Tri-City Medical Center

“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: 45909 Based on interview and record review, the facility failed to provide a comfortable and safe environment for one patient (Patient 1) when Patient 1’s urinary retention (UR - unable to empty the bladder completely) was not attended to. This failure had the potential to affect Patient 1’s health, comfort, and well-being. Findings: Patient 1 was admitted to the facility on 8/20/25 with diagnoses of osteoarthritis (joint disorder that causes pain), per the admission record. A concurrent interview and record review was conducted with Clinical Nurse Educator (CNE) 1 on 8/28/25 at 3 P.M. Patient 1’s nursing genitourinary assessment (NGUA -nursing evaluation of a patient’s urine status) dated 8/27/25 at 12:42 P.M. and 4 P.M., indicated that Patient 1 had not voided (urinated) and had UR. CNE 1 stated that there was no indication in Patient 1’s medical record that Patient 1 refused care, and Patient 1 was not reassessed until 8/28/25 at 8 A.M. CNE 1 stated that a bladder scan (non-invasive procedure to measure the urine in the bladder) should had been completed on Patient 1 to identify how much urine Patient 1 had in the bladder. CNE 1 further stated that the nurse should have called the physician to obtain an order for urinary catheterization (tube inserted to drain urine) to help alleviate Patient 1’s UR and/or discomfort. The facility’s policy titled, Patient Care Services, dated 5/2024 indicated, “V ...System Review ...1. GU: b. Assess for urine color and clarity, frequency and voiding difficulty. 3. Use bladder scanner to assess for urinary retention. “”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 43674 Based on interview and record review, the facility failed to ensure patient monitoring for restraint was completed per physician order and hospital policy for 1 of 30 patients (Patient 24). This failure had the potential to affect Patient 24’s safety and well-being. Findings: Patient 24 was admitted to the facility on 8/27/25 with diagnoses which included subdural hematoma (bleeding near the brain) status post (after) unwitnessed fall and delirium (a change in mental abilities), per the History and Physical (H & P) dated 8/27/25. A review of Patient 24’s physician’s orders dated August 2025 was reviewed. An order dated 8/27/25 at 7 P.M. indicated, Restraint Monitoring Non-Violent: Frequency: 12 times per day ... Restraint Location: RUE/LUE (right upper extremity/left upper extremity).” An order dated 8/27/25 at 9:57 P.M. indicated, “Restraint Monitoring Non-Violent: Frequency: 12 times per day ... Restraint Location: posey vest.” A review of Patient 24’s restraint information indicated that restraint on the torso (central part of the body that includes the chest, abdomen, and back) was initiated (applied) on 8/27/25 at 6 P.M., and the restraint on the bilateral upper extremity was initiated on 8/27/25 at 8:30 P.M. A review of Patient 24’s restraint information, dated 8/29/25 was conducted. There was no documentation of restraint monitoring between 5 A.M. to 8:04 A.M. A concurrent interview and record review was conducted on 8/29/25 at 2:45 P.M. with the Director of Regulatory (DR). The DR stated that per Patient 24’s physician’s order, restraint monitoring was (supposed to be) 12 times per day and approximately every 2 hours. However, on 8/29/25, Patient 24’s torso and bilateral upper extremity were not monitored between 5 A.M. to 8:04 A.M. Further review of Patient 24’s record titled Restraint Information, dated 8/29/25 was conducted and indicated that restraint monitoring was monitored nine (9) times and not 12 times per physician order. A review of the hospital’s policy and procedure titled, Restraint Used for Non-Violent/Non-Self-Destructive Behavior last revised 8/2019 I indicated, “F. Orders: 1. Restraint is used upon the order of a physician/AHP. H. Ongoing Monitoring and Documentation ... 4. Assessment and Reassessment. A. The RN shall reassess patients in restraint approximately every 2 hours or more frequently if necessary ...””

“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: 48270 Based on interview and record review, the facility failed to ensure policy and procedures related to the end-of-surgery count for surgical instruments, were followed. This failure resulted in a retained foreign object (RFO- an item, such as a sponge, instrument, or device, that is unintentionally left inside a patient after a surgical or other invasive procedure) for one patient (Patient 19). Findings: Patient 19 was admitted to the facility on 1/22/25 for arthroplasty (surgical procedure where a damaged or diseased joint is removed and replaced with an artificial joint to relieve pain and improve function) of the left knee due to osteoarthritis (breakdown of cartilage in the joints, leading to pain, stiffness, and reduced movement), per the discharge summary record. Per this record, on 1/22/25, Patient 19 underwent a left knee total arthroplasty by Medical Doctor (MD) 19 with robotic assistant, and was discharged home on 1/23/25. Per the Emergency Department (ED) provider note, dated 1/25/25, Patient 19 went to the ED complaining of left knee redness and heat. An x-ray of the left knee showed “a potential loose screw that does not appear to be attached to anything in the knee.” On 3/14/25, at 12:25 P.M., a joint interview was conducted with MD 19 and the Manager of Regulatory Compliance and Accreditation (MRCA). MD 19 stated that he concluded that a tracker pin (used to guide the robotic arm and ensure accurate implant placement) was retained during Patient 19’s surgery. MD 19 stated that the tracker pin was supposed to be removed prior to the completion of a surgical procedure. MD 19 stated that he might have pulled on the tracker pin to remove it but did not pull it out all the way, and did not realize it was still implanted in Patient 19. MD 19 stated that tracker pins should be included in the surgical instrument count and that the count was important to ensure that all equipment was accounted for, to prevent an RFO. Per the facility’s undated policy titled Sponge, Sharps, and Instrument counts, Prevention of Retained Surgical Items, “ ...instrument counts are performed during surgery ...to provide for safe patient care and prevent retained surgical items.””

