Regional One Health

“COMPLIANCE WITH LAWS CFR(s): 482.11 Compliance with Federal, State and Local Laws This Condition is not met as evidenced by: 32777 Based on policy review, personnel file review, facility documents and interviews, the Hospital failed to ensure the Hospital was in compliance with Federal, State and Local Laws when 1 of 1 imposter nurses (Imposter Nurse A) was hired as a Registered Nurse using another person’s (Nurse B) valid and current nursing license, practiced professional nursing and provided nursing care to patients in the hospital. The findings include: 1. Review of the hospital system’s policy, “On-Boarding” with an initial release date of February 8, 2021 revealed applicants would be hired based off a thorough pre-employment on-boarding process to include background check, reference and education verification, employment would be contingent upon satisfactory completion of appropriate reference and background reviews and the Human Resource (HR) Recruiter or Recruitment Specialist would obtain documentation from all applicants who had received offers of employment into a position that requires a valid and active license. 2. Review of personnel files for Imposter Nurse A revealed the Imposter Nurse worked for the hospital from 1/13/2025 - 1/27/2025 on the Skilled Nursing Unit of the hospital. On 1/27/2025, Imposter Nurse A was terminated from the hospital for violation of the hospital’s Standards of Conduct. Further review of Imposter Nurse A’s personnel file revealed the Imposter Nurse had used two (2) different Social Security Numbers (SSN) and three (3) different dates of birth on her employment Onboarding documents. There was no evidence the Hospital questioned or did any cross referencing that would have identified inconstancies in the pre-employment documents. Refer to A0023”

“LICENSURE OF PERSONNEL CFR(s): 482.11(c) The hospital must assure that personnel are licensed or meet other applicable standards that are required by State or local laws. This Standard is not met as evidenced by: 32777 Based on policy review, personnel file review, facility documents and interviews, the Hospital failed to assure that personnel requiring a license to work as a Registered Nurse (RN) were licensed and in compliance with the State’s licensure laws when 1 of 1 imposter nurses (Imposter Nurse A) was hired using another person’s (Nurse B) current and valid RN license and provided professional nursing care to the hospital’s patients. The findings include: Review of the Hospital System’s policy, “On-Boarding” with an initial release date of February 8, 2021 revealed, “ ...All applicants who are selected for hire and on-board ...must successfully complete a thorough pre-employment on-boarding process to include background check, reference and education verification, and pre-employment physical screening ...All offers of employment will be contingent upon satisfactory completion of appropriate reference and background reviews ...Applicants will not be given further consideration for employment based on background investigation findings that include ...Any misrepresentation, falsification, omission of material facts, or other indication that the candidate is attempting to mislead [Named Hospital] ...Such findings will also be grounds for termination after an applicant is hired ...The HR Recruiter or Recruitment Specialist will obtain documentation from all candidates who have received offers of employment into a position that requires a valid and active license ... “ Review of a copy of a W-4 form dated and signed by Imposter Nurse A on 01/06/2025 matched the Social Security Number (SSN) and the first and last name listed on the I-9 (Employment Eligibility Verification Form) signed 01/13/2025. The SSN and Imposter Nurse A’s full name listed on the W-4 and I-9 forms did not match the SSN and Imposter Nurse A’s full name listed on Background Screening Report dated 12/27/2024. Review of Imposter Nurse A’s birth certificate, the Background Screening Report and a timecard report show three different birth dates. Review of a separation notice dated 01/27/2025 revealed Imposter Nurse A was terminated for a violation of Standard of Conduct. During an interview on 09/18/2025 beginning at 1:30 PM, the Interim Director of Quality verified Imposter Nurse A was employed from 01/13/2025 to 01/27/2025 as a Registered Nurse in the Skilled Nursing Unit. During an interview on 09/19/2025 at 2:00 PM, the Interim Director of Quality stated Imposter Nurse A accessed 14 patient records while employeed. The Interim Director of Quality stated Imposter Nurse A didn’t administer medications because Imposter Nurse A was with a preceptor for the two (2) actual days she had worked on the floor. There was no evidence the Hospital questioned or did any cross referencing that would have identified inconstancies in the pre-employment documents.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 35244 Based on policy review, medical record review and interview, the facility failed to provide an appropriate medical screening exam for one (1) of 20 (Patient #3) sampled patients. The findings included: 1. Medical record review revealed Patient #3 presented to Hospital #1’s Emergency Department (ED) on 11/11/24 at 9:07 AM with a chief complaint of legs swelling and blood in the urine. Patient #3 was a 66 year old female who presented to the ED via private vehicle. Patient #3 reported both legs swelling, blood in the urine and an odor to the urine for 1 day. A Medical Screening Exam (MSE) was initiated on 11/11/24 at 9:49 AM by Physician #1. Physician #1 documented that Patient #3 reported ankles swelling at times, ankles had chronic changes associated with Peripheral Vascular Disease (PVD- circulation disorder caused by narrowing or blockage of blood vessels), but there was no swelling noted during MSE. Patient reported she did not wear compression stockings and didn’t know what blood pressure medication she was taking. Physician #1 documented the history of present illness as bilateral lower extremity chronic changes without wounding or swelling. Patient had elevated blood pressure. Patient reported no pain. Physician #1 documented on the physical examination, “...Alert, mild distress...” Physician #1 ordered a N-terminal pro-B-type natriuretic peptide (NT-ProBNP- lab test used to diagnose and monitor heart failure) on 11/11/24 with a result of 904 picograms per milliliter (pg/ml). Normal level is less than 125 pg/ml for people under 75 years old. Physician #1 ordered a Troponin T High Sensitivity (Troponin T HS- lab test used to diagnose heart attack and risk of cardiovascular disease) on 11/11/24 with a result of 26 nanograms per Liter (ng/L). Greater than 22 ng/L for women could indicate high risk for cardiovascular disease and above 14 ng/L that increased in follow-up testing could indicate concern for heart attack. Physician #1 ordered a urinalysis with microscopic on 11/11/24. The urinalysis revealed a moderate amount of blood in the urine, white blood cell count (WBC) of 22 (10 or more may indicate inflammation or infection), red blood cell count (RBC) of 36 (less than 3 would be within normal range), and 4 plus bacteria (could be an indicator of bacterial infection). Physician #1 documented Patient #3’s impression and plan as follows, “...Diagnosis...Hypertensive [high blood pressure] urgency, Hematuria [blood in urine], Lichen of skin [inflammation of skin]...Disposition...Discharged...Prescriptions...losartan [used to treat high blood pressure] 25 mg [milligrams] oral tablet [tab]...1 tab, oral, daily, 30 tab...Follow up with...Dermatology [named hospital] Within 1 to 2 weeks...FOLLOW UP WITH A PRIMARY CARE DOCTOR...Podiatry [named hospital] Within 1 to 2 weeks...FOLLOW UP WITH UROLOGIST FOR YOUR BLOOD IN YOUR URINE...” Review of the medical record for Patient #3 at Hospital #2 revealed the Patient arrived to the ED on 11/15/24 at 4:14 PM. Patient #3’s chief complaint was altered mental status that started around noon. Patient #3 reported past medical history of stroke with right sided weakness. Review of Patient #3’s ED course at Hospital #2 revealed, “...patient does have a mild AKI [acute kidney injury] as well as elevated troponin. Given these findings with her altered mental status, we would like to have her admitted...Diagnoses...Hypertensive Encephalopathy...Acute cystitis with hematuria...” Patient #3 was discharged home on 11/11/24 at 2:53 PM. Hospital #1 did not address or order follow-up testing of the abnormal NT-ProBNP or Troponin T HS during Patient #3’s stay in the ED on 11/11/24 to further assess Patient #3’s cardiac condition. Hospital #1 did not address or treat Patient #3’s abnormal urinalysis while in the ED on 11/11/24 or provide prescription treatment upon discharge. Hospital #1 failed to provide a complete MSE to determine if Patient #3 had an Emergency Medical Condition. Refer to A-2406”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 35244 Based on policy review, medical record review and interview, the facility failed to provide a complete or appropriate medical screening exam (MSE) to determine if an Emergency Medical Condition (EMC) existed for 1 of 20 (Patient #3) sampled patients who presented to the facility’s Emergency Department (ED) seeking medical care. The findings included: 1. Review of the facility’s “EMTALA” policy (revised 5/10/21) revealed, “...An MSE consists of an assessment and any ancillary tests (based on the patient’s chief complaint) necessary to determine if an emergency medical condition (EMC) exists...Emergency medical condition (EMC) is a medical condition manifesting itself by acute, severe symptoms...that, without immediate medical attention, could result in...Serious impairment to bodily functions, or Serious dysfunction of any bodily organ or part...If an EMC exists...[named hospital] will provide appropriate treatment to stabilize the EMC...” 2. Medical record review revealed Patient #3 presented to Hospital #1’s ED on 11/11/24 at 9:07 AM with a chief complaint of legs swelling and blood in urine. Patient #3 was a 66 year old female who presented to the ED via private vehicle. Patient #3 reported both legs swelling, blood in urine and an odor to the urine for 1 day. Patient #3 reported recent blood pressure changes with a past medical history of Hypertension. A MSE was initiated on 11/11/24 at 9:49 AM by Physician #1. Physician #1 documented Patient #3 reported ankles swelling at times, ankles had chronic changes associated with Peripheral Vascular Disease (PVD- circulation disorder caused by narrowing or blockage of blood vessels), but there was no swelling noted during the MSE. Patient reported she did not wear compression stockings and didn’t know what blood pressure medication she was taking. Physician #1 documented the history of present illness as bilateral lower extremity chronic changes without wounding or swelling. Patient had elevated blood pressure. Patient reported no pain. Physician #1 documented on the physical examination, “ ...Alert, mild distress ...” Physician #1 ordered a N-terminal pro-B-type natriuretic peptide (NT-ProBNP- lab test used to diagnose and monitor heart failure) on 11/11/24 with a result of 904 picograms per milliliter (pg/ml). Normal level is less than 125 pg/ml for people under 75 years old. Physician #1 ordered a Troponin T High Sensitivity (Troponin T HS- lab test used to diagnose heart attack and risk of cardiovascular disease) on 11/11/24 with a result of 26 nanograms per Liter (ng/L). Greater than 22 ng/L for women could indicate high risk for cardiovascular disease and above 14 ng/L that increased in follow-up testing could indicate concern for heart attack. Physician #1 ordered a urinalysis with microscopic on 11/11/24. The urinalysis revealed a moderate amount of blood in the urine, white blood cell count (WBC) of 22 (10 or more may indicate inflammation or infection), red blood cell count (RBC) of 36 (less than 3 would be within normal range), and 4 plus bacteria (could be an indicator of bacterial infection). Physician #1 documented Patient #3’s impression and plan as follows, “...Diagnosis...Hypertensive [high blood pressure] urgency, Hematuria [blood in urine], Lichen of skin [inflammation of skin]...Disposition...Discharged...Prescriptions...losartan [used to treat high blood pressure] 25 mg [milligrams] oral tablet [tab]...1 tab, oral, daily, 30 tab...Follow up with...Dermatology [named hospital] Within 1 to 2 weeks ...FOLLOW UP WITH A PRIMARY CARE DOCTOR...Podiatry [named hospital] Within 1 to 2 weeks ...FOLLOW UP WITH UROLOGIST FOR YOUR BLOOD IN YOUR URINE...” Review of the medical record for Patient #3 at Hospital #2 revealed the Patient arrived to the ED at Hospital #2 on 11/15/24 at 4:14 PM. Patient #3’s chief complaint was altered mental status that started around noon. Patient #3 reported past medical history of stroke with right sided weakness. Patient #3’s blood pressure was 148/77 on 11/15/24 at 4:19 PM, but it increased to 226/108 at 5:33 PM. Patient #3 received hydralazine (used to treat high blood pressure) 10 mg intravenous (IV) at 5:51 PM. Patient #3’s blood pressure decreased to 128/60 at 6:05 PM. Patient #3’s blood pressure started to increase again to 187/85 on 11/16/24 at 4:00 AM. Patient #3 received a second dose of hydralazine 10 mg IV on 11/16/24 at 4:54 AM, and Patient #3’s blood pressure decreased to 153/68 at 5:00 AM and to 130/62 at 6:00 AM. Patient #3 was admitted to Hospital #2 on 11/16/24. Review of Patient #3’s ED course at Hospital #2 revealed, “...patient does have a mild AKI [acute kidney injury] as well as elevated troponin. Given these findings with her altered mental status, we would like to have her admitted...Diagnoses...Hypertensive Encephalopathy...Acute cystitis with hematuria...” In an interview on 4/9/25 at 12:00 PM, the ED Nurse Manager stated it was a case by case basis, regarding Urinary Tract Infection (UTI) or blood in urine. The Manager stated if WBC’s were elevated in the urine and the patient was having symptoms, the patient might receive fluids, antibiotics or pain medications while in the ED. The patient would most likely go home with antibiotics. In an interview on 4/9/25 at 2:20 PM, ED Registered Nurse (RN) #1 stated patient history was going to count when it came to treating a UTI. Every case could be different. ED RN #1 stated the patient might get fluids while in the ED. If it was a complicated case, they would get intravenous (IV) antibiotics while in the ED and go home on by mouth antibiotics. In an interview on 4/10/25 at 12:06 PM, ED Physician #1 stated Patient #3 was worked up in the ED and had some hematuria. If a patient was stable, like Patient #3, they should be referred to a urologist for scope of bladder that can be done on an outpatient basis. ED Physician #1 stated there was nothing emergent during Patient #3’s ED visit. In an email correspondence on 4/11/25, Physician #2 stated the course of treatment for hematuria would be highly dependent on the cause. The ED’s role was to evaluate for emergent issues. Physician #2 stated an uncomplicated UTI would not alone merit admission to the hospital. There would need to be complicating factors such as sepsis. Physician #2 stated Patient #3 had no findings related to UTI that would require admission. Regarding elevated BnP and Troponin, Physician #2 stated, “An elevated BNP with clear lungs and no hypoxia would merit outpatient follow up. High sensitivity troponin testing is so sensitive that many times patients have low level elevations and a level that low would only need to be rechecked if there were concerns for acute coronary syndrome ...This patient had improved bp [blood pressure] after medication and had no symptoms suggestive of ACS [acute coronary syndrome]. There is no benefit to trend bnp levels as this is a lab test and clinical evaluation of the patient is the only additional testing necessary ...” Patient #3 was discharged home on 11/11/24 at 2:53 PM. Hospital #1 did not address or order follow-up testing of the abnormal NT-ProBNP or Troponin T HS during Patient #3’s stay in the ED on 11/11/24 to further assess Patient #3’s cardiac condition. Hospital #1 did not address or treat Patient #3’s abnormal urinalysis while in the ED on 11/11/24 or provide prescription treatment upon discharge. Hospital #1 failed to provide a complete MSE to determine if Patient #3 had an Emergency Medical Condition.”

