Riverwoods Behavioral Health System

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 47718 Based on review of medical records, policies and procedures, staff interviews, and observations, it was determined that the facility failed to ensure that 1 (P1) of 4 (P1, P2, P3, and P4) patients reviewed received care in a safe setting. Specifically, the facility’s staff failed to provide P1 with a knee brace as per order after P1 was involved in a patient-to-patient altercation on 08/09/2026 and reported pain and swelling to her left knee while attempting to move away from the other patient. This resulted in P1 not receiving the prescribed intervention for her documented knee injury, which was inconsistent with the facility’s responsibility to protect and promote patient rights and ensure patients receive care in a safe setting. Findings included: A review of Patient (P)1’s medical record revealed that P1 was admitted involuntarily (1013) on 08/04/2026 to the facility’s 1North (1N) unit. A review of the nursing note on 08/05/2026 at 08:59 A.M. revealed that P1 stated she did not feel safe and would like to move to another unit because she received a verbal threat from another patient. Documentation revealed that P1 also stated that another patient tried to intimidate her and made her uncomfortable by touching her. A review of the order listing report revealed an order on 08/07/2026 at 9:09 A.M. to transfer P1 to the 2 South (2S) unit when a bed was available, a more appropriate unit for P1 ’ s clinical presentation as per the provider’s recommendation. Documentation failed to reveal that P1 was transferred to the 2S unit. A continued review of the order listing report revealed another order on 08/09/2026 at 10:51 A.M. to transfer P1 to the 3West (3W) unit. A review of the nursing progress notes electronically signed on 08/09/2026 at 10:53 A.M. revealed that P1 was in the dayroom and another patient hit P1 on the head with her hand. Documentation revealed that P1 denied injury, and the staff immediately separated the patients, and P1 was ordered to transfer to another unit for her safety. A review of the medical consultation report on 08/09/2026 at 06:00 P.M. revealed that P1 reported she was sitting at the nurses’ station earlier in the morning when another patient punched her in the left face (cheek and temple) in the 1N unit. Documentation revealed that P1 reported she stood up to get away and turned, twisting her whole body, and felt pain in her left knee. Documentation revealed that the left kneecap had some pain and swelling, with an unlikely fracture. Recommendation included RICE (Rest, Ice, Compress, and Elevate): start a compression knee brace, ice as needed, and elevate the leg when seated. Documentation also revealed P1 was in the 3W unit at the time of the evaluation. A continued review of the order listing report on 08/09/2026 at 06:56 P.M. revealed an order for a compression knee brace to be worn on the left knee while ambulating. Documentation also revealed a request to check if P1 ’ s family could bring the knee brace; otherwise, the facility’s staff/pharmacy was to provide it. The indication was for left knee pain/injury. Documentation failed to reveal that P1 was provided with the knee brace. P1 was discharged on 08/11/2026 at 01:00 P.M. A review of the facility’s “ Process Improvement Program, “ last revised 1/2026, revealed that the facility is dedicated to providing measurement-based, quality care and services for all patients in a safe, clean, and therapeutic environment. A review of the facility’s policy titled “ Change in Condition - Notification, “ policy #18831396, last approved 02/2026, revealed that the process for recognizing and responding as soon as a patient’s condition appears to be worsening or when there are refusals of care shall be established. A review of the facility’s policy titled “ Patient Rights, “ policy #20211086, last approved 05/2026, revealed that the hospital protects and promotes patients’ rights that are extended to all patients and prohibits discrimination. It is the policy of the hospital to ensure that patient rights are communicated to all patients, their legal guardians, and employees to avoid any misunderstanding of those rights, and to provide a list of patients’ rights to all patients or their legal guardians upon admission. . A review of the facility’s policy titled “ Nursing Standards of Care, “ policy # NR-007, last revised 11/2019, revealed that it is the policy that all patients admitted to the facility will have their nursing care delivered in accordance with established standards of care and practice. The nursing basis for providing care is built on the recognition and identification of actual potential health problems that are within the scope of nursing practice. The Registered Nurse uses the activities of daily living in a good, directed way to foster adequate self-care and physical and mental well-being of clients. Respect and protect the patient’s rights. The patient will remain safe from self-inflicted harm or injury. DQ AA sent an email notification on 09/02/2026 at 01:41 P.M. stating that she reached out to corporate, and she could confirm that the facility did not have a policy that specifically addressed obtaining medical supplies/equipment. A telephone interview was conducted in the facility’s boardroom on 09/01/2026 at 11:15 A.M. with Behavioral Health Associate (BHA) FF, who stated that P1 was irritated for some reason and was cussing at her (BHA FF). BHA FF stated she requested from her supervisor if she could go to another unit because P1 targeted her and kept cussing whenever she rounded on her (P1), but she (BHA FF) could not be moved to avoid staffing issues. BHA FF stated that she tried to remain in proximity to P1 for safety and observation when she noticed another patient (P2) was targeting P1 and even separated their room to be far apart; however, P2 had come directly from her room and punched P1 in the back of the head, while P1 was by the medication window. BHA FF stated that other staff members had promptly intervened and de-escalated the situation. BHA FF stated that P1 was assessed by the nurse and there were no visible injuries or bleeding. A telephone interview was conducted in the facility’s boardroom on 09/01/2026 at 12:30 P.M. with Physician Assistant (PA) GG, who stated that she got a consultation to go see P1 regarding her knee. PA GG stated that P1 had reported to her that she felt some pain when she tried to get up from the chair after having an altercation with another patient (P2). PA GG continued to state that she assessed and evaluated P1 and nothing appeared broken; even though there was some swelling, it appeared to be just a sprain. PA GG stated that she recommended ice, ibuprofen, rest, elevation, and a knee brace for compression for additional support. PA GG stated that the facility did not stock the knee brace, so it was recommended that the family could get one over the counter, but it seemed P1 was discharged home before the knee brace could be provided. An interview was conducted in the facility’s boardroom on 09/01/2026 at 12:45 P.M. with BHA HH, who stated that P1 was transferred from the 1N unit to the 3W unit for safety and because she was ok for the most part. BHA HH stated that the 1N unit was more for acute cases, and the plan was to transfer P1 to another unit, so when the incident with P2 occurred in the 1N unit, it expedited the transfer process. BHA HH stated that he did not personally witness any incidents involving P1.”

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 49224 Based on medical record review, facility policy and procedures, and staff interviews, it was determined that the facility failed to confirm and relay necessary patient medication information to a patient ’ s follow-up treatment facility. Specifically, the facility failed to ensure that one patient (P) (P1) of four (P2, P3, P4) patient ’ s medication reconciliation report was complete for the continuity of care of P1 upon discharge. P1’s medical record failed to reveal that P1 received a one-time dose of a long-acting injectable psychotropic medication prior to discharge. Findings included: A review of medical records revealed that P1 was admitted to the facility on 02/23/2026 at 5:36 PM and diagnosed with schizoaffective disorder, bipolar (a mental health condition that combines symptoms of hallucinations and delusions with mood disorder symptoms). Medical record for P1 failed to reveal the date and time that the long-acting injection of Paliperidone Palmitate (Invega Sustenna) - LAI (long-acting injection) (used to help manage symptoms) was administered. P1 ’ s medical record failed to reveal the last administered dose of Invega Sustenna. A review of a facility policy titled “ Discharge Planning, “ number 19349993, effective 12/2025 revealed discharge care plan components included a final diagnosis, where the patient will live following discharge, the level of care which the patient will be discharged to, a listing of all medications that the patient was to continue taking after discharge and patient ’ s method for obtaining medications. all professionals who will follow-up with the patient, including medical follow-up to monitor medications, referrals to self-help groups, support groups, or community resources. The continuing care plan must address discharge medications, dosage and indication for use or that no medications were ordered at discharge. A review of a facility policy titled “ [Template] Medication Administration and Documentation, “ number 17970745, effective 7/2025 revealed a complete medication order included the name of the drug, the dosage and frequency of administration, the route, rationale, date, time, and signature of the prescriber. The patient ’ s medical administration record was checked for accuracy to verify the patient, medication, dosage, route, frequency, and stop date. Medication administration documentation process included to chart the time the medication was given to include the injection site. All medications were charted on the medication administration record immediately following administration. The signature of the nurse must include the initials, surname, and nursing category. A review of a facility policy titled “ Transcription of Physician Orders, “ number IM-044, effective 05/2006 revealed the registered or licensed practical nurse was responsible to ensure there was a valid, complete medication/treatment order from an authorized prescriber prior to the administration of any prescriptive or non-prescriptive medication or the implementation of a medical intervention/treatment. The licensed nurse shall review the orders and all accompanying documents and