Emory Long Term Acute Care

“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: 46188 Based on review of Governing Board Bylaws, policy and procedures, and interviews, it was determined that the Governing Board failed to: 1.) ensure that patient rights were promoted and protected 2.) ensure that nursing staff secured the immediate physical safety of a patient as required when one (P2) of six (P1, P2, P3, P4, P5, P6) patients reviewed suffered a fall, while in bilateral wrist restraints and mittens, on 02/11/2026 and 3.) ensure disclosure was made to P2’s guardian in a timely manner. A Patient Care Technician (PCT), unintentionally, informed P2’s guardian of the fall. Findings Included: Cross refer to A-0115 as it relates to the facility’s failure to protect Patient’s Rights to receive care in a safe setting when on one (P2) of six (P1, P2, P3, P4, P5, P6) patients reviewed suffered a fall, while in bilateral wrist restraints and mittens, on 02/11/2026. The facility failed to provide timely disclosure of the incident to P2’s guardian and promote the right to make informed decisions regarding care resulting in distrust and distress from P2’s guardian. Cross refer to A-0385 as it relates to facility’s failure to ensure that nursing staff followed policy and procedures regarding management of care for a restrained patient and disclosure of incidents following an adverse event. This failure resulted in P2 suffering avoidable pain and delayed treatment or care. A review of the facility’s “Amended and Restated Bylaws”, last approved on 02/21/2024, revealed Article Two, Board of Directors, Section 2.1., Composition: a. General Powers, Number and Election, the affairs of the Corporation will be managed by its Board of Directors. A review of the facility’s policy titled, “Disclosure of Adverse Events”, no policy number, last effective 02/19/2024, revealed that the purpose of the policy was to disclose information to patients and families of any adverse outcomes or unintended occurrences associated with treatment. Continued review of the Policy Statement revealed that the facility was committed to transparency in communications with patients recognizing their right to know all aspects of their care, treatment and service. Essential to this transparency is a commitment to truthful and prompt disclosure to patients and families of any adverse outcomes or unintended occurrences associated with treatment. Continued review revealed, Procedure: I. General Principles a. Disclosure is a process over time rather than a single event. It involves telling what is known to the patient/family in the context of ongoing care. b. Every effort should be made to ensure that communication with patient/families is carried out by a member of the health care team who has a trusting relationship with the involved patient/family. c. Many situations have immediacy, requiring decisions to be made and communication to begin urgently. d. Timeliness of communication is key to maintaining trust. f. Notification of Risk Management or nursing/physician leadership of disclosable events is essential to the ability of the facility to improve care Continued review revealed, II, Roles and Responsibilities: B. Emory Healthcare Support Staff i. Risk Manager (RM) of the entity b. Assistance with decision-making about disclosure. When uncertain, the RM will escalate the decision to the Chief Quality Officer (CQO), Chief Medical Officer (CMO), Clinical Director, and/or the Chief Nursing Officer (CNO). d. Assistance with event investigation ii. Chief Quality Officer (or CMO if CQO is not available) b. Assistance with decision-making about disclosure. When uncertain, the CNO will confer with the Clinic Director, CQO, or CMO. d. Oversight of system learning through review of events and investigations A review of the facility’s policy titled, “Falls Prevention and Management”, no policy number, effective date of 02/26/2026, revealed that the purpose of the policy was to provide identification and ongoing assessment of patients who are at risk of falling and provide resources for staff to implement fall safety interventions. Continued review revealed, Post-Fall Assessment and Interventions. Post-Fall, patients and rooms should be assessed to determine cause of fall as well as potential injuries to the patient. Post-Fall Assessment: 1. Perform a thorough assessment to determine presence of injury and reassess the fall score. 2. Assess vital signs and neurological status. Post-Fall Care Plan: 1. Ensure the patient is safe and notify the provider that the fall occurred. 2. Place patient on high-risk fall precautions. 3. Complete the post-fall huddle process and implement interventions based on the cause of the fall. Complete post fall assessments and interventions and document appropriately in the electronic medical record to reflect the patient care provided. Continued review revealed, Post-Fall Huddle: The post-fall huddle is a brief discussion that takes place with the patient and the nursing care team to establish the cause of the fall and how a similar fall can be prevented from reoccurring. The post-fall huddle should take place: 1. Once the patient is stabilized 2. At the general location where the fall occurred 3. With direct input from the patient, family, and/or staff members involved An interview was conducted on 04/02/2026 at 11:27 AM with NM GG in the conference room. NM GG said that if a patient or family member reported complaints or concerns about nursing care to NM GG, NM GG would investigate the complaint to learn more about it and then follow up with staff for resolution. NM GG said that NM GG conducts huddle education at 7:00 AM, 11:00 AM, and at 7:00 PM with staff members to address any concerns or updates with areas for improvement. NM GG said that NM GG conducts daily rounding on patients to get an idea for areas of improvement. NM GG said that if concerns involve another department, such as respiratory care, then NM GG would get that department manager involved and the same if it were wound care concerns. NM GG recalled that there have been a few general concerns voiced by family members about overall nursing care and NM GG said that staff have had a refreshment on intentional rounding with the four P’s (pain, potty or personal needs, positioning, and possession placement) in mind to help address those concerns. NM GG said that if a family voiced a concern to staff or NM GG, NM GG’s expectation is to handle it in real time. NM GG said that the physician and nurse should discuss the fall with the patient’s family member and only provide information on what occurred and what steps are upcoming, if any.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 46188 Based on a review of medical records, policies and procedures, and interviews, it was determined that the facility failed to: 1.) ensure that patient’s rights were promoted and protected and that care was received in a safe setting when one (P2) of six patients (P1, P2, P3, P4, P5, P6) reviewed suffered a fall, while in bilateral wrist restraints and mittens, on 02/11/2026 which led to P2 suffering avoidable pain while under the care of the facility; 2.) ensure timely disclosure of the fall to P2’s guardian; and 3.) ensure family participation in the decision-making process for discharge planning. Findings Included: Cross refer to A-0175 as it relates to the facility’s failure to preserve the immediate physical safety of a patient when one (P2) of six (P1, P2, P3, P4, P5, P6) patients reviewed, while in bilateral upper extremity limb restraints and mittens, suffered a fall on 02/11/2026 and was found on the ground by staff at 07:40 AM. Cross refer to A-0132 as it relates to the facility’s failure to promote the patient’s or his or her representative’s rights to make informed decisions regarding care when one (P2) of six (P1, P2, P3, P4, P5, P6) patients reviewed suffered a fall, while in bilateral wrist restraints and mittens on 02/11/2026, and was found on the ground at 07:40 AM by staff. P2 reported neck pain to staff. P2’s guardian was not notified of the fall until a Patient Care Technician (PCT) unintentionally disclosed the incident upon P2’s guardian’s arrival to the facility in the afternoon of 02/11/2026. A Physician Assistant (PA) discussed the fall with P2’s guardian on 02/11/2026 at 2:34 PM. P2’s guardian requested the PA to obtain imaging of P2’s neck. Instead, the PA ordered imaging of P2’s pelvis on 02/11/2026 at 14:46. A spine and complete cervical imaging was ordered on 02/12/2026 at 12:31 PM by the PA. The facility’s failure to provide timely disclosure resulted in P2’s guardian’s distrust and additional distress with the facility to exercise the right to request and make an informed decision on behalf of P2. Cross refer to A-0130 as it relates to the facility’s failure to protect patent’s rights and participation in care when the family representative of one (P1) of six (P1, P2, P3, P4, P5) patients reviewed requested post-facility medications to be sent to a preferred pharmacy established upon admission to the facility, yet the discharging physician sent it to a pharmacy of the physician’s choice. The facility’s failure resulted in a delay of P1 receiving post-discharge medications and the family’s right to participate in the discharge process. A review of an “H&P Notes”, with a date of service of 12/30/2025 at 8:56 PM, by a physician, revealed that P2 was hit by a motor vehicle while riding scooter and admitted for trauma care at an outside facility on 11/28/2025. Continued review revealed that P2 had multiple injuries including but not limited to: multiple bilateral rib fractures, a lamina (bony plates on each side of the neck bone and spine) fracture, a zygomaxillary (referring to the bones in the check and its surrounding points) fracture, a pterygoid plate (a bone plate that forms a part of the palate) fracture, a skull fracture extending into the orbital (bone surrounding the eye) wall fracture, left arm fracture, and bilateral femoral (thigh bone) fractures. A review of a “Nursing Note”, with a service date of 02/11/2026 at 9:23 AM, by RN CC revealed that P2 was found around 07:40 on the left side of the bed with their back up against the bed facing the hallway as if P2 fell or slid down off the bed. RN CC noted that a staff assist was called and P3 was lifted back into the bed, placed on bedside monitoring, restraints, and provided pain medication. RN CC noted that P2 reported neck pain as an eight out of 10. A review of the facility’s policy titled, “Patient Rights and Responsibilities”, no policy number, effective date of 08/13/2025, revealed that the purpose of the policy was to establish guidelines for patient care that recognize each patient as an individual with unique healthcare needs, values, and cultural perspectives. To respect, promote, and protect the basic human rights of each individual. Continued review revealed that all patients at the facility are entitled to the listed rights below: “ Expect care to be given in an environment free from neglect During a telephone interview on 03/19/2026 at 1:51 PM, Registered Nurse (RN) CC said that RN CC did not recall when P2 fell. RN CC said that if a patient fell, RN CC was informed to check on the patient but to not get them patient off the floor and to alert a staff assist needed. RN CC said that RN CC would monitor the patient, assess for any pain, and provide treatment per the plan of care. RN CC said that the RN is to document a post-fall assessment in the patient’s chart along with any assessments or injuries on the body. An interview was conducted on 03/20/2026 at 9:37 AM in the conference room, Nurse Manager (NM) EE said that NM EE said that if a patient fell, then nurses are to assess the patient first for any immediate injuries, notify a physician, implement any orders by the physician, and then file an incident report. NM EE said that staff should continue to monitor the patient and conduct a post-fall debrief. An interview was conducted on 04/02/2026 at 11:27 AM with NM GG in the conference room. NM GG said that if a nurse found a patient on the floor, then the nurse should conduct an assessment, provide care for the patient, document what happened, notify the provider, file an incident report, and then ensure safety measures are in place. A telephone interview was conducted on 04/10/2026 at 2:42 PM with Family Member (FM) 1. FM1 said that FM1 is the primary guardian for P2. FM1 recalled that when P2 fell on 02/11/2026, FM1 recalled that the PA informed FM1 that there was no visible injury to P2. FM1 recalled that FM1 requested imaging for P2’s neck or to speak with a physician because FM1 was concerned that P2 may have more injury to the neck area because P2 already had issues with it and after the fall this was the area where P2 reported the most pain.”

