UNC Hospitals

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) Unless superseded by State law that is more restrictive-- (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1-hour for children under 9 years of age; This Standard is not met as evidenced by: 50111 Based on review of facility policy, medical records and staff interviews, facility staff failed to ensure an active, time-limited order for violent restraints for 1 of 3 medical records reviewed for patients placed in violent restraints (Patient #2). The findings include: Review on 07/08/2025 of facility policy “Restraint and Seclusion Use,” effective 03/2023, revealed, “... 3. Restraints for Non-violent Behavior Restraints are used for patients with nonviolent behavior that is not self-destructive ... 4. Restraints for Violent Behavior Restraints are used for patients whose behavior is violent or self-destructive when restraint is necessary to ensure the immediate physical safety of the patient, a staff member, or others ... c. ... an RN (Registered Nurse) should obtain an order from and consult with a trained physician or a trained licensed practitioner about the patient’s physical and psychological condition within 15 minutes after the restraint or seclusion has been initiated ... e. The order must be time-limited ... Each order for a physical restraint or seclusion must be limited to ... 2 hours for children and adolescents aged 9 to 17 ... f. ... When an order is about to expire, an RN must contact the physician or other licensed practitioner, report the results of his or her most recent assessment, and request that the original order be renewed ...” Open medical record review on 07/01/2025 for Patient #2 (Pt) revealed an adolescent patient admitted to Facility A, Unit A on 04/12/2025 at 0825 with a diagnosis of altered mental status. Record review revealed orders were not obtained timely on the following occasions. Violent restraints were applied on 04/23/2025 at 0045. Review of the physician’s order on 04/23/2025 at 0152 (1 hour and 7 minutes after initiation) revealed an order for “Restraints violent or self-destructive adolescent.” The restraints were discontinued at 0200. Restraints were applied on 04/26/2025 at 1600. Review of the physician’s order on 04/26/2025 at 1556 revealed a two-hour time limited order for “Restraints violent or self-destructive adolescent” which expired at 1756. The next order was obtained at 2016 (2 hours and 20 minutes after the previous order expired). Record review revealed Pt #2 was in 4-point restraints from 05/01/2025 at 1230 until 05/09/2025 at 1400 (for 8 days). Record review revealed two-hour time limited orders were not obtained timely on the following occasions. Review of the physician’s order on 05/02/2025 at 0755 revealed an order for “Restraints violent or self-destructive adolescent” which expired at 0953. The next order was obtained at 1119 (1 hour and 26 minutes after expiration). Review of the physician’s order on 05/02/2025 at 1719 revealed an order for “Restraints violent or self-destructive adolescent” which expired at 1919. The next order was obtained at 1936 (17 minutes after expiration). The order for “Restraints violent or self-destructive adolescent” at 1936 expired at 2126. The next order was obtained at 2158 (22 minutes after the previous order expired). Review of the physician’s orders on 05/03/2025 at 1618 revealed an order for “Restraints violent or self-destructive adolescent” which expired at 1818. The next order was obtained at 1836 (18 minutes after the expiration). The order for “Restraints violent or self-destructive adolescent” at 1836 expired at 2036. The following order was obtained at 2153 (1 hour and 17 minutes after the previous order expired). The order for “Restraints violent or self-destructive adolescent” at 2153 expired at 2353. The next order was obtained on 05/04/2025 at 0014 (21 minutes after the previous order expired). Review of the physician’s order on 05/05/2025 at 1119 revealed an order for “Restraints violent or self-destructive adolescent” which expired at 1319. The next order was obtained at 1352 (33 minutes after the expiration). Review revealed an order at 1452 for “Restraints violent or self-destructive adolescent” which expired at 1652. The following order was obtained at 1739 (47 minutes after the previous order expired). Review of the physician’s order on 05/06/2025 at 0315 revealed an order for “Restraints violent or self-destructive adolescent” which expired at 0515. The next order was obtained at 0549 (34 minutes after the expiration). Review of the physician’s order on 05/07/2025 at 0007 revealed an order for “Restraints violent or self-destructive