Abbott Northwestern Hospital

“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: 47264 Based on interview and document review, the facility failed to ensure an allegation patient were free from all forms of abuse for 1 of 10 patients (P5) reviewed for patient rights when a staff member took multiple photographs of patients medical condition on an a personal device, and the facility conducted an inadequate investigation to determine if the event was an isolated incident. Reeducation was provided to all medical surgical staff after the date of the State Agency’s entrance. Findings Include: A hospital document titled VA Investigation Alleged Event dated 5/3/26 indicated staff report a registered nurse (RN)-A taking out their personal phone during report to the oncoming assigned nurse to show photos of P5’s vomited blood with clots. The first photo was a “close-up” of blood clots near P5’s neck and ear. The second and third were full body views with P5 exposed from head to waist, eyes closed showing blood clots. - 5/4/26 - notify risk, HR, and appropriate teams. Leader approached RN-A who showed the same three photos reported and additional photo of what appeared to be of another patient’s wound, the patient could not be identified. Other administrative areas were notified, and RN-A would be placed on administrative leave prior to next shift. - 5/6/26 - RN-A placed on administrative leave, risk informed, report submitted to state agency, no social media posts were found, HR outlines investigation process. - 5/7/26 - investigation underway, no report made to the Board of Nursing. - 5/11/26 - requested update on investigation from HR. - 5/13/26 - RN-A resigned from position, confirmed photos were deleted from personal devise and not shared with anyone or platforms. - 5/20/26 - Board of Nursing information submitted. In an email subject titled “Medical Record Requests” dated 5/27/26 at 2:16 p.m., the facility was requested to send all compliance reports for P5 to the State Agency for review. In an email subject titled “Re: [P5] Event Summary” dated 5/28/26 at 9:27 a.m., the facility provided the document “VA Investigation Alleged Event” as their compliance investigation. P5 was a 98-year-old female who presented to the hospital via emergency medical services transfer from an outside hospital on 5/1/26 at 3:46 a.m. for hematemesis. P5’s relevant medical history included stage three chronic kidney disease, thrombocytosis, myeloproliferative disorder, and anxiety. P5’s history and physical report dated 5/1/26 at 3:51 a.m. indicated P5 had presented to an outside hospital after episodes of nausea and hematemesis (vomiting blood) following a left hip intramedullary nailing on 4/27/26. She was admitted to the hospital with concern for upper gastrointestinal bleeds. A nursing note dated 5/1/26 at 4:10 a.m. indicated P5 was admitted to the renal medical surgical floor. P5’s surgical information indicated on 5/1/26 at 12:55 p.m. an esophagogastroduodenoscopy (EGD) (minimally invasive procedure to examine the upper gastrointestinal tract -esophagus, stomach, small intestine) was performed. A biopsy was obtained. Anesthesia was concluded at 2:01 p.m. A nursing note dated 5/1/26 at 2:45 p.m. indicated P5 was transferred back to the renal medical surgical floor post operatively. A critical test result notification dated 6:39 a.m. indicated P5’s hemoglobin at 6:32 a.m. was 6.8 g/dL (normal range for women 12.0 g/dl to 15.5g/dl). The provider was notified. An order dated 5/2/26 at 9:09 a.m. indicated P5 was to receive one unit of red blood cells. The transfusion record indicated the transfusion started on 5/2/26 at 9:45 a.m. and ended at 12:51 p.m.; 300 milliliters (ml) of blood was administered. A flowsheet entry titled Nausea dated 5/2/26 at 8:07 p.m. by RN-A indicated P5 had nausea with vomiting, which contained maroon clots. An order dated 5/2/26 at 10:50 p.m. indicated P5 was to receive one unit of red blood cells. The transfusion record indicated the transfusion started on 5/2/26 at 11:26 p.m. and ended on 5/3/26 at 3:15 a.m.; 300 ml of blood was administered. An order dated 5/3/26 at 2:27 a.m. indicated P5 was to receive one unit of red blood cells. A rapid response note dated 5/3/26 at 3:02 a.m. indicated RN-A had initiated a rapid response for significant bleeding and hematemesis. P5 had been receiving a unit of red blood cells when she removed her peripheral IV and vomited a large amount of blood. The blood transfusion was stopped, vital signs were obtained, and staff assisted P5 with hygiene. A new peripheral IV was placed, and another unit of red blood cells was ordered. A flowsheet entry titled Transfuse RBC dated 5/3/26 at 3:15 a.m. indicated P5 received 300 ml of blood and the transfusion was uneventful. During an interview on 5/27/26 at 12:33 p.m., RN-B stated leadership did not interview her on the topic of taking photos of patients. RN-B stated patient care nurses are not allowed to take photographs of patients. If she saw another staff nurse doing this, she would notify her manager. During an interview on 5/27/26 at 12:58 p.m., RN-C stated she had not been interviewed by leadership to discuss patient privacy. RN-C stated staff nurses are not allowed to take photographs of their patients. During an interview on 5/27/26 at 1:23 p.m., RN-D stated she had not been interviewed by leadership to discuss patient privacy. Staff were not allowed to take photographs of patients, especially on their personal mobile devices. During an interview on 5/27/26 at 1:47 p.m., the patient care supervisor stated nursing assistant (NA)-A informed her via text message on 5/3/26 that a nurse, RN-A, had taken photographs of a patient on their personal mobile device. On 5/4/5, the patient care supervisor spoke with other leaders during a leadership huddle who advised her to speak with their human resources department for next steps. On her way to her office to contact human resources, the patient care supervisor saw RN-A on the unit. She stopped and asked RN-A about his weekend shifts. RN-A told her about his shifts and then proceeded to show the patient care supervisor photographs he had taken on his phone. The first photograph showed bloody emesis on P5’s neck and bedsheets. The second and third photographs were taken from the doorway of P5’s room. In these two photographs, P5 was lying in her hospital bed with her gown around her waist and both breasts exposed. Bloody emesis could be seen on P5’s body and her bed. As RN-A was accessing these photographs, the patient care supervisor saw another photograph on his phone. This appeared to be a photograph of a patient’s skin without any identifying information. The patient care supervisor stated she was unable to determine if this was a photograph of P5 or another patient. The patient care supervisor finished her conversation with RN-A and contacted senior employee relations specialist. The patient care supervisor attempted to contact RN-A via phone on 5/4/26 to inform him he had been placed on administrate leave but was unable to directly contact him. Charge nurses and the scheduling department were informed RN-A could not report for additional shifts between his regularly scheduled weekend shifts. The patient care supervisor was able to contact RN-A on 5/6/26 and inform him he had been placed on administrative leave. RN-A submitted his resignation via email on 5/13/26 prior to a Human Resources investigative meeting scheduled for 5/14/26. The patient care supervisor stated human resources completed additional interviews with staff. The patient care supervisor stated she did not conduct additional interviews with staff outside of those involved because she was not concerned about other staff members having photographs of patients. The patient care supervisor stated she believes no other staff were taking photographs because they had all received annual education, and staff are transparent with her. The patient care supervisor stated she reached out to risk management on 5/26/26 to request guidance on how to create effective education that would follow their existing structures. The intention is to provide re-education to staff via email, 1:1s, and structured leadership huddles, known as tier one huddles. During an interview on 5/27/26 at 4:28 p.m., the senior accreditation specialist stated the hospital had provided reeducation materials to 599 direct patient care staff and leaders via email as of 5/27/26 at 4:25 p.m. This reeducation material included information on protecting patient privacy, reporting expectations, links to hospital policies, and self-guided knowledge checks in the form of compliance modules. Further training would be provided to staff in weekly emails and quarterly updates. During an interview on 5/28/26 at 9:29 a.m., RN-E stated nursing staff cannot take photographs of patients on their personal mobile devices. If she saw this, she would immediately let her manager know. During an interview on 5/28/26 at 1:06 p.m. the risk and patient care liaison manager stated human resources had been leading the investigation into P5’s incident. During an interview on 5/28/26 at 2:27 p.m., the employee relations consultant stated she was informed of the situation by the senior employee relations specialist and asked to assist in their investigation. Their investigation indicated this was an isolated incident. The employee relation consultant stated she gathered information by reviewing notes taken by the patient care supervisor during her first-hand witness interviews and interviewing the senior employee relations specialist. The employee relations consultant did not interview any staff nurses. The employee relations consultant stated the senior employee relations specialist would know if other employees were interviewed as she would have conducted them. The employee relations consultant stated her role was to serve as a “neutral factfinder” and was not responsible for advising or assisting any leader in this investigation. During an interview on 5/28/26 at 2:48 p.m., the patient care manager stated she was manager from a different department. Her role was to support the patient care supervisor throughout the investigation. The patient care manager stated she did not conduct any staff interviews. During an interview on 6/2/26 at 8:39 a.m., NA-A stated while she was arriving on her shift on 5/3/26, she overheard someone gasping. When NA-A looked over, RN-A showed her the photos on his personal phone and then handed it to her. The photos showed a naked woman lying in a hospital bed covered in blood. NA-A gasped and handed the phone back to RN-A who was giving report to RN-G, then continued with her own work. NA-A stated this deeply disturbed her and she sought further advice from a staff nurse who works with rapid response. This rapid response nurse told her to report the instance immediately. NA-A stated she texted the patient care supervisor immediately after this conversation. Neither RN-A nor any other staff had ever shown her pictures of patients on their personal