Longview Continuecare Hospital

“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: 32143 Based on interviews, policy, and medical chart reviews, the facility failed to ensure timely nursing reassessments were performed for 2(patients #1, #2, and #3) out of 5 (Patients #1-5) patient medical charts reviewed. Findings include: Patient #1 A review of the History and Physical in the medical records dated 12/2/2025 07:20 AM stated, “Hospital Course: Limited is a 74-year-old female with a past medical history significant for CVA/amyloid angiopathic who presented to Good Shepherd ED on 11/27 with concerns of being found on the floor RV with left-sided weakness and right deviated gaze. ED code stroke was initiated. Head revealed large acute intraparenchymal hematoma frontal lobe with 8 mm right to left midline shift. Head was negative for significant occlusive aneurysm. 3 consulted. Patient underwent craniotomy on 11/28/2025. This initiated seizure prevention. Dobbhoff placed concerns for oral dysphagia. PT/OT/SLP PT consulted for therapy recommendations. Continues to have left-sided weakness, dysphagia and developed visual impairment. Mated to LTAC for continued management.” A review of the incident report revealed Patient #1 had a fall on 12/14/25. The report stated that on 12/14/25 at 12:20 PM, the Registered Nurse (RN) working as an aide for that shift, who was helping patient #1 transfer, stated the patient’s foot “hung in the bed”. The patient and nurse fell to the floor, with the patient bumping her head. The physician (intensivist) was notified, and the patient was transferred to a higher level of care floor for close monitoring. The patient’s spouse was notified. A review of provider orders revealed that an order dated 12/14/25 1:28 PM stated to send the patient for a CT scan of the head. A review of the nursing progress notes on 12/14/26 at 2:15 PM stated, “Patient transferred via bed with belongings and husband present to room 1185. Report given to ____(staff RN #7) who will assume care of patient.” A review of the flowsheets at 2:18 PM, the patient had a set of vital signs completed. There was no nursing reassessment found after the fall or during the vital sign check. Staff #4 confirmed there was no nursing assessment found after the patient’s fall until 12/14/26 at 7:01 PM. There was no provider note found until 12/15/25 at 4:43 PM. The note stated, “12/15/2025: Seen and examined. She is sitting up in bed with no visible signs of distress. Her respirations are even and unlabored. She sustained a ground-level fall yesterday resulting in her hitting her head. She has no new focal deficits; however, CT did reveal a recurring hematoma. Findings were discussed with neurosurgery and IV Decadron was started with last day tomorrow. Resume tube feeds. Therapy following. Continue Keppra for seizure prevention. Will follow. Expected DC date: 12/23/2025 Date of Service: 12/15/2025. Patient was seen and examined in collaboration with Advanced Practice Provider, ____ (staff #5). We have discussed the case, and I have reviewed the documentation and I agree with it as written. ____ (staff #6).” A review of provider orders revealed that an order dated 12/14/25 1:28 PM to send the patient for a CT scan of the head. A review of the nursing progress notes dated 12/14/25 at 8:54 PM stated, “Pt. To CAT scan via bed, accompanied by transport tech at 1950. Pt. Back to room at 2015. Denies pain or discomfort.” There was no documentation on why there was a delay from when the scan was ordered and performed. Staff #4 confirmed there was no nursing assessment found after the patient’s fall, nor concerning the delay in care. Patient #2 A review of the medical record for patient #2 revealed he was admitted to the facility on 02/13/2026 2131 (9:31 PM). The patient diagnosis upon admission was Acute hypoxic respiratory failure Secondary to pneumonia versus autoimmune/organizing pneumonia, ETT on vent-controlled. A review of the incident report dated 3/25/26 at 5:00 AM revealed patient #2 had an incident while being turned in the bed. The incident report stated the patient was being turned in the bed, while performing wound care, and his head hit the side rail. The report stated the RN contacted the provider and the patients at 8:50 AM. A CT scan of the brain was ordered by the physician on 03/25/26 at 8:57 AM. A review of the provider notes revealed the patient was seen on 3/25/26 by the provider. The note stated, “Patient had traumatic bump on the right forehead today while undergoing wound care. Will order CT of brain today. Wife has been notified. Wound care has placed Band-Aid on small laceration that is clean and not bleeding.” There was no nursing documentation found on the chart of the patient incident or a nursing assessment. Staff #4 confirmed there was no nursing assessment found after the patient’s incident. Patient #3 A review of the incident report revealed patient #3 had a fall on 3/11/26 at 5:10 AM. A review of the medical record revealed there was no documentation that the patient had a nursing assessment after the fall. The chart revealed the patient was not seen by the nurse practitioner until 1:14 PM on 3/11/25. Policy “A review of the facility policy and procedure “Assessment and Reassessment” Reference # 03.379.22 stated, “Each clinical discipline within the organization has a developed scope of assessment, practice standard, or defining statement/guideline that conforms to its scope of practice, licensure laws, and regulations, and applicable certifications. Patients are reassessed to determine their response to treatment, when a significant change occurs in the patient’s condition, and when a significant change occurs in the patient’s diagnosis. Patient assessment, at minimum, considers physical, psychological, and social status as well as patient age and developmental stage. This assessment and reassessment continues through the patient’s hospital stay. Assessment and reassessment data will be documented in the patient’s medical record. The initial assessment considers the patient’s immediate and emerging needs and helps staff determine what care the patient needs as well as any further assessments. Reassessment is a documented description of the patient’s response/status relative to medical and /or nursing interventions, effectiveness of interventions, resolution of patient problems/needs, and discharge preparation. All data collected on patients is reviewed and analyzed by the RN assigned to oversee care for the patient; interdisciplinary team goals are adjusted based upon the changing needs of the patient and/or their response to prescribed interventions. Reassessment is documented once each shift and when the patient’s condition warrants.””

“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: 40989 Based on document review and interview, the hospital failed to: 1. ensure 3 (Physician #10, #11, and #12) of 3 physicians’ orders included a rate for the transfusion of blood/blood products in 4 (Patient #2, #3, #4, and #6) of 4 patient medical records reviewed. 2. ensure 3 (Physician #10, #11, and #12) of 3 physicians gave orders to increase the rate of the transfusion of blood/blood products in 4 (Patient #2, #3, #4, and #6) of 4 patient medical records reviewed. 3. ensure the nursing staff had a properly executed informed consent before initiating a blood/blood product transfusion in 4 (Patients #2, #3, #4, and #6) of 4 patient medical records reviewed. 4. ensure the hospital policy and procedure gave clear guidelines for all blood/blood product administration. 5. ensure that a blood transfusion was completed within 4 hours in 1 (Patient #2) of 4 (Patients #2, #3, #4, and #6) patient medical records reviewed. 6. ensure a 2-person verification was completed before initiating a blood/blood product transfusion in 4 (Patients #2, #3, #4, and #6) of 4 patient medical records reviewed. The deficient practices identified under the following Conditions of Participation were determined to pose Immediate Jeopardy to patient health and safety. They placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death. 7. ensure that nursing staff safely administered patient medications and followed its policy titled, “Medication Administration” in 1 (Patient #1) of 1 patient chart reviewed.