Bayshore Medical Center

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 51986 Based on medical record review, staff interview, and review of facility documents, it was determined the facility failed to ensure that restraint monitoring, assessment, and discontinuation, are performed and documented in accordance with facility policy, in two of 10 medical records reviewed (Patient (P)8 and P10). Findings include: Facility document titled, “Restraints” (Effective 09/2025) stated, “... Evaluation by the LP [Licensed Provider] ... Within one hour of giving the initial order, an LP shall respond, conduct, and document a face-to-face evaluation of the patient ... Documentation: ... Time of initiation of the restraint ... must be documented ... Interventions: Interventions while a patient is restrained shall be performed by nursing personnel in accordance with nursing policy ... Each assessment and nursing intervention should be made as follows: ... Current behaviors indicating need for restraints ... Circulation and skin assessment ... Release of Restraints to: Assess skin circulation and integrity ... Perform skin care ... Perform range of motion at minimum of 5 minutes/limb ... Patient comfort needs offered: Fluids and Nutrition ... Toileting ... Visual Observation: For Restraints for Non-Violent Behavior ... visual observation will be continuous or period ... and will be documented at a minimum of every two hours ... Removal of Restraints ... Restraints must be discontinued at the earliest possible time regardless of the length of time identified in the order ... “ On 01/28/25 at 11:53 AM, medical record review was conducted with S12, in the presence of S3. A review of P10’s medical record revealed the following: On 12/09/25 at 12:08 PM, a physician placed a STAT [requires immediate action] order for “Restraints Non-Violent (To prevent disruption of treatment).” The restraint type ordered was “Soft Limb - Wrist (Both Right and Left).” P10’s observed behavior was documented in the order as “Disoriented” and the clinical justification for the restraint was documented in the order as, “Prevent unintentional Harm to Self.” The initial documentation for a Non-Violent Bilateral Soft Limb Wrist restraint in P10’s medical record restraint flowsheet was dated 12/09/25 at 8:00 PM. This entry was documented as “continued.” Upon interview, at the time of discovery, S12 stated that the initial restraint documentation should have been documented as “started,” rather than “continued,” to indicate when the restraints were first applied. S12 stated that “continued” suggested the restraints were already in place and would be assessed every two hours for the patient’s ongoing need. Once a restraint is “started,” the subsequent documentation options are “continued” or “discontinued.” On 12/10/25 between the hours of 10:00 AM and 8:00 PM, there was no documented evidence that nursing performed assessments of the patient while on restraints. At the time of discovery, S12 confirmed these findings and stated there should have been documentation every two hours in P10’s restraint flowsheet. On 12/13/25 at 6:00 AM, there was no documented evidence that nursing performed an assessment of the patient while on restraints. At the time of discovery, S12 confirmed these findings and stated there should have been documentation every two hours in P10’s restraint flowsheet. A review of P8’s medical record revealed the following: On 12/04/25 at 9:09 PM, a physician placed a STAT order for “Restraints Non-Violent (To prevent disruption of treatment).” The restraint type ordered was “Soft Limb - Wrist (Both Right and Left).” P10’s observed behavior was documented in the order as “Attempting to Disrupt treatment” and the clinical justification for the restraint was documented as “Prevent unintentional Harm to Self.” On 12/06/25 at 6:00 AM, the final documentation discovered in P8’s restraint flowsheet was documented as “continued.” On 12/06/25 at 12:58 PM, the physician discontinued the order for “Restraints Non-Violent (To prevent disruption of treatment).” At the time of discovery, S12 stated there should be documentation indicating P10’s restraints were discontinued by nursing and that the current documentation did not indicate when P10 was removed from his/her restraints. On 01/28/26 at 1:05 PM, S12 confirmed the above findings. S12 stated P10’s restraint flowsheet did not have initial documentation on when P10 was placed in restraints. S12 stated P10 had several gaps in documentation that was required every two hours. S12 confirmed that P8’s restraint flowsheet did not reveal when P8 had his/her restraints discontinued. S3 confirmed the above findings.”