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 35370 Based on interview and record review, the facility failed to ensure nurse-to-patient ratio (defines the number of patients a nurse is assigned to care for; used to inform staffing decisions and ensure safe and adequate nursing care is provided; specific ratio is mandated in California) was maintained in the intensive care unit (ICU) according to standards of practice. This failure had the potential to affect the safe delivery and quality of patient care and treatment. In addition, this failure had the potential to affect staff workload and morale. Findings: A complaint validation was conducted at the facility from 3/11/25 through 3/14/25. A concurrent interview and review of the staffing assignments dated 2/1/25 through 2/14/25 were conducted with the ICU nurse manager (NM) 13 on 3/13/25 at 1:46 P.M. a. Per the “night (7 P.M. to 7 A.M.) shift (work hours)” assignment sheet dated 2/3/25, licensed nurse (LN) 14 was assigned to care for three (3) patients. NM 13 stated that LN 14 started the work shift at 7 P.M. with two (2) assigned patients to care for, however, that at 3:30 A.M., received a third patient. NM 13 stated that LN 14 had worked “out of ratio” when the third patient was admitted and assigned to LN 14’s care on 2/3/25. b. Per the “day (7 A.M. to 7 P.M.) shift” assignment sheet dated 2/4/25, LN 15 was assigned to care for 3 patients. NM 13 stated that LN 15 “probably received” a third patient “later in the day (shift)”, and acknowledged that LN 15 had worked “out of ratio” when the third patient was assigned to LN 15’s care on 2/4/25. c. A concurrent interview and review of the staffing assignment dated 3/14/25 was conducted with the charge nurse (CN) 15 on 3/14/25 at 11:22 A.M. CN 15 stated that there were three LNs who were working “out of ratio.” Per the staffing assignment, LN 16, LN 17, and LN 18 were each assigned to provide care for 3 patients in the ICU. c.1. A concurrent interview and review of the day shift assignment sheet dated 3/14/25, was conducted with LN 16 on 3/14/25 at 11:40 A.M. LN 16 stated that the nurse-to-patient ratio in the ICU was “typically two patients to one nurse.” LN 16 referred to the assignment sheet and identified 3 patients next to her name. LN 16 stated that when she started her shift at 7 A.M., she was assigned to care for the identified 3 patients. c.2. A concurrent interview and review of the staffing assignment dated 3/14/25 was conducted with LN 17 on 3/14/25 at 11:50 A.M. LN 17 stated that the nurse-to-patient ratio in the ICU was “two patients to one nurse.” LN 17 referred to the assignment sheet and identified two (2) patients next to her name. LN 17 stated that when she started her shift at 7 A.M., she was assigned to care for the identified 2 patients. LN 17 stated that a third patient was admitted and assigned to her at 8:30 A.M. LN 17 acknowledged that since 8:30 A.M., she was assigned to care for 3 patients. c.3. A concurrent interview and review of the staffing assignment dated 3/14/25 was conducted with LN 18 on 3/14/25 at 11:55 A.M. LN 18 stated that the nurse-to-patient ratio in the ICU was “supposed to be two patients to one nurse.” LN 18 stated that when he started his shift at 7 A.M., he was assigned to care for 2 patients. LN 18 stated that he received a third patient to care for “about an hour ago (at approximately 10:45 A.M.)” LN 18 referred to the assignment sheet and identified 3 patients that he was assigned to care for. In an interview with CN 15 on 3/14/25 at 12:06 P.M., CN 15 stated that the nurse-to-patient ratio in the ICU was one nurse to two patients and acknowledged that LN 16, LN 17, and LN 18 were (working) “out of ratio” when they were each assigned to care for three patients in the ICU. The facility’s policy titled, Plan for Nursing Care, dated/reviewed 2/2024, indicated, “... XI. Staffing Plans A. Staffing plans and scheduling for patient care service departments are developed based on the mandated RN (registered nurse) to patient ratio ...””

“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: 45063 Based on interview and record review, the facility staff failed to ensure physician’s orders were followed when: 1. Patient 1 was not transferred to a higher level of care from the Emergency Department (ED). 2. Pain relief measures were not provided for Patient 20. 3. Pain assessment and reassessment were not completed for Patients 10 and 26. These failures had the potential to result in the preventable demise (death) of Patient 1 and compromised pain relief and comfort for Patients 20, 10, and 26. Findings : 1. Patient 1 was admitted to the facility on 1/30/25 with diagnoses which included opiate (highly addictive class of drug used to reduce moderate to severe pain) overdose, per the History and Physical (H & P). Per the H & P, Patient 1 had a history of mood disorder, alcohol use disorder, polysubstance (using more than one drug/substance at the same time) use disorder, was in rehabilitation, and had left Against Medical Advice (AMA) two weeks prior. During a review of Patient 1’s physician’s orders dated 1/30/25, Patient 1’s record included the following orders per [a Doctor of Osteopathy; licensed medical professional; emphasizing on holistic approach to patient care] in the ED: 1/30/25 at 16:13 “...Request for admit (admission to) Telemetry (nursing unit where continuous monitoring of the patient’s heart activity, respiratory rate, and oxygen saturations are done, while automatically transmitting information to a central monitor)...” 1/30/25 at 17:19 “...Admit to Inpatient Med/Surg (medical/surgical; nursing unit where nurses provide care for patients with medical and surgical conditions that do not require constant monitoring)...” 