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 40989 Based on document review and interview the hospital failed to ensure a properly executed informed consent was completed in 4 (Patient #2, #3, #4, and #6) of 4 patient medical records reviewed. Also, the hospital failed to follow the policy titled, “Anesthesia, Surgical, and Medical Informed Consent”. Medical records were reviewed with Registered Nurse (RN) Staff #4 on 2/24/2025 after 10:30 AM. Findings: Patient #2 Patient #2 was a 54-year-old male admitted to the hospital on 1/31/2025 by Physician #10. Further review revealed Patient #2 received a blood transfusion on 2/01/2025. A review of the informed consent for a blood transfusion dated 2/01/2025 revealed Patient #2 signed the informed consent on 2/01/2024 at 1440 (2:40 PM) and the RN witnessed the consent on 2/01/2025 at 1440. The informed consent document had a signature line for the physician, but Physician #10 failed to sign the informed consent document. There was no documentation in the medical record by Physician #10 that the risks and benefits had been explained to the patient before Patient #2 gave informed consent to receive a blood transfusion. Patient #3 Patient #3 was a 74-year-old male admitted to the hospital on 2/05/2025 by Physician #11. Further review revealed Patient #3 received a blood transfusion on 2/07/2025. A review of the informed consent for a blood transfusion dated 2/07/2025 revealed Patient #3’s Medical Power of Attorney (MPOA) gave telephone consent on 2/07/2025. Two RNs signed and witnessed the telephone consent on 2/07/2025 at 10:13 AM. The informed consent document had a signature line for the physician, but Physician #11 failed to sign the informed consent document. There was no documentation in the medical record by Physician #11 that the risks and benefits had been explained to the patient’s MPOA before the informed consent for the blood transfusion was verbally given to the RN. Patient #4 Patient #4 was a 63-year-old male who was admitted to the hospital on 2/19/2025. Further review revealed Patient #4 received a blood transfusion on 2/20/2025. A review of the informed consent for a blood transfusion dated 2/20/2025 revealed Patient #4 gave verbal consent on 2/20/2025 at 12:11 PM and two RNs signed and witnessed the informed consent on 2/20/2025 at 12:11 PM. The informed consent document had a signature line for the physician, but Physician #12 failed to sign the informed consent. There was no documentation in the medical record by Physician #12 that the risks and benefits had been explained to the patient before Patient #4 gave informed consent to receive a blood transfusion. Patient #6 Patient #6 was a 44-year-old female admitted to the hospital on 1/11/2025. Further review revealed Patient #6 received two blood transfusions on 1/20/2025. A review of the medical record did not reveal a signed informed consent for the blood transfusions. An interview was conducted with RN Staff #4 on 2/24/2025 at 11:30 AM. RN Staff #4 was asked if an informed consent was signed by the patient before the initiation of the blood transfusions. RN Staff #4 confirmed there was no signed informed consent for the blood transfusions. RN Staff #4 was asked how the staff would know if the physician talked to the patient regarding the risks and benefits of a blood transfusion. RN Staff #4 stated, “The physicians are required to sign the consent confirming they informed the patient of the risks and benefits of a blood transfusion”. An interview was conducted with Patient #6 on 2/24/2025 at 3:30 PM in the presence of RN Staff #4. Patient #6 was asked if she signed an informed consent for the blood transfusions. Patient #6 confirmed there was no informed consent signed before the blood transfusions. A review of the hospital titled, Anesthesia, Surgical, and Medical Informed Consent” Policy Number 03.106.22 (3.8), with a reviewed date of 5/24 was as follows: “1.0 PURPOSE 1.1 To Inform the patient of the nature of the treatment/procedure in language and terms the patient can understand, as well as an explanation as to what will occur (see Attachment A) and of possible risks and hazards to which they are consenting during the treatment or procedure. 1.2 To Inform the patient of the risks associated with the procedure that are reasonably foreseeable and significant for that particular patient. 1.3 To inform the patient of the benefits of the procedure and how this will benefit the patient. 1.4 To Inform the patient of alternatives to the treatment, including the alternative of forgoing the treatment. 1.5 To conform as well as abide by the Texas Medical Disclosure and Consent for Anesthesia, Surgical and Medical Consents. 2.0 POLICY 2.1 The physician is responsible for disclosing to the patient all risks, benefits and alternatives ... 2.2 Hospital personnel or the physician may assist with completion of the Disclosure and Consent Form answer any questions the patient may have which is in their area of expertise and witness the patient’s signature provided the physician has disclosed the risks, benefits, and alternatives involved with the procedure to the specific patient ...” An interview was conducted with RN Staff #13 On 2/24/2025 AT 3:55 pm. Rn Staff #13 was asked who had the responsibility to get the informed consent signed by the patient before the blood transfusion was started. RN Staff #13 stated, “The nurses get the consent by the consent signed by the patient”. RN #13 was asked if the nurse explained the risks and benefits of a blood transfusion to the patient. RN Staff #13 stated, “The risks and benefits are written on the consent, and we just get the consent signed”. An interview was conducted with RN Staff #14 on 2/24/2025 at 4:17 PM. RN Staff #14 was asked who explained the risks and benefits of a blood transfusion to a patient. RN Staff #14 said, “That is the physician’s responsibility and not the nurses”. RN staff #14 was asked where would the physician document that the risks and benefits had been explained to the patient. RN Staff #14 stated,” The policy states the physician has to sign the informed consent, and the risks and benefits are listed on the consent document”. An interview was conducted on 2/24/2025 in the afternoon with RN Staff #2, #3, and #4. RN Staff #2, #3, and #4 confirmed it was hospital policy that the physician signs the informed consent for the transfusion of blood or blood products. RN Staff #4 confirmed the physician failed to sign the informed consent in 4 (Patients #2, #3, #4, and #6) of 4 patient medical records reviewed.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 47892 Based on documentation review and interview the hospital failed to ensure that nursing staff safely administered patient medications and followed its policy titled, “Medication Administration” in 1 (Patient #1) of 1 patient chart reviewed. Findings: A review of the incident and complaint log was conducted on 2/24/2025 after 10:00 AM with Licensed Vocational Nurse (LVN) Staff #3. LVN Staff #3 confirmed Patient #1 was not on either log for a complaint or incident. An interview was conducted with the Chief Nursing Officer (CNO) on 2/24/2025 at 12:34 PM. CNO Staff #2 was asked if Patient #1 or the patient’s family made a complaint to her regarding the patient’s care. CNO Staff #2 confirmed Patient #1s family was concerned about the patient’s medications being left in the patient’s room on the bedside table. CNO Staff #2 stated, “Patient #1’s medication was left on the bedside table by the nurse, and I was called to speak to the family”. CNO Staff #2 confirmed she spoke to the nursing staff and addressed the concerns with the charge nurse but failed to document any education given to the nursing staff or specific findings in the patient’s medical record. CNO Staff #2 was asked what the procedure was for handing out medication to patients. CNO Staff #2 stated, “The nurse handing out medication to patients is to remain with the patient while they take the medication”. A review of the facility’s policy titled “Medication Administration” approved 05/2024 was as follows: “Purpose: To establish a procedure for the administration of medication hospital wide that ensures patient safety ... Procedure: ...Staff must remain with the patient until the patient takes the medication ...” In an interview on 2/24/2025 at 12:34 PM CNO staff #2 confirmed that nursing staff did not follow the facility policy.”

