Riverside Methodist Hospital

“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: 21893 Based on record review interview and policy review, the hospital facility failed to ensure when non-violent restraints were used, the condition of the patient who was restrained was monitored by a physician, other licensed practitioner or trained staff at an interval determined by hospital policy. This affected four (Patients #1, #9, #13, and #4) of seven patients reviewed with non-violent restraints. The hospital’s census was 768. Findings include: 1. Review of the medical record for Patient #9 revealed orders for restraints from 07/02/24 through 07/09/24. The medical record lacked documentation every two hours of patient and restraint assessments on 07/05/24 from 4:00 PM through 8:00 PM. The last patient and restraint assessment documented was on 07/09/24 at 8:00 AM. The last restraint order was dated 07/09/24 at 7:48 AM. The medical record lacked documentation of when the restraint was discontinued. During an interview on 04/22/25 at 1:45 PM, Staff D verified the lack of documentation. 2. Review of the medical record for Patient #1 revealed orders for restraints from 11/25/24 through 12/10/24. The medical record lacked documentation every two hours of patient and restraint assessments on 11/26/24 from 12:00 AM to 8:00 AM and on 12/07/24 from 12:00 AM to 4:00 AM. During an interview on 04/22/25 at 2:13 PM, Staff D verified the lack of documentation. 3. Review of the medical record for Patient #13 revealed an order for mitten restraints to both hands on 12/04/24 at 12:51 AM. The medical record documented the restraints were applied on 12/03/24 at 10:30 PM. The medical record lacked documentation every two hours of patient and restraint assessments from 10:30 PM on 12/03/24 to 6:41 AM on 12/04/24, and from 6:41 AM to 8:00 PM on 12/04/24 when the restraints were discontinued. During an interview on 04/22/25 at 2:48 PM, Staff D verified the lack of documentation. 32088 4. Review of Patient #10’s medical record revealed the patient arrived via emergency medical services on 02/05/25 at 11:50 PM. On 02/05/25 at 11:56 PM the nurse charted the patient was pulling at her medical lines and was disoriented and agitated. Redirection, personal alarms, and decreased stimuli were not effective so soft wrist and ankle restraints were ordered. These restraints stayed on through 02/11/25 at 10:23 AM. On 02/11/25 at 3:40 PM the patient was put back in ankle and wrist restraints for agitation, pulling at lines, and disorientation. On 02/11/25 at 6:43 PM the restraint order was changed to non-violent bilateral soft wrist restraints. On 02/14/25 at 3:29 AM the provider ordered bilateral soft wrist restraints and the order was good for 30 hours or until discontinued. However, the every two hour restraint checks were not completed on 02/14/25 from 6:00 AM until at 6:00 PM. On 02/16/25 at 4:30 PM the staff stopped the restraint charting. On 02/22/25 at 2:51 AM non-violent soft wrist restraints were applied due to the patient pulling lines, pulling out her trach, and agitation with Behavioral Health was consulted. On 02/22/25 at 10:32 AM the wrist restraints were discontinued and then reordered at 4:40 PM for hallucinations. On 02/24/25 at 4:00 PM the restraints were discontinued. During an interview on 04/17/25, Staff C verified the findings. Review of the policy titled “Use of Restraints” policy, effective 03/10/22, revealed the patient should be evaluated every two hours by the nurse. The documentation every two hours of this evaluation should include a visual check, behavior in restraints, alternatives and effectiveness, circulation, skin check, range of motion, fluids, food/meals, elimination, and vital signs if medically appropriate. When the restraints are discontinued, the nurse should document the time the restraints were removed, the criteria for discontinuation, and the plan of care should be updated.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 21893 Based on record review, interview and policy review, the facility failed to patients restrained for violent or self-destructive behavior was seen face-to-face by a physician or other licensed practitioner within one hour after the initiation of the restraints. This affected one (Patient #20) of two patients reviewed with violent or self-destructive behavior restraints. The facility’s census was 768. Findings include: Review of the medical record for Patient #20 revealed orders for violent or self-destructive behavior restraints (four point locked restraints) on 04/23/25 from 2:30 AM to 1:15 PM at the time of record review. The medical record lacked documentation of a face-to-face evaluation by the provider or other licensed practitioner on 04/23/25. During an interview on 04/23/25 at 1:15 PM, Staff C verified the findings. Review of the policy titled “Use of Restraints”, effective 03/10/22, revealed when restraints for violent or self-destructive behavior are applied, the Licensed Independent Practitioner should evaluate the patient face-to-face within one hour of the application of the restraints. The evaluation must include the evaluation of the patient’s immediate situation, reaction to the intervention, medical and behavioral condition, and the need to continue or terminate the restraint. If the restraints are removed the episode is completed. If restraints are needed again, another episode starts and a new order is needed.”

