Community Health Network 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: 48704 Based on document review, interview, and observation, nursing services failed to complete hourly rounding for 8 of 10 (patients 1, 2, 4, 6, 7, 8, 9, and 10) medical records reviewed; failed to document output for 1 of 10 (patient 4) medical records reviewed; failed to follow provider orders for 1 of 10 (patient 4) medical records reviewed; and failed to notify provider of change in patient condition for 1 of 10 (patient 4) medical records reviewed. The cumulative effects of these systemic problems resulted in the facility’s inability to provide nursing care in a safe manner.”

“LICENSURE OF NURSING STAFF CFR(s): 482.23(b)(2) The nursing service must have a procedure in place to ensure that hospital nursing personnel for whom current licensure is required have a valid and current licensure. This Standard is not met as evidenced by: 48704 Based on document review and interview, the facility failed to ensure that all nursing staff had a valid and current license. Findings include: 1. Facility policy titled, Assessment adn Reassessment, Policy PC130, Effective Date February 19, 2026, under Procedure indicated, The initial Nursing Assessment is completed on each patient by a Registered Nurse within 24 hours of admision, in order to assess the patient’s nursing care needs and obtain information for initiating the rehabilitation nursing plan of care; to identify patients who are at functional or nutritional risk; to determine potential discharge planning needs; and to orient the patient and family members to the Hospital environment and routine activities. 2. Review of the investigative report dated June 2024 for S1 (Former Employee) indicated the following: a. S1 was hired on 10/23/2023. S1 had a current license for a Licensed Practical Nurse and a temporary registered nurse state license which expired on 02/28/2024. b. On June 5, 2024, the facility was notified that S1’s temporary license expired on 02/28/2024. c. S1 indicated that they had not passed the National Council Licensure Examination and knew that their temporary license had expired and did not share this with the facility. d. A review of the patients assigned to S1 from 02/28/2024 through 05/29/2024 completed admission assessments for 9 patients. 3. Interview with A1 on 06/15/2026 at approximately 10:20 a.m. indicated that the facility should have verified that S1 held a valid state license as a Registered Nurse.”

“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: 48704 Based on document review, interview, and observation, nursing failed to document output in 1 of 10 (patient 4) medical records reviewed, failed to follow provider orders in 1 of 10 (patient 4) medical records reviewed, failed to notify provider of patient condition change in 1 of 10 (patient 4) medical records reviewed, and failed to complete hourly rounding in 8 of 10 (patients 1, 2, 4, 6, 7, 8, 9, and 10) medical records reviewed. Findings include: 1. Facility Policy titled, Recognition and Response To Change in Patient’s Condition, Policy PC 325, effective date May 22, 2025, indicated under Change in Medical Status, All clinical staff should be able to recognize the signs and symptoms of a decline in medical status and seek additional help to avoid medical crisis. 2. Facility policy titled, Nursing Interventions and Clinical Skills, Policy PC 535, effective date May 22, 2025, indicated under Policy, It is the policy of the nursing department to utilize the Lippincott Williams and Wilkins Guide to Nursing Procedures to provide guidance and direction for clinical practice in the absence of any specific Hospital nursing intervention or clinical skill policies or procedures. 3. Review of Lippincott Williams and Wilkins Guide, titled Intake and output measurement. revised April 21, 2026, indicated under introduction, Fluid output includes urine, liquid stool, vomitus, blood, and drainage from tubes (such as chest, nephrostomy, or nasogastric tubes), ileostomies, suction devices, and wound and surgical drains and under Documentation, documentation associated with intake and output measurement includes: shift total for intake and output for each category of fluid, physical assessment of findings, and output characteristics. 4. Review of facility document titled, Competency Validation, Purposeful Rounding, indicated under Competency: Identify the components of successful purposeful hourly rounding using the “4 Ps.” 5. Review of video observation on 06/11/2026 at approximately 4:24 p.m. with A1 (Chief Executive Officer) indicated on 05/27/2026 no staff entering patient 4’s room between 3:39 am until 5:56 am (2 hours 17 minutes). 6. Review of patient 4’s medical record indicated the following: a. The patient was admitted on 05/13/2026. b. On 05/13/2026, provider order indicated vital signs to be completed twice a day. c. On 05/26/2026, medical record lacked documentation of patient temperature on day and night shift. Nursing note indicated the patient had abdominal tenderness at 9:52 p.m. d. On 05/27/2026, at 1:09 a.m. the medical record indicated the patient was nauseated and had vomited; medical record lacked documentation of emesis output. Medical record indicated that purposeful rounding was completed at 4:00 a.m. documented at 4:47 a.m. and 5:00 a.m. documented at 5:12 a.m. At 5:59 a.m. the patient was found unresponsive, patient had no palpable pulse, rapid response was called, emergency medical services (EMS) called, cardiopulmonary resuscitation (CPR) initiated, automatic external defibrillator (AED) applied and analyzed, no shock advised. CPR continued. At 6:12 a.m. EMS arrived and assumed care of the patient. EMS called the time of death at 6:27 a.m. 7. Interview with A1 (Chief Executive Officer) on 06/11/2026 at approximately 5:50 p.m. confirmed that no staff members entered patient 4’s room between 3:39 a.m. to 5:55 a.m. 8. Interview with M2 (Physician) on 06/12/2026 at approximately 10:03 a.m. indicated that if patient 4 was still nauseated or emesis continued, to call the provider on call. M2 indicated that the on-call provider was never called during the night shift of 05/26/2026 into 05/27/2026. 