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Based on interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Governing Body (They guide the hospital's direction by making strategic decisions and setting policies, and they are ultimately accountable for the safety and quality of care provided) was met, as evidenced by:

1. The facility's Governing Body/Governing Board failed to ensure that recommendations of the medical staff were considered before making medical staff reappointments when, the Governing Body/Governing Board granted sixty (60) day or 2-month reappointments and privileges (specific authorizations granted to doctors by a healthcare facility, like a hospital, that allow them to perform certain procedures or treat specific conditions within that facility) to physicians without considering recommendations from the medical staff for six (6) of 10 sampled Medical Staff physicians (MD 1, MD 7, MD 8, MD 9, and MD 10) and sixty-nine (69) additional physicians (MD 12 through MD 81) for a total of seventy-four (74) of 220 active physicians, between January 2025 through March 2025. In addition, twenty-seven (27) of the 74 physicians (MD 1, 7, 8, 9, 13, 18, 19, 21, 23, 24, 26, 30, 31, 38, 42, 43, 45, 47, 55, 59, 63, 66, 67, 68, 73, 78, and 79) were granted a second (2nd) 2-month re-appointment.

This deficient practice undermined the integrity of the Medical Staff credentialing process (the process of verifying a healthcare professional's qualifications, education, training, and experience to ensure they are properly qualified to provide healthcare services) and called into question the current professional competence of the reappointed candidates, and thus the quality of medical care they provide, as the candidates were reappointed by the Governing Board/Governing Body without considering recommendations by the Medical Executive Committee (MEC, primarily composed of physicians and other key medical staff members. It acts as a representative body for the medical staff, making decisions related to patient care, clinical policies, and physician performance) as required by the Medical Staff Bylaws. This in turn raised concern for potential risk of harm to patients under the care of these reappointed practitioners. (Refer to A-0046)

2. The facility's Governing Body/Governing Board (They guide the hospital's direction by making strategic decisions and setting policies, and they are ultimately accountable for the safety and quality of care provided) failed to ensure that the process articulated in the medical staff bylaws (are a set of rules and regulations that govern the structure, conduct, and responsibilities of a hospital's medical staff. They define how the medical staff operates, including processes for credentialing, privileging, and decision-making. These bylaws are crucial for ensuring patient safety, maintaining quality of care, and managing the hospital's legal and regulatory obligations), rules, or regulations which included criteria for determining the privileges that may be granted to individual practitioners and a procedure for applying the criteria to individual practitioners, was followed, when the Governing Body granted sixty (60) day or 2-month reappointments and privileges (specific authorizations granted to doctors by a healthcare facility, like a hospital, that allow them to perform certain procedures or treat specific conditions within that facility) to physicians without verifying that the physicians met the criteria for reappointment based on individual character, competence, training, experience and judgment for six (6) of 10 sampled Medical Staff physicians (MD 1, MD 7, MD 8, MD 9, and MD 10) and sixty-nine (69) additional physicians (MD 12 through MD 81) for a total of seventy-four (74) of 220 active physicians, between January 2025 through March 2025. In addition, twenty-seven (27) of the 74 physicians (MD 1, 7, 8, 9, 13, 18, 19, 21, 23, 24, 26, 30, 31, 38, 42, 43, 45, 47, 55, 59, 63, 66, 67, 68, 73, 78, and 79) were granted a second (2nd) 2-month re-appointment.

This deficient practice undermined the integrity of the Medical Staff credentialing process (the process of verifying a healthcare professional's qualifications, education, training, and experience to ensure they are properly qualified to provide healthcare services) and called into question the current professional competence of the reappointed candidates, and thus the quality of medical care they provide, as the candidates were reappointed by the Governing Board/Governing Body without examination of their credentials by the Medical Staff Credentials Committee as required by the Medical Staff Bylaws. This in turn raised concern for potential risk of harm to patients under the care of these reappointed practitioners. (Refer to A-0050)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe environment.

Based on observation, interview and record review the facility failed to ensure the Condition of Participation for Patient Rights was met, as evidenced by:

1. The facility's nursing staff failed to ensure that interpreter information was documented, when and if the interpreter was used to translate information regarding advance directives acknowledgement form (a form confirming that a healthcare provider has received and understands an individual's advance directive [outlines their wishes regarding future medical treatment]), for one of 30 sampled patients (Patient 12), whose preferred written and spoken language was Korean, in accordance with the facility's policy and procedure regarding interpreter services (facilitate communication between healthcare providers and patients who do not share a common language. These services ensure patients receive quality care and understand medical information, diagnoses, and treatment plans. Interpreters, whether in-person, via phone, or video, bridge language gaps, enabling effective communication and promoting patient safety and satisfaction).

This deficient practice had the potential to result in Patient 12 misunderstanding the information regarding advance directives, which could compromise Patient 12's ability to make informed decisions (means patients understand their health condition, treatment options, risks, benefits, and alternatives, allowing them to make choices aligned with their values and preferences) about their healthcare. (Refer to A-0129)

2. The facility failed to ensure its nursing staff escalated an alleged physical abuse (including hitting, slapping, pinching, and kicking) to the house supervisor, for one of 30 sampled patients (Patient 6), in accordance with the facility's policy and procedure regarding abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish), when Patient 6 reported to Registered Nurse (RN 5) that Certified Nursing Assistant (CNA 5) punched Patient 6 in the face.

This deficient practice resulted in CNA 5 not being removed from the facility immediately and putting Patient 6 and other patients at risk for further abuse. (Refer to A-0145)

3. The facility failed to ensure its nursing staff developed a restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) care plan (a document that outlines an individual's assessed needs and the specific support or care required to meet those needs, ensuring the right level of care is provided), for one of 30 sampled patients (Patient 3), in accordance with the facility's policy and procedure regarding restraints use, when Patient 3 was placed on 4-point behavioral (bilateral [both] wrists and bilateral ankles) restraints.

This deficient practice had the potential to result in lack of monitoring regarding restraints use and the potential for inappropriate or prolonged restraints use, which may result in complications such as skin breakdown (damage to the skin and underlying tissue), psychological distress, etc. (Refer to A-0166)

4. The facility failed to ensure a physicians' order for restraints (any manual method, physical, mechanical device, material, or equipment that immobilized or reduces the ability of a patient to move his or her arms, legs, body, or head freely) included the indication for restraints for one of 30 sampled patients (Patients 23), in accordance with the facility's policy regarding restraints use.

This deficient practice had the potential for patients to be restrained unnecessarily and may lead to lack of monitoring to determine if the restraints are still necessary in order to reduce or eliminate the need for restraints due to potential complications such as skin injury, circulation (blood flow) problems, psychological distress, etc. (Refer to A-0168)

5. The facility failed to ensure staff assessed and evaluated a patient's behavior when renewing a behavioral restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) order for one of 30 sampled patients (Patient 3), in accordance with facility's policy and procedure regarding restraints use, when the physician restraint renewal order and nursing assessment did not indicate what was Patient 3's behavior, which was indicative of immediate danger to self or others to warrant the use of restraints.

This deficient practice resulted in unnecessary restraint use on Patient 3 from 12:40 a.m. to 4:40 a.m. (total four [4] hours) on 4/15/2025 and put Patient 3 at risk for injury including skin breakdown (damage to the skin, ranging from mild irritation to deep tissue injury, often caused by sustained pressure or moisture), emotional distress, etc. (Refer to A-0171)

6. The facility failed to ensure its nursing staff discontinued restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) use at the earliest possible time for one of 30 sampled patients (Patient 3), in accordance with the facility's policy and procedure regarding restraints use, when Patient 3 was placed on 4-point behavioral (bilateral [both] wrists and bilateral ankles) restraints from 8:40 p.m. to 4:40 a.m. (total right [8] hours) despite Patient 3 documented as being calm and sleeping most of the time from 9:15 p.m. to 4:45 a.m. (7.5 hours) during the restraint episode.

This deficient practice resulted in unnecessary restraint use on Patient 3 and put Patient 3 at risk for injury including skin breakdown (damage to the skin, ranging from mild irritation to deep tissue injury, often caused by sustained pressure or moisture), emotional distress, etc. (Refer to A-0174)

7. The facility failed to ensure its nursing staff assessed and monitored one of 30 sampled patients (Patient 3), upon initiation of behavioral restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body), in accordance with the facility's policy regarding restraints use, when nursing assessment started twenty (20) minutes after initiation of 4-point behavioral restraints (bilateral [both] wrists and bilateral ankles). There was no assessment completed/documented upon initiation of restraints at 8:40 p.m. on 4/14/2025.

This deficient practice resulted in nursing staff not assessing and monitoring Patient 3 during the first 20 minutes during the restraint episode and put Patient 3 at risk for injury including skin breakdown (damage to the skin, ranging from mild irritation to deep tissue injury, often caused by sustained pressure or moisture) and circulation (blood flow) problem. (Refer to A-0175)

8. The facility failed to ensure its physician performed a face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]), within an hour after the initiation of a 4-point (bilateral [both] wrists and bilateral ankles) behavioral restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body), for one of 30 sampled patients (Patient 3), in accordance with facility's policy and procedure regarding restraints use.

This deficient practice had the potential to result in lack of evaluation of Patient 3's response to behavioral restraints initiated including assessment for continued need for restraints and/or other interventions, which may result in unnecessary use of restraints and other complications such as skin tear, dehydration, psychological distress, etc. (Refer to A-0178)

9. The facility failed to ensure its physician documented a face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]), within an hour after the initiation of a 4-point (bilateral [both] wrists and bilateral ankles) behavioral restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body), for one of 30 sampled patients (Patient 3), in accordance with facility's policy and procedure regarding restraints use.

This deficient practice had the potential to result in lack of evaluation of Patient 3's response to behavioral restraints initiated including assessment for continued need for restraints and/or other interventions, which may result in unnecessary use of restraints and other complication such as skin tear, dehydration, psychological distress, etc. (Refer to A-0184)

10. The facility failed to ensure there was a documentation of patient's specific behavior for one of 30 sampled patients (Patient 3), in accordance with the facility's policy regarding restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) use, when the physician restraint renewal order and nursing assessment did not indicate what was Patient 3's behavior which was indicative of Patient 3 posing immediate danger to self or others that warrants the use of restraints.

This deficient practice resulted in unnecessary restraint use on Patient 3 from 12:40 a.m. to 4:40 a.m. (total four [4] hours) on 4/15/2025 and put Patient 3 at risk for injury including skin breakdown (damage to the skin, ranging from mild irritation to deep tissue injury, often caused by sustained pressure or moisture). (Refer to A-0185)

11. The facility failed to ensure nursing staff documented the reason for placing on restraints (any manual method, physical, mechanical device, material, or equipment that immobilized or reduces the ability of a patient to move his or her arms, legs, body, or head freely), one of 30 sampled patients (Patient 23), in accordance with the facility's policy regarding restraints use.
This deficient practice had the potential for the patients to be restrained unnecessarily, which may result in complications such as skin breakdown (damage to the skin, ranging from mild irritation to deep tissue injury, often caused by sustained pressure or moisture), circulation (blood flow) problem, psychological distress, etc. (Refer to A-0187)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe environment.

Based on interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Medical Staff was met, as evidenced by:

1. The facility failed to ensure its Medical Staff reviewed the credentials (the process of verifying a healthcare professional's qualifications, education, training, and experience to ensure they are properly qualified to provide healthcare services) of six of 10 sampled candidates (physicians) eligible for reappointment to the Medical Staff and made recommendations to the Governing Board (They guide the hospital's direction by making strategic decisions and setting policies, and they are ultimately accountable for the safety and quality of care provided) on the reappointment of candidates prior to the Board approval, in accordance with the Medical Staff Bylaws (are a set of rules and regulations that govern the structure, conduct, and responsibilities of a hospital's medical staff. They define how the medical staff operates, including processes for credentialing, privileging, and decision-making. These bylaws are crucial for ensuring patient safety, maintaining quality of care, and managing the hospital's legal and regulatory obligations) The candidates were approved for continued membership in the Medical Staff and their clinical privileges were granted by the Governing Board despite the key steps of the credentialing and reappointment procedure being bypassed.

This deficient practice undermined the integrity of the Medical Staff credentialing process and called into question the current professional competence of the reappointed candidates, and thus the quality of medical care they provide, as the candidates were reappointed without examination of their credentials by the Medical Staff Credentials Committee and the Medical Executive Committee (MEC, primarily composed of physicians and other key medical staff members. It acts as a representative body for the medical staff, making decisions related to patient care, clinical policies, and physician performance) as required by the Medical Staff Bylaws. This in turn raised concern for potential risk of harm to patients under care of these reappointed practitioners. (Refer to A-0341)

2. The facility failed to ensure its Medical Executive Committee was held accountable for applying the criteria for privileging and appointment of eligible candidates and to make their recommendations, before the Governing Body makes a final decision to reappoint a practitioner to the medical staff when, its Medical Staff did not review the credentials (the process of verifying a healthcare professional's qualifications, education, training, and experience to ensure they are properly qualified to provide healthcare services) of six of 10 sampled candidates (physicians) eligible for reappointment to the Medical Staff and did not make recommendations to the Governing Board (They guide the hospital's direction by making strategic decisions and setting policies, and they are ultimately accountable for the safety and quality of care provided) on the reappointment of candidates prior to the Board approval, in accordance with the Medical Staff Bylaws (are a set of rules and regulations that govern the structure, conduct, and responsibilities of a hospital's medical staff. They define how the medical staff operates, including processes for credentialing, privileging, and decision-making. These bylaws are crucial for ensuring patient safety, maintaining quality of care, and managing the hospital's legal and regulatory obligations). The candidates were approved for continued membership in the Medical Staff and their clinical privileges were granted by the Governing Board despite the key steps of the credentialing and reappointment procedure being bypassed.

This deficient practice undermined the integrity of the Medical Staff credentialing process and called into question the current professional competence of the reappointed candidates, and thus the quality of medical care they provide, as the candidates were reappointed without examination of their credentials by the Medical Staff Credentials Committee and the Medical Executive Committee (MEC, primarily composed of physicians and other key medical staff members. It acts as a representative body for the medical staff, making decisions related to patient care, clinical policies, and physician performance) as required by the Medical Staff Bylaws. This in turn raised concern for potential risk of harm to the patients under care of these reappointed practitioners. (Refer to A-0347)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe environment.

Based on interview and record review the facility failed to ensure the Condition of Participation for Nursing Services was met, as evidenced by:

1. The facility failed to ensure that one of 30 sampled patients (Patient 12), who was admitted to the facility after sustaining a fall (an event which results in a person coming to rest inadvertently on the ground or floor or other lower level), when Patient 12 fell out of the bed and fractured a right 7th rib (broken rib), had their (Patient 12) reported pain level of 7 out of 10 (7/10- moderate pain) and 5 out of 10 (5/10-moderate pain) addressed, when Patient 12 was not provided an intervention (any action taken to alleviate or manage pain) for pain relief, in accordance with the facility's policy regarding pain management.

This deficient practice resulted in Patient 12's pain not being managed and had the potential for Patient 12 to be in significant discomfort and prolonged suffering, leading to increased risk of complications associated with unmanaged pain, such as respiratory issues due to shallow breathing or avoidance of moving. (Refer to A-0395)

2. The facility failed to ensure the pain level was assessed prior to and after administering a pain medication for two of 30 sampled patients (Patients 21 and 22), in accordance with the facility's policy regarding pain management.

This deficient practice had the potential for ineffective pain relief, which may result in functional limitations (Example: reduced Mobility, etc.), prolonged discomfort, prolonged hospital stay, anxiety, etc. (Refer to A-0395)

3. The facility failed to formulate an individualized nursing care plan (a documented strategy that outlines patient care goals, interventions, and evaluations to address specific health issues and provides a means of communication among health care providers) for one of 30 sampled patients (Patient 22) to address Patient 22's high risk for falls (an event which results in a person coming to rest inadvertently on the ground or floor or other lower level), in accordance with the facility's policy regarding plan of care.

This deficient practice had the potential for the lack implementation of fall precautions (a multi-faceted approach to minimize the risk of falls, encompassing universal interventions for all patients, as well as individualized strategies based on specific risk factors. These precautions include ensuring a safe environment, assisting with mobility, and educating patients and their families) for Patient 22, which could result in a fall and possible serious injury or harm such fracture (broken bones), etc. (Refer to A-0396)

4. The facility failed to ensure that one of 30 sampled patients (Patient 12), had their (Patient 12) pain assessment (the systemic evaluation of a patient's pain experience, including intensity, location, quality, and acceptable level of pain) performed/assessed every four hours along with vital signs (VS, measurements of essential bodily functions including hear rate, blood pressure, respiratory rate, and temperature), in accordance with the facility's policy and procedure regarding pain assessment and management.

This deficient practice had the potential for Patient 12's pain to be inadequately managed, leading to Patient 12's prolonged discomfort and suffering, and a negative impact on the patient's overall recovery (delayed healing process). (Refer to A-0398)

5. The facility failed to ensure one of 30 sampled patients (Patient 21), who complained of moderate pain (4 - 7 rate out of 10 on the pain scale), was treated with a pain medication ordered to treat moderate pain, in accordance with the facility's policy regarding pain management. Instead, Patient 21 was treated with a pain medication (Tylenol, an over-the-counter pain medication), which was ordered to treat mild pain and not moderate pain.

This deficient practice resulted in inadequate pain relief for Patient 21, which also has the potential to result in prolonged discomfort, psychological distress, etc. (Refer to A-0405)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe environment.

Based on interview and record review the facility failed to ensure the Condition of Participation for Medical Record Services was met, as evidenced by:

1. The facility failed to ensure that the medical record for one of 30 sampled patients (Patient 14), contained pertinent information when:

1.a. The administration site for 10 milligrams (mg, measuring unit) of Haldol (a medication used to treat various psychiatric conditions [behavior, mood, thoughts, and perception]), for one of 30 sampled patients (Patient 14), was not documented, in accordance with the facility's policy regarding documentation of medication administration.

This deficient practice had the potential to compromise Patient 14's safety due to lack of communication among healthcare providers and lack of monitoring for the potential adverse events and complications at the injection site (Example: infection, nerve damage, allergic reactions, etc.). (Refer to A-0449)

1.b. There was no correctly filled out behavioral restraint (interventions used to manage violent or self-destructive behaviors that pose an immediate threat to the individual or others) physician order(s) and restraint assessment documentation containing all the necessary elements (justification for restraint use, type of restraints, duration of restraint, monitoring requirements, and alternatives considered), for one of 30 sampled patients (Patient 14), in accordance with the facility's policy and procedure regarding behavioral restraints assessment and documentation.

