North Star Hospital

“Special Medical Record Requirements CFR(s): Condition of Participation: Special Medical Record Requirements for Psychiatric Hospitals The medical records maintained by a psychiatric hospital must permit determination of the degree and intensity of the treatment provided to individuals who are furnished services in the institution. This Condition is not met as evidenced by: 42377 . Based on record review and interview, the facility failed to ensure medical records contained completed seclusion and restraint interventions and evaluations for two patients (#2 and #3), out of 10 patients. Specifically, the facility failed to: 1) ensure documentation for Patient #2’s restraint and seclusion interventions and follow-up were completed; 2) ensure Patient #3 received debriefing after a seclusion; and 3) ensure Patient #3 was assessed on the effects of the intervention and strategies used to prevent repeat use of seclusion. This failed practice had the potential to place all patients (based on a census of 97), who required restraint or seclusion, at risk for not having their medical, psychological, and psychosocial needs addressed after a seclusion and/or restraint. Findings: Patient #2 Record review on 4/1-2/25, revealed Patient #2 was admitted to the facility with diagnoses that included post-traumatic stress disorder (PTSD), attention-deficit hyperactivity disorder (ADHD - a neurodevelopmental disorder with symptoms of inattention, hyperactivity, impulsivity, and emotional dysregulation), and intermittent explosive disorder (IED - repeated, sudden bouts of impulsive aggressive, violent behavior or angry verbal outbursts). Review of the Patient #2’s “North Star Behavioral Health Seclusion and Restraint” packet, dated 1/25/25, revealed the following sections had missing information/signatures: - The “Seclusion/Restraint/Chemical Restraint Order” had no transcribing nurse signature. - The “Post Intervention Face to Face Evaluation,” in the notification section, the nurse supervisor was left blank; and in the Administrative Debriefing, the reviewing nurse supervisor was left blank. Review of the Patient #2’s “North Star Behavioral Health Seclusion and Restraint” packet, dated 2/13/25, revealed in the “Administrative Debriefing,” the reviewing nurse supervisor was left blank. Patient #3 Record review on 4/1-2/25, revealed Patient #3 was admitted in the facility with diagnoses that included ADHD and major depressive disorder (MDD - mood disorder). Review of Patient #3’s “North Star Behavioral Health Seclusion/Restraint/Emergency Medication Patient/Resident Debriefing,” dated 2/20/25 at 10:45 AM, revealed the only documentation on the form was Licensed Nurse (LN)#2’s signature. Review of Patient #3’s “North Star Behavioral Health Seclusion/Restraint/Emergency Medication Patient/Resident Debriefing,” dated 2/20/25 at 11:27 AM, revealed the only documentation on the form was LN #2’s signature. Review of Patient #3’s “North Star Behavioral Health Seclusion/Restraint/Emergency Medication Patient/Resident Debriefing,” dated 2/20/25 at 3:10 PM, revealed the only documentation on the form was LN #2’s signature. During an interview on 4/2/25 at 1:10 PM, LN #1 stated the “North Star Behavioral Health Seclusion/Restraint/Emergency Medication Patient/Resident Debriefing,” form should have been completed by any staff member the patient felt comfortable talking to. LN #1 further stated the unit nurse reviews all the restraint/seclusion forms after the intervention to ensure they were completed. LN #1 stated that all restraint/seclusion forms should be completed within 24 hours. During an interview on 4/2/25 at 3:11 PM, when asked if Patient #2’s and #3’s seclusion and restraint forms should had been completed, the Chief Nursing Officer (CNO) stated they should not be blank and were expected to be completed within 24 hours by the unit nurse. The CNO stated the nursing supervisors reviewed all documentation of restraints and seclusions to ensure forms had been completed. The CNO further stated the supervisor would reach out to the appropriate LN if documentation was not completed. The CNO stated that she compiled all the data from the restraints and the seclusions forms for monitoring and tracking. The CNO further stated if the nursing supervisor missed identifying that the restraint/seclusion forms were not completed, she would follow up with that nursing supervisor. The CNO further stated, “we have identified a gap.” Review of the facility’s “North Star Behavioral Health Seclusion/Restraint/Emergency Medication Patient/Restraint Debriefing” form, dated 5/13/24, revealed; “Initiation of Intervention . . . To be completed within 24 hours of intervention, Debriefing Completed. . . Did Patient/Resident request that family/significant other be involved in debriefing? No Yes, Comments: Interventions to involve family: Staff involved in Debrief . . . 1. Patient/Resident perception of events/triggers leading to intervention: 2. Patient/Resident description of what happened to cause behaviors: 3. Patient/Resident perception of anything that could have been done differently: 4. Did the Patient/Resident feel his/her well-being, psychological comfort, and right to privacy were maintained? Yes No If no, explain: 5. Was . . . trauma experienced by the Patient/Resident? No Yes If yes, describe counseling provided: 6. Strategies to prevent repeat use of intervention and/or to address factors contributing to the incident: Additional Comments: Staff Leading the Debrief, Name: Signature: Date: Time.” Review of the facility’s policy, “Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion - Acute, PC112,” dated 7/2023, revealed; “. . . Physical Restraints: the application of any manual method that immobilizes or reduces the ability of the patient to move his or her arms, legs, body, or head freely . . . Seclusion: the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. If a patient is restricted to a room alone and staff are physically intervening to prevent the patient from leaving the room or giving the perception that threatens the patient with physical intervention if the patient attempts to leave the room, the room is considered locked, whether or not the door is actually locked or not . . . Policy . . . The patient’s rights, dignity, privacy, safety, and well-being will be supported and maintained . . . Procedures . . .10. Post-Restraint/Seclusion Debriefing: Debriefing following the use of restraint/seclusion. The patient and staff participate in a debriefing session following the restraint/seclusion episode. The patient and, if appropriate, the patient’s family, participate with the staff who were involved in the episode and who are available, in a debriefing about each episode of restraint/seclusion use. The debriefing occurs as soon as possible, and as appropriate, but no longer than 24 hours after the episode 1. The debriefing is used to: 1. Identify what led to the incident and what could have been handled differently; 2. Ascertain that the individual’s physical well-being, psychological comfort, and right to privacy were addressed; 3. Counsel the individual involved for any trauma that may have resulted from the incident, and 4. When indicated, modify the treatment plan. 2. Information obtained from debriefing is used in performance improvement activities. 13. Documentation of use of restraint/seclusion . . . 12. Debriefing of the patient with staff. 2. Data is collected on all restraint/seclusion episodes . . . 10. Results of the debriefing 3. Analysis of data includes particular attention to: 1. Multiple instances of restraint/seclusion use experienced by a patient within a 12 hour time frame . . .” .”

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 42377 . Based on record review and interview, the facility failed to ensure the medical records contained a completed treatment plans (plans of care, after the initial treatment plan upon admission, that outlined a patient’s inpatient treatment to include diagnoses, short term and long term goals of identified problems to address during treatment, and discharge planning goals) for eight patients (#’s 2, 3, 5, 6, 7, 8, 9 and 10), out of 10 sampled patients. Specifically, the patient’s treatment plans did not have signatures of the interdisciplinary team who reviewed the treatment plans, and it did not have signatures of the patient and/or guardian after the clinician discussed the treatment plans with them. This failed practice had the potential to not inform the patients and/or guardians of their treatment progress and response to treatment. Additionally, this failed practice had the potential to not provide the necessary services at the patient’s discharge. Findings: Patient #2 Record review on 4/1-2/25 revealed Patient #2 was admitted to the facility with diagnoses that included post-traumatic stress disorder (PTSD), attention-deficit hyperactivity disorder (ADHD - neurodevelopmental disorder with symptoms of inattention, hyperactivity, impulsivity, and emotional dysregulation), and intermittent explosive disorder (IED - repeated, sudden bouts of impulsive aggressive, violent behavior or angry verbal outbursts). Review of Patient #2’s multiple treatment plans revealed: - Treatment plans, dated 1/29/25, 2/5/25, 3/5/25, and 3/19/25, revealed no patient and guardian signatures; - The treatment plan, dated 1/29/25, revealed no clinician and nurse signature; and - The treatment plan, dated 3/5/25, revealed no clinician signature. Patient #3 Record review on 4/1-2/25 revealed Patient #3 was admitted in the facility with diagnoses that included ADHD and major depressive disorder (MDD - a mood disorder). Review of Patient #3’s treatment plan, dated 1/27/25, revealed no nurse or patient and guardian signatures. Patient #5 Record review on 4/1-2/25, revealed Patient #5 was admitted to the facility with a diagnosis of ADHD. Review of Patient #2’s multiple treatment plans revealed: - Treatment plans, dated 1/22/25, 1/29/25, 2/12/25, 2/19/25, 2/26/25, 3/5/25, and 3/19/25, revealed no patient and guardian signatures; and - The treatment plan, dated 1/22/25, revealed no provider and nurse signature. Patient #6 Record review on 4/1-2/25, revealed Patient #6 was admitted to the facility with diagnoses that included MDD, reactive attachment disorder (RAD - a childhood psychiatric condition that can make it difficult to form lasting relationships and show affection), and oppositional defiant disorder (ODD - A childhood disorder that causes defiant and disobedient behavior to authority figures). Review of Patient #6’s multiple treatment plans revealed: - Treatment plans, dated 12/3/24 and 12/11/24, revealed no nurse signature; - The treatment plan, dated 12/23/24, revealed no patient, guardian, nurse and clinician signatures; - A treatment plan, undated, revealed no patient, guardian, and nurse signatures; and - The treatment plan, dated 1/3/25, revealed no guardian, provider, and nurse signatures. Patient #7 Record review on 4/1-2/25, revealed Patient #7 was admitted to the facility with diagnoses that included IED, and MDD. Review of Patient #7’s treatment plan, dated 1/20/25, revealed no patient and guardian signatures. Patient #8 Record review on 4/1-2/25, revealed Patient #8 was admitted to the facility with diagnoses that included PTSD and RAD. Review of Patient #8’s treatment plan, dated 3/11/25, revealed no patient and guardian signatures. Patient #9 Record review on 4/1-2/25, revealed Patient #9 was admitted to the facility with diagnoses that included PTSD and active stress reaction disorder (ASRD- mental health condition with symptoms of intrusive memories, avoidance, and hyperarousal). Review of Patient #9’s treatment plan, dated 3/19/25, revealed no patient and guardian signatures. Patient #10 Record review on 4/1-2/25, revealed Patient #10 was admitted to the facility with diagnoses that included ADHD and unspecified cognitive disorder (brain’s ability to process and store information). Review of Patient #10’s treatment plan, dated 3/21/25, revealed no nurse and provider signatures. During an interview on 4/2/25 at 2:25 PM, Mental Health Clinical Therapist (MHCT) stated the treatment plan was reviewed weekly with the treatment team, patient and caregiver. During the meeting, goals were developed and modified to meet the patient’s needs. If the guardian was unable to attend, then a phone call follow up was conducted to discuss the weekly meeting and the discharge plan. The MHCT stated the treatment plans should be signed by all members of the team. He/she further stated if the guardian was unable to attend and updated over the phone, then that should have been documented on the treatment plan. He/she stated the patient was always involved but did not always sign the treatment plan. Record review of the facility’s “Interdisciplinary Treatment Plan” dated 11/2024, revealed; “Policy . . . each patient/resident have a written, comprehensive, assessment-based, and individualized treatment plan that drives the treatment process, guides the patient/resident toward achieving goals/objectives, monitors progress, and establishes a sound discharge plan for continued success after completing treatment. Expectations . . . the plan shall describe assessment-based patient/resident strengths and disabilities; goals and objectives of treatment; clinical interventions prescribed; patient/resident progress in meeting treatment goals and objectives. . . Procedure . . . 1. . . the treatment team shall further develop the ITP into a Master Treatment Plan (MTP). . . The team will consist of the physician, the RN, the clinical therapist, patient/resident, guardian, and representatives from other clinical disciplines . . . IX. The patient/resident and guardian signs the Treatment Plan after review with a member of the treatment team. . . The clinical therapist is responsible for obtaining signatures from all treatment team members. . . If the parent/guardian of a child is unable to attend the face-to-face meeting in person, then the clinical therapist shall discuss the plan over the telephone and annotated the discussion date/time on the treatment plan signature sheet and in a progress note. If a patient/resident refuses or declines to attend a scheduled treatment team meeting, the clinical therapist is responsible for documenting this refusal on the MTP/U and in a progress note. . .” .”

“LICENSURE OF PERSONNEL CFR(s): 482.11(c) The hospital must assure that personnel are licensed or meet other applicable standards that are required by State or local laws. This Standard is not met as evidenced by: 42377 . Based on record review and interview, the facility failed to ensure two providers (#s 1 and 2), out of two medical providers reviewed for medical credentialing, had valid license and other credentials. Specifically, the facility failed to ensure: 1) Medical privileges were approved by the Governing Board for Provider #1; 2) A peer evaluation was current for Provider #2; 3) Malpractice insurance was valid for both Providers #1 and #2; and 4) The Drug Enforcement Authorization (DEA) License was valid for Provider #1. These failed practices, placed all patients at risk of receiving care and treatment from medical staff without valid credentials. Findings: During a review of the medical providers credentials, on 10/9/24 at 1:34 PM with the Executive Assistant (EA) and Performance Improvement Director (PID), the providers credentials were not up to date. Medical Privileges: Provider #1 Review of the facility’s “INITIAL REQUEST/CHANGES CLINICAL PRIVILEGE DELINEATION FORM,” dated 6/28/23 for Provider #1, revealed it was approved by the Medical Executive Committee Chair on 7/12/23, but was not approved by the Governing Board. Review of the facility’s “INITIAL REQUEST/CHANGES CLINICAL PRIVILEGE DELINEATION FORM,” dated 6/28/23 for Provider #1, provided by the facility by fax on 10/10/24, after the onsite survey, the Governing Board had signed the form, dated 10/9/24. Peer Evaluation: Provider #2 Review of Provider #2’s current credential file, on 10/9/24 at 1:34 PM, revealed the Peer Evaluation within, for Provider #2, was dated 10/12/21. During an interview on 10/9/24 at 1:34 PM, the EA stated a more current peer review might be in another folder because the Provider was up for reapplication soon. A copy was requested by the surveyor but was not provided at the end of the onsite survey. Malpractice Insurance: Provider #1 Review of Provider #1’s malpractice insurance “CERTIFICATE OF INSURANCE,” revealed it expired on 8/11/24. The EA stated, she would find out if there was an updated insurance for Provider #1. A copy of the document was requested by the surveyor. A copy was not provided by the end of the onsite survey. Review of the facility’s email sent on 10/10/24, revealed a copy of the malpractice insurance “CERTIFICATE OF INSURANCE,” for Provider #1, effective date on 8/11/24 and valid through 8/11/25. Provider #2 Review of Provider #2’s malpractice insurance “Certificate of Insurance,” revealed it expired on 10/1/23. The EA stated, she would find out if there was an updated insurance for Provider #2. A copy of the document was requested by the surveyor. A copy was not provided by the end of the onsite survey. Review of the faxed document sent by the facility on 10/10/24, revealed Provider #2’s “Certificate of Insurance,” policy period was 10/1/24 to 10/10/25, was signed by the officer of the company on 10/10/24. There was no evidence of malpractice insurance coverage for Provider #2 between 10/1/23 to 10/1/24. DEA License: Provider #1 Review of Provider #1’s DEA license, revealed it expired on 9/30/24. During an interview on 10/9/24 at 1:34 PM, EA stated she did not notice the DEA was expired and she did not notify Physician #1. A copy of the current license was requested by the surveyor. The PID stated the pharmacy was looking for it. The valid license was provided on 10/10/24 after the onsite survey. Review of the facility’s “Medical Staff Bylaws,” dated 8/8/24, revealed: “. . . CREDENTIALS FUNCTION. Duties (a) Review the credentials of all applicants for Medical Staff appointment, reappointment, and for granting, renewing, or revising clinical privileges, to evaluate and interview such applicants as maybe necessary, and to make a written. . . findings and recommendations for the Medical Executive Committee. . .assure that a separate credentials file is maintained for each Staff Member, each Physician with Clinical Privileges, and each designated professional personnel . . .” Further review of the “Medical Staff Bylaws,” revealed: “. . . CREDENTIALING I. AUTHORITY AND RESPONSIBILITY The board of trustee of North Star Behavioral Health System, having final authority for the provision of care to patients, has delegated the authority and responsibility for such provision of high quality of care to the medical staff. Privilege criteria are developed and recommended by the Credentials Function in consultation with the Medical Staff, the Medical Executive Committee, and the Board of Trustees, and are reviewed, at a minimum, every two years. . . CREDENTIAL PROCESS. . .PHYSICIANS All clinical privileges for physicians require compliance with all the following criteria . . .Documentation of professional malpractice liability insurance coverage of at least $1,000,000/$3,000,000. . . A Current DEA certificate . . .””

