Select Specialty Hospital - Birmingham

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 49894 Based on review of medical records, policies and procedures, Incident Report Log, incident report documentation, and staff interviews it was determined the Governing Body failed to ensure compliance with the Conditions of Participation for hospitals was maintained and quality patient care was provided in a safe manner. This deficient practice had the potential to negatively affect all patients served by the hospital. Findings include: Refer to A-0049, A-0115, A-0144, A-0166, A-0175, A-0392.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 49894 Based on review of medical records, hospital policy and procedure, Incident Report Log, incident report documentation, and staff interviews, it was determined the hospital failed to protect and promote each patient’s rights to care in a safe setting and safe use of restraints. These deficient practices did affect Patient Identifiers (PI) # 1, PI # 2, and PI # 3, and had the potential to negatively affect all patients served by the hospital. Findings include: Refer to A-0144, A-0166, A-0175.”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 49894 Based on review of medical records (MR), Incident Report logs, incident report documentation, policy and procedure, and staff interviews, it was determined the Governing Body and Medical Staff failed to ensure: 1. Patients were cared for in a safe setting. 2. Staff followed the hospital policies and procedures for patient events, documentation in the medical record, and notification of the physician. 3. Policies for use of restraints were followed by staff. 4. Physician orders for a sitter for patient safety was carried out. These deficient practices affected Patient Identifier (PI) # 3, PI # 1 and PI # 2, and had the potential to negatively affect all patients served by the hospital. Findings include: Hospital Policy: Incident Reporting and Sentinel Events Policy Number: 200-QM Issue Date: 1/1/26 Purpose: 1. To contribute to the promotion of a safe environment for all occupants of the hospital through the implementation of a hospital-wide incident reporting system and review system.... 2. To improve patient care, treatment, and services and prevent sentinel events. 3. To focus attention on underlying causes and on changing processes and systems to reduce the probability of future incidents. Definitions: 1. Incident- An event involving a patient that is not consistent with the routine care, normal hospital operations, or the expected performance of a facility system... Includes Patient Safety Events, near misses, and unsafe conditions. 2. Patient Safety Event- An incident or condition that could have resulted or did result in harm to a patient... 4. Injury- Physicals or psychological harm suffered by a patient as a result of a Patient Safety Event, which may be classified as follows: a. Level of Injury 1- No injury to the patient. b. Level of Injury 2- Minor injury (such as contusion, laceration) that requires medical treatment. c. Level of Injury 3- Significant injury that requires increased length of stay and/or invasive medical treatment. d. Level of Injury 4- Serious injury (i.e. loss of limb, loss of body part, or death). ...6. Sentinel Event- ...Patient safety event (not related to the natural course of the patient’s illness or underlying condition) that reaches a patient and results in death, severe harm, or permanent harm... 7. Unsafe Condition- A circumstance that increases the likelihood of a Patient Safety Event Occurring... Policy: 1. A confidential incident report must be completed promptly and accurately by any hospital workforce member involved in or discovering an incident reported to him/her by a patient or visitor...In order to ensure patient and employee safety, any Patient Safety Event with injury level of 3 or 4 or that meets the definition of a Sentinel Event will have a root cause analysis (RCA)... Procedure: When an Incident occurs, the following areas must be addressed, and appropriate steps taken: 1. Patient Care: a. Medical and nursing staff provide prompt and appropriate care to the involved patient/individual, including ensuring the patient/individual...is assessed for injury, and receives medical treatment as needed. 2. Communication: a. Notify the Clinical Supervisor. b. Notify the patient’s physician or licensed practioner. c. In the case of a Patient Safety Event or Sentinel Event...ensure appropriate disclosure of objective facts from the medical record related to the event to the patient and family will be completed... d. If the patient sustained an injury requiring more than first aid, immediately notify the Chief Executive Officer/Administrator On Call (CEO/AOC) and Chief Nursing Officer (CNO)... 