Meadowwood Behavioral Health System

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 44819 Based on medical record review, facility policy review, and staff interview, it was determined the facility failed to protect and promote each patient’s rights as evidenced by: failure to obtain consent from the patient before the administration of psychotropic medication (A0117) and failure to provide proper staff supervision resulting in a patient elopement (A0144). Cross Reference: 482.13(a)(1) Patients Rights: Notice of Rights 482.13(c)(2) Patient Rights: Care in a Safe Setting”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 44819 Based on review of facility policies and documents, review of medical records, and interviews with staff, it was determined that the facility failed to maintain an organized nursing service as evidenced by: failure to ensure adequate numbers of nursing staff for 3 patient care units (A392); failure to complete patient observations as ordered (A395); and failure to ensure adherence to their medication administration policy (A405). Cross Reference: 482.23(b) Staffing and Delivery of Care 482.23(b)(3) RN Supervision of Nursing Care 482.23 (c)(1),(c)(1)(i) & (c)(2) Administration of Drugs”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 44819 Based on medical record review, facility policy review, and staff interview, it was determined that for 1 of 7 patients (MR3) sampled, the Facility failed to obtain consent from the patient before the administration of psychotropic medication. Findings include: Review of facility policy “Consent for Treatment with Psychiatric Medication”, effective 10/2017 and revised 6/2023, revealed “MeadowWood Behavioral Health System obtains the informed consent from the patient...prior to initiating psychotherapeutic medications...This specifically includes any medication whose primary purpose in this use is the treatment of a psychiatric/mental health disorder...” MR3 “Practitioner Order Sheet” dated 8/26/24 at 12:00 noon documented orders for: - Zyprexa 5 mg (milligrams) by mouth every morning. - Zyprexa 10 mg by mouth every night at bedtime. - Zyprexa 10 mg by mouth every 6 hours as needed for agitation. - Ativan 2 mg by mouth every 6 hours as needed for agitation. “Medication Administration Record” revealed patient received: - Zyprexa 5 mg by mouth on 8/27/24 at 9:00 AM. - Zyprexa 10 mg by mouth on 8/26/24 at 9:00 PM. - Zyprexa 10 mg and Ativan 2 mg by mouth on 8/26/24 at 9:30 PM. There was no evidence of patient consent for treatment with these medications. This finding was confirmed with EMP3 on 9/13/24 at 12:03 PM.”

“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: 44819 Based on facility policies, observations, interviews with staff, and a review of surveillance video, it was determined that for 6 of 6 patients (Patients #2, #8, #9, #10, #11, #12) observed, the facility failed to provide proper staff supervision resulting in a patient elopement. Findings include: Review of facility policy “Nursing Accountability” dated 8/93 and revised 6/2023, revealed “...Inpatient nursing staff consists of Registered Nurses...and Behavioral Health Associates...Charge Nurse...delegates tasks and supervises the work of all nursing staff on the unit during the shift...All Licenses [sic] Nurse Staff are responsible for...the overall safety...of individual patients...” Review of facility policy “Locked Units” dated 8/93 and revised 6/96, revealed “...The unit’s outside doors are locked at all times...Staff members do not open the door if they feel insecure about controlling the patient(s) near the door. Instead, the staff member asks the patient(s) to leave the area. If patient(s) do not leave, the staff member gets extra staff to direct the patient(s) away from the door...” Review of video surveillance from September 10, 2024, between 11:00 AM and 1:13:45 PM of the elopement incident revealed the exit door was unlocked and unstaffed from 11:38:11 AM to 1:13:45 PM (1 hour 35 minutes). Patient #2 is observed exiting the facility through the unlocked exit door at 12:59:48 PM. Five other patients can be seen walking in the hallway between 12:55:19 and 1:13:45 PM while the unlocked exit door was not staffed. Inspection of unit D-East on 9/12/24 between 9:10 and 9:16 AM revealed the now secured exit door, which was the means of the patient elopement, at the end of the patient hallway. Interview on 9/12/24 between 1:45 and 2:00 PM with EMP9, Charge Nurse, revealed the Nursing Coordinator notified him/her on 9/10/24 that the emergency exit door would be unlocked. Interview on 9/12/24 between 2:13 and 2:25 PM with EMP18 revealed the delivery men notified him/her that the door was unlocked and before he/she escorted the patients to lunch at 12:30 PM, “a third-party person” told him/her they were done moving furniture so he/she thought the door was locked at that time. On 9/13/24 at 9:57 AM, EMP2 confirmed that Patient #2 eloped through the unlocked and unstaffed emergency exit door on 9/10/24 at 12:59:48 PM. He/she also acknowledged that five other patients were seen walking in the hallway between 12:55:19 and 1:13:45 PM while the unlocked emergency exit door was not staffed.”