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 40989 Based on document review and interview, the hospital failed to: 1. ensure 3 (Physician #10, #11, and #12) of 3 physicians’ orders included a rate for the transfusion of blood/blood products in 4 (Patient #2, #3, #4, and #6) of 4 patient medical records reviewed. 2. ensure 3 (Physician #10, #11, and #12) of 3 physicians gave orders to increase the rate of the transfusion of blood/blood products in 4 (Patient #2, #3, #4, and #6) of 4 patient medical records reviewed. 3. ensure the nursing staff had a properly executed informed consent before initiating a blood/blood product transfusion in 4 (Patients #2, #3, #4, and #6) of 4 patient medical records reviewed. 4. ensure the hospital policy and procedure gave clear guidelines for all blood/blood product administration. 5. ensure that a blood transfusion was completed within 4 hours in 1 (Patient #2) of 4 (Patients #2, #3, #4, and #6) patient medical records reviewed. 6. ensure a 2-person verification was completed before initiating a blood/blood product transfusion in 4 (Patients #2, #3, #4, and #6) of 4 patient medical records reviewed. The deficient practices identified under the following Conditions of Participation were determined to pose Immediate Jeopardy to patient health and safety. They placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death. Medical record reviews were conducted with Registered Nurse Staff #4 on 2/24/2025. Findings: Patient #2 Patient #2 was a 54-year-old male admitted to the hospital on 1/31/2025 with Necrotizing pancreatitis, Gallbladder fossa abscess, Recent Coranary Artery diseaase with a stent placement for a heart attack, Anemia, Hypertension, Diabetes, Atrial fibrillation, and Sqamous cell cancer of the neck and metastises to the neck lymph nodes. . A review of the order dated 2/01/2025 at 10:50 AM by Physician #10 was as follows: “Transfuse RBC (Red Blood Cells) 1 Unit, Routine. Comments: RBC estimated total volume per unit: 350 milliliters (ml) Adult non-emergent transfusions should be initiated at a rate of 100ml/hour(hr) for the first 15 minutes, then for a duration of 1.5-4 hours per unit, unless otherwise specified by the provider ... Results Transfusion Information, Transfuse RBC-(Unit number), Status-Completed 2/02/2025, Volume-881.25 ml, Start-2/01/2025 at 1500 (3:00 PM), End-2/01/2025 at 2100 (9:00 PM). Order Questions Has consent been obtained? Yes Transfusion duration per unit (within): 2 hours ...” A review of the transfusion flow sheet dated 2/01/2025 revealed the blood transfusion was started at 1500 (3:00 PM) at 75ml/hr and increased to a rate of 150ml/hr at 1515 (3:15 PM) and ended at 2100 (9:00 PM) with a total RBC volume infused of 881.25 ml. This was a total transfusion time of 6 hours. A review of the 2-person verification for safe blood administration was signed by RN Staff #15 at 1254 PM. This was greater than 2 hours before the blood transfusion was started. There was no documentation indicating the presence or absence of any suspected transfusion reaction in the medical record. An interview was conducted with Chief Nursing Officer (CNO) Staff #2 on 2/26/2025 at 9:30 AM. CNO Staff was asked if the patient’s blood transfusion dated 2/01/2025 lasted a total of 6 hours. CNO Staff #2 confirmed the documented completion time was 2/01/2025 at 2100 (9:00 PM with 881.25 ml total RBC volume infused. CNO Staff #2 stated, “The system does an automatic calculation of the total volume infused based on the transfusion rate and the length of time for the transfusion. There was a set of vital signs documented at 1901 (7:01 PM) during the transfusion and then the vital signs returned to every 4 hours so I think someone realized the blood transfusion was not charted as complete and at the end of the shift the nurse just documented at that time and did not go back and see what the actual completion time was”. A review of the order dated 2/08/2025 at 8:49 AM by Physician #12 was as follows: “Transfuse RBC (Red Blood Cells) 2 Unit, Routine. Comments: RBC estimated total volume per unit: 350 milliliters (ml) Adult non-emergent transfusions should be initiated at a rate of 100ml/hour for the first 15 minutes, then for a duration of 1.5-4 hours per unit, unless otherwise specified by the provider ... Results Transfusion Information, Transfuse RBC-(Unit number #1), Status-Completed 2/08/2025, Volume-395 ml, Start-2/08/2025 at 1234, End-2/01/2025 at 1555. Transfusion Information, Transfuse RBC-(Unit number #2), Status-Transfusing, Volume-(blank), Start-2/08/2025 at 1642, End-(blank). Order Questions Has consent been obtained? Yes Transfusion duration per unit (within): 2 hours ...” A review of the transfusion flow sheet dated 2/08/2025 for Unit #1 revealed the blood transfusion was started at 1234 (12:34 PM) at 75ml/hr, increased to a rate of 100ml/hr at 1250 (12:50 PM), and increased again to 125ml/hr at 1300 (1:00 PM). There was no physician order to increase the rate of the transfusion. The blood transfusion was ended at 1555 (3:55 PM) with a total RBC volume infused of 395 ml. This was a total time of greater than 3 hours. There was no documentation of a 2-person verification at the patient’s bedside for safe blood administration before the blood transfusion was started. There was no documentation indicating the presence or absence of any suspected transfusion reaction in the medical record. A review of the transfusion flow sheet dated 2/08/2025 for Unit #2 revealed the blood transfusion was started at 1642 (4:42 PM) at 75ml/hr. Further review revealed there was no end date, time, or total RBC volume infused documented for the Unit #2 blood transfusion. There was no documentation of a 2-person verification at the patient’s bedside for safe blood administration before the blood transfusion was started. There was no documentation indicating the presence or absence of any suspected transfusion reaction in the medical record. An interview was conducted with CNO Staff #2 on 2/24/2025 after 11:00 AM. CNO Staff #2 was asked if the “Comments” section on the blood transfusion was considered the specified rate that the physician ordered. CNO Staff #2 stated, “That is an automatic default, and the physician should uncheck the box to give specific orders”. CNO Staff #2 was asked if the physician orders the blood transfusion to be completed in 2 hours and the default says 100 ml/hr for the first 15 minutes and then no specific rate after the first 15 minutes how was the nurse to know what rate to run the blood transfusion. CNO Staff #2 confirmed that the physician would need to order a specific rate for the transfusion of blood/blood products and confirmed that just ordering a duration does not give clear guidelines to the nurses on how fast or slow the blood needs to be transfused. RN Staff #4 confirmed that Physician #12 failed to sign the informed consent dated 2/01/2025 confirming that the risks and benefits of a blood transfusion were discussed with the patient before the blood was administered. Patient #3 Patient #3 was a 74-year-old male admitted to the hospital on 2/05/2025 with a diagnosis of Sepsis secondary to pneumonia, Hypotension, Acute respiratory failure with hypoxia, Acute metabolic encephalopathy secondary to sepsis, Acute chronic heart failure with preserved EF, Restless leg syndrome, and Hyperlipidemia. A review of the order dated 2/07/2025 at 7:23 AM by Physician #11 was as follows: “Transfuse RBC (Red Blood Cells) 1 Unit, Routine. Comments: RBC estimated total volume per unit: 350 milliliters (ml) Adult non-emergent transfusions should be initiated at a rate of 100ml/hour for the first 15 minutes, then for a duration of 1.5-4 hours per unit, unless otherwise specified by the provider ... Results Transfusion Information, Transfuse RBC-(Unit number), Status-Completed 2/07/2025 at 1745 (5:45 PM), Volume-347.5ml, Start-2/07/2025 at 1504, End-2/07/2025 at 1730. Order Questions Has consent been obtained? Yes Transfusion duration per unit (within): 2 hours ...” A review of the transfusion flow sheet dated 2/07/2025 revealed the blood transfusion was started at 1504 (3:04 PM) at 75ml/hr and ended at 1730 (5:30 PM) with a total RBC volume infused of 347.5 ml. This was a total time of greater than 2 hours. There was no documentation of a 2-person verification for safe blood administration before starting the blood transfusion. There was no documentation indicating the presence or absence of any suspected transfusion reaction in the medical record. RN Staff #4 confirmed that the blood was not administered within 2 hours as the physician ordered and that the nurse failed to follow the defaulted rate for the initiation of the transfusion ordered by Physician #11. RN Staff #4 confirmed there was no physician name or signature on the informed consent for the transfusion of blood/blood products. Patient #4 Patient #4 is a 63-year-old male who was admitted to the hospital on 2/19/2025 with a diagnosis of Spinal cord injury, quadriplegia, Acute respiratory failure with hypercapnia-ventilator dependent, Dysphagia, and Stage 2 sacral decubitus. A review of the order dated 2/20/2025 at 11:16 AM by Physician #12 was as follows: “Transfuse RBC (Red Blood Cells) 2 Unit, Routine. Comments: RBC estimated total volume per unit: 350 milliliters (ml) Adult non-emergent transfusions should be initiated at a rate of 100ml/hour for the first 15 minutes, then for a duration of 1.5-4 hours per unit, unless otherwise specified by the provider ... Results Transfusion Information, Transfuse RBC-(Unit number #1), Status-Completed 2/20/2025 at 1654, Volume-342 ml, Start-2/08/2025 at 1355, End-2/01/2025 at 1653. Transfusion Information, Transfuse RBC-(Unit number #2), Status-Completed, Volume-412.5ml, Start-2/20/2025 at 1715 (5:15 PM), End-2033 )8:33 PM). Order Questions Has consent been obtained? Yes Transfusion duration per unit (within): 2 hours ...” A review of the transfusion flow sheet dated 