4. Documentation: a. A confidential incident report will be completed electronically prior to the end of the shift by the staff member that witnessed the incident... b. Ensure medical record documentation is accurate and complete regarding objective information related to the incident and any follow-up medical care or treatment... 6. Reporting: a. The incident report will be automatically and electronically reported to the hospital’s Patient Safety Organization. b. ...the Director of Quality Management (DQM) or designee will determine if the incident is reportable to any federal, state, or local agency or authority...the DQM or designee will notify agencies...utilizing relevant information from the medical record. 7. Quality Improvement Actions and Monitoring: a. ...The DQM or designee performs the initial review of the incident report and assigns the severity level. b. After initial review...if the incident category is Fall, Medication Related, Nonspecific Medication Process Related Event or Adverse Drug Event...the Director of Pharmacy or designee investigates the incident within 72 hours of notification of the incident... d. DQM categorizes and trends reported incidents. e. DQM records aggregate information on appropriate logs and reports to the Quality Assurance Performance Improvement (QAPI) Team and Quality Improvement Committee... 10. The DQM will provide a summary report of the findings of the Root Cause Analysis to the Quality Improvement Committee and Governing Body. Hospital Policy: Fall Reduction Program Policy Number: F02-G Revision Date: 1/26 ...Policy... A. Every patient will be assessed on admission, every shift, and after a fall to identify fall risk and fall prevention bundle interventions. E. Post Fall Assessment and Revision to Plan of Care 1. For any patient fall regardless of injury, there must be an immediate revision to the plan of care. a. Previous strategies must be evaluated and a plan developed.... b. Notify the Physician (with complete assessment information), Administrator on call, and family. 2. Post fall assessment must include: a. Vital Signs, b. (Complete) location and quality of any pain, c. Complete neurological and vascular assessment, d. Observation for fractures..., e. Bruising, f. Lacerations. 3. Patient will be on Neuro-vascular checks and vital signs: a. Every 15 minutes (min) times (X) 4 (Repeat every 15 min for a total of one hour) then, b. Every one hour X 4 (Repeat every hour for a total of four more hours), c. Every two hours X 4 (Repeat every two hours for a total of eight more hours), d. Every four hours X 3 (Repeat every four hours for a total of twelve more hours). F. If the patient is on anticoagulants continue neuro-vascular checks and vital signs every four hours for twenty-four additional hours (Repeat every four hours for a total of twenty-four more hours.)... Hospital Policy: Restraints and Seclusion Policy Number: R02-N Revision Date: 10/1/24 ...Purpose: To keep the patient safe... ...Procedure: Medical Record Documentation and Plan of Care: ...Modification of the patient’s treatment plan related to restraint use, patient’s response to restraint, and plan for reduction/elimination is included in the patient’s medical record. ...Medical Record Documentation and Plan of Care: Every use of restraint is to be documented in the patient’s record. At a minimum, documentation must include: The alternatives tried prior to restraint use, the justification for restraint, the patient assessment that demonstrates the need for restraint as part of the patient’s treatment, a time limited order by a physician or licensed practioner, evidence of monitoring the patient’s condition during restraint, demonstration of the need for continuing restraint beyond the initial order or the satisfaction of criteria for release. Modification of the patient’s treatment plan related to restraint use, patient’s response to restraint, and plan for reduction/elimination is included in the medical record. Interdisciplinary Team Member documentation must: ...State plan of care (at implementation and daily) ...State observations/interventions/findings from periodic observations, to include: safety, comfort, mobility, skin integrity, food/hydration, toileting, removal of restraints for at least ten minutes every two hours or more often (observations every two hours for medical restraints and every fifteen minutes for behavioral restraints). 