Cjw Medical Center

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 42929 Based on review of medical records (MR), review of documents, and interviews with staff (EMP) it was determined the facility failed to ensure patients were able to participate in their plan of care. Specifically the facility failed to ensure patients signed discharge instructions per policy indicating that the discharge instruction form was reviewed and received by the patient for five (5) of five (5) patients’ (MR) medical records reviewed for discharge instructions, MR1, MR2, MR3, MR4, and MR5 and failed to ensure patients’ pain was assessed and reassessed per policy for three (3) of five (5) patients’ medical records reviewed for pain assessments, MR3, MR4, and MR5. Findings: Review of facility document “Discharge of Patients” last revised July 2026 reads in part: “... Documentation: A. Complete discharge instruction form, discuss with patient/significant other and have them sign. Provide patient with copies ...” Review of facility document “Assessment and Reassessment of ED Patients” last revised May 2023 reads in part: “... A pain scale may also be included for those patients with pain as a component to their presenting complaint....” Review of facility document “Assessment and Reassessment of Patients” last revised June 2026 reads in part: “... B. PAIN ASSESSMENT: ... 5. Reassessment of the patient is ongoing to determine effectiveness of treatment approaches/techniques. Pain is reassessed within 60 minutes of a pain intervention....” Review of the medical records for MR1, MR2, MR3, MR4, and MR5 revealed no evidence that the discharge instruction form was signed by the patient per policy. Review of the emergency department medical record for MR3 dated July 7, 2026, revealed MR3 presented to the emergency department with complaints of leg pain. There was no documented pain assessment upon arrival at 6:34 AM. MR3 was assessed for pain of eight (8) out of ten (10) at 8:38 AM and given pain medication at that time. There was no reassessment of pain prior to MR3’s discharge at 10:54 AM. Review of the emergency department medical record for MR4 dated July 6, 2026, revealed MR4 presented to the emergency department with complaints of hip and back pain. MR4 was eight (8) out of ten (10) pain at 2:17 AM and given pain medication at that time. There was no reassessment of pain prior to MR4’s discharge at 3:30 AM. Review of the emergency department medical record for MR5 dated July 6, 2026, revealed MR5 presented to the emergency department with complaints of left flank and left quadrant abdominal pain. There was no documented pain assessment upon arrival at 3:36 AM. MR5 was assessed for pain of ten (10) out of ten (10) at 5:20 AM and given pain medication at that time. The next pain reassessment was documented as seven (7) out of ten (10) pain at 9:11 AM, over three (3) hours after the pain intervention not within sixty (60) minutes per policy. Interview on September 3, 2026, at 7:32 AM, EMP6 indicated that pain is reassessed within thirty (30) minutes to an hour after a pain intervention such as medication administration. EMP6 indicated that not all staff have the patient sign the discharge instructions, but when it is signed a copy goes into a box to be scanned into the patient’s medical record. Interview on September 3, 2026, around 9:30 AM, EMP7 indicated that the emergency department staff previously had patients sign their discharge instructions but that stopped during COVID. Interview on September 3, 2026, around 9:30 AM, EMP8 indicated that pain should be assessed within one (1) hour of administration of a pain medication. Interview on September 3, 2026, at 12:30 PM, EMP12 indicated that EMP12 does not have emergency department patients sign the discharge instructions but the policy states the discharge instructions should be signed by the patient. EMP12 indicated that pain should be reassessed within an hour after a pain intervention and the reassessment documented in the patient’s medical record.”

“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: 42725 Based on medical record review and document review, it was determined the facility failed to ensure two (2) patients were informed of their patient’s rights within a reasonable timeframe (MR1 and MR5). Findings: A facility document titled, Patient Rights, under the heading “Purpose” reads, in part: “Ensure that all patients receiving care and/or patient representatives are informed of their rights”. The document was effective July 1, 2020. A facility document titled, Procedure for Registration Forms and Signatures, under the heading “Purpose” reads: “To ensure that applicable state and federal laws and signature requirements are followed regarding obtaining signatures on all registrations forms, including the Conditions of Admission and Consent for Outpatient Services.” Under the heading “Policy”, it partly reads: “The Patient Access Department obtains signatures on all registration forms, from the patient or legally authorized individual, prior to or during the registration process or within a reasonable time frame based upon the patient circumstance... Reasonable attempts will be made for follow up on signatures not obtained during the registration process... Standard forms required at time of Pre-Registration or Registration: 1. The Conditions of Admission and Consent for Outpatient Services (COA/COS) is obtained for all types of Registrations...”. The document was effective December 2025. On the “Conditions of Admission and Consent for Inpatient and/or Surgical Care” form, #21 is titled, “Acknowledgement of Notice of Patient Rights and Responsibilities” and reads, in part: “I have been furnished with a Statement of Patient Rights and Responsibilities ensuring that I am treated with respect and dignity...”. There is a box to initial acknowledging the receipt. Review of MR1 indicated that the COA was signed; however, EMP12 was unable to locate the document. EMP15 reviewed the record again and confirmed on June 16, 2026 at 3:25 PM that there was no signed COA located in the record. Review of MR5 indicated the patient was admitted on May 28, 2026 and was still there during the time of the investigation. A signed COA was not located during review of MR5. On June 16, 2026 at approximately 3:30 PM, the SA was provided a signed COA. It was electronically signed on June 16, 2026 at 11:55 AM. There was no evidence in the record indicating the patient was unable to sign the COA at the time of registration.”

