St Clair Hospital

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 50899 Based on a review of facility policies, medical record (MR), Medication Error log, and employee interview (EMP), it was determined the facility failed follow policy in three of eleven medical records. Findings include: On July 29, 2026, a review of policy “Patient Safety and Occurance Reporting, C-8”, last approved 3, 2026, revealed the following. “The patient and/or family should be provided with a prompt, factual, description of the occurence and any effect on the patient (short and long-term effects). They should be informed that the occurence will be reviewed and, if appropriate, preventative measures will be implemented to prevent a recurrence. The disclosure should be documented in the patient’s medical record (what was disclosed and to whom).” ... “Medical Record Documentation: If a medical record exists, document a factual synopsis of the occurence, physical assessment and observations, all treatment interventions and the individual’s response to the treatment and/or diagnositic results.” On July 28, 2026, at 12:00 PM, a review of medical records (MR) revealed the following. Emergency Department patient MR2 appears on the facility “Medication Errors” log with an event date of July 21, 2025, and a description that includes the patient receiving a lactated ringer’s infusion rather than the ordered insulin infusion after verification by two Registered Nurses. This event was not documented in the medical record and no record of explanation to the patient for family exists. Emergency Department patient MR3 appears on the facility “Medication Errors” log with an event date of June 10, 2026, and a description that includes the patient receiving three doses of Unasyn 3g every 6 hours as ordered. This dosage did not consider the patient’s history of end stage renal disease, with hemodialysis three times a week for the past ten years. The Unasyn order was switched to a renal dose of 3g every 24 hours. This was an overdosage based on the patient’s past medical history. This event was not documented in the medical record and no record of explanation to the patient for family exists. Emergency Department patient MR7 appears on the facility “Medication Errors” log with an event date of June 6, 2026, and a description that includes the patient receiving calcium chloride 1000mg/10mL rather than the ordered sodium bicarbonate 50mL IV push X2. This event was not documented in the medical record and no record of explanation to the patient for family exists. On July 29, 2026, at 1:30 PM the above findings were confirmed by EMP2.”

“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: 50900 Based on a review of facility documents, medical records (MR), and employee interview (EMP), it was determined that the facility failed to follow policy in the administration of medications for three of eleven medical records reviewed (MR1, MR9, MR10). Findings include: Review of facility policy “Medication Administration, E-44”, last approved 12/2025, revealed: “Confirmation of Five Rights. Medications are to be administered using the five rights of medication administration. ... The five rights of medication administration include: 1. Right patient ... b. Manual: Verify the patients identity by checking the patient’s identification band for two identifiers ... and verbally stating the patient’s name. ... 2. Right Medication ... d. If the medication was not scanned a reason should be provided. e. Manual: Compare the eMAR/MAR [electronic Medication Administration Record] or the physician order with the label on the drug container/package. ... 3. Right Time ... 4. Right Route ... 5. Right Dose ...” On July 28, 2026, review of MR1 revealed a 65-year-old patient who presented the Emergency Department on July 8, 2026, at approximately 2:00 PM, referred by their primary care provider (PCP) for symptoms of dizziness and heart palpitations. Initial cardiac assessment revealed the patient to be experiencing atrial flutter/fibrillation (inconsistent, rapid heartbeat with irregular squeezing of heart chambers). Medication orders were placed for a diltiazem (Cardizem) bolus (fast-paced administration): “Diltiazem IV push STAT- 10mg” and diltiazem drip: “Diltiazem drip 125mg, Titrate Give ^5mg/hr at 5ml/hr IV ... Titration Goals: HR<100 BPM [beats per minute]”. During administration of the Diltiazem drip, EMP6 scanned MR1’s patient identification band, but did not scan the drug package- which prompted a pop-up warning on the eMAR: “Drug not scanned WARNING. Medication being administered without matching using scanning. Please ensure correct dose is administered.” EMP6 selected “Override” on the pop-up warning and selected “Barcode damaged, no other pack” in order to continue documentation of the medication being administered. On July 28, 2026, review of incident report “Medication Error Event (73255)”, dated 07/08/2026, revealed: “While caring for a patient requiring a diltiazem infusion for atrial fibrillation/flutter ... the patient developed hypotension. During review of the medication administration, it was identified that dexmedetomidine (Precedex) had been inadvertently administered instead of the ordered diltiazem infusion.” On July 28, 2026, during employee interview at 11:30 AM, EMP8 confirmed that EMP6 did not follow facility policy by verifying the correct medication prior to administration to the patient (MR1). On July 29, 2026, review of MR9 revealed a 78-year-old patient who presented to the Emergency Department on July 8, 2026, at approximately 12:30 PM. At the time of registration, the patient was given an incorrect patient