The Nebraska Medical Center

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 04546 Standards cited below resulted in the Condition of Participation for Infection Prevention & Control to not be met: A0750 - IC Surveillance/Prevention A0751 - IC Scope & Complexity A0771 - Hospital Acquired Infections & QAPI & A0776 - IC Professional Adherence to Policies Based on observations, work order reviews, staff interviews and facility policy and document review, the facility performed 1397 surgeries per month in two Operating ROOM towers. The facility failed to provide adherence to best practices for Infection Prevention and Control including: - a safe environment with properly repaired and cleanable surfaces for Hixson-Lied Operating Room (OR), 1 (one) of 2 (two) facility Operating Rooms (A0750) - a Hospital wide monitoring of all Surgical Site Infections (SSI) for the Infection Prevention (IP) program at the facility. Facility included approved list of over 7500 types of surgeries, with only 12 types of surgeries reported and reviewed by the IP Team. (A0751) - criteria for surgeries with potential infection surveillance concerns as relates to facility Quality Data reporting to the Governing Body (A0771) - proper terminal cleaning of Operating Rooms, proper staff personal protective attire during sterile processing and to ensure correct water temperature monitoring for sterilization/cleaning of equipment. (A0776)”

“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: 52353 Based on staff interviews, review of quarterly quality improvement meeting minutes and quality improvement data, the facility failed to have comprehensive quality analysis on surgical site infections and within sterile processing department. The facility also failed to identify opportunities for improvement and set priorities for its quality performance improvement. This failed practice has the potential to cause harm to all patients of the facility. On day of entrance the facility census was 542. Findings are: A. Interview with Vice President of Quality Improvement-Infection Control (VPQI) (5/20/26 at 2:00 PM) revealed, the facility fails to collect data on all surgical site infections. The VPQI identified the facility collects site information on 12 different types of surgical site infections (SSI’s) - with two SSI’s being required to report to Centers for Medicare/Medicaid Services (CMS). When inquired regarding Quality graph data with 44 events of bone and/or tissue contamination issues with sterilization the VPQI stated that it was “44 shout out for safety (SOS) forms (event report) were completed, multiple staff could have filled out the form for the same incident” affecting the numbers. The facility is currently not collecting any data regarding sterilization contamination that was identified in slide show of information received with a time frame from January -June 2025 with 192 shout out for safety forms completed regarding contamination/sterilization issues identified. -Review of the immediate use steam sterilization (IUSS) use (method used to quickly sterilize medical equipment in urgent situations) data shows an increase of 1% in the past year. When inquired if it was being reviewed at a quality level, the VPQI stated “We were still under our goal, so why would we look at it?” -Review of policy titled Disinfections/Sterilization Template in Perioperative Services (last reviewed 8/24) revealed,....”Immediate use sterilization should occur only in unanticipated situations.” -The survey team requested the facility dashboard for the operating room and/or facility wide to review quality projects currently being completed. At the time of exit this information request had not been provided to survey team. B. Interview during tour with Sterile Processing Manager (5/20/26 at 2:00PM) included discussing department surgical instrument tray “tracer” audits. Steps include following random instrument trays from manual decontamination process to being wrapped and assembled. Audits are conducted by staff shift leads, sterilization processing associates or supervisors. Audit include checking for items such as bone fragments and positive chemical indicator change. The facility has ability to track the employee who performs instrument sterilization tasks to allow for 1:1 real time coaching in areas of concern. The Sterile Processing Department “usually do around 5 instrument tray audits weekly, and educator does 5-10 tray audits weekly.” -Review of document titled Sterilization/Disinfection/Contamination ...”Real time tray audits 2/2025.” reveals audits began 2/25 and are included along with other interventions related to (SOS) events within sterilization processing department. -Review of facility audit form for surgical tray audits reveals the following data collected: “Product Name; Product Index Number; Work Date Done; Scan Site facility Location;User Full Name;” -Interview with Sterile Processing Manager (5/21/26 at 9:20 AM) confirms “no” additional quality information is being captured in surgical instrument tray audits such as pass/fail rate of trays being inspected, 1:1 employee real time education, or tracking of areas of concern. Audits also lack documentation of educator involvement and any trends from data collected. -The survey team requested any additional quality data or projects related to sterile processing for review. At the time of exit this information request had not been provided to survey team.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 52353 Based on observation, policy and procedure review, and staff interviews, the facility failed to have a cleanable surface for operating room (OR) wood doors, inside OR door rubber seals, floors beneath OR scrub sinks, in OR sinks, hallway walls, ceiling tiles, and surgical mattress surfaces. The facility also failed to identify used medical beds in surgical bed storage area. This failed practice had the potential to cause harm to all patients who present to the facility for surgery. The average number of surgeries performed per month are 1,167. Findings are: A. Surgical tour (5/19/26 from 10:00AM-01:00PM) with RN Surgical Manager-A and RN Surgical Manager-B included the following observations of uncleanable surfaces: - OR entrance wood double doors revealed 10 out of 21 (1, 5, 8, 9, 10, 12, 14, 15, 16, and 21) doors with rough exposed splintered wood present. Clear tape is found in various areas on doors with rolled rough dark edges present. - OR entrance double doors revealed 18 of 21 (1, 5, 8, 9, 10, 12, 14, 16, and 21) with missing sections of rubber seal creating a jagged and rough surface. -OR scrub sink outside of OR 5 with laminated sign work order placed 2/11/26 with notation “do not use leaking.” -Eye washing station outside of OR 19 with hard water deposits and corrosion at point of contact for eyes and around faucet. -OR scrub sink outside of OR 17 with cracks on porcelain sink at lip and inside sink basin. -Ceiling tiles outside of OR 19 dislodged with dark gray exposed edge of tile visible. -20 of 20 scrub sink floor areas with white colored film spots, various hard water lines from under sink basin to floor and around foot control pedals, white and yellow discoloration around blue floor pedals used to dispense soap. Hard water film in various areas throughout. -Surgical hallways with various gouges creating exposed drywall, various drywall patches without paint, and various drywall dust collections where the bottom wall meets the floor tile or metal trim. - 2 of 2 Marquet Surgical Beds (used for surgery involving bone) with rough tears in mattress surface with exposed sponge mattress coming out through mattress cover. Cloth and clear tape rolled on various portions of mattress creating rough surfaces throughout the bed. - 2 of 2 Jackson Spine Surgical Beds (used for surgery involving spine) with rough tears in mattress surface with exposed sponge mattress coming out through mattress cover. Cloth and clear tape rolled on various portions of mattress creating rough surfaces throughout the bed. -1 of 4 patient medical beds in transport storage area with identifier laminated card “14” above bed on wall to indicate bed belonged to patient in OR room 14. The remaining 4 beds were within hallway with no identifier. 1 of 4 medical beds observed with used oxygen tubing, open ambo bag (used for breathing) on top of bed along with dried red substance on inside bed rail. -Orange tape in Core 2 (in between OR rooms) with gray colored tape edges, gray strip in middle of tape with fraying of product and stickiness on edges. B. Review of policy, titled Environmental Services Infection Control Policy (Last reviewed 01/22) revealed “Dust, soil and microbial contaminants in the environment ...a potential source of hospital acquired infections.” C. Interview with RN Surgical Manager-B (5/19/26 at 12:30 PM) confirms “yes” the above list contained uncleanable surfaces. States multiple work orders have been placed in Archibus workplace forum (facility on-line work order system) for items needing repair in surgical area, currently Surgical Manager-B keeps an excel spread sheet of outstanding work orders, current list is approximately 63. -Interview with Surgical Director (5/19/26 at 12:30 PM) states if work order item is observed as not repaired on monthly rounds with RN Surgical Managers, next process is to “write an email” to environmental services. Surgical Director states “I don’t know” next processes after email has been sent and items are not repaired. -Interview with Vice President of Environmental Services (5/20/26 at 10:00AM) states “We do track performance, and the OR maintenance data, we are at 98 percent completion rate in less than 24 hours, oldest ticket is 3 weeks old.” (5/20/26 7:32 PM) Vice President of Environmental Services provided the following data: -Total work order tickets submitted by OR from 1/1/26-current: 340 -Total outstanding: 27, of those outstanding less than 30 days old=19, greater than 30 days old=8 -Interview with RN Surgical Manger-B (5/19/26 at 12:30 PM) confirms “yes” only 1 of the 4 beds in the holding space has the appropriate OR room card identifier, stating “we place a card on the wall above the bed which corresponds to the OR number.” This identification allows corresponding bed to be pushed into OR to transfer pt out of surgery.”