“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: 42725 Based on medical record review, document review, and interview, it was determined that the facility failed to follow their process of obtaining an informed consent prior to performing a surgical procedure for one (1) patient (MR2). Findings: Review of facility document, Procedure for Registration Forms and Signatures, under the title “General Definitions and General Guidance”, partly reads: “Legally Empowered/Legally Authorized Representative: Generally, a legally authorized representative/legally powered individual is ... Power of Attorney for Healthcare or Legal Guardian. To appropriately determine an authorized representative/legally empowered individual, be certain to read all legal guardianship papers thoroughly. There is a difference between financial guardianship/power of attorney and healthcare decisions (full) legal guardianship/power of attorney. The full legal guardianship/power of attorney (pertaining to healthcare decisions) is what is necessary for a guardian to sign consent paperwork. Any person possessing Power of Attorney for Healthcare or Legal Guardianship at the time of registration should provide a copy of the Power of Attorney for Healthcare or Legal Guardianship paperwork is received for hospital records (copy to the Medical Record) prior to obtaining this person’s signature...”. Under the title “Procedure”, it partly reads: “... Circumstances below should be addressed in the following manner: ... D. Patient unable to sign, legally authorized/legally empowered, Power of Attorney or Legal Guardian is present. The person possessing the Power of Attorney or Legal Guardianship may sign all registration specific paperwork. The paperwork should be presented prior to obtaining a signature, copied, and placed in the patient’s medical record...”. The document was effective December 2025. Review of facility document, Advance Directives, under the title “Summary of Criteria”, partly reads: “In order to be valid, each of the following must be present: ... 2. Agent - Health Care Power of Attorney-Surrogate-Proxy: Patient who is 18 years of age or older. Document in writing - No special form required. Signed by patient. Signed by two witnesses. Specifies an individual to make healthcare decisions where patient is “Incapable of Making an Informed Decision,” as determined by attending physician or capacity reviewer...”. The document was effective October 2023. Review of facility document, Consent (Informed) - Written Confirmation, under the title “Definitions”, partly reads: “... H. Guardian/Surrogate Decision-Maker I. The status of a person with the legal authority to make medical decisions for another (i.e., a minor or a person mentally or medically incapable) should be documented in the patient’s record by the practitioner, or verified with legal documents, or both”. The document was effective June 2026. Review of MR2 revealed the patient was accompanied by an individual who identified themselves as a family member, MR2’s caretaker, and MR2’s healthcare power of attorney (POA). Documentation throughout MR2 referred to the individual as the POA; however, there was no documentation or paperwork in the record to confirm this. MR2 underwent a surgical procedure on March 26, 2026 with both the surgical consent and anesthesia consent signed by this individual. There was no documentation to support the facility staff attempted to obtain a copy of the POA paperwork for the medical record. An interview on June 16, 2026 at 2:50 PM, EMP17 indicated that advance directive paperwork or power of attorney documents are “obtained if they bring it in”. EMP17 said, “We will ask them for the paperwork, but a lot of times they don’t have it with them so we will tell them to bring it in.” EMP17 said if the paperwork is brought in, it will be scanned so it becomes a part of the patient’s universal medical record. EMP17 indicated that staff can make a note in the “collections section” if they discussed the paperwork with the patient/patient representative. When/if the paperwork is brought in, EMP17 said, “We tell them to make sure they let the floor (nurses) know”. EMP17 indicated that it is on the patient/patient representative to bring in the paperwork; the staff do not loop back around to ask for it.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) [Unless superseded by State law that is more restrictive,] (iii) Each order for restraint used to ensure the physical safety of the non-violent or non-self-destructive patient may be renewed as authorized by hospital policy. This Standard is not met as evidenced by: 42725 Based on medical record review, document review, and interview, it was determined the facility failed to ensure a renewal order was entered to continue the use of a restraint for one (1) of three (3) patients sampled for restraint/seclusion review (MR6). Findings: Review of facility document, Seclusion, Restraints and Restraint Alternatives, under the heading “Procedure” reads, in part: “... 5A. Order for Restraint with Non-Violent or Non-Self-Destructive Behavior. a. Initial restraint order: An initial order for restraint must not exceed 24 hours... c. Renewal restraint order: If reassessment indicates an ongoing need for restraint, a renewal restraint order must be entered into the medical record within 24 hours of the initial restraint order...”. The document was effective May 2024. Review of MR6 revealed a non-violent restraint order entered on May 19, 2026 at 8:53 AM for the initiation of soft bilateral upper extremity restraints. The restraints were discontinued on May 21, 2026 at 3:50 AM. EMP15, who was assisting the state agency (SA) with the record review, was unable to locate a restraint renewal order for May 20, 2026.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a) Patients’ Rights: Notice of Rights This Standard is not met as evidenced by: 42929 Based on review of medical records (MR), review of documents, and interviews with staff (EMP) it was determined the facility failed to ensure patients received access to qualified interpreters as per facility policy for three (3) of three (3) patients’ with accessibility needs medical records reviewed, MR5, MR6, and MR7. Findings: Review of facility document “Patient Rights” effective July 1, 2020, reads in part: “... Policy: ... All Company-affiliated facilities must provide each patient with a written statement of patient rights at the time of registration and again at the time any patient or patient’s representative has questions regarding their rights. The written statement of patient rights must be provided to the patient in their preferred language or manner that can be understood. When necessary, interpreter services must be provided to ensure the patient and/or patient’s representative receive patient rights notification in a language and/or manner they understand....” Review of facility document “Patient Rights and Responsibilities” brochure dated October 2025, reads in part: “Access to Services: To receive, as soon as possible, the free services of a translator and/or interpreter, telecommunications devices, and any other necessary services or devices to facilitate communication between the patient and the hospitals’ health care personnel (e.g., qualified interpreters, written information in other languages, large print, accessible electronic formats) ...” Review of facility document “Access to Services” effective May 1, 2018, reads in part: “... 4. HCA Healthcare-affiliated facilities are required to follow this and related policies, including: ... c. Accommodating Persons Who are Deaf or Hard-of-Hearing Model Policy; d. Accommodating Persons Who are Blind or Have Low Vision Model Policy; and f. Accommodating Persons with Limited English Proficiency (LEP) Model Policy....” Review of facility document “Accommodating Persons Who Are Deaf or Hard-Of-Hearing Policy” last revised September 2025 reads in part: “... The regulation implementing the Acts requires that persons who are deaf or hard-of hearing be provided with auxiliary aids at no cost to allow them an equal opportunity to participate in and benefit from healthcare services. The decision as to the method to be used for communication requires the input of any individual requiring auxiliary aids, and their choice must be given primary consideration. FACILITY is committed to compliance with federal and state laws prohibiting discrimination on the basis of disability in the offering or delivery of healthcare services. FACILITY recognizes its legal obligation to ensure effective communication with persons with disabilities and makes every effort to pro-actively assess communication needs as well as providing the most compassionate care.... RESPONSIBLE PERSONS: All FACILITY staff.... IV. POLICY STATEMENT: FACILITY will take appropriate steps to ensure persons with disabilities, including persons who may be deaf or hard-of-hearing, have an equal opportunity to participate in our services, activities and other benefits. The procedures outlined below are intended to ensure the effective communication with all individuals involving medical conditions, treatment, services, and benefits. All necessary language assistance services shall be provided free of charge. FACILITY staff will be provided notice of this policy and procedure. Staff that may have direct contact with individuals with disabilities will be trained in effective communication techniques. FACILITY staff will inform individuals who may be deaf or hard-of-hearing - including individuals seeking access to services at FACILITY and any family member or friend of such individual who is an appropriate person with whom FACILITY should communicate - of the availability, at no cost to them, of language services in order to effectively communicate. V. Procedure: ... B. Identification and Assessment of Persons who may be Deaf or Hard-of-Hearing. FACILITY will identify the language and communication needs of persons who may be deaf or hard-of-hearing as needed to ensure effective communication. As soon as FACILITY becomes aware of such needs, staff will use the form “Services for Persons Who are Deaf or Hard-of-Hearing [also titled “CJW Medical Center Notice of Waiver Deaf Hard of Hearing”] to inform such persons of services and determine what language assistance services may be needed. If language services are declined by an individual who may be deaf or hard-of-hearing, staff will then use the “Waiver of Language Assistance” to not only document the refusal but also to serve as notice to the individual that they may still request a free qualified interpreter at any time. The form(s), “Services for Persons Who are Deaf or Hard-of-Hearing” and/or the form, “Waiver of Language Assistance” will be included in the patient’s medical record.... D. Obtaining a Qualified Interpreter. All staff are responsible for obtaining a qualified interpreter when needed to effectively communicate.... 1. If a person uses sign language, all medical and psychiatric evaluations or discussions regarding a patient’s symptoms, treatment (including individual and group psychotherapy), diagnosis, progress, and prognosis must be communicated through the use of a qualified sign language interpreter.... E. The Use of Family or Friends for Professional Language Services. 1. Family members or friends will not be used for language assistance except: a. in an emergency ... 2. Except in an emergency, family members or friends may be used for language assistance only after an offer of free qualified language assistance is offered and documented by the use of the form, “Services for Persons Who are Deaf or Hard of Hearing.” 3. A “Waiver of Language Assistance” will be used if any language services are provided by persons not procured by the Facility.” ... VI. POLICY IMPLEMENTATION ... 3. Face to Face Interpretation. a. When a patient requests a face to face interpreter call ... e. Request American Sign Language [ASL]. f. Record the coordinator’s name and information you receive regarding the interpreter and their arrival.... II. DOCUMENTATION: A. Any and all contacts with interpreting agencies must be documented in patient records. The staff member will document in the medical record that assistance has been provided, offered or refused by the use of the form “Services for Persons Who are Deaf or Hard of Hearing” which is attached to this policy. B. A “Waiver of Language Assistance” will be used if any language services are refused by an individual who may be deaf or hard-of-hearing....” Review of facility document “Services for Persons Who are Deaf or Hard-of-Hearing [also titled “CJW Medical Center Notice of Waiver Deaf Hard of Hearing”] dated May 2021 reads in part: “... Explanation of Document (for providers and staff) ... Individuals who are deaf or hard-of-hearing have the right to refuse a qualified medical interpreter and request that a family (or friend) provide interpreting services. An offer of free qualified language assistance must be offered and documented in the medical record by the use of the form, Notice of Services for Persons Who Are Deaf or Hard of Hearing. The potential risks of using an interpreter that is not qualified must be explained to such individuals in the persons’s primary or preferred language by the use of the Waiver of Language Assistance which will be documented in the medical record. Individuals who are deaf or hard-of hearing must sign the Waiver of Language Assistance each and every time qualified language services are refused by such individuals and this Waiver must be included in the medical record....” Review of facility document “Accommodating Persons With Limited English Proficiency (Lep) Policy” last revised September 2025 reads in part: “... C. Identification of Persons who may be LEP. FACILITY will identify the language and communication needs of persons with LEP as needed to ensure effective communication.... As soon as FACILITY becomes aware of such needs, staff will use the form “Notice of Language Assistance Services” to inform such persons of services and determine what language assistance services may be needed. If language services are declined by an individual with LEP, staff will then use the “Waiver of Language Assistance” to not only document the refusal but also to serve as notice to the individual that they may still request a free qualified interpreter at any time. The form(s), “Notice of Language Assistance Services” and/or the form, “Waiver of Language Assistance” will be included in the patient’s medical record.... D. Obtaining a Qualified Interpreter. All staff are responsible for obtaining a qualified interpreter when needed to effectively communicate.... VIII. DOCUMENTATION: A. Any and all contacts with interpreting agencies must be documented in patient records. The staff member will document in the medical record that assistance has been provided, offered or refused by the use of the form “Notice of Language Assistance Services” which is attached to this policy. B. A “Waiver of Language Assistance” will be used if any language services are refused by an individual with LEP....” MR5 Review of the Rapid Initial Assessment for MR5 dated March 8, 2026, at 12:20 PM revealed “Preferred language: Spanish.” There was no documentation that a qualified language interpreter was offered or used to communicate with MR5. Review of the medical record revealed no evidence of the required “Notice of Language Assistance Services” or “Waiver of Language Assistance” forms documented in MR5’s medical record. Review of the “Conditions of Admission and Consent for Inpatient and/or Surgical Care” document that indicates “Acknowledgement of Notice of Patient Rights and Responsibilities” by documentation of patient’s initials, signed by MR5 on March 8, 2026, at 1:05 PM was in English, not Spanish as per facility policy. Review of the History and Physical for MR5 dated March 8, 2026, at 4:26 PM revealed no documentation that a qualified language interpreter was offered or used to communicate with MR5. Review of the Discharge Summary for MR5 dated March 10, 2026, at 9:20 AM revealed “... Sister-in-law at bedside. History obtained primarily with the help of [MR5’s] interpreter.... Patient Education and Monograph Language: ENGLISH.” There was no documentation that a qualified language interpreter was offered or used to communicate with MR5. Review of the discharge instructions for MR5 dated March 10, 2026, at 9:26 AM revealed some of the discharge instructions to include medications, activity, diet, additional instructions for “... DMV recommendations for episodes of passing out: no driving until cleared x 6 months...”, and followup appointments were documented in English. Other generic instructions were documented in Spanish. MR6 Review of the Rapid Initial Assessment for MR6 dated January 17, 2026, at 11:05 AM revealed “... Accessibility needs: Deaf/hard-of-hearing ...” There was no documentation that a qualified language interpreter was offered or used to communicate with MR6. Review of the medical record revealed no evidence of the required “Notice of Services for Persons Who Are Deaf or Hard of Hearing,” “CJW Medical Center Notice of Waiver Deaf Hard of Hearing,” or “Waiver of Language Assistance” forms documented in MR6’s medical record. Review of the registration documentation for MR7 dated February 17, 2026, revealed “Does the patient have accessibility needs: Yes. Accessibility needs: Deaf/hard-of-hearing; Language services: Patient/rep accepts.” Review of the Critical Care Consult Note for MR6 dated January 18, 2026, at 2:33 AM revealed “... Patient is hard of hearing but able to read lips with clear on inspiration [sic - enunciation]....” There was no documentation that a qualified ASL interpreter was offered or used to communicate with MR6. Review of the nursing note for MR6 dated January 19, 2026, at 5:45 PM revealed documentation that MR6 complained of nausea and stomach tightness and later stated feeling better. There was no documentation that a qualified ASL interpreter was offered or used to communicate with MR6. Review of the nursing note for MR6 dated January 28, 2026, at 10:07 AM revealed documentation that MR6 reported having nausea and vomiting and “thinks” Tylenol is making MR6 sick. There was no documentation that a qualified ASL interpreter was offered or used to communicate with MR6. MR7 Review of the Rapid Initial Assessment for MR7 dated February 15, 2026, at 7:00 PM revealed “... Preferred Language: Sign Language; Accessibility needs: Deaf/hard-of-hearing; Language services: Patient/representative accepts; Language services type: Interpretation via phone, Interpretation via video ... Pt writes [patient’s] left knee hurts ...” There was no documentation that a qualified ASL interpreter was offered or used to communicate with MR7. Review of the Rapid Initial Assessment for MR7 dated February 16, 2026, at 4:06 PM revealed documentation “... Accessibility needs: Deaf/hard-of-hearing, Language services: Patient/representative accepts; Language services type: Interpretation via phone, Interpretation via video; Additional language services detail: AMERICAN SIGN LANGUAGE ...” There was no documentation that a qualified ASL interpreter was offered or used to communicate with MR7. Review of the registration documentation for MR7 dated February 17, 2026, revealed “Does the patient have accessibility needs: Yes. Accessibility needs: Blind/low vision; Deaf/hard-of-hearing; Additional language services detail: Sign Language Interpreter.” Review of the medical record revealed no evidence of the required “Notice of Services for Persons Who Are Deaf or Hard of Hearing,” “CJW Medical Center Notice of Waiver Deaf Hard of Hearing,” or “Waiver of Language Assistance” forms documented in MR7’s medical record. Review of a Hospitalist Progress Note dated February 18, 2026, at 3:26 PM revealed “... patient communicates writing material. American sign language was attempted at bedside, however was not available ... Patient uses sign language [MR7] is chronic deafness.... Patient also uses written communication to communicate with staff. There was no documentation that a qualified ASL interpreter was used to communicate with MR7. Review of twelve (12) nursing Teaching and Education flow sheets dated February 18, 2026, through February 26, 2026, revealed patient is “Deaf” or “Impaired hearing” and Method of education was documented “Verbal discussion” and/or “Responsiveness to learning: Verbalized understanding.” Only one (1) of twenty (20) nursing Teaching and Education flow sheets indicated “Method of education ... Interpreter.” Review of Hospitalist Progress Note dated February 21, 2026, at 2:32 PM revealed “... has been difficult to get ASL interpreter on phone...used voice to text on iphone instead... Objective: ... PSYCH: appears appropriate though limited assessment as the patient is nonverbal....” There was no documentation that a qualified ASL interpreter was used to communicate with MR7. Review of Hospitalist Progress Note dated February 24, 2026, at 1:54 PM revealed “... has been difficult to get ASL interpreter on phone...used voice to text on iphone instead but [MR7] gets frustrated with this ... Unable to get ASL interpreter at this time.... Objective: ... PSYCH: appears appropriate though limited assessment as the patient is nonverbal....” There was no documentation that a qualified ASL interpreter was used to communicate with MR7. Review of Hospitalist Progress Note dated March 1, 2026, at 4:01 PM revealed “... patient, significantly hearing disabled who uses ASL ...” There was no documentation that a qualified ASL interpreter was used to communicate with MR7. Review of Hospitalist Progress Note dated February 26, 2026, at 3:24 PM revealed “... communications via written paper. Have been difficult to obtain ASL interpreter.....” There was no documentation that a qualified ASL interpreter was used to communicate MR7. Review of History and Physical dated March 1, 2026, at 4:45 PM revealed “... Assessment and Plan ... chronic deafness, ASL Interpreter ...” There was no documentation that a qualified ASL interpreter was used to communicate with MR7. Interview on March 18, 2026, at 12:48 PM, EMP19 indicated that EMP19 communicated with MR7 using paper and pencil. EMP19 indicated that the ASL interpretation service was not working the two days EMP19 cared for MR7. EMP19 indicated hearing that MR7 did not like staff using talk to text to communicate. EMP19 had never seen or used the “Services for Persons Who are Deaf or Hard-of-Hearing” and “Waiver of Language Assistance” forms. Interview on March 18, 2026, at 2:12 PM, EMP22 indicated that the facility has access to the language interpreter line through the imobile device and electronic pads on stands. EMP22 indicated that EMP22 asks patients their preferred language, and if the patient accepts the use of the interpreter, then it is documented in the admission history. EMP22 documents the interpreter’s name and identification number in the patient’s medical record in a nurse’s note when an interpreter is used to communicate with the patient. EMP22 had never seen or used the “Services for Persons Who are Deaf or Hard-of-Hearing” or “Waiver of Language Assistance” forms. Interview on March 18, 2026, at 2:23 PM, EMP23 indicated communicating with MR7 by writing in a book of paper. EMP23 indicated that there was a sign on the board in the MR7’s room indicating that the patient preferred to communicate via writing. EMP23 confirmed with MR7 that it was okay to communicate via writing. EMP23 had never seen or used the “Services for Persons Who are Deaf or Hard-of-Hearing” or “Waiver of Language Assistance” forms. Interview on March 18, 2026, at 2:23 PM, EMP24 indicated that MR7 preferred writing, but a family friend called with concerns that MR7 was not provided an ASL interpreter. EMP24 indicated that after the call the staff started using the ASL interpreter through the application on the imobile or electronic pad. EMP24 indicated that in-person ASL interpretation services can take up to twenty-four (24) hours to arrive at the facility. EMP24 indicated that if an interpreter is used, staff should document the name and identification number of the interpreter in the medical record.”