“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: 47821 Based on hospital document review, policy review, and staff interview it was determined that the Hospital failed to ensure adequate numbers of nursing staff for 3 (Unit D East, D West and G) of 3 patient care units. Findings include: Review of facility policy “Nursing Accountability,” effective August 1993, revised June 2023, revealed,”...Staff are assigned to units and patients by Registered Nurses based on assessment both of specific patient needs and staff competency...Inpatient nursing staff consists of Registered Nurses, Licensed Practical Nurses, and Behavioral Health Associates...” Review of facility policy “Staffing Plan for Nursing Services,” effective January 26, 2021, revised August 30, 2022, revealed, “...Core coverage includes ensuring there is 1 RN [registered nurse] on each unit at all times and that there is at minimum 2 staff on each unit at all times...The goal of staffing each nursing unit is to ensure patient safety in healthcare delivery...” Interview conducted with EMP7 on 9/13/2024 from 11:09-11:15 AM. EMP7 stated, “Staffing ratios are 1:5 overall for 7A-3P and 3P-11P shifts and 1:10 overall for 11P-7A.” Surveyors reviewed hospital staffing records for the following dates: 2/11/2024 7/6/2024 7/7/2024 7/8/2024 8/30/2024 9/10/2024 The following units were missing staff on the following days: Sunday 2/11/2024 7 PM to 11 PM: Unit D East; 19 patients. Staff: 1 RN, 2 BHA’s [behavioral health associate]. Short 1 staff member. Friday 7/7/2024 7 PM to 11 PM: Unit G; 17 patients. Staff: 1 LPN [licensed practical nurse], 2 BHA’s. Short 1 RN. Friday 7/7/2024 11 PM to 7 AM: Unit D West; 15 patients. Staff: 1 BHA. Short 1 RN. Saturday 7/8/2024 11 PM to 7 AM: Unit D West; 16 patients. Staff: 1 BHA. Short 1 RN. These findings were confirmed with EMP7 during an interview conducted on 9/13//2024 from 11:30-11:40 AM.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 47821 Based on review of medical records, review of facility policies, and interview with staff, it was determined that the Hospital failed to complete ordered patient observations for 2 out of 7 patients sampled (Patient #1 and Patient #5). Findings include: Review of facility policy “Routine Observation Of Inpatients,” effective June 2022, revised June 2023, revealed, “In order to maintain patient safety, the Hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner...Staff documents all pertinent information on each patient’s observation form...Each entry is to include the following: Level of observation, Precaution, Location, Behavior, Activity, Time, Staff initial and Signature ...” MR1 “Meadowwood Behavioral Health Admission Order” revealed “Date of Order: 2/9/2024...Time of Order: 8:40 PM... Level of Observation: Q 15 minutes...” “Patient Observation Sheet,” dated February 13, 2024, revealed no documentation of 15-minute patient observation at 4:00 AM, as ordered. “Patient Observation Sheet,” dated February 16, 2024, revealed no documentation of 15-minute patient observation at 3:00 PM, as ordered. These findings were confirmed with EMP3 during an interview conducted on September 13, 2024, at 1:49 PM. MR5 “Meadowwood Behavioral Health Admission Order” revealed “Date of Order: 12/15/23...Time of Order: 12:30 PM... Level of Observation: Q 15 minutes...” “Patient Observation Sheet,” dated February 11, 2024, revealed no documentation of 15-minute patient observation at 5:30 PM and 5:45 PM as ordered. These findings were confirmed with EMP3 during an interview conducted on September 13, 2024 at 2:15 PM. “Practitioner Order Sheet” revealed “Date Order Written: 2/11/24...Time Order Written: 7:00 PM... Order: Q 5 W/A [while awake] Q 15 W/S [while asleep] ...” “Patient Observation Sheet,” dated February 11, 2024, revealed no evidence of patient observations at: 7:05 PM to 7:10 PM (2 observations not documented) 7:20 PM to 7:25 PM (2 observations not documented) 7:35 PM to 7:40 PM (2 observations not documented) 7:50 PM to 7:55 PM (2 observations not documented) 8:05 PM to 8:50 PM (2 observations not documented) These findings were confirmed with EMP3 during an interview conducted on September 13, 2024 at 2:15 PM.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 47821 Based on medical record review, hospital policy review, and staff interview, it was determined that the Hospital failed to ensure adherence to their medication administration policy for 1 of 7 patients (Patient #4) sampled. Findings include: Review of facility policy “Medication Administration and Documentation”, original date of issue August 8, 2020, revealed, “ ...All ordered medications administered to patients will be documented on the Medication Administration Record ... Document on the MAR (Medication Administration Record) the following information in the appropriate column: Dose, time, route (if not PO [by mouth]), site (if appropriate), and initials ...Document all refused drugs on the patient’s MAR (Medication Administration Record) ... If patient refuses the medication, circle your initials on the MAR (Medication Administration Record) and mark “refused”...Document physician notification in the Progress Note...” Review of MR4 revealed: - Physician orders dated 7/3/2024 at 1443 documented order Latanoprost 0.005% instill 1 drop in both eyes QHS (every night at bedtime). - Medication Administration Record has omitted documentation for Latanoprost 0.005% on 7/7/2024 at 2100. - Physician orders dated 6/30/2024 at 2315 documented order Vraylar 1.5mg PO (by mouth) QHS (every night at bedtime). - Medication Administration Record has omitted documentation for Vraylar 1.5mg on 7/6/2024 and 7/7/2024 at 2100. - Physician orders dated 6/30/2024 at 2315 documented order Carvedilol 12.5mg PO (by mouth) BID (twice a day). - Medication Administration Record has omitted documentation for Carvedilol 12.5mg on 7/6/2024 and 7/7/2024 at 2100. - Physician orders dated 7/2/2024 at 1036 documented order Losartan 100 mg PO (by mouth) daily. - Medication Administration Record has omitted documentation for Losartan 100mg on 7/7/2024 at 0900. - Physician orders dated 7/4/2024 at 1100 documented order Remeron 30mg PO (by mouth) QHS (every night at bedtime). - Medication Administration Record has omitted documentation for Remeron 30mg on 7/6/2024 and 7/7/2024 at 2100. - Physician orders dated 6/30/2024 at 2315 documented order Brimonidine ophthalmic 0.2% instill 1 drop both eyes Q8 (every 8 hours). - Medication Administration Record has omitted documentation for Brimonidine ophthalmic 0.2% on 7/6/2024 and 7/7/2024 at 1600 and 2400. During an interview on 9/13/2024 at 1100, EMP3 confirmed the omitted documentation of 6 out of 13 scheduled medications with no evidence of physician notification.”

