Freeman Health System - Freeman West

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 47504 Based on observation, interview, record review and policy review, the Governing Body failed to ensure that care was provided in a safe setting and adequate nursing supervision was provided when the Chief Executive Officer (CEO) failed to effectively manage the entire hospital, including accountability for the effective oversight of staff to comply with the requirements under 42 CFR 482.13 Condition of Participation (COP): Patient’s Rights, 42 CFR 482.23 COP: Nursing Services, and 42 CFR 482.51 Surgical Services. These failures had the potential to adversely affect the quality of care and safety of all patients in the hospital. This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.12 COP: Governing Body. Please refer to tag A-0049 and A-0057.”

“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: - Provide a safe environment for two current suicidal (SI, thoughts of causing one’s own death) patients (#43 and #103) out of two SI patients observed; (A-0144) - Provide constant visual monitoring for one current SI patient (#103) with a tele-sitter (caregivers that watch at-risk patients via monitor and report to the primary caregiver) observed; (A-0144) - Ensure safety rounds were completed for two current SI patients (#113 and #114) of five SI patients reviewed; (A-0144) - Provide care in a safe setting for one discharged SI patient (#97) of one eloped (when a patient makes an intentional, unauthorized departure from a medical facility) patient reviewed; (A-0144) - Provide staff education in response to the use of nonsterile equipment in the operating room (OR) for one current patient (#102) of two OR patients observed; (A-0144) - Follow the sharps (a term used for devices with sharp points or edges that can puncture or cut the skin) safety policy for one current OR patient (#70) of two OR patients observed; (A-0144) - Remove one staff member with an allegation of abuse for one discharged patient (#112) of one abuse event reviewed; (A-0145) - Develop a care plan to include the use of restraints (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) for one patient (#116) of one secluded patient reviewed. (A-0166) - Ensure all patients placed in restraints (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) had a physician order for restraint or seclusion for two current patients (#43 and #83) and two discharged patients (#116 and #117) of four patient’s reviewed for restraint and seclusion orders. (A-0168) - Follow their policy and ensure orders for restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) were not written as standing orders for one patient (#117) of four restraint patients reviewed. (A-0169) Additionally, after the discovery of an unsafe patient care environment and limited recognition of the potential for negative patient outcomes the situation constituted an Immediate Jeopardy (IJ) and placed all patients of the hospital at risk. The hospital submitted a document to abate the IJ for Patient’s Rights on 06/04/26 and provided an acceptable plan of correction to prevent further risk to patients. These failed practices resulted in a systemic failure and noncompliance with 42 CFR 482.13 COP: Patient’s Rights. Please refer to A-0144, A-0145, A-0166, A-0168 and A-0169.”

“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: 47504 Based on observation, interview, record review, and policy review, the hospital failed to ensure: - Staff failed to follow hospital policy for patients with a high fall risk by ensuring fall prevention measures were implemented for three discharged patients (#49, #50 and #52) that experienced falls resulting in death, of ten fall incidents reviewed. (A-0395) - Staff failed to follow hospital policy for patients with a high fall risk by ensuring fall prevention measures were implemented for one current patient (#36) and six discharged patients (#44, #45, #46, #47, #48 and #51) that experienced falls resulting in serious injuries, of ten fall incidents reviewed. (A-0395) - Staff failed to follow hospital policy for patients with a high fall risk when they failed to implement fall prevention measures including bed alarms, fall risk arm bands, fall alert signs and nonskid socks for three current high fall risk patients (#22, #23, #24) of four current high fall risk patients observed. (A-0395) - Staff failed to follow hospital policy for patients with a high fall risk when they did not ensure confused high fall risk patients had a one to one (1:1, continuous visual contact with close physical proximity) safety sitter for two current confused, high fall risk patients (#40 and #41) of two confused fall risk patients observed. (A-0395) - Nursing staff failed to follow the hospital policy for diabetic patients presenting with an insulin pump for two discharged patients (#91 and #96) of two discharged patients with insulin pumps reviewed. (A-405) - Nursing staff failed to follow the Hypoglycemia (low blood glucose [BG, sugar that circulates in the blood]) Protocol and physician orders for one current patient (#98) with hypoglycemia reviewed. (A-405) - Nursing staff failed to follow hospital policy for critical medication administration times for seven discharged patients (#105, #106, #107, #108, #109, #110 and #111) of 14 discharged patients reviewed. (A-405) - Nursing staff failed to follow hospital policy for medication labeling for one current patient (#70) of one surgical patient observed. (A-405) Additionally, after the discovery of an unsafe patient care environment and limited recognition of the potential for negative patient outcomes the situation constituted an Immediate Jeopardy (IJ) and placed all patients of the hospital at risk. The hospital submitted a document to abate the IJ for Nursing Services on 05/04/26 to provide an acceptable plan of correction to prevent further risk to patients. Additionally, after the discovery of a second unsafe patient care environment and limited recognition of the potential for negative patient outcomes the situation constituted another IJ and placed all patients of the hospital at risk. The hospital submitted a document to abate the IJ for Nursing Services on 06/03/26 to provide an acceptable plan of correction to prevent further risk to patients. These failed practices 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-0405.”

“SURGICAL SERVICES CFR(s): 482.51 If the hospital provides surgical services, the services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. This Condition is not met as evidenced by: 48359 Based on observation, interview, record review and document review, the hospital failed to meet industry safety standards and follow hospital policy: - When performing universal timeouts (a mandatory, final pause taken by the entire operating team just before a surgery begins to verbally confirm the correct patient, the correct surgical plan and the correct body part to ensure absolute safety) for one current patient (#70) and two discharged patients (#75 and #76) of four surgical patients reviewed; (A-0951) - When surgical dry times were not followed for two current patients (#75 and #76) of two surgical patients observed; (A-0951) and - When a surgical site was not marked for one current patient (#69) of one surgical patient observed.(A-0951) Additionally, after the discovery of unsafe patient care practices and limited recognition of the potential for negative patient outcomes the situation constituted Immediate Jeopardy (IJ) and placed all patients of the hospital at risk. On 05/28/26, the hospital submitted a document to abate the IJ and to provide an acceptable plan of correction to prevent further risk to patients. These failed practices resulted in a systemic failure and noncompliance with 42 CFR 482.51 Condition of Participation (CoP): Surgical Services. Please refer to A-0951. 47504”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 47504 Based on document review, medical record review and interview, the Governing Body failed to ensure staff education/follow up was completed after surgical safety events occurred with four discharged patients (#99, #100, #101 and #115) of seven surgical patient safety events reviewed. Findings included: Review of the hospital’s policy titled, “Risk Management Plan - 2026,” reviewed 02/2026, showed: - The risk management program is designed to enhance continuous improvement of patient care services in a safe healthcare environment. - The board of directors has the ultimate responsibility to ensure the provision of a safe environment. - The program involves continuous quality improvement activities. - The objectives are to review the performance of all persons providing care to patients, to identify and correct practices which may present unnecessary risks to patients or deviate from acceptable practices, and to organize/present educational programs on topics to promote awareness of risk and safer practices. - Administration/Management, along with professional staff (Physicians, Nurses, and other licensed health care practitioners) identify, implement and support corrective actions and monitors results for effectiveness. Review of the hospital’s undated document titled, “SAFE Reports Safety Assures Freeman’s Excellence,” showed the purpose and process of the SAFE report was to document actions and to maintain clear records of investigations, findings and corrective actions taken. Review of Patient #99’s medical record, dated 05/12/26, showed she was a 41-year-old admitted to the hospital for abnormal uterine (an organ within a woman’s pelvis where a fetus develops and grows) bleeding. Review of the hospital’s document titled, “Safe Report,” dated 05/12/26, showed: - Patient #99 was asked if she was willing to allow a student to scrub into the surgery and assist Staff HHHH, Physician. She indicated she did not want a student scrubbing into her case but was okay with a student observing her surgery. - Patient #99 was asked if she would be okay with a student intubating (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) her and administering medications to put her to sleep under the observation of a licensed anesthesia (a state of controlled, temporary loss of sensation or awareness that is induced for medical purposes) provider. She indicated she was not comfortable with a student putting her to sleep. - Staff IIII, Physician, was informed of the patient’s wishes and he responded, “why would you tell her that?” - The medical student was informed that Patient #99 did not want them to scrub into her case. - Staff IIII administered the medication to put her to sleep. Once she was asleep, the student intubated her. - Staff HHHH was informed the patient did not want a student scrubbing into her case and he replied, “then there shouldn’t be a student.” - Staff IIII asked if the student should leave. Staff HHHH responded, “No, I’ve known and taken care of this patient for 30 plus years, I think she would be okay with a student.” - The nurse informed Staff HHHH the patient specifically said she did not want a student scrubbed into her case or putting her to sleep. Staff HHHH said, “it will be okay.” - The medical student scrubbed into the surgery and placed sutures (a strand or thread used to sew skin and other body tissues together to close up a surgical incision or a tear). - On 06/02/26, the day the safety event was reviewed by the state surveyor, a comment showed the event was discussed with Staff HHHH. He was aware the patient expressed her wishes regarding student participation and was aware of the need to honor those wishes at all times. In the future, the surgical consent will be reviewed in detail in the provider’s office, along with the expectation of student participation ahead of time to alleviate any confusion and honor the patient’s wishes. Staff HHHH agreed to the consent review. During an interview on 06/02/26 at 12:00 PM and 06/04/26 at 10:45 AM, Staff AAA, Risk Management Director, stated that when the nurse informed the medical staff of the patient’s wishes for no medical students, the students should have been removed. She expected a patient’s wishes to be respected when a nurse advocated those wishes. On 05/12/26, she sent the information to the service line director but did not receive any feedback. She believed education was provided to Staff HHHH, Physician, within a “reasonable” timeframe, but did not have confirmation. Review of Patient #100’s medical record, dated 05/21/26, showed he was a 76-year-old admitted to the hospital for atrial fibrillation (A-fib, an irregular, often rapid heart rate that commonly causes poor blood flow) and heart bypass surgery. Review of the hospital’s document titled, “Safe Report,” dated 05/22/26, showed: - Patient #100 was in the operating room (OR) with his chest open, when Staff EEEE, Physician, entered the room, from another OR, with a bloody surgical gown and gloves. He approached the OR table to speak with Staff FFFF, Physician. - On 05/22/26, the Safe Report status was “need more information” and showed there was a request to follow up with the physician to reinforce sterile (completely clean and free from germs) precautions. - On 06/02/26, the day the safety event was reviewed by the state surveyor, a comment was added and showed “will discuss with Staff EEEE (he is currently on vacation). Please add this to the next meeting to address with the team. During an interview on 06/02/26 at 12:00 PM, Staff AAA, Risk Management Director, stated this event remained open. A message was sent to the service line director with a request for a comment, but the comment was not received. She “trusted” the service line director had completed a “verbal” follow up with Staff EEEE, Physician. The initial comment request was originally sent to the wrong individual. Review of Patient #101’s medical record, dated 03/25/26, showed he was a 51-year-old who was admitted to the hospital for atherosclerosis (a condition where sticky deposits called plaque up inside your artery walls) and right leg angiogram (an x-ray [test that creates pictures of the structures inside the body-particularly bones] procedure that evaluates blockages of the arterial system while injecting contrast or dye). Review of the hospital’s document titled, “Safe Report,” dated 03/25/26, showed: - Staff FFFF, Physician, had a nurse remove his mask during a procedure, due to his “glasses fogging up.” - The strings of the mask came undone and touched the sterile field. - The Certified Registered Nurse Anesthetists (CRNA, registered nurses who have obtained graduate-level education and board certification in anesthesia) asked Staff FFFF to remove the mask and he refused. - Staff FFFF was again informed that it was hospital policy for him to wear a mask during a procedure. He changed gown, gloves and rescrubbed. - No follow up was documented. During an interview on 06/02/26 at 12:00 PM and 06/04/26 at 10:45 AM, Staff AAA, Risk Management Director, stated she did not receive any feedback from the service line director. The initial comment request was sent to the wrong individual. Review of Patient #115’s medical record, dated 05/04/26, showed he was a 19-year-old admitted to the hospital for appendicitis (inflammation of an organ located in the lower right abdomen). Review of the hospital’s document titled, “Safe Report,” dated 05/01/26, showed: - At 4:00 PM, a nurse attempted to retrieve Patient #115 for surgery and found the surgical consent was not signed by the physician. - At 4:08 PM, the nurse texted Staff GGGG, Physician, and asked him to sign the consent. - Staff GGGG responded “No, seeing a patient in the Emergency Department (ED), just put them in the room?!!!!!.” - The nurse responded, “we were told that we cannot go back without the consent signed.” - The nurse informed the charge nurse and manager. - The manager responded that the nurse should wait for Staff GGGG to sign the consent. - The charge nurse responded to bring the patient; the nurse responded that she was not comfortable with that. - The charge nurse responded that she would come and get the patient and take them to the OR. Staff GGGG could sign the consent later. - On 05/11/26, a note was entered and showed a request was made to the service line director to follow up with Staff GGGG regarding expectations of adherence to established policies and procedures to ensure safe surgical practices. - On 06/22/26, the day the safety event was reviewed by the state surveyor, a comment showed the Safe Report was reviewed with Staff GGGG and he indicated he was aware and had discussed the report with the service line director. He understood the concerns and the need to obtain informed consent before taking the patient to the OR, along with the expectations for appropriate behavior and interactions with staff at all times. During an interview on 06/02/26 at 12:00 PM and 06/04/26 at 10:45 AM, Staff AAA, Risk Management Director, stated that Staff GGGG, Physician, had not been informed of the policy change. She encouraged service line directors to maintain coaching records. She agreed the Safe Report did not show any follow-up to the event. Staff GGGG’s behavior was unacceptable, and she expected him to follow the hospital’s policy when he was informed by the nursing staff. She believed Staff GGGG was provided education and follow-up, but the Safe Report was not updated by the service line director. During a telephone interview on 06/10/26 at 10:00 AM, Staff XXX, Market President, stated that she expected the Governing Body to ensure follow-up on safety events, they needed to “close the loop.” A meeting was held last week to provide the Governing Body with a full update of the survey events. Events should be reviewed within a “couple of hours” of the event. The hospital’s policy needed revision to include defined expectations and timelines for event follow-up. She expected timely follow-up according to the severity of the event. Coaching and education should be documented in the staff member’s personnel file and in the Safe Report. House wide education should be provided for all events that had the potential for harm. 48359”

“CHIEF EXECUTIVE OFFICER CFR(s): 482.12(b) The governing body must appoint a chief executive officer who is responsible for managing the hospital. This Standard is not met as evidenced by: 47504 Based on observation, interview and policy review, the Governing Body failed to ensure the Chief Executive Officer (CEO )was responsible for management of the entire hospital including the accountability for the effective oversight of staff to comply with the requirements of 42 CFR 482.23 Condition of Participation (COP): Nursing Services, 42 CFR 482.13 COP: Patient’s Rights, and 42 CF 482.51 COP: Surgical Services. Review of hospital document titled, “Medical Staff Bylaws,” approved 05/15/26, showed: - The CEO is the President of the hospital and is accountable to the board, in conjunction with the Medical Executive Committee, for the quality and efficiency of clinical services, performance and effectiveness of patient care, along with review and quality management functions delegated to the staff. - The CEO will communicate and represent the opinions, policies, concerns, needs, and grievances of the medical staff to the Board, CEO and other staff officials. - The CEO will oversee the functions of the clinical organization of the medical staff and supervision of care/clinical work in all divisions. Review of the hospital’s Organizational Chart, dated 2026, showed Staff EEE, CEO as the President/CEO over the hospital and all staff. The CEO reports directly to the Board of Directors. During an interview on 06/18/26 at 8:45 AM, Staff EEE, CEO, stated he was responsible for the oversight of the hospital and all staff. These failures had the potential to affect the quality of care and safety of all patients, resulting in a systemic failure and noncompliance with 42 CFR 482.12 Condition of Participation (CoP): Governing Body.”

