Healthalliance Hospital Marys Avenue Campus

“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: 48001 . Based on medical record review, document review, and interview, in one (1) of ten (10) medical records reviewed, the facility failed to inform the patient’s representatives of significant changes in the patient’s medical condition (Patient #2). Findings include: Review of policy and procedure (P&P) titled “Patient Death and Management of - Nursing and Security” last revised 05/2024 indicates “Procedure, 1. Nursing will make the following contacts once the patient is pronounced dead: a-Center for Organ Donation and Transplant (CDT) within one hour of death; b-Switchboard; c-Facilities occupied by the deceased before hospitalization (e.g., nursing home, homes for those with developmental disabilities, etc.).” Review of the medical record for Patient #2 revealed the patient presented to the Emergency Department on 07/13/2023 at 00:55 AM from a Nursing Facility in respiratory distress. The patient had low oxygen levels and an elevated body temperature. The patient had an intellectual disability. The patient’s medical condition deteriorated, requiring oral intubation and mechanical ventilation. On 07/13/2023 at 08:53 PM, the patient was pronounced dead after unsuccessful resuscitation attempts. The medical record face sheet documented the patient’s court-appointed guardian and their contact information. There was no documented evidence that facility’s staff informed the patient’s guardian of changes in their medical condition and of the patient’s death, or notified the patient’s residece. During an interview with the patient’s guardian on 09/05/2025 at 01:45 PM, they reported that they learned of the patient’s death 15 days later when they contacted the facility to inquire about the patient. During an interview on 09/05/2025 at 12:13 PM via phone, Staff R (Nurse) reported they were not aware of the Death and Management policy and nursing staff responsibilities. During an interview on 09/05/2025 at 12:04 PM, Staff S (Nurse Administrator) acknowledged that staff did not adhere to the policy.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 35161 . Based on medical record review, document review, and interview, in one (1) of three (3) medical records reviewed, the facility failed to ensure that a patient was monitored for safety in accordance with the physician order and the facility’s policies and procedures on “Observation of Patients in Non-Behavioral Health Areas” (Patient #1). Findings: Review of the facility policy titled “Observation of Patients in Non-Behavioral Health Areas: Close Observation (non-suicidal patients), 1:1 Observation (suicidal, homicidal, or non -suicidal aggressive patient),” revised 11/2023 stated “All patients that make statements regarding suicidal or homicidal ideation or had an attempt or any patient whose behavior demonstrates the high likelihood of imminent harm to self or others must be placed on 1:1 until discontinued by the order of the consulting Licensed Independent Practitioner (LIP) from the psychiatric services.” Review of the policy titled “Levels of Observation for Patients Hospitalized in Behavioral Health Units,” revised 11/2024, revealed that the policy applies to Behavioral Health inpatient units only and is not to be used in other areas of the hospital. Review of the medical record for Patient #1 identified that the patient presented to the Emergency Department (ED) on 08/01/2025 at 05:25 PM, accompanied by police officers for a mental health evaluation due to emotional disturbance, suicidal ideations, and depression. On 08/01/2025 at 05:49 PM, the patient was placed on continuous one-to-one observation for safety, as per the physician’s order. At 06:20 PM, the patient was transferred to the Psychiatric ED for continued care. Review of the observation records revealed that the patient was on one-to-one observation in the Medical ED but underwent every 15-minute visual checks in the Psychiatric ED. The Behavioral Health Social Worker on 08/02/2025 at 05:49 PM documented that the patient endorses suicidal ideation, and that the on-call nurse practitioner determined that the patient meets criteria for inpatient hospitalization for safety and stabilization. There was no documented evidence that the physician discontinued the patient’s order for one-to-one observation before the nursing staff changed the level of observation for the patient, who remained a threat to self. On 09/04/2025, at 02:00 PM, during an over-the-phone interview with Staff X (Psychiatric ED Technician), they reported that in the Psychiatric ED, patients are not placed on one-to-one monitoring unless they are restrained. There was no documented evidence that the facility’s observation policy for patients placed on one-to-one observation for safety purposes was consistently implemented. During the interview on 09/05/2025 at 3:08 PM, Staff Y (Psychiatric ED Administrator) stated that the Psychiatric ED implements a combination of policies, including the “Observation of Patients in Non-Behavioral Health Areas” and the “Levels of Observation for Patients Hospitalized in Behavioral Health Units.” Staff Y confirmed that a patient who is a threat to self or others would be placed on one-to-one observation.”

“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: 35161 Based on medical record review, document review, and interview, in one (1) of ten (10) medical records reviewed, nursing staff failed to appropriately manage pressure injury in accordance with the facility’s policy for Skin Assessment, Pressure Injury Assessment, and Treatment Guidelines. Specifically, the patient risk for pressure injury, descriptions of the wound were not consistently documented by staff, and wound consultation was not implemented (Patient #2). Findings include: See Tag: 0392 .”