“Psych Eval - Medical History CFR(s): [Each patient must receive a psychiatric evaluation that must--] Include a medical history; This Standard is not met as evidenced by: 44819 Based on medical record review, facility policy and document review, and staff interview, it was determined that for 1 of 7 patients (MR3) sampled, the Facility failed to ensure that a history and physical was completed. Findings include: Review of facility policy “Timeliness of Documentation”, effective 10/96 and revised 11/2015, revealed “Documented assessments...are completed...within the timeframes outlined below...History & Physical 24 hours...” Review of facility document “Medical Staff Bylaws” effective 12/1/2022, revealed “...3.3.11 prepare and complete in a timely manner the medical...records...This includes the requirement for completing and documenting medical histories and physical examination for each acute services patient no more than...24 hours after admission...” Review of MR3 for showed no evidence that a history and physical was completed for the 8/23/24 inpatient services admission. This finding was confirmed with EMP3 on 9/13/24 at 12:26 PM.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 44819 Based on review of facility policies and documents, review of medical records, and interviews with staff, it was determined that the facility failed to maintain an organized nursing service as evidenced by: failure to ensure adequate numbers of nursing staff (A392); failure to have a Registered Nures assess a patient entering the detoxification program (A398). Cross Reference: 482.23(b) Staffing and Delivery of Care 482.23(b)(6) Supervision of Contract Staff”

“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: 47821 Based on hospital document review, policy review, and staff interview it was determined that the Hospital failed to ensure adequate numbers of nursing staff for 8 (Unit A, B, C, D East, D West, E, G and T) of 8 patient care units, including not staffing appropriately for one-to-one observations and not ensuring a Registered Nurse (RN) is present and available on each unit. Findings include: Review of facility policy “Nursing Accountability,” effective August 1993, revised June 2023, revealed, “...Staff are assigned to units and patients by Registered Nurses based on assessment both of specific patient needs and staff competency...Inpatient nursing staff consists of Registered Nurses, Licensed Practical Nurses, and Behavioral Health Associates...” Surveyors reviewed hospital staffing records for the following dates: 4/12-4/15/2024 4/20-4/21/2024 4/26-4/28/2024 5/4-5/5/2024 5/10-5/12/2024 5/18-5/19/2024 5/24-5/26/2024 6/1-6/2/2024 6/6-6/7/2024 Review of facility policy “Staffing Plan for Nursing Services,” effective January 26, 2001, revised August 30, 2022, revealed, “...Core coverage includes ensuring there is 1 RN [registered nurse] on each unit at all times and that there is at minimum 2 staff on each unit at all times...The goal of staffing each nursing unit is to ensure patient safety in healthcare delivery...” The following units had no RN assigned for the following dates: Sunday 5/12/2024 3 PM to 7 PM: Unit A had a census of 22 patients. Staff assigned were one LPN (Licensed Practical Nurse) and 3 BHAs (Behavioral Health Associates). Friday 5/24/2024 7 PM to 11 PM: Unit G had a census of 20 patients. Staff assigned were one LPN and 3 BHAs. Sunday 6/2/2024 11 PM to 7 AM: Two Units (Unit A and Unit C) had no RN assigned. Unit A had a census of 19 patients, with 1 LPN and 1 BHA assigned. Unit C had a census of 14 patients, with 2 BHAs assigned. Saturday, 6/8/2024 11 PM to 7 AM: Unit E had a census of 17 patients with one LPN assigned. Additionally, per hospital policy, a minimum of two staff members should be present at all times. Review of facility policy “Routine Observation of Inpatients,” effective June 2002, revised September 2020, revealed, “In order to maintain patient safety, the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered...1:1 is the highest level of observation and is reserved for patients who are so unpredictable that without a dedicated staff member there is a risk of patient harming self or others...Staff who are assigned to monitor the patient on 1:1 observation will have no other assignments...” The following Units did not have enough staff assigned to provide 1:1 observation as ordered for patients: Sunday, 5/19/2024 7 AM to 3 PM: Unit B had a census of 9 patients with two ordered for 1:1 observation. Only one RN and one BHA were assigned to this Unit. Sunday, 5/19/2024 3 PM to 7 PM: Unit B’s census increased to 11 patients with two ordered for 1:1 observation. Assigned staff included one RN, one nurse, and one BHA. Friday, 5/24/2024 7 AM to 3 PM: Unit B had a census of 12 patients with two ordered for 1:1 observation. Staff included two RNs and one BHA. Saturday, 5/25/2024, Unit C was understaffed from 7 AM to 11 PM. From 7 AM to 3 PM, the census was 16 with 3 patients ordered 1:1 observation while awake. However, there were only two staff members present - one RN and one BHA. From 3 PM to 7 PM, the census remained 16 with 3 1:1 orders. However, there were only 3 staff members assigned - one RN, one nurse, and one BHA. From 7 PM to 11 PM, the census remained 16 with the 3 patients onrdered 1:1 observation while awake. However, only three staff members were assigned to this Unit, leaving coverage short until those 1:1 patients were asleep. The staff included one RN, one nurse, and one BHA. Sunday, 5/26/2024, 7 AM to 3 PM: Unit C remained with 16 patients and two with 1:1 observation orders. However staff assigned were one RN, one nurse, and one BHA. Interview conducted with EMP12 on 6/14/2024 from 10AM to 12:15PM. EMP12 stated, “Staffing ratios are 1:5 overall for 7A-3P and 3P-11P shifts and 1:10 overall for 11P-7A.” Surveyors confirmed with EMP12 that the staffing ratios do not reflect patients on 1:1 observation, as those staff are not permitted to have any other assignments per facility policy. The following Units did not meet the minimum staffing ratios by shift: Saturday 4/13/2024 7 AM to 3 PM: Unit A; 19 patients. Staff: 1 RN, 2 BHA’s. Short 1 staff member. Sunday 4/14/2024 7 AM to 3 PM: Unit D West; 20 patients. Staff: 1 RN, 2 BHA’s. Short 1 staff member. Sunday 4/21/2024 7 AM to 3 PM: Unit A; 23 patients. Staff: 1 RN, 1 