1/30/25 at 17:51 “...Change Accommodation (Transfer Patient/Change Accommodation...) Telemetry...” An interview with Registered Nurse (RN) 1 on 3/12/25 at 9:30 A.M. was conducted. RN 1 stated that she was the primary RN for Patient 1. RN 1 stated that Patient 1 was admitted to the medical-surgical (MS) unit at 8:30 P.M., from the ED. RN 1 stated that the Emergency Department Registered Nurse (EDRN) 1 provided hand-off report (structured communication method used in healthcare to ensure safe and effective transfer of patient care responsibility and information from one caregiver to another) by phone to their Charge Nurse (CN) 1. RN 1 stated that EDRN 1 notified CN 1 that Patient 1 was being admitted to the MS unit. RN 1 stated that CN 1 then gave her (RN 1) the report of Patient 1’s admission to the MS unit. RN 1 stated that she questioned CN 1 on whether or not Patient 1 was appropriate to be admitted to the MS unit without a telemonitor (healthcare technology that uses computers to remotely monitor a patient’s status and vital signs; cardiac [heart] monitor). RN 1 stated that she shared her concern with CN 1, because Patient 1 was hypoxic (condition where there is an inadequate supply of oxygen to the body tissues) and had a Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA- Alcohol Withdrawal Assessment) score of 12 (CIWA score of 8 or greater - patient would need a higher level of care such as Intensive Care Unit [ICU] or Telemetry). RN 1 stated that CN 1 told her “don’t worry, they [have] already given Ativan (medication used to treat and control agitation caused by alcohol withdrawal) at the ED”. RN 1 stated that Patient 1 was drowsy and answered “yes and no” questions upon arrival to the MS unit. RN 1 stated that on 1/31/25 at 12:45 A.M., she found Patient 1 in her room lying in a prone position, with vomit on the pillow. RN 1 stated that CN 1 called a code (a hospital emergency indicating an adult patient is experiencing a life threatening medical emergency) at 12:46 A.M. RN 1 further stated that despite the code, Patient 1 expired (died) at 1:01 A.M. RN 1 stated she was not aware Patient 1 had an order to be on telemonitoring. RN 1 stated that she should have checked physicians’ orders before Patient 1’s arrival to the floor. An interview with CN 1 was conducted on 3/12/25 at 12:25 P.M. CN 1 stated that she received the report from EDRN 1 prior to Patient 1 arriving to the MS unit. CN 1 stated that Patient 1 had a medical-surgical bed assigned on the [name of bed assignment system], but acknowledged that she did not check the physician’s orders prior to sending Patient 1 to the MS unit. CN 1 stated that she completed an “RL” (an internal reporting system) after Patient 1’s demise. CN 1 stated an RL was completed because the death was an unexpected event. A concurrent interview and record review was conducted with EDRN 1 on 3/12/25 at 10:05 A.M. EDRN 1 stated that he received two different reports from two day shift (work hours beginning at 7 A.M. to 7 P.M.) ED nurses, one after the other at 7 P.M. EDRN 1 stated that he could not remember who gave him the report for Patient 1, and was not sure if the ED nurses were a “code nurse (nurse who responds to codes that may be called), a float nurse (nurse who is trained to work in multiple unit/departments to fill staffing gaps and ensure consistent patient care), or a break nurse (nurse who provides work coverage for other nurse’s breaks/meal periods, to ensure uninterrupted patient care).” EDRN 1 stated that neither of the ED RNs who gave him report, knew what was happening to Patient 1, or why Patient 1 was admitted. EDRN 1 stated that neither nurse knew what Patient 1’s diagnosis was. EDRN 1 stated he “did not receive a good (complete) hand-off report” for Patient 1. EDRN 1 stated that Patient 1 was not on a continuous cardiac monitoring while at the ED. EDRN 1 stated he was not aware if Patient 1 had telemetry orders. EDRN 1 stated he gave report to CN 1 at 8 P.M., and that CN 1 did not have any resistance admitting Patient 1 to the MS unit. EDRN 1 stated he gave report to CN 1, then sent Patient 1 to the MS unit at 8:30 P.M., with an Emergency Department Technician (EMT), without a telemonitoring box. An interview with the House Supervisor (HS) 1 was conducted on 3/12/25 at 11:55 A.M. HS 1 acknowledged that Patient 1 had an order to be admitted to the Telemetry unit but was sent to the MS unit instead. HS 1 stated that she found out that Patient 1 had telemetry orders on 1/31/25 at 12:45 A.M., while conducting her chart reviews. HS 1 stated that the Charge Nurse should have caught the order. HS 1 stated that Patient 1 had a Fentanyl (potent opioid drug ) overdose and should had been “considered a crisis.” HS 1 further stated that Patient 1 should had been placed on telemetry monitoring. HS 1 stated that if Patient 1 was placed on a telemetry unit as ordered, the “tele monitor (cardiac monitor)” could have noticed the bradycardic (slow heart rate where the heart beats fewer than 60 times per minute) or tachycardic (rapid heart rate, exceeding 100 beats per minute at rest) changes of Patient 1. A concurrent interview and record review with Unit Manager (UM) 1 was conducted on 3/13/25 at 2:31 P.M. UM 1 validated Patient 1 had a Telemetry order from the ED on 1/30/25 at 5:51 P.M. UM 1 stated Patient 1 should had been sent to a Telemetry unit, but was not. UM 1 stated Patient 1 was sent to the MS unit at 8:30 P.M. UM 1 stated Patient 1 should have not been sent to the MS unit. UM 1 further stated, it was a wrong level of care for Patient 1, because Patient 1 needed to be monitored closely due to her admitting diagnosis, which was an opiate overdose. UM 1 stated that staff were expected to review physician orders when giving and receiving hand-off report. UM 1 stated Patient 1’s CIWA score was 12, which meant the patient needed a higher level of care such as ICU or Telemetry, so that she could have been monitored closely. UM 1 stated that RN 1 acknowledged the telemetry orders at 10:43 P.M., in the [name of electronic medical record system] but did not implement (carry out/follow) the order. UM 1 stated that RN 1 should have informed CN 1 of Patient 1’s telemetry orders and Patient 1 should have been monitored closely. The facility’s policy and procedure (P & P) titled, “Patient Care Services, Subject: Alcohol Withdrawal Symptom Management,” revision date 8/20, indicated, “ ...C.2. b. if the CIWA- ... score is greater than or equal to 8.. i. Request a higher level of care (i.e. Telemetry or Intensive Care Unit) bed. “ The facility’s P & P titled, “Patient Care Services, Subject: Physician/Allied Health Professionals (AHP) Inpatient Orders” dated 12/01, indicated, “...C. Policy 3. Transfer Process: a. When a patient is transferred from one level of care to another the physician/AHP updates the orders ...The nurse will review the orders and contact the physician /AHP for any clarification of orders. 4. Reviewing orders ...a. All orders entered electronically ...must be reviewed for correctness ...i. Notify the physician / AHP if needed for clarification of any orders ...” 