“MEDICAL STAFF - APPOINTMENTS CFR(s): 482.12(a)(2) [The governing body must] appoint members of the medical staff after considering the recommendations of the existing members of the medical staff. This Standard is not met as evidenced by: 42377 . Based on record review and interview, the facility failed to ensure Medical privileges were approved by the Governing Board for Provider #1, out of two medical providers reviewed for medical credentialing. This failed practice had the potential to place all patients at risk of receiving care and treatment from a medical staff without a valid medical privileges. Findings: During a review of the medical providers credentials, on 10/9/24 at 1:34 PM with the Executive Assistant (EA) and Performance Improvement Director (PID), the providers credentials were not up to date . Medical Privileges: Provider #1 Review of the facility’s “INITIAL REQUEST/CHANGES CLINICAL PRIVILEGE DELINEATION FORM,” dated 6/28/23 for Provider #1, revealed it was approved by the Medical Executive Committee Chair on 7/12/23, but was not approved by the Governing Board. Review of the facility’s “INITIAL REQUEST/CHANGES CLINICAL PRIVILEGE DELINEATION FORM,” dated 6/28/23 for Provider #1, provided by the facility by fax on 10/10/24, after the onsite survey, the Governing Board signed the form, dated 10/9/24. Review of the facility’s “BY LAWS OF THE BOARD OF GOVERNORS OF NORTH STAR BEHAVIORAL HEALTH SYSTEM,” effective date 12/1/23, revealed: “. . .The Board shall organize all physicians and practitioners granted clinical privileges at the Hospital. Allied Health Professionals are granted privileges by the Board in accordance with the rules and regulations adopted by the Medical Staff of the Hospital.” Review of the facility’s “Medical Staff Bylaws,” dated 8/8/24, revealed: “. . . CREDENTIALING I. AUTHORITY AND RESPONSIBILITY The board of trustee of North Star Behavioral Health System, having final authority for the provision of care to patients, has delegated the authority and responsibility for such provision of high quality of care to the medical staff. Privilege criteria are developed and recommended by the Credentials Function in consultation with the Medical Staff, the Medical Executive Committee, and the Board of Trustees, and are reviewed, at a minimum, every two years. .”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 42377 . Based on record review, interview, and observation, the facility failed to ensure a patient’s rights to receive care in a safe setting was followed for the following: A) Procedures for the use of ankle monitor (device that uses satellites for tracking) was accurately applied for one patient (#1), out of 7 sampled patients. Specifically, the facility failed to ensure: 1) the ankle monitor was functional before its use; 2) a licensed nurse (LN) or charge nurse was responsible for applying and removing the ankle monitor; 3) the use of the ankle monitor was ordered by a physician; 4) a system was in placed to supervise the use the ankle monitor; 5) an investigation of the ankle monitor’s failure during an elopement; and 6) an updated ankle monitor policy and procedures. B) A safe environment was maintained for 2 sampled patients (#s 1 and 2), out of 7 sampled patients and 11 unsampled patients (#s 8; 9; 10; 11; 12; 13; 14; 15; 16; 17; and 18), out of 13 patients in the Denali unit. These failed practices had the potential to: 1) place all patients, using the ankle monitor procedures, at risk of harm for not being promptly located, especially during patient’s elopement; and 2) place all patients in the Denali unit (bases on a census of 13) at risk of harm during an emergency. Findings: A) Ankle Monitor Procedures Record review on 10/8-9/24, revealed Patient #1 was admitted to the facility with diagnoses that included major depressive disorder (a mood disorder) and recurrent oppositional defiant disorder (a continuing pattern of uncooperative, defiant, and hostile behavior toward people in authority). Elopement incident: Review of the “Adult Protective Services Intake Report,” for an incident dated 9/29/24, revealed “[Patient #1] was left unattended at [Facility #2] by staff [Staff #2]. When staff [#2] was told to return to stay with . . . [Patient #1], [Patient #1] had eloped. Police and AOC [Administrator on call] (this writer) were notified. Patient [#1] was found > [more than] 3 miles away after ‘getting afraid’ and going into . . . [a hardware store] and asking cashier to call the police for her. . .” During an interview on 10/8/24 at 3:22 PM, with the Performance Improvement Director (PID), she stated Patient #1 was taken to the emergency room at Facility #2. The patient eloped and was returned to the facility by the police. During an interview on 10/8/24 at 3:46 PM, the Director of Risk, Facility Compliance Officer (DOR, FCO), stated she received the incident report on 9/30/24. Based on the facility investigation, Staff #2, who escorted Patient #1 to the emergency room , called the facility’s Milieu Manager (MM), informing the MM that Patient #1 was refusing to get into the cab (public transportation) when it was time to return to the facility after being medically cleared. Review of Patient #1’s “Patient Observation Record,” dated 9/29/24, revealed: “Special precautions: AWOL [absence without leave] elopement was marked. . . back on ELP (elopement) [Patient #1] not allowed to go outside. . . awoled [eloped] from medical appt [appointment] with [Staff #2].” During an interview on 10/9/24 at 9:38 AM, Staff #2 stated on 9/29/24 (Sunday), he/she was requested to escort Patient #1 to Facility #2 because the Patient swallowed pieces of Styrofoam (a building insulation material). When Staff #2 came into the facility at 12:30 PM, Patient #1 was not exhibiting any behaviors and was repeatedly saying he/she wanted to go out. Staff #2 applied the ankle monitor to Patient #1 until a “click” was heard which means the ankle monitor was locked. Staff #2 stated he/she did not check if the battery was fully charged because it was not his/her responsibility. Staff #2 stated he/she relied on the staff in-charge of charging the ankle monitor battery to ensure it was charged. Staff #2 also stated after the ankle monitor was secured, Staff #2 called the cab. Then, Staff #2 and Patient #1 went to Facility #2. Patient #1 had an X-ray and was checked by the provider. After the provider informed them that Patient #1 was getting discharged, Patient #1 said “no.” Patient #1 told the physician that the facility was mean, hurt kids, and they (the Facility) were liars. Staff #2 encouraged Patient #1 to come back but he/she kept on refusing. Staff #2 and Patient #1 went to the entrance door of the Facility #2 and Staff #2 called for a cab but Patient #1 refused to go back to the facility. Staff #2 further stated that he/she called different staff at the facility and reported Patient #1’s continued refusal to come back. Staff #2 stated that Licensed Nurse (LN) #3 told Staff #2 to call the police if Staff #2 could not get Patient #1 back to the facility. Staff #2 kept telling the Patient that Staff #2 did not want to call the police. Staff #2 called two to three cabs, but the Patient continued to refuse. About an hour and a half of trying to encourage Patient #1 to go back to the facility, Staff #2 called LN #3. LN #3 told Staff #2 to call the police. After 20 minutes, Staff #2 called another staff (LN #4) and then called the MM. During that time, Patient #1 was banging his/herself against an unknown object. When the cab came, Staff #2 went inside the cab, but Patient #1 did not want to get into the cab. Staff #2 stated he/she called the police while inside the cab. Staff #2 stated Patient #1 was left behind right inside Facility #2’s main entrance. When asked why Staff #2 left Patient #1 at Facility #2, Staff #2 stated “because [Staff #2 ] thought once [he/she] called the police, [he/she] could go back to the facility and the police would get the Patient [#1].” Staff #2 further stated, when he/she returned to the facility and found out that it was not right to leave Patient #1 at Facility #2, Staff #2 returned to Facility #2, but Patient #1 was not there anymore. Staff #2 did not find Patient #1. Staff #2 was instructed to go back to the facility and met with the MM for an interview. After which, the police called Staff #2 informing him/her that the police found Patient #1. Staff #2 was placed on administrative leave on that day 9/29/24 and nobody contacted him/her. After three days, Staff # 2 reached out to the facility, he/she was told to report on 10/3/24 and was told that he/she would be demoted to a Mental Health Specialist position. He/she would also no longer take a “consult [escort]” role anymore. Out of system consult escort: During an interview on 10/9/24 at 9:38 AM, Staff #2 stated “No,” when asked if being a patient escort to an out of system consult (transfer of a patient from one facility to another for emergency/medical care, or dental appointments) was included in his/her job description. Staff #2 stated he/she was a Health Unit Coordinator (HUC) but he/she had been doing the role as an escort for a long time, he/she had escorted about 15 patients per month. Staff #2 stated being HUC, he/she would provide support to the nurses, conduct inventory and other tasks assigned to him/her, stating he/she was a “jack of all trades.” Use of Ankle monitor: During an interview on 10/8/24 at 2:29 PM, when asked about the use of an ankle monitor for patients, LN #1 stated an ankle monitor would be used for every patient every time they go out for an appointment, transfer from one facility to another, or going to the airport. When asked if the staff were trained how to use an ankle monitor, he/she stated the milieu managers, nurses, and the person assigned to escort a patient for an out of system consult were trained. During an interview on 10/9/24 at 9:38 AM, Staff #2 stated “no,” when asked if he/she was trained to be an escort. But when he/she first took an escort role, the former Chief Nursing Officer (CNO) told him/her to apply an ankle monitor to a patient, stay with the patient and take a cab as a mode of transportation. Staff #2 stated there were no written instructions on how to perform the escort job. Staff #2 stated he/she learned more to apply the ankle monitor as he/she gained experience in his/her escort role. Review of the facility’s policy “GPS [Global Positioning System] Ankle Monitors, R1 121,” effective date 5/2023, revealed: “. . . Application and removal of the ankle monitor will be done by the Nurse Manager or charge nurse . . .” During an interview on 10/9/24 at 11:48 AM, when asked who was responsible to apply and remove the ankle monitor, the Assistant Chief Nursing Officer (ACNO) stated the nurses were responsible for applying the ankle monitor because it was a physician’s order. She also stated Staff #2 had no training in the use of an ankle monitor. Physician order of an ankle monitor: During an interview on 10/8/24 at 2:56 PM, the ACNO stated the use of an ankle monitor was ordered by the physician. When requested to provide the physician’s order for the use of the ankle monitor on 9/29/24, the ACNO provided a physician’s order dated 9/30/24. The physician’s order for the ankle monitor on 9/29/24 was never provided. Review of the facility’s policy “GPS Ankle Monitors, R1 121,” effective date 5/2023, revealed: “. . . the attending Physician will make the recommendation that a GPS ankle monitor is needed and provide an order for its use. . .” Ankle monitor battery: During an interview on 10/8/24 at 2:29 PM, LN #1 stated the ankle monitors were charged in the medication storage room. A green light would indicate the ankle monitor had been charged and a red light would indicate no battery. The LN #1 further stated, the nurse would ensure an ankle monitor was locked and secured, the nurse would then measure a correct ankle band size. The patient would then go out for their appointment. Upon arrival back to the facility, the nurse would ensure the ankle monitor was placed properly in its charging station. During an interview on 10/8/24 at 2:56 PM, when asked if she received a notification if an ankle monitor had a low battery, the ACNO stated “no.” The ACNO stated that she could check the ankle monitor battery status on her computer. An observation on 10/8/24 at 2:56 PM, the ACNO showed the computer screen to the surveyors. Observation of the battery status revealed three monitors (Main #’s 2, 3, and 4) were in red. When asked what the red color meant, she stated the batteries were not charged. When asked how often she checked the ankle monitor battery status, she stated once a week. When asked if there was a report that the battery had been checked, she stated “no.” The ACNO stated she would only receive an email notification when a patient with ankle monitor left the facility. When asked if she received a notification when a patient with ankle monitor left a certain location, such as dental office or hospital, she stated there was no notification. She stated there would be a staff member who would stay with the patient. Ankle Monitor supervision: During an interview on 10/8/24 at 2:29 PM, when asked how the facility ensured that the ankle monitor was working and how the facility tracked the ankle monitor while it was in use, LN #1 stated it was being tracked by a GPS, but nurses did not track the ankle monitor and it “maybe somebody in the building.” During an interview on 10/8/24 at 3:22 PM, when asked what corrective actions were in place after Patient #1’s elopement, ACNO stated she was actively monitoring the ankle monitors when someone left the facility. When asked if there was a document to monitor when an ankle monitor was checked-in/checked-out, she stated there was no such document. She also stated she “will start that.” The ACNO stated that when an ankle monitor was in use, there was no staff member responsible for actively monitoring its location. Ankle monitor “glitch”: During an interview on 10/9/24 at 11:48 AM, the ACNO stated she was not notified that the ankle monitor left the facility on 9/29/24. She stated she did not receive an email. When asked if there was an active monitoring of the ankle monitors, she stated, “no” and that the only time she tracked the ankle monitor was when there was an elopement. She stated she was not able to track the ankle monitor on the day Patient #1 eloped. She stated there was no routine checking to ensure Patient #1 was still in the location. When asked why the ACNO couldn’t receive notifications or track the ankle monitor when it left the facility, she said the ankle monitor company couldn’t figure out what caused the “glitch.” When asked if the facility investigated to determine the “glitch,” in the ankle monitor, the ACNO stated, “no.” Ankle Monitor policy and Procedure: Review of the facility’s policy “GPS Ankle Monitors, R1 121,” effective date 5/2023, revealed: “Nurse Manager /administrator/Charge Nurse will then contact the ankle monitoring company by telephone at 1-800-466-1377. . .” During an interview on 10/9/24 at 3:17 PM, when asked if she contacted the ankle monitor company before use and during the elopement incident according to the policy and procedure, the ACNO stated she did not call the company because the ankle monitor turns on right away when applied. She explained that the existing policy was for the old ankle monitor. The ankle monitor that the facility was using was acquired in February (2024) the ACNO also stated that she would “update the policy right now.” B) Environmental Safety An observation of the facility’s second floor patient care area on 10/9/24 at 4:00 PM, revealed the floor was divided into two units (Alyeska and Denali) with a nursing station located in the middle. Exit egresses to stairwells was observed on at the end of each unit which served as the only two exit egress pathways from the floor. Each unit was separated from the elevator common area/front of nursing station by a set of double doors equipped with magnetic locking devices. Continued observation on 10/9/24, revealed the outside of the double doors leading into the Alyeska unit, on the side of the elevator common area/front of nurses’ station area, was covered with a plastic sheet. The sheet covered the doors from ceiling to approximately 18 inches off the floor. The plastic sheet was held in place, on both vertical sides of the door frame, by vice-like floor to ceiling braces. Once the plastic sheet was removed by the Maintenance Director, there were two handwritten signs, one on the door and one on the keycard reader, that indicated not to enter the area. Once on the unit, the length of the corridor was filled with construction equipment and tools resulting in a narrowed corridor. Items included five-gallon buckets of plaster-like materials, hand tools, power tools, hand trowels, and ladders accessible to patients in the event the unit needed to be used for evacuation. During an interview on 10/9/24, the ACNO stated both units were the current path of egress. During an interview on 10/9/24, the Contractor #1 stated he/she placed the plastic sheet over the unit’s double doors to “impede” people from entering the unit while he/she was making repairs. During an interview on 10/9/24, the Maintenance Director stated the plastic sheeting over the double doors should not have been utilized. The Maintenance Director further stated the corridor was not free of obstructions. .”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 42377 . Based on record review and interview, the facility failed to ensure a medication consent form was completed for two patients (#s 3 and 4), out of 7 sampled patients. Specifically, the facility failed to ensure: 1) a physician’s name and signature on the consent forms was completed within the specified timeframe; and 2) a witness signature was affixed on the consent form for verbal authorization. This failed practice placed the patients at risk of receiving medications without a properly executed consent. Findings: Patient #3: Record review on 10/8-9/24, revealed Patient #3 was admitted in the facility with diagnoses that included Major Depressive Disorder (a mood disorder). Review of Patient #3’s medication consent form for Benadryl (for agitation and insomnia), dated 7/30/24, revealed there was no physician’s name and signature. Review of Patient #3’s medication administration record (MAR) for Benadryl, revealed the medication was ordered with a start date of 7/31/24. The medication was administered on 7/31/24-8/2/24, 8/6-14/24, 8/16-20/24, 8/23/24-9/6/24, 9/8-9/24, 9/11-16/24, and 9/19/24-10/7/24 (a total of 52 doses) without a completed consent form. Review of Patient #3’s medication consent form for Melatonin (a supplement to regulate sleep and wake cycle), dated 7/30/24, revealed the Patient’s parent consented for the use of the medication but there was no physician’s name and signature in the form. Review of Patient #3’s MAR for Melatonin, revealed the medication was ordered with a start date of 7/31/24. The medication was administered on 7/31/24-8/1/24, 8/6/24, 8/8-9/24, 8/12-14/24, 8/16-19/24, 8/23-30/24, 9/1/24, 9/4-6/24, 9/8-9/24, 9/11-16/24, 9/19-25/24, and 10/1-8/24 (a total of 47 doses) without a completed consent form. Patient #4: Record review on 10/8-9/24, revealed Patient #4 was admitted in the facility with diagnoses that included Major Depressive Disorder. Review of Patient #4’s medication consent form for Melatonin, dated 9/30/24, revealed the Patient’s parent consented for the use of the medication but there was no physician’s name and signature in the form. Review of Patient #4’s MAR for Melatonin, revealed the medication was ordered with start date of 9/30/24. The medication was administered on 9/30/24 to 10/6/24 (a total of 7 doses) without a completed consent form. Review of Patient #4’s medication consent form for Benadryl, dated 9/30/24, revealed the Patient’s parent consented for the use of the medication but there was no physician’s name and signature in the form. Review of Patient #4’s MAR for Benadryl, revealed the medication was ordered with a start date on 9/30/24. The medication was administered on 9/30/24, 10/1/24, 10/4/24, 10/5 24 and 10/6/24 (a total of 5 doses) without a completed consent form. Review of Patient #4’s medication consent form for Remeron (an antidepressant), dated 10/2/24, revealed the Patient’s parent consented for the use of the medication through a telephone call but there was no witness signature for a verbal authorization and there was no physician’s name and signature in the form. During an interview with the facility’s Medical Director (MD) on 10/8/24 at 2:23 PM, the MD confirmed that all medication consent forms must be signed by a physician within 24-72 hours of the medication being prescribed. During an interview on 10/8/24 at 2:29 PM, License Nurse (LN) #1 confirmed the facility’s process. LN #1 stated before medications would be administered, a medication consent form must be signed by a physician. Review of the facility’s policy “Medical Record Documentation, IM 102.04,” effective 9/2024, revealed: “. . .all entries must include a legible signature, legal name (printed in block letters), and discipline. . .””

“LIFE SAFETY FROM FIRE CFR(s): 482.41(b)(1)(2)(3) (b) Standard: Life safety from fire. (1) Except as otherwise provided in this section— (i) The hospital must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) Outpatient surgical departments must meet the provisions applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served. (ii) Notwithstanding paragraph (b)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. (2) In consideration of a recommendation by the State survey agency or Accrediting Organization or at the discretion of the Secretary, may waive, for periods deemed appropriate, specific provisions of the Life Safety Code, which would result in unreasonable hardship upon a hospital, but only if the waiver will not adversely affect the health and safety of the patients. (3) The provisions of the Life Safety Code do not apply in a State where CMS finds that a fire and safety code imposed by State law adequately protects patients in hospitals. This Standard is not met as evidenced by: 42377 . Based on observation and interview, the facility failed to ensure the hospital met the applicable provisions and were compliance in accordance with NFPA 101 Life Safety Code. Specifically, the facility failed to: 1) ensure one out of two required exit egresses was free from obstruction or impediment to allow for a full instant use in accordance with NFPA 101: 7.1.10.1 as referenced by NFPA 19.2; 2) ensure an exit sign was free from visible obstruction in accordance with NFPA 101: 7.10.1.8 as referenced by NFPA 101: 19.2.10.1; 3) implement a fire watch when a portion of the fire alarm system was not in operable condition in accordance with NFPA 101: 9.6.1.6.; and 4) staff were periodically instructed and informed of evacuation plan regarding egress during construction and repair of the Alyeska unit in accordance with NFPA 101: 19.7.2. This failed practice placed 13 patients (#s 1; 2; 8; 9; 10; 11; 12; 13; 14; 15; 16; 17; and 18), out of 13 patients on Denali unit at risk for a delay in egress during an emergency and/or exposure to a smoke and/or fire environment. Findings: An observation of the facility’s second floor patient care area on 10/9/24 at 4:00 PM, revealed the floor was divided into two units (Alyeska and Denali) with a nursing station located in the middle. Exit egresses to stairwells was observed on at the end of each unit which served as the only two exit egress pathways from the floor. Each unit was separated from the elevator common area/front of nursing station by a set of double doors equipped with magnetic locking devices. Continued observation on 10/9/24, revealed the outside of the double doors leading into the Alyeska unit, on the side of the elevator common area/front of nurses’ station area, was covered with a plastic sheet. The sheet covered the doors from ceiling to approximately 18 inches off the floor. The plastic sheet was held in place, on both vertical sides of the door frame, by vice-like floor to ceiling braces. Once the plastic sheet was removed by the Maintenance Director, there were two handwritten signs, one on the door and one on the keycard reader, that indicated not to enter the area, and an exit sign located above the door. Once on the unit, the length of the corridor was filled with construction equipment and tools resulting in a narrowed corridor width. Items included five-gallon buckets of plaster-like materials, hand tools, power tools, hand trowels, and ladders. Further observation revealed the smoke detectors were observed to be covered by a plastic wrapping material. As a result, this caused a significant portion of the smoke detection system non-operational. During an interview on 10/9/24, the Assistant Chief Nursing Officer (ACNO) stated both units were the current path of egress. The ACNO further stated that the facility had not provided any periodic update to the evacuation plan during construction and repair of the Alyeska unit and no modification to the evacuation plan had been implemented. During an interview on 10/9/24, the Contractor #1 stated he/she placed the plastic sheet over the unit’s double doors to “impede” people from entering the unit while he/she was making repairs. During an interview on 10/9/24, the Maintenance Director stated the plastic sheeting over the double doors should not have been utilized as it blocked the exit access and covered the exit sign. The Maintenance Director stated no additional guidance or updates were provided to staff regarding the egress path through the construction area. Maintenance Director further stated the corridor was not free of obstructions and available for full use due to decreased width. .”