devices. NA-A stated the only reeducation she received was over email, which had been sent on 5/28/26. During an interview on 6/2/26 at 8:50 a.m., RN-H stated she was not interviewed about patient privacy. During an interview on 6/2/26 at 8:55 a.m., RN-I stated she was not interviewed on patient privacy by leadership. During an interview on 6/2/26 at 9:26 a.m., RN-J stated she had never been shown a photograph of a patient on a personal mobile device and if she did, she would immediately notify management. RN-J stated she was part of the rapid response care team who provided care to P5 on 5/3/26 at approximately 3:00 a.m. When she arrived, RN-A informed her this was P5’s third episode of bloody emesis that evening. RN-J contacted the provider and received an order for an additional unit of blood, which was then administered. RN-J stated RN-A did show her a photograph on his phone. The photograph showed bloody emesis with dark clots. RN-J stated no one in leadership had asked her about the incident. During an interview on 6/2/26 at 11:03 a.m., RN-K stated nursing staff are not allowed to take photos of patients. If nursing staff showed her a picture of a patient on their phone, she would notify leadership and risk management. During an interview on 6/2/26 at 1:32 p.m., RN-F stated nursing staff are not allowed to take photos of patients on their phones. RN-F stated on the morning of 5/3/26, she was coming onto shift when NA-A came up to her and asked, “Did you see what happened last night?” and then showed her a photograph of P5. The photo showed a large amount of bloody emesis on P5 and included a portion of her neck and head. RN-F clarified NA-A had not taken the photographs. Then she informed the charge nurse who told her it was already escalated to management. RN-F stated she had never been shown photographs of patients on a staff member’s phone prior to this incident. During an interview on 6/2/26 at 3:25 p.m., the patient care director stated she was involved in the investigation through conversation on 5/4/26. The investigative process was a combined effort between the patient care manager, the patient care supervisor, and human resources. The patient care manager’s role was to walk the patient care supervisor through the steps of their investigative process. The patient care director stated she did not conduct any interviews. Interviews with staff were conducted by the patient care manager and/or the patient care supervisor. Determining if the event was an isolated incident was a decision made by those involved directly in the investigation. During an interview on 6/2/26 at 3:57 p.m., RN-A stated he first worked with P5 on the night of 5/2/26 into 5/3/26. RN-A entered P5’s room at the beginning of the shift and P5 reported she was nauseous. He began charting on the computer inside the room. When he looked at P5, there was “clotted blood flowing from her mouth like lava.” RN-A immediately got an emesis basin and provided care until the emesis stopped. After, P5 reported no nausea or pain, and RN-A cleaned her up. RN-A contacted the provider who ordered one unit of red blood cells for P5. While the blood was infusing, RN-A provided care to another patient. As he was on the phone with the provider discussing another patient, he saw P5 was naked in her room. RN-A immediately ran into the room and saw P5 had vomited blood again. P5 had pulled out her IV and was no longer receiving the blood. RN-A stated he took a picture with P5’s permission to try and prove how unstable she was. RN-A stated his personal phone was an unsecured device. RN-A initiated a rapid response and cleaned P5 again. When rapid response arrived, he showed the staff the pictures to communicate how much blood P5 had lost. The rapid response nurses administered another unit of blood. RN-A stated he then left his shift on the morning of 5/3/26. When RN-A returned for his shift on the evening of 5/3/26, he was assigned to care for P5 again. At the beginning of the shift, P5 complained of intense left shoulder pain without chest pain. RN-A used heat packs and cold packs to address the pain, without affect . RN-A administered a PRN analgesic and left the room to care for another patient. As he was telling other nurses they needed to keep an extra eye on P5 in case she vomited blood again, he heard P5’s pulse oximeter alarming. RN-A was concerned P5 had disrobed again and was vomiting blood, so he went into her room. When he arrived, P6 was dead in her bed. RN-A stated he only took pictures during the overnight shift from 5/2/26 to 5/3/26. RN-A stated he did this to “show how much of a mess the shift had been.” RN-A stated he deleted the pictures of P5 on the morning of 5/3/26 after showing them to the nurse in report. RN-A stated he had taken multiple pictures of patients before with his personal phone. RN-A stated he had taken photos of IV sites, rashes, toes, and “little things,” to track their progression between his shifts. During an interview on 6/2/26 at 4:18 p.m., the senior employee relations specialist stated on the morning of 5/4/26, two leadership staff contacted her with the allegations made by staff. The senior employee relations specialist also brought the incident to the employee relations consultant. Any staff interviews were conducted by the patient care supervisor and the patient care manager. The determination as to whether the incident was an isolated event was made by the patient care supervisor. During an interview on 6/2/26 at 4:34 p.m., the patient care supervisor stated she did not interview RN-A or NA-A. The patient care supervisor stated the only additional staff she interviewed was RN-F when she also reported the allegation. No additional patient care staff members were interviewed. The patient care supervisor stated she determined this was an isolated incident because she “[feels] everyone at the hospital knows they are mandated reporters, and they all know it is wrong to take those kinds of photos of patients.” An education record dated 11/18/25 indicated RN-A had completed mandatory hospital provided training regarding patient rights to privacy. A policy titled “Use of Personal Electronic Equipment” dated 3/1/21 indicated the use of a personal electronic devices, such as cellphones and smartphones, to capture images of a patient without documented consent is impermissible. The use of personal phones was not permitted in patient care areas, which included patient rooms.”

“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 a patient was free from restraint when taken to the ground by staff, a mental health technician (MHT)-C, during an incident that did not pose an imminent threat to staff or patients for 1 of 2 patients (P1) reviewed for restraint. P1 was restrained by staff when he threw crackers at a nurse. In addition, the facility failed to ensure an allegation of abuse was immediately reported to the state agency for 1 of 1 patient (P1) reviewed for abuse. P1 was taken to the ground by staff, a mental health technician (MHT)-C, when P1 threw crackers at a nurse. MHT-C continued to work with other patients after the incident occurred on 11/22/25. The incident was reported to the state agency on 12/1/25. As a result, the hospital was found out of compliance with the Condition of Participation at 482.13 - Patient’s Rights. See A-0154 and 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: 33925 Based on interview and document review, the facility failed to ensure an allegation of abuse was immediately reported to the state agency for 1 of 1 patient (P1) reviewed for abuse. P1 was taken to the ground by staff, a mental health technician (MHT)-C, when P1 threw crackers at a nurse. MHT-C continued to work with other patients after the incident occurred on 11/22/25. The incident was reported to the state agency on 12/1/25. Findings include: P1’s ED record was reviewed. P1 admitted to the hospital ED on 11/21/25 at 5:23 p.m. via emergency medical service (EMS). P1’s Progress Note, dated 11/22/25 at 4:28 a.m., identified P1 had thrown an object against a window in his room. A code green was called at 4:18 a.m. P1 was given intramuscular (IM) medication. A corresponding Critical Care Note, dated 11/22/25 at 4:28 a.m. (ten minutes after the code), identified the medical provider spent 35 minutes doing a critical care exam with treatment and outlined rationale listed as, “Mental health.” Neither of the progress notes mentioned any physical restraints, including a manual hold or takedown, as being utilized on P1. A hospital-reported incident to the state agency on 12/1/25, identified P1 was in the emergency room on 11/22/25 for mental health issues because he threatened a group home staff with a butter knife. P1 had a history of adjustment disorder, depression, depressive disorder alcohol and substance use disorder, post-traumatic stress disorder, and anxiety. At approximately 4:20 a.m., P1 exited his room to the nursing station, asked the nurse for some crackers, received crackers, then the nurse asked P1 to use the bathroom, P1 became agitated told the nurse his bladder can’t make it to the bathroom, throwing the crackers at the nurse and walked away when MHT-C had the patient on the floor. A “code green” (alerts staff that there is a behavioral emergency that threatens the life and safety of staff or patients) was called in response to MHT-C having P1 on the floor after throwing crackers. On 12/2/25 at 1:05 p.m., P1’s medical record was reviewed with RN-A and RN-B present: -RN-B reviewed the entire record and verified it lacked any physician order or direction to utilize a physical hold/restraint on P1. -RN-B stated they had since learned the nurse assigned to P1 at the time of the incident, RN-C, talked about the situation with the next oncoming nurse, RN-D, who then reported the use of the manual takedown and hold to leadership several days later on 11/26/25. RN-B stated if anything happens outside of the normal process then nurses and staff are told to “stop the line” but added, “It does not sound like it [happened].” -RN-A stated they had seen the video footage of the event since it happened in the hallway, however, since then the footage had been lost due to the server crashing. RN-A explained the video showed P1 was brought a walker to use by MHT-C and P1 then exited his room coming to the nursing station to get crackers. There was some evident conversation between P1 and RN-C who was seated behind the glass partition at the nursing station. P1 then could be seen raising his arm the throwing the crackers at the nurse but they did not strike the nurse from the footage. RN-A stated they were unsure what, if any, de-escalation techniques were attempted then by MHT-C as there was no audio. RN-A stated when the crackers were thrown to when MHT-C took P1 down to the ground, it was an instant response. - RN-A and RN-B both stated crackers being thrown were “not going to hurt anyone” and the hospital restraint policy supported use of them only if “an active threat to your safety” was present. RN-B stated they had