Christus St Vincent Regional Medical Center

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 53401 Based on record review and interview the facility failed to ensure that patient grievances were promptly resolved for 2 (P[patient]5 and P6) out of 2 (P4 and P6) patients reviewed for filing a grievance. This deficient practice could lead to unresolved issues that could negatively impact patient safety, quality of care, and trust in the hospital. The findings are: A. Record review of the facility’s grievance and resolution log from 08/2025 through 01/2026 revealed grievance on 08/25/25 with a resolution date of 12/17/25. The grievance was filed by P4’s representative. 1. Review of a letter from the facility dated 12/17/25 regarding the grievance identified above revealed that the letter was addressed to P5 and stated, “[Name of Facility] “ ...We acknowledge receipt of your written correspondence and are grateful for the opportunity to review the issues you raised. We also appreciate your conversation with our Case Management leadership, as your perspective helped us better understand your experience.” There is no evidence that P5 or P5’s representative was satisfied with the actions of the facility. B. Record review of the facility’s grievance and resolution log from 08/2025 through 01/2026 revealed grievance on 11/10/25 with a resolution date of 12/12/25. The grievance was filed by P6’s representative 1. Review of a letter from the facility dated 12/23/2025 regarding the grievance identified above revealed that the letter was addressed to P6’s representative and stated, “Thank you for taking the time to share your concerns regarding your mother, (P6), recent inpatient stay at [Name of facility]. We recognize how difficult this period has been for you and your family ...Thank you for taking the time to share your concerns regarding your mother’s recent inpatient stay at [Name of facility ...” 2. During an Interview on 2/13/26 at 07:00 am with P5’s representative it was confirmed that her grievance was not resolved in a timely fashion. P5’s representative stated when she spoke with the case manager supervisor, P5’s representative felt that the supervisor did not take any accountability with her [P5’s representative] concerns. P5’s representative stated had she been given the impression that there was urgency in finalizing her husband’s transport, that may have made her feel better. She stated she never heard any words like, “this shouldn’t have happened.” Instead, she reported she was given answers such as, “sorry, you feel we dropped the ball.” and “they are doing their job.” C. During an interview on 02/10/26 at 1:15 pm with S(staff)12, non-clinical, the process for resolving grievances was reviewed. It was explained that they try and have same day contact when they have been notified of a grievance. S12 explained they try to get leaders involved from the department according to what the grievance is. When S12 was asked if they provide other phone numbers or information if the patient is not satisfied with the resolution, S12 replied no”

“PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES CFR(s): 482.13(a)(2)(ii) At a minimum: The grievance process must specify time frames for review of the grievance and the provision of a response. This Standard is not met as evidenced by: 53401 Based on record review and interview the facility failed to ensure that patient grievances were promptly resolved for 2 (P[patient]4 and P6) out of 2 (P4 and P6) patients reviewed for filing a grievance. This deficient practice could lead to unresolved issues that could negatively impact patient safety, quality of care, and trust in the hospital. The findings are: A. Refer to Tag A-0118 B. Refer to Tag A-0118 C. During an interview on 02/10/26 at 1:15 pm with S(staff)12, non-clinical, the process for resolving grievances was reviewed. It was explained that they try and have same day contact when they have been notified of a grievance. S12 explained they try to get leaders involved from the department according to what the grievance is. When S12 was asked if they provided other phone numbers or information if the patient is not satisfied with the resolution, S12 replied to no. Additionally S12 reported they are aware they have 7 days to acknowledge a grievance and 30 days to send out a resolution letter.”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 53401 Based on record review and interview the facility failed to protect and promote each patient’s rights for 4(P[patient]4, P1, P8, and P9) out of 4 (P1-P9) patients reviewed for ensuring patient hygiene and oral care was offered or performed. This deficient practice could negatively impact patient dignity, respect and comfort. The findings are: A. Record review of document dated 09/22/22 and titled, “Patient Rights and Responsibilities” under number one, stated, “Respect, Compassion, and Dignity. The right to considerate, compassionate and respectful care at all times in an environment that promotes a positive self-image.” The facility has failed to follow its own policy. B. Record review of a patient’s grievance letter dated 08/21/25 reveals a grievance with repeated requests for oral care. The response to the patient was, “we recognize how important comfort measures are and regret that this need was not better addressed.” The facility has failed to protect and promote patients’ rights by not providing basic care. C. Record review of P4’s medical record for admission date of 01/9/26 revealed no hygiene or oral care was performed. The facility has failed to protect and promote patients’ rights by not providing basic care during his 24 hour stay at the facility. D. Record review of P1’s medical record for admission date of 08/21/25, revealed no oral care was performed. The facility has failed to protect and promote patients’ rights by not providing basic care during her 6-day hospitalization at the facility. E. During an interview on 02/12/26 at 4:30 pm with P8 a currently admitted patient, stated she had not been offered a bath, only peri care and no oral care was offered or performed. The facility has failed to protect and promote patients’ rights by not providing basic care. F. During an interview on 02/12/26 at 4:40 pm, with P9 currently admitted patient, stated he was “wiped down.” but did not have oral care offered. The facility has failed to protect and promote patients’ rights by not providing basic care. G. During an interview on 02/11/26 at 4:37 pm with a certified nursing assistant reported baths and hygiene duties are assigned in the “Brain” in epic and they are required to perform, and document daily.”

