Miami Valley Hospital

“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: 42492 Based on medical record review, staff interviews, and policy review, the facility failed to ensure patients were prepared for discharge in safe, dignified manner, In addition, the facility failed to ensure patients were appropriately assessed to establish clinical necessity before as needed (PRN) medications were administered or that patients were reassessed after as needed medications were administered to establish effectiveness. See A0395 and A0405.”

“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: 42492 Based on medical record review, staff interviews, review of the Joint Commission investigation, and policy review, the facility failed to respond to patient grievances. This affected one (Patient #01) of five patients sampled for grievances. The facility census was 785. Findings include: Review of the medical record revealed Patient #01 presented to the Emergency Department (ED) on 01/07/26 at 10:55 A.M. with a chief complaint of shortness of breath. He was admitted for observation, was boarded in the ED on 01/07/26 at 2:24 P.M., and was discharged home on 01/08/26 at 3:03 P.M. Review of the Joint Commission (JC) report for investigation completed on 02/17/26 revealed the JC found there was no evidence of action taken in response to a grievance submitted by a family member to the patient’s pulmonologist. The pulmonologist gave the letter to the hospital leadership on 01/27/26. This was not consistent with the hospital’s policy for grievances effective 03/01/24 which stated that letters given to any member of the staff constituted a grievance. The ED nurse manager and the Associate Chief Nursing Officer (ACNO) were present at the time of the finding. During an interview on 03/05/26 at 1:23 P.M. Regulatory Specialist B stated the hospital received a letter on 01/27/26, approximately two weeks after Patient #01’s visit to the ED. Patient #01’s pulmonologist received the letter in the mail and gave the letter to the nursing administration to address. When the nurse manager was asked, she felt the issue was resolved. Regulatory Specialist B confirmed the letter was never turned over to patient experience, and the opportunity to create a grievance was missed. The Joint Commission came on 02/17/26 and completed an investigation in which they determined the hospital did not follow the grievance policy. Regulatory staff educated nursing leadership regarding the grievance policy. The hospital received the official report on 03/04/26 and scheduled a meeting on 03/05/26 to discuss the action plan. The meeting was canceled due to regulatory leadership being unavailable. There had been no steps taken other than the education the ED Nurse manager provided to the ED Registered Nurse (RN) N after the incident and Regulatory staff provided to Nurse management. During a telephone interview on 03/04/26 at 8:28 A.M. the ED Nurse Manager M stated she received a message on 01/08/26 about the complaint and telephoned Patient #01’s wife on 01/09/26. The spouse was frustrated that her husband was discharged while she was away from the hospital and staff had not called her, as she held Power of Attorney (POA). She was also upset that he was sent to wait in the lobby and had chosen to remain in a hospital gown instead of getting dressed. Additionally, the patient had a condom catheter in place with a urine collection bag visible and attached to the wheelchair. The ED Nurse Manager M stated at the time of service, Patient #01 was alert and oriented. The nurse manager explained POA parameters but agreed it would have been better service to have called her. The ED Nurse Manager M acknowledged she had educated ED RN N regarding expectations for condom catheter removal and safe storage of portable oxygen tanks prior to discharge. The ED Nurse Manager M stated she felt the issue was resolved on 01/09/26, and when she became aware of a complaint letter on 01/21/26, she told the nursing administration the issue had been addressed and resolved. There was no further investigation as a grievance. Review of policy titled “Premier Patient and Visitor Complaint Grievance Policy” dated 03/01/2024 revealed all written complaints were considered to be grievances and patients had the right to expect prompt resolution to their grievances. This deficiency represents noncompliance investigated under Complain Number OH00169510.”

