Froedtert Memorial Lutheran Hospital

“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: 29972 Based on interview and record review the facility staff failed to implement a plan to ensure patients are kept safe when staff are made aware of allegations and during investigations for alleged caregiver misconduct in 2 of 2 caregiver misconduct allegations reviewed (Patient (Pt) #1, Pt #2), in a total sample of 2 allegations reviewed. Findings Include: Review of policy and procedure #565 titled, “Caregiver Misconduct and injury of Unknown Source Investigation and Reporting Policy” last reviewed 02/24/2026 revealed: - “If Caregiver Misconduct is alleged, known, or suspected, the Workforce Members immediately notify leadership and take any and all necessary steps to protect patient(s)...Such steps may include monitoring the accused, reassignment, and/or removing the accused from patient care responsibilities.” - “If Caregiver Misconduct is alleged, known, or suspected, the following individuals are notified as applicable: the department leader...Human Resources (HR), Risk Management (RM), Patient Relations...This team will: 1. Perform an initial review of the situation, including gathering written and other information and interviewing the people involved and witnesses to the incident. 2. Consider immediately placing any Workforce Member involved in the incident on administrative leave for the duration of the investigation...” Pt #1: Review of Pt 1’s medical record revealed Pt #1 is a 69 year old women who presented to the Neurology Rehabilitation department on 02/04/2026 for an Occupational Therapy (OT) Pre-Driving Evaluation and Assessment. Pt #1’s reason for visit was to help provide assessment and recommendation for physician to determine final recommendation to drive. Per OT A’s progress note on 02/04/2026, Recommendations revealed, “Appeared to complete the components of advanced community mobility and does not demonstrate the skills necessary for driving. Recommend the patient abstain from driving with the approval of the physician. OT to inform the referring provider to discuss driving cessation (stopping) with patient.” Review of Pt #1’s grievance revealed that Pt #1 called Patient Relations on Friday 02/13/2026 and reported that on 02/04/2026 (9 days earlier) OT A “...touched her buttocks, which she perceived as sexual assault.” Per Pt #1 (OT A) approached her and “used the palm of her hand to rub (Pt #1’s) buttocks from the bottom upward...” Review of the Pt #1’s Caregiver Misconduct investigation revealed the investigation started on Tuesday 02/16/2026 (3 days after allegation was reported) with Manager B interviewing OT A and on 02/17/2026 HR, RM, and leadership met to review and discuss Pt #1’s allegation as well as OT A’s response (no witnesses to interview). On 02/23/2026 staff concluded the investigation and determined it was unsubstantiated. Review of Pt #1’s Caregiver Misconduct investigation revealed there was no documented evidence of any actions taken by HR, Risk, and/or leadership to protect the patient(s) once they learned of the allegations and during the caregiver misconduct investigation (02/13/2026 to 02/23/2026) including, but not limited to; monitoring the accused, reassignment, and/or removing the accused from patient care responsibilities, as per policy. Pt #2: Review of Pt #2’s medical record revealed Pt #2 is a 55 year old male who presented to the Neurology Rehabilitation department for an Initial Occupational Therapy Evaluation & Plan of Care with OT A on 05/28/2026. Pt #2 is receiving radiation treatment for Glioblastoma (a fast growing, grade 4 cancerous brain tumor) at the Neuro-Oncology Clinic and has a history of seizures. Review of Pt #2’s Grievance revealed that Pt #2 called Patient Relations on Monday 06/01/2026 stating he needed to discuss an incident that occurred with Occupational Therapist (OT) A on 05/28/2026. Per Pt #2’s complaint, “Pt. wanted to make leadership aware of (OT A’s) sexual overtures that made him feel uncomfortable.” Review of Patient Relation K’s documentation on 06/04/2026 at 11:32 AM revealed, “Writer called pt and pt stated he would have to call me back a little later. Pt was given writer’s contact info. Writer called back stated he is very upset about the behavior of the occupational therapist (OT A) on 05/28. Pt states (OT A) told him to sit on a bench and (OT A) ‘straddled’ her knee in between his leg and her other knee on the outside of his leg. Pt. stated (OT A) began to rotate her hips upward on the roller stool she was sitting on while wearing spandex pants...Pt felt the rotation of her hips was in an overly sexual way, ‘like she was trying to get me to look at her crouch.’ Pt states while doing tests on his hands (Pt #2) stated he felt he was being interrogated like he was being invested for a crime. Pt stated (OT A) asked him, ‘Are you sure?’ ‘Do you promise?’ and then pursed her lips like she was going to try to kiss him. Pt states he feels like his rights were violated...Pt states some of the questions (OT A) asked were, ‘are you sexually active.’ Pt states (OT A) was asking him questions about his driving, and asking him why is he driving. Pt feels that (OT A) entered a lot of false statements and information in her notes...” Review of Pt #2’s Caregiver Misconduct Investigation revealed that an event report was entered by Patient Relations K. Per Discussion timeline, Manager of Rehabilitation Services B was notified by Patient Relations K on 06/04/2026 at 2:30 PM and on 06/04/2026 at 4:30 PM HR F revealed “HR is aware of case and has connected with leader (Manager B) on next steps to investigate allegations.” Staff interviews were conducted from 06/04/2026 through 06/08/2026 and on 06/11/2026 at 4:59 PM, HR F revealed, “Investigation has concluded and been determined through witness statements and standard of care that (OTA A) proximity to patient is necessary for evaluation and delivery of care. The allegation has not been substantiated...” Review of Pt #2’s Caregiver Misconduct Investigation Worksheet revealed there was no documented evidence of any actions taken by HR, Risk, and leadership to protect the patient(s) during the caregiver misconduct investigation (06/04/2026 to 06/11/2026) including, but not limited to; monitoring the accused, reassignment, and/or removing the accused from patient care responsibilities, as per policy. Per interview with OT A on 08/04/2026 beginning at 12:25 PM, OT A stated that she continued to conduct 1:1 driver evaluations and OT evaluations/assessments independently using a private room, while staff conducted the investigation into Pt #1 and Pt #2’s allegations in February 2026 and May of 2026. Per OT A she did not have added monitoring/supervision or schedule/assignment changes during the investigations. Per interview with Manager B on 08/04/2026 beginning at 2:28 PM, Manager B stated that OT A continued her normal work routine during both investigations and there were no additional safety measures put into place to protect patients during the investigations. Manager B stated that she was not informed by RM or HR to add supervision or make any changes to OT A’s schedule or job duties while they were investigating the allegations in February 2026 and May 2026.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 47413 Based on interview and record review the facility failed to appropriately transfer 1 (Patient#1) of 7 of patients requiring transfer and failed to provide a complete medical screening exam (MSE) in 1 (Patient #2) of 20 patients with an emergency medical condition in a total of 20 medical records reviewed. Findings include: The facility failed to provide a complete MSE to a patient. See Tag A-2406. The facility failed to appropriately transfer patients. See Tag A-2409.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 53566 Based on record review and interview, the facility failed to provide a complete medical screening exam (MSE) for 1 (Patient #2) of 20 patients with an emergency medical condition in a total sample of 20 medical records reviewed. A review of the facility’s policy titled “FMLH (Froedtert Memorial Lutheran Hospital) EMTALA Policy” last reviewed 6/29/2024 revealed, “ ...B. Emergency Medical Condition. 