2/20/2025 for Unit #1 revealed the blood transfusion was started at 1355 (1:55 PM) at 125ml/hr and ended at 1653 (4:53 PM) with a total RBC volume infused of 342 ml. This was greater than a 2-hour total infusion time. There was no documentation of a 2-person verification at the patient’s bedside for safe blood administration before starting the blood transfusion. There was no documentation indicating the presence or absence of any suspected transfusion reaction in the medical record. A review of the transfusion flow sheet dated 2/20/2025 for Unit #2 revealed the blood transfusion was started at 1715 (5:15 PM) at 125ml/hr and ended at 2033 (8:33 PM) with a total RBC volume infused of 252.08ml. There was no documentation of a 2-person verification at the patient’s bedside for safe blood administration before starting the blood transfusion. There was no documentation indicating the presence or absence of any suspected transfusion reaction in the medical record. During an interview on 2/24/2025 after 10:00 AM, RN Staff #4 confirmed Physician #12 failed to sign the informed consent for the blood transfusion. Patient #6 Patient #6 was a 44-year-old female admitted to the hospital on 1/11/2025 with a diagnosis of septic arthritis, L5-S1 discitis/osteomyelitis, Ovarian Cysts, intractable chronic pain, and Morbid obesity. A review of the order dated 1/20/2025 at 1:21 PM by Physician #10 was as follows: “Transfuse RBC (Red Blood Cells) 2 Unit, Routine. Comments: RBC estimated total volume per unit: 350 milliliters (ml) Adult non-emergent transfusions should be initiated at a rate of 100ml/hour for the first 15 minutes, then for a duration of 1.5-4 hours per unit, unless otherwise specified by the provider ... Results Transfusion Information, Transfuse RBC-(Unit number #1), Status-Stopped, Volume-250ml ml, Start-1/20/2025 at 1745, End-1/20/2025 at 2015. Transfusion Information, Transfuse RBC-(Unit number #2), Status-Stopped, Volume-350ml, Start-1/20/2025 at 2300, End 1/21/2025 2:30 AM. Order Questions Has consent been obtained? Yes Transfusion duration per unit (within): 3 hours ...” A review of the transfusion flow sheet dated 1/20/2025 for Unit #1 revealed the blood transfusion was started at 1745 (5:45 PM) at 100ml/hr and ended at 2015 (8:15 PM) with a total RBC volume infused of 250ml. There was no documentation of a 2-person verification at the patient’s bedside for safe blood administration before the transfusion was started. There was no documentation indicating the presence or absence of any suspected transfusion reaction in the medical record. A review of the transfusion flow sheet dated 1/20/2025 for Unit #2 revealed the blood transfusion was started at 2300 (11:00 PM) at 100ml/hr by the RN. The transfusion ended on 1/21/2025 at 2:30 AM with a total RBC volume infused of 350ml. There was no documentation of a 2-person verification at the patient’s bedside for safe blood administration before the blood transfusion was started. There was no documentation indicating the presence or absence of any suspected transfusion reaction in the medical record. A review of the medical record did not reveal a signed informed consent for the blood transfusions. An interview was conducted with RN Staff #4 on 2/24/2025 at 11:30 AM. RN Staff #4 was asked if an informed consent was signed by the patient before the initiation of the blood transfusions. RN Staff #4 confirmed there was no signed informed consent for the blood transfusions. An interview was conducted with Patient #6 on 2/24/2025 at 3:30 PM in the presence of RN Staff #4. Patient #6 was asked if she had signed an informed consent for the blood transfusions. Patient #6 confirmed there was no informed consent signed before the blood transfusions. A review of the hospital policy titled “Laboratory Collection and Patient Care Administrative Policy for Transfusing Blood and Blood Bank Components” Policy Number 03.343.21 with a review date of 5/2024 was as follows: “1. PURPOSE ... 2. POLICY 2.1 The initiation of blood and/or component therapy may be performed only by a physician or RN. 2.2 All blood and blood products must be identified by two (2) licensed nursing personnel prior to administration using the Compatibility Transfusion Tab. One of these must be an RN ... 2.6 Transfusions should be completed within four (4) hours. No blood container or recipient tubing should hang longer than four (4) hours. Red blood cells should be infused within two (2) hours unless physician orders otherwise ... 4. PATIENT PREPARATION 4.1 Check chart for physician’s order ... 4.9 Check blood or blood component verifying identification data. 4.9.1 Inspect the blood or blood component unit for abnormal color or appearance. 4.9.2 Check unit of blood or blood component compatibility transfusion tab, and patient’s armband to verify. a. Patient’s name b. Patient’s identification number c. Unit number d. ABO and RH type of blood component e. Expiration date 4.9.3 Check patient’s identification armband. 4.9.4 Check all data at patient’s bedside. Two (2) licensed staff members should check data together. One of the staff members should be an RN or physician. 4.9.5 Both licensed staff members are to sign a Compatibility Transfusion Tab. Affix the tag label to the Transfusion Record. DO NOT detach the tag from the flood container at any time ... 4.10 Administer blood component, as prescribed by the physician ... 4.10.4 Infuse slowly for first 15 minutes, observing the patient for signs and symptoms of an adverse reaction. The patient will be observed every 30 minutes during the transfusion. 4.10.5 Vital Signs to be taken at initiation, 15 minutes, 30 minutes, then every hour until completion and 1 hour post completion. 4.10.6 Adjust infusion rate based on clinical condition of the patient and blood product being transfused ... 4.12 Complete the Transfusion Record, Record and sign the appropriate space. 4.12.1 Indicate presence or absence of any suspected transfusion reaction. The transfusion record is a legal document and must be retrained in the care ... 5. Nursing Administration Addendum 5.1 The patient’s assigned nurse per each shift is accountable to ensure the physicians order for blood administration is fulfilled. If unable to complete the transfusion as ordered the chart will reflect reason and action-taken to notify physician for need to amend original order. 5.2 When blood/blood components are ordered to be given in a “series,” the off-going shift nurse will validate order and number of units given to the on-going shift nurse. She will also validate blood documentation for off-going shift is correct prior to leaving duty”. An interview was conducted with RN Staff #13 on 224/2025 at 4:00 PM. RN Staff #14 was asked if the physicians ordered a rate for a blood transfusion. RN Staff #14 stated, “No, they usually don’t write a rate on the order; they will just give you a duration time for the transfusion”. RN Staff #14 was asked how she knew how fast or slow to run the blood. RN Staff #14 stated, “I will usually start it at about 100ml/hr or 125ml/hr and then increase it to 150ml/hr. It just depends on how the patient is doing”. RN Staff #14 was asked to clarify what the ordered rate was on the actual physician order. RN Staff #14 confirmed that was a default box and that was not the rate that the nursing staff followed. RN Staff #14 stated, “The doctors should be unchecking that box when they give a blood order, but they usually just leave it checked so that is why it’s on every order”. An interview was conducted with RN Staff #14 on 2/24/2025 at 4:17 PM. RN Staff #14 was asked if the physicians ordered a specific rate when they ordered a blood transfusion. RN Staff #14 confirmed that the physician did not include the rate for the transfusion in the order. RN Staff #14 was asked how he knew what rate to start the transfusion. RN Staff #14 stated, “I usually just start it at 75-100ml/hr and then increase it depending on the patient’s health. RN Staff #14 was asked if the hospital required two nurses to verify the blood before the beginning of the transfusion. RN Staff #14 confirmed the hospital policy required two nurses to verify the blood at the patient’s bedside before the blood transfusion was started”. An interview was conducted with RN Staff #4 and Licensed Vocational Nurse (LVN) #3 on 2/24/2025 at 4:40 PM. RN Staff #4 confirmed that physicians did not write a rate with the blood transfusion order. RN Staff #4 confirmed the nursing staff failed to make sure that there was a complete order that included the rate for blood transfusions. During an interview on 2/26/2025 with CNO Staff #2, it was confirmed there was no 2-person verification at the patient’s bedside before starting a blood transfusion in 4 (Patient #2, #3, #4, and #6) of 4 patient medical records reviewed. Also, CNO Staff #2 confirmed that the policy did not give clear guidelines to ensure that a physician’s order for the rate of the blood transfusion was required to start or increase the rate of the blood transfusion.