“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: 42492 Based on medical record review, staff interview, and policy review, the facility failed to ensure patients received oral care as recommended and were prepared for discharge in a safe and dignified manner. This affected two (Patients #01 and #21) of twenty patients reviewed for nursing services. The facility census was 785. Findings include: 1. Review of the medical record revealed Patient #21 was admitted to the hospital on 01/05/26 with a diagnosis of intracranial hemorrhage and was discharged to an acute care rehab on 01/28/26. Review of the progress note dated 01/23/26 at 10:43 A.M. revealed the Speech Language Pathologist (SLP) completed a consult with Patient #21 related to reports of coughing with oral intake earlier in the day. The patient had waxing and waning alertness during the session. There were no overt signs of aspiration with limited trials. Recommendations included regular solids, thin liquids with a straw for medications per nurse discretion/patient preference, aspiration precautions, and oral care four times daily. Review of the medical record revealed Patient #21 had oral care provided four times during his admission: 01/06/26 at 10:00 AM, 01/09/26 at 9:17 AM, 01/16/26 at 4:00 AM , and 01/23/26 at 4:00 PM. During an interview on 03/17/26 at 10:17 AM Nurse Educator G said oral care should have been documented in the flowsheet by the patient care technician (PCT) or the nurse. Expectations were for oral care to be completed twice a day for patients with a diet order, and every 2 hours or as ordered for nothing by mouth (NPO) status. She verified Patient #21 had no documentation of oral care provided four times daily as per SLP recommendations or as per standards of care twice daily while the patient was eating and drinking. During an interview on 03/17/26 at 10:25 A.M. Regulatory Specialist B stated the facility did not have a policy specific to oral care. 2. Review of the medical record revealed Patient #01 presented to the emergency department (ED) on 01/07/26 at 10:55 A.M. with a chief complaint of shortness of breath. He was admitted for observation while boarding in the ED on 01/07/26 at 2:24 P.M. and was discharged home on 01/08/26 at 3:03 P.M. Review of the initial History and Physical note dated 01/07/26 at 3:01 P.M. revealed Patient #01 was admitted to the hospital from home with a diagnosis of acute-on-chronic respiratory failure with hypoxia. The plan was to discharge home on 01/11/26. Patient #01 reported he had been getting short of breath for more than one week and it was progressively getting worse He reported using 2 liters of oxygen and nighttime and was now requiring oxygen during the daytime. His oxygen level was desaturating in the 70’s at home. He denied any new fever or cough. He was seen at his primary care physician’s office where he was desaturation with ambulation on 4 liters per minute of oxygen. The patient reported he was getting radiation treatment up until last week for his prostate. He stated he had some tenderness in his abdomen and felt dehydrated related to having a lot of diarrhea. The patient had no signs of infection. The plan of care included starting intravenous (IV) fluids for dehydration, start Solu-Medrol (a steroid medication), and continue home Lasix (a diuretic medication), inhalers, and nebulizer treatments. Review of a progress note dated 01/08/26 at 5:02 P.M. revealed Patient #01 was alert and oriented and was discharged home. The patient’s skin was warm, pink, and dry. The Registered Nurse (RN) educated the patient regarding discharge instructions with teach back from the patient to the RN. The outpatient prescription for prednisone (a steroid medication) was to be picked up at the Wright Patterson pharmacy. The patient said he would be able to obtain his prescription the following morning. Patient #01 denied needs and or questions and stated he would follow-up as directed. The patient was encouraged to return for new or worsening symptoms or other concerns. Review of the Addendum progress note dated 01/09/26 at 12:28 PM revealed his RN offered to have the patient sit in lobby with oxygen applied to wait for his spouse following discharge, and the patient consented to this plan. The RN confirmed that this plan was acceptable with another nurse. The RN also offered for patient to get dressed in his home clothing prior to waiting in lobby, and the patient refused stating “I just want to wear this gown with a blanket”. The RN covered patient with a blanket and placed the patient in a wheelchair in the lobby with one liter of oxygen applied to the patient where he could be observed by the triage nurse at the front desk with emergency entrance in view to be able to see spouse arrive. During a telephone interview on 03/04/26 at 8:28 A.M. the ED Nurse Manager M stated she received a message on 01/08/26 about the complaint and telephoned Patient #01’s wife on 01/09/26. The spouse was frustrated that her husband was discharged while she was away from the hospital and staff had not called her, as she was his Power of Attorney. She was also upset that he was sent to wait in the lobby and had chosen to remain in a hospital gown instead of getting dressed. Additionally, the patient had a condom catheter in place with a urine collection bag visible and attached to the wheelchair. The nurse manager stated at the time of service, Patient #01 was alert and oriented. The nurse manager explained POA parameters but agreed it would have been better service to have called her. The nurse manager also acknowledged she had educated ED RN N regarding expectations for condom catheter removal and safe storage of portable oxygen tanks. The ED Nurse Manager M stated she felt the issue was resolved on 01/09/26. During a telephone interview on 03/16/26 at 9:30 A.M. the ED RN N stated she offered to call Patient #01’s wife, but the patient declined. He stated he would do it himself and did not trust anyone else to do it. ED RN N stated Patient #01 had been alert and oriented throughout the visit. ED RN N stated she offered