Jackson Park Hospital

“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: 39802 Based on document review and interview, the Hospital failed to comply with the Condition of Participation 42 CFR 482.23, Nursing Services. Finding include: 1. The Hospital failed to ensure that the nurse(s) supervising the care of the patient did not interfere with management of the patient’s artificial airway in an emergency situation. (A-395 A) 2. The Hospital failed to ensure that the nurse supervising the care of the patient filed an incident report for an unusual occurrence involving a tracheostomy tube (artificial airway in the neck) dislodgement, so that the incident could be reviewed/investigated. (A-395 B)”

“RESPIRATORY CARE SERVICES CFR(s): 482.57 The hospital must meet the needs of the patients in accordance with acceptable standards of practice. The following requirements apply if the hospital provides respiratory care services. This Condition is not met as evidenced by: 39802 Based on document review and interview, the Hospital failed to comply with the Condition of Participation 42 CFR 482.57, Respiratory Services. Finding include: 1. The Hospital failed to ensure that written policies were in place for the respiratory staff response and procedures to follow in the event of tracheostomy (artificial airway in the neck) tube displacement. (A-1160 A). 2. The Hospital failed to ensure that written policies were in place for the respiratory staff in regard to emergency bedside equipment, ventilator checks, and cuff pressure checks. (A-1160 B). An immediate jeopardy (IJ) began on 12/09/2025 and was identified on 02/10/2026 due to the Hospital’s failure to ensure that written policies were in place for the respiratory staff response and procedures to follow in the event of tracheostomy tube displacement, for 1 of 1 patient (Pt #1) on a mechanical ventilator whose tracheostomy tube became dislodged. Subsequently, a Code Blue (response to cardiac arrest) was called and Pt #1 expired. The IJ was announced on 02/10/2026 at 2:00 PM during a meeting with the Senior Vice President of Patient Care, the Senior Vice President of Quality, the Director of Quality, Clinical Director of ICU and ED, Clinical Director of Behavioral Health, and the Manager of Respiratory Therapy. The IJ was removed/not removed by survey exit day of 02/11/2026.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 39802 A. Based on document review and interview, the Hospital failed to ensure that the nurse(s) supervising the care of the patient did not interfere with management of the patient’s artificial airway in an emergency situation, for 1 of 1 patient (Pt #1) on a mechanical ventilator whose tracheostomy (artificial airway in the neck) tube became dislodged. Findings include: 1. The Hospital’s policy titled, “Tracheostomy Care” (revised 08/2006), was reviewed on 02/04/2026 and included suctioning, inner tube care, and stoma care as responsibilities of the nursing staff. The policy did not address what procedure to follow, including which personnel was designated and trained to perform, if a tracheostomy tube becomes dislodged/decannulated. 2. The Hospital’s policy titled, “Code Blue Responsibilities” (revised 04/2017), was reviewed on 02/04/2026 and indicated that ICU Nurses and Respiratory Therapists are part of the Code Blue (cardiac arrest) response team. The policy included, “ ...Second Nurse Responsibilities: ...Sets up the oxygen equipment if Respiratory Therapy has not arrived. a. Open respiratory code box. B. Connect bag valve, mask and oxygen tubing. c. Connect oxygen tubing to oxygen flow meter on Twin-High Pressure and turn rate up to 10 liters. d. Reopen the airway to insert the oral pharyngeal airway. e. Maintaining an open airway, place the mask over the nose and mouth, form a tight seal and ventilate. Watch for chest expansion with ventilation and auscultate breath sounds ... Respiratory Therapist Responsibilities: a. Sets up the oxygen equipment if not already done. b. After intubation, airway patency and ventilation is maintained by the Respiratory Therapist. c. Assumes management of ventilator if needed ...” 3. The clinical record for Pt. #1 was reviewed on 02/04/2026. Pt. #1 arrived to the Hospital’s emergency room (ED) via ambulance on 11/07/2025 with complaints of respiratory failure, severe acute bronchospasm (tightening of air passage), unresponsiveness CO2 (carbon dioxide) narcosis (severe, life-threatening condition caused by extreme high levels of CO2 leading to a depressed level of consciousness, confusion, seizures, or coma). The record indicated that Pt. #1 was intubated (insert a tube into (a person or a body part, especially the trachea for ventilation).while in the ED and was placed on a mechanical ventilator. The History & Physical, dated 11/07/2025 at 10:23 AM, included “ ...COPD [chronic obstructive pulmonary disease] exacerbation with CO2 narcosis, Narcotic induced respiratory failure ... Plan: Admit to ICU [Intensive Care Unite] ... Pulmonary [MD#5] on consult ...” Physician and Nursing Progress Notes from 11/07/2025 to 11/29/2025 indicated the following: - Pt. #1 was sedated and remained on a ventilator from 11/07/2025 through 12/02/2025. - Pt. #1 underwent a surgical procedure to create a tracheostomy on 11/29/2025. - Pt. #1 was weaned off sedation starting on 12/03/2025, after which Pt. #1 woke up, but remained on the ventilator after failed attempts to wean off mechanical ventilation. - Pt. #1’s condition was noted as much improved with plans to transfer Pt. #1 to a LTACH (long-term acute care hospital) - Pt. #1’s behavior was noted to be alert with periods of restlessness and agitation requiring as needed administration of Lorazepam (antianxiety medication) and/or Haldol (antipsychotic). - Tracheostomy care including suction and stoma care was completed by nursing personnel minimally every 4 hours and as needed. ICU Nurse Note (E#12), dated 12/09/2025 at 8:38 PM, included “[12/09/2025 at] 6:10 PM- Noted patient trach tube was out. Tried to reinsert but unsuccessful. Paged respiratory and informed [Resident Physician MD#2]. Informed Anesthesia and [Anesthesiologist MD#3] intubated the patient. Patient went in PEA [pulseless electrical activity]. ACLS [advanced cardiac life support] protocol initiated. Patient developed subcutaneous emphysema [air trapped in the tissues under the skin, most often in the chest and neck causing swelling and a crackling sensation (crepitus)] and [ED Physician MD#4] inserted chest tube. CPR [cardiopulmonary resuscitation] continued [until] patient was pronounced at 7:04 PM ...” The Code Blue Sheet, dated 12/09/2025, indicated that Pt. #1 went into cardiac arrest at 6:15 PM and CPR was initiated. The sheet indicated that the Code team arrived at 6:20 PM and the patient was then intubated with an endotracheal (ETT) tube. Team Members documented on the sheet included, Resident Physician (MD#2), ICU Nurse (E#13), Anesthesiologist (MD#3), Respiratory Therapist (E#14), and Nursing Supervisor (E#11). The Resident (MD#2) Code Blue Note, dated 12/09/2025 at 7:26 PM, included “Nursing staff called at 6:10 PM reporting patient desaturation. Patient had been restless throughout the day despite soft restraints. Upon arrival, tracheostomy tube was noted to be partially dislodged. Patient rapidly deteriorated. [Events:] At 6:10 PM, patient found desaturating with partially dislodged tracheostomy. Repositioning was attempted but was unsuccessful. Bag-mask ventilation initiated. Anesthesiologist [MD#3] unable to re-establish ventilation via tracheostomy; patient orotracheally intubated at 6:20 PM ... Patient noted to be in PEA arrest: HR [heart rate] on monitor 75 [normal range 60-100] but no palpable pulses or Doppler-detectable pulses. High-quality CPR initiated at 6:20 PM. Rhythm remained non-shockable throughout resuscitation ... Portable chest x-ray at 6:37 PM revealed pneumothorax [collapsed lung caused by air leaking into the space between the lung and chest wall] and subcutaneous emphysema. Chest tube placed at 6:43 PM by ER Physician [MD#4] ... No return of spontaneous circulation. Time of death: 7:04 PM. Assessment: Cardiopulmonary arrest (PEA [pulseless electrical activity - life threatening heart rhythm with electrical activity but no pulse/mechanical action does not generate blood flow, and defibrillation is not indicated]) secondary to acute hypoxic respiratory failure following self/accidental tracheostomy dislodgement. Complicated by pneumothorax and subcutaneous emphysema ...” The ED Physician (MD#4) note, dated 12/09/2025 at 7:13 PM included, “I was called from ED for code blue patient with concern for need for chest tube. When I arrived, patient already intubated by anesthesia, PEA, a few rounds epi [emergency medication]; had very visible signs of subcutaneous emphysema (left thorax and face notably swollen/crepitus). I was told by nurses that patient had been in ICU for a long time, trached and vented on trach[tracheostomy] for some time. The trach had started to dislodge, vent was alarming, and after they pushed it back in, [Pt. #1] started to get panicked, was bagged through the trach and then coded. Suspected that the trach somehow went into a facial plan [space between soft tissues]. Still, was unclear to me why this would lead to coding except for hypoxia from no O2 [oxygen], but then didn’t come back from PEA with intubation. [Anesthesiologist MD#3] claimed MD#3 got no color change [changes from purple to yellow in the presence of CO2 which would indicate being in the airway] with CO2 detector (Despite good ETT/endotracheal tube placement on CXR/chest x-ray later performed) ... [Chest tubes placed], no rush of air - didn’t seem clinically like tension pneumothorax but I also couldn’t think why [Pt. #1] would have coded and not gotten ROSC [return of spontaneous circulation] with such a reportedly brief interval between trach dislodgement and intubation ...” 4. A telephone interview was conducted with ICU Nurse (E#12) on 02/05/2026 at approximately 12:19 PM. E#12 stated that E#12 was sitting right outside E#12’s room when E#12 heard the vent alarm sound around 6:10 PM on 12/09/2025. E#12 went in the room immediately and saw that Pt. #1 was moving around in the bed and the trach tube was partially dislodged and the patient was desaturating. E#12 stated that E#12 called for help and another ICU nurse (E#13) came to help. E#12 stated that E#13 pushed the trach back in. E#12 stated that they paged respiratory and a resident doctor (unknown) came as well. E#12 stated that respiratory came within 5 minutes and they started to ambu [use Ambu bag-a handheld, manual resuscitator that delivers positive pressure ventilation to patients with inadequate or no breathing the patient through the trach]. E#12 stated that they started to notice subcutaneous emphysema developing and stopped bagging through the trach. E#12 stated anesthesia was there at that time and then intubated the patient. E#12 stated that the patient when into cardiac arrest shortly after and MD#2 called a code blue. E#12 stated, “We did everything right with this patient.” E#12 denied having any concerns with Respiratory Therapy’s (RT) response time or how MD#2 handled the code. E#12 stated that if a vent alarm goes off, they will call respiratory to come. E#12 stated that if ventilator tubing disconnects, they (nurses) are able to put it back. E#12 stated that if a trach tube comes out fully, they will not try to reinsert it. E#12 stated that they