University Health System, Inc.

“A Life Safety Code Complaint Investigation #TN00077926 was conducted by the State of Tennessee Health Facilities Commission on 7/1/2026. During this Life Safety Complaint Survey, The University of Tennessee Medical Center was found in substantial compliance with the requirements for participation of Medicare/Medicaid at 42 CFR Subpart 482.41(b), Life Safety from Fire, and the related National Fire Protection Association (NFPA) standard 101-2012 Edition. The requirements at 42 CFR, Subpart 482.41(b) are MET as evidence by: During the Life Safety Complaint Survey #TN00077926, conducted on 7/1/2026, no deficiencies were cited under 42 CFR PART 482.41, Requirements for Hospitals.”

“A Life Safety Code Complaint Investigation #TN00076914 was conducted by the State of Tennessee Health Facilities Commission on 11/18/2025. During this Life Safety Complaint Survey, The University of TN Medical Center, was found in substantial compliance with the requirements for participation of Medicare/Medicaid at 42 CFR Subpart 482.41(b), Life Safety from Fire, and the related National Fire Protection Association (NFPA) Life Safety Code 101-2012 Edition. The requirements at 42 CFR, Subpart 482.41(b) are MET as evidence by: During the Life Safety Complaint Survey #TN00076914, conducted on 11/18/2025, no deficiencies were cited under 42 CFR PART 482.41, Requirements for Hospitals.”

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 51701 Based on review of facility policies, review of security video, an Emergency Medical Services (EMS) Run Report, medical record review and interview, the facility failed to ensure the exercise of patient’s rights requirements were met for 1 patient (#1) who was held in the EMS holding area of the facility of 3 patients reviewed. The findings include: Review of the facility policy, “Pain Management,” revised 3/2024, revealed “...The relief of pain and suffering is integral to the mission of the [name of hospital]. Each patient has the right to appropriate assessment and management of pain. [name of hospital] has made the relief of pain a priority for the institution and is committed to ensure that adequate pain management is provided to patients...Management of pain is based on appropriate pain assessment, which includes an understanding that pain is individualized and is a subjective experience. Therefore, the patient is usually the best judge of the intensity of pain and effectiveness of pain relief...” Review of the facility, “Patient Guide: Your Hospital Rights and Responsibilities,” not dated revealed “You have the right to an appropriate pain assessment and management...” Review of the Emergency Medical Service (EMS) Run Report dated 8/25/2025 at 3:31 PM, revealed EMS responded to Patient #1, 57-year-old-female who fell at home and suffered a fracture of her right humerus (upper arm). Patient #1”...described her arm as backwards...” Patient #1 complained of severe pain in her upper right arm and reported a pain level of “...above 10...” Patient #1’s blood pressure was 154/70. Further review of the EMS Run Report indicated a possible complete rotation of her arm from her body. A report of the patient’s condition was called by the EMS Paramedic to the ED with a trauma alert. Intravenous (IV) pain medication was administered four times during transport to the hospital for pain control. Review of the Security Video Recording on 8/25/2025 at 6:29 PM, revealed the Emergency Medical Services (EMS) transporting Patient #1 into the facility on a stretcher into the EMS holding area. The EMS Paramedic was visualized going to the Medic Desk at 6:33 PM. The Trauma Nurse was visualized standing by Patient #1’s stretcher in the EMS holding area at 6:38 PM. The EMS Paramedic was seen leaving the ED (emergency department) holding area’s double doors. A Hospital Paramedic was visualized administering medication to Patient #1 at 7:40 PM. The patient was transported from the ED holding area at 8:03 PM by EMS enroute to an ED Room. Medical record review of the ED record dated 8/25/2025 at 7:44 PM, revealed Morphine Sulfate 2 milligrams (mg) (a unit of metric measurement equal to one-thousandth of a gram) was ordered by Physician #1 and was administered IV for pain while the patient was in the EMS holding area. Review revealed Patient #1 had waited one hour and eleven minutes before pain medication was administered for a complex humerus fracture. Record review of the ED x-ray report revealed a comminuted (bone is broken into multiple small pieces) and Angulated (bone fragments are displaced at an angle to each other) Fracture of the Proximal (closest) to Mid Humerus (the long bone in the upper arm) with Large Butterfly (when two fracture lines meet to form a triangle) Fragment. Record review revealed no pain assessment was performed by the Facility ED Staff prior to the EMS Paramedic asking ED staff for pain medication for Patient #1. A pain score of 10 was documented in the Medication Administration Record (MAR) after ED staff administered the pain medication. Record review dated 8/25/2025 at 8:06 PM, by RN A revealed Patient #1 was moved from the EMS holding area to an ED room after waiting for 1 hour and 34 minutes. Patient #1’s vital signs were taken after the patient was moved to an ED room; temperature was 97.5 degrees Fahrenheit, Pulse 69, Respirations 21, Blood Pressure 210/87, and the Pulse Oxygen was 99% and the patient’s pain level was documented as 10, representing severe pain. During an interview on 9/12/2025 at 1:48 PM, with the Emergency Department Medical Director revealed there is a surge staffing plan. He stated technically EMS staff cannot give anything for pain in the ED. The ED Medical Director stated there was probably a staffing challenge that day and it looked like the surge plan failed. During an interview on 9/12/2025 at 2:07 PM, with the ED Nurse Manager revealed on 8/25/2025 the ED Team Leader was also the RN in charge at the Medic Desk. The Nurse Manager explained on 8/25/2025 there was 105 patients in the ED at one time. She stated the average time spent by EMS in the holding area with their patients is 21.9 minutes. When the Nurse Manager was asked why the patient did not receive pain medication for greater than an hour after arriving in the ED, the Nurse Manager stated the patient had 300 mcg. of Fentanyl in the ambulance enroute to the ED. During an interview on 9/15/2025 at 9:51 AM, the Trauma Nurse revealed on 8/25/2025 all the trauma bays were full and the Main ED was full. The Trauma Nurse revealed the patient was in a type of blow-up full body immobilizer. He stated this splint was challenging. She had a long bone fracture and he stated the patient was in a lot of pain. He evaluated her for trauma but “.... there wasn’t anything they could do...” He confirmed “...he did not document his assessment...” During a telephone interview on 9/15/25 at 11:21 AM, Physician #2 revealed the patient had an odd fracture pattern with a Butterfly fracture, “...Her bone had broken into three pieces.” He stated the fracture was not a simple reduction, it was displaced. Physician #2 stated the humerus fracture “...caused a lot of pain...” During a telephone interview on 9/15/2025 at 11:45 AM, Physician #1 revealed he was the lead physician in Trauma Bay the evening Patient #1 came to the ED. He stated he was approached by the EMS Paramedic who asked for pain medication for the patient. He gave the order for pain medication while the patient was in the ED holding area. During a telephone interview on 9/15/2025 at 4:03 PM, RN A revealed she helped transfer the patient from the EMS stretcher to an ED stretcher in the Main ED and stated “the patient told us she was in a lot of pain.” During a telephone interview on 9/15/2025 at 4:14 PM, RN B stated “...You didn’t need an x-ray to tell her arm was broken. She had the kind of break that can only be fixed in surgery to take the pain away...” During a telephone interview on 9/16/2025 at 8:55 PM, the EMS Advanced Emergency Medical Technician (AEMT) revealed he was in the ED holding area with the patient on 8/25/2025. He stated Patient #1 was given pain medication in the ambulance, but it had worn off while they were waiting in the ED holding area. He stated the patient began to cry out loudly in pain, and was moaning. The EMS AEMT stated the EMS Paramedic left multiple times and went to the Medic Desk and into the Main ED to get help for Patient #1.”

“A Life Safety Code Complaint Investigation #TN00076675 was conducted by the State of Tennessee Health Facilities Commission on 9/10/2025. During this Life Safety Complaint Survey, The University of TN Medical Center, was found in substantial compliance with the requirements for participation of Medicare/Medicaid at 42 CFR Subpart 482.41(b), Life Safety from Fire, and the related National Fire Protection Association (NFPA) Life Safety Code 101-2012 Edition. The requirements at 42 CFR, Subpart 482.41(b) are MET as evidence by: During the Life Safety Complaint Survey #TN00076675, conducted on 9/10/2025, no deficiencies were cited under 42 CFR PART 482.41, Requirements for Hospitals.”

“A Life Safety Code Complaint Investigation #TN00074647 was conducted by the State of Tennessee Health Facilities Commission on 5/7/2025. During this Life Safety Complaint Survey, The University of TN Medical Center, was found in substantial compliance with the requirements for participation of Medicare/Medicaid at 42 CFR Subpart 482.41(b), Life Safety from Fire, and the related National Fire Protection Association (NFPA) Life Safety Code 101-2012 Edition. The requirements at 42 CFR, Subpart 482.41(b) are MET as evidence by: During the Life Safety Complaint Survey #TN00074647, conducted on 5/7/2025, no deficiencies were cited under 42 CFR PART 482.41, Requirements for Hospitals.”

