Winchester Medical Center

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 36946 Based on staff (EMP) interview and document review, it was determined hospital staff failed to monitor patients in restraints in two (2) of two (2) patients in violent restraints reviewed in the survey sample. Medical records (MR)14 and MR15. Findings: MR14 was reviewed and indicated the patient was placed in restraints (soft restraints to left wrist, right wrist, and right ankle) for violent behavior at 3:13 AM on July 14, 2026. Monitoring by the Registered Nurse (RN) was documented at 3:19 AM, 4:59 AM, and 6:25 AM. There was no monitoring documented every 15 minutes as required by hospital policy. Restraints were discontinued at 6:30 AM on July 14, 2026. MR15 was reviewed and indicated the patient was placed in restraints on July 13, 2026, for violent behaviors (soft restraints to left and right wrist) at 5:16 AM. Monitoring was documented by the RN at 5:17 AM, 5:26 AM, 6:00 AM, and 8:00 AM. There was no documentation of 15 minute monitoring as required by hospital policy. The hospital’s policy, “Restraint Use,” last revised October 2025, was reviewed and reads in part, “...Nursing Assessment, Documentation Requirements, Violent Behavior Restraint, Continuous one-to-one monitoring by nursing staff with every 15 minute documentation for the entire restraint episode...” An interview was conducted with EMP18 at 9:10 AM on July 28, 2026. EMP18 indicated that patients in violent restraints should be monitored every 15 minutes by nursing staff or 1:1 attendants. The RN is to assess and document the patient’s condition in violent restraints every two (2) hours. EMP18 indicated they were able to locate documentation in the medical record that MR14 had a 1:1 attendant at bedside during the restraint episode, but was unable to identify any documentation of patient monitoring every 15 minutes. EMP18 indicated they were unable to locate any documentation that MR15 had a 1:1 attendant or documentation of 15 minute checks while in violent restraints.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 36946 Based on staff (EMP) interview and document review, it was determined hospital staff failed to follow policies related to obtaining vital signs in the emergency department (ED) in one (1) of nineteen (19) medical records (MR) reviewed in the survey sample. MR7. Findings: MR7 was reviewed and contained documentation that the patient arrived in the ED on June 10, 2026, at 11:58 PM. The triage nurse documented that patient was complaining of migraine and vomiting for four (4) days. The note indicated the patient was seen earlier that day and viral testing had been negative, but migraine and vomiting had worsened since that visit. Vital signs were obtained at 11:59 PM as follows - 119/63, 87, 20, 99.2, 97 % on room air. The patient was assigned an ESI level of 3 (emergency severity index - a tool that categorizes patients into five levels, from Level 1 (most urgent) to Level 5 (least urgent), based on both acuity and the number of resources likely required for care). There were no further documented patient interactions in the record. The record indicated the patient was discharged (left without being seen after triage) at 4:26 AM on June 11, 2026. There was no documentation of any vital signs or assessment obtained after 11:59 PM on June 10, 2026. The facility’s policy, “Vital Signs,” last revised January 2026, was reviewed and reads in part, “...Complete and document vital signs promptly upon arrival...Frequency based on triage acuity, patient condition, chief complaint, minimum every two hours for ESI 1-3 (acute care patients). An interview was conducted with EMP8 and EMP23 at 11:15 AM on July 28, 2026. EMP8 indicated that vital signs should be checked at least every two (2) hours for patients assigned ESI levels 1-3. EMP23 indicated that the triage nurse or tech is responsible for obtaining vital signs for patients in the waiting room and/or in triage while awaiting a room. During the interview, EMP23 showed the surveyor the bed board in the EMR (electronic medical record) that displays patients in the triage area and their length of stay. If the length of stay has exceeded 120 minutes, a different color is displayed that indicates the patient requires vital signs taken again. EMP23 confirmed there was no further documentation in MR7’s record to indicate what time the patient left the facility. EMP23 indicated the patient was likely called to the back around 04:26 AM, and was not in the waiting room, and discharged. EMP21 indicated that there is often a note to indicate the patient was called for, but no longer in waiting room, but there was no such documentation in the MR7.