“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: 53401 Based on document review, observation and interview, the facility failed to ensure that all Hospital Acquired Infections (HAIs) are addressed in collaboration with Quality Assurance Performance Improvement (QAPI) leadership for 1(P[Patient] ) out of 1 (P1) reviewed for Hospital Acquired Infections. This deficient practice could lead to placing patients at risk for ongoing transmission of infection and adverse clinical outcomes. The findings are: A.Record review of document dated 04/24/25 titled “Quality Management Council Minutes” revealed only Central Line Associated Blood Stream Infection (CLABSI) and Catheter-Associated Urinary Tract Infection (CAUTI) were reported in this meeting. B.Record review of document dated 06/26/25 titled “Quality Management Council Minutes” revealed there was one CLABSI reported in this meeting. C.Record review of document dated 12/04/25 titled “Quality Management Council Minutes” revealed no new CAUTIs or CLABSIs were acquired. D.Record review of P5’s medical record for admission date of 08/16/25 revealed a positive Methicillin Resistant Staphylococcus Aureus blood culture from 08/20/25. The patient was initially admitted for Gastrointestinal Bleed and Non- ST-segment Elevation Myocardial Infarction (heart attack). With no documented signs of infection upon admission. Unable to determine if P5 was identified with an HAI. E.During an interview on 02/12/26 at 09:06 am with S1, when asked how the facility’s tracked their HAIs he reported they use a program called “Bugsby”. When S1 was asked to provide HAIs audits, no audits were provided, making it difficult to assess the facility’s HAIs tracking and quality efforts.”

“ABX STEWARDSHIP LEADERSHIP DOCUMENTATION CFR(s): [The leader(s) of the antibiotic stewardship program is responsible for:] (ii) All documentation, written or electronic, of antibiotic stewardship program activities. This Standard is not met as evidenced by: 53401 Based on record review, observation and interview, the facility failed to ensure a safe environment to its patient by preventing the spread of transmissible infections. This deficient practice could lead to the transmission of infectious diseases among patients and staff, resulting in avoidable illness, increased morbidity, potential mortality, and compromised patient outcomes. The findings are: A. Record review of document dated 03/2023 titled, “Standard and Transmission Based Precautions” under section C. Contact precautions, number 1. reads, “All Christus associates or clinicians entering a patient room under contact precautions is expected to wear a gown and gloves at all times while in the room.” staff has failed to follow the facility’s policy. B. During an observation on 02/10/26 at 10:45 am, S (Staff)10 was observed to be in a patient’s room not wearing a gown. This patient was on contact isolation precautions and signage was posted on the entry door. C. During an interview on 02/10/26 at 10:48 am with S10 and asked why she was not wearing protective equipment (gown) she replied an IV alarm was sounding and that she was priming an IV (an intravenous tool for administering medications in the vein). S10 further replied, “but I was not providing patient care.””