“A Life Safety Code Complaint Investigation #TN00074646 and #TN00075123 was conducted by the State of Tennessee Health Facilities Commission on 4/28/2025. During this Life Safety Complaint Survey, The University of TN Medical Center, was found in substantial compliance with the requirements for participation of Medicare/Medicaid at 42 CFR Subpart 482.41(b), Life Safety from Fire, and the related National Fire Protection Association (NFPA) Life Safety Code 101-2012 Edition. The requirements at 42 CFR, Subpart 482.41(b) are MET as evidence by: During the Life Safety Complaint Survey #TN00074646, conducted on 4/28/2025, no deficiencies were cited under 42 CFR PART 482.41, Requirements for Hospitals.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 18784 Based on facility policy review, medical record review and interview, the facility failed to follow the hospital’s policy regarding restraint usage, failed to conduct the daily comprehensive assessments required for a restrained patient, failed to safely use a restraint, and failed to prevent the use of 2 psychoactive drugs as needed (PRN) for the purpose of controlling behaviors for 1 patient (Patient #2) of 3 restrained patients reviewed. §482.13 Condition of Participation: Patient Rights not met. The hospital must protect and promote each patient’s rights, including the right to receive safe care. This failure resulted in the facility placing Patient #2 in an Immediate Jeopardy situation, when Patient #2 was restrained with 1 to 3 physical restraints applied in tandem and concurrent with a chemical restraint. Patient #2 suffered a 21-pound weight loss (10% of his weight) and developed skin impairment, during the 18-day hospital stay. The hospital’s non-compliance placed all restrained patients in an Immediate Jeopardy situation which created the need for immediate action. The findings include: On admission, Patient #2 was diagnosed with an extension of a cerebral vascular accident and as a result had acute cognitive decline. Patient #2 received chemical restraints, including a scheduled antipsychotic, PRN Haldol, and Ativan. Patient #2 was physically restrained by methods poorly documented for time periods and duration that were frequently not defined. The medical record did not include a daily documented assessment of the restraints in use and the need for continuation. During the 18 hospitalized days, Patient #2 was restrained from the day of admission until the day of dismissal with only 4 orders for restraints documented in the medical record. Refer to A-0154 and A-0160”

“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: 18784 Based on facility policy review, medical record review and interviews, the hospital failed to provide nursing services to meet the needs of 1 patient (Patient #2), a physically and chemically restrained patient with impaired cognition and agitated behaviors. The hospital’s nursing staff failed to provide a plan of care to ensure the patient’s safety and to assess and implement a plan to ensure the patient was not overly sedated and could receive adequate nutrition, hydration, and assistance with toileting, of 3 restrained patients reviewed. §482.23 Condition of Participation: Nursing Services not met. The hospital’s nursing services must protect and promote each patient’s safety, including the right to receive safe care when restrained. The hospital’s nursing services failed to address 1 patient (Patient #2’s) needs due to being restrained daily. This failure resulted in the facility placing Patient #2 in immediate jeopardy, when he was restrained with 1 to 3 physical restraints applied in tandem and concurrent chemical restraint. Patient #2 experienced a 21-pound weight loss (10% of his weight) and developed skin impairment during the 18-day hospital stay. The hospital’s non-compliance placed all restrained patients in an immediate jeopardy situation which has created the need for immediate action. The findings include: Medical record review revealed Patient #2 was restrained both chemically and physically throughout his 18-day hospital stay. Ativan and Haldol were ordered PRN (as needed) and frequently given out of the ordered sequence. There was not consistent nursing documentation noting the effect of the 2 PRN psychoactive drugs on Patient #2. On at least one occasion, the effect of the 2 PRN drugs resulted in the patient being sedated and unresponsive, as documented in a physician’s progress note on 3/17/2025 at 1:51 PM. The medical record did not contain ongoing comprehensive assessments for the continued use or need to discontinue the use of these drugs. On days the Haldol was administered, this constituted 2 different antipsychotic drugs being given as the patient was on Seroquel 100 milligrams 3 times a day. The patient lost 21 pounds over an 18-day hospital stay. Patient #2’s percentage of meal intake was frequently either not documented by nursing staff or recorded as 50% or less. The weight loss was not recognized or addressed in a plan of care by nursing. In addition, Patient #2 was physically restrained, frequently with 2 restraint systems, at times with waist and wrist restraints and/or 4 side rails used in the up position. There were no documented daily assessments of the physical restraints being used. The restrained patient experienced increasing skin impairment in the genital region from incontinence when his toileting needs were not met. Refer to A-0396”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 18784 Based on facility policy review, facility documentation review, medical record review, and interview, the facility failed to conduct the daily comprehensive assessments during the use of restraint and to safely restrain 1 patient (Patient #2) of 3 restrained patients reviewed. This failure resulted in the facility placing Patient #2 in an Immediate Jeopardy situation, when Patient #2 was restrained with 1 to 3 physical restraints applied in tandem and concurrent with a chemical restraint. Patient #2 suffered a 21-pound weight loss and developed skin impairment during the 18-day hospital stay. The findings include: Review of the facility’s policy titled, “Restraint and Seclusion,” dated 1/2023 revealed “...ORGANIZATIONAL PHILOSOPHY...The use of non-physical intervention as preferred intervention...Chemical restraint is a medication used to control behavior or restrict the patient’s freedom of movement and is not a standard treatment for a patient’s medical or psychiatric condition...Use of side rails to restrict the patient’s freedom or prevent the patient from exiting the bed is considered a restraint...RESTRAINT APPLICATION...1. Medical and Post-Surgical Care (Non-Violent or Non-Self-Destructive Behavior)-Apply when the primary reason for the use directly supports medical healing. 2. Violent or Self-Destructive-Apply to protect the individual against serious injury to self or others because of an emergency or crisis situation where the patient’s behavior becomes aggressive or violent...RESTRAINT ORDERS...All orders for restraints must be based on the assessed need of the patient...The order is written in accordance with a written modification to the patient’s plan of care...The plan of care will be reviewed each shift and revised as appropriate...SAFETY STANDARDS...4. Assessment and monitoring may occur more frequently than outlined in policy, based on changes in clinical status or occurrences of significant event...ALTERNATIVES TO RESTRAINTS...1. Ambulation...3. Diversional activity...5. Family/sitter with patient...7. Increased observation level...15. Up in chair...REQUIREMENTS SPECIFIC TO RESTRAINTS FOR ACUTE MEDICAL AND POST-SURGICAL CARE...1...c. Impaired thought processes/mental status changes...Prior to initiation of restraint, reasonable alternatives that have been utilized are to be documented. The RN is to document: a. The alternative(s) attempted...b. Success of alternative strategies...2. If [medical provider] is not available, the RN will supervise the application of restraints, notify the [medical provider] of the assessed need for restraint, and obtain a verbal order immediately. Verbal orders for med-surg restraints must be accompanied by a written order by the end of the next calendar day. 3. Specific requirements of the Med-Surg restraint order: a. An examination and written order by the [medical provider] is entered into the medical record by the end of the next calendar day. b. A [medical provider] order is required for each episode of restraint...Supervised temporary release while team members or family members are present does not qualify as the end of an episode...” Medical record review revealed Patient #2 was admitted to the facility on 3/5/2025, with a Left Anterior Lobe Infarction (stroke caused by blocked blood flow to the section of the brain that controls speech and language) and a Right Parietal Temporal Lobe Infarction (stroke caused by blocked blood flow to the parietal section of the brain which controls the ability to perform daily tasks). Upon arrival, the chief complaint was Code Stroke Red (stroke involving hemorrhage). Patient #2 was confused with left-sided weakness and left facial droop. Medical record review of the Electronic Health Record (EHR) Restraint Order Set, dated 3/6/2025 at 7:35 AM, revealed the first physician order for a “medical-surgical restraint” was for soft wrist restraints. Medical record review of the Restraint Record dated 3/6/2025 at 8:28 AM, revealed mittens, soft wrist restraints bilaterally (both wrists) and a waist restraint was applied for “Altered Level of Consciousness due to critical illness.” There was no physician order for the waist restraint placed on Patient #2. There was no documentation denoting whether the mittens were attached to the bed or whether the mittens