North Tampa Behavioral Health

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48190 Based on review of video footage, medical record reviews, review of facility policies, and interviews conducted, the facility failed to ensure the safety of patients in an acute care psychiatric setting after a male patient showed increased sexual activity in 2 (Patient #2 and Patient #17) of 17 patients reviewed. Refer to A142. Due to the immediate actions completed by facility and verified by the surveys on 07/02/2025 the immediacy was removed. The action conducted included: 1. Staff Education and Awareness regarding Sexual Acting Out (SAO) Precautions. Risk Factors/ Behaviors Include: · History of past sexual abuse · Prior sexual acting out · Exposing self in public · Inappropriate touching · Excessive or public masturbation Potential Staff Responses: · Pair with gender specific staff (if possible) · Program in gender specific groups (if available) · Consider alternative treatment protocol if behavior escalates in mixed gender group setting · Place in single room; assign room in close proximity to the nurses station · Increase level of observation for severe or repeated behaviors to reduce impulse 2. Protocol Implementation Admission Screening: Patients with a known history of sexual acting out will be identified during the admission process through a review of prior medical records, intake assessments, and collateral information. Upon identification, they will be immediately placed on Sexual Acting Out (SAO) precautions. Leadership Rounds: Daily leadership rounds will be completed to verify the implementation of the level of precautions and room placement. Safety Huddles: SAO patients and those with recent sexual acting out behaviors will be discussed daily to ensure appropriate observation levels are assigned. Validation: Leadership will validate compliance through direct observation and documentation review during rounds. 3. Monitoring and Reporting- Daily Monitoring: SAO precautions will be reviewed daily during safety huddles and the Daily meeting. Computerized Report: Nursing managers will run a daily report to identify all in-house patients on SAO precautions. Quality Program- Track and trend monthly & report in our monthly and QAPI (Quality Assurance and Performance Improvement) meetings. This will be presented at our July QAPI meeting. An email to our quality team including our corporate quality of the changes and additions to our quality program. 4. Immediate Response to Incidents- Inappropriate Contact: Any patient involved in exposure or inappropriate touching will be placed on a 1:1 immediately until reevaluated by a provider. Proximity Adjustment: All patients on SAO precautions will be housed closer to the nursing station. Incident Reporting: If a patient reports harassment: Staff will immediately notify the provider and nursing team, the patient will be considered for transfer to a different unit, and an incident report will be completed and reviewed by leadership. Verification that facility staff was informed and education was started was verified on 07/02/2025 through observations and interviews of 15 nurses and 10 unlicensed staff.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 48190 Based on review of facility policies and document, video footage, medical records, and interviews, the facility failed to do a full investigation and implement an ongoing performance improvement program for identified patient safety events in 1 of 3 events reviewed. Refer to A286. Due to the immediate actions completed by facility and verified by the surveys on 07/02/2025 the immediacy was removed. The action conducted included: 1. Staff Education and Awareness regarding Sexual Acting Out (SAO) Precautions. Risk Factors/ Behaviors Include: · History of past sexual abuse · Prior sexual acting out · Exposing self in public · Inappropriate touching · Excessive or public masturbation Potential Staff Responses: · Pair with gender specific staff (if possible) · Program in gender specific groups (if available) · Consider alternative treatment protocol if behavior escalates in mixed gender group setting · Place in single room; assign room in close proximity to the nurses station · Increase level of observation for severe or repeated behaviors to reduce impulse 2. Protocol Implementation Admission Screening: Patients with a known history of sexual acting out will be identified during the admission process through a review of prior medical records, intake assessments, and collateral information. Upon identification, they will be immediately placed on Sexual Acting Out (SAO) precautions. Leadership Rounds: Daily leadership rounds will be completed to verify the implementation of the level of precautions and room placement. Safety Huddles: SAO patients and those with recent sexual acting out behaviors will be discussed daily to ensure appropriate observation levels are assigned. Validation: Leadership will validate compliance through direct observation and documentation review during rounds. 3. Monitoring and Reporting- Daily Monitoring: SAO precautions will be reviewed daily during safety huddles and the Daily Flash meeting. WellSky Report: Nursing managers will run a daily WellSky report to identify all in-house patients on SAO precautions. Quality Program- Track and trend monthly & report in our monthly and QAPI meetings. This will be presented at our July QAPI meeting. An email to our quality team including our corporate quality of the changes and additions to our quality program. 4. Immediate Response to Incidents- Inappropriate Contact: Any patient involved in exposure or inappropriate touching will be placed on a 1:1 immediately until reevaluated by a provider. Proximity Adjustment: All patients on SAO precautions will be housed closer to the nursing station. Incident Reporting: If a patient reports harassment: Staff will immediately notify the provider and nursing team, the patient will be considered for transfer to a different unit, and an incident report will be completed and reviewed by leadership. Verification that facility staff was informed and education was started was verified on 07/02/2025 through observations and interviews of 15 nurses and 10 unlicensed staff.”

“PATIENT RIGHTS: PRIVACY AND SAFETY CFR(s): 482.13(c) Patient Rights: Privacy and Safety This Standard is not met as evidenced by: 48190 Based on review of video footage, medical record, facility policies and documents, and interviews conducted, the facility failed to ensure the safety of patients in an acute care psychiatric setting after a male patient (Patient #13) showed increased sexual activity in 2 (Patient #2 and Patient #17) of 17 patients reviewed. Findings included: Review of facility video footage, undated and untimed, revealed one male staff rounding in the hall. Patient #13 and a second male patient are seen walking down the hallway. Then Patient #13 and Patient #2 are seen walking back down the hall together and entering Patient #13’s room together. A behavioral health associate is observed rounding in the hall and he enters the room and quickly exits. He then is seen attempting to get other staff for help. Patient #2 exits the room without her glasses, wrapped only in a blanket. She was then observed wandering back and forth in the hallway, attempting to keep herself covered with the blanket; she appears distressed. She then goes off the camera entering into a side room, possibly the rocking room (room designed to provide a calming and therapeutic environment for patients experiencing distress, anxiety, agitation, or other emotional challenges). The nurse is seen entering Patient #13 room, then Patient #13 is seen dressed walking down the hallway and enters the day room where there are two female patients and one male patient and no staff present. The nurse and both behavioral health associates are seen with other staff members at the nurse’s station in front of the day room, approximately 15 feet away. Patient #2 is eventually escorted off the unit and Patient #13 is placed on one to one. Review of medical record revealed Patient #13 was admitted on 05/11/2025 at 9:05 AM for schizoaffective disorder, bipolar type. History of Bipolar, schizoaffective, MDD (major depressive disorder) and anxiety. Poor historian, restless. Multiple hospitalization history. Non-compliant with meds. Per APRN (Advance Practice Registered Nurse) progress note on 05/13/2025, “patient presents with pressured speech and manipulative behavior. Patient touched a female peer on the unit yesterday and exposed himself to 2 female patients today. SAO (Sexually Acting Out) precautions implemented. Poor insight and judgement noted”. Per nursing note on 05/13/2025, “patient was violating female pt. Found hiding in his bathroom. Female found in her room trying to cover herself with a blanket. Police, supervisor notified”. Patient placed on 1:1 observation. On 05/14/2025, “emergency treatment team meeting help with patient #13. Patient calm and cooperative but minimized the severity of the incident. Acknowledged the situation and accepted the current treatment goals. Boundaries were discussed. Acknowledges feeling inappropriate sexual urges when feeling down or depressed. Remains on 1:1 observation”. Per collateral note on 05/14/2025, “mother reported that patient has engaged in several inappropriate sexual behaviors, including soliciting sexual favors from church members, exposing himself and masturbating in public”. Review of medical record revealed, Patient #2 was admitted on 05/13/2025 at 4:10 PM for altered mental status. Patient presented manic and anxious, speech hesitant, flight of ideas, inattentive, distractive, responding to internal stimuli, A/V (auditory/visual) hallucinations, has not eaten or slept in 3 days and distracted. Per incident note on 05/13/2025, a male patient was found hiding in his bathroom while Patient#2 was found naked trying to cover herself with a blanket. Nursing supervisor and police notified. Patient escorted to Unit B, ambulance called and arrived at 7:00 PM. Patient transported to [Hospital Name]. Patient #2 mother, house supervisor and Risk manager made aware. Review of the medical record revealed Patient #17 admitted on 05/04/2025 at 11:34 AM for altered mental status, hesitant, pressured speech, responding to internal stimuli and staring at the wall or laying on table staring at the ceiling. Minimally responsive and preoccupied with internal thoughts. Previous history of schizoaffective disorder. Non-aggressive in ED (emergency department) but had history of homicidal ideation. Administered Vistaril (medication for anxiety) at 7 PM and Geodon (antipsychotic medication) at 10 PM at hospital. A/V hallucinations, paranoia and disoriented. Unable to answer questions. Per APRN progress note on 05/12/2025 at 8:56 PM, Patient #17 transferred to unit G due to safety concerns from inappropriate contact by another patient (Patient #13). Review of the policy titled Precautions, Sexually Acting Out, last reviewed 5/25 stated Policy: Provision of a safe therapeutic environment of care includes the prevention of patient to patient sexual incidents. Patients shall not have sexual contact with one another. Patients are assessed for risk of sexual acting out behavior. Patients are educated upon admission that they have a responsibility to report any sexual verbal physical abuse or threats of sexual abuse by others. If the hospital determines that there has been an allegation of sexual familiarity (contact) between patients, an immediate investigation must take place. Procedure: During hospitalization, all patients will be assessed and observed for behavior which may increase potential for sexual acting out behavior (ie., inappropriate touching or sexual comments, etc.) Any changes in behavior or events which may impact on a patient’s potential for sexual acting out behavior are to be reported to the charge nurse. The charge nurse will