1. A medical condition manifesting itself by acute symptoms of sufficient severity (including ...psychiatric disturbances ...) such that the absence of immediate medical attention could reasonably be expected to result in: a. Placing the health of the individual in serious jeopardy ...C. Medical Screening Examination (MSE). 1. The process required to reach, with reasonable clinical confidence, the point at which it may be determined whether a medical emergency does or does not exist. The Medical Screening Examination should be appropriate to the individual’s presenting symptoms ...B. If an Emergency Medical Condition exists, the Emergency Department ...will coordinate further medical examination and treatment ...or provider an appropriate transfer to another medical facility ...F. Individuals requiring transfer ...for care not provided at [Hospital A] are managed according to the “Patient Transfers to and from [Hospital A] policy ...” A review of “ED Provider Notes” written by ED APNP U on 2/30/2026 between 4:33 PM and 7:32 PM revealed, “ ...22 y/o M (22-year-old male) brought to ED in PD (police department custody) ...after punching a mirror, denies SI/HI (suicidal ideation/homicidal ideation) ...low risk SI precautions initiated d/t h/o (due to history of) suicide attempt, schizophrenia, police presence ...[Patient #2] in room near nurse’s station with curtain fully open ...” At 4:58 PM, orders placed by ED APNP U revealed, “Restraints - Suicide precautions. Nourishments - Message to Nutritional Services: Suicide Risk - Disposable Utensils and Dishes Only/No Hand Wipes...” At 5:00 PM, “Patient Safety Observation” entry by ED RN V revealed, “Continuous Observation. Clinical Indication for Observation: Suicide Risk. Observation Type: Tele Observation. Observation Status: Initiated.” At 5:05 PM, “ED Notes” written by ED RN V revealed, “Room Safety Interventions. Actions take to promote safety and protect patient at risk for self harm...[ED Physician W] notified of need for safety evaluation...Curtains opened...Cards locked and removed from room...Belongings removed and secured...Telephone removed...Linen cabinet secured with lock or cable ties...No visitors in room until provider exam...Security notified by RN....Trash cans removed from room...” During an interview on 3/10/2026 at 2:33 PM, ED APNP U stated, “[Patient #2] arrived in custody of the PD and had a 3-party-petition (legal process for civil commitment). PD shared he should be seen for the hand laceration ...the sheriff was at bedside the entire time and told me there was no need for a doc-to-doc (doctor-to-doctor phone call with receiving facility) since he had mental health care in place, but now I know better than to listen to them next time.” Per medical record review, ED APNP U repaired Patient #2’s hand laceration and on 2/3/2026 at 7:30 PM, Patient #2 was discharged from Hospital A in custody of police, who transferred Patient #2 to Hospital B. A review of “ED Care Timeline” from Hospital B revealed that on 2/3/2026 at 7:59 PM, Patient #2 arrived at Hospital B in law enforcement custody for a mental health evaluation. “Arrival Documentation” written by RN X at 8:49 PM revealed, “...Type of Legal Considerations: Emergency Detention Status/Petition and Cert (certification)...” At 8:50 PM, RN X documented chief complaint as “Psychotic Symptoms.” At 8:56 PM, “BH (behavioral health) Intake Assess (assessment)” by RN Y revealed, “...Patient stated reason for treatment: [Patient #2] here on 3 party petition, denies necessity for placement...Reason for assessment: Behavioral Disturbance. The Patient is Experiencing: An increase in acute symptomatology; A deterioration in the level of role functioning within the last 7 days...” There is no evidence that Hospital A performed a medical screening exam to identify or rule out a psychiatric/behavioral health emergency medical condition, despite ED orders for continuous observation and safety interventions related to suicide risk and history. 47413”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 47413 Based on record review and interview, the facility failed to obtain acceptance from a receiving facility for 1 of 7 patients (Patient #1) transferred from the Emergency Department (ED) in a total of 20 medical records reviewed. Findings Include: A review of facility policy “FMLH ED EMTALA Policy” last reviewed 6/9/2024 revealed, “ ...B. Emergency Medical Condition. 1. A medical condition manifesting itself by acute symptoms of sufficient severity (including ...psychiatric disturbances ...) such that the absence of immediate medical attention could reasonably be expected to result in: a. Placing the health of the individual in serious jeopardy ...B. If an Emergency Medical Condition exists, the Emergency Department ...will coordinate further medical examination and treatment ...or provider an appropriate transfer to another medical facility ...F. Individuals requiring transfer ...for care not provided at [Hospital A] are managed according to the “Patient Transfers to and from [Hospital A] policy ...” A review of the facility’s policy #2855 titled, “FMLH ED Patient Transfers to and from [Hospital A] Policy” last reviewed 02/09/2026 revealed, “...III. Definitions; A. Appropriate Transfer- a transfer.:. 2. In which the receiving facility: b. Has agreed to accept the transfer of the individual and to provide appropriate medical treatment... IV. Policy...B. Transfers from [Hospital A]...1. The attending physician is responsible to make the determination of appropriateness of transfer and initiate arrangements with a physician at the receiving facility...4. Patients going to another medical facility must be managed as formal transfers and not as discharges...6. Prior to an Appropriate Transfer of an individual to any acute care facility, the treating physician and nurse will complete a Physician’s Certificate of Transfer Form...V. Procedure...2. The transferring physician will contact a physician at the receiving facility for acceptance of the transfer...” Patient #1: A review of Patient #1’s “Patient Care Timeline” dated 01/27/2026 at 1:48 AM revealed Patient #1 arrived to Hospital A on 01/27/2026 at 1:52 AM in police custody under an involuntary hold following ingestion of a foreign body, suicidal ideations, chest pain, and hallucinations. Following a medical screening examination, Patient #1 was medically cleared and discharged from Hospital A on 01/27/2026 at 5:02 AM. Patient #1 arrived at Hospital B in police custody for further psychiatric evaluation at 5:23 AM (21 minutes later). A review of the medical record revealed the following notes from Hospital A: “ED Provider Notes” on 01/27/2026 at 4:08 AM by ED Resident N: “...[Patient #1] was discharged in police custody and was taken to [Hospital B] for further evaluation...Spoke with [MHEC Psychiatrist P] regarding transfer for further evaluation and management of [Patient #1’s] SI (suicidal ideation), who said they would be comfortable with managing the battery ingestion. Communicated that patient would be transferred there. Did not obtain name of accepting physician...” “ED Notes” on 01/27/2026 at 4:23 AM by ED RN (Registered Nurse) H: “...Spoke with [Police Sergeant], will have officer come pick pt (patient) up for transfer to [Hospital B]...” There was no evidence of a physician to physician or nurse to nurse report, or evidence of an accepting physician. A review of the medical record revealed the following note from Hospital B: “Clinical Notes” on 01/27/2026 at 6:14 AM by RN R: “...1/27/2026 Patient came to facility with law enforcement and ambulance...Patient was medically cleared at [Hospital A] but [Hospital B] did not receive a doc-doc (doctor to doctor report)...” During an interview on 03/10/2026 at 1:16 PM with ED Medical Director I, he stated, “Yes it seems like there was confusion by our team.” ED Medical Director I stated that staff contacted Hospital B’s Psychiatrist to ensure capability and that they were medically able to care for Patient #1. He stated, “That did not constitute as an official transfer. They need to fill out an official transfer form with an accepting physician’s name.””

