Lewisgale Hospital Montgomery

“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: 46466 Based on interviews, medical record review and facility document review, the facility failed to modify the patient’s plan of care for three (3) of three (3) sampled medical records reviewed. The findings include: A review of the facility’s policy “Patient Restraint/Seclusion Policy”, effective 6/2024, indicated in part: “...1. Care of the Patient/Plan of Care14. a. The plan of care will clearly reflect a loop of assessment, intervention, and evaluation for restraint, seclusion and medications...1. Documentation requirements17. The medical record contains documentation of...n. Modifications of the plan of care...”. On April 28, 2026, the surveyors reviewed medical records of Patient’s #7, #8, and #9. Patient #7’s record indicated that they were placed in restraints on April 10, 2026, at 5:13 AM. The patient’s plan of care was not modified to reflect that the patient was placed in restraints. Patient #8’s record indicated that they were placed in restraints on April 24, 2026, at 11:59 AM. The patient’s plan of care was not modified to reflect that the patient was placed in restraints. Patient #9’s record indicated that they were placed in restraints on April 18, 2026, at 5:26 PM. The patient’s plan of care was not modified to reflect that the patient was placed in restraints. An interview was conducted with Staff Member #2 on April 28, 2026. Staff Member #2 stated that the facility’s Electronic Medical Record (EMR) was updated in March 2026 and there was no option for the nurse to add restraints to the patient’s Plan of Care.”

“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: 46466 Based on interviews, document review, and review of medical records, it was determined that the hospital failed to ensure nursing staff on Medical Surgery unit assessed and monitored an outpatient post-operative patient in their care according to the established policies and procedures for patients in Ambulatory Surgery Center (ASC) settings. The findings include: Policy and Procedures A review of the facility’s policy “Post-Operative Care”, last revised 12/2025, indicated in part: “...Admission of patient from PACU a. Assess 1. Vital signs (Temperature, BP, P, R, SpO2) will be assessed on return, 15 minutes after return for 1 hour, every 30 minutes for 1 hour, every hour for 4 hours and then every 4 hours if stable for 24 hours. 2. Level of consciousness. 3. Skin Color, Temperature, turgor. 4. Lung and bowel sounds...8. Pain status...10. Specific assessments as may relate to type of surgery...”. A review of the facility’s policy “ACS Assessment/Reassessment”, last revised 3/2021, indicated in part: “...III. Procedure Admission to ACS 1. Surgical/Endoscopy/Invasive procedures patients will be assessed upon arrival to the unit according to ASPAN Standards...Reassessment 1. Reassessment will occur by an RN upon return to the unit following procedure and be repeated at 15 minutes following procedure and for any changes in assessment findings...”. A review of the facility’s policy “Pain Assessment and Management”, last revised 4/2024, indicated in part: “...Expectations of the Nurse in the Assessment & Management of Pain. The nurse is expected to...Document assessments and reassessments accurately and completely, using a numeric value based on the appropriate scale for the patient as well as narrative documentation whenever needed to document a complete pain assessment...”. Medical Record Patient #5 came to this facility’s ASC on March 19, 2026 for a planned surgical intervention, and after successful surgery received care in the facility’s PACU (Post Anesthesia Care Unit). Patient #5 was transferred to the hospital’s Medical Surgery floor on March 19, 2026, at 7:26 PM for recovery and observation with a plan to discharge to home. Review of Patient #5’s medical record revealed that pain assessment and initial nursing assessment were first documented on this unit at 9:45 PM and the first set of partial vital signs (pulse and pulse oximetry) at 10:21 PM. Interviews On April 29, 2026, at 9:20 AM, Staff Member #9 revealed in an interview that the standard care for post operative patients when they arrive to the Medical Surgery unit was for the nursing staff to take report from the PACU Registered Nurse, obtain vital signs and assess the patient. On April 29, 2026, at 12:45 PM, Staff Member #13 explained in an interview that after surgery, outpatients recover in the PACU first and then are transferred to ASC until they are determined ready for discharge. The standard of care when a patient arrived at ASC was to monitor their vital signs every 15 minutes for one hour, every 30 minutes for the next hour and then hourly afterwards until the patient was stable for discharge. Staff Member #13 stated that the assigned nurse would complete a head-to-toe assessment and assess the patient’s pain level and give medications as needed. On April 29, 2026, at 1:00 PM, Staff Member #1 revealed in the interview that the nurses on the Medical Surgery unit are expected to follow the above noted policies for monitoring of post-surgical patients from ASC while recovering in their unit. Staff Member #1 stated that there were no separate policies for inpatient or outpatient post-surgical care. Medical Surgical nurses should be completing the vital signs, pain assessments and initial assessments as ASC. On April 29, 2026, at 1:30 PM, Staff Member #8 explained in an interview that they were in the room when Patient #5 arrived at the Medical Surgical unit and received the report from the PACU nurse and assessed the patient’s pain. Staff Member #8 believed that they documented the pain assessment in the medical record. Staff Member #8 reported that post-operative patients from ASC should have vital signs monitored every 15 minutes for an hour and their pain assessed. SM8 stated that this was the first “outpatient” post-operative patient that they cared for on the Medical Surgical floor since they started working there and did not recall receiving any specific training regarding assessment and care for an outpatient post-operative patients vs to an inpatient post-operative patients. 2”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 46466 Based on medical record documentation review the facility failed to maintain an accurately written medical record for one (1) of 12 patient records reviewed.(Patient #5) The findings include: On April 28, 2026, the surveyor reviewed Patient #5’s medical record. Patient #5’s History and Physical documented by the Hospitalist on March 19, 2026, at 9:57 PM, indicated “...After procedure pt was moved to the 4th floor for further observation and to receive postop pain medication. However, due to delay in pain medication administration, patient’s pain became uncontrolled requiring IV pain medication. Due to uncontrollable pain hospitalist Service asked to admit for observation to assist with pain control. After receiving IV fentanyl pt states (their) pain somewhat improved however on evaluation (their) pain was starting to come back...”. Review of Patient #5’s medication administration record report revealed that the Hospitalist ordered IV (intravenous) fentanyl for breakthrough pain on March 19, 2026, at 10:57 PM, however, this medication was never administered to Patient #5.”

