Lakes Regional Healthcare

“Plan Based on All Hazards Risk Assessment CFR(s): §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: 51493 Based on record review and interview, the facility failed to provide plans for all hazards in accordance with the Code of Federal Regulations (CFR) at §483.73(a)(2). This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 49 and a census of 21. Findings include: 1. Record review and interview on 09/16/25 at 10:00 a.m., revealed that the facility was unable to provide documentation in their Emergency Preparedness Plan for how to deal with all events identified in their risk assessment. The facility did not identified infectious diseases in their risk assessment of their Emergency Preparedness Plan. The CEO and Maintenance Supervisor verified this observation at the time of the survey process. 2. Record Review and interview on 09/16/25 at 10:00 a.m., revealed that the facility was unalbe to provide documentation in there Emergency Preparedness Plan for how to deal with all events identified in their risk assessment. The facility did not identified cyber attack in their risk assessment of their Emergency Preparedness Plan. The CEO and Maintenance Supervisor verified this observation at the time of the survey process.”

“42 CFR 485.623(d) Lakes Regional Healthcare was found to be not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 485.623(d), Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 - 2012 edition. Lakes Regional Healthcare is a two story building with a basement of Type II (111) construction that was built 1964 with an addition in 1972. The building is fully sprinklered and there is supervised smoke detection located in the corridors, resident rooms and the spaces open to the corridors. The facility has 49 certified beds. All 49 beds are certified for Medicare/Medicaid only. At the time of the survey the census was 21. The requirement at 42 CFR 485.623(d) is NOT MET as evidenced by:”

“Illumination of Means of Egress CFR(s): NFPA 101 Illumination of Means of Egress Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention. 18.2.8, 19.2.8 This Standard is not met as evidenced by: 51493 Based on observation and interview, the facility failed to provide illumination of means of egress in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-7.8.1.1 and Section-7.9.2.7), 2012 Edition. This deficient practice affects all residents, staff, and visitors in all smoke zones. This facility has a capacity of 49 and a census of 21. Findings include: Observation and interview on 09/17/25 at 11:15 a.m., revealed the diesel emergency generator was enclosed and did not have any emergency lights on the inside of the closer that were battery powered. The reasoning for the battery powered emergency light in the enclosed area to help in case of a power failure of the emergency generator. The area of the enclosed emergency generator should have at least two battery powered back up emergency lights. The Maintenance Supervisor confirmed this finding during the process of the survey.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 51493 1. Based on record review and interview, the facility did not maintain the fire alarm system in accordance with the National Fire Protection Association (NFPA) 72, National Fire Alarm and Signaling Code, 2010 Edition, 14.6.2.4, 14.3.1, and 14.4.5. The deficient practice of not conduction semi-annual inspections of the fire alarm system does not ensure proper operation and prompt repair, affecting all occupants. This facility had a capacity of 49 and a census of 21 residents at the time of the survey. Findings include: Record review on 09/17/25 at 9:48 a.m., of the fire alarm inspection and testing forms conducted by General Fire and Knight Protection revealed the fire alarm system was inspected and tested on 05/27/25 and 04/23/24, however, this inspection and testing of the fire alarm system was overdue and did not ensure proper operation of the system. This deficient practice was confirmed by the Maintenance Supervisor at the time of the survey. 2. Based on observation and interview, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-9.6.1.3), 2012 Edition and National Fire Protection Association (NFPA) 72, National Fire Alarm and Signaling Code (Section-14.2.1.2.2), 2010 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 49 and a census of 21. Findings include: Observation and interview on 09/17/25 at 12:07 p.m., revealed the medical surgery floor kitchen area open to the corridor on the second floor was missing a required smoke detector. This deficient practice was confirmed by the Maintenance Supervisor at the time of the survey.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 51493 Based on record review and interview, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (Section-5.1.1.2), 2011 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 49 and a census of 21. Findings include: Record review and interview on 09/17/25 at 9:42 a.m., revealed the facility failed to conduct quarterly testing of the sprinkler system for the first quarter of 2024/2025. The Mainentance verified this observation at the time of the survey process.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 51493 Based on record review and interview, the facility was not properly documenting all elements of testing for the emergency generator in accordance with National Fire Protection Association (NFPA) 110, Standard for Emergency and Standby Power Systems (Section-8.4.2), 2010 Edition. This deficient practice affects all residents, staff, and visitors throughout the facility. This facility has a capacity of 49 and a census of 21. Findings include: Record review and interview on 06/17/25 at 11:11 a.m., revealed the facility was doing the monthly load testing of the facility ’ s diesel powered Emergency Generator. The facility was not documenting an testing done for the months of February or May in 2025. The Maintenance Supervisor verified this observation at the time of the survey process.