“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 review of medical records, facility document review and interviews with facility staff (EMP), it was determined the facility failed to document a written modification to the Plan of Care/Treatment Plan/Recovery Plan to document the usage of restraints in four (4) out of four (4) medical records (MR) reviewed, MR8, MR9, MR10 and MR11. Findings: Review of facility document, “Seclusion, Restraints and Restraint Alternatives,” document number 1575831, last revised May 2024, reads in part: ... “10. Care of the Patient/Plan of Care: a. The plan of care will clearly reflect a loop of assessment, intervention, and evaluation for restraint, seclusion and medications. ... 12. Documentation Requirements ... n. Modifications of the plan of care.” Review of facility document, “Recovery Plan,” document number 13667231, last revised January 2020, reads in part: “PURPOSE STATEMENT: To provide a multidisciplinary, patient centered plan of care based on a patient’s initial and ongoing treatment needs .... The Recovery Plan is an active means of hand-off communication between shifts and caregivers. ... POLICY STATEMENT: ... Short term goals (STG), long term goals (LTG), and interventions are then added to the active problems.” Review of facility document, “Guidance for Recovery Planning, dated October 2019, reads in part: ... “Scope: Inpatient Behavioral Health Purpose: To ensure plans for care, treatment and services are individualized to meet the patient’s needs and circumstances. ...Each patient admitted to the Program has an individualized written Recovery Plan .... ... General Guidance ... B. The RN assigned to the patient will review the patient’s Recovery Plan each shift and will document the patient’s progress or lack thereof to each problem at a minimum of once per shift.” Review of the medical record on March 18, 2026, revealed MR8 was placed in a hold from 11:19 AM to 11:29 AM on March 10, 2026. At 11:29 AM, MR8 was placed in seclusion until 12:50 PM. There was no documentation of modification in the Recovery Plan of the restraints used on MR8. Review of the medical record on March 18, 2026, revealed MR9 was placed in several physical holds on March 17, 2026. PM. There was no documentation of modification in the Recovery Plan of the restraints used on MR9. Review of the medical record on March 18, 2026, revealed MR10 was placed in non-violent restraints at 5:30 AM on March 12, 2026. There was no documentation of modification in the Plan of Care of the restraints used on MR10. Review of the medical record on March 18, 2026, revealed MR11 was placed in non-violent restraints at 5:21 AM on March 18, 2026. There was no documentation of modification in the Plan of Care of the restraints used on MR10. During an interview in the afternoon of March 18, 2026, EMP3 indicated the “Recovery Plan” is considered the “treatment plan” for Tucker Pavilion patients. EMP3 indicated that each day’s Recovery Plan is prepopulated from the prior day, so patient goals are continued each day. Upon review of the medical records with EMP3, there was agreement there was no documentation that the Plan of Care or the Recovery Plan had been amended to include the initiation nor the termination of the applied restraints. During a telephone interview the afternoon of March 18, 2026, EMP3 indicated that treatment plans, including recovery plans, should be amended to include the initiation and termination of any restraints applied to the patient. EMP3 indicated goals are ongoing, versus the occurrence of events, which would require modification to the treatment/recovery plan.”

“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 review of medical records, facility document review and interview with facility staff (EMP), it was determined the facility failed to obtain a restraint order for two (2) of four (4) medical records (MR) reviewed, MR8 and MR10. Findings: Review of facility document, “Seclusion, Restraints and Restraint Alternatives,” document number 1575831, last revised May 2024, reads in part: “... Procedure: ... 5. Order for Restraint or Seclusion a. An order for restraint or seclusion must be obtained from a physician or other licensed practitioner who is acting within their State Scope of Practice, authorized by State law as having authority for ordering restraints, and is responsible for the care of the patient prior to the application of restraint or seclusion. ... d. When a physician or other licensed practitioner, authorized by State law to order restraints, is not available to issue a restraint or seclusion order, an RN with demonstrated competence may initiate restraint or seclusion use based upon face-to-face assessment of the patient. In these emergency situations, the order must be obtained during the emergency application or immediately (within minutes) after the restraint or seclusion is initiated. ... 12. Documentation Requirements ... f. Order for restraint or seclusion and any renewal orders for restraint or seclusion ....” Review of the medical record on March 18, 2026, revealed MR8 was placed in a hold at 11:19 AM on March 10, 2026. The hold was discontinued at 11:28 AM. At 11:29 AM, MR8 was placed in seclusion until 12:50 PM. The provider order for the hold was obtained at 12:21 PM. The order for seclusion was obtained at 4:44 PM. Review of the medical record on March 18, 2026, revealed MR10 was placed in soft bilateral upper extremity restraints at 5:30 AM on March 12, 2026. No documentation of a provider order for the restraint was present in the medical record. During an interview the afternoon of March 18, 2026, EMP3 confirmed the orders for violent restraints used on MR8 were obtained after the policy mandated time limit. EMP3 also confirmed there was no documentation for a restraint order for MR10.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 49355 Based on facility staff (EMP) interviews and document review, it was determined the facility failed to ensure clinical staff possess and maintain current certification in life saving measures, per facility job description, in one (1) out of six (6) personnel records reviewed. The findings: Review of facility document, “Patient Care Tech Job Description,” last revised date July 24, 2019, reads in part: ... “Licensure, Certifications, Training: ... Basic Life Support (BLS) required.” Review of personnel records with EMP24, EMP25 and EMP26, the afternoon of February 18, 2026, revealed an expiration date of November 8, 2025, for EMP13’s BLS certification. EMP25 indicated they had reached out to EMP13’s unit manager to ascertain whether the employee had a newer BLS card. This surveyor was not provided with a current BLS card for EMP13 prior to exit later in the day.”

“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: 49355 Based on medical record (MR) review, facility staff (EMP) interviews and document review, it was determined the facility failed to adhere to policies and procedures regarding documentation requirements for Rapid Response activation. The findings: Review of facility document, “Rapid Response Team,” number 15574441, revised March 2025, reads in part: ... “7. A registered nurse documents the Rapid Response Team’s assessment and interventions on the “Rapid Response Team Documentation Too. 8. The bedside nurse assures completion of the Rapid Response Team Documentation tool and facilitates the faxing of the Rapid Response Team Documentation Tool to the Quality and Compliance Department. ... After a copy of the Rapid Response Team Documentation Tool is faxed to the Quality and Compliance Department, the original Rapid Response Team Documentation Tool will be placed in the MD progress notes section of the medical record. Nursing Directors will review documentation and may debrief with their nursing staff.” Review of the medical record for MR2 on February 17, 2026, revealed references by two (2) providers concerning a Rapid Response (RR) called by EMP11 on December 4, 2025. There was no documentation contained in the record of the RR Documentation Tool (RRDT) or an associated nursing note. During an interview the morning of February 18, 2026, EMP4, EMP20 and EMP21 were not aware an RR had been called on the 6 Front unit on December 4, 2025. During an interview at 10:22 AM on February 18, 2026, EMP11 indicated they had called a RR on MR2 on December 4, 2025, due to a suspected seizure. EMP11 indicated MR2 was unresponsive and “released” urine. EMP11 indicated it was the first time they had ever called a RR and were unsure whether they had documented the incident or even if documentation was necessary. During an interview the morning of February 18, 2026, EMP3 indicated a copy of the completed RRDT could not be located in Quality and Compliance Department files nor in the MD progress notes section of MR2’s medical record.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 42929 Based on review of medical records (MR), review of documents and interview with staff (EMP) it was determined the facility failed to ensure patients were informed of their rights as evidenced by: failure to provide evidence as per the facility’s policy that patients were informed of their rights; failure to include the phone number and address for lodging a grievance with the State Agency in patient rights; and failure to obtain an order for restraint. The facility had deficiencies related to ensuring patients were informed of their rights on May 7, 2025, March 4, 2025, May 14, 2024, February 21, 2024, and November 15, 2023. Cross Reference: §482.13(a)(1) Patient Rights: Notice of Rights §482.13(a)(2) Patient Rights: Grievances §482.13(e)(5) Patient Rights: Restraint or Seclusion”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 42929 Based on observations, review of medical records (MR), review of documents, and interviews with staff (EMP) it was determined the facility failed to implement a well-organized nursing service as evidenced by: failure to document a new skin alteration and implement interventions; failure to document skin alterations and congruent skin assessments each shift; failure to document that two (2) nurses assessed patients for skin integrity upon admission or transfer to another unit as per the facility’s policy; failure to document wound care as per physician’s order; failure to document actions taken as the result of notification of an abnormal arrhythmia alert; and failure to document in the patient’s medical record the staff member who obtained labs. Cross Reference: §482.23(b)(6) Nursing Services: Supervision of Contract Staff”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 42929 Based on review of medical records (MR), review of documents, and interviews with staff (EMP) it was determined the facility failed to provide evidence that patients were informed of their rights for ten (10) of fifteen (15) medical records reviewed, MR2, MR3, MR4, MR7, MR8, MR10, MR11, MR12, and MR14. Findings: Review of facility document “PARA.PP.PTAC.038 Procedure for Registration Forms and Signatures,” approval date May 1, 2024, reads in part: “ ... Policy: The Patient Access Department obtains signatures on all registration forms, from the patient or legally authorized individual, prior to or during the registration process or within a reasonable time frame based upon the patient circumstance .... The Consent should be obtained for each account within the episode of care. Reasonable attempts will be made for follow up on signatures not obtained during the registration process. ... Documentation requirements when a patient is unable to sign: A physician or a licensed clinical person should document a medical reason why the patient is unable to provide a signature, within the medical record. ... Guidelines for witness signatures and titles: ... Special Note: If a signature is not received from the patient or telephone consent from an authorized person, no treatment should be rendered unless it is an emergency. ... Circumstances below should be addressed in the following manor: ... B. Patient unable to sign, no legally authorized/legally empowered individual, Power of Attorney for Healthcare, Legal Guardian or family is present and phone consent received or not received. Telephone consent from a legally authorized/legally empowered person or family member ...must be obtained. The name of the person providing consent and their relationship to the patient is documented or circled on the consent form in the area provided if phone consent is received .... If telephone consent is not obtained, treatment should not be rendered unless it is a life-threatening emergency as defined by a physician...” Review of facility document “Conditions of Admission and Consent for Inpatient and/or Surgical Care,” is signed and initialed by patients indicating patients are informed of their rights to include: Consent to Treat, Use and Disclosure of Information, Patient Visitation Rights, Notice of Privacy Rights, Patient Self Determination Act and Acknowledgement of Notice of Patient Rights and Responsibilities....” Review of the “Patient Rights and Responsibilities” brochure revealed that “... Each individual shall be informed of the patient’s rights and responsibilities in advance of administering or discontinuing patient care....” Review of the medical record for Patient (MR)1, and MR11 revealed no evidence of a “Conditions of Admission” [COA] document. EMP20 was unable to provide documentation the COA had been signed or supporting information that reasonable attempts had been made to obtain the patients’ signatures. Review of the medical records for MR2, MR3, MR8, MR10, and MR14 revealed a COA document with “Patient is Unable to Sign” box checked. Two witnesses had signed the document. EMP20 was unable to provide supporting information, indicating reasonable attempts had been made to obtain the patients’ or representatives’ signatures. Review of the medical record for MR4 revealed a COA document was present in the medical record, with “Patient is Unable to Sign” box checked. Two witnesses had signed the document. EMP20 provided a report that indicated on two different dates, August 22, 2025, and August 25, 2025, an “account review” occurred. Review of the medical record for MR7 revealed a COA document with “Patient is Unable to Sign” box checked. Two witnesses had signed the document. EMP20 provided a report that indicated on two different dates, August 23, 2025, and August 24, 2025, an “account review” occurred. Review of the medical record for MR12 revealed no evidence of a COA document with “Patient is Unable to Sign” box checked. Two witnesses had signed the document. EMP20 provided a report that indicated on August 11, 2025, through August 15, 2025, and on August 18, 2025, through August 21, 2025, an “account review” occurred. There was no additional evidence provided that MR2, MR3, MR4, MR7, MR8, MR10, MR11, MR12, and MR14 were informed of their rights. Interview on August 26, 2025, at 3:53 PM and August 27, 2025, EMP20 indicated a work list report of patients without a signed COA is generated to alert the Patient Accounts staff that a signature has not been obtained. The Patient Accounts staff should attempt to obtain a signature while the patient is still in the Emergency Department (ED) or once the patient has been admitted to the facility. EMP20 indicated the Patient Accounts staff will visit the patient in their room to obtain the necessary signatures. EMP20 provided a report for MR1 and MR11 indicating an “account review” had occurred on the noted dates. EMP20 indicated the “account review” documentation shows attempts made to obtain the patient’s signature. The report contained no evidence of the time, staff, or method, such as visit to room or telephone call, or that the “account review” indicated attempts for signature. EMP20 indicated there is no policy or procedure documenting this process. EMP20 indicated that if the Patient Access staff erroneously check the box in the patient’s medical record indicating that the COA was signed, then the patient with an unsigned COA will not appear on the work list report for follow up.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 42929 Based on review of documents and interviews with staff (EMP) it was determined that the facility failed to provide the phone number and address for lodging a grievance with the State Agency in patient rights. Findings: Review of facility document “Patient Grievance and Complaint Management Policy” last revised October 2023 reads in part: “... Policy: Each patient and/or the patient’s representative will be informed of the grievance process including whom to contact to file a grievance or complaint. The patient will be informed that a grievance may be directly lodge with the Virginia Department of Health, regardless of whether he/she has first used the organization’s grievance process.... Procedure: A. Notification of Rights Regarding Complaint/Grievance Resolution. 1. Each patient and/or patient representative is informed of the rights and responsibilities afforded patients upon entry into the facility, and the process by which they may lodge a complaint. This information is provided through the Patient Information Packet on admission, Patient Rights and Responsibilities signage and Conditions of admission forms provided during the Registration process.... 2. Each patient received information on how to lodge a grievance with the state agency upon entry to the facility. The Virginia Department of Health, Office of Licensure and Certification phone number, and address are provided in the event that the patient decides not to use the internal grievance process....” Review of facility document “Patient Rights and Responsibilities” brochure revealed that “... Each individual shall be informed of the patient’s rights and responsibilities in advance of administering or discontinuing patient care. We adopt and affirm as policy the following rights of patient/clients who receive services from our facility: ... To file a complaint with the Department of Health ... if he/she has a concern about patient abuse, neglect, about misappropriation of patient’s property in the facility or other unresolved complaint, patient safety or quality concern....” The back of the brochure revealed “To Report a Patient Rights Concern, Please Contact:...”, but failed to provide a phone number and address for lodging a grievance with the State agency, the Virginia Department of Health. Interview on August 25, 2025, in the afternoon EMP1 reviewed the “Patient Rights and Responsibilities” brochure and confirmed that the State agency’s phone number and address were not included on the brochure.”