adolescent” which expired at 0207. The next order was obtained at 0229 (22 minutes after the expiration). Review of the physician’s order at 0956 revealed an order for “Restraints violent or self-destructive adolescent” which expired at 1156. The next order was obtained at 1243 (47 minutes after the expiration). Review of the physician’s order at 1537 revealed an order for “Restraints violent or self-destructive adolescent” which expired at 1737. The next order was obtained at 1805 (28 minutes after the expiration). Review of the physician’s order on 05/08/2025 at 1123 revealed an order for “Restraints violent or self-destructive adolescent” which expired at 1323. The next order was obtained at 1342 (19 minutes after the expiration). Review at 1657 revealed an order for “Restraints violent or self-destructive adolescent” which expired at 1857. The next order was obtained at 1933 (36 minutes after the expiration). The order for “Restraints violent or self-destructive adolescent” at 1933 expired at 2133. The next order was obtained at 2203 (30 minutes after the expiration). The order for “Restraints violent or self-destructive adolescent” at 2203 expired on 05/09/2025 at 0003. The next order was obtained on 05/09/2025 at 0023 (20 minutes after the expiration). Review of the physician’s order at 0405 revealed an order for “Restraints violent or self-destructive adolescent” which expired at 0605. The next order was obtained at 0631 (26 minutes after the expiration). Record review revealed non-violent bilateral wrist restraints were applied on 05/11/2025 at 1730. Review of the physician’s order on 05/11/2025 at 1846 (1 hour and 16 minutes after restraints were initiated) revealed an order for “Restraints non-violent or non-self destructive.” Restraints were removed on 05/12/2025 at 1240. Additionally, record review revealed non-violent restraints were ordered following a violent behavior event as follows. Review of the physician’s note on 04/26/2025 at 2116 revealed, “19:33: Received page that a Behavioral Response was being called for patient ... patient positioned in 4-pt (point) violent restraints ... Nursing team reported that patient had been in the bathroom and again began hitting his head against the mirror, causing some visible facial swelling ...” Review of physician’s order on 04/26/2025 at 2159 revealed an order for “Restraints non-violent or non-self destructive ... Restraint type: 4 Point ...” Review of the restraint order revealed no two-hour time limited order placed for the restraints following a violent behavior incident. Pt #2 remained in 4-point restraints until 04/30/2025 at 2145 (4 days). Pt #2 was placed in 4-point restraints after exhibiting violent behavior on 05/01/2025 at 1230. Review of physician’s order on 05/01/2025 at 1444 (2 hours and 14 minutes after restraints were initiated) revealed an order for “Restraints non-violent or non-self destructive ... Restraint type: 4 Point ...” Review of the restraint order revealed no two-hour time limited order placed for the restraints following the violent behavior incident. Review of the nursing note at 2004 revealed, “... (Pt #2) jumped out of the bed again and attacked the Chaplain ... Multiple police officers and staff members required to apply restraints at 1230 ...” Pt #2 remained in 4-point restraints until 05/09/2025 at 1400 (8 days). Review of physician’s order on 05/13/2025 at 1923 revealed an order for “Restraints non-violent or non-self destructive ... 2 Point - Wrist ...” Review of the restraint documentation revealed that violent 4-point restraints were applied at 1945. Review of the nursing note at 1952 revealed, “... patient picked up bedside commode over his head and threw bedside commode ... Feces splattered over the walls of the room, floor, as well as RN’s present. Patient also punched daytime charge RN at this time ... MD gave verbal order for violent restraints to be placed at 1920 ... Upon looking at orders, RN discovered that incorrect restraint order was placed and ask (sic) MD to modify. Patient currently on violent 4 point restraints with 2 sitters at bedside ...” Review of physician’s order at 2107 (1 hour and 23 minutes after violent restraints were placed on the patient) revealed a two-hour time limited order for violent restraints. Review of physician’s order on 05/13/2025 at 2254 revealed a new order for “Restraints non-violent or non-self destructive ... Restraint Type: 4 Point ...” Pt #2 remained in 4-point restraints until 05/15/2025 0645. Pt #2 was transferred to Facility B on 05/16/2025 at 1521. Pt #2 was a current admission at Facility B during record review. Interview on 07/03/2025 at 1336 with Registered