Silver Lake Hospital LTACH

“DISCHARGE PLANNING-QUALIFIED PERSONNEL CFR(s): Any discharge planning evaluation or discharge plan under this paragraph must be developed by or under the supervision of a registered nurse, social worker, or other appropriately qualified personnel. This Standard is not met as evidenced by: 48414 Based on medical record review, staff interview, and review of facility documents, it was determined the facility failed to ensure that discharge planning is developed under the supervision of a social worker in accordance with facility policy. Findings include: Facility policy titled, “Social Work Process” revised 12/23/19, stated, “Policy: The social worker is responsible for the coordination of continuing care services for patients who need or request assistance. He/she shall coordinate services as necessary in order to establish a plan for the appropriate, safe, and timely discharge of the patient from the hospital to home or other healthcare facility. ...” On 5/13/25 at 10:00 AM, an entrance conference was conducted with Staff (S)1 (Chief Compliance Officer and Director of Quality). S1 stated the Long-Term Acute Care Hospital (LTACH) has two units with a total of 63-beds, that had a total census of 31 patients. At 10:05 AM, during an interview, S1 indicated that the facility does not have a social worker for the LTACH and stated, “I am the director of quality and doing social work, do you think I know what I am doing?” S1 confirmed that he/she was responsible for planning the patients social work interventions, including discharge planning. On 5/13/25, a review of medical records revealed the following: A review of P1’s medical record review was conducted with S8 (Director of Medical Records). P1 was admitted on 3/4/25 at 1:20 PM with a diagnosis of Cellulitis of right lower limb. The IDT (Interdisciplinary Team) Weekly Round note on 3/10/25 and 3/17/25, stated, “ ...IDT-Social Work The patient requires the following: SW (social work) and CM (case management) to follow for discharge Interventions: SW and CM to follow safe and appropriate discharge plan. ... “ Upon interview, S8 stated that the IDT team consists of all disciplines including nursing, dietary, respiratory therapy, pharmacy, and wound nursing. The IDT Weekly Round notes on 3/31/25, 4/8/25, 4/16/25,4/21/25, 4/28/25, 5/4/25, 5/11/25 lacked documentation from a social worker. S8 further stated that S1 has been filling in as the social worker, and that S1 does not document in the social work section of the IDT notes, since he/she is not a social worker. A review of P11’s medical record indicated that P11 was admitted to the facility on 2/26/25 with the diagnosis of respiratory failure, dependence on respirator, heart failure, and diabetes. The IDT [interdisciplinary] Weekly Round report dated 4/21/25 was reviewed. The report was signed by Nutrition, Respiratory, Physical Therapy, and Wound Care. The Social Work section was blank. The Discharge Summary stated, “ Condition at time of discharge ...Cleared by PMD [primary medical doctor] to be discharge [sic] home on trach as per family requested with home care services ...” Upon interview, S1 stated it was blank because there was no social worker at the facility. P11 was discharged from the facility on 4/25/25. During the interview, S1 confirmed that there was no documentation in the medical record that services were set up for visiting nurse services and oxygen therapy prior to discharge. On 5/13/25 at 4:05 PM, S1 confirmed the LTACH has been without a social worker since February 2025.”

“PATIENT RIGHTS: REVIEW OF GRIEVANCES CFR(s): 482.13(a)(2) [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.] The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. This Standard is not met as evidenced by: 39724 Based on facility document review and staff interview, it was determined the facility failed to provide evidence that the complaint and grievance process is implemented in accordance with facility policy. Findings include: Facility policy titled “Complaint and Grievance Process” dated 6/14/21, states, “...If an issue cannot be resolved at the time of the complaint by Hospital staff or it is postponed for later resolution, requires investigation, and/or requires further action, then the complaint becomes a grievance. Staff members shall notify his/her supervisor and complete the complaint form... The Manager/Director of the Department involved in the grievance will investigate the circumstances surrounding the concern or complaint and report the issue (s) and results of the investigation to the Patient Advocate... A letter response will be sent within 7 calendar days. If the resolution cannot be completed within 7 calendar days due to the complicated nature of the grievance, an acknowledgement letter will be issued to inform the patient or their representative that a final resolution letter will be completed within 30 calendar days from the receipt of the grievance. ...Complaints/Grievances will be monitored monthly for the previous month... Monthly data will be collected for the PI[performance improvement] Report Card... .” On 7/2/24 at 10:45 AM during an entrance conference with S3, Board Advisor, and S4, Director of Nursing (DON), the documentation for the complaint and grievance process, including the complaint and grievance log for 6/1/24 to 7/2/24, complaint forms, and facility letters, were requested for review. S3 stated the facility could not provide documentation of the complaint and grievance process to the surveyors for review, as per a recommendation from their legal department. On 7/2/24 at 12:10PM, S3 confirmed they could not allow the review of documents related to the facility’s complaint and grievance process as requested. It was explained to S3 and S4 that the complaint and grievance process is a patient’s right and the failure to provide documentation to the surveyors, would prevent the surveyors from assessing compliance with this regulation. During medical record review conducted on 7/2/24 and 7/3/24, documentation of incidents occurring between patients and between patients and staff, were identified. They include the following: On 7/3/24, the review of MR 2 was conducted with S4. The “Nursing Admission Assessment” notes, dated 6/5/24, state, “... During the intake/admission process, patient repeatedly threatened me stating, “I’ll slap the [expletive] out of you.” On several occasions the patient entered the nurses’ station after being asked several times to stay outside of the nurse’s station. ...Following this, the other patients were asked to remain in the dayroom because they did not feel safe... .” The “Daily Nursing Assessment 7a - 7p” found in MR2, dated 6/9/24, states, “10:20 [AM] pt [patient] hit on the upper body by another patient... 