HCA Healthone Mountain Ridge

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 45020 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.43 Discharge Planning, was out of compliance. A-0800: (a) The hospital’s discharge planning process must identify at an early stage of hospitalization those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient’s representative, or patient’s physician. Based on interviews and document reviews, the facility failed to ensure case management was involved in the discharge process to ensure a safe discharge plan in one of three inpatient medical records reviewed. (Patient #2)”

“DISCHARGE PLANNING - EARLY IDENTIFICATION CFR(s): 482.43(a) The hospital’s discharge planning process must identify at an early stage of hospitalization those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient’s representative, or patient’s physician. This Standard is not met as evidenced by: 45020 Based on interviews and document reviews, the facility failed to ensure case management was involved in the discharge process to ensure a safe discharge plan in one of three inpatient medical records reviewed. (Patient #2) Findings include: Facility policies: The Discharge Planning/Continued Care Process policy read, the purpose of this policy is to ensure adequate and accurate screening and follow-up on continued care needs for all patients. Discharge planning is accomplished for all patients and is the cumulative responsibility of all health care providers. A registered nurse (RN) case manager or a social worker, will review all patients on medical, surgical and intensive care (ICU) units including those who meet case management screening criteria and/or for whom they have received referrals. RN case managers and/or social workers will continually assess for discharge planning needs as they conduct concurrent medical record review and interdisciplinary communication. The Discharge Planning policy read, the discharge planning activities and care coordination are documented in the medical record. For patients who are not discharged home, an assessment of discharge planning needs includes the patient’s medical and psychosocial needs with consideration as to whether the patient will be able to safely return to their previous setting. 1. The facility failed to ensure a patient was assessed by a case manager or social worker to ensure the patient returned to their skilled nursing facility (SNF - temporary living facility for patients who require rehabilitation or medical treatments for an illness or injury). A. Document Review i. Review of Patient #2’s medical record revealed Patient #2 was admitted to the medical surgical unit on 2/19/26 for evaluation of abdominal pain. Provider #1’s history and physical revealed Patient #2 had recently moved to the area and resided at a SNF. On 2/21/26, Provider #1’s progress note revealed case management (CM) was to provide resources as the patient was unhoused, however, no CM consult order was placed. Review of Patient #2’s discharge summary dated 2/22/26 read, the patient was unhoused and CM had provided resources for shelters. Patient #2 was discharged on 2/22/26 at 4:48 p.m., and was transported from the facility by a contracted ride service to a shelter. Patient #2’s medical record failed to reveal evidence of a CM or social worker assessment, and failed to reveal why Patient #2 was not returned to their SNF. This was in contrast to the Discharge Planning policy, which read, an assessment of discharge planning needs included consideration as to whether the patient was able to safely return to their previous setting. Discharge planning activities and care coordination should have been documented in the medical record. This was also in contrast to the Discharge Planning/Continued Care Process policy, which read, discharge planning was the cumulative responsibility of all healthcare providers. An RN case manager or social worker reviewed all patients on medical and surgical units. RN case managers and/or social workers continually assessed for discharge planning needs as they conducted concurrent medical record review and interdisciplinary communication. B. Interviews i. On 5/11/26 at 9:13 a.m., an interview was conducted with RN #2. RN #2 stated discharge planning began when patients were admitted. RN #2 stated case management assessed every patient to ensure barriers were addressed and their discharge needs were met. RN #2 stated if a patient arrived from a SNF and discharged to a shelter, there was a risk the patient’s needs might not have been met, which could have caused rehospitalization. ii. On 5/12/26 at 8:54 a.m., an interview was conducted with CM #3. CM #3 stated discharge planning was performed to ensure a plan was in place to ensure patients were discharged safely. CM #3 stated the facility used an artificial intelligence (AI) system, which automatically screened every patient within the first eight hours of admission and determined if case management was needed for an in-person consult. CM #3 stated when patients were admitted from a SNF, AI determined the patient would return to the SNF, and a CM consult was not triggered. CM #3 stated a provider could have ordered a CM consult if they determined the patient needed resources. iii. On 5/13/26 at 11:38 a.m., an interview was conducted with CM #5. CM #5 stated an AI program was used on Patient #2’s medical record, the patient was screened out, and AI had not triggered case management to consult on the patient. CM #5 stated they were unsure why Patient #2 was discharged to a shelter. CM #5 stated the SNF Patient #2 had resided in before they were admitted to the hospital was considered Patient #2’s home. CM #5 stated they were unsure why AI had screened the patient out and had not triggered a CM consult. iv. On 5/12/26 at 11:54 a.m., an interview was conducted with medical doctor (MD) #4. MD #4 stated a consult for case management was to be ordered by the provider when it was determined a patient was in need of resources. This was in contrast to Patient #2’s medical record, which failed to reveal evidence of a CM consult order when it was determined resources were needed. MD #4 stated case management consulted on every patient. This was in contrast to Patient #2’s medical record, which failed to reveal evidence of a case management assessment. MD #4 stated they were not aware of the AI program in place used to screen patients for case management needs. MD #4 stated if a patient was admitted from another facility and discharged to a shelter, there was a risk the patient might not have received the care they needed.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48269 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.13 Patient Rights was out of compliance. A-0144 Patient Rights: care in a safe setting. The patient has the right to receive care in a safe setting. Based on document review and interviews, the facility failed to keep patients who had been identified as high-risk safe. Specifically, the facility failed to ensure interventions were in place to prevent patients on an M1 hold (a 72-hour involuntary mental health treatment process used when a professional determined that someone was a danger to themselves or others, or was so disabled by mental illness that they could not care for themselves) from eloping in two of three patients reviewed.”

