Mercy Hospital

“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: 47264 Based on interview and document review, the facility failed to perform a face-to-face assessment for 1 of 10 patients (P7) reviewed for restraints. P7 had behaviors requiring an as needed medication and was restrained by a manual hold. Findings Include: P7’s medical record was reviewed. P7 was directly transferred to the inpatient psychiatric unit for evaluation of mental health decompensation and stabilization on 6/29/26. P7’s past medical history included traumatic brain injury, attention deficit disorder, oppositional defiant disorder, and post-traumatic stress disorder. A recreational therapist note dated 7/20/26 at 3:18 p.m. indicated P7 was heard yelling at staff in the hallway when staff attempted to redirect patient from trading shoes with another patient. Staff were holding a meal tray and P7 hit this out of the staff hands. Code green was called. The recreational therapist, registered nurse (RN), and staff attempted to redirect P7. He continued yelling and began making threatening statements to staff “I’m going to fucking kick your ass. Call in security let’s fucking go.” P7 continued to escalate while staff attempted to disengage. P7 began posturing, went to his room, and continued to come out yelling at staff several times while waiting for the code green team to respond. See RN note for additional details. The nursing note for additional details dated 7/20/26 at 8:17 p.m., indicated problem: distorted thinking process, goal: mood equilibrium, outcome: progressing. P7 was yelling at staff in the hallway, and the staff attempted to redirect the pt from trading shoes with another patient. P7 became verbally loud, yelling and escalated. Staff were holding a meal tray at the time of the interaction. P7 struck the tray out of the staff hands, knocked it to the floor, P7 was not redirectable. Code green was initiated. Staff approached P7 to verbally de-escalate and redirect. P7 continued to yell making threatening statements toward staff stating, “I’m going to fucking kick your ass call in security let’s fucking go.”. Staff maintained a safe distance and attempted to disengage. P7 began posturing at staff responding to the code green. As needed medication intramuscular Haldol 5 milligrams was administered with a manual hold of P7. The medication was effective. P7 discharged to another hospital by protected transport at 4:12 p.m. An order dated 7/20/26 at 3:32 p.m. indicated a manual hold restraint was initiated at 3:00 p.m. The order indicated that a face-to-face assessment must be completed within one hour of initiation of restraints/seclusion. A flowsheet entry titled Restraint Summary dated 7/20/26 at 3:39 p.m. indicated a manual hold was initiated at 3:00 p.m., and discontinued at 3:10 p.m. A flowsheet entry titled Violent Restraints dated 7/20/26 at 3:49 p.m. indicated a face-to-face evaluation was performed within one hour of restraint initiation at 3:00 p.m. However, the medical record did not reflect a face-to-face was performed to assess P7’s reaction to the manual hold or his medical and behavioral condition. A discharge note dated 7/20/26 at 4:10 p.m. indicated P7 was discharged to a community behavioral health center. P7’s entire medical record was reviewed and did not contain a face-to-face assessment to assess P7’s reaction to the manual hold or his medical and behavioral condition for the manual restraint episode on 7/20/26 at 3:00 p.m. During chart review on 8/12/26 at 1:54 p.m., the patient care supervisor stated that either the nursing staff or the provider are able to complete a face-to-face assessment. The patient care supervisor was unable to locate the face-to-face assessment for P7’s episode of restraint on 7/20/26 at 3:00 p.m. During an interview on 8/11/26 at 2:56 p.m., RN-C stated a manual hold is considered a restraint. RN-C stated a face-to-face assessment must be obtained within one hour of restraint application. During an interview on 8/12/26 at 9:16 a.m., RN-E stated within one hour of restraint application, staff must obtain a face-to-face assessment. The face-to-face assessment may be completed by either the RN or the provider. During an interview on 8/12/26 at 10:37 a.m., medical doctor (MD)-A stated when providers are on-site, they complete face-to-face assessments of patients who have been placed in restraints. During an interview on 8/12/26 at 10:51 a.m., MD-B stated after restraints have been applied to the patient, a face-to-face assessment must be completed. The face-to-face assessment is completed to determine if the patient is safe, their behavioral needs, the presence of injuries, and/or the need to continue the restraint. If the provider is not available, such as during an evening shift, the charge nurse would complete the face-to-face assessment. During an interview on 8/12/26 at 11:19 a.m., RN-F stated manual hold restraints require a face-to-face assessment. During an interview on 8/12/26 at 11:27 a.m., the patient care manager stated either the nurse or the provider can complete a face-to-face assessment for the application of restraints. A facility policy titled “Restraints/Seclusion - Management of Violent and/or Self-Destructive Behavior,” dated June 2025 indicated a face-to-face assessment of the patient must be completed with 1 hour of initiation of restraint or seclusion. The face-to-face assessment must address the patient’s reaction to the application of the restraint, and their patient’s medical and behavioral condition.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(iii) [there must be documentation in the patient’s medical record of] Alternatives or other less restrictive interventions attempted (as applicable); This Standard is not met as evidenced by: 47264 Based on interview and document review, the facility failed to ensure adequate documentation for less restrictive interventions attempted prior to the application of restraints for 1 of 10 patients (P10) reviewed for restraint use. Findings Include: P10 presented to the emergency room (ER) via ambulance on 5/27/26 at 7:16 a.m. for treatment of a gunshot wound to the head. P10’s past medical history included Parkinson’s disease, diabetes, hypertension, and cauda equina syndrome with neurogenic bladder. P10 was given stabilizing care in the emergency department and transported to the intensive care unit on ventilator support at 11:32 p.m. A flowsheet entry dated 5/28/26 at 12:00 a.m. indicated bilateral non-violent wrist restraints were initiated due to delirium, disorientation, and pulling at lines and tubes. The flowsheet indicated P10 exhibited calm behavior from 10:00 a.m. - 2:00 p.m. P10’s restraints were discontinued on 5/28/26 at 4:00 p.m. A nursing care plan summary note dated 5/28/26 at 5:07 a.m. indicated P10 was in non-violent restraints. The behaviors P10 was exhibiting were “sedated, disoriented,” and was tolerating the use of restraints. A provider note dated 5/28/26 at 4:42 p.m. indicated a conversation regarding P10’s goals of care was held with family. Education and prognosis were provided, and P10’s decision maker indicated they would like to move forward with compassionate extubation after family had the chance to visit with P10. A nursing care plan summary note dated 5/28/26 at 10:34 p.m. indicated P10’s restraints were discontinued due to lack of purposeful movements. A respiratory therapy note dated 5/29/26 at 4:51 p.m. indicated P10 was extubated per physician order and placed on room air. A death of patient note dated 5/30/26 at 4:30 a.m. indicated a provider pronounced P10 expired at 3:30 a.m. on 5/20/26. P10’s entire medical record was reviewed. Documentation of interventions attempted prior to the use of restraints was not recorded. During an interview on 5/11/26 at 2:56 p.m., registered nurse (RN)-C stated restraints are used as a last resort. Staff should try multiple interventions prior to the use of restraints. During an interview on 5/12/26 at 10:03 p.m. RN-E stated the use of restraints must be a “last resort,” and staff should try everything before applying restraints. During an interview on 5/12/26 at 11:27 p.m. the patient care manager stated staff are trained to treat restraints as a last resort. A facility policy titled “Restraints/Seclusion - Management of Violent and/or Self-Destructive Behavior,” dated June 2025 indicated less restrictive interventions do not need to be attempted by staff, but must always be considered. Alternative interventions, or the rationale for not using said interventions prior to the application of restraint must be documented.”

“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 interview and document review, the hospital failed to ensure a sacral pressure ulcer was adequately monitored and documented by nursing in the medical record to ensure ongoing continuity of care for 1 of 10 patients (P6) reviewed for their nursing care. P6 admitted to the medical unit on 4/14/26 with a sacral pressure ulcer; however, the record lacked evidence of any recorded wound characteristics (i.e., size, odor, drainage) by nursing staff from 4/15/26 to 4/19/26 (four days). Findings include: On 6/16/26 at 8:36 a.m., P6 was interviewed and expressed multiple concerns about the care received at the hospital during the April 2026 admission. P6 stated they had a pressure sore on their backside from years prior when they had been dropped from a mechanical lift in another state. P6 stated when they admitted to the medical unit, none of the nurses did a skin check and P6 was told by a nurse, “We don’t do that here.” P6 stated they didn’t recall anyone ever telling them how big the wound was, or how it was progressing while in the hospital adding, “Nobody came in to do the wound.” P6 was frustrated by the lack of attention to the wound and expressed, “I don’t understand it.” P6’s hospital medical record, dated 4/13/26 to 4/21/26, identified P6 presented to the emergency department (ED) on 4/13/26 for concerns about a possible urinary tract infection (UTI). P6 had a wound recorded, “Pressure injury of skin of sacral region, unspecified injury stage.” P6 admitted to the “1 West” unit from the ED on 4/14/26 at 8:48 a.m. Wound-ostomy-continence nurse (WOCN)-A evaluated P6 on 4/14/26 at 11:50 a.m. for a pressure ulcer on her sacrum. P6 had multiple medical conditions including paraplegia, diabetes mellitus, and chronic peripheral neuropathy. P6’s pressure ulcer was listed as, “Full Thickness,” and measured 2.0 X 3.0 centimeters (cm) in size with small serosanguinous drainage and no odor. The note recorded, “Healing stage 3-4.” WOCN-A wrote a plan of care for a daily dressing change and discussed the cares/plan with the nursing staff. P6’s EPIC Integumentary flowsheet, dated 4/14/26 to 4/19/26, identified the nursing staff’s recorded evaluations of the pressure ulcer. These included: - On 4/14/26 at 9:00 a.m., P6 was recorded with a “Skin Problem.” The nursing flowsheet entry lacked any further information on what the problem was or any wound characteristics. - On 4/14/26 at 4:55 p.m., P6 was recorded with a “Skin Problem.” The nursing flowsheet entry lacked any further information on the wound characteristics. P6’s corresponding nurse progress note, dated 4/14/26 at 11:51 p.m., identified P6’s had a sacrum wound and an MRI completed to rule out osteomyelitis (infection of the bone) or abscess (pocket of pus). A dressing change was completed on the wound on the day shift. The note lacked any recorded wound characteristics. - On 4/15/26 at 9:25 p.m., P6 was recorded with a “Skin Problem.” The nursing flowsheet lacked any further wound characteristics. - On 4/16/26 at 8:31 a.m., the flowsheet recorded a, “Done, Full Skin Assessment.” The dictation recorded, “No additional issues identified,” but again lacked any recorded pressure ulcer characteristics for the wound. - On 4/16/26 at 4:19 p.m., the flowsheet recorded another, “Done, Full Skin Assessment.” However, again, the flowsheet recorded no additional issues were identified but lacked any recorded pressure ulcer characteristics for the wound. - On 4/17/26 at 6:00 a.m., the flowsheet recorded a “Focused Assessment” was completed. The nursing flowsheet lacked any further recorded wound characteristics. - On 4/17/26 at 9:37 a.m., the flowsheet recorded P6 as having a “Skin Problem,” but again, lacked any further recorded wound characteristics. In total, P6’s nursing Integumentary flowsheet, dated 4/14/26 to 4/19/26, lacked any recorded wound characteristics for P6’s sacral pressure ulcer until 4/19/26 at 7:00 a.m., when the wound was recorded on the flowsheet as having erythema (redness), denuded skin peri-wound (skin injury where top layer of skin is removed and exposes the underlying tissue), and having a foam dressing in place with a small amount of drainage. When interviewed on 6/16/26 at 9:47 a.m., registered nurse (RN)-B stated a “skin check” was completed on every patient when they admitted to the unit and recorded in the medical record under the flowsheet. If wounds were present, then they would also be charted with characteristics and a consult to the WOCN placed. The WOCN then would develop a plan of care for nursing to implement. On 6/16/26 at 10:02 a.m., P6’s medical record was reviewed with the unit’s patient care manager (PCM)-A and patient care supervisor (PCS)-A. They acknowledged the lack of documented nursing skin check on the flowsheet when P6 admitted to the unit on 4/14/26 and stated the wound should have been identified in the same flowsheets. PCM stated, “I don’t have anything documented.” PCM stated there was some recorded information within various nurses’ notes; however, it was somewhat vague information and didn’t speak to the wound characteristics. PCM verified the flowsheets lacked any recorded pressure ulcer characteristics until 4/19/26, and stated dressing changes and wound characteristics should both be recorded on the flowsheets to help ensure the wound was “not getting worse” or becoming infected. PCM and PCS stated they would continue to review the medical record and provided more documentation, if located. No further information was provided. On 6/16/26 at 11:32 a.m., WOCN-A was interviewed and stated the “expectation” was for nursing to do a full skin assessment every 24 hours with the “focused” assessment being done in-between for known skin issues like a pressure ulcer. Wounds were often tracked using the “LDA” which would pull the same information into the flowsheets. WOCN-A stated P6 had a pressure ulcer on her sacral area when she admitted to the unit, which was seen again by infectious disease on 4/20/26 and had not worsened. WOCN-A stated that “ideally” the nurses should be documenting the wound characteristics on the flowsheets at least daily as it helps other staff, including the WOCN, have a clearer picture of the wound as they track it. WOCN-A stated the nurses on the floor may need some clarification on how and when to document on developed wounds adding, “With wounds, the more detail the better.” A hospital Skin Assessment policy, dated 1/2026, identified the clinical practice standard was to complete a full head-to-toe skin assessment upon admission within 24 hours, complete a “Full Skin Assessment” once daily on the day shift or per unit routine, and complete a “Focused Skin Assessment” for known skin problems once each shift if the full assessment was not completed. A procedure was listed to guide how this process should be completed and listed several items to be considered including color of the skin, moisture of the skin, temperature of the skin, and presence of existing wound or scar. The policy outlined, “Unique skin injuries must be added to LDA. In med/surge [sic], generalized skin exceptions (i.e. dry, bruised, fragile) should be documented on the assessment flowsheet.””

“DISCHARGE PLANNING EVALUATION CFR(s): The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). This Standard is not met as evidenced by: 33925 Based on interview and document review, the hospital failed to provide notice of discharge to a receiving care venue in accordance with established policies and procedures for 1 of 10 patients (P7) reviewed for discharge planning. P7 discharged from the hospital on 4/15/26 back to their mental treatment program; however, the program was not appropriately notified prior to P7’s discharge, causing P7 to arrive back to the program with little or no warning, which could have compromised the continuity of care for P7. Findings include: A Vulnerable Adult Maltreatment Report, dated 4/16/26, identified concerns about P7 being discharged from the hospital back to a mental health treatment program. The report identified P7 arrived back at the center on 4/15/26, in the late evening adding, “[the hospital] did not notify [center] staff prior to this.” P7’s hospital medical record, dated 4/13/26 to 4/15/26, identified P7 admitted to the hospital on 4/13/26 through the emergency department (ED) with concerns for heart failure and chest pain. P7 was transferred to the “3 West” unit from the ED. P7’s progress notes, dated 4/13/26 to 4/16/26, identified the following items about the discharge planning for P7: - On 4/14/26, a social worker consult note identified an admission screening was completed and P7’s current living situation was recorded as, “Treatment Center.” The center had contacted the hospital asking for an update, but the social worker was unable to reach them on return call. - On 4/15/26, P7 was identified as medically ready for discharge and P7 wanted to return to the treatment center. P7 was on 2 liters of oxygen and a potential “home 02 assessment” was discussed. The medical provider stated P7 would need home oxygen and asked if the center could accept them back with that. A call was placed to the treatment center to discuss this. A section labeled, “Barriers to D/C plan,” identified, “Home O2.” A return call was received from the treatment center around 4:00 p.m., and they stated P7 would have to be on concentrated oxygen (not refillable) and would have to manage it themselves to return. P7 was then asked and expressed they felt comfortable managing the oxygen without help. The note identified transportation still needed to be arranged for P7 and listed a section labeled, “Social Work next steps,” which identified they were arranging transfer to the treatment center adding, “Need to confirm with facility that they can take her back on new home O2.” The note lacked evidence that a discharge decision had been made and that P7’s impending discharge had been communicated to the treatment center. Social worker (SW)-A authored the note. - On 4/15/26, the oxygen assessment was completed and P7 was recorded as being 96% on room air (Sp02). - On 4/15/26, a nurse note identified P7 had diminished lung sounds and had a “home O2 assessment” done which identified P7 did not need oxygen at home. The note recorded, “D/C home today. Uber ride voucher given to patient.” The note lacked any recorded information on whether the treatment center was contacted with the updated discharge plan and that P7 would be discharged imminently. There was no recorded nurse-to-nurse report. Registered nurse (RN)-D authored the note. - On 4/16/26, a social worker note identified P7 had discharged on 4/15/26 as they did not need home oxygen. SW-A authored the note. P7’s medical record lacked clear evidence the treatment center was told a date or time of P7’s discharge prior to it happening to allow the center a chance to ensure P7 would be cared for adequately upon arrival back to their campus. On 6/16/26 at 11:09 a.m., a telephone call was made to the treatment center, and a voicemail was left seeking a call back. However, the call was not returned. When interviewed on 6/16/26 at 1:03 p.m., RN-F stated the primary nurse often started the discharge planning process, and if services would be needed upon discharge that a consult to care management team was placed. If a patient arrived from a care venue and returned to one, then care management would also be involved with that. RN-F stated all communications to the receiving facility were supposed to be recorded in the progress notes and if the patient was leaving to another care venue, then a “nurse to nurse” report was to be done and charted. When interviewed on 6/16/26 at 1:50 p.m., SW-A explained they worked with case management and would help with the discharge process back to a care venue if the patient came from one. SW-A verified they were able to review P7’s medical record and explained that P7 resided at a mental health treatment center which was across the street from the hospital (but not part of the hospital CCN). SW-A recalled there were some questions on whether P7 would need oxygen upon discharge, and the treatment center had some concerns with accepting P7 back on that. P7 then had an oxygen assessment after SW-A had left for the day (on 4/15) and then a decision to discharge was made following that when P7 didn’t need oxygen. SW-A stated when they last spoke with the treatment center prior to P7’s discharge, that is when they voiced concerns about the oxygen use. They then left a voicemail with the center saying an oxygen assessment would be done and P7 “may or may not go [discharge] depending on how that goes.” SW-A stated they typically tried to communicate with a receiving care venue on when a patient would be discharged and returning but in P7’s case, they felt there was a medical report to give the venue so a report to them “didn’t need to happen.” SW-A stated communicating more exact details of the discharge would sometimes fall to the primary nurses’ responsibility adding, “It can.” SW-A verified any communications about discharge plans should be documented in the progress notes by either nurses or the case management team. When interviewed on 6/17/26 at 8:38 a.m., RN-D stated a discharge back to a care venue should include a “shift note” in the progress notes with details of the communication to the receiving provider. RN-D added, “We should be documenting that.” RN-D stated they could not recall ever calling the treatment center about P7’s discharge plan then added, “Not that I know of [calling them].” RN-D stated if they had called the treatment center, then they believe it would have been charted as being done. RN-D then stated they recalled possibly thinking P7 was just discharging back to home and not to a care venue but then reiterated they couldn’t recall details about it. A hospital Discharge Planning/Discharge Patients policy, dated 2/2025, identified discharge planning needed communication and cooperation from the patient, physician, nurses and outside providers, when applicable. Discharge planning started upon admission and planning “ ... may occur between hospital units, from hospital to another care facility, or from hospital to home.” The policy outlined that case management staff would be involved and contribute to the plan if additional care is needed at another venue of care. Further, the policy outlined the staff RN was responsible for, “ ... Communicating with significant others and receiving agencies the anticipated discharge date and needs.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 43080 Based on observation, interview, and document review, the hospital failed to ensure staff utilized de-escalation techniques, and the least physical interventions, to mitigate behavioral escalations for 1 of 7 patients (P2) reviewed for behavioral events and patient rights. P2 was pushed by a security officer (SO), fell to the ground, and sustained a laceration on his head that required staples when the SO responded to a perceived threat before any other applicable interventions were utilized. This had the potential to impact all patients who displayed behavioral emergencies and required security officer response. See A-0145 for additional information. Based on interview and document review, the facility failed to obtain a specific physician or licensed practitioner restraint order prior to, during, or immediately (within a few minutes) following, each episode of restraint or seclusion use for 7 of 7 patients (P2, P3, P11, P12, P13, P14, P15) reviewed for violent restraint and seclusion use. This had the potential to affect all patients who required restraints and/or seclusion. See A-0168 for additional information. Based on interview and document review, the facility failed to discontinue restraints, and/or restraint/seclusion orders, at the earliest possible time once restraint criteria were no longer met, for 7 of 7 patients (P2, P3, P11, P12, P13, P14, P15) reviewed for violent restraint and seclusion use. This resulted in P3 restrained for longer than necessary, along with patients’ having active restraint orders despite their removal once criteria for discontinuation were met. See A-0174 for additional information. Based on interview and document review, the facility failed to ensure restrained and/or secluded patients were monitored, and that the monitoring documentation were completed timely by trained staff, per facility protocols, for 7 of 7 patients (P2, P3, P11, P12, P13, P14, P15) reviewed for restraint and seclusion utilization. This had the potential to affect all patients who utilized restraints and/or seclusion. See A-0175 for additional information. Based on interview and document review, the facility failed to ensure the contracted emergency department (ED) providers were minimally trained in facility restraint and seclusion policies for 3 of 3 providers (MD-G, DO-B, and MD-C) reviewed. This had the potential to affect all patients who presented to the ED and required the use of restraints and/or seclusion. See A-0176 for additional information. Based on interview and document review, the facility failed to provide a face-to-face evaluation (a physical and behavioral assessment of the patient by a qualified practitioner/registered nurse (RN), and a comprehensive review of the patients status at the time of the face-to-face evaluation, within an hour of restraint and/or seclusion initiation, for 7 of 7 patients (P2, P3, P11, P12, P13, P14, P15) who were physically restrained, and/or placed in seclusion. This had the potential to affect all patients who required restraints and/or seclusion. See A-0179 for additional information. As a result, the hospital was found out of compliance with the Condition of Participation: Patient Rights at 42 CFR 482.13.”

“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: 43080 Based on interview and document review, the facility failed to re-evaluate and reconcile discharge medication orders and determine the discharge discrepancy for 1 of 7 patients (P5) reviewed for discharge medication processes. As a result, P5 was discharged with an order for Dexamethasone (steroid), which was 20 times higher than the initial discharge order documented by the doctor. P5 subsequently passed away 11 days after discharge from a gastrointestinal (GI) bleed. This has the continued potential to impact patients who required re-evaluation of their medications when discharge plans were modified. As a result, the hospital was found out of compliance with the Condition of Participation: Discharge Planning at 42 CFR 428.43. See A-802 for additional information.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 43080 Based on observation, interview, and document review, the hospital failed to ensure staff utilized de-escalation techniques, and the least physical interventions, to mitigate behavioral escalations for 1 of 7 patients (P2) reviewed for behavioral events and patient rights. P2 was pushed by a security officer (SO), fell to the ground, and sustained a laceration on his head that required staples when the SO responded to a perceived threat before any other applicable interventions were utilized. This had the potential to impact all patients who displayed behavioral emergencies and required security officer response. Findings include: On 4/9/26, at 2:47 p.m., video footage was reviewed with the security manager (SM)-A, regional security manager (SM)-B, risk manager (RM)-A, system accreditation specialist (AS)-A, and accreditation specialist (AS)-B. The video, which lacked audio, lasted for 7 minutes and 50 seconds, where most of the video displayed staffs’ response once P2 was on the floor. Based on the nature of how the video was saved, actual event time stamps were not available. Staff reported the video began on 3/28/26, at 3:13 a.m. with P2 and registered nurse (RN)-C standing by each other just outside of the triage doorway. P2 took a step backwards, began to lose his balance, and RN-C grabbed onto him to steady him. In response, P2 placed his right hand onto RN-C’s upper back/neck area. RN-C did not remove P2’s hand. Immediately after, RN-R rushed towards P2 and RN-C, and once he approached, RN-C guided P2 into a chair closest to the triage doorway. While this occurred, security officer (SO)-A entered the triage room from a back room adjacent to the triage room, remained within the triage room, and faced towards the location of P2, RN-C, and RN-R. Within approximately five seconds, both RN-C and RN-R walked toward the triage room. RN-C entered first, and RN-R followed. Just as RN-R crossed the threshold of the triage room, RN-R turned around and faced P2. Almost immediately after, P2 placed both hands on the triage chair arms and stood up swiftly, clenched his fists and then unclenched them, and started to walk towards where RN-R stood. In response, RN-R stepped backwards towards the triage room corner wall. From the chair to the triage room, P2’s gait appeared steady, his fists remained unclenched and appeared relaxed, and his arms were at his sides without physical displays of aggression. When P2 entered the triage room his head remained positioned towards RN-R’s direction and did not turn his head towards SO-A. P2’s head remained positioned towards RN-R’s direction. As P2 crossed the triage room threshold and continued to take another step towards RN-R, SO-A stepped towards P2, raised his hands, placed his palms on P2’s chest and pushed with enough force that his elbows extended, his wrists upright and palms face forward on P2’s chest moving P2 backwards where he landed on his back, in a prone position, between the chair he rose from and the triage door threshold. From the video’s angle, a view of P2’s upper body was obstructed by the triage door frame; however, his legs lacked movement. Staff responded immediately and ultimately placed P2 on a back board and he was removed from that area. The video lacked observational evidence of the hospital used the least restrictive methods to deescalate P2’s behavior. P2’s provider Emergency Department Note, dated 3/28/26, identified he presented at 2:50 a.m., related to chest pain after having an argument with his girlfriend while intoxicated. P2’s nursing progress note, signed 3/28/26, at 3:19 a.m., by registered nurse (RN)-C, identified during the triage process, P2 stated he was a strong man and expletives towards an unknown female. He was unsteady on his feet, stumbled around the lobby, and required frequent redirection. P2’s nursing progress note, signed 3/28/26, at 4:01 a.m., by RN-R, identified that at approximately 3:10 a.m., P2 yelled out in the lobby, ‘Fuck you!’ In response, RN-R walked to P2 and calmly asked P2 to not yell out in the lobby. P2 yelled, ‘Oh yeah?’ and stood up and aggressively charged toward him with a steady gait and both of his fists balled. RN-R walked backwards towards triage one while he maintained visualization on P2. He felt unsafe and concerned about his safety. RN-R stated, ‘Are you going to assault me?’ P2 was a few feet from RN-R when security stepped between him and P2. The security officer verbally directed P2 to stop; however, P2 continued to charge towards him and the security officer. The security officer went hands-on and P2 fell backwards. P2’s nursing progress note, signed 3/28/26, at 4:05 a.m., by RN-T, identified RN-T witnessed P2 being helped into a lobby chair due to an unsteady gait. After, P2 raised his voice to nurses and raised his hands while sitting. She was unable to hear what was said. A code green was called. Seconds later, P2 launched out of his chair with clenched fists, leaning forward in a quick aggressive manner towards the triage nurse. When P2 was within arms-reach of the nurse, security went in between and pushed P2 back away from the nurse and P2 fell to the floor. P2’s nursing progress note, signed 3/28/26, at 5:20 a.m., by RN-C, indicated he witnessed P2 charge towards another RN with clenched fist with an intent to assault, security stepped in prior to P2 assaulting or causing harm towards that RN. P2’s provider Emergency Department Note, signed 3/28/26, at 6:11 a.m., identified a “3 cm (centimeter)” scalp laceration to the back of his head that required six staples to close. P2 was clinically intoxicated and displayed mild confusion related to the intoxication. The note indicated P2 had a closed head injury without bleeding within the brain or any skull fractures. P2 provided information related to concussion symptoms as well as signs of delayed complications. P2 continued to be monitored and when he was awake and clinically sober, or had an adult come pick him up, he was ready for discharge. During the video review on 4/9/26, at 2:47 p.m., RM-A stated P2 was brought in by ambulance and the ED did not have an available bed at that time, so P2 was brought to the waiting area which was relatively busy and housed another intoxicated patient. Up to the point of the event, P2 had not yet been screened but had his vitals taken and maybe some cardiac monitoring. SM-B identified that SO-A was in the triage area due to the other intoxicated patient. Once P2 shot up from the chair, SO-A stepped in and tried to stop P2 from coming any closer, which was the context of their training to stop an incoming threat. When interviewed on 4/10/26, at 10:38 a.m., RN-R stated that de-escalation techniques were expected to be used if a patient showed an escalation in their behaviors. This was a challenge at times, especially when a patient was intoxicated by alcohol or drugs and explained it was very hard to reason with patients in such situations. Despite this, de-escalation was expected to be attempted with any patient behaviors even if the staff knew it was not going to be effective. RN-R explained, at the very least, verbal statements to set boundaries and expectations were to be stated. RN-R identified he communicated with security when he felt unsafe so that they could be there for a show of support. He attempted to communicate patient escalations sooner than later to help mitigate unprovoked acts of aggression. RN-R stated he had been “attacked” by patients in the past; however, despite this concern, he stated he did not have his panic button on him at the time of the event. RN-R explained that the nurses drove behavioral interventions; however, a security officer was allowed to go hands-on a patient if there was imminent danger to staff. For a security officer to get in between a patient and staff, verbal redirection was expected such as “stop,” and then if the patient continued to come after staff aggressively, the security officer could defend the staff, and themselves, from being assaulted. RN-R stated he was not concerned with any security to patient encounters that he considered excessive in force. RN-R explained that P2 was brought in by the ambulance in which he was “boisterous,” swearing and yelling; however, he was able to be triaged. The triage nurse walked him to the lobby and sat him down. When he approached, P2 was yelling out and screaming to which he verbalized to P2, “Hey man, you cannot yell out like that.” Immediately after, P2 stood up, hunched his shoulders and with fists bunched up stated, “oh yeah man,” and started to walk towards RN-R. RN-R was unsure what P2 may have heard him say but RN-R felt that P2 wanted to punch him, and thus he started to back up as P2 continued to walk towards him. RN-R knew he could not turn his back on P2 as he had to keep him in his line of sight. RN-R explained his heart raced and he was afraid as he thought he was going to be assaulted, especially as P2 “was a big guy,” and could have ended RN-R’s career. While P2 walked toward him. RN-R stated he asked P2 if P2 was going to assault him. “I was so surprised.” P2 lacked a response to his question. At that moment, SO-A came between him and P2. RN-R thought SO-A stated to P2 he needed to back up, “or something like that.” Despite this, P2 continued to charge toward him. When P2 kept advancing, SO-A put his arms out and P2 fell backwards and “unfortunately hit his head” on the corner of the lobby scale. Due to SO-A’s position, RN-R was unable to see the physical aspect(s) of SO-A’s actions towards P2. After, someone called a code green (behavioral event response) and staff responded. When P2 was on the waiting room floor, he yelled out but was cooperative with staff. He was not thrashing out or physically behavioral. When interviewed on 4/10/26, at 11:27 a.m., SO-A stated he primarily worked in the ED and on the mental health unit. When there was a patient who displayed behavior escalations, the priority was de-escalation. If that did not work, disengagement was attempted, if it was safe for the patient to be left alone as he did not want the patient to become more aggravated. If there was imminent harm and/or danger, his role was to support the nursing staff and protect everyone involved, with a worst-case scenario, he had to go hands on. This process required “prerequisites”, and he needed a code green and associated nurse direction. However, SO-A stated there were times when he could initiate actions himself such as emergencies where the patient was already attacking someone, or about to, and/or in situations where there was not enough time, such as with a patient advancing on staff. In such situations, he would not wait for the code green to be called. SO-A explained, his reaction(s) depended on what the patient was doing. His actions centered around the least possible to achieve a goal of safety, but if the patient choked a staff, then that would enable him to do “whatever necessary.” When presented with a situation where the patient was coming towards a staff, and his response to the situation, he indicated that was a tough question and verbalized, “Our policy is written in such a way that I am not necessarily obligated to do something,” but, with his background, “I am a protector of sorts.” He clarified in such situations; he, however, did not want to go overboard. SO-A explained P2’s situation, and P2’s distance to staff, did not allow enough time to try commands to stop or step back, which would have been ideal to attempt if the situation presented differently. SO-A stated he heard P2 express from around the corner, “fuck you.” As RN-C, then RN-R, came into the triage room, he heard RN-R state from the doorway, “Oh you are going to assault me. That peeked my ears.” In response, without saying anything initially to P2, he placed himself between P2 and RN-R as P2 continued to advance towards RN-R. SO-A stated P2 walked briskly into the triage room, straight as an arrow with clenched fists, despite earlier gait unsteadiness. He explained he only had a couple of seconds between when P2 walked into the triage room, to being in his “bubble,” and did not have time to issue any commands such as stop or get back. As SO-A perceived P2 to be taller than him and P2’s actions as an immediate threat, he “pushed him ...not that hard.” “Did not launch him, but it was a “general push.” He felt that due to P2’s intoxication, which he was aware of before the interaction, the action was “amplified” and P2 was unable to catch himself before he fell and hit his head. In such a situation, his intention was to create distance or a safe reactionary gap as the more distance that was present, allowed for more options to provide instructions or call for help. In this situation, SO-A stated P2 was in his face and he “did not have time to think.” It was more of an “immediate reaction to a threat,” versus stopping and thinking. He explained in that moment, his brain selected the highest level of training, and he was trained he could push someone away like that. He explained he was trained annually on the use of force where hands on techniques and tool usage were taught. SO-A explained that after this incident, the night shift supervisor talked with him. He was placed on administrative leave; however, was allowed to come back that same day. He identified he was told staff watched the video and it was found to be clear aggression on P2’s part in which he performed a two-handed shove. He was cleared of any policy, or regulatory violations. On 4/10/26, at 1:50 p.m., the facility’s investigation was reviewed with RM-A, AS-B, patient safety and quality advisor (QA)-A, RN-K (ED patient care manager), and the ED patient care director. RM-A identified an ACA (apparent cause analysis) was initiated by nursing on 3/31/26; however, a security investigation began right away. The ACA documentation identified the information noted in P2’s medical record, and that clinical staff, based on interviews, felt they would have been assaulted had security not been present. Immediate action identified policy review, and the