Bon Secours St Marys Hospital

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 45736 Based on medical record review, interview and document review, it was determined the facility failed to assess vital signs for two (2) of three (3) patients (Patient #8 and #9) according to their facility blood transfusion policy. The findings include: During blood transfusion medical record review for Patient #8, the afternoon of January 20, 2026, with Staff Member #5, it was determined that Patient #8’s had a blood transfusion of packed red blood cells, on January 17, 2026, that began at 11:13 AM and ended at 1:20 PM. Patient #8 had a full set of vital signs assessed 11:13 AM, 11:38 AM and 6:00 PM (greater than 60 minutes after the end of the transfusion). During blood transfusion medical record review for Patient #9, the afternoon of January 20, 2026, with Staff Member #5, it was determined that Patient #9’s had a blood transfusion of packed red blood cells, on January 12, 2026, that began at 12:21 PM and ended at 3:39 PM. Patient #9 had a full set of vital signs assessed 12:21 PM, 12:37 PM, 1:34 PM, and 5:46 PM (greater than 60 minutes after the end of the transfusion). During an interview with Staff Member #5, the afternoon of January 20, 2026, the surveyor asked what vital signs are to be assessed and documented. Staff Member #5 stated, “a full set,” indicating that that would include blood pressure, temperature, pulse, oxygen saturation, temperature, and respirations. A facility policy, Transfusions of Blood Products, last revised August 8, 2025, revealed, in part, “...E....8. Vital signs are performed: a. within 30 minutes prior to start of transfusion. b. approximately 15 minutes after start of the transfusion (the start time is when the blood reaches the patient). c. within 60 minutes after the end of the transfusion, and d. as needed based on clinical observation or if patient reports new symptoms of transfusion reaction...””

“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: 42725 Based on record review, document review, and interview, it was determined the facility staff failed to obtain an order for the use of a restraint for the management of one (1) violent or self-destructive patient (MR2). Findings: Review of facility document, Restraints or Seclusion for Violent, Self-Destructive Patient Situations, under the heading “D. Restraint or Seclusion Order (to manage violent or self-destructive behavior)”, it partly reads: “1. Any type of violent restraint including, but not limited to, 4-point restraints, chemical restraints, physical hold, or use of force in order to medicate a patient, seclusion, etc. requires a provider order. 2. In the absence of an order, the RN may initiate use of restraints or seclusion in emergency situations. In emergency situations, the order must be obtained either during the emergency application of the restraint or initiation of seclusion or immediately (within a few minutes) after the restraint has been applied or seclusion has been initiated. Failure to immediately obtain an order is viewed as the application of a restraint or seclusion without an order. [CMS.482.13(e)(5)]...”. The document was effective November 20, 2025, with a change relating to the removal of immediate notification and CNO within 4 hours. The prior version of the document was effective June 23, 2025. A comprehensive review of MR2 revealed that on September 30, 2025 at 3:30 PM, MR2 was observed becoming “increasingly agitated” walking back to the stretcher after using the restroom. EMP11 noted that the patient was screaming and was moved into room 17 with law enforcement remaining at the bedside. EMP13 entered a note at 4:29 PM that read, “The patient increasingly agitated in the emergency department, kicking, threatening to bite, and spitting on staff. Patient required physical restraint by staff followed by 4 point forensic restraints to shackled the patient to the bed. [Patient] received 5 mg of IM Haldol as well as 5 mg of IM Valium for chemical restraint”. Interview on December 17, 2025 at 3:34 PM, EMP13 indicated that MR2’s behavior began to escalate and continued to escalate. EMP13 acknowledged that MR2 was offered medication, but “[patient] continued to decline it”. MR2’s behavior escalated to the point that “[patient] became physical with staff” and “we had to take the action most appropriate at the time of the incident”. EMP13 acknowledged that a physical hold (by facility staff) was necessary to de-escalate the patient and administer IM medications. A review of the orders during MR2’s ED visit did not reveal a physician’s order for restraints; for either the physical hold or the chemical restraint.”