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 47892 Based on record review and interview the facility failed to follow its own policy titled; “Anesthesia, Surgical and Medical Informed Consent” and ensure a properly executed informed consent was complete and in the medical record before medical treatment or procedures in 8 of 12 (Patients #1, 2, 3, 4, 5, 7, 11, and 12) patient medical records reviewed as exhibited by: A. Physician staff failed to sign and date the informed consent in patients #1, 2, 3, 4, 5, 7, 11, and 12. B. Physician staff failed to explain the risks and benefits of the medical treatment before the patient signed the informed consent in patients #1, 2, 3, 4, 5, and 7. C. Physician staff failed to document the diagnosis and procedure on the informed consent in patient #1 D. Nursing staff failed to print their name in the appropriate section of the informed consent in patient #1. This deficient practice had the likelihood to affect all patients. Findings: Patient #2 A review of Patient #2’s medical record was conducted on 10/2/2024 before 11:00 AM with Staff # 3. The history and physical dated 4/15/2024 and documented by Physician #6 revealed Patient #2 was a 21-year-old male diagnosed with a traumatic brain injury secondary to a fall from 18 feet height, closed pelvic fracture, and traumatic pulmonary laceration. Patient #2 had a signed informed consent for a blood transfusion in his medical chart dated 4/15/2024. The consent was signed by Patient #2’s legal representative and witnessed by a registered nurse (RN) at 5:25 PM. The nurse’s signature was illegible. The physician’s signature line was left blank. Patient #3 A review of Patient #3’s medical record was conducted on 10/2/2024 be 11:00 AM with Staff # 3. The history and physical dated 4/29/2024 and documented by Physician #7 revealed Patient #3 was a 31-year-old male diagnosed with acute respiratory failure with hypoxia, anoxic brain injury, dysautonomia with agitation, mixed hyperlipidemia, essential hypertension, new-onset refractory status epilepticus, post hypoxic myoclonus, and diabetes mellitus II. Patient #3 had a signed informed consent for a blood transfusion in his medical chart dated 4/29/2024. The consent was signed by Patient #3’s legal representative and witnessed by an RN at 6:00 PM. The physician’s signature line was left blank. Patient #4 A review of Patient #4’s medical record was conducted on 10/2/2024 before 11:00 AM with Staff # 3. The history and physical dated 7/12/2024 and documented by Physician #8 revealed Patient #4 was an 81-year-old male diagnosed with bacteremia, scrotal abscess with coccygeal osteomyelitis, coronary artery disease, chronic heart failure, hypertension, and type 2 diabetes. Patient #4 had a signed informed consent for a blood transfusion in his medical chart dated 7/12/2024. The consent was signed by Patient #4’s spouse and witnessed by an RN at 7:52 PM. The physician’s signature line was left blank. Patient #5 A review of Patient #5’s medical record was conducted on 10/2/2024 before 11:00 AM with Staff # 3. The history and physical dated 9/28/2024 and documented by Physician #9 revealed Patient #5 was a 43-year-old male diagnosed with an infected stage IV sacral decubitus ulcer, chronic anemia, and HIV/AIDS. Patient #5 had a signed informed consent for a blood transfusion in his medical chart dated 9/27/2024. The consent was signed by Patient #5’s legal representative and witnessed by an RN at 6:00 PM. The nurse’s signature was illegible. The physician’s signature line was left blank. Patient #7 A review of Patient #7’s medical record was conducted on 10/2/2024 before 11:00 AM with Staff # 3. The history and physical dated 7/29/2024 and documented by Physician #8 revealed Patient #7 was a 53-year-old female diagnosed with acute respiratory failure with hypoxia, MVA (motor vehicle accident) with multiple traumatic injuries. Patient #7 had a signed informed consent for a blood transfusion in his medical chart dated 4/15/2024. The consent was signed by Patient #7’s legal representative at 5:08 PM and witnessed by an RN at 5:30 PM. The nurse’s signature was illegible. The physician’s signature line was left blank. An interview was conducted with Staff #3 on 10/02/2024 after 11:00 AM. Staff #3 was asked when do your physicians sign the blood transfusion consents. Staff #3 stated, “Only if the physician decides to give a blood transfusion.” Staff #3 was asked when the did physician explain the risks and benefits to the patient or the patient’s family. Staff #3 stated, “The physicians explain the risks and benefits to the patient before we start the blood transfusions and then the physician will sign the consent”. Staff #3 was asked why all the blood transfusions were not signed by a physician on any of these patients. Staff #3 stated, “The patient never received blood”. Staff #3 was asked if this blood transfusion consent was in the admission packet and does every patient admitted signed one upon admission. Staff #3 stated, “The blood transfusion consents are in our admission packet and the nurses get them signed at admission”. Staff #2 was asked to get an admission packet for review on 10/02/2024 after 11:00 AM. The blood transfusion consent was in the admission packet. Staff #3 was asked who was responsible for explaining the risks and benefits to the patient. Staff #3 stated “The physician”. Staff #3 was asked then how the nurse could have the patient or the patient’s family sign these consents without the physician explaining the risks and benefits first. Staff #3 stated, “We should not be getting them signed at admission”. Staff #3 confirmed the informed consent for blood transfusions was signed at the time of admission before the physician explained the risks and benefits to the patient or the patient’s legal representative. During an interview on 10/02/2024 after 11:00 AM, Staff #3 confirmed the facility failed to follow its policy titled, “Anesthesia, Surgical and Medical Informed Consent”. A review was conducted on 10/02/2024 after 11:00 AM of the policy titled “Anesthesia, Surgical and Medical Informed Consent” policy number 03.106.22(3.8) last reviewed 05/24 states. “1.0 PURPOSE 1.1 To inform the patient of the nature of the treatment/procedure in language and terms the patient can understand, as well as an explanation as to what will occur (see Attachment A) and of possible risks and hazards to which they are consenting during treatment or procedure. 1.2 To inform the patient of the risks associated with the procedure that are reasonably foreseeable and significant for that particular patient. 1.3 To inform the patient of the benefits of the procedure and how this will benefit the patient. 1.4 To inform the patient of alternatives to the treatment, including the alternative of forgoing the treatment. 1.5 To conform as well as abide by the Texas Medical Disclosure and consent for Anesthesia, Surgical and Medical Consents. 2.0 POLICY 2.1 The physician is responsible for disclosing to the patient all risks and benefits and alternatives ... 2.2 Hospital personnel or the physician may assist with completion of the Disclosure and Consent Form answer any question the patient may have which is in their area of expertise and witness the patient’s signature provided the physician has disclosed the risks, benefits, and alternatives involved with the procedure to the specific patient ...” During an interview on 10/02/2024 after 11:00 AM, Staff #3 confirmed the facility failed to follow its policy titled, “Anesthesia, Surgical and Medical Informed Consent”. 