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 40259 . Based on record review and interview, the facility failed to meet the Condition of Participation of Quality Assessment and Performance Improvement Program (QAPI) in accordance with CFR 482.21. The facility failed to comply with Federal requirements to maintain an effective, ongoing, hospital-wide, data-driven QAPI program that focused on indicators related to improved health outcomes and the prevention and reduction of medical errors to include quality assessment and performance improvement. Findings: 1. The facility’s QAPI Program failed to identify opportunities for improvement and changes that would lead to improvement. Specifically, the QAPI Program failed to: 1) collect data on suicide behavior, gestures, and attempts to ascertain potential opportunities to mitigate occurrences; and 2) set priorities for its performance improvement activities that considered the suicide incidence, prevalence, and severity of the problem. (Refer to A-283). 2. The facility’s QAPI Program failed to measure, analyze, and track adverse patient events that included: 1) patient suicide behavior, gestures, and attempts; and 2) patient emergent higher level of care situations that required Emergency Department (ED) visits. On 8/15/24 at 2:20 PM, the facility Chief Operations Officer (COO), Quality Director, and Risk Manager were informed in person of the determination of immediate jeopardy related to the QAPI program’s failure to design and implement a program that measured, analyzed, and tracked adverse events. The facility submitted an acceptable removal plan on 8/15/24 at 6:00 PM. Implementation of the removal plan was verified on 8/16/24. The immediacy was removed on 8/16/24 at 9:58 AM. Following the removal of the immediacy, noncompliance remained that was not immediate. (Refer to A-286). 3. The facility failed to ensure facility’s Governing Body, medical staff, and administrative officials were responsible and accountable for ensuring that the hospital-wide QAPI Program efforts addressed priorities for improved quality of care and patient safety specific to: 1) patient suicide behavior, gestures, and attempts; and 2) patient emergent higher level of care situations that required Emergency Department (ED) visits. (Refer to A-309). .”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 40259 . Based on record review and interview, the facility failed to meet the Condition of Participation of Nursing Services in accordance with CFR 482.23. The facility failed to comply with Federal requirements to have an organized nursing service that provided 24-hour nursing services to meet the needs of all patients through adequate, competent, and complete delivery of care. Findings: 1) Based on record review and interview, the facility failed to ensure that facility admission assessments were completed for 10 patients (#s 1; 2; 3; 4; 9; 11; 15; 18; 23; and 26), out of 25 sampled patients. Specifically, the “Nursing Admission Assessment” and/or the assigned section of the “Standardized Intake Assessment” were not completed by Licensed Nurses (LNs) in their entirety for a full, completed, and accurate assessment. This failed practice placed all patients (based on a census of 63) at risk for not receiving necessary and/or appropriate medical, psychological, or psychosocial care, services, and treatments, to include treatment planning, during their inpatient programming due to the lack of consistent, accurate, and timely admission screenings/assessments. (Refer to A-395). 2) Based on record review and interview, the facility failed to ensure initial treatment plans were implemented for 2 patients (#s 9 and 26), out of 13 sampled patients actively admitted in the facility. Without timely treatment plans, to identify patient’s mental, medical, and psychosocial needs, and create measurable interventions to meet these needs, these patients were at risk of not receiving the necessary and/or appropriate care and services to ensure patient safety and well-being. (Refer to A-396). 3) Based on record review and interview, the facility failed to ensure: 1) All licensed nurses (LNs) were provided adequate orientation training and completed these trainings and competencies before providing care to patients; 2) All Mental Health Specialists (MHSs) were provided adequate orientation training and completed these trainings and competencies before providing care to patients; and 3) LNs who worked in the adult substance abuse programs received education and training on how to appropriately conduct and interpret detoxification assessments (detox - a structured approach to safely remove toxins or harmful substances from the body) and provide interventions based on those assessments, to include when to administer medications and when to notify a doctor. Specifically, the facility failed to ensure accurate interpretation and implementation of detoxification assessments and treatments for 1 Patient (#8), out of 14 detox patients reviewed, which resulted in an adverse event and required emergent higher level of care and hospitalization. This failed practice regarding detoxification assessments and interventions placed all adult patients actively participating in withdrawal protocols (based on a census of 5) at risk for complications during their detoxification process. The failed practices regarding orientational training of LNs and MHSs placed all patients (based on a census of 63) at risk for subquality of care. On 8/15/24 at 2:20 PM, the facility Chief Operations Officer (COO), Quality Director, and Risk Manager were informed in person of the determination of immediate jeopardy related to the Nursing Leadership’s failure to ensure the operation of nursing services provided accurate substance abuse withdrawal assessments and appropriate and timely interventions to ensure patient safety. The facility submitted an acceptable removal plan on 8/15/24 at 6:00 PM. Implementation of the removal plan was verified on 8/19/24. The immediacy was removed on 8/19/24 at 1:27 PM. Following the removal of the immediacy, noncompliance remained that was not immediate. (Refer to A-397). .”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 40259 . Based on record review and interview, the facility failed to ensure patients received care in a safe setting. Specifically, the facility failed to ensure: 1) Suicide safety precautions were followed for 1 Patient (#19), out of 1 patient reviewed for a suicide gesture and attempt; 2) Every-15 (Q15) minute observation check sheets (monitoring sheets that accompanied staff working with patients; staff were to physically locate and identify the patient’s behavior, location, and position every 15 minutes of the day, 24 hours a day) were completed on the Arctic Recovery detox (detoxification - a structured approach to safely remove toxins or harmful substances from the body) unit for one full nightshift on 7/29/24, from 11:30 PM to 7/30/24 at 7:00 AM, for 4 Patients (#’s 8, 11, 15, and 18) actively on withdrawal protocol, out of 4 patients reviewed for that unit’s total census. 3) Q15 minute observations were physically completed by staff, working with patients on the Arctic Recovery rehabilitation unit, accurately and timely; and 4) Q15 minute observation check sheets were completed accurately and timely for 13 Patients (#’s 2, 3, 4, 5, 6, 8, 9, 13, 16, 18, 19, 20, and 23), out of 26 patients reviewed for Q15 observation documentation. These failed practices placed: 1) Patient #19 at risk for injury, up to and including death; 2) all patients of the Arctic Recovery detox unit on 7/29-30/24 (based on a census of 4) at risk for withdrawal adverse events, delay in care, and injury, up to and including death; and 3) all patients of the Arctic Recovery programs (based on a census of 14) at risk for subquality of care and safety risks due to decreased monitoring. Findings: 1) Suicide Precautions for Safety Patient #19 Record review on 8/8-19/24 revealed Patient #19 was admitted to the facility on 6/24/24 with diagnoses that included opioid dependence and other stimulant dependence. Further review revealed that Patient #19’s admission intake assessment, dated 6/24/24, revealed Patient #19 reported having fleeting suicidal ideation (thoughts of suicide) in the past month prior to admission. The intake assessment documented that Patient #19 reported that he/she had not work out, or started to work out, the details of how he/she would kill himself/herself and didn’t think he/she would act upon these thoughts, however, did report a past serious attempt which required Cardiopulmonary Resuscitation (CPR) intervention. Patient #19’s overall level of suicide risk status was “higher than patients who are safely treated on the inpatient unit.” Patient #19’s High Risk Notification Alert, dated 6/24/24, revealed patient was placed on precautions for safety that included suicide and self-injury behavior. A review of Patient #19’s Q15 minute observation check sheets, dated 6/24/24 through 7/21/24, revealed Patient #19 remained on suicide and self-harm precautions throughout his/her admission. 7/5/24 Incident: During an interview on 8/9/24 at 12:10 PM, Clinical Manager (CM) #1 stated that on Tuesday, 7/9/24, Patient #19 had reported he/she had attempted to “hang” himself/herself last Saturday (7/6/24) and was upset that no one had come to speak to him/her about this attempt yet. From this information, CM #1 started to investigate Patient #19’s report, as it was not known this occurred, and informed leadership as well. During an interview on 8/9/24 at 2:04 PM, the Risk Manager stated that CM #1 alerted leadership about Patient #19’s report of his/her attempt to hang himself/herself on 7/6/24. CM #1 submitted an Incident Report (IR) into the facility’s MIDAS system (their electronic reporting system for incidents) on 7/10/24, identifying the date of incident as 7/6/24, and the Risk Manager began an investigation. The Risk Manager stated a camera review and record review for 7/6/24 was completed with no indications of suicidal behavior or documentation of the incident was identified. However, the patient’s doctor and clinical therapist were informed, and on 7/9/24, Patient #19 was placed on one-on-one (one staff assigned to one patient) observation for safety. The Risk Manager did not review other dates to see if this incident might have occurred at a different time, nor if any other incidents or behaviors occurred regarding Patient #19. During an interview on 8/13/24 at 12:56 PM, Licensed Nurse (LN) #11 stated that on 7/6/24 around 7:45 PM timeframe, he/she was asked to talk to Patient #19, who was tearful and not wanting to take his/her medication. LN #11 stated that when he/she walked down the unit’s hall into Patient #19’s bedroom, he/she stated he/she observed Patient #19 standing in the bathroom door frame holding onto the legs of a pair of legging-like pants that the patient had draped over the top of the bathroom door. When asked how he/she interpreted Patient #19’s behavior, LN #11 stated it was a suicidal gesture, as in the patient was testing to see if the pants could be used as a ligature. LN #11 further stated he/she intervened by asking Patient #19 to come into the dayroom to talk. LN #11 stated he/she talked with Patient #19 for about 30 to 45 minutes, had the second nurse (LN #5) secure the patient’s bedroom, and offered Patient #19 medication for anxiety, which he/she had accepted. LN #11 stated he/she also requested Clinical Therapist (CT) #4 talk with Patient #19 to further help to calm him/her and assess for safety. LN #11 stated that after talking with Patient #19, CT #4 told him/her that Patient #19 wasn’t suicidal and that a note would be written about the CT’s interaction. When asked what kind of documentation and notifications LN #11 made about the incident, LN #11 stated because there was not enough space on the nursing note to write out a total account of the incident, and he/she wrote a very brief synopsis and had assumed that CT #4’s note would cover the rest of the incident. LN #11 stated he/she had not contacted the Patient’s therapist or doctor about the incident. LN #11 had not completed an incident report, although admitted it should have been completed. Review of Patient #19’s medical record, on 8/13/24 at 1:00 PM, revealed no documentation from CT #4 of any encounters with Patient #19. During the course of this complaint survey, the Assistant Chief Nursing Officer (ACNO) completed a more thorough review of the facility’s staffing schedule, camera review, and medical record review, and on 8/13/24 determined that Patient #19’s suicidal gesture actually occurred on Friday 7/5/24. Review of Patient #19’s nurse’s note, dated 7/5/24 and completed by LN #11 for the night shift (7:00 PM through 7:00 AM), revealed written documentation dated 7/6/24 at 6:30 AM about the suicide gesture on evening of 7/5/24: “Behavior/Events . . . Thought Content: Goal oriented, SI [suicidal ideation] . . . RN [registered nurse] to Document to Treatment Plan Progress (Note observations, interventions, and Progress Towards Treatment Plan Goals): . . . At approx. [approximately] [7:35 PM] Pt [patient] was discovered [with] a makeshift “noose” draped over bathroom door. This nurse spoke [with] patient [administered] prn [as needed] Ativan [an antianxiety medication], advised Pt to speak [with] therapist. Pt denied SI/HI [suicidal ideation/homicidal ideation] . . . Pt met [with] therapist and processed [behaviors]. Patient denies having further thoughts of SI/HI at this time . . .” Further review of the nurse’s daily note, dated 7/5/24, revealed an AMSR (assessing and managing suicide risk) Daily Screening, that was completed for day shift (7:00 AM to 7:00 PM) and night shift (7:00 PM to 7:00 AM). Further review revealed for the night shift, LN #11 documented “No” to the question: “1. Thoughts: Since you were last asked, have you actually had thoughts about killing yourself? (if yes, ask 2-5, if no, go to #5)” and also answered “No” to the question: “5. Suicide Behavior: Since you were last asked have you done anything, started to do anything, or prepared to do anything to end you life while hospitalized? If yes, what did you do?” LN #11 did not answer the following questions: “2. Suicidal Thoughts with Method: Have you been thinking about how you might do this?”, “3. Suicidal Intent (without Specific Plan): Have you had these thoughts and had some intention of acting on them?”; and “4. Suicide Intent with Specific Plan: Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?” At the bottom of this screening was the following instructions: “If on Suicide Precautions perform AMSR ASSESSMENT. IF AMSR SCREENS POSITVE: Place on Suicide Precautions, contact physician, perform AMSR assessment.” A review of the facility’s recorded video, dated 7/5/24 from 7:00 PM to 8:46 PM, revealed that LN #11 entered Patient #19’s bedroom at 7:15 PM. At 7:19 PM, both LN #11 and Patient #19 exited the bedroom and went into the common area of the unit. LN #5 was observed to close Patient #19’s bedroom door at 7:37 PM, however did not remove any items from the room. From 7:44 PM to 7:54 PM both nurses interacted with Patient #19 in the common area. At 7:57 PM, CT #4 was seen talking with the nurses in the nurse’s station while Patient #19 remained in the common area. At 8:03 PM, CT #4 and Patient #19 entered an office together, and at 8:45 PM they exited. CT #4 was seen talking with the nurses in the nurse’s station at 8:46 PM. During an interview on 8/14/24 at 11:05 AM, the Risk Manager stated the camera review never showed staff removing items from Patient #19’s bedroom. When informed it was a pair of legging-like pants that Patient #19 had used to hang over the bathroom door, the Risk Manager stated the pants should have been removed from Patient #19’s bedroom for safety. During an interview on 8/14/24 at 11:26 AM, CT #4 stated that when LNs #5 and #11 asked him/her to talk with Patient #19, they never indicated that Patient #19 had made a suicide gesture of hang pants over the bathroom door. CT #4 was asked to talk to Patient #19 because he/she was upset and was trying to leave Against Medical Advice. When asked if CT #4 had documented the encounter with Patient #19, he/she stated he/she had not because “[he/she] wasn’t my patient.” CT #4 stated he/she and Patient #19 processed what was currently bothering him/her and used deep breathing and light therapy to help de-escalate. Patient #19, once calm, decided to remain at the facility and continue treatment. Patient #19 remained on one-on-one staffing precautions until 7/15/24, then returned to Q15 minute observations. Patient remained on suicide and self-harm precautions. 7/21/24 Incident Review of Patient #19’s nurse’s note, dated 7/21/24 at 8:59 PM, revealed: “. . . Pt [patient] is pleasant and appropriate [with] interactions. Pt [Patient] denied SI/SH [suicidal ideation/self-harm] numerous times throughout the day. When this RN [registered nurse] went to admin [administer] nic [nicotine] lozenge at [2:30 PM] pt didn’t respond to name as [he/she] usually does. When this RN went into pts room a tied sheet was observed in the corner of the door . . . This RN went to open door . . . pt fell to floor and was unconscious but did still have a pulse. Sternum rub performed [rubbing knuckles to a patient sternum to illicit a pain response] and pt [patient] gasped for air. [Physician #2] notified at [2:33 PM] pt sent to PAMC [Providence Alaska Medical Center] ED [emergency department] for further eval [evaluation].” At 9:45 PM the following was documented: “Pt [Patient] discharged following notification that pt [patient] was admitted to Prov [Providence] placed on psych [psychiatric] hold. Appropriate parties notified . . .” During an interview on 8/9/24 at 3:05 PM, the Risk Manager stated Patient #19 used three pillowcases tied together with a pair of shorts with a drawstring to make a noose. The drawstring was used around the patient’s neck. During an interview on 8/9/24 at 3:38 PM, the Risk Manager stated Patient #19’s 7/21/24 suicide attempt never should have happened as unit staff had not followed the facility’s safety precautions restrictions outlined for safety. Review of the facility’s “Safety Precautions Standard Work” standardization of implementation of precautions, dated 1/16/23, revealed: “. . . Precautions are intended for specific use to ensure patient safety . . . Precautions are to be documented as a part of the treatment team plan. Restrictions should be implemented at the least restrictive level to current functioning: - Safety considerations for all patients . . . Monitoring . . . Presence with patients to be maintained at all times (must be able to see/hear patients). Patient should never be left unattended . . . Patient room access: Doors to all rooms must remain closed during programming hours . . . Contraband/High Risk items: Please follow the contraband policy to ensure high risk items are not accessible to patients. Contraband searches on unit and in rooms to occur daily . . . - Suicide Precautions: No clothing in patient room and no access to clothing . . . Monitored during dressing, bathing, and toileting with staff maintaining auditory contact. Patient never to be left alone behind a closed door . . . daily room and person contraband searches . . .” Review of facility video recordings, dated 7/5/24, 7/6/24, and 7/21/24, revealed all unit bedroom doors were open during programming hours, Patient #19 was allowed to close his/her bedroom door at times for extended periods of time without staff present, and clothing was not restricted as Patient #19 was seen entering his/her bedroom, and then exiting in different clothes on two occasions on different days. During an interview on 8/12/24 at 2:19 PM, while reviewing video recordings with surveyors, for the dates of 7/5/24 and 7/6/24, the Risk Manager stated bedroom doors were not allowed to be left open during programming hours as they were seen on videos. Review of the facility’s policy “Contraband Items/Suspected Drugs,” effective 5/2024, revealed: “. . . contraband refers to property that is illegal and/or prohibited to possess in a psychiatric facility due to probability for the item to be used in a potentially harmful way. The item is prohibited due to the ability of the patient/resident to harm themselves or others either by using the item correctly or incorrectly . . . Staff will ensure that all items listed as contraband will be removed from the patient/resident to prevent self-harm or harm to others . . . The following items are considered contraband and will be taken upon admission to the hospital . . . and locked in a separate storage area . . . Drawstrings in clothing . . .” Review of the facility’s policy “Special Precautions and Levels of Monitoring, Motion Sensors,” effective 5/2024, revealed: “. . . Suicide Precautions . . . The attending physician . . . may order suicide precautions for patient/residents who as assessed to be suicidal and, without heightened supervision, are at risk for self-harm up to and including death . . . When suicide precautions are ordered, the physician in collaboration with the treatment team will identify and order interventions to keep the patient safety . . . The RN [registered nurse] shall complete a suicide risk assessment each shift. Any change of the assessment indicating an enhanced risk of harm will be conveyed to the physician within 1 hour of the assessment . . . All patient/resident specific interventions will be review at each shift change by nursing and MHS staff . . .” 2) 7/29/24 Nightshift Q15 Observation Completion The facility’s Arctic Recovery program consisted of two units: the detox unit, where newly admitted patients went through detox protocols for close monitoring during withdrawal; and the rehabilitation unit, where patients move to after detox is completed and the participate in active programming. During an interview on 8/8/24 at 12:29 PM, the Assistant Chief Nursing Officer (ACNO) stated that the facility had a goal of staffing each unit with at least one LN and one MHS. More staff would be added based on census and acuity of each unit. During an interview on 8/11/24 at 12:40 AM, Mental Health Specialist (MHS) #61 stated that on the nightshift of 7/30/24, which started on 7/29/24 at 11:30 PM and stopped on 7/30/24 at 7:00 AM, the schedule reflected that the Arctic Recovery programs two units only had two LNs (#’s 9 and 46) and one MHS, himself/herself, and knew coming to work that day the units were missing one MHS. Due to census numbers, MHS #61 was assigned to the rehabilitation unit along with LN #46, and since there were only four patients on the detox unit, LN #9 was assigned to that side alone. MHS #61 further stated that LN #9 was angry there was no MHS for the detox unit and stated it wasn’t his/her responsibility to complete Q15 observation sheets and rounding. MHS #61 stated he/she stayed on the rehabilitation unit and completed his/her assigned duties all night. It wasn’t until 7:00 AM on 7/30/24 that it was discovered LN #9 never completed any of the Q15 minute observations for the entire nightshift. During an interview on 8/12/24 at 2:06 PM, the Risk Manager stated that through camera review it was confirmed that LN #9 hadn’t completed any Q15 observation rounds on the nightshift on 7/29-30/24. Review of Patient #’s 8, 11, 15, and 18’s Q15 observation check sheets, from 7/29/24 at 11:30 PM to 7/30/24 at 7:00 AM, revealed no documentation every 15 minutes per policy. Further review revealed the following documentation over the 15-minute slots: “7/31/24: Late entry for 7/30/24. The Q15 documentation did not support rounding from [11:00 PM - 7:00 AM]. This was followed up on by nursing leadership.” Review of the facility’s policy “Detoxification Services,” effective 5/2024, revealed: “. . . The purpose of this policy is to establish treatment provision of services guidelines for patients/residents who are in need of detoxification services in a manner that . . . May relieve the patient’s/resident’s discomfort . . . Prevent the development of more serious symptoms, and . . . Forestall cumulative effects that might worsen future withdrawals . . . [The facilities] are equipped to provide detoxification services that meet the unique recovery needs of the medically compromised patient . . . The intensity of withdrawal cannot always be predicted accurately and requires close observation . . . A precaution flow sheet will be initiated at the time of admission and the patient will be monitored at fifteen (15) minute intervals. Note: Patients who are at a higher risk for over sedation and respiratory depression include: Patient with new orders for opioids-first 24 hours, Patients with shallow respirations upon respiratory assessment as indicated by monitoring the risk and fall of the patient’s chest to determine the rate, depth, and regularity of respirations, [and] patient with periods of apnea . . .” 