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 52395 Based on record review and interview, the facility failed to implement an effective quality process to promote patient safety and prevent patient falls in 1 of 1 patient safety quality indicators (patient falls) reviewed. Findings include: Facility staff failed to perform analysis for 3 of 3 reported adverse events reviewed and failed to perform cause analysis and implement corrective actions for an increased trend in patient falls. See tag A286.”

“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: 52395 Based on observation, record review and interview, facility staff failed to implement fall prevention interventions for 5 of 13 patients (Patients #1, #9, #10, #12, #13). Findings include: Staff failed to prevent falls for 3 of 7 patient falls reviewed and failed to implement fall prevention interventions for 2 of 3 patients observed. See tag A-395.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 52395 Based on record review and interview, facility staff failed to analyze and implement preventive actions for 3 of 3 patient fall events (Patients #1, #9, #10) in a total sample of 10 medical records reviewed and failed to perform quality assurance and performance improvement activities in response to an increased trend in patient falls. Findings include: Review of facility policy “Patient Safety Event Reporting and Investigation Policy” last reviewed on 09/06/2024, revealed “III. Definitions. A. Adverse Event: Any event (preventable or non-preventable) that caused harm to a patient as a result of medical care rather than underlying disease. Harm can include additional monitoring, treatment, temporary or permanent disability, or death. B. Error: Any act of commission (doing something wrong) or omission (failing to do the right thing) that exposes patients to a potentially hazardous situation. ...E. Harm Event: An Error that adversely altered the course of the patient’s illness or condition OR resulted in added burden of care interventions without added benefit. I. Patient Safety Event: Event, incident or condition that could result or did result in harm to a patient. ...2. Investigation and Follow-up of Reported Patient Safety Events: ...f. Local leader responsibilities for all events: ...iv. The leader and assigned stakeholders will conduct an apparent cause analysis to understand factors contributing to the event. Contributing factors, conclusions reached, and actions taken will be documented in the RELI (Report, Evaluate, Learn, Improve-software system for event reporting) system (Analysis tab) within 30 days of the reported date.” Review of Patient #1’s medical record revealed Patient #1 was a 78-year-old male admitted to the facility on 12/14/2025 after a stroke with significant weakness and cognitive deficits, with a baseline orientation of oriented to person only. Review of Patient #1’s physical therapy (PT) notes revealed Patient #1 “requires maximal assist to total assist to maintain sitting balance due to strong posterior lean and push to right side. ...poor balance recovery when sitting unsupported.” Patient #1 required mechanical lift for transfers to/from bed and PT recommendations for staff included a “tilt in space” wheelchair. Review of nursing progress note dated 12/22/2025 at 3:49 PM revealed “Patient found by [RN] approximately at 2:05 PM. Patient chair alarm sounding. Patient found sitting on wheelchair foot pedals. Per patient report he was attempting to get up to use the bathroom...” Review of physician notes dated 12/22/2025 at 6:25 PM, Patient #1 sustained an “unwitnessed fall from wheelchair. ...Patient was found by nursing staff sitting on the foot pedals of manual wheelchair. ...Plan to send to emergency department for CT head given age, unreliable historian and unwitnessed nature of fall.” Patient #1 was discharged from the facility on 12/22/2025 and admitted to an acute care hospital.” There was no evidence in the medical record that Patient #1’s wheelchair was tilted per PT recommendations to prevent sliding/falling from chair. Review of Patient #9’s medical record revealed that Patient #9 was a 52-year-old male admitted to the facility on 1/7/2026 for confusion and cognitive deficits after end stage liver disease and liver transplant. Review of an Occupational Therapy (OT) note dated 1/16/2026 revealed Patient #9 sustained a fall during OT session on 1/16/2026: “Patient sustained a fall during therapy session ... The following injuries were sustained from the fall: minor wound at posterior sacral region and minor cut noted at lateral aspect of right lower extremity. ...fall on this date during showering session [due to] attempting to stand with use of grab bar independently ...” During an interview on 2/10/2026 at 11:30 AM, Regulatory Coordinator BB stated Patient #9 fell after being left unattended in the shower. Review of Patient #10’s medical record revealed that Patient #10 was a 72-year-old male that was admitted to the facility on 12/12/2025 with weakness, cognitive deficits after experiencing multiple strokes and history of falls. Per medical record review, Patient #10 sustained an unwitnessed fall on 12/28/2025 and was found “laying on his back with legs propped on his wheelchair.” During an interview on 2/10/2026 at 12:35 PM, Unit Manager D stated the CNA placed Patient #10 on the toilet commode then the CNA left Patient #10 unattended on the commode to retrieve linen and Patient #10 fell backward out of the commode. Review of Patient #10’s post-fall CT scan report dated 12/28/2025 revealed a “new” and “acute” lumbar compression fracture at L3 vertebra. Review of Patient #10’s discharge summary dated 1/6/2026 revealed “Admitted to [facility] from 12/12/2025 - 1/6/2026 ... [inpatient rehabilitation] was complicated by fall with resultant L3 compression fracture.” During an interview on 2/11/2026 at 9:00 AM with the system falls team, Clinical Nurse Leader (CNL) O stated that they base their follow up on mild, moderate, or high level of injury. Only moderate or major falls are entered to do the RCA (root cause analysis) and mild or no injury fall events should be reviewed and followed up by unit leadership. CNL O stated that an RCA was not conducted for Patients #1 and #9 per their policy and follow up was deferred to site leadership. Regarding Patient #10, CNL O stated that an RCA “is being completed but we can’t give you any more information because the follow up is confidential.” No further evidence of cause analysis or preventive actions was provided. During an interview on 2/11/2026 at 9:35 AM, Unit Manager D and Quality Coordinator N stated that fall prevention