will call RT and RT will keep it covered and ambu the patient through the face mask only. E#12 stated that if the trach is not fully out, then they can reinsert it. E#12 stated that this was verbally told to them by their Medical Director of ICU (MD#5) but there is no training or specific policy about it. 5. A telephone interview was conducted with ICU Nurse (E#13) on 02/05/2026, at approximately 4:05 PM. E#13 stated that Nurse E#12 called for help to room #7 for Pt. #1. E#13 stated that Pt. #1’s trach was partially out and the patient was still awake and alert. E#13 stated that the pushed it back in but not all the way. E#13 stated that the trach was still connected to the vent. E#13 stated that RT arrived within 2-3 minutes and started bagging the patient through the trach. E#13 stated that RT was aware that the trach had been partially dislodged. E#13 stated that RT is typically responsible for maintaining the airway and oxygenating the patient. E#13 stated that the patient continued to desaturate and anesthesia came to intubate the patient and a code blue was called. E#13 stated that if a trach comes out, they will usually call RT who takes care of those things. E#13 stated that if a trach comes complete out completely, they will bag[sic] through a face mask. E#13 stated that if the trach only comes out partially, they will ventilate the patient through the trach with an ambu-bag [Ambu bag-a handheld, manual resuscitator that delivers positive pressure ventilation to patients with inadequate or no breathing or the ventilator]. E#13 stated that there has been no education since this incident on how to handle trach dislodgements. 6. An interview was conducted with Pulmonologist/ Medical Director of ICU and Respiratory Therapy (MD#5) on 02/05/2026 at approximately 2:30 PM. MD#5 stated that during a medical staff meeting on 01/29/2026, they discussed the case of Pt. #1. MD#5 stated that after review they determined that likely the trach was misplaced when reinserted. MD#5 stated that staff should not try to reinsert a new trach and should not try to bag through a misplaced/dislodged trach. MD#5 stated that RT is supposed to call anesthesia to intubate the patient as they are not trained to handle tracheostomy tubes in that manner (re-insertion). MD#5 stated that in the meantime while waiting for anesthesia to arrive, they should cover the trach and bag the patient through a face mask. MD#5 stated that if the trach goes into the wrong place the patient will not be oxygenated and other problems could arise such as the patient developing emphysema. MD#5 stated that after reviewing the x-ray images, they noted pneumomediastinum (air in the mediastinum/central compartment of the thoracic cavity). MD#5 stated that as more air enters the mediastinum it compresses the veins leading to the heart, which can cause pump failure and ultimately lead to cardiac arrest. MD#5 also stated that under increased pressure, they air could shift between the tissues and stated that it was a possibility the air migrated to the right side and could have led to the pneumothorax. MD#5 stated that at this time they do not have a written policy/procedure for how to handle decannulated trachs but are discussing setting a policy. MD#5 was not aware of any changes that have been made thus far to address the findings and recommendations from the review. B. Based on document review and interview, the Hospital failed to ensure that the nurse supervising the care of the patient filed an incident report for an unusual occurrence involving a tracheostomy tube dislodgement, so that the incident could be reviewed/investigated, for 1 of 1 patient (Pt #1) on a mechanical ventilator whose tracheostomy tube became dislodged. Findings include: 1. The Hospital’s policy titled, “Incident Reporting” (revised 01/2025), was reviewed and required, “ ...Incident: Any unusual or unexpected occurrence that results in injury or potential injury to patients, staff, or visitors ... Employees who witness or are aware of an incident are responsible for completing an Incident Report at the time they become aware of the incident ... Submit the completed form to the Nursing Staffing Office in the Risk Management file box. The Risk Management Department will pick-up all incident reports from Nursing Staffing Office ...The Risk Manager will review all Incident Reports and injury type ... Risk Management will enter information from each occurrence into a database. Information contained in the database will be summarized and reviewed by the Safety Committee and a summary report will be given to the Quality Improvement Committee ...” 2. The clinical record for Pt. #1 was reviewed on 02/04/2026. Pt. #1 arrived to the Hospital’s emergency room via ambulance on 11/07/2025 with complaints of respiratory failure, severe acute bronchospasm (tightening of air passage), unresponsiveness CO2 (carbon dioxide) narcosis (severe, life-threatening condition caused by extreme high levels of CO2 leading to a depressed level of consciousness, confusion, seizures, or coma). The record indicated that Pt. #1 was intubated while in the ED and was placed on a mechanical ventilator. Pt. #1 was then admitted to the Intensive Care Unit on 11/07/2025 and remained on the ventilator. Pt. #1 underwent a surgical procedure to create a tracheostomy on 11/29/2025 and was weaned off sedation on 12/03/2025. Pt. #1’s behavior was noted to be alert with periods of restlessness and agitation requiring as needed administration of Lorazepam (antianxiety medication) and/or Haldol (antipsychotic). On 12/09/2025 at 6:10 PM, Pt. #1’s trach was found to be partially dislodged. Subsequently, Pt. #1 went into cardiac arrest, Code Blue was called and CPR initiated; however, Pt. #1 expired on 12/09/2025 at 7:04 PM. 3. The Incident log from 11/1/2025-2/4/2026, was reviewed on 2/4/2026. There was only one incident related to Pt #1 that was filed as a Code Blue. Per the Risk Manager/Director of Quality (E#16) on 02/04/2026, there is no written incident report for Code Blues, they only include them on the incident log to track them. E#16 stated unless there was a reported incident/concern with a code, a review would not be completed. E#16 confirmed that that no review was completed for Pt. #1’s code on 12/09/2025. 