Ohio State University State Health System

“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: 42492 Based on medical record review, staff interview, and policy review, the hospital failed to ensure patients in non-violent restraints had active physician orders This affected one (Patient #24) of four patients sampled for restraints. The hospital census was 755. Findings include: Review of the medical record revealed Patient #24 was admitted to the hospital on 10/08/25 with a diagnosis of left-sided pleural abscess. He was discharged to a skilled nursing facility in fair condition on 11/22/25. Review of the medical record revealed Patient #24 had physician orders dated 10/22/25 at 4:07 P.M., for non-violent soft limb bilateral wrist restraints which expired on 10/23/25 at 4:06 P.M. Review of the medical record revealed Patient #24 was in bilateral wrist soft limb restraints from 10/22/25 until the restraints were discontinued on 10/24/25 at 10:00 P.M. During an interview on 12/01/25 at 1:10 P.M. Accreditation Officer AA verified Patient #24 was in non-violent restraints from 10/23/25 at 4:06 P.M. to 10/24/25 at 10:00 P.M. without an active physician’s order. Review of policy titled “Restraint and Seclusion 03-30” dated 11/15/24 revealed orders for non-violent restraints expired in 24 hours. Upon the expiration of an order, the patient must be removed from restraint unless a new order is obtained.”

“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: 42492 Based on medical record review, staff interview, and policy review, the hospital failed to ensure patients in non-violent restraints were monitored appropriately . This affected one (Patient #29) of four patients sampled for restraints. The hospital census was 755. Findings include: Review of the medical record revealed Patient #29 was admitted to the hospital on 10/09/25 with an admitting diagnosis of ischemic cardiomyopathy status post Coronary Artery Bypass Graft (CABG). He was discharged to Inpatient Rehabilitation on 11/06/25. Review of the medical record revealed Patient #29 had physician orders dated 10/11/25 at 3:03 P.M. for non-violent soft limb bilateral wrist restraints. Orders were renewed daily without modification until the restraints were discontinued on 10/18/25 at 3:37 P.M. Review of the medical record revealed Patient #29 had a physician order dated 10/23/25 at 6:39 P.M. for nonviolent soft limb bilateral wrist restraints. Orders were renewed daily without modification until the restraints were discontinued on 10/26/25 at 9:18 A.M. Review of the flowsheet history revealed staff had not documented monitoring for mood, behavior, or circulation on 10/11/25 from 1:01 P.M. to 8:00 P.M. There was no documentation for circulation or skin checks on 10/12/25 from 12:02 P.M. to 3:00 P.M. There was no documentation of behaviors, skin integrity, or patient safety on 10/12/25 from 5:21 P.M. to 8:00 P.M. There was no documentation for skin checks on 10/14/25 at 10:00 P.M. and 10/15/25 at 12:00 A.M. There was no documentation for any monitoring of patient safety, skin integrity, mood/behavior, circulation, or patient care needs on 10/25/25 from 3:33 P.M. to 7:30 P.M. During an interview on 12/02/25 at 3:00 P.M. Accreditation Officer AA verified Patient #29’s medical record had missing documentation for monitoring related to non-violent restraints. Review of policy titled “Restraint and Seclusion 03-30” dated 11/15/24 revealed soft Limb restraints for 1-3 limbs required monitoring every two hours including patient safety, skin integrity under the restraint, mood/behavior, circulation, and patient care needs including positioning, elimination, food/fluids, and means to summon assistance.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 32088 Based on medical record review, staff interview and policy review, the hospital failed to ensure a neurology consult was completed timely. In addition, the hospital failed to ensure critical Magnetic Resonance Imaging (MRI) results for a patient were immediately notified to the physician. This affected one (Patient #1) of four patient records reviewed for Emergency Department (ED) neurology consult orders and receiving radiology services. The census was 755.”

