Encompass Rehabilitation Hospital of Montgomery

“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: 30952 Based on review of medical records, facility Nursing Protocol, facility policy, Grievance Log documentation, and staff interviews it was determined the Governing Body failed to ensure compliance with the Conditions of Participation for hospitals was maintained, patient rights were protected, and quality patient care was provided in a safe manner. These deficient practices had the potential to negatively affect all patients served by the hospital. Refer to A-0118, and A-0392 for findings.”

“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: 30952 Based on review of medical records (MR), and staff interviews, it was determined the facility failed to ensure nursing staff provided care according to the facility Nursing Hypotension Protocol and Physician Orders, obtained Physican Orders for care, and documented care provided. This affected Patient Identifiers (PI) # 9, PI # 3, PI # 4, PI # 1, in four (4) of 10 (ten) MRs reviewed and had the potential to affect all patients served by the facility. Refer to A-0392 for findings.”

“PATIENT RIGHTS: 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. This Standard is not met as evidenced by: 49797 Based on a review of the facility’s grievance log, facility policy, complaint investigation documentation, and staff interview, it was determined the facility staff failed to ensure all complaints received were: 1. Documented in the facility grievance log to be tracked and trended. 2. Investigated completely with investigation documentation. This deficient practice affected one of two grievance Medical Records (MR) reviewed to include Patient Identifier (PI) # 1 and had the potential to affect all patients served by this facility. Findings include: Facility policy: Patient and Customer Complaint or Grievance. Policy number: 8 Policy review date: 8/27/25 Purpose: To establish guidelines for the hospital to follow in the development of hospital-specific complaint and grievance processes requirements... Policy: ... All complaints must be recorded in the hospital complaint system (ecalm). The case must include: *Date received *Nature of complaint *Who responded *Action taken *Date of resolution... Patient Grievances-Actions to be taken... 1. Staff will document all communications with the patient and/or patient’s representative. The staff will include the date, time and a summary of the conversation. 2. Hospital Chief Executive Officer (CEO) or designee must initiate an investigation... 3. A written communication must be sent to the patient (or patient’s legal representative), even if either method of communication are used (such as a family meeting). On average, the written response should be complete within seven calendar days of receipt of the grievance... 4. If the hospital CEO or designee determines the investigation is not or will not be completed within seven calendar days, he/she must provide the patient/family of a verbal progress note... 1. PI # 1 was admitted to the facility on 1/16/26 with diagnoses of Chronic Obstructive Pulmonary Disease and Vancomycin Resistant Enterococci Urinary Tract Infection. On 2/4/26 the facility’s grievance log was requested by the surveyor. There was no documentation a grievance had been filed prior to 1/30/26 regarding PI # 1. An interview was conducted on 2/5/26 at 1:57 PM with Employee Identifier (EI) # 8, Case Manager, who reported the caregiver of the patient had voiced a complaint regarding the use of the Bilevel Positive Airway Pressure (BiPAP) (a non invasive ventilator used to assist breathing) and EI # 8 asked the caregiver if they would like to file a grievance. The caregiver responded, no, one had already been filed. EI # 8 was unsure of the date when this conversation occurred. An interview was conducted on 2/6/26 at 10:20 AM with EI # 12, House Supervisor, who reported another staff member asked him/her to follow up with the staff due to complaints voiced by caregivers regarding the use of the BiPAP. EI # 12 was unsure of the date when this conversation occurred. An interview was conducted on 2/6/26 at 10:56 AM with EI # 14, Registered Nurse (RN), who reported on 1/23/26 the caregiver was at the nurse’s desk yelling, “No one is doing anything” and EI # 13, Educator, had to calm them down. EI # 14 stated she/he reported this to EI # 12. There was no documentation of a grievance following the 1/23/26 complaint. An interview was conducted on 2/6/26 at 11:07 AM with EI # 1, Chief Nursing Officer, who reported she/he had a conversation with the caregiver on 1/23/26 regarding a complaint. EI # 1 reported EI # 5, CEO had been called by PI # 1’s caregiver and then asked EI # 1, to call the caregiver back. EI # 1 was asked if a complaint was entered into the grievance log (ecalm) and EI # 1 responded, “Very possible that it is not.””