wished MHT-C would have just walked away or backed off P1. RN-B then explained RN-C, who had been involved in this event, never notified them (leadership) about it happening which they should have been. E-mail correspondence from the hospital, dated 12/2/25, identified MHT-C’s worked shifts between 11/22/25 and 11/26/25. MHT-C worked on 11/23 and 11/25 before being placed on leave despite the incident of potential physical abuse or mistreatment being witnessed and known to the floor staff on 11/22/25. When interviewed on 12/2/25 at 2:15 p.m., RN-D stated they had taken report from RN-C following the event on 11/22/25. RN-D explained they had been told P1 had been using a cup in his room to urinate into so RN-C had asked them to use the restroom when he came out to the desk to get crackers. P1 then got upset by that and threw the crackers back at RN-C which caused MHT-C who was standing next to P1 to react who “took the guy [P1] down.” RN-D stated RN-C seemed to be surprised by the incident. RN-D asked RN-C if the if the takedown of P1 was needed in that situation as it felt “over the top” to which RN-C agreed. RN-D stated they then worked their shift but over the following days the use of the takedown in that situation “just stayed with me”. RN-D then reported it to their manager via a voicemail on 11/26/25. On 12/2/25 at 3:09 p.m., the patient care director and interim mental health supervisor (PCD)-A was interviewed. PCD-A verified leadership had been notified of the incident on 11/26/25 (four days later) when they took action to remove MHT-C from the schedule which remained in effect. PCD-A stated a RN should be the person directing a MHT to go “hands on” with a patient, and they were still investigating the situation to determine what, if any, education was needed for staff members. PCD-A verified MHT-C was never directed to go “hands on” by RN-C to their understanding of the event. PCD-A stated that, so far, it seemed like MHT-C went outside of policy and acted when he had not been instructed to do so. PCD-A stated throwing crackers at someone would not be considered an imminent threat to warrant the use of a takedown or manual hold restraint. PCD-A stated MHT-C was not immediately removed from the schedule or placed on supervised care until 11/26/25, and they had likely worked several shifts between the date of incident and removal due to leadership not being notified timely of the event. When interviewed on 12/3/25 at 9:34 a.m., MHT-C stated P1 as needing a walker to ambulate and needing “constant redirection” at times. MHT-C stated on 11/22/25, P1 had wanted crackers so they brought him his walker and were standing next to him at the desk. P1 then got upset with the nurses’ redirection to the restroom and threw the handful of four or five saltine crackers back towards the nurse who was seated in “the bubble” of the station. MHT-C stated P1 then turned around away from the nurse and MHT-C told him aloud, “We’re not going to be doing that [throwing items].” P1 then turned towards MHT-C which MHT-C stated made them “go hands on” and take P1 down to the ground. MHT-C stated while P1 was held on the ground, he told P1 “we’re not going to be disrespectful” to staff. MHT-C stated P1 never threatened him before the takedown but acted with that intervention as they were unaware of P1’s mentality and “for our safety.” MHT-C stated they felt there was no ability to step away from P1 before doing the takedown and hold as they were in the hallway and there was not enough space. MHT-C stated they did not think a post-event debrief was completed after the incident. MHT-C stated they finished working their shift on 11/22/25 and were contacted several days later by management and removed from the schedule with no supervised care being done in-between. On 12/3/25 at 10:35 a.m., a group interview was held with the hospital senior accreditation specialist (SAS), safety and quality manager (SQM), and the risk manager (RM). SQM stated MHT-C’s use of that physical intervention was not appropriate for the situation adding, “We can agree this would not be the correct use of a manual hold.” SQM explained there was always a leadership position on-call who staff should contact if events, such as that on 11/22/25, happened or they need direction. RM stated a safety event report was also not initiated timely on the incident as staff did not report it for several days. SAS stated the lack of timely reporting to leadership caused a delay in response, but it was underway now. SQM stated the nurse involved with witnessing the event was where the primary deficit happened, and RM acknowledged the use of an inappropriate manual takedown and hold would be a VA reportable situation. RM stated MHT-C should have been placed on leave immediately after the event and SAS reiterated the lack of timely reporting to them caused delays in the response. The hospital Vulnerable Adult Maltreatment: Assessment and Reporting in Minnesota policy, dated 8/2025, identified mandated reporters at the hospital must make a report whenever there is reason to believe a patient has been maltreated. The policy provided several definitions which defined abuse as including, “Intentional and nontherapeutic infliction of physical pain or injury.” A corresponding Response Process to Allegations of Abuse and/or Assault policy, dated 7/2025, identified a series of actions the hospital would take to such an allegation. This included notifying Risk Manager and human resources (HR) if the subject of a complaint was an employee. The process outlined if the subject was an employee, then HR would “... Take action to remove an identified Subject from all contact with patients, as soon as Subject is identified.””

“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: 33925 Based on interview, and document review, the hospital failed to ensure a patient was free from restraint when taken to the ground by staff during an incident that did not pose an imminent threat to staff or patients for 1 of 2 patients (P1) reviewed for restraint. P1 was restrained by staff when he threw crackers at a nurse. Findings include: P1’s ED record was reviewed. P1 admitted to the hospital ED on 11/21/25 at 5:23 p.m. via emergency medical service (EMS). P1’s Progress Note, dated 11/22/25 at 12:32 a.m., identified P1 had been accepted to another hospital campus and would be discharging from the ED. P1’s Progress Note, dated 11/22/25 at 4:28 a.m., identified P1 had thrown an object against a window in his room. A code green was called at 4:18 a.m. P1 was given intramuscular (IM) medication. A corresponding Critical Care Note, dated 11/22/25 at 4:28 a.m. (ten minutes after the code), identified the medical provider spent 35 minutes doing a critical care exam with treatment and outlined rationale listed as, “Mental health.” Neither of the progress notes mentioned any physical restraints, including a manual hold or takedown, as being utilized on P1. A hospital-reported incident to the state agency on 12/1/25, identified P1 was in the emergency room on 11/22/25 for mental health issues because he threatened a group home staff with a butter knife. P1 had a history of adjustment disorder, depression, depressive disorder alcohol and substance use disorder, post-traumatic stress disorder, and anxiety. At approximately 4:20 a.m., P1 exited his room to the nursing station, asked the nurse for some crackers, received crackers, then the nurse asked P1 to use the bathroom, P1 became agitated told the nurse his bladder can’t make it to the bathroom, throwing the crackers at the nurse and walked away when mental health technician (MHT)-C had the patient on the floor. A “code green” (alerts staff that there is a behavioral emergency that threatens the life and safety of staff or patients) was called in response to MHT-C having P1 on the floor after throwing crackers. On 12/2/25 at 12:01 p.m., the hospital main emergency department (ED) was toured with RN-A and ED manager (RN)-B present. -The ED consisted of a 38-bed capacity with seven dedicated mental health rooms present behind a badge-locked door system. The rooms were arranged in a U-shaped pattern with a central, glass-enclosed nursing station. -RN-B explained the mental health unit of the ED was staffed with a variety of disciplines including RN(s) and MHT(s). -RN-B stated all restraint training for MHT’s was done by the MHT department and not from the ED. RN-B verified P1 had since discharged from the hospital and was not available for interview. -MHT-A was interviewed during the unit tour at 12:18 p.m. and stated their home unit was the adult psychiatric unit, but there was usually one MHT assigned to the ED unit to help with various tasks like charting, safety checks, and working with patients adding the job varies based on day-to-day needs. MHT-A stated they were taught to always try de-escalation techniques with patients who are getting agitated adding there were several items available to re-direct patients such as stress balls and fidget spinners to use. MHT-A stated they are also taught code green training, and they did participate in the response of one. This could include the use of the restraint chair. MHT-A stated rarely would a manual hold or takedown be needed and that would be your last option to use on a patient adding such use required there to be an imminent risk of harm. MHT-A stated they also helped train new employees on code green responses and reiterated physical intervention, such as a restraint or takedown, was a last resort situation. MHT-A stated a patient throwing an inanimate, non-lethal object, such as crackers, towards a staff would not be an appropriate situation where a physical takedown or hold was needed. MHT-A stated they were unaware of any such situations like that happening recently. -RN-A stated they had seen the video footage of the event since it happened in the hallway, however, the footage had been lost due to the server crashing. RN-A explained the video showed P1 was brought a walker to use by MHT-C and P1 then exited his room coming to the nursing station to get crackers. There was some evident conversation between P1 and RN-C who was seated behind the glass of the nursing station. P1 then could be seen raising his arm the throwing the crackers at the nurse but they did not strike the nurse from the footage. RN-A stated they were unsure what, if any, de-escalation techniques were attempted by MHT-C as there was no audio. RN-A stated when the crackers were thrown MHT-C took P1 down to the ground, which was an instant response. -RN-A and RN-B both expressed crackers being thrown were not going to hurt anyone and the hospital restraint policy supported use of them only if “an active threat to your safety” was present. RN-B explained RN-C, who had been involved in this event, never notified them (leadership) about it happening which they should have been. RN-B stated the post-event code green documentation was also not completed as it should have been. -RN-A stated since they were notified of the event, on 11/26/25, they