“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: 32088 Based on medical record review, staff interview and policy review, the hospital failed to ensure a neurology consult was completed timely. In addition, the hospital failed to ensure critical Magnetic Resonance Imaging (MRI) results for a patient were immediately notified to the physician. This affected one (Patient #1) of four patient records reviewed for Emergency Department (ED) neurology consult orders and receiving radiology services. The census was 755. Findings include: Review of the medical record revealed Patient #1 arrived to the ED on 09/27/25 at 5:34 P.M. after being sent by a provider at an affiliated Urgent Care for complaints of weakness and confusion. The Urgent Care Provider noted she wanted the patient to go to the ED for head imaging, urinalysis, and labs based on the severity of her symptoms. The patient was triaged at 5:35 P.M. and her acuity was set at two (required urgent attention). The Triage Nurse noted the patient reported falling out of bed when trying to get up at night and entered confusion as the chief complaint. Her vital signs were 98 degrees Fahrenheit, heart rate 91 beats per minute (BPM), respirations 15 breaths per minute, blood pressure 162/72 millimeters of mercury (mm/Hg), 98 percent oxygen saturation on room air (RA) and the patient was noted as alert and calm. While in the ED lobby staff were monitoring the patient’s vital signs and at 8:46 P.M. the patient’s blood pressure was noted at 200/104 mm/Hg and the mean arterial pressure (MAP) was elevated at 136. At 9:51 P.M. the patient’s blood pressure was 221/102 mm/Hg and at 10:54 P.M. the blood pressure was 234/105 mm/Hg. The MAP remained elevated between 134 and 150. The patient reported she had not taken her Procardia (calcium channel blocker used to treat high blood pressure) for the day. On 09/27/25 at 11:11 P.M. the patient was placed in an ED room. The patient’s blood pressure remained elevated throughout the night between 136/74 mm/Hg and 208/88 mm/Hg. On 09/28/25 1:38 A.M. a computed tomography (CT) scan was ordered and completed at 2:43 A.M. indicating remote lacunar infarcts, a moderate background of microvascular ischemia and no acute intracranial findings. At 5:45 A.M. an order was placed for Procardia XL (a calcium channel blocking medication used to treat high blood pressure) 30 milligram (mg) daily by mouth. On 09/28/25 at 6:10 A.M. an order was placed for a neurology consultation. On 09/28/25 at 7:38 P.M. the family was asking the doctor about the patient’s elevated blood pressure and ropinirole (medication for restless leg syndrome (RLS) order. The patient’s blood pressures were slightly lower but remained elevated and on 09/29/25 at 4:10 A.M. the Procardia XL was increased to 60 mg a day. At 5:25 A.M. the nurse informed the physician of a systolic blood pressure of 224 and 198 at recheck. At 6:01 A.M. intravenous (IV) hydralazine (vasodilator used to treat high blood pressure) was given. At 6:38 A.M. the patient’s blood pressure was 164/73 mm/Hg. At 10:36 A.M. the patient was transferred to the Clinical Decision-Making Unit (CDU). On 09/29/25 at 11:00 A.M. registered nurse (RN), Staff H completed a focused assessment and noted slurred speech, the patient was unable to stick out her tongue, and not able to move left leg. The patient denied numbness or tingling. At 11:17 A.M. Staff H notified provider, Staff C to inform him of the patient’s slurred speech, not being physically capable of moving her left leg and being much weaker from when she saw her on Saturday. On 09/29/25 at 10:31 A.M. Staff C ordered an magnetic resonance imaging (MRI) of the head related to the patient’s ongoing lethargy, history of transient ischemic attack (TIA), dementia work up and microvascular disease. The head MRI resulted on 09/29/25 at 4:42 P.M. revealing an acute right ACA territory infarct with no evidence of hemorrhagic transformation, microvascular ischemic changes and a small remote infarct in the superior left cerebellum. The MRI was signed by radiologist, Staff K. There was no note indicating a provider was notified of the critical result. Patient #1’s nurse completed frequent neuro assessments and staff noted the patient’s symptoms indicating the patient was slowly getting better. On 09/28/25 at 9:58 P.M. Hospitalist, Staff J noted the patient’s family was extremely upset about the level of care the patient was receiving. Staff J noted the patient had an MRI that was positive for a right ACA territory stroke. She noted neurology had been consulted but there were no recommendations provided. Staff J noted the patient was unable to receive aspirin, but she would defer that to neurology. Staff J paged the overnight neurology team. Staff J placed orders for continuous cardiac monitoring, continuous pulse oximetry monitoring, aspiration precautions, a sequential compression device, a swallow screen and full national institute of health (NIH) stroke scale assessments every four hours. On 09/29/25 at 10:08 P.M. neurologist, Staff F assessed the patient and Staff E attested. Staff F noted the patient was not a candidate for IV thrombolysis due to being out of the window and no thrombectomy due to unlikely large vessel occlusion. The neurologist recommended