“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: 42929 Based on review of medical records (MR), review of documents, and interviews with staff (EMP) it was determined the staff failed to obtain a restraint order for one (1) of five (5) patients’ restraint documentation reviewed, MR3. Findings: Review of facility document “Seclusion, Restraints and Restraint Alternatives” last revised May 2024 reads in part: “... 5. Order for Restraint or Seclusion. a. An order for restraint or seclusion must be obtained from a physician or other licensed practitioner who is acting within their State Scope of Practice, authorized by State law as having authority for ordering restraints, and is responsible for the care of the patient prior to the application of restraint or seclusion....” Review of the medical record for MR3 revealed the nurse documented MR3 was in restraints on June 11, 2025, at 12:30 AM and 2:00 AM. The restraint order revealed the patient had an order for restraint that expired on June 10, 2025, at 11:59 PM. A new restraint order was documented as starting on June 11, 2025, at 3:55 AM. There was no restraint order for June 11, 2025, from 12:00 AM to 3:54 AM, and it was documented that the patient was in restraints during that time. Review of the medical record for MR3 revealed the nurse documented MR3 was in restraints on June 14, 2025, at 12:00 PM, 2:00 PM, and 4:00 PM. The restraint order revealed the patient had an order for restraints that expired on June 14, 2025, at 11:22 AM. A new restraint order was documented as starting on June 14, 2025, at 4:56 PM. There was no restraint order for June 14, 2025, from 11:23 AM to 4:55 PM, and it was documented that the patient was in restraints during that time. Interview on August 27, 2025, in the afternoon, EMP9 confirmed that there was no order for restraints for MR3 during those times. EMP9 indicated that a patient can only be in restraints for the timeframe documented in the physician’s orders.”