to assist Patient #01 to dress. He stated he would get dressed when he got home, and she did not want to force the issue. It was not uncommon, for elderly men especially, to leave the hospital in a gown. ED RN N stated she asked the charge nurse on duty, who agreed this was acceptable and she placed the patient in the lobby with his belongings in a bag. ED RN N stated the ED was very busy that day, and she overlooked that Patient #01 was still wearing a condom catheter when she assisted him to the lobby. She verified Patient had not worn a condom catheter at home prior to hospitalization, and it should have been removed prior to discharge. She also confirmed she had carried the metal oxygen tank and set it on the floor next to wheelchair. She verified this was not an appropriate way to transfer or store oxygen and stated it should have either been secured to the wheelchair or in a carrier. During a telephone interview on 03/17/26 at 8:51 A.M. ED RN BBB stated she was the team lead on 01/08/26 when Patient #01 was discharged from the hospital. ED RN BBB stated she responded when she heard raised voices in the hallway. She directed the woman to a conference room for privacy and directed the ED RN N to return to her assignment. The patient’s wife was upset that she had not been notified that her husband was discharged, and he was placed in the lobby wearing a gown. The nurse stated she listened to the complaint and accompanied the patient’s wife to the lobby. ED RN BBB stated in the waiting area/lobby she observed Patient #01 was seated in a wheelchair and was wearing a hospital gown. She stated she originally thought he had a Foley catheter in place because she could see the urine collection bag attached to the wheelchair. Additionally, the patient was wearing a nasal cannula and had a metal, portable oxygen tank that was on the floor beside the wheelchair. ED RN BBB stated when she spoke to the patient, he was alert and oriented and seemed frustrated that his wife was frustrated. The nurse assisted in getting him dressed, removing the condom catheter, and helping the patient into the car. The nurse stated she had written down the contact information and left all the details in a message for the nurse manager. The nurse verified Patient #01’s catheter should have been removed prior to discharge and the oxygen tank was not stored in a safe manner. Review of policy titled “Discharge Assessment and Discharge Plan” dated 08/10/25 revealed the bedside nurse will coordinate the remaining steps necessary to discharge the patient to the next level of care safely. This deficiency represents noncompliance investigated under Complain Number OH00169552 and Complain Number OH00169510.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 42492 Based on medical record review, staff interview, and policy review, the facility failed to ensure patients were appropriately assessed to establish clinical necessity before as needed (PRN) medications were administered or that patients were reassessed after as needed medications were administered to establish effectiveness. This affected two (Patients #21 and #25) of eight patients reviewed for medication administration. The facility census was 785. Findings include: 1. Review of the medical record revealed Patient #21 was admitted to the hospital on 01/05/26 with a diagnosis of intracranial hemorrhage and was discharged to acute care rehab on 01/28/26. Review of the medical record revealed Patient #21 had physician orders dated 01/05/26 for Fentanyl 50 micrograms (mcg) by Intravenous Push (IVP) every hour as needed (PRN) for moderate to severe pain. This medication was administered on 01/08/26 at 4:02 P.M. for complaints of right groin constant aching a seven out of 10 (7/10) pain scale. There was no documentation of pain reassessment to monitor for the effectiveness of the prn pain medication. Additional review revealed Patient #21 had a physician order dated 01/09/26 at 11:55 A.M. for Olanzapine 2.5 milligrams (mg) Intramuscularly (IM) or IVP twice daily PRN for agitation. This medications was administered on 01/21/26 at 11:42 P.M. per IVP for disorientation and inability to focus on tasks. There was no documentation related to reassessment or effectiveness. During an interview on 03/17/26 at 11:17 A.M. Nurse Educator G verified there was no documentation in Patient #21’s medical record regarding effectiveness after PRN Fentanyl 50 mcg was administered on 01/08/26 at 4:02 P.M. or after PRN Olanzapine 2.5 mg was administered on 01/21/26 at 11:42 P.M. 2. Review of the medical record revealed Patient #25 walked into the emergency department (ED) on 01/21/25 at 3:46 P.M. with a chief complaint of shortness of breath. She was admitted for observation on 01/22/25 at 8:03 P.M. with a diagnosis of acute asthma exacerbation, and was discharged home on 01/23/25 at 8:03 P.M. Review of the medical record revealed Patient #25 had physician orders dated 01/21/25 at 9:18 P.M. for Tylenol 650 mg by mouth every four hours PRN for pain. This medication was administered on 01/22/25 at 12:47 A.M. Review of the medical record revealed there was no documentation in the record for a pain assessment prior to or after the administration of Tylenol on 01/22/25. During an interview on 03/17/26 at 4:13 P.M. the Regulatory Specialist B verified Resident #25’s record had no documentation for pain assessment prior to administration of PRN Tylenol or pain reassessment after the medication was administered. Review of policy titled “Premier Nursing Services Pain Assessment” dated 09/13/2024, revealed pain reassessments were performed within 60 minutes of administering pain medications. Review of policy titled “Administration of Medications” dated 12/04/2025 revealed he patient ’ s clinical response to medication will be assessed and documented in the patient ’ s electronic medical record, including the patient ’ s perception of side effects and efficacy of drug along with clinical signs and symptoms. This deficiency represents noncompliance investigated under Complaint Number OH00169552 and Complaint Number OH00168475.”