4. An interview was conducted with the Senior Vice President of Patient Care (E#1) on 02/09/2026 at 10:28 AM. E#1 stated that all the nursing managers report up to E#1, as E#1 oversees nursing. E#1 stated that the managers will verbally report any concerns to E#1 during daily meetings around 9 AM. E#1 stated that there were no concerns reported to E#1 specifically regarding Pt. #1’s code. E#1 stated that if E#1 had known, they would have done an investigation. E#1 stated that E#1 was only informed that Pt. #1’s trach had come out and they could not successfully re-insert it so they intubated the patient. E#1 stated that the have a family practice physician who reviews all the code blue forms at the end of each month. E#1 stated that the analyses are reviewed in their acute care meetings. E#1 stated that E#1 does not recall a particular analysis on Pt. #1’s case in their last meeting in December. E#1 stated that they would do an analysis if a concern was reported/identified. E#1 stated that there has been no changes to nursing practice because they were not aware that anything was wrong. E#1 stated that staff should fill out an incident report if a trach tube becomes dislodged so that it can be investigated/reviewed. E#1 stated that anyone who discovers it should report it. E#1 stated that all staff are aware on how to file a report using the written form.”

“RESPIRATORY CARE SERVICES POLICIES CFR(s): 482.57(b) Services must be delivered in accordance with medical staff directives. This Standard is not met as evidenced by: 39802 A. Based on document review and interview, the Hospital failed to ensure that written policies were in place for the respiratory staff response and procedures to follow in the event of tracheostomy tube displacement, for 1 of 1 patient (Pt #1) on a mechanical ventilator whose tracheostomy tube became dislodged. Subsequently, a Code Blue (response to cardiac arrest) was called and Pt #1 expired. Findings include: 1. The Hospital’s policy titled, “Tracheostomy Care” (revised 08/2006), was reviewed on 02/04/2026. The policy did not address what procedure to follow if a tracheostomy (artificial airway created in the neck) tube becomes dislodged/displaced. 2. The Hospital’s policy titled, “Code Blue Responsibilities” (revised 04/2017), was reviewed on 02/04/2026 and indicated that Respiratory Therapists are part of the Code Blue (cardiac arrest) response team. The policy included, “Respiratory Therapist Responsibilities: a. Sets up the oxygen equipment if not already done. b. After intubation, airway patency and ventilation is maintained by the Respiratory Therapist. c. Assumes management of ventilator if needed ...” 3. The Hospital’s policy titled, “Physician Orders for Mechanical Ventilation” (revised 07/2006), was reviewed on 02/04/2026 and indicated that respiratory therapy was responsible for executing physician orders related to ventilator management and respiratory treatments. The policy did not address what procedure to follow if a tracheostomy (artificial airway created in the neck) tube becomes dislodged/ displaced. 4. The clinical record for Pt. #1 was reviewed on 02/04/2026. Pt. #1 arrived to the Hospital’s emergency room (ED) via ambulance on 11/07/2025 with complaints of respiratory failure, severe acute bronchospasm (tightening of air passage), unresponsiveness CO2 (carbon dioxide) narcosis (severe, life-threatening condition caused by extreme high levels of CO2 leading to a depressed level of consciousness, confusion, seizures, or coma). The record indicated that Pt. #1 was intubated (insert a tube into the windpipe for ventilation) while in the ED and was placed on a ventilator. The History & Physical, dated 11/07/2025 at 10:23 AM, included “ ...COPD [chronic obstructive pulmonary disease] exacerbation with CO2 narcosis, Narcotic induced respiratory failure ... Plan: Admit to ICU ... Pulmonary [MD#5] on consult ...” Physician and Nursing Progress Notes from 11/07/2025 to 11/29/2025 indicated the following: - Pt. #1 was sedated and remained on a ventilator from 11/07/2025 through 12/02/2025. - Pt. #1 underwent a surgical procedure to create a tracheostomy on 11/29/2025. - Pt. #1 was weaned off sedation starting on 12/03/2025, after which Pt. #1 woke up, but remained on the ventilator after failed attempts to wean off mechanical ventilation. - Pt. #1’s condition was noted as much improved with plans to transfer Pt. #1 to a LTACH (long-term acute care hospital) - Pt. #1’s behavior was noted to be alert with periods of restlessness and agitation requiring as needed administration of Lorazepam (antianxiety medication) and/or Haldol (antipsychotic). - Tracheostomy care including suction and stoma care was completed by nursing personnel minimally every 4 hours and as needed. Respiratory Therapy (RT) Notes from 11/07/2025-12/09/2025 were reviewed and indicated that ventilator settings and alarm checks were completed every 4 hours, with the last documented check completed on 12/09/2025 at 2:00 PM. ICU Nurse Note (E#12), dated 12/09/2025 at 8:38 PM, included “[12/09/2025 at] 6:10 PM- Noted patient trach tube was out. Tried to reinsert but unsuccessful. Paged respiratory and informed [Resident Physician MD#2]. Informed