This deficient practice had the potential to result in Patient 14's increased risk of harm due to inappropriate continuation of restraints, exposing the patient (Patient 14) to physical and psychological harm. Additionally, without proper assessment and documentation, changes in Patient 14's condition may go unnoticed, increasing the risk of complications such as injury (example: skin breakdown- damage to the skin, ranging from mild irritation to deep tissue injury, often caused by sustained pressure or moisture`), emotional distress and/or death. (Refer to A-0449)

2. The facility failed to ensure there was documentation of a patient's specific behavior for one of 30 sampled patients (Patient 3), when the physician restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) renewal order and the nursing assessment, did not indicate what was Patient 3's behavior that would indicate that Patient 3 was posing immediate danger to self or others, in accordance with the facility's policy regarding restraints use and documentation.

This deficient practice resulted in unnecessary restraint use on Patient 3 from 12:40 a.m. to 4:40 a.m. (total four [4] hours on 4/15/2025) and put Patient 3 at risk for injury including skin breakdown (damage to the skin, ranging from mild irritation to deep tissue injury, often caused by sustained pressure or moisture), emotional distress, etc. (Refer to A-0450)

3. The facility failed to ensure two of 30 sampled patients' (Patient 12, and Patient 17) medical records contained appropriate documentation of assessments and findings when:

3.a. For Patient 12, pain assessment was not recorded in Patient 12's medical record, along with vital signs (VS, measurements of the body's most basic functions), obtained and documented every 4 hours, in accordance with the facility's policy regarding pain assessment and documentation.

This deficient practice compromised Patient 12's medical record integrity by undermining the completeness and accuracy of the documentation, essential for effective patient care and pain management. In addition, this deficient practice had the potential for Patient 12's pain to be unrecognized, leading to inadequate pain management and delayed interventions that could prevent complications related to unmanaged pain. (Refer to A-0467)

3.b. For Patient 17, the medical record contained no nursing documentation of Patient 17 sustaining a fall (an event which results in a person coming to rest inadvertently on the ground or floor or other lower level) in the emergency department (ED, a designated area within a hospital that provides immediate, specialized medical care to patients experiencing sudden, serious health issues or injuries), during Patient 17's hospital stay on 1/22/2025, in accordance with the facility's policy regarding fall prevention and management. In addition, Patient 17 sustained an open left ankle fracture (a type of bone fracture [broken] where the bone breaks through the skin, exposing the fracture site to the outside environment).

This deficient practice had the potential to result in Patient 17's condition and injury to be overlooked by providers, potentially leading to complications arising from the fall and fracture, such as infection and impaired healing, adversely affecting Patient 17's health and care. (Refer A-0467)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe environment.

Based on interview and record review, the Governing Body/Governing Board (They guide the hospital's direction by making strategic decisions and setting policies, and they are ultimately accountable for the safety and quality of care provided) failed to ensure that recommendations of the medical staff were considered before making medical staff reappointments when, the Governing Body/Governing Board granted sixty (60) day or 2-month reappointments and privileges (specific authorizations granted to doctors by a healthcare facility, like a hospital, that allow them to perform certain procedures or treat specific conditions within that facility) to physicians without considering recommendations from the medical staff for six (6) of 10 sampled Medical Staff physicians (MD 1, MD 7, MD 8, MD 9, and MD 10) and sixty-nine (69) additional physicians (MD 12 through MD 81) for a total of seventy-four (74) of 220 active physicians, between January 2025 through March 2025. In addition, twenty-seven (27) of the 74 physicians (MD 1, 7, 8, 9, 13, 18, 19, 21, 23, 24, 26, 30, 31, 38, 42, 43, 45, 47, 55, 59, 63, 66, 67, 68, 73, 78, and 79) were granted a second (2nd) 2-month re-appointment.

This deficient practice undermined the integrity of the Medical Staff credentialing process (the process of verifying a healthcare professional's qualifications, education, training, and experience to ensure they are properly qualified to provide healthcare services) and called into question the current professional competence of the reappointed candidates, and thus the quality of medical care they provide, as the candidates were reappointed by the Governing Board/Governing Body without considering recommendations by the Medical Executive Committee (MEC, primarily composed of physicians and other key medical staff members. It acts as a representative body for the medical staff, making decisions related to patient care, clinical policies, and physician performance) as required by the Medical Staff Bylaws. This in turn raised concern for potential risk of harm to patients under the care of these reappointed practitioners.

Findings:

During a concurrent interview and record review on 4/16/2025 and 4/18/2025, in the presence of the Chief Medical Officer (CMO) and the Associate Director of Medical Staff (ADMS), the credential files of ten (10) selected sample of the facility's Medical Staff, were reviewed, with the assistance of Medical Staff Coordinator 1 (MSC1). The files of six (6) physicians (MD1, MD6, MD7, MD8, MD9, MD10) indicated these individuals' most recent reappointment to the Medical Staff and their requested clinical privileges (specific authorizations granted to doctors by a healthcare facility, like a hospital, that allow them to perform certain procedures or treat specific conditions within that facility) had been approved by the Governing Board for sixty (60) days. Additionally, the files showed four (4) of the physicians (MD1, MD7, MD8, MD9) had their 60-day reappointment with privileges extended for another 60 days. MSC1 stated that members were normally reappointed to the Medical Staff for two (2) years at a time but confirmed that the latest reappointment period of these six candidates spanned 60 days.

During an interview on 4/17/2025 at 1:37 p.m. with the Chief of Medical Staff (COS), the COS stated that the Medical Staff Committee's (MEC, primarily composed of physicians and other key medical staff members. It acts as a representative body for the medical staff, making decisions related to patient care, clinical policies, and physician performance) duties included making recommendations to the Governing Body/Governing Board for physicians seeking initial appointments and re-appointments to the medical staff. The Medical Executive Committee did not meet in January, February, and March of 2025 due to questionable election results for Medical Staff Committee members which occurred at the end of 2024. The COS also stated that the Governing Body/Governing Board has now re-appointed medical staff for sixty (60) day extensions without the recommendations of the Medical Staff.

During an interview on 4/18/2025 at 9:36 a.m. with the Chief Executive Officer (CEO), the CEO stated the following: The credentialing process of appointing and re-appointment starts with a physician submitting an application and other required documents to the Medical Staff Office (handles the appointments of physicians). The Credentialing Committee reviews the application, and forwards the application to the Medical Staff Committee, who then makes recommendations to grant or deny privileges. The Medical Staff Committee then sends the recommendations to the Governing Board for approval. The CEO stated the MEC did not meet in January, February, and March of 2025, and therefore, no recommendations were made for appointments or re-appointments. The Governing Board reached out to the MEC, but there was no response. Due to this unprecedented situation, the Governing Board wanted to ensure there was no lapse in the re-appointment of privileges and care of the patients, therefore, the Governing Board reviewed the credentialing files and decided to grant 2-month reappointments, in leu of 2-year reappointments. Some physicians were granted a second (2nd) 2-month reappointment, thereby, bypassing some steps in the usual credentialing process.

During a review of an untitled and undated document, provided by the facility to indicate which physicians had been granted a 2-month reappointment, the document indicated that seventy-four (74) physicians (MD 1, 7, 8, 9, 10, 12 - 81) were granted a 2-month reappointment. In addition, twenty-seven (27) of the 74 physicians (MD 1, 7, 8, 9, 13, 18, 19, 21, 23, 24, 26, 30, 31, 38, 42, 43, 45, 47, 55, 59, 63, 66, 67, 68, 73, 78, and 79) were granted a second (2nd) 2-month re-appointment, which was due to expire on 5/31/2025.

During a review of the facility's "Medical Staff Executive Committee," meeting minutes (a written record of what transpired during a meeting, including who attended, what was discussed, what decisions were made, and any action items assigned), the minutes indicated there were no meeting minutes documented for the month of January 2025.

During a review of the facility's "Medical Staff Executive Committee," meeting minutes, dated 2/19/2025, the minutes indicated the Committee "chose not to recognize the Credentials Report, and did not review the report ..."

During a review of the facility's "Governing Board," meeting minutes, dated 1/22/2025, the meeting minutes indicated that the Governing Board would expect to have a credentials report at this meeting to review and approve, but due to ongoing medical staff issues, the MEC meeting was cancelled in January 2025 ... The meeting minutes also indicated the medical staff is self-functioning and has a responsibility that they must address on a monthly basis. Presently, there is no MEC ...They (MEC) have cancelled their obligation of their work for January 2025, thus far ...MEC was asked to follow their Medical Staff Bylaws (are a set of rules and regulations that govern the structure, conduct, and responsibilities of a hospital's medical staff. They define how the medical staff operates, including processes for credentialing, privileging, and decision-making. These bylaws are crucial for ensuring patient safety, maintaining quality of care, and managing the hospital's legal and regulatory obligations) ...It was questioned whether it would make more sense not to act on credentials and such until this was resolved. While in essences this may be the case, not acting on credentials could allow physicians credentials to lapse, thereby not allowing those physicians to treat their patients. The Governing Board is in charge of the ultimate quality of the hospital and ensuring that policies and procedures, Bylaws, Rules and Regulations are being fulfilled. These Governing Body Minutes were reviewed and verified with the Chief Executive Officer (CEO) and the Secretary of the Board.

During a review of the facility's "Governing Board," meeting minutes, dated 2/26/2025, the meeting minutes indicated the following: The following items were voted on and approved off-cycle and require ratification: Resolution providing 60-day approval of physician's credentials. Approval was required due to lack of MEC meeting in January 2025.
During a review of the facility's "Governing Board By-Laws," dated 1/12/2023, the Governing Board By-Laws indicated the following: Section 1. Duties and Functions Generally ...ii. Oversee and have ultimate accountability for the safety and quality of patient care, treatment, and services at the Hospital ...The Governing Board shall also take action as necessary to: ...Require the Medical Staff, including but not limited to the Medical Executive Committee, to follow the Medical Staff Bylaws; and Require the Medical Staff to fulfill its responsibility and accountability to the Governing Board ...
During a review of the Medical Staff Bylaws, last amended and approved by the Governing Board in October 2020, indicated under Section 7.3-3 "Reappointment Procedure:"

a) When a member of the Medical Staff is scheduled for biennial review, the Chairman of the Department, with his Department or a Committee thereof, shall review the application for the reappointment of the member and specifically concern itself with evaluation of the current professional competence, clinical judgment of the member, his participation in departmental activities relative to quality of patient care, and if available, relevant practitioner-specific data compared to aggregate data and performance measurement data, including morbidity and mortality data. The Department Chair then shall make a recommendation to the Credentials Committee specifically with regard to clinical privileges. When recommendation is for reduction in clinical privileges, the reason for such recommendation shall be stated and documented.

b) The extent of his participation in patient care, admission of patients, and consultation shall also be considered.

c) Prior to the meeting of the Medical Executive Committee, the Credentials Committee shall review the Departmental recommendation for reappointment of a member and shall also consider: his compliance with the Medical Staff Bylaws and Rules and Regulations, attendance at Medical Staff meetings, timely completion of records, his ethics and conduct, his cooperation with medical center personnel, his relation with other practitioners, and his general attitude towards patients, the medical center, and the public. [ ...]

d) The Medical Executive Committee meeting shall make written recommendation to the Governing Board, through the Chief Executive Officer concerning the reappointment, including the clinical privileges for the ensuing period. Where non-reappointment or a change in clinical privileges is recommended, the reasons for such recommendation shall be stated and documented.
Section 14.2-1 b) of the Bylaws lists the Medical Executive Committee Authority and Duties, which include: 9) To review the credentials of the applicants through Credentials Committee reports and make recommendations for Staff membership, assignments to Departments, and delineation of clinical privileges; 10) To review periodically all information available, (normally by means of Credentials and Department reports), regarding the performance and clinical competence of staff members and other practitioners with clinical privileges and as a result of such reviews to make recommendations for reappointments and renewal or changes in clinical privileges.

Based on interview and record review, the Governing Body/Governing Board (They guide the hospital's direction by making strategic decisions and setting policies, and they are ultimately accountable for the safety and quality of care provided) failed to ensure that the process articulated in the medical staff bylaws (are a set of rules and regulations that govern the structure, conduct, and responsibilities of a hospital's medical staff. They define how the medical staff operates, including processes for credentialing, privileging, and decision-making. These bylaws are crucial for ensuring patient safety, maintaining quality of care, and managing the hospital's legal and regulatory obligations), rules, or regulations which included criteria for determining the privileges that may be granted to individual practitioners and a procedure for applying the criteria to individual practitioners, was followed, when the Governing Body granted sixty (60) day or 2-month reappointments and privileges (specific authorizations granted to doctors by a healthcare facility, like a hospital, that allow them to perform certain procedures or treat specific conditions within that facility) to physicians without verifying that the physicians met the criteria for reappointment based on individual character, competence, training, experience and judgment for six (6) of 10 sampled Medical Staff physicians (MD 1, MD 7, MD 8, MD 9, and MD 10) and sixty-nine (69) additional physicians (MD 12 through MD 81) for a total of seventy-four (74) of 220 active physicians, between January 2025 through March 2025. In addition, twenty-seven (27) of the 74 physicians (MD 1, 7, 8, 9, 13, 18, 19, 21, 23, 24, 26, 30, 31, 38, 42, 43, 45, 47, 55, 59, 63, 66, 67, 68, 73, 78, and 79) were granted a second (2nd) 2-month re-appointment.

This deficient practice undermined the integrity of the Medical Staff credentialing process (the process of verifying a healthcare professional's qualifications, education, training, and experience to ensure they are properly qualified to provide healthcare services) and called into question the current professional competence of the reappointed candidates, and thus the quality of medical care they provide, as the candidates were reappointed by the Governing Board/Governing Body without examination of their credentials by the Medical Staff Credentials Committee as required by the Medical Staff Bylaws. This in turn raised concern for potential risk of harm to patients under the care of these reappointed practitioners.

Findings:

During a concurrent interview and record review on 4/16/2025 and 4/18/2025, in the presence of the Chief Medical Officer (CMO) and the Associate Director of Medical Staff (ADMS), the credential files of ten (10) selected sample of the facility's Medical Staff, were reviewed, with the assistance of Medical Staff Coordinator 1 (MSC1). The files of six (6) physicians (MD1, MD6, MD7, MD8, MD9, MD10) indicated these individuals' most recent reappointment to the Medical Staff and their requested clinical privileges had been approved by the Governing Board for sixty (60) days (2/1/2025 - 3/31/2025 for MD1, MD7, MD8, MD9; 4/1/2025 - 5/31/2025 for MD6, MD10). Additionally, the files showed four (4) of the physicians (MD1, MD7, MD8, MD9) had their 60-day reappointment with privileges (specific authorizations granted to doctors by a healthcare facility, like a hospital, that allow them to perform certain procedures or treat specific conditions within that facility) extended for another 60 days (4/1/2025 - 5/31/2025). MSC1 stated that members are normally reappointed to the Medical Staff for two (2) years at a time but confirmed that the latest reappointment period of these six candidates spanned 60 days.

During concurrent interview on 4/16/2025 at 2:20 p.m. with the Chief Medical Officer (CMO), the CMO explained that the credentials of candidates for reappointment to the Medical Staff were normally reviewed by the department chairs, the Credentials Committee, and the MEC (Medical Executive Committee, primarily composed of physicians and other key medical staff members. It acts as a representative body for the medical staff, making decisions related to patient care, clinical policies, and physician performance) before any recommendations were made to the Governing Board/Governing Body (They guide the hospital's direction by making strategic decisions and setting policies, and they are ultimately accountable for the safety and quality of care provided) on the reappointments, but at present the Medical Staff did not have an official Credentials Committee Chair and since January of this year (2025), full MEC meetings have not been conducted because not all members of the MEC participated. The CMO stated that few of the officers were newly elected last year, but the election was disputed, and at this time the Medical Staff does not have a full functioning MEC. The CMO added that the Governing Board, in an effort to resolve the dispute, had requested a meeting of the Joint Conference Committee (JCC) comprised of the Board/Governing Body, the President and the President-Elect of the MEC, but the President refused, and therefore the Board (Governing Board/Governing Body) granted a temporary 60-day reappointment to candidates in order to maintain continued patient care.

During an interview on 4/18/2025 at 9:36 a.m. with the Chief Executive Officer (CEO), the CEO stated the following: The credentialing process (the process of verifying a healthcare professional's qualifications, education, training, and experience to ensure they are properly qualified to provide healthcare services) of appointing and re-appointment starts with a physician submitting an application and other required documents to the Medical Staff Office (handles the appointments of physicians). The Credentialing Committee reviews the application, and forwards the application to the Medical Staff Committee, who then makes recommendations to grant or deny privileges. The Medical Staff Committee then sends the recommendations to the Governing Board/Governing Body for approval. The CEO stated that the MEC did not meet in January, February, and March of 2025, and therefore, no recommendations were made for appointments or re-appointments. The Governing Board reached out to the MEC, but there was no response. Due to this unprecedented situation of no Credentialing Committee or Medical Executive Committee, the Governing Board wanted to ensure there was no lapse in the re-appointment of privileges and care of the patients, therefore, the Governing Board reviewed the credentialing files and decided to grant 2-month reappointments, in leu of 2-year reappointments. Some physicians were granted a second (2nd) 2-month reappointment, thereby, bypassing some steps in the usual credentialing process.

During a review of an untitled and undated document, provided by the facility to indicate which physicians had been granted a 2-month reappointment, the document indicated that seventy-four (74) physicians (MD 1, 7, 8, 9, 10, 12 - 81) were granted a 2-month reappointment. In addition, twenty-seven (27) of the 74 physicians (MD 1, 7, 8, 9, 13, 18, 19, 21, 23, 24, 26, 30, 31, 38, 42, 43, 45, 47, 55, 59, 63, 66, 67, 68, 73, 78, and 79) were granted a second (2nd) 2-month re-appointment, which is due to expire on 5/31/2025.

During a review of the facility's "Governing Board," meeting minutes, dated 1/22/2025, the meeting minutes (a written record of what transpired during a meeting, including who attended, what was discussed, what decisions were made, and any action items assigned) indicated that the Governing Board would expect to have a credentials report at this meeting to review and approve, but due to ongoing medical staff issues, the MEC meeting was cancelled in January 2025 ... The medical staff is self-functioning and has a responsibility that they must address on a monthly basis. Presently, there is no MEC ...They (MEC) have cancelled their obligation of their work for January 2025, thus far ...MEC was asked to follow their Medical Staff Bylaws (are a set of rules and regulations that govern the structure, conduct, and responsibilities of a hospital's medical staff. They define how the medical staff operates, including processes for credentialing, privileging, and decision-making. These bylaws are crucial for ensuring patient safety, maintaining quality of care, and managing the hospital's legal and regulatory obligations) ...It was questioned whether it would make more sense not to act on credentials and such until this was resolved. While in essences this may be the case, not acting on credentials could allow physicians credentials to lapse, thereby not allowing those physicians to treat their patients. The Governing Board is in charge of the ultimate quality of the hospital and ensuring that policies and procedures, Bylaws, Rules and Regulations are being fulfilled. These Governing Body Minutes were reviewed and verified with the Chief Executive Officer (CEO) and the Secretary of the Board.