“RESPIRATORY CARE SERVICES POLICIES CFR(s): 482.57(b) Services must be delivered in accordance with medical staff directives. This Standard is not met as evidenced by: 42492 Based on medical record review, staff interviews, and policy review, the facility failed to ensure patients received breathing treatments as ordered. This affected one (Patient #25) of five patients reviewed for respiratory care. The census was 785. Findings include: Review of the medical record revealed Patient #25 walked into the emergency department (ED) on 01/21/25 at 3:46 P.M. with a chief complaint of shortness of breath. She was admitted for observation on 01/22/25 at 8:03 P.M. with a diagnosis of acute asthma exacerbation, and was discharged home on 01/23/25 at 8:03 P.M. Review of the Medication Administration Record (MAR) revealed Patient #25 had a physician’s order for Albuterol 1.25 milligram (mg) nebulizer solution every 4 hours and every 4 hours as needed. Albuterol nebulizer solution 1.25 mg was administered on 01/21/25 at 11:15 P.M. and 01/22/25 at 3:09 A.M., 01/22/25 at 9:59 A.M., and was not administered again until 01/22/25 at 10:22 P.M. During an interview on 03/17/26 at 4:13 P.M. the Regulatory Specialist B verified Patient #25 did not receive routine administration of Albuterol nebulizer solution on 01/22/25 between 10:00 A.M. and 10:00 P.M. During an interview on 03/19/26 at 9:12 A.M. Respiratory Therapist (RT) CCC reviewed Patient #25’s medical record, confirmed she was working as the only RT in the ED on 01/22/25, and confirmed she had not administered any breathing treatments to Patient #25 that day. RT CCC stated it was unusual for a physician to have ordered a routine breathing treatment for a patient and stated orders for ED boarded patients did not show up in the RT’s MAR. The usual procedure included nursing reporting to the RT if a patient required or asked for a PRN breathing treatment. She did not remember this patient and could not answer patient-specific questions. Review of the policy titled “Administration of Medications” dated 12/04/2025 revealed medications were administered following a prescriber’s orders. This deficiency represents noncompliance investigated under Complaint Number OH00168475.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 28999 Based on record review, interview and policy review the facility failed to perform restraint checks every two hours. This affected Patient #10. Findings include: Review of the medical record of Patient #10 revealed the patient presented to the Emergency Department on 03/11/25 at 5:52 PM with complaints of having tested positive for Influenza A the week prior and was started on Tamiflu. The patient became progressively weak. He then started to have diarrhea which worsened. In the ED, the patient received three liters of IV fluids and was started on antibiotics. The critical care physicians made the decision to admit the patient for septic shock likely related to pneumonia. He was also started on Norepinephrine (a vasopressor typically administered to maintain mean arterial pressure via increased systemic vascular resistance). According to the physician’s history and physical, the patient had a history of peripheral vascular disease status post bilateral above the knee amputation, end stage renal disease on home hemodialysis. The decision was made to intubate the patient on 03/12/25 due to worsening metabolic acidosis. The patient remained intubated until 03/19/25. A physician ordered bilateral soft wrist restraints due to the patient pulling at medical devices. Review of the restraint flowsheet revealed the restraints were initiated on 03/12/25 at 6:45 AM. The restraints continued through 03/13/25. The medical record lacked documentation of a physician order on 03/13/25. Every two hour restraint checks continued until 03/15/25 at 2:00 PM. The medical record lacked documentation of the two hour restraint check until 8:00 PM, six hours later. On 03/16/25 at 4:00 AM, a restraint check was completed, however the next check wasn’t completed until 8:00 AM. On 03/20/25 at 2:00 PM, a restraint check was completed, however, the medical record lacked documentation of another check until 10:15 PM. On 03/23/25 a restraint check was completed by a staff nurse at 2:00 PM. The medical record lacked documentation of the next restraint check until 12:00 AM. The medical record also lacked documentation of a physician order for restraints on 04/19/25. These facts were confirmed during an interview on 05/29/25 at 4:05 PM with Staff A. The facility policy titled “Premier Nursing Services Non-Violent Restraint Policy”, effective 03/27/25, stated restraint is any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or reduces the ability to have normal access to his or her body, or does not promote the patient’s independent function. A non-violent or non-self-destructive behavior restraint is utilized for a non-violent/non-self-destructive patient to protect the patient who demonstrates impaired safety judgment. A verbal or electronic order is required from the Qualified LIP or LIP’s designee who is primarily responsible for the patient’s care at the time or immediately (within a few minutes) after the restraint is applied. Authentication of a telephone order/verbal order based upon an examination of the patient by a Qualified LIP is required to be in the electronic medical record within 24 hours of initiation and every 24 hours.