assess the patient and contact the attending physician covering practitioner to communicate the change in behavior. The practitioner shall order level of observation and precautions consistent with the assessed level of risk. Changes and level of observations or implementation of precautions will be communicated to all staff. Risk of sexual acting out behaviors will be addressed in the interdisciplinary treatment plan. Treatment plan will be updated as needed. Review of May 2025 incident log revealed no reports of Patient #13 exposing himself or displaying inappropiate behvavior. During an interview on 07/01/2025 at 12:00 PM, Staff A/ APRN stated I was notified by the techs for both incidents. For the touching I was made aware the day of and the exposing I was not in the building. The first incident that was brought to my attention; he was new to me, and I hadn’t spoken to the patient yet. I saw him the following day on the 13th before the incident. I spoke to nursing in a text and the plan was to place the patient on sexually acting out precautions and to transfer the remaining females off the unit. The census was low and there weren’t many females on the unit. I Do not recall exact time frame but Patient #2’s situation was sometime in the afternoon. I spoke to the techs and nursing and at the time he was on SAO and monitoring while we figured out who to transfer off the unit. One on one would have been an extra layer of precautions. There was no formal training or education, I’m not aware of any documentation or education. During an interview on 07/01/2025 at 1:15 PM, Staff D, BHT (Behavioral Health Technician) stated he needed to work on his personal boundaries. He walked up to people and was staring right in their face. The first day wasn’t too bad. I knew there was something off with him, so I wanted to go read his chart to know what we were dealing with. He did have other behaviors prior. There were 2 other incidents. He put his hand on the thigh of another female patient who was playing cards with 2 other patients. The therapist and the female tech on the floor reported it. They wrote an incident report. That is when we began communication with the NP (ARNP). We started being more hypervigilant watching him. A female staff member said when she was handing him his food that he was inappropriately caressing her hand, and it made her uncomfortable. There was also an incident report for that. At that point he was having male staff interaction only. It progressed very quickly. A patient told me that while she was playing cards he came up to her and exposed his erect penis to her. There was an incident report for that also. It was reported to us later on, so we don’t know exactly when it happened. The nurse was aware. I told the practitioner we needed to move the females off the unit because it was escalating. He said he was going to figure out how to do that. There wasn’t much time before the incident happened after that. They said in hindsight, one to one would have been the best action to take. During a telephone interview on 07/01/25 at 3:31 PM, Staff C, BHT stated he was brand new. It was the first time I had him. The first incident was in the day room and another tech witnessed him touching a female patient ‘s leg and his hand kept getting higher. Night shift said he purposely exposed himself to the female staff. He was a Q15 (every 15-minute checks) before the incident. I did not witness them (Patient #2 and Patient #13) going into the room. I heard voices and the second one was a female which prompted me to open the door. He was on top of her, both unclothed. I repeatedly told him to get off of her. They got off the bed. They were both flustered. She seemed shocked, pretty confused. She grabbed a sheet to cover herself. I made sure she got to her room safely. I kept Patient #13 in his room. I did try to call for help, but I don’t think anyone heard me. I grabbed her a gown from the linen closet for her to dress herself. I let the other tech know what happened. I told the other nurse on the floor; she called the supervisor, and she was prompted to call the police. I am not sure when he went on 1:1 (one to one). Yes, I do feel it was sexual assault. I don’t think there’s a difference between Q15 checks and SAO. It ’ s more of a heads up that this is what they have been doing, and to look out for it. During an interview on 07/01/2025 at 4:27 PM, Staff E, House Supervisor stated I was called, and I called everybody; I called the managers and AOC (administrator on call). The floor did an incident report (a written account of the incident, including when, where, and how it happened, the individuals involved, and other relevant details - such as the nature and extent of injuries or damages), and we called the provider; she did not call back. I do not call DCF (Department of Children and Family); that would be risk management. The nurses called the police then we got the order for 1:1 from the provider. It was quick; in less than 2 hours. As soon as we call the provider and they give the order, we closed the room for evidence. We called the police then we got the 1:1 order. I transferred Patient #2 to unit B; I did not wait for that order. She was confused and disoriented. I cannot say there have been any changes or education. I didn’t receive anything. We need more staff. During an interview on 07/02/2025 at 11:04 AM, the CMO (Chief Medical Officer) stated we have to evaluate the risks before we implement one to one. In an ideal world, where staff are available it would be implemented immediately. In the real world, the resources are not readily available to do that. If the risk is high enough, we could certainly implement that to manage the risk.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 48190 Based on review of facility policies and documents, video footage, medical records, and interviews, the facility failed to do a full investigation and implement an ongoing performance improvement program for identified patient safety events in 1 of 3 events reviewed. Findings included: Review of the policy titled Precautions, Sexually Acting Out, last reviewed 5/25 stated Policy: Provision of a safe therapeutic environment of care includes the prevention of patient to patient sexual incidents. Patients shall not have sexual contact with one another. Patients are assessed for risk of sexual acting out behavior. Patients are educated upon admission that they have a responsibility to report any sexual verbal physical abuse or threats of sexual abuse by others. If the hospital determines that there has been an allegation of sexual familiarity (contact) between patients, an immediate investigation must take place. Procedure: During hospitalization, all patients will be assessed and observed for behavior which may increase potential for sexual acting out behavior (ie., inappropriate touching or sexual comments, etc.)Any changes in behavior or events which may impact on a patient’s potential for sexual acting out behavior are to be reported to the charge nurse. The charge nurse will assess the patient and contact the attending physician covering practitioner to communicate the change in behavior. The practitioner shall order level of observation and precautions consistent with the assessed level of risk. Changes and level of observations or implementation of precautions will be communicated to all staff. Risk of sexual acting out behaviors will be addressed in the interdisciplinary treatment plan. Treatment plan will be updated as needed. Review of the policy titled Risk Management Incident Investigation Policy, last reviewed 1/24 stated Policy: It is the policy of North Tampa Behavioral Health to utilize investigation as a preventative tool to strive to avoid incidents from reoccurring and to improve quality of care. Additionally, investigations helped to cultivate an educational mindset of safety amongst all levels of employees at the facility. Procedure: Determine if the incident requires an investigation after reviewing and evaluating the incident report. Control the scene. Determine immediate action to be taken after evaluating existing environment. Preserve the evidence. Gather data. Analyze data next slide share findings with the facility CEO, corporate risk management and corporate quality and compliance department. Write the investigative report. Complete the incident investigation report. Complete the incident data analysis, if required. Review of May 2025 incident log revealed no reports of Patient #13 exposing himself or displaying innappropriate behavior. Review of video footage revealed one male staff rounding in the hall. Patient #13 and a second male patient are seen walking down the hallway. Then Patient #13 and Patient #2 are seen walking back down the hall together and entering Patient #13’s room together. A behavioral health associate is observed rounding in the hall and he enters the room and quickly exits. He then is seen attempting to get other staff for help. Patient #2 exits the room without her glasses, wrapped only in a blanket. She was then observed wandering back and forth in the hallway, attempting to keep herself covered with the blanket; she appears distressed. She then goes off the camera entering into a side room, possibly the rocking room. The nurse is seen entering Patient #13 room, then Patient #13 is seen dressed walking down the hallway and enters the day room where there are two female patients and one male patient and no staff present. The nurse and both behavioral health associates are seen with other staff members at the nurse’s station in front of the day room, approximately 15 feet away. Patient #2 is eventually escorted off the unit and Patient #13 is placed on one to one. Review of medical record revealed Patient #13 was admitted on 05/11/2025 at 9:05 AM for schizoaffective disorder, bipolar type. History of Bipolar, schizoaffective, MDD (major depressive disorder) and anxiety. Poor historian, restless. Multiple hospitalization history. Non-compliant with meds. Per APRN (advance practice registered nurse) progress note on 05/13/2025, “patient presents with pressured speech and manipulative behavior. Patient touched a female peer on the unit yesterday and exposed himself to 2 female patients today. SAO (Sexually Acting Out) precautions implemented. Poor insight and judgement noted”. Per nursing note on 05/13/2025, “patient was violating female pt. Found hiding in his bathroom. Female found in her room trying to cover herself with a blanket. Police, supervisor notified”. Patient placed on 1:1 observation. On 05/14/2025, “emergency treatment team meeting help with patient #13. Patient calm and cooperative but minimized the severity of the incident. Acknowledged the situation and accepted the current treatment goals. Boundaries were discussed. Acknowledges feeling inappropriate sexual urges when feeling down or depressed. Remains on 1:1 observation”. Per collateral note on 05/14/2025, “mother reported that patient has engaged in several inappropriate sexual behaviors, including soliciting sexual favors from church members, exposing himself and masturbating in public”. Review of medical record revealed, Patient #2 was admitted on 05/13/2025 at 4:10 PM for altered mental status. Patient presented manic and anxious, speech hesitant, flight of ideas, inattentive, distractive, responding to internal stimuli, A/V (auditory/visual) hallucinations, has not eaten or slept in 3 days and distracted. Per incident note on 05/13/2025, a male patient was found hiding in his bathroom while Patient#2 was found naked trying to cover herself with a blanket. Nursing supervisor and police notified. Patient escorted to Unit B, ambulance called and arrived at 7:00 PM. Patient transported to [Hospital Name]. Patient #2 mother, house supervisor and Risk manager made aware. Review of the medical record revealed Patient #17 admitted on 05/04/2025 at 11:34 AM for altered mental