“INFECTION CONTROL SCOPE COMPLEXITY CFR(s): The infection prevention and control program reflects the scope and complexity of the hospital services provided. This Standard is not met as evidenced by: 46123 Based on Infection Prevention Plan 2026 review, facility identified surgical site infections and interviews with staff. The facility fails to ensure all types of surgical site (SSI) infections are monitored. This failed practice has the potential to cause harm to all patients having surgery in this area of the facility. The facility conducts on average 1,167 surgeries per month in the Hickson Lied Operating rooms. Findings are: A. Review of the Infection Prevention Plan 2026 revealed, the goals and strategies include reducing SSIs with a focus on Total Hips and Knees (THK) and, Colon surgeries (COLOs). Continuing to partner with surgical quality and Information Technology (IT) to develop the SSI Dashboard. Continuing to partner with Surgical quality to identify SSI trends and themes for all specialties. B. Interview with Medical Doctor - E (MD-E) (5/21/26 at 9:40AM) revealed, currently the department does not have the human manpower or the ability to track all of the facilities SSIs. C. Review of the facility provided document listing patients identified with surgical site infections since January 1st, 2025 - April 1st, 2026 reveals that the facility is not tracking all surgical site infections only the 12 surgical types that were identified by the Vice President of Quality. Of the 10 medical records reviewed all with surgical site infections 5 of the medical records do not qualify in the facilities 12 surgical types that are tracked.”

“HOSP ACQUIRED INFECTIONS AND QAPI CFR(s): [The governing body must ensure all of the following:] (ii) All HAIs and other infectious diseases identified by the infection prevention and control program as well as antibiotic use issues identified by the antibiotic stewardship program are addressed in collaboration with hospital QAPI leadership. This Standard is not met as evidenced by: 04546 Based on record review, staff interview and surveillance report review, the facility failed to monitor all Surgical Site Infections (SSI) to ensure hospital wide Infection Prevention (IP) concerns could be addressed. The failed practice had the potential to affect all surgery patients. Facility provided monthly 1397 surgeries hospital wide. The facility monitored only 12 types of surgeries for SSI rates with failure to monitor all patient SSIs creating missed opportunities for compiling Quality Data for the Governing Body to ensure hospital wide IP concerns could be addressed. Facility patient census on entrance was 542. Findings are: A. Interview with Vice President of IP and Quality Assurance (5/20/2026 at 2:26pm) revealed “the facility tracks 12 SSI’s and we are only required to report 2 areas to CMS.” B. Surveillance report provided to surveyors that tracks procedure count, and number of infections, that are monitored by the facility IP team for SSIs - as evidenced by the following categories of surgeries listed: - Kidney Transplant, -Liver Transplant, - Colon surgeries for deep wound and organ space, -Colon Surgeries for All wound depths, - Hysterectomies deep wound and organ space -Hysterectomies All wound depths, -Cardiac Valve Replacement, -Cardiac Leg vein graft, - Cardiac chest vein graft, -Cardiac Pacemakers, -Breast Surgery, -Hip Prosthesis, -Knee Prosthesis. C. Interview with Medical Director/Board Certified Physician for the IP program (5/21/2026 at 9:22am) revealed “there are missed opportunities as we only track the 12 SSI’s currently as we do not have enough human capacity or technology assists to identify entire surgical case volume load; we look for trends to address issues for staff training - for practice driven gaps, we also look at commonalities and meet with Microbiology department if see an up tic (increase) and reach out to IP team, the surgical teams do their own internal reviews and we use Shout out for Safety (SOS - employee completed concerns) liberally and encourage employees to submit SOS’s and route those to IP team if concerns.””

“IC PROFESSIONAL ADHERENCE TO POLICIES CFR(s): [The infection preventionist(s)/infection control professional(s) is responsible for:] (v) The prevention and control of HAIs, including auditing of adherence to infection prevention and control policies and procedures by hospital personnel. This Standard is not met as evidenced by: 52353 Based on observation, policy and procedure review, and staff interviews, the facility failed to ensure used intravenous (IV) products were removed before terminal cleaning (meticulous disinfection) of OR room and to ensure employee personal protective equipment was in place during sterile processing. The facility also failed ensure accuracy of sterilization equipment water temperature readings. This failed practice had the potential to cause harm to all patients who present to the facility for surgery. The average number of surgeries performed per month are 1,167. Findings are: A. Observations during surgical tour (5/19/26 from 10:00AM-01:00PM) with RN Surgical Manager-A and RN Surgical Manager-B include the following: - Observation (5/19/26 at 10:20AM) Trauma Operating Room (Room 1) post terminal clean and available for patient use. 1000 milliliter (ml) IV bag of Normal Saline (used for hydration) spiked and hung with approximately 800 (ml) of fluid left in used IV bag. IV tubing threaded through fluid warmer. B. Review of policy titled Operating Room Surgical Invasive Areas and Delivery Rooms Terminal Cleaning at The End of the Day (Sedexo version 2/3/00) revealed, “Before beginning the terminal cleaning, confirm that all post-operative cleanups have been completed by the operating room staff .... Anesthesia equipment ...are cleaned by operating room staff.” C. Interview (5/19/26 at 10:20AM) with MD-C confirmed “yes” used IV bag is spiked and hanging with approximately 200 ml of fluid used out of bag with no label on tubing or on bag. States trauma and post anesthesia care unit (PACU) usually check OR rooms, if OR room opened anything like IV fluids “it would be thrown away.” MD-C states “this IV bag was probably used on last trauma on Sunday (5/17/26).” D. Observations during tour of Sterile Processing Department (5/19/26 from 2:00PM-3:00PM) with Sterile Processing Manager and Manager of Integrated Service Center included the following: - Observation (5/19/26 at 2:20PM) of Sterile Processing Associate-D inspecting instrument trays without beard guard in place. States had on “before lunch break.” E. Review of policy titled Sterile Processing Infection Control Policy (last reviewed 12/24) revealed, “ ...dress code for Sterile Processing Services ...a beard guard ...must be worn during inspection and packaging of trays.” F. Interview (5/19/26 at 2:20PM) with Sterile Processing Manager confirms “yes” beard guard is required of this employee. G. Observation (5/19/26 at 2:00PM) of Sterile Processing Associate-G performing first step in sterilization process with the manual decontamination of used surgical instruments. Water was run into processing sink to 5 gallon mark inside sink with temperature probe and detergent hose placed in sink which are connected to a Getinge CSD DoseTech device (delivers correct amount of detergent and monitors correct water temperature). The facilities sterile processing department has a total of 7 Getinge systems in use at manual decontamination sinks. If the Getinge system is working correctly the light on the screen is green. The light on the Getinge machine remained “red” during Sterile Processing Associate-G manual decontamination of instruments. Sterile Processing Associate-G confirmed the screen was “red not green but temperature reads in range at 96 degrees.” Getinge screen was observed with reading of 96 degrees (facility acceptable range posted above sink 77-113 degrees). H. Facility unable to produce entire copy of manufactures Instruction Manuel for Getinge CSD DoseTech. I-Interview (5/26/26 at 12:00PM) with Sterile Processing Manager confirmed “no” maintenance documentation on 7 of 7 Getinge CSD DoseTech currently in use for monitoring of correct water temperature and soap dispensing.”