“MEDICAL RECORD SERVICES CFR(s): 482.24 The hospital must have a medical record service that has administrative responsibility for medical records. A medical record must be maintained for every individual evaluated or treated in the hospital. This Condition is not met as evidenced by: 46674 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.24 Medical Record Services was out of compliance. A0438- FORM AND RETENTION OF RECORDS. 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. Based on document reviews and interviews, the facility failed to ensure medical records were accurately documented in four of eight emergency department (ED) patients’ records reviewed.”

“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: 48269 Based on document review and interviews, the facility failed to keep patients who had been identified as high-risk safe. Specifically, the facility failed to ensure interventions were in place to prevent patients on an M1 hold (a 72-hour involuntary mental health treatment process used when a professional determined that someone was a danger to themselves or others, or was so disabled by mental illness that they could not care for themselves) from eloping in two of three patients reviewed. (Patients #2 and #3) Findings include: Policies: The Patient Rights and Responsibilities policy read, patients have the right to expect reasonable safety insofar as the corporation practices and environment are concerned. Patients have the right to be placed in protective privacy when the patient and/or their physician believe it is necessary for the patient’s personal safety. The Mental Health Holds - Emergency Evaluations of Persons Incapacitated Due to Mental Illness policy read, its purpose was to provide safe, quality care for patients with a mental illness who are in need of 72-hour Mental Health (M1) Hold under provisions of C.R.S. 27-65, and who require emergency department medical clearance and psychiatric evaluation or acute inpatient medical/surgical nursing care beyond the capability of an inpatient psychiatric unit or who may be awaiting placement/bed availability on an inpatient psychiatric unit. The Patient Elopement policy read, its purpose was to ensure the safety of patients at risk for elopement and to establish a systematic approach to searching for patients who are missing. Elopement is defined as a patient who presents to the facility for clinical evaluation, leaves without completing the visit or treatment, or hospitalization, and does not notify clinical staff before leaving. An at-risk patient is a person who is “susceptible to mistreatment, self-neglect, or exploitation because s/he is unable to perform or obtain services necessary for his or her health, safety, or welfare, or lacks sufficient understanding or capacity to make or communicate responsible decisions concerning his or her person or affairs.” Patients who express a wish to leave the facility against medical advice (AMA) are not considered to be an elopement unless it is determined that the patient is at-risk. At-risk patients examples include involuntary hold patients, mental status changes, neurological disorders affecting judgment, and a physical condition that places the patient at-risk. The facility will provide a safe environment for patients, visitors, and staff. Staff will implement appropriate interventions as needed in order to prevent elopement by patients. However, in the event of a patient’s elopement, an immediate response by staff will be initiated. The AMA Policy read, a patient on a mental health (M1) or alcohol or drug hold may not sign out AMA and may be restrained in accordance with hospital restraint policies to prevent them from leaving. The Suicide Risk Assessment policy read, its purpose was to provide guidance to assist with the identification of patients in non-Behavioral Health (BH) settings who are at risk for suicide, ensuring a safe environment for the provision of care. It is the policy of the facility to create an environment of care that will foster the assessment, identification, and management of patients who are at increased risk for suicide or self-harming behaviors. Patients who are at an increased risk for suicide or self-harming behaviors require intensive support, close observations, and frequent reassessment for their emotional and physical well-being. The scope of this plan begins with the patient’s initial presentation to the hospital and continues until the patient is discharged. The Occurrence Reporting policy read, its purpose was to identify, trend, and analyze occurrences in the aggregate that will lead to improvements in patient, staff, and visitor safety; to meet regulatory reporting requirements; to provide a system for follow-up, intensive analysis, and investigation of sentinel events and other adverse outcomes which lead to improvements in patient safety. The facility’s list of “Reportable Events” included elopement after a search of the facility if the patient is at risk or greater than eight hours regardless of the risk to the patient. The Serious Safety Event Identification, Notification, and Management policy read, its purpose was to provide direction to the facility on identification, notification, and management of patient serious safety events (SSE). Improve the facility’s culture, systems, and processes with the intent to prevent recurrence and improve safety systems. An event may be considered an SSE regardless of the severity of harm caused to the patient, the event is indicative of a serious gap in safety systems, policies, or processes that directly increases risk of future occurrence of an SSE. Any elopement (that is, unauthorized departure) of a patient from a staffed around-the-clock care setting (including the ED), leading to death, permanent harm, or severe harm to the patient. Reference: The Performance Improvement Risk Management Patient Safety Plan 2024 read, the facility has a comprehensive ongoing Performance Improvement (PI), Risk Management (RM), and Patient Safety (PS) Plan that supports the mission, vision, and values developed by the facility board of trustees. Leadership will set priorities that ensure the safety and quality of care and treatment. Facility leadership responsibilities include but are not limited to upholding the values and principles of the facility’s mission; fostering communication, coordination, safety, and timeliness of care among individuals and departments to coordinate patient care and improve patient safety; and implementing an effective program to continuously measure, assess, and improve performance, reduce risks, and improve patient safety. 