“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 provide care in a safe setting when: - Staff failed to remove safety risks from the patient environment for two current suicidal (SI, thoughts of causing one’s own death) patients (#43 and #103) of two current SI patients observed; - Staff failed to provide constant visual monitoring for one current SI patient (#103) with a tele-sitter (caregivers that watch at-risk patients via monitor and report to the primary caregiver) observed; - Ensure safety rounds were completed for two current SI patients (#113 and #114) of five SI patients reviewed; - Staff failed to ensure a safe environment for one discharged SI patient (#97) who eloped (when a patient makes an intentional, unauthorized departure from a medical facility) of one elopement patient reviewed; - Staff education was not provided in response to the use of nonsterile equipment in the operating room (OR) for one current patient (#102) of two OR patients reviewed; and - Staff failed to follow the sharps (a term used for devices with sharp points or edges that can puncture or cut the skin) safety policy for one current OR patient (#70) of two OR patients observed. Review of the hospital’s policy titled, “Suicide Precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm),” reviewed 05/2019, showed: - All patients aged nine and older will receive a nursing admission assessment, including a suicide risk assessment. - Based on the findings of the suicide risk assessment, historical data of the patient, or clinical judgement, any patient that is found to be at risk for suicide will receive appropriate intervention immediately. If a patient is found to be at risk the electronic health record (EHR) will trigger a care plan problem that will indicate the risk level of the patient and suggest appropriate interventions, assessments and nurse-driven orders. - Clinical staff will regularly assess patients for warning signs of suicide throughout their hospitalization. If warning signs are present, another suicide risk assessment will be completed, and appropriate interventions will be implemented. - For patients determined to be a moderate risk for suicide, the provider will be notified. Interventions ordered and implemented may include: placing a blue “Please Leave Patient Room Door Open” sign on their door; , placing psychiatry (the study and treatment of mental illness) and social services consults (requires physician order); requiring assistance to the bathroom, with ambulation and during transport through the hospital; searching patient belongings for contraband (items that are illegal, forbidden, or that can be used to harm self or others), weapons or other prohibited/dangerous items; increased frequency of rounding; place the patient in a room close to the nurse’s station; limiting visitors if appropriate and clinically indicated; disposing of all syringes in the sharps container or other secured disposal bin; cover necessary intravenous (IV, in the vein) access devices and ports (a small medical appliance installed beneath the skin in the chest region and connects the port to a vein and is used to administer medications and draw blood) with a tamper-proof sticker when not in use; completing a visual oral check after all controlled substance (drugs or medications that are high risk for personal consumption or abuse) medication administrations to confirm ingestion; keeping patient room doors open; completing safe environment checklists immediately and with each shift. - For patients determined to be at high risk for suicide, interventions include those for moderate risk, along with ensuring a staff member remains with the patient while awaiting further orders; immediately notifying the provider; obtaining a continuous observation order; and placing a psychiatry consult. - Care providers will utilize the safe environment checklist located in the EHR each shift to assess the environment of patients at risk for suicide and document actions taken to mitigate risks. - Care of the suicidal patient in the general inpatient setting involves assessment of the modifiable and non-modifiable risks that exist in the environment. Actions should be taken to mitigate risks whenever possible without interfering with the medical treatment of the patient. - Identifying environmental hazards is the responsibility of all those who provide services to the patient during their hospitalization, including housekeeping, dietary, pharmacy, etc. - Hazards that may be brought into the patient room as part of daily tasks or treatment must be taken out upon exiting the room to ensure maintenance of a safe environment. - Examples of hazards/risks to be considered when assessing the patient environment include but are not limited to: overfull sharps containers, medical supplies, chemical agents (cleaning supplies, wipes, etc.), metal, glass or plastic items (silverware, lab tubes, mirrors, etc.), medical equipment, medications, purses or bags, plastic bags, items that are dangerous if ingested (batteries, etc.), windows that can be opened or broken and unprotected light fixtures. - Examples of ligature risks include items such as nurse call cords, bed cords, phone cords, phone chargers, shoe strings, belts, trash bags, extra linens, tubing (suction, oxygen, IV, etc.), medical equipment, drapes or curtains, medical supplies (tourniquets, etc.), door knobs and hinges, exposed plumbing and pipes, soap, paper towel or toilet paper dispensers, light fixtures and projections from the ceiling. Review of the hospital’s policy titled, “Continuous Observations for Patient Safety,” revised 08/2022, showed: - Patients that are a danger to themselves, or others, are combative, aggressive and/or suicidal should be under continuous observation - A tele-sitter or a patient safety attendant is required for these patients as there is a high risk of potential for injury to the patient or another patient. - All patients that are suicidal should have SP in place with or without a physician order. Observation on 06/02/26 at 12:16 PM, showed Patient #43, with SP and frequent observation orders had access to a call light, bed and a vital sign (VS, measurements of the body’s most basic functions) machine cords, all greater than 18 inches long. There were plastic linen and trash bags, and two non-breakaway shower curtains in their room. Observation on 06/02/26 at 12:10 PM, showed Patient #103, who was on a 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) with continuous observation of a tele-sitter for SI was alone in the bathroom with the door closed. A staff member entered the room, opened the patient’s bathroom door, peered at him, then closed the door, leaving the patient alone inside the bathroom. The staff member then exited the patient room. Continuous visualization monitoring was not maintained Patient #103 had access to call light and bed cords greater than 18 inches. During an interview on 06/16/26 at 3:15 PM, Staff RRRR, Critical Care Director, stated that patients with SP ordered remain in the staff member’s continuous line of sight (LOS, continuous visual contact with the patient), including when in the bathroom. He expected the tele-sitters to contact floor nursing staff immediately if the patient was not visualized. Any items that could be used as a weapon or cause harm to the patient or others should be removed from the patient’s room, if not medically necessary. There should be no cables, cords or plastic bags left in the room. During an interview on 06/16/26 at 3:15 PM, Staff TTTT, Critical Care Assistant Director, stated that it was not organizational practice to remove privacy curtains or shower curtains from patient rooms. Review of Patient # 113’s medical record, dated 05/26/26, showed: - At 9:09 PM, a 72-year-old female presented to the Emergency Department (ED) via law enforcement for hallucinations (seeing or hearing things which are not there) and dementia (a loss of thinking abilities and memory). She saw dead people in her house, lived alone and could not take care of herself. - At 9:10 PM, she was placed on a 96-hour hold. An order was placed for hourly rounding with every 15-minute safety rounds (15-minute visualization and documentation of the safety of each patient). A 15-minute observation was completed but was not documented until 11:05 PM. - At 9:31 PM, a safe environment checklist was completed. - She was medically cleared for admission to a geriatric behavioral health unit (BHU), but no beds were available. She remained in the ED pending placement. - Hourly rounding was completed at 9:33 PM and 11:06 PM, not every hour. - On 05/27/26 at 2:55 AM, 6:05 AM, 8:02 AM, 10:55 AM and 11:05 AM, hourly rounding was completed. From 11:00 PM through 1:45 PM, 15-minute observations were completed but were not documented until 2:55 AM. From 1:45 AM through 5:00 AM, there were no 15-minute observations documented. From 5:00 AM through 5:45 AM, 15-minute rounding was completed but was not documented until 6:05 PM. From 5:45 AM though 7:15 AM, there were no 15-minute observations. - On 05/27/26 at 11:05 AM, she was discharged from the ED and transferred to the BHU. - Hourly nurse rounding and one to one (1:1, continuous visual contact with close physical proximity) observations were not completed as ordered multiple times throughout her stay in the ED. Review of Patient #114’s medical record, dated 05/19/26, showed: - At 9:41 AM, a 51-year-old male presented to the ED via Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.). He was picked up at a local gas station with a complaint of SI, chest pain and anxiety. He had a plan but would not reveal it. - His past medical history included methamphetamine (a drug with more rapid and lasting effects than amphetamine, used illegally as a stimulant) abuse, alcohol abuse, anxiety, depression (extreme sadness that doesn’t go away), high blood pressure (BP, normal adult blood pressure is between 90/60 and 120/80), alcohol withdrawal (symptoms that occur when someone stops using alcohol after a period of heavy drinking) and a seizure disorder (sudden, uncontrolled electrical disturbance in the brain which cause changes in behavior, movements and/or in levels of consciousness). - At 9:58 am, the physician ordered every 15-minute safety rounds and a 96-hour hold. - At 10:44 AM, he had an electrocardiogram (ECG or EKG, test that records the electrical signal from the heart to check for different heart conditions) which showed atrial fibrillation (A-fib, an irregular, often rapid heart rate that commonly causes poor blood flow). He was started on a continuous IV heparin (a medication used as a blood thinner or to prevent blood clots from forming) infusion. - At 11:26 AM, he received a BH evaluation. The SI assessment indicated he was suicidal with the ability to carry out a plan and he required admission to a BHU for potential imminent danger to self and continuous observation. - At 2:26 PM, admission to a medical unit to treat A-fib, shortness of breath, and metabolic acidosis (condition where too much acid accumulates in the body and can be related to a buildup of body toxins or kidney failure) was determined. He was transferred to the inpatient telemetry (remote observation of a person’s heart rhythm, using signals that are transmitted from the patient to a computer screen) unit. - At 4:47 PM, an order was placed for SP - On 05/19/26, from 7:00 PM until 8:00 PM, there were no 15-minute observations documented. - On 05/20/26, from 12:00 AM until 7:00 AM, there were no 15-minute observations documented, and from 8:00 AM until 9:00 AM, there were no 15-minute observations documented. - On 05/22/26, from 7:15 AM until 8:30 AM, there were no 15-minute observations documented. - On 05/24/26, from 8:45 PM until 10:00 PM, and from 11:45 PM until 1:00 AM, there were no 15-minute observations documented. During an interview on 06/17/26 at 3:30 PM, Staff NN, Chief Nursing Officer (CNO), stated that a SI patients with a sitter/tele-sitter were to remain in staff’s direct LOS, including while in the bathroom or shower. If a tele-sitter lost sight of the patient, it should be immediately escalated to their nurse. Nurses are expected to immediately respond and to have someone remain with the patient at all times. All high-risk SI patients with SP should have long cords, trash bags, and non-breakaway curtains removed from their rooms and be assigned a 1:1 sitter. On the telemetry unit she expected everything to be removed from the rooms, except what was needed for direct care of the patient. If staff are unable to remove items directly related to the patient care, a 1:1 sitter should be assigned. All safety rounds should be observed and documented every 15 minutes. During an interview on 06/18/26 at 8:00 AM, Staff XXXX, Market President, stated that a SI patients with a sitter/tele-sitter should remain in staff’s direct LOS, including while in the bathroom or shower. Tele sitters should notify staff immediately if a patient was out of their line of sight. When notified, nurses should immediately respond and visualize the patient. Then stay with the patient until they were back in view of the tele-sitter. All staff should follow policy and remove all hazardous items from SI patient rooms, except for what was needed for direct care of the patient. It was not appropriate for documentation of 15-minute observations conducted over three hours to be documented all at the same time. Staff should follow policy and document every 15-minutes. There should be no gaps of time with the documentation of safety rounds. Within the ED it would be inappropriate for a staff member to be assigned a 1:1, as well as additional patients. That was not acceptable. During a telephone interview on 06/10/26 at 4:30 PM, Staff NNNN, Patient Care Technician (PCT), stated that she worked night shift in the ED and after midnight she was the only PCT. She was typically assigned to six patients to round on and assist to the bathroom. In addition to the six patients, she was often assigned as the 1:1 sitter. At times there were multiple patients in the ED that required a 1:1 sitter and she was unable to meet that demand. Several elopements occurred as a direct result of not having a dedicated 1:1 sitter. Some 1:1 patients were suicidal and should not be left unattended. She would “catch-up on every 15-minute round documentation” all at one time but not actually make the observations. She was aware that they should be documented every 15 minutes, but that did not always occur Management was aware of the situation. Review of the hospital’s policy titled, “Patient Elopement Policy,” reviewed 06/2026, showed: - Assessing risk of elopement can be completed by a provider, nurse or BH assessment team member and should be completed upon admission, throughout hospitalization, any time there were changes in patient acuity or status. - Things to consider when assessing risk for elopement included whether they are a danger to self or others or if they have physical or mental impairments that increase their risk of harm to self or others. If so, then the patient should be considered a risk for elopement. - Interventions that may be initiated include placement close to the nursing station, requesting family to remain at the bedside, increasing the frequency of rounding, providing diversional activities, placing a patient safety attendant for observation, and using yellow patient gowns as a visual indicator of patient risk for elopement. Review of the hospital’s policy titled, “Safe Reporting (Safe Assures Freeman’s Excellence [SAFE Report]), reviewed 06/2025, showed a Safe Report shall be completed for any circumstance identified that could lead to an unsafe patient condition or error, an unplanned action, event, or outcome with or without consequences and any deviation from usual practices or medical care that poses a risk of harm or causes injury to a patient. Review of the hospital’s undated document titled, “Elopement,” showed only one Safe Report was written for ED elopements within the previous six months. Review of the hospital’s undated document titled, “Elopement,” showed: - On 01/14/26, at approximately 5:40 AM, Patient #97 eloped from the ED. - He was observed leaving the ED on camera by security. Security staff followed him off property, but lost sight of him. - At 5:42 AM, 911 was called and law enforcement notified of the elopement. - He was later returned to the ED bylaw enforcement. Although requested, the hospital failed to provide ED staff elopement education in response to Patient #97’s elopement event. Review of Patient #97’s medical record, dated 01/14/26, showed: - At 4:10 AM, a 