“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: 46188 Based on a review of medical records, staff interviews, and policies and procedures, it was determined that the facility failed to: 1.) ensure that patient’s rights were promoted and protected, 2.) ensure that nursing staff followed policy and procedures for documentation and implementation of wound care dressing changes and nutrition tube feeding intake, and 4.) ensure the immediate physical safety of a patient in restraints, while under the care of the facility, as required when one (P2) of six (P1, P2, P3, P4, P5, P6) patients reviewed suffered a fall on 02/11/2026. Findings Included: Cross refer to A-0132 as it relates to the facility’s failure to promote the patient’s or his or her representative’s rights to make informed decisions regarding care when one (P2) of six (P1, P2, P3, P4, P5, P6) patients reviewed suffered a fall, while in bilateral wrist restraints and mittens on 02/11/2026, and was found on the ground at 07:40 AM by staff. P2 reported neck pain to staff. P2’s guardian was not notified of the fall until a Patient Care Technician (PCT) unintentionally disclosed the incident upon P2’s guardian’s arrival to the facility in the afternoon of 02/11/2026. A Physician Assistant (PA) discussed the fall with P2’s guardian on 02/11/2026 at 2:34 PM. P2’s guardian requested the PA to obtain imaging of P2’s neck. Instead, the PA ordered imaging of P2’s pelvis on 02/11/2026 at 14:46. A spine and complete cervical imaging was ordered on 02/12/2026 at 12:31 PM by the PA. The facility’s failure to provide timely disclosure resulted in P2’s guardian’s distrust and additional distress with the facility to exercise the right to request and make an informed decision on behalf of P2. Cross refer to A-0398 as it relates to the facility’s failure to ensure nursing staff implemented and documented wound care treatment and dressing changes per facility policy when six (P1, P2, P3, P4, P5, P6) of six (P1, P2, P3, P4, P5, P6) patients reviewed failed to have multiple shifts and dates of wound care treatment and dressing changes per physician orders. The facility’s failure to ensure that nursing staff implemented wound care treatment and dressing changes has the potential to result in delayed wound healing and deterioration of PIs for all patients at risk while under the care of the facility. Additionally, the facility failed to ensure that nursing staff documented accurate daily intake of nutrition tube feeding when one (P6) patients of six (P1, P2, P3, P4, P5, P6) patients reviewed failed to have multiple shifts and dates entered. Additionally, the facility failed to ensure that a post-fall assessment was completed when one (P2) of six (P1, P2, P3, P4, P5, P6) patients reviewed, suffered a fall on 02/11/2026. At the time of discovery of P2 on the ground at 07:40 AM, the patient reported neck pain of eight out of 10. Cross refer to A-0175 as it relates to the facility’s failure to preserve the immediate physical safety of a patient when one (P2) of six (P1, P2, P3, P4, P5, P6) patients reviewed, while in bilateral upper extremity limb restraints and mittens, suffered a fall on 02/11/2026 and was found on the ground by staff at 07:40 AM.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 46188 Based on a review of a medical record, policies and procedures, and interviews, it was determined that the facility failed to ensure that the patient or patient’s representative had a freedom of choice and participation in the plan of care for discharge when on (P1) of five (P1, P2, P3, P4, P5) patients reviewed had a family member present during discharge planning. P1’s family member requested the discharging physician to send medication prescriptions to a preferred pharmacy, previously noted in the medical record, but the physician refused and directed it to another pharmacy. This failure resulted in a delay in retrieving medications for P1 upon discharge from the facility to home. Findings included: A review of “Clinical Notes”, filed on 02/05/2026 at 5:39 PM by Case Manager (CM) AA revealed that P1 had discharge planning assessment conducted with P1’s family members. CM AA listed a preferred pharmacy as Centerwell, who also is the prior home health service provider. CM AA noted that P1’s family members denied any hardships at the time of the assessment and the plan was to have P1 transition home when medically stable. A review of an “After Visit Summary” revealed that 24 medications/supplies were sent to a Walgreens Drug Store. A review of the facility’s policy titled, “Patient Rights and Responsibilities”, no policy number, effective date of 08/13/2025, revealed that the purpose of the policy was to establish guidelines for patient care that recognize each patient as an individual with unique healthcare needs, values, and cultural perspectives. To respect, promote, and protect the basic human rights of each individual. Continued review revealed that all patients at the facility are entitled to the listed rights below: “ Participate in the development and implementation of their plan of care “ Make informed decisions regarding their care “ Have a family member involved in decisions about care, treatment, and services “ Expect reasonable continuity of care and coordination of patient care services when discharging home or transferring to another facility or agency A telephone interview was conducted on 03/17/2026 at 11:52 AM with Complainant (C) 1. C1 recalled asking MD BB if P1’s medications were going to be sent to the established pharmacy on file because P1 and the family were familiar with pharmacy. C1 recalled that the MD BB declined and informed C1 that it was being sent to another pharmacy. C1 recalled inquiring if this could be changed and the reasoning for it. C1 recalled that MD BB reported to C1 that it could not be changed and that MD BB was doing C1 and P1 a favor because MD BB was making the cost of the medications cheaper by sending them to the alternate pharmacy. C1 recalled informing MD BB that this was not accurate as P1 had Medicare. C1 recalled MD BB saying that MD BB was not going to speak on the subject any longer. During an interview on 03/19/2026 at 1:32 PM in a conference room, Case Manager (CM) AA recalled that C1 expressed concerns about MD BB’s behavior towards C1 and that MD BB refused to address some of C1’s concerns regarding medications. CM AA recalled that C1 expressed another concern where C1 requested all of P1’s medications to go to their preferred pharmacy and if there were any new or urgent medications then it could be sent to where the provider decided. CM AA recalled that MD BB told C1 that all of the medications were sent to the provider’s choice of pharmacy and that MD BB was providing C1 and P1 with a favor because MD BB lowered the cost of the medication. CM AA recalled that C1 expressed that this was not true because P1 was on Medicare and Medicaid and did not understand why MD BB is acting in that manner. CM AA recalled that C1 had a preferred pharmacy because it was the same group that managed home health for P1 and it was for ease and continuity of care that C1 requested this from MD BB.”

