Regions Hospital

“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: 49618 Based on interview and record review, the facility failed to report a fall with serious harm to the state agency for one of ten (P6) patients reviewed for falls. P6 had an unwitnessed fall on 6/1/26 that led to a closed fracture of neck of right femur. Findings include: P6’s medical records indicated P6 was admitted to the facility on 5/26/26 due to seizures. P6’s additional diagnoses included closed fracture of neck of right femur, osteoporosis with pathological fracture, and expressive aphasia. P6 was discharged from the facility on 6/11/26. P6’s precautions orders dated 5/27/26 indicated P6 was on seizure precautions and delirium precautions. P6’s progress note dated 6/1/26 indicated P6 had an unwitnessed fall on 6/1/26. The registered nurse (RN) heard a loud noise coming from P6’s room and found P6 on the floor. Staff assisted P6 to standing and then back to bed after assessing for visible injury and finding none. The provider and charge nurse were notified. P6’s progress note dated 6/1/26 indicated the provider was notified about P6 falling. The notification indicated staff had just assisted P6 to the commode after the fall and the RN noted P6 had significant pain to right hip, groin down to her knee and dragging her leg when P6 pivoted. When the RN got P6 into bed, P6 could not lift the right leg into bed. The provider ordered x-rays. P6’s Safety Report dated 6/2/26 indicated P6 had an unwitnessed fall on 6/1/26. The fall was considered a fall with harm/serious injury. The report indicated a nurse was sitting outside P6’s room when she heard a bang sound, looked in the door, and found P6 sitting next to the bed. Additional staff entered the room and assessed P6 and found no visible injuries. Staff assisted P6 back to bed. Before the fall, P6 was sitting upright in bed for dinner with her spouse at beside. The bed alarm was turned off due to alarm dysfunction due to P6’s positioning and P6’s spouse was at beside assisting P6 with eating. P6’s spouse left the room and staff were unaware. The bed alarm was not active at the time of the fall. The root cause was identified as a gap in intentional hourly rounding practices that led to missed opportunity to anticipate P6’s needs and ensure her safety, including bed alarm activation. The facility started an investigation. The facility started performing randomized audits using the departmental rounding signoff sheet to verify that intentional rounding was completed and documented during the previous shift in alignment with unit expectations. Audits would be completed at a minimum of ten days each month for four consecutive months, targeting a compliance rate of ninety percent or greater. The leadership team would also develop and disseminate a Safety Story to reinforce expectations related to Universal Fall Precautions, specifically intentional rounding with completion of safety checks during shift handoff and accurate documentation of completion. The Safety Story would be shared during daily huddles for one to two weeks, distributed via email, and post in shared staff spaces with a goal of reaching one hundred percent of staff. The root cause analysis (RCA) marked any fracture and surgery, casting, or traction under sentinel event reportability. The date it stated the facility reported this event was on 6/4/26. The facility’s Safety Story with an unknown date described P6’s fall. The education stated staff need to perform intentional rounding and communicate clearly. Staff were responsible for completing the Nursing Learning Assessment, educate patients and families on fall risks and prevention strategies, document all education that was provided, update and document targeted interventions to reflect the patient’s current clinical state and immediate needs, and document intentional rounding and all assessments. During an interview on 9/1/26 at 2:14 p.m., RN-P stated P6’s spouse was with P6 and had left. When P6 fell, she was sitting upright in bed without her spouse at bedside. Between the time P6’s spouse left and the fall happened, it was around one hour. At the time of the fall, P6 was on fall precautions and seizure precautions. RN-P stated fall precautions consisted of utilizing a bed alarm. The facility started the investigation and determined the bed alarm was turned off by RN-U prior to P6 falling. The nurse had told RN-P that the bed alarm wasn’t on because P6 was sitting up in bed and the alarm continued to go off. The education department put out a Patient Safety Story via email about what happened, safety behaviors, and interventions that was sent to all units. RN-P reinforced the expectation that nursing assistants (NA) would verify that all patient bed alarms were on. RN-P also spoke with RN-U one to one and reinforced expectations and education was provided. During an email correspondence on 9/1/26 at 3:01 p.m., Quality and Safety Manager (QSM)-A stated the facility did not have a seizure precautions policy and procedure. During an email correspondence on 9/1/26 at 3:08 p.m., QSM-A stated the facility did not report the event to the state agency. Surveyor attempted to contact NA-A on 9/2/26 at 8:50 a.m. and 1:15 p.m. with no answer. Surveyor left a voicemail but did not receive a phone call back. During an interview on 9/2/26 at 9:16 a.m., RN-U stated when a patient sits up in bed at about a ninety-degree angle, the bed alarm doesn’t work properly because it continuously goes off. RN-U stated it is a common problem. When P6 fell, RN-U heard a noise from P6’s room, so he entered her room and found her sitting on the floor on the side of the bed. P6 had her electroencephalogram (EEG) (wires attached to her head to measure electrical activity of the brain) still hooked up. Staff got P6 back into bed and notified the provider. RN-U stated the bed alarm was not on because the head of the bed was up to the point where the alarm wouldn’t have worked properly. RN-U stated the bed alarm is turning on and off manually. P6 was on fall precautions at the time of the fall. RN-U stated this fall happened at shift change, so the oncoming RN was also on the floor at the time of the fall. RN-U stated that after this fall, the team did a post-fall huddle, and the team had reviewed bed practices. Surveyor attempted to contact RN-O on 9/2/26 at 9:31 a.m. and 1:15 p.m. with no answer. Surveyor left a voicemail but did not receive a phone call back. During an interview on 9/2/26 at 11:43 a.m., family member (FM)-D stated he was not with P6 when she fell. FM-D stated he was at P6’s bedside when a staff member stated they were going to unhook her bed alarm because staff stated it went off too often. After P6 fell, FM-D received a call from facility staff stating P6’s bed alarm wasn’t turned on because P6 was “light weight” and the alarm continued to alarm when she would sit up in bed. The facility’s Preventing, Identifying, Investigating, and Reporting Maltreatment of a Vulnerable Adult policy dated 9/13/26 indicated the definition of neglect was the absence or likelihood of absence of care of services, including but not limited to, food, clothing, shelter, healthcare, or supervision necessary to maintain the physical and mental health of the vulnerable adult which a reasonable person would deem essential to obtain or maintain the vulnerable adult’s health, safety, or comfort considering the physical or mental capacity or dysfunction of the vulnerable adult. The policy stated if the investigator does have a reason to believe, based upon the investigation, that a vulnerable adult was being or has been maltreated while at the facility, the manager shall report the suspected maltreatment to Minnesota Adult Abuse Reporting Center. The facility’s Fall Prevention policy with an unknown date indicated alarms should be activated and in use on patients with identified risk factors including mobility, fall history, toileting, behavior, and mental status. The alarm would be implemented upon the discretion of the nurse.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 49618 Based on interview and Record Review the facility failed to promote patient safety utilizing restraint and/or seclusion interventions for five of ten patients (P1, P3, P4, P5, P6) when orders were not initiated and renewed timely, a patient was not assessed every 24 hours, and face-to-face assessments were not completed within one hour of the interventions. As a result, the hospital was found out of compliance with the Condition of Participation Patient Rights at 42 CFR 482.13. Based on interview and record review, the facility failed to put in a restraint or seclusion order within a few minutes of the application of the restraints or seclusion for two of seven patients (P1, P3) review for restraint and seclusion orders and obtain a restraint order for five of seven patients (P1, P3, P4, P5, and P6) when the restraints or seclusion had been applied. See A-0168 for additional information. Based on interview and record review, the facility failed to renew orders for restraints or seclusion every four hours for three of seven patients (P1, P3, P4) reviewed for restraint and seclusion orders. See A-0171 for additional information. Based on interview and record review, the facility failed to see and assess a patient every 24 hours while the patient was in restraints for one of seven patients (P1) reviewed for face-to-face assessments. See A-0172 for additional information. Based on interview and record review, the facility failed to complete a face-to-face assessment within one hour of the restraint or seclusion application for two of seven patients (P1, P3) reviewed for face-to-face assessments. See A-0179 for additional information.”

“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: 49618 Based on interview and record review, the facility failed to put in a restraint or seclusion order within a few minutes of the application of the restraints or seclusion for two of seven patients (P1, P3) review for restraint and seclusion orders and obtain a restraint order for five of seven patients (P1, P3, P4, P5, and P6) when the restraints or seclusion had been applied. Findings include: P1’s medical record indicated P1 admitted to the facility on 2/17/26 with a primary diagnosis of psychosis. P1’s additional diagnoses included schizophrenia and anti-social personality disorder. P1 was still at the facility at the time of the survey. P1’s restraint and seclusion flow sheet indicated P1 was placed in a restraint chair on 2/17/26 at 9:05 p.m. The order was entered at 10:28 p.m. P1’s restraint and seclusion flow sheet indicated P1 was placed in a restraint chair on 2/18/26 at 9:30 a.m. and discontinued at 11:43 a.m. No order was obtained from the provider. P1’s restraint and seclusion flow sheet indicated P1 was placed in a lap belt and Velcro restraints on 2/27/26 at 7:46 a.m. and discontinued at 8:04 a.m. No order was obtained from the provider. P1’s restraint and seclusion flow sheet indicated P1 was placed in a lap belt and Velcro restraints on 4/6/26 at 7:36 a.m. and discontinued at 8:03 a.m. No order was obtained from the provider. P3’s medical record indicated P3 was admitted to the facility on 3/9/26 with a primary diagnosis of schizoaffective disorder. P3’s additional diagnoses included suicidal ideation, anxiety, and schizoaffective disorder (bipolar type). P3 was discharged from the facility on 4/24/26. P3’s restraint and seclusion flow sheet indicated P3 was placed in seclusion on 4/11/26 at 3:45 p.m. and was discontinued at 4:30 p.m. No order was obtained from the provider. P3’s restraint and seclusion flow sheet indicated P3 was placed in a restraint chair on 3/13/26 at 1:40 p.m. The order was entered at 2:17 p.m. P3’s restraint and seclusion flow sheet indicated P3 was placed in seclusion on 4/11/26 at 5:00 p.m. The order was entered at 5:35 p.m. P4’s medical record indicated P4 was admitted to the facility on 4/22/26 with a primary diagnosis of psychosis. P4’s additional diagnoses included alcohol use disorder and cannabis use disorder. P4 was still admitted to the facility at the time of the survey. P4’s restraint and seclusion flow sheet indicated P4 was placed in a spit hood and Velcro restraints on 4/22/26 at 7:00 p.m. The spit hood was discontinued at 7:20 p.m. The Velcro restraints were discontinued at 8:41 p.m. No order was obtained from the provider. P4’s restraint and seclusion flow sheet indicated P4 was placed in the restraint chair on 4/24/26 at 9:31 a.m. and was discontinued at 10:45 a.m. No order was obtained from the provider. P5’s medical record indicated P5 was admitted to the facility on 2/26/26 with a primary diagnosis of schizophrenia. P5’s additional diagnosis included anti-social personality disorder. P5 was still admitted to the facility at the time of the survey. P5’s restraint and seclusion flowsheet indicated P5 was placed in Velcro restraints on 4/1/26 at 7:00 a.m. and was discontinued at 8:05 a.m. No order was obtained from the provider. P5’s restraint and seclusion flowsheet indicated P5 was placed in a lap belt restraint on 4/1/26 at 8:07 a.m. and was discontinued at 9:10 a.m. No order was obtained from the provider. P6’s medical record indicated P6 was admitted to the facility on 2/15/26 with a primary diagnosis of psychosis. P6’s additional diagnoses included cannabis use disorder, polysubstance use, obsessive compulsive disorder, schizoaffective disorder, anxiety, self-injurious behavior, anti-social personality disorder, and severe manic bipolar one disorder with psychotic features. P6 was discharged from the facility on 4/13/26. P6’s restraint and seclusion flowsheet indicated P6 was placed in a manual restraint on 2/17/26 at 9:08 p.m. and was discontinued at 9:10 p.m. No order was obtained from the provider. During an interview on 5/28/26 at 1:03 p.m., provider (P)-F stated if a patient needs to be placed in restraints or seclusion, she would have to enter the order within 60 minutes of the restraint or seclusion application. P-F stated all applications of restraints or seclusion needs an order. During an interview on 5/28/26 at 1:10 p.m., P-D stated if a patient needs to be placed in restraints or seclusion, she would have to enter the order within 60 minutes of the restraint or seclusion application. P-A stated all applications of restraints or seclusion needs an order. During an interview on 5/28/26 at 1:29 p.m., P-A stated if a patient needs to be placed in restraints or seclusion, she would have to enter the order within 60 minutes of the restraint or seclusion application. P-A stated all applications of restraints or seclusion needs an order. During an interview on 5/28/26 at 1:35 p.m., P-E stated if a patient needs to be placed in restraints or seclusion, she would have to enter the order within 60 minutes of the restraint or seclusion application. P-E stated all applications of restraints or seclusion needs an order. During an interview on 5/28/26 at 1:51 p.m., P-C stated if a patient needs to be placed in restraints or seclusion, she would have to enter the order within 60 minutes of the restraint or seclusion application. P-C stated all applications of restraints or seclusion needs an order. The facility’s Restraint (Non-Violent and Violent) and Seclusion policy indicated the use of restraints or seclusion must be in accordance with the order of a practitioner who is responsible for the care of the patient. The policy indicated the order must be obtained either during the emergency application of the restraints or seclusion, or immediately (within 60 minutes) after the restraint or seclusion had been applied.