10:25 [AM] [staff name] rn [Registered Nurse] apn [Advanced Practice Nurse] made aware of incident 10:45 am patient seen by house officer [staff name] rn apn ... .” The “Daily Nursing Assessment 7p- 7a” found in MR2, dated 6/10/24, states, “...2230 [11:30 PM] While staff was cleaning up water spilled on the floor by the patient, [P2] became aggressive, combative, violent and punched staff on the nose and led to nose bleeding. Patient is harm to himself, to staff and to his peers. Security officer and DON (Director of Nursing) [name] were on the unit and immediately proceeded to intervene... .” The “Daily Nursing Assessment 7p -7a” found in MR2, dated 6/12/24, states. “... 9:20 [PM]-RN [Registered Nurse] heard a commotion on the unit and came out of the medication room to see staff holding the patient. Per the MHT [mental health technician], patient attempted to force himself inside the staff working area and he/she was stopped. Patient reportedly became agitated, physically aggressive, an [sic] punched the MHT in the jaw area, staff and hospital security held the patient down. Verbal deescalation was ineffective.... .” The “Daily Nursing Assessment 7p-7a” found in MR2, dated 6/13/24, states, “...8:20 PM- Per the MHTs, patient sneaked behind and punched another patient. Patient is aggressive and not re-directable...” On 7/2/24 at 12:15 PM the facility’s quality assessment performance improvement (QAPI) meeting minutes were requested to assess, the complaint and grievance process included in the policy referenced above, was followed. On 7/3/24 at 4:00PM S3 provided a copy of the “Silver Lake Hospital QA/PI Committee Meeting Minutes,” dated 11/15/23, 12/20/23, 1/17/24, 3/20/24, 4/17/24, and 5/15/24. The majority of these documents were crossed out, redacted. The following information was identified: The “Silver Lake Hospital QA/PI Committee Meeting Minutes,” dated 11/15/23, included, “Topic; Discussion; Action/Recommendations” columns. The “ ...Complaints & Grievances” topic, the “Discussion” and “Actions/Recommendations” columns were redacted. The “Silver Lake Hospital QA/PI Committee Meeting Minutes,” dated 12/20/23 stated, “Topic; Discussion; Action/Recommendations” the “ ...Complaints & Grievances” topic, the “Discussion” and “Actions/Recommendations” columns were redacted. The “Silver Lake Hospital QA/PI Committee Meeting Minutes,” dated 1/17/24 stated, “Discussion; Action/Recommendations” for the “ ...Complaints & Grievances” topic, the “Discussion” column was redacted and the “Actions/Recommendation” column was blank. The “Silver Lake Hospital QA/PI Committee Meeting Minutes,” dated 3/20/24 stated, “Discussion; Action/Recommendations” for the “ ...Complaints & Grievances” topic, the “Discussion” column was redacted and the “Actions/Recommendation” column was blank. The “Silver Lake Hospital QA/PI Committee Meeting Minutes,” dated 4/17/24 stated, “Discussion; Action/Recommendations” for the “ ...Complaints & Grievances” topic, the “Discussion” column was redacted and the “Actions/Recommendations” column was blank. The “Silver Lake Hospital QA/PI Committee Meeting Minutes,” dated 5/15/24 stated, “Discussion; Action/Recommendations” for the “ ...Complaints & Grievances” topic, the “Discussion” column was redacted and the “Actions/Recommendations” column was blank. It could not be determined if the facility addressed complaint and grievances filed with the facility, completed investigations, or provided the complainants with follow up letter(s) as required by facility policy. It could not be determined if the facility reviewed each complaint and grievance monthly in the QA/PI Committee, identified trends, or followed through with actions or recommendations to address issues identified during the complaint and grievance investigation process. On 7/3/24 at 4:10 PM, S3 confirmed the above findings and confirmed that the majority of the “Silver Lake Hospital QA/PI Committee Meeting Minutes” provided to the surveyors were redacted. 43214 Facility policy titled “Complaint and Grievance Process (revised 6/1/24) states, “ ... POLICY: Silver Lake Hospital has established a mechanism for receiving, acting upon, and responding to patients, families, and visitors expressing concern for patient treatment and all areas of care. It is the policy of the Hospital to respond to such complaints promptly. ... PROCEDURE: ...4. A failure to afford a patient their rights in accordance with the following list of issues may constitute a complaint: ...f) Patient was abused, harassed and/or neglected; ... .” On 7/3/24 at 1:05 PM, Patient (P) 4’s medical record was reviewed with S3, Board Advisor. P4 was admitted to the facilities Dual Diagnosis inpatient unit on 4/22/24. The History and Physical from 4/24/24 states, “ ... Reason for Admission: detox from polysubstances. ...Past Medical History: Anxiety, Depression, Bipolar Disorder, ETOH [ethanol] abuse, Marijuana abuse, Sedative abuse. ... .” The “Daily Nursing Assessment 7a-7p” found in MR4, dated 6/7/24 states, “ ...Nursing Note: ...Patient [P2’s initials] touched patient’s breast, emotional support offered to patient, patient transferred to 1 East due to this incident to ensure distance between [P2] and this patient; endorsed care to 1 East RN. ... .” This Nursing Note was electronically signed by S4, Director of Nursing. On 7/3/24 at 1:24 PM, during an interview with S4, he/she explained that this incident occurred on the 1 West unit while P2 and P4 were walking down the hallway. S4 explained that P2 brushed P4’s breasts as he/she walked by and P4 complained and was upset by it. S4 explained he/she moved P4 to a different unit so he/she would not have to interact with P2. S3 explained that when incidents between patients occur, the staff would separate the patients, handle the issue, and then complete an incident report. When asked if an incident report was filled out on the incident, S3 answered yes. On 7/3/24 at 4:15 PM, S4 confirmed he/she filled out an incident report related to the incident between P2 and P4. Incident reports were requested and S3 stated, as per the facilities legal department, they would not provide incident reports for review by the surveyors. It could not be determined if the facility implemented the facility policy referenced above.”