“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: 47302 Based on record review and interview the facility failed to ensure staff followed the facility’s policies and protocols for 1 (P [patient]1) out of 1 (P1) patient reviewed for adherence to urinary catheter (catheter placed to drain urine from the bladder) and discharge policies. This deficient practice can lead to the lack of care for patients with urinary catheters. The findings are: A. Refer to tag A-0813 for staff not following discharge policies. Catheter policies: B. Record review of the facility’s policy titled, “Urinary Catheter Placement, Care, Maintenance and Removal” dated 11/2024 on page 6 under, “Catheter Removal” stated, “When the patient no longer meets the indications for an indwelling urinary catheter, the catheter may be removed by a licensed nurse or other qualified staff. See Appendix A Urinary Catheter Removal. . . Following removal of the indwelling urinary catheter, the patient will be monitored for any signs and symptoms of urinary retention [the inability to void]. For suspected urinary retention the patient should be encouraged to utilize natural voiding measures. If the patient is still unable to void within 6 hours, further interventions should be guided by bladder scanning [bedside scan that shows if there is urine in the bladder]. C. Bladder management guidelines for adult patients. 1. The patient will be monitored for spontaneous voiding within 6 hours of catheter removal. . .” C. Record review of the facility’s protocol titled, “Urinary Catheter [UC] Removal Protocol” dated 10/17/2023 under “Procedure” stated, “Step 1: Verify that the patient is an appropriate candidate for removal. If the patient has any of the following, STOP and do NOT proceed with catheter removal. . . Step 2: Does the patient meet criteria for continued catheterization?. . . Step 3: If none of the criteria met, the nurse will proceed with Adult Urinary Catheter Removal Protocol. A. The RN can remove the urinary catheter. The nurse documents in the Avatar [program used in the electronic record to identify lines, access and wounds] on the patient that the urinary catheter was removed, removal reason per protocol. 1. Call the Provider only with questions or concerns. 2. If the Removal Protocol is NOT ordered, call for an order if indicated and remove the Invasive Urinary Catheter. B. Once the urinary catheter meets criteria for removal, but is not removed, the nurse must document in the EHR [electronic health record] under urethral catheter criteria - Other Specified per MD [medical doctor] order- and specify reason for not discontinuing UC in the comments. C. Invasive urinary catheter must [be] reassessed for need daily and must be reported to the Clinical Supervisor and Provider.” On page 5 there is a table titled, “Post-Catheter Removal Process” it stated, “After removal of the urinary catheter, the RN assesses and documents the following: 1. The patient is spontaneously voiding 2. The patient is not voiding however is comfortable and expresses no desire to void within 6 hours after the UC has been removed. (Do Not Bladder Scan) 3. A bladder scan should be done for any of the following: a. Patient is uncomfortable at any time, whether voiding or not. b. Patient has an urge or tried to void but is unable to do so. c. Patient is incontinent at any time. d. Patient is unable to void 6 hours after the UC was removed. e. Perform a bladder scan on patients with new onset of mental status change or confusion to ensure adequate bladder emptying. . .” D. Record review of P1’s provider note for admission date 05/14/2024 revealed P1 had a urinary catheter placed on admission for acute urinary retention (inability to void). Subsequent provider notes dated 05/14/2024 at 9:45 PM and 05/15/2024 at 12:37 PM did not reveal any discussion of a urinary catheter or indication for continued urinary catheter. E. Record review of P1’s nursing assessment dated 05/14/2024 at 10:10 AM under “Urethral Catheter Criteria Assessment” stated, “Urinary Catheter Removal Protocol order exits: No.” There was no evidence of a discussion between the nurse and provider indicating whether the urinary catheter should be continued. F. Record review of P1’s provider note for an emergency department visit on 05/15/2024 at 3:09 PM revealed P1 presented for foley removal. Under “Discussion with Independent Historian” stated, “Paramedics, discharged today with a Foley catheter. The facility he is at stated that they cannot have him there with the Foley. He also would like Foley catheter out.” G. Record review of P1’s urinary catheter chart revealed the catheter was removed on 05/15/2024 at 3:18 PM. H. Record review of P1’s “Patient Care Timeline” revealed P1 was discharged on 05/15/2024 at 4:46 PM. There was no verification that 1 was able to spontaneously void prior to discharge after the catheter was removed. I. During an interview on 11/19/2024 at 12:00 PM with S (Staff) 4, non-clinical, it was confirmed that there was no verification that P1 could spontaneously void.”

