. During an interview on 7/21/25 at 12:38 p.m., FM-A stated he was in ED room 5 when RN-A tried to convince P1 to wear the hospital scrubs provided, he was sitting in a chair to the right of the bed and P1 was sitting in bed. They brought P1 into the ED because the jail provider had encouraged him to get set up with resources out in the community. FM-A stated when P1 tried to initially leave the ED, RN-A said P1 could not leave. Once they returned to the room, RN-A and NAR-A started removing supplies from the room. RN-A gave P1 a set of hospital scrubs and instructed him to change clothes. FM-A stated P1 refused and stated he just wanted to speak with a provider. FM-A stated RN-A then approached P1 who was sitting on the bed and said he would help P1 change into the scrubs and pressed his personal alarm button. Security ran in and grabbed P1 to him down to the bed. P1 reacted to staff touching him and began resisting against security staff. FM-A stated more nurses came in and they began to restrain P1. FM-A stated he was telling staff to stop and was then escorted out of the room by security. During an interview on 7/21/25 at 1:27 p.m., SG-C stated on 7/7/25 he was working at the hospital’s front entrance and heard the duress button activation and heard P1 was attempting to elope. He ran to the ED and saw RN-A, SG-A, and SG-B corral patient back to his room. He stopped and spoke to the charge nurse and asked if P1 was on a hold. SG-C stated he was told P1 was not on a hold, and that the provider needed to evaluate him to determine if he was holdable. SG-C asked for clarification and the charge nurse told him P1 was on a hold pending physician assessment. He then joined SG-A and SG-B in the hallway as RN-A tried to convince P1 to change into scrubs. He heard P1 tell RN-A “I am not changing and if you try to change me, someone is getting hurt.” SG-C stated he felt this was a threat and security entered the room. SG-C stated P1 sprung out of bed and at that point, RN-A said “No” and all three securities applied a manual hold to one of P1’s limbs. SG-C stated P1 twisted his thumb back causing extreme pain, and SG-C employed a pain control tactic by pressing on P1’s mandibular angle. SG-C stated once P1 released his thumb, he stopped applying pressure to the mandibular angle and continued applying the manual hold. Restraints were applied because P1 threatened to hurt RN-A if he forcibly changed him into scrubs. During an interview on 7/23/25 at 2:05 p.m., MD-A stated she assessed P1 after he was placed into restraints and told nursing staff to remove them. She was told by nursing staff P1 had been placed into restraints because he was trying to leave while on a “mental health hold.” MD-A stated because P1 was a high suicide risk, he was placed on a mental health hold by nursing and was not allowed to leave the ED until seen by a provider. P1 was in restraints because he was trying to leave the ED. MD-A stated P1 did not meet the criteria for a 72-hour hold because he was not as high of a risk as he screened. It is common for acute stressors to make patients say things they do not mean. If a patient screens as high risk for suicide, a provider is notified, and they are not allowed to leave the ED until assessed by a provider. During an interview on 7/23/25 at 2:29 p.m., SG-A stated P1 had been placed into restraints for posturing towards RN-A. SG-A stated P1 stood up, glared, and looked down at RN-A. SG-A stated he thought P1 was placed in restraints for a combination of aggression and attempting to leave the ED. SG-A stated once MD-A completed the assessment and let P1 leave without implementing a 72-hour hold, SG-A was confused why they had placed P1 in restraints at all. Nursing staff did not make it clear to security P1 was not on a hold. SG-A stated applying restraints were at the direction of licensed staff, but he thought the restraints were applied not just for P1’s aggressive behavior, but also to keep him from eloping. SG-A stated, “I don’t know why we put him in restraints if he wasn’t even on the hold.” “We should not have put P1 into restraints.” If a patient is not on a hold, staff cannot keep them in the ED. P1 initially attempted to elope, a staff member pressed their duress button, and he responded. Staff were able to get P1 back into him room and when RN-A asked P1 to put on the hospital scrubs, P1 stood up in a combative stance with one foot in front of the other. SG-A stated he looked to RN-A for direction, and RN-A stated “Alright, let’s put you into restraints.” SG-A stated from there he assisted with holding P1 to the bed and RN-A and other nursing staff applied four-point restraints. When the provider arrived and instructed staff to remove P1 from restraints, he was surprised. During an interview on 7/21/25 at 2:53 p.m., RN-A stated restraints can be used on patients if they are harming themselves or others, are exhibiting behaviors, and based off screenings for suicidal and homicidal ideations. RN-A stated when he attempted to have P1 change into scrubs, P1 stood up, postured, and started pushing staff. He did not remember how P1 postured. He did not remember how P1 pushed staff or who P1 pushed. RN-A stated he then had security and nursing staff