signify verification of accuracy with signature, date, and time on the order form prior to implementation of the orders. Licensed nursing staff was responsibility for implementation of physician orders. An interview was conducted with the Director of Quality (DQ) AA on 03/23/2026 at 4:30 PM in the conference room. DQ AA stated she was aware of the complaint that involved discrepancies in medication administration to P1 that was not documented. An interview was conducted with Registered Nurse (RN) CC on 03/24/2026 at 10:16 AM in the conference room. RN CC stated an order was placed to give P1 a long-acting injection of medicine to last thirty days. She said P1 was to receive the medication prior to discharge. She said she was the Charge Nurse on the day that RN EE told her that she administered the medication to P1. RN CC stated RN EE did not document that the medication was administered and RN CC stated she was not aware of this until after P1 was discharged. She said that she suspected there was an error with the order or the ability to enter the documentation into the EMR. An interview was conducted with RN DD on 03/24/2026 at 11:03 AM in the conference room. RN DD stated she was the facility ’ s Nurse Manager. She said she became aware of a grievance the facility received from P1 ’ s receiving care team from the written grievance and from Chief Nursing Officer (CNO) GG. She said P1 ’ s receiving care team had concerns that needed clarification that revolved around the medication dosages that P1 received while hospitalized and the medication dosages that needed to continue after discharge. She further stated she was aware that documentation failed to show that P1 received the long-acting injectable medication prior to discharge. However, RN DD stated she spoke with RN CC and RN EE regarding this and that both nurses stated the medication was given. She said an internal investigation was conducted and found that the medication was confirmed with pharmacy to have been signed out and delivered to P1 ’ s unit to be administered to P1. RN DD stated she believed the nurses when they told her the medication was given. She said she educated the nurses regarding the importance of communication and documenting their work, especially medication administration. RN DD stated it was important for P1 ’ s care team after discharge to know about the medications P1 received during hospitalization and at discharge for purposes of continuity of care. RN DD stated a nurse ’ s meeting was scheduled for 03/30/2026 regarding medication administration and adhering to doctor orders. An interview was conducted with RN EE on 03/24/2026 at 11:35 AM via telephone. RN EE stated she was the medication nurse on P1 ’ s floor. She said the doctor ordered an injectable medication to be administered to P1 prior to his discharge. She said she was aware there had been an order given to staff on the previous shift to give P1 the medication and the medication had already been delivered to the floor by pharmacy. She said the order had timed out within the electronic medical record (EMR), and a new one-time order was needed to document that the medication was administered. RN EE stated she communicated with RN CC regarding this, and RN CC was to place a new order with the pharmacy ’ s confirmation. She said she didn’t know whether pharmacy had confirmed the order for the medication. RN EE stated she administered the injectable medication to P1 but did not document the administration because there was no place in the EMR to annotate the information and she said she didn’t follow up because she became busy with other patients. RN EE stated that in hindsight, she would not have given the medication before she saw the order re-entered into the EMR. She said she understood how important it was for a patient ’ s medications to be documented into their record for the purposes of continuity of care while hospitalized and after discharge. An interview was conducted with Nurse Practitioner (NP) FF on 03/24/2026 at 12:01 PM in the conference room. NP FF stated she spoke with P1 ’ s post discharge treatment team via telephone after P1 ’ s discharge regarding clarification concerning medications. She said she spoke to a nurse practitioner and the medical director on P1 ’ s treatment team regarding the reduction of P1 ’ s medication dosages. NP FF further stated she wrote prescriptions annotating the change in P1 ’ s medication with P1 ’ s discharge information and communicated to P1 ’ s treatment team that P1 ’ s dosage of medication was lowered so that P1 would not be on so many sedative medications. NP FF stated she was aware that P1 ’ s treatment team had concerns whether P1 received the long-acting injectable medication before discharge because it wasn’t documented in P1 ’ s record that he received it. She said the long-acting injectable medication was a one-time dose that lasted for thirty days and that she sent the prescription for the next dose to P1 ’ s discharged treatment team with the next dose due on 03/26/2026. An interview was conducted with Chief Nursing Officer (CNO) GG on 03/24/2026 at 12:33 PM in the conference room. CNO GG stated she had been the CNO since December of 2026. She said she was aware the facility received a call from P1 ’ s post discharge treatment team regarding clarification on medications for continuity of care. She said she understood RN CC and RN EE were responsible to ensure P1 received some medication prior to discharge. She said RN CC and RN EE stated that medication was administered but it was not documented. She said she educated RN CC and RN EE on the importance of documenting their work and for P1 ’ s continuity of care at discharge. She said she spoke with someone from pharmacy and confirmed that the injectable medication administered to P1 had been signed out for P1 and recorded as sent to P#1 ’ s unit. CNO GG stated the non-documentation for the medication administration was an anomaly since her tenure at the facility.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 49398 Based on a review of the EMTALA Log, medical records, Medical Staff Bylaws, policy and procedures, and staff interviews, it was determined that the facility failed to: 1. Based on a review of medical records, Emergency Department Logs, Medical Staff Bylaws, facility policy and procedures, and staff interviews it was determined that the facility failed to provide an appropriate medical screening examination (MSE) within the capability of the facility to determine whether or not an emergency medical condition (EMC) exists for five ( P #1, P#2, P#11, P#16, P#18) of 20 sampled patients. Specifically: Medical Screening Examinations were not documented for five (5) (P#1, P#2, P#11, P#16, P#18) of 20 sampled patients that entered the facility seeking psychiatric treatment. Cross-refer to A-2406 as it relates to the facility’s failure to ensure that an appropriate medical screening examination was completed. 2. Based on review of the EMTALA Log, medical records, ‘Rules and Regulations of the Medical Staff’, policies and procedures, and staff interviews it was determined that the facility failed to provide an appropriate transfer by failing to: 1.) ensure that a signed transfer certification based on the information available at the time of the transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual; 2.) provide medical treatment within its capacity to minimize the risks of the individual’s health; 3.) ensure the receiving facility had available space and qualified personnel for treatment of the individual; 4.) ensure the facility had agreed to accept the individual; 5.) send the receiving hospital medical records; 6.) utilize qualified personnel and transportation for one (P#1) of 20 sampled patients reviewed. Specifically: P#1 presented to the facility on 5/19/25 at 7:25 p.m. accompanied by a legal guardian. While in the intake area, P#1 became combative and uncooperative. Facility staff instructed the legal guardian to take P#1 to a local emergency room for a medical clearance. While leaving the facility, the legal guardian had to call local law enforcement for assistance in transporting P#1 to the local emergency department. Cross -refer to A- 2409 as it relates to the facility’s failure to provide an appropriate transfer.”

“HOSPITAL MUST MAINTAIN RECORDS CFR(s): 489.20(r)(1) [The provider agrees,] in the case of a hospital as defined in §489.24(b), (including both the transferring and receiving hospitals), to maintain medical and other records related to individuals transferred to or from the hospital for a period of 5 years from the date of the transfer. This Standard is not met as evidenced by: 49398 Based on review of the EMTALA Log, medical records, policies and procedures, and staff interviews, it was determined that the facility failed to ensure that a medical record was initiated/generated for 11 (P#1, P#5, P#6, P#7, P#8, P#9, P#10, P#13, P#15, P#17, and P#20) of 20 sampled patients that presented to the facility’s Intake Department. Findings Included: During a review of the facility’s EMTALA Log dated 3/1/25 through 5/30/25, the facility was unable to produce medical records for 11 (P#1, P#5, P#6, P#7, P#8, P#9, P#10, P#13, P#13, P#15, P#17 and P#20) of 20 sampled medical records requested. A review of the facility’s policy: “RETENTION, LOCATION and STORAGE”, #: IM-018, last revised, 3/2024, revealed that all medical records for all service lines shall be secured and retained in hard copy and EMR (Electronic Medical Record) format in their entirety. During a follow up interview on 6/3/25 at 1:00 p.m. with the Director of Utilization Review (DUR) DD in a conference room, DUR DD explained that the facility was unable to produce the medical records for 11 (P#1, P#5, P#6, P#7, P#8, P#9, P#10, P#13, P#15, P#17 and P#20) of 20 requested medical records. DUR DD stated that every patient presenting to the facility seeking emergency medical or mental health services should have a medical record, regardless of whether they are admitted, refuse care, or are transported. A review of the facility’s “EMTALA Log” revealed that Patient (P) #1 presented to the facility’s Intake Department and was registered as a patient on 5/19/25 at 7:25 p.m. The facility failed to produce a medical record for P#1. A telephone interview was conducted on 6/4/25 at 12:30 p.m. with Master Level Clinician (MLC) EE. MLC EE couldn’t explain why P#1 didn’t have a medical record. She added that, even though she was unable to conduct an assessment due to his lack of cooperation, she documented the information and believed she had created a file. She acknowledged that there should have been a medical record for P#1. She added that every patient who comes to the facility seeking help should get an MSE and should have a medical record created for the encounter. During an interview on 5/6/25 at 9:30 a.m. with Registered Nurse (RN) HH in a conference room, RN HH stated that every patient should have an account set up in the facility’s electronic medical record (EMR) system without exception. During an interview on 6/5/25, at 10:00 a.m. with Medical Director (MD) BB in a conference room, MD BB noted that every patient who enters the facility should have a medical record on file. MD BB said he found it shocking that 11 patients selected for medical record review did not have a medical record. A telephone interview was conducted on 6/5/25 at 10:30 a.m. with Nurse Practitioner (NP) AA. NP AA stated that all patients who enter the facility should be added to the EMTALA Log but will not get a medical record unless they are admitted. A telephone interview was conducted on 6/5/25 at 11:00 a.m. with Master Level Clinician (MLC) GG. MLC GG said that every patient who comes to the facility should have a medical record created. During an interview on 6/5/25 at 12:36 p.m. with Intake Director (ID) II in a conference room. ID II explained that her expectations of the intake staff were to ensure that every patient who enters the facility seeking treatment was entered the EMTALA Log, triaged, had a medical record created.