3) Conducting Q15 minute Observation Reviews Q15 minute Observation Protocol Review of the facility’s policy “Special Precautions and Levels of Monitoring, Motion Sensors,” effective 5/2024, revealed: “. . . The standard monitoring procedure in all [facility name] facilities is 15 minutes visual monitoring unless otherwise ordered by the physician. During 15 minute monitoring, staff are to directly observe the patient/resident every 15 minutes while remaining close enough to hear the patient/resident and respond to needs and events at all times . . . Documentation: Monitoring staff will maintain an observation record and document every 15 minutes the patient’s/resident’s location and observed behavior. The RN [registered nurse] will provide oversight of the observation rounds and will document oversight at least 3 times in a 12-hour period (a minimum of 6 times in 24/hour period) . . .” The facility utilized a patient observation sheet called a “Patient Observation Record [and] Milieu Group” sheet. This sheet had blocked times every 15 minutes and staff would document at each 15-minute interval the patient’s location, behavior, and position. Nurses would then check these observation sheets, called “nursing oversight” on the sheet, three times per their 12-hour shift to ensure they were completed accurately and timely, by signing and dating the sheets at each oversight. During an interview on 8/13/24 at 8:30 AM, the Program Educator stated MHS and LN staff received training on Q15-minute observation policy, and documentation to be completed during patient observations, at their new hire orientation. The Program Educator further stated staff signed a Q15-minute observation attestation which stated they understood the education and would follow the protocol standards. Camera Reviews Review of facility recorded video on the Arctic Recovery rehabilitation unit, on 7/6/24 from 9:30 AM to 10:49 AM, revealed no Q15 minute rounding was physically conducted from 9:42 AM to 10:47 AM (1 hours and 5 minutes). During this timeframe there were patients in their rooms and out of sight from staff. Review of Q15 minute observation documentation revealed observations were documented as being completed every 15 minutes during these missed rounding periods. Review of facility recorded video on the Arctic Recovery rehabilitation unit, on 7/6/24 from 7:38 PM to 11:23 PM, revealed no Q15 minute rounding was physically conducted from 7:42 PM to 11:07 PM (3 hours and 25 minutes). During this timeframe there were patients in their rooms and out of sight from staff. Review of Q15 minute observation documentation revealed observations were documented as being completed every 15 minutes during these missed rounding periods. 4) Q15 Minute Observation Check Sheet Documentation Review Review of patient Q15 minute observation sheets, on 8/8-19/24, revealed: Patient #2 Record revealed Patient #2 was admitted to the facility on 6/13/24 with a diagnosis of alcohol dependence and cannabis abuse. Review of Patient #2’s Q15 observation sheets revealed the following deficiencies: - 7/5/24: The Q15 observation sheet was missing one nightshift (7:00 PM - 7:00 AM) Licensed Nurse (LN) oversight signature. Further review of the sheet revealed there was no documentation of the patient’s location, behavior, or position at 11:15 AM and 1:45 PM. - 7/6/24: The Q15 observation sheet was missing one nightshift and two dayshift (7:00 AM - 7:00 PM) LN oversight signatures. - 7/19/24: The Q15 observation sheet was missing all three of the nightshift LN oversight signatures. - 7/20/24: The Q15 observation sheet was missing all six of the LN oversight signatures. - 7/22/24: The Q15 observation sheet was missing one nightshift LN oversight signature. - 8/7/24: The Q15 observation sheet was missing two nightshift LN oversight signatures. - 8/8/24: The Q15 observation sheet was missing one nightshift LN oversight signature. Patient #3 Record revealed Patient #3 was admitted to the facility on 7/9/24 with a diagnosis of opioid dependence and other stimulant dependence, uncomplicated. Review of Patient #3’s Q15 monitoring sheets revealed the following deficiencies: - 8/7/24: The Q15 monitoring sheet was missing one nightshift and one dayshift LN oversight signatures. - 8/8/24: The Q15 monitoring sheet was missing one nightshift LN oversight signature. Patient #4 Record revealed Patient #4 was admitted to the facility on 7/22/24 with a diagnosis of alcohol dependence. Review of Patient #4’s Q15 monitoring sheets revealed the following deficiencies: - 7/22/24: The Q15 monitoring sheet was missing all three of the nightshift LN oversight signatures and two dayshift LN oversight signatures. - 8/7/24: The Q15 monitoring sheet was missing two nightshift LN oversight signatures. Patient #5 Record revealed Patient #5 was admitted to the facility on 7/18/24 with a diagnosis of alcohol dependence and other stimulant dependence, uncomplicated. Review of Patient #5’s Q15 monitoring sheets revealed the following deficiencies: - 7/20/24: The Q15 monitoring sheet was missing one nightshift LN oversight signature. - 7/21/24: The Q15 monitoring sheet was missing one nightshift LN oversight signature. - 7/22/24: The Q15 monitoring sheet was missing all three of the dayshift LN oversight signatures. - 8/7/24: The Q15 monitoring sheet was missing two nightshift LN oversight signatures. - 8/8/24: The Q15 monitoring sheet was missing one nightshift LN oversight signatures. Patient #6 Record revealed Patient #6 was admitted to the facility on 8/5/24 with a diagnosis of post-traumatic stress disorder (PTSD) Review of Patient #6’s Q15 monitoring sheet, dated 8/6/24, revealed it was missing two nightshift LN oversight signatures. Patient #8 Record revealed Patient #8 was admitted to the facility on 8/6/24 with a diagnosis of PTSD. Review of Patient #8’s Q15 monitoring sheet, dated 8/6/24, was missing two nightshift LN oversight signatures. Patient #9 Record revealed Patient #9 was admitted to the facility on 7/22/24 with a diagnosis of PTSD. Review of Patient #9’s Q15 monitoring sheet, dated 8/6/24, was missing two nightshift LN oversight signatures. Patient #13 Record revealed Patient #13 was admitted to the facility on 2/10/24 through 5/12/24 with a diagnosis of major depressive disorder, recurrent, severe, with psychosis. Review of Patient #13’s Q15 monitoring sheets revealed the following deficiencies: - 2/10/24: The Q15 monitoring sheet was missing one nightshift LN oversight signature. - 2/18/24: The Q15 monitoring sheet was missing one nightshift and all three of the dayshift LN oversight signatures. - 2/29/24: The Q15 monitoring sheet revealed there was no documentation of the patient’s location, behavior, or position at 7:45 AM and 14:30 PM. - 4/5/24: The Q15 monitoring sheet was missing two dayshift LN oversight signatures. Further review of the sheet revealed there was no documentation of the patient’s location, behavior, or position at 4:30 PM. - 4/6/24: The Q15 monitoring sheet was missing all three of the dayshift LN oversight signatures. Further review of the sheet revealed there was no documentation of the patient’s location, behavior, or position at 8:15 PM and 8:30 PM. Patient #16 Record revealed Patient #16 was admitted to the facility on 6/1/24 through 8/2/24 with a diagnosis of major depressive disorder, single episode, severe with psychotic features. Review of Patient #16’s Q15 monitoring sheets revealed the following deficiencies: - 6/18/24: The Q15 monitoring sheet revealed there was no documentation of the patient’s location, behavior, or position at 3:45 PM. -7/10/24: The Q15 monitoring sheet was missing one nightshift LN oversight signature. Patient #18 Record revealed Patient #18 was admitted to the facility on 7/22/24 through 8/1/24 with a diagnosis of alcohol dependence. Review of Patient #18’s Q15 monitoring sheet, dated 7/22/24, was missing two nightshift and all three of the dayshift LN oversight signatures. Further review of the 7/22/24 Q15 observation sheet revealed there was no documentation of the patient’s location, behavior, or position at 7:15 PM, 7:30 PM, 7:45 PM, 8:00 PM, 8:15 PM, 8:30 PM, 8:45 PM, 9:00 PM, and 9:15 PM. Patient #19 Record revealed Patient #19 was admitted to the facility on 6/24/24 through 7/21/24 with a diagnosis of opioid dependence and other stimulant dependence. Review of Patient #19’s Q15 monitoring sheets revealed the following deficiencies: - 7/6/24: The Q15 monitoring sheet was missing one nightshift and two dayshift LN oversight signatures. -7/21/24: The Q15 monitoring sheet was missing one nightshift LN oversight signatures. Patient #20 Record revealed Patient #20 was admitted to the facility on 7/22/24 through 7/26/24 with a diagnosis of alcohol dependence and other stimulant dependence. Review of Patient #20’s Q15 monitoring sheet, dated 7/22/24, was missing all three of nightshift LN oversight signatures. Patient #23 Record revealed Patient #23 was admitted to the facility on 7/22/24 through 7/24/24 with a diagnosis of alcohol dependence. Review of Patient #23’s Q15 monitoring sheet, dated 7/22/24, was missing all three of nightshift and two dayshift LN oversight signatures. Review of the facility’s policy “Patient Rights,” effective 5/2023, revealed: “. . . It is the policy of the [facility] to protect the fundamental, human, civil, and constitutional rights of each patient/resident . . . The right to move about freely on the unit as their treatment plan and unit safety allow . . . The right to a clean and safe unit and hospital . . . [the facility] seeks to render care and treatment in a way that considers, respects, and protects the rights and personal dignity of each patient/resident . . . Care will be provided at the least restrictive level consistent with patient/resident safety and the treatment plan . . .” .”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 40259 . Based on interview and record review, the facility’s Quality Assessment and Performance Improvement (QAPI) Program failed to identify opportunities for improvement and changes that would lead to improvement. Specifically, the QAPI Program failed to: 1) collect data on suicide behavior, gestures, and attempts to ascertain potential opportunities to mitigate occurrences; and 2) set priorities for its performance improvement activities that considered the suicide incidence, prevalence, and severity of the problem. This failed practice limited the QAPI Program from reviewing potential deficient practices, that could have contributed to opportunities of suicidal behavior, gestures, and attempts, and placed all patient (based on a census of 63) at risk for injury, up to and including death, and/or substandard quality of care. Findings: Patient #19 Record review on 8/8-19/24 revealed Patient #19 was admitted to the facility on 6/24/24 with diagnoses that included opioid dependence and other stimulant dependence. Patient #19 was also assessed as being high risk for suicide and self-harm behavior and was placed on suicide and self-harm precautions. Reviews of Patient #19’s medical records and facility camera recordings, dated 7/5/24 and 7/21/24, revealed Patient #19 made a suicidal gesture on 7/5/24 witnessed by staff, by draping a pair of legging-like pants over the bedroom’s bathroom door as a makeshift “noose”, and then made a suicide attempt, by hanging on 7/21/24 to the point of losing consciousness and required medical intervention. Facility’s Investigation 7/5/24 Incident Review of the facility’s investigation, of the 7/5/24 incident, revealed the facility’s inability to thoroughly investigation the incident and to correctly identify the actual date of when the incident occurred and because of this, subsequently did not identify potential deficient practices that could have contributed to the incident: During an interview on 8/9/24 at 12:10 PM, Clinical Manager (CM) #1 stated that on Tuesday, 7/9/24, Patient #19 had reported he/she had attempted to “hang” himself/herself last Saturday (7/6/24) and was upset that no one had come to process this attempt yet. From this information, CM #1 started to investigate Patient #19’s report, as it was not known this occurred, and informed leadership as well. During an interview on 8/9/24 at 2:04 PM, the Risk Manager stated that CM #1 alerted leadership about Patient #19’s report of his/her attempt to hang himself/herself on 7/6/24. CM #1 submitted an Incident Report (IR) into the facility’s MIDAS system (their electronic reporting system for incidents) on 7/10/24, identifying the date of incident as 7/6/24, and the Risk Manager began an investigation. The Risk Manager stated a camera review and record review for 7/6/24 was completed with no indications of suicidal behavior or documentation of the incident was identified. The Risk Manager did not review other dates to see if this incident might have occurred at a different time, nor if any other incidents or behaviors occurred regarding Patient #19. During the course of this complaint survey, the Assistant Chief Nursing Officer (ACNO) completed a more thorough review of the facility’s staffing schedule, camera review, and medical records review, and on 8/13/24 determined that Patient #19’s suicidal behavior actually occurred on Friday 7/5/24. During an interview on 8/13/24 at 9:51 AM, the Chief Nursing Officer (CNO) stated that Licensed Nurse (LN) #11, who was a travel nurse, was working the day Patient #19 made the 7/6/24 suicide gesture and failed to complete an Incident Report (IR), failed to document the incident in the nurse’s note for that shift, and did not notify the Provider. (At the time of the CNO’s investigation, the facility still had the 7/6/24 date identified as the date of incident) During an interview on 8/13/24 at 11:00 AM, the CNO stated she had only learned of the incident 3 days later and completed a telephone interview with LN #11 to ascertain what exactly occurred, however did not document this interview. The CNO further stated that because LN #11 was a travel nurse, the facility didn’t have the authority to discipline travel nurses and that the travel agency was contacted to do this. The CNO stated she verbally coached LN #11 on the appropriate processes for submitting an IR, however the absence of documentation for Patient #19’s suicidal gesture was not addressed. The CNO stated this coaching was not documented. During an interview on 8/13/24 at 11:45 AM, the Human Resources Director stated she was not informed of the need to contact any travel agency for disciplinary needs for LN #11. During an interview on 8/14/24 at 9:37 AM, the Quality Director stated the facility acknowledged it could have done better documenting the 7/5/24 incident and the facility’s investigation of the incident. 7/21/24 Incident Review of the facility’s investigation, of the 7/21/24 incident, revealed the facility failed to ensure unit staff followed facility standardization of implementation of safety precautions to mitigate the potential for Patient #19’s suicide attempt, that were present during the 7/5/24 incident. Review of the facility’s “Safety Precautions Standard Work” standardization of implementation of precautions, dated 1/16/23, revealed: “. . . Precautions are intended for specific use to ensure patient safety . . . Precautions are to be documented as a part of the treatment team plan. Restrictions should be implemented at the least restrictive level to current functioning: - Safety considerations for all patients . . . Monitoring . . . Presence with patients to be maintained at all times (must be able to see/hear patients). Patient should never be left unattended . . . Patient room access: Doors to all rooms must remain closed during programming hours . . . Contraband/High Risk items: Please follow the contraband policy to ensure high risk items are not accessible to patients. Contraband searches on unit and in rooms to occur daily . . . - Suicide Precautions: No clothing in patient room and no access to clothing . . . Monitored during dressing, bathing, and toileting with staff maintaining auditory contact. Patient never to be left alone behind a closed door . . . daily room and person contraband searches . . .” During an interview on 8/9/24 at 3:38 PM, the Risk Manager stated Patient #19’s 7/21/24 suicide attempt never should have happened as unit staff had not followed the facility’s safety precautions restrictions outlined for safety. Review of facility video recordings, dated 7/5/24, 7/6/24, and 7/21/24, revealed all unit bedroom doors were open during programming hours, Patient #19 was allowed to close his/her bedroom door at times for extended periods of time without staff present, and clothing was not restricted as Patient #19 was seen entering his/her bedroom, and then exiting in different clothes on two occasions on different days. During an interview on 8/12/24 at 2:19 PM, while reviewing video recordings with surveyors, the Risk Manager stated bedroom doors were not allowed to be left open during programming hours as they were seen on videos. Facility Risk Management and Quality Assurance Oversignt During an interview on 8/13/24 at 10:47 AM, the Risk Manager stated the Patient Safety Council meetings were completed once a month and the committee measured and monitored the following items: - Restraints/Seclusions rates; - Patient injuries in restraints/seclusions; - Patient aggression with and without injuries; - Elopements; - Falls; - Medication variances (like medication errors or adverse reactions); and - Patient safety alert advisory topics (these are presented to staff for reminders to help assure safety. Example: keep keys and badges secure) Review of facility Patient Safety Council meeting minutes, dated 1/2024 through 6/2024, revealed no measurements or monitoring for suicide behavior, gestures, or attempts. During an interview on 8/13/24 at 12:09 PM, the Quality Director stated the facility’s Performance Improvement (PI) committee (the facility’s QAPI Program) only monitored performance tasks. Review of the facility’s “BH [Behavioral Health] Performance Indicator Database - Acute” list, undated, revealed the list included “Suicide Risk Assessment/Management” which measured: “Compliance with initial suicide risk assessment; overall suicide risk level documented and proper mitigation taken based on risk level; do precautions march risk level; discharge education provided based on risk.” Further review of the performance indicator list revealed no monitoring of suicide behavior, gesture, or attempts. During an interview on 8/15/24 at 12:42 PM, the Risk Manager and Quality Director stated that suicidal behavior, gesture, and attempt data was not collected and assessed for performance improvement activities. Review of the facility’s “Quality Assurance [and] Performance Improvement (QAPI)” plan, dated 2024, revealed: “. . . The successful execution of the QAPI program is the result of the foundation of leadership commitment, education in performance improvement techniques, commitment of resources to execute improvement opportunities, information management systems for data display and comparisons and employee involvement in improving their own work processes . . . We believe important hospital processes and functions that perform well result in high quality patient care. The facility fulfills its responsibilities to patients, professionals, support staff and the community through continuous and systematic measurement, assessment and improvement of its systems and processes. The 2024 Plan addresses patient-focused and organization-wide processes and functions that have the greatest potential to improve patient safety and outcomes . . .” .”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 40259 . Based on interview and record review, the facility’s Quality Assessment and Performance Improvement (QAPI) Program failed to measure, analyze, and track adverse patient events that included: 1) patient suicide behavior, gestures, and attempts; and 2) patient emergent higher level of care situations that required Emergency Department (ED) visits. This failed practice limited the QAPI Program from reviewing potential deficient practices, that could have contributed to: 1) opportunities of suicidal behavior, gestures, and attempts; and 2) the need for emergent higher level of care. This placed all patient (based on a census of 63) at risk for injury, up to and including death, and/or substandard quality of care. On 8/15/24 at 2:20 PM, the facility Chief Operations Officer (COO), Quality Director, and Risk Manager were informed in person of the determination of immediate jeopardy related to the QAPI program’s failure to design and implement a program that measured, analyzed, and tracked adverse events. The facility submitted an acceptable removal plan on 8/15/24 at 6:00 PM. Implementation of the removal plan was verified on 8/16/24. The immediacy was removed on 8/16/24 at 9:58 AM. Following the removal of the immediacy, noncompliance remained that is not immediate. Findings: Suicide Behavior, Gestures, and Attempts Patient #19 Record review on 8/8-19/24 revealed Patient #19 was admitted to the facility on 6/24/24 with diagnoses that included opioid dependence and other stimulant dependence. Patient #19 was also assessed as being high risk for suicide and self-harm behavior and was placed on suicide and self-harm precautions. Reviews of Patient #19’s medical records and facility camera recordings, dated 7/5/24 and 7/21/24, revealed Patient #19 made a suicidal gesture on 7/5/24 witnessed by staff, by draping a pair of legging-like pants over the bedroom’s bathroom door as a makeshift “noose”, and then made a suicide attempt, by hanging on 7/21/24 to the point of losing consciousness and required medical intervention. Facility’s Investigation 7/5/24 Incident Review of the facility’s investigation, of the 7/5/24 incident, revealed the facility’s inability to thoroughly investigation the incident and to correctly identify the actual date of when the incident occurred and because of this, subsequently did not identify potential deficient practices that could have contributed to the incident: During an interview on 8/9/24 at 12:10 PM, Clinical Manager (CM) #1 stated that on Tuesday, 7/9/24, Patient #19 had reported he/she had attempted to “hang” himself/herself last Saturday (7/6/24) and was upset that no one had come to process this attempt yet. From this information, CM #1 started to investigate Patient #19’s report, as it was not known this occurred, and informed leadership as well. During an interview on 8/9/24 at 2:04 PM, the Risk Manager stated that CM #1 alerted leadership about Patient #19’s report of his/her attempt to hang himself/herself on 7/6/24. CM #1 submitted an Incident Report (IR) into the facility’s MIDAS system (their electronic reporting system for incidents) on 7/10/24, identifying the date of incident as 7/6/24, and the Risk Manager began an investigation. The Risk Manager stated a camera review and record review for 7/6/24 was completed with no indications of suicidal behavior or documentation of the incident was identified. The Risk Manager did not review other dates to see if this incident might have occurred at a different time, nor if any other incidents or behaviors occurred regarding Patient #19. During the course of this complaint survey, the Assistant Chief Nursing Officer (ACNO) completed a more thorough review of the facility’s staffing schedule, camera review, and medical records review, and on 8/13/24 determined that Patient #19’s suicidal behavior actually occurred on Friday 7/5/24. During an interview on 8/13/24 at 9:51 AM, the Chief Nursing Officer (CNO) stated that Licensed Nurse (LN) #11, who was a travel nurse, was working the day Patient #19 made the 7/6/24 suicide gesture and failed to complete an Incident Report (IR), failed to document the incident in the nurse’s note for that shift, and did not notify the Provider. (At the time of the CNO’s investigation, the facility still had the 7/6/24 date identified as the date of incident) During an interview on 8/13/24 at 11:00 AM, the CNO stated she had only learned of the incident 3 days later and completed a telephone interview with LN #11 to ascertain what exactly occurred, however did not document this interview. The CNO further stated that because LN #11 was a travel nurse, the facility didn’t have the authority to discipline travel nurses and that the travel agency was contacted to do this. The CNO stated she verbally coached LN #11 on the appropriate processes for submitting an IR, however the absence of documentation for Patient #19’s suicidal gesture was not addressed. The CNO stated this coaching was not documented. During an interview on 8/13/24 at 11:45 AM, the Human Resources Director stated she was not informed of the need to contact any travel agency for disciplinary needs for LN #11. During an interview on 8/14/24 at 9:37 AM, the Quality Director stated the facility acknowledged it could have done better documenting the 7/5/24 incident and the facility’s investigation of the incident. 