9. Interview with T1 on 06/15/2026 at approximately 9:28 a.m. indicated that during their shift the patient 4 had three different episodes of emesis and that each of those were reported to the nurse. 10. Interview with A1 on 06/15/2026 at approximately 1:55 p.m. confirmed the Lippincott reference to intake and output indicated that emesis is output, nursing should document emesis, and patient 4’s medical record lacked documentation of emesis output. 11. Review of patient 1’s medical record indicated the following: a. The patient was admitted on 05/28/2026. b. On 06/02/2026, medical record lacked documentation of purposeful rounding at 5:00 a.m. and 6:00 a.m. c. On 06/03/2026, medical record lacked documentation of purposeful rounding at 6:00 p.m. d. On 06/06/2026, medical record lacked documentation of purposeful rounding at 11:00 a.m. and 12:00 p.m. e. The patient was transferred on 06/07/2026 to an acute care facility for treatment; patient did not return and was discharged. 12. Review of patient 2’s medical record indicated the following: a. The patient was admitted on 05/09/2026. b. On 05/13/2026, medical record lacked documentation of purposeful rounding at 7:00 p.m., 8:00 p.m., 9:00 p.m., 10:00 p.m., and 11:00 p.m. c. On 05/14/2026, medical record lacked documentation of purposeful rounding at 12:00 a.m., 1:00 a.m., 2:00 a.m., 3:00 a.m., 4:00 a.m., 5:00 a.m., 6 a.m., 7:00 p.m., 8:00 p.m., 9:00 p.m., 10:00 p.m., and 11:00 p.m. d. On 05/17/2026, medical record lacked documentation of purposeful rounding at 7:00 a.m, 8:00 a.m., 9:00 a.m., 10:00 a.m. and 11:00 a.m. e. On 05/24/2026, medical record lacked documentation of purposeful rounding at 5:00 a.m., 6:00 a.m., and 6 p.m. f. The patient was transferred on 05/26/2026 and admitted to an acute care facility for further treatment; patient did not return and was discharged. 13. Review of patient 6’s medical record indicated the following: a. The patient was admitted on 05/13/2026. b. On 05/25/2026, medical record lacked documentation of purposeful rounding at 5:00 a.m. and 6:00 a.m. c. The patient was transferred on 05/26/2026 and admitted to an acute care facility; the patient did not return and was discharged. 14. Review of patient 7’s medical record indicated the following: a. The patient was admitted on 06/05/2026. b. On 05/08/2026, medical record lacked documentation of purposeful rounding at 5:00 a.m. and 6:00 a.m. c. On 05/09/2026, medical record lacked documentation of purposeful rounding at 6:00 a.m. d. On 05/10/2026, medical record lacked documentation of purposeful rounding at 4:00 a.m., 5:00 a.m. and 6:00 a.m. e. On 05/11/2026, medical record lacked documentation of purposeful rounding at 2:00 a.m., 3:00 a.m., 4:00 a.m., 5:00 a.m. and 6:00 a.m. f. On 05/17/2026, medical record lacked documentation of purposeful rounding at 1:00 a.m., 4:00 p.m., 5:00 p.m. and 6:00 p.m. g. On 05/20/2026, medical record lacked documentation of purposeful rounding at 7:00 a.m., 8:00 a.m., 12:00 p.m., 2:00 p.m. and 5:00 p.m. h. On 05/21/2026, medical record lacked documentation of purposeful rounding at 7:00 a.m., 3:00 p.m., 4:00 p.m. and 6:00 p.m. i. On 05/25/2026, medical record lacked documentation of purposeful rounding at 5:00 a.m. and 6:00 a.m. j. On 05/26/2026, medical record lacked documentation of purposeful rounding at 6:00 a.m. k. The patient was transferred on 05/26/2026 to acute care for further treatment; patient did not return and was discharged. 15. Review of patient 8’s medical record indicated the following: a. The patient was admitted on 05/24/2026. b. On 05/17/2026, medical record lacked documentation of purposeful rounding at 5:00 a.m., 6:00 a.m., 7:00 a.m., 8:00 a.m., 9:00 a.m., 10:00 a.m., and 11:00 a.m. c. The patient was transferred on 05/22/2026 to acute care for further treatment; patient did not return and was discharged. 16. Review of patient 9’s medical record indicated the following: a. The patient was admitted on 02/23/2026. b. On 02/28/2056, medical record lacked documentation of purposeful rounding at 5:00 a.m. and 6:00 a.m. c. On 03/01/2026, medical record lacked documentation of purposeful rounding at 3:00 a.m., 4:00 a.m., 5:00 a.m., and 6:00 a.m. d. On 03/03/2026, medical record lacked documentation of purposeful rounding at 4:00 p.m. e. On 03/06/2026, medical record lacked documentation of purposeful rounding at 5:00 p.m. and 6:00 p.m. f. On 03/08/2026, medical record lacked documentation of purposeful rounding at 2:00 a.m. g. The patient was transferred on 03/12/2026 to an acute care facility for further treatment; patient did not return and was discharged. 17. Review of patient 10’s medical record indicated the following: a. The patient was admitted on 06/09/2026. b. On 06/10/2026, medical record lacked documentation of purposeful rounding at 2:00 a.m., 3:00 a.m., 4:00 a.m., 5:00 a.m., and 6:00 a.m. c. The patient remained an inpatient at the time the survey was conducted. 18. Interview with A2 (Chief Nursing Officer) on 06/12/2026 at approximately 3:15 p.m. confirmed patients 1, 2, 4, 5, 6, 7, 8, 9, and 10 lacked documentation of purposeful rounding as indicated above and indicated that rounding is done hourly.”