“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: 50767 Based on policy review, medical record review, and interview, the facility failed to ensure Nursing Services provided oversight and supervision to ensure patients were appropriately assessed and met eligibility criteria for use of the Telesitter (camera-based system that monitors patients in their rooms and alerts staff to concerns or emergencies) for 5 of 7 (Patient #2, #4, #6, #7, and #8) sampled patients, and failed to ensure Nursing Services provided adequate oversight and supervision to ensure wound assessments and interventions to treat wounds were completed and accurately documented per facility policy for 2 of 2 (Patient #1 and #2) sampled patients with pressure injuries. The findings included: 1. Review of the hospital’s “Telesitter/Continuous Video Monitoring (CVM)” policy revised on 4/17/2024, revealed, “...The following terms shall have the meanings set forth below when used in this policy: Continuous Video Monitoring: A video monitoring system allows patients with safety risks to be monitored from a separate location contained on-site within the facility...This policy will outline the process for the Tele-sitter/Continuous Monitoring Program implementation and management...The use of CVM [Continuous Video Monitoring] is on a continuum of least restrictive methods. The use of CVM requires utilization of the least restrictive guidelines based on clinical assessment by the provider. Patient and or support person is documented according to the patient’s individualized plan of care...Inclusion criteria: For patients requiring a sitter for safety, CVM appropriate as the initial intervention and is implemented per the CVM Physician Order. CVM patients meeting exclusion criteria in the first 24 hours will be placed on one-to-one continuous observation per physician order...Exclusion criteria: If patient exhibits any exclusion criteria in the first 24 hours of CVM, the house supervisor is notified of the need to transition patient to a constant observer. Patient remains on CVM until constant observer is available...Physical restraints...unable to follow commands...Traumatic Brain Injury...Registered Nurse Responsibilities: Registered Nurses notify the provider, obtain an order, and place patients requiring monitoring for safety on CVM...Registered Nurses reassess appropriateness using inclusion and exclusion criteria and notify the provider if the patient needs change...Conducts CVM education with patient and or support persons to promote patient safety...Assesses the need for CVM every shift (12 hours) and document patient utilization of CVM EHR [electronic health record] every 12 shift (12 hours)...Inform patient/family when CVM is discontinued when applicable...” Review of the hospital’s “Patient Rights & [and] Responsibilities” policy revised on 3/27/2018, revealed, “...[Hospital #1] will respect the rights and responsibilities of patients, families, and surrogates...Considerate and respectful care in a safe environment...An environment that preserves dignity and contributes to a positive self-image...Provide information about healthcare for patients with...cognitive impairments in a manner that meets the patient’s needs...Make decisions about the plan of care prior to and during the course of treatment...” 2. Medical record review for Patient #2 revealed an admission date of 8/15/2024 with diagnoses which included Altered Mental Status, Acute Encephalopathy and a Sacral Wound. Patient #2, a cognitively impaired male who was unable to answer direct questions or follow commands and required the use of mitten restraints to prevent pulling and removing intravenous lines, received Telesitter services from 8/29/2024 through 8/30/2024. Patient #2 was observed on the Telesitter monitor attempting to get out of bed without assistance and was not easily redirected. Nursing Services failed to ensure Patient #2 was reassessed every 12 hours to determine eligibility for use of the Telesitter per policy, failed to identify Patient #2 was not eligible for safe use of the Telesitter, and failed to educate Patient #2’s support persons regarding safe use of the Telesitter and/or discontinuation of the Telesitter. 3. Medical record review for Patient #4 revealed as admission date of 11/13/2024 with diagnoses which included Right Humeral Neck Fracture with Dislocation, Left Inferior Pubic Ramus/Posterior, Acetabulum Fracture, Bilateral Sacral Wing Fracture, Left Rib Fracture, Right Frontal Subarachnoid Hemorrhage and Right Transverse Processes of the Lower Lumbar #3, #4, and #5. Patient #4 was considered a high risk for falls. Patient #4 received Telesitter services from 12/1/2024 until 12/2/2024 and re-ordered later on 12/2/2024 through 12/10/2024. Nursing Services failed to ensure Patient #4 was reassessed every 12 hours to determine eligibility for use of the Telesitter per policy and failed to educate Patient #4’s support persons regarding safe use of the Telesitter and/or discontinuation of the Telesitter. 4. Medical record review for Patient #5 revealed an admission date to the inpatient rehabilitation unit on 11/30/2024 with diagnoses which included Status Post Subdural Hematoma, Acute Stroke due to Ischemia, Atrial Fibrillation and Impaired Mobility and Activities of Daily Living. Patient #5 was considered a high risk for falls. Patient #5 received Telesitter services from 12/2/2024 through 12/10/2024. Nursing Services failed to ensure Patient #5 was reassessed every 12 hours to determine eligibility for use of the Telesitter per policy and failed to educate Patient #5’s support persons regarding safe use of the Telesitter and/or discontinuation of the Telesitter. 5. Medical record review for Patient #6 revealed an admission date of 11/9/2024 with diagnoses which included large Subdural Hemorrhage (A subdural hematoma is bleeding in the brain usually caused by a traumatic brain injury). Patient #6 underwent an emergent Craniotomy Decompression and was admitted to the Trauma Intensive Care Unit. Patient #6 suffered a Traumatic Brain Injury and was documented as unable to follow commands and rarely alert or conscious. Patient #6 received Telesitter services from 12/2/2024 through 12/5/2024. Nursing Services failed to ensure Patient #6 was reassessed every 12 hours to determine eligibility for use of the Telesitter per policy, failed to identify Patient #6 was not eligible for safe use of the Telesitter, and failed to educate Patient #6’s support persons regarding safe use of the Telesitter and/or discontinuation of the Telesitter. 6. Medical record review for Patient #7 revealed an admission date of 11/21/2024 with diagnosis of a Post-operative Infection of the Left Knee. Patient #7 was received Telesitter services from 11/22/2024 through 12/11/2024. Nursing Services failed to educate Patient #7’s support persons regarding safe use of the Telesitter and/or discontinuation of the Telesitter. 7. Medical record review for Patient #8 revealed an admission date of 10/22/2024 with diagnoses which included Pneumocephalus, Idiopathic Pulmonary Hemosiderosis, Subarachnoid Hemorrhage, Subdural Hematoma, Impending Herniation, Left Vertebral Artery Injury at the Cervical 6th fracture, Left Internal Carotid Artery Intimal Injury, Bilaterial Frontal, Parietal, Temporal, Skull Base Fracture, Sphenoid Fracture, Left Occipital Condyle Fracture, LeFort I, + II, Right LeFort III, Right Zygomaticomaxillary Complex Fracture, Nasal Bone + Septum Fracture, Middle Mandible Fracture, Transverse Process Fracture, Thoracic 1 Vertebral Fracture, and Distal Radius Fracture. Patient #8 was cognitively impaired and unable to follow commands. Patient #8 required the use of bilateral wrist restraints to prevent dislodgment of life saving equipment. Patient #8 received Telesitter services from 12/2/2024 through 12/4/2024, while still requiring wrist restraints. Nursing Services failed to ensure Patient #8 was reassessed every 12 hours to determine eligibility for use of the Telesitter per policy, failed to identify Patient #8 was not eligible for safe use of the Telesitter, and failed to educate Patient #8’s support persons regarding safe use of the Telesitter and/or discontinuation of the Telesitter. 8. In an interview on 1/16/2024 at 12:11 PM, the Interim Director of Quality (IDQ), the Vice President of Nursing (VPN), the Director of Risk Management (DRM), the Director of Nursing Medical Services (DON), and the Vice President of Patient Care (VPPC) verified Nursing Services were expected to assess patients every 12 hours to ensure the patients met eligibility criteria for use of the Telesitter. The IDQ, VPN, DRM, DON, and VPPC confirmed patients had to be able to follow commands be easily redirected to meet eligibility requirements for Telesitter services. 9. Review of the hospital’s “Prevention and Treatment for Skin Integrity” policy revised on 11/17/2021, revealed, “...Pressure Injury Treatment Pathway: Patients with impaired skin or suspected pressure injury...Collaborate with Provider...Consult WOCN [Wound, Ostomy, and Continence Nurse], Consult Medical Nutrition Therapy, and Initiate Pressure Injury Order Set if pressure injury present or suspected...When a consult for WOCN is initiated, the consult order includes location and a brief description of the site needing evaluation and treatment...Assessments/Interventions...Nurse ...Assesses and documents the skin and Braden Assessment scale...within 24 hours of admission and daily after that...Implements a patient-specific plan of care Notifies the Provider for impaired skin integrity...Consults WOCN for impaired skin integrity...Provider or WOCN...Completes staging of pressure injuries...Completes the assessment and documentation of bruising and erythema...Measures the wound as needed...” Review of the facility’s “Guidelines: Prevention and Treatment for Skin Integrity” policy reviewed on 7/27/2022, revealed, “...Pressure Injury (Staged per National Pressure Ulcer Advisory Panel Guidelines): Pressure injury: localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device...Assess and document the skin and the Braden Assessment scale with 24 hours of admission and minimally daily thereafter...Implement patient-specific plan of care and review with patient and/or family...Notifies the Provider for impaired skin integrity...Consults WOCN for impaired skin integrity...Assess and document pressure injuries with each dressing change and/or at least once per shift unless treatment orders contraindicate. Documentation will include location, approximate size, drainage (amount, color, odor), undermining, tunneling, character of wound, status of tissue surrounding the wound, stage (after completion by Provider or WOCN) dressing and pain...” 10. Medical record review for Patient #1 revealed an admission date of 8/29/2024 with diagnoses which included Acute Hypotension, Cellulitis, Pressure Ulcers, Septic Shock, Chronic Hypoxic Respiratory Failure, Sleep Apnea, Asthma, and Morbid Obesity. Patient #1 had unstageable infected pressure ulcers on his left back, left flank, a skin tear to his sacrum, cellulitis of both lower extremities, and a fungal infection of his toenail. Nursing Services failed ensure wound assessments and/or care provided were documented accurately, failed to notify the provider and develop a patient specific plan of care when the Patient’s sacral skin tear was reclassified as a pressure injury, and failed to identify and address measures to treat the Patient’s cellulitis and toenail fungus. 11. Medical record review for Patient #2 revealed an admission date of 8/15/2024 with diagnoses which included Altered Mental Status, Acute Encephalopathy and a Sacral Wound. Patient #2 presented with a “healing Stage 4” pressure injury to the sacrum that re-opened during his hospital stay. Nursing Services failed ensure wound assessments and/or care provided were documented accurately, failed to develop a patient-specific plan of care for wounds, and failed to provide Patient #2’s support persons education related to wound condition and/or care. Refer to A395.”

