Marshfield Medical Center - Weston

“PATIENT RIGHTS: REVIEW OF GRIEVANCES CFR(s): 482.13(a)(2) [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.] The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. This Standard is not met as evidenced by: 50644 Based on record review and interview the facility failed to file and follow up on a written patient grievance per policy in 1 out of 1 (Patient #1) grievances reviewed. Findings include: A review of facility policy titled, “Patient Complaint and Grievance Resolution Policy” last reviewed/revised on 04/22/2026 revealed, “...Grievance: A formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient’s representative, regarding the patient’s care...incident reporting system is used for documenting grievances or other patient complaints...Any member of the care team could be involved in the investigation and review process...If a complicated grievance is not resolved within seven (7) business days, the patient will be informed via letter that the investigation is ongoing...Every effort will be made to complete the grievance investigation and provide written notification of a decision within 30 business days. If a complicated grievance is not resolved within thirty (30) business days, the patient will be informed in writing that he investigation is ongoing...All grievances will be reviewed by the Grievance Committee...” A review of facility complaint and grievance log from 01/01/2026 through 06/08/2026 revealed no evidence of a complaint or grievance in the system for Patient #1 from Complainant A. During an interview on 6/8/2026 at 12:11 PM, President D stated that when letters are received from patients or family they are loaded into the computer system to track and appropriate parties are notified. He stated that the RL (event reporting) system is used to track and manage complaints and grievances. During a follow up interview with President D on 6/8/2026 at 12:58 PM, he stated that the grievance from Complainant A was received on 4/20/2026 but has not been scanned into the RL reporting system or followed up on at this point. President D stated that it was with the legal team because it was Patient #1’s wife who filed the complaint after Patient #1 had passed away and not the patient himself. He stated that “within 7 days should at least follow up with the patient at a minimum stating it was received and being reviewed.””

“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: 50644 Based on record review and interview, facility staff failed to complete a nursing care plan regarding restraint use for 1 out of 5 (Patient #5) patients in restraints in a total universe of 10 patient medical records reviewed. Findings include: A review of facility policy titled, “Restraints Policy” last reviewed/revised 09/17/2025 revealed, “...The patient’s need for restraints will be reflected in the plan of care. (Any patient changes will be updated and documented.) This includes: Initial documentation to reflect the necessity of a restraint. Ongoing review of the patient’s plan of care that reflects the necessity of the restraint...” A review of Patient #5’s medical record from 5/30/2026 through 6/1/2026 revealed that bilateral mitt restraints were applied to Patient #5 on 5/31/2026 at 3:48 AM to prevent dislodging of medical tubes. Restraints were removed on 6/1/2026 at 8:44 AM. There is no evidence of a care plan created for restraint use for Patient #5. During an interview with IMC (Intermediate Care) Manager T on 6/8/2026 at 2:18 PM, she stated that she could not find a care plan where she would expect to see it.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(iii) [there must be documentation in the patient’s medical record of] Alternatives or other less restrictive interventions attempted (as applicable); This Standard is not met as evidenced by: 50644 Based on record review and interview, facility staff failed to document alternative or less restrictive interventions for 2 out of 5 (Patient #4 and Patient #6) restrained patients in a total universe of 10 patient medical records reviewed. Findings Include: A review of facility policy titled, “Restraints Policy” last reviewed/revised on 09/17/2025 revealed, “...Before a restraint is applied, less restrictive measures are considered or have been attempted and are documented. Document behavior or events leading to restraint and the alternatives attempted...” A review of Patient #4’s medical record revealed that Patient #4 was placed in bilateral wrist restraints on 4/30/2026 at 7:05 PM and remained in restraints until 5/1/2026 at 11:17 PM. There was no evidence of documentation of alternative or less restrictive interventions attempted prior to the initiation of restraints or continued use of restraints. A review of Patient #6’s medial record revealed Patient #6 was placed in bilateral wrist restraints on 4/3/2026 at 8:44 PM and remained in restraints until 4/6/2026 at 1:00 PM. There was no evidence of documentation of alternative or less restrictive interventions attempted prior to the initiation of restraints or continued use of restraints. During an interview on 6/8/2026 at 2:08 PM, IMC (Intermediate Care) Manager T confirmed there was no documentation of alternatives in the medical records.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(v) [there must be documentation in the patient’s medical record of the following:] The patient’s response to the intervention(s) used, including the rationale for continued use of the intervention. This Standard is not met as evidenced by: 50644 Based on record review and interview the facility staff failed to document the impact of the intervention on the patient behavior and response to the intervention for 2 out of 5 (Patient #4 and #6) restrained patients in a total universe of 10 medical records reviewed. Findings Include: A review of facility policy titled, “Restraints Policy” last reviewed/revised on 09/17/2025 revealed, “...Affect/Behavior while restrained: Assess and document the patient’s physical and emotional bell-being while in restraints...” A review of Patient #4’s medical record revealed that Patient #4 was placed in bilateral wrist restraints on 4/30/2026 at 7:05 PM and remained in restraints until 5/1/2026 at 11:17 PM. There was no evidence of documentation of impact of the intervention on the patient’s behavior or the patient’s response to the intervention. A review of Patient #6’s medial record revealed Patient #6 was placed in bilateral wrist restraints on 4/3/2026 at 8:44 PM and remained in restraints until 4/6/2026 at 1:00 PM. There was no evidence of documentation of impact of the intervention on the patient’s behavior or the patient’s response to the intervention. During an interview on 6/8/2026 at 2:28 PM, IMC (Intermediate Care) Manager T confirmed these findings.”

