Centra Health - Lynchburg Gen Hospital

“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: 33906 Based on interview and document reviews the hospital failed to provide patients with the Important Message for Medicare (IMM) for 3 (three) of 4 (four) visits reviewed affecting 2 (two) patients. Patient #4 and Patient #5. The findings include: Review of the medical record for Patient #4 revealed hospitalizations on 2/6/2026 through 2/14/2026 and on 2/16/2026 through 3/6/2026. The record failed to document evidence the hospital staff provided the IMM for the 2/14/26 discharge. Review of the medical record for Patient #5 revealed hospitalizations on 1/16/2026 through 1/23/2026 and on 1/24/2026 through 1/28/2026. The record failed to document evidence the hospital staff provided the IMM for either of the discharges. Interview with Staff #12 on 3/31/26 at 1:03 PM, revealed it is part of the duties of the care management team to ensure the patient is provided with the IMM which informs the patient of their right to appeal a discharge, the process to file the appeal if they feel they are being discharge too soon.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 33906 Based on observations, interview, document review, and the investigation of a complaint it was determined the facility failed to provide adequate oversight of the sterilization process. The findings included: Facility quality measures related to monitoring of surgical instruments conditions and reporting of instrument issues failed to identify surgical instruments that should have been replaced, repaired and/or removed from service. Cross reference: §482.21(a), 482.21(b)(1), 482.21(b)(2)(i) - Quality Assessment and Performance Improvement Program (QAPI) Scope and §482.21(b)(3) - QAPI Data Collection”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 33906 Based on observation, interviews, document review and the investigation of a complaint, the facility failed to ensure the prevention and potential spread of infectious diseases to patients receiving surgical services by failing to monitor and ensure the proper decontamination and sterilization of surgical instruments. Findings include: Observations of sterile surgical trays conducted on February 12, 2024, revealed concerns related to the proper decontamination and sterilization of surgical instruments which have the potential to adversely affect patients undergoing a surgical procedure. Inspections of five surgical instrument trays revealed pitting, scribing and staining of instruments in all five trays and identified additional infection control concerns. Cross reference 482.42(a)(3), The Infection Prevention and Control Program”

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 33906 Based on observation, interview, document review, and the investigation of a complaint, it was determined the facility’s Quality Assurance and Performance Improvement Program (QAPI) after implementing actions to improve the sterilization process for surgical instruments, failed to measure the effectiveness of the actions taken, by tracking, trending, and analyzing reported issues. The failure resulted in the survey team observing surgical instruments that were inadequately sterilized and/or in need of replacement and/or repair in five (5) of five (5) surgical trays included in the survey sample. The findings include: On February 12, 2024 at 2:05 PM the survey team made observations in the Central Sterile Processing (SPD-Sterile Processing Department) where surgical instruments are decontaminated and sterilized. Present during the tour were hospital Staff #6, Staff #7, Staff #8, Staff #10, Staff #11 and Staff #15. After a tour of the area, the survey team asked to inspect five (5) “ready for use” surgical trays. The surveyors inspected the following surgical trays processed at the facility’s SPD: 1. a “cardio-thoracic set” processed 2/6/24- had a small brown colored spot. 2. a “lap set” processed 2/12/24- contained a sticky residue on two instruments and a small moveable white spot on another instrument and two instruments had visible pitting. 3. a “lap soft tissue set” processed 2/10/24- included an instrument with a white residue that easily rubbed off, an instrument with dark brown material that easily rubbed off and three visibly pitted instruments. 4. a “total knee set” processed 2/12/24- had an instrument with residue that could be removed with fingernail and three instruments with pitting and deep scratches at the tip of instruments. 