1. PI # 3 was admitted to the hospital on 11/29/25 with a primary diagnosis of Respiratory Failure. PI # 3 expired on 1/19/26 at 12:40 AM, thirty minutes after being found sitting on the floor beside the bed. Discharge planning was in progress at the time of this fall. Review of the physician’s orders revealed an order dated 12/5/25 for Heparin (anticoagulant) 5000 units injected subcutaneously every eight hours. Further review of the physician’s orders revealed an order for a sitter at the bedside dated 12/22/25 at 12:48 AM for suicide risk and an order for suicide precautions. Both orders were discontinued on 12/25/25 at 4:49 AM. The MR revealed no documentation of a sitter until 12/22/25 at 8:00 AM, which was seven hours and twelve minutes after the physician’s order. Further review of the medical record revealed no documentation of a sitter as follows: 12/22/25 at 8:00 PM until 12/23/25 at 4:16 AM 12/23/25 at 4:16 AM until 12/23/25 at 3:00 PM 12/24/25 at 4:45 AM until 12/24/25 at 7:00 PM On 12/24/25 at 10:27 AM the nurse caring for PI # 3 documented, “Patient will not stop attempting to get out of bed,” and at 1:12 PM, “Patient is in restraints and still managing to pull off leads and take off his oxygen. This patient is suppose to have a ‘sitter’, we don’t have the staff for one. I am constantly having to go in the patients room, literally every 5 minutes. Redirecting does not help.” Review of the hospital Incident Report Log revealed PI # 3 fell on 1/15/26 at 2:30 PM and a second fall on 1/19/26 at 12:10 AM. The fall on 1/19/26 was listed as Level 1 - No Injury. Review of the incident report documentation revealed on 1/19/26 at 12:10 AM the patient was found sitting on the floor beside the bed and was assisted back to bed by the staff. Review of the MR revealed on 1/18/26 PI # 3 was alert, oriented, ambulatory, and ready for discharge, pending placement at a skilled nursing or rehabilitation facility. The MR revealed no documentation of the fall on 1/19/26, no post fall assessment as directed in the hospital policy, and no documentation the physician, CEO/AOC, CNO, and/or patient’s family were immediately notified. There was no documentation of the patient status at the time of the fall and leading up to the patient’s death 30 minutes after being found on the floor. The MR did include a Record of Death documenting the date and time of death was 1/19/26 at 12:40 AM. The surveyor asked Employer Identifier (EI) # 1, Chief Nursing Officer, to provide all nurses notes and physician documentation of the objective information related to the patient’s fall and death. EI # 1 responded there was no documentation of the objective information related to the fall and/or the patient’s death. Review of the hospital event investigation documentation revealed: Clinical Reviewer Comments: “Review of chart and current processes completed. Online safety briefing completed which included: bed alarm education and compliance monitoring by leadership...Instructional resources provided for referencing if questions arise. Attestation with signatures collected.” Pharmacy Reviewer Comments: “Patient has scheduled Gabapentin and Risperidone on Medication Administration Record. Patient received as needed (PRN) Ativan 1/18 at 1:36 PM and PRN Percocet on 1/18 at 1:37 PM and 9:37 PM. All of these can contribute to dizziness, drowsiness, and sedation.” Initial Reviewer Comments: “CNO to review. Fall debrief complete. No injuries identified.” An interview was conducted on 1/29/26 at 3:15 PM with Employee Identifier # 1, who confirmed there was no documentation in the MR of the objective information related to the patient’s fall and/or death and the hospital did not consider the patient’s fall on 1/19/26 a Sentinel Event, therefore, it was not investigated or a Root Cause Analysis performed. 2. PI # 1 was admitted to the hospital on 9/16/25 with diagnoses including Wound, Ulcerative Colitis Flare, and Severe Protein Calorie Malnutrition. Review of the physician’s orders revealed orders dated 9/16/25 at 11:33 PM, 9/17/25 at 1:40 AM, and 9/17/25 at 9:42 AM for Restraint, non-violent or non-self destructive, Right Mitten, untied, and Left Mitten, untied, for interference with medical treatment. Review of restraint monitoring revealed no documentation the patient was monitored every two hours from 9/17/25 at 4:00 PM until the restraints were discontinued on 9/18/25 at 1:36 AM. Review of the patient’s plan of care revealed there was no documentation the care plan was modified to include the use of restraints until 9/19/25 at 1:03 AM. Further review of the physician’s orders revealed orders dated 9/23/25 at 12:51 AM, 9/23/25 at 4:41 PM, 9/24/25 at 12:39 AM, and 9/24/25 at 7:18 PM for Restraint, non-violent or non-self destructive, Right Mitten, tied, and Left Mitten, tied, for interference with medical treatment. Review of the patient’s plan of care revealed no documentation the care plan was modified for the restraints to be tied. Review of the hospital Incident Report Log revealed PI # 1 fell on 9/17/25 at 2:00 PM. The MR revealed no documentation of the fall, no documentation of a post fall assessment or vital signs as directed per hospital policy, and no documentation the physician, on-call administrator, or family were notified of the fall. Review of the plan of care revealed no documentation of a fall risk assessment with fall prevention interventions developed until 9/19/25 at 1:03 AM. Interviews were conducted on 1/30/26 at 12:02 PM and 1:25 PM with EI # 1, who confirmed staff failed to follow the hospital policy for falls, incident reporting, and notification regarding the fall to the physician, on-call administrator, or family and failed to follow the hospital policies for falls and use of restraints. 