Nurse, 2 BHA’s. Short 1 staff member. Sunday 4/21/2024 3 PM to 7 PM: Unit A; 23 patients. Staff: 1 RN, 1 Nurse, 2 BHA’s. Short 1 staff member. Saturday 4/27/2024 3 PM to 7 PM: Unit D East; 19 patients. Staff: 1 RN, 1 Nurse, 1 BHA. Short 1 staff member. Saturday 5/11/2024 3PM to 7PM: Unit B; 9 patients with 3 1:1’s while awake. Staff: 1 RN and 3 BHA’s. Short 1 staff member. Saturday 5/11/2024 7PM to 11PM: Unit B; 9 patients with 3 1:1’s while awake. Staff: 1 RN, 3 BHA’s. Short 1 staff member. Sunday 5/12/2024 7AM to 3PM: Unit A; 22 patients. Staff: 1 RN, 1 Nurse, 1 BHA. Short 2 staff members. Sunday 5/12/2024 7AM to 3PM: Unit D East; 17 patients. Staff: 1 RN, 1 BHA. Short 2 staff members. Sunday 5/12/2024 7AM to 3PM: Unit D West; 20 patients. Staff: 1 RN, 2 BHA’s. Short 1 staff member. Sunday 5/12/2024 7AM to 3PM: Unit E; 16 patients. Staff: 1 RN, 1 Nurse, 1 BHA. Short 1 staff member. Sunday 5/12/2024 7AM to 3PM: Unit G; 20 patients. Staff: 1 RN, 1 Nurse, 1 BHA. Short 1 staff member. Sunday 5/12/2024 7AM to 3PM: Unit T; 14 patients with 1 1:1 while awake. Staff: 1 RN, 2 BHA’s. Short 1 staff member. Sunday 5/12/2024 3PM to 7PM: Unit A; 22 patients. Staff: 1 LPN, 3 BHA’s. Short 1 RN. Sunday 5/12/2024 3PM to 7PM: Unit D West; 20 patients. Staff: 1 RN, 2 BHA’s. Short 1 staff member. Sunday 5/12/2024 3PM to 7PM: Unit T; 14 patients with 1 1:1 while awake. Staff: 1 RN, 2 BHA ’ s. Short 1 staff member. Sunday 5/12/2024 7PM to 11PM: Unit A; 22 patients. Staff: 1 RN, 1 Nurse, 2 BHA’s. Short 1 staff member. Sunday 5/12/2024 11PM to 7AM: Unit D East; 17 patients. Staff: 1 BHA. Short 1 RN. Saturday 5/18/2024 3PM to 7PM: Unit A; 21 patients. Staff: 1 RN, 1 Nurse, 2 BHA’s. Short 1 staff member. Saturday 5/18/2024 3pm to 7PM: Unit B; 9 patients with 2 1:1’s while awake. Staff: 1 RN, 2 BHA’s. Short 1 staff member. Saturday 5/18/2024 7PM to 11PM: Unit A; 23 patients. Staff: 1 RN, 2 BHA’s. Short 2 staff members. Saturday 5/18/2024 7PM to 11PM: Unit G; 16 patients. Staff: 1 RN, 1 Nurse, 1 BHA. Short 1 staff member. Sunday 5/19/2024 7AM to 3PM: Unit A; 23 patients. Staff: 1 RN, 1 Nurse, 2 BHA’s. Short 1 staff member. Sunday 5/19/2024 7AM to 3PM: Unit B; 9 patients with 2 1:1’s while awake. Staff: 1 RN and 1 BHA. Short 2 staff members. Sunday 5/19/2024 3PM to 7PM: Unit A; 23 patients. Staff: 1 RN, 1 Nurse and 2 BHA’s. Short 1 staff member. Sunday 5/19/2024 3PM to 7PM: Unit B; 11 patients with 2 1:1 ’ s while awake. Staff: 1 RN, 1 Nurse and 1 BHA. Short 1 staff member. Sunday 5/19/2024 3PM to 7PM: Unit T; 17 patients with 1 1:1 while awake. Staff: 1 RN and 2 BHA’s. Short 2 staff members. Sunday 5/19/2024 7PM to 11PM: Unit T; 17 patients. Staff: 1 RN and 2 BHA’s. Short 1 staff member. Friday 5/24/2024 7AM to 3PM: Unit G; 20 patients. Staff: 1 RN, 1 Nurse and 1 BHA. Short 1 staff member. Friday 5/24/2024 7AM to 3PM: Unit B; 12 patients with 1 1:1 and 1 1:1 while awake. Staff: 2 RN’s and 1 BHA. Short 1 staff member. Friday 5/24/2024 3PM to 7PM: Unit A; 22 patients. Staff: 1 RN, 1 Nurse and 2 BHA’s. Short 1 staff member. Friday 5/24/2024 3PM to 7PM: Unit C; 14 patients with 1 1:1 and 1 1:1 while awake. Staff: 2 RN’s and 2 BHA’s. Short 1 staff member. Friday 5/24/2024 7PM to 11PM: Unit A; 22 patients. Staff: 1 RN, 1 Nurse and 2 BHA’s. Short 1 staff member. Friday 5/24/2024 7PM to 11PM: Unit C; 14 patients with 2 1:1’s. Staff: 1 RN and 3 BHA’s. Short 1 staff member. Saturday 5/25/2024 7AM to 3PM: Unit C; 16 patients with 3 1:1’s. Staff: 1 RN and 1 BHA. Short 4 staff members. Saturday 5/25/2024 3PM to 7PM: Unit C; 16 patients with 3 1:1’s while awake. Staff: 1 RN, 1 Nurse and 1 BHA. Short 3 staff members. Saturday 5/25/2024 7PM to 11PM: Unit C; 16 patients with 3 1:1’s while awake. Staff: 1 RN, 1 Nurse and 1 BHA. Short 3 staff members. Sunday 5/26/2024 7AM to 3 PM: Unit C; 16 patients with 2 1:1’s while awake. Staff: 1 RN, 1 Nurse and 1 BHA. Short 2 staff members. Sunday 5/26/2024 3PM to 7PM: Unit C; 16 patients. Staff: 1 RN and 2 BHA’s. Short 1 staff member. Sunday 5/26/2024 7PM to 11PM: Unit C; 16 patients. Staff: 1 RN and 2 BHA’s. Short 1 staff member. Saturday 6/1/2024 7PM to 11PM: Unit D West; 16 patients. Staff: 1 RN, 1 Nurse and 1 BHA. Short 1 staff member. Sunday 6/2/2024 7PM to 11PM: Unit D East; 18 patients. Staff: 1 RN, 1 Nurse and 1 BHA. Short 1 staff member. Sunday 6/2/2024 7PM to 11PM: Unit D West; 16 patients. Staff: 1 RN and 2 BHA’s. Short 1 staff member. Sunday 6/2/2024 11PM to 7AM: Unit C; 14 patients. Staff: 2 BHA’s. Short 1 RN. Friday 6/7/2024 3PM to 7PM: Unit A; 23 patients. Staff: 1 RN and 2 BHA’s. Short 2 staff members. Friday 6/7/2024 3PM to 7PM: Unit D East; 16 patients. Staff: 1 RN and 2 BHA’s. Short 1 staff member. Friday 6/7/2024 7PM to 11PM: Unit A; 23 patients. Staff: 1 RN, 1 Nurse and 2 BHA’s. Short 1 staff member. Saturday 6/8/2024 3PM to 7PM: Unit A; 23 patients. Staff: 1 RN, 1 Nurse and 2 BHA’s. Short 1 staff member. Saturday 6/8/2024 7PM to 11PM: Unit A; 23 patients. Staff: 1 RN, 1 Nurse and 2 BHA’s. Short 1 staff member. Saturday 6/8/2024 11PM to 7AM: Unit E; 17 patients. Staff: 1 LPN. Short 1 RN. Sunday 6/9/2024 7AM to 3PM: Unit A; 23 patients. Staff: 1 RN, 1 Nurse and 1 BHA. Short 2 staff members. Sunday 6/9/2024 3PM to 7PM: Unit A; 23 patients. Staff: 1 RN, 1 Nurse and 2 BHA’s. Short 1 staff member. Sunday 6/9/2024 3PM to 7PM: Unit D West; 17 patients. Staff: 1 RN and 2 BHA’s. Short 1 staff member. Sunday 6/9/2024 7PM to 11PM: Unit A; 23 patients. Staff: 1 RN, 1 Nurse and 2 BHA’s. Short 1 staff member. Monday 6/10/2024 7AM to 3PM: Unit A; 23 patients. Staff: 1 RN, 1 Nurse and 2 BHA’s. Short 1 staff member. These findings were confirmed with EMP12 on 6/14/2024 from 10AM-12:15PM.