1. The facility failed to prevent high-risk patients placed on M1 holds from eloping. A. Document review i. Patient #2’s medical record was reviewed and revealed Patient #2 was brought into the Emergency Department (ED) by ambulance on 9/29/24 at 4:40 p.m. Patient #2 had been assaulted and sustained a head injury. Patient #2 also reported daily alcohol use and withdrawal symptoms. The medical record revealed Patient #2 had been treated with intravenous (IV) fluids, medication for alcohol withdrawal symptoms, lab work, and imaging. At 5:16 p.m., Patient #2’s blood alcohol level was 267. Further medical record review revealed Patient #2 left the ED at 6:41 p.m. before being reassessed by the provider and before they had received discharge instructions. Patient #2 was escorted by security to a nearby bus stop. The police department arrived to assist and witnessed Patient #2 fall to the ground and hit their head so the police called emergency medical services (EMS) to transport Patient #2 back to the ED. ii. Patient #2 returned to the ED by ambulance at 6:52 p.m. Medical record review revealed Patient #2 was evaluated by an ED provider who documented Patient #2 was a 30-year-old male who presented with acute psychosis (symptoms that indicated a person had lost touch with reality or was having difficulty relating to others), auditory hallucinations, and thoughts of harming others, which posed a threat to life or bodily function. Additionally, the record revealed Patient #2 had a history of schizophrenia (a chronic mental illness that affects a person’s thoughts, feelings, and behaviors) and had experienced a fall, which necessitated head imaging to rule out serious injury. Additionally, the provider documentation read, Patient #2 was placed on an M1 hold at 6:52 p.m. immediately after evaluation for endorsing auditory hallucinations and thoughts of wanting to harm people. Further, the provider’s documentation read, the nurse had notified them that although the patient was initially calm and cooperative during evaluation, when security went to the bedside Patient #2 got agitated, leaped out of bed, and eloped from the ED at 7:00 p.m. The medical record read, Patient #2 was being aggressive and threatening toward staff as he was leaving the ED and was unable to be safely detained. Documentation revealed the police department had been called to search for Patient #2 because the patient still had an IV in place and was on an M1 psychiatric hold. Further review of Patient #2’s medical record revealed there was no evidence of safety interventions such as a sitter at the bedside, fifteen-minute checks, or that a safe environment checklist was implemented for Patient #2 on this ED visit. This was in contrast to the Suicide Risk Assessment policy which read, patients who were at an increased risk for suicide or self-harming behaviors required intensive support, close observations, and frequent reassessment for their emotional and physical well-being. The scope of this plan should have begun with the patient’s initial presentation to the hospital and continued until the patient was discharged. a. A security report on 9/29/24 read, Patient #2 was picked up by the police after falling and brought back to the ED by ambulance at 6:52 p.m. The security report read, at 6:57 p.m. Patient #2 eloped after the doctor had put them on an M1 hold. The security report read, the police department was called immediately and the patient was followed off the grounds until they were no longer in sight. b. On 11/25/24, a review of the facility’s incident log revealed no incident report was filed for Patient #2’s elopement. This was in contrast to the Occurrence Reporting policy which read, the facility’s list of reportable events included elopement after a search of the facility if the patient was at risk. c. A review of the AMA policy revealed patients on an M1 hold could be physically restrained if they tried to sign out AMA. However, upon request, the facility was unable to provide a policy or guidance staff were to follow when a patient on an M1 hold tried to elope from the facility. ii. Patient #3’s medical record was reviewed and revealed Patient #3 came to the ED on 10/27/24 at 2:40 p.m. with the chief complaint of abdominal pain. The record revealed the ED provider assessed the patient at 2:42 p.m. and documented Patient #3 had stabbed themselves in the abdomen with an object and had concerns about worsening abdominal pain. The medical record also read, Patient #3 was an 18-year-old female with a history of morbid obesity, borderline personality disorder, and recurrent self-harm behavior. Further, the record revealed Patient #3’s case had been immediately discussed with the attending physician who had recommended an M1 medical hold for self-harm. The medical record read, orders were placed, the M1 form was filled out, and the staff were notified of Patient #3’s high-risk status. Further, the medical record read, at 3:41 p.m. Patient #3 ran out of the ED front door and nursing staff and security were unable to stop the patient. Nursing documentation read, security notified the police department of the patient’s elopement while on a high-risk M1 hold. a. A security report placed on 10/27/24 read, Patient #3 ran out the front door followed by security and medical staff who stated the patient was not free to leave and had an IV in place. The report read, Patient #3 got in their car, ripped their IV out, and blood started shooting out of the IV site. Patient #3 then drove off. The report further read that the police department did not respond when facility security called to notify them of Patient #3’s elopement. The security response ended at 5:03 p.m. with no further information to report. b. A review of the facility’s incident log revealed on 10/27/24 an incident report had been filed that read, Patient #3 had eloped and the police department was called but did not find the patient. Additionally, the facility completed an SSE analysis of this event on 10/30/24. c. A review of the AMA policy revealed patients on an M1 hold could be physically restrained if they tried to sign out AMA. However, upon request, the facility was unable to provide a policy or guidance staff were to follow when a patient on an M1 hold tried to elope from the facility. B. Interviews i. On 11/26/24 at 3:17 p.m., an interview and live record review was conducted with registered nurse (RN) #2. RN #2 verified Patient #2 had been brought in by ambulance, was