Mercy Hospital South

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 50321 Based on observation, interview, record review and policy review, the hospital failed to follow the hospital’s seizure precaution (SP, precautions designed to protect a patient from injury and to reduce stimuli that may trigger the onset of a seizure [sudden, uncontrolled electrical disturbance in the brain which cause changes in behavior, movements and/or in levels of consciousness]) policy for three current patients (#21, #44 and #45) of four current patients with SPs observed and follow the hospital’s isolation precaution (IP, techniques used to prevent the spread of highly contagious or high risk infections) policy for three current patients (#23, #39 and #53) of three current patients with IPs observed. Please refer to A-0395.”

“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: 50321 Based on observation, interview, record review and policy review, the hospital failed to follow the hospital’s seizure precaution (SP, precautions designed to protect a patient from injury and to reduce stimuli that may trigger the onset of a seizure [sudden, uncontrolled electrical disturbance in the brain which cause changes in behavior, movements and/or in levels of consciousness]) policy for three current patients (#21, #44 and #45) of four current patients with SPs observed and follow the hospital’s isolation precaution (IP, techniques used to prevent the spread of highly contagious or high risk infections) policy for three current patients (#23, #39 and #53) of three current patients with IPs observed. Findings included: Review of the hospital’s document titled, “Managing Seizures in Adults in the Hospital,” dated 2026, showed supplies necessary for the management of seizures in adult patient’s included padding for side rails. The implementation of precautions to prevent seizure related injury included placing a sign at the patient’s bedside to indicate they were on SPs. Review of the hospital’s policy titled, “Inpatient Contact Precautions,” dated 12/02/25, showed staff should don an isolation gown and gloves before they enter a patient’s room with a contact isolation (precautions used to minimize the risk of infection spreading through touching an infected person or contaminated object) order. The isolation gown should fully cover the torso (upper body, consisting of shoulders, chest, abdomen, back and hips) from the neck to knees, arms to the end of wrists, and wrap around the back, fastened in the back of the neck and waist. Review of Patient #21’s medical record, dated 03/23/26, showed: - She was admitted to the hospital for alcohol detoxification (the process of removing drugs or alcohol from the body). - She had a history of alcohol use disorder (an addiction to the consumption of alcoholic liquor), alcohol withdrawal (symptoms that occur upon abrupt discontinuation of medications, alcohol or drugs) and experienced a seizure on 03/01/25 related to benzodiazepine (medication used to relieve anxiety and muscle spasms and reduce seizures; produce sedation) withdrawal. - SPs were ordered. Observation on 03/30/26 at 3:06 PM, on the fifth floor, showed Patient #21 was in her bed. She did not have seizure pads on her side rails, nor a SP sign on her door or near her bed. There were no seizure pads in her room. Review of Patient #44’s medical record, dated 03/25/26, showed: - He was admitted to the hospital after a syncopal (to faint) event. - He had a history of alcohol use disorder and alcohol withdrawal with previous seizures. - He experienced a seizure while in the emergency department (ED). - SPs were ordered. Observation on 03/31/26 at 2:17 PM, on the sixth floor, showed Patient #44 was in his bed. He did not have seizure pads on his side rails. Seizure pads were on the floor in front of his bed. Review of Patient #45’s medical record showed: - On 03/29/26, he was admitted to the hospital after a witnessed seizure. - Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) reported that he required intubation (process where a healthcare provider inserts a tube through a person’s mouth or nose down into their windpipe when a person is not breathing on their own) for status epilepticus (a seizure lasting longer than five minutes, or multiple seizures occurring close together without the person regaining consciousness in between). - He had a history of seizures, and experienced intermittent seizures every couple of weeks per family report. - SPs were ordered. Observation on 03/31/26 at 2:20 PM, on the eighth floor, showed Patient #45 was in his bed. He did not have seizure pads on his side rails, nor a SP sign on his door or near his bed. There were no seizure pads in his room. Review of Patient #23’s medical record, dated 03/26/26, showed: - He was admitted to the hospital after he pulled his ostomy (a surgery to create an opening [stoma] from an area inside the body to the outside) out. - He had a history of Methicillin-Resistant Staphylococcus aureus (MRSA, highly contagious bacteria, that causes infections in different parts of the body and is resistant to many common antibiotics) infections. - Contact IPs were ordered. Observation on 03/30/26 from 2:15 PM to 3:00 PM, Staff WW, RN, was in Patient #23’s room and wore an isolation gown with unsecured ties at the waist. As Staff WW walked around the room, her gown moved and exposed her lower torso, legs and back. At 2:45 PM, Staff XX, RN, donned an isolation gown with unsecured ties at the waist and entered Patient #23’s room. As she walked around the room, her gown moved and exposed her lower torso, legs and back. Both Staff WW and Staff XX repeatedly withdrew their unit provided phones and other supplies from their pockets and returned the items to their pockets without cleaning them, further exposing their lower torso, legs and back to contaminated surfaces in Patient #23’s room. Review of Patient #39’s medical record, dated 03/24/26, showed: - He was admitted to the hospital for Osteomyelitis (infection of the bone) of the right foot. - He had a history of vancomycin-resistant enterococci (VRE, bacteria resistant to vancomycin [antibiotic]) and multi-drug-resistant organism (MDRO; bacteria resistant to many antibiotics) infections. - Contact IPs were ordered. Observation on 03/31/26 from 10:00 AM to 10:30 AM, on the cardiovascular progressive care unit (CVPCU), showed Staff EEE, Nursing Instructor, donned an isolation gown and entered Patient #39’s room three times with unsecured ties at the waist. As she walked around the room, her gown moved and exposed her lower torso, legs and back. Review of Patient #53’s medical record, dated 03/24/26, showed: - He was admitted to the hospital for potential pneumonia (infection in the lungs). - He had a history of MRSA, VRE and MDRO infections. - Contact IPs were ordered. Concurrent observation and interview on 03/31/26 at 2:17 PM, on the sixth floor, Staff III, RN, stood at the doorway of Patient #53’s room. He wore an isolation gown with unsecured ties at the waist. Staff III stated that Patient #44 had SPs ordered. He was unaware the seizure pads were on the floor and not secured to the side rails. After interview from the doorway, Staff III turned and entered Patient #53’s room. As he walked, his gown moved and exposed his lower torso, legs and back. During an interview on 04/01/26 at 11:13 AM, Staff RR, Patient Care Vice President (VP), stated that he expected staff to implement SPs when ordered. SPs included seizure pads applied to side rails and signage. He agreed that Isolation gowns should be secured and tied at the waist to fully cover the lower torso, legs and back, per policy.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47504 Based on observation, interview, record review and policy review, the hospital failed to ensure: - Staff followed policy and procedure to ensure a consent for treatment was obtained for six current patients (#1, #9, #20, #24, #25 and #37) of 18 patients reviewed. (A-0131) - Staff could identify current patients with a durable power of attorney (DPOA, a legal document that lets a person name someone else to make decisions about their health care in case they were not able to make those decisions themselves) for health care for seven current patients (#6, #9,#12, #20, #21, #22, and #24) of nine patients observed. (A-0131) - Staff followed policy and procedure to provide a one-to-one (1:1, continuous visual contact with close physical proximity) oversight for two current patients (#19 and #49) who were on suicide precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm) with a 1:1 continuous order. (A-0144) - Staff followed policy and procedure for completion of safety room checks on patients assigned a 1:1 observer when the rooms of three current patients (#19, #48, and #49) on 1:1 were not checked. (A-0144) - The safety of one discharged behavioral health patient (#27) of one patient reviewed with a 30-day court ordered hold (a court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) for mental health care was discharged after receiving ten days of therapy. (A-0144) - Staff followed policy and procedure for assessing and monitoring of all patients placed in restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) or seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving). (A-0154) - Staff followed policy and procedure for identifying the use of chemical restraints (a form of medical restraint in which a drug is used to restrict the freedom or movement of a patient) and placement of one chemically restrained discharged patient (#27) out of one patient reviewed on the restraint log. (A-0165) - Staff followed policy and procedure to ensure all restraints were placed on the restraint log and able to provide an accurate restraint log in a timely manner. (A-0175) These failed practices resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation (CoP): Patient’s Rights. Please refer to A-0131, A-0144, A-0154, A-0165 and A-0175.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 47504 Based on observation, interview, record review and policy review, the hospital failed to ensure staff followed the hospital’s policy and procedure to ensure a consent for treatment was obtained for six current patients (#1, #9, #20, #24, #25 and #37) out of 18 patients reviewed. And that staff could identify current patients with a durable power of attorney for health care (DPOA, a legal document that lets a person name someone else to make decisions about their health care in case they were not able to make those decisions themselves) for seven current patients (#6, #9,#12, #20, #21, #22, and #24) of nine patients observed. Findings included: Review of hospital policy titled, “MW Informed Consent Policy,” dated 01/31/2025, showed the policy was to establish guidelines for obtaining informed consent from patients for surgical, diagnostic medical procedures, treatments and anesthesia. The maximum duration of a consent form was 30 days. This policy did not address specifically the general consent to treat form obtained upon admission. Although requested, a policy for consent to treat was not provided. Review of Patient #1’s medical record showed he was admitted on 10/2/25 and his consent to treat was dated 04/09/25. Review of Patient #9’s medical record showed he was admitted on 10/16/25 and his consent to treat was dated 11/17/24. Review of Patient #20’s medical record showed he was admitted on 10/19/25 and his consent to treat was dated 04/19/24. Review of Patient #24’s medical record showed he was admitted on 10/27/25 and his consent to treat was dated 11/11/24. Review of Patient #25’s medical record showed she was admitted on 10/27/25 and her consent to treat was dated 11/22/24. Review of Patient #37’s medical record showed she was admitted on 10/28/25 and her consent to treat was dated 11/19/24. Review of hospital policy titled, “Patient Rights and Responsibilities Policy,” dated 02/02/2023, showed all patients have a right to formulate or review and revise advanced directives and have hospital co-workers comply with these directives in accordance with the law and hospital’s capabilities. Review of hospital policy titled, “Advance Directive Policy,” dated 08/05/2022, showed an advance directive was a general term for a signed document that gives instructions about a patient’s health care and/or appoints a person and/or agent to make future medical treatment decisions if and when the patient becomes unable to make those decisions. These documents may be known by various names, including Durable Powers of Attorney for Health Care. All patients should receive care that honors their advance directives. Staff must be aware of the existence of advance directives in the medical record and ensure that if and/or when a patient becomes unable to make decisions, their legally valid advance directives and wishes are implemented to the extent permissible under state law. Review of hospital policy titled, “Communication between Caregivers Policy,” dated 04/22/2024, showed a hand-off communication was defined as the transfer of accountability for patient care from one care provider to another. The primary objective of the policy was to provide patient safety and ensure accurate information about a patient’s care was communicated. All hand-offs should include resuscitation status, advanced directives and the current condition of the patient. Review of an untitled and undated hospital document showed there were 24 patients identified as having a legal guardian or DPOA on the third floor, and 11 patients on the fifth floor. Review of the medical record for Patient #6, showed she was admitted on 10/22/25 to the third floor general surgery unit with a DPOA on file. Review of the medical record for Patient #20, showed he was admitted on 10/19/25 to the third floor general surgery unit with a DPOA file. Review of the medical record for Patient #21, showed she was admitted on 10/23/25 to third floor general surgery with a DPOA on file. Review of the medical record for Patient #22, showed he was admitted on 10/25/25 to third floor generally surgery with