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 49398 Based on a review of medical records, Emergency Department Logs, Medical Staff Bylaws, facility policy and procedures, and staff interviews it was determined that the facility failed to provide an appropriate medical screening examination (MSE) within the capability of the facility to determine whether or not an emergency medical condition (EMC) exists for five ( P #1, P#2, P#11, P#16, P#18) of 20 sampled patients. Specifically: Medical Screening Examinations were not documented for in for five (P#1, P#2, P#11, P#16, P#18) of 20 sampled patients that entered the facility seeking psychiatric treatment. Findings Included: A review of the ED Log dated 5/19/2025 revealed that Patient #1 arrived to the hospital’s emergency department (ED) at 7:25 PM via car. The patient’s complaint was listed as “Psychiatric”. The section of the ED Log titled “Emergency Medical/Psych condition, “No”. Further review of the ED log revealed that Patient #1 departed the hospital’s ED 10:14 P.M, via Police Car. The patient’s disposition was listed as “Refused/referred for Medical”. The facility failed to provide documented evidence that an medical screening examination was performed. A review of P#2’s medical record revealed that P#2 presented to the facility’s Intake Department on 5/23/25 at 1:15 p.m. with a chief complaint of suicidal thoughts. A review of “INTAKE QUESTIONNAIRE FOR PATIENTS/FAMILIES:” dated 5/23/25, revealed that P#2 checked “areas of concern” for sleep disturbance, tense or nervous feelings, excessive worrying, unwanted thoughts, difficulty concentrating, loss of interest or enjoyment in activities, feelings that others are out to get you, feelings of wanting to harm self, and constant suicidal thoughts. Further review of the medical record failed to reveal evidence of a documented medical screening exam (MSE) for P#2. A review of P#11’s medical record revealed P#11 presented to the facility’s Intake Department on 2/14/25 at 12:40 p.m. with a chief complaint of anxiety (emotion involving feelings of worry, unease, and apprehension), and impulsivity (acting without forethought or consideration of consequences).Continued review revealed that P#11 had a history of anxiety, suicidal ideation (the thought process of having ideas or ruminations about the possibility of dying by suicide), and attention-deficit/hyperactivity disorder (ADHD) (a neurodevelopmental disorder characterized by difficulties with attention, hyperactivity, and impulsivity). A review of the “Intake Assessment” revealed that P#11 denied active suicidal and homicidal ideation, drug, alcohol, or tobacco use. Further review of the medical record failed to reveal evidence of a documented medical screening exam (MSE) for P#11. Continued review of the medical record revealed that Medical Doctor (MD) BB was consulted and recommended that P#11 be discharged and referred to an intensive outpatient program (IOP). A review of P#16’s medical record revealed P#16 presented to the facility’s Intake Department on 3/18/25 at 11:00 a.m. A review of the facility’s “INTAKE QUESTIONNAIRE FOR PATIENTS/FAMILIES,” dated 3/18/25, revealed that P#16 had checked “areas of concern” for appetite change, sleep disturbance, tense or nervous feelings, feelings of anger, difficulty concentrating, and loss of interest or enjoyment in activities. A continued review of the medical record failed to reveal evidence of a documented medical screening exam (MSE). A review of P#18’s medical record revealed that P#18 presented to the facility’s Intake Department on 3/13/25 at 9:30 a.m. with a chief complaint of depression and anxiety. A review of the facility’s “INTAKE QUESTIONNAIRE FOR PATIENTS/FAMILIES,” dated 3/13/25, revealed that P#18 had checked “areas of concern” for marital or relationship stressors, feelings of anger, and crying spells. A continued review of the medical record failed to reveal evidence of a documented medical screening exam (MSE). A review of the facility’s “MEDICAL STAFF BYLAWS OF [the facility],” effective date 6/24/24, revealed; “Exhibit A to the Medical Staff Bylaws of [the facility]” revealed the following are recognized as qualified medical professionals (QMP): physicians, nurse practitioners, physician assistants, and registered nurses. A review of the facility’s policy titled “EMTALA- Compliance”, #: AD-1012, last revised, 2/13/24 revealed that the purpose of the policy was to ensure that all patients that arrive to the facility with medical emergencies were not denied treatment based on any reason other than those that reflect the hospital’s capacity to examine, conduct tests, and treat the emergency condition. POLICY: It was the intent of the facility to provide the following services to all individuals who would present to the facility with a request for examination and/or treatment: a. Appropriate medical screening and assessment would be performed in a non-discriminatory manner. DEFINITIONS & DESCRIPTIONS Assess/Screening: When a patient would arrive at the facility and request examination or treatment of a medical or psychiatric condition, a screening would be completed without delay to determine whether an emergency medical condition existed. A telephone interview was conducted on 6/4/25 at 12:30 p.m. with Master Level Clinician (MLC) EE. MLC EE explained that every patient who comes to the facility seeking help should get an MSE. During an interview on 5/6/25 at 9:30 a.m. with Registered Nurse (RN) HH in a conference room, RN HH stated that an MSE should be conducted on every patient entering the facility, without exception, and it should be added to the patient’s medical record. During an interview on 6/5/25, at 10:00 a.m. with Medical Director (MD) BB in a conference room, MD BB was asked to review P#2, P#11, P#16, and P#18 medical records for a documented MSE. MD BB said he was unable to locate a documented MSE for P#2, P#11, P#16, and P#18. He added that he was shocked that there were no documented MSEs in those patient medical records. He stated that he expects every patient to have an MSE and that it should be documented in the medical record. A telephone interview was conducted on 6/4/2025 at 12:30 P.M., with the Master Level Clinician (MLC) EE. She stated that she was unable to conduct an assessment due to his (Patient #1) lack if cooperation. She added that every patient who comes to the facility seeking help should get an medical screening examination. A telephone interview was conducted on 6/5/25 at 10:30 a.m. with Nurse Practitioner (NP) AA. NP AA was unsure if all patients received an MSE or if it is only required if a patient has a medical concern. A telephone interview was conducted on 6/5/25 at 11:00 a.m. with Master Level Clinician (MLC) GG. MLC GG said that all patients who enter the facility should have an MSE. During an interview on 6/5/25 at 12:36 p.m. with Intake Director (ID) II in a conference room. ID II stated that she is aware of issues of noncompliance in the Intake Department related to EMTALA, medical MSEs, and the overall intake process. The facility failed to ensure that their policies and procedures were followed as evidenced by failing to ensure that an appropriate Medical Screening Examination was provided for P1, P2, P11, P16 and P18, that was within the capability of the hospital’s emergency department to determine whether or not an emergency medical/psychiatric condition existed.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 49398 Based on review of the EMTALA Log, medical records, ‘Rules and Regulations of the Medical Staff’, policies and procedures, and staff interviews it was determined that the facility failed to provide an appropriate transfer by failing to: 1.) ensure a signed transfer certification based on the information available at the time of the transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual; 2.) provide medical treatment within its capacity to minimize the risks of the individual’s health; 3.) ensuring the receiving facility had available space and qualified personnel for treatment of the individual; 4.) ensure facility had agreed to accept the individual; 5.) Send the receiving hospital medical records; 6.) utilize qualified personnel and transportation for one (P#1) of 20 sampled patients reviewed. Specifically: P#1 presented to the facility on 5/19/25 at 7:25 p.m. accompanied by a legal guardian. While in the intake area, P#1 became combative and uncooperative. Facility staff instructed the legal guardian to take P#1 to a local emergency room for a medical clearance. While leaving the facility, the legal guardian had to call local law enforcement for assistance in transporting P#1 to the local emergency department. Findings Included: A review of the facility’s “EMTALA Log” revealed that Patient (P) #1 presented to the facility’s Intake Department and was registered as a patient on 5/19/25 at 7:25 p.m. The facility’s policy: “EMTALA- Compliance”, policy #: AD-1012, last revised, 2/13/24 was reviewed. POLICY: It was the intent of the facility to provide the following services to all individuals who would present to the facility with a request for examination and/or treatment: c. Appropriate transfer of the patient to a facility that had the capability to capacity to provide the treatment necessary to stabilize the emergency medical condition. A review of “Rules and