Anesthesia and [Anesthesiologist MD#3] intubated the patient. Patient went in PEA [pulseless electrical activity]. ACLS [advanced cardiac life support] protocol initiated. Patient developed subcutaneous emphysema [air trapped in the tissues under the skin, most often in the chest and neck causing swelling and a crackling sensation (crepitus)] and [ED Physician MD#4] inserted chest tube. CPR [cardiopulmonary resuscitation] continued [until] patient was pronounced at 7:04 PM ...” The Code Blue Sheet, dated 12/09/2025, indicated that Pt. #1 went into cardiac arrest at 6:15 PM and CPR (cardiopulmonary resuscitation) was initiated. The sheet indicated that the Code team arrived at 6:20 PM and the patient was then intubated with an endotracheal (ETT) tube. Team Members documented on the sheet included, Resident Physician (MD#2), ICU Nurse (E#13), Anesthesiologist (MD#3), Respiratory Therapist (E#14), and Nursing Supervisor (E#11). The Resident (MD#2) Code Blue Note, dated 12/09/2025 at 7:26 PM, included “Nursing staff called at 6:10 PM reporting patient desaturation [a drop in blood oxygen]. Patient had been restless throughout the day despite soft restraints. Upon arrival, tracheostomy tube was noted to be partially dislodged. Patient rapidly deteriorated. [Events:] At 6:10 PM, patient found desaturating with partially dislodged tracheostomy. Repositioning was attempted but was unsuccessful. Bag-mask ventilation initiated. Anesthesiologist [MD#3] unable to re-establish ventilation via tracheostomy; patient orotracheally intubated at 6:20 PM ... Patient noted to be in PEA arrest: HR [heart rate] on monitor 75 [normal range 60-100] but no palpable pulses or Doppler-detectable pulses. High-quality CPR initiated at 6:20 PM. Rhythm remained non-shockable throughout resuscitation ... Portable chest x-ray at 6:37 PM revealed pneumothorax [collapsed lung caused by air leaking into the space between the lung and chest wall] and subcutaneous emphysema. Chest tube placed at 6:43 PM by ER Physician [MD#4] ... No return of spontaneous circulation. Time of death: 7:04 PM. Assessment: Cardiopulmonary arrest (PEA [pulseless electrical activity - life threatening heart rhythm with electrical activity but no pulse/mechanical action does not generate blood flow, and defibrillation is not indicated]) secondary to acute hypoxic respiratory failure following self/accidental tracheostomy dislodgement. Complicated by pneumothorax and subcutaneous emphysema ...” The ED Physician (MD#4) note, dated 12/09/2025 at 7:13 PM included, “I was called from ED for code blue patient with concern for need for chest tube. When I arrived, patient already intubated by anesthesia, PEA, a few rounds epi [emergency medication]; had very visible signs of subcutaneous emphysema (left thorax and face notably swollen/crepitus). I was told by nurses that patient had been in ICU for a long time, trached and vented on trach for some time. The trach[tracheostomy] had started to dislodge, vent was alarming, and after they pushed it back in, [Pt. #1] started to get panicked, was bagged through the trach and then coded. Suspected that the trach somehow went into a facial plan [space between soft tissues]. Still, was unclear to me why this would lead to coding except for hypoxia from no O2 [oxygen], but then didn’t come back from PEA with intubation. [Anesthesiologist MD#3] claimed MD#3 got no color change [changes from purple to yellow in the presence of CO2 which would indicate being in the airway] with CO2 detector (Despite good ETT/endotracheal tube placement on CXR/chest x-ray later performed) ... [Chest tubes placed], no rush of air - didn’t seem clinically like tension pneumothorax but I also couldn’t think why [Pt. #1] would have coded and not gotten ROSC [return of spontaneous circulation] with such a reportedly brief interval between trach dislodgement and intubation ...” 4. A telephone interview was conducted with ED Physician (MD#4) on 02/05/2026, at approximately 10:06 AM. MD#4 stated that MD#4 was requested to insert a chest tube due to suspected pneumothorax during Pt. #1’ code blue on 12/09/2026. MD#4 stated that upon arrival the patient had already been intubated and there were very noticeable signs of severe subcutaneous emphysema on the patient’s left side. MD#4 stated that this can happen if air is leaking (i.e. from a hole in the lung on that side) or being fed into the tissues such as if the trach is placed in the fascial plane (tissues), which MD#4 later suspected when there was no air return after placing the chest tube. MD#4 stated that MD#4 had placed the chest tube on the left side because that was where the patient was showing signs of air under the skin (emphysema). MD#4 stated that the chest x-ray later showed that the pneumothorax was actually on the right side. 5. A interview was conducted with Anesthesiologist (MD#3) on 02/05/2026, at approximately 11:16 AM. MD#3 stated that when MD#3 arrived, the respiratory therapist was bagging Pt. #1 through the trach. MD#3 stated that there were visible signs of subcutaneous emphysema on the left side. MD#3 stated that MD#3 was told that the trach had been dislodged. MD#3 stated that MD#3 told them to stop bagging and MD#3 gave one breath into the trach and did not get any end tidal CO2 (no color change to indicate being in the airway) and stated that they were not in the lungs. MD#3 stated that MD#3 did not ask how long they had been bagging the patient through the trach. MD#3 stated that MD#3 wanted to establish a new airway right away because encephalopathy (brain damage) can occur within 2-3 minutes without oxygen. MD#3 then intubated the patient from above (via mouth) with an endotracheal tube and was able to get end-tidal CO2. MD#3 stated that with new trachs that are not developed (under two weeks old), when reinserting the trach, there is a higher chance that the trach may go in between the layers of tissue instead of into the airway, so it’s important to make sure that the trach is in the right place. 