Weatherford Regional Hospital, Inc. of Weatherford

“PATIENT CARE POLICIES CFR(s): (1) The CAH’s health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law. This Standard is not met as evidenced by: 54216 Based on record review and interview, the hospital failed to ensure: 1. Availability of history and physical (H&P) for three (Patients #1, 2, 3) of 20 patient charts reviewed; 2. Documentation of patient disposition requirements for one (Patient #4) of 20 patients reviewed; 3. The development and implementation of a policy for assessing and reassessing patient pain for all patients. Findings: HISTORY AND PHYSICAL Patient #1 Review of the medical record showed the patient was admitted on 04/03/25 at 9:55 PM and the provider signed the H&P on 04/06/25 at 5:14 PM. (over 67 hours after admission) Patient #2 Review of the medical record showed the patient was admitted on 11/15/25 at 5:04 PM and the provider signed the admission H&P on 11/17/25 at 6:40 AM. (37 hours after admission) Patient #3 Review of the medical record showed the patient admitted on 07/09/25 at 1:48 PM and the provider signed the admission H&P on 08/24/25 at 2:42 P. (over 30 days after admission) Review of a document titled “Medical Staff Bylaws” read in part, “The admitting physician or practitioner will be responsible for the completion of an admission history and physical examination no more than 30 days before or 24 hours after admission. The history and physical examination must be on a patient’s chart within 24 hours of admission.” On 04/01/26 at 1:46 PM, Staff F stated: 1. H&P documentation should be completed within 24 hours of admission. 2. Patient #1’s H&P was completed over 24 hours after admission. On 04/01/26 at 3:04 PM, Staff I stated: 1. The H&P for Patient #2 was completed on the day of discharge; over 24 hours after admission. 2. The H&P for Patient #3 was completed over 30 days after admission. On 04/01/26 at 4:24 PM Staff E stated the rule was to have H&P documentation completed within 24 hours of admission. DISPOSITION REQUIREMENTS Patient #4 Review of the medical record showed patient arrived at the ED on 06/20/25 at 9:35 PM and was discharged as LWBE on 06/20/25 at 9:46 PM. The record showed no documentation of search efforts, signed forms, or notes. Review of a policy titled “Patient Leaving Against Medical Advice, Leaving Before Being Evaluated, or Discharged and Elopement” last updated 05/2025 read in part, “If the patient left without notifying staff or before the provider evaluates the patient, or was not visualized leaving: Attempt to locate the patient at least three times before discharging the patient from the system. Attempts will be documented within the electronic health record. Patient should complete the Release of Responsibility form for Refusal of Screening Exam, Refusal of Care, Leaving Against Medical Advice and staff will place in the Medical Record.” On 04/01/25 at 2:22 PM, Staff C stated: 1.The AMA/Elopement/Abduction/LWBE tab was not filled out. 2.The staff were expected to search for and call the patient/responsible party. 3.The nurses should have charted their efforts in the progress notes. PAIN ASSESSMENT Review of facility policies showed no policy addressing pain assessment, reassessment, and management. On 04/01/25 at 4:30 PM, Staff F stated there was no pain assessment policy.”

“PATIENT CARE POLICIES CFR(s): §485.635(a)(2) The policies are developed with the advice of members of the CAH’s professional healthcare staff, including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists, if they are on staff under the provisions of §485.631(a)(1). §485.635(a)(4) These policies are reviewed at least biennially by the group of professional personnel required under paragraph (a)(2) of this section, and reviewed as necessary by the CAH. This Standard is not met as evidenced by: 54216 Based on record review and interview, the critical access hospital failed to ensure policy review for all patients and staff. Findings: A review of facility policies showed multiple policies without documented evidence of periodic reassessment. Specifically: 1. Policy titled “Swing Bed Certification” showed last review 06/22. (nearly two years past due) 2. Policy titled “Disinfectants for Ultrasound Transducers” showed last review 06/30/20. (nearly four years past due) 3. Policy titled “Diagnostic After Hours Call” showed last review 07/15/22. (nearly two years past due) 4. Policy titled “Crash Carts” showed last review 4/21. ( nearly three years past due) Review of the GB Bylaws dated 08/25/25, showed no policy review frequency guidelines. On 04/01/26 at 11:49 AM, Staff E stated: 1. The facility policies were reviewed annually. 2. The GB reviewed and approved an entire manual of policies at a time. 3. The GB indicated policy review completion by signing and dating a singular sheet located on the first page of the printed policy manual. 4. GB minutes only indicated the policy manual review, not which individual policies were reviewed.”