48270 2. Patient 20 was admitted to the facility on 3/10/25 after undergoing a left hip arthroplasty (surgical procedure that involves replacing the damaged components of the left hip joint with artificial implants) per the History and Physical (H & P). On 3/11/25, at 9 A.M., a concurrent observation and interview was conducted with Patient 20 in her room. Patient 20 stated that she did not sleep well the night prior because she was in pain. Patient 20 stated that she did not receive pain medication from 3 P.M. on 3/10/25 until 8 A.M., on 3/11/25. Patient 20 stated that she was not instructed by the nursing staff to ask for pain medication if she needed it. Patient 20 stated that “if she laid still and did not move”, she did not feel pain. Patient 20 further stated that it would have been beneficial if the nurse communicated to her that she needed to ask for pain medication if she was experiencing pain. On 3/13/25, at 1:30 P.M., a concurrent interview and record review was conducted with the Clinical Nurse Educator (CNE) 19. Patient 20’s record for pain assessments dated 3/11/25 indicated that she was assessed by the nurse at 2:13 A.M. and at 5:42 A.M. with a pain scale at a level 2 (1 to 3 - mild pain; 4 to 6 - moderate pain; 7 to 10 - severe pain) for both assessments. Per the physician’s orders, Patient 20 could have received Acetaminophen 1,300 milligrams (mg) by mouth as needed for mild pain. CNE 19 acknowledged that the patient was not offered or provided pain relief measures when the patient was assessed to have pain. On 3/14/25, at 9:52 A.M., an interview was conducted with Unit Manager (UM) 20. UM 20 stated that pain management and relief was one of their top priorities for the ortho/rehab unit (orthopedic/rehabilitation; nursing unit; specializes to help individuals recover from musculoskeletal injuries, diseases, or surgeries affecting muscles, bones, joints; to improve mobility and reduce pain). UM 20 stated it was her expectation that all nurses assessed their patients for pain, provided relief accordingly, and reassessed for effectiveness (of pain medication/relief). A review of the facility’s Patient Care Services policy and procedure titled Pain Management dated/revised 11/2018 indicated, “ ...B.6. Assessment and reassessment of pain level and pain relief should be performed with routine vital signs and as needed. Findings should be documented in the electronic health record (EHR) ...C.3. Document pain assessment in the EHR ...”. 38175 3. Patient 10 was admitted to the facility on 3/9/25 with diagnoses which included chest pain per the facility’s History and Physical (H & P). On 3/13/25 at 11:29 A.M., a concurrent interview and review of Patient 10’s medical record was conducted with Unit manager (UM) 7. Patient 10’s Medication Administration Record (MAR) indicated that on 3/12/25 at 6:22 P.M., Patient 10 was administered (given) 50 milligrams (mg) of tramadol (pain medication). UM 7 reviewed Patient10’s Electronic Medical Record (EMR). Under the pain assessment tab, a nurse documented, “0” (zero) pain on 3/12/25 at 3:12 P.M. The next recorded pain assessment on the same day was “0” at 9 P.M. UM 7 stated that there should had been a post (after) pain level assessment completed after the administration of the pain medication. UM 7 acknowledged that pain assessment was not completed and documented for Patient 10. On 3/14/25 at 10:10 A.M., an interview and joint review of Patient 10’s EMR was conducted with RN 7. RN 7 stated that there was a missing pain assessment prior to administering Resident 10’s pain medication (on 3/12/25). In addition, RN 7 stated that a post pain assessment should had been completed within 45 minutes to an hour after administration of a pain medication by mouth. A review of the facility’s Patient Care Services policy and procedure titled Pain Management dated/revised 11/2018 indicated, “ ...B.6. Assessment and reassessment of pain level and pain relief should be performed with routine vital signs and as needed. Findings should be documented in the electronic health record (EHR) ...C.3. Document pain assessment in the EHR ...”.”

“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: 35370 Based on interview and record review, the facility failed to ensure nursing care plans (document indicating a patient’s needs and goals) were developed (created) per the facility’s policy, for 5 of 31 sampled patients (14, 7, 9, 10, and 8). As a result, a care plan related to pain was not developed and included in three patient’s (14, 10, 8) medical record, and a care plan related to cardiac (heart) condition was not developed and included in three patient’s (7, 9, 8) medical record. This failure had the potential to affect the patient’s needed interventions related to comfort, care, and treatment. Findings: 1. Patient 14 was admitted to the facility on 3/9/25 with diagnoses which included pulmonary embolism (a blood clot in the lung, cutting off blood flow), per Patient 14’s History and Physical (H & P; assessment notes written by the physician). A review of Patient 14’s medical record was conducted on 3/12/25. Per the H & P dated 3/9/25, Patient 14 “ ...presented to [name of hospital] for chest pain..” Per this record, Patient 14 had a past medical history of chronic pain. The recapitulated physician’s orders dated March 2025 included an order for “Acetaminophen (Tylenol) 500 milligrams (mg) ... every four (4) hr (hours) PRN (as needed for) pain ..., Oxycodone 5 mg ...every 4 hr PRN pain ..., Oxycodone 10 mg ...every 4 hr PRN pain ...” A concurrent interview and review of Patient 14’s medication administration flowsheet record dated March 2025, was conducted on 3/12/25 at 3:21 P.M. with the Clinical Supervisor (CS) 13. CS 13 stated that Patient 14 complained of pain on 3/10/25 and 3/11/25. The medication administration flowsheet record included documentation that Patient 14 received Oxycodone 5 mg on 3/10/25 at 8:56 P.M. and Acetaminophen 500 mg on 3/11/25 at 2:19 A.M. A joint review of Patient 14’s care plans were conducted with CS 13 on 3/12/25 at 3:25 P.M. A care plan that addressed comfort and/or pain was not included in Patient 14’s medical record. In an interview with CS 13 on 3/12/25 at 3:33 P.M., CS 13 stated that care plans of the patient’s actively treated diagnoses were usually developed and included in the patient’s record. CS 13 acknowledged that upon assessment, Patient 14 had a history of chronic pain and had recently complained of pain. CS 13 stated that there was “...definitely an option” to include a nursing care plan for pain and acknowledged that a care plan for pain was not developed or included in Patient 14’s record. A review of the facility’s Patient Care Services policy and procedure titled, Interdisciplinary Plan of Care (IPOC) dated/revised 7/2018, indicated, “...IPOCs shall be kept current by ongoing assessment of the patient’s needs and of the patient’s response to interventions, assessment of patient treatment goals, and updating or revising the patient’s IPOC in response to assessments ...” 