St Elizabeths Hospital

“MEDICAL STAFF CFR(s): 482.22 The hospital must have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital. This Condition is not met as evidenced by: 49189 Based on medical by-laws and rules and responsibilities review, hospital policy reviews, medical record review, and interviews, the facility failed to meet the Condition of Participation for Medical Staff by failing to ensure medical staff operates under bylaws and is responsible for the quality of medical care provided to patients by the hospital as evidenced by: The facility’s Medical Staff failed to enforce by laws and rules and responsibilities related to hospital policy compliance by failing to (1) complete medical evaluation forms for a patient who required a transfer to a higher level of care for five (5) out of five (5) patients and (2) Conduct an annual History and Physical for one (1) out of fifteen patients. See Tag 353.”

“FOOD AND DIETETIC SERVICES CFR(s): 482.28 The hospital must have organized dietary services that are directed and staffed by adequate qualified personnel. However, a hospital that has a contract with an outside food management company may be found to meet this Condition of Participation if the company has a dietitian who serves the hospital on a full-time, part-time, or consultant basis, and if the company maintains at least the minimum standards specified in this section and provides for constant liaison with the hospital medical staff for recommendations on dietetic policies affecting patient treatment. This Condition is not met as evidenced by: 47548 The facility failed to meet the Condition of Participation for providing minimum standards for recommendations according to dietetic policies. Based on medical record reviews, hospital policy review,and interview, the facility failed to ensure that nutritional assessments were being conducted by a Registered Dietician for 16 out of 16 patients sampled (Patients # 25, 26, 27, 28, 29, 32, 41, 42, 43, 44, 45, 46, 47, 48, 49, and 50).”

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 43420 Based on medical record review, policy review, and staff interview the hospital staff failed to resolve grievances promptly for one (1) of one (1) patient (Patient #53). The Findings Include: A review of the facility’s policy titled “Grievances By Individuals in Care” revised 09/29/2015 showed “I. Policy: It is the policy of [Hospital Name] to provide a process for promptly responding to, and resolving grievances brought by individuals in care and their families/representatives on behalf of the individual in care ...” A review of the medical record showed Patient #53 was admitted with diagnosis to include Bipolar Disorder. The surveyor interviewed Patient #53 on 05/06/2024 at approximately 1:40 PM. According to Patient #53, grievance forms were submitted to the facility ’ s staff, however there was no resolution provided. Review of Patient #53’s “Form A New Grievance” documents were filed on 11/17/2023 and 11/18/2023. The surveyor requested documentation of follow-up and outcome of grievances presented. The hospital staff was unable to provide the requested documentation. The surveyor conducted an interview with Employee #28, Grievance Compliance Coordinator, on 05/09/2024 at approximately 11:50 AM. According to Employee #28, the patient advocate should resolve grievances unless the concerns are related to the patient ’ s rights. Patient rights grievances are escalated to the unit ’ s supervisor and should be addressed within a ten-business day timeframe. Additionally, Employee #28 stated documentation of the resolution should be completed for all grievances filed.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 49189 Based on medical record review, hospital policy review, and staff interview, the hospital failed to document the use of interpreters for the care of one (1) out of six (6) patients sampled (Patient # 32). The Findings Include: A review of the facility’s Communication Alternatives for Individuals with Disabilities or with Limited English Proficiency policy, revised 02/28/2022, revealed under procedures: “Staff utilizing interpreter services shall document in the individual’s chart that the face-to-face meeting was conducted with the assistance of a language/communication service.” A review of Patient #32 ’ s medical record reviewed that they were admitted to the facility on 01/31/2024 for competency evaluation. A further review of initial nursing assessment from 01/31/2024 revealed documentation that Patient #32 ’ s primary language is Spanish. A further review of Patient #32 ’ s nursing notes from 04/21/2024 to 04/23/2024 revealed no documentation of the use of interpreters in the nursing care. According to a psychiatry note dated 04/23/2024 revealed no documentation of the use of an interpreter during the assessment. A further review of Patient #32 ’ s UI (Unusual Incident) nursing note from 04/25/2024 revealed that Patient #32 had an altercation with another patient as evidenced by the following: “At about 7:40am while in the dining room, [Patient #32] was standing by the dining room window while her name was not yet called. She was redirected to go back to her seat and wait for her name to be called so that the person whose tray was on the window would get her tray and leave, [Patient #32] refused to be redirected speaking in Spanish. Another IIC [individual in care, patient] who speaks Spanish went to her to explain what was being said to her and instead of listening, she started cursing at the peer in Spanish, called her “[racially derogatory term]”, swung at the peer, and started hitting her while the peer tried to defend herself. Staff present rushed to them and separated them while code 13 [behavioral health emergency response code] was called simultaneously @ [at] 8:45am. Staff were able to separate them before the code responder arrived, [Patient #32] stormed out of the dining room to her room. Code 13 was therefore cancelled immediately @ [at] 8:51am, and an on-call psychiatrist was notified.” The medical record lacked documentation that a facility approved interpreter was used to convey directions to Patient #32 prior to the altercation. A further review of Patient #32 ’ s General Medical Officer note from 04/25/2024 revealed: “Patient was involved in an altercation and suffer trauma to right eye - small abrasion patient refused to be seen by me. Order placed for site to be cleaned then triple antibiotic to be applied to site. Patient is otherwise clinically stable.” There is no documentation that a facility approved interpreter was used to discuss the purpose of the assessment prior to Patient #32 ’ s refusal for care. On 05/07/2024 at approximately 10:18 AM, the surveyor conducted a face-to-face interview with Employee #21 Registered Nurse. Employee# 21 confirmed that the facility has interpreter services both in person and phones that can be used at all times. Employee #21 stated that in person interpreters have a form they bring to document what patients had their services. Employee #21 was unable to provide copies of the documentation of the use of interpreters for Patient #32 for the date range of 4/21 to 4/23/24 and the date of 4/25/2024.”