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 46188 Based on a review of medical records, policies and procedures, and interviews, it was determined that the facility failed to promote the patient’s or his or her representative’s rights to make informed decisions regarding care when one (P2) of six (P1, P2, P3, P4, P5, P6) patients reviewed suffered a fall, while in bilateral wrist restraints and mittens on 02/11/2026, and was found on the ground at 07:40 AM by staff. P2 reported neck pain to staff. P2’s guardian was not notified of the fall until a Patient Care Technician (PCT) unintentionally disclosed the incident upon P2’s guardian’s arrival to the facility in the afternoon of 02/11/2026. A Physician Assistant (PA) discussed the fall with P2’s guardian on 02/11/2026 at 2:34 PM. P2’s guardian requested the PA to obtain imaging of P2’s neck. Instead, the PA ordered imaging of P2’s pelvis on 02/11/2026 at 14:46. A spine and complete cervical imaging was ordered on 02/12/2026 at 12:31 PM by the PA. The facility’s failure to provide timely disclosure resulted in P2’s guardian’s distrust and additional distress with the facility to exercise the right to request and make an informed decision on behalf of P2. Findings Included: A review of “Clinical Notes”, with a service date of 02/11/2026 at 7:45 AM by a Respiratory Therapist (RT) revealed that a rapid response was initiated as P2 fell out of the bed. A review of a “Nursing Note”, with a service date of 02/11/2026 at 9:23AM, by RN CC revealed that P2 was found around 07:40 on the left side of the bed with their back up against the bed facing the hallway as if P2 fell or slid down off the bed. RN CC noted that a staff assist was called and P3 was lifted back into the bed, placed on bedside monitoring, restraints, and provided pain medication. RN CC noted that P2 reported neck pain as an eight out of 10. Continued review of P2’s medical record revealed that on 02/11/2026 at 09:23 AM, RN CC noted under a care team notification, shift event, of a fall. Continued review of P2’s medical record revealed that a Physician Assistant (PA) ordered for an x-ray of P2’s pelvis on 02/11/2026 at 14:46 with the reason for the exam listed as post fall. The findings revealed no acute injuries. Continued review of P2’s medical record revealed that on 02/12/2026 at 12:31 PM, a PA ordered for an x-ray of P2’s spine and complete cervical with a reason for the exam listed as post fall. The findings of the imaging noted that in the setting of acute trauma, consider a computed tomography (CT) of the cervical spine for further evaluation. Continued review of P2’s medical record revealed that on 02/13/2026 at 08:08, a PA ordered a CT of the cervical spine with the reason for the exam listed as post-fall. The findings revealed no acute fracture of the cervical spine. A review of the facility’s policy titled, “Patient Rights and Responsibilities”, no policy number, effective date of 08/13/2025, revealed that the purpose of the policy was to establish guidelines for patient care that recognize each patient as an individual with unique healthcare needs, values, and cultural perspectives. To respect, promote, and protect the basic human rights of each individual. Continued review revealed that all patients at the facility are entitled to the listed rights below: “ Participate in the development and implementation of their plan of care “ Make informed decisions regarding their care “ Ask for and receive complete and understandable information about their condition and care, tailored to the patient’s age and ability to understand “ Have a family member involved in decisions about care, treatment, and services A review of the facility’s policy titled, “Disclosure of Adverse Events”, no policy number, last effective 02/19/2024, revealed that the purpose of the policy was to disclose information to patients and families of any adverse outcomes or unintended occurrences associated with treatment. Continued review of the Policy Statement revealed that the facility was committed to transparency in communications with patients recognizing their right ot know all aspects of their care, treatment and service. Essential to this transparency is a commitment to truthful and prompt disclosure to patients and families of any adverse outcomes or unintended occurrences associated with treatment. Continued review revealed, Procedure: I. General Principles a. Disclosure is a process over time rather than a single event. It involves telling what is known to the patient/family in the context of ongoing care. b. Every effort should be made to ensure that communication with patient/families is carried out by a member of the health care team who has a trusting relationship with the involved patient/family. c. Many situations have immediacy, requiring decisions to be made and communication to begin urgently. d. Timeliness of communication is key to maintaining trust. A telephone interview was conducted on 03/18/2026 at 12:53 PM in the conference room. Patient Care Technician (PCT) JJ recalled that on 02/11/2026, PCT JJ informed FM1 that P2 was found on the ground by staff. PCT JJ recalled that PCT JJ was under the assumption that the information regarding the fall was already supplied to FM1 as FM1 was the primary guardian for P2 and because it occurred in the early morning of 02/11/2026. PCT JJ recalled that FM1 arrived at the facility in the middle of the afternoon on 02/11/2026. PCT JJ recalled that FM1 told PCT JJ that FM1 was unaware that P2 fell and was not contacted by any staff member. PCT JJ recalled that FM1 requested to speak to P2’s nurse and the charge nurse. PCT JJ recalled that FM1 told PCT JJ that FM1 felt that staff were attempting to cover up the fall and if PCT JJ did not mention it ot FM1, FM1 would have never known about it. During a telephone interview on 03/19/2026 at 1:51 PM, Registered Nurse (RN) CC said that that it is the physician’s responsibility to inform family members when a patient falls because they can provide more information regarding the treatment portion of it. An interview was conducted on 03/20/2026 at 9:37 AM in the conference room, Nurse Manager (NM) EE said that it is the nurses’ responsibility to notify the family of the incident. An interview was conducted on 04/02/2026 at 11:27 AM with NM GG in the conference room. NM GG said that the physician and nurse should discuss the fall with the patient’s family member and only provide information on what occurred and what steps are upcoming, if any. A telephone interview was conducted on 04/10/2026 at 2:42 PM with Family Member (FM) 1. FM1 said that FM1 is the primary guardian for P2. FM1 recalled that when P2 fell on 02/11/2026, FM1 was not contacted by any staff member when it occurred or immediately afterwards. FM1 recalled that when FM1 arrived at the facility in the afternoon that same day, C2 inquired if FM1 was aware that P2 fell earlier in the morning. FM1 recalled telling C2 that FM1 was not aware and asked why staff did not contact FM1. FM1 recalled asking to speak with a charge nurse or physician to discuss some concerns. FM1 recalled that a Physician Assistant (PA) came to talk to FM1. FM1 recalled that the PA informed FM1 that there was no visible injury to P2. FM1 recalled that FM1 requested imaging for P2’s neck or to speak with a physician because FM1 was concerned that P2 may have more injury to the neck area because P2 already had issues with it and after the fall this was the area where P2 reported the most pain. FM1 recalled that eventually imaging was ordered for P2 after a couple of days, but it took a lot of pleading with staff members. FM1 recalled that the PA initially ordered imaging for P2’s hips first instead of addressing the neck per FM1’s request. FM1 said that FM1 believed the facility attempted to hide the fall and if it was not for C2 asking if FM1 was aware or not aware of the fall, then FM1 would have not known about the fall. FM1 recalled that FM1 requested more information about the fall but no staff member provided FM1 with any direct answers. FM1 recalled that P2 was restrained and was very dependent on staff for movement so FM1 was perplexed on how P2 fell out of the bed and onto the floor.”