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 50212 Based on medical record review, policy review, and patient and staff interviews, the ACH ’ s administrative staff failed to ensure Emergency Department (ED) staff appropriately involved the designated representative of 1 of 5 sampled patients (Patient #15) in the development of his or her plan of care. Failure to appropriately involve all patients and their respective representatives in care planning and treatment decisions could result in the provision of medical services contrary to the patient ’ s wishes, as well as the withholding of services preferential to said patient or representative. The ACH ’ s administrative staff identified a total census of 17 patients who presented to the ED on 1/21/25 requesting medical services. Findings include: 1. Review of Patient #15 ’ s 1/21/25 medical records revealed the following: a. On 1/21/25 at 8:42 AM, Patient #15, a 98-year-old resident of an assisted living facility (ALF), presented to the ED with increased confusion, weakness, somnolence (drowsiness), shaking, yelling out, and inability to ambulate (move or walk independently). Staff PP (ED RN) documented the patient repeatedly stated, “ Oh [expletive], “ “ I ’ ll freeze, “ and “ I don ’ t know what ’ s wrong with me “ and had limited ability to communicate beyond these refrains. Staff H (Patient Access Representative) documented “ not physically able to sign “ on the patient ’ s consent for treatment form in lieu of a signature from the patient or their designated representative. b. On 1/21/25 at 8:48 AM, Staff PP documented the patient was unable to answer basic questions or follow simple instructions. Staff PP characterized the patient ’ s behavior and verbal responses as “ moans “ and “ confused conversation “ and identified the patient as “ cognitively impaired. “ At 9:16 AM, Staff WW (ED Physician) diagnosed the patient with acute altered mental status (AMS) and acute encephalopathy (serious brain dysfunction associated with confusion and memory loss), and at 6:41 PM, Staff YY (ED RN) identified the patient as “ cognitively unable “ to swallow oral medication. 2. Review of Patient #15 ’ s 6/3/2011 Durable Power of Attorney (DPOA), which hospital staff uploaded to the patient ’ s medical records on 11/6/23, revealed the following: “ I, [Patient #15] . . . designate: [DPOA designee] . . . as my agent for all matters relating to my health care, including, without limitation, full power to give or refuse consent to all medical surgical, hospital and related health care . . . This power of attorney is effective on my inability to make or communicate health care decisions. “ 3. During an interview on 1/23/25 at 11:30 AM, Patient #15 could neither articulate the reason for their hospitalization nor approximate the length of the admission, estimating “ At least a few weeks, “ despite arriving at the hospital two days prior. 4. During an interview on 1/22/25 at 2:25 PM, Patient #15 ’ s DPOA designee reported hospital staff had not-in accordance with the patient ’ s advanced directives-contacted them to enable their participation in the development and implementation of the patient ’ s care plan. 5. During an interview on 1/23/25 at 10:35 AM, Staff PP (ED RN) reported the patient presented to the ED on 1/21/25 with ALF staff, who reported the patient had developed an inability to communicate intelligibly, instead repeating “ Oh [expletive], oh [expletive], oh [expletive]. “ Staff PP reported awareness that registration staff unsuccessfully attempted to obtain the patient ’ s signature for informed consent. Staff PP confirmed they documented the patient was unable to answer basic questions or follow simple instructions but denied asking said questions or providing said instructions to the patient. Staff PP acknowledged they were expected to contact a patient ’ s DPOA if the patient could not make their own informed medical decisions but stated, “ It wasn ’ t clear if the POA needed to be contacted, “ despite the patient ’ s inability to communicate or make decisions. 6. During an interview on 1/27/25 at 11:30 AM, Staff H (Patient Access Representative) reported they attempted to obtain consent from the patient upon their arrival to the ED; however, the patient was unable to communicate, open their eyes, or hold the provided writing instrument. Staff H reported the patient appeared to flutter their eyes but appeared otherwise unresponsive. Given this information, Staff H acknowledged the appropriate response would have been to obtain a signature for consent from the patient ’ s representative. Staff H identified a need for further staff education on the appropriate steps to take when a patient has a representative (e.g., legal guardian or DPOA assignee). 7. During an interview on 1/22/25 at 3:10 PM, Staff C (Director of Outpatient and Emergency Services) reported they expected staff to review the patient ’ s emergency contact list if unsure whether a patient had a guardian or representative and to inform the patient representative, if applicable, of any procedures or other aspects of the patient ’ s care. 8. During an interview on 1/23/25 at 9:35 AM, Staff II (ED Supervisor) reported they expected ED providers to make a determination of whether a patient with altered mental status could make their own medical decisions, and they expected staff to contact the patient ’ s representative, when applicable, as soon as they had an opportunity to do so. 9. Review of the hospital ’ s 11/2022 “ Patient or Representative Rights and Responsibilities “ policy revealed in part: “ Patient or Representative Rights and Responsibilities. The patient or representative has the right to: . . . 7. Participate in the development and implementation of his/her plan of care. Participate in making decisions about the medical care that he/she may receive. “”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 50212 Based on medical record review, policy review, and staff interviews, the hospital’s administrative staff failed to ensure: 1) hospital staff informed a patient’s legal representative of their rights to exercise on behalf of the patient in advance of furnishing or discontinuing care (see A0117); 2) hospital staff informed a patient’s representative of decisions regarding care of the patient including their health status, involvement in care planning and treatment and being able to request or refuse treatment on behalf of the patient (see A0131); 3) hospital staff provided care and treatment to the patient in a safe setting by providing appropriate safeguards to maintain physical safety (see A0144); and, 4) hospital staff failed to maintain evidence of the appropriate use of physical restraints (see A0185). The cumulative effect of these deficient practices resulted the failure of hospital staff to protect and promote the rights of a patient and resulted in the failure of hospital staff to protect the patient from harm. The hospital reported a census of 22 at the time of the complaint investigation survey.”