38175 2. Patient 7 was admitted to the facility on 3/9/25 with diagnoses which included anemia (blood disorder reducing the ability to carry oxygen in the body), and bradycardia (slow heart rate) per Patient 7’s History and Physical (H & P). A review of Patient 7’s medical record was conducted. Per the physician’s order dated 3/12/25, admitting orders included, “Telemetry (heart monitor that measures and records heart rate and movement) ... Review Care Plan ...” On 3/12/25 at 2:44 P.M., a concurrent interview and review of Patient 7’s medical record was conducted with the Intensive Care Unit Manager (ICM). The ICM stated Patient 7 was placed on telemetry due to her past medical history. Upon reviewing Patient 7’s nursing assessment dated 3/15/25, a nurse documented, “...sinus brady (slow heart rate)” at 1 P. M. and at 4 P. M. On the same date, a nurse documented, “atrial fibrillation (rapid and irregular heartbeat)”. The ICM stated that a care plan that addressed Patient 7’s heart condition was not created and included in Patient 7’s medical record. 3. Patient 9 was admitted to the facility on 2/22/25 with diagnoses which included non-elevated ST (partial blockage of one of the heart’s arteries) per Patient 9’s History and Physical (H & P). On 3/13/25 at 10:56 A.M., a concurrent interview and review of Patient 9’s medical record was conducted with Unit Manager (UM) 7. UM 7 stated that Patient 9 was admitted on 2/22/25 with “heart issues”. UM 7 stated that nursing assessment on patients with telemetry monitor were completed every four hours. UM 7 looked for Patient 9’s cardiac care plan and stated, “There was none”. UM 7 stated the care plans should be created upon admission to ensure the patient met their care delivery goals. On 3/14/25 at 10:10 A.M., an interview was conducted with Registered Nurse (RN) 7. RN 7 stated that care plans should be initiated within four to eight hours of admission. 4. Patient 10 was admitted to the facility on 3/9/25 with diagnoses which included chest pain per Patient 10’s History and Physical (H & P). On 3/13/25 at 11:29 A.M., a concurrent interview and review of Patient 10’s medical record was conducted with Unit Manager (UM) 7. Patient 10’s medication administration record indicated that on 3/12/25 at 6:22 P.M., Patient 10 was administered (given) 50 milligrams (mgs) of tramadol (pain medication). UM 7 reviewed Patient 10’s care plan for pain, and stated he could not find one. UM 7 further stated there should had been a care plan for pain, because the patient had orders for pain medication, and it required a pre (before) and post (after) pain level assessment. On 3/14/25 at 10:25 A.M., a concurrent interview and review of Patient 10’s medical record was conducted with RN 7. RN 7 stated that Patient 10’s record did not include a care plan for pain, and acknowledged that one should had been created. 5. Patient 8 was admitted to the facility on 3/11/25 with diagnoses which included cardiac arrest (heart suddenly stops beating) per Patient 8’s History and Physical (H & P). On 3/14/25 at 9:25 A.M., a concurrent interview and review of Patient 8’s medical record was conducted with RN 8. RN 8 stated that Patient 8 was receiving Fentanyl (a potent opioid drug) titration (a way to adjust the dosage/administration of medication over time) intravenously (IV - access line to give medications). RN 8 stated that Patient 8 was admitted to the intensive care unit (ICU) on 3/11/25 because of cardiac arrest. RN 8 stated that Patient 8’s record did not include a care plan for cardiac issues or pain management. RN 8 stated that care plans should be developed and initiated right away, upon admission. A review of the facility’s Patient Care Services policy and procedure titled, Interdisciplinary Plan of Care (IPOC) dated/revised 7/2018, indicated, “ ...1. An Interdisciplinary Plan of Care (IPOC) shall be initiated within eight (8) hours of patient’s arrival to an inpatient care area. 2. The IPOC includes planning the patient’s nursing care to meet the patient’s needs and interventions toward meeting the patient treatment goals ...””

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 43674 Based on observation, interview, and record review the hospital did not ensure personal privacy was provided to 24 of 24 Justice involved patients (inmates) when patients were video monitored without documented clinical need and patient awareness of the video monitoring. In addition, the hospital did not have a policy and procedure for video monitoring. These failures violated the patients’ privacy. Finding: A concurrent observation and interview were conducted on 10/22/24 at 10:55 A.M., in 3 North and 3 South (PCU - Progressive Care Unit) with the Charge Nurse (CN) 11. The nursing station was observed with video monitors that continuously monitored the patients in the 24 rooms of the unit. CN 11 stated the patients inside the rooms were continuously video monitored. An interview was conducted on 10/23/24 at 3:40 P.M., with Unit Manager (UM) 11. UM 11 stated the PCU have 24 patient rooms and each room had a camera for video monitoring. UM 11 stated the hospital and PCU did not have a policy and procedure (P&P) on the use of the camera for video monitoring. UM 11 stated the video monitored patients did not have clinical indication/need documented in their Electronic Health Record (EHR). In addition, there were no documentation of patient awareness of the video monitoring. UM 11 stated video monitoring was not a requirement for justice involved patients, video monitoring can be turned off and would not be a conflict with security and custodial policies. UM 11 acknowledged that the hospital should have P&P on video monitoring, and the patients should have a documented awareness and clinical need for video monitoring but did not have. UM 11 further stated patient privacy was important because it was every patient’s right. A review of hospital’s P&P indicated there was no P&P on video monitoring. A review of hospital’s policy and procedure titled, Patient Right and Responsibilities last revised on 8/2018 indicated “D. Related Documents: ...2. Justice Involved Patient’s Rights and Responsibilities ... A patient’s rights and responsibilities shall include but not limited to: ...2. Considerate and respectful care, including privacy in treatment and in care of personal needs, when not in conflict with security and custodial policies ...””

