Encompass Health Deaconess Rehabilitation Hospital

“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: 50584 Based on document review and interview, nursing services failed to turn and reposition patient as ordered in 1 of 10 MRs (Medical Records) reviewed (P1); failed to perform dressing changes per physician order in 9 of 10 MRs reviewed (P1, P2, P3, P4, P5, P6, P7, P9, P10); failed to document wound photographs per physician order in 1 of 10 MRs reviewed (P1); failed to maintain documentation Glucerna supplement was given to patient per physician order in 1 of 10 MRs reviewed (P1); failed to follow physician order to float heels in 1 of 10 MRs reviewed (P5); failed to enter standardized orders to include wheelchair cushion, turning and repositioning, and application of barrier cream indicated for each patient Braden scale score in 4 of 10 MRs reviewed. (P4, P6, P9, P10); and failed to provide documentation of an event report for a venous stasis ulcer that was not present on patient admission in 1 of 10 MRs (Medical Records) reviewed. (P4) The cumulative effects of these systemic problems resulted in the facility’s inability to provide nursing care in a safe manner.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 50584 Based on document review and interview, nursing services failed to turn and reposition patient as ordered in 1 of 10 MRs (Medical Records) reviewed (P1); failed to perform dressing changes per physician order in 9 of 10 MRs reviewed (P1, P2, P3, P4, P5, P6, P7, P9, P10); failed to document wound photographs per physician order in 1 of 10 MRs reviewed (P1); failed to maintain documentation Glucerna supplement was given to patient per physician order in 1 of 10 MRs reviewed (P1); failed to follow physician order to float heels in 1 of 10 MRs reviewed (P5); failed to enter standardized orders to include wheelchair cushion, turning and repositioning, and application of barrier cream indicated for each patient Braden scale score in 4 of 10 MRs reviewed. (P4, P6, P9, P10) Findings include: 1. Facility policy titled Wound Assessment and Documentation, Policy # 2, Last Reviewed Date: 11/20/2025, page 1 under Purpose: 1. To improve and/or maintain patients’ skin integrity. 2. To ensure standard documentation related to the assessment of skin and wounds. 3. To facilitate accuracy in wound assessment and quality reporting and assist in fulfilling CMS’s requirement to report data related to hospital acquired and worsening wounds. Page 2, under Policy: I. Assessment: 2. The Braden scale is used to assess all patients for risk of skin breakdown. Findings are documented upon admission and weekly at a minimum. 5. Photographs, if required, are to be taken no later than 24 hours from discovery of the wound, weekly and within two days of discharge. Page 3, under III. Documentation: 1. Documentation of Assessment: The licensed clinician will describe the wound, as applicable, which may include: A. Wound label, B. Measurements, C. Exudate, D. Wound Base, E: Wound edges, F. Condition of surrounding skin, G. Signs and symptoms of infection. 4. Weekly documentation will include: A. Re-assessment: i. skin inspections, ii. documentation of current treatment, B. The Plan of Care documents the current risk for skin breakdown through use of the Braden Scale and a status update, including progress toward goals. Page 5, under VI. Policy adherence and Reporting, 1. The following situations require completion of an event report through the hospital Electronic Event Reporting System. A. If a patient is admitted without a documented pressure injury, but develops a pressure injury, Stage 2 or greater. 2. Facility policy titled Assessment, Re-Assessment, Policy #3, Last Reviewed Date, 08/21/2025, page 1, under Policy: II. Reassessments are performed by each discipline according to the patients vital signs, laboratory results, status or condition in accordance with the professional’s scope of practice. RNs (Registered Nurses) conduct daily reassessments of the patient’s condition as documented in the medical record, page 2, IV. Reassessment across all disciplines is ongoing and occurs at designated intervals during the patient’s stay/treatment to determine the response to and effectiveness of certain care, treatment and services received. 3. Facility document Standardized Orders Based on Braden Score: 17-18: Low Risk: Heel Offloading, 15-16 Moderate Risk: Heel Offloading, Barrier Prevention, Repositioning, Cushion, 9-14 High Risk: Heel Offloading, Barrier Prevention, Repositioning, Cushion, Specialty Mattress, Stage 2 or greater: notify wound care and place order for specialty mattress, place isoflex/Stryker pump and wound care will order the appropriate mattress. 4. Review of P1 MR indicated: a. On 4/28/26 P1 was admitted to F1 (rehabilitation hospital) with diagnosis of acute cervical spinal cord injury. Braden score 16 indicated a moderate risk for skin breakdown. b. On 4/29/26 order placed to cleanse sacral area with soap and water, apply Remedy protect cream bid (two times daily) and as needed. Take wound photo of buttock every Wednesday. MR lacked documentation of bid treatment to buttock on 5/2/26, 5/3/26, 5/4/26, 5/7/26, 5/9/26, and 5/10/26 with area to the buttock only cleansed and barrier cream applied one time daily. MR lacked wound photo on 5/6/26. c. On 5/12/26 Wound Care note indicated sacral area was assessed, new Kennedy ulcer was found, measurement 9 cm (centimeters) length x 11 cm width x 0.1 cm depth, physician notified, referral made for wound consultation, and order placed for sacral area to be cleansed with soap and water, apply Leptospermum Honey and cover with a foam dressing daily at bedtime and prn if soiled. d. On 5/12/26 Glucerna supplement shakes were ordered three times a day. MR lacked documentation that P1 received Glucerna supplement on 5/15/26, 5/16/26, 5/17/26, and 5/18/26. e. On 5/13/26 physician order placed for wound photo to right and left buttock every two days. MR lacked wound photos on 5/14/26, 5/16/26, 5/18/26 and 5/20/26. f. P1 was up in a chair on 5/2/26 from 0845 hours to 1600 hours with no weight shifts documented from 0845 hours to 1306 hours, and on 5/10/26 from 1200 hours to 1800 hours with no weight shifts documented.. 5. Review of P2 MR indicated: a. On 12/28/25 P2 was admitted to F1 with diagnosis of severe weakness following COVID-19 (Coronavirus). Braden score was 16, indicated a moderate risk for skin breakdown. b. On 12/29/25 P2 had orders to cleanse buttock, apply barrier cream two times daily and as needed for incontinence episodes. c. MR lacked documentation wound to buttocks was cleansed and barrier cream applied bid on 1/3/26, 1/5/26, 1/7/26, 1/16/26, and 1/17/26. Buttocks were cleansed and barrier cream applied only one time a day. d. MR lacked documentation buttocks were cleansed or barrier cream applied on 1/6/26, 1/9/26, 1/18/26 and 1/21/26. 