Plains Regional Medical Center

“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: 53779 482.23 (b) (6) Standard: All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital The standard is not met as evidenced by: Based on interviews, observation and record reviews, the facility failed to comply with hygiene requirements for 4 (P [patient] 5, P6, P8 and P9, out of 9 (P1-P9) patients. This deficient practice places patients at risk for developing dental caries and tooth loss, oral lesions, skin breakdown, pressure ulcers from matted hair and infections. The findings are: A. Record Review of the policy titled, “Nursing Guidelines for Care - Adult Medicine/Surgical” dated 04/21/25 indicated, “Patients on the unit will receive care consistent with the guidelines outlined in this policy and within specified time frames ....Assistance with complete bath or shower is offered and documented in the patient’s EMR at least once every 24 hours ...Oral hygiene is performed and documented in the patient’s EMR at least once a shift and as needed ...Routine care of dentures is performed each shift ...” B. Record Review of the policy titled, “Nursing Guidelines for Care - Adult Intensive Care Units Guidelines” dated 03/02/23 specified the facility requires the Nurse to provide, “ Assistance with complete bath or shower is offered at least once every 24 hours ....Oral hygiene is performed every 4 hours and as needed for all intubated patients and patients with decreased level of consciousness (LOC).” C. During an interview with S (Staff) 12, clinical, on 03/03/26 at 12:12 pm, S12 reported they were unaware of a policy specifying bathing frequency. S12 stated they ensured bathing and linen changes were completed at least every two days. S12 also stated, “For the HCG wipes, the night shift wipes down the patient.” D. During an interview with S14, clinical, on 03/03/26 at 12:45 pm, S14 reported that baths had previously been assigned by shifts using odd and even numbered days. S14 stated they were unaware of any current policy or routine addressing hygiene care and that they ask patients whether they wanted a bath or shower. E. During an interview with the family member Power of Attorney for P(Patient)6 on 03/03/26 at 2:45 pm, the family member and Power of Attorney for P(Patient)6 reported the patient was unable to perform any self-bathing care and was non verbal. The family member stated they remained at the bedside during the first few days of hospitalization but then had to leave for work. Upon returning a few days later, they observed the patient’s hair was completely matted and that the patient had developed a rash on the chin due to drooling. F. During an interview with S20, clinical, on 03/04/26 at 6:00 am, S20 stated there was no specific policy or routine for patient hygiene care. If it was not completed on their shift, they just reported that to the oncoming shift so that it would get done. S20 also stated they used to use the ‘sticky note’ feature in the electronic chart to help keep track of when hygiene was due, but staff no longer use that function. G. During a record review of the medical chart for P5 on 03/04/2026 at 8:00 am it was noted that this intubated, sedated patient had not received the required oral care every 4 hours. H. During a record review of the patient care flowsheets for P6 it was revealed that this patient had not received a complete bed bath, hair care and oral care per policy. P6 is mentally and physically unable to complete any personal care or communicate their needs. There were multiple entries in the nursing assessments noting dry mouth and cracked lips. P6 is unable to eat or drink by mouth and receives nutrition through a tube in their abdominal wall. I. During an interview with P8 on 03/04/26 at 1:45 pm, P8 stated in the 5 days they had been on the unit that no one had offered to help brush their teeth. P8 reported being unable to get out of bed the first two days. P8 stated, “I didn’t know I was going to end up in the hospital so I didn’t pack anything.” P8 stated they had no toothbrush or toothpaste during their stay, or if they were provided then, “No one told me where they were.” J. During an interview with P9 on 03/04/2026 at 2:00 pm, P9 stated their dentures had not been removed from their mouth or cleaned in the 4 days since admission. P9 states they are unable to get out of bed to the bathroom without help because of the fall they sustained before entering the hospital. 