Encompass Health Rehab Hospital of Morgantown

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 40269 Based on document review, medical record review, and interviews, it was determined the facility failed to follow their policy for utilizing a rapid response for a deteriorating patient in one (1) of ten (10) patients, patient 3. This failure has the potential to negatively affect patients receiving care at the facility. Findings include: A policy was reviewed titled, “Change in Patient Condition,” last reviewed 11/19/25. The policy states in part, “...Policy: The Rapid Response Team (RRT) will be utilized in all areas of the hospital ...1. Criteria to consider in calling the RRT may include, but are not limited to: 1. Family member reports a change in the patient’s condition and additional assessment is warranted. 2. Staff member identifies the patient condition is deteriorating. 3. Acute change in heart rate from baseline. 4. Acute change in systolic blood pressure from baseline. 5. Acute change in respiratory rate or threatened airway. 6. Acute change in oxygen saturation requiring intervention. 7. Acute change in level of consciousness. 8. Acute or increased bleeding. 9. New, repeated, or prolonged seizures. 10. Failure of patient to respond to treatment for an acute problem/ symptom. 11. Chest pain, pressure and discomfort. 12. Critical labs results with symptoms present. 13. Professional judgment of the RN that more in depth assessment is warranted ll. Once the page is received, the Rapid Response Team will report to the specified department or room number immediately. ln the event the team is already present in the room, the code will be called to alert other clinicians ol the critical situation occurring should additional help be needed ...V. Documentation 1. The staff nurse will document the time the RRT is called, the team members who respond, assessment findings, and interventions provided to the patient in the patient medical record ...” A medical record review was completed for patient 3. The patient arrived at the facility on 2/28/26. An “History and Physical Addendum” created by staff 21 on 3/1/26 at 12:48 p.m. states in part, “Upon examination this morning, patient is currently lying in bed. Patient is endorsing a significant amount of left hip helical pain. Patient is reporting that last night [he/she] was in the bathroom and lost [his/her] balance, falling back onto the commode resulting in his hip pain. Patient does have some mild bruising noted to this area. Plan to obtain an x-ray of the pelvis hip. Patient has been utilizing as needed Tylenol with minimal pain relief. Will trial lidocaine patch. Patient is a poor historian. Reports that [he/she] went to the hospital for a stroke. Did have to reorient [him/her] to [his/her] hospital stay. Patient does not recall any details from home regarding [his/her] stroke symptoms. Denies any shortness of breath. Denies any dizziness. Denies any nausea or vomiting. Patient is currently restless. Reviewed previous medical records. No acute events noted overnight, per nursing staff.” A “Post Fall Assessment” dated 03/01/2026 at 12:25 p.m. and performed by staff 26 states in part, “Rapid Pain Assessment: Hip, Left, Sharp, Tenderness and Pain Rating: [6]. Pain Associated Behaviors: Sighing, Fidgeting, Irritability and Resistance to care. Consciousness: Alert. Fall: Unwitnessed. Fall Location: Patient room. Fall Related Injury: No injury. Date/Time of Fall: 03/01/2026 12:00 ...” A “Flowsheet” dated 03/01/2026 states in part, “Oxycodone, 5 [five] mg [milligram], Start date 03/01/26 at 13:00 [1:00 pm]. May request lower dose/less potent med, Hip-Bilateral.” An “Adult Patient History” dated 03/01/2026 at 16:38 (4:38) p.m. and completed by staff 28 states in part, “Post Fall Evaluation Comments: Beside [staff 27], responded to patient ’ s bed alarm sounding. [She/He] then requested assistance from RN. Patient was found on [his/her] knees on the floor beside the bed. Patient restless and uncooperative when attempting to assess [him/her] for injuries. Bedrails used to assist patient to a standing position. LPN and RN assisted patient back to bed once standing. Patient stated “I didn’t fall. I was stretching my back.” Patient denies injury, hitting [his/her] head, or any new pain. RN supervisor notified staff 22 of patient fall.” A “Progress Note-Nurse” dated 03/01/2026 at 17:02 (5:02 p.m.) states, “Per [staff 27] report that patient had unwitnessed fall this