3. PI # 2 was admitted to the hospital on 12/1/25 with a primary diagnosis of Respiratory Failure. Review of the MR revealed the following physician’s orders dated: 1/5/26 at 3:27 AM, 1/6/26 at 7:28 AM, 1/7/26 at 12:07 AM, 1/8/26 at 12:42 AM, 1/23/26 at 7:34 AM, 1/23/26 at 6:35 PM, and 1/24/26 at 1:29 AM for Restraint, non-violent or non-self destructive, soft wrist, Right, and Soft Wrist, Left, for interference with medical treatment. Review of the patient’s plan of care revealed no documentation the care plan was modified to include the use of restraints per hospital policy. The MR included an order dated 12/1/25 for Eliquis 5 mg twice daily. Review of the hospital Incident Report Log revealed PI # 2 fell on 1/9/25 at 9:15 AM. Review of the MR revealed no documentation of the fall, no documentation of a post fall assessment and post fall vital signs and neuro-vascular checks per the hospital policy, and no documentation the physician, on-call administrator, and/or family were notified of the fall, Review of the plan of care revealed there was no documentation previous strategies to prevent falls were evaluated until 1/10/26 at 1:10 AM. There is no documentation a new plan to prevent falls was developed. Further, the care plan was not modified to include the use of restraints. Interviews conducted on 1/29/26 at 2:47 PM and 1/30/26 at 1:25 PM with EI # 1, confirmed the staff failed to follow the hospital policy for falls, incident reporting, and notification regarding the fall to the physician, on-call administrator, and/or family and failed to modify the care plan per hospital policy.”

“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: 49894 Based on review of medical records (MR), Incident Report log, incident report documentation, policy and procedure, and staff interview, it was determined the hospital failed to ensure staff: 1. Followed the hospital policy for patient falls. 2. Notified the physician, hospital leadership, and/or family of falls. 3. Notified the physician of patient’s death. 4. Assessed patients on admission to develop strategies for fall prevention or revised plans of care immediately after falls to evaluate previous strategies to prevent falls and develop a new plan. 5. Followed the physician’s order for a sitter at the bedside for a patient on suicide precautions. This affected Patient Identifiers (PI) # 3, PI # 1, and PI # 2, in three of three MRs reviewed and had the potential to affect all patients served by the hospital. Findings include: Hospital Policy: Fall Reduction Program Policy Number: F02-G Revision Date: 1/26 ...Policy... A. Every patient will be assessed on admission, every shift, and after a fall to identify fall risk and fall prevention bundle interventions. E. Post Fall Assessment and Revision to Plan of Care 1. For any patient fall regardless of injury, there must be an immediate revision to the plan of care. a. Previous strategies must be evaluated and a plan developed.... b. Notify the Physician (with complete assessment information), Administrator on call, and family. 2. Post fall assessment must include: a. Vital Signs, b. (Complete) location and quality of any pain, c. Complete neurological and vascular assessment, d. Observation for fractures..., e. Bruising, f. Lacerations. 3. Patient will be on Neuro-vascular checks and vital signs: a. Every 15 minutes (min) times (X) 4 (Repeat every 15 min for a total of one hour) then, b. Every one hour X 4 (Repeat every hour for a total of four more hours), c. Every two hours X 4 (Repeat every two hours for a total of eight more hours), d. Every four hours X 3 (Repeat every four hours for a total of twelve more hours). F. If the patient is on anticoagulants continue neuro-vascular checks and vital signs every four hours for twenty-four additional hours (Repeat every four hours for a total of twenty-four more hours.)... Hospital Policy: Incident Reporting and Sentinel Events Policy Number: 200-QM Issue Date: 1/1/26 Purpose: 1. To contribute to the promotion of a safe environment for all occupants of the Hospital... Definitions: 1. Incident- An event involving a patient that is not consistent with the routine care... 2. Patient Safety Event- An incident or condition that could have resulted or did result in harm to a patient... Procedure: ...2. Communication a. Notify the Clinical Supervisor. b. Notify the patient’s physician or licensed practioner... 