“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: 30952 Based on review of medical records (MR), and staff interviews, it was determined the facility failed to ensure staff: 1. Followed the Nursing Services Protocol for Hypotension (abnormally low blood pressure [BP]). 2. Followed Physician Orders and performed neuro (neurological) checks every (q) 2 (two) hours. 3. Followed Physician Orders for Orthostatic Vital Signs (measuring heart rate and blood pressure while lying, sitting, and standing to identify Orthostatic hypotension) or tachycardia (increase in heart rate). 4. Followed Physician Orders for Wound Team Consultation, Evaluation/Treat. 5. Followed Physician Orders for application of a Below the Knee Intermittent Pneumatic Compression Device (medical apparatus used to improve blood circulation and reduce swelling by applying external pressure to limbs using inflatable sleeves or garments). 6. Performed midline catheter site care as ordered by the physician. 7. Obtained a physician’s order for Bilevel Positive Airway Pressure (BiPAP) (a non invasive ventilator used to assist breathing) prior to patient use. 8. Documented the patient’s use of the BiPAP in the nursing IView on 1/21/26, 1/22/26 and 1/23/26. This affected Patient Identifiers (PI) # 9, PI # 3, PI # 4, PI # 1, in four (4) of 10 (ten) MRs reviewed and had the potential to affect all patients served by the facility. Findings include: 1. PI # 9 was admitted to the facility on 11/7/25 with a diagnosis of Cerebrovascular Accident, and expired (died) 12/1/25 at 12:10 AM. MR review revealed a Nursing Services Protocol for Hypotension, dated 11/26/25 at 9:40 AM, that included the following: ...3. Obtain vital signs (vs) NOW and every 2 (two) hours (hrs.) for 6 (six) hrs., then every 4 (four) hrs. for a total of 24 hours... Review of the MR documentation revealed the physician was notified the BP was 80/40 (low) on 11/26/25 at 9:45 AM. Further record review revealed vs were documented on 11/26/25 at 10:58 AM, at 2:34 PM, and 6:24 PM, and not every 2 hrs. for 6 hrs. per the Hypotension Protocol. Review of the record revealed the next vs were documented on 11/27/25 at 6:02 AM and at 6:20 PM, and not every 4 hrs. for 24 hrs. per the Hypotension Protocol. Staff failed to follow the Hypotension Protocol for vs checks. Review of the record revealed Physician Orders dated 11/26/25 at 10:59 AM for Neuro Checks every 2 hrs. and discontinue 12/1/25 at 1:16 AM. Record review revealed documentation of “neuro assessments” were performed and documented greater than every 2 hrs. On 11/26/25 from 2:55 PM to 6:21 PM. On 11/26/25 from 11:00 PM to 11/27/25 at 8:00 AM. On 11/27/25 from 8:00 AM to 7:27 PM. On 11/28/25 from 7:40 AM to 11:28 AM, and 3:54 PM to 9:09 PM. An interview was conducted on 2/6/26 at 2:00 PM with Employee Identifier (EI) 13, Educator, who confirmed staff failed to follow the Hypotension Protocol and Physician Orders for neuro checks. 2. PI # 3 was admitted to the facility on 1/20/26 at 8:10 PM with a diagnoses of Encephalopathy secondary to Congestive Heart Failure, and Respiratory Failure. Record review revealed Physician Orders dated 1/20/26 at 9:18 PM for Orthostatic Vital Signs, discontinue on 1/29/26 7:42 PM. Review of the MR revealed no Orthostatic Vital Signs were documented as ordered. An interview was conducted on 2/6/26 at 2:35 PM with EI # 13, who confirmed no Orthostatic Vital Signs were documented. 