7/21/24 Incident Review of the facility’s investigation, of the 7/21/24 incident, revealed the facility failed to ensure unit staff followed facility standardization of implementation of safety precautions to mitigate the potential for Patient #19’s suicide attempt, that were present during the 7/5/24 incident. Review of the facility’s “Safety Precautions Standard Work” standardization of implementation of precautions, dated 1/16/23, revealed: “. . . Precautions are intended for specific use to ensure patient safety . . . Precautions are to be documented as a part of the treatment team plan. Restrictions should be implemented at the least restrictive level to current functioning: - Safety considerations for all patients . . . Monitoring . . . Presence with patients to be maintained at all times (must be able to see/hear patients). Patient should never be left unattended . . . Patient room access: Doors to all rooms must remain closed during programming hours . . . Contraband/High Risk items: Please follow the contraband policy to ensure high risk items are not accessible to patients. Contraband searches on unit and in rooms to occur daily . . . - Suicide Precautions: No clothing in patient room and no access to clothing . . . Monitored during dressing, bathing, and toileting with staff maintaining auditory contact. Patient never to be left alone behind a closed door . . . daily room and person contraband searches . . .” During an interview on 8/9/24 at 3:38 PM, the Risk Manager stated Patient #19’s 7/21/24 suicide attempt never should have happened as unit staff had not followed the facility’s safety precautions restrictions outlined for safety. Review of facility video recordings, dated 7/5/24, 7/6/24, and 7/21/24, revealed all unit bedroom doors were open during programming hours, Patient #19 was allowed to close his/her bedroom door at times for extended periods of time without staff present, and clothing was not restricted as Patient #19 was seen entering his/her bedroom, and then exiting in different clothes on two occasions on different days. During an interview on 8/12/24 at 2:19 PM, while reviewing video recordings with surveyors, the Risk Manager stated bedroom doors were not allowed to be left open during programming hours as they were seen on videos. Facility Risk Management and Quality Assurance Oversignt During an interview on 8/13/24 at 10:47 AM, the Risk Manager stated the Patient Safety Council meetings were completed once a month and the committee measured and monitored the following items: - Restraints/Seclusions rates; - Patient injuries in restraints/seclusions; - Patient aggression with and without injuries; - Elopements; - Falls; - Medication variances (like medication errors or adverse reactions); and - Patient safety alert advisory topics (these are presented to staff for reminders to help assure safety. Example: keep keys and badges secure) Review of facility Patient Safety Council meeting minutes, dated 1/2024 through 6/2024, revealed no measurements or monitoring for suicide behavior, gestures, or attempts. During an interview on 8/13/24 at 12:09 PM, the Quality Director stated the facility’s Performance Improvement (PI) committee (the facility’s QAPI Program) only monitored performance tasks. Review of the facility’s “BH [Behavioral Health] Performance Indicator Database - Acute” list, undated, revealed the list included “Suicide Risk Assessment/Management” which measured: “Compliance with initial suicide risk assessment; overall suicide risk level documented and proper mitigation taken based on risk level; do precautions march risk level; discharge education provided based on risk.” Further review of the performance indicator list revealed no monitoring of suicide behavior, gesture, or attempts. ED Visits Detoxification (Detox) Protocol The facility had two inpatient programs for adults: 1) The Arctic Recovery Program which offered detox and rehabilitation for substance abuse to civilians; and 2) The Chris Kyle Patriot Hospital which offered trauma-focused care, detox and rehabilitation for military, veterans, their families, and first responders. During the detox process, nurses monitored newly admitted patients through their withdrawal symptoms and provided scheduled and PRN (as needed) medications and treatments to help safely guide them through detoxing from alcohol and/or opioids (narcotic medications). Two assessment forms were used: 1. Alcohol Withdrawal - A Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) form; and 2. Opioid Withdrawal - A Clinical Opiate Withdrawal Scale (COWS) form. The detox monitoring typically started upon admission and was completed every 4 hours, then graduated to every 6 hours and then every 8 hours, depending on how individual patients responded to detoxing. These assessments entailed obtaining vital signs and rating the patient’s symptoms on severity scales. A total score would be ascertained at every assessment, and based on that total score medications would be administered and treatments would be implemented. During an interview on 8/12/24 at 4:24 PM, LN #2 stated new nurses completed an in-class structured orientation, and after this would have 2 to 3 shadow days with a nurse to learn the role. After this, new nurses were assigned a shift and put into direct patient care. LN #2 stated that from his/her experience in working with newly hired nurses, they weren’t prepared and didn’t know where things were or how to appropriately monitor detox patients. During an interview on 8/12/24 at 4:45 PM, LN #8 stated newly hired nurses didn’t know their roles after they completed orientation and shadow days. Experiencing orientation when hired, LN #8 stated he/she had no detox training at orientation and hadn’t known about withdrawal symptoms from alcohol or substances, how to perform CIWA (shortened version of CAIW-Ar) or COWS screenings, and what the scores meant. 7/31/24 Incident During an interview on 8/12/24 at 5:31 PM, LN #7 stated he/she had picked up an extra shift on Arctic Recovery, which started at 11:00 PM. When he/she arrived, it was discovered that Patient #8 was newly admitted for alcohol dependence and was experiencing distressing withdrawal symptoms. When LN #7 talked with the nurses who were currently working, LNs #30 and #41, it was discovered the nurses had not provided withdrawal PRN medication interventions, since admission because they thought it was facility policy that they could not provide medications if the patient’s blood alcohol level was still elevated and not within the legal limit (0.08 in Alaska), which was not the case. LN #7 stated he/she began to assess Patient #8. His/her blood alcohol level was 0.11 and he/she was shaking to the point that a wheelchair was required to transfer the patient to his/her bedroom. LN #7 initiated PRN medication interventions, of Ativan (an antianxiety medication) and attempted to get the patient’s symptoms under control, however, could not. At around 5:00 AM, LN #7 called the provider on-call and received orders to have the patient transferred to the ED. The patient was subsequently admitted to the hospital. LN #7 further stated that an incident report was filed, and he/she reported to nursing leadership of the concern that these newer nurses were not administering detox protocols appropriately which may have contributed to Patient #8’s decline and need for emergent higher level of care. Review of Patient #8’s medical record, dated 7/31/24 through 8/1/24, revealed the following information: - Patient #8’s blood alcohol level upon admission, on 7/31/24 at 10:15 AM, was 0.36 (According to the National Institute on Alcohol Abuse and Alcoholism article entitled “Alcohol’s Effects on Health”, dated January 2023 reveal a level between 0.31 to 0.45 is considered life threating and may contribute to unconsciousness and significant risk of death due to suppression of vital life functions.) - Patient #8 had a history of seizures, the last seizure occurred in 5/2023. - During the admission process, Patient #8 had vomited and was sent over to the ED for medical clearance prior to being admitted. Patient was medically cleared and returned to the facility around 5:00 PM. - At 5:00 PM, Patient #8’s CIWA score was 9 (which indicated minimal to mild withdrawal), however was rated as having visible tremors, more than mildly anxious, and had beads of sweat obvious on his/her forehead. No medication intervention was documented as given. - At 6:00 PM, his/her blood alcohol level was 0.27 (According to the National Institute on Alcohol Abuse and Alcoholism article entitled “Alcohol’s Effects on Health”, dated January 2023 reveal a level between 0.15 to 0.30 is considered severe impairment and may contribute to confusion, vomiting, drowsiness, and unconsciousness.) - At 8:00 PM, Patient #8’s CIWA score was 10 (which still indicated minimal to mild withdrawal), however his/her symptoms were more increased: mildly nauseous, tremors were less, mildly anxious, beads of sweat were still visible on forehead, and had a mild headache or fullness in head. LN #30 documented “1.9 BRAK [blood alcohol level] scheduled” where medications were to be listed if given. Medications that were given was gabapentin (An anticonvulsant medication used for seizures, nerve pain, and restless legs) at 8:38 PM, Seroquel at 8:39 PM, and Tylenol at 8:40 PM. - Once LN #7 was on shift, he/she took over Patient #8’s care. - At 12:00 AM, Patient #8’s CIWA score was 9, with elevated anxiety and headache, and LN #7 administered Tylenol and Ativan by mouth. - At 3:10 AM, Patient #9’s CIAWA score remained 9, however Patient #8’s anxiety increased. Ativan was again administered by mouth. - At 4:30 AM, Patient #8’s CIWA score was 18 (which indicated severe withdrawal), and Ativan was administered via injection. When this was not effective, LN #7 notified the provider and the decision was made to transport the patient to the ED. Patient #8 left, with a staff escort and EMS at 5:50 AM. Patient #8 was without withdrawal PRN medication treatment for approximately 6 hours prior to LN #7 arriving for work. During an interview on 8/13/24 at 11:00 AM, the ACNO stated LN #7 did contact her and the CNO about the 7/31/24 incident and verbalized concerns that LNs #30 and #41 didn’t give CIWA score intervention. As they investigated this, nursing leadership realized there was a gap in the CIWA and COWS assessments and ordered medication interventions, where that there were no parameters set to alert nurses to provide certain interventions based on scores of the assessments. The ACNO stated that they were working with the facility’s pharmacist to add score parameters for medications, however this was not completed and not being used by nurses currently. During an interview at 8/15/24 at 10:02 AM, when asked what Risk had investigated regarding the 7/31/24 incident, the Risk Manager stated, “I don’t investigate stuff like this” and stated she referred it to nursing leadership to review. During an interview on 8/15/24 at 11:06 AM, the ACNO stated that the Incident Report was reviewed during safety huddle and nursing leadership followed up on the change of condition to only see if the patient returned to the facility or not. Usually, when a patient went to the ED, nurse leadership ascertained if they returned to the facility, and if they did, to ensure they were seen by medical personnel the next day. Patient #7 had not returned to the facility. When asked if the facility ever requests medical records for patients that were seen at the ED, the ACNO stated no and that they only received records that were returned with patients from the ED. When asked what nursing leadership had done regarding the 7/31/24 incident and the nurse’s misinterpretation of how to perform detox assessments and interventions, the ACNO stated because LN #7 stated he/she had educated LNs #30 and #41 that night, nursing leadership provided no education, guidance, or coaching to the nurses. During the course of this complaint survey, it was discovered there was a lack of in-class or on-line orientation training which addressed how to appropriately perform detox assessments, signs and symptoms to look for, and when to provide interventions based on the assessments, to include when to notify the provider. Because nursing leadership had not investigated why new nurses lacked knowledge of how to appropriately perform CIWA and/or COWS assessments, this was not discovered prior to this complaint survey. Review of Detox Assessments and Medication Orders Review of the facility’s CIWA assessment sheets currently used in the facility, and standing orders in the electronic Medication Administration Record (MAR) for detox of alcohol and opioids, revealed no parameters to guide the nurses when assessing or treating detox patients: CIWA Assessment sheet Review of the facility’s CIWA-Ar assessment sheet, last revised 3/2015, revealed: “. . . Administer medications per Alcohol/Benzodiazepine Withdrawal Protocol orders based on patient’s vital signs and total CIWA-Ar score. Notify MD [medical doctor] if vital signs and/or total CIWA-Ar score remain outside normal limits upon reassessment following medication administration . . .” In the section where nurses were to document which medications were given, it was titled “Meds [medications] given [more than] 9.” Further review of the CIWA-Ar assessment sheet revealed no guideline to show score ranges or what they meant, what medications to give when, or when to notify the provider. COWS Assessment Sheet Review of the facility’s COWS assessment sheet, last revised 3/2015, revealed: “. . . Administer medications per Opioid Withdrawal Protocol orders based on patient’s vital signs and [signs and symptoms] of opioid withdrawal. Notify MD if vital signs and/or withdrawal [signs and symptoms] remain outside normal limits upon reassessment following medication administration . . .” In the section where nurses were to document which medications were given, it was titled “Meds given [equal to more than] 15.” Further review of the COWS assessment sheet revealed total score interpretation scale, however there was no guidance on what medications to give when, or when to notify the provider. Standing Orders Review of the facility’s “Guide: Order Sets for Admissions,” undated, revealed order set for Adult Admission Orders; Admission Alcohol Acute Hospital Orders; and Admission Opiate Withdrawal Protocol orders. Further review revealed no parameters for PRN medication sets. Review of the facility’s policy “Detoxification Services,” effective 5/2024, revealed: “. . . [facilities] are equipped to provide detoxification services that meet the unique needs of the medically compromised patient who had been under the influence of drugs and/or alcohol. The procedure below has been established to guide the provision of detox services. These general guidelines for these services include: 1. Treatment of medical symptoms of withdrawal will be individualized and is dependent on a thorough assessment. 2. The intensity of withdrawal cannot always be predicted accurately and requires: a. Close observation. b. Review of vital signs. c. Communication with the patient, family, and members of the treatment team. d. Knowledge of expected outcomes and potential negative symptoms. 3. Complete physical examination with special attention to neurologic signs. 4. Establish methods to track vital signs, medications, the presence and severity of physical symptoms, mood, and interaction with others. 5. Administration of medications as per detoxification protocols to prevent acute withdrawal symptoms and maintain physical comfort . . .” QAPI and Adverse Events During an interview on 8/15/24 at 12:42 PM, the Risk Manager and Quality Director stated that suicidal behavior, gesture, and attempt data, or the need for ED visits, were not tracked or analyzed by the facility’s Performance Improvement (PI) committee (the facility’s QAPI Program). Review of the facility’s “Quality Assurance [and] Performance Improvement (QAPI)” plan, dated 2024, revealed: “. . . The successful execution of the QAPI program is the result of the foundation of leadership commitment, education in performance improvement techniques, commitment of resources to execute improvement opportunities, information management systems for data display and comparisons and employee involvement in improving their own work processes . . . We believe important hospital processes and functions that perform well result in high quality patient care. The facility fulfills its responsibilities to patients, professionals, support staff and the community through continuous and systematic measurement, assessment and improvement of its systems and processes. The 2024 Plan addresses patient-focused and organization-wide processes and functions that have the greatest potential to improve patient safety and outcomes . . .”

“QAPI EXECUTIVE RESPONSIBILITIES CFR(s): 482.21(e)(1), (e)(2), (e)(5) The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: 1) That an ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained . (2) That the hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated. (5) That the determination of the number of distinct improvement projects is conducted annually. This Standard is not met as evidenced by: 40259 . Based on interview and record review, the facility failed to ensure facility’s Governing Body, medical staff, and administrative officials were responsible and accountable for ensuring that the hospital-wide Quality Assessment and Performance Improvement (QAPI) Program efforts addressed priorities for improved quality of care and patient safety specific to: 1) patient suicide behavior, gestures, and attempts; and 2) patient emergent higher level of care situations that required Emergency Department (ED) visits. This failed practice placed all patient (based on a census of 63) at risk for injury, up to and including death, and/or substandard quality of care. Findings: Facility Risk Management and Quality Assurance Oversignt During an interview on 8/13/24 at 10:47 AM, the Risk Manager stated the Patient Safety Council meetings were completed once a month and the Chief Executive Officer (CEO), Chief Operations Officer (COO), Risk Manager, Chief Nursing Officer (CNO), Medical Director, and Assistant Chief Nursing Officer (ACNO) attended the meetings. The Risk Manager further stated that the Quality Director’s attendance was optional. The Risk Manager stated that the Patient Safety Council measured and monitored the following items: - Restraints/Seclusions rates; - Patient injuries in restraints/seclusions; - Patient aggression with and without injuries; - Elopements; - Falls; - Medication variances (like medication errors or adverse reactions); and - Patient safety alert advisory topics (these are presented to staff for reminders to help assure safety. Example: keep keys and badges secure) Review of facility Patient Safety Council meeting minutes, dated 1/2024 through 6/2024, revealed no measurements or monitoring for suicide behavior, gestures, or attempts or patient ED visits. During an interview on 8/13/24 at 12:09 PM, the Quality Director stated patient safety council meeting minutes were shared in the facility’s Performance Improvement (PI) committee (the facility’s QAPI Program), and that the PI committee only monitored performance tasks. When asked how information was shared with the Governing Body (or Governing Board), the Quality Director stated that the same facility members who attended the Patient Safety Council also attended the PI committee meetings. The Governing Body consisted of the CEO and the Medical Director, and they took what was discussed in both the Patient Safety Council and the PI meetings into the Medical Executive Committee (MEC) meetings. Because the CEO and the medical Director were the Governing Board, they already knew the information from those meetings. The Quality Director further stated that she would determine if anything from the PI committee needed to be presented to the Governing Body. When asked if anything had been brought to the Governing Body during this 2024 year, the Quality Director stated nothing had been brough forward. Review of the facility’s “BH [Behavioral Health] Performance Indicator Database - Acute” list, undated, revealed the list included “Suicide Risk Assessment/Management” which measured: “Compliance with initial suicide risk assessment; overall suicide risk level documented and proper mitigation taken based on risk level; do precautions march risk level; discharge education provided based on risk.” Further review of the performance indicator list revealed no monitoring of suicide behavior, gesture, or attempts or patient ED visits. During an interview on 8/15/24 at 12:42 PM, the Risk Manager and Quality Director stated that suicidal behavior, gesture, and attempt data, or the need for ED visits, were not tracked or analyzed by the facility’s Performance Improvement (PI) committee (the facility’s QAPI Program). Review of the facility’s “Quality Assurance [and] Performance Improvement (QAPI)” plan, dated 2024, revealed: “. . . The successful execution of the QAPI program is the result of the foundation of leadership commitment, education in performance improvement techniques, commitment of resources to execute improvement opportunities, information management systems for data display and comparisons and employee involvement in improving their own work processes . . . We believe important hospital processes and functions that perform well result in high quality patient care. The facility fulfills its responsibilities to patients, professionals, support staff and the community through continuous and systematic measurement, assessment and improvement of its systems and processes. The 2024 Plan addresses patient-focused and organization-wide processes and functions that have the greatest potential to improve patient safety and outcomes . . .” Review of the facility’s “Bylaws of the Board of Governors of North Star Behavioral Health System,” undated, revealed: “. . . The board shall be accountable for the safety and quality of care, treatment and services of the Hospital . . . The principal duties and responsibilities of the Board shall be to . . . ensure continuous quality improvement through monitoring of professional services provided by the Medical Staff, allied health professionals and other health care providers who provide services at the Hospital . . . Make recommendations to the CEO/Managing Director and the Corporate Entity regarding support systems for quality assessment/performance improvement and risk management . . .” .”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 40259 . Based on record review and interview, the facility failed to ensure that facility admission assessments were completed for 10 patients (#s 1; 2; 3; 4; 9; 11; 15; 18; 23; and 26), out of 25 sampled patients. Specifically, the “Nursing Admission Assessment” and/or the assigned section of the “Standardized Intake Assessment” were not completed by Licensed Nurses (LNs) in their entirety for a full, completed, and accurate assessment. This failed practice placed all patients (based on a census of 63) at risk for not receiving necessary and/or appropriate medical, psychological, or psychosocial care, services, and treatments, to include treatment planning, during their inpatient programming due to the lack of consistent, accurate, and timely admission screenings/assessments. Findings: LN Admission Process The facility’s LNs were responsible for accepting newly admitted patients and complete a “Nursing Admission Assessment.” This assessment reviewed the following areas: - “Demographic Information; - Admitting Vital Signs; - Allergies; - Reason for Admission; - History of Present Illness; - Medical History; - Medical Condition Patient/Family Educational Needs; - Infection Disease Screening; - Tobacco Use Screening; - Suicide Risk Assessment; - Substance Abuse Assessment; - Sexually Aggressive Behavior; - Potential for Sexual Victimization; - Homicidal/Violence/Aggression Risk Assessment; - Elopement Risk Assessment; - Psychological Trauma History; - Heightened Risk Associated with Potential Restrain/Seclusion Intervention; - Sleep History; - Berlin Questionnaire (to screen for obstructive sleep apnea) - Functional Assessment [to determine level of dependence for eating, bathing, dressing/grooming, toileting, ambulation, transferring, or assistive devices]; - Nutritional Screening; - Pasero-Opioid Induced Sedation Scale (POSS) Baseline [to screen for possible sedation that could compromise breathing]; - Fall Risk; - Learning Readiness and Preferences; - Mental Status Assessment; - Review of (body) systems; - Skin Assessment; - Patient Orientation [to the unit and program]; - Pain Assessment; [and] - Nursing Admission Narrative Summary.” Different formats of Nursing Admission Assessments were used through the facility’s different programs and had an extra section titled, “Summary Risk Assessment Treatment Interventions” which summarized risks for suicide/self-injury; fall risk; assault/homicide; homicide; seizure; medically compromised; elopement; sexual victimization risk; and sexual aggression risk. The LNs also completed a section within the “Standardized Intake Assessment,” which was completed by the admission’s office Intake Staff, that the LN completed. This section was titled, “Interventions implemented following discussion with provider (to be completed by Unit RN).” Within this section, the LN was to document: - “Observation Level;” - “Provider’s clinical justification for choosing Q15 [every 15 minutes] observations for patients at higher risk;” and - “Other Interventions - Check all interventions that apply below which will be implemented to maintain safety of patient. Interventions chosen must be added to the Treatment Plan.” Review of the “Other Interventions” list revealed the following options: - “Linen restriction - No additional linens in room; - Plastic silverware and paper products for plates/bowls; - Daily Contraband checks; - RN to complete cheek check after every med [medication] pass [administration]; - Patient will have a roommate; - Bathroom supervision; - Ensure all staff know any special anniversary dates that may be difficult for patient (specify date and reason); - Observe for any command hallucination and report to RN/medication nurse for prn [as needed] medications; - Clothing restriction - no more than [space to add number] setts of clothes in room; - Finger foods; - Patient cannot have pencils or utensils unobserved; - Room close to nurses station; - Unit Restriction; - Monitor patient response to phone calls/visitations; - Monitor patient for any isolation; - Strict adherence to no room time except during hours of sleep; - Observe for resistance to answering questions during suicide reassessments; [and] - N/A [not applicable].” Further review of the section revealed: “By signing this document, the RN completing the Nursing Assessment/Admission attests they reviewed the Initial Suicide Risk Assessment above and will implement appropriate interventions determined by provider to maintain safety of patient.” There was a place directly below for the LN to sign, print, date, and time this assessment. Medical Record Review Record review on 8/8-19/24 revealed the follow incomplete LN assessments: Patient #1 Record review on 8/8/24 at 4:00 PM, revealed Patient #1 was admitted on 6/28/24 for alcohol dependence. Further review