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 47821 Based on policy review, document review, medical record (MR) review, employee record review and staff interview, it was determined that for 1 out of 12 patients (Patient #3) in the patient sample, the Hospital failed to adhere to the policies and procedures of the hospital. Findings include: Review of facility policy “Detoxification,” effective April 1999, revised December 2016, revealed, “...Patients who are experiencing significant medical withdrawal from addictive substances are admitted to an inpatient program and managed safely...All patients receive a level of care assessment in admissions that includes an assessment of...Substance use history...Presence/history of psychiatric disorder/current risks to self and others...History of drug and alcohol/mental health treatment...Intensity of recent use and other risk factors for acute withdrawal reaction...This assessment is conducted by a Registered Nurse...” A review of MR3’s “Face Sheet” revealed “... Admitting Diagnosis...Opioid Abuse with Withdrawal...” A review of MR3’s “Meadowwood Behavioral Health Intake”, from 4/20/24 at 5:20 PM, revealed the following information completed by EMP25, Admissions Specilaist: “...presented...for detox from opiates...Pt [patient] using 5-6 ...bags Fentanyl X [times] 2 years snorting last use 4-19-24. Pt using crack cocaine...Pt denies SI [suicidal ideation], HI [homicidal ideation] and psychotic symptoms with history of suicide attempt via OD [overdose] pills 5 years ago...Pt not feeling well due to symptoms...Past Diagnosis: Bipolar disorder, Opiate use disorder...List of Current Medications...No meds...Level of Care Recommendations...Physician Contacted: [EMP33-Physician]...Contact Date: 4/20/24...Contact Time: 6:00PM...Diagnosis per Physician: Opiate use disorder...” Per resume provided by EMP7 on 6/14/2024, EMP25, Admissions Specialist, is not an RN. EMP25 was not qualified to complete the level of care assessment per the facility’s “Detoxification” policy. This finding was confirmed with EMP2 on 6/14/2024 at 12:42PM.”

“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: 44819 Based on observation, staff interview, review of medical records (MR), and policy review, it was determined that for 5 of 5 medical records (MR4, MR5, MR6, MR7, and MR8) sampled, the Hospital failed to ensure the “Interdisciplinary Treatment Plan” was developed collaboratively by the treatment team and the patient, as evidenced by a signature of acknowledgement. Findings include: Review of facility policy “Treatment Planning,” effective May 1996, revised June 2023, revealed, “ It is the policy of MeadowWood Behavioral Health System to develop a Multidisciplinary treatment plan for each patient admitted to an inpatient program...will be individualized and identify the specific needs and goals of the patient and the specific interventions to be conducted by staff to promote ongoing recovery...The purpose of the Multidisciplinary treatment plan is to guide the staff treating the patient...Each clinical discipline has specific intervention(s) that they will utilize...Treatment Plan Review...The multidisciplinary treatment reviews the treatment plan with the patient...The multidisciplinary treatment team members and the patient sign the treatment plan...” 1. Medical record review revealed no evidence of physician/provider signature on the “Interdisciplinary Treatment Plan Update” from 6/14/24 for 4 of 5 (MR4, MR5, MR7 and MR8) records sampled. 2. Medical record review revealed no evidence that the Interdisciplinary Treatment Plan reflected the involvement of the patient for 2 of the 5 (MR6 and MR7) medical records sampled, as evidenced by patient signature. Review of MR6’s “Interdisciplinary Treatment Plan Master Sheets” dated 6/4/2024, stated, “...Patient/Legal Representative Involvement: This Treatment Plan has been presented to/reviewed with the patient...The Patient/legal rep have been given the opportunity to ask questions and make suggestions. (By signing this, patient/legal rep agrees that he/she has actively participated in treatment planning and agrees to the plan.) ...Patient Signature: Blank [no signature noted] ...” Review of MR6’s “Interdisciplinary Treatment Plan Update”, dated 6/14/24, stated, “...Treatment Team/Conference Date: 6/14/24...Patient/Family/ Legal Representative Involvement: Changes in the Treatment Plan have been reviewed with the patient and/or family/legal representative. The patient has been given an opportunity to ask questions and provide feedback on the revisions to the Interdisciplinary Treatment Plan...Patient Signature: Blank [no signature noted] ...” Review of MR7’s “Interdisciplinary Treatment Plan Update”, dated 5/6/24, stated, “...Treatment Team/Conference Date: May 6, 2024....Patient/ Family/ Legal Representative Involvement: Changes in the Treatment Plan have been reviewed with the patient and/or family/legal representative. The patient has been given an opportunity to ask questions and provide feedback on the revisions to the Interdisciplinary Treatment Plan...Patient Signature: Blank [no signature noted] ...” 3. There was no evidence that the interdisciplinary treatment plan reflected the involvement of nursing for 2 of the 5 (MR6 and MR7) patients sampled. Review of MR6 revealed: “Interdisciplinary Treatment Plan Master Sheets”, dated 6/4/24, stated, “...Date of Admission: 6/4/24...Staff Signatures of those involved in the Treatment Plan and Physician Approval of the Treatment Plan...Nursing: Blank [no signature noted] ...” “Interdisciplinary Treatment Plan Update”, dated 6/14/24, stated, “...Treatment Team/Conference Date: 6/14/24...Nurse Signature/Credentials....Blank [no signature noted] ...” Review of MR7 revealed: “Interdisciplinary Treatment Plan Update”, dated 5/10/24, stated “...Treatment Team/Conference Date: May 10, 2024... Nurse Signature/Credentials....Blank [no signature noted] ...” “Interdisciplinary Treatment Plan Update”, dated 5/20/24, stated “...Treatment Team/Conference Date: May 20, 2024... Nurse Signature/Credentials....Blank [no signature noted] ...” “Interdisciplinary Treatment Plan Update”, dated 6/7/24, stated “...Treatment Team/Conference Date: June 7, 2024... Nurse Signature/Credentials....Blank [no signature noted] ...””