17-year-old male presented to the ED with SI. - At 4:13 AM, he stated “its ‘just been a shitty year’.” He was SI without a plan, but his last suicide attempt was a couple of months ago with a gun. - His assessment indicated he was anxious, depressed and had SI. - At 4:50 AM, his BH assessment disclosed he had a near suicide attempt approximately six months ago in which he held a gun to his head but was interrupted by his girlfriend. He presented to the ED after having a highly stressful day, which was the same date his sister attempted suicide by crashing her car. He felt intense guilt related to the past trauma involving his sister. He appeared distressed, emotionally labile (abnormal variability in mood with repeated, rapid, and abrupt shifts in emotional expression) and had acute (sudden onset) psychosocial (relating to the interrelation between social factors and individual thought and behavior) stressors, with several risk factors for potential suicidal behavior. He reported the wish to die and access to means. A past suicidal attempt, increased feelings of hopelessness, increased depression and loneliness were documented. He stated he was impulsive and would act on things when upset. He was at high risk and further evaluation and/or treatment were indicated. - At 5:40 AM, he eloped and was observed by security personnel leaving the ED on camera. The police were called immediately, and he was followed by security staff off property, but they eventually lost sight of him. - At 6:10 AM, he was returned to the ED bylaw enforcement. A red card was placed on his door to identify him as high risk. - At 7:00 AM, every 15-minute observations began, two hours and 50 minutes after his initial arrival and 50 minutes after he was returned to the ED after he eloped. - At 3:04 PM, he was transferred to an inpatient BHU. An elopement assessment was not completed and he did not have SP or elopement precautions (EP, interventions to prevent someone from leaving who may be at risk for self-harm or injury) ordered during his hospital stay. During interviews on 06/02/26 at 12:00 PM and 06/04/26 at 10:45 AM, Staff AAA, Risk Management Director, stated that Patient #97 entered the ED and stated that he was suicidal without a plan. He had a BH examination which recommended inpatient BH treatment. He was placed in a yellow gown but walked out the door. Security identified the yellow gown on camera and ground personnel were notified to keep him within LOS. 911 was called and notified of the elopement. Law enforcement found him near the hospital and returned him to the ED. He was uncooperative and he had no injuries. He was later transferred to an inpatient psychiatric hospital. Staff were provided with annual elopement education. Staff AAA was unable to confirm that staff education was specifically provided in response to Patient #97’s event. His primary nurse did not receive any direct education in response to the event. During an interview on 06/04/26 at 1:10 PM and a telephone interview on 06/11/26 at 8:45 AM, Staff QQ, ED Director, stated that no staff education was provided in response to Patient #97’s elopement. She expected that Patient #97 would have been placed on EP upon his arrival to the ED due to his chief complaint. The hospital’s EHR system does not have a specific elopement assessment tool built into the program. The hospital provides staff with the tools and education necessary to assess and manage patients at risk for elopement. Patient #97 was screened as a high risk for suicide by his BHE and should have been placed on high-risk SP. High risk SPs directed staff to place a patient in paper scrubs and/or a yellow gown, inventory their belongings, complete an environmental check for safety, initiate every 15-minute rounding and maintain continuous LOS. She did not have an explanation as to why every 15-minute rounding did not begin until 7:00 AM. She agreed EP and SP were not implemented as required for Patient #97. She stated that the hospital’s policies needed to be reviewed, and staff needed to be educated to ensure clarity of the expectations for staff to ensure patient safety. During a telephone interview on 06/10/26 at 10:00 AM, Staff XXX, Market President, stated that she expected staff education would have been provided in response to Patient #97’s elopement. The hospital had an opportunity to review the hospital’s policies to ensure less ambiguity. Her minimum expectation was for EP to be placed for SI patients upon arrival at the hospital. Suicidal patients were to remain in the staff member’s continuous LOS and accompanied at all times until a provider evaluated and identified the needed interventions. Patient #97 should have been placed in a yellow gown when he arrived at the ED with SI. The yellow gown was the only way for staff to identify a high-risk patient. SP were to be in place for all patients with a moderate or high-risk assessment for suicide. Review of the hospital’s policy titled, “Sterilization Process, Duties and Operations (System-Wide),” approved 04/30/26, showed chemical indicators, internal and external, are processed with each package sterilized. If the indicator does not turn on according to manufacturer’s specifications, the load must be reprocessed. Review of the hospital’s policy titled, “Bloodborne Pathogen (infectious microorganisms [organisms, such as bacteria, too small for the naked eye], such as viruses or bacteria, carried in human blood and bodily fluids that can cause serious or fatal diseases in humans) Patient Exposure (needle stick, an injury creating an opportunity for exposure to blood or body fluids) Control and Response Plan,” effective 05/13/26, showed: - Postexposure prophylaxis (PEP) protocols would be used as a preventative medical treatment started after exposure to an infectious pathogen. - The patient’s provider, the Infectious Disease (a branch of medicine concerned with the study and treatment of pathogens like viruses, bacteria, fungi, and parasites) provider and Infection Prevention and Control staff, should collaborate on determining the exposed patient’s need for PEP and the appropriate course of treatment. - Long-term postexposure follow-up recommendations, including any plan for repeat blood drawings and consultations with the infectious disease department, should be discussed with the patient. - Department or Unit Managers will support the education of frontline staff’s need to respond to bloodborne pathogen exposures and ensure that all staff are educated on the components if needed. Review of the hospital’s document titled, “Safe Report,” dated 04/06/26, showed: - A urology (medical specialty concerned with the function and disorders of the urinary system) camera was found in the OR with a red tape, indicating that it had not been sterilized. When sterilized the red tape will turn yellow. - The unsterilized camera had been used since there were no other cameras open from the completed procedure. - On 04/07/26, the Sterile Processing Department (SPD, area designated to clean, prepare, sterilize [process that eliminates viruses and bacterial], store and track reusable medical and surgical instruments or equipment) responded to the Safe Report and stated that SPD staff checked all OR instruments and no other unsterile instruments were found. The SPD staging area was changed to better identify sterile and unsterile items. - The provider disclosed the use of the unsterilized camera to Patient #102. - Staff DDD, Infection Prevention and Quality Director, requested patient identifiers for all patients the device was used on. - There was no OR staff response documented. Review of Patient #102’s medical record, dated 04/04/26, showed: - He was a 65-year-old who presented to the hospital with testicular pain and swelling. - On 04/06/26, he had a cystoscopy (a procedure where a thin flexible tube, with a camera, is inserted into the urethra and the bladder). - No PEP was provided. During an interview on 06/04/26 at 12:00 PM, Staff AAA, Risk Management Director, stated that the urology camera was manually cleaned but not sterilized. SPD responded with process changes and staff education. She was unaware of any education provided to the OR staff in regard to Patient #102’s event. During a telephone interview on 06/10/26 at 2:30 PM, Staff JJJJ, OR Director, stated that Patient #102’s procedure was invasive, and he was exposed to an unsterile surgical device. She expected OR staff to assess sterilization indicators and tape changes prior to procedures. She believed the OR educator provided education to the staff members involved. There was no documentation about that education. She stated that there was no department wide education provided in response to Patient #102’s exposure event and she would have expected bloodborne pathogen testing and appropriate PEP to be completed. During a telephone interview on 06/10/26 at 10:00 AM, Staff XXX, Market President, stated that she expected OR staff to be educated in response to Patient #102’s event. Her expectations were absolutely not met with the unsterile urology camera. Review of the hospital’s policy titled, “Needle/Sharps Safety,” reviewed 02/2026, showed recapping should be performed using a mechanical device or the one-handed technique. Observation on 05/27/26 at 10:00 AM, in the OR, showed Staff DDDD, Physician, recapped a needle used for Patient #70 with two hands. During a telephone interview on 06/10/26 at 10:00 AM, Staff XXX, Market President, stated that she expected all staff to follow the sharp safety policy. 48359 51509”

“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 document review, policy review, medical record review and interview, the hospital failed to follow hospital policy to remove one staff member after an allegation of abuse was received for one discharged patient (#112) of one abuse event reviewed. Findings included: Review of the hospital’s policy titled, “Allegations of Abuse/Neglect on Premises Policy,” approved 12/08/23, showed: - Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment, resulting in physical harm, pain or mental anguish. This includes staff neglect or indifference to infliction of injury. - Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. - In the event that there is a report of an allegation of abuse/neglect, immediate action will ensure the safety of those involved and thorough investigation of the event. - This internal investigation report will include immediate actions taken to ensure patient safety during the investigation including removal of an accused staff member from direct patient care and placing them on administrative leave pending the outcome of investigation. Review of the hospital’s document titled, “Safe Report,” dated 03/18/26, showed: - On 03/13/26, Patient #112 reported her experience with Staff JJJJ, Registered Nurse (RN), in the Emergency Department (ED) to the Operating Room (OR) staff. - She reported she had requested pain medication multiple times, Staff JJJJ was rude, interrupted her, threw a needle cap at her and stormed out of the room. - The patient reported her concerns, and the charge nurse took over her care. - All staff involved were interviewed, but there were no direct witnesses. - Video was reviewed and it was “unclear” if Staff JJJJ threw the needle cap. She was observed placing a medication vial into her pocket. - The OR staff escalated the patient’s report to the administrator on call (AOC). - The AOC provided service recovery and informed the ED Director. - Staff JJJJ was not removed from care and there was no documented follow up education provided to Staff JJJJ until she met with Human Resources (HR) in April 2026. - The safe report was completed five days after the event. Review of the hospital’s document titled, “Staff JJJJ, Joplin - Nursing ED, March 2026,” dated 03/2026, showed Staff JJJJ completed her shift on 03/13/26 and worked on 03/14/26. Review of Patient #112’s medical record, dated 03/13/26, showed she was a 27-year-old who arrived at the ED with wound dehiscence (separation of previously approximated wound edge, due to a failure of proper wound healing). During an interview on 06/04/26 at 12:00 PM, Staff AAA, Risk Management Director, stated that on 03/18/26 risk management received a phone call from Patient #112 regarding her experience with Staff JJJJ in the ED on 03/13/26. Risk management had not been informed of the event prior to the phone call. They decided to work the grievance (a formal written or verbal complaint related to care or service that cannot be resolved immediately at the bedside) as an abuse allegation. On 03/18/26, the allegation was unsubstantiated for abuse. Staff JJJJJ, RN, was referred to HR for conduct not consistent with the hospital’s code of conduct. On Saturday, 04/11/26, Staff JJJJ, met with HR for coaching regarding behavior and conduct, 29 days after the event. During a telephone interview on 06/10/26 at 10:00 AM, Staff XXX, Market President, stated that she expected staff to follow all hospital policies and procedures. Risk Management should have been notified of the allegations by the AOC and the alleged staff member should have been removed from patient care until an investigation was completed. She expected HR to follow up with a referred staff member within a minimum of a “couple of weeks,” depending on the severity of the event.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 51509 Based on interview, record review and policy review, the hospital failed to develop a care plan to include the use of restraints (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) for one patient (#116) of one secluded patient reviewed. This had the potential to affect the care of all patients in restraints or seclusion. Findings included: Review of hospital document titled, “Restraint Policy (Medical, Behavioral - Chemical, Seclusion),” revised 06/2024, showed: - The plan of care should be modified to include individualized documentation of restraint and seclusion by adding the nursing problem of “Restraint-Medical,” “Restraint- Behavioral,” “Restraints- Chemical,” which will trigger the appropriate interventions (Restraint Flowsheet Assessment - RN, Restraint Patient Care Tasks - NT, One Hour Face to Face) to be added to the worklist, which will include timed reassessments. - The patient’s care plan should include interventions, monitoring and reassessments, including the frequency. Reassessments should include items such as vital signs (VS, measurements of the body’s most basic functions), mental status, circulation checks, skin integrity, comfort, safety, toileting and readiness for release from restraint or seclusion. - The patient or patient’s representative should be informed of the changes in the care plan. - The safe application of restraints and communication of updates should be documented in the care plan. Review of Patient #116’s medical record, dated 03/06/26, showed: - On 03/12/26, from 8:45 PM through 10:45 PM, he was in seclusion. There was no restraint/seclusion care plan within his record until 03/14/26. - On 04/01/26, he died. - On 04/13/26, Staff SSSS, registered nurse (RN), documented he was in seclusion on 03/12/26 from 8:45 PM through 10:45 PM, 31 days after the seclusion event. During an interview on 6/11/26 at 11:00 AM, Staff TT, Behavioral Health Director, stated that care plans were dependent on the patient’s symptoms and were automatically generated when an order for restraints were placed. Chart audits were completed for the past 24 hours on each shift. Staff were educated on any areas of improvement identified so that future documentation was correct. Staff would not be expected to go back and correct previous documentation. She was unaware Patient #116’s seclusion was documented a month late. She believed Staff SSSS, RN, was a float pool nurse and explained that any concerns regarding staff outside her direction would be managed by their respective leader for correction or follow-up. During an interview on 6/16/26 at 3:15 PM, Staff RRRR, Critical Care Director, stated that care plans were automatically generated with the first RN assessment if an order set was used. The care plan should include restraints and seclusion if they were utilized in the patient’s care. During an interview on 06/17/26 at 3:30 PM, Staff NN, Chief Nursing Officer (CNO), stated that every patient placed in a restraint or seclusion should have a care plan initiated immediately for the restraint or seclusion. Chart audits were performed by the manager of the units for all restraints. Documentation should not be entered a month after a restraint or seclusion was initiated, even if it was found during a chart audit.”