“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: 42725 Based on record review, document review, and interview, it was determined the facility staff failed to monitor two (2) patients in restraints as directed by facility procedure (MR2 and MR8). Findings: Review of facility document, Restraints for Nonviolent, Non-Self-Destructive Patient Situations: Medical Use of Restraints, under the heading “V. Procedure”, it partly reads: “... F. SAFE APPLICATION / MONITORING / DOCUMENTATION / REMOVAL ... 2. Monitoring / Documentation a) A patient’s physical and emotional needs are considered while the individual is in restraint. The basic rights of human dignity and respect are maintained, ... c) Assessment of the patient during restraint use is the responsibility of the Registered Nurse or LPN under the supervision of the RN ... d) Every 2 hours, perform the following: i. Continued Justification ii. Visual/Safety check iii. Circulation / Skin Integrity iv. Range of Motion v. Fluids vi. Food and Meal vii. Elimination e) Vital signs as indicated by patient status...”. The document was effective on October 27, 2025. Review of facility document, Restraints or Seclusion for Violent, Self-Destructive Patient Situations, under the heading “F. SAFE APPLICATION / MONITORING / DOCUMENTATION / REMOVAL”, it partly reads: “... 2. Monitoring / Documentation a) Any patient placed in restraints or seclusion for the management of violent or self-destructive behavior must be monitored continuously by trained staff until the restraints are removed or seclusion is discontinued... g) Assessment of the patient during restraint or seclusion use is the responsibility of the Registered Nurse... h) Minimum Documentation in the medical record from restraints or seclusion related to violent and/or self-destructive behavior includes: i. Every 15 minutes, assess the need for intervention on the following: a. Checking Circulation & Restraint applied properly (not applicable to seclusion) b. Continuous Observation c. Physical Comfort d. Psychological status...”. The document was effective November 20, 2025, with a change relating to the removal of immediate notification and CNO within 4 hours. The prior version of the document was effective June 23, 2025. A review of MR8 revealed an order for “restraints non-violent or non-self-destructive” was entered on November 1, 2025 at 6:15 PM. The restraint type used were soft bilateral (both) wrist and they were applied at 6:30 PM. The restraints were discontinued on November 2, 2025 at 1:01 AM. Between the time of application and the time of discontinuation, there was no documentation to indicate the patient was monitored every two hours as the facility’s procedure instructs. A comprehensive review of MR2 revealed that on September 30, 2025 at 4:29 PM, EMP13 entered a note that read, “The patient increasingly agitated in the emergency department, kicking, threatening to bite, and spitting on staff. Patient required physical restraint by staff followed by 4 point forensic restraints to shackled the patient to the bed. [Patient] received 5 mg of IM Haldol as well as 5 mg of IM Valium for chemical restraint”. Interview on December 17, 2025 at 3:34 PM, EMP13 indicated that MR2’s behavior began to escalate and continued to escalate. EMP13 acknowledged that MR2 was offered medication, but “[patient] continued to decline it”. MR2’s behavior escalated to the point that “[patient] became physical with staff” and “we had to take the action most appropriate at the time of the incident”. EMP13 acknowledged that a physical hold (by facility staff) was necessary, lasting “approximately about twenty minutes”, to de-escalate the patient and administer IM medications. There was no documentation to indicate that MR2 was monitored as instructed by the facility’s procedure for violent, self-destructive 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: 42042 Based on interview, medical record, and facility document review, it was determined the facility failed to perform all necessary vital signs-to include temperature monitoring-within sixty minutes of completion of blood product transfusion, per policy, for two (2) of four (4) patients reviewed. The findings include: The facility’s policy titled “Transfusion of Blood Products” (effective date 08/08/2025), stated in part, “Vital signs are performed ...within 60 [sixty] minutes after the end of the transfusion ...”. On 09/09/2025 at 2:04 PM, the surveyor initiated the medical record review of four sampled patients (Patient # 3-6) who had received recent blood product transfusions with the assistance of Staff Member #3 and Staff Member #4. The following information was ascertained from the blood transfusion records of Patient #5 and Patient #6: Patient #5: Blood product was transfused on 09/08/2025 between 10:35 AM until 1:45 PM. Vital sign flowsheet record indicated that the patient’s temperature was not collected until 09/08/2025 at 4:00 PM following transfusion completion. Patient #6: Blood product was transfused on 09/08/2025 between 11:31 AM until 2 :00 PM. Vital sign flowsheet record indicated that the patient’s temperature was not collected until 09/08/2025 at 4:00 PM following transfusion completion. In the afternoon of 09/09/2025, the surveyor verified and confirmed with Staff Member #3 during interview that there were no other recorded temperatures documented within the medical record for either aforementioned patient within one hour of transfusion completion. On 09/10/2025 at approximately 1:30 PM, the surveyor met with Staff Member #2, Staff Member #11, and Staff Member #12. The surveyor reiterated the above findings and received confirmation that appropriate temperature monitoring throughout a blood transfusion is an important component in assessing for transfusion-related reactions.”

