Lifeways Hospital

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 44100 Based on staff interview, review of meeting minutes, policies, and medical records, it was determined the hospital’s Governing Body failed to provide effective oversight and direction to hospital staff. This resulted in a compromise of patient safety. Findings include: 1. Refer to A144, as it relates to the failure of the hospital to ensure care was provided in a safe setting. The Governing Body was aware ligature risks existed in patient rooms both before and after the patient death. Plans to mitigate the ligature risks was in process but surveyors noted ligature risks remained in most patient rooms. The hospital failed to remove the immediacy of the risks.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 49416 Based on medical record review and staff interview, it was determined the hospital failed to ensure patients received care in a safe setting for 1 of 12 patients (Patient #1) whose medical records were reviewed. This caused Patient #1 to be able to strangle himself and he eventually died. This had the potential to affect all patients receiving services at the hospital. Findings include: 1. Refer to A144, as it relates to the failure of the hospital to ensure care was provided in a safe setting.”

“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: 49416 Based on medical record review, staff interview, and facility internal investigation reports, it was determined the hospital failed to ensure patients received care in a safe setting for 1 of 12 patients (Patient #1) whose medical records were reviewed. This failure resulted in Patient #1 being able to inflict self-harm by strangulation, which subsequently resulted in his death. This had the potential to affect all patients receiving services at the hospital. Findings include: Patient #1 was a 46-year-old male who was transferred from an outside facility for suicidality on 9/23/25 on a hold and admitted to this facility on 9/24/25 at 8:38 PM. The medical record from the transferring hospital documented that Patient #1 was brought in by police after an overdose with intent to commit suicide. In addition, prior to the transfer, Patient #1 then attempted to hang himself in the bathroom of the transferring hospital per social worker note in the medical record. The transferring hospital placed Patient #1 on a hold and filed related court documents. The hold was continued by Designated Examiner on 9/26/25 at the facility and documented that a new hearing would be held within 5 days. Patient #1’s medical record from this facility contained Psychiatric Technician Charting/ADLs and observation forms. Patient #1’s charting forms recorded admission to this facility on 9/24/25 at 8:23 PM on one-on-one observation status. The PT charting form for 9/25/25 day shift recorded observations as LOS, a change from the previous 12 hours. The PT charting form for 9/26/25 day shift recorded observation as Q15, a change from the previous 12 hours. Patient #1’s PT charting forms documented Q15 for the reminder of his admission. Patient #1’s medical record contained Physician’s Orders documented as observation orders. Patient #1’s Physician’s Orders upon admission documented, “Pt to remain on LOS after arrival/safety contract” at 6:00 PM on 9/24/25. A Physician Order on 9/26/25 at 11:22 AM documented “[change] LOS to Q15min OBS Keep camera up during NOC [no] shower curtain - reassess each for appropriateness.” Subsequent days of admission 9/27/25, 9/28/25, 9/29/25, 9/30/25 and 10/1/25 at 6:30 AM reaffirmed Q15 min observations. Patient #1’s medical record contained nurse progress notes. Nurse Progress Note on 9/26/25 9:13 AM documented, “[Patient #1] is cooperative with cares, pleasant, visibly sad, upset and stressed out. Rates his depression 5, anxiety 5, stated that he could contract for safety, states that he feels a little better after the PRN Ativan. [Patient #1] is attending groups, remains on LOS status. Denies SI/HI/HA.” Patient #1 was on Q15 at this time per chart. Additional Nurse Progress Note on the morning of 9/29/25 noted depression and anxiety as “extreme” although Patient #1 denied SI/SA/SH however the nurse documented for Patient #1, “noted in treatment team that he “didn’t think” he would have a suicide plan on discharge.” Patient #1’s evening of 9/29/25 Progress Notes noted “evidence of responding to internal stimulation, stated his head is just so full of voices.” The 9/29/25 Progress Note also noted Patient #1 was not compliant with evening medications and was “so very sad” but was “able to contract for safety.” Additionally, Patient #1’s medical record continued a “High Risk Notification Alert” note which documented on 9/29/25 and 9/30/25 new hallucinations but no corresponding changes to plan of care or medications were found in the medical record. Patient #1’s chart on 10/1/25 documented Q15 observations, with the night shift PT initialed at 6:00 AM and 6:15 AM that Patient #1 was lying down and the day shift initialed at 6:30 AM and 6:45 AM that Patient #1 was sleeping. There was also a camera in Patient #1’s room that could be monitored from the nurses station. However, as Patient #1 was found unresponsive with no respirations at 6:56 AM, it was unlikely he was asleep at the 6:45 AM observation time. The facility’s Root Cause Analysis of Patient #1’s strangulation was reviewed. An accounting of the morning of 10/1/25 was documented and detailed that at 6:56 AM nurses responded to Patient #1’s room. At 6:58 AM the nurse cut “the ligature from patient’s neck” and CPR was initiated. At 7:07 AM, EMS arrived and took over resuscitative efforts and succeeded in obtaining a pulse. At 7:31 AM the paramedics left the facility with Patient #1 and transported him to an outside trauma hospital. Patient #1 later succumbed to his injuries at the outside hospital on 10/1/25 at 11:04 PM. PT A, who was working on 10/1/25 was interviewed on 11/18/25 beginning at 11:00 AM. PT A confirmed the observation policies had been updated to make observations more specific; this included visualizing the patient’s face and hands and that signs of life must be confirmed. If a patient was not visualized, they must be located at that time of observation before proceeding to the next patient check. PT A further confirmed she had conducted the Q15 checks on Patient #1 at 6:30 AM and 6:45 AM and she mistakenly thought Patient #1 was in his bed under blankets. She confirmed she had not checked to see his face, hands or signs of life. The RCA stated PT A, “glanced at the foot of the bed and thought she saw patient present.” The RCA further documented, “PT [B] enters room for vitals, observes patient not in bed, calls out for patient, then continues vital checks for other assigned patients.” Two staff members had the opportunity to check on and assure safety of Patient #1 at 6:45 AM and 6:48 AM but failed to do so. The DNS and ADNS were interviewed on 11/18/25 beginning at 4:15 PM. The DNS also confirmed that polices on observation had been updated to be more detailed and explicit but that the options of 1:1, LOS and Q15 continued to be the options, with the providers writing those orders. The DNS also confirmed that ligature risks currently remained in patient rooms. When asked if ligature risks were identified prior to this incident, the ADNS reported it had been identified by the previous administrator and “while ligature risks were identified prior to the incident but red tape holds up everything.” The hospital failed to ensure patients were properly observed to protect from serious injury, harm or death. The facility was notified of an Immediate Jeopardy finding at A 0144 on 11/18/25 at 1:45 PM. A plan of correction was submitted and accepted on 11/19/25 at 9:45 AM. The POC included implementation of updated policies and staff training involving additonal assessment of suicidality, the addition of a moderate risk protocol, and reduction in census to allow for increased monitoring of patients with SI. Observations and interviews were conducted in the facility on 11/19/25 begining at 10:30 AM. The facility was notified the Immediate Jeopardy was removed at 11/19/25 at 11:30 AM .”