analysis were initiated, along with a vulnerable adult report being filed to the State agency (SA). RM-A stated, the reason for the SA report, was there was a lot of discussion around this event but ultimately when the specifics of the statutes were broken down and there was a potential issue related to anything meeting the definition of assault, the facility wanted to error on the extreme side of caution. The report identified there were no gaps or clinical deviations identified as the care team verbally attempted to redirect P2, expediated bed placement in the ED, and were concerned for the safety of other patients in the lobby, along with an appropriate trauma response after the event. A security perspective section identified a potential opportunity for reinforcing high reliability skill of “STAR” (stop, think, act, review) and promoting situational awareness in future events; however, with the proximity of P2 to the care team, in conjunction with his verbal threats of violence and non-verbal physical displays, such as the clenched fists, resulted in the immediate need for security to intervene as the team perceived an imminent physical threat of bodily harm. An Apparent Cause Statement identified a highly intoxicated patient who came into the ED lobby and was disruptive and aggressive towards nursing staff. Security intervened and it resulted in the P2 needing staples for laceration repair. When staff were interviewed after the ACA review, QA-A identified the facility’s investigation into this situation was fully completed. RM-A explained this ACA was clinically driven while security did their own investigation process. The security ACA was briefly reviewed which identified a security 72-hour review section that identified “initial findings deemed it appropriate given the training received and the situation. Upon further review actions deemed inappropriate following ER guidance; however, any questions related to this report, and further review of this report, were directed to be asked/completed during any security staff interviews. RM-A, and RN-K, stated initially, both had concerns after they watched the video; however, after repeated views, and talking to staff, there was not malintent and they determined the video did not show a true picture of the situation events based on P2’s chart documentation and staff interviews. The situation happened so fast, and staff did not expect such action. RM-A stated If security were not present, staff would have been assaulted as “this was a bright red level of threat situation. It would have been a code green if they had time.” When interviewed on 4/10/26, at 2:24 p.m., RN-T stated she had witnessed P2, and another intoxicated patient antagonized each other in the ED lobby when she arrived at work. Shortly after that, she assisted her patient to the bathroom adjacent to the lobby, RN-C and RN-R interacted with P2 as P2 was assisted to a lobby chair. She heard RN-R explain to P2 it was going to be a bit and to have a seat. P2 vocal tone was loud with slurred speech. When P2 started to verbalize expletives, RN-R stated, “Shhhhh,” and informed P2 there was no swearing in the lobby. After RN-R turned around and walked toward the triage room, while RN-R’s back was still turned towards P2, P2 jumped up out of the chair, leaned forward and lurched his arms up to about a 90-degree angle from his body. Once standing, P2 took about three steps towards RN-R, with his arms still stretched out, in a threatening way. RN-T was unable to recollect if P2’s hands were fisted but she knew they were raised. Once P2 was within arms-reach of RN-R, who had just entered the triage room, RN-R turned around toward P2. At that same time, before P2 even entered the triage room, “security jumped in,” placed his two hands, palms up, on P2’s chest, and “pushed” P2 back. P2 stumbled, fell, and hit his head. RN-T explained, “Security just came out of the room and pushed.” She was unable to recollect if she heard the security officer say anything, but she verbalized that when security verbally de-escalates a patient, they use a loud voice, which she did not hear. When interviewed on 4/10/26, at 3:29 p.m., RN-C stated P2 was brought in for domestic abuse where P2 identified he drank earlier and had chest pain. During the triage process, P2 was agitated and upset about the situation at his home. P2 stated “stupid bitch” and that he was a strong man. After RN-C was able to calm P2 down slightly, he escorted him to the lobby. Due to P2’s unsteady gait, he guided him to the closest chair. After RN-R arrived, and P2 was seated, P2 made comments of profanity. RN-C explained that in response, RN-R informed P2 he could not use such language in the lobby. When RN-C returned to the triage room, he explained he heard RN-R and P2 exchange words where P2 stated, “oh yeah, oh yeah.” After, P2 stood up quickly, fisted both of his hands, and came towards RN-R. RN-C explained, it appeared that once RN-R realized P2 approached him, RN-R turned around, stepped back and stated to P2, “Are you going to assault me?” P2 responded, “Yes.” When P2 was within arms-reach of RN-R, two to three steps inside the triage room, RN-C knew P2’s intent was harm, based on how P2 stood up, how his fists were, and how he postured. RN-C explained, before he was able to respond to the threat, a security officer positioned himself in between P2 and RN-R and “pushed” P2 which caused P2 to wobble and fall backwards; however, later in the interview, when questioned more on the push, he was not one hundred percent sure he witnessed it. Additionally, RN-C was unsure whether he heard the security officer say anything to P2 before he intercepted him. When interviewed on 4/13/26, at 9:51 a.m., SM-B stated typically when security interacted with a behavioral patient, a code green event was triggered and security was expected to follow the directives of the clinical team; however, if there was an immediate risk of harm towards others, security were to step in with attempted actions to stop the assaultive behavior, such as verbal redirection and/or placement of themselves between the patient and staff if necessary. He expected a security officer to make an in-the-moment assessment of the situation, attempt verbal de-escalation techniques, putting hands up as a visual physical deterrent and possibly “stand like a brick,” and if all those were unsuccessful and there was a need for a hands-on approach, those situations required the least amount of force as possible. As security officers were taught this, he expected them to follow this process; however, there were times when things happened that required mitigation from this particular education, such as in the case of P2, especially when P2 was intoxicated, unpredictable, and made threats towards staff while he quickly advanced on staff in an aggressive way, in more of a confined space that staff could not retreat from. SM-B explained, in P2’s situation, the officer stopped P2’s incoming threat advancement with raised hands; however, due to the quickness of the maneuver, P2 ended up immediately falling backwards when contact was made. When questioned on the statement in the 72-hour security ACA report about concerns being identified, SM-B stated initially concerns were questioned as pushing a patient was not a “security move of any sorts.” Thus, human resources were involved in the investigation to help decide if SO-A’s actions warranted any educational and/or disciplinary actions. In response, the video was reviewed, statements were obtained, and an investigation occurred. Based on all of this, it was determined SO-A’s actions were in defense of staff to stop a threat and that he acted within his code green and violence prevention training. When interviewed on 4/13/26, at 10:37 a.m., P2 stated, “One of the big guys shoved me ...that is what a doctor told me.” Due to this, he received a “big blow to the head.” He noticed blood all over the hospital bed when he woke up. P2 stated he did not remember any events that led to this event, but he stated he probably just tried to go home. He felt this lack of remembrance was due to the blow on his head and did not feel he was that intoxicated. This event, and the events that occurred after, upset him as he did not feel it took “seven of them” to interact with him especially as he was a “little man,” about five feet nine inches and only weighed about 170 pounds. He felt security should be investigated due to their excessive force. He explained he did not report this himself as he was not that kind of person. A Behavioral Emergencies policy, dated November 2024, identified patient behaviors that put the patient, or others, at risk required clinical support and intervention. Staff were to first address the behaviors in a therapeutic manner and security interventions were to only be used in circumstances defined in the Security Intervention Policy. The policy directed that staff were to encourage the patient to stop the behaviors with appropriate therapeutic de-escalation techniques. If unsuccessful, the patient was to be offered access to a less stimulating environment, the provider was to be updated, and security was to be contacted. After, security and staff were to collaborate to support the patient and the patient’s safety plan. If the patient posed an immediate threat or substantial bodily harm or great bodily harm to self or others, security was to intervene in accordance with security policies. If the patient posed an imminent danger to self or others, staff could escort the patient to the ED. The policy lacked techniques or strategies related to pushing a patient out of the way to mitigate potential harm. A Hospital Code Green policy, dated December 2024, identified verbal de-escalation and other less restrictive interventions were preferred and first response to a potential or actual behavioral emergency with physical interventions being used as a last resort if a less restrictive intervention did not make the situation safe. The policy defined code green as a code used to notify an summon staff trained to respond to a potential or actual behavioral emergency; a behavioral emergency as a situation where a patient presented as being an imminent risk of behaving in a way that could result in serious harm to self or others; de-escalation as therapeutic verbal and non-verbal communication techniques used to assist a patient experiencing a behavioral emergency to remain, or to return to a state of calm and safety in which the goal of this was to reduce the need for physical interventions to obtain safety and thus reduce the incidents of violence; and physical interventions as interventions used at the point that a patient has not regained safety over their behavior through de-escalation techniques and has escalated to a point where the patient or others are in immediate danger of being physically harmed. Physical interventions involved staff putting hands on the patient to move the patient to a safe place and/or to initiate restraint application. The policy lacked directives to push a patient out of the way to mitigate potential harm. A Use of Security Interventions policy, dated 1/23/25, identified security officers to use security interventions that were reasonable for the circumstances. The policy directed the security officer to consider the following when deciding to use security interventions: Does the person pose an immediate risk of substantial bodily harm or great bodily harm to them or others; Have alternative methods been used and/or reasonable exhausted; Is disengagement from the situation a reasonable option. The policy defined security interventions as non-clinical interventions which included application of physical techniques; substantial bodily harm as bodily injury that involved temporary but substantial disfigurement, loss or impairment of function, or fracture; and great bodily harm as bodily injury that created a high probability of death, serious permanent disfigurement, permanent or protracted loss or impairment of body function, or other serious bodily harm. The policy lacked techniques or strategies related to pushing a patient out of the way to mitigate potential harm. A Workplace Safety: Violence Prevention training transcript, dated November 2025, identified subjects such as internal and external triggers, alerts, situational awareness, grounding techniques, proxemics (safe distancing), body language, patient engagement, hope generation, validation, and de-escalation strategies. The section for de-escalation strategies directed staff to respect personal space, do not be provocative, establish verbal contact, be concise, offer choices and optimism, etc. Additionally, tips for this included intervene as early as possible when agitation is at the lowest level, acknowledge factors that could be impacting the patient’s perceptions and behaviors such as intoxication, and recognize the warning signs of agitation such as loud or excessive talking and threatening behavior. A section labeled Personal Safety Technique Introduction identified goals of always start by pushing duress badge and if there is no badge, call for help, step and drag with arms up and back away toward the door, and get out of harm’s way safely. This section demonstrated techniques such as defensive stance/step and drag, one-handed wrist grab, two-handed wrist grab, bite releases, hair pulling, and choke releases. This section, and the policy, lacked techniques and/or strategies that surrounded pushing a patient out of the way to mitigate potential harm. A Restraints/Seclusion - Management of Violent and/or Self-Destructive Behavior policy, dated June 2025, identified all patients have the right to be free of physical abuse. Restraints, or seclusion, may only be utilized to ensure the immediate physical safety of the patient, staff, and others. Staff were to employ non-physical interventions when sufficient to maintain safety. The scope of the policy applied to the use of restraints or seclusion to manage patient behaviors that were violent, self-destructive, and jeopardized the immediate physical safety of other patients, staff, and others. The policy indicated restraints, or seclusion, were justified when less restrictive interventions posed a greater risk than the application of restraints, and or initiation of seclusion. In emergency situations, a qualified RN may initiate a restraint or seclusion for violent/self-destructive behavior before an order was obtained. A physical restraint was defined, but not limited to, a manual method that immobilized, or reduced the ability of the patient to move parts of their body. Examples included physical escort and physical holding. The policy identified, when needed, based on identified criteria, restraints or seclusion were an applicable intervention to utilize when behavioral emergencies occurred that threatened patient and/or staff safety.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 43080 Based on interview and document review, the facility failed to obtain a specific physician or licensed practitioner restraint order prior to, during, or immediately (within a few minutes) following, each episode of restraint or seclusion use for 7 of 7 patients (P2, P3, P11, P12, P13, P14, P15) reviewed for violent restraint and seclusion use. This had the potential to affect all patients who required restraints and/or seclusion. Findings include: A copy of Restraint information provided to providers, dated 2026, directed providers to order restraints within one hour of the restraint episode and cues them they may change the timing of the order to reflect the actual time of restraints. To ask nursing for the exact time so that their documentation matched the providers. An Emergency Department (ED) Restraints for Violent Behavior monthly audit percentage grid, identified data from January 2026, and February 2026. The grid identified a goal of 90 percent (%). The percentages for January identified a 95% goal of obtaining an order within 60 minutes, and 33% for order renewal. The percentages for February identified 100% for goal of obtaining an order within 60 minutes, and 0% for order renewal. An Accreditation Update Medical Executive Committee PowerPoint, dated February 2026, identified a slide labeled Vulnerabilities - Restraints. This was a reminder violent restraints required a licensed practitioner to issue the restraint order within one hour of restraint implementation, and orders must be renewed daily if restraints were still needed. Common findings identified missing or late orders. A Restraint Committee Meeting minutes, dated 3/16/26, identified a section labeled Education. This section lacked information related to any identified concerns for restraint orders. The section identified all education and competencies were completed. Another section labeled Restraint audit documents, identified there were many audits in “SmartWorks,” and thus they planned to investigate this for potential unification of the forms. Next meeting agenda topics considered evaluation of restraint types in six months, or a year, depending on what information a follow up report identified. A Restraint Audit, dated March 2026, conducted by RN-E, identified the following: -P11: 3/30/26, seclusion. The Initial Order Start box was blank and the Initial Order, Initiation In Goal, and Episode Order were all “N.” A notes section identified an entry “seclusion, top part of FS not done.” -P11: 3/30/26, locked limb and seclusion. The boxes for Monitor Renewal Order “FLG,” and Monitoring in Goal, both were identified as “N.” -P11: The audit does not reflect the manual hold identified in her progress notes. A Restraint Audit, dated April 2026, provided by RN-K, identified 12 ED patients were audited for restraint use. Out of these, no concerns were identified for order process concerns. P13 was identified on the audit related to her locked restraints on 4/1/26. The audit lacked any identified concerns with the review of her restraint event. Restraint Education for Hospital Nursing Staff screenshots, undated, identified the following: -Types of Patient Restraints: ‘manual method, physical or mechanical device ...that immobilizes or reduces the ability of a patient to move their arms, legs, body, or head freely.’ Examples were provided: two-person manual escort, spit sock hood, etc. The pictured example lacked a manual hold picture for medication administration. -Violent Restraint Orders - Initial: A licensed provider created the restraint order and entered it into the system before the initiation of the restraint. In emergency situations, the nurse may apply the restraint but then must notify the provider and obtain an order immediately after the restraint(s) have been applied and the patient’s safety ensured. -Violent Restraint - Order Renewal: Orders are limited to the patient’s age and must be discontinued or renewed when the time expires. The existing order must be renewed before its expiration time. P3’s medical record indicated P3 presented to the ED on 8/7/25, at 4:40 p.m., with a chief complaint of suicidal ideation and self-injurious behavior. P3 was an adolescent. P3’s nursing progress note, dated 8/8/25, P3 attempted to cut her wrists with a broken spoon. A code green was called and P3 attempted to kick, hit, and bite staff as they attempted to get the spoon from P3. Intramuscular (IM) medication was administered with a “manual hold” was used to ensure staff and P3’s safety. The note lacked identification if the provider was present and/or notified of the manual hold utilization. P3’s medical record lacked evidence an order was obtained for the 8/8/25 manual hold/hands on restraint(s). P3’s nursing progress note, dated 8/11/25, identified a time of service at 2:00 p.m. P3 gripped her blanket harder and attempted to kick staff when they attempted to remove a blanket from her head. All efforts of verbal redirection were unsuccessful, and a show of support was called. “Staff went hands on to remove blanket” as P3 continued to kick and swing at them. P3 started to bite her right arm, and another code green was called. P3 was placed in 4-point locked limb restraints. Shortly after, P3 attempted to flip her mattress and attempted to bite her bicep and thus bicep restraints were applied. P3’s nursing progress note, dated 8/11/25, identified another nurse’s entry related to the 2:00 p.m. incident. P3 bite her left arm. Despite verbal redirection, P3 failed to stop, and a code green was called. P3 was “restrained” and an IM medication administered. P3 continued to be physically aggressive towards multiple staff who were at her bedside and ultimately was placed in 6-point restraints as she continued to be aggressive with attempts to hit her head repeatedly on the bedside rails. P3’s 8/11/25 Violent Restraints flowsheet section and Orders section identified the following: -From 2:00 p.m., through 4:15 p.m., locked limbs (bilateral wrist and bilateral ankles - 4-point) were utilized. -2:11 p.m., “Locked limbs” were ordered by MD-I (11 minutes after the restraints were applied). -At 2:15 p.m., through 3:30 p.m., bilateral locked bicep restraints were utilized (6-point status). P3’s medical record lacked evidence that an order was obtained for the 8/11/25 manual hold(s)/hands on restraint(s), or the application of the bilateral bicep restraints 15 minutes after the 4-point restraints were applied. P3’s nursing progress note, dated 8/12/25, identified at 11:30 a.m., P3 started to bite herself and “attempts at preventing her from biting led to [P3] kicking, biting staff.” A code green was called, provider was notified, and P3 was placed in 4-point restraints. P3’s nursing progress note, dated 8/12/25, identified a service time of 2:05 p.m. P3 banged her wrist against the headboard while restrained. Security was called and the wrist restraints were adjusted. P3 became increasingly aggressive and attempted to bite self and staff, kicked at bed and staff, and twisted her upper body in unnatural positions to bite herself. Bicep restraints were added to the already 4-point restraints being utilized at that time (6-point status). P3’s psychologist progress note, dated 8/12/25, identified a service time of 3:46 p.m. The note identified P3 remained in restraints and continued to be agitated since the provider arrived around 12:00 p.m. P3 currently screamed. The provider prescribed an IM medication and assisted with a “manual hold” for the RN to administer. P3 screamed ‘Let me die!’ and ‘Let me out.’ P3’s 8/12/25 Violent Restraints flowsheet section, Orders section, and provider notes, identified the following: -From 11:59 a.m., through 5:07 p.m., 4-point restraints were utilized. -12:01 p.m., “Locked limbs” were initially ordered by MD-G -At 1:46 p.m., “Locked limbs” were reordered by MD-G due to continued need (before the initiation of the bicep restraints). -From 2:00 p.m., through 5:07 p.m., bilateral bicep restraints were utilized (6-point status) -At 3:46 p.m., the locked limbs reorder automatically discontinued after it expired. -At 4:52 p.m., “Locked limbs” were re-ordered by DO-C. -Between 3:46 p.m., when the 1:46 p.m. order expired, and the 4:52 p.m. renewal order, P3 was restrained without an active order for one hour and seven minutes. P3’s medical record lacked evidence an order was obtained for the 8/12/25 manual hold(s)/hands on restraint(s), or a specific, timely order for the application of the bilateral bicep restraints at 2:00 p.m. P3’s nursing progress note, signed 8/16/25, at 2:35 p.m., identified P3 bit herself and despite verbal redirection and opportunities to participate in the assessment and cooperate with staff’s requests, P3 continued to refuse. IM medication was given. After a few minutes, P3 continued to be resistive to staff direction for safety and P3 was placed in wrist “soft restraints” to mitigate self-harm. Security was present throughout all communications with P3. The note lacked identification if the provider was present and/or notified of the restraint application(s). P3’s nursing progress note, dated 8/16/25, identified the time of service at 7:10 p.m. P3 hid her head under the covers and was unable to be redirected. P3 was asked by different staff to remove the blankets and when she failed to respond, staff removed them. In response, P3 attempted to kick at staff. P3 bite herself with great force and failed to respond to redirection. Show of support called and staff “physically assisted [P3] in removing [her] arm from [her] mouth with difficulty.” When placed into wrist and bicep restraints, P3 began to thrash and attempted to roll off the cart, attempted to bit shoulders and staff, and thus was placed in 6-point (the initial wrist and bicep, with the addition of ankle restraints). Due to P3’s ability to verbalize understanding of appropriate behavior, and her contract for safety, the restraints were removed. The note lacked identification if the provider was present and/or notified of the manual hold and/or the 6-point restraint application. P3’s nursing progress note, signed 8/16/25, at 7:18 p.m., identified P3 bit herself on the right wrist and was unable to be redirected. P3 was placed in wrist and bicep restraints for her safety. Report was provided to RN-H. The note lacked identification the provider was present and/or notified of the restraint application. P3’s subsequent nursing progress note, dated 8/16/25, and entered as a late entry by RN-H due to patient care, identified shortly after RN-H started his shift, P3’s primary RN, another staff, and her one-on-one were involved in “manually preventing [P3] from biting her wrists.” A decision was made to restrain her. The note lacked additional restraint details, or identification if the provider was present and/or notified of the manual hold. P3’s 8/16/25 Restraints flowsheet sections, Orders section, and providers notes, identified the following: -At 2:11 p.m., “Soft limbs” were ordered by MD-F. -From 2:15 p.m., through 3:00 p.m., soft bilateral wrist restraints were utilized. -From 7:17 p.m., through 7:30 p.m., 6-point restraints were utilized. -At 8:49 p.m., an order for “Locked limbs” was entered by RN-H via “Ordering in Provider co-sign required mode (approximately one hour and 30 minutes after the restraint was initiated).” DO-D acknowledged the order at 9:53 p.m. P3’s medical record lacked evidence an order was obtained for the 8/16/25 manual hold(s)/hands on restraint(s). P12’s medical record indicated P12 presented to the ED on 3/17/26, at 4:53 p.m., with a chief complaint of behaviors in the setting of a urinary tract infection (UTI). P12 required admission. P12’s nursing progress note, dated 3/20/26, identified a time of service at 10:20 a.m. At 9:35 a.m., a code green was called in response to P12’s behavioral exit seeking escalated to the point where he crawled out of bed and continued to attempt to leave. Once staff helped him into bed, he continued to be agitated and attempted to leave again with attempts to grab at staff. P12’s 3/20/26 Violent Restraints flowsheet section, and Orders section identified the following: -From 9:45 a.m., through 11:00 a.m., 4-point (locked limbs) were utilized. -At 9:53 a.m., “Soft limbs” was ordered by MD-O (eight minutes after the locked limbs were initiated). -Based on the 9:53 a.m. order, either the provider entered the incorrect restraint type to the order, or staff failed to follow the restraints ordered. P12’s nursing progress note, dated 3/21/26, identified a time of service at 6:56 p.m. P12 walked toward the elevator and became physically and verbally aggressive towards staff when staff attempted to redirect him. P12 swung at staff and hit staff multiple times while staff attempted to help P12 into the wheelchair as P12 had periods of losing his balance. A code green was paged and P12 was brought back to his room. He hit staff in the shoulder and security and the code green team “were able to hold patient’s arms and leg” while an IM medication was given. P12 was transferred to bed, and 4-point restraints were applied. P12’s 3/21/26 Violent Restraints flowsheet section, and Orders section identified the following: -From 6:00 p.m. through 7:30 p.m., 4-point restraints were utilized. -At 6:29 p.m., “Locked limbs” were ordered by nurse practitioner (NP)-A (29 minutes after the restraint was initiated). P12’s medical record lacked evidence an order was obtained for the 3/21/26 manual hold(s)/hands on restraint(s). P2’s medical record indicated P2 presented to the emergency department (ED) on 3/28/26, at 2:50 a.m., with a chief complaint of chest pain and intoxication after an argument with his girlfriend. P2’s nursing progress note, signed 3/28/26, at 4:35 a.m., identified P2 attempted to sit up and move his head once a c-collar was placed, was non-compliant and non-redirectable, and attempted to become combative with staff, thus risking injury to himself and others. P2’s 3/28/26 Violent Restraints flowsheet section, and Order’s section, identified the following: -3:23 a.m., locked limbs (bilateral wrist and bilateral ankles - 4-point) were started. -3:28 a.m., 4-point restraints continued, and bilateral locked bicep restraints started (6-point status). -4:19 a.m., DO-B entered an order for “locked limbs,” (56 minutes after restraint application and four minutes after the restraints were removed. . P14’s medical record indicated P14 presented to the ED on 3/27/26, at 3:28 p.m., with a chief complaint of mental health issues and medication reaction in setting of schizoaffective disorder, depressive type. P14’s nursing progress note, dated 3/30/26, identified a time of service at 7:57 a.m. P14 was offered oral and IM medication to assist with behavioral control in the setting of dysregulation. She declined both and security was called. Upon their arrival, P14 continued to be physically and verbally aggressive, “throwing fist,” swore, cursed, and yelled. A code green was initiated and P14 was “manually held” to administer an IM medication. Due to continued uncooperative behavior, seclusion was initiated. However, P14 refused to walk to Wing one for seclusion and was aggressive, yelled continuously, threw fist, and kicked towards staff and thus the restraint chair was initiated, and she was put in seclusion. P14’s nursing progress note, dated 3/31/26, signed at 6:55 a.m., identified P14 required seclusion on 3/20/26, at 8:30 p.m., due to continual yelling and getting into people’s faces. Due to increased verbal loudness and aggressive behavior, she was escorted to the seclusion room. P14’s 3/30/26 Violent Restraints flowsheet section identified the following: -From 6:43 a.m., through 6:45 a.m., a manual hold was utilized. -From 6:45 a.m., through 12:05 p.m., a restraint chair was utilized -At 6:45 a.m., seclusion started; however, from this initial entry, through 12:05 p.m., the flow sheets lacked information the seclusion continued and/or when the seclusion ended. -At 7:01 a.m., “Manual hold, Seclusion, Restraint Chair - Duration Per Policy” were ordered via a verbal/telephone order mode (approximately 15 minutes after the restraints were initiated). -At 8:40 a.m., “Manual hold, Seclusion, Restraint Chair - Duration Per Policy” were re-ordered by the provider. -At 11:53 a.m., “Manual hold, Seclusion, Restraint Chair - Duration Per Policy” were re-ordered by the provider. -From 12:05 p.m., through 11:40 p.m., seclusion was utilized. -At 3:59 p.m., the 11:53 a.m. restraint order expired, and the system automatically discontinued it; however, based on the restraint flow sheets, seclusion continued without an active order, until 8:44 p.m., when seclusion was again ordered. In response, P14 went four hours and 45 minutes in seclusion without an active order. -At 8:44 p.m., Seclusion was ordered. -At 10:29 p.m., the seclusion order expired, and the system automatically discontinued it; however, based on the restrain flow sheets, seclusion continued without an active order, until 11:40 p.m. when the seclusion ended. In response, P14 went approximately one hour and 15 minutes in seclusion without an active order. P11’s medical record indicated P11 presented to the ED on 3/29/26, at 7:42 p.m., with a chief complaint of being assaulted by family. P11 was an adolescent. P11’s nursing progress note, dated 3/30/26, identified a time of service at 11:03 a.m. P11 continued to hit the nursing station window “after being forced out of the office.” P11 was “escorted to her room,” and given medications. Around 10:45 a.m., P11 was placed in seclusion. Another P11 nursing progress note, dated 3/20/26, identified a time of service at 11:03 a.m. P11 banged on glass, yelled at staff, attempted to bite staff and hit them. IM medication was administered and P11 was placed in seclusion. P11’s MD-J provider note, dated 3/30/26, indicated a date of service at 2:13 p.m. At approximately 3:15 p.m., a second code green was called as P11 hit her head against the wall. P11 became aggressive and attempted to hit staff and spit at them. A third alert was called and P11 was provided an IM medication. She was “placed in restraints in a secluded room.” MD-J was at the beside the entire time. P11’s nursing progress note, dated 3/30/26, identified a time of service at 3:45 p.m. P3 began to destroy hospital property by peeling labels from the walls. She lunged at the nurse. A security officer and another staff “assisted writer in helping [P11] return to room.” P11 began to grab, scratch, bit, and spit at staff. A code green was initiated, and the spit hood was reapplied. IM medication was administered and P11 was “assisted” to her room. Once in her room, the spit hood was removed, and seclusion was initiated. However, she started to destroy a wall panel and thus a manual hold was conducted by security, and the spit hood was applied. P11 was assisted to bed and “restrained to bed.” The spit hood was removed prior to staffs exit from the room. P11’s nursing progress note, dated 3/30/26, identified a time of service at 3:54 p.m. P11 was upset and yelled out due to her belongings being taken away. Due to continued yelling out, security was present. P11 was not receptive to verbal de-escalation, or redirection at that time. The writer, P11’s primary nurse, and a security officer, attempted to escort P3 back to her room. P11 flailed and attempted to bite and swing at staff. While P11 was escorted back to her room, she dropped her weight to the ground and attempted to spit and kick at staff. Code green was called, and a spit hood was placed by the primary nurse, and an IM medication was administered. She was escorted back to her room and placed in seclusion at 3:26 p.m. Due to P11’s “picking at flooring and wall,” and her ability to remove a “large piece of wall,” she was removed from seclusion and placed in restraints at 3:30 p.m. as she was unable to keep herself safe. P11 was administered another IM medication. P11’s 3/30/26 Violent Restraints flowsheet section, and Orders section identified the following: -At 11:00 a.m., a manual hold was utilized and discontinued. -From 11:00 a.m., through 1:00 p.m., seclusion was utilized. -At 1:43 p.m., Seclusion was ordered by MD-J (one hour and 43 minutes after the seclusion was initiated). -At 3:26 p.m., Seclusion and Spit Hood were ordered by MD-J. -From 3:26 p.m., through 3:30 p.m., both a manual hold and seclusion were utilized. Additionally, a spit hood was placed. The flow sheets lacked evidence when the spit hood was removed. -From 3:30 p.m., through 6:56 p.m., 4-point restraints were utilized. -At 3:34 p.m., “Locked limbs” and Spit Hood were ordered by MD-J. -At 5:34 p.m., the 3:34 p.m., locked limbs and spit hood order expired, and the order was automatically discontinued by the system. -Between 5:34 p.m., when the locked limb order expired, to 6:00 p.m., 4-point restraints continued to be utilized. P11 was restrained for 26 minutes without an active order. -At 6:00 p.m., “Locked limbs” were re-ordered by MD-K. P11’s medical record lacked evidence an order was obtained for the 3/30/26 manual hold(s)/hands on restraint(s). P11’s nursing progress note, dated 3/31/25, signed at 9:03 a.m., identified P11 was resistive to cares. She swung her arm away from the RN when the blood pressure cuff attempted to be placed. P11 stated, ‘Shut up! Your not my boss.’ “Arm held in place and BP cuff placed for a reading.” P11 pulled finger away from the pulse oximetry so a manual pulse was taken by the RN. P11’s nursing progress note, dated 4/6/26, identified a time of service at 5:18 p.m. P11’s behaviors escalated, and she started to block staffs’ ability to enter and exit areas of the unit. During such an episode, when she refused to allow staff entry, despite numerous attempts to redirect her, P11 started to flail and strike out at staff. A show of support was called, and she was “escorted back to her room all the while attempting to scratch, hit, and bite staff.” After P11 agreed to accept an oral medication to assist with behavior management; however, when the nurse went to obtain the medication, P11 again blocked the nurse and began to push, grab at, and succeeded in digging her nails into the nurse’s skin. P11’s nursing progress note, dated 4/6/26, identified a time of service at 7:49 p.m., and was signed by a behavioral health associate at 8:14 p.m. P11 became restless in the hall and began to run up and down the halls, attempted to enter other patients’ rooms, and attempted to gain entry into the nurse’s station, where she attempted to grab onto staff. As the unit door opened, P11 sprinted through the doors, and was “promptly stopped by staff in the hall and brought back to the suite.” P11’s medical record lacked evidence an order was obtained for the 3/31/26, and 4/6/26, manual hold(s)/hands on restraint(s). P13’s medical record indicated P13 presented to the ED on 4/1/26, at 3:02 p.m., with a chief complaint of muscle spasms, agitation, and behavioral dysregulation. P13’s nursing progress note, dated 4/1/26, and signed 3:09 p.m., identified P13 yelled, spit at, and hit ambulance personnel. “Four-point restraints” were applied. P13’s 4/1/26 Violent Restraints flowsheet section, and Orders section, identified the following: -From 3:02 p.m., through 3:56 p.m., 4-point (locked limbs) were utilized. -At 3:43 p.m., “Soft limbs” were ordered by MD-F (41 minutes after the restraints were initiated). -Based on the 3:43 p.m. order, either the provider entered the incorrect restraint type to the order, or staff failed to follow the restraints ordered. P15’s medical record indicated P15 presented to the ED on 4/6/26, at 2:33 a.m., with a chief complaint of alcohol poisoning and withdrawal. P15’s nursing progress note, dated 4/6/26, signed 10:42 a.m., identified a code green was called at 9:06 a.m. in response to P15’s behavioral dysregulation and visual hallucinations and 4-point restraints were applied at 9:35 a.m. P15’s Order section identified the following order: -4/6/26, at 10:22 a.m., “Locked limbs” was ordered for a frequency of four hours. The order automatically discontinued after it expired at 1:34 p.m. P15’s 4/6/26 Violent Restraints flowsheet section, and Orders section, identified the following: -From 9:35 a.m., through 11:15 a.m., 4-point locked restraints were utilized. -At 10:22 a.m., “Locked limbs” was ordered (approximately 45 minutes after the restraints were initiated). When interviewed on 4/10/26, at 10:38 a.m., RN-R stated that restraint orders were required to be entered by the provider within an hour of their application and that restraints were required to be removed as soon as possible. RN-R provided an example that if a patient was asleep, the restraints were to be discontinued. RN-R stated that when a provider ordered locked limbs, that indicated to him 4-point locked restraints were to be utilized. In the event the patient trashed around and was at risk for injury to themselves, the bicep restraints could be added for a 6-point restraint status utilizing the initial locked limbs order. In such situations, he was not required to obtain additional orders for the bicep restraints; however, as this was a change in the patient’s status, he was required to at least notify the provider of the increased behaviors and injury risk. When interviewed on 4/10/26, at 2:24 p.m., RN-T stated a restraint order was expected to be obtained within an hour of restraint application, and that each restraint required its own order. If three restraints were utilized, three orders were needed. RN-T indicated locked restraints meant 4-point or 6-point and explained, typically, a patient was initially placed in the 4-point restraints and then if the patient displayed behaviors that increased their injury risk, such as “bucking,” then the bicep restraints were applied. She did not feel a new order was needed for the bicep restraints if the bicep restraints were applied within a relatively short time frame from the 4-point restraints; however, if they were required an hour after, she was unsure what the expectation was for an updated, or new, restraint order. When interviewed on 4/10/26, at 3:29 p.m., RN-C stated restraints required the least restrictive application first and if he was required to go hands on, apply a restraint, or seclude a patient, he updated the provider on the restraint use and when the restraint was applied. After, the provider assessed the patient and placed an order as he was not allowed to place a verbal restraint order. He explained, once he updated the provider, the provider was typically there within five to 10 minutes, but there were times when it could be 30 minutes to an hour, especially during the times of only one provider in the emergency department. When interviewed on 4/13/26, 11:40 a.m., RN-A, an inpatient mental health nurse, stated she was expected to obtain restraint orders within one hour of initiation. RN-A explained, if the provider was present on the unit, they entered their own orders: however, during emergency situations and/or during the evening or night hours, there were situations when the nurse entered a verbal order. When interviewed on 4/13/26, at 11:55 a.m., RN-B, an inpatient mental health nurse, stated he was expected to obtain restraint orders within one hour of initiation. RN-B explained, if the provider was on the unit at the time, they entered the order, otherwise, they utilized a verbal order. When interviewed on 4/13/26, at 12:10 p.m., RN-S, an inpatient mental health patient care supervisor, stated she expected restraint orders to be obtained within one hour of initiation and entered by the provider as nurses never entered restraint orders. When interviewed on 4/13/26, at 1:00 p.m., RN-K, an emergency department (ED) manager, stated restraint use was only attempted after verbal de-escalation and/or other least restrictive interventions failed. Additionally, restraints were removed once criteria were met, such as lack of behaviors. Both 4-point and 6-point options were available in the ED. Restraint orders were typically placed by the providers as this triggered the face-to-face process; however, a nursing verbal order process was allowed in certain situations. RN-K expected a new restraint order for each restraint episode, such as a patient was manually held and then needed to be placed in locked limb restraints. This equated two separate orders. RN-K identified an order for locked limbs, which meant all four limbs were restrained with locked restraints. If the biceps required restraining, a new order was not necessary as this still was “technically the same as all four limbs” being restrained. RN-K explained ED restraint audits were conducted “every day,” by herself or a colleague in response to a notification they received when an order was placed; however, later stated they attempted to conduct these audits “every week” to stay on top of the process. Recently, the audits were free of identified restraint concerns. When interviewed on 4/13/26, at 1:39 p.m., RN-Q stated she was expected to update the provider as soon as possible for the provider to enter the restraint order “for the time that it occurred.” She explained this typically was not an issue as there usually was a provider present when the restraint was initiated. RN-Q stated each restraint initiation required a restraint order and each restraint required discontinuation as soon as possible after the patient no longer displayed the behaviors that the restraint was utilized for. When interviewed on 4/13/26, at 3:53 p.m., RN-Y, patient care manager, stated a restraint order was expected to be obtained immediately, which by facility standards, meant within one hour of the restraint initiation as there were situations that had the potential to delay the order entry. RN-Y explained that during a behavioral emergency, a code green was called and staff responded. If the provider was not present, someone usually secure chatted with the provider, the provider presented and performed the face-to-face evaluation and placed the order. RN-Y stated the nurses do not enter restraint orders. During her restraint auditing processes, she had no trending restraint concerns. When interviewed on 4/15/26, at 11:40 a.m., DO-B stated much of the time he entered his own restraint orders. Each restraint required its own order, and the associated order required the specific time the restraint was applied, the type of restraint required such as locked limb, 4-point, or vest, and the frequency for the order. DO-B explained, as soon as the nurse and he talked about the behavioral situation, and was able to return to his desk, he entered the order so that the order could be followed, and to ensure accuracy when things happened. When it came to restraint order types, DO-B stated a locked limbs restraint was a restraint that required a lock and key mechanism; however, thought the meaning was “variable.” Due to this, within the orders, there were options to identify which type of restraint needs to be ordered. If locked limbs were ordered, he expected to see clarification of how many limbs are restrained. With such an order he expected to see two or four restraint devices i.e. 2-point or 4-point. DO-B verbalized bicep restraints were an additional restraint as if you had a restraint initially and you added another one, that would be more restraints. DO-B was unable to remember P3; however, he recollected P2. When questioned on restraint order entry timeframe, he was unable to remember reasons for the lateness of the order; however, he stated his “hair was on fire all night,” and he was probably the only provider in the ED at that time, and he probably did not get to it until then. When interviewed on 4/15/26, at 12:39 p.m., RN-L stated behavioral events, a code green was called for extra staff support as overall staff did not have time to call the provider. During a code green, a provider was always present; however, the provider did not provide the restraint order as this was a role of the primary nurse who ran the code. Due to this, that nurse made the decision on when to go hands on. RN-L explained that typically the nurses determine the restraints and then tell the provider the rationale for them. After the restraints were applied, then the primary ED care provider entered the order, which should be entered within five to 15 minutes from the time the restraints were applied, as nurses were not allowed to enter verbal orders for restraints. When questioned on manual restraints, i.e. manual holds, RN-L stated manual holds occurred “so infrequently.” When a manual hold was utilized, it was “not a conscious thing that happens,” as it happens very quickly. She stated that a lot of the time, she did not procure manual hold orders from the provider and typically only procured a restraint order if another type of restraint was required after the manual hold. RN-L stated the providers only provided an order for locked limbs as the number of limbs that needed to be restrained were based on the situation. Not everyone needed 4-point or 6-point, but the nurse would determine how many based on achieving the least amount of movement as possible for the patient to remain safe. RN-L vaguely remembered P3. She was able to recollect some details, if she had the right patient, related to holding the patient’s limbs to keep her legs and arms down, but other than that lacked specific details. When her P3 progress notes were read to her, she stated, “Sounds about right.” She stated that P3 was strong, and she can remember times of needed extra assistance. When interviewed on 4/15/26, at 1:04 p.m., RN-I stated that usually the provider entered the restraint order and ordered the restraint they wanted. She explained that an order needed to be provided right away, which was usually a verbal order, so everyone was aware of the plan in the moment of the restraint need, and then after, the provider entered the order. If she identified a patient needed a restraint, such as a manual hold for a medication, she talked with the charge nurse for further direction. Even if she received an order for a manual hold, for something such as IM medication administration, which she identified he needed before going hands on, she attempted to get compliance from the patient first before initiating the hold. When it came to a locked limb order, she stated she would utilize the order based on their protocols. She identified that usually 2-point or 4-point restraints were used when locked limbs were ordered; however, also commented she thought the locked limb order may be more directed as soft restraints. RN-I stated any time staff went hands on a patient to restrain them, it was a restraint, and she needed an associated order. RN-I was unable to remember specifics related to P3; however, when her progress notes were read back to her, she recollected her more and felt her notes were an accurate reflection of P3’s situation. When interviewed on 4/15/26, at 2:39 p.m., MD-G stated restraint orders were usually, almost immediately, given orally; however, he placed his own restraint orders and did not utilize verbal order processes for such situations. He explained restraint orders were expected to be entered “right away,” but within five minutes or so. At times, this extended to 10 minutes or longer and was determinate on what occurred with the patient at that time, and/or other patients. MD-G stated staff were good at “texting” him information about the type of restraints that were utilized, and the time of application. MD-G stated when he ordered locked limbs, based on his experience, this referred to the Velcro restraints to the wrist/legs: “Like a 4-point.” When these locked limbs were ordered, staff “usually” started with 4-point application and attempted to release the restraint from there. He was unsure about the processes for 6-point application, and a new order would be required. MD-G stated each new restraint required a new order. In situations where staff had to hold a behavioral patient for an IM medication, this was considered a manual hold and required an order and assessment. MD-G was questioned on P3; however, he lacked remembrance for her. When interviewed on 4/15/26, at 2:02 p.m., RN-J stated if a manual hold was needed, a code green was usually called and an order was provided by the provider, so she thought, but she was not sure. She explained she had not seen a manual hold order placed before. In general, restraint orders were expected to be put in ideally before the restraint was initiated and she expected the order to be entered by the provider right away as this placed a time stamp on the documentation. RN-J stated any restraint required an order and, other than an initial emergency when the restraint was needed before an order was procured, a patient was not allowed to be in restraints unless there was an order. She was expected to ensure restraints were removed as soon as possible, such as when a patient was calm, and no longer showed behaviors. RN-J thought she remembered P3. She described her as loud and not nice. Other than this, she was unable to remember any specific details. When interviewed on 4/15/26, at 2:32 p.m., RN-H stated it was expected the provider entered restraint orders. He was unaware of any situations when he was required to do this but was able to explain the process if needed without concern. He expected restraint orders to be entered as soon as humanly possible, at the providers’ first convenience, which ensured appropriate charting and that the order lined up with the behavioral event. RN-H explained locked limbs meant violent restraints with a locked device to all four limbs. He was unsure what the order looked like if only two limbs were required. He stated he did not think the ED utilized 2-point restraints. He was unsure if he needed a new, or adjusted order, if 6-point restraints were required after the 4-point were initiated. When questioned on manual holds and the need for an order, he stated, “That is a good question.” “I do not believe so.” RN-H explained most of the time when a patient was manually restrained, they were administered an IM medication, and they attempted to avoid locked restraints and/or longer manual holds. RN-H stated he considered holding onto a patient to prevent them from biting themselves constituted a manual restraint and again stated he was unsure if he was required to get an order in that situation. He did not see the appropriateness of an order if the hold was only for a time frame such as 30 seconds; however, again, he commented he did not know this for sure. RN-H stated he was unable to recollect P3. When interviewed on 4/16/26, at 9:08 a.m., RN-G, the ED patient care manager, stated that any time a patient was placed in restraints, such as locked restraints, manual hold, or putting hands on them to escort them to their room when they were behavioral, required an order. She stated that usually the nurse placed the restraint order, in the moment when the provider was not immediately available; however, this process ultimately was to be completed by the provider. Restraint orders were expected to be entered within 60 minutes of the initiation, but she usually noted this to occur before this time frame. Timely order entry was necessary for collaboration between the nurse and the provider, but patient care came first. RN-G explained locked limbs were locked restraints applied to the wrist and/or ankle. She explained the orders did not clarify which arm or leg: “We never just leave one.” If bicep restraints were needed (6-point), that should be another order, or a conversation with the provider. She was unsure if the order had the ability to indicate which limb the restraint was to be applied to. She stated she would not know if the provider would know which limb to apply the restraint to, as that was a nursing decision. Overall, behavioral situations happened fast, and staff did not have time to wait for the provider and often the nurse told the provider what was applied. During her audits of this process, she indicated the process was not 100 percent and there were always ongoing concerns. When concerns were identified, staff were followed up in real time. She indicated RN-F conducted the restraint audits and she was provided with a monthly report. For restraint auditing, based on how well they were doing with prior audits, a random sample of so many charts was flagged for audit. Over the past two months, RN-G identified restraint education was provided during huddles and posted information by the timecard. Mainly, they have done education in the moment with staff and added the information to their weekly need to know newsletters. Despite continued concerns, there have not been unit wide mandatory education related to restraint concerns. When interviewed on 4/16/26, at 11:04 a.m., MD-C stated behavioral events typically happened quickly and thus the restraint order was placed often after the restraint was initiated. She stated she had up to an hour to enter the order; however, then commented she was not 100 percent sure of this. After the restraint event, she spoke to the nurse to determine the time of the restraint, so the order timing was consistent with the application. She was required to specify which restraint was utilized, such as locked limb, seclusion, and manual hold, along with some other options. Timely order entry, and the restraint time, were required, as part of the order triggered the face-to-face evaluation, along with reassessments, and order renewals when needed. The order process was important to help reinforce there was a patient involved and to emphasize the significance of what the restraint was to the patient. MD-C stated, when locked limbs were ordered, there was an order for 2-point and 4-point options, and “maybe one for six locked limbs.” Most of the time, the 4-point locked restraints were utilized. If 4-points were applied, and 6-point restraints were required after that, she was unsure if a new order was required. She needed to review the policy. She stated a manual hold for things such as IM medication administration in a behavioral situation was a restraint and required an order. MD-C reviewed P3’s chart and remembered her. After reviewing the record for her time with P3, she stated staff should have alerted her to the manual hold so that her processes could have been followed as this was considered a restraint. On 4/16/26, at 11:27 a.m., restraint record review began with RN-F (quality advisor), RN-D (mental health clinical nurse specialist - restraint auditor), and RN-E (clinical nurse specialist - restraint auditor). The records of P2, P3, P11, P12, P13, P14, and P15 were reviewed. In summation, both RN-D and RN-E identified restraint orders were required to be entered within an hour of restraint initiation and during the review, orders were confirmed to be entered past this hour mark. RN-E explained once the guidance came out related to restraints needing to be obtained immediately, within a few minutes, they consulted their legal team to assist with defining immediately. Based on restraint events requiring additional steps, such as evaluation and assessments, the legal team determined immediately could be up to an hour. Despite audits identifying orders being often placed less than this hour, the one-hour requirement was what was taught during restraint education. RN-E identified a manual hold of any kind, was considered a restraint and she expected an order. RN-E and RN-D stated restraint orders were expected to be reflective of the actual restraint need and were expected to be followed. Additionally, staff were expected to ensure renewal orders were completed in timely manners so as not to have a lapse in restraint coverage. When it came to questions related to locked limb orders, RN-E stated they were not required to be specific in the order, as this information was documented in the restraint flow sheets. RN-E explained, historically, they obtained a new order when they went from 2-point restraints to 4-point restraints; however, after a Joint Commission (accreditation) consultant was involved in their restraint process, they were provided guidance they were not required to designate 2-point versus 4-point any longer. RN-E commented, “but things have changed since then.” RN-E identified each department and conducted their own restraint audits. She indicated she was unsure how robust these audits were and stated that was each department’s responsibility. Once the audits were completed, the information was shared monthly. RN-D stated the mental health units do the audits; however, she did not think they got to the pieces related to the order elements. She was worried staff only looked to ensure the order was completed, not that it was correct. RN-E agreed. Both RN-E and RN-D stated there was not any recent education related to the overall concerns identified with the review. In response to the patient review, they both indicated they would change their education and processes. When interviewed on 4/16/26, at 4:38 p.m., MD-A, one of the ED medical directors, and the chief of staff, stated the providers were required to enter the restraint order within an hour of restraint initiation, but overall, as soon as the provider was able. He felt the current regulation of “immediately - within a few minutes” was unreasonable due to the workings of the ED and the ability of the providers to access a computer timely and felt it was not appropriate for nurses to enter restraint orders. MD-A expected the one-hour timeframe to be followed as this ensured staff were aware of the restraint need and the identification of the restraint order time frames and any associated monitoring/assessment processes. MD-A stated the providers really only had the option of a soft restraint or locked restraints when restraints were ordered. Overall, locked limb restraints were for violent behaviors, while soft limb restraints were utilized more for medical necessities such as for a patient who pulled at lines and tubes. When it came to the differences between the 4-point restraint and the 6-point restraint, MD-A stated no additional order would be required for the 6-point application as that was considered part of the locked limb order. MD-A stated all restraint initiations required an order, this included a manual hold. If a manual hold, or any other restraint was utilized, he expected to receive a secure chat message related to that so that he placed an order. Related to restraint audits, MD-A reported there were designated staff that did that, and he was provided with information when needed, such as patterns/trends. He was unable to recollect the last time he was provided feedback on any provider performance issues. When interviewed on 4/17/26, at 9:30 a.m., the chief nursing officer (CNO) stated restraint orders were either entered by the nurse or the provider depending on the situation; however, the goal was for the provide to enter the order. He expected the order to be entered as soon as possible to ensure awareness and staff safety. When questioned on the manual hold process, for such situations as IM medication administration during behavioral events, he explained such situations were “for a second,” and was unaware of the exact language in the policy. The CNO stated any restraint initiation required an order for patient and staff safety. When asked about his thoughts related to orders for locked limbs, he again stated he could not comment as he did not have the policy in front of him. He expected staff to follow the policy. When the concerns were reviewed with him, he verbalized he understood them. He identified that he met monthly with the staff who conducted the restraint audits and stated there were always areas for improvement. When interviewed on 4/17/26, at 10:00 a.m., MD-B, one of the ED medical directors, stated order timing was challenging at times, especially when the provider was expected to be at the bedside and place restraint orders “in the moment,” and there were other situations that occurred in the ED. She continued to work on the best way to manage the requirements. MD-B explained, overall, restraint orders were to be entered as soon as it was safe for the provider to leave the bedside, and if there was not another situation the provider had to attend to first. Ideally, the provider placed the order right away after initiation. Generally, the practice was for the provider to enter the order versus a verbal order by the nurse. Timely orders and documentation helped assure the chart identified the patient events and assisted with continuity of care. When it came to locked limbs, MD-B stated this order meant 4-point locked restraints. She explained that occasionally 2-point restraints would suffice, but often they start with 4-point with the thought of removal as soon as they were safe to do so. When it came to the decision to utilize 4-point versus 6-point, it came down to the patient situation. If 4-point restraints were initiated first and then 6-point restraints were needed, an order for the 6-point restraints depended on the application timing. If a few hours had passed, then maybe a new order was needed. MD-B stated if a patient was held by staff during a behavioral situation and the patient did not comply and staff had to forcibly do something, that was considered a manual restraint and an order was required. MD-B stated a provider was expected to be present during a code green, which assisted in the ability of the providers to manage the orders and/or the face-to-face process. MD-B stated she did not do restraint audits; however, she was provided with information from nursing leaders, or the risk department, if concerns were identified. She denied knowledge of restraint concerns over the last month or so and was unaware of missed face-to-face evaluations. During a subsequent interview on 4/17/26, at 11:55 a.m., with RN-K, she stated that once she and her colleague started to see restraint process concerns, they developed an audit process that was more informal and internal, and not one defined by the facility. She stated, once the audit was conducted, the audit forms were not retained. RN-K explained, once an order was placed, her colleague received a notification and then they audited the process to ensure things were appropriately completed. If concerns were identified, the staff were followed up with in real time. During the audits, order timeliness was audited to ensure the order was placed within 60 minutes of initiation. RN-K was unsure if the facility restraint auditors were aware of her own auditing process. She stated she was sent a monthly audit report from those staff, and she was unaware of any trending concerns in the past couple of months. An Orders: Types, Transcription and Implementation of Provider Orders Reference, dated 12/16/23, identified verbal/telephone provider orders were discouraged and should only be used to meet the care needs of the patient when it is impossible or impractical for the ordering practitioner to enter it into the computer without delaying treatment. The policy lacked evidence verbal/telephone orders for restraints or seclusion, related to behavioral emergency events in such impossible or impractical provider order situations, were prohibited. A Restraint/Seclusion - Management of Violent and/or Self-Destructive Behavior policy, dated June 2025, identified the patient had the right to be free from restraint or seclusion, of any form and may only be used to ensure the immediate physical safety of the patient, staff, or others and must be discontinued at the earliest possible time. Only clinical staff were allowed to determine restraint or seclusion use. The use of restraint or seclusion must be based on a comprehensive, individualized assessment of present facts and circumstances. The policy defined a physical restraint as “any manual method, physical or mechanical device ...that immobilizes or reduces the ability of the patient to move their arms, legs, body, or head freely.” This included physical escort: ‘light grasp,’ to escort the patient to a desired location which the patient cannot easily escape from; physical holding: holding a patient in a manner that restricts their movement against their will which included holds that some members of the medical community termed ‘therapeutic holds’; spit hoods: temporary intervention to reduce the spread of contaminants through saliva or other bodily fluids through the mouth. The policy directed that an order was required for the implementation of restraint or seclusion. The order was to include a time limitation, not to exceed the maximum time limits allowed (the renewal was based on the time of the restraint application, not the time of the order), the reason for the restraint or seclusion, and the “specification” of the type of intervention to be used. A Time Limitations on Orders section directed the order for restraint or seclusion must not exceed the following time limits: adults (18 or older) were for four hours; a child/adolescent (9-17) was for two hours; child under 9 was for one hour. A Renewal Order section identified that the existing order must be renewed before its expiration time. In certain emergency situations, where the behaviors(s) occurred so quickly that an order could not be obtained prior to application, the order must be obtained during the emergency application, or immediately (within a few minutes) after the restraint or seclusion was applied. The policy lacked evidence that the order process was allowed to take up to an hour, or the ability of a nurse to utilize a verbal order for restraint or seclusion placement.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 43080 Based on interview and document review, the facility failed to discontinue restraints, and/or restraint/seclusion orders, at the earliest possible time once restraint criteria were no longer met, for 7 of 7 patients (P2, P3, P11, P12, P13, P14, P15) reviewed for violent restraint and seclusion use. This resulted in P3 restrained for longer than necessary, along with patients’ having active restraint orders despite their removal once criteria for discontinuation were met. Findings include: P3’s medical record indicated P3 presented to the Emergency Department (ED) on 8/7/25, at 4:40 p.m., with a chief complaint of suicidal ideation and self-injurious behavior. P3 was an adolescent. P3’s 8/11/25 Restraint Monitoring Flowsheets, Order’s section, and nursing progress notes identified: -2:11 p.m., “Locked limbs” were ordered with a frequency of two hours. -3:30 p.m., bicep restraints were removed (4-point restraints continued). -4:10 p.m., the order expired, and it was automatically discontinued (approximately 45 minutes after the bicep restraints were removed and five minutes before the 4-point restraints were removed. -4:15 p.m., the 4-point restraints were removed. A nursing progress note identified P3 was taken out of restraints approximately 15 minutes past the restraint expiration time due to a behavioral emergency with another patient. P3’s 8/12/25 Restraint Monitoring Flowsheets, Order’s section, and progress notes identified: -12:01 p.m., “Locked limbs” were ordered with a frequency of two hours. -1:46 p.m., “Locked limbs” were [re-ordered] with a frequency of two hours. -2:01 p.m., the 12:01 p.m. locked limbs order expired and was automatically discontinued (approximately 15 minutes after the locked limb restraints were re-ordered). -3:46 p.m., the 1:46 p.m., locked limbs reorder expired and was automatically discontinued (two hours after it was reordered and approximately one hour before the next reorder was placed). -Between 4:30 p.m., and 5:00 p.m., P3 was “cooperative” and “asleep.” Despite this, 6-point restraints remained on. -4:52 p.m., “Locked limbs” were [re-ordered] with a frequency of two hours despite P3’s documentation that identified she was cooperative and asleep at that time. -5:07 p.m., the 6-point restraints were removed (approximately 30 minutes after P3 documented to be cooperative and asleep). -5:59 p.m., the 4:52 p.m. order expired and was automatically discontinued (approximately one hour after the restraints were removed). P3’s 8/16/25 Restraint Monitoring Flowsheets, Order’s section, and progress notes identified: -2:11 p.m., “Soft limb” restraints were ordered with a frequency of two hours. -3:00 p.m., the soft restraints were removed. -4:11 p.m., the soft limb order expired and was automatically discontinued (approximately one hour and 15 minutes after the restraints were removed). -7:30 p.m., 6-point restraints were removed. -8:49 p.m., the “Locked limbs” [6-point] order was entered by RN-H via “Ordering in Provider co-sign required mode,” with a frequency of two hours. -9:14 p.m., the locked limbs order expired and was automatically discontinued. P12’s medical record indicated P12 presented to the ED on 3/17/26, at 4:53 p.m., with a chief complaint of behaviors in the setting of a urinary tract infection (UTI). P12 required admission. P12’s 3/21/26 Restraint Monitoring Flowsheets and Order’s section identified: -6:29 p.m., “Locked limbs” was ordered with a frequency for four hours. -7:30 p.m., 4-point restraints were removed. -10:29 p.m., the order expired and was automatically discontinued (approximately three hours after the restraint was removed). P14’s medical record indicated P14 presented to the ED on 3/27/26, at 3:28 p.m., with a chief complaint of mental health issues and medication reaction in setting of schizoaffective disorder, depressive type. P14’s 3/30/26 Restraint Monitoring Flowsheets and Order’s section identified: -6:45 a.m., a manual hold ended. -7:01 a.m., “Manual hold, Seclusion, Restraint Chair - Duration Per Policy” was ordered via a verbal/telephone order mode, with a frequency of four hours. -8:40 a.m., the 7:01 a.m. manual hold, seclusion, and restraint chair order was discontinued by the provider (approximately two hours after the manual hold ended. The chair restraint continued. Based on the flow sheets, it was unknown whether the seclusion continued or not). -8:40 a.m., “Manual hold, Seclusion, Restraint Chair - Duration Per Policy” were re-ordered by the provider with a frequency of four hours. -11:53 a.m., the 8:40 a.m. “Manual hold, Seclusion, Restraint Chair - Duration Per Policy” reorder expired and was again re-ordered by the provider with a frequency of four hours. -12:05 p.m., the restraint chair ended. -3:59 p.m., the 11:53 a.m. “Manual hold, Seclusion, Restraint Chair - Duration Per Policy” expired and was automatically discontinued (approximately four hours after the restraint chair ended). -8:44 p.m., Seclusion was ordered with a frequency of two hours. -10:29 p.m., the 8:44 p.m. seclusion order expired and was automatically discontinued (seclusion continued). -11:40 p.m., seclusion ended. P2’s medical record indicated P2 presented to the emergency department (ED) on 3/28/26, at 2:50 a.m., with a chief complaint of chest pain and intoxication after an argument with his girlfriend. P2’s 3/28/26 Restraint Monitoring Flowsheets and Order’s section identified: -4:05 a.m., bicep restraints were removed. -4:15 a.m., 4-point restraints were removed. -4:19 a.m. “Locked limbs” were ordered with a frequency of four hours. -7:22 a.m., the order expired and was automatically discontinued (approximately three hours after the restraints were removed). P11’s medical record indicated P11 presented to the ED on 3/29/26, at 7:42 p.m., with a chief complaint of being assaulted by family. P11 was an adolescent. P11’s 3/30/26 Restraint Monitoring Flowsheets and Order’s section identified: -11:00 a.m., a manual hold ended. -1:00 p.m., seclusion ended. -1:43 p.m., Seclusion was ordered with a frequency for two hours. -3:43 p.m., the seclusion order expired and was automatically discontinued. P11’s subsequent 3/30/26 Restraint Monitoring Flowsheets and Order’s section identified: -3:26 p.m., Seclusion and Spit Hood were ordered with a frequency for two hours. -3:30 p.m., a manual hold and seclusion ended. -3:34 p.m., “Locked limbs and Spit Hood” were ordered with a frequency for two hours. -5:25 p.m., the 3:26 p.m. seclusion and spit hood order expired and was automatically discontinued (approximately two hours after the seclusion ended. The flow sheets lacked evidence when the spit hood ended). -5:34 p.m., the 3:34 p.m. locked limb and spit hood order expired and was automatically discontinued (locked limbs continued despite the order expiration). -6:00 p.m., “Locked limbs” were re-ordered with a frequency for two hours. -6:56 p.m., the 4-point restraints were removed. -7:59 p.m., the 6:00 p.m. locked limbs reorder expired and was automatically discontinued (approximately an hour after the restraints were removed). P13’s medical record indicated P13 presented to the ED on 4/1/26, at 3:02 p.m., with a chief complaint of muscle spasms, agitation, and behavioral dysregulation. P13’s 4/1/26 Restraint Monitoring Flowsheets and Order’s section identified: -From 3:02 p.m., through 3:56 p.m., 4-point (locked limbs) were utilized. -3:43 p.m., “Soft limbs” were ordered. -7:01 p.m., the order expired and was automatically discontinued (approximately three hours after the restraint was removed). P13’s 4/1/26 MD Restraint for Violent Behavior Face to Face Evaluation, identified that it was conducted at 3:02 p.m., related to restraint initiation at that time. The evaluation was signed by MD-F at 3:44 p.m. The evaluation contained four sections: Patient’s Immediate Situation-Patient demonstrated behaviors: “Agitation, Spitting, Scratching,” Patient’s Reaction to the Intervention - Patient understood the reason for the restraint: “No,” Medical Condition - Any evidence of compromises: “No,” Behavioral Condition -Continued need for the restraint: “No.” The note instructed to See Restraint Flowsheet for complete restraint documentation and assessment. The face-to-face note identified P13 no longer required continued restraints, based on the evaluation; however, despite this, the restraints lasted for an additional 54 minutes after the provider decided the need was no longer there. P15’s medical record indicated P15 presented to the ED on 4/6/26, at 2:33 a.m., with a chief complaint of alcohol poisoning and withdrawal. P15’s 4/6/26 Restraint Monitoring Flowsheets and Order’s section identified: -10:22 a.m., “Locked limbs” were ordered for a frequency of four hours. -11:15 a.m., 4-point restraints were removed. -1:34 p.m., the order expired and was automatically discontinued (approximately two hours and 15 minutes after the restraints were removed). When interviewed on 4/10/26, at 10:38 a.m., RN-R stated it was not his practice to discontinue restraint orders in the system once he removed them from the patient. He explained that once the restraint was removed, it was done, and they were required to get a new order if the restraints needed to be applied again. When interviewed on 4/10/26, at 2:24 p.m., RN-T stated that once a patient’s restraints were removed, she did nothing with the order as it expired on its own. She explained that discontinuation of the order was not required as she documented the removal in the restraint flow sheets. Once a restraint was removed, “it is done.” If another incident occurred, a new order was required. When interviewed on 4/10/26, at 3:29 p.m., RN-C stated he never went into the orders and discontinued them after a restraint was removed as the order expired automatically. When interviewed on 4/13/26, at 1:39 p.m., RN-Q stated she did not discontinue the restraint order when the restraints were removed. She was only expected to document the removal in the restraint flow sheets. As she would need a new order to reapply restraints once removed, she did not feel the order needed to be discontinued. When interviewed on 4/13/26, at 3:53 p.m., RN-Y, patient care manager, stated a restraint order should be discontinued in the active orders once the restraint ended to help mitigate the risk of misinterpretation of the order and the restraint may be reapplied without getting a new order. RN-Y stated that every single time a restraint was applied, a new order was required, so staff should thus discontinue the old one. When interviewed on 4/13/26, at 1:00 p.m., RN-K, an emergency department (ED) manager, stated she was unsure as to the process for restraint order discontinuation. She was unsure whether this was an automated process or conducted by staff. RN-K explained the nurses documented on the restraint flow sheets when the restraints were removed. Once removed, the order was no longer valid and if restraints were again needed, a new order would need to be obtained. RN-K explained ED restraint audits were conducted “every day,” by herself or a colleague in response to a notification they received when an order was placed; however, later stated they attempted to conduct these audits “every week” to stay on top of the process. Recently, the audits were free of identified restraint concerns. When interviewed on 4/15/26, at 11:40 a.m., DO-B stated restraint orders were “practically” automatically discontinued when the order expired. He stated he had discontinued restraint orders when restraints change and it was clear the restraint was no longer needed, but it was more common for them to discontinue automatically. DO-B stated it was best practice for the order to be discontinued right away once the restraints were removed; however, it was not practical. He explained he was able to review the restraint flow sheets to identify when restraints were removed. When interviewed on 4/15/26, at 12:39 p.m., RN-L stated restraint orders were expected to be discontinued after they ended, as this was policy. Any restraints after they were discontinued would then require a new order. Once the restraints were removed, she updated the provider and the provider then discontinued the order. If she noticed the provider had not discontinued the order after a while, she contacted the provider again and entered a progress note related to that communication. When interviewed on 4/15/26, at 1:04 p.m., RN-I stated restraint orders must be reflective of what was going on, thus, when a restraint was removed, she was expected to update the provider so that they could discontinue the active order. When interviewed on 4/15/26, at 2:02 p.m., RN-J stated she never discontinued a restraint order, but then commented, “I am sure the right answer is you are supposed to.” She explained the reason was this was how she was taught as you were required to get a new order if restraints were needed again. RN-J stated locked limbs “usually” applied to 4-point restraints. She stated she knew this as she told the provider what restraints they initiated and thus she knew the details of the order. RN-J was unsure whether a 6-point restraint, applied after a 4-point restraint was already on, required its own order. When interviewed on 4/16/26, at 9:08 a.m., RN-G, the ED patient care manager, stated that restraint orders are not routinely discontinued after removal, but staff are taught if all the restraints were removed, and if the patient had another episode, a new order was required. RN-G verbalized a lot of their orders discontinue automatically. RN-G stated, discontinuation of the order would be a great idea for clarity for all. When interviewed on 4/16/26, at 4:38 p.m., MD-A, one of the ED medical directors, and the chief of staff, stated the providers did not discontinue restraint orders in the system. The providers were notified via secure chat when they were removed and if a new order, or continuation of an order was needed. He assumed the discontinuation of the order was something completed on the nursing side. MD-A stated he had never discontinued a restraint order as a new restraint required a new order. When interviewed on 4/17/26, at 9:30 a.m., the chief nursing officer (CNO) stated, when questioned on the expectations for restraint orders to be discontinued after removal, he reported he lacked the policy in front of him and was unaware of its contents. He stated he expected staff to follow the policy. When the concerns were reviewed with him, he verbalized he understood the concerns. He identified that he met monthly with the staff who conducted the restraint audits and stated there were always areas for improvement. When interviewed on 4/17/26, at 10:00 a.m., MD-B, one of the ED medical directors, stated she was unable to answer the question related to restraint order discontinuation as the providers generally did not do that. She was unsure whether that was a nursing flow process. MD-B stated the restraint orders being removed from the active orders was best practice, just like a medication order and a change in the care plan. The safest option for the patient was for it to be removed from the active part of the chart as a person would want to simplify things as much as possible and decrease the risk of chaos. The record had to be accurate as she relied heavily on it. A Restraint/Seclusion - Management of Violent and/or Self-Destructive Behavior policy, dated June 2025, identified all patients had the right to be free from restraints or seclusion, and that restraints or seclusion could only be used to ensure the immediate physical safety of the patient, staff, and others and must be discontinued at the earliest possible time. A section labeled Discontinuation directed restraints and seclusion must be discontinued at the earliest possible time and restraints or seclusion must not be considered a routine part of patient care. A subsequent section labeled Discontinuation of Restraint/Seclusion identified once the patient’s behavior(s) that created the imminent risk of physical harm to the patient or others ends the use of restraint or seclusion should be discontinued. Restraint/seclusion was to be terminated at the earliest possible time regardless of the length of the order.