“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: 32088 Based on record review, interview, and policy review, the hospital failed to ensure appropriate interventions were in place to prevent falls, failed to notify the responsible party when a patient fell and had a change in condition and failed to ensure it was documented when a patient was placed in isolation for an infection. This affected two (Patients #4 and #5) of two patients reviewed for falls and isolation. The census was 768. Findings include: 1. Record review revealed Patient #4 was transferred to the hospital via emergency medical transportation on 11/25/24 at 9:37 PM for palliative radiation after falling at a skilled nursing facility. The patient was to receive physical and occupational therapy up to five days each week. Review of the Radiology Oncology Inpatient Consult note dated 11/25/24 revealed Patient #4 had a history of high grade invasive urothelial carcinoma of the bladder as well as stage IV high grade neuroendocrine carcinoma with brain metastasis. He noted magnetic resonance imaging (MRI) of the brain without contrast showed multifocal progression in brain including brainstem lesions and stated the patient would be receiving palliative radiation therapy. Patient #4 was assessed for falls on 11/25/24 and was at high risk. The e-companion (camera in room with a virtual assistant that notes movements on the camera that alerts or reminds the patients for safety reasons) intervention was implemented on 11/25/24 at 9:40 PM. On 12/05/24 at 7:21 AM the nurse documented she removed the e-companion at 5:00 AM as the patient had improved balance when going to the bathroom. Patient #4 was expected to be discharged after radiation the following day. The patient fell on 12/06/25 at 6:53 PM. Review of the fall risk interventions revealed appropriate interventions were documented as implemented prior to the fall, to include a bed alarm. Review of nursing note dated 12/06/24 at 6:43 PM revealed the patient had an unwitnessed fall, did not hit head, his blood pressure was low, the patient was reporting no pain. Rapid Response was called. Skin tears were assessed. There was no documentation stating Patient #4’s responsible party was notified of the fall. Review of the Post fall Assessment (SWARM Card) dated 12/06/24 for Patient #4 revealed the patient had an unobserved fall at 6:30 PM and obtained a skin tear. Pre-fall interventions were listed as yellow socks, fall risk armband, and gait belt. Keep the e-companion for patient safety was listed for post fall interventions implemented. The provider was notified. During an interview on 04/22/24 at 12:25 PM, Staff C verified the above findings. 2. Review of Patient #5’s medical record revealed the patient arrived on 11/29/24 at 5:08 PM via emergency medical services (EMS) as a transfer from another hospital. On 11/29/24 at 5:17 PM, Patient #5 was assessed for falls and scored 2, indicating no risk. On 11/30/24 at 12:03 AM the patient was assessed for falls and scored a 3. The intervention implemented was to assist the patient with ambulation. On 11/30/24 at 8:00 AM the fall risk score was 1. On 11/30/24 at 8:09 PM the fall risk score was 4, and the intervention was to ambulate with assistive devices and keep the call light in reach. On 12/01/24 at 12:00 AM the patient scored a 4 and a bed alarm was added. On 12/01/24 at 7:12 AM the fall risk score was 5 due to the patient having a fall during this stay. The interventions implemented were bed