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 36946 Based on staff (EMP) interview and document review, it was determined hospital staff failed to administer medication in accordance with hospital policies and procedures and accepted standards of practice in two (2) of two (2) medication administrations observed in the survey sample. Medical records (MR)1 and MR19. Findings: The surveyor observed EMP10 administer intravenous (IV) Zosyn 4.5 mg (an antibiotic) to MR1 at 11:47 AM on July 27, 2026. EMP10 was observed picking up trash with gloved hands from the floor and disposing in trash can. EMP10 proceeded to administer IV Zosyn without changing gloves or performing hand hygiene. EMP10 then administered Zosyn in the peripheral IV line without first flushing or checking patency of the line. The surveyor observed EMP27 administer IV Zofran (an anti-nausea mediation) to MR19 at 2:01 PM on July 28, 2026. EMP27 removed the cap from the vial and withdrew the medication without scrubbing the vial stopper with alcohol. EMP27 then scrubbed the hub of the IV catheter for less than five (5) seconds and proceeded to administer the medication. The facility’s policy, “Peripheral Intravenous (IV) Therapy: Insertion, Care and Maintenance” (last revised October 2023) was reviewed and reads in part, “...Flushing...all short peripheral IV’s should be flushed with normal saline solution (NSS) before and after each use and at least every 12 hours with a minimum of 2 mL of NSS....To flush PIVs: Disinfect cap with one-time use alcohol pad with vigorous scrubbing for a minimum of 15 seconds. “Scrubs the hub”... Check for patency of the PIV before and after every use...Once patency confirmed, administration of IV push medication (one time use only) or an intermittent or one-time small volume IV medication can be given...” The facility provided an undated, untitled, procedure document for administering IV medications that reads in part, “...21. Disinfect vials by cleaning the access diaphragm using friction and sterile 70% isopropyl alcohol, ethyl alcohol, an iodophor, or other approved antiseptic swab and allow to dry for at least 10 seconds...Administration through an Intermittent vascular access device...3. Clean the connection surface and sides of the needless connector using vigorous mechanical scrubbing for 5 to 15 seconds using 70% isopropyl alcohol or alcohol-based chlorhexidine. Allow the solution to dry...” The facility’s policy, “Hand Hygiene,” last revised October 2024, was reviewed and reads in part, “...Before handling invasive devices, regardless of whether or not gloves are used...Gloves must be changed between different care of treatment activities (i.e. changing incontinent patient and then proceeding to sterile dressing change; changing incontinent patient and proceeding to obtain vital signs...” An interview was conducted with EMP1 at 3:15 PM on July 28, 2026 who confirmed the above referenced policies/procedures should be followed when administering medications.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(3) The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient or others from harm. This Standard is not met as evidenced by: 46466 Based on interviews, medical record review and facility document review, the facility failed to use the least restrictive type of restraint for one (1) of four (4) restraint medical records reviewed. The findings include: A review of the facility’s policy “Restraints Use: Prevention and Reduction Plan”, last reviewed May 2021, indicated in part: “...Procedure...A. Prior to the use of restraint(s), staff will try alternative interventions and document these alternative interventions attempted. Document any emergency event that prevented the use of less restrictive alternative interventions...D. Restraints will be initiated using the least restrictive type of restraint that will be effective to protect the patient, staff members, or others from harm based on the assessed need of the patient...Restraint Types A. Least to Most Restrictive Devices...3. Mitts...4. Roll Belts...Care of the Violent/Self-Destructive Behavior Restraint (Behavioral Restraint) Patient...H. Chemical restraint assessment by the nurse includes medication effectiveness of the behavior trying to eliminate or change. I. Discontinuation...2. Chemical restraint monitoring can be discontinued when desired outcome of medication is obtained...Documentation of Violent/Self-Destructive Behavior Restraints (Behavioral Restraints)...B. Document all alternatives to restraint that were attempted prior to the application of a restraint...F. Patient’s response to the intervention...”. On December 1 and 2, 2025, a review of Patient #7’s medical record was conducted. The physician orders found in Patient #1’s record indicated on November 10, 2025, that the patient was ordered a chemical restraint at 10:35 PM, a physical hold for danger to self, at 10:39 PM and non-violent restraints of mitts and a roll belt at 10:47 PM. The chemical restraint was administered at 10:42 PM and the mitts and roll belt were applied at 10:47 PM. The medical record did not contain documentation of the patient’s response to the chemical restraint nor the patients behavior after administering the chemical restraint and prior to placing the patient in non-violent restraints. In an interview on December 2, 2025 at , with Staff Member #15, Staff Member #15 verified that the medication administered to Patient #7 (geodon) was intended to be administered as a chemical restraint. The medical record indicated that the physician ordered the staff to give one (1) medication early, increase another medication, administer the geodon and place the patient in mitts and a roll belt. Staff Member #15 stated that staff told them that the physical hold did not happen because the patient had begun to calm down prior to the administration of the geodon. Staff Member #15 reviewed the record and indicated the patient’s CIWA (Clinical Institute Withdrawal Assessment for Alcohol) scores indicated that the patient was still agitated and restless after the administration of the medications, chemical restraint and physical restraints. However, Staff Member #15 agreed that the documentation for the evaluation of the chemical restraint was lacking and did not paint a picture as to what was happening and the reason why the non-violent restraints were applied after the chemical restraint. Staff Member #15 also stated the physical hold order should have been discontinued since it did not occur.