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 43080 Based on interview and document review, the facility failed to ensure restrained and/or secluded patients were monitored, and that the monitoring documentation were completed timely by trained staff, per facility protocols, for 7 of 7 patients (P2, P3, P11, P12, P13, P14, P15) reviewed for restraint and seclusion utilization. This had the potential to affect all patients who utilized restraints and/or seclusion. Findings include: An Emergency Department (ED) Restraints for Violent Behavior monthly audit percentage grid identified data from January 2026, and February 2026. The grid identified a goal of 90 percent (%). The percentages for January identified a 64% completion of initiation portion of restraint flowsheet, and 64% for completion of every 15-minute monitoring flowsheet. The percentages for February, identified 25% for completion of initiation portion of restraint flowsheet, and 58% for completion of every 15-minute monitoring flowsheet. The grid identified two identified themes: Complete 15-minute checks, and the completion of initiation was usually the notification of family not documented. A Restraint Committee Meeting minutes, dated 3/16/26, identified a section labeled Education. This section lacked information related to any identified concerns for restraint documentation. The section identified all education and competencies were completed. Another section labeled Restraint audit documents, identified there were many audits in “SmartWorks,” and thus they planned to investigate this for potential unification of the forms. Next meeting agenda topics lacked follow up related to this concern. A Restraint Audit, dated March 2026, conducted by RN-E, identified the following: -P11: 3/30/26, seclusion. No concerns for monitoring were identified. -P11: 3/30/26, locked limb and seclusion. The box for Monitoring in Goal was marked as “N”, meaning no. -P11: The audit does not reflect the manual hold identified in her progress notes. An additional 16 other ED patient restraint events were audited. Out of these, six failed in Initiation in Goal and Monitoring in Goal. Four failed in Q 15-minute monitoring for psych status, physical status, and Monitoring Method. Two failed in Q two-hour monitoring for circulation, elimination, fluid, food, and range of motion. A Restraint Audit, dated April 2026, provided by RN-K, identified 12 ED patients were audited for restraint use. Out of these, one review was identified to miss the debrief note. An email was sent. P13 was identified on the audit related to her locked restraints on 4/1/26. The audit lacked any identified concerns with the review of her restraint event. Restraint Education for Hospital Nursing Staff screenshots, undated, identified the following: -Types of Patient Restraints: ‘manual method, physical or mechanical device ...that immobilizes or reduces the ability of a patient to move their arms, legs, body, or head freely.’ Examples were provided: two-person manual escort, spit sock hood, etc. The pictured example lacked a manual hold picture for medication administration. -Violent Assessments - 15-minute checks and documentation elements: Checks were to occur every 15 minutes, the evaluation was to be ongoing to determine if circumstances led to use of less restrictive device or termination of restraint use, when documenting, and do not select, ‘unable due to patient condition.’ The Violent Behavior Electronic Medical Record (EMR) flowsheet identified the following monitoring/assessment questions/information. -R/S (restraint/seclusion) Order: Obtain Order/Renewal Order From LIP, Renewal Order Due at, Clinical Leadership Notified (See row detail). -R/S Assessment: Comprehensive Nursing Assessment, Alternative/Less Restrictive Interventions Attempted. -R/S Order Reason: Clinical Justification. -Notification: Patient’s Request of Notification. -Criteria for Discontinuation: Criteria for D/C (discontinuation) Explained to Patient, Patient Response to Explanation. -Restraint Types/Seclusion: Restraint Types. -Restraint Safe Application: Safe Application Verified. -Q (every) 15 min (minute) R/S Monitoring: Psychological Status, Physical Safety/Comfort Status, Monitoring Method. -Q 15 Min to 2 (two) Hrs. (hours) R/S Monitoring: Circulation, Range of Motion, Fluids, Food/Meal, Elimination, ADL’s (activities of daily living)/Hygiene. -Debriefing: Debriefing After D/C. Based on the timing of the monitoring/assessment, the sections fluctuated; however, the Q 15 Min Monitoring was present for all times. P3’s medical record indicated P3 presented to the ED on 8/7/25, at 4:40 p.m., with a chief complaint of suicidal ideation and self-injurious behavior. P3 was an adolescent. P3’s nursing progress note, dated 8/8/25, identified a time of service at 1:38 p.m. and was entered by RN-L. A code green was called and P3 attempted to kick, hit, and bite staff as they attempted to get the spoon from P3 that she used to attempt self-harm. Intramuscular (IM) medication was administered with a “manual hold” used to ensure staff and P3’s safety. P3’s nursing progress note, dated 8/11/25, identified a time of service at 2:00 p.m.; however, the note was signed at 3:17 p.m. P3 attempted to kick staff and “Staff went hands on to remove blanket” as P3 continued to kick and swing at them. P3’s nursing progress note, dated 8/11/25, identified a time of service at 2:58 p.m.; however, the note was signed at 5:32 p.m. P3 was “restrained” and an IM medication administered. P3’s nursing progress note, dated 8/12/25, identified a time of service at 12:00 p.m.; however, the note was signed at 2:03 p.m. At 11:30 a.m., P3 started to bite herself and “attempts at preventing her from biting led to [P3] kicking, biting staff.” P3’s psychologist progress note, dated 8/12/25, identified a service time of 3:46 p.m., the provider prescribed an IM medication and assisted with a “manual hold” for the RN to administer. P3’s nursing progress note, signed 8/16/25, at 2:35 p.m., by RN-L, identified P3 bit herself and despite verbal redirection and opportunities to participate in the assessment and cooperate with staff’s requests, P3 continued to refuse. IM medication was given. After a few minutes, P3 continued to be resistive to staff direction for safety and P3 was placed in wrist “soft restraints” to mitigate self-harm. P3’s nursing progress note, dated 8/16/25, identified a time of service at 7:10 p.m.; however, the note was signed at 9:24 p.m. by a behavioral health associate. P3 attempted to kick at staff. P3 bite herself with great force and failed to respond to redirection. Show of support called and staff “physically assisted [P3] in removing [her] arm from [her] mouth with difficulty.” P3’s nursing progress note, signed 8/16/25, at 9:22 p.m., by RN-H as a late entry due to patient care, identified shortly after RN-H started his shift, P3’s primary RN, another staff, and her one-on-one were involved in “manually preventing [P3] from biting her wrists.” P3’s 8/11/25 Violent Restraints flowsheet section identified the following: -2:00 p.m., locked limbs (bilateral wrist and bilateral ankles - 4-point) were started and an initial RN assessment was completed. At 2:41 p.m., the RN entered this documentation into the medical record. The documentation lacked information related to P3’s psychological/safety/comfort status and the items listed under the Q 15 min to two-hour monitoring. -2:15 p.m., 4-point restraints continued, and bilateral locked bicep restraints started (6-point status). At 2:42 p.m., the RN started this documentation. P3 was free of injury; however, the Q 15 min to two-hour documentation was unable to be completed due to her behavior. The Order, Assessment, and Criteria for Discontinuation sections, related to the addition of the bicep restraint, remained blank. -2:30 p.m., 6-point restraints continued. At 2:44 p.m. the RN started this documentation and completed it at 3:02 p.m. -2:45 p.m., 6-point restraints continued. At 3:00 p.m. the RN entered this documentation. -3:00 p.m., 6-point restraints continued. -3:15 p.m., 6-point restraints continued. At 4:30 p.m. the RN started this documentation; however, the Monitoring Method question entry, and the Q 15 min to two-hour monitoring section that identified no signs of circulatory injury, were documented by the RN at 9:22 p.m. The Psychological and Physical Safety/Comfort questions remained blank. -3:30 p.m., 4-point restraints continued, and the bilateral bicep restraints were discontinued. At 4:30 p.m., the RN started this documentation; however, the Q 15 monitoring method was entered at 9:22 p.m., along with no signs of circulatory injury, and the Psychological and Safety/Comfort questions were entered at 9:34 p.m. -3:45 p.m., 4-point restraints continued. At 4:30 p.m., the RN started this documentation; however, the Q 15 monitoring method was entered at 9:22 p.m., along with no signs of circulatory injury, and the Psychological and Safety/Comfort questions were entered at 9:34 p.m. -4:00 p.m., 4-point restraints continued. At 4:30 p.m., the RN started this documentation. The required Q 15-minute monitoring section was blank. -4:15 p.m., 4-point restraints were discontinued. At 4:29 p.m., the RN started this documentation; however, this section only identified they were discontinued. The section lacked an assessment of P3’s status at that time. P3’s 8/12/25 Violent Restraints flowsheet section identified the following: -12:15 p.m., 4-point restraints started. At 2:24 p.m., the RN entered this documentation. The Order information identified the order was due for renewal at 2:02 p.m. -Between 12:45 p.m., and 1:45 p.m., this flow sheet section lacked the required Q 15-minute RN assessments. The Patient Observation/Attendant documentation identified P3 was in restraints as ordered. -2:00 p.m., 4-point restraints continued, and bilateral bicep restraints started (6-point status). At 2:29 p.m., the RN entered this documentation. -2:15 p.m., P3 was identified as tearful and subdued. At 2:32 p.m., RN-I entered this documentation. This check lacked the restraint type designation and/or any associated monitoring. -2:30 p.m., P3 was identified as subdued. At 2:32 p.m., RN-I entered this documentation. This check lacked the restraint type designation and/or any associated monitoring. -At 2:45 p.m., this flow sheet section lacked the required 15-minute RN assessment. The Patient Observation/Attendant documentation identified P3 was in restraints as ordered. -3:00 p.m., 6-point restraints continued. At 5:53 p.m., RN-J entered this documentation. -3:15 p.m., P3 was identified as agitated and verbally abusive. At 5:53 p.m., RN-J entered this documentation. The check lacked the restraint type designation, P3’s physical safety/comfort status and monitoring method. She was free of circulatory injury, and the remaining monitoring was unable to be completed due to her behavior. -3:30 p.m., P3 was identified as agitated and verbally abusive. At 5:53 p.m., RN-J entered this documentation. The check lacked the restraint type designation, P3’s physical safety/comfort status and monitoring method. She was free of circulatory injury, and the remaining monitoring was unable to be completed due to her behavior. -3:45 p.m., P3 was identified as agitated and verbally abusive. At 5:53 p.m., RN-J entered this documentation. The check lacked the restraint type designation, P3’s physical safety/comfort status and monitoring method. She was free of circulatory injury, and the remaining monitoring was unable to be completed due to her behavior. -4:00 p.m., 6-point restraints continued. At 5:22 p.m., RN-J started the documentation. -4:15 p.m., 6-point restraints continued. At 6:00 p.m., RN-J entered the documentation. -4:30 p.m., 6-point restraints continued, despite documentation P3 was cooperative and asleep. At 6:00 p.m., RN-J entered the documentation. -4:45 p.m., 6-point restraints continued, despite documentation P3 being cooperative and asleep. At 6:00 p.m., RN-J entered the documentation. -5:00 p.m., 6-point restraints continued, despite documentation P3 being cooperative and asleep. At 6:00 p.m., RN-J entered the documentation. -5:07 p.m., 6-point restraints were discontinued as P3 as cooperative and asleep. At 5:55 p.m., RN-J entered the documentation. P3’s 8/16/25 Non-Violent Restraints flowsheet section identified the following (incorrect flow sheet for P3’s restraint event - should have been documented under the Violent Restraints flow sheets): -2:15 p.m., soft bilateral wrist restraints were started and P3 was assessed by the RN-L. At 3:04 p.m., RN-L entered this documentation. -At 2:30 p.m., this flow sheet section, or the violent restraint flowsheets, lacked the required 15-minute RN assessment. The Patient Observation/Attendant documentation identified P3 was in restraints as ordered. -At 2:45 p.m., this flow sheet section, or the violent restraint flowsheets, lacked the required 15-minute RN assessment. The Patient Observation/Attendant documentation identified P3 was in restraints as ordered. -3:00 p.m., the restraints were discontinued. P3’s 8/16/25 Violent Restraints flowsheet section identified the following: -7:15 p.m., 6-point restraints were started. At 8:58 p.m., RN-H started the documentation and completed it at 9:18 p.m. -7:30 p.m., 6-point restraints were discontinued. At 9:18 p.m., RN-H entered the documentation. The documentation identified P3 was free of circulatory injury; however, the documentation lacked any additional assessment information. P3’s Restraints flowsheets lacked documentation/monitoring in relation to P3’s manual hold restraints. P12’s medical record indicated P12 presented to the ED on 3/17/26, at 4:53 p.m., with a chief complaint of behaviors in the setting of a urinary tract infection (UTI). P12 required admission. P12’s nursing progress note, dated 3/20/26, identified a time of service at 10:20 a.m., and was signed by the RN at 12:33 p.m. At 9:35 a.m., a code green was called in response to P12’s behavioral exit seeking escalated to the point where he crawled out of bed and continued to attempt to leave. Once staff helped him into bed, he continued to be agitated and attempted to leave again with attempts to grab at staff. At 9:45 a.m., 4-point restraints were initiated. P12’s nursing progress note, dated 3/21/26, identified the time of service at 6:56 p.m., and was signed by the RN at 10:44 p.m. P12 walked toward the elevator and became physically and verbally aggressive towards staff when staff attempted to redirect him. P12 swung at staff and hit staff multiple times while staff attempted to help P12 into the wheelchair as P12 had periods of losing his balance. A code green was paged and P12 was brought back to his room. He hit staff in the shoulder and security and the code green team “were able to hold patient’s arms and leg” while an IM medication was given. P12 was transferred to bed, and 4-point restraints were applied. P12’s 3/20/26 Violent Restraints flowsheet section identified the following: -9:45 a.m., 4-point locked limbs were started. At 10:26 a.m., the RN started the documentation and completed it at 10:52 a.m. -10:00 a.m., 4-point restraints continued. At 10:26 a.m., the RN started the documentation and completed it at 10:52 a.m. -10:15 a.m., 4-point restraints continued. At 10:30 a.m., the RN started the documentation and completed it at 10:52 a.m. -10:30 a.m., 4-point restraints continued. At 10:30 a.m., the RN started the documentation and completed it at 10:59 a.m. -10:45 a.m., 4-point restraints continued. At 10:52 a.m., the RN entered the documentation. -11:00 a.m., 4-point restraints discontinued. At 10:59 a.m., the RN started the documentation and completed it at 11:11 a.m. P12’s 3/21/26 Violent Restraints flowsheet section identified the following: -6:00 p.m., 4-point restraints were started. At 6:19 p.m., the RN started the documentation and completed it at 6:39 p.m. -6:15 p.m., and 6:30 p.m., 4-point restraints continued. At 6:38 p.m., the RN entered the documentation for both. -6:45 p.m., 4-point restraints continued. At 6:43 p.m., the RN entered the documentation. -7:00 p.m., 4-point restraints continued. At 6:56 p.m., the RN entered the documentation. -7:15 p.m., 4-point restraints continued. At 7:12 p.m., the RN entered the documentation. -7:30 p.m., 4-point restraints were discontinued. At 7:59 p.m., the RN entered the documentation. P12’s Violent Restraints flowsheets lacked documentation/monitoring in relation to P12’s 3/21/26 manual hold restraint. P2’s medical record indicated P2 presented to the emergency department (ED) on 3/28/26, at 2:50 a.m., with a chief complaint of chest pain and intoxication after an argument with his girlfriend. P2’s 3/28/26 Violent Restraints flowsheet section identified the following: -3:23 a.m., locked limbs (bilateral wrist and bilateral ankles - 4-point) were started. At 4:32 a.m., registered nurse (RN)-Q entered this documentation into the medical record. -3:28 a.m., bilateral locked bicep restraints were started (6-point status). At 4:32 a.m., RN-Q entered this documentation. -3:30 a.m., 6-point restraints continued. At 4:37 a.m., RN-Q entered this documentation. -3:45 a.m., 6-point restraints continued. At 4:49 a.m., RN-N entered this documentation. -4:00 a.m., 6-point restraints continued. At 4:49 a.m., RN-N entered this documentation. -4:05 a.m., the bilateral bicep restraints were discontinued, and the 4-point restraints continued. At 4:45 a.m., RN-N entered this documentation. -4:15 a.m., 4-point restraints were discontinued. At 4:45 a.m., RN-N entered this documentation. P11’s medical record indicated P11 presented to the ED on 3/29/26, at 7:42 p.m., with a chief complaint of being assaulted by family. P11 was an adolescent. P11’s nursing progress note, dated 3/30/26, identified a time of service at 11:03 a.m. P11 continued to hit the nursing station window “after being forced out of the office.” P11 was “escorted to her room,” and given medications. Another P11 nursing progress note, dated 3/30/26, identified the time of service at 11:03 a.m. P11 banged on glass, yelled at staff, attempted to bite staff and hit them. IM medication was administered. P11’s MD-J provider note, dated 3/30/26, indicated a date of service at 2:13 p.m., and was signed at 3:38 p.m. At approximately 3:15 p.m., a second code green was called P11 hit her head against the wall. P11 became aggressive and attempted to hit staff and spit at them. A third alert was called and P11 was provided an IM medication. P11’s nursing progress note, dated 3/30/26, identified a time of service at 3:45 p.m., and was signed by the RN at 4:44 p.m. P3 lunged at the nurse. A security officer and another staff “assisted writer in helping [P11] return to room.” P11 began to grab, scratch, bit, and spit at staff. IM medication was administered and P11 was “assisted” to her room. P11 was assisted to bed and “restrained to bed.” P11’s nursing progress note, dated 3/30/26, identified the time of service at 3:54 p.m., and was signed by a patient care tech (PCT) at 4:23 p.m. The writer, P11’s primary nurse, and a security officer, attempted to escort P3 back to her room. P11 flailed and attempted to bite and swing at staff. While P11 was escorted back to her room, she dropped her weight to the ground and attempted to spit and kick at staff. Code green was called, and an IM medication was administered. She was escorted back to her room and placed in seclusion. P11 was administered another IM medication due to continued inability to keep herself safe. P11’s nursing progress note, dated 3/31/25, signed at 9:03 a.m., identified P11 was resistive to cares. She swung her arm away from the RN when the blood pressure cuff attempted to be placed. P11 stated, ‘Shut up! You are not my boss.’ “Arm held in place and BP cuff placed for a reading.” P11 pulled finger away from the pulse oximetry so a manual pulse was taken by the RN. P11’s nursing progress note, dated 4/6/26, identified a time of service at 5:18 p.m., and was signed by the RN at 6:15 p.m. P11’s behaviors escalated, and she started to block staffs’ ability to enter and exit areas of the unit. During such an episode, when she refused to allow staff entry, despite numerous attempts to redirect her, P11 started to flail and strike out at staff. A show of support was called, and she was “escorted back to her room all the while attempting to scratch, hit, and bite staff.” After P11 agreed to accept an oral medication to assist with behavior management; however, when the nurse went to obtain the medication, P11 again blocked the nurse and began to push, grab at, and succeeded in digging her nails into the nurse’s skin. P11’s nursing progress note, dated 4/6/26, identified a time of service at 7:49 p.m., and was signed by a behavioral health associate at 8:14 p.m. P11 became restless in the hall and began to run up and down the halls, attempted to enter other patients’ rooms, and attempted to gain entry into the nurse’s station, where she attempted to grab onto staff. As the unit door opened, P11 sprinted through the doors, and was “promptly stopped by staff in the hall and brought back to the suite.” P11’s Violent Restraints flowsheet section identified the following events on 3/30/26: -11:00 a.m., “Seclusion; Manual Hold” started, and the Manual Hold was discontinued. At 1:53 p.m., the RN entered the documentation. -From 11:15 a.m., through 12:45 p.m., seclusion continued. At 1:56 p.m., the RN entered the documentation for all seven of these times. -1:00 p.m., seclusion discontinued. At 1:54 p.m., the RN entered the documentation. -3:26 p.m., seclusion started, manual hold and spit hood started. At 3:54 p.m., the RN started the documentation, and completed it at 4:09 p.m. -3:30 p.m., manual hold was discontinued, seclusion was discontinued, the spit hood continued, and 4-point restraints were started. At 4:09 p.m., the RN entered the documentation. -3:45 p.m., 4-point restraints continued. At 4:26 p.m., the RN entered the documentation. -4:00 p.m., through 4:15 p.m., 4-point restraints continued. At 4:27 p.m., the RN started the documentation for both times, and completed both at 6:02 p.m. -4:30 p.m., through 5:00 p.m., 4-point restraints continued. At 5:58 p.m., the RN entered the documentation for all three, and completed them all at 6:02 p.m. -5:15 p.m., through 5:30 p.m., 4-point restraints continued. At 5:59 p.m., the RN entered the documentation for both, and completed both at 6:02 p.m. -5:45 p.m., 4-point restraints continued. At 6:00 p.m., the RN entered the documentation, and completed it at 6:02 p.m. -6:00 p.m., 4-point restraints continued. At 6:00 p.m., the RN entered the documentation, and completed it at 6:37 p.m. -From 6:15 p.m., through 6:45 p.m., 4-point restraints continued. -6:56 p.m., 4-point restraints were discontinued. P11’s Violent Restraints flowsheets lacked documentation/monitoring in relation to P11’s 3/31/26, and 4/6/26 events. P13’s medical record indicated P13 presented to the ED on 4/1/26, at 3:02 p.m., with a chief complaint of muscle spasms, agitation, and behavioral dysregulation. P13’s nursing progress note, dated 4/1/26, and signed 3:09 p.m., identified P13 yelled, spit at, and hit ambulance personnel. “Four-point restraints” were applied. P13’s Violent Restraints flowsheet section identified the following events on 4/1/26: -3:02 p.m., 4-point (locked limbs) were started. The RN started the documentation at 3:20 p.m. -3:15 p.m., 3:30 p.m., and 3:45 p.m., 4-point (locked limbs) continued. The RN started the documentation at 4:02 p.m. for all three; however, entered the Q 15-minute assessment documentation for all three on 4/2/26, at 5:50 p.m. -3:56 p.m., 4-point (locked limbs) were discontinued. The RN started the documentation at 3:59 p.m.; however, entered the Q 15-minute assessment documentation on 4/2/26, at 5:50 p.m. P14’s medical record indicated P14 presented to the ED on 3/27/26, at 3:28 p.m., with a chief complaint of mental health issues and medication reaction in setting of schizoaffective disorder, depressive type. P14’s nursing progress note, dated 3/30/26, identified a time of service at 7:57 a.m., and was signed at 9:04 a.m. A code green was initiated and P14 was “manually held” to administer an IM medication in response to escalating physically aggressive behaviors. P14’s nursing progress note, dated 3/31/26, signed at 6:55 a.m., identified P14 required seclusion on 3/20/26, at 8:30 p.m., due to continual yelling and getting into people’s faces. Due to increased verbal loudness and aggressive behavior, she was escorted to the seclusion room. P14’s 3/30/26 Violent Restraints flowsheet section identified the following: -6:43 a.m., a manual hold started. The RN entered the documentation at 7:51 a.m. -6:45 a.m., the manual hold was discontinued and the restraint chair, along with seclusion started. The RN started the documentation at 7:57 a.m., and finished the seclusion information at 8:13 a.m. -7:00 a.m., and 7:15 a.m., the restraint chair and seclusion continued. For both times, the RN started the documentation at 7:57 a.m., and finished the seclusion information at 8:13 a.m. -7:30 a.m., the restraint chair continued; however, the entry had a dash in the seclusion section. At 7:49 a.m., the RN started the documentation. -7:45 a.m., the restraint chair continued; however, the entry had a dash in the seclusion section. At 7:50 a.m., the RN started the documentation. -8:00 a.m., through 8:30 a.m., the restraint chair continued. The entry lacked information related to seclusion. -8:43 a.m., the restraint chair continued. The entry lacked information related to seclusion. At 9:19 a.m., the RN entered the documentation. -8:45 a.m., the restraint chair continued. The entry lacked information related to seclusion. At 8:48 a.m., the RN entered the documentation. -9:00 a.m., through 10:30 a.m., the restraint chair continued. The entry lacked information related to seclusion. -10:43 a.m., the restraint chair continued. The entry lacked information related to seclusion. The next day on 3/31/26, at 10:01 a.m., the RN entered the documentation. -10:45 a.m., through 12:00 p.m., the restraint chair continued. The entry lacked information related to seclusion. -12:00 p.m., the restraint chair continued. At 12:26 p.m., the RN entered the documentation. -Between the time of 7:15 a.m., when the seclusion was identified to have continued, through 12:00 p.m., there was no identification when the seclusion was discontinued. -12:05 p.m., the restraint chair was discontinued, and seclusion started. At 12:35 p.m., the RN started the documentation; however, it was not until 3/31/26 at 10:01 a.m., that it was completed. -12:15 p.m., through 5:00 p.m., seclusion continued. -5:15 p.m., through 5:45 p.m., seclusion continued. For all three of these 15-minute checks, the RN started the documentation at 5:48 p.m., and completed it at 6:07 p.m. -6:00 p.m., through 7:15 p.m., seclusion continued. -The flow sheets lacked a 7:30 p.m. 15-minute RN assessment. -7:45 p.m., seclusion continued. The section for every 15-minute check was blank. At 9:26 p.m., the RN entered documentation into every 15 minutes to two-hour monitoring section. -The flow sheets lacked the 8:00 p.m. and 8:15 p.m. 15-minute RN assessments. -8:30 p.m., seclusion continued. At 8:49 p.m., the RN started the documentation; however, completed it at 10:21 p.m. -8:45 p.m., through 10:30 p.m., seclusion continued. At 10:34 p.m., the RN started the documentation for all eight assessment times; however, for all eight, at 5:44 a.m. the next morning, the RN entered the restraint type (seclusion) and that it “continued.” -10:45 p.m., through 11:15 p.m., seclusion continued. At 11:33 p.m., the RN started the documentation for all three assessment times; however, for all three, at 5:44 a.m. the next morning, the RN entered the restraint type (seclusion) and that it “continued.” -11:30 p.m., seclusion continued. At 11:36 p.m., the RN started the documentation; however, at 5:44 a.m. the next morning, the RN entered the restraint type (seclusion) and that it “continued.” -11:40 p.m., seclusion was discontinued. P15’s medical record indicated P15 presented to the ED on 4/6/26, at 2:33 a.m., with a chief complaint of alcohol poisoning and withdrawal. P15’s nursing progress note, dated 4/6/26, signed 10:42 a.m., identified a code green was called at 9:06 a.m. in response to P15’s behavioral dysregulation and visual hallucinations and 4-point restraints were applied at 9:35 a.m. P15’s 4/6/26 Violent Restraints flowsheet section identified the following: -9:35 a.m., 4-point locked restraints were started. At 10:14 a.m., the RN entered the documentation. -9:50 a.m., 10:05 a.m., and 10:15 a.m., identified 15-minute monitoring, which was documented by the RN at 10:44 a.m.; however, these three-time lacked indication of what restraints were utilized at those times. -10:30 a.m., identified a 15-minute RN assessment, entered by the RN at 10:45 a.m.; however, the time lacked an indication of what restraint(s) were utilized at that time. -10:45 a.m. and 11:00 a.m., 4-point restraints continued. At 11:13 a.m., the RN started the documentation for both times and then completed both at 11:30 a.m. -11:15 a.m., 4-point restraints were discontinued. When interviewed on 4/10/26, at 10:38 a.m., RN-R stated he was expected to assess/monitor a restrained patient every 15 minutes. This process helped identify if the restraint was used appropriately, was not too tight, the patient’s range of motion was good, if there was an injury present, if the patient’s hierarchy of needs was being met, and if there were criteria for discontinuation identified. RN-R explained restraint charting was annoying as there was a lot of documentation. Despite this, he was expected to perform the 15-minute monitoring, and to ensure this documentation was charted as he performed the assessment. He explained he laid eyes on the patient and then did the charting. When interviewed on 4/10/26, at 2:24 p.m., RN-T stated restraint monitoring was expected to be done every 15 minutes to ensure safe application, appropriate circulation, motion, and sensation, there was no injury, there were no airway compromises, and to assist the patient with positioning and range of motion. The documentation for this assessment process depended on how busy she was and the behavioral situation of the patient. Overall, the documentation was expected to be completed as the assessment occurred and at least within the first 15 or 30 minutes after the assessment; however, she also stated “within the hour for sure.” RN-T explained that timely documentation was important as restrained patients were a high priority. When interviewed on 4/10/26, at 3:29 p.m., RN-C stated he was expected to monitor, and document the monitoring details, every 15 minutes when restraints were utilized at a minimum; however, if the patient was “very active” in the restraints, he may do the monitoring more frequently. This documentation was expected to be documented when the monitoring occurred for patient safety. Despite the expectation, and attempted process, at times there were delays based on the patient’s behavioral situation or other patient events at that time; however, such delays were expected to not be the norm. When interviewed on 4/13/26, at 1:00 p.m., RN-K, an emergency department (ED) manager, stated staff were expected to monitor/assess restrained patients every 15 minutes, along with real time documentation. Additional times were expected, such as every two hours, to monitor such things as circulation, motion, sensation, injury, meeting of needs, etc. During both time checks, she expected staff to attempt documentation as close to the identified time as possible. She explained there were situations where the documentation could not be conducted in the moment; however, they have “back-up staff” that could assist with the 15-minute checks when applicable and thus, overall, the documentation should be completed before the next check (within 15 minutes of the last check). RN-K stated it was not an identified practice to utilize paper in place of the electronic flow sheet documentation. RN-K explained ED restraint audits were conducted “every day,” by herself or a colleague in response to a notification they received when an order was placed; however, later stated they attempted to conduct these audits “every week” to stay on top of the process. Recently, the audits were free of identified restraint concerns. When interviewed on 4/13/26, at 1:39 p.m., RN-Q stated she was expected to complete restraint monitoring/assessments every 15 minutes, which were expected to be documented in real time. RN-Q explained, P2 did not recollect reasons as to P2’s restraint documentation timing; however, she stated P2, due to the timing of the restraint, was not assigned to a primary nurse yet and they had to figure out who that nurse was. When interviewed on 4/13/26, at 3:22 p.m., RN-N stated a restraint patient required monitoring/assessment every 15 minutes. She was expected to follow this and was expected to document the information at the same time. Despite this, there were times, based on patient situations/events, that this was harder to accomplish; however, she explained there were other staff present that assisted her in such situations. At times when this did occur, and she did not have assistance, she kept the information in her memory and did not utilize paper. RN-N stated she took over care of P2 when he was calm. She stated, related to the later restraint documentation times, she felt there was a lot of transition going on at that time where there were so many staff interacting with him and no one knew who should be doing the documentation. After things calmed down, she thought that was when she may have gone in and completed the documentation. When interviewed on 4/13/26, at 3:53 p.m., RN-Y, patient care manager, stated restrained patients were expected to be visualized every 15 minutes, and staff were expected to follow additional monitoring guidelines identified in the restraint flow sheets. Additionally, she expected the associated documentation to be entered “as you go, otherwise you are backdating your documentation.” Late documentation posed a risk of other staff not knowing the restraint monitoring details when comparisons in status were needed. During her restraint auditing processes, she had no trending restraint concerns. When interviewed on 4/15/26, at 12:39 p.m., RN-L stated restrained patients were required to be monitored every 15 minutes. This was required to ensure circulation, limb positioning, sensation, adverse effects, etc., and to determine if they were safe to have the restraints discontinued as she did not want the patients in restraints longer than necessary. RN-L stated she was expected to document at the same time as the checks; however, at times this was delayed based on the patient and/or other patient situations. Overall, she would expect no longer than a few minutes delay, especially as there was not much to the documentation, and time was everything, especially if something happened and staff wanted to catch it right away. Additionally, if not completed and/or documented timely, the patient may be in restraints longer than necessary. Further, she was expected to ensure all the questions in the restraint flow sheets were answered during the assessment process. When interviewed on 4/15/26, at 1:04 p.m., RN-I stated restrained patients “usually” were monitored every 15 minutes. Once she completed her monitoring, she was expected to document the assessment right away. There were situations that may extend the documentation timing; however, she was still expected to document as soon as possible. Timely monitoring and documentation entailed circulation, injury, airway, breathing, safety, and abnormality determinations. Additionally, at those times, she talked with the patients to assist with getting them out of the restraints as soon as possible. If documentation were late, or not completed, she would be unaware of concerns such as redness/bruising or other status changes. When interviewed on 4/15/26, at 2:02 p.m., RN-J stated a restrained patient required every 15-minute monitoring to assess for potential concerns related to their pulse, circulation, range of motion, sensation, skin, and restraint use. Additionally, some patients are at increased risk for skin breakdown and getting out of the restraints. Routine checks helped ensure safety. When she documented, she was expected to fill out all the required, triggered restraint flowsheet sections which assisted to prove she monitored the patient as expected. Ideally this documentation occurred right away after the assessment process. She identified, at times, there was back charting; however, this was usually at the start of the restraint use. RN-J thought she remembered P3. She described her as loud and not nice. Other than this, she was unable to remember any specific details. When interviewed on 4/15/26, at 2:32 p.m., RN-H stated a restrained patient required monitoring and an assessment every 15 minutes, along with associated documentation at the time of the process, or his earliest convenience, as long as it was before the next 15-minute check. At times, this may be delayed; however, he was able to delegate to ensure the patient remained safe while in restraints. As he was expected to ensure the patient was breathing, was free of injury, had good circulation, and continued to require the restraint during the 15-minute time, this process was expected. If a patient were not monitored as expected, there would be risks to the patient; the patient may stop breathing, and it could be catastrophic. Documentation also supported staff did their due diligence and looked out for the best interests of the patient. RN-H stated he was unable to recollect P3. When interviewed on 4/16/26, at 9:08 a.m., RN-G, the ED patient care manager, stated restrained patients required monitoring every 15 minutes for assessment of certain items and then there was another assessment process at two hours. These were reflected in the restraint flow sheets. Ideally, she expected the documentation to be entered within five minutes, or by the next 15-minute check, and expected all the flow sheet boxes to be filled out. If a patient utilized restraints for five hours, she expected there to be a flow sheet time for every 15 minutes. This helped to ensure the patient utilized restraints appropriately. During her audits of this process, she indicated the process was not 100 percent and there were always ongoing concerns. When concerns were identified, staff were followed up in real time. She indicated RN-F conducted the restraint audits and she was provided with a monthly report. For restraint auditing, based on how well they were doing with prior audits, a random sample of so many charts was flagged for audit. Over the past two months, RN-G identified restraint education was provided during huddles and posted information by the timecard. In the last four to five weeks, they have noticed some of the 15-minute checks missing documentation in a few boxes with a trend of one to two boxes. They have done education in the moment with staff and added the information to their weekly need to know newsletters. Despite continued concerns, there have not been unit wide mandatory education related to restraint concerns. On 4/16/26, at 11:27 a.m., restraint record review began with RN-F (quality advisor), RN-D (mental health clinical nurse specialist - restraint auditor), and RN-E (clinical nurse specialist - restraint auditor). The records of P2, P3, P11, P12, P13, P14, and P15 were reviewed. In summation, RN-E identified a manual hold of any kind, was considered a restraint and she expected appropriate restraint documentation. Appropriate documentation included the restraint under the appropriate restraint flow sheet i.e., non-violent restraints versus violent restraints as the documentation was about the behavior, not the device. RN-E expressed concerns when the timelines of restraint documentation processes were entered into the record and stated documentation was expected to be entered as close to the designated monitoring times as able. RN-E stated restrained patients required every 15-minute monitoring, where she expected all the required fields for the identified monitoring/assessment times to be completed timely. RN-E identified each department and conducted their own restraint audits. She indicated she was unsure how robust these audits were and stated that was each department’s responsibility. Once the audits were completed, the information was shared monthly. RN-D stated the mental health units do the audits; however, she did not think they got to the pieces related to documentation filing. RN-E stated that was not something they emphasized. RN-D stated staff documented in the restraint columns and the staff were not aware they paid attention to the details. Both RN-E and RN-D stated there was not any recent education related to the overall concerns identified with the review. In response to the patient review, they both indicated they would change their education and processes. When interviewed on 4/17/26, at 9:30 a.m., the chief nursing officer (CNO) stated, when questioned on his expectations for the documentation and monitoring of restraints, he did not have the policy in front of him and was unable to answer the question. He expected staff to follow the policy. He was updated on the concerns and verbalized he understood them. He identified that he met monthly with the staff who conducted the restraint audits and stated there were always areas for improvement. During a subsequent interview on 4/17/26, at 11:55 a.m., with RN-K, she stated that once she and her colleague started to see restraint process concerns, they developed an audit process that was more informal and internal, and not one defined by the facility. She stated, once the audit was conducted, the audit forms were not retained. RN-K explained, once an order was placed, her colleague received a notification and then they audited the process to ensure things were appropriately completed. If concerns were identified, the staff was followed up in real time. RN-K was unsure whether the facility restraint auditors were aware of her own auditing process. She stated she was sent a monthly audit report from those staff, and she was unaware of any trending concerns in the past couple of months. A Restraint/Seclusion - Management of Violent and/or Self-Destructive Behavior policy, dated June 2025, identified the patient had the right to be free from restraint or seclusion, of any form and may only be used to ensure the immediate physical safety of the patient, staff, or others and must be discontinued at the earliest possible time. Only clinical staff were allowed to determine restraint or seclusion use. The use of restraint or seclusion must be based on a comprehensive, individualized assessment of present facts and circumstances. The policy defined a physical restraint as “any manual method, physical or mechanical device ...that immobilizes or reduces the ability of the patient to move their arms, legs, body, or head freely.” This included physical escort: ‘light grasp,’ to escort the patient to a desired location which the patient cannot easily escape from; physical holding: holding a patient in a manner that restricts their movement against their will which included holds that some members of the medical community termed ‘therapeutic holds’; spit hoods: temporary intervention to reduce the spread of contaminants through saliva or other bodily fluids through the mouth. A policy section labeled Monitoring/Reassessment, directed a trained and qualified RN must monitor and assess the patient to determine the need for notification and discussion with the practitioner, to update plan of care when indicated, and to evaluate the patient’s readiness for discontinuation or to determine whether a new order needs to be secured to continue the intervention; and to respond to and appropriately treat signs of physical and psychological distress. An RN may delegate the direct care of a patient in restraint and/or seclusion to an appropriately trained staff member. The selection of an intervention and determination of the necessary frequency of assessment and monitoring was to be individualized, and took into consideration variables such as the patient’s condition, cognitive status, and risks associated with the use of the chosen intervention, and other relevant factors. The visual safety check must include a description of the patient’s psychological status, patient’s physical safety and comfort status, and documentation of how the visual check was completed. Frequency of monitoring was dependent upon patient need, so more frequent monitoring could be required. Monitoring parameters were included on the restraints for violent behavior Electronic Medical Record (EMR) flowsheet. Staff must take extra care to protect the safety of the patient when more restrictive interventions are used. Monitoring must be appropriate to the intervention chosen, so that the patient was protected from abuse, assault, or self-injury during the intervention.