were bulky or not bulky. There was no documentation denoting if Patient #2 could remove the mittens. There was no documentation denoting whether the patient’s hand or fingers was immobilized. Further review revealed on 3/6/2025 at 10:00 PM, soft bilateral wrist restraints, and a waist restraint continued to be in place. Continued review revealed no physician’s order for the use of a waist restraint. Medical record review of the Restraint Record dated 3/7/2025 at 10:00 PM, revealed Patient #2 continued with soft bilateral wrist restraints and a waist restraint. The waist restraint continued with no physician’s order. Documentation revealed on 3/7/2025 at 10:00 AM, Patient #2 was released from the soft wrist and waist restraints, and was assisted out of the bed. The medical record revealed the interval of time and duration was not documented. Medical record review of the Restraint record dated 3/8/2025 at 6:00 AM, revealed Patient #2 was restrained with soft bilateral wrist restraints and mittens. Continued review revealed the waist restraint remained on Patient #2 without a physician order for the restraint. Medical record review of Nurse’s Notes dated 3/8/2025 at 3:45 PM, revealed Patient #2 “...unrestrained himself and removed the 5th IV [intravenous site] in 48 hours. Pt [Patient] is agitated and confused...” Continued review revealed on 3/8/2025 at 6:00 PM, the restraints were temporarily released with family visiting. Medical record review of the Restraint record revealed Patient #2 was transferred from an intensive care (ICU) unit to an acute care unit on 3/9/2025 at 3:30 PM, with mittens, soft bilateral wrist restraints, and waist restraints in place. Continued review revealed the waist restraint remained on Patient #2 without a physician’s order. Review of the Restraint record dated 3/10/2025 at 8:00 AM, revealed Patient #2 remained in mittens, bilateral soft wrist restraints, and a waist restraint with no physician’s order for the waist restraint. Review of the Restraint record dated 3/11/2025 at 8:00 AM, revealed Patient #2 remained in bilateral soft wrist restraints and a waist restraint. There was no physician order for a waist restraint. Review of the Restraint record dated 3/12/2025 at 8:00 AM, revealed Patient #2 remained in bilateral wrist restraints and a waist restraint. There was no physician order for a waist restraint. Review of the Restraint record dated 3/13/2025 at 8:00 AM, revealed Patient #2 remained in soft wrist restraints bilaterally and a waist restraint. There was no physician order for waist restraint. Review of the Restraint record dated 3/14/2025 at 8:00 AM, revealed Patient #2’s bilateral wrist restraints and a waist restraint remained in place until 8:00 PM. There was no physician order for the waist restraint. Continued review revealed at 8:00 PM, the bilateral wrist restraints and the waist restraints were temporarily released while Patient #2’s family visited. Review of a hospital “Medicine” progress note dated 3/14/2025 at 12:59 PM, revealed “...Pt remains in restraints while his wife is not here. We are removing them while she is with him... “ Review of the Restraint record dated 3/15/2025 at 4:00 AM, revealed Patient #2 had mittens, bilateral wrist restraints, and a waist restraint in place. There was no physician order for the waist restraint. Further documentation revealed bilateral wrist restraints, and the waist restraint were temporarily removed at 12:00 PM during a family/other visitation. The bilateral wrist restraints and waist restraints remained off until they were reapplied 16 hours later on 3/16/2025 at 4:00 AM. Review of the Restraint record dated 3/16/2025 at 4:00 PM, revealed the restraints were temporarily released at 12:00 PM, while Patient #2’s family visited. Medical record review of a physician’s order revealed the soft restraints were discontinued on 3/16/2025 at 10:00 PM. Medical record review of the 10-day period, dated 3/7/2025 - 3/16/2025, revealed the hospital used all 4 side rails of the patient’s bed in the up position while the patient was in bed and Patient #2 remained in a waist restraint without physician’s orders for the use of the side rails or the waist restraint. Medical record review of a physician order dated 3/17/2025 at 1:34 PM, revealed a second physician ordered a waist restraint for Patient #2 for “Altered Mental Status.” Medical record review of a physician’s progress note dated 3/17/2025 at 1:51 PM, revealed “... According to the nursing staff, he [Patient #2] was very agitated earlier, received some Ativan [antianxiety medication] and Haldol [antipsychotic medication]. He is now sedated and unresponsive...” Continued review revealed “...his course was complicated with severe delirium requiring chemical and mechanical restraints...” Medical record review of the Psychiatry progress notes dated 3/17/2025 at 2:23 PM, revealed “...Attempted to see...[Patient #2]...twice this morning but he was sleeping. Chart review revealed multiple PRN [as needed] medications administered over the weekend for further agitation and wandering. Went to evaluate patient again this afternoon and it was noted he was agitated and trying to get out of bed. Per his RN, he was given PRN Ativan followed by Haldol within the past hour. I attempted to talk to [Patient #2] for a few minutes, but he quickly fell asleep during our conversation...” Review of the Restraint record dated 3/17/2025 at 8:00 PM, revealed a waist restraint and 4 raised side rails were in use for Patient #2. There was no physician order for the 4 raised side rails. Continued review revealed Patient #2 remained in the waist restraint with the 4 raised side rails until 3/18/2025 at 8:00 AM. Review of the Restraint record dated 3/18/2025 at 8:00 AM, revealed Patient #2 was restrained with the waist restraint. Review of the Restraint record dated 3/19/2025 at 12:00 AM, revealed a second restraint, bilateral wrist restraints, were placed on Patient #2 without obtaining a physician’s order (1st order for bilateral wrist restraints were discontinued on 3/16/2025). Continued review revealed Patient #2 had the bilateral wrist restraints and the waist restraint in place until 3/19/2025 at 10:44 PM (a period of 10 hours and 44 minutes). Continued review revealed at 10:44 PM, a third physician ordered bilateral soft wrist restraints and a waist restraint for “...Impaired Thought Process-Mental Status Change...” Medical record review of a Hospitalist progress notes dated 3/20/2025 at 3:38 PM, revealed “...My [Physician Hospitalist] preference would still be that we have ongoing sitters and/or family members, and we avoid restraining him. I think a lot of his agitation is that we tried keeping him in bed and I do not think he is a significant fall risk, he was ambulating in ICU prior to coming to the floor...” Continued review revealed the Hospitalist physician documented a conversation with the Nurse Manager of Patient #2’s unit to encourage frequency out of bed, frequent ambulation and to “...do all we can to avoid restraints...” Review of the Restraint record dated 3/21/2025 at 4:00 PM, revealed bilateral wrist restraints, and waist restrains remained in place. Continued review revealed at 4:00 PM, the restraints were removed “temporarily...family/other with patient...” The bilateral wrist restraints and waist restraints were released on 3/21/2025 at 10:00 PM, when the restraints were discontinued. Medical record review of a Hospitalist progress notes dated 3/22/2025 at 12:20 PM, revealed Patient #2 “...remains confused and has intermittent agitation requiring as needed medications...but transfer currently delayed because of recurrent episodes of agitation requiring restraints for safety...” Medical record review dated 3/22/2025 at 1:20 PM, of the EHR [Electronic Health Record] “Restraint Order Set” revealed a waist restraint was reapplied to Patient #2 for “...Impaired thought processes/mental status change...” Review of a Care Giver Rounding note dated 3/23/2025 at 9:52 AM, revealed Patient #2 “...was fighting restraints, verbally aggressive and Ativan intramuscular [IM] was given...” Continued review revealed the waist restraint was in place on Patient #2 until 3/23/2025 at 2:14 PM. Patient #2 was discharged to home with Home Health ordered on the same day, 3/23/2025. Medical record review of the Weight record throughout Patient #2’s hospital stay revealed Patient #2’s weight on admission 3/5/2025, was 201.4 pounds. Further review revealed Patient #2 was weighed daily on a bed scale and on 3/22/2025, the weight was recorded at 180 pounds, signifying a 21-pound weight loss during the 18-day hospital stay. Medical record review of Patient #2’s Wound Documentation began on 3/11/2025 as follows: 3/11/2025 at 4:14 PM, revealed barrier cream was applied to Patient #2’s genitalia. Genitalia was open to air and “...edges separated, Pink...” 3/13/25 at 10:47 PM, revealed genitalia edges approximated and red. The surrounding tissue was documented as erythema (redness), excoriation (erosion of the skin). 3/15/25 at 9:47 AM, revealed the edges were approximated, erythema continued and (name of barrier cream) was applied topically (to skin). 3/18/25 at 10:30 PM, revealed erythema of the genitalia continued, and the treatment was changed to a second skin barrier paste. 