“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: 42929 Based on review of medical records (MR), review of documents, and interviews with staff (EMP) it was determined the staff: (A) failed to document a new skin alteration and implement interventions when the skin alteration was first observed for one (1) of three (3) patients’ medical records reviewed, MR3; (B) failed to document skin alterations on skin assessments each shift for three (3) of three (3) patients’ medical records reviewed for skin assessments, MR3, MR4, and MR5; (C) failed to document that two (2) nurses assessed patients for skin integrity upon admission or transfer to another unit as per the facility’s policy for three (3) out of three (3) patients’ medical records reviewed, MR3, MR4, and MR5; (D) failed to document wound care as per physician’s order for one (1) of one (1) patient’s wound care documentation reviewed, MR5; (E) failed to document actions taken as the result of notification of an abnormal arrhythmia alert from the telemetry team for one (1) of one (1) patient’s medical record reviewed, MR2; and (F) failed to document in the patient’s medical record the staff member who obtained labs for one (1) of one (1) patient’s medical record reviewed, MR2. Findings: (A) Review of facility document “Skin Care Policy/Protocol” last revised April 2024 reads in part: “A. All patients are assessed by two (2) Registered Nurse [sic] for skin integrity risk factors and actual skin breakdown within [eight] 8 hours of admission or transfer to another unit ....” B. Patients are reassessed every shift and upon transfer to another unit. C. Assessments are documented per facility policy on the following as applicable: 1. Admission Physical Assessment - Meditech. 2. Shift Assessment - Meditech. 3. Skin/Wound Assessment Screen - Meditech. 4. Or other approved method - (e.g. hourly rounding tool) ... F. Consultation to Wound - Ostomy [surgical operation that creates an opening (stoma) in your abdomen ... for waste to come out, www.clevelandclinic.org]- Continence Nurse (WOCN) for patients at risk for or with actual skin breakdown per physician or RN post-assessment nursing .... Notification to physician of any actual or potential skin breakdown is required ....” Interview on August 27, 2025, at 9:06 AM, EMP1 indicated that there is no other facility policy, procedure/ training, or guidance on the procedure for documenting skin assessments and skin alterations. MR3 Review of the medical record for MR3 revealed an order for wound care evaluation dated June 11, 2025, at 3:51 PM, for a new abrasion on the right side of the patient’s face. This was the first date and time the facial skin alteration was documented in MR3’s medical record. Review of the nursing skin assessment for MR3 dated June 11, 2025, at 12:49 AM revealed no documentation of a new facial skin alteration, and no documentation that two (2) nurses performed the skin assessment upon unit transfer. The next documented nursing skin assessment dated June 11, 2025, at 6:11 PM, was the first nursing skin assessment to document the facial skin alteration “Abrasion Anterior Check right” with a dry, intact dressing. Interview on August 27, 2025, at 9:06 AM, EMP19 indicated that EMP19 observed a skin alteration on MR3’s face when EMP19 received the patient upon transfer from the trauma stepdown unit sometime before midnight on June 10, 2025. EMP19 indicated that the trauma stepdown unit nurse was bedside during the transfer, and pointed out the skin alteration on the MR3’s face indicating that it was caused by the patient’s mitts. EMP19 indicated that skin assessments are documented at least once every 12-hour shift, and a full skin assessment is performed by two (2) nurses upon admission and transfer to another unit. EMP19 indicated that the nurses should document any skin alteration observed. Interview on August 27, 2025, at 1:49 PM, EMP28 indicated that during morning hand off on June 11, 2025, EMP19 pointed out the skin alteration on MR3’s face. EMP19 told EMP28 that the patient may have scratched their face with the Velcro in the mitts. EMP28 indicated that if the nurse is notified about a skin alteration in hand off, then the skin alteration should already be documented in the medical record. (B) Review of facility document “Skin Care Policy/Protocol” last revised April 2024 reads in part: “B. Patients are reassessed every shift and upon transfer to another unit. C. Assessments are documented per facility policy on the following as applicable: 1. Admission Physical Assessment - Meditech [electronic medical record [EMR] system]. 2. Shift Assessment - Meditech. 3. Skin/Wound Assessment Screen - Meditech. 4. Or other approved method - (e.g. hourly rounding tool) ... Interview on August 27, 2025, EMP1 indicated that there is no other facility policy, training, or guidance on how to document skin assessments and skin alterations. Review of the integumentary (skin) assessments for MR3 dated June 9, 2025, through June 25,2025 revealed the following inconsistent and contradictory skin alteration documentation. Review of nursing skin assessment for MR3 dated June 8, 2025, at 8:00 PM revealed documentation of four (4) skin alterations “Skin alteration: Present/Exists ... Abrasion Anterior Cheek right ... Abrasion Anterior Umbilical ... Pressure injury Anterior Labia right ... Scratch Anterior Abdomen ...” with descriptions and dressing changes documented. Review of nursing skin assessment for MR3 dated June 9, 2025, at 9:03 AM revealed that a skin assessment was completed with no skin alterations documented. Review of nursing skin assessment for MR3 dated June 9, 2025, at 8:00 PM revealed that a skin assessment was completed with no skin alterations documented. Review of nursing skin assessment for MR3 dated June 10, 2025, at 8:29 AM revealed a skin assessment documenting “Skin alteration: Present/Exists” of “Pressure injury Anterior Labia right ... Stage 2”. No other description of the skin alteration, and no other skin alterations documented. Review of nursing skin assessment dated June 11, 2025, at 12:49 AM revealed a skin of assessment documenting “Skin alteration: Present/Exists” of “Scratch Anterior Abdomen” with description of appearance and dressing. No other skin alterations documented. Review of nursing skin assessment for MR3 dated June 11, 2025, at 6:11 PM revealed “Skin alteration: Present/Exists ... Abrasion Anterior Check right” with a dry, intact dressing. No other description of the skin alteration, and no other skin alterations documented. Review of nursing skin assessment for MR3 dated June 13, 2025, at 12:32 AM revealed “Skin alteration: Present/Exists”. No other skin alterations documented. Review of nursing skin assessment for MR3 dated June 13, 2025, at 8:00 AM revealed “Skin alteration: None”. No other skin alterations documented. Review of nursing skin assessment for MR3 dated June 14, 2025, at 9:30 AM revealed “Skin alteration: Present/Exists ... Abrasion Anterior Cheek right ... Abrasion Anterior Umbilical ... Pressure injury Anterior Labia right ... Scratch Anterior Abdomen ...” with descriptions and dressing changes documented. Review of nursing skin assessment for MR3 dated June 14, 2025, 9:33 PM revealed “Skin alteration: Present/Exists”. No other skin alterations documented. Review of nursing skin assessment for MR3 June 16, 2025, 7:11 AM “Skin alteration: Present/Exists ... Abrasion Anterior Cheek right ... Abrasion Anterior Umbilical ... Pressure injury Anterior Labia right ... Scratch Anterior Abdomen ... Blister Anterior Abdomen left lower quad ...” Review of nursing skin assessment for MR3 dated June 17, 2025, 11:52 PM revealed “Skin alteration: Present/Exists”. No other skin alterations documented. Review of nursing skin assessment for MR3 dated June 18, 2025, at 11:50 PM revealed “Skin alteration: Present/Exists”. No other skin alterations documented. . Review of nursing skin assessment for MR3 dated June 19, 2025, at 8:00 PM revealed “Skin alteration: Present/Exists ... Abrasion Anterior Check right” with no description. No other skin alterations documented. Review of nursing skin assessment for MR3 dated June 20, 2025, 6:49 PM revealed “Skin alteration: Present/Exists ... Abrasion Anterior Umbilical ... Pressure injury Anterior Labia right ...” No other skin alterations documented. Review of nursing skin assessment for MR3 dated June 20, 2025, at 11:00 PM revealed “Skin alteration: Present/Exists ... Abrasion Anterior Cheek right ... Abrasion Anterior Umbilical ... Pressure injury Anterior Labia right ... Scratch Anterior Abdomen ...” New skin alteration documented “Pressure injury Posterior Back”. Review of nursing skin assessment for MR3 dated June 21, 2025, at 3:33 PM revealed that a skin assessment was completed with no skin alterations documented. Review of nursing skin assessment for MR3 dated June 23, 2025, at 8:00 PM revealed five (5) skin alterations were documented as “Inactive”. MR4 Review of the integumentary assessments for MR4 dated August 21, 2025, through August 24, 2025, revealed the following inconsistent and contradictory skin alteration documentation. Review of nursing skin assessment for MR4 dated August 21, 2025, at 9:00 AM, revealed skin condition as “Cracked/Dry”, Posterior Sacrum Pressure injury” present on admission that is “Beefy red” and a dressing, “Right Lateral Hip Pressure injury” present on admission that is “Beefy red” and a dressing, “Left Lateral Hip Pressure injury” present on admission that is “Beefy red, Tunneling” and an adhesive wound dressing with packing. Review of nursing skin assessment for MR4 dated August 21, 2025, at 9:21 PM, revealed “Integumentary” assessment documented as “All normal” and no skin alterations documented. Review of nursing skin assessment for MR4 dated August 22, 2025, at 9:00 AM, revealed documentation that the three (3) originally documented skin alterations were documented as present on admission, but there was no description of the wound or dressing type. Review of nursing skin assessment for MR4 dated August 22, 2025, at 9:00 PM, revealed “Integumentary” assessment documented as “All normal”, and documented all three (3) previously documented skin alterations indicating each had a dressing. Review of nursing skin assessment for MR4 dated August 23, 2025, at 9:00 AM, 5:30 PM, 9:00 PM, August 24, 2025, at 9:00 AM revealed “Integumentary” assessment documented as “All normal” and no skin alterations documented. MR5 Review of the integumentary assessments for MR5 dated August 8, 2025, through August 26,2025 revealed the following inconsistent and contradictory skin alteration documentation. Review of nursing skin assessment for MR5 dated August 8, 2025, at 9:46 PM, revealed “bilateral new abrasion”. “Pressure injury present on admission” was documented as “No”, and left anterior forearm “resolving bruising”. Review of nursing skin assessment for MR5 dated August 9, 2025, at 9:00 PM, revealed “Integumentary” assessment documented as “All normal”, and documented “bilateral knew abrasion”. “Pressure injury present on admission” was documented as “Yes”. Review of nursing skin assessment for MR5 dated August 10, 2025, at 8:00 AM, revealed “Integumentary” assessment documented as “All normal”, and no documentation of the skin alterations documented in the prior shift assessment, and at 3:22 PM left anterior forearm “reddened”. Review of nursing skin assessment for MR5 dated August 10, 2025, at 8:00 PM, revealed “Integumentary” assessment documented as “All normal”, and documented “Bilateral Anterior Abdomen” wound described as “ ... Wound surrounding tissue temperature: Warm, Wound closure: Intact, Wound drainage description: Sanguineous ... Wound drainage order: No odor, Dressing status: Dry, Intact ... Dressing type: Negative pressure wound therapy. “Bilateral Knee Abrasion ... Skin alteration details: pink ... Wound surround tissue appearance: Pink, Wound surrounding tissue temperature: Warm ... Wound drainage amount: None, Wound drainage odor: No odor ...”. Left anterior forearm “pink”. Review of nursing skin assessment for MR5 dated August 11, 2025, at 9:00 AM and 9:00 PM revealed “Integumentary” assessment documented as “All normal”, and left anterior forearm “reddened”. No other documentation of the skin alterations documented in the prior shift assessment. Review of nursing skin assessment for MR5 dated August 12, 2025, at 9:00 AM revealed “Integumentary” assessment documented as “All normal”, and documented “Bilateral Anterior Abdomen” wound assessed to include “Negative pressure wound therapy”. No other skin alterations documented. Review of nursing skin assessment for MR5 dated August 12, 8:00 PM revealed “Integumentary” assessment documented as “All normal”, and documented “Anterior Abdomen Procedural Site” wound described as “Wound closure: Intact, Staples. Wound drainage description: Serosanguineous. Wound drainage amount: Small, Wound drainage odor: No odor. Wound cleansing: Other. Other wound cleansing: primapore (adhesive non-woven wound dressing, www.smith-nephew.com). Dressing status: Dry, Intact ....” There was no documentation of the previously documented “Bilateral Anterior Abdomen” wound. Unclear if both anterior abdomen wounds are the same or different. No other skin alterations documented. Review of nursing skin assessment for MR5 dated August 13, 2025, at 9:00 AM revealed “Integumentary” assessment documented as “All normal” and no other skin alterations documented. Review of nursing skin assessment for MR5 dated August 13, 2025, at 8:00 PM revealed “Integumentary” assessment documented as “All normal”, and documented a new skin alteration “Bilateral Posterior Buttock Pressure injury”, and previously documented alterations “Anterior Abdomen Procedural site”, and “Bilateral Anterior Abdomen” all with additional descriptions. Left anterior forearm “reddened”. Review of nursing skin assessment for MR5 dated August 14, 2025, at 9:00 AM revealed “Integumentary” assessment documented as “All normal” and no other skin alterations documented. Review of nursing skin assessment for MR5 dated August 14, 2025, at 8:00 PM revealed “Integumentary” assessment documented as “All normal”, and documented “Bilateral Posterior Buttock Pressure injury”, “Anterior Abdomen Procedural site”, and “Bilateral Anterior Abdomen” all with additional descriptions. Left anterior forearm “resolving bruise”. Review of nursing skin assessment for MR5 dated August 15, 2025, at 8:00 AM revealed “Integumentary” assessment documented as “All normal”, and documented “Anterior Abdomen Procedural site”, with additional descriptions. The documentation for the “Bilateral Anterior Abdomen” was “Other skin alteration details: bilateral jp (Jackson-Pratt) drains noted, with no additional wound and drainage descriptions. Also documented “Bilateral Knee Abrasion”, “Other skin alteration details: c/d/I (clean/dry/intact).” Review of nursing skin assessment for MR5 dated August 15, 2025, at 9:00 PM revealed “Integumentary” assessment documented as “All normal”, and documented “Anterior Abdomen Procedural site”, “Bilateral Anterior Abdomen”, and “Bilateral Knee Abrasion”. No other skin alterations documented. Review of nursing skin assessment for MR5 dated August 16, 2025, at 8:00 AM revealed “Integumentary” assessment documented as “All normal”, and documented “Bilateral Posterior Buttock Pressure injury” as “Other skin alteration details: NO PRESSURE INJURY NOTED”. The documentation addressed all other documented skin alterations except for “Bilateral Posterior Sacrum Pressure injury. Review of nursing skin assessment for MR5 dated August 16, 2025, at 9:00 PM, and August 17, 2025, at 8:00 AM and 8:00 PM, and August 18, 2025, at 9:00 AM revealed “Integumentary” assessment documented as “All normal” and no skin alterations documented. Review of nursing skin assessment for MR5 dated August 18, 2025, at 9:00 PM revealed “Integumentary” assessment documented “Anterior Abdomen Procedural site”, “Bilateral Anterior Abdomen”, and “Bilateral Knee Abrasion” with descriptions of wound, drainage, and dressing as appropriate. No other skin alterations documented. Review of nursing skin assessment for MR5 dated August 19, 2025, at 9:00 AM and 9:00 PM, August 20, 2025, at 9:00 AM and 9:18 PM, August 20, 2025, at 9:00 AM and 9:00 PM revealed “Integumentary” assessment documented as “All normal” and no skin alterations documented. Review of nursing skin assessment for MR5 dated August 22, 2025, at 11:19 AM revealed “Integumentary” assessment documented as “All normal”, and documented “Anterior Abdomen Procedural site” and dressing change due to soiled from ostomy, “Bilateral Anterior Abdomen”, dressing changed, and “Bilateral Knee Abrasion ... site open to air. Skin intact.” Documentation at 3:43 PM on the same shift, “Bilateral Posterior Sacrum Pressure injury” documented as “Stage 1”, cleansed, and dressing applied. Review of nursing skin assessment for MR5 dated August 22, 2025, at 9:00 PM revealed “Integumentary” assessment documented as “All normal”, and documented “Bilateral Posterior Sacrum Pressure injury”, “Anterior Abdomen Procedural site” to include “Wound closure: Intact, Staples”, “Bilateral Anterior Abdomen”, and “Bilateral Knee Abrasion” with description. Review of nursing skin assessment for MR5 dated August 23, 2025, at 2:10 PM revealed “Integumentary” assessment documented as “All normal”, and documented “Skin Color: Left Anterior Forearm: Skin color: Resolving bruising.” No other skin alterations documented. Review of nursing skin assessment for MR5 dated August 23, 2025, at 9:00 PM revealed “Integumentary” assessment documented as “All normal”, and documented “Left Anterior Forearm: Skin color: Resolving bruising”, “Bilateral Posterior Sacrum Pressure injury” and “Bilateral Posterior Buttock Pressure injury” to include documentation of “Beefy red” with scant serous drainage, “Anterior Abdomen Procedural site” intact with staples, and “Bilateral Knee Abrasion” as warm and “Beefy red”. Review of nursing skin assessment for MR5 dated August 24, 2025, at 9:00 AM and 9:00 PM, August 25, 2025, at 9:00 AM and 9:00 PM, and August 26, 2025, at 9:00 AM and 9:00 PM revealed “Integumentary” assessment documented as “All normal” and no skin alterations documented. There was no documentation that any of the skin alterations had resolved except for August 16, 2025, at 8:00 AM revealed “Bilateral Posterior Buttock Pressure injury” as “Other skin alteration details: NO PRESSURE INJURY NOTED”. Interview on August 26, 2025, at 1:55 PM, EMP16 indicated that if a skin alteration is documented as “Present/Exists” then the description and location of the alteration should be documented. EMP16 indicated that the documentation is by exception, which means the nurses are to document anything that is abnormal on every skin assessment at least once per shift. Interview on August 27, 2025, at 9:06 AM, EMP19 indicated that skin assessments are documented at least once every 12-hour shift. EMP19 indicated that the nurse should document every skin alteration observed, and the nurse should not document the skin assessment as “normal” if there are any skin alterations. (C) Review of facility document “Skin Care Policy/Protocol” last revised April 2024 reads in part: “A. All patients are assessed by two (2) Registered Nurse [sic] for skin integrity risk factors and actual skin breakdown within [eight] 8 hours of admission or transfer to another unit ....” Review of the medical record for MR1 revealed no documented evidence of two (2) nurses assessing skin integrity and breakdown for the admission assessment on August 7, 2025, and for a unit transfer on August 11, 2025. Review of the medical record for MR3 revealed no documented evidence of two (2) nurses assessing skin integrity and breakdown for unit transfers on June 8, 2025, and June 10, 2025. Review of the medical record for MR4 revealed no documented evidence of two (2) nurses assessing skin integrity and breakdown for the admission assessment on August 21, 2025, and for a unit transfer on August 23, 2025. Review of the medical record for MR5 revealed no documented evidence of two (2) nurses assessing skin integrity and breakdown for unit transfers on August 9, 2025, and August 21, 2025. Interview on August 27, 2025, at 9:06 AM, EMP19 indicated that a full skin assessment is performed by two (2) nurses upon admission and transfer to another unit. EMP19 did not know if there was a way to document the second nurse performing the skin assessment in the electronic medical record (EMR). Interview on August 27, 2025, at 12:45 PM, EMP8 and EMP9 confirmed that the medical records for MR1, MR3, MR4, and MR5 revealed that only one (1) nurse was documented as assessing skin integrity and breakdown on the dates noted. EMP8 indicated that the facility’s old and new electronic medical records systems did not have a specific location for documentation of the second nurse performing the skin assessment. EMP8 indicated that if the second nurse was documented it would be in a nursing note. (D) Review of physician’s order for MR5 dated August 24, 2025, at 12:39 PM revealed “Location: Midline incision/ostomy. Dressings need to be changed by nursing team regularly to avoid infection. Frequency: BID (twice a day). Clean with Other. Other clean with Soap and Water. Packing Iodoform ½ inch [gauze packed into wounds to help prevent bacterial infection and promote healing, www.thewoundpros.com]. Reinforce dressing if required: yes.” Review of the medical record for MR5 dated August 24, 2025, at 9:00 PM, August 25, 2025, at 9:00 AM and 9:00 PM, August 26, 9:00 AM and 9:00 PM, revealed no documentation of wound care performed on any shift following the physician’s order. Interview on August 27, 2025, at 12:45 PM, EMP9 confirmed that EMP9 could not locate any documentation of wound care in MR5’s medical record as per the physician’s order. EMP9 indicated that the physicians’ orders should be followed, and wound care should be documented in the medical record. (E) Review of facility document “Telemetry Policy” last revised date July 2025, reads in part: “ ... Policy: ... 4. The provider will be notified of all cardiac events and what action was taken .... IV. Patient Monitoring Alarms ... 4. Caregivers will respond to and escalate alarms as appropriate based on their scope of practice. 5. The following arrhythmia and dysrhythmia alarms MUST be activated at all times. ... d. Severe bradycardia. ... f. If an arrhythmia occurs, the RN must initiate appropriate live-saving actions and immediately notify the attending provider. ... VI. Telemetry Escalation Process 1. In the event that a non-lethal arrhythmia is detected, the Monitor/Telemetry Technician will initiate the following procedure according to the Telemetry Notification and Escalation Workflow .... a. Initial Notification: a. The Monitor/Telemetry Technician will immediately call the Primary Nurse and document communication within the Manage/Refer/Contact/Notify screen of the EHR, or via the Telemetry Escalation Log. b. Within 2 minutes a nurse will assess the patient and contact the Monitor/Telemetry Technician to provide an update on patient status and ensure rhythm transmission. In addition, the nurse will notify the provider in the event the changes are an abnormal rhythm. a. Second Notification: i. If no resolution from a nurse within 2 minutes from time of initial notification, the Monitor/Telemetry Technician will send a unit broadcast. Available nurses on the unit will assess the patient’s status and contact the Monitor/Telemetry Technician to provide an update on patient status and ensure rhythm transmission. In addition, the nurse will notify the provider in the event the changes are an abnormal rhythm ....” Review of the “Telemetry Escalation Log” dated July 27, 2025, at 7:12 AM revealed documentation that the Monitor/Telemetry Technician called the nurse’s station but there was no answer. The Monitor/Telemetry Technician made a second phone call to the nurse’s station at 7:16 AM and notified a staff member that MR2 had a heart rate of 28 beats per minute (bpm). The event was documented as “resolved” on the Telemetry Escalation Log. Review of the medical record for MR2 dated July 27, 2025, revealed no documentation that the patient’s heart rate was 28 bpm, or that the Monitor/Telemetry Technician reported the heart rate of 28 bpm. There was no documentation of interventions implemented or that a provider was notified of the event. Interview on August 27, 2025, at 10:22 AM, EMP16 indicated it is the expectation for the nurse to document the Monitor/Telemetry Technician’s notification of the event in the medical record, detailing subsequent interventions and whether the provider was notified. EMP16 indicated that nursing staff should immediately check on a patient with an abnormal reading to determine the patient’s status and whether a rapid response or code blue should be called. The nurse should notify the attending physician, who may order an EKG, even if the patient appears stable. The Telemetry Escalation Log is not part of the patient’s medical record. (F) Review of the medical record for MR2 revealed documentation of lab specimens obtained on July 25, 2025, at 5:31 PM, and July 27, 2025, at 2:35 AM. There was no documentation in the patient’s medical record of the staff member who obtained the lab specimens. Interview on August 25, 2025, at 2:40 PM, and August 26, 2025, at 12:32 PM, EMP7 indicated that the identification of the person who obtains the lab specimens is not documented in the patient’s medical record.”

