SSM St Clare Health Center

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 46856 Based on interview, record review and policy review, the hospital failed to: - Remove staff involved in abuse allegations and perform a thorough investigation related to incident reports with allegations of abuse for two discharged patients (#16 and #38) of two discharged patients reviewed with abuse allegations. (A-0145) - Ensure the use of 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) was in accordance with the order from the licensed practitioner (LP) for three discharged patients (#13, #14 & #15) of three discharged patients reviewed with violent restraints. (A-0168) - Ensure violent restraint (medical cuffs applied to both arms and both legs to prevent someone form causing harm to themselves or others) orders were renewed according to hospital policy for one discharged patient (#15) of three discharged patients reviewed with violent restraints. (A-0171) - Ensure appropriate monitoring and nursing documentation during the use of violent restraints for one discharged patient (#14) of three discharged patients reviewed with violent restraints. (A-0175) - Follow their policy and complete a face-to-face assessment within one hour after violent restraints were placed on two discharged patients (#14 and #15) of three discharged patients reviewed with violent restraints. (A-0178) These failed practices resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation (CoP): Patient’s Rights. The hospital census was 112. Please refer to A-0145, A-0168, A-0171, A-0175 and A-0178.”

“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: 46856 Based on interview, record review and policy review, the hospital failed to remove staff involved in abuse allegations and perform a thorough investigation related to incident reports with allegations of abuse for two discharged patients (#16 and #38) of two discharged patients reviewed with abuse allegations. This failure had the potential to affect the quality of care and safety of all patients. Findings included: Review of the hospital’s policy titled, “Caregiver Misconduct, Patient Abuse, Neglect, Misappropriation of Property, and Harassment,” revised 11/17/23, showed for the protection of patients and involved personnel, patient care providers involved in patient abuse, neglect, or harassment must be relieved of patient care responsibilities and removed from patient care areas of the hospital during the pendency of a prompt investigation. An investigation into all incidents of possible caregiver abuse should be initiated within one business day of identification and be given high priority by those individuals needed to participate in the investigation. Risk Management (RM) and Human Resources (HR) will oversee the investigation, which should include: collecting and preserving any physical and documentary evidence; interviewing all alleged victims, witnesses, and, if deemed appropriate, those alleged to have committed acts of abuse; collecting other corroborating or disproving evidence; involving other regulatory authorities (e.g., local law enforcement); and documenting each step taken during the internal investigation. The results of investigations and remedial actions will be communicated to appropriate hospital leadership, HR, Regulatory, appropriate medical staff leadership, and affiliated organizations, as indicated. Review of the hospital’s document titled, “Opportunity for Improvement,” dated 02/27/25, showed Patient #38 reported that a nurse intentionally hurt her by pushing in medications as retaliation. She felt that the nurse did not address her concerns or ask about pain. The patient was interviewed and stated that she was upset with the care she received from the nurse, and when she voiced those concerns, she felt the nurse delivered care that intentionally hurt her. The nurse was removed from her care. Patient #38 and her family were grateful with the care she received after the staffing change was made. RM reviewed the medical record and statements, concluding that this incident did not meet the definition of abuse. During concurrent interview and abuse investigation report review on 10/02/25 at 12:00 PM, Staff FF, RM System Operations, stated that Patient #38 was trying to fill out some paperwork. The nurse and Clinical Partner (CP) were assisting her. She did not voice any complaints of pain to them. They left the room, and the physician entered. He found the patient crying and she told the physician that she was in pain. The physician told the nurse to give the patient some pain medication. The nurse administered 0.5 milligrams (mg) of Dilaudid (medication used to treat severe pain) intravenously (IV, in the vein). On 02/27/25, the patient and her family called in a complaint stating that the nurse intentionally hurt the patient in retaliation. RM was notified, reviewed the medical record and created a timeline. The unit manager interviewed the patient. RM discussed the incident with the Chief Nursing Officer (CNO) and