“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: 39724 Based on medical record review, facility document review, and staff interview, it was determined the facility failed to ensure that complaints, grievances, and incidents are addressed in accordance with facility policies, to ensure care is provided in a safe setting. Findings include: Facility policy titled “Patient Rights and Restrictions,” dated 8/23/21, states, “... The individual served has the right to voice opinions, recommendations, and grievances related to policies and services offered on the unit... The individual served has the right to be free from mental, physical, sexual, and verbal abuse, neglect and/or exploitation...” Facility policy titled “Patient Incident Report and Department Manager Review,” dated 8/16/23, states, “Purpose: To ensure that the appropriate department manager reviews all incident reports timely and formulates an appropriate plan of action. Policy: Patient incidents are entered into the computer under Clinical Documentation Assessment Add Incident Report. The Quality Department/ Nursing Department will run a daily report to see what incidents have occurred. The appropriate Department Manager... will be notified to review the incident and enter an appropriate/effective management plan of action as soon as possible after the incident occurs...” Facility policy titled “Incident Reporting Employee,” dated 8/16/23, states, “...1. Any employee involved in an incident or observing an incident resulting in an employee injury or occurrence is responsible for completing and [sic] Employee incident Report prior to the end of shift. 2. The supervisor assures that the employee is offered medical assessment/treatment...The supervisor reviews the Employee Incident Report for completeness and investigates as necessary. The supervisor’s corrective actions are recorded... within 24 hours... 7. Supervisor forwards completed incident report to the HR [human resources] Coordinator and a copy to the Quality Manager/ Risk Manager ... 11. The Director of HR records aggregate information and reports to the Safety Committee.” Facility policy titled “Complaint and Grievance Process,” dated 6/14/21, states, “... A failure to afford a patient their rights in accordance with the following list of issues may constitute a complaint: ...Patient was abused, harassed and/or neglected; ...if an issue cannot be resolved at the time of the complaint by Hospital staff or it is postponed for later resolution, requires investigation, and/or it requires further action, then the complaint becomes a grievance. Staff member shall notify his/her supervisor and complete the complaint form.... A letter response will be sent within 7 calendar days. If resolution cannot be completed within 7 calendar days,,, an acknowledgment letter will be issued to inform the complainant or their representative that a final resolution letter will be completed within 30 calendar days... Complaints/Grievances will be monitored monthly for the previous month...” On 7/2/24 at 10:45 AM during an entrance conference with S3, Board Advisor, and S4, Director of Nursing (DON), the documentation for the complaint and grievance process, including the complaint and grievance log for 6/1/24 to 7/2/24, complaint forms, facility letters, the incident log for 6/1/24 to 7/2/24, and documentation of the incident reporting process were requested. S3 stated that the facility could not provide documentation of the complaint and grievance process or the incident reporting process to the surveyors as per a recommendation from their legal department. On 7/2/24 at 12:10PM, S3 confirmed they could not provide the documents related to the facility’s complaint and grievance process and incident reporting process as requested. It was explained to S3 and S4 that failure to provide the above documentation would prevent the surveyors from assessing compliance with the Federal regulations and facility policies. During medical record review conducted on 7/2/24 and 7/3/24, with S3 and S4, evidence of incidents occurring between patients and between patients and staff were identified. The following documentation was found: On 7/3/24, the review of MR2 was conducted with S4. The “Nursing Admission Assessment” notes dated 6/5/24, state, “... During the intake/admission process, patient repeatedly threatened me stating, “I’ll slap the [expletive] out of you.” On several occasions the patient entered the nurses’ station after being asked several times to stay outside of the nurse’s station. ...Following this, the other patients were asked to remain in the dayroom because they did not feel safe... “ The incident report for this event was requested for review on 7/3/24, and S4 confirmed incident reports could not be reviewed by the surveyors. The “Daily Nursing Assessment 7a - 7p” found in MR2, dated 6/9/24, states, “10:20 [AM] pt [patient] hit on the upper body by another patient... 10:25 [AM] [staff name] rn [Registered Nurse] apn [Advanced Practice Nurse] made aware of incident 10:45 am patient seen by house officer [staff name] rn apn ...” The incident report for this event was requested for review 7/3/24, and S4 confirmed incident reports could not be reviewed by surveyors. The “Daily Nursing Assessment 7p - 7a” found in MR2, dated 6/10/24, states, “...2230 [11:30 PM] While staff was cleaning up water spilled on the floor by the patient, [P2] became aggressive, combative, violent and punched staff on the nose and led to nose bleeding. Patient is harm to himself, to staff and to his peers. Security officer and DON (Director of Nursing) [name] were on the unit and immediately proceeded to intervene... “ The incident report and security reports for this event were requested for review on 7/3/24, and S4 confirmed incident reports and security reports could not be reviewed by surveyors. The “Daily Nursing Assessment 7p -7a,” found in MR2, dated 6/12/24, states, “... 