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 50767 Based on policy review, medical record review, and interview, the hospital failed to ensure arrangements for post-hospital needs were completed prior to discharge for 1 of 3 [Patient #1] sampled patients reviewed for discharge. The findings included: 1. Review of the hospital’s “Discharge Planning” policy dated 5/9/2016, revealed, “...The plan must take into consideration the medical, social and financial needs of the patient. Discharge planning is an interdisciplinary process, with each discipline playing an important role in provision of continuity of care...Discharge planning will begin on admission to identify the patient’s discharge needs and to assist the patient and/or family in arranging for those services to meet the needs...” 2. Medical record review for Patient #1 revealed an admission date of 8/29/2024 with diagnoses which included Acute Hypotension, Cellulitis, Pressure Ulcers, Septic Shock, Chronic Hypoxic Respiratory Failure, Sleep Apnea, Asthma, and Morbid Obesity. Patient #1 was a morbidly obese male weighing 573 pounds with known infected pressure injuries and osteomyelitis. The Patient was evaluated by the facility’s Physical Therapy team regarding his discharge needs who determined Patient #1 should have been discharged to a Skilled Nursing Facility where appropriate restorative therapy and wound care the family was unable to provide, could be provided. Patient #1 was in need of a bariatric hospital bed with an air mattress as the bed in the Patient’s home was twin-sized and broken “sitting on bricks.” The Patient was also in need of a new patient lift, as the one in the home was broken, and the Patient was unable to transfer himself from the bed to the wheelchair. The facility was unable to secure placement in a Skilled Nursing Facility and discharged Patient #1 home “independently” with no referrals for home health, no orders for a bariatric hospital bed, no orders for a pressure relief air mattress, no orders for wound care supplies, and no trained family members to provide his care. Refer to A813.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 50767 Based on policy review, medical record review and interview, the facility failed to ensure physician’s orders were obtained for physical restraint use for 2 of 2 (Patient #2 and #4) sampled patients reviewed for restraints. The findings included: 1. Review of the hospital’s “Restraint: Non-Violent or Non-Self Destruction” policy, revealed, “... Restraints... All manual, physical, mechanical and material devices used to involuntarily limit freedom of movement, immobilize, or reduce the ability of a patient to move his/her arms. Legs. Body, or head freely... The registered nurse (RN) will initiate restraint use based on appropriate assessment of the patient... Each episode of restraint... requires an order by the provider... If the provider responsible is not available to initiate the order, qualified staff will initiate restraints based on assessment but notifies the provider as soon as possible, to obtain a telephone or verbal order... A renewal order is obtained within one (1) calendar day and justification of need to continue/discontinue the restraint documented in the medical record, as well as the patient’s response to less restrictive measures...” 2. Medical record review revealed Patient #2 was admitted on 8/15/2024 with a diagnosis of Altered Mental Status. Review of the internal medicine note dated 8/29/2024 at 7:00 AM, revealed, “...Medically ready for discharge, pending SNF [Skilled Nursing Facility]...Has been out of restraints for several days, not needed to reorder restraints. Mittens [hand restraint which hinders the patient from picking or pulling] only in place for patient protection. Additionally, has only required Haldol 1-2x [times] per 24h [hour] to assist with restlessness during daytime. Plan for discharge today...Delirium precautions...” Review of the psychiatric progress note dated 8/29/2024 at 10:51 AM, revealed, “...Patient was seen and examined by the psychiatry team and attending physician this morning... He was A [Alert] & [and] O [Oriented] and could not identify a pen but was able to identify how many fingers we were holding. He was unable to answer direct questions. Patient received PRN [as needed] Haldol [an antipsychotic medication used to treat agitation and psychosis]. 8/28 [2024] afternoon and evening per nursing due to agitation and him attempting to get out of bed, He did not require restraints and is wearing mittens, At this point it appears patient’s agitation and fluctuating mental status is likely to delirium...” Review of the physician progress note dated 8/29/2024 at 5:47 PM, revealed “...Pt [Patient] is eating breakfast with the help of nursing staff this morning. In mittens, No Restraints... Assessment/Plan... Altered Mental Status... Orders... TeleSitter... Mental status improved with holding of psychiatric medications... Has been out of restraints for several days, but not needed to reorder restraints. Mittens only in place for patient protection... Medically ready for discharge, plan to dc [discharge] to SNF, avoid restraints as able, Delirium precautions...” Review of the Nursing Narrative Note dated 8/29/2024 at 6:26 PM, revealed, “...Handoff from ongoing nurse, advised by staff nurse patient’s daughter took mittens off and applied restraints to BIL [bilateral] UE [Upper Extremities]. Restraints removed and mittens reapplied to BIL UE. Patient tolerated well...” There were no physician’s orders noted for the application and use of mittens for Patient #2. In an email dated 1/29/2025 at 1:35 PM, the Interim Director of Quality was asked if mittens were considered a form of restraints. In an email received on 1/30/2025 at 9:53 AM the Interim Director of Quality replied, “...Yes...” and verified mittens were a form of restraint. 3. Medical record review for Patient #4 revealed an admission date of 11/13/2024 with diagnoses which included Right Humeral Neck Fracture with Dislocation, Left Inferior Pubic Ramus/Posterior, Acetabulum Fracture, Bilateral Sacral Wing Fracture, Left Rib Fracture, Right Frontal Subarachnoid Hemorrhage and Right Transverse Processes of the Lower Lumbar #3, #4, and #5. Review of the physician orders dated 11/19/2024 at 8:00 AM revealed an order for Non-Violent bilateral wrist restraints for the dislodgement of life saving equipment. There was no documentation the order for bilateral wrist restraints was renewed on 11/20/2024 per facility policy. Review of the nursing flowsheets dated 11/20/2024 through 11/21/2024 revealed Patient #4 was in bilateral wrist restraints without a physician’s order from 10:00 AM on 11/20/2024 until 6:00 AM on 11/21/2024, a total of 22 hours.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 50767 Based on policy review, medical record review, and interview, the facility failed to ensure Nursing Services provided oversight and supervision to ensure patients were appropriately assessed and met eligibility criteria for use of the Telesitter (camera-based system that monitors patients in their rooms and alerts staff to concerns or emergencies) for 5 of 7 (Patient #2, #4, #6, #7, and #8) sampled patients, and failed to ensure Nursing Services provided adequate oversight and supervision to ensure wound assessments and interventions to treat wounds were completed and accurately documented per facility policy for 2 of 2 (Patient #1 and #2) sampled patients with pressure injuries. The findings included: 1. Review of the hospital’s “Telesitter/Continuous Video Monitoring (CVM) policy revised on 4/17/2024, revealed, “...The following terms shall have the meanings set forth below when used in this policy: Continuous Video Monitoring: A video monitoring system allows patients with safety risks to be monitored from a separate location contained on-site within the facility. The video monitoring system allows the monitor technician to speak to the patient directly. The monitor technician can contact staff members to respond to the patient if necessary. Monitor Technician: A qualified individual who monitors patient activity through a continuous video monitoring system. One-to-One Continuous Observation: In-person continuous, unobstructed observation of patients who are assessed as high risk for self-harm, harm to others, and any other behaviors that warrant this intense level of observation. Constant Observer: Staff that provides continuous in-person observation and visualization of the patient to ensure safety...This policy will outline the process for the Tele-sitter/Continuous Monitoring Program implementation and management. [Hospital #1] directs efforts in providing a safe environment that is least restrictive and free from harm for our patients, unless their safety or the safety of others is in jeopardy. The use of CVM [Continuous Video Monitoring] is on a continuum of least restrictive methods. The use of CVM requires utilization of the least restrictive guidelines based on clinical assessment by the provider. Patient and or support person is documented according to the patient’s individualized plan of care...Inclusion criteria: For patients requiring a sitter for safety, CVM appropriate as the initial intervention and is implemented per the CVM Physician Order. CVM patients meeting exclusion criteria in the first 24 hours will be placed on one-to-one continuous observation per physician order. Safety Considerations: Cognitive impairment/confusion, and able to follow commands...Safety concerns (examples: forgets limitations, but not limited to)...High risk of falls/injury as identified by fall risk scale (Morse Fall scale >[greater than] 45)...Suicidal (Low risk only) PER Columbia Suicide Severity Rating Scale...Homicidal...Under law enforcement custody (Forensic Patients)...Alcohol Withdrawal and able to follow commands ...Exclusion criteria: If patient exhibits any exclusion criteria in the first 24 hours of CVM, the house supervisor is notified of the need to transition patient to a constant observer. Patient remains on CVM until constant observer is available...Physical restraints...unable to follow commands...Traumatic Brain Injury...Registered Nurse Responsibilities: Registered Nurses notify the provider, obtain an order, and place patients requiring monitoring for safety on CVM...Registered Nurses reassess appropriateness using inclusion and exclusion criteria and notify the provider if the patient needs change...Conducts CVM education with patient and or support persons to promote patient safety...Post CVM signage on the camera cart and the patient’s door...Assesses the need for CVM every shift (12 hours) and document patient utilization of CVM EHR [electronic health record] every 12 shift (12 hours)...Inform patient/family when CVM is discontinued when applicable...Monitor Technician Responsibilities: Documents initiation of CVM on the Monitor Tech Log including the patient name, unit and reason for CVM...Verbally redirect patients...Notifies the nursing unit when issues arise requiring staff intervention (e.g.[for example] patient leaves zone, attempting to get out of bed, and needs to be redirected)...Documents...Patient activities, Any verbal patient cueing and Notification to the nursing unit ...Completes Documentation...” Review of the hospital’s “Patient Rights & [and] Responsibilities” policy revised on 3/27/2018, revealed, “...[Hospital #1] will respect the rights and responsibilities of patients, families, and surrogates...Considerate and respectful care in a safe environment...An environment that preserves dignity and contributes to a positive self-image...Provide information about healthcare for patients with...cognitive impairments in a manner that meets the patient’s needs...Make decisions about the plan of care prior to and during the course of treatment...” 