status, hesitant, pressured speech, responding to internal stimuli and staring at the wall or laying on table staring at the ceiling. Minimally responsive and preoccupied with internal thoughts. Previous history of schizoaffective disorder. Non-aggressive in ED (emergency department) but had history of homicidal ideation. Administered Vistaril (medication for anxiety) at 7 PM and Geodon (antipsychotic medication) at 10 PM at hospital. A/V hallucinations, paranoia and disoriented. Unable to answer questions. Per APRN progress note on 05/12/2025 at 8:56 PM, Patient #17 transferred to unit G due to safety concerns from inappropriate contact by another patient (Patient #13). During an interview on 07/01/2025 at 12:00 PM, Staff A/ APRN stated I participated in the investigation. Patients with any sexually acting out we are implementing one on ones from the beginning. There was just education between staff; no formal training or education that I am aware of. During a group interview on 07/01/2025 at 1:38 PM, Staff G, RN (Registered Nurse) and Staff H, RN stated we have had patients transferred from B unit and put on one to one for being touchy. Usually, manics are hypersexual and placed on Q5 (every 5) minute checks, 1 to 1 and medications added. We are not aware of any education about a sexual assault. They did do an in service on rounding; making sure to go in the room and see the patient. SAO are checks Q15 (every 15) minutes or Q5 minute as ordered. They have been going straight to one-on-one. We redirect them if we hear them making sexual comments. It’s not acceptable for anyone to hear it. During an interview on 07/01/2025 at 3:31 PM, C, Staff BHT (Behavioral Health Technician) stated there has been no additional training that I am know of. During an interview on 07/01/2025 at 4:15 PM, Staff I, BHT stated she has not had any training, education, in servicing. During an interview 07/01/2025 at 4:27 PM, the House Supervisor stated I can not say there have been any changes or education. I didn’t receive anything. We need more staff. During an interview on 07/02/2025 at 9:10 AM, the Risk Manager stated the BHT’s were part of the RCA. We had a town hall meeting and spoke about Zero harm and the SAO policy with sign in sheets. There has been an increase in cases of sexually acting out across Acadia so they have launched a training series on Zero Harm. Observe for SAO behaviors, document them, and follow the providers monitoring orders. The focus is on reporting. Staff A, APRN was educated at the time during the RCA. They all participated in the RCA. I didn’t document it. I sent out an email to all of the providers last night and I got an attestation from Staff A, APRN. The staff had to sign an attestation for the education on the SAO policy that we started last night. During an interview on 07/02/2025 at 11:04 AM, the CMO stated we have to evaluate the risks before we implement one to one. In an ideal world, where staff are available it would be implemented immediately. In the real world, the resources are not readily available to do that. If the risk is high enough, we could certainly implement that to manage the risk.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48190 Based on facility policies, documents, observations and interviews conducted, the facility failed to protect and promote the rights of 8 (10,11, 12, 13, 26, 27, 28, 29) of 8 patients reviewed and 2(A, B) of 2 units observed. The facility failed to follow the established process for investigating and resolving complaints and grievances in a timely, reasonable and consistent manner. Refer to A0118. The Governing Body failed to ensure that patient grievances were reviewed, investigated, resolved and documented. Refer to A0119. The facility failed to form an individual treatment plan in cooperation with the patient. Refer to A0130. The faciltiy failed to ensure the patients basic right to respect, dignity and comfort. Refer to A0143”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 48190 Based on facility policy, documentation and interviews conducted, the facility failed to follow the established process for investigating and resolving complaints and grievances in a timely, reasonable and consistent manner for 4 (patients 26, 27, 28, 29) of 4 grievances reviewed. Findings included: Facility policy Complaints and Grievances, last reviewed 07/2024, states “When grievances are received, the Patient Advocate and/or Risk Manager will review, investigate and resolve grievances and determine the appropriate response to the complainant. Documentation should include ... .... resolution of grievance and follow up.” Review of facility’s complaints and grievances revealed: On 09/28/2024 Patient #26 filled out the complaint and grievance form. There is no documentation of resolutions or follow ups noted. On 09/30/2024 Patient #27 filled out the complaint and grievance form. There is no documentation of resolutions or follow ups noted. On 10/20/2024 Patient #28 filled out the complaint and grievance form. There is no documentation of resolutions or follow ups noted. On 10/22/2024 Patient #29 filled out the complaint and grievance form. There is no documentation of resolutions or follow ups noted. Review of document labeled “Grievances” given by Staff S/Patient Advocate, reveals “no grievances recorded for this time period”. During an interview on 11/06/2024 at 09:02 AM, Staff S/Patient Advocate stated I did follow ups to the complaint and grievances, but I did not document it. I did not know I was supposed to. Yes, I see it does not look good and looks as if it was not fully investigated. During an interview on 11/06/2024 at 12:15 PM, the CEO stated I am involved with all the complaints and grievances to make sure they are resolved properly and closed accordingly; I work very closely with the patient advocate.”

“PATIENT RIGHTS: REVIEW OF GRIEVANCES CFR(s): 482.13(a)(2) [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.] The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. This Standard is not met as evidenced by: 48190 Based on facility policy, documentation and interviews conducted, the Governing Body failed to ensure that patient grievances were reviewed, investigated, resolved and documented in 4 (#) of 4 grievances reviewed. Failure to review and resolve patient grievances places patients at risk of not receiving appropriate care and services. Findings included: Facility policy “Complaints and Grievances” last reviewed 07/2024 states “When grievances are received, the Patient Advocate and/or Risk Manager will review, investigate and resolve grievances and determine the appropriate response to the complaint. Documentation should include ... .... resolution of grievance and follow up.” Review of facility’s complaints and grievances revealed on 09/28/2024 Patient 26 filled out the complaint and grievance form and there is no documentation of resolution’s or follow ups noted. On 09/30/2024 Patient 27 filled out the complaint and grievance form and there is no documentation of resolution’s or follow ups noted. On 10/20/2024 Patient 28 filled out the complaint and grievance form and there is no documentation of resolution’s or follow ups noted. On 10/22/2024 Patient 29 filled out the complaint and grievance form and there is no documentation of resolution’s or follow ups noted. During an interview on 11/06/2024 at 09:02 AM, Staff S/Patient Advocate stated I did do follow ups to the complaint and grievances, but I did not document it. I did not know I was supposed to. Yes, I see it does not look good and looks as if it was not fully investigated. During an interview on 11/06/2024 at 12:15 PM, the CEO stated I am involved with all the complaints and grievances to make sure they are resolved properly and closed accordingly; I work very closely with the patient advocate.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 45309 Based on facility policy, facility documents, medical record review, and interviews, the facility failed to form an individual treatment plan in cooperation with the patient in 4 (#10, #11, #12, and #13) out of 4 medical records reviewed on Unit M. Findings included: Review of the Policy and Procedure title, “Treatment Planning and Review”, #0651.COMP.1018.004, review 12/2023, Policy- Every patient shall actively participate in treatment planning needs ...and have an individual comprehensive treatment plan ...A comprehensive interdisciplinary treatment plan is initiated upon the patient admission through the first 24 hours and is fully develop/ reviewed/ revised by the multidisciplinary treatment team within 72 hours ...Patient will be expected to participate in all, or a portion, of their team conference, including the planning and evaluation of their individual treatment plan. Treatment team takes place at least 3 times weekly on all units ...Care, Treatment or services for each patient is based on the treatment plan ... Review of the Policy and procedure title, “Treatment planning”, # 651.OP-029.001, reviewed 07/2024 ... Patient and families ...are involved in the treatment planning ...B. problems entered on the master problem list form the basis of the master treatment plan. Each discipline performing an assessment adds their findings to the problems in the master problem list ... Patients should sign the master treatment plan indicating their review and understanding. Review of facility document titled Interdisciplinary Treatment Plan master sheets showed this treatment plan has been presented to/ reviewed with the patient and/or legal representative. The patient / legal representative 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) area. The area for patient comments and patient signature with date and time. Review of Patient #10’s medical record revealed that patient was admitted on 10/29/2024 with diagnosis major depressive disorder. The initial treatment plan was started 10/29/2024 at 8:05 PM. Interdisciplinary Treatment Plan was not completed. The area for patient comments and patient signature with date and time was blank. There was no evidence that the patient participated in their treatment plan. The patient was discharged 11/04/2024 at 4:05 PM. Review of Patient # 11’s medical record revealed that patient was admitted on 10/31/2024 with diagnosis of major depressive disorder. The initial treatment plan started on 10/31/2024 at 22:35 PM. Interdisciplinary treatment plan master sheets not completed. The area for patient comments and patient signature with date and time was blank. There is no evidence that patient participated in their treatment plan. The patient discharged 11/05/2024 at 5:00 PM. Review of Patient #12’s medical record review revealed that the patient was admitted on 11/01/2024 with diagnosis major depressive disorder. The Interdisciplinary Treatment Plan revealed the patient signed on 11/04/2024 at 4:06 PM, which was one hour and 7 minutes before discharge from the facility. Review of Patient #13 Medical record review revealed that the patient was admitted on 10/31/2024 with diagnosis major depressive disorder. The Interdisciplinary Treatment Plan revealed the patient signed on 11/05.2024 at 12:39 PM, which was one hour and forty-seven minutes before discharge from the facility. During an interview on 11/05/2024 at 9:37 AM, Staff R/Therapist stated the treatment team meets every morning, and they will meet with the patient one to two days after admission. The patient signs the plan. If the patient refuses to sign, then the therapist would document that. During an interview on 11/05/2024 at 3:02 PM, Staff M/ Nurse Manager reviewed Patient #12’s care plan signed by the patient 1 hour and 7 minutes prior to discharge. He stated it should have been done earlier. The patient’s signature means he/she is agreeing to actively participate in the treatment plan. Staff M reviewed Treatment Plan for Patient’s #10, 11, and 13 and stated, “I can’t tell you what happened, other than it was not done.””