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(11) Physician and other licensed independent practitioner training requirements must be specified in hospital policy. At a minimum, physicians and other licensed practitioners authorized to order restraint or seclusion by hospital policy in accordance with State law must have a working knowledge of hospital policy regarding the use of restraint or seclusion. This Standard is not met as evidenced by: 43080 Based on interview and document review, the facility failed to ensure the contracted emergency department (ED) providers were minimally trained in facility restraint and seclusion policies for 3 of 3 providers (MD-G, DO-B, and MD-C) reviewed. This had the potential to affect all patients who presented to the ED and required the use of restraints and/or seclusion. Findings include: A Restraint Committee Meeting minutes, dated 3/16/26, identified a section labeled Education. This section lacked information related to any identified concerns for restraint orders, restraint face-to-face processes, restraint documentation, and/or restraint order discontinuations. The section identified all education and competencies were completed. During the 4/17/26, human resources record review, with human resources business partner (HR)-A and accreditation specialist (AS)-B, the following was identified: -Medical Doctor (MD)-G lacked documented evidence of orientation, and/or annual, policy education related to restraints and seclusion. -Doctor of Osteopathic Medicine (DO)-B lacked documented evidence of orientation, and/or annual, policy education related to restraints and seclusion. -MD-C lacked documented evidence of orientation, and/or annual, policy education related to restraints and seclusion. A Medical Staff roster, identified the following: -MD-G was an active ED provider employed through Emergency Physicians PA (EPPA-medical provider contracted agency). -DO-B was an active ED provider employed through EPPA. -MD-C was an active ED provider employed through EPPA. An email, dated 4/17/26, sent by AS-B, identified AS-B reached out to staff in relation to EPPA provider restraint and seclusion education. Per the medical staff office, they responded, ‘We don’t have annual education requirements at this time.’ New providers are “requested” to complete ‘some e-learning modules.’ One that included a Credentialed Provider Education module that included information on restraints. Requirements for the ED and restraint training were identified as “Annual Code Green training (including restraints) for all staff.” Documentation that MD-G, DO-B, and MD-C were educated on the facility’s restraint and seclusion policy and associated expectations was requested; however, the facility was unable to find/provide evidence of such training. When interviewed on 4/15/26, at 2:39 p.m., MD-G, a contracted ED provider, stated he worked for the facility for approximately two years. He was unsure how often, or the last time, he was trained by the facility on restraint/seclusion expectations and/or policies. He stated, when he missed something, he usually receives an email. MD-G stated when he ordered locked limbs, based on his experience, this referred to the Velcro restraints to the wrist/legs: “Like a 4-point.” He was unsure about the processes for 6-point application, and if a new order would be required. When interviewed on 4/16/26, at 4:38 p.m., MD-A, one of the ED medical directors, and the chief of staff, identified a contracted agency provided the facility with their ED providers. He was unaware of what education these providers were provided or not provided. MD-A explained, these providers were brought through orientation and talked to about mental health aspects of care. Additionally, they were provided with regular education through department meetings and emails. He explained he searched his email for restraint information and found six over the past year and a half with the weekly emails that were sent out. Additionally, several PowerPoints were provided that focused on restraints over the past one and a half years. MD-A stated, “This comes up a lot.” Additionally, restraints were talked about during their last Joint Commission (accreditation) survey follow up. When interviewed on 4/17/26, at 10:00 a.m., MD-B, one of the ED medical directors, stated she thought restraint education was part of the onboarding process for the contracted providers, which she herself was one of; however, she was unaware of what this orientation entailed in detail, or how such education was monitored. She explained, related to restraint education, weekly email updates and monthly department meetings occurred and when needed restraint information was brought up. Additionally, when things changed, such as policies, this information was also provided to the providers. A Restraint/Seclusion - Management of Violent and/or Self-Destructive Behavior policy, dated June 2025, identified a section for staff training. The policy identified that physicians and other LPs authorized to order restraint and/or seclusion must have a working knowledge of hospital policy regarding the use of restraint and/or seclusion. The policy lacked information related to how often the providers were expected to be trained and/or how they were expected to show competence with policy expectations. The policy further identified to minimize the use of restraint and seclusion, all direct care staff and any other staff involved in the use of restraint and seclusion must receive education, training, and demonstrate knowledge based on the specific needs of the patient population in at least the following: techniques to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require the use of a restraint or seclusion, the use of nonphysical intervention skills, the safe application and use of all types of restraint or seclusion used in the hospital, including training in how to recognize and respond to signs of physical and psychological distress (for example, positional asphyxia), monitoring the physical and psychological well-being of the patient who is restrained or secluded, the use of first aid techniques and education in the use of cardiopulmonary resuscitation, including required periodic education, and staff must be trained and demonstrate competency in their ability to identify specific patient behavioral changes that may indicate that restraint or seclusion is no longer necessary and can be safely discontinued.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) [the patient must be seen face-to-face within 1 hour after the initiation of the intervention -- ] §482.13(e)(12)(ii)To evaluate - 1. The patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. This Standard is not met as evidenced by: 43080 Based on interview and document review, the facility failed to provide a face-to-face evaluation (a physical and behavioral assessment of the patient by a qualified practitioner/registered nurse (RN), and a comprehensive review of the patients status at the time of the face-to-face evaluation, within an hour of restraint and/or seclusion initiation, for 7 of 7 patients (P2, P3, P11, P12, P13, P14, P15) who were physically restrained, and/or placed in seclusion. This had the potential to affect all patients who required restraints and/or seclusion. Findings include: A copy of Restraint information provided to providers, dated 2026, directed providers place a face-to-face note that was ‘timed’ after but within an hour of the restraint time. Do the face-to-face, even if it does not seem necessary (seclusion, manual hold for medication). An Emergency Department (ED) Restraints for Violent Behavior monthly audit percentage grid identified data from January 2026, and February 2026. The grid identified a goal of 90 percent (%) and monitored the following: obtaining an order within 60 minutes, order renewal, completion of initiation portion of restraint flowsheet, and completion of every 15-minute monitoring flowsheet. The audit lacked face-to-face percentage details. An Accreditation Update Medical Executive Committee PowerPoint, dated February 2026, identified a slide labeled Vulnerabilities - Restraints. This was a reminder violent restraint required a timely face-to-face evaluation. Common findings identified missing or late face-to-face evaluations, and face-to-face evaluations lacked the required elements. A Restraint Committee Meeting minutes, dated 3/16/26, identified a section labeled Education. This section lacked information related to any identified concerns for restraint face-to-face processes or restraint documentation. The section identified all education and competencies were completed. Another section labeled Restraint audit documents, identified there were many audits in “SmartWorks,” and thus they planned to investigate this for potential unification of the forms. Next meeting agenda topics lacked information related to the identified concerns. A Restraint Audit, dated March 2026, conducted by RN-E, identified the following: -P11: 3/30/26, seclusion. The Any Face-to-Face box was marked “Y” means yes. -P11: 3/30/26, locked limb and seclusion. The Any Face-to-Face box was marked “Y.” -P11: The audit lacked reflection of the manual hold identified in her progress notes. An additional 16 other ED patient restraint events were audited. Out of these, all the Any Face-to-Face boxes were marked “Y.” A Restraint Audit, dated April 2026, provided by RN-K, identified 12 ED patients were audited for restraint use. Out of these, one review was identified to miss the debrief note. An email was sent. P13 was identified on the audit related to her locked restraints on 4/1/26. The audit lacked any identified concerns with the review of her restraint event. Restraint Education for Hospital Nursing Staff screenshots, undated, identified the following: -Types of Patient Restraints: ‘manual method, physical or mechanical device ...that immobilizes or reduces the ability of a patient to move their arms, legs, body, or head freely.’ Examples were provided: two-person manual escort, spit sock hood, etc. The pictured example lacked a manual hold picture for medication administration. -Face-to-Face Assessment - Violent Only: Within an hour of restraint initiation, the attending provider, or a trained nurse, completes the evaluation and documents it in the chart. P3’s medical record indicated P3 presented to the ED on 8/7/25, at 4:40 p.m., with a chief complaint of suicidal ideation and self-injurious behavior. P3 was an adolescent. P3’s nursing progress note, dated 8/8/25, identified P3 attempted to cut her wrists with a broken spoon. A code green was called and P3 attempted to kick, hit, and bite staff as they attempted to get the spoon from P3. Intramuscular (IM) medication was administered with a “manual hold” to ensure staff and P3’s safety. P3’s medical record lacked evidence a face-to-face evaluation was conducted in response to the 8/8/25 manual hold/hands on restraint(s). P3’s 8/11/25 Violent Restraints flow sheet section identified the following: -From 2:00 p.m., through 4:15 p.m., locked limbs (bilateral wrist and bilateral ankles - 4-point) were utilized. -At 2:15 p.m., through 3:30 p.m., bilateral locked bicep restraints were utilized (6-point status). P3’s nursing progress note, dated 8/11/25, identified the time of service at 2:00 p.m. P3 gripped a blanket hard and attempted to kick staff as they attempted to remove it from her. Show of support was called. “Staff went hands on to remove blanket” as P3 continued to kick and swing at them and started to bite her right arm. P3 was placed in 4-point locked limb restraints. Shortly after, P3 attempted to flip her mattress and to bite her bicep and thus bicep restraints were applied. P3’s nursing progress note, dated 8/11/25, identified another nurse’s entry related to the 2:00 p.m. incident. P3 bit her left arm and failed to stop with redirection. Code green was called. P3 was “restrained” and an IM medication administered. P3 continued to be physically aggressive with attempts to hit her head repeatedly on the bedside rail and, she was placed in 6-point restraints. P3’s 8/11/25 MD Restraint for Violent Behavior Face to Face Evaluation, identified the evaluation was conducted at 2:10 p.m., in relation to a 2:05 p.m. restraint initiation. The evaluation was signed by medical doctor (MD)-I at 2:11 p.m. The evaluation was conducted prior to the bilateral bicep restraints. The evaluation contained four sections: Patient’s Immediate Situation-Patient demonstrated behaviors: “Rubbing head against the wall. Shopping [sec] bed across the room. Hiding under the blanket. Kicking and biting,” Patient’s Reaction to the Intervention - Patient understood the reason for the restraint: “Yes,” Medical Condition - Any evidence of compromises: “No,” Behavioral Condition -Continued need for the restraint: “Yes.” The note instructed to See Restraint Flowsheet for complete restraint documentation and assessment. The face-to-face note lacked evidence of which restraint the evaluation was for i.e., “hands on,” 4-point restraints, and/or 6-point restraints, and failed to provide a comprehensive review of P3’s condition in relation to the restraint application and continued need. Additionally, P3’s record lacked evidence a separate face-to-face was conducted for each restraint application. P3’s 8/12/25 Violent Restraints flow sheet section identified the following: -From 12:15 p.m., through 5:07 p.m., 4-point restraints were utilized. -From 2:00 p.m., through 5:07 p.m., bilateral bicep restraints were utilized (6-point status). P3’s nursing progress note, dated 8/12/25, identified at 11:30 a.m., P3 started to bite herself and “attempts at preventing her from biting led to [P3] kicking, biting staff.” A code green was called, provider was notified, and P3 was placed in 4-point restraints. P3’s 8/12/25 MD Restraint for Violent Behavior Face to Face Evaluation, identified it was conducted at 11:59 a.m. related to a restraint initiation at that same time. The evaluation was signed by MD-G at 12:02 p.m. The restraint flow sheets identified this started at 12:15 p.m. The evaluation contained four sections: Patient’s Immediate Situation-Patient demonstrated behaviors: “Patient banging head on the side rail, trying to grab added [sec] bit attendant, trying to get out of bed,” Patient’s Reaction to the Intervention - Patient understood the reason for the restraint: “Unknown,” Medical Condition - Any evidence of compromises: “No,” Behavioral Condition -Continued need for the restraint: “Yes.” The note instructed to See Restraint Flowsheet for complete restraint documentation and assessment. The face-to-face note lacked evidence of which restraint the evaluation was for and failed to provide a comprehensive review of P3’s condition in relation to the restraint application and continued need. P3’s subsequent 8/12/25 MD Restraint for Violent Behavior Face to Face Evaluation, identified it was conducted at 1:49 p.m., related to a restraint initiation [order renewal] at that time. This was conducted prior to the bilateral bicep restraint. The evaluation was signed by MD-G at 2:51 p.m. The evaluation contained four sections: Patient’s Immediate Situation-Patient demonstrated behaviors: “Trying to grab and kick staff trying to bite people, banging head on bed,” Patient’s Reaction to the Intervention - Patient understood the reason for the restraint: “Unknown,” Medical Condition - Any evidence of compromises: “No,” Behavioral Condition -Continued need for the restraint: “Yes.” The note instructed to See Restraint Flowsheet for complete restraint documentation and assessment. The face-to-face note lacked evidence of which restraint the evaluation was for and failed to provide a comprehensive review of P3’s condition in relation to the restraint application and continued need. P3’s nursing progress note, dated 8/12/25, identified a service time of 2:05 p.m. P3 banged her wrist against the headboard while restrained. Security was called and the wrist restraints were adjusted. P3 became increasingly aggressive and attempted to bite self and staff, kicked at bed and staff, and twisted her upper body in unnatural positions to bite herself. Bicep restraints were added to the already 4-point restraints being utilized at that time (6-point status). The provider was updated. P3’s medical record lacked a face-to-face evaluation related to the addition of the bilateral bicep restraints. P3’s psychologist progress note, dated 8/12/25, identified a service time of 3:46 p.m. P3 remained in restraints and continued to be agitated since the provider arrived around 12:00 p.m. P3 currently screamed. The provider prescribed an IM medication and assisted with a “manual hold” for the RN to administer. P3’s medical record lacked a face-to-face evaluation related to the manual hold. P3’s third 8/12/25 MD Restraint for Violent Behavior Face to Face Evaluation, identified it was conducted at 4:05 p.m., related to a 4:00 p.m. restraint initiation [order renewal]. The evaluation was signed by Doctor of Osteopathic Medicine (DO)-C at 4:53 p.m. The evaluation contained four sections: Patient’s Immediate Situation-Patient demonstrated behaviors: “Agitation, screaming, trying to kick and bite staff,” Patient’s Reaction to the Intervention - Patient understood the reason for the restraint: “No, she keeps screaming and asking for the restraints off however when they are attempted to be taken off she is violent towards staff, reports she does not understand why we won’t just take them off,” Medical Condition - Any evidence of compromises: “No,” Behavioral Condition -Continued need for the restraint: “Yes.” The note instructed to See Restraint Flowsheet for complete restraint documentation and assessment. The face-to-face note lacked evidence of which restraint the evaluation was for and failed to provide a comprehensive review of P3’s condition in relation to the restraint application and continued need. P3’s 8/16/25 Restraints flow sheet sections identified the following: -From 2:15 p.m., through 3:00 p.m., soft bilateral wrist restraints were utilized. -From 7:15 p.m., through 7:30 p.m., 6-point restraints were utilized. P3’s nursing progress note, signed 8/16/25, at 2:35 p.m., identified P3 bit herself and despite verbal redirection and opportunities to participate in the assessment and cooperate with staff’s requests, P3 continued to refuse. IM medication was given. P3 continued to be resistive to staff direction for safety and P3 was placed in wrist “soft restraints” to mitigate self-harm. P3’s medical record lacked a face-to-face evaluation related to the 2:15 p.m. soft [violent] restraints. P3’s nursing progress note, dated 8/16/25, identified the time of service at 7:10 p.m. P3 was asked to remove blankets from her head and when she failed to respond, staff removed them. In response, P3 kicked at staff. P3 bit herself with great force and failed to respond to redirection. Show of support called and staff “physically assisted [P3] in removing [her] arm from [her] mouth with difficulty.” When placed into wrist and bicep restraints, P3 began to thrash and attempted to roll off the cart, attempted to bit shoulders and staff, and thus was placed in 6-point (the initial wrist and bicep, with the addition of ankle restraints). The note lacked identification if the provider was present and/or notified of the manual hold and/or the 6-point restraint application. P3’s nursing progress note, signed 8/16/25, at 7:18 p.m., identified P3 bit herself on the right wrist and was unable to be redirected. P3 was placed in wrist and bicep restraints for her safety. P3’s subsequent nursing progress note, dated 8/16/25, and entered as a late entry by RN-H due to patient care, identified shortly after RN-H started his shift, P3’s primary RN, another staff, and her one-on-one were involved in “manually preventing [P3] from biting her wrists.” P3’s 8/16/25 MD Restraint for Violent Behavior Face to Face Evaluation, identified it was conducted at 7:30 p.m., related to a 7:17 p.m. restraint initiation. The evaluation was signed by DO-D at 9:14 p.m. The evaluation contained four sections: Patient’s Immediate Situation-Patient demonstrated behaviors: “[P3 ...was biting herself on her wrists. She did not respond to verbal de-escalation and was aggressive with staff and attempting to get her to stop. She was placed in 4-point restraints to maintain safety to herself,” Patient’s Reaction to the Intervention - Patient understood the reason for the restraint: “No,” Medical Condition - Any evidence of compromises: “No,” Behavioral Condition -Continued need for the restraint: “Yes.” The note instructed to See Restraint Flowsheet for complete restraint documentation and assessment. The face-to-face note lacked evidence that the provider also conducted the evaluation in response to the manual hold and failed to provide a comprehensive review of P3’s condition in relation to the restraint application and continued need. P12’s medical record indicated P12 presented to the ED on 3/17/26, at 4:53 p.m., with a chief complaint of behaviors in the setting of a urinary tract infection (UTI). P12 required admission. P12’s 3/20/26 Violent Restraints flow sheet section identified the following: -From 9:45 a.m., through 11:00 a.m., 4-point restraints were utilized. P12’s nursing progress note, dated 3/20/26, identified a time of service at 10:20 a.m. At 9:35 a.m., a code green was called as P12’s behavioral exit seeking escalated to the point where he crawled out of bed and continued to attempt to leave. Once staff helped him into bed, he continued to be agitated and attempted to leave again with attempts to grab at staff. P12’s 3/20/26 MD Restraint for Violent Behavior Face to Face Evaluation, identified it was conducted at 10:45 a.m., related to 9:45 a.m. restraint initiation. The evaluation was signed by MD-L at 12:26 p.m. The evaluation contained four sections: Patient’s Immediate Situation-Patient demonstrated behaviors: “Agitative/combative,” Patient’s Reaction to the Intervention - Patient understood the reason for the restraint: “Yes,” Medical Condition - Any evidence of compromises: “No,” Behavioral Condition -Continued need for the restraint: “No.” The note instructed to See Restraint Flowsheet for complete restraint documentation and assessment. The face-to-face note failed to provide a comprehensive review of P12’s condition in relation to the restraint applications and lack of continued need. P12’s 3/21/26 Violent Restraints flow sheet section identified the following: -From 6:00 p.m. through 7:30 p.m., 4-point restraints were utilized. P12’s nursing progress note, dated 3/21/26, identified a time of service at 6:56 p.m. P12 walked toward the elevator and became physically and verbally aggressive towards staff when staff attempted to redirect him. P12 swung at staff and hit staff multiple times while staff attempted to help P12 into the wheelchair as P12 had periods of losing his balance. A code green was paged and P12 was brought back to his room. He hit staff in the shoulder and security and the code green team “were able to hold patient’s arms and leg” while an IM medication was given. P12 was transferred to bed, and 4-point restraints were applied. P12’s 3/21/26 MD Restraint for Violent Behavior Face to Face Evaluation, identified it as conducted at 6:50 p.m., in response to a 6:00 p.m. restraint initiation. The evaluation identified a date/time of service for 3/21/26, at 6:57 p.m.; however, was signed by MD-N on 3/22/26, at 4:10 p.m. The evaluation contained four sections: Patient’s Immediate Situation-Patient demonstrated behaviors: “agitation,” Patient’s Reaction to the Intervention - Patient understood the reason for the restraint: “No,” Medical Condition - Any evidence of compromises: “No,” Behavioral Condition -Continued need for the restraint: “Yes.” The note instructed to See Restraint Flowsheet for complete restraint documentation and assessment. The face-to-face note lacked evidence of which restraint the evaluation was for i.e., manual hold and/or 4-point restraints and failed to provide a comprehensive review of P12’s condition in relation to the restraint applications and continued need. P14’s medical record indicated P14 presented to the ED on 3/27/26, at 3:28 p.m., with a chief complaint of mental health issues and medication reaction in setting of schizoaffective disorder, depressive type. P14’s 3/30/26 Violent Restraints flow sheet section identified the following: -From 6:43 a.m., through 6:45 a.m., a manual hold was utilized. -From 6:45 a.m., through 12:05 p.m., a restraint chair was utilized -At 6:45 a.m., seclusion started; however, from this initial entry, through 12:05 p.m., the flow sheets lacked information the seclusion continued and/or when the seclusion ended. -From 12:35 p.m., through 11:40 p.m., seclusion was utilized. P14’s nursing progress note, dated 3/30/26, identified P14 continued to be physically and verbally aggressive, “throwing fist,” swore, cursed, and yelled. A code green was called and P14 was “manually held” to administer an IM medication. Due to continued uncooperative behavior, seclusion was initiated. However, P14 refused to be walked to Wing one for seclusion and was aggressive, yelled continuously, threw fist, and kicked towards staff and thus the restraint chair was initiated, and she was put in seclusion. P14’s 3/30/26 RN Restraint for Violent Behavior Face to Face Evaluation, identified it as conducted at 7:40 a.m., related to 6:43 a.m. restraint initiation. The evaluation was signed by the RN at 3:30 p.m. The evaluation contained four sections: Patient’s Immediate Situation-Patient demonstrated behaviors: “Entering peer’s room for sex, yelling and arguing w/ another peer. Unable to follow redirection and spit at and attempted to kick and punch staff while attempting to restrain,” Patient’s Reaction to the Intervention - Patient understood the reason for the restraint: “No,” Medical Condition - Any evidence of compromises: “No,” Behavioral Condition -Continued need for the restraint: “Yes.” The evaluation indicated the provider was notified at 7:00 a.m. where P14’s status was discussed, which included the immediate situation and her reaction to the intervention, along with her medical and behavioral condition; however, the evaluation lacked details to which restraint the evaluation was in reference to i.e. manual hold, restraint chair, seclusion, and failed to provide a comprehensive review of P14’s condition in relation to the restraint application and continued need. P14’s nursing progress note, dated 3/31/26 (the day after the incident), signed at 6:55 a.m., identified P14 required seclusion on 3/30/26, at 8:30 p.m., due to continual yelling and getting into people’s faces. Due to increased verbal loudness and aggressive behavior, she was escorted to the seclusion room and was released at 11:40 p.m. P14’s subsequent 3/30/26 RN Restraint for Violent Behavior Face to Face Evaluation, identified it was conducted at 8:40 p.m., in relation to an 8:29 p.m. restraint initiation [re-order]. The evaluation was signed at 9:21 p.m. The evaluation contained four sections: Patient’s Immediate Situation-Patient demonstrated behaviors: “Screaming, not taking redirection. Pt is highly delusional. Yelling that she needs sex. Patient walked into the seclusion room willingly and staff did not have to put hands on her,” Patient’s Reaction to the Intervention - Patient understood the reason for the restraint: “Yes,” Medical Condition - Any evidence of compromises: “No,” Behavioral Condition -Continued need for the restraint: “Yes.” The evaluation indicated the provider was notified at 8:40 p.m. where P14’s status was discussed, which included the immediate situation and her reaction to the intervention, along with her medical and behavioral condition; however, the evaluation lacked details to which restraint the evaluation was in reference to and failed to provide a comprehensive review of P14’s condition in relation to the restraint application and continued need. P14’s 3/31/26 Late Entry RN Restraint for Violent Behavior Face to Face Evaluation, identified it was conducted at 6:45 a.m., related to a restraint initiation at 12:00 p.m. [re-order]. The evaluation was signed by the RN on 3/31/26, at 12:23 p.m. The evaluation contained four sections: Patient’s Immediate Situation-Patient demonstrated behaviors: “Patient relatively calm, but unable to contract for safety. Continued to express that they ‘need to have sex,” Patient’s Reaction to the Intervention - Patient understood the reason for the restraint: “No,” Medical Condition - Any evidence of compromises: “No,” Behavioral Condition -Continued need for the restraint: “No.” The evaluation indicated the RN and the provider discussed P14’s status several times throughout the day, which included the immediate situation and her reaction to the intervention, along with her medical and behavioral condition. The evaluation failed to provide a comprehensive review of P14’s condition in relation to restraint/seclusion application and lack of continued need, despite restraints documented as continued. P14’s 3/31/26 Late Entry RN Restraint for Violent Behavior Face to Face Evaluation, identified it was conducted at 7:30 p.m. (approximately 12 hours later), related to a restraint initiation at 6:45 a.m. The evaluation was signed by the RN on 3/31/26, at 10:56 a.m. The evaluation contained four sections: Patient’s Immediate Situation-Patient demonstrated behaviors: “Minimal understanding of necessity for seclusion or d/c (discontinuation) criteria. Still disorganized and occasionally yelling out and hitting door,” Patient’s Reaction to the Intervention - Patient understood the reason for the restraint: “No,” Medical Condition - Any evidence of compromises: “No,” Behavioral Condition -Continued need for the restraint: “No.” The evaluation indicated the RN and the provider discussed P14’s status multiple times throughout the day, which included the immediate situation and her reaction to the intervention, along with her medical and behavioral condition. The evaluation identified P14’s minimal understanding for seclusion; however, the restraint chair also started at 6:45 a.m. and this evaluation lacked such information and failed to provide a comprehensive review of P14’s condition in relation to the restraint/seclusion application and lack of continued need, despite restraints documented as continued. P2’s medical record indicated P2 presented to the emergency department (ED) on 3/28/26, at 2:50 a.m., with a chief complaint of chest pain and intoxication after an argument with his girlfriend. P2’s nursing progress note, dated 3/28/26, identified P2 attempted to sit up and move his head once a c-collar was placed, was non-compliant and non-redirectable, and attempted to become combative with staff, thus risking injury to himself and others. P2’s Violent Restraints flow sheet section identified the following events on 3/28/26: -From 3:23 a.m., through 4:15 p.m., locked limbs (bilateral wrist and bilateral ankles - 4-point) were utilized. -At 3:28 a.m., through 4:05 p.m., bilateral locked bicep restraints were utilized (6-point status). P2’s 3/28/26 MD Restraint for Violent Behavior Face to Face Evaluation, identified it was conducted at 3:30 a.m. The evaluation was signed by DO-B at 6:14 a.m. The evaluation contained four sections: Patient’s Immediate Situation-Patient demonstrated behaviors: “agitated, threatening staff,” Patient’s Reaction to the Intervention - Patient understood the reason for the restraint: “Yes,” Medical Condition - Any evidence of compromises: “No,” Behavioral Condition -Continued need for the restraint: “Yes.” The note instructed to See Restraint Flowsheet for complete restraint documentation and assessment. The face-to-face note lacked evidence which restraint the evaluation was for i.e., 4-point or 6-point and did not provide a comprehensive review of P2’s condition in relation to the restraint application and continued need. P11’s medical record indicated P11 presented to the ED on 3/29/26, at 7:42 p.m., with a chief complaint of being assaulted by family. P11 was an adolescent. P11’s 3/30/26 Violent Restraints flow sheet section identified the following: -At 11:00 a.m., a manual hold was utilized and discontinued. -From 11:00 a.m., through 1:00 p.m., seclusion was utilized. -From 3:26 p.m., through 3:30 p.m., seclusion was utilized. -From 3:26 p.m., through 3:30 p.m., a manual hold was utilized. -At 3:26 p.m., a spit hood was placed. The flow sheets do not identify when this ended. -From 3:30 p.m., through 6:56 p.m., 4-point restraints were utilized. P11’s nursing progress note, dated 3/30/26, identified a time of service at 11:03 a.m. P11 continued to hit the nursing station window “after being forced out of the office.” P11 was “escorted to her room,” and given medications. Around 10:45 a.m., P11 was placed in seclusion. Another P11 nursing progress note, dated 3/30/26, identified the time of service at 11:03 a.m. P11 banged on glass, yelled at staff, attempted to bite staff and hit them. IM medication was administered and P11 was placed in seclusion. P11’s 3/30/26 MD Restraint for Violent Behavior Face to Face Evaluation, identified it was conducted at 11:00 a.m., related to 11:00 a.m. restraint initiation. The evaluation was signed by MD-J on 3/30/26. The evaluation contained four sections: Patient’s Immediate Situation-Patient demonstrated behaviors: “Aggressive behavior, threats to staff. Striking windows,” Patient’s Reaction to the Intervention - Patient understood the reason for the restraint: “Yes,” Medical Condition - Any evidence of compromises: “No,” Behavioral Condition -Continued need for the restraint: “Yes.” The note instructed to See Restraint Flowsheet for complete restraint documentation and assessment. The face-to-face note lacked evidence which restraint the evaluation was for i.e., manual hold and/or seclusion and failed to provide a comprehensive review of P11’s condition in relation to the restraint applications and continued need. P11’s MD-J provider note, dated 3/30/26, indicated a date of service at 2:13 p.m., and was signed at 3:38 p.m. At approximately 3:15 p.m., a second code green was called as P11 hit her head against the wall. P11 became aggressive and attempted to hit staff and spit at them. A third alert was called and P11 was provided an IM medication. She was “placed in restraints in a secluded room.” P11’s subsequent nursing progress note, dated 3/30/26, identified P3 destroyed hospital property by peeling labels from the walls. She lunged at the nurse. A security officer and another staff “assisted writer in helping [P11] return to room.” P11 grabbed, scratched, bit, and spit at staff. A code green was initiated, and the spit hood was reapplied. IM medication was administered and P11 was “assisted” to her room. The spit hood was removed, and seclusion was initiated. However, she started to destroy a wall panel and thus a manual hold was conducted by security, and the spit hood was applied. P11 was assisted to bed and “restrained to bed.” The spit hood was removed prior to staffs exit from the room. P11’s subsequent nursing progress note, dated 3/30/26, identified P11 was upset and yelled out while security was present. P11 was not receptive to verbal de-escalation, or redirection. The writer, P11’s primary nurse, and a security officer, attempted to escort P3 back to her room. P11 flailed and attempted to bite and swing at staff. While P11 was escorted back to her room, she dropped her weight to the ground and attempted to spit and kick at staff. Code green was called, and a spit hood was placed, and an IM medication was administered. She was escorted back to her room and placed in seclusion at 3:26 p.m. Due to P11’s “picking at flooring and wall,” and her ability to remove a “large piece of wall,” she was removed from seclusion and placed in restraints at 3:30 p.m. as she was unable to keep herself safe. P11 was administered another IM medication. P11’s subsequent 3/30/26 MD Restraint for Violent Behavior Face to Face Evaluation, identified it was conducted at 3:30 p.m., for a 3:30 p.m. restraint initiation. The evaluation was signed by MD-J at 3:33 p.m. The evaluation contained four sections: Patient’s Immediate Situation-Patient demonstrated behaviors: “Aggressive behavior, physically threatening staff. Attempting to spit [and] bite staff. Hitting her head against the wall,” Patient’s Reaction to the Intervention - Patient understood the reason for the restraint: “Yes,” Medical Condition - Any evidence of compromises: “No,” Behavioral Condition -Continued need for the restraint: “Yes.” The note instructed to See Restraint Flowsheet for complete restraint documentation and assessment. The face-to-face note lacked evidence of which restraint the evaluation was for i.e., manual hold, spit hood, and/or 4-point restraints, and failed to provide a comprehensive review of P11’s condition in relation to the restraint applications and continued need. P11’s nursing progress note, dated 3/31/25, signed at 9:03 a.m., identified P11 was resistive to cares. She swung her arm away from the RN when the blood pressure cuff attempted to be placed. P11 stated, ‘Shut up! You are not my boss.’ “Arm held in place and BP cuff placed for a reading.” P11 pulled finger away from the pulse oximetry so a manual pulse was taken by the RN. P11’s nursing progress note, dated 4/6/26, identified a time of service at 5:18 p.m. P11’s behaviors escalated, and she blocked staffs’ ability to enter and exit unit areas. During such an episode, when she refused to allow staff entry, despite numerous attempts to redirect her, P11 flailed and struck out at staff. A show of support was called, and she was “escorted back to her room all the while attempting to scratch, hit, and bite staff.” After P11 agreed to accept an oral medication to assist with behavior management; however, when the nurse went to obtain the medication, P11 again blocked the nurse and began to push, grab at, and succeeded in digging her nails into the nurse’s skin. P11’s nursing progress note, dated 4/6/26, identified the time of service at 7:49 p.m. P11 became restless in the hall and ran up and down the halls, attempted to enter other patients’ rooms, and attempted to enter the nurse’s station, where she attempted to grab onto staff. As the unit door opened, P11 sprinted through the doors, and was “promptly stopped by staff in the hall and brought back to the suite.” P11’s medical record lacked evidence of face-to-face evaluations related to the 3/31/26 and 4/6/26 hands-on interactions. P13’s medical record indicated P13 presented to the ED on 4/1/26, at 3:02 p.m., with a chief complaint of muscle spasms, agitation, and behavioral dysregulation. P13’s 4/1/26 Violent Restraints flow sheet section identified the following: -From 3:02 p.m., through 3:56 p.m., 4-point restraints were utilized. P13’s nursing progress note, dated 4/1/26, and signed 3:09 p.m., identified P13 yelled, spit at, and hit ambulance personnel. “Four-point restraints” were applied. P13’s 4/1/26 MD Restraint for Violent Behavior Face to Face Evaluation, identified it conducted at 3:02 p.m., related to restraint initiation at that time. The evaluation was signed by MD-F at 3:44 p.m. The evaluation contained four sections: Patient’s Immediate Situation-Patient demonstrated behaviors: “Agitation, Spitting, Scratching,” Patient’s Reaction to the Intervention - Patient understood the reason for the restraint: “No,” Medical Condition - Any evidence of compromises: “No,” Behavioral Condition -Continued need for the restraint: “No.” The note instructed to See Restraint Flowsheet for complete restraint documentation and assessment. The face-to-face note failed to provide a comprehensive review of P13’s condition in relation to the restraint applications and lack of continued need, despite the restraint lasting until 3:56 p.m. (54 minutes after the evaluation). P15’s medical record indicated P15 presented to the ED on 4/6/26, at 2:33 a.m., with a chief complaint of alcohol poisoning and withdrawal. P15’s 4/6/26 Violent Restraints flow sheet section identified the following: -From 9:35 a.m., through 11:15 a.m., 4-point locked restraints were utilized. P15’s nursing progress note, dated 4/6/26, identified a code green was called at 9:06 a.m. in response to P15’s behavioral dysregulation and visual hallucinations and 4-point restraints were applied at 9:35 a.m. P15’s 3/21/26 MD Restraint for Violent Behavior Face to Face Evaluation, identified it was conducted at 9:35 a.m., related to the 9:35 a.m. restraint initiation. The evaluation was signed at 10:22 a.m. by the provider. The evaluation contained four sections: Patient’s Immediate Situation-Patient demonstrated behaviors: “agitated, DT, fighting with staff,” Patient’s Reaction to the Intervention - Patient understood the reason for the restraint: “No,” Medical Condition - Any evidence of compromises: “No,” Behavioral Condition -Continued need for the restraint: “Yes.” The evaluation failed to provide a comprehensive review of P15’s condition in relation to the restraint application and continued need. When interviewed on 4/13/26, at 1:00 p.m., RN-K, an emergency department (ED) manager, stated that ED providers do the face-to-face evaluations within one hour of restraint initiation. This process and associated documentation triggered when the provider placed the order. RN-K explained ED restraint audits were conducted “every day,” by herself or a colleague in response to a notification they received when an order was placed; however, later stated they attempted to conduct these audits “every week” to stay on top of the process. Recently, the audits were free of identified restraint concerns. When interviewed on 4/15/26, at 11:40 a.m., DO-F stated once the restraint order was placed, a face-to-face evaluation was triggered. When a patient required two separate restraints, the face-to-face process depended on the timeline of initiation, but he stated each restraint would have its own evaluation completed within an hour of initiation. The purpose of the face-to-face was to ensure patients were restrained properly, to ensure they were safe, and to verify if the restraint needed to remain, or could be removed. When interviewed on 4/15/26, at 2:39 p.m., MD-G stated once he placed a restraint order, there was a hard stop for the completion of a face-to-face evaluation. This was required to be completed within an hour of the restraint initiation. Additionally, the evaluation documentation was also expected within that time. The evaluation was a drop-down formatted note where he was to enter the behaviors present at that time and if the patient understood the reason for the restraint. Overall, the process was to assess the patient for restraint associated concerns. MD-G stated the documentation of the evaluation was necessary to ensure the event could be reviewed retroactively and see what happened. MD-G was questioned on P3; however, he lacked remembrance of her. He reviewed P3’s medical record and was unable to find the 8/16/25 face-to-face evaluation documentation. When interviewed on 4/16/26, at 11:04 a.m., MD-C stated the order process triggered the face-to-face evaluation that she was required to complete within an hour of restraint initiation. The face-to-face process was important to help reinforce there was a patient involved and to emphasize the significance of what the restraint was to the patient. Additionally, the face-to-face process assisted to determine if there were compromises to the patient’s limbs, what behaviors were exhibited, if the patient understood the need for the restraint, and if there was continued need for the restraint after conferring with the nurse. She stated a manual hold for things such as IM medication administration in a behavioral situation was a restraint and required a face-to-face evaluation. MD-C reviewed P3’s chart and remembered her. After reviewing the record for her time with P3, she stated staff should have alerted her to the manual hold so that her processes could have been followed as this was considered a restraint. On 4/16/26, at 11:27 a.m., restraint record review began with RN-F (quality advisor), RN-D (mental health clinical nurse specialist - restraint auditor), and RN-E (clinical nurse specialist - restraint auditor). The records of P2, P3, P11, P12, P13, P14, and P15 were reviewed. In summation, RN-E identified a manual hold of any kind, was considered a restraint and she expected an order, a face-to-face, and appropriate restraint documentation. RN-E expressed concerns when the timelines of restraint documentation processes were entered into the record and stated documentation was expected to be entered as close to the designated monitoring times as able. Additionally, the face-to-face evaluations should also be completed/signed closer to the actual time of the evaluation. RN-E identified each department conducted their own restraint audits. She indicated she was unsure how robust these audits were and stated that was each department’s responsibility. Once the audits were completed, the information was shared monthly. RN-D stated the mental health units do the audits; however, she did not think they got to the pieces related documentation filing. RN-E stated that was not something they emphasized. RN-E agreed. Both RN-E and RN-D stated there was not any recent education related to the overall concerns identified with the review. In response to the patient review, they both indicated they would change their education and processes. When interviewed on 4/16/26, at 4:38 p.m., MD-A, one of the ED medical directors, and the chief of staff, stated all restraint initiations required an order, this included a manual hold. If a restraint was utilized, he expected to receive a secure chat message related to that so that he placed an order and completed a face-to-face evaluation. When he was updated about the patients who lacked a face-to-face evaluation after the order was placed, this surprised him as it was part of the order process. MD-A was unaware of any trends related to the face-to-face not being completed, but he was aware of some concerns related to the timeline designations of the face-to-face timing. Overall, MD-A expected the evaluation to be completed within an hour of the restraint initiation, which was not hard as they were present for the code green events, or there very shortly after. He stated the providers were trained to complete this process when they were in the room with the nurse and the restraint was being applied. MD-A stated this evaluation was important as the process helped to ensure patient medical safety. Related to restraint audits, MD-A reported there were designated staff that did that, and he was provided information when needed, such as patterns/trends. He was unable to recollect the last time he was provided feedback on any provider performance issues. When interviewed on 4/17/26, at 10:00 a.m., MD-B, one of the ED medical directors, stated the face-to-face was expected to be completed within one hour of the restraint initiation. Best practice centered around as soon as the provider could leave the bedside as everything was still fresh in their minds. MD-B stated a provider was expected to be present during a code green, which assisted in the ability of the providers to manage the orders and/or the face-to-face process. MD-B stated she did not do restraint audits; however, she was provided with information from nursing leaders, or the risk department, if concerns were identified. She denied knowledge of restraint concerns over the last month or so and was unaware of missed face-to-face evaluations. During a subsequent interview on 4/17/26, at 11:55 a.m., with RN-K, she stated that once she and her colleague started to see restraint process concerns, they developed an audit process that was more informal and internal, and not one defined by the facility. She stated, once the audit was conducted, the audit forms were not retained. RN-K explained, once an order was placed, her colleague received a notification and then they audited the process to ensure things were appropriately completed. If concerns were identified, the staff were followed up in real time. During the audits, order timeliness was audited to ensure the order was placed within 60 minutes of initiation. RN-K was unsure whether the facility restraint auditors were aware of her own auditing process. She stated she was sent a monthly audit report from those staff, and she was unaware of any trending concerns in the past couple of months. A Restraint/Seclusion - Management of Violent and/or Self-Destructive Behavior policy, dated June 2025, identified the patient had the right to be free from restraint or seclusion, of any form and may only be used to ensure the immediate physical safety of the patient, staff, or others and must be discontinued at the earliest possible time. Only clinical staff were allowed to determine restraint or seclusion use. The use of restraint or seclusion must be based on a comprehensive, individualized assessment of present facts and circumstances. The policy defined a physical restraint as “any manual method, physical or mechanical device ...that immobilizes or reduces the ability of the patient to move their arms, legs, body, or head freely.” This included physical escort: ‘light grasp,’ to escort the patient to a desired location which the patient cannot easily escape from; physical holding: holding a patient in a manner that restricts their movement against their will which included holds that some members of the medical community termed ‘therapeutic holds’; spit hoods: temporary intervention to reduce the spread of contaminants through saliva or other bodily fluids through the mouth. A Face-to-Face Assessment (In-person Evaluation) section identified that when restraint or seclusion was ordered, the patient must be assessed face-to-face by a licensed provider within one hour of the restraint initiation and at subsequent intervals as detailed in site specific policies/procedures. A copy of site-specific details was provided; however, due to the facility not having any, was not provided. The required face-to-face assessment may be performed by a trained and qualified RN. The face-to-face assessment must address each of the following elements: The patient’s immediate situation; The patient’s reaction to the intervention; The patient’s medical and behavioral condition; and the need to continue or terminate the restraint or seclusion. The face-to-face assessment must include both a physical and behavioral assessment of the patient and an evaluation of the patient’s medical condition that included a complete review of systems, behavior, history, drugs and medications, most recent lab results, etc. The purpose was to complete a comprehensive review of the patient’s condition to determine if other factors, such as drug or medication interactions, electrolyte imbalances, hypoxia, sepsis, etc., may have contributed to the patient’s violent or self-destructive behavior. If a patient’s behavior resolved and the restraint or seclusion intervention was discontinued before the face-to-face evaluation was able to be completed, the evaluation was still required. If the face-to-face evaluation was conducted by a trained RN, the RN must consult the practitioner within 30 minutes after the evaluation was completed, or before renewal of an order for restraint or seclusion, whichever is earlier, to report the findings of the evaluation and to discuss the need for other interventions or treatments and to either continue or discontinue the restraint or seclusion.”

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 43080 Based on interview and document review, the facility failed to re-evaluate and reconcile discharge medication orders and determine the discharge discrepancy for 1 of 7 patients (P5) reviewed for discharge medication processes. As a result, P5 was discharged with an order for Dexamethasone (steroid), which was 20 times higher than the initial discharge order documented by the doctor. P5 subsequently passed away 11 days after discharge from a gastrointestinal (GI) bleed. This has the continued potential to impact patients who required re-evaluation of their medications when discharge plans were modified. Findings include: P5’s History and Physical, dated 12/3/25, completed by Doctor of Osteopathic Medicine (DO)-A, identified P5 admitted from the clinic where she was noted to be hypotensive (low blood pressure) and atrial fibrillation with rapid ventricular rate (RVR - high irregular heartbeat). She was admitted for severe sepsis secondary to community acquired pneumonia. P5’s home medications included omeprazole (medication to reduce stomach acid); however, the note did not indicate a reference to reason for taking and/or evidence of prior GI bleed and/or GI ulcers. An Oncology Progress Note, dated 12/8/25, by medical doctor (MD)-H, identified P5 was suspected to have metastatic (spreading) [cancer] of the right upper lung with concerns this had spread to her liver and bones. Chemotherapy was discussed and agreed upon in an outpatient setting. An initial order printout, identified that on 12/8/25, at 3:57 p.m., P5 was ordered, as an outpatient order, dexamethasone 4 milligrams (mg) by mouth “ever [sec] 12-6 hours” prior to paclitaxel per MD-H. This was ordered to have 10 tablets dispensed with three refills. However, embedded with this order were details that identified a registered nurse clinician (RN)-X discontinued the order on 12/11/25 at 1:22 p.m., per a verbal order from DO-A. A Discharge Summary, dated 12/10/25, completed by DO-A, identified P5 was planned to discharge that day. Her principal diagnosis included severe sepsis secondary to pneumonia, along with a possible COPD (chronic obstructive pulmonary disease) exacerbation, and a new finding of a large right upper lobe mass found to be metastatic (spreading) cancer. At that time, P5’s plan was to discharge home with her daughter and follow up with oncology for chemotherapy in the outpatient setting. Her first chemotherapy session was to begin on 12/19/25. Due to P5’s identified continued issues with atrial fibrillation, her metoprolol was increased, and she was started on digoxin. The discharge summary lacked mention of a GI bleed or GI ulcer concerns. A follow up appointment with outpatient oncology on 12/17/25 for lab work and provider visit were set up. The Discharge medications section identified the following medication administration directions: -Dexamethasone 4 mg, one tablet by mouth “ever 12-6 hours” prior to paclitaxel (chemotherapy). -Doxycycline (antibiotic) 100 mg twice a day for five days to treat her pneumonia of the right upper lung lobe. -Olanzapine (antipsychotic medication) 2.5 mg once a day at bedtime with instructions to take four days starting day one of chemotherapy for nausea. -Digoxin 125 mcg (micrograms) once a day. -Metoprolol 100 mg twice a day. -Omeprazole 20 mg once daily before a meal. P5’s After Visit Summary (AVS - patient discharge instructions), identified to be printed by registered nurse (RN)-W on 12/10/25, at 5:04 p.m., indicated P5 was to start taking dexamethasone. The AVS directed P5 to take dexamethasone 4 mg (milligrams) by mouth every “12 to 6” hours prior to paclitaxel (chemotherapy). A column time section adjacent to the order identified a check box in the Morning, Afternoon, Evening, and Bedtime time spots where under each check mark an entry of “5 tablets” was noted. The additional medication directions in the discharge summary were also identified on the AVS. A Progress Note, dated 12/11/25, completed by DO-A, identified P5 had not discharged on 12/10/25 as the daughter determined she was unable to care for P5 at home, and that P5 declined home care services. A Modify order printout, identified that on 12/11/25, at 1:22 p.m., RN-X adjusted the initial dexamethasone order (4 mg) per verbal order from DO-A. The modified outpatient order directed P5 to take “5 Tablets (20 mg) by mouth every 6 hours,” due to an associated diagnosis of COPD. DO-A authenticated this order on 12/13/25 at 10:40 a.m. A Gastroenterology Progress Note, dated 12/14/25, identified P5 experienced black stool (potential indicator of blood) on 12/10/25. P5 reported she was anemic all her life. There had been no overt GI bleeding. Her last colonoscopy was almost 30 years ago. A colonoscopy was ordered. A Cardiology progress note, dated 12/15/25, identified P5 required re-consultation with cardiology due to ongoing issues with atrial fibrillation and the need for medication management. On 12/13/25, P5 was noted to be bradycardic (fewer than 60 heart beats a minute) so the metoprolol succinate 100 mg twice a day was held. After, she went back into atrial fibrillation with elevated heart rates and thus metoprolol tartrate 25 mg three times a day was started. She required an extra dose of 25 mg that morning with improved heart rates; however, P5 expressed she was completely asymptomatic from a cardiovascular standpoint. The provider recommended P5 resume metoprolol succinate 50 mg twice a day and to titrate slowly if needed for rate control. The provider identified P5 may not tolerate 100 mg twice a day. Additionally, the provider discontinued P5’s digoxin order as it was not helpful at that time. P5’s Medication Administration Record (MAR) identified the following medication administrations: -Dexamethasone was not administered during the hospital stay. -Digoxin was last administered on 12/14/25, at 4:23 p.m. (five days prior to discharge). -Doxycycline was last administered on 12/15/25, at 5:24 a.m. (four days prior to discharge). -Metoprolol succinate 50 mg twice a day was administered from 12/15/25, through 12/19/25 (discharge). A progress note dated 12/18/25 completed by MD-M identified P5’s discharge was delayed as P5 declined short term rehab and home care services, along with chemotherapy, despite initial agreement to the cancer treatment. After this, palliative care was consulted, a meeting was held with P5 and family, and a decision was made to pursue short term rehab with the goal of chemotherapy once stronger. Initially, after GI was consulted, P5 refused a colonoscopy for the blood in her stool as she wished to go on hospice (end of life) care. With another change in her care goals to wanting short term rehab, she agreed to the GI workup. On 12/16/25, the workup identified non-bleeding duodenal ulcers (sores) and polyps (small growths) but no active GI bleeding. In the note’s assessment/plan section, the following were identified: -P5 restarted doxycycline on 12/11/25 for persistent leukocytosis which was discontinued on 12/13/25. A repeat infectious workup was negative. Additionally, this section identified P5 previously in her stay completed a five-day treatment for COPD with acute exacerbation and such was resolved. -P5’s physical exam identified normal breath sounds with a normal pulmonary effort [no signs/symptoms of active respiratory infection or continued COPD exacerbation]. -No indication the digoxin was discontinued on 12/15/25. -No indication the metoprolol was adjusted to metoprolol succinate 50 mg twice a day on 12/15/25. A Discharge Summary, dated 12/19/25, completed by MD-M, identified P5 was discharged to a transitional care unit (TCU)/skilled nursing facility (SNF). The principal diagnosis was the right lung cancer. The additional diagnoses list lacked a GI bleed diagnosis; however, the note identified the GI ulcers and polyps and indicated she was started on twice daily proton pump inhibitor (reduce stomach acid production). Additionally, a section labeled Recommendations for Outpatient Provider, identified the new lung cancer and “GI bleed” and duodenal ulcer. P5’s rehab potential was identified as “Good.” The Discharge Medications section identified the following: -Dexamethasone 4 mg “ever [sec] 12-6” hours prior to paclitaxel (no longer applicable due to declining chemotherapy). -Doxycycline 100 mg twice a day for five days for the pneumonia of the right upper lung lobe (no longer applicable as order was completed due to continued hospital stay and no active respiratory infection at discharge). -Digoxin 125 mcg once a day for atrial fibrillation with RVR (discontinued on 12/15/25). -Olanzapine 2.5 mg daily at bedtime with instructions to take four days starting day one of chemotherapy for nausea (no longer applicable due to declining chemotherapy). -Omeprazole 20 mg once daily continued. -This section lacked a twice a day proton pump inhibitor order. -Metoprolol succinate 100 mg twice a day for atrial fibrillation with RVR (order changed to 50 mg twice a day on 12/15/25 with provider cautioning P5’s ability to tolerate the 100 mg twice a day dosing). P5’s Discharge Summary, dated 12/19/25 from the hospital to the TCU/SNF After Discharge Orders, dated 12/19/25, identified the following medication administration directives: -Dexamethasone 4 mg tablets: take 5 Tablets (20 mg) by mouth every 6 hours” for COPD. -The dexamethasone 4 mg prior to chemotherapy was not identified. -Doxycycline for the pneumonia; however, the order lacked the discharge summary’s five-day length of time for administration. -Digoxin once daily. -The olanzapine for chemotherapy induced nausea. -Pantoprazole (proton pump inhibitor) twice daily. -The omeprazole (proton pump inhibitor) as per home order. -Metoprolol succinate 100 mg twice a day. -Additionally, the orders identified a follow up appointment with outpatient oncology on 12/17/25 for lab work and provider visit. P5’s TCU/SNF medical records identified the following: -12/19/25, the facility received an order to hold the olanzapine while at the facility. -12/22/25, a pharmacist reviewed P5’s medications and recommended consideration to discontinue either the pantoprazole or the omeprazole to “avoid adverse effects [increased risk of side effects and can mask serious underlying conditions].” P5’s TCU/SNF Medication Administration Record (MAR) identified the following: -Dexamethasone 20 mg every six hours was administered on 12/19/25, at 6:00 p.m., through 12/23/25 at 6:00 p.m., for a total of 17 doses, and then again from 12/24/25, at 6:00 p.m., through 12/28/25 at 12:00 a.m., for a total of 14 doses. Combined, P5 received 30 doses of dexamethasone at 20 mg each administration. -Doxycycline was administered from 12/19/25, through 12/27/25. -Eliquis (blood thinner), at 5 mg twice a day, was administered from 12/19/25, through 12/27/25. -Pantoprazole was administered from 12/19/25, through 12/27/25. -Metoprolol succinate was administered from 12/19/25, through 12/27/25. -Omeprazole was administered from 12/20/25, through 12/27/25. -Digoxin was administered from 12/20/25, through 12/27/25. -On 12/27/25, calcium carbonate (antacid) was administered at 2:55 p.m. for an upset stomach. -On 12/27/25, Ondansetron HCL (prevents nausea and vomiting) was administered at 6:19 p.m. for nausea and vomiting. P5’s TCU/SNF progress notes identified the following: -12/26/25, P5 required increased assist with transfers due to inability to stand and she reported ‘I am feeling icky.’ She was nauseated and lightheaded after the transfer. -12/28/25, P5 was weak, tired, and did not want to do much moving in bed or out of bed. -12/29/25, P5 had a change in status with hallucinations and increased weakness, along with not knowing time or situation. She complained of an upset stomach and refused interventions. Provider was updated and she was transported to a hospital at 5:20 a.m. -12/31/25, P5 passed away on 12/30/25 while at the hospital. P5’s Minnesota Documentation of Death record indicated, on 12/30/25, at 8:36 p.m., P5 passed away with the immediate cause of death related to an upper GI bleed. Additional diagnoses were identified as sepsis, hyperkalemia, and acute kidney injury. A Department of Medicine meeting minutes, dated 3/5/26, identified the medical director of safety and quality for internal medicine (MD)-E provided an update to the medical providers and the advanced practice providers who were in attendance. The minutes indicated she “ ...emphasized the need to carefully review discharge medications, especially comment sections, to prevent errors.” DO-A was present; however, MD-M was not. When interviewed on 4/9/26, at 11:08 a.m., family member (FM)-A stated the hospital decided to discharge P5 on 12/10/25; however, the hospital failed to provide accurate details related to P5’s status to family, which would have risked P5’s safety at home as she required more assistance than was reported. From her understanding, the hospital discharge paperwork that was given to the TCU/SNF on 12/19/25 were the discharge orders that were prepared for P5’s 12/10/25 discharge. FM-A stated someone should have caught this, especially as the dexamethasone was “way too much.” FM-A stated she was not present for P5’s discharge and was unsure whether the hospital nurse went over the paperwork with P5 before going to the TCU/SNF. Upon P5’s discharge from the hospital, P5 was alert/oriented, and the plan was for her to get stronger, return home, and begin chemotherapy. FM-A explained, initially at the TCU/SNF, P5 did well; however, due to the dexamethasone, she went downhill very fast. FM-A stated after the TCU/SNF transferred P5 to the emergency department, the provider there contacted family and informed them P5 was over medicated based on information that provider reviewed in P5’s hospital records. FM-A stated that P5 “should be here right now, but because of such a buildup of steroid,” and the hospital’s inability to just stop the steroid when she got to the emergency department as this needed to be weaned to prevent adrenal shut down, she was not. On 4/15/26, at 10:11 a.m., the facility’s investigation was reviewed with risk manager (RM)-A, accreditation specialist (AS)-B, and patient safety and quality advisor (QA)-B. RM-A stated risk management was updated on 2/13/26, at 11:32 a.m., by MD-M, after MD-M spoke to a Minnesota Department of Health (MDH) surveyor and was informed P5 passed away after a medication error. This was the first time the facility was aware of the concern. RM-A denied that a grievance was filed with the facility. Due to the “high concern” of this case, the facility conducted a SERT (severity event review team) review with a goal of determining gaps, and if there were gaps, did they reach the patient, and was the outcome related to the gaps. RM-A explained this concern went through the SERT process on 2/16/26, with another discussion on 2/19/26. The review was marked as complete on 2/24/26 and because “There were gaps that did impact the patient,” the event became an RCA (risk cause analysis) process. QA-B stated that on 3/4/26, the RCA was entered initially into their Riskonnect system (risk management software) with their first RCA meeting held on 3/9/26 (25 days after the concern was initially reported.) At this meeting, they reviewed the details of the event and determined interviews needed. QA-B identified that some of the interviews had occurred; however, due to personal time off (PTO), staff being out of the office, and a Joint Commission (accreditation) survey that occurred 3/23/26, through 3/26/26, not all the staff identified were yet interviewed. QA-B was unable to state information from an interview with MD-M as he had yet to be talked to due to MD-M being on vacation. QA-B stated a second RCA meeting occurred on 4/14/26 (after the current survey process began), where they discussed the learnings from the interviews they had conducted with attempts to establish root causes. A meeting was set up for 4/21/26 to establish an action plan. Based on their interviews with staff, the concern was “multifactorial.” There were family dynamics when it came to P5’s discharge, which delayed the original discharge after the discharge orders were already placed, and then because the discharge location changed, a diagnosis for the medication order was needed, and thus added in which something occurred where the dosage was changed and the order was available and carried forward for her discharge on 12/19/25. Due to the time lapse, staffs’ memories were not remembering the situation. QA-B explained, when a patient discharged home, the AVS was gone over with them; however, when the patient discharged to a TCU/SNF, the AVS was not reviewed with the patient at the time of discharge. In those situations, it was just sent to the facility. The error was reviewed and identified that on 12/8/25, MD-H added the original dexamethasone order for 4 mg prior to chemotherapy. On 12/11/25, RN-X adjusted the order. After this adjustment, the order changed to reflect the 20 mg every six hours. QA-B stated, the way it should have worked was for the initial order to be discontinued “in the back end” and it should have placed the new verbal order, which should have carried over the original order details, for the provider to acknowledge. “Somehow in the process the dosage got changed.” RM-A identified they worked on a larger analysis related to discharge medication reconciliation errors; however, this was only in the identification stage at this time to determine which cases have such issues so that they can go forward and figure out what happened. RM-A stated medication reconciliation errors have occurred, but he has not seen this type of situation before. QA-B identified, based on what they know so far, nothing was put into place to mitigate this error from recurring, other than this issue being brought to a hospitalist meeting where MD-E discussed it. RM-A stated he had a hard time believing this issue arose from a software concern and felt it was more likely to have been a human error instead: Ultimately, P5’s medications were not reconciled appropriately by the provider at discharge. When interviewed on 4/15/26, at 12:15 p.m., MD-E stated she was aware of P5’s case; however, she was unsure what occurred. She explained, she reviewed P5’s chart where the initial dexamethasone order did not completely make sense as there appeared to be a typo. After, when P5 was getting ready to discharge, RN-X changed the order, which appeared to be went the error occurred. This order also did not make sense. MD-E stated RN-X was unable to recollect these actions but thought maybe she had adjusted the diagnosis, as a nursing home required such. Typically, the nurse clinicians did not place medication orders, to help avoid errors. MD-E stated during an email conversation with DO-A, DO-A did not recollect providing an order to change the dosing. MD-E stated it appeared as if DO-A went in a few days later and “batch signed” orders and had not been aware of any possible errors. MD-E stated she had yet to converse with MD-M about the error. She thought maybe MD-M had not recognized the order was there as the first batch of discharge orders would have been from the first physician and already completed; however, the discharging physician was still required to reconcile the medications at discharge. In follow up of this concern, MD-E identified she brought concerns to their department meeting on 3/5/26. There, she discussed a reminder to not utilize the nurses for verbal discharge medications. Additionally, she talked to the nurse clinicians to be more careful with orders. Other than participating in some meetings surrounding the event, no additional actions were taken to mitigate the concern from recurring. MD-E stated the initial dexamethasone order was reasonable; however, 20 mg every six hours was “quite high.” Additionally, she did not see dexamethasone used for COPD; however, after she calculated a dose adjustment based on a typical COPD prednisone (steroid) 40 mg once a day dosing, the equivalent was 5 mg of dexamethasone. MD-E explained that 20 mg every six hours “certainly could delay healing of ulcers,” and could contribute to GI bleeding. When interviewed on 4/15/26, at 3:01 p.m., MD-D stated that after P5 was found to have cancer, hematology was consulted, and chemotherapy was agreed upon. After, hematology ordered the original dexamethasone order for the 4 mg; however, she stated she was not aware of the dexamethasone script during the time she cared for P5. After the initial chemotherapy decision, P5 changed her mind and did not want it, but wanted more of a palliative approach. P5 then decided to discharge to short term rehab. MD-D was unsure what occurred with the dexamethasone order in relation to those decisions. MD-D identified P5 started on a blood thinner for her atrial fibrillation and developed a GI bleed. Additionally, she was treated with steroids for COPD. MD-D was unsure whether the GI bleed was related to cancer, the medications, or something else, but stated even a 4 mg dose can cause gastric lining irritation and GI bleeding. This, in addition to the blood thinner P5 took, “definitely” increased the risk even more. “It was not all a good mix.” MD-D stated P5 took a proton pump inhibitor which offered a little protection for a GI bleed; however, that “really means nothing in this care.” While P5 determined if she wished to go forward with a colonoscopy, another hospitalist picked up P5’s care and she had no additional interactions with P5. After the order concerns were brought forward, MD-D reviewed P5’s chart and identified RN-X had placed a verbal order under her name which changed the original 4 mg order. MD-D stated she never would have ordered such a high dose and this error significantly upset her. There seemed to be missed communication, and she was not informed. She was unsure how this error occurred and how it got past so many checkpoints where it should have been discovered. MD-D explained, the typical process was for the nurse to put in the non-medication related discharge orders and then she was to sign them, but when she “just signs them, there may be “80 of them.” She had since changed her habits, and she now went through each order. MD-D identified 20 mg of dexamethasone every six hours was “intense,” and not an appropriate dose: “It does not take a super educated provider, nurse, or pharmacist to flag this.” MD-D explained the facility had conducted some interviews and provided some reminders at meetings, but other than that, was unsure what else was done. An interview was attempted with RN-X during the survey process; however, it was unsuccessful. On 4/16/26, at 2:36 a.m., an interview with MD-M was attempted without success; however, he returned the call on 4/21/26, at 9:15 a.m. MD-D identified he was away from work for approximately the past month and had since returned. The number he called from was a facility number. He explained he was made aware of the dexamethasone concerns when an MDH surveyor contacted him. After that call, and after being updated P5 passed away, he called risk management and left a voicemail with the information. He stated he continued to work after that, before he went on vacation, and that he had not talked to anyone about the situation since he left the voicemail. He reviewed his phone and messages and denied any attempts from the facility to contact him while he was on vacation. MD-M explained, from what he did remember, P5 was planned to discharge before he took over her care. When he took over, all the discharge orders were already put in and filled out. Due to this, he did not go through each order like he normally did, which he was expected to do. In such situations, discharge medication reconciliation processes were “a little tricky,” and not as straight forward as just reviewing the discharge navigator tab in the medical record for home medications, and the medications they received during their admission, and then clicking which orders he wanted to stay, or which ones needed to go. In P5’s situation, he would have had to go through her medication orders “piecemeal.” MD-M reviewed P5’s chart and stated the initial dexamethasone 4 mg order was an acceptable order, which he could see when he looked at his discharge note; however, the 20 mg every six hours was not identified and was only seen when he looked in other places. He stated that modified order was “way too big a dose without an end point.” He explained, in a COPD exacerbation, that it may have been acceptable, but such an order would have only lasted for 24 hours. MD-M stated that based on what was expected when it came to discharge medication reconciliation, despite the event situations, he took responsibility for the error. A Hospitalist Discharge Order Planning policy, dated 7/17/24, directed the nurse to institute the appropriate discharge orders according to the reason for admission, consultation with the discharging hospitalist, and relevant progress notes. Orders were to be entered as ‘provider cosign required’ with the discharging hospitalist listed as the ordering physician. The discharging physician then electronically signed the order in the electronic ordering system once the patient was seen and/or cleared for discharge. A Discharge Medication Reconciliation policy, dated 11/18/24, defined discharge medication reconciliation as the process by which an accurate accounting of medications to be taken was provided to the patient upon discharge. The policy provided the following guidelines to provide a safe, efficient provision of patient care when preparing a patient for discharge: -The primary service was responsible for completing the discharge medication reconciliation. -Any consulting service should have recommendations for specific discharge medications, including name of medication, dose, duration, and monitoring or follow up plan documented in a progress note in the patient chart by 8 p.m. on the night prior to planned discharge. -If a consulting service recommended a change to a discharge medication on the day of discharge, the consulting service was responsible for completing the discharge prescription for this medication and for notifying the primary service this change was made. -A consulting service may elect to prescribe specific discharge medications if the consulting service and the primary service agree. If there was a disagreement, the primary service had final decision-making capacity for discharge medications. A Discharge Planning/Discharge Patients policy, dated February 2025, identified the facility was dedicated to meeting patients’ health care needs with a comprehensive continuum of care with proactive discharge planning to address continuing needs, treatment, and services after discharge. The policy indicated individualized discharge planning included reassessment of the patient’s needs throughout their continuum of care. The policy directed the facility provide discharge instructions and appropriate resources, based upon assessed patient needs, which included, but not limited to, follow-up appointments, medications, any specific instructions, or treatments, etc.