5. “colon closing tray” processed 2/7/24- included an instrument with a brown substance that easily wiped off. The survey team identified concerns for five (5) of five (5) trays. (see A-0750). Each finding of concern was witnessed and confirmed by a member of the hospital staff accompanying the survey team. Failure to track surgical instruments and/or surgical trays returned to SPD (Sterile Processing Department) Review of the facility’s QAPI documentation for the past 12 months including infection control (IC) plan and meeting minutes, revealed the facility was aware of issues related to the sterilization of surgical instruments in April 2023. Review of facility document “Sterilization- Biological & UISS” presented by the Infection Control Committee on 4/19/23, revealed, in part: ... “Huddle Point: Quality Checks of Surgical Instruments Before Use:” ... “Background: Throughout the system, (hospital name) staff and (healthcare performance improvement company) surveyors have found surgical instruments that were not properly stored, had compromised packaging, instruments with visible damage, and single use items that have been mistakenly reprocessed. All of the items could potentially cause harm if used on a patient.” Noted under “Sterile Instrument Quality Checklist ... Returning Instrument to SPD” ... “3. A Surgical Instrument Documentation Form must be fully completed and accompany all instrument {sic} returned to SPD for reprocessing.” The document indicates there is no education in place to guide staff on how to perform quality checks on sterilized surgical instruments and includes recommendations for Surgical Services and Infection prevention to develop education. The document also explains what quality checks should focus on -instruments are stored in appropriate area, barrier wrap has not been compromised, chemical indicator appropriate color, instruments are clean and have no visible damage and single use items have not been reprocessed. QAPI documentation failed to identify any corrective actions that would be taken and how their affectivity would be monitored and revised if needed. The facility provided mandatory In -service for SPD and OR staff as following: 4/12/23 “Visual Inspection of Instruments, 4/26/23 “(company name): Borescopes”, 5/3/23 “(company name): Verify All Clean, Ultrasonic Verify”, 7/19/23 “(company name): Protecting your instruments”, 7/27/23 “(company name): Inspection and Assembly” and on 10/25/23 “Protecting Your Instruments.” On February 13, 2024 at 1:00 PM, Staff #10 and Staff #15, provided the survey team with a document (chart) showing random audits findings, conducted by SPD and/or IC staff, for year 2023. The document failed to identify how many audits were conducted only that a total of 81 errors (i.e broken/damaged instruments, missing indicator, incorrect/missing/extra instruments in the tray, dirty instruments...) were identified in the year 2023. Staff #10 and Staff #15 indicate no specific staff was assigned to track, trend and/or monitor the identified errors and the data had not been analyzed in detail (i.e. type of instruments returned, type of surgical trays, assembler, etc.) The survey team was provided evidence of five (5) tray audits conducted in January 2024, by Staff #25 (SPD educator), with the last one performed on 01/15/24. It was indicated to the surveyor the SPD educator would have addressed the findings of audits they conduct with SPD staff. The survey team was not provided with documentation of how processes in SPD are regularly monitored by infection preventionist and/or quality control staff. Staff #10 and Staff #15 indicated the Quality and Education position for SPD had been consolidated in 2023 and that staff education is tailored according to audit findings by Staff #25. Failure to implement an effective mitigation plan The survey team’s findings during inspection of five random surgical trays (noted above) indicated the facility’s actions to mitigate identified issues with the sterilization process were ineffective. The facility’s lack of tracking, trending and analyzing for surgical trays returned to SPD due to issues with contamination or condition of instruments, failed to provide the information needed to monitor the plan and make needed changes. In an interview on February 12, 2024, Staff # 11 indicated the instruments should have been removed from the trays when they were assembled. Staff #11 revealed they (SPD) do not audit of surgical trays “not anymore”. The facility “used to have a Quality Coordinator that did that” and they are looking at adding that task to someone’s job duties. Staff #11 explained the process for returning surgical instruments to the SPD for issues related to contamination or damage as follows: OR staff would (when finding an issue) complete a form titled “Audit Tracking Tool for Case Carts” or “error sheet”. The tracking document is returned to SPD with the tray. There the instrument identified as defective or needing repair is tagged and placed in the repair bin by SPD staff. Staff #11 informed the survey team that they have a company that comes by and checks the instruments and makes repairs. Staff were unable to provide the survey team with documentation of tracking and trending of returned trays and/or the reporting of issues to QAPI. The hospital uses “SensiTrac” (instrument tracking