Nurse (RN) Specialist #5 and RN Educator #6 revealed restraint orders should be obtained within 15 minutes of restraint initiation. Orders for violent restraints required a time limited order of 2 hours for adolescents. Interview on 07/03/2025 at 1336 with RN Specialist #5 and RN Educator #6 revealed restraints were considered violent restraints when they were used on patients that were exhibiting aggressive behaviors toward others or harming themselves. RN Specialist #5 revealed a new order should be obtained prior to the restraint order’s expiration if a patient needed to remain in restraints. The primary RN was responsible for monitoring the orders, the timing of expirations, and notifying the provider when a new order was needed. Interview on 07/03/2025 at 1136 with RN #10 revealed the primary RN was responsible for making sure there was an active restraint order. Interview revealed RN #10 had difficulty sending the provider requests to update the order every 2 hours because of patient care responsibilities. Interview on 07/07/2025 at 1105 with Medical Doctor #1 (MD) revealed violent restraints should be ordered when the patient is at high risk of harming themself or others. Non-violent 4-point restraints were not typically ordered following a violent event or if a patient was at risk for harming themself or others. Interview revealed MD #1 relied on nursing staff for reminders to place restraint orders. Interview on 07/03/2025 at 1415 with MD #12 revealed MD #12 did not recall the rationale for ordering non-violent restraints after a violent behavior event. Interview on 07/07/2025 at 1210 with MD #11 revealed an order for restraints should have been placed as soon as possible after the restraint was initiated. MD #11 stated Pt #2 could not control his behaviors and was at risk of causing significant harm to himself or others. Interview revealed violent restraints, instead of non-violent restraints, should have been ordered after an aggressive behavior incident. MD #13, who ordered non-violent restraints after a behavioral event, was unavailable for interview. In summary, orders were not obtained timely per facility policy for twenty-two occurrences. Non-violent restraints were ordered following a violent behavior event on three occasions.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(11) Physician and other licensed independent practitioner training requirements must be specified in hospital policy. At a minimum, physicians and other licensed practitioners authorized to order restraint or seclusion by hospital policy in accordance with State law must have a working knowledge of hospital policy regarding the use of restraint or seclusion. This Standard is not met as evidenced by: 50111 Based on review of facility policy, credentialing files and staff interviews, the facility failed to ensure providers had completed restraint training according to facility policy for 2 of 3 sampled files reviewed for providers that ordered restraints (Medical Doctor #1 [MD], MD #2). The findings include: Review on 07/08/2025 of facility policy “Restraint and Seclusion Use,” effective 03/2023, revealed, “... 3. Restraints for Non-violent Behavior Restraints are used for patients with nonviolent behavior that is not self-destructive ... 4. Restraints for Violent Behavior Restraints are used for patients whose behavior is violent or self-destructive when restraint is necessary to ensure the immediate physical safety of the patient, a staff member, or others ... Any physician or licensed practitioner permitted by law, hospital policy, and license, who has completed the restraint/seclusion training (a ‘trained physician or a trained licensed practitioner’), can independently order restraints or seclusion for patients ... Restraints for Patients With Violent Behavior ... i. A physician or other licensed practitioner ... must evaluate the patient face-to-face and in person within one hour of the initiation of restraint/seclusion (even if the patient is no longer in restraint/seclusion) and document the findings, including the following information: 1. the patient’s immediate situation; 2. the patient’s reaction to the intervention; 3. the patient’s medical and behavioral condition; and 4. the need to continue or terminate the restraint or seclusion ...” 