3/22/25 at 7:45 PM, revealed the genitalia to be ecchymotic (a bruise formed when blood vessels near the skin’s surface leak and blood pools). Erythema was still present, and the genitalia remained open to air. During a telephone interview on 4/10/2025 at 3:35 PM, RN #1 stated she had applied restraints on Patient #2 in the ICU. RN #1 stated Patient #2 was confused, ripping IV’s out five times and showed aggressive behavior. During the interview, RN #1 stated “...you can add on the extra restraint under the restraint policy...” During a telephone interview on 4/10/2025 at 3:58 PM, with RN #2, who worked in the ICU with Patient #2, stated “typically” restraints must be ordered by a physician and when he came on duty, he did not check the patient’s restraint order. RN #2 stated he kept the restraints on that were in place (bilateral mittens, soft bilateral wrist restraints and the waist restraint). RN #2 stated Patient #2 removed the restraints and climbed over the 4 raised side rails. RN #2 stated in the EHR system there is only 1 space to get an order for 1 type of a restraint at a time. During a telephone interview on 4/10/2025 at 11:46, with the ICU Manager, where Patient #2 was initially admitted, stated if a patient was exhibiting the same behavior after a temporary restraint release, the patient would be placed back in the same restraint and a new order was not required. The ICU Manager stated an episode for a restraint was when a patient exhibited the same behavior and the same order for the restraint can be followed. During a telephone interview on 4/10/2025 at 12:20 PM, with RN #3, working with Patient #2 during his ICU stay, stated when a restraint was needed, she usually requested the type of restraint needed by texting the physician and requesting an order. RN #3 stated if a new behavior was exhibited, she would ask for a new restraint order. RN #3 confirmed at one point Patient #2 had two restraints and staff failed to obtain an order for both restraints. RN #3 stated 4 raised side rails were restraints and a physician’s order was needed. RN #3 stated (in error) restraint orders were good for 24 to 48 hours. During a telephone interview on 4/10/2025 at 1:58 PM, with RN #4, who cared for Patient #2 during his ICU stay, stated a physician order was needed for mittens and when all 4 side rails were used in the up position. RN #4 stated a new physician’s order for a restraint was needed if a patient’s behavior escalated, de-escalated, or for a temporary release from the restraints. RN #4 stated when she recognized a patient needed a restraint, she described the situation to the physician by using (name of an electronic application), the physician responded and gave an order for the restraints. RN #4 further stated staff could replace the restraint after it had been temporarily removed if the patient’s behavior was the same. RN #4 stated she “...sees restraints on this floor often.” During a telephone interview on 4/10/2025 at 2:22 PM, RN #5 stated the nights she took care of Patient #2 he was in wrist and waist restraints. She added the physician must reassess the restraints daily. RN #5 stated when she obtained an order for restraints “... the restraints must be applied in that same hour, or the physician order is null and void...” RN #5 stated a patient can be on a temporary release of the restraint if the nurse is with the patient. If the temporary restraint lasts longer than one hour, then a new order must be obtained. If the patient exhibited violent behavior, then the physician must re-assess the patient. RN #5 further stated Patient #2 removed the soft wrist restraints himself, then she raised all 4 side rails. She explained that by raising all 4 side rails the buckle attached to the soft wrist restraints was hidden and the patient could not see to unbuckle the soft wrist restraints. During a telephone interview on 4/10/2025 at 3:43 PM, Physician #1 stated Patient #2 was persistently confused and agitated. Physician #1 stated the nurses decided on the type of restraint needed, requested an order from the physician, and then the nursing staff managed all the restraints. Physician #1 stated “...this...[Patient #2]...was difficult and always restless...” Physician #1 further stated during the last four days of Patient #2’s admission, he had a sitter. Physician #1 revealed the patient was not accepted at any other facilities as a patient due the inability to discontinue the restraints and the patient was discharged home. Summary of interviews: During interviews with several RN’s who cared for Patient #2 (both nurses in the intensive care unit and nurses on the general unit), revealed a lack of knowledge and understanding of the facility’s restraint policy. For example, the facility’s policy did not cover the use of an “extra restraint,” or a doctor’s order was not required for the temporary release of restraint. One of the RN’s stated Patient #2 had 3 restraints applied and in use when he reported for duty and continued the 3 restraints without questioning or verifying physician’s orders for the use of all 3 restraints. The same RN stated Patient #2 crawled over all 4 side rails, which were in the up position and proved to be unsafe for the patient. However, the 4 side rails continued to be used at intervals during the hospital stay. Another nurse stated erroneously a new restraint order was needed if the restraint was off for more than an hour and the fifth nurse interviewed stated, erroneously an order for a restraint expired in 24-48 hours. Medical record review of the complete nursing record and documentation revealed Patient #2’s behavior may have changed and the nursing documentation did not support the behavior changes or the need for additional restraints. Continued review revealed the nursing staff documented temporarily releasing the restraint several times and the documentation was inconsistent regarding the actual time or duration the restraint was released, the actual time the restraint was reapplied, and the rationale for the need to continue the order to restrain Patient #2. In addition, review revealed a lack of documentation by the nurses of alternatives to restraint used for Patient #2. The nursing staff did not consistently document when the patient was released for meals or what time the patient was re- restrained. Medical record review of Patient #2’s medical provider progress notes, including Hospitalist, Consulting Physicians, and Nurse Practitioners revealed there were only 5 days of the 18-day hospitalization stay, when a medical provider documented a comprehensive assessment for Patient #2 for the continued use of the restraints as follows: 3/14/2025 - a physician note from “Medicine” service 3/16/2025 - the Hospitalist physician note 3/17/2025 - the Hospitalist physician note 3/20/2025 - the Hospitalist physician note 3/22/2025 - the Hospitalist physician note The medical providers did not document any recognition of Patient #2’s ongoing weight loss or worsening skin impairment.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(B) [A restraint is-] (B) A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. This Standard is not met as evidenced by: 18784 Based on facility policy review, medical record review and interview, the facility failed to prevent the use of 2 as needed (PRN) psychoactive drugs for the purpose of controlling behaviors for chemical restraint for 1 patient (Patient #2) for 3 patients reviewed for restraints. This failure resulted in the facility placing Patient #2 in an Immediate Jeopardy situation, when Patient #2 was restrained with 3 physical restraints applied in tandem, concurrent with chemical restraint. Patient #2 suffered a 21-pound weight loss and developed skin impairment during the 18-day hospital stay. The findings include: Review of the facility policy titled, “Restraints and Seclusion,” revised 1/2023, revealed “...Chemical restraint is a medication used to control behavior or restrict a patient’s freedom of movement and is not standard treatment for a patient’s medical or psychiatric condition...” Medical record review revealed Patient #2 was admitted to the Emergency Department (ED) on 3/5/2025 with diagnoses including Stroke due to a Left Frontal Lobe Hemorrhage (bleeding) and Insulin Dependent Diabetes. Review revealed earlier in the day on 3/5/2025, Patient #2 experienced a headache and went to a local ED, became unresponsive, developed left sided weakness and left facial droop. Patient #2 was transferred to the medical center and was admitted to the Neurological Critical Care Unit on 3/6/2025. Medical record review of a Neurology Consult dated 3/6/2025 at 12:55 AM, revealed Patient #2 was previously admitted to the hospital on 2/16/2025 for Altered Mental Status and Dysarthria (slurred speech) and discharged on 3/3/2025. Review revealed mental confusion continued for the two days he was home. Medical record review dated 3/6/2025 at 7:16 AM, revealed Nurse Practitioner #1 ordered Haldol Injection 2 milligrams equals 0.4 milliliters Intravenous (IV) push now (a one time dose). Medical record review of the physician’s Rehabilitation Consult dated 3/7/2025 at 2:00 PM, revealed Patient #2’s chief concern was “...a sip of water...Take these [mitten restraints] off and go home...” Further review revealed “...Behavioral problems expected with bifrontal brain injury. Today he is too agitated to respond to any counseling about his stroke...The family (and all of our staff) need to be aware that Nondominant Parietal Lobe Syndrome causes confusion of dream and reality, distrust, and paranoia, distortion of time awareness, inability to recognize one’s own deficits, impulsivity, trouble with visual memory and other problems...