9:20 [PM]-RN [Registered Nurse] heard a commotion on the unit and came out of the medication room to see staff holding the patient. Per the MHT [mental health technician], patient attempted to force himself inside the staff working area and he/she was stopped. Patient reportedly became agitated, physically aggressive, an [sic] punched the MHT in the jaw area, staff and hospital security held the patient down. Verbal deescalation was ineffective....” The incident report for this event was requested for review on 7/3/24, and S4 confirmed that incident reports could not be reviewed by surveyors. The “Daily Nursing Assessment 7p-7a,” found in MR2, dated 6/13/24, states, “...8:20 PM - Per the MHTs, patient sneaked behind and punched another patient. Patient is aggressive and not re-directable...” The incident report for this event was requested for review on 7/3, and S4 confirmed incident reports could not be reviewed by surveyors. On 7/3/24, the review of MR4 was conducted with S3. The “Daily Nursing Assessment 7a - 7p” found in MR4, dated 6/7/24 states, “ ...Nursing Note: ...Patient (P) [P2’s initials] touched patient’s breast, emotional support offered to patient, patient transferred to 1 East due to this incident to ensure distance between [P2] and this patient; endorsed care to 1 East RN. ...” This Nursing Note was electronically signed by S4, Director of Nursing. On 7/3/24 at 1:24 PM during an interview with S4, he/she explained that this incident occurred on the 1 West unit while P2 and P4 were walking down the hallway. S4 explained that P2 brushed P4’s breasts as he/she walked by and P4 complained and was upset by it. S4 explained he/she moved P4 to a different unit so that he/she would not have to interact with P2 anymore. S4 explained that when incidents between patients occur, the staff would separate the patients, handle the issue, and then fill out an incident report. When asked if an incident report was completed, S4 confirmed he/she did fill out an incident report regarding the incident between P2 and P4. The incident report for this event was requested for review on 7/3/24, and S4 confirmed incident reports could not be reviewed by surveyors. On 7/3/24, it could not be determined if the facility followed the incident reporting policies and procedures referenced above. It could not be determined if the incidents were reported, reviewed by facility management, investigated, or if the facility implemented changes to improve patient and staff safety. On 7/2/24 at 12:15 PM the facility’s quality assessment performance improvement (QAPI) meeting minutes were requested to assess if the complaint and grievance processes and incident reporting processes, included in the policies referenced above, were followed. On 7/3/24 at 4:00PM S3 provided a copy of the “Silver Lake Hospital QA/PI Committee Meeting Minutes,” dated 11/15/23, 12/20/23, 1/17/24, 3/20/24, 4/17/24, and 5/15/24. The majority of these documents were redacted. The “Silver Lake Hospital QA/PI Committee Meeting Minutes” dated 11/15/23 included, “Topic; Discussion; Action/Recommendations” columns. The “Incident Report Summary”, the “Discussion,” and “Actions/Recommendations” were redacted. For the “ ...Complaints & Grievances” the “Discussion” and “Actions/Recommendations” columns were redacted. The “Silver Lake Hospital QA/PI Committee Meeting Minutes” dated 12/20/23 stated, “Topic; Discussion; Action/Recommendations ... Incident Report Summary.” The “Discussion” and “Actions/Recommendations” were redacted; ...Complaints & Grievances. the “Discussion” and “Actions/Recommendations” were redacted. The “Silver Lake Hospital QA/PI Committee Meeting Minutes” dated 1/17/24 stated, “Discussion; Action/Recommendations ... The Incident Report Summary.” The “Discussion” and “Actions/Recommendations” were redacted; “...Complaints & Grievances.” The “Discussion” was redacted and the “Actions/Recommendations” column was blank. The “Silver Lake Hospital QA/PI Committee Meeting Minutes” dated 3/20/24 stated, “Discussion; Action/Recommendations ...The Incident Report Summary.” The “Discussion: and “Actions/Recommendations” were redacted; “...Complaints & Grievances.” The “Discussion” column was redacted and the “Actions/Recommendation” column was blank. The “Silver Lake Hospital QA/PI Committee Meeting Minutes” dated 4/17/24 stated, “Discussion; Action/Recommendations ... Incident Report Summary.” The “Discussion” column stated, “March had [redacted] incidents in DD [dual diagnosis]” the remaining was redacted. And the “Actions/Recommendations” column was redacted; “...Complaints & Grievances.” The “Discussion” column was redacted, and the “Actions/Recommendations” column was blank. The “Silver Lake Hospital QA/PI Committee Meeting Minutes,” dated 5/15/24, stated, “Discussion; Action/Recommendations ...Incident Report Summary.” “April had [redacted] incidents in DD.” The “Discussion” and “Actions/Recommendations” columns were redacted; “...Complaints & Grievances.” The “Discussion” column was redacted and the “Actions/Recommendations” column was blank. On 7/3/24 at 4:10 PM, S3 confirmed the above findings and confirmed the majority of the “Silver Lake Hospital QA/PI Committee Meeting Minutes” provided, were redacted. It was determined that incidents occurred in the Dual Diagnosis Unit in March and April of 2024, however, it could not be determined if the facility reviewed incident reports, investigated events, and addressed patient safety issues in accordance with their policies referenced above.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(6) Orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis (PRN). This Standard is not met as evidenced by: 39724 Based on the review of 1 of 1 medical record (MR)2, that contained orders for seclusion, facility document review, and staff interviews, it was determined the facility failed to ensure that orders for seclusion are not written “PRN” (as needed). Findings include: Facility policy titled “Restraint and Seclusion Policy and Procedure” dated 11/1/21, states, “...Orders are never to be written as a PRN order or a standing basis...” Review of MR2, conducted 7/3/24 at 2:00 PM, with S4, Director of Nursing, identified a provider’s order for seclusion, dated 6/7/24 at 2:27 PM, which stated, “Restraint/Seclusion every 4 hours PRN [pro re nata, as needed]... Patient to be placed in seclusion Q [every] 4 hours and then released for supervised 1 hour...” The “Daily Nursing Assessment 7a-7p,” dated 6/7/24, states, “4:30 PM patient in seclusion room due to behavior... 6:30 [PM] Patient taken out of seclusion room. Calm and cooperative.” MR2 lacked any additional orders for seclusion on 6/7/24. During medical record review, S4 stated that orders for seclusion or restraint should not be written “PRN” and that he/she notified the ordering provider that that was not allowed. This finding was confirmed by S4 on 7/3/24 at 2:05 PM.”