“The facility is a single-story, Type V (111) structure, originally built in 1990. The facility is fully sprinklered with an interconnected fire alarm/smoke detection system. The kitchen, dining area, staff lounge and administration offices are separated from the sleeping rooms by a two-hour fire separation. The facility is currently licensed for 16 beds with a census of 16 on the date of the survey. The following deficiencies were cited during the Fire/Life Safety survey conducted on June 25, 2024. The facility was surveyed under the Life Safety Code, 2012 Edition, Chapter 19, Existing Healthcare Occupancies, in accordance with 42 CFR 482.41.”

“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: 49551 Based on record review and interview, the facility failed to ensure installed fire alarm/smoke detection systems were inspected and/or tested in accordance with NFPA 72. Failure to ensure fire alarm and smoke detection systems are inspected and tested in accordance with the standard, has the potential to hinder system and staff response during a fire event. This deficient practice affected 16 patients, staff and visitors on the date of the survey. Findings include: During review of provided system inspection records conducted on June 25, 2024 from 8:30 am - 11:30 am, the facility failed to provide documentation for (1) location of all devices tested including but not limited to pull stations, horn strobes, smoke detectors and heat detectors. (2) smoke detection sensitivity testing within the previous five years. When asked at 11:00 am the maintenance director stated all smoke detectors were replaced in April of 2022 with no further testing of sensitivity. Actual NFPA standard: NFPA 72 14.4 Testing. 14.4.5.3.1 Sensitivity shall be checked within 1 year after installation. 14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3. 14.4.5.3.3 After the second required calibration test, if sensitivity tests indicate that the device has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. 14.6.2 Maintenance, Inspection, and Testing Records. 14.6.2.1 Records shall be retained until the next test and for 1 year thereafter. 14.6.2.4% A record of all inspections, testing, and maintenance shall be provided that inc”