During a review of the facility's "Governing Board," meeting minutes, dated 2/26/2025, the meeting minutes indicated the following: There is a concern to the validation of the Credentials Report, as it may not have been approved by the Medical Executive Committee (MEC) .... there is no Credentialing Committee in existence.

During a review of the facility's "Governing Board By-Laws," dated 1/12/2023, the Governing Board By-Laws indicated the following: Section 1. Duties and Functions Generally ...ii. Oversee and have ultimate accountability for the safety and quality of patient care, treatment, and services at the Hospital ...The Governing Board shall also take action as necessary to: ...Require the Medical Staff, including but not limited to the Medical Executive Committee, to follow the Medical Staff Bylaws; and Require the Medical Staff to fulfill its responsibility and accountability to the Governing Board... Article VII, Medical Staff Appointments: Section 1. Governing Board Authority. The Governing Board shall have authority and responsibility for all appointments and reappointments of the Medical Staff members and assignment of clinical privileges in accordance with these Bylaws and the Medical Staff Bylaws ...

During a review of the facility's "Medical Staff Bylaws," dated 10/31/2020, the Medical Staff Bylaws indicated the following: 7.3-1, Reappointment Process ... In no case shall reappraisal and reappointment be greater than two (2) years from the previous reappraisal and reappointment ....
7.3-3 Reappointment Procedure.
a) When a member of the Medical Staff is scheduled for biennial review, the Chairman of the Department, with his Department or Committee thereof, shall review the application for appointment of the member and specifically concern itself with evaluation of the current professional competence, clinical judgment of the member, his participation in departmental activities relative to quality of patient care ... The Department Chair then shall make a recommendation to the Credentials Committee specifically with regard for clinical privileges ....

c) Prior to the meeting of Medical Executive Committee, the Credentials Committee shall review the Departmental recommendation for the reappointment of a member ...The Credentials Committee shall also consider the: his compliance with the Medical Staff Bylaws and Rules and Regulations, attendance at Medical Staff meetings ...his ethics and conduct ...his general attitude towards patients, the medical center, and the public ...The Credentials Committee shall also consider the applicant's physical and mental health; the recommendation of the Department Chairman concerning the findings of monitoring and evaluation activities; and his fulfillment of continuing medical education requirements ... The Credentials Committee shall transmit its recommendation, in writing, to the Medical Executive Committee ...
During a review of the facility's policy and procedure (P&P) titled, "Reappointment Application Process for Medical Staff," dated 12/1/2021, the P&P indicated the following: The Medical Staff Services Department will adhere to the processes detailed in this policy when processing applications for providers seeking reappointment to the Medical or Allied Health Professional Staff of the Hospital ...6. Shortened, Conditional Reappointment.

-6.1. Medical Staff Bylaw 7.3-7 states: "Whenever any of the of the procedure authorized by these Bylaws shall have been initiated against any member of the Medical Staff who otherwise would have been a candidate for reappointment pursuant to these Bylaws, reappointment made shall be conditional in nature and the practitioner's right to continued Medical Staff membership shall be contingent upon the outcome of the procedures authored within these Bylaws.
-6.2. To support this process, the Medical Executive Committee, upon the recommendation of the Credentials Committee, may approve a shortened, conditional reappointment (less than two years), in situations where the reapplicant has demonstrated patient safety concerns related to clinical competency, professional behavior, and/or well-being.
-6.2.1. In cases where a shortened, conditional reappointment is recommended, the reason, and the specific actions needed in order to qualify for reappointment after the shortened period, must be clearly articulated...

Based on observation, interview, and record review, the facility's nursing staff failed to ensure that interpreter information was documented, when and if the interpreter was used to translate information regarding advance directives acknowledgement form (a form confirming that a healthcare provider has received and understands an individual's advance directive [outlines their wishes regarding future medical treatment]), for one of 30 sampled patients (Patient 12), whose preferred written and spoken language was Korean, in accordance with the facility's policy and procedure regarding interpreter services (facilitate communication between healthcare providers and patients who do not share a common language. These services ensure patients receive quality care and understand medical information, diagnoses, and treatment plans. Interpreters, whether in-person, via phone, or video, bridge language gaps, enabling effective communication and promoting patient safety and satisfaction).

This deficient practice had the potential to result in Patient 12 misunderstanding the information regarding advance directives, which could compromise Patient 12's ability to make informed decisions (means patients understand their health condition, treatment options, risks, benefits, and alternatives, allowing them to make choices aligned with their values and preferences) about their (Patient 12) healthcare.

Findings:

During a review of Patient 12's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 4/12/2025, the H&P indicated that Patient 12 was admitted to the facility on 4/12/2025 with right chest wall pain, after falling off the bed. The H&P further indicated that Patient 12 had past medical history (PMH, a patient's previous medical conditions, surgeries, hospitalizations, and treatments) of dementia (a condition characterized by progressive or persistent loss of intellectual functioning), hypertension (a condition in which the force of blood against the walls of the arteries is consistently too high leading to high blood pressure readings), and history of stroke (occurs when blood flow to a part of the brain is interrupted or reduced, causing damage to brain tissue).

During an observation on 4/15/2025 at 3:22 p.m., with Patient 12, in Patient 12's room, Patient 12 was observed lying down in bed, with a family member at bedside. Patient 12 did not speak English, and a translator was utilized to conduct an interview. Patient 12 verified that their preferred language (written and spoken) was Korean.

During a concurrent interview and record review on 4/18/2025, at 11:02 a.m. with Nurse Manager (NM 1), Patient 12's "Face sheet (a document the provides essential patient demographic information, including the details such as the patient's name, date of birth, medical record number, preferred language and contact information), was reviewed. NM 1 stated that according to Patient 12's face sheet, Patient 12's documented primary spoken and written language was Korean.

During a concurrent interview and record review on 4/18/2025 at 11:02 a.m. with Nurse Manager (NM 1), Patient 12's electronic medical record (EMR, digital version of paper chart) titled, "Advance Directive acknowledgment form (a form confirming that a healthcare provider has received and understands an individual's advance directive [a legal document that allows an individual to state in advance their wishes regarding future medical care shall they become incapacitated (means a person lacks the ability to make informed decisions or to manage their own affairs due to a physical or mental condition. This could be temporary or permanent, and the condition may affect their ability to perform daily tasks or make medical decision) to make medical decisions...])," dated 4/12/2025, was reviewed.The form indicated that it was in Korean language and was dated 4/12/2025. NM 1 stated that for advance directive forms, nurses should use the interpreter (facilitate communication between healthcare providers and patients who do not share a common language. These services ensure patients receive quality care and understand medical information, diagnoses, and treatment plans. Interpreters, whether in-person, via phone, or video, bridge language gaps, enabling effective communication and promoting patient safety and satisfaction) as per facility's policy if the patient's preferred language was not English. NM 1 also said," No interpreter use was documented on this form. I don't speak Korean, so I don't know what is said here, but I don't see the interpreter identification (ID) documented. We have an English version of the form; should it be in the chart? I am not sure, but perhaps we should include a copy of the English version of the form to mirror the document. Per our policy, the patient signs in their own language, and we do have forms in the Korean language."

During a review of the facility's policy and procedure (P&P) titled, "Interpreter Service," dated 8/24/2024, the P&P indicated that, "Staff shall document in the patient's electronic health record the name of the interpreter and the interpreter identification (ID) number ... If the patient feels strongly that a family member or friend can interpret, staff shall make a notation in the patient's record that an offer of an interpreter was made and declined and enter the name of the person serving as interpreter at the patient's request."

During a review of the facility's policy and procedure (P&P) titled, "PATIENTS RIGHTS AND RESPONSIBILITIES," dated 3/2023, the P&P indicated that patients have the right to considerate and respectful care and the right to respect for their cultural ... preferences... They have the right to effective communication...

Based on interview and record review, the facility failed to ensure its nursing staff escalated an alleged physical abuse (including hitting, slapping, pinching, and kicking) to the house supervisor, for one of 30 sampled patients (Patient 6), in accordance with the facility's policy and procedure regarding abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish), when Patient 6 reported to Registered Nurse (RN 5) that Certified Nursing Assistant (CNA 5) punched Patient 6 in the face.

This deficient practice resulted in CNA 5 not being removed from the facility immediately and putting Patient 6 and other patients at risk for further abuse.

Findings:

During a review of Patient 6's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 1/19/2025, the H&P indicated, Patient 6 was admitted to the facility with diagnoses including but not limited to acute kidney injury (a sudden and often temporary loss of kidney function), right pleural effusion (excessive fluids accumulates in the area between the lungs and the chest wall), anemia (a condition marked by a deficiency of red blood cells or of hemoglobin [a protein found in red blood cells that carries oxygen from the lungs to the rest of the body] in the blood, resulting in pallor [pale] and weariness) and leukocytosis (high white blood cell count).

During an interview on 4/16/2025 at 10:19 a.m. with the Vice President of Quality and Risk Management (VPQRM), VPQRM stated the following: Patient 6 reported to the patient experience staff (individual whose primary focus is on ensuring a positive experience for patient and their families throughout their interactions with the facility) during morning round on 2/26/2025 that a Certified Nursing Assistant (CNA 5) punched him (Patient 6) in the face last night. The patient experience staff escalated to the department director (DIR 2) and triggered internal investigation.

During the same interview on 4/16/2025 at 10:19 a.m. with the Vice President of Quality and Risk Management (VPQRM), VPQRM stated CNA 5 was placed on suspension during the facility's investigation of the alleged abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish).

During an interview on 4/16/2025 at 11:08 a.m. with the Director (DIR 2) of Medical-Surgical (Med-Surg, general patient population hospitalized for various causes such as illness and surgery), DIR 2 stated the following: on 2/26/2025 at around 10 a.m. the patient experience staff informed him (DIR 2) about Patient 6's alleged abuse. He (DIR 2) interviewed Patient 6's primary nurse (RN 5) from night shift (6:45 p.m. to 6:45 a.m. shift) and found out Patient 6 had reported to RN 5 that CNA 5 punched him (Patient 6) on 2/26/2025 early morning around 5 or 6 a.m. RN 5 reported the alleged abuse to the charge nurse (CN 2). However, CN 2 did not escalate to the house supervisor on duty.

During the same interview on 4/16/2025 at 11:08 a.m. with the Director (DIR 2) of Medical-Surgical, DIR 2 stated RN 5 and CN 2 should have escalated to the house supervisor, so proper action could be taken including removing the alleged staff (CNA 5) from the facility immediately, for patient safety while conducting investigation.

During a concurrent interview and record review on 4/18/2025 at 3:47 p.m. with the Human Resources Manager (HRM), CNA 5's timecard record, dated 2/25/2025, was reviewed. The timecard record indicated, CNA 5 clocked in at 6:44 p.m. on 2/25/2025 and clocked out at 7:28 a.m. on 2/26/2025. HRM stated CNA 5 had completed the whole shift. HRM also stated CNA 5 should have been sent home immediately after the alleged abuse was reported in order to protect the patient and others.

During a review of the facility's policy and procedure (P&P) titled, "Abuse: Prevention, Identification, Investigation, and Protection," dated 6/2021, the P&P indicated, "In accordance with [the facility's] covenant of promoting and ensuring patients' rights, [the facility] is committed to take those steps within its control to prevent and protect patient from abuse and to investigate any suspected or actual incidence of abuse to patients ... The patient/resident shall be protected from further abusive behavior by the immediate removal of the offending party from patient care areas and immediately suspension of any staff member who threatens of willfully harms a patient ... This may include the immediate removal of any employee or staff member purportedly involved in the abuse/neglect and placing the individual(s) on investigatory suspension for the duration of the ensuing review. When an allegation of abuse is reported, the appropriate department or unit leader and/or administration shall be immediately notified."

Based on interview and record review, the facility failed to ensure its nursing staff developed a restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) care plan (a document that outlines an individual's assessed needs and the specific support or care required to meet those needs, ensuring the right level of care is provided) for one of 30 sampled patients (Patient 3), in accordance with the facility's policy and procedure regarding restraints use, when Patient 3 was placed on 4-point behavioral (bilateral [both] wrists and bilateral ankles) restraints.

This deficient practice had the potential to result in lack of monitoring regarding restraints use and the potential for inappropriate or prolonged restraints use, which may result in complications such as skin breakdown (damage to the skin and underlying tissue), psychological distress, etc.

Findings:

During a review of Patient 3's "Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) Notes (ED notes, assessment notes completed by ED physician)," dated 4/14/2025, the ED notes indicated, Patient 3 was brought to the facility's emergency Department by local law enforcement on 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for suicidal ideation (thought of harming self) and bizarre behavior (actions or conduct that are unusually strange, odd or unexpected). The ED notes also indicated, Patient 3 elbowed the wall, broke a plastic frame and attempted to get out of the gurney which resulted to being chemically sedated (medications given to calm down the patient) and restrained with 4-point (bilateral [both] wrists and bilateral ankles) restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) shortly after arrival to the ED.

During a review of Patient 3's "Physician Order Restraints," dated 4/14/2025, the "Physician Order Restraints" indicated, behavioral restraints with soft bilateral wrists and ankles (4-point restraint) was started on 4/14/2025 at 8:40 p.m. with indication for restraint (must identify the specific behavior requiring restraint such as harming self, hitting throwing objects): injury to self - attempting to kick and punch while being in hand cuffs; injury to others - with [local law enforcement], aggressive, combative, laughing hysterically."

During a review of Patient 3's "Restraint Flowsheet (documentation of restraints assessment and monitoring by nursing staff)," dated 4/14/2025, the restraint flowsheet indicated, the 4-point restraint was removed at 4:40 a.m. on 4/15/2025.

During a concurrent interview and record review on 4/18/2025 at 2:37 p.m. with the ED Clinical Educator (CE), Patient 3's "Outpatient Care Plan (a document that outlines an individual's assessed needs and the specific support or care required to meet those needs, ensuring the right level of care is provided)," dated 4/14/2025, was reviewed. The "Outpatient Care Plan" indicated, "primary problem was suicide (hurting self) self-restraint with interventions including environmental management, violence prevention, suicide prevention and potential physical restraint."
CE stated the following: the facility's electronic health record (EHR) had limited option of care plan for nursing staff to choose from. There was no care plan developed for Patient 3 after behavioral restraints was started. Nurse should have developed a restraint related care plan for Patient 3 to set goals and interventions in order to evaluate Patient 3's progress and determine when restraints could be safely removed and to avoid prolonged restraint use.

During a review of the facility's policy and procedure (P&P) titled, "Restraints: Violent Behavior," dated 12/2021, the P&P indicated, "To provide standardized procedure in which restraints are used for the provision of a safe patient environment. To ensure restraints are used safely, responsibly and minimally in accordance with regulations pertaining to patients' rights ... Policy ... 11. The use of restraint is ... in accordance with a written modification to the patient's plan of care ... Procedure ... 3. Behavioral Health Care restraint use is limited to the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others ... Documentation ... use available electronic health records (EHR) flow sheets and order forms and narrative notes to document all pertinent information in the medical record including but not limited to ... plan of care/ treatment - include criteria for discontinuation when applicable."

Based on interview and record review, the facility failed to ensure a physicians' order for restraints (any manual method, physical, mechanical device, material, or equipment that immobilized or reduces the ability of a patient to move his or her arms, legs, body, or head freely) included the indication for restraints for one of 30 sampled patients (Patients 23), in accordance with the facility's policy regarding restraints.

This deficient practice had the potential for patients to be restrained unnecessarily and may lead to lack of monitoring to determine if the restraints are still necessary in order to reduce or eliminate the need for restraints due to potential complications such as skin injury, circulation (blood flow) problems, psychological distress, etc.

Findings:

During a concurrent interview and record review on 4/16/2025 at 11:45 a.m. with the Nurse Manager (NM) 1, Patient 23's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/7/2025, and the physician orders, were reviewed. NM 1 stated Patient 23 was admitted to the facility on 4/6/2025 for altered mental status (a change in a person's usual level of mental function, encompassing changes in awareness, thinking, and behavior) and confusion. Patient 23 was diagnosed with hepatic encephalopathy (brain dysfunction due to liver dysfunction, when the liver is no longer able to remove toxins from the blood). Patient 23 was placed on soft restraints (any manual method, physical, mechanical device, material, or equipment that immobilized or reduces the ability of a patient to move his or her arms, legs, body, or head freely) to both wrists on 4/7/2025 and on 4/11/2025. NM 1 reviewed the physician's orders for the restraints and verified that the indication for the restraint was not documented in the physician's order. NM 1 stated that the physician order should indicate the reason for the use of restraints.

During a review of Patient 23's physician's order dated 4/7/2025 at 5:15 a.m., the physician's order indicated the following: Soft Wrist Right Restraint. The indication for the restraint was not documented on the order. This was verified with the Nurse Manager (NM 1) during an interview on 4/16/2025.

During a review of Patient 23's physician's order dated 4/7/2025 at 5:15 a.m., the physician's order indicated the following. Soft Wrist Left Restraint. The indication for the restraint was not documented on the order. This was verified with the Nurse Manager (NM 1) during an interview on 4/16/2025.

During a review of Patient 23's physician's order dated 4/11/2025 at 12:37 a.m., the physician's order indicated the following: Soft Wrist Right Restraint. The indication for the restraint was not documented on the order. This was verified with the Nurse Manager (NM) 1 during an interview on 4/16/2025.

During a review of Patient 23's physician's order dated 4/11/2025 at 12:37 a.m., the physician's order indicated the following. Soft Wrist Left Restraint. The indication for the restraint was not documented on the order. This was verified with the Nurse Manager (NM) 1 during an interview on 4/16/2025.

During a review of the facility's "Medical Staff Rules and Regulations," dated 10/31/2020, the Rules and Regulations indicated the following: Restraints. The Physician Order Restraints form must include ... Indication for restraints based on assessment ...

Based on interview and record review, the facility failed to ensure staff assessed and evaluated a patient's behavior when renewing a behavioral restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) order for one of 30 sampled patients (Patient 3), in accordance with facility's policy and procedure regarding restraints use, when the physician restraint renewal order and the nursing assessment did not indicate what was Patient 3's behavior, which was indicative of immediate danger to self or others that warrants the use of restraints.