“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: 49189 Based on hospital policy review, medical record review, and interview, hospital staff failed to provide care in a safe setting by failing to complete security checks for four (4) out of six (6) patients sampled (Patients #30, 33, 34, & 38). The Findings Include: A review of the facility ’ s Security Checks and Unit Safety policy, revised 03/03/2023, revealed under Purpose: “-to ensure that all individuals in care are present and accounted for, are not in distress and not engaged in potentially harmful behavior.... Procedure -The staff member(s) assigned to complete security checks shall document the location of each individual on the Security Check Sheet... Documentation : “Security checks shall be maintained on the unit for a period of one month then forwarded to the Director of Nursing Performance Improvement no later than the fifth day of the next month where they shall be maintained for three (3) years.” 1. A review of Patient #30 ’ s medical record revealed they were admitted to the facility on 11/21/2023 for a competency evaluation and treatment of unspecified psychosis not due to a substance or known physiological condition. Further review of Patient #30 ’ s orders showed active orders for 2:1 observation. Further review of Patient #30 ’ s Security Check sheets from 04/26/2024 to 05/03/2024 showed no documentation of Patient #30’s behavior on 04/26/2024 at 11:45 PM. Also, on 05/01/2024 at 7:45 AM there is no documentation of Patient #30 ’ s behavior. 2. A review of Patient #33 ’ s medical record revealed they were admitted to the facility on 03/06/2024 for a competency evaluation and treatment of Bipolar Disorder. Further review showed that on 04/22/2024 Patient # 33 had a physical hold event and line of sight observation order after engaging in a physical altercation with another patient. Further review of Patient #33 ’ s Security Check sheets from 04/24/2024 to 05/01/2024 revealed the following: On 04/24/2024 at 7:15 AM there is no documentation of a security check being done. On 04/27/2024 at 3:15 PM there is no documentation of a security check being done. On 04/29/2024 from 2:15 PM to 3:15 PM there is no documentation of a security check being done. On 04/30/2024 at 7:15 AM there is no documentation of a security check being done. On 05/01/2024 there is no documentation of Patient # 33 ’ s behavior. 3. A review of Patient #34 ’ s medical record revealed they were admitted to the facility on 09/15/2017 under the legal status of Not Guilty by Reason of Insanity for treatment of Schizoaffective Disorder Bipolar Type. Further review of Patient #34 ’ s order revealed active 15-minute security checks for the date range of 11/10/2023 to 11/16/2023. Further review of Patient # 34 ’ s Security Check sheets from 11/10/2024 to 11/16/2024 revealed the following: On 11/10/2023 from 10:30 AM to 11:00 AM there is no documentation of Patient #34 ’ s behavior. On 11/13/2023 from 10:30 AM to 11:15 AM there is no documentation of Patient #34 ’ s behavior. 4. A review of Patient #38 ’ s medical record revealed an admission to the facility on 11/25/2020 for treatment of Borderline Personality Disorder. Further review of Patient #38 ’ s order revealed that from 08/20/2023 to 09/22/2023 they had active orders for One to One Constant Supervision at Arms Length of reach. Further review of Patient # 38 ’ s nursing note from 09/05/2023 revealed: “At about 7:20 p, on 9/5/2023 [Patient #38] was observed by this writer running in the day room immediately dropping herself on floor facing down on prom [sp] position. Staff immediately intervened and took her to the treatment room. While in the treatment room, IIC [individual in care] started banging her head on the floor.” A review of Patient #38 ’ s Unusual Incident Report from 09/05/2023 revealed under incident type that the event described in the nursing note was defined as: “Psych Emerg; Falls; Selfinjurious behavior; Aggressive Behavior; Arg_PToSelf (Psychatric Emergency; Falls; Self Injurious Behavior; Aggression Patient to Self).” Further review of Patient #38 ’ s Security Check sheets from 08/25/2023 to 09/22/2023 revealed the following: From 08/25/2023 to 09/07/2023 there is no documentation of security checks being done. From 09/15/2023 to 09/22/2023 there is no documentation of security checks being done. On 05/08/2024 at approximately 10:45 AM, the surveyor conducted a face-to-face interview with Employee #21 Registered Nurse. Employee #21 confirmed that the process for completing Security Check sheets is to have it assigned by the charge nurse, document the patient ’ s location and behavior, and at the end of the shift to return it to the Charge Nurse to have them review and sign it. Employee # 21 confirmed that there was no documentation in the medical record of security checks being done for Patient #38 after they had their self injurious event.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 49189 Based on medical record review, hospital policy review, and staff interview, hospital staff failed to include restraint events in the reassessment of a plan of care for one (1) out of six (6) patients sampled (Patient #36). The Findings Include: A review of the facility ’ s Restraint and Seclusion for Behavioral Reasons policy revised 10/20/2016, under ’ N. Recovery Team Requirements ’ revealed: “2. In addition, the IRPT, with participation from the individual, shall review and update as indicated, the IRP and /Personal Comfort Planning form within one business day whenever any of the following conditions occur: a. Two or more episodes of seclusion or restraint within a 24- hour period; b. Three or more episodes of seclusion or restraint within any consecutive 30-day period; d. An episode of restraint or seclusion on two or more consecutive days.” A review of Patient #36 ’ s medical record reviewed that they were admitted to the facility on 04/18/2023 for treatment of Schizoaffective Disorder Bipolar Type. Further review revealed that Patient #36 had restraint events on the following dates: 06/01/2023, 06/06/2023, 06/07/2023, and 06/12/2023. Further review of Patient #36 ’ s Individual Recovery Plan revealed no mentioning of Patient #36 ’ s restraint events despite having two restraint events within 24 hours, three restraint events within 30 days, and episodes of restraint on two consecutive days. On 05/08/2024 at approximately 10:30 AM, the surveyors conducted a face-to-face interview with Employee #7 Director of Rehabilitation Services. Employee #7 confirmed that restraint events are to be included in the reassessment of a patient ’ s Individual Recovery Plan.”