“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: 48575 Based on protocol review, medical record review, and staff interview, the facility failed to ensure adequate supervision by nursing to notify the physician of a catheterized bladder volume over 1 liter per the urinary management protocol as ordered for 1 (Patient 3) out of 6 post operative sampled patients with a complication of a urinary tract infection (bacteria in the urine that required medicine to treat). This failed practice has the potential to cause negative outcomes for any patient who presents to the hospital for care. The facility census on entrance was 605. Findings include: A. Review of facility policy, urinary bladder management protocol, last revised 8/2025 revealed urinary retention (unable to empty the bladder) will be assessed and managed to prevent complications. Per provider order the nurse is to notify the physician if an intermittent straight catheterization (ISC - a tube goes into the bladder to drain urine and then removed) volume is greater than 1 liter (metric measurement). The nurse is to document all provider notifications in the medical record. B. Review of the electronic medical record (EMR) history and physical (H&P) from 11/20/2025, revealed Patient 3 was admitted for a planned cervical (spine) surgery. Patient 3’s past medical history included but was not limited to chronic progressive back pain for the past 2 years, with initial lumbar spine (lower back) surgery in 2006, Benign Prostatic Hyperplasia (BPH), traumatic brain injury (TBI) in 2019, and alcohol (ETOH) abuse in remission. -Review of the EMR nursing documentation from 11/20/2025 at 2:54pm, revealed Patient 3 was admitted to the inpatient floor from the post-operative recovery area. -Review of the EMR orders by Physician-A from 11/20/2025 at 3:00pm, revealed Patient 3 was ordered for nursing to start the urinary management protocol. -Review of the EMR H&P by Physician-B from 11/20/2025 at 6:28pm, revealed the plan for Patient 3’s history of BPH with post-operative urinary retention was to ISC as needed for a post-void residual (PVR - amount left in the bladder) over 300 milliliter (mL). -Review of the EMR nursing intake and output documentation from 11/20/2025 - 11/21/2025 revealed Patient 3 required intermittent straight catheterization (ISC - a tube is placed into the bladder to drain the urine and then removed) 5 times in 12 hours. -Review of the EMR nursing intake and output documentation from 11/21/2025 at 5:53am, Patient 3’s bladder volume index (BVI) scan (a beside ultrasound that shows the estimated urine in the bladder) was 1173mL, and the bladder was emptied via ISC for 1100mL. -Review of the EMR nursing intake and output documentation from 11/21/2025 at 4:20pm revealed Patient 3’s BVI was 940mL, and the bladder was emptied via ISC for 1025mL. -Review of the EMR nursing note documentation from 11/22/2025 at 2:35AM revealed Patient 3 refused ISC, education on risks of delaying the ISC was provided by nursing but lacked notification to the physician, confirmed by Registered Nurse (RN)-A on 4/7/2026 at 9:47am. -Review of the EMR nursing intake and output documentation from 11/24/2025 at 11:45am revealed Patient 3’s BVI was not checked, and the bladder was emptied via ISC for 1000mL. -Review of the EMR nursing to physician notification documentation from 11/24/2025 at 9:38pm revealed the nurse notified the physician of Patient 3’s temperature of 38.6 degrees Celsius (101.5 degrees Fahrenheit). -Review of the EMR physician progress note from 11/24/2025 at 10:02pm revealed the physician ordered labs (CBC, CMP - blood sample) and reviewed the urinalysis (UA) collected at 12:34pm [9 hours prior] that was positive for Escherichia coli (bacterial infection). -Review of the EMR CBC lab report from 11/23/2025 - 11/24/2025 revealed the white blood cell (WBC) count increased from 11.7 to 18.7. -Review of the EMR orders from 11/24/2025 at 10:04pm revealed the physician ordered Patient 3 an antibiotic intravenous (IV) Rocephin 2 grams every 24 hours for 7 days. C. Interview on 4/7/2026 at 9:47am with Registered Nurse (RN)-A confirmed that Patient 3’s EMR lacked evidence of the nurse notifying the physician of a bladder volume over 1 liter (1000mL) on 11/21/2025 at 5:53am, 4:20pm, and 11/24/2025 at 9:38pm per physician order on 11/20/2025.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 48575 Based on Emergency Medical Treatment and Transfer Policy (EMTALA) policy review, Medical Screening Exam (MSE) policy, medical record review, and medical staff interviews the facility failed to follow their policy for 3 (Patient 7, P9 & P14) of 20 sampled Emergency Department (ED) patients. This failed practice has the potential to cause negative outcomes for all patients who present to the ED seeking emergent care and treatment. According to facility provided data the ED saw an average of 5,467 patients per month for the past 6 months. See citation A2406 and A2407, that also resulted in A2400 to not be met.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 48575 Based on policy review, medical record review, medical staff interviews and administrative interviews the facility failed to ensure 2 (Patient 9 & P14) of 20 Emergency Department (ED) sampled patients were provided a complete Medical Screening Exam (MSE) to determine whether the presence of an Emergency Medical Condition (EMC) existed prior to patient disposition (final determination of the patients next level of care which includes discharge, admit, or transfer). P9 presented to the ED with a chief complaint of chest pain and waited to be roomed after triage for 3 hours before the patient left without being seen by a qualified medical professional to rule out an EMC. P14 was discharged from the facility’s ED without a psychiatric evaluation. This failed practice has the potential to cause harm or death to patients who present to the ED with an EMC. According to facility provided data the ED saw an average of 5,467 patients per month for the past 6 months. See citation A2400 and A2407, that also resulted in A2406 to not be met. Findings include: A. Review of facility Emergency Medical Treatment and Transfer policy, approved 8/2024 revealed: A MSE is defined as the process required to reach with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist. EMC is defined as a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate attention could reasonably be expected to result in placing the health of the individual in serious jeopardy. A QMP is defined as individuals authorized to perform a MSE in accordance with the facility policy Medical Screening Exam. Review of the facility Medical Screen Exam policy, approved 4/2023 revealed: A medical exam performance eligibility criteria for the ED and the Psychiatric Emergency Services (PES) includes a licensed Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO) who is a medical staff member or supervised house officer. B. Review of P9’s medical record revealed, P9 presented to the acute care hospital ED on 2/11/2025 at 5:35PM via walk in, with a chief complaint of chest pain, and triaged at 5:38PM for a Emergency Severity Index (ESI) of 3 (urgent level of priority for severity of a patient’s injury or illness on a scale of 1-5, 1=highest priority and 5=non-urgent). At 5:38PM, the triage nurse placed ED chest pain protocol orders for P9 which included but was not limited to: -An intravenous (IV) (inserting a needle into a vein to give fluids or medication). P9’s medical record lacked evidence of the IV being placed, confirmed by Registered Nurse (RN)-A. -A high sensitivity troponin (a blood test that measures heart muscle damage.), collected at 6:31PM and resulted at 8:46PM. [3 hours after the order was placed with an expected result time of 1 hour after drawn, confirmed by Physician-A.] At 5:43PM, P9 reported 10/10 middle upper chest pain with an onset of 20 minutes (the time symptoms started) prior to arrival that radiated (the pain moves to another location of the body) to the left chest and jaw, denied nausea/vomiting, and no precipitating emotional events to the triage nurse. At 5:46PM, P9 was sent out to the lobby to wait for a room to be seen by a QMP for an MSE to rule out an EMC. P9 left the ED without being seen by a QMP at 8:20PM. P9 was called to room at 8:50PM (the staff says the patients name in the ED lobby to take them to a room to be seen by a QMP to provide an MSE to rule out or treat an EMC.) P9’s medical record lacked evidence of any repeat vitals, assessment or exam from a QMP prior to the patient leaving the ED 3 hours after arrival with a chief complaint of radiating chest pain. Review of P14’s medical record revealed, P14 presented to the acute care hospital ED on 11/18/2024 at 8:46PM via ambulance, with a chief complaint of altered mental status from a possible drug overdose. P14 medical record lacked evidence of a psychiatric evaluation prior to the 11/19/2024 discharge at 6:39AM, confirmed by Physician-A. C. During an interview on 2/25/2025 at 11:36 AM, RN-B confirmed P9’s medical record lacked evidence of any repeat vitals, assessment or exam from a QMP prior to the patient leaving the ED 3 hours after arrival with a chief complaint of radiating chest pain. During an interview on 2/26/2025 at 11:41 AM, Physician-A confirmed P9’s medical record lacked evidence of the high sensitivity troponin resulting within the 1 hour expected time frame, and any repeat vitals, assessment or exam from an RN or QMP prior to the patient leaving the ED 3 hours after arrival with a chief complaint of radiating chest pain. During an interview on 2/26/2025 at 11:45 AM, Physician-A revealed a gap was identified with the psychiatric consult. P14’s physicians shift ended at 12:24AM on 11/19/2024, and the oncoming physician thought the Licensed Mental Health Practitioner (LMHP) (a health professional who can assess, diagnose, and treat mental health) was notified to evaluate P14 prior to discharge. Physician-A confirmed P14 medical record lacked evidence of a psychiatric evaluation from an LMHP prior to the 11/19/2024 discharge at 6:39AM. The facility created a hard stop in the electronic medical record to require a note from the LMHP prior to disposition, and the ED physicians now call the consulting provider directly.