“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: 50602 Based on review of four out of eleven medical records (Patient (P)1, P7, P9, and P10), review of facility policy, and staff interviews, it was determined that the facility failed to ensure that complete assessments of wounds are documented upon admission in accordance with facility policy. Findings include: Facility policy titled “Wound Assessment and Management,” last revised on 05/2025, stated “ ...Assessment: 1. A complete assessment of pressure injuries/wounds should be documented: On admission (if present), On development during the hospital stay, On noting a change in the wound (improvement, deterioration, evolution), Weekly during hospital stay, Upon transfer, Prior to discharge ...3. Pressure Injuries/sounds [sic] should be further assessed and documented as follows: Location ...Dressing Condition ...Dressing Type ...Stage (only for pressure injuries) ...Size Measure all pressure injuries/wounds in centimeters(cm), Measure length, width, and depth at the longest, widest and deepest aspect ...Wound Appearance/Tissue Type/Color ...4. Drainage ...Periwound Skin ...” On 11/26/25 at 10:31 AM, upon interview, Staff (S)18 explained that skin assessments are completed by two nurses upon admission for patients. All wounds are measured and documented, and the nurse notifies the admitting provider and requests a wound consultation with the wound care nurse (WCN). On 11/26/25 at 12:00 PM, upon interview, S7 stated that he/she usually documents his/her consults in the progress notes. S7 stated that he/she will do their own measurements of wounds for new patient consults. On 11/25/25 at 11:45 AM, medical records were reviewed in the presence of S10 and S12. S10 stated that initial skin and wound assessments would be found in the assessment flowsheets. Patient (P)1’s medical record was reviewed. On P1’s assessment flowsheet, the following wounds were documented upon admission on 08/16/25: “ ...Pressure Injury (PI) ...Coccyx ... Stage - Unstageable [unable to assess stage of wound due to presence of dead tissue] ...Pressure Injury ... Buttocks Left ...Stage- 3 ...Pressure injury Buttocks Right ...Stage-3 ...Pressure Injury ...Heel Right ...Stage- Unstageable ...Pressure Injury ...Tibial Left; Posterior ...” The flowsheet lacked documentation that P1’s pressure injuries were measured upon admission. In P1’s medical record, a progress note dated 09/10/25 at 10:00 AM, stated “Wound care Pt [patient] laying on envella [special hospital bed used to help treat and prevent pressure injuries], vented, lethargic. With assistance from primary RN [Registered Nurse] and PCT [Patient Care Technician] pt turned ...noted sacrum unstageable, wound bed necrotic [dead tissue] small amount of serosanguinous [a mixture of blood and watery fluid] drainage. Wound cleaned with vashe [wound cleanser], santyl [a topical medication used to clean and remove dead tissue] applied to all necrotic area, covered with gauze ...Recommend frequent turning and repositioning every 2 hour Offloading boots Primary RN updated.” The progress note lacked measurements of P1’s pressure injuries. The medical record lacked evidence that P1’s pressure injuries were measured and documented in accordance with facility policy. On 11/26/25, additional medical records were reviewed in the presence of S10. On P7’s flowsheet, the following wounds were documented upon admission on 10/04/25: “...Wound Pressure Injury ...Buttocks Left ... Stage- 1 ...Wound Pressure Injury ...Buttocks Right ...Stage- 3.” The medical record lacked evidence that the measurements and the appearance of P7’s pressure injuries were documented on admission in accordance with facility policy. On P9’s flowsheet, the following wounds were documented upon admission on 11/02/25: “...Pressure Injury Right Heel ...Periwound Skin- Erythema ...Site Assessment-Drainage ...Wound Drainage Amount- Scant ...Drainage Description-Tan ...Wound Odor- Malodorous ...Pressure Injury Left Ischium ...Periwound Skin-Erythma ...Tunneling (cm)-2 ...Undermining (cm)- 2 ...Site Assessment- Drainage; Fibinous; Sloughing ...Wound Drainage Amount-Scant ...Drainage Description-Tan ...Wound Odor- Malodorous ...Pressure Injury Right; Upper/Superior; Dorsal Arm ...Periwound Skin- Erythema ...Site Assessment- Pink; Sloughing ...Wound Odor- No Odor ...Pressure Injury Left Pretibial ... Periwound Skin- Erythema ...Site Assessment- Fibrinous; Sloughing ...Wound Odor- Malodorous ...Pressure Injury Right; Lateral Thigh ...” P9’s flowsheet lacked evidnence of measurements and staging of pressure injuries upon admission. On P10’s flowsheet, the following wounds were documented upon admission on 11/23/25: “Pressure Injury Mid Sacrum ...Pressure Injury Right Ischium ...Pressure Injury Right Heel ...Pressure Injury Left; Posterior Ankle ...Pressure Injury Lateral; Left Leg ...Pressure Injury Midline; Anterior Head ...” Under “2 RN Skin Assessment,” section, next to “Name of 2nd RN,” was a blank space. This finding was confirmed by S10. S10 confirmed that the only assessments completed for P10’s pressure injuries were documented by the bedside nurse in the flowsheets. P10’s admission flowsheet lacked documentation of skin assessment completion with a second nurse, staging of wounds, appearance, as well as measurements as per policy. The above finding was confirmed with S10 at the time of discovery.”