2. Medical record review for Patient #2 revealed an admission date of 8/15/2024 with diagnoses which Altered Mental Status, Acute Encephalopathy and a Sacral Wound. Review of the physician’s order dated 8/23/2024 at 6:13 AM, revealed, “...Constant [continuous] order, Delirium precautions. Lights on during the daytime 8:00 AM - 8:00 PM lights off at night. Minimize disruptions at night as able, frequent reorientating...” Review of a psychiatric progress note dated 8/29/2024 at 10:51 AM, revealed, “...Patient was seen and examined by the psychiatry team and attending physician this morning...He was A [Alert] & [and] O [Oriented] and could not identify a pen but was able to identify how many fingers and we were holding. He was unable to answer direct questions. Patient received PRN [as needed] Haldol 8/28 [2024] afternoon and evening per nursing due to agitation and him attempting to get out of bed, He did not require restraints and is wearing mittens [hand restraint which hinders the patient from picking or pulling]...At this point it appears patient’s agitation and fluctuating mental status is likely to delirium...Please sit patient up in bed, interact, use glasses during the day time; appreciate nursing’s efforts to help with this complex patient...Continue Haldol 1 mg [milligram] PRN for agitation...Cognition: moderate to significant deficits...Insight/Judgement” poor/poor...” Review of the physician’s orders dated 8/29/2024 at 5:40 PM, revealed an order for a TeleSitter with a stop date of 8/30/2024 at 5:24PM. Review of a physician’s progress note dated 8/29/2024 at 5:47 PM, revealed, “...Pt [Patient] is eating breakfast with the help of nursing staff this morning. In mittens, No Restraints... Assessment/Plan...Altered Mental Status...Orders...TeleSitter...Mental status not improved with holding of psychiatric medications...Has been out of restraints for several days, but not needed to reorder restraints. Mittens only in place for patient protection...Medically ready for discharge, plan to dc [discharge] to SNF [Skilled Nursing Facility], avoid restraints as able, Delirium precautions...” Review of a nursing narrative note dated 8/29/2024 at 7:21 PM, revealed “...Tele-sitter initiated at 6:00 PM. [Patient #2] climbing out of bed and unable to be re-directed. Notified [Physician #1] with Med team C [Medical Provider Team]. Per [Physician #1] will order Haldol and continue with tele-sitter for now. If [Patient #2] continues to be unable to re-direct, please notify me and we will proceed from there. [Nightshift RN #3] notified during handoff...” Review of the monitoring technician (tech) log revealed an onboarding (start) time of 8/29/2024 at 6:02 PM and an offboarding (end) time of 8/30/2024 at 5:55 PM. On 8/29/2024 action was taken at 6:21PM, 6:29 PM, 6:33 PM, 7:49 PM, 8:03 PM, and 11:30 PM for Patient #2 trying to get out of bed/chair and the stat button (button used by staff for urgent assistance) was pushed twice at 6:21PM and 6:29 PM. On 8/30/2024 action was taken at 8:24 AM, 8:25 AM, 8:26 AM and 8:31 AM for Patient #2 trying to get out of bed/chair. There was no documentation Patient #2 was reassessed to determine eligibility for the Telesitter every 12 hours per policy. Nursing staff failed to identify Patient #2 did not meet eligibility criteria for the Telesitter as he was unable to follow commands, not easily redirected, and required the use of mitten restraints to prevent him from pulling out his IV lines. There was no documentation nursing staff provided the patient and/or support persons education regarding the use of the Telesitter, and no documentation the Patient’s support persons where notified when the CVM was discontinued. 3. Medical record review for Patient #4 revealed as admission date of 11/13/2024 with diagnoses which included Right Humeral Neck Fracture with Dislocation, Left Inferior Pubic Ramus/Posterior, Acetabulum Fracture, Bilateral Sacral Wing Fracture, Left Rib Fracture, Right Frontal Subarachnoid Hemorrhage and Right Transverse Processes of the Lower Lumbar #3, #4, and #5. Review of the nursing flowsheet dated 12/1/2024 revealed, “...Morse Fall Score [tool used in hospitals to assess a patient’s risk of falling; total score of 0 indicates no risk for falls, less than 25 indicates low risk of falls, 25-45 indicates moderate risk of falls, and greater than 45 indicates a high risk of falls]...50...” Review of the physician’s order dated 12/1/2024 at 5:18 PM revealed an order for a Telesitter with a stop date of 12/1/2024 at 5:18 PM, the same time the order was written. Review of the monitoring tech log for Patient #4 revealed the onboarding date and time of 12/1/2024 at 7:26 PM and an offboarding date and time of 12/2/2024 at 6:06 PM. The log revealed as second onboarding date and time of 12/2/2024 at 6:07 PM and an offboarding date and time of 12/10/2024 at 5:43 PM. Review of the Camera Check In and Out (the sign out sheet for a camera which recorded the time taken from the holding area to the patient room and the time the camera is removed from the patient’s room) for Patient #4 revealed, a check out date of 12/1/2024 at 7:40 PM. There was no check in time documented. There was no documentation Patient #4 was reassessed to determine eligibility for the Telesitter every 12 hours per policy. There was no documentation nursing staff provided the patient and/or support persons education regarding the use of the Telesitter, and no documentation the Patient’s support persons where notified when the CVM was discontinued. 4. Medical record review for Patient #5 revealed an admission date to the inpatient rehabilitation unit on 11/30/2024 with diagnoses which included Status Post Subdural Hematoma, Acute Stroke due to Ischemia, Atrial Fibrillation and Impaired Mobility and Activities of Daily Living. Review of the History and Physical revealed, “...Once they [Patient #5] were deemed stable, they were seen and evaluate [evaluated] acute care therapy and based on their therapy assessment they [Patient #5] were referred to inpatient rehabilitation as they were functioning below their baseline. It was felt that they would benefit from a multidisciplinary approach in the inpatient rehab setting to receive intensive therapy services to increase their independence and promote performance of ADLs [Activities of Daily Living] and functional ability to safely discharge home and back to the community...” Review of the nursing flowsheet dated 12/2/2024 at 7:00 AM, revealed, “...Morse Fall Score 85...” Review of the physician orders dated 12/2/2024 at 12:54 PM, revealed a constant order for the Telesitter. Review of the monitoring tech log revealed an onboarding date and time of 12/1/2024 at 7:21 PM and an offboarding date and time of 12/10/2024 at 2:35 PM. Review of the camera check in and out log revealed a checking out date of 12/1/2024 with a checking in date of 12/10/2024. There was no physician’s order to discontinue the Telesitter. There was no documentation nursing staff provided the patient and/or support persons education regarding the use of the Telesitter, and no documentation the Patient’s support persons where notified when the CVM was discontinued. 5. Medical record review for Patient #6 revealed an admission date of 11/9/2024 with diagnoses which included large Subdural Hemorrhage (A subdural hematoma is bleeding in the brain usually caused by a traumatic brain injury). Patient #6 underwent an emergent Craniotomy Decompression and was admitted to the Trauma Intensive Care Unit. Review of the physician orders dated 12/2/2024 at 6:40 PM, revealed Telesitter, with a Stop date of 12/2/2024 at 6:40 PM, the same time the order was written. Review of the monitoring tech log revealed an onboarding date and time of 12/2/2024 at 6:30 PM and an offboarding date and time of 12/5/2024 at 1:14 AM. Review of the camera in and out log for Patient #6 revealed a checking out date of 12/2/2024 at 6:30 PM and a checking in date of 12/5/2024. at 1:14 AM. Review of the nursing flowsheet dated 12/2/2024 at 4:00 PM, revealed, “...Level of Consciousness-Obtunded [state of reduced consciousness]...” Review of the nursing flowsheet dated 12/2/2024 at 6:18 PM, revealed, “...Characteristics of Communication-No communication intent [a mental state that represents a person’s commitment to doing something in the future]...” Review of the nursing flowsheet dated 12/2/2024 at 8:00 PM, revealed, “...Mobility Braden-Completely immobile...Activity Braden-Bedfast...Characteristics of Communication-No communication intent...Safety/Judgement-Unable to use call light...Ability to Pay Attention-Unable to focus...Cognition-Impaired cognition ...Ability to follow commands-Unable to follow direct command...Morse Fall Score-75...Orientation Assessment-Disoriented x 4 [disoriented to person, place, time, and event]...Side Rail Location-Upper x 2, Lower right...” Review of the nursing flowsheet dated 12/3/2024 at 8:00 AM, revealed, “...Problem Solving-Unable to solve basic daily task problems...Yes/No Reliability-Unable to test...Activity Braden-Bedfast...Mobility Braden-Completely immobile...Characteristics assess...Level of Consciousness-Obtunded...Safety/Judgement-Unable to use call light...Ability to Pay Attention-Unable to focus...Cognition-Impaired cognition...Ability to follow commands-Able to follow single command...Mental status Fall Risk Morse-Forgets limitations...Morse Fall Score-75...Orientation Assessment-Disoriented x 4...” Review of the nursing flowsheet dated 12/3/2024 at 8:00 PM, revealed, “...Problem Solving-Unable to solve basic daily task problems...Yes/No Reliability-Unable to test...Activity Braden-Bedfast ...Mobility Braden-Completely immobile ...Characteristics of Communication-No communication intent...Level of Consciousness-Stuporous [a state of extreme unresponsiveness where a person can only be briefly aroused by intense stimulation like loud noises] ...Safety/Judgement-Unable to use call light...Ability to Pay Attention-Unable to focus...Cognition-Impaired cognition...Ability to follow commands-Unable to follow direct command...Mental status Fall Risk Morse-Forgets limitations...Morse Fall Score-75...Orientation Assessment-Disoriented x 4...” Review of the nursing flowsheet dated 12/3/2024 at 10:00 PM, revealed, “...Level of Consciousness-Stuporous...” Review of the nursing flowsheet dated 12/4/2024 at 2:00 AM, revealed, “...Level of Consciousness-Stuporous...” Review of the nursing flowsheet dated 12/4/2024 at 4:00 AM, revealed, “...Level of Consciousness-Stuporous...” Review of the nursing flowsheet dated 12/4/2024 at 8:00 AM, revealed, “...Problem Solving-Unable to solve basic daily task problems...Yes/No Reliability-Unable to test...Activity Braden-Bedfast...Mobility Braden-Completely immobile...Characteristics of Communication-No communication intent...Level of Consciousness-Obtunded...Safety/Judgement-Unable to use call light...Ability to Pay Attention-Unable to focus...Cognition-Impaired cognition...Ability to follow commands-Unable to follow direct command...Mental status Fall Risk Morse-Forgets limitations...Morse Fall Score-75...Orientation Assessment-Disoriented x 4...” Review of the nursing flowsheet dated 12/4/2024 at 9:00 AM, revealed, “...Level of Consciousness-Stuporous...” Review of the nursing flowsheet dated 12/4/2024 at 10:25 AM, revealed, “...Pain Inability to Self-Report-18 years or older, FLACC [Face, Legs, Activity, Cry, Consolability] FLACC score-1 [behavioral pain assessment tool used to evaulate pain in children and nonverbal adults who are unable to communicate their pain; total score of 0-3 indicates mild pain, 4-6 indicates moderate pain, and 7-10 indicates severe pain)...Safety/Judgement-Unable to use call light...Behavior-Passive...Orientation Assessment-Disoriented x 4...” Review of the nursing flowsheet dated 12/4/2024 at 11:00 AM, revealed, “...Level of Consciousness-Stuporous...” Review of the nursing flowsheet dated 12/4/2024 at 12:00 PM, revealed, “...Level of Consciousness-Alert...” Review of the nursing flowsheet dated 12/4/2024 at 1:00 PM, revealed, “...Level of Consciousness-Stuporous...” Review of the nursing flowsheet dated 12/4/2024 at 3:00 PM, revealed, “...Level of Consciousness-Stuporous...” Review of the nursing flowsheet dated 12/4/2024 at 5:00 PM, revealed, “...Level of Consciousness-Stuporous...” There was no documentation Patient #6 was reassessed to determine eligibility for the Telesitter every 12 hours per policy. Nursing staff failed to identify Patient #6 did not meet eligibility criteria for the Telesitter as the Patient had impaired cognition from a traumatic brain injury, was unable to follow commands and required the use of restraints to prevent pulling out lines and medical devices. There was no documentation nursing staff provided the patient and/or support persons education regarding the use of the Telesitter, and no documentation the Patient’s support persons where notified when the CVM was discontinued. 