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 50212 Based on medical record review, policy review, and staff interviews, the hospital’s administrative staff failed to ensure hospital staff appropriately transferred a patient from their hospital to an inpatient hospital with the capabilities to treat the patient after the patient displayed serious incidences of self-harming behavior (see A0802). This deficient practice resulted in hospital staff discharging a patient with suicidal ideation home rather than to the appropriate acute level of care for mental health inpatient treatment. The hospital reported a census of 22 at the time of the complaint investigation survey.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 50212 Based on medical record review, policy review, and staff interviews, the hospitals staff failed to inform the legal representative of 1 of 10 sampled patients (Patient #4) the patient’s rights in advance of furnishing or discontinuing care. Failure to inform legal guardians of the patient’s rights placed patients at risk for receiving or not receiving care per the wishes of the patient. Findings include: 1. Review of the 11/2022 policy “Patient or Representative Rights and Responsibilities” revealed in part: “The patient or representative has the right to: . . .” a. “9. Have a family member or representative and his/her own physician notified promptly on his/her admission to the hospital upon his/her request.” b. “22. Be informed of hospital policies and practices that relate to patient care treatment and responsibilities.” 2. Review of the Patient #4’s medical records revealed the following: a. On 8/10/24 at 1:19 PM, the patient presented to the ED for intentional overdose of a combination of prescription medications and ingestion of multiple foreign objects. b. On 8/11/24 at 6:38 AM, Staff DD (ED RN) obtained verbal consent from the Legal Guardian to perform an Esophagogastroduodenoscopy (EGD) with foreign body removal. c. The medical record did not include documentation of the provision of Patient ’ s Rights information to the Legal Guardian prior to furnishing or discontinuing care of the patient. 3. During an interview on 10/10/24 at 11:30 AM, Staff AA (ED RN) reported ED registration staff would typically discuss Patient ’ s Rights with patients or their Legal Guardians prior to initiating treatment. 4. During an interview on 10/17/24 at 1:00 PM, Staff G (ED Physician) reported ED registration staff and ED RNs were expected to provide information regarding Patient ’ s Rights to patients and their Legal Guardians when applicable. 5. During an interview on 10/10/24 at 9:00 AM, Staff C (Director of Outpatient & Emergency Services) confirmed ED registration staff were expected to provide patients or their representatives with information regarding Patient ’ s Rights. 6. During an interview on 10/8/24 at 7:15 AM, Patient #4 ’ s Legal Guardian (LG) provided the following information: a. LG reported the patient presented to the ED on 8/10/24 for an intentional overdose of a combination of prescription medications and ingestion of multiple foreign objects. b. LG reported hospital staff requested consent from LG on 8/11/24 to perform an esophagogastroduodenoscopy (EGD) procedure to remove foreign objects from the patient ’ s stomach, at which time the hospital staff notified LG of the patient ’ s ED admission the prior day. c. LG reported hospital staff did not provide Patient ’ s Rights information prior to furnishing care to the patient on 8/10/24 or thereafter. Furthermore, LG reported hospital staff did not provide Patient ’ s Rights information prior to discontinuing care of the patient on 8/15/24.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 50212 Based on medical record review, policy review, and staff interviews, hospital staff failed to involve the Legal Guardian of 1 of 10 sampled patients (Patient #4) in patient care planning and treatment decisions. Failure to involve the patient’s legal representative in care planning and treatment placed the patient at risk for not receiving treatment according to the wishes of the patient. Findings include: 1. Review of the 02/2024 policy “Plan of Care/Problem List” revealed in part: a. “I. Purpose: The plan of care is developed at the time of admission to respond to each patient ’ s unique needs, expectations, and characteristics with effective, efficient and individualized care . . .” b. “C. Patients are involved in the care planning process and are provided with sufficient information to participate and make decisions regarding their care.” c. “1. When a patient who is not incapacitated has designated, either orally to hospital staff or in writing, another individual to be his/her representative, the designated representative is involved in the patient ’ s plan of care.” 2. Review of the 11/2022 policy “Patient or Representative Rights and Responsibilities” revealed in part: a. “The patient or representative has the right to: . . . 7. Participate in the development and implementation of his/her plan of care. Participate in making decisions about the medical care that he/she may receive.” b. “9. Have a family member or representative and his/her own physician notified promptly on his/her admission to the hospital upon his/her request.” c. “22. Be informed of hospital policies and practices that relate to patient care treatment and responsibilities.” 3. Review of the 06/2024 policy “Informed Consent Policy” revealed in part: a. “The goal of the informed consent process is to ensure a mutual understanding between the patient and the provider about the care, treatment and services being provided.” b. “[The hospital] promotes and defends human dignity by assisting patients or their surrogate decision-makers (herein collectively referred to as “patient”) to make voluntary and informed decisions about the care and treatment provided.” c. “26. The free and informed consent of the person or the person ’ s surrogate is required for medical treatments and procedures, except in an emergency situation when consent cannot be obtained and there is no indication that the patient would refuse consent to the treatment.” d. “27. Free and informed consent requires that the person or the person ’ s surrogate receive all reasonable information about the essential nature of the proposed treatment and its benefits; its risks, side effects, consequences, and cost; and any reasonable and morally legitimate alternatives, including no treatment at all.” e. “Guidelines for Informed Consent: 2. Written Confirmation of Informed Consent: A written confirmation of informed consent must be obtained prior to any medical treatment being performed.” f. “4. Emergency Situations: If a patient lacks decision-making capacity in an urgent or emergent situation involving a threat to the patient ’ s life or health, consent to treatment is implied provided that there is no indication that that [sic] the patient would have refused such treatment. In emergencies in which informed consent for treatment cannot be immediately obtained from the parents, guardian, or next of kin, the information must be documented in the