“CONTENT OF RECORD: CONSULTATIVE RECORDS CFR(s): 482.24(c)(4)(iii) [All records must document the following, as appropriate:] Results of all consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient. This Standard is not met as evidenced by: 50602 Based on a review of three out of eleven medical records reviewed (Patient (P)1, P7, and P8), staff interviews, and a review of facility documents, it was determined that the facility failed to ensure that wound care consults are completed promptly. Findings include: On 11/25/25 at 10:15 AM, in the intensive care unit (ICU), upon interview, Staff (S)11 described the process for admission skin assessments. S11 explained that two Registered Nurses (RN) will look at the patient’s skin together. If they observe a stage one to four pressure injury (damage to skin and the tissue underneath it caused by constant pressure on one area) upon admission, he/she will put in a consult for the wound care nurse (WCN), especially if there are multiple identified so they can get further recommendations. On 11/26/25 at 10:31 AM, upon interview, S18 explained that skin assessments are completed by two nurses at admission. All wounds are measured and documented, and the nurse notifies the admitting provider and requests a wound consultation with the WCN. S18 indicated that the WCN usually sees the patient within 24 to 48 hours. If the consultation is not completed within that time frame, S18 stated, “I would message the WCN through Epic and notify the nursing supervisor. I would also document in the ‘Nursing Communication’ section in Epic.” On 11/25/25 at 12:30 PM, S1 explained that the WCN does his/her rounds every day, however there is no coverage on the weekends. S1 stated that the facility has wound care champions that could sometimes provide coverage for the WCN. S1 also stated that recently the facility has changed the wound care structure, and the outpatient wound care nurses are now covering for the inpatient WCN. On 11/26/25 at 12:00 PM, an interview with S7 (Wound Care Nurse) was conducted. S7 stated that he/she can have as little as four consults to as much as eighteen consults in one day. S7’s works Monday through Friday, and there is no coverage on weekends. S7 explained their process when they come in is to print out the census for the day, and usually will prioritize completing the oldest consults, or new ostomies first. On days when he/she has up to 18 patients to see, it is very difficult to complete them all and often will have to carry over onto the following day, although S7 will prioritize seeing them first the following day. At 11:45 AM, medical records were reviewed in the presence of S10 and S12. S10 stated that initial skin and wound assessments would be found in the assessment flowsheets. On P1’s nursing flowsheet, the following wounds were documented upon admission on 08/16/25: “...Pressure Injury (PI) ...Coccyx ... Stage -Unstageable [unable to assess stage of wound due to presence of dead tissue] ...Pressure Injury... Buttocks Left ...Stage- 3 ...Pressure injury Buttocks Right ...Stage-3 ...Pressure Injury ...Heel Right ...Stage- Unstageable ...Pressure Injury...Tibial Left; Posterior ...” An order for “Inpatient Referral to Wound/Ostomy Care,” was placed on 08/16/25 at 3:37 AM. The Progress Note dated 08/19/25 at 10:30 AM, entered by the Wound Care Registered Nurse (RN) stated, “Pt [patient] receiving dialysis will follow another time. Primary RN updated.” A follow-up Wound Care Progress Note was completed on 09/10/25 at 10:00 AM. S10 confirmed that P1’s medical record lacked documentation of being evaluated by the Wound Care RN until 09/10/25. On P7’s flowsheet, the following wounds were documented upon admission on 10/04/25: “...Pressure Injury ...Buttocks Left ...Stage-1...Pressure Injury ...Buttocks Right ...Stage- 3 ...” An order for “Inpatient Referral to Wound/Ostomy Care,” was placed on 10/04/25. The Progress Note for Wound Care was documented as being completed on 10/17/25. S10 confirmed that P7’s medical record lacked documentation of being evaluated by the Wound Care RN until 10/17/25. On P8’s flowsheets, the following wounds were documented upon admission on 08/30/25: “...Pressure Injury ...Sacrum.” An order for “Inpatient Referral to Wound/Ostomy Care,” was placed on 08/30/25. A Progress Note for Wound Care was documented as being completed on 09/03/25. S10 confirmed that P8’s medical record lacked documentation of being evaluated by the Wound Care RN until 09/03/25. At 2:40 PM, when asked when the wound care nurse should see the patient, S12 stated they would want them to see a patient within 24 hours