“MEDICAL STAFF BYLAWS CFR(s): 482.22(c) The medical staff must adopt and enforce bylaws to carry out its responsibilities. The bylaws must: This Standard is not met as evidenced by: 43420 Based on medical record review, policy review, and staff interview the medical staff failed to: (1) complete medical evaluation forms for a patient who required a transfer to a higher level of care for five (5) out of five (5) patients (Patient #53, Patient #1, Patient #4, Patient # 33, and Patient #34), and (2) Conduct an annual History and Physical for one (1) out of fifteen patients (Patient # 34). The Findings Included... 1A. A review of the facility ’ s Medical Staff Bylaws, dated 12/17/2018, revealed under ’ Conditions of Membership and Duration of Appointment ’ : “Members of the Medical Staff Organization are subject to DBH (Department of Behavioral Health) Policies and Procedures...” A review of the facility ’ s policy titled “ Emergency Medical Services (EMS) and Emergency Transfers to Medical Facilities” revised 07/05/2018 showed “D. Emergency (EMS-Ambulance) Medical Transfers of Individuals on Care to outside Medical Facilities ...a. General Medical Officer/Nurse Practitioner: i. Completes all sections of the Transfer for Medical Evaluation Form and Orders, except that 911 transfers shall not be delayed while the report and/or an order is being completed. In the event the form and/or orders are not completed prior to transfer, it/they shall be completed and transmitted by email or facsimile to the medical facility immediately after notification of where the individual is receiving care. A progress note shall document that this form was sent to the medical facility.” A review of the medical record showed Patient #53 was admitted with diagnosis to include Bipolar Disorder. According to a physician progress note dated 03/05/2024 at 12:38 PM “Patient [Patient #53] provoked a fight with IIC [Individual In Care] and sustained a large laceration on the inside of his left cheek. He was sent to the ER [Emergency Room] ...” The medical record lacked documentation of the Transfer for Medical Evaluation form and completion of a progress note indicating the form was sent to the outside facility for Patient #53. The surveyor conducted an interview with Employee #4, Supervisory General Medical Officer (GMO) on 05/09/2024 at approximately 1:30 PM. According to Employee #4 if a patient requires a transfer to a higher level of care, the patient is evaluated by the GMO and the medical evaluation transfer form should be completed electronically. Additionally, Employee #4 stated the form is printed out, and sent with the patient. 47548 1B. Review of Patient #1 ’ s medical record showed a General Medical Officier (GMO) admission note dated 06/16/2023. The patient has a history of “Schizo-affective Disorder [Schizophrenic-Affective Disorder], Bipolar ...” Patient #1 ’ s transfer note dated 12/20/2023 showed “Part III: Summary And Additional Information: Reason for Transfer and History of Present Illness: Physical Examination Findings: Hypoxic episode of saturation under 80% [80 percent], rales and rhonchi, Concerned about acute congestive heart failure and/or pneumonia. Impression: r/o [rule out] hypoxic episode, r/o congestive heart failure.” Further review revealed Patient #1 was transferred to an outside medical facility on 12/20/2023 for evaluation of r/o hypoxic episode, and r/o congestive heart failure. A review of Patient #1 ’ s Transfer for Medical Evaluation form dated 12/20/2023 revealed incomplete documentation with the following prompts not being answered: Contact Facility, Attending Psychiatrist, Genera. Medical Officer and Legal Barrier to Discharge and Part II: Transfer Diagnosis The Surveyor conducted a face-to-face interview with Employee #22, Registered Nurse on 05/10/2024 at approximately 10:00 AM. Employee #22 confirmed Patient #1 ’ s Transfer Medical Evaluation form was not filled out completely with respect to the above prompts. 1C. Medical record review of Patient #4 ’ s admission GMO note dated 06/16/2023 showed a history of “Unspecified Schizophrenia, Unspecified Dementia with Behavioral Disturbances, and Bipolar.” Patient #4 ’ s Transfer Medical Evaluation form dated 03/24/2024 at 5:24 PM showed “Part III: Summary And additional Information: Reason for Transfer and History of Present Illness ...” “slurred speech, and drooling of saliva for further evaluation of AMS [Altered Mental Status] R/O Stroke Physical Examination Findings ...” “tongue protruding as he speak, (+) drooling of saliva ...” “Impression: AMS r/o Stroke ...” Further review revealed Patient #4 was transferred to an external medical facility on 03/24/2024 for evaluation of r/o stroke. A review of Patient #4 ’ s Transfer for Medical Evaluation form dated 03/24/2024 revealed incomplete documentation with the following prompts not being answered: Contact Facility, Attending Psychiatrist, General Medical Officer and Legal Barrier to Discharge and Part II: Transfer DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) Diagnosis The Surveyor conducted a face-to-face interview with Employee #22, Registered Nurse on 05/10/2024 at approximately 10:00 AM. Employee #22 confirmed Patient #4 ’ s Transfer Medical Evaluation form was not filled out completely with respect to the above prompts. 