patient ’ s medical record by the provider.” g. “7. Persons Under the Influence of Drugs or Alcohol: A person under the influence of drugs or alcohol who, in the opinion of the provider, is unable to make an informed decision should not consent to medical treatment. Consent should be obtained from a surrogate decision-maker in accordance with current state law.” 4. Review of the 12/2023 policy “Discharge Planning” revealed in part: a. “Policy: 1. Discharge planning is a process and multidisciplinary approach that involves determining the appropriate post-discharge destination or services for a patient: Identifying what the patient requires for a smooth and safe transition from hospital to discharge destination and beginning the process of meeting the patients [sic] identified post-discharge needs.” b. “2. A discharge plan includes: patient teaching, assessment of need for community services and/or equipment and follow up care.” c. “Discharge planning is initiated on/or before hospital admission for all inpatients and outpatients.” d. “3. The patient and/or patient representative has the right to be involved in the discharge planning process and assist with decision making process for community services that are needed upon discharge.” e. “[The hospital] will engage the patient and/or patient representative in the development of discharge planning evolution, not only as a source of information but also to incorporate the patient ’ s goals and preferences as part of the evaluation.” f. “4. b. Staff should incorporate information provided by the patient and/or patient representative and family/caregivers to implement the discharge planning process.” g. “c . . . The patient has right [sic] to be engaged in the discharge plan and has the freedom to choose their post discharge services. Keeping the patient and/or patient representative informed throughout the development plan is essential for success.” 5. Review of Patient #4’s medical records revealed the following: a. Emergency Contact Information, dated 8/10/24: [Legal Guardian]. Relationship . . . Guardian.” b. No wet ink or verbal signature documenting informed consent of the Legal Guardian on 8/10/24 noted in the patient ’ s records. c. On 8/11/24 at 6:38 AM, Staff DD (ED RN) obtained verbal consent from the Legal Guardian to perform an Esophagogastroduodenoscopy (EGD) with foreign body removal. d. On 8/11/24 at 7:13 AM, Staff M (General Surgeon) documented the following progress note: “Lives in group home: [Group Home]-guardian [Legal Guardian].” e. On 8/11/24 at 5:30 PM, Staff Q (Emergency Department (ED) Advanced Registered Nurse Practitioner (ARNP)) documented the following progress note: [The patient] has a court-appointed guardian . . .” f. On 8/14/24 at 9:45 AM, Staff C (Director of Outpatient and Emergency Services) documented the following nursing note: “Call placed to [Group Home] to see about 1:1 care at facility as unable to find acute bed placement. Had to leave message.” At 12:15 PM, Staff C documented the following nursing note: “Second call placed to [Group Home] . . . [Staff V (Assistant Director)] states they do not feel they are able to keep [the patient] safe in the community if [the patient] were to come back to [Group Home] without an inpatient stay.” g. On 8/15/24 at 11:00 AM, Staff DD (ED Registered Nurse) provided discharge instructions to the patient. No wet ink or verbal signature by the Legal Guardian noted on the document. h. On 8/15/24 at 11:45 AM, Staff C (Director of Outpatient and Emergency Services) documented the following nursing note: “Visited with [Legal Guardian] to apologize that we did not do that [discuss discharge plan with Legal Guardian] prior to [Patient #4 ’ s] departure as it was assumed by myself and other staff that since this plan has been developing since Monday that [Legal Guardian] was aware.” 6. Review of the 8/21/24 letter provided to Patient #4 ’ s Legal Guardian revealed the following: “Our grievance committee and Chief Medical Officer carefully reviewed your case. We sincerely apologize for not communicating appropriately regarding [the patient ’ s] treatment plan.” 7. During an interview on 10/8/24 at 7:15 AM, Patient #4 ’ s Legal Guardian (LG) provided the following information: a. LG reported the patient presented to the ED on 8/10/24 for an intentional overdose of a combination of prescription medications and ingestion of multiple foreign objects. b. LG reported hospital staff obtained consent for treatment from the patient on 8/10/24 despite the patient being a dependent adult and under the influence of various medications. c. LG reported hospital staff requested consent from LG on 8/11/24 to perform an esophagogastroduodenoscopy (EGD) procedure to remove foreign objects from the patient ’ s stomach-at which time the hospital staff notified LG of the patient ’ s ED admission the prior day. d. LG reported contacting hospital staff on either 8/12/24 or 8/13/24, and hospital staff indicated they were in the process of seeking inpatient care for the patient. Per LG, hospital staff did not communicate a plan to discharge the patient at this time. e. LG reported hospital staff subsequently discharged the patient to their home on 8/15/24 without providing prior notification of the discharge to LG. 8. During an interview on 10/10/24 at 11:30 AM, Staff AA (ED RN) provided the following information: a. Staff AA acknowledged dependent adults cannot provide informed consent and reported awareness that hospital staff must receive consent from the Legal Guardian of a dependent adult prior to treatment. b. Staff AA reported Patient #4 ’ s nurse would have been expected to notify the patient ’ s Legal Guardian of their admission and discharge. Additionally, Staff AA reported the patient ’ s nurse or provider would have been expected to obtain consent for treatment from the patient ’ s Legal Guardian. 9. During an interview on 10/10/24 at 10:45 AM, Staff BB (ED RN) acknowledged hospital staff would typically contact the Legal Guardian of a dependent adult to obtain informed consent. Staff BB reported Patient #4 ’ s nurse would have been expected to notify the patient ’ s Legal Guardian of their admission and discharge. 10. During an interview on 10/10/24 at 9:00 AM, Staff C (Director of Outpatient & Emergency Services) provided the following information: a. Staff C reported dependent adults cannot provide informed consent and indicated hospital staff would be expected to obtain consent from the Legal Guardian of a dependent adult patient. b. Staff C acknowledged ED staff discharged the patient to their group home without notifying or involving the Legal Guardian. Staff reported discharging a dependent adult without notifying their Legal Guardian would not be an appropriate practice. 11. During an interview on 10/17/24 at 1:00 PM, Staff G (ED Physician) acknowledged hospital staff often would not communicate with patients ’ Legal Guardians when they reside at a group home. Staff G reported hospital staff often assumed the group home staff would communicate with the respective Legal Guardian, thereby removing the need for hospital staff to involve said Legal Guardian.”