10135 Patient #1 Review of a critical care history and physical dated 02/15/2024 revealed Patient #1 was a 60-year- old female who had diagnoses which included hypercholesteremia, hypertension and Type 2 Diabetes. Patient #1 was transferred to the unit for long term acute care management. Review of consents on the chart revealed the following: Admission consents dated 02/15/2024 revealed a blood consent. The responsible party and a nurse signed the consent. There was a blank which indicated the physician was supposed to sign also, but he did not. Review of blood administration records dated 03/25/2024 revealed Patient #1 received two units of blood. There was no new consent obtained. During an interview on 10/02/2024 after 10:25 a.m., Staff #5 (Registered nurse) confirmed Patient #1 received a unit of blood and that they were using the consent dated 02/15/2024. Staff #5 (Registered nurse) confirmed that she could not find a physician progress notes explaining the risk and benefits for blood for 03/25/2024. There was a consent dated 02/19/2024 for an esophagogastroduodenoscopy (EGD) and a percutaneous endoscopic gastrostomy tube placement. Two nurses signed the form as receiving phone consent from Patient #1’s husband. The nurse did not print their name out by their signature as the form called for. There was no documentation that Patient #1’s husband was asked to sign the form later or send a fax or telegram giving consent. There was a consent dated 02/27/2024 for a peripherally inserted central catheter (PICC). The consent was signed by the responsible party and a nurse. The consent also called for the names to be printed and they were not. There was a blank which indicated the provider physician was supposed to sign and date, but this was not done. There was an undated consent for a trachea which did not identify the procedure. Two nurses signed the form as receiving phone consent from the Patient #1’s husband. They did not print their name out by the signature as the form called for. There was no documentation that Patient #1’s husband was asked to sign the form later or send a fax or telegram giving consent. During an interview on 10/08/2024 after 9:00 a.m., Staff #3 (Quality nurse) confirmed the missing information on the consents. Patient #11 Review of a history and physical dated 08/15/2024 revealed Patient #11 was a 54-year-old male with diagnoses which included a motor vehicle accident with a spinal cord injury. Patient #11 had a blood consent on the record dated 08/15/2024 which was signed by the power of attorney and a nurse. The area for the physician’s signature was blank. Patient #12 Review of a history and physical dated 09/20/2024 revealed Patient #12 was a 62-year-old female with diagnoses which included acute renal failure, hypertension, and Type II Diabetes. Patient #12 had a blood consent on the record dated 09/21/2024 which was signed by Patient #12 and a nurse. The area for the physician’s signature was blank. During an interview and record review on 10/02/2024 after 10:25 a.m., Staff #5 (Registered nurse) confirmed Patient #’s 11 and 12 had not received blood. Staff #5 (Registered nurse) confirmed the consents had not been signed by the physician. According to a facility’s policy named “SUBJECT: Telephone Consent” revised 05/2024 revealed: “...3.0 PROCEDURE... ...3.4 The individual giving the consent should be requested to sign the consent as soon as possible and/or send a facsimile and /or telegram confirming the consent.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 32143 Based on review and interview the facility failed to ensure A. patients were not restrained for staff convenience, and that appropriate orders were written for non-violent vs violent restraints. The facility failed to release the patient from restraints when no longer required, the physician failed to document the continuation or need for restraint in daily progress notes, and patients were not monitored, assessed, and released for range of motion every two hours per facility policy in 3 of 3 (#1, 5, and 3) patient charts reviewed. Refer to Tag A 154 B. chemical restraints that were given or may be administered Intramuscular (IM) or Intravenous (IV) for behavioral emergencies were identified and monitored as chemical restraints, ensure the policy and procedures instructed on the assessment and re-assessment of the patient after the administration of a chemical restraint, ensure all restraints were addressed in the patient plan of care, ensure staff was educated on the administration of chemical restraints and safe monitoring after administration, ensure chemical restraints were added to the restraint log and monitored through Risk and Quality in 1 of 1(#1) patient chart reviewed. Refer to Tag A160”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 32143 Based on review and interview the facility failed to ensure patients were not restrained for staff convenience, and that appropriate orders were written for non-violent vs violent restraints. The facility failed to release the patient from restraints when no longer required, the physician failed to document the continuation or need for restraint in daily progress notes, and patients were not monitored, assessed, and released for range of motion every two hours per facility policy in 3 of 3 (#1, 5, and 3) patient charts reviewed. A review of patient #1’s chart was conducted with staff # 2. Staff #2 stated that she was very familiar with the patient, his care, discharge, and family involvement during his stay at the facility. A review of Staff #1’s chart revealed he was admitted to the facility on 02/01/2024 at 1630 (4:30 p.m.) review of the patient’s physician history and physical dated 2/1/24 stated, “Chief Complaint: Confusion Fall Vomiting Altered mental status- improving _____ (patient #1) is a 72 y.o. male presented to the ED with altered mental status for one day duration following a GLF (ground level fall)... Code stroke initiated, CT head negative...Infectious disease was consulted at Longview and recommended IV Vancomycin and Ceftazidime until March 6, 2024.Patient transferred to Tyler Continuity Care Hospital LTAC for IV antibiotics, and further care.” A review of patient #1’s chart revealed he had episodes of agitation being combative with staff and family. A review of the physician orders revealed a verbal telephone order was taken on 2/3/24 at 2306 (11:06 p.m.) for bilateral wrist restraints. The order stated the patient required restraints due to a “Lack of safety awareness. Climbing/getting OOB and Pulling out tubes/lines.” The order stated, “Frequency: Routine Until Discontinued- Until Specified.” The restraints were discontinued on 2/4/24 at 0310. A review of patient #1’s chart revealed a physician’s note on 2/12/202. The note stated, “Patient agitated and combative this morning. Not cooperating for IV-line placement. He is refusing medications. Will put him back on restraints and low-dose Seroquel.” A review of patient #1’s chart revealed a physician order written on 2/12/24 at 8:36 a.m. to apply mittens bilaterally for altered LOC, Lack of safety awareness, climbing/getting OOB, Inappropriate wandering, pulling out tubes/lines. The order stated under process instructions, “The restraint event order remains in effect until the restraints are removed. It is recommended that a time limit be noted in the restraint order. At that time, the order is considered complete/ discontinued, and a new order must be obtained if it becomes necessary to re-apply the restraints.” The physician’s order did not give a specific time frame to discontinue. The order read, “Frequency: Routine Until Discontinued 02/12/24 0836 - Until Specified.” A review of the case manager’s progress note dated 2/13/24 at 11:11 a.m. revealed patient # 1’s daughter wanted to speak with her concerning patient #1’s restraints. The case manager documented, “Received notification that the patient’s daughter wanted to speak with me. Reviewed chart and noted that pt in restraints r/t hitting staff and agitation. Met with ____ (patient #1’s daughter) at bedside who verbalizes frustration that staff were not able to handle patient better yesterday. ____ (patient #1’s daughter) notes that pt went several days without behaving in an agitated manner and feels there must have been something that prompted his agitation because patient does not act that way when she is present. “The case manager documented that she explained to the daughter about dementia and how patients become uneasy when surrounded by unfamiliar faces and sounds. The case manager documented, “____ (patient #1’s daughter) notes frustration that physical restraints had to be used and that she would have preferred a sitter. Expressed to ____ (patient #1’s daughter) that we have used sitters when there was available staffing, however, due to staffing limitations there was not flexibility for sitters and for the protection of the patient, and staff restraints were used. ____ (patient #1’s daughter) notes that she does not agree, and sitters should have been provided and TCCH should have found the staffing to accommodate the patient.” The physician ordered non-violent restraints for patient #1 however, nursing documented the patient was hitting, attempted to kick a staff member in the face, and was very agitated. The patient was not ordered a violent restraint to control the agitated behavior. An interview was conducted with staff #2 on 2/29/24. Staff #2 stated that sitters are only available if they have extra staff scheduled or they can call in a nursing assistant. Staff #2 stated they did not have a sitter pool and it was difficult to get a sitter so they will restrain the patients if needed. A review of the policy and procedure, “Patient Restraints or Seclusions stated, “2.0 POLICY. 