1. Open medical record review on 07/01/2025 for Patient #2 (Pt) revealed an adolescent patient that was admitted to Facility A, Unit A on 04/12/2025 at 0825 with a diagnosis of altered mental status. Review revealed MD #1 ordered “Restraints violent or self-destructive adolescent” on 04/26/2025 at 1556. Record review failed to reveal a face-to-face assessment within one hour of initiation of the violent behavior restraint application. Pt #2 was transferred to Facility B on 05/16/2025 at 1521. Pt #2 was a current admission at Facility B during record review. Review on 07/02/2025 of MD #1’s credentialing file revealed MD #1 was credentialed from 08/16/2017 until time of the review. Review failed to reveal evidence of restraint training. Interview on 07/07/2025 at 1105 with Medical Doctor #1 (MD) revealed a face-to-face assessment should be completed within one hour of ordering restraints for violent behavior. MD #1 did not recall a face-to-face note being completed for Pt #2 after MD #1 ordered violent restraints. Interview revealed MD #1 was unsure if restraint training had been provided. Interview on 07/08/2025 at 1840 with Manager #3 revealed 2025 resident providers had received restraint training, but other providers had not received restraint training. 2. Open medical record review on 07/01/2025 for Patient #2 (Pt) revealed a 17-year-old patient that was admitted to Facility A, Unit A on 04/12/2025 at 0825 with a diagnosis of altered mental status. Review of MD #2’s note on 04/26/2025 at 2116 revealed, “19:33: Received page that a Behavioral Response was being called for patient ... patient positioned in 4-pt (point) violent restraints ... Nursing team reported that patient had been in the bathroom and again began hitting his head against the mirror, causing some visible facial swelling ...” Review revealed MD #2 ordered “Restraints non-violent or non-self destructive ... Restraint type: 4 Point ...” on 04/26/2025 at 2159. Pt #2 was transferred to Facility B on 05/16/2025 at 1521. Review on 07/02/2025 of MD #2’s file revealed MD #2 was a resident provider at the facility for 3 years in the pediatric program. MD #2 graduated on 06/23/2025. Review failed to reveal evidence of restraint training. Interview on 07/07/2025 at 1210 with MD #11 revealed violent restraints, instead of non-violent restraints, should have been ordered after an aggressive behavior incident. Interview on 07/08/2025 at 1840 with Manager #3 revealed 2025 resident providers had received restraint training, but other providers had not received restraint training. MD #2 was not available for interview.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) [the patient must be seen face-to-face within 1 hour after the initiation of the intervention -- ] §482.13(e)(12)(ii)To evaluate - 1. The patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. This Standard is not met as evidenced by: 50111 Based on review of facility policy, medical records and staff interviews, the facility failed to ensure a face-to-face assessment was completed within one hour of initiation of violent restraints for 2 of 3 medical records reviewed for patients placed in violent restraints (Patient #2, Patient #11). The findings include: Review on 07/08/2025 of facility policy “Restraint and Seclusion Use,” effective 03/2023, revealed, “... Restraints for Violent Behavior Restraints are used for patients whose behavior is violent or self-destructive when restraint is necessary to ensure the immediate physical safety of the patient, a staff member, or others ... Restraints for Patients With Violent Behavior ... i. A physician or other licensed practitioner ... must evaluate the patient face-to-face and in person within one hour of the initiation of restraint/seclusion (even if the patient is no longer in restraint/seclusion) and document the findings, including the following information: 1. the patient’s immediate situation; 2. the patient’s reaction to the intervention; 3. the patient’s medical and behavioral condition; and 4. the need to continue or terminate the restraint or seclusion ...” 1. Open medical record review on 07/01/2025 for Patient #2 (Pt) revealed an adolescent patient that was admitted to Facility A, Unit A on 04/12/2025 at 0825 with a diagnosis of altered mental status. Record review revealed violent behavior restraints were applied as follows: on 04/23/2025 from 0045 until 0200; on 04/23/2025 from 1430 until 1715; and on 04/25/2025 from 2120 until 2330. Record review failed to reveal a face-to-face assessment within one hour of initiation for each of the three violent behavior restraint applications listed above. Violent behavior restraints were applied on 04/26/2025 at 1600. Pt #2 remained in 4-point restraints (restraints applied to all 4 extremities) until 04/30/2025 at 2145. Record review failed to reveal a face-to-face assessment within one hour of initiation of the violent behavior restraint application. Pt #2 was placed in 4-point restraints after exhibiting violent behavior on 05/01/2025 at 1230. Record