education to staff was provided in December with a focus on use of bed alarms. When asked if this education provided would have helped prevent the falls for Patients #1, #9 and/or #10, Unit Manager D stated “no.” Unit Manager D and Quality Coordinator N were not able to provide evidence that Patient #1 or Patient #9’s falls were analyzed and when asked were unable to state potential factors that may have contributed the the falls. There was no evidence that any corrective actions based on contributing factors were implemented. Review of the facility’s quality data related to fall trends revealed an increase in falls events over time: October 2025 (4 patient falls), November 2025 (4 patient falls), December 2025 (13 patient falls), January (8 patient falls). During an interview with the Quality Coordinator N on 2/11/2026 at 9:40 AM when asked about the fall rate increasing from October 2025 to the present, Quality Coordinator N stated there were more confused patients in December. When asked what was being done for quality improvement related to falls, she stated that they are working on the use of bed alarms. There was no evidence that bed alarms were a contributing factor to the increased fall trends. There was no evidence provided that the increased trends were being analyzed or acted upon.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 52395 Based on observation, record review and interview, hospital staff failed to implement interventions sufficient to prevent falls in 3 of 7 patients identified as high fall risk (Patients #1, #9, #10) and failed to implement universal fall precautions for 2 of 3 patients observed (Patient #12, Patient #13) in a total sample of 10 patients. Failure to implement fall prevention interventions resulted in falls for Patient #1, Patient #9 and Patient #10. Findings Include: Review of facility policy “Patient Care Services Fall Prevention and Management Policy” last review date: 06/02/2025 revealed, “Procedure A. The RN selects individualized Fall prevention interventions for each subcategory of the Hester Davis (HD) Falls Assessment Tool...1. If a HD category scores a 3 or greater, the RN implements the corresponding Tailoring Interventions for Patient Safety (TIPS) interventions. 2. If the HD Fall risk score is 15 or greater, the patient is classified as a High Fall Risk ...” Review of Patient #1’s medical record revealed Patient #1 was a 78 year old male admitted to the facility on 12/14/2025 after a stroke with significant weakness and cognitive deficits. Patient #1 had an admission falls risk score of “21” (high risk) and nursing interventions identified as “out of bed with 2 people and bed alarm on” with all subsequent fall risk scores documented as high throughout Patient #1’s hospitalization. Review of Patient #1’s medical record revealed Patient #1’s baseline orientation is oriented to person only. Review of Patient #1’s occupational therapy (OT) evaluation dated 12/15/2025 revealed “Cognition: Follows <50% of simple commands, requires tactile and verbal cues.” Review of Patient #1’s physical therapy (PT) notes revealed Patient #1 “requires maximal assist to total assist to maintain sitting balance due to strong posterior lean and push to right side. ...poor balance recovery when sitting unsupported.” Patient #1 required mechanical lift for transfers to/from bed and PT recommendations for staff included a “tilt in space” wheelchair. Review of nursing progress note dated 12/22/2025 at 3:49 PM revealed “Patient found by [RN] approximately at 2:05 PM. Patient chair alarm sounding. Patient found sitting on wheelchair foot pedals. Per patient report he was attempting to get up to use the bathroom ...” Review of physician notes dated 12/22/2025 at 6:25 PM, Patient #1 sustained an “unwitnessed fall from wheelchair. ...Patient was found by nursing staff sitting on the foot pedals of manual wheelchair. ...Plan to send to emergency department for CT head given age, unreliable historian and unwitnessed nature of fall.” Patient #1 was discharged from the facility on 12/22/2025 and admitted to an acute care hospital. There was no evidence in the medical record that Patient #1’s wheelchair was tilted per PT recommendations to prevent sliding/falling from chair. During an interview on 2/10/2026 at 12:35 PM, Nurse Manager D stated Patient #1 was found sitting in front of his wheelchair. Per D, Patient #1 had a seatbelt on while sitting in the wheelchair, but it had been removed upon discovering the patient on the floor. Nurse Manager D stated Patient #1 removed the seatbelt while trying to get out of the wheelchair. Review of Patient #9’s medical record revealed that Patient #9 was a 52 year old male admitted to the facility on 1/7/2026 for confusion and cognitive deficits after end stage liver disease and liver transplant. Patient #9 had an activated power of attorney due lack of decision-making capacity. Further medical record review revealed limited capacity to follow commands and verbal cues and response to education as “no evidence of learning.” Review of Patient #9’s Mobility/ADL/Cognition Quality Indicators assessment revealed a shower/bath admission score of ‘2 - substantial/maximal assistance’ with a discharge goal of ‘supervision or touch assistance.’ Per medical record review, on 1/16/2026 Patient #9’s fall risk was documented as “20” (high risk) with interventions for “out of bed with 2 people; bed alarm on.” Review of an Occupational Therapy (OT) note dated 1/16/2026 revealed Patient #9 sustained a fall during OT session on 1/16/2026: “Patient sustained a fall during therapy session ... The following injuries were sustained from the fall: minor wound at posterior sacral region and minor cut noted at lateral aspect of right lower extremity. ...fall on this date during showering session [due to] attempting to stand with use of grab bar independently while therapist retrieve’s [sic] needed items by patient. Patient has previously been educated on importance of having assistance during all standing bouts during showering to ensure overall safety; will need ongoing assistance for showering needs upon discharge.” During an interview on 2/10/2026 at 11:30 AM, Regulatory Coordinator BB stated Patient #9 fell after being left unattended in the shower. During an interview on 2/10/2026 at 3:45 PM, when asked if they would ever leave a cognitively impaired individual in the bathroom or room alone, Occupational Therapist S stated, “never” and that OT S would use the vocera (staff to staff phone system) or the red cord (call light) in the bathroom to call if needed. Review of Patient #10’s medical record revealed that Patient #10 was a 72 year old male that was admitted to the facility on 12/12/2025 with weakness, cognitive deficits after experiencing multiple strokes and history of falls. Review of the medical record revealed Patient #10’s fall risk score was 18 (high risk) and standard nursing interventions were identified as “out of bed with 2 people and bed alarm on.” Review of Patient #10’s Mobility/ADL/Cognition Quality Indicators assessment revealed a toileting/transfer admission score of ‘1 - dependent or assist of two helpers’ with a discharge score of ‘3 - partial/moderate assistance.’ Per medical record review, Patient #10 sustained an unwitnessed fall on 12/28/2025 and was found “laying on his back with legs propped on his wheelchair.” During an interview on 2/10/2026 at 12:35 PM, Unit Manager D stated the CNA placed Patient #10 on the toilet commode, which did not have a back on it. Per D, the CNA left Patient #10 unattended on the commode to retrieve linen and Patient #10 fell backward out of the commode. Unit Manager D stated “the CNA didn’t know there wasn’t a back on the commode.” Review of Patient #10’s post-fall CT scan report dated 12/28/2025 revealed a “new” and “acute” lumbar compression fracture at L3 vertebra. Review of Patient #10’s discharge summary dated 1/6/2026 revealed “Admitted to [facility] from 12/12/2025 - 1/6/2026 ... [inpatient rehabilitation] was complicated by fall with resultant L3 compression fracture.” Review of facility workflow titled: “Hospitalized Patient Fall Preventions Interventions” revealed “Universal Fall Precautions (ALL PATIENTS): -Call light with in reach; -Non-skid footwear when out of bed ... High Fall Risk Interventions (HD score of 15 or greater): -Non-skid footwear, yellow color preferred; -Yellow clip put on patient wristband ...” Per medical record review, Patient #12 was identified as high risk for falls. During an observation on 2/11/2026 at 8:36 AM, Patient #12 was observed to be sitting on the side of the bed, no fall socks on and no yellow band clip on wrist. Per medical record review, Patient #13 was identified as high risk for falls. During an observation on 2/11/2026 at 8:40 AM, Patient #13 did not have the yellow wrist band clip. During an interview on 2/11/2026 at 9:15 AM Clinical Nurse Leader O stated all patients who are high risk for falls are expected to have the yellow wrist band clip on.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 43264 Based on interview and record review, the facility failed to protect patient’s rights by failure to review daily medication orders to assure correct medication administration and medication end dates for 1 of 1 patients (Patient #1), failed to administer tube feedings according to written orders for 1 of 1 patients (Patient #1), failed to administer medications via correct route for 1 of 1 patients (Patient #1), and failed to report a safety event within 24 hours of an abuse allegation per policy for 1 of 1 patients (Patient #11) in a sample of 11 records reviewed. Findings: The facility failed to review daily medication orders to assure correct medication administration and medication end dates. See tag A-0144 The facility failed to administer tube feedings according to written orders. See tag A-0144 The facility failed to administer medications via correct route. See tag A-0144 The facility failed to report a safety event within 24 hours of an abuse allegation - per facility policy. See tag A-0145”

“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: 43264 Based on interview and record review, the facility failed to provide a safe setting by failure to review daily medication orders to assure correct medication administration and medication end dates for 1 of 1 patients (Patient #1), failed to administer tube feedings according to written orders for 1 of 1 patients (Patient #1), and failed to administer medications via correct route for 1 of 1 patients (Patient #1) in a sample of 11 records reviewed. Findings Include: A review of facility policy, titled “Medication Reconciliation Policy”, last reviewed 08/24/2022, revealed: “...Purpose: To provide safety measures that will minimize patient risk from inadvertent omission or continuation of medication across the continuum of care. The reconciliation process is used to increase the accuracy in medications that patients receive by identifying duplications, omissions, dosing errors or drug interactions...Policy:...every patient who will receive a medication will have their medication list reconciled initially, at each change in level of care, and at discharge, which is consistent with the Joint Commission National Patient Safety Goals...B. Transfer medication Reconciliation: 1. Medication reconciliation must occur whenever a patient is transferred (e.g., transfer to another level of care). 2. The prescribing provider will review both the medication history and the current inpatient medication list and will indicate if each of the medication is to continue or to be held. a. The pharmacist will handle the transfer medication list as medication orders per policy...” Patient #1 was admitted on 11/13/2023 for Shortness of Breath. Per medical review, Patient #1 was prescribed Dexamethasone 4mg QID (4 times daily) on an outpatient basis. Medication Reconciliation was completed on admission per policy, and the orders revealed Dexamethasone 4mg QID was continued and administered as ordered from 11/13/2023 at 10:11 PM until the last dose administered on 11/22/2023 at 5:07 PM. Further review of the medical record revealed discharge for Patient #1 was ordered on 11/22/2023. Discharge medication reconciliation was completed per policy, which revealed continuation of the Dexamethasone 4mg QID was indicated on an outpatient basis. Review indicated further doses of the Dexamethasone were not present on the MAR once the discharge order was placed. Patient #1’s discharge was cancelled on 11/22/2023 due to a decline in condition. A consequent Medication Reconciliation was not completed per policy when Patient #1’s discharge was cancelled. As a result, Patient #1 did not receive Dexamethasone from 11/22/2023 at 5:07 PM until 11/24/2023 at 5:09 PM (7 missed doses). During an interview with Executive Director of Patient Safety/Patient Relations F on 04/16/2024 at 1:00 PM, when asked about Patient (Pt.) #1’s missed Dexamethasone medication during her 11/13/2023 admission and the complaint investigation results, Executive Director F stated “Not sure who the error of omission fell on.” The admitting physician “resumed” the steroid order from an outside provider with an original stop date of 11/22/2023, the home steroid prescription was for tapering. Pt. #1 was a discharge on 