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) Unless superseded by State law that is more restrictive-- (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1-hour for children under 9 years of age; This Standard is not met as evidenced by: 49618 Based on interview and record review, the facility failed to renew orders for restraints or seclusion every four hours for three of seven patients (P1, P3, P4) reviewed for restraint and seclusion orders. Findings include: P1’s medical record indicated P1 admitted to the facility on 2/17/26 with a primary diagnosis of psychosis. P1’s additional diagnoses included schizophrenia and anti-social personality disorder. P1 was still at the facility at the time of the survey. P1’s provider ordered bilateral Velcro restraints on 2/18/26 at 8:18 a.m. The order indicated all seclusion orders must be reviewed every four hours per policy. The order was renewed at 10:28 p.m. P1’s provider ordered seclusion on 2/19/26 at 5:45 a.m. The order indicated all seclusion orders must be reviewed every four hours per policy. The order was renewed at 1:02 a.m. P1’s provider ordered seclusion on 2/19/26 at 10:02 a.m. The order indicated all seclusion orders must be reviewed every four hours per policy. The order was renewed at 4:50 p.m. P1’s provider ordered seclusion on 2/20/26 at 8:33 p.m. The order indicated all seclusion orders must be reviewed every four hours per policy. The order was renewed on 2/21/26 at 2:43 a.m. P1’s provider ordered seclusion on 2/23/26 at 10:03 a.m. The order indicated all seclusion orders must be reviewed every four hours per policy. The order was renewed at 2:49 p.m. P1’s provider ordered seclusion on 2/23/26 at 5:36 p.m. The order indicated all seclusion orders must be reviewed every four hours per policy. The order was renewed at 9:43 p.m. P1’s provider ordered seclusion on 2/24/26 at 12:58 a.m. The order indicated all seclusion orders must be reviewed every four hours per policy. The order was renewed at 5:41 a.m. P1’s provider ordered seclusion on 2/24/26 at 8:46 a.m. The order indicated all seclusion orders must be reviewed every four hours per policy. The order was renewed at 2:46 p.m. P1’s provider ordered seclusion on 2/25/26 at 12:46 a.m. The order indicated all seclusion orders must be reviewed every four hours per policy. The order was renewed at 5:32 a.m. P1’s provider ordered seclusion on 2/26/26 at 12:42 a.m. The order indicated all seclusion orders must be reviewed every four hours per policy. The order was renewed at 5:08 a.m. P1’s provider ordered seclusion on 4/4/26 at 12:39 a.m. The order indicated all seclusion orders must be reviewed every four hours per policy. The order was renewed at 5:54 a.m. P1’s provider ordered seclusion on 4/4/26 at 5:54 a.m. The order indicated all seclusion orders must be reviewed every four hours per policy. The order was renewed at 10:58 a.m. P1’s provider ordered seclusion on 4/4/26 at 12:55 p.m. The order indicated all seclusion orders must be reviewed every four hours per policy. The order was renewed at 4:59 p.m. P1’s provider ordered seclusion on 4/5/26 at 8:44 a.m. The order indicated all seclusion orders must be reviewed every four hours per policy. The order was renewed at 4:18 p.m. P1’s provider ordered seclusion on 4/6/26 at 11:46 a.m. The order indicated all seclusion orders must be reviewed every four hours per policy. The order was renewed at 3:26 p.m. P1’s provider ordered seclusion on 4/7/26 at 6:12 a.m. The order indicated all seclusion orders must be reviewed every four hours per policy. The order was renewed at 2:41 p.m. P1’s provider ordered seclusion on 4/8/26 at 2:38 a.m. The order indicated all seclusion orders must be reviewed every four hours per policy. The order was renewed at 6:40 a.m. P1’s provider ordered seclusion on 4/8/26 at 6:40 a.m. The order indicated all seclusion orders must be reviewed every four hours per policy. The order was renewed at 3:58 p.m. P1’s provider ordered seclusion on 4/9/26 at 11:05 p.m. The order indicated all seclusion orders must be reviewed every four hours per policy. The order was renewed on 4/10/26 at 2:46 a.m. P3’s medical record indicated P3 was admitted to the facility on 3/9/26 with a primary diagnosis of schizoaffective disorder. P3’s additional diagnoses included suicidal ideation, anxiety, and schizoaffective disorder (bipolar type). P3 was discharged from the facility on 4/24/26. P3’s provider ordered seclusion on 4/12/26 at 5:42 a.m. The order indicated all seclusion orders must be reviewed every four hours per policy. The order was renewed at 10:53 a.m. P3’s provider ordered seclusion on 4/13/26 at 6:08 a.m. The order indicated all seclusion orders must be reviewed every four hours per policy. The order was renewed at 10:21 a.m. P3’s ordered seclusion on 4/14/26 at 1:22 a.m. The order indicated all seclusion orders must be reviewed every four hours per policy. The order was renewed at 5:43 a.m. P3’s provider ordered seclusion on 4/14/26 at 8:51 a.m. The order indicated all seclusion orders must be reviewed every four hours per policy. The order was renewed at 1:40 p.m. P3’s provider ordered seclusion on 4/15/26 at 5:47 a.m. The order indicated all seclusion orders must be reviewed every four hours per policy. The order was renewed at 10:13 a.m. P3’s provider ordered seclusion on 4/15/26 at 10:13 a.m. The order indicated all seclusion orders must be reviewed every four hours per policy. The order was renewed at 3:14 p.m. P3’s provider ordered seclusion on 4/15/26 at 3:14 p.m. The order indicated all seclusion orders must be reviewed every four hours per policy. The order was renewed at 7:29 p.m. P3’s provider ordered seclusion on 4/15/26 at 9:55 p.m. The order indicated all seclusion orders must be reviewed every four hours per policy. The order was renewed on 4/16/26 at 3:08 a.m. P3’s provider ordered seclusion on 4/16/26 at 10:10 a.m. The order indicated all seclusion orders must be reviewed every four hours per policy. The order was renewed at 3:43 p.m. P4’s medical record indicated P4 was admitted to the facility on 4/22/26 with a primary diagnosis of psychosis. P4’s additional diagnoses included alcohol use disorder and cannabis use disorder. P4 was still admitted to the facility at the time of the survey. P4’s provider ordered seclusion on 4/24/26 at 9:44 p.m. The order indicated all seclusion orders must be reviewed every four hours per policy. The order was renewed on 4/25/26 at 1:58 a.m. P4’s provider ordered seclusion on 5/25/26 at 1:58 a.m. The order indicated all seclusion orders must be reviewed every four hours per policy. The order was renewed at 6:06 a.m. P4’s provider ordered seclusion on 4/26/26 at 2:47 a.m. The order indicated all seclusion orders must be reviewed every four hours per policy. The order was renewed at 8:19 a.m. P4’s provider ordered seclusion on 4/26/26 at 6:49 p.m. The order indicated all seclusion orders must be reviewed every four hours per policy. The order was renewed at 11:30 p.m. During an interview on 5/28/26 at 1:03 p.m., provider (P)-F stated a seclusion order should be renewed every four hours. During an interview on 5/28/26 at 1:10 p.m., P-D stated a seclusion order should be reordered every four hours. P-D stated she will “keep tabs” on the time the restraint or seclusion order was done last and then after four hours, she will renew the restraint or seclusion order. During an interview on 5/28/26 at 1:29 p.m., P-A stated a seclusion order should be reordered every four hours. P-A stated she will make a mental note on when the seclusion order needs to be reordered and then she will put the renewal order in. P-A stated the nurses are also responsible for paging P-A to let her know the orders need to be renewed. During an interview on 5/28/26 at 1:35 p.m., P-E stated a seclusion order needs to be renewed every four hours. P-E stated he will have a list of patients who are in restraints or seclusion and then he would set an alarm to reorder the restraints or seclusion at the four-hour mark. P-E stated occasionally the nurses will send him a message before the restraints or seclusion order is set to expire so that P-E can renew the order. During an interview on 5/28/26 at 1:51 p.m., P-C stated a seclusion order needs to be renewed every four hours. P-C stated at the start of her shift she will gather a list of patients who are in restraints or seclusion and then she will renew all orders at the same time for all patients. P-C stated at the end of her shift, she will renew the restraint and seclusion orders for all patients. The facility’s Restraint (Non-Violent and Violent) and Seclusion policy indicated a restraint or seclusion order must be renewed every four hours for patients 18 years old and older. The facility’s Seclusion Use Procedure policy indicated a seclusion order should be renewed every four hours for patients 18 years old and older.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) [Unless superseded by State law that is more restrictive,] (ii) After 24 hours, before writing a new order for the use of restraint or seclusion for the management of violent or self-destructive behavior, 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 must see and assess the patient. This Standard is not met as evidenced by: 49618 Based on interview and record review, the facility failed to see and assess a patient every 24 hours while the patient was in restraints for one of seven patients (P1) reviewed for face-to-face assessments. Findings include: P1 was admitted to the facility on 2/17/26 with a primary diagnosis of psychosis. P1’s additional diagnoses included schizophrenia and anti-social personality disorder. P1 was still at the facility at the time of the survey. P1’s restraint and seclusion flow sheet indicated P1 was put in seclusion starting on 4/3/26 at 8:03 p.m. due to uncooperative with monitoring. P1’s seclusion ended on 4/10/26 at 12:15 p.m. P1’s face-to-face assessment flow sheet indicated P1 had a face-to-face assessment on 4/3/26 at 8:07 p.m., 4/4/26 at 12:55 p.m., 4/5/26 at 10:51 a.m., 4/6/26 at 7:07 a.m., 4/6/26 at 7:36 a.m., 4/6/26 at 8:58 a.m., 4/6/26 at 11:00 a.m., 4/7/26 at 11:00 a.m., 4/7/26 at 2:40 a.m., 4/8/26 at 2:25 p.m., 4/9/26 at 10:05 a.m., 4/9/26 at 2:50 p.m., and 4/20/26 at 11:10 a.m. There were more than 24 hours between the face-to-face assessment on 4/6/26 at 7:36 a.m., and the face-to-face assessment on 4/7/26 at 11:00 a.m. There were more than 24 hours between the face-to-face assessment on 4/7/26 at 11:00 a.m. and then face-face-to-face assessment on 4/8/26 at 2:25 p.m. During an interview on 5/28/26 at 1:03 p.m., provider (P)-F stated if a seclusion order is being renewed, a patient should be seen and assessed every 24 hours. During an interview on 5/28/26 at 1:10 p.m., P-D stated if a seclusion order is being renewed, a patient should be seen and assessed every 24 hours. During an interview on 5/28/26 at 1:29 p.m., P-A stated if a seclusion order is being renewed, a patient should be seen and assessed every 24 hours. During an interview on 5/28/26 at 1:35 p.m., P-E stated if a seclusion order is being renewed, a patient should be seen and assessed every 24 hours. During an interview on 5/28/26 at 1:51 p.m., P-C stated if a seclusion order is being renewed, a patient should be seen and assessed every 24 hours. The facility’s Restraint (Non-Violent and Violent) and Seclusion policy indicated after 24 hours, before writing a new order for the seclusion for management of violent or self-destructive behavior, a licensed practitioner must conduct a new face-to-face assessment. The facility’s Seclusion Use Procedure policy indicated if a seclusion episode lasts longer than 24 hours, a new face-to-face assessment is required.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) [the patient must be seen face-to-face within 1 hour after the initiation of the intervention -- ] §482.13(e)(12)(ii)To evaluate - 1. The patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. This Standard is not met as evidenced by: 49618 Based on interview and record review, the facility failed to complete a face-to-face assessment within one hour of the restraint or seclusion application for two of seven patients (P1, P3) reviewed for face-to-face assessments. Findings include: P1’s medical records printed on 5/19/26 was admitted to the facility on 2/17/26 with a primary diagnosis of psychosis. P1’s additional diagnoses included schizophrenia and anti-social personality disorder. P1 was still at the facility at the time of the survey. P1’s restraint and seclusion flow sheet indicated P1 was put in the restraint chair on 2/17/26 at 9:05 p.m. due to threatening, agitated, restless, and psychotic. The face-to-face flow sheet indicated the assessment was not completed until 10:28 p.m. P1’s restraint and seclusion flow sheet indicated P1 was put in the restraint chair on 2/18/26 at 8:32 a.m. due to agitation, restlessness, and uncooperative with monitoring. The face-to-face flow sheet indicated the assessment was not completed until 11:45 a.m., P1’s restraint and seclusion flow sheet indicated P1 was put in a lap belt and locking Nylon/Velcro on left ankle and left and right wrist on 2/23/26 at 8:59 a.m. due to electroconvulsive therapy (ECT) procedure. The face-to-face flow sheet indicated the assessment was not completed until 10:03 a.m. P3’s medical records indicated P3 was admitted to the facility on 3/9/26 with a primary diagnosis of schizoaffective disorder. P3’s additional diagnoses included suicidal ideation, anxiety, and schizoaffective disorder (bipolar type). P3 was discharged from the facility on 4/24/26. P3’s restraint and seclusion flow sheet indicated P3 was put in the restraint chair on 4/11/26 at 2:45 p.m. due to agitation, restlessness, combative, destructive to property, uncooperative with monitoring, verbally abusive, threatening, shouting and screaming, psychotic, hallucination, self-harm, violence, delusional, and confused. The face-to-face flow sheet indicated the assessment was not done until 4:52 p.m. P3’s restraint and seclusion flow sheet indicated P3 was put in seclusion on 4/11/26 at 5:00 p.m. due to uncooperative with monitoring. The face-to-face flow sheet indicated the assessment was not completed until 6:52 p.m. P3’s restraint and seclusion flow sheet indicated P3 was put in the restraint chair on 4/14/26 at 1:40 p.m. The face-to-face flow sheet indicated the assessment was not completed until 4:25 p.m. During an interview on 5/28/26 at 1:03 p.m., provider (P)-F stated a face-to-face assessment needs to be completed within one hour of the restraint or seclusion application. During an interview on 5/28/26 at 1:10 p.m., P-D stated a face-to-face assessment needs to be completed within one hour of the restraint or seclusion application. During an interview on 5/28/26 at 1:29 p.m., P-A stated a face-to-face assessment needs to be completed within one hour of the restraint or seclusion application. During an interview on 5/28/26 at 1:35 p.m., P-E stated a face-to-face assessment needs to be completed within one hour of the restraint or seclusion application. During an interview on 5/28/26 at 1:51 p.m., P-C stated a face-to-face assessment needs to be completed within one hour of the restraint or seclusion application. The facility’s Restraint (Non-Violent and Violent) and Seclusion policy indicated when a violent restraint or seclusion are used, the patient must be seen face-to-face by a licensed practitioner or a registered nurse who has been trained to conduct face-to-face assessments within one hour after the initiation of the restraint or seclusion. The facility’s Seclusion Use Procedure policy indicated a face to-face assessment must be completed by a practitioner within one hour of the seclusion initiation.”

