Christus Trinity Mother Frances Rehab, A Partner O

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 10135 Based on observation, interview and record review, the facility failed to ensure patients were educated prior to implementation of their care plans which involved usage of self-releasing seatbelts 4 of 10 sampled patients (‘s 1,2,4 and 6). This deficient practice had the likelihood to cause harm in all patients admitted to the facility. Findings include: Patient #1 Review of a physician’s history and physical dated revealed Patient #1 was a 74-year-old female who was admitted 05/05/2026 to the rehab hospital with diagnoses which included diabetes, hypertension, stroke and mild cognitive impairment. According to the physician’s history and physical the plan was to admit to the comprehensive stroke rehab program for 14 days. Physician orders were written on 05/05/2026 for physical therapy (PT), occupational therapy (OT) and speech therapy (ST) to evaluate and treat. Fall physician orders documented Patient #1 was deemed as being at high fall risk on 05/05/2026 at 1:11 p.m., with the following listed: Bathroom supervision... Bed alarm Chair alarm Seat Belts- self releasing with alarm Review of therapy notes revealed that on 05/06/2026 at 12:26 p.m. Patient #1 was assessed by physical therapy to not have the ability to remove the seatbelt. Review of the fall prevention physician orders for 05/06/2026 at 12:48 p.m. revealed the fall level was changed to standard precautions (meaning no seatbelt). On 05/06/2026 at 3:43 p.m. the fall level was increased back to high level. On 05/06/2026 at 1:24 p.m. there was documentation of a team conference being held with facility staff only being in attendance. On 05/06/2026 there was documentation of Staff #14 the case manager talking to one of Patient #1’s daughters about the patient’s plan. There was no education documentation about the seat belt. Nursing documentation on 05/11/2026 revealed the following: On 05/11/2026 at 10:19 a.m., the daughter was upset because her mom was restrained by the seat belt alarm. She took her mom for a follow-up appointment and afterwards came back and removed her belongings. Review of chart revealed no documentation of training on the seatbelt and alarm prior to implementation. Review of the facility’s patient’s rights form which was signed by Patient #1 on 05/05/2026 revealed the following: “INFORMED DECISIONS You have the right to: Receive information about your current health, care, outcomes, ongoing healthcare needs, and future health status in terms that you understand ... ...Be involved in all aspects of your care and take part in decisions about your care including making choices about your care based on your own spiritual and personal values ...” During an interview on 06/23/2026 after 8:32 a.m., Staff #3 nursing manager confirmed not being able to find documentation of staff training or instructing the patient on usage of the seatbelt/alarm. During observation and interview the following was stated: On 06/22/2026 at 2:47 p.m., Staff #4 the Director of Therapy demonstrated how the seat belt alarm worked with the surveyor. The seatbelt was attached by Velcro. Staff #4 stated that all patients were considered high risk for falls when they first came into the facility and the belts were applied. On the second day therapy evaluated the patients and determined their safety status. They could downgrade or upgrade their fall status. On 06/23/2026 at 10:21 a.m., Staff #17, occupational therapist stated that on admit all patients are deemed high fall risk. They do not explain the seat belt and alarm to the patients. Someone in admission does that. On 06/23/2026 at 10:50 a.m., Staff #12, administrative liaison(admissions), revealed the drivers place the seat belts and alarms on when the patients that come in from the hospital. When the patients come from home the admission staff put them on, but they are already connected to the wheelchair. They did not explain how to use them that nursing probably does that. On 06/23/2026 at 11:00 a.m., the case manager Staff #14. Patient #1 was not aggressive and did not complain at all. Staff #14 said that all of the patients wear seat belts. They do get some push back from some people on the belts, but they explain that they are on until therapy or the doctor deems them to be safe. Patient #1 was concerned because she would have to call for help and she felt like she did not have a lot of time to get to the bathroom. Staff #14 confirmed she had not documented talking to the family about the seatbelt during the 