“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: 50644 Based on record review and interview the facility failed to report a patient fall as an adverse event in 1 of 10 medical records reviewed (Patient #2). Findings include: Review of the facility’s policy titled, “Patient Bill of Rights and Responsibilities” last revised 1/27/2026 revealed, “...Every patient has the following rights...Personal Safety: To have medical providers and other staff do everything possible to ensure the patient’s safety while in the facilities...” Review of the facility’s policy titled, “Incident Reporting System” last revised 4/21/2026 revealed, “...Reportable Incident: An occurrence or event requiring documentation in the Incident Reporting System. Patient Safety Event: An event, incident, or condition that could have resulted or did result in harm to a patient. These can include, but are not limited to: Adverse event: Event that resulted in harm to a patient. No-harm event: Event that reaches the patient but does not cause harm. ‘Near Miss’ or ‘Good Catch’ event: Event that did not reach the patient. Hazardous Condition: A condition (other than the patient’s own disease process or condition) that increases the probability of an adverse event...Reporting system. a. If an individual is unsure whether an event requires reporting, they can seek guidance from their manager, or the Risk Management or Patient Safety teams...b. A report should be filed in a timely manner after immediate patient needs are attended to. c.The incident report should be complete and factual, entered by the involved or notified employee, physician, provider, or department manager (or his/her delegated representative in the area in which the incident occurred...” Review of Patient #2’s medical record “Individual Observation Record” video monitoring note on 5/18/2026 at 12:36 AM by Monitor Technician U revealed, “...Behavior: Disruptive, Explosive, Restless, Self-endangering, Uncooperative...[Patient #2] had fallen out of bed by flipping over the left railing. There were staff present when he had fallen. I am not aware whether he had hit his head or not. When viewed [Patient #2] was already on the floor and legs were in the air. He was being helped up.” Review of Patient #2’s medical record “Nurses Note” on 5/18/2026 at 5:35 PM by IMC (Intermediate Care Unit) RN S revealed, “[Patient #2] this evening was increasingly restless and agitated, yelling incoherently and unable to follow commands...[Patient #2] then dislodged his IV while he was moving requiring replacement for medications. [Patient #2] required the assistance of 6 staff to successfully place another IV. While medications were being obtained he again was very restless in bed, moving from side to side, kicking legs in the air and sitting up at times. While he was sitting up in the center of the bed [Patient #2] suddenly lunged to side falling over in-between the two side rails that were up. [Patient #2] was partially caught by the CNA (certified nursing assistant) at bedside but did lightly strike his head on the floor. [Patient #2] was then lowered all the way to the floor, assessed for injury and assisted back to bed. During this time [Patient #2] behavior did not vary, he was restless, agitated, incoherently yelling and unable to follow commands. MD (medical doctor) Q was at bedside and witnessed the incident. [Patient #2] did not show any signs of injury. [Patient #2] was given lorazepam [sedation medication] x 2 per MD order with little change in condition and transferred to the ICU for ongoing care of agitation.” Review of the facility Adverse Event log did not reveal any events entered for Patient #2 during his admission. During an interview on 6/8/2026 at 5:00 PM RN Manager C stated that she would consider Patient #2’s fall out of bed in IMC an event that should be reported.”