“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: 46188 Based on a review of medical records, policies and procedures, and interviews, it was determined that the facility failed to protect the patient’s rights and ensure the immediate physical safety of a patient when one (P2) patient of six (P1, P2, P3, P4, P5, P6) patients reviewed, while in bilateral wrist restraints and mittens on 02/11/2026, was found on the floor of the patient room. The facility’s failure resulted in P2 suffering avoidable pain and had the likelihood of an adverse outcome. Additionally, after the fall, the facility failed to ensure ongoing nurse monitoring was conducted while P2 was in restraints. Cross-refer to A-0398 as it relates to the facility’s failure to ensure that nursing staff completed a post-fall assessment when one (P2) of six (P1, P2, P3, P4, P5, P6) patients reviewed, suffered a fall on 02/11/2026. At the time of discovery of P2 on the ground at 07:40 AM, the patient reported neck pain of eight out of 10. Findings included: A review of P2’s medical record revealed that on 02/10/2026 at 12:55 PM a physician ordered bilateral upper extremity limb restraints and mittens for P2 due to interference with medical treatment. Continued review of P2’s medical record revealed that on 02/10/2026 at 12:55 an RN documented initiation of bilateral non-violent wrist restraints and mitten for P2. Continued review of P2’s medical record revealed that an RN documented nurse monitoring of the restraints on 02/11/2026 at 06:00 and the restraints were continued as P2 did not meet criteria for restraint release. A review of “Clinical Notes”, with a service date of 02/11/2026 at 7:45 AM by a Respiratory Therapist (RT) revealed that a rapid response was initiated as P2 fell out of the bed. The RT noted that upon arrival, P2 was on the floor and assisted back into bed and no respiratory distress was noted. The RT noted that P2 had a trach that was capped and saturated 98 percent while on room air. Continued review of P2’s medical record did not reveal restraint discontinuation by nursing staff. Continued review of P2’s medical record revealed that on 02/11/2026 at 7:47 AM, a physician ordered non-violent restraints for bilateral upper extremities, mittens, and a roll belt due to interference with medical treatment. A review of a “Nursing Note”, with a service date of 02/11/2026 at 9:23AM, by RN CC revealed that P2 was found around 07:40 on the left side of the bed with their back up against the bed facing the hallway as if P2 fell or slid down off the bed. RN CC noted that a staff assist was called and P3 was lifted back into the bed, placed on bedside monitoring, restraints, and provided pain medication. RN CC noted that P2 reported neck pain as an eight out of 10. A review of P2’s medical record revealed that on 02/16/2026 at 18:20, P2’s restraints were continued. Continued review failed to reveal restraint monitoring on 02/16/2026 at 20:00, on 02/17/2026 at 00:00, and on 02/17/2026 at 02:00. Continued review failed to reveal discontinuation of restraints. Continued review revealed that on 02/17/2026 at 07:41, an RN documented initiation of restraints under the date and time of 02/17/2026 at 04:32. Continued review failed to reveal restraint monitoring on 02/17/2026 at 06:00. A review of the facility’s policy titled, “Restraints”, no policy number, effective date of 04/12/2023, revealed that the purpose of the policy was to provide guidelines for the use of restraint and/or seclusion to promote the safe and appropriate use of monitoring of restraint or seclusion. Restraint and seclusion of patients is utilized to ensure the immediate physical safety of the patient when preventative or alternative strategies are inadequate in providing a safe environment for all. Continued review revealed that time frames for the ongoing monitoring of the patient’s psychological and physical status during the use of restraint or seclusion will be defined as follows: “ Patients restrained due to unsafe or therapeutically disruptive behavior will be assessed every two hours or more frequently as needed. Continued review revealed, Continuous Monitoring and Care of the Restrained Patient: 1. The condition of the patient and the restraint must be continually assessed, monitored, re-evaluated, and documented. d. Every two hours, or more frequently as needed, the RN will assess: 1. Respiratory effort 2. Circulation of each restrained extremity 3. Skin integrity 4. Level of consciousness e. Every two hours, or more frequently as needed, the patient must: 5. Have restraints released/be assisted to change positions/have ROM exercises 6. Have fluids and nourishments provided. 7. Have the opportunity to use the toilet. Bedpan or urinal as appropriate. 8. Be assessed for patient readiness for release from restraints. Continued review revealed, Removal of Restraint, removal of restrain must be initiated by the physician or RN when the patient meets the criteria for discontinuation as follows: 1. Improve cognitive status 2. Compliant with instruction for safety 3. Treatment change 4. Less restrictive measures effective 5. No longer demonstrating behaviors associated with disrupting care and patient safety Continued review revealed, Documentation Requirements: 1. Assessment and care a. Alternatives attempted b. Assessment of behaviors exhibited by patients to determine need for use of restraints c. Intervention and patient’s response to the intervention d. Evaluation e. Criteria for discontinuation During a telephone interview on 03/19/2026 at 1:51 PM, Registered Nurse (RN) CC said that RN CC did not recall when P2 fell. RN CC said that when a patient is in restraints, nurses are to assess and document the restraint every two hours. RN CC said that restraint orders detail what restraints are applied and the order is usually good for 24 hours. RN CC said that if a patient is removed from a restraint, then the nurse must obtain a new order. RN CC said that staff try to release a patient from restraints as soon as possible, but they make sure that it is safe for the patient prior to doing it. An interview was conducted on 03/20/2026 at 9:37 AM in the conference room, Nurse Manager (NM) EE said that nurses are supposed to document restraints every two hours and ensure that the order is active. NM EE said that it is the nurses’ responsibility to make sure it is safe for the patient to be released from the restraint prior to releasing the patient. NM EE said that if a patient is removed from a restraint, then the nurse must obtain a new order from a provider. NM EE said that nurses’ are supposed to document in real time when they discontinue a restraint or start it.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 46188 Based on a review of medical records, policies and procedures, and interviews, it was determined that the facility failed to ensure that nursing staff implemented and documented wound care dressing changes per facility policy when six (P1, P2, P3, P4, P5, P6) of six (P1, P2, P3, P4, P5, P6) patients reviewed failed to have multiple shifts and dates of wound care treatment and dressing changes per physician orders. This failure has the potential to result in delayed wound healing and deterioration of PI for all patients while under the care of the facility. Additionally, the facility failed to ensure that nursing staff documented accurate daily intake of nutrition tube feeding when one (P6) patient of six (P1, P2, P3, P4, P5, P6) patients reviewed failed to have multiple shifts and dates of nutrition tube feeding entered. This failure resulted in inaccurate measurements fluid volume status and for the increased likelihood of an adverse outcome to occur. Additionally, the facility failed to ensure that a post-fall assessment was completed when one (P2) of six (P1, P2, P3, P4, P5, P6) patients reviewed, suffered a fall on 02/11/2026. Findings included: A review of a “Progress Note” signed 02/13/2026 at 1:05 PM by a wound care (WOC) Registered Nurse (RN) revealed a wound assessment for P1of the sacrum with a wound care order for dressing changes and treatment to occur every 24 hours and to start on 02/05/2026 at 8:00 AM. Continued review of a “Progress Note” signed 02/13/2026 at 1:05 PM by a WOC RN revealed a left ulcer of the anterior (near the front) foot with a wound care order for dressing changes and treatment to occur every 24 hours and to start on 02/05/2026 at 8:00 AM. Continued review of a “Progress Note” signed 02/13/2026 at 1:05 PM by a WOC RN revealed a PI on the right anterior neck with a wound care order for dressing changes and treatment to occur every 24 hours and to start on 02/05/2026 at 8:00 AM. A review of a “Progress Note” signed 02/23/2026 at 2:08 PM by a WOC RN revealed a follow up assessment of P1’s sacrum, left foot, and right neck wounds. The WOC RN updated the treatment plan. The sacrum PI dressing treatment and changes were to occur every 12 hours and to start on 02/23/2026 at 20:00. The left foot and right neck wounds were continued for every 24 hours. A review of P1’s medical record failed to reveal daily wound dressing changes for the sacrum on 02/20/2026, 02/22/2026, and 03/02/2026. Continued review failed to reveal night shift dressing changes on 03/04/2026, 03/05/2026, 03/08/2026, 03/09/2026, and 03/10/2026. A review of P1’s medical record failed to reveal daily wound dressing changes for the right neck on 02/05/2026, 02/06/2026, 02/07/2026, 02/14/2026, 02/15/2026, 02/20/2026, 02/21/2026, and 02/22/2026. A review of P1’s medical record failed to reveal daily wound dressing changes for the left foot on 02/05/2026, 02/06/2026, 02/07/2026, 02/15/2026, 02/20/2026, 02/21/2026, and 02/22/2026. A review of P2’s medical record revealed a “Progress Note” signed 01/08/2026 at 1:59 PM by a WOC RN of a right posterior (most behind) leg with wound care orders to occur every 24 hours to start on 01/09/2026 at 8:00 AM. Continued review of P2’s medical record revealed a “Progress Note” signed on 01/08/2026 at 1:59 PM by a WOC RN of a surgical wound of the lower sternum with wound care orders to occur every 24 hours to start on 01/01/2026 at 8:00 AM. Continued review of P2’s medical record revealed a “Progress Note” signed on 01/08/2026 at 1:59 PM by a WOC RN of a left upper chest wound with wound care orders to occur every 24 hours to start on 01/09/2026 at 8:00 AM. Continued review of P2’s medical record revealed a “Progress Note” signed on 01/08/2026 at 1:59 PM by a WOC RN of a PI of the sacrum with wound car orders to occur every 12 hours to start on 12/31/2025 at 20:00. Continued review of P2’s medical record revealed that the wound care orders for the right posterior leg, lower sternum, left upper chest, and sacrum occurrences had no changes in frequency of treatment. A review of P2’s medical record failed to reveal daily wound dressing changes for the right posterior leg on 01/01/2026, 01/07/2026, and 01/14/2026. A review of P2’s medical record failed to reveal daily wound dressing changes for the lower sternum on 01/01/2026, 01/14/2026, 01/26/2026, 01/31/2026, and 