started some immediate re-education with the nurses about code green situations and physical restraint use. However, they had not done re-education with any of the MHT staff as they were not their reporting staff to oversee. -RN-B stated they did not know where in the re-education process the MHT staff were. On 12/2/25 at 1:05 p.m., P1’s medical record was reviewed with RN-A and RN-B present. -RN-B stated P1 had thrown crackers at the nurse which is what lead to the code green response. RN-B verified at the time just prior to the code green that a “manual hold” was used on the patient as MHT-C involved felt P1 had been “non-cooperative at that moment.” -RN-B reviewed the entire record and verified it lacked any physician order or direction to utilize a physical hold/restraint on P1. -RN-B stated they had since learned the nurse assigned to P1 at the time of the incident, RN-C, talked about the situation with the next oncoming nurse, RN-D, who then several days later reported the use of the manual takedown and hold to leadership on 11/26/25. RN-B stated if anything happens outside of the normal process then nurses and staff are told to “stop the line” but added, “It does not sound like it [happened].” A document, undated, identified MHT-C’s completed training. This identified MHT-C had completed all required code green training(s) prior to the incident on 11/22/25. When interviewed on 12/2/25 at 12:50 p.m., MHT-B stated they had worked in the ED. MHT-B explained many of the MHT staff were floated to the ED in a rotation and the tasks they did depended on what was needed at the time from vital signs to anything not medicine related. MHT-B stated they had helped with restraint application in the ED and expressed the nurses run the situation when that happens. MHT-B expressed there was a different threshold in the ED for when a code green was activated versus on the psychiatric units as some items in the ED would not elicit that same response on the psychiatric unit. MHT-A stated crackers being thrown at a patient could be a code green situation and then staff would attempt to get the patient to take a time out or step into the seclusion room; however, MHT-B stated it would not be appropriate to “just take them down to the ground” in that situation. MHT-B stated they had not heard of any such situation recently happening. When interviewed on 12/2/25 at 2:15 p.m., RN-D stated they had taken report from RN-C following the event on 11/22/25. RN-D explained they had been told P1 had been using a cup in his room to urinate into so RN-C had asked them to use the restroom when he came out to the desk to get crackers. P1 then got upset by that and threw the crackers back at RN-C which caused MHT-C who was standing next to P1 to react who “took the guy [P1] down.” RN-D stated RN-C seemed to be surprised by the incident. RN-D asked RN-C if the if the takedown of P1 was needed in that situation as it felt “over the top” to which RN-C agreed. RN-D stated they then worked their shift but over the following days the use of the takedown in that situation “just stayed with me”. RN-D then reported it to their manager via a voicemail on 11/26/25. RN-D stated they completed some code green training last week. When interviewed on 12/3/25 at 10:06 a.m. RN-C verified they were the nurse assigned to P1 on 11/22/25. RN-C stated they had worked at the hospital “about a year” and “only work[ed] in the ED.” RN-C recalled the incident involving P1 on 11/22/25, and explained the previous nurse had reported P1 as being “a little bit inappropriate” with female staff members and P1 needed a walker to ambulate. P1 asked for crackers which they encouraged P1 to come to the desk to receive. RN-C asked P1 to use the bathroom while he was up and in the hallway which caused P1 to get upset. P1 then tossed the crackers back at them. RN-C stated then suddenly upon looking away and looking back at P1, both P1 and the MHT-C who had been standing next to him “were gone.” RN-C stated in the moment of them looking away, they saw MHT-C and P1 “on the ground having an altercation.” RN-C then pushed their duress button and a code green response was activated. RN-C stated a take down and manual hold would be considered a restraint per hospital policy. RN-C stated staff were told only to use them in situations where somebody would be in danger of getting hurt. RN-C verified they never attempted to get or received an order for the manual restraint being used by MHT-C on P1 prior to the code green being activated, and they never directed MHT-C to take P1 down to the ground or hold him. RN-C stated they had never gone through anything like that prior and were not familiar with the need for an order; however, following the incident their manager had since re-educated them that an order was needed. RN-C attributed the lack of an order to the situation just happening fast. RN-C stated following a code green event the staff should also conduct a debrief of the event to see what went right and went wrong. RN-C stated there was no debriefing after the incident and was unsure why these steps in the restraint and code green process did not get done for this incident. On 12/2/25 at 3:09 p.m., the patient care director and interim mental health supervisor (PCD)-A was interviewed. PCD-A verified leadership had been notified of the incident on 11/26/25 (four days later) and, upon that, they took action to remove MHT-C from the schedule which remain in effect. PCD-A stated a RN should be the person directing a MHT to go “hands on” with a patient, and they were still investigating the situation to determine what, if any, education was needed for staff members. PCD-A stated they expected the investigation to be completed soon and then education would be sent out. PCD-A verified there was no immediate education sent out, such as there had been with the ED, to the MHT staff members so far, there was nothing immediate related to this event. PCD-A verified MHT-C was never directed to go “hands on” by RN-C to their understanding of the event. PCD-A stated that, so far, it seemed like MHT-C went “outside of policy” and acted when he had not been instructed to do so. PCD-A stated throwing crackers at someone would not be considered an imminent threat to warrant the use of a takedown or manual hold restraint. PCD-A stated they had seen the material the ED had sent immediately following the event. On 12/3/25 at 8:34 a.m., clinical practice coordinator (CPC) was interviewed, and verified they helped teach physical interventions and code green situations to the staff members. CPC explained staff were taught to remove themselves from harms’ way and to try to have a team present before a physical intervention is implemented. However, the policy did allow a single person takedown or hold if warranted in “the heat of the moment.” CPC stated a single person takedown was not something routinely taught to staff, including how to safely do it, and reiterated a team intervention is always the preference. CPC stated use of physical interventions can be difficult as staff have to use their judgement to determine what is needed for the situation and it was hard to always predict patient’ violence. CPC stated staff are always told there has to be “imminent risk” before using such interventions. CPC verified a manual hold would be considered a restraint and that prior to doing one, staff should attempt de-escalation techniques. CPC stated they were aware some immediate re-education to the MHT staff members was sent out the evening during the survey on 12/2/25 which included some language to help better define what an “imminent risk” would be considered. When interviewed on 12/3/25 at 9:34 a.m., MHT-C stated P1 as needing a walker to ambulate and needing “constant redirection” at times. MHT-C stated on 11/22/25, P1 had wanted crackers so they brought him his walker and were standing next to him at the desk. P1 then got upset with the nurses’ redirection to the restroom and threw the handful of four or five saltine crackers back towards the nurse who was seated in “the bubble” of the station. MHT-C stated P1 then turned around away from the nurse and MHT-C told him aloud, “We’re not going to be doing that [throwing items].” P1 then turned towards MHT-C which MHT-C stated made them “go hands on” and take P1 down to the ground. MHT-C stated while P1 was held on the ground, he told P1 “we’re not going to be disrespectful” to staff. MHT-C stated P1 never threatened him before the takedown but acted with that intervention as they were unaware of P1’s mentality and “for our safety.” MHT-C stated they felt there was no ability to step away from P1 before doing the takedown and hold as they were in the hallway and there was not enough space. MHT-C reiterated they felt using a physical intervention on P1 was warranted adding if there is an immediate threat then “I do what I have to do.” MHT-C stated they did not think a post-event debrief was completed after the incident. MHT-C stated they finished working their shift on 11/22/25 and were contacted several days later by management and removed from the schedule with no supervised care being done in-between. On 12/3/25 at 10:35 a.m., a group interview was held with the hospital senior accreditation specialist (SAS), safety and quality manager (SQM), and risk manager (RM). They verified a manual takedown, and subsequent hold would be considered a physical restraint; and that no orders for one were obtained either prior or immediately following with P1’s incident on 11/22/25, and that no post-event debrief had been completed. SQM stated MHT-C’s use of that physical intervention was not appropriate for the situation. SQM explained there was always a leadership position on-call who staff should contact if events, such as that on 11/22/25, happened or they need direction. RM stated a safety event report was also not initiated timely on the incident as staff did not report it for several days. SAS stated the lack of timely reporting to leadership caused a delay in response, but it was underway now. SQM stated the nurse involved with witnessing the event was where the primary deficit happened, and SAS reiterated the lack of timely reporting to them caused delays in the response. A hospital-provided Restraints/Seclusion - Management of Violent and/or Self-Destructive Behavior policy, dated 5/2024, identified all patients have the right to be free of physical or mental abuse. The policy outlined restraint, or seclusion may only be imposed to ensure the immediate physical safety of the patient, staff or others and must be discontinued at the earliest possible time. The policy outlined a process for application of a restraint including doing an individual assessment of the patient, obtaining an order for the restraint, and doing a face-to-face within one hour. The policy outlined the staff training and/or qualifications to care for a patient needing restraints which included, “The safe application and use of all types of restraint or seclusion used in the hospital ...”.”