6. Review of P3 MR indicated: a. On 1/15/25 P3 was admitted to F1 with diagnosis of status post laminectomy. Braden score was 16, indicating a moderate risk for skin breakdown. b. On 1/16/26 P3 had orders to cleanse buttock with soap and water, pat dry, apply remedy protect cream two times daily and as needed for incontinence. e. MR lacked documentation buttock was cleansed and remedy cream applied bid on 1/27/26, 2/2/26, 2/5/26, 2/7/26, and 2/12/26. Buttocks were cleansed and barrier cream applied only one time a day. f. MR lacked documentation buttock was cleansed and remedy cream applied on 1/28/26 and 2/1/26. 7. Review of P4 MR indicated: a. On 3/16/26 P4 was admitted to F1 with diagnosis of post status left total knee arthroplasty. Braden score was a 16 indicating a moderate risk for skin breakdown. b. On 3/19/26 P4 had a physician order to cleanse right Great toe and second toe daily with betadine; MR lacked documentation toes were cleansed with betadine on 3/19/26, 3/20/26, 3/21/26, 3/22/26, 4/5/26 and 4/6/26. c. On 3/19/26 P4 had an order to cleanse buttock and apply barrier cream two times daily. MR lacked documentation buttock was cleansed and barrier cream applied bid on 3/20/26, 3/21/26, 3/24/26, 3/26/26, and 4/6/26. Buttocks cleansed and barrier cream applied only one time daily. d. On 3/19/26 P4 had orders to cleanse left heel pressure ulcer with betadine daily and apply foam dressing. MR lacked documentation of daily dressing change on 3/22/26 and 3/30/26. Dressing order was changed to every other day on 4/1/26. MR lacked documentation of dressing changes on 4/3/26, 4/4/26, and 4/5/26. e. On 3/23/26 Nursing Note indicated P4 was found to have a new venous stasis ulcer to his/her left calf. Physician order obtained to change dressing to left calf every other day. MR lacked documentation of dressing change to left calf on 4/2/26, 4/3/26 and 4/4/26. f. MR lacked documentation for standardized order for Braden score 15-16 to include turning and repositioning of P4 every two hours and wheelchair cushion as needed when P4 was up in chair. 8. Review of P5 MR indicated: a. On 3/30/26 P5 was admitted to F1 with diagnosis of seizures. Braden score 17, indicating a low risk for skin breakdown. b. On 3/31/26 P5 was ordered to float heels. c. MR lacked documentation heels were floated on 4/4/26 at 1900 hours through 4/5/26 at 0600 hours, from 4/6/26 at 1800 hours through 4/7/26 at 0600 hours, from 4/7/26 at 2000 hours through 4/8/26 at 0700 hours, and 4/9/26 at 1900 hours through 4/10/26 at 0600 hours. d. On 4/14/26 P5 had an order to clean right heel with betadine daily and apply foam dressing. MR lacked documentation of daily dressing changes on 4/15/26 and 4/16/26. 9. Review of P6 MR indicated: a. On 4/23/26 P6 was admitted to F1 with diagnosis of right foot gangrene. Braden score 17, indicating a low risk for skin breakdown. b. On 4/23/26 P6 had an order for daily dressing changes to his/her right heel to cleanse with betadine and cover with gauze dressing. MR lacked documentation of a daily dressing change from 4/23/26 through 5/4/26, and on 5/8/26. d. On 4/23/26 P6 had an order for a daily dressing change to his/her coccyx wound to cleanse with soap and water, pat dry, apply skin prep and foam dressing. MR lacked documentation of daily dressing changes on 4/24/26, 4/25/26, 4/26/26, 4/27/26, 4/28/26, 4/30/26, 5/1/26, 5/2/26, 5/3/26, 5/4/26, and 5/5/26. e. On 4/26/26 Braden score was 16, indicating a moderate risk for skin breakdown. f. MR lacked documentation for standardized order for Braden score 15-16 to include turning and repositioning of P6 every two hours and wheelchair cushion as needed when up in chair. 10. Review of P7 MR indicated: a. On 5/13/26 P7 was admitted to F1 with diagnosis of post status left total hip arthroscopy. Braden score 16, indicating a moderate risk for skin breakdown. b. MR lacked documentation for standardized order for Braden score 15-16 to include application of barrier cream to coccyx two times daily and as needed and wheelchair cushion. 11. Review of P9 MR indicated: a. On 5/29/26 P9 was admitted to F1 with diagnosis of post status right knee replacement. Braden score 15, indicating a moderate risk for skin breakdown. b. MR lacked documentation barrier cream applied to coccyx bid on 5/29/26, 6/1/26, 6/2/26, and applied one time daily on 5/31/26 and 6/3/26. c. On 6/4/26 an order was placed to apply Triad paste to sacral area bid. MR indicated on 6/5/26 Triad paste was applied one time a day, on 6/9/26 MR lacked documentation Triad paste was applied. d. On 6/5/26 a deep tissue injury to P9’s left heel was discovered and order was placed to cleanse left heel with wound cleanser, pat dry, apply thin layer of Triad over wound and cover with foam dressing daily. MR lacked documentation of daily dressing change on 6/8/26, 6/9/26 and 6/10/26. 9. Review of P10 MR indicated: a. On 5/23/26 P10 was admitted to F1 with diagnosis of status post CABG (Coronary Artery Bypass Grafting). Braden score 18 indicated a low risk for skin breakdown. b. MR lacked documentation for standardized order for Braden score 17-18 to include heel offloading. c. On 5/23/26 an order was written to cleanse right calf wound, pat dry, and apply composite dressing every day. MR lacked documentation of daily changes to right calf on 5/23/26, 5/24/26, 5/25/26, 5/26/26, 5/28/26, 5/3026, 6/1/26, 6/2/26, 6/3/26, 6/4/26, and 6/5/26. d. On 5/23/26 an order was written for wound vac dressing changes to P10’s medial chest wound on Monday-Wednesday- Friday. The dressing was changed on Tuesday and Thursday the week of 5/31/26. e. On 6/4/26 a dressing change to a new left ankle wound was performed without an order. f. On 6/5/26 an order was placed for daily dressing changes to P10’s left ankle and MR lacked documentation of a daily dressing change to left ankle on 6/5/26, 6/6/26, and 6/7/26. 