6. Medical record review for Patient #7 revealed an admission date of 11/21/2024 with diagnosis of a Post-operative Infection of the Left Knee. Review of the physician orders dated 11/22/2024 at 10:23 AM, revealed a constant order for a Telesitter. Review of the monitoring tech log revealed an onboarding date and time of 11/22/2024 at 12:22 PM and an offboarding date and time of 12/11/2024 at 1:56 PM. Review of the camera in and out log revealed the checking out date and time of 11/22/2024 at 7:00 PM and a checking in date and time of 12/11/2024 at 1:51 PM. There were no physician’s orders to discontinue the Telesitter. There was no documentation nursing staff provided the patient and/or support persons education regarding the use of the Telesitter, and no documentation the Patient’s support persons where notified when the CVM was discontinued. 7. Medical record review for Patient #8 revealed an admission date of 10/22/2024 with diagnoses which included Pneumocephalus, Idiopathic Pulmonary Hemosiderosis, Subarachnoid Hemorrhage, Subdural Hematoma, Impending Herniation, Left Vertebral Artery Injury at the Cervical 6th fracture, Left Internal Carotid Artery Intimal Injury, Bilaterial Frontal, Parietal, Temporal, Skull Base Fracture, Sphenoid Fracture, Left Occipital Condyle Fracture, LeFort I, + II, Right LeFort III, Right Zygomaticomaxillary Complex Fracture, Nasal Bone + Septum Fracture, Middle Mandible Fracture, Transverse Process Fracture, Thoracic 1 Vertebra Fracture, and Distal Radius Fracture. Review of the physician’s order dated 12/2/2024 at 8:00 AM, revealed an order for Bilateral wrist restraints for dislodgement of life saving equipment valid for 1 calendar day. Review of the physician’s order dated 12/2/2024 at 6:39 PM revealed an order for a Telesitter with a stop date of12/2/2024 at 6:39 PM, the same date and time the order was written. Review of the monitoring tech log revealed an onboarding date and time of 12/2/2024 at 6:47 PM and an offboarding date and time of 12/4/2023 at 5:47 PM. Review of the camera in and out log revealed a checking out date and time of 12/2/2024 at 6:30 PM and a checking in date and time of 12/4/2024 at 5:51 PM. Review of the nursing flowsheet dated 12/2/2024 at 8:00 AM revealed, “...Morse Fall Score of 60...” Review of the nursing flowsheet dated 12/2/2024 at 8:00 PM revealed, “...Activity Braden...Bedfast...Mobility...Very Limited...Characteristics of Communication...No communication intent...Characteristics of Speech...Vented, can’t speak...Characteristics of Verbal Expression...Unable to assess...Level of Consciousness...Alert...Change in Mental Status...Uncertain...Level of Consciousness AVPU [Alert, Verbal, Pain, Unresponsive; a scale used to assess a patient’s level of consciousness]...Responds to verbal stimuli...Characteristics of Comprehension...Unable to assess...Cognition...Impaired cognition...Unable to follow direct command...Mental Status Fall Risk Morse...Forgets limitations...Morse Fall Score...60...” Review of the physician’s order dated 12/3/2024 at 7:00 AM, revealed an order for Bilateral wrist restraints for dislodgement of life saving equipment valid for 1 calendar day. Review of the nursing flowsheet dated 12/3/2024 at 8:00 AM, revealed, “...Problem Solving...Unable to solve basic daily task problems...Inconsistently reliable...No communication intent...No vocalization...Level of Consciousness...Alert...Change in Mental Status...Uncertain...Characteristics of Comprehension...Unable to Assess...Cognition...Impaired Cognition...Unable to follow direct command...Morse Fall Score...60...” Review of the nursing flowsheet dated 12/3/2024 at 3:00 PM, revealed, “...Restraint Activity Type (Left, Wrist]...Assessment...Release Criteria for Restraint: (Left, Wrist)...Decreased patient safety risk, Decreased interference with...Evaluation of Status on Restraints: (Left, Wrist)...Restraint applied properly, No evidence of adverse effect...” Review of the nursing flowsheet dated 12/3/2024 at 8:00 PM, revealed, “...Characteristics or Communication...Expressive language difficulty...Level of Consciousness...Alert...Safety/Judgement...Unable to remember safety instructions...Ability to Pay Attention...Unable to Focus...Characteristics of Comprehension...Unable to assess...Cognition...Impaired cognition...Ability to follow commands...Unable to follow direct command...Orientation Assessment...Disoriented x 4...Restraint Initiation Behavior Reason...Attempted/successful. Climbing, Pulling at tubes and lines...Restraints Episodes Activity Type...Continue episode...Restraints DC [discontinue] Readiness Attempts...Enhanced observation...Restraints Activity Type: (Left, Wrist)...Restraint applied properly, No evidence of adverse effect...Release Criteria for Restraints (Left, Wrist)...Decreased safety risk, Decreased interference with...Evaluation of Status in Restraints: (Left, Wrist)...Restraints applied properly, No evidence of adverse effect...Restraint Reason for Release (Left, Wrist)...Range of motion, Receiving care/treatment...Restraint ROM [Range of Motion] (Left, Wrist)...Active range of motion...Restraint Nutrition/Hydration (Left, Wrist)...Tube feeding...Restraint Elimination (Left, Wrist)...Incontinent...Restraint Hygiene (Left, Wrist)...Oral Care...Patient Safety Attendant Criteria...Fall risk: patient does NOT respond to other interventions...Patient Specific Safety Measures...tele sitter...” Review of the nursing flowsheet dated 12/3/2024 at 10:00 PM, revealed, “...Restraint Initiation Behavior Reason...Attempted/successful. Climbing, Pulling at tubes and lines...Restraints Episodes Activity Type...Continue episode...Restraints DC...Readiness Attempts...Diversional Activities...Release Criteria for Restraints (Left, Wrist)...Decreased safety risk, Decreased interference with...Evaluation of Status in Restraints: (Left, Wrist)...Restraints applied properly, No evidence of adverse effect...Restraint Reason for Release (Left, Wrist)...Sleeping, Restful...Restraint ROM [Range of Motion] (Left, Wrist)...Passive range of motion...Restraint Nutrition/Hydration (Left, Wrist)...Tube feeding...Restraint Elimination (Left, Wrist)...Incontinent...Restraint Hygiene (Left, Wrist)...Oral Care...” Review of the nursing flowsheet dated 12/4/2024 at 12:00 AM, revealed, “...Restraint Initiation Behavior Reason...Attempted/successful. Climbing, Pulling at tubes and lines...Restraints Episodes Activity Type...Continue episode...Restraints DC...Readiness Attempts...Diversional activities...) Restraint Activity Type (Left, Wrist)...Assessment...Release Criteria for Restraints (Left, Wrist)...Decreased safety risk, Decreased interference with...Evaluation of Status in Restraints: (Left, Wrist)...Restraints applied properly, No evidence of adverse effect...Restraint Reason for Release (Left, Wrist)...Sleeping, Restful...Restraint ROM [Range of Motion] (Left, Wrist)...Passive range of motion...Restraint Nutrition/Hydration (Left, Wrist)...Tube feeding...Restraint Elimination (Left, Wrist)...Incontinent...Restraint Hygiene (Left, Wrist)...Oral Care...” Review of the nursing flowsheet dated 12/4/2024 at 2:00 AM, revealed, “...Restraint Initiation Behavior Reason...Attempted/successful. Climbing, Pulling at tubes and lines...Restraints Episodes Activity Type...Continue episode...Restraints DC...Readiness Attempts...Negotiation...Restraint Activity Type (Left, Wrist)...Assessment...Release Criteria for Restraints (Left, Wrist)...Decreased safety risk, Decreased interference with...Evaluation of Status in Restraints: (Left, Wrist)...Restraints applied properly, No evidence of adverse effect...Restraint Reason for Release (Left, Wrist)...Range of motion...Restraint ROM [Range of Motion] (Left, Wrist)...Active range of motion...Restraint Nutrition/Hydration (Left, Wrist)...Tube feeding...Restraint Elimination (Left, Wrist)...Incontinent...Restraint Hygiene (Left, Wrist)...Oral Care...” Review of the nursing flowsheet dated 12/4/2024 at 4:00 AM, revealed, “...Restraint Initiation Behavior Reason...Attempted/successful. Climbing, Pulling at tubes and lines...Restraints Episodes Activity Type...Continue episode...Restraints DC...Readiness Attempts...Reality orientation...Restraint Activity Type (Left, Wrist)...Assessment...Release Criteria for Restraints (Left, Wrist)...Decreased patient safety risk, Decreased interference with...Evaluation of Status in Restraints: (Left, Wrist)...Restraints applied properly, No evidence of adverse effect...Restraint reason for Release (Left Wrist)...Range of motion...Restraint ROM [Range of Motion] (Left, Wrist)...Passive range of motion...Restraint Nutrition/Hydration (Left, Wrist)...Tube feeding...Restraint Elimination (Left, Wrist)...Incontinent...Restraint Hygiene (Left, Wrist)...Oral Care...” Review of the nursing flowsheet dated 12/4/2024 at 6:00 AM, revealed, “...Restraint Initiation Behavior Reason-Attempted/successful. Climbing, Pulling at tubes and lines...Restraints Episodes Activity Type-Continue episode ..Restraints DC...Readiness Attempts-Diversional Activities...Restraint Activity Type (Left, Wrist)-Assessment...Release Criteria for Restraints (Left, Wrist)-Decreased safety risk, Decreased interference with...Evaluation of Status in Restraints: (Left, Wrist)-Restraints applied properly, No evidence of adverse effect...Restraint Reason for Release (Left, Wrist)-Range of motion, Receiving care/treatment...Restraint ROM [Range of Motion] (Left, Wrist)-Passive range of motion...Restraint Nutrition/Hydration (Left, Wrist)-Tube feeding...Restraint Elimination (Left, Wrist)-Incontinent...Restraint Hygiene (Left, Wrist)-Oral Care...” Review of the nursing flowsheet dated 12/4/2024 at 8:00 AM, revealed, “...Characteristics of Communication...Appropriate for developmental age...Safety/Judgement-Unable to remember safety instructions...Ability to Pay Attention-Unable to focus...Change in Mental Status-Uncertain...Cognition-Impaired cognition...Ability to Follow Commands...Slowed complex command response...Morse Fall Score-75...Orientation Assessment-Disoriented x 4...Restraint Response to Alternatives-Behavior decreased...” Review of the nursing flowsheet dated 12/4/2024, revealed, “...Level of Consciousness-Obtunded...” Review of the nursing flowsheet dated 12/4/2024 at 10:00 AM, revealed, “...Level of Consciousness-Obtunded...” Review of the nursing flowsheet dated 12/4/2023 at 11:00 AM, revealed, “...Level of Consciousness-Obtunded...” Review of the nursing flowsheet dated 12/4/2023 at 1:00 PM, revealed, “...Level of Consciousness-Obtunded...” Review of the nursing flowsheet dated 12/4/2023 at 3:00 PM, revealed, “...Level of Consciousness-Obtunded...” There was no documentation Patient #8 was reassessed to determine eligibility for the Telesitter every 12 hours per policy. Nursing staff failed to identify Patient #8 did not meet eligibility criteria for the Telesitter as the Patient required bilateral wrist restraints to prevent dislodging of life saving equipment. There was no documentation nursing staff provided the patient and/or support persons education regarding the use of the Telesitter, and no documentation the Patient’s support persons where notified when the CVM was discontinued. 8. In an interview on 1/16/2025 at 12:11 PM, the Interim Director of Quality (IDQ), the Vice President of Nursing (VPN), the Director of Risk Management DRM, the Director of Nursing Medical Services (DON), and the Vice President of Patient Care (VPPC) were asked to describe the purpose of the Telesitter program. The IDQ, VPN, DRM, DON, and VPPC stated, “ ...It [Telesitter] started about 3 years ago to prevent patient harm...It’s just like having a sitter in the room except the sitter is in a different location...” The IDQ, VPN, DRM, DON, and VPPC were asked if staff should document the reason the Telesitter was in use. The IDQ, VPN, DRM, DON, and VPPC stated, “...yes...” The IDQ, VPN, DRM, DON, and VPPC were asked if the nurse reassess the patient every shift to see if they still required the Telesitter. The IDQ, VPN, DRM, DON, and VPPC stated, “...Yes...” The IDQ, VPN, DRM, DON, and VPPC stated the assessment she be documented on the nurse’s flowsheet. “under the Neuro assessment focusing on their cognitive status and the patients should be able to be easily directed. We use the Telesitter for our High Risk falls if they have a Morse Fall Score of greater than 45...” In an email dated 1/30/2025 at 10:19 AM, the surveyor asked the Interim Director of Quality was asked if an order contained a stop date and time, did that mean the order was stopped at that date and time. In an email response received on 1/30/2025 at 11:23 AM, the Interim Director of Quality replied, “...Please see the DON response below: The EMR [Electronic Medical Record] system is programmed to automatically stop certain orders once the related task is marked as completed. For this specific order[Telesitter] when it is marked as completed in the system, the order will be stopped immediately, without waiting for the scheduled stop time. This automatic stopping process is different from discontinuing an order...” 