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 28999 Based on record review, interview and policy review, the facility failed to ensure there was a physician order for non-violent restraints in two patients. This affected two (Patients #5 and #10) patients. Findings include: 1. Review of the medical record of Patient #5 revealed the patient presented to the Emergency Department on 01/21/25 at 5:11 PM after being being hit by a truck traveling at 30 miles per hour. The patient sustained the following injuries: occipital bone fracture, clivus fracture, left orbital fracture, subdural hematoma, subarachnoid hemorrhage, intraparenchymal hemorrhage, and acute respiratory failure. Upon arrival to the Emergency Department, the patient was hemodynamically stable but the patient had been intubated prior to arrival for a depressed Glasgow Coma Scale. The patient was transported to the facility’s Medical Surgical Intensive Care Unit (MSICU) at 6:15 PM. Given the patient’s prolonged mechanical ventilation, tracheostomy and percutaneous endoscopic gastrostomy tube placement were performed on 02/01/25. The patient remained hospitalized until 02/24/25 when he was discharged to a long term acute care facility. Review of the medical record of Patient #5 revealed the patient required non-violent restraints from 01/21/25 to 02/14/25 due to pulling at his medical devices. A physician ordered bilateral soft wrist restraints on 01/22/25. The medical record lacked documentation of a physician order on 01/21/25. Although the patient remained in bilateral soft wrist restraints on 01/23/25 and 01/24/25, the medical record lacked documentation of a physician order. There were also no physician orders for restraints on 01/27/25, 01/30/25, 01/31/25, 02/03/25, 02/06/25, 02/08/25, 02/12/25, and 02/13/25. 2. Review of the medical record of Patient #10 revealed the patient presented to the Emergency Department on 03/11/25 at 5:52 PM with complaints of having tested positive for Influenza A the week prior and was started on Tamiflu. The patient became progressively weak. He then started to have diarrhea which worsened. In the ED, the patient received three liters of IV fluids and was started on antibiotics. The critical care physicians made the decision to admit the patient for septic shock likely related to pneumonia. He was also started on Norepinephrine (a vasopressor typically administered to maintain mean arterial pressure via increased systemic vascular resistance). According to the physician’s history and physical, the patient had a history of peripheral vascular disease status post bilateral above the knee amputation, end stage renal disease on home hemodialysis. The decision was made to intubate the patient on 03/12/25 due to worsening metabolic acidosis. Review of the patient’s medical record revealed a physician ordered bilateral soft wrist restraints due to the patient pulling at medical devices. Review of the restraint flowsheet revealed the restraints were initiated on 03/12/25 at 6:45 AM. The restraints continued through 03/13/25. The medical record lacked documentation of a physician order on 03/13/25. Every two hour restraint checks continued until 03/15/25 at 2:00 PM. The medical record lacked documentation of the two hour restraint check until 8:00 PM, six hours later. On 03/16/25 at 4:00 AM, a restraint check was completed, however the next check wasn’t completed until 8:00 AM. On 03/20/25 at 2:00 PM, a restraint check was completed, however, the medical record lacked documentation of another check until 10:15 PM. On 03/23/25 a restraint check was completed by a staff nurse at 2:00 PM. The medical record lacked documentation of the next restraint check until 12:00 AM. The medical record also lacked documentation of a physician order for restraints on 04/19/25. The patient experienced cardiac arrest on 04/20/25 and despite resuscitative efforts did not survive and passed away at 9:29 AM. During an interview on 05/28/25 at 3:30 PM, Staff A confirmed the medical record lacked documentation of a physician orders for restraints for Patients #5 and #10. The facility policy titled “Premier Nursing Services Non-Violent Restraint Policy”, effective 03/27/25, stated a restraint is any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or reduces the ability to have normal access to his or her body, or does not promote the patient’s independent function. A non-violent or non-self-destructive behavior restraint is utilized for a non-violent/non-self-destructive patient to protect the patient who demonstrates impaired safety judgment. A verbal or electronic order is required from the Qualified LIP or LIP’s designee who is primarily responsible for the patient’s care at the time or immediately (within a few minutes) after the restraint is applied. Authentication of a telephone order/verbal order based upon an examination of the patient by a Qualified LIP is required to be in the electronic medical record within 24 hours of initiation and every 24 hours.”