“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: 50212 Based on medical record review, policy review, and staff interviews, hospital staff failed to ensure 1 of 10 sampled patients (Patient #4) received care in an environment in which a reasonable person would consider to be safe from actual or potential harm. Failure to provide appropriate safeguards to maintain the physical safety of all patients could result in serious physiological adverse health outcomes-including disability or death. Findings include: 1. Review of the 11/2022 policy “Patient or Representative Rights and Responsibilities” revealed in part: “The patient or representative has the right to: . . . 2. Receive care in a safe setting. Have all care and treatments provided to his/her [sic] in a safe and secure area.” 2. Review of Patient #4’s medical records revealed the following: a. On 8/10/24 at 1:19 PM, the patient presented to the ED for intentional overdose of a combination of prescription medications and ingestion of multiple foreign objects. b. On 8/11/24 at 5:30 PM, Staff Q (Emergency Department (ED) Advanced Registered Nurse Practitioner (ARNP)) documented the following progress note: “[The patient] admitted to still having suicidal thoughts during the consultation and expressed anger and disappointment that [their] suicide attempt was not successful. [The patient] also admitted to feeling worthless and having a racing mind . . . [The patient] has a court-appointed guardian . . . The patient expressed a desire to return home but acknowledged that [their] current mindset may not make that a safe option . . . expressing discomfort with the idea of returning home given [their] current suicidal thoughts . . . Overall Level of Risk: High . . . Patient is a current danger to [themself]. [The patient] had a suicide attempt yesterday and regrets that [the patient] was not successful in ending [their] life. [The patient] continues to have suicidal ideations at this time. I recommend inpatient hospitalization for further stabilization.” c. On 8/11/24 at 9:07 PM, Staff AA (ED RN) documented the following nursing note: “Pt staff member was yelling out, pt was hitting bedside table and attempting to break parts off to hurt [themself] . . . [Staff G (ED Physician)] took pt down due to pt becoming violent. Called local PD during this time and ERP gave a verbal order to give IM ativan.” d. On 8/11/24 at 9:24 PM, Staff AA (ED RN) documented the following restraint notes: “Reason initiated: physical violence, property damage, suicide attempt, threat of harm, verbal aggression . . . Triggers leading up to event: Pt swallowed [their] necklace, then requested to go back home. Explained to pt that [the patient] was not going home due to continued harm to self and suicidal attempts. Explained that we were looking for placement. Pt appeared angry . . . Description of event: Pt took bedside table and attempted to break parts off of the table to harm [themself]. Tried to verbally redirect pt without success, had to become physical with pt due to immediate harm to self and others. Pt began to fight against staff, had to have multiple staff members to hold down pt for safety of others and [themself].” 3. During an interview on 10/14/24 at 2:20 PM, Staff Y (Director) provided the following information: a. Staff Y reported their organization provided home-based rehabilitation services to Patient #4, who required care 24 hours per day, 7 days per week (24/7) due to severe mental illness and an extensive history of self-harm behaviors. b. Staff Y reported the patient forcefully gained access to their secured medications on 8/10/24 and intentionally overdosed on the medications in addition to swallowing multiple foreign objects. c. Staff Y reported Staff FF (Program Assistant) visited the patient in the ED on 8/11/24 to provide additional supervision of the patient. Per Staff Y, Staff FF reported hospital staff inadvertently left the patient ’ s belongings in the room, resulting in the patient retrieving and swallowing their necklace. Additionally, the patient found a retractable mirror attached to their bedside table, which the patient shattered and attempted to harm themself with the mirror fragments. d. Staff Y reported hospital staff restrained the patient to protect them from self-harm. Staff Y noted the patient had bruising on their cheek following the restraint and attributed the bruising to the patient intentionally and repeatedly hitting their head on the floor and wall of the ED during the restraint application. 4. During an interview on 10/17/24 at 10:30 AM, Staff FF (Program Assistant) provided the following information: a. Staff FF reported they provided home-based services to Patient #4, including assistance with activities of daily living (ADLs). Staff FF reported the patient had an extensive history of self-harm behaviors, including attempting to cut their wrists with knives and ingesting hazardous foreign objects. b. Staff FF reported the patient intentionally overdosed on their medications on 8/10/24 and swallowed multiple foreign objects, including tweezers. Staff FF reported visiting the patient on 8/11/24 to provide one-to-one (1:1) supervision of the patient while in the ED. Staff FF reported the patient appeared visibly agitated, anxious, and restless upon their arrival. c. Staff FF reported hospital staff declined to provide crayons to the patient due to concerns the patient would swallow the crayons. Per Staff FF, the patient responded with dissatisfaction and forcefully removed an intravenous (IV) catheter from their arm, resulting in bleeding. The patient proceeded to conspicuously search for items in the ED room to swallow but was initially unsuccessful due to hospital staff preemptively removing supplies and other items from the room. d. Staff FF reported hospital staff failed to remove the patient ’ s belongings from the room, which included clothing and a necklace in a bag. Recognizing this, the patient retrieved and swallowed the necklace despite Staff FF ’ s attempt to confiscate the item from the patient. e. Approximately 2 hours post-ingestion of the necklace, the patient accessed a retractable mirror attached to their bedside table and shattered the mirror with their bare hands. Staff FF then called for assistance from the ED staff who then entered the room and initiated a brief manual restraint of the patient by holding their limbs and head to the floor to prevent the patient from further harming themself or others. 