02/13/2026. A review of P2’s medical record failed to reveal daily wound dressing changes for the left upper chest on 12/31/2025, 01/01/2026, and 01/07/2026. A review of P2’s medical record failed to reveal daily wound dressing changes for the sacrum on 01/01/2026, 01/14/2026, 01/22/026, and 02/13/2026. Continued review of P2’s medical record failed to reveal night shift dressing changes on 01/02/2026, 01/09/2026, 01/12/2026, 01/13/2026, 01/26/2026, 01/27/2026, 01/30/2026, 01/31/2026, 02/01/2026, and 02/14/2026. Continued review of P2’s medical record failed to reveal day shift dressing changes on 01/05/2026, 01/10/2026, 01/11/2026, 01/23/2026, 02/01/2026, 02/15/2026, 02/20/2026, and 02/21/2026. A review of P2’s medical record failed to reveal a post-fall or physical assessment by clinical staff. Continued review of P2’s medical record did not reveal restraint discontinuation by nursing staff. A review of P3’s medical record revealed a “Progress Note” signed on 01/27/2026 at 3:25 PM by a WOC RN of a right anterior ankle with wound care orders to occur every 24 hours to start on 01/24/2026 at 8:00 AM. Continued review of P3’s medical record revealed a “Progress Note” signed on 01/27/2026 at 3:25 PM by a WOC RN of a left lower PI of the distal (further away from an center of origin or attachment part of the body) leg with wound care orders to occur every 12 hours to start on 01/23/2026 at 20:00. Continued review of P3’s medical record revealed a “Progress Note” signed on 01/27/2026 at 3:25 PM by a WOC RN of a left PI of the interior foot with wound care orders to occur every 12 hours to start on 01/23/2026 at 20:00. Continued review of P3’s medical record revealed a “Progress Note” signed on 01/27/2026 at 3:25 PM by a WOC RN of a PI of the left ankle with wound care orders to occur every 24 hours to start on 01/24/2026 at 8:00 AM. Continued review of P3’s medical record revealed a “Progress Note” signed on 01/27/2026 at 3:25 PM by a WOC RN of a PI of the right heel with wound care orders to occur every 24 hours to start on 01/24/2026 at 8:00 AM. Continued review of P3’s medical record revealed a “Progress Note” signed on 01/27/2026 at 3:25 PM by a WOC RN of a PI of the left heel with wound care orders to occur every 24 hours to start on 01/24/2026 at 8:00 AM. Continued review of P3’s medical record revealed a “Progress Note” signed on 01/27/2026 at 3:25 PM by a WOC RN of a PI coccyx (tailbone) with wound care orders to occur every 12 hours to start on 01/23/2026 at 20:00. A review of P3’s medical record failed to reveal daily wound dressing changes for the right anterior ankle on 03/11/2026, 03/12/2026, 03/13/2026, 03/14/2026, and 03/15/2026. A review of P3’s medical record failed to reveal daily wound dressing changes of the left lower PI of the distal leg on 03/14/2026 and 03/15/2026. Continued review of P3’s medical record failed to reveal day shift wound dressing changes on 01/30/2026, 02/02/2026, 02/25/2026, 02/26/2026, 02/28/2026, 03/06/2026, 03/07/2026, 03/10/2026, 03/12/2026, and 03/13/2026 Continued review of P3’s medical record failed to reveal night shift wound dressing changes on 02/04/2026, 02/07/2026, 02/08/2026, 02/17/2026, 02/18/2026, 02/23/2026, and 03/09/2026. A review of P3’s medical record failed to reveal daily wound dressing changes for the left anterior foot on 02/03/2026, 02/04/2026, 02/06/2026, 03/11/2026, 03/14/2026, 03/15/2026. Continued review of P3’s medical record failed to reveal day shift wound dressing changes on 01/24/2026, 01/25/2026, 02/02/2026, 02/07/2026, 02/25/2026, 02/26/2026, 02/27/2026, 02/28/2026, 03/01/2026, 03/06/2026, 03/07/2026, 03/10/2026, 03/12/2026, and 03/13/2026. Continued review of P3’s medical record failed to reveal night shift wound dressing changes on 02/08/2026, 02/13/2026, 02/17/2026, and 03/09/2026. A review of P3’s medical record failed to reveal daily wound dressing changes for a PI of the left ankle on 03/10/2026, 03/11/2026, 03/12/2026, 03/13/2026, 03/14/2026, and 03/15/2026. A review of P3’s medical record failed to reveal daily wound dressing changes for the right heel on 03/11/2026, 03/14/2026, and 03/15/2026. A review of P3’s medical record failed to reveal daily wound dressing changes for the left heel on 03/11/2026 and 03/15/2026. A review of P3’s medical record failed to reveal daily wound dressing changes for the coccyx on 03/13/2026, 03/14/2026, and 03/15/2026. Continued review of P3’s medical record failed to reveal day shift wound dressing changes on 03/10/2026. Continued review of P3’s medical record failed to reveal night shift wound dressing changes on 03/09/2026. A review of P4’s medical record revealed a “Progress Note” signed on 02/11/2026 at 1:17 PM by a WOC RN of a wound assessment of a PI of the sacrum with wound care orders for every 12 hours to start on 02/04/2026 at 20:00. A review of P4’s medical record failed to reveal daily wound dressing changes for a PI of the sacrum on 03/04/2026 and 03/07/2026. Continued review of P4’s medical record failed to reveal day shift wound dressing changes on 02/19/2026 and 02/21/2026. Continued review of P4’s medical record failed to reveal night shift wound dressing changes on 02/09/2026, 02/16/2026, 02/24/2026, 02/27/2026, 03/05/2026, and 03/12/2026. A review of P5’s medical record revealed a “Progress Note” signed 01/13/2026 at 4:32 PM by a WOC RN of a wound assessment of the upper back with wound care orders for every 24 hours to start on 01/14/2026 at 8:00 AM. Continued review of P5’s medical record revealed the wound care orders for the upper back remained at a frequency for every 24 hours through 03/19/2026. Continued review of P5’s medical record revealed a “Progress Note” signed 01/13/2026 at 4:32 PM by a WOC RN of a wound assessment of the right buttocks with wound care orders to change every 12 hours to start on 01/31/2026 at 20:00. Continued review of P5’s medical record revealed that the wound care orders for the right buttocks remained at a frequency of every 12 hours through 03/19/2026. Continued review of P5’s medical record revealed a “Progress Note” signed 01/13/2026 at 4:32 PM by a WOC RN of a wound assessment of a PI on the coccyx with wound care orders for every 12 hours to start on 01/06/2026. Continued review of P5’s medical record revealed that the wound care orders for the coccyx remained at a frequency of every 12 hours through 03/19/2026. Continued review of P5’s medical record revealed a “Progress Note” signed 01/13/2026 at 4:32 PM by a WOC RN of a wound assessment of a PI of the left anterior, proximal (closer to the trunk of the body) thigh with wound care orders for every 12 hours to start on 01/06/2026. Continued review of P5’s medical record revealed that the wound care orders for the left anterior, proximal thigh remained at a frequency for every 12 hours through 03/19/2026. Continued review of P5’s medical record revealed a “Progress Note” signed 01/13/2026 at 4:32 PM by a WOC RN of a wound assessment of a PI of the left anterior knee with wound care orders for every 24 hours to start on 01/14/2026 at 8:00 AM.Continued review of P5’s medical record revealed that the wound care orders for the left anterior knee remained at a frequency for every 24 hours through 03/19/2026. A review of P5’s medical record failed to reveal daily wound dressing changes for the upper back on 01/26/2026, 01/30/2026, 02/18/2026, 02/28/2026, 03/10/2026, 03/14/2026, 03/15/2026, and 03/16/2026. A review of P5’s medical record failed to reveal daily wound dressing changes for the right buttocks on 01/26/2026 and 03/10/2026. Continued review of P5’s medical record failed to reveal day shift wound dressing changes on 01/09/2026, 01/19/2026, 01/22/2026, 01/24/2026, 01/27/2026, 02/05/2026, 02/08/2026, 02/18/2026, 02/21/2026, and 03/15/2026. Continued review of P5’s medical record failed to reveal night shift wound dressing changes on 01/07/2026, 01/29/2026, 02/12/2026, and 03/09/2026. A review of P5’s medical record failed to reveal daily wound dressing changes for the coccyx on 01/26/2026 and 03/14/2026. Continued review of P5’s medical record failed to reveal day shift wound dressing changes on 01/19/2026, 01/24/2026, 01/25/2026, 01/27/2026, 02/05/2026, 02/08/2026, 02/18/2026, 02/21/2026, and 03/15/2026. Continued review of P5’s medical record failed to reveal night shift wound dressing changes on 02/09/2026, 02/12/2026, 02/19/2026, 02/20/2026, 03/02/2026, and 03/09/2026. A review of P5’s medical record failed to reveal daily wound dressing changes for the left anterior, proximal thigh on 03/10/2026, 03/14/2026, and 03/15/2026. Continued review of P5’s medical record failed to reveal day shift wound dressing changes on 02/18/2026, 02/21/2026, and 03/11/2026. Continued review of P5’s medical record failed to reveal night shift wound dressing changes on 03/02/2026 and 03/09/2026. A review of P5’s medical record failed to reveal daily wound dressing changes for the left anterior knee on 03/02/2026, 03/14/2026, 03/15/02026, 03/16/2026. Continued review of P6’s medical record revealed wound care orders for the perineum to occur every 12 hours with the first occurrence starting on 02/09/2026 at 20:00. A review of P6’s medical record failed to reveal day shift dressing changes on 02/21/2026, 02/22/2026, 03/07/2026, and 03/12/2026. Continued review revealed there were no night shift dressing changes on 02/07/2026 and 03/28/2026. Continued review revealed that there were no dressing changes documented on 03/10/2026, 03/13/2026, and 03/15/2026. A review of P6’s medical record revealed that on 02/07/2026 at 15:12, tube feeding was ordered with a total goal volume of 1,100 mL per day. A review of P6’s medical record revealed that the total documented intake for 02/12/2026 was 635 mL, on 02/19/2026 total intake was 450 mL, on 02/22/2026 total intake was 0.5 mL, on 03/14/2026 total intake was 690 mL, on 03/21/2026 total intake was 819 mL, on 03/26/2026 total intake was 250 mL on 03/27/2026 total intake was 750 mL, on 03/28/2026 total intake was 738 mL, and on 03/29/2026 total intake was 350 mL. Continued review of P6’s medical record failed to reveal intake documentation on 02/14/2026, 02/21/2026, 02/26/2026, 03/03/2026, 03/07/2026, 03/08/2026, 03/10/2026, 03/17/2026, and on 03/24/2026. A review of the facility’s policy titled, “Nurse-Drive Skin Care Prevention and Management”, no policy number, last effective 03/07/2025, revealed that the purpose of the policy was to document and track pressure injures that are present on admission to the hospital, to prevent and manage skin breakdown and injuries, and to promote and maintain general skin health. Continued review revealed, Procedure: 1. RN/LPN/LPVN are responsible for completing an integumentary assessment within eight hours of admission and repeated every shift. Document assessment in the electronic medical record (EMR). 