10. In interview on 6/11/26 at 1630 hours with A6, he/she confirmed the following: P1: Glucerna supplement was ordered for P1 three times a day and MR lacked documentation P1 received Glucerna supplement on 5/15/26, 5/16/26, 5/17/26, and 5/18/26. P1 had left buttock shearing upon admission to F1 and A6 also confirmed that a patients weight should be shifted every two hours while up in chair. and P1 was up in a chair on 5/2/26 from 0845 hours to 1600 hours with no weight shifts from 0845 hours through 1305 hours and on 5/10/26 from 1200 hours to 1800 hours with no weight shifts documented. On 4/29/26 an order was placed to cleanse the area and apply a barrier cream two times a day. MR lacked documentation of bid treatment to buttock on 5/2/26, 5/3/26, 5/4/26, 5/7/26, 5/9/26, and 5/10/26 with area to the buttock only cleansed and barrier cream applied one time daily. P2: On 12/29/25 P2 had orders to cleanse buttock and apply barrier cream two times daily. MR lacked documentation wound to buttocks was cleansed and barrier cream applied bid on 1/3/26, 1/5/26, 1/7/26, 1/16/26, and 1/17/26. Buttocks were cleansed and barrier cream applied only one time a day, and on 1/6/26, 1/9/26, 1/18/26 and 1/21/26 buttocks were not cleansed or barrier cream applied. P3: On 1/16/26 P3 had orders to cleanse buttock with soap and water, pat dry, apply remedy protect cream two times daily and as needed for incontinence. P3 MR indicated buttock was cleansed and remedy cream applied one time a day on 1/27/26, 2/2/26, 2/5/26, 2/7/26, and 2/12/26. P3 MR lacked documentation buttock was cleansed and remedy cream applied on 1/28/26 and 2/1/26. P4: P4 had orders to cleanse left heel pressure ulcer with betadine daily and apply foam dressing. MR lacked documentation of daily dressing change on 3/22/26 and 3/30/26. Dressing order was changed to every other day on 4/1/26 and MR lacked documentation of dressing changes on 4/3/26, 4/4/26, and 4/5/26. On 3/19/26 P4 had an order for to cleanse right Great toe and second to daily with betadine and MR lacked documentation toes were cleansed with betadine on 3/19/26, 3/20/26, 3/21/26, 3/22/26, 4/5/26 and 4/6/26. P4: P4 had an order to change dressing to left calf every other day and MR lacked documentation of dressing change to left calf on 4/2/26, 4/3/26 and 4/4/26. P4 had an order on 3/19/26 to cleanse buttock and apply barrier cream two times daily and MR indicated buttock cleansed and barrier cream applied one time daily on 3/20/26, 3/21/26, 3/24/26, 3/26/26, and 4/6/26. P5: On 3/31/26 P5 was ordered to float heels and MR lacked documentation heels were floated on 4/4/26 at 1900 hours through 4/5/26 at 0600 hours, from 4/6/26 at 1800 hours, through 4/7/26 at 0600 hours, from 4/7/26 at 2000 hours through 4/8/26 at 0700 hours, and 4/9/26 at 1900 hours through 4/10/26 at 0600 hours. On 4/14/26 P5 had an order to clean right heel with betadine and apply foam dressing and MR lacked documentation of daily dressing changes on 4/15/26 and 4/16/26. P6: On 4/23/26 P6 had an order for daily dressing changes to his/her right heel and MR lacked documentation of a daily dressing change from 4/23/26 through 5/4/26, and on 5/8/26. P6 had an order for a daily dressing change to his/her coccyx wound and MR lacked documentation of daily dressing changes on 4/24/26, 4/25/26, 4/26/26, 4/27/26, 4/28/26, 4/30/26, 5/1/26, 5/2/26, 5/3/26, 5/4/26, and 5/5/26. P7: On 5/13/26 P7 lacked documentation of standardized order to apply barrier cream to coccyx two times daily and wheelchair cushion. P9: On 6/5/26 P9 had an order for daily dressing change to his/her heel and MR lacked documentation of daily dressing change on 6/8/26, 6/9/26 and 6/10/26. On 6/4/26 P9 had an order for dressing changes to sacral area two times daily and MR lacked documentation of dressing change performed at all on 6/9/26. Dressing changes to sacral area were changed one time daily on 6/5/26. MR lacked documentation for standardized order for Braden score 15-16 to include application of barrier cream to coccyx two times daily and as needed and wheelchair cushion. MR lacked documentation barrier cream applied to coccyx bid on 5/29/26, 6/1/26, 6/2/26, and applied one time daily on 5/31/26 and 6/3/26. P10: On 5/23/26 an order was written for dressing changes to P10’s right calf every day and MR lacked documentation of daily changes to right calf on 5/23/26, 5/24/26, 5/25/26, 5/26/26, 5/28/26, 5/3026, 6/1/26, 6/2/26, 6/3/26, 6/4/26, and 6/5/26. On 6/4/26 a dressing change to P10’s left ankle was performed without an order. On 5/23/26 an order was written for wound vac dressing changes to P10’s medial chest wound on Monday-Wednesday- Friday and dressing was changed on Tuesday and Thursday the week of 5/31/26. On 6/5/26 an order was placed for daily dressing changes to P10’s left ankle and MR lacked documentation of a daily dressing change to left ankle on 6/5/26, 6/6/26, and 6/7/26.”

“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: 50584 Based on document review and interview, nursing services failed to provide documentation of an event report for a venous stasis ulcer that was not present on patient admission to F1 in 1 of 10 MRs (Medical Records) reviewed. (P4) Findings include: 1. Facility policy titled Wound Assessment and Documentation, Policy # 2, Last Reviewed Date: 11/20/2025, indicated on page 5, under VI. Policy adherence and Reporting, 1. The following situations require completion of an event report through the hospital Electronic Event Reporting System. A. If a patient is admitted without a documented pressure injury, but develops a pressure injury. Stage 2 or greater. 2. Facility policy titled Electronic Event Reporting, Policy # 600, Last Reviewed Date: 5/15/2025, page 1 under Purpose: To establish guidelines to report and document certain events involving patients, visitors, volunteers, etc., at the hospital in a system that provides a confidential mechanism of identification, tracking, trending, and follow-up of all such events. Page 2, under Policy: The foundation of a Risk Management program is based upon the ability to promptly obtain important facts and the details of the circumstances surrounding an event within a reasonable time frame of when the event occurred. To this end, an event report is to be completed for every occurrence which meets the following definition: any happening not consistent with the routine care or operation of the facility, or the desired routine care of the patient and/or operation of the facility, which places our patients and visitors at increased risk for harm. 3. Review of P4 MR indicated: a. On 3/16/26 P4 was admitted to F1 with diagnosis of post status left total knee arthroplasty. Braden score was a 16 indicating a moderate risk for skin breakdown. b. On 3/23/26 P4 was found to have a new venous stasis ulcer to his/her left calf. 4. Review of Incident Reports from 12/11/25 through 6/11/25 lacked an incident report related to P4 wound to his/her left calf. 5. In interview on 6/11/26 at 1200 hours with A2 (Director Quality/Risk), he/she confirmed an incident report should have been filled out on 3/23/26 for a new venous stasis ulcer discovered on P4’s left calf. A2 confirmed there was not an incident report.”