05/06/2026 call. During an interview on 06/23/2026 at 11:28 a.m., Staff #15 nursing supervisor stated that the patients are told they will have the seat belts on for the first 3 days they are there. If they refuse to wear it, the patients are told that it is the facility’s protocol. Staff #15 stated that they do not document that they have spoken to patients about the seat belts. Patient #2 Review of a physician’s history and physical dated 06/1/2026 revealed Patient #2 was an 82-year-old female who was admitted to the rehab hospital on 06/17/2026 and had diagnoses which included hypertension, atrial fibrillation and an abdominal aortic aneurysm repair. According to the physician’s history and physical the plan was to admit to in patient rehab for 5 days a week. Physician orders were written on 06/17/2026 for physical therapy (PT) and occupational therapy (OT) to evaluate and treat. Fall physician orders documented Patient #2 was deemed as being at high fall risk on 06/17/2026 at 4:47 p.m., with the following listed: Bathroom supervision... Bed alarm Chair alarm Seat Belts- self releasing with alarm Review of therapy notes revealed that on 06/18/2026 at 9:06 a.m. Patient #2 was assessed by physical therapy to have the ability to remove the seatbelt. Fall physician orders documented Patient #2 was deemed as being at standard fall risk on 06/18/2026 at 5:29 p.m. During an interview on 06/23/2026 after 8:32 a.m., Staff #3 nursing manager confirmed not being able to find documentation of staff training or instructing the patient on usage of the seatbelt/alarm. Patient #4 Review of a physician’s history and physical revealed Patient #4 was a 62-year-old male who was admitted to the rehab hospital on 06/17/2026 and had diagnoses which included an acute occipital hemorrhage. Patient #4 signed his consent to treat on 06/17/2026 at 6:05 p.m. Physician orders were written on 06/18/2026 for physical therapy (PT), occupational therapy (OT) and speech therapy (ST) to evaluate and treat. Fall physician orders documented Patient #4 was deemed as being at high fall risk on 06/17/2026 at 6:06 p.m., with the following listed: Bathroom supervision... Bed alarm Chair alarm Seat Belts- self releasing with alarm Review of therapy notes revealed that on 06/18/2026 at 1:00 p.m. Patient #4 was assessed by physical therapy. The first documentation of an assessment of seatbelt usage was at 11:09 p.m. Patient #4 did not have the ability to remove the seatbelt. Fall physician orders documented Patient #1 was deemed as being at standard fall risk on 06/18/2026 at 5:29 p.m. During an interview on 06/23/2026 after 8:32 a.m., Staff #3 nursing manager confirmed not being able to find documentation of staff training or instructing the patient on usage of the seatbelt/alarm. Patient #6 Review of the history and physical on Patient #6 revealed she was a 71-year-old female who was admitted on 06/22/2026 with a diagnosis of Chronic inflammatory demyelinating polyneuropathy. Patient #6 consent to treat was signed on 06/22/2026 at 10:55 a.m. Physician orders dated 06/22/2026 at 10:32 a.m. showed Patient #6 was deemed at high fall risk. Physician orders were written on 06/22/2026 for physical therapy (PT), and occupational therapy (OT) to evaluate and treat. Review of a nursing assessment signed off 06/22/2026 at 1:00 p.m. revealed documentation that Patient #6 was utilizing a chair alarm. As of 06/23/2026 at 1:51 p.m. there was no documentation of a therapy assessment of the patient’s ability to use the seatbelt chair alarm. During interview on 06/23/2026 Staff #3 and 4 confirmed there was no documented assessment on the record. Review of the facility’s policy named” Fall Prevention Program” dated 02/10/2026 revealed the following: “ ...1. Fall Risk Predictive Model Upon admission the electronic medical record begins gathering data entered from assessments and documentation entered by physicians, nurses, physical therapists, occupational therapists, and speech language pathologist .... These data use predictive modeling to suggest a risk level. Clinical judgement is then used to determine the best safety for each patient. Until all assessments are complete, all patients are treated at high risk for falls, usually lasting no longer than the first 24-48 hours. II. Admission Fall Precautions: Upon admission, plan of care for fall prevention will be initiated to include at a minimum: Bed Alarm Chair Alarm Self-Releasing Alarmed Wheelchair Belts Supervision in the Bathroom The patient will be educated regarding the fall prevention program and safety measures put in place ...””