a DPOA on file. During an interview on 10/27/25 at 4:00 PM, Staff G, Registered Nurse (RN) Supervisor of third floor general surgery, stated there were currently no patients on the unit with legal guardians or with a DPOA. During an interview on 10/27/25 at 4:10 PM, Staff H, RN, stated there were no current patients on the third-floor general surgery unit with legal guardians or with a DPOA. During an interview on 10/27/25 at 4:15 PM, Staff I, Licensed Practical Nurse (LPN), stated there were no current patients on the third-floor general surgery unit with legal guardians or with a DPOA. During an interview on 10/27/25 at 4:30 PM, Staff F, RN, stated there were no current patients on the third-floor general surgery unit with legal guardians or with a DPOA. During an interview on 10/27/25 at 4:45 PM, Staff L, Vice President of Patient Care/Chief Nursing Officer (CNO), stated it was odd that there were no patients on the entire third floor with a legal guardian or DPOA. “I don’t think that is correct, I requested a list for all the patients on the third floor with a legal guardian or DPOA from the administration office.” Staff should be able to identify patients with a legal guardian or DPOA. Review of the medical record for Patient #12, showed he was admitted on 10/27/25 to the third floor medical intensive care unit (MICU) with a DPOA on file. During an interview on 10/28/25 at 11:45 AM, Staff U, RN, who was assigned to Patient #12 was not aware he had a DPOA. Staff U stated he could look in the Electronic Medical Record (EMR) to check, but would not know who to contact if there was an emergency. Review of the medical record for Patient #24, showed he was admitted on 10/27/25 to four south with a DPOA. During an interview on 10/28/25 at 11:15 AM, Staff LL, RN, stated that she did not currently have any patients with a DPOA on four south. DPOA information was passed on in report. “We should review our patients daily to ensure we are aware of our patients that have a DPOA.” Staff LL was assigned to care for Patient #24. During an interview on 10/28/25 at 3:15 PM, Staff E, Manager, stated that each nurse should look and be aware of their patients that have a legal guardian or DPOA. It should be relayed in shift report and supervisors and managers are responsible to know who on their floor has a DPOA.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 47504 Based on observation, interview, record review, and policy review, the hospital failed to: - Follow policy and procedure when providing one-to-one (1:1, continuous visual contact with close physical proximity) continuous observation for two current patients (#19 and #49) of two patients reviewed who were on suicide precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm) with a 1:1 continuous observation order. - Ensure safety room checks were completed for three current patients (#19, #48, and #49) of three patients observed with 1:1 observation orders. - Ensure the safety of one discharged behavioral health patient (#27) on a 30-day hold (a court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) for mental health care was discharged after receiving ten days of therapy for one patient reviewed. Findings included: Review of the hospital’s policy titled, “Suicidal (to cause one’s own death) Patients, Admission Assessment, Level of Care, and Suicide Precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm) Policy,” dated 10/03/2023, showed: - A safe environment would be provided for all patients who were identified as having a suicide risk or having SP ordered. - Patients identified as a high suicide risk were those with a plan to kill themselves and were unable to attest to safety plan. A 1:1 sitter should be assigned. - Patients identified as a moderate suicide risk patients were those having suicidal thoughts but no specific plan to kill themselves. A 1:1 sitter should be considered. - All suicidal patients should be placed in psychiatric safe scrubs and items considered to be dangerous, such as wire hangers, plastic bags, toiletry items, call light cords, shoelaces, belts and all sharp objects, should be removed. - Observations provided by safety sitters should be documented in the behavioral health safety rounding flowsheet within the electronic medical record (EMR) every 30 minutes. Review of Patient #19’s medical record showed he was a 71-year-old who presented to the Emergency Department (ED) on 10/22/25 with an altered mental status (AMS, any change in a person’s mood, behavior, psychomotor skills, and/or cognition). He was not eating or drinking, refusing to take prescribed medication, had a flat affect (absence or near absence of emotional expression), was depressed (extreme sadness that doesn’t go away), and providing one-word answers. He was admitted to the medical floor with the diagnosis of acute metabolic encephalopathy (a sudden brain dysfunction caused by a chemical imbalance, leading to symptoms like confusion) and major depressive disorder (a long period of feeling worried or empty with a loss of interest in activities once enjoyed). During his initial behavioral health (BH) evaluation it was determined that he did not meet criteria for in-patient therapy. On 10/27/25 at 2:14 PM, Patient #19 stated someone was coming to the hospital to kill him and his son. He wanted to go home and kill himself. His physician placed him on SP, and he was assigned a 1:1 safety sitter. On 10/28/25 at 1:28 PM, he was re-evaluated and was deemed a safety risk to himself and others. A 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) was initiated and he was admitted for in-patient care on the BHU. While on the medical floor, no documentation of a 1:1 safety sitter was found for 10/27/25 at 1:15 PM through 10/28/25 at 6:30 AM. There were no room safety checks documented from 10/27/25 through 10/31/25. The room safety checks were inconsistent and not completed each shift. Review of Patient #49’s medical record showed he was 27-year-old who was admitted on 10/25/25, to the medical floor with AMS due to a possible overdose. He was diagnosed with acute metabolic encephalopathy. He was placed on SP with a 1:1 safety sitter. On 11/01/25 there was no 1:1 documentation from 7:00 AM until 2:30 PM. There were no room safety checks documented on 11/01/25, 11/03/25, 11/04/25, 11/06/25, 11/07/25 and 11/10/25. The room safety checks were inconsistent and not completed each shift. Review of Patient #48’s medical record showed he was a 48-year-old admitted on 10/26/25 for an attempted suicide. He was placed on SP. There were no room safety checks documented from 10/31/25 through 11/03/25. With only one room safety check documented on 10/26/25 at 8:33 PM, on 10/27/25 at 7:15 PM, and on 10/28/25 at 8:15 AM. The room safety checks were inconsistent and not completed each shift. During an interview on 11/11/25 at 1:00 PM, Staff PP, BHU Director, stated that room safety checks were to be completed on every shift by the Patient Care Technicians (PCT). All 1:1 patients should have a safety sitter assigned and they should document per policy. During an interview on 11/11/25 at 2:00 PM, Staff L, Vice President (VP) Patient Care, stated that room safety checks should be completed every shift. He was not sure who was responsible for completing the room safety checks but it was ultimately the responsibility of the assigned nurse to ensure they had been completed. All patients assigned a 1:1 continuous safety sitter should have a staff member present at all times and be documented on every 15 minutes. During an interview on 11/11/25, Staff XX, Quality VP, stated room safety checks should be completed every shift. The hospital’s policy did not designate whether the 1:1 safety sitter, PCT, or Registered Nurse (RN) should complete the room safety checks. All SP patients with a continuous 1:1 order should have a person assigned to them 24 hours per day. Safety sitters should document every 15 minutes. Review of the undated hospital document titled, “Resolution Manager Form Complaint,” showed: - On 06/16/25, Patient #27’s guardian (the person appointed by a judge to manage the property and rights of another person who is considered incapable of doing so themselves) filed a complaint indicating that the hospital had violated two court orders. One appointing guardianship and a second order for 30-day commitment. - Patient #27 was discharged without his guardian’s consent. - An investigation was not initiated for this complaint. Review of hospital document titled, “Circuit Court of St Louis County, Missouri,” dated 09/03/25 showed, “The court finds that a guardian was appointed for (Patient #27), his parents. His release is authorized to the care of his guardians. His guardians were to transport him directly to inpatient mental health treatment immediately from discharge from the Department of Justice Services. This inpatient mental health treatment is to last for at least 30 days with authorization from the court for further.” It was signed by the Judge on 09/03/25. Review of the undated hospital document titled, “Affidavit in Support of Application for Detention, Evaluation and Treatment/Rehabilitation (a supervised in the care and treatment of the physical restorative needs of patients) Admission for 96 hours,” showed Patient #27 had been released from jail and exhibited dangerous behavior. He threw his pants off in public and ran around the outside of the court building ranting insults and calling people names. He jumped over the turn style to re-enter the court building and yelled he wanted to kill everyone who worked at the Justic Center. He insisted he speak with the Judge. Patient #27 was unaware of personal aspects of his life, paranoid (excessive suspiciousness without adequate cause), and needed to be committed until he can be treated and was not a threat to others.” No witness signature was present. Review of hospital policy titled, “BH Inpatient Involuntary Commitment,” dated 05/09/25, the designated mental health professional was responsible for patients admitted under an involuntary admission, or 96-hour hold. They should obtain all necessary forms, interview the patient and whomever accompanied the patient. Original affidavits provided by collateral persons should be obtained when available. All documents should be notarized. Although requested, a policy was not provided for court mandated orders greater than 96 hours. Review of Patient #27’s medical record showed he was a 36-year-old male who presented to ED via EMS on 09/03/25 at 12:17 PM. He was at the courthouse after being released from jail. His parents were made legal guardians (LG) at the court hearing. While at the courthouse Patient #27 took his clothes off and was running around the courthouse threatening to kill people. The Circuit Court ordered inpatient mental health treatment for at least 30 days. He was evaluated and upon examination he was agitated and paranoid. He was administered Haldol (a medication used to treat mental disorders by decreasing excitement of the brain) and Lorazepam (a medication used to treat anxiety or sleep difficulty) and required the use of restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head). He was admitted and transferred to the BHU on 09/07/25 at 6:18 PM. He was diagnosed with schizoaffective disorder, bipolar type (mental illness that is characterized by symptoms of mania, depression and mood disturbances) with agitation (a state of feeling irritated or restless) and generalized anxiety disorder (chronic condition where fear and worry impairs a person’s ability to function and interferes with their well-being). His treatment care plan indicated that severity and complexity of his illness was high. On 09/08/25 at 2:44 PM, an initial discharge planning assessment was completed. The Social Worker (SW) met with Patient #27 on the BHU to develop treatment goals and to initiate discharge plans. On 09/09/25 at 2:15 PM, a SW called the LG to inquire about a home plan. His LG stated Patient #27 could not discharge to home. His LG stated her understanding of the court order was for him to discharge to a mental facility. The Case manager (CM) discussed placement options. His LG stated he received Medicaid and had no source of income. The CM informed his LG that Patient #27 would need a source of income prior to sending out placement referrals. Patient #27 stated he had no money, and parents were unable to pay out of pocket for placement. On 09/17/25 at 12:02, Patient #27 was discharged to home. A risk assessment was completed at discharge and his imminent risk of suicide or self harm was determined to be at a safe level for discharge. He denied thoughts of self-harm or suicidal ideation and could identify protective factors. A personalized safety plan was developed and sent with him. Patient #27 agreed with their safety plan as well as to return to the hospital, if necessary. He was given information for outpatient services. During an interview on 10/29/25 at 2:30 PM and 11/11/25 at 12:00 PM, Staff PP, BHU Director, stated that Patient #27 had been treated and discharged appropriately. He stated, “We are acute care not long-term care, and we do not abide by court orders if a physician determined he was safe to discharge. He also had a 96 hour hold and we completed that. We went by that document.” He was discharged home to his LGs via cab with discharge instructions. He stated, “We do not treat drug and alcohol long term, and he had problems.” On 11/11/25, he stated the discharge planner had made a “robust” discharge plan for Patient #27. He was medically stabilized and discharged. This plan was discussed with his LG and they agreed with this decision. “This court order was from a circuit court, it was a strange order, we do not deal with court orders from a circuit court.” He was stabilized with medication, had an outpatient appointment set up for follow-up and we discharged him home to the care of his LG. “I did consult legal and asked them to review this case prior to his discharge.” There was no documentation provided that showed the consult with legal. The 96-hour hold was not notarized. .”