of the order being placed, but it is not stated in a policy. The facility policy titled “Wound Assessment and Management,” last revised 05/2025, stated, “...KeyPoints Notify provider & Wound, Ostomy, Continence (WOC) or Wound Care Certified (WCC) nurse of all patients with pressure injuries Stage 2, 3, 4, DTPI [Deep Tissue Pressure Injury], and unstageable pressure injuries...” The policy did not specify that the wound care consult needed to be completed with 24 to 48 hours as per staff interviews. The policy addressing Wound Care Consults, which included the timeframes for conducting consults, was requested and not received. The above findings were confirmed with S10 at the time of discovery.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 50613 Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to ensure that 1). pain assessment and reassessments are performed in accordance with facility policy for one of 10 patients (Patient (P) 6); and 2). interventions to alleviate pain are implemented according to facility policy in two of 10 medical records reviewed (P7 and P10). Findings include: The facility policy titled, “Pain Management” effective 10/2021, stated, “A. Purpose: [Facility name] requires that pain be assessed in all locations where care is provided. When pain is identified, appropriate interventions or referrals are utilized and follow up evaluations and documentation ensues to assess outcomes. ..D. Procedure. 1. Pain Assessment...the presence or absence of pain continues to be evaluated and documented no less often than once every eight hours and upon discharge for inpatients and more frequently as necessary...G. Documentation ...b. Pain reassessment is completed within a maximum of one hour following pain medication administration and is documented ... Appendix A Pain/Sedation Screening ...Pain Severity Scales= mild 1-3, moderate 4-7, and severe 8-10. “ 1. A review of P6’s medical records revealed that P6 presented to the ED on 12/7/24 at 1:24 PM, with a chief complaint of dental pain. At 1:31 PM, P6’s pain was assessed at a 10/10. At 1:54 PM, P6 was medicated for pain with Toradol 30mg (milligrams) and at 2:00 PM with xylocaine 2% viscous solution (a medication used to numb the mouth). P6 was discharged at 2:05 PM. P6’s pain level was not re-assessed after pain medication was administered or prior to be patient being discharged. At 12:15 PM, an interview was conducted with Staff (S)4, the Emergency Department Nurse Manager. S4 stated that pain should have been re-assessed “ideally within 30 minutes of the patient being medicated, or at most one hour.” S4 confirmed that the emergency department follows the parameters documented in the “Pain Management” policy and procedure. 2) On 2/11/25, a review of P7’s medical record was conducted with S14, the Nurse Professional Development Specialist. P7 presented to the Emergency Department (ED) on 1/11/25 at 1:56 PM, with a chief complaint of abscess (complicated). At 2:03 PM, P7’s pain was assessed as a 9/10 on the numeric pain severity scale. At 3:40 PM, P7’s CT Facial Bones with Contrast Impression stated, “ ...Significant lucency surrounding left maxillary tooth (#13) could reflect dental caries with possible osteomyelitis ...” At 4:26 PM, P7’s pain was assessed as a 6/10 on the numeric pain severity scale. P7 was discharged home at 4:27 PM with an oral antibiotic prescription of Clindamycin 300 mg (milligrams). At 11:25 AM, upon interview, S10, the Emergency Department Chair Medical Director, stated, “typically a patient with tooth pain would receive a lidocaine block or some kind of pain relief medication.” S10 further stated that P7 should have received medication for pain, and if the patient was offered pain medication and refused that would be documented. S10 confirmed P7’s medical record lacked evidence that P7 received an intervention for pain. On 2/11/25, a review of P10’s medical record was conducted with S14. P10 arrived at the ED on 1/7/25 at 7:01 PM for an evaluation of vomiting and diffuse abdominal pain. At 7:10 PM, P10 reported pain as 8/10 on the numeric pain severity scale. At 9:10 PM, Zofran 4mg (milligrams) IV (intravenous) was administered for nausea. At 10:05 PM, the results of the CT scan of the abdomen and pelvis were unremarkable. At 11:35 PM, the patient was reassessed for pain and P10’s pain was a 2/10 on the numeric pain severity scale. At 11:43 PM, P10 was discharged home. At 12:00 PM, upon interview, S10 stated that if a patient presents with 8/10 pain, he/she would be given an immediate intervention for pain relief. S10 confirmed P10 did not receive any intervention for two hours.”