Regulations of the Medical Staff of [the facility],” effective date 5/23/23, revealed: 4.0 ADMISSION TO HOSPITAL 4.1 Patients whose illness was such that they posed a clear and uncontrollable danger to other patients or personnel would not be admitted to the hospital. In an emergency, such patients would be stabilized to the extent possible and, as medically appropriate, transferred to a facility equipped to treat their conditions, in accordance with the hospital’s policies on EMTALA. The medical record where patient #1 was taken on 5/19/25 was reviewed. The medical record revealed the patient arrived at the other hospital on 5/19/2025 at 10:22 P.M. Further review revealed the Chief complaint was listed as “Wellness Check (Taken by DFACS Lakeview Behavioral ... needed medical clearance. Sent here Hx (history) of Behavioral health issues). Behavioral Complaint-Visit Dx (diagnosis) “Mania”(mental illness marked by periods of great excitement, delusion and overactivity). The patient was triaged as a level-2 “Emergent”. Further review of the medical record revealed that patient #1 received an appropriate MSE and a psychological evaluation . The patient was placed on a 1013 ( involuntary mental health evaluation and temporary hold. It is a protective measure used when an individual is experiencing a mental health crisis and poses a substantial, imminent risk of harm to self and others) appropriately transferred to another facility on 5/20/2025 because he required a higher level of care. A telephone interview was conducted on 6/4/25 at 12:30 p.m. with Master Level Clinician (MLC) EE. MLC EE explained that P#1 was an adolescent, standing in the facility lobby with an adult female who introduced herself as a worker with the [State] Division of Family and Children Services (DFCS) worker, as she arrived on shift around 9:00 p.m. on 5/19/25. MLC EE said that she took P#1 to the adolescent intake patient room and spoke with his chaperone in a separate room when she heard loud thuds and bangs coming from P#1’s room. She continued to explain that she observed P#1 climbing up the wall, attempting to elope through the window, and demanding to be released. MLC EE called Nurse Practitioner (NP) AA and explained what was going on with P#1. NP AA explained that P#1 could not be admitted because he needed to be medically cleared to ensure he was not under the influence of drugs or alcohol. MLC EE recalled that she explained to the DFCS chaperone that she needed to take P#1 to an Emergency Department (ED) and be medically cleared by a physician before he could be admitted to the facility. She stated that the DFCS chaperone agreed to drive P#1 to the local emergency department. Once in the parking lot, P#1 refused to get into the DFCS chaperone’s car, and the DFCS chaperone called the local police. MLC EE said she thought P#1 would eventually be brought back to the facility, but he never returned. She was unsure if he ultimately went by emergency medical service (EMS) or if the police took him to the hospital. MLC EE explained that unless a patient is in acute medical distress, when a patient requires medical clearance, they are sent to the local emergency department with whoever brought them to the facility. During an interview on 5/6/25 at 9:30 a.m. with Registered Nurse (RN) HH in a conference room, RN HH explained that if a patient required stabilization prior to transfer, they should be stabilized appropriately, as this facility has some stabilizing capabilities. She stated that patients requiring transfer should have a Memorandum of Transfer (MOT) form completed with their patient information, including date and time, as well as the receiving facility’s information and a staff signature. RN HH added that it was not appropriate to transport patients by private vehicle unless they refuse EMS transfer; in such cases, she would require the patient to complete a refusal form. During an interview on 6/5/25, at 10:00 a.m. with Medical Director (MD) BB in a conference room, MD BB explained that he heard about the encounter with P#1 during a meeting the day after he presented to the facility. He continued to say that it was explained to him that the intake staff told the DFCS worker to transport P#1 to the hospital for a medical clearance. MD BB stated that the staff should not have done that, and they should have initiated a transfer by EMS. MD BB noted that he could not comment on whether P#1 was stable for transfer, as he was not notified of the situation in real-time. A telephone interview was conducted on 6/5/25 at 10:30 a.m. with Nurse Practitioner (NP) AA. NP AA stated that if a patient requires medical clearance, they were sometimes transported by private means or EMS, depending on the situation. A telephone interview was conducted on 6/5/25 at 11:00 a.m. with Master Level Clinician (MLC) GG. MLC GG said if a patient requires medical clearance, MLC GG will arrange EMS transport, complete a MOT form, call the receiving facility’s emergency department, and provide report. MLC GG added that it was acceptable to allow a patient to be sent with whoever brought them to the facility if they were not a risk to themselves or others. During an interview on 6/5/25 at 12:36 p.m. with Intake Director (ID) II in a conference room. ID II stated that she expected staff to secure EMS transport, complete a MOT and notify the receiving facility when a patient required transfer. The facility failed to ensure that an appropriate transfer was provided from Patient #1 on 5/19/2025.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 49224 Based on review of patient intake documentation, Medical Staff Bylaws, Medical Staff Rules and Regulations, facility policy and procedures, and staff interviews, it was determined that the facility failed to provide an appropriate medical screening exam (MSE) within its capability and capacity, including psychiatric services to determine if an emergency medical condition (EMC) existed for five (P#1, P#2, P#3, P#4, P#5) of 20 sampled patients. Specifically, P#1, accompanied by his legal guardian, presented to the facility’s intake desk on 5/15/25 at 1:47 p.m. seeking a psychiatric assessment and left without being seen at 5:51 p.m. On 5/16/25 at 8:59 p.m., P#1 accompanied by his legal guardian, presented to the facility’s intake desk to seek psychiatric assessment. P#1 and legal guardian left the facility at 12:00 a.m. on 5/17/25 without being seen. P#2, P#3, P#4, and P#5 presented to the facility requesting psychiatric services and all left prior to being seen by a Qualified Medical Provider (QMP). Findings included: Cross refer to Tag A-2406 as it relates to the facility’s failure to provide an appropriate medical screening examination to five patients (P#1, P#2, P#3, P#4, P#5).”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 49224 Based on review of patient intake documentation, Medical Staff Bylaws, Medical Staff Rules and Regulations, facility policy and procedures, and staff interviews, it was determined that the facility failed to provide an appropriate medical screening exam (MSE) within its capability and capacity, including psychiatric services to determine if an emergency medical condition (EMC) existed for five (P#1, P#2, P#3, P#4, P#5) of 20 sampled patients. Specifically, P#1, accompanied by his legal guardian, presented to the facility’s intake desk on 5/15/25 at 1:47 p.m. seeking a psychiatric assessment and left without being seen at 5:51 p.m. On 5/16/25 at 8:59 p.m., P#1 accompanied by his legal guardian, presented to the facility’s intake desk to seek psychiatric assessment. P#1 and legal guardian left the facility at 12:00 a.m. on 5/17/25 without being seen. P#2, P#3, P#4, and P#5 presented to the facility requesting psychiatric services and all left prior to being seen by a Qualified Medical Provider (QMP). Findings: A review of P#1’s “Intake Questionnaire “revealed that he presented to facility accompanied by his legal guardian on 5/15/25 at 1:47 p.m. to seek psychiatric services. An ‘Intake Questionnaire’ form, completed and signed by P#1’s legal guardian on 5/15/25 revealed the following areas of concern: - Problems at school (with elaboration): “got caught doing sexual activity in stairwell” - Feelings of anger (with elaboration): “always angry when asked to do something he doesn’t want to do” - Easily annoyed or irritated - Temper Outburst/Destructive Behavior - History of Physical or Sexual Abuse - Suicidal Thoughts - past - Suicide Attempts - 9/5/2023 Continued review of the ‘Intake Questionnaire’ revealed that the event/problem precipitating this request for help was “refuses to listen or take ownership for his actions”. Medical Problems: Sickle Cell trait/Autism. Further review revealed the patient’s mother signed the Georgia Department of Behavioral Health and Developmental Disabilities (DBHDD). Form 1009 & 1012 Application for Voluntary Status (allows the patient to admit themselves for treatment willingly) & Physician Review of Application requesting the patient to be admitted to Riverwoods Behavioral Health. There was no documentation in the medical record to indicate the patient was triaged or seen by a psychiatrist. There was no documentation of an evaluation patient’s mental status. There was no documentation that a suicide screening was performed to determine whether or not he was safe for discharge given the area of concerns listed in the MR. Additionally, there was no documentation the patient was triaged. Further review failed to reveal documentation of an assessment or that a medical screening examination was provided by a QMP. A review of P#2’s ‘Intake Questionnaire” revealed he presented to the facility on 5/15/25 at 3:47 p.m. The section of the form titled “Reason for admission” Sucdie (Suicide -misspelled). Further review of the section of this questionnaire titled Area of Concern revealed the following: Unwanted Thoughts-yes; Difficulty Concentrating: Yes; Alcohol and/or Drug abuse: Yes; Easily Annoyed or irritated: Yes; Temper Outburst/Destructive Behavior- yes; Impulsiveness/Acting without thinking: yes; Feelings that others are out to get you: yes; Seeing or hearing things that others Do not: Yes’ Suicidal Thoughts (past was checked); Suicide attempts (if yes when) yes sucdie (Misspelled-suicide) no date as to when suicide attempt was listed by the patient. What recent events/problems have brought your request for help? Drugs, Alcohol. Medical Problems: High Blood pressure. Do you take your medication as prescribed? Yes. The patient signed the Georgia Department of Behavioral Health and Developmental Disabilities (DBHDD). FORM 1009 &1012 Application for Voluntary Status & Review of Application dated 5.15.25. Further review revealed the patient requested