UNC Health Nash

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 47421 Based on review of hospital policy, medical record reviews, and staff interviews, the facility staff failed to follow hospital policy by failing to ensure the correct level of observation was in place for a suicidal risk patient for 3 of 3 medical records reviewed. (Pt #22, 23, 3) The findings include: Review of hospital policy titled “Screening for Suicide Risk,” last revised 02/2023 revealed “ ...Procedure: A ... 3. If a patient answers “yes” to one or more of the first 4 questions, only then is the patient asked question 5 ... (5. Are you having thoughts of killing yourself right now?) 4. The outcome of the ASQ (Ask Suicide-Screening Questions- a 5-question suicide risk screening tool to determine the level of risk and appropriate management) screening tool determines the next steps ... B ... 1. There are 3 possible outcomes after the administration of the ASQ ... a. Negative screen (No intervention is Necessary) ...b. Potential Risk: patient answers “yes” to one or more of the questions 1 through 4, but “no” to question 5 ... Patient requires a BSA (brief suicide safety assessment) to determine appropriate clinical follow-up ... until the BSA is completed the patient will be placed on every 15 minute checks (observed at prescribed intervals by staff in person or via video monitoring [remote]). c. Imminent Risk: patient answers “yes” to one or more of questions 1 through 4, AND “yes” to question 5 (imminent risk identified)- Suicide precautions implemented to include 1:1 (consist of one-to-one staff observation of a patient) observation ...” 1. Open medical record review for Patient #22 revealed a 33-year-old male patient that presented to the Emergency Department on 06/07/2026 at 0312 for suicidal ideation. At 0330 a remote video sitter completed the first q15 minute rounds. At 0337 the ASQ revealed the patient was identified as an acute positive screen (imminent risk). At 0400 a remote video sitter was requested (already in place). Record review failed to reveal 1:1 observation was put in place for an imminent risk patient per the facility policy. Interview on 06/11/2026 at 1440 with SW Manager #1 revealed that when a patient screened as an imminent risk for suicide, the patient should have 1:1 monitoring based on the ASQ. Interview on 06/11/2026 at 1700 with ED Director #2 revealed that Patient #22 should have had 1:1 monitoring based on the ASQ score. Interview revealed that the patient was not assigned the correct level of observation per hospital policy. Interview revealed that reeducation was provided to staff in 12/2025 related to ASQ and 1:1 level of observation for identified imminent risk patients. 2. Open medical record review for Patient #23 revealed a 62-year-old male patient that presented to the Emergency Department on 06/09/2026 at 0128 for suicidal ideation, homicidal ideation and ETOH (alcohol consumption). At 0200 a remote video sitter was requested. At 0200 a remote video sitter completed the first q15 minute rounds. At 0230 the ASQ revealed the patient was identified as an acute positive screen (imminent risk). Record review failed to reveal 1:1 observation was put in place for an imminent risk patient per the facility policy. Interview on 06/11/2026 at 1440 with SW Manager #1 revealed that when a patient screened as an imminent risk for suicide, the patient should have 1:1 monitoring based on the ASQ. Interview on 06/11/2026 at 1700 with ED Director #2 revealed that Patient #23 should have had 1:1 monitoring based on the ASQ score. Interview revealed that the patient was not assigned the correct level of observation per hospital policy. Interview revealed that reeducation was provided to staff in 12/2025 related to ASQ and 1:1 level of observation for identified imminent risk patients. 3. Closed medical record review for Patient #3 revealed a 49-year-old male patient that presented to the Emergency Department on 11/20/2025 at 1522 for alcohol intoxication and psychiatric evaluation. At 1525 the ASQ revealed the patient was identified as an imminent risk. At 1600 a remote video sitter was requested. At 1615 the remote video sitter completed the first q15 minute rounds. Record review failed to reveal 1:1 observation was put in place for an imminent risk patient per the facility policy. Interview on 06/11/2026 at 0945 with ED Director #2 revealed that Patient #3 should have had 1:1 monitoring based on the ASQ score. Interview revealed that the patient was not assigned the correct level of observation per hospital policy. Interview revealed that reeducation was provided to staff in 12/2025 related to ASQ and 1:1 level of observation for identified imminent risk patients. Interview on 06/11/2026 at 1440 with SW Manager #1 revealed that Patient #3 was an imminent risk for suicide and the patient should have had 1:1 monitoring based on the ASQ. NC00234817, 235486, 237772, 224922, 237383, 227654, 230774, and 235595.