2. RN/LPN/LVN are responsible for documenting all wounds present on admission A review of the facility’s policy titled, “Wound Care Management for WOC Nursing”, no policy number, effective date of 02/10/2026, revealed that the purpose of the policy was to guide staff in the provision of evidenced-based topical wound care therapy included in the patient’s individualized plan of care. Continued review revealed that the scope was for all registered nurses, certified Wound, Ostomy, Continence (WOC) nurses, advanced practice registered nurses, physician assistants, and physicians in inpatient clinical areas. A review of the facility’s policy titled, “Falls Prevention and Management”, no policy number, effective date of 02/26/2026, revealed that the purpose of the policy was to provide identification and ongoing assessment of patients who are at risk of falling and provide resources for staff to implement fall safety interventions. Continued review revealed, Post-Fall Assessment and Interventions. Post-Fall, patients and rooms should be assessed to determine cause of fall as well as potential injuries to the patient. Post-Fall Assessment: 1. Perform a thorough assessment to determine presence of injury and reassess the fall score. 2. Assess vital signs and neurological status. A review of the facility’s policy titled, “Assessment and Reassessment of Patients”, no policy number, effective date of 02/22/2024, revealed that the purpose of the policy was to identify initial assessment and reassessment components of the patient’s condition by assigned discipline. Continued review revealed, Procedure, General Information: 5. Reassessment of patient’s condition should be performed periodically at appropriate intervals. Reassessment should occur at least: a. Following a change in the patient’s condition or level of care. Continued review revealed, the facility “Assessment and Reassessment Matrix”: Nursing: “ Reassessment - at the beginning of each shift of 12 hours or less, prior to discharge as determined by patient condition, and as identified by standards of care or indicated by nursing or MD order. An interview was conducted on 3/18/2026 at 10:53 AM in the conference with Wound Care Manager (WCM) FF during medical record review. WCM FF said that wound care orders are often associated with multiple wounds for ease of ordering if the treatment is the same. WCM FF said that if the wound care nurse or provider wishes to stop treatment for one wound that is associated in that order it is not usually discontinued because they would have to then redo it for the other remaining associated wounds. WCM FF said that instead the order will remain active and the nurse may chart in the medical record that the wound has healed and a wound care nurse will follow up with a photography. WCM FF said that there should be further education for staff on documentation on if staff select “other” regarding dressing changes, then there should be a comment left. WCM FF said that selecting “other” does not constitute as a dressing change unless there is an explanation or comment for it. WCM FF said that staff are to document all dressing changes and wound treatment in the patient’s medical record. An interview was conducted on 3/19/2026 at 9:38 AM in the conference room with WCM FF during medical record review. WCM FF said that on 03/14/2026 and 03/15/2026 there were education days which may account for why wound care was not completed for multiple patients by nursing staff. WCM FF said that education days did not override patient care. WCM FF said that WCM FF was not sure if the education days occurred during the night shift as well. WCM FF said that for patients with multiple wounds, it was not uncommon for nurses to perform wound dressing changes for one side first and then perform the other later in the shift. WCM FF said that all dressing changes should be documented. During a telephone interview on 03/19/2026 at 1:51 PM, Registered Nurse (RN) CC said that wound care is performed by the RN per the wound care order and document it in the patient’s chart. RN CC said that there is a section in the chart for dressing treatment and changes that staff are to utilize. RN CC said that if staff selects “other” then you are supposed to leave a comment as it tells you to do so. RN CC said that every nurse is supposed to conduct a head-to-toe assessment of their patient including the skin and all wounds. RN CC said that the RN is to document a post-fall assessment in the patient’s chart along with any assessments or injuries on the body. RN CC said that staff are to enter in the total intake of tube feeding of a patient during their shift to account for accurate intake. An interview was conducted on 03/20/2026 at 9:37 AM in the conference room, Nurse Manager (NM) EE said that the expectation is that all nurses are to conduct a patient’s head-to-toe assessment within two hours and as needed if there is a change in patient condition. NM EE said nurses are expected to document all intake and output, dressing treatment and changes, and a change of shift report between each shift. NM EE said that management conducts random chart audits along with the unit educator on wounds and provides staff with real-time correction and coaching. NM EE said that if the nurse cannot perform the dressing change per the wound care order, then it should be communicated to the next nurse. NM EE said that wound care should not be documented if it was not performed but charted that the nurse was unable to perform it. An interview was conducted on 04/02/2026 at 11:27 AM with NM GG in the conference room. NM GG said that nursing staff should document physical head-to-toe assessments once a shift with any changes as the shift progresses. NM GG said that nurses should follow all orders for wound care and it should be done on the shift because there are so many resources available such as a buddy, the charge nurse, and even NM GG. NM GG said that if a nurse found a patient on the floor, then the nurse should conduct an assessment, provide care for the patient, document what happened, notify the provider, file an incident report, and then ensure safety measures are in place. NM GG said that nurses are responsible for entering in the total intake of tube feeding delivered on their shifts at least once a shift.”

“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: 47718 Based on the review of medical records, the facility’s policy/procedures, and staff interviews, it was determined that the facility’s nursing staff failed to administer a nutrition supplement (Juven) as per the dietitian’s order for two patients (P) (P#1 and P#3) of four patients (P#1, P#2, P#3, and P#4) reviewed. Findings included: A review of medical record revealed that P#1 was admitted to the facility on 10/23/25 at 8:22 p.m. with the diagnosis of decubitus ulcer of the sacral bed (a localized injury to the skin and underlying tissue over the tailbone/lower spine caused by prolonged pressure, shearing, and friction). Review of P#1 ’ s medical record revealed an order on 10/24/25 at 10:15 a.m., for Juven (a therapeutic nutritional powder designed to support wound healing) twice daily and on 10/24/25 at 12:08 p.m. a dietary nutrition supplement/lunch and dinner Review of nursing flowsheets on the following dates failed to reveal documentation that Juven was given as ordered: - 11/8/25, 11/10/25, and 11/11/25 - 11/13/25 and 11/15/25 - 11/18/25 to 11/20/25 - 11/24/25 to 11/27/25 - 12/1/25 - 12/13/25, 12/14/25, and 12/15/25 - 12/17/25 - 1/1/26, 1/2/26, 1/4/26, and 1/5/26 - 1/15/26, 1/18/26, and 1/21/26 A review of medical records for P#3 revealed that she was admitted to the facility on 12/26/25 at 1:53 p.m. with the diagnosis of Cutaneous T-Cell lymphoma (a rare, slow-growing cancerous tumor). A continued review of P#3 ’ s medical record revealed an adult nutrition initial assessment on 12/27/25 at 12:28 p.m., and an order for dietary nutrition supplements of Juven (supplement to help heal wounds), one packet orally twice daily. A review of the nursing flow sheets failed to reveal documentation that Juven was administered to P#3 from 12/26/25 to 1/8/26. A review of the facility’s policy titled “Diet Orders, “ effective 11/30/23, revealed that: The physician would document the initial diet order per hospital policy. During the course of the patient’s hospital stay, the RD/LD (Registered Dietitian, licensed by the State of Georgia) may implement certain diet order modifications. The