the patient be transferred to the neurovascular service and orders were place for a swallow evaluation prior to any oral intake, Plavix 75 mg daily, computed tomography angiography (CTA) of the brain and neck, echocardiogram (ECHO) to evaluate cardiac function, lipid panel, liver function tests (LFT) and hemoglobin A1c (HgbA1c) to evaluate secondary risk factors for ischemic stroke, start a high intensity statin and consults for physical, occupational and speech therapy were placed. The Neurologist noted the patient should continue the ropinirole for now, and he recommended switching to gabapentin (medicine used to manage neuropathic nerve pain) 300 mg two hours prior to bedtime after discharge to avoid rebound symptoms in the long term. On 09/30/25 at 12:21 A.M. the patient was transferred to the Brain and Spine Unit. Interview on 12/01/25 at 2:45 P.M. with the radiologist (that read the critical MRI for Patient #1 on 09/29/25 at 4:42 P.M.) Staff K, revealed he did not feel that this would be an acute finding because he was under the impression that the team knew the patient had already had an infarct. A lot of the MRI’s show strokes on them but he does not think it was a good idea to call every one of them. He stated he did not call because he felt they would read the report. He stated it was simple without life effects and not life threatening. He stated, “I was hoping they would see it and I should have called it.” Interview on 12/01/25 at 2:51 P.M. Radiologist, Staff L revealed when reading MRI results he stated he immediately calls to notify the provider of any critical result like an acute stroke or any infarct and he notes it right on the MRI read results. Interview on 12/01/25 at 3:03 P.M. with the ED Medical Director, Staff M revealed Patient #1 was seen at an Urgent care reporting falls and weakness over the last few days. He stated the patient presented to the ED and since her symptoms presented two to three days prior she was outside of the 24-hour window for an acute stroke so a stroke alert would not be called. They completed a CT scan of the head and neck and nothing was there. Her BP was elevated and the patient was falling a lot at home so the family was concerned that they did not feel safe with her going home and she was admitted on 09/28/25. He stated she remained in ED because of capacity issues. When her signs and neurological symptoms changed, an MRI was obtained and showed an acute stroke. He stated he was not sure when the stroke occurred, it could have been two to three days ago. An acute stroke would not have necessarily shown on the CT scan if changes in the brain tissue have not happened yet. The initial CT scan may not show anything. He stated she was outside the international window of 24 hrs. Her symptoms were waxing and waning and the ED providers felt the neurological assessment was okay. When questioned why the neurology consult ordered on 09/28/25 at 6:10 P.M. was not completed until 09/29/25 at 10:08 P.M. he replied, “I cannot speak to timeliness of neurology consult.” He stated a routine neurology consult needs to be completed within 24 hours. Interview with Hospitalist, Staff J on 12/01/25 at 3:49 P.M. revealed she provided care for Patient #1 on the evening of 09/29/25 in the capacity of a nocturnist. She stated the patient had a CT scan evidencing non-acute remote strokes but with physical changes like falls, cramping, and worsening of the symptoms. She stated the plan was to manage her hypertension (htn). She stated the patient had a naproxen (non-steroidal anti-inflammatory drug used to relive pain, fever and inflammation) allergy. The Hospitalist said the patient’s admission note listed her as a “boarder” on 09/28/25 at 4:21 A.M. She stated when a patient is a “boarder” the Hospitalist completes rounds on those patients. An MRI was ordered on 09/29/25 10:31 A.M. by the “daytime rounder” and at 4:40 P.M. the MRI resulted. She stated she did not get an alert for the results and found out when the nurse called her to the patient’s bedside. She stated the nurse expressed the family’s frustration as they were saying no one came to review results of the MRI with them. Staff J stated her exam at the time revealed the patient was alert and oriented times three, cranial nerves two to 11 were intact, she could/did not cooperate for cranial nerve 12, which is the nerve for tongue movement. Staff J stated she did not walk her. Staff J stated even though the provider was not notified of the MRI results which revealed an acute ACA territory stroke from 4:40 P.M. through until she checked at approximately 9:58 P.M., there was no delay in care. However, when asked what orders were put into place after the MRI was acknowledged by a provider and she stated they consulted neurology and they came immediately, an urgent CT Angiogram of the brain and neck was ordered, a swallow screen, continuous cardiac monitoring, lower extremity compression device, full NIH assessments with vitals signs every four hours and aspirin was ordered the next day after providers discussed and decided she was not allergic to it. She stated the difference was that she notified the stroke team that they had a positive stroke result and they were in to assess the patient and immediately got her admitted