revealed his/her “Nursing Admission Assessment,” dated 6/28/24, was incomplete. The following assessment sections were not completed: - Psychosocial Trauma History; - Sleep History; - Berlin Questionnaire; and - Functional Assessment. Patient #2 Record review on 8/8/24 at 4:05 PM, revealed Patient #2 was admitted on 6/13/24 for alcohol dependence. Further review revealed his/her “Nursing Admission Assessment,” dated 6/13/24, was incomplete. The following assessment sections were not completed, or only partially completed: - Homicidal/Violence/Aggression Risk Assessment; - Fall Risk Assessment; - Learning Readiness and Preferences; and - Patient orientation; Patient #3 Record review on 8/8/24 at 4:12 PM, revealed Patient #3 was admitted on 7/9/24 for opioid dependence and other stimulant dependence. Further review revealed his/her “Nursing Admission Assessment,” dated 7/10/24, was incomplete. The following assessment sections were not completed, or only partially completed: - Allergies; - Reason for Admission; - History of Present Illness; - Fall Assessment; - Review of Systems (skin integrity section); - Patient Orientation; and - Pain Assessment. Patient #4 Record review on 8/8/24 at 4:20 PM, revealed Patient #4 was admitted on 7/22/24 for alcohol dependence. Further review revealed the LN’s section on the “Standardized Intake Assessment,” dated 7/22/24, was incomplete. The following assessment sections were not completed: - Observation Level; and - Provider’s clinical justification for choosing Q15 observations for patients at higher risk. Patient #9 Record review on 8/9/24 at 11:30 AM, revealed Patient #9 was admitted on 7/22/24 for post-traumatic stress disorder (PTSD). Further review revealed his/her “Nursing Admission Assessment,” which was not dated, was incomplete. The following assessment sections were not completed, or only partially completed: - Skin Assessment; - Patient Orientation; - History of Present Illness; - Berline Questionnaire; - Suicide Risk Assessment; - Fall Risk Assessment; - Summary Risk Assessment Treatment Interventions; and - The Nursing Admission Narrative Statement was not completed, and the LN did not sign, date, or time the assessment. Review of Patient #9’s “Standardized Intake Assessment,” dated 7/17/24 was incomplete. The sections entire section for the LN to completed was blank. Further review revealed the LN did not sign, date, or time this assessment section. Patient #11 Record review on 8/12/24 at 2:05 PM, Patient #11 was admitted on 7/12/24 for unspecified psychosis not due to a substance. Further review revealed his/her “Nursing Admission Assessment,” which was not dated, was incomplete. The following assessment sections were not completed, or only partially completed: - Allergies; - Skin Assessment; - Infectious Disease Screening; - Nutritional Screen; - Fall Risk Assessment; - Substance Abuse Assessment; - Mental Status Assessment; - Suicide Risk Assessment; - Potential for Sexual Victimization; - Sexually Aggressive Behavior; - Homicidal/Violence/Aggression Risk Assessment; - Psychological Trauma History; - Elopement Risk Assessment; - Heightened Risk Associated with Potential Restraint/Seclusion Intervention; - Medical Condition Patient/Family Educational Needs; - Summary Risk Assessment Treatment Interventions; and - The Nursing Admission Narrative Statement was not completed, and the LN did not sign, date, or time the assessment. Patient # 15 Record review on 8/12/24 at 1:36 PM, Patient #15 was admitted on 4/18/24 through 5/14/24 for major depressive disorder single episode, severe without psychotic features. Further review revealed his/her “Nursing Admission Assessment,” dated 4/18/24, was incomplete. The Berlin Questionnaire section was not completed. Further review revealed the LN’s section on the “Standardized Intake Assessment,” dated 4/18/24, was incomplete. The following assessment section was not completed: - Provider’s clinical justification for choosing Q15 observations for patients at higher risk. Patient #18 Record review on 8/12/24 at 11:52 AM, Patient #18 was admitted on 7/22/24 through 8/1/24 for alcohol dependence. Further review revealed his/her “Nursing Admission Assessment,” dated 7/22/24, was incomplete. The following assessment sections were not completed, or only partially completed: - Allergies; - Berlin Questionnaire; - Nutritional Screen; - Learning Readiness and Preferences; - Skin Assessment; - Patient Orientation; - Pain Assessment; and - The Nursing Admission Narrative Statement was not completed, and the LN did not sign, date, or time the assessment. Further review revealed the LN’s section on the “Standardized Intake Assessment,” dated 7/22/24, was incomplete. The following assessment section was not completed: - Observation Level; - Provider’s clinical justification for choosing Q15 observations for patients at higher risk; and - Other Interventions - Check all interventions that apply below which will be implemented to maintain safety of patient. Interventions chosen must be added to the Treatment Plan. The LN signed this section but did not complete it. Patient #23 Record review on 8/12/24 at 11:00 AM, revealed Patient #23 was admitted 7/22/24 through 7/24/24 for alcohol dependence. Further review revealed the LN’s section on the “Standardized Intake Assessment,” dated 7/22/24, was incomplete. The following assessment sections were not completed: - Observation Level; and - Provider’s clinical justification for choosing Q15 observations for patients at higher risk. Patient #26 Record review on 8/12/24 at 11:10 AM, Patient #26 was admitted 8/2/24 for PTSD and reactive attachment disorder (RAD). Further review revealed his/her “Nursing Admission Assessment,” was not dated and was incomplete. The following assessment sections were not completed, or only partially completed: - Skin Assessment; - History of Present Illness; - Berlin Questionnaire; - Nutritional Screen; - Pasero-Opioid-Induced Sedation Scale Baseline; - Fall Assessment; - Substance Abuse Assessment; - Mental Status Assessment; - Suicide Risk Assessment; - Potential for Sexual Victimization; - Sexually Aggressive Behavior; - Psychological Trauma History; - Elopement Risk Assessment; - Heightened Risk Associated with Potential Restraint/Seclusion Intervention; - Medial Condition Patient/Family Educational Needs; - Summary Risk Assessment Treatment Interventions; and - The Nursing Admission Narrative Statement was not completed, and the LN did not sign, date, or time the assessment. During an interview on 8/12/24 at, 3:40 PM, the Medical Director stated nursing admission assessment forms had a history of not being completed consistently. The Medical Director stated that she had verbally reported the incomplete nursing admission assessment concern to the Assistant Chief Nursing Officer (ACNO). During an interview on 8/14/24 at 11:52 AM, the ACNO stated all nursing admission assessments were to be completed within 24 hours of an admission. When asked how medical record audits were completed to ensure all assessments reviewed to ensure they were completed, the ACNO stated audits were completed by the house supervisors three days per week. If a deficiency was identified, an email was sent to the admitting nurse to complete their missing documentation. The ACNO further stated that nursing admission assessment deficiencies were not communicated to the ACNO or the CNO. During this interview, when asked how nursing leadership followed up to ensure deficiencies identified on nursing admission assessments were corrected, the ACNO did not give a definitive answer and could not be clearly identified. During the survey, it was requested for the facility to provide proof of emails sent regarding deficiencies found during audits of admission nursing assessments. 18 emails were presented, however only two contained information regarding admission assessment audits. The remaining 16 emails were regarding nursing notes or observation sheets missing items. Review of the facility policy “Patient/Resident Admission Procedures,” effective date 6/2023, revealed: “. . . Registered Nurse will complete a nursing assessment . . . The receiving RN completes the initial treatment plan and admission note.” Review of the facility policy “Medical Record Documentation,” last revised date 5/2023, revealed: “. . . Each entry is to be dated and timed. . . The medical record is a legal document. . . Empty spaces are not left in documentation. . . Entries are to be written legibly. All entries must include a legible signature, legal name (printed in block letters), and discipline. . .” .”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 40259 . Based on record review and interview, the facility failed to ensure Initial Treatment Plans (ITPs) were implemented for 2 patients (#s 9 and 26), out of 13 sampled patients actively admitted in the facility. Without timely treatment plans, to identify patient’s mental, medical, and psychosocial needs, and create measurable interventions to meet these needs, these patients were at risk of not receiving the necessary and/or appropriate care and services to ensure patient safety and well-being. Findings: Patient #9 Record review on 8/9/24 at 11:34 AM, revealed Patient #9 was admitted on 7/22/24 for post-traumatic stress disorder (PTSD). Further review revealed Patient #9’s ITP was not completed and remained blank in the medical record. Patient #9’s Master Treatment Plan was completed on 7/24/24, two days after admission. Patient #9 had no treatment plan for the first two days of admission. Patient #26 Record review on 8/12/24 at 11:10 AM, revealed Patient #26 was admitted on 8/2/24 for PTSD and reactive attachment disorder (RAD). Further review revealed Patient #26’s ITP was completed on 8/5/24 (3 days after admission). Further review of the ITP documented instructions revealed the following guidance: “. . . The ITP must be completed within 24 hours. . .” During interview on 8/13/24 at 8:30 AM, the Program Educator stated on Thursdays of the orientation week, nurses were orientated on the admission process. This included the completion of the Initial Treatment Plan within 24 hours. Review of facility’s policy, “IDT Patient Centered Planning- Acute”, dated 7/2023, revealed, “. . . 3. Policy . . . North Star Behavioral Health Systems to provide therapeutic services based upon a patient-centered, individualized treatment plan . . . 4. Procedure . . . 1. The Nurse completing the Nursing Assessment or designee shall develop the Initial Treatment Plan within eight (8) hours of admission.” Review of facility’s policy, “Patient/Resident Admission Procedures, PC191”, dated 6/2023, revealed, “. . . 14. The receiving RN [Registered Nurse] completes the initial treatment plan and admission note.” .”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 40259 Based on record review and interview, the facility failed to ensure: 1) All licensed nurses (LNs) were provided adequate orientation training and completed these trainings and competencies before providing care to patients; 2) All Mental Health Specialists (MHSs) were provided adequate orientation training and completed these trainings and competencies before providing care to patients; and 3) LNs who worked in the adult substance abuse programs received education and training on how to appropriately conduct and interpret detoxification assessments (detox - a structured approach to safely remove toxins or harmful substances from the body) and provide interventions based on those assessments, to include when to administer medications and when to notify a doctor. Specifically, the facility failed to ensure accurate interpretation and implementation of detoxification assessments and treatments for 1 Patient (#8), out of 14 detox patients reviewed, which resulted in an adverse event and required emergent higher level of care and hospitalization. This failed practice regarding detoxification assessments and interventions placed all adult patients actively participating in withdrawal protocols (based on a census of 5) at risk for complications during their detoxification process. The failed practices regarding orientational training of LNs and MHSs placed all patients (based on a census of 63) at risk for subquality of care. On 8/15/24 at 2:20 PM, the facility Chief Operations Officer (COO), Quality Director, and Risk Manager were informed in person of the determination of immediate jeopardy related to the Nursing Leadership’s failure to ensure the operation of nursing services provided accurate substance abuse withdrawal assessments and appropriate and timely interventions to ensure patient safety. The facility submitted an acceptable removal plan on 8/15/24 at 6:00 PM. Implementation of the removal plan was verified on 8/19/24. The immediacy was removed on 8/19/24 at 1:27 PM. Following the removal of the immediacy, noncompliance remained that was not immediate. Findings: Facility Programs The facility consisted of three acute care inpatient programs totaling 140 beds: 1. The main building’s program was an acute care behavioral health, psychiatric, inpatient program for children, preteens, and adolescents. The building had four units for patient care: 1) two 20-bed units (Alyeska and Denali) on the second floor for adolescents; 2) one 16-bed unit (Chena) on the third floor for children and preteens; and 3) one 18-bed unit (Kenai) on the third floor that was not currently a full time programmed unit, however was used for evening programming and sleeping for select adolescents from the second floor; 2. The Arctic Recovery Program was in a different building on the same campus as the main building. This 30-bed program offered acute inpatient care for adults and offered detox and rehabilitation for substance abuse to non-military adults; and 3. The Chris Kyle Patriot Hospital, which was at a different location in town. This 36-bed program offered acute inpatient care for adults and offered trauma-focused care and detox and rehabilitation for substance abuse for active military, veterans, and first responders. 1) Orientation Training Process for Nurses The facility hired LNs through individuals who applied through the facility’s positions posted to the public (applicant nurses) and through contract agencies that were associated with Universal Health Services, the facility’s corporate branch (contract nurses). Applicant Nurses During an interview on 8/13/24 at 9:05 AM, the Senior Human Resources (HR) Generalist and Program Educator stated all applicant nurses, once they have completed the hiring process and have completed a background check, began the orientation process to work at the facility: - The first week (Monday through Friday) consisted of onboarding for all new hires: Monday/Tuesday: initial orientation, meet leadership, and CPR (if needed); Wednesday: verbal de-escalation training: Thursday: Handle with Care training (de-escalation and manual hold techniques); and Friday: independent, on-line class trainings assigned on HealthStream (the facility’s on-line education platform). - The second week (Monday through Friday) was for LNs and MHSs called “Bootcamp.” Monday: facility specific requirements - 1) how to fill out seclusion and restraint paperwork and every-15 (Q15) minute check sheets (monitoring sheets that accompany staff working with patients; staff were to be physically located and staff identified the patient’s behavior, location, and position every 15 minutes of the day, 24 hours a day); 2) milieu management; 3) acute changes in condition; 4) normal vital signs and what to report to the LNs; 4) safety precautions and what they mean; Tuesday: Simulation scenario-based training, review Handle with Care. Review of the facility’s in-class orientation training curriculum during Bootcamp included: - Acute Change of Condition [didn’t include information on CIWA or COWS] - Addiction Training [didn’t include information on CIWA or COWS] - Group Facilitation Training - Initial Competency - RN (or MHS) - Mileu Management Training - North Star Onboarding - RN (or MHS) - Nursing Department Management Review - Precautions Training - Q15 Attestation - Q15 Observation Training - Standard Safety Precautions At this point, nurses would split off from MHS and complete training on nursing practice protocols the rest of the week: admission paperwork, initial treatment plans, paper charting and where to find things. Computer charting, on their HCS system, how to navigate the system and made sure they obtained computer accesses. There was a training entitled “QRN” where the face-to-face assessments for seclusion and restraints was reviewed, warning signs were also taught, and how to fill out the paperwork. Also, specific equipment was reviewed (needles, syringes, point of care testing supplies, epi pens, and AEDs). Friday was a catch-up day, to include finishing HealthStream trainings. The Senior HR Generalist and Program Educator further stated that applicant nurses could not start job-specific orientation, called shadowing, on the units until all assigned HealthStream trainings were completed. Once completed, the applicant nurses would get two weeks (six 12-hour shifts) to shadow a senior nurse to learn the job through demonstration and direct patient care practice. During this shadowing orientation, the nurses completed two orientation check lists: 1) The “[facility] Initial Competency/Department Orientation Checklist, Registered Nurse;” and 2) The “[facility] Onboarding Nurse Competencies During Orientation” checklist. Review of the facility’s orientation checklist, “[Facility] Initial Competency/Department Orientation Checklist, Registered Nurse,” undated, revealed orientating nurses received education/training through demonstration, observation, being tested, or verbalization methods. The training component of skill sections included; - Job description; - Nursing responsibilities; - Unit safety walkthrough; - Patient appointments; - Milieu management principles; - Medication test/competency checklist; - Pharmacy procedures; - Admission procedures checklist; - Discharge procedures/checklist; - Daily nursing note and BIRP (Behavior, Intervention, Response, Plan charting method); - Shift to shift reporting; - Seclusion and restraint procedures/documentation; - Writing a discharge note; - Vitals; - Observation checks; - Emergency procedures/codes; - Treatment team procedures/documentation; - 1 2 3 magic test (behavior redirection technique); - Group competency; - Medication administration; - Staff assignment sheet; - In system consult/out of system consult; - Activities of daily living/ADL’s; - Precautions; - EMTALA (Emergency Medical Treatment and Active Labor Act); - Intake Backup; - MD orders and transcription; - Searches (contraband/body searches); - Attendance/call-in procedures; - Time clock/Kronos; and - Phone system. Further review revealed this form had sections for both the preceptor and employee to make comments and then sign and date when the form was completed. Review of the facility’s orientation checklist “[facility] Onboarding Nurse Competencies During Orientation,” undated, revealed orientating nurses received education/training in the following areas: - AMA (against medical advice) Process; - In facility consults; - Out of facility consults; - Patient assessment documentation; - Admissions; - Discharges; - Initial treatment plan; - Medical treatment plan and problem sheets; - Q15 forms; - General info-phone etiquette/phone binders; - Pill cutters; - Code red response; - Treatment team; - Daily documentation; - Seclusion and restraint; - Contraband searches; - Environment of care (form); - Incident reports/Midas (incident reporting computer program); - COWS (Clinical Opiate Withdrawal Scale)/CIWA (Clinical Institute Withdrawal Assessment for Alcohol) forms (as needed); - Breathalyzer competency; - Omnicell Access/Medication Administration; - Precautions; - Suicide Risk Assessment; - Narcan Administration (medication to administer for opioid overdose); - Bedsheet/How to use; - Chart checks; - Home medications; - Code Blue (forms and bags); - Cutter tool competency; - Epi pens; - Glucometer; - POC (point of care) testing (drug testing/strep/pregnancy); - EKG (electrocardiogram); - Oxygen administration; - Specimen collection (MRSA, COVID-19); - Unit assignment sheets (coverage for codes, lunch, breaks); - Vital signs/vital signs form; - Code intervention response; and - Tour. Further review revealed a box to check that “ALL HealthStream Completed” and a place for a manager or educator to sign. The following attestation was also on the onboarding form, “I [nurse’s name], acknowledge and agree that I have been trained in the above stated trainings and will adhere to the agency policies and Safety procedures to [ensure] patient and staff safety at all times. I have received and read the Orientation materials. I agree to abide by all Hospital Policies and Procedures. I understand that it is my responsibility to follow up with any questions related to this information with a representative of the Human Resources Department or my immediate supervisor. Any incidents or safety issues will be reported during my working shift. Other concerns will be brought to my immediate supervisor.” The employee printed their name, signed and dated this attestation. Applicant Nurses Orientation Review Random personnel record reviews, on 8/13-14/24, revealed that applicant nurse’s orientations were missing components of the orientation expectations presented by the Senior HR Generalist and Program Educator. LN #2 Review of LN #2’s personnel record, on 8/13/24, revealed: - LN #2 was hired 7/2022. - LN #2’s record revealed he/she completed his/her shadowing shifts on 8/2-5/22. Further review revealed LN #2 didn’t complete his/her “[facility] Initial Competency/Department Orientation Checklist, Registered Nurse” checklist until 3/23/23 (230 days after his/her shadowing shifts). LN #8 Review of LN #8’s personnel record, on 8/13/24, revealed: - LN #8 was hired 10/16/23. - LN #8’s record revealed he/she completed his/her shadowing shifts on 10/30/23 - 11/3/23. Further review revealed LN #8 didn’t complete his/her “[facility] Initial Competency/Department Orientation Checklist, Registered Nurse” checklist until 1/15/24 (73 days after his/her shadowing shifts). During an interview on 8/12/24 at 4:45 PM, LN #8 stated when he/she went through the orientation training, and was assigned to work the Arctic Recovery program, he/she wasn’t even aware there were adult programs at the facility. LN #8 stated that orientation was focused on the children, preteen, and adolescent programs and not the adults. There was no detox training, and he/she had no experience with withdrawal symptoms or the detox assessments. LN #30 Review of LN #30’s personnel record, on 8/13/24, revealed: - LN #30 was hired 3/18/24. - LN #30’s record revealed he/she completed his/her shadowing shifts on 4/3-10/24. Further review revealed LN #30 didn’t complete his/her “[facility] Initial Competency/Department Orientation Checklist, Registered Nurse” and “[facility] Onboarding Nurse Competencies During Orientation” checklists until 5/7/24 (25 days after his/her shadowing shifts). LN #41 Review of LN #41’s personnel record, on 8/14/24, revealed: - LN #41 was hired 4/29/24. - LN #41’s record didn’t contain the “[facility] Initial Competency/Department Orientation Checklist, Registered Nurse;” or “[facility] Onboarding Nurse Competencies During Orientation” checklists. LN #46 Review of LN #46’s personnel record, on 8/13/24, revealed: - LN #46 was hired 8/22/22. - LN #46’s record didn’t contain the “[facility] Initial Competency/Department Orientation Checklist, Registered Nurse;” or “[facility] Onboarding Nurse Competencies During Orientation” checklists. Contract Nurses There were two contract agencies currently used by the facility: 1) Horizon Health, or Adventure RN; and 2) Supplemental Health Care. During an interview on 8/13/24 at 9:05 AM, the Senior HR Generalist and Program Educator stated all contract nurses, once they have completed the hiring process and have completed a background check, began the orientation process to work at the facility. The contract nurses completed the first week of onboarding that consisted of completing verbal de-escalation, Handle with Care, and CPR. The contract nurses would not complete “Bootcamp” like applicant nurses, and instead completed a bridged orientation in QRN training, chart paperwork, equipment, and safety precautions. Once these orientation trainings were completed, contract nurses were provided with one 12-hour shadow shift and also were required to complete the “[facility] Initial Competency/Department Orientation Checklist, Registered Nurse;” and “[facility] Onboarding Nurse Competencies During Orientation” checklists. During an interview on 8/14/24 at 2:30 PM, the Quality Director and Program Educator stated contract nurses were also assigned independent, on-line class trainings on HealthStream, however their assignment set differed from applicant nurses and, depending on which contract agency they came from, had a different assignment set per agency (Horizon Health, Adventure RN contract nurses were to be assigned 35 trainings and Supplemental Health Care contract nurses were to be assigned 54 trainings). The Program Educator further stated contract nurses didn’t have a timeline to complete their assigned HealthStream training and were “due when they get it done.” The contract nurses would start working with patients after their shadow orientation day, regardless of whether their HealthStream training was completed or not. Contract Nurses Orientation Review The facility currently had six contract nurses working at the facility: - LN #’s 22, 27, and 32 were contract nurses with Horizon Health, Adventure RN; and - LN #s 11, 16, and 39 were contract nurses with Supplemental