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 48575 Based on policy review, medical record review and interviews the facility failed to ensure 2 (Patient 7 & P9) of 20 Emergency Department (ED) sampled patients were provided a timely medical screening exam (MSE) to rule out an Emergency Medical Condition (EMC) to determine if stabilizing treatment was required within 3 hours of initial presentation with chief complaints of an allergic reaction, and chest pain. The facility failed to monitor or reassess (the triage nurse reassess to ensure the triage level is still appropriate if the MSE is delayed) P7 and P9 while in the lobby waiting to be seen by a qualified medical personnel (QMP) for 3 hours. This failed practice has the potential to cause harm or death due to a delay in stabilizing treatment to all patients who present to the facility ED with an Emergency Medical Condition (EMC). According to facility provided data the ED saw an average of 5,467 patient per month for the past 6 months. See citation A2400 and A2406, that also resulted in 2407 to not be met. Findings include: A. Review of facility Emergency Medical Treatment and Transfer policy, approved 8/2024 revealed: A MSE is defined as the process required to reach with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist. EMC is defined as a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate attention could reasonably be expected to result in placing the health of the individual in serious jeopardy. A QMP is defined as individuals authorized to perform a MSE in accordance with the facility policy Medical Screening Exam. Review of the facility Medical Screen Exam policy, approved 4/2023 revealed: A medical exam performance eligibility criteria for the ED and the Psychiatric Emergency Services (PES) includes a licensed Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO) who is a medical staff member or supervised house officer. B. Review of P7’s medical record revealed, P7 presented to the acute care hospital ED on 1/7/2025 at 8:17PM with a chief complaint of an allergic reaction with shortness of breath after taking a first dose of antibiotic (medication for an infection) at 6:30PM, symptoms of itchiness and throat closing up began 15 minutes later, P7 took two Benadryl (allergy medicine) but was still having trouble breathing prior to going to the ED. P7 was triaged at 8:20PM for an Emergency Severity Index (ESI) of 3 (urgent level of priority for severity of a patient’s injury or illness on a scale of 1-5, 1=highest priority and 5=non-urgent). At 8:24PM, P7 was sent out to the lobby to wait for a room to be seen by a QMP for an MSE to rule out an EMC. P7’s medical record lacked evidence of any repeat vitals, assessment or exam from a QMP prior to the patient’s MSE that started at 11:23PM [3 hours after arrival with a chief complaint of an allergic reaction.] P7’s MSE revealed complaints of throat tight and “not right” was given treatment for potential anaphylaxis (a severe life threatening allergic reaction that occurs when the body’s immune system overreacts to an allergen) on 11/19/2024 at 12:18AM. Review of P9’s medical record revealed, P9 presented to the acute care hospital ED on 2/11/2025 at 5:35PM via walk in, with a chief complaint of chest pain, and triaged at 5:38PM for a Emergency Severity Index (ESI) of 3 (urgent level of priority for severity of a patient’s injury or illness on a scale of 1-5, 1=highest priority and 5=non-urgent). A high sensitivity troponin (a blood test that measures heart muscle damage.) was ordered at 5:38PM, collected at 6:31PM and resulted at 8:46PM. [3 hours after the order was placed with an expected result time of 1 hour after drawn, confirmed by Physician-A.] C. During an interview on 2/26/2025 at 11:00 AM, Physician-A revealed that treatment does not define acuity (how serious a patient’s medical condition is), P7 did not have any stridor or wheezing, if changes occurred then the patient severity would have been escalated and treated. Physician-A confirmed P7’s medical record lacked evidence of any repeat vitals, assessment or exam from a QMP prior to the patient’s MSE that started at 11:23 PM [3 hours after arrival with a chief complaint of an allergic reaction.] During an interview on 2/26/2025 at 11:41 AM, Physician-A confirmed P9’s medical record lacked evidence of the high sensitivity troponin resulting within the 1 hour expected time frame, and any repeat vitals, assessment or exam from an RN or QMP prior to the patient leaving the ED 3 hours after arrival with a chief complaint of radiating 10/10 chest pain (highest level of pain that moves from the chest to another location).”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. 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. This Standard is not met as evidenced by: 48575 Based on policy review, medical record review, and staff interview the facility failed to ensure 1 (Patient 4) of 4 sampled patients placed in physical restraints to protect staff and the patients were ordered appropriately per the hospital policy. This failed practice has the potential to cause harm or negative outcomes to all inpatients who present to the hospital for care. The facility inpatient census at the time of entrance was 661. Findings are: A. Review of the policy titled Restraint Use (last reviewed 6/2022) revealed: 1. Restraints used on patients because of violent or self-destructive behavior is limited to emergencies in which there is imminent risk of a patient physically harming himself, staff or others, and non-physical interventions would not be effective. 2. Only RNs (Registered Nurses) who prove competency in orientation, complete mandatory education, and competency......may make decisions about, implement, and discontinue restraint use. This staff training and education will focus on: -Strategies to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require the use of restraint. 3. Physical Restraints are defined by the facility as: any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. 4.. The Restraint Procedure included: -The use of restraints will be determined by the treating practitioner. The facility policy defines a Medical Surgical Restraint (Protection of Tubes/Lines) (Non-Violent) vs. Restraint for Violent Behavior, and indications for use per type. B. Review of the medical record (11/19/2024 at 10:45AM) revealed Patient 4 admitted to the hospital on 10/24/2024 for care and treatment of an odontoid fracture (broken neck) from a ground level fall with a past medical history of Alzheimer’s (a disorder of the brain that affects memory, thinking and leads to the inability to carry out daily tasks independently). Patient 4’s electronic medical record (EMR) psychosocial patient behavior documentation on 11/2/2024 included anxious, aggression, hitting and kicking staff [violent behavior] with a non-violent four-point restraint (restraints that are applied to both wrists and ankles at the same time that restricts/prevents a person from moving) order indicated for tube and line protection from 11/2/2024 at 1:00AM until discontinued at 9:25AM, confirmed by an Accreditation Coordinator. Patient 4’s EMR documentation revealed a “saline lock” intravenous (IV) (a line in the arm not being used), and a C-Collar (neck device used to protect the spine), confirmed by an Accreditation Coordinator. Patient 4’s EMR restraint documentation lacked evidence of the facility following policy regarding four-point restraint use on 11/2/2024, confirmed by an Accreditation Coordinator. C. During an interview with an Accreditation Coordinator (11/19/2024 at 10:45AM) confirmed Patient 4’s medical record lacked evidence of a violent four-point restraint order on 11/2/2024.”

“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: 46123 Based on medical record review, review of the facilities policy and procedures and staff interviews, the Acute Care Hospital (ACH) failed to ensure that 2 of 13 sampled patients (Patients 4 and 7) reviewed had documentation of a fall while a patient at the ACH. This failed practice has the potential to affect all patients of the ACH. The facility census on day of entrance was 563. Findings are: A. Review of Patient 4’s medical record revealed the patient was admitted for 8 days (6/25/24 - 7/2/24) for a coronary artery bypass graft (CABG a surgical procedure that improves blood flow to they heart by rerouting blood around a blocked coronary artery) of one vessel. The patient had a fall on 6/27/24 between 3:00 AM - 3:45 AM. Review of the medical record revealed a lack of documentation of the post fall flowsheet in the electronic medical record (EMR). B. Review of Patient 7’s medical record revealed the patient was admitted on 8/15/24 for seizures. The patient had a fall on 8/16/24 at 2:00 PM. Review of the medical record revealed a lack of documentation of a fall risk assessment, seizure precautions, and equipment in use since 3:39 AM that morning. A fall risk assessment was completed after the fall at 2:14 PM. The patient scored a 25 which meant the patient was a high risk for falls. Documentation of equipment, alarms, and seizure precautions were not documented again until 8:10 PM that evening. C. Review of facility policy titled Inpatient Fall Risk Assessment and Interventions (Dated 7/2024) revealed that a nurse will assess patients 15 years of age and older, using the Hester Davis Scale (a fall risk assessment 9 factor scale). This assessment will be performed at a minimum of once per 12-hour shift, and in the event of status clinical change. Documentation of equipment in use once per shift after fall risk assessment completed. In the event of a fall the nurse will complete the Post Fall flowsheet template within the electronic medical record. D. Review of facility policy titled SOS Reporting (Dated 8/2023) Shout Out Safety (SOS) Reporting revealed completion of an SOS report does not replace documentation of the event in the medical record. Document in the medical record a statement of the event as it relates to the patient. E. Interview with RN-A (8/22/24 at 10:30 AM) confirmed that Patient 4’s medical record lacked evidence of the fall and the post fall huddle. F. Interview with RN-B (8/22/24 at 2:53 PM) confirmed that Patient 7’s medical record lacked evidence of the Hester Davis Scale, equipment, alarms, and seizure precautions in use since 3:39 AM on 8/16/24. RN-B also confirmed the medical record lacked documentation of equipment, alarms, and seizure precautions in use after patients fall on 8/16/24 at 2:00 PM until 8:10 PM.”