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 48190 Based on observations, interviews, documents, and policy review, the hospital failed to ensure the patients basic right to respect, dignity and comfort while in the hospital on 2 (Unit A and B) of 5 nursing units for patients that do not require 1:1 observation. Failure to allow capacitated patients the right to use the restroom in private, access to their bedrooms and denying personnel hygiene items results in violating the patients dignity and worth. Findings included: On 11/04/2024 at 09:44 AM, a tour was conducted on Unit A; census 21 patients. The supply closet with all the following bins empty: toothpaste, soap, lotion, deodorant, brush/comb, maxi pads and socks. 3 tampons and adult diapers were present. During an interview on 11/04/2024 at 09:50 AM, Staff Y/ BHT stated the patients sit around a lot and just watch TV because there is nothing for them to do. The supply closet is never stocked so the patient’s basic hygiene needs are not being met. If we call the person who is supposed to stock the closet, she will say supplies are in the patient’s room but they are not in there. For example, the employee hired for stocking was supposed to stock the supply closet prior to leaving on Friday but she did not so we had to call family members and ask them to bring in feminine hygiene products since we didn’t have any. We had many female patients that needed feminine hygiene products. The families were not happy we did not have the supplies to meet their basic needs. During an interview on 11/04/2024 at 9:55 AM, Patient #4 stated “I don’t like that the room doors are locked all day. You can’t go in the room. It’s locked from 7:00 [AM] to curfew [bedtime]. You’re not allowed in your room except for hygiene. That’s their policy. They are very short staffed. Water, tea and the phone are only accessible from a tech [a tech is a behavioral health assistant-BHT], so it’s very difficult to get anything. It’s very hard on her and us. You have to wait for a beverage. It may be a while, because there is only one tech. There is a locked bathroom in the TV room. The tech has to let you in. You can’t close the door. You have to leave it cracked.” During an interview on 11/04/2024 at 10:16 AM, Staff T/BHT confirmed the patient rooms are locked during the day. There has to be an order for them to be in their room. If they are not feeling well and want to lie down, there are exceptions. “But from 8 AM to 5 or 6 PM the rooms are locked. We open them for hygiene care. They don’t want to go to groups. They will stay in their room and sleep and then won’t go to group. Then they will say we didn’t wake them up for group. During an interview on 11/04/024 at 10:22AM, Staff Z/RN stated the patient’s basic hygiene needs are not being met because the supply closet is never stocked like it is supposed to. The patients do spend a lot of time sitting around watching TV because there not enough room for them to do activities like play cards, write, etc. They are not allowed to have markers or crayons due to the acuity. During an interview on 11/04/2024 at 03:05 PM, Staff E/ Medical Director said “the room lockout is during groups. They told me I can override them and write an order for them to be allowed to go to their room. I do not expect them to be locked out all day and I do not expect to write an order to allow them to go in their room. They are detoxing. They have detox symptoms and medications for withdrawals that make them tired. They need rest.” During an interview on 11/05/2024 at 09:22 AM, Staff L, Nurse Manager confirmed the rooms on the detox unit (Unit B) are locked during the day. “The new schedule we are implementing in a couple of days will include nap times in the morning and afternoon. The rooms are locked for the patients’ safety. We do allow for room access if the patient doesn’t feel well. They are available in the morning and evening. We do not leave hygiene supplies in the patients’ rooms for safety reasons. It is a detox unit, but we do have some suicide/homicide risk patients on that unit sometimes. We do allow for room access if the patient doesn’t feel well. We had pitchers and cups out and the infection preventionist said that is an infection control issue. We moved it to the nurses’ station and infection control said it can’t be at the nurses’ station either. She also stated anticholinergic (a group of medications used in psychiatric disorders that stop involuntary muscle movements and various bodily functions) side effects includes dry mouth. Beverages are in the kitchen and provided by the BHT upon request. I gave the last package of sanitary napkins to another unit yesterday. The product was not provided in the last order. She stated sanitary napkins should be available and they bought some this morning on the corporate credit card. Towels are stocked two times a day by environmental services. They are provided during hygiene times. They are available in the morning and evening. During an interview on 11/06/2024 at 11:37 AM, the CEO (Chief Executive Officer) stated we do not differentiate in the population (mental health vs detox patients). The safety of the unit and the patient is the same for every unit. We can’t determine fully the risks of detox patients. Many are here on a Marchman [detoxification order], which is the equivalent of a Baker Act. There are exceptions. If a patient is not feeling well and needs to lie down and rest they can. These are basic safety measures we are mandated to abide by. They need a doctor’s order to be able to have access to their rooms. When they are not sleeping or performing hygiene, the rooms are locked. If they don’t feel well the nurse needs to call the doctor and get some orders to care for them. Patients hide in bathrooms or isolate to their rooms. When they are not present or visible they may be difficult to locate for fifteen-minute checks. It also prevents acting out of sexual behaviors. The tech has to be able to see and hear the patient. They can’t use the bathroom in the TV room and lock the door. “These are best practices and safety measures in psychiatry. The tech needs to have access to the bathroom. The patient has to keep the door cracked for their safety. The tech must have unrestricted access to the patient. The tech has to remain in the vicinity of the patient. There are two nurses and one tech on B unit for thirteen patients. That’s a ratio of five to one. The nurses are responsible for the supervision of the patients. In fifteen minutes, anything can happen. The liability is great.” During an interview on 11/06/2024 at 12:15, the CEO stated 6-8 weeks ago, we changed the ways supplies are distributed. We found the quantity of supply items (shampoo, soap, toothpaste, etc) in the patient’s room were becoming unsafe. So, we reorganized the system of stocking. We hired an employee to manage the supplies on the floor. The floors, maybe CNA’s, did not like the re-organization. Every Friday there is a meeting held with all employees so they can ask questions and clarifying any confusion they may have. I cannot answer if the employees all comprehended what we told them, but I can say that we did tell them. We did communicate with the staff but they clearly are not understanding. I will have to re-evaluate the plan with the employee hired for stocking the units or come up with another plan for distribution. After the hurricane, our supplier was not able to restock properly, so we bought our own supplies to make sure the facility is fully stocked for the patients. A review of the policy, Patient Rights and Responsibilities, last reviewed 7/23, revealed the following: Policy: Patient Rights: These rights will adhere to Florida Statute 394 as established by the Baker Act. These rights shall include, but not be limited to, the patient’s right to: e. Considerate, dignified, and respectful care, provided in a safe environment, free from all forms of abuse, neglect, harassment and/or exploitation... ff. Reasonable continuity of care to include freedom of movement and fresh air (scheduled daily at least ½ hour daily unless clinically contraindicated.)... pp. The right to personal privacy and confidentiality includes at a minimum that patients have privacy during personal hygiene activities and when requested by the patient as appropriate. A policy for room lock-outs was requested three times throughout the survey and was not provided. A review of the Patient Handbook reflected “we discourage you isolating in your room while not in active programing.””

“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: 48190 Based on facility policy, facility documents, medical record review, and interviews, the facility failed to form an individual treatment plan in 4 (#10, #11, #12, and #13) out of 4 medical records reviewed on Unit M. Findings included: Review of the Policy and Procedure title, “Treatment Planning and Review”, #0651.COMP.1018.004, review 12/2023, Policy- Every patient shall actively participate in treatment planning needs ...and have an individual comprehensive treatment plan ...A comprehensive interdisciplinary treatment plan is initiated upon the patient admission through the first 24 hours and is fully develop/ reviewed/ revised by the multidisciplinary treatment team within 72 hours ...Patient will be expected to participate in all, or a portion, of their team conference, including the planning and evaluation of their individual treatment plan. Treatment team takes place at least 3 times weekly on all units ...Care, Treatment or services for each patient is based on the treatment plan ... Review of the Policy and procedure title, “Treatment planning”, # 651.OP-029.001, reviewed 07/2024 ... Patient and families ...are involved in the treatment planning ...B. problems entered on the master problem list form the basis of the master treatment plan. Each discipline performing an assessment adds their findings to the problems in the master problem list ... Patients should sign the master treatment plan indicating their review and understanding. Review of facility document titled Interdisciplinary Treatment Plan master sheets showed this treatment plan has been presented to/ reviewed with the patient and/or legal representative. The patient / legal representative 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) area. The area for patient comments and patient signature with date and time. Review of Patient #10’s medical record revealed that patient was admitted on 10/29/2024 with diagnosis major depressive disorder. The initial treatment plan was started 10/29/2024 at 8:05 PM. Interdisciplinary Treatment Plan was not completed. The area for patient comments and patient signature with date and time was blank. There was no evidence that the patient participated in their treatment plan. The patient was discharged 11/04/2024 at 4:05 PM. Review of Patient # 11’s medical record revealed that patient was admitted on 10/31/2024 with diagnosis of major depressive disorder. The initial treatment plan started on 10/31/2024 at 22:35 PM. Interdisciplinary treatment plan master sheets not completed. The area for patient comments and patient signature with date and time was blank. There is no evidence that patient participated in their treatment plan. The patient discharged 11/05/2024 at 5:00 PM. Review of Patient #12’s medical record review revealed that the patient was admitted on 11/01/2024 with diagnosis major depressive disorder. The Interdisciplinary Treatment Plan revealed the patient signed on 11/04/2024 at 4:06 PM, which was one hour and 7 minutes before discharge from the facility. Review of Patient #13 Medical record review revealed that the patient was admitted on 10/31/2024 with diagnosis major depressive disorder. The Interdisciplinary Treatment Plan revealed the patient signed on 11/05.2024 at 12:39 PM, which was one hour and forty-seven minutes before discharge from the facility. During an interview on 11/05/2024 at 9:37 AM, Staff R/Therapist stated the treatment team meets every morning, and they will meet with the patient one to two days after admission. The patient signs the plan. If the patient refuses to sign, then the therapist would document that. During an interview on 11/05/2024 at 3:02 PM, Staff M/ Nurse Manager reviewed Patient #12’s care plan signed by the patient 1 hour and 7 minutes prior to discharge. He stated it should have been done earlier. The patient’s signature means he/she is agreeing to actively participate in the treatment plan. Staff M reviewed Treatment Plan for Patient’s #10, 11, and 13 and stated, “I can’t tell you what happened, other than it was not done.””

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 48190 Based on facility policy review, record review, and interviews, the facility failed to have an effective discharge plan for 3 (Patient #3, #4, #5) out of 7 patients reviewed for discharge planning, resulting in 1 patient (#5) being discharged without guardian notification and is currently listed as a missing person. Refer to A0808. The facility provided an Immediate Jeopardy removal plan on 02/14/2024 which was accepted. This included Clinical staff, including Inpatient Clinicians, Therapists, Outpatient Clinicians, and Discharge Planners, to complete training on discharge planning and transitions of care. They will sign an attestation of understanding related to Clinical Expectation and Discharge Planning. All staff mentioned to complete this training prior to their next assigned shift unless working 02/14/2024 with expectation to complete prior to leaving current shift or be removed from their shifts until completion. This was verified by review of educational material and interviews of current staff working on site (4 Registered Nurses, 1 Licensed Practical nurse, 2 Therapists, 2 Discharge Planners, 2 Behavioral Health Technicians, and 1 Utilization Manager). The staff was able to explain the training received and the transition of care expectations for patients to discharge. Immediate Jeopardy was removed on 02/14/2024.”