alarm, call light in reach and the fall risk bundle. Review of nursing notes dated 12/01/24 at 7:12 AM revealed the patient had an unwitnessed fall. She stated she was uncomfortable in bed and wanted to change positions and fell to the ground on her buttock. The nurse noted the patient was very weak. Patient #5 was assessed, the nurse notified provider, there were no injuries noted. Her interventions that were implemented after the fall were a bed alarm and yellow socks. Review of the SWARM Card: Post fall form for Patient #5 dated 12/01/24 at 7:12 AM completed by the charge nurse revealed the patient had an unwitnessed fall and no injury was observed. The physician was notified. The intervention noted as in place prior to the fall was a fall risk sign on the door. The nurse noted the bed alarm was turned off. Post-fall interventions were bed exit alarm, fall risk wristband, yellow socks and keeping the call light in reach. Review of the provider notes dated 12/14/24 at 9:10 AM revealed the physician suspected the patient had clostridium difficile colitis (C-diff) and a polymerase chain reaction (PCR) test was sent to the lab for testing. The lab resulted on 12/14/24 at 3:56 PM and the lab called the patient’s nurse to inform of the positive C-Diff results. On 12/19/24 at 1:32 PM the provider noted C-diff was caused by prolonged antibiotics and an extended hospital stay. There was no documentation in the medical record indicating the patient was in contact isolation and contact precautions were implemented until 12/15/24 at 8:10 AM. During an interview on 04/22/24 at 12:25 PM, Staff C verified the findings. Review of the hospital’s policy titled “Fall Prevention”, dated 10/13/22, revealed all patients should be assessed for risk of falling with the initial AM or PM assessment and as needed using the fall risk assessment tool. Any patient that receives a score of three or higher on the fall risk assessment tool is considered to be high risk. Fall care interventions for all patients include orienting the patient to the room, adequate lighting, bed in the lowest position, locked equipment, assess pain, repositioning, and anticipating toileting needs. Fall interventions for patients at an elevated fall risk were for staff to apply a yellow fall risk wristband, encourage patients to wear yellow non-skid footwear, place a visual identifier to communicate the elevated risk for falls and any individualized interventions based on the reason the patient is at risk for falls. For patients with altered mental status consider applying bed/chair alarms or providing a patient observer or e-companion. In the event a patient experiences a fall, staff should secure the physical environment and a safe position for the patient to decrease the risk of injury. The registered nurse (RN) should complete a post fall assessment to include a full set of vitals. The SWARM (post-fall huddle with staff caring for the patient to discuss the fall) should be completed by the patient care team, a physician should be notified. If the patient is not competent, the nurse should notify the patient’s next of kin as soon as appropriate before the end of the shift. The documentation in the medical record should include a post fall assessment, nursing interventions implemented, notification of the physician. Prior to a fall, documentation in the medical record should include the fall risk assessment tool. interventions/outcomes and patient education should be documented in the medical record.”