“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: 33925 Based on observation, interview, and document review, the hospital failed to ensure nursing assessments for suicide risk were completed in accordance with hospital policies to demonstrate the ongoing evaluation of care for 1 of 10 patients (P3) reviewed. P3 was determined to be high-risk for suicide which required a reassessment from nursing to be done every shift; this was missed multiple times between 2/27/26 and 3/4/26, and P3 attempted suicide while admitted to the hospital on 3/4/26. P3 was assessed daily by psychiatrist (MD)-A. As a result, the hospital was found out of compliance with the Condition of Participation Nursing Service at 42 CFR 482.23. A condition level deficiency was issued at A-0385. See A-0395 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: 33925 Based on observation, interview, and document review, the hospital failed to ensure nursing assessments for suicide risk were completed in accordance with hospital policies to demonstrate the ongoing evaluation of care for 1 of 10 patients (P3) reviewed. P3 was determined to be high-risk for suicide which required a reassessment from nursing to be done every shift; however, this was missed multiple times between 2/27/26 and 3/4/26, and P3 attempted suicide while admitted to the hospital on 3/4/26. Findings include: P3’s ED to Hosp-Admission note, dated 2/17/26, identified P3 was a trauma case which presented via emergency medical services (EMS) to the emergency department (ED) with lacerations of the head, neck, and right arm. A main problem was listed, “Suicide attempt.” P3 was taken to surgery from the ED for the lacerations. P3’s Adult Behavioral Health Plan of Care, started 2/26/26, identified P3 would adhere to safety considerations for himself and others, and not have new injuries or illnesses. The plan directed multiple interventions including identifying risk factors for violence to self or others, obtain clinical history, discussing safety concerns with patient, and provide immediate and ongoing protective physical environment. The plan included a drop-down section labeled, “Outcomes,” which the nurses recorded P3 as progressing with these interventions on 2/27/26, 2/28/26, 3/1/26, 3/3/26, and 3/4/26 (3:35 a.m.). There was nothing recorded for 3/2/26. P3’s Behavioral Health (BH) Daily Progress Note, dated 2/27/26, identified an interdisciplinary team (IDT) meeting was held and P3 remained on 1:1 observation with restraints in place. P3 was placed in 4-point restraints by nursing due to severe agitation and clawing at his eyes. Medications were ordered and P3 denied being suicidal when asked by the provider. P3 had developed a potential infection in his arm laceration and would be transferred to the medical unit for care due to potential sepsis. The physician determined P3 to be high-risk for self-harm. The note included, “Suicide Risk: High,” and a safety assistant was in place. P3’s admission, discharge, transfer (ADT) Events, undated, identified P3’s unit locations while under the hospital’s care. This identified P3 was admitted on 2/17/26 to the emergency department (ED), was transferred to surgery and then to the inpatient psychiatric unit on 2/25/26. P3 was then transferred to the medical unit from 2/27/26 to 3/4/26. P3’s Department of Psychiatry Follow-Up Consult Notes, dated 3/1/26 to 3/3/26, indicated P3’s psychiatry history to date which showed P3 had been seen multiple times by the psychiatric provider (MD)-A while on the medical unit. These visits included: - On 3/1/26, P3 was seen and found to be significantly better with reduced neuropsychiatric symptoms. The provider outlined they were unsure whether the original suicide attempt was due to psychiatric or medical reasons. P3 was recorded as high-risk of self-harm. - On 3/2/26, P3 was seen and recorded as alert with mild confusion. P3 denied suicidal ideation but was unable to recall or explain the events prior to admission. The provider felt the attempt and subsequent self-injurious behaviors were related to an ongoing process which had not yet been identified. P3 needed to remain in a highly monitored area. - On 3/3/26, P3 was seen and now admitted that trying to remove his eyes (on 2/27/26) was a suicide attempt with P3 “ ... clearly remembers more about events that willing to discuss.” P3 remained at high-risk for self-harm. P3’s Flowsheet History, dated 2/27/26 to 3/4/26, identified the nursing suicide risk assessments which were to be completed every shift and what interventions the nurses identified to do for P3 from the assessment. These identified: - On 2/27/26 at 9:15 a.m., P3 denied being suicidal, and the interventions directed to reassess his suicide risk every shift and do an environmental assessment for safety. - On 2/28/26 at 8:00 p.m., P3 denied being suicidal, and the interventions directed to reassess his suicide risk every shift and do an environmental assessment for safety. - On 3/3/26 at 5:00 p.m., P3 denied being suicidal, and the interventions directed to reassess his suicide risk every shift and do an environmental assessment for safety. - On 3/4/26 at 8:14 a.m., P3 was recorded as, “Unable to assess.” There were no completed suicide risk assessments completed by the nursing team between 2/28/26 at 8:00 p.m. to 3/3/26 at 5:00 p.m., nor was there one completed for the night shift leading into 3/4/26 (7:00 p.m. to 7:00 a.m.) despite P3 being identified as a high-risk of suicide. P3’s Behavioral Emergency Response Team (BERT) Note, dated 3/4/26, identified at 8:05 a.m. a BERT was called for P3 who was doing self-injurious behavior. P3 was lying in bed when he suddenly started trying to claw and gouge his eyes out. The 1:1 sitter attempted to immediately intervene, however, P3 then physically assaulted them. The video camera alarmed due to the incident and the registered nurse (RN)-E assigned to P3 responded. P3 was then restrained. The note recorded, “Both eyes [P3] red and scratches and blood on face, and RIGHT eye in particular with significant trauma, bleeding continuously and swollen, unable to open.” A debrief was completed with staff and a safety plan was developed for P3 which included having security present for all cares when the now-applied restraints would be removed. P3’s Department of Psychiatry Follow-Up Consult Note, dated 3/4/26, identified P3 was evaluated after the self-harm attempt. The note outlined P3 became agitated and then attempted suicide by gouging at his eyes and attempting to jump out of the window resulting in significant injury. P3 also assaulted a staff member who was present and attempting to stop him from the self-harm acts. During observation and interview on 3/10/26 at 10:10 a.m., P3 was observed lying in bed in a private room. P3 had a visible white bandage over his right eye with a hard, clear plastic cover in place. P3 was restrained to the bed via 4-point restraints with white-colored mittens applied to both hands. P3 had visible lacerations on his arms and neck which had sutures in place. P3 stated he had “a mental breakdown” which made him try to pull it out of the socket and “scratch it out.” He wanted to harm himself when he did the act but denied wanting to harm himself now. P3 was asked about the restraints applied to him in bed and responded, “I know why they’re there.” Nursing assistant (NA)-A was present in the doorway for P3’s 1:1 which remained in place. NA-A stated a 1:1 was used for P3 to help ensure he remained safe and was immediately present to intervene with him if needed. On 3/10/26 at 11:11 a.m., P3’s medical record was reviewed with registered nurse managers (RN)-B and RN-C. They explained the floor nurses worked either 8- or 12-hour shifts on the unit, and a nursing suicide risk assessment should be completed every shift for P3 due to his risk level and history or suicide attempts. RN-C stated the medical record lacked several nursing suicide risk assessments being documented which should have been done. RN-C stated the record showed “gaps in that,” but reiterated the psychiatric provider had been following P3 while on the medical unit. RN-B and RN-C both stated no education with nursing staff had been started about ensuring their suicide risk assessments get completed each shift. There was a meeting scheduled for later that week which is where they would decide what needed to be re-educated from P3’s incident. RN-B and RN-C both expressed it was important to complete the flowsheet assessments so there was an ongoing understanding of the risk of self-harm with P3 since P3 had a history of “back and forth” with his stated suicidal ideation. During an interview on 3/10/26 at 10:38 a.m., registered nurse (RN)-A stated they were assigned care for P3 on 3/9/26 and 3/10/26. P3 needed help with most cares due to the restraints which were being removed every two hours for skin checks. RN-A stated P3 had a 1:1 sitter in place since he came to the unit for safety due to previous self-injurious behaviors. RN-A explained the nurses should be completing a suicide risk assessment in the flowsheets every shift due to P3’s history of suicide attempt. RN-A verified P3 would be considered “high risk” due to his history. RN-A could not recall any recent education on these flowsheet assessments being done. During an interview on 3/11/26 at 10:16 a.m., the manager for nursing education (MNE) was interviewed and stated staff were provided education on the suicide risk assessments upon hire and ongoing with periodic refreshers afterward. The frequency of a patient reassessment while admitted was determined by their risk level, and they should be completed per policy. MNE stated the assessments were important to get done and recorded to help monitor for changes in suicidal ideation and then to adjust interventions if needed. During an interview on 3/11/26 at 11:02 a.m., MD-A stated they were one of the psychiatric providers who had been involved with P3 since he was admitted to the hospital. P3 transferred to the medical unit on 2/27/26, after discussion with the medical team to better manage his acute infection. MD-A stated they had been working on medication adjustment for P3, and they felt P3 had improved on the medical unit up until his attempted self-harm act on 3/4/26. P3 had been “waxing and waning” with his reported suicidal ideation but felt there was no obvious warning signs P3 would attempt to injure himself again like he did on 3/4/26. MD-A stated P3 would be considered “high-risk” for suicide since he admitted to the hospital, but they did not think the missed nursing assessments would have identified the imminent self-harm act on 3/4/26. The hospital Suicide Risk Assessment Policy, undated, identified a purpose of providing guidelines on assessing and reassessing the risk for suicide in patients. All patients assessed to be at-risk for suicide would have appropriate actions taken to mitigate the risk. The RN has authority and responsibility to initiate suicide precautions. The policy directed, “Patients assessed as moderate or high risk will be reassessed every care shift while awake ... [it] will include suicidal thoughts/ideation, method, plan/intent, and active self-harm behaviors.””

“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: 33925 Based on observation, interview, and document review, the hospital failed to ensure a developed skin condition on the feet was acted upon, evaluated and, if needed, treated to prevent worsening or complication (i.e., infection, discomfort) for 1 of 10 patients (P1) reviewed. In addition, the hospital failed to ensure thick, dystrophic toenails were re-evaluated and, if needed, referred back to podiatry to be addressed for 1 of 10 patients (P1) reviewed for coordination of care. Findings include: On 11/10/25 at 10:43 a.m., the Northeast 8 unit was toured with registered nurse (RN)-A present. The unit consisted of 20 beds and was primarily a psychiatric care unit. Following, at 10:56 a.m., P1 was observed seated in the commons area watching television dressed in dark-orange-colored scrubs and wearing bilateral gripper socks. P1 was interviewed and expressed several frustrations while at the hospital including a perceived lack of medical care coordination. P1 explained she had a previous history of lower extremity swelling and her legs were never the same since. P1 removed the socks from her feet which exposed multiple, long, and thick toenails which were dark yellow in color. P1’s skin on her bilateral feet appeared with white scaling present on the anterior and plantar surface of the foot extending up the back of the heel and shin. P1 stated her feet had been in that condition “awhile” and explained a “foot doctor” had looked at her feet awhile prior and reported it was an outpatient issue to be done when she left the hospital. However, nobody had ever followed up since then despite P1 remaining in the hospital for so long. P1 stated she was agreeable to treatment for her skin and toenails adding, “Oh, absolutely!” P1 reiterated the lack of care coordination was frustrating for her adding aloud, “The follow-up is not good.” P1’s Note, dated 8/25/25, identified P1 complained of being “held hostage” and was unhappy with not being able to discharge. The note outlined, “ ... Wants to see a podiatrist regarding her ingrown fungal toenails, is unhappy that it cannot be done impatiently. Tried to soak her feet and had this RN attempt to cut her toenails but it was not successful [because] lack of right tools.” P1’s Foot & Ankle Consultation note, dated 9/29/25, identified a referral was placed due to bilateral great toe dystrophic nails (i.e., deformed, thickened, discolored). The note outlined P1 as having a history of lymphoma, manic mood disorder, and a hemorrhagic stroke along with a recent history of DVT (deep vein thrombosis) and being started on anticoagulant medication. The note outlined two diagnoses were made including, “1. Dystrophic nails, bilateral hallux and 2nd digit,” and “2. Bilateral lower extremity edema, recurrent.” The plan for them detailed, “ ... Discussed with the patient in great detail their current situation ... given her clinical picture, there is not acute concern for an infection that requires antibiotics or procedural or surgical intervention from our team ... in the outpatient setting we may address dystrophic or fungal nails ... Patient expressed understanding ... will place are [sic] clinic information in her discharge tab so that when she leaves the hospital she can schedule a follow up ...” P1’s Social Work Progress Note, dated 10/6/25, identified P1’s family member (FM) was contacted, and guardianship process was underway. The note identified FM reported, “ ... concern about [P1] feet, toenails, reports that when [they] last visited [P1] weeks ago, they were discolored, appeared to have fungus. Writer relayed concern to attending and RN, who reports podiatry has been consulted previously [9/29/25].” P1’s subsequent Social Work Progress Note, dated 10/9/25, identified P1 the provider consulted with podiatry on the FM concerns, however, the note outlined, “Podiatry and wound are unavailable to consult.” P1’s Flowsheet(s), dated 9/12/25 to current, identified the nursing monitoring being completed for P1 such as vital signs, skin condition, and pulses. This identified the last charted reference on 11/10/25 at 11:19 a.m., which charted P1’s skin condition as, “WDL [within defined limits].” The charting lacked any further information or dictation on what, if any, interventions were being done for the dried skin or toenails. Further, P1’s most recent Braden Risk Assessment, dated 11/9/25, identified a score of 23 (i.e., No Risk). P1’s medical record was reviewed, and lacked evidence P1 had been re-evaluated or referred to the podiatry specialty to address her overgrown toenails since it had attempted on 10/6/25, despite P1 remaining in the hospital and likely to be there for several more weeks with known toenail impairments. In addition, the record lacked evidence P1’s lower extremity skin had been identified, acted upon, or addressed with P1 (i.e., treatment offered) despite having impaired skin on her lower legs/feet and have a history of circulation concerns in her legs. When interviewed on 11/10/25 at 1:08 p.m., registered nurse (RN)-B verified they had worked with P1 prior. RN-B explained P1 admitted to the medical unit several months prior and then transferred to the psychiatric unit following that while remaining on infusions for treatment. RN-B stated P1 had a history of DVT and explained the hospital’ process for skin checks or monitoring was usually a skin check on admission and then “orders” following that adding a “more focused assessment” would be done if issues were identified. RN-B verified they had observed P1’s feet and legs prior and, at the request of the surveyor, went to observe them. RN-B verified P1’s feet and toenails, then expressed aloud that maybe the ongoing infusion therapy “dried her out a little bit.” RN-B described P1’s feet as “definitely very dry,” and added the toenails were “pretty thick,” which was a noticeable change from when they (RN-B) had last observed them. RN-B explained if a skin condition, such as P1’s feet condition, was noticed then it should be referred to the medical provider who could order treatment or a consult. RN-B stated they recalled P1 having a skin cream ordered prior; however, it was for her arm and a rash that had since resolved. RN-B expressed P1 did have a podiatry consult at one time, however, was unsure exactly when or what details were reviewed. Further, RN-B reiterated P1’s skin on her feet looked “very, very dry” and verified P1 had no current treatments ordered for it to their knowledge. On 11/10/25 at 2:26 p.m., medical doctor (MD)-A was interviewed, and expressed they were “somewhat” involved with P1’s care at the hospital having admitted P1 to the psychiatry unit back in September 2025. MD-A explained P1 had been seen prior by the foot service (9/29/25), however, expressed he felt that service “could be courteous and do something” with her toenails. MD-A stated the service, when they saw P1 on 9/29/25, likely did not realize how long P1 would be at the hospital still when they deferred her to outpatient treatment. MD-A stated neither P1 or the nursing staff had reported to them any concerns with P1’s toenails or lower extremity skin condition adding, “It has not been brought up this week.” MD-A stated they could address it if it had been, adding timely treatment was important to prevent infection. MD-A added since P1 was in the hospital then, “We’ve got to address all [her] physical health.” On 11/12/25 at 10:42 a.m., registered nurse unit manager (RN)-C and social worker (SW)-A were interviewed, and RN-C verified they had been given an opportunity to review P1’s medical record. RN-C explained the hospital’ skin monitoring process depends heavily on the Braden scale (tool used to determine pressure injury risk) which is completed and, from that, if a “focused area” is not identified then items could be missed. RN-C verified they had observed P1’s feet and expressed they “looked very dry.” RN-C verified they were unable to locate any documentation to show P1 had been asked about her feet skin condition, such as treatment being offered, or any re-evaluation of the toenails and expressed that should be recorded in the medical record if it was done. RN-C the medical team just reviewed P1 yesterday (11/11) and now a cream was ordered which P1 was allowing to be done. RN-C reiterated ongoing skin checks (i.e., head to toe) are done “only if there’s a known problem.” RN-C reviewed P1’s care plan in the medical record which listed a section labeled, “Basic Skin Care,” but lacked any monitoring or interventions for P1’s lower extremity skin condition or toenails. RN-C stated the Braden Scale(s) were being done but “not capturing the focused issue.” RN-C stated adding that to the care plan would be “great.” Further, RN-C stated the hospital would look at a process to ensure items such as toenails and skin impairments on the psychiatric unit were re-evaluated timely adding aloud, “I think the opportunities are clear.” A hospital Skin and Risk Assessment policy, undated, identified the hospital would evaluate each patient for the presence of skin breakdown and risk of developing pressure injuries adding, “When a problem or its potential is identified, appropriate interdisciplinary care and interventions will be implemented and the response to the interventions will be documented in the patient’s record of care.” The policy directed a full head-to-toe skin assessment would be completed upon admission, and the RN would complete risk assessments (i.e., Braden) throughout the hospital admission. The policy directed these assessments would be done based on unit location; this included, “ii. Mental Health and Birth Center units daily for patients that: 1. are bed/chair bound 2. have a Braden score [equal to, less than] 18 3. or have an existing skin injury.””