“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: 38236 Based on interview, record review and policy review the hospital failed to assess and monitor the use of restraint and seclusion. This failure placed all patients at risk for their safety. Findings included: Review of the hospital’s policy titled, “Safety Plan Policy,” reviewed 07/29/25, showed: - Quality monitoring was the ongoing surveillance of outcomes and the processes which affect them in order to assure that expected levels of performance are maintained. - Priorities were set for its performance improvement which included activity that affect health outcomes, patient safety and quality of care. - Data will be gathered, analyzed and reported to leadership. Restraint use was included in the data gathering. Although requested, the hospital failed to provide assessment and monitoring of restraint and seclusion. During an interview on 11/11/25 at 2:30 PM, Staff XX, Vice President (VP) Quality, stated that restraints were reviewed in the moment by nurse leaders. They were audited by exception in the moment by patient safety and workplace committee. 47504”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(3) The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient or others from harm. This Standard is not met as evidenced by: 38236 Based on observation, interview, record review and policy review, the hospital failed to follow policy and procedure and ensure all chemical restraints (a form of medical restraint in which a drug is used to restrict the freedom or movement of a patient) were identified as a restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body or head) and placed on the restraint log for one discharged patient (#27) out of one patient reviewed. Findings included: Review of hospital policy titled, “Use of Restraint and Seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) for Management of violent or self-destructive behavior policy,” dated 06/04/25, showed a chemical restraint was a medication or combination of medications used to control behavior or to restrict a patient’s movement and is not a standard treatment or dosage for the patient’s condition. If the overall effect of a medication, or combination of medications, was to reduce the patient’s ability to effectively or appropriately interact with the world around them (the patient becomes sedated or somnolent), then the medication is not being used as a standard treatment or dosage for the patient’s condition. Review of hospital policy titled, “Patient Death While In Restraint Or Seclusion Policy,” dated 01/30/24, showed a restraint was any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move their arms, legs, body, or head freely; or a drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. Restraint Logs must be immediately available to surveyors on request. Although requested, a policy for restraint logs was not provided. Review of the hospital’s document titled, “Current Active Restraint Orders,” dated 10/29/25 at 3:29 PM, showed there were 14 patients with active restraint orders. No chemical restraints were identified on the restraint log. Review of the hospital’s document titled, “Main Hospital Restraints Past Six Months,” dated 10/29/25 at 4:06 PM, showed no chemical restraints were identified on the restraint log. Review of the hospital’s document titled, “Hyland Restraints Past Six Months,” dated 10/30/25 at 9:29 AM, showed no chemical restraints were identified on the restraint log. Review of the hospital’s document titled, “ED Restraint Log,” dated 11/3/25 at 2:25 PM, showed no chemical restraints were identified on the restraint log. Review of Patient #27’s medical record showed he was a 36-year-old male who presented to the Emergency Department (ED) via Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) on 09/03/25 at 12:17 PM. He was at the courthouse after being released from jail. His parents were made legal guardians (LG, a person appointed by a judge to take care of and manage the property and rights of a person who is considered incapable of administering his or her own affairs) at his court hearing. While at the courthouse Patient #27 took his clothes off and ran around the courthouse threatening to kill people. The Circuit Court ordered inpatient mental health treatment for at least 30 days. He was evaluated and upon examination he was agitated and paranoid (excessive suspiciousness without adequate cause) and was administered Haldol (a medication used to treat mental disorders by decreasing excitement of the brain) five mg and Lorazepam (a medication used to treat anxiety or sleep difficulty) two mg intramuscularly (IM, within the muscle). There were no chemical restraints identified on the restraint log. During an interview on 11/11/25 at 2:00 PM, Staff L, Vice President (VP) Patient Care, stated he was unaware chemical restraints were not listed on the restraint log. He stated, “chemical restraints were considered a restraint and should be identified on the restraint log, but their system did not identify them.” During an interview on 11/11/25 at 12:00 PM, Staff PP, Behavioral Health Unit (BHU) Director, stated, “If you looked at the manual holds, that would be the chemical restraints.” Their system did not identify chemical restraints. Any medication that was given for a patient’s behavior was considered a chemical restraint. During an interview on 11/25/25 at 2:30 PM, Staff XX, VP Quality, stated that the original restraint log that was given did not contain the ED restraints. She was unaware it was kept on a separate log. She stated that chemical restraints were identified in their policy as a restraint, but their system did not identify a chemical restraint on their restraint log. 47504”

“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: 47504 Based on observation, interview, record review, and policy review, the hospital failed to follow their policy and procedure and ensure all incidents of restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body or head) were placed on the restraint log and to provide an accurate restraint log in a timely manner. Findings include: Review of hospital policy titled, “Patient Death While In Restraint Or Seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) Policy,” dated 01/30/24, showed a restraint was any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move their arms, legs, body, or head freely; or a drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. Restraint logs must be immediately available to surveyors upon request. Review of the request list presented to the hospital on 10/27/25 at 2:30 PM, showed a request for the restraint log for the past six months. On 10/28/25 at 4:46 PM, a hospital document titled, “Injuries from Restraints,” was provided to the survey team. The document showed nine patients identified with an injury from a restraint. Three out of nine patients were not identified on the restraint log that was previously presented to the survey team. On 10/29/25 at 8:30 AM, an additional request was made for the hospital to identify the type of all restraints. On 10/29/25 at 4:06 PM, the hospital’s document titled, “Main Hospital Restraints Past Six Months,” was provided to the survey team. The log displayed restraints for the hospital for the past six months. On 10/30/25 at 9:29 AM, the hospital’s document titled, “Hyland Restraints Past Six months,” was provided to the survey team. The log displayed restraints for the Behavioral Health Unit (BHU) only. Chemical restraints (a form of medical restraint in which a drug is used to restrict the freedom or movement of a patient) were not identified. On 10/30/25 at 2:50 PM, an additional request was made by the survey team for all logs related to restraints. On 11/03/25 at 2:35 PM, the hospital’s document titled, Emergency Department (ED) Restraint Log,” was provided to the survey team. The log displayed restraints for the ED only. No other logs were provided to the survey team. During an interview on 11/11/25 at 2:00 PM, Staff L, Vice President (VP) Patient Care, stated he was unaware chemical restraints were not listed on the restraint log, and he was not aware the survey team had received multiple copies of the restraint log. He was not aware that there were multiple restraint logs from various departments. He did not know who was responsible for the restraint log. During an interview on 11/11/25 at 12:00 PM, Staff PP, BHU Director, stated “If you looked at the manual holds, that would be the chemical restraints.” Their system did not identify chemical restraints. Any medication that was given for a patient’s behavior was considered a chemical restraint. He reviewed all restraints at the BHU. The BHU restraint log was different from the main hospital. During an interview on 11/25/25 at 2:30 PM, Staff XX, VP Quality, stated that the original restraint log that was given did not contain the ED restraints. She was unaware it was kept on a separate log. She stated that chemical restraints were identified in their policy as a restraint, but their system did not identify a chemical restraint on their restraint log.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 48359 Based on interview, record review and policy review, the hospital failed to: - Provide registered nurse (RN) supervision and evaluation of nursing care for two patients (#32 and #33) of two patients with wounds reviewed; (A-0395) - Follow the hospital’s policy for skin assessment and care for four patients (#5, #14, #32 and #33) of four medical records reviewed; (A-0398) - Follow the hospital’s policy for pain assessment and management for two patients (#36 and, #37) of three Emergency Department (ED) medical records reviewed; (A-0398) - Follow the hospital’s policy for fall prevention for three patients (#42, #43 and #44) of three medical records reviewed; (A-0398) - Follow the hospital’s policy for visitor safety in isolation precautions (techniques used to prevent the spread of highly contagious or high-risk infections) rooms for one patient (#16) of one patient observed; (A-0398); - Follow the hospital’s policy for labeling intravenous (IV, in the vein) dressings and tubing for 11 patients (#1, #3, #4, #5, #6, #9, #10, #11, #17, #18 and #27) of 22 patients observed; (A-0398) and - Follow the hospital’s policy for Standard Precautions (also known as universal precautions, avoiding contact with patients’ bodily fluids by means of wearing gloves, goggles and face shields) for 14 patients (#3, #5, #7, #10, #12, #15, #16, #17, #19, #21, #22, #26, #28 and #30) of 18 patients observed. This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.23 Condition of Participation (CoP): Nursing Services. Please refer to A-0395 and A-0398.”

“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: 38236 Based on interview, medical record review and document review, the hospital failed to provide registered nurse (RN) supervision and evaluation of nursing care for two patients (#32 and #33) of two patients with wounds reviewed. These failures had the potential to lead to poor outcomes for patients with wounds and those at risk for skin breakdown. Findings include: Review of the hospital’s document titled, “Card Tele Audits,” dated 07/15/25 through 08/15/25, showed the audit review included the Braden Scale assessment (an assessment tool for predicting the risk of bed sores or pressure ulcers) completion, two-person skin assessment documentation, door signage for staff awareness, appropriate patient surface, reposition completion and documentation every two hours. On 08/04/25 at 11:27 AM, one audit was performed for Patient #32 and showed within defined limits. Review of Patient #32’s medical record, dated 07/27/25 through 08/04/25 showed: - On 07/27/25 from 12:00 AM to 6:30 AM, he was not repositioned. His Braden score was 19. - On 07/28/25 from 10:40 PM to 6:40 AM, he was not repositioned. - On 07/29/25 at 10:09 AM, Patient #32 complained of bottom pain which was very red. His Braden score was not updated with the new skin condition. No skin/pressure injury (injury to the skin and/or underlying tissue, usually over a bony area) prevention interventions were implemented. - At 3:00 PM, 6:00 PM and from 10:15 PM to 4:00 AM, he was not repositioned. - At 5:35 PM, he was transferred to a higher level of care and a skin assessment showed his buttocks had non-blanchable (paling or whitening of the skin when pressed, when skin does not become pale with pressure it is often an indication of injury to the tissue) redness. The skin, wound and ostomy team (SWOT) was consulted, and the patient was placed on an air mattress. His Braden score was 15. Wound pictures showed redness, a large open blister on the left side of the buttocks and several closed blisters on his buttocks. Although requested the hospital failed to provide leadership skin and wound care audits for the Medical-Stepdown unit, none were completed. Review of Patient #33’s medical record dated 06/15/25, showed he was in the Medical-Stepdown unit from 06/15/25 through 06/29/25. During a telephone interview on 08/28/25 at 9:00 AM, Staff A, Chief Nursing Officer (CNO), stated the unit managers were expected to perform daily skin and wound care audits to ensure all of the correct processes were in place and provide follow up education to staff who did not meet the expectations. 51292”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 48359 Based on observation, interview and policy review; the hospital failed to follow the hospital’s policy for: - Skin assessment and care for four patients (#5, #14, #32 and #33) of four medical records reviewed; - Pain assessment and management for two patients (#36 and, #37) of three Emergency Department (ED) medical records reviewed; - Fall prevention for three patients (#42, #43 and #44) of three medical records reviewed; - Visitor safety in isolation precautions (techniques used to prevent the spread of highly contagious or high-risk infections) rooms for one patient (#16) of one patient observed; - Labeling intravenous (IV, in the vein) dressings and tubing for 11 patients (#1, #3, #4, #5, #6, #9, #10, #11, #17, #18 and #27) of 22 patients observed; and - Standard Precautions (also known as universal precautions, avoiding contact with patients’ bodily fluids by means of wearing gloves, goggles and face shields) for 14 patients (#3, #5, #7, #10, #12, #15, #16, #17, #19, #21, #22, #26, #28 and #30) of 18 patients observed. These failures could place all patients at risk for their safety. Findings included: Review of the hospital’s policy titled, “Nursing Standards and Documentation Guidelines,” approved 01/24/25, showed a comprehensive and systematic head-to-toe assessment is performed and documented at the beginning of each shift, when assuming care of the patient, upon transfer to a new unit, with any major or minor change in patient condition and more often, as necessary by patient condition. A Braden Scale (an assessment tool for predicting the risk of bed sores or pressure injury [injury to the skin and/or underlying tissue, usually over a bony area]) score of 18 or less will prompt further interventions. Review of Patient #5’s medical record dated 08/18/25, showed: - He was a 60-year-old who was admitted through the ED with congestive heart failure (CHF, a weakness of the heart that causes it to not pump blood like it should leading to a buildup of fluid in the lungs and surrounding body tissues.). - He had a history of high blood pressure, right toe osteomyelitis (infection of the bone), chronic obstructive pulmonary disease (COPD, a lung disease that prevents normal airflow and breathing), diabetes (a disease that affects how the body produces or uses blood sugar and can cause poor healing) and peripheral artery disease (PAD, blood circulation disorder that causes arteries to narrow, block or spasm and cause pain and tiredness in the legs, arms, or other body parts). - At 10:19 AM, a wound care order for his right foot was written for every eight hours. There were no specific wound care directions and there was no attempt to clarify the order. - From 08/18/25 at 11:05 AM through 08/19/25 at 8:11 AM, he was not turned. - At 