place P1 in restraints for risk of suicide because P1 did not appear to be in the right state of mind. Nurses cannot place RN-A stated holds, there are only peace officer holds from police, and 72-hour holds from providers. If a patient who is a high suicide risk wants to leave, nursing staff should call security to help keep them in their room. If a patient still wants to leave, he is unsure what he would do. When P1 came to the ED on 7/7/25, P1 was placed in a room in front of the nursing station because of his high suicide risk, however it took much longer than it should have for a provider to assess him. P1 got up and tried to leave the ED, so he contacted security. Nursing and security staff were able to redirect P1 back to his room without physical contact. RN-A stated when they got back into the room, he asked P1 to change into a set of hospital scrubs. P1 thought he was going to be placed into a “slack jacket,” which they do not have available, so RN-A explained why they want mental health patients in scrubs and that is when the incident occurred leading to P1’s restraints. RN-A stated the provider eventually came and assessed P1, then instructed staff to remove the restraints. During an interview on 7/22/5 at 8:49 a.m., P1 stated he went to the ED on 7/7/25 to establish care with a provider as part of his bail conditions. P1 stated he went voluntarily and was accompanied by FM-A and FM-B. P1 stated he was depressed and did not want to live but had felt that way for a couple of years, did not have intent or a plan to kill himself. He waited in ED room 5 for approximately 30 minutes before he decided he wanted to leave. P1 stated he tried to leave, but RN-A stood in front of the door and told him the nursing staff could not let P1 leave. He turned around and walked past the room, trying to leave the emergency department, but more staff stood in front of him and prevented him from leaving. P1 stated he went back to his room and waited on his bed until RN-A told him he needed to change into scrubs. He refused as he was in the ED to establish care for his mental health. P1 stated RN-A said, “You’re going to put them on, or I’ll make you,” then pressed an alarm button. RN-A then grabbed his right arm and P1 tried to pull away. P1 stated security came into the room at the moment and all they saw was him struggling against RN-A and security came in and held him down. P1 stated he started resisting aggressively after RN-A and security grabbed him. P1 stated he was then placed into restraints. During an interview on 7/22/25 at 10:05 a.m., FM-B stated she was sitting in ED room 5 with P1 during the incident. FM-B stated she was with P1 during the entirety of the triage process. FM-B stated P1 endorsed suicidal thoughts, but did not have a plan or intent to commit suicide. They waited in a room in the ED for approximately 30 minutes before P1 tried to leave to go to a neighboring hospital for faster care. FM-B stated RN-A told them P1 could not leave the ED. When they returned to the ED room, P1 sat on the bed while RN-A tried to convince him to put on the hospital scrubs. RN-A grabbed P1’s arm and told him to put on the scrubs, then pressed the alarm button. Security came in immediately and saw P1 trying to get away from RN-A. FM-B stated staff held P1 down and put him in restraints. FM-B stated when the provider came to the room, they explained why they were there, and the provider told staff to remove P1’s restraints. During an interview on 7/22/25 at 10:45 a.m., NAR-A stated if a non-suicidal patient wanted to leave the ED, the nurse has them sign AMA paperwork prior to leaving. NAR-A stated she was outside the room watching through the glass when RN-A told P1 to change into scrubs and P1 refused. NAR-A stated RN-A told P1 if he did not change into scrubs, the staff would have to help him. NAR-A stated this made P1 agitated as he sat on the bed with his feet up and his arms crossed. RN-A then pressed his duress button and security entered and held P1 onto the bed. NAR-A stated nursing staff placed restraints on P1 because he was resisting against being held against the bed by security. NAR-A stated only a doctor can place a patient on an emergency 72-hour hold. If a patient on an emergency hold is trying to leave the hospital, she should call security and the police. She helped RN-A take the supplies out of P1’s room because he was a high suicide risk patient. During an interview on 7/22/25 at 111:41 a.m., the manager of the ED stated the expectation for any patient who presents to the ED to wear the hospital gown or scrubs as appropriate. An additional security screening with a metal detecting wand occurs for any patient who screens for a high risk of suicide of violence, and or at the request of nursing staff. If a patient refused to change out of their clothes, staff should educate patient on the safety concerns and involve security if necessary. The manager of the ED stated if a patient continued to refuse clothes, the provider would need to be involved. Without the provider’s order, nursing staff and security are not allowed to change a patient’s clothing without their consent. If a patient screens as high risk for suicide, they must have a medical exam prior