5. During an interview on 10/21/24 at 1:00 PM, Patient #4 provided the following information: a. The patient reported they intentionally overdosed on their prescription medications on 8/10/24 in an attempt to commit suicide. The patient reported they informed hospital staff of their intention to commit suicide on multiple occasions during the 8/10/24 to 8/15/24 ED encounter. b. The patient reported hospital staff reviewed the patient ’ s belongings, which included clothing and a necklace. The patient reported they then informed hospital staff they intended to swallow their necklace and anything else in sight. The patient reported hospital staff responded to this by stating something to the effect of “Go ahead. You have nothing in here” prior to leaving the patient ’ s belongings unattended in the ED room. The patient then retrieved and swallowed the necklace in an attempt to commit suicide. c. The patient reported hospital staff left a bedside table with an attached mirror in the patient ’ s ED room. The patient subsequently broke the mirror to obtain a glass fragment to utilize in an additional attempt to commit suicide prior to being restrained by hospital staff. 6. During an interview on 10/17/24 at 1:00 PM, Staff G (ED Physician) provided the following information: a. Staff G reported Patient #4 had a known history of high-risk behaviors, including ingestion of a variety of foreign objects and high impulsivity. b. Staff G reported the patient identified a glass mirror attached to their bedside table, which they then broke and attempted to consume fragments of the glass prior to staff intervening. Staff G reported they and other hospital staff were unaware of the presence of the mirror attached to the patient ’ s bedside table. c. Staff G reported a high likelihood that the patient would have sustained a perforated colon or other serious complications if they had successfully ingested the broken glass. Staff G acknowledged they were unsure of how they or other hospital staff would have responded had the patient ingested the glass. 7. During an interview on 10/10/24 at 11:30 AM, Staff AA (ED RN) confirmed Patient #4 intentionally broke a concealed glass mirror attached to their table to obtain glass fragments. Staff AA indicated they suspected the patient intended to utilize the broken glass to attempt suicide. 8. During an interview on 10/10/24 at 9:00 AM, Staff C (Director of Outpatient & Emergency Services) reported Patient #4 deliberately shattered glass attached to their bedside table and attempted to ingest the glass fragments. 9. During an interview on 10/10/24 at 10:45 AM, Staff BB (ED RN) Staff BB reported hospital staff were aware of Patient #4 ’ s extensive history of self-harm.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(ii) [there must be documentation in the patient’s medical record of the following:] A description of the patient’s behavior and the intervention used. This Standard is not met as evidenced by: 50212 Based on medical record review, policy review, and staff interviews, hospital staff failed to maintain adequate documentation of the application of restraints for 1 of 10 sampled patients. Failure to appropriately document all chemical and physical restraint applications could hinder the ability of the hospital’s administrative staff to review the appropriateness and propriety of prior restraint applications and ensure ongoing compliance with hospital policies, State and Federal laws, and acceptable standards of practice regarding the use of patient restraints. Findings include: 1. Review of the 4/5/2024 policy “AH - Patient Restraints” revealed in part: a. “B. Violent, self-destructive behavior: Physical Restraints. 1. Provider Responsibility. a. A provider must see, evaluate and document the initial need for restraints within one hour after initiation of the intervention.” b. “b. Orders for restraints must include start date and time, stop date and time, type, rationale for restraint and length of time for application.” c. “2. Nursing Staff Responsibility. a. In some situations, the need for a restraint intervention may occur so quickly that an order cannot be obtained prior to the application of restraint. In these emergency application situations restraint use can be initiated by an RN based on the assessment of the patient.” d. “The order must be obtained either during the emergency application of the restraint or immediately after the restraint has been applied informing the provider of the patient condition/behavior and type of restraint applied.” e. “Documentation: Physical Restraints . . . 3. Close observation assessment documented every 15 minutes for violent, self-destructive behavior restraints.” 2. Review of Patient #4’s medical records revealed the following: a. On 8/10/24 at 1:19 PM, the patient presented to the ED for intentional overdose of a combination of prescription medications and ingestion of multiple foreign objects. b. On 8/11/24 at 9:07 PM, Staff AA (ED RN) documented the following nursing note: “Pt staff member was yelling out, pt was hitting bedside table and attempting to break parts off to hurt [themself] . . . [Staff G (ED Physician)] took pt down due to pt becoming violent. Called local PD during this time and ERP gave a verbal order to give IM ativan.” c. On 8/11/24 at 9:24 PM, Staff G (ED Physician) ordered 4-point soft (neoprene) restraints and 1 mg lorazepam IV. At 9:30 PM, Staff G documented a face-to-face evaluation of the patient. d. On 8/11/24 at 9:24 PM, Staff AA (ED RN) documented the following restraint notes: “Reason initiated: physical violence, property damage, suicide attempt, threat of harm, verbal aggression. Number of staff responders: 6. Triggers leading up to event: Pt swallowed [their] necklace, then requested to go back home. Explained