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 50318 Based on policy reviews, medical record review, incident report reviews, staff meeting review, facility meeting, and staff interviews, the facility failed to investigate a patient’s repeated elopement attempts for 1 of 1 behavioral health patients with attempted elopements (Patient #1). The findings include: Review of hospital policy “Elopement - PC 210.106,” effective 06/2022, revealed, “Definitions: A. Elopement - Occurs when a patient departs from a care area without the knowledge/permission of the patient care team. A fully cognizant and competent patient may elope, or elopement may be related to a patient’s underlying medical or behavioral health condition, e.g. dementia, delirium, psychosis, etc. ... “ Review of hospital policy “Plan for Quality and Patient Safety,” effective 10/2021, revealed, “ ... Meaningful performance improvement activities and action plans are dependent on the collection, analysis, and reporting of clinical quality and patient safety indicators... There is a need to proactively address potential quality and patient safety risks in addition to reacting to quality and patient safety events in a retrospective manner... “ Closed medical record review on 10/16/2024 revealed a 22 year old patient (Patient #1) presented to the ED (Emergency Department) on 08/15/2024 at 2120 for worsening psychosis and had been off medications for approximately 19 months. The patient was roomed in the locked behavioral health (BH) area of the ED at 2151. MD#11 initiated IVC (involuntary commitment) paperwork at 2200, as the patient experienced delusional and psychotic behaviors, had illogical thought, and could not contract for safety; the patient was deemed to be a threat/danger to self. A security alert was called at 2354 to the BH area of the ED as the patient was throwing chairs and trying to get out of the locked unit. BH Consult was conducted on 08/16/2024 at 0006, which recommended inpatient psychiatric care. Psychiatric Consult was conducted on 08/16/2024 at 0903 and revealed, IVC status was maintained with concerns for acute psychosis and differential diagnosis of schizophrenia. The patient was accepted to Campus B and was transferred at 1530. Behavioral Response Significant Event Note revealed, at 1643, the patient was standing at the doorway trying to open the door. RN #4 approached the patient to redirect the patient away from the door when the patient lunged at RN #4, grabbed and pulled RN#4’s hair, then tried to put RN#4 in a chokehold. RN#4 blocked the patient when Patient #8 jumped on Patient #1 and punched Patient #1 in the head multiple times. Security alert was called, staff separated the patients, and Patient #1 received IM (Intramuscular) medications for agitation and aggression. A CT scan (computed tomography scan, specialized x-ray to produce cross-sectional images) of the patient’s head was performed at 1955, which was negative. On 08/17/2024 at approximately 2350, the patient was checking the doors to elope and climbed the door on the female side of the unit. The patient had to be redirected several times and was given oral medications for agitation. SW (Social Worker) Note on 08/18/2024 at 1604 revealed, the SW was bringing patients back from the group session, and Patient #1 came from the dayroom towards the unit door. The patient grabbed the door and wrapped their fingers around it to keep it from closing. The SW redirected the patient to let go of the door and return to the dayroom. On 08/20/2024 at 1615, the patient followed a staff member off the unit without the staff member noticing. Staff and security immediately went after the patient, who was stopped by the West unit door; the patient was escorted back to the East unit. At 1655, the patient was moved to the West unit. SW Note on 08/21/2024 at 1613 revealed, SW met the patient at the entrance to the West unit and made repeated requests for the patient to move back from the door. SW then demanded in a forceful tone for the patient to move away from the door, and the patient retreated to the unit. The patient was observed at the end of the hall at the exit door. Nurse’s Note at 1727 revealed, the patient was agitated, restless, and paced around the door. The patient climbed through the door to the unit that was closed off. Security was called, and the patient came back to the unit without assistance. Nurse’s Note on 08/24/2024 at 0449 revealed, the patient was seen pacing at the beginning of the night shift, stood at the unit doors, and required much redirection from the staff. Patient #1 was discharged home on 08/28/2024. Record review revealed the patient did not have an order for elopement precautions and level of observation was maintained at Q15 (every 15) minute checks throughout the patient’s hospitalization. Incident Report review on 10/17/2024 revealed on 08/15/2024 at 2354, (named security officers) responded to a security alert in the ED locked BH area regarding Patient #1, who had thrown chairs, thrown water on the floor, and locked themselves in the restroom. Upon security’s arrival, the clinical staff had redirected the patient back to the assigned room without further incident. Incident Reports review on 10/17/2024 revealed on 08/16/24 at 1642, RN #4 approached the patient who was trying to get out of the door when the patient lunged at RN #4, grabbed and pulled RN #4’s hair, and attempted a chokehold. Another patient (Patient #8) jumped on Patient #1, repeatedly punched Patient #1 in the head. Security alert was called, staff intervened to separate and de-escalate the situation, and Patient #1 was medicated. Three incident reports