“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: 10135 Based on interview and record review, the facility failed to ensure informed consent was obtained prior to 2 of 2 transfusions on Patient #10 (5/14/2026 and 05/17/2026). The facility failed to ensure the physician explained risk and benefits of blood transfusions to Patient #10. This deficient practice had the likelihood to cause harm to all patients receiving blood products. Findings include: 05/14/2026 Review of a physician consult note dated 04/26/2026 revealed Patient #10 was a 46-year-old-male with diagnoses which included diabetes, peripheral artery disease and anemia. Review of the facility’s admission forms revealed Patient #10 was admitted to the rehab hospital on 05/07/2026. Review of a physician’s order dated 05/14/2026 revealed a blood transfusion order for “Stat, PRBC, 2 units, 50 ml/hr, Anemia, unspec., IV, May increase to 200 mL/hr after 15 min if no signs or symptoms of transfusion reaction; Administer over 2-4 hours.” Review of a blood transfusion consent for 2 units of packed red blood cells dated 05/14/2026 revealed Patient #10 and a facility nurse signed the form. There was no documentation of the physician signing the form or writing in progress notes that the risk and benefits were explained to the patient. Review of the blood transfusion administration record dated 05/14/2026 revealed Patient #10 received a blood transfusion. A transfusion reaction form dated 05/14/2026 revealed the physician was notified at 9:30 a.m. a blood transfusion reaction. 05/17/2026 Patient #10 received a second unit of blood on 05/17/2026. During an interview on 06/23/2026 after 1:00 p.m., Staff #3 revealed not being able to find in the clinical record where the physician explained the risk and benefits. Review of the facility’s policy named “Blood Administration” dated 05/12/2026 revealed the following: “...4. Informed consent for the blood transfusion must be obtained from the patient and/or designee after the procedure has been explained to them. Informed consent will include risks, benefits, and alternative treatments available...””

“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: 10135 Based on interview and record review, the facility failed to ensure blood was administered per their policy in 2 of 2 transfusions on Patient #10 (5/14/2026 and 05/17/2026). The facility failed to: A. Ensure nurses documented the start and stop time of a blood transfusion on Patient #10. B. Ensure nurses accurately documented vital signs on Patient #10 who was receiving a blood transfusion. C. Ensure nurses documented the rate of blood transfusions and total amount infused on Patient #10. This deficient practice had the likelihood to cause harm to all patients receiving blood products. Findings include: 05/14/2026 Review of a physician consult note dated 04/26/2026 revealed Patient #10 was a 46-year-old-male with diagnoses which included diabetes, peripheral artery disease and anemia. Review of the facility’s admission forms revealed Patient #10 was admitted to the rehab hospital on 05/07/2026. Review of lab dated 05/13/2026 revealed the following results: Hemoglobin of 7.0 with reference ranges being 13.5-17.5. Hematocrit of 20.9 with reference ranges being 41.0-53.0. Review of lab dated 05/14/2026 revealed the following results: Hemoglobin of 6.9 with reference ranges being 13.5-17.5. Hematocrit of 20.5 with reference ranges being 41.0-53.0. Review of a physician’s order dated 05/14/2026 revealed a blood transfusion order for “Stat, PRBC, 2 units, 50 ml/hr, Anemia, unspec., IV, May increase to 200 mL/hr after 15 min if no signs or symptoms of transfusion reaction; Administer over 2-4 hours.” Review of the blood transfusion administration record dated 05/14/2026 revealed the following vital signs: 9:00 a.m., blood pressure of 144/91, temperature 98.6, pulse 115 and respirations 18. 9:15 a.m.,blood pressure of 184/91, temperature 98.7, pulse 118 and respirations 19. 9:30 a.m., blood pressure of 182/100, temperature 98.8, pulse 118 and respirations 18. 10:00 a.m., blood pressure of 158/100, temperature 100.2, pulse 126 and respirations 18. There was no documentation of the start and stop time of the transfusion on the form. There was no documentation of what the rate of the transfusion was nor the total volume infused. There was no documentation of signatures of who was transfusing or who was monitoring the blood transfusion. The only way to tell when the transfusion was started and stopped was on the transfusion reaction record. There was documentation that the transfusion started at 9:00 a.m. and stopped at 9:30 a.m. and the physician was notified at 9:30 a.m. 05/17/2026 Patient #10 received a second unit of blood on 05/17/2026. The following was found on the blood transfusion form: The timeframe between the pre-vitals (10:24 p.m.) and the first set of vital signs (10:50 p.m.) was 26 minutes. At 10:50 p.m. there was documentation that the transfusion was increased to 150cc per hour, but there was no documentation of the rate it was started at. There was no documentation of the start and stop time of the transfusion on the form. Review of the facility’s policy named “Blood Administration” dated 05/12/2026 revealed the following: “ ...6. Check the patient’s vital signs prior to starting the procedure (temperature, pulse, blood pressure and respiratory rate). Document the vital signs in the medical record ....” 11. Start infusing the blood slowly for the first 15 minutes. Then set to desired rate appropriate to patient condition and type of product administered. Document the time the blood was started. Monitor the patient closely for signs and symptoms of a transfusion reaction ... 12. Check vital signs after the initial 15 minutes .... ...14. At completion, check and document the vital signs ...””