Bon Secours Southside Medical Center

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 49355 Based on medical record reviews, interviews and document review, it was determined the facility failed to document the notification to the family concerning the application of restraints in one (1) out of five (5) medical records reviewed for the usage of restraints. Specifically, there was no documentation that the family of MR2 was notified of the usage of restraints. The findings: A review of the facility’s policy entitled, “Restraints for Nonviolent, Non-Self-Destructive Patient Situations: Medical Use of Restraints,” effective date February 10, 2025, reads, in part: ... “G. Plan of Care/Patient Education.... ... 3. The patient/family will be educated on the use of restraints, on an individual basis while their preferences and insights related to prevention and alternatives will be incorporated into the plan of care, whenever possible. All education is documented in the medical record.” A review of the medical record of MR2 revealed the usage of nonviolent restraints documented in the flowsheet on February 13, 2025, at 8:24 P.M. There is no documentation on the flowsheet that the family was notified. There is no documentation in the plan of care that MR2’s family was notified of the usage of restraints. During an interview on June 2, 2025, Employee (EMP) 1 indicated that there should have been a notation in the medical record, on the flowsheet and in the plan of care, that MR2’s family was notified of the usage of restraints. During an interview on June 2, 2025, at 12:15 P.M., EMP3 confirmed documentation of notification to MR2’s family was absent from MR2’s flowsheet and the plan of care.”

“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: 49355 Based on medical record reviews, interviews and document reviews, it was determined the facility failed to obtain an order for a restraint in one (1) out of five (5) medical records reviewed for the usage of restraints. Specifically, there was no order for a hold involving Patient (MR) 6. The findings: The facility’s policy entitled, “Restraints or Seclusion for Violent, Self-Destructive Patient Situations,” effective date April 29, 2025, reads, in part: ... “D. Restraint or Seclusion Order (to manage violent or self-destructive behavior) 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.” A review of the medical record for MR6 on June 2, 2025, revealed an entry on the flowsheet of a physical hold on June 4, 2024, at 4:10 P.M. The medical record did not contain documentation of a physician order for the physical hold. During an interview on June 3, 2025, EMP1 confirmed the lack of an order for a physical hold in the medical record of MR6. During an interview on June 3, 2025, at 11:20 A.M., EMP5 confirmed an physician order was required for the physical hold of MR6 that occurred on June 4, 2024.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(iii) [there must be documentation in the patient’s medical record of] Alternatives or other less restrictive interventions attempted (as applicable); This Standard is not met as evidenced by: 49355 Based on medical record reviews, interviews and document review, it was determined the facility failed to document the less restrictive interventions employed prior to the usage of a restraint in one (1) out of five (5) medical records reviewed. Specifically, there was no documentation that less restrictive interventions were attempted prior to using a restraint on Patient (MR) 2. The findings: A review of the facility’s policy entitled, “Restraints for Nonviolent, Non-Self Destructive Patient Situations: Medical Use of Restraints,” effective date February 10, 2025, reads, in part: ... “C. Alternatives - Least Restrictive 1. The organization’s culture promotes a physical and social environment that minimizes the use of restraint through preventive or alternative strategies. The use of restraint occurs when other less-restrictive interventions have been attempted but found ineffective for providing a safe and therapeutic environment for the patient, staff, and others.” A review of the medical record for MR2 revealed there was no documentation on the flowsheet of less restrictive alternatives to a restraint on February 13, 2025, at 8:24 P.M., prior to the initiation of a restraint on MR2. There is no documentation in the medical record that less restrictive alternatives to restraint were attempted prior to the initiation of the restraint. During an interview on June 2, 2025, Employee (EMP) 1 indicated that there should have been a notation in MR2’s medical record and on the flowsheet that less restrictive alternatives were attempted prior to the usage of a restraint. During an interview on June 3, 2025, at 11:20 A.M., EMP5 indicated that less restrictive alternatives should be attempted prior to initiating restraints on a patient. EMP5 further indicated that those attempts should be documented on the flowsheet and noted in the patient’s medical record.”