49189 1D. A review of Patient #33 ’ s medial record revealed they were admitted to the facility on 03/06/2024 for a competency evaluation and treatment of Bipolar Disorder. Further review revealed that Patient #33 was transferred to an external medical facility on 03/08/2024 for evaluation of suspected gangrenous appearing index and middle finger of the left hand and evluation after a physicial altercation. A review of Patient #33 ’ s Transfer for Medical Evaluation form dated 03/08/2024 and 4/22/2024 revealed incomplete documentation with the following prompts not being answered: Contact Facility, Attending Psychiatrist, General Medical Officier, Legal Barier to Discharge, Current behavior and Special Precautions and Part II- Transfer Diagnosis. On 4/23/2024, Patient #33 was transferred to an external medical facility for evaluation of instability of cervical spine. A review of Patient #33 ’ s Transfer for Medical Evaluation form dated 04/23/2024 revealed incomplete documentation with the following prompts not being answered: Contact Facility and Part II: Transfer DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) Diagnosis: Further review showed no documentation that a medical provider contacted the receiving facility to relay the above information. 1E. A review of Patient #34 ’ s medical record revealed they were admitted to the facility on 09/15/2017 under the legal status of Not Guilty by Reason of Insanity for treatment of Schizoaffective Disorder Bipolar Type. Further review revealed that Patient #34 was transferred to an external medical facility on 03/08/2020 for evaluation after a physical altercation. A review of Patient #34 ’ s Transfer for Medical Evaluation form dated 03/08/2020 revealed incomplete documentation with the following prompts not being answered: 1. Attending Psychiatrist 2. Legal Barrier to Discharge (Commitment/Involuntary Admission)? (3) Part II: Transfer DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) Diagnosis and Current behavior Special Precautions Further review showed no documentation that a medical provider contacted the receiving facility to relay the above information. Further review revealed that Patient #34 was transferred to an external medical facility on 08/25/2023 for evaluation after a physical altercation. A review of Patient #34 ’ s Transfer for Medical Evaluation form dated 08/25/2023 revealed incomplete documentation with the following prompts not being answered: (1.) Legal Barrier to Discharge (Commitment/ Involuntary Admission)? (2.)? Part II: Transfer DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) Diagnosis and 3.Current behavior and Special Precautions: Further review showed no documentation that a medical provider contacted the receiving facility to relay the above information. On 05/08/2024 at approximately 11:45 AM the surveyor conducted a face to face interview with Employee #21 Registered Nurse. Employee #21 reviewed Patient #33 and 34 ’ s medical records with the surveyor and confirmed that both patients had legal barriers to discharge. On 05/09/2024 at approximately 1:46 PM the surveyors conducted a face-to-face interview with Employee #4 Supervising General Medical Officer. Employee #4 confirmed that the transfer for Medical Evaluation form is the paper report form that is used to give the receiving facility hand off. Employee #4 reported that the medical staff does not call the receiving facilities to give verbal report and that only areas the medical provider deem pertinent are filled out to address the medical issue. The surveyor inquired on documenting if a patient has a legal barrier to discharge for the receiving facility. Employee #4 confirmed that if a patient has a legal barrier to discharge then the patient will present to the facility shackled with staff present and the transfer form will have the box “YES” checked on the prompt. 2. A review of patient #34 ’ s medical record revealed that they were admitted to the facility on 09/15/2017 under the legal status of Not Guilty by Reason of Insanity for treatment of Schizoaffective Disorder Bipolar Type. A further review revealed that Patient #34 had an annual History and Physical done on 02/22/2023. There is no documentation of an annual History and Physical done by 02/22/2024. On 05/09/2024 at approximately 1:46 PM the surveyors conducted a face-to-face interview with Employee #4 Supervisory General Medical Officer. Employee #4 confirmed that every patient is to have an annual History and Physical done by the General Medical Officer.”

“ORGANIZATION CFR(s): 482.28(a) Organization This Standard is not met as evidenced by: 01300 Based on observations, dietary services failed to ensure foods are prepared and served in a safe and sanitary manner. The Findings Include... On 05/06/2024 at approximately 10:15 AM the surveyor observed in the presence of Employee #34 Director of Dietary Services: 1. The shelf surfaces of two large racks in the Pot and Pan Wash Area were soiled with dust and food particles. 2. The interior surfaces open drains in the Booster Room and Combi Ovens in the Cooks Preparation Area, were soiled with leftover food particles, on the interior surfaces, and enamel surfaces were chipped, worn and damaged in Cooks Preparation Areas. 3. Floor surfaces in the rear deep fryers were soiled with debris, and accumulated grease was observed on Deep Fryer wheels in the Cook ’ s Preparation Area. 4. The Steamer exhaust in the Cooks Preparation was soiled with dust and soiled products and rust accumulation was observed on the top surfaces o the Steamer Cover.”