“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: 51509 Based on interview, record review and policy review the hospital failed to follow their policy and ensure all patients placed in restraints (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) had a physician order for restraint or seclusion for two current patients (#43 and #83) and two discharged patients (#116 and #117) of four patient’s reviewed for restraint and seclusion orders. This failure had the potential to affect all patients placed in restraints or seclusion. Findings included: Review of hospital’s policy titled, “Restraint Policy (Medical, Behavioral - Chemical, Seclusion),” revised 06/2024, showed: - A physical restraint is defined as any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of the patient to move his or her arms, legs, body, or head freely. If the patient cannot “easily remove” the device, material or equipment in the same manner it was applied by staff, it would be considered a restraint. Individual patient circumstances should be evaluated to determine their cognitive and physical ability to “easily remove” the device, material or equipment. - Exemptions or non-restraints include: mechanical support or devices; surgical dressings or bandages; protective helmets or other methods that aid in performing routine exams or tests; intravenous (IV, in the vein) arm boards to stabilize an IV line; use of one hand mitt, if not tied down and able to easily be removed by the patient; physically redirecting, holding or picking up an infant or small child to comfort; staff holding the patient’s arm during IV insertion; use of side rails to protect the patient from falling out of bed; medication used for standard procedures; timeout intervention in which a patient agrees to be alone for an agreed upon timeframe, as long as they are not physically prevented from leaving; use of handcuffs, shackles or other chain-type restraints applied by law enforcement officials for custody, detention and public safety reasons. - Types of physical restraints included behavioral restraints, medical restraints, chemical restraints, physical holds, and seclusion. - A behavioral restraint is a 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. - A medical restraint is a restraint used to ensure the physical safety of the non-violent or non-self-destructive patient, such as pulling at lines or tubes, a confused patient picking at an incision or wounds, unintentionally striking others, etc. - A chemical restraint is defined as the use of a medication that is not part of the patient’s standard treatment or dosage that is used to restrict the patient’s behavior or freedom of movement. - A physical hold when administering a medication or performing a task or procedure against the patient’s wishes is considered a restraint. If a patient is under a court order for medication, the court order only removes the patient’s right to refuse the medication. If an emergent situation arises and a patient needs to be medicated against their wishes, the use of force must have a physician’s order prior to the application of the restraint and/or physical hold. Healthcare staff are expected to use the least restrictive method of administering medications to avoid or reduce the use of force. The one-hour face to face requirement also applies in the use of physical holding. - Seclusion is the involuntary confinement of a patient alone in a room or area in which the patient is physically prevented from leaving and may only be used for the management of violent or self-destructive behaviors that jeopardize the immediate physical safety of the patient, a staff member or others. - The order for restraint or seclusion must be provided by a physician or resident. Physician extenders, nurse practitioners, and physician assistants may not write restraint orders. - In the absence of a physician, in an emergent situation, a registered nurse (RN) may initiate the use of physical restraint or seclusion as the least restrictive intervention to protect the patient, staff or others. The nurse must immediately notify the physician and obtain an order within 30 minutes or as soon as possible after the occurrence of the emergency. Failure to immediately obtain an order is viewed as the application of restraint or seclusion without an order. - The use of standing orders or as needed (PRN) orders for restraint or seclusion are prohibited. - Restraints must be discontinued at the earliest possible time, regardless of the length of order. The physician or nurse may discontinue the use of restraint or seclusion. Review of Patient #43’s medical record, dated 03/27/26, showed: - On 05/21/26 at 3:55 PM, she was placed in a physical hold for five minutes. - On 05/22/26 at 1:39 PM, she was placed in a physical hold for 10 minutes. - On 05/28/26 at 4:15 PM, she was placed in a locked chest strap. - At 5:23 PM, a corresponding order was placed, 68 minutes after the event. - There were no orders for a physical hold. Review of Patient #83’s medical record, dated 05/23/26, showed: - On 05/26/26 at 11:12 AM, he was placed in seclusion and given a chemical restraint. - At 11:23 AM, plastic locked bilateral wrist and ankle restraints were applied. - At 11:30 AM, a chest strap was applied. - On 05/27/26 at 11:53 AM, a corresponding order for the restraints was placed, 24 hours and 41 minutes after the event. The order included seclusion, a chemical restraint, and bilateral soft wrist and ankle restraints. There was no order for a chest strap. Review of Patient #116’s medical record, dated 03/06/26, admitted to Geriatric BH, showed on 03/13/26 at 11:21 PM, he was placed in a physical hold for three minutes and plastic locked bilateral wrist and ankle restraints were applied. There was no order for a physical hold. Review of Patient #117’s medical record, dated 01/10/26, showed: - On 01/12/26 at 7:00 AM, he was placed in bilateral soft wrist restraints. The order was not entered until the next day at 12:16 AM,17 hours and 16 minutes after the event. The physician did not sign the order until 01/19/26, seven days later. - On 01/15/26 at 11:00 AM, he was placed in bilateral mittens. The order was not placed until 3:43 PM, four hours and 43 minutes after the event. - On 01/19/26 at 7:00 AM, he was placed in bilateral mittens. The order was not placed until 10:20 AM, three hours and 20 minutes after the event. - On 01/22/26, he was in restraints between 7:00 AM and 9:47 AM, without an order. During an interview on 6/11/26 at 11:00 AM, Staff TT, Behavioral Health Director, stated that nurses should contact the physician immediately for restraint or seclusion orders. The orders should be placed as soon as possible. Soft restraints were not utilized in the behavioral health area so an order for them would have been written in error. The facility also did not utilize leather restraints. That was just an “old school” term that was listed as an option in the electronic health record (EHR). The restraints used were all made from polyvinyl material. During an interview on 06/17/26 at 3:30 PM, Staff NN, Chief Nursing Officer (CNO), stated that she expected all restraints or seclusion to have an order placed. Ideally it would be at the initiation of the restraint or seclusion, however that was not always possible. If unable to obtain an order at the initiation, she expected it to be as soon as possible, reasonably within an hour. Physical holds and chest straps were considered restraints and should have an order within an hour of their initiation. Physicians should sign restraint or seclusion orders within 24 hours.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(6) Orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis (PRN). This Standard is not met as evidenced by: 51509 Based on interview, record review and policy review, the hospital failed to follow their policy and ensure orders for restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) were not written as standing orders for one patient (#117) of four restraint patients reviewed. This failure had the potential to affect all patients placed in restraints or seclusion. Findings included: Review of hospital document titled, “Restraint Policy (Medical, Behavioral - Chemical, Seclusion),” revised 06/2024, showed: - All patients have the right to be free from restraint or seclusion. , 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 based on patient assessment and reevaluation. -An order for restraint or seclusion must be provided by a physician or resident. Physician extenders, nurse practitioners and physician assistants may not write restraint orders. - If a physician other than the attending physician provides the initial order for restraint, the attending physician should be notified and updated promptly. - In an emergent situation, a registered nurse (RN) may initiate the use of physical restraint or seclusion to protect the patient, staff or others. The nurse must immediately notify the physician and obtain an order within 30 minutes or as soon as possible after the event. Failure to immediately obtain an order is viewed as the application of restraint or seclusion without an order. - Medical restraints are defined as restraints used to ensure the physical safety of the non-violent or non-self-destructive patient, and may be written for a timeframe up to 24 hours. The physician has the discretion to write the order for a shorter length of time. - Restraints must be discontinued at the earliest possible time regardless of the length of order. The physician or nurse may discontinue the use of restraint or seclusion. - The use of standing orders or as needed (PRN) orders for restraint or seclusion are prohibited. Review of Patient #117’s medical record, dated 01/10/26, showed: - On 01/13/26 at 12:15 AM, an order was placed for bilateral soft wrist restraints to start at 7:00 AM, six hours and 45 minutes after the order was written. - On 01/13/26 at 11:53 PM, an order was placed for bilateral soft wrist restraints to start on 01/14/26 at 7:00 AM, seven hours and seven minutes after the order was written. - On 01/15/26 at 1:38 AM, an order was placed for bilateral soft wrist restraints to start at 7:00 AM, five hours and 22 minutes after the order was written. - On 01/15/26 at 11:10 PM, an order was placed for bilateral mittens to start on 01/16/26 at 7:00 AM, seven hours and 50 minutes after the order was written. - On 01/20/26 at 1:01 AM, an order was placed for bilateral mittens to start at 7:00 AM, five hours and 59 minutes after the order was written. - On 1/21/26 at 4:50 AM, an order was placed for bilateral mittens to start at 7:00 AM, two hours and 10 minutes after the order was written. During an interview on 06/16/26 at 3:00 PM, Staff RRRR, Critical Care Director, stated that standing orders were not utilized for restraints. Medical restraint orders were to be renewed daily if still required. When it was realized that charge nurses were entering daily orders ahead of time, the process was eliminated. The expectation was for the day shift nurses to enter the orders in real time. During an interview on 6/17/26 at 3:30 PM, Staff NN, Chief Nursing Officer (CNO), stated standing orders were not utilized for restraints in medically intubated patients. The charge nurses had been entering the orders early to prevent a lapse in orders. She did not consider an order entered prior to the daily initiation time a standing order. When asked if it was acceptable for an order to be entered at midnight to start at seven am, she stated “no.””

“ORGANIZATION OF NURSING SERVICES CFR(s): 482.23(a) The hospital must have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The director of the nursing service must be a licensed registered nurse. He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. This Standard is not met as evidenced by: 47504 Based on observation, interview, record review, and policy review, the hospital failed to ensure the Chief Nursing Officer (CNO) provided adequate oversight and supervision of nursing personnel when established policies and procedures were not followed resulting in unsafe patient care procedures. These failures had the potential to affect the quality of care and safety of all patients in the hospital. Findings included: Review of the hospital’s Organizational Chart, dated 2026, showed that Staff NN, Chief Nursing Officer (CNO) was directly responsible for overseeing all nursing staff. Review of Chief Nursing Officer Job Description, dated 03/18/26, showed the CNO: - Provides leadership through planning, directing, coordinating and evaluating nursing and ancillary services. - Coordinates and standardizes nursing operations. - Implements initiatives focusing on quality patient outcomes. - Collaborates in the development of quality initiatives and mechanisms to monitor, evaluate, and improve the quality and safety of clinical services within the system. - Hires, terminates, supervises, develops, mentors and completes performance reviews for direct reports. - Makes recommendations and implements mechanisms to ensure effective orientation, training and competency of nursing staff in the delivery of effective patient care. - Provides leadership and vision for nursing departments. During an interview on 06/17/26 at 3:30 PM, Staff NN, CNO, stated she was directly responsible for overseeing all nursing staff.”