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 33925 Based on interview and document review, the hospital failed to ensure vital sign monitoring during a blood transfusion was completed or documented in the medical record in accordance with hospital policies to promote continuity of care for 1 of 2 patients (P4) reviewed who had received a blood transfusion. Findings include: P4’s Flowsheets, dated 10/21/25, identified P4 had a blood product administration completed on the medical floor on the same date. The documentation outlined P4 had a history of previous transfusion reaction(s) and recorded the following information: At 1:40 p.m., P4’s vital signs were obtained and recorded. At 1:46 p.m., P4’s blood product was started. At 2:23 p.m. (37 minutes later), the first set of vital signs after the blood product was started was recorded. This identified P4’s temperature as 98.8 (F), pulse 86, blood pressure of 103/60 (mmHg), and an elevated respiratory rate of 29. At 5:43 p.m., the blood administration was recorded as, “Completed.” P4’s corresponding Note, dated 10/21/25 at 6:16 p.m., identified P4 was alert and oriented and had stable vital signs. The note outlined, “Pt received one unit pRBCs [blood product] without issue.” The note was authored by registered nurse (RN)-H, however, lacked any further information or dictation on the blood administration or vital signs obtained with it. On 11/12/25 at 8:31 a.m., P4’s medical record was reviewed with registered nurse (RN)-E and RN-F present. RN-E explained P4 admitted to the hospital on 10/14/25, adding P4 had several recorded blood transfusions completed. The most recent one being on 10/21/25 which was completed on the medical floor. During the interview, RN-G joined via Teams and reviewed the record. RN-E and RN-G both verified the lack of vital sign documentation at 15 minutes after the blood was started, and RN-G stated aloud, “This was off, this was not 15 minutes.” RN-F reviewed the hospital policy on blood transfusion during this time, and they verified vital signs were to be taken and recorded at the 15 minute interval after blood products were started. RN-G added aloud, “They’re really shouldn’t be any reason it’s not being documented.” Following, on 11/12/25 at 1:11 p.m., RN-H was interviewed via telephone, and verified they did administer blood on the medical units at times. RN-H stated blood product needed to be started “right away” after arriving to the floor and explained they take vital signs just prior to starting it, about 15 minutes after the blood physically enters the patient, and upon the completion of the administration. RN-H stated if the patient had a history of reaction to blood product, then they would often place the patient on telemetry monitoring to help monitor the vital signs. However, the telemetry equipment did not automatically record vital signs, and the nurse was still responsible to enter those into the record adding the nurse typically had to manually enter vital signs into the record aside from the blood pressure. RN-H expressed the nurse remains with the patient after starting the blood product until, at minimum, the first set of vital signs are obtained. RN-H stated from the minute when the pump was activated to when the blood reached the patients bloodstream (via IV) was usually only “about five minutes or so.” RN-H recalled P4 and expressed the family was often present in the room and P4 did not speak fluent English. RN-H stated they did not recall the exact specifics or rationale why P4’s vital signs wouldn’t have been recorded in the record timely, but reiterated they would have remained with the patient after starting it. RN-H added aloud, “Maybe I should have taken another one [set of vitals].” The hospital Blood Product Administration Procedure policy, dated 6/2023, identified a section labeled, “Procedure,” which directed a step-by-step process to administer the blood product adding the start of a transfusion was established as, “ ... when the blood product reaches the hub of the patient’s [IV] catheter.” The policy continued and listed a sub-section labeled, “D. Assessments,” which directed vital signs should “ ... occur as follows unless otherwise delineated in Blood Product Transfusion Protocol or Practitioner order ... [including] b. 15 minutes after the start of the transfusion.””

“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 documentation and interview, the facility failed to ensure restraints were not applied as a form of convenience for one out of four patients (P4) reviewed for restraints when nonviolent bilateral restraints were applied by nursing to prevent falls, and other non-invasive interventions were not attempted. P4 presented to the emergency department (ED) via ambulance on 8/28/25 at 3:38 p.m. for concerns of weakness and altered mental status. P4’s relevant medical history included autism spectrum disorder requiring very substantial support, seizures, and dysphagia. A provider note dated 8/28/25 at 3:41 p.m. indicated P4 presented from longstanding group home with increased incidence of falls and decreased responsiveness. The note indicated P4 would be admitted on an observation basis. A nursing note written by registered nurse (RN)-A dated 8/28/25 at 4:15 p.m. indicated P4 baseline was nonverbal and presented with their group home staff member. The note indicated P4 made multiple attempts to leave bed, requiring nursing staff intervention for each instance. A nursing note written by RN-A dated 8/28/25 at 6:40 p.m. indicated P4’s baseline in the community was to be restless and pacing. On 8/28/25 at 4:34 p.m., a provider order for nonviolent bilateral soft wrist and ankle restraints was placed. A nonviolent restraint flowsheet entry by RN-A on 8/28/25 at 4:56 p.m. indicated soft wrist restraints were applied to P4’s left and right wrist due to his high fall risk. The flowsheet indicated RN-A attempted calming techniques, emotional support, offering medication, and having P4’s group home staff member at bedside. The flowsheet did not indicate if a 1:1 safety monitoring assistant was attempted. A fall risk completed on 8/28/25 at 5:00 p.m. indicated P4 was within staff’s reach, and universal fall precautions were in place per best practice. The fall risk indicated P4 was at risk for falls due to generalized weakness. A nonviolent restraint flowsheet entry by RN-A on 8/28/25 at 6:56 p.m. indicated P4 continued in restraints due to high fall risk. A nonviolent restraint flowsheet 8/28/25 at 8:56 p.m. indicated P4 continued in nonviolent restraints due to concerns with pulling at lines and tubes. On 8/28/25 at 10:22 p.m., P4 was transferred to observation. On 8/29/25 at 3:27 p.m. P4 was transferred to south 10, a neuro and general medicine inpatient unit. On 8/29/25 at 11:59 p.m., the order for nonviolent bilateral soft wrist and ankle restraints was renewed. On 8/30/25 at 2:00 a.m., P4 was removed from restraints. On 8/29/25 at 3:36 a.m., nursing staff noted the use of a safety assistant at the bedside was used to maintain safety. A safety assistant hourly documentation flowsheet created at 8/29/25 at 7:47 a.m. indicated P4 was kept in bed through verbal redirection, reorientation, and distraction. On 8/29/25 at 10:05 a.m., an order for a safety assistant was placed. During an interview on 9/17/25 at 11:31 a.m., RN-B stated nonviolent restraints are used if a patient is not redirectable and pull-on lines and tubing that put their health at risk. RN-B stated prior to using restraints, the staff should attempt other interventions such as medication, video monitoring, distracting the patient, or having family present at bedside. During an interview on 9/17/25 at 11:48 a.m., RN-C stated the use of soft or nonviolent restraints is only if a patient is trying to remove lines or tubing. RN-C stated staff can attempt verbal de-escalation or recognizing the patient’s triggers. During an interview on 9/17/25 at 12:03 p.m., RN-D stated nonviolent restraints are used only when staff have attempted all other interventions and patient is still pulling on their lines. RN-D stated staff can try music therapy, massage, as needed medications, or high low beds as alternatives to restraints. RN-D stated P4 was a patient who wanted to be up and walking around and interacting with the unit. RN-D stated they used a 1:1 safety assistant to push P4 around the unit and P4 did not need to be in restraints. During an interview on 9/18/25 at 10:42 a.m., nurse manager-A stated restraints are used on patients who are a danger to themselves or other. Nurse manager-A stated nursing staff must begin with the least restrictive methods, such as reorientation, reeducation, medications, or a 1:1 patient safety assignment. Nurse Manager-A stated if an unstable patient is trying to leave bed, the staff should reorient or reeducate the patient on the safety risks and importance of staying in bed. During an interview on 9/18/25 at 12:11 p.m., RN-E stated P4 was placed on a 1:1 for his own safety because he needed two staff to ambulate. RN-E stated P4 needed constant redirection, but he could follow directions. During an interview on 9/18/25 at 1:05 p.m., RN-F stated soft restraints are used if a patient is removing important tubing and medical equipment or are a safety risk to themselves. RN-F stated prior to using restraints, staff should attempt other interventions such as higher levels of supervision, video safety assistants, bed alarms, calming measures, 1:1 staff assignment, or as needed medications. During an interview on 9/18/25 at 3:42 p.m., RN-A stated nonviolent restraints can be used for patient safety, such as pulling at lines and tubes and those who are fall risks. RN-A stated staff should attempt to redirect, reorient, or distracting the patient. RN-A stated she did not know how soon after applying restraints she needs to get an order. RN-A stated restraints are removed from a patient if they are oriented, able to follow commands, and understand why they cannot pull at lines. RN-A stated if a patient is nonverbal, staff may discontinue the restraints if the patient is “not trying to crawl out of bed.” RN-A stated she did not remember caring for P4. During an interview on 9/18/25 at 1:56 p.m., nurse manager-B stated staff apply restraints when patients are pulling at lines, tubing, or medical devices. Nurse manager-B stated restraints are not used to prevent falls. Nurse manager-B stated if a patient continues to try and get out of bed, staff need to use bed or chair alarms and remind the patient to stay in bed. During an interview on 9/18/25 at 4:26 p.m., the director of nursing for medical surgical and acute rehabilitation services stated restraints are typically not a strategy the hospital uses to prevent falls. The director stated staff need to begin with low beds, bed alarms, chair alarms, video safety assistants, or in-person safety assistant monitoring. The director stated the interventions attempted are dependent on the patient’s needs. An undated facility policy titled “Restraint (Non-violent and Violent) and Seclusion Policy” indicated non-violent restraints may be applied if less restrictive measures have been applied. The policy indicated least restrictive interventions may be safety monitoring, coping techniques, or offering medications.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(ii) [there must be documentation in the patient’s medical record of the following:] A description of the patient’s behavior and the intervention used. This Standard is not met as evidenced by: 47264 Based on interview and document review, the facility failed to appropriately document the type of restraints used for one of four patients (P1) reviewed for restraint application when P1 was placed in violent restraints to prevent imminent harm to others. Findings include: P1 presented to the emergency department on 6/28/25 at 3:11 p.m. via ambulance after being found unresponsive in the community. P1 did not have a chief complaint on file and did not have a relevant medical history. An order dated 6/28/25 at 4:31 p.m. indicated P1 was placed in bilateral wrist and ankle non-violent restraints to prevent pulling at lines and tubes. There was no order for placement of violent restraints in P1’s medical record. Flowsheet documentation under non-violent restraints on 6/28/25 at 4:40 p.m., bilateral soft wrist restraints were applied to P1 for pulling lines and tubes. The flowsheet documentation indicated alternative methods could not be attempted due to P1’s condition. Flowsheet documentation did not indicate P1 was placed in violent restraints during his hospitalization. A provider note dated 6/28/25 at 4:54 p.m., indicated P1 had run out of his room while screaming and hitting equipment and furniture. Security was involved and P1 was placed in four-point restraints. The note indicated despite restraints, P1 continued violent behavior, and multiple medications were administered to chemically sedate the patient. Despite additional medications, P1 continued to scream and fight the restraints, creating a high-risk of self-harm. The note indicated P1 was given additional medication and then intubated for airway protection. During an interview on 7/9/25 11:19 a.m., registered nurse (RN) -A stated staff are trained how to use nonviolent restraints, which are often called soft restraints. RN-A stated staff can place patients in four-point locking restraints as well, which are often referred to as hard restraints. During an interview on 7/9/25 at 2:32 p.m., RN-B stated four-point violent restraints are used to if a patient is threatening or hurting staff or others. RN-B stated non-violent restraints are to protect a patient if they are pulling at their tubes supporting their airway. During an interview on 7/10/525 at 9:12 a.m., medical doctor (MD)-A stated he had been caring for P1 in the ED on 6/28/25. MD-A stated he observed as security, nursing, and the police transferred to P1 to a bed and was placed in four-point restraints. MD-A stated P1 was so agitated the decision was made to chemically sedate P1 and intubate to protect his airway as he was a risk to hurting himself while restrained. MD-A stated P1 was then transitioned to non-violent restraints. During an interview on 7/10/25 at 11:00 a.m., security guard (SG) - A stated he was trained how to use multiple types of medical restraints, including violent restraints and soft restraints. SG-A stated he assisted in placing P1 into four-point hard restraints, and then medical staff intubated P1. During an interview on 7/10/25 at 11:21 a.m., SG-B stated he was trained in soft restraints and four-point locked restraints. SG-B stated he assisted placing P1 in four-point hard restraints in the ED. During an interview on 7/10/25 at 1:47 p.m., RN-C stated she was working in the ED on 6/28/25 when P1 began having a behavioral episode. RN-C stated when P1 was placed into four-point restraints, she administered an IM dose of a chemical restraint with a verbal order from a provider. During an interview on 7/10/25 at 2:03 p.m., RN-D stated violent restraints requiring documentation by a nurse every fifteen minutes. During an interview on 7/14/25 at 8:36 a.m., RN-E stated she was at break during P1’s behavioral outburst on 6/28/25. RN-E stated when she returned, P1 was being manually held on the bed by staff as they waited for sedation to take effect. RN-E stated afterwards, they placed P1 into bilateral wrist soft restraints. During chart review on 7/14/25 at 9:49 a.m., the nursing informatics program manager stated there was no order in P1’s chart for violent restraints, and there was no charting for placement of violent restraints. During an interview on 7/14/25 at 11:44 a.m., the nursing supervisor of the ED stated restraints violent restraints should be documented on every 15 minutes by the nurse. An undated facility policy titled “Restraint (Non-violent and Violent) and Seclusion Policy,” indicated upon initiation of restraint there must be documentation of the type of intervention used.”