“MEDICAL STAFF CFR(s): 482.22 The hospital must have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital. This Condition is not met as evidenced by: 50584 Based on document review and interview physicain failed to write and/or give a verbal order for orthotic braces and spinal precautions in 2 of 10 MRs (Medical Records) reviewed. (P2, P10); Physician failed to write and/or give a verbal order for Oxygen upon patient admission to facility in 1 of 10 MRs reviewed. (P3) The cumulative effects of these systemic problems resulted in the facility’s inability to provide quality Medical Services.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 50584 Based on document review and interview, the facility failed to document follow-up and education to staff involved in complaint/grievance for 1 of 10 MRs (Medical Records) reviewed. (P3) Findings include: 1. Facility policy titled Patient and Customer Complaint or Grievance, Policy # 8, Last Reviewed Date: 08/15/2024, Page 3 under Patient Grievances-Actions to be taken, The hospital must review, investigate and resolve each patient’s grievance within a reasonable timeframe and provide a written response. 5. Hospital Human Resources will follow up with departmental supervisor for action taken regarding employee issues, if indicated. 2. Complaint Raised: 02/28/2025, Concern Involves: General Care, Medication related, Relevant Departments: Nursing, Description of Complaint: FM2 (Spouse) left message on 2/27/25 that he/she does not want N2 (RNT [Rehabilitation Nursing Technician]) to care for P3 again. N2 did not put P3’s back brace on him/her until P3 was out of bed and applied it incorrectly. FM2 indicated N2 left P3 in the bathroom without brace on and was pulling on his/her arms to get him/her out of bed. FM2 is afraid for N2 to take care of P3. Action Taken: Education provided in real time by N1 (CRRN [Certified Rehabilitation Registered Nurse]) and OT (Occupational Therapist) with N2 regarding brace, how to put it on and the need for it. Coaching tool also provided to N2. N1 spoke with FM2 about concerns and apologized for the care P3 received on 2/27/25. FM2 was pleasant and appreciated the apology and someone coming to talk with her. N1 explained facility will follow up with N2 and education will be given to him/her about the situation. N2 would not be assigned top P3’s care for the remainder of his/her stay. Resolution date and time: 3/05/2025 1016 hours Central. Complaint/Grievance lacked documentation on Coaching tool and follow up education provided to N2. 3. Personnel file for N2, lacked documentation of a coaching tool and reeducation for incident on 2/27/25. 4. In interview on 3/26/25 at 1125 hours with A1 (Director of Quality Risk), he/she confirmed there is no documentation of education/coaching tool for staff regarding use of brace on P3. 5. In interview on 3/26/25 at approximately 1515 hours with N2, he/she confirmed not receiving education or coaching tool regarding any incident involving an orthotic brace.”

“MEDICAL STAFF BYLAWS CFR(s): 482.22(c) The medical staff must adopt and enforce bylaws to carry out its responsibilities. The bylaws must: This Standard is not met as evidenced by: 50584 Based on document review and interview physician failed to write and/or give a verbal order for orthotic braces and spinal precautions in 2 of 10 MRs (Medical Records) reviewed. (P2, P10); Physician failed to write and/or give a verbal order for Oxygen upon patient admission to facility in 1 of 10 MRs reviewed. (P3) Findings include: 1. Facility policy titled Care Planning, Policy # 230, Last Reviewed Date: 08/15/2024, Page 1, under Purpose: All inpatients will have a plan of care developed by the interdisciplinary team (IDT) responsible for their care which included provider’s orders. 2. Facility policy titled Supplemental Oxygen, Policy # 300, Last Reviewed Date: 05/16/2024, Page 1, under Policy: Supplemental oxygen is provided pursuant to a prescriber order and may be initiated by a registered nurse or respiratory therapist. Physician Orders: The use of oxygen requires an order from physician or physician extender authorized to order medications. 3. Facility Medical Staff Bylaws, last approved by the Governing Board 2/20/2025, Page 2, 2.2 Responsibilities of the Medical Staff. It shall be the responsibility of the Medical Staff, acting through the Medical Executive Committee as authorized by these Bylaws, to account to the Governing Board for the quality, safety, and appropriateness of patient care provided by Practitioners, by the way of the following measures: Page 3, 2.2.6 Drugs and Biologicals and Other Services. Orders for drugs, biologicals, and other services (including, but not limited to, rehabilitation and respiratory services shall be made by a Practitioner responsible for the care of the patient, acting within his or her scope of practice under State law, and who is authorized by these Bylaws to order the drugs, biologicals, or other services in accordance with the Medical Staff rules and regulations and/or Hospital policies. 4. Review of P2 MR indicated: a. P2 was admitted on 3/8/25 with diagnosis of Atrial fibrillation, CAD (Coronary Artery Disease) and L4 (fourth lumbar vertebra) fracture. b. History and Physical on 3/9/25 at 0920 hours indicated under Impression and Plan: Monitor and manage pain, LSO (Lumbosacral orthosis) when out of bed. c. MR lacked documentation of an order for LSO brace when out of bed and/or spinal precautions. d. Physician Progress Note on 3/10/25 at 1824 hours indicated under Rehab Risks/Complications Plan and Recommendations to mitigate the risks: Spinal precautions, neighboring as tolerated bilateral lower extremities. (TSLO [Thoracic-Lumbar-Sacral Orthosis]) when out of bed. Patient has bilateral foot drops he will be advised to wear ankle-foot orthosis to prevent high steppage gait and falls. e. MR lacked documentation of an order for TSLO orthotic and bilateral ankle-foot orthosis. 