system) to track location and use of instruments but the system is not being used to track returned instruments/trays. On February 13, 2024 at 1:00 PM, Staff #10 and Staff #15 met with the survey team to provide more information related to the surveyor’s observations in SPD. Staff #15 revealed in the interview “we should have caught it” and discussed immediate actions that had been implemented by the facility since the above noted observation of the survey team. A “Surgical Instrument Action Plan” was created to address survey findings and was shared with the survey team. The actions included an immediate Safety Stand Down held with all staff in sterile processing and operating room to discuss the concerns. The survey team was advised the company contracted to maintain surgical instruments had been contacted and representatives are on site to begin the process of instrument evaluation for all trays.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 33906 Based on observations, interviews, document review and the investigation of a complaint, the facility failed to ensure the prevention and potential spread of infectious diseases by failing to ensure the proper decontamination and sterilization of surgical instruments. The survey team inspected five (5) surgical trays that were identified as sterile and ready for use. Five (5) of five (5) trays observed contained visibly damaged and/or contaminated instruments. The findings included: On February 12, 2024 at 2:05 PM the survey team made observations in the Central Sterile Processing (SPD-Sterile Processing Department) where surgical instruments are decontaminated and sterilized. The surveyors were accompanied by Staff #6, Staff #7, Staff #8, Staff #10, Staff #11 and Staff #15. After a tour of the area, the survey team asked to inspect five (5) post-sterilization trays. The surveyors inspected the surgical trays and observed the following: 1. a “cardio-thoracic set” processed 2/6/24- had a small brown colored spot. 2. a “lap set” processed 2/12/24- contained a sticky residue on two instruments, a small moveable white spot on another instrument and two instruments had visible pitting. 3. a “lap soft tissue set” processed 2/10/24- included an instrument with a white residue that easily rubbed off, an instrument with dark brown material that easily rubbed off and three visibly pitted instruments. 4. a “total knee set” processed 2/12/24- had an instrument with residue that could be removed with fingernail and three instruments with pitting and deep scratches at the tip of instruments. 5. “colon closing tray” processed 2/7/24- included an instrument with a brown substance that easily wiped off. The survey team identified concerns in five (5) of five (5) trays. Each finding of concern was shown to a member of the facility staff accompanying the survey team. The facility was aware of issues related to the sterilization of surgical instruments as evidenced by review of facility document “Sterilization- Biological & UISS” presented by the Infection Control Committee on 4/19/23. The document revealed, in part: ... “Huddle Point: Quality Checks of Surgical Instruments Before Use:” ... “Background: Throughout the system, (hospital name) staff and (healthcare performance improvement company) surveyors have found surgical instruments that were not properly stored, had compromised packaging, instruments with visible damage, and single use items that have been mistakenly reprocessed. All of the items could potentially cause harm if used on a patient.” Noted under “Sterile Instrument Quality Checklist ... Returning Instrument to SPD” ... “3. A Surgical Instrument Documentation Form must be fully completed and accompany all instrument {sic} returned to SPD for reprocessing.” The facility didn’t provide documentation of any actions taken, monitoring and assessment or of corrective measures beyond providing staff training. The facility provided mandatory In -service for SPD and OR staff as following: 4/26/23 “(company name): Borescopes”, 5/3/23 “(company name): Verify All Clean, Ultrasonic Verify”, 7/19/23 “(company name): Protecting your instruments”, 7/27/23 “(company name): Inspection and Assembly” and on 10/25/23 “Protecting Your Instruments.” Facility policy “Infection Prevention Ch 01: Infection Prevention Program” effective 5/21/2021, revealed, in part: “ ...O. Policies governing low and intermediate level cleaning and disinfection, high-level disinfection and sterilization will be implemented and monitored.” Facility policy “Infection Prevention: Surveillance, Prevention, and Control of Infection” revealed, in part: “ ... II. Prevention and Control of Infection - Evidence Based Practices A. (hospital name) will use evidence based practices to prevent the transmission of infectious disease throughout the organization. B. Evidence based practices are those recommended or mandated by governmental agencies such as the Centers