review revealed face-to-face assessment notes on 05/03/2025 at 1000 (2 days after the initiation of restraints), on 05/04/2025 at 1100, and on 05/05/2025 at 1342. Pt #2 remained in 4-point restraints until 05/09/2025 at 1400. Violent behavior restraints were applied on 05/13/2025 at 1945. Pt #2 remained in 4-point restraints until 05/15/2025 0645. Record review failed to reveal a face-to-face assessment within one hour of initiation of the violent restraint application. Pt #2 was transferred to Facility B on 05/16/2025 at 1521. Pt #2 was a current admission at Facility B during record review. Interview on 07/08/2025 at 0940 with Director #4 revealed all a face-to-face assessments were supposed to be completed within one hour of violent restraint initiation. Interview revealed there were no notes in the patient’s record to indicate that face-to-face assessments were completed within an hour of initiation for each of the violent restraint applications. Interview on 07/07/2025 at 1105 with Medical Doctor #1 (MD) revealed a face-to-face assessment should be completed within one hour of ordering restraints for violent behavior. MD #1 did not recall a face-to-face note being completed for Pt #2 after MD #1 ordered violent restraints. Interview on 07/03/2025 at 1336 with Registered Nurse (RN) Specialist #5 and RN Educator #6 revealed a face-to-face assessment should be conducted by the provider within one hour of initiation of restraints for violent behavior. Interview revealed the face-to-face assessment must include the required elements listed in the restraint policy. MD #7, a provider that cared for Pt #2, was not available for interview. 2. Closed medical record review on 07/08/2025 for Patient #11 (Pt) revealed an adolescent patient that was admitted to Facility A, Unit A on 06/09/2025 at 0338 with a diagnosis substance induced mood disorder. Review of the restraint record revealed Pt #11 was placed in restraints following violent behavior on 06/10/2025 at 1600. Record review failed to reveal a face-to-face assessment within one hour of initiation of violent restraints. Pt #11 was transferred to Unit B at 1629. Review of the nursing note at 1856 revealed, “... (Pt #11) arrived on the unit in 4 point restraints (restraints applied to all 4 extremities) ...” Record review failed to reveal documentation of when the restraints were discontinued. Pt #11 received further care and was discharged on 06/18/2025 at 1330. Interview on 07/08/2025 at 1526 with RN #9 revealed restraints were removed immediately upon arrival to Unit B on 06/10/2025 at 1629 but RN #9 forgot to document the discontinuation of restraints in the medical record. Interview on 07/08/2025 at 1640 with Director #8 revealed there was no documentation that a face-to-face assessment was completed within one hour of initiation of violent restraints on 06/10/2025 at 1600. Interview on 07/07/2025 at 1105 with Medical Doctor #1 (MD) revealed a face-to-face assessment should be completed within one hour of ordering restraints for violent behavior. Interview on 07/03/2025 at 1336 with Registered Nurse (RN) Specialist #5 and RN Educator #6 revealed a face-to-face assessment should be conducted by the provider within one hour of initiation of restraints for violent behavior. Interview revealed the face-to-face assessment must include the required elements listed in the restraint policy. NC00230323; NC00231720; NC00231842; NC00228832; NC00230419”

“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: 33790 Based on policy review, medical record reviews and staff interviews, the hospital staff failed to assess, reassess and manage pain for 5 of 14 patients reviewed for pain. (Pts #6, #10, #54, #58, #59) The findings included: Review on 02/24/2025 of the policy “Pain Management” last approved 10/2023 revealed “...Description. A. Describes expectations for assessment, treatment and reassessment of pain. B. Policy 1. Pain Assessment and Goals. a. ii. ... a Patient roomed in the emergency department (ED). Pain is assessed: A. At least once per encounter. (clinic or ED visit). iii. All care areas, Patients roomed in the ED. A. First report of pain. B. At any new report of pain, not previously addressed. (a new pain type, a new pain location). Also consider any family member reports of pain and/or behavioral manifestations consistent with pain. C. Immediately prior to administration of a PRN (as needed) pharmacologic or non-pharmacologic intervention to reduce pain. D. Within 5 to 60 minutes after administration of a PRN pharmacologic or non-pharmacologic intervention to reduce pain. ...E. Pain assessments and reassessments are documented in the electronic medical