HR on 02/27/25. They found the allegation was unsubstantiated. Their rationale for unsubstantiating the allegation was that while Dilaudid was given to the patient, it had known potential to cause a burning sensation when administered through an IV. On 02/28/25, the CP sent in an email statement; on 03/04/25, the unit manager sent a review of her findings regarding the incident; and on 03/05/25, the nurse sent in an email statement. There was no education completed after the investigation. During an interview on 10/02/25 at 1:30 PM, Staff GG, Regulatory Compliance Director, stated that on 02/27/25, the nurse was removed from patient care that day while the allegation was investigated. She later returned to work the same day after the allegations were unsubstantiated. During concurrent interviews and abuse investigation report review on 10/02/25 at 8:05 AM, 10:45 AM and 12:00 PM, Staff FF, RM System Operations, stated the following: - On 04/05/25, Patient #16 was told that she could no longer get up to the bathroom, because she was on non-weight bearing status due to a fracture. The previous nightshift staff had allowed her to get up to the bathroom. The dayshift staff offered to let her use a bedside commode (BSC, portable toilet that does not use running water) or bedpan. They had physical therapy (PT, focuses on range of motion and decreasing pain after an injury or illness) re-educate the patient on weight bearing restrictions, her weakness, and the use of a BSC. Patient #16 became angry that her bathroom privileges were “taken away.” She made a statement that she would “throw herself out of bed onto the floor.” In response to her statement, the nurse placed a floor mat next to her bed for safety. Patient #16 stated that staff were violating her patient’s rights, that a CP had pulled her arm, and she was being blocked from using the bathroom by the placement of the floor mat. The charge nurse (CN) was made aware, and the primary nurse brought a second nurse any time she had to assist Patient #16. The house supervisor was made aware of the situation, and an assessment of the patient’s arm was negative for bruising or redness. - On 04/06/25, Staff II, Administrative Supervisor and night shift house supervisor was made aware of the situation and informed that the patient was starting to collect staff names. - On 04/07/25, Staff II, Administrative Supervisor, notified the unit manager and RM of the situation (because of the name collecting). RM identified the arm pulling as potential abuse, made sure the nurse and CP were pulled/not working, and started the investigation. There was no incident report completed at that time. Staff interviews and statements indicated that Patient #16 was very challenging. The CP stated that the patient had out of control behavior (agitation, swinging at staff, etc.). The nurse stated that the patient had requested her thyroid (a large gland in the neck that secretes hormones that regulate growth and development) medication, and when she was unable to provide the thyroid medication, the patient became angry. She then refused to take her other medications. - On 04/09/25, the allegation was discussed with the CNO and HR, they determined it to be unsubstantiated. The arm pulling did not rise to the level of abuse. When assessed, there were no obvious injuries to her arm. The floor mat was placed as a safety intervention due to the patient’s statement that she was going to throw herself out of bed. The floor mat was not physically blocking the patient’s access to the bathroom. - The only education provided was to the unit manager on filing an incident report. During an interview on 10/02/25 at 2:00 PM, Staff II, Administrative Supervisor, stated that on the evening of 04/06/25, the CN notified her that Patient #16 was collecting staff names, and had alleged that the CP had pulled her arm. Staff II documented the notification at the end of her shift and notified the unit manager. Staff FF, RM System Operations was notified upon arrival to the hospital on the morning of 04/07/25. Patient #16 collecting staff names prompted Staff II to notify Staff FF. Staff II did not register the arm pulling as possible abuse. Staff II verified that the nurse and CP were not working on 04/07/25. During an interview on 10/02/25 at 1:30 PM, Staff GG, Regulatory Compliance Director, stated that the CP involved in Patient #16’s arm pulling event worked on 04/08/25.