“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: 46466 Based on interviews, facility documents and medical record review, it was determined the facility failed to notify a patient of their rights and responsibilities for one (1) of seven (7) patient records sampled (Patient #2). The findings include: On May 6, 2025, a review of Patient #2’s medical record was conducted. Patient #2’s “Conditions of Admission and Consent for Inpatient and/or Surgical Care”, which included Consent for Treatment, Patient Self Determination Act, and Acknowledgement of Notice of Patient Rights and Responsibilities, was not signed by Patient #2. The form was signed by one (1) Patient Access Representative as a witness and the box “Patient is Unable to Sign” was checked. In addition, the Patient Self Determination Act box was checked by the statement “I have not executed an Advance Directive and do not wish to execute one at this time”. On May 6, 2025 a review of Patient #2’s medical record was conducted. Patient #2’s medical record documented the objective assessment as P2 being alert and oriented times four (4) and ambulatory. There was nothing documented in P2’s medical record from a physician or a licensed clinical person that P2 was unable to sign any documents. On May 7, 2025, an interview was conducted with Staff Member #14. Staff Member #14 stated that Patient Access Representatives round in the Emergency Department (ED) to register and obtain signatures from patients. If a Patient Access Representative was unable to obtain the registration and signature, the Patient Access Representative would follow up on that patient again at a later time. Staff Member #14 stated that the Patient Access Representatives were required to obtain signatures from all patients, unless the patient were unable to sign or refused to sign, and regardless of why the patient is being seen in the facility. A review of the facility’s policy “PAPA.PP.PTAC.038 Procedure for Registration Forms and Signatures”, last approved 5/1/24 and provided by Staff Member #14 indicated in part: “...The Patient Access Department obtains signatures on all registration forms, from the patient or legally authorized individual, prior to or during the registration process or within a reasonable time from based upon the patient circumstance...The Consent should be obtained for each account within the episode of care. Reasonable attempts will be made for follow up on signatures not obtained during the registration process... Documentation requirements when a patient is unable to sign: A physician or a licensed clinical person should document a medical reason why the patient is unable to provide a signature, within the medical record. The documentation should include the physician’s or licensed clinical person’s signature and title including the last and first name...””

“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, facility documents and medical record reviews, it was determined the facility’s nurses failed to follow facility policy and procedure for a patient discharge for one (1) of seven (7) patient records sampled Patient #1). The findings include: On May 6, 2025, a review of Patient #1’s medical record revealed that Patient #1 was discharged from the facility on March 18, 2025. Patient #1’s Discharge General Information, which included discharge instructions, was not signed by Patient #1. The discharge instructions were only signed by the assigned Registered Nurse (RN). Patient #1’s discharge nursing notes were also reviewed and found no documentation to indicate that the RN reviewed the discharge instructions with the patient and/or that the patient refused to sign the discharge instructions. A review of the facility’s policy “Discharge of Patients”, effective 5/2023, indicated in part: “...Policy Statements...F. Discharge instructions will be reviewed by a nurse with the patient or significant other...Documentation: A. Complete discharge instruction form, discuss with patient/significant other and have them sign. Provide patient with copies...”.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 19883 Based on observation, staff interview, and facility policy review, it was determined the facility failed to clean food delivery carts in accordance with the facility’s Cleaning Food Carts, Tray Closets, and Menus, and Food and Nutrition Department Infection Control/Prevention policy. The findings include: On May 6, 2025 at approximately 12:15 PM, during a tour of the third floor unit in the facility’s behavioral health facility, a food delivery cart was observed on the unit. The food delivery cart contained lunch trays for the patients on the unit. Observation and inspection of the food delivery cart revealed the cart was visibly soiled at the bottom inside portion of the cart doors in the area of the door hinges, as well as on the exterior portion of the cart. There was a brown substance at the bottom of each of the three doors in the area of the door hinges. There were ink marks on the outside of the cart, as well as streaks of dried liquid on the inside of one of the cart doors. Staff Member #8 reported during an interview on May 6, 2025 that the meal delivery carts are supposed to be cleaned three times a day. When asked to provide documentation to show the most recent cleaning schedule, such as the times and dates of the cleaning of the meal delivery carts, Staff Member #8 stated that there was no documentation to show the dates or times of the cleanings. Review of the facility’s policy titled: “Cleaning Food Carts, Tray Closets, and Menus” with a most recent revision date of August 2022, was reviewed and reads in part: “...Food carts will be cleaned between soiled and cleaned patient meal delivery by Nutrition Department staff-3 times a day at a minimum, or as needed.” Review of the facility’s policy titled: “Food and Nutrition Department Infection Control/Prevention with a most recent revision date of April 2, 2025 reads in part:”...2. Food Carts: b. Carts are cleaned and sanitized after each use. Carts are also washed on a scheduled basis.” Staff Member #8 could not verify that the meal delivery cart had been cleaned.”

“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: 42725 Based on interview and document review, it was determined the facility failed to ensure two (2) patients were informed of their patient’s rights at the time of registration. Findings: The facility’s policy titled, Patient Rights, was reviewed and reads, in part: “... POLICY: ...All Company-affiliated facilities must provide each patient with a written statement of patient rights at the time of registration and again at the time any patient or patient’s representative has questions regarding their rights...”. The policy was effective July 1, 2020. During the review of medical record (MR) 20 and 22 on March 4, 2025 at approximately 12:30 PM, the state agency (SA) requested to see documentation of the patient’s acknowledgement that they were informed of their patient rights. The documentation could not be located for either MR20 or MR22. During the review, employee (EMP) 19 advised the SA the documentation “was likely” on the unit because both patients were still admitted. EMP19 notified EMP1 of the requested documentation. At 3:00 PM, EMP1 provided the SA with a copy of MR20’s “Condition of Admission and Consent for Inpatient and/or Surgical Care”. The document is nine pages; on page 8, number 20 is a paragraph titled “Acknowledgement of Notice of Patient Rights and Responsibilities that partly reads, “I have been furnished with a Statement of Patient Rights and Responsibilities...”. Page nine contained the patient’s electronic signature that was captured on March 4, 2024, at 2:18 PM. MR20 was admitted to the facility on February 25, 2025. At 3:25 PM, EMP1 provided the SA with a copy of MR22’s “Condition of Admission and Consent for Inpatient and/or Surgical Care”. Page nine contained the patient’s electronic signature that was captured on March 4, 2024, at 2:43 PM. MR22 was admitted to the facility on February 18, 2025.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 42725 Based on medical record review, document review, and interview, it was determined the facility failed to conduct assessment and monitoring every two (2) hours for one (1) of four (4) patients placed in restraint. Findings: The facility’s policy titled, Seclusion, Restraints and Restraint Alternatives, was reviewed and reads, in part: “ PROCEDURE: ... 7. Monitoring the Patient in Restraints or Seclusion a. Patients are assessed by an RN immediately after restraints or seclusion are initiated to assure safe application/initiation of the restraint or seclusion. b. A RN will assess the patient at least every two hours....” The policy was last revised and effective May 2024. A review was conducted of MR20 on March 4, 2025, at approximately 12:30 PM. The review revealed the physician entered a restraint order on February 26, 2025, at 9:46 PM for “combative” behavior and “OOB [Out of bed] is extreme inj [injury] risk”. The level of restraint was “violent/self-destructive” with the restraint device documented as “soft LUE [left upper extremity] soft RUE [right upper extremity]”. MR20 was placed in the restraints on February 26, 2025, at 10:00 PM. Nursing restraint documentation indicated MR20 was assessed on February 27, 2025, at 12:00 AM and again at 2:00 AM. There was no nursing restraint documentation indicating an assessment was performed at 4:00 AM or 6:00 AM. A nursing restraint documentation note on February 27, 2025, at 8:00 AM indicated the restraints were being discontinued. EMP19 assisted the SA with the medical record review. EMP19 confirmed there was no documentation in the record indicating the patient was monitored/assessed, while in restraints, on February 27, 2025, at 4:00 AM and 6:00 AM.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(i) When restraint or seclusion is used, there must be documentation in the patient’s medical record of the following: The 1-hour face-to-face medical and behavioral evaluation if restraint or seclusion is used to manage violent or self-destructive behavior. This Standard is not met as evidenced by: 42725 Based on medical record review and document review, it was determined the facility failed to conduct a face-to-face evaluation within one (1) hour of applying a violent restraint for one (1) of four (4) patients sampled for restraint/seclusion review. Findings: The facility’s policy titled, Seclusion, Restraints and Restraint Alternatives, was reviewed and reads, in part: “ PROCEDURE: ... 9. Face-to-face assessment by a Physician or Licensed Practitioner a. A face-to-face assessment by a physician or licensed practitioner, RN or physician assistant with demonstrated competence, must be done within one hour of restraint or seclusion initiation or administration of medication to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others....” The policy was last revised and effective May 2024. A review was conducted of MR20 on March 4, 2025, at approximately 12:30 PM. The review revealed the physician entered a restraint order on February 26, 2025, at 9:46 PM for “combative” behavior and “OOB [Out of bed] is extreme inj [injury] risk”. The level of restraint was “violent/self-destructive” with the restraint device documented as “soft LUE [left upper extremity] soft RUE [right upper extremity]”. MR20 was placed in the restraints on February 26, 2025, at 10:00 PM. There was no documentation to indicate a face-to-face assessment was performed. EMP19 assisted the SA with the medical record review. EMP19 conducted an additional review of the record and confirmed that there was no documentation indicating a face-to-face assessment was performed.”

“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: 36946 Based on staff interview and document review, it was determined that nursing staff failed to implement the interventions outlined in the patient’s plan of care in one (1) of eight (8) medical records reviewed in the survey sample. Specifically, nursing staff failed to implement fall prevention measures outlined in Patient #2’s plan of care. Findings: The medical record for Patient #2 contained documentation that the patient was transferred from an outside hospital on February 8, 2024 with new onset seizure activity. Documentation indicated the patient had altered mental status and was intubated and sedated on February 8, 2024. On February 09, 2024, the patient was extubated and alert, but confused. On February 10, 2024 Patient #2 was transferred from the ICU (intensive care unit) to a medical floor where the patient’s mental status continued to be documented as confused with difficulty answering questions. The record contained documentation that on February 11, 2024 the patient was more alert and waiting on evaluation from physical and occupational therapy. The nursing assessment from February 11, 2024 at 12:49 PM contained documentation from the Registered Nurse (RN) that the patient was “bedfast” with no out of bed activity and transferring status was documented as “immobile.” The RN documented that Patient #2 was a “high” fall risk and the following interventions were to be implemented: “low bed, bed/chair alarm, slow position changes...supervised toileting.” The RN documented the following on February 11, 2024 at 5:52 PM: “Patient’s bed alarm went off. I went in and [patient] said they needed to use the restroom (bowel movement). I assisted the patient to the restroom. Patient sat safely on toilet. Patient was informed to pull emergency string when they were finished using the restroom. Myself and patient’s sister began to talk and I heard a loud noise. When I went into the restroom, patient was on the floor...” An interview was conducted on October 28, 2024 with Staff Member #13 at 2:00 PM. Staff Member #13 stated that if a patient is identified as a high fall risk, the patient should not be left unattended in the bathroom unless the patient requests privacy. The medical record for Patient #2 did not contain documentation that the patient requested to be alone in the bathroom. The medical record for Patient #2 contained no documentation that the patient’s mobility/ambulation status had been re-evaluated by nursing on February 11, 2024 after documentation that the patient was “bedfast” and “immobile” at 12:49 PM. It was unclear from the medical record and patient’s plan of care whether or not the patient could safely ambulate and what assistance if any they required. The medical record for Patient #2 contained no documentation of the reason the patient was left unattended in the bathroom after being identified as a high fall risk and why the care planned intervention of supervised toileting was not implemented. The facility’s policy, Fall prevention policy was reviewed and reads in part: Each patient will have a fall scale score and risk level documented within the Electronic Health Record...2. Following the calculation of a fall score and risk level, the nurse will document all active, applicable interventions pursuant to the individual needs of each patient. 3. Every patient should have fall prevention measures listed as part of their individualized plan of care.”