“QUALIFIED DIETITIAN CFR(s): 482.28(a)(2) There must be a qualified dietitian, full-time, part-time, or on a consultant basis. This Standard is not met as evidenced by: 47548 Based on medical record reviews, hospital policy review,and interview, hospital staff failed to ensure that nutritional assessments were being conducted by a Registered Dietician for 16 out of 16 patients sampled (Patients # 25, 26, 27, 28, 29, 32, 41, 42, 43, 44, 45, 46, 47, 48, 49, and 50). The Findings Include: A review of the facility ’ s Clinical Records Manual, revised 01/19/2023, revealed under ’ Exhibit 1-Frequencies of Required Medical Record Documentation Initial Assessments by Other Disciplines ’ : “Social Work, Rehabilitation Services, Registered Dietician by the 5th [fifth] calendar day of the admission, ensuring that it is completed prior to the development of the IRP (Individual Recovery Plan).” 1A. Review of Patient #25 ’ s medical record showed admission date of 03/28/2024. GMO (General Medical Officer) note dated 03/29/2024 at 2:33 PM showed history of Diabetes Mellitus. The Medical Assessment Record showed finger sticks 3x/day (three times per day) before meals with sliding scale coverage and Lantus at bedtime. Further review revealed no documentation of an initial nutritional assessment, or any documentation done by a Registered Dietician. 1B. Review of Patient #26 ’ s medical record showed admission date of 04/11/2024. GMO note dated 04/12/2024 at 11:25 AM history of “Diabetes: Metformin 500 mg (milligrams) BID” (twice daily). Medical Assessment Record showed 2000-2400 ADA [American Diabetes Association diet].” Further review revealed no documentation of an initial nutritional assessment, or any documentation done by a Registered Dietician. 1C. Review of Patient #27 ’ s medical record showed admission date of 03/21/2024. GMO note dated 03/21/2024 showed diagnosis of Anxiety Disorder without any history of medical diseases. Further review revealed no documentation of an initial nutritional assessment, or any documentation done by a Registered Dietician. 1D. Review of Patient #28 ’ s medical record showed admission date of 04/01/2024. GMO noted dated 04/01/2024 showed diagnosis of Adjustment Disorder without any history of medical diseases. Further review revealed no documentation of an initial nutritional assessment, or any documentation done by a Registered Dietician. 1E. Review of Patient #29 ’ s medical record showed admission date of 04/03/2024. GMO note dated 04/03/2024 showed diagnosis of Schizophrenia without any history of medical diseases. Further review revealed no documentation of an initial nutritional assessment, or any documentation done by a Registered Dietician. The surveyor conducted a face-to-face interview with Employee #22 Registered Nurse (RN) on 05/10/2024 at approximately 10:00 AM. Employee #22 confirmed no Registered Dietician assessment notes in the medical record for Patients #25, 26, 27, 28, and 29. 49189 F. A review of Patient #32’s medical record revealed that they were admitted to the facility on 03/25/2024 for treatment of unspecified psychosis not due to a substance or known physiological condition. Further review revealed no documentation of an initial nutritional assessment, or any documentation done by a Registered Dietician. G. A review of Patient # 41 ’ s medical record revealed that they were admitted to the facility on 04/01/2024 for treatment of Hallucinogenic Dependence. Further review revealed no documentation of an initial nutritional assessment, or any documentation done by a Registered Dietician. H. A review of Patient #42 ’ s medical record revealed that they were admitted to the facility on 03/27/2024 for treatment of Bipolar Disorder. Further review revealed no documentation of an initial nutritional assessment, or any documentation done by a Registered Dietician. I. A review of Patient #43 ’ s medical record revealed that they were admitted to the facility on 05/03/2024 for treatment of unspecified psychosis not due to a substance or known physiological condition. Further review revealed no documentation of an initial nutritional assessment, or any documentation done by a Registered Dietician. J. A review of Patient #44 ’ s medical record revealed that they were admitted to the facility on 04/15/2024 for treatment of Mood Disorder. Further review revealed no documentation of an initial nutritional assessment, or any documentation done by a Registered Dietician. K. A review of Patient #45 ’ s medical record revealed that they were admitted to the facility on 05/03/2024 for treatment of unspecified psychosis not due to a substance or known physiological condition. Further review revealed no documentation of an initial nutritional assessment, or any documentation done by a Registered Dietician. L. A review of Patient #46 ’ s medical record revealed that they were admitted to the facility on 05/03/2024 for treatment of unspecified psychosis not due to a substance or known physiological condition. Further review revealed no documentation of an initial nutritional assessment, or any documentation done by a Registered Dietician. M. A review of Patient #47 ’ s medical record revealed that they were admitted to the facility on 05/02/2024 for treatment of Schizoaffective Disorder. Further review revealed no documentation of an initial nutritional assessment, or any documentation done by a Registered Dietician. N. A review of Patient #48 ’ s medical record revealed that they were admitted to the facility on 04/29/2024 for treatment of Schizoaffective Disorder. Further review revealed no documentation of an initial nutritional assessment, or any documentation done by a Registered Dietician. O. A review of Patient #49 ’ s medical record revealed that they were admitted to the facility on 03/25/2024 for treatment of Schizophrenia. Further review revealed no documentation of an initial nutritional assessment, or any documentation done by a Registered Dietician. P. A review of Patient #50 ’ s medical record revealed that they were admitted to the facility for treatment of Delusional Disorders. Further review revealed no documentation of an initial nutritional assessment, or any documentation done by a Registered Dietician. On 05/10/2024 at approximately 11:00AM the surveyors conducted a face-to-face interview with Employee #34 Director of Nutritional Services. Employee #34 confirmed that as of 03/21/2024 they were the only Registered Dietician employed at the facility and that they also manage the entire nutritional services department. Employee #34 reiterated that there is no Nutritional of Registered Dietician documentation on any patient after the date 03/21/2024. The surveyor inquired if any consults were placed since 03/21/2024 to assess the nutritional status of any patients in the facility. Employee #34 confirmed that no consults have been placed.