2.1 All patients have the right to be free from restraints that are not medically necessary or are used for purposes other than patient benefit and safety. Restraints shall be used only where alternative methods are not sufficient to protect patients or others from injury and are not substituted for less restrictive forms of protective restraint. All patients will have an assessment performed by a competent and appropriate staff member to determine the safety and protective needs of the patient prior to the application of restraints or medical protective device ... 3.4 Violent or self-destructive behavior is Behavior that jeopardizes the immediate physical safety of and/or presents an immediate and serious danger to self, staff, or others ... Restraints or seclusion must be discontinued as soon as is safely possible, regardless of the length of time, if identified in the order. The decision to discontinue the intervention is based on the ongoing assessment be a Registered Nurse ... 7.6 Discontinuation: Restraints are discontinued at the earliest possible time. Restraints are only used while the unsafe situation continues.” 40989 An observation of Patient #5 was conducted on 2/29/2024 at 10:45 AM with RN Staff #13. Patient #5 Patient #5 was a 93-year-old female admitted to the facility on 2/16/2024 after a motor vehicle accident (MVA). During the observation, Patient #5 was observed in her private room with a soft left wrist restraint tied to the bedrail and all 4 side rails were up on the bed. Her right hand was not in restraints but was noted to have a soft wrist brace due to an injury that occurred in the MVA. A review of the medical record revealed a verbal order dated 2/23/2024 at 2:59 AM from Physician #12 that read, “ ...Continuous Non-Violent Restraints due to lack of safety awareness, confusion, Climbing/getting out of bed, pulling out tubes/lines. Soft restraint wrist-LUE (left upper extremity) ...” RN Staff #13 was asked why the patient was placed in restraints. She replied, “She was pulling at the EKG leads”. She was then asked if they ever removed the restraint from the patient to see if she would be safe without it. RN Staff #13 released the restraint to the left wrist on 2/29/2024 at 10:45 AM. This surveyor noted RN Staff #13 did not perform an assessment or Range of Motion (ROM) as she stood at the bedside while the patient was released from the restraint. The patient did not attempt to pull at lines or cause harm to self or the staff. She was noted to raise her left arm to her nose and rub her nose on two occasions. After 9 minutes this surveyor left the room and observed RN Staff #13 reapply the restraint to the left wrist and restrain the patient to the bed restricting movement of the left arm. An interview was conducted with RN Staff #13 on 2/29/2024 at 11:00 AM. Staff # 13 was asked why she placed Patient #5 back into restraints when the patient did not exhibit any signs of needing to be restrained. She stated, “I was thinking of that. I am going to see if I can get an order for some mittens and have the charge nurse call the doctor.” RN Staff #13 confirmed there was no physician order to restart the restraint on the left wrist after Patient #5 was released for 9 minutes. Also, RN Staff #13 confirmed the release was in addition to the every 2-hour restraint assessment and ROM required by the facility policy. A review of the daily progress notes by Physician #12 dated 2/23-2/27/2024 did not document Patient #5’s continuous need for restraints. The physician failed to document the patient remained in restraints and that any less restrictive interventions were attempted. There was no documentation by Physician #12 that Patient #5 was in restraints or the need to continue the restraint after the daily physical assessments were completed for 5 of 5 days reviewed. A review of the progress note dated 2/28/2024 at 11:18 AM revealed Physician #15 failed to document that the patient remained in a soft left wrist restraint and the need to continue the restraint. A review of the facility policy titled, “Patient Restraints or Seclusion” with a reviewed date of 11/2023 was as follows: “ ...2.0 POLICY 2.1 All patients have the right to be free from restraints that are not medically necessary or are used for purposes other than patient benefit and safety. Restraints shall be used only where alternative methods are not sufficient to protect patients or others from injury and are not substituted for less restrictive forms of protective restraint. All patients will have an assessment performed by a competent and appropriate staff member to determine the safety and protective needs of the patient prior to the application of restraints or medical protective device .... 4.0 Restraints or Seclusion Orders ... 4.2 ... * When a patient is released from restraint or seclusion and exhibits behavior that can only be managed with reapplication of restraints or seclusion, a new order is required. * A temporary, directly supervised release that occurs for the purpose of caring for a patient’s needs is NOT considered a discontinuation, as long as the patient remains under direct staff supervision ...” RN Staff #13 confirmed the release of the left wrist restraint on 2/29/2024 at 10:45 AM was not done to perform patient care and should have required a new order from the physician. 48749 A review of the electronic health record (EHR) for Patient #3 revealed the patient was admitted with a diagnosis of Sepsis (A life-threatening complication of an infection), Encephalopathy (a broad term for any brain disease that alters brain function or structure), and Decubitus Ulcer (the medical term for bedsore). The patient was placed in bilateral soft wrist restraints on 12/23/2023 for altered mental status and pulling at lines. Further review of the patient’s electronic health record (EHR) revealed there was no documentation found supporting that the patient was released from restraints every two hours during the hours of 5:00 AM until 7:15 PM on 12/24/2023. The nurse failed to follow the facility’s policy. A review of the facility’s policy and procedure “Patient Restraints or Seclusion” dated 11/2023 stated, “8.9 The condition of the restrained patient will be continually assessed, monitored, and re-evaluated. This will be documented in the EMR. 8.10 Frequency of monitoring and assessment for NON-VIOLENT Restraints will be performed and documented every Two hours. Monitoring and assessment include performance and documentation of all appropriate patient care activities (E.g., circulation, range of motion, repositioning, hydration, nutrition, and/or elimination as well as neurological evaluations such as mental status and cognitive functioning.)” On 02/29/2024 at 11:00 AM, an observation of the patient in room #408 was conducted with Staff# 3. Staff # 4 was observed performing a restraint release on Patient # 8 who was in bilateral upper extremity soft restraints that were secured to the side rails of the patient’s bed. It was observed that Staff # 4 did not perform range of motion exercises on the patient’s extremities. The nurse failed to follow the facility’s policy “ Patient Restraints or Seclusion” dated 11/2023. An interview was conducted on 02/28/2024 at approximately 11:00 AM with Staff #3. When questioned if all patients are released from their restraints every two hours, Staff #3 Reported, “Yes, we release them, check their pulses and perform range of motion.” Staff #3 was asked if any documentation on releasing patient #3 from restraints could be found during the time between 5:00 AM and 7:15 PM on 12/24/2023, Staff #3 reported “No.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(B) [A restraint is-] (B) A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. This Standard is not met as evidenced by: 32143 Based on review and interviews the facility failed to ensure that chemical restraints that were given or may be administered Intramuscular (IM) or Intravenous (IV) for behavioral emergencies were identified and monitored as chemical restraints, ensure the policy and procedures instructed on the assessment and re-assessment of the patient after the administration of a chemical restraint, ensure all restraints were addressed in the patient plan of care, ensure staff was educated on the administration of chemical restraints and safe monitoring after administration, ensure chemical restraints were added to the restraint log and monitored through Risk and Quality in 1 of 1(#1) patient chart reviewed. Patient #1 A review of patient #1’s chart was conducted with staff # 2. Staff #2 stated that she was very familiar with the patient, his care, discharge, and family involvement during his stay at the facility. A review of Staff #1’s chart revealed he was admitted to the facility on 02/01/2024 at 1630 (4:30 p.m.) review of the patient’s physician history and physical dated 2/1/24 stated, “Chief Complaint: Confusion Fall Vomiting Altered mental status- improving _____ (patient #1) is a 72 y.o. male presented to the ED with altered mental status for one day duration following a GLF (ground level fall)... Code stroke initiated, CT head negative...Infectious disease