Bon Secours St Francis Medical Center

“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: 36946 Based on staff (EMP) interview, observation, and document review, it was determined the hospital failed to ensure each nurse followed policies and procedures of the hospital. Specifically, the hospital failed to ensure nursing staff adhered to established infection control and medication administration policies and procedures in one (1) of one (1) observation of medication administration in the survey sample. Medical Record (MR)9. Findings: An observation of medication administration was conducted at 11:30 AM on June 10, 2026. EMP12 performed hand hygiene with alcohol based hand rub and donned clean gloves upon entering MR9’s room. EMP12 utilized the computer keyboard and mouse to access the patient’s electronic medical record. EMP12 then removed the caps from three (3) single use vials - two (2) vials of normal saline and one (1) vial of ceftriaxone (an antibiotic). EMP12 punctured each of the vials with a single needle without disinfecting the vial stopper using an alcohol pad. EMP12 retrieved a disinfectant pad from their pocket with their gloved hand and utilized it to clean the hub of the intravenous catheter. EMP12 then administered IV (intravenous) ceftriaxone and flushed the patient’s IV with normal saline. EMP12 retrieved unused supplies and put them back into their pockets. EMP12 then disposed of trash and removed gloves and performed hand hygiene. EMP12 failed to perform hand hygiene or change gloves after touching the computer keyboard and before handling IV medications and before manipulating the patient’s IV catheter. Hand hygiene was only performed upon entering and exiting the room. Gloves were donned on entrance and doffed on exit, but were not changed during medication preparation and administration. An interview was conducted with EMP2 (a Registered Nurse) on June 10, 2026, after medication administration. EMP2 indicated they were unsure if a single use vial required scrubbing the stopper with alcohol and they would have to consult facility policy. An interview was conducted with EMP10 (a Registered Nurse) on June 10, 2026 at 12:05 PM related to expectations for hand hygiene, specifically related to hand hygiene between touching the computer and keyboard and the patient’s IV. EMP10 indicated that hand hygiene was unnecessary between touching a computer and touching the patient’s IV because the computer was dedicated to the patient’s room and not shared between patients. The facility’s procedure, “IV solution preparation, adding medications to the container” (reviewed September 15, 2025) reads in part, “...For medication from a vial. Remove the lid from the medication vial. Perform a vigorous mechanical scrub of the vial stopper using an alcohol pad. Allow it to dry completely. If you must dilute the medication, perform a vigorous mechanical scrub of the port of the diluent container using an alcohol pad, allow it to dry completely, and then withdraw the necessary volume of diluent...” An educational document recently shared with facility nurses, “PIV (peripheral IV) Catheter Bundle Recap” (March 2026) was reviewed and reads in part, “...perform hand hygiene and don gloves before manipulation of any IV system component...” The facility’s policy “Hand Hygiene” effective December 20, 2024, was reviewed and reads in part, “...Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications:...before performing an aseptic task (e.g. placing an indwelling device) or handling invasive medical devices...after touching a patient or the patient’s immediate environment...after contact with blood, body fluids, or contaminated surfaces...” An interview was conducted with EMP1 at 12:36 on June 10, 2026 who confirmed the facility’s policies and procedures to include scrubbing the stopper of a single dose vial before use and performing hand hygiene before manipulating IV components.”