“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: 32088 Based on medical record review, surveyor observations, facility policy review, and patient and staff interview, the facility failed to ensure patients were free from the use of side rails as restraints. This affected three (Patient #22, Patient #24, and Patient #25) patients identified with all four side rails in use during the survey. The hospital census was 799. Findings include: 1. Observation and interview during tour of the Cardiac Specialty Unit (3 Red) on 11/20/24 at 4:38 PM with Staff T revealed Patient #24 in Room 3330 in bed with four side rails up and no staff in the room. At this time Staff T verified patients should only have a maximum of three side rails up or it is considered a restraint. Staff T stated Patient #24 did not have an order for restraints. Interview with Patient #24 on 11/20/24 at 4:45 PM revealed staff always keep four siderails up on the bed. The patient stated they keep the siderails up because staff does not want him getting out of bed on his own due to being hooked up to intravenous (IV) therapy. He also stated there was a bed alarm on his bed. Review of the medical record for Patient #24 revealed the patient was admitted directly to the Cardiac Specialty Unit (3 Red) Room 3330 on 11/16/22 at 11:32 PM from a surrounding area emergency room for cardiogenic shock and transaortic valve replacement. Review of the orders revealed no orders for restraints. Review of the flow sheets revealed on 11/21/24 the patient care assistant (PSA) documented side rails up times four from 7:50 PM through 10:18 PM. The patient was discharged to home on 11/22/24. 2. Review of the medical record of Patient #25 revealed the patient was directly admitted from home on 11/19/24 with chest pain for expedited cardiology workup. Review of the physician orders revealed there was no order for restraints. Observation and interview during tour of the Cardiac Specialty Unit (3 Red) on 11/20/24 at 4:38 PM with Staff T revealed Patient #25 with four siderails up o the bed. It was confirmed with Staff T at the time of the observation Patient #25 had all four siderails up. 3. Interview on 11/20/24 at 4:50 PM, Patient #22, a patient on 3 Red, stated any time she was in the bed staff consistently raised all four side rails. She stated the raised side rails made her feel claustrophobic, like she was a prisoner. The patient stated she began to sleep in the chair to prevent staff from raising the siderails. Review of the medical record of Patient #22 revealed the patient was a direct admit to the Cardiac Specialty unit (3 Red) for electrophysiology evaluation on 11/08/24 at 6:54 PM. Review of the safe environment flow sheet revealed on 11/09/24 at 12:05 AM and 2:05 AM all four siderails were up. The medical record lacked documentation of a physician order restraints. Review on 11/26/24 of the policy titled “Use of Restraints,” effective 03/10/2022, revealed side rails are a restraint if they are used to keep a patient from getting out of bed and/or if the side rails completely surround the patient when all of the segments are up including two full length or four half-length and cannot be lowered by the patient. If a restraint is used there must be a physician order that indicates the date and time of the order, restraint type, location of the restraint, duration, reason for the restraint, multidisciplinary teams members involved in discussion and evaluation of need, attempted alternatives prior to application, or in the event of renewal, the previous 24 hours and currently observed behaviors. A renewal restraint order should be obtained daily during rounding, not to exceed 30 hours. For violent restraints visual observation must completed and documented every 15 minutes. For nonviolent restraints the visual check needs to be completed and documented every two hours.”

“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: 32088 Based on medical record review, patient interview, and staff interview, the facility failed to ensure staff performed oral care during the hospital stay for three patients (Patient #3, Patient #22, and Patient #24). The hospital census was 799. Findings include 1. Interview on 11/20/24 at 4:50 PM, Patient #22 reported staff has not provided mouth care since she has been hospitalized. A family member brought her toothbrush from home and family provides mouth care. Review of the medical record of Patient #22 revealed the patient was a direct admit to the Cardiac Specialty unit (3 Red) on 11/08/24 at 6:54 PM. Review of the daily cares flowsheet from admission to the day of discharge, on 11/22/24, revealed no oral care was performed by nursing staff. 2. Review of Patient #3’s medical record with Staff P revealed the patient was admitted on 10/17/24 at 6:01 AM. . The hospitalist noted on 10/17/24 the patient was diagnosed with thrush and oral Nystatin was started. Further review of the medical record revealed there was no oral care offered or provided during the patient’s stay. A bed bath was noted on 10/17/24 at 9:23 PM. The patient left against medical advice (AMA) on 11/24/2024 at 8:30 PM. This finding was verified on 11/20/24 at 11:56 AM by Staff P during the medical record review. 3. Review of Patient #24’s medical record revealed the patient was admitted directly to the Cardiac Specialty Unit (3 Red) on 11/16/22 at 11:32 PM for cardiogenic shock and transaortic valve replacement. The patient was discharged home on 11/22/24. Review of the flow sheets revealed there was no oral care provided or offered except for on 11/17/24. This finding was verified on 11/21/24 at 12:15 PM by Staff F during medical record review.”