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 46466 Based on medical record review and facility document review, the facility failed to discontinue restraints at the earliest possible time for two (2) of four (4) medical records reviewed. The findings include: A review of the facility’s policy “Restraints Use: Prevention and Reduction Plan”, last revised May 2021, read in part: “...Procedure...I. Restraints will be discontinued at the earliest possible time, regardless of the scheduled expiration of the order...”. On December 1, 2025, a review of Patient #5’s medical record revealed that the patient was placed in bilateral soft wrist restraints on November 6, 2025 prior to midnight. The nursing flowsheets documented that the patient was “asleep” on November 7, 2025 at 4:00 AM and 6:00 AM. The patient restraints were not removed until 10:00 AM on November 7, 2025. On December 1, 2025, a review of Patient #6’s medical record revealed that the patient was placed in bilateral mitts on November 25, 2025 at at 9:12 AM. The nursing flowsheets documented that the patient was “subdued” at 11:17 AM, 12:00 PM, 2:00 PM, 4:00 PM, 6:00 PM and 8:00 PM. The restraints were removed at 9:11 PM on November 25, 2025.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 46466 Based on interviews, medical record review and facility document review, the facility failed to monitor a restrained patient according to facility policy for one (1) of four (4) medical records reviewed. The findings include: A review of the facility’s policy “Restraints Use: Prevention and Reduction Plan”, last reviewed May 2021, indicated in part: “...Care of the Violent/Self-Destructive Behavior Restraint...D. Chemical restraint monitoring can be discontinued when the desired outcome of the medication is obtained. 1. Chemical restraint monitoring may include the following. a. Heart rate b. Respiration rate c. Blood Pressure d. Oxygen saturation. E. All patients in behavioral restraints will receive 1:1 care. 1. Safety CNA will provide continuous observation of the patient and document every fifteen (15) minutes. a. Continuous observation of patient b. Observations: agitated/restless, verbally abusive, tearful, hallucination, delusional, subdued, patient asleep, confused, or other...”. On December 1 and 2, 2025, a review of Patient #7’s medical record was conducted. On November 10, 2025 at 10:42 PM, Patient #7 was administered the chemical restraint, geodon. The medical record did not contain evidence that the patient was monitored according to facility policy after the administration of the chemical restraint. In an interview on December 2, 2025 at , with Staff Member #15, Staff Member #15 verified that the medication administered to Patient #7 (geodon) was intended to be administered as a chemical restraint. Staff Member #15 agreed that the monitoring documentation for the chemical restraint was lacking.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(v) [there must be documentation in the patient’s medical record of the following:] The patient’s response to the intervention(s) used, including the rationale for continued use of the intervention. This Standard is not met as evidenced by: 46466 Based on interviews, medical record review and facility document review, the facility failed to document the patient’s response to the intervention of a restraint and failed to document a description of the patient’s behavior that warranted the use of restraints for one (1) of four (4) patient records reviewed. The findings include: A review of the facility’s policy “Restraints Use: Prevention and Reduction Plan”, last reviewed May 2021, indicated in part: “...Care of the Violent/Self-Destructive Behavior Restraint (Behavioral Restraint) Patient...H. Chemical restraint assessment by the nurse includes medication effectiveness on the behavior trying to eliminate or change...Documentation of Violent/Self-Destructive Behavior Restraints (Behavioral Restraints) A. Description of the patient’s behavior or patient’s condition or symptom/symptoms that warrants the use of the restraints...F. Patient’s response to the intervention...I. When restraint interventions are discontinued the nursing assessment and restraint removal is documented along with the date and time restraints are discontinued...”. On December 1 and 2, 2025, a review of Patient #7’s medical record was conducted. The physician orders found in Patient #1’s record indicated on November 10, 2025, that the patient was ordered a chemical restraint at 10:35 PM and a non-violent restraint of mitts and a roll belt. The chemical restraint was administered at 10:42 PM and mitts and a roll belt restraints were applied to the patient at 10:47 PM. The medical record did not contain documentation of the patient’s response to the chemical restraint, the patient’s behavior prior to initiating the mitts and roll belt and the alternatives attempted prior to placing the non-violent restraints on the patient. In an interview on December 2, 2025, with Staff Member #15, agreed that the restraint documentation for this incident with Patient #7 was lacking and did not give a picture as to what was happening with patient at that moment.”