11:15 AM, his Braden Scale was 18. - At 11:00 AM, skin assessment pictures showed he had buttock and penis irritation, his right foot had peeled skin and discoloration and his right first toe had a black wound. - No wound care was provided. Review of Patient #14 medical record, dated 07/31/25 showed: - He was a 62-year-old admitted for a planned tracheostomy (an opening created in the neck in order to place a tube into a person’s windpipe that allows air to enter the lungs) and percutaneous endoscopic gastrostomy (PEG, a tube inserted through a person’s abdomen directly into the stomach to provide a means of feeding when oral intake is not possible) placement following a heart attack that left him with an anoxic brain injury (harm to the brain due to a lack of oxygen). - His initial skin assessment showed he had no skin abnormalities. His Braden Scale score was eight, which initiated the hospital protocol for a pressure relieving mattress, heel elevation, repositioning wedges, turning every two hours and foam dressings to protect bony prominences (parts of the body where a bone is close to the skin’s surface). - On 08/01/25, he was not turned from 4:00 PM to 8:00 PM. - On 08/02/25, he was not turned from 3:00 PM to 6:47 PM. - On 08/03/25, he was not turned from 9:00 AM to 1:00 PM. - On 08/04/25, he was not turned from 11:00 AM to 3:00 PM and 5:00 PM to 8:00 PM. - On 08/05/25, he was not turned from 9:00 AM to 6:00 PM. Review of Patient #32’s medical record, dated 07/27/25, showed: - He was an 89-year-old admitted through the ED with bradycardia (slow heart rate) and lower leg swelling. - He had a history of atrial fibrillation (A-fib, an irregular, often rapid heart rate that commonly causes poor blood flow), CHF, high blood pressure, prediabetes (higher than normal blood sugar levels but not high enough for a diabetes diagnosis), neuropathy (nerve damage that causes numbness, tingling, burning pain and muscle weakness in the hands and feet) and a stroke (a medical emergency that occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients) with paralysis. The patient was weak, lightheaded, dizzy and incontinent (unable to control urination). - At 9:46 PM, his Braden Scale score was 19. No pressure injury prevention interventions were implemented. He was not turned from 12:00 AM through 6:30 AM. - On 07/28/25, he was not turned from 10:40 PM through 6:40 AM. There was no skin assessment documented on the night shift. - On 07/29/25 at 10:09 AM, the physical therapist (a healthcare professional who focus on range or motion and decreasing pain after an injury or illness) documented that was the first time he was out of bed, he complained of bottom pain and his bottom was very red. She notified the patient’s nurse. The nurse applied lotion to his bottom. No pressure injury prevention interventions were implemented. His Braden Scale score was not updated with the new skin concerns. - At 3:30 PM, a different nurse took over care of the patient within the dayshift without completing a skin assessment. His Braden Scale score was 19. The patient was not turned at 3:00 PM, 6:00 PM and from 10:15 PM through 4:00 AM. - At 5:35 PM, he was transferred to a higher level of care, and a skin assessment was completed. His buttocks had non-blanchable (paling or whitening of the skin when pressed, when skin does not become pale with pressure it is often an indication of injury to the tissue) redness. The Skin, Wound and Ostomy Team (SWOT) was consulted, and the patient was placed on an air mattress. His Braden Scale score was 15. Wound pictures showed redness, a large open blister on the left side of the buttocks and several closed blisters on his buttocks. Prevention injury interventions were implemented. There was no skin assessment documented on the night shift. - 07/31/25 at 9:10 AM, a skin/wound care nurse assessment was completed. The buttock wound was a deep tissue pressure injury (DTI, intact or non-intact skin that has red, maroon or purple discoloration that does not go away if pressure is applied) measured 13 by 15 centimeters (cm). The wound base was purple, non-blanchable with serous (water-like fluid) filled blisters and a small amount of drainage. During an interview on 08/19/25 at 10:45 AM, Staff JJ, Registered Nurse (RN), stated that patients with a Braden Scale score of 16 to 18 should have a specialty mattress and those with a score of less than 16 should have an air mattress. In addition, for a score of 18 or less, the patient should be turned every two hours with the use of wedges/pillows, have heel boots and should be educated on why turning was important. Review of Patient #33’s medical record, dated 06/15/25, showed: - On 06/15/25, he was a 74-year-old admitted through the ED for altered mental status (AMS, mental functioning ranging from slight confusion to coma), inability to use his left arm and pain in his buttocks. - He had a history of stroke with right sided weakness, paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease) and he resided at a rehabilitation unit (an inpatient area staffed and medically supervised in the care and treatment of the physical restorative needs of patients). - On 06/15/25 at 7:02 PM, a pressure injury to his tailbone area caused pain. Pillows were placed under the patient for comfort and the provider was notified. The provider documented the wound appearance as a stage one pressure injury (intact skin with an area of redness that does not go away when pressure is applied) to a Stage two pressure injury (a shallow opening in the skin with red or pink tissue, or may present as a fluid filled blister) on his tailbone, both heels and several more wounds present on both feet. No measurements were documented, and a consult for SWOT was ordered. - On 06/16/25 at 4:56 PM, pictures were taken to document the wounds. No description of the wounds was documented. Two-hour turning was initiated. - On 06/17/25 at 1:57 PM, Staff CCC, SWOT RN, documented pressure injuries to his tailbone measuring 2.7 by 2.5 cm with pink thin skin surrounding the wound on both sides, a left heel wound measuring 2 by 3.2 cm with a closed blister without drainage and several closed wounds to both feet including the great toe, seven wounds in total. Wound care orders included to clean the wounds gently with soap and water, pat dry, apply barrier cream to the tailbone area, keep uncovered, turn every two hours and notify SWOT if the wounds deteriorated. - On 06/27/25 at 2:28 PM, the SWOT RN reassessed the wounds and found the wound on the left heel was 7 by 10 cm, open and draining. The wound to the tailbone area was 6 by 5 cm, sloughing (layer of dead tissue separated from surrounding living tissue, as in a wound, sore or inflammation), beefy red and draining. SWOT was not notified of the wound deterioration. Review of Patient #33’s medical record, dated 07/04/25, showed: - On 07/04/25, he was admitted through the ED for AMS. A skin assessment showed wounds were photographed, and a SWOT consult was ordered. The provider ordered all wounds except the buttock wound to be cleansed with Chlorhexidine Gluconate (CHG, an antiseptic solution used to reduce the bacteria on a patient’s skin) wipes, allowed to dry and apply a thin layer of Venelex (an ointment to help skin wounds heal) ointment twice daily. No orders were written for the buttock wound. - On 07/04/25, 07/05/25, 07/06/25 and 07/07/25 wound care was provided once daily. - On 07/08/25 at 2:21 PM, a skin assessment of seven wounds with pictures was performed by a SWOT RN. Wound care for the buttocks/tailbone wounds was to be provided twice daily, with specific instructions for cleaning and dressing. Wound care for the left heel and remaining wounds was to be performed three times daily with specific instructions for cleaning and dressing. - On 07/09/25 at 1:58 AM and 5:16 PM, although provided, wound care was not performed as ordered. Wound care was not provided a third time. - On 07/10/25 at 7:59 AM, 07/11/25 at 5:45 PM and 07/13/25 at 7:45 AM, although provided, wound care was not performed as ordered. Wound care was not provided a second and third time. - 07/12/25 at 2:11 AM and 12:36 PM, although provided, wound care was not performed as ordered. Wound care was not provided a third time. - On 07/14/25, no wound care was provided, he was discharged to a rehabilitation unit. During a telephone interview on 08/28/25 at 9:00 AM, Staff A, Chief Nursing Officer (CNO), stated that he expected staff to follow the hospital’s policy for skin care and wound management. He expected patients were repositioned every two hours with a Braden Scale score of 18 or less. He expected nursing to follow orders. He expected the patient’s position and refusals were documented in the medical record. Braden scale assessment education was provided to staff upon hire and at the unit level during orientation. He was aware the SWOT team identified inconsistencies in the Braden Scale Assessments. A yearly summit was developed in an effort to improve consistency. The SWOT team adjusted the Braden score as needed. Review of the hospital’s policy titled, “Pain Assessment and Reassessment Policy,” dated 04/22/25, showed pain assessment and documentation occurs upon admission assessment or triage (process of determining the priority of a patient’s treatment based on the severity of their condition) assessment and at regular intervals in accordance with the patient’s status. Review of the hospital’s untitled document, dated 02/18/25 to 08/18/25, showed eight patient grievances (a formal written or verbal complaint related to care or service that cannot be resolved immediately at the bedside) were filed with the hospital in regard to poor pain management in the ED between 05/27/25 to 08/18/25. Review of the hospital’s document titled, “Resolution Manager Form ID 77120,” dated 08/05/25, showed: - Patient #36’s daughter commented on the patient’s survey and stated, “your triage system is terrible. My mom had two broken arms, and it took hours to get at least just something for pain. X-rays (test that creates pictures of the structures inside the body-particularly bones) were attempted in triage, when she was unable to tolerate the pain, they received nothing but attitude.” - The findings included a statement that Patient #36 received the standard of care, but there were systems in place where a nurse could ask a provider for pain medication, or the charge nurse could place protocol orders. - The plan was to follow up with the team to ensure they had the resources they needed to help future patients. Review of Patient #36’s medical record dated 07/26/25, showed: - At 2:59 PM, she was a 70-year-old who presented to the ED for a fall and stated she had pain in both arms. - At 3:01 PM, her triage assessment began. - At 3:06 PM, her triage assessment was completed. No pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) was completed during triage. - At 3:58 PM, a pain scale assessment showed she rated her pain at a 10. Her pain was assessed 52 minutes after her triage assessment was completed. She stated she was unable to tolerate the pain for x-rays. - At 4:38 PM, a right arm x-ray showed a fracture (break in a bone) to both bones in her lower right arm. - At 4:40 PM, a left arm x-ray showed a fracture to her left upper arm bone. - At 4:44 PM, she received morphine (an opioid pain medication) intramuscularly (IM, within the muscle), one hour and 38 minutes after her triage assessment was completed. Review of the hospital’s document titled, “Resolution Manager Form ID 77387,” dated 08/18/25, showed: - Patient #37 filed a formal complaint regarding her treatment in the ED. - At approximately 12:00 AM, she arrived at the ED via an ambulance with severe flank pain (discomfort felt in the area between the ribs and the hip, can indicate infection in the kidney). - While in the waiting room she requested a blanket and was denied because of a low-grade fever of 99o Fahrenheit (F). - She explained to a nurse that sitting upright in a wheelchair made her pain worse and she requested to lie down. She was ignored. No attempt was made to address her pain, assess her worsening condition or provide basic accommodations. - When a computed tomography (CT, a combination of x-rays and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) was completed she was informed she required emergency surgery. Review of Patient #37’s medical record dated 08/15/25, showed: - At 11:55 PM, she was a 37-year-old who presented to the ED with back pain and urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, ureters, bladder and urethra) symptoms. - At 11:58 PM, her triage assessment began. - At 11:59 PM, her triage assessment was completed. No pain scale assessment was completed during triage. - At 5:53 AM, a CT scan showed an obstructing stone to her right ureter (tube that carries urine from the kidneys to the bladder) with hydronephrosis (a condition characterized by excess fluid in a kidney due to a backup of urine and inflammation). Possible obstructive uropathy (a condition where urine flow is blocked in the urinary tract, causing urine to back up into the kidney and potentially leading to kidney damage) or pyelonephritis (a life-threatening bacterial infection in the kidneys and urinary tract) with concern for a possible abscess (collection or pocket of thick fluid caused by an infection). - At 3:06 AM, Morphine intravenous push (IVP, to manually administer a dose of medication through a tube into a vein) was ordered. - At 4:54 AM, Morphine IVP was administered, four hours and 55 minutes after her triage assessment was completed. - On 08/16/25 at 6:40 AM, the first pain assessment showed she complained of pain. No pain scale assessment was completed. During an interview on 08/20/25 at 1:10 PM, Staff PP, ED Director, stated that he expected staff to follow the hospital’s pain assessment and management policy. A pain assessment was to be completed during the triage assessment and with vital signs (VS, measurements of the body’s most basic functions) every two hours. He was not aware of the increase in patient grievances related to pain management in the ED. He did not perform audits in regard to pain management. He expected the ED staff to provide comfort within the capability of the ED. A blanket warmer was moved closer to the waiting room, and he expected a patient to be given a blanket upon request even with a fever. During a telephone interview on 08/28/25 at 9:00 AM, Staff A, CNO, stated that he expected patients were rounded on in the ED every hour. The ED Director recently brought the increase in patient grievances related to pain management to his attention, in response to the survey. He expected staff to follow the hospital’s policy for pain assessment and management. He expected patients to receive pain management while in the waiting room based on their pain scale assessment score. Review of the hospital’s untitled document, dated 02/18/25 to 08/18/25, showed 595 patient falls occurred within the hospital. Review of the hospital’s policy titled, “Nursing Standards and Documentation Guidelines,” dated 01/24/25, showed: - Hourly safety rounding is a standard component of Mercy practice. - Hourly safety rounding is to be completed and consist of: - Checking the environment for safety; - Addressing the 5 P’s (pain, personal needs, positioning, personal items, pick up the environment); - Communicating a review of the plan of care/address questions or concerns; - Current predicted fall risk; and - Safety precautions to be documented if applicable. - Documentation will be performed in electronic heath record (EHR) in the Daily Care flowsheet. Review of the hospital’s policy titled, “Patient Falls Policy,” dated 03/05/24, showed post fall documentation in the medical record included a fall risk assessment, actual time and event description, name and time of provider notification and name of leadership notified. Review of the hospital’s document titled, “SAFE 435033 Factual Event Summary,” dated 03/15/25, showed: - At 6:45 PM, a safety rounding was performed, Patient #42 was in bed, all four side rails were up, the bed was locked and in the low position, her