“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: 43080 Based on interview and document review, the hospital failed to provide An Important Message from Medicare (IM) notice within two days of admission, and/or two days of discharge, for 6 of 10 Medicare beneficiary inpatient patients (P2, P33, P35, P37, P39, P40). This had the potential to impact all Medicare beneficiaries admitted to, and discharged from, 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 2/13/24, during the abbreviated medical record review process, which started at 1:12 p.m., the following information was identified: -P2 admitted on 12/11/24 and discharged on 12/19/24. P2’s insurance was identified as Medicare. The Patient Contact section identified two sons as emergency contacts. P2’s record identified an unsigned IM notice “Copy”, effective 12/12/24. P2’s record lacked documentation as to why the notice was placed into P2’s record unsigned and/or if the notice was officially provided as required. In addition, P2’s record lacked a discharge provided signed and dated IM notice, or documentation to support attempt(s) to provide the notice. An email, dated 2/13/25 at 4:04 p.m., from the accreditation and regulatory compliance manager (CM)-A, identified P2 was in isolation and thus a patient access registration staff member (PR) left the IM notice, and a copy, with the HUC (health unit coordinator) on P2’s unit with the intent the HUC would obtain P2’s signature on one of the IM notices and then the other copy would be left with P2. In response, PR staff entered an unsigned copy of the IM notice in P2’s record and marked it ‘received.’ CM-A identified P2’s chart lacked an admission signed IM notice. Additionally, the email identified, “It appears we missed delivering the IMM on day of discharge. Patient registration leadership acknowledges this, and that further staff education is needed.” In follow-up, additional investigation and record review was conducted, and the following information was identified: -P40 was admitted on 1/15/25 and discharged on 2/13/25. P40’s face sheet identified Medicare benefits. A Hospital Account History entry, dated 1/16/25, identified PR staff attempted to interview P40; however, they were unsuccessful. A Comment identified, “procedure.” A follow-up account history entry, dated 1/17/25, identified the 1/15/25 unsuccessful interview; however, the Comments section identified P40 was oriented to self. An account history entry, dated 1/20/25, identified the admission IM was provided to P40. The Patient Contact section identified P40’s son was her HCA, along with a significant other as an emergency contact and a daughter. P40’s medical record lacked documentation to support attempt(s) to provide the admission IM notice to P40’s contacts when P40 was unable to sign the IM notice within two days of his admission. Additionally, P40’s medical record lacked evidence of a discharge provided signed and dated IM notice, or documentation to support attempt(s) to provide the notice to P40, his son, or one of his other contacts. -P37 admitted on 1/30/25 and discharged on 2/13/25. P33’s face sheet identified Medicare benefits. A Hospital Account History entry, dated 1/31/25, identified P37 was provided the admission IM notice along with a copy of the IM signed notice. The Patient Contact section identified two daughters as emergency contacts. P33’s medical record lacked evidence of a discharge provided signed and dated IM notice, or documentation to support attempt(s) to provide the notice to P33 or one of P33’s daughters. -P39 admitted on 2/5/25 and discharged on 2/13/25. P39’s face sheet identified Medicare benefits. A Hospital Account History entry, dated 2/6/25, identified P39 was provided the admission IM notice along with a copy of the IM signed notice. The Patient Contact section identified a son and daughter as emergency contacts. P39’s medical record lacked evidence of a discharge provided signed and dated IM notice, or documentation to support attempt(s) to provide the notice to P39 and/or P33’s son or daughter. -P35 admitted on 2/7/25 and discharged on 2/13/25 due to death. P35’s face sheet identified Medicare benefits. The Patient Contact section identified P35’s son was power of attorney (POA), along with three grandchildren as additional emergency contacts. A Hospital Account History entry, identified on 2/7/25, P35’s son assisted with the registration process due to P35’s “medical condition.” P35’s medical record lacked documentation the IM notice was provided at that time. A follow-up account history entry, dated 2/7/25, identified the IM was attempted with P35; however, P35 was “not waking.” P35’s medical record identified P35 was lethargic, and the son was not present with P35 at that time. An additional account history entry, dated 2/13/25, identified PR staff again attempted to visit with P35; however, staff identified P35 had passed away. P35’s medical record lacked evidence of an admission provided signed and dated IM notice, or documentation to support attempt(s) to provide the notice to P35’s son or emergency contacts. -P33 admitted on 2/8/25 and discharged on 2/14/25 due to death. P33’s face sheet identified Medicare benefits. A Hospital Account History notes, identified P33’s 2/8/25 registration process was “pushed through due to a code CVA (stroke),” and the registration process was not completed. A follow-up account history entry, dated 2/10/25, identified that due to P33’s continued condition, registration again was not completed. The Patient Contact section identified P33’s wife as his Health Care Agent (HCA), along with a sibling as an additional emergency contact. P33’s medical record lacked evidence of an admission provided signed and dated IM notice, or documentation to support attempt(s) to provide the notice to P33’s wife or emergency contacts. When interviewed on 2/14/24 at 4:15 p.m., PR-A stated the IM notices were to be issued within the first two days of admission and a signature obtained on the notice, and then, up to four hours prior to discharge, they were required to provide a copy of the signed admission notice. If the patient was unable to sign when first approached for issuance, she was instructed to document the reason for the unsuccessful attempt, and then she was to continue to approach each day until a signature was obtained. All continued unsuccessful attempts were expected to be documented. PR-A stated that for someone else, other than the patient, to sign the IM notice, the patient needed to consent to the other person signing the notice and that person had to be the spouse or family. If the patient was unable to provide such consent, the signer needed to be a legal guardian or POA, in which she had to ensure the patient’s medical record contained the necessary paperwork to provide evidence of such designations. PR-A explained she was to only call via the telephone for notice issuance “if it was clear” who she could talk to: “We cannot call the neighbor.” If the patient was unable to sign, and there was no one present who could sign, they checked back with the patient the next “rotation” to see if the patient was able to sign, or if any of the above individuals were present, which could still be that same day or the next day, if it was reattempted within 24 hours. PR-A stated she overall was able to complete these processes “in house” without having to call. PR-A explained the patients’ names stayed within the utilized system until the signatures were obtained, and thus each day this system was checked for workflows. Additionally, once the discharge date was entered into this system, the workflow would identify the need for a discharge IM notice process. For discharging patients, they ensured the copy was provided and documentation was entered to support this process. After the copy was provided, the copy, which was labeled “copy,” was scanned into the medical chart as evidence this process was completed. PR-A stated, at times, depending on the patient’s medical condition and/or situation, she left the IM notice with nursing staff for nursing staff to obtain the signature and/or to provide a copy to the patient. She explained this was what occurred with P2. PR-A explained she went to issue the admission IM notice to P2; however, P2 was not alert, and thus she was unable to give. She provided a copy of the form to the HUC, with instructions to provide to P2, in case P2 woke up enough and wanted the information on the form. PR-A denied she contacted anyone on P2’s contact list. PR-A explained she missed the window for the admission notice issuance and because P2 did not sign the form, and the way the system worked and how she documented the copy provided to the nursing staff, P2 did not get a copy of a signed notice prior to discharge. PR-A stated she was never instructed to leave the notices with nursing staff, and she was unsure if nursing and/or the HUC provided P2 with the paperwork she left for P2. During a telephone interview on 2/14/25 at 4:46 p.m., the patient access registration manager (PRM) stated an admission IM notice was expected within two days of admission and two days prior to discharge and there were no exceptions. She explained the PR staff worked out of the work cues and checked this daily for when admission and discharge IM processes were expected to be completed. She expected the admission IM notice contained a signature, and the discharge IM notice was a copy of this signed admission notice. If the patient was unable to sign, “anyone can sign” the notice on behalf of the patient. If the patient was unable to sign and there were no visitors present, a copy of the form was left with the HUC, or nurse, and they were asked to provide it when able, or the PR staff would continue to make attempts. The PRM was unsure if nursing staff and/or the HUC were trained to issue the notices, and she was unsure how often this practice occurred. Additionally, she was unable to verify these forms were returned when nursing and/or the HUC was asked to assist. If the patient had a POA or HCA, PR staff attempted to contact them via a telephone call. This was expected to be completed within the required timeframes of issuance and was to be documented. The PRM explained PR staffing was limited at this time and felt this was one factor that increased the risk of notice deliverance concerns; however, she was unaware of any current issues, prior to the abbreviated survey, with this process as there were no recent audits on this process. The PRM identified the PR staff required re-education as when she conducted record review on the six patients, she was unable to find evidence staff contacted the representative and/or followed the required processes for notice issuance. On 2/14/25 at 5:08 p.m., CM-A, the senior director of hospital quality (DHQ), and the regulatory specialist (RS)-A were interviewed. CM-A was unaware of any recent education directed at PR staff related to IM processes. She identified their hospital system was working on system wide processes to unify the IM processes amongst all their hospitals, as another hospital in their system was identified to have concerns in this area. All were unaware of concerns with the IM processes within their facility, prior to the abbreviated survey; however, “some gaps” were identified this day, despite staff being expected to follow the process standards. CM-A identified there was no current policy related to IM notices; however, PR staff were to follow an IM workflow process. An IMM: 1st and 2nd Letter Process procedural standard flowsheet, dated 4/28/24, identified the facility had determined due to staffing levels, these forms were not provided timely which potentially led to financial hardship of Medicare beneficiaries if Medicare did not pay, or if patients were not fully aware of their rights during their inpatient stay. After they investigated these concerns, they determined their current workflow was not sufficient to meet compliance requirements and a plan was put into place. The procedure directed the first IM notice was to be provided within two days (48 hours) of admission and the second IM letter copy was to be provided within two days (48 hours) of discharge. Going forward, staff were to work from the work cues and instructions on this process were provided on how to determine which patients required which letter and when. The procedure identified that anyone (spouse, children, etc.,) can sign the IM for the patient: it was not limited to the POA or guardian. If the patient was unable to sign and the POA was out of town, or unable to come to the hospital in a timely manner, a verbal consent was to be obtained, and the conversation documented. The facility had an undated procedure outlining the process to issue the Important Message (IMM) from Medicare to patients identifying not giving the IMM timely can cause financial hardships for the patient if Medicare does not pay, or the patient is not fully aware of their rights during their inpatient say.”