(He could easily have a disturbing dream, think it really happened, and tell others that the disturbing thing was done to him by hospital staff of by a family member)...” Medical record review revealed a Speech Pathology consult dated 3/7/2025 at 12:35 PM, determined Patient #2 could swallow pureed, thin liquids, and ice without aspiration and recommended a regular diet with thin liquids as tolerated. Medical record review dated 3/7/25 at 2:56 PM, revealed Nurse Practitioner #2 ordered Ativan Injection 2 milligrams (mg) equals 1 milliliter (ml) Intravenous (IV) push every 6 hours PRN for agitation to be used second for agitation; use with Haldol 5 mg for severe agitation; use intramuscular (IM) if no IV access. Medical record review dated 3/7/2025 at 2:58 PM, revealed Nurse Practitioner #2 ordered Haldol Injection 5 mg equals 1 ml every 6 hours PRN for agitation. Use first for agitation; use Ativan 2 mg for severe agitation; use IM if no IV access. Medical record review of Patient #2’s Medication Administration Records (MARs) from 3/6/2025 to 3/23/2025 revealed: 3/6/2025 at 7:22 AM, Haldol Injection 2 mg IV push for agitation. 3/8/2025 at 4:12 AM, Haldol Injection 5 mg IV push for agitation. 3/8/2025 at 11:53 AM, Haldol Injection 5 mg IV push for agitation. 3/8/2025 at 7:26 PM, Ativan 2 mg IV push for agitation. 3/9/2025 at 12:18 AM, Ativan 2 mg IV push for agitation (note the Haldol was not administered first as ordered on 3/7/2025). 3/9/2025 at 12:22 PM, Ativan 2 mg IV push for agitation (note the Haldol was not administered first as ordered on 3/7/2025). 3/10/2025 at 3:59 PM, Haldol Injection 5 mg IM for agitation. 3/11/25 10:38 PM, Haldol Injection 5 mg IV push for agitation. 3/12/25 at 4:42 AM, Haldol Injection 5 mg IV push for agitation. 3/12/25 at 3:34 PM, Haldol Injection 5 mg IV push for agitation (note 4 days transpired before the next documented PRN psychoactive drug dose). 3/16/25 at 4:49 PM, Ativan 2 mg IV push for agitation (note the Haldol was not administered first as ordered on 3/7/2025). 3/17/25 at 2:41 AM, Ativan 2 mg IV push for agitation (note the Haldol was not administered first as ordered on 3/7/2025). 3/17/25 at 12:15 PM, Ativan 2 mg IV push for agitation (note the Haldol was not administered first as ordered on 3/7/2025). 3/17/25 at 1:14 PM, Haldol Injection IM left upper arm for agitation. 3/18/25 at 5:59 AM, Ativan 2 mg IM left gluteus for agitation (note the Haldol was not administered first as ordered on 3/7/2025). 3/18/25 at 7:48 AM, Haldol Injection IM to right upper arm for agitation, 3/18/25 12:42 PM, Ativan 2 mg Left upper arm for agitation (note 4 days transpired before the next documented PRN psychoactive drug dose). 3/22/25 at 1:10 PM, Ativan 2 mg IM to right upper arm for agitation (note the Haldol was not administered first as ordered on 3/7/2025). 3/23/25 at 9:43 AM, Ativan 2 mg to right upper arm for agitation (note the Haldol was not administered first as ordered on 3/7/2025). Medical record review revealed Patient #2 was transferred to an Acute Care Unit on 3/9/2025 at 3:30 PM. Medical record review dated 3/17/2025 revealed Patient #5 was taking 25 active medications, twelve of the 25 medications were scheduled and included quetiapine (Seroquel an atypical antipsychotic used to treat schizophrenia, bipolar disorder, bipolar depression, and major depressive order and used as a sleep aid) 100 milligrams by mouth three times a day; rivastigmine ( Exelon patch used to treat symptoms of dementia) 4.6 milligrams (1 patch) transdermal (route of administration when place on the skin) once a day; and sertraline (anti-depressant) 100 milligrams by mouth once a day. The 13 PRN medications included haloperidol ( Haldol an antipsychotic medication) Injection 5 milligrams intramuscularly (IM) every 6 hours as needed; Haloperidol Injection 5 milligrams IV (Intravenous) every 6 hours as needed; Lorazepam (Ativan used to treat anxiety disorders) 2 milligrams IM every 6 hours as needed and Lorazepam 2 milligrams IV push every 6 hours as needed. Medical record review of the Hospitalist Progress note dated 3/17/2025 at 1:51 PM, revealed “...According to the nursing staff, he [Patient #2] was very agitated earlier, received some Ativan and Haldol. He is now sedated and unresponsive...” Continued review revealed “...his course was complicated with severe delirium requiring chemical and mechanical restraints...” Medical record review of the Hospitalist Progress note dated 3/20/2025 at 3:38 PM, revealed “...My preference would still be that we have ongoing sitters and/or family members, and we avoid restraining him. I think a lot of his agitation is that we tried keeping him in bed and I do not think he is a significant fall risk, he was ambulating in ICU prior to coming to the floor...” The Hospitalist documented a conversation with the Nurse Manager for staff to encourage frequency out of bed, frequent ambulation, and to “...do all we can to avoid restraints...” Medical records review of Patient #2’s weights revealed on 3/5/2025 (day of admission) a weight of 201.4 pounds was documented. Review revealed the patient was weighed daily on a bed scale. A documented weight on 3/22/2025 at 5:00 AM, revealed a weight of 180 pounds, a 21 pound weight loss during the 18-day hospital stay. During an interview on 4/1/2025 at 1:35 PM, the Clinical Nutrition Manager stated the hospital had a policy to identify patients as a potential nutritional risk. A patient who is admitted and does not have one of the diagnoses that trigger a consult, would not be seen unless the doctor or a nurse completed a consult request. The Clinical Nutrition Manager confirmed Patient #2 was not seen or evaluated by a dietician while he was in the hospital. During a telephone interview on 4/11/2025 at 10:25 AM, Registered Nurse (RN) #7, working on Patient #2’s unit, stated she remembered the patient was sleepy, confused, combative, a falls risk and strong. RN #7 stated she ambulated Patient #2 at night and released the restraints so he could eat ice cream. RN #7 said Patient #2 tried to elope and got as far as the elevators on one occasion. RN #7 further stated she remembered administering Patient #2 “...an injection that didn’t work...” and administered another (medication) to make him calm. During a telephone interview on 4/11/2025 at 4:58, Nurse Practitioner (NP) #2 stated when restraints were needed, the patient’s RN paged a message to the provider. NP #2 stated the staff nurse usually decided on the type of restraint needed and the order was active for 24 hours. NP #2 stated it was each individual provider’s decision regarding the use of chemical restraints. In summary, Patient #2 was restrained chemically (with scheduled and PRN psychoactive drugs) daily and physically restrained throughout his hospital stay. Ativan and Haldol were ordered PRN and 1 physician documented it was for behaviors. There were no daily documented comprehensive assessments as required for a restrained patient. Patient #2 received 2 PRN psychoactive drugs, and at intervals, was documented as being sedated, and in 1 instance unresponsive. During the 18-day hospital stay, Patient #2’s percentage of meal intake was frequently either not documented or recorded as 50% or less and Patient #2 had a 21-pound weight loss during his hospitalization. Refer to A-0154”

“PATIENT VISITATION RIGHTS CFR(s): 482.13(h) A hospital must have written policies and procedures regarding the visitation rights of patients, including those setting forth any clinically necessary or reasonable restriction or limitation that the hospital may need to place on such rights and the reasons for the clinical restriction or limitation .... This Standard is not met as evidenced by: 51701 Based on the facility Patient Guide review, medical record review, and interview, the facility failed to have a written policy and procedure which addressed the right for patients to have visitors in 1 patient (Patient #1) of 4 patients reviewed. The findings include: Review of the facility titled, “Patient Guide,” on page 14 “...Your Hospital Rights and Responsibilities...You have the right to choose who visits you and have your visitors allowed full and equal visitation privileges regardless of disability, age, race, color, religion, sex, sexual orientation, gender identity expression, national origin, ethnicity, socioeconomic status, veteran status, or other protected class...” Medical record review revealed Patient #1 was admitted on 11/12/2024 with a diagnosis of Fell at home, Bilateral Fractured Ribs, Thoracic (between the neck and waist) Spine Fractures, and Right Distal Radius ( thumb side of the arm) Fracture. Medical record review of the Nurse’s Note dated 11/22/2024 at 7:00 AM, revealed Patient #1 was confused, delirious, and had pulled out the Intravenous (IV) Lines and medical devices. Patient #1 was placed on Delirium Precautions and mittens were applied by Registered Nurse (RN) #1. Patient #1 was discharged from the Intensive Care Unit to an acute care room on 11/24/2024 until discharged home with home health on 11/29/2024. During a telephone interview on 4/1/2025 at 12:42 PM, the Complainant stated the family had not been notified by the hospital staff Patient #1 had been placed in restraints and was surprised when she entered the patient’s room and to see restraints had been applied. The Complainant stated she requested to spend the night with her grandmother, stating when the family was there, her grandmother was fine and did not need the restraints. The Complainant stated the House Supervisor denied her request. During an interview on 4/1/2025 at 3:00 PM, the Vice-President (VP) of Quality and Patient Safety stated the concerns about visitation were brought to the Critical Care Committee on 1/9/2025. A subcommittee was created to make suggestions on how to improve visitation. On 1/30/2025 and 3/6/2025 the subcommittee met and reviewed the Patient Guide. The Patient Guide was given to patients on admission. After the meeting, the subcommittee realized the Patient Guide had not been updated since the outbreak of COVID-19. During an interview on 4/1/2025 at 4:00 PM, the VP of Emergency Services stated the hospital did not have the ability to accommodate for family to spend the night in the critical care units. The VP of Emergency Services sated the critical care units were implementing new visitation rules on 4/9/2025. The new rules will allow open visitation. This will allow a family member to be present at night and sleep in the patient’s room provided the patient’s condition permits, “...If the family insists on staying with the patient in this unit, we can provide them with a straight back chair, and they would have to stay in it...” In summary, the 2 administration staff interviews confirmed there was a need to improve visitation policies and the family member of Patient #1 was not afforded the opportunity to sit with the elderly, confused patient to prevent restraints being applied.