“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: 45063 Based on interview and record review, the facility did not ensure staff follow its policy and procedure when: 1. Cardiac defibrillator pads were not remove prior going for MRI (Magnetic Resonance Imaging- test that creates clear images of the structures inside your body using a large magnet, radio waves and a computer) testing for Patient 1. 2. Two patients (Patient 21 and Patient 22) were able to leave the Emergency Department (ED) without supervision. These failures had the potential to compromise patient’s health and safety. Findings : 1.Patient 1 was admitted to the facility on 9/9/24 with chief complaint of back pain per History and Physical (H&P). During a review of patient 1’s physician order dated 9/9/24, Patient 1 had an order for MRI Spine Lumbar without contrast. A concurrent interview and record review with the Radiology Manager (RM) on 10/22/24 at 2:27 P.M., was conducted. The RM stated it was reported to him that Patient 1 was scheduled to have MRI on 9/10/24. The RM also stated, Patient 1 had defibrillator pads while on the unit. The RM further stated Patient 1 was on an external defibrillator monitor on the way to MRI. The RM also stated, the Intensive Care Unit Nurse (ICU-N) transported Patient 1 to MRI, ICU-N then removed the portable defibrillator monitor, but did not remove the defibrillator pads prior to MRI procedure. The RM further stated, Patient 1 went into the MRI machine with defibrillator pads attached to his left lateral abdomen rib cage area and back area, he then felt something warm and press the emergency button. The RM stated, the MRI tech took him out of the machine and found the defibrillator pads on his left lateral rib cage area and back area. The RM stated each patient was to fill out a MRI screening online, the nurse on the unit fills it out online. The RM stated, once the patient arrives at the MRI trailer, MRI tech was supposed to review each question on the screening form to avoid missed items by the patients. The RM stated the ICU-N should have made sure everything was taken off of Patient 1 prior to sending them for MRI testing. The RM stated when the patient arrives in the MRI trailer, the MRI tech should have visually checked the patient and use a magnetic metal wand to screen Patient 1. The RM stated, it was important to make sure patient did not have anything on them because MRI machine heats up as it scan. The RM stated, the MRI tech assigned to this patient failed to visually check the patient and use a magnetic metal wand. The RM acknowledged by leaving the defibrillator pads on Patient 1’s skin, it could have resulted in a burn. An interview with MRI Technician (MRI-tech) 1 was conducted on 10/22/24 at 2:45 P.M. MRI tech 1 stated ICU-N told him the defibrillator pads were all plastic and patient was ready to go for an MRI. MRI -tech 1 stated he did not used the magnetic metal detector wand in screening Patient 1 prior to MRI testing. MRI-tech 1 stated he should have been more diligent in screening Patient 1 prior to MRI testing. MRI -tech 1 stated it’s a safety issue, leaving the defibrillator pads on Patient 1’s skin. An interview with MRI Technician (MRI-tech) 2 was conducted on 10/22/24 at 2:55 P.M. MRI- tech 2 stated MRI-tech 1 should have done a visual check, taken the pads off and used the magnetic wand to scan patient 1 prior to MRI testing. MRI-tech 2 stated that by leaving the defibrillator pads on Patient 1’s skin, it could have resulted in a burn. An interview with the Intensive Care Unit Nurse (ICU-N) was conducted on 10/23/24 at 2:00 P.M. The ICU-N stated she was with Patient 1 when Patient 1 was sent for MRI testing. The ICU- N stated she should have read the packaging of the defibrillator pads prior to MRI testing. ICU- N stated the defibrillator pads packaging indicated it was not MRI safe. ICU- N stated she did not know what she was thinking and told MRI -tech 1, all the pads were plastic, and the patient was ready to go for MRI testing. During a review of Patient 1’s Wound Care Nurse notes on 10/25/24 at 10:25 A.M., with the Wound Care Nurse (WCON) 1, the note indicated, “Patient 1 had serous filled blister at left upper lateral abdominal rib back area 0.6 cm x 2 cm and erythema 4 cm x 8cm back area.” The WCON 1 stated this image was taken the day after the incident, 9/11/24. During a review of facility’s policy and procedure titled, Procedure: MRI Metallic Object Screening 7633-112 ...undated, indicated, “ ...A. Procedure 1. Metallic Object Screening shall be performed on all patients ...who enter MRI Safety Zone 3 ...” 45909 2 a. A review of Patient 21’s first admission notes to the ED dated 9/27/24 at 6:56 A.M., indicated, Patient 21 had a medical diagnosis of hyperglycemia (elevated blood sugar), hypertension (elevated blood pressure) and suicidal ideation (SI- thought of taking own life). Patient 21 was discharged to home on 9/27/24 at 12:12 P.M. Review of Patient 21’s second admission to the ED, the ED Triage (EDT - process of prioritizing treatment) notes dated 9/27/24 at 4:32 P.M., indicated, Patient 21 was confused in a local store and was brought back into the ED by the police department (PD). A concurrent interview and record review were conducted with Registered Nurse (RN) 21on 10/23/24 at 10:03 A.M. Per Patient 21’s EDT notes dated 9/27/24 at 5:50 P.M., Patient 21 was called for registration three times in the waiting area but did not respond. The EDT comment dated 9/27/24 further indicated, Patient 21 eloped prior to registration. RN 21 stated Patient 21 had a history of confusion and should have been placed in a room and a hospital staff should have stayed with Patient 21. RN 21 further stated the ED staff should have called the PD when the unit found out Patient 21 eloped. An interview was conducted with the Clinical Nurse Manager (CNM) 21 on 10/24/24 at 11:30 A.M. The CNM 21 stated staff should have continuously monitored the behavior of patients in the ED and to report changes in behavior to the physician. CNM 21 further stated Patient 21 should have been in a room with a hospital staff to provide safety check. During an interview with the House Supervisor (HS) on 10/25/24 at 1 P.M. The HS stated Patient 21 was in the ED waiting area and should have been placed in a room in the ED unit for safety checks by hospital staff. 