This deficient practice resulted in unnecessary restraint use on Patient 3 from 12:40 a.m. to 4:40 a.m. (total four [4] hours) on 4/15/2025 and put Patient 3 at risk for injury including skin breakdown (damage to the skin, ranging from mild irritation to deep tissue injury, often caused by sustained pressure or moisture), emotional distress, etc.

Findings:

During a review of Patient 3's "Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) Notes (ED notes, assessment notes completed by ED physician)," dated 4/14/2025, the ED notes indicated, Patient 3 was brought to the facility's emergency Department by local law enforcement on 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for suicidal ideation (thought of harming self) and bizarre behavior (actions or conduct that are unusually strange, odd or unexpected). The ED notes also indicated, Patient 3 elbowed the wall, broke a plastic frame and attempted to get out of the gurney which resulted to being chemically sedated (medications given to calm down the patient) and restrained with 4-point (bilateral [both] wrists and bilateral ankles) restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body), shortly after arrival to the ED.

During a review of Patient 3's "Physician Order Restraints," dated 4/14/2025, the "Physician Order Restraints" indicated, behavioral restraints with soft bilateral wrists and ankles (4-point restraint) was started on 4/14/2025 at 8:40 p.m. with Indication for restraint (must identify the specific behavior requiring restraint such as harming self, hitting throwing objects): injury to self - attempting to kick and punch while being in hand cuffs; injury to others - with [local law enforcement], aggressive, combative, laughing hysterically."

During a review of Patient 3's "Restraint Flowsheet (restraints flowsheet, documentation of restraints assessment and monitoring by nursing staff)," dated 4/14/2025, the restraint flowsheet indicated, the 4-point restraint was removed at 4:40 a.m. on 4/15/2025.

During a concurrent interview and record review on 4/18/2025 at 11:58 a.m. with the Senior Ancillary Systems Analyst (SA 1), Patient 3's "Restraint Flowsheet," dated 4/14/2025, was reviewed. The restraint flowsheet indicated Patient 3's behavior as follows:
-At 9 p.m.: agitated (a state of feeling restless, uneasy, or irritable, often accompanied by physical symptoms like pacing or hand-wringing)/Restless (4/14/2025)
-At 11 p.m.: calm (4/14/2025)
-At 1 a.m.: awake and alert (4/15/2025)
-At 2 a.m.: awake and alert (4/15/2025)
-At 4 a.m.: awake and alert (4/15/2025)

During the same interview on 4/18/2025 at 11:58 a.m. with the Senior Ancillary Systems Analyst (SA 1), SA 1 stated the restraint flowsheet indicated Patient 3 was agitated only at 9 p.m. on 4/14/2025.

During an interview on 4/18/2025 at 12:55 p.m. with the ED Clinical Educator (CE), CE stated the following: nurse should monitor patient every fifteen (15) minutes while on behavioral restraints and document what patient's behavior warrants continued use of restraints. When patient was resting and calm, nurse should slowly remove restraints one limb at a time, start from lower extremities then to upper extremities. The goal was to remove restraints as early as possible.

During a concurrent interview and record review on 4/18/2025 at 5:17 p.m. with the Chief Nursing Officer (CNO), Patient 3's "Physician Order Restraints," dated 4/14/2025 and 4/15/2025, were reviewed. The "Physician Order Restraints" indicated the following:

-On 4/14/2025 at 8:40 p.m.: Behavioral Restraints Up to four (4) hours ... date restraints initiated: 4/14/2025; time restraints initiated: 8:40 p.m.;
Indication for restraint (must identify the specific behavior requiring restraint such as harming self, hitting throwing objects): injury to self - attempting to kick and punch while being in hand cuffs; injury to others - with [local law enforcement], aggressive, combative, laughing hysterically."

-On 4/15/2025 at 12:40 a.m.: Behavioral Restraints Up to four (4) hours ... date restraints initiated: 4/15/2025; time restraints initiated: 12:40 a.m.; Indication for restraint (must identify the specific behavior requiring restraint such as harming self, hitting throwing objects): injury to self - attempting to kick and punch while being in hand cuffs; injury to others - with [local law enforcement], aggressive, combative, laughing hysterically."

During the same interview on 4/18/2025 at 5:17 p.m. with the Chief Nursing Officer (CNO), the CNO stated the following: the behavior documented on the restraint renewal order on 4/15/2025 at 12:40 a.m. was the same as the initial restraint order (4 hours ago). It did not describe any specific behavior Patient 3 was exhibiting to warrant continuous use of behavioral restraints.

During a review of the facility's policy and procedure (P&P) titled, "Restraints: Violent Behavior," dated 12/2021, the P&P indicated, "To provide standardized procedure in which restraints are used for the provision of a safe patient environment. To ensure restraints are used safely, responsibly and minimally in accordance with regulations pertaining to patients' rights ... Policy ... 4. Restraint 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 ... 14. Restraints is discontinued by a trained Registered Nurse (RN) or Licensed Independent Practitioner (LIP) at the earliest possible time, regardless of the length of time identified in the order. Procedure ... 3. Behavioral Health Care restraint use is limited to the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others ... Documentation ... use available electronic health records (EHR) flow sheets and order forms and narrative notes to document all pertinent information in the medical record including but not limited to ... assessment and care provided ... circumstances that led to use restraint."

Based on interview and record review, the facility failed to ensure its nursing staff discontinued restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) use at the earliest possible time for one of 30 sampled patients (Patient 3), in accordance with the facility's policy and procedure regarding restraints use, when Patient 3 was placed on 4-point behavioral (bilateral [both] wrists and bilateral ankles) restraints from 8:40 p.m. to 4:40 a.m. (total right [8] hours) despite Patient 3 documented as being calm and sleeping most of the time from 9:15 p.m. to 4:45 a.m. (7.5 hours) during the restraint episode.

This deficient practice resulted in unnecessary restraint use on Patient 3 and put Patient 3 at risk for injury including skin breakdown (damage to the skin, ranging from mild irritation to deep tissue injury, often caused by sustained pressure or moisture) and emotional distress.

Findings:

During a review of Patient 3's "Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) Notes (ED notes, assessment notes completed by ED physician)," dated 4/14/2025, the ED notes indicated, Patient 3 was brought to the facility's emergency Department by local law enforcement on 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for suicidal ideation (thought of harming self) and bizarre behavior (actions or conduct that are unusually strange, odd or unexpected). The ED notes also indicated, Patient 3 elbowed the wall, broke a plastic frame and attempted to get out of the gurney which resulted to being chemically sedated (medications given to calm down the patient) and restrained with 4-point (bilateral [both] wrists and bilateral ankles) restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body), shortly after arrival to ED.

During a review of Patient 3's "Physician Order Restraints," dated 4/14/2025, the "Physician Order Restraints" indicated, behavioral restraints with soft bilateral wrists and ankles (4-point restraint), was started on 4/14/2025 at 8:40 p.m. with Indication for restraint (must identify the specific behavior requiring restraint such as harming self, hitting throwing objects): injury to self - attempting to kick and punch while being in hand cuffs; injury to others - with [local law enforcement], aggressive, combative, laughing hysterically."

During a review of Patient 3's "Restraint Flowsheet (restraints flowsheet, documentation of restraints assessment and monitoring by nursing staff)," dated 4/14/2025, the restraint flowsheet indicated, the 4-point restraint was removed at 4:40 a.m. on 4/15/2025.

During an interview on 4/15/2025 at 2:24 p.m. with Certified Nursing Assistant (CNA 1), CNA 1 stated a sitter (staff stay close to patient to perform constant observation) was required for patients on 5150-hold to provide constant observation. CNA 1 also stated a sitter would document the patient's behavior every 15 minutes on the "Suicide (thoughts of taking one's own life) Prevention Monitor Observation Flowsheet."

During a concurrent interview and record review on 4/18/2025 at 11:58 a.m. with the Senior Ancillary Systems Analyst (SA 1), Patient 3's "Restraint Flowsheet," dated 4/14/2025, was reviewed. The restraint flowsheet indicated Patient 3's behavior as follows:

-At 9 p.m.: agitated (a state of feeling restless, uneasy, or irritable, often accompanied by physical symptoms like pacing or hand-wringing)/Restless (4/14/2025)
-At 11 p.m.: calm (4/14/2025)
-At 1 a.m.: awake and alert (4/15/2025)
-At 2 a.m.: awake and alert (4/15/2025)
-At 4 a.m.: awake and alert (4/15/2025)

During the same interview on 4/18/2025 at 11:58 a.m. with the Senior Ancillary Systems Analyst (SA 1), SA 1 stated the restraint flowsheet indicated Patient 3 was agitated only at 9 p.m.

During a concurrent interview and record review on 4/18/2025 at 12:02 p.m. with the Senior Ancillary Systems Analyst (SA 1), Patient 3's "Suicide Prevention Monitor Observation Flowsheet (sitter flowsheet)," dated 4/14/2025, was reviewed. The sitter flowsheet indicated Patient 3's behavior as follows:

-9 p.m. behavior: awake and agitated (4/14/2025)
-9:15 p.m. to 9:45 p.m. behavior: awake and calm (4/14/2025)
-10 p.m. to 11:45 p.m. behavior: sleeping (4/14/2025)
-12 a.m. to 1 a.m. behavior: awake and calm (4/15/2025)
-1:15 a.m. to 4:45 a.m. behavior: sleeping (4/15/2025)

During the same interview on 4/18/2025 at 12:02 p.m. with the Senior Ancillary Systems Analyst (SA 1), SA 1 stated that based on sitter flowsheet, Patient 3 was asleep most of the time while on restraints.

During an interview on 4/18/2025 at 12:55 p.m. with the ED Clinical Educator (CE), CE stated the following: nurse should monitor patients every fifteen (15) minutes while on behavioral restraints and document what patient's behavior warrants continued use of restraints. When patient was resting and calm, nurse should slowly remove restraints one limb at a time, start from lower extremities then to upper extremities. The goal was to remove restraints as early as possible.

During a review of the facility's policy and procedure (P&P) titled, "Restraints: Violent Behavior," dated 12/2021, the P&P indicated, "To provide standardized procedure in which restraints are used for the provision of a safe patient environment. To ensure restraints are used safely, responsibly and minimally in accordance with regulations pertaining to patients' rights ... Policy ... 4. Restraint 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 ... 14. Restraints is discontinued by a trained Registered Nurse (RN) or Licensed Independent Practitioner (LIP) at the earliest possible time, regardless of the length of time identified in the order. Procedure ... 3. Behavioral Health Care restraint use is limited to the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others ... Assessment/Monitoring/ Care - Violent or Self-Destructive Restraints ... 2. Readiness of discontinuation of restraint - restraints are discontinued when the patient meet behavior criteria for their discontinuation - staff assist the patient to meet these criteria ... behavior criteria may include the ability of the patient to contract for safety; the patient is oriented to the environment and/or cessation of verbal threats ... Documentation ... use available electronic health records (EHR) flow sheets and order forms and narrative notes to document all pertinent information in the medical record including but not limited to ... assessment and care provided ... circumstances that led to use restraint"

Based on interview and record review, the facility failed to ensure its nursing staff assessed and monitored one of 30 sampled patients (Patient 3), upon initiation of behavioral restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body), in accordance with the facility's policy regarding restraints use, when nursing assessment started twenty (20) minutes after initiation of 4-point behavioral restraints (bilateral [both] wrists and bilateral ankles). There was no assessment completed/documented upon initiation of restraints at 8:40 p.m. on 4/14/2025.

This deficient practice resulted in nursing staff not assessing and monitoring Patient 3 during the first 20 minutes during the restraint episode and put Patient 3 at risk for injury including skin breakdown (damage to the skin, ranging from mild irritation to deep tissue injury, often caused by sustained pressure or moisture) and circulation (blood flow) problem.

Findings:

During a review of Patient 3's "Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) Notes (ED notes, assessment notes completed by ED physician)," dated 4/14/2025, the ED notes indicated, Patient 3 was brought to the facility's emergency Department by local law enforcement on 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for suicidal ideation (thought of harming self) and bizarre behavior (actions or conduct that are unusually strange, odd or unexpected). The ED notes also indicated, Patient 3 elbowed the wall, broke a plastic frame and attempted to get out of the gurney which resulted to being chemically sedated (medications given to calm down the patient) and restrained with 4-point (bilateral [both] wrists and bilateral ankles) restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body), shortly after arrival to the ED.

During a review of Patient 3's "Physician Order Restraints," dated 4/14/2025, the "Physician Order Restraints" indicated, behavioral restraints with soft bilateral wrists and ankles (4-point restraint) started on 4/14/2025 at 8:40 p.m. with Indication for restraint (must identify the specific behavior requiring restraint such as harming self, hitting throwing objects): injury to self - attempting to kick and punch while being in hand cuffs; injury to others - with [local law enforcement], aggressive, combative, laughing hysterically."

During a review of Patient 3's "Restraint Flowsheet (restraints flowsheet, documentation of restraints assessment and monitoring by nursing staff)," dated 4/14/2025, the restraint flowsheet indicated, the 4-point restraint was removed at 4:40 a.m. on 4/15/2025.

During an interview on 4/18/2025 at 12:55 p.m. with the ED Clinical Educator (CE), CE stated the following: nurse should monitor patients every fifteen (15) minutes while on behavioral restraints to ensure patient's safety.

During a concurrent interview and record review on 4/18/2025 at 5:25 p.m. with the Chief Nursing Officer (CNO), Patient 3's "Restraint Flowsheet," dated 4/14/2025, was reviewed. The restraint flowsheet indicated first nursing monitoring and assessment started at 9 p.m. on 4/14/2025. The CNO stated the assessment was done late. It should be done at 8:40 p.m. when the 4-point restraint was first initiated. The CNO also said the assessment was not done every fifteen (15) minutes per facility's policy. The CNO further said it was important to assess and monitor patient while on restraints to ensure patient's safety.

During a review of the facility's policy and procedure (P&P) titled, "Restraints: Violent Behavior," dated 12/2021, the P&P indicated, "To provide standardized procedure in which restraints are used for the provision of a safe patient environment. To ensure restraints are used safely, responsibly and minimally in accordance with regulations pertaining to patients' rights ... Policy ... 4. Restraint 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 ... 14. Restraints is discontinued by a trained Registered Nurse (RN) or Licensed Independent Practitioner (LIP) at the earliest possible time, regardless of the length of time identified in the order. Procedure ... Assessment/Monitoring/Care - Violent or Self-Destructive Restraints ... 1. A staff member who is trained and competent assesses the patient at the initiation of restraint and every 15 minutes thereafter to include as appropriate to the type of restraint: a. signs of injury associated with application of restraint b. nutrition and hydration c. circulation and range of motion in the extremities d. vital signs e. hygiene and elimination f. physical and psychological comfort."

Based on interview and record review, the facility failed to ensure its physician performed a face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]), within an hour after the initiation of 4-point (bilateral [both] wrists and bilateral ankles) behavioral restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body), for one of 30 sampled patients (Patient 3), in accordance with facility's policy and procedure regarding restraints use.

This deficient practice had the potential to result in lack of evaluation of Patient 3's response to behavioral restraints initiated including assessment for continued need for restraints and/or other interventions, which may result in unnecessary use of restraints and other complications such as skin tear, dehydration, psychological distress, etc.

Findings:

During a review of Patient 3's "Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) Notes (ED notes, assessment notes completed by ED physician)," dated 4/14/2025, the ED notes indicated, Patient 3 was brought to the facility's emergency Department by local law enforcement on 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for suicidal ideation (thought of harming self) and bizarre behavior (actions or conduct that are unusually strange, odd or unexpected). The ED notes also indicated, Patient 3 elbowed the wall, broke a plastic frame and attempted to get out of the gurney which resulted to being chemically sedated (medications given to calm down the patient) and restrained with 4-point (bilateral [both] wrists and bilateral ankles) restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body), shortly after arrival to the ED.

During a review of Patient 3's "Physician Order Restraints," dated 4/14/2025, the "Physician Order Restraints" indicated, behavioral restraints with soft bilateral wrists and ankles (4-point restraint) started on 4/14/2025 at 8:40 p.m. with Indication for restraint (must identify the specific behavior requiring restraint such as harming self, hitting throwing objects): injury to self - attempting to kick and punch while being in hand cuffs; injury to others - with [local law enforcement], aggressive, combative, laughing hysterically."

During a review of Patient 3's "Restraint Flowsheet (restraints flowsheet, documentation of restraints assessment and monitoring by nursing staff)," dated 4/14/2025, the restraint flowsheet indicated, the 4-point restraint was removed at 4:40 a.m. on 4/15/2025.

During a concurrent interview and record review on 4/18/2025 at 2:46 p.m. with the Emergency Department (ED) Physician (MD 2), Patient 3's ED notes, dated 4/14/2025, documented by ED Physician (MD 82), was reviewed. The ED notes indicated, "shortly after arrival, patient (Patient 3) elbowed the wall and broke a plastic frame, attempted to get out of the gurney. Patient (Patient 3) was subsequently chemically sedated and restrained with 4-point restraints ... On reassessment, patient is more calm and cooperative. Restraints have been removed."

During the same interview on 4/18/2025 at 2:46 p.m. with the Emergency Department (ED) Physician (MD 2), MD 2 stated the following: physician should be the one performing face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) after patient (Patient 3) was placed on behavioral restraints. The purpose of face-to-face assessment was to evaluate patient, assess cardiovascular (condition of heart and blood vessels) status and behavioral status, evaluate patient's response to restraints and determine the need for continuation of restraints. The face-to-face assessment should be done within an hour after behavioral restraint was initiated and documented in the notes. Based on ED notes by MD 82, it was unclear what time the reassessment was done because there was no time documented.

During a review of the facility's policy and procedure (P&P) titled, "Restraints: Violent Behavior," dated 12/2021, the P&P indicated, "To provide standardized procedure in which restraints are used for the provision of a safe patient environment. To ensure restraints are used safely, responsibly and minimally in accordance with regulations pertaining to patients' rights ... Policy ... 4. Restraint 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 ... Procedure ... Restraints Orders - Violent or Self Destructive ... Initiation of Restraints 1. The patient for whom restraint is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, is seen face-to-face as soon as possible, but no later than one (1) hour after the initiation of the intervention by a: a. physician ... 2. The face-to-face is to evaluate: a. the patient's immediate situation; b. the patient's reaction to the intervention; c. the patient's medical and behavioral condition; and e. the need to continue or terminate the restraints; f. the need for social services referral."