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 18784 Based on facility policy, medical record review, and interview, the facility failed to provide nursing services that developed and implemented a plan of care to address 1 restrained patient’s safety (Patient #2) of 3 restrained patients reviewed. This failure resulted in the facility placing Patient #2 in immediate jeopardy, when he was restrained with 1 to 3 physical restraints applied in tandem and concurrent chemical restraint. Patient #2 experienced a 21-pound weight loss and development of skin impairment during the 18-day hospital stay. The findings include: Review of the facility’s policy titled, “Restraint and Seclusion,” dated 1/2023 revealed “...ORGANIZATIONAL PHILOSOPHY...The use of non-physical intervention as preferred intervention...Chemical restraint is a medication used to control behavior or restrict the patient’s freedom of movement and is not a standard treatment for a patient’s medical or psychiatric condition...Use of side rails to restrict the patient’s freedom or prevent the patient from exiting the bed is considered a restraint... RESTRAINT ORDERS...All orders for restraints must be based on the assessed need of the patient...The order is written in accordance with a written modification to the patient’s plan of care...The plan of care will be reviewed each shift and revised as appropriate...SAFETY STANDARDS...4. Assessment and monitoring may occur more frequently than outlined in policy...ALTERNATIVES TO RESTRAINTS...1. Ambulation...3. Diversional activity...5. Family/sitter with patient...7. Increased observation level...15. Up in chair...REQUIREMENTS SPECIFIC TO RESTRAINTS FOR ACUTE MEDICAL AND POST-SURGICAL CARE...1...c. Impaired thought processes/mental status changes...Prior to initiation of restraint, reasonable alternatives that have been utilized are to be documented. The RN is to document: a. The alternative(s) attempted...b. Success of alternative strategies...2. If [medical provider] is not available, the RN will supervise the application of restraints, notify the [medical provider] of the assessed need for restraint, and obtain a verbal order...The order is written in accordance with a written modification to the patient’s plan of care. The plan of care will be modified to reflect use of restraints by the end of the next shift. The plan of care will be reviewed each shift and revised as appropriate...The rational that a patient “might” fall is an inadequate basis for using a restraint. When addressing and care planning for the patient, consideration should be given to whether the patient has a history of falling or a medical condition or symptom that indicates a need for a proactive intervention...” Medical record review revealed Patient #2 was admitted to the facility on 3/5/2025, with a Left Anterior Lobe Infarction (stroke caused by block blood flow to the section of the brain that controls speech and language) and a Right Parietal Temporal Lobe Infarction (stroke caused by blocked blood flow to the parietal section of the brain which controls the ability to perform daily tasks). Medical record review of the Electronic Health Record (EHR) Restraint Order Set, dated 3/6/2025 at 7:35 AM, revealed the first physician order for a “medical-surgical restraint” was for soft wrist restraints. Medical record review of the nursing Restraint record dated 3/6/2025 at 8:28 AM, revealed mittens, soft bilateral (both wrist) wrist restraints, and a waist restraint was applied for “Altered Level of Consciousness due to critical illness.” There was no physician order for the waist restraint placed on Patient #2. There was no nursing documentation denoting whether the mittens were attached to the bed, whether the mittens were bulky or not bulky, or if Patient #2 could remove the mittens. Further review revealed on 3/6/2025 at 10:00 PM, the soft bilateral wrist restraints and a waist restraint were still applied without a physician’s order for the waist restraint. Review of the nursing Restraint record dated 3/7/2025 at 10:00 PM, revealed Patient #2 continued with soft bilateral wrist restraints and a waist restraint. Continued review revealed no physician order for a waist restraint. Nursing documentation revealed earlier on 3/7/2025 at 10:00 AM, Patient #2 was released from the soft wrist and waist restraints and assisted out of the bed for an unspecified interval of time, which nursing had not documented. Review of the nursing Restraint record dated 3/8/2025 at 6:00 AM, documented by nursing revealed Patient #2 was restrained with soft bilateral wrist restraints, a waist restraint, and mittens in use with no physician order for the waist restraint. Review of Nurse’s Notes dated 3/8/2025 at 3:45 PM, revealed Patient #2 “...unrestrained himself and removed the 5th IV [intravenous site] in 48 hours. Pt [Patient] is agitated and confused...” Continued review revealed on 3/8/2025 at 6:00 PM, the restraints were temporarily released with family visiting. Review of the nursing Restraint record revealed Patient #2 was transferred from an intensive care (ICU) unit to an acute care unit on 3/9/2025 at 3:30 PM, with mittens, soft bilateral wrist restraints, and a waist restraints in place. There continued to be no physician order for the waist restraint. Review of the nursing Restraint record dated 3/10/2025 at 8:00 AM, revealed the mittens, soft bilateral wrist restraints, and the waist restraint were in place with no physician order for the waist restraint. Review of the nursing Restraint record dated 3/11/2025 at 8:00 AM, revealed Patient #2 remained in the soft bilateral wrist restraints and the waist restraint with no physician order for the waist restraint. Review of the nursing Restraint record dated 3/12/2025 at 8:00 AM, revealed Patient #2 remained in soft bilateral wrist restraints and the waist restraint with no physician order for the waist restraint. Review of the nursing Restraint record dated 3/13/2025 at 8:00 AM, revealed Patient #2 remained in the soft bilateral wrist restraints and the waist restraint with no physician order for the waist restraint. Review of the nursing Restraint record dated 3/14/2025 at 8:00 AM, revealed Patient #2’s soft bilateral wrist restraints and the waist restraint remained in place until 8:00 PM. There was no physician order for the waist restraint. Continued review revealed at 8:00 PM, bilateral wrist restraints and waist restraints were temporarily released while family visited. Review of the nursing Restraint record dated 3/15/2025 at 4:00 AM, revealed Patient #2 had mittens, soft bilateral wrist restraints, and a waist restraint in place with no physician order for the waist restraint. Further documentation revealed bilateral wrist restraints, and the waist restraint were temporarily removed at 12:00 PM during a family/other visitation. The bilateral wrist restraints and waist restraints remained off until they were reapplied 16 hours later on 3/16/2025 at 4:00 AM, without nursing requesting or obtaining a new restraint order from the physician. Medical record review revealed for the 10-day period, from 3/7/2025-3/16/2025, the physician’s order for the application of the soft wrist restraints was in place. During this same time period, the waist restraint and all 4 side rails on Patient #2’s bed were raised in the up position and there was no physician order obtained for the waist restraint or for the 4 raised side rails used. Medical record review of a physician’s order revealed the soft wrist restraints were discontinued on 3/16/2025 at 10:00 PM. Medical record review of a physician order dated 3/17/2025 at 1:34 PM, revealed the first order for a waist restraint (11 days after the initial use of the waist restraint began) for Patient #2 for “Altered Mental Status.” Medical record review of a physician’s progress note on 3/17/2025 at 1:51 PM, revealed “... According to the nursing staff, he [Patient #2] was very agitated earlier, received some Ativan and Haldol. He is now sedated and unresponsive...” Continued review revealed “...his course was complicated with severe delirium requiring chemical and mechanical restraints...” Medical record review of the Psychiatry progress notes dated 3/17/2025 at 2:23 PM, revealed “...Attempted to see patient twice this morning but he was sleeping. Chart review revealed multiple PRN [as needed] medications administered over the weekend for further agitation and wandering. Went to evaluate patient again this afternoon and it was noted he was agitated and trying to get out of bed. Per his RN [registered nurse], he was given PRN Ativan followed by Haldol within the past hour. I attempted to talk to [Patient #2] for a few minutes, but he quickly fell asleep during our conversation...” Review of the nursing Restraint record dated 3/17/2025 at 8:00 PM, revealed a waist restraint and 4 raised side rails were in place. There was no physician order for the 4 raised side rails. Review revealed Patient #2 remained in the waist restraint with the 4 raised side rails until 3/18/2025 at 8:00 AM. Review of the nursing Restraint record dated 3/18/2025 at 8:00 AM, revealed Patient #2 was restrained