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 36946 Based on staff interview and document review, it was determined the hospital failed to ensure blood transfusions were administered in accordance with approved policies in one (1) of two (2) records reviewed of patients who received blood products in the survey sample. Medical record (MR7). Findings: MR7 received a unit of packed red blood cells on May 28, 2026. The blood transfusion was initiated at 1:14 PM. Vital signs were obtained at 1:14 PM and at 1:34 PM. The record contained no further documentation of vital signs or assessment after 1:34 PM on May 28, 2026. The medical record indicated the patient was discharged home at 6:06 PM on May 28, 2026. The record did not contain documentation related to how long the transfusion lasted, when the transfusion was stopped, total volume infused, vital signs as required by policy, or an assessment of the patient during or after the administration of the blood product. The facility’s policy, “Transfusion of Blood Products” effective August 8, 2025 was reviewed and reads in part, “...Vital signs are performed: a. within 30 minutes prior to start of transfusion. b. approximately 15 minutes after the start of the transfusion (the start time is when the blood reaches the patient), c. within 60 minutes after the end of the transfusion, and d. as needed based on clinical observation or if patient reports new symptoms of transfusion reaction...Required EHR documentation...2. Document hospital consent form signed, education, date, time started, initial rate, rate change, vital signs, total volume transfused, and transfusion completion time on the blood administration flowsheet in the EHR...record and notify provider and blood bank of any adverse reactions.” An interview was conducted with EMP12 on June 10, 2026 at 11:20 AM. EMP12 indicated that vital signs should be taken and documented at the start of the transfusion, 15 minutes into the transfusion, and when the transfusion was completed.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 42929 Based on review of medical records (MR), review of facility documents, and interviews with staff (EMP) it was determined that the facility staff failed to report and investigate a serious reportable safety event as per facility policy. Findings: Review of facility document “Safety and/or Sentinel Event and/or Serious Reportable Event Reporting and Management” last revised September 8, 2025, reads in part: “... This policy provides a supportive structure with a goal of preventing patient safety events.... Policy. BSMH empowers all associates to report safety events, incidents or unsafe conditions that are inconsistent with routine operations and quality medical care. Events determined to be safety and/or sentinel events and/or National Quality Forum (NQF) Serious Reportable Events (SREs), near miss events and unsafe conditions are investigated within the BSMH Patient Safety Evaluation System (PSES) to identify real and potential risk points and implement process changes to improve patient safety.... V. Policy Details. Event, incident, hazard, or condition occurs, which resulted in an actual potential patient harm or no patient harm (near miss) or identification of an unsafe condition that does not involve a patient.... B. Event escalation: The Event Escalation Protocol ensures leadership involvement and facilitates rapid diffusion of information across facilities and throughout the ministry. The Protocol provides a guide to decision making of when and to whom to escalate serious events. 1. Sentinel, SRE, and harm events that reach the patient require staff to follow the escalation protocol. 2. The reporter of an event which results in serious harm, poses imminent risk of serious harm or is a sentinel event or SRE initiates the escalation policy.... D. Event reporting: All entities within the organization ... are responsible for reporting patient safety occurrences and potential occurrences. 1. Associates who identify or observe a safety event document the circumstances and facts in the event reporting system.... 2. Clinically pertinent information is documented in the medical record.... Review of the internal medicine progress note dated August 12, 2025, at 5:15 PM revealed documentation that MR4 had a left posterior shoulder dislocation and fracture. The progress note revealed that the injury likely occurred during a seizure and was not present on admission to the hospital. Review of the orthopedics progress note dated August 13, 2025, at 9:32 AM revealed that there was no fracture of the left proximal humerus on MR4’s x-ray from August 7, 2025, and there was no documentation of a fall in the patient’s medical record. Interview on September 22, 2025, at 3:22 PM, EMP2 indicated that there was no “SafeCare” event report submitted for MR4’s left humerus fracture diagnosed on August 12, 2025, that was not present on the x-ray completed on August 7, 2025, when the patient came to the hospital. EMP2 indicated that the patient safety team was notified of the hospital acquired fracture at the end of August 2025 via a report that is run based on the electronic medical record system’s review of records for key words, such as “fall with fracture”. EMP2 indicated that MR4’s hospital acquired left humerus fracture would be reviewed at the next patient safety committee meeting to determine if the event met criteria for a root cause analysis. Interview on September 24, 2025, at 12:39 PM, EMP10 indicated that if there is a patient injury that occurs while the patient is in the hospital and the injury was not present upon admission to the hospital, then it should be escalated as per the event notification process. Interview on September 24, 2025, at 12:41 PM, EMP28 indicated that MR4’s left humerus fracture should have been reported in the facility’s event reporting system, and “thankfully” the electronic medical record system report identified it. Interview on September 24, 2025, at 2:18 PM, EMP30 indicated that MR4’s left humerus fracture should be reported in the facility’s event reporting system.”