6. An interview was conducted with Pulmonologist/ Medical Director of ICU and Respiratory Therapy (MD#5) on 02/05/2026 at approximately 2:30 PM. MD#5 stated that during a medical staff meeting on 01/29/2026, they discussed the case of Pt. #1. MD#5 stated that after review they determined that likely the trach was misplaced when reinserted. MD#5 stated that staff should not try to reinsert a new trach and should not try to bag through a misplaced/dislodged trach. MD#5 stated that RT is supposed to call anesthesia to intubate the patient as they are not trained to handle tracheostomy tubes in that manner (re-insertion). MD#5 stated that in the meantime while waiting for anesthesia to arrive, they should cover the trach and bag the patient through a face mask. MD#5 stated that if the trach goes into the wrong place the patient will not be oxygenated and other problems could arise such as the patient developing emphysema. MD#5 stated that after reviewing the x-ray images, they noted pneumomediastinum (air in the mediastinum/central compartment of the thoracic cavity). MD#5 stated that as more air enters the mediastinum it compresses the veins leading to the heart, which can cause pump failure and ultimately lead to cardiac arrest. MD#5 also stated that under increased pressure, they air could shift between the tissues and stated that it was a possibility the air migrated to the right side and could have led to the pneumothorax. MD#5 stated that at this time they do not have a written policy/procedure for how to handle decannulated trachs but are discussing setting a policy. MD#5 was not aware of any changes that have been made thus far to address the findings and recommendations from the review. 7. Interviews were conducted on 02/05/2026 with the two ICU Nurses (E#12 and E#13) involved in Pt. #1’s code on 12/09/2025. E#12 stated that Pt. #1 was moving Pt. #1’s head up and down and that caused the trach to come out partially. E#12 and E#13 stated that the trach was reinserted while still connected to the ventilator, but the patient continued to desaturate (decreased oxygen levels). Both nurses stated that within a few minutes Respiratory Therapy arrived and started bagging the patient through the trach until anesthesia came to intubate the patient. Both E#12 and E#13 stated that if a trach comes completely out, they will call respiratory to come, and in the meantime will cover the stoma and bag through the face; however, if it just comes partially out, they will push it back in and bag through the trach. Both E#12 and E#13 stated that there has not been any education on how to handle trach dislodgement since this incident. 8. A telephone interview was conducted with Respiratory Therapist/RT (E#14) on 02/05/2026, at approximately 4:19 PM. E#14 was one of the RTs that responded to Pt. #1’s code on 12/09/2026. E#14 stated that RT must respond to all Code Blues. E#14 stated that RT is responsible for maintaining the airway and ventilating the patient. E#14 stated that when E#14 arrived at the code, RT E#15 was already bagging Pt. #1 via the trach. E#14 stated that the only way to bag a patient that way on a ventilator is through the trach. E#14 stated that if a trach becomes dislodged partially or fully, they will call anesthesia. When asked how to ventilate the patient with a dislodged/decannulated trach, E#14 stated that E#14 has never been in a situation when a trach has been dislodged and stated that E#14 just knows to call anesthesia. E#14 stated that E#14 had not received any training on how to handle trach dislodgement besides being told to call anesthesia. 9. An interview was conducted with RT (E#15) on 02/09/2026, at approximately 9:30 AM. E#15 stated that RT is generally responsible for complete ventilator checks, nebulizer treatments, and changing vent settings if ordered by the physician. E#15 stated that they must also respond to all Code Blues. E#15 stated that E#15 was the first RT to arrive for Pt. #1’s code on 12/09/2026. E#15 stated that when E#15 arrived, the nurses were doing CPR and the patient’s trach was connected to the ventilator. E#15 stated that E#15 started to bag the patient through the trach. E#15 stated that nobody had reported to E#15 that the trach tube had been dislodged prior. E#15 did not recall checking for CO2 in the trach prior to bagging the patient. E#15 stated that if a trach tube is out, they will try to put it back in and check the placement with the CO2 detector or look at the vent to see if they are getting return volume. E#15 stated that if they bag through the mouth, they will lose air through the trach hole. E#15 stated that E#15 last worked on Tuesday 02/03/2026 and stated that E#15 had not been asked about what happened with Pt. #1’s case and stated that there had not been any changes to their practice. B. Based on document review, observation, and interview, the Hospital failed to ensure that written policies were in place for the respiratory staff in regard to emergency bedside equipment, ventilator checks, and cuff pressure checks. Findings include: 1. The Hospital’s policy titled, “Physician Orders for Mechanical Ventilation” (revised 07/2006), was reviewed on 02/04/2026 and indicated that respiratory therapy was responsible for executing physician orders related to ventilator management and respiratory treatments. The policy included, “Cardiopulmonary staff is responsible for making all ventilator adjustments via physician order. The policy did not address how often ventilator checks should be completed and what is required for each check (i.e. checking cuff pressure or minimal leak test to ensure cuff is not overinflated). Policies regarding emergency bedside equipment, ventilator checks, etc. were requested on 02/04/2026 and 02/05/2026 at approximately 9:00 AM. Per the Senior Vice President of Patient Care (E#1) on 02/05/2026, they did not have any written policies or competencies to covered these topics. 