was consulted at Longview and recommended IV Vancomycin and Ceftazidime until March 6, 2024.Patient transferred to Tyler Continuity Care Hospital LTAC for IV antibiotics, and further care...Infectious disease was consulted at Longview and recommended IV Vancomycin and Ceftazidime until March 6, 2024...Patient transferred to Tyler Continuity Care Hospital LTAC for IV antibiotics, and further care.” A review of patient #1’s chart revealed he had episodes of agitation being combative with staff and family. A review of the physician orders revealed a verbal telephone order was taken on 2/3/24 at 2306 (11:06 p.m.) for bilateral wrist restraints. The order stated the patient required restraints due to a “Lack of safety awareness. Climbing/getting OOB and Pulling out tubes/lines.” The order stated, “Frequency: Routine Until Discontinued- Until Specified.” The restraints were discontinued on 2/4/24 at 0310. A review of patient #1’s chart revealed a physician’s note on 2/12/202. The note stated, “Patient agitated and combative this morning. Not cooperating for IV-line placement. He is refusing medications. Will put him back on restraints and low-dose Seroquel.” A physician order was noted on 2/12/24 for Mitten (secured)-BIL- Frequency: Routine Until Discontinued 02/12/24 0836 - Until Specified. A review of patient #1’s physician orders revealed there was an order for ziprasidone (Geodon- antipsychotic) injection 10mg on 12/12/24 at 2004 (8:04 p.m.). The physician (staff #18) wrote the order for once and for severe agitation. Staff #18 was not the patient’s primary provider. There was no documentation that the provider assessed the patient, what behaviors the patient was exhibiting, or that the primary physician was notified. Staff #2 confirmed there was no documented physician note. A review of patient #1’s chart revealed the RN administered the Geodon IM 10 mg at 2037 (8:37 p.m.) There was no documentation by the nurse that this was given as a restraint. There was no documentation of the patient’s behaviors except for “agitation and impulsive”. There was no documentation if the Geodon was effective or if the nurse monitored the patient until 11:00 p.m. when the first vital signs were taken. There was no documentation that the Crisis Intervention Management Team was called, that any family was notified, that the primary physician was notified nor was there any documentation on the patient’s care plan. A review of a nursing progress note dated 2/13/24 at 3:45 PM by staff # 19 Licensed Vocational Nurse (LVN) stated, “____ (pt #1’s daughter) whom is patients daughter was present for IDT team meeting. ________ (pt #1’s daughter) verbalized that she is upset that patient was in restraints. We explained that we had to use restraints due to patient behaviors. We explained guidelines for restraints including nurse rounding and review by a MD every 24 hours. ____ (pt #1’s daughter)had questions in regards to what happened last night. It was reported that the unit tech had been kicked in the face last night. ____ ____ (pt #1’s daughter) questioned what provoked the kicking and why he was being disturbed in the night. We explained we have various reasons for checking on a patient throughout the night including assessment to see if patient needs to be changed, vitals, and circulation checks since patient was in restraints. ____ (pt #1’s daughter) stated that patient should have been left alone to calm down, staff re-lnterated that per policy and regulation nursing has to assess patient, especially when restrained. _____ (staff #20) RT states that he and _____ (staff #21) PT were walking by yesterday when they noticed the patient was grabbing the nurse on the arm and verbally threatening the nurse. _____ (staff #20) informed ____ (Pt #1’s daughter) that the patient attempted to kick him and used profanity for _____ (staff #20) to leave. ____ (Pt #1’s daughter) asked why he did not get to walk with therapy yesterday, in which _____ (staff #21 PT) explained that the therapy student worked with patient for first attempt and did bed exercises and attempted to allow patient to rest to calm down or deescalate agitation, however, the patient was more agitated upon reassessment and therapist was unsuccessful due to agitation ...” A review of the policy and procedure, “Patient Restraints or Seclusions”stated, “5. 0 Violent or Self-Destructive Behavior. 5.1 When patients demonstrate violent or self-destructive behaviors, aggressive behaviors, assaultive behaviors, threatening behaviors, or are an immediate danger to themselves or others, the Crisis Intervention Management Team (Dr. Strong) may be called to de-escalate the patient ... ... The provider responsible for caring for the patient must evaluate the patient face-to-face within one hour of applying violent behavior restraints or seclusion. If a patient’s violent or self-destructive behavior resolves and the restraint or seclusion intervention is discontinued before the practitioner arrives to perform the 1-hour face-to-face evaluation, the practitioner is still required to see the patient face-to-face and conduct the evaluation within 1 hour after the initiation of the intervention. This requirement also applies when a drug or medication is used as a restraint to manage violent or self-destructive behaviors. 5.2 The in-person provider evaluation includes the following: o The patient’s immediate situation (conditions or symptoms that warranted the use of emergent restraint or seclusion). o The patient’s reaction to the interventions used including alternatives attempted if applicable. o The patient’s medical and behavioral condition and the need to continue or terminate the restraint or seclusion. The provider may write an order to continue the use of restraints or seclusion after the in-person evaluation has been completed ... 4.2- The Registered Nurse is responsible to provide education and information regarding the use of the restraints and the patient’s Plan of Care to the patient/family/caregiver. The Registered Nurse is responsible to update the Plan of Care as the patient’s status and need for restraint/seclusion changes.” An interview with staff #2 on 2/29/23 revealed that the patient had been having aggressive behaviors and was hitting staff, cursing, and kicked a staff member in the face. Staff #2 confirmed there was no incident report filed of the incident. Staff #2 confirmed this was a behavioral incident and the patient was at harm of hurting himself and/or someone else. Staff #2 confirmed there was no order or note to show this was medication given for violent behavior and was not addressed or treated as a chemical restraint. Staff #2 confirmed that she was not aware of any guidelines in the policy for how soon the nurse should assess the patient after the administration of a chemical restraint, how frequently, or how often. An interview was conducted with Staff #5 RN, #22 RN, and #23 RN on 2/29/24 at 10:45 a.m. Staff #5, 22, and 23 were asked if a psychotropic medication was ordered for patient behaviors that were a threat to staff or the patient, would that be a chemical restraint/ emergency behavioral medication and what would be the procedure for that? Staff #22 and 23 stated they were not sure and staff #5 stated that they didn’t give chemical restraints/ emergency behavioral medication and if one was ordered he would have to ask his charge nurse because he had never dealt with that issue. Staff #5, 22, and 23 were asked if they had any training on chemical restraints and how would the patient be assessed and reassessed. Staff #5, 22, and 23 stated they were not aware of any specific training and would have to ask the charge nurse. An interview was conducted with Staff # 25 RN Educator on 2/28/24 at 9:45 a.m. Staff #25 was asked what a violent restraint was. Staff #25 stated, “I guess when they are in 4-point restraints.” Staff #25 presented the survey team with a restraint log but there were no chemical restraints on the log. Staff #25 stated that she had just recently been assigned this task and was not aware she needed to be putting chemical restraints on the log. Staff #25 stated, “We have not been looking at chemical restraints. I didn’t know I needed to.” Staff #25 was asked how she monitored the restraint and if the restraint charts were being audited appropriately. Staff #25 stated that she just checks to make sure they have an order. There was no written process for her to follow. A review of employee charts (staff # 25, 13, 17, and 26) was conducted with staff #25. Staff # 25 stated that the staff had basic restraint training on health streams (a computer program that has general information on restraints and usage) and they have a health fair yearly, but it was geared more towards physical restraint use and not for chemical restraints. Staff #25 confirmed there was no chemical restraint information reported to quality.”