1. During an observation of P9’s room on 03/04/2026 at 2:00 pm an empty denture cup was on the bedside table. Dentures were present in P9’s mouth. A pink basin containing supplies, including an unopened toothbrush and toothpaste, was located on a shelf across the room from the bed.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(2) Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm. This Standard is not met as evidenced by: 49835 Based on record review and interviews the facility failed to ensure the least restrictive restraint was used on 1(P[patient] 2) out of 3 (P1- P3) patients causing harm with restraint being too tight and around P2’s neck causing respiratory distress and possibly P2’s death. This deficient practice could place all patients with Posey Vest (a vest that goes around the chest of the patient and is tied to the bed or wheelchair, designed to immobilize the patient and protect patients from falling) restraints at risk for respiratory distress and possible death. The findings are: A. Record review of facility’s policy titled, “Restraint Management,” dated 04/22/25 stated the following: 1. Under Purpose of this policy, it stated, “Restraints are not to be used for convenience and that they are not to be used routinely for fall prevention.” 2. Under section 2 it stated, “Restraints have the potential to produce serious consequences, such as physical or psychological harm, loss of dignity, violation of an individual’s rights and even death. Before a restraint is applied, alternate and less restrictive measures are attempted and documented before utilizing restraints.” 3. Under section 5- “initiation and management of the restraint is reflected in the patients care plan”. 4. Under Central Delivery System Section 6- “Staff Communication with Provider Regarding Discontinuation or Intiation of Restraint” 6.1 “In an emergency application situations, a provider order must be obtained either during the emergency applicationof the restraint, or immediately (within a few minutes) after the restraint has been applied”. Under 6.2 “In a non-emergent situations where assessment indicates a need for restraint, staff notifies the provider and must receive the order before applying a restraint”. B. Record review of P2’s emergency room medical record, with admission date 07/26/25 at 1:03 pm. P2 was admitted with a chief complaint of altered mental status, hypothyroidism, Myasthenia gravis, and sepsis. 1. On 07/26/2025 at 2:00 pm under Ed- Nurses notes it revealed P2 had a fall in the last 90 days reported by daughter, it also revealed soft bilateral wrist restraints (padded, non-locking cuffs applied to both of patients wrists to limit their ability to grab or remove medical devices, interfere with care, or self harm) were ordered by the provider because the patient was pulling out their intravenous line (catheter in the vein where fluids, medications, or nutrition are delivered) and pulling at their Foley Catheter (a thin tube inserted into the bladder to drain urine continuously). Fall precautions were also ordered and to keep patient in line of sight due to impaired safety judgement. This order remained through P2’s hospital stay. 2. Review of P2’s medical record under flowsheet, dated 07/28/25 at 3:00 pm, on the Medical-Surgical unit (hospital unit that cares for a diverse range of adult patients with general medical conditions) the nurse caring for P2 removed the bilateral soft wrist restraints and applied a Posey Vest restraint. There was no documentation of the provider or family being notified of the application of the Posey Vest Restraint being applied. There was no order for the Posey Vest Restraint and no documentation of the need for the Posey Vest Restraint. There was no documentation that an assessment of the Posey Vest restraint was completed to ensure it was applied correctly and not too tight. 3. On 07/29/25 at 5:00 am the documentation uner restraint documentation flowsheet revealed that the vest restraint was in place. There was no assessment of the patient response to the vest restraint or assessment that the vest restraint was applied correctly. 