“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: 28999 Based on record review, interview and policy review, the facility failed to ensure patients were turned and repositioned, that endotracheal tubes were repositioned and that arterial lines were assessed. This affected two (Patients #5 and #10) patients. The hospital census was 857. Findings include: 1. Review of the medical record of Patient #5 revealed the patient presented to the Emergency Department on 01/21/25 at 5:11 PM after being being hit by a truck traveling at 30 miles per hour. The patient sustained the following injuries: occipital bone fracture, clivus fracture, left orbital fracture, subdural hematoma, subarachnoid hemorrhage, intraparenchymal hemorrhage, and acute respiratory failure. Upon arrival to the Emergency Department, the patient was hemodynamically stable but the patient had been intubated prior to arrival for a depressed Glasgow Coma Scale. The patient was transported to the facility’s Medical Surgical Intensive Care Unit (MSICU) at 6:15 PM. A skin assessment was performed by a staff nurse on admission on 01/21/25 at 6:10 PM. Although there were no pressure sores noted on the patient, advanced skin protectant in the form of foam dressing was applied to the patient’s coccyx. Given the patient’s prolonged mechanical ventilation, tracheostomy and percutaneous endoscopic gastrostomy tube placement were performed on 02/01/25. The activity flow sheet where staff documented turning and repositioning the patient was reviewed. On 01/21/25 at 6:10 PM, the patient was repositioned to a supine position. At 8:00 PM, the patient was turned and repositioned to a supine position. At 4:00 AM on 01/22/25, the patient was repositioned to a supine position and two hours later, at 6:00 AM, the patient was repositioned to a supine position. On 01/28/25 at 2:00 AM, the patient was repositioned to a supine position. Two hours later, at 4:00 AM, the medical record revealed the patient was repositioned to a supine position. At 6:00 AM, the patient was repositioned to a supine position. At 12:00 PM the patient was repositioned from his left side to a supine position. He was not repositioned again for four hours, at 4:00 PM. The medical record revealed the patient was repositioned to a supine position at this time. A wound nurse’s progress note on 02/02/25 at 5:52 PM stated the patient had a deep tissue injury to his sacrum/coccyx. The wound nurse recommended nursing staff turn the patient every two hours. Review of the activity flow sheet revealed that on 02/03/25 at 6:00 AM, the patient was repositioned from his left side to a supine position. At 8:29 AM, staff repositioned the patient to a supine position. He was repositioned to his left side at 10:00 AM. Two hours later, at 12:00 PM, the patient was repositioned to a supine position. At 2:00 PM, 3:24 PM, and 4:00 PM, each position change was in a supine position. He remained in a supine position until 6:00 PM when he was repositioned to his right side. On 02/05/25 at 6:00 PM, the patient was repositioned from his right side to a supine position. When he was repositioned again two hours later, at 8:00 PM, he was again placed in a supine position where he remained until 10:00 PM. He was repositioned to his left side at this time. Staff continued to reposition the patient until he was discharged on 02/24/25. Numerous times staff repositioned the patient to the same position he was in two hours prior. During an interview on 05/29/25 at 5:05 PM, Staff O confirmed that patients should be repositioned every two hours to prevent pressure injuries and should be repositioned to a new position. 2. Review of the medical record of Patient #10 revealed the patient presented to the Emergency Department on 03/11/25 at 5:52 PM with complaints of having tested positive for Influenza A the week prior and was started on Tamiflu. The patient became progressively weak. He then started to have diarrhea which worsened. In the ED, the patient received three liters of IV fluids and was started on antibiotics. The critical care physicians made the decision to admit the patient for septic shock likely related to pneumonia. He was also started on Norepinephrine (a vasopressor typically administered to maintain mean arterial pressure via increased systemic vascular resistance). According to the physician’s history and physical, the patient had a history of peripheral vascular disease status post bilateral above the knee amputation, end stage renal disease on home hemodialysis. The decision was made to intubate the patient on 03/12/25 due to worsening metabolic acidosis. The patient remained intubated until 03/19/25. The endotracheal tube was secured with an anchoring device. The flow sheet that identified the tube repositioning was reviewed. On 03/12/25 at 6:55 AM, the tube was positioned in the center with the patient’s teeth/gums as landmarks. At 1:45 PM, the tube was repositioned to the center. At 03/12/25 at 8:09 PM, the tube was repositioned to the left side. On 3/13/25 at 12:38 AM, the tube was repositioned to the center. The medical record lacked documentation the tube was repositioned again until 8:21 AM, eight hours later. It was repositioned to the left side. At 12:26 PM, the tube was repositioned to the left side. The medical record lacked documentation the tube was positioned again until 11:55 AM on 03/14/25. It was repositioned to the left side again at this time. Staff continued to reposition the tube every four hours. By 03/18/25 at 4:34 AM, the tube was repositioned to the right side. At 8:36 AM, the tube was repositioned to the right side. The medical record lacked documentation the tube was actually repositioned to a different position until 1:16 PM. It was repositioned to the center at this time. On 03/19/25 at 4:11 AM, the tube was repositioned to the center, however at 7:17 AM, the flow sheet revealed the tube was repositioned to the center again. A physician’s progress note on 03/23/25 stated the tube was secured against the patient’s lip causing full thickness necrosis. Given that the patient was a poor surgical candidate, a debridement under light sedation with local sedation was performed on 04/09/25. The operative report revealed that when the necrotic tissue was excised down to the healthy tissue, it was noted to communicate with the patient’s oral cavity. There were no immediate postoperative complications. The Hollister Anchor Fast endotracheal tube fastener instructions for use were reviewed. Under precautions, the instructions stated to minimize the risk of pressure injury, inspect the patient’s lips, skin and oral cavity at least every two hours or more frequently if the patient’s condition dictates. A right arterial line was placed in the patient’s arm on 03/12/25 at 5:37 AM. The left arm could not be used as a graft for hemodialysis was located in the left arm. Review arterial line flow sheet revealed