5. Review of P3 MR indicated: a. P3 admitted on 2/25/25 with diagnosis of Cervical neck fracture, T10 fracture and Acute hypoxic respiratory failure secondary to pneumonia. b. Adult Admission Assessment on 2/25/25 at 1830 hours indicated under Vital signs: Oxygen flow rate 3 Liters per Nasal Cannula Continuous. c. MR lacked documentation of an order for Oxygen 3 Liters per Nasal Cannula Continuous. 6. Review of P10 MR indicated: a. P10 admitted on 12/30/24 with diagnosis of Status post T11-L3 fusion, and major multiple trauma. b. Physical Therapy Initial Evaluation on 12/31/25 at 1100 hours indicated patient required spinal precautions and Jewett brace prior to transition. c. History and Physical on 12/31/25 at 1931 hours indicated a cervical collar and Jewett brace was recommended. d. MR lacked documentation of an order written for cervical collar, Jewett brace and spinal precautions. 7. In interview on 3/26/25 at 1230 hours with A8 (CNO [Chief Nursing Officer]), he/she confirmed an order should be written if a patient is to wear an orthotic brace with instructions on type of brace, when to apply brace and duration the patient must wear brace. A8 confirmed P2’s MR lacked order for back brace, spinal precautions, bilateral extremity braces when out of bed and P10’s MR lacked documentation of order for cervical collar, Jewett brace and spinal precautions. 8. In interview on 3/26/25 at approximately 1300 hours with A4 (RRT [ Registered Respiratory Therapist]), he/she confirmed documentation indicated P3 was wearing oxygen on 2/25/25, and an order was not placed for oxygen until 2/27/25.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 50584 Based on document review and interview, nursing services failed to maintain documentation of the application of an orthotic brace when patient out of bed in 3 of 10 MRs reviewed. (P2, P3, P10) Findings include: 1. Facility policy titled Assessment, Re-Assessment, Policy #3, Last Reviewed Date: 08/15/2024, under Policy IV. Reassessment across all disciplines is ongoing and occurs at designated intervals during the patient’s stay/treatment to determine the response to and effectiveness of certain care, treatment and services received. 2. Review of P2 MR indicated: a. P2 was admitted on 3/8/25 with diagnosis of Atrial fibrillation, CAD (Coronary Artery Disease) and L4 (fourth lumbar vertebra) fracture. b. History and Physical on 3/9/25 at 0920 hours indicated under Impression and Plan: Monitor and manage pain, LSO (Lumbosacral orthosis) when out of bed. c. Physician Progress Note on 3/10/25 at 1824 hours indicated under Rehab Risks/Complications Plan and Recommendations to mitigate the risks: Spinal precautions, weight bearing as tolerated bilateral lower extremities. (TSLO [Thoracic-Lumbar-Sacral Orthosis]) when out of bed. Patient has bilateral foot drops he will be advised to wear ankle-foot orthosis to prevent high steppage gait and falls. d. Foresheets lacked documentation of RNT (Rehabilitation Nursing Technicians) applying orthotic braces when P2 out of bed, including, but not limited to dates from 3/19/25 at 1500 hours through 3/20/25 at 1100 hours. 3. Review of P3 MR indicated: a. P3 admitted on 2/25/25 with diagnosis of Cervical neck fracture, T10 fracture and Acute hypoxic respiratory failure secondary to pneumonia. b. Adult Admission Assessment on 2/25/25 at 1830 hours indicated under Vital signs: Oxygen flow rate 3 Liters per Nasal Cannula Continuous. c. MR lacked documentation of an order for Oxygen 3 Liters per Nasal Cannula Continuous. d. Order sheet on 2/25/25 at 1833 hours indicated Brace must remain on while patient is up out of bed. Order comments: may remove at night for comfort, brace must be put on before all out of bed activities. Spinal Precautions No twist/bend with bed mobility/transfer. e. Physical Therapy note on 2/27/25 at 1530 hours indicated upon arrival to P3’s room, P3 sitting on commode without Jewett brace on, educated patient and spouse that the nursing staff should have donned the brace prior to the patient leaving the bed. PT (Physical Therapist) immediately donned brace while Patient was on commode. Patient reported 9/10 pain in back. f. Flowsheets lacked documentation of RNT applying orthotic brace to patient when out of bed including, but not limited to on 2/27/25 from 0800 hours through 2000 hours, and 3/2/25 at 1900 hours through 3/3/25 at 1108 hours. g. Physician Discharge Summary indicated P3 Condition at time of Discharge: Stable. Prognosis: guarded. 4. Review of P10 MR indicated: a. P10 admitted on 12/30/24 with diagnosis of Status post T11-L3 fusion, and major multiple trauma. b. Physical Therapy Initial Evaluation on 12/31/25 at 1100 hours indicated patient required spinal precautions and Jewett brace prior to transition. c. Flowsheets lacked documentation of RNT applying orthotic braces to P10 when out of bed including, but not limited to from 12/30/25 at 2000 hours through 1/1/25 at 0800 hours. 5. In interview on 3/26/25 at 1230 hours with A8 (CNO [Chief Nursing Officer]), he/she confirmed if the patient must wear brace, it should be documented in medical record if staff placed brace on patient for activities of ambulation, up to bathroom or up in chair. A8 confirmed P2 MR lacked documentation of application of braces by technicians with patient transfers and ambulation; P3 MR lacked documentation of technicians applying brace to patient prior to ambulation and transfers; P10 MR lacked documentation of application of brace by technicians with patient transfers and ambulation.”