“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: 48575 Based on policy and procedure review, job description review, medical record review, staff, patient and family interviews, nursing staffing grid and schedules, video monitor log review, and observations the facility failed to ensure Nursing Services were provided an adequate number of staff to meet the needs of the patient. Medical record review revealed 4 (P5, P18, P19, P20) of 21 patients had an adverse event while inpatient resulting in injury due to lack of staffing, and the facility not following policy and procedures to keep the patients safe from preventable injuries. This failed practice had the potential to affect all patients presenting to the Acute Care Facility (ACF). The facility census was 603 on entrance. The standard cited A0392 and A0395 also resulted in the Condition of Participation for Nursing Services to be not met. The condition is not met as evidenced by: A. Review of policy, “Fall Reduction Program (last reviewed 9/2023),” revealed, “A patient is considered at increased fall risk if at least one risk factor is present on the Modified Schmid Risk Assessment Tool: impaired mobility (ambulates/transfers with assistive devices or assist, OR ambulates with unsteady gait), impaired mentation (periodic confusion OR confusion at all times) confusion is defined as disoriented, forgetful, impulsive, combative, delirious, and/or poor safety awareness, impaired elimination (incontinence ...needs assistance with toileting), fall within the past 6 months (before admission or unknown vs during this admission), fall inducing medication received within the past 24 hours (anticonvulsants/sedatives or psychotropics/hypnotics, diuretics, laxatives, antihypertensives, opiates).” -“Care/Interventions will be individualized, according to a patient’s fall risk factor(s): ..... For patients with impaired mentation (confusion), the following interventions will be implemented: ....increase frequency of rounding, set bed and chair alarm, consider use of sitter, and/or video monitoring, use a fall mat unless the patient is intubated ....” -“For patients with a history of a fall within the past six months, the following interventions will be implemented: consider cause of prior fall(s) and reduce contributing factors during hospitalization, as appropriate (e.g. if a patient has fallen at home on the way to the bathroom at night, establish toileting schedule during night time hours). Use a fall mat.” -“For patients who have received a fall-inducing medication (labeled SCHMID on medication administration record within the past 24 hours, the following interventions will be implemented: Collaborate with the provider and pharmacist to adjust medication regimens that may put the inpatient at an increased risk for falls, as appropriate. Consider side effects of medications that may cause fall risk factors (impaired mentation, impaired mobility, and/or impaired elimination.” -“Post-Fall Management Protocol: If head, neck, or spinal trauma is suspected call and RRT immediately for assistance. Consult provider on frequency and duration of neuro checks if head/beck trauma is suspected or confirmed (i.e., Neuro checks every hours for a duration of up to 6 hours. May be extended for actual head trauma and provider may consult the Neurology/Neurosurgery team).” B. Review of policy, “Nursing Pressure Injury Prevention (last reviewed 1/2023),” revealed, “Hospital Acquired Pressure Injury (HAPI) defined as localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. HAPIs occur while the patient is hospitalized-Staged at 1-4, Unstageable, Deep Tissue Injury or Mucosal membrane pressure injury.” -The facility utilizes the Braden Scale as a Risk Assessment Tool to “predict the risk of pressure ulcers, based on the scores given in the categories of sensory perception, moisture, activity, mobility, nutrition, and friction/shear.” Non-blanchable erythema defined in the hospital policy reads, “Visible skin redness that persists with the application of pressure. It indicates structural damage to the capillary bed/microcirculation (Stage 1 Pressure Injury).” -“Screen all patients for nutrition risk upon admission.” -“If a pressure injury is present, notify the provider and consult inpatient wound and ostomy services.” C. Review of policy, “Wound Ostomy Services-Patient Care (last reviewed 5/18/2023),” revealed, “The Wound Ostomy Services (WOS) nurse receives consults from providers and nurses. The WOS nurse will have two business days to assess the patient.” D. Review of policy, “Acute Care Nursing Scheduling and Staffing of Nursing Personnel (last reviewed 6/22),” revealed, “The Resource Management Center (RMC) is accountable for inpatient unit schedule development and ensuring that appropriate staffing levels are maintained to meet patient care needs. This includes the determination of staffing patterns and shift lengths to meet the workload in the designated area. Managers are expected to review distributed reports to ensure accuracy.” “Staffing Process: The RMC, in conjunction with the Unit Leadership and Nursing Resource Coordinators (NRC), are responsible for staffing adjustments from shift to shift. These decisions are made with consideration of patient census, acuity, anticipated admissions/dismissals, and the experience and skills of the staff. Nurse patient ratios alone do not dictate staffing needs ....Staffing adjustments may require a variety of approaches based on staffing policies and patient care needs. Unresolved staffing concerns should be communicated to the NRC and RMC.” “Floating of Professional Staff and Unlicensed Personnel to Another Unit: ...Float assignments are made with continuity of care and patient safety as the main priority. Every effort is made to ensure that the assignment of the float nurse is not changed during the course of the shift.” E. Review of Job Description #30537, “Vice President Operations,” revealed, “The Vice President of Operations (VPO) delivers our brand promise of Serious Medicine, Extraordinary Care. As VPO ..... lead your assigned organizational areas ... responsibilities include: driving results to achieve strategic and operational goals while maintaining high organizational accountability ...exemplify values and demand the same from your teams-to achieve this, you must commit to a culture of safety and reliability to eliminate patient harm, cultivate trust and well-being, partner with multiple stake holders across a variety of disciplines and organization to meet the needs of those we serve provide an engaging experience, and you must drive best practices that encourage innovation while practicing stewardship. Essential Functions: ....Develop, implement, and enforce policies and procedures of the organization to improve the overall operation and effectiveness of the corporation. Develop, implement, and evaluate strategic business plans by assessment of patient populations, environment, technology, and competitors to provide the highest possible efficiency and quality of patient care. Apply quality problem-solving tools in leading and collaborating with others to improve outcomes/goals (including patient safety) and processes. Effectively utilize organizational information systems and data related to continuous improvement. Ensure staff and self are educated on an ongoing basis an in compliance with state, federal, and regulatory agency(s) requirements, in addition to adherence with organizational and departmental policies, procedures and practices of the organization.” -Review of the Nursing Services Organizational Chart revealed that the VPO reports to the Chief Nursing Officer (CNO) for Nursing Practice. F. Review of Patient 20 (P20)’s electronic medical record (EMR) (2/1/2024 at 9:30AM) revealed P20 was a direct admit to the ACF intensive care unit (ICU) on 10/22/2023 due to a ground level fall (GLF) at home resulting in a large right epidural hematoma (blood clot in the brain) causing a 0.8 centimeter (cm) midline shift, subarachnoid hemorrhage (SAH) (bleeding in the brain) and left facial fracture and with cerebral spinal fluid (CSF) leak through the nares (nose). -The fall risk screen assessment for P20 revealed “high fall risk,” and determined interventions which included bed and chair alarms to prevent falls. -Review of P20’s EMR RN-A documented on 11/2/2023 revealed at 9:45PM P20 was moved from the chair to the bed, and at 9:56PM bed alarm was charted as “on.” At 11:24PM P20 was found on the floor by the lead nurse who initiated a rapid response team (RRT), CT head was obtained, and orders were given by PA-A. RN-A documented “no changes in CT, addressed back of the head laceration with staples and stated to continue to monitor.” 11/3/2023 at 1:01AM and 3:24AM “rounds found no new neuro changes.” At 3:41AM, “P20 bleeding through pressure dressing, dressing changed, and PA-A notified, told to put surgical and coban.” At 4:45AM, “went to give meds to P20 and found coughing/throwing up tan/pink sputum, Dobhoff (DHT)(a tube that goes through the nose, down the esophagus into the stomach) dislodged (not in the correct place) and 5-10cm out, tube feeding (TF)(nutrition) stopped.” At 5:10AM another CT head was obtained. At 5:34AM PA-A was notified of DHT (49 minutes after event occurred), RN-A documented, “P20 more disoriented x3, having more trouble following commands.” At 6:10AM RN-A documented notification of second CT results to a NP-A. PA-B evaluated P20 after fall, and PA-B evaluated P20 11/3/2023 at 7:05AM. -Review of P20’s EMR documented by NP-B on 11/3/2023 at 10:30AM revealed, “ ....patient had an unwitnessed fall, unsure LOC, found by staff with laceration to posterior scalp (back of the head), worsening altered mental status (AMS)(confusion), and DHT partially dislodged. Rapid Response Team (RRT) was called. Staples placed at bedside. Repeat CT head obtained with findings of worsening Subdural Hematoma (SDH) (bleeding in the brain that clots) with increased mass defect, 1 centimeter (cm) left shift. Neurosurgery was reconsulted by NP-B. -Patient 20 was transferred to a higher level of care within the ACF after an emergent craniotomy (surgery to cut through the skull and remove the blood clot in the brain) with neurosurgery. Patient 20 required intubation (breathing tube through the mouth into the windpipe to assist the patient to breath), sedation (medication induced coma), required intravenous (IV) drips of medication before and after surgery, and a unit of blood due to a hemoglobin of 7.8 (low levels of blood in the body). -An interview with RN-B on 2/5/2024 at 7:51AM revealed that RN-B transferred P20 from the chair to bed, assisted with nighttime cares, and set the bed alarm prior to leaving the room. RN-B recalled the bed alarm was not alarming at the time P20 was found on the floor (fall). -Review of the fall event #264894 filed by RN-A on 11/3/2023 revealed RN-A documented, “ .....Later, upon returning patient to the room from CT, I attempted to put on the bed alarm. However, the bed alarm would beep on then beep four times and turn off. I informed lead nurse (charge nurse for the unit) about this issue and the bed was exchanged [after the fall occurred]. Bed alarm and video monitoring added for patient safety.” -Review of the hospital staffing assignments for 11/2/2023 (night shift, 7:00PM to 7:00AM) revealed the following: -1 Lead Nurse (charge nurse): responsible to care for 4 patients (as well as leadership responsibilites for 44 patients). -4 RN’s, each responsible for care of 6 patients. -2 Patient Care Techs (PCT), each responsible for the care of 10 patients. -1 PCT Lead: Responsible for the care of 8 patients (as well as lead duties for 28 patients). G. Review of the EMR revealed Patient 18 (P18) was admitted to the ACF on 12/6/2023 for a surgical procedure and was discharged to home on 12/7/2023. Once at home P18 experienced seizures and a fall and was transported by EMS to a different ED, who transferred back to the ACF for a direct re-admit on 12/8/2023. -The fall risk screen for P18 revealed, “high fall risk.” Fall prevention interventions included bed alarm, video monitor (a person watching the patient on a screen who is not in the room) to prevent falls. -Review of the EMR revealed P18 was transferred to a “lower level of care” neuro unit within the ACF 12/8/2023 at 6:18 PM (within 17 hours of admit). Fall with head injury while in restraints occurred at 11:00PM (less than 23 hours from admission). P18 was transferred back to Neuro ICU at 1:10AM on 12/9/2023 for hourly neuro assessments, altered mental status (decreased awareness) post fall that resulted in a new subdural hematoma (brain bleed) management. -During an interview on 12/8/2023 confidential staff #1 stated that P18’s unit started with 1 RN short on 12/8/2023 and is a common occurrence for the area (confidential due to fear of retaliation from the facility). -Review of P18’s EMR revealed on 12/8/2023 RN-D documented, “Patient restless and agitated from the moment arrived to the floor at 6:12PM. As needed Seroquel (medication used for mental health conditions, a hormone that regulates mood, behavior, thoughts, and increases the risk for falls) given in ICU seemingly has no effect. RN unable to leave this patient’s room for over 30 minutes on arrival as P18 would not stop trying to get out of bed. Unable to redirect. ... ...sitter request submitted, “no staff to cover.” 