“MEDICAL STAFF BYLAWS CFR(s): 482.22(c) The medical staff must adopt and enforce bylaws to carry out its responsibilities. The bylaws must: This Standard is not met as evidenced by: 42929 Based on review of medical records (MR) and interviews with staff (EMP), it was determined that medical staff failed to ensure an order for seizure precautions was documented in the patient’s medical record for one (1) of one (1) patient’s medical record reviewed, MR4. Findings: Review of facility document “Medical Staff Rules & Regulations” approved by the Board on January 23, 2025, reads in part: “... 3.5 Patient Orders ... Orders must be documented in the patient’s medical record....” Review of facility document “Lippencott Procedures - Seizure Management” last revised November 18, 2024, reads in part: “... Patients at risk for seizures need precautionary measures to help prevent injury if a seizure occurs. Equipment ... Padding for side rails .... If the patient is at risk for seizures, pad the patient’s side rails ... Documentation. Documentation associated with seizure precautions includes: reason seizure precautions are required, all precautions taken ... interventions you performed ... Review of the internal medicine significant event addendum for MR4 dated August 10, 2025, at 2:20 AM revealed documentation that the patient had an episode of “generalized shaking” and was on Keppra (medication used to treat certain types of seizures in people with epilepsy, including partial onset seizures, myoclonic seizures, and tonic-clonic seizures) for seizure like symptoms and “seizure precautions”. Review of the medical record for MR4 with EMP10 revealed no documentation of an order for seizure precautions and no nursing documentation that seizure precautions were implemented during the patient’s admission. Interview on September 24, 2025, at 11:11 AM, EMP17 did no recall EMP4 having padded bed rails as a seizure precaution during the shifts EMP17 cared for MR4. Interview on September 24, 2025, at 11:54 AM, EMP10 confirmed that there was no order for seizure precautions in MR4’s medical record but there was a note by internal medicine that documented “seizure precautions”. EMP10 indicated that there was no nursing documentation that seizure precautions were implemented during MR4’s admission at the facility. Interview on September 24, 2025, at 2:00 PM, EMP30 indicated that a patient diagnosed with seizures and witnessed seizures must have seizure precautions ordered as it is the standard of care. Seizure precautions would include padded side rails, bed alarms, frequent checks, and no restraints for tonic-clonic seizures. EMP30 indicated that MR4 should have had an order for seizure precautions.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 36946 Based on staff [EMP] interview and facility document review, it was determined the hospital failed to develop comprehensive policies and procedures related to investigation of allegations of abuse and neglect to include methods to protect patients from abuse during the investigation. Findings: Review of facility document, “Care of Victims and Perpetrators of Abuse, Neglect, or Exploitation” last revised August 19, 2022, revealed, “...Reports abuse/neglect/exploitation occurred on the premise of a BSR facility. Required Action. Obtain information specific to the reported events. ..Who is alleging that abuse, neglect, or exploitation occurred (patient, visitor, staff member, etc.)? What type of abuse, neglect or exploitation occurred and by whom? When did the abuse/neglect/exploitation occur? Where did the abuse/neglect/exploitation occur (in what jurisdiction)? Implement steps to preserve or avoid the destruction of potential evidence...Mandated Reporting Requirements. If the reported abuse, neglect, or exploitation is a mandated reporting requirement, notify either Adult Protective Services or Child Protective Services as appropriate...Document agencies and individuals contacted in patient’s medical record on-duty...” The above noted policy did not include information related to how the hospital would investigate allegations of abuse or how the hospital would protect patients from abuse during the investigation. Review of facility document, “Corrective Action” last revised October 31, 2019, was reviewed and reads in part,”...An associate may be placed on administrative leave pending an investigation into an event, behavior, or performance...” The policy does not describe what events, behavior, or performance may indicate the need for administrative leave or that employees under investigation for patient abuse and neglect would be placed on such leave to protect patients from abuse during such an investigation. An interview was conducted with EMP12 on July 01, 2025 at 10:30 AM who indicated hospital leadership was working on a new policy to address investigation of abuse and neglect, but this policy was still in development. The hospital currently had no written policy and/or procedure related to conducting investigations of patient abuse and neglect. On June 30, 2025, the hospital became aware of an allegation of abuse between an employee and Patient alleged to have occurred June 12, 2025. An interview was conducted with EMP5 on June 30, 2025 at 2:30 PM. EMP5 was unclear on what procedures should be followed if a patient alleged abuse or neglect by a staff member. Interview with EMP10 at 9:30 AM on July 01, 2025 indicated the hospital did not have a written policy related to actions that would be taken if a staff member was alleged or suspected to be a perpetrator of abuse and/or neglect to include protecting patients from further abuse while the facility conducted an investigation.