call light was within reach and her daughter was at the bedside. - At 6:50 PM, the daughter informed the nurse she was leaving. - At 7:15 PM, the patient was found face down on the floor next to the bed. No bed alarm sounded, and the patient was unresponsive and breathing. - Opportunities identified included nurse awareness that four side rails qualified as a non-violent restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head), shift report was not completed at the bedside, the physician informed the patient it was okay to sit on the edge of the bed as long as family was present which did not align with patient safety guidelines and a bed alarm refusal was not documented. Review of Patient #42’s medical record, dated 03/06/25, showed: - At 2:31 PM, she was admitted with a pulmonary embolism (PE, blood clot in the lung). - On 03/15/25 at 9:15 AM, a safety check was completed. - At 6:45 PM, patient rounding was completed and showed her pain was addressed and the call light was within reach. - At 7:48 PM, a rapid response (a changing situation that requires more staff to address the current needs of the patient) team note showed the patient was lying in bed after being lifted to bed after an unwitnessed fall. The patient did not have a pulse (normal pulse/heartbeats for adults range from 60 to 100 per minute) and was a Do Not Resuscitate (DNR, written instructions from a physician telling health care providers not to perform cardiopulmonary resuscitation [CPR, emergency life-saving procedure performed when a person’s breathing or heartbeat has stopped]). The provider and house supervisor were at the bedside. The patient died and the family was notified. - The last safety check was completed 10 hours 33 minutes prior to Patient #42’s fall. Review of the hospital’s untitled document dated 3/07/25, showed: - At 5:38 PM, Patient #43 was admitted with COVID-19 (highly contagious, and sometimes fatal, virus) and dehydration (a condition caused by excessive loss of water from the body). - She was confused. - Staff stated that during bedside shift report she was in bed and the bed alarm was on. - At 6:50 PM, Patient #43 was found in a sitting position on the ground, her back was against the wall. - The bed alarm did not sound. - The patient denied pain. - There was no documented toileting from the time of admission to the time of the fall. - The nurse reported that she tried to use the bed alarm, but it was not working. She notified the charge nurse. - On 03/08/25, the patient stated she had pain in her right hip and an x-ray showed a fracture. Review of Patient #43’s medical record dated 03/07/25, showed: - On 03/07/25 at 6:15 PM, a safety check was completed. - At 6:30 PM, a safety check showed she was a predicted high fall risk. The safety check did not include the 5 P’s, a review of the plan of care/address questions or concerns or safety precautions. - At 7:24 PM, the patient was found on the ground against the wall, she was assisted to bed. No injuries were noted, VS were stable, the provider, family and charge nurse were notified. - There was no documented post fall patient assessment. - At 10:06 PM, a safety check was completed, three hours and 51 minutes after the previous safety check. - On 03/08/25 at 3:47 PM, a right hip x-ray, showed a fracture. Review of the hospital’s untitled document, dated 04/24/25, showed: - On 04/24/25 at 10:46 AM, Patient #44 fell resulting in a fracture of his right thumb. - He had a history of alcohol abuse. Clinical Institute Withdrawal Assessments (CIWA, a 10-item scale used in the assessment and management of alcohol withdrawal) were ordered but discontinued because he was sober for eight months. The patient was confused and agitated during the admission which was later attributed to acute (sudden onset) metabolic encephalopathy (a disease in which the functioning of the brain is affected by an illness or organs that are not working as well as they should, such as with a viral infection or toxins in the blood). - He had a fall on 04/23/25 and 04/24/25, he got out of bed unattended and fell hitting his hand against the wall. - A safety sitter (person assigned to continuously observe a patient within close proximity, to ensure their safety) and psychiatric (relating to mental illness) consult were ordered. - Opportunities identified included an early psychiatry consult and medications for agitation. Review of Patient #44’s medical record dated 04/18/25, showed: - He was a 66-year-old admitted with seizures (sudden, uncontrolled electrical disturbance in the brain which cause changes in behavior, movements and/or in levels of consciousness). - His history included alcohol withdrawal, arthritis (inflammation that causes pain, stiffness and swelling in and around the tissues that connect bones), back pain and chronic (long-term, ongoing) hypoxic respiratory failure (a condition where there is not enough oxygen reaching the tissues of the body caused by a failure of the respiratory system). - On 04/22/25 at 11:17 PM, a safety check was completed. - On 04/23/25 at 8:00 AM, Patient #44’s bed alarm sounded, he was found in the bathroom, he lost his balance and fell to a seated position. A safety check showed he was a predicted high fall risk. The safety check did not include the 5 P’s, a review of the plan of care/address questions or concerns or safety precautions. There was no documented leadership notification. - At 8:18 PM, a safety check was completed, 12 hours and 18 minutes after the previous safety check. - On 04/24/25 at 12:00 PM, a safety check was completed. - There was no documented post fall patient assessment, post fall risk assessment, actual time and event description, name and time of provider notification or leadership notification. - At 12:22 PM, a right wrist x-ray showed a fractured right thumb. - At 2:00 PM, a safety check was completed, two hours after the previous safety check. During a telephone interview on 08/20/25 at 9:00 AM, Staff A, CNO, stated that he expected staff to follow the hospital’s policy for fall prevention and management. He was aware of the frequency of falls in the hospital. The hospital worked to reduce falls by performing weekly audits and white board updates for staff review. The audits were to ensure precautions were in place and “just in time” education was provided to staff as indicated. He was not surprised by the inconsistencies of the hourly rounding. He expected patients were rounded on every hour by either a nurse or a patient care technician (PCT). The rounding was a shared responsibility. He expected rounding to be documented in the medical record. Review of the hospital’s policy titled, “MP IP Enhanced Contact Precautions Policy,” dated 09/10/24, directed staff to provide patient and family/visitor education to explain precautions and document in the EHR upon the initiation of isolation. Observation with concurrent interview on 08/19/25 at 9:20 AM, showed Patient #16 was on contact precautions (precautions used to minimize the risk of infection spreading through touching an infected person or contaminated object) for Methicillin-Resistant Staphylococcus aureus (MRSA, highly contagious bacteria, that causes infections in different parts of the body and is resistant to many common antibiotics). Visitors were in the patient’s room without personal protective equipment (PPE, such as gloves, gowns, goggles and masks). Patient #16’s visitor stated that she was not educated on PPE, hand hygiene or safety related to the precautions. During an interview on 08/19/25 at 9:25 AM, Staff T, Supervisor, stated that staff were expected to have a conversation with a demonstration of proper safety techniques with visitors of patients on isolation precautions upon initiation of the precautions. Review of the hospital’s policy titled, “Intravascular and Intraosseous (IO, the insertion of a needle through the skin directly into the bone marrow in order to inject medications and fluids when IV access is not available) Therapy - Adult Policy,” approved 05/07/25, showed IV dressing should be labeled with date, time, and initials. The nurse who initiates IV tubing affixes a label to the tubing with the date and time of initiation, the date and time to be discarded and the nurse’s initials. Observation on 08/18/25 at 2:00 PM, on the Neurology (a branch of medicine concerned with the study and treatment of disorders of the nervous system) floor, showed Patient #1’s IV dressing was not labeled with date, time or initials. Observation on 08/18/25 at 2:40 PM, on Seven West, showed Patient #3’s IV dressing and tubing were not labeled with the date, time or initials. Observation on 08/18/25 at 2:45 PM, on Seven East, showed Patient #4’s IV dressing was not labeled with date, time or initials. Observation on 08/18/25 at 2:50 PM, on Seven East, showed Patient #5’s IV dressing and tubing were not labeled with date, time or initials. Observation on 08/18/25 at 3:00 PM, on Seven West, showed Patient #6’s IV dressing was not labeled with date, time or initials. Observation on 08/18/25 at 2:00 PM, on Five West, showed Patient #9’s IV dressing and tubing were not labeled with date, time or initials. Observation on 08/18/25 at 2:15 PM, on Five West, showed Patient #10’s IV tubing was not labeled with date, time or initials. Observation on 08/18/25 at 3:00 PM, on Five East, showed Patient #11’s IV tubing was not labeled with date, time or initials. Observation on 08/19/25 at 9:50 AM, on Seven East, showed Patient #17’s IV dressing was not labeled with date, time or initials. Observation on 08/19/25 at 10:05 AM, on Three East, showed Patient #18’s IV dressing was not labeled with date, time or initials. Observation on 08/19/25 at 10:20 AM, on Surgical Intensive Care Unit (ICU, a unit where critically ill patients are cared for), showed Patient #27’s IV dressing and tubing were not labeled with date, time or initials. During a telephone interview on 08/28/25 at 9:00 AM, Staff A, CNO, stated that he expected staff to follow the “IV and IO Therapy - Adult Policy,” for labeling IV dressings and tubing. The labels were to include the nurse’s initials, date and time. Review of the hospital’s policy titled, “Standard Precautions and Use of Protective Barriers Policy,” dated 09/11/2023, showed: - Hand hygiene must be performed immediately prior to donning, and immediately after removal of gloves. - Gloves should be changed between tasks and procedures on the same patient after contact with potentially infectious material, when moving from a contaminated site to a clean site. - Staff must practice safe handling of potentially contaminated equipment, linen or surfaces in the patient environment and any patient contact that might result in bleeding or exposure to potentially infectious material. Observation on 08/18/25 at 2:40 PM, in Seven West, showed Staff E, Licensed Practical Nurse (LPN), failed to perform hand hygiene and glove changes when she retrieved and returned her mobile device to her pocket. Staff E placed medications on the dirty linen hamper and workstation on wheels (WOW, a computer or supply and medication storage on a wheeled stand, that can be moved from patient to patient) and failed to provide a clean barrier. Staff E removed a blunt needle from a syringe with the open package that was placed on the WOW prior to administration to Patient #3. Observation on 08/18/25 at 2:50 PM, on Seven East, showed Staff F, RN, failed to perform hand hygiene and glove changes when she retrieved and returned her mobile device to her pocket and between touching a dirty and clean area while she administered medications to Patient #5. Observation on 08/18/25 at 3:30 PM, on the Labor and Delivery Unit, showed Staff H, RN, failed to perform hand hygiene between glove changes when she started an intravenous catheter (IVC, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream). Staff H placed IVC insertion supplies on the blanket and failed to provide a clean barrier while she provided care to patient #7. Observation on 08/18/25 at 2:15 PM, on Five West, showed Staff K, RN, placed medications on the bedside table and failed to provide a clean barrier prior to administration to Patient #10. Observation on 08/18/25 at 2:35 PM, on Five West, showed Staff J, RN, failed to perform hand hygiene and glove changes when she retrieved and returned her mobile device to her pocket when she provided care to Patient #12, who was on isolation precautions. Observation on 08/19/25 at 9:00 AM, on Seven West, showed Staff I, RN, failed to perform hand hygiene between glove changes when she started an IVC. Staff I placed IVC insertion supplies on the bedside table and failed to provide a clean barrier for Patient #15. Observation on 08/19/25 at 9:20 AM, on Seven West, showed Staff V, RN failed to perform hand hygiene with glove changes. Staff V placed medications on the WOW and failed to provide a clean barrier while she provided care to Patient #16. Observation on 08/19/25 at 9:50 AM, on Seven East, showed Staff W, LPN failed to perform hand hygiene with glove changes while she administered medications to Patient #17. Observation on 08/19/25 at 8:55 AM, on Six West, showed Staff L, RN, failed to perform hand hygiene and glove changes when she retrieved and returned her mobile device to her pocket when she provided care to Patient #19. Observation on 08/19/25 at 9:50 AM, on Six East, showed Staff AA, RN, placed wound care supplies on the bedside table and failed to provide a clean barrier. Staff AA failed to perform hand hygiene and gloves changes after she removed two soiled wound dressings, cleansed both wounds, applied two new wound dressings and retrieved and returned a pen to her pocket while she provided care for Patient #21. Observation on 08/19/25 at 10:15 AM, on Six West, showed Staff BB, RN, failed to perform hand hygiene and glove changes when he prepared a clean surface, retrieved supplies from of a mobile cart, moved equipment in the patient’s room, inserted an IVC and retrieved and returned a pen to his pocket when he provided care to Patient #22. Observation on 08/19/25 at 10:10 AM, on Surgical ICU, showed Staff HH, RN, failed to perform hand hygiene and glove changes when she retrieved and returned her mobile device to her pocket and between touching a dirty and clean area while she administered IV medications to Patient #26. Observation on 08/19/25 at 10:30 AM, on Surgical ICU, showed Staff II, RN, placed wound dressing supplies on a dirty linen hamper and WOW and failed to provide clean barriers. Staff II failed to perform hand hygiene and glove changes when she applied cream to three different wounds and on Patient #28. Observation on 08/19/25 at 11:38 AM, on Five East, showed Staff MM, RN, failed to perform hand hygiene and a glove change when she retrieved and returned a pen to her pocket when she provided care to Patient #30, who was on isolation precautions. During a telephone interview on 08/28/25 at 9:00 AM, Staff A, CNO, stated that he expected staff to follow the “Standard Precautions and Use of Protective Barriers” policy. He expected staff to perform hand hygiene and glove changes before room entry and exit and when moving from a dirty area to a clean area. 51292”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48359 Based on observation, interview, record review and policy review, the hospital failed to: - Provide house wide staff education regarding abuse and neglect when an abuse allegation was substantiated. (A-0145) - Ensure the presence of emergency airway equipment for one unit of two units observed. (A-0144) - Ensure the presence of food expiration dates, removal of expired food items and the separation of staff and patient food on three units of 16 units observed. (A-0144) - Ensure all Behavioral Health Units (BHU) provide psychiatric safe rooms (a room that has been cleared of any objects a patient might use to harm themselves or others). (A-0144) These failures had the potential to place all patients seeking care at the hospital at risk for their safety. The cumulative effect of these systemic practices resulted in the overall non-compliance with 42 CFR 482.13, Condition of Participation (CoP): Patient’s Rights.”