4. Documentation a. A confidential incident report will be completed electronically prior to the end of the shift by the staff member that witnessed the incident... b. Ensure the medical record is accurate and complete regarding objective information related to the incident and any follow-up medical care or treatment. 1. PI # 3 was admitted to the hospital on 11/29/25 with a primary diagnosis of Respiratory Failure. PI # 3 expired on 1/19/26 at 12:40 AM, thirty minutes after being found sitting on the floor beside the bed. Discharge planning was in progress at the time of the fall. Review of the physician’s orders revealed an order dated 12/5/25 for Heparin (anticoagulant) 5000 units injected subcutaneously every eight hours. Further review of the physician’s orders revealed an order for a sitter at the bedside dated 12/22/25 at 12:48 AM for suicide risk and an order for suicide precautions. Both of these orders were discontinued on 12/25/25 at 4:49 AM. Review of the MR revealed no documentation of a sitter until 12/22/25 at 8:00 AM, which was seven hours and twelve minutes after the physician’s order for a sitter. Further review of the medical record revealed no documentation of a sitter as follows: 12/22/25 at 8:00 PM until 12/23/25 at 4:16 AM 12/23/25 at 4:16 AM until 12/23/25 at 3:00 PM 12/24/25 at 4:45 AM until 12/24/25 at 7:00 PM Medical record review revealed on 12/24/25 at 10:27 AM the nurse caring for PI # 3 documented, “Patient will not stop attempting to get out of bed.” and at 1:12 PM, “Patient is in restraints and still managing to pull off leads and take off his oxygen. This patient is suppose to have a “sitter,” we don’t have the staff for one. I am constantly having to go in the patients room, literally every 5 minutes. Redirecting does not help.” Review of the hospital Incident Report Log revealed PI # 3 fell on 1/15/26 at 2:30 PM. Review of the MR revealed no documentation of the fall, no documentation of a post fall assessment and post fall vital signs and neuro-vascular checks, and no documentation the physician, on-call administrator, and/or family were notified of the fall. Review of the plan of care revealed no documentation previous strategies to prevent falls were evaluated until 1/16/26 at 11:50 AM. There is no documentation a new plan to prevent falls was developed. Further review of the hospital Incident Report Log revealed PI # 3 experienced a second fall on 1/19/26 at 12:10 AM. Incident Report documentation revealed at 12:10 AM the patient was found sitting on the floor beside the bed and was assisted back to bed. The MR revealed on 1/18/26, PI # 3 was alert, oriented, ambulatory, and ready for discharge pending placement to a skilled nursing or rehabilitation facility. Review of the MR revealed no documentation of the fall on 1/19/26, no documentation the physician, on-call administrator, and/or family were notified of the fall, and no documentation of a post fall assessment, vital signs, and neuro-vascular checks per the hospital policy. MR review revealed no documentation of the patient’s vital signs, care provided post fall, and no documentation of PI # 3’s status from the time of the fall leading up to death, 30 minutes later. There was no objective information documented related to the patient death, name of the physician or on-call supervisor notified of the death, or time the body was released. The medical record did include a Record of Death documenting PI # 3 expired on 1/19/26 at 12:40 AM. PI # 3 expired thirty minutes after being found on the floor. An interview was conducted on 1/28/26 at 9:12 AM with Employee Identifier (EI) # 2, Registered Nurse, who stated, “...after (PI # 3) was assisted back to bed, he/she started to breath very heavily.” EI # 2 stated no Rapid Response was called and care was not escalated. An interview was conducted on 1/29/26 at 3:15 PM with EI # 1, Chief Nursing Officer, who confirmed staff failed to follow the hospital policy for falls, incident reporting, and notification of falls and/or patient death to the physician and/or on-call administrator. EI # 1 also confirmed staff failed to follow a physician’s order for a sitter at the bedside of a patient on suicide precautions. 2. PI # 1 was admitted to the hospital on 9/16/25 with diagnoses including Wound, Ulcerative Colitis Flare, and Severe Protein Calorie Malnutrition. Review of the hospital Incident Report Log revealed PI # 1 fell on 9/17/25 at 2:00 PM. Review of the MR revealed no documentation of the fall, no documentation the physician, on-call administrator, or family were notified of the fall, and no documentation of a post fall assessment and post fall vital signs as directed in the hospital policy. Review of the plan of care revealed no documentation of a fall risk assessment with fall prevention interventions developed until 9/19/25 at 1:03 AM. An interview was conducted on 1/30/26 at 12:02 PM with EI # 1, who confirmed staff failed to follow the hospital policy for falls, incident reporting, and notification regarding the fall to the physician, on-call administrator, or family. 