admission to Riverwoods Behavioral Health facility on a voluntary basis. The review revealed the patient was not triaged, and there was no appropriate suicide screening performed. The only vital sign documented was the patient’s temperature . There was no documentation the patient’s blood pressure was taken despite the patient listed on the “Intake Questionnaire” he had a history of high blood pressure. There was no documentation that an appropriate MSE was performed by a QMP. A review of P#3’s “Patient Demographic Sheet” revealed that she presented to the facility on 5/15/25 at 6:43 p.m. accompanied by a parent for ‘hitting siblings’. Per the facility’s Central Log, P#3’s mode of arrival was a walk-in, P#3’s disposition was ‘refused treatment’ and left the facility on 5/15/25 at 8:51 p.m. The “Intake Questionnaire” dated 5/15/2025 for patient #3 was reviewed. The section of the form titled “Area of Concerns” revealed the following: Difficulty Concentrating: ADHD (Attention Deficit Hyperactivity Disorder-most common mental disorders affecting children. Symptoms include inattention, hyperactivity and impulsiveness); Temper Outburst/Destructive Behavior: Breaks stuff and hits siblings; Impulsiveness/Acting without Thinking: Screaming; What recent events/problems have brought about your request for help? Hitting siblings. Medical Problems: ADHD and ODD (Oppositional Defiant Disorder- a behavioral disorder angry or irritable mood, Argumentative and defiant behavior, and Vindictiveness). The patient’s mother signed the Georgia Department of Behavioral Health and Developmental Disabilities (DBHDD). FORM 1009 &1012 Application for Voluntary Status & Review of Application dated 5.15.25. Further review revealed the patient requested admission to Riverwoods Behavioral Health facility on a voluntary basis. Continued review revealed the patient was not triaged.. There was no documentation of a suicide screening was performed, nor that the patient was safe for discharge. There was no documentation in the medical record to indicate that an appropriate MSE was performed. A review of P#4’s “Patient Demographic Sheet” revealed the he presented to the facility on 5/15/25 at 7:46 A.M. Per the facility’s Central Log, P#4’s mode of arrival was a walk-in, P#4’s disposition was ‘refused treatment’ and left the facility on 5/15/25 at 1:39 p.m. The “Intake Questionnaire” dated 5/15/2025 was reviewed. The section of the form titled “Area of Concerns revealed the following: Sleep disturbance, Tense or nervous Feelings, Problems at work, Excessive worrying, Unwanted Thoughts, Difficulty Concentrating, Crying Spells, Loss of Interest/Enjoyment in Activities, Easily Annoyed or irritated. What recent events/problems have brought about your request for help? Panic Attack, anxiety, cannot sleep eat. Medical Problems: Fell like cannot breathe, back and seizure. The patient signed the Georgia Department of Behavioral Health and Developmental Disabilities (DBHDD). FORM 1009 &1012 Application for Voluntary Status & Review of Application dated 5.15.25. Further review revealed the patient requested admission to Riverwoods Behavioral Health facility on a voluntary basis. Further review revealed the patient was not triaged, the only vital signs were obtained was the patient’s temperature. Continued review revealed there was no suicide screening performed by facility staff to ensure the patient safe for discharge. There was no documentation in the MR to indicate the patient received an appropriate MSE by a QMP. A review of P#5’s “Patient Demographic Sheet” ’ revealed that P#5 presented to the facility on 1/7/25 at 11:54 A.M. Per the facility’s Central Log, P#5’s mode of arrival was a walk-in, P#5’s disposition was ‘refused treatment’ and left the facility on 1/7/25 at 12:42 p.m. The “Intake Questionnaire” dated 1/7/2025 was reviewed. The section of the “Intake Questionnaire” titled “Areas of Concerns” were listed as: Appetite Change, Sleep Disturbance, Excessive worrying, Difficulty Concentrating, Crying Spells, Alcohol and/or Drug Use/Abuse, History of Physical or Sexual Abuse, Feelings that Others are out to get You, Seeing or Hearing Things that other Do Not, Feelings of Wanting to Harm Self. The patient signed the Georgia Department of Behavioral Health and Developmental Disabilities (DBHDD). FORM 1009 &1012 Application for Voluntary Status & Review of Application dated 01/07.2025. Further review revealed the patient requested admission to Riverwoods Behavioral Health facility on a voluntary basis. The patient was not triaged, no documentation that a suicide screening was performed to ensure the patient was safe for discharge given the areas of concerns that were checked off. There was no documentation in the MR to indicate the patient received an MSE by a QMP. A review of the Medical Staff Bylaws effective 6/24/24, Preamble revealed that the facility’s purpose was to strive for quality treatment, the medical staff must work with and be subject to the authority of the Governing Board, and the cooperative efforts of the Medical Staff, the administration, and the Governing Board were necessary to provide quality care. Exhibit A to the Medical Staff Bylaws of Facility revealed a Qualified Medical Personnel (QMP) as a Physician, Nurse Practitioner, Physician Assistant, and Registered Nurse. A review of the Medical Staff Rules and Regulations, effective 5/23/23 revealed 4.7 Appendices, The Psychiatric Evaluation and Mental Status Exam was performed by a physician or nurse practitioner. A review of the policy titled, “Pre-Admissions Screening”, number AD-1001, last revised 2/13/24 revealed that the purpose of the Admissions Screening was to determine the proper level of care for inpatient and outpatient services at the facility. The admissions screening consisted of completion of an admissions assessment. Determination was made whether the patient met admission criteria. If the patient did not meet admission criteria, intake staff consulted attending physician so that an appropriate disposition could be made. If the prospective patient was not willing to undergo a screening and/or refused voluntary admission to the facility, staff reviewed the Triage Questionnaire to determine if further intervention was needed and consulted with the physician if necessary. If the patient did not experience a psychiatric emergency, then Facility staff would provide the patient with a list of alternative mental health resources prior to departure. A review of the policy titled, “EMTALA Compliance”, number AD-1012, last revised 2/13/24 revealed the purpose was to ensure that all patients that arrived at the Facility with medical emergencies were not denied treatment based on any reason other than those that reflect the hospital’s capacity to examine, conduct tests, and treat the emergency condition. It was the intent of the Facility to provide to all individuals who presented to Facility with a request for examination and/or treatment an appropriate medical screening and assessment in a non-discriminatory manner, stabilizing treatment that was within the capacity/competency of Facility for emergency medical conditions such as, but not limited to intoxication, suicidal and/or homicidal thoughts or gestures, and severe symptoms or withdrawal from drugs and/or alcohol; or appropriate transfer of the patient if Facility did not have capability or capacity to provide the treatment necessary to stabilize the emergency medical condition. The procedure was that when a patient arrived at Facility and requested examination or treatment of a medical or psychiatric condition, a screening would be completed without delay to determine whether an emergency medical condition existed. The screening would be conducted by qualified medical personnel (QMP), trained to identify emergency medical conditions, a resident physician, or an attending physician. If a patient refused examination, treatment, or transfer, the facility would obtain written and informed refusal of examination, treatment, or appropriate transfer. An interview was conducted with Counselor CC on 6/3/25 at 9:40 a.m. She said the facility’s practice was to assess all patients to determine whether they were experiencing a crisis. An interview was conducted with Intake Director (ID) AA on 6/4/25 at 9:57 a.m. ID AA stated that when a patient walked into the facility for services, the patient or their family member would need to verbally tell the receptionist that the patient was suicidal or homicidal or annotate that they were suicidal or homicidal on the Intake Questionnaire so that the information was immediately communicated to the Counselor for an immediate patient assessment. She said patient cases, including walk-ins, were prioritized in accordance with the needs of the patient and that the counselor made the decision regarding the order in which patients were seen. She said the counselor initiated the registration, obtained consent for examination, and conducted an assessment. She further explained that the registered nurse initiated the patient’s medical screening exam, and the psychiatrist completed it and determined the appropriate level of care. There was no documentation in the medical records to indicate that Patient #1, Patient #2, Patient #3, Patient #4 or Patient #5 medical screening examinations were initiated by a registered Nurse. Additionally, a psychiatrist did not complete the MSE to determine the appropriate level of care for Patient #1, Patient #2, Patient #3, Patient #4 and Patient #5. Patient #2 documented on the Patient Questionnaire form his reason for admission was “Suicide”, there was no documented evidence that this information was immediately communicated to the Counselor for an immediate patient assessment of his complaint of feeling suicidal. The facility failed to ensure that appropriate Medical Screening Examinations within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department to determine whether or not emergency psychiatric conditions existed for Patient #1, Patient #2, Patient #3, Patient #4 and Patient #5.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 49398 Based on review of medical records, video surveillance, policy and procedures, and staff interviews, it was determined that the facility failed to ensure that the rights of patients were protected and promoted for three patients (P) (P#1, P#2, P#4) of four patients reviewed. Findings included: Cross- refer to A0144 as it relates to the facility’s failure to provide care for in a safe environment for P#1 and P#2. Cross -refer to A0385 as it relates to the facility’s failure to ensure that nursing services adhered to the facility’s policy and procedures related to restraints and seclusion for P#1 and P#4.”