2 b. Review of Patient 22’s first EDT notes in the hospital dated 9/24/24 at 1:17 A.M., indicated Patient 22 was in the ED for SI with her partner. The EDT notes also indicated, multiple attempts to locate Patient 22 within the vicinity were attempted but unsuccessful. Review of Patient 22’s second EDT notes dated 9/24/24 at 7:22 A.M., indicated Patient 22 was still having SI. A concurrent interview and record review were conducted with RN 21 on 10/23/24 at 10:17 A.M. RN 21 stated per review of Patient 22’s EDT notes, Patient 22 and her partner should have not been in the waiting area but should have been placed in a room with a hospital staff to prevent Patient 22 from eloping. An interview was conducted with the CNM 21 on 10/24/24 at 1:45 P.M. CNM 21 stated Patient 22 should have been placed inside a room and should have been assigned a hospital staff to conduct safety checks. CNM 21 further stated there was no documentation Patient 22 was assigned a hospital staff for safety checks. Review of the hospital’s policy titled Emergency Department revised, 04/2023, indicated, “2. Appropriate steps shall be taken to attempt to prevent at risk patients from leaving the ED without authorization...2 Identifiers for patients at risk for elopement ... confusion or change in mental status. e. Request clothing and/or personal belongings, f. active 5150 hold ...3. Patient determined to be missing ...Attempts shall be made to locate the patient. Hospital security or law enforcement shall be notified as appropriate.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 43674 Based on interview and record review the hospital did not ensure that use of restraint to 1 of 1 patient (Patient 19) were in accordance with a physician order when: 1. Patient 19 was placed on soft limb bilateral restraint on 10/22/24 from 4:58 A.M. to 6:06 P.M. without a restraint order. 2. Patient 19’s restraint monitoring and reassessment were not consistently done per physician order. 3. Patient 19 did not have documentation in EHR of restraint discontinuation and that restraint’s release criteria was met. These failures had the potential risk on Patient 19’s care and well-being. Findings: 1. Patient 19 was admitted to the hospital on 10/10/24 for diagnoses which included severe sepsis with septic shock (infection) per undated Admission Records. A review of Patient 19’s Restraint Evaluation dated 10/22/24 indicated that Patient 19 was placed on soft limb bilateral upper restraint on 10/22/24 at 4:58 A.M. until 6:06 P.M. A review of Patient 19’s Physician Orders on restraint did not indicate that Patient 19 had an order for restraint for soft limb bilateral upper restraint. A concurrent interview and record review of Patient 19’s Restraint Evaluation and Restraint Orders were conducted on 10/25/24 at 1:32 P.M., with Clinical Nurse Educator (CNE) 11. CNE 11 stated Patient 19’s Restraint Evaluation indicated Patient 19 was placed on soft limb bilateral upper restraint on 10/22/24 at 4:58 A.M., until 6:06 P.M. CNE 11 further stated Patient 19 did not have a physician order for restraint of soft limb bilateral upper for 10/22/24 restraint initiation. A review of hospital’s policy and procedure titled, Restraint Used for Non-Violent/Non-Self-Destructive Behavior last revised 8/2019 indicated “ ...F. Orders: 1. Restraint is used upon the order of a physician/AHP (Allied Health Professional) ...5. A written order, based on examination of the patient by a physician is entered into the EHR on the initiation of restraint ...” 2. Patient 19 was admitted to the hospital on 10/10/24 for diagnoses which included severe sepsis with septic shock (infection) per undated Admission Records. A review of Patient 19’s Restraint Evaluation indicated that Patient 19 was placed on restraint intermittently from 10/12/24 to 10/23/24. Further review indicated Patient 19’s restraint monitoring and reassessment were not consistently documented every 2 hours per hospital policy while on restraint. A concurrent interview and record review of Patient 19’s Restraint Evaluation and Restraint Orders were conducted on 10/25/24 at 1:32 P.M. with Clinical Nurse Educator (CNE) 11. CNE 11 stated Patient 19 was placed on restraint intermittently between 10/12/24 to 10/23/24. CNE 11 further stated the same document indicated that nursing staff did not consistently document the restraint monitoring and reassessment every 2 hours per hospital policy. CNE 11 acknowledged that Patient 19’s restraint monitoring and reassessment should have been documented but was not. A review of hospital’s policy and procedure titled, Restraint Used for Non-Violent/Non-Self-Destructive Behavior last revised 8/2019 indicated, “ ...H. Ongoing Monitoring and Documentation: ...3. Patient Care: a. The RN or designee trained and competent in use of restraint shall address and document the following patient care needs approximately every 2 hours in the EHR i. Range of Motion ii. Elimination iii. Nutrition/Hydration iv. Allowance for the patient to have maximum movement ... 4. Assessment and Reassessment a. The RN shall reassess patient in restraint approximately every 2 hours or more frequently if necessary. i. The patient will be assessed for the following: 1. Need to continue to use restraints 2. Mental status and behavior 3. Physical/Emotional well-being 4. Respiratory Status 5. Limb circulation 6. Maintenance of the patient’s rights, dignity and security 7. Monitoring of the correctness of the application, removal and reapplication of restraint 8. Skin ...” 3. Patient 19 was admitted to the hospital on 10/10/24 for diagnoses which included severe sepsis with septic shock (infection) per undated Admission Records. A review of Patient 19’s Restraint monitoring indicated the last restraint monitoring on 10/22/24 at 6 P.M., was “Restraint Activity: Continue restraint”. The document further indicated that following the 6 P.M., documentation, there were no other documentation on restraint. A concurrent interview and record review was conducted on 10/25/24 at 1:32 P.M., with Clinical Nurse Educator (CNE) 11. CNE 11 stated the restraint monitoring was last documented as continue restraint on 10/22/24 at 6 P.M. CNE 11 acknowledged that there was no documentation of Patient 19’s restraint’s discontinuation. CNE 11 also acknowledge that there was no documentation that criteria for release of restraint was met. CNE 11 further stated that discontinuation of restraint and criteria for release of restraint should have been documented but was not. A review of hospital’s policy and procedure titled, Restraint Used for Non-Violent/Non-Self-Destructive Behavior last revised 8/2019 indicated, “ ...K. Discontinuation: 1. Restraint shall be discontinued when criteria for release are met or as soon as possible regardless of the length of time identified in the order. 2. Document discontinuation of restraint in the EHR ...””