9. Review of the hospital’s “Prevention and Treatment for Skin Integrity” policy revised on 11/17/2021, revealed, “...Pressure Injury Treatment Pathway: Patients with impaired skin or suspected pressure injury...Collaborate with Provider...Consult WOCN [Wound, Ostomy, Continence Nurse], Consult Medical Nutrition Therapy, and Initiate Pressure Injury Order Set if pressure injury present or suspected...Wound, Ostomy, and Continence Nurse...may be consulted by a Provider or Nurse for...Pressure injuries (decubitus ulcers, pressure ulcers, and bed sores)...The Provider is responsible for recommendations of a wound, ostomy, and continence care in the absence of the WOCN...The Provider or nurse orders follow-up per consult to the WOCN for continued care and treatment plan evaluation...When a consult for WOCN is initiated, the consult order includes location and a brief description of the site needing evaluation and treatment...Assessments/Interventions...Nurse ...Assesses and documents the skin and Braden Assessment scale...within 24 hours of admission and daily after that...Implements a patient-specific plan of care Notifies the Provider for impaired skin integrity...Consults WOCN for impaired skin integrity...Provider or WOCN...Completes staging of pressure injuries...Completes the assessment and documentation of bruising and erythema...Measures the wound as needed...” Review of the facility’s “Guidelines: Prevention and Treatment for Skin Integrity” policy reviewed on 7/27/2022, revealed, “...Pressure Injury (Staged per National Pressure Ulcer Advisory Panel Guidelines): Pressure injury: localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can be present as intact skin or an open ulcer and may be painful...Pressure Injury Prevention Guidelines...Expected Outcomes: Patients receive preventative measures to decrease the risk of development of pressure injury...Assessment/Interventions...1. Assess and document the skin and the Braden Assessment scale with 24 hours of admission and minimally daily thereafter 2. Implement the following interventions if not contraindicated for patients with a Braden Score of 16 or less...Follow...Implement patient-specific plan of care and review with patient and/or family...Assessments/Interventions...Assesses and documents the skin and the Braden Assessment scale within 24 hours of admission and daily after that ...Implements a patient-specific plan of care...Notifies the Provider for impaired skin integrity...Consults WOCN for impaired skin integrity...Assess and document pressure injuries with each dressing change and/or at least once per shift unless treatment orders contraindicate. Documentation will include location, approximate size, drainage (amount, color, odor), undermining, tunneling, character of wound, status of tissue surrounding the wound, stage (after completion by Provider or WOCN) dressing and pain...Place the patient on the appropriate pressure re-distribution support surface per the Support Surface Algorithm...Utilize pressure Injury Prevention Guidelines to control risk of additional pressure injury...Nurse updates and reviews plan of care with patient and /or family...” 10. Medical record review for Patient #1 revealed an admission date of 8/29/2024 with diagnoses which included Acute Hypotension, Cellulitis, Pressure Ulcers, Septic Shock, Chronic Hypoxic Respiratory Failure, Sleep Apnea, Asthma, and Morbid Obesity. Review of the Emergency Department (ED) Note Physician dated 8/29/2024, revealed, “...History of Present Illness...The patient presents with abscess and infestation, The onset was just prior to arrival. The course/duration of symptoms is improving. Location: back. The character of symptoms is pain, swelling and oozing... Patient...endorses pain as well as malodorous discharge...Wound images were uploaded into the clinical media tab. large areas of cellulitis with induration and skin breakdown. No obvious fluctuance...” Review of the physician’s orders dated 8/29/2024 at 10:37 PM, revealed wound care was to be completed every 24 hours. Review of the Consultation Physician Note dated 8/30/2024, documented, “...Over the last 2-3 weeks, his family has noticed increased drainage from wound on his back. They are unable to turn him regularly to check/clean his wounds. A few days ago, he started to have sharp pains in the area of the left shoulder blade...In the ED...Wounds were evaluated by surgery who found induration [a process that causes soft tissue, particularly skin, to thicken and harden] of lateral and posterior left axilla and weeping shallow ulcerations of left back...Assessment/Plan...presented for back pain related to pressure wounds on his left back. Patient requires ICU [Intensive Care Unit] level for management of septic shock likely due to wound infection...Clinical suspicion for osteomyelitis due to excessive tissue between wound and bones...” Review of the physician’s order dated 8/30/2024 at 5:44 AM, revealed a consult for the Wound/Ostomy/Continence Specialist to evaluate and treat the Patient’s open wound on the left back from the shoulder to sacrum, cellulitis of legs bilaterally, and a skin tear to the sacrum. Review of the physician’s order dated 8/30/2024 at 11:04 AM, revealed wound care to be completed twice a day. Review of the wound images that were uploaded into the clinical media tab revealed the following: 8/29/2024 and 8/30/24 - images of a foot with no description of the problem or side of the body documented. 9/2/204 - 2 separate images of wounds; neither of the wounds were labeled to indicate the locations and/or stages of the wounds. 9/30/2024 - 9 separate images of wounds; none of the wounds were labeled to indicate the locations and/or stages of the wounds. Review of the physician’s orders dated 8/30/2024 at 11:04 AM, revealed an order for the Wound/Ostomy/Continence Specialist to follow up in the AM to evaluate and treat an unstageable wound on the Patient’s left upper back and an unstageable wound on the Patient’s left flank. Wound care was ordered which included cleaning with antiseptic wound cleanser and apply honey gel wound dressings. Review of a Wound Care Progress notes dated 8/30/2024 at 11:04 AM, revealed, “...WOCN initial consult to eval [evaluate] and treat patient on arrival with pressure injuries to L [left] upper back and to L flank. Patient also has cellulitis to bilateral lower extremities with dry and flaking skin...Right upper back is unstageable, measuring 15 cm [centimeters] x [times] 5 cm, scattered, moist, pink, yellow with slough. Periwound excoriated and moist. No odor. Wound and periwound cleaned with vashe. Periwound dressed with zinc oxide. Wound bed dressed with therahoney, xeroform [contract layer in dressing wounds] bordered mepilex [to cover open wounds]...Right flank unstageable, measuring 12 cm x 6 cm, scattered, moist, pink and yellow with slough. Periwound excoriated and moist. No odor. Wound and periwound cleaned with vashe. Periwound dressed with zinc oxide. Wound bed dressed with therahoney, xeroform, bordered mepilex WOCN q [every] 2 [two] h [hours] repositioning with foam wedge. Patient is on an air mattress...WOCN will continue to monitor...” (The progress note contained conflicting information regarding the location of the Patient’s wounds, changing from left to right in the documentation). There was no documentation the WOCN identified, evaluated, and/or treated Patient #1’s sacral skin tear. Review of the Critical Care Progress Note dated 8/30/2024, revealed, “...Skin...pressure ulcers...cellulitis...consult wound care...[Named] emollient Tropical Cream...1 app [apply]...a day...theraHoney Gel...app...Topical BID [twice a day]...” Review of the nursing integumentary flowsheet for “Incision/Wound” dated 8/30/2024 through 9/1/2024, revealed, “Back Left Lumbar, Middle, Upper” wound and a sacral skin tear. The assessments did not indicate two separate pressure injuries on the Patient’s left back as documented by the WOCN on 8/30/2024. On 9/2/2024, the Patient’s sacral wound was changed from a “skin tear” to a “pressure injury.” There was no documentation the provider was notified and no documentation a patient specific care plan was developed with interventions to address the Patient’s sacral pressure injury. Nursing staff failed to document the location, approximate size, amount color and odor of drainage, undermining, tunneling, character of the wounds, status of tissue surrounding the wounds, dressing, pain and/or stage of the wounds with each dressing change per facility policy on any of the flowsheets from 8/30/2024 through 9/6/2024, when the Patient was discharged home. There was no documentation nursing staff identified and/or addressed the Patient’s Cellulitis and/or toenail fungus. In an email dated 1/2/2025 at 9:51 AM, the Interim Director of Quality was asked if each pressure injury should be documented separately. In an email response received on 1/30/2025 at 1:35 PM, the Interim Director of Quality verified staff should document each pressure injury separately. 11. Medical record review for Patient #2 revealed an admission date of 8/15/2024 with diagnoses which Altered Mental Status, Acute Encephalopathy and a Sacral Wound. Review of the wound care nursing progress note dated 8/16/2024 at 1:19 PM, revealed, “...Consulted to evaluate and treat: buttock...No wounds noted to buttocks. Patient has a healing stage 4 pressure injury to sacrum s [status]/p [post] multiple surgical debridement with pink wound...” Review of the physician’s orders dated 8/16/2024 at 1:27 PM, revealed, “Wound/Ostomy/Continence Specialist Follow Up...Pressure Ulcer, Wound location Sacrum stg4 [stage 4]...” Review of the physician’s orders dated 8/20/2024, revealed wound care to be completed twice a day. Review of the wound care nursing progress note dated 8/20/2024 at 7:55 AM, revealed, “...Follow up visit for stage 4 pressure injury to sacrococcyx area. Wound measures: 5 x 3 x 1cm with tunneling at 6:00 [oclock] approximately 4 cm. Wound is pink and mainly clean. Will began Vashe dressing changes bid...” (The pressure injury’s location was documented as the “sacrococcyx” area instead of the sacrum as documented by all other nurses and providers). Review of the nursing integumentary flowsheet for “Incision/Wound” dated 8/27/2024 at 11:15 PM, revealed, “...Sacrum...Skin Abnormality Type: Pressure Injury...Pressure Injury Stage: Stage 4...Incision, Wound Length: 5...Incision, Wound Width: 1.5...Incision, Wound Depth: 1.5...Wound Status: Recurrent/chronic...” Review of the physician’s orders dated 8/27/2024 at 1:03 PM, revealed, “Wound/Ostomy/Continence Specialist Follow Up...Pressure Ulcer, Wound location Sacrum stg4 [stage 4]...” Review of the nursing integumentary flowsheet for “Incision/Wound” dated 8/16/2024 through 9/5/2024, revealed Patient #2 had a sacral wound. Nursing staff failed to document the location, approximate size, amount color and odor of drainage, undermining, tunneling, character of the wound, status of tissue surrounding the wounds, dressing, pain and/or stage of the wound with each dressing change per facility policy. There was no documentation Patient #2’s family was instructed how to care for the Patient’s wound. In review of the medical records from 8/16/2024 through discharge on 9/5/2024, there was a Sacrum/wound/pressure injury documented in the wound care nursing progress notes in the “Incision/Wound” section under the Integumentary nursing flowsheet. There was not a patient-specific plan of care. The assessment and documentation of the Sacrum wound/ pressure injury did not include with each dressing change the following documentation: location, approximate size, drainage (amount, color, odor), undermining, tunneling, character of wound, status of tissue surrounding the wound, stage (after completion by Provider or WOCN [Wound, Ostomy, Continence Nurse] dressing and pain. There were no updates for the plan of care to education the family as there was no plan of care.”