“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: 47504 Based on observation, interview, record review, and policy review, the hospital failed to ensure: - Staff failed to follow hospital policy for patients with a high fall risk by ensuring fall prevention measures were implemented for three discharged patients (#49, #50 and #52) that experienced falls resulting in death, of ten fall incidents reviewed. - Staff failed to follow hospital policy for patients with a high fall risk by ensuring fall prevention measures were implemented for one current patient (#36) and six discharged patients (#44, #45, #46, #47, #48 and #51) that experienced falls resulting in serious injuries, of ten fall incidents reviewed. - Staff failed to follow hospital policy for patients with a high fall risk when they failed to implement fall prevention measures including bed alarms, fall risk arm bands, fall alert signs and slip free socks for three current high fall risk patients (#22, #23, #24) of four current high fall risk patients observed. - Staff failed to follow hospital policy for patients with a high fall risk when they did not ensure confused high fall risk patients had a one to one (1:1, continuous visual contact with close physical proximity) safety sitter for two current confused, high fall risk patients (#40 and #41) of two confused fall risk patients observed. Findings included: Review of hospital policy titled, “Fall Risk Prevention and Mobility Program,” revised 04/2025, showed: - The purpose of the fall risk prevention and mobility program is to minimize the risk of patient falls without compromising the mobility and functional independence of patients; to promote proactive healthcare practices for patient care planning, which minimizes the risk for fall; and to educate patients, families and visitors on measures to prevent falls and promote safety. - A fall is defined as an unplanned descent to the floor with or without injury. - An assisted fall occurs when a staff member is present to ease the patient’s descent or break the fall. - The Fall Risk Prevention and Mobility Program was designed to promote a safe environment for the patient through initial and ongoing assessment of patient’s mobility and fall risk, as well as improved communication with all care team providers as to patient’s actual and potential needs on admission, throughout their stay, and at discharge. - The Fall Risk Prevention and Mobility Program includes: a baseline assessment of the patient’s mobility and fall risk prior to admission, a physical assessment on admission of their actual mobility and fall risk, implementation of fall risk interventions and shift assessments of their fall risk, along with daily assessments of mobility compared with their baseline assessment. - Low Fall Risk Assessment (scoring less than six) and interventions include: orientation to the room and surroundings; placing a call light within reach at all times; educating patients to call for assistance; the use of appropriate signage; beds in low position and locked; ; two side rails up at all times; closely observing patients following medication changes; reducing environmental hazards; and ensuring patients wear nonskid footwear. - Moderate Fall Risk Assessment (scoring between six and 13) and interventions include: all of the Low Fall Risk interventions; using assistive devices/lift equipment when ambulating or transferring; offering two-hour toileting while awake and every four hours during sleep hours; and considering the use of fall mats, chair alarms, and other fall prevention tools as appropriate. - High Fall Risk Assessment (scoring greater than 13) and interventions include: all Low and Moderate Fall Risk Interventions; placing a body/bed alarm; assigning a room close to the nurses’ station; constant supervision while transferring, ambulating, or toileting; and considering the use of a tele sitter or 1:1 observation. - All staff who interact with patients are responsible for ensuring a safe environment for the patient to prevent a possible fall (clear clutter, move tubing, etc.) and to protect from injuries should a fall occur. Encourage compliance with fall and fall-related injury interventions. Communicate and collaborate with interdisciplinary team members regarding fall risks, notify the patient’s nurse and participate in the post fall debriefs. - Staff nurses are to assess factors that make patients at risk for falling, notify the charge nurse of any patients admitted due to a fall, develop an individualized fall and injury prevention care plan and ensure patient communication is updated, including the whiteboard and fall risk visualization cues. - Post Fall Assessments include an immediate complete physical assessment of the patient to identify and treat any obvious injuries document the nursing assessment in the medical record. The post fall debriefing should involve the primary nurse and the interdisciplinary treatment team, including a patient assessment. Review of Patient #49’s medical record, on 05/21/26 at 12:30 PM, showed: - On 01/06/26, Patient #49 was a 53-year-old who had been admitted into inpatient rehabilitation (the action of restoring someone to health or normal life through training and therapy) following a recent fall with a subdural hematoma (a pool of blood between the brain and its outermost covering). - On 01/12/26, he had physical therapy (PT, focuses on range of motion and decreasing pain after an injury or illness) session. He completed his treatment and was assisted into a chair. The PT failed to turn on his chair alarm. When Patient #49 attempted to get up by himself, he fell. He was assessed and the fall was reported to his provider. The physician was not aware that Patient #49 had hit his head. - On 01/13/26, a computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) scan was completed and showed progressive changes with a large subdural hematoma of the right frontoparietal (front lobes of the brain) lobe with increasing size, prominence and a midline shift (a shift of the brain past its center line). - On 01/13/26 at 11:03 AM, Patient #49 was transported via EMS and admitted into the Intensive Care Unit (ICU, a unit where critically ill patients are cared for). - On 01/14/26 at 12:10 PM, he underwent a burr hole evacuation (a procedure in which a surgeon drills one or more small holes into the skull to access and drain excess fluid, blood, or pus that is placing dangerous pressure on the brain), but was unable to be extubated (removal of breathing tube) following the procedure. He then developed atrial fibrillation (A-fib, an irregular, often rapid heart rate that commonly causes poor blood flow.) - On 01/16/26 at 7:25 AM, an echocardiogram (ECHO, a test that makes images of the heart and surrounding structures) was done that revealed a pericardial effusion (a buildup of extra fluid in the space around the heart). The cardiologist (a physician that specializes in the care of your heart and blood vessels) believed he was in cardiac tamponade (a life-threatening medical emergency that occurs when blood or excess fluid rapidly builds up in the sac surrounding the heart) and recommended a pericardiocentesis (a procedure used to drain excess fluid from the sac surrounding the heart). - Due to multiple issues, including a severe brain bleed, the family did not want aggressive measures. They elected to proceed with comfort care (a patient care plan that is focused on symptom control, pain relief, and quality of life at the end of life) measures. - On 01/16/26 at 8:36 AM, Patient #49 passed away. During an interview on 05/21/26 at 12:30 PM, Staff AAA, Risk Management Director, stated: -The Root Cause Analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to find the root cause) investigation showed Patient #49 did not have a high-risk yellow wristband on and his call light and walker were not near him. - Per interview, Patient #49’s family had complained about staff failure to use the bed alarm, but there was no documentation of their complaints. His bed alarm had been turned off. - There was no documentation that the physician was notified that Patient #49 hit his head during the fall. - Neurological assessments were completed every four to six hours. - Immediate education was not provided to staff following this significant safety event that resulted in patient death. Although requested the complete medical record for Patient #49, his rehabilitation admission and notes related to his fall were not provided. Review of Patient #50’s medical record, on 05/21/26 at 12:30 PM, showed: - On 03/01/26 at 2:11 PM, Patient #50, an 83-year-old, presented to the ED for an evaluation after a fall at home. He had become lightheaded and fell to the ground. He was found unconscious. He was admitted for syncope (to pass out), hypocalcemia (condition in which the blood has too little calcium) and an abnormal EKG. - On 03/03/26 at 11:50 PM, he was found on the floor in the bathroom with blood around his head. - He was alert and oriented to person and place but could not remember getting out of bed. Upon evaluation there was significant bruising and deformity around his nose. He became increasingly confused and developed severe dizziness. A CT scan of the head was ordered. Prior to the CT scan being performed, he became unresponsive and was taken to the ICU. Upon admission to the ICU, his cardiac rhythm converted to asystole (absence of activity of the heart). He was pronounced deceased at 12:24 AM. During an interview on 05/21/26 at 12:30 PM, Staff AAA, Risk Management Director, stated the RCA investigation showed Patient #50 was a high fall risk upon admission due to his recent fall at home. He did not have a bed alarm on, he was confused and there was no tele-sitter or 1:1. The hospital did not provide any education related to falls until April 3, 2026. Review of Patient #52’s medical record, on 05/21/26 at 12:30 PM, showed: - On 04/08/26, Patient #52 ,a 72-year-old was admitted for inpatient rehabilitation following an acute (sudden onset) ischemic (restriction in blood supply to tissues, causing a shortage of oxygen needed to keep tissue alive) 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). - On 04/12/26, he requested to shower. He had required moderate assistance throughout his admission, but one Patient Care Tech (PCT) assisted him with the shower. While in the shower, he dropped the washcloth and leaned down to pick it up. As he leaned down, he began to slide out of the shower chair and struck the left side of his face and head against the shower wall and floor. He was transferred to the Emergency Department (ED) for evaluation since he was taking various blood thinners. - A head CT was completed that revealed new right occipital lobe (back of the brain) edema (swelling), along with left frontal scalp soft tissue swelling. Neurosurgery (a branch of medicine or surgery performed on the nervous system, especially the brain and spinal cord) was consulted and he was admitted to the hospital for medical management. - On 04/14/26 at 8:30 AM, Patient #52 became unresponsive with stroke-like symptoms. He developed Pulseless Electrical Activity (PEA) cardiac arrest (the heart muscle fails to pump blood resulting in no detectable pulse) and a code blue (emergency situation where a patient’s heart or breathing has stopped, and staff quickly respond to attempt to restore the heartbeat or breathing) was initiated. Cardiopulmonary Resuscitation (CPR, emergency life-saving procedure performed when a person’s breathing or heartbeat has stopped) was performed, but he was pronounced dead at 9:22 AM. During an interview on 05/21/26 at 12:30 PM, Staff AAA, Risk Management Director, stated Patient #52’s RCA investigation showed he was a high-fall risk patient with significant neurological (neuro, relating to or affecting the nervous system) impairment and decreased safety awareness. There should have been an evaluation to assess his need for a higher level of assistance during the showering due to his decreased cognition, safety awareness and the noted left side weakness from his previous stroke. He should not have been showering with only a single person assist. There was no immediate education to staff following this safety event which resulted in patient death. Although requested the complete medical record for Patient #53, his rehabilitation admission and notes related to his fall were not provided. Review of Patient #36’s medical record, on 05/21/26 at 12:30 PM, showed: - On 04/08/26 at 3:16 AM, Patient #36 was a 77-year-old who was admitted for a fall at home with a medical history of dementia (a loss of thinking abilities and memory). - On 05/06/26, Patient #36 fell while under direct observation of a 1:1 patient safety sitter. The 1:1 safety sitter was changing the linens of a bed when Patient #36 got up out of the chair and began to ambulate using her walker. When she attempted to sit down, there was no chair, and she fell down to the floor. - A left hip x-ray (test that creates pictures of the structures inside the body-particularly bones) and computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) of her pelvis was completed and showed a fracture. During an interview on 05/12/26 at 12:30 PM, Staff AAA, Risk Management Director, stated Patient #36’s RCA investigation identified that the 1:1 safety sitter was watching two high risk fall patients at the same time. The patient did not have a gait belt in place at the time of her fall. There was no documentation related to timed toileting. During an observation on 05/12/26 at 2:30 PM, Patient #36 was sitting in a chair with a 1:1 safety sitter in the room. The sitter was cleaning the room, not paying attention to the patient. Patient #36’s chair alarm was off; she did not have a fall risk bracelet on and there was no fall identification sign on her door. Review of Patient #44’s medical record, on 05/21/26 at 12:30 PM, showed: - On 11/14/25 at 4:08 PM, an 83-year-old was admitted for confusion and a urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, ureters, bladder and urethra). - He had a past medical history of A-fib and 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). Upon admission he was diagnosed with acute encephalopathy (damage or disease that affects the brain) with suspected underlying major neurocognitive disorder (decreased mental function either in language, learning, memory, or socially; and loss of ability to do daily tasks). - His fall assessment indicated he was at high risk for falls, even though his overall score varied from nurse to nurse, ranging from an eight (Moderate Risk) to a 14 (High Risk). - On 11/19/26 at 5:13 PM, the PCT found Patient #44 on the floor. The physician was notified and orders received for imaging. The x-ray showed a fracture of the left collarbone. The nurse had documented the bed alarm was on and active. During an interview on 05/21/26 at 12:30 PM, Staff AAA, Risk Management Director, stated Patient #44’s RCA investigation showed he was confused, had no bed alarm on, no fall risk bracelet, and no non-skid socks. He was not receiving timed toileting. A gait belt was appropriately being used. His documentation prior to his indicated all of the above interventions were in place, but none of them were identified during the post fall investigation. Staff did not receive immediate education or training following this serious injury safety event which resulted in patient harm. Patient #44 suffered a fractured clavicle. Review of Patient #45’s medical record, on 05/21/26 at 12:30 PM, showed: - On 12/10/25, a 40-year-old was admitted for worsening left side weakness. She was diagnosed with an acute stroke. - Her previous medical history included multiple strokes including a left brainstem stroke, a heart attack, and diabetes (a disease that affects how the body produces or uses blood sugar and can cause poor healing). - On 12/13/26, Patient #45 was sitting up on the side of the bed drinking a beverage with a tray table placed over her. She fell from the bed, suffering a laceration to her left eyebrow and a nondisplaced, left side, 6th rib fracture. She had experienced a similar fall the previous night when she was left sitting on the side of her bed. During an interview, on 05/21/26 at 12:30 PM, Staff AAA, Risk Management Director, stated Patient #45’s RCA revealed no gait belt was present and a bed alarm was not in place. Patient #45 should not have been left sitting on the side of the bed with her history of strokes and overall weakness. There were no additional precautions taken following the fall that occurred on 12/12/26. She was left sitting on the side of her bed, again on 12/13/26, which resulted in the fall with injuries. Review of Patient #46’s medical record, on 05/21/26 at 12:30 PM, showed: - On 12/11/26 at 1:52 PM, a 78-year-old was admitted for a worsening subdural hematoma. He had experienced a fall on 11/19/25 with loss consciousness. A CT scan at that time revealed a subdural hematoma on the right side of the head. He was discharged on 11/25/25. Since the fall, he experienced headaches, slight confusion and slight memory problems. - A CT scan on 12/11/26 at 1:48 PM showed the subdural hematoma had increased in size and neurosurgery was planning a burr hole with subdural evacuation. - On 12/16/25 at 8:00 PM, Patient #46 fell. Documentation showed the physician was notified. Other than his fall, there was no other nursing documentation. Later that night, he complained of right hip pain and an x-ray and CT scan were ordered. Documentation showed there was no bed alarm in place at the time of his fall. - On 12/17/26 at 1:26 AM, a CT scan of the pelvis showed a right hip fracture. During an interview, on 05/21/26 at 12:30 PM, Staff AAA, Risk Management Director, stated Patient #46’s RCA investigation showed he was a high fall risk with intermittent confusion, memory problems and previous falls. There was no 1:1 safety sitter or tele sitter, no bed alarm, and the bedside commode was not near the patient at the time of his fall. Review of Patient #47’s medical record, on 05/21/26 at 12:30 PM, showed: - On 12/18/25 at 7:11 PM, a 66-year-old presented to the ED for generalized weakness and a fall at home. She had a prior history of lymphoma (a cancer that begins in infection-fighting cells of the immune system and the cells change and grow out of control) and was currently undergoing chemotherapy (a drug treatment that uses powerful chemicals to kill fast growing cells or cancer in the body). - On 12/19/25 at 11:53 AM she was admitted for inpatient rehabilitation. - On 12/26/25 at 5:18 PM, Patient #47 attempted to get up out of bed unassisted. She lost her balance and fell to the floor. Nursing staff assisted her back into bed. - On 12/26/25 at 7:38 PM, an x-ray revealed a fracture of the right wrist. She underwent surgical repair of this fracture. During an interview, on 05/21/26 at 12:30 PM, Staff AAA, Risk Management Director, stated Patient #47’s RCA investigation showed there was no documentation of timed toileting and her bed alarm was not on at the time of fall. Review of Patient #51’s medical record, on 05/21/26 at 12:30 PM, showed: - On 03/08/26 at 6:15 PM, a 72-year-old was admitted for vomiting and dizziness. He had been diagnosed with Stage IV lung cancer in December 2025. - On 03/10/26 at 10:43 AM, Patient #51 had a fall while trying to get up out of bed. There was no injury from the fall. A CT scan revealed brain metastasis (the spread of cancer cells from the place where they first formed to another part of the body). - On 03/13/26 at 3:45 PM, Patient #51’s primary nurse was retrieving medications when another RN notified her that they had assisted him to the bedside commode. He was left alone since she was unsure if he required continuous supervision. - Patient #51’s nurse returned to his room and found him lying on the floor in a fetal position on his right side. He denied hitting his head but complained of right sided hip pain. - At 4:15 PM, an x-ray of his hip was done that revealed a right hip fracture. During an interview, 05/21/26 at 12:30 PM, Staff AAA, Risk Management Director, stated Patient #51’s RCA investigation showed his room was not within the direct line of sight of the nurses’ station. - Staffing was not appropriate, the unit had a census of 42 patients, 3 patients requiring physical sitters and multiple bed alarms were in use. At the time of the fall, there were four nurse technicians on the floor, even though the matrix called for six. There were six nurses, including the charge nurse, who was assigned to a team of patients rather than functioning without an assignment of patients. Overall, the staffing did not meet the established matrix at the time of the event. - Patient #51 was a high fall risk, left unattended, was not receiving timed toileting, there was no gait belt in the room, nor fall signage on his door. During an observation on 05/12/26 at 1:45 PM, Patient #22, a high fall risk patient, did not have a fall identification bracelet on, a bed alarm, non-skid socks, nor fall signage on the door. During an observation on 05/12/26 at 2:00 PM, Patient #23, a high fall risk patient, did not have a bed alarm, non-skid- socks, nor fall signage on the door. Patient #23 stated she fell a few days ago. During an observation on 05/12/26 at 9:15 AM, Patient #24, a high fall risk patient, did not have a fall identification bracelet on, a bed alarm, non-skid socks, nor fall signage on the door. During an observation on 05/12/26 at 2:45 PM, Staff UUUU, PCT, was monitoring two high fall risk patients. She was at the bedside of Patient # 40. He did not have a fall identification band on or non-skid socks. While she was assisting Patient #40, Patient # 41 attempted to get out of bed. This surveyor went to the bedside to speak with him in an attempt to prevent him from getting out of bed and potentially falling. Staff UUUU stated she was often assigned to watch two confused, high fall risk patients at a time and she could not keep them both safe. Both Patient #40 and Patient #41 were confused. Their bed alarms were not turned on. During an interview on 06/17/26 at 3:30 PM, Staff NN, Chief Nursing Officer (CNO) stated she expected staff to follow the hospital’s policy and ensure all high risk fall patients had appropriate fall precautions in place. The precautions included fall risk signage on the door, fall risk identification bands, bed alarms turned on, and non-skid socks. All confused patients were high fall risks and should be assigned to a 1:1 safety sitter. Safety sitters should only be observing one, 1:1 patient. She was not aware of all the fall incidents that had resulted in a serious injury or death. The cases were discussed in a quarterly safety meeting. She stated, “I should have been notified immediately of a fall that resulted in a serious injury or death.””

