Stonesprings Hospital Center

“SAFETY POLICY AND PROCEDURES CFR(s): 482.26(b) [§482.26 Condition of Participation: Radiologic Services §. If therapeutic services are also provided, they, as well as the diagnostic services, must meet professionally approved standards for safety and personnel qualifications.] §482.26(b) Standard: Safety for Patients and Personnel The radiologic services, particularly ionizing radiology procedures, must be free from hazards for patients and personnel. This Standard is not met as evidenced by: 40084 Based on observation, interview and document review, it was determined the computed tomography (CT) staff failed to conduct medical pre-screening for an at-risk patient according to facility procedure for one (1) of three (3) CTs with contrast sampled (Patient #10). The findings include: During a tour of the CT area on the morning of June 1, 2026, the surveyor met with a CT technologist, Staff Member #15. The surveyor asked if a checklist is used to screen patient’s prior to administering a CT. The Staff Member advised there is a form used and pulled one of the forms (CT History Sheet) from a stack on the desktop. The Staff Member advised the form is filled out prior to administering a CT with contrast to a patient. During a review of the medical record for Patient #10, who received a CT with contrast on February 6, 2026 and February 14, 2026, with Staff Members #1, 13, 14 on the morning of June 2, 2026, a CT History Sheet was not located for either of the service dates. Staff Member #2 advised the radiology department uses a different system to maintain records from that department. During the afternoon of June 2, 2026, Staff Member #1 provided a CT History Sheet for the CT with contrast performed on Patient #10 on February 14, 2026. A variety of sections on the form were not completed, such as the question related to kidney disease. Additionally, Staff Member #1 advised that no other CT History Sheets for the patient could be found and thus one was not available for the CT with contract conducted on February 6, 2026. Staff Member #1 further advised that a policy is not available regarding the use of the CT History Sheet form. On the afternoon of June 2, 2026, the surveyor spoke with Staff Member #3, the Director of Radiology, who advised the CT History Sheet is used for screening patients who require a CT with contrast.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 40084 Based on document review and interview, it was determined the facility failed to conduct timely re-assessments of pain for patients who received pain medication in the emergency department (ED) for two (2) out of seven (7) patients sampled (Patient #7 and Patient #8). The findings include: During a review of the medical record for Patient #7 on June 2, 2026 with Staff Members #1, 13, 14, it was revealed the ED staff administered Ibuprofen to the patient during the course of ED treatment on August 2, 2025 at 8:15 p.m. The ED staff conducted a pain assessment after twenty (20) minutes and another pain assessment one (1) hour and fifty-nine (59) minutes later. During a review of the medical record for Patient #8 on June 2, 2026 with Staff Members #1, 13, 14, it was revealed the ED staff administered morphine during the course of ED treatment on March 11, 2026 at 10:50 a.m. The patient was discharged ten (10) minutes later at 11:00 a.m. with no assessment of pain completed prior to discharge. During an interview with Staff Members #1, 13, 14 on the afternoon of June 2, 2026, it was revealed that nursing staff are expected to conduct reassessments of pain thirty (30) minutes after administering medications intravenously and one (1) hour after administering medications orally. It was further revealed that this expectation is included in the “Medical Surgical Unit Standard of Care” and not the “Emergency Department Standard of Care”, but facility staff are expected to follow the former guidelines. Additionally, the medical records system prompts ED staff to conduct pain reassessments at the appropriate time. A review of the facility policy titled “Medical Surgical Unit Standard of Care” states in part: “...Reassess and document pain assessment 60 minutes after intervention for PO and 30 minutes after for IV.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 46466 Based on medical record review and facility document review, it was determined the facility failed to modify the patient’s plan of care after the use of seclusion for one (1) of seven (7) sampled medical records (MR) reviewed. The findings include: On July 28, 2025, a review of MR7 was conducted. MR7’s record indicated that MR7 was placed in seclusion on July 1, 2025. The medical record did not contain documentation that the patient’s plan of care was modified to reflect that the patient was placed in seclusion for their violent/destructive behavior. A review of the facility’s policy “Patient Restraint/Seclusion”, effective 7/1/2023, indicated 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. The medical record contains documentation of...n. Modifications of the plan of care...”.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 46466 Based on medical record review and facility document review, it was determined the facility failed to use a restraint in accordance with the order from a physician for two (2) of seven (7) medical records (MR) reviewed. The findings include: On June 23, 2025 at 11:57 PM, MR5’s medical record documented a physician order for “non-violent, soft, bilateral upper extremity restraints” for MR5 attempting to remove devices. At the same time and date, a Registered Nurse (RN) documented that violent/self destructive, soft bilateral wrist and ankle restraints were applied to MR5. There was no documentation that the physician canceled the non-violent order nor that the RN replaced the violent, 4-point restraints with non-violent, 2-point restraints per the physician’s order. On June 29, 2025 at 10:45 PM, MR6’s medical record documented that MR6 was placed in a physical hold and transported to seclusion for presenting as a danger to others. There was no physician order found for MR6’s physical hold. A review of the facility’s policy “Patient Restraint/Seclusion”, effective 7/1/2023, indicated 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...E. Physical Holds...Holding a patient in a manner that restricts the patient’s movement against the patient’s will is considered restraint...”.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 46466 Based on medical record and facility document review, it was determined the facility failed to conduct face-to-face assessments of patients after initiating violent restraints and/or seclusion for three (3) of seven (7) medical records (MR) reviewed. The findings include: On June 23, 2025, MR5 was placed in violent, 4-point restraints at 11:57 PM. There was no documentation found in MR5’s medical record that a face-to-face assessment was completed by a physician, licensed practitioner, Registered Nurse (RN) or physician assistant within one (1) hour of initiating the restraints. On June 29, 2025, MR6 was placed in seclusion at 8:36 PM. There was no documentation found in MR6’s medical record that a face-to-face assessment was completed by a physician, licensed practitioner, registered nurse (RN) or physician assistant within one (1) hour of initiating the seclusion. On July 1, 2025, MR7 was placed in seclusion at 5:24 PM. There was no documentation found in MR7’s medical record that a face-to-face assessment was completed by a physician, licensed practitioner, registered nurse (RN) or physician assistant within one (1) hour of initiating the seclusion. A review of the facility’s policy “Patient Restraint/Seclusion”, effective 7/1/2023, indicated in part: “...9. Face-to-face assessment by a Physician or Licensed Practitioner. a. A face-to-face assessment by a physician, licensed practitioner, RN or physician assistant with demonstrated competence, must be done within one hour of restraint or seclusion initiation...”.”