evaluated by the ED provider, and was placed on an M1 hold immediately after evaluation. RN #2 stated M1 hold paperwork had been initiated at 6:52 p.m. and was in the record. Also, RN #2 stated there was no nursing documentation in the record. RN #2 stated they were not sure why there was no nursing documentation in the record and there should have been a nursing note. Additionally, RN #2 stated there should have been an incident report placed for Patient #2’s elopement so the facility could find areas for improvement and address any gaps in care. ii. On 12/2/2024 at 9:40 a.m., an interview was conducted with ED manager (Manager) #3. Manager #3 stated patients placed on an M1 hold should have had a behavioral health (BH) huddle (a brief meeting to discuss the patient’s risk level) at the bedside which included the provider, the charge nurse, and the primary nurse. Manager #3 stated if the patient was high-risk no one should have left the patient’s room and the ED charge nurse would have assigned someone to stay in the room with the patient. Manager #3 stated high-risk patients could not be left alone because they could harm themselves and it was the ED staff’s job to keep them safe. Also, Manager #3 stated if a patient on an M1 hold tried to leave, the M1 policy directed the staff not to physically restrain the patient. Manager #3 stated ED staff were to call security for assistance. Manager #3 stated some patients got violent and angry and that would have been when staff relied on security and the police department to assist. Manager #3 explained that if a patient started to run, staff would have been able to verbally try to persuade them to stay but the policy stated they could not physically restrain the patient. Manager #3 said security or the police would have been able to restrain the patient. This was in contrast to the AMA policy which revealed patients on an M1 hold could be physically restrained if they tried to sign out AMA. However, upon request, the facility was unable to provide a policy or guidance staff were to follow when a patient on an M1 hold tried to elope from the facility. Additionally, Manager #3 stated Patient #2’s medical record revealed that an M1 hold had been placed. Manager #3 stated interventions to ensure Patient #2’s safety should have included a sitter at the bedside, documentation on the sitter checklist, and documentation of a safe environment. Manager #3 stated they had no idea why none of these safety interventions had been implemented. Further, Manager #3 stated Patient #2 had eloped. Manager #3 stated the nurse caring for Patient #2 should have completed an incident report. Manager #3 stated they could not answer why no incident report had been filed. Manager #3 stated incident reports were important to educate staff, to trigger a review of the medical record, and to identify processes that could have been done differently to prevent a similar situation from occurring again. iii. On 12/2/24 at 11:30 a.m., an interview was conducted with ED director (Director) #4. Director #4 stated interventions implemented to keep M1 patients safe included conducting a BH huddle at the patient’s bedside, implementing an in-person or virtual sitter, and that the primary nurse would have done the safety checklist and implemented interventions that would have created a safe environment. Director #4 stated the safety interventions were important to protect patients and staff. Director #4 stated if an M1 patient wanted to leave, staff would have tried to verbally persuade the patient to stay, and then notified security and the police if necessary. Director #4 explained staff would not have gone hands-on with a patient unless there had been a threat to themselves or staff, and in that case, would have restrained the patient. Director #4 stated if an M1 patient eloped and made it out of the building, the staff should have called the police department. Director #4 stated the ED staff would have done all within their power to keep the patient safe, but if the patient darted out the door, it would have been the police department’s responsibility at that point. Also, Director #4 stated ED nursing staff should have documented a nurse’s note about the event if a patient had eloped. Director #4 stated the nurse should have notified the provider, documented the events and that the provider had been notified, documented that security and the police had been notified, and discharged the patient from the system. Additionally, Director #4 stated an incident report should have been placed after a patient elopement. Director #4 stated anyone would have been able to place an incident report, but the primary nurse would have been ultimately responsible. Finally, Director #4 stated they did not know why there had been no nursing notes about Patient #2’s care, safety interventions, and elopement. Director #4 stated even though there had been no nursing assessment documented there still should have been a note with Patient #2’s disposition. Director #4 stated the disposition note would have been important to document that Patient #2 had been in the ED, what the staff had done to keep them safe, where the patient had gone after discharge, and what condition they had been in when they left. Director #4 stated they had no idea why an incident report had not been filed about Patient #2’s elopement. iv. On 12/2/24 at 1:17 p.m., an interview was conducted with the vice president of quality, risk, and infection control (VP) #1. VP #1 stated they did not know why an incident report had not been completed about Patient #2’s elopement. VP #1 stated because an incident report had been filed for Patient #3’s elopement, the facility completed an SSE analysis to investigate what processes had failed and what the facility could have done to improve patient safety. VP #1 stated incident reporting was important to improve patient safety and so that the facility would have been able to fix processes that might have been failing. VP #1 stated if they had been aware of Patient #2’s incident, it could have been investigated and actions could have been taken to prevent future patient elopements from the ED such as Patient #3’s incident. These interviews were in contrast to The Patient Rights and Responsibilities policy which read, patients had the right to expect reasonable safety as far as the facility’s practices and environment were concerned. Patients had the right to be placed in protective privacy when the patient and/or their physician believed it was necessary for the patient’s safety.”