“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: 39724 Based on the review of one of one medical records (MR), MR2, of a patient who had an order for seclusion, facility document review, and staff interviews, it was determined the facility failed to ensure that monitoring of a patient in seclusion is documented in the medical record as required by facility policy. Findings include: Facility policy titled “Restraint and Seclusion Policy and Procedure,” dated 11/1/21, states, “... While in restraints or seclusion the RN [Registered Nurse] will assess the patient every 15 minutes and will monitor and document for the following: a. Signs of injury; b. physical and psychological status; ...” During medical record review on 7/3/24, between 1:50 PM and 2:35 PM, Staff (S) 4, Director of Nursing, explained that patients in the seclusion room are continuously monitored either by surveillance camera or by a staff member standing in the ante room, and that the monitoring is documented in the “Observation” column of the “Accountability Flow Sheet” every 15 minutes. S4 showed the surveyor a example of the “Accountability Flow Sheet” found in MR2 and explained that the flow sheet included the documentation of the patient’s location in the facility, behavior, or any other relevant status changes. The “Accountability Flow Sheet” and the “Daily Nursing Assessment” notes for P2 were reviewed with S4 and the following was identified: The “Nursing Assessment 7p-7a,” dated 6/11/24, states, “... 5:30 [AM] Blood drawn for BMP [basic metabolic panel] and Lipid panel. 6:25 [AM] Patient showed signs of agitation, back to the seclusion room. 7:00 [AM] care endorsed to the day shift nurse.” And the “Daily Nursing Assessment 7a - 7p,” dated 6/12/24, stated, “7:00 [AM] Received patient sleeping in Seclusion room. Respiration easy on room air. 8:00 [AM] Patient out of seclusion...” This documentation indicates P2 was in the seclusion room from 6:25 AM until 8:00 AM. Review of the “Observations” column on the “Accountability Flow Sheet” found in MR2, and dated 6/12/24, states, “5:30 [AM]: Engaging Staff at the Nursing Station. 7:00 [AM]: Other. 7:15 [AM]: Other. 7:30 [AM]:Other. 7:45 [AM]: Other. 8:00 [AM]: Other. 8:15 [AM]: Other....” The “Accountability Flow Sheet” lacked comprehensive documentation of the every 15 minute monitoring between 5:30 AM and 7:00 AM, during which time the nursing note indicates P2 was in the seclusion room. MR2 lacks documentation of the required monitoring every 15 minutes. The physical and psychological status of P2 could not be determined. The “Nursing Assessment 7a-7p” dated 6/12/24, states, “...15:00 [3:00 PM] Patient restrained in seclusion room as ordered by the house doctor due to agitation, injurious to staff. 16:00 [4:00 PM] Closely monitored, in seclusion room. 17:00 [5:00 PM] Sleeping in seclusion room. 18:00 [6:00 PM] Patient still sleeping in seclusion room. 19:00 [7:00 PM] Patient awake, out of the seclusion room, dinner and due medications served. Redirection in progress.” The corresponding “Accountability Flow Sheet” found in MR2, dated 6/12/24, states the following under the “Observation” column, “... 6/12/24 at 14:30 [2:30 PM]; Observed to be awake in rounds. Monitored for safety, comfort, and appropriate boundaries; 6/12/24 at 14:45 [2:45 PM]; Other; 6/12/24 at 15:00 [3:00 PM]: Other...” and the remaining entries documented every 15 minutes in the “Observation” column on 6/12/24 between 3:15 PM and 7:15 PM state “Other.” The monitoring conducted every 15 minutes was not documented as required by facility policy. The physical and psychological status of P2 while in seclusion could not be determined. These findings were confirmed by S4 on 7/3/24 at 4:25 PM”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(i) When restraint or seclusion is used, there must be documentation in the patient’s medical record of the following: The 1-hour face-to-face medical and behavioral evaluation if restraint or seclusion is used to manage violent or self-destructive behavior. This Standard is not met as evidenced by: 39724 Based on review of one of one medical record (MR) of a patient who was ordered seclusion, (MR2), facility document review, and staff interview, it was determined the facility failed to ensure the required face-to face medical and behavioral evaluation by a provider, required within one hour of seclusion, is documented in the medical record, in accordance with facility policy. Findings include: Facility policy titled, “Restraint and Seclusion Policy and Procedure,” dated 11/1/21, states, “...Standard of Care... The practitioners must evaluate the patient within 1 hour of the application of restraints. The evaluation note (face to face) must be documented in the EMR (electronic medical record).” During the review of MR2 on 7/3/24, between 1:30 PM and 4:30 PM, with Staff (S) 4, Director of Nursing, S4 stated that the provider should document, in the medical record, a face to face evaluation of the patient, within one hour of the order for seclusion. Four of six orders for seclusion, found in MR2, and reviewed on 7/3/24, lacked documentation of the face to face evaluation by a provider within one hour. The following was identified: The provider orders for seclusion, dated 6/5/24 at 11:00 PM, lacked documentation of the provider’s face to face evaluation. This was confirmed by S4 on 7/3/24 at 1:35 PM. The provider orders for seclusion, dated 6/7/24 at 2:27 PM, lacked documentation of the provider’s face to face evaluation. This was confirmed by S4 on 7/3/24 at 1:45 PM. The provider orders for seclusion, dated 6/11/24 at 10:00 PM, lacked documentation of the provider’s face to face evaluation. This was confirmed by S4 on 7/3/24 at 1:50 PM. The provider orders for seclusion, dated 6/12/24 at 6:00 AM, lacked documentation of the provider’s face to face evaluation. This was confirmed by S4 on 7/3/24 at 2:35 PM.”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 34119 Based on observation, staff interviews, medical record review, and review of facility documents, it was determined the facility failed to ensure that methods for preventing and controlling the transmission of infectious diseases within the facility are implemented. Findings include: The facility failed to ensure that all chemicals used for cleaning and disinfection of the internal pathways of the hemodialysis machines, including after use on a Hepatitis B positive patient, is used by the manufacturer’s best by date. (Cross-refer A-0749)”