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 50767 Based on policy review, medical record review, and interview, the hospital failed to ensure arrangements for post-hospital needs were completed prior to discharge for 1 of 3 [Patient #1] sampled patients reviewed for discharge. The findings included: 1. Review of the hospital’s “Discharge Planning” policy dated 5/9/2016, revealed, “...The purpose of discharge planning is to provide high-quality, cost-effective patient care which is timely, individualized, interdisciplinary and continuous. Patient and family preferences, as well as availability of resources are important factors in the planning process. The plan must take into consideration the medical, social and financial needs of the patient. Discharge planning is an interdisciplinary process, with each discipline playing an important role in provision of continuity of care...Discharge planning will begin on admission to identify the patient’s discharge needs and to assist the patient and/or family in arranging for those services to meet the needs...A referral is made to a Case Manager and/or Social Worker when indicated by the patient assessment/re-assessment data. The discharge plan will be established according to the patient’s health care needs and the patient/family’s informed decision about the plan. Referrals are forwarded to other disciplines, such as Physical Therapist, Nutritionist, Pharmacist and Chaplain when the patient’s discharge planning assessment indicates the need for the discipline’s qualified assessment and intervention. Each discipline will document assessments, re-assessments and interventions in the medical record...Discharge planning is considered an integral part of the total plan of care....Referrals may be made through a variety of methods...Social Work/Case Manager screening/case finding...Physician referral...Nursing referral...Referrals from other health care professionals...self-referral...Community referral...Referral from other hospital personnel...financial counselor...patient accounts...Case Management staff ensures appropriate communication with the attending physician/resident during the assessment, planning, and implementation process...Case Management and Social Worker will facilitate the required intervention from other disciplines...” 2. Medical record review for Patient #1 revealed an admission date of 8/29/2024 with diagnoses which included Acute Hypotension, Cellulitis, Pressure Ulcers, Septic Shock, Chronic Hypoxic Respiratory Failure, Sleep Apnea, Asthma, and Morbid Obesity. Review of the ED [Emergency Department] Note Physician dated 8/29/2024, revealed, “...History of Present Illness...The patient presents with abscess and infestation. The onset was just prior to arrival. The course/duration of symptoms is improving. Location: back. The character of symptoms is pain, swelling and oozing. The degree is moderate...Review of Systems...Skin Symptoms: No rash, no pruritus...Medical Decision Making...Patient...endorses pain as well as malodorous discharge...Wound images were uploaded into the clinical media tab. large areas of cellulitis with induration and skin breakdown. No obvious fluctuance...We were unable to get a CT [Computed Tomography] scan due to stated size. Ultrasound was unable to obtain due to his body habitus [physical build]...Radiology results: US [Ultrasound] Abdomen Limited...Impression: Due to body habitus and inability to roll on the side unable to obtain images visualizing fluid collection of concern...” Review of the History and Physical dated 8/29/2024, revealed, “...Home/Environment...Lives with children...Divorced...Living Situation Home with assistance...Oxygen, Walker Home equipment, home health Special Services & [and] Community Resources...Skin...pressure ulcers, cellulitis...Skin: dry skin with diffuse peeling, left back with shallow skin breakdown with area of bleeding and areas of purulence, fungal toenail growth...” Review of the physician’s orders dated 8/29/2024 at 11:00 PM, revealed wound care was to be completed every 24 hours. Review of the nursing flowsheet functional section dated 8/29/2024, revealed Patient #1 required “...Complete Assist...” from staff. Review of a Consultation Note dated 8/30/2024, revealed, “...Over the last 2-3 weeks, his family has noticed increased drainage from wound on his back. They are unable to turn him regularly to check/clean his wounds. A few days ago, he started to have sharp pains in the area of the left shoulder blade. Family was also concerned about some apparent hardening of the skin around his chest...In the ED...Wounds were evaluated by surgery who found induration of lateral and posterior left axilla and weeping shallow ulcerations of left back...Assessment/Plan...presented for back pain related to pressure wounds on his left back. Patient requires ICU [Intensive Care Unit] level for management of septic shock likely due to wound infection...Clinical suspicion for osteomyelitis due to excessive tissue between wound and bones...Social History...Lives at home with son who is his caretaker. Believes his son tries his best to help him, but would be open to getting home health for medical needs...” Review of the Nursing Progress note dated 8/30/2024, revealed, “...WOCN [Wound, Ostomy, and Continence Nurse] initial consult to eval [evaluate] and treat patient on arrival with pressure injuries to L [left] upper back and to L flank. Patient also has cellulitis to bilateral lower extremities with dry and flaking skin...Right upper back is unstageable, measuring 15 cm [centimeters] x [times] 5 cm, scattered, moist, pink, yellow with slough. Periwound excoriated and moist. No odor. Wound and periwound cleaned with vashe [wound cleaner]. Periwound dressed with zinc oxide. Wound bed dressed with therahoney [creates a moist wound healing environment], xeroform [contract layer in dressing wounds] bordered mepilex [to cover open wounds]...Right flank unstageable, measuring 12 cm x 6 cm, scattered, moist, pink and yellow with slough. Periwound excoriated and moist. No odor. Wound and periwound cleaned with vashe. Periwound dressed with zinc oxide. Wound bed dressed with therahoney, xeroform, bordered mepilex WOCN q [every] 2 [two] h [hours] repositioning with foam wedge. Patient is on an air mattress. WOCN recommends for all skin injuries are in order. WOCN will continue to monitor...” Review of a Critical Care Progress Note dated 8/30/2024, revealed, “...Skin...pressure ulcers...cellulitis...consult wound care...[Brand name] emollient Tropical Cream...1 app [apply]...a day...[Brand name honey gel dressing]...app...Topical BID [twice a day]...” Review of the Social Service Progress Note dated 8/30/2024, revealed, “DCP [Discharge Planning] discussed with patient at bedside, patient able to recall DC [Discharge] and difficulty with located SNF [Skilled Nursing Facility] placement due to 573 [pounds] weight. Patient again requested SNF referrals to be sent, explained that referrals will be sent but upon denials, assistance will be provided with DC [Discharge] home with home health and Choices referral be sent...” Review of the pharmacy progress note dated 9/1/1024 revealed,” Patient is a 63 yo [year old] Male on Vancomycin [antibiotic] for left back cellulitis. PMH [Past Medical History] significant for morbid obesity...” Review of the physician note dated 8/31/2025 at 3:06 PM, revealed, “...Infected pressure wounds...” Review of the pharmacy progress note dated 9/1/1024, revealed, “Patient #1 is a 63 year old male being treated for infected pressure wounds with IV [Intravenous] antibiotics...” Review of the nursing flowsheet functional section dated 9/2/2024, revealed, “...Home Living Additional Information...reports that he does not sit up at EOB [edge of bed] or transfer to his w/c [Wheelchair] at home. Son assists patient with all mobility and self-care tasks. Report to have recently been receiving home health services (aide, therapy), but that they were discontinued...Living Situation...Home with family care...Detail Areas of Responsibilities...Home with family care, Home with home health...Current Home Treatments...Oxygen ...” Review of the physician’s order dated 9/2/2024 at 11:52 AM, revealed Physical Therapy and Occupational Therapy to evaluate and treat Patient #1. Review of the Physical Therapy Forms dated 9/2/2024 at 3:04 PM, revealed, “...Patient is a 63 y [year]/ o [old] male who presented with back pain, drainage from back wound and decreased ability for family to manage his needs. He was admitted for septic shock, concern for osteo [osteomyelitis]. Being managed with antibiotic coverage, wound care...Lives with his son and his son’s mother. Reports being bedbound x 2 years. Reports to have a w/c and a hospital bed, which is broken [sitting or bricks]...Reports that he does not sit up on EOB or transfer to his w/c at home. Son assists with all mobility and self-care tasks. Report to have recently been receiving home health services (aide, therapy). But that they were discontinued...PT [Physical Therapy] Treatment Recommendations: Patient presents with multiple impairments, including decreased strength, impaired activity tolerance, decreased postural control, and decreased independence with bed mobility, which are likely close to patient’s baseline as he has been bedbound for 2 years. Recommending long term placement to optimize his safety upon discharge...PT Equipment Anticipated or Recommended...Bariatric hospital bed with low air-loss mattress, mechanical lift...” Review of a physician note dated 9/3/2024, revealed, “...Remains medically stable for discharge @ [at] this time. Per SW [Social Worker] authorization can proceed currently look for Bariatric bed...Osteo @ this time...Wound changes w [with]/ Periwound dressing W/ Zinc Oxide and Xeroform...” Review of the Nutrition Note dated 9/3/2024, revealed, “...Nutrition Recommendations...Continue 2g [gram] Na [sodium] diet adding double meats for extra protein for wound healing...Add MVI [multivitamin], zinc sulfate 220 mg [milligrams] BID x 14 days and ascorbic acid 500 mg BID. Reason for Assessment...RN [Registered Nurse] screen for skin breakdown. Visited pt [patient] at bedside...Skin...Right upper back is unstageable, measuring 15 cm x 5 cm, scattered, moist, pink, and yellow with slough...” Review of the Social Service Progress Note dated 9/4/2024 at 3:10 PM, revealed, “...The insurance is requesting that the patient admit to a facility in [Named State]. I called the following facilities to see if they could accommodate the patient because he is bariatric...” Review of the Physical Therapy Forms dated 9/5/2024 at 12:21 PM, revealed, “...The pt motivated with improving his overall functional mobility. He is limited by his size and would benefit from weight loss intervention. The pt currently has limited active movement and continues to require a lot of assists from staff...” Review of the physician note dated 9/5/2024 at 12:31 PM, revealed, “...Assessment/Plan...wound changes w/Periwound dressing w/Zinc Oxide and Xeroform...Recently transferred from the ICU after septic shock resolved. Currently treating Pressure wounds for concerns of Osteo given elevated CRP [Lab test for inflammation in the body]. If pt’s [patient’s] insurance does not approve the facility will discharge pt...” Review of the Case Manager Progress Note dated 9/5/2024, revealed, “...Case Manager discuss patient with team, patient after review of chart was at [Hospital #1] in 2022 and wanted placement but declined the place in Alabama and his sister also. Patient #1 at prior stay was discharged home back with his son...Patient sister aware the patient is medically cleared for discharge today and will likely go home. Barrier to home services is he weighs 260 kg [kilograms - 573 pounds]. CM [Case Management] updated Upper level staff for assistance with this case. Denied at multiple SNF due to weight...CM called number listed in UR [notes] for [Managed Care network #1] telephone number to help with DCP [discharge planning] and was transferred to the [Managed Care network #1] Medicare Line. CM left v [voice]/m [message] asking for assistance with DCP for Patient #1 And