“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: 46466 Based on interviews, medical record review and facility document review, the facility failed to follow facility policy when discharging a patient. The findings include: A review of the facility’s policy “Alias”, last revised March 2022, indicated in part: “...Alias Patient Discharge A. The AA, RN, or Physician will contact Patient Access prior to discharge and sending prescriptions electronically to the preferred pharmacy to have the Alias name removed. B. Patient Access Specialist will go under demographics and add the patient’s legal name back on the MRN. C. Standard discharge procedure will be followed at this time and electronic prescriptions sent. D. The AA will send e-mail notification to the Alias Notification Group informing them of the patient’s discharge. E. The AA prints labels and a face sheet with the patient’s legal name for distribution to the Health Information management Department and the Patient Accounts Manager. F. The AA prints labels with the patient’s legal name to place on every sheet of the medical record prior to sending the chart to the Health Information Management Department...”. On December 1, 2025, a review of Patient #1’s medical record was conducted. The viewed medical record located in the facility’s Electronic Medical Record (EMR) revealed Patient #1’s real, legal name and a medical record number (MRN) (3...). Patient #1’s consent for treatment was printed with an alias name and a different MRN (4...). Patient #1’s discharge instructions included Patient #1’s real name with parentheses next to it reading “Legal name: (alias name)” and MRN (4...). Name labels attached to the paperwork that had been scanned into Patient #1’s medical record was printed as Patient #1’s real name with parentheses next to it reading “Legal: (alias)...MRN (4...). On December 2, 2025, at 2:30 PM, an interview was conducted with Staff Member #16. Staff Member #16 stated that when a patient record is set up as an alias, and the actual patient’s medical record is discovered afterwards, Patient Access marked the medical record to “merge”. The two (2) records could not be merged together until after the patient had discharged. Staff Member #16 confirmed that Patient #1’s medical record was merged with the alias medical record on August 18, 2025 at 7:56 AM. Staff Member #16 stated that Patient Access was responsible for inputting the patient’s legal name into the alias record. On December 2, 2025, at 3:15 PM, an interview was conducted with Staff Member #12. Staff Member #12 stated that Patient Access updated Patient #1’s legal name appropriately into Patient #1’s alias record, but the update did not occur until the records were merged after discharge. Staff Member #12 stated that the clinical staff was responsible to contact Patient Access prior to the patient’s discharge to change the legal name from the alias to the patient’s real name. Staff Member #12 stated that Patient #1’s discharge instructions contained the alias as the legal name because clinical staff did not alert Patient Access to make that switch prior to Patient #1’s discharge. On December 2, 2025 at 3:25 PM, in an interview with Staff Member’s #2 and #6, Staff Member #6 stated in November, the facility updated their EMR system to allow for a notification to pop up in an alias patient’s chart for the clinical staff. The alert would flag the clinical staff as a reminder to verify that the alias name was correct prior to discharge. This change to the EMR was intended to be a reminder and notification to prevent an error occurring in the future. Both Staff Member’s #2 and #6 agreed that the mistake occurred with the clinical staff not contacting Patient Access to correct Patient #1’s medical record prior to electronically sending Patient #1’s prescriptions to the pharmacy and discharging the patient.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 40084 Based on staff interview and document review the facility failed to promote and protect each patients ’ rights as evidenced by: failing to honor a patient ’ s right to refuse medication, failing obtain informed consent for a surgical procedure (A0131), failed to follow the facility seclusion policy (Patient #6) (A0167), and failed to obtain orders for restraint (A0168). Cross Reference: §482.13(e)(4)(ii) Restraint and Seclusion Policy §482.13(e)(5) Restraint and Seclusion Orders §482.13(b)(2) Informed decisions”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 36946 Based on staff interview and document review, it was determined the facility failed to honor the patient’s right to refuse treatment by administering medication to a patient after the patient refused the medication in one (1) of two (2) medication administration records reviewed in the survey sample (Patient #6). Additionally, the facility failed to obtain informed consent for surgical procedures in two (2) of four (4) procedures reviewed in the survey sample (Patients #’s 1 and 5). Findings: The hospital’s policy, Patient Rights was reviewed and reads in part: “...BHS (Behavioral Health) staff maintains patient human rights including the following:...Right to participate in decisions regarding services including..c. Give or not give informed consent to receive psychotropic medications, electroconvulsive therapy, surgical procedures, and/or to participate in human research. Emergency exception. If immediate treatment is required to avoid harm, death, or injury to patient/others.” The medical record for Patient #6 was reviewed on October 16, 2024. The record indicated that the patient was placed in a physical hold by security to