“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: 48359 Based on interview, record review and policy review the hospital failed to arrange a safe discharge for two patients (#43 and #46) of three medical records reviewed. This failure had the potential to lead to unsafe discharges, inappropriate transitions of care and result in poor discharge outcomes for all patients in the hospital. The severity and cumulative effects of the systemic failures resulted in the hospital being out of compliance with 42 CFR Condition of Participation (CoP): Discharge Planning.”

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 47504 Based on interview, record review and policy review, the hospital failed to follow their own policies and procedures that outlined staff roles for informing, retrieving, assisting with formulation, and documenting Advance Directive (AD, a legal document where the patient can direct their medical care wishes should the patient become unable to make their own decisions) information for 10 (#15, #24, #25, #26, #27, #28, #30, #31, #33 and #34) current patients of 41 current patients reviewed. These failures had the potential to affect all patients who presented to the hospital seeking care. Findings included: Review of the hospital’s policy titled, “South Administration AD Policy,” dated 08/05/22, showed: - Patients with decision-making capacity who are 18 years of age or older have the right to formulate, review, change, rescind or modify an AD regarding health-care decisions in the event they become unable to make decisions. - Hospital co-workers will inform patients regarding AD and provide information to his/her family or representattve if the patient is currently unable to receive information. - Hospital co-workers will inquire periodically and document in the patient’s medical record as to whether an individual has executed an AD and if so, seek to obtain a copy for the medical record. - Hospital co-workers will have a conversation with patients regarding AD at or near the time of admission, or initial encounter. - Hospital co-workers will ask if the patient already has an AD. If the patient responds yes, the co-worker is to ask for a copy; confirm if the AD is already in the medical record; ask if the patient wants to change the AD; ask the patient to provide a copy of the AD and follow up to obtain the AD. - If the patient reponds no, the co-worker will offer information and available AD forms; answer questions as appropriate or refer to the AD educator or another co-worker to assist with the patient’s questions; contact the Pastoral Care AD resources and notary assistance; assist the patient with the execution of a completed document with witnesses or a notary public when needed and follow up with the patient to obtain a signed copy if forms are provided but not signed. - The co-worker will place the AD in the appropriate medical record through scanning or other appropriate and available means, document the conversation and existence of ADs in the medical record and document any change or revocations of the AD in the medical record. Review of Patient #15’s medical record showed, she was not assessed for the need to formulate and/or revise an AD. Review of Patient #24’s medical record showed, she was not assessed for the need to formulate and/or revise an AD. Review of Patient #25’s medical record showed, she was not assessed for the need to formulate and/or revise an AD. Review of Patient #26’s medical record showed, she was not assessed for the need to formulate and/or revise an AD. Review of Patient #27’s medical record showed, she was not assessed for the need to formulate and/or revise an AD. Review of Patient #28’s medical record showed, he was not assessed for the need to formulate and/or revise an AD. Review of Patient #30’s medical record showed, he was not assessed for the need to formulate and/or revise an AD. Review of Patient #31’s medical record showed, he was not assessed for the need to formulate and/or revise an AD. Review of Patient #33’s medical record showed, she was not assessed for the need to formulate and/or revise an AD. Review of Patient #34’s medical record showed, she was not assessed for the need to formulate and/or revise an AD. During an interview on 08/13/24 at 9:35 AM, Patient #28’s family member stated he asked several times for help with an AD, and no one came to help. His father was just diagnosed with stage four cancer, and he needed to get this completed. He stated, “when you receive information like this it is very traumatizing, and I was very frustrated because no one would help me.” During an interview on 08/13/24 at 10:30 AM, Staff LL, Nurse Manager, stated they have a social worker that checks on every patient and addressed their needs. She was unaware of the lack of documentation for AD and did not know why patients did not have documentation for follow-up when information was requested. The nurses answered the question but there was no computer message that was sent. The nurse should notify the social worker if someone needed assistance. During an interview on 08/13/24 at 11:00 AM, Staff QQ, Social Worker, stated that she saw every patient on the floor and followed-up if they wanted additional information for AD. She did not know why these patients did not have any documentation.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 39354 Based on observation, interview, record review and policy review, the hospital failed to: - Ensure the presence of emergency airway equipment for one unit of two units observed. - Ensure the presence of food expiration dates, removal of expired food items and the separation of staff and patient food on three units of 16 units observed. - Ensure that all Behavioral Health Units (BHU) provide psychiatric safe rooms (a room that has been cleared of any objects a patient might use to harm themselves or others). Observation on 08/13/24 at 3:05 PM, of the BHU showed: - In patient room 229, an unsecure toothbrush in the bathroom. - In the common area of unit 2B, five patient chairs with torn seat and backing covering; one unsecured plastic clock; one table with a broken metal leg and unsecured white board. - In the common area of unit 2C, two patient chairs with torn seat coverings. During an interview, on 08/13/14 at 3:35 PM, Staff HHH, BHU Director, stated that the toothbrush should not be left in the patient’s room, the chairs should not have tears in them, the table should not have a broken leg and the clock and white board should be fastened securely to the wall. Review of the hospital’s document titled, “Resources for Optimal Care of the Injured Patient,” dated 03/2022 showed all trauma centers must have equipment immediately available to establish an emergency airway. Observation on 08/13/24 at 8:50 AM, in the Labor and Delivery Operating Room Area, showed no emergency tracheostomy equipment. During an interview on 08/13/24 at 8:50 AM, Staff R, Labor and Delivery/Post Partum (LDRP) Manager stated there was no emergency tracheostomy equipment in the operating room area. During an interview on 08/15/24 at 9:07 AM, Staff GGGG, CNO, stated she expected emergency tracheostomy equipment to be available in the Labor and Delivery operating room area. Observation on 08/12/24 at 4:15 PM, in the 4700-unit patient nutrition room, showed: - One box of tea bags without an expiration date. - One box of tea bags with an expiration date of 12/09/21. - Coffee ground bags without expiration dates. - One package of horseradish without an expiration date. - Single pack tea bags without expiration dates. Observation on 08/13/24 at 8:45 AM, in the Labor and Delivery and Post Partum Unit patient nutrition room, showed: - One box of tea bags with an expiration date of 12/09/21. - Single pack tea bags without expiration dates. - Broth packages without expiration dates. - Coffee pods without expiration dates. - Hot chocolate packages without expiration dates. - Creamer packages without expiration dates. - Sugar packages without expiration dates. - Sweetener packages without expiration dates. Observation on 08/13/24 at 9:40 AM, in the 4600-unit patient nutrition room, showed: - One open single-use ranch dressing packet in the refrigerator. - Salt packets without expiration dates. - Pepper packets without expiration dates. - One staff multi-use flavored coffee creamer in the patient’s refrigerator. During an interview on 08/15/24 at 9:07 AM, Staff GGGG, CNO, stated that expired food in the patient care areas did not meet her expectations. She expected all food items to be dated for expiration and bagged. Staff food items did not belong in patient refrigerators. 47504 48359”

“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: 48359 Based on observation, interview, record review, and policy review, the hospital failed to provide hospital-wide staff education for abuse, de-escalation and Mandt (a behavioral crisis interaction training program that focuses on communication skills and conflict management) to all employees after a substantiated incident of abuse from an employee to one discharged patient (#14) to prevent re-occurence. Findings included: Review of the hospital’s policy titled, “Alleged Patient Abuse, Neglect or Harassment by a Co-Worker Policy,” dated 05/16/22, showed: - The hospital sets an expectation of zero tolerance for all forms of abuse, neglect and harassment whether reportedly inflicted by co-workers, patients, visitors or other persons. - Abuse is the willful inflection of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. - Willful, as used in this definition of abuse, means the individual must have intended to inflict injury or harm. - Co-workers must report witnessed or alleged abuse, neglect or harassment and clinical indicators of suspected abuse. Clinical indicators include the following: bruises, fractures, burns, decayed teeth, matted or tangled hair, nails needing clipping, malnutrition/dehydration, bed sores, injuries to sexual organs, acute (sudden onset) untreated medical conditions, indicators of chemical restraints (medication administered with the primary intent of restraining a patient who presents a likelihood of serious physical injury to himself or others, and not prescribed to treat a person’s medical condition) and patient abandonment. - Alleged abuse, neglect, or harassment is defined as any report from family members, patients, or co-workers of abuse, neglect or harassment. - There must be a report made even if the co-worker does not believe the allegation is true. - Co-workers are responsible for reporting any abuse, neglect, or complaint allegation. Co- workers will document the observation/allegation in the medical record and who was notified. Review of the hospital’s policy titled, “Agitated and Combative Person Response Security Assistance and Code Strong (a response from all available staff to respond to an escalating patient in attempt to de-escalate the situation without using force and using the least restrictive intervention),” dated 01/01/2019, showed: - This emergency response plan is intended to guide the response and the management of escalating behavior by clients, patients and/or visitors, before or during a violent eruption of aggressive or violent behavior, with use of verbal de-escalation techniques and the minimum control necessary by our employees to ensure the safety of all hospital staff and clients, patients and/or visitors. - The facility prohibits physical assaults such as strikes, grabs, threatening comments, intimidation, harassment, intentional destruction of any hospital property or merchandise, or any behavior that causes intimidation or reasonable fear responses in others. - The Code Strong Response Team objectives include the utilization of verbal control techniques prior to the initiation of escort techniques or positive control techniques unless a safety issue demands an immediate physical control response. - The response process was designed to deal with and control unarmed persons who display behaviors consistent with that of a person who has lost control of their actions and may pose an imminent threat (direct or indirect) to the wellbeing of themselves or others. This may also include persons who appear to be unmanageable and/or assaultive. - The response of any employee who is witnessing or working with a difficult, agitated patient or person should begin with de-escalation and include the following: a team intervention should be utilized when at all possible, starting with verbal de-escalation techniques, before any hands-on techniques, one person at a time should speak/communicate with the acting out person, employ verbal de-escalation techniques, monitor non-verbal cues by staff and the person acting out, maintain a protective distance between staff and the acting out person and if the person continues to escalate, and verbal de-escalation techniques are not working, or staff feel/sense that the situation is escalating and would benefit from early intervention the local police should be contacted by dialing 911. Review of the hospital’s policy titled, “Performing Event Reviews Root Cause Analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to find the root cause) Policy,” dated 08/16/22, showed: - A RCA is a structured facilitated team process to identify root causes of an event that resulted in an undesired outcome and develop corrective actions. - This event review process provides a way to identify breakdowns in processes and systems that contributed to the event and how to prevent future events. Event reviews do not focus on individual performance. Instead, event reviews focus on process or performance improvement through a review of hospital systems. - The Mercy Event Review Process will be followed for all serious reportable events. Review of the hospital’s document titled, “Missouri Department of Health and Senior Services (DHSS) Self-Report Investigation,” dated 09/25/23, showed: - On 9/23/23 at 12:37 AM, a 44-year-old male arrived at Mercy Hospital South Emergency Department (ED) following a multi-vehicle