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 43080 Based on interview, document, and audio review, the receiving hospital (HOSP)-A failed to collaborate with and/or accept transfers from transferring HOSP-B, when HOSP-A had capability to provide care and services for 2 of 2 (P31, P32) patients who required ophthalmology surgical care and treatment that HOSP-B was unable to provide. The findings include: P32’s HOSP-B medical record identified P32 presented to the emergency department (ED) on 10/13/24 (Sunday) at 4:27 p.m. for evaluation of a high force eye injury. P32 experienced, about an hour before arrival, an incident where an air compressor’s metal tubing, with a PSI of 100, hit him in the eye when he disconnected it from the air compressor. P32 was initially unable to see out of his right eye; however, when the eye was “forcibly opened,” he could see. During the medical screening exam, performed by medical provider (MD)-A, P32’s right upper and lower eye lids were edematous and crepitus was present. Anisocoria of the pupil appeared tear drop in share compared to the left. Additionally, there was chemosis of the right eye and some bubbles formed in the top portion. P32 had a positive Seidel sign. MD-A suspected P32 sustained likely facial fractures and an open globe eye injury. In addition, MD-A wanted retrobulbar hematoma to be ruled out. P32’s MD-A Emergency Department Course and Medical Decision Making entry, dated 10/13/24, identified MD-A contacted HOSP-A that evening and spoke to Health Partners Direct (HPD) staff, to coordinate an ED to ED transfer for management of an open globe injury that needed emergent ophthalmologic evaluation with likely operating room (OR) repair as P32 presented with a significant threat to his vision, and made it very clear they did not have ophthalmology services at that time. In response to the call, HPD staff communicated with their ophthalmologist, who in turn, declined the transfer because HOSP-B had the ‘ability to care for this patient,’ and HOSP-A did not accept out of system transfers for eye problems. Additionally, HOSP-A’s trauma surgeon and ED provider also declined, based on ophthalmology’s refusal. After this, MD-A was able to secure transfer acceptance to a different level 1 trauma center for P32’s needed eye repair. An Inter-Facility Transfer Form, dated 10/13/24, identified P32 required ALS (advanced life support) transfer for ophthalmologic trauma services as HOSP-B lacked the capability to render further examination and treatment. On 10/13/24 at 6:36 p.m., P32’s medical record identified he transferred out. HPD call audio recordings, dated 10/13/24, identified the following relevant synopses of conversations: -5:29 p.m., MD-A spoke to HPD-A and requested an ED-to-ED transfer as P32 required an ophthalmology eval for eye trauma and a globe rupture. HPD-A verified the hospital and asked if P32 was part of the HP system or if P32 was just a trauma transfer. MD-A reported trauma transfer. -5:33 p.m., HPD-A relayed there were changes with their policy and questioned if the only injury was related to the eye. MD-A confirmed and explained again the nature of the transfer request. HPD-A asked if HOSP-B had ophthalmology trauma coverage. MD-A responded “no ophtho” and “certainly no ophthalmology trauma” coverage. MD-A requested to speak to an ED provider as they would know what type of coverage HOSP-A had. HPD-A explained changes in their ophthalmology policy, and they no longer provided consults out of the system and no longer accepted transfers from hospitals that had ophthalmology resources within their own systems. MD-A again stated HOSP-B did not have such services there and P32 required a level one trauma center. -5:35 p.m., HPD-A requested additional P32 details and inquired if P32 required surgery that night. MD-A confirmed and asked to speak to someone to understand the coverage there that evening to understand what sort of coverage they had. -5:41 p.m., HPD-A contacted ophthalmology (MD)-B and explained their new policy changes and the ED-to-ED transfer request for a global rupture. “Do we accept those from [HOSP-B]?” MD-B responded “No” and explained HOSP-B was supposed to consult within their own eye physicians first. “That is all I can say.” “I am not accepting a transfer from [HOSP-B].” “If their ED physician talks to our physician and they decide that is what needs to be done, that is a course they can take. But [HOSP-A], we are not part of [their] system.” HPD-B joined the conversation and questioned the response to MD-A if MD-A was to “push” the transfer and ended up stating they would just do an ED-to-ED transfer, as it was his understanding they were not supposed to do just an ED-to-ED transfer if ophthalmology declined the transfer. MD-B confirmed; however, he stated he could not tell MD-A or their ED physician what to do. -5:47 p.m., HPD-A contacted MD-A and declined the transfer, and recommended MD-A speak to her system ophthalmologist. MD-A reiterated HOSP-B did not have ophthalmology coverage at that time. HPD-B joined the conversation and explained ophthalmology was spoken to and “they are unable to entertain transfer or consults for this patient.” MD-A asked to speak to the ED physician. HPD-B stated, “Unfortunately the ED providers want ophthalmology consulted and when ophthalmology declines, they were unable to put them through to the ED.” MD-A explained P32 sustained blunt facial polytrauma and needed a level 1 trauma. HPD-B inquired if this was an isolated eye injury. MD-A confirmed and stated they did not have the CT (computed tomography - type of x-ray scan) back to confirm P32’s facial fractures. HPD-B stated if not polytrauma, then they did not involve the trauma surgeons, and being they already spoke with ophthalmology, this was something that needed to be addressed within their own system. MD-A again asked to speak to the ED provider for better understanding. HPD-B stated it did not matter as they went through their ophthalmology provider for these isolated eye injury situations, and they were not willing to do consults or transfers for outside services. HPD-B further stated if there was poly trauma they could connect with the trauma surgeon; however, they did their due diligence with ophthalmology and ophthalmology declined. MD-A asked to speak to the trauma surgeon. -5:50 p.m., HPD-B contacted trauma surgeon (MD)-C and explained the situation and it sounded like an isolated eye injury. He identified they consulted with ophthalmology and explained the policy. HPD-B believed HOSP-B had ophthalmology services and thus ophthalmology wanted MD-A to go through HOSP-B’s ophthalmology providers. Additionally, HPD-B stated MD-A was pretty persistent and wanted to talk with someone; however, their ED providers wanted ophthalmology consulted first on these cases as if they were not going to do anything, they did not want them sent to the ED. HPD-B asked MD-C if he wanted to talk with MD-A but again stated MD-A had her own ophthalmology within their network from his understanding. MD-C explained he prepped for surgery but would be happy to call MD-A back when able. HPD-B stated he did not want to bother MD-C and asked if it sounded reasonable to tell MD-A they could not take P32. MD-C responded if P32 had an isolated globe injury and their ophthalmologist were unable to see them, then trauma could not provide any additional services. If there were other injuries that trauma needed to address, then they would be happy to take the patient. -5:53 p.m., HPD-B again spoke to MD-A and explained the trauma surgeon was unable to speak with her as he prepped for surgery, and would only talk with her if P32 experienced polytrauma as if ophthalmology declined the transfer there was nothing more trauma could provide. MD-A asked to speak to the ED physician to garner more information as P32 had a vision threat. -5:57 p.m., HPD-B contacted the ED physician (MD)-D and updated on the situation. HPD-B explained ophthalmology was updated and due to a policy change, which he explained to MD-D, they were unable to accept. MD-D stated he tried to figure that process out; however, he stated if ophthalmology “cannot entertain this than I cannot either.” HPD-B inquired into the process of the ED physicians wanting ophthalmology consulted first before ED-to-ED transfer was accepted, which MD-D confirmed. MD-D questioned trauma’s response. HPD-B stated trauma was involved and because the situation did not appear to be polytrauma, and the ophthalmologist declined, then trauma declined also. MD-D stated, “I am kind of surprised that this is the case” as there was a traumatic globe rupture with threatening vision injury and they were a trauma hospital. MD-D followed up with, “This is kind of weird.” HPD-B explained their policy used to entertain these sorts of traumas, but their ophthalmology went away from this practice as other hospitals called them when they had their own system ophthalmology. MD-D stated they simply could not accept patients who their specialists were not able to see: “That is something I cannot do.” MD-D asked to have the director of trauma (MD)-E brought into the conversation as “this does not seem right.” -6:01 p.m., HPD-B contacted MD-E in which MD-E confirmed their current consult and transfer policy and thus there was nothing trauma was able to do. -6:02 p.m., MD-E stated to MD-D the direction for HOSP-B was to utilize their own system resources first. MD-D questioned their policy if they were okay with them, being a level 1 trauma center, not taking this patient. MD-E recommended MD-A send P32 to where their own eye surgeons were as this was an isolated eye injury and thus it would not be an issue. -6:03 p.m., MD-D conversed with MD-A and stated, “I am just clearly surprised as you;” however, his team did not take isolated traumatic eye injuries: “Apparently that is our policy.” He was unable to further explain but commented, “Seems very strange to me because we are obviously a level one trauma center.” MD-A questioned if this lack of acceptance was an EMTALA (Emergency Medical Treatment and Labor Act) violation as they lacked ophthalmology services and P32 required such. MD-D stated, “He needs to go to OR (operating room) clearly but this is something we do not accept.” MD-D asked if there was ophthalmology surgery coverage at HOSP-C (within HOSP-B’s system). MD-A denied. MD-D encouraged MD-A to contact HOSP-D and commented, “And frankly I am just as surprised as you,” but if ophthalmology and MD-E stated they could not take, “I wish I had a better answer.” MD-A verbalized it appeared HOSP-A did not want to transfer someone in from outside their system and she was quite sure if patients presented their ophthalmology would take them into the operating room. MD-D confirmed there was ophthalmology coverage there and MD-A responded they just did not take them from out of their system. The 10/13/24 audio recording identified MD-A expressed, on multiple occasions to multiple HOSP-A employees, they were unable to manage P32’s eye trauma due to the lack of ophthalmology and ophthalmology surgery services at HOSP-B and at HOSP-C. HOSP-A employees expressed to MD-A that due to their current policy they were unable to accept consults or transfers from outside hospitals that had ophthalmology services within their own system. Neither HPD-A or HPD-B, nor MD-B or MD-C or MD-D stated HOSP-A was unable to manage P32’s care due to capacity and/or provider capabilities. All expressed that because HOSP-B’s system had ophthalmology services, or that ophthalmology declined the transfer, MD-A needed to consult with her system resources or transfer to a different hospital. In addition, MD-E repeated this policy and process consensus; however, he also did not provide MD-A with information he was unable to take P32 related to the ED census at that time, and only declined the transfer as others within the team declined it. A HOSP-B system Memorandum from the director of surgical services and the director of perioperative services, dated 12/6/24, identified system leaders and the ophthalmology team was updated that starting on 12/7/24, HOSP-C would “resume some support for urgent/emergent ophthalmology care on weekends. The memorandum listed the three weekends in December; however, did not reflect dates going forward. Additionally, the weekend hours were identified from 7:30 a.m. to 3:00 p.m. Weekday urgent/emergent availability was available from 12:00 p.m. to 3:00 p.m. Additional communication would be available when additional coverage could be provided. Based on a summarized event word document, provided by HOSP-A’s vice president and chief medical officer (CMO), following 10/13/24, HOSP-A and HOSP-B administration worked together to develop improved collaboration when it came to ophthalmology patients. The form identified that on 11/6/24, the HOSP-A team met and determined HOSP-B’s system “had dozens” of ophthalmology doctors who were all trained in globe trauma. This was considered “bread and butter eye care,” and thus the team was confused on why such treatment was not managed by HOSP-B’s health system. A meeting on 1/9/25, held with both hospital staff, identified HOSP-B now had ophthalmology coverage from an outside eye group. An agreement was made that HOSP-A would “be happy to help with eye issues,” but they preferred that an ophthalmology-to-ophthalmology phone consult occurred. MD-E was to work with HPD on protocols. P31’s HOSP-B medical record identified P31 presented to the emergency department on 1/26/25 (Sunday) at 8:45 a.m. for evaluation after a fall from bed where P31 hit her left eye on the nightstand which resulted in a left eye (OS) globe rupture, along with a closed nondisplaced fracture of the left radius head. An Ophthalmology Consultation, dated 1/26/25, identified P31’s was assessed by ophthalmologist (MD)-F. P31 had a history of retinal detachment and scleral buckle (retinal detachment) of the OS “a long time ago,” where her vision had always been poor, but she was able to read an eye chart. Currently her visual acuity was only to light perception and her pupil was “2mm (two millimeters), irregular, and nonreactive. Eye pressure “appears soft” with an attempted check. The left eye anterior exam identified the adnexa had “mild edema and bruising on the upper and lower lids and she showed subconjunctival bleeding with additional scattered inferior subconjunctival bleeding and observed corneal plague buildup. The anterior chamber showed “deep, small layered hyphema (blood in eye) inferiorly and 3+ RBCs (red blood cells).” “POOR dilation both eyes (OU), No view OS 2/2 heme.” A dilated fundus exam of the left eye identified there was “no view” for vitreous, nerve, vessels, macula, periphery with comment “B scan deferred given concern for applying pressure with c/f (closed or full thickness) ruptured globe.” -Head, Facial Bone, and Cervical Spine CT scans were completed and identified the ophthalmologist’s assessment and plan were as follows: “Hyphema OS,” concerns for ruptured globe OS as head and face CT scans revealed posterior medial flattening deformity of left globe in a patient with hyphema, lateral hemorrhagic chemosis (bleeding), and globe flattening deformity on CT. Recommendations were to transfer P31 to HOSP-D (level three trauma), HOSP-E (level one trauma), or a “level 1 trauma center” for surgical globe exploration given high concern for posterior ruptured globe. An Emergency Department Staff Physician Note, dated 1/26/25, identified P31 was assessed by MD-A. P31’s OS appeared “somewhat sunken” with chemosis of the lateral conjunctival. MD-A spoke with MD-F who came into the ED to examine P31; however, MD-F identified they do not repair traumatic open globes and recommended P31 be transferred to a trauma facility for exploration. MD-A contacted HOSP-A to initiate a transfer; however, when asked to speak with their ophthalmology staff, HPD-A refused to connect her due to HOSP-B having this type of coverage. MD-A verified they did not have coverage for traumatic open globe patients. MD-A additionally asked if MD-F could consult with HOSP-A’s ophthalmologist; however, this also was refused. An Inter-Facility Transfer Form, dated 1/26/25, identified P31 required BLS (basic life support) transfer for ophthalmologic trauma services as HOSP-B lacked the capability to render further examination and treatment and the benefits of transfer to another facility outweighed the benefits of remaining there. On 1/26/25 at 3:05 p.m., P31 was transferred to HOSP-D. HPD call audio recordings, dated 1/26/25, identified the following relevant synopses of conversations: -2:31 p.m., Physician assist (PA)-A explained to HPD-B their ophthalmologist was there and wished to transfer P31 due to eye trauma and a fracture. HPD-B questioned if the transfer was specifically for the isolated eye injury. PA-A confirmed. After a brief hold, HPD-B stated, “Unfortunately the fact that you are out of network we are unable to facilitate any sort of consult or transfer for isolated eye injuries. You can probably try [HOSP-D] potentially.” PA-A questioned this reason and HPD-A replied “They do not accept consults or transfers out of network eye injuries. Our ophthalmology department does not take those.” After PA-A asked HPD-A to hold the line, HPD-A immediately stated, “We have had this conversation with your department before and that is the policy and that is kind of how it is so unfortunately I am not able to facilitate a transfer or consult for you. PA-A acknowledged this, and the call ended. -2:35 p.m., MD-A explained to HPD-A the situation and that P31 was examined by their ophthalmologist and a transfer for a traumatic eye injury was requested. -2:37 p.m., HPD-A inquired if this was an isolated eye injury. MD-A confirmed. HPD-A explained, “Health Partners, we are not able to provide ophthalmology consults or accept ophthalmology transfers for external sites with these services available in their health system at this time. So, we cannot accept a transfer.” MD-A explained, “We do not have traumatic eye coverage. We have ophthalmology coverage, but they do not treat open globe so not a service we have in our health system. HPD-A stated, “ [HOSP-B] is aware of this. This has been a concern, but we are unable to accept any transfers. MD-A asked to speak with the on-call ophthalmologist and identified their ophthalmologist was present who wanted to do “doc to doc on this case.” HPD-A stated, “They do not accept them.” MD-A again asked to do a physician to physician to confirm they do not accept. HPD-A stated, “No, they do not accept consults. MD-A questioned if this was an EMTALA violation and indicated this needed to be escalated. HPD-A stated that it would and were escalated in the past. The 1/26/25 audio recording identified PA-A and MD-A attempted to transfer P31 to HOSP-A, where MD-A expressed they were unable to manage P31’s need for surgical trauma services after their ophthalmologist had assessed the patient and confirmed such services were not available at that time. MD-A requested multiple times for a provider-to-provider consult; however, was repeatedly denied this request due to reasons HOSP-B had ophthalmology services in their network and thus HOSP-A ophthalmology would not consult with providers out of the HP network. Neither HPD-A or HPD-B explained the reason for the denied request was due to their current capacity and/or provider capabilities. A summarized event word document, provided by the CMO, identified that on 1/26/25 a “New [HOSP-B] eye case” occurred. On 2/3/25, the CMO communicated with MD-E and MD-E explained he had connected with HPD’s manager (HPDM) “last week” and “ensured that the direction of our HP team was to allow eye doc to eye doc connection for isolated eye trauma transfers.” An HPD Newsletter, dated 2/4/25, identified a section HP Direct Updates which indicated an agreement was made between the hospital ophthalmology and HOSP-B. HOSP-B now contracted with an outside eye clinic effective 1/1/25 and HOSP-B was expected to consult with this clinic prior to transfer requests. Effective immediately, if HOSP-B consulted with this clinic and the clinic provider continued to request the transfer, HPD staff were to take the patient. In addition, there was to be a “handoff” between the clinic provider and hospital ophthalmology for acceptance. The injured patient protocol was to be utilized. If HOSP-B attempted to consult with the clinic provider and was unsuccessful, the request was to be sent through. An email, dated 2/5/25, from the HPDM