11/22/2023 but then was re-admitted the night of 11/22/2023 due to “weakness/hypoxia.” Discharge order was canceled on 11/22/2023 after the discharge med reconciliation had been done, “the discharge med reconciliation had steroids being resumed at discharge, but the steroid fell off the list and not put back on the med list; deviation was the med reconciliation.” During an interview with Pharmacy Director G on 04/16/2024 at 2:20 PM, Director G stated that Pt. #1’s discharge status changed and remained admitted, the steroid medication fell off the medication list. “Med reconciliation was done on admission with 36 doses with a stop date of 11/22/2023. There was a ‘gap’ with the nurse who stopped the med for a day or 2, there was team miscommunication; there was an order that was discontinued due to an expiration date.” During an interview with Medication Safety Officer H on 04/16/2024 at 2:24 PM, Officer H stated the pharmacists round every morning on the units and meds are reviewed during daily rounding, the steroid medication error “wasn’t caught that next morning, that should have been traditionally been caught the next morning; it was caught on 11/24/2023 by Pharmacist [I]. Previous dose ended on 11/22/2023 at 12:59 PM, EPIC (electronic health record) dropped the steroid off the MAR (medication administration record).” During an interview with Pharmacy Director G on 04/16/2024 at 2:26 PM, Director G stated the steroid was ordered on admission as an “outpatient retail prescription, the order was accepted as is” and the team accepted the transfer prescription from home med list with a discontinue date. A medication reconciliation was done, but Dexamethasone (steroid) was ordered with an end date, Neurosurgery Outpatient was prescribing the Dexamethasone every 2 weeks and patient was to follow-up in 2 weeks for steroid refills. Director G stated, “We should be looking closer at end dates that don’t appear to be relevant.” During an interview with Pharmacist I on 04/18/2024 at 12:00 PM, when asked if she recalled rounding on the 7CFAC unit on the morning of 11/23/2023, Pharmacist I stated “We do not round on holidays or weekends unless the Attending Physician requests.” Pharmacist I could not recall if she was the pharmacist who rounded the next day (11/24/2023) on the 7CFAC unit. The missed steroid medication wasn’t caught on rounding on the 24th, “it was caught due to a family member asking about the steroid.” The steroid fell off the MAR, “I’ve caught this a couple of times, the end date is not flagging us on end dates on admission reconciliation.” During an interview with Quality & Regulatory Coordinator B on 04/17/2024 at 1:00 PM, Coordinator B stated that Medication Safety Officer H confirmed “there are no care coordinator rounds on holidays, there is an ‘ad-hoc’ (on-demand) for CCR’s (care coordinator rounds) as needed.” During an interview with Oncologist K on 04/17/2024 at 10:55 AM, when asked about the effect on Pt. #1 regarding the missed steroid doses, Oncologist K stated that there was “weakness noted” on Pt. #1’s exams but this was a “temporary effect, there may have been a sharper downward trajectory until the steroid took affect again.” Oncologist K confirmed that Pt. #1 should have resumed taking Dexamethasone after discharge was canceled on 11/22/2023. - Tube Feeding Findings: A review of facility policy, titled “...Food and Nutrition Services Enteral Feeding (Tube Feeding) Policy”, last reviewed 04/10/2024, revealed: “..Purpose: To define the enteral feeding process for patient in the inpatient environment...1. All enteral feeding orders are ordered by completing the IP (inpatient) Enteral Nutrition order set in the electronic health record (EHR)...6. Nursing will: a. Verify and document feeding tube position with each assessment as needed...” A review of Pt. #1’s medical record, revealed: - 04/12/2023 at 10:59 PM: placement of GJT (gastrojejunostomy tube with a G portion inserted into the stomach and J portion inserted into the small intestine). - 04/24/2023 at 10:30 AM: Standing order placed by NP II for Continuous PEG (Percutaneous Endoscopic Gastrostomy - a tube to the stomach) feeds, initial delivery rate 195mL/hour with goal delivery rate of 390mL/hour (cycled feedings 0000, 0600, 1200, 1800). - 04/24/2023 at 11:38 AM: Medical Nutrition Therapy Progress Note by Dietician JJ, “Enteral Nutrition Regimen: Pt (patient) tolerating continuous EN (Enteral) at goal of Osmolite 1.2 @ 65 mL/h via PEG + 1 Prosource daily...Plan to transition to intermittent feedings...goal 390 mL 4 times per day at 0600 (6:00 AM), 1200 (12:00 PM), 1800 (6:00 PM), 0000 (12:00 AM)...RN to assess for tolerance run first feeding over two hours at 195 ml/hr.” - 04/24/2023 at 12:49 PM: Patient received first intermittent (bolus) feeding of Osmolite 1.2 (full strength) at 195 mL/hr via J-port (tube to the small intestine). - 04/24/2023 at 5:19 PM: Patient received intermittent (bolus) feeding of Osmolite 1.2 at 390 mL/hr via J-port. - 04/25/2023 at 12:26 PM: Patient received intermittent (bolus) feeding of Osmolite 1.2 at 195 mL/hr via J-port. - 04/25/2023 at 2:12 PM: Medical Nutrition Therapy Progress Note by Dietician FF, “Per discussion with provider, patient currently receiving bolus feeds via J-port while enteral nutrition order specifies G-tube (PEG). Loose stools and discomfort with feeds likely (due to) using wrong port of tube.” During an interview with Oncologist K on 04/17/2024 at 10:55 AM, when asked about intermittent/bolus feedings via J tube instead of via G tube portion, Oncologist K stated, “J tube was probably an error.” - Medication Administration Route Findings: A review of Pt. #1’s medical record, revealed: - 02/05/2024 at 9:18 PM: Patient admitted to the Emergency Department (ED) via ambulance for “Shortness of Breath” and husband reports “increased oxygen requirement, and inability to tolerate GJ (G-tube/J-tube) medications/feeds over the past few days - 02/06/2024 at 9:59 AM: Progress Note by Physician MM, “GJ tube evaluated in fluoro with concern for aspirating tube feeds. Positioned properly and functioning well...all medications through J portion of tube except PPI [Pantoprazole] (to be given through G tube portion). - 02/11/2024 at 9:00 AM: Medication order written for Pantoprazole (PPI) oral suspension 40mg daily via JT (J tube) route. - 02/12/2024 at 10:00 AM: Pantoprazole oral suspension 40mg given via G tube. During an interview with Executive Director of Patient Safety/Patient Relations F on 04/16/2024 at 1:00 PM, Executive Director F stated that “EPIC (electronic health record) function does not flag when multiple routes are being used for a patient.””