record...” Closed medical record review, on 02/24/2025, revealed Patient (Pt) #6, an 86-year-old, arrived to the Emergency Department (ED) on 04/30/2024 at 1652 following a fall that occurred when the patient stood from the office chair and her “feet got caught in the wheels”. Pt #6 sustained a right humeral shaft fracture (a break in a bone in the right upper arm). Pt #6 was placed in a coaptation splint (U shaped splint to immobilize the arm). Review of the pain evaluations revealed the last pain evaluation on 04/30/2024 was noted at 2130. Review revealed an order for Oxycodone (oral pain medicine for moderate to severe pain) 5 mg (milligrams) orally “once” on 05/01/2024 at 0330. The Medication Administration Record (MAR) revealed the medicine was given at 0334. Record review did not reveal a pain assessment or reassessment related to the oxycodone given. Record review revealed the next notation of a pain score was noted in Physical Therapy (PT) and Occupational Therapy (OT) evaluations, date and time of service 05/01/2024 at 0939 (6 hours after pain medication administration). The PT note indicated Pt #6 “...Endorsed 10/10 RUE (pain score 10 on a scale of 1 to 10 [where 10 is worst pain] right upper extremity) pain initially, improved to 7/10 following mobility.” An OT note, date/time of service also 05/01/2024 at 0939, revealed “...Pain....reports 10/10 RUE,” Review of the MAR revealed an order for Morphine (pain medication for moderate to severe pain) 4 mg (milligrams) IV “once” at 1049 and administered at 1110. No pain reassessment was noted. Review revealed an order on 05/01/2024 at 1742 for Oxycodone (oral pain medicine that treats moderate to severe pain) immediate release tablet 2.5 mg every six (6) hours prn (as needed) for three (3) occurrences . Review revealed 2.5 mg was given on 05/01/2024 at 2120, and on 05/02/2024 at 0419 and 1007. Review of pain assessments failed to find any assessments or reassessments of pain associated with the three oxycodone 2.5 mg doses given. MAR review revealed an order for Oxycodone 2.5 mg every 4 hours prn on 05/02/2024 at 1432 with a dose documented as given at 1521. No pain assessment or reassessment was noted until 2022 (almost six hours later) when the pain score was recorded as six (6). Interview on 02/28/2025 at 1140 with the ED Director and Nurse Manager revealed medical providers assessed patients and wrote pain orders and then the nurses gave the medications. Interview revealed one time orders and scheduled pain medications did not require pain reassessment according to policy. The Director stated staff were trying to follow policy and do what they thought was right, and further indicated, “I think this is an opportunity for us.” 39307 2. Closed medical record review on 02/18/2025 revealed Patient #10 presented to the ED on 10/10/2023 at 2011 with a chief complaint of acute back pain. Review revealed the patient had history of chronic back pain with an implanted spinal cord stimulator that was currently off. Record review revealed on 10/10/2023 at 2106 Patient #10 had a documented pain score of 9 (scoring used to describe intensity of pain whereby 10 is the most pain) and at 2122 an order for Dilaudid (medication used to treat pain) injection 0.5mg (milligrams, a unit of measure) once was ordered and at 2137 administration by RN #16. Review failed to reveal a reassessment pain score within 60 minutes of administration of pain medication. Review revealed on 10/11/2023 at 0206 through 10/12/2023 at 2125 an order was entered for Flexeril 10 mg tablet 3 times a day PRN (as needed) for muscle spasms. At 1100 the patient reported a pain score of 10 and Flexeril 10mg tablet was administered as ordered PRN. At 1113 Dilaudid injection 2mg once was ordered and at 1126 administration. Review failed to reveal a reassessment pain score within 60 minutes of administration of the pain medication. At 1400 the documented patient pain score was 0. At 1510 Dilaudid injection 2mg once was ordered and at 1555 administration. Review failed to reveal a reassessment pain score within 60 minutes of administration of pain medication. At 2028 the patient had a pain score was 6 out of 10. At 2103 Toradal (medication used to treat pain) 15mg injection was ordered and at 2115 administration. Review failed to reveal a documented reassessment pain score after Toradal administration. Review revealed the nursing staff failed to document completion of a pain reassessment after 4 medication administrations while the patient was in the emergency department. Interview on 02/26/2025 at 1100 with an ED RN revealed it was the expectation of nursing staff to document reassessment of pain within 60 minutes after the administration of a pain medication. Interview on 02/26/2025 at 1330 with the ED RN Director revealed it was the expectation of nursing staff to document reassessment of pain within 60 minutes after the administration of a pain medication. 