“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 interview and document review, it was determined that hospital staff failed to modify a patient’s plan of care to reflect the use of restraints in one (1) out of three (3) medical records. The findings include: Three (3) medical records of patients listed as having restraints from May 1,2024 to July 1, 2024 were reviewed on 07/01/2024 at 12:37 p.m. with the assistance of Staff Member #10, acting as a navigator for the electronic medical records. Patient #4 had three (3) orders for soft bilateral upper extremity non-violent restraints noted in the record. The orders were dated 02/01/2024, 02/09/2024 and 02/10/2024. The usage of restraints was documented on 02/01/2024 in the plan of care. There was no modification present in the medical record to indicate usage of restraints in the plan of care for the 02/09/2024 order, nor the 02/10/2024. The other two (2) medical records indicated changes had been made to the plan of care. In interviews with Staff Members #4, 5 and 10 on 07/01/2024, there was agreement that the plan of care needs to be modified with each new order for restraints. A review of the facility’s policy entitled, “Seclusion, Restraints and Restraint Alternatives,” ID #15758361, last revised 05/2024, reads, in part: ... “Procedure: ... 10. Care of the Patient/Plan of Care: a. The plan of care will clearly reflect a loop of assessment, intervention, and evaluation for restraint, seclusion and medications. ... 12. Documentation Requirements ... n. Modifications of the plan of care” The above findings were discussed at the exit interview on 07/01/2024.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 42929 Based on interview and document review, it was determined the facility failed to inform two (2) of four (4) (Patient #1 and 14) labor and delivery patients of their patient rights. Findings: A review of the facility’s policy titled “Patient Rights” effective date 07/01/2020 states in part: “Ensure that all patients receiving care and/or patient representatives are informed of their rights.... All Company-affiliated facilities must provide each patient with a written statement of patient rights at the time of registration and again at the time any patient or patient’s representative has questions regarding their rights. The written statement of patient’s rights must be provided to the patient in their preferred language or manner that can be understood....” On 02/20/2024, the surveyor reviewed the medical records for Patients #1 and #14, labor and delivery patients in the Maternal Infant Unit (MIU), with Staff Member #15. Staff Member #15 was unable to locate a signed “Conditions of Admission and Consent for Inpatient and/or Surgical Care (COA)” for Patient #1 and #14. The facility’s COA document includes the “... 20. Acknowledgement of Notice of Patient Rights and Responsibilities ...” that requires “Initials” to confirm acknowledgement of patient rights and a space at the end of the document for the “Patient/Patient Representative Signature”. Staff Member #15 advised after conferring with the registration staff, there was a note in the electronic medical record (EMR) for Patient #1 and #14 stating that the COA was “unable to obtain”, with no other information as to the reason it was not obtained. No other evidence was provided that the patients’ were informed of their rights or provided with a written statement of patient rights at the time of registration as per the facility’s “Patient Rights” policy. During a tour of the MIU 02/21/2024 at 9:25 a.m., Staff Member #35 stated that when patients present to the MIU, the patient checks in with the secretary at the registration desk on the unit to provide some basic patient information. The nurse has the patient sign specific consents but the nurses do not have the patients sign the facility’s COA that includes informing the patient of their patient rights. Staff Member #35 confirmed that there is no patient rights information given to the patient by the nurses on the MIU. Staff Member #35 stated that the patient speaks via telephone with the facility’s registration department located near the emergency department for additional information, but the registration staff do not come to the MIU to see the patient.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(2) Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm. This Standard is not met as evidenced by: 36946 Based on staff interview and document review, it was determined the hospital failed to ensure the medical record documented the behavior requiring restraint, restraint orders specified the reason for the restraint, the type of restraint ordered was appropriate, restraints were applied as ordered for the documented behavior and restraint devices were not used without a valid order in two (2) of two (2) patients reviewed in the survey sample (Patients #9 and 17). Findings: The facility’s policy, Seclusion, Restraints, and Restraint Alternatives was reviewed and reads in part: Orders for restraint or seclusion. The order must specify clinical justification for the restraint or seclusion, the date and time ordered, the duration of use, the type of restraint to be used,and the behavior-based criteria for release....Order for Restraint with Violent or Self-Destructive Behavior. Orders for restraint or seclusion must be time limited and must specify clinical justification for the restraint or seclusion, the date and time ordered, duration of restraint or seclusion use, the type of restraint, and the type of restraint and behavior based criteria for release. Orders for restraint or seclusion must not exceed: 1. Four hours for adults, aged 18 years and older...To continue restraint or seclusion beyond the initial order duration, the RN determine that the patient is not ready for release and calls the ordering physician or licensed practitioner, authorized by state law to order restraints, to obtain a renewal order. Renewal orders for restraint/seclusion may not exceed: 1. Four hours for adults, aged 18 years or older. The medical record for Patient #9 contained evidence that the patient was ordered soft wrist restraints on 01/21/24 at 9:35 PM for “attempting to remove device.” The medical record contained no documentation of the patient attempting to remove a device. The device type was not specified in the medical record. The medical record for Patient #9 contained an order for soft bilateral upper extremity restraints on 01/22/24 at 8:46 PM for twelve (12) hours for attempting to remove device. The medical record contained no documentation that the patient was attempting to remove a device. An order was then placed for an enclosure bed for “extreme injury risk” at 6:37 PM on 01/22/24. The medical record did not contain documentation of the rationale for placing the patient in both an enclosure bed and soft wrist restraints simultaneously. The enclosure bed was not obtained for the patient for approximately four (4) hours after the physician ordered the restraint at 10:40 PM. The physician was not notified of the delay in obtaining the bed and no alternate interventions were documented for the patient’s “extreme injury risk” while waiting to obtain the bed. The medical record for Patient #17 contained documentation that a 56-year-old with Alzheimer’s disease came to the emergency department (ED) on 01/26/24 with agitation and violent behaviors. The patient was placed in restraints at 5:03 PM on 01/26/23 (soft restraints to all four extremities) for attempting to kick staff members. The patient continued in four point restraints for the next 24 hours. On 01/27/24 at 5:30 PM, the four point restraints were discontinued and an order for an enclosure bed was placed. Documentation in the medical record indicated that the patient continued in four point restraints and four side rails from 5:30 PM to 10:03 PM with no orders for the four point restraints or the use of four bed rails. Patient #17 continued in the enclosure bed restraint and a new order was placed for the enclosure bed on 01/30/24 for a “violent/self-destructive” restraint for patient “attempts self harm.” The length of the order was indicated as 12:27 PM to 4:27 PM. The restraint order discontinued after four hours and no renewal order was written. Despite no order for the enclosure bed, nursing documentation indicated that the patient remained in the bed from 4:27 PM on 01/30/24 to 4:06 PM on 01/31/24. On 01/24/24, an order was written to continue the enclosure bed for 24 hours. The indication on the order was documented as “attempts to remove device.” The medical record contained no documented evidence that the patient was attempting to remove their device. Staff member #31 confirmed that the enclosure bed would not keep a patient from removing a device and there was no documented clinical reason for the restraint in the medical record. An interview was conducted with staff member #24 on 02/21/24 at 2:00 PM. Staff member #24 advised that it was not common for a patient to be placed on two (2) different restraint types (i.e. wrist restraints and an enclosure bed) simultaneously and the patient would have to have extreme/aggressive/agitated behaviors to warrant it. Interviews were conducted with staff member #17 and staff member #18 during record review on 02/21/24. Staff members #17 and 18 reviewed the above noted patient restraint concerns in the medical records. The staff members confirmed that orders for violent restraints should be renewed every four (4) hours and non-violent restraints every 12-24 hours depending on circumstance.”