were created for this event - one event type was listed as a disorderly person (patient) event; one was listed as a workplace violence event as a patient to staff physical assault; and the third was listed as a disruptive/intimidating behavior event (patient to patient). Incident Reports review on 10/17/2024 revealed on 08/20/2024 at 1615, the patient followed a staff member off the unit without the staff member noticing. Staff and security immediately went after the patient, and a code elopement was called. The patient was stopped in the hall by the west unit door and was escorted back to the east unit with security and staff. Additional information in the second incident report created by security revealed, the patient pushed past the staff member, who was escorting a Provider off the unit, and attempted to open all the doors while running. The patient made it to the west unit, but the attempt to run was ended as the patient could not enter the unit. Security and another staff member escorted the patient back to the east unit. All doors in the hallway were secured and checked. Both incident reports were classified as an elopement event type. Review on 10/18/2024 of Campus B Staff Meeting PowerPoint on 08/29/2024 revealed departmental updates related to staff safety, such as security notification and use of staff duress badges. Review revealed no documentation on departmental updates related to elopement. Review on 10/18/2024 of additional information related to Campus B Staff Meeting revealed Dir #2 scheduled the staff meeting in response to workplace violent events and attempted elopement events. The meeting emphasized employee safety, interventions in place for safety such as duress badges and situational awareness, which included monitoring doors and their surroundings. Fifty-five of sixty-seven employees attended the staff meeting sessions (82% compliance rate). Compliance rate was expected to be 100% by November 1, 2024. Review on 10/18/2024 of an education attestation created by ANM#1 revealed an education discussion between Secretary #12 and ANM#1 had occurred on 08/21/2024 regarding the importance of monitoring doors upon entrance to a unit and ensuring doors were closed when entering/exiting a unit. Situational awareness and utilizing clinical staff instead of entering a unit when patients were identified as a risk of elopement was also discussed. Interview on 10/17/2024 at 1350 with ANM#1 and Dir#2 revealed no incident reports were created when the patient climbed on the door on 08/17/2024 and when the patient went through the door to the closed off part of the unit on 08/21/2024. ANM#1 and Dir#2 would not expect to see incident reports for these as there were no injuries and were psychosis-related behaviors; the nurse’s notes would be sufficient. Telephone Interview on 10/18/2024 at 1011 with NP#10 revealed the patient’s level of observation was not changed as there was concern over aggression towards the staff if the patient was on a 1:1 observation and concern that the patient would feel like they were being followed if the observation was changed to line of sight. NP#10 revealed for elopement precautions, the staff would monitor the doors, ensure the doors closed behind the staff, with a heightened situational awareness among the staff. NP#10 emphasized communication between the staff and Providers when patients were a high risk for elopement. Interview on 10/18/2024 at 1045 with ANM#1 revealed for Patient #1, there was not an order for Elopement Precautions/Risk. Meeting with Dir#2 and RN#9 related to Patient #1’s attempted elopements and the facility’s response was held on 10/18/2024 at 1330. BH staff meeting was held on 08/29/2024, which was focused on staff safety, with additional verbal information related to elopement. There was not a separate/specific discussion related to elopement. Elopement precaution signs were updated in red and were always in place on the unit doors. Elopement Precautions would not change a lot with the patient’s care unless the Provider changed the level of observation to 1:1. Patient #1 was moved to a smaller unit to keep a closer eye on the patient, and they did not think the patient needed 1:1 observation as there was concern of further agitation to the patient and safety risk to the staff. They could not recall if the patient’s aggression in the ED was specifically mentioned prior to transfer to Campus B, but the ED RN did give report. Overall, the patient’s elopement attempts were not reviewed or escalated for Quality as there was no patient or staff injury, and when the patient left the unit, it was not considered a true elopement as the patient did not leave care or leave the building itself. NC00220961”