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 46466 Based on interviews, medical record review and facility document review, the facility staff failed to document nursing notes for one (1) of 13 medical records reviewed. (Patient #5) The findings include: A review of the facility’s policy “Pain Assessment and Management”, last revised 4/2024, indicated in part: “...Expectations of the Nurse in the Assessment & Management of Pain. The nurse is expected to...Document assessments and reassessments accurately and completely, using a numeric value based on the appropriate scale for the patient as well as narrative documentation whenever needed to document a complete pain assessment...”. Patient #5’s medical record was reviewed on April 28, 2026, and indicated that Patient #5 arrived at the facility’s Ambulatory Surgery Center for outpatient surgery. After recovery in the facility’s PACU, Patient #5 was transferred as an outpatient to the facility’s Medical Surgery floor to recover prior to discharge. The medical record indicated that Patient #5 arrived at the Medical Surgery floor at 7:26 PM on March 19, 2026. There was no nursing documentation that Staff Member #8 (the assigned nurse) completed an assessment on Patient #5 when they arrived at the floor. On April 29, 2026, at 1:30 PM, an interview was conducted with Staff Member #8. Staff Member #8 stated that they were present in the room with Patient #5 when Patient #5 arrived from PACU. Staff Member #8 stated that they took report from the PACU nurse and assessed the patient’s pain. Staff Member #8 stated that they thought they documented the pain assessment in the patient’s chart.”

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 46466 Based on interviews, facility document and medical record reviews, the facility failed to interpret the results of performed test and/or procedure per facility policy. The findings include: On August 5, 2024 a review of Patient #1’s medical record was conducted with Staff Member #2. The facility received an order for Patient #1 dated October 25, 2023 for an electrocardiogram (EKG), and other tests. The EKG was performed on October 31, 2023 at 10:16 AM and the result was electronically signed by a physician on November 7, 2023 at 7:42 AM. The facility received an order for Patient #1 with a handwritten date of July 3, 2024 for another EKG. The EKG was performed on July 8, 2024 at 9:32 AM and the result was electronically signed by a physician on July 13, 2024 at 9:44 PM. A review of the facility’s policy “Cardiology Procedure Timeliness Policy”, effective 3/2022, revealed in part “...Routine Tests...Any routine diagnostic test ordered. This includes but is not limited to...EKGs...Goal: Interpretation and dictation of routine test results will occur within 48 hours of test completion...”. The findings were discussed with Staff Members #1, #2, #7, #8 and #9 at the exit conference on August 6, 2024 at 9:15 AM.”