to our stroke floor. She stated the 88-year-old patient was not a candidate for thrombolytics or vascular therapy she was outside of the treatment window, and she was already receiving statin therapy. Staff J stated although the patient underwent an acute stroke, she was already having symptoms and was outside of the window for help. Interview on 12/04/25 at 11:30 A.M. with the registered nurse (RN) who provided care for Patient #1 on the evening of 09/29/25 starting at 7:00 P.M., Staff D revealed when she started caring for the patient on 09/29/25 the family was upset because the patient had an neurology workup and MRI hours earlier and they had not spoken to a doctor or heard anything since. She stated she pulled the results for the MRI and it was positive so she sent a message to the provider caring for the patient and the ED doctor to inform that the patient’s family was upset because some time had passed by after the positive MRI was completed and they had heard nothing. She stated a few hours later neurology assessed the patient and by 11:00 P.M. on 09/29/25 admission orders were placed to admit the patient to the stroke unit. Staff D stated the ordering providers should follow and track the results of their patients’ tests. She stated the patient waited three days after her change in condition to report to the hospital and therefore she would not have been a candidate for acute thrombolytics. She stated aggravation of times may have changed. She stated the patient had already had a negative CT scan, her symptoms were resolving on their own and her NIH scores remained low. She stated there was no slurred speech, leg weakness or left side weakness when she provided care for the patient. Staff D stated a CT scan only shows if there are hemorrhagic concerns, a MRI is more in depth. She stated the prior nurse was questioning the slurred speech and residual slurred speech was reported to me during report, but she did not notice it. Staff D stated the patient’s outcome would have been the same. She stated with a positive MRI, neurology needs to be at the bedside as soon as possible. Staff D stated that night she sent a message to the doctor asking where was neurology? She knew neurology would admit the patient and get orders in. She stated the patient would have been in a bed on the Brain and Spine Unit in no time at all. Staff D said she apologized to the patient and family and tried to reassure them that there was no miss in treatment. Interview with Staff C, Hospitalist (provider who ordered MRI on 09/29/25) on 12/04/25 at 8:45 A.M. revealed he ordered the MRI for Patient #1 on 09/29/25. He stated the patient was in the ED for one day and her symptoms were not clearly defined. He stated a neurology consult was placed the the previous day and they triage patients and see them in that order. He stated on his assessment he noted the patient was lethargic, but she was moving her extremities. He stated Patient #1 had seen five other doctors before getting to him. He stated her exam did not show up as an automatic stroke, there was no clear motor deficit and the fact that the MRI was not ordered was because the providers did not feel she needed an MRI. He stated he is not sure if they were unclear on what was going on or if there had been too much time since symptom onset. He stated he doesn’t remember if there was a secure chat about the MRI results and stated, “I don’t know what happened but if it is a stroke they will alert us, if they don’t alert us we don’t know and we find out whenever we go look at the chart.” He stated he did not get a chance to look at the MRI again before his shift was over at 7:00 P.M. He stated he doesn’t know why he was not alerted there was an acute report found on the MRI. He stated Radiology usually pages them and there was no page regarding the critical MRI. He stated if he was notified of the results he would have notified neurology team to assess the patient. He stated even though the physician was notified of the MRI results late the patient was already out of the window for TPA or a vascular procedure related to timing of her symptoms. Interview on 12/04/25 at 1:30 P.M. with the Attending neurologist on the evening of 09/29/25, Staff E revealed Patient #1’s initial presentation was atypical and not clear cut for a stroke. She complained of falls, cramps and weakness. Initially the ED providers completed acute CT imaging and her last known well (LKW) so far the urgency was not there. He stated tenecteplase (TNK) (a clot busting medication) should be started within 4.5 hours, and a thrombectomy should be completed within 24 hours of the LKW. He stated a stroke alert would not be called after these timeframes. The neurologist stated after we need to do work up to see if the stroke is still going on and provide treatment to prevent future strokes like aspirin and statins (medications that reduce the risk of stroke and heart attack). He stated the head ct-scan and c- spine revealed no acute findings. He stated a MRI is not considered emergent imaging, and most patients get the MRI the next day. It is for informational purposes. He stated when the imaging was clear they got the aspirin and Lipitor (statin) ordered. He stated it was recommended to start aspirin and statins