“PATIENT RIGHTS: REVIEW OF GRIEVANCES CFR(s): 482.13(a)(2) [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.] The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. This Standard is not met as evidenced by: 48190 Based on review of facility policy, grievance log and interviews the facility failed to properly investigate and document grievances/complaints for each month in 6 (August, September, October, November, December, January) of six months reviewed. Review of the facility policy, Complaints and Grievances, last reviewed 07/2023, revealed when grievances are received, the Patient Advocate and/or Risk Manager will review, investigate, and resolve grievances and determine the appropriate response to the complainant. The Risk Manager/designee will attempt to respond in writing to all grievances within seven (7) calendar days of receipt of the grievance. If a written response cannot be made within seven calendar days, the Risk Manager or Patient Advocate will inform the patient or his/her representative that the hospital is still working to resolve the grievance and a written response will be made within thirty (30) calendar days of receipt of the grievance. Review of grievance log from 08/05/2023 to 02/14/2024 reveals 95 entries in the log. No letter or written response was documented to the complainant for 91 out of 94 entries. There were no complaints/grievances listed on the log after 01/18/2024. During an interview with Staff G, Division President, on 2/13/24 between the hours of 12:00PM and 2:00PM, the grievance log was reviewed, and she stated that it is highly unlikely that no grievances or complaints were received [in that time period]. In an interview on 02/14/2024 at 2:00 PM, regarding Patient #5, Staff D, Risk Manager (RM) stated Staff C, Discharge Planner (DCP) had let her know that Department of Childrens and Families (Florida State Agency that investigates adult and child abuse and neglect) was in the building and was asking for information about Patient #5’s discharge that occurred 01/11/2024. Then she notified Staff A, Director of Clinical services (DCS) of the situation; Staff A, DCS made calls and investigated when the breakdown occurred. There was no RCA (Root Cause Analysis) performed, we only met for meetings at the round table. There was a grievance filed with the ethics committee; I will get the information for you on it. No information was provided.”

“DISCHARGE PLANNING EVALUATION CFR(s): The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). This Standard is not met as evidenced by: 48190 Based on facility policy review, medical record review, interviews, and review of Florida Department of Law Enforcement Missing and Endangered Persons Information Clearinghouse, the facility failed to establish appropriate discharge plans to ensure patient and patient representatives’ involvement and provided appropriate follow up care in 3 (#3, #4, #5) out of 7 patients reviewed. Findings included: Review of facility policy, Discharge Planning, last reviewed 12/2023, revealed: The facility ensures that appropriate patient care and clinical information is exchanged when patients are referred, transferred, to discharged to include: reason for transfer, referral or discharge, patients physical and psychosocial status, summary of care provided and progress toward goals, and community resources and referrals provided to the patient. Aftercare plans are communicated to the patient/family/legal representative or receiving facility/agency, as appropriate and documented in the medical record. A copy of the aftercare/discharge form is given to the patient/family/ legal representative or sent to the receiving facility/agency with the patient. In developing discharge aftercare plans, the following is assessed: Physical and psychiatric needs, housing and/or placement issues, social and recreational needs, accessibility to community resources, transportation problems related to after care treatment ...The discharge/aftercare plan is a multidisciplinary form and defines the following: Where the patient will live following discharge based on patient/family needs or wants. The level of care which the patient will be to (i.e., partial hospitalization, ...etc.) . . . All professionals who will follow-up with the patient, including medical follow-up, to monitor medications. State all appropriate recommendations and specific plans to include ...psychiatric, medical, case management, housing, ...and community resources available to meet these needs. The treatment team will develop a discharge plan with active participation from patient/family/legal representative. This post discharge plan shall be reviewed and signed by the patient/family/legal representative and by each member of the clinical treatment team responsible for reviewing the plan with the patient. A patients’ inability or refusal to sign or participation in discharge planning and the patient’s reason for such shall be documented on the plan. A review of Patient #3’s medical record showed he was admitted to the hospital on 12/22/2023 on a BA52 (a Baker Act is the Florida Mental Health Act, commonly referred to as the Baker Act, focuses on crisis services for individuals with mental illness.) Patient #3 was admitted to the hospital from an acute medical hospital in another county. Patient #3 was homeless and used a wheelchair for mobility. He was alert and oriented and capable of making his own decisions. A review of nursing progress notes reflected Patient #3 was discharged on 01/10/2024. The note reflected that he was refusing to engage in a conversation, yelling, cussing, and attempting to delay discharge. The note stated he received assistance from a staff member to escort him to the front where his ride was waiting. Review of Staff E, Therapist/ Discharge Planner’s (T/DP) note dated 01/09/2024, showed she called a homeless shelter in another county, and no one answered. Patient #3 was supposed to be transported by a facility van, but the driver said he doesn’t transport patients in wheelchairs. Attempts were made to contact his family, with no answer. The CFO (Chief Financial Officer) approved a [Ride Share Company] (a non-medical transportation company with an app that allows passengers to hail a ride and drivers to charge fares and get paid) transport. The CEO (Chief Executive Officer) said the best option was to send the patient to a shelter. Patient #3 was discharged to the homeless shelter via [Ride share Company]. A review of the discharge care plan provided to Patient #3 reflected Patient #3 needed after care appointments for medication management and for therapy/mental health. A note on the form indicated the patient refused to engage in the discharge instructions. He also had 4 prescriptions for medication and needed a follow up with a primary care physician and cardiologist. In an interview conducted with the Director of Quality on 02/12/2024 at 03:47 PM, the Director of Quality said there was a video on social media. The video showed Patient #3 being dropped off at the homeless shelter. The driver from the [Ride share Company] was interviewed and said the patient didn’t want to be there. The Director of Quality admitted there was no documentation in his record that another facility would not take him. The discharge planners are supposed to arrange placement and services. There are facility vans to take the patients where they want to go. If not, we send them in a [Ride share Company vehicle]. At 1:27 PM on 02/12/2024 an interview was conducted with Staff A, Director of Clinical Services (DCS). Staff A said there should at least have been some arrangements for Patient #3’s follow up appointments. An assessment of his community resources should have been the least that was done. Staff A confirmed there was no documentation the homeless shelter was notified and agreed to take the patient. On 02/12/23 at 4:14 PM an interview was conducted with Staff E, Therapist. She stated Patient # 3 was in a wheelchair. She was having difficulty finding placement for him. He had a lot of medical issues. She tried to get him into an Assisted Living Facility (ALF). The ALF denied him. There is only one ALF company that the facility uses. It has several different ALFs. Patient #3 discharged to a homeless shelter. The discharge planners make the follow-up appointments. Prescriptions are the nurses and providers responsibility. It was difficult. Staff E said she didn’t know what to do. Staff E asked administration what to do. Staff E stated she was not provided case management or discharge planning orientation. On 02/13/2024 at 9:25 AM an interview was conducted with the Division President (DP). The DP stated the CEO was terminated because of Patient #3 and #5. “We do not send a man who is in a wheelchair to a homeless shelter in a [Ride Share Company].” Staff E, Therapist wrote an inappropriate note in the patient’s chart, but she wasn’t equipped to address that circumstance and reached out for help, and they failed her. On 02/14/2024 at 10:15 AM an interview was conducted with the Risk Manager (RM). The RM said the facility sent Patient #3 in a [Ride Share Company] versus the facility vehicle. The van cannot take wheelchairs. The patient arrived in a wheelchair, and he was going to discharge in a wheelchair. His wheelchair was an assistive device due to his neuropathy and pain. The outside records did not indicate he was wheelchair bound. There was not much documentation on the patient’s involvement in the discharge process. “We don’t send patients to a shelter that doesn’t accept patients in wheelchairs. There was no proof they would accept a patient in a wheelchair.” The risk manager said she was not aware there was a problem with discharging patients to shelters. She was under the assumption the shelter was a place where they would have a bed versus a street corner. A review of the record for Patient #4 revealed he was admitted to the facility on 01/23/2024 under a BA52 (Baker Act), with multiple medical diagnoses including type 2 diabetes mellitus, right below the knee amputation (RBKA) with use of a wheelchair. Patient #4 was homeless. A review of the 01/25/2024 psychosocial assessment reflected Patient #4 wants to go to an ALF. A physician’s note dated 01/30/2024 reflected the ALF can’t take the patient until 01/31/2024, cancel discharge. The discharge care plan dated 01/30/2024 had no documentation reflecting where Patient #4 discharged to. The instructions reflected to follow up with his PCP (primary care physician) within 1 week. There were copies of prescriptions he was discharged with in the record. There was no documentation of any arrangements to obtain his medications or arrangement for his follow-up appointments. Further review of the record revealed an untitled, undated form indicating a planned discharge to a shelter in another county, with approval for a [Ride share Company] to transport. The initial discharge planning assessment dated 01/25/2024 reflected Patient #4 would like placement in ALF. On 02/12/24 at 1:51 PM an interview was conducted with Staff E, Therapist. Staff E said she participates in discharge planning. Patient #4 was in a wheelchair. He said he wanted an ALF. He was living with his sister. They had an argument and he left. He did not want to go back there. Staff E said she called an ALF company they use to help with referrals to one of their ALFs. The owner came and met the patient. He noticed Patient #4 had an ulcer on his stump. The next day Staff E called the ALF and he said he would not take the patient because the patient wanted [narcotic pain medication] and they couldn’t give that at the Alf. Patient #4 did not have access to his income, because he was from another state, and he didn’t have any resources so that’s why he was discharged to a shelter. Shelters are first come first serve. They don’t hold beds. If they have a wheelchair a phone call is made to the shelter to see if they can take them. Staff E said she did call, and they didn’t answer the phone at the shelter. It is a last resort after talking to the director about not being able to place him. It appeared he may have had medical issues. He had an amputated leg. Staff E said she had not heard the facility is responsible to assist with getting medications or appointments. She has worked in this role since July of 2023. She does not recall any requirement to know what the discharge