Based on interview and record review, the facility failed to ensure its physician documented a face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]), within an hour after the initiation of 4-point (bilateral [both] wrists and bilateral ankles) behavioral restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body), for one of 30 sampled patients (Patient 3), in accordance with facility's policy and procedure regarding restraints use.

This deficient practice had the potential to result in lack of evaluation of Patient 3's response to behavioral restraints initiated including assessment for continued need for restraints and/or other interventions, which may result in unnecessary use of restraints and other complication such as skin tear, dehydration, psychological distress, etc.

Findings:

During a review of Patient 3's "Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) Notes (ED notes, assessment notes completed by ED physician)," dated 4/14/2025, the ED notes indicated, Patient 3 was brought to the facility's emergency Department by local law enforcement on 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for suicidal ideation (thought of harming self) and bizarre behavior (actions or conduct that are unusually strange, odd or unexpected). The ED notes also indicated, Patient 3 elbowed the wall, broke a plastic frame and attempted to get out of the gurney which resulted to being chemically sedated (medications given to calm down the patient) and restrained with 4-point (bilateral [both] wrists and bilateral ankles) restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body), shortly after arrival to the ED.

During a review of Patient 3's "Physician Order Restraints," dated 4/14/2025, the "Physician Order Restraints" indicated, behavioral restraints with soft bilateral wrists and ankles (4-point restraint) started on 4/14/2025 at 8:40 p.m. with Indication for restraint (must identify the specific behavior requiring restraint such as harming self, hitting throwing objects): injury to self - attempting to kick and punch while being in hand cuffs; injury to others - with [local law enforcement], aggressive, combative, laughing hysterically."

During a review of Patient 3's "Restraint Flowsheet (restraints flowsheet, documentation of restraints assessment and monitoring by nursing staff)," dated 4/14/2025, the restraint flowsheet indicated, the 4-point restraint was removed at 4:40 a.m. on 4/15/2025.

During a concurrent interview and record review on 4/18/2025 at 2:46 p.m. with the Emergency Department (ED) Physician (MD 2), Patient 3's ED notes, dated 4/14/2025, documented by ED Physician (MD 82), was reviewed. The ED notes indicated, "shortly after arrival, patient (Patient 3) elbowed the wall and broke a plastic frame, attempted to get out of the gurney. Patient (Patient 3) was subsequently chemically sedated and restrained with 4-point restraints ... On reassessment, patient is more calm and cooperative. Restraints have been removed."

During the same interview on 4/18/2025 at 2:46 p.m. with the Emergency Department (ED) Physician (MD 2), MD 2 stated the following: physician should be the one performing face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) after patient (Patient 3) was placed on behavioral restraints. The purpose of face-to-face assessment was to evaluate patient, assess cardiovascular (condition of heart and blood vessels) status and behavioral status, evaluate patient's response to restraints and determine the need for continuation of restraints. The face-to-face assessment should be done within an hour after behavioral restraint was initiated and documented in the notes. Based on ED notes by MD 82, it was unclear what time the reassessment was done because there was no time documented.

During a review of the facility's policy and procedure (P&P) titled, "Restraints: Violent Behavior," dated 12/2021, the P&P indicated, "To provide standardized procedure in which restraints are used for the provision of a safe patient environment. To ensure restraints are used safely, responsibly and minimally in accordance with regulations pertaining to patients' rights ... Policy ... 4. Restraint 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 ... Procedure ... Restraints Orders - Violent or Self Destructive ... Initiation of Restraints 1. The patient for whom restraint is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, is seen face-to-face as soon as possible, but no later than one (1) hour after the initiation of the intervention by a: a. physician ... 2. The face-to-face is to evaluate: a. the patient's immediate situation; b. the patient's reaction to the intervention; c. the patient's medical and behavioral condition; and e. the need to continue or terminate the restraints; f. the need for social services referral... Documentation ... use available electronic health records (EHR) flow sheets and order forms and narrative notes to document all pertinent information in the medical record including but not limited to ... assessment and care provided ... circumstances that led to use restraint"

Based on interview and record review, the facility failed to ensure there was a documentation of patient's specific behavior for one of 30 sampled patients (Patient 3), in accordance with the facility's policy regarding restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) use, when the physician restraint renewal order and nursing assessment did not indicate what was Patient 3's behavior which was indicative of Patient 3 posing immediate danger to self or others that warrants the use of restraints.

This deficient practice resulted in unnecessary restraint use on Patient 3 from 12:40 a.m. to 4:40 a.m. (total four [4] hours) on 4/15/2025 and put Patient 3 at risk for injury including skin breakdown (damage to the skin, ranging from mild irritation to deep tissue injury, often caused by sustained pressure or moisture) and emotional distress.

Findings:

During a review of Patient 3's "Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) Notes (ED notes, assessment notes completed by ED physician)," dated 4/14/2025, the ED notes indicated, Patient 3 was brought to the facility's emergency Department by local law enforcement on 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for suicidal ideation (thought of harming self) and bizarre behavior (actions or conduct that are unusually strange, odd or unexpected). The ED notes also indicated, Patient 3 elbowed the wall, broke a plastic frame and attempted to get out of the gurney which resulted to being chemically sedated (medications given to calm down the patient) and restrained with 4-point (bilateral [both] wrists and bilateral ankles) restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body), shortly after arrival to the ED.

During a review of Patient 3's "Physician Order Restraints," dated 4/14/2025, the "Physician Order Restraints" indicated, behavioral restraints with soft bilateral wrists and ankles (4-point restraint) started on 4/14/2025 at 8:40 p.m. with Indication for restraint (must identify the specific behavior requiring restraint such as harming self, hitting throwing objects): injury to self - attempting to kick and punch while being in hand cuffs; injury to others - with [local law enforcement], aggressive, combative, laughing hysterically."

During a review of Patient 3's "Restraint Flowsheet (restraints flowsheet, documentation of restraints assessment and monitoring by nursing staff)," dated 4/14/2025, the restraint flowsheet indicated, the 4-point restraint was removed at 4:40 a.m. on 4/15/2025.

During a concurrent interview and record review on 4/18/2025 at 11:58 a.m. with the Senior Ancillary Systems Analyst (SA 1), Patient 3's "Restraint Flowsheet," dated 4/14/2025, was reviewed. The restraint flowsheet indicated Patient 3's behavior as follows:
-At 9 p.m.: agitated/ Restless (4/14/2025)
-At 11 p.m.: calm (4/14/2025)
-At 1 a.m.: awake and alert (4/15/2025)
-At 2 a.m.: awake and alert (4/15/2025)
-At 4 a.m.: awake and alert (4/15/2025)

During the same interview on 4/18/2025 at 11:58 a.m. with the Senior Ancillary Systems Analyst (SA 1), SA 1 stated the restraint flowsheet indicated Patient 3 was agitated only at 9 p.m. on 4/14/2025.

During an interview on 4/18/2025 at 12:55 p.m. with the ED Clinical Educator (CE), CE stated the following: nurse should monitor patients every fifteen (15) minutes while on behavioral restraints and document what patient's behavior warrants continued use of restraints. When patient was resting and calm, the nurse should slowly remove restraints one limb at a time, start from lower extremities then to upper extremities. The goal was to remove restraints as early as possible.

During a concurrent interview and record review on 4/18/2025 at 5:17 p.m. with the Chief Nursing Officer (CNO), Patient 3's "Physician Order Restraints," dated 4/14/2025 and 4/15/2025, were reviewed. The "Physician Order Restraints" indicated the following:

-On 4/14/2025 at 8:40 p.m.: Behavioral Restraints Up to four (4) hours ... date restraints initiated: 4/14/2025; time restraints initiated: 8:40 p.m.; Indication for restraint (must identify the specific behavior requiring restraint such as harming self, hitting throwing objects): injury to self - attempting to kick and punch while being in hand cuffs; injury to others - with [local law enforcement], aggressive, combative, laughing hysterically."

-On 4/15/2025 at 12:40 a.m.: Behavioral Restraints Up to four (4) hours ... date restraints initiated: 4/15/2025; time restraints initiated: 12:40 a.m.; Indication for restraint (must identify the specific behavior requiring restraint such as harming self, hitting throwing objects): injury to self - attempting to kick and punch while being in hand cuffs; injury to others - with [local law enforcement], aggressive, combative, laughing hysterically."

During the same interview on 4/18/2025 at 5:17 p.m. with the Chief Nursing Officer (CNO), the CNO stated the following: the behavior documented on the restraint renewal order on 4/15/2025 at 12:40 a.m. was the same as the initial restraint order (4 hours ago). It did not describe any specific behavior Patient 3 was exhibiting to warrant continuous use of behavioral restraints.

During a review of the facility's policy and procedure (P&P) titled, "Restraints: Violent Behavior," dated 12/2021, the P&P indicated, "To provide standardized procedure in which restraints are used for the provision of a safe patient environment. To ensure restraints are used safely, responsibly and minimally in accordance with regulations pertaining to patients' rights ... Policy ... 4. Restraint 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 ... 14. Restraints is discontinued by a trained Registered Nurse (RN) or Licensed Independent Practitioner (LIP) at the earliest possible time, regardless of the length of time identified in the order. Procedure ... 3. Behavioral Health Care restraint use is limited to the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others ... Documentation ... use available electronic health records (EHR) flow sheets and order forms and narrative notes to document all pertinent information in the medical record including but not limited to ... assessment and care provided ... circumstances that led to use restraint."

Based on interview and record review, the facility failed to ensure nursing staff documented the reason for placing on restraints (any manual method, physical, mechanical device, material, or equipment that immobilized or reduces the ability of a patient to move his or her arms, legs, body, or head freely), one of 30 sampled patients (Patient 23), in accordance with the facility's policy regarding restraints use.

This deficient practice had the potential for the patients to be restrained unnecessarily, which may result in complications such as skin breakdown (damage to the skin, ranging from mild irritation to deep tissue injury, often caused by sustained pressure or moisture), circulation (blood flow) problem, psychological distress, etc.

Findings:

During a concurrent interview and record review on 4/16/2025 at 11:45 a.m. with the Nurse Manager (NM) 1, Patient 23's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/7/2025, and the physician orders, were reviewed. NM 1 stated Patient 23 was admitted to the facility on 4/6/2025 for altered mental status (a change in a person's usual level of mental function, encompassing changes in awareness, thinking, and behavior) and confusion. Patient 23 was diagnosed with hepatic encephalopathy (brain dysfunction due to liver dysfunction, when the liver is no longer able to remove toxins from the blood). Patient 23 was placed on soft restraints (any manual method, physical, mechanical device, material, or equipment that immobilized or reduces the ability of a patient to move his or her arms, legs, body, or head freely) to both wrists on 4/7/2025 at 5 a.m. NM 1 verified the nursing documentation did not indicate the reason for use of the restraints on 4/7/2025 at 5 a.m. and 6 a.m. NM 1 also verified that the behavior that led to Patient 23 being placed on restraints was not documented on 4/7/2025 from 5 a.m. through 12 p.m.

During a review of a physician's order dated 4/7/2025 at 5:15 a.m., the physician's order indicated the following: Soft Wrist Right Restraint. The indication for the restraint was not documented on the order. This was verified with the Nurse Manager (NM) 1 during an interview on 4/16/2025.

During a review of a physician's order dated 4/7/2025 at 5:15 a.m., the physician's order indicated the following: Soft Wrist Left Restraint. The indication for the restraint was not documented on the order. This was verified with the Nurse Manager (NM) 1 during an interview on 4/16/2025.

During a review of Patient 23's Flowsheet (a tool for organizing and displaying patient data over time in a structured format) titled, "Daily Assessment Inquiry," dated 4/7/2025, the Flowsheet indicated the following. At 5 a.m., and 6 a.m., Patient 23 was on soft restraints to the right and left wrist. The indication for the restraints was not documented in the Flowsheet. This was verified with the Nurse Manager (NM) 1 during an interview on 4/16/2025.

During a review of the facility's policy and procedure (P&P) titled, "Restraints: Non-Violent Behavior," dated 8/2024, the P&P indicated the following. Document all patient information in the medical record including but not limited to ...circumstances that led to the use of restraints.

Based on interview and record review, the facility failed to ensure its Medical Staff reviewed the credentials (the process of verifying a healthcare professional's qualifications, education, training, and experience to ensure they are properly qualified to provide healthcare services) of six of 10 sampled candidates (physicians) eligible for reappointment to the Medical Staff and made recommendations to the Governing Board (They guide the hospital's direction by making strategic decisions and setting policies, and they are ultimately accountable for the safety and quality of care provided) on the reappointment of candidates prior to the Board approval, in accordance with the Medical Staff Bylaws (are a set of rules and regulations that govern the structure, conduct, and responsibilities of a hospital's medical staff. They define how the medical staff operates, including processes for credentialing, privileging, and decision-making. These bylaws are crucial for ensuring patient safety, maintaining quality of care, and managing the hospital's legal and regulatory obligations) The candidates were approved for continued membership in the Medical Staff and their clinical privileges were granted by the Governing Board despite the key steps of the credentialing and reappointment procedure being bypassed.

This deficient practice undermined the integrity of the Medical Staff credentialing process and called into question the current professional competence of the reappointed candidates, and thus the quality of medical care they provide, as the candidates were reappointed without examination of their credentials by the Medical Staff Credentials Committee and the Medical Executive Committee (MEC, primarily composed of physicians and other key medical staff members. It acts as a representative body for the medical staff, making decisions related to patient care, clinical policies, and physician performance) as required by the Medical Staff Bylaws. This in turn raised concern for potential risk of harm to patients under care of these reappointed practitioners.

Findings:

During a concurrent interview and record review on 4/16/2025 and 4/18/2025, in the presence of the Chief Medical Officer (CMO) and the Associate Director of Medical Staff (ADMS), the credential files of ten (10) selected sample of the facility's Medical Staff, were reviewed, with the assistance of Medical Staff Coordinator 1 (MSC1). The files of six (6) physicians (MD1, MD6, MD7, MD8, MD9, MD10) indicated these individuals' most recent reappointment to the Medical Staff and their requested clinical privileges had been approved by the Governing Board for sixty (60) days (2/1/2025 - 3/31/2025 for MD1, MD7, MD8, MD9; 4/1/2025 - 5/31/2025 for MD6, MD10). Additionally, the files showed four (4) of the physicians (MD1, MD7, MD8, MD9) had their 60-day reappointment with privileges (specific authorizations granted to healthcare practitioners, allowing them to perform certain clinical activities and procedures within a healthcare facility) extended for another 60 days (4/1/2025 - 5/31/2025). MSC1 stated that members were normally reappointed to the Medical Staff for two (2) years at a time but confirmed that the latest reappointment period of these six candidates spanned 60 days.

During an interview on 4/16/2025 at 2:20 p.m. with the Chief Medical Officer (CMO), the CMO explained that the credentials of candidates (the process of verifying a healthcare professional's qualifications, education, training, and experience to ensure they are properly qualified to provide healthcare services) for reappointment to the Medical Staff were normally reviewed by the department chairs, the Credentials Committee, and the Medical Executive Committee (MEC, primarily composed of physicians and other key medical staff members. It acts as a representative body for the medical staff, making decisions related to patient care, clinical policies, and physician performance) before any recommendations were made to the Governing Board on the reappointments, but at present, the Medical Staff does not have an official Credentials Committee Chair and since January of this year (2025), full MEC meetings have not been conducted because not all members of the MEC participated. The CMO stated that few of the officers were newly elected last year (2024), but the election was disputed, and at this time the Medical Staff does not have a full functioning MEC. The CMO added that the Governing Board, in an effort to resolve the dispute, had requested a meeting of the Joint Conference Committee (JCC) comprised of the Board, the President and the President-Elect of the MEC, but the President refused, and therefore the Board granted a temporary 60-day reappointment to candidates in order to maintain continued patient care.

During a telephone interview on 4/18/2025 at 9:35 a.m. with the Chief Executive Officer (CEO), who is a member of the Governing Board, the CEO stated that the issues with Medical Staff credentials stemmed from an issue with the Medical Staff election that was held at the end of last year (2024), following which the Chief of Medical Staff (the same individual who also holds the title of President of the Medical Staff and acts as Chairman of the MEC) canceled the MEC meeting and therefore the MEC never met in mid-January (2025) as normally scheduled. The CEO reported the Board requested an emergency meeting of the MEC in January (2025) to review the Medical Staff credentials but received no response from the MEC; hence the Board "had no choice but to be creative." The CEO stated that the Board (Governing Body) reviewed the credential files and granted a 2-month reappointment extension, adding that the Board sought and received advice from the facility's legal counsel prior to proceeding with this extension. The CEO further stated that in April (the current month), the Credentials Committee did meet, chaired by an Interim Chair, and the MEC met two days ago (4/16/2025).

During a concurrent interview and record review on 4/18/2025 at 3:15 p.m., selected Medical Staff credential files, were reviewed. The CMO reported that in April (2025), the Medical Staff had a "normal" credentialing and reappointment process, with the MEC having met two days ago and the Credentials Committee two weeks ago, the latter comprised of three (3) department chairs and three (3) elected officers who voted one of the MEC members-at-large to serve as the Interim Chair of the Committee for that meeting. The CMO stated that the plan at the moment, while the Medical Staff and the Board work to resolve the current issue of dispute, is to do the same in May for the Medical Staff credentialing and reappointment, with participation of the elected officers, department chairs, and interim chair. As for the future dates beyond May, the CMO was unable to comment on the facility's plans.

During a review of the Medical Staff Bylaws, last amended and approved by the Governing Board in October 2020, indicated under Section 7.3-3 "Reappointment Procedure:"

a) When a member of the Medical Staff is scheduled for biennial review, the Chairman of the Department, with his Department or a Committee thereof, shall review the application for the reappointment of the member and specifically concern itself with evaluation of the current professional competence, clinical judgment of the member, his participation in departmental activities relative to quality of patient care, and if available, relevant practitioner-specific data compared to aggregate data and performance measurement data, including morbidity and mortality data. The Department Chair then shall make a recommendation to the Credentials Committee specifically with regard to clinical privileges. When recommendation is for reduction in clinical privileges, the reason for such recommendation shall be stated and documented.

b) The extent of his participation in patient care, admission of patients, and consultation shall also be considered.

c) Prior to the meeting of the Medical Executive Committee, the Credentials Committee shall review the Departmental recommendation for reappointment of a member and shall also consider: his compliance with the Medical Staff Bylaws and Rules and Regulations, attendance at Medical Staff meetings, timely completion of records, his ethics and conduct, his cooperation with medical center personnel, his relation with other practitioners, and his general attitude towards patients, the medical center, and the public. [ ...]

d) The Medical Executive Committee meeting shall make written recommendation to the Governing Board, through the Chief Executive Officer concerning the reappointment, including the clinical privileges for the ensuing period. Where non-reappointment or a change in clinical privileges is recommended, the reasons for such recommendation shall be stated and documented.
Section 14.2-1 b) of the Bylaws lists the Medical Executive Committee Authority and Duties, which include: 9) To review the credentials of the applicants through Credentials Committee reports and make recommendations for Staff membership, assignments to Departments, and delineation of clinical privileges; 10) To review periodically all information available, (normally by means of Credentials and Department reports), regarding the performance and clinical competence of staff members and other practitioners with clinical privileges and as a result of such reviews to make recommendations for reappointments and renewal or changes in clinical privileges.