“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: 40084 Based on observation, interviews and facility document review, it was determined the facility failed to inform patients/patient representatives of their patient rights and responsibilities upon entry to the facility. The findings include: On April 22, 2025 at 11:50 AM, Staff Member #6 conducted a tour of the facility’s Adult ED waiting area. The location where the “Patient Rights and Responsibilities” signage was to be posted, was empty. Staff Member #6 did not know the reason that the signage was taken down. Staff Member #6 and the surveyor walked over to the separate Pediatric ED and found posted Patient Rights and Responsibilities signs in English and Spanish. The signs did not include information indicating how a patient could obtain a copy of their Patient Rights and Responsibilities. On April 22, 2025 at 11:45 AM, an interview was conducted with Staff Member #6. Staff Member #6 stated that the Patient Registration personnel in the Emergency Department (ED) did not discuss patient rights information while registering patients. Staff Member #6 explained that Patient Rights and Responsibilities are posted on a sign in ED waiting room. Staff Member #6 explained that the script contained in the policy “Consent for Treatment Fact Sheet”, effective 3/19/24, did not include any verbiage about Patient Rights. Staff Member #6 stated that if a patient requested a copy of their Patient Rights in a manner that they could understand (i.e. blind, speaks a language other than English or Spanish per the posted signs), then the patient would be provided with a copy or with an interpreter to review their rights. Staff Member #6 stated that Patient Registration used to provide printed brochures to patients, but they ran out of copies and did not know how to order any more. On April 22, 2025 at 11:51 AM, an interview was conducted with Staff Member #14. When asked for a copy of the facility’s “Patient Rights and Responsibilities”, Staff Member #14 left the desk and retrieved a laminated, ringed copy of the facility’s “Patient Agreement”. Staff Member #14 pointed to the underlined headings - Consent to Medical Examination, Care & Treatment: Telehealth, Medical Education Programs and Affiliated Provider Fees, indicating that these were the Patients Rights and Responsibilities. Staff Member #14 did not provide a copy of the facility’s Patient Rights and Responsibilities. A review of a policy, (not affiliated with the facility) “Front End: Consent for Treatment Fact Sheet”, effective date 3/19/24, did not contain any information related to the facility’s Patient Rights and Responsibilities. A review of the facility’s policy “Individual’s Rights and Responsibilities”, effective date, 12/19/24, indicated in part: “...Patients/residents/clients shall receive patient rights information at the point of entry of service that informs them about their rights...”. A review of the facility’s “Patient Agreement” retrieved from a sampled medical record and signed by a patient, indicated in part: “...I acknowledge that (facility) has made available to me those notices that are required by State or Federal law, including Patient Rights & Responsibilities documentation, and I understand that I may ask (facility) any questions about such notices...”. This was the only reference to Patient Rights found in the entire agreement.”