physician may disapprove of any change made by the RD/LD by rewriting the diet order in its entirety. A review of the facility’s policy titled “Nutrition Screening, “ effective 12/4/23, revealed that nutrition screening was completed for patients to identify patients with nutrition risk and determine if nutrition intervention would be recommended. A review of the facility’s policy titled “Nutrition Support Services, “ effective 7/31/23, revealed that Nutrition Support Therapy would be managed with an interdisciplinary approach that may include the patient, physician, nurse, dietitian, and pharmacist. Patients would be monitored daily with documentation in the medical record at least once weekly for calories, protein, fat, vitamins, trace elements, fluid, and electrolyte adjustments. Abnormal values or suboptimal therapies would be addressed. A review of the facility’s policy titled “Patient Care Orders, “ effective 5/5/23, revealed that all orders for medical treatment must originate from an authorized healthcare provider or a member of the house staff and must be documented in the medical record in accordance with this policy. All patient care orders must be either documented electronically or written on an approved form and validated with a signature, date, and time. A Licensed Practitioner (LP) would document the initial diet order per hospital policy. A telephone interview was conducted in the facility’s conference room on 1/28/26 at 9:45 a.m. with Clinical Dietitian (CD) AA, who stated that the dietitian relied on the nurses ’ documentation to ensure patients were receiving nutrition supplements as ordered, and that it should have been documented in the MAR (medication administration record) chart or intake and output in the nursing flow sheets. A telephone interview was conducted in the facility’s conference room on 1/28/26 at 11:45 a.m. with Licensed Practical Nurse (LPN) EE, who stated that the administration of Juven should be documented in the intake and output chart During an interview with Dietitian Manager (DM) LL on 1/28/26 at 1:44 p.m., she reported that the facility was working on implementing a Nutrition Administration Report (NAR) to document consumption of patient nutritional supplements. DM LL further reported that they currently depend on the nurses’ charting to determine whether a nutritional order was given to a patient. An interview took place in the facility’s conference room on 1/28/26 at 2:30 p.m. with Charge Nurse (CN) DD, who stated that the staff had reported that P#1 had poor intake and was spitting out food. CN DD stated that Juven was ordered by the dietitian for nutritional support and usually came from the kitchen, where it was added to the patient’s tray at every meal as per order. CN DD expressed that the documentation for the administration of Juven should be documented in the intake and output chart under nutrition. An interview was conducted in the facility’s conference room on 1/28/26 at 3:30 p.m. with Director of Nursing (DON) NN, who stated that nurses should be documenting administration of nutritional supplement, for example, Juven, on the intake and output chart, that if it was not documented, it probably meant it was not done.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 45841 Based on facility policy review, record review, and staff interviews, the facility failed to ensure staff adherence to a facility policy related to pain assessments for three patients (P) (P#1, P#2, and P#3) of three patients reviewed for pain., This failure increases the potential for improper pain management. Findings included: A facility policy titled “Pain Management,” effective 11/30/2022, indicated, “The standard of [facility name] is to provide every patient with safe and effective pain management as a part of their plan of care.” The policy also indicated, “The RN shall perform ongoing assessment and monitoring of the patient’s pain.” The policy noted, “Pain Reassessment 1. Pain reassessment is performed within one-hour [sic] of interventions. 2. For both pharmacological and non-pharmacological pain interventions, effectiveness of the intervention is evaluated through reassessment.” 1. P#1’s “H&P [History and Physical]” indicated the facility admitted the patient on 01/28/2025. According to the H&P, the patient had a medical history that included a chief complaint of acute respiratory failure with the need for ventilator weaning. P#1’s order for “acetaminophen (Tylenol) tablet 650 mg” was placed on 02/03/2025 at 3:24 p.m. and discontinued on 04/28/2025 at 12:12 p.m., due to the patient being discharged. The order revealed the frequency for administration was every six hours as needed (pro re nata; PRN). P#1’s “Medication Administrations” revealed the patient received 650 mg of acetaminophen on 03/02/2025 at 1:16 p.m. P#1’s “Pain Assessment” flowsheet lacked failed to reveal documentation showing the patient’s pain was assessed or reassessed in association with the acetaminophen administration on 03/02/2025 at 1:16 p.m. P#1’s order for “oxyCODONE (Roxicodone) (an opioid analgesic used to treat moderate to severe pain) immediate release tablet 5 mg [milligrams]” every six hours PRN was placed on 01/28/2025 and discontinued on 04/28/2025 due to the patient being discharged. P#1’s “Medication Administration” revealed the patient received 5 mg of oxycodone on 03/06/2025 at 3:54 p.m. P#1’s “Pain Assessment” flowsheet failed to reveal documentation that the patient’s pain was assessed or reassessed in association with the oxycodone administration on 03/06/2025 at 3:54 p.m. P#1’s “Medication Administrations” revealed the patient received 5 mg of oxycodone on 03/21/2025 at 11:51 p.m. P#1’s “Pain Assessment” flowsheet revealed no documentation that the patient’s pain was assessed for the oxycodone administration on 03/21/2025 at 11:51 PM. During an interview on 05/14/2025 at 10:51 a.m., Accreditation Manager (AM) #1 stated there was no pain assessment documented for the administration of acetaminophen or pain reassessment documented for P#1 on 03/02/2025 at 1:16 p.m. During an interview on 05/14/2025 at 10:53 a.m., the Director of Patient Care Services (DPCS) stated there was no pain assessment or reassessment documented around the time of P #1’s oxycodone administration on 03/06/2025 at 3:54 p.m. During an interview on 05/14/2025 at 10:55 a.m., the DPCS stated that there was no pain assessment associated with Patient #1’s oxycodone administration on 03/21/2025 at 11:51 PM. 2. P#2’s “H&P [History and Physical],” dated 03/27/2025, revealed the patient was admitted due to a need for wound care and antibiotics. P#2’s order for “acetaminophen (Tylenol) tablet 650 mg” every 6 hours as needed (pro re nata; PRN) was placed on 03/27/2025 at 12:36 PM and discontinued on 04/07/2025 at 10:58 a.m. P#2’s “Medication Administrations” revealed the patient received acetaminophen 650 mg on 03/28/2025 at 1:52 p.m., 04/03/2025 at 7:30 p.m., 04/04/2025 at 9:12 a.m., 04/05/2025 at 8:35 a.m., 04/06/2025 at 5:30 a.m., and 04/07/2025 at 9:19 a.m. P#2’s “Pain Assessment” flowsheet lacked documentation of pain assessments or reassessments associated with the acetaminophen administrations on 03/28/2025 at 1:52 p.m., 04/03/2025 at 7:30 p.m., 04/04/2025 at 9:12 a.m., 04/05/2025 at 8:35 a.m., 04/06/2025 at 5:30 a.m., or 04/07/2025 at 9:19 a.m. During an interview on 05/14/2025 at 10:39 a.m. the DPCS stated there were no pain assessments or reassessments documented for P#2’s acetaminophen administrations that occurred on 03/28/2025 at 1:52 p.m.,, 04/03/2025 at 7:30 p.m., 04/04/2025 at 9:12 a.m., 04/05/2025 at 8:35 a.m.,, 04/06/2025 at 5:30 a.m.,, or 04/07/2025 at 9:19 a.m. 3. P#3’s “H&P [History and Physical],” dated 04/01/2025, revealed the patient was admitted due to acute respiratory failure. P#3’s order for “acetaminophen (Tylenol) tablet 650 mg” every six hours as needed (pro re nata; PRN) was placed on 04/01/2025 at 3:04 p.m., and discontinued on 04/10/2025 at 11:13 a.m. P#3’s “Medication Administrations” revealed the patient received acetaminophen 650 mg on 04/05/2025 at 6:26 PM and 04/07/2025 at 8:48 p.m. P#3’s “Pain Assessment” flowsheet lacked documentation of pain assessments or reassessments associated with the acetaminophen administrations that occurred on 04/05/2025 at 6:26 PM and 04/07/2025 at 8:48 p.m. During an interview on 05/14/2025 at 9:42 a.m., the DPCS stated Patient #3’s flowsheet revealed no documented pain assessments or reassessments associated with the acetaminophen administrations that occurred on 04/05/2025 at 6:26 p.m. and 04/07/2025 at 8:48 p.m. P#3’s order for “oxyCODONE (Roxicodone) immediate release tablet 5 mg” every six hours PRN was placed on 04/01/2025 at 3:29 p.m., and discontinued on 04/10/2025 at 11:13 a.m. P#3’s “Medication Administrations” revealed the patient received oxycodone 5 mg on 04/03/2025 at 3:57 a.m., 04/04/2025 at 1:33 p.m., and 04/08/2025 at 9:49 p.m. P#3’s “Pain Assessment” flowsheet lacked documentation of pain assessments associated with the oxycodone administrations that occurred on 04/03/2025 at 3:57 a.m., 04/04/2025 at 1:33 p.m., or 04/08/2025 at 9:49 p.m. During an interview on 05/14/2025 at 10:14 a.m., the DPCS stated there was no pain assessment documented for Patient #3’s oxycodone administration on 04/03/2025 at 3:57 a.m., noting there was only documentation of a reassessment at 4:47 a.m., on 04/03/2025. She stated there was no pain assessment or reassessment for the administration of oxycodone on 04/04/2025 at 1:33 p.m., and stated there was no pain assessment for the oxycodone administration on 04/08/2025 at 9:49 p.m., noting there was a pain reassessment documented.”