administer an intramuscular injection of Zyprexa after the patient disrobed and refused to put clothes on while on the unit and on the unit patio. The medical record indicated the patient refused the medication and had to be held by security in order for it to be administered. The medical record contained documentation that the patient was receiving behavioral health treatment and admitted to the facility on a voluntary basis. The medical record contained no documentation that the patient was a danger to themselves or others, or of an emergent situation requiring the use of Zyprexa after being refused by the patient. During an interview on October 16, 2024, at 12:06 PM, Staff Member #18 indicated that Patient #6 refused the injection and had to be held down by security for it to be administered. Staff Member #18 stated that the patient disrobed and was unable to be redirected. Staff Member #18 indicated that the nurse, the charge nurse, and the physician collaborated and decided “it was in the patient’s best interest” to protect their privacy and safety to administer the medication against the patient’s wishes. An interview was conducted with Staff Member #20 on October 16, 2024 at 2:30 PM. Staff Member #20 indicated that patients could be administered medication even if they refuse in two (2) circumstances. First, if a patient was hospitalized involuntarily, a court order could be obtained to administer “medications over objection” and the patient could have medications injected after refusing them. The second circumstance would be in the event of an emergency when the patient was a danger to self or others, medications could be given to a patient even after the patient refused. The medical record for Patient #6’s did not contain documentation indicating that the circumstances surrounding the administration of Zyprexa after patient refusal constituted an emergency that required immediate treatment to avoid harm, death, or injury to the patient or others as defined in hospital policy. The hospital’s policy, Informed Consent for Treatment was reviewed and reads in part: “Surgical and Invasive Procedures. Written informed consent will be obtained for all surgical or invasive procedures. An “invasive procedure” is any diagnostic or therapeutic intervention that is not part of routine, general care, and that requires specific informed consent as determined by the Medical Staff....The physician or health care practitioner who is to perform the surgery or procedure will be responsible for obtaining the informed consent of the patent and/or legally authorized representative to a proposed surgical or invasive procedure. When obtaining informed consent, the physician, his/her professional associate or designee will be responsible for discussing:...the recommended treatment or procedure to be preformed...the risks, side effects, and potential hazards of the proposed treatment or procedure. The physician, his/her professional associate or designee and the consenting party will sign, time and date the consent to operation or procedure form.” The medical record for Patient #5 was reviewed on October 16, 2024. The record indicated the patient was admitted to the hospital on January 23, 2024 with worsening NSTEMI (Non-ST-Elevation Myocardial Infarction (Heart Attack). The patient had a cardiac catheterization on January 24, 2024. The medical record contain no documentation that informed consent was obtained from the patient before the procedure. An interview was conducted with Staff Member #5 on October 16, 2024 at 10:00 AM who confirmed the absence of informed consent for the cardiac catheterization on Patient #5. The medical record for Patient #1 was reviewed on October 16, 2024. The record indicated the patient underwent a planned procedure to insert endobronchial valves (EBV) via bronchoscopy on January 23, 2024. The informed consent dated and signed by the patient and surgeon on January 23, 2024 describes the procedure in part... “Fiberoptic bronchoscopy with endobronchial and/or transbronchial or transmural needle biopsy; an exam to diagnosis [sic] lung problems that provides a direst view of your breathing passages that may be used to gather tissue samples.” The informed consent failed to describe the planned procedure of implanting the EBVs or what if any additional risks beyond the bronchoscopy could be incurred with insertion of the valves.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 36946 Based on staff interview and document review, it was determined the facility placed a patient in seclusion without meeting the seclusion criteria as outlined in hospital policy for (1) of one (1) secluded patient reviewed in the survey sample (Patient #6). Findings: The hospital’s policy, Seclusion was reviewed and reads in part: “...Seclusion 1. The involuntary confinement of a patient alone in a room or an area where the patient is physically prevented from leaving. 