“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: 50584 Based on document review and interview, Nursing services failed to turn and reposition patients as ordered in 5 of 10 MRs (Medical Records) reviewed (P1, P2, P3, P4, P6); failed to perform daily dressing changes and/or apply daily barrier cream to patients in 3 of 10 MRs reviewed (P1, P2, P10); failed to document wound measurements in 5 of 10 MRs reviewed (P1, P4, P7, P8, P9); failed to document wound photographs in 5 of 10 MRs reviewed. ( P1, P3, P7, P8, P9). (tag 0395) and failed to document follow up and education to staff involved in missed dressing changes for 1 of 10 MRs (Medical Records) reviewed. (P10) (tag 0398). The cumulative effects of this systemic problem resulted in the facilities inability to provide nursing services in a safe manner.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 50584 Based on document review and interview, the facility failed to provide documentation of a RCA (Root Cause Analysis) for 1 of 1 Adverse Events reviewed. (P10) Findings include: 1. Facility policy titled Electronic Event Reporting, Policy # 600, Last Reviewed Date 05/16/2024, Page 2, under Policy, An event report is to be completed for every occurance which meets the following definition: any happening not consistent with the routine care or operation of the facility, or the desired routine care of the patient and/or operation of the facility, which places our patients and visitors at increased risk for harm. The Quality Committee has delegated the task of investigation of adverse events to the DQR (Director of Quality Risk), and the DQR may designate individuals to assist with these investigations as needed. Page 4, under II. Response to Sentinel Event: The Governing Board/Quality Committee has delegated the task of investigation of adverse events determining if an adverse event meets the definition of a sentinel event and if so, completing a Root Cause Analysis to the Director of Quality/Risk (DQR) 2. Facility policy titled Sentinel Events, Policy # 692, Last Reviewed Date: 5/16/2024, Page 1, under Definitions: Sentinel Event: For the purpose of this policy, A Sentinel Event is defined as a patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches a patient and is considered “sentinel” because it signals a need for immediate investigation and response. Page 4, under II. Response to Sentinel Event: The Governing Board/Quality Committee has delegated the task of investigation of adverse events determining if an adverse event meets the definition of a sentinel event and if so, completing a Root Cause Analysis to the Director of Quality/Risk (DQR), and the DQR may designate individuals to assist with investigation as needed. Under Non-Reviewable Root Cause Analysis, Page 5, 1. Upon determination or suspicion that a Non-Reviewable Sentinel Event has occurred, the DQR may choose to do a Modified Root Cause Analysis and Action Plan form. 3. Event dated 1/7/25, Entered date 1/8/25, P10 admitted to facility on 12/27/24, indicated a patient care advocate noted a bad odor in patients room and requested surgical incision to be checked. Nurse entered room, noticed bad smell, removed dressing and noted wound to be dehisced and infected. Wound cleansed, redressed and physician notified. Later that evening the physician assessed wound and ordered antibiotics. An order was previously written for daily dressing changes on 12/30/24 due to patient having excess drainage, multiple nurses ignored the order, and the dressing change only completed a couple of times since 12/20/24.Security level D. No harm-Reached patient monitoring required. Sentinel Event: yes, No outcome actions or subsequent actions listed. Event lacked documentation of a Root Cause Analysis. 4. In interview on 3/12/25 at approximately 1120 hours with A3, he/she confirmed that there was no follow up education with employees involved in the incident reported on 1/7/25 of missed dressing changes on dates 12/31/24, 1/3/25 and 1/4/25 for P10 and event lacked documentation of Root Cause Analysis.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 50584 Based on document review and interview, Nursing services failed to turn and reposition patients as ordered in 5 of 10 MRs (Medical Records) reviewed (P1, P2, P3, P4, P6); failed to perform daily dressing changes and/or apply daily barrier cream to patients in 3 of 10 MRs reviewed (P1, P2, P10); failed to document wound measurements in 5 of 10 MRs reviewed (P1, P4, P7, P8, P9); failed to document wound photographs in 5 of 10 MRs reviewed. ( P1, P3, P7, P8, P9) Findings include: 1. Facility policy titled Wound Assessment and Documentation, Policy #2, Last reviewed Date: 08/15/2024, indicated on Page 2, under Policy: All patients admitted to the hospital will be screened within 8 hours for risk of skin breakdown and for alteration in skin integrity by a registered nurse. For a Braden score of 18 or less, the Pressure Injury Prevention Protocol will be initiated and incorporated into the plan of care. I. Assessment: An RN (Registered Nurse) will inspect each patient’s skin daily and as often as indicated. 1. The Braden Scale is used to assess all patients for risk of skin breakdown. Findings are recorded upon admission and weekly at a minimum. A. A full skin assessment is completed within 8 hours of admission (or discovery of a new wound) to include descriptions, measurements, and physician notification if applicable. D. Pressure injuries/ulcers will be staged, measured, and photographed in accordance with the wound treatment plan, but no less than weekly. E. Within 2 days before discharge a final complete assessment is conducted, including descriptions, staging, measuring, and photography as appropriate. 3. Skin tears, procedure-related wounds, or lower extremity ulcers (arterial, venous, or neuropathic) are not staged unless pressure is a primary factor. These types of alterations in skin integrity should be described, measured and photographed as addressed further in this policy. Page 4, under III. Documentation: 2. Daily documentation of skin and wound inspection completed by an RN will include the following, if present: A. skin condition, B. dressing integrity, C. description of wound drainage, odor, pain, signs of inflammation or infection, if present. Page 5, IV. Wound Photography: 2. The following wounds are to be photographed within 24 hours of discovery, weekly, and within 2 days of discharge as below: A. all pressure injuries/ulcers Stage 2 or above, B. any procedure-related wound that is not proceeding on an expected healing course, C. any other alterations in skin integrity with significant clinical characteristics such as drainage or signs of infection, D. any wound that would trigger the completion of a Skin/Tissue Electronic Event Report. 2. Review of P1 MR indicated: a. P1 admitted to the facility on 1/15/25 with Diagnosis of Acute metabolic encephalopathy. Braden Scale Score 14. (Moderate risk for pressure ulcer development) b. Patient admitted to facility with traumatic wound to top of Left foot, MR lacked documentation of wound measurements of left foot from 1/15/25 through 1/29/25, MR lacked documentation of photograph within two days of discharge. c. Wounds to Right Posterior Lower Leg and Right Anterior Lower Leg were measured on 1/17/25, MR lacked documentation of wound measurements from 1/18/25 through 1/29/25. d. On 1/17/25 wound to coccyx noted and wound care nurse ordered barrier cream to apply as needed and with each incontinent episode as a preventative measure, lacked documentation of barrier cream applied to coccyx from 1/17/25 through 1/24/25. e. Nursing flowsheets lacked documentation of turning and repositioning patient including, but not limited to 1/15/25 at 2100 hours through 1/16/25 at 1400 hours. Patient required assistance to turn and reposition. 