“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 observation, interview, and document review, the hospital failed to ensure the safe use of appropriate manual restraint (i.e., “hands-on” hold) procedures were applied for 1 of 4 patients (P11) reviewed for restraints. P11 had a rear-chokehold (a grappling hold that restricts air or blood flow through the neck) applied by a security officer for an unknown amount of time during a behavioral episode which resulted in him having shortness of breath and hyperventilation. As a result, the hospital was found out of compliance with the Condition of Participation at 482.13 - Patient’s Rights. A condition-level deficiency was issued at A-154. See A-154 for additional information.”

“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: 33925 Based on observation, interview, and document review, the hospital failed to ensure the safe use of appropriate manual restraint (i.e., “hands-on” hold) procedures were applied for 1 of 4 patients (P11) reviewed for restraints. P11 had a rear-chokehold (a grappling hold that restricts air or blood flow through the neck) applied by a security officer for an unknown amount of time during a behavioral episode which resulted in him having shortness of breath and hyperventilation. Findings include: On 10/28/25 at 8:45 a.m., a tour of the CK4700 unit was completed with registered nurse manager (RN)-A and registered nurse supervisor (RN)-B present, who explained the unit was one of two an adult mental health unit with a current census of 14 patients. RN-B stated they address multiple diagnoses on the unit including schizophrenia, depression, and bipolar disorder. P11’s Progress Note, dated 10/17/25, was recorded by the medical provider, and outlined P11 as being admitted to the adult mental health unit of the hospital on 10/15/25. P11 was recorded as being on a 72-hour hold and listed a diagnosis reading, “Substance abuse psychosis.” The note continued and identified P11 used an interpreter for communication and, at times, appeared restless, confused, and agitated. The note outlined P11 had both scheduled and as-needed (PRN) medications for his mental condition given and/or available including lorazepam (an anti-anxiety medication), olanzapine (an antipsychotic medication), and chlorpromazine (a sedative). P11’s Precipitating Seclusion/Restraint Note, dated 10/25/25, identified P11 started to become more agitated and impulsive in the late-morning hours which included tipping over furniture and removal metal screws from them. P11 was placed on 1:2 staffing at that time. Later, at 1:40 p.m., P11 started wandering the unit and closing doorways. The nurse communicated with P11 via an online interpreter which P11 voiced, “ ... was angry about being kept in the hospital.” P11 was agreeable to taking a PRN medication and resting. Later, at 2:45 p.m., P11 then was tipping over tables in the lounge area and was not re-directable. The note outlined, “ ... Show of support was called.” P11 then went to his room and started slamming furniture and escalating including attempting to stick his finger into an electrical outlet. In response, a “code green” was called. The note outlined P11 was afforded an opportunity to walk into seclusion, however, tried to push staff and leave so, as a result, “ ... nursing staff and security went “hands-on” to place the patient into the restraint chair. Patient began to fight and bit a security guard. At this time, one of the security officers staff obstructed patient’s airway by putting his arm around the patient’s neck. Charge RN (director), another RN, and another security officer told staff to remove his arm multiple times. The security officer eventually removed his arm and was removed from the room ... [P11] airway was assessed and found to be patient.” The note outlined P11 was successfully placed into the restraint chair and both internal medicine and rapid response were called to evaluate P11 following the event. The note added, “Patient had a mild episode of hyperventilation following this incident. Patient was visibly upset and crying once in the restraint chair ... Both Internal Medicine and Rapid Response did not find any evidence of lasting injury from this event.” The corresponding Case Report, dated 10/25/25, identified the security report of the event. This report identified a security response was called which escalated into a “code green” situation. The director of the code gave the direction to go “hands-on” and the officers took control of P11 who resisted and was grabbing onto their vests. The note outlined, “[SO-C] had taken control of the patient’s head area ... [another SO] had directed [SO-C] to leave the room and let go of the patients head due to the patient face visibly turning red. [SO-C] refused to leave the room - at this point the director had also directed [SO-C] to leave the room ... left the room at [3:04 p.m.].” In addition, the Post-Code Green Debrief Form, dated 10/25/25, identified the unit of the event and listed sections to be completed by the staff such as what items were done well, and what items could have been done better. This identified security’s actions could have been done better and directed the reader to another form (quality-protected). P11’s corresponding Rapid Response note, dated 10/27/25, identified P11 was seen on 10/25/25 for a situation outlined as, “Asked to assess patient by primary RN and internal medicine regarding concerns for airway being compromised during a code green.” The note outlined no obvious signs of injury were obtained. On 10/28/25 at 9:54 a.m., a medical record review of P11’s chart was done with RN-A, RN-B, registered nurse manager (RN)-D present. P11 admitted from a rural hospital and used an interpreter for communication. RN-B identified the 10/25/25 event ‘code director’ as RN-E, and expressed they had seen the event “debrief form” earlier that morning. RN-A explained those forms are reviewed at the monthly safety committee to see if “any gaps” could be identified, however, the next one was scheduled for November 2025. RN-B verified the security officer involved with the event was removed from service that same day and had not returned to work thus far. RN-B also expressed there was no visible video footage they could locate of the actual event since it happened in the patient’ room. RN-B and RN-D verified there had not yet been any formal re-education or direction to the staff yet as the incident had just happened a few days prior and they “we’re still in the early stages” of the data gathering. However, all three present verified a rear chokehold was not an acceptable physical hold to use on a patient with RN-C adding such a hold “could absolutely compromise the airway” and leave bruising or skin injury. RN-D stated the staff all underwent “code green training” on a routine basis and would defer to security to speak to their individual training for their officers. However, RN-A, RN-B, and RN-D all expressed they felt the response to the event by the nursing staff was appropriate; but RN-A expressed the event remained “a very unfortunate event” with some of the involved nurses still “very upset by it.” Security Officer (SO)-C personnel record was reviewed on 10/28/25. SO-C had completed all required courses for ‘code green’ training prior to the 10/25/25 incident. When interviewed on 10/28/25 at 9:00 a.m., RN-C stated they had worked at the hospital for several years and typically worked the adult mental health units. RN-C explained staff did, at times, have to apply restraints to a patient and explained the process aloud. The staff would typically attempt several “de-escalation” techniques prior to prevent the patient escalating to the point of needing physical restraint intervention. However, if it is needed, then staff call for help using a “code green” with includes a security officer response. The team assembles quickly, and roles are assigned to the staff including a director (directs the other staff members on what actions to take) and an airway nurse (monitors the airway to ensure patent). RN-C verified the nurses and security officers both physical perform the actual physical “hands-on” of the patient, if needed. RN-C explained they were taught when physically “hands-on” of a patient to not touch the neck or spine or joints. Following a code green, there is then a debrief process where staff review the event and complete a paper form. RN-C stated if at any point during the event something is deemed or seen as unsafe, then staff should “speak up” right away. RN-C stated the security officers were taught the same steps to their knowledge adding, “They have other tools [i.e., taser, spray].” RN-C then explained they had just that day heard of an incident which happened recently where a patient was being restrained and a security officer “in a chokehold,” and the officer had to be told several times by the other staff to let the patient go as that hold “was unsafe.” RN-C stated they were unsure of the details adding, “This is all hearsay,” however, expressed there had not been any formal direction or education put forth by administration about the incident to their recall. On 10/28/25 at 9:38 a.m., P11 was interviewed using an online interpreter service. P11 was dressed in a pair of orange-colored scrubs and did not have any visible bruising on his exposed neck. P11 was asked about his hospital stay and expressed he had been at the campus for “two weeks or even more.” P11 denied being abused by anyone at the hospital. P11 was asked about the event on 10/25/25, where staff had to help him into the restraint chair and responded, “Oh yea.” P11 stated aloud, “They held me,” but was unable to recall detail of the event saying aloud, “I have no idea on what to tell you.” P11 stated he recalled having some issues with breathing after it happened adding, “Breathing, which was the one.” P11 stated his breathing had since returned to normal and he felt safe at the hospital but wanted to leave so he could get back to work. When interviewed on 10/28/25 at 10:23 a.m., RN-E verified they were the ‘code director’ for the event on 10/25/25 involving P11. RN-E explained P11 had been escalating to the point the decision was made to call the “code green.” RN-E stated they assumed the director role of the code and, when de-escalating attempts continued to fail, decided to direct the team to go “hands-on.” RN-E expressed during this, a security officer did get bit, however, they were still able