“RESPIRATORY CARE SERVICES CFR(s): 482.57 The hospital must meet the needs of the patients in accordance with acceptable standards of practice. The following requirements apply if the hospital provides respiratory care services. This Condition is not met as evidenced by: 37432 Based on staff interviews, medical record review, and review of facility documents, it was determined the facility failed to ensure that respiratory services performed by respiratory therapists, are available 24 hours a day, seven days a week. Findings include: 1. The facility failed to ensure that respiratory services provided by a respiratory therapist are available at all times. (Cross refer to Tag A-1154) 2. The facility failed to ensure that patients on mechanical ventilation receive reassessments by a respiratory therapist at least daily, in accordance with facility policy. (Cross refer to Tag A-1160)”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 34119 Based on observation, medical record review, staff interview, and facility document review, it was determined the facility failed to ensure that chemicals utilized for the cleaning and disinfection of the internal pathways of the hemodialysis machines, including after use on a Hepatitis B positive patient, is used by the manufacturer’s best by date. Findings include: Reference #1: Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, Recommendations for Preventing Transmission of Infections Among chronic Hemodialysis Patients, April 27, 2001/Vol. 50/No. RR-5, stated, “HBV-Infected Patients ... designate a separate room for their treatment and dedicate machines, ... If a machine that has been used on an HBsAG-positive patient is needed for an HBV-susceptible patient, internal pathways of the machine can be disinfected using conventional protocols ...” Reference #2: Fresenius Medical Care 2008T Hemodialysis Machine Operator’s Manual, states, “... Cleaning and Disinfection ... Acid Clean Daily ... vinegar ...Heat Disinfect Daily ... Chemical/Rinse Weekly ... bleach ...” On 11/6/23 at 10:20 AM, a tour of the 5th floor was conducted in the presence of Staff #6 (S6), Director of Nursing, and S9, Charge Nurse for Hemodialysis. S9 stated that the hemodialysis machine designated for Hepatitis B positive (HBsAG+) patients has been broken. S9 stated he/she thought the machine was put out of service sometime in August 2023, but was not sure of the actual date. S9 stated they are using Machine #2 to dialyze the HBsAG+ patient at the end of the day. S9 also stated they do use Machine #2 on Hepatitis B Surface Antigen negative (HBsAG-) patients prior to performing hemodialysis on the HBsAG+ patient. S9 stated that all hemodialysis patients are in private rooms. S9 stated that after every treatment, staff will do an external cleaning of the machines, using bleach wipes at the end of the day, and that the machine will be internally cleaned using 5% vinegar and a heat disinfect. S9 stated that all hemodialysis machines are cleaned internally with bleach weekly. S9 stated that after Machine #2 is used on the HBsAg+ patient, it is cleaned externally using a bleach wipe, and is internally cleaned using 5% vinegar, heat disinfect, and cleaned internally with bleach. Upon review of P3’s medical record on 11/6/23, in the presence of S9, it was revealed that P3 was admitted on 10/29/23 and was receiving hemodialysis at the facility. On 10/30/23, P3’s lab result indicated the following: HBsAG (hepatitis B surface antigen) reactive, HBsAB (Hepatitis B surface antibody) 0.72, Hepatitis B Core Total Antibody Reactive. These lab results indicated that P3 was Hepatitis B positive. Review of P3’s Hemodialysis Flowsheets revealed that P3 received hemodialysis using Machine #2 on the following days: On 10/30/23, the treatment was started at 1545 (3:45 PM) and ended at 1845 (6:45 PM). On 11/1/23, the treatment was started at 1545 (3:45 PM) and ended at 1845 (6:45 PM). On 11/3/23, the treatment was started at 17:25 (5:25 PM) and ended at 20:25 (8:25 PM). On 11/6/23, the treatment was started at 19:40 (7:40 PM) and ended at 2240 (10:40 PM). Review of P1’s medical records on 11/6/23, in the presence of S9, revealed P1 was admitted on 10/10/23 and was receiving hemodialysis at the facility. On 10/11/23, P1’s lab results indicated the following: HBsAG Nonreactive; HBsAG 13.25; Hepatitis B Core Total Antibody Nonreactive. These lab results indicated that P1 was Hepatitis B negative and had antibodies (protection) against Hepatitis B. A review of P1’s Hemodialysis Flowsheets revealed that P1 received hemodialysis using Machine #2 on 11/6/23. The treatment started at 1555 (3:55 PM) and ended at 1855 (6:55 PM). Review of P7’s medical records on 11/6/23, in the presence of S9, revealed P7 was admitted on 10/2/23 and was receiving hemodialysis at the facility. P7’s lab results, dated 11/8/23, indicated the following: HBsAG Nonreactive; HBsAG 48.31; Hepatitis B Core Total Antibody Nonreactive. These lab results indicated that P7 was Hepatitis B negative and had antibodies (protection) against Hepatitis B. P7’s Hemodialysis Flowsheets revealed that P7 received hemodialysis on Machine #2 on 11/6/23. The treatment started at 6:57 AM and ended at 10:27 AM. Review of P26’s medical records on 11/6/23, in the presence of S9, revealed P26 was admitted on 10/28/23 and was receiving hemodialysis at the facility. P26’s lab results on 10/30/23 indicated the following: HBsAG Nonreactive; HBsAG 18164.68; Hepatitis B Core Total Antibody Nonreactive. These lab results indicated that P26 was Hepatitis B negative and had antibodies (protection) against Hepatitis B. P26’s Hemodialysis Flowsheets revealed that P26 received hemodialysis using Machine #2 on the following days: On 10/30/23, the treatment was started at 11:30 AM and ended at 1430 (2:30 PM). On 11/1/23, the treatment was started at 7:06 AM and ended at 10:06 AM. On 11/3/23, the treatment was started at 7:13 AM and ended at 10:13 AM. Review of P27’s medical records on 11/6/23, in the presence of S9, revealed P27 was admitted on 11/1/23 and was receiving hemodialysis at the facility. P27’s lab results on 11/3/23 indicated the following: HBsAG nonreactive; HBsAG 0.88 susceptible non-immune; Hepatitis B Core Total Antibody Nonreactive. These results indicated P27 was Hepatitis B negative, was susceptible (non-immune) to Hepatitis B and did not have antibodies (protection) against the disease. A review of P27’s Hemodialysis Flowsheets indicated P27 received hemodialysis using Machine #2 on the following days: On 11/3/23, the treatment was started at 11:40 AM and ended at 1450 (2:50 PM). On 11/6/23, the treatment was started at 11:50 AM and ended at 14:50 (2:50 PM). On 11/6/23 at 10:25 AM, S9 confirmed P27 was not immune to Hepatitis B and was dialyzed on the same machine as P3, who is Hepatitis B positive. On 11/8/23 10:05 AM, a tour of the 5th floor was conducted in the presence of Staff #6 (S6), Director of Nursing. At the time of the tour, there were two patients on dialysis; one patient was using Machine #2 and one is using Machine #3. Both patients were in single rooms. Both patients on dialysis were Hepatitis B