for Disease Control and Prevention, the Food and Drug Administration (FDA), or professional organizations such as the Association for Professionals in Infection Prevention and Control (APIC), the Association of perioperative Registered Nurses (AORN), or Association for the Advancement of Medical Instrumentation (AAMI) Standards.” On February 13, 2024 at 1:00 PM, Staff #10 and Staff #15 met with the survey team to provide additional information. The survey team was provided with a document evidencing results of unknown number of random surgical trays audits conducted in 2023. The document (chart) failed to identify how many audits were conducted only that a total of 81 (eighty-one) errors (i.e broken/damaged instruments, missing indicator, incorrect/missing/extra instruments in the tray, dirty instruments...) were identified in the year 2023. The survey team was provided evidence of five (5) tray audits conducted in January 2024, by Staff #25 (SPD educator), with the last one performed on January 15, 2024. It was indicated to the surveyor the SPD educator would have addressed the findings of audits they conduct with SPD staff. Staff #10 and Staff #15 indicated the Quality and Education position for SPD had been consolidated in 2023 and that staff education is tailored according to audit findings by Staff #25. In an interview on February 13, 2024 at 11:45 AM, Staff #18 and Staff #19, indicated a team which includes infection preventionists make environment of care rounds in SPD. The team makes observations of general cleanliness of the area, look for integrity of packaging, expiration dates , check individually packaged instruments for integrity and that instruments are not clamped. They do not audit surgical instrument trays. Their goal is to round at least quarterly. Per Staff #11 a contracted staff #24 performs at least once per week preventive maintenance of instruments that are due and inspects instruments placed in the “repair bin”. Based on their condition Staff #24 repairs, removes, replaces or orders new items. In an interview on February 13, 2024 Staff #15 indicated, “we should have caught it” and explained the immediate actions that had been implemented by the hospital since the discovery by the survey team the previous day. A “Surgical Instrument Action Plan” was created to address survey findings and was shared with the survey team and included an immediate Safety Stand Down held with all staff in sterile processing and operating room to discuss the concerns. The company contracted to maintain surgical instruments had been contacted and representatives were on site to begin the process of instrument evaluation for all trays. The survey team identified multiple issues related to the condition of surgical instruments indicating a systemic problem.”

“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: 46466 Based on interviews, medical record review and facility document review, the facility staff failed to evaluate and assess one (1) of three (3) patient’s care needs according to facility policy. Patient #1 (P1) The findings include: On 1/8/24 at 2:15 p.m., a review of three (3) patient records included in the survey sample was conducted with Staff Members #6, #8, and #9. A hospitalist progress note for Patient #1 (P1) documented on 5/17/23 at 10:56 p.m. noted, “...Patient had a fall tonight, with hematoma of the forehead, CT head obtained, showing acute left frontal subdural hematoma measuring 11 mm in thickness, Patient has been confused per nursing, even prior to the fall, no change in (P1’s) mentation, no headache, Continue with frequent neurochecks, every 4 hours headache (sic). Discussed with neurosurgery (physician name) on call tonight, (physician) agreed with discontinuation of heparin, and repeat CT head in 6 hours. Neurosurgery consult in the morning...”. A review of P1’s Post Fall Follow up on 5/17/23 at 10:30 p.m. documented “...Fall Follow Up With Head Strike - no change, reassess q4 hrs for 48 hours...”. A review of the nursing flowsheet from 5/17/23 at 8:00 p.m. through 5/19/23 at 9:36 a.m. revealed that P1’s assigned nurses performed neurology checks on P1 at the following dates and times: 5/18/23 at 2:00 a.m. 5/18/23 at 8:00 a.m. 5/18/23 at 12:00 p.m. 5/18/23 at 2:30 p.m. 5/18/23 at 9:30 p.m. 5/19/23 at 9:36 a.m. Staff Member #1 (SM1) confirmed in an interview on 1/9/24 at 11:00 a.m., that the dates and times listed on the nursing flowsheet for P1’s neurology checks were correct and the neurology checks were not completed every four (4) hours for forty-eight (48) hours after P1’s fall. A review of the facility’s policy titled “Patient Care Services Falls Risk Assessment/Preventative Measures”, last reviewed 6/12/23, stated in part: “...10. Document “Fall Follow-up” every 4 hours for 48 in the event of a Head Strike”. The findings were discussed with Staff Members #1, #4, #19, #22 and #23 at the exit conference on 1/9/24 at 1:40 p.m.”