to leaving the hospital. If a provider cannot complete the screening, nursing staff can redirect patients and try to keep them in the ED. Nurses cannot stand in the way of patients trying to leave and they may not tell a patient they cannot leave. The manager of the ED stated if a patient desires to leave against medical advice, they cannot prevent the patient from leaving without a provider’s order for an emergency 72-hour hold. During an interview on 7/22/25 at 12:37 p.m. the director of patient operations stated if a patient screens as a high suicide risk and wants to the leave the ED prior to an assessment, nursing staff must prevent the patient from leaving. In that scenario staff may tell a patient they are not allowed to leave. The director of patient operations stated staff may use “hands on” tactics such as blocking the exits and restraints to prevent patients from leaving. The direct of patient operations stated to keep suicidal patients from leaving the ED prior to seeing a provider, staff may need to “tackle” the patient to keep them safe. A facility policy titled “Restraints Policy” dated 2/2025 indicated restraints will not be used as a means of coercion, discipline, convenience, or a form of retaliation. The policy indicated restraints may only be used to ensure the safety of patients and staff when less invasive alternatives have been attempted. A policy titled “Holds - Emergency, Involuntary, and Minor Holds” dated 11/2023 indicated the facility will hold and treat patients who refuse to consent to treatment when their condition presents a danger to themselves or others. The policy indicated an emergency hold may only be applied to a patient by an examiner who is either a licensed physician, doctoral psychologist, advanced practice nurse in mental health, or a physician assistant.”

“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: 47264 Based on observation, interview, and document review, the facility failed to ensure one of ten patients (P1) reviewed for use of restraints had an order from a licensed physician for the placement of four-point restraints. Findings include: During an observation on 7/21/25 at 12:45 p.m., footage of the ED hallway on 7/7/25 at 6:19 p.m. was reviewed with the security manager. In the footage, P1 was seen exiting ED room 5 and walking around the nursing station. Family member (FM)-A and FM-B exited ED room 5 and walked after P1. Registered nurse (RN)-A and other staff members in the nurses station immediately began to follow P1. P1, FM-A and FM-B exited the frame. Shortly afterwards, P1 returned and walked towards ED room 5, followed by RN-A, security guard (SG)-A and SG-B, FM-A and FM-B. P1 then quickly walked past ED room 5, down another hallway, and out of frame. SG-A responded by running behind the nursing station as RN-A and SG-B followed P1. At 6:22 p.m., P1, FM-A, and FM-B returned to ED room. SG-A and SG-B stayed in the hallway. RN-A entered ED room 5 with nursing assistant (NAR)-A and began removing supplies from the room. As supplies were removed, SG-C arrived and spoke with SG-A and SG-B in the hallway. RN-A left ED room 5, then returned with a folded set of teal scrubs as NAR-A left the room. After a few moments, SG-A, SG-B and SG-C walked into ED room 5. The privacy curtain in ED room 5 moved erratically and FM-B exited the room to stand in the doorway. NAR-A reentered room 5. FM-A exited ED room 5 and spoke with FM-B in the hallway. More nursing staff ran into ED room 5, one of which was holding a green bag. FM-A and FM-B reentered the room but exited with NAR-A shortly afterwards to stand in the hallway. Room 5’s privacy curtain was then drawn. FM-A and FM-B reentered the room, and SG-D arrived. Shortly afterwards, FM-A left the room with an unknown nursing staff and SG-D. At approximately 6:28 p.m., multiple nursing staff and security staff exited the room and were discussing in the hallway. Medical doctor (MD)-A entered the hallway and was seen speaking with RN-A and security staff. MD-A then entered the room for a few minutes before going back to RN-A. At 6:45 p.m., RN-A and multiple staff reentered ED room 5. P1 was a 39-year-old male who presented to the ED on 7/7/25 at 5:49 via private car for suicidal ideation. A triage note dated 7/7/25 at 5:59 p.m. indicated P1 had presented from the local jail with suicidal thoughts for several years. The triage note indicated P1 was accompanied by FM-A and FM-B. P1’s suicide screening dated 7/7/25 at 6:02 p.m. indicated P1 was a high risk for suicide, and a provider was notified. P1 was roomed in ED room 5 at 6:03 p.m. A nursing note dated 7/7/25 at 7:04 p.m. indicated at 6:30 p.m. P1 attempted to elope from the emergency department and was brought back to his room. The note indicated P1 refused to change into provided hospital scrubs and began to elope. The note indicated P1 then postured and pushed staff. The note indicated security was notified and assisted in placing P1 into restraints to keep himself and staff safe. The note indicated at 6:45 p.m., P1 was removed from violent restraints per provider request. A care coordination note dated 7/7/25 at 7:04 indicated P1 was given information about local mental health resources. A provider note dated 