“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 facility failed to obtain an accurate order for restraint use in one (1) of four (4) medical records of patients in restraints reviewed in the survey sample MR7 (Medical Record). Findings: A review of MR7 revealed a nursing progress note on April 9, 2025 at 11:28 PM that indicated the patient was anxious, crying, and yelling. The patient was offered medication for anxiety, but the patient refused. At midnight on April 10, 2025 the nurse documented that the patient was agitated and repetitively banging their head on the side rails, causing a cut on the forehead. Security was called and responded. The nurse documented at midnight, “Patient becoming more agitated, physically and verbally aggressive, and trying to harm self by constantly hitting head on bed rails. Soft wrist restraints were applied.” MR7 contained an order for restraints placed at 1:51 AM by the night shift nurse practitioner. The order was for “Restraints non-violent; non-self destructive...Soft bilateral wrist restraints.” The documented reason for restraint was, “interference with medical treatment, pulling lines, tubes, dressing, equipment” despite no evidence in the medical record that the patient was pulling at lines or tubes. The only documented behaviors in the medical record necessitating restraints were related to self-destructive behaviors, but the practitioners orders for restraints were for non-violent restraints instead of violent or self-destructive restraints. The facility’s policy, Restraints or Seclusion for Violent, Self-Destructive Patient Situations (last revised 12/20/24), was reviewed and reads in part, “...any type of violent restraint....requires a provider order. In the absence of an order, the RN may initiate use of restraints or seclusion in an emergency situations. In emergency situations, the order must be obtained either during the emergency application of the restraint or initiation of seclusion or immediately (within a few minutes) after the restraint has been applied or seclusion has been initiated. Failure to immediately obtain an order is viewed as the application of restraint without an order.” MR7 contained documentation that restraints were applied at midnight, and an order for the restraints was not obtained until 1:51 AM on April 10, 2025 (almost two hours after the initiation of restraints). An interview was conducted with EMP16 at 11:58 AM on April 22, 2025. EMP16 confirmed that staff was trained on the application and monitoring of restraints on hire and annually. EMP16 confirmed that the order for MR7’s restraints was for non-violent restraints and that there was no documentation in the medical record to support that the patient was pulling at lines or tubes. EMP16 confirmed the nurse had documented applying restraints due to the self-destructive behavior of hitting head on the bedrails causing injury and requiring security to be called.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(7) The attending physician must be consulted as soon as possible if the attending physician did not order the restraint or seclusion. This Standard is not met as evidenced by: 40084 Based on staff interview and document review, it was determined the facility failed ensure the patient’s attending physician was notified of a patient being placed in restraints in one (1) of four (4) medical records of patients in restraints reviewed in the survey sample MR7 (Medical Record). Findings: MR7 contained an order for restraints placed at 1:51 AM by the night shift nurse practitioner. The order was for “Restraints non-violent; non-self destructive...Soft bilateral wrist restraints.” The documented reason for restraint was, “interference with medical treatment, pulling lines, tubes, dressing, equipment” despite no evidence in the medical record that the patient was pulling at lines or tubes. The only documented behaviors in the medical record necessitating restraints were related to self-destructive behaviors, but the practitioners orders for restraints were for non-violent restraints instead of violent or self-destructive restraints. The facility’s policy, Restraints or Seclusion for Violent, Self-Destructive Patient Situations (last revised 12/20/24) reads, “...If violent restraints or seclusion was not ordered by the attending or the face-to-face evaluation is conducted by someone other than the attending physician...they must consult the attending physician or other licensed practitioner who is responsible for the care of the patient as soon as possible and/or after the completion of the 1-hour face-to-face evaluation....” MR7 contained no documentation that the patient’s attending physician was made aware of the order for restraints. An interview was conducted with EMP12 (employee) at 11:00 AM on April 22, 2025 who confirmed the lack of notification to the attending physician in MR7.”