4. On 07/29/25 at 8:00 am under nurses narrative the Posey Vest restraint was removed due to the restraint preventing the patient from fully expanding their lungs. The patient was unresponsive with a pulse present, the patient was in respiratory distress and needed 15 liters of oxygen. The emergency medical team was called and P2 was transferred to the intensive care unit (specialized care for critically ill patients with life threatening conditions). 5. On 07/30/25 at 8:45 am, under care plan notes by RN (Registered Nurse) P2 was admitted to in-patient hospice (a specialized care in the hospital for people with serious illnesses, focused on comfort quality of life, and dignity rather than a cure typically when a doctor projects a life expectancy of 6 months or less). 6. On 07/31/2025 under care plan notes P2 passed away and was pronounced at 8:18pm. C. During an interview with S(staff)4, clinical, on 08/19/25 at 7:15 am, S4 stated Soft bilateral wrist restraints are used to keep patients from pulling out IV’s, tubes, and Foley Catheters and are used to prevent falls, especially if we don’t have enough staff. S4 confirmed Posey Vest restraints are used to prevent falls, S4 explained that soft wrist restraints are to stop patients from pulling on lines and foleys. D. During an interview with S2, clinical, on 08/19/25 at 12:15 pm, S2 confirmed the wrist restraint should not have been changed to a Posey Vest Restraint, especially without speaking to the provider and getting an order first. S2 also confirmed, the Posey Vest restraint and wrist restraints are not the same, the wrist restraints are used to keep the patient from pulling out IV’s and Foley Catheter and a Posey Vest Restraint is used to prevent falls, other interventions are to be attempted before using restraints. S2 confirmed that no other interventions were attempted prior to the application of the Posey Vest restraint for P2. E. During an interview with S1, clinical, on 08/19/25 at 3:30 pm, it was confirmed there was no order for a Posey Vest restraint, the Posey Vest restraint should not have been applied, and the care plan was not updated for Posey Vest restraint. There was no assessment of the restraint placement. The Posey vest restraint is not used for the same reason the wrist restraints are ordered. With the Posey Vest restraint around the chest tied to the bed it prevented the patient from falling, it would not have prevented the patient from pulling on lines and tubes which was the reason the wrist restraints were ordered. F. During an interview on 08/20/25 at 7:30 am with S5,clinical, S5 stated we try to use chemical restraints first and then we use physical restraints to prevent falls and to keep the patient from pulling out IV’s, Foley Catheters and tubes. S5 also confirmed the staff does not attempt other interventions prior to applying physical restraint to prevent falls. G. During an interview with S7, clinical, on 08/20/25 at 7:45 am, S7 explained that P2 was found in bed sitting up with the Posey Vest restraint tight on her neck and the Posey Vest restraint was too tight around the chest preventing the lungs from expanding, P2 was unresponsive with a pulse, in respiratory distress, with an increased need for oxygen. P2 was transferred to ICU where she was placed on comfort care (provides physical, emotional, social and spiritual support to patients and families, focusing on control of pain and other symptoms to improve quality of life rather than providing a cure) with P2 being given Morphine (liquid narcotic for pain) and Ativan (antianxiety medication) for anxiety. H. During an interview with S6, clinical, on 08/20/25 at 9:30 am, it was confirmed they applied the Posey Vest restraint because the patient’s wrists were red and the patient was trying to get out of bed. S6 confirmed the provider was not called for an order, and the family was not notified of the Posey Vest restraint being placed on P2. S6 confirmed the wrist restraints were not for high fall risk but to prevent the patient from pulling out lines and the Foley Catheter and a Posey Vest restraint is used to prevent falls.”