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 48359 Based on observation, interview, document review and policy review, the hospital failed to: - Follow hospital policy for diabetic (a disease that affects how the body produces or uses blood sugar and can cause poor healing) patients presenting with an insulin (medication that regulates the amount of sugar in the blood) pump (delivery device for insulin [medication that regulates the amount of sugar in the blood]) for two discharged patients (#91 and #96) out of two discharged patients with insulin pumps reviewed. - Follow hospital policy for medication labeling for one current patient (#70) of one surgical patient observed; - Follow the Hypoglycemia (low blood glucose [BG, sugar that circulates in the blood]) Protocol and physician orders for one current patient (#98) of one current patient with hypoglycemia reviewed. - Follow hospital policy for critical medication administration times for seven discharged patients (#105, #106, #107, #108, #109, #110 and #111) of 14 discharged patients reviewed. Findings included: Review of the hospital’s policy titled, “Clinical Care-Insulin Pump Use,” revised 08/2023, showed: - Diabetic patients admitted to the hospital with insulin pumps in place may be maintained and monitored through their insulin pump only with a physician order is obtained and specific criteria are met. - The physician will determine if the patient can safely manage their own dosing and administration of insulin with their pump. - All patients who are at risk for suicide (to cause one’s own death) are contraindicated for the use of insulin pumps. - The diabetes nurse educator should be involved in the ongoing management of any patient with an insulin pump, and a consultation should be ordered at the time of admission. - An insulin pump should never be removed without first administering subcutaneous SQ, (under the skin) basal insulin (long-acting insulin used to maintain stable blood sugar levels between meals and during sleep). The pumps infuse rapid-acting insulin, disconnecting an insulin pump for more than one hour requires the patient to have an alternate delivery for insulin. - An interruption in insulin delivery for more than two hours, in a person with Diabetes Type 1 (a condition where the body produces little to no insulin resulting in the person requiring artificial insulin injections or medication) can lead to severe hyperglycemia (high BG) and diabetic ketoacidosis (DKA, life-threatening condition affecting people with diabetes; occurs when the body breaks down fat too fast causing the blood to become acidic). - The nurse must obtain an order to implement alternate insulin delivery. - The physician must provide current pump settings and previous dose information to properly order insulin dosages for the patient. - BG monitoring should be provided during the patient’s stay using the hospital glucose monitoring equipment. Review of an undated hospital document titled, “Insulin Pump Checklist,” showed the nurse must verify there is an order for long-acting insulin and that it is given before disconnecting a pump. Without the insulin pump or long-acting insulin, the patient will likely go into DKA. A sliding scale insulin (SSI, the progressive increase in the pre-meal or the or nighttime insulin dose, based on predefined BG) was not enough. Review of Patient #91’s medical record, dated 01/31/26, showed: - He was 60 years old with a past medical history significant for coronary artery disease (CAD, the narrowing or blockage of the coronary arteries usually caused by the buildup of cholesterol and fatty deposits on the inner walls of the arteries), high blood pressure and diabetes. - The patient had a prior history of discitis (inflammation of the intervertebral disc spaces in the spine usually caused by an infection) and had a partial vertebrectomy (a procedure to remove portions of damaged spine to relieve spinal cord compressions) and allograft placement (transplanted of bone or tendons from a human donor) with extensive hardware (reconstructive technique that utilizes metal plates, screws or rods to stabilize the joints). He was discharged home on 01/15/26 with continued antibiotic therapy and a wound vacuum (wound VAC, a device that decreases air pressure on a wound to help it heal more quickly) assisted closure. - On 01/31/26 at 1:59 AM, Patient #91 was a direct admit from another hospital for evaluation of increased back pain with suspected infection from the previous surgery in 12/2025. - During the course of his admission, he was taken to the operating room (OR) on four separate occasions for a washout and debridement (the removal of damaged tissue or debris from a wound). - On 02/02/26 at 6:45 PM, he had a debridement in the OR and arrived back from surgery. A documented report was given by the OR staff to the floor nurse that included the removal of Patient #91’s insulin pump for the procedure. After the procedure Patient #91 had requested not to have the insulin pump hooked back up until he woke up from anesthesia. The receiving nurse’s documentation showed it was shift change and she reported the request to Staff LLLL, RN. Staff LLLL assumed care of the patient for the night shift on 02/02/26. - At 11:30 PM, a neurological (neuro, relating to or affecting the nervous system) assessment showed Patient #91 was unable to move his left leg. - At 11:40 PM, Staff LLLL, notified the physician regarding the neurological assessment. There was no documentation regarding the patient’s insulin pump. - On 02/03/26 at 11:57 PM, an addendum was entered by Staff LLLL, that showed on 02/03/26 at 5:50 AM, notification was made to the physician of critical lab values. Patient #91’s BG was 564. An electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions) was ordered that indicated a heart attack. At that time, Patient #91 complained of chest pain so a first team code (emergency situation where a patient’s heart or breathing is involved and staff quickly respond to attempt to restore the heartbeat or breathing) was initiated. - At 6:42 AM, the nurse documented that he had educated the patient multiple times throughout the shift, but the patient refused to put his insulin pump back on. - At 6:46 AM, the physician ordered the patient to be transferred to an Intensive Care Unit (ICU, a unit where critically ill patients are cared for). -On 02/04/26, a second addendum was entered that showed on 02/02/26 at 9:00 PM, Patient #91’s BG result was 314. He was strongly encouraged to put his insulin pump back on and he refused. There was no documentation indicating the provider was notified of the patient’s refusal. - On 02/03/26 at 9:00 AM, the Hospitalist (physician whose primary professional focus is the general medical care of hospitalized patients) documented that Patient #91 went into DKA. Per discussion with the diabetic nurse, the patient had requested to discontinue his insulin pump, but this was never relayed to a physician. The provider was unaware, so t Patient #91 was not started on SQ insulin. He then started on intravenous (IV, in the vein) insulin for treatment of DKA. - On 02/20/26, the Hospitalist discharge note indicated that Patient #91 had been on an insulin pump for the management of his diabetes. He discontinued the use of his insulin pump during his hospitalization. He was not started on SQ insulin when he discontinued the pump and developed DKA. During an interview on 05/27/26 at 10:00 AM, Staff AAA, Risk Management Director, stated the event report (a staff report of an unexpected occurrence) review and Root Cause Analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to find the root cause) investigation showed that hospital staff did not follow policy and procedure for patients with insulin pumps. The nurse failed to notify the physician and obtain orders following the patient’s refusal to re-connect the insulin pump following his surgical procedure. During a telephone interview on 06/10/26 at 6:45 PM, Staff LLLL, Registered Nurse (RN), stated that Patient #91 refused to put his insulin pump back on following his surgical procedure. He did not notify the physician of the refusal. He notified the physician of his elevated BG at 8:30 PM, but there was no documentation to show he did. Staff LLL stated he got busy and did not follow the policy. During a telephone interview on 06/11/26 at 2:30 PM, Staff MMMM, Diabetic Education Nurse, stated that she consulted with Patient #91 on 02/02/26 at 9:56 AM. She had everything set up per policy for the patient to continue using his insulin pump during his admission. All patients were given a packet and provided with documentation to keep at the bedside for BG checks. When patients go to surgery the insulin pump was removed but should have been placed back on the patient following surgery. Documentation showed the patient did not want to reconnect his insulin pump. At that instance, the nurse should have notified the physician and documented it in the medical record. Hospital policy for insulin pumps was very specific regarding what to do if a pump was removed. Patient #91’s BG became elevated at 8:30 PM, but there was no documentation the physician was notified. His next lab result showed a BG above 400. Patient #91 became symptomatic, and the physician was notified. The nurse failed to follow policy and as a result Patient #91 was transferred to an ICU unit for DKA. Review of Patient #96’s medical record, dated 04/25/26, showed: - At 2:49 AM, she presented to the Emergency Department (ED) for intoxication and suicidal/suicidal ideation (SI, thoughts of causing one’s own death) with a reported overdose of 10 beers, 100 tramadol (a narcotic-like pain reliever used to treat moderate to severe pain), 30 lisinopril (medication used to treat high blood pressure) and an unknown amount of escitalopram (medication for the treatment of depression and anxiety). - Her past medical history included diabetes Type 1 (a condition where the body produces little to no insulin resulting in the person requiring artificial insulin injections or medication). - At 02:59 AM, she was placed on a 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) for SI. - At 03:15 AM, orders were placed to remove her insulin pump as she was at risk of suicide. - At 03:29 AM, she received 14 units of Lantus (long-acting blood-glucose-lowering medication). - At 03:30 AM, orders were placed for a low dose SSI prior to each meal and at bedtime. - At 06:00 AM, the discharge summary showed she was stable for discharge and needed prescription management of insulin. The ED physician documented her diagnosis as Major Depressive Disorder (MDD, a mental health condition that causes persistently low mood and loss of interest in activities that once brought joy) and diabetes Type 1 per patient and in parenthesis it stated, “likely Type 2 (a chronic condition where the body cannot properly use or make enough insulin)”. A SSI was ordered with a carbohydrate consistent diet (helps manage blood sugar by ensuring you eat the same amount of carbohydrates each meal). - At 09: 07 AM, she was admitted to the behavioral health unit. - Between 04/25/26 through 04/26/26, BG levels were obtained, and insulin was administered per SSI. - On 04/27/26 at 09:13 AM, nurse assessment showed her BG was 351 and she received five units of Humalog (a rapid-acting blood-glucose-lowering medication) insulin per SSI. Her respiration rate (RR, normal breaths per minute for an adult at rest ranges from 12 to 20 breaths per minute [bpm]) was 24. - At 10:21 AM, she was reassessed and found to by lying in bed and RR was 32. She reported extreme thirst, frequent urination and was somewhat diaphoretic (excessive, abnormal sweating). Her BG was 353. She stated that she felt similar symptoms with a prior episode of DKA. The physician was notified, and she was given five units of Humalog at 10:28 AM. Orders were received for her to be sent to the ED for evaluation. - At 11:13 AM, she was evaluated in the ED. She was confused, lethargic (weak, sluggish) and complained of chest pain that progressively worsened. She was diagnosed with DKA, had an elevated lactic acid (lactic acid built up in the blood as a result of altered glucose metabolism that can result in metabolic acidosis [condition where too much acid accumulates in the body and can be related to a buildup of body toxins or kidney failure]; normal is 0.5 to 2.2) level of 3.7, elevated white blood cell count (WBC, the number of white cells [infection-fighting cells] in the blood [normal range is 4 to 10]) of 26.6 and had a recent overdose. Her anion gap (a measure for electrolyte imbalances and acid-base imbalances in your blood, normal is 2-15) was high at 18 and indicated metabolic acidosis and ketonuria (when a type of sugar is present in the urine, may indicate high BG levels in the body) consistent with DKA and acute (sudden onset) kidney injury. She was admitted into the ICU for DKA. - Patient #96’s insulin pump was discontinued and there were no orders for a long-acting insulin. She had not received long-acting insulin since a one-time administration on 04/25/26 at 03:29 AM, in the ED and there was no consultation for the diabetic education nurse. During an interview and concurrent review of Patient #96’s incident report and RCA review, on 05/27/26 at 10:00 AM, Staff AAA, Risk Management Director, stated that the investigation showed that hospital staff did not follow policy and procedure for patients with insulin pumps. The ED physician ordered a one-time dose of long-acting insulin but nothing else was ordered. The Psychiatrist (physician who specializes in mental health disorders) did not order a long-acting insulin and the nurse did not notify the physician that the patient was not on a long-acting insulin. During a telephone interview on 06/11/26 at 2:30 PM, Staff MMMM, Diabetic Education Nurse, stated that Diabetes Type One patients did not make insulin on their own and required both long acting and short acting insulins. Patient #96 received one dose of long-acting insulin in the ED, but no other long-acting insulin was ordered or given. When behavioral health patients present with SI symptoms their insulin pumps were removed for safety. The Psychiatrist should have consulted with a Hospitalist to ensure that patient had orders for a long-acting insulin. Once SI patients were discharged from the ED and transferred to the behavioral health unit it was the Psychiatrist’s responsibility to ensure patients have appropriate orders. They often consulted the Hospitalists over the phone and should document this in the medical record. There was no consultation with a Hospitalist documented for Patient #96. She went into DKA because of not receiving a long-acting insulin. During a telephone interview on 06/17/26 at 3:30 PM, Staff NN, Chief Nursing Officer (CNO), stated that she expected nursing staff to follow hospital policy. All patients who were on an insulin pump must receive a long-acting insulin two hours prior to the discontinuation of their insulin pump. If a patient refuses to wear their insulin pump, staff must immediately notify the physician. Review of the hospital’s policy titled, “Clinical Care- Medication Administration,” revised 01/2026, showed labels must be applied to all solutions and medications stored in all types of