policy says. She was trained by someone and had orientation from them and was provided an orientation packet. Review of Patient #5’s medical record showed Patient #5 was admitted on 01/05/2024 for Disorganized Schizophrenia after eloping from her ALF (Assisted Living Facility). Staff B /Social Worker/Therapist (SW/T) documented that she placed a call to Patient #5’s ALF and learned Patient #5 cannot return there. Patient #5 was given a 45- day notice and the last day was believed to be 01/24/2024. Patient #5 has a guardian who is aware and reportedly working on finding her a placement. The guardian’s name and phone number were noted in the chart. Staff B placed a call to the guardian, but he stated he needed to call Staff B back; facility number provided. Staff B placed legal guardian paperwork in the chart and informed the interdisciplinary team during huddle (meeting) the paperwork is on the chart. Staff C/ Discharge Planner (DCP) discharged patient on 01/11/2024 to a homeless shelter in another county. In an interview with Staff A, DCS on 02/12/2024 at 1:09 PM, Staff A, DCS stated [the guardian agency] filed a complaint/grievance and he called to speak to the guardian. The guardian told him that he needed to see the chart and the records were sent to him. Staff A stated he investigated the chart. He then went to Staff B, Social Worker/Therapist (SW/T), and she said she was made aware Patient #5 had a guardian and she told him she needed the paperwork. The paperwork was sent in, and Staff B, SW/T said she put it in the chart. Staff B, SW/T informed the discharge planner. Staff C, DCP did not see the paperwork in the chart, so he set up discharge to the homeless shelter in another county. Staff B, SW/T did document the guardian paperwork was placed in chart, but Staff C, DCP did not see the note from Staff B, SW/T. Staff C, DCP did not read the social workers notes prior to setting up location and transportation for discharge. “The guardian, told me that he was going to file a formal complaint with the state, and I knew AHCA (Agency for Healthcare Administration) was going to be coming in again soon.” In an interview with Staff B, SW/T on 02/12/2024 at 2:55 PM, Staff B, SW/T stated Patient #5 was being discharged. I made contact with the ALF she came from and was told she couldn’t come back, and that she had a legal guardian. Even though they said 01/24/2024 is the last day she can stay there, they still would not accept her back. I contacted the guardian again when she was being discharged but he did not have a place for her to go to yet. The patient expressed wanting to go to [another County], so I told the guardian. He said he did not want her discharged there and not to discharge her because he is working on placement. I told the team that in the morning huddle. The guardian sent over the paperwork for the legal guardianship. I printed the paperwork and put it in the chart. In an interview with Staff C, DCP (Discharge Planner) on 02/12/2024 at 3:15 PM, Staff C, DCP stated Patient #5 was on Unit A and there was talk about discharge. I was getting ready to set Patient #5 up to go back to her ALF but got notice she could not go back. I let the patient know she can’t go back but she stated she is willing to go to a shelter in [another County] because she knows people in [another County]. So, I set up transport for her and she left. I didn’t see anything in her chart regarding a guardian. Sometimes I look through the chart, but I do rely on the information communicated in the huddles. In an interview with Staff D, Risk Manager (RM) on 02/14/2024 at 2:00 PM, Staff D stated Staff C, DCP called and said DCF (Department of Children and Families - State Agency that investigates abuse) was in the building and was asking for information about Patient #5’s discharge. He confirmed it was ok to give the information, then notified Staff A, DCS of the situation. Staff A, DCS made all the calls and investigated when the breakdown occurred. “I did not perform an RCA (Root Cause Analysis); I only met for meetings at the round table. I did not feel it was necessary. I do know the patient is a missing person but did not feel the situation needed to be investigated. There was a grievance filed with the ethics committee; I will get the information for you on it.” No information was provided. A review of FDLE (Florida Department of Law Enforcement) missing and endangered persons information clearing house, Patient #5 is listed as a purple alert missing person as of 02/15/2024. The Florida Purple Alert is used to assist in the location of missing adults suffering from a mental or cognitive disability that is not Alzheimer’s disease or a dementia-related disorder; an intellectual disability or a developmental disability; a brain injury; other physical, mental or emotional disabilities that are not related to substance abuse; or a combination of any of these and whose disappearance poses a credible threat of immediate danger or seriously bodily harm.”

“Social Services Staff Responsibilities CFR(s): Social service staff responsibilities must include, but are not limited to, participating in discharge, planning, arranging for follow-up care, and developing mechanisms for exchange of appropriate information with sources outside the hospital. This Standard is not met as evidenced by: 48190 Based on facility policy review, record review, interviews and review of job description, the facility failed to ensure social services were involved in discharge planning to arrange appropriate follow up care and exchange of information with sources outside the hospital in 3 (#3, #4, #5) out of 7 patients reviewed for discharge planning. Findings included: Review of facility policy, Discharge Planning reviewed 12/2023, stated the facility ensures that appropriate patient care and clinical information is exchanged when patients are referred, transferred, to discharged to include: reason for transfer, referral or discharge, patients physical and psychosocial status, summary of care provided and progress toward goals, and community resources and referrals provided to the patient. The physician, therapist, and discharge planner with the support of nursing, coordinate the discharge arrangements with the patient and family. Certain dispositions/discharge needs may be considered for the patient, including a return to the home, placement in an ALF or SNF, partial hospitalization, outpatient therapy ...transportation, medical follow up ... Aftercare plans are communicated to the patient/family/legal representative or receiving facility/agency, as appropriate and documented in the medical record. A copy of the aftercare/discharge form is given to the patient/family/ legal representative or sent to the receiving facility/agency with the patient. The treatment team will develop a discharge plan with active participation from patient/family/legal representative. This post discharge plan shall be reviewed and signed by the patient/family/legal representative and by each member of the clinical treatment team responsible for reviewing the plan with the patient. A patients’ inability or refusal to sign or participation in discharge planning and the patient reason for such, shall be documented on the plan. A review of Patient #3’s medical record showed he was admitted to the hospital on 12/22/2023 on BA52 (Baker Act- The Florida Mental Health Act, commonly referred to as the Baker Act, focuses on crisis services for individuals with mental illness.) Patient #3 was admitted to the hospital from an acute medical hospital in another county. Patient #3 was homeless and used a wheelchair for mobility. He was alert and oriented and capable of making his own decisions. A review of nursing progress notes reflected Patient #3 was discharged on 1/10/2024. The note reflected he was refusing to engage in a conversation, yelling, cussing, and attempting to delay discharge. Received assistance from staff member to escort him to the front where his ride was waiting. Review of the discharge planner’s (Staff E, Therapist) note dated 1/9/2024, showed she called a homeless shelter in another county, and no one answered. Patient #3 was supposed to be transported by a facility van, but the driver said he doesn’t transport patients in wheelchairs. Attempts made to contact his family, no answer. CFO (Chief Financial Officer) approved a [Ride Share Company] transport. CEO (Chief Executive Officer) said the best option was to send the patient to a shelter. The patient was discharged to a homeless shelter via [Ride share Company], (a non-medical transportation company with an app that allows passengers to hail a ride and drivers to charge fares and get paid). A review of the discharge care plan provided to Patient #3, reflected Patient #3 needed after care appointments for medication management and for therapy/mental health. A note on the form indicated the patient refused to engage in the discharge instructions. He had 4 prescriptions for medication and needed a follow up with a primary care physician and cardiologist. An interview was conducted with the Director of Quality on 02/12/2024 at 3:47 PM. The Director of Quality said there was a video on social media. The video showed Patient #3 being dropped off at a homeless shelter. The driver from the [Ride share Company] was interviewed and said the patient didn’t want to be there. The Director of Quality admitted here was no documentation in his record that another facility would not take him. The discharge planners are supposed to arrange placement and services. There are facility vans to take the patients where they want to go. If not, we send them in a [Ride share Company vehicle]. At 1:27 PM on 02/12/2024 an interview was conducted with Staff A, Director of Clinical Services. Staff A said there should at least have been some arrangements for Patient #3’s follow up appointments. An assessment of his community resources should have been the least that was done. Staff A confirmed there was no documentation the homeless shelter was notified and agreed to take the patient. On 02/12/23 at 4:14 PM an interview was conducted with Staff E, Therapist. Patient # 3 was in a wheelchair. Staff A said she was having difficulty finding placement for him. He had a lot of medical issues. She tried to get him into an ALF (Assisted Living Facility). The ALF denied him. There is only one ALF company that the facility uses. It has several different ALFs. Patient #3 discharged to a homeless shelter. The discharge planners make the follow up appointments. Prescriptions are the nurses and providers responsibility. It was difficult. Staff E said she didn’t know what to do. Staff A asked administration what to do. Staff A stated she was not provided case management or discharge planning orientation. On 02/13/2024 at 9:25 AM an interview was conducted with the Division President (DP). The DP stated the CEO (Chief Executive Officer) was terminated because of Patient #3 and 5. “We do not send a man who is in a wheelchair to a homeless shelter in a [Ride Share Company vehicle].” Staff E, Therapist wrote an inappropriate note in the patient’s chart, but she wasn’t equipped to address that circumstance and reached out for help, and they failed her. Every discharge is reviewed every morning in [morning meeting]. On 02/14/2024 at 10:15 AM an interview was conducted with the Risk Manager (RM). The RM said the facility sent Patient #3 in a [Ride Share Company] versus the facility vehicle. The van cannot take wheelchairs. The patient arrived in a wheelchair, and he was going to discharge in a wheelchair. His wheelchair was an assistive device due to his neuropathy and pain. There was not much documentation on the patient’s involvement in the discharge process. “We don’t send patients to a shelter that doesn’t accept patients in wheelchairs. There was no proof they would accept a patient in a wheelchair.” The risk manager said she was not aware there was a problem with discharging patients to shelters. She was under the assumption the shelter was a place where they would have a bed versus a street corner. A review of the record for Patient #4 revealed he was admitted to the facility on 01/23/2024 under a BA52 (Baker Act), with multiple medical diagnoses including type 2 diabetes mellitus, right below the knee amputation (RBKA) with use of a wheelchair. Patient #4 was also homeless. A review of the 