2. Seclusion may only be used for the management of violent or self-destructive behavior and is limited to the inpatient units on BHS (Behavioral Health)...A comprehensive assessment of the patient must determine that the risks associated with the use of seclusion are outweighed by the risk of not using the procedure.” The medical record for Patient #6 was reviewed on October 16, 2024. The record indicated the patient was “yelling and disrobing out on the milieu and on the patio” the morning of October 10, 2024. Nursing documentation indicated the patient was unable to be redirected and refusing medication. Security staff physically held the patient for three (3) minutes to administer an antipsychotic injection after the patient refused the medication. A few minutes later, the patient walked out of their room and sat on the unit floor unclothed. The patient was then given an injection of lorazepam; haldol, and benadryl. The time the above medications were administered was not clear from nursing staff documentation. The patient was then placed in seclusion from 10:20 AM - 10:55 AM. The physician documented that the “patient was becoming increasingly agitated and required security to be called as patient was attempting to disrobe and is sitting on the floor in the group room area.” An interview was conducted with Staff Member #18 October 16, 2024, at 12:06 PM. Staff Member #18 indicated that on October 10, 2024, Patient #6’s day started out “okay” but then the patient was unable to be redirected. The patient was continuously disrobing on the patio and in the milieu. Staff Member #18 indicated that the patient was first given an as needed injection of Zyprexa and then given a one time dose of lorazepam, haldol, and benadryl because the patient continued to disrobe and would not remained clothed. Staff Member #16 indicated that Patient #6 stated they “did not want to hurt us”, and the patient did not display any violent behaviors toward the staff. The patient was then taken to the seclusion room because they would not remain clothed. Staff Member #16 confirmed the patient was not displaying any violent or self-destructive behaviors.”

“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: 36946 Based on staff interview and document review, it was determined the hospital failed to obtain an order for restraint in one (1) of three (3) patient records reviewed in restraint in the survey sample (Patient #6). Findings: The hospital’s policy, Restraints was reviewed and reads in part: “...Definitions...a physical or mechanical hold or device used to manage behavior..a physician or psychiatric nurse practitioner order is needed for restraint.” The medical record for Patient #6 was reviewed on October 16, 2024. The record dated October 11, 2024 indicated that the patient was... “disrobing out on the milieu and on the patio. Patient unable to be redirected at this time and was escorted to room. Patient offered medication at this time but refused. Patient continued to be uncooperative and would not stay clothed. Doctor authorized to give IM Zyprexa. Security called and patient was put into a physical hold for three (3) minutes to give medication.” The medical record for Patient #6 contained no documentation of a physician order for the physical hold. An interview was conducted with Staff Member #2 during record review on October 16, 2024 who confirmed the lack of orders for the physical hold. An interview was conducted with Staff Member #18 at 12:00 PM on October 16, 2024 who indicated a physician order was required to physically hold a patient for medication administration.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 36946 Based on staff interview and document review, it was determined the hospital failed to ensure that the times medications were administered were documented accurately, the response to as needed medications were assessed and documented, and the medication orders were followed in one (1) of two (2) medication administration records reviewed in the survey sample (Patient #6). Findings: The hospital’s policy, Administration of Medication was reviewed and reads in part: “...Prior to administration, the administering health care professional discusses any unresolved concerns about the medication with the patient’s licensed independent practitioner, prescriber, and/or staff involved with the patients care, treatment and services...Medication administration is documented on the e-Medication Administration (e-MAR) for any unit live on e-MAR....Documentation of the effectiveness of PRN (as needed) medication should be charted on the medical record.” The medical record for Patient #6 was reviewed on October 16, 2024. The record contained documentation that the patient was ordered the following as needed medications: Zyprexa injection 5 mg every 6 hours intramuscularly (IM) for severe agitation. Administration instructions: Maximum of 3 doses of 10 mg administered 2-4 hours apart per 24 hours. Separate from IM lorazepam by at least two hours. The medical record also contained orders dated October 10, 2024 for one time medication administration: haldol injection 7.5 mg once and lorazepam injection 1 mg IM once, and Benadryl injection IM once. The medication administration record indicated that haldol and lorazepam were administered at 10:09 AM and Benadryl and Zyprexa were administered to the patient at 10:10 AM on October 10, 2024. Conversely, a nursing progress note dated October 10, 2024 indicated the nurse administered IM Zyprexa and a few minutes later administered Haldol, Benadryl, and Lorazepam together, conflicting with information recorded in the medication administration record. Staff Member #20 provided documentation that indicated Zyprexa was retrieved form the medication dispensing unit at 9:40 AM and the Haldol, Lorazepam, and Benadryl were not dispensed until 10:00 AM. An interview was conducted with Staff Member #18 on October 16, 2024 who indicated that the medications should be recorded accurately on the medication administration record. Staff Member #18 recalled administering Zyprexa and then administering