right away, at least within 24 hours because they were stroke treatment standards. He stated he didn’t remember why the aspirin and statin should be started as soon as possible but stated based on Joint Commission guidelines they should be implemented within 24 hours. He stated in this case they did not see the patient worsening, or the signs that the stroke had gotten bigger or evidence of a new stroke. He stated there was a delay in recognition of the stroke, but he didn’t think it affected her overall care. He stated the routine MRI was positive of an ACA territory stroke, staff should notify neurology so they can order a CT-angiogram. He stated the treating physician should follow up on the results when they order tests. The results should not go unnoticed. He stated if a patient had a positive MRI for an ACA territory stroke, he would like to be notified right away. He stated consults are taken care of by residents and nurse practitioners and he is unsure why the neurology consult ordered on 09/28/25 at 6:10 A.M. was not completed until 09/29/25 at 10:08 P.M. Review of the hospital policy titled “Inpatient Consult Communication” revealed routine consult orders for the ED must be completed within two hours and inpatient consults made prior to 10:00 AM would be completed and recommendations should be entered into the medical record within that business day. Inpatient consults made after 10:00 AM would be completed and recommendations should be entered into the medical record within 24 hours. Consult teams were obligated to communicate summary recommendations with the primary team and to enter the final consult recommendations in the medical record within 24 hours. Review of the hospital policy titled “Critical Results Reporting of Findings on Radiology Issues” revealed once identified a critical finding will be communicated to the physician/practioner by the radiologist in a manner that reasonably ensures timely receipt of the findings but no later that one hour from the time the diagnosis is made. Examples of critical findings were listed as acute vascular concerns affecting the brain. Review of the hospital policy titled “Inpatient Consult Communication” revealed routine consult orders for the E must be completed within two hours and inpatient consults made prior to 10:00 A.M. will be completed and recommendations should be entered into the medical record within that business day. Inpatient consults made after 10:00 A.M. will be completed and recommendations should be entered into the medical record within 24 hours. Consult teams are obligated to communicate summary recommendations with the primary team and to enter the final consult recommendations in the medical record within 24 hours. Review of the hospital policy titled “ED Stroke Response” revealed an acute stroke alert is to be activated on all patients with a last known well (LKW) within 24 hours and meet stroke alert criteria. This include patients who present for stroke alert/TIA who develop new or worsening stroke like symptoms while in the ED. Patients who develop new symptoms should be re-assessed and a stroke alert reconsidered with an updated last known well.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. 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 staff reviewed patient rights with one patient. This affected Patient #1. Findings include: Review of the medical record of Patient #1 revealed the patient presented to the ED on 12/01/23 at 11:00 PM after intentionally taking 800 mg Trazodone (medication used to treat depression), 1 mg Ativan (medication used to treat anxiety), and 8 mg Klonopin (antiepileptic medication with an off-label use of treatment of anxiety) in an attempt to commit suicide. She reported no psychiatric history prior to 09/21, however, stated that she did not want to wake up. An application for emergency admission (pink slip) was completed by an emergency physician. The medical record lacked documentation any staff member reviewed the patient rights or provided a copy of the patient rights to the patient. Nursing notes revealed the patient was most often sleeping in the ED but when awakened, she was cooperative. She remained in the ED until she was admitted to NP5 on 12/02/23 at 7:40 PM. On admission to NP5, a nurse’s note on 12/02/23 at 10:20 PM stated the patient reported feeling very overwhelmed and stressed. She stated that she didn’t know if it was all worth it and reported taking an overdose of medication the day before. Although the note stated that she was given a tour of the unit, the medical record lacked documentation a staff member reviewed patient rights with her. The facility policy titled Patient Rights and Responsibilities, effective 09/01/21, was reviewed on 01/31/24 at 5:45 PM. According to the policy, all employees and staff have an ethical obligation to ensure that the rights of every patient are supported in all interactions and in the provision of health care services. Patient rights will be offered to and reviewed with the patient every time a patient is admitted to the hospital or the Emergency Department. Staff C was interviewed on 01/31/24 and asked to provide documentation the patient rights were reviewed with the patient. The medical record contained no such documentation.”