crash. - Lab results were positive for alcohol (ETOH, level of alcohol in your body, normal is less than 10) level of 159. - The patient’s medical history included polysubstance (multiple drugs) abuse, depression and anxiety. - Affidavits were obtained from the police and it was planned to admit the patient involuntarily. - While awaiting placement to a BHU, he remained in the ED BH area. - On 9/24/23 at 3:00 PM, he escalated, harmed himself and was verbally and physically aggressive toward coworkers. - Security was called and during this interaction, Staff PPPP, Paramedic, worked on the unit and assisted with the patient. He used inappropriate language with the patient as well as excessive force when managing the incident. Staff PPPP, did not use Mandt approved techniques. - He was removed from the room. - The patient complained of jaw pain following the altercation, x-rays (test that creates pictures of the structures inside the body-particularly bones) of his jaw were obtained and resulted negative. - The patient was transferred to a BH bed on 9/25/2023 at 1:50 PM. - Staff PPPP was suspended indefinitely while termination was in process with Human Resources. Review of education that was submitted with the self-report, showed ED personnel were educated on the Abuse Policy, education was not provided house-wide. Review of the education provided with the self-report, showed de-escalation training and Mandt simulation was not provided following this event. The hospital submitted prior yearly education of the training. Review of Patient #14’s medical record dated 09/23/23, showed: - Patient #14 presented to the ED via Emergency Medical Services (EMS, emergency response personnel, such as paramedics (a healthcare professional that provides advanced emergency medical care), first responders, etc.) following a multi-vehicle collision on 09/23/23 at 12:37 AM. - Past medical history included polysubstance abuse, depression (extreme sadness that doesn’t go away) and anxiety (a feeling of fear or worry experienced intermittently). - Laboratory results showed an ETOH level of 159 - He was seen by central intake for a mental health evaluation due to suicidal ideation (SI, thoughts of causing one’s own death) and alcohol intoxication (the condition of having physical or mental control markedly diminished by the effects of alcohol or drugs). - He was verbally aggressive, agitated and refused to answer assessment questions. - It was determined Patient #14 would be admitted to an in-patient BHU as he was an imminent danger to self and others. - On 09/23/23 at 1:25 PM, he became agitated, banged his head on the wall that resulted in a hole in the wall. Additional staff were requested, and Patient #14 was given Haldol (a medication used to treat mental disorders by decreasing excitement of the brain) and Ativan (a medication used to treat anxiety or sleep difficulty). - At 11:20 PM, the patient was agitated, slammed the door and walked out of his room to the restroom shouting profanities. He returned to his room, knocked items off table and slammed the table into wall. Security was notified, who then called for additional security. He attempted to block the door with a table and attempted to cover the security camera with a napkin. The panic button was activated, additional security, physician and other staff members arrived. - Orders given for Haldol and Ativan were given by the physician. When the nurse arrived with the medication, Patient #14 charged at the nurse. He was stopped by security and then was restrained. - On 09/24/23 at 3:00 PM, Patient #14 awaited transfer when he became aggressive toward staff. Security was called and multiple staff members present in the room. The patient punched himself in the throat and hit his head against a television. He became physically aggressive with staff and spit at staff. The physician was paged, and the patient was placed in restraints. - On 09/24/23 at 4:25 PM, Patient #14 complained of jaw pain following the altercation. He alleged he was “pushed hard with an open hand into the bed” by a medic in the ED. - The patient stated that, “I was being an ass, I know, but he pushed me really hard with an open hand multiple times into the bed and now the left side of my jaw feels like it’s broke.” He was examined by the physician; an x-ray of his jaw was obtained and was negative for an injury. - He was transferred to a BHU on 09/25/23 at 10:50 AM. During an interview with Staff L, CNO, on 08/14/24 at 2:30 PM, stated that she was the Quality Risk Manager at the time of the incident. She stated that she did not provide house wide education for abuse and did not provide additional de-escalation and Mandt simulation following this incident. She did complete the investigation but failed to recognize the importance of educating all staff in the hospital. Staff PPPP, Paramedic, was terminated following the investigation. During an interview with Staff DDD, ED Director, on 08/14/24 at 3:00 PM, stated that if an employee was accused of abuse, that employee was immediately removed from patient care. He then conducted interviews of everyone involved and escalated up the chain of command. He stated that the abuse education for Patient #14 was provided to the ED staff only and was not escalated to hospital-wide education.”

“DISCHARGE PLANNING - EARLY IDENTIFICATION CFR(s): 482.43(a) The hospital’s discharge planning process must identify at an early stage of hospitalization those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient’s representative, or patient’s physician. This Standard is not met as evidenced by: 47504 Based on interview, record review and policy review the hospital failed to provide a safe discharge for two patients (#43 and #46) of three medical records reviewed. Review of the hospital’s policy titled, “Case Management (CM) Discharge Planning Policy,” dated 08/04/23 showed: - CM recognizes discharge planning as a process and service. - Discharge planning is provided to patients for assessing, evaluation and assisting with safe transition to the discharge designation. - The discharge planning process may include, but is not limited to, identification of needs, evaluation of patient and any planning for needs the patient will need for a safe and smooth transition. - Discharge planning is a multi-disciplinary, hospital wide process available to assist patients and families in establishing a safe and efficient hospital plan to the patient discharging. - CM will develop or supervise the development of and reassess the discharge plan, identify available resources and involve the patient and/or patient representative in the discharge planning process. - Reassessment and documentation are required with a change in the discharge plan or each time the CM has relevant information regarding the patient’s situation or condition. - If a patient previously identified as not needing discharge planning has a change in condition, an assessment should be authorized, and an evaluation completed. - Screening, assessment and additional information is documented in the electronic medical record (EMR). Review of Patient #43’s medical record dated 08/01/24, showed: - At 7:17 AM, she was a 54-year-old female who arrived at the gastroenterology (GI, branch of medicine concerned with the structure and diseases of the stomach and intestines) laboratory for an elective scheduled outpatient procedure. - Her past medical history was Aagenaes syndrome (impaired bile [a digestive fluid] flow from the liver), anxiety (a feeling of fear or worry experienced intermittently), autoimmune autonomic ganglionopathy (when your immune system attacks healthy nerve cells), bone cancer, celiac disease (disorder that damages the small intestine and is triggered by eating foods containing gluten), liver failure, diabetes (a disease that affects how the body produces or uses blood sugar and can cause poor healing), gastroparesis (a paralysis of your stomach muscle), high blood pressure, irritable bowel syndrome (IBS, ongoing disorder of the colon which includes diarrhea, cramping and abdominal pain), sclerosing cholangitis (liver disease), MALToma gastric (a type of lymphoma [a cancer that begins in infection-fighting cells of the immune system and the cells change and grow out of control]), nutritional anemia (when the body does not get enough nutrients from the diet), pancreatitis (inflammation of the pancreas) and stomach cancer. - Her past surgical history was eight esophagogastroduodenoscopy (EGD, procedure in which a thin scope with a light and camera at its tip is used to look inside the organs of the upper digestive tract) with gastrostomy tube (G-tube, soft, flexible tube inserted through the skin of the abdomen and into the stomach) placements, hysterectomy (hollow, pear-shaped organ that is located in a woman’s lower abdomen between the bladder and the rectum), appendectomy (a surgical procedure that removes the appendix [a small tube-shaped part that is joined to the intestines on the right side of the intestines]), liver biopsy (take a sample of tissue or cells for testing), a jejunostomy tube (J-tube, soft, flexible tube placed through the skin of the abdomen into the midsection of the small intestine) placement, cholecystectomy (surgical removal of the gallbladder; a small organ that stores liquid called bile and helps your body break down food) and bone tumor removal. - At 7:30 AM, she signed a consent for procedure form for an “esophagogastroduodenoscopy to replace “PEG” tube. - At 8:30 AM, the procedure started. - At 8:55 AM, her preprocedural history and physical (H&P, a document in a patient’s medical record that contains the physician’s initial assessment and treatment plan) showed she was alert and oriented times four (A&O x 4, a person is oriented to person, place, time, and situation). The procedure planned was an EGD for replacement of the percutaneous endoscopic gastrostomy (PEG, a tube inserted through a person’s abdomen directly into the stomach to provide a means of feeding when oral intake is not possible) J-tube due to feeding tube dysfunction. Staff OOO, Physician, discussed the plan, risks, benefits and alternatives with the patient. - At 10:10 AM, she was upset the new tube was placed in the old site due to skin irritation. Staff OOO and QQQ, NP, were at her bedside to explain the reasoning to keep the tube in the old site. The patient insisted she wanted the tube removed. The tube was removed, and pressure was applied to the site by Staff OOO and Staff QQQ. Staff RRR applied a dressing to the site. The patient called her son and he requested to speak with Staff OOO. Staff MMMM, Endoscopy Manager, was at the patient’s bedside to talk with the patient and provide comfort. Staff OOO returned to bedside to discuss placing another tube, the patient was referred back to Staff PPP, Physician, for management of her reoccurring symptoms. Staff PPP’s contact information was provided to the patient. - At 12:00 PM, she sat on the bed dressed and waited for her son’s arrival for transport home. Discharge instructions were provided, the patient was advised to access her “My Mercy” account for new instructions for after PEG tube removal care. She verbalized an understanding. - At 12:28 PM, a progress note showed she was scheduled for a replacement of the feeding tube for leakage of tube feeding causing skin irritation. The tube was found coiled in the stomach which was the most likely cause for the leaking of feeding material around the tube. A new site was not created because the reason for the leakage was the coiled tube, not the location of the tube. Post procedure the patient was upset because the site was not changed. It was explained to the patient that placing a new tube through a new site would not eliminate the problem of leakage. The patient requested tube removal, she was concerned for recurrent leakage and aggravation of the skin irritation and soreness. Staff OOO believed the tube removal and an oral gastroparesis diet was an alternative option for management of her illness in the presence of significant skin irritation. The patient was given instructions for a gastroparesis diet, to start with clear liquids and advance to full liquids the following day and then advance as tolerated. She was encouraged to eat small portions frequently of a low residual diet with increased physical activity. The patient’s son was educated on the patient’s condition and the recommendations. The patient was referred back to Staff PPP, Physician, for further management of her recurrent symptoms of nausea, vomiting and gastroparesis. - At 12:19, she was assisted to the car, was pleasant and thankful. - Her discharge instructions showed she was discharged to home. She was instructed to resume her previous diet and return to her primary physician. She had no upcoming appointments scheduled. The discharge instructions showed if a complication or emergency arose and she was unable to reach her physician, she was to go to the nearest Emergency Department (ED) with the discharge form. Review of Patient #43’s medical record from Facility B dated 08/08/24, showed: - She received a feeding tube in 01/2022 which was replaced multiple times. - One week ago, her feeding tube was removed and not replaced. - She reported she did not tolerate oral intake due to nausea and vomiting. - She stated that everything she ate came “right through the tube feeding site.” The site appeared to be healing without leakage. - Her weight at Hospital A was 151 pounds, at Facility B she weighed 145 pounds. - Her blood sugar logs showed low blood sugar readings. - The plan was to trial oral feeds and adjust her medication regimen, if she failed the trial in one month, consider a feeding tube insertion or referral to surgery. During an interview on 08/14/24 at 11:15 AM, Staff OOO, Physician, stated he cared for Patient #43 for two and a half years. Her previous tube coiled back into her stomach, the tube feeding pooled in her stomach and leaked out of the tube insertion site. He confirmed the tube was coiled via an