“PATIENT RIGHTS:RESTRAINT/SECLUSION DEATH RPT CFR(s): 482.13(g)(1) & (3)(i) [Death Reporting Requirements: Hospitals must report deaths associated with the use of seclusion or restraint.] (1) With the exception of deaths described under paragraph (g)(2) of this section, the hospital must report the following information to CMS by telephone, facsimile, or electronically, as determined by CMS, no later than the close of business on the next business day following knowledge of the patient’s death: (i) Each death that occurs while a patient is in restraint or seclusion. (ii) Each death that occurs within 24 hours after the patient has been removed from restraint or seclusion. (iii) Each death known to the hospital that occurs within 1 week after restraint or seclusion where it is reasonable to assume that use of restraint or placement in seclusion contributed directly or indirectly to a patient’s death, regardless of the type(s) of restraint used on the patient during this time.”Reasonable to assume” in this context includes, but is not limited to, deaths related to restrictions of movement for prolonged periods of time, or death related to chest compression, restriction of breathing or asphyxiation.... (3) The staff must document in the patient’s medical record the date and time the death was: (i) Reported to CMS for deaths described in paragraph (g)(1) of this section; or .... This Standard is not met as evidenced by: 49835 Based on record reviews and interviews the facility failed to ensure that the death of a patient using a Posey Vest Restraint was reported to the CMS for 1(P[Patient]2) out of 3 (P1-P3) patients. This deficient practice could result in incidents of abuse, neglect and deaths not being analized, investigated and an appropriate corrective action to occur according to the State and Federal law. The findings are: A. Record review of facility’s policy titled, “Restraint Management,” dated 04/22/25 stated the following: 1. Under Purpose of this policy, it stated, “Restraints are not to be used for convenience and that they are not to be used routinely for fall prevention.” 2. Under section 2 it stated, “Restraints have the potential to produce serious consequences, such as physical or psychological harm, loss of dignity, violation of an individual’s rights and even death. Before a restraint is applied, alternate and less restrictive measures are attempted and documented before utilizing restraints.” 3. Under section 5- “initiation and management of the restraint is reflected in the patients care plan”. 4. Under Central Delivery System Section 6- “Staff Communication with Provider Regarding Discontinuation or Intiation of Restraint” 6.1 “In an emergency application situations, a provider order must be obtained either during the emergency applicationof the restraint, or immediately (within a few minutes) after the restraint has been applied”. Under 6.2 “In a non-emergent situations where assessment indicates a need for restraint, staff notifies the provider and must receive the order before applying a restraint”. B. Record review of P2’s emergency room medical record, with admission date 07/26/25 at 1:03 pm. P2 was admitted with a chief complaint of altered mental status, hypothyroidism, Myasthenia gravis, and sepsis. 1. On 07/26/2025 at 2:00 pm under Ed- Nurses notes it revealed P2 had a fall in the last 90 days reported by daughter, it also revealed soft bilateral wrist restraints (padded, non-locking cuffs applied to both of patients wrists to limit their ability to grab or remove medical devices, interfere with care, or self harm) were ordered by the provider because the patient was pulling out their intravenous line (catheter in the vein where fluids, medications, or nutrition are delivered) and pulling at their Foley Catheter (a thin tube inserted into the bladder to drain urine continuously). Fall precautions were also ordered and to keep patient in line of sight due to impaired safety judgement. This order remained through P2’s hospital stay. 2. Review of P2’s medical record under flowsheet, dated 07/28/25 at 3:00 pm, on the Medical-Surgical unit (hospital unit that cares for a diverse range of adult patients with general medical conditions) the nurse caring for P2 removed the bilateral soft wrist restraints and applied a Posey Vest restraint. There was no documentation of the provider or family being notified of the application of the Posey Vest Restraint being applied. There was no order for the Posey Vest Restraint and no documentation of the need for the Posey Vest Restraint. There was no documentation that an assessment of the Posey Vest restraint was completed to ensure it was applied correctly and not too tight. 3. On 07/29/25 at 5:00 am the documentation uner restraint documentation flowsheet revealed that the vest restraint was in place. There was no assessment of the patient response to the vest restraint or assessment that the vest restraint was applied correctly. 4. On 07/29/25 at 8:00 am under nurses narrative the Posey Vest restraint was removed due to the restraint preventing the patient from fully expanding their lungs. The patient was unresponsive with a pulse present, the patient was in respiratory distress and needed 15 liters of oxygen. The emergency medical team was called and P2 was transferred to the intensive care unit (specialized care for critically ill patients with life threatening conditions). 