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 43080 Based on observation, interview and document review the hospital failed to ensure cleanliness of the emergency department (ED) and labor and delivery (L&D) room baby warmers were free from dust particles for 8 of 45 ED rooms, two hallway areas (1, 2, 4, 5, 24, 34, 37, 39, top of cabinets for duress badges, top of housing for electrical EKG power supply), and on 10 of 13 L&D room baby warmers (2, 3, 4, 5, 6, 7, 8, 10, 11, 12) visualized for cleanliness. Findings include: An Emergency Department Room Cleaning Procedure, dated 3/2024, directed all ED rooms were to be cleaned after every patient using the following procedures: -Stabilization Room [#1, #2, #3, #4]: If no large volumes of blood or body fluids are present, the “room turnover” process, with the exception of extra details to equipment including but not limited to “ ... cardiac monitors and cables, ...Acrylic airway case and/or airway cart,” was to be utilized. -Room Turnover definition directed “ED staff” to wipe down all high touch areas between patients. -Terminal Clean definition directed “EVS” to clean all high touch areas, “high dusts, and mop the floor. This was to be completed “at least once every 24 hours as rooms are available.” ED Environmental Service Aide Duty Lists, dated 3/5/25, indicated three EVS staff shifts: Day Shift (7:00 a.m. - 3:30 p.m.), Evening Shift (2:30 p.m. - 11:00 p.m.), Night Shift (11:00 p.m. - 7:30 a.m.) Day and evening shifts had one list each and the night shift had two separate lists. The following was identified: -All four lists: A section labeled “10-Step Cleaning [steps]” directed: “High dust ...Sanitize all Horizontal surfaces. -All four lists: A section labeled “Discharge Cleaning” directed: “Follow 10-Step Cleaning procedure ...Clean/disinfect bed, mattress and pillow.” -All four lists: A section labeled “Daily Focus” directed: “Tuesday - Corners/Edges/Baseboards ...Wednesday - High Dusting ...” -Evening Shift: A section labeled “Area” directed: “Detail Dust Hallways.” -Night Shift-EVS #1: “Area” directed: “Deep cleaning” of rooms 1 through 28. -Night Shift-EVS #2: “Area” directed: “Deep Clean” rooms 29 through 43, and A through F. -Night Shift-EVS #1 and #2: A section labeled “Discharge Cleaning Log” housed space for four rooms to be manually entered into this section once cleaned. A Comprehensive Tracker Report, dated 5/20/25, indicated the Emergency Department underwent their annual environmental rounds process for review of EVS, fire/life safety, infection prevention, medical equipment, safety, security management, and utilities. The total compliance percentage was 74.1% (percent). The following information was identified related to cleanliness/dust: -EVS question #3: Vents do not have any surface dust/dirt with a compliance percentage of 0.0%. -EVS question #4: Storage, cabinets, shelves, cupboards, and floors are clean with a compliance percentage of 0.0%. -Infection Prevention (IP) question #5: Environment - The environment is dust free and clean with a compliance percentage of 0.0%. -IP question #22: Supplies - Storage cabinets, shelves, bins, and floors are clean and dust free with a compliance percentage of 0.0%. An email, dated 5/20/25, identified infection preventionist (IP)-A sent an email to ED leadership and IP-B that updated on the 5/20/25 environmental round findings with a comment: “General concern of cleaning everywhere. Will reach out to EVS on this. They are clearly not performing high dusting, and we found tons of dust bunnies on the ground.” Follow up documentation related to 5/20/25 identified concerns were requested; however, none was provided. In its place, an email was provided, dated 1/2/26, from registered nurse (RN)-A, an ED patient care supervisor, which identified follow up of which she was aware. The supplied information did not reference the dust concerns, but that the kitchen was deep cleaned. ED OQC (Operations Quality Council) meeting minutes, held 6/18/25 and 10/15/25, lacked information related to cleaning/dust concerns and/or information for mitigation of such concerns. Meeting minutes from May 2025 and any after 10/15/25 were requested; however, none were provided. EVS committee meeting minutes were requested; however, it was reported EVS did not have an official committee meeting process but instead held quarterly staff meetings. Meeting minutes were not documented; however, a PowerPoint slide presentation was provided from the “September 2025” staff meeting. This PowerPoint lacked information related to any cleaning improvement process education or identified cleaning concerns. No additional information was provided to support EVS involvement in ED cleanliness concerns. An ED EVS Notes and Recommendations word document, created 11/11/25, identified “Several systemic issues that directly impact patient experience, safety, and operations efficiency:,” and indicated the following Key Themes Identified: inconsistent EVS coverage and unclear responsibilities, delayed room turnovers, confusion about cleaning expectations; EVS lack of access to real-time room status tools and unsureness when or where to clean, resulting in missed opportunities for timely service; both EVS and ED staff reports of limited training on cleaning protocols with no standardized deep cleaning process in place; dust accumulation, stained floors, and poorly maintained equipment compromise the perception of cleanliness and safety; absence of regular meetings between EVS and ED leadership prevents shared problem-solving and continuous improvements. These identified concerns contribute to, but not limited to, inconsistent cleanliness standards and increased risk of infection and poor outcomes. A section that identified goal timelines indicated a timeliness between “Week 1 and Week 4-5.” By week 5, the goals were to map current EVS workflows and identify gaps by the EVS supervisor, crease shared room status visibility tool by IT and the ED manager, develop joint cleaning protocols and training modules by infection control, schedule monthly EVS-ED collaboration huddles by ED and EVS leaders, and conduct facility hygiene audits and prioritize fixes by Facilities manager. The word document does not provide, nor was information provided, reflective to the processes outlined in the document. A SQE (Safety Quality Experience) Pillar Agenda meeting minutes, held 11/19/25, identified a topic section labeled Patient Experience. This section housed another column for Comments from Pillar that indicated, “Comments for Mercy: cleanliness ...,” with “areas for improvement such as cleanliness ...with specific feedback from Mercy ...and strategies for sharing comments and addressing concerns.” No additional information was documented. Information was requested for additional details; however, none was provided. An ED Room Refresh Project listing identified a roster of 49 ED rooms/areas to monitor when each room/area underwent/undergoes the refresh process. So far, the listing identified the dust accumulated room #5 was completed on 12/9/25 and #39 was completed on 12/18/25. Rooms #1, #2, #4, #24, #34, and #37 have yet to be completed. Eleven non-toured rooms were completed between 12/9/25, and 12/18/25. The form does not identify rooms were worked on after 12/18/25. ED Environmental Service Aide completed Duty Lists identified the following: -12/23/25 (Tuesday - Corners/Edges/Baseboard Daily Focus cleaning), day shift: no completed list was provided. -12/23/25, evening shift: a squiggly line was drawn down the two Completed columns for that day’s Area cleaning with the second column identifying Detail Dust Hallways. The Tuesday’s Daily Focus lacked staff indication(s) this cleaning was completed. The section for Discharge Cleaning Log lacked information EVS discharge cleaned any rooms. -12/23/25, night shift: no completed list was provided. -12/24/25 (Wednesday - High Dusting), day shift: no completed list was provided. -12/24/25, evening shift: a checkmark was hand marked next to the Detail Dust Hallways. The Wednesday’s Daily Focus lacked staff indication(s) this cleaning was completed. The section for Discharge Cleaning Log lacked information EVS discharge cleaned any rooms. -12/24/25, night shift: no completed list was provided. -12/25/25: no completed lists were provided for any shift. -12/26/25: an evening list was the only list provided and indicated Detail Dust Hallways was completed. No discharge room cleaning was identified. -12/27/25, evening shift: a checkmark was next to the Detail Dust Hallway identified Area. No discharge room cleaning was identified. -12/27/25, night shift: one of the two lists was provided. The provided list identified rooms 29 through 43 [#34, #37, and #39 were included], along with rooms A, through E, were deep cleaned as evidenced by a handwritten slash next to each room in the completed column. -12/28/25, evening shift: squiggly line drawn down the two Completed columns indicating Detail Dust Hallways was completed. Additionally, the list had a handwritten note that identified the EVS staff cleaned the room #4 due to a “bloody trauma” and “blood splatter everywhere.” -12/29/25: no completed sheets were provided. Based on an email, dated 12/31/25, the EVS manager identified the cleaning checklists were a guide for staff and that they did not check them daily to ensure they were turned in. During an observational tour of the ED, on 12/30/25, which started at 9:15 a.m., with RN-A, RN-B, and accreditation specialist (AS)-A, eight rooms (1, 2, 4, 5, 24, 34, 37, 39) that were identified as cleaned and awaited a patient, were visualized for cleanliness. The first room toured was #34 where a whitish fluffy substance was visualized to have accumulated/built-up on the top surfaces of the overhead swing/boom light, ceiling lift, and cardiac monitor. RN-A and RN-B confirmed this was dust. RN-B stated the ED worked on a current deep cleaning process and RN-A explained they were shutting down rooms as able and doing overall maintenance in them. Additionally, she indicated EVS leadership was newer in the “last couple of years.” Room #39 presented visible dust accumulation on the glove boxes/bin, light boom, and cardiac monitor, with dust accumulation noted during a finger swipe on the picture frame. The tour of Room #5 identified visible dust accumulation on the ceiling lift, light boom, cardiac monitor, a longer metal wall over the bed console unit, and on the slanted top of a supply cabinet. Dust was noted on a picture frame after a fingertip swipe. The supply cabinet top, visible from the doorway, had a whitish appearance from the accumulation that covered its entirety. Room #37 displayed visible dust accumulation on the overhead console, light boom, cardiac monitor, and paper towel holder. Room #24 displayed visible dust accumulation on the cardiac monitor, overhead console, ceiling lift, light boom, top of the supply cabinet, back top surface of the patient hand-held scanner, along with noted dust after a fingertip swipe on the picture frame. Stabilization (trauma bay) room #4 showed dust accumulation on the top surface of the main housing that medical equipment was attached to, such as monitors and the light boom, which was grayer in color. Additionally, dust accumulation was noted on the upper most top surface of an airway supplies clear acrylic wall attached case/cabinet. This cabinet was located a few feet from the head of the room’s overall centrally located emergency bed. Four white packages of laryngoscope supplies were propped up on the top of the cabinet and sat in the dust accumulation. This accumulation was a darker gray in color, and thicker in some areas. In the #2 stabilization room, dust accumulation was visualized on the light boom that was situated over the room’s emergency bed, the top surface of the medical equipment main housing, along with the acrylic airway supply wall mounted cabinet. On top of this cabinet, six packages of airway supplies were propped up and situated in whiter to grayish colored dust accumulation. In the #1 stabilization room, dust accumulation was observed on the top surface of the medical equipment main housing, along with one of the attached monitors. Dust accumulation also noted on the top of the acrylic airway supply cabinet in which six packages of airway supplies sat in the dust. In addition, during the tour, the tops of five smaller wall mounted metal cabinets, located outside of room #5, were examined. Staff identified these cabinets housed the duress badges. All five cabinets had significant dust buildup, darker gray in color, over their entire top surfaces; however, each cabinet displayed tracks of cleared dust, [made from fingers being run across the top surface to open the cabinets]. A finger test on a few inches of a wall long electrical power housing, where EKG machines were plugged into, presented whitish to grayish dust visualization. During the tour of the above areas, the dust accumulation visualized ranged from a whiter color to a darker gray color, along with variations in actual accumulation; however, the dust coated the areas it sat on and in many areas had patches of “dust bunnies” (loose, tangled balls of dust, lint, particles of skin, hair, etc.). In many of the areas, when fingertips were ran across the surfaces, the dust was dislodged, plumed into the air, and fell to the surfaces in which they were over. During an interview on 12/30/25, at 9:55 a.m., RN-C stated that overall the RNs performed high touch surface room cleaning between patients and EVS was responsible for deep cleaning, along with cleaning the rest of the ED. RN-C identified dust accumulation was not a new issue; however, it was currently better than it had previously been. RN-C explained if staff had more time, and less surfaces, cleaning would be better. Currently, it took RN-C approximately five minutes to clean the room between patients before putting the room back together. RN-C identified, if dust accumulation were present, any patient lung issues could potentially be exacerbated, an open wound’s infection risk could be increased, or “bad things” could happen if procedures such as port or catheter placements were performed. When interviewed on 12/30/25, at 10:18 a.m., ED tech (ET)-A stated, during a patient room turnover, anything a patient may have touched, or had the potential to touch, was to be cleaned. She identified this process typically took her anywhere from three to five minutes on average and she never cleaned things “up high.” ET-A stated the nurses overall clean the stabilization rooms and if she saw dust accumulation, the dust would be cleaned right away. ET-A denied concerns with dust buildup; however, had yet to clean any rooms this day. During an interview on 12/30/25, at 10:30 a.m., RN-D stated he only cleaned high touch surfaces between patients that he was able to reach and cleaned on top of the monitors “as much as” he was able. For anything higher, EVS was expected to maintain those surfaces. Additionally, he expected EVS to deep clean each room “every night.” RN-D explained it took him approximately five minutes to clean the rooms after patients, but indicated he tried to keep the rooms cleaner while the patient was there to save time on cleaning once they departed. RN-D indicated the dust accumulation was not a new finding; however, he had not talked to anyone about prior concerns: he just took care of it when he saw it. RN-D explained dust had the potential, if excessive or “agitated and freed,” to increase respiratory concerns in patients. When interviewed on 12/30/25, at 10:40 a.m., ET-B stated the nurses clean the rooms overall and basically the only time she cleaned a room was when she had time. She was unsure when she last completed a room clean, but indicated she cleaned a hallway bed this day. When she cleaned, only higher touch surfaces were given her attention as she was unable to reach, and did not have the supplies, for higher up surfaces. ET-B stated the ED needs people to do deep cleans because our department is dirty not cleaned well. ET-B was not surprised to see increased dust accumulation and explained she visualized dust every day, ED was a dusty environment. She identified “dust bunnies” were often seen on the floor. ET-B stated this was an infection risk for anyone with open wounds. She talked with EVS about her concerns; however, had not brought the concerns to nursing leadership. During an interview on 12/30/25, at 10:55 a.m., medical provider (MD)-A stated the nurses overall turn over the rooms between patients in which they are provided “very little” time to do this task. During these turnovers, he expected all areas touched by patients to be cleaned. After this, he was unaware when any other surfaces were cleaned but had seen EVS cleaning higher surfaces “from time to time.” MD-A stated not having visualized dust accumulation on surfaces; however, felt this was a potential in response to the large volume of staff and patients who entered the ED and carried in things on their shoes. MD-A explained he felt EVS needed to play a larger role in ED patient room cleanings as this was not a role of the RN, as RNs were required for more patient care related job duties. This was especially needed, as the ED saw high-capacity patient encounters, and as soon as a patient was discharged, the room needed to be cleaned. MD-A stated he did not feel the dust accumulation described to him from today’s observations were of any significant concern as the patients were not “digging in it,” and thus the dust was not going to medically make their condition any different. When interviewed on 12/30/25, at 11:10 a.m., EVS-A stated, during the day shift hours, he only deep cleaned a patient room when asked by nursing to do so. He stated there was not a process for routine deep cleaning, but they had checklists they followed. He explained the only time this was done was when there were less patients, and they were able. EVS-A identified he cleaned the trauma bays, which are expected to be cleaned every day and as needed, in which he cleaned the acrylic airway supply cabinet two to three times a week but not every day. He stated he could see “dust bunnies” daily as you can clean one day and then see them the next and wonder where they came from. EVS-A identified “Friday [12/26/25],” when he was questioned on the last time he dusted/cleaned the tops of the duress badges cabinets. He stated he would expect to see dust there again this day. When EVS-A was brought to the cabinets to visualize the top of the cabinets, and again questioned on cleaning, he denied they were cleaned on Friday. During an interview on 12/30/25, at 11:25 a.m., RN-A, who was identified as the patient care supervisor, stated it was in the ED tech’s job description to clean rooms between patients and that RN’s, based on their employment contracting, were not required to clean rooms; however, a lot do it. During cleaning between patients, RN-A expected all surfaces used/touched by a patient were to be cleaned. EVS was then responsible for higher surface dusting/cleaning that included dusting “top to bottom.” She was unsure whether they utilized a checklist or if a checklist included dusting. RN-A stated dust has been brought up many times, but continued to be an issue; however, nothing to the degree that was noted during this day’s tour. The last time this was discussed was about two weeks ago when dust was found in the nursing station under desks and on monitors. She was unsure the last time dust in patient rooms was discussed but identified they worked on developing a scheduled reliable cadence for room turnovers. Two room turnovers were recently completed with approximately five completed up to this point. RN-A stated maintenance was questioned on air flow last week, but she was unsure what prompted this conversation. When RN-A was questioned on the five duress badges cabinets, and the other concerns observed during the tour, she stated the cabinets were not cleaned on Friday, nothing was cleaned Friday. RN-A stated the dust accumulations observed were there “a long time,” was a lot,” and could be a risk to a patient with respiratory concerns or dust allergies, along with increased risk in critical care rooms [stabilization rooms], or rooms where procedures were completed. When questioned on the airway supplies that sat in dust accumulation, she identified infection control risks. On 12/30/25, at 2:26 p.m., infection prevention manager (IPM)-A and infection preventionist (IP)-B were interviewed together. It was identified the facility performed an environment of care rounding process on each facility area, at least once a year. The ED underwent this process in May; however, due to census, it was hard to get into all the rooms and not all areas were visualized. When a recent ED (non-dust) concern was brought forward another ED audit was conducted; however, not all areas were again able to be visualized due to census. During that tour, a dusty vent was identified, which was escalated to EVS who indicated they would take care of it. Follow up was not conducted and ED nursing management was not updated. IPM-A explained ED cleaning processes were different from inpatient processes. ED staff were expected to wipe down high touch surfaces and clean the area and then EVS was to deeper clean periodically, and stated the goal was to access the spaces every 24-hours. IMP-A stated IP did not do any auditing of ED EVS or nursing staff for cleaning, only inpatient and surgical services units. However, they monitored for aspergillus and fungal infections that may be carried on dust in which they have not found increased hospital acquired infections or clusters with their monitoring. IP-B stated she was very concerned about the dust accumulation observed on this day, the environment [stabilization rooms], because dust contains allergens and can carry microorganisms. This was a standard concern across the board. She explained she was shown by staff pictures of the dust on the airway supply cabinets but had yet to visit the ED for visualization. She stated, the hospital knows what the challenges are for getting in and doing a deep clean. IPM-A verbalized the ED had a good air exchange and was surprised dust was found. She explained that if “pluming” happened with intubation, she felt they would have found concerns during their surveillance processes; however, it took steps to have lined up to see concerns such as a patient who was immunocompromised (weakened immune system), poorer hand hygiene, plume into the environment, etc. For most people, unless you were immunocompromised, dust was not an overall issue. IPM-A stated she knew EVS needed support in the ED, but she was not previously aware of dust concerns relative to this day’s findings, and thus from an IP standpoint, they have done nothing about the dust concerns, especially as during prior rounds, nothing was “dust heavy. When interviewed on 12/31/25, at 9:00 a.m., ED medical director (MD)-B stated the ED worked on a cadence for processes related to a non-dust concern that was recently identified; however, she was not aware of dust concerns. MD-B explained ED rooms did not sit empty for long and time is a premium, and there have been ongoing discussions on if the ED has enough EVS, or other ancillary staff, to get things done; however, she identified she sat on hospital and system wide committees and dust related topics have not been addressed and/or increased infection control ED concerns identified. MD-B identified staff worked hard to keep things as good as they could to ensure a safe environment for the patients and as this was a hospital, her expectations for cleanliness were to be followed. She expected any surfaces the patient reasonably touched or that staff were to touch while caring for patients were to be cleaned, via a joint effort of nurses and EVS, but was unable to express a timeframe on when this expectation was to be carried out, or the processes in place. She mentioned overnight EVS staff usually were seen cleaning more areas due to fewer people in the ED and more spaces they were able to get into. MD-B stated the ED currently shut down a room to two where EVS did a deeper clean, but once updated on this day’s dust observation, stated they needed to make a cadence plan for cleaning because it is not being done. Additionally, she was glad the airway supplies were in single sterile packaging, but stated the dust is very disgusting. MD-B explained, overall the dust was not an overly high risk; however, there was a slight increased risk in the rooms where more sterile procedures were performed and in the stabilization rooms as the bed was a foot or two away from the areas of concern and the packaging was opened and/or placed right by the patient. For those with dust allergies, MD-B stated that it would take quite a bit of dust to have a significant clinical impact on the patient but a patient with an open wound had an increased risk potential. Overall, MD-B stated they need a better plan, which was followed by the team, on when deep cleaning happened on all the ED surfaces. On 12/31/25, at 9:40 p.m., the Facility manager (FM)-A, and two Facility leads (FL)-A and FL-B were interviewed together. This department was involved in the environment of care rounds where one of these was completed in the ED around November. Due to the results of this, facility (maintenance) staff, have started to shut down one ED room at a time so that they could repair the rooms i.e., walls, floors, painting, sprinkler head cleaning, broken corner guards, worn down areas, etc. They indicated such routine work was harder to maintain as the ED was so busy. They were unaware of dust concerns and explained they installed a new HVAC system for the ED in July of this year and no one has asked them to check the filters due to any identified dust concerns. Mechanically, the HVAC system worked as expected. During an interview on 12/31/25, at 10:50 p.m., the EVS manager stated nothing had been brought to his attention related to any recent EVS cleaning issues or any major trends related to dust during any of the environment of care rounds, in which he was involved. He explained, that due to a non-dust issue identified in the ED, “deep cleaning” started a couple of weeks ago. This involved the process to ensure needed maintenance items and repairs in the ED rooms were completed such as damage to floors, walls, etc. After these repairs were completed, then EVS went in and did a floor to ceiling cleaning of the room. Despite the recent non-dust unfolding and current processes to fix those identified room concerns, not all the ED rooms have been audited for concerns as staff could not get into them all due to census. The EVS manager identified overall the cleanliness in the ED rooms was an expectation of the EVS staff, but nursing staff also assisted. He explained day and evening shifts went into rooms after nursing staff called them once the patient was discharged and a quick turnover occurred. This consisted of trash disposal, wiping down high touch items, the floor, and then, if time allowed, before the nurse was at the door with the next patient, dusting. After this, the overnight shift was responsible for a more dedicated thoroughness that consisted of top to bottom cleaning. EVS ED staffing consisted of one dedicated housekeeper on day and evening shifts and then two staff on night shift. In areas of the ED other than the patient rooms, he expected staff to clean surfaces a couple times a week, and they were to make sure items/surfaces were dusted when they went room to room. Despite this expectation, and a check list on the areas needed to be cleaned each shift, there is not always a guarantee where every single room will be deep cleaned. Rooms could go without being deep cleaned for a couple of days, but some rooms have nonstop patients in them and EVS are unable to perform their duties. EVS staff fill out a checklist and he asked them if they were unable to clean a room or area they were to collaborate with nursing on a better time. He expressed their needed to be an easier and more effective tracking method from shift to shift and that he would appreciate more staff as he saw a need, but, he has not had staffing conversations with leadership. When the dust from this day’s tour was discussed, he was embarrassed to hear about it: “We are consistent in cleaning but that does not show that,” and he identified this was not a concern anywhere else in the facility. He expressed he would not expect to see the amount of dust found this day and his biggest priority was consistent ED cleaning. When interviewed on 12/31/25, at 1:46 p.m., RN-E, identified as the ED patient care director, stated he had general environmental cleanliness concerns that centered around observations such as scuff marks on floors, bathroom odors, dust on electronics, vents, overhead console, mopboards, etc., higher up on areas such as cabinets, etc., and that in October a collaboration with maintenance and EVS was performed to do a walk-through of the ED. With this, several areas were reviewed, and concerns were brought up. He stated he had not seen or been aware of dust buildup on patient room equipment prior to since these collaborations and indicated he felt dust buildup was unlikely in the ED. When the non-dust concerns arose, they revisited these areas of opportunity. Since, a cadence of two to three rooms a night was setup to refinish the floors and make sure things were clean in those spaces. A week or so ago, he indicated RN-A reached out to EVS about the dust and the overall cleanliness again. RN-E identified there were yet no formal changes with staffing that he was aware of to assist with cleanliness processes. High touch cleaning fell on EVS responsibilities during turnovers and then “gross decontamination” of spaces, such as bodily fluid/emesis cleanup, fell on nursing staff. After RN-E was updated on this day’s dust findings, which he was unaware of before the interview, his initial response was one for concern of patient’s with respiratory concerns. The dust buildup on the stabilization airway cabinets “[gave] him pause,” and disturbed him, especially when he expected all the equipment used to be clean and aseptic when applicable and the environment was the opposite of that. He again reiterated there had been no prior concerns of dust to this degree, and that any dust found was reported and remedied when discovered. Systemically, nothing was put into place based on the scope and magnitude of what was described to him during the interview and there has yet to be a condition level all hands-on deck, let’s take care of this approach between all the required stake holders. A Standard Work Activity Sheet, dated 1/12/22, stated its purpose was to improve quality/efficiency of nursing assistant support on L&D. A section labeled Cleaning and Stocking a Labor Room directed steps for the management of the baby warmer. This section directed staff, but not limited to, “Wipe down all surfaces.” A Comprehensive Tracker Report, dated 3/25/25, indicated L&D underwent their annual environmental rounds process for review of EVS, fire/life safety, infection prevention, medical equipment, safety, security management, and utilities. The total compliance percentage was 82.8% (percent). The following information was identified related to cleanliness/dust: -Infection Prevention (IP) question #5: Environment - The environment is dust free and clean with a compliance percentage of 0.0%. -IP question #22: Supplies - Storage cabinets, shelves, bins, and floors are clean and dust free with a compliance percentage of 0.0%. Information related to specific details and follow up were requested; however, none were provided. An L&D NA Daily Checklist directed daily work and unit tasks. The back side of the checklist housed a section for the NA to input rooms that were cleaned and stocked. The checklist lacked specific information related to the baby warmers: only information to “Clean & Stock LD Rooms.” The last 30 days of completed checklists were requested, and 16 days (out of 30) were provided. The completed checklists, dated between 12/26/25, and 12/30/25, identify the following dates cleaning and stocking were documented: #1 = 12/30/25; #2 = 12/28/25; #3 = 12/26/25; #4 = 12/16/25; #5 = 12/26/25 and 12/29/25; #6 = 12/29/25; #7 = 12/26/25; #8 = 12/26/25 and 12/28/25; #9 = 12/29/25; #10 = 12/29/25; #11 = 12/26/25 and 12/28/25; #12 = 12/26/25; #13 = 12/26/25. All 13 rooms show at least one documented cleaning by an NA from 12/26/25, through 12/30/25. During a tour of the inpatient hospital units on 12/31/25, around 12:40 p.m., the L&D unit was toured with safety and quality advisor (QA)-A and RN-F. The first room toured was #5. A whitish fluffy substance was visualized to have accumulated/built-up on the upper most top surface of the baby warmer (housing for the warmer’s heating element. RN-A and RN-B confirmed this was dust. The tour continued to rooms #2, #3, #4, #6, #7, #8, #10, #11, #12, and #13. Room’s #1 and #9 were occupied by patients and thus not toured. Room #13’s baby warmer was free of dust accumulation; however, all the other nine remaining baby warmers displayed dust accumulation. The accumulation varied from warmer to warmer with most warmers that showed areas where the dust clumped together i.e., dust bunnies. The color of the dust varied from a whitish color to a darker gray color. Room #3 and room #4 showed increased accumulation. RN-F stated these two rooms were not used as often as the rest. Room #2 had a patient who discharged this day, and the room awaited cleaning; however, dust accumulation was visualized. RN-F identified the nursing assistants (NA) were responsible for cleaning the baby warmers, not EVS. On the back of each room door was a laminated check list labeled L&D NA Room Checklist. This checklist broke down cleaning and stocking tasks with the back side designated for the “Infant Warmer.” Overall, this side provided guidance on stocking the warmer and lacked direction on cleaning direction(s). During an interview on 12/31/25, at 1:04 p.m., nursing assistant (NA)-A stated she was responsible for cleaning and stocking the baby warmers, which included cleaning from the top to the bottom. If not cleaned as expected risk to the baby’s health was a potential concern especially if the baby had a weaker immune system. NA-A indicated no one ever checked her work, just asked if it was completed. NA-A was asked to visualize the top of the baby warmer #5. She stated she observed “dust build-up ...looks like it was not cleaned ...for a few days.” NA-A stated she had not observed this build up before and reiterated that she cleaned this surface when she cleaned. She identified it took her approximately eight minutes to perform her required cleaning processes and that no one has ever talked to her about dust build up. When interviewed on 12/31/25, at 1:10 p.m., RN-G, patient care supervisor, stated the NA was responsible to clean the front parts of the baby warmer upon discharge, and she assumed EVS cleaned the very top. She explained the NA’s were instructed with orientation to wipe down all surfaces of the baby warmer - surfaces used during deliveries, just not the very top. RN-G lacked concerns related to NA cleaning processes and overall lacked concerns related to risks associated with the dust accumulation as we do not touch up there. Additionally, she was not overly concerned for dust pluming as the baby warmer stayed relatively in the same spot despite the potential for it to get pulled away from the wall. RN-G stated the only audits conducted were to ensure the checklists were completed, not actual visualization of the NA work processes. After RN-G visualized the top of the baby warmer in room #5, she stated the top was dusty and described it as noticeable. She explained the problem was some staff cannot see the top from certain angles. RN-G identified babies that utilize the baby warmer range from healthy, full-term babies to babies that required resuscitation or any other type of intervention due to assessed concerns. During an interview on 12/31/25, at 1:20 p.m., RN-F, the patient care manager, stated she expected the NAs to clean anything touched or noted to be dirty with the baby warmer overall being completely wiped down. She verbalized if NAs did this as expected, dust accumulation as observed this day, would not be present. RN-F’s biggest concern related to the buildup was fire risk as the infection control risk was lower due to staff not touching the top of the warmer. She was not aware of any cleaning concerns and deferred any questions related to audits to RN-G. She stated the baby warmers are dust magnets, and that amount of dust may settle in a couple of days. When questioned on room #3, RN-F indicated it may have been weeks since that warmer was cleaned due to the amount of dust buildup observed. When interviewed on 12/31/25, at 1:33 p.m., EVS-B stated she was not responsible for cleaning the baby warmer but if she were to notice that it needed cleaning after the NA was done, she would touch it up. She explained there have been situations where she observed “blood” on the bottom parts of the warmer which she cleaned. EVS-B observed the baby warmer in room #2 that she was in the process of cleaning. She identified dust and indicated the aide is supposed to do that. It needs to be wiped. While she visualized the warmer, EVS-B stated, Look, it is flying. Dust particles could be seen floating in the air by the warmer. EVS-B verbalized the baby warmer needed something that would cover the baby so the dust would not land on them. During an interview on 12/31/25, at 2:34 p.m., NA-B stated she was expected to clean everything on the baby warmer to ensure safety. This included the very top. If not cleaned properly, this was not good for the baby and was an infection control risk. She was unsure whether she was visually audited for her cleaning practices, and she denied she had visualized dust buildup that was a concern. An Environmental Services Cleaning Guidebook: Inpatient Care Areas, last revised 2025, defined cleaning as “The physical removal or dust, soil, blood and body fluids. Cleaning physically removes germs.” High Dusting was defined to include “all horizontal surfaces and fixtures above shoulder height, including vents. Ideally, the patient should be out of the room during high dusting to reduce the risk of inhaled dust particles. Hospital Clean was defined as a measure of cleanliness routinely maintained in care areas which included “All horizontal surfaces” were to be free of visible dust or streaks. This included furniture, window ledges, overhead lights, picture frames, etc. Additionally, noncritical medical equipment was to be cleaned and disinfected between patients. Terminal/Discharge Cleaning was defined as a thorough cleaning following a discharge to remove germs and organisms that might be transferred to the next patient.”