identification band of another person with the same first name, also in the ED. On July 29, 2026, review of incident report “Error Related to Procedure/Treatment/Test Event (73259)”, dated 07/09/2026, revealed: “The assigned patient, [MR9], was inadvertently wearing [OTH1]’s identification band. ... The incorrect identification was not discovered until after the patient’s ED workup had been completed. Before the error was identified, laboratory specimens, medications, and the EKG obtained for [MR9] were documented under [OTH1]’s medical record due to the incorrect wristband.” A duplicate incident report was filed for this event by EMP11 on 07/10/2026 and was inserted into the initial report: “[EMP9] ... was medicated under [OTH1]’s name and account.” On July 29, 2026, during employee interview at 11:00 AM, EMP2 confirmed that the facility did not follow policy by not verifying the correct patient prior to administering medication to the patient (MR9). On July 29, 2026, review of MR10 revealed a 24-year-old patient who presented to the Emergency Department on June 21, 2026, at approximately 10:30 AM, following an injury while working out at the gym. MR10 was exercising and began feeling sharp pain in their right lower back. The patient was ordered one dose of a 10mg cyclobenzaprine (Flexiril, muscle relaxer) tablet, however, was inadvertently given 250mcg of digoxin (heart failure medication). Due to this medication error, MR10 was required to complete bloodwork and be monitored in the Emergency Department for an additional eight hours, as the physician was directed by the Poison Control Center. There was no documentation of the incorrect medication being administered in the eMAR. On July 29, 2026, during employee interview, EMP8 revealed that internal investigation revealed the nurse administered three medications to the patient prior to completing barcode-scanning of the digoxin. On July 29, 2026, during employee interview at 12:15 PM, EMP8 confirmed that the facility did not follow policy by not verifying the correct medication prior to administration to the patient (MR10).”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 50899 This condition is not met as evidenced by: Based upon a review of facility documents, medical records (MR), and staff interviews (EMP), it was determined that the facility failed to maintain emotional health and safety of a patient by permitting a transportation company to place the patient in forensic restraints in order to transfer to another facility (A-0144) and failed to adhere to policy requirements for violent restraints (A-0167). Cross reference 482.13(c)(2) Patient Rights: Care in a Safe Setting 482.13(e)(4)(ii) Patient Rights: Restraint or Seclusion”

“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: 50899 Based upon a review of facility documents, medical records (MR), and staff interviews (EMP), it was determined that the facility failed to maintain emotional health and safety of a patient by permitting a transportation company to place the patient in forensic restraints in order to transfer to another facility for one of one medical records reviewed (MR1). Findings include: On March 24, 2025, a review of the policy “Restraints and Seclusion” (Last Approved: 12/2024; Last Revised: 12/2024) was completed and revealed the following: “Definitions: ...4. Exceptions to Restraints- The following situations are not considered restraint interventions: ...3. The use of handcuffs or other restrictive devices applied by law enforcement for custody, detention, and criminal activity effecting public safety. Interventions and Procedures: 1. Restraint Initiation: The decision to use restraint or seclusion is not specific to any treatment setting or diagnosis but rather to the situation or behavior the restraint is being used to address. 1. Restraint can only be used when less restrictive interventions/alternatives have been determined to be ineffective to protect the patient or others from harm. These must be documented. ...” On March 24, 2025, a review of the policy “Patient Rights and Responsibilities, F-03” (Last Approved: 03/2024; Last Revised 04/2018) was completed and revealed the following: “... You have the right to good quality care and high professional standards that are continually maintained and reviewed. ... You have the right to be free from restraints and seclusion of any form that are not medically necessary or are used as means of coercion, discipline, convenience or retaliation by staff.” On March 24, 2025, a review of MR1 revealed that the patient presented to the Emergency Department on March 12, 2025, with depression and voluntarily sought admittance for psychiatric care. On March 12, 2025, MR1 was to be transported to another facility for psychiatric care and was placed in handcuffs and a waist chain for transport. MR1 was not under the control of law enforcement: thus, this intervention did not meet the requirement of a restraint exception. During an interview on March 24, 2025, at 12:05 PM, EMP6, the employee responsible for the handoff of MR1 to the transport company was interviewed and asked to explain what occurred at the time of the incident. EMP6 explained that voluntary commitment forms and paperwork were provided to, and report was given to EMP8 that MR1 was not a behavioral problem. EMP6 explained that EMP8 began to handcuff and shackle MR1. EMP6 intervened and explained that MR1 is voluntarily committed and that restraints were not appropriate. EMP6 recalled that EMP8 responded, “We signed a contract- ride in our cars, you are going to wear cuffs.” On March 24, 2025, at 11:52 AM, the above findings were confirmed by EMP4.”