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 36946 Based on staff interview [EMP] and document review, it was determined the facility failed to ensure each episode of restraint was conducted in accordance with the physician’s order for two (2) of five (5) records reviewed of patients in restraints (Medical records (MR) 8 and 10). Findings: Review of facility document, “Restraints for Nonviolent, non-self destructive patient situations. Medical use of Restraints” last revised February 10, 2025, revealed, “...An order from a physician or authorized practitioner is required for all instances of restraint...type of restraint to use must be designated....Removal. The decision to discontinue the intervention should be based on the determination that the medical need for restraint is no longer present of the patient’s needs can be met with less restrictive methods...Absence of the behavior that required restraints allows for the removal or termination of the restraint....The plan of care and/or treatment plan must be modified to include end address the use of restraints...” Review of facility document, “Restraints or seclusion for violent, self-destructive patient situations” revealed, “...Any type of violent restraint including, but not limited to 4-point restraints, chemical restraints, physical hold, or use of force in order to medicate a patient, seclusion, etc. requires a provider order...The plan of care and/or treatment plan must be modified to include and address the use of restraints or seclusion for violent or self-destructive behavior...” Review of MR8 revealed on June 27, 2025, the physician documented the patient was attempting to bite staff and bilateral wrist restraints were ordered for “patient and staff safety.” On June 27, 2025, the nurse added problems and interventions for both violent and non-violent restraints to the patient’s care plan, despite the patient not being in non-violent restraints and having no physician order for non-violent restraints. The violent restraints were discontinued at 10:29 PM on June 27, 2025. On June 28, 2025, at 10:43 AM, the nurse documented problems and interventions for both violent and non-violent restraints in the patient’s record, despite the patient’s restraints being discontinued approximately twelve (12) hours prior to the documentation and the patient not being in any restraints on June 28, 2025. Review of MR10 revealed the physician ordered hard two-point opposing wrist and ankle restraints on June 12, 2205 at 6:30 PM. Nursing flowsheet documentation indicated that the patient was in two-point opposing wrist and ankle restraints from 6:30 PM to 10:30 PM on June 12, 2025. The flow sheet did not contain documentation related to which limb was restrained (i.e. right or left) or the rationale for determining what side limb to restrain. Nursing and physician documentation reviewed for June 12, 2025 indicated the patient had a new dialysis fistula and pitting edema to the right arm. Nursing note documentation was reviewed and indicated the patient was placed in soft bilateral wrist restraints at 6:30 PM on June 12, 2025 and not opposing wrist and ankle restraints as ordered by the physician and documented in the nursing flowsheet during the same time period. The patient was again placed in bilateral wrist restraints for interfering with medical treatment on June 16, 2025 and remained in restraints on June 17, 2025, June 18, 2025, and June 19, 2025 for pulling at lines and tubes. On June 17-18, 2025, nursing documented that the patient was “sedated” every two (2) hours for the fourteen (14) hour time period from 4:00 PM - 8:00 AM. The medical record contain no documentation that the patient continued to meet the criteria for restraints (pulling at lines and tubes) during this time period. There was no documentation in the record that nursing staff attempted to discontinue the restraints or utilize a less restrictive alternative to restraints while the patient was “sedated.” Interview with EMP15 at 1:15 PM on July 01, 2025, revealed that the physician erroneously entered the order for MR10 to have hard restraints to opposing wrist and ankle. EMP15 indicated that the facility does not have hard restraints. EMP15 indicated the physician meant to order bilateral soft upper extremity restraints. EMP15 indicated that during a chart audit they noticed the discrepancy in the restraint documentation and had nursing staff enter a narrative note indicating the patient was actually put into soft wrist restraints and not opposing hard restraints as documented on the flowsheet and ordered by the physician. EMP15 indicated it was inappropriate for MR10 to be left in restraints for 14 hours while sleeping/sedated and a less restrictive alternative should have been implemented by nursing staff.”