morning. Received patient confused oriented to self only. Squirming in bed. Reported pain while rubbing chest and nauseous. Vomit content was just saliva. Patient impulsive. Bed alarm alarming all the time. Patient redirected but unable to follow commands. Squirming in bed and unable to settle down. Restless. Looks pale. BP [blood pressure] low. Notified [staff 21] via phone. Order Zyprexa 2.5 [two point five] mg IM [intramuscular] and a bolus of NS [normal saline] 1000 [one thousand] ml [milliliters]. [Staff 23] made aware of patient.” A “Flowsheet” dated 03/01/2026 states in part, “...Zyprexa, 2.5 [two point five] mg, Indication: Agitation, Injection, Intramuscular, Once PRN [as needed] Anxiety, Start Date: 03/01/26 16:26:00 [4:26 p.m.] ...” A “Nursing Note” dated 3/1/26 at 7:01 p.m. and completed by staff 20 states, “15:03 [3:03 p.m.] Patient moved from 210B to room 239B ...Patient seen in bed confused and oriented to person only. Unable to redirect patients. Bed alarm on and alarming multiple times due to impulsiveness. Patient c/o [complaining of] pain in [his/her] chest while rubbing it and did feel nauseous and vomited only saliva. [Staff 21] was called via phone and notified that patient complaints of chest pain and nauseous and vomiting. No orders given. [Staff 23] aware and was talking to [staff 21]. Sitters RNT [Rehab Nursing Tech] at bedside. Did take in vitals and BP [Blood Pressure] low 86 [eighty-six systolic] / [over] 61 [sixty-one diastolic]. Notified [staff 21] of low BP and patient squirming and still c/o mild chest pain. Restless and agitated. Orders to give 2.5 [two point five] mg of Zyprexa IM and NS 1000 [one thousand] ml. 17:30 [5:30 p.m.] Called by RNT [staff 6] that patient is not responding and cold. Patient not responding to questions and only says help. Called [staff 21] unable to reach. Called [staff 22] and notified patient situation. No orders given. Did try taking vitals 2x [two times] but unable to get one. Supervisors at bedside. Vitals were attempted again but unable to get one. Patient coded and supervisors and RN were at bedside. CPR [Cardiopulmonary Resuscitation] started, an EMS [Emergency Medical Services] arrived and took over the code. [Staff 24] at bedside while code in progress.” A “Physician Discharge Summary” dated 3/2/26 at 11:04 a.m. completed by staff 21 states, “Hospital Course: Upon evaluation of 3/1/2026, patient was observed in bed. At that time, patient was restless and complaining of bilateral hip pain. Patient reported that [he/she] had fallen down onto the toilet seat hard when attempting to get up to use the restroom, resulting in pain ... Later in the afternoon, patient continued to report pain, so [he/she] was given additional pain medication. [He/She] did have some episodes of restlessness and hypotension for which [he/she] was given Zyprexa, as well as one [1] L [liter] normal saline bolus. Nursing staff called reporting that the patient was less responsive, but [he/she] was moving extremities. They reported having difficulty obtaining a blood pressure via the Dinamap [vital signs machine] due to the patient moving [his/her] arms. Orders to obtain a manual pressure was obtained, however, prior to being able to obtain a manual pressure, patient did have a cardiac arrest. [He/She] was noted to be asystole on the monitor. Resuscitation was attempted, however unsuccessful, and time of death was called at 18:32 [6:32] p.m.” An interview was conducted with staff 9 on 03/16/26. Regarding patient 3, staff 9 states in part, “We had a nurse Tech sit with [him/her]. The nurse was having difficulty with the patient, saying the patient was having chest pain and increased agitation and called the doctor. The doctor ordered Zyprexa. After being given Zyprexa, shortly after, they reported that the patient was minimally responsive. I went to the room, and we couldn’t get a blood pressure and ended up calling a code ...” An interview was conducted with staff 2 on 03/17/26 at 9:52 a.m. Regarding patient 3, staff 2 states in part “As the day progressed, the patient became more agitated with increased thrashing and pain. The supervisor came to help assess and did vitals, then the patient coded. I talked with the physician and [he/she] discussed that the patient had had a massive cardiac history. We did a mortality review, and the doctor felt that the falls were not related to the death. Also, during the review the nurse described the patient’s symptoms as agitation with chest