Health Care. Random reviews, on 8/13-14/24, revealed that each contract nurse’s orientations were missing components of the orientation expectations presented by the Senior HR Generalist and Program Educator. Horizon Health, Adventure RN Contract Nurses LN #22 Review of LN #22’s personnel record, on 8/14/24, revealed: - LN #22 was hired 7/22/24. - LN #22’s record didn’t contain the “[facility] Initial Competency/Department Orientation Checklist, Registered Nurse;” or “[facility] Onboarding Nurse Competencies During Orientation” checklists. - LN #22 was assigned 55 HealthStream trainings. Further review revealed LN #22 had five incomplete HealthStream trainings, which included pain management, patient safety discharge process, and trauma informed care. LN #27 Review of LN #27’s personnel record, on 8/13/24, revealed: - LN #27 was hired 7/15/24. - LN #27’s record didn’t contain the “[facility] Initial Competency/Department Orientation Checklist, Registered Nurse” checklist. - LN #27 was assigned 46 HealthStream trainings. Further review revealed LN #27 had seven incomplete HealthStream trainings, which included suicide assessment and reassessment, suicide prevention, and pain management. LN #32 Review of LN #32’s personnel record, on 8/14/24, revealed: - LN #32 was hired 8/5/24. - LN #32 was still completing shadowing shifts and his/her orientation checklists were pending. - LN #32 was assigned the following 49 HealthStream trainings: Further review revealed LN #32 had five incomplete HealthStream trainings, which included schizophrenia and psychotic disorders and pain management. Supplemental Health Care Contract Nurses LN #11 Review of LN #11’s personnel record, on 8/13/24, revealed: - LN #11 was hired 6/10/24. - LN #11’s record didn’t contain the “[facility] Initial Competency/Department Orientation Checklist, Registered Nurse;” or “[facility] Onboarding Nurse Competencies During Orientation” checklists. - LN #11 was assigned 33 HealthStream trainings. Further review revealed LN #11 had 21 incomplete HealthStream trainings, which included assessing and managing suicide risk units 1-3; key points in crisis management; discharge planning 4 - safety planning; and precautions and prevention of high-risk behaviors. During an interview on 8/11/24 at 1:16 AM, LN #11 stated he/she had never worked acute detox or a psychiatric hospital before and agreed that the orientation could have been more focused on working the acute adult programs. LN #11 stated there was no orientation to detox protocols or assessments. LN #16 Review of LN #16’s personnel record, on 8/14/24, revealed: - LN #16 was hired 7/22/24. - LN #16’s record didn’t contain the “[facility] Initial Competency/Department Orientation Checklist, Registered Nurse;” or “[facility] Onboarding Nurse Competencies During Orientation” checklists. - LN #16 was assigned 40 HealthStream trainings. Further review revealed LN #16 had two incomplete HealthStream trainings, which were about patient safety discharge process and suicide assessment/reassessment. LN #39 Review of LN #39’s personnel record, on 8/13/24, revealed: - LN #39 was hired 7/8/24. - LN #39’s record didn’t contain the “[facility] Initial Competency/Department Orientation Checklist, Registered Nurse;” or “[facility] Onboarding Nurse Competencies During Orientation” checklists. - LN #39 was assigned 44 HealthStream trainings. Further review revealed LN #39 had 19 incomplete HealthStream trainings, which included suicide assessment and reassessment. Review of facility’s orientation curriculum training form, “Nursing Department Management Review,” undated, revealed: “. . . Continuing Education. . . Education is provided through various platforms, including: Health Stream and in-person classroom. Caregivers, including travelers, are required to complete assigned education by their due dates, or they will be removed from the schedule.” Further review revealed the form had an acknowledgement statement, “I acknowledge I have received this information and will be accountable to adhering to the expectations outlined” and this form was signed and dated by the employees. 2) Orientation Training Process for MHS Review of the facility’s orientation training for MHS revealed the same hiring and orientation training process. After Bootcamp, however, they split off from the nurses and completed MHS specific training. During an interview on 8/13/24 at 9:05 AM, the Senior HR Generalist and Program Educator stated MHS staff would get one week (five 8-hour shifts) to shadow a senior MHS staff to learn the job through demonstration and direct patient care practice. During this shadowing orientation, the MHS completed two orientation check lists: 1) The “[facility] Initial Competency/Department Orientation Checklist, MHS;” and the “[facility] Onboarding Mental Health Specialists Competencies During Orientation” checklists. Review of the facility’s orientation checklist, “[Facility] Initial Competency/Department Orientation Checklist, MHS,” undated, revealed orientating MHS staff received education/training through demonstration, observation, being tested, or verbalization methods. The training component of skill sections included; - Job description; - MHS responsibilities; - Unit safety walkthrough; - Attendance/call-in procedures; - Time clock/Kronos; and - Phone system. Further review revealed this form had sections for both the preceptor and employee to make comments and then sign and date when the form was completed. Review of the facility’s orientation checklist “[facility] Onboarding Mental Health Specialists Competencies During Orientation,” undated, revealed orientating MHS staff received education/training in the following areas: Day 1: - General info-phone etiquette/phone binders; - Overhead pages; - Vital signs/vital signs form; - Q15 Sheet - Bedsheet/How to use; and - Tour of Units (as needed). Day 2: - Transitioning from one activity to another (i.e., lunch, gym, visitation); - Cutter Tool Competency; - Linen (storage and limit use)/Laundry room protocol; - Shift to Shift/Handoff; and - Code Red Response. Day 3: - Hygiene Bins/Protocol; - Precautions; - 1:1 [one-to-one]/Seclusion Observation; and - Incident Reports/Midas. Day 4: - Reporting to Nurse; - Code Blue Response; - Patient belongings/Inventory; and - Contraband Searches. Day 5: - Environmental Rounds/Environment of Care; - Intervention Response; - Night Rounds; and - Hallway Presence. Behaviors: - Recognizes signs of escalation; - Builds rapport with patients; - Collaborates with peers; - Recognizes potential safety hazards; - Actively listens to patients; - Maintains appropriate boundaries; and - Demonstrates limit-setting. Further review revealed a box to check that “ALL HealthStream Completed,” a statement, “During you shadow experience, work on building rapport with the patients, verbal de-escalation and learning the routines of the unit,” and a place for a manager or educator to sign. The following attestation was also on the onboarding form, “I [nurse’s name], acknowledge and agree that I have been trained in the above stated trainings and will adhere to the agency policies and Safety procedures to [ensure] patient and staff safety at all times. I have received and read the Orientation materials. I agree to abide by all Hospital Policies and Procedures. I understand that it is my responsibility to follow up with any questions related to his information with a representative of the Human Resources Department or my immediate supervisor. Any incidents or safety issues will be reported during my working shift. Other concerns will be brought to my immediate supervisor.” The employee printed their name, signed and dated this attestation. MHS Orientation Review Random personnel record reviews, on 8/13/24, revealed that MHS’s orientations were missing components of the orientation expectations presented by the Senior HR Generalist and Program Educator. MHS #3 Review of MHS #3’s personnel record, on 8/13/24, revealed: - MHS #3 was hired 3/6/24. - MHS #3 completed his/her shadow shifts on 3/13-22/24. Further review revealed MHS #3 didn’t complete his/her “[facility] Initial Competency/Department Orientation Checklist, MHS” checklist until 4/2/24 (11 days after his/her shadowing shifts). MHS #15 Review of MHS #15’s personnel record, on 8/13/24, revealed: - MHS #15 was hired 6/24/24. - MHS #15’s record didn’t contain the “[facility] Initial Competency/Department Orientation Checklist, MHS” checklist. MHS #61 Review of MHS #61’s personnel record, on 8/13/24, revealed: - MHS #61 was hired 5/2024. - MHS #61’s record didn’t contain the “[facility] Initial Competency/Department Orientation Checklist, MHS;” or “[facility] Onboarding Mental Health Specialists Competencies During Orientation” checklists. During an interview on 8/11/24 at 12:40 AM, MHS #61 stated he/she felt the hire orientation training was focused on working at the acute inpatient children, preteen, and adolescent units and did not provide any adult or detox orientation. MHS #61 stated he/she had to try and learn about detox during shadowing days which was a challenge. MHS #61 further stated that in his/her experience all MHS staff, who are new and the work adult units after shadowing, still don’t know anything about the unit. They didn’t know the rules, where anything was, or about detox signs. As MHS staff, MHS #61 stated that they “learn as we go together” and “wing it” on the job until it becomes familiar. MHS #82 Review of MHS #82’s personnel record, on 8/13/24, revealed: - MHS #82 was hired 3/2024. - MHS #82’s record didn’t contain the “[facility] Onboarding Mental Health Specialists Competencies During Orientation” checklist. - MHS #82 completed his/her shadow shifts on 4/2-6/24. Further review revealed MHS #82 didn’t complete his/her “[facility] Initial Competency/Department Orientation Checklist, MHS” checklist until 4/18/24 (12 days after his/her shadowing shifts). MHS #94 Review of MHS #94’s personnel record, on 8/13/24, revealed: - MHS #94 was hired 3/2024. - MHS #94’s record didn’t contain the “[facility] Initial Competency/Department Orientation Checklist, MHS” checklist. MHS #100 Review of MHS #100’s personnel record, on 8/13/24, revealed: - MHS #100 was hired 3/4/24. - MHS #100 completed his/her shadow shifts on 3/19-23/24. Further review revealed MHS #100 didn’t complete his/her “[facility] Initial Competency/Department Orientation Checklist, MHS” checklist until 8/13/24 (143 days after his/her shadowing shifts). During an interview on 8/12/24 at 4:45 PM, LN #8 stated he/she felt that new MHS orientation training was insufficient because when they started working on the units, they were unfamiliar with their roles. During an interview on 8/13/24 at 9:37 AM, the Quality Director stated the facility acknowledged they could do a better job on documentation in personnel records. Detox Assessment and Implementation (Immediate Jeopardy) Detox Protocol During the detox process, nurses monitored newly admitted patients through their withdrawal symptoms and provided scheduled and PRN (as needed) medications and treatments to help safely guide them through detoxing from alcohol and/or opioids (narcotic medications). Two assessment forms were used: 1. Alcohol Withdrawal - A Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) form; and 2. Opioid Withdrawal - A Clinical Opiate Withdrawal Scale (COWS) form. The detox monitoring usually started upon admission and was completed every 4 hours, then graduated to every 6 hours and then every 8 hours, depending on how individual patients responded to detoxing. These assessments entailed obtaining vital signs and rating the patient’s symptoms on severity scales. A total score would be ascertained at every assessment, and based on that total score medications would be administered and treatments would be implemented. 7/31/24 Incident During an interview on 8/12/24 at 5:31 PM, LN #7 stated he/she had picked up an extra shift on Arctic Recovery, which started at 11:00 PM. When he/she arrived, it was discovered that Patient #8 was newly admitted for alcohol dependence and was experiencing distressing withdrawal symptoms. When LN #7 talked with the nurses who were currently working, LNs #30 and #41, it was discovered the nurses had not provided withdrawal PRN medication interventions, since admission because they thought it was facility policy that they could not provide medications if the patient’s blood alcohol level was still elevated and not within the legal limit (0.08 in Alaska), which was not the case. LN #7 stated he/she began to assess Patient #8. His/her blood alcohol level was 0.11 and he/she was shaking to the point that a wheelchair was required to transfer the patient to his/her bedroom. LN #7 initiated PRN medication interventions, of Ativan (an antianxiety medication) and attempted to get the patient’s symptoms under control, however, could not. At around 5:00 AM, LN #7 called the provider on-call and received orders to have the patient transferred to the ED. The patient was subsequently admitted to the hospital. LN #7 further stated that an incident report was filed, and he/she reported to nursing leadership of the concern that these newer nurses were not administering detox protocols appropriately which may have contributed to Patient #8’s decline and need for emergent higher level of care. Review of Patient #8’s medical record, dated 7/31/24 through 8/1/24, revealed the following information: - Patient #8’s blood alcohol level upon admission, on 7/31/24 at 10:15 AM, was 0.36 (According to the National Institute on Alcohol Abuse and Alcoholism article entitled “Alcohol’s Effects on Health”, dated January 2023 reveal a level between 0.31 to 0.45 is considered life threating and may contribute to unconsciousness and significant risk of death due to suppression of vital life functions.) - Patient #8 had a history of seizures, the last seizure occurred in 5/2023. - During the admission process, Patient #8 had vomited and was sent over to the ED for medical clearance prior to being admitted. Patient was medically cleared and returned to the facility around 5:00 PM. - At 5:00 PM, Patient #8’s CIWA score was 9 (which indicated minimal to mild withdrawal), however was rated as having visible tremors, more than mildly anxious, and had beads of sweat obvious on his/her forehead. No medication intervention was documented as given. - At 6:00 PM, his/her blood alcohol level was 0.27 (According to the National Institute on Alcohol Abuse and Alcoholism article entitled “Alcohol’s Effects on Health”, dated January 2023 reveal a level between 0.15 to 0.30 is considered severe impairment and may contribute to confusion, vomiting, drowsiness, and unconsciousness.) - At 8:00 PM, Patient #8’s CIWA score was 10 (which still indicated minimal to mild withdrawal), however his/her symptoms were more increased: mildly nauseous, tremors were less, mildly anxious, beads of sweat were still visible on forehead, and had a mild headache or fullness in head. LN #30 documented “1.9 BRAK [blood alcohol level] scheduled” where medications were to be listed if given. Medications that were given was gabapentin (An anticonvulsant medication used for seizures, nerve pain, and restless legs) at 8:38 PM, Seroquel at 8:39 PM, and Tylenol at 8:40 PM. - Once LN #7 was on shift, he/she took over Patient #8’s care. - At 12:00 AM, Patient #8’s CIWA score was 9, with elevated anxiety and headache, and LN #7 administered Tylenol and Ativan by mouth. - At 3:10 AM, Patient #9’s CIAWA score remained 9, however Patient #8’s anxiety increased. Ativan was again administered by mouth. - At 4:30 AM, Patient #8’s CIWA score was 18 (which indicated severe withdrawal), and Ativan was administered via injection. When this was not effective, LN #7 notified the provider and the decision was made to transport the patient to the ED. Patient #8 left, with a staff escort and EMS at 5:50 AM. Patient #8 was without withdrawal PRN medication treatment for approximately 6 hours prior to LN #7 arriving for work. Patient #8 was admitted to the hospital. LN Interviews During an interview on 8/12/24 at 4:24 PM, Licensed Nurse (LN) #2 stated new nurses completed an in-class structured orientation, and after this would have 2 to 3 shadow days with a nurse to learn the role. After this, new nurses were assigned a shift and put into direct patient care. LN #2 stated that from his/her experience in working with newly hired nurses, they weren’t prepared and didn’t know where things were or how to appropriately monitor detox patients. During an interview on 8/12/24 at 4:45 PM, LN #8 stated newly hired nurses didn’t know their roles after they completed orientation and shadow days. Experiencing orientation when hired, LN #8 stated he/she had no detox training at orientation and hadn’t known about withdrawal symptoms from alcohol or substances, how to perform CIWA (shortened version of CAIW-Ar) or COWS screenings, and what the scores meant. Detox Orientation Training Review of the facility’s current detox orientation training, on 8/8-19/24, revealed: - The “[facility] Initial Competency/Department Orientation Checklist, Registered Nurse;” checklist did not contain any training component of skill for detox protocol on how to conduct, interpret, or implement detox assessments and treatments. - The “[facility] Onboarding Nurse Competencies During Orientation” checklist contained a competency for “COWS/CIWA Forms (as needed).” The goals documented on the checklist for this competency training was: “. . . Demonstrate how to perform COWS assessment; Demonstrate how to perform CIWA assessment; documents both assessments; and verbalizes when to notify provider.” Further review revealed no guidance standard on the onboarding checklist to ensure nurses are trained how interpret assessments, when to give medications, or when to notify the provider. During an interview on 8/13/24 at 11:00 AM, the Assistant Chief Nursing Officer (ACNO) stated LN #7 did contact her and the Chief Nursing Officer (CNO) about the 7/31/24 incident and verbalized concerns that LNs #30 and #41 didn’t give CIWA score intervention. As they investigated this, nursing leadership realized there was a gap in the CIWA and COWS assessments and ordered medication interventions, where that there were no parameters set to alert nurses to provide certain interventions based on scores of the assessments. The ACNO stated that they were working with the facility’s pharmacist to add score parameters for medications, however this was not completed and not being used by nurses currently. During an interview on 8/13/24 at 3:53 PM, the HR Director stated detox and rehabilitation training was initially only in HealthStream but was changed to an in-person training called “Addiction Training.” Review of the Bootcamp orientation training curriculum for “Addiction Training” revealed this training was a power point presentation titled “Substance Use Disorder Culture,” undated, and trained on addiction culture, what is addiction, and behaviors of addiction. Further review revealed no training for detox protocol on how to conduct, interpret, or implement detox assessments and treatments. During an interview on 8/14/24 at 9:50 AM, the Program Educator stated a gap had been identified in the nursing training as CIWA and COWS education was not being completed prior to nurse working with detox patients. During an interview on 8/15/24 at 11:06 AM, when asked what nursing leadership had done regarding the 7/31/24 incident and the nurse’s misinterpretation of how to perform detox assessments and interventions, the ACNO stated because LN #7 stated he/she had educated LNs #30 and #41 that night, nursing leadership provided no education, guidance, or coaching to the nurses or any other nursing staff. Review of Detox Assessments and Medication Orders Review of the facility’s CIWA assessment sheets currently used in the facility, and standing orders in the electronic Medication Administration Record (MAR) for detox of alcohol and opioids, revealed no parameters to guide the nurses when assessing or treating detox patients: CIWA Assessment sheet Review of the facility’s CIWA-Ar assessment sheet, last revised 3/2015, revealed: “. . . Administer medications per Alcohol/Benzodiazepine Withdrawal Protocol orders based on patient’s vital signs and total CIWA-Ar score. Notify MD [medical doctor] if vital signs and/or total CIWA-Ar score remain outside normal limits upon reassessment following medication administration . . .” In the section where nurses were to document which medications were given, it was titled “Meds [medications] given [more than] 9.” Further review of the CIWA-Ar assessment sheet revealed no guideline to show score ranges or what they meant, what medications to give when, or when to notify the provider. COWS Assessment Sheet Review of the facility’s COWS assessment sheet, last revised 3/2015, revealed: “. . . Administer medications per Opioid Withdrawal Protocol orders based on patient’s vital signs and [signs and symptoms] of opioid withdrawal. Notify MD if vital signs and/or withdrawal [signs and symptoms] remain outside normal limits upon reassessment following medication administration . . .” In the section where nurses were to document which medications were given, it was titled “Meds given [equal to more than] 15.” Further review of the COWS assessment sheet revealed total score interpretation scale, however there was no guidance on what medications to give when, or when to notify the provider. Standing Orders Review of the facility’s “Guide: Order Sets for Admissions,” undated, revealed order set for Adult Admission Orders; Admission Alcohol Acute Hospital Orders; and Admission Opiate Withdrawal Protocol orders. Further review revealed no parameters for PRN medication sets. Review of the facility’s policy “Detoxification Services,” effective 5/2024, revealed: “. . . [facilities] are equipped to provide detoxification services that meet the unique needs of the medically compromised patient who had been under the influence of drugs and/or alcohol. The procedure below has been established to guide the provision of detox services. These general guidelines for these services include: 1. Treatment of medical symptoms of withdrawal will be individualized and is dependent on a thorough assessment. 2. The intensity of withdrawal cannot always be predicted accurately and requires: a. Close observation. b. Review of vital signs. c. Communication with the patient, family, and members of the treatment team. d. Knowledge of expected outcomes and potential negative symptoms. 3. Complete physical examination with special attention to neurologic signs. 4. Establish methods to track vital signs, medications, the presence and severity of physical symptoms, mood, and interaction with others. 5. Administration of medications as per detoxification protocols to prevent acute withdrawal symptoms and maintain physical comfort . . .” .”

“CONTENT OF RECORD CFR(s): 482.24(c) The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and services. This Standard is not met as evidenced by: 40259 . Based on interview and record review, the facility failed to ensure medical records contained information to describe the patient’s progress and response to services. Specifically, the facility failed to ensure Mental Health Specialists (MHSs - direct patient care staff working daily with patients within the program environment) had access to document in the medical record. This failed practice placed all patients (based on a census of 63) at risk for not having documentation of daily witnessed interactions and behaviors, as well as interventions received by MHS staff in their medical records, which had the potential to limit appropriate services and/or treatments needed to address their medical, psychological, and psychosocial needs. Findings: During an interview on 8/8/29 at 4:04 PM, Licensed Nurse (LN) #10 stated MHS no longer complete daily progress note charting. LN #10 was unsure of the rational for the removal of MHS ability daily progress note and considered it an importance piece of medical record documentation to accurately reflect the patient’s daily behavior and participation. During an interview on 8/12/24 at 4:25 PM, LN #2 stated MHS documentation stopped occurring in November or December 2023. MHS interactions with patients were no longer being documented in the medical record. During an interview on 8/12/24 at 5:45 PM, LN #7 stated MHS documentation had been taken away. MHS only now could document on the “Acute Patient Observation Record/Milieu Groups” Every-15-minute (Q15) form (monitoring sheets that accompany staff working with patients; staff are to physically locate and identify the patient’s behavior, location, and position every 15 minutes of the day, 24 hours a day). There was nowhere for MHS to document de-escalation with patients or anything else they did with the patients. During an interview on 8/14/24 at 10:15 AM, the Assistant Chief Nursing Officer (ACNO) stated MHS stopped documenting “notes a longtime ago,” and sometime in 2022 documenting was taking away and the MHS was only documenting on the “Acute Patient Observation Record/Milieu Groups” Q15 form. The ACNO further stated he/she identified there was a gap in documentation with the missing MHS notes. During an interview on 8/19/24 at 12:15 PM, MHS #3 stated MHS did not document in the medical record. MHS documentation was completed on the “Acute Patient Observation Record/Milieu Groups” Q15 form. MHS only documents every 15-minute checks and group/activity participation. Review of the facility’s policy “Medical Record Documentation,” dated 1/2022, revealed: “. . . E. The medical record is a legal document: thus, it includes facts, no speculation. Entries are to describe patient behavior, interventions utilized, response to interventions, and plan . . .” .”