“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: 45574 Based on a review of facility documents, medical records (MR), and employee interview (EMP), it was determined that the facility failed to adhere to policy requirements for violent restraints (extremities locked) for three of four restraint records reviewed (MR1, MR2 and MR3). Findings include: On March 24, 2025, a review of the policy “Restraints and Seclusion” (Last Approved: 12/2024; Last Revised: 12/2024) was completed and revealed the following: “Definitions: ...4. Exceptions to Restraints- The following situations are not considered restraint interventions: ...3. The use of handcuffs or other restrictive devices applied by law enforcement for custody, detention, and criminal activity effecting public safety. Interventions and Procedures: 1. Restraint Initiation: The decision to use restraint or seclusion is not specific to any treatment setting or diagnosis but rather to the situation or behavior the restraint is being used to address. 1. Restraint can only be used when less restrictive interventions/alternatives have been determined to be ineffective to protect the patient or others from harm. These must be documented. Violent Behavioral Restraints: A. Patients in violent behavioral mechanical extremity restraint/seclusion are placed in Special Constant Observation (SCO) until assessed by a Licensed Practitioner whom at the time, may order an alternate observation status. G. Assessment and Monitoring: 1. The patient is assessed by an RN at the time of restraint/seclusion and not to exceed every two hours thereafter, with the exclusion of chemical and physical hold restraints, and attends to their personal needs to prevent or reduce the potential physical and emotional complications of restraint use and to determine the continuing need for restraint to facilitate release at the earliest possible time. I. The restraint order is not to exceed 4 hours for adults ...K. A licensed practitioner is required to perform a face to face assessment within ONE hour of the initiation of the restrain/seclusion intervention. If the patient is released from seclusion, restraint, or physical hold within one hour, the one hour face to face must still be performed. Q. If a patient remains in restraint or seclusion for the management of violent or self-destructive behavior 24 hours after the original order, a licensed practitioner must examine the patient and conduct a face to face reevaluation before writing a new order for continued use ...”. On March 24, 2025, a review of MR1 revealed that the patient presented to the Emergency Department on March 12, 2025, with depression and voluntarily sought admittance for psychiatric care. On March 12, 2025, MR1 was to be transported to another facility for psychiatric care and was placed in handcuffs and a waist chain for transport. MR1 was not under the control of law enforcement: thus, this intervention did not meet the requirement of a restraint exception. On March 24, 2025, a review of MR2 was completed and revealed the patient presented to the Emergency Department on 03/19/2025 at 21:31 after a fall. On 03/20/2025, MR2 was placed in violent restraints (“extremities locked”) at 21:00. A physician face to face was completed on 03/20/2025 at 21:33. On March 20, 2025, at 1300, the patient was, again, placed in violent restraint (extremities locked). A physician face to face was completed on 03/20/2025 at 13:45. On 03/20/2025, an order was written, at 17:10 for the continuation of violent restraints. This order exceeds the 4 hour time limited policy for violent restraint as outlined by the facility. Further review of MR2 revealed that on March 20, 2025, at 21:38, an order was entered for the continuation of violent restraints. This order exceeds the 4 hour time limited policy for violent restraint as outlined by the facility. A face to face was completed by the practitioner. On March 21, 2025, violent restraint was reduced to 2 point restraint at 03:00 and discontinued on 03/21/2025, at 05:47, exceeding the 4 hour time limit without an additional order. On 3/21/2025 at 07:04, MR2 was again ordered violent restraints. Violent restraint was discontinued at 23:59. There are no orders for violent restraint at 11:04, 15:04, and 19:04. All documentation for the use of violent restraints ceases on 03/21/2025 at 17:00. On March 24, 2025, at 11:52 AM, the above findings were confirmed by EMP4. A review of MR3 revealed that on March 15, 2025, violent restraints (extremities locked) were initiated at 19:47 and discontinued at 22:46. MR3 was also placed in Special Constant Observation (SCO). There was no documented evidence of a face to face assessment by the physician for this 3 hour time period. On March 15, 2025, a second order was written for violent restraints at 20:04 and discontinued on March 16, 2025 at 00:49. MR3 was also placed in Special Constant Observation (SCO). There was no documented evidence of a face to face assessment by the physician for this approximately 3 hour period. Further review of MR3 revealed that on March 16, 2025, at 06:25, violent restraints were again initiated with a practitioner face to face occurring at 06:27. On March 16, 2025, MR3 remained in 2 point violent restraints at 10:30. The order was written at 11:07. This order exceeds the 4 hour time limited policy for violent restraint as outlined by the facility. The violent restraints were discontinued at 12:38. On March 17, 2025, at 00:00, an order was placed for the continuation of violent restraint that was initiated on March 16, 2025 at 10:30. The discontinuation time for restraint was documented in the MR3 as March 19, 2025 at 13:59. There was no documentation or entries in the chart regarding monitoring/assessment of restraint or additional 4 hours orders by the licensed practitioner after March 16, 2025 at 12:34. On March 24, 2025 at 12:34 PM, EMP4 confirmed the above findings.”