Forrest General Hospital

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 45467 Based on interview, document review and policy and procedure review, the facility failed to provide documented evidence of an effective corrective action plan which included monitoring to ensure corrective actions/improvements are sustained for one (1) of one (1) patient adverse event reviewed; Patient #1. This adverse event has the potential to affect all patients on telemetry monitors. Findings Include: An interview on 01/05/2026 at 1:17 p.m. with the Director of Risk Management/Patient Advocate (DORM) confirmed no knowledge of the telemetry incident with Patient #1 on telemetry with leads off on 12/09/2025 resulting in a patient who was found not breathing and pulseless. During an interview on 01/05/2026 at 3:16 p.m. with the Director of Quality (DOQ) the surveyor requested Quality Assurance Performance Improvement (QAPI) documentation for the telemetry incident on 12/09/2025. Facility QAPI documents for the telemetry incident on 12/09/2025 were not made available for review. An interview on 01/06/2025 at 10:12 a.m. with Patient Care Manager (PCM) #1 confirms in addition to the termination of MT #1 and #2, re-evaluation of Monitor Room process was completed and re-education on job descriptions, patient’s rights, policy and procedure for Centralized Monitoring Process and included employee reevaluations for all Central Monitor Room (CMR) staff began on 12/22/2025 and was completed on 01/01/2026. No Corrective Action Plan presented for review to indicate the facility’s plan to ensure corrective actions/improvements will be sustained. Review of attendance record for re-education for CMR protocols for staff dated 12/22/2025 confirm education was provided to sixteen employees working in the CMR. No other documentation presented for corrective actions. Review of Patient #1’s medical record, “flowsheet,” dated 12/09/2025 at 1:57 a.m. reveals the call light and overbed table within reach, bed in lowest position and wheels locked, side rails at three quarters high (¾), with chest rising and falling and eyes closed, repositioned to a supine position with head of bed (HOB) at 30 degrees, and heels elevated. Patient #1’s vital signs were documented as temperature 98.1 Fahrenheit, blood pressure 113/85, pulse 107, respirations 18, patient in sitting position, weight 183 pounds 3.2 ounces (83.1 kilograms). Review of Patient #1’s medical record “Nurse Daily Cares/Safety documentation” dated 12/09/2025 at 3:15 a.m. reveals patient awake and staff assisting patient with a coke. Further review of medical record documentation reveals patient was found not breathing and pulseless and a “Code Blue” was called at 3:55 a.m. Cardiopulmonary resuscitation (CPR) and Bag valve mask ventilations were in progress upon arrival of family nurse practitioner (FNP) and initial cardiac rhythm of Pulseless Electrical Activity (PEA). Time of death called at 4:10 a.m. Review of Code Note dated 12/09/2025 by Medical Doctor (MD) #1, reveals being called for a Code Blue, patient was asystole, continued CPR and giving epinephrine every three minutes, a total of 2 bicarbonate’s were administered, and one ampule of calcium gluconate, patient was intubated with a 7.5 endotracheal tube (ETT), with continued resuscitation and the patient last time seen active was about 30 minutes prior to code and actually do not know exactly how long the patient was in cardiopulmonary arrest. Facility was unable to reach family member until 2:35 p.m. Patient #1 was discharged to the morgue on 12/09/2025 at 4:30 a.m. with discharge disposition of expired. Review of a Human Resource email “Termination Request” for MT #1 and #2 with a summary of the investigation on the email document, dated 12/19/2025 at 11:06 a.m., to Human Resources reveals Monitor Technician (MT) #1 was assigned responsibility for Patient #1’s continuous telemetry surveillance and immediate notification to nursing staff of critical alarms or loss of leads. The investigation revealed MT #1 assumed responsibility for scanning paperwork for multiple technicians which required approximately three and one half (3.5) hours which resulted in prolonged absence from assigned monitors, then left for meal break at 2:23 a.m. to 3:02 a.m. Video footage reveals MT #1 was not at monitor at 2:44 a.m. when leads became disconnected. MT #1 alleges calling floor about leads prior to leaving for meal break. No call log found which documents a call from the Monitor Room at or around 2:44 a.m. and multiple nurses confirm no call was received. MT #1 also states she called nurse’s station around 3:35 a.m. which is the first documented call. The report also reveals MT #2 was responsible to monitor both his and MR #1’s monitors while MT #1 was scanning reports and at meal break. Camera footage reveals MT #2 was not actively monitoring either his assigned telemetry monitors or MT #1’s monitors during this time but engaged in personal cell phone use and social interaction with coworkers failing to recognize or respond to Patient #1’s loss of telemetry for approximately one (1) hour. MT #1 and #2 were terminated for Patient Abuse/Neglect, Cell phone use on unit, Leaving assigned work area during working time, Job performance, and Patient Safety. Video footage for Central Monitor