“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: 45909 Based on interview and record review, the hospital’s Quality Assessment and Performance Improvement (QAPI) Committee, failed to develop a plan to ensure patient safety, risk reports generated from the Emergency Department’s data of elopement activities. As a result, this failure had the potential to place patient safety at risk in an emergency department which receives patients with psychosocial needs. Finding: A review of the hospital’s monthly Risk Report by the events for the period of January - April 2024 indicated; patient elopement was identified as a high risk area for patient safety concerns. During an interview and record review with the Emergency Department Director (EDD) on 10/25/24 at 1:30 P.M., the EDD stated the total number of elopement cases that happened in the ED for the last three months were to be documented, submitted, and discussed at the QAPI quarterly meeting. A review of the facility’s QAPI committee tracking sheet dated 10/15/24, did not indicate there was a comprehensive discussion or accurate gathering of data related to ED elopements. The EDD further stated the description of elopement cases in the ED should have been entered accurately into the event report system to identify if the event was related to medical, behavioral or lack of resources. During the QAPI meeting on 10/25/24 at 3:00 P.M., the Chief Nursing Executive (CNE) stated, the ED should have submitted the accurate number with the specific description of elopement cases through the hospital’s process of filing an event report for discussion during the QAPI meeting. The CNE, stated the QAPI committee could have discussed further and could have implemented specific methods to address the specific issues on elopement as it was considered to be a high-risk area of concern in the hospital’s ED unit and when pertaining to patient safety. A review of the hospital’s policy titled, Quality Assessment Performance Improvement (QAPI) Plan Administrative Patient Care, 2023 & 2024, indicated, “ ...D. CULTURE OF SAFETY ...3. Priorities are identified and categorized based on the Institute of Medicine (IOM) Six Aims of Healthcare: ...d. Efficient: (timely data analytic, clinical documentation improvement ...f. Patient Centered (e.g. Patient Rights and values guide all clinical decisions) ...””

“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: 45909 Based on interview and record review, the hospital failed to continuously monitor the psychological (mental health) needs when two of two patients (Patient 21 and Patient 22) were able to leave the emergency department (ED) without supervision. This failure had the potential to affect the patient’s wellbeing. Findings: 1. Review of Patient 21’s first admission notes to the ED dated 9/27/24 at 6:56 A.M., indicated, Patient 21 had a medical diagnoses of hyperglycemia (elevated blood sugar), hypertension (elevated blood pressure) and suicidal ideation (SI- thought of taking own life). Patient 21 was discharged to home on 9/27/24 at 12:12 P.M. Review of Patient 21’s second admission to the ED, the ED Triage (EDT - process of prioritizing treatment) notes dated 9/27/24 at 4:32 P.M. indicated, Patient 21 was confused in a local store and was brought back into the ED by the police department (PD). A concurrent interview and record review were conducted with Registered Nurse (RN) 21 on 10/23/24 at 10:03 A.M. Per Patient 21’s EDT notes dated 9/27/24 at 5:50 P.M., Patient 21 was called for registration three times in the waiting area but did not respond. The EDT comment dated 9/27/24 further indicated, Patient 21 eloped prior to registration. RN 21 stated Patient 21 had a history of confusion and should have been placed in a room for continuous psychological monitoring and a hospital staff should have stayed with Patient 21. RN 21 further stated the ED staff should have called the PD when the unit found out Patient 21 eloped. An interview was conducted with the Clinical Nurse Manager (CNM) on 10/24/24 at 11:30 A.M. The CLM stated staff should continuously monitor the behavior of patients in the ED to report any changes to the physician. The CLM further stated Patient 21 should have been in a room with a hospital staff to provide safety check. During an interview with the House Supervisor (HS) on 10/25/24 at 1:00 P.M. The HS stated Patient 21 was in the ED waiting area and should have been placed in a room in the ED unit for safety checks by hospital staff. 2. Review of Patient 22’s first EDT notes in the hospital dated 9/24/24 at 1:17 A.M., indicated, Patient 22 was in the ED for SI with her partner. The EDT notes also indicated, multiple attempts to locate Patient 22 within the vicinity were attempted but unsuccessful. Review of Patient 22’s second EDT notes dated 9/24/24 at 7:22 A.M. indicated, Patient 22 was still having SI. A concurrent interview and record review were conducted with RN 21 on 10/23/24 at 10:17 A.M. RN 21 stated per review of Patient 22’s EDT notes, Patient 22 and her partner should have not been in the waiting area but should have been placed in a room for continuous psychological monitoring with a hospital staff to prevent Patient 22 from eloping. An interview was conducted with the Clinical Nurse Manager (CNM) on 10/24/24 at 1:45 P.M. The CNM stated Patient 22 should have been placed inside a room and should have been assigned a hospital staff to conduct safety checks. The CNM further stated there was no documentation Patient 22 was assigned a hospital staff for safety checks. Review of the hospital’s policy titled, Emergency Department revised, 04/2023, indicated, “2. Appropriate steps shall be taken to attempt to prevent at risk patients from leaving the ED without authorization..2 Identifiers for patients at risk for elopement: ...confusion or change in mental status. e.request clothing and/or personal belongings, f. active 5150 hold ...3. Patient determined to be missing: ...Attempts shall be made to locate the patient. Hospital security or law enforcement shall be notified as appropriate.””