to pt that [the patient] was not going home due to continued harm to self and suicidal attempts. Explained that we were looking for placement. Pt appeared angry. Less restrictive interventions attempted: 1:1 staffing, 1:1 talk, diversional activities, verbal instruction. Description of event: Pt took bedside table and attempted to break parts off of the table to harm [themself]. Tried to verbally redirect pt without success, had to become physical with pt due to immediate harm to self and others. Pt began to fight against staff, had to have multiple staff members to hold down pt for safety of others and [themself]. Outcome of event: Pt is in 4 point restraints. Plan of care: Attempt to get pt out of restraints and for pt to become calm.” e. The patient ’ s medical record did not include a provider ’ s order-either prospective or retrospective-for the manual restraint implemented by staff on 8/11/24 prior to application of the soft restraints and chemical restraint. 3. During an interview on 10/21/24 at 1:00 PM, Patient #4 provided the following information: a. The patient confirmed they intentionally overdosed on their prescription medications on 8/10/24 in an attempt to commit suicide. The patient reported they informed hospital staff of their intention to commit suicide on multiple occasions during the 8/10/24 to 8/15/24 ED encounter. b. The patient reported hospital staff left a bedside table with an attached mirror in the patient ’ s ED room, which allowed the patient to break said mirror to obtain a glass fragment to utilize in an additional attempt to commit suicide. c. The patient reported hospital staff intervened and manually restrained the patient to retrieve the glass fragment. Shortly thereafter, hospital staff applied soft restraints to the patient. 4. During an interview on 10/10/24 at 11:30 AM, Staff AA (ED RN) provided the following information: a. Staff AA reported Patient #4 intentionally broke a concealed glass mirror attached to their bedside table to obtain glass fragments with the intention to attempt suicide. b. Per Staff AA, the patient refused to release the glass fragment in their hand; thus, hospital staff manually restrained the patient on the ground, retrieved the broken glass, administered lorazepam, transported the patient to another ED room, and subsequently applied soft restraints to the patient. 5. During an interview on 10/17/24 at 1:00 PM, Staff G (ED Physician) provided the following information: a. Staff G reported the patient had a known history of high-risk behaviors, including ingestion of a variety of foreign objects, a history of suicide attempts, and high impulsivity. b. Staff G reported Patient #4 remained calm during the first day of the ED encounter; however, their behaviors suddenly escalated such that they jeopardized their safety and the safety of hospital staff. These behaviors included lunging at staff, intentionally hitting their head on the wall and floor of the ED, breaking glass, and attempting to ingest fragments of glass. c. Staff G reported they and other hospital staff manually restrained the patient to prevent the patient from self-harming with the glass fragment they had obtained. Subsequently, the staff applied soft restraints until they determined the patient no longer posed a risk to themself or to others. d. Staff G confirmed they placed an order for the application of soft restraints on 8/11/24 but reported they were not aware of any orders being placed for the initial manual restraint of the patient. Staff G indicated they were not aware manual restraints required a corresponding order by a provider.”

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 50212 Based on medical record review, policy review, and staff interviews, hospital staff failed to ensure they updated the discharge plan to include transfer to an appropriate healthcare facility with the capabilities to treat the patient after the patient displayed serious incidences of self-harming behavior for 1 of 10 sampled patients (Patient #4). Failure to update the discharge plan to accurately reflect the needs of the patient and provide appropriate transfer to all patients who require said transfer resulted in hospital staff discharging a patient with suicidal ideation home rather than to the appropriate acute level of care for mental health inpatient treatment. Findings include: 1. Review of the 09/2024 policy “Emergency Medical Screening and Examination and Treatment (EMTALA)” revealed in part: “D. Further Examination and Treatment. If the [Medical Screening Examination] reveals that the individual has an [Emergency Medical Condition], the Hospital shall provide either: a. “1. Within the capabilities of the staff and facilities available at the Hospital, further medical examination and treatment as required to stabilize the medical condition; or . . .” b. “2. Appropriate transfer to another medical facility.” 2. Review of the 11/2022 policy “Patient or Representative Rights and Responsibilities” revealed in part: “The patient or representative has the right to: . . . 11. Expect reasonable continuity of care when appropriate . . .” 3. Review of Patient #4’s medical records revealed the following: a. On 8/10/24 at 1:19 PM, the patient presented to the ED for intentional overdose of a combination of prescription medications and ingestion of multiple foreign objects. b. On 8/11/24 at 5:30 PM, Staff Q (Emergency Department (ED) Advanced Registered Nurse Practitioner (ARNP)) documented the following progress notes: “[The patient] admitted to still having suicidal thoughts during the consultation and expressed anger and disappointment that [their] suicide attempt was not successful. [The patient] also admitted to feeling worthless and having a racing mind . . . The patient expressed a desire to return home but acknowledged that [their] current mindset may not make that a safe option . . . expressing discomfort with the idea of returning home given [their] current suicidal thoughts . . . Overall Level of Risk: High . . . Patient is a current danger to [themself]. [The patient] had a suicide attempt yesterday and regrets that [the