“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: 28999 Based on medical record review, and staff interview, the facility failed to ensure nurses followed a physician order for a sound machine to aid in sleep. This affected Patient #1. Findings include: Review of the medical record of Patient #1 revealed the patient presented to the ED on 12/01/23 at 11:00 PM after intentionally taking 800 mg Trazodone (medication used to treat depression), 1 mg Ativan (medication used to treat anxiety), and 8 mg Klonopin (antiepileptic medication with an off-label use of treatment of anxiety) in an attempt to commit suicide. She reported no psychiatric history prior to 09/21, however, stated that she did not want to wake up. An application for emergency admission (pink slip) was completed by an emergency physician. Nursing notes revealed the patient was most often sleeping in the ED but when awakened, she was cooperative. She remained in the ED until she was admitted to NP5 on 12/02/23 at 7:40 PM. A physician’s communication order for nursing care dated 12/04/23 at 11:41 AM stated patient can have a sound machine in room to help with sleep at night. The order remained in effect until the patient was discharged on 12/07/23. An occupational therapist’s (OT) note dated 12/04/23 at 4:03 PM stated an OT discussed with the patient, a psychiatric physician and registered nurse the use of a sound machine to assist patient with sleep. The physician verbally approved the sound machine. The OT demonstrated use of the sound machine and the patient verbalized understanding use of the machine. The sound machine was placed behind the nurse’s station for use at night. The medical record lacked documentation a sound machine was provided to the patient to aid with sleep. Staff E was interviewed on 01/31/24 at 7:04 PM. Staff E was asked if she provided a sound machine in the patient’s room at night to aid in sleep. She stated there was not a sound machine in the patient’s room. Staff E was unaware of the order for a sound machine. Staff C was interviewed on 01/31/24 at 7:30 PM. It was confirmed that the physician’s order was not followed as the patient never received a sound machine to aid with sleep.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 28999 Based on record review, staff interview and policy review, the facility failed to enusre a confused patient did not leave the hospital unattended. Patient #4 left the hospital unattended and did not return to the unit. Patient #4 was found by a passing ambulance crew, wandering the sidewalk wearing a hospital gown. He was taken to another area hospital and admitted with a chief complaint of altered mental status. See A144.”

“PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION CFR(s): 482.13(b)(4) The patient has the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital. This Standard is not met as evidenced by: 28999 Based on record review, interview and policy review, the hospital failed to notify a patient’s emergency contact when he left the nursing unit and did not return. This affected one (Patient #4) of ten patients reviewed. The hospital census was 954. Findings include: Review of the medical record of Patient #4 revealed the patient presented to an outside hospital on 10/06/23 after a syncopal event at home. The decision was made to transfer the patient to a tertiary facility for further care. Nursing notes documented on 10/09/23 at 5:19 PM, Patient #4 left the nursing unit to “get some air”. After more than an hour, the patient did not return and a staff nurse was unable to locate him. The patient was discharged against medical advice (AMA). Review of the medical record from another hospital revealed Patient #4 was found by a paramedic crew on 10/09/23 at 6:09 PM, wandering the streets wearing only a hospital gown. . Paramedics transported the patient to another hospital where he was admitted with a chief complaint of altered mental status and diagnoses including encephalopathy, alcohol withdrawal, hyponatremia and substance use disorder. A physician’s progress note on admission stated the patient reported he and his wife going to a hotel to celebrate their anniversary. They had an argument and while he was in the shower, his wife took all of his belongings leaving only a hospital gown on the hotel bed. The patient reported that he put the gown on and was walking around outside when the paramedics found him. According to the outside record, the patient was placed on medical hold. The physician from the outside hospital stated in a progress note, that the patient had an altered recollection as the patient still believed he was in a hotel as opposed to the hospital. He remained inpatient until 10/13/23. During an interview on 11/29/23 at 1:00 PM, Staff P confirmed that the medical record lacked documentation the patient’s emergency was contacted regarding the patient not returning from leaving the unit. The facility policy titled “Patients Leaving Units Independently (03-53)”, effective 03/01/21 documented if the patient does not return within the agreed upon timeframe and/or there is a concern for the safety of the patient, unit staff shall attempt to locate the patient, staff shall also notify the manager and/or nursing supervisor who will continue to contact the patient and/or the emergency contact, unit staff shall attempt to contact the emergency contact if unable to locate the patient.”