3. PI # 2 was admitted to the hospital on 12/1/25 with a primary diagnosis of Respiratory Failure. Review of the physician’s orders revealed an order dated 12/1/25 for Eliquis 5 mg twice daily. Review of the hospital Incident Report Log revealed PI # 2 fell on 1/9/25 at 9:15 AM. Review of the MR revealed no documentation of the fall, no documentation of a post fall assessment and post fall vital signs and neuro-vascular checks as directed in the hospital policy, and no documentation the physician, on-call administrator, and/or family were notified of the fall. Review of the plan of care revealed no documentation previous strategies to prevent falls were evaluated until 1/10/26 at 1:10 AM. There is no documentation a new plan to prevent falls was developed. An interview was conducted on 1/29/26 at 2:47 PM with EI # 1, who confirmed staff failed to follow the hospital policy for falls, incident reporting, and notification regarding the fall to the physician, on-call administrator, and/or family and failed to modify the patient’s care plan.”

“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: 49894 Based on review of medical records (MR), policy and procedure, and staff interview it was determined the hospital failed to modify the patient’s plan of care for the use of restraints per the hospital policy. This affected Patient Identifiers (PI) # 1, PI # 2, and PI # 3, three of three MRs reviewed of patients with restraints and had the potential to negatively affect all patients with restraints served by the hospital. Findings include: Hospital Policy: Restraints and Seclusion Policy Number: R02-N Revision Date: 10/1/24 ...Purpose: To keep the patient safe... ...Procedure: Medical Record Documentation and Plan of Care: ...Modification of the patient’s treatment plan related to restraint use, patient’s response to restraint, and plan for reduction/elimination is included in the patient’s medical record. Interdisciplinary Team Member documentation must: ...State plan of care (at implementation and daily) 1. PI # 1 was admitted to the hospital on 9/16/25 with diagnoses including Wound, Ulcerative Colitis Flare, and Severe Protein Calorie Malnutrition. Review of the physician’s orders revealed orders dated 9/16/25 at 11:33 PM, 9/17/25 at 1:40 AM, and 9/17/25 at 9:42 AM for Restraint, non-violent or non-self destructive, Right Mitten, untied, and Left Mitten, untied, for interference with medical treatment. Review of the patient’s plan of care revealed there was no documentation the care plan was modified to include the use of restraints until 9/19/25 at 1:03 AM. Further review of the physician’s orders revealed orders dated 9/23/25 at 12:51 AM, 9/23/25 at 4:41 PM, 9/24/25 at 12:39 AM, and 9/24/25 at 7:18 PM for Restraint, non-violent or non-self destructive, Right Mitten, tied, and Left Mitten, tied, for interference with medical treatment. Review of the patient’s plan of care revealed no documentation the care plan was modified to include the restraints now being tied. An interview was conducted on 1/30/26 at 1:25 PM with Employee Identifier (EI) # 1, Chief Nursing Officer, who confirmed staff failed to modify the patient’s care plan for the use of restraints per hospital policy. 2. PI # 2 was admitted to the hospital on 12/1/25 with a primary diagnosis of Respiratory Failure. Review of the MR revealed the following physician’s orders dated: 1/5/26 at 3:27 AM, 1/6/26 at 7:28 AM, 1/7/26 at 12:07 AM, 1/8/26 at 12:42 AM, 1/23/26 at 7:34 AM, 1/23/26 at 6:35 PM, and 1/24/26 at 1:29 AM for Restraint, non-violent or non-self destructive, soft wrist, Right, and Soft Wrist, Left, for interference with medical treatment. Review of the patient’s plan of care revealed no documentation the care plan was modified to include the use of restraints per hospital policy. An interview was conducted on 1/30/26 at 1:25 PM with EI # 1, who confirmed staff failed to modify the patient’s care plan for the use of restraints per hospital policy. 3. PI # 3 was admitted to the hospital on 11/29/25 with a primary diagnosis of Respiratory Failure. Review of the medical record revealed physician’s orders dated 12/20/25 at 12:15 AM and 12/20/25 at 1:24 PM for Restraint, non-violent or non-self destructive, soft wrist, Right, and Soft Wrist, Left, for interference with medical treatment. Review of the patient’s plan of care revealed no documentation the patient’s care plan was modified on implementation of restraints on 12/20/25. An interview was conducted on 1/30/26 at 1:25 PM with EI # 1, who confirmed staff failed to modify the patient’s care plan for the use of restraints per hospital policy.”