“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 hospital policy review, medical record review and staff interview the hospital staff failed to complete a face-to-face assessment within 1 hour after the initiation of violent/self-destructive physical restraint in 1 of 2 (Patient #18) violent/self-destructive restraint patient records reviewed. Findings include: Review on 01/31/2024 of the hospital policy “Restraints and Seclusion: Security Alert/Violent/Self-Destructive Behavior - PC 210.43” last revised 04/2023, states “ ... F. Initiation of Violent/Self-Destructive Behavior Restraints, Medication Restraints or Seclusion: ... 5. When Violent/Self-Destructive restraints, Medication restraints or Seclusion are initiated, the MD, other LIP, or QRN must see and evaluate the need for restraint or seclusion within one (1) hour after the initiation of the restraint intervention (which includes therapeutic holds and seclusion). ...” Closed medical record review of Patient #18 (Pt#18) revealed an 11 year old male patient that presented to the Emergency Department, with police, on 12/14/2023 at 1543 with agitation and suicidal ideation for involuntary commitment evaluation. The medical record review revealed a written Physician Order for “Restraints Violent or Self-Destructive Adolescent (Age 9 - 17),” dated 12/14/2023 at 1558. Medical record review revealed that restraints were applied on 12/14/2023 at 1600 and discontinued on 12/14/2023 at 1700. Review of the medical record revealed no documentation of a one (1) hour face-to-face assessment completed by a Medical Doctor (MD) that included the patient’s immediate situation, the patient’s reaction to the intervention, the patient’s medical and behavioral condition, and the need to continue or terminate the restraint. Interview on 02/01/24 with MD#1 revealed the physician did not recall Pt#18. MD#1 stated if there was no documentation in the medical record of a 1 hour face-to-face assessment for Pt#18, that he could not confirm that one was completed. Interview revealed MD#1 would have seen a juvenile patient brought into the ED by police, with violent restraints, but could not say a face-to-face was completed that included all required components. Interview confirmed hospital policy was not followed for obtaining or documenting a 1 hour face-to-face assessment after initiation of a Violent/Self-Destructive Behavior restraint.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 50115 Based on review of hospital policies, medical record reviews, and staff interviews the hospital staff failed to turn and reposition a patient to prevent skin breakdown in 1 of 5 patients (Patient # 14) identified as being at risk for skin breakdown. Findings include: Review on 02/01/2024 of a Lippincott policy, “Pressure Injury Prevention,” revised 02/20/2023, revealed “...properly identifying whether a patient’s skin damage is caused by pressure or moisture is key to providing adequate treatment. Keep in mind that incontinent patients who can’t reposition themselves may have a condition that results from pressure and moisture...Turn and reposition the patient regularly and frequently unless contraindicated. Base the frequency of repositioning on the patient’s tissue tolerance, skin condition, mobility, medical condition, and treatment goals...” Medical record review revealed Patient #14 was a 69 year old female with a medical history of arthritis (joint inflammation), emphysema of lungs (gradual damage of lungs), hypertension (elevated blood pressure), neuropathy (nerve damage), and peripheral vascular disease (reduced blood flow to extremities) who was admitted to the hospital on 10/14/2023 “...after having an episode of bright red blood per rectum at home.” Review also revealed “Left lower extremity is ischemic with chronic left lower extremity wound extending to posterior lateral calf.” which ultimately required amputation on 11/03/2023. On 10/14/2023 at 0739, the admission nurse’s skin assessment revealed “very dry scaly, several large scabbed sores to left ankle, no drainage, no redness, and lower extremity weakness.” The admission assessment did not indicate any other wounds were present on admission. Flowsheet review revealed on 10/22/2023 at 0600 the patient’s level of assistance was documented as dependent. Flowsheet review revealed no evidence of repositioning of Patient #14 from 10/24/2023 at 0000 to 0800 (8 hours). Review of the flowsheet did not reveal repositioning from 10/24/2023 at 1600 to 10/27/2023 at 0920 (65 hours) with the exception of the words bed in chair and supine/back. Nurse’s note by LPN #2 on 10/27/2023 at 1924 Patient #14 revealed “...found with skin tear/shear on left buttock while assisting patient with bed pan this shift. Zinc cream applied and encouraged patient to reposition every 2 hours.” Further review of medical record revealed no evidence Patient #14 was repositioned from 11/01/2023 at 0800 to 11/1/2023 at 1820 (10 hours). Further medical record review revealed Patient #14 was not repositioned from 11/02/2023 1252 to 1820, 11/03/2023 at 0400 to 0811 (4 hours) and 11/03/2023 from 1240 to 11/04/2023 at 0600 (over 17 hours). Patient #14 was assessed by RN #3, wound care nurse, on 11/6/2023 at 1100, and noted “...groin area macerated and broken down in several areas. Sacrum, inner thighs has moisture associated skin damage. Review of the Discharge Summary on 11/7/2023 at 1529 revealed discharge diagnoses that included sacral pressure ulcer...” Interview with RN #4 on 02/01/2024 at 1150 revealed bed in chair to supine redistributes pressure, it is not considered a full turn and full turns are expected to be done on dependent patients. Interview with LPN #2 on 02/01/2024 at 1348 regarding the care of dependent patients. LPN #2 stated they should be turned every 2 hours when in bed. Interview revealed it was the responsibility of the nurse and nursing assistant to turn patients.”