pain and an emphasis on the agitation. The nurse did not relate that they felt that the patient had cardiac issues, or that the pain was cardiac in nature. An x-ray was attempted twice on the patient’s hip, and they were unable to do it due to the patient moving. The nurse did not consider it a cardiac event and did not relay that information to the physician.” A telephone interview was conducted with staff 19 on 03/1 7/26 at 1:38 p.m. Regarding patient 3, staff 19 states in part, “ On March 1st, they had me go sit with a patient. The patient was squirming, [he/she] kept saying like [he/she] was not feeling right, felt like [he/she] was overdosing. The nurse had called the physician a couple of times and then called the nurse practitioner. [He/she] did not seem good for a while. I kept trying to tell the supervisor, but [he/she] kept blowing me off. The nurse said they had nine [9] patients. I was sitting in there and watching to make sure the patient didn’t squirm out of bed. The nurse kept coming in frequently to check on [him/her] as [he/she] felt something was not right either ... There were two [2] supervisors on that day, and I kept going to [staff 9] and telling [him/her]. The other Supervisor was running around other places. By the end, both came in, and at that point the patient was unresponsive and coded. I was getting frustrated previously that no one came. I went and got [staff 9] finally and brought [him/her] to the room and the other supervisor came in at that time as well. They tried to get the vital signs, and they were unable to, so they pressed the code button. Previously, they had given [him/her] a shot in [his/her] arms then [he/she] stopped squirming and started talking less. [He/she] was a little too tame, and I explained to the supervisor [he/she]’s not talking to me anymore. [He/she] just told me [he/she] would be like this after this shot. I said [he/she] was too knocked out though, and something wasn’t right. I told [him/her] to come to the room. [He/she] finally came after the last time. The RN kept getting the vitals and [he/she] had fluids, but they weren’t running, something was wrong with it, and they stopped running in. I know that [he/she] got blood work early on. The patient never complained of chest pain that I saw.” An interview was conducted with staff 20 on 03/17/26 at 2:04 p.m. Regarding patient 3, staff 20 states, “That patient was in room 210. That day was complete chaos. The patient was moved to my room 239 at some point during the day. That was the time I got [him/her]. [He/she] was confused, restless, agitated, and not answering questions appropriately. [He/she] had fallen down in the previous room, and there was a problem with the roommate, that’s why [he/she] was moved. I was concerned [he/she] would fall again. I called the doctor and went to the supervisor. When I was on the phone with the doctor, I gave the phone to the supervisor, and they were talking about moving the patient. The patient was having chest pain, and I thought the doctor would order EKG and cardiac markers. I was also concerned about the change in mental status, as a nurse said previously [he/she] could answer questions appropriately and now [he/she] wasn’t. When I did [his/her] vital signs a second time, [his/her] blood pressure systolic was eighty-six [86], and [he/she] was more agitated. [He/she] was not answering questions at all. I wanted [him/her] sent out. I called [staff 21] and all [he/she] did was order Zyprexa and a fluid bolus. I gave [him/her] the Bolus and the zyprexa. It didn’t help [him/her] and [he/she] continued to go downhill. The tech came out and told me the patient was not responding and was cold. We went in and couldn’t get vitals. I called the doctor and didn’t get an answer, so I called the nurse practitioner. [He/she] said [he/she] would look into the chart and call me back. The patient coded before [he/she] could call me back. The patient complained of hip pain all day. When I called the doctor, I told [him/her] that the patient was rubbing [his/her] chest saying that it hurt and was confused.” An interview was conducted with staff 21 on 03/17/26 at 3:25 p.m. Regarding patient 3, staff 21 states in part, “The nurse called me and said the patient was restless and agitated. I ordered a sitter to be at the bedside and zyprexa. The patient was experiencing chest discomfort but also had nausea. I told the nurse to check with a supervisor and have them check the patient ...The