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 46856 Based on interview, record review and policy review, the hospital failed to ensure the use of 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) was in accordance with the order of the licensed practitioner (LP) for three discharged patients (#13, #14 & #15) of three discharged patients reviewed with violent restraints. This failure created an unsafe environment and had the potential to cause poor outcomes for all patients placed in violent restraints (medical cuffs applied to both arms and both legs to prevent someone form causing harm to themselves or others). Findings included: Review of the hospital’s policy titled, “Violent Restraint Utilization (For the Management of Violent or Self-Destructive Behaviors),” revised 08/15/24, showed the physician or another licensed independent practitioner who is responsible for the care of the patient, who is permitted by the state to order seclusion or restraints, gives the order only when less restrictive measures have been found to be ineffective to protect the patient or others from harm. The order for restraint/seclusion shall include type of restraint or device employed; maximum length of time restraint may be utilized; and specific behaviors that present a danger to the patient or others which require the use of restraint. Review of Patient #13’s medical record showed the following: - He was a 32-year-old male who was admitted on 05/06/25 for psychosis (mental illness characterized by defective or lost contact with reality) - On 05/06/25 at 9:14 PM, a provider placed an order for non-violent restraints. Nursing documented that he was at imminent risk of harm to self and others and was placed in violent restraints. - At 10:15 PM, Patient #13 was released from restraints. Review of Patient #14’s medical record showed the following: - He was an 18-year-old male who was admitted on 06/03/25 for substance abuse withdrawal. - On 06/05/25 at 4:22 PM, Staff U, RN, documented that Patient #14 was hitting himself in the face. Soft bilateral wrist restraints were applied. - At 5:06 PM, a provider placed an order for four-point (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others) violent restraints. - At 5:19 PM, Staff NN, Hospitalist (physician whose primary professional focus is the general medical care of hospitalized patients), discontinued the four-point restraint order and ordered five-point (medical cuffs applied to both arms, both legs and waist to prevent someone from causing harm to themselves or others) restraints. - From 4:22 PM through 7:00 PM, nursing documented that Patient #14 was in bilateral soft wrist restraints. - From 7:30 PM through 10:00 PM, nursing documented that Patient #14 was in seclusion. There was no documentation that Patient #14 was released from restraints. - At 11:00 PM, nursing documented that Patient #14 was released from seclusion. - There was no order for seclusion. Review of Patient #15’s medical record showed the following: - He was a 33-year-old male who was admitted on 07/11/25 for visual hallucinations (seeing or hearing things which are not there). - On 07/11/25 at 11:02 PM, the provider placed an order for four-point restraints. - At 11:03 PM, nursing documented that he was placed in four-point restraints and seclusion. His behavior was documented as erratic, pacing, grabbing, trying to pull open cabinets, and he was an imminent risk of harm to self and others. - From 11:15 PM through 07/12/25 at 11:45 PM, nursing documented that Patient #15 was in four-point restraints. - On 07/12/25 at 3:23 AM, 6:29 AM, 9:43 AM, 3:35 PM, 7:05 PM and 10:51 PM, provider orders were placed for four-point violent restraints. - On 07/13/25 at 12:00 AM, nursing documented that Patient #15 was released from restraints. - There was no documentation that seclusion was discontinued and no order for seclusion. During an interview on 10/02/25 at 1:50 PM, Staff A, Regulatory Specialist, stated that seclusion was not done at SSM Health St. Clare Hospital. The seclusion was documented in error.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) Unless superseded by State law that is more restrictive-- (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1-hour for children under 9 years of age; This Standard is not met as evidenced by: 46856 Based on record review and policy review, the hospital failed to ensure violent restraint (medical cuffs applied to both arms and both legs to prevent someone form causing harm to themselves or others) orders were renewed according to hospital policy for one discharged patient (#15) of three discharged patients reviewed with violent restraints. This failure had the potential to cause poor outcomes for all patients placed in violent restraints. Findings included: Review of the hospital’s policy titled, “Violent Restraint Utilization (For the Management of Violent or Self-Destructive Behaviors),” revised 08/15/24, showed written orders for restraint for violent or self-destructive behaviors are limited to four hours for adults 18 years or older. Patients must be reevaluated for continued restraint use at least every four hours for patient’s ages 18 years and older. If the order is about to expire and the registered nurse’s (RN) assessment shows that the patient requires continued restraint, the RN will contact the physician and request that the original order be renewed for another period of time. Review of Patient #14’s medical record showed the following: - He was an 18-year-old male who was admitted on 06/03/25 for substance abuse withdrawal. - On 06/05/25 at 4:22 PM, Staff U, RN, documented