7/7/25 at 9:39 p.m. indicated P1 was assessed by MD-A at 6:40 p.m. The note indicated P1 presented to the ED following release from jail with a bail condition to seek mental health services in the community due to P1’s suicidal statements. P1 attempted to elope from the ED due to long wait times and was successfully verbally redirected back to his room. P1 became physically aggressive with staff and was placed in four-point restraints. P1 had chronic thoughts of suicide but verbalized them in the setting of an acute life stressor of being in jail over the weekend. P1 did not have a history of suicide attempts or previous psychiatric hospitalization. P1 did not have suicidal intent or a plan. The note indicated P1 was to be discharged home. There was no order submitted for placement of four-point restraints. P1 was discharged from the ED to the community on 7/7/25 at 7:05 p.m. During an interview on 7/21/25 at 9:43 a.m., RN-B stated four-point restraints are used when patients are a danger to themselves or others. The use of restraints requires a provider’s order within an hour of application. During an interview on 7/21/25 at 10:06 a.m., RN-C stated four-point restraints are used if a patient wants to hurt themselves or others. Applying restraints to a patient requires an order. RN-C stated an order must be obtained within one hour of applying restraints. During an interview on 7/21/25 at 10:26 a.m., the clinical coordinator stated ED staff use four-point restraints for patients attempting to harm themselves or others. A provider order is needed as soon as possible. During an interview on 7/21/25 at 1:27 P.M., SG-C stated after the staff applied restraints to P1, the provider went in and spoke with the patient. He then went in with RN-A and other security to stand-by as the restraints were removed. During an interview on 7/21/25 at 2:05 p.m., MD-A stated she assessed P1 after he was placed into restraints and told nursing staff to remove them. She did not feel the restraints were necessary because P1 was calm and not trying to hurt anyone. During an interview on 7/21/25 at 2:53 p.m., RN-A stated four-point locking restraints are used if a patient is harming themselves or others. An order is required to apply restraints but was unsure about the time for obtaining said order. A facility policy titled “Restraints Policy” dated 2/2025 indicated four-point locking restraints were considered a violent restraint. The policy indicated an order from a physician or advanced practice clinician must be obtained as soon as possible after the application of restraints.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 42587 Based on interview and document review, the hospital failed to provide An Important Message from Medicare (IM) notice within two days of admission for 2 of 18 Medicare beneficiary inpatient patients (P1, P17). This had the potential to impact all Medicare beneficiaries admitted to the hospital. Findings include: The CMS Beneficiary Notices Initiative (BNI) website, dated 12/3/24, directed hospitals were “required to deliver the [IM notice] ...CMS-10065 to all Medicare beneficiaries ...” who were hospital inpatients. This notice informed patients of their hospital discharge appeal rights. CMS-10065 notice instructions, located in the Medicare Claims Processing Manual - Chapter 30, dated 8/1/24, section 200.3.3 - Hospital Delivery of the IM, directed the hospital “must ensure that the beneficiary or representative signs and dates the IM to demonstrate that the beneficiary or representative received the notice and understands its contents.” The section 200.3.4 - Required Delivery Timeframes, directed the hospital to deliver an initial copy of the IM “at or near admission, but no later than 2 (two) calendar days following the date of the beneficiary’s admission to the hospital.” In addition, the section identified a follow-up IM was to be delivered “Two days before discharge” and no later than four hours prior to discharge. The section lacked identification for issuance exceptions. On 2/25/25, during the abbreviated medical record review process, the following information was identified: -P1 admitted on 2/16/25, and was currently admitted. P1’s insurance was identified as Medicare. The Emergency Contact section identified a cousin as the emergency contact. P1’s record identified a refusal to sign dated 2/24/25, eight days after admission. Registered nurse (RN)-A verified the IM was not provided to P1 within two days of admission and did not know why it was not provided until 2/24/25. On 2/27/25, during the abbreviated medical record review process, the following information was identified: -P17 admitted 2/21/25, and was currently admitted. P17’s insurance was identified as Medicare. The Emergency Contact section identified a friend as the emergency contact. P17’s record identified P17 signed the IM on 2/26/25, five days after admission. RN-B verified the IM was not provided within two days of admission. On 2/27/25 at 3:35 p.m., case management director verified the IM should be provided to the patient within the first two days of admission so they would have the opportunity to appeal decisions. A policy on providing IM to patients was requested but not provided.”