staff did not assess the arterial line. A physician ordered the arterial line to be removed on 03/15/25 as it was not functioning. A vascular surgeon progress note on 03/23/25 at 9:22 AM stated the patient’s hand was discolored and there was no evidence of full thickness gangrene or ischemia. During an interview on 06/03/25 at 2:07 PM, Staff Q stated respiratory staff should reposition the endotracheal tube every four hours. During an interview on 06/05/25 at 9:10 AM, Staff A confirmed that the medical record lacked documentation of the arterial line assessment every four hours. The facility policy titled “Premier Nursing Services Skin Integrity Maintenance Program and Pressure Ulcer Prevention Program Initiatives”, effective 06/24/24, stated staff is instructed to perform the following interventions to prevent pressure injuries: 1. Off-loading of bony prominences 2. Minimization of friction and shear 3. Repositioning as appropriate to redistribute pressure 4. Management of moisture The facility policy titled “Patient Monitoring and Care” stated nurses are instructed to assess the arterial line immediately after catheter insertion and every four hours.”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 42492 Based on record review, staff interview, and policy review, the facility failed to maintain accurate documentation in the medical record. This affected one (Patient #2) of ten records reviewed. Findings include: Review of the medical record revealed Patient #2 presented the ER at the North campus on 01/12/24 at 11:07 PM with a chief complaint of dental pain and was discharged on 01/13/24 at 12:04 A.M. Review of the medical record revealed Provider note dated 01/13/23 at 12:10 A.M., amended on 01/17/24 at 5:02 P.M. stated Patient #2 was requesting a topical medication for his left shoulder and later in the same note stated the patient had chronic right shoulder pain. The note had been amended on 02/27/2024 at 10:28 A.M. and in which details of left or right were omitted and referred to only as “shoulder pain”. Review of Patient Relations (PR) Worksheet revealed on 01/16/23 at 12:36 P.M. Patient #2 left a message that his care was atrocious, he had filed a complaint with the medical board, and he requested a return call. PR called back on 01/16/23 at 11:52 A.M. and the patient stated among other complaints that his medical record was “fabricated and stated he had chronic right shoulder pain when he had left shoulder pain from an accident. On 01/26/24 at 10:27 A.M., Patient #2 called and left a message with PR requesting a return call. The PR rep returned a call on 01/26/24 at 11:40 A.M. and told Patient #2 the documentation of right versus left shoulder had been corrected. On 02/08/24 at 8:53 A.M., the PR Manager documented the patient continued to call back on 02/06/24 and was upset the amendment to the medical record was still inaccurate and stated he had both re-requested an amendment in writing and had contacted the state. The patient complained the chart was updated previously indicating there were injuries to the left shoulder; however, in one sentence it was corrected to state left shoulder and in the following sentence it still stated right shoulder pain. PR confirmed the note in the record remained inaccurate, and the concerns were elevated for further review. During an interview on 02/27/24 at 8:18 A.M. North ER Nurse Manager I stated she was aware the patient, very upset, had called within 24 hours of his ER visit and complained the PA had charted he had chronic right shoulder pain when it had actually been acute left shoulder pain. North ER Nurse Manager I stated the note had been corrected, then verified after looking at the amended note dated 01/13/23 at 12:10 A.M., amended on 01/17/24 at 5:02 P.M. was still inaccurate and contained references to both left and right shoulder pain. The Nurse Manager stated she had told the patient the note had been corrected without confirming for herself that it was correct. Review of nine additional patient records revealed no concerns with accuracy of medical records. Review of policy titled “Premier Health Information Management Services Amendments, addendums, and Corrections in EPIC Policy” dated 02/28/22 revealed medical records were corrected to ensure the integrity and accuracy of patient information.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) Unless superseded by State law that is more restrictive-- (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1-hour for children under 9 years of age; This Standard is not met as evidenced by: 42492 Based on record review, interview and policy review, the facility failed to ensure residents were not placed in restraints without appropriate physician orders. Th:is affected two (Patients #9 and #10) patients placed in non-violent restraints. Findings include: 1. Review of the medical record revealed Patient #9 admitted to the the hospital on 11/05/2023 at 5:21 A.M. with a diagnosis of subarachnoid hemorrhage. Review of the medical record revealed Patient #9 had physician orders dated 11/05/2023 at 5:46 A.M. for bilateral soft wrist restraints related to unsafe mobility and poor safety judgement. The order was renewed on 11/07/2023 at 10:12 A.M. There was no renewal order on file for 11/06/2023. During an interview on 11/08/2023 at 10:39 A.M. Associate Nurse Manager O verified Patient #9 did not have physician orders dated 11/06/2023 or 11/08/2023 to continue soft wrist restraints. During an observation on 11/08/2023 at 2:02 P.M., Patient #9 was lying in bed with the eyes closed. The left wrist was held in soft restraint that was tied to bed frame. 2. Review of the medical record revealed Patient #10 admitted to the hospital on 11/02/2023 at 9:02 PM as a direct admit from another hospital with a diagnosis of symptomatic carotid stenosis. Review of the medial record revealed Patient #10 had physician orders dated 11/02/2023 at 10:52 P.M. for bilateral soft wrist restraints and Swedish belt with a justification of impulsiveness. The order was discontinued on 11/05/2023. There were no orders to continue restraints on 11/03/2023, 11/04/2023, or 11/05/2023. Additional review revealed Patient #10’s restraints were stopped on 11/03/2023 at 4:00 P.M. and restraints were restarted on 11/03/2023 at 5:45 P.M. without a new physician’s order. During an interview on 11/08/2023 at 10:39 A.M. Associate Nurse Manager O verified Patient #10 did not have physician orders to renew restraints every 24 hours and did not have a new physician order to initiate restraints after restraints had been stopped on 11/03/2023. Review of policy titled “Premier Nursing Services Non-Violent Restraint Policy” dated 05/03/2022 revealed each order for non-violent restraints was limited to 24 hours for adults and if a patient’s restraints were removed for any reason other than to provide patient care, a new order was required to reapply restraints.”