that Patient #14 was hitting himself in the face. Soft bilateral wrist restraints were applied. - At 5:06 PM, an APRN placed an order for four-point (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others) violent restraints. - At 5:19 PM, Staff NN, Hospitalist (physician whose primary professional focus is the general medical care of hospitalized patients), discontinued the four-point restraint order and ordered five-point (medical cuffs applied to both arms, both legs and waist to prevent someone from causing harm to themselves or others) restraints. The order expired after four hours. - At 11:00 PM, Patient #14 was released from restraints. There was a one hour and 41-minute gap where Patient #14 was in restraints with no order. Review of Patient #15’s medical record showed the following: - He was a 33-year-old male who was admitted on 07/11/25 for visual hallucinations (seeing or hearing things which are not there). - On 07/11/25 at 11:02 PM, the provider placed an order for four-point restraints. The order expired after four hours. - At 11:03 PM, he was placed in four-point restraints. His behavior was documented as erratic, pacing, grabbing, trying to pull open cabinets, and he was an imminent risk of harm to self and others. - On 07/12/25 at 3:23 AM, a provider order was placed for four-point violent restraints. There was a 20-minute gap where Patient #15 was in restraints with no order. - At 6:29 AM and 9:43 AM, a provider order renewed Patient #15’s four-point violent restraints. - At 3:35 PM, a provider order was placed for four-point violent restraints. There was a one hour and 52-minute gap where Patient #15 was in restraints with no order. - At 7:05 PM and 10:51 PM, a provider order renewed Patient #15’s four-point violent restraints. - On 07/13/25 at 12:00 AM, nursing documented that Patient #15 was released from restraints.”

“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: 46856 Based on interview, record review and policy review, the hospital failed to ensure appropriate monitoring and nursing documentation during the use of violent restraints (medical cuffs applied to both arms and both legs to prevent someone form causing harm to themselves or others) for one discharged patient (#14) of three discharged patients reviewed with violent restraints. This failure created an unsafe environment and had the potential to cause poor outcomes for all patients placed in violent restraints. Findings included: Review of the hospital’s policy titled, “Violent Restraint Utilization (For the Management of Violent or Self-Destructive Behaviors),” revised 08/15/24, showed an assigned staff member must monitor the patient and document the findings at the initiation of restraints and every 15 minutes thereafter. The following will be monitored every 15 minutes: signs of any injury associated with the application of restraint; circulation in the restrained extremities; physical and psychological status and comfort (including pain); maintenance of the head of bed elevation of 30 degrees for patients restrained in supine position, unless medically contraindicated; readiness for discontinuation of restraint; suction equipment will be readily available in the department for use if mechanical restraints are utilized. Each episode of restraint includes documentation of the status of the patient every 15 minutes. Review of Patient #14’s medical record showed the following: - He was an 18-year-old male who was admitted on 06/03/25 for substance abuse withdrawal. - On 06/05/25 at 4:22 PM, Staff U, Registered Nurse (RN), documented that Patient #14 was hitting himself in the face. Soft bilateral wrist restraints were applied. - At 5:06 PM, a provider placed an order for four-point (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others) violent restraints. - At 5:19 PM, Staff NN, Hospitalist (physician whose primary professional focus is the general medical care of hospitalized patients), discontinued the four-point restraint order and ordered five-point restraints (medical cuffs applied to both arms, both legs and waist to prevent someone from causing harm to themselves or others). - There were 11 missing nursing restraint assessments (missing from 6:15 PM, 7:15 PM, 7:45 PM, 8:15 PM, 8:45 PM, 9:15 PM, 9:30 PM, 9:45 PM, 10:15 PM, 10:30 PM, and 10:45 PM). - At 11:00 PM, Patient #14 was released from restraints. During an interview on 09/30/25 at 10:00 AM, Staff U, RN, stated that patients in violent restraints required frequent documentation every 15 minutes. If a patient was placed in four-point restraints, a nurse had to be one to one (1:1, continuous visual contact with close physical proximity) with that patient.