North Alabama Specialty Hospital

“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: 41624 Based on medical record (MR) reviews, hospital policy and procedure, and staff interview 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. Findings include: Refer to A 166, A 175 and A 1133.”

“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: 41624 Based on medical record (MR) reviews, hospital policy and procedure, and staff interview it was determined the hospital failed to document a written modification to the patient’s Plan of Care (POC) with the use of restraints. This deficient practice affected one of one MR’s reviewed for restrained patients including Patient Identifier (PI) # 1, and had the potential to affect all patients restrained at this hospital. Findings include: Hospital Policy: Caring for the Patient in Restraints and Seclusion. Policy Number: None Last Revised: December 2023 I. Purpose A. To provide information and guidelines on the use of Non-Violent, Non-Self Destructive and Violent, Self Destructive restraint or seclusion that promotes the patient’s rights, dignity and wellbeing... II. Definitions A. A restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely... IV. Procedure for Non-Violent, Non-Self Destructive Restraint ...L. Initiate and maintain documentation in the MR at least every two hours and modify the patient’s care plan as appropriate. 1. PI # 1 was admitted on 12/15/25 with a diagnosis of Cellulitis of Right Lower Limb, and discharged to a skilled nursing facility on 1/5/26. Review of the Nursing Plan of Care dated 12/15/25 revealed Care Plans including: a. Impaired Physical Mobility due to functional limitation with walking, transfer and bed mobility. Also for generalized weakness and pain/discomfort. b. Self-Care Deficit with bathing, grooming, eating and dressing. c. Risk for Unstable Blood Glucose. d. Altered Urine Elimination due to indwelling catheter. e. Discharge Planning Needs related to wound care needs, kidney and cardiac medications. Review of the Restraint Order Sheet dated 12/19/25 at 11:15 AM revealed a telephone order for restraint. Reasons documented for restraint were to prevent injury of self and attempting to remove foley catheter and IV (intravenous) - peripheral or central. Review of the Nursing Narrative Note dated 12/19/25 at 11:15 AM revealed the nurse documented PI # 1 was attempting to get out of bed unassisted despite verbal redirection, and soft wrist restraints were applied per physician order to maintain patient safety. Further review of the Care Plan revealed no updates to the Care Plan after application of the restraints on 12/19/25. An interview was conducted on 3/20/26 at 6:05 PM with Employee Identifier # 1, Director of Quality, who confirmed there were no changes or modifications made to the Care Plan per policy after the application of restraints on 12/19/25.”

“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: 41624 Based on medical record (MR) review, policy and procedure, and staff interviews, it was determined the hospital failed to ensure staff monitored restrained patients every two hours per policy. This affected Patient Identifier (PI) # 1, one of one MRs reviewed with restraints and had the potential to negatively affect all restrained patients served by this hospital. Findings include: Hospital Policy: Caring for the Patient in Restraints and Seclusion. Policy Number: None Last Revised: December 2023 I. Purpose A. To provide information and guidelines on the use of Non-Violent, Non-Self Destructive and Violent, Self Destructive restraint or seclusion that promotes the patient’s rights, dignity and wellbeing... II. Definitions A. A restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely... E. Qualified members of hospital staff - Those staff that, after completing required training on restraint and seclusion, are authorized to apply the intervention of restraint...monitor, assess, or provide care for a patient in restraint... VI. Procedure for Non-Violent, Non-Self Destructive Restraint B. Provider or RN (Registered Nurse) orders non-violent restraint. The order is valid per restraint episode, no matter the time frame. ...J. The nurse (RN or LPN) (Licensed Practical Nurse) assesses and documents patient’s clinical condition including but not limited to mental status, circulation, condition of limbs, skin integrity, and VS (vital signs) (Blood Pressure, Pulse, Respirations, Oxygen Saturation, Temperature), ROM (range of motion), and turning/repositioning at least every 2 hours and PRN (as needed) using observation, interaction with the patient, or direct examination. ...L. Initiate and maintain documentation in the MR at least every two hours and modify the patient’s care plan as appropriate. ...R. Restraint monitoring is documented at least every 2 hours, and includes the following: 1. Reason for non-violent restraint. 2. Behavior requiring non-violent restraint that justifies reason for non-violent restraint. 3. ROM 4. Nutrition/hydration/elimination and hygiene. 5. D/C (discontinue) readiness attempts. 6. Position change. 7. Correct application of restraint including any adverse events related to restraint application if applicable. 8. Mental status. 9. Integumentary (skin). 10. Restraint neuromuscular/extremity sensation. 1. PI # 1 was admitted on 12/15/25 with a diagnosis of Cellulitis of Right Lower Limb and discharged to a skilled nursing facility on 1/5/26. Review of the Restraint Order Sheet dated 12/19/25 at 11:15 AM revealed a telephone order for restraint. Reasons documented for restraint were to prevent injury of self and attempting to remove foley catheter and IV (intravenous) - peripheral or central. Review of the MR revealed PI # 1 remained in wrist restraints from 12/19/25 to 12/29/25. Review of the Restraint Management Documentation Forms from 12/19/25 to 12/29/25 revealed there was no documentation PI # 1 was assessed for safety and physical needs every two hours per policy on the following dates and times: 12/22/25 - 7:00 AM to 6:00 PM. 12/23/25 - 7:00 AM to 6:00 PM. 12/27/25 - 11:00 AM to 6:00 PM PI # 1 was not assessed every two hours while in restraint per policy. An interview was conducted on 3/20/26 at 6:05 PM with Employee Identifier # 1, Director of Quality, who confirmed the staff did not follow the hospital’s policy for reassessment of patients while in restraints.”