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48779 Based on medical record review, Facility policy and document review and staff interview, it was determined that the Facility failed to obtain consent from the patient, or the patient representative, before the administration of a psychotropic medication (refer to A 117); failed to provide care in a safe setting (refer to A 144); and failed to act to keep patients free from neglect (refer to 145). The cumulative effect of these deficient practices resulted in the Facility’s inability to protect patient rights and ensure that patients received care in a safe setting. Cross reference: 482.13(a)(1) Patient Rights: Notice of Rights 482.13(c)(2) Patient Rights: Care in a Safe Setting 482.13(c)(3) Patient Rights: Free From Abuse/Harassment”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 47821 Based on medical record review, facility policy review and staff interview, it was determined that for 1 of 9 patients (MR4) sampled, the Facility failed to obtain consent from the patient before the administration of psychotropic medication. Findings include: Review of facility policy “Patient Rights & Responsibilities” revealed “...Consent-You have the right to know how certain treatments could affect you and what other choices you have...” Review of facility policy “Consent for Treatment with Psychiatric Medication”, effective October 2017, revised June 2023, revealed “MeadowWood Behavioral Health System obtains the informed consent from the patient...prior to initiating psychotherapeutic medications...This specifically includes any medication whose primary purpose in this use is the treatment of a psychiatric/mental health disorder...” MR4 - The “Practitioner Order Sheet” dated 12/31/23 at 11:00 AM documented an order for: Haldol 30 mg (milligram) PO (by mouth) X (times) 1 dose for severe agitation/physical fight. - The “Practitioner Order Sheet” dated 1/1/24 at 9:50 AM documented an order for: Haldol 40 mg PO X 1 now for severe agitation. - The “Medication Administration Record” documented the following medication administered: Haldol 30 mg PO X 1 on 12/31/23 at 11:00 AM. Haldol 40 mg PO X 1 on 1/1/24 at 9:50 AM. There was no evidence of patient consent for treatment with this medication. This finding was confirmed with EMP5 on 4/9/2024 at 12:30 PM.”

“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: 44819 Based on observation, medical record review, facility policy and document review, and staff interviews, it was determined for 6 of 9 patients (MR1, MR2, MR5, MR6, MR7, and MR8) sampled, the Facility failed to ensure that patient safety rounds and observations were completed as ordered, failed to ensure a patient was transferred to another unit as ordered, and failed to provide proper staff supervision resulting in patient elopements. Findings include: I. Observations Review of facility policy “Routine Observation of Inpatients”, effective June 2002, revised September 2020, revealed “In order to maintain patient safety, the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner...Documentation of 5 minute observations occurs q [every] 5 minutes...” The facility document titled “Patient Observation Sheet” states, “...(M) in front of the Observer Name shows that the observation was part of a 1:1 - Minder Session.” A. MR1; Admitted on 9/28/23 with a mental health diagnosis of Disruptive Mood Dysregulation Disorder; eloped on 10/17/23. Medical Record Review revealed: - “Practitioner orders” dated 10/25/23 at 12:48 AM included orders for “every 5-minute observations while awake.” - The “Patient Observation Sheet” showed no evidence that patient observations were completed every 5-minutes while awake on the following dates: 10/25 - 10/31/23 (7 days) 11/4 - 11/7/23 (4 days) 11/15/23 11/23/23 11/26 - 12/13/23 (18 days) These findings were confirmed by EMP4 on 4/10/24 at 10:30 AM. B. MR2; Admitted on 9/22/23 with a mental health diagnosis Disruptive Mood Dysregulation Disorder; eloped on 10/17/23. Medical Record Review revealed: - The “Facility Practitioner Order Sheet” dated 10/17/23 at 2:15 PM included orders to begin “every 5-minute checks while awake.” - The “Patient Observation Sheet” showed no evidence that patient observations were completed every 5-minutes while awake on the following dates: 10/27/23 - 10/29/23 (3 days) 11/2/23 - 11/6/23 (5 days) 11/8/23 - 11/9/23 (2 days) 11/13/23 11/15/23 These findings were confirmed by EMP5 on 4/9/24 at 2:15 PM. C. MR5; Admitted on 3/1/24 with a diagnosis of unspecified psychosis and alleged sexual misconduct by a peer on 3/4/24. Medical record review revealed: - Practitioner orders on 3/4/24 at 9:45 PM included orders to stop every 15-minute observations and to start every 5-minute observations. - The “Patient Observation Sheet” showed no evidence that patient observations were completed every 5 minutes from 3/5/24 at 2:45 AM to discharge on 3/8/24 at 1:15 PM (82.5 hours). During an interview on 4/10/24 at 1:45 PM, EMP4 confirmed these findings. D. MR6; Admitted on 3/4/24 with a diagnosis of schizophrenia with exacerbations of auditory hallucinations and worsening symptoms who reported that a peer sexually assaulted him/her on 4/4/24. Medical record review revealed: -Practitioner admitting orders on 3/4/24 at 2:08 PM included an order for every 15-minute observations which were discontinued on 4/4/24 at 8:00 PM. Orders on 4/4/24 at 8:00 PM stated to change to every 5-minute observations. -The “Patient Observation Sheet” showed no evidence that the patient was observed every 5 minutes between 4/4/24 at 8:00 PM and 4/5/24 at 2:00 AM (approximately 6 hours). These findings were confirmed by EMP4 on 4/10/24 at 1:52 PM. E. MR7; Admitted 2/19/24 with a diagnosis of major depressive disorder with suicidal ideations with a plan, who was accused of sexual misconduct by a peer on 3/4/24. Medical record review revealed: - Practitioner admitting orders on 2/19/24 at 11:15 PM included an order for 1:1 observation which was discontinued on 2/20/24 at 10:47 AM. - Practitioner orders on 3/4/24 at 8:45 PM included orders to stop every 15-minute observations and to start every 5-minute observations. - The “Patient Observation Sheet” showed no evidence that MR7 was placed on 1:1 observation between 2/19/24 at 11:15 PM to 2/20/24 at 10:47 AM (approximately 10.75 hours). - The “Patient Observation Sheet” showed no evidence that MR7 received observations q 5 minutes from 3/4/24 at 9:00 PM to discharge on 3/6/24 at 9:30 AM (36.5 hours). During an interview on 4/10/24 at 2:15 PM, EMP4 confirmed these findings. F. MR8; Admitted on 3/30/24 at 7:28 AM with a diagnosis of opioid abuse, uncomplicated who was accused by a peer of sexual assault on 4/4/24. Medical record review revealed: - Practitioner admitting orders on 3/30/24 at 7:27 AM included an order for every 15-minute observations which was discontinued on 4/4/24 at 8:00 PM. - Practitioner orders on 4/4/24 at 8:00 PM included an order to change to every 5-minute observations. - Practitioner orders on 4/5/24 at 7:20 AM included orders to discontinue every 5-minute observations and begin 