to get him seated into the chair. RN-E stated they then saw one of the officer’s hands sticking “over the back of the chair” which was odd, so they moved positions to see a better view when they saw an officer had “wrapped his arm around the patient’s neck in a chokehold.” RN-E stated they immediately told the officer to release the neck, but he did not, which caused the other security officer present to have to yell at him to release P11’s neck and “leave this code right now.” The officer then released the patient, however, seemed to hover around and “refused to leave. This caused the staff to have to deal with both an escalated patient and now a staff member. RN-E reiterated it was a chokehold around the neck which had been witnessed and expressed P11’s face was “completely maroon” colored and he “was not breathing” when the hold was applied, and they saw it. RN-E stated P11 started to breath when the hold was released and hyperventilated for several minutes to catch his breath. RN-E stated they were unsure exactly how long the officer’s arm had been around the patient’s neck, but expressed when they noticed it to when it was released was about “five to 10 seconds.” RN-E stated there was “no reason for his [officer] arm to be around the airway,” and the entire event made her feel “very upset.” RN-E stated they completed the debrief following the code, and the only item which “did not go well” was the patient being placed into a chokehold adding such a hold was “extremely against our policies.” RN-E then expressed multiple questions aloud such as why the airway nurse did not see it or call it out prior to themselves noticing it and wondering how or what actions they can take against staff should the staff not follow a command (i.e., let him go). RN-E added, “I would like some education on that.” When interviewed on 10/28/25 at 11:04 a.m., security officer (SO)-B explained when a “code green” is called that security would often respond to the unit and then check-in with the nursing staff about the situation adding nursing staff have “full control” of the situation since it’s a clinical setting. SO-B stated the roles of the code are then assigned and security often helps with limb restraint or physical holds of the patient. SO-B explained the security officers get a “basic training” on holds when hired and the goal was for limb control adding staff should never apply a hold “around the neck or throat.” SO-B stated they felt the training on hold application was appropriate and “adequate” to show what is or is not acceptable to use. SO-B stated there was never a situation outside of a deadly force event from the patient where applying a chokehold would be acceptable. S0-B stated they had heard about an incident which happened recently where SO-C applied a chokehold to a patient (P11), but nobody really went “into too much detail” about it so they were unsure specifics or any post-incident education or guidance. SO-B stated after “all the pieces fall” for the investigation process, then likely some education or new guidance would be coming from the incident. Further, SO-B stated they had worked with SO-C in the past and never noticed concerning behavior before. On 10/28/25 at 12:17 p.m., the security supervisor (SS)-A and registered nurse for quality and patient safety (QPRN) were interviewed. SS-A explained that security officers were provided with “pre-NEO shadowing” onsite and then go through a general NEO (new employee orientation) process which includes a “field training” which teaches de-escalation techniques and use of their tools (i.e., spray, tasers). The officers are then taught “code green training” which has a Power Point and LMS portion to complete, along with a physical show and return demonstration of the various holds and maneuvers they could have to use. SS-A described the training as “very methodical” and the officers are then refreshed via training annually after hire. SS-A stated the officers are not taught any holds which involve the head or neck area, and felt the training did say any such hold like that, including a chokehold, would be something staff are told to not do adding aloud, “I would say yes [told not to do that].” SS-A stated they just had finished a debrief with the involved officer (SO-C) who expressed they had “no recollection” of the event, like the officer had “blanked” on it. SS-A was asked what, if any, training they complete with officers on potential disassociation and how to address it to which he responded there was none but doing that would be “a good idea though.” SS-A explained that following an incident like had happened, there is an investigation which includes video review, if applicable, report writing and interviews with various staff members. Then following those, a decision would be made on what, if any, post-education needed to be done. SS-A stated there was a shift-to-shift “role call” which happens where the staff cover items which may have been abnormal on their shift; however, nothing had been presented to the staff from leadership so far about this incident or any education about it adding leadership was still “getting through all the facts.” QPRN verified aloud that following the entire review, then decisions on post-incident education, if any, would be made. SS-A stated the involved officer did not have any prior written warnings about performance prior to the 10/25/25 incident, and expressed they felt this incident was “a performance issue” and “a one off” situation. Following, on 10/28/25 at 12:48 p.m., SO-C was interviewed via telephone. SO-C explained they had worked at the hospital for about one year and verified their title as security officer. SO-C stated if a “code green” is called, they usually respond and help de-escalate the patient with nursing staff adding if that fails, then they go to “whatever the next step is” as determined by the RN director. SO-C stated they do have to go “hands-on” from “time to time” and described it as usually just securing a patient’ limb and helping them to a seated or flat position. SO-C stated they recalled going through several trainings of the process adding they had just completed one “last week” sometime. SO-C recalled the event from 10/25/25, and expressed he had his arm around the patient’s upper chest he felt and not his neck. SO-C stated he recalled someone telling him to “break away” from holding the patient adding, “Which I did.” SO-C stated that was “pretty much it from my recollection.” SO-C denied ever having an arm placed around P11’s neck or having P11 in a chokehold adding, “I do not recall that.” SO-C stated there would never be a reason to physically choke a patient. On 10/29/25 at 11:24 a.m., the clinical practice coordinator (CPC) was interviewed, and verified they helped complete the training with new staff members on ‘code green’ and manual holds. CPC explained staff members are required to attend annual classes after being hired, and the new hires have a little more in-depth training which is completed since the material is new and not just a refresh. CPC stated all staff are trained in using the “least restrictive interventions” possible but there was not a “magic list” of least to most restrictive holds as each situation may call for something different. CPC stated the training classes are “quite prescriptive” and done purposefully so staff are “doing different things.” CPC stated they “100 percent” discuss with staff to avoid restraining a patient in the head or neck area as best possible, but they don’t teach certain holds (i.e., a chokehold) as being unacceptable adding “[We don’t use] the words, don’t use a chokehold.” CPC reiterated the use of a rear chokehold is “absolutely not” taught to staff, rather they are taught how to remove themselves from one if a patient had them in one. CPC stated using a chokehold on a patient who was already seated was “completely inappropriate,” and thankfully the staff involved called the officer out on that quickly. CPC stated staff are also taught to follow the commands of the code director. Further, CPC stated investigating into why the airway nurse did not first notice the chokehold being applied to P11 was “an excellent point” and added aloud, “I hadn’t thought of that.” CPC reiterated the hospital-wide concern for patient safety and added, “This [incident] is not us; this is not our care.” The hospital training regarding code green, undated indicated: -A provided Code Green Course Objectives, undated, outlined three different courses were used including a new hire course, an annual training course, and an essentials training course. The provided objectives outlined the courses reviewed the roles during a code green, de-escalation techniques, engagement scenarios, and physical interventions. These courses included mock code green scenarios with them. -A provided Power Point titled, “Code Green Annual Training for Code Green Responders,” undated, outlined a 98-page education on the code green process. This included multiple scenarios and clickable videos which demonstrated how to apply a physical hold or escape a patient if they had a hold of the staff member; however, none of the information directly outlined situations when, or if, a chokehold could be applied to a patient. A hospital-provided Restraints/Seclusion - Management of Violent and/or Self-Destructive Behavior policy, dated 5/2024, identified all patients have the right to be free of physical or mental abuse. The policy outlined restraint, or seclusion may only be imposed to ensure the immediate physical safety of the patient, staff or others and must be discontinued at the earliest possible time. A section labeled, “Prohibited Restraints,” outlined weapons, handcuffs, and shackles were not allowed to be used. The policy outlined a process for application of a restraint including doing an individual assessment of the patient, obtaining an order for the restraint, and doing a face-to-face within one hour. The policy outlined the staff training and/or qualifications to care for a patient needing restraints which included, “The safe application and use of all types of restraint or seclusion used in the hospital, including training in how to recognize and respond to signs of physical and psychological distress (for example, positional asphyxia). The policy listed definitions which directed a physical hold would be considered a physical restraint, however, the policy lacked information on what, if any, types of holds were not to be used.”