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 46856 Based on interview, record review and policy review, the hospital failed to follow their policy and complete a face-to-face assessment within one hour after violent restraints (medical cuffs applied to both arms and both legs to prevent someone form causing harm to themselves or others) were placed on two discharged patients (#14 and #15) of three discharged patients reviewed with violent restraints. This failure had the potential to cause poor outcomes for all patients placed in violent restraints. Findings included: Review of the hospital’s policy titled, “Violent Restraint Utilization (For the Management of Violent or Self-Destructive Behaviors),” revised 08/15/24, showed when a restraint is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff member or others, the patient must be seen face-to-face within one hour after the initiation of the intervention by a physician, licensed independent practitioner or Advanced Practice Registered Nurse (APRN). Review of Patient #14’s medical record showed the following: - He was an 18-year-old male who was admitted on 06/03/25 for substance abuse withdrawal. - On 06/05/25 at 4:15 PM, Staff U, Registered Nurse (RN), documented that she called Staff NN, Hospitalist (physician whose primary professional focus is the general medical care of hospitalized patients), for medication orders and that it was an emergency. Staff NN stated that he was on the phone with a patient’s family member, said he would call Staff U back, and then hung up. - At 4:22 PM, Staff U documented that Patient #14 was hitting himself in the face. Soft bilateral wrist restraints were applied. - At 5:06 PM, an APRN placed an order for four-point (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others) violent restraints. - At 5:19 PM, Staff NN, Hospitalist, discontinued the four-point restraint order and ordered five-point restraints (medical cuffs applied to both arms, both legs and waist to prevent someone from causing harm to themselves or others). The order expired after four hours. Staff NN documented a face-to-face evaluation. - At 6:20 PM, Staff U, RN, documented that had she reminded Staff NN that he was supposed to assess the patient within one hour of violent restraints. She reminded Staff NN an hour later again. He stated that he was already halfway home to Illinois and that he could not assess the patient. If anything, he would cancel the order. Staff U notified the Intensive Care Unit (ICU, a unit where critically ill patients are cared for) charge nurse. - At 11:00 PM, Patient #14 was released from restraints. During an interview on 10/01/25 at 4:10 PM, Staff U, RN, stated that she was the one to one (1:1, continuous visual contact with close physical proximity) for Patient #14 while he was on the Stepdown Unit (a telemetry [remote observation of a person’s heart rhythm, using signals that are transmitted from the patient to a computer screen] monitored unit that provides care for adult patients requiring continuous cardiac monitoring). Earlier in the shift, he had several behavioral outbursts that required additional staff for de-escalation. The patient ran out into the hall and tried to hit himself. He took off running down the hallway toward some construction stuff but was brought back by security staff. Patient #14 was agreeable to being placed in restraints for safety. Staff U contacted the provider, who placed orders for restraints and medications. Staff U stayed with Patient #14 as his 1:1 observer, while he was on the unit. She notified the provider that he needed to do a face-to-face assessment. The provider told her that he was “on his way home and he couldn’t make it back, so he might cancel the order.” He never came to the patient’s room. The patient was transferred to the ICU for 1:1 monitoring. Staff U notified the ICU charge nurse of the provider not doing a face-to-face on the patient. Although requested, Staff NN, Hospitalist, was unavailable for interview. Review of Patient #15’s medical record showed the following: - He was a 33-year-old male who was admitted on 07/11/25 for visual hallucinations (seeing or hearing things which are not there). - On 07/11/25 at 11:02 PM, the provider placed an order for four-point restraints. The order expired after four hours. A face-to-face evaluation was completed by the provider. - At 11:03 PM, he was placed in four-point restraints. His behavior was documented as erratic, pacing, grabbing, trying to pull open cabinets, and he was an imminent risk of harm to self and others. - On 07/12/25 at 3:23 AM, a provider order was placed for four-point violent restraints. A face-to-face evaluation was completed by the provider. - At 6:29 AM and 9:43 AM, a provider order renewed Patient #15’s four-point violent restraints. - At 3:35 PM, a provider order was placed for four-point violent restraints. There was no face-to-face evaluation completed by the provider. - At 7:05 PM and 10:51 PM, a provider order renewed Patient #15’s four-point violent restraints. - On 07/13/25 at 12:00 AM, nursing documented that Patient #15 was released from restraints. During a telephone interview on 10/02/25 at 1:15 PM, Staff HH, Hospitalists Medical Director, stated that he expected the providers to perform an in-person face-to-face exam per hospital policy for patients in violent restraints.”