lorazepam, haldol, and benadryl together after “some time” had gone by, but was unable to recall how much time elapsed between medication administrations. Staff Member #20 provided documentation that indicated Zyprexa was retrieved form the medication dispensing unit at 9:40 AM and the Haldol, Lorazepam, and Benadryl were not dispensed until 10:00 AM. However, there was no documentation in the medical record to determine what times these medications were actually administered. Nursing documentation revealed that at 10:21 AM on October 10, 2024 after being given as needed Zyprexa and the one time dose of haldol, lorazepam, and benadryl that the patient “apologized and laid in bed.” The record does not indicate if a therapeutic response to the Zyprexa was attained or whether or not the patient was assessed for the effectiveness of the Zyprexa before being administered additional injected agents to control disrobing behavior. There was also no documentation in the medical record as to why the administration instructions of the Zyprexa not to be given within two hours of IM lorazepam were not followed.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 42929 Based on interviews and document review, it was determined the facility failed to provide evidence that patients were informed of their patient rights in advance of furnishing care for three (3) of three (3) outpatient rehabilitation patients sampled. Findings: On 12/5/2023 in the afternoon, the surveyor conducted a review of three (3) outpatient rehabilitation (rehab) patient’s medical records. A review of the records contained no evidence of a signed consent to treat or that the patient was informed of patient rights for Patients (P) 2, P3, and P4. During a discussion with Staff Member (SM) 1, SM8, SM14, and SM15, the surveyor discussed that the facility’s three (3) patient rights related policies and consent to treat form did not address evidence of informing outpatients and emergency department patients of their patient rights. SM1 stated that the facility would review their policies and procedures and update them to align with the federal regulations. During an interview on 12/6/2023 at 10:57 a.m., SM1 advised that the registration staff member for the outpatient rehab stated that the electronic signature device used for patients to sign consent documentation was “broken”, so the registration staff member was obtaining “verbal consent” and not documenting that consent was received. There was no documented evidence of signed consents or that P2, P3, and P4 were informed of patient rights. SM1 stated that the electronic signature pad has not been working since 2022. At the exit conference, SM1 confirmed that the electronic signature pad was working as of “today”. A review of the facility’s policy titled “Patient’s Rights and Responsibilities” states in part: “... All inpatients and surgery patients are informed about their rights and responsibilities. These rights and responsibilities are found in the Patient Handbook that is given to patients at the time of admission and prior to surgery. Signs displaying Patient Rights and Responsibilities are posted in registration areas....” This policy only addresses inpatients and surgery patients, there is no mention of outpatients or emergency department patients and how they are informed of their rights. A review of the facility’s policy titled “Patient Rights” states in part: “... Upon admission as an inpatient, each patient will receive a copy of the Patient Handbook, which includes a copy of the Patient Rights and information regarding contacting the Patient Advocate. A review of the facility’s policy titled “Communication of Patient Rights” related to Rehabilitation Services states in part: ... 1. On admission every patient will be given a patient handbook. 2. Nursing will document in the electronic record that patient received the patient handbook....” This policy only addresses patients admitted to the facility, not outpatients. A review of the facility’s “Agreement & Consent to Conditions of Treatment” states in part: ... 6. Patients Right To Decide: I understand that I have the right to make decisions about my care. I have the right to refuse or accept treatment. I have the right to have a “Living Will”, Advance Directive or to designate someone to make decisions for my [sic] by using a “Durable Power of Attorney for Health Care”.... There is no other evidence on this consent form that the patient was given or informed of all other patient rights. The above concerns were discussed at the exit conference on 12/6/2023 at 12:30 p.m.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 42929 Based on observations, interviews, and document review, it was determined the facility failed to ensure risks were minimized for patients, employees, and visitors by not repairing a leaking toilet in a patient’s room on the rehabilitation unit in a timely manner to assure the safety and well-being of the patient, staff, and visitors. Findings: A review of the documentation submitted by the complainant contained photographic evidence of Patient (P) 1’s bathroom at the rehabilitation (rehab) facility with a disposable absorbent mat (PIG mat) on the floor and water surrounding the mat and toilet. On 12/5/2023 at 11:42 a.m., the surveyor received a “work order” document for the leaking toilet in rehabilitation unit room 3303 from 9/21/2023. The work order contained evidence that the patient’s family was concerned about the toilet leaking onto the floor, behind the commode. The