to HPD staff, identified ophthalmology process changes. The following direction was provided: HPD was to determine if a transfer request was for an injured patient. If an isolated eye injury from an external site, HPD inquired if the patient was an HP patient, or if the patient received related specialty care within their system in the last two years. If the referring location was Mayo, Fairview, or Allina (health systems), HPD was to inquire if they consulted or attempted to consult with their local ophthalmology services. If consulted, HPD staff were to facilitate a provider-to-provider consult. If the receiving ophthalmologist accepted, the transfer continued. If declined, the transfer was declined. If attempted, a consult was to be facilitated between their ophthalmology and the ED provider. Then, if accepted, the transfer continued. If declined, the transfer was declined. If no consult or attempt, HP was not able to provide ophthalmology consults or accept ophthalmology transfers for external sites with these services available within their health system and HPD staff encouraged the caller to call back if the transfer was still needed once their local ophthalmology providers was contacted. During a telephone interview on 2/11/25 at 10:39 a.m., MD-A identified both P31 and P32 experienced traumatic open globe injuries in which HOSP-A declined both transfer requests as they felt she had access to ophthalmology. MD-A stated she did not have ophthalmology covered services at HOSP-B for P32. MD-A explained HOSP-C had ophthalmology coverage; however, after she talked with the on-call trauma surgeon, she was informed HOSP-C was unable to manage traumatic open globes and they also were required to transfer these cases to a higher level of care. MD-A stated HOSP-B was able to secure ophthalmology coverage “mid-January.” She had contacted this coverage for P31, and this provider presented to the ED and examined P31. The provider recommendation a transfer to a trauma center as the provider did not operate on open globe injuries, as those cases went to trauma centers. MD-A understood that when P31 presented to the ED and such a transfer was needed, once they consulted with their on-call ophthalmology, HOSP-B would allow a provider-to-provider consult. When interviewed on 2/12/25 at 1:44 p.m., the ED director (MD)-G stated if a patient required services and the presenting hospital did not have the specialty to manage those services, a transfer to a facility that could manage would be expected. If a patient were to sustain polytrauma with an eye globe injury, there would be no issue with accepting that patient; however, if it was an isolated globe trauma, then the need for a level 1 trauma center was debatable. MD-G stated there was no special training for ophthalmologists to manage globe issues and thus any ophthalmologist would be able to manage. MD-G confirmed HOSP-A could manage an isolated globe patient; however, he believed HOSP-B also did and commented, “Maybe [the on-call staff] are not answering [the hospital provider’s] phone call.” MD-G explained HOSP-B’s health system had many contracts with ophthalmology providers based on shared providers in both networks and thus they should call “their own people.” MD-G provided an example if a call came into the call center for infectious disease - the call center would deny that transfer as the transferring hospital would have those services. If an eye issue was requested for transfer, he most likely would expect HPD to put that provider through to the trauma doctor; however, this was based on who the facility was: “If larger [hospital systems], may not go through.” MD-G was aware of P31 and P32’s and identified dialogues occurred over the past couple of weeks related to this. MD-G explained there were a lot of parts to this, but as far as he knew, the facility followed what they should have. During an interview on 2/12/25 at 3:01 p.m., the CMO explained, prior to COVID-19, there was a 100 percent acceptance of all transfer requests; however, due to the impact of COVID-19 on their capacity, they became more “insular” in this acceptance; however, when it came to “trauma,” which he questioned how this term should be defined, he explained, “As a level 1 [trauma center] we have to say yes if [the request was related to] trauma.” For ophthalmology, the CMO stated their ophthalmology team told him that every ophthalmologist was knowledgeable, and able, to manage ruptured globe emergencies: “Primary globe rupture is just standard bread and butter [care];” but, if an ophthalmologist had not managed such emergencies in 10 years, and was not comfortable with this, then that provider would be in “over their head” and he would expect that ophthalmologist to confer with his ophthalmologist and they would accept the transfer. The CMO explained, his staff struggled with HOSP-B ophthalmology transfer requests as HOSP-B’s health system had “38” ophthalmologists and thus there was a debate related to HOSP-B and their ability to not manage globe eye traumas. HOSP-B was thus expected to consult with their own ophthalmologists first, prior to contacting HOSP-A. He stated his preference was to manage care for those facilities that lacked ophthalmology consulting capabilities or if the ophthalmologist needed assistance. The CMO identified HPD utilized protocols and to ease their processes and understanding, their guidance was put on paper; however, due to the collaborative conversations with HOSP-B administration, this guidance was adjusted and all HPD staff were educated on the changes. Based on this guidance and education, HPD staff were expected to inquire if HOSP-B had consulted with their ophthalmologist before they requested transfer and if so, HPD were to initiate a provider-to-provider call. When interviewed via telephone on 2/12/25 at 3:31 p.m., the HPDM stated she expected HPD staff to follow their directed work standard processes and protocols. These differed and were dependent on each call. Staff reviewed the reason for the call, the department specialty required for potential care, and hospital capacity. With this process, based on questions asked and information provided, there were instances where HPD was allowed to make the decision to not accept a transfer. Ophthalmology transfer requests followed the injured patient process and protocols. The HPDM identified HPD calls for ophthalmology transfers were mostly related to trauma. Based on that, those requests would always get put through to ophthalmologist for an acceptance or declined decision. For ophthalmology, recent changes were made and they attempted to determine when the appropriate time was for HRD to call them versus when not. If the call was related to an eye infection, not caused by injury, “we could potentially decline.” Consults were not initiated for “external facilities unless they meet the injured patient criteria,” which then was also dependent on other injuries potentially involved. The HPDM thought EMTALA training was provided during standard onboarding; however, was unable to state it was provided at the department level. The HPDM identified HPD staff were privy to which hospital in their system had specialty services; however, there were limited details on providers, thus one of the main reasons for a provider to provider consult for service capabilities. Over the past few months, there was “a lot of tension with [HOSP-B] and the ophthalmology group.” Due to this, changes were made, and all staff were trained. When P32’s transfer was declined, there was communication out that the hospital needed to connect with their own ophthalmology first and call back if services were still needed. That was what HPD staff followed. Since, HOSP-B now had ophthalmology coverage, and they were expected to collaborate with this coverage before they called. The HPDM was unsure of all the details surrounding P31’s request and at what point the request was declined and/or if there was connection with their ophthalmology. Based on her knowledge, she felt HPD staff followed their work standard process and protocols, but maybe P31’s event got “caught in the middle of the change,” and maybe the work standard processes and/or protocols were not updated everywhere they needed to be. During an interview via telephone on 2/13/25 at 11:55 a.m., MD-F stated she assessed P31 after P31 presented with concerns for a posterior left eye globe rupture where the integrity of P31’s eye was no longer there, and she needed exploratory surgery. The rupture was unable to be found on the front part of the eye and thus the reason for the need for exploratory surgery. MD-F explained HOSP-B lacked an ophthalmology OR and it was difficult to get after hours and weekend ophthalmology at HOSP-C due to staffing shortages and limited time frames of when urgent surgeries were allowed. MD-F stated if this situation would have occurred during a weekday, it would not have been an issue; however, it was “near impossible.’ after hours and on weekends. MD-F explained she performed surgeries, but HOSP-B did not have the OR capability for this repair process. When interviewed via telephone on 2/13/25 at 12:19 p.m., the on call HOSP-B lead ophthalmologist (MD)-H stated there was a long-standing history on how to manage eye trauma, especially global eye ruptures. The bottom line however was the patient required surgical intervention. MD-H identified HOSP-B lacked OR resources and HOSP-C had limited availability with one room: only available during certain business hours, when not being utilized already. At other times, “there was nobody.” MD-H stated if a call came into their company, the provider would see the patent to ensure appropriate treatment/care determination and if needed, would then consult with another ophthalmologist. He was aware of the 1/26/25 transfer denial and HOSP-A’s lack of allowing such a consult. He stated, “If we would have had the place to do [the surgery], we would have.” During a telephone interview on 2/13/25 at 2:30 p.m., HPD-A stated she followed computer-based workflow protocols which were initiated based on dedicated questions and information obtained from the caller. During these calls, she followed a “script.” if injury was identified, there was an injury protocol, and if information entered met the criteria, the call would be pushed through to the needed specialty for that specialty to accept or deny. Despite this, she explained there was one script for ophthalmology that indicated if the eye injury was isolated, and the caller was from another health system that had their own ophthalmologists on site, they did not accept those cases and did not have to coordinate a provider-to-provider consult. The only time she would coordinate this was when the patient was a HP patient and seen recently by ophthalmology. HPD-A explained she read this script verbatim when these calls came in. She was unable to clarify what “on site” meant and stated HOSP-B’s health system had ophthalmology coverage. HPD-A identified processes were being reviewed and changed; however, she had yet to be updated on final changes, the script had yet to be changed, and if there was a call this day from an out of system provider for an isolated eye injury, and they had yet to connect with their own ophthalmologist(s), she would deny the transfer and would not pass the call onto her ophthalmologist. For P31 and P32, HPD-A stated she followed the provided scripts and collaborated with her coworkers for these calls. HPD-A was aware of EMTALA regulations based on education from past employers; however, she stated her hands were tied and she just followed the script. When interviewed via telephone on 2/13/25 at 3:38 p.m., HPD-C stated she followed computer-based workflow protocols for determination on next steps. She explained as a broad rule, and based on bed availability, if the patient was an HP patient or the requesting hospital did not have specialty services that they had, the transfer request was accepted and/or a consult with that specialty coordinated. The only times a patient was declined, was if the hospital was on a “full status,” unless the patient fell into categories such as HP patient, trauma, stroke, etc. If the patient was not a HP patient, transfer was declined. When questioned on eye injuries, HPD-C stated those fell into the injured patient protocols and she determined if the injury was isolated. During the interview, she reviewed the workflow/protocol. First, she determined their connection to HP and the time frame of that connection. If not an HP patient, and no connection, she asked if the provider consulted with their system. If so, she identified the ophthalmologist consulted. If not, she updated them they could not provide consult(s) or transfer acceptance if that system had such services. After the consult with their own system, if services were still needed, and they called back, she coordinated a provider-to-provider consult. HPD-C expressed it would be strange if hospitals lacked ophthalmology on call coverage, but if in fact they did not have coverage, she was required to help facilitate them being seen there due to EMTALA regulations. During a telephone interview on 2/13/25 at 4:01 p.m., the vice chair of ophthalmology (MD)-I stated if there was a call for an acute eye issue, “we take care of it” and they are always available for consults, but explained there were recent issues with HOSP-B’s health system where it appeared as if this health system overly relied on his hospital for ophthalmology services. This concerned him based on the increased number of calls his department received from them, along with some of these patient transfers, when assessed by his team, appeared “deceptive” and/or “false alarms,” and were found to not need the skills of a level 1 trauma center. MD-I explained HOSP-B’s health system was a “really big” system; however, even if HOSP-B did not have ophthalmology on call services, why was his hospital their first option and why did they not reach out to other hospitals within their own system? MD-I stated he was involved with discussions related to these concerns and he understood that in October HOSP-B lacked dedicated eye coverage, but they could have reached out to another facility in their system that did. He also was made aware HOSP-C was able to perform afterhours eye surgery but not trauma surgery. Additionally, recently due to staffing concerns, HOSP-C was unable to do retinal surgery after hours and their OR access was limited. MD-I stated, despite all of this, and their frustrations, his team would always say yes to a transfer, and they would deal with the consequences after. In follow-up, MD-I explained he would make sure he talked with the outside ophthalmologist to ensure an informed acceptance decision and to confirm that facility was unable to manage the patient needs. This was what he expected should have occurred for P31. “This one the stars aligned perfectly.” The ophthalmologist saw them, they were unable to do surgery, and his facility did not have the opportunity to figure out all the details. With this, he was concerned HPD was “just going through their motions and not taking care of the problems.” “The opportunity was not granted to [HOSP-B] to justify” their reason for the transfer request. When interviewed via telephone on 2/13/25 at 4:43 p.m., MD-B stated when he conferred with a provider, who was not affiliated with HOSP-A, he first questioned if their ophthalmologist was consulted and assessed the patient, as he expected those providers to initiate that step first. If that facility lacked such ophthalmology services, he would then accept the transfer. To initiate this acceptance review, he expected HPD to contact him for a provider to provider consult when such calls came in, or at a minimum to provide him with all the necessary information where he may ask HPD to ask the outside provider more questions if needed so that he made an informed decision. MD-B explained he was updated by HPD there was a change in processes related to these calls and they were unable to accept transfers from outside providers. He was unsure how accurate that was; however, that did not change the questioning on how he reviewed his responsibilities. MD-B reported he potentially was on call when P32’s transfer was requested but he was unsure of the smaller details. He stated, “I would never refuse care. I can tell you that, but I am not accepting a transfer until your ophthalmologist can see them, But, if they do not have one, we would skip that step.” He further stated, “I told our person that they had to call ophthalmology. [HPD] did not say that [HOSP-B] did not have coverage. But, [HOSP-B] do have coverage in their system all the time.” He expected HPD would have updated him HOSP-B did not have ophthalmology coverage. This would have been a different situation, and we would have taken the transfer.” In addition, he explained if the provider spoke to the ED provider and a decision was made to transfer, we would not get in the way of that as HOSP-A had capability to manage globe surgery; however, “a ruptured globe is not a true emergency. Standard of care is to have surgery within 24 hours,” and their system should have been able to manage this if surgical services were available the next morning. On 2/14/24 at 2:05 p.m., the audio recordings from 10/13/24 and 1/26/25 were listened to with the CMO, MD-E, and risk manager (RM)-A. The CMO reported, after he previously listened to the January call, he was embarrassed and maybe appalled. He believed patients deserved good service and he did not sense this occurred, and/or trouble shooting versus just following their scripts. MD-E stated HOSP-B’s health system not having resources sounded like “ignorance” or staff not willing or wanting to work to transfer within their own systems. MD-E understood the direction he heard was HOSP-B was directed to utilize their own systems first; however, “clearly there is not a desire to do that” and in response, those patients, who may not even require a level 1 trauma center, were transferred there. MD-E stated ophthalmology was not going to just take a patient without consulting, but if the ED to ED communicated and they brought them there, they would take them. MD-E was aware of EMTALA regulations and commented “we cannot take them if we do not have the capacity. Capacity in this situation is loosely defined. If they come to our ED, we figure it out even if we are full.” He stated they could not refuse trauma patients due to a very liberal policy, and due to this, there were times when they were “abused” by other systems when those systems had services but still requested transfers. Thus, outside providers were directed to use their own resources. The CMO identified since COVID they have grown their hospital to meet the needs of the community and have worked very hard to ensure community demands were met. Because of this, they did not divert and they did not say no. MD-E stated, with P31’s call, there was a potential information implementation lag to HPD once HOSP-B obtained on call coverage as once this coverage was initiated HOSP-B was to consult with their on call coverage and if a transfer was still needed, then that ophthalmologist would reach out to their ophthalmologist for consult. “That message did not get to the front lines.” Currently, HPD staff were expected to facilitate such a consult. The CMO stated the reason for not accepting ophthalmology consults out of their system which do not meet the trauma definition centered around their providers were under contracts to care for those patients within their system, not those from other systems. An Emergency Medical Treatment and Labor Act (EMTALA) policy, approved 2/13/14, identified its purpose was to outline requirements for compliance with EMTALA. The policy identified a section labeled Receiving a Patient With an Emergency Medical Condition that indicated a hospital with specialized capabilities or facilities could not refuse to accept from a referring hospital an appropriate transfer of an individual who required such specialized capacities or facilities if the receiving hospital had the capability to treat the individual. The policy defined capacity as the ability of the hospital to accommodate the individual who requested examination or treatment of the transferred individual. Capacity encompassed such things as numbers and availability of qualified staff, beds, and equipment and the hospital’s past practices of accommodating additional patients more than its occupancy limits.”