“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: 28999 Based on medical record review, facility policy review, and staff interview, the facility failed to ensure Emergency Department personnel provided an appropriate medical screening examination which included a magnetic resonance imaging (MRI) scan and a neurosurgery consult to determine if a medical emergency condition existed in a patient prior to transfer to another emergency department (ED). This affected Patient #1. The census was 799. Findings include: The medical record revealed Patient #1 revealed the patient had a history of herniated disks and was instructed if she experienced severe back pain and incontinence of stool or urine, she should go to the nearest ED to be evaluated for cauda equina syndrome, is a serious medical emergency that occurs when the nerve roots at the base of the spinal cord are compressed. The only way to determine if this condition exists is by performing an MRI. The patient presented to a local ED on 10/26/24 for complaints of back pain, numbness of the left lower extremity, and fecal incontinence. The patient was then transferred to this ED at 3:02 PM. The history and physical at this ED revealed Patient #1 was transferred for MRI and a neurosurgery evaluation. An ED triage transfer note stated the patient reported chronic issues with back but today woke up with fecal incontinence. The patient reported to staff she had never done this in the past. At 3:06 PM, the patient rated her pain a six on a zero to ten scale. A physician order at 3:13 PM requested a neurosurgeon consult. At 3:14 PM the ED provider note revealed medical decision making included the patient will be hospitalized, a MRI will be ordered and neurosurgery notified. At 3:29 PM an order was placed to admit the patient to the facility’s Medical Observation unit. A peripheral intravenous (IV) access was placed in the patient’s right antecubital at 4:07 PM. According to the Medication Administration Record (MAR), the patient was medicated with Morphine 4 milligram (mg) IV at 4:15 PM. The patient rated her pain an eight on a zero to ten scale at the time she was medicated. Review of the neurological assessment at 4:45 PM revealed the patient had numbness in her left lower extremity. At 4:59 PM the bed previously ordered in the Medical Observation unit was discontinued. At 5:00 PM an order was placed to discontinue the IV and discharge the patient. At 5:50 PM a physician ordered for the patient to be transferred to an outside hospital. The patient was discharged at 6:12 PM. The medical record lacked documentation the MRI or neurosurgery consult was obtained prior to transferring the patient. The neurosurgeon, Staff AA, was interviewed on 11/20/24 at 12:21 PM. He stated he was not willing to do a work-up, which included a MRI, on a patient whose surgeon was in town. Staff AA stated he did not see the patient while she was in the ED and he arranged for the transfer via phone. Review of the facility policy titled “Compliance with the Emergency Medical Treatment and Active Labor Act (EMTALA),” effective 02/10/22, defined an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in: Placing the health of the individual in serious jeopardy; Serious impairment to bodily functions; or Serious dysfunction of any body organ or part. The policy defines medical screening examination as the process required to reach, with reasonable clinical competence, the point at which it can be determined whether or not an emergency medical condition exists. Such screening must be done within the hospital’s capability and available personnel, including on-call physicians. The medical screening examination is an ongoing process, and the medical record must reflect continued monitoring based on the patient’s needs until it is determined whether or not the individual has an emergency medical condition and, if he/she does, until the patient is either stabilized or appropriately transferred. Screening is to be conducted to the extent necessary by physicians and/or other qualified medical personnel to determine whether an emergency medical condition exists. Under stabilizing treatment, the policy states if an individual is determined to have an emergency medical condition, the patient will be provided treatment to stabilize the individual’s emergency medical condition within the capability of it’s ED (including routinely available ancillary services). Stabilized means an individual has, within reasonable clinical confidence, reached the point where continued care, including diagnostic work-up and/or treatment, could be reasonably performed as an outpatient or later as an inpatient. If the individual’s emergency medical condition cannot be stabilized within the capabilities of the hospital, an appropriate transfer should be made. Staff A was interviewed on 11/26/24 at 3:45 PM. confirmed an MRI was not performed in order to determine if a medical emergency condition existed prior to the patient being transferred to another facility.”