“CONTENT OF RECORD: CONSULTATIVE RECORDS CFR(s): 482.24(c)(4)(iii) [All records must document the following, as appropriate:] Results of all consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient. This Standard is not met as evidenced by: 36956 Based on hospital medical staff rules and regulations, medical record review, staff interview and family interview the hospital staff failed to document consult results for 1 of 8 patients (Patient #24). Findings include: Review on 02/02/2024 of hospital “Medical Staff Rules and Regulations” last revised 12/2021 revealed “Article V. Consultant, Consultation, ...2. Consultations ....b. Requests when feasible. Consultations should be requested as needed by written order....The attending physician is responsible for initiating the request of consultation and is also responsible for providing adequate and timely information in the patient’s Hospital clinical record, or in person, sufficient for the consultant to carry out the consultation without delay in completing the consultation. All consultation requests should be initiated and documented by the consultant within 24 hours unless an alternative arrangement is agreed to by the attending physician. If not completed on the initial visit, it should be completed within 48 hours of the request....d. Required consultations. A consultation shall be requested and accomplished in the following cases: 1. When required by applicable statutes or regulations of the state or federal governments...” Review of an open medical record on 02/01/2024 for Patient #24 revealed a 58 year old female was transported to the ED (Emergency Department) via EMS on 1/22/2024 at 1519 with a chief complaint of G-Tube problem. ED Provider Note dated 01/22/2024 at 1534 revealed Patient #24 was bedbound and non-verbal. Review revealed Patient #24 had past medical history that included Chronic respiratory failure with hypoxia, CVA (Cardiovascular Accident - Stroke), Anoxic brain damage, breakthrough seizures, and Patient #24 was G-Tube and Tracheostomy dependent. Provider note at 2145 revealed “awaiting CT scan abdomen pelvis.” Review of the Provider note dated 01/23/2024 at 0444 noted “I assumed care of the patient from the previous ED provider ...at change of shift. The plan of care as discussed is pending CT A/P” and “Final Disposition: admit” Review of H&P (History and Physical) dated 01/23/2024 at 0502 revealed “Assessment/Plan:...Left femoral fracture (sic) Orthopedic surgery consultation placed (sic) X-ray femur, x-ray hip ordered” Review of the Provider Orders revealed an order for “Inpatient consult to Orthopedic Surgery (Order 1984186788) ordered at 0502. Review of the H&P note revealed the Radiologist documented “3. Comminuted and displaced fracture of the proximal left femur involving the intertrochanteric region possibly subacute as it is new since October 23, 2023. Please correlate clinically.” As of 02/01/2024 there was no documentation of the Orthopedic Surgery consult having been completed. An interview on 2/1/2024 at 1327 with Patient #24’s husband revealed the patient was admitted to the hospital on 1/22/2024 and at the time of the interview the patient’s husband was made aware on 2/1/2024 that Patient #24 had a broken femur by an unnamed RN. The unnamed RN told the husband the information regarding the broken femur had been in the computer since 1/24/2024. Patient #24’s husband was concerned the patient had a broken femur, husband had just become aware of the patient’s broken femur and no discussion regarding the broken femur plan of care. An interview on 2/2/2024 at 1307 with the ED Medical Director (EDMD) #6 revealed Patient #24’s femur fracture was identified incidentally on the CT Scan. The order showed “somehow the documentation was missed and came up as not released.” Interview revealed the EDMD #6 expected all consult orders to be followed up by the specific consultant. NC00209880, NC00203994, NC00202424, NC00199443, NC00198202”