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 01300 Based on observation and staff interview the hospital staff failed to provide care in a safe and sanitary manner. The Findings Include: The surveyor conducted a tour of Unit 1A at on 05/08/2024 at approximately 09:50 AM, in the presence of Employees #37 Director of Facilities, #38 Facilities Manager, #39 Housekeeping Supervisor, and #20 Nurse Manager and observed: 1. Privacy was not afforded to patients, while using the toilet at the entrance to Room 1A54. 2. Floor tiles were damaged at the entrance to Room 1A 55. 3. The lower surfaces of the door and door jambs were marred, and large box o supplies were inappropriately stored on floor surfaces in Room 1A62. 4. Bed frame surfaces were soiled with dust, wall surfaces were marred near the bed, and the lower surfaces of the entrance door was marred in Room 1A58 and 1A61. 5. Furniture was worn and torn on the seat and backrest surfaces in the Lounge at the entrance to Hallway B, and C. 6. The base surfaces around the toilet were soiled and in need of recaulking in Toilet Room 1A46. 7. The lower surfaces of walls in in Room 1A43 were marred. 8. The open drain in the shower was clogged with debris and water was standing on the floor and floor tiles were damaged at the entrance to Room 1A23. 9. The faucet was unable to cut off the supply of water in Shower Room 1A24. 10. The lower surfaces of the entrance door to Room 1A29. 11. Window seals surfaces were soiled with dust; a multiple outlet on the floor was soiled with dust and soiled debris, and the lower wall surfaces were marred and soiled in Medication Room 1A29. 12. Chair surfaces in the staff break room were soiled and worn and the hot water temperature qt the handwashing sink in the break room was 69 degrees Fahrenheit, and below the 105-degree Fahrenheit minimum temperature, and the interior surfaces of exhaust vents were soiled. 13. The electrical outlet on the wall was not secured, and could potentially could cause an electrical shock; a dustpan and broom were improperly stored on the floor in the Nutrition Room. 14. The interior surfaces of the exhaust vent wee soiled with dust, small penetrations were observed in wall surfaces near the door, and door jambs were marred near the entrance to the Dining Room. 15.The cold and hot water hoses were soiled with dust in the rear of the washer, the lower ductwork was duty, and the washer and dryer surfaces were soiled the rear in the Laundry Room. B. The following findings were observed during a tour of Unit 1B, beginning at 10:55 AM, on May 8,2024, in the presence of employees #38, the Facilities Manager, #39 Housekeeping Supervisor, and #40 Nurse Manager. 1. Entrance door surfaces at the entrance to Unit 1A were marred. 2. Furnishings, such as sofa and chairs were worn on the seating and armrest surfaces in the Group Room. 3. Baseboards surfaces were soiled with debris in the Dining Room near the Nutritional Area. 4. The bottom shelf surfaces were soiled with debris, and wall surfaces were marred in the Laundry Room. 6. Rust accumulation was observed on the lower door jams surfaces at the entrance to Room 1B23. 7. Floor tiles were damaged at the entrance; the lower shower walls were soiled, and the grout surfaces were damaged in Room 1B24. 8. The frontal surfaces of the access panel were rusty in Toilet Room 125. 9. The horizontal surfaces of the bed frame were soiled with dust in Room 1B29. 10. Tile grout surfaces, were damaged, along the walls in Room 1B49, and tile grout surfaces were soiled and dingy in Shower Room 1B48 and 1B53 11. Grab bars were missing near the toilet in Toilet Room 1B46, and the threshold was missing at the entrance. 12. Bed frame surfaces soiled with dust on the horizontal surfaces wall and the lower door surfaces were marred in Room 1B45. 13. The bed headboard was missing, and the horizontal surfaces of the bed frame was dusty in Room 1B42. 14. The lower surfaces of the toilet were soiled and needed recaulking around the base, in Room 1B54, and 1B55. 15. The lower door jamb surfaces where surfaces were marred at the entrances to 1B61 and 1B62. 16. The headboard was missing in Room 1B61. 17. The horizontal surfaces of the bed frame were dusty, and the lower surfaces of the door jamb were marred (scratched) in Room 1B58. 18. The lower surfaces of the entrance door was marred in Room 1B60. C. The following findings were observed during a tour of Unit 1G, at 10:05 AM on May 9, 2024, in the presence of employees #38 Facilities Manage, and #39 Housekeeping Supervisor, and #41 Nurse Manager 1G. 1. The lower shelf surfaces of a large rack were soiled, and the lower wall surfaces in Linen Room 1G05 were marred, the threshold at the entrance door was missing and the lower wall surfaces were marred in Room 1G05. 2. The threshold was missing at the entrance; the lower wall surfaces were marred in Room 1G06. 3. The interior surfaces of the exhaust vent in Room 1G10, and 1G53. 4. Water drained slowly in the sink when the sink water temperature was tested, the lower surfaces of walls near the entrance door were marred in Room 1G21. 5. Furniture was worn and damaged in the Lounge Area at the entrance to hallway A. 6. Wall grout between tiles was worn, and soiled, in Shower Room 1G23, and 1G53. 7. The interior surfaces of the exhaust vent, were soiled with dust, tile grout surfaces were worn and soiled between tiles in Room 1G24. 8. The base surfaces of the toilet were soiled and need to be re-caulked, in 1G25. 9. Floor surfaces were stained, and the mattress surfaces were stained on one side in Room 1G34. 