“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: 40084 Based on staff interview and document review, it was determined the facility failed to ensure that patients in restraints were adequately monitored in one (1) of four (4) medical records of patients in restraints reviewed in the survey sample MR7 (Medical Record). Findings: MR7 contained an order for restraints placed at 1:51 AM by the night shift nurse practitioner. The order was for “Restraints non-violent; non-self destructive...Soft bilateral wrist restraints.” The documented reason for restraint was, “interference with medical treatment, pulling lines, tubes, dressing, equipment” despite no evidence in the medical record that the patient was pulling at lines or tubes. The only documented behaviors in the medical record necessitating restraints were related to self-destructive behaviors, but the practitioners orders for restraints were for non-violent restraints instead of violent or self-destructive restraints. MR7 contained documentation that the patient was placed in bilateral soft wrist restraints on April 10, 2025 at midnight, but contained no documentation of patient monitoring by the RN until 2:00 AM on April 10, 2025. The restraints were discontinued at 2:20 AM on April 10, 2025. The facility’s policy, Restraints or Seclusion for Violent, Self-Destructive Patient Situations (last revised 12/20/24) reads in part, “...Minimum documentation in the medical record from restraints or seclusion related to violent and/or self-destructive behavior includes: Every 15 minutes assess the need for intervention on the following: A. Checking circulation and restraint applied properly; b. continuous observation; c. Physical comfort; d. psychological status...A minimum of every two hours, assess the need for intervention on the following: a. clinical justification criteria (RN only); b. hygiene and elimination needs; c. food/meals offered/nutritional status; d. fluids/hydration status; e. ROM reposition, skin integrity checked; f. Readiness for removal of restraints or discontinuing seclusion; g. assisting individuals to meet behavioral expectations of discontinuation of restraints or seclusion....” An interview was conducted with EMP12 (employee) at 11:00 AM on April 22, 2025 who confirmed the lack of documentation of required monitoring for MR7.”

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 42042 Based on interview and document review, it was determined the facility failed to utilize the Grievance Committee for the review and resolution of a submitted grievance, and failed to notify the grievant in writing of the status of the grievance within seven (7) days for one (1) patient (Patient #1). The findings include: On 05/07/24 at 12:39 pm, the surveyor met with Staff Member #15 for interview. Staff Member #15 advised they received a verbal, telephone report of Patient #1’s complaint following the patient’s encounter while in the ED (Emergency Department). On 05/08/24 at 10:29 am, the surveyor met again with Staff Member #15 who advised that the Grievance Committee never met to review Patient #1’s documented grievance, nor was the grievant ever provided a follow-up letter regarding the review, status, or resolution of the grievance. The surveyor was supplied the facility policy titled, “Individual’s Rights and Responsibilities” (with last effective date of 05/05/23). Under “Dispute Resolution” of page four (4), the policy stated that all patients have the right to have disputes, grievances, and conflicts resolved “respectfully, in a timely manner, and in writing”. The surveyor was also supplied the facility policy titled, “Patient Complaint and Grievance” (with last effective date of 05/22/23). The policy stated, in part, that regardless of whether made verbally or in writing, any complaint received “involving or alleging a violation of a patient’s rights is a grievance”. The policy continued to state that grievances are to be reviewed by the Grievance Committee, and that the “Grievant must receive a written response which shall promptly be made within the average time frame of seven (7) days. If the grievance cannot be resolved within this seven-day timeframe, the grievant must be notified that the hospital is still working to resolve the grievance ...” On page five (5) of same policy, an algorithm depiction indicated that any verbal dispute or conflict which was not resolved in real-time regardless of whether or not it was received during admission would be classified as a formal grievance. On 05/08/24 at approximately 12:00 pm, the surveyor disseminated the findings to Staff Member # (1, 2, 4, 11, 12, 14, 26, 27). Opportunity for questions and clarification provided.”