“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: 43264 Based on record review and interview, the facility staff failed to ensure that patients are free from abuse by failure to report a safety event within 24 hours of an abuse allegation per facility policy for 1 of 1 patients (Patient #11) in a sample of 11 records reviewed. Findings Include: A review of policy, titled “...Caregiver Misconduct Policy” last reviewed 08/09/2022, revealed: “...I. Any known or suspected report of caregiver misconduct will be investigated and a safety event report generated...” A review of policy, titled “...Patient Safety Serious Safety Event Management Policy” last reviewed 04/11/2024, revealed: “...Submit a Safety Event report in our Safety Reporting system. Staff must enter the occurrence using the event reporting software within 24 hours of the occurrence or upon becoming aware of an event...” During an interview with Pt. #11 (at bedside) on 04/18/2024 at 1:58 PM, Pt. #11 stated that there was a male in her room a few days ago that “man-handled” her and grabbed her “with force” when she was trying to get out of bed to use the bathroom. When asked if she had reported the incident to anyone, Pt. #11 stated, “There was someone that came in to talk to me after the incident” but could not recall who it was. Review of Patient (Pt.) #11’s medical record, revealed: Pt #11 was 81-year-old female admitted to the hospital on 03/24/2024 with chief complaint of shortness of breath; Pt #11 was a current inpatient on the Oncology 8CFAC unit at the time of survey. Per Pt #11’s medical record, Pt #11 had a history of lung adenocarcinoma, COPD and chronic respiratory failure. Patient was fall risk with a bed alarm at time of survey. A review of Pt. #11’s Nursing skin assessments documented from 04/16/2024 - 04/18/2024 revealed no new wounds and/or bruising. On 04/16/2024 at 5:33 AM, Registered Nurse (RN) III’s note, revealed: “Pt set off bed alarm attempting to get out of bed without assistance and writer responded to alarm and attempted to assist pt back to bed to prevent fall. Pt became aggressive and yelling/swearing at writer and significant other in room and not following instructions to stay safe. CNA (JJJ) came to room to try to assist and pt remained belligerent with staff. Contacted charge nurse (LLL) to assist and pt was speaking to family in [sic] personal phone and was able to place pt on bed pan to void/bm (bowel movement) and then return to bed.” A review of the text message from the Nurse KKK to Manager GGG (sent on 04/16/2024 at 9:31 AM), revealed: “...I told Charge Nurse [LLL] about a minor situation that happened last night but wanted to fill you in as well in case you wanted to round w the patient/family. Room 18 felt RN [III] and CNA [JJJ] were “man handling” her to stay in bed when she set off the bed alarm (she is a heavy 2 assist/hoyer). I was able to diffuse the situation, but she did call her son and said a security guard was manhandling her and forcing her to do things (stay in bed). I explained he was a nurse but she was still upset so I just wanted to make sure you were in the loop about it. I also put a flag for no males on her bc (because) I think she has been that way in the past and am wondering if that could have made the situation worse.” As of survey exit on 04/18/2024, there was no evidence found that a safety event report regarding Patient #11’s allegation of abuse was entered, per facility policy. During an interview with 8CFAC Nurse Manager GGG on 04/18/2024 at 2:28 PM, Manager GGG stated that the incident happened on the evening shift on 04/15/2024 - she was made aware via a text message from Nurse [KKK] on 04/16/2024 at 9:31 AM. Manager GGG went in to talk to Pt. #11 after the incident (with pt’s husband at bedside) for her recollection of the event, Pt. #11 set off her bed alarm and was a hoyer lift, she said that RN III came in said “you have to swing your legs in” and she said “no, I have to go to the bathroom. RN [III] held her shoulders on both sides to prevent her from getting up, the husband was asleep and then awoke mid-incident. Husband said another CNA [JJJ] got her back to bed and they were ‘tossing her back and forth in bed’. Patient shut her husband down and said he was in the bathroom at the time.” Manager GGG stated s/he talked with RN III on the morning of 04/17/2024 about the event. RN III stated that Pt. #11 was “belligerent and cussing”, her alarm was going off, she was not safe to walk and needed to use bedpan. CNA JJJ was called to help, got her back to bed and also called Charge Nurse LLL to help. When Manager GGG asked RN III if he put his hands on Pt. #11’s shoulders he said, “I think so.” When asked if Manager GGG had submitted a Safety Event through their internal reporting system, Manager GGG stated that she was still waiting to get a hold of CNA JJJ who was a witness to the event and then she was going to put an event into the facility’s “Reli” reporting system. When asked if RN III has worked with Pt. #11 or other patients on the floor since the reported event, Manager GGG stated that RN III hasn’t worked with Pt. #11 since the event and has worked another night shift on the floor since that event. During an interview with 8CFAC Director HHH on 04/18/2024 at 3:18 PM, when asked if she was aware of the incident and/or the investigation regarding Pt. #11, Director HHH stated that she was not aware and that her staff prepare the investigation first and then they come to her. During an interview with Human Resources (HR) MMM on 04/18/2024 at 4:20 PM, when asked if an allegation of man-handling would be reported as physical abuse, HR MMM stated “Yes.””