“PATIENT RIGHTS: PRIVACY AND SAFETY CFR(s): 482.13(c) Patient Rights: Privacy and Safety This Standard is not met as evidenced by: 45736 Based on medical record review, staff interview and facility document review, the facility staff failed to ensure Patient 1’s (Pt1) family was notified of their fall that occurred on 12/14/23 at 1:25 a.m., as per facility policy. The findings included: Pt1 was admitted to this facility on 12/6/23 for management and evaluation of fluid overload causing shortness of breath, generalized swelling and substantial weight gain. The review of Pt1’s medical record contained fall documentation by nursing staff. Staff member #12 (SM12), on 12/14/23 at 1:25 a.m., documented in part, “Notified (doctor) of patient fall. Patient had called using call light, CNA (certified nursing assistant) answered the call light to find patient sitting on the floor. No obvious injury. Patient has been sitting/sleeping in chair per patient preference and stated (they) slipped out of the chair. Patient is alert and oriented without any deficits noted, however, when asked if patient hit head, patient stated head hit floor. Vital signs WNLs (within normal limits). New order for head CT without contrast. Will continue to monitor.” Staff Member #9 (SM9) on 12/14/23 at 6:09 a.m., documented in part, “Patient experienced an unwitnessed fall at 0130. This nurse found the patient sitting on the floor after (they) pressed the call light for help. Patient stated, “I was pulling my blanket up and leaned forward, I just tipped over.” Assist x3 to help patient back to bed. VS (vital signs) taken, paged doctor. Patient stated (they) hit their head- STAT Head CT performed. Currently patient is on 4-5 L NC (nasal cannula) while asleep, but baseline is 2LNC. No changes in AO (alert oriented) status, remains A&Ox4. No complaints of pain per patient. Bed alarm on, call light within reach, bed locked and in lowest position. Plan of care ongoing.” In an interview with SM9, the morning of 1/9/24, the surveyor asked about Pt1’s fall and actions that were taken. SM9 stated that they found Pt1 on their bottom on the floor. Once it was known that Pt1 hit their head, a CT of the head was ordered, vital signs were taken and Pt1 was alert and oriented to person, place, time and event. With assistance from other staff, Pt1 was placed back into the bed. SM9 confirmed that they didn’t notify Pt1’s family at the time of the fall and didn’t call Pt1’s family prior to their shift ending on 12/14/23. In an interview with SM12, the morning of 1/9/24, the surveyor asked about Pt1’s fall and actions that were taken. SM12 recalled that they were notified of the fall around 1:30 a.m. of this unwitnessed fall. They went to Pt1’s room and asked for additional assistance with getting Pt1 back in bed. They assessed Pt1 injuries and found none. Pt1 was alert and oriented, and once up off the floor, they walked to the bed with assistance. SM12 requested that SM9 do the event write up and to notify the doctor and Pt1’s family. SM12 entered the adverse event in the facility’s adverse event system. SM12 told the surveyor that they did not call Pt1’s family and did not follow up to see if the family was called prior to their shift ending on 12/14/23. In an interview with SM10, the morning of 1/9/24, when the surveyor asked about the procedure related to notifying the family of a fall, SM10 stated, “Family would be notified of a fall.” A facility policy, Patient Care Services Falls Risk Assessment/Prevention Measures, last reviewed 06/12/2023, evidenced, in part, “ ...G. Post Fall Actions ...4. Notify family.” This identified deficiency was discussed with the leadership team at the exit conference on 1/9/24 at 1:45 p.m.