“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 obtain a physician order for the use of restraints for 3 of 10 patients (P2, P7, and P9) prior to or after, the initiation of a nonviolent restraint. All patients were restrained with hand mitts. P2 was restrained for picking at an incision site and pulling IV lines, P7 was restrained for repeated attempts to get out of bed with chest tubes, telemetry wires, and a bed alarm, P9 was restrained for anxious, agitated, and combative behaviors. 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 A0161. See A0161 for additional information. A standard level deficiency was issued at A0145.”

“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 report an allegation of abuse and neglect immediately to the State Agency (SA) for 1 of 10 patients (P1) reviewed for patient rights. It was alleged a visitor and P1 had sex in P1’s bathroom, and it was alleged the visitor brought P1 contraband during a visit. Findings include: Review of a facilities report titled: Internal Investigation CK4800 dated 8/30/25 indicated the following, writer received a page at 8:16 p.m. 8/30/25 from CK4800 charge RN. Charge RN informed this writer that patient was found in the bathroom with a male visitor. Initially patient denied any sexual actions took place however after empty Ibuprofen bottle found behind the toilet and staff noticed patient reaching into pants patient claimed that they did have sexual intercourse and during process patients’ tampon was “pushed up too far”. Visitor was escorted off the unit. Patient monitoring increased due to suspicion of contraband hidden in patients’ vagina. Person search completed with no items found however, staff to maintain visual of patient at all times due to suspicion. MD on call updated. Visitor restrictions put into place until could be further evaluated by the interdisciplinary team. Charge RN instructed to contact risk management and SER submitted. Charge RN confirmed patient stated acts were consensual. Patients refused to submit urine for drug toxicity screening. Upon video review patient and visitor went into patient’s bedroom following staff completing 15-min. checks. On 9/17/25, at 2:43 p.m. during an interview Registered Nurse (RN)-A, unit manager confirmed the facility had not filled a VA report to the state agency regarding the incident involving P1 and the male visitor. P1 and the male visitor went into P1’s room without staff knowing and engaged in sexual contact. The male visitor had also brought in the drug meth which was given to P1. The meth was confiscated by staff later that day when P1 was going to the bathroom. P1 was on increased supervisor at the time of the incident and staff should not have allowed the male visitor and P1 to go into P1’s room. Visitors are not allowed in patients rooms. Review of the facility Vulnerable Adult Maltreatment Assessment and Reporting in Minnesota policy review date 8/2025, directed staff all mandated reporters at Allina Health must make a vulnerable adult report whenever they have reason to believe that a patient or client in Minnesota, who is considered a vulnerable adult, is being or has been maltreated; or they have knowledge that a vulnerable adult has sustained emotional abuse and/or a physical injury that is not reasonably explained. The policy further indicated the required reports must be made as soon as possible, but in no event longer than 24 hours after the mandated reporter becomes aware of the suspected or known incident of maltreatment or unexplained physical injury.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(C) A restraint does not include devices, such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets, or other methods that involve the physical holding of a patient for the purpose of conducting routine physical examinations or tests, or to protect the patient from falling out of bed, or to permit the patient to participate in activities without the risk of physical harm (this does not include a physical escort) This Standard is not met as evidenced by: 40945 Based on interview and document review, the hospital failed to obtain a physician order for the use of restraints for 3 of 10 patients (P2, P7, and P9) prior to or after, the initiation of a nonviolent restraint. All patients were restrained with hand mitts. P2 was restrained for picking at an incision site and pulling IV lines, P7 was restrained for repeated attempts to get out of bed with chest tubes, telemetry wires, and a bed alarm, P9 was restrained for anxious, agitated, and combative behaviors. Findings include: P2’s electronic health record (EHR) indicated P2 was admitted to the facility on 8/12/25, with diagnoses including bilateral subdural hematomas (bleeding near brain) and right craniotomy (surgical procedure that involves removing a portion of the skull to access the brain). A nursing note dated 8/16/25, at 6:50 a.m. indicated P2 was in mitts this morning. P2 stated no pain, asking for water and if he can shower. No new numbness, tingling, weakness, vision changes, shortness of breath, chest pain or vomiting. General Awake, alert, restless and pulling at mitts continuously. The medical record lacked a physician order for nonviolent mitt restraint. A nursing note dated 8/18/25, at 7:59 a.m. indicated P2 was in mitts intermittently required due to P2 picking at incision site and pulling at IV lines. The medical record lacked a physician order for nonviolent mitt restraint. A nursing note dated 8/19/25, at 7:41 p.m. indicated P2 was confused and restless overnight pulled out atrial line. P2 was placed in mitts. The medical record lacked a physician order for nonviolent mitt restraint. A nursing note dated 8/25/25, at 7:47 a.m. indicated P2 was restless intermittently and picking at wires, mitts on/off. The medical record lacked a physician order for nonviolent mitt restraint. A nursing note dated 8/26/25, at 7:44 a.m. indicated P2 continued to have a headache and pain persisted. P2 successfully pulled EEG (non- invasive test that records the electrical activity of the brain using electrodes placed on the scalp) wires. EEG wires since have been reapplied to head and mitts applied. The medical record lacked a physician order for nonviolent mitt restraint. A nursing note dated 8/26/25, at 6:20 p.m. indicated P2 seems to be better this evening, resting comfortably in bed. Tolerating mitts. The medical record lacked a physician order for nonviolent mitt restraint. A nursing note dated 9/4/25, at 5:24 a.m. indicated P2 was placed in bilateral mitts due to attempts to pull keofeed (nasogastric feeding tube). The medical record lacked a physician order for nonviolent mitt restraint. A nursing note dated 9/6/25, at 6:55 a.m. indicated P2 was in soft mitts on bilaterally. The medical record lacked a physician order for nonviolent mitt restraint. A nursing note date 9/6/25, at 2:38 p.m. indicated P2 was in mitts to prevent puling of foley catheter. The medical record lacked a physician order for nonviolent mitt restraint. A nursing note date 9/7/25, at 6:09 a.m. indicated P2 was placed in soft mitts on bilaterally. The medical record lacked a physician order for nonviolent mitt restraint. A nursing note date 9/7/25, at 7:37 p.m. indicated P2 was in mitts to prevent puling of foley catheter. P2 severely restless this evening necessitating bilateral hand mitts; more restless with them on but risk of dislodging keofeed too great currently despite use of sitter at the bedside. The medical record lacked a physician order for nonviolent mitt restraint. A nursing note dated 9/10/25, at 6:25 a.m. indicated P2 had in place mitts on both hands due to pulling on IV (intravenous), NG (nasogastric)tube, and other wires. The medical record lacked a physician order for nonviolent mitt restraint. A nursing note dated 9/11/25, at 6:50 a.m. indicated P2 had mitts placed to prevent pulling on NG (nasogastric)tube. The medical record lacked a physician order for nonviolent mitt restraint. A nursing note dated 9/12/25, at 6:21 a.m. indicated P2 had mitts on and off overnight as needed. The medical record lacked a physician order for nonviolent mitt restraint. P7’s electronic health record (EHR) indicated P7 was admitted to the facility on 8/5/25, with diagnoses including acute blood loss and aortic valve repair. A nursing note dated 8/9/25, at 2:38 a.m. indicated P7 was confused and getting out of bed at 12:30 a.m. with chest tubes, tele, and wires hanging, bed alarm going off. Mitts placed and PRN (as needed) medication administered. The medical record lacked a physician order for nonviolent mitt restraint. P9’s electronic health record (EHR) indicated P9 was admitted to the facility on 9/12/25, with diagnoses including dementia with behavioral disturbance, seizures, and confusion. A nursing note dated 9/13/25, at 3:02 p.m. indicated P9 is anxious, agitated, combative and will try to hit. Sometimes refuses cares and assessments. 