Based on interview and record review, the facility failed to ensure its Medical Executive Committee was held accountable for applying the criteria for privileging and appointment of eligible candidates and to make their recommendations, before the Governing Body makes a final decision to reappoint a practitioner to the medical staff when, its Medical Staff did not review the credentials (the process of verifying a healthcare professional's qualifications, education, training, and experience to ensure they are properly qualified to provide healthcare services) of six of 10 sampled candidates (physicians) eligible for reappointment to the Medical Staff and did not make recommendations to the Governing Board (They guide the hospital's direction by making strategic decisions and setting policies, and they are ultimately accountable for the safety and quality of care provided) on the reappointment of candidates prior to the Board approval, in accordance with the Medical Staff Bylaws (are a set of rules and regulations that govern the structure, conduct, and responsibilities of a hospital's medical staff. They define how the medical staff operates, including processes for credentialing, privileging, and decision-making. These bylaws are crucial for ensuring patient safety, maintaining quality of care, and managing the hospital's legal and regulatory obligations). The candidates were approved for continued membership in the Medical Staff and their clinical privileges were granted by the Governing Board despite the key steps of the credentialing and reappointment procedure being bypassed.

This deficient practice undermined the integrity of the Medical Staff credentialing process and called into question the current professional competence of the reappointed candidates, and thus the quality of medical care they provide, as the candidates were reappointed without examination of their credentials by the Medical Staff Credentials Committee and the Medical Executive Committee (MEC, primarily composed of physicians and other key medical staff members. It acts as a representative body for the medical staff, making decisions related to patient care, clinical policies, and physician performance) as required by the Medical Staff Bylaws. This in turn raised concern for potential risk of harm to patients under the care of these reappointed practitioners.

Findings:

During a concurrent interview and record review on 4/16/2025 and 4/18/2025, in the presence of the Chief Medical Officer (CMO) and the Associate Director of Medical Staff (ADMS), the credential files of ten (10) selected sample of the facility's Medical Staff, were reviewed, with the assistance of Medical Staff Coordinator 1 (MSC1). The files of six (6) physicians (MD1, MD6, MD7, MD8, MD9, MD10) indicated these individuals' most recent reappointment to the Medical Staff and their requested clinical privileges had been approved by the Governing Board for sixty (60) days (2/1/2025 - 3/31/2025 for MD1, MD7, MD8, MD9; 4/1/2025 - 5/31/2025 for MD6, MD10). Additionally, the files showed four (4) of the physicians (MD1, MD7, MD8, MD9) had their 60-day reappointment with privileges (specific authorizations granted to healthcare practitioners, allowing them to perform certain clinical activities and procedures within a healthcare facility) extended for another 60 days (4/1/2025 - 5/31/2025). MSC1 stated that members were normally reappointed to the Medical Staff for two (2) years at a time but confirmed that the latest reappointment period of these six candidates spanned 60 days.

During an interview on 4/16/2025 at 2:20 p.m. with the Chief Medical Officer (CMO), the CMO explained that the credentials of candidates (the process of verifying a healthcare professional's qualifications, education, training, and experience to ensure they are properly qualified to provide healthcare services) for reappointment to the Medical Staff were normally reviewed by the department chairs, the Credentials Committee, and the Medical Executive Committee (MEC, primarily composed of physicians and other key medical staff members. It acts as a representative body for the medical staff, making decisions related to patient care, clinical policies, and physician performance) before any recommendations were made to the Governing Board/Governing Body on the reappointments, but at present, the Medical Staff does not have an official Credentials Committee Chair and since January of this year (2025), full MEC meetings had not been conducted because not all members of the MEC participated. The CMO stated that few of the officers were newly elected last year (2024), but the election was disputed, and at this time the Medical Staff does not have a full functioning MEC. The CMO added that the Governing Board, in an effort to resolve the dispute, had requested a meeting of the Joint Conference Committee (JCC) comprised of the Board (Governing Board/Governing Body), the President and the President-Elect of the MEC, but the President refused, and therefore, the Board granted a temporary 60-day reappointment to candidates in order to maintain continued patient care.

During a telephone interview on 4/18/2025 at 9:35 a.m. with the Chief Executive Officer (CEO), who is a member of the Governing Board/Governing Body, the CEO stated that the issues with Medical Staff credentials, stemmed from an issue with the Medical Staff election that was held at the end of last year (2024), following which the Chief of Medical Staff (the same individual who also holds the title of President of the Medical Staff and acts as Chairman of the MEC) canceled the MEC meeting and therefore, the MEC never met in mid-January (2025) as normally scheduled.
The CEO reported the Board requested an emergency meeting of the MEC in January (2025) to review the Medical Staff credentials but received no response from the MEC; hence the Board "had no choice but to be creative." The CEO stated that the Board (Governing Body) reviewed the credential files and granted a 2-month reappointment extension, adding that the Board sought and received advice from the facility's legal counsel prior to proceeding with this extension. The CEO further stated that in April (the current month), the Credentials Committee did meet, chaired by an Interim Chair, and the MEC met two days ago (4/16/2025).

During a review of an untitled and undated document, provided by the facility to indicate which physicians had been granted a 2-month reappointment, the document indicated that seventy-four (74) physicians (MD 1, 7, 8, 9, 10, 12 - 81) were granted a 2-month reappointment. In addition, twenty-seven (27) of the 74 physicians (MD 1, 7, 8, 9, 13, 18, 19, 21, 23, 24, 26, 30, 31, 38, 42, 43, 45, 47, 55, 59, 63, 66, 67, 68, 73, 78, and 79) were granted a second (2nd) 2-month re-appointment, which is due to expire on 5/31/2025.

During a review of the facility's "Medical Staff Executive Committee," meeting minutes (a written record of what transpired during a meeting, including who attended, what was discussed, what decisions were made, and any action items assigned), the minutes indicated there were no meeting minutes documented for the month of January 2025.

During a review of the facility's "Medical Staff Executive Committee," meeting minutes, dated 2/19/2025, the minutes indicated the Committee chose not to recognize the Credentials Report, and did not review the report ...

During a review of the facility's "Governing Board," meeting minutes, dated 1/22/2025, the meeting minutes indicated that the Governing Board would expect to have a credentials report at this meeting to review and approve, but due to ongoing medical staff issues, the MEC meeting was cancelled in January 2025 ... The minutes also indicated that the medical staff is self-functioning and has a responsibility that they must address on a monthly basis. Presently, there is no MEC ...They (MEC) have cancelled their obligation of their work for January 2025, thus far ...MEC was asked to follow their Medical Staff Bylaws ...It was questioned whether it would make more sense not to act on credentials and such until this was resolved. While in essences this may be the case, not acting on credentials could allow physicians credentials to lapse, thereby not allowing those physicians to treat their patients. The Governing Board is in charge of the ultimate quality of the hospital and ensuring that policies and procedures, Bylaws, Rules and Regulations are being fulfilled. These Governing Body Minutes were reviewed and verified with the Chief Executive Officer (CEO) and the Secretary of the Board.

During a review of the facility's "Governing Board," meeting minutes, dated 2/26/2025, the meeting minutes indicated the following: The following items were voted on and approved off-cycle and require ratification: Resolution providing 60-day approval of physician's credentials. Approval was required due to lack of MEC meeting in January 2025.

During a review of "The Medical Staff Bylaws (are a set of rules and regulations that govern the structure, conduct, and responsibilities of a hospital's medical staff. They define how the medical staff operates, including processes for credentialing, privileging, and decision-making. These bylaws are crucial for ensuring patient safety, maintaining quality of care, and managing the hospital's legal and regulatory obligations)," last amended and approved by the Governing Board in October 2020, the Medical Staff Bylaws indicated under Section 7.3-3 "Reappointment Procedure," the following:
d) The Medical Executive Committee meeting shall make written recommendation to the Governing Board, through the Chief Executive Officer concerning the reappointment, including the clinical privileges for the ensuing period. Where non-reappointment or a change in clinical privileges is recommended, the reasons for such recommendation shall be stated and documented.

During a review of the facility's "Governing Board By-Laws," dated 1/12/2023, the Governing Board By-Laws indicated the following: Section 1. Duties and Functions Generally ...ii. Oversee and have ultimate accountability for the safety and quality of patient care, treatment, and services at the Hospital ...The Governing Board shall also take action as necessary to: ...Require the Medical Staff, including but not limited to the Medical Executive Committee, to follow the Medical Staff Bylaws; and Require the Medical Staff to fulfill its responsibility and accountability to the Governing Board ...Article VII, Medical Staff Appointments: Section 1. Governing Board Authority. The Governing Board shall have authority and responsibility for all appointments and reappointments of the Medical Staff members and assignment of clinical privileges in accordance with these Bylaws and the Medical Staff Bylaws ...

Based on interview and record review, the facility failed to:

1. Ensure that one of 30 sampled patients (Patient 12), who was admitted to the facility after sustaining a fall (an event which results in a person coming to rest inadvertently on the ground or floor or other lower level) when Patient 12 fell out of the bed and fractured a right 7th rib (broken rib), had their (Patient 12) reported pain level of 7 out of 10 (7/10- moderate pain) and 5 out of 10 (5/10-moderate pain) addressed, when Patient 12 was not provided an intervention ( any action taken to alleviate or manage pain) for pain relief, in accordance with the facility's policy regarding pain management.

This deficient practice resulted in Patient 12's pain not being managed and had the potential for Patient 12 to be in significant discomfort and prolonged suffering, leading to increased risk of complications associated with unmanaged pain, such as respiratory issues due to shallow breathing or avoidance of moving.

2. Ensure the pain level was assessed prior to and after administering a pain medication for two of 30 sampled patients (Patients 21 and 22), in accordance with the facility's policy regarding pain management.

This deficient practice had the potential for ineffective pain relief, which may result in functional limitations (Example: reduced Mobility, etc.), prolonged discomfort, prolonged hospital stay, anxiety, etc.

Findings:

1. During a review of Patient 12's medical record (MR) titled, " Triage (the process of rapidly evaluating patients in the emergency settings, to determine the urgency of their condition and prioritize their treatment based on a system of priorities)," dated 4/11/2025 at 9:10 p.m., the MR indicated that Patient 12 presented to the facility's Emergency Department (ED, a designated area within a hospital that provides immediate, specialized medical care to patients experiencing sudden, serious health issues or injuries) on 4/11/2025 with a complaint of confusion and a fractured (broken) right 7th rib. The MR also indicated that Patient 12 presented with pain level of 7 (0- no pain, Mild pain - 1-3; Moderate pain 4-7; Severe pain 8-10).

During a review of Patient 12's "Emergency Department (ED) Summary Report," dated 4/11/2025 through 4/12/2025, the report indicated that Patient 12 was assessed for the presence of pain at the following times:
On 4/11/2025 at 10:22 p.m.-Pain level was 7 (ribs)
On 4/11/2025 at 10:51 p.m.-Pain level was 5 (ribs)
On 4/12/2025 at 1:22 a.m.-Pain level was 5 (ribs)
On 4/12/2025 at 3:30 a.m.-Pain level was 5 (ribs)
On 4/12/2025 at 6:10 a.m.-Pain level was 5 (ribs).

During a concurrent interview and record review on 4/16/2025 at 11:18 a.m. with the Clinical Applications Specialist Nurse (CAS), Patient 12's medical record titled, "Emergency Department (ED) Summary Report (a concise document that summarizes a patient's experience in the Emergency Department )," dated 4/11/2025 through 4/12/2025, was reviewed. The CAS stated that during Patient 12's admission to the facility's emergency department (ED), Patient 12 had an order for 1000 milligrams (mg, measuring unit) of Tylenol (a pain-relieving medication for mild to moderate pain) to be given one time, but the medication was not administered. The CAS also stated that Patient 12's electronic medical record (EMR, digital version of paper chart) contained no nursing note indicating that Patient 12's pain was addressed and/or Patient 12 refused an intervention for the reported pain levels of 7/10 and 5/10 from 9:10 a.m. on 4/11/2025 through 6:10 a.m. on 4/12/2025.

During an interview on 4/18/2025 at 12:40 p.m. with the Emergency Department (ED) Clinical Educator (CE), the CE stated the following regarding pain management in the ED: "If a patient reports being in pain, the pain should be addressed. In the pain assessment flowsheet (a tool used to document a patient's pain assessment, including location, intensity, quality, and other relevant factors), located under the pain tab (a section in the electronic medical records [EMR] where all pain-related assessments and interventions are recorded) nurses document pain assessment where they ask patients about their acceptable pain level and document the response there. Intervention for pain is also documented under the same pain tab. Every patient has their pain assessed every two hours because pain level and patient's condition can change. Nursing interventions for pain can consist of providing a warm blanket or ice. Other interventions for pain should include notifying a physician, and this should also be documented under the MD (Medical Doctor) Notification tab, where nurses should record what was discussed with the provider, orders received, the name of the physician notified, and/or reasons why orders were not received."

During a review of the facility's policy and procedure (P&P) titled, "Pain Management," dated 9/2023, the P&P indicated the following: "Pain: An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Pain Management: Alleviation of pain or a reduction of pain to a level of comfort that is acceptable. For PRN (as needed) Pain Medication orders without specific pain scale, the following definitions will be utilized: Mild pain - Pain scale 1; Moderate pain - Pain scale of 4-7; Severe pain- Pain scale of 8-10. The experience of pain is highly individual and variable. The subjective level of pain will be assessed... The self-report of pain by the patient should be considered as evidence that pain is a problem to be addressed ... The nurse will utilize the assessment findings to initiate and or collaborate with physician in the appropriate non-invasive and invasive pharmacological modalities."
During a review of the facility's policy and procedure (P&P) titled, "Patient Rights and Responsibilities," dated 3/22/2023, the P&P indicated the following: "Patients have the right to receive appropriate assessment and management of their pain, information about pain, pain relief measures and to participate in pain management decisions..."

2.a. During a concurrent interview and record review on 4/16/2025 at 10:15 a.m. with the Nurse Manager (NM) 1, Patient 21's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/15/2025, was reviewed. NM 1 stated the following: Patient 21 was admitted to the facility on 4/15/2025 for weakness and headache. Patient 21 was medicated with Tylenol (acetaminophen, an over-the counter pain reliever) 500 milligrams (mg, a unit of measurement) on 4/16/2025 at 8:55 a.m. NM 1 verified that there was no pain assessment prior to or after the administration of Tylenol, which was ordered for a pain level of 1 - 3 (mild pain; [0- no pain, Mild pain - 1-3; Moderate pain 4-7; Severe pain 8-10]). NM 1 stated patients should be assessed for pain level prior to administering a pain medication to ensure the patient was medicated with the appropriate medication and should be reassessed an hour later to assess whether or not the pain medication was effective.

During a review of Patient 21's "History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/15/2025, the H&P indicated Patient 21 presented with generalized weakness and headache and was admitted for further treatment.

During a review of Patient 21's physician's order, dated 4/15/2025, the order indicated to give Tylenol 500 mg by mouth every 4 hours as needed for pain 1 - 3 (mild pain).

During a review of Patient 21's "Medication Administration Record (MAR)," dated 4/16/25025, the MAR indicated Tylenol 500 mg was given at 8:55 a.m. There was no pain assessment documented prior to or after the administration of Tylenol. This was verified with the Nurse Manager (NM) 1 during an interview on 4/16/2025.

During a review of the facility's policy and procedure (P&P) titled, "Pain Management," dated 5/2023, the P&P indicated the following ... Ongoing pain assessments is necessary to evaluate the changing nature of pain, as well as the effectiveness of treatments for pain. Pain should be reassessed before and after each intervention.

2.b. During a concurrent interview and record review on 4/15/2025 at 11:09 a.m. with the Nurse Manager (NM) 1, Patient 22's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/13/2025, was reviewed. NM 1 stated Patient 22 was admitted on 4/13/2025 with acute hyponatremia (low salt [sodium] in the blood is too low, can cause nausea [urge to vomit], confusion ...), dehydration (a dangerous loss of body fluid caused by illness, sweating, or inadequate intake) and stage 4 endometrial cancer (cancer that has spread beyond the uterus [womb] and other organs). Patient 22 received Ketorolac (a very strong nonsteroidal anti-inflammatory drug that treats moderately severe pain) 20 mg intravenously (IV, in the vein) for a pain level of 7 of 10 on 4/16/2025 at 1:23 a.m. There was no reassessment documented for efficacy. Patient also received Ketorolac 20 mg IV on 4/16/2025 at 9:14 a.m., no pain level was documented before and after the administration of the pain medication. NM 1 stated the pain level should be assessed before administering a pain medication and one hour later assess for efficacy.

During a review of Patient 22's physician's order, dated 4/16/2025 at 1:14 a.m., the physician's order indicated to give Ketorolac 20 mg, as needed for pain via intravenous push (in the vein).

During a review of Patient 22's MAR dated 4/16/2025, the MAR indicated the following:
-At 1:23 a.m., the pain level was 7/10, to the abdomen, upper quadrant, right internal..., Ketorolac 20 mg was administered via IV. There was no reassessment of the pain documented in the MAR.
-At 9:14 a.m., Ketorolac 20 mg was administered via IV. No pain assessment was documented prior to or one hour after administration of the medication.

During a review of the facility's policy and procedure (P&P) titled, "Pain Management," dated 5/2023, the P&P indicated the following ... Ongoing pain assessments is necessary to evaluate the changing nature of pain, as well as the effectiveness of treatments for pain. Pain should be reassessed before and after each intervention.

Based on interview and record review, the facility failed to formulate an individualized nursing care plan (a documented strategy that outlines patient care goals, interventions, and evaluations to address specific health issues and provides a means of communication among health care providers) for one of 30 sampled patients (Patient 22) to address Patient 22's high risk for falls (an event which results in a person coming to rest inadvertently on the ground or floor or other lower level), in accordance with the facility's policy regarding plan of care.