“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: 46674 Based on document reviews and interviews, the facility failed to ensure medical records were accurately documented in four of eight emergency department (ED) patients’ records reviewed. (Patients #2 and #3) Findings include: Facility policies: The Patient Elopement: Prevention and Search Guidelines policy read, elopement is defined as a patient who presents to the facility for clinical evaluation, leaves without completing the visit or treatment, or hospitalization, and does not notify clinical staff before leaving. Patients who express a wish to leave the facility against medical advice (AMA) are not considered to be an elopement unless it is determined that the patient is at-risk. At-risk patients include involuntary hold (M1 hold) patients. The AMA policy read, a patient can sign out of the hospital against medical advice. At any time, a patient may choose to be discharged or leave the facility. If, despite every effort to dissuade them, a patient insists on leaving the facility without the written order or consent of their provider, efforts will be made to inform the patient of the risks involved that may result from this action. Patients on an M1 hold may not leave AMA. When a patient expresses the desire to leave the facility AMA, staff will contact the patient’s provider and advise them about the patient’s decision to leave. Prior to contacting the provider, staff will attempt to explore the patient’s anxieties, conflicts, expectations, and disappointments in regard to the treatment they are receiving. If a provider refuses to discharge the patient, the provider or designee shall discuss the possible effects/consequences of leaving AMA with the patient and also offer alternatives to leaving AMA. Any patient who makes the decision to leave AMA will be asked to sign the Informed Consent to Refuse form. If the patient refuses to sign the form, document the reason/refusal on the form and place it in the medical record. Providers/staff will document all pertinent information and the patient’s rationale for leaving AMA in the patient’s medical record. 1. The facility failed to ensure patient dispositions were accurately documented in the medical records. A. Document Review i. Review of the facility’s ED patients list revealed Patient #2 left the facility AMA on 8/10/24. a. A medical record review was conducted for Patient #2. The coding summary revealed Patient #2 left the facility AMA on 8/10/24 at 9:49 p.m. Nursing documentation revealed Patient #2’s disposition was AMA and they had refused treatment. This was in contrast to the Provider’s documentation which revealed a plan was discussed with Patient #2 who understood their return precautions and follow-up. The provider further documented Patient #2 agreed with the plan and was discharged home. b. On 11/25/24 at 4:49 p.m., email correspondence from the infection prevention manager to the surveyors revealed the ED manager had reviewed Patient #2’s medical record and did not know why the nurse documented Patient #2 had left AMA. ii. Review of the facility’s ED patients list revealed Patient #2 had been discharged home on 9/29/24. a. A medical record review was conducted for Patient #2. The coding summary revealed Patient #2 was discharged home on 9/29/24 at 6:43 p.m. Nursing documentation revealed Patient #2’s disposition was AMA and they had refused treatment. This was in contrast to the Provider’s documentation which revealed Patient #2 had eloped before they were reassessed for discharge and the police department had been called to bring them back to the facility. iii. Review of the facility’s ED patients list revealed Patient #2 had left the facility AMA on 9/29/24. a. A medical record review was conducted for Patient #2. The coding summary revealed Patient #2 left the facility AMA on 9/29/24 at 7:00 p.m. This was in contrast to the Provider’s documentation which revealed Patient #2 eloped from the ED and the police department had been called to search for them because they were on an M1 hold. There was no nursing documentation located in Patient #2’s record. Patient #2’s disposition documented on the ED patients list and coding summary were in contrast to the AMA policy which read, patients on an M1 hold could not leave AMA. iv. Review of the facility’s ED patients list revealed Patient #3 had left the facility AMA on 10/27/24. a. A medical record review was conducted for Patient #3. The coding summary revealed Patient #3 left the facility AMA on 10/27/24 at 3:41 p.m. Nursing documentation revealed Patient #2’s disposition was AMA and they had refused treatment. This was in contrast to a nursing note and the Provider’s documentation which revealed Patient #2 was on an M1 hold and had eloped from the ED. Patient #3’s disposition documented on the ED patients list, coding summary, and nursing documentation for disposition were in contrast to the AMA policy which read, patients on an M1 hold could not leave AMA. v. On 12/3/24 at 9:30 a.m., email correspondence from the vice president of quality, risk, and infection control (VP) #1 to the surveyors revealed there were no AMA forms for Patient #2 or Patient #3 located in their medical records. vi. The Ongoing Medical Record Quality Reviews policy read, the purpose was to ensure medical records were monitored regularly for completeness, timeliness, and accuracy. Resulting actions were taken to improve quality and timeliness of documentation and in rare instances, health information management (HIM) was responsible for facilitating. Medical records were reviewed on a monthly basis collaboratively by nursing, patient care staff, and occasionally HIM. A random sampling of all patient types, service lines, and payers would be utilized. The findings from the reviews were collectively reported to the specific hospital committee for actions related to any deficiencies identified, and escalated to the specific hospital committee as