“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: 36946 Based on staff interview and document review, it was determined the hospital failed to ensure all staff adhered to the policies and procedures of the hospital. Specifically, nursing staff failed to adhere to hospital policy related to fall prevention in two (2) of four (4) medical records reviewed in the survey sample (Patient #’s 2 and 5). Findings: The hospital’s policy, Falls Prevention Policy was reviewed and reads in part, “Assessment: Morse Fall Risk Assessment and Falls Predictive Analytics (FPA) tool. a) Inpatients and observation patients, including Behavioral Health Units, will be assessed by nursing according to the Morse Fall Risk Assessment and Falls Predictive Analytics (FPA) tool upon: b) Initial nursing assessment (Morse will only be used for admission assessment) for the first 12 hours....4. Kinder 1 Fall Risk Emergency Department Patients, 18 years of age and older, will be assessed using the Kinder 1 Fall Risk Assessment Screening Tool during the triage process....Documentation: Each patient should have the following documentation within the EHR (electronic health record): 1. Fall risk assessment score per patient type as indicated. 2. Interventions as outlined above...Kinder 1 Fall Risk Assessment Tool: YES to any risk category = high fall risk.” The medical record for Patient #2 contained documentation that the patient presented to the ED with seizures on August 04, 2024. The patient was identified as a high fall risk on the Kinder 1 Fall Risk Assessment tool. The medical record failed to contain documentation that any interventions to prevent falls were implemented while the patient was in the ED. The medical record for Patient #5 contained documentation that the patient arrived to the Emergency Department (ED) on August 2, 2024 at 12:11 AM with rectal bleeding. The ED nursing assessment indicated the patient was a high fall risk due to “nursing judgement” and fall risk interventions were put in place while in the ED. The patient was admitted to the intermediate care unit at 3:00 AM on August 02, 2024. Per hospital policy, a Morse Fall Risk Assessment should have been completed upon admission as an inpatient on August 02, 2024, but the medical record for Patient #5 did not contain documentation of the Morse Fall Risk Assessment being completed until August 05, 2024 at 8:00 AM. An interview was conducted with Staff Member #2 on November 4 at 11:30 AM who indicated that the Morse Fall Risk Assessment should be completed on all inpatients upon admission. Staff Member #2 indicated all interventions to prevent falls should be documented in the medical record.”