12/8/2023 at 6:38PM medical record revealed that P18 was placed in restraints without an order, confirmed in an interview with RN-D on 2/5/2024 at 1:54PM. RN-D documented that provider deferred to consult hospital medicine regarding P18, and as of 7:07PM had not received an order for the restraints for, “continued agitation, pulling at lines, and kicking husband and staff.” (prior to P18 fall at 11:00PM). -Post fall lacked documentation of new interventions (i.e.: sitter-someone to be in the room with the unsafe patient to prevent further injuries) confirmed by RN-C 2/1/2024 at 10:33AM. -A review of P18’s video monitor log from 12/8/2023 revealed at 6:31PM [within 1 minute of P18 transfer to a different unit], “left arm restraint off, violent with husband at 6:33PM. Tried to get up without help at 8PM-called the care tech *=got ahold of. 11:00PM patient up at end of bed, RN in room, patient states she fell.” A review of the entire 12/8/2023 video monitor log lacked evidence of the video monitor tech witnessing, notifying, or reporting P18 attempt to get out of bed, before fall at 11:00PM, confirmed in an interview with Staff A on 2/6/2024 at 10:50AM. -The CT head on 12/8/2023 at 11:15PM revealed that P18’s 11:00PM fall resulted in a new subdural hematoma (brain bleed). -During an interview on 2/5/2024 at 1:54PM RN-D stated RN-D had 2 admissions within minutes of each other, one of them being P18 with a total of 5 patients. -During an interview on 2/5/2024 at 6:59PM with RN-E revealed that at P18 was incontinent (could not recall time), RN-E asked RN-G and a patient care tech to assist the patient so RN-E could finish assessments and medication pass for the other 5 patients assigned. RN-E found P18 standing at the end of the bed alone with bilateral restraints to wrists no longer attached to the bed, and 1 leg restraint still attached to bed and patient (P18 told RN-E that they fell and hit their head). RN-E revealed that no bed alarm was sounding, and no notification from the video monitor techs were received prior, during or after P18 fall on 12/8/2023. -Review of the staffing assignments for 12/8/2023 night shift revealed that RN-E was assigned 6 patients with a significant gap between P18 and the other patient rooms (floor plan included with room numbers assigned). RN-G was also assigned 6 patients. 48 bed unit. -During an interview on 2/5/2024 at 7:12PM with RN-G revealed that after cleaning up the patient from an incontinence, re-tied soft restraints bilateral wrists and left leg, “I did it myself, so I know they were tied well.” RN-G recalled that video monitoring and bed alarm were on before leaving P18’s room (could not recall time). RN-G confirmed that no calls were received from video monitoring regarding P18 before, during, or after the 11:00PM fall on 12/8/2023. H. Review of Patient 19 (P19)’s EMR (1/31/2024 at 3:22PM) revealed P19 was a direct admit on 12/17/2023 at 12:02AM from an outside facility via ambulance (ground transport time approximately 5 hours 45 minutes) for hypoglycemia (low blood sugar). History of falls. -On 12/17/2023 at 8:42PM nursing documentation revealed Modified Scmid (fall score) of: Mobility=1, Mentation=0, Elimination=0, Prior fall history=1, Current meds=1. “High Fall Risk.” An interview with RN-F on 2/6/2024 at 10:17AM revealed Modified Scmid Fall scoring system interpretation of 0 = Not in the past 6 months, 1 = Yes in the past 6 months (or before admission), 2=Fall during admission. -On 12/19/2023 at 12:45PM P19 self-transferred out of bed without assistance and fell to knees attempting to walk to husband who was on the couch. P19’s fall resulted injury “stable small subdural hematoma per neurosurgery documentation.” I. A review of Patient 5 (P5)’s medical record (1/31/2024 at 11:32AM) revealed P5 was admitted on 1/17/2024 to the ACF for an Acute Pulmonary Embolism (blood clot that could result in death if not emergently treated). The entire medical record lacked evidence of a nutritional risk screen interventions completed within 24 hours of admission, confirmed by RN-F on 1/31/2024 at 12:13PM. -P5 developed a hospital acquired pressure injury (HAPI) during the inpatient visit. On 1/18/2024 at 3:59AM first skin assessment documentation revealed, “blanchable redness to coccyx.” (indicated beginning stages of a pressure injury). A wound consult was not submitted until 1/19/2024 at 11:53AM for the coccyx, the Wound Ostomy Services (WOS) nurse did not consult/assess P5 until 1/22/2024 at 12:04PM (the facility policy states 2 business days-which fell over a weekend, resulting in P5 not being seen for 4 days, and 5 days since the nurse had initially documented the beginning of a pressure injury). 1/22/2024 documentation revealed a Stage II pressure injury to the coccyx 1cm x 1cm x 1cm that was not present on admission (tailbone caused by not providing appropriate pressure relief to the area, ie repositioning, offloading).”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 48575 Based on policy and procedure review, job description review, medical record review, staff, patient and family interviews, nursing staffing grid and schedules, video monitor log review, and observations the facility failed to maintain staffing assignments that correlate to the number and aquity of patients, and review and revise staffing schedules to meet the needs of the patients. Medical record review revealed 4 (P5, P18, P19, P20) of 21 patients had an adverse event while inpatient resulting in injury due to lack of staffing, and the facility not following policy and procedures to keep the patients safe from preventable injuries. This failed practice had the potential to affect all patients presenting to the Acute Care Facility (ACF). The facility census was 603 on entrance. The standard cited A0395, and condition level A0385 also resulted in the Condition of Participation for Nursing Services to be not met. Findings Include: A. A review of policy, “Acute Care Nursing Scheduling and Staffing of Nursing Personnel (last reviewed 6/22),” revealed, “The Resource Management Center (RMC) is accountable for inpatient unit schedule development and ensuring that appropriate staffing levels are maintained to meet patient care needs. This includes the determination of staffing patterns and shift lengths to meet the workload in the designated area. Managers are expected to review distributed reports to ensure accuracy.” “Staffing Process: The RMC, in conjunction with the Unit Leadership and Nursing Resource Coordinators (NRC), are responsible for staffing adjustments from shift to shift. These decisions are made with consideration of patient census, acuity, anticipated admissions/dismissals, and the experience and skills of the staff. Nurse patient ratios alone do not dictate staffing needs ....Staffing adjustments may require a variety of approaches based on staffing policies and patient care needs. Unresolved staffing concerns should be communicated to the NRC and RMC.” “Floating of Professional Staff and Unlicensed Personnel to Another Unit: ...Float assignments are made with continuity of care and patient safety as the main priority. Every effort is made to ensure that the assignment of the float nurse is not changed during the course of the shift.” B. A review of Job Description #30537, “Vice President Operations,” revealed, “The Vice President of Operations (VPO) delivers our brand promise of Serious Medicine, Extraordinary Care. As VPO ..... lead your assigned organizational areas ... responsibilities include: driving results to achieve strategic and operational goals while maintaining high organizational accountability ...exemplify values and demand the same from your teams-to achieve this, you must commit to a culture of safety and reliability to eliminate patient harm, cultivate trust and well-being, partner with multiple stake holders across a variety of disciplines and organization to meet the needs of those we serve provide an engaging experience, and you must drive best practices that encourage innovation while practicing stewardship. Essential Functions: ....Develop, implement, and enforce policies and procedures of the organization to improve the overall operation and effectiveness of the corporation. Develop, implement, and evaluate strategic business plans by assessment of patient populations, environment, technology, and competitors to provide the highest possible efficiency and quality of patient care. Apply quality problem-solving tools in leading and collaborating with others to improve outcomes/goals (including patient safety) and processes. Effectively utilize organizational information systems and data related to continuous improvement. Ensure staff and self are educated on an ongoing basis an in compliance with state, federal, and regulatory agency(s) requirements, in addition to adherence with organizational and departmental policies, procedures and practices of the organization.” C. A review of the Nursing Services Organizational Chart revealed that the VPO reports to the Chief Nursing Officer (CNO) for Nursing Practice. D. The facility staffing schedules lacked evidence of providing adequate staffing to meet the needs of the patients. The facility does not capture real time census at the bed management meeting conducted at 4:30pm daily, when staffing for the night shift. There is a discrepency between the number of admissions and discharges that are occuring from 4:30pm-6:30pm for the night shift staffing. The facility failed to maintain accurate staffing assignments for the direct care of their patients. E. Confidential staff interviews were conducted facility wide during the survey with a frequent message that staff do not have a safe place or system to report problems within the facility due to fear of retaliation, or multiple failed attempts voicing concern to higher management with no results and have given up. Frequent messages from the staff also included not being able to provide adequate/safe nursing care to their patients due to the number of patients being assigned to them for the shift. Staff stated that when they voice concerns for safety in staff to patient ratio the response given is “don’t tell us it’s your license if you don’t feel safe don’t work here.” Staff state they have had to lower their standards in patient care. Patient needs are met at the expense of the nursing staff by not taking breaks and don’t eat. Several nurses stated that patients are not getting turned like they need to be or that “lines, caps and tubing are not being changed like they should be. We can’t even train new nurses correctly.” Staff are concerned with the ratio of patients being assigned on med surg floors and Intravenous (IV) drips that need managed stating those patients are a progressive care level. Bedside staff voiced concern with nurses having 8-9 patients assigned at a time with discharges and admissions or the care techs can have 18 patients at a time, and they can’t get to all of the cares for patients and nurses are expected to help but we can’t get our own work done. The Team Lead nurses are having to take patients and are not being counted in staffing for pulling double duty. With the Team Leads taking patients they are not a resource to help bedside nurses. In an interview with a new nurse of less than 1 month they stated that they are overwhelmed by themselves with 5 patients. The new nurse did not finish the first assessment charting until 9 hours into their shift. F. Observation on 6 Neuro releaved there is not a night supervisor, confirmed in a confidential interview on 2/5/2024 at 7:51PM the night supervisor for 9 Trauma goes back and forth between 9 Trauma and 6 Neuro. G. During an interview on 2/6/24 at 10:30am staff A brought report for 1:1 staffing and video monitoring. While reviewing report for 2/5/24 it was noted that there were only 3 patients from 8 Werner (patient care area) listed. Surveyor had been informed of request for 4 1:1 sitters for day shift had been made and only 2 were filled. When questioning staff-A about report they were unable to answer why 4th request was not on the list. The 4th requested 1:1 patient had been transferred to another unit. Staff-A was unsure how to know how many 1:1 requests are being made compared to how many are being filled. Staff-A stated that if they are unable to fill the sitter request, they put the patient on video monitoring.”