41946 3. A closed medical record review on 02/25/2025 revealed Patient #54, a 76-year-old female who presented to Hospital A emergency department (ED) by private vehicle on 12/04/2024 at 1909 for complaints of chest pain. The Triage Note at 1910 by Registered Nurse (RN) #1 revealed “Seen here previously for similar. 7/10 chest pain (0 is no pain, 10 is the most severe pain) that began 1 hour PTA (prior to arrival). No previous heart hx (history).” An ESI (emergency severity index 3-urgent) was set to 3. Patient #54 returned to the ED waiting room. Review of the ED Patient Care Timeline at 2312 by RN #3 revealed “...No change in chief complaint and ESI.” There was no pain reassessment documented (4 hours and 2 minutes). On 12/5/2024 at 0239 Patient #54 had reassessment by RN #3, “ ... Reassessed: No change in chief complaint and ESI.) There was no pain reassessment documented. (6 hours and 29 minutes) At 0452 Patient #54 was transferred from the ED waiting room to an ED room. (8 hrs. and 43 min after arrival with no pain reassessment). At 0524 the MSE was completed by ED Resident MD #5. At 0553 ED RN #4 documented “Cardiac: Exceptions to WDL [within defined limits] (chest pressure). At 0647 ED Disposition was set to discharge by ED MD #5. Patient #54 had vital signs taken at 0700 by ED RN #6. No pain reassessment documented. 0725 Review of ED Quick Updates by RN #6 revealed “Pt. (patient) refusing to discharge until provider talks with her again.” Record review revealed Patient #54 was discharged home on 12/05/2024 at 0729. The medical record review failed to reveal a pain reassessment from 12/04/2024 at 1910 through 12/05/2024 at 0725. (12 hours and 25 minutes). Request to interview ED Discharge RN #6 revealed they were unavailable to interview. Request to interview ED MD #5 revealed they were unavailable for interview. Request to interview ED RN #3 revealed they were unavailable for interview. Interview on 02/28/2025 at 1045 with the ED Director revealed “...I would have expected the nurse to document a pain level once the patient was roomed. Pain assessments should be completed with any intervention for pain. We see opportunities and plan to relook at the policy...” The interview revealed Patient #54 should have had a pain reassessment while in the ED. 4. A open medical review on 02/26/2025 revealed Patient #58, an 81-year-old male who presented to Hospital A emergency department (ED) on 02/24/2025 at 1648 with complaints of chest pain. The Triage Note at 1649 “Chest pain and shortness of breath. Afebrile. Atraumatic”, with a pain assessment of 0/10 [0 is no pain, and 10 the most severe pain]. On 02/24/2025 at 1704 the ED Nurse Note revealed “Pt reports chest pain and SOB for last several days. ‘For three days, ended up taking 3 doses of nitrogen.” [sic] Helps with chest pain. Today chest pain started at 1430, but pain has resolved now. Reports feeling indigestion.” An ESI 3 [urgent] was assigned, and Patient #58 was returned to the ED waiting room. On 02/24/2025 at 2113 Patient #58 was roomed in the ED. Review of nursing documentation at 2230 by RN #7 failed to reveal a pain reassessment. (5 hours and 26 minutes). On 02/25/2025 at 0557 the ED Disposition was set to admit. The medical record review failed to reveal a pain reassessment was completed 02/25/2025 1704 through 02/26/2025 at 0700 for Patient #58. (13 hours and 54 minutes). Patient #58 was admitted to an inpatient bed on 02/26/2025 at 1129. Request to interview the ED RN #7 revealed they were unavailable for interview. Interview on 02/28/2025 at 1045 with the ED Director revealed “...I would have expected the nurse to document a pain level once the patient was roomed. Pain assessments should be completed with any intervention for pain. We see opportunities and plan to relook at the policy...” The interview revealed Patient #58 should have had a pain assessment every shift by the RN. 5. A closed medical record review on 02/26/2025 revealed Patient #59, a 65-year-old male who presented to the emergency department (ED) on 02/24/2025 at 1815 via emergency medical services (EMS) with complaints of chest pain. Review of the Triage Note at 1821 by RN #19 revealed “Around 1730 severe chest pain, dizziness (doesn’t feel like normal vertigo), with nausea. Pain still 10/10 (0 no pain, and 10 most severe pain). No emesis with EMS. ... Given 50 Fentanyl (an opioid medication used for pain) ...” At 1824 an ESI acuity