“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: 49398 Based on a review of medical records, video surveillance, facility policies and procedures, and staff interviews it was determined that the facility failed to ensure the following: 1. Patient observation/monitoring was conducted as ordered and per facility policies for two (P#1 and P#2) of four sampled patients (P#1, P#2, P#3, P#4). 2. Signed physician’s order for seclusion and physical restraint was documented for two patients (P#1 and P#4) of four (P#1, P#2, P#3, and P#4) sampled patients. Findings included: Cross -refer to A 0144 as it relates to the facility’s failure to provide care to the patient in a safe setting when P#1 and P#2 were not visually observed as ordered. Cross -refer to A 0398 as it relates to staff failure to adhere to policy and procedures related to restraints and seclusion for P#1 and P#4.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 49398 Based on review of medical records, video surveillance, policy and procedures, and staff interviews, it was determined that the facility failed to ensure that patients received care in a safe setting for two patients (P) (P#1, P#2) of four patients reviewed. Specifically, video surveillance revealed that P#1 and P#2 were in a patient room with the door closed for approximately 46 minutes without a staff member opening the door to conduct visual observation. Further, P#1 had an active order for peer restriction and a blocked room (restricted from having a roommate), both patients (P#1 and P#2) were ordered to be observed at a minimum of every 15 minutes. Findings included: 1. A review of P#1’s medical record revealed that he was admitted to the facility on 4/29/25 with a diagnosis of disruptive mood disorder (a condition in which children or adolescents experience ongoing irritability, anger, and frequent, intense temper outburst) and oppositional defiant disorder (a behavioral condition characterized by a pattern of uncooperative, defiant, and hostile behavior toward authority figures). A review of a “Progress Notes ,” dated 4/30/25, a Registered Nurse (RN) note revealed that staff received complaints from patients about inappropriate behavior exhibited by P#1 including telling a female patient on the unit that he would “come to her room at night and do things to her”. “Progress note” additionally revealed that P#1 also made “inappropriate comments.” A review of “Physician Orders” revealed that a peer restriction order and sexually acting out (SAO) precaution order was entered on 4/30/25, and signed 5/1/25 at 8:11 p.m. A review of “Physician Orders,” dated 5/1/25, revealed an order for observations to be conducted every 15 minutes. A review of “Physician Orders,” dated 5/2/25 at 10:30 a.m., revealed an order for P#1 to be on a blocked room (cannot have roommates). A review of “Progress Notes,” dated 5/2/25 at 11:33 p.m., revealed that during reflection time, a patient stated that P#1 sexually assaulted him. The nurse called the Medical Director (MD) AA who gave an order for a blocked room and sexual abuse precautions. P#1 was asked if he wanted to speak with a counselor, to which he replied, ‘no’. A review of “Progress Notes,” dated 5/3/25 at 11:44 p.m., revealed that that a house supervisor contacted Registered Nurse (RN) BB that P#1 was alleging that he was sexually abused by P#2. The supervisor advised RN BB to call and get a transfer order to have P#1 transferred for a medical evaluation . A review of the “EMTALA Memorandum of Transfer-[Facility],” dated 5/3/25, revealed that on 5/4/25, at 4:00 a.m., P#1 was transferred by Emergency Medical Services (EMS) to a local facility for a medical assessment. 2. A review of P#2’s medical record revealed a “Progress Note” dated 5/2/25 at 9:49 p.m. by RN DD that during reflection time, P#2 came out of his room and reported that his roommate (P#1) sexually assaulted him. RN DD notified Medical Doctor (MD) AA, who gave the order to block P#2’s room and to place P#2 on a precaution for sexually acting out (SAO). RN DD offered, and P#2 accepted to speak with a counselor. RN DD notified the Chief Nursing Officer (CNO) and the Administrator On-Call (AOC). An order was given to transfer P#2 to an emergency room (ER) for an assessment. RN DD notified P#2’s case manager (CM). A review of an “Emergency Medical Treatment and Labor Act (EMTALA) Memorandum of Transfer,” dated 5/2/25 at 11:18 p.m., revealed that P#2 was transferred via Emergency Medical Services (EMS) to an outside hospital for rectal bleeding. A review of a “Progress Note,” dated 5/3/25 at 4:03 p.m., revealed that a Registered Nurse (RN) contacted the receiving facility for P#2 and was informed that P#2 would not be returning to the facility. The receiving facility representative confirmed that a rape kit had been collected. The RN updated the Chief Nursing Officer (CNO), Risk Management, and Medical Doctor (MD) AA. A review of a Discharge Summary dated 5/6/25 at 7:20 a.m. revealed that P#2 was transferred from the facility to an outside facility emergency room (ER) on 5/2/25 for complaints of rectal bleeding. Continued review revealed that on 5/4/25 at 2:00 p.m., P#2 was discharged from the facility due to being transferred and that P#2 would be sent to different facility for continuation of treatment. A review of the facility’s security video footage dated 5/2/25, beginning at time-stamped 5:44 p.m., revealed a hallway with P#1 and P#2’s room #312 on the left side and the nurses’ station across the right side of the hallway. P#1 and P#2 were identified and observed to be walking together back and forth from their room to the hallway and the nurse’s station. P#1 and P#2 were observed interacting with staff and other patients in the hallway. At 5:49:08 p.m., P#1 and P#2 were observed entering room #312, and closing the door. At 5:50:44 p.m., P#1 and P#2 were observed peaking their heads out of the door, which remained ajar. At 5:55:30 p.m., a patient wearing a blue shirt and long leggings was observed approaching room #312. She peaked her head inside the room but remained in the hallway. At 5:56:13 p.m., the same patient was observed moving away from room #312’s door and walking to the nurses’ station. The door had been closed at this time. At 5:56:37 p.m., the same patient returned to room #312 and was observed knocking on the door. No one opened the door, and the patient left. At 6:03:16 p.m., BHA EE was observed walking with a tablet conducting observation rounds. P#1 and P#2 remained in room #312 with the door closed. BHA EE appeared to be documenting on the tablet. BHA EE was observed near the door to room #312 but not opening it. At 6:19:13 p.m., BHA EE was observed walking with a tablet conducting observation rounds. P#1 and P#2 remained in room #312 with the door closed. BHA EE appeared to be documenting on the tablet. BHA EE was observed near the door to room #312 but not opening it. At 6:30:38 p.m., BHA EE was observed walking with a tablet conducting observation rounds. P#1 and P#2 remained in room #312 with the door closed. BHA EE appeared to be documenting on the tablet. BHA EE was observed near the door to room #312 but not opening it. At 6:42:09 p.m., the door to Room #312 was observed opening a couple of inches from the inside, and BHA EE was observed entering the doorway. BHA EE and P#1 and P#2 were observed leaving the room. At 6:45:08 p.m., BHA EE was observed taking vital signs on patients in the unit. P#2 was observed speaking to Registered Nurse (RN) DD in the hallway. BHA EE soon joined them. During that time, P#1 was observed returning to room #312 and lingering in the doorway. At 6:45:38 p.m., RN DD, BHA EE, and P#2 are seen walking down the hall and out of the camera’s view. At 6:52:00 p.m., RN DD, BHA EE, and P#2 return in view of the camera, and P#2 sat in a chair near the nurse’s station. P#1 was observed speaking from the doorway #312 when RN DD points her finger at him. P#1 left the doorway and returned to room #312. A review of the facility’s policy titled “Rights and Responsibilities of Individuals,” revealed that the purpose of the policy was to detail that the facility protects and promotes patient’s rights that are extended to all patients. Continued review revealed, Procedure, Patient Rights: 1. The following rights shall be afforded to all patients and are not subject to modification: a. Patients have the right to be protected by the Hospital from neglect; from physical, verbal, and emotional abuse; and from all forms of misappropriation and/or exploitation. During an interview on 5/14/25 at 11:00 a.m. in the conference room, Medical Doctor (MD) AA recalled a sexual assault allegation incident that happened on 5/2/25 in the evening and the on-call provider was contacted. MD AA recalled that he was contacted due to the nature of the allegations. MD AA recalled that P#1 was supposed to be in a block room with precautions for sexually acting out (SAO) and peer restrictions. MD AA recalled that after learning about the incident, MD AA told staff to separate P#1 and P#2 and block their rooms, ensure both P#1 and P#2 are on SAO precautions, and alert the administrator on-call. MD AA said that P#1 was placed on peer restrictions and SAO precautions prior to the current incident due to making inappropriate sexual comments to a peer. MD AA recalled that the blocked room order was active for P#1, meaning that P#1 was not allowed to have a roommate and was unsure why P#1 was moved in with P#2. A telephone interview was conducted on 5/13/25 at 3:17 p.m. with Registered Nurse (RN) DD RN DD recalled that on 5/2/25, she was the charge nurse on the Three South Unit. She recalled that Behavioral Health Assistant (BHA) EE approached her and explained that he wanted to change some patient rooms around because a patient sharing a room with P#2 wanted out of the room because of something P#2, said that was sexual in nature. She said she instructed BHA EE to make the changes he wanted, but to let her know who he moved when he was finished so she could update the bed board. RN DD recalled that the unit was very busy that day, and BH EE was very busy, so after some time had passed, she had not asked for an update. RN DD said she recalled that P#1 was on a blocked room order and SAO precautions for a previous incident, but that BHA EE did not say he was going to move P#1. She continued to say that after the incident, she asked BHA EE why he moved P#1 into P#2’s room when P#1 was on a blocked room order. BHA EE told her that he was not aware P#1 was on a blocked bed order because it was not on the tablet. RN DD explained that P#1 should not have been assigned a roommate because he was on a blocked room order. RN DD recalled that that evening, P#2 came to speak with her regarding an incident in his room. She said P#2 explained that P#1 had put his penis into P#2’s rectum and mouth and forced a pillow in his face and added that he was bleeding from his rectum. BHA EE accompanied RN DD and P#2 to the bathroom so that she (RN DD) could physically assess P#2’s injuries. RN DD explained that