needed. The review of medical records would be based on hospital-defined indicators that addressed the presence, timeliness, readability, quality, consistency, clarity, accuracy, completeness, and authentication of data and information contained within the record. The specific hospital committee determined the number, type, review criteria, and responsibility for the reviews. The specific committee was responsible for identification of deficiencies, pursuing opportunities for improvement, and assured improvement was attained for enhancement of patient care. This was in contrast to the continental division 2024 reporting calendar to quality and patient safety council (QPSC)/clinical patient safety and quality committee (CPSQC) which revealed medical records were reviewed for timeliness/delinquency, completeness/legibility, and quality of history and physicals, not accuracy of documentation. B. Interviews i. On 11/26/24 at 3:16 p.m., an interview and live medical record review was conducted with registered nurse (RN) #2. RN #2 stated elopement meant a patient had fled the premises without having a conversation with staff to discuss the risks and benefits of leaving. RN #2 stated patients who left AMA were alert, oriented, and of sound mind and staff had explained the risks of leaving AMA. RN #2 reviewed Patient #2’s medical records and confirmed Patient #2 was discharged home on 8/10/24. RN #2 also confirmed Patient #2 eloped during both ED visits on 9/29/24. Additionally, RN #2 reviewed Patient #3’s medical record and confirmed they had eloped from the ED on 10/27/24. RN #2 stated it was in patients’ best interests to ensure care was properly documented and medical records were accurate. ii. On 12/2/24 at 9:40 a.m., an interview and live medical record review was conducted with ED manager (Manager) #3. Manager #3 stated they did not know why the medical record for Patient #2 on 8/10/24 indicated they left AMA when the Provider’s note read Patient #2 had been discharged home. Manager #3 also confirmed Patient #2 had eloped during their first visit on 9/29/24 and did not know why the ED patient list read Patient #2 had been discharged home. Manager #3 stated AMA was documented in the same way as elopement in their electronic medical record (EMR) system. Manager #3 stated there was not an option in the EMR for staff to document elopements, which was why staff documented patients who eloped as leaving AMA. Manager #3 stated staff followed policy the best they could with what options were available to them in the EMR. iii. On 12/2/24 at 11:30 a.m., an interview was conducted with ED director (Director) #4. Director #4 stated all changes to the facility’s EMR system had to go through corporate. Director #4 stated there had never been a way for staff to document elopement dispositions in the EMR in the eight years they had worked at the facility. iv. On 12/2/24 at 1:17 p.m., an interview was conducted with VP #1. VP #1 stated there was a difference between elopement and AMA. VP #1 stated the EMR did not give staff the option to document elopements in the medical record. VP #1 stated it was important for patients’ dispositions to be accurately documented to ensure the facility was able to follow up with patients if needed.”

“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: 48269 Based on document reviews and interviews, the facility failed to ensure minimum staffing requirements were maintained to allow adequate numbers of licensed registered nurses (RNs) to provide nursing care to all patients as needed, in accordance with the facility’s nurse staffing plan in one of three nursing units reviewed (Two South). Findings include: Facility policy: The Master Staffing Plan policy read, its purpose was to establish Colorado hospital provisions as well as standards of performance for safe nursing care. The hospital shall have a staffing system based on the assessment of patient needs in conformance with the accreditation requirements of the Joint Commission and a documented staffing plan in accordance with HB 22-1401: Hospital Nursing Staffing Standards and Colorado Department of Public Health and Environment (CDPHE) Standards for Hospitals and Health Facilities Chapter 4. A nurse staffing plan shall be developed based on scope of care that meets the needs of the patient population, acuity, and frequency of care to be provided. References: According to the Standards for Hospitals and Health Facilities Chapter 4 - General Hospitals 6 CCR 1011-1 Chapter 4, Part 14.7 Nurse Staffing Plans, (A) Master Nurse Staffing Plan, (1) The nurse staffing committee shall annually develop and oversee a master nurse staffing plan for the hospital that: (c) Includes minimum staffing requirements for each inpatient unit and emergency department that are aligned with nationally recognized standards and guidelines. The staffing plans, which were identified by staff as the facility’s staffing grids, were provided by the facility. The staffing plans listed the name of each unit at the facility, specified the variable patient census range for each unit, and the specified number of registered nurses (RN) and certified nursing assistants (CNA) expected to be staffed and present on each unit according to the current patient census. The staffing plans specified the nurse-to-patient ratios according to the patient census and amount of nurses required. The Scope of Service - Telemetry for the Two South unit read, services provided include diagnosis, treatment, and coordination of care to patients with multiplex complex medical/surgical problems in the inpatient setting. Nurses are competent to care for this wide variety of patient populations and care needs. The unit is staffed based on each shift’s patient census. According to the RN Clinical Nurse Coordinator (CNC) (charge nurse) job description, the CNCs job responsibilities are to provide leadership, support, and coordination of the unit’s daily operations during designated shifts. Assists in directing, organizing, and prioritizing all shift activities ensuring patient care and staff needs are met. Ensures appropriateness of admission/cases to the unit/department and appropriate staff skill mix exists to provide safe patient care. Immediate problem-solving patient complaints and other issues that could negatively impact patient care. Functions effectively as relief Nurse Manager as needed/requested. Evaluates staff performance; completes annual staff evaluations as requested. 