of 3 [urgent] was assigned by the RN #24. At 1832, ED Quick Updates by RN #18 revealed “50 mcg (micrograms) of fentanyl (given IM (intramuscular) by EMS for total of 100 mcg given by EMS.” At 1956 review of the ED Care Timeline revealed “ED Disposition set to LWBS [left without being seen] after triage.” Review revealed on 02/24/2025 at 2315, (3 hours and 19 minutes later) Patient #59 had vital signs documented, and at 2324 ED RN #8 documented “ED Triage Reassess, No change in chief complaint and ESI.” (no pain assessment documented on return to the ED) On 02/24/2025 at 2341 Patient #59 was roomed. At 0023 RN #20 completed a pain assessment of 4/10. Further review failed to reveal a pain reassessment was completed for Patient #59 02/25/2025 0024 through 02/25/2025 0724 (7 hours). Patient #59 was discharged home 02/25/2025 at 1627. Request to interview ED RN #8 revealed they were unavailable for interview. Request to interview ED RN #20 revealed they were unavailable for interview. Interview on 02/28/2025 at 1045 with the ED Director revealed “..There should have been pain reassessed. We should have offered a pain intervention. ...We see opportunities and plan to relook at the policy...” The interview revealed an expectation for the nurse to complete a follow-up pain assessment for Patient #59’s report of pain was not completed.”

“DIETS CFR(s): 482.28(b)(2) All patient diets, including therapeutic diets, must be ordered by a practitioner responsible for the care of the patient, or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff and in accordance with State law governing dietitians and nutrition professionals. This Standard is not met as evidenced by: 33790 Based on policy review, medical record review and interview, hospital staff failed to provide lactose free food to 1 of 1 patients reviewed with a lactose intolerance. (Pt #6) The findings included: Review of a policy titled “Patient Diet Orders, Meal Orders, and Meal Frequency,” effective 07/2021, revealed “...The Nutrition and Food Services.... Department will prepare and deliver meals to patients in accordance with the diet order....Diet orders indicate the type of food....to be provided to patients during hospitalization....Diet orders....are entered into the Electronic Medical Record (EPIC) by a provider....The patient’s diet order interfaces from (name of the Electronic Medical Record system) to the computerized meal ordering system.... Dietary restrictions, allergens, and nutrients are built into (name of computerized meal ordering system) to ensure patients receive appropriate foods in accordance with their therapeutic diet. ...” Review of the policy did not reveal specific information about food intolerances or patients in the emergency department. Medical record review, on 02/24/2025, revealed a physician order, dated 05/01/2024 at 1740, which noted “Nutrition Therapy Regular/House” diet along with “...Comments Lactose intolerant!” Review of an “ED Progress Note,” date of service 05/02/2024 at 1021, revealed “...Pt has been eating well in general prior to hospitalization, but reports she doesn’t like the food. She reports she was served a meal ‘finally and it had cheese on it and I’m lactose intolerant.’” Record review revealed the previous diet order was discontinued and a new order was entered for “Nutrition Therapy Regular/Lactose Restricted” on 05/02/2024 at 1035. Interview with Dietician #21, on 02/25/2025 at 1130 revealed the first nutrition order was an incorrect order. For a lactose intolerant diet, Dietician #21 indicated, the order should specify lactose free/ lactose restricted rather than be noted as a comment under a regular diet order. Interview revealed allergies and specific diet orders crossed over from the hospital electronic medical record system (EMR) to the computerized meal ordering system used by the Food and Nutrition Department to fill diet orders. Interview revealed any notes made in the “comments” section of the order did not cross over from the hospital EMR to the meal ordering system and would not be seen by dietary when filling nutrition orders. Telephone interview on 02/27/2025 at 1500 with MD #22, a Resident who placed the first diet order revealed MD #22 had never been notified that using “comments” to indicate lactose intolerance was not an appropriate way to order for it. MD #23, a physician on the interview call, revealed the thought that “most of us would have done the same thing.” NC00226177, NC00225689, NC00225279, NC00224508, NC00222219, NC00221524, NC00221333, NC00218427, NC00217931, NC00216089, NC00216032, NC00214019, NC00213789, NC00213522, NC00212156, NC00211688, NC00211164, NC00211159, NC00210850”