“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: 28999 Based on record review, staff interview and policy review, the facility failed to ensure a confused patient did not heave the hospital unattended. Patient #4 left the hospital unattended and did not return to the unit. Patient #4 was found by a passing ambulance crew, wandering the sidewalk wearing on a hospital gown. He was taken to another area hospital and admitted with a chief complaint of altered mental status. This affected Patient #4. The hospital census was 954. Findings include: Review of the medical record of Patient #4 revealed the patient presented to an outside hospital on 10/06/23 after a syncopal event at home. The patient had a tonic-clonic seizure (a type of seizure that involves violent muscle contractions) and was transferred to the current hospital for further care. Diagnoses included seizure and alcoholism. Patient #4 arrived at the hospital on 10/07/23 at 6:29 AM. A progress note on admission revealed the patient was tremulous, diaphoretic, and anxious. Although the patient was able to state his name and the year, he had to be told it was October and was unable to report his current city. A physician stated, in her history and physical, that the patient was evaluated at an outside hospital in March 2023 after a motor vehicle accident where he suffered numerous fractures and his alcohol level was elevated on initial evaluation. The physician also stated she suspected the seizures were related to alcohol withdrawal. Patient #4 was admitted to the facility’s East Tower unit (ET 7), a medical surgical unit. A physician ordered seizure precautions, continuous telemetry monitoring, Clinical Institute Withdrawal Assessment (CIWA) for alcohol withdrawal, and as needed Ativan, an anti-anxiety medication. The CIWA protocol for alcohol withdrawal is a questionnaire that measures the severity of an individual’s alcohol withdrawal symptoms. A score less than 8 requires vital signs and CIWA scoring frequency every 4 hours, times six. If the score remains less than 8, nurses can stop the vital signs and CIWA scoring and no Ativan is administered. If the score is between 8-14, vital signs and CIWA scoring is required every two hours and Ativan 1 milligram (mg) is administered intravenously. If the score is between 15-20, vital signs and CIWA scoring is required hourly and Ativan 2 mg is administered. A score between 21 and 30 requires nurses are required to assess vital signs and CIWA scoring hourly and Ativan 3 mg is administered. A score between 31 and 45 requires vital signs and CIWA scoring every hourly and Ativan 4 mg is administered. A nurses note on 10/07/23 at 6:45 AM stated a pre-fall huddle, performed by two staff nurses on admission, noted that the patient had fall risk factors including a history of falls and an altered mobility and/or gait. A bed exit alarm was initiated as an intervention to prevent the patient from falling. Review of the toxicity assessment dated 10/07/23 at 6:45 AM, revealed the patient received a CIWA score of an 11 which included the highest possible score of a 4 for orientation as the patient was disoriented to place and/or person. At 8:31 AM, Patient #4 received an orientation score of a 0 as the patient was oriented and able to complete serial additions. The total CIWA score was an 8 at this time. At 10:00 AM and 11:48 AM, the patient continued to be oriented and able to complete serial additions. The total CIWA scores were 8 and 4 respectively. At 4:00 PM, the toxicity assessment revealed the patient was again disoriented to place and/or person. A nurse’s note at this time stated the patient turned the bed alarm off and was found wandering the halls, trying to leave the unit. A video sitter was initiated. At 6:12 PM, the CIWA score was 16 which included an orientation score of a 4 as the patient remained disoriented. A nurse’s note at 6:58 PM revealed the patient fell on his bottom attempting to get out of bed as he had become increasingly confused and restless. Bilateral soft wrist restraints and an in-person sitter were initiated at 7:31 PM as ordered by a physician. An emergency response team physician called to the bedside to assess the patient post fall stated in a progress note that a medical hold would be placed to prevent elopement and potential injury. The medical hold was ordered and the patient was placed in a purple hospital gown to differentiate him from other patients. A phenobarbital taper was also ordered. The patient was transferred to the facility’s Progressive Care Unit at 8:33 PM where Phenobarbital was initiated. A sitter remained in constant attendance, the patient remained in restraints, and CIWA scoring and seizure precautions continued. The patient remained disoriented to place and/or person receiving a 4 on the orientation of the CIWA scoring on 10/07/23 at 9:40 PM and on 10/08/23 at 12:09 AM, 3:45 AM, 8:50 AM, 12:20 PM, 4:00 PM, 6:00 PM, and 7:40 PM. Patient #4 remained disoriented to place and/or person through the night, however, on 10/09/23 by 10:20 AM, the patient received an orientation score of a 0 as the patient was oriented and able to complete serial additions. The attending physician’s progress note on 10/09/23 at 10:24 AM stated the patient was doing much better on phenobarbital taper which was scheduled to be completed two days later. The physician documented the sitter and the restraints would be discontinued. The restraints were discontinued on 10/08/23 at 9:00 PM and the sitter was discontinued on 10/09/23 at 9:49 AM. At 