“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: 42042 Based on interview and document review, it was determined the facility failed to obtain consent for treatment for two (2) of eight (8) patients treated at the facility (Patient #3 and Patient #6). The findings include: On 05/07/24 at 9:45 am, the surveyor initiated the medical record review of Patient # (1-8) with the assistance of Staff Member #12 who served as EMR (electronic medical record) navigator. The surveyor received information from Staff Member #13 that consent for treatment can be found on the “Universal Patient Encounter” (formerly known as “BSMH Patient Agreement”) document. During review, the surveyor was unable to locate any completed “Universal Patient Encounter” documents for Patient #3 and Patient #6 nor any other related documentation. In the morning of 07/07/24, the surveyor met with Staff Member #13 who confirmed that all patients, whether inpatient or outpatient, are expected to have informed consents for treatment unless documentation exists that support the patient’s inability to otherwise consent. The surveyor requested Staff Member #13 to verify whether there was any consent for treatment documentation available for either patient. On 05/07/24 at 11:17 am, Staff Member #13 returned to provide verbal statement that they were unable to locate any evidence of Patient #3 and Patient #6 having ever consented for treatment. Staff Member #13 added there was also no documentation of the rationale for the missing consent forms. The surveyor was provided by Staff Member #13 the facility policy titled, “Individual’s Rights and Responsibilities” (with last effective date of 05/05/23) which stated that patients have the right to be involved in decision-making and care, including consenting for treatment services. The surveyor was also provided both the Standard Operating Procedure (SOP) titled, “Patient Access: Consent for Treatment” (with last effective date of 09/01/19) and the “Front End: Consent for Treatment Fact Sheet” (with last effective date of 03/19/24) documents. The documents stated, in part, that all patients are expected to consent to, via signature, the receiving of medical care and treatment services. If unable to sign, there must be accompanying documentation in the medical record. In the afternoon of 05/07/24, the surveyor reiterated the findings to Staff Member #13 who demonstrated understanding.”

“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: 42725 Based on medical record review and document review, it was determined the facility staff failed to update the patient’s care plan based on the patient requiring a blood transfusion for three (3) of eight (8) patients sampled and failed to document patient education regarding blood transfusions for two (2) of the eight (8) patients. Findings: On 1/3/24, the surveyor reviewed eight (8) medical records for patients who received blood transfusions with SM8. For three (3) medical records, the surveyor could not find evidence that the care plan was updated to reflect the blood transfusion. Additionally, for two (2) medical records, the surveyor could not find evidence that patients received patient education regarding blood transfusions. SM8 was unable to locate an entry/update that referenced these missing items in the medical records for each patient. SM5 was present during the review and looked through the charts as well and was unable to locate the information. SM5 acknowledged that care plans should be updated to reflect the patient’s needs and patient education should be documented. SM5 provided the surveyor with the procedure document followed by the facility titled, Lippincott Procedures: Blood and blood product transfusion, that reads, in part: “... Implementation... Explain the procedure to the patient and family (if appropriate) according to their individual communication and learning needs to increase their understanding, allay their fears, and enhance cooperation... Patient Teaching... When developing a teaching plan, set objectives based on the information you gathered during your assessment. Set criteria for evaluating whether your objectives were met... Documentation... teaching provided to the patient and family (if applicable), understanding of that teaching and follow-up teaching needed...”. During the exit conference, the surveyor reviewed the findings with SMs 1, 3, 5 and 17.”