patient] was not successful in ending [their] life. [The patient] continues to have suicidal ideations at this time. I recommend inpatient hospitalization for further stabilization.” c. On 8/14/24 at 9:45 AM, Staff C (Director of Outpatient and Emergency Services) documented the following nursing note: “Call placed to [Group Home] to see about 1:1 care at facility as unable to find acute bed placement. Had to leave message.” At 12:15 PM, Staff C documented the following nursing note: “Second call placed to [Group Home] . . . [Staff V (Assistant Director)] states they do not feel they are able to keep [the patient] safe in the community if [the patient] were to come back to [Group Home] without an inpatient stay.” d. On 8/15/24 at 9:52 AM, Staff W (Psychiatric Nurse Practitioner (NP)) documented the following psychiatric consultation notes: “Suicidal Ideation: Endorses . . . Follow up with Psych provider and therapist as soon as possible . . . Keep patient on the wait list to be admitted to [Hospital B].” 4. During an interview on 10/8/24 at 7:15 AM, Patient #4 ’ s Legal Guardian (LG) provided the following information: a. LG reported the patient presented to the ED on 8/10/24 for an intentional overdose of a combination of prescription medications and ingestion of multiple foreign objects. b. LG reported contacting hospital staff on either 8/12/24 or 8/13/24, and hospital staff indicated they were in the process of seeking inpatient care for the patient. Per LG, hospital staff did not communicate a plan to discharge the patient at this time. c. LG reported hospital staff subsequently discharged the patient to their home without providing prior notification of the discharge to LG. 5. During an interview on 10/21/24 at 1:00 PM, Patient #4 provided the following information: a. The patient reported they intentionally overdosed on their prescription medications on 8/10/24 in an attempt to commit suicide. b. The patient reported they informed hospital staff of their intention to commit suicide on multiple occasions during the 8/10/24 to 8/15/24 ED encounter. The patient reported they attempted to do so on 2 separate events on 8/11/24, which included the patient ingesting their necklace and shattering a mirror attached to their bedside table in an attempt to obtain glass fragments to inflict fatal self-injury(ies). 6. During an interview on 10/17/24 at 1:00 PM, Staff G (ED Physician) provided the following information: a. Staff G reported Patient #4 had a known history of high-risk behaviors, including ingestion of a variety of foreign objects, a history of suicide attempts, and high impulsivity. b. Staff G reported the patient remained calm during the first day of the ED encounter; however, their behaviors suddenly escalated such that they began to jeopardize the safety of staff and themself. These behaviors included lunging at hospital staff, intentionally hitting their head on the wall and floor of the ED, breaking glass, and attempting to ingest fragments of glass. c. Staff G reported the patient required long-term psychiatric care in an inpatient setting, but due to difficulties finding placement in another healthcare facility, hospital staff discharged the patient to their group home. Staff G reported hospital staff provided instructions for the group home staff to maintain 24/7 supervision of the patient due to the ongoing risk of suicide. d. Staff G reported patients who were determined to require inpatient psychiatric services were often discharged to their home or group home while awaiting placement at another healthcare facility-rather than transferred to said facility-when hospital staff felt they had exhausted their options for inpatient placement at that time. 7. During an interview on 10/10/24 at 11:30 AM, Staff AA (ED RN) reported Patient #4 intentionally broke a concealed glass mirror attached to their table to obtain glass fragments. Staff AA indicated they suspected the patient intended to utilize the broken glass to attempt suicide. 8. During an interview on 10/10/24 at 9:00 AM, Staff C (Director of Outpatient & Emergency Services) provided the following information: a. Staff C confirmed Patient #4 shattered glass attached to their bedside table, attempted to ingest the glass fragments, intentionally hit their head on their bedside table, and attempted to push staff away when they intervened. b. Staff C reported speaking to Staff D (Social Worker) at Patient #4 ’ s group home prior to the patient ’ s discharge. Per Staff C, Staff D communicated they did believe they would be able to provide 1:1 supervision of the patient at all times to maintain the patient ’ s safety post-discharge. 9. During an interview on 10/14/24 at 2:20 PM, Staff Y (Director of [Group Home]) provided the following information: a. Staff Y reported their organization provided home-based rehabilitation services to Patient #4, who required care 24/7 due to severe mental illness and an extensive history of self-harm behaviors. b. Staff Y reported the patient forcefully gained access to their secured medications on 8/10/24 and intentionally overdosed on the medications in addition to swallowing multiple foreign objects, resulting in admission to the ED on 8/10/24. c. Staff Y reported the patient twice attempted to harm themself during the 8/10/24 to 8/15/24 ED admission and presented an ongoing risk to themself and to others at discharge. Per Staff Y, hospital staff discharged the patient home for 24/7 supervision by their regular home-based rehabilitation staff; however, Staff Y indicated they did not feel this plan would sufficiently preserve the patient ’ s safety given their acute needs. 10. During an interview on 10/14/24 at 1:50 PM, Staff D (Social Worker, Hospital B) provided the following information: a. Staff D confirmed hospital staff discharged Patient #4 to the patient ’ s home where they received home-based healthcare services prior to the patient ’ s admission to Hospital B on 8/19/24. b. Staff D indicated patients in need of an inpatient level of psychiatric care typically would not be discharged from the hospital to their home while awaiting admission to Hospital B.”