“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: 35161 . Based on medical record review, document review, and interview, in one (1) of ten (10) medical records reviewed, nursing staff failed to appropriately manage pressure injury in accordance with the facility’s policy for Skin Assessment, Pressure Injury Assessment, and Treatment Guidelines. Specifically, the patient risk for pressure injury, descriptions of the wound were not consistently documented by staff, and wound consultation was not implemented. Findings include: The facility’s policy and procedure titled “Skin Assessment, Pressure Injury Assessment, and Treatment Guidelines,” effective February 2011, states,” ... All medical-surgical and critical care patients will be assessed for pressure injury risk on admission, and each shift using the Braden Scale ... Any alteration in skin integrity is to be documented. All open wounds will be described in detail, including location, size, color, drainage and odor, and peri-wound tissue ... Inform the physician of any changes or alterations in skin integrity. The LIP [Licensed Independent Practitioner] must order a Wound Care consultation as needed ...” A review of the medical record for Patient #1 identified a 77-year-old who was admitted to the facility on 12/12/2023 with an admitting diagnosis of non-purulent cellulitis of the right lower leg. The initial nursing assessment on 12/12/23 at 8:00 PM revealed the following: The patient was alert and oriented to person, place, time, and situation. The Braden score for predicting pressure sore was 19/23-not at risk (Mild risk: Total score 15-18; Moderate Risk: Total score 13-14; High Risk: Total score 10-12; Severe Risk: Total score less than or equal to 9). The patient had redness and swelling in the right lower extremity, but the skin was intact. Nurse on 12/25/2023 at 9:00 AM documented “red blanchable buttocks.” Braden score: 15 (Mild Risk). On 12/25/2023 at 8:00 PM, the nurse documented Braden score: 20 (No Risk). “Patient demonstrates the ability to reposition self, assistance provided for comfort. Patient declines turning and repositioning at this time.” Bilateral +3 edema to bilateral lower extremities. On 12/28/2023 at 8:10 AM, the nurse documented Braden score: 12 (High Risk). Coccyx wound with pale yellow wound base and excoriated peri-wound; no drainage noted-scattered areas of linear deep purple discoloration. 12/28/2023 at 7:20 PM, Braden score: 16 (Mild Risk). “Patient with an unstageable wound to the coccyx and another pressure area to the bottom.” 12/29/2023 at 8:10 AM - Braden score 14 (Moderate Risk). Coccyx wound with pale yellow wound base and excoriated peri-wound; no drainage noted. The physician documented an order for wound consultation on 12/29 at 12:50 PM. No documentation was found that indicated the patient was evaluated by a wound consultant prior to discharge on 1/4/2024. On 1/1/2024 at 7:47 PM, the nurse documented Braden score 14 (Moderate Risk)-patient with stage 2 to left buttock and an unstageable wound to the coccyx. On 1/3/2024 at 5:30 PM, the nurse documented an unstageable coccyx wound (yellow/tan slough noted), a small (1” diameter) stage II wound in the left buttock, and a 1” scab on the left heel of the foot. On 1/4/2024 at 8:00 AM, a nurse assessment revealed a Braden score of 16 (Mild Risk): “Skin is intact; skin protection intervention implemented.” The patient was discharged to a sub-acute facility on 1/04/2024. Nursing documentation of the patient’s Braden score for predicting pressure sore risk revealed the patient was assessed as mild to moderate risk after they developed a stage I pressure injury to the buttocks on 12/25/2023. The patient’s pressure injuries progressed to an unstageable wound on 12/28/2023. On the day of discharge on 1/04/2024, the nurse documented at 8:00 AM that the patient was at a mild risk for pressure injury with intact skin. Nurses’ assessments of the patient’s ability to position themselves in bed on 12/21/2023, 12/24/2023, 12/26/2023, 12/27/2023, 12/30/2023, 12/31/2023, 1/2/2024, and 1/4/2024 indicated that the patient could reposition self. These assessments were inconsistent with the daily Physical Therapist evaluation from 12/20/2023 to 1/04/2024, which stated that the patient was dependent on turning in bed and needed maximum assistance with mobility. No documentation was found that all open wounds were described in detail, including location, size, color, drainage, odor, and peri-wound tissue, per the facility’s “Skin Assessment, Pressure Injury Assessment, and Treatment Guidelines.” There was no nursing documentation that indicated the physician was informed of the patient’s skin condition at discharge. During an interview with Staff T (Physician Assistant) on 03/29/2024 at 1:00 PM, the staff stated he was unaware the patient had pressure injuries at discharge on 1/04/2024. During an interview on 04/03/2024 at 11:30 AM with Staff Dd (Regional VP, Nurse Executive), she acknowledged the findings. She stated wound consultation was unavailable on the weekend [12/30/2023 to 12/31/2023] and that Monday [1/01/2024] was a holiday. At an interview with Staff V (RN, Wound Care) on 04/04/2024 at 10:56 AM, the staff stated she sees patients based on her availability and that there is no specified time frame for implementing an order for wound consultation. No information was provided for the lack of implementation of the wound consult before the patient was discharged on 1/04/2024.”

“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: 35161 . Based on medical record review and interview, in one (1) of three (3) medical records reviewed, the facility failed to provide medical information pertaining to the patient’s pressure injury and treatment plan to the post-acute care service provider at the time of discharge (Patient #1). Findings include: A review of the medical record for Patient #1 identified the following information: The patient was admitted on 12/12/2023 with a diagnosis of non-purulent cellulitis of the right lower leg. On 12/25/2023, at 09:00 AM, the nurse documented “red blanchable buttocks.” As per nursing progress notes on 12/28/2023 at 08:10 AM, the wound progressed to “coccyx unstageable with pale yellow, dry wound base multiple scattered linear purple discolorations.” The patient was discharged to a sub-acute facility on 01/04/2024. A review of the Patient Review Instrument (PRI) dated 01/04/2024 revealed documentation of a stage II pressure ulcer and the need for wound care. The PRI did not accurately document the stage of the patient’s pressure wounds at discharge. The discharge instructions documented by Staff T (Physician Assistant) revealed no documentation of the patient’s pressure injury, the severity of the wound, and a treatment plan for management of the wound. During an interview with Staff T on 03/29/2024 at 1:00 PM, the staff stated that he was unaware of the patient’s wounds at discharge on 01/04/2024. During an interview with Staff U (Attending M.D.) on 3/29/2024 at 1:05 PM, staff reported that she was not aware of the patient’s wounds and the need for post-hospital care. She stated that she relied on the information from the mid-level provider when she co-signed the discharge instructions.”