3. Review of P2 MR indicated: a. P2 admitted to the facility on 12/27/24 with Diagnosis of Encephalopathy. Braden Scale Score 16. (Mild risk for pressure ulcer development) b. Patient was on dialysis, diabetic with a surgical incision and abscess on left thigh. Patient unable to reposition self. c. On 12/27/24 initial assessment indicated skin to buttock red and blanchable, on 12/30/24 wound care nurse ordered Remedy Protect: apply to buttock area as needed and with incontinent episodes, cream applied to area on 12/30/24 and 1/2/25 through 1/6/25. Lacked documentation of preventative cream applied on 12/31/24, 1/1/25 and 1/7/25. d. On 12/31/24 orders for repositioning with pillow support, off-load heels, Reposition per patients’ needs. e. MR lacked documentation of turning and repositioning patient per order including, but not limited from 12/28/24 at 0600 hours through 12/28/24 at 1700 hours. Patient dependent on repositioning. 4. Event dated 1/8/25, P2 admitted to facility on 12/27/24, indicated a deep tissue pressure to gluteal cleft discovered by nursing staff. Two areas were still dark purple and non-blanchable, the rest was 100% adherent slough tissue. P2 is a Hoyer lift/slide board transfer. P2 incontinent of urine and stool. Wound is most likely a pressure injury to contributing factors of shearing and moisture. 5. Review of P3 MR indicated: a. Patient was admitted to the facility on 2/7/25 with Diagnosis of Femur fracture. Braden Scale Score 16. (Mild risk for pressure ulcer development) b. Patient admitted with surgical incision to left hip. Patient incontinent of bowel and bladder. c. MR lacked documentation of turning and repositioning patient including, but not limited to, from 2/7/25 from 1200 hours through 2/7/25 at 2000 hours, 2/8/25 at 0500 hours through 2/8/25 at 2300 hours, 2/8/25 at 0200 hours through 2/9/25 at 1200 hours. Patient dependent for repositioning. d. On 2/10/25 wound care order placed to cleanse sacral area with soap and water, apply skin prep and Optiview dressing every 5 nights, pressure relief when up in chair with specialty cushion, reposition with pillow support in bed, off-load heels. e. On 2/13/25 wound care nurse notified of DTPI (Deep Traumatic Pressure Injury) and wound care orders placed to cleanse wound with soap and water and apply Plurogel and foam dressing to sacral area. f. Lacked documentation of photograph of sacral wound within 2 days of discharge on 2/28/25. 6. Review of P4 MR indicated: a. Patient was admitted to the facility on 1/28/25 with Diagnosis of CVA with left side affected. Colon Cancer with status post colostomy and Chronic kidney Disease stage 3. PEG (Percutaneous Endoscopic Gastrostomy) tube placement. Braden Score 15. (Mild risk for pressure ulcer development) b. Patient admitted to the facility with a sacral deep tissue pressure injury measuring 4.8 cm (centimeters) long x 3.5 cm wide x 0.2 cm depth. Maceration noted to scrotum and groin area. Photographs taken of wounds on admission. c. On 1/29/25 wound care orders for groin, sacral area and scrotum: Cleanse with Anacept wound cleanser, pat dry, do not scrub. Apply skin prep to peri wound, apply Anacept gel to wound bed and apply sacral foam at bedtime daily and as needed with soiling, saturation or dislodgement. d. Orders on 1/29/25 Advanced boot to stroke affected side (Left side), Blue boot to right foot, Float heels while in bed. Reposition patient as needed when up in chair. Reposition with pillow support in bed, check for toileting incontinence. Order comments: Reposition per patients’ needs, Evolving DTPI to sacrum, incontinent and dependent for mobility. e. On 2/11/25 a blister to the abdomen was noted, MR lacked documentation of measurements of wound from 2/11/25 through 2/19/25. f. On 2/18/25 wound noted to end of penis, lacked documentation of measurements. g. On 2/18/25 deep tissue injury noted to left heel measuring 5 cm x 6 cm x 0 cm. Off-loading boots were not on patient as ordered at the time the wound was discovered. Order placed to paint heel with betadine every 3 days and place optiview dressing. Daily head to toe skin assessment from 1/28/25 through 2/17/25 lacked documentation of any skin alterations to left heel. h. Nursing flowsheets lacked documentation of turning and repositioning patient including, but not limited to, from 1/28/25 at 1900 hours through 1/29/25 at 0600 hours. Patient dependent on repositioning and transfers with Hoyer lift. i. Sacral wound on 2/18/25 measured 12.5 cm x 15 cm x 1 cm. j. Patient discharged to skilled nursing facility on 2/19/25. 7. Event dated 2/18/25, P4 admitted to facility on 1/28/25, indicated wound care nurse making routine rounds and discovered P4 in bed without off-loading heel boots. Blood blister to left heel noted. Wound care completed and off-loading boots applied, and patient repositioned to right side with pillow support. 8. Review of P6 MR indicated: a. Patient admitted to the facility on 2/19/25 for Diagnosis of UTI (Urinary Tract Infection). Braden Scale Score 17 (Mild risk for pressure ulcer development) b. On 2/20/25 orders written per wound nurse to Float heels in bed, reposition as needed when up in chair, reposition with pillow support in bed, check every 2 hours, if area of skin is not red may increase the time patient stays on that side, if patient is red reduce the time the patient needs to be turned. Wheelchair cushion. c. Nursing flowsheets lacked documentation of turning and repositioning patient every 2-3 hours per order including, but not limited to, from 2/19/25 at 1300 hours through 2/20/25 at 1300 hours. Patient required moderate assist to turn and reposition. 9. Review of P7 MR indicated: a. Patient admitted to the facility on 1/29/25 with Diagnosis of Hip fracture. Braden Scale Score 14. (Moderate risk for pressure ulcer development) b. Patient admitted with wounds: left lower leg venous ulcer, right lower leg venous ulcer, left heel pressure injury and left lateral leg incision. c. MR lacked wound measurements to Left lower leg venous ulcer and right lower leg venous ulcer from 1/29/25 through 2/11/25. MR lacked photograph of wounds within 2 days prior to discharge. d. MR lacked documentation of measurements to right heel wound from 1/30/25 through 2/11/25. Lacked photograph of wound from 1/30/25 through 2/11/25. 10. Review of P8 MR indicated: a. Patient admitted to the facility on 1/27/25 with Diagnosis of Wound Dehiscence. Braden Scale Score 16. (Mild risk for pressure ulcer development) b. Patient admitted with right hip skin tear, right breast skin tear, buttock skin damage and right chest surgical incision. c. MR lacked documentation of right hip skin tear measurements and photographs from 1/27/25 through 2/9/25. d. MR lacked documentation of right breast skin tear measurements from 1/27/25 through 2/9/25. Lacked documentation of wound photographs from 1/28/25 through 2/9/25. e. MR lacked documentation of right chest surgical incision measurements from 1/27/25 through 2/9/25. Lacked documentation of wound photographs from 1/28/25 through 2/9/25. 11. Review of P9 MR indicated: a. Patient admitted to the facility on 2/12/25 with Diagnosis of 7-9 Posterior rib fracture. Braden Scale Score 18. (Mild risk for pressure ulcer development) b. Admitted with left heel fissure. Lacked documentation of measurements to wound from 2/12/25 through 2/19/25. MR lacked documentation of wound photographs from 2/13/25 through 2/19/25. 