work order was submitted on 9/21/2023 at 5:26 a.m. SM12 noted “labor” on 9/22/2023, another staff member documented “labor” on 9/26/2023, and the work was documented as “completed” on 9/26/2023 at 6:32 a.m. There is a note stating that the issue was inspected, extra hands were needed to complete, and the completion was planned for Monday 9/25/2023. The work order was prioritized as “Routine/Corrective”. A Nurse Note Summary for P1 from 9/20/2023 at 11:40 p.m. contained evidence of documentation from SM19 that the patient’s spouse was “anxious” that the patient’s bathroom was “not clean enough and toilet leaking.” There was a work order placed by the day shift charge nurse and SM19 placed “black absorb [sic] pads around toilet to make sure area was dry if patient needed to get up ... I would not allow [the patient] to use restroom if there was any water on the floor ... Patient used urinal throughout the night.” There was no documented evidence that the patient was provided a bedside commode or used a bedside commode during the patient’s hospital stay. A nursing progress note from 9/21/2023 at 3:26 p.m. contained the documentation that the patient’s spouse “expressed concerns about [the patient’s] toilet in [the patient’s] room leaking and I directed [the spouse] to the Charge RN who then placed a work order for building maintenance.” There was no documented evidence that the patient was provided a bedside commode or used a bedside commode during the patient’s hospital stay. During an interview on 12/5/2023 at 10:58 a.m., SM5 stated that the inpatient rehabilitation unit has seventeen (17) rooms with a total of thirty (30) beds. SM5 stated that some rooms have two (2) beds per room and some rooms are private. During an interview on 12/5/2023 at 11:42 a.m., SM7 stated that SM7 worked night shift on the day P1 was admitted. P1’s spouse had notified day shift that the toilet was leaking, and SM7 placed absorbent pads around the toilet, and would not take the patient in the bathroom if it was leaking at the time. SM7 stated that there was a urinal and a bedside commode, and “facilities” was supposed to come to fix the leak the next day. SM7 notified the nurse manager and was told that they were “full” and did not have another room available for the patient. During an interview on 12/5/2023 at 12:46 p.m., SM13 stated that the work order for the leak was submitted in the “evening” and then SM12 went to assess the leak the next day. SM12’s background was in “electrical” so SM12 required assistance with fixing the leak. SM13 stated that the leak was assessed on a Friday, and since facilities management did not work on the weekends, the repair had to wait till Monday. SM12 stated that the issue was “pretty minor” and the rags on the floor were damp, but there was “no visible water.” SM13 noted that the work order was documented as “Routine.” The surveyor inquired what would have been done if the water was “spraying out” and SM13 stated that “it would have been taken care of right then.” SM13 stated that work orders are prioritized based on the priority level identified by the person submitting the work order. SM13 stated that the nurse entered the work order as “routine.” SM13 stated that there is no training of staff about priority levels for work orders, the priority level is designated based on the staff members assessment of the situation. SM14 later confirmed that there is no facility policy or procedure that outlines “priority” designations for work orders. During an interview on 12/5/2023 at 3:32 p.m., SM20 stated that P1’s spouse was upset about the leaking toilet and a work order was submitted, but facilities couldn’t come fix it that evening since it wasn’t an “emergency.” SM20 did not recall any other information about the leak including when it was fixed or other concerns from the spouse. SM20 did not recall if there was a bedside commode in the patient’s room. During an interview on 12/5/2023 at 3:38 p.m., SM21 recalled that P1’s spouse made the staff aware that there was a “leak” in P1’s bathroom, and that absorbent mats were placed around the toilet. SM21 did not recall if the patient had a bedside commode and did not assist P1 to the toilet or the shower. On 12/6/2023 at 11:40 a.m., SM8 confirmed that there was no evidence in P1’s medical record documenting that the patient was offered or given a commode, or that the patient used or was assisted to the commode during the patient’s admission. A review of the rehabilitation units census from 9/20/2023 through 9/25/2023 provided by SM1 on 12/6/2023 at 11:25 a.m. contained evidence that there were between thirteen (13) to sixteen (16) patients on that unit on any of those nights. SM5 had stated that there were seventeen (17) rooms on the rehabilitation unit, so as per the above census information, there would have been a room available every night even if all patients on the census had their own room. As per the complaint, P1’s spouse requested to be moved to a different room, but was told there were no other beds available. Document Review A review of the facility’s policy titled “Patient Rights” states in part: ... 4. Personal Safety - The patient and/or patient’s representative have the right to receive care in a safe setting, free from all forms of abuse, neglect, harassment, and mistreatment, as well as an expectation of reasonable safety insofar as the Hospital practices and environment are concerned. The above concerns were discussed at the exit conference on 12/6/2023 at 12:30 p.m.”