Room (CMR) on 12/08/2025 from 11:48 p.m. to 12/09/2025 at 3:39 a.m. reviewed with Patient Care Manager (PCM) #1, confirmed MT #1 standing in the CMR at the scanner from 11:48 p.m. to 2:23 a.m. then leaving the CMR from 2:23 a.m. to 2:58 a.m. returning to the scanner 2:58 a.m. to 3:36 a.m. MT #1 returns to the telemetry monitors and removes her coat, then exits the CMR at 3:37 a.m. and returns to CMR at 3:44 a.m. sits down looks at the monitors and places a phone call at 3:45 a.m. Video footage review from 11:48 p.m. to 3:39 a.m. reveals MT #2 is sitting at the monitor stations talking with coworkers and engaging on a cellular device but not actively monitoring the telemetry monitors. Video footage at 3:39 a.m. reveals MT #2 looking at his monitors. Review of the facility’s “Performance Improvement Plan” policy, effective date 08/22/2023, last review date 07/18/2024 revealed “ ... ...Performance measurement is ...part of each initiative and is used to drive next steps ...Lessons learned are communicated extensively ...all patient occurrences ranging from “no-harm” to “near misses” to sentinel events ...The aim ...is to prevent and reduce risk, errors and harm to patients ...accomplished by detecting and preventing adverse events, acting accordingly to improve processes through corrective/preventative action and monitoring the effectiveness of those actions ...detection ...preventative and corrective action ...defined process to reduce risk ...implementation of action plans and on-going measurement to ensure action effectiveness ...Management review of patient adverse events and other data analysis ... Any Manager/Director receiving a report of a possible sentinel event or near miss sentinel event will assure that the Risk Manager, Administrator on call, or Patient Care Supervisor are promptly notified to determine the status of the event ...The Risk Manager in consultation with the President will determine if the event is reportable ...The root cause analysis findings and action plan should be completed no more than 30 days after determination that a sentinel event has occurred ...The Risk Manager will retain the only copy of the accident/event analysis and related documented action with other secured confidential files ...”. The Exit conference was completed on 01/08/2026 at 12:30 p.m. with Executive Director of Nursing Services, Medical Nursing Director, Executive Director of Quality Operations, Patient Care Manager #1, Director of Quality Management, Director of Risk Management, and Chief Operations Officer. No additional information was presented for review.”

“FREEDOM FROM ABUSE, NEGLECT, AND EXPLOITATION CFR(s): §482.58(b)(3) Freedom from abuse, neglect, and exploitation (§483.12(a)(1), (a)(2), (a)(3)(i), (a)(3)(ii), (a)(4), (b)(1), (b)(2), (c)) • §483.12(a)(1): The facility must (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. • §483.12(a)(2): Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident’s medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. • §483.12(a)(3)(i): Not employ or otherwise engage individuals who (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. • §483.12(a)(3)(ii): Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. • §483.12(a)(4): Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. • §483.12(b)(1): The facility must develop and implement written policies and procedures that: (1)Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. • §483.12(b)(2): Establish policies and procedures to investigate any such allegations. • §483.12(c): In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This Standard is not met as evidenced by: 45467 Based on review of Patient #1’s medical record, interviews with Patient Care Manager #1, review of employee handbook, review of human resource documents of termination of Monitor Technician (MT) #1 and Monitor Technician #2, and review of facility policy Vulnerable Adult Abuse/Neglect, the facility failed to report an incident of neglect resulting in death of Patient #1 to the State Department of Health and Medicaid Fraud Control Unit of the Attorney General’s office for one (1) of one (1) Patient adverse event reviewed; Patient #1 Findings Include An interview on 01/05/2026 at 1:17 p.m. with the Director of Risk Management/Patient Advocate (DORM) confirmed no knowledge of the telemetry incident with Patient #1 on telemetry with leads off on 12/09/2025 resulting in a patient found not breathing and pulseless. During an interview on 01/05/2026 at 3:16 p.m. with the Director of Quality (DOQ) the surveyor requested Quality Assurance Performance Improvement (QAPI) documentation for the telemetry incident on 12/09/2025. Facility QAPI documents for the telemetry incident on 12/09/2025 was not made available for review. An interview on 01/06/2025 at 10:12 a.m. with Patient Care Manager (PCM) #1 confirms in addition to the termination of MT #1 and #2, re-evaluation of Monitor Room process was completed and re-education on job descriptions, patient’s rights, policy and procedure for Centralized Monitoring Process and included employee reevaluations for all Central Monitor Room (CMR) staff began on 12/22/2025 and was completed on 01/01/2026. No documentation presented for monitoring to ensure corrective actions/improvements will be sustained. During an interview on 01/06/2026 