when she assessed P#2’s rectum, she did not see any visible trauma or blood. She asked P#2 to wipe his bottom and saw no blood on the tissue paper. She then instructed P#2 to wipe again, and this time she and BHA EE would step out of the bathroom and allow him some privacy because he felt uncomfortable. She said when P#2 came out of the bathroom, there was a tiny spot of blood on the tissue. RN DD recalled P#2’s initial history and physical (H&P), noting lacerations on his arm and his buttocks from an incident that had occurred at his previous facility. RN DD said she was unsure whether the blood on the tissue had come from those previous wounds or had come from his rectum. Nonetheless, she called the doctors, the AOC and the Director of Nursing and notified them of the incident. An order was placed to have P#2 transferred to a local hospital for a medical evaluation and treatment. RN DD added that when staff spoke to P#1 about the incident, he began shouting that he was innocent, and that P#2 was a liar. She said P#1 maintained that nothing had occurred between the two boys until the next day, when the police questioned him about the incident. RN DD said both patients were separated until P#2 was sent to the local hospital. RN DD said that the doors to patient rooms were to remain open while patients were in their rooms. The patients were all in their rooms because it was reflection time. During the day, patients were not allowed in their rooms, and the doors remained closed and locked. She added that when the BHAs conduct their observation rounds, they should observe the patient face to face because some questions require the BHA to see the patient to answer. Even when the patients are sleeping, BHAs must go into the room and stand close enough to observe three breaths to ensure that the patient is breathing. RN DD acknowledged that nursing staff manage and supervise BHAs. During a telephone interview on 5/14/25 at 12:30 p.m., BHA EE recalled the incident involving P#1 and P#2 on 5/2/25 because it occurred shortly before shift change. In addition, the shift had been hectic because one of the BHA’s working on the unit had been re-assigned to another unit which left him alone with a lot of high acuity patients. BHA EE stated that he knew P#1 and #2 were behind closed doors. BHA EE explained that because earlier, they had been fighting, arguing with another patient, throwing water at one another and shouting, he did not want to excite them further by going into their room to conduct observation rounds. BHA EE explained that on 5/2/25, P#2 had been roomed with another patient. Throughout the day, his roommate complained that P#2 was making homosexual comments towards him and making him uncomfortable. The other patient wanted to be moved out of the room. BHA EE recalled that he moved P#2’s former roommate to a different room further down the hallway. BHA EE continued to explain that during that time, P#1 requested to be moved into P#2’s room, and BHA EE granted P#1 permission to move into P#2’s room. He added that at the time, he was unaware that P#1 was on blocked bed orders, which meant that that patient cannot be roomed with another patient. He added that the charge nurse would tell which patients were on these orders during the shift huddle. Sometimes that information was also shown on the bed board On 5/2/25, BHA EE was unaware of the order because the blocked bed did not appear on the tablet for P#1. So, unless it was discussed, he could not know if a patient had a blocked bed order. BHA EE said the assistants can make patient room changes without permission, and the charge nurse usually updated the bed board to reflect the changes. BHA EE continued to say that the facility’s policy was that patient doors remained open except for bedtime, when patients are in the room. Some patients cannot sleep when the door was open request that the door be closed. In this case, staff placed a towel on the top corner of the door to prevent it from closing all the way and latching, was mostly closed. BHA EE explained that with a peer restriction order patients were not allowed to be in a room with other patients but can remain interacting with their peers in the unit. He could not recall if P#1 had been on a peer restriction order. BHA EE explained that when conducting observation rounds, the tablet used interacts with a Bluetooth beacon in the patient’s armband and automatically populates the information into the tablet. The questions he must answer require him to see the patient face-to-face unless they are in a restroom. In this case, allowing the Bluetooth beacon to document the observation without conducting the face-to-face portion would be acceptable.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 49398 Based on a review of medical records, facility policy and procedures, and staff interviews, it was determined that the facility failed to ensure that nursing services adhered to established policies and procedures for two (P#1, P#4) of four patients reviewed when: 1. P#1’s medical record failed to reveal a physician’s order, patient monitoring, and post-seclusion debriefs per facility policy for a seclusion incident that occurred 5/3/25. 2. P#4’s medical record failed to reveal a physician’s order for a physical restraint on 3/19/25. Findings included: 1. A review of P#1’s medical record revealed that he was admitted to the facility on 4/29/25 with a diagnosis of disruptive mood disorder (a condition in which children or adolescents experience ongoing irritability, anger, and frequent, intense temper outburst) and oppositional defiant disorder (a behavioral condition characterized by a pattern of uncooperative, defiant, and hostile behavior toward authority figures). A review of P#1’s “Seclusion/Restraint One Hour Face to Face Assessment,” dated 5/3/25, revealed that physical, chemical, and seclusion restraints were initiated for P#1 for aggressive behavior from 12:25 p.m. until 12:35 p.m. A review of the “Behavioral Health-Patient Observation Sheet,” dated 5/3/24 from 12:25 p.m. through 1:25 p.m., failed to reveal documented observations of P#1 while he was in the seclusion room. Further review failed to reveal evidence of a post seclusion debriefing documentation related to P#1’s seclusion intervention. A review of P#1’s “Discharge Summary,” dated 5/3/25, noted that at approximately 12:20 p.m., P#1 was heard yelling from the group room and was brought out by staff for being combative, aggressive, and physically and verbally abusive. The provider was notified, and P#1 was placed in a seclusion/restraint at 12:25 p.m. The provider ordered an intramuscular injection at 12:31 p.m., and P#1 tolerated it well. P#1 was taken out of the seclusion room at 1:10 p.m. Further review of P#1’s medical record failed to reveal a physician’s order for seclusion on 5/3/25. 2. A review P#4’s “Seclusion/Restraint One Hour Face to Face Assessment”, dated 3/19/25 at 7:56 a.m., a Registered Nurse (RN) noted that P#4 was in a restraint hold due to being verbally and physically aggressive at 3:35 a.m., a face-to-face assessment was conducted at 3:50 a.m. A continued review revealed that the restraint had been discontinued prior to the face-to-face assessment. A review of P#4’s medical record failed to reveal a provider’s order for restraints on 3/19/25. A review of the facility’s policy titled, “Seclusion and Restraint”, #CTS-031, last reviewed 11/2024, revealed that the purpose of the policy was to provide guidelines for the use of seclusion or restraints in emergency situations to ensure the patient’s and/or other’s safety. Seclusion or restraint shall be considered and emergency management intervention when a patient demonstrates an overt and immediate threat of harm to self or others, and when less restrictive interventions have been attempted and proven unsuccessful. Continued review revealed, F, The Use of Seclusion: 1. Document the use of seclusion in the medical record including observable behavior and least restrictive methods employed. Continued review revealed, G, The Use of Restraints: 1. Document the use of restraints in the medical record including observable behavior and the least restrictive methods employed. 2. Restraints are used upon the written or verbal order of a physician. A registered nurse, after personally observing the patient may initiate restraint if he/she is clinically satisfied and the use of restraint is justified. A physician shall confirm orders written by a registered nurse within one hour. When the order for seclusion expires, the patient is re-evaluated by a physician, Licensed Independent Practitioner (LIP), or registered nurse via direct observation. 3. The restraint order should specify: a. The length of time is authorized for up to two hours for adolescents ages nine to 17 years. b. Purpose of restraint. c. Precipitating events leading to need for restraint/clinical justification. d. Close observation will be by continuous in-person monitoring. e. Criteria for discontinuing seclusion. Continued review revealed K, following every seclusion or restraint episode, the staff will have two debriefings. The patient and family, if possible and appropriate, participate in one meeting. The staff will also debrief separately. The purpose of the debriefing is to: identify what led to the incident and what could have been handled differently, ascertain that the patients’ physical and well-being, psychological comfort, and the right to privacy were addressed; and counsel the patient from any trauma that may have resulted from the incident. Continued review revealed, Procedure, B, Restraint, Assigned Staff: 6. If the patient is an adolescent notify the parent/guardian of the initiation of restraint. 7. Monitor the patient through in-person, continuous observation and document every fifteen minutes. 11. After the patient is released from restraints, staff will debrief with the patient. 12. Staff debriefing may take place prior to or after debriefing with the patient. 