containers used on and off the surgical field in the perioperative setting. Observation on 05/27/26 at 10:00 AM, showed three unlabeled syringes located on the nurse workstation in the operating room (OR) for Patient #70. One of the unlabeled syringes was provided to the surgeon for injection into Patient #70’s right nipple. Review of Patient #70’s medical record, dated 05/27/26, showed she was a 72-year-old who presented to the hospital for right breast cancer. She had a planned lumpectomy (a breast surgery used to remove a tumor along with a small rim of surrounding healthy tissue) with sentinel lymph node (the very first lymph node [small bean shaped structures thar are part of the immune system] that fluid from a tumor drains into) biopsy (take a sample of tissue or cells for testing). During a telephone interview on 06/10/26 at 2:30 PM, Staff JJJJ, OR Director, stated that she expected all syringes to be labeled. During a telephone interview on 06/10/26 at 10:00 AM, Staff XXX, Market President, stated that she expected all staff to follow hospital policies and procedures. All predrawn medication syringes were to be labeled according to policy, especially when the medications were left unattended. Review of the hospital’s undated document titled, “Hypoglycemia,” showed - Hypoglycemia is a condition in which BG levels are lower than the standard range. For BG less than 70 milligrams (mg)/deciliter (dl) the Hypoglycemia Protocol is to be followed. - If BG is less than 70mg/dl notify the physician, if asymptomatic (the absence of symptoms), give four ounces juice or regular cola. - Recheck BG in 15 minutes after any intervention. - If still less than 70 mg/dl, repeat four ounces of juice or cola - If recheck is greater than 70 mg/dl follow up within one hour with cheese/crackers or peanut butter/crackers. - Document all treatments, physician notifications and orders received. Review of the hospital’s undated document titled, “Hyperglycemia,” directed staff to report persistent hyperglycemia and hypoglycemia to the physician. Review of Patient #98’s medical record, dated 05/23/26, showed: - He was a 59-year-old admitted to the hospital for seizures (sudden, uncontrolled electrical disturbance in the brain which cause changes in behavior, movements and/or in levels of consciousness). - His past medical history included diabetes and extensive amputations (removal of an injured or diseased body part) of both legs. - On 05/25/26 at 3:46 AM, his BG was 55 mgs/dl, no treatment was provided and the physician was not notified. - At 6:33 AM, his BG was 55 mg/dl, two hours and 32 minutes late, he was given eight ounces of orange juice, the order was for four ounces. - At 7:00 AM, 12 minutes late, his BG was 67 mg/dl, treatment was provided. - At 7:17 AM, two minutes late, his BG was 85 mg/dl. He was not given cheese/crackers or peanut butter/crackers within one hour. - At 9:04 PM, Glargine insulin (long-acting type of insulin [a hormone that regulates the amount of sugar in the blood] that works slowly, over 24 hours) was administered. Patient #98 had persistent hypoglycemia throughout the day. - On 05/26/26 at 6:17 AM, his BG was 51 mg/dl, juice was provided, the physician was not notified. - At 6:41 AM, nine minutes late, his BG was 52 mg/dl, juice was provided, the physician was not notified. The nurse reported to the oncoming nurse that a BG assessment was due at 7:00 AM. - At 7:21 AM, 25 minutes late, his BG was 57 mg/dl, no treatment was provided and the physician was not notified. - At 9:00 AM, one hour and 24 minutes late, his BG was 134 mg/dl. He was not given cheese/crackers or peanut butter/crackers within one hour. - At 11:37 AM, Lispro (a fast-acting, man-made insulin used to control blood sugar in people with diabetes) was administered per the SSI order, two hours and 37 minutes after the BG assessment. - At 8:56 PM, Glargine was administered. Patient #98 had persistent hypoglycemia throughout the day. - On 05/27/26 at 4:16 AM, his BG was 89 mg/dl. At 6:27 AM, his BG was 107 mg/dl. At 8:15AM, Glargine was administered. The patient continued with persistent hypoglycemia. - At 7:30 AM, Lispro was administered per the SSI order, one hour and three minutes after the BG assessment. - At 10:49 AM, his BG was 58 mg/dl, treatment was provided, the physician was not notified. - At 11:08 AM, four minutes late, his BG was 71 mg/dl. He was “attempting” to eat lunch. He was not given cheese/crackers or peanut butter/crackers within one hour. - At 12:58 PM, his BG was 55 mg/dl, treatment was provided. - At 1:11 PM, his BG was 54 mg/dl, treatment was provided, the physician was not notified. - At 1:27 PM, his BG was 71 mg/dl. - At 3:25 PM, his blood glucose was 51 mg/dl, no treatment was given and the physician was not notified. - At 3:43 PM, three minutes late, his BG was 48 mg/dl, treatment was given, the physician was not notified. - At 3:58 PM, his BG was 64 mg/dl, treatment was given, the physician was not notified. - At 4:22 PM, nine minutes late, his BG was 68 mg/dl, treatment was given, the physician was not notified. - At 4:40 PM, three minutes late, his BG was 88 mg/dl. He was not given cheese/crackers or peanut butter/crackers within one hour. - On 05/28/26 at 12:20 AM, his BG was 48 mg/dl, treatment was provided. - At 12:46 AM, 11 minutes late, his BG was 55 mg/dl, no treatment was provided, the physician was notified. - At 1:05 AM, four minutes late, his BG was 81 mg/dl. He was not given cheese/crackers or peanut butter/crackers within one hour. - At 7:26 AM, Lispro was administered per the SSI order, one hour and 22 minutes after the BG assessment. During a telephone interview on 06/10/26 at 10:00 AM, Staff XXX, Market President, stated that she expected all staff to follow the hypoglycemia/hyperglycemia protocols and document all interventions/actions. She stated that the hospital’s policy needed revision to define best practice for insulin administration timing with BG assessments and reassessment once a patient’s BG was at least 70 mg/dl. She planned to develop a robust re-education process. She wanted to ensure the diabetic educators had channels to escalate their concerns. During an interview on 05/28/26 at 10:25 AM, Staff WWW, Diabetes Educator, stated that she expected insulin administration within 30 minutes of a BG assessment. She was not surprised that insulin administrations were not within the expected timeframe. She had tried to express her concerns for insulin and diabetes management with leadership. Training had been done at a staff meeting and during staff on-boarding. She was not aware of any current education. She believed the hospital had an opportunity to improve nursing knowledge for diabetes and insulin management. Review of the hospital’s policy titled, “Clinical Care - Medication Administration,” revised 01/2026, showed medications eligible for scheduled dosing times and are time-critical will have a one hour window to administer. These medications include antibiotics, anticoagulants (medications to prevent blood clots [clumps that occur when blood hardens from a liquid to a solid]), anticonvulsants (medications to prevent seizures) and immunosuppressive agents (medications that reduce the strength of your body’s immune system). Review of Patient #105’s medical record, dated 02/22/26, showed: - He was a 31-year-old admitted to the behavioral health unit on a 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others). - On 02/24/26, Keppra (medication used to treat seizures) was ordered every 12 hours, at 9:00 AM and 9:00 PM. - On 03/03/26 at 7:49 AM, Keppra was administered, one hour and 11 minutes before the scheduled time. - At 7:55 PM, Keppra was administered one hour and five minutes before the scheduled time. Review of Patient #106’s medical record, dated 02/20/26, showed: - She was a 70-year-old admitted for a subdural hematoma (a pool of blood between the brain and its outermost covering). - On 2/24/26, Keppra was ordered every 12 hours, at 9:00 AM and 9:00 PM. - On 03/01/26 at 10:07 AM, Keppra was administered one hour and seven minutes after the scheduled time. Review of Patient #107’s medical record, dated 02/25/26, showed: - He was a 72-year-old admitted to the hospital for diabetes. - On 02/25/26, Keppra was ordered every eight hours, at 6:00 AM, 2:00 PM and 9:00 PM. The 9:00 PM dose was scheduled one hour early. - On 03/01/26 at 4 :14 AM, Keppra was administered, one hour and 46 minutes before the scheduled time. - On 03/02/26 at 3:29 AM, Keppra was administered two hours and 31 minutes before to the scheduled time. Review of Patient #108’s medical record, dated 01/10/26, showed: - He was a 48-year-old admitted following a motor vehicle crash. - On 01/21/26, Lovenox (a medication used to help prevent the formation of blood clots) was ordered every 24 hours, at 9:00 PM. - On 03/02/26 at 7:26 PM, Lovenox was administered, one hour and 34 minutes before the scheduled time. - On 03/03/26 at 7:51 PM, Lovenox was administered, one hour and nine minutes before the scheduled time. - On 03/09/26 at 10:16 PM, Lovenox was administered, one hour and 16 minutes after the scheduled time. Review of Patient #109’s medical record, dated 01/27/26, showed: - She was a 44-year-old admitted to the hospital for breast cancer. - On 02/15/26, Lovenox was ordered every 12 hours, at 9:00 AM and 9:00 PM. - On 03/02/26 at 7:36 AM, Lovenox was administered, one hour and 24 minutes before the scheduled time. - On 03/13/26 at 7:58 AM, Lovenox was administered, one hour and two minutes before the scheduled time. - On 03/14/26 at 7:32 PM, Lovenox was administered, one hour and 28 minutes before the scheduled time. - On 03/15/26 at 7:48 PM, Lovenox was administered, one hour and 12 minutes before the scheduled time. - On 03/16/26 at 10:13 AM, Lovenox was administered, one hour and 13 minutes after the scheduled time. Review of Patient #110’s medical record, dated 02/25/26, showed: - She was a 71-year-old admitted to the hospital for lumbar spondylolisthesis (a spinal condition in the lower back where one vertebra [backbone] slips out of place and moves forward over the bone beneath it). - On 03/05/26, Xarelto (a medication used to help prevent the formation of blood clots) was ordered every 12 hours at 8:00 AM and 6:00 PM, the 6:00 PM dose was scheduled two hours early. - On 03/06/26 at 9:23 AM, Xarelto was administered, one hour and 23 minutes after the scheduled time. Review of Patient #111’s medical record, dated 02/12/26, showed: - He was a 58-year-old admitted to the hospital for diabetes. - On 02/21/26, Xarelto was ordered every twelve hours, at 9:00 AM and 9:00 PM. - On 03/01/26 at 10:22 PM, Xarelto was administered, one hour and 22 minutes after the scheduled time. - On 03/03/26 at 7:26 AM, Xarelto was administered, one hour and 24 minutes before the scheduled time. - On 03/03/26 at 10:03 PM, Xarelto was administered, one hour and three minutes after the scheduled time. During a telephone interview on 06/10/26 at 10:00 AM, Staff XXX, Market President, stated that she expected staff to follow the hospital’s policies and procedures. She expected critical medications to be administered within one hour of the scheduled time and that medications were scheduled as ordered. She planned to review the medical records to identify opportunities and develop education. 47504”

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 48359 Based on observation, interview, record review and document review, the hospital failed to meet industry safety standards and follow hospital policy: - When performing universal timeouts (a mandatory, final pause taken by the entire operating team just before a surgery begins to verbally confirm the correct patient, the correct surgical plan and the correct body part to ensure absolute safety) for one current patient (#70) and two discharged patients (#75 and #76) of four surgical patients reviewed; - When surgical dry times were not followed for two current patients (#75 and #76) of two surgical patients observed; and - When a surgical site was not marked for one current patient (#69) of one surgical patient observed. Findings included: Review of the hospital’s policy titled, “Universal Time Out Policy,” revised 01/2026, showed: - The expected outcome is that the correct procedure is performed on the correct patient, site, side and/or level and that every member of the surgical team is aware of what is to be done and participates in the verification process. - The Preoperative Safety Checklist will be completed on each patient, then reviewed and signed prior to going to the operating room (OR). - Preprocedural interventions directed scheduling to obtain the side and/or level of the procedure to be performed when scheduling a surgical procedure. Write out fully on the procedure/OR schedule and on all relevant documentation (consents) the words right, left or bilateral for scheduling procedure that involve anatomical sites that have laterality. - Preoperative verification included comparing the scheduled surgical procedure as stated by the patient to the posted schedule. - The patient, physician or his/her designee will mark the site at or adjacent to the incision site at a location that will be visible after the patient is prepped (deep cleaning of a patient’s surgical site before an operation) and draped (covered entirely by sterile [completely clean and free from germs] sheets to create an isolated, germ-free zone). The person who performed the site marking will be documented in the medical record. - The person marking the site will use a “YES” for the mark. - Timeouts will address the correct side and site marked and agreement on the procedure to be done. - The Preoperative Safety Checklist is reviewed by procedural staff and then initialed, signed and completed prior to performing the procedure. - The nurse will document the patient’s inability and the alternative method used to mark the site. - A patient introduction will be performed before all surgical procedures. Upon entering the surgical room, the Registered Nurse (RN) will state to the other members of the surgical team “This is (Patient Name), Doctor (Physician’s Name) will be performing (Name of Procedure,) including right, left, bilateral and/or level,” this can be stated by the patient if they are not sedated and the RN will verify the information provided. - Before the start of the procedure, ensure all information is completed on the timeout board prior to the patient entering the room, the informed consent is present, completed, signed, timed and dated by the patient, witness and physician and the patient is in the correct position. - Timeouts will be performed immediately prior to the beginning of the procedure. - Timeouts will be conducted utilizing the surgical consent. - Timeouts will cause all other activities to be suspended during the timeout and involve all members of the surgical team. - Timeouts will address the correct patient identity, the correct side and site are marked, agreement on the procedure to be done, confirm the skin prep has dried and fire risk assessment to be low, moderate or high risk. Review of the hospital’s policy titled, “Verification of Correct Patient and Operative Procedure,” revised 02/2026, showed: - The scheduler will pay careful attention to specifying the correct operative site, including right or