This deficient practice had the potential for the lack implementation of fall precautions (a multi-faceted approach to minimize the risk of falls, encompassing universal interventions for all patients, as well as individualized strategies based on specific risk factors. These precautions include ensuring a safe environment, assisting with mobility, and educating patients and their families) for Patient 22, which could result in a fall and possible serious injury or harm such fracture (broken bones), etc.

Findings:

During a concurrent interview and record review on 4/15/2025 at 11:09 a.m. with the Nurse Manager (NM) 1, Patient 22's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/13/2025, was reviewed. NM 1 stated Patient 22 was admitted on 4/13/2025 with acute hyponatremia (low salt [sodium] in the blood is too low, can cause nausea [urge to vomit], confusion ...), dehydration (a dangerous loss of body fluid caused by illness, sweating, or inadequate intake) and stage 4 endometrial cancer (cancer that has spread beyond the uterus [womb] and other organs). The initial nursing assessment indicated Patient 22 was at high risk for fall (an event which results in a person coming to rest inadvertently on the ground or floor or other lower level). NM 1 verified that a care plan for falls was not developed to address Patient 22's high risk for falls. NM 1 stated the care plan should have been developed within 12 hours of admission, to provide independent nursing care to help the patient (Patient 22) get back to their baseline.

During a review of Patient 22's "Initial Nursing Assessment," dated 4/13/2025 at 2:15 p.m., the nursing assessment indicated Patient 22 was at high risk of falls with a score of 45.

During a review of Patient 22's "Care Plans," initiated on 4/13/2025, the Care Plans indicated there was no care plan addressing Patient 22's high risk for falls. This was verified by NM 1 during an interview on 4/15/2025.

During a review of the facility's policy and procedure (P&P) titled, "Plan of Care Documentation, Interdisciplinary," dated 8/2022, the P&P indicated the following: Purpose: To provide guidelines in completing the Interdisciplinary care plan to ensure that each patient has a completed care plan period ...The Interdisciplinary plan of care should include:
A. The RN initiates the Interdisciplinary plan of care after completion of the initial assessment. The plan of care is initiated within 12 hours of patient's admission ...
B. The Interdisciplinary plan of care will be updated every shift and as patient condition indicates.

During a review of the facility's policy and procedure (P&P) titled, "Fall Prevention and Management," dated 4/24/2024, the P&P indicated the following: Assessment and Reassessment.
1. The patient's fall risk will be assessed at the time of initial physical assessment, at the time of admission, every shift, upon transfer to another level of care, and after a patient fall.
2. Evidence-based fall risk interventions will be implemented based upon an age-appropriate fall risk assessment tool.

Based on interview and record review the facility failed to ensure that one of 30 sampled patients (Patient 12), had their (Patient 12) pain assessment (the systemic evaluation of a patient's pain experience, including intensity, location, quality, and acceptable level of pain) performed/assessed every four hours along with vital signs (VS, measurements of essential bodily functions including hear rate, blood pressure, respiratory rate, and temperature), in accordance with the facility's policy and procedure regarding pain assessment and management.

This deficient practice had the potential for Patient 12's pain to be inadequately managed, leading to Patient 12's prolonged discomfort and suffering, and a negative impact on the patient's overall recovery (delayed healing process).

Findings:

During a review of Patient 12's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 4/12/2025, the H&P indicated that Patient 12 was admitted to the facility on 4/12/2025 with right chest wall pain, after falling off the bed. The H&P further indicated that Patient 12 had past medical history (PMH, a patient's previous medical conditions, surgeries, hospitalizations, and treatments) of dementia (a condition characterized by progressive or persistent loss of intellectual functioning), hypertension (a condition in which the force of blood against the walls of the arteries is consistently too high causing elevated blood pressure), and history of stroke (occurs when blood flow to a part of the brain is interrupted or reduced, causing damage to brain tissue).

During further review of Patient 12's History and Physical (H&P), dated 4/12/2025, the H&P indicated that Patient 12 had multiple rib fractures (refer to three or more broken ribs).

During a concurrent interview and record review on 4/6/2025 at 10:18 a.m. a.m. with the Clinical Applications Specialist (CAS), Patient 12's medical record titled, "Vitals Inquiry (refers to the collection and documentation of patient's vital signs, [VS, measurements of the body's basic functions, including body temperature, pulse rate, respiration rate, and blood pressure])," dated 4/12/2025 (01:22 a.m.) to 4/16/2025 (8:00 a.m.), was reviewed. The record indicated that Patient 12's VS (body temperature, pulse rate, respiratory rate [breaths per minute], and blood pressure [BP, the force of your blood pushing against the walls of your arteries as your heart pumps blood throughout your body]), were obtained and recorded every four hours. CAS stated that Patient 12's record had no documentation of a pain assessment being performed and recorded every 4 hours (along with vital signs) in Patient 12's electronic medical record (EMR).

During an interview on 4/16/2025 at 11:11 a.m., with nurse manager (NM 1), NM 1 stated that patients were assessed for the presence or absence of pain every four hours (along with vital signs [VS]), and pain assessment should be recorded, along with vital signs (VS), in the patients' medical record, in accordance with the facility's protocol.

During a review of the facility's policy and procedure (P&P) titled, "Pain Management," dated 9/2023, the P&P indicated the following: The effective treatment of pain is contingent upon an accurate pain assessment. The features of pain assessment include Assessments of pain are communicated using both verbal report and written documentation ...The nurse and patient will collaboratively establish a desirable "Comfort Zone" utilizing a pain scale ... Assess pain as the 5th vital sign and as needed ... Assess pain each time vital signs are assessed ... Evaluate the efficacy of behavioral, environmental, and pharmacological interventions in a timeframe appropriate to the intervention.

During a review of the facility's policy and procedure (P&P) titled, "Pain Management," dated 9/2023, the P&P indicated the following: "Documentation of pain assessment/reassessment is to be documented in the Electronic Medical Record (EMR) under:
a. The initial and daily assessments
b. Nurse's notes.
c. With vital signs

Based on interview and record review, the facility failed to ensure one of 30 sampled patients (Patient 21), who complained of moderate pain (4 - 7 rate out of 10 on the pain scale), was treated with a pain medication ordered to treat moderate pain, in accordance with the facility's policy regarding pain management. Instead, Patient 21 was treated with a pain medication (Tylenol, an over-the-counter pain medication), which was ordered to treat mild pain and not moderate pain.

This deficient practice resulted in inadequate pain relief for Patient 21, which also has the potential to result in prolonged discomfort, psychological distress, etc.

Findings:

During a concurrent interview and record review on 4/16/2025 at 10:15 a.m. with the Nurse Manager (NM) 1, Patient 21's Medication Administration Record (MAR), dated 4/15/2025, was reviewed. NM 1 stated the following: Patient 21 was admitted to the facility on 4/15/2025 for weakness and headache. The physician ordered Tylenol 500 mg (milligrams, a unit of measurement) as needed for mild pain (1-3 out of 10 on the pain scale). The Medication Administration Record (MAR), dated 4/15/2025 at 3:48 p.m., indicated Patient 21 received Tylenol (acetaminophen, an over-the-counter pain medication) 500 milligrams (mg) for a pain level of 5 (moderate pain). NM 1 verified there was no pain medication ordered for moderate pain (4-7) and stated the nurse should have called the physician to obtain a pain medication order to treat Patient 21's moderate pain, instead of treating Patient 21 with a medication (Tylenol) intended to treat mild pain. On 4/15/2025 at 5:36 p.m., the pain was reassessed at 3 (mild pain). NM 1 stated Patient 21 was not appropriately treated for Patient 21's pain level.

During a review of Patient 21's "History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/15/2025, the H&P indicated Patient 21 presented with generalized weakness and headache and was admitted for further treatment.

During a review of Patient 21's physician's order, dated 4/15/2025, the order indicated to give Tylenol 500 mg by mouth every 4 hours as needed for pain 1 - 3 (mild pain).

During a review of Patient 21's "MAR (Medication Administration Record)," dated 4/15/25025, the MAR indicated Tylenol 500 mg was given at 3:48 p.m., for a pain level of 5 (moderate pain). At 5:36 p.m., Patient 21's pain level was reassessed at 3 (mild).

During a review of the facility's policy and procedure (P&P) titled, "Pain Management," dated 5/2023, the P&P indicated the following ... Assessment: The effective treatment of pain is contingent upon an accurate pain assessment. The patient's report of pain. Pain is an extremely subjective experience therefore: the patient is the best judge of the intensity and relief of pain. Ongoing pain assessments is necessary to evaluate the changing nature of pain, as well as the effectiveness of treatments for pain. Pain should be reassessed before and after each intervention.

During a review of the facility's policy and procedure (P&P) titled, "Medication System Pharmacy Responsibilities," dated 9/28/2022, the P&P indicated each new order should be carefully reviewed for clarity and therapeutic correctness. All unclear orders or unusual dosages should be questioned and brought to the attention of the prescriber.

Based on interview and record review, the facility failed to ensure that the medical record for one of 30 sampled patients (Patient 14), contained pertinent information when:

1. The administration site for 10 milligrams (mg, measuring unit) of Haldol (a medication used to treat various psychiatric conditions [behavior, mood, thoughts, and perception]), for one of 30 sampled patients (Patient 14), was not documented, in accordance with the facility's policy regarding documentation of medication administration.

This deficient practice had the potential to compromise Patient 14's safety due to lack of communication among healthcare providers and lack of monitoring for the potential adverse events and complications at the injection site (Example: infection, nerve damage, allergic reactions, etc.).

2. There was no correctly filled out behavioral restraint (interventions used to manage violent or self-destructive behaviors that pose an immediate threat to the individual or others) physician order(s) and restraint assessment documentation containing all the necessary elements (justification for restraint use, type of restraints, duration of restraint, monitoring requirements, and alternatives considered), for one of 30 sampled patients (Patient 14), in accordance with the facility's policy and procedure regarding behavioral restraints assessment and documentation.

This deficient practice had the potential to result in Patient 14's increased risk of harm due to inappropriate continuation of restraints, exposing the patient (Patient 14) to physical and psychological harm. Additionally, without proper assessment and documentation, changes in Patient 14's condition may go unnoticed, increasing the risk of complications such as injury (example: skin breakdown- damage to the skin, ranging from mild irritation to deep tissue injury, often caused by sustained pressure or moisture`), emotional distress and/or death.

Findings:

1. During a review of Patient 14's History of Present Illness (HPI, refers to a detailed narrative of a patient's current health problem, including when it began, the symptoms experienced, and any changes over time), dated 4/14/2025, the HPI indicated that Patient 14 was admitted to the emergency department (ED, a designated area within a hospital that provides immediate, specialized medical care to patients experiencing sudden, serious health issues or injuries) on 4/14/2025 due to a complaint of altered mental status (AMS, a significant change in a person's normal cognitive [thinking, reasoning, remembering] function) and concerns for hallucinations ( an experience involving the apparent perception of something not present).

During a review of Patient 14's Medication Administration Record (MAR), dated 4/16/2025, the MAR indicated that Patient 14 was given 10 milligrams (mg, measuring unit) of Haldol (a medication used to treat various psychiatric conditions) for psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality) that was ordered to be given intramuscularly (IM, within or into a muscle, specifically referring to the action of administering something (like a medication) into the muscle tissue).

During an interview on 4/16/2025 at 11:50 a.m. with Clinical Applications Specialist Nurse (CAS), CAS reviewed Patient 14's Medication Administration Record (MAR), dated 4/16/2025, for the administration of 5 mg of Haldol (administered on 4/16/2025 at 6:58 a.m.), and verified that the nurse who administered 10 mg of Haldol via intramuscular (IM), did not document the administration site in the MAR in the allocated space.

During an interview on 4/18/2025 at 12:56 p.m. with the Clinical Educator Nurse (CE), the CE stated the following regarding the documentation of an injection site when administering intramuscular (IM) medications: "The administration site for IM medications should be documented in the MAR. If a patient develops a reaction such as infection or cellulitis (a bacterial infection of the deeper layers of skin and underlying tissues) at the injection site, we are able to trace back to identify the specific location of the injection (crucial for assessing potential causes of any adverse reactions and ensuring appropriate follow-up care or interventions)."

During a review of the facility's policy and procedure (P&P) titled, "Medication System Nursing Responsibilities and Administration Guidelines," dated 9/2022, the P&P indicated the following: "Each professional administering a medication to a patient has the responsibility to accurately document... proper administration as prescribed in the patient's electronic Medication Administration Record (MAR)..."

2. During a review of Patient 14's History of Present Illness (HPI, refers to a detailed narrative of a patient's current health problem, including when it began, the symptoms experienced, and any changes over time), dated 4/14/2025, the HPI indicated that Patient 14 was admitted to the emergency department (ED, a designated area within a hospital that provides immediate, specialized medical care to patients experiencing sudden, serious health issues or injuries) on 4/14/2025 due to a complaint of altered mental status (AMS, a significant change in a person's normal cognitive function) and concerns for hallucinations (an experience involving the apparent perception of something not present).

During a review of Patient 14's medical record (MR) titled, "5150 Hold (a 72-hour involuntary detention period for mentally distressed individuals in approved facilities)," dated 4/15/2025, the MR indicated that Patient 14 was placed on the involuntary 5150 hold on 4/15/2025 at 1:00 p.m. due to danger to self and gravely disabled (GD, means a condition where a person, as a result of a mental health disorder or a severe substance use disorder, is unable to provide for their basic needs for food, clothing, or shelter, or cannot provide for their personal safety or necessary medical care) and required transfer to a psychiatric facility for further treatment and evaluation.

During a review of Patient 14's medical record (MR), on 4/16/2025 at 11:50 a.m., with the Clinical Applications Specialist Nurse (CAS), Patient 14's medical record titled, "Physician's Orders," dated 4/15/2025 a.m., was reviewed. The MR indicated that Patient 14 had four (4) orders for a Restraint Device: 1. Soft Wrist Right, 2. Soft Wrist Left; 3. Soft Ankle Right and 4. Soft Ankle Left: placed at 1:54 a.m. on 4/15/2025. The order did not indicate whether the restraints were classified as violent or non-violent (which is crucial for determining the appropriate context and guidelines for use: Violent restraints applied when a patient poses an immediate threat to themselves or others due to aggressive behavior, while non-violent restraints are used to prevent patients from inadvertently harming themselves due to medical conditions or lack of capacity to understand risks). Additionally, the order did not contain an explanation of the justification for the use of restraints. The CAS verified that the four orders for a Restraint Device, did not indicate whether the order was meant for violent or non-violent restraints use and did not indicate the justification for the use of 4-point restraints (use of restraints on all four limbs simultaneously). The CAS stated that no other orders for restraints were found in Patient 14's electronic medical record (EMR) from 4/12/2025 through 4/16/2025.

During a concurrent interview and record review on 4/16/2025 at 11:50 a.m. with the Clinical Applications Specialist Nurse (CAS), Patient 14's Electronic Medical Record (EMR) was reviewed to locate the documentation of the 4-point restraint assessment (a comprehensive evaluation to ensure the use of restraints is justified, monitored, and evaluated according to facility's policy). The CAS stated that no documentation of patient 14's restraint assessment was found recorded on 4/15/2025 in Patient 14's EMR.

During a concurrent interview and record review on 4/16/2025 at 11:55 a.m. with the Clinical Applications Specialist Nurse (CAS), Patient 14's medical record (MR) titled, "Social Worker Notes," dated 4/16/2025 at 11:02 a.m., was reviewed. The MR indicated that Patient 14 was placed on four-point restraints and sedated (the process of using medication to induce a state of calmness, relaxation, or drowsiness) due to agitation (a state of feeling restless, uneasy, or irritable, often accompanied by physical symptoms like pacing or hand-wringing).

During a concurrent interview and record review on 4/18/2025 at 9:19 a.m. with the Nurse Manager (NM 1), Patient 14's paper charting documentation of the restraint assessment was reviewed, and the assessment indicated the following:
-On 4/14/2025, Patient 14 was in 4-point restraints from 9:00 p.m. through 4/15/2025 at 5:00 a.m. due to being aggressive and combative.
-On 4/16/2025 Patient 14 was in 4-point restraints at 12:02 p.m. for 1 hour and 15 minutes due to aggressive behavior. Blood pressure was obtained at 12:02 p.m., and Patient 14 was documented to be agitated and combative.

During the same interview on 4/18/2025 at 9:19 a.m. with the Nurse Manager (NM) 1, NM 1 stated that according to Patient 14's assessment record, Patient 14's restraint assessment documentation was recorded every two hours, and only visual observations were initialed every 15 minutes (min) during the time Patient 14 remained in behavioral restraints (behavioral restraints are interventions used to manage violent or self-destructive behaviors that pose an immediate threat to the individual or others).

During a concurrent interview and record review on 4/18/2025 at 10:41 a.m. with the Director of the Emergency Department (Dir 1), Patient 14's Physician's Restraint Orders (paper format), dated 4/14/2025 through 4/16/2025, were reviewed. The Dir 1 reviewed the orders and confirmed that Patient 14 was placed in behavioral 4-point restraints, that were meant to be applied for up to 4 hours, due to combative and aggressive behavior. The Dir 1 also stated that the criteria for discontinuing restraints was not marked on the physician's order form for restraints. The Dir 1 stated that Physician's Restraint Orders were not filled out correctly. The Dir 1 said: "The physician should define the type of restraints to be applied and indicate when the restraints can be discontinued. For violent restraints, assessment of the patient should be done every 15 min, and patient should be one- to-one (1:1, a nurse provides constant supervision and direct care to a single patient) with the nurse. The criteria for discontinuation of the restraints should be specified and documented on the physician's order. The Dir 1 then reviewed the facility's policy regarding violent restraint use and stated, "Violent restraint orders can be placed for up to 4 hours, and the criteria for the discontinuation of the order should be specified by the physician. Assessment should be done every 15 minutes, according to the policy."

During an interview on 4/18/2025 at 12:40 p.m. with the Emergency Department (ED) Clinical Educator (CE), the CE stated the following regarding violent and non-violent restraints orders and the required restraints assessments: "Physicians are used to signing the paper order form for placing orders for restraints, but the expectations for the physicians are to place orders for restraints in the patient's electronic medical record. We only recently had our annual skills fair training on restraints, where we discussed the non-violent versus (vs) violent restraints orders and assessments. The order for violent (behavioral restraints) should be renewed every 4 hours and placed in EMR as well. Part of the assessment for violent restraints is to assess and document justification for restraint use, vital signs (VS), level of consciousness, skin condition and patient's condition every 15 minutes." The CE also stated that nurses can and should document restraints assessment in the patients' the electronic medical records (EMR).