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 45736 Based on medical record review, staff interview and facility document review, the facility staff failed to ensure: A, one (1) of three (3) patients included in the survey sample received an initial skin assessment and ongoing skin assessments every twenty-four (24) hours, as per facility policy. Patient #1 (Pt1) B, one (1) of three (3) patients received hourly monitoring as per facility policy. Patient #1 Findings included: A, Pt1 was admitted to this facility on 12/6/23 for management and evaluation of fluid overload causing shortness of breath, generalized swelling and substantial weight gain. The review of Pt1’s medical record failed to contain evidence clinical staff completed on admission an appropriate initial skin assessment, including presence or absence of pressure injuries. During this hospital stay Pt1’s medical record evidenced two (2) of seven (7) skin/pressure injury assessments were completed. First skin/pressure injury assessment was completed on 12/7/23 at 7:30 p.m. and a sacral (area at lower back/tailbone) wound was noted in the flowsheet. The second skin/pressure injury assessment was completed on 12/9/23 at 9:45 a.m. and a sacral injury was noted in the flowsheet. The medical record failed to contain evidence of interventions taken to treat and/or prevent worsening of the pressure injury. Documentation in the facility’s adverse event log evidenced the following, “12/14/23 Skin/Tissue, Patient found to have a stage II on sacral area.” In an interview with Staff Member #5 (SM5) on 1/8/24 at approximately 2:45 p.m., the surveyor asked SM5 about the timing of skin assessments at this facility. SM5 explained that a skin assessment is conducted on admission and then additional skin assessments should be performed every twenty-four (24) hours. A facility policy titled “Pressure Injuries, Prevention and Care”, last review date 04/28/2021, evidenced, in part, “I. Assessment ...a. An RN (registered nurse) and an RN or LPN (licensed practical nurse) is to perform a skin and/or wound assessment on admission. b. An RN is to perform a skin and/or wound assessment every 24 hours and when there is a change in status.” B, Pt1’s complete medical record was reviewed on 1/8/24 at 2:15 p.m., including Pt1’s hourly rounding flowsheets from 12/6/23 through 12/14/23. These flowsheets included rounding on patients for: bathroom, pain, position, personal items, plan, and precautions. Three (3) of nine (9) daily flowsheets evidenced that Pt1 did not receive appropriate hourly rounding on those days. 12/7/23- between the hours of 12:00 a.m. and 11:40 p.m., nineteen (19) of twenty-four (24) patient checks were completed. 12/8/23- between the hours of 2:08 a.m. and 10:00 p.m., fifteen (15) of twenty-four (24) patient checks were completed. 12/9/23- between the hours of 12:36 a.m. and 11:00 p.m., sixteen (16) of twenty-four (24) patient checks were completed. Pt1 was off the unit for five (5) hours and sixteen (16) minutes. A facility policy titled “Patient Care Services Falls Risk Assessment/Prevention Measures”, last reviewed 06/12/2023, evidenced, in part, “ ...C. Interventions 1. All patients are to have intentional rounding addressing the 6 Components defined below: Bathroom ....Pain ...Position ...Personal Items ...Plan ...Precautions ...Hourly visual checks (assessing the six components of rounding).” These identified deficiencies were discussed with the leadership team at the exit conference on 1/9/24 at 1:45 p.m.”