14. All restraint episodes must be logged into the Restraint/Seclusion Log. A telephone interview was conducted on 5/13/25 at 3:17 p.m. with Registered Nurse (RN) DD. RN DD. She said that a Behavioral Health Assistant (BHA) will stand at the seclusion door for the duration of the seclusion to ensure continuous face-to-face observation of the patient and that observations should be documented every 10 to 15 minutes while the patient is in seclusion. RN DD said that when a patient was placed in a physical restraint or seclusion, an order must be in the electronic medical record (EMR). During an interview on 5/14/25 at 11:00 a.m. with Medical Doctor (MD) AA in a conference room, MD AA stated that he is the facility’s Medical Director. He added that when a patient is placed in seclusion, an initial assessment of the patient should be documented, and a debriefing should be documented when the patient is removed from seclusion. MD AA continued to explain that a BHA is assigned at the seclusion room door when a patient is in seclusion. They must apply pressure to the door handle while the patient is in the room to maintain continuous face-to-face observation until the patient is released from seclusion. The individual observing the patient is supposed to document the observations. He was unsure of the frequency with which observations are to be documented. A telephone interview was conducted on 5/14/25 at 12:30 p.m. with Behavioral Health Assistant (BHA) EE.BHA EE stated that when a patient is placed in seclusion, a technician will stand at the door and apply pressure to the handle to ensure that the door remains locked, and that continuous face-to-face observation of the patient is conducted. He explained that he believes he is supposed to document his observations of a patient in seclusion but was unsure of the frequency. He explained that he’s heard it’s every 15 minutes, but he’s not sure because he’s also heard that it’s every hour, but he thinks he should document seclusion observations hourly. A telephone interview was conducted on 5/14/25 at 12:41 p.m. with Registered Nurse (RN) FF. RN FF could recall hearing yelling coming from the group room, and staff were unsuccessful in de-escalating the situation with P#1 and had to remove him from the group room. A code purple was called, and when RN FF responded to the code, she recalled seeing that a BHA and the supervisor had placed P#1 in a physical hold by holding his arms, and the provider, who was present, gave RN FF verbal orders for a chemical restraint. RN FF said she went to the medication room, drew the medication, and put the orders in the electronic medical record (EMR). When she came back to where the patient was, he had already been moved to the seclusion room, and the supervisor took the medications and went down to the seclusion room to administer them to P#1. RN FF recalled that when she conducted the one-hour face-to-face assessment, P#1 would not speak and eventually fell asleep, and she could not debrief him when he was taken out of seclusion. She could not recall if she documented any information related to the debriefing in the EMR. She explained that when patients come out of seclusion, they are supposed to be debriefed twice. The first debriefing includes asking the patient about the incident and the intervention. The second debriefing does not involve questioning the patient but observing them in the environment after they have been removed from seclusion. She added that the debriefings are supposed to be documented in the EMR. RN FF explained that when a patient is in seclusion, a BHA is always present, providing continuous face-to-face observation, and the BHA should document these observations every five minutes.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 46188 Based on a review of policy and procedures, medical records, and staff interviews, it was determined that the facility failed to ensure that nursing staff administered medications using appropriate patient identifiers and per physician’s orders when: 1. One (P#4) of five (P#1, P#2, P#3, and P#5) patients reviewed received another patient’s medications. 2. One (P#1) of five (P#2, P#3, P#4, and P#5) patients reviewed failed to receive two doses of an ordered antibiotic Findings included: A review of the facility’s policy titled, “Medication Management and Documentation”, date of issue: 8/2020, revealed the following: Procedure: 1. Orders a. Only Practitioners who are lawfully authorized to prescribe and privileged to practice at this Hospital may write medication orders. b. Medication orders are to be reviewed by the Pharmacists for appropriateness of all medication orders prior to dispensing by the Pharmisit. 2. Administration a. a. No drugs shall be administered except by licensed personal authorized to administers upon the order of a person lawfully authorized to prescribe. b. e. Medication should be administered as soon as possible after being prepared. c. g. Any nurse administering medications has the right to refuse to do so if there is any question regarding the safety of administering the medication. The physician will be notified of why the medication was not given. d. i. Report drug administration errors and adverse or untoward drug reactions immediately to the attending physician, pharmacist, and patient and/or family (as appropriate). Prepare and submit reports as required by the facility. e. m. Check patient’s Medication Administration Record (MAR) to ensure the order was accurate: f. r. Review the five rights prior to administering medication. i. Right Patient- You must use two identifiers: ii. Patient picture iii. Patient arm band iv. (alternate) ask patient date of birth and verify with the MAR v. Right medication vi. Right dosage vii. Right route viii. Right time g. s. Do not administer the medications if there were any questions, inconsistencies, or unclear items identified by the five rights. Any questions or inconsistencies should be clarified by consulting the physician, another nurse, a pharmacist and/or reference materials as appropriate. h. t. Document on the MAR the following information in the appropriate column: dose, time, route (if not PO), site (if appropriate)”, and initials. i. v. Properly identify patient by checking patient armband and picture and asking the patient to state his/her name. j. w. Double check the order if the patient questions or expresses doubts about the drug, dose, administration route or technique, etc. k. y. Document all refused drugs on the patient’s MAR. Notification of the practitioner was also to be documented in the progress note. If patient refuses the medication, circle your initials on the MAR and mark “refused”. 3. PRN Medication Administration Guidelines: a. Medication should be administered within 15 minutes of a patient’s request after verification is completed that the patient was appropriate for medication. If the patient was unable to receive the medication the patient should be notified why not and when they can receive the medication. b. One hour after administration of medication, reassess the patient and document effectiveness of medication on the PRN Effectiveness Record. 4. Labeling and Storage of Drugs a. The pharmacist shall be responsible for proper disposal of the expired medication. 5. Medication Administration Documentation Process a. Chart the time in the appropriate column to indicate that the medication was given. b. All medications must be charted on the MAR immediately following administration. c. Record and circle the scheduled time on MAR if for any reason any scheduled drug was not administered based on nursing assessment or patient refusal. Indicate the date, medication, dosage, time, reason, and nurse signature. Document physician notification in the Progress Note. A review of the facility’s “Patient Handbook” revealed that tips to promote the best experience included asking a nurse to check the patient’s arm band prior to administering a medication, identifying oneself, and asking for an explanation for the reason for the medication. In addition, the patient was entitled to safe and quality care, and the facility was committed to meeting those needs. A review of “Physician Orders” dated 2/29/24 revealed that P#1’s observation status was to be monitored every 15 minutes (Q15) and given the following medications and dosages: Cephalexin (Keflex) (antibiotic to treat infections) every six hours, Phenazopyridine HCL (Urinary Pain Relief) three times a day, sertraline HCL (treatment of depression) once a day. A review of “Medication Administration Record” dated 2/29/24 to 5/1/24 revealed on 2/29/24 at 5:14 a.m. a Registered Nurse (RN) attempted to administer Keflex and P#1 refused medication. P#1 received Ondansetron and Keflex on 2/29/24 at 12:21p.m. Continued review revealed that P#1 received Keflex on 3/1/24 at 1:30 a.m., 3/2/24 at 6:50 a.m., 3/2/24 at 2:13 p.m. and on 3/2/24 at 12:01 a.m. A telephone interview was conducted with Registered Nurse (RN) DD on 5/3/24 at 9:45 a.m. RN DD had worked at the facility for six months and explained that RN DD had moved to different units when it was short-staffed. RN DD stated that medications were generally prepared in advance, and the Behavioral Health Associate (BHA) would bring the patient to the nurses’ station for medication. RN DD asked the patient for their name and date of birth. In addition, RN DD could verify the patient by looking at the patient’s photograph, which was available in the medical record (MR). RN DD explained that the patient had a wristband identifying the patient’s name. There were times when a patient did not have a wristband because the patient had not received one, the wristband fell off, or the patient removed it. RN DD said patient-identifying wristbands were not consistently provided or worn. Only about 50 percent of the patients wore wristbands. RN DD continued to say that the patient’s photographs were also not consistently entered into the patient’s medical record due to short staffing. RN DD was unaware of a hospital policy addressing patient identification when administering medication. RN DD stated she did not recall P#4. RN DD remembered an incident when a patient received another patient’s medications in error. RN DD stated that this occurred when RN DD was unfamiliar with the patient and the unit was short-staffed. RN DD said she had been given a description of the patient who was to arrive for medication, and a patient arrived at the medication window. RN DD said she asked the patient their name, and the patient responded with what RN DD heard as the name that RN DD had medication ready for. RN DD called the patient’s name prior to administering the medication, but the patient at the window had not corrected RN DD. RN DD administered the medication to the patient and later when the actual patient came up for their medications, RN DD realized the error. A review of an Incident Report Form dated 1/20/24 9:05 p.m. revealed an incident involving P#4. A summary of the events revealed that P#4 presented to the medication window. When the staff asked P#4 her name, she told them a different name other than her own. No picture or patient armband was available for verification. P#4 was then administered medication for the name of the patient’s name she told staff. About 45 minutes after medications had been administered, the actual patient whose name was provided by P#4 approached and the medication error was noted. P#4 did not receive her scheduled medications due to the medication error. A review of the Nurse Progress Note dated 1/20/24 at 8:20 p.m. by RN DD revealed that P#4 approached the medication window, and when asked, P#4 stated her name was another patient name (no picture or armband). The medication under that patient’s name was then pulled and given. The medications were methocarbamol (Robaxin) (muscle relaxant) 750 milligram (mg), Vistaril (antihistamine) 25 mg, quetiapine fumarate (used to treat depressive disorders) 50 mg, and gabapentin (treated nerve pain) 300mg. About 45 minutes later, a patient with the same name approached, and the medication error was noticed.”