1. The facility failed to ensure minimum staffing requirements were maintained to allow adequate numbers of licensed registered nurses (RNs) to provide nursing care to all patients as needed. A. Document Review i. The Two South staffing assignment sheets revealed multiple occasions between 7/30/24 and 8/6/24 when staffing did not align with the unit staffing plan. Examples included: a. From 7/30/24 to 8/6/24 for a census of 27 patients Two South was consistently staffed with one charge nurse who was assigned at least two patients and five nurses who were assigned at least five patients. This was in contrast to the Two South - telemetry staffing grid which read for 27 patients the unit should have been staffed with one charge nurse and six RNs on the 7:00 a.m. to 7:00 p.m. shift and the 7:00 p.m. to 7:00 a.m. shift. b. On 8/4/24 the Two South staffing assignment sheet for 7:00 p.m. to 7:00 a.m. revealed for a census of 28 patients the charge nurse was assigned five patients from midnight to 7:00 a.m., three RNs were assigned six patients for the shift, and one RN was assigned five patients for the shift. One of the RNs taking a six patient assignment was the unit manager. This was in contrast to the Two South - telemetry staffing grid which read for 28 patients the unit should have been staffed with one charge nurse and six RNs as opposed to the actual staffing for the shift which was deficient two RNs and had a charge nurse with a five patient assignment. c. On 8/6/24 the Two South staffing assignment sheet for 7:00 a.m. to 7:00 p.m. revealed for a census of 27 patients the charge nurse was assigned two patients, four RNs were assigned five patients, an LPN was assigned five patients, and three patient care technicians (PCT) were on duty. This was in contrast to the Two South - telemetry staffing grid which read for 27 patients the unit should have been staffed with one charge nurse, six RNs, and four PCTs. The Two South - telemetry staffing grid did not include LPNs who had a limited scope of practice compared with RNs who were needed due to the complexity of patients on the unit. The actual staffing for the shift was deficient two RNs and one PCT. d. On 8/6/24 the Two South staffing assignment sheet for 7:00 p.m. to 7:00 a.m. revealed for a census of 26 patients the charge nurse was assigned three patients, three RNs were assigned six patients, and one RN was assigned five patients. Also, there was only one PCT on the assignment sheet for the shift. This was in contrast to the Two South - telemetry staffing grid which read for 26 patients the unit should have been staffed with one charge nurse, five RNs, and three PCTs. The actual staffing for the shift was deficient two PCTs, an RN, and the charge nurse had three patients. ii. The Master Staffing Plan policy did not align with the actual implementation of the policy. a. The Master Staffing Plan policy read, its purpose was to establish Colorado hospital provisions as well as standards of performance for safe nursing care. The policy read the hospital would have a staffing system based on the assessment of patient needs in accordance with HB 22-1401: Hospital Nursing Staffing Standards and Colorado Department of Public Health and Environment (CDPHE) Standards for Hospitals and Health Facilities Chapter 4. Also, the policy read a nurse staffing plan would be developed based on scope of care that met the needs of the patient population, acuity, and frequency of care provided. This was in contrast to the Scope of Service - Telemetry for the Two South unit which read the unit was staffed each shift based on the patient census. Additionally, an acuity tool to determine nurse staffing needs was requested and facility leaders stated that an acuity tool was not utilized at the facility. b. According to the Standards for Hospitals and Health Facilities Chapter 4 - General Hospitals 6 CCR 1011-1 Chapter 4, Part 14.7 Nurse Staffing Plans, (A) Master Nurse Staffing Plan, (1) The nurse staffing committee would annually develop and oversee a master nurse staffing plan for the hospital that: (c) Included minimum staffing requirements for each inpatient unit and emergency department that were aligned with nationally recognized standards and guidelines. The staffing grids provided by the facility were referred to as guidelines by facility leaders which was in contrast to the regulation which stated the nurse staffing committee would annually develop and oversee a master nurse staffing plan that included minimum staffing requirements for each inpatient unit. Additionally, national guidelines used to determine the facility master staffing plan were requested and facility leaders did not provide any. Furthermore, CNO #5 stated they were unaware of national guidelines for staffing medical-surgical nursing units. B. Interviews i. On 9/26/24 at 11:24 a.m. an interview was conducted with RN #1. RN #1 stated Two South was the cardiac and trauma floor with higher acuity patients. RN #1 stated staffing ratios on the unit were one nurse to five or six patients. Also, RN #1 stated on Two South the CNC (clinical nurse coordinator, or charge nurse) would take a patient assignment; however, there were few charge nurse-appropriate patients on Two South due to the higher acuity patients. This made the CNC less available to the staff. RN #1 compared the Two South staffing with nurse staffing on the other medical-surgical units in the facility which utilized a pod