“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: 49894 Based on review of medical records (MR), policy and procedure, and staff interviews, it was determined the hospital failed to ensure staff monitored restrained patients every two hours. This affected Patient Identifiers (PI) # 1 and PI # 2, in two of three MRs reviewed with restraints and had the potential to negatively affect all restrained patients served by the hospital. Findings include: Hospital Policy: Restraints and Seclusion Policy Number: R02-N Revision Date: 10/1/24 Purpose: ...To keep the patient safe... Policy: ...Restraint is used ONLY to meet the patient’s individual clinical needs. Restraint must be the least restrictive intervention that protects the patient’s safety...This must be demonstrated by patient care staff through their documentation. Procedure: ...Medical Record Documentation and Plan of Care: Every use of restraint is to be documented in the patient’s record. At a minimum, documentation must include: The alternatives tried prior to restraint use, the justification for restraint, the patient assessment that demonstrates the need for restraint as part of the patient’s treatment, a time limited order by a physician or licensed practioner, evidence of monitoring the patient’s condition during restraint, demonstration of the need for continuing restraint beyond the initial order or the satisfaction of criteria for release. Modification of the patient’s treatment plan related to restraint use, patient’s response to restraint, and plan for reduction/elimination is included in the medical record. Interdisciplinary Team Member documentation must: ...State observations/interventions/findings from periodic observations, to include: safety, comfort, mobility, skin integrity, food/hydration, toileting, removal of restraints for at least ten minutes every two hours or more often (observations every two hours for medical restraints and every fifteen minutes for behavioral restraints). 1. PI # 1 was admitted to the hospital on 9/16/25 with diagnoses including Wound, Ulcerative Colitis Flare, and Severe Protein Calorie Malnutrition. Review of the physician’s order revealed an order dated 9/17/25 at 1:40 AM, and 9/17/25 at 9:42 AM for Restraint, non-violent or non-self destructive, Right Mitten, untied, and Left Mitten, untied, for interference with medical treatment. Review of restraint monitoring revealed no documentation the patient was monitored every two hours from 9/17/25 at 4:00 PM until the restraints were discontinued on 9/18/25 at 1:36 AM. An interview was conducted on 1/30/26 at 1:25 PM with Employee Identifier (EI) # 1, Chief Nursing Officer, who confirmed staff failed to monitor a restrained patient every two hours per hospital policy. 2. PI # 2 was admitted to the hospital on 12/1/25 with a primary diagnosis of Respiratory Failure. Review of the physician’s order revealed orders dated 1/15/26 at 6:26 PM and 1/16/26 at 12:35 AM for Restraint, non-violent or non-self destructive, Right Mitten, tied, and Left Mitten, tied, for interference with medical treatment. Review of restraint monitoring revealed the restraints were placed on the patient on 1/15/26 at 7:01 PM. There was no documentation every two hour monitoring from 1/15/26 at 7 :01 PM to 1/16/26 at 8:00 AM. An interview was conducted on 1/29/26 at 2:47 PM with EI # 1, who confirmed staff failed to monitor a restrained patient every two hours per hospital policy.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 49894 Based on review of medical records (MR), Incident Report log, incident report documentation, policy and procedure, and staff interview, it was determined the hospital failed to ensure staff: 1. Notified the physician of patient falls. 2. Notified the physician of a patient death. 3. Documented patient falls and/or death in the medical record. 4. Conducted and documented post-fall assessments according to the hospital policy. 