“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: 42492 Based on record review, interview and policy review, the facility failed to follow physician orders regarding feeding assistance and repositioning which resulted in a patient developing an avoidable pressure ulcer. This affected Patient #3. Findings include: 1a. Review of the medical record revealed Patient #3 was transferred to the hospital on 09/01/2023 from another hospital for hip surgery related to a fall at home on 08/29/2023. The patient was discharged to and Extended Care Facility (ECF) on 09/28/2023. Review of Speech Therapy Care plan dated 09/15/2023 at 9:40 A.M. revealed Patient #3 had video fluoroscopy completed which observed silent aspiration with consecutive swallows of thin liquids. Recommendations included regular diet with nectar-thick liquids, no straws, alternate solids and liquids (one bite, then one drink), aspiration precautions, and 1:1 with all oral intake. Review of diet orders revealed Patient #3’s diet was changed on 09/21/2023 at 1:06 P.M. from regular diet to dysphagia level III diet with nectar-thick liquids, no straws, alternating solids and liquids (one bite, then one drink), aspiration precautions, and 1:1 with all oral intake. Review of Nutrition flow sheets dated 09/19/2023 to 09/27/2203 revealed the FSP received partial assistance with setup for meals on 09/19/2023, setup assistance only from 09/21/2023 to 09/24/2023, and partial assistance with meals on 09/26/2023 and 09/27/2023. 1b. Review of Wound Care Medical Staff Progress note dated 09/12/2023 at 11:17 A.M. revealed Patient #3 was transferred to the hospital on 08/29/2023 after sustaining a fall that resulted in a left femoral neck fracture. The patient had left hip arthroplasty on 09/3/2023. Additionally, on 09/03/2023 vascular service was consulted regarding delayed wound healing of the left posterior calf and left heel, both present upon admission. An arterial duplex was completed which showed severe bilateral lower extremity arterial insufficiency. The patient was assessed for limb salvage ability and was scheduled for a left above the knee amputation on 09/11/2023. The plan of care included in the note stated Patient #3 was to have complete lateral turns on sides every two hours to avoid pressure and friction injury. Review of flow sheets dated 09/01/2203 to 09/28/2023 revealed Patient #3 was positioned on his back in bed from 09/02/2023 at 10:00 P.M. to 09/03/2023 at 8:00 A.M.; from 09/03/2023 at 8:00 P.M. to 09/04/2023 at 2:00 A.M.; on 9/10/2023 from 2:00 A.M. to 8:00 A.M.; from 09/14/2023 at 6:00 P.M. to 09/15/2023 at 10:00 A.M.; from 09/15/2023 at 8:00 P.M. to 09/16/2023 at 8:00 A.M.; on 09/19/2023 from 2:00 P.M. to 10:14 P.M.; on 09/22/2023 from 4:00 A.M. to 4:39 P.M.; and from 09/25/2023 at 7:42 P.M. to 09/26/2203 at 3:31 A.M. Additional review of nursing assessment skin flow sheets revealed the FSP developed a pressure injury to the upper middle back first discovered on 09/13/2203 at 10:23 P.M. The area was unmeasured and was described as dry and intact. The area was covered with a foam dressing and was unresolved upon discharge on 09/28/2023. During an interview on 11/08/2023 at 3:50 P.M. Director of Quality A and Regulatory Coordinator Y verified there was no documentation in Patient #3’s chart which indicated staff had offered or FSP had refused to be turned every two hours as ordered, and Patient #3 did not receive 1:1 feeding assistance as ordered. Review of policy titled “Premier Nursing Services Skin Integrity Maintenance Program and Pressure Ulcer Prevention Program Initiatives”, dated 12/13/2022, revealed patients were assessed for risk of pressure injury upon admission, twice daily, with changes in clinical status, and upon transfer. Nurses notified the attending provider of all suspected and actual pressure injuries and notified the appropriate wound service for stage III, stage IV, and deep tissue injuries. Efforts were made to use repositioning to minimize pressure.”