01/25/2024 psychosocial assessment reflected Patient #4 wants to go to an ALF. A physician’s note dated 01/30/2024 reflected the ALF can’t take patient until 01/31/2024, cancel discharge. The discharge care plan dated 01/30/2024 had no documentation reflecting where Patient #4 discharged to. The instructions reflected to follow up with his Primary Care Physician within 1 week. There were copies of prescriptions he was discharged with in the record. There was no documentation of any arrangements to obtain his medications or arrangement for his follow up appointments. Further review of the record revealed an untitled, undated form indicating a planned discharge to a shelter in another county, with approval for a [Ride share Company] to transport. The initial discharge planning assessment dated 1/25/2024 reflected Patient #4 would like placement in ALF. On 2/12/24 at 1:51 PM an interview was conducted with Staff E, Therapist. Staff E said she participates in discharge planning. Patient #4 was in a wheelchair. He said he wanted an ALF. He was living with his sister. They had an argument and he left. He did not want to go back there. Staff E said she called an ALF company they use to help with referrals to one of their ALFs. The owner came and met the patient. He noticed Patient #4 had an ulcer on his stump. The next day Staff E called the ALF and he said he wouldn’t take the patient because the patient wanted [a narcotic pain medication] and they couldn’t give that at the ALF. Patient #4 did not have access to his income, because he was from another state, and he didn’t have any resources so that’s why he was discharged to a shelter. Shelters are first come first serve. They don’t hold beds. If they have a wheelchair a phone call is made to the shelter to see if they can take them. Staff E said she did call and they didn’t answer the phone at the shelter. It is a last resort after talking to the director about not being able to place him. It appeared he may have had medical issues. He had an amputated leg. Staff E said she had not heard the facility is responsible to assist with getting medications or appointments. She has worked in this role since July of 2023. She does not recall any requirement to know what the discharge policy says. She was trained by someone and had orientation from them and was provided an orientation packet. Review of Patient #5’s medical record, Patient #5 was admitted on 01/05/2024 for Disorganized Schizophrenia after eloping from her ALF (Assisted Living Facility). Staff B /Social Worker/Therapist (SW/T) documented she placed a call to Patient #5’s ALF and learned Patient #5 cannot return there. Patient #5 was given a 45- day notice and the last day was believed to be 01/24/2024. Patient #5 has a guardian who is aware and reportedly working on finding her a placement. The guardian’s name and phone number was noted in the chart. Staff B placed a call to the guardian, but he stated he needed to call Staff B back; facility number provided. Staff B placed legal guardian paperwork in chart and informed the interdisciplinary team during huddle (meeting) the paperwork is on the chart. Staff C/ Discharge Planner (DCP) discharged patient on 01/11/2024 to a homeless shelter in another county. In an interview with Staff B, SW/T on 02/12/2024 at 2:55 PM, Staff B/SW/T stated Patient #5 was being discharged. I made contact with the ALF she came from and was told she couldn’t come back, and that she had a legal guardian. Even though they said January 24th is the last day she can stay there, they still would not accept her back. I contacted the guardian again when she was being discharged but he did not have a place for her to go to yet. The patient expressed wanting to go to [another county], so I told the guardian. He said he did not want her discharged there and not to discharge her because he is working on placement. I told the team that in the morning huddle. The guardian sent over the paperwork for the legal guardianship. I printed the paperwork and put it in the chart. In an interview with Staff C, DCP on 02/12/2024 at 3:15 PM, Staff C/DCP stated Patient #5 was on Unit A and there was talk about discharge. I was getting ready to set Patient #5 up to go back to her ALF but got notice she could not go back. I let the patient know she can’t go back but she stated she is willing to go to [a homeless shelter] in [another County] because she knows people there. So, I set up transport for her and she left. I didn’t see anything in her chart regarding a guardian. Sometimes I look through the chart, but I do rely on the information communicated in the huddles. A review of the job description for Staff E, therapist revealed: Essential functions: May perform case management, discharge or after care planning as needed.”

“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: 36678 Based on review of facility medical staff rules and regulations, medical record review and interviews the hospital failed to do a thorough physical examination and timely response to critical labs for one patient (#3) of three sampled, resulting in a delay in care and life sustaining measures requiring transfer to a high level of care. Refer to A0347, Standard. The facility provided an Immediate Jeopardy removal plan on 12/13/2023, which included review of 100% of current hospitalized patients to identify active medical diagnoses that were not appropriate for hospitalization at the facility. For new admissions, staff will reconcile clinical documentation from transferring facilities to ensure active medical conditions have been addressed on the history and physical documentation by medical staff. Nurses will be re-educated on the exclusionary criteria and chain of command notification for identified patients. Medical and psychiatric providers re-educated on medical exclusionary criteria. Intake nurses reeducated on review of patient information for exclusionary criteria., and training on skin assessments per policy Verification of education was completed with interviews of nurses in 5 different units. Verification of audits of transfer patients had begun via interviews. 40% of staff had been educated with phone calls and emails continuing. Staff are unable to work without acknowledging education. Verification of 100% of medical staff have educated via email attestation. Through verification of the hospital Immediacy Removal Plan, it was determined the immediacy was removed for A0338 on 12/13/2023 at 4:00 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: 36678 Based on record review, interviews, and policy review the hospital failed to ensure nursing services provided met professional standards of practice for a dialysis patient in 1 (#3) of 3 patients sampled. A system-wide failure of nursing services resulted in a dialysis patient requiring a higher level of care in the ICU (intensive care unit) and could have resulted in death. Refer to A0396, Standard. The facility provided an Immediate Jeopardy removal plan on 12/13/2023, which included review of 100% of current hospitalized patients to identify active medical diagnoses that were not appropriate for hospitalization at the facility. For new admissions, staff will reconcile clinical documentation from transferring facilities to ensure active medical conditions have been addressed on the history and physical documentation by medical staff. Nurses will be re-educated on the exclusionary criteria and chain of command notification for identified patients. Medical and psychiatric providers re-educated on medical exclusionary criteria. Intake nurses reeducated on review of patient information for exclusionary criteria., and training on skin assessments per policy Verification of education was completed with interviews of nurses in 5 different units. Verification of audits of transfer patients had begun via interviews. 40% of staff had been educated with phone calls and emails continuing. Staff are unable to work without acknowledging education. Verification of 100% of medical staff have educated via email attestation. Through verification of the hospital Immediacy Removal Plan, it was determined the immediacy was removed for A0385 on 12/13/2023 at 4:00 PM.”

“MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY CFR(s): 482.22(b)(1), (2), (3) The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. (1) The medical staff must be organized in a manner approved by the governing body. (2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy. (3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: (i) An individual doctor of medicine or osteopathy. (ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located. (iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located. This Standard is not met as evidenced by: 36678 Based on the hospital medical staff Rules and Regulations, medical record review and interviews the facility failed to provide quality medical care to one patient (#3) of three sampled, which resulted in a delay in care and life sustain measures requiring transfer to a higher level of care. Findings included: Review of the facility Medical Staff Rules and Regulations showed that admission to the facility a history and physical examination to be performed by a practitioner with clinical privileges to perform such tasks ...The following shall be included in the documentation ...review of systems, physical examination ... Review of the sending hospital documentation in Patient #3’s record, revealed a nephrology assessment and plan dated 11/15/23: patient making minimal urine at this time continue HD (hemodialysis) Tuesday, Thursday, Saturday. S/P (status post) tunneled HD catheter. Further review of the sending hospital documentation dated 11/17/23 reflected a physician progress note CM (case management) to help with outpatient HD. Needs inpatient psychiatry and HD capabilities. Review of the medical record for Patient #3 reflected he was transferred from a medical hospital on 11/17/2023, for inpatient treatment. A review of the nursing admission assessment entered by Staff A reflected a “dialysis port” was present on Patient #3’s right upper chest. The nursing admission note dated 11/18/2023 12:50 AM reflected “patient is a dialysis patient”. A review of nursing notes dated 11/23/2023 revealed Patient #3 was transported to hospital for dialysis access removal. Documentation in nursing notes dated the same day at 6:30 PM reflected Patient #3 was admitted to ICU for stat (immediate) dialysis. Review of medical staff documentation reflected an H and P (History and Physical Examination) dated 11/18/2023, entered by Staff C, PA (physician assistant). There wasn’t any documentation Staff C was aware of Patient #3’s dialysis access site. A review of lab results dated 11/20/23 and a report date of 11/22/23 showed a CMP (complete metabolic panel) was completed. Report reflected the results were verified by repeat analysis, and that specimen was received hemolyzed and the value may be increased by hemolysis. Clinical correlation indicated. The report reflected a Creatinine of 12.7 (normal is 0.76-1.27), and was marked as high, and a potassium level of 6.1 (normal is 3.5-5.2), marked as critical. Staff E, APRN (advanced practiced nurse practitioner) noted the lab report and ordered stat (immediate) repeat of creatinine, potassium, CMP, and EKG (electrocardiogram-a test that looks at the electrical activity of the heart). Review of an order entered by Staff D dated 11/23/2023 10:06 AM, reflected Staff D ordered maintain dialysis access with daily flushing with heparin/saline, PICC line dressing change every 7 days, Change caps every 7 days with dressing change, Apply curasol caps to double lumen, followed by Transfer to hospital for dialysis access removal. Review of the lab report dated 11/29/23 for 11/22/23 labs, revealed a Creatinine of 14.07 verified by repeat analysis, and a potassium of 6.7, also verified by repeat analysis. During an interview on 12/12/2023 at 9:20 AM with Staff D, APRN. Staff D said she is a medical, family nurse practitioner. Staff D, APRN disclosed that it was brought to her attention that Patient #3 had dialysis access. That was the first time that she saw the patient. Staff D, APRN said she had not reviewed his record yet. Staff D, APRN said she knew Patient #3 could not be in that facility with the dialysis catheter because this hospital had no way to maintain it. Staff D, APRN said she looked at his last dressing change and it was dated November 14th. He needed flushes and dressing changes and maintenance. During an interview on 12/12/2023 at 10:05 AM with Staff C, PA (physician’s assistant), Staff C said she documented Patient #3’s History and Physical. She doesn’t recall that he had dialysis access. During a follow up interview with Staff C, PA on 12/12/2023 at 11:10 Staff C, PA said her assessment doesn’t include removing their clothes. Whatever she can see. During a telephone interview on 12/12/2023 at 1:23 PM with the CMO (Chief Medical Officer), he said the medical staff look at the patients’ labs and should have seen that [abnormal results] in his labs. They may have thought he was finished with dialysis. The hospital does not take care of patients who are getting dialysis. During a telephone interview on 12/12/2023 at 5:16 PM with Staff E, APRN (Advanced Registered Nurse Practitioner), Staff E said she was not sure if the hospital had any medical exclusions for admission. Stat medical orders would be completed by the next day. The lab usually calls with critical results. They would call the nurse on the unit. They are also supposed to fax the results. Critical results should be called to a nurse or provider. But the medical staff look when they come in.