11:11 AM, an addiction physician noted the patient’s risk of serious withdrawal complications was severe and staff should continue monitoring the CIWA with the phenobarbital taper. On 10/09/23 at 5:19 PM, a nursing note documented Patient #4 left the unit to “get some air”. After more than an hour, Patient #4 did not return and a staff nurse was unable to locate him. The patient was discharged against medical advice (AMA). Review of the medical record revealed no physician order to leave the unit and no documentation staff accompanied Patient #4 off the unit. Review of the medical record from an outside hospital documented Patient #4 was found by a paramedic crew on 10/09/23 at 6:09 PM, wandering the streets wearing only a hearing only a hospital gown. Patient #4 still had a heparin locked IV access in his arm. Paramedics transported the patient to another hospital. Patient #4 was admitted with a chief complaint of altered mental status and diagnoses including encephalopathy, alcohol withdrawal, hyponatremia and substance use disorder. A physician’s progress note on admission stated Patient #4 reported he and his wife were going to a hotel to celebrate their anniversary. They had an argument and while he was in the shower, his wife took all of his belongings leaving only a hospital gown on the hotel bed. The patient reported that he put the gown on and was walking around outside when the paramedics found him. A physician progress note documented Patient #4 had an altered recollection as the patient still believed he was in a hotel as opposed to the hospital. He remained inpatient until 10/13/23. During an interview on 11/29/23 at 1:00 PM., Staff P, the manager of the Progressive Care Unit, stated patients are required to sign out and in on a log kept at the nurse’s station when leaving the floor. Patients should also sign a Safety Agreement prior to leaving the unit. The signed agreement should be part of the patient’s permanent medical record. Staff P stated although there is a log kept at the nurse’s station, once the log is full, it is discarded. The log where the patient signed out was no longer available. During an interview on 11/29/23 at 2:00 PM, Staff O, the charge nurse on duty on 10/09/23 when Patient #4 left the hospital, stated she remembered Patient #4 leaving the floor multiple times on 10/09/23. Staff O stated Patient #4 was wearing street clothes all day. During a telephone interview on 11/30/23 at 12:10 PM, Staff L stated she vaguely remembering caring for Patient #4. She stated that when the patient told her that he was going out to get some fresh air, she reminded him to sign the log but did not physically see him sign out. She stated she remembered the patient wearing a hospital gown when he left the unit. During interview on 11/30/23 at 3:00 PM., Staff A and Staff B both confirmed Patient #4 was on seizure precautions, was a high risk for a fall, and was on telemetry but was permitted to leave the unit independently wearing only a gown. It was confirmed that the medical record lacked documentation the patient was accompanied by a staff member and lacked documentation a physician ordered that the patient was permitted to leave the unit independently. Review of the facility policy titled “ Patients Leaving Units Independently (03-53)”, effective 03/01/21, documented it is in the best interest of patients to remain in their area of care while in the hospital. By patients staying on the nursing unit/area of care, the hospital staff’s ability to promote the safety of the patient, and to proceed with treatment plans without unexpected delays or interruptions in enhanced. Nursing should review this expectation with patients and families during the admission process. The patient is expected to stay on the unit. It is normally considered unsafe for patients with certain clinical conditions or treatments to leave the unit unaccompanied by a staff member. Patients with the below medical conditions/equipment should not be given permission to leave the unit unaccompanied by a staff member unless cleared by a physician. If the patient is permitted to leave the unit with one of the conditions listed below, a nursing communication order by an attending is required. 1. Receiving an infusion of a high alert medication or controlled substance. 2. Recently administered medications that may cause clinically significant sedation. 3. Receiving a blood transfusion. 4. On isolation precautions 5. On seizure precautions 6. At high risk for falls or injury 7. On telemetry 8. On supplemental oxygen 9. With unstable vital signs including fluctuating oxygen saturation. 10. And/or any condition in the judgement of the care team may compromise the patient’s safety. The policy further stated if the patient leaves the unit with one of the clinical conditions, staff should document that the patient was counseled on the safety risks of leaving the unit, but left the unit against medical advice. If the patient does not fall into one of the categories, the patient may leave the unit. The patient may leave for 60 minutes. Units will keep a log of patients that leave the unit with the agreed upon location. If the patient does not return within the agreed upon timeframe and/or there is a concern for the safety of the patient, unit staff shall attempt to locate the patient, staff shall also notify the manager and/or nursing supervisor who will continue to contact the patient and/or the emergency contact, unit staff shall attempt to contact the emergency contact if unable to locate the patient.”