“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: 41624 Based on medical record (MR) review, hospital policies and interview with staff, it was determined the hospital failed to ensure wounds were measured and assessments documented per hospital policy. This deficient practice affected Patient Identifier (PI) # 3, one of three MRs reviewed with wounds, and had the potential to affect all patients with wounds at this hospital. Findings include: Hospital Policy: Standard Skin Care - Wounds/Pressure Injuries Policy Number: None Effective Date: April 2025 ...VI. Documentation ...E. Wound measurements are completed weekly, PRN (as needed), or per provider order. Hospital Policy: Turn Team Policy Policy Number: None Date Last Revised: May 2025 ...V. Documentation ...C. Wound Care Nurse: ...3. Patients with wounds...each wound will have its own wound care documentation form to track progress (to include but not limited to: size, drainage present...Records will be placed in the patient’s MR... 1. PI # 3 was admitted to the hospital on 12/24/25 with a diagnosis of Unspecified Open Wound Left Foot, Sequelae, and discharged home on 1/21/26. Review of the MR revealed PI # 3 had five wounds to his/her bilateral lower extremities. Review of the weekly wound assessments dated 12/30/25, 1/8/26, 1/12/26 and 1/19/26 revealed no documentation of measurements for the five wounds. Further review revealed there was no documentation of the presence or absence of drainage by the wound care staff on 12/30/25, 1/8/26, or 1/19/26. Wound care staff failed to document the assessments of PI # 3’s wounds per policy. An interview was conducted on 3/20/26 at 4:50 PM with Employee Identifier (EI) # 1, Director of Quality, and EI # 3, Chief Clinical Offier, who confirmed wound care staff did not measure the wounds weekly per policy, nor document the presence or absence of wound drainage per policy.”

“DELIVERY OF SERVICES CFR(s): 482.56(b)(1) All rehabilitation services orders must be documented in the patient’s medical record in accordance with the requirements at §482.24. This Standard is not met as evidenced by: 41624 Based on medical record (MR) review, hospital polices and procedures and interview, it was determined the hospital failed to ensure: 1. Initial therapy evaluations were performed as ordered. 2. Therapy was provided per ordered frequency. This deficient practice affected two of three MRs reviewed with therapy, including Patient Identifier (PI) # 1 and PI # 3, and had the potential to affect all patients requiring therapy at this hospital. Findings include: Hospital Policy: Initial Therapy Evaluation Policy Number: None Effective Date: 02/2024 Policy: Every patient will be seen and evaluated within 3 business days of admission by Physical and Speech Therapy services... Procedure: ...2. The appropriate therapists will perform initial evaluation within 3 business days of admission. If deemed appropriate for skilled therapy, an appropriate POC (plan of care) will be implemented. Hospital Policy: Therapist Duties Policy Number: None Effective Date: 02/2024 Policy: Therapist(s) will evaluate and provide therapy to patients based on individual deficits and needs. Only licensed therapist with appropriate credentials shall deliver and oversee delivery of therapeutic interventions as indicated within POC. Hospital Policy: Therapist Treatments Policy Number: None Effective Date: 02/2024 Policy: To carry out treatment plan as outlined in the initial evaluation. Procedure: 1. Therapy treatments will be provided Monday through Friday excluding holidays.. Procedure: ...5. Missed treatment sessions: Therapist will attempt 3 times to complete session. If session is not completed, therapist will document reason for missed session... 1. PI # 1 was admitted on 12/15/25 with a diagnosis of Cellulitis of Right Lower Limb, and discharged to a skilled nursing facility on 1/5/26. Review of admission orders revealed an order for PT (Physical Therapy) evaluation functional screen was written on 12/15/25 at 12:45 PM. Review of the MR revealed there was no documentation a PT evaluation was performed. Continued review of physician orders revealed an order written 12/19/25 at 11:35 AM for OT (Occupational Therapy) to evaluate and treat, and a second order written 12/19/25 at 12:10 PM for OT to see PI # 1 one time a week for ADL (activities of daily living) training. Review of the MR revealed an OT visit was made on 12/19/25 and 12/29/25, which was 10 days later. No other OT visits were documented. OT failed to meet the ordered frequency of one time a week. Continued review of the MR revealed a Speech Therapy (ST) evaluation was made on 12/18/25. Further review of physician orders revealed an order written 12/19/25 at 3:00 PM for ST to treat one to three times a week to address cognitive deficits and oropharyngeal dysphagia (difficulty swallowing). Review of the ST documentation revealed a ST visit was made on 12/29/25, which was 10 days after the initial evaluation. No other ST visits were documented. ST failed to meet the ordered frequency of one to three times a week. An interview was conducted on 3/20/26 at 6:05 PM with Employee Identifier (EI) # 1, Director of Quality, who confirmed PT failed to evaluate the patient, and ST and OT failed to complete the physician ordered frequency. 2. PI # 3 was admitted to the hospital on 12/24/25 with a diagnosis of Unspecified Open Wound Left Foot, Sequelae, and discharged home on 1/21/26. Review of physician orders revealed an order written 12/29/25 at 6:35 PM for further OT one to three times a week to increase safety with ADL’s and mobility. Review of the MR revealed an OT evaluation was performed on 12/24/25. No other OT visits were documented. OT failed to meet the ordered frequency of one to three times a week. An interview was conducted on 3/20/26 at 5:50 PM with EI # 1 who confirmed OT was not provided per ordered frequency.”