concept of RNs and LPNs working as a team. RN #1 stated the RN could assist the LPN but there were few things the RN could delegate to the LPN which created a heavier workload for RNs. Additionally, RN #1 stated they were not aware of a nurse staffing committee in the facility. Further, RN #1 stated front-line nurses did not have a say in staffing decisions. ii. On 9/30/24 at 12:32 p.m. an interview was conducted with CNC #2. CNC #2 stated Two South was the main telemetry and trauma unit which admitted patients who were ICU stepdown level of care. CNC #2 stated their charge nurse duties included to ensure discharges were timely, assign new admissions, unit throughput (moving admitted and discharged patients in and out of the unit efficiently), assist the nursing staff with clinical questions, round on patients and families, and to ensure patients were cared for while all staff got a lunch break. CNC #2 stated they had supervisory and management duties like coaching staff in the moment when issues occurred. Also, CNC #2 stated they provided patient care every shift taking two patients. They said the ratio on Two South was one nurse to five patients and they staffed to a census of 27 so the charge nurse always took two patient assignments. CNC #2 said this was decided by a prior CNO when they were adjusting their matrix. CNC #2 stated today staffing on Two South was one CNC, five RNs, and two PCTs with a census of 27 patients. CNC #2 described this as typical staffing except they were short one PCT. CNC #2 stated charge nurse tasks that got delayed due to patient care included shift audits such as neuro checks or restraint use. CNC #2 stated when charge duties got too busy they relied on other RNs and PCTs to help with patient care or patients just had to wait. Further, CNC #2 stated they did not know if there was a specific staffing committee. They said there was a bed meeting each shift where nursing supervisors and CNCs met to determine staffing needs and allocate resources for a shift and that might be considered a nurse staffing committee. CNC #2 stated frontline nursing staff would bring staffing concerns to the unit manager, staff meeting, or unit-based council (UBC) meetings. iii. On 9/26/24 at 9:45 a.m. an interview was conducted with nursing supervisor (Supervisor) #3. Supervisor #3 stated their responsibility was to look at the schedule for the day and reallocate resources as needed. Supervisor #3 stated the nursing supervisors received sick calls and recently there had been a high volume. Supervisor #3 stated there was a staffing grid for each unit which was used as a guideline. The goal was to staff each unit according to the grid but they could not always achieve it. Supervisor #3 said if they could not achieve the staffing grid then they had the option to cap the census on a given unit. Also, Supervisor #3 stated Two South was considered a more acute unit which took trauma, stroke, and cardiac patients and needed more staff resources. Finally, Supervisor #3 stated they did not know what the staffing grids were based on and they were not involved in how the staffing grids were developed. Supervisor #3 stated they thought the grids were standard throughout the entire hospital division. iv. On 9/25/24 at 2:06 p.m. an interview was conducted with nurse manager (Manager) #4. Manager #4 stated the Two South staffing grid was used as a guideline to staff the unit. Manager #4 stated the grids were a guideline, a budgeted amount of staff for the unit. Also, they stated the charge nurse looked at staffing shift by shift and if acuity was high would adjust staff as needed. Manager #4 stated there was no acuity tool used to measure patient acuity. Additionally, Manager #4 stated they did not know what national guidelines were used to make the staffing grids. Further, Manager #4 stated the unit would cap census at times based on census and acuity however this process was not written in policy. Manager #4 described the nurse staffing committee as the unit-based council (UBC) which consisted of themselves and the charge nurses on the unit and others were welcome to attend. Minutes of the UBC meetings were submitted to the CNO for the master staffing plan. Manager #4 stated the CNC council was the hospital-wide staffing committee. v. On 9/25/24 at 2:40 p.m. an interview was conducted with chief nursing officer (CNO) #5. CNO #5 stated that each unit had a unit-based staffing committee that met monthly. CNO #5 stated UBCs were attended by a combination of the bedside nurses and the CNCs with the nurse manager. According to CNO #5, the UBCs were intended to be a discussion about concerns and suggestions for improvement which were forwarded to the CNO and brought to the quarterly CNC council meetings. CNO #5 stated the CNC council meetings were the quarterly staffing committee review and the recommendations were brought to the quarterly executive review, which was a meeting of all nurse leaders, to determine what recommendations the facility could implement. Also, CNO #5 stated the staffing grids were a budgeted amount of staffing provided on an annual basis and reviewed during the year as needed. CNO #5 stated they did not know how the grids were budgeted and did not know of any national guidelines used to determine staffing on a medical-surgical nursing unit. CNO #5 stated all sister facilities fell into the same grid system based on the type of patient unit. On 9/30/24 at 1:15 p.m., an additional interview was conducted with CNO #5. CNO #5 stated CNCs were considered front-line staff because, while it was not ideal or an everyday occurrence, CNCs still provided patient care. CNO #5 stated the preference was for CNCs not to have a patient assignment but they were not always able to achieve that. This interview was in contrast to the Two South daily staffing assignment sheets and previous interviews which revealed the CNCs on Two South took a patient assignment of two or more patients daily.”