5. Followed the hospital policies for patient incidents/events and fall reduction. This affected Patient Identifiers (PI) # 3, PI # 1, and PI # 2, in three of three MRs reviewed and had the potential to affect all patients served by the facility. Findings include: Hospital Policy: Fall Reduction Program Policy Number: F02-G Revision Date: 1/26 ...Policy... E. Post Fall Assessment and Revision to Plan of Care ...b. Notify the Physician (with complete assessment information), Administrator on call, and family. Hospital Policy: Incident Reporting and Sentinel Events Policy Number: 200-QM Issue Date: 1/1/26 Purpose: 1. To contribute to the promotion of a safe environment for all occupants of the Hospital... Definitions: 1. Incident- An event involving a patient that is not consistent with the routine care... 2. Patient Safety Event- An incident or condition that could have resulted or did result in harm to a patient... Procedure: ...2. Communication a. Notify the Clinical Supervisor. b. Notify the patient’s physician or licensed practioner... 4. Documentation a. A confidential incident report will be completed electronically prior to the end of the shift by the staff member that witnessed the incident... b. Ensure the medical record is accurate and complete regarding objective information related to the incident and any follow-up medical care or treatment. 1. PI # 3 was admitted to the hospital on 11/29/25 with a primary diagnosis of Respiratory Failure. PI # 3 expired on 1/19/26 at 12:40 AM, thirty minutes after being found sitting on the floor beside the bed. Discharge planning was in progress at the time of the fall. Review of the MR revealed PI # 3 was alert, oriented, ambulatory, and ready for discharge pending placement at a skilled nursing or rehabilitation facility. Review of the hospital Incident Report Log revealed PI # 3 fell on 1/15/26 at 2:30 PM. Review of the MR revealed no documentation of the fall and no documentation the physician, on-call administrator, and/or family were notified of the fall. Further review of the hospital Incident Report Log revealed PI # 3 had a second fall on 1/19/26 at 12:10 AM. Review of the incident report documentation revealed at 12:10 AM the patient was found sitting on the floor beside the bed and was assisted back to bed. Review of the MR revealed no documentation of the fall, no post fall assessment or vital signs, and no documentation the physician, on-call administrator, or family were notified of the fall. The medical record did include a Record of Death documenting PI # 3 expired on 1/19/26 at 12:40 AM. PI # 3 expired thirty minutes after being found on the floor. There was no documentation of the patient status from the time of the fall to the patient’s death at 12:40 AM. An interview was conducted on 1/28/26 at 9:12 AM with Employee Identifier (EI) # 2, Registered Nurse, who stated, “...after (PI # 3) was assisted back to bed, he/she started to breath very heavily.” EI # 2 stated no Rapid Response was called and care was not escalated. An interview was conducted on 1/29/26 at 3:15 PM with EI # 1, Chief Nursing Officer, who confirmed staff failed to follow the hospital policy for falls, incident reporting, and notification regarding falls and patient death to the physician, on-call administrator, and/or family. 2. PI # 1 was admitted to the hospital on 9/16/25 with diagnoses including Wound, Ulcerative Colitis Flare, and Severe Protein Calorie Malnutrition. Review of the hospital Incident Report Log revealed PI # 1 fell on 9/17/25 at 2:00 PM. Review of the MR revealed there was no documentation of the fall, and no documentation the physician, on-call administrator, or family were notified of the fall. An interview was conducted on 1/30/26 at 12:02 PM with EI # 1, who confirmed staff failed to follow the hospital policy for falls, incident reporting, and notification regarding the fall to the physician, on-call administrator, and/or family. 3. PI # 2 was admitted to the hospital on 12/1/25 with a primary diagnosis of Respiratory Failure. Review of the hospital Incident Report Log revealed PI # 2 fell on 1/9/26 at 9:15 AM. Review of the MR revealed there was no documentation of the fall and no documentation the physician, on-call administrator, and/or family were notified of the fall. An interview was conducted on 1/29/26 at 2:47 PM with EI # 1, who confirmed staff failed to follow the hospital policy for falls, incident reporting, and notification regarding the fall to the physician, on-call administrator, and/or family.”