surface Antigen (HBsAg) negative (-). In an interview on 11/8/23 at 10:10 AM, S9 stated that the HBsAg positive (+) patient, P3, gets dialyzed last because there were only two available machines; Machine #2 and #3. Per S9, the dialysis machine dedicated for the Hepatitis B + patient was broken sometime in August or September 2023. S9 stated, that to prevent other dialysis patients from getting infected with Hepatitis B, the staff internally disinfects the machine that is used by P3, with bleach after his/her treatment. The machine disinfection logs for Machine #2 and #3 for the month of October and November were reviewed, and indicated Machine #2 and #3 were internally disinfected with 5% vinegar and a heat disinfection at the end of each day patients were dialyzed. On 11/8/23, a review of the Dialysis Machine Logs for Machine #2 indicated the machine was internally cleaned with bleach on the following days: On 11/3/23 at 15:30 (3:30 PM) and again at 2100 (9:00 PM), after P3’s treatment On 11/6/23 at 23:13 (11:13 PM) A review of the Dialysis Machine Log for Machine #3 indicated the weekly internal cleaning and disinfection of the machine, with bleach, on 11/3/23 at 2100 (3:00 PM). The machine disinfection log for Machine #2 contained documentation that it was internally cleaned with bleach after the Hepatitis B positive patient was dialyzed on 10/30/23 at 19:35 (7:35 PM) and on 11/1/23 at 19:25 (7:25 PM), although, it is not known if the bleach used to internally clean and disinfect Machine #2 on these days was used by the Manufacturer’s Best By Date, as the bleach solution used on these days was not present. On 11/8/23 at 10:45 AM, a tour of the dialysis storage room was conducted in the presence of S6 and S9. There were two hemodialysis (HD) machines and two portable RO (reverse osmosis) machines in the room, Machine #5 containing a round red sticker on the top of the machine, which indicated it was dedicated for an isolation patient, and Machine #1. One of the two portable RO’s had a red sticker, also indicating it was for isolation only. Per S9, these machines were fixed on November 6, 2023, and were waiting for the results of cultures and endotoxins. The dialysis supply room also contained dialysate jugs, bicarbonate jugs, and two jugs of bleach solution with a label that read, “Pure Bright Germicidal Ultra Bleach,” which contained dates of opening of: 11/3/23 and 11/6/23 handwritten by the facility staff. Both Bleach containers contained a manufacturer’s label that read, “Best by December 2, 2022.” Both containers did not contain storage instructions. Per S9, these were the bleach solutions being used to internally disinfect the machines (Machine #2 and #3), that were currently in use on patients. There were no other bleach containers in the storage room. S9 confirmed the “Pure Bright Germicidal Ultra Bleach,” which contained dates of opening of: 11/3/23 and 11/6/23 and a “Best by December 2, 2022,” were used to perform the internal cleaning and disinfection on Machine #2 and #3 on 11/3/23 and 11/6/23. Upon interview on 11/8/23 at 12:00 PM, S21, Vice President of Facilities, when asked about the ‘Best By date,’ stated the bleach might be less effective for disinfecting the machines. S21 could not provide evidence that the bleach solution with the Best By Date of December 2, 2022 was still effective. Per S21, they will dispose of the old solutions. Two new bleach solution jugs were brought to the conference room by S21 at the end of the day on 11/8/23. The facility policy titled, Dialyzing Patients with positive Hepatitis B Antigen (HBsAg+), dated 3/29/23, stated, “... If there are current HBsAg positive patients on census, ... equipment cannot be used for HBV [Hepatitis B Virus] negative patients on other shifts or days due to risk of cross contamination. ... Equipment and Supplies ... Separated dedicated supplies and equipment, ... must be used to provide care to the HBsAg positive patient. ... Equipment used for the HBsAG positive patients should be reserved for the HBsAG positive patient unless repair or maintenance is needed ... Follow manufacturer’s instructions to carry out routine disinfection of the dialysis machine. EMERGENCY SITUATION IN WHICH A SEPARATE MACHINE IS NOT POSSIBLE ... disinfect internal components of the machine using conventional procedures for internal bleaching. ... Avoid using this on HBV negative patients. It is recommended to use the machine on patients who are Hepatitis B antibody positive. ...” On 11/8/2023, the Immediate Jeopardy (IJ) was identified regarding the facility’s failure to ensure an effective bleach solution is used to clean and disinfect the internal pathways of the hemodialysis machine after being used to provide hemodialysis on a Hepatitis B positive patient. Staff #1 (Quality and Compliance Officer), Staff #2 (President and Chief Operating Officer), and Staff #14 (Advisor to the Board) were informed of the IJ and provided the IJ template on 11/8/23 at 2:48 PM. Two new bleach solution jugs were brought to the conference room by S21 at the end of the day on 11/8/23 at 2:55 PM. On 11/13/23, the facility submitted an acceptable removal plan and verification of the implementation of the removal plan was conducted while surveyors were on-site. Verification included: a tour of the dialysis supply room, staff interviews, review of Hepatitis B lab results for dialysis patients, and review of staff re-education regarding the new facility policy “Bleach Disinfectant for Hemodialysis.” A copy of the form titled, “BLEACH DISINFECTANT FOR HEMODIALYSIS INSERVICE November 8th, 2023,” was provided to the surveyors. The IJ was removed on 11/13/23 at 11:10 AM. On 11/13/23 at 10:40 AM, a tour of the 5th floor in the presence of S6, a tour of the dialysis supply room at 10:50 AM, revealed a new container of Clorox Bleach with expiration date of April 2025. Per S6 and S21, Machines #2 and #3 were internally disinfected by the new bleach solution. On 11/9/23, the facility received the culture results for Machine #5, the dedicated machine for the Hepatitis B positive patient, and it was cleared to be used. On 11/10/23, Machine #5 was used to provide hemodialysis for P3, the Hepatitis B positive patient. The facility had educated all dialysis staff members, biomed technicians, and material management staff. Proof of a staff inservice dated November 8, 2023, was provided to the surveyors. On 11/13/23 at 10:40 AM, an interview with S17 and S18 was conducted, and both stated they received education on checking for bleach disinfectant integrity per manufacturer’s instructions and the new policy, “Bleach Disinfectant for Hemodialysis.” On 11/13/23, a review of P1, P6, P7, P26, and P27’s Hepatitis B Surface Antigen lab results, dated 11/8/23, indicated all patients were nonreactive (negative) for Hepatitis B.”