“EMERGENCY PROCEDURES CFR(s): §485.635(b)(4) Emergency procedures. In accordance with the requirements of §485.618, the CAH provides medical services as a first response to common life-threatening injuries and acute illness. This Standard is not met as evidenced by: 54216 Based on observation and interview, the hospital failed to ensure crash carts were secure for one (Bay 7 Pediatric Cart) of four ED crash carts. Findings: During a tour of the emergency department on 04/01/26 from 9:45 - 10:00 AM, a pediatric crash cart in trauma room 7 was observed to be unlocked. On 04/01/26 at 9:48 AM, Staff H stated: 1. The cart was unlocked by surgery to obtain a pediatric airway device. 2. The cart had not been relocked. 3. The unsecure drawers have risks of infection control. 4. The unsecure drawers have risks of decreased emergent supply availability.”

“NURSING SERVICES CFR(s): A nursing care plan must be developed and kept current for each inpatient. This Standard is not met as evidenced by: 54216 Based on record review and interview, the hospital failed to ensure involvement of the patient or the patient’s representative in the development of the plan of care for two (Patient #2 ane #7) of 20 patient records reviewed. Findings: Review of a policy titled “Admission Assessment and Ongoing Reassessment of the Medical Surgical Patient” last updated 09/25 read in part, “At the time of the admission assessment, a care plan should be initiated.” Patient #2 Review of the All Recorded Flowsheet Data dated showed the patient’s admission assessment was initiated on 11/15/25 at 9:01 PM and did not show a Plan of Care was initiated. 1. On 04/01/25 at 3:15 PM, Staff I reviewed the patient’s chart and stated: 1. Patient care plan was not initiated for Patient #2. 2. Care plans were to be initiated by the Registered Nurse doing the admission at the time of admit.”

“DISCHARGE PLANNING PROCESS CFR(s): The CAH’s discharge planning process must identify, at an early stage of hospitalization, those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient’s representative, or patient’s physician. This Standard is not met as evidenced by: 54216 Based on record review and interview, the facility failed to ensure: 1. Discharge planning was initiated at admission for two (Patient #2 and #6) of 20 patients reviewed. 2. Patient or patient representative involvement in discharge planning for one (Patient #6) of 20 patients reviewed. Findings: Patient #6 Review of the History and Physical dated 03/28/25 at 9:00 AM showed the patient had a swing bed admission on 03/27/25 at 1:59 PM. Review of the nursing Admission flowsheet date 03/27/25 at 2:52 PM and the Case Management Progress Note dated 03/28/25 at 7:30 AM showed no documentation of discussion with the patient or family in discharge planning. Review of the Case Management Progress Noted dated 04/02/25 at 3:55 PM showed documented discussion with the patient’s family. (six days after admission) On 04/01/26 at approximately 12:15 PM, Staff F reviewed the patient’s medical record and stated: 1. Discharge planning was to occur at admission. 2. It was important to engage the patient in discharge planning early in their stay so the patient knew expectations and their plan of care. 3. The patient’s earliest discharge planning note was 03/28/25 at 7:30 AM and it did not show the patient was included. Review of policy titled “Discharge and Discharge Planning” last updated 09/25 read in part: 1. “ ...discharge planning will begin at the time of the patient’s admission ...” 2. “The admissions nurse will initiate the Discharge Evaluation and Psychosocial Assessment form at the time of admission.””

“GRIEVANCES CFR(s): § 485.614(a)(2) Grievances The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. The hospital’s governing body must approve and be responsible for the effective operation of the grievance process and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. The grievance process must include a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the appropriate Utilization and Quality Control Quality Improvement Organization. At a minimum: This Standard is not met as evidenced by: 54216 Based on record review and interview, the hospital failed to ensure patients received notice of their right to file a grievance for all patients. Findings: A review of a document titled “Patient’s Bill of Rights,” showed no information on how or whom to file a complaint or grievance. On 04/01/25 at 4:11 PM, Staff F stated the same bill of rights was provided to the patients admitted to inpatient and swing bed. On 04/01/25 at 4:24 PM, Staff E reviewed the admission packet provided to all patients being admitted to the facility and stated there was no information on how or whom to file a complaint or grievance.”