with the waist restraint. Review of the nursing Restraint record dated 3/19/2025 at 12:00 AM, revealed a second restraint, bilateral wrist restraints, were placed on Patient #2 (3 days after being discontinued) without obtaining a new physician’s order. Continued review revealed Patient #2 had the bilateral wrist restraints and the waist restraint used until 3/19/2025 at 10:44 PM (a period of 10 hours and 44 minutes). Continued review revealed at 10:44 PM, a physician order for restraints, soft wrist restraints and a waist restraint, was ordered for “Impaired Thought Process-Mental Status Change.” Medical record review of a Hospitalist progress notes dated 3/20/2025 at 3:38 PM, revealed “...My preference would still be that we have ongoing sitters and/or family members, and we avoid restraining him. I think a lot of his agitation is that we tried keeping him in bed and I do not think he is a significant fall risk, he was ambulating in ICU prior to coming to the floor...” Continued review revealed the Hospitalist physician documented a conversation with the Nurse Manager of Patient #2’s unit to encourage frequency out of bed, frequent ambulation and to “...do all we can to avoid restraints...” Review of the nursing Restraint record dated 3/21/2025 at 4:00 PM, revealed bilateral wrist restraints, and waist restrains remained in place. Review revealed at 4:00 PM, the restraints were removed temporarily... family/other with patient...” The bilateral wrist restraints and waist restraints were released on 3/21/2025 at 10:00 PM, when the restraints were discontinued. Medical record review of a Hospitalist progress notes dated 3/22/2025 at 12:20 PM, revealed at an undocumented time Patient #2 had restraints reapplied, “...remains confused and has intermittent agitation requiring as needed medications...but transfer currently delayed because of recurrent episodes of agitation requiring restraints for safety...” Review of a Care Giver Rounding note dated 3/23/2025 at 9:52 AM, revealed Patient #2 “...was fighting restraints, verbally aggressive and Ativan IM [intramuscular] was given...” Continued review revealed the waist restraint was in place on Patient #2 until 3/23/2025 at 2:14 PM. Patient #2 was discharged to home on the same day, 3/23/2025. Medical record review of Patient #2’s Medication Administration records from 3/6/25 to 3/23/25 revealed concurrent chemical restraint as follows: 3/6/2025 at 7:22 AM, Haldol Injection 2 milligrams (mg) Intravenous (IV) push for agitation. 3/8/2025 at 4:12 AM, Haldol Injection 5 mh IV push for agitation. 3/8/2025 at 11:53 AM, Haldol Injection 5 mg IV push for agitation. 3/8/2025 at 7:26 PM, Ativan 2 mg IV push for agitation. 3/9/2025 at 12:18 AM, Ativan 2 mg IV push for agitation (note the Haldol was not administered first as ordered on 3/7/2025). 3/9/2025 at 12:22 PM, Ativan 2 mg IV push for agitation (note the Haldol was not administered first as ordered on 3/7/2025). 3/10/2025 at 3:59 PM, Haldol Injection 5 mg IM for agitation. 3/11/25 10:38 PM, Haldol Injection 5 mg IV push for agitation. 3/12/25 at 4:42 AM, Haldol Injection 5 mg IV push for agitation. 3/12/25 at 3:34 PM, Haldol Injection 5 mg IV push for agitation (note 4 days transpired before the next documented PRN psychoactive drug dose). 3/16/25 at 4:49 PM, Ativan 2 mg IV push for agitation (note the Haldol was not administered first as ordered on 3/7/2025). 3/17/25 at 2:41 AM, Ativan 2 mg IV push for agitation (note the Haldol was not administered first as ordered on 3/7/2025). 3/17/25 at 12:15 PM, Ativan 2 mg IV push for agitation (note the Haldol was not administered first as ordered on 3/7/2025). 3/17/25 at 1:14 PM, Haldol Injection IM left upper arm for agitation. 3/18/25 at 5:59 AM, Ativan 2 mg IM left gluteus for agitation (note the Haldol was not administered first as ordered on 3/7/2025). 3/18/25 at 7:48 AM, Haldol Injection IM to right upper arm for agitation, 3/18/25 12:42 PM, Ativan 2 mg Left upper arm for agitation (note 4 days transpired before the next documented PRN psychoactive drug dose). 3/22/25 at 1:10 PM, Ativan 2 mg IM to right upper arm for agitation (note the Haldol was not administered first as ordered on 3/7/2025). 3/23/25 at 9:43 AM, Ativan 2 mg to right upper arm for agitation (note the Haldol was not administered first as ordered on 3/7/2025). Medical record review revealed Ativan and Haldol were ordered as needed (PRN) and frequently given out of the ordered sequence. There wasn’t consistent nursing documentation of the effect of the 2 PRN psychoactive drugs on Patient #2. On at least 1 occasion, the effect of the 2 PRN drugs resulted in Patient #2 being sedated and unresponsive, as documented in a physician’s progress note on 3/17/2025 at 1:51 PM. Review revealed there were no comprehensive assessment or change to the 2 PRN drugs being used. During the 18-day hospital stay, Patient #2’s percentage of meal intake was frequently either not documented by nursing or recorded as 50% or less. Medical record review of the Weight record throughout Patient #2’s hospital stay revealed Patient #2’s weight on day of admission 3/5/2025, was 201.4 pounds. Further review revealed Patient #2 was weighed daily on a bed scale and on 3/22/2025, his weight was 180 pounds, signifying a 21-pound weight loss during the 18-day hospital stay. The weight loss was not recognized by the nursing staff or addressed in the nursing plan of care. Medical record review of Patient #2’s Wound Documentation began on 3/11/2025 as follows: 3/11/2025 at 4:14 PM, revealed barrier cream was applied to Patient #2’s genitalia. Genitalia was open to air and “...edges separated, Pink...” 3/13/25 at 10:47 PM, revealed genitalia edges approximated and red. The surrounding tissue was documented as erythema (redness), excoriation (erosion of the skin). 3/15/25 at 9:47 AM, revealed the edges were approximated, erythema continued and [name of barrier cream] was applied topically (to skin). 3/18/25 at 10:30 PM, revealed erythema of the genitalia continued, and the treatment was changed to a second skin barrier paste. 3/22/25 at 7:45 PM, revealed the genitalia to be ecchymotic (a bruise formed when blood vessels near the skin’s surface leak and blood pools). Erythema was still present, and the genitalia remained open to air. Review revealed nursing did not address the patient’s skin condition daily. During a telephone interview on 4/10/2025 at 3:35 PM, RN #1 revealed she had applied restraints on Patient #2 in the intensive care unit. RN #1 stated Patient #2 was confused, ripping IV’s out five times and showed aggressive behavior. During the interview, RN #1 stated “...you can add on the extra restraint under the restraint policy.” During a telephone interview on 4/10/2025 at 3:58 PM, with RN #2, who worked in the ICU with Patient #2, he stated “typically’ restraints must be ordered by a physician and when he reported for duty, he failed to check the patient’s restraint order. RN #2 stated he kept the restraints on that were in place (mittens, soft wrist restraints and the waist restraint). RN #2 revealed Patient #2 removed his restraints and climbed over the 4 raised side rails. RN #2 stated in the EHR system there was only 1 space to obtain an order for 1 type of a restraint at a time. During a telephone interview on 4/10/2025 at 11:46, with the ICU Manager, where Patient #2 was initially admitted, stated if a patient was exhibiting the same behavior after a temporary restraint release, the patient would be placed back in the same restraint and a new order was not required. The ICU Manager stated for an episode of restraint use, would be when a patient exhibited the same behavior therefore the same physician order for the restraint could be followed. During a telephone interview on 4/10/2025 at 12:20 PM, with RN #3, working with Patient #2 during his ICU stay, revealed when a restraint was needed, she usually requested the type of restraint needed by texting the physician and requesting for an order. RN #3 stated if there was a new behavior exhibited she would ask for a new restraint. RN #3 confirmed at one point Patient #2 had two restraints in use and the staff should have requested an order for the use both restraints. RN #3 further stated 4 raised side rails were a restraint and a physician’s order was needed. RN #3 stated restraint orders were good for 24 to 48 hours. During a telephone interview on 4/10/2025 at 1:58 PM, with RN #4, who cared for Patient #2 during his ICU stay, stated a physician order was needed for mittens and when all 4 side rails were used in the up position. RN #4 stated a new physician order for a restraint was needed if a patient’s behavior escalated, de-escalated, or for a temporary release from the restraints. RN #4 further stated when she recognized a patient needed a restraint, she described the situation to the physician by using [name of an electronic application], the physician responded, and give an order for the use of the restraints. RN #4 continued to state, the staff could replace the restraint after it had been temporarily removed if the patient’s behavior was the same. RN #4 stated she “...sees restraints on this floor often.” During a telephone interview on 4/10/2025 at 2:22 PM, RN #5 stated the nights she took care of Patient #2, the bilateral wrist restraints and the waist restraints were in use. She added the physician must reassess the patient daily for restraints.RN #5 stated when she obtained an order for restraints “... the restraints must be applied in that same hour, or the physician order is null and void...” RN #5 stated a patient could be on a temporary release of the restraint if the nurse was with the patient. If the temporary release lasted longer than one hour, then a new order must be obtained from the physician. If the patient