10. Furnishing were worn and damaged in the Lounge at the entrance to Hallways B and C. 11. A section of floor tile was missing, near the entrance door to the Toilet Room 1G46. 12. The lower surfaces of the door were marred in Room 1G45. 13. Signage was missing outside of Room 1G62. 14. Gnats were observed fling in Room 1G58 near areas where food was stored in Room 1G58. D. The following findings were observed during a tour of duty on Unit 2B at 11:25 AM on May 9th, 2024, at 11:25 AM in the presence of Employee #15 Nurse Manager, #39 Housekeeping Supervisor, and #38 Facilities Manager. 1. Dining Room walls were marred, and penetrations were observed in wall where equipment seat and armrest surfaces. 7. Privacy was compromised to patients in the toilet room because of a missing privacy curtain, at the entrance to the Toilet Room, and the access panel cover was rusty in Room 2B25. 8. Furnishing in the Lounge at the entrance to Hallway B, were worn, torn on the seat, backrest, and armrest surfaces. 9. The shower curtains was soiled and stained, in Room 2B47. 10. The horizontal surfaces of the bed frames A & B, were soiled with dust in Room 2B45. 11. Floor surfaces were marred near the entrance, and the horizontal surfaces of the bed frame was soiled with dust in Room 253B, 2B56 and 2B58. 12. The frontal surfaces of the entrance door was marred in Room 2B58. E. The following finding were observed during a tour of the Dental Clinic. 1. The base surface of the Dental Chair were soiled with dust and other debris. 49189 B. On 05/06/2024 at approximately 12:30 PM the surveyor conducted an observational tour of nursing unit 2TR. The following was revealed: 1 (1) multiuse metallic pill crusher with white residue inside indicating having been used in the medication room. On 05/06/2024 at approximately 12:35 PM the surveyor conducted a face-to-face interview with Employee #36 Charge Nurse. Employee# 36 confirmed that the metallic pill crusher appeared to have been used but confirmed that it has been months since a patient required crushed pills on this nursing unit.”

“EMERGENCY POWER AND LIGHTING CFR(s): 482.41(a)(1) There must be emergency power and lighting in at least the operating, recovery, intensive care, and emergency rooms, and stairwells. In all other areas not serviced by the emergency supply source, battery lamps and flashlights must be available. This Standard is not met as evidenced by: 01300 Based on a review of the facility Emergency Generator Policy (2022 Edition) and Emergency Generator Log, the hospital staff failed to include the ATS (Automatic Transfer Switches) in the required monthly exercises of the Emergency Generator. The Findings Included: Review of the Emergency Generator, NFPA 110 (02), Section 8.4.5, and NFPA 110 Section 4.6.1, showed Automatic Transfer Switches, are to be electrically operated and tested monthly. During a review of the Emergency Generator Logs and the Emergency Generator Policy it was determined that documentation in the logbook failed to support, monthly electrical testing of the Automatic Transfer Switches, and inspections of the Automatic Switches, for dust and dirt. The facility has a contract with an outside vendor to test the Automatic Transfer Switches Quarterly, which does not meet the monthly requirement, the last test was conducted on April 16, 2024. The requirement is for the Automatic Transfer Switches, to be tested and operated when the Emergency Generator is exercised, and transfer switches must be inspected monthly to ensure they are free of accumulated dust to check for detioration of switches; the facility records failed to support testing. This finding was discussed in the presence of Employees #37, the Director of Facilities, #38 Facilities Manager and #46 Facilities Supervisor on 05/09/ 2024, at 9:35 AM.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 49189 Based on hospital policy review, observations, and staff interview, the hospital staff failed to ensure infection control items, including those used for prevention, detection, or treatment, were readily available for use. The Findings Include: A review of the facility’ s Hand Hygiene Program Policy, dated 07/01/2016, revealed under ’ Performance Improvement: ’ “The Infection Control Coordinator collaborates with Material Management and Housekeeping departments to ensure hand hygiene products are readily available for all HCWs (health care workers) and individuals in care.” On 05/06/2024 at approximately 12:30 PM the surveyor conducted an observational tour of nursing unit 2TR. The following were revealed: Two (2) bottles of hand sanitizer with an expiration date of 05/26/2020 in the treatment room. On 05/06/2024 at approximately 12:35 PM the surveyor conducted a face to face interview with Employee #29 Nurse Manager. Employee #29 confirmed that the presented bottles of hand sanitizers were expired, and that nursing routinely checks the unit for expired products. On 05/06/2024 at approximately 1:00 PM the surveyor conducted an observational tour of nursing unit 1D. The following were revealed: Five (5) bacterial culture swabs with an expiration date of 02/28/2023 in the medication room. On 05/06/2024 at approximately 1:24 PM the surveyor conducted a face-to-face interview with Employee #35 Nurse Manager. Employee #35 was presented the bacterial culture swabs and confirmed they were expired. Employee #35 confirmed that nursing routinely checks the unit for expired products. On 05/08/2024 at approximately 10:00 AM the surveyor conducted a face-to-face interview with Employee #5 Compliance Performance Improvement Officer. Employee #5 confirmed that the facility does not have a policy regarding expired products, or the management of materials used for patient care. On 05/09/2024 at approximately 2:20 PM the surveyor conducted a face-to-face interview with Employee #9 Infection Control Coordinator. Employee #9 stated Materials Management staff is responsible for ensuring expired supplies are not provided and are removed from the units. Additionally, Employee #9 acknowledged that expired donated hand sanitizer was dispensed to the units and Material Management staff is aware.”