x-ray and discussed the findings with her prior to scheduling her procedure. He was called to her room because she was upset the tube was not relocated. She “demanded” he take the tube out. He offered for her to keep the tube in place for a few days because it was replaced into her intestine and was no longer coiled in her stomach. If she was dissatisfied after a few days she could come to his office, and he would remove the tube. She did not agree to that option and wanted the tube out. He asked her if she was able to eat before he agreed to remove the tube. He believed she could tolerate food and liquid in small amounts. He believed she was able to supplement her nutrition orally when her tube leaked or clogged in the past. He felt “strongly” she was able to eat. He removed the tube according to the “standard of care, it came out easily and only took two seconds.” He instructed her to keep the site clean and dry with gauze until the site healed. The hole would close in a few days. During an interview on 08/14/24 at 11:30 AM, Staff PPP, Physician, stated he called to check on Patient #43 after her procedure. She did not tolerate an oral diet well. She was a very complicated case and he cared for her for two to three years. When she initially arrived at his office she weighed 80 pounds, with the tube she weighed 140 to 150 pounds. He instructed her to follow up at Facility B for a different type of tube placement. She was an established patient at Facility B. He believed she would be scheduled quickly. He informed her if she had a delay in scheduling an appointment at Facility B she could come to his office. He instructed her to return to the ED if she “felt dehydrated.” She could not be admitted to the hospital on the day of her procedure because she did not have a “diagnosis.” Patient #43 made the decision to have the tube removed and go home. During an interview on 08/14/24 at 11:35 AM, Staff QQQ, NP, stated Patient #43 was well known to her, she had undergone multiple procedures. Patient #43 reached out to her when the feeding tube began to leak. Her feeding tube was a tube within a tube, and it shimmied up and coiled into the stomach. The tube feeding then went into the stomach and leaked. An x-ray confirmed the tube was coiled into the stomach prior to this procedure. She spoke with Patient #43 about the coiling and scheduled her for the outpatient procedure. She walked into Patient #43’s room when she saw her speaking with Staff OOO, Physician, and the nurse. The patient was upset because a new tube was placed into the same site. Staff OOO requested the patient try the tube for a few days. If she was not satisfied, she could come to the office and the tube would be removed. The patient wanted the tube out. She was reminded she would not have access to food. Patient #43 responded that “she would change her ways and wanted the tube out.” Staff QQQ gathered gauze and tape and returned to the room. She and Staff OOO donned gloves and pulled the tube. The patient was instructed the hole would close. Staff OOO spoke with Staff PPP, physician, to explain the patient no longer wanted the tube. Staff QQQ was unsure of what resources were available for Patient #43 prior to her discharge. She did not provide outside resources for Patient #43. The patient stated she would “do what she needed to do.” Staff OOO instructed her how to eat small sips of clear liquids and advance her diet over the weekend. She agreed a social service consult could have been beneficial. During an interview on 08/15/24 at 9:07 AM, Staff GGGG, CNO, stated she expected to see follow up appointments with the doctor on Patient #43’s discharge paperwork. She expected collaboration between the physician, social work and a nutritionist to ensure Patient #43 was successful at home. It was not acceptable to wait for the patient to develop symptoms and return to the hospital. Patient education goes a long way. During an interview on 08/15/24 at 10:12 AM, Staff MMMM, Endoscopy Manager, stated she met Patient #43 after the tube was removed. She was “very upset” and wanted the tube moved. She gave a detailed description of how the tube’s location affected her life, and she requested the tube was removed. Patient #43 planned to follow up with “friends” at an “urgent care facility” she frequented if she had needs. Staff MMMM believed Patient #43 clearly understood the consequences of her decision and the physician wanted her to try small sips of clear liquids through Friday and advance to full liquids by Saturday. She asked Patient #43 if she was “okay” to go home. Social work was never consulted. Staff MMMM called Staff PPP, Physician, to tell him the tube was removed. Staff PPP followed up with the patient. During an interview on 08/15/24 at 9:56 AM, Staff KKK, CM Manager, stated if CM was aware of Patient #43’s situation, they would have consulted with her to determine what was the best course of action for her. A follow up phone call could have taken place to “close the loop.” Resources could have been provided if CM was notified. It was not acceptable to discharge a patient with a plan to return to the ED if he/she developed dehydration. During an interview on 08/15/24 at 10:18 AM, Staff A, Quality Vice President, stated on 08/02/24 the Patient Relations department received a call from Patient #43. She verbalized her blood glucose (sugar that circulates in the blood and when too high or too low can be detrimental to a person’s health) was low and she was worried. She was told she could return to the ED. She was concerned that Patient #43 was unsafe for the weekend. Staff PPP reached out to Patient #43 for a follow up in his office on Monday or a referral to another hospital. She was scheduled at Facility B. She agreed a “cool off” period could have been offered to Patient #43 before the tube was removed while she waited in the recovery room. A Social Service consult was always available. There was a difference of opinion between the physicians regarding Patient #43’s ability to eat. It would be beneficial to provide resources to future patients in similar situations. She agreed the endoscopy staff needed increased awareness of how to reach out to Social Services. During an interview on 08/14/24 at 11:55 AM, Staff RRR, Registered Nurse (RN), stated she was Patient #43’s recovery nurse. The patient told Staff OOO, Physician, and Staff QQQ, NP, she was unhappy with the feeding tube in the same site. The patient was tearful. The patient was told to follow up with Staff PPP, Physician. She believed a consult to a nutritionist and/or Social Services would have been best. During an interview on 08/14/24 at 1:17 PM, Staff UUU, RN, stated she discharged Patient #43. The patient stated she was unhappy with the feeding tube location and asked for it to be removed. She asked the patient if she could eat. The patient responded, “little bits.” Staff UUU was not aware Patient #43 could not eat. If a patient was not able to get nutrition, they could not be sent home. She believed Patient #43 could “sustain herself.” She did not look malnourished, she looked well. Staff UUU was unaware of Patient #43’s complex condition. Staff UUU was aware she could call for assistance with outside resource prior to discharging a patient. During an interview on 08/14/24 at 1:30 PM, Staff VVV, RN, stated she was the room nurse for Patient #43’s procedure. Patient #43 was a “frequent flyer.” She was aware Patient #43 could not tolerate oral intake and was “surprised” she chose to have the tube removed. If she was concerned about discharging a patient, she would refer to her manager for help with available resources. She expected resources were offered to patients in need. She would “absolutely” have given Patient #43 resources for expectations and follow up appointments. During an interview on 08/15/24 at 8:45 AM, Staff IIII, RN, stated she was the procedure nurse for Patient #43. She stated Patient #43 needed to be educated by the physician, nurse and/or NP to ensure she understood the consequences of the decision she made. Review of Patient #46’s medical record dated 08/07/24 showed: - He was an 80-year-old male with no past medical history on file. - At 8:58 PM, he arrived to the ED via Emergency Medical Service (EMS, emergency response personnel, such as paramedics, first responders, etc.) due to having an altercation with his son at home and he did not feel safe at home. - At 10:46 PM, Staff AAA, ED Physician, made initial contact with patient. He documented there was a concern for elder abuse. The patient’s son threatened to beat him up and wanted to kill him. The patient stated that his son struck him three to four times on the right wrist. Patient #46 declined to press charges. - Documentation showed he was alert and oriented times four (A&O x 4, a person is oriented to person, place, time, and situation) and had the capacity to make his own decisions. Patient #46 wanted to go back home. Social Services was notified, and they were going to report the case. Patient #46 denied any other medical concerns. - At 3:00 AM on 08/08/24, Staff NNNN, RN, documented she received report from the triage (process of determining the priority of a patient’s treatment based on the severity of their condition) nurse and Patient #46 needed an EMS transfer home. He was at the ED because he did not feel safe at home. Staff NNNN told Patient #46 social services could help find a better placement for him in the morning if he decided to stay with them. He told her he did not want to stay, and it was safe to go home. - At 4:33 AM, he was discharged home. Review of Patient #46’s medical record dated 08/11/24 showed: - At 2:37 PM, he arrived at the ED via EMS. - He presented with left hip pain and requested placement into a nursing home. - Staff BBB, ED Physician, documented there was a concern for elder abuse versus poor social setting at home. - The patient had chronic (long-term, ongoing) left hip pain due to the setting of a non-surgically treated left hip fracture (break in a bone). The patient was wheelchair-bound, reported he had an argument with son and was unable to live at home. The patient had no active thoughts of wanting to hurt himself or other mental health issues. The left hip appeared to be chronic pain in nature with a low suspicion for an acute (sudden onset) injury or infectious etiology at this time. - At 9:44 PM, documentation showed a social worker from the Veterans Affairs (VA) called and stated that the patient was not safe to go back to his son’s house due to the son’s threatening behavior towards the patient. They stated that they should have beds for placement that night. - At 10:06 PM, Staff BBB documented based on the initial story, concern for elder abuse by the son and with no living situation at that time Patient #46 needed to be admitted. The patient was wheelchair bound due to a chronic left hip injury and fracture. At that time, it was an unsafe to discharge him and he was admitted to in-patient care for placement and a concern of malnutrition. - He remained in the hospital awaiting placement. During a telephone interview on 08/21/24 at 10:00 PM, Staff NNNN, RN, stated Patient #46 hung out in triage while she received report from the triage nurse. She was told to contact EMS to take Patient #46 home. She was aware of the alleged abuse but followed instructions to discharge the patient. She stated, “I did not necessarily agree to discharge the patient to an unsafe environment, but he answered all the orientation questions correctly.” She did not fill out an against medical advice (AMA) form and he was discharged. He did state that he was ready to go home. She was not aware that social services were available 24 hours per day. She made him comfortable until EMS arrived. She was unsure if the physicians saw the patient in triage. The physicians did not routinely see the patients in triage, so she was usure when the physician saw the patient. During an interview on 08/15/24 at 10:10 AM, Patient #46 stated: - When he called 911 on 08/07/24, he wanted to be transported to the VA. EMS told him that they called the VA, and they could not see him, so he was transported to Mercy Hospital South. - When he was at the hospital, the ED physician told him he needed to see the case manager from the VA, there was nothing they could do for him at that time. - He received verbal abuse when he got home and then was roughed up by his son. His son wanted him out of his home. His son charged him his entire social security check to live there, and he had no money left over. He had nowhere else to go. He was very tearful and did not make eye contact during this interview. During a telephone interview on 08/14/24 at 3:00 PM, and 08/15/24 at 10:00 AM, Staff GGG, ED Medical Director, stated he would notify the police in these situations when the patient did not want to file charges. The police would come to the ED and usually the patient agreed to press charges or obtain a restraining order, depending on the circumstances. It was hard to hold a patient if they wanted to go home. An AMA was not completed with the patient. The hospital had been pushing the physicians to decrease the total numbers of AMA’s but that he did not mean they could not use the AMA form. An ED provider meeting was scheduled for the following week and planned to use Patient #46’s situation as a teaching tool. He reviewed the entire chart, and a hotline call was made to report the alleged abuse. He felt that based on all the documentation, the hospital did everything they could for this man. During a telephone interview on 08/16/24 at 10:00 AM, Staff AAA, ED Physician, stated Patient #46 was alert and oriented and able to make his own decisions. He wanted to go home, and he discharged him. He felt like the patient changed his stories and was not sure if the alleged abuse had actually occurred. During a telephone interview on 08/16/24 at 11:00 AM, Staff BBBB, ED Physician, stated he felt that Patient #46 was unsafe to be discharged due to the alleged abuse. He looked unkept and malnourished. 48359”