“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 hospital failed to arrange for essential medical equipment (oxygen) prior to the patient’s discharge for 1 of 5 patients (P7) reviewed for discharge planning. Findings include: On 5/15/25 at 1:06 p.m. P7’s durable medical equipment progress note indicated P7 would benefit from home oxygen therapy following home oxygen assessment. On 5/15/25 at 3:04 p.m. P7’s social work progress note indicated P7’s family had chosen and been accepted by a hospice agency. On 5/16/25 at 12:12 p.m. P7’s provider discharge orders included oxygen for home use with bubbler/humidity as needed for patient comfort. Liters per minute: 4 per nasal cannula. On 5/16/25 at 11:37 a.m. P7’s social work progress note indicated social worker (SW)-A had spoken with P7’s daughter, a registered nurse (RN) at the assisted living facility (ALF) P7 would be returning to, and a hospice RN. All parties were agreeable to the discharge plan. The ALF requested P7 be discharged with oxygen. On 5/22/25 at 9:28 a.m., hospice registered nurse (RN)-C stated P7 had been accepted by the hospice agency. A SW from the hospital called the hospice company on Friday to inform them of the transport time, but did not mention the need for supplemental oxygen. When R7 arrived home, she was utilizing 6 liters of oxygen which was provided by the medical transport. There was no supplemental oxygen at P7’s home, so the medical transport team waited while the hospice agency sent at an immediate delivery order to the oxygen supply company. The medical transport team waited about 2 hours for the oxygen to be delivered. The hospice agency did not receive P7’s discharge orders until Monday (3 days after discharge). On 5/22/25 at 12:29 p.m., RN-A stated the hospital nurse discharging a patient needed to call the oxygen supply company to set up a delivery time, and confirm with the family there would be someone at the home to receive the delivery. Nurses do not call to ensure the oxygen was delivered. On 5/23/25 at 9:22 a.m., RN-B stated when a patient who required oxygen is being discharged, the discharging nurse will call the oxygen delivery company to set up a delivery time before the patient discharges. It is important the oxygen is delivered before the patient discharges so the patient can use it as soon as they are home. If a patient started hospice before they discharged from the hospital, it was the hospice agency’s duty to be sure the oxygen was delivered. RN-B could not recall P7’s discharge, but stated she entered all the discharge information she was provided in the nursing discharge note. On 5/23/2025 at 9:30 a.m., social worker (SW)-A stated the bedside nurse coordinated with the oxygen supply company. A social worker would arrange a transport time based on the time of the oxygen delivery. It was important the equipment was delivered before the patient arrived home. SW-A could not recall specifics of P7’s discharge. On 5/23/2025 at 10:11 a.m., SW-B was interviewed and stated it is the hospice agency’s responsibility to coordinate delivery with oxygen supply company. The hospital social worker should set up a transportation time based on the oxygen delivery time provided by the hospice company. On 5/23/2025 at 11:34 a.m., the RN care coordinator (RN)-D stated the hospice agency would order any durable medical equipment including oxygen. The RNCC would not be involved with oxygen delivery. The facility Standard Work Activity Sheet Hospice Post-Acute dated 10/22/24 instructed the social worker to ensure hospice has arranged durable medical equipment, if needed, and confirm medications to be filled at hospital or elsewhere. The Discharge Planning/Discharge Patients policy dated April 2024 directed the staff RN to facility timely discharge via coordination with members of the care team including coordinating acquisition of resources/equipment/supplies, so items are available for patient upon leaving the hospital.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 49337 Based on observation, interview, and document review, the hospital failed to protect and promote patient rights for 1 of 10 patients (P1) reviewed for behavioral disturbances. A security officer used a taser (a law enforcement tool) to restrain P who fell to the ground, and sustained a laceration on his head which required sutures. As a result, the hospital was found NOT in compliance with Condition of Participation Patient Rights at 42 CFR 482.13. The IJ began on 11/30/24 when a facility security officer used a taser on P1, who then fell and sustained a laceration on his head requiring sutures. The Vice President (VP) of Medical Affairs, VP of Nursing, Mental Health Director, Mental Health Manager, Security Director, Security Manager, Risk Manager, Accreditation Specialist, Accreditation Strategist, Safety Quality Director were notified of the IJ findings on 12/12/24 at 4:10 p.m. The IJ was removed on 12/17/24 at 12:30 p.m., after verification of an acceptable removal plan, but a condition level deficiency was issued. A condition level deficiency was issued. See A-0154”

“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: 49337 Based on observation, interview, and document review, the hospital failed to protect and promote patient rights for 1 of 10 patients (P1) reviewed for behavioral disturbances. A security officer used a taser (a law enforcement tool) to restrain P1. P1 fell to the ground, and sustained a laceration on his head which required sutures. Findings include: P1’s emergency department (ED) admission record indicated P1 presented to the ED on 11/12/24. P1’s diagnoses from this visit included schizoaffective disorder, paranoia, psychosis, and substance abuse. P1’s Physician Order dated 11/14/24 directed “Assault Precautions” (undefined) with the following interventions: Document reason for precaution in staff alerts, communicate assault precautions in report, review behavioral expectations for no violence at start of shift, assist patient to identify triggers to violence and develop a plan to de-escalate, consider a private room near the nursing station, consider space restriction from other patients, consider use of increased security presence on unit, consider removing items in the lounge that could be thrown. On 11/30/24 at 2:00 p.m., a progress note indicated P1 was observed on camera throwing an object and a chair. There was a show of support call (when security officers, nursing staff or other staff are summoned to be present as a visual deterrent to decrease the likelihood of physical confrontation, and to support de-escalation efforts to prevent physical contact with the patient prior to requiring to call a (Code Green) was initiated. P1 was saying he would be violent if staff entered his secured area. A Code Green (overhead announcement for immediate staff assistance for a patient who is presenting, through behavior or threats, a danger of harm to self or others) was initiated. Security officers were on the unit and tried to verbally de-escalate P1, and encouraged him to sit down. P1 continued to escalate and was non-redirectable. P1 was yelling and kicking the doors. Security officers then opened the doors to the closed observation area. P1 was holding a cordless phone and threw it at the security officers. In response, P1 was tased and fell to the ground sustaining a laceration to the right temporal region. The as needed medications were administered, and P1 was moved to the seclusion area and placed in four-point restraints. The rapid response team and internal medicine physician were paged. The physician determined P1 required a CT scan, and would need to be transported to the emergency department (ED) for suturing of the laceration. P1 was in restraints for a total of 15 minutes. P1 was transported to the CT scan without incident, and was calm and cooperative. On 11/30/24 at 12:44 p.m., a video recording (without audio) was reviewed. P1 was observed pacing around his room, the hallway, and lounge area. There were no other patients or staff in the secured area. P1 repeatedly slammed a door and threw a weighted chair across the room. From 12:47 p.m. through 12:54 p.m. P1 sat on the chair and talked on a cordless phone. At 12:55 p.m. P1 moved two chairs to make a partial barricade in front of the door. At 12:56 p.m. four security officers (SO) entered the area. P1 moved towards them, made verbal threats, and threw the phone at them. The phone did not strike any of the SOs. The SO-A immediately deployed his taser hiting P1 who fell and hit his head on the wall. Nursing staff entered the area, and both nursing and SO attended to P1. Two taser darts were removed from P1’s shoulder and groin area. Approximately 15-30 minutes later, SO brought P1 to the ED where he required four sutures to his forehead and a CT as a result of the fall. On 12/9/24 at 11:57 a.m., P1 stated no de-escalation techniques were used during the incident. His shoulder and neck were still sore from the fall, and he still had bruises on right shoulder and groin area from the taser. He had four sutures on his forehead. He was upset about how he was treated. P1 was not able to provide a succinct answer for why he was upset on 11/30/24. P1 stated staff did not try de-escalation techniques with him. On 12/9/24 at 12:29 p.m., registered nurse (RN)-A stated she was present during the incident. She showed up for the show of support and was not able to see the taser deployment. She was not able to specify what type of de-escalation techniques were used, or to what extent they were tried. She suggested calling the police. There was a debrief following the incident. On 12/10/24 at 12:30 p.m., RN-B (the patient care manager of the mental health unit) stated nursing staff and security officers had a plan to administer medications to P1, move the chairs out of the area and then leave the area, but plans changed due to the continued verbal threats and the phone being thrown. Nursing staff and security officers were trying to verbally de-escalate the patient by talking through the window between the secured area and the nursing station. The patient was in a secured area to make sure the other patients were safe. On 12/10/24 at 2:19 p.m., SO-C stated SOs arrived to the unit for a show of support, and the nurses did not have a plan besides administering medications for P1’s agitation. P1 could see the SOs through the window and was making verbal threats. Security determined it should be called a Code Green to obtain more staff support. None of the nursing staff wanted to assume the role of Code Green director. Although SO-C did not deploy the taser on P1, tasers could be used on patients if there was a threat of harm. Following the incident, he did a debrief with the security manager, and discussed having a Code Green director. On 12/10/24 at 2:34 p.m., SO-D stated SOs arrived to the unit for a show of support, which turned into a Code Green. The SOs went into the secured area, and were telling P1 to go to his room. He threatened to throw the phone several times before he threw it, and we tased him. SO-D was unable to state if there was a plan to obtain the cell phone from P1, or if the four SOs had designated roles before entering the secure area. SO-C reviewed the incident with leadership, and the suggestion was to make sure there was a Code Green director identified before SOs could do anything. On 12/10/24 at 2:42 p.m., RN-C stated she called for a show of support so she could administer P1 his medications for his agitation. P1 was agitated because the family members he was trying to call were not answering the phone. When the SOs arrived, they decided to call a Code Green. P1 started throwing the chairs and the tables, so the SOs decided to go in and try to hold him down to administer his medications via intramuscular injection. On 12/10/24 at 2:56 p.m., the security manager (SM)-A stated the SO’s response to the incident was rushed. The SOs could have waited it out, entered when P1 wasn’t escalated, which may have led to a better outcome. Following the taser deployment, a debriefing was held with the SOs. They discussed concerns with identifying the director of the code green. There was no indication the debriefing discussed SM-A’s concern the incident was rushed. On 12/11/24 at 11:09 a.m., SO-A stated de-escalation did not work on P1, and clinical staff had asked security to take control. P1 was making threats, had created a barricade, and threw the phone. That is when he deployed the taser. On 12/11/24 at 11:33 a.m., medical doctor (MD)-A stated she responded to the incident since she was called about P1’s forehead laceration. She did not have concerns about the use of the taser on P1. She responded to assess the forehead laceration. On 12/11/24 at 11:40 a.m., SO-B stated the use of a taser was indicated when a patient was posing substantial to great bodily harm to others. He observed P1 throw the chair on camera, and felt the Code Green should have been called a lot sooner. On 12/11/24 at 4:00 p.m. risk manager (RM)-A stated SOs made attempts to verbally de-escalate P1 through the door. The hospital determined the use of the taser on P1 was appropriate because of the potential for a significant threat of injury to the four security officers, and P1’s throwing of the phone was considered criminal activity. There was no better way to deal with this, and all four SOs acted within their scope. All actions were reasonable. The facility policy Use of Security Interventions dated 5/24, directed law enforcement weapons may be used only on the rare occasion where there is immediate risk of substantial or great bodily harm, after available de-escalation techniques have been utilized. Law enforcement tools must not be used as a clinical intervention including to gain patient compliance or subdue a patient to place them in restraint or seclusion. The IJ was removed on 12/17/24 at 12:30 p.m. after the following actions were completed: Facility policies Use of Security Interventions, System-wide policy: Code Green and Restraints/Seclusion - Management of Violent and/or Self-Destructive Behavior were reviewed with no changes. Education was provided to all relevant staff on the policies and procedures. Examples were provided to security staff to determine when additional assistance would be required. The education included Know Why and Comply Behavioral Escalation and Clinical Interventions, De-escalation tip sheet, Agitation Protocol, Violence Prevention Program - Situational Awareness, Mercy Hospital Code Green Officer Guidance and Scenarios. A new admission form, How I Cope, was created to identify patient specific de-escalation techniques. Audits were completed using the Violent Restraint/Seclusion Documentation Audit form. This was verified through interview and document review.”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 33925 Based on observation, interview, and document review, the hospital failed to ensure appropriate signage was displayed, as required, in all areas of patient entrance and awaiting and/or receiving treatment for the Emergency Medical Treatment and Labor Act (EMTALA). The lack of signage had potential to affect anyone arriving to the ED via emergency response (i.e., EMS) or receiving care within the ED. Findings include: On 9/16/24 at 11:15 a.m., a tour was completed of the Mercy Hospital - Coon Rapids emergency department (ED) with the ED patient care director (PCD)-A present who explained the ED consisted of 48 rooms and included both stabilization (i.e., STAB) rooms and mental health dedicated (i.e., seclusion, monitored) rooms. The main entrance to the ED was observed and opened to the outside with a large awning above the double set of sliding doors which displayed to the public, red-colored lettering reading, “EMERGENCY.” Inside the entrance, a set of sliding doors opened to the waiting area and reception desk which had multiple persons seated and, on the left side of this entrance, was signage for EMTALA and the associated rights thereof. The tour continued, and access to the ED corridor required security badge access. Inside, the ambulance garage was toured which PCD-A verified was where EMS presenting patients would enter the ED. However, the entire space and corridor attaching it to the ED lacked any EMTALA signage. PCD-A verified the lack of signage and expressed the area had been re-modeled months prior and the signage must not have been replaced yet. The tour continued and no further EMTALA signage was located in the treatment area hallways or corridors which PCD-A verified adding no such signage was displayed or posted, at least to their knowledge, adding aloud, “We don’t [have posted] in the ED proper.” During subsequent interview, on 9/16/24 at 2:45 p.m., PCD-A clarified the ambulance garage area was re-modeled back in July 2024 and they believed a work-ticket had been submitted then to replace the EMTALA signage. PCD-A stated they would locate and, if able, provide the work-order ticket. However, during the onsite abbreviated survey from 9/16/24 to 9/18/24, it was not provided or received. A hospital’ provided Emergency Medical Treatment and Labor Act (EMTALA) policy, dated 1/2024, identified the policy applied to the hospital campus under survey and included a section labeled, “Signs,” which directed EMTALA signage was to be conspicuously posted in any entrances, emergency department and place likely to be noticed by persons waiting examination. The policy continued, “This would include but is not limited to entrances, admitting areas, waiting rooms, ambulance bays, and labor and delivery triage areas.” The policy directed the signage must display the rights of persons with emergency conditions seeking care and indicate if the hospital participates in the Medicaid program.”

“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 observation, interview, and document review, the hospital failed to protect and promote patient rights for 1 of 10 patients (P1) reviwed for behavior disturbances. A security guard restrained P1 using a taser and handcuffs that are law enforcement tools. This resulted in the potential for serious harm, injuries or death for P1. 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 5/11/24 when facility security officer used a taser and handcuffs on P1. The Hospital Accreditation and Certification Program Specialist, 2 Safety and Quality Advisors, Patient Care Director, Security Director, System Accreditation Specialist, Vice President (VP) of Nursing Services, VP of Medical Affairs, VP of Security, VP of Safety, Quality and Experience and Director of Risk Management were notified of the IJ findings on 5/22/24 at 5:30 p.m. The IJ was removed on 5/24/24 at 2:00 p.m. after verification of an acceptable removal plan, but a condition level deficiency was issued. The IJ was removed on 5/24/24 at 2:00 p.m. after the following actions were completed: Facility policies Restraints/Seclusion - Management of Violent and/or Self-Destructive Behavior and Use of Security Interventions were reviewed, and revisions approved. Facility policy Restraints: Non-Violent Behavior was reviewed with no changes. Hospital-wide procedure: Restraint/Seclusion for Violent and/or Self-Destructive Behavior was discontinued. Process change was implemented on the mental health unit. Code Green response team roles were reinforced, and role of clinical staff clarified in facility policy Restraints/Seclusion - Management of Violent and/or Self-Destructive Behavior. P1’s care plan was updated. Audits were completed for utilization of agitation protocol on all patients on the mental health unit. Education was provided to all relevant staff prior to start of shift. Violent Restraint/Seclusion document audit was completed for all patients with active restraint use. This was verified through staff interview and document review. Findings include: See A-0154 Based on observation, interview and document review, the hospital failed to ensure a patient’s rights to be free from restraint when a security officer used a taser and handcuffs that are law enforcement tool, for 1 of 10 patients (P1) reviewed for behavorial incidents.”

“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: 48300 Based on observation, interview and document review, the hospital failed to ensure a patient’s rights to be free from restraint when a security officer used a taser and handcuffs that are law enforcement tool, for 1 of 10 patients (P1) reviewed for behavioral incidents. P1 was tased and placed in handcuffs during a behavioral health event with security officers. Findings include: P1’s electronic medical record (EMR) indicated P1 was transferred to Mercy Hospital - Unity campus on 5/9/24. P1’s diagnoses included schizoaffective disorder, bipolar type and methamphetamine use disorder. P1’s care plan 5/9/24 indicated risk for violence towards others with the following interventions: assist with self-control of anger, utilize verbal de-escalation preferences, initiate patient identified de-escalation preferences, manage inappropriate sexual behavior, manage aggressive behavior, safe application of restraints, seclusion, administer medications, and monitor effectiveness of medication. Facility case report dated 5/11/24 indicated a taser was deployed with darts hitting P1 in the chest and sternum. P1 was then handcuffed and escorted into the seclusion room. The local police department arrived at the hospital but did not assume custody of P1. On 5/11/23 at 12:28 p.m., video recording indicated P1 was in his room with the door closed. At 12:33:00, P1 entered the hallway and knelt on the floor with both hands placed on his head. Three security officers (SOs) were in the hallway approximately 6-8 feet from P1. P1 jumped to his feet, elbows at 90-degree angle with fists closed. He bounced around on his feet from side to side and backwards. The SOs were facing P1. P1’s hands drop to his side, and he took a step towards the SOs. At 12:33:12, Two SOs drew their taser’s and state “Don’t do it” loudly several times. At 12:33:16, SO-A deployed his taser on P1. P1 fell to the floor and the SO and nursing staff attended to the patient. P1 was assisted to his feet with handcuffs around his wrists and was escorted to the seclusion room. The handcuffs were removed and P1 was placed in 4-point locked restraints. The taser darts were removed and 3 puncture areas were visible on P1’s chest. P1’s EMR lacked documentation of interventions attempted prior to 12:28 p.m. video recording for event de-escalation. On 5/21/2024 at 2:34 p.m., security manager stated the deployment of a taser is a law enforcement action. P1 was placed in handcuffs and the local police department were notified. When the police department arrived P1 was not placed into police custody. On 5/22/2024 at 9:45 a.m., RN-A stated assessment of a patient after taser deployment was not part of any education he has received. On 5/22/2024 at 10:58 a.m., SO-A stated the use of a taser is indicated when a patient is committing an assault on a nurse, security officer, or a visitor fears a patient will cause substantial or great bodily harm. SO-A stated the call started as a show of support (security presence in support of nursing staff) request. P1 was in his room yelling and doing push-ups and squats with his shirt off. SO-A felt very scared and fearful because elevated heart rate and pumped-up muscles are pre-attack indicators. SO-A stated he knew from report, P1’s capability for violence was high due to P1’s background. P1 came out of his room and knelt on the floor with his fingers interlaced on his head. When the Code Green (a code called by a staff member who identified unsafe or threatening behavior on the part of a patient, to summon additional personnel to continue de-escalation or to intervene) was paged overhead, P1 jumped to his feet and took several bladed stances (one foot in front of the other and the body is at an angle to the person in front that provides power for attacking, used in boxing). P1 made threatening comments. Then took one or two steps backwards and put his hands down then he took one step forward. As soon as P1 took that step forward SO-A thought he was about to get punched in the face so SO-A deployed his Taser. SO-A further stated one of the first darts missed P1, so SO-A deployed the second cartridge because two connections are required to get neuromuscular incapacitation (disruption of muscle function to stop an attacker). P1 was then handcuffed. On 5/20/2024 at 4:20 p.m., RN-B stated when a patient’s behavior is beginning to escalate, least restrictive interventions should be tried first like talking with the patient, music, decreased stimulation, food, beverage, and/or as needed medication. If the patient’s behavior continues to escalate, the nurse could request a show of support from security officers. If that does not resolve the situation, a Code Green can be called. Verbal de-escalation should be continued during the entire process. RN-B stated she has not been trained to use a taser or handcuffs or to assess a patient following taser or handcuff use. RN-B stated the patient’s nurse is responsible to lead a Code Green. On 5/22/2024 at 1:38 p.m., Security manager (SM) stated security officers receive the same Code Green training as the nursing staff that includes the use of least restrictive interventions with the addition of security based training that is scenario based. A Code Green can be called by any staff member, but a nurse is always in charge of leading the code. Security is part of the team, but cannot make any clinical decisions like restraint application. Security staff are trained to utilize a TASER with specific training that is supplied by TASER and instructed by a TASER certified trainer. SM stated security staff are trained to use a TASER when an officer perceives an imminent risk of substantial (bite, kick, punch) or great (broken bone, death) bodily harm. SM stated they reviewed the event after it occurred. Based on the review P1 other measures that were least restrictive should have been implemented creating more space between SO-A and P1. SO-A seemed to have been leading to the Code Green. The Code Green process includes a registered nurse as the director of a Code Green. On 5/22/2024 at 2:47 p.m., MD-A stated staff should utilize de-escalation techniques like talking, coping skills, a quieter environment, relaxation skills, or as needed medications when a patient is getting agitated. MD-A stated use of a taser could be a traumatic experience. On 5/22/2024 at 3:34 p.m., MD-B stated the use of a taser could cause a life-threatening irregular heartbeat or a heart attack in a person with heart disease. MD-B would worry about taser use in the hospital because staff do not always know all of a patient’s health conditions. On 5/21/2024 at 2:39 p.m., accreditation program manager stated de-escalation techniques should be attempted first during a Code Green before a clinical decision is made for restraint use. A nurse or provider make clinical decisions during a code green. A TASER and handcuffs are not clinical restraints and should not be used as such. The TASER Handheld Energy Weapon Warnings, Instructions, and Information: Law enforcement manufacturer document dated 9/20/22 indicated use of a taser could cause death or serious injuries including hernia rupture, dislocation, tear, or other injury to soft tissue, organ, muscle, tendon, ligament, cartilage, disk, nerve, bone or joint. Injuries may be more serious and more likely to occur in people with pre-existing injuries, orthopedic hardware, and other conditions or special susceptibilities including pregnancy, low bone density, spinal injury, or previous muscle, disk, ligament, joint, bone or tendon damage or surgery. Energy weapon use, anticipation of use, or response to use can cause startle, panic, fear, anger, rage, temporary discomfort, pain, or stress. The TASER - Conducted Electrical Weapon policy dated 11/2022 instructed the TASER will not be used as a health care intervention to restrain patients, to place patients in seclusion, to punish, or to gain compliance of a resistant, nonviolent individual. The Use of Security Interventions policy dated 1/23/24 instructed law enforcement tools must not be used as a clinical intervention or any part of patient care, including to gain patient compliance or subdue a patient to place the patient in restraint or seclusion. Law enforcement restraint devices may be used only to hold a person in custody when effecting an arrest and delivering them to the custody of law enforcement.”