last I heard, the staff could not get a blood pressure, but the patient was moving all over the place. They said they felt that they couldn’t get the blood pressure because the patient wouldn’t stop moving. I was not clearly informed about the patient’s condition or what was actually happening. In this case, the staff definitely should have called a rapid response as I’m not there to put eyes on the patient, and if a doctor was in the house they would have responded to the rapid response ...When I called the nurse supervisor after the patient’s nurse called me, I told them to check on the patient and that this nurse needs help taking care of this patient. [His/her] confusion that day would be common with the type of stroke [he/she] had, so I was not concerned about that. [Staff 23] was the supervisor I talked to, that I told to go check on the patient.” An interview was conducted with staff 22 on 03/18/26 at 9:31 a.m. Regarding patient 3, staff 22 states in part, “The next thing I was informed of is the nurse called me and said [he/she] couldn’t get a blood pressure. [He/she] said the reason was because [he/she] kept moving [his/her] arms and yelling help. I called the supervisor and at that time [staff 23] went into the room. The nurse said that the patient was clammy and didn’t look well. I spoke with the other supervisor [staff 9], that said the patient told [him/her] earlier that day that [he/she] gets clammy after pain medications. When I was notified that they couldn’t get a blood pressure, the patient was hypotensive prior. The physician had ordered a fluid bolus and zyprexa. The supervisor [staff 9] told me [he/she] would get a manual blood pressure cuff and get a blood pressure and call back. By the time they called me back, the patient had already coded. The only report I got was that the patient was less responsive but [he/she] had gotten Zyprexa, so this was expected. I was told the reason they couldn’t get a blood pressure is because the patient was moving [his/her] arm too much ...” An interview was conducted with staff 23 on 03/18/26 at 12:56 p.m. Regarding patient 3, staff 23 states in part, “Most of [his/her] care that day, [staff 9] took care of. The nurse notified the doctor after the patient had said [he/she] fell and got orders. We tried to get x-rays on the patient. That’s all I know prior to the end of the shift. I didn’t know the patient had been deteriorating. The nurse asked me to help, and we had called the nurse practitioner right before [he/she] coded to say we couldn’t get a blood pressure. The only time I spoke to the doctor was earlier in the day, I spoke to [staff 21], and [he/she] wanted the patient moved to SCU, but there were no beds. So, we ordered a one-on-one [1:1] to sit with the patient. I didn’t know anything prior. Then, by the time I got involved again, we had trouble getting a blood pressure, so I called the nurse practitioner. [He/she] said we really need to get a blood pressure on [him/her] as I was told we couldn’t get a blood pressure because the patient was moving around too much. The other supervisor went to get a manual blood pressure cuff to take a manual blood pressure to get a reading, and we were to call the nurse practitioner back. While we were trying to get the blood pressure, the patient went unresponsive and no blood pressure could be obtained, so we called a code. The staff is supposed to call a rapid response for immediate help, and anyone can call a rapid response. I’m not sure why it wasn’t done in this case ...””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 38282 Based on medical record review, document review, and staff interview, the hospital failed to ensure that nursing adhered to the Bladder Program Policy for three (3) of three (3) patients (#1, #5, and #9) with documented episodes of incontinence. This failure has the potential to affect all patients receiving services at the hospital. Findings are as follows: A review was completed of the medical records for Patient #1. Patient #1 was admitted from 10/17/23 to 11/04/23, with a diagnosis of cerebrovascular accident (CVA). During the stay, Patient #1 had no roommates; and consults were made for Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST), Neuropsychology, and Case Management (CM). A Family Conference Meeting was held on 10/27/23, with Patient #1, adult child with their spouse, live-in significant other and their parent in attendance. Updates were given to progress, including: “Having trouble with incontinence - does not always feel sensation or gets it too late, has trouble verbalizing ... Continue toileting schedule and if need to, will increase frequency with nursing ...” There were no physician orders for Bladder Training. A review of the Bladder Management Flow Sheet revealed that with a few exceptions, Patient #1 was incontinent of urine. The Bladder Management Flow Sheet documentation included, but was not limited to: 10/18/23: five (5) hours three (3) minutes between checks 10/19/23: fifteen (15) hours forty-four (44) minutes between checks 10/20/23: sixteen (16) hours thirty (30) minutes between checks 10/21/23: seven (7) hours five (5) minutes between checks 10/22/23: five (5) hours eight (8) minutes between checks 10/23/23: ten (10) hours fifty-four (54) minutes between checks 10/24/23: twenty-six (26) hours twenty-three (23) minutes between checks 10/25/23: fourteen (14) hours one (1) minute between checks 10/26/23: ten (10) hours one (1) minute between checks 10/27/23: twelve (12) hours thirty-nine (39) minutes between checks 10/28/23: four (4) hours fifty (50) minutes between checks 10/29/23: nine (9) hours twenty-seven (27) minutes between checks 10/30/23: six (6) hours twenty-seven (27) minutes between checks 10/31/23: thirteen (13) hours nineteen (19) minutes between checks 11/01/23: eight (8) hours fifteen (15) minutes between checks 11/02/23: two (2) hours thirty-five (35) minutes between checks 11/03/23: nineteen (19) hours fifty-two (52) minutes between checks 11/04/23: seven (7) hours twenty-one (21) minutes between checks A review was completed of the medical records for Patient #5. Patient #5 was admitted 11/08/23 to present with a diagnosis of rib fractures status post (S/P) all-terrain vehicle (ATV) accident. There were no physician orders for Bladder Training. A review of the Bladder Management Flow Sheet revealed the following, including, but not limited to: 11/10/23: an episode of incontinence with the previous documentation fifteen (15) hours and fifty (50) minutes prior. 11/13/23: an episode of incontinence with the previous documentation twenty-one (21) hours and forty (40) minutes prior. A review was completed of the medical records for Patient #9. Patient #9 was admitted 07/27/23 to 08/02/23 with a diagnosis of CVA with Ataxia. There was a physician order for Bladder Training every two (2) hours. A review of the Bladder Management Flow Sheet revealed the following, including, but not limited to: 07/27/23: an episode of incontinence with the previous documentation six (6) hours and forty (40) minutes prior. 07/30/23: an episode of incontinence with the previous documentation seven (7) hours and forty-eight (48) minutes prior. 07/31/23: an episode of incontinence with the previous documentation five (5) hours and thirty-one (31) minutes prior. 08/07/23: an episode of incontinence with the previous documentation nine (9) hours and thirty-nine (39) minutes prior. A review of the policy, titled “Bladder Program” reviewed: 08/24/23; stated in pertinent part, “... It is the responsibility of the licensed staff to set up a bladder program for each patient with impaired bladder elimination ...” A review of the complaints and grievances over the past three (3) months revealed that at least twenty (20) involved slow response to call lights and/or issues with elimination. Two (2) were filed on behalf of Patient #1: An interview was conducted on 10/13/23 at 12:10 p.m. with the Director Quality Risk (DQR) regarding Patient #1. The DQR confirmed that they were currently investigating two complaints placed on behalf of Patient #1 - on 10/30/23 and 11/03/23; and that they had observed negative postings on social media. An interview was conducted on 11/15/23 at 9:50 a.m. with the Director Quality Risk (DQR) regarding bladder management. The DQR confirmed that the bladder management policy listed specific bladder training for spinal cord injury patients; but all other patients would have individualized bladder management ordered by the physician after being assessed to need and discussed in the weekly team conference meetings. The DQR confirmed that Patient #1 had no bladder management ordered by the physician; and that while there was no standard, elimination needs should be addressed at every hourly check. The DQR confirmed after reviewing the documentation for Patient #1, #5, and #9, that the incontinence and time frames for checking and documenting were unacceptable.”