1:1 observation until discharge. -The “Patient Observation Sheet” showed no evidence that the patient was observed every 5 minutes between 4/4/24 at 8:00 PM and 4/5/24 at 7:20 AM (approximately 11 hours and 20 minutes). -The “Patient Observation Sheet” showed no evidence that the patient was on 1:1 observation from 4/5/24 at 7:20 AM until discharge at 11:45 AM (approximately 4 hours and 25 minutes). These findings were confirmed by EMP4 on 4/10/24 at 2:27 PM. II. Safe Environment Review of facility policy, “Nursing Accountability,” effective August 1993, revised June 2023, revealed “Each nursing staff member is responsible for providing care to assigned patients...To provide nursing care in which all nursing staff have accountability...All Licenses [sic] Nursing Staff are responsible for ...Careful execution of all applicable physician ...orders ...” Review of facility policy “Inpatient Precautions - Sexual Acting Out Precautions”, effective December 1995, reviewed/revised April 2019, revealed “ ...Staff members will take reasonable steps to prevent the opportunity for sexual contact between patients ...Patients may be moved to a different unit ...” MR7 Medical record review revealed: - “Nursing Note” dated 2/28/24 at 11:50 AM documented that the patient made “...threats towards male peer...” - Practitioner order on 2/29/24 at 2:35 PM stated that the patient “may be transferred to Unit E when bed was available” and was signed off by nursing staff on 2/29/24 at 3:00 PM. - “Nursing Note” dated 3/3/24 at 10:22 PM documented the patient had “...poor boundaries with a female patient on the unit...” - Practitioner order on 3/4/24 at 9:30 AM stated to “please transfer to Unit E” and was signed off by nursing staff on 3/4/24 at 9:40 AM. - “Nursing Note dated 3/4/24 at 7:16 PM documented patient with “ ...poor boundaries c [with] female peer. Redirected several times ...” - “Progress Notes” dated 3/5/24 “late entry for 3/4/23 [at 9:30 PM]” documented, “Allegations of unconsensual sexual activity with another peers [sic] received ...” - There was no evidence in the medical record that an attempt was made to transfer MR7 to Unit or that MR7 refused to be transferred to Unit E. During an interview on 4/11/24 at 9:10 AM, EMP4 stated the maximum census for Unit E is 17 patients and that if a patient did not want to be transferred and exhibited behavior that could result in a code (behavioral code) being called, the transfer would not occur unless there was a safety issue. Facility census reports documented that the census of Unit E on 2/29/24 was 16, 3/1/24 was 13, and 3/4/24 was 15, below the maximum census of 17 for Unit E. During an interview on 4/11/24 at 10:00 AM, EMP4 confirmed the patient was not transferred to Unit E as ordered and that a bed was available in Unit E on 3/1/24 and 3/4/24. He/she also confirmed there was no evidence of documentation in the medical record of why the patient was not transferred. III. Code Blue Drills Facility policy titled “Medical Emergencies” revised 8/2014 stated, “...The DON [Director of Nursing] will assign Nurse Coordinator to perform - MOCK Code Blue drills each shift, minimum quarterly on each shift...” During an interview on 4/8/24 at 11:35 AM, EMP4, DON, stated the Facility’s Code Blue drills are held once a month so that each shift will have a drill quarterly, and, if an actual Code Blue is called, this will be used as a drill. A review of the Facility’s 2024 First Quarter Code Blue log revealed an actual Code Blue was called on 1/7/24 at 4:16 AM, an actual Code Blue was called on 2/26/24 at 8:53 AM, and a MOCK Code Blue drill was completed on 3/11/24 at 11:00 AM. There was no evidence that an actual or MOCK Code Blue was called or completed during the evening shift hours of 3:00 PM to 11:00 PM. During an interview on 4/11/24 at 9:05 AM, EMP4 confirmed a Code Blue drill was not held or an actual Code Blue was not called during the evening shift for the first quarter of 2024.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 48779 Based on medical record review, facility policy review, and staff interview, it was determined that for 3 of 9 patients (MR1, MR2, and MR3) sampled, the Facility failed to prevent neglect of patients leading to patient elopements. Findings include: Review of facility policy “Inpatient Precautions - Elopement Precautions,” effective December 1995, reviewed/revised April 2019, revealed “...A patient on Elopement Precautions (EP) must be maintained on a 1:1, Line of Sight (LOS), or a Unit Restriction...Place patient room in close proximity to the nurse’s station and away from exit doors...Awareness of unit activity which will result in doors to unit being open...Patients on EP are not permitted to leave the locked inpatient unit except if a physician has determined there is a therapeutic benefit...” Review of facility policy “Routine Observation of Inpatients,” effective June 2002, revised June 2023, revealed “...In order to maintain patient safety, the hospital staff makes and documents routine safety rounds...Q [every] 15 Minute Rounds ...Make direct visual contact; look for signs of danger or distress ...Remain vigilant for specific risks for patients on Special Precautions ...A staff member must always accompany a patient while off the unit ...” MR1 and MR2 Medical record review of MR2 revealed: - “Progress Note” dated 10/17/23 at 2:10 PM documented, “At approximately [1:00 PM], pt [patient] eloped from facility through exit door during fire alarm testing ...” A review of the Facility document “Incident Investigation Report” dated 11/21/23 related to the 10/17/23 incident involving MR1 and MR2 documented, “ ...Two ...patients, [MR1 and MR2] had eloped from the unit during a fire alarm system testing event ...” The investigation determined a lack of communication between Facility departments, regarding the planned fire alarm system testing. During an interview on 4/8/24 at 10:30 AM, EMP4 stated that, currently, staff do not monitor unit exit doors during fire drills and confirmed the 10/17/24 elopement of MR1 and MR2. MR3 Medical record review revealed: - “High Risk Notification Form” dated 11/17/23 identified patient as an elopement risk. - “MeadowWood Behavioral Health Admission Order” dated 11/17/23 at 7:07 PM included orders for Elopement Precautions and every 15-minute level of observations. - “Admission