3. PI # 4 was admitted to the facility on 1/14/26 with a diagnosis of Metabolic Encephalopathy. Record review revealed Physician Orders dated 1/15/26 for Coccyx Wound Care twice daily, Left Arm wound care every 5 days, Consult Wound Team-Evaluate and Treat, and (apply) Below the Knee Intermittent Pneumatic Compression Device. Review of the MR revealed no documentation the Wound Team Consult to Evaluate/Treat was performed and no documentation the Below the Knee Intermittent Pneumatic Compression Device was applied. An interview was conducted on 2/6/26 at 2:40 PM with EI # 13, who confirmed there was no Wound Team Consult and no documentation staff applied the Intermittent Compression device. 49797 4. PI # 1 was admitted to the facility on 1/16/26 with diagnoses of Chronic Obstructive Pulmonary Disease and Vancomycin Resistant Enterococci Urinary Tract Infection. Review of the MR revealed at 9:29 AM on 1/19/26 a physician’s order was written for BiPAP to be placed on the patient daily at bedtime. On 1/23/26 a physician’s order for midline catheter site care every 96 hours. Further review of the MR revealed the nurse documented the BiPAP in the IView (clinicians’ note) on 1/18/26 at 7:47 PM prior to the order. There was no documentation of the patient use of the BiPAP in the nursing IView on 1/21/26, 1/22/26 and 1/23/26 and no documentation the midline catheter site care was performed during the patient stay 1/23/26 to 1/30/26. An interview was conducted on 2/6/26 at 2:16 PM with EI # 13, who confirmed the there was no order for the BiPAP on 1/18/26, the staff failed to perform the midline catheter site care as ordered, and there was no documentation of the BiPAP use for the dates listed above.”

“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, facility policy and interview, it was determined the facility failed to ensure the Skilled Nurse (SN) provided wound care as ordered by the physician. This deficient practice affected three of four MR’s reviewed with wounds, including Patient Identifier (PI) # 3, PI # 6, and PI # 2, and had the potential to affect all patients served by this facility. Findings include: Facility Policy: Wound Assessment and Documentation Policy Number: 2 Last Reviewed Date: 08/28/2024 Policy: ...V. Responsibilities: ...5. Nursing and therapy staff provide wound care as ordered via protocol or physician order. 1. PI # 3 was admitted to the facility for rehabilitation services on 3/4/25 following a Large Acute Left Parietal Intraparenchymal Hemorrhage (a stroke due to bleeding on the brain). Review of the MR revealed PI # 3 had a pressure injury to the coccyx at the time of his/her admission that was evaluated by the facility Wound Care Program Director (WCPD) on 3/5/25 at 3:14 PM. The WCPD documented the wound was an unstageable Deep Tissue Injury (DTI) measuring six centimeters (cm) in length, 2.5 cm in width, and 0.2 cm in depth. A physician order was written on 3/5/25 at 3:44 PM to clean the wound to the coccyx with soap and water, apply orange cap barrier cream, (identified as zinc oxide during an interview with the WCPD), and place a foam dressing over the sacrum every other day and when soiled. Review of the SN wound care documentation revealed the following: 3/7/25 - no zinc oxide ointment was applied. 3/10/25 - no wound care was provided after last being provided 3/8/25. 3/11/25 - no zinc oxide ointment was applied. 3/13/25 - not cleaned with soap and water, no foam dressing applied. The SN failed to provide wound care as currently ordered. Further review of the MR revealed a new physician order for wound care dated 3/18/25 at 11:14 AM to cleanse the coccyx with soap and water, apply Triad Ointment and cover with sacral foam every other day and when soiled. Review of the SN wound care documentation revealed the following: 3/20/25 - no wound care was provided after last being provided 3/18/25. 3/21/25 - no wound care was provided after last being provided 3/18/25. 