12. Review of P10 MR indicated: a. Patient admitted to the facility on 12/27/24 with Diagnosis of Right hip fracture. Braden Scale Score 18. (Mild risk for pressure ulcer development) b. Patient admitted with an abdominal incision. MR lacked measurement of incision on admission. Incision open to air. c. On 12/30/24 order written for daily dressing change to abdominal incision due to increased drainage. d. MR lacked documentation of daily dressing change to abdomen on 12/31/24, 1/3/25 and 1/4/25. 13. In interview on 3/12/25 at approximately 1200 hours with A4 (Wound Program Coordinator), he/she indicated they do not measure every wound that comes into the facility. A4 indicated the wounds that are measured are pressure wounds, or those wounds that require a Wound Vacuum. A4 or N1 (Wound Care Nurse) write the wound care orders for patients, precautionary measures to prevent further skin breakdown including but not limited to turning and repositioning patients, and off-loading measures including but not limited to air mattress and heel protectors. A4 confirmed P1’s MR lacked documentation of wound measurements, photographs, turning and repositioning of patient, and no barrier cream applied to coccyx as ordered on 1/17/25 through 1/24/25; P2’s MR lacked documentation of turning and repositioning patient and applying barrier cream to patients coccyx on 12/3/24, 1/1/25 and 1/7/25 as ordered; P3’s MR lacked documentation of photograph of sacral wound within 2 days prior to discharge and turning and repositioning patient as ordered; P4’s MR lacked documentation of turning and repositioning patient as ordered and wound measurements of abdomen, penis and groin; P6’s MR lacked documentation of turning and repositioning patient as ordered; P7’s MR lacked documentation of wound measurements of right and left leg venous ulcers from 1/29/25 through 2/11/25, lacked wound measurements and photograph of right heel from 1/30/25 through 2/11/25, and turning and repositioning patient as ordered; P8’s MR lacked documentation of right hip skin tear measurements and photographs from 1/27/25 through 2/9/25, right breast skin tear measurements from 1/27/25 through 2/9/25 and wound photographs from 1/28/25 through 2/9/25, right chest surgical incision measurements from 1/27/25 through 2/9/25 and photographs from 1/28/25 through 2/9/25; P9’s MR lacked documentation of left heel fissure measurements from 2/12/25 through 2/19/25 and lacked documentation of wound photographs from 2/13/25 through 2/19/25; P10’s MR lacked documentation of daily dressing change to abdomen per order on 12/31/24, 1/3/25 and 1/4/25. A4 also confirmed if repositioning of patients is ordered, it is per patients’ needs. If the patient is dependent on turning and repositioning it is every 2 hours.”

“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: 50584 Based on document review and interview Nursing Services failed to document follow up and education to staff involved in missed dressing changes for 1 of 10 MRs (Medical Records) reviewed. (P10) Findings include: 1. Facility policy titled Electronic Event Reporting, Policy # 600, Last Reviewed Date 05/16/2024, Page 2, under Policy, An event report is to be completed for every occurance which meets the following definition: any happening not consistent with the routine care or operation of the facility, or the desired routine care of the patient and/or operation of the facility, which places our patients and visitors at increased risk for harm. The Quality Committee has delegated the task of investigation of adverse events to the DQR (Director of Quality Risk), and the DQR may designate individuals to assist with these investigations as needed. 2. Review of P10 MR indicated: a. a. Patient admitted to the facility on 12/27/24 with Diagnosis of Right hip fracture. Braden Scale Score 18. (Mild risk for pressure ulcer development) b. On 12/30/24 order written for daily dressing change to abdominal incision due to increased drainage. c. MR lacked documentation of daily dressing change to abdomen on 12/31/24, 1/3/25 and 1/4/25. 3. Event dated 1/7/25, Entered date 1/8/25, P10 admitted to facility on 12/27/24, indicated a patient care advocate noted a bad odor in patients room and requested surgical incision to be checked. Nurse entered room, noticed bad smell, removed dressing and noted wound to be dehisced and infected. Wound cleansed, redressed and physician notified. Later that evening the physician assessed wound and ordered antibiotics. An order was previously written for daily dressing changes on 12/30/24 due to patient having excess drainage, multiple nurses ignored the order, and the dressing change only completed a couple of times since 12/20/24.Security level D. No harm-Reached patient monitoring required. Sentinel Event: yes, No outcome actions or subsequent actions listed. 4. In interview on 3/12/25 at approximately 1120 hours with A3, he/she confirmed that there was no follow up education with employees involved in the incident reported on 1/7/25 of missed dressing changes on dates 12/31/24, 1/3/25 and 1/4/25 for P10.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 49128 Based on document review and interview, the facility failed to provide safe environment for patients by failing to make timely corrections to known issue with coffee temperature in 2 of 10 instances. Findings include; 1. Review of P1’s MR indicated the following: a. Facility admission 1/29/24 through 2/13/24 for acute cerebral vascular accident (CVA) and hypertension (HTN). b. Nurses note entered 2/3/24 at 6:30 am indicated P1 was burned from spilling a cup of hot coffee on his/her right leg. Medical Doctor (MD) was notified and orders received to cleanse burned area, apply ice and silver sulfadine cream. c. Wound care note entered 2/6/24 at 2:15 pm indicated P1 had been seen at his/her dermatology office as an outpatient, where the partial thickness burn, 2nd degree, had been assessed by the dermatologist. 2. Incident report for P2, entered 1/2/24 at 4:06 pm, indicated incident occurred 12/27/23 at 8:00 am. Incident report indicated P2 spilled coffee on his/her chest. Wound care notified day of spill, and there was some redness noted. No interventions ordered. A couple days later, the skin looked like it was peeling. Plurogel was ordered. 3. Review of facility document work order indicated a work order was placed 2/4/24 at 11:17 am. In the description area read “Patient injury on 2/3/24 from hot coffee spill. Please check/adjust temperature of coffee brewed in nutrition rooms on NUR1 and NUR2.” The general notes area indicated a technician looked at the coffee machines, and determined they were set to the lowest temperature setting. 4. Review of facility Operations Committee Meeting minutes, dated 2/5/24, indicated the coffee machines in patient areas were discussed. Action/Discussion section of this indicated the Facilities Management director would contact the coffee machine vendor and request the temperature be turned down. Alternative cups would be looked for. Staff would be instructed to put ice in the coffee before giving it to patients, and would ensure a lid on the cup before giving it to the patients. 5. In interview, on 5/23/24 at approximately 3:50 pm, A4 (Facilities Management Director) verified he/she called the rental company that the facility rents the coffee machines from to ask about decreasing the coffee machine temperatures. The rental company is to come next week to install a temperature regulator on the coffee machines. No visit by rental company had occurred at time of survey.”