2. The clinical record for Pt. #1 was reviewed on 02/04/2026. Pt. #1 arrived to the Hospital’s emergency room (ED) via ambulance on 11/07/2025 with complaints of respiratory failure, severe acute bronchospasm (tightening of air passage), unresponsiveness CO2 (carbon dioxide) narcosis (severe, life-threatening condition caused by extreme high levels of CO2 leading to a depressed level of consciousness, confusion, seizures, or coma). The record indicated that Pt. #1 was intubated while in the ED and placed on a ventilator. Pt. #1 was then admitted to the Intensive Care Unit and remained on the ventilator until 12/09/2025. Respiratory Therapy (RT) Notes and Flowsheets from 11/07/2025-12/09/2025 were reviewed and indicated that ventilator settings and alarm checks were completed every 4 hours, with the last documented check completed on 12/09/2025 at 2:00 PM. The Ventilator Check sheet on 12/09/2025 indicated that the last time the cuff pressure was tested using the minimal leak test/MLT (involves inflating the cuff to seal the airway, then slowly removing air until a slight leak is heard. This prevents over-inflation which can lead to airway injury) was at 12:15 AM. The record lacked documentation that the cuff was checked at each of the ventilator checks thereafter including the first check of the day shift (starting at 7 AM) at 8:00 AM. 3. On 2/4/2026 at 10:15 AM, an observational tour of the Intensive Care Unit was conducted. There was one patient (Pt #2) on a mechanical ventilator, via an endotracheal tube. The suction apparatus and the Ambu-bag [a handheld, manual resuscitator that delivers positive pressure ventilation to patients with inadequate or no breathing]were at Pt #2’s bedside. There were no patients with tracheostomies. CO2 detectors were available in the crash cart and supply room, but there was no CO2 detector at the bedside of Pt. #2. 4. An interview with the Manager of Respiratory Therapy (E#17) on 02/10/2026 at approximately 12:15 PM. E#17 stated that a CO2 detector and ambubag should be available at the bedside for each patient that has an artificial airway (i.e. endotracheal/ETT or trach tube). E#17 stated that they are also in the crash cart and have more in the supply room if needed. E#17 stated that it should be in a policy that those things are required at the bedside for these patients and stated that it’s common sense. E#17 stated that ventilator checks are required minimally every 4 hours. E#17 stated that a minimal leak test to ensure that the cuff/balloon is inflated the right amount should be done at least twice a shift with one being at the start of the shift. E#17 stated that their shifts go from 7:00 AM to 7:00 PM. E#17 stated that they do not have a policy to outline the requirements for how often ventilator checks should be done, what is included, and how often a minimal leak test should be completed. E#17 stated that these are verbally taught to staff during orientation. E#17 stated that E#17 typically makes policies for RT if needed, and the Medical Director (MD#5) of Respiratory must approve them. E#17 reviewed Pt. #1’s vent sheets from 12/09/2025 and stated, “I can’t say it [checking cuff pressure] wasn’t done, but it was not documented.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 34411 Based on video surveillance review, document review and interview, it was determined that the Hospital failed to comply with the Condition of Participation 42 CFR 482.13 Patient Rights. Findings include: 1. The Hospital failed to ensure that patients were free from abuse, by not initiating an investigation upon notification of an abuse allegation. See deficiency at A-145 (A). 2. The Hospital failed to follow the procedure for responding to abuse allegations, by not removing the alleged staff, from the Hospital, as required. See deficiency at A-145 (B). An immediate jeopardy (IJ) investigation was conducted on 12/19/2024 through 12/26/2024 for complaint #IL00182769/2421583. The immediate jeopardy began on 12/9/2024, due to the Facility’s failure to initiate an investigation upon notification of a physical abuse allegation and failed to suspend alleged staff members following the notification of the allegation, that led to IJ. The IJ was identified on 12/26/2024 at 42 CFR 482.13 Patient Rights. The IJ was announced on 12/26/2024 at 5:00 PM, during a meeting with the Senior Vice President of Patient Care; The Executive Vice President; and the Director of Quality and Risk, and was not removed by the survey exit date of 12/26/2024. .”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 34411 A. Based on document review, video surveillance review, and interview, it was determined that for 1 of 4 (Pt #1), clinical record reviewed for abuse, the Hospital failed to ensure that a patient was free from abuse, by not initiating an investigation, upon notification of a physical abuse allegation.. Findings include: 1. The Hospital’s policy titled, “Resolution of Patient Complaints and Grievances (dated 6/13/2022), was reviewed and required, “...Procedure: 1. Any allegations of abuse must be escalated and investigated immediately in accordance with [Hospital] Abuse and Neglect Policy. To resolve an issue as soon as possible any staff member that is aware of a concern should notify their supervisor or manager...” 