exhibited violent behaviors then the physician must re-assess the patient. RN #5 stated Patient #2 removed the soft bilateral wrist restraints himself, at which time she raised all 4 side rails. RN #5 explained that by raising all 4 side rails the buckle attached to the soft wrist restraints were hidden and the patient could not see to unbuckle the soft wrist restraints. During a telephone interview on 4/10/2025 at 3:43 PM, Physician #1 stated Patient #2 was persistently confused and agitated. He stated the nurses decided what type of restraint was needed, asked the physician for an order, and then the nursing staff managed the restraints. During a telephone interview on 4/10/2025 at 4:58 PM, Nurse Practitioner #2 stated when restraints were needed the RN paged a message to the provider. The nurse usually decided what type of restraint was needed and the order for the restraints was active for 24 hours. Summary of interviews: Above interviews with registered nurses who cared for Patient #2 (both nurses in the intensive care unit and nurses on the general unit), revealed a lack of knowledge of the facility’s restraint policy, reflected in their comments during interviews. For example, the facility’s policy doesn’t cover an “extra restraint,” a doctor’s order was not required for a temporary release of restraint, an RN shared the patient had 3 restraints applied when he came on duty and he continued the 3 restraints without questioning if there were orders for all 3 or checking if the physician’s orders were in place. The same RN stated Patient #2 crawled over all 4 side rails which were in the up position, proving unsafe environment for Patient #2, but the side rails continued to be used at intervals throughout the patient’s hospitalization. Another nurse stated, erroneously, a new restraint order was needed if the restraint was off for more than an hour and the fifth nurse interviewed stated, erroneously, an order for a restraint expired in 24-48 hours. Medical record review of the complete nursing documentation revealed Patient #2’s behavior may have changed, but nursing documentation did not support a behavior change or additional restraints. Review revealed the nursing staff documented temporarily releasing the patient several times, but documentation was inconsistent regarding the actual time the restraint was released, the actual time when the restraint was reapplied, and why they were continuing the order to restrain. In addition, the nurses for Patient #2 did not consistently document when he is released for meals and what time he is re-restrained. Medical record review revealed Patient #2 was restrained both chemically and physically throughout his hospital stay, resulting in sedation, weight loss and skin impairment. Nursing did not develop a comprehensive plan of care to address the complex behaviors of Patient #2 and the interventions needed to ensure the proper use of restraints and mitigate the restraints’ harmful effects. Refer to A-0154 and A-0160”

“QUALIFIED EMERGENCY SERVICES PERSONNEL CFR(s): 482.55(b)(2) There must be adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility. This Standard is not met as evidenced by: 30553 Based on review of facility policy, review of facility Standard Work documents, review of an Emergency Medical Services (EMS) record, medical record review and interviews, the facility failed to provide a timely assessment for 1 patient (#14) who presented to the Emergency Department (ED) related to an Altered Mental Status of 24 ED records reviewed. The findings include: Review of facility policy “Emergency Triage”, last revised 2/2022, showed “...a triage nurse is responsible for providing a timely triage to all patients to the Emergency Department. Each patient is assigned a triage classification based on the Emergency Severity Index. The Emergency Severity Index is a five-level ED triage algorithm that provides clinically relevant stratification of patients into five groups from 1 [most urgent] to 5 [least urgent] based on acuity and resource needs...” Review of a Standard Work document (no date) showed “...patients not meeting immediate offload criteria will be evaluated by a Registered Nurse [RN] or Paramedic for triage, offload zone [OZ] or immediate bedding...If maintained by hospital staff these patients should be protocoled and given a room as soon as feasible while not impacting the movement of critical patient...” Review of a Standard Work document (no date) showed “...Triage 1: Also known as “quick look” to staff. Includes vital signs, presenting complaint, comment section if needed, and a tracking acuity-this acuity can be changed during triage 2 and is a first impression only. Triage 1 is completed by nurse or medic. Triage 2: Triage part 2 is the “full triage” and includes more details about visit. This can be done after triage 1 or stand alone...a patient acuity is assigned or verified from part 1, and allergies are confirmed. Acuity can be changed during triage 2 and is a first impression only...” Review of an EMS Patient Care Record dated 8/26/2024, showed Patient #14 was transported from home. The patient arrived at the facility’s ED at 12:56 AM. The patient was transferred from the EMS stretcher to the ED bed at 4:30 AM (3 hours and 34 minutes after arrival). The report showed “...extended wait for bed placement, approximately 3.5 hrs [hours], during which time crew contacts supervisor, assistant director, ED Team Leader, and paramedic controlling bed placement with requests for bed placement repeatedly. Crew is informed they do not have any bed no prospects for crew to receive one repeatedly. During this time, no attempt is made by nursing staff or physician to assess, triage, or obtain vitals on patient...” There was no documentation of vital signs, an assessment, or Triage 1 for 8/27/2024, from the arrival time, 12:55 AM until 4:22 AM. Medical record review of an ED Nursing Triage Part 2 record dated 8/27/2024 at 4:22 AM (3 hours and 26 minutes after arrival in the ED by EMS) recorded Patient #14’s vital signs were as follows: BP 100/67, Pulse 81, Respirations 16, Temperature 96.0° (degrees) Fahrenheit, and Pulse Oximetry 100% on room air. The patient was triaged with an Emergency Severity Index (ESI) score of a 2 indicating emergent/urgent needs. Medical record review of an ED Provider Record dated 8/27/2024 at 5:11 AM, showed Patient #14 presented with Altered Mental Status (AMS). The patient was found to be hypotensive with a BP of 90/67 and he was given IV fluids and steroids. Diagnostic testing showed a Sodium level of 109 (normal 135-145) and labs showed concerns related to acute renal insufficiency due to a Potassium of 5.9 (normal 3.5-4.5) and elevated liver function test. The Computed Tomography (CT) of the head showed persistent metastatic disease to the brain with a decrease of vasogenic edema. The Hospitalist services were contacted for admission. Medical record review of an Admission History and Physical dated 8/27/2024 at 9:26 AM, showed Patient #14 was admitted with diagnoses including Acute Encephalopathy (likely metabolic), Severe Hyponatremia, Metastatic Adenocarcinoma of the Lung, Brain Metastasis s/p radiation, Adrenal Metastasis, Acute Renal Failure, Hypertension, and Hyperkalemia. Medical record review of the Discharge Summary dated 8/30/2024 at 11:06 AM, showed the patient continued to have decline and expired on 8/30/2024. During an interview on 10/2/2024 at 11:00 AM, Paramedic #1 stated on arrival in the ED, the Paramedic or nurse would document a Triage 1 assessment of the patient indicating the patient’s complaint, the vital signs, and a brief assessment of the patient. The ED Paramedic or nurse would make the decision where the patient would be moved. During an interview on 10/3/2024 at 10:15 AM, ED Nurse Manager #1, stated the facility had an EMS surge policy and ED Standard Work for patients who presented to the ED for treatment. The ED Nurse Manager confirmed there was no triage 1 documented for Patient #14 and nursing triage Part 2 was completed on 8/27/2024 at 4:22 AM for the patient (3 hours and 26 minutes after arrival in the ED by EMS). During an interview on 10/3/2024 at 2:50 PM, the Director of Environment and Health Services and Emergency Management, stated the facility had an Emergency Surge policy which was incorporated into the Emergency Preparedness Plan. The Emergency Plan was not activated on 8/27/2024. During a telephone interview on 10/3/2024 at 7:10 PM, Paramedic #2 stated when EMS arrived with a patient, she would obtain the patient’s vital signs and document in the Triage Part 1 of the medical record. She confirmed there were no vital signs or an assessment documented in the medical record upon Patient #14’s arrival in the ED. During a telephone interview on 10/4/2024 at 7:15 PM, RN #1 stated the patient arrived by EMS and the ED was extremely busy on 8/27/2024. The patient was held in the trauma bay with the EMS provider in attendance. The EMS provider had informed the nurse they had waited for 2-3 hours for a bed. RN #1 had completed the Triage Part 2 on 8/27/2024 at 4:22 AM for Patient #14, but the Part 1 had not been completed. She confirmed Part 1 was to be performed at the EMS entrance area. During a telephone interview on 10/4/2024 at 7:40 AM, EMS Paramedic #3 stated the ED staff did not triage the patient or get any vital signs on the patient when they arrived in the ED. She waited with the patient for 3.5 hours and the patient was not evaluated by a nurse or a physician. During a telephone interview on 10/4/2024 at 7:50 AM, the ED Medical Director stated all EMS patients are to be evaluated by the Paramedic in the EMS entrance bay and offloaded based on the assessment. This evaluation included a quick assessment and vital signs.”