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 36678 Based on medical record review, interviews, and policy review the hospital failed to ensure the identification of care needs for a dialysis patient prior to admission, after admission, and during the hospitalization, for one patient (#3) of three patients sampled for transfer to a higher level of care. Findings included: A review of the sending hospital referral dated 11/02/2023 revealed Patient #3 needed to be discharged to an inpatient psychiatric hospital with hemodialysis capabilities, for continuation of dialysis Tuesday, Thursday, and Saturday for major depressive disorder with suicidal ideation and attempt. Review of the sending hospital documentation in Patient #3’s record, revealed a nephrology assessment and plan dated 11/15/2023: patient making minimal urine at this time continue HD (hemodialysis) Tuesday, Thursday, Saturday. S/P (status post) tunneled HD catheter. Further review of the sending hospital documentation dated 11/17/2023 reflected a physician progress note CM (case management) to help with outpatient HD. Needs inpatient psychiatry and HD capabilities. Review of the medical record for Patient #3 reflected he was transferred from an acute care hospital on 11/17/2023, for inpatient psychiatric treatment. A review of the nursing admission assessment entered by Staff A, RN (Registered Nurse) reflected a “dialysis port” was present on Patient #3’s right upper chest. The nursing admission note dated 11/18/2023 12:50 AM reflected “patient is a dialysis patient”. Further review of the record revealed a care plan was started 11/18/2023 at 1:05 AM. The care plan did not reflect the presence of a dialysis access site. Review of nursing documentation from 11/18/2023 to 11/22/2023 revealed no other documentation related to the dialysis access site, nor any notification to a provider of the presence of the dialysis access, until 11/23/2023, six days after Patient #3 was admitted. Review of an order entered by Staff D, APRN dated 11/23/2023, reflected transfer to medical hospital for dialysis access removal. A review of nursing notes dated 11/23/2023 revealed Patient #3 was transported to hospital for dialysis access removal. Documentation in nursing notes the same day at 6:30 PM reflected Patient #3 was admitted to ICU for stat (immediate) dialysis. During an interview on 12/11/2023 at 1:25 PM with the RM (Risk manager), the RM said she was told Patient #3 was not on dialysis. “That would be exclusionary criteria.” She reported that Nursing staff said the patient was being sent to the acute care hospital for dialysis port removal, but they kept him for dialysis. The RM said she was going to talk to the nurse, because they don’t accept this kind of patient and they should be letting them know and escalating it up the chain of command. Usually, intake identifies that, and it wouldn’t even make it to the floor. Intake does the exclusion form, and they get a nursing verbal report and review the hospital record for orders. During an interview on 12/11/2023 at 2:30 PM with Staff H, Director of Admissions, Staff H said the nurse reviews the hospital record. “We would deflect. We don’t take dialysis patients. We ask if they have ports or other medical devices. If they say no, we accept them. I heard his dialysis was completed, and the port needed to be removed. Medical is supposed to review the chart. I didn’t hear he had dialysis orders.” During an interview on 12/12/2023 at 9:20 AM with Staff D, APRN (Advanced Practice Registered Nurse), Staff D said she is a medical, family nurse practitioner. Staff D, APRN disclosed that it was brought to her attention that Patient #3 had dialysis access. That was the first time that she saw the patient. Staff D, APRN said she had not reviewed his record yet. Staff D, APRN said she knew Patient #3 could not be in the facility with the dialysis catheter because the hospital had no way to maintain it. Staff D, APRN said she looked at Patient #3’s last dressing change and it was dated November 14th. Staff D, APRN said she involved the supervisor because the hospital could not maintain his line. He could not be here. During an interview on 12/12/2023 at 10:26 AM with the Chief Nursing Officer (CNO), the CNO said Patient #3’s record was reviewed and identified he had a port. That’s why he went to the hospital. “We reviewed the nursing process to see where the problem was. The staff need to escalate when they find a port because we don’t take patients with ports. The port was identified on admission. If they make it through admissions with the port, it should have been identified and escalated. The assumption is they are cleared from a medical facility, and we accept them based on that clearance. He never should have been accepted.” During a telephone interview with Staff A, RN on 12/12/2023 at 2:52 PM, Staff A said she put the patient in the medical consult book for the nurse practitioner to review. She was not sure if she had put the reason. She said she gave report to the next nurse. Staff A, RN said it was the first time she had a patient with a dialysis port. “Usually if they come with something like that, we send them back to the hospital, pending review by the nurse practitioner.” A review of the medical consult book for the dates of 11/17/2023 to 11/18/2023 revealed no entry for Patient #3. Review of the policy, Medical Exclusionary Guidelines, last review, 7/20/2023, revealed: Purpose: To prevent the presentation for admission of individuals with the following conditions ... 2. Chronically physically ill individuals who require clinical services not available or not appropriate to provide in a free-standing psychiatric hospital. Appropriate identification of individuals in each of the above categories prior to referral and presentation for admission allows that individual to be referred to a more appropriate treatment setting ... Policy All patients will be medically screened to ensure that North Tampa Behavioral Health has the competency to appropriately treat psychiatric and medical conditions concurrently. NTBH uses a four-tier approach to allow all intake staff to accurately vet referrals for appropriateness. Procedure Medical exclusionary guidelines The following four tier medical exclusionary guideline information is to be applied when considering persons for referral to NTBH who present with known or suspected medical conditions ... If questions or concerns arise contact the director of admissions or designated administrator to discuss the appropriateness of accommodation or alternative placement options. Individuals referred that are medically inappropriate or unstable will be followed up by NTBH with the referring facility. Tier 4 Patients in this category have been determined by the medical staff to be outside the capability to provide care for in the facility ...hemo or peritoneal dialysis.”

“Provisional or Admitting Diagnosis CFR(s): A provisional or admitting diagnosis must be made on every patient at the time of admission, and must include the diagnosis of intercurrent diseases as well as the psychiatric diagnosis. This Standard is not met as evidenced by: 36678 Based on review of facility documents, medical records and interviews, the facility failed to ensure a provisional or admitting diagnosis made included the diagnosis of intercurrent diseases and psychiatric diagnosis at the time of admission, for one patient (#3) of three sampled, resulting in delayed care requiring transfer to a higher level of care for life saving treatment. Findings included: Review of the facility Medical Staff Rules and Regulations showed that admission to the facility a history and physical examination to be performed by a practitioner with clinical privileges to perform such tasks ...The following shall be included in the documentation ...review of systems, physical examination ... Review of the sending acute care hospital documentation in Patient #3’s record, revealed a nephrology assessment and plan dated 11/15/2023: patient making minimal urine at this time continue HD (hemodialysis) Tuesday, Thursday, Saturday. S/P (status post) tunneled HD catheter. Further review of the sending hospital documentation dated 11/17/2023 reflected a physician progress note CM (case management) to help with outpatient HD. Needs inpatient psychiatry and HD capabilities. Review of the medical record for Patient #3 reflected he was transferred from an acute care hospital on 11/17/2023 for inpatient psychiatric treatment. A review of the nursing admission assessment entered by Staff A, RN (Registered Nurse) reflected a “dialysis port” was present on Patient #3’s right upper chest. (A central venous catheter, also known as dialysis line, or port is a flexible, hollow tube inserted into a large vein in the chest, close to the heart which allows dialysis to occur. Dialysis is a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly by diverting blood to a machine to be cleaned.) The nursing admission note dated 11/18/2023 12:50 AM reflected “patient is a dialysis patient”. Review of medical staff documentation reflected documentation of an H and P (History and Physical Examination) dated 11/18/2023, entered by Staff C, PA (Physician’s Assistant). Diagnoses listed were Hypertension, HLD ( Hyperlipidemia), Diabetes Mellitus, Diarrhea, and MDD rec severe w/o PF (Major depressive disorder, recurrent, severe, without psychotic features). There was no documentation that Staff C, PA was aware of Patient #3’s dialysis access site located in his right upper chest, had kidney failure, or that she was aware Patient #3 needed dialysis, as documented by the transferring hospital physician. A review of lab results for Patient #3 dated 11/20/2023 and a report date of 11/22/2023, showed a CMP (complete metabolic panel) was completed. The report documented the results were verified by repeat analysis, and that the specimen was received hemolyzed (breakdown of the red blood cells) and the value may be increased, clinical correlation indicated. The report reflected a Creatinine of 12.7 mg/dl (normal is 0.76-1.27mg/dl), and was marked as high, and a potassium level of 6.1 mmol/L (normal is 3.5-5.2mmol/L), marked as critical. Staff E, APRN (Advanced Practiced Nurse Practitioner) noted the lab report and ordered stat (immediate) labs to repeat a creatinine, potassium, CMP, and EKG (electrocardiogram-a test that looks at the electrical activity of the heart). A review of nursing notes dated 11/23/2023 revealed Patient #3 was transported to an acute care hospital for dialysis access removal. Documentation in nursing notes the same day at 6:30 PM reflected Patient #3 was admitted to ICU for stat (immediate) dialysis. During an interview on 12/12/2023 at 10:05 AM with Staff C, PA (physician’s assistant), Staff C said she documented Patient #3’s History and Physical. She doesn’t recall that he had dialysis access. During a follow up interview with Staff C, PA on 12/12/2023 at 11:10 Staff C, PA said her assessment doesn’t include removing their clothes, it inlcudes whatever she can see without disrobing the patient.”