“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: 42725 Based on medical record review, interviews and document review, it was determined the facility staff failed to ensure the correct administration of a vaccine for one (1) of eight (8) patients sampled. Findings: A review of P4’s medical record evidenced that P4 received HRIG (human rabies immune globulin) and one dose of a rabies vaccine in the same anatomical site. The following was documented in P4’s record: “Most Recent Administration... 11/8/23 at 1:28 a.m. 1 mL IntraMUSCular. Deltoid Left, given by [SM12]... Most Recent Administration... 11/8/23 at 1:27 a.m. 1,740 Units IntraMUSCular left deltoid... comment: split between left & right deltoid given by [SM12]...”. The following information was available to staff at the time of HRIG medication administration: “Administration: IM... Do not administer rabies vaccine in the same syringe or at the same administration site as HRIG [human rabies immune globulin]...”. During a telephone interview on 1/3/24 at 11:20 a.m., SM9 said, “I think it’s pretty well known that they [Ig and vaccine] are given in separate sites.” During a telephone interview on 1/3/24 at 11:40 a.m., SM12 said, “I knew they couldn’t go in the same syringe [Ig and rabies vaccine], but I didn’t know they couldn’t go in the same site... I learned how to give it through my preceptor”. A facility policy titled, Medication Administration (with Barcoding) and IV Addendum, was reviewed and reads, in part: “... POLICY STATEMENT: [Name of facility[ is committed to safe medication administration by ensuring the right patient receives the right medication, by the right route, at the right time, and in the right dose... I. PERSONNEL AUTHORIZED TO ADMINISTER MEDICATIONS: A. Medications will be administered by a registered nurse (RN), licensed practical nurse (LPN),... after validation of competency... Medication safety is part of ongoing education and competencies... III. PROCEDURE: MEDICATION ADMINISTRATION:... 4. Before administering a medication, the authorized personnel are to: a. Verify the “5 Rights” of medication safety: right patient, drug, dose, time, and route...”.”

“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: 42042 Based on interviews and document review, it was determined the facility staff failed to immediately obtain an appropriate order for the use of a restraint or seclusion for the management of two (2) of three (3) violent or self-destructive patients reviewed. The findings include: On 12/12/23 at 10:12 am, the surveyor initiated the review of the restraint and seclusion documentation for Patient # (4-6) with the assistance of Staff Member #1. Under the restraint flowsheet documentation of Patient #5, the surveyor observed that seclusion was initiated from 11/10/23 at 8:15 pm until 8:45 pm for the management of violent behavior. The surveyor confirmed that the order for Patient #5’s seclusion was not obtained until 11/10/23 at 8:45 pm following the discontinuation of the restrictive intervention. Under the restraint flowsheet documentation of Patient #6, the surveyor observed that the patient was restrained in “Hard 4-Point” restraints on 10/30/23 at 9:30 pm until 10:45 pm for the management of violent behavior. The surveyor confirmed that the order for Patient #6’s violent behavioral restraints were not obtained until 10/30/23 at 9:59 pm. At approximately 10:30 am on 12/12/23, the surveyor conducted interview with Staff Member #1. Following additional review of both Patient #5 and Patient #6’s medical record, Staff Member #1 confirmed the surveyor findings were accurate. Staff Member #1 confirmed there were no other orders related to the restraint and seclusion interventions appropriate to the aforementioned timeframes. In the afternoon of 12/12/23, the surveyor reviewed the facility policy titled, “Physical Restraint or Seclusion-Use of Restraints or Seclusion for Violent, Self-Destructive Patient Situations” (with last effective date of 07/27/23). Under “Restraint or Seclusion Order (to manage violent or self-destructive behavior)” section of page two (2), the policy reads in part, “In the absence of an order, the RN may initiate use of restraints or seclusion in emergency situations. In emergency situations, the order must be obtained either during the emergency application of the restraint or initiations of seclusion or immediately (within a few minutes) after the restraint has been applied or seclusion has been initiated. Failure to immediately obtain an order is viewed as the application of restraint or seclusion without an order”. On 12/13/23 at 4:15 pm, the surveyor met with Staff Member #2 and Staff Member #9 to disseminate the aforementioned findings regarding the use of restrictive interventions with opportunity for clarification and questions.”