During a review of the facility's policy and procedure (P&P) titled, "Restraints: VIOLENT Behavior," dated 12/2021, the P&P indicated the following: "3. Behavioral Health Care restraint use is limited to the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others.
ASSESSMENT / MONITORING / CARE - Violent or Self-Destructive Restraints

1. A staff member who is trained and competent assesses the patient at the initiation of restraint and every 15 minutes thereafter to include as appropriate to the type of restraint:
a. Sign of injury associated with application of restraint
b. Nutrition and hydration
c. Circulation and range of motion in the extremities
d. Vital signs
e. Hygiene and elimination
f. Physical and psychological comfort

2. Readiness for discontinuation of restraint - restraints are discontinued when the patient meets behavior criteria for their discontinuation - staff assist the patient to meet these criteria
a. Behavior criteria may include the ability of the patient to contract for safety; the patient is oriented to the environment and/or cessation of verbal threats.

3. Monitoring is done through continuous in-person observation by an assigned staff member who is competent and trained (see training section).

Documentation:
Use available electronic health records {EHR) flow sheets and order forms and narrative notes to document all pertinent information in the medical record including but not limited to:
- Assessments and care provided
- Alternative attempted
- Circumstances that led to use restraint/seclusion
- Physician/family notifications
- Monitoring activities - include each 15 min assessment as applicable..."

Based on interview and record review, the facility failed to ensure there was documentation of a patient's specific behavior for one of 30 sampled patients (Patient 3), when the physician restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) renewal order and the nursing assessment, did not indicate what was Patient 3's behavior that would indicate that Patient 3 was posing immediate danger to self or others, in accordance with the facility's policy regarding restraints use and documentation.

This deficient practice resulted in unnecessary restraint use on Patient 3 from 12:40 a.m. to 4:40 a.m. (total four [4] hours on 4/15/2025) and put Patient 3 at risk for injury including skin breakdown (damage to the skin, ranging from mild irritation to deep tissue injury, often caused by sustained pressure or moisture), emotional distress, etc.

Findings:

During a review of Patient 3's "Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) Notes (ED notes, assessment notes completed by ED physician)," dated 4/14/2025, the ED notes indicated, Patient 3 was brought to the facility's emergency Department by local law enforcement on 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for suicidal ideation (thought of harming self) and bizarre behavior (actions or conduct that are unusually strange, odd or unexpected).
The ED notes also indicated, Patient 3 elbowed the wall, broke a plastic frame and attempted to get out of the gurney which resulted to being chemically sedated (medications given to calm down the patient) and restrained with 4-point (bilateral [both] wrists and bilateral ankles) restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) shortly after arrival to ED.

During a review of Patient 3's "Physician Order Restraints," dated 4/14/2025, the "Physician Order Restraints" indicated, behavioral restraints with soft bilateral wrists and ankles (4-point restraint) were started on 4/14/2025 at 8:40 p.m. with Indication for restraint (must identify the specific behavior requiring restraint such as harming self, hitting throwing objects): injury to self - attempting to kick and punch while being in hand cuffs; injury to others - with [local law enforcement], aggressive, combative, laughing hysterically."

During a review of Patient 3's "Restraint Flowsheet (restraints flowsheet, documentation of restraints assessment and monitoring by nursing staff)," dated 4/14/2025, the restraint flowsheet indicated, the 4-point restraint was removed at 4:40 a.m. on 4/15/2025.

During a concurrent interview and record review on 4/18/2025 at 11:58 a.m. with the Senior Ancillary Systems Analyst (SA 1), Patient 3's "Restraint Flowsheet," dated 4/14/2025, was reviewed. The restraint flowsheet indicated Patient 3's behavior as followed:
At 9 p.m.: agitated (a state of feeling restless, uneasy, or irritable, often accompanied by physical symptoms like pacing or hand-wringing)/Restless
-At 11 p.m.: calm
-At 1 a.m.: awake and alert (4/15/2025)
-At 2 a.m.: awake and alert (4/15/2025)
-At 4 a.m.: awake and alert (4/15/2025)

During the same interview on 4/18/2025 at 11:58 a.m. with the Senior Ancillary Systems Analyst (SA 1), SA 1 stated the restraint flowsheet indicated Patient 3 was agitated only at 9 p.m. on 4/14/2025.

During an interview on 4/18/2025 at 12:55 p.m. with the ED Clinical Educator (CE), CE stated the following: nurse should monitor patients every fifteen (15) minutes while on behavioral restraints and document patient's behavior that warrant continued use of restraints. When patient was resting and calm, nurse should slowly remove restraints one limb at a time, start from lower extremities then to upper extremities. The goal was to remove restraints as early as possible.

During a concurrent interview and record review on 4/18/2025 at 5:17 p.m. with the Chief Nursing Officer (CNO), Patient 3's "Physician Order Restraints," dated 4/14/2025 and 4/15/2025 were reviewed. The "Physician Order Restraints" indicated the following:

-On 4/14/2025 at 8:40 p.m.: Behavioral Restraints Up to four (4) hours ... date restraints initiated: 4/14/2025; time restraints initiated: 8:40 p.m.; Indication for restraint (must identify the specific behavior requiring restraint such as harming self, hitting throwing objects): injury to self - attempting to kick and punch while being in hand cuffs; injury to others - with [local law enforcement], aggressive, combative, laughing hysterically."
-On 4/15/2025 at 12:40 a.m.: Behavioral Restraints Up to four (4) hours ... date restraints initiated: 4/15/2025; time restraints initiated: 12:40 a.m.; Indication for restraint (must identify the specific behavior requiring restraint such as harming self, hitting throwing objects): injury to self - attempting to kick and punch while being in hand cuffs; injury to others - with [local law enforcement], aggressive, combative, laughing hysterically."

During the same interview on 4/18/2025 at 5:17 p.m. with the Chief Nursing Officer (CNO), the CNO stated the following: the behavior documented on the restraint renewal order on 4/15/2025 at 12:40 a.m. was the same as the initial restraint order (4 hours ago). It did not describe any specific behavior Patient 3 was exhibiting to warrant continuous use of behavioral restraints.

During a review of the facility's policy and procedure (P&P) titled, "Restraints: Violent Behavior," dated 12/2021, the P&P indicated, "To provide standardized procedure in which restraints are used for the provision of a safe patient environment. To ensure restraints are used safely, responsibly and minimally in accordance with regulations pertaining to patients' rights ... Policy ... 4. Restraint 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 ... 14. Restraints is discontinued by a trained Registered Nurse (RN) or Licensed Independent Practitioner (LIP) at the earliest possible time, regardless of the length of time identified in the order. Procedure ... 3. Behavioral Health Care restraint use is limited to the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others ... Documentation ... use available electronic health records (EHR) flow sheets and order forms and narrative notes to document all pertinent information in the medical record including but not limited to ... assessment and care provided ... circumstances that led to use restraint."

Based on interview and record review, the facility failed to ensure two of 30 sampled patients' (Patient 12, and Patient 17) medical records contained appropriate documentation of assessments and findings when:

1. For Patient 12, pain assessment was not recorded in Patient 12's medical record, along with vital signs (VS, measurements of the body's most basic functions), obtained and documented every 4 hours, in accordance with the facility's policy regarding pain assessment and documentation.

This deficient practice compromised Patient 12's medical record integrity by undermining the completeness and accuracy of the documentation, essential for effective patient care and pain management. In addition, this deficient practice had the potential for Patient 12's pain to be unrecognized, leading to inadequate pain management and delayed interventions that could prevent complications related to unmanaged pain.

2. For Patient 17, the medical record contained no nursing documentation of Patient 17 sustaining a fall (an event which results in a person coming to rest inadvertently on the ground or floor or other lower level) in the emergency department (ED, a designated area within a hospital that provides immediate, specialized medical care to patients experiencing sudden, serious health issues or injuries), during Patient 17's hospital stay on 1/22/2025, in accordance with the facility's policy regarding fall prevention and management. In addition, Patient 17 sustained an open left ankle fracture (a type of bone fracture [broken] where the bone breaks through the skin, exposing the fracture site to the outside environment).

This deficient practice had the potential to result in Patient 17's condition and injury to be overlooked by providers, potentially leading to complications arising from the fall and fracture, such as infection and impaired healing, adversely affecting Patient 17's health and care.

Findings:

1. During a review of Patient 12's medical record (MR) titled, " Triage (the process of rapidly evaluating patients in the emergency settings, to determine the urgency of their condition and prioritize their treatment based on a system of priorities)," dated 4/11/2025 at 9:10 p.m., the MR indicated that Patient 12 presented to the facility's Emergency Department (ED, a designated area within a hospital that provides immediate, specialized medical care to patients experiencing sudden, serious health issues or injuries) on 4/11/2025 with a complaint of confusion and a fractured (broken) right 7th rib. The MR also indicated that Patient 12 presented with pain level of 7/10 (0- no pain, Mild pain - 1-3; Moderate pain 4-7; Severe pain 8-10).

During a review of Patient 12's "Emergency Department (ED) Summary Report," dated 4/11/2025 through 4/12/2025, the report indicated that Patient 12 was assessed for the presence of pain at the following times (along with vital signs [VS, measurements of the body's basic functions, including body temperature, pulse rate, respiration rate, and blood pressure]):
-On 4/11/2025 at 10:22 p.m.-Pain level was 7/10 (ribs)
-On 4/11/2025 at 10:51 p.m.-Pain level was 5/10 (ribs)
-On 4/12/2025 at 1:22 a.m.-Pain level was 5/10 (ribs)
-On 4/12/2025 at 3:30 a.m.-Pain level was 5/10 (ribs)
-On 4/12/2025 at 6:10 a.m.-Pain level was 5/10 (ribs)

During a review of Patient 12's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 4/12/2025, the H&P indicated that Patient 12 was admitted to the facility (inpatient admission- the process of a patient being admitted to a hospital for overnight care and treatment) on 4/12/2025 (at 6:50 a.m.) with a diagnosis of right chest wall pain. The H&P indicated that Patient 12 had multiple rib fractures (refer to three or more broken ribs).

During a concurrent interview and record review on 4/16/2025 at 10:18 a.m. a.m. with the Clinical Applications Specialist (CAS), Patient 12's medical record titled, "Vitals Inquiry (refers to the collection and documentation of a patient's vital signs [VS]), dated 4/12/2025 (01:22 a.m.) to 4/16/2025 (8:00 a.m.), was reviewed. The record indicated that Patient 12's VS (body temperature, pulse rate, respiratory rate [breaths per minute], and blood pressure [BP, the force of your blood pushing against the walls of your arteries as your heart pumps blood throughout your body]), were obtained and recorded every four hours. The CAS stated that Patient 12's record had no documentation of a pain level assessment that was recorded (along with vital signs) every 4 hours from 4/12/2025 to 4/16/2025.

During an interview on 4/16/2025 at 11:11 a.m. with nurse manager (NM 1), NM 1 stated that patients were assessed for the presence or absence of pain every four hours (along with vital signs), and pain level assessment should be recorded, along with vital signs (VS), in the patients' medical record, in accordance with the facility's protocol.

During a review of the facility's policy and procedure (P&P) titled, "Pain Management," dated 9/2023, the P&P indicated the following: The effective treatment of pain is contingent upon an accurate pain assessment. The features of pain assessment include Assessments of pain are communicated using both verbal report and written documentation ...The nurse and patient will collaboratively establish a desirable "Comfort Zone" utilizing a pain scale ... Assess pain as the 5th vital sign and as needed ... Assess pain each time vital signs are assessed ...

During a review of the facility's policy and procedure (P&P) titled, "Pain Management," dated 9/2023, the P&P indicated the following: "Documentation of pain assessment/reassessment is to be documented in the Electronic Medical Record (EMR) under:
a. The initial and daily assessments
b. Nurse's notes.
c. With vital signs

2. During a review of Patient 17's Emergency Department (ED) Summary Report (a document that summarizes a patient's ED visit, including their medical history, the course of treatment, and follow-up plans), dated 1/21/2025 through 1/23/2025, the ED Summary Report indicated that Patient 17 arrived at the Emergency Department on 1/21/2025 at 11:18 p.m.

During a review of Patient 17's History of Present Illness (HPI, a chronological account of a patient's current medical problem, including the development of symptoms, from the first sign to the present), dated 1/22/2025, the HPI indicated that Patient 17 presented to the Emergency Department (ED, a designated area within a hospital that provides immediate, specialized medical care to patients experiencing sudden, serious health issues or injuries) with a chief complaint of left ankle pain after Patient 17 tripped and fell (a patient fall is an unplanned descent to the floor with or without injury), twisting the left ankle. The HPI indicated that Patient 17 complained of pain in the left ankle. The HPI also indicated that Patient 17 was alert and oriented x 4 (oriented to place, time, person, and event), speaking in full sentences, and had intact skin and had a left ankle with obvious deformity, tender to palpation (a medical examination technique that involves feeling or touching a specific area of the body to detect abnormalities).

During further review of Patient 17's History of Present Illness (HPI), dated 1/22/2024, the HPI indicated the following: "Initial X-ray of the ankle showed evidence of fracture or dislocation. Second x-ray (use of radiation to create images of the inside of the body) shows worse in the fracture or dislocation, open fracture...I was informed by nursing staff that patient (Patient 17) was found on the floor adjacent to the gurney. Patient [Patient 17] was evaluated on the floor, with a now obvious open fracture of the left ankle...For open fracture, I discussed case emergently with our on-call orthopedic surgeon (who advised to reduce the fracture [a procedure to line up the ends of a broken bone without the need for surgery] and transfer out to trauma center [a hospital unit specialized in treating patients with severe and life-threatening traumatic injuries], for higher level of care [HLC, a more intensive and specialized type of treatment or service than what is typically offered in outpatient settings or primary care]). Procedural sedation manual reduction of the open fracture left ankle was performed."

During review of Patient 17's Emergency Department (ED) Progress Note (EDPN), dated 1/22/2025, the EDPN indicated that Patient 17 was re-evaluated at bedside and found to have "the medial malleolus (bony prominence located on the inner side of the ankle) appears to be protruding noticeably through the skin (bone is visibly displayed) surface with angulation (foot is angled outward, away from the midline of the body) of the foot laterally" and underwent second manual reduction of the left ankle open fracture. The EDPN also indicated on 1/22/2025 at 4:42 p.m., Patient 17 continued to remain in the facility's emergency department (ED) pending transfer to a trauma center.

During a review of Patient 17's Emergency Department (ED) Progress Note (EDPN), dated 1/23/2025, the EDON indicated that on 1/23/2025, at 10:00 a.m., Patient 17 signed out against medical advice (AMA, a patient chooses to leave before their doctor has recommended discharge, even though the doctor believes they need further care) due to a delay in transfer..."Patient stated...would like to go to a nearby trauma center with the help of a friend..."

During a concurrent interview and record review on 4/18/2025 at 11:51 a.m. with the Nurse Manager (NM 1), Patient 17's electronic medical record (EMR) was reviewed in an attempt to find late documentation regarding Patient 17's sustained fall in the Emergency Department on 1/22/2025. The NM 1 stated that Patient 17's EMR contained no documentation indicating that on 1/22/2025, Patient 17 sustained a fall (that resulted in an open ankle fracture) in the Emergency Department, while admitted for the left ankle dislocation. The NM 1 also verified that there was no nursing note that indicated that Patient 17 fell in the Emergency Department. The NM 1 also verified that aside from the physician's progress note, dated 1/22/2025, when the physician documented that "nursing staff informed them [the physician] of Patient 17 being found on the ground," Patient 17's EMR contained no other record that would indicate that a fall was sustained by Patient 17 during the admission stay in the facility's ED on 1/22/2025.

During an interview on 4/18/2025 at 12:20 p.m. with the Risk Manager (RM), the RM stated that she (RM) remembered the case and stated the following: "I remember this case. This fall incident was reported to risk management through the internal incident reporting channel (a confidential way for employees to raise concerns about potential wrongdoing without fear of retaliation, promoting transparency and accountability within the organization) and at that time, I had been here for a week and a half. I assigned the case to be investigated to the Emergency Department (ED) leadership and the director of the ED signed off on it. This was reported as a witnessed fall, as the patient came in with ankle injury, and needed to go to the bathroom. The patient [Patient 17] refused the bedpan, or something did not work, and the patient was provided with a bedside commode. When the patient got up, she (Patient 17) fell, and the report says that the gurney's siderail was down. The patient [Patient 17] sustained an open fracture as a result of the fall."

During an interview on 4/18/2025, at 12:40 p.m. with the Clinical Educator (CE), the CE stated the following regarding the content of patient medical records after a fall: "After a fall, the charge nurse and the house supervisor get informed, and nurses fill out an incident report and a fall debriefing tool (designed to systemically analyze the circumstances surrounding the fall to identify contributing factors and areas for improvement in care). Charge nurse then, should conduct a post-fall huddle to discuss the event and gather additional insights. The physician is notified of the fall to assess and re-assess the patient and to evaluate the extent of any injuries. Nurses should document all the objective data, perform their own assessment, and document the findings in the records. Pain assessment and vital signs are a must after a fall. Nurses should also document who was notified regarding the fall, and all documentation should be thorough to facilitate further evaluation in the event of a change in the patient's condition."

During a review of the facility's policy and procedure (P&P) titled," Fall Prevention and Management," dated 4/2024, the P&P indicated the following:
"F. Post Fall Management
1. Assessment
a. Immediately perform and document complete head-to-toe assessment including neuro check, vital signs, and assessment for possible injuries. Identify changes from pre-fall status.
d. Monitor patient for any effects of the fall
e. Reassess patient as appropriate, including physical and neuro status
f. Conduct Post Fall Debrief, and complete Post Fall Debrief Form. Ask the patient what happened, if patient able to self-report. Information may be used to prevent repeat falls

2. Notify
a. Notify the Licensed Independent Provider immediately at the time of the fall. Provide the following:
i. Change in neurological status and vital signs;
ii. Injury or complaint of pain;
iii. Anti-coagulation medication; and
iv. Obtain order(s) for medical interventions/ diagnostic procedures
b. Follow chain of command
c. Patient's representative as appropriate
d. Risk Management/Patient Safety Officer- if the patient fall results in one of the following:
i. Significant injury involving higher level of care or
medical/surgical intervention
ii. Confirmed injury by diagnostic test
iii. Death

3. Documentation
a. Assessment of patient's condition, patient's explanation of what happened, name and time the Licensed Independent Provider and family (if appropriate) was notified, and any interventions initiated by the Licensed Independent Provider or nurse.
b. Initiate or update the interdisciplinary plan of care (ipoc)
c. Re-assessment of patient
d. Complete an online event report
e. Complete Post Fall Debriefing Form for all falls and send original to Unit Manager/Director
f. Manager/Director will review and send to Risk Management/ Patient Safety Officer/ or designee