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 48300 Based on interview and document review, the facility failed to provide safe discharge planning for 1 of 5 minor patients (P1) when P1 was discharged to the main office building of a youth outreach organization. This resulted in an immediate jeopardy (IJ) for P1 when the hospital discharged him without services. The immediate jeopardy (IJ) began on 11/15/24, when P1 was discharged to the main office building of a youth outreach organization with no services for youth available at that location. On 12/6/24 at 12:15 p.m. hospital president, vice president of patient care services, director of nursing for the emergency department, senior patient safety specialist, social work manager, manager of accreditation and regulatory compliance, and senior patient safety specialist were notified of the IJ. As a result, the hospital was found NOT in compliance with the Condition of Participation discharge Planning at §482.43 A condition level deficiency was issued. See A0813 for additional information.”

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 48300 Based on interview and document review, the facility failed to provide safe discharge planning for 1 of 5 minor patients (P1) when P1 was discharged to the main office building of a youth outreach organization without any services or supports. This resulted in an immediate jeopardy (IJ) for P1 when the hospital discharged him to this location. Findings include: P1’s Psychiatric Consultation dated 11/2/24 indicated P1 presented to the emergency department (ED) 11/1/24 following a suicide attempt. P1 ran into traffic and was struck by a vehicle. P1 was boarded in the ED, awaiting inpatient adolescent psychiatry for safety and further assessment. The note continued to indicate long-term, P1 would benefit from specialized mental health services for trauma and intellectual disability. P1’s diagnoses included autism, development language disorder, disruptive mood dysregulation disorder, mild intellectual disability, and post-traumatic stress disorder. P1’s psychiatric provider note dated 11/12/24 indicated P1 refused to return to his group home. P1 stated he had been physically abused at the group home, and would kill someone or kill himself if he was forced to return. P1’s psychiatric progress note dated 11/14/24 indicated P1 continued to have episodic elevated behavior/agitation. Plan was to discharge P1 to the community having exceeded any therapeutic benefit of emergency department/acute hospital setting. P1 needed a strict behavioral plan, and psychosocial interventions to address his symptoms. P1’s social work note dated 11/15/24 indicated P1’s county mental health supervisor asked for P1 not to be discharged, and leadership from P1’s county workers wanted to speak with hospital leadership. Hospital leadership was not available. P1 was discharged via cab to a “youth shelter.” P1’s psychiatric progress note dated 11/15/24 indicated P1 was discharged to a “shelter.” P1 needed long-term residential treatment. “It is unsustainable to keep the patient in the ED.” P1’s discharge summary dated 11/15/24 indicated key discharge instructions included take medications as prescribed. P1’s adolescent psych bed call list dated 11/2/24 through 11/12/24, indicated P1 had been declined (at some facilities multiple times), at all inpatient adolescent mental health units available in Minnesota and Wisconsin for reasons including aggression, need for high level of care, and no beds available. The hospital’s list of adolescent youth homeless shelters contacted for P1 and dated 11/14/24, indicated multiple shelters were contacted with no beds available. The name of the community organization P1 was discharged to was not on the list. P1’s cab ride receipt dated 11/15/24 indicated P1 was transported from the hospital at 11:03 a.m. to the main office building of a youth outreach organization arriving at 11:29 a.m. On 12/4/24 at 9:28 a.m., P1’s county worker (CW)-A stated P1 was extremely impulsive. P1 needed staff to assist him with daily needs like food and medication administration. He functioned at a much lower level than a normal 17-year-old. A request was made to the hospital not to discharge P1 on 11/15/24 as planned, because a bed would be available at an in-patient child and adolescent behavioral health hospital early the following week. On 12/4/24 at 12:01 p.m., registered nurse (RN)-A stated she was uncertain if P1 had the knowledge to self-administer medication, and no assessment or education was provided to P1 about medication administration prior to discharge. She did not speak up about P1’s discharge to the shelter because the staff were told there was no other place for him to go. She thought the shelter would be a place for him to get food and sleep. On 12/4/24 at 12:14 p.m. social worker (SW)-A stated a shelter would be contacted to secure a bed before an adolescent would be discharged to a shelter. A day program could be part of the plan, but it was not a discharge location. On 12/4/24 at 2:34 p.m. SW-B stated P1 was discharged to a drop-in center that had daytime programing, but was not a place P1 could sleep. It would be up to P1’s guardians to find him a place to sleep that night. SW-B’s progress note identified P1 was discharged to youth shelter. On 12/5/24 at 10:07 a.m., medical doctor (MD)-A stated they did not feel hospitalization was beneficial to P1. There was no clinical indication to keep him in the hospital. P1 needed a structured setting with consistent staff, but the hospital could not find a bed for him. The day program was preferable for him. On 12/5/24 at 10:32 a.m., SW-C stated a county worker had informed the hospital social worker that the county was trying to get P1 admitted to an in-patient child and adolescent behavioral health hospital, but there was no date provided before P1 was discharged from hospital. When discharging a minor patient to a youth shelter, a social worker would call the shelter to secure a bed before discharging the patient. On 12/6/24 at 10:49 a.m. P1’s legal guardian (G)-A stated she had asked the hospital to not discharge P1 because there would be a bed for him at a child and adolescent behavioral health hospital early the following week. After P1 was discharged, G-A received a phone call from the day program who informed her that P1 was at their main office. G-A confirmed the address P1 was picked up from was the main office building of a youth outreach organization. This location did not provide a place to sleep, recevie food or services needed. On 12/6/24 at 11:15 a.m., the youth outreach center worker (OCW)-A stated P1 just showed up at the main office building of their youth outreach organization without any communicaiton from the hospital. OCW-A confirmed P1 was sent to their office building with no services provided to youth. P1 had utilized services at a different location within the organization in the past, so they contacted P1’s legal guardian who sent someone to pick him up. The undated facility Patient Discharge Policy directed patient care needs, including, but not limited to psychosocial care, physical care, treatment, and services needed after discharge is to be addressed by the interdisciplinary care team. The IJ was removed on 12/12/24 when the hospital had submitted and implemented an acceptable removal plan. Facility discharge policy was updated to include assessment of availability of necessary community supports or resources, likelihood of the patient needing post-hospital services, and to determine appropriateness of patient’s ability to access basic care needs. Facility patient discharge procedure was updated to include minors cannot be discharged until parent or legal guardian is informed of and in agreement with the discharge plan. If a parent or guardian can’t be reached, the interdisciplinary team will reassess DC plan. Also added was, in the case of minors, the disposition location must be contacted and confirm acceptance of the patient incoming arrival. Education was started for all nursing, provider and social work staff involved in discharges. This was verified through interview and document review.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48300 Based on interview and document review, the facility failed to ensure 1 of 10 patients (P1) was free from abuse when a security officer (SO)-A punched P1 in the back of the head three times. As a result of these failures, the deficient practices resulted in an immediate jeopardy (IJ). The hospital was found out of compliance with Condition of Participation Patient Rights at 42 CFR 482.13. The IJ began on 8/29/24 at approximately 9:26 p.m. when SO-A and SO-B responded to a staff request for assistance to place P1 into restraints. P1 was agitated and refused to cooperate with staff and security officers. P1 bit SO-A after being placed into a manual hold, and would not release the bite. SO-A punched P1 in the back of the head three times to get P1 to release the bite. On 9/13/24 at 4:30 p.m. the hospital president, chief nursing officer, accreditation and regulatory compliance manager, patient safety manager, director of security, patient safety specialist, and senior director of regulatory and quality were notified of the IJ. The immediate jeopardy that began on 9/13/24, was removed on 9/16/24, when it was verified the facility implemented the following corrective actions with updating Preventing, Identifying, Investigating, and Reporting Maltreatment of a Vulnerable Adult policy to integrate with the Security Officer Use of Force Interventions policy and include education of security officers about said policies. Updated the Use of Force policy to distinguish between offensive and defensive force, identify that offensive force is prohibited, prohibit the use of closed handed strikes, and created a Managing Violence in the Care Environment reference document. Re-educated all security officer regarding abuse prevention, use of restraints, approved and non-approved methods of force to subdue patients, and related policy revisions prior to starting their next shift. Completed security officer attestations of the receipt and understanding of this education. This was verified through observation, interview and document review. Findings include: See A-0145: Based on interview and document review, the facility failed to ensure 1 of 10 patients (P1) was free from abuse when a security officer (SO)-A punched P1 in the back of the head three times.”

“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: 48300 Based on interview and document review, the facility failed to ensure 1 of 10 patients (P1) was free from abuse when a security officer (SO)-A punched P1 in the back of the head three times during an incident. Findings include: On 8/30/24, a Vulnerable Adult Maltreatment Report submitted by the hospital outlined P1 was admitted to a medical unit for evaluation/treatment following a jump from a second floor and self-inflicted lacerations on 8/28/24. On 8/29/24, P1 was agitated (kicking, yelling, spitting) and required restraints to prevent self-harm and/or harm to others. P1 arrived to the mental health unit at 4:15 p.m. in restraints, was transferred to a restraint chair and then was transitioned to seclusion at 8:45 p.m. While in seclusion, P1 attempted to rip off his cast (on his foot) and a bandage on his neck. Security and staff attempted to intervene at which time P1 assaulted security officer and required physical intervention. On 8/28/24, an emergency medicine visit note indicated P1 presented to the emergency department (ED) with emergency medical services following a jump out of a two-story building with self-inflicted knife wounds. P1’s diagnoses included laceration of neck, closed fracture of nasal bone, right foot fracture and self-inflicted harm/suicidality. On 8/29/24, a psychiatry consult note indicated P1 also had diagnosis of schizoaffective disorder bipolar type. On 8/29/24 at 5:08 p.m. a nursing progress note indicated P1 was placed in four-point restraints (restraints on both wrists and both ankles) at 2:45 p.m. due to agitation, uncontrollable thrashing, screaming, and attempting to bite self and staff. P1 was transferred to a mental health unit at 4:00 p.m. and placed into the restraint chair. On 8/30/24 at 12:56 a.m. a nursing progress note indicated P1 was removed from the restraint chair and placed into the seclusion room at 8:45 p.m. At 9:20 p.m., P1 became irritable, verbally abusive and ignored redirection. Security was called. P1 continued to be agitated and presented clenched fists towards security officers. P1 was placed in a physical hold after lunging at security officers. P1 bit a security guard and would not release the bite. On 8/30/24 at 2:48 a.m. a facility security report indicated security officers called to assist with P1 in the seclusion room at 9:26 p.m. The narrative text written by SO-A indicated P1 was in the seclusion room tearing off bandages from the wound to his ankle. SO-A and SO-B attempted to place P1 in a hold, but all lost balance and fell on the bed. P1 bit SO-A on the right forearm and would not let go. SO-A “threw 3-4 closed fist punched to the back of [P1’s] head, but it was ineffective.” SO-A decided to push as hard as he could onto P1’s head hoping he would let go of the bite. Eventually, P1 loosened the bite. The narrative text written by SO-B indicated P1 bit SO-A’s right forearm and would not let go. The bite became severe, and SO-A did closed fist defensive strikes to the area of the bite. SO-B drew his Taser and yelled, “TASER, TASER, TASER!!” SO-A was able to push off from P1’s bite and stepped away. SO-B did not deploy the Taser. On 9/13/24 at 9:33 a.m. director of security (DS)-A stated the facility had not done an internal investigation of SO-A punching P1. The training currently provided to security officers did not include the use of closed hand strikes. in a follow-up interview at 2:30 p.m. DS-A stated it would have been appropriate to use the Taser or chemical spray on P1 if he had not released the bite, since P1 was actively assaulting SO-A. On 9/13/24, at 1:56 p.m. SO-B stated he was with SO-A when they were trying to get P1 into the restraint chair. He was ready to deploy his Taser when P1 released the bite on SO-A’s arm. He did not receive any re-education from the facility. On 9/13/24 at 2:32 p.m. senior director of regulatory and quality (DRQ)-A stated the maltreatment of a vulnerable adult policy does not address use of force. Attempts made to interview SO-A were unsuccessful. The facility Preventing, Identifying, Investigating, and Reporting Maltreatment of a Vulnerable Adult dated 5/11/23, lacked identification of use of force.”

“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: 45841 Based on record review, interview, and facility policy review, the facility failed to ensure a restraint was not utilized without an order from a physician or other licensed practitioner for 1 of 4 patients (P21) reviewed for restraints. Findings included: The facility’s undated policy titled, “Restraint (Non-violent and Violent) and Seclusion Policy” indicated, “E. Practitioners order restraint or seclusion.” P21’s “Admission Information” revealed the hospital admitted the patient on 04/25/2024. A “Cardiology Consult Note” for a date of service of 04/26/2024 revealed that the patient presented with generalized weakness, falls, and shortness of breath. Per the note, the patient was admitted to the intensive care unit (ICU) for further evaluation and management, with plans to perform a right and left heat catheterization. A “Non-Violent Restraints” flowsheet revealed soft wrist restraints to the patient’s right and left wrists were started on 04/26/2024 at 12:48 PM, because the patient was pulling at lines and tubes and removing equipment. P21’s medical record did not reflect an order for the use of the restraints, and there was no further documentation regarding ongoing use or discontinuation of the wrist restraints. During an interview on 05/30/2024 at 10:24 AM, Nurse Educator #4 said there was no order for P21’s restraints. During a follow-up interview on 05/30/2024 at 10:29 AM, Nurse Educator #4 said that P21 went for a procedure right after they were intubated, then moved to a different floor. Nurse Educator #4 said if the patient arrived at a different floor without restraints in place, the nurse would not have thought to document the removal of them. During an interview on 05/30/2024 at 10:26 AM, the Clinical Nurse Practice Specialist of the Mental Health (MH) Department said that there was no documentation in P21’s medical record regarding an order for restraints.”