3/22/25 - no wound care was provided after last being provided 3/18/25. The SN failed to provide wound care as currently ordered. Further review of the MR revealed a new physician order for wound care dated 3/23/25 at 5:58 PM to cleanse the coccyx with soap and water, apply Santyl Ointment and cover with wet to damp dressing twice daily. Review of the SN wound care documentation revealed the following: 3/23/25 PM - no wet to damp dressing was applied. 3/24/25 AM - no Santyl Ointment was applied. 3/25/25 AM - no wound care was provided. 3/25/25 PM - no Santyl Ointment was applied. The SN failed to provide wound care as currently ordered. An interview was conducted on 4/10/25 at 5:11 PM with Employee Identifier (EI) # 1, Regional Associate Chief Nursing Officer, who confirmed the SN failed to provide wound care as ordered by the physician. 2. PI # 6 was admitted to the facility for rehabilitation services on 2/6/25 following Thoracentesis and Pneumonia. Review of the MR revealed PI # 6 had a pressure injury to the sacrum, present on admission, that was evaluated by the facility WCPD on 2/7/25 at 10:01 AM. The WCPD documented the wound was a stage three sacral area pressure injury (SAPI) measuring 3 cm in length, 2.5 cm in width, and 0.8 cm in depth. A physician order was written on 2/7/25 at 11:37 AM to clean the SAPI with soap and water, apply Santyl Ointment to the wound bed, and cover with wet to damp dressing BID (twice daily). Review of the SN wound care documentation revealed the following: 2/7/25 PM - no wound care was provided after last being provided 2/7/25 AM. 2/8/25 AM - no wet to damp dressing applied. 2/10/25 AM - no wound care was provided after last being provided 2/9/25 PM. 2/10/25 PM - no Santyl Ointment was applied to the wound bed. 2/11/25 PM - no wound care was provided after last being provided 2/11/25 AM. The SN documented the SAPI was open to air. 2/13/25 PM - no wound care was provided after last being provided 2/13/25 AM. 2/14/25 AM - no wound care was provided after last being provided 2/13/25 AM. 2/15/25 PM - no documentation what specific wound care the SN provided. 2/16/25 AM - no Santyl Ointment was applied to the wound bed. The SN documented Plurogel was utilized. There was no order for Plurogel. 2/16/25 PM - no wound care was provided after last being provided 2/16/25 AM. 2/17/25 PM - no wound care was provided after last being provided 2/17/25 AM. The SN failed to provide wound care per the physician order. An interview was conducted on 4/10/25 at 5:35 PM with EI #1, who confirmed the SN failed to provide wound care as ordered by the physician. 46290 3. PI # 2 was admitted to the facility on 4/3/25 with diagnoses including Critical Illness Myopathy and Polyneuropathy, Recent Right Above Knee Amputee and Left Below Knee Amputee. Review of the MR revealed PI # 2 had a SAPI present at the time of his/her admission and was evaluated by the facility WCPD on 4/4/25 at 2:56 PM. The WCPD documented the wound was an unstageable DTI measuring five cm in length, and 10 cm in width. Further review of the MR revealed a physician order dated 4/4/25 to clean the SAPI with sterile saline and dry, BID. Review of the SN wound care documentation of the SAPI revealed the following: 4/4/25 PM - No wound care was documented. 4/5/25 AM - Ointment was documented. There was no order for ointment. 4/5/25 PM - No wound care was documented. 4/6/25 AM - “Changed ointment (Santyl), ABD (abdomen) pad.” There was no order for Santyl or ABD pad. 4/6/25 PM - “Changed gauze dressing, Santyl ointment ABD pad.” There was no order for gauze dressing, Santyl or ABD pad. 4/7/25 AM - “Changed gauze dressing, Santyl, ABD pad.” There was no order for gauze dressing, Santyl or ABD pad. The SN failed to provide wound care as ordered. An interview was conducted on 4/10/25 at 5:42 PM with EI # 1, who confirmed the staff failed to follow the physician wound care orders.”