“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: 40084 Based on medical record review, facility policy review and interview, it was determined the facility failed to conduct required fall assessments, failed to conduct monitoring of patients after a fall, and failed to use interventions identified to reduce the fall risk for three (3) inpatients. Findings: The Fall Prevention Policy was reviewed and reads, in part: “2. Fall risk and physical assessment will occur at the following intervals: a. Upon admission; b. Once per shift; c. Following a change in medical condition or level of care; and d. Post fall, if applicable. ...DOCUMENTATION: 1. Each patient will have a fall scale score and risk level documented within the Electronic Medical Record (EHR) according to the timeframes outlined in this policy... 2. Following the calculation of a fall score and risk level, the nurse will document all active, applicable interventions pursuant to the individual needs of each patient... POST-FALL PROCESS: 1. Injury assessment a. Prior to being moved, the patient will be immediately assessed for obvious injuries and to determine level of severity. Assessment will include: vital signs, neurological, musculoskeletal, circulatory, integumentary, psychological status, and pain. i. Record vital signs and neurological checks at least hourly for 4 hours, then every 4 hours for 24 hours. Notify attending provider of any changes... a. For each patient fall, the nurse will document in the Post Fall Assessment intervention within the EHR [electronic health record].” Patient #6 was admitted to the facility on 11/23/23 for “weakness” and a medical history that included Parkinson’s disease. Upon admission, Patient #6 was identified as a moderate fall risk with the following interventions in place: bed alarm, low bed and supervised/assisted ambulation. Between 11/23/23 and 12/1/23, there were four (4) times a fall risk assessment was not documented during the night shift (11/16/23, 11/27/23, 11/28/23, 11/29/23). During the day shift, there were three (3) times where a moderate to high fall risk score was calculated, but there were no interventions documented (11/28/23, 11/29/23, 11/30/23). Patient #6 fell on 11/25/23 at approximately 1:30 p.m. and nursing documentation did not demonstrate hourly neurological checks and vital signs post-fall. Patient #8 was admitted to the facility on 11/21/23 at approximately 2:27 p.m. for “alcohol withdrawal”. The fall assessment was documented on 11/22/23 at 6:14 p.m. Patient #8 was identified as a high fall risk and the only intervention listed was “low bed”. Patient #8 fell on 11/23/23 at approximately 3:13 p.m. and nursing documentation did not demonstrate hourly neurological checks and vital signs post-fall. Patient #8 fell again on 11/27/23 at approximately 2:00 a.m. There was no fall risk assessment performed following the fall and nursing documentation did not demonstrate hourly neurological checks and vital signs post-fall. Between 11/22/23 and 12/8/23, there were nine (9) times a fall risk assessment was not documented during the night shift (11/22/23, 11/23/23, 11/24/23, 11/25/23, 11/29/23, 11/30/23, 12/01/23, 12/02/23, 12/03/23 . There were three (3) times on night shift a high fall risk score was calculated, but there were no interventions documented (11/26/23, 11/28/23, 11/29/23). During the day shift, there were two (2) times a fall risk assessment was not documented (12/03/23, 12/08/23). Patient #9 was admitted on 12/4/23 for a “hypertensive emergency”. A fall risk assessment was performed on 12/16/23 at 8:51 p.m., Patient #9 was identified as a medium fall risk with “interventions noted, hourly rounding”. Patient #9 fell on 12/16/23 at approximately 11:30 p.m. and a fall risk assessment was not performed following the fall . Patient #9 fell again on 1/21/23 at approximately 8:50 p.m. and a fall risk assessment was not performed following the fall. Staff Member #16 confirmed that an assessment should be documented every shift (one for day shift, one for night shift). Additionally, if a patient experiences a fall, the staff should perform neurological checks and vital signs per the policy.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 42929 Based on interviews and document review, it was determined the facility staff failed to follow policies and procedures related to informing patients of patient rights for four (4) of seven (7) patients sampled. Findings: The surveyors reviewed the “Conditions of Admission and Consent for Inpatient and/or Surgical Care (Consent)” which includes “Acknowledgement of Notice of Patient Rights and Responsibilities,” “Notice of Privacy Practices,” advanced directives, Limited Power of Attorney, that require patient initials, for seven (7) patients sampled. A review of the Consent form for Patient #3 (P3) contained no evidence that the form was signed or initialed by the patient, and no other documentation of the reason the form was not signed. P3’s form was electronically signed as witnessed by a Patient Access Representative and a witness. A review of the Consent form for P4 contained no evidence that the form was signed or initialed by the patient. “Verbal Consent” was documented on the “Signature Required” line and the form was electronically signed as witnessed by a Patient Access Representative and a witness. A review of the Consent form for P5 contained no evidence that the form was signed or initialed by the patient. “VC” was documented on the “Signature Required” line and the form was electronically signed as witnessed by one (1) Patient Access Representative. A review of the Consent form for P9 contained no evidence that the form was signed or initialed by the patient. “VC” was documented on the “Signature Required” line and “... Relationship to the Patient” was documented as “Patient.” The “Unable to Sign” box was left blank. The form was electronically signed by one (1) Patient Access Representative. During an interview on 11/14/2023 at 1:46 p.m., Staff Member (SM) 23 confirmed that “VC” documented on the consent stands for “verbal consent” but the staff should have “spelled out” those words. SM23 stated that the staff will document verbal consent if a patient is not physically able to sign. SM23 explained that the facility’s freestanding emergency department conducts “virtual registration” that happens through a touch screen. On 11/15/2023 the surveyor reviewed the facility’s policy “Procedure for Registration Forms and Signatures” provided by SM23. The policy contained no evidence of a process or procedure for obtaining verbal consent or for verbal consent related to the “virtual registration” process that is solely used at the facility’s freestanding emergency department. During an interview on 11/15/2023 at 11:47 a.m., SM23 described the “virtual registration” process that occurs at the freestanding emergency department. All of the Patient Access Representatives work remotely and are viewed by the patient on a large tablet. The Patient Access Representative reviews the documentation with the patient and the patient is required to sign the Consent form electronically on the tablet. SM23 stated that some patients are unable or unwilling to sign on the tablet, so the Patient Access Representative will obtain and document “verbal consent.” During the interview, both SM1 and SM23 confirmed that the facility’s does not have a policy or procedure that addresses “virtual registration” or obtaining “verbal consent.” The surveyor noted that the facility’s “Procedure for Registration Forms and Signatures” policy states that if a patient is unable or unwilling to sign consents on the tablet, then “provide the patient with paper forms to sign.” SM1 stated that providing the patient a paper form to sign would be extra work for the nurse. A review of the facility’s policy titled “Procedure for Registration Forms and Signatures” states in part: ... Policy: The Patient Access Department obtains signatures on all registration forms, from the patient or legally authorized individual, prior to or during the registration process or within a reasonable time frame based upon the patient circumstance.... Reasonable attempts will be made for follow up signatures not obtained during the registration process.... 1. The Conditions of Admission and Consent for Outpatient Services (COA/COS) is obtained for all types of Registrations (Outpatient, Emergency, Observation, Surgery, Inpatient, and Newborn).... 3. Patient Bill of rights ... Guidelines for patient’s inability or unwillingness to use technology: In the situation a patient is unable or unwilling to sign consents on the tablet, make reasonable effort to instruct patient how to unitize the tablet signature box and consider using a stylus. If patient is still unwilling to use the tablet, provide the patient with paper forms to sign. Once signed documents are obtained, scan into the document management system.... Guidelines for witness signatures and titles: In the event a patient, a legally authorized individual, or a family member is medically unable to sign, two staff members can act as a witness on the consent form. The two witnesses may be registration and clinical staff. A witness’ signature includes a staff member’s full first name, last name and title. Title abbreviations may also be used. Utilization of title abbreviations may be determined by the SSC. Special Note: If a signature is not received from the patient or telephone consent from an authorized person, no treatment should be rendered unless it is an emergency.... Patient Access: ... B. Patient unable to sign, no legally authorized/legally empowered individual, Power of Attorney for Healthcare, Legal Guardian or family is present and phone consent received or not received. Telephone consent from a legally authorized/legally empowered person or family member ... must be obtained.... Regardless of whether phone consent is or is not received, two (2) witness signatures are required on the consent in the format defined in the witness’ signature and title section in this policy...”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 42725 Based on medical record review, document review and interview, it was determined the facility staff failed to accurately document the use of restraints as per facility policy for two (2) of (3) patients sampled specifically for restraint review. The findings included: The surveyor reviewed three (3) medical records for restraint use. In two (2) of the medical records, the nursing documentation reflected a violent level restraint. The surveyor was unable to locate a face-to-face assessment within one (1) hour or a restraint renewal order within four (4) hours. After further review, it was discovered that the orders were written as a non-violent level restraint and incorrectly documented as a violent level during the initiation of the restraint. P13 - an order was entered on 11/9/23 at 1:51 a.m. by a medical provider that reads, in part: “Level of restraint: Non-violent...”. Nurse documentation at the start of the restraint reads, in part: “... Level of restraint: Violent/self-destructive...”. The order was for “Soft BUE” (bilateral upper extremity), which is what was documented as being applied. P14 - an order was entered on 11/12/23 at 10:40 a.m. by a medical provider that reads, in part: “Level of restraint: Non-violent...”. Nurse documentation at the start of the restraint reads, in part: “... Level of restraint: Violent/self-destruction...”. The order was for “Soft BUE” (bilateral upper extremity”, which is what was documented as being applied. On 11/15/23, the surveyor reviewed the findings with SM1 who acknowledged that it was “documented incorrectly” and that parts of the restraint documentation flowsheet (violent versus non-violent) carry over until the order is discontinued. The surveyor discussed the concern regarding incorrectly documenting a restraint with SM1 who agreed that it is a concern and will be addressed. The finding was reviewed with SMs 1, 2, 3, 24 and 26 during the exit conference on 11/15/23.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 42929 Based on interviews, and document review, it was determined the facility staff failed to ensure nursing care was assigned for one (1) of seven (7) patients sampled. Findings: The surveyor reviewed the medical record for Patient (P) 7 on 11/14/2023 with Staff Member (SM) 1. The “Emergency Patient Record” contained evidence that P7 was at the emergency department (ED) from 11:54 a.m. through 10:13 p.m. on 10/31/2023. As per the nursing notes, the patient had been transferred from the facility’s free standing emergency department with the diagnosis of a pulmonary embolism (PE) and was transferred on a heparin drip for treatment of the PE. Based on the medical record documentation and interviews with their staff, SM1 and SM3 were unable to confirm P7’s exact time of arrival at the main hospital ED or determine which nurse was assigned to care for P7 upon arrival. There was no documentation of nursing hand off received at the ED. The first documented nursing note at the hospital campus ED, was at 3:18 p.m. stating “Pt moved to bed 22A. No report given.” No other nursing notes were documented for P7’s time in the ED, where the patient stayed until at least 10:13 p.m. that same day, as per the documentation in the electronic medical record (EMR). During an interview via telephone on 11/14/2023 at 11:36 a.m., SM14 could not recall the time P7 arrived at the main hospital ED or which nurse was assigned to that patient, as it was “very busy” that day. SM14 recalled that P7 arrived and SM14 asked emergency medical services (EMS) transport to place the patient in the waiting room and SM14 would “put the patient on the monitor.” SM14 stated that SM14 did place P7 on a portable monitor in the waiting room. SM14 was not aware if P7 was placed on a monitor in the Transitional Care Area (TCA) of the ED later that day. SM14 stated that typically EMS would give report to the nurse prior to dropping off the patient, but SM18 did not recall receiving report and did not obtain vital signs on P7 upon arrival. During an interview via telephone on 11/15/2023 at 11:55 a.m., SM18 did not recall P7, but stated that SM18 works until 3:00 p.m. daily, so based on SM18’s documentation in the patient’s medical record at 3:18 p.m., SM18 must have just received that patient, made sure that the patient was “ok” and had a call bell in reach, and then SM18 left for the day. SM1 and SM3 were unable to provide documentation of the nurse assigned to P7 upon arrival at the main hospital ED until SM18 assumed care of P7 at 3:18 p.m., as documented in the nursing note. There was no documentation provided of the nurse assigned care after SM18 left around 3:18 p.m. through the time P7 was transferred out of the Hospital ED was around 10:13 p.m. that evening. A review of the facility’s policy titled “Assessment and Reassessment of Patients” states in part: ... A. Nursing Assessment 1. A registered nurse assesses the patient’s need for nursing care in all settings where nursing care is provided.... B. Nursing Reassessment 1. An RN completes the reassessment to include an update of the Plan of Care or completes the assessment portion of the nurse’s notes: ... d. When the patient is transferred from one unit to another unit ... Documentation Requirements: A. 1. All assessments and reassessments are documented on the patient’s medical record....”

“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: 42929 Based on interviews, and document review, it was determined the nursing staff failed to ensure that one (1) of seven (7) patients were assessed and monitored as per policy and physician’s orders. Findings: A review of the medical record for Patient (P) 7 on 11/14/2023 contained evidence that P7 was diagnosed with a pulmonary embolism (PE) at the facility’s free standing emergency department and placed on a heparin drip. A review of the “Bridge Orders - ED” from 10/31/2023 at 5:44 a.m. contained evidence of orders for vital signs every four (4) hours. P7 was transferred to the main hospital Emergency Department (ED) with documented evidence of P7 in the “inpatient holding” on 10/31/2023 from 11:54 a.m. through 10:13 p.m. A review of the medical record for P7 with Staff Member (SM) 1 contained evidence of the last set of vital signs obtained at the free standing emergency department at 11:30 a.m. and the next set of vital signs documented at the main hospital ED at 7:41 p.m., more than eight (8) hours after the last set of vital signs. There was no evidence that vital signs were obtained, no documentation of the nurse assigned to care for P7, and no documentation of nursing report received, upon P7’s arrival at the main hospital ED, and this was confirmed by SM1. The first documented nursing note at the main hospital ED was at 3:18 p.m. stating “Pt moved to bed 22A. No report given.” No other nursing notes were documented for P7’s time in the ED where the patient stayed until at least 10:13 p.m. that same day, as per the electronic medical record documentation (EMR). During an interview via telephone on 11/14/2023 at 11:36 a.m., SM14 could not recall the time P7 arrived at the main hospital ED or which nurse was assigned to that patient, as it was “very busy” that day. SM14 recalled that the P7 arrived and SM14 asked Emergency Medical Services (EMS) transport to place the patient in the waiting room, and then SM14 placed P7 on a portable monitor. SM14 was not aware if P7 was placed on a monitor in the Transitional Care Area (TCA) of the ED later that day. SM14 stated that typically EMS would give report to the nurse prior to dropping off the patient, but SM18 did not recall receiving report and did not obtain vital signs on P7 upon arrival. During an interview via telephone on 11/15/2023 at 11:55 a.m., SM18 did not recall P7, but stated that SM18 works until 3:00 p.m. daily, and based SM18’s documentation in the patient’s medical record at 3:18 p.m., SM18 must have just received that patient, made sure that the patient was “ok”, and had a call bell in reach, and then SM18 left for the day. A review of the facility’s policy titled “Assessment and Reassessment of Patients” states in part: ... A. Nursing Assessment 1. A registered nurse assesses the patient’s need for nursing care in all settings where nursing care is provided.... B. Nursing Reassessment 1. An RN completes the reassessment to include an update of the Plan of Care or complete the assessment portion of the nurse’s notes: ... d. When the patient is transferred from one unit to another unit ... Documentation Requirements: A. 1. All assessments and reassessments are documented on the patient’s medical record....”

“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, and document review, it was determined the facility staff failed to complete medication administration and medication documentation as per facility policy for one (1) of (7) patients sampled. The findings included: A review of Patient #3’s (P3) medication administration record revealed the following medication administrations did not contain a one (1) hour reassessment or the medication was not administered as ordered: During the ED stay, one (1) 5 mg (milligram) tablet of oxycodone (a narcotic pain medication) administered on: 9/9/23 at 11:28 p.m. for a verbalized pain intensity of “5” out of 10. At 1:01 a.m. on 9/10/23, a pain reassessment note documented a reassessment was not conducted because “pt [patient] sleeping”. 9/10/23 at 10:36 a.m. for a verbalized pain intensity of “7” out of 10. At 11:07 a.m., there was no documentation to indicate a pain reassessment was conducted. 9/10/23 at 3:53 p.m. for a verbalized pain intensity of “7” out of 10. At 4:23 p.m., there was no documentation to indicate a pain reassessment was conducted. There were two (2) administrations on 9/12/23 at 8:20 a.m. and 1:13 p.m., with a note stating “barcode was torn would not scan at bedside”. There was no pain intensity assessment documented or pain reassessment documented for those two entries. A dulera HFA 200/5 mcg HFA - per puff inhaler was ordered on 9/9/23 at 10:20 p.m. for “BID” (BID - twice a day) administration. On 9/10/23 at 8:00 p.m., there was no documented administration of the medication. On 9/11/23 at 7:39 a.m., a nurse documented “not on my shift” for the previously scheduled administration. While on the 6 Front unit, P3 had an order for hydralazine 25 mg tablet PO (by mouth) Q6H. On 9/15/23 an entry at 0400 documented the following: “Not administered... Missed medication not loaded and too close to next dose”. The findings regarding the missed medication administrations were reviewed with SMs 1, 2, 3, 24 and 26 during the exit conference on 11/15/23. A facility policy titled, Adult Medication Orders & Administration, was reviewed and reads, in part: “PURPOSE STATEMENT: To establish a process for the organized systematic control, distribution, monitoring and administration of medications... G. Administration 1. General guidelines should be observed when administering medications. a. Scheduled medications should be administered within 60 minutes around the time the medication is due... 10. Chart the effectiveness of PRN [as needed] medications 1 hour after administration in the appropriate Meditech intervention screen or nurses notes...”.”