Psychiatric Evaluation” dated 11/18/23 documented, Patient “...started on elopement...precautions with q [every] 15 minute checks.” - “Practitioner Order Sheet” dated 11/20/23 at 11:19 AM included orders for patient to be on “HR [house restrictions].” Review of surveillance video on 4/11/24 of the 11/22/23 5:20 PM elopement revealed: - 5:15:14- the receptionist is sitting at the front desk while another employee (not identified) is standing to the left of the desk. - 5:20:05- the unidentified employee leaves the lobby by entering through a facility door to the left of the front desk. - Between 5:20:05-5:21:17- the receptionist is looking at a cell phone, answers the desk phone, then hangs up. - 5:21:18- the receptionist gets up and walks around the desk to the right side and enters through a door (identified as the restroom). - 5:21:56- visible through the interior hallway window from the lobby is one individual (identified as EMP15) who approaches the glass lobby door, which is locked. A second individual (identified as MR3), is visible through the hallway window running in the hallway towards EMP15. While EMP15 unlocks the lobby door, MR3 pushes past them and enters the lobby. MR3 is seen running through the lobby and exiting through the front doors of the Facility while EMP15 is walking through the lobby and exits from the facility through the front doors. Outside video surveillance footage shows EMP15 walking from the building to the parking lot. MR3 is no longer visible on the footage. - 5:23:51- the receptionist returns to the front desk. - 5:25:00- a nursing employee (identified as EMP14), enters the lobby through the interior glass doors from the hallway and walks to the front desk where the receptionist is sitting. - 5:26:30- the receptionist uses the front desk telephone with EMP14 standing at the front desk next to her. - Video ends. The review of the video surveillance revealed no evidence that MR3 was within “Line of Sight” of nursing staff, as stated in the hospital’s elopement precautions policy. This finding was confirmed by EMP3 on 4/11/24 between 12:45 PM and 1:30 PM.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48779 Based on medical record review, facility policy reviewand staff interview, it was determined that for 1 of 9 patients (MR4) sampled, the Facility failed to ensure nursing documented the effectiveness of medications administered as an urgent order or to authenticate their medication administration according to their policy. Findings include: Review of facility policy “Medication Administration and Documentation”, original date of issue August 2020, revealed “...All ordered medications administered to patients will be documented on the Medication Administration Record...One (1) hour after administration of medication, reassess the patient and document effectiveness of medication on the PRN [as needed] Effectiveness Record...All medications must be charted on the Medication Administration Record immediately following administration...Sign each patient’s Medication Administration Record...” MR4 a.”Practitioner Order Sheet” dated 12/31/23 at 11:00 AM documented an order for: -Haldol 30 mg PO (by mouth) X (times) 1 dose and Ativan 3 mg PO X 1 dose for severe agitation/physical fight. - The “Medication Administration Record” (MAR) documented the following medication administered: Haldol 30 mg PO X 1 on 12/31/23 at 11:00 AM. Ativan 3 mg PO X 1 on 12/31/23 at 11:00 AM. No evidence of documentation of the effectiveness of the medication within 1 hour noted in the Medication Administration Record or in a progress note. This finding was confirmed with EMP5 on 4/9/2024 at 12:35 PM. b. “Practitioner Order Sheet” dated 1/4/24 at 2:30 AM documented an order for: -Ativan 2 mg IM (intramuscular) X 1, Thorazine 100 mg IM X 1, and Benadryl 100 mg IM X 1 for psychosis. - The “Medication Administration Record” documented the following under “One Time Medication Administration”: Thorazine 100 mg IM X 1 now at 3:00 AM on 1/4/24. Ativan 2 mg IM X 1 now at 3:00 AM on 1/4/24. Benadryl 100 mg IM X 1 now at 3:00 AM on 1/4/24. No evidence of nursing authentication via initials or signature was found on the MAR for the above medications when administered as ordered. No documentation of the effectiveness of the above medications within 1 hour of administration noted in the Medication Administration Record or in a progress note. This finding was confirmed by EMP5 on 4/9/24 at 12:38 PM.”

“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: 44819 Based on medical record review, facility policy review and staff interview, it was determined that for 1 of 9 patients (MR4) sampled, the Facility failed to ensure staff reviewed and reassessed the multidisciplinary treatment plan according to their policy. Findings include: Review of facility policy “Treatment Planning”, effective May 1996, revised June 2023, revealed “The Multidisciplinary treatment plan will...identify the specific needs and goals of the patient and the specific interventions...A review and reassessment of the progress and or lack of progress toward the Treatment Plan Goals identified...The review and reassessment is done every 7 days...” MR4 -Registration Admission Form stated, “...Admission Date & Time, 12/26/23 at 3:14 PM... Discharge Date & Time, 1/07/24 at 5:40 AM...Admitting diagnosis, bipolar disorder...Severe with Psychosis...” -The Interdisciplinary Treatment Plan Medical Problem Sheet identified the following problems: “...Problem: Health Maintenance...Birth Control/Family Planning...Date Initiated, 12/26/23...” “...Problem: Ineffective airway management related to Asthma...Date Initiated, 12/26/23...” “...Problem: Impaired Metabolism related to Diabetes...Date Initiated, 12/26/23...” “...Problem: Altered Tissue Perfusion related to HTN [hypertension], Hyperlipidemia [high cholesterol] ...Date Initiated, 12/26/23...” “...Problem: Impaired metabolism related to Diabetes...Date Initiated, 12/26/23...” “...Problem: Altered Health Maintenance related to infectious disease as manifested by medical history of herpes...Date Initiated, 12/26/23...” “...Problem: Manic Mood with Psychosis...Date Initiated, 12/26/23...” There is no evidence the multidisciplinary treatment plan was reviewed or reassessed between 12/27/23 and 1/6/24 (11 days). This finding was confirmed with EMP5 on 4/9/24 at 12:23 PM.”