“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: 42042 Based on document review and interview, it was determined the facility failed to monitor the patient in non-violent restraints in accordance with the facility policy for two (2) of four (4) patients sampled. The finding include: On 09/30/2024 at 2:25 PM, the surveyor initiated the medical record review of four patients who had received non-violent restraints [Patient # (2-5)] with the assistance of Staff Member #3. During review, the surveyor observed missing monitoring documentation for both Patient #2 and Patient #4 (see below). Patient #2: Restrained with soft bilateral wrist restraints from [3:38 AM until 8:19 AM] on July 10, 2024. Throughout restraint use, there was no documentation of restraint justification, visual/safety checks, circulation, range of motion, fluid and food, or toileting. Patient #4: Restrained with soft bilateral wrist restraints from [8:15 PM until 9:41 AM] on August 21, 2024, and August 22, 2024, respectively. There was no documentation of restraint justification, visual/safety checks, circulation, range of motion, fluid and food, or toileting after 6:00 AM until the restraint was discontinued at 9:41 AM. In the afternoon of September 30, 2024, the surveyor received and reviewed the facility policy titled, “Restraints for Nonviolent, Non-Self-Destructive Patient Situations: Medical Use of Restraints” (Approval Date: 11/02/2023). Under “Monitoring/Documentation” section of page four, the policy stated, in part, that the following monitoring documentation of general care needs for patients in restraints should be performed every two hours: “Continued Justification, Visual / Safety check, Circulation / Skin Integrity, Range of Motion, Fluids, Food and Meal, and Elimination” [sic]. On September 30, 2024, at approximately 4:30 PM, the surveyor met with Staff Member #2 regarding the missing restraint documentation. The surveyor discussed the concerns regarding the missing documentation for Patient #2 and Patient #4. The surveyor received verbal confirmation from the staff member that that restraint monitoring and assessment documentation should be documented at least every two hours, consistent with the aforementioned restraint policy.”

“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: 42042 Based on interview and document review, it was determined the facility failed to administer blood products in accordance with provider orders for four (4) of four (4) blood transfusions reviewed. The findings include: On July 29, at 12:08 PM, the surveyor initiated the medical record review of four (4) selected patients who had received blood transfusions since June 2024. With the assistance of Staff Member #4, the surveyor identified the following transfusions of Packed Red Blood Cells (PRBs) not administered as ordered: Patient #4: One (1) unit of PRBs administered on July 20, 2024, between 7:49 PM through 10:46 PM. The signed provider order released on July 20, 2024, at 7:49 PM stated, “Start infusion at 60 ml/hr x 15 minutes [60 milliliters per hour for fifteen minutes]” [sic]. The surveyor confirmed with Staff Member #4 that the initial infusion rate exceeded the ordered rate at “65 mL/hr” until 8:04 PM. Patient #5: Two (2) units of PRBs administered on June 4, 2024, between 11:59 AM through 3:15 PM and 6:03 PM through 9:01 PM, respectively. The signed provider order released on July 4, 2024, at 6:02 PM stated, “Start infusion at 60 ml/hr x 15 minutes [60 milliliters per hour for fifteen minutes]” [sic]. The surveyor confirmed with Staff Member #4 that the initial infusion rate for the first transfusion exceeded the ordered rate at “75 mL/hr” until 12:14 PM. The surveyor confirmed with Staff Member #4 that the second infusion rate exceeded the ordered rate at “75 mL/hr” until 6:16 PM. Patient #6: One (1) unit of PRBs administered on June 30, 2024, between 10:34 AM through 1:00 PM. The signed provider order released on July 30, 2024, at 10:32 AM stated, “Start infusion at 60 ml/hr x 15 minutes [60 milliliters per hour for fifteen minutes]” [sic]. The surveyor confirmed with Staff Member #4 that the initial infusion rate exceeded the ordered rate at “75 mL/hr” until 10:45 PM. In the afternoon of July 29, 2024, the surveyor received the facility policy titled, “Transfusion of Blood Products” (with last effective date of 07/03/24), which stated the importance of nurse monitoring for the first fifteen (15) minutes from the start of the transfusion in order to assess for signs and symptoms of a transfusion reaction or other complication. The surveyor reviewed the Lippincott Nursing Procedures for the transfusion of blood products provided by Staff Member #4 on July 29, 2024, at 1:40 PM. Under “Nursing considerations” of PRBs section, the procedure stated to initiate the blood transfusion “at a slow rate as prescribed”. On July 29, at 1:33 PM, the surveyor met with Staff Member #1 and Staff Member #4 for interview regarding the aforementioned orders not followed as prescribed. The surveyor received confirmation that nursing staff are expected to follow provider orders as prescribed to include the administration of blood products.”