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 47302 Based on record review and interview the facility failed to ensure that patients were provided education regarding their diagnosis and discharge condition at discharge for 1 (P [patient]1) out of 3 (P1-P3) patients reviewed for discharge from the hospital. This deficient practice could lead to patients not being prepared to care for themselves at home and could result in a return to the hospital. The findings are: A. Record review of the facility’s policy titled, “Discharge and Transfer of Patients” dated 11/12/2021 under “Purpose” stated, “The purpose of this policy is to provide for efficient and safe guidelines for patient discharge and transfer through good communication with patient, family, significant others and members of the health care team.” Under, “Procedure” stated “A. The patient shall be discharged upon written order of the physician/designee based on the following criteria:. . . 9. Medical support (e.g. catheter, ventilator, IV’s etc.) needs addressed. . . B. . . . Written discharge instructions including written patient and family education will be provided to the patient or other service provider.” B. Record review of P1’s medical record for the admission date 05/14/2024 revealed the following: 1. Review of the provider’s note dated 05/14/2024 revealed P1 presented with shaking for several days. P1 was found to be retaining urine (not voiding) and a foley catheter was placed. 2. Review of the discharge summary dated 05/15/2024 did not reveal urinary retention as a discharge diagnosis and the note by a provider did not reveal any mention that a foley catheter was placed. 3. Review of P1’s discharge instructions printed on 05/15/2024 at 1:06 PM under “Diagnoses” it listed urinary retention and under “Done Today” stated, “Insert Foley catheter”. The discharge instructions did not reveal any evidence of education on the care of a foley catheter. C. Record review of P1’s provider note for an emergency department visit on 05/15/2024 at 3:09 PM revealed P1 was presented for foley removal. Under “Discussion with Independent Historian” stated, “Paramedics, discharged today with a Foley catheter. The facility he was at stated that they cannot have him there with the Foley. He also would like Foley catheter out.” Patient was discharged on 05/15/2024 at 4:46 PM. D. During an interview on 11/19/2024 at 12:00 PM with S (staff) 4, non-clinical, it was confirmed that there was no evidence that P1 or the caregivers received information about being discharged with a urinary catheter.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 49844 Based on interview and record reviews the facility failed to obtain a consent for treatment for 1 (P [patient] 10) of 10 (P1-P10) patients being reviewed for Patient Rights. This failed practice to obtain consent is likely to result in a violation of patients’ rights to consent or refuse treatment. The findings are: A. Record review of the facility’s policy titled “Patient Rights and Responsibilities” Dated 05/30/23, stated “Informed Consent: You have the right to reasonable, informed participation in decisions involving your health care. You have the right to give informed consent prior to the start of any procedure or treatment.” B. Record review of P10’s Medical Record revealed P10 was admitted to the facility on 03/11/24, and discharged on 03/17/24, home with a family member. During this time the patent received treatment including medications, laboratory blood samples, diagnostic imaging (the use of electromagnetic radiation and certain other technologies to produce images of internal structures of the body for the purpose of accurate diagnosis) and assessments. The patient was noted to be alert and oriented and also had family members at the bedside. C. Record review of the P10’s Medical Record section “Registration History for the Patient Encounter” stated on 03/13/2,4 at 10:34 AM “[name of facility] REG [registration] PT [patient] MISSING CONSENT FOR TREATMENT” and on the day of discharge 03/17/24 ,at 12:50 PM “[name of facility] REG PT MISSING CONSENT FOR TREATMENT DOCUMENT,” indicated that consent for treatment had not been obtained. D. During an interview with Staff (S)12, Patient Access Service Director, on 03/27/24, at 11:38 AM, S12 confirmed that there was no consent for treatment obtained for P10. When asked who should sign a consent for treatment form. S12 stated “The patient, if the patient is not able to give consent, then we would ask a family member or someone that can give consent for the patient.” When asked what patients should give consent for treatment. S12 stated “all patients.””