“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: 48575 Based on policy and procedure review, job description review, medical record review, staff, patient and family interviews, nursing staffing grid and schedules, video monitor log review, and observations the facility failed to ensure Nursing Services were provided adequate number of staff to meet the needs of the patients. Medical record review revealed 4 (P5, P18, P19, P20) of 21 patients had an adverse event while inpatient resulting in injury due to lack of staffing, and the facility not following policy and procedures to keep the patients safe from preventable injuries. This failed practice had the potential to affect all patients presenting to the Acute Care Facility (ACF). The facility census was 603 on entrance. The standard cited A0392, and condition level A0385 also resulted in the Condition of Participation for Nursing Services to be not met. Findings Include: A. Review of policy, “Fall Reduction Program (last reviewed 9/2023),” revealed, “A patient is considered at increased fall risk if at least one risk factor is present on the Modified Schmid Risk Assessment Tool: impaired mobility (ambulates/transfers with assistive devices or assist, OR ambulates with unsteady gait), impaired mentation (periodic confusion OR confusion at all times) confusion is defined as disoriented, forgetful, impulsive, combative, delirious, and/or poor safety awareness, impaired elimination (incontinence ...needs assistance with toileting), fall within the past 6 months (before admission or unknown vs during this admission), fall inducing medication received within the past 24 hours (anticonvulsants/sedatives or psychotropics/hypnotics, diuretics, laxatives, antihypertensives, opiates).” -“Care/Interventions will be individualized, according to a patient’s fall risk factor(s): ..... For patients with impaired mentation (confusion), the following interventions will be implemented: ....increase frequency of rounding, set bed and chair alarm, consider use of sitter, and/or video monitoring, use a fall mat unless the patient is intubated ....” -“For patients with a history of a fall within the past six months, the following interventions will be implemented: consider cause of prior fall(s) and reduce contributing factors during hospitalization, as appropriate (e.g. if a patient has fallen at home on the way to the bathroom at night, establish toileting schedule during night time hours). Use a fall mat.” -“For patients who have received a fall-inducing medication (labeled SCHMID on medication administration record within the past 24 hours, the following interventions will be implemented: Collaborate with the provider and pharmacist to adjust medication regimens that may put the inpatient at an increased risk for falls, as appropriate. Consider side effects of medications that may cause fall risk factors (impaired mentation, impaired mobility, and/or impaired elimination.” -“Post-Fall Management Protocol: If head, neck, or spinal trauma is suspected call and RRT immediately for assistance. Consult provider on frequency and duration of neuro checks if head/beck trauma is suspected or confirmed (i.e., Neuro checks every hours for a duration of up to 6 hours. May be extended for actual head trauma and provider may consult the Neurology/Neurosurgery team).” B. Review of policy, “Nursing Pressure Injury Prevention (last reviewed 1/2023),” revealed, “Hospital Acquired Pressure Injury (HAPI) defined as localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. HAPIs occur while the patient is hospitalized-Staged at 1-4, Unstageable, Deep Tissue Injury or Mucosal membrane pressure injury.” -The facility utilizes the Braden Scale as a Risk Assessment Tool to “predict the risk of pressure ulcers, based on the scores given in the categories of sensory perception, moisture, activity, mobility, nutrition, and friction/shear.” Non-blanchable erythema defined in the hospital policy reads, “Visible skin redness that persists with the application of pressure. It indicates structural damage to the capillary bed/microcirculation (Stage 1 Pressure Injury).” -“Screen all patients for nutrition risk upon admission.” -“If a pressure injury is present, notify the provider and consult inpatient wound and ostomy services.” C. Review of policy, “Wound Ostomy Services-Patient Care (last reviewed 5/18/2023),” revealed, “The Wound Ostomy Services (WOS) nurse receives consults from providers and nurses. The WOS nurse will have two business days to assess the patient.” D. Review of policy, “Acute Care Nursing Scheduling and Staffing of Nursing Personnel (last reviewed 6/22),” revealed, “The Resource Management Center (RMC) is accountable for inpatient unit schedule development and ensuring that appropriate staffing levels are maintained to meet patient care needs. This includes the determination of staffing patterns and shift lengths to meet the workload in the designated area. Managers are expected to review distributed reports to ensure accuracy.” “Staffing Process: The RMC, in conjunction with the Unit Leadership and Nursing Resource Coordinators (NRC), are responsible for staffing adjustments from shift to shift. These decisions are made with consideration of patient census, acuity, anticipated admissions/dismissals, and the experience and skills of the staff. Nurse patient ratios alone do not dictate staffing needs ....Staffing adjustments may require a variety of approaches based on staffing policies and patient care needs. Unresolved staffing concerns should be communicated to the NRC and RMC.” “Floating of Professional Staff and Unlicensed Personnel to Another Unit: ...Float assignments are made with continuity of care and patient safety as the main priority. Every effort is made to ensure that the assignment of the float nurse is not changed during the course of the shift.” E. Review of Job Description #30537, “Vice President Operations,” revealed, “The Vice President of Operations (VPO) delivers our brand promise of Serious Medicine, Extraordinary Care. As VPO ..... lead your assigned organizational areas ... responsibilities include: driving results to achieve strategic and operational goals while maintaining high organizational accountability ...exemplify values and demand the same from your teams-to achieve this, you must commit to a culture of safety and reliability to eliminate patient harm, cultivate trust and well-being, partner with multiple stake holders across a variety of disciplines and organization to meet the needs of those we serve provide an engaging experience, and you must drive best practices that encourage innovation while practicing stewardship. Essential Functions: ....Develop, implement, and enforce policies and procedures of the organization to improve the overall operation and effectiveness of the corporation. Develop, implement, and evaluate strategic business plans by assessment of patient populations, environment, technology, and competitors to provide the highest possible efficiency and quality of patient care. Apply quality problem-solving tools in leading and collaborating with others to improve outcomes/goals (including patient safety) and processes. Effectively utilize organizational information systems and data related to continuous improvement. Ensure staff and self are educated on an ongoing basis an in compliance with state, federal, and regulatory agency(s) requirements, in addition to adherence with organizational and departmental policies, procedures and practices of the organization.” -Review of the Nursing Services Organizational Chart revealed that the VPO reports to the Chief Nursing Officer (CNO) for Nursing Practice. F. Review of job description #30011 - Chief Nursing Officer (CNO) (Exempt) revealed, the CNO is to provide overall administration, direction and coordination for nursing and patient care services across [Name of facility]. Job responsibilities include, build an effective workforce by following established employment practices and guidelines, labor/scope of practice laws, and effective use of labor. Direct operations to ensure the development, monitoring and achievement of goals and objectives that support consistent high-quality services and drive operations in alignment with strategic plans. Effectively utilize organizational information systems and data related to operational management. G. Review of Patient 20 (P20)’s electronic medical record (EMR) (2/1/2024 at 9:30AM) revealed P20 was a direct admit to the ACF intensive care unit (ICU) on 10/22/2023 due to a ground level fall (GLF) at home resulting in a large right epidural hematoma (blood clot in the brain) causing a 0.8 centimeter (cm) midline shift, subarachnoid hemorrhage (SAH) (bleeding in the brain) and left facial fracture and with cerebral spinal fluid (CSF) leak through the nares (nose). -The fall risk screen assessment for P20 revealed “high fall risk,” and determined interventions which included bed and chair alarms to prevent falls. -Review of P20’s EMR RN-A documented on 11/2/2023 revealed at 9:45PM P20 was moved from the chair to the bed, and at 9:56PM bed alarm was charted as “on.” At 11:24PM P20 was found on the floor by the lead nurse who initiated a rapid response team (RRT), CT head was obtained, and orders were given by PA-A. RN-A documented “no changes in CT, addressed back of the head laceration with staples and stated to continue to monitor.” 