“DELIVERY OF SERVICES CFR(s): 482.56(b)(2) The provision of care and the personnel qualifications must be in accordance with national acceptable standards of practice and must also meet the requirements of §409.17 of this chapter. This Standard is not met as evidenced by: 49189 Based on hospital policy review, medical record review, and interview, the hospital staff failed to conduct a rehabilitation assessment for one (1) out of patients sampled (Patient # 33). The Findings Include: A review of the facility ’ s Clinical Records Manual, revised 01/19/2023, revealed under ’ Exhibit 1-Frequencies of Required Medical Record Documentation Initial Assessments by Other Disciplines ’ : “Social Work, Rehabilitation Services, Registered Dietician by the 5th [fifth] calendar day of the admission, ensuring that it is completed prior to the development of the IRP (Individual Recovery Plan).” A review of patient #33 ’ s medical record revealed that they were admitted on 03/06/2024 with the legal status of full competency evaluation for the treatment of bipolar disorder. A further review revealed no documentation of an Initial Rehabilitation Assessment being conducted. On 05/09/2024 at approximately 10:30 AM, the surveyors conducted a face-to-face interview with Employee #7 Director of Rehabilitation Services. Employee#7 confirmed that the initial rehabilitation assessment is to be completed within five days of admission for every patient.”

“Treatment Plan CFR(s): Standard Treatment Plan Each patient must have an individualized, comprehensive treatment plan based on an inventory of the patient’s strengths and disabilities. This Standard is not met as evidenced by: 43420 Based on medical record review, policy review, and staff interview, the hospital staff failed to update the Interdisciplinary Recovery Plan (IRP) for two (2) of six (6) medical records reviewed (Patient #51 & Patient #54). The Findings Include: Review of the facility ’ s policy titled “Interdisciplinary Recovery Planning for Inpatient Services” revised 04/30/2015 showed “I. Policy; It is the policy of [Hospital Name] that all individuals in care shall receive comprehensive Interdisciplinary Recovery Plans that reflect medically necessary care that is individualized, trauma-informed, recovery-oriented and integrated across all disciplines ...B. Interdisciplinary Recovery Plan Completion Schedules ...3. IRP updates shall be performed by the 30th calendar day of the admission, 60th calendar day of the admission, and every 60th calendar day thereafter ...” 1A. A review of the medical record showed Patient #51 was admitted with a diagnosis to include Schizophrenia. Further review of the medical record showed an Interdisciplinary Recovery Plan was completed on 02/08/2024. The following updated IRP was completed on 04/30/2024, twenty-two days after the sixty-day update requirement. The surveyor interviewed Employee #22, Registered Nurse, on 05/06/2024 at approximately 2:00 PM. Employee #22 confirmed Patient #51 ’ s IRP was not updated within the required sixty-day timeframe mentioned above. The surveyor interviewed Employee #8, Director Clinical Administrator on 05/09/2024 at approximately 10:00 AM. Employee #8 stated IRPs should be updated every sixty days and if they are not, there should be documentation in the medical record indicating why it was not completed. 1B. Review of the medical record showed Patient #54 was admitted with a diagnosis to include Unspecified Psychosis. Further review of the medical record showed an Interdisciplinary Recovery Plan was completed on 01/12/2024. There were no further IRP updates located in Patient #54 ’ s medical record. The surveyor interviewed Employee #22 Registered Nurse on 05/06/2024 at approximately 2:00 PM. Employee #22 confirmed Patient #54 ’ s IRP was not updated within the required sixty-day timeframe mentioned above. The surveyor interviewed Employee #8, Director Clinical Administrator on 05/09/2024 at approximately 10:00 AM. Employee #8 stated IRPs should be updated every sixty days and if they are not, there should be documentation in the medical record indicating why it was not completed.”

“Therapeutic Activities - Program CFR(s): The program must be appropriate to the needs and interests of patients and be directed toward restoring and maintaining optimal levels of physical and psychosocial functioning. This Standard is not met as evidenced by: 43420 Based on medical record review, policy review, and staff interviews the hospital staff failed to provide Occupational Therapy services per physician’s order for one (1) of one (1) patient (Patient #53). The Findings Include: A review of the facility ’ s policy titled “Clinical Assessments and Progress Notes” revised 01/19/2023 showed “F. Rehabilitation Services (including Recreation, Creative Arts, Vocational Rehabilitation, Occupational Therapy, Education Therapy, and Chaplaincy Services) 1. A rehabilitation services initial assessment is required on newly admitted and readmitted individuals prior to the Interdisciplinary Recovery Planning (IRP) conference ...2 The assessment shall document findings of abilities, needs and recommended treatment ...3. Progress notes shall be written (as needed per clinical event while the individual is receiving services, but at minimum a monthly progress note shall be documented ...” A review of the medical record showed Patient #53 was admitted with a diagnosis to include Bipolar Disorder. Further medical record review showed a physician ordered an Occupational Therapy consultation on 12/07/2023. Additionally, the order revealed Patient #53 sustained a right index finger fracture on 11/15/2023 and was evaluated by an Orthopedic Physician. The patient’s hand was splinted and further recommendations included “ patient [Patient #53] occupational therapy to evaluate and treat 1 time per week x [times] 4 weeks with goal of “index rom [Range of Motion] ...” The medical record lacked documented evidence of Patient #53 receiving any Occupational Therapy services as ordered. The surveyor interviewed Employee #22, Registered Nurse, on 05/07/2024 at approximately 2:00 PM who confirmed there were no Occupational Therapy progress notes documented in Patient #53 ’ s medical record. The surveyor conducted an interview with Employee #7, Director of Rehabilitation Services, on 05/09/2024 at approximately 10:20 AM. According to Employee #7 occupational consultations are ordered by a physician and a notification is sent to the department by email. The Occupational Therapist should follow up with an evaluation of the patient and document progress notes in the medical record.”