left. - Prior to sedation medications, the nurse shall verify the procedure specifically by asking the patient what his/her understanding is of the procedure to be done. If the patient is unable to communicate, the nurse should verify the information with the family member. If no family members are available, the nurse shall use the consent form as the final check. If there is any discrepancy between the consent and what the patient states, the nurse must notify the physician, who must speak with the patient. The assigned nurse or designee must perform all consent verification and preoperative checklist prior to the administration of sedation medications. - In addition to verifying the correct patient and operative site, which includes the marked right or left side, the circulator should also verify that all information such as the chart, x-rays (test that creates pictures of the structures inside the body-particularly bones) and other reports in the operating suite are verified as the correct patient, side and procedure scheduled. - Some bedside procedures may indicate the need for site marking. The established policy for site marking and timeout shall be followed and documented. Review of the hospital’s policy titled, “Intraoperative Skin Preparation,” revised 03/2025, showed: - The objective was to provide evidence-based guidance for preoperative skin antisepsis (chemical that kills harmful germs) to promote patient safety and reduce the risk of surgical site infection. - Allow chlorhexidine gluconate and isopropyl alcohol solution (CHG, a fast-acting, long-lasting antiseptic skin cleanser used by medical professionals to kill bacteria on the skin before surgeries) to completely dry for a minimum of three minutes. Do not use a towel to blot dry. - Allow povidone Iodine solution (a powerful liquid antiseptic used to clean skin and prevent infections) to dry about two minutes and up to an hour in hair. Do not use a towel to blot dry. Review of Patient #75’s medical record, dated 02/26/26, showed: - She was a 77-year-old who presented to the hospital for surgical repair of a right upper arm bone fracture (break in a bone). - The Preoperative Safety Checklist showed no time to the OR was documented. - The Surgical Case Record showed she had an intravenous catheter (IVC, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream) in her left forearm, dressing to her right shoulder and a black sling to her right arm. - At 9:15 AM, Staff CCCC, Physician, was at the bedside to place an anesthesia (treatment with certain medications that puts the patient into a deep sleep so that they do not feel any pain during surgery) block (a targeted numbing injection that numbs a specific area) to her right arm. - At 9:20 AM, the anesthesia block administration was completed. There was no documentation of a timeout at the bedside prior to the block. - At 9:26 AM, Staff CCCC, returned to the bedside and stated that she had done the block to the left arm, the wrong side. - The Anesthesia Post/Pre/Anesthesia Record showed the incorrect side was blocked. The right side was the correct side. The block on the left side did not work. The mistake was explained to the patient and the decision was made not to block the right side. - On 02/27/26, a progress note showed she had pain in her shoulder where she had surgery, she inadvertently had the anesthesia block done on the left side and surgery on the right side. The surgical site was correct but the block was on the wrong side. Review of the Root Cause Analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to find root cause) related to patient #75’s event, dated 02/26/26, showed: - The preoperative anesthesia evaluation was performed by a Certified Registered Nurse Anesthetists (CRNA, registered nurses who have obtained graduate-level education and board certification in anesthesia) that did not perform the anesthesia for Patient #75’s surgery or the anesthesia block. - The plan for the anesthesia block was developed after the surgery was completed. - There was no preprocedural verification for the anesthesia block. During an interview on 05/27/26 at 11:45 AM, Staff AAA, Risk Management Director, stated that a timeout was not completed prior to the anesthesia block placement for Patient #75. An RCA was completed. The patient had an arm sling and dressing to her right side. Staff failed to follow the hospital’s policy for Patient #75’s second procedure timeout. The post anesthesia care unit RN had just arrived and did not review the procedure documentation. The anesthesiologist stated “I did not stop; I did not slow down. The surgical site was pretty visible.” Surgical staff education was provided at a mandatory staff meeting in regard to the operating room culture and the Universal Time Out policy. Anesthesia staff were educated on the timeout process. The hospital developed a “Stop Before You Block” campaign for staff education. Although requested, the hospital failed to provide the OR schedule for Patient #76. Review of Patient 76’s medical record, dated 04/21/26, showed: - She was a 79-year-old admitted to the hospital for surgical repair of a right hip after a fall at home - She was confused, mostly nonverbal and oriented only to herself. - On 04/22/26, the Orthopedic (medical specialty dealing with bones) Consultation Note showed her husband signed a consent form for surgical repair of her right hip fracture planned for the following day. - On 04/22/26, the hospitalist (physician whose primary professional focus is the general medical care of hospitalized patients) progress note showed her surgery was postponed until the following day. - On 04/23/26, the Anesthesia Pre/Post Anesthesia Record showed the patient had a right hip fracture. - At 10:36 AM, the witness signed the General Consent to Surgical and Medical Procedures and Other Services form for a right hip replacement for a right hip fracture. At 10:37 AM, the patient’s husband signed the consent form, after the witness signature. At 11:00 AM, the Orthopedic Surgeon physically signed the consent form. At 2:51 PM, the Orthopedic Surgeon electronically signed the consent form. - At 11:45 AM, an anesthesia block was performed on her right hip. - The Preoperative Safety Checklist showed the correct surgical permit matched the physician orders and schedule. The correct (right) side/site was verified and marked, the location was not documented. There was no documentation of who marked the site. There was no OR nurse signature or initials. The time to OR was not documented. - At 12:07 PM, the patient entered the OR. - At 12:41 PM, the surgical timeout was completed. - The Surgical Case Record showed nursing obtained surgical and anesthesia consents from her husband. The proposed procedure was left total hip replacement and the actual procedure was bilateral (both sides) hip replacements. - The Operative Report showed the patient was given general anesthesia, placed with her left side up and a surgical timeout was completed. After the left hip was dislocated (when the ball-shaped head of the thighbone is forced entirely out of its socket in the pelvis), it was realized that left was the incorrect side and the surgeon had to proceed with replacement of the left hip. The patient was then repositioned with her right side up; the patient’s husband was notified of the wrong side surgery and the surgeon proceeded with the right hip replacement. - On 04/24/26, the hospitalist progress note showed the patient had bilateral hip surgery the day before due to an OR error. - On 04/28/26, the hospitalist progress note showed the patient had bilateral hip replacements due to a surgical timeout error. - The Discharge Summary showed a surgical error was made in the OR. Her left hip was surgically prepped, draped and dislocated due to a surgical timeout error. Review of the RCA related to Patient #76’s event, dated 04/23/26, showed: - The patient was initially scheduled for a right hip replacement on 04/22/26, the surgery was cancelled and rescheduled for 04/23/26. - On 04/22/26, the patient was scheduled for a right hip replacement. - On 04/23/26, the patient was scheduled for a left hip replacement. - Staff BBBB, Orthopedic Surgeon, verbally called to reschedule the patient’s surgery and reported the left hip. - The preoperative nurse did not match the schedule to the patient’s surgical consent form. - The timeout was based on the “white board” in the OR, the team did not review the surgical consent form. During an interview on 05/27/26 at 11:45 AM, Staff AAA, Risk Management Director, stated that the event with Patient #76 was the second wrong surgical site event this year. The surgery was rescheduled for 04/23/26, because the surgeon changed. It was believed Staff AAAA, Orthopedic Surgeon, was a better choice to perform Patient #76’s surgery. On 04/22/26, Staff BBBB, Orthopedic Surgeon, called OR scheduling to reschedule the patient for the following day and verbally stated “left hip.” The preoperative nurse did not match the schedule to the patient’s surgical consent form. The patient was consented for a right hip replacement but the surgical schedule showed left hip replacement. The timeout was based on the “white board” in the OR, the team did not review the surgical consent form for verification during the timeout process. The surgical site was marked by the patient’s husband and she believed the mark was not visible once the patient was draped. Staff did not follow the policy. The surgeon recognized the wrong side once he dislocated the hip and realized the hip was not fractured. Once the bone was dislocated the surgeon had no choice but to replace the left hip. When the wrong side was realized the team paused, a full timeout was performed, the situation was disclosed to the patient’s spouse and escalated to leadership. An RCA was completed and education was again provided to all surgical staff in regard to the timeout process expectations. Observation on 05/27/26 at 9:30 AM, showed: - When Patient #69 entered the OR he stated his name and date of birth but failed to state the surgical procedure and site. - He had a blue circle drawn around a bump to his right upper back. The site was not marked with a “YES.” He had no additional surgical sites marked. - Povidone Iodine solution was painted to his chest and forehead. The patient’s head hair was clipped but remained past the surgical site. The solution was applied to his hair. The solution was blotted from his chest and forehead before the surgical drapes were applied approximately two minutes after the povidone Iodine solution was applied. - The povidone iodine solution was not scrubbed and blotted prior to painting and the painting was blotted. - The OR did not have a functional timer to ensure dry time. Review of Patient #69’s medical record, dated 05/27/26, showed he was a 61-year-old who presented to the hospital for surgical removal of back mass (an abnormal growth of tissue) and a right forehead lesion (an abnormal area of tissue inside or outside the body). The Preoperative Safety Checklist showed the correct side/site verification was not applicable and no location was documented. There was no documented time to the OR and the OR nurse failed to document her initials. Observation on 05/27/26 at 10:00 AM, showed Patient #70 entered the OR. At 10:12 AM, the surgeon injected dye into her right nipple, prior to the timeout. At 10:20:26 AM, CHG solution was applied to her right breast, the solution was blotted from her chest. At 10:21:51 AM, surgical drapes were applied, one minute and 25 seconds after the isopropyl alcohol solution application was completed. At 10:22 AM, the timeout was completed. Review of Patient #70’s medical record dated, 05/27/26, showed: - She was a 72-year-old who presented to the hospital for right breast cancer. She had a planned lumpectomy (a breast surgery used to remove a tumor along with a small rim of surrounding healthy tissue) with sentinel lymph node (the very first lymph node [small bean shaped structures thar are part of the immune system] that fluid from a tumor drains into) biopsy (take a sample of tissue or cells for testing). - The General Consent to Surgical and Medical Procedures and Other Services was not dated and timed by the physician. - The Preoperative Safety Checklist showed the correct side/site was verified and marked; no location was documented. There was no documented time to the OR. During a telephone interview on 06/10/26 at 10:00 AM, Staff XXX, Market President, stated that she expected staff to follow the hospital’s policies and procedures. She expected a timeout to be completed before the start of any invasive procedure, without exception. She expected all surgical sites were marked with “YES” as directed in the policy. She expected to see documentation of who marked the surgical site. She expected dry times to be applied according to the hospital’s policy and product recommendations. She expected there to be an OR focus on dry times. She expected each OR to have a functional timer to ensure dry times were completed. She expected patient’s to participate in their OR introduction and announce their name, date of birth and surgical procedure if they were capable. She expected the Preoperative Safety Checklist to be completely filled out. She became aware of the two wrong site surgeries when she recently assumed her role as Market President. She was very concerned because the events were likely preventable. She was surprised to find that surveyor observations showed staff continued noncompliance with the timeout policy. She expected staff to be compliant with corrective action, coaching and performance improvement plans. She expected reobservations to ensure compliance. During an interview on 06/10/26 at 2:30 PM, Staff JJJJ, OR Director, stated that she expected staff to follow the hospital’s policies and procedures. She expected a timeout prior to any invasive procedure. She was surprised and disappointed in the surveyor’s observation of noncompliance. The timeout was nonnegotiable. Failure to complete a time out was unacceptable. A wrong surgical site was a never event. Failures in the timeout led to wrong surgical sites and placed patients in jeopardy. Staff were previously educated on the policy expectations which were evidence based best practices. Observation audits began immediately following the education and standards were met. She was shocked. She expected all surgical sites were marked with a “YES” as directed in the policy. She expected documentation of who marked the site. She expected a patient’s introduction to the OR to be complete and include the planned procedure. She stated that CHG dry time was two minutes. CHG was not blotted. Povidone Iodine solution dry time was two minutes. Povidone iodine solution was applied by scrubbing and then blotted and then painted, without further blotting. Her expectations were not met when Patient #69’s hair was painted and draped before it was fully dry. She expected each OR to have a functional timer. She planned to review the hospital’s policy due to the conflicting directives for the dry times and lack of detail for the povidone iodine prep. She expected the Preoperative Safety Checklist to be completely filled out. She was surprised to know the location was not documented on any of the reviewed checklists. 47504”