“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: 49224 Based on medical record review, staff interviews, and facility policy and procedures, it was determined that the facility failed to follow MD (Medical Doctor) orders to turn and reposition two patients (P) (P#1 and P#4) of five patients (P#1, P#2, P#3, P#4, P#5) reviewed. Findings include: A review of the document “EHC Nurse-Driven Skin Care Decision Tree” revealed that Patients were AT RISK if their Braden Score was 18 or less. Implement all appropriate interventions and products: - Repositioning - Pressure Protection - Moisture Management A review of the facility’s policy titled “Wound Care Management for WOC Nursing ,” effective date 10/18/24, revealed that the policy’s purpose was to provide evidenced-based topical wound care therapy included in the patient’s individualized plan of care. PROTOCOL Desired Outcomes: 1. Develop individualized dressing selection recommendations that follow the principles of evidence-based topical therapy by providing passive and active support of wound healing (McNichol et al., 2021). 2. Address systemic factors that affect wound healing including adequate nutrition, hydration, pressure redistribution, and preventing infection. 3. Patient/ family demonstrate understanding of skin breakdown causes and techniques for prevention of further skin breakdown by discharge. Review of policy titled “Nurse-Driven Skin Care Prevention and Management,” effective 02/28/2024, revealed that its’ purpose was to document and track pressure injuries that are present on admission to hospital. To prevent and manage skin breakdown and injuries. To promote and maintain general skin health, patient/family/care partner verbalizes understanding of skin breakdown causes and preventative skin care measures by discharge. To provide a systematic, and ongoing assessment tool to identify patients with altered skin integrity and those at risk for development of skin impairments. To provide nursing personnel guidelines for planning and evaluating appropriate interventions for patients with or at risk for skin breakdown. Procedure: 1. Nursing team members are responsible for completing “It Takes Two” Screening within the first 8 hours of admission and transfer. Refer to It Takes Two Screening Policy. 2. RN/LPN/LVN are responsible for completing an Integumentary assessment within 8 hours of admission and repeated every shift. Document assessment in EeMR. 3. RN/LPN/LVN are responsible for assessing patients’ risk for the development of pressure injuries, a Braden Scale risk assessment is completed within 8 hours of admission and repeated every shift. A patient is at risk if the Braden score is 18 or less. 4. RN/LPN/LVN are responsible for documenting all wounds present on admission (POA) per EHC operational definition (see definition below). a. EeMR documentation and photography should be done promptly on admission and transfer as soon as possible within the first 8 hours to capture an accurate assessment on admission and transfer. b. If POA status is clinically undetermined, document as such in EeMR. c. Continue to document suspected differential wound assessment and/or the possibility the wound condition is POA as the condition evolves, regardless of timeframe. Nursing team members are responsible for photographing of wounds using hospital-issued handheld devices should be taken at the determined standard intervals: a. All admissions and transfers, within the first 8 hours of admission or transfers during the It Takes Two procedure. b. Every 7-10 days; tasked every Wednesday known as “Wound Wednesday” unless a photo has been taken and recorded in EeMR within the last 72 hours or not clinically indicated. c. Upon discharge at last dressing change or within 72 hours of discharge unless not clinically indicated. d. Wound photos can be rescheduled if not clinically indicated on Wednesday. Acceptable contraindications include: i. Approximated/closed surgical incision ii. Difficult or non-removable dressing change not due iii. Informed by provider or WOC nurse to reschedule iv. Palliative/hospice care Patient/care partner refusal vi. Patient is too unstable vii. Patient is unavailable due to long procedure viii. Uncontrolled pain or discomfort e. Clearly communicate outstanding photo needs during beside shift reports or nurse to nurse patient handoffs. f. Wounds in scope for photography: pressure injury; venous ulcer; arterial ulcer, diabetic/neuropathic ulcer; open incision; skin tear; burn; traumatic wound; radiation wound; soft tissue necrosis; moisture associated skin damage; medical adhesive related skin Injury; blister; mass/tumor; skin graft; or other skin abnormalities based on clinical judgment. A WOC nurse should be consulted for all patients admitted with unstageable, deep tissue injuries, stage 3 or 4 pressure injuries, full thickness wounds, and all suspected hospital acquired pressure injuries. Patients were turned and repositioned every 2- 4 hour and as needed. At risk patients with a Braden of 18 or less were required more frequent turning. 1. A review of P#1’s medical record revealed an MD order on 9/11/24 at 6:00 p.m., to reposition every two hours. Flowsheet assessments from 9/12/24 at 12:15 after midnight until P#1’s discharge on 10/10/24 at 6:11 p.m. failed to reveal that P#1 was consistently turned every two hours per doctor’s orders. Each week revealed more than two-hour time lapses to turn and reposition P#1. 2. A review of medical records for P#4 revealed that P#4 was admitted to the facility on 7/2/24 at 7:03 p.m. with the diagnosis of Acute Respiratory Failure with Hypoxia (when there isn’t enough oxygen in the body’s tissues). A review of the History and Physical (H&P) on 7/2/24 at 8:08 p.m. revealed that P#4 had a heart transplant in November 2022 and had a past medical history of End Stage Renal Disease (a condition in which the kidneys lose the ability to remove waste and balance fluids) and was on Hemodialysis (a procedure that filters the blood of a person whose kidneys are no longer working properly). Documentation under the nursing progress notes on 10/2/24 at 10:59 a.m. revealed that P#4 had a partial thickness/shallow wound on the right posterior thigh, which was not present on admission. An electronic medical record review at the facility revealed that P#4 was not turned two-hourly as per the order. Documentation for P#4 revealed the following: On 7/2/24, last turned at 7:50 p.m. and was not turned again until 2:00 a.m. On 7/3/24, last turned at 1:44 p.m. and was not turned again until 6:00 p.m. On 7/12/24, last turned at 6:00 a.m. and was not turned again until noon. On 7/13/24, last turned at 5:22 a.m. and was not turned again until 8:00 p.m. On 7/14/24, last turned at 6:00 a.m. and was not turned again until 8:00 p.m. On 7/15/24, last turned 6:00 a.m., and was not turned again until 8:00 p.m. On 7/22/24, last turned at 6:00 a.m. and was not turned again until 8:00 p.m. On 8/5/24, last turned 8:00 p.m., and was not turned again until 8:00 a.m. the next day. On 8/7/24, last turned at 1:00 a.m. and was not turned again until 8:00 a.m. On 8/13/24, last turned at 12:00 a.m. and was not turned again until 8:00 a.m. On 9/13/24, last turned at 6:00 a.m. and was not turned again until 7:43 a.m. On 9/17/24, last turned at 6:00 a.m. and was not turned again until 4:00 p.m. On 9/19/24, last turned at 2:00 p.m. and was not turned again until 8:00 a.m. On 9/26/24, was last turned at 8:00 p.m. and was not turned again until 10:00 a.m. the next day 9/27/24. An interview took place in the facility’s conference room on 10/29/2024 at 11:30 a.m., with Director, Wound Care Nurse (WCN) DD who stated that P#4 had an unstageable pressure injury (a full-thickness skin and tissue loss where the extent of damage is not clear because the base of the wound is covered with dead tissue) present on admission, which was adequately cared for and got better before P#4 left. WCN DD stated that the wound P#4 had on his right posterior thigh was an abrasion and not a pressure injury, which was also healed by the time patient was discharged. An interview took place at the facility’s conference room on 10/29/2024 at 12:20 p.m. with Wound Care Nurse (WCN) CC who stated that she saw P#4 back in August when patient needed a debridement (a medical procedure that removes dead, damaged, or infected tissue from a wound to help the healthy tissue heal) because the wound on the sacrum had a lot of necrotic (dead) tissue. WCN CC stated that she called P#4’s family member to give an update regarding the debridement, and family member of P#4 only had a concern if the wound was infected, which was not. An interview took place at the facility’s conference room on 10/29/2024 at 12:35 p.m., with Registered Nurse (RN) FF who stated that she could not recall P#4. However, if a patient comes in with wounds present on admission, an assessment would be done with another nurse for verification purposes, pictures would be taken, and the wound care protocol would be followed. An interview took place at the facility’s conference room on 10/29/24 at 1:10 p.m. with Patient Care Technician (PCT) HH who stated that P#4 had wounds and was on a two-hourly turn. PCT HH stated that she rounded on all patients assigned to her at 10:00 a.m. where she would clean/groom patients. PCT HH stated that if she was with a patient, and she could not make it to another patient on time, she would call the nurse to help. An interview was conducted with Registered Nurse (RN) II on 10/29/2024 at 2:01 p.m., RN II stated that she remembered P#1 and that patient was admitted to the unit in the late evening hour towards the end of her shift. She said P#1 had some pinkish excoriation to sacral area on the initial assessment. She stated she conducted P#1’s assessment towards the end of her shift and remembered that P#1’s family member was present at shift change on the day of P#1’s admission. RN II stated that she spoke with P#1’s family member and informed her that wound care would come to assess P#1’s wound. She said that patients are repositioned and turned every two hours to prevent pressure ulcers and patients that can’t call out for help were checked on the same schedule as other patients. RN II recalled that P#1’s family was always at the patient’s bedside. An interview was conducted with Licensed Practical Nurse (LPN) KK on 10/29/2024 at 3:33 p.m. LPN KK stated that she remembered P#1 and that she required total care. LPN KK stated she was P#1’s discharging nurse, and that P#1 was discharged to home hospice care. She said P#1 was medicated for pain prior to discharge. She said some of the supplies P#1 needed prior to the outside agency taking over were sent home with her. LPN KK stated that P#1’s family was aware that P#1 had a sacral wound. LPN KK said that she provided P#1 with daily care and was turned every two hours and as needed per protocol. She said that if she noticed any change in any of her patients’ condition, she’d notify her charge nurse of the changes.”