11/3/2023 at 1:01AM and 3:24AM “rounds found no new neuro changes.” At 3:41AM, “P20 bleeding through pressure dressing, dressing changed, and PA-A notified, told to put surgical and coban.” At 4:45AM, “went to give meds to P20 and found coughing/throwing up tan/pink sputum, Dobhoff (DHT)(a tube that goes through the nose, down the esophagus into the stomach) dislodged (not in the correct place) and 5-10cm out, tube feeding (TF)(nutrition) stopped.” At 5:10AM another CT head was obtained. At 5:34AM PA-A was notified of DHT (49 minutes after event occurred), RN-A documented, “P20 more disoriented x3, having more trouble following commands.” At 6:10AM RN-A documented notification of second CT results to a NP-A. PA-B evaluated P20 after fall, and PA-B evaluated P20 11/3/2023 at 7:05AM. -Review of P20’s EMR documented by NP-B on 11/3/2023 at 10:30AM revealed, “ ....patient had an unwitnessed fall, unsure LOC, found by staff with laceration to posterior scalp (back of the head), worsening altered mental status (AMS)(confusion), and DHT partially dislodged. Rapid Response Team (RRT) was called. Staples placed at bedside. Repeat CT head obtained with findings of worsening Subdural Hematoma (SDH) (bleeding in the brain that clots) with increased mass defect, 1 centimeter (cm) left shift. Neurosurgery was reconsulted by NP-B. -Patient 20 was transferred to a higher level of care within the ACF after an emergent craniotomy (surgery to cut through the skull and remove the blood clot in the brain) with neurosurgery. Patient 20 required intubation (breathing tube through the mouth into the windpipe to assist the patient to breath), sedation (medication induced coma), required intravenous (IV) drips of medication before and after surgery, and a unit of blood due to a hemoglobin of 7.8 (low levels of blood in the body). -An interview with RN-B on 2/5/2024 at 7:51AM revealed that RN-B transferred P20 from the chair to bed, assisted with nighttime cares, and set the bed alarm prior to leaving the room. RN-B recalled the bed alarm was not alarming at the time P20 was found on the floor (fall). -Review of the fall event #264894 filed by RN-A on 11/3/2023 revealed RN-A documented, “ .....Later, upon returning patient to the room from CT, I attempted to put on the bed alarm. However, the bed alarm would beep on then beep four times and turn off. I informed lead nurse (charge nurse for the unit) about this issue and the bed was exchanged [after the fall occurred]. Bed alarm and video monitoring added for patient safety.” -Review of the hospital staffing assignments for 11/2/2023 (night shift, 7:00PM to 7:00AM) revealed the following: -1 Lead Nurse (charge nurse): responsible to care for 4 patients (as well as leadership responsibilites for 44 patients). -4 RN’s, each responsible for care of 6 patients. -2 Patient Care Techs (PCT), each responsible for the care of 10 patients. -1 PCT Lead: Responsible for the care of 8 patients (as well as lead duties for 28 patients). H. Review of the EMR revealed Patient 18 (P18) was admitted to the ACF on 12/6/2023 for a surgical procedure and was discharged to home on 12/7/2023. Once at home P18 experienced seizures and a fall and was transported by EMS to a different ED, who transferred back to the ACF for a direct re-admit on 12/8/2023. -The fall risk screen for P18 revealed, “high fall risk.” Fall prevention interventions included bed alarm, video monitor (a person watching the patient on a screen who is not in the room) to prevent falls. -Review of the EMR revealed P18 was transferred to a “lower level of care” neuro unit within the ACF 12/8/2023 at 6:18 PM (within 17 hours of admit). Fall with head injury while in restraints occurred at 11:00PM (less than 23 hours from admission). P18 was transferred back to Neuro ICU at 1:10AM on 12/9/2023 for hourly neuro assessments, altered mental status (decreased awareness) post fall that resulted in a new subdural hematoma (brain bleed) management. -During an interview on 12/8/2023 confidential staff #1 stated that P18’s unit started with 1 RN short on 12/8/2023 and is a common occurrence for the area (confidential due to fear of retaliation from the facility). -Review of P18’s EMR revealed on 12/8/2023 RN-D documented, “Patient restless and agitated from the moment arrived to the floor at 6:12PM. As needed Seroquel (medication used for mental health conditions, a hormone that regulates mood, behavior, thoughts, and increases the risk for falls) given in ICU seemingly has no effect. RN unable to leave this patient’s room for over 30 minutes on arrival as P18 would not stop trying to get out of bed. Unable to redirect. ... ...sitter request submitted, “no staff to cover.” 12/8/2023 at 6:38PM medical record revealed that P18 was placed in restraints without an order, confirmed in an interview with RN-D on 2/5/2024 at 1:54PM. RN-D documented that provider deferred to consult hospital medicine regarding P18, and as of 7:07PM had not received an order for the restraints for, “continued agitation, pulling at lines, and kicking husband and staff.” (prior to P18 fall at 11:00PM). -Post fall lacked documentation of new interventions (i.e.: sitter-someone to be in the room with the unsafe patient to prevent further injuries) confirmed by RN-C 2/1/2024 at 10:33AM. -Review of P18’s video monitor log from 12/8/2023 revealed at 6:31PM [within 1 minute of P18 transfer to a different unit], “left arm restraint off, violent with husband at 6:33PM. Tried to get up without help at 8PM-called the care tech *=got ahold of. 11:00PM patient up at end of bed, RN in room, patient states she fell.” A review of the entire 12/8/2023 video monitor log lacked evidence of the video monitor tech witnessing, notifying, or reporting P18 attempt to get out of bed, before fall at 11:00PM, confirmed in an interview with Staff A on 2/6/2024 at 10:50AM. -The CT head on 12/8/2023 at 11:15PM revealed that P18’s 11:00PM fall resulted in a new subdural hematoma (brain bleed). -During an interview on 2/5/2024 at 1:54PM RN-D stated RN-D had 2 admissions within minutes of each other, one of them being P18 with a total of 5 patients. -During an interview on 2/5/2024 at 6:59PM with RN-E revealed that at P18 was incontinent (could not recall time), RN-E asked RN-G and a patient care tech to assist the patient so RN-E could finish assessments and medication pass for the other 5 patients assigned. RN-E found P18 standing at the end of the bed alone with bilateral restraints to wrists no longer attached to the bed, and 1 leg restraint still attached to bed and patient (P18 told RN-E that they fell and hit their head). RN-E revealed that no bed alarm was sounding, and no notification from the video monitor techs were received prior, during or after P18 fall on 12/8/2023. -Review of the staffing assignments for 12/8/2023 night shift revealed that RN-E was assigned 6 patients with a significant gap between P18 and the other patient rooms (floor plan included with room numbers assigned). RN-G was also assigned 6 patients. 48 bed unit. -During an interview on 2/5/2024 at 7:12PM with RN-G revealed that after cleaning up the patient from an incontinence, re-tied soft restraints bilateral wrists and left leg, “I did it myself, so I know they were tied well.” RN-G recalled that video monitoring and bed alarm were on before leaving P18’s room (could not recall time). RN-G confirmed that no calls were received from video monitoring regarding P18 before, during, or after the 11:00PM fall on 12/8/2023. I. Review of Patient 19 (P19)’s EMR (1/31/2024 at 3:22PM) revealed P19 was a direct admit on 12/17/2023 at 12:02AM from an outside facility via ambulance (ground transport time approximately 5 hours 45 minutes) for hypoglycemia (low blood sugar). History of falls. -On 12/17/2023 at 8:42PM nursing documentation revealed Modified Scmid (fall score) of: Mobility=1, Mentation=0, Elimination=0, Prior fall history=1, Current meds=1. “High Fall Risk.” An interview with RN-F on 2/6/2024 at 10:17AM revealed Modified Scmid Fall scoring system interpretation of 0 = Not in the past 6 months, 1 = Yes in the past 6 months (or before admission), 2=Fall during admission. -On 12/19/2023 at 12:45PM P19 self-transferred out of bed without assistance and fell to knees attempting to walk to husband who was on the couch. P19’s fall resulted injury “stable small subdural hematoma per neurosurgery documentation.” J. A review of Patient 5 (P5)’s EMR (1/31/2024 at 11:32AM) revealed P5 was admitted on 1/17/2024 to the ACF for an Acute Pulmonary Embolism (blood clot that could result in death if not emergently treated). The entire medical record lacked evidence of a nutritional risk screen interventions completed within 24 hours of admission, confirmed by RN-F on 1/31/2024 at 12:13PM. -P5 developed a hospital acquired pressure injury (HAPI) during the inpatient visit. On 1/18/2024 at 3:59AM first skin assessment documentation revealed, “blanchable redness to coccyx.” (indicated beginning stages of a pressure injury). A wound consult was not submitted until 1/19/2024 at 11:53AM for the coccyx, the Wound Ostomy Services (WOS) nurse did not consult/assess P5 until 1/22/2024 at 12:04PM (the facility policy states 2 business days-which fell over a weekend, resulting in P5 not being seen for 4 days, and 5 days since the nurse had initially documented the beginning of a pressure injury). 1/22/2024 documentation revealed a Stage II pressure injury to the coccyx 1cm x 1cm x 1cm that was not present on admission (tailbone caused by not providing appropriate pressure relief to the area, ie repositioning, offloading).”