“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: 36946 Based on staff interview and document review, it was determined the hospital failed to ensure all licensed nurses who provide services in the hospital adhered to hospital policies and procedures. Specifically, nursing staff failed to comply with the hospital’s policy related to documentation of the inventory of patient belongings in twelve (12) of fourteen (14) medical records reviewed in the survey sample (Patient #’s 1, 2, 4, 5, 6, 8, 9, 10, 11, 12, 13, and 14); failed to comply with fall documentation requirements in one (1) of one (1) patient fall medical record reviewed in the survey sample (Patient #8); and failed to ensure nursing staff adhered to hospital policy related to providing complete and accurate information in the handoff report to a receiving facility in one (1) of six (6) medical records reviewed in the survey sample of patients who were transferred or discharged to other facilities (Patient #8). Findings: The hospital’s policies related to Patient Belongings were reviewed. The hospital’s policy, “Patient Belongings/Valuables in Non-Behavioral Health Areas,” approval date 08/01/2023, states, in part: ... “I. Guideline ... Patients have the right to retain their belongings/valuables... ... the facility records an inventory of the patient’s belongings/valuables... ... II. Procedure ... Inventory and securing patients belongings/valuables ... Staff will document belongings in the electronic health record (EHR).” The facility’s procedure, “Nursing Documentation Requirements,” approval date 02/06/2024, was reviewed and states, in part: ... “Procedure ... I. Documentation to be completed initially: ... A. Admitted Adult Inpatient and Observation patients... ... Patient Belongings ... C. Emergency Department ... Patient Belongings. The medical record for Patient #1 contained documentation that the patient was seen in the Emergency Department (ED) on 03/14/24. The medical record failed to contain documentation that the hospital conducted an inventory of the patient’s belongings. The medical record for Patient #2 contained documentation that the patient was seen in the ED on 03/12/24. The medical record failed to contain documentation that the hospital conducted an inventory of the patient’s belongings. The medical record for Patient #4 contained documentation that the patient was seen in the ED on 03/2/24. The medical record failed to contain documentation that the hospital conducted an inventory of the patient’s belongings. The medical record for Patient #5 contained documentation that the patient was seen in the ED on 03/9/24. The medical record failed to contain documentation that the hospital conducted an inventory of the patient’s belongings. The medical record for Patient #6 contained documentation that the patient was seen in the ED on 03/19/24. The medical record failed to contain documentation that the hospital conducted an inventory of the patient’s belongings. The medical record for Patient #8 contained documentation that the patient was seen in the ED on 06/18/23. The medical record failed to contain documentation that the hospital conducted an inventory of the patient’s belongings. The medical record for Patient #9 contained documentation that the patient was seen in the ED on 03/23/24. The medical record failed to contain documentation that the hospital conducted an inventory of the patient’s belongings. The medical record for Patient #10 contained documentation that the patient was seen in the ED on 03/22/24. The medical record failed to contain documentation that the hospital conducted an inventory of the patient’s belongings. The medical record for Patient #11 contained documentation that the patient was seen in the ED on 03/30/2024. The medical record failed to contain documentation that the hospital conducted an inventory of the patient’s belongings. The medical record for Patient #12 contained documentation that the patient was seen in the ED on 02/15/2024 . The medical record failed to contain documentation that the hospital conducted an inventory of the patient’s belongings. The medical record for Patient #13 contained documentation that the patient was seen in the ED on 03/26/2024. The medical record failed to contain documentation that the hospital conducted an inventory of the patient’s belongings. The medical record for Patient #14 contained documentation that the patient was seen in the ED on 03/30/2024 . The medical record failed to contain documentation that the hospital conducted an inventory of the patient’s belongings. In an interview on 04/01/2024 at 3:57 p.m. with Staff Member #9, the surveyor asked Staff Member #9 about