“ADEQUATE RESPIRATORY CARE STAFFING CFR(s): 482.57(a)(2) There must be adequate numbers of respiratory therapists, respiratory therapy technicians, and other personnel who meet the qualifications specified by the medical staff, consistent with State law. This Standard is not met as evidenced by: 37432 Based on review of facility documents and staff interview, it was determined the facility failed to ensure that respiratory services provided by a Respiratory Therapist are available at all times. Findings include: On 11/3/23, review of the respiratory therapist’s staffing schedule from May 2023 to October 2023, revealed that on Monday, 10/30/23, and Tuesday, 10/31/23, during the 7:00 AM to 7:00 PM shift, there was no respiratory therapist assigned. On those dates and times, the respiratory therapist staffing schedule stated, “(Unassigned) House Officer.” During an interview on 11/3/23 at 11:30 AM, Staff #7 (S7), Respiratory Therapist (RT), stated that Advanced Nurse Practitioners (APN) were used as the House Officers. Upon interview on 11/3/23 at 11:34 AM, S1, Quality and Compliance Officer, stated, the RT for the day shift had an emergency and called out on work on 10/30/23 and 10/31/23. S1 stated that on 10/30/23, the House Officer covered the shift from 11:00 AM to 3:00 PM and that the night shift RT stayed until 11:00 AM to help cover the shift and the RT scheduled for the night shift came in early to help cover the shift. S1 explained further that on 10/31/23, the House Officer covered the shift from 7:00 AM to 3:00 PM. S1 confirmed there was no RT working in the facility on 10/30/23 from 11:00 AM to 3:00 PM and on 10/31/23 from 7:00 AM to 3:00 PM. Upon interview on 11/6/23 at 12:10 PM, S26, APN and self identified House Officer covering the facility from 7:00 AM to 7:00 PM, stated House Officers help out in emergencies when needed and “If we were covering for a Respiratory Therapist, we wouldn’t take their assignment. We would just help out if there was a problem.” Facility policy titled, “Scope of Care Respiratory,” effective 8/16/23, stated, “ ... It is the objective of this department to deliver quality cardiopulmonary/respiratory care to inpatients by competent respiratory therapists under medical supervision. ... All services provided by Respiratory Therapy are delivered on a 24 hour, 7 day a week basis.””

“RESPIRATORY CARE SERVICES POLICIES CFR(s): 482.57(b) Services must be delivered in accordance with medical staff directives. This Standard is not met as evidenced by: 37432 Based on staff interview, review of three of three medical records of patients (P1, P6, and P7)on mechanical ventilation, and review of facility policy and procedure, it was determined the facility failed to ensure that patients on mechanical ventilation receive reassessments by a respiratory therapist at least daily. Findings include: 1. Review of P1’s medical record on 11/8/23, in the presence of Staff #14 (S14), Advisor to the Board, revealed the following: P1 was admitted to the facility on 10/10/23 with a diagnosis of acute respiratory failure. P1 was ventilator dependent and receiving ventilator management. Review of physician orders indicated respiratory therapy (RT) assessments were ordered twice a day. On 10/30/23, review of the RT documentation sheets revealed a RT assessment was conducted on 10/30/23 at 9:16 PM. There was no evidence that an additional RT assessment was conducted at any other time on 10/30/23. There was no evidence that RT assessments were conducted on 10/31/23. 2. Review of P6’s medical record on 11/8/23, in the presence of S14, revealed the following: P6 was admitted to the facility on 10/13/23 with a diagnosis of ventilator dependent respiratory failure. Review of physician orders indicated RT assessments were ordered twice a day. On 10/30/23, review of the RT documentation sheets revealed a RT assessment was conducted on 10/30/23 at 9:23 PM. There was no evidence that an additional RT assessment was conducted at any other time on 10/30/23. There was no evidence that RT assessments were conducted on 10/31/23. 3. Review of P7’s medical record on 11/8/23, in the presence of S14, revealed the following: P7 was admitted to the facility on 10/2/23 with a diagnosis of respiratory failure and was ventilator dependent. Review of physician orders indicated RT assessments were ordered every 12 hours. On 10/30/23, review of the RT documentation sheets revealed a RT assessment was conducted on 10/30/23 at 9:24 PM. There was no evidence that an additional RT assessment was conducted at any other time on 10/30/23. There was no evidence that RT assessments were conducted on 10/31/23. On 11/8/23 at 11:30 AM, S14 confirmed that P1, P6, and P7’s medical records lacked evidence of a second RT assessment on 10/30/23 and that no RT assessments were conducted on 10/31/23. Facility policy titled, “Assessment and Reassessment - RT,” effective 5/18/22, stated, “ ... Patients on mechanical ventilation will be reassessed at least every (4) hours, while those receiving less intense therapy will be assessed daily. Therapy will be evaluated to determine effectiveness and noted in the patient record.””