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 40259 . Based on record review and interview, the facility failed to ensure medical records were complete and legible for 8 patients (#’s 10, 12, 13, 14, 16, 19, 22, and 24,) out of 26 sampled records reviewed. Specifically, the facility failed to ensure: 1) Patient forms in the medical record were original, and instead were photocopies of repeated photocopies, rendering the forms illegible; 2) medical records were complete; and 3) Proper discharge instructions counseling was documented as being completed. These failed practices placed the patient at risk for: 1) incomplete and illegible medical records, which could affect their ability to obtain continuity of care in the future; and 2) failure at a lower level of care and an increase opportunity for readmission. Findings: Patient #10 Record review on 8/13/24 at 8:23 AM, revealed Patient #10 was admitted on 7/2/24 for major depressive disorder, recurrent. The initial admission consent and acknowledgement form, revised 5/2017, was not an original form, but a photocopied form, which made the words of the form illegible. Patient #12 Record review on 8/13/24 at 2:15 PM, revealed Patient #12 was admitted on 7/31/24 for major depressive disorder, recurrent. Further review revealed Patient #12’s “Daily Nurse Progress Note,” dated 8/12/24, was not an original form, but a photocopied form, which made the words and shaded areas of the form illegible. Patient #13 Record review on 8/12/24 at 2:20 PM, revealed Patient #13 was admitted 2/10/24 through 5/12/24 for diagnosis major depressive disorder recurrent, severe, with psychosis. Further review revealed Patient #13 “Daily Nurse Progress Note” forms, dated 2/14/24, 2/18-24/24, 3/24/24, 3/26/-27/24, 3/31-4/1/24, 4/6-9/24, 4/29/24, were not original forms, but photocopied forms, which made the words and shaded areas of the forms illegible. Patient #14 Record review on 8/12/24 at 1:32 PM, revealed Patient #14 was admitted 4/16/24 through 5/15/24 for PTSD and ADHD. Further review revealed Patient #14’s discharge paperwork was illegible and incomplete: - The “Discharge Plan Part I;” “Aftercare/Discharge Plan Part II;” “Discharge Suicide Risk Reassessment;” “Discharge Safety Plan;” and “Pre-Discharge Evaluation of Risk to Self/Others” forms were not original forms, but photocopied forms, which made the words and shaded areas of the forms illegible. - Patient #14’s “Aftercare/Discharge Plan Part II,” paperwork’s section “Patient Understanding Discharge Plan” was not completed. The following areas were left unchecked on the paperwork: “Patient/Family able to verbalize discharge instructions;” “Patient/Family verbalizes understanding of when/how to seek further treatment;” and “Educational materials provided to patient.” Further review revealed it was also not signed by a social worker/therapist or staff member. Patient #16 Record review on 8/12/24 at 12:20 PM, revealed Patient #16 was admitted 6/1/24 through 8/2/24 for major depressive disorder, single episode, severe with psychotic features. Further review revealed Patient #16’s “Daily Nurse Progress Note” forms dated 6/25-26/24, 7/2-5/24, 7/9-10/24, 7/16-17/24, 7/23-25/24, and 7/30-31/24, were not original forms, but photocopied forms, which made the words and shaded areas of the forms illegible. Patient #19 Record review on 8/12/24 at 11:43 AM, revealed Patient #19 was admitted 6/24/24 through 7/21/24 for opioid dependence. Further review revealed Patient #19’s “Daily Nurse Progress Note,” dated 7/18/24, was not completed: The nurse note’s section “2300-0700 Sleep/Behaviors Note” was not completed and the nurse signature, date, and time was missing, and the note’s section “Pain [assessment]- 1900-0700” was not completed. Patient #22 Record review on 8/9/24 at 1:40 PM, revealed Patient #22 was admitted 6/14/24 through 6/30/24 for intermittent explosive disorder. Further review revealed Patient #22’s discharge paperwork was illegible and incomplete: - The “Aftercare/Discharge Plan Part II;” “Discharge Suicide Risk Reassessment;” “Discharge Safety Plan;” and “Pre-Discharge Evaluation of Risk to Self/Others” forms were not original forms, but photocopied forms, which made the words and shaded areas of the forms illegible. - Patient #22’s “Aftercare/Discharge Plan Part II” paperwork’s section “Patient Understanding Discharge Plan” was not completed. The following areas were left unchecked on the paperwork: “Patient/Family able to verbalize discharge instructions;” “Patient/Family verbalizes understanding of when/how to seek further treatment;” and “Educational materials provided to patient.” Further review of Patient #22’s “Aftercare/Discharge Plan Part II”, revealed the section “Nurse to Complete: Condition on Discharge” was missing from the form and medical record. Patient #24 Record review on 8/9/24 at 1:29 PM, revealed Patient #24 was admitted 6/20/24 through 6/26/24 for post-traumatic stress disorder (PTSD) and attention deficit hyperactivity disorder (ADHD). Further review revealed Patient #24’s discharge paperwork was illegible and incomplete: - The “Discharge Plan Part I;” “Aftercare/Discharge Plan Part II;” “Discharge Suicide Risk Reassessment;” and “Pre-Discharge Evaluation of Risk to Self/Others” forms were not original forms, but photocopied forms, which made the words and shaded areas of the forms illegible. - Patient #24’s “Aftercare/Discharge Plan Part II” paperwork’s section “Patient Understanding Discharge Plan” was not completed. The following areas were left unchecked on the paperwork: “Patient/Family able to verbalize discharge instructions;” “Patient/Family verbalizes understanding of when/how to seek further treatment;” and “Educational materials provided to patient.” Further review revealed Patient #24’s “Aftercare/Discharge Plan, Part II”, revealed the section “Nurse to Complete: Condition on Discharge” was missing from the form and medical record. Review of the facility’s original “Aftercare/Discharge Plan Part II” form, revealed a section titled, “Nurse to Complete: Condition on Discharge.” If any answers of “yes” to the questions, required a physician to review. Questions reviewed during the assessment: - “Does the patient/resident or others report:” - “The patient/resident reporting suicide ideation/threats? Yes/No;” - “The patient/resident reporting homicidal ideation/threats? Yes/No;” - “The patient/resident reporting self-injurious ideation/behavior? Yes/No;” - “The patient/resident reporting symptoms of psychosis? Yes/No;” and - “The patient/resident’s mood is inappropriate for the situation? Yes/No.” During interview on 8/13/24 at 12:50 PM, Licensed Nurse (LN) #4 reviewed the blank admission paperwork, in an empty chart that was set up for a new admission, and stated some forms were difficult to read. This blank packet of admission paperwork contained photocopied forms. LN #4 acknowledged the forms were placed in empty charts to prepare for admissions. LN #4 stated prepared charts come from the medical records department. He/she stated sometimes completed admission paperwork was received via fax or email making the forms more distorted. During an interview on 8/13/24at 2:29 PM, the Director of Health Information Management (HIM - Medical Records Director) stated the medical records staff prepped all new medical record charts for potential admissions by placing blank paperwork forms, including discharge paperwork, into the charts for the LNs to use. When asked to review the blank, photocopied forms in active and closed records, as well as new charts prepped for use, the Director of HIM acknowledged the photocopied forms were illegible and shouldn’t have been used. During an interview on 8/14/24 at 11:52 AM, the Director of Quality stated if the discharge instruction box on the discharge paperwork was not checked, no discharge instructions were available. During an interview on 8/14/24 at 12:10 PM, Clinical Manager (CM) #1 stated the “Aftercare/Discharge Plan Part II” form’ section “Nurse to Complete: Condition on Discharge” was removed by the facility’s corporate office. CM #1 was unable to recall when the section was removed. CM#1 stated all areas of the discharge paperwork should be completed. During an interview on 8/14/24 at 12:29 PM, the Quality Director stated that the “Nurse to Complete: Condition on Discharge” LN assessment on the “Aftercare/Discharge Plan Part II” form was removed sometime within the last two years. The Quality Director stated the LNs of the facility had requested it be reinstated and was subsequently put back on recently. The Quality Director acknowledged the inconsistency identified between the adult discharge packet and the children, preteen, and adolescent discharge packet regarding the “Nurse to Complete: Condition on Discharge” assessment’s presence and acknowledged the inconsistency of the “Nurse to Complete: Condition on Discharge” assessment being consistently completed at discharge. The Quality Director further stated the “Condition on Discharge” LN assessment should be on the Aftercare/Discharge Plan Part II document and it should be on every unit for the LNs to complete for every discharge in the facility. Review of the facility policy “Discharge/Aftercare Planning, PC128”, last revised 12/2023 revealed: “. . . 2. The Discharge Plan should: A. Prepare the patient/resident and family for transition to the next level of care. B. Address the patient’/resident’s and family’s need for instruction about continued treatment. C. Delineate how progress made in the current level of care will continue after discharge. D. Identify problems to be addressed in the next level of care. E. Identify the responsibility for ensuring that the prescribed follow-up is accomplished. F. Include timely and direct communication with and transfer of information to other programs, agencies, or individuals that will be providing continuing care. . . 3. . . The discharge plan should take into account the continuation or completion of those treatments that were generated in the current level of care and the initiation of those treatments that are needed but were deferred to another phase of treatment . . . 5. The discharge/aftercare plan should define the following: A. Final diagnosis; B. Where the patient/resident will live following discharge; C. With whom the patient/resident will live and in what circumstances; D. the level of care that the patient/resident will be discharge to. . . E. A listing of all medications that patient/resident is to continue taking after discharge; F. All professionals who will follow-up with the patient/resident, including medical follow-up to monitor medications; G. Referrals. . . H. Specific efforts to educate the family regarding the patient’s/resident’s treatment interventions, medication, and prognosis; I. Follow up appointments . . . J. Condition on discharge; L. Identified problems and the outcome of those problems; and M. Safety plan. . . 6. Aftercare plans are communicated to the patient/resident and family, as appropriate, and documented in the medical record. Additionally, will be provided to the Guardian at discharge. . . “ Review of the facility policy “Medical Record Documentation,” dated 1/2022, revealed: “. . . each entry is to be dated and timed . . . medical record is a legal document . . . Empty spaces are not left in documentation. . . entries are to be written legibly . . .” .”

“Document Therapeutic Efforts CFR(s): The treatment received by the patient must be documented in such a way to assure that all active therapeutic efforts are included. This Standard is not met as evidenced by: 40259 . Based on interview and record review, the facility failed to ensure medical records were completed and accurate to reflect patients’ progress and response to treatment. Specifically, the facility failed to ensure Mental Health Specialists (MHSs - direct patient care staff working daily with patients within the program environment) had access to document in the medical record to ensure assigned responsibilities from the individualized patient treatment care plans were completed for 5 patients (#’s, 2, 4, 13, 14, and 19), out of 5 sampled patients reviewed for treatment plan implementation. This failed practice placed all patients (based on a census of 63) at risk for not having documentation of daily witnessed interactions and behaviors, as well as interventions received by MHS staff in their medical records, which had the potential to limit appropriate services and/or treatments needed to address their medical, psychological, and psychosocial needs. Findings: During an interview on 8/8/29 at 4:04 PM, Licensed Nurse (LN) #10 stated MHS no longer complete daily progress note charting. LN #10 was unsure of the rational for the removal of MHS ability daily progress note and considered it an importance piece of medical record documentation to accurately reflect the patient’s daily behavior and participation. During an interview on 8/12/24 at 4:25 PM, LN #2 stated MHS documentation stopped occurring in November or December 2023. MHS interactions with patients were no longer being documented in the medical record. During an interview on 8/12/24 at 5:45 PM, LN #7 stated MHS documentation had been taken away. MHS only now could document on the “Acute Patient Observation Record/Milieu Groups” Every-15-minute (Q15) form (monitoring sheets that accompany staff working with patients; staff are to physically locate and identify the patient’s behavior, location, and position every 15 minutes of the day, 24 hours a day). There was nowhere for MHS to document de-escalation with patients or anything else they did with the patients. During an interview on 8/14/24 at 10:15 AM, the Assistant Chief Nursing Officer (ACNO) stated MHS stopped documenting “notes a longtime ago,” and sometime in 2022 documenting was taking away and the MHS was only documenting on the “Acute Patient Observation Record/Milieu Groups” Q15 form. The ACNO further stated he/she identified there was a gap in documentation with the missing MHS notes. During an interview on 8/19/24 at 11:39 PM, Clinical Therapist (CT) #15 agreed that MHS were assigned interventions in the individualized treatment plans of patients. When asked how the MHS documented about those interventions assigned, CT #15 couldn’t explain how since they were no longer charting in the medical record. During an interview on 8/19/24 at 12:15 PM, MHS #3 stated MHS did not document in the medical record. MHS documentation was completed on the “Acute Patient Observation Record/Milieu Groups” Q15 form. MHS only documents every 15-minute checks and group/activity participation. During an interview on 8/19/24 at 12:15 PM, Milieu Manager #1 stated MHS did not directly document in the medical record. When asked how MHS would document interventions assigned to them in the individualize treatment plans for patients, like encourage use of coping skills, Milieu Manager stated those interventions would not be documented in the medical record and agreed it created the inability to properly document all interventions provided. Record review on 8/15/24 at 8:24 AM, of patient “Acute Master Interdisciplinary Treatment Plans”, which included staff responsibilities, patient activities, goals, and target dates, revealed interventions in patient goals that were to be conducted by MHS staff: Patient #2 Patient #2 was admitted on 6/13/24 for alcohol dependence. Further review revealed Patient #2’s treatment plans, dated 6/14/24, 6/20/24, 6/27/24, 7/5/24, 7/11/24, 7/18/24, 7/25/24, 8/8/24, and 8/13/24, identified: “Short-Term Goals/Objectives”: Each time I have the urge/thought to use alcohol I will use a safe distraction to eliminate/reduce substance consumption and share with staff each shift and with CT during IT sessions for 7 days.” “Staff Interventions”: “During daily CD/psychoeducation group, MHS staff will provide psychoeducation about substance abuse and AA step work in order to increase self-awareness and reduce severity of urges. Daily, MHS staff will process homework assignments for AA step work in order to increase understanding of AA principles.” Patient #4 Patient #4 was admitted on 7/22/24 for alcohol dependence. Further review revealed Patient #4’s treatment plans, dated 7/25/24, 7/31/24, 8/7/24, 8/14/24, identified: “Short-Term Goals/Objectives”: Each time I have the urge/thought to use alcohol I will use a safe distraction to eliminate/reduce substance consumption and share with staff each shift and with CT during IT sessions for 7 days.” “Staff Interventions”: “During daily CD/psychoeducation group, MHS staff will provide psychoeducation about substance abuse and AA step work in order to increase self-awareness and reduce severity of urges. Daily, MHS staff will process homework assignments for AA step work in order to increase understanding of AA principles.” Patient #13 Patient #13 was admitted 2/10/24 through 5/12/24 for major depressive disorder recurrent severe with psychosis. Further review revealed Patient #13’s treatment plans, dated 2/14/24, 2/21/24, 2/28/24, 3/6/24, 3/13/24, 3/20/24, 3/27/24, 4/3/24, 4/10/24, 4/17/24, 4/24/24, 4/29/24, and 5/7/24, identified: “Short-Term Goals/Objectives”: Each time I have the urge to hurt myself or thoughts of committing suicide, I will journal, or take a walk and/or talk with someone I trust, without acting upon the urge, share my thoughts with staff each shift and weekly with my CT during IT and FT for 1 week. “Staff Interventions”: “MHS [#3] will closely monitor for signs, suicidal ideation, aggression, and emotional dysregulation that includes depressed mood and feelings of anxiety. Staff will encourage youth to use coping skills (i.e., coloring, listening to music, talking to staff) as well as notify the nurse of any concerns.” Additional treatment plans, dated, 4/26/24 and 5/7/24, included: “Short-Term Goals/Objectives”: Each time I have the urge/behavior/or hear voices that tell me to hurt or kill myself or others, I will ask for a walk or talk to staff without acting on the urge/thought and use a safe distraction or distress tolerance skill from my Special program and then return to regular scheduled programming for 7 days. I will share with staff each shift and with my CT weekly during IT/FT.” “Staff Interventions”: “MHS [#3] will closely monitor for signs and symptoms of depression, isolation, self-harm, or responding to internal stimuli & encourage the patient to take a time out for five minutes and utilizing a distraction or distress tolerance coping skill as well as notify the nurse or MD of any concerns.” Patient #14 Patient #14 was admitted on 6/26/24 for attention deficit hyperactivity disorder (ADHD) and Post-Traumatic Stress Disorder (PTSD). Further review revealed Patient #14’s treatment plans, dated 6/28/24, 7/3/24, 7/10/24, 7/17/24, 7/24/24, 7/31/24, and 8/7/24, identified: 1. “Short-Term Goals/Objectives”: Each time I feel angry, I will ask for a 5-minute break and write things out or discuss with staff each shift and with my CT weekly during IT and FT sessions for 1 week.” “Staff Interventions”: MHS [#3] will closely monitor for signs, suicidal ideation, aggression, and emotional dysregulation that includes depressed mood and feelings of anxiety. Staff will encourage youth to use coping skills (i.e., coloring, listening to music, talking to staff) as well as notify the nurse of any concerns. 2. “Short-Term Goals/Objectives”: “When I feel like I am being bullied, I will walk away from the situation and immediately report to staff without engaging in arguments or hitting my peers. I will use a skill from my BMP to manage my mood, 3 out of 4 times. I will share my success and challenge with staff daily and CT in IT/FT for 1 week.” “Staff Interventions”: MHS [#3] will closely monitor for signs and symptoms of depression, isolation, self-harm, or responding to internal stimuli & encourage the patient to take a time out for five minutes and utilizing a distraction or distress tolerance coping skill as well as notify the nurse or MD of any concerns.” 3. “Short-Term Goals/Objectives”: Each time I have the urge to hurt myself or thoughts of committing suicide, I will stop the thought, and distract myself by asking to take a walk, without acting upon the urge, share my thoughts with staff each sift and weekly with my CT during IT and FT for 1 week.” “Staff Interventions”: MHS [#3] will closely monitor for signs Suicidal Ideation, Aggression, and emotional Dysregulation that includes depressed mood and feelings of anxiety. Staff will encourage youth to use coping skills (i.e., Writing, Walking, Talking to Staff” as well as notify the nurse of any concerns.” Patient #19 Patient #19 was admitted 6/24/24 through 7/21/24 for opioid dependence. Further review revealed Patient #19’s treatment plans, dated 6/26/24, 7/3/24, 7/10/24, and 7/16/24, identified: “Short-Term Goals/Objectives”: “Each time I have the urge/thought to use fentanyl I will use a safe distraction to eliminate/reduce substance consumption and share with staff each shift and with CT during IT session for 7 days.” “Staff Interventions”: “Daily CD/psychoeducation group, MHS staff will provide psychoeducation about substance abuse and AA Step work in order to increase self-awareness and reduce severity of urges. Daily, MHS staff will process homework assignments from AA step work in order to increase understanding of AA principles.” Review of the facility’s policy “Medical Record Documentation,” dated 1/2022, revealed: “. . . E. The medical record is a legal document: thus, it includes facts, no speculation. Entries are to describe patient behavior, interventions utilized, response to interventions, and plan . . .” Review of the facility’s policy “Interdisciplinary Patient-Centered Care Planning- Acute,” dated 7/2023, revealed: “. . . Each discipline completing their individual assessments will begin to identify the patient’s problems to be treated and the focus on their treatment interventions which will be included in the MTP [Master Treatment Plan] . . . Interventions will include the action/task, patient-specific focus, and the name/credentials of the individual responsible for the intervention. . .” .”

“Discharge Summary - Patient Condition CFR(s): [The record of each patient who has been discharged must have] a brief summary of the patient’s condition on discharge. This Standard is not met as evidenced by: 40259 . Based on record review and interview, the facility failed to ensure a brief summary of the patient’s condition on discharge was documented for 4 Patients (#’s 14, 22, 23, and 28), out of 13 closed patient records reviewed. Without an accurate assessment of the patient’s immediate status at discharge, to include psychiatric, physical, and functional conditions, these patient were risk for complications after discharge. Findings: Discharge Paperwork Review Adult Programs Review of the discharge paperwork for the Arctic Recovery Program and the Chris Kyle Patriot Hospital revealed the following paperwork was included in the “discharge packet”: 1. Pre-Discharge Checklist 2. Discharge Assessment Plan for Nursing Department This assessment included a checklist that included answering “yes” or “no” if vital signs were completed (but not documented on the form), ensuring all patient belongings were accounted for, the patient’s room has been cleared, all facility property was returned, and all copies and prescriptions were collected and provided to the patient. Also, medication reconciliation (ensuring all medication brought in on admission were returned) and medication education was completed. The patient’s diagnosis was discussed, and any answers were discussed, answered any concerns the patient had about discharge, and identifying any escort associated with the discharge. There was also a section to complete if a patient was leaving against medical advice (AMA). Signature lines were provided for the patient, escort, and nurse to sign, date, and time the form. 3. Pre-discharge evaluation of risk to self/others. This form assessed any suicidal or homicidal thoughts and any risk management considerations to discharge. The Provider completed this form and if it was a sudden or immediate discharge, there was a place for the nurse to conduct a verbal review with the Provider if they were not available. 4. Discharge Suicide Risk Reassessment This form was a reassessment, once treatment has been completed, to ascertain if there were any immediate risks for suicide and any actions taken based on that risk. The Clinical Therapist and Provider would sign this form. 5. Discharge Safety Plan This form reviewed potential trigger, warning signs, and coping strategies, and how to make a safe environment for after discharge. 6. Discharge Plan Part I This was the Providers documentation of discharge to include reason for admission, medical procedures performed during admission, medical follow-ups if needed, tobacco cessation medication at discharge if applicable, and discharge diagnosis and medication supplied. 7. Aftercare/Discharge Plan Part II This form had different sections for the Clinical Therapist and Licensed Nurse (LN) to completed. - The Clinical Therapist completed the sections “Follow-up appointments;” “Other Aftercare Services/Referrals;” “Family Involvement;” and “Patient Understanding of Discharge Plan.” - The LN completed the date of admission and discharge, what type of discharge it was (scheduled, AMA, at family’s request, or other). On page two of the paper was a “Condition on Discharge” assessment the LN completed which reviewed and suicidal or homicidal thoughts, and self-injurious thoughts, and ruled out any psychosis or inappropriate mood concerns. A set of vital signs were documented, and the LN signed this assessment. There was also a check list to ensure appropriate copies were provide to the patient. 8. There were also papers that reflected lab values, what behaviors were observed during the admission, discharge medication instructions, and health-related needs. Children, Preteen, and Adolescent Programs Review of the discharge paperwork for the inpatient program for minors revealed the following paperwork was included in the “discharge packet”: 1. Pre-Discharge Checklist 2. A discharge cover letter 3. Pre-discharge evaluation of risk to self/others. 4. Discharge Suicide Risk Reassessment 5. Discharge Safety Plan 6. Discharge Plan Part I 7. Aftercare/Discharge Plan Part II The Children, Preteen, and Adolescent’s After/care Discharge Plan Part II was missing the LN “Condition of Discharge” assessment that should have been on page two of the paper. 8. There were also papers that reflected lab values, what behaviors were observed during the admission, discharge medication instructions, and health-related needs. Medical Record Review Children, Preteen, Adolescent Closed Records Patient #14 Record review on 8/12/24 revealed Patient #14 was admitted to the facility on 4/16/24 and discharged on 5/15/24 at 5:00 PM. Further review revealed the following deficiencies: - Pre-discharge evaluation of risk to self/others: Was completed on 5/14/24 at 1:00 PM. - Discharge Suicide Risk Reassessment: was completed on 5/13/25 at 4:30 PM. - Discharge Safety Plan: This was completed 5/13/24 at 7:30 AM. - Discharge Plan Part I: Was completed on 5/15/24 however the time of completion could not be legibly interpretated. - Aftercare/Discharge Plan Part II: Was completed, but not signed, dated, or times by the Clinical Therapist who completed the paperwork. It could not be determined when this piece of the discharge paperwork was completed. There was no “condition on discharge” assessment on the paper. Further review of the discharge paperwork revealed no condition on discharge assessment at the time of discharge, 5/15/24 at 5:00 PM. Patient #22 Record review on 8/9/24 revealed Patient #22 was admitted to the facility on 6/14/24 and discharged on 7/11/24 at 7:00 PM. Further review revealed the following deficiencies: - Pre-discharge evaluation of risk to self/others: Was completed on 7/11/24 at 5:00 PM. - Discharge Suicide Risk Reassessment: was completed on 7/10/24 at 4:00 PM. - Discharge Safety Plan: This was completed 7/10/24 at 4:00 PM. - Discharge Plan Part I: Was completed on 7/11/24 however the time of completion could not be legibly interpretated. - Aftercare/Discharge Plan Part II: Was completed by the Clinical Therapist on 7/10/24 at 4:00 PM. There was no LN “condition on discharge” assessment on the paper. Further review of the discharge paperwork revealed no condition on discharge assessment at the time of discharge, 7/11/24 at 7:00 PM. Adult Closed Records Patient #23 Record review on 8/12/24 revealed Patient #23 was admitted to the facility on 7/22/24 and discharged on 7/22/24 at 3:15 PM. Further review revealed the Aftercare/Discharge Plan Part II paperwork was incomplete. The “Condition of Discharge” LN section was left blank. Patient #28 Record review on 8/19/24 revealed Patient #28 was admitted to the facility on 8/3/24 and discharged on 8/17/24 at 5:00 PM. Further review revealed the Aftercare/Discharge Plan Part II paperwork was incomplete. The “Condition of Discharge” LN section was left blank. During an interview on 8/14/24 at 12:29 PM, the Quality Director stated that the “Condition on Discharge” LN assessment on the Aftercare/Discharge Plan Part II document was removed sometime within the last two years. The Quality Director stated the LNs of the facility had requested it be reinstated and was subsequently put back on recently. The Quality Director acknowledged the inconsistency identified between the adult discharge packet and the children, preteen, and adolescent discharge packet regarding the “Condition on Discharge” assessment’s presence and acknowledged the inconsistency on getting the “Condition on Discharge” assessment completed at discharge. The Quality Director stated the “Condition on Discharge” LN assessment should be on the Aftercare/Discharge Plan Part II document and it should be on every unit for the LNs to complete for every discharge in the facility. Review of the facility’s policy “Discharge/Aftercare Planning,” effective 12/2023, revealed: “. . . The discharge/aftercare plan should define the following . . . condition on discharge . . .” .”