left the listed contact for his sister...son...patient...SW/CM [case management discussed with upper mgt [management] and Medicine team-Patient medically ready for discharge...” Review of the Discharge Reconciliation dated 9/5/2024, revealed orders for Ascorbic Acid 1 tablet 500 mg twice a day, emollients, topical cream, multivitamin with minerals 1 tablet with breakfast, and zinc 220 mg 1 capsule twice a day with meals. Review of a physician’s order dated 9/6/2024 at 1:20 PM, revealed regular home diet for discharge, and a discharge disposition of home independently. There were no orders for home health services, home medical equipment, or wound care supplies noted. Review of the Social Service Progress Note dated 9/6/2024 at 11:34 AM, revealed, “...Family was notified pt is medically cleared for dispo [disposition] and has been denied several facilities in [Named City] and [Named State] due to weight. They mentioned can pt go to [Named State] which he was approved in the past. Pt and pt family denied services last time [previous admission in 2022] stating it was too far. The sister reports she never denied services it was her bother [brother]. She also stated pt cannot come live with her because she works and disable. Family tried to stop the DC [discharge] on today one [family member] said pt does not have a bed then stated it’s a twin-size bed...Pt stated he has been bed bound for 6 years. He reports his bed never came with an air mattress. He received the bed from [Named Company] #1 His wheels are broken, and bed is currently on bricks and the top of the bed that moves makes noises. He also reports he called [Named Company] #1 and they told him it was out of warranty. SW informed the CM and CM will call to see what they can do about the pt bed. Therapy also recommended a Hoyer lift for pt...Pt unable to DC because no manpower available at this time. Pt should DC 9/6/24 in the am [AM]. Medical ness [necessity] H&P [History and Physical]. Facesheet placed in chart...” Review of the Case Manager Progress Note dated 9/6/2024, revealed, “...Scheduled clinic appointment w/OPC [Outpatient Clinic] int. [Internal] Med [Medicine] 1 [One] on 9/9/24 @ 8:20 AM...” There was no documentation ambulance transportation was arranged for the Patient. Review of the Discharge Documentation dated 9/6/2024, revealed, “...Discharge Diagnosis of Septic Shock and Cellulitis...Patient #1 is a 63 YOM [year old male] with PMHX [past medical history] of morbid obesity, sleep apnea, HTN [hypertension] gout and asthma who presented for back pain. Over the last 2-3 weeks, his family has noticed increased drainage from a wound on his back. They are unable to turn him regularly or check/clean his wounds. A few days ago he started to have sharp pains in the area of the left shoulder blade. Family was also concerned about some apparent hardening of the skin around his chest...Wounds were evaluated by surgery who found induration of lateral and posterior left axilla and weeping shallow ulcerations of left back...Patient was started on Vancomycin and Cefepime [used to treat bacterial infections] and ICU was called for admission for septic shock...Hospital Course...Wound care and nursing staff continued to work consistently to make sure patient wounds were well taken care of and up to date. Pt was unfortunately denied from specific [skilled] facilities thus patient needed to return home w/family once transportation arrived. Pt was transported back w/ family on 9/6/2025...Physical Exam...General morbidly obese male...See pictures of wounds on clinical media. Dry skin fungal toenail growth ...Discharge Medications...Home...Albuterol [respiratory inhaler]...Allopurinol [decreases uric acid levels in the blood]...Amlodipine [used to treat high blood pressure]... Atorvastatin [lowers bad cholesterol]...Montelukast [medication used to treat asthma and allergies]...Tamoxifen [treat breast cancer]...Valsartan [medication used to treat high blood pressure]...Patient Instructions...Discharge Activity...No...Restriction...Discharge Diet Instructions...Regular home diet...Discharge Disposition...Home Independently...Discharge Plan...Wound changes w/Periwound dressing w/ Zinc Oxide [medication for the skin only] and [Brand name for a yellow, petroleum-impregnated gauze dressing for wound care]...Patient Discharge Condition...Stable...Discharge Disposition...Home...” There were no physician’s orders for home health services, wound care supplies, bariatric bed with air mattress, or Hoyer lift written. Patient #1 was discharged home “independently” when he required total assistance from staff and/or others for all aspects of his care. There was no documentation Patient #1’s family/caregivers were taught how to care for the Patient’s wounds. There was no documentation transportation for Patient #1’s follow up appointment was arranged. The hospital failed to ensure post-hospital needs were arranged prior to the Patient’s discharge on 9/6/2024. In an email received on 12/5/2024 at 2:46 PM, Insurance Case Manager #1 wrote, “...To Summarize our discussion about [Patient #1] this morning I received a referral from [CM #1] at [Hospital #1] that mbr [member Patient #1] was ready for discharge and they were unable to find a place to send him. They identified the need for placement due to safety concerns and physical therapy needs and then sent mbr [Patient #1] home without collaborating with his health plan to find placement. No denials were issued by the health plan. The mbr [Patient #1] had a broken bed, broken [named patient lift] lift, and a son who couldn’t meet his needs at home. I was able to find a facility to take him Medicaid pending from home, but it took about a month and half at home...” In an interview on 1/7/2025 at 1:30 PM, the Director of Case Management (DCM) was asked if Patient #1 received a safe discharge by being sent home with a broken bed, a broken patient Lift, no home health, no discharge teaching for his pressure injures, no medication or supplies for his pressure injuries, and his caretaker was his son who was unable to care for him. The DCM stated, “...[Patient #1] was denied by several Skilled Nursing Facilities due to his weight. He was sent home with a bed that had been broken for 2 years and it was out of warranty, and it had a part that had not been ordered and when the company came to fix it, he refused for them to fix it. [Patient #1] was discharging home to his son on his previous discharge, and that was not a problem then.” The DCM was asked other than the 20 denials of Skilled Nursing Facilities, did the hospital try and place Patient #1 with any Home Health agencies. The DCM stated since COVID especially if a patient had Insurance Company #2, Home Health would not except a patient with wounds because they do not get paid. The DCM was asked if there were any Home Health agencies contacted for Home Health. The DCM stated, “...I can’t find any documentation of that. We did contact [Insurance Company #1] to help with placement but, they would not return our calls.” The DCM was asked if they arranged transportation services to transport Patient #1 to his follow up appointment since the Patient weighed 573 pounds and it took 12 men to get him in and out of the house. The DCM stated, “...Well, if the patient had [Insurance Company #2], they would have to call and arrange their transportation, otherwise we would schedule the transportation and pay for it.” The DCM was asked if Patient #1 had Insurance Company #2. The DCM stated, “ ...I will have to check...” In an interview on 1/7/2025 at 2:30 PM, the DCM stated Patient #1 did not have Insurance Company #2, and Hospital #1 should have scheduled and paid for transportation services to take Patient #1 to his follow up appointment. In an interview on 1/8/2024 at 11:47 AM, RN #4, #5 and #6 were asked if Patient #1 should have been discharged home with the pressure injuries he had. RN #4, #5, and #6 all stated that Patient #1 should not have gone home with no one to take care of the wounds on his back. During an email conversation 1/7/2025 through 1/14/2025, Insurance Case Manger (ICM) #1 was asked if Patient #1 was responsible for making arrangements for his transportation to his follow up appointment. ICM #1 replied, “[Insurance Company #1; Patient #1’s provider] can refer to either Medicare or Medicaid or a combination of the two. My understanding is that he had Medicare type which is preferred by providers...Because he needs an ambulance a prior auth [authorization] would be required. He can’t do that by himself someone has to order it and call precert [precertification]...” ICM #1 was asked if Hospital #1 should have made arrangements for Home Health Services and would they pay for wound care. The ICM replied, “wound care would have been skilled home care and they would have had to set that up with an in network provider for Medicare...I do not think they would have been able to find a Home Health that could safely accommodate his size as it takes multiple people to move him. That’s part of what makes it so bad they sent him home. They should not have sent him home. They should have sent him to a facility since he is willing to go and that is what their PT recommended. And that is ultimately what I made happen for him from the community. If they decided not to do that, they should have at lease sent referrals to all HH [Home Health] agencies and documented that they declined the referral and done the same for skilled nursing facilities. To my knowledge they did neither...””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 33763 Based on policy review, medical record review, and interview the hospital failed to ensure physician’s orders for vital signs assessments were followed for 1 of 7 (Patient #5) sampled patients. The findings included: 1. Review of the hospital policy titled, “Nursing Documentation of the Patient Medical Record” revealed, “...Re-assessment is completed based on patient acuity with specific guidelines established by each department...As ordered by the Provider...Nursing documentation...Assessments...” 2. Medical record review for Patient #5 revealed a 28 year old male hospitalized 10/9/2023 through 10/10/2023 for a scheduled partial nephrectomy (kidney removal) to remove a mass from his left kidney. Review of the Operative Report dated 10/9/2023 revealed, “...Indication for Surgery [Named Patient #5] is a 28 y/o [year old] M [male] with an incidentally found large left renal [kidney] mass with invasion in to the collecting system who presents today for Robot-assisted laparoscopic left partial vs radical nephrectomy [total kidney removal]...Preoperative Diagnosis Left renal mass...Findings 1. Left partially exophytic renal mass [mass growing from the outer surface of the kidney] with invasion in to collecting system and major branches of renal artery 2. Conversion to radical nephrectomy...The patient tolerated the procedure well, without any complications...” Review of a Physician’s Order dated 10/9/2023 at 11:33 AM revealed, “...Vital Signs...q [every] 4h [hours]...” Review of the nursing Flowsheet, “Vital Signs” section revealed Patient #5’s vital signs were assessed at 8:45 PM on 10/9/2023. There was no documentation the patient’s vital signs were re-assessed until 4:00 AM on 10/10/23, a total of 6 hours and 15 minutes later. Further review of the nursing Flowsheet, “Vital Signs” section revealed Patient #5’s vital signs were assessed at 7:49 AM on 10/10/2023. There was no documentation the patient’s vital signs were re-assessed until 3:55 PM, a total of 8 hours and 6 minutes later. In an interview on 3/4/2024 at 3:25 PM, the Director of Quality verified nursing staff failed to assess Patient #5’s vital signs every 4 hours as ordered by the physician. In an interview on 3/5/2024 at 11:18 AM, Registered Nurse (RN) #1 verified Patient #5’s vital signs were not assessed every 4 hours as ordered by the physician. In a telephone interview in the presence of the Director of Quality on 3/5/2024 at 11:40 AM, RN #2 verified vital signs should be assessed as ordered by the physician. RN #2 was asked who was responsible for assessing patient’s vital signs. The RN stated, “I am.””