5. On 07/30/25 at 8:45 am, under care plan notes by RN (Registered Nurse) P2 was admitted to in-patient hospice (a specialized care in the hospital for people with serious illnesses, focused on comfort quality of life, and dignity rather than a cure typically when a doctor projects a life expectancy of 6 months or less). 6. On 07/31/2025 under care plan notes P2 passed away and was pronounced at 8:18pm. C. During an interview with S(staff)4, clinical, on 08/19/25 at 7:15 am, S4 stated Soft bilateral wrist restraints are used to keep patients from pulling out IV’s, tubes, and Foley Catheters and are used to prevent falls, especially if we don’t have enough staff. S4 confirmed Posey Vest restraints are used to prevent falls, S4 explained that soft wrist restraints are to stop patients from pulling on lines and foleys. D. During an interview with S2, clinical, on 08/19/25 at 12:15 pm, S2 confirmed the wrist restraint should not have been changed to a Posey Vest Restraint, especially without speaking to the provider and getting an order first. S2 also confirmed, the Posey Vest restraint and wrist restraints are not the same, the wrist restraints are used to keep the patient from pulling out IV’s and Foley Catheter and a Posey Vest Restraint is used to prevent falls, other interventions are to be attempted before using restraints. S2 confirmed that no other interventions were attempted prior to the application of the Posey Vest restraint for P2. E. During an interview with S1, clinical, on 08/19/25 at 3:30 pm, it was confirmed there was no order for a Posey Vest restraint, the Posey Vest restraint should not have been applied, and the care plan was not updated for Posey Vest restraint. There was no assessment of the restraint placement. The Posey vest restraint is not used for the same reason the wrist restraints are ordered. With the Posey Vest restraint around the chest tied to the bed it prevented the patient from falling, it would not have prevented the patient from pulling on lines and tubes which was the reason the wrist restraints were ordered. F. During an interview on 08/20/25 at 7:30 am with S5,clinical, S5 stated we try to use chemical restraints first and then we use physical restraints to prevent falls and to keep the patient from pulling out IV’s, Foley Catheters and tubes. S5 also confirmed the staff does not attempt other interventions prior to applying physical restraint to prevent falls. G. During an interview with S7, clinical, on 08/20/25 at 7:45 am, S7 explained that P2 was found in bed sitting up with the Posey Vest restraint tight on her neck and the Posey Vest restraint was too tight around the chest preventing the lungs from expanding, P2 was unresponsive with a pulse, in respiratory distress, with an increased need for oxygen. P2 was transferred to ICU where she was placed on comfort care (provides physical, emotional, social and spiritual support to patients and families, focusing on control of pain and other symptoms to improve quality of life rather than providing a cure) with P2 being given Morphine (liquid narcotic for pain) and Ativan (antianxiety medication) for anxiety. H. During an interview with S6, clinical, on 08/20/25 at 9:30 am, it was confirmed they applied the Posey Vest restraint because the patient’s wrists were red and the patient was trying to get out of bed. S6 confirmed the provider was not called for an order, and the family was not notified of the Posey Vest restraint being placed on P2. S6 confirmed the wrist restraints were not for high fall risk but to prevent the patient from pulling out lines and the Foley Catheter and a Posey Vest restraint is used to prevent falls. I. Record review of the facility’s, “Incident Report Log,” dated from 05/14/25 through 08/14/25, revealed, P2’s death was not found. J. Record review of P2’s chart, confirms on 07/30/25 at 10:30 am a conversation between P2’s daughter who is also the power of attorney and the case manager for the hospital, it was reported to the case manager that the patient was in a Posey Vest restraint that was too tight and P2 could not breath. In this documentation it is noted that the daughter had talked to S(Staff)8, non-clinical, and was told that the Corporation in Albuquerque will investigate the complaint. K. During an interview with S9, clinical, on 08/20/25 at 9:45 am, S9 confirmed that they were notified of the vest restraint incident resulting in death and there was no incident report completed. The facility did not conduct an investigation of this incident. S9 also confirmed that the incident did not get reported to the State of New Mexico. S9 explained that P2’s daughter did come to them to file a compaint and S9 gave the the daughter the corporate number of the hospital to file the complaint. L. During an interview with S8, non-clinical on 08/20/25 at 10:00 am, S8 confirmed they were notified of the vest restraint incident and explained that the incident report should trigger an investigation at corporate level. S8 did not know that an incident report was not completed and therefore no investigation of the incident was done. S8 confirmed that the incident was not reported to CMS for a death related to restraint use.”