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 29972 Based on record review and interview, staff failed develop a comprehensive action plan to address adverse events in 1 of 2 adverse events reviewed (Patient (Pt) #1), in a total sample of 2 adverse events reviewed. Findings Include: Review of policy and procedure #3079 titled, “...Patient Safety Event Reporting and Investigation” last reviewed 11/09/2023 revealed the following: -Reached the individual Safety Event Classification 4: “...Event reached patient; mild and transient anxiety or pain or physical discomfort, but without the need for additional treatment other than monitoring (such as observation; physical examination...” -“Any safety event, error or unusual occurrence involving patients...must be reported upon discovery.” -“The objectives of the policy are to:...identify opportunities to improve the quality and safety of care and mitigate/minimize hazards and risk and/or future events.” Review of Pt #1’s medical record revealed Pt #1 was admitted to the hospital on 08/13/2023 at 9:02 PM post cardiac arrest and cardiogenic shock; Pt #1 was a current inpatient at the time of survey. Per Pt #1’s medical record, Pt #1 had a history of type 2 diabetes. Review of Pt #1’s hygiene nursing flowsheet revealed Registered Nurse (RN) G documented trimming Pt #1’s fingernails on 11/29/2023 at 4:00 AM (3rd shift). Review of Pt #1’s adverse event report dated 12/01/2023 at 4:35 PM revealed, “(Pt #1’s) sister (A) called RN (Registered Nurse) on 11/29 at 1615 (4:15 PM) (1st shift RN) to ask about small cut on left index finger and thumb. RN noted small cut that may have been caused by nail cutter. Sister (A) asked how this happened and RN told her she did not know. No active bleeding noted, dried blood present...Sister (A) called unit on 11/30 and wanted to speak to director of the unit. Manager (C) present during call and Sister (A) accused...staff of intentionally injuring patient...Manager (C) called night RN (G) who stated that she had cut (Pt #1’s) nails during the night as she has done before to protect skin on palm since patient clenches his fists. (RN G) did note that skin was broken and cleansed area and applied a Band-Aid to index finger.” Review of the adverse event report revealed the incident was investigated for caregiver misconduct, but there was no plan of action to prevent future incidents occurring from untrained staff trimming patient’s nails. Review of Pt #1’s Internal Medicine Daily Progress Noted dated 12/01/2023 at 8:54 AM revealed, “...Left index finger with small wound to tip of the finger with dried blood. faint erythema (redness), no drainage...Right thumb with small wound to the tip of the finger with dried blood. No erythema or drainage...” Per interview with Associate Chief Nursing Officer (CNO) B on 01/04/2024 at 1:49 PM, nursing staff (RNs) should not be clipping any patient’s nails; Per CNO B, there is an Advanced Practice Nurse who can do this if needed. Per interview with Nurse Manager C on 01/04/2024 at 2:00 PM, Manager C stated that RN G was informed that “staff really should not be cutting patients nails, especially a diabetic patient.” Manager C stated that she/he was not aware who could trim patient’s nails if needed. Manager C stated that she/he was not aware that there is an Advanced Practice Nurse who can do this as per CNO B stated. Per Manager C, there is currently no process/procedure in place addressing nail trimming and no action plans have been implemented in response to this adverse event, to ensure all staff are educated on who can trim patient’s nails. Per interview with RN G on 01/08/2024 beginning at 9:45 AM, RN G stated that Pt #1 was always flexing his/her hands into chest so RN G trimmed Pt #1’s index fingernail and accidentally cut the nail too short; RN G stated that she/he went “a tiny bit too deep.” RN G did not recall trimming the thumb nail too short. RN G stated that she/he did not think “there was any reason to notify the physician” and did not complete an adverse event report. Per RN G, there was no unit guideline on who was supposed to trim patient nails. RN G denied having training on trimming patient’s nails.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 29972 Based on record review and interview, staff failed to perform wound assessments and interventions in 1 of 10 patient medical records reviewed (Patient (Pt) #1); and failed to perform pain assessments and reassessments as per policy in 1 of 10 medical records reviewed (Pt #1), in a total sample of 10 medical records reviewed. Findings Include: Review of policy and procedure #1728 titled, “Nursing Skin and Wound Assessment and Management” last reviewed 10/03/2023 revealed the following: 1. “A head-to-toe skin assessment will be conducted as follows:...1. Every shift.” 2. A focused wound assessment will be completed for any wound identified in the basic skin assessment...2. With every dressing change...a. With each dressing change, the wound will be observed for developments that may indicate the need for a change in treatment (e.g., wound improvement, wound deterioration, more or less exudate, sign of infection or other complications)...3. Upon discovery...” Review of policy and procedure #1902 titled, “Patient Care Services Pain Management Policy” last reviewed 07/13/2023 revealed the following: 1. “Patient will be screened and assessed for pain by using the appropriate pain scale according to the patient’s age, condition...” 2. “Assessment and reassessment of pain will be documented in the medical record.” 3. “To ensure patient safety and care efficiency, pain reassessment will occur prior to and following every intervention...” Review of Pt #1’s medical record revealed Pt #1 was admitted to the hospital on 08/13/2023 at 9:02 PM post cardiac arrest and cardiogenic shock; Pt #1 was a current inpatient at the time of survey. Per Pt #1’s medical record, Pt #1 had a history of type 2 diabetes. Review of Pt #1’s nursing flowsheets revealed the following: On 09/23/2024: -At 6:41 AM, Pt #1 was given Oxycodone 5 mg (milligrams) (narcotic for pain) via Pt #1’s gastric tube; there was no reassessment of Pt #1’s pain following the intervention as per policy. -At 12:01 PM, Pt #1 was given Oxycodone 5 mg, there was no assessment of Pt #1’s pain. -At 4:34 PM, Pt #1 was given Oxycodone 5 mg, there was no assessment of Pt #1’s pain. On 09/24/2024: -At 6:13 AM, Pt #1 was given Oxycodone 5 mg, Pt #1’s pain was not reassessed until 8:00 AM (1 hour and 47 minutes later). -At 10:24 AM, Pt #1 was given Oxycodone 5 mg, there was no assessment of Pt #1’s pain. -At 2:26 PM, Pt #1 was given Oxycodone 5 mg, there was no assessment of Pt #1’s pain. Per interview with Clinical Nurse Specialist (CNS) D, while reviewing Pt #1’s medical record, CNS D stated that nursing staff should be performing a pain assessment prior to, and an hour after administering oral pain medications. Review of Pt #1’s hygiene nursing flowsheet revealed Registered Nurse (RN) G documented trimming Pt #1’s fingernails on 11/29/2023 at 4:00 AM. Review of Pt #1’s Internal Medicine Daily Progress Noted dated 12/01/2023 at 8:54 AM revealed, “...Left index finger with small wound to tip of the finger with dried blood. faint erythema (redness), no drainage...Right thumb with small wound to the tip of the finger with dried blood. No erythema or drainage...” Per interview with RN G on 01/08/2024 beginning at 9:45 AM, RN G stated that she/he trimmed Pt #1’s index fingernail too short and the finger tip was red; RN G stated that she/he accidentally went “a tiny bit too deep.” RN G stated that she/he placed a Band-Aid over the fingertip. RN G did not recall trimming the thumb nail too short. Review of Pt #1’s medical record revealed there was no documented evidence of RN G performing an initial focused wound assessment addressing the injury to Pt #1’s finger tips after trimming Pt #1’s nails. Per interview with CNS D, while reviewing Pt #1’s medical record, CNS D confirmed there was no documented evidence of a nursing assessment of Pt #1’s fingernail wounds until 12/02/2023 (3 days later). CNS stated that RN G should have opened a wound assessment and documented an assessment and interventions.”