“MEDICAL STAFF BYLAWS CFR(s): 482.22(c) The medical staff must adopt and enforce bylaws to carry out its responsibilities. The bylaws must: This Standard is not met as evidenced by: 42042 Based on interviews and document review, it was determined the facility’s medical staff failed to record the results for one (1) of six (6) patients in a timely manner. Specifically, an ordered “STAT” priority transthoracic echocardiogram (TTE) cardiovascular test was not duly recorded with interpretation results by the consulting cardiologist within the one (1) hour time frame requirement. The findings include: The surveyor reviewed Patient #1 ’ s medical record on 11/14/23. That review revealed that Patient #1 presented to the Emergency Department (ED) by EMS (Emergency Medical Services) following a fall at home on 09/23/23 at 5:50 pm. The patient was determined to have a complex fracture (break in bone) and required surgery by the orthopedic surgeon within seventy-two (72) hours. Following communication with the anesthesiologist, the orthopedic surgeon had requested the patient to have a transthoracic echocardiogram (TTE) prior to surgery in order to determine whether the patient was safe for general anesthesia during surgery. The TTE was ordered by the surgeon as “STAT” priority which is required to be fully completed in its entirety to include interpretation results within one (1) hour. The order set and imaging results information of Patient #1 revealed that the ordered priority “STAT” TTE exam was ordered by the Orthopedic Surgeon (Staff Member #12) on 09/24/23 at 3:12 pm and to be interpreted the consulting cardiologist (Staff Member #14). The surveyor identified that the TTE was successfully completed on 09/24/23 at 4:17 pm. The exam results, however, were not interpreted and read by the cardiologist (Staff Member #14) until 09/25/23 at 11:14 am. The provider progress note by the orthopedic surgeon on 09/24/23 stated, “The patient has multiple medical problems to include significant cardiac history requiring cardiology consult. Echo is still pending” [sic]. Under “Assessment/Plan” section of the same progress note, the provider continued to say, in part, “ 83-year-old female with right proximal femoral shaft fracture with significant comorbidities. [Patient #1] has been seen by cardiology but the TTE is still pending. [Patient #1] would benefit from surgery as soon as possible. I have discussed this case at length with anesthesia and we are awaiting the TTE results to ensure [Patient #1 ’ s] ejection fraction is known to optimize anesthetic services” [sic]. The progress note written by the same provider with date of service of 09/24/23 at 6:02 pm reads, in part, the following: “After discussing with anesthesia, we will not be able to perform the surgery today since we do not have the results of the TTE. These results are needed to help guide anesthesia interventions”. The surveyor continued to review the provider notes and identified a progress note by the consulting cardiologist (Staff Member #14) with date of service on 09/25/23 at 12:31 pm. The cardiologist ’ s note revealed the following: “Discussed with the patient ’ s family members who are at the bedside, and they are somewhat unhappy that surgery was not done yesterday. I had mentioned clearly in my note that [sic] should proceed with the surgery as cardiac risk stratification is not feasible. Echocardiogram was not done until very late in the day and I had waited a [sic] few hours and when nurse called me late evening about reviewing echocardiogram I was out of hospital in a funeral, and I told her that should proceed with the surgery and the surgeon was ready according to my information however anesthesiologist would not want to proceed [sic]. “ [Note: Following review of previous progress notes by Staff Member #14, the surveyor was unable to identify any documentation indicating the cardiologist had recommended the patient to undergo surgery prior to completion of the echocardiogram as referenced.] The documentation by the surgeon with corresponding date of service of 09/25/23 at 6:29 pm read, in part, “Multiple delays today and this patient was delayed because of anesthesia results of cardiogram. Late hour of the day this patients has been n.p.o. [nothing by mouth] for 48 hours I feel that it is possibly best to proceed in the morning ...I spoke to the family in spite of the additional delays I think is [Patient #1’s] best interest to have a fresh team in the morning for such a difficult surgery. [Patient #1] will be given a diet tonight and n.p.o. after midnight and will proceed tomorrow at 7:30 am” [sic]. The surveyor was supplied the facility policy titled, “Transthoracic 2D Echocardiogram Examination” (with approval date of 06/08/22) by Staff Member #5 (Director of Quality) in the afternoon of 11/14/23. Under “Exam Time Recommendations” section of page six (6), the policy stated the following: “High quality, accurate results are fundamental elements of the echo examination. A combination of indirect and direct exam components is the foundation for maximizing exam quality and accuracy. Total recommended time allotment is 60 minutes”. The surveyor received additional verbal confirmation during interviews with both Staff Member #23 and Staff Member #26 on 11/15/23 at 2:07 pm and 3:42 pm, respectively. Both staff members reiterated the facility expectations for the completion of a “STAT” TTE exam within one hour, with Staff Member #26 clarifying that interpreted results of the TTE by the provider are included within the (60) minute time frame. The patient did ultimately receive the surgery within the seventy-two (72) hour timeframe.”