at 10:17 a.m. with Patient Care Manager (PCM) #1 confirms documentation of termination email to Human Resources, dated 12/19/2025 at 11:06 a.m. confirms Monitor Technician (MT) #1 was terminated due to “ ...Her actions constitute patient neglect and a serious breach of patient safety responsibilities, directly contributing to delayed clinical response ...failed to maintain continuous telemetry surveillance, use approved workflows, ensure timely notification of nursing staff, provide accurate and consistent statements during investigation ...” During an interview on 01/06/2026 at 10:20 a.m. PCM #1 confirmed documentation of termination email to Human Resources, dated 12/19/2025 at 11:06 a.m. confirms MT #2 was terminated based on “ ...His inaction represents failure to exercise reasonable care in a high-risk patient monitoring role, ...maintain active surveillance of assigned monitors, escalate unsafe workload conditions, ensure critical telemetry alerts were addressed, intervene when MT #2 abandoned monitoring station. Facility’s Employee Handbook, not dated, no revision date, section 6-11, “ ...Your Job Performance ...Achieving and maintaining excellence in job performance requires continuous evaluation and adjustment ...You are encouraged to evaluate and adjust your own performance ...From time to time, your supervisor may speak with you regarding performance improvement process, and you are asked to accept it in the same spirit in which it is offered ...If you do not improve your job performance according to your supervisor’s expectations, you may be subject to corrective action up to including termination of employment ...6-17 Leaving The Facility Or Your Work Area During Working Time ...Your supervisor depends on you to be in your assigned work area performing your job duties ...Failure to meet this requirement may be considered job abandonment and subject you to corrective action up to and including termination of employment ...6-29 Cell Phones And Other Mobile Devices ...use of your cell phone or other device is generally prohibited while at work ...Failure to adhere to this expectation may subject violators to corrective action up to and including termination of employment ...6-32 Patient Abuse, Neglect, and Exploitation ...The hospital prohibits any abuse, neglect, or exploitation of patients ...If an investigation reveals that an employee has violated this policy in any manner, he or she will be subject to corrective action up to and including termination of employment ...”. Facility’s Termination Meeting Summary dated 12/22/2025 at 10:30 a.m. for MT #1, Monitor Technician, document confirms the employee termination date of 12/23/2025, based on failure to provide continuous monitoring, failure to actively monitor, and failure to timely escalate patient safety concerns. The Corrective Action document dated 12/22/2025 confirmed employee termination. Facility’s Termination Meeting Summary dated 12/22/2025 at 10:00 a.m. for MT #2, Monitor Technician, document confirms the employee termination date of 12/23/2025, based on Policy Violation, failure to provide continuous active-monitoring, particularly in a life-sustaining monitoring role, constitutes a serious violation of hospital policy and patient safety standards. The Corrective Action document dated 12/22/2025 confirmed employee termination. Review of the facility’s policy titled, “Medical Social Services Department, Vulnerable Adult Abuse/Neglect in Health Care Facility,” effective date 07/23/2024 reveals “ ...persons ...who have knowledge of or reasonably suspect or observe adult abuse/neglect or exploitation in their professional capacity or within the scope of their employment to report such suspected instances of abuse to the Medical Social Services Department ...The Medical Social Worker will notify the Patient Advocate ...After complete investigation, the Medical Social Worker will be responsible for ...reporting telephonically and in writing to the Mississippi State Department of Health and the Medicaid Fraud Control Unit of the Attorney General’s office ...”. Facility’s Termination Meeting Summary dated 12/22/2025 at 10:30 a.m. for MT #1, Monitor Technician, document confirms the employee termination date of 12/23/2025, based on failure to provide continuous monitoring, failure to actively monitor, and failure to timely escalate patient safety concerns. The Corrective Action document dated 12/22/2025 confirmed employee termination. Facility’s Termination Meeting Summary dated 12/22/2025 at 10:00 a.m. for MT #2, Monitor Technician, document confirms the employee termination date of 12/23/2025, based on Policy Violation, failure to provide continuous active-monitoring, particularly in a life-sustaining monitoring role, constitutes a serious violation of hospital policy and patient safety standards. The Corrective Action document dated 12/22/2025 confirmed employee termination. Cross Reference to A-0263/482.21(c)(3) for additional information. The Exit conference was completed on 01/08/2026 at 12:30 p.m. with Executive Director of Nursing Services, Medical Nursing Director, Executive Director of Quality Operations, Patient Care Manager #1, Director of Quality Management, Director of Risk Management, and Chief Operations Officer. No additional information was presented for review.”