the facility’s expectation concerning the inventory of patient’s belongings in the ED. Staff Member #9 responded that documentation of patient belongings is an area of opportunity for improvement in the hospital. In an interview conducted on 04/02/2024 at 7:30 a.m., Staff Member #7 stated that ED staff do not inventory patient belongings. This information is contrary to hospital policy. The facility’s policy, Bon Secours Mercy Health Fall Prevention effective 02/09/24 was reviewed and read in part: When a patient rolls off a low bed onto a mat or is found on a surface where you would not expect to find a patient, this is considered a fall...Unobserved falls include any case when a staff member finds the patient on the floor or other surface or when a fall is reported by the patient, a family member, or visitor....Patient experiences a fall: Complete a post fall assessment including vital signs and neuro check...document description of the fall in the progress notes; communicate any changes in the plan of care related to the fall...Notifications and follow-up post fall. Patient and family education: Instruct the patient and family/guardian on the environment ,plan of care to prevent a fall, and interventions implemented to reduce the potential for falls. Document education that was provided to patient and family/guardian in the EHR. The medical record for Patient #8 was reviewed and contained no documentation that the patient fell or was found on the floor on 06/18/23 - 06/19/23. The MFI requested a list of falls in the facility in June 2023. Patient #8 was listed as having fallen in the ED on 06/18/23 despite there being no documentation in the medical record that the patient fell. An interview was conducted with Staff Member # 5 on 04/01/24 at 3:30 PM. Staff member #5 stated that Patient #8 was found on the floor in the ED on 03/18/23. The nurse reported finding the patient on the floor and was unaware that a patient found on the floor under unknown circumstances should be documented and treated as a fall. Staff member #5 confirmed this event should have been logged as a fall and documented in the medical record. Staff member #2, present during the interview and record review, confirmed the absence of any documentation related to a fall in the patient’s medical record. The facility’s policy, Handoff Communication Guideline, effective May 23, 2023 was reviewed and reads in part: Handoffs take place whenever a transition in care occurs, including ...when a patient moves from one setting to another or from the hospital to another facility, such as rehabilitation or skilled nursing facility....Ensure the information is current and use technology such as electronic health records (EHR) to enhance communication. Shift handoff, transfer handoff, periop handoff documentation is done on a flowsheet in EHR. The minimum patient information made available during handoff includes:...Safety issues such as fall risk or isolation...Additional patient information during handoffs from one licensed caregiver to another includes the information necessary to take over the care of the patient, such as: ...IV access, tubes, and lines; most recent labs, tests, procedures, highlighting critical results/values and abnormal, skin/dressings...plan of care needs. Documentation in the medical record for Patient #8 indicated the patient’s tracheostomy tube had fallen out during the ED stay. The physician attempted two times to replace the tube, but was unable. The tracheostomy tube was replaced on the third attempt by a respiratory therapist. The nurse documented at 2:56 AM on 06/18/24 that report was called to the receiving provider. The nurse documented, “Discharge paperwork was handed over to [name of transport agency].” The record contained no documentation of what information was included in the handoff report to the receiving LTACH. The patient’s discharge documentation (After Visit Summary) was reviewed and the information failed to contain any documentation related to an unwitnessed fall (see above fall information regarding Patient #8) and/or the replacement of the tracheostomy tube. An interview was conducted on 04/02/24 at 7:30 AM with Staff Member #7. Staff member #7 stated all relevant information should be included in the report when the patient is sent to another facility, but there was no hospital specific form, template, or documentation related to what was included in the report to the receiving facility. Staff Member #7 reported that the only the After Visit Summary is sent with the patient at discharge. 49355 The above noted deficiency was confirmed with Staff Member #’s 1, 2, 9, 20 and 21 at the exit conference on 04/02/2024 at 1:00 p.m.”