“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: 42042 Based on interviews and document review, it was determined the facility staff failed to administer blood products in accordance with the ordered transfusion rate of 60 mL/hr for two (2) of three (3) patients reviewed with blood product transfusions. The findings include: On 12/11/23 at 12:36 pm, the surveyor initiated the review of patients who had received blood product transfusions with the assistance of Staff Member #1 and Staff Member #6. The surveyor reviewed the order set information of Patient #2 and identified a provider order for the transfusion on 10/12/23, which stated, “Start infusion at 60 mL/hr x 15 minutes then increase rate to infuse entire unit within the specified transfusion duration above”. The blood product transfusion documentation for Patient #2 revealed that the transfusion was initiated on 10/12/23 at 8:41am with a rate of “75 mL/hr” (milliliter per hour). The same documentation revealed the rate remained unchanged throughout the remainder of the transfusion duration. The surveyor reviewed the order set information of Patient #3 which revealed the provider had ordered the transfusion of Packed Red Blood Cells on both 10/13/23 at 1:44 pm. The transfusion order had the same instructions regarding the initial transfusion rate-“Start infusion at 60 mL/hr x 15 minutes then increase rate to infuse entire unit within the specified transfusion duration above”. The surveyor observed that the first unit had been initiated on 10/13/23 at 5:18 pm with an initial rate of “75 mL/hr” for the first thirty-two (32) minutes of the transfusion. In the afternoon of 12/11/23, the surveyor met with Staff Member #1 for interview. The surveyor informed the staff member of the discrepancies regarding the transfusion rate ordered by the provider and the rate administered. Staff Member #1 reviewed both blood product flowsheet documentation for both Patient #2 and Patient #3, and acknowledged the aforementioned variances. In the evening of 12/11/23, the surveyor was provided the facility blood transfusion procedure titled, “Lippincott Procedure-Blood and blood product transfusion” (with last revision date of 08/21/23) by Staff Member #9. Under page three (3), the document delineates the procedure for the administration of blood products, and state, “Start the blood transfusion at a slow rate as prescribed and increase the rate as prescribed if no signs of a reaction occur ...” [sic]. On 12/13/23 at 4:15 pm, the surveyor met with Staff Member #2 and Staff Member #9 to disseminate the aforementioned blood transfusion findings with opportunity for clarification and questions.”

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 42042 Based on interviews and document review, it was determined the facility staff failed to obtain an appropriate informed consent prior to the administration of blood products for one (1) of four (4) transfusions reviewed. The findings include: On 12/11/23 at 12:36 pm, the surveyor initiated the review of patients who had received blood product transfusions with the assistance of Staff Member #1 and Staff Member #6. The blood transfusion flowsheet documentation revealed that Patient #1 had received a transfusion of red blood cells following a provider order on 10/15/23. Despite several efforts, the surveyor was unable to locate an informed consent associated with the blood products. Under the Order Set information of Patient #1’s medical record, the surveyor identified a nursing order ordered by the provider on 10/15/23 at 2:23 pm reading, “Verify hospital blood product consent form has been signed and witnessed”. At approximately 1:00 pm on 12/11/23, the surveyor voiced the concerns related to the lack of a blood product consent form for Patient #1 to Staff Member #1. Both Staff Member #1 and Staff Member #6 confirmed that no such consent was available within Patient #1’s medical record related to the 10/15/23 hospitalization encounter. In the evening of 12/11/23, the surveyor was provided the facility policy titled, “Transfusion of Blood Products” (with last effective date of 11/01/23) by Staff Member #6. Under “Procedure” section, the policy reads in part, “1. Obtain informed consent from the patient or legally responsible person ...b. Informed consent for blood product transfusion must be obtained once per hospital admission and documented via an electronic “Consent” Note Type signed by the initial ordering provider”. The same policy continued to read, “e. Nursing staff will obtain a signature from the patient or legally responsible person once per admission (or once every 90 days in ambulatory settings) using the BSMH Blood Product Transfusion Consent and Refusal Form and witness the form prior to initiating transfusion”. On 12/13/23 at 4:15 pm, the surveyor met with Staff Member #2 and Staff Member #9 to disseminate the missing informed consent for the blood transfusion with opportunity for clarification and questions.”