2:1 sitter, vest restraint and mitts on. The medical record lacked a physician order for nonviolent mitt restraint. A nursing note dated 9/13/25, at 9:49 p.m. indicated P9 is alert and oriented to self. Confusion, agitation, and restlessness noted, vest restraint and mitts on. The medical record lacked a physician order for nonviolent mitt restraint. A nursing note dated 9/14/25, at 4:01 p.m. indicated P9 is alert and oriented to self. Confusion, agitation, and restlessness noted, vest restraint and mitts on. The medical record lacked a physician order for nonviolent mitt restraint. A nursing note dated 9/14/25, at 6:22 p.m. indicated P9 is very confused, agitated, and restless during shift. Mitts on to help stop pulling at lines. The medical record lacked a physician order for nonviolent mitt restraint. A nursing note dated 9/15/25, at 6:49 a.m. indicated P9 is confused and occasionally restless, P9 able to say full name when asked. In place are vest and mitts. The medical record lacked a physician order for nonviolent mitt restraint. During an interview on 9/16/25, at 2:00 p.m., Registered nurse (RN)-A stated RNs are allowed to implement the soft mitts without a physician order. Soft mitt restraints are used to prevent a patient from harming themselves by pulling out central lines and or feeding tubes. When the mitts are in place the patient is not able to use their fingers or hands, which prevents the patient from pulling out tubes and lines. There is no requirement to get a physician order to implement the use of mitts. During an interview on 9/16/25, at 2:09 p.m., RN-B stated soft mitts are not considered a restraint. RNs are allowed to use their own judgement to implement the mitts. The use of the mitts is a safety measure to prevent the patient from pulling at lines. There is no requirement to get a physician order to implement the mitts, nor does there have to be a provider face to face with the patient. During an interview on 9/16/25, at 2:09 p.m., RN-C stated the use of soft mitts is at the nurses discretion. Use of the mitts would be for a patient who is unable to be redirected when pulling at lines. No provider face to face or provider order is required for the use of the mitts. As nurses, we can just get the mitts from the supply room and implement as needed. No additional assessment is required to implement the mitts. During an interview on 9/16/25, at 2:55 p.m., the nurse manager stated the current practice is a patient’s primary nurse is allowed to implement soft mitts without a physician order. The mitts are used to prevent a patient from pulling at critical lines. When the mitts are in place the patient cannot move their hands and fingers. Current practice is the soft mitts are not considered a restraint. During an interview on 9/16/25, at 3:29 p.m. medical doctor (MD)-A stated a provider order was required for all nonviolent and violent restraints. In addition, a face to face is required. Mitts because they reduce the ability to use their hands and finger, which is necessary to prevent self-injury from pulling tubes, would then be considered a restraint. In addition, skin checks, circulation checks and need for the restraint to continue would apply. I believe the hospital currently does require an order for the soft mitts. The expectation is nursing staff follow the hospitals restraint policy and procedures. During an interview on 9/18/25, at 9:58 a.m. the nurse administrator stated nursing is allowed to implement the use of soft mitts to prevent the patient from pulling out lines or causing harm to themselves. The nurses can determine the need for the mitts, and we do not consider them a restraint. If we were to consider the soft mitts as a restraint a provider order and face to face would be required as well as ongoing monitoring. During an interview on 9/18/25, at 10:38 a.m. chief nursing officer (CNO) stated the current practice is nurses are allowed to place soft mitts on patients without a provider order. The mitts are meant to decrease movement of the patients’ fingers and hands. The mitts limit the patient’s ability to use hands and grab items. We need to change the practice and treat the mitts as a restraint. The mitts need to be treated like any other type of non-violent restraint. The Restraints: Non-Violent Behavior policy dated 6/2025, directed, an order is required for the implementation of restraints. The policy directed staff monitoring/reassessment of the patient in restraints must occur. The selection of an intervention and determination of the necessary frequency of assessment and monitoring should be individualized, taking into consideration variables such as the patient’s condition, cognitive status, and risks associated with the use of the chosen intervention, and other relevant factors. At least every 2 hours, a trained staff member will assess and document: level of distress and agitation, mental status, cognitive functioning, color, movement, and circulatory checks; offer food and fluids; skin assessment and position changes; limb exercises; and offer appropriate means of elimination. Depending on the condition of the patient, more frequent monitoring, including continual monitoring, may need to be considered. Required documentation includes the following: Restraint Alternatives, Comprehensive Assessment, MD Restraint Order, Patient/Family Education, Restraint Care Plan, Clinical Justification, Restraint Types, and Visual Safety Checks.”

“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: 48300 Based on interview and document review, the facility failed to update the provider and get an order for oxygen for 1 of 10 patients (P3). P3 was started on oxygen without his provider’s knowledge, discharged without the needed supplemental oxygen supplies, and subsequently required an immediate transfer to a local hospital to receive supplemental oxygen. As a result, the hospital was found out of compliance with the Condition of Participation Nursing Services at 42 CFR 482.45. A condition level deficiency was issued at A0385. See A0395 for additional information.”

“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: 48300 Based on interview and document review, the facility failed to update the provider and get an order for oxygen for 1 of 10 patients (P3). P3 was started on oxygen without his provider’s knowledge, discharged without the needed supplemental oxygen supplies, and subsequently required an immediate transfer to a local hospital to receive supplemental oxygen. Findings include: P3’s Face Sheet indicated P3 admitted on 4/25/25 and discharged on 5/1/25. P3’s Diagnoses List dated 4/25/25 included non-ST elevated myocardial infarction, anemia, and history of transient ischemic attack. On 4/30/25 at 6:39 p.m. a nursing note written by registered nurse (RN)-D indicated P3’s oxygen saturations had dropped to 85% with increased work of breathing. 4L of supplemental oxygen was provided via nasal cannula. The note lacked documentation of notifying P3’s provider. On 5/1/25 at 1:04 p.m. a provider discharge summary lacked information about P3’s use of supplemental oxygen. On 5/1/25 at 2:01 p.m. a discharge note lacked information about P3’s use of supplemental oxygen. On 5/1/25 at 6:18 p.m. a nursing note written by RN-E indicated P3 was utilizing 2L of supplemental oxygen. P3’s EMR lacked documentation of a supplemental oxygen provider order. P3’s Emergency Medical Services (EMS) Transportation run sheet dated 5/1/25 indicated P3 was picked up from the hospital at 1:46 p.m. P3 utilized 2L of supplemental oxygen during the transportation to the assisted living facility (ALF). P3 arrived at the ALF at 2:58 p.m. EMS transport team departed the ALF at 3:45 p.m. P3’s EMS Patient Care Report dated 5/1/25 indicated P3 was picked up from the ALF at 3:54 p.m. and transported to the local hospital. The report also indicated P3 was placed on 3L of supplemental oxygen for low oxygen saturations during transportation to the local hospital. On 6/3/25 at 2:13 p.m., a representative from P3’s ALF (R)-A stated P3 arrived at the ALF utilizing supplemental oxygen. P3 did not have any personal oxygen equipment at the assisted living. P3 would need a provider order to obtain supplemental oxygen equipment, but there was no provider order for oxygen in P3’s discharge orders. On 6/4/25 at 1:50 p.m., a registered nurse from P3’s ALF (RN)-F was interviewed and stated she was the nurse responsible for taking nurse to nurse reports. She was not informed of P3’s utilization of supplemental oxygen. She was present when P3 returned to the ALF utilizing supplemental oxygen. When the supplemental oxygen was removed, P3’s oxygen saturation would drop. She called 911 immediately to transport P3 to the nearest (local) hospital because the ALF did not have the needed oxygen supply equipment. P3 was admitted to the local hospital for four days with a primary diagnosis of weakness. On 6/3/2025 at 2:28 p.m., registered nurse (RN)-A stated she was the registered nurse care coordinator (RNCC) who had reviewed P3’s discharge orders on the day of discharge. She had not noticed P3 had been placed on supplemental oxygen overnight. The bedside nurse did not complete the Oxygen Saturations Note, or place a RNCC consult. P3 did not have a provider order for supplemental oxygen. RN-A stated it was the RNCC’s responsibility to check for a provider order for home oxygen, and arrange for transport supplemental oxygen if the patient was going to a facility. The receiving facility would be responsible for setting up delivery of supplemental oxygen equipment at their facility. On 6/4/25 at 3:00 p.m., medical doctor (MD)-A stated she was P3’s discharging provider. She had not been notified P3 had been placed on supplemental oxygen. If she had been aware, she would have placed the appropriate orders for home oxygen. On 6/5/25 at 12:32 p.m., RN-E stated she would not have looked for an order for oxygen, or updated the provider, because P3 was utilizing supplemental oxygen when she assumed his care. When a patient needed supplemental oxygen, the nurse starting the oxygen should write a nursing note. If the patient required more than 2L, the provider should be notified right away. If 2L was adequate, the provider did not need to be updated, because the providers read the nursing notes. On 6/5/25 at 12:44 p.m., a message was left for RN-D with no return phone call. On 6/5/2025 at 1:01 p.m., RN-C stated providers were notified of patient changes via secure message or a page. The communication should be documented in a provider notification note. P3’s EMR did not contain an Oxygen Saturations note that was required when a patient would be discharging with home oxygen. The nurse completing the oxygen saturations note should also contact the RNCC to arrange supplementary oxygen equipment for after discharge. P3 did not have an order for home oxygen, and the documentation in P3’s chart made it sound like he was not on supplemental oxygen when he left the facility. The facility Oxygen Assessment and Management policy dated 3/25 directed to notify the covering provider after initiating supplemental oxygen. A policy on patient change in condition and notification of provider was requested, but not provided.”