2. The Hospital’s policy titled, “Incident Reporting” (dated 6/2024), was reviewed and required, “A report of Unusual Incident Form must completed for all accidents/incidents occurring to patient on hospital property...” 3. There was an event summary regarding Pt #1’s event, that was documented by the Nursing Supervisor (E #3). However, there was no formal incident report initiated by E #3. The event summary included. “ ...Incident Summary: [E #1] was handcuffed and arrested by [local police department] for alleged battery of a male psychiatric patient. The arrest was based on a report by an EMT [emergency medical technician] employee from [ambulance company], who claimed to have witnessed the incident. [EMT] stated that [E #1] was arguing and verbally aggressive with patient [Pt #1] while trying to get the patient to take a bath. [Nurse/E #6] reported that the patient was the aggressor and that [E #6] did not witness [E #1] assaulting the client. After reviewing the footage, the Director of Security [E #2] found the allegations to be false. Response and Actions: CNO [E #4], and [E #2] were notified; ER Nurse [E #9], Receiving Nurse [E #6], and Supervisor [E #3] assessed the patient for injuries, followed by the resident doctor; No injuries were reported by the on-call resident ...”This event summary was reported to tE #4, E #2, and E #8. However, it was not escalated to the Risk Department, as required per policy. 4. The clinical record for Pt #1 was reviewed on 12/23/2024. Pt #1 was a direct admit to 4 East (Adult Male Behavioral Health) Unit on 12/9/2024. Pt #1 was discharged home on 12/15/2024. - The Initial Psychiatric Evaluation (dated 12/9/2024), documented by the Attending Psychiatrist (MD #1), included, “[Pt #1] with a longstanding history of very poorly controlled diagnosis of schizoaffective disorder [serious mental illness]. - A Nursing admission note (dated 12/10/2024 at 2:05 AM), documented by the 4 East Registered Nurse (RN/E #6), included, “Pt arrived [to] the unit at 0040 [12:40 AM] on a stretcher [accompanied] by [Hospital transporter] and security. Pt is a direct admit from [a local hospital]. Pt is involuntary admission and petitioned. Pt was taken to 4 Main [an unoccupied unit] to clean up because per report, pt has lice and bedbugs ...Per protocol with pt with bed bugs and lice, pt should shower with medicated soap ...before the pt can be admitted to the unit. Pt is violent toward staff and difficult to follow instruction to shower ...pt is aggressive and extremely violent towards others .... No physical injuries noted on pt.” - A General note (dated 12/10/2024 at 6:19 AM), documented by a Resident Physician (MD #2), included, “I [MD #2] was called by the nurse at 5:05 am to assess the patient [Pt #1] after [Pt #1] was physically hit by a security guard at the hospital during admission. Nurse stated that EMS personnels witnessed the incident and called the police who came to the hospital and made the report. On encounter, patient was sleeping and no signs of bruises and denies any pain.” 5. On 12/23/2024 at 11:55 AM, video footage of the incident regarding Pt #1’s incident on 12/10/2024, was reviewed with the Director of Public Safety (E#2). The identity of the persons in the video footage were confirmed with E #2 and the Behavioral Health Director (E #8). The footage was from the 4 Main hallway, on 12/10/2024 at 12:39 AM-1:07 AM. Due to the angle of the footage, unable to get a direct view into the shower room. The following was noted on the footage. At 12:39 AM, Pt #1 was brought to the 4 Main unit, by the EMS, and a Nurse Tech (E #9) via stretcher. At approximately 12:40 PM, Pt #1’s admitting nurse (E #6), was seen walking in the hallways. At 12:42 AM, Pt #1 walked into the shower room, with 1 EMT remaining in the hallway (no staff at that time). At 12:48 AM, the 2 security officers (E #1, E#7), a Nurse Tech (E #9), and the 2nd EMS re-entered the unit, while Pt #1 remained in the shower. At 12:48:28, Pt #1 comes to the entrance of the shower door and has verbal interaction with the 2 officers (E #1, E #7) and the nurse (E #6). At 12:48:44, E #1’s left arm went towards the shower door in a pushing motion, and then E #1’s right arm went towards the shower room in a striking motion (from the angle of the camera view, was unable to determine if any physical contact was made). At 12:48:55 AM, the 2 EMTs left the unit, while Pt #1 remained in the shower room. At 12:49:08 AM, both E #1 and E #7 re-entered the shower room where Pt #1 was still present (without clinical staff). At 12:50:10 AM (approximately 1 minute later), the 2 officers (E #1 and E #7), exited out of the shower room. At 1:07:33 AM, Pt #1 ambulated out of the shower room and was escorted off 4 Main to 4 East (admitting unit) by the 2 officers (E #1, E #7), and the nurse tech (E #9). 6. The Incidents logs from 10/2024-12/23/2024, were reviewed. The log did not include any incidents or investigation regarding Pt #1. On 12/23/2024 at approximately 1:00 PM, an interview was conducted with the Director of Quality and Risk (E #5). E #5 stated that E #5 was not made aware of the incident involving Pt #1 and E #1. E #5 stated that, therefore, there is no incident report or investigation, from the Quality and Risk department. 7. On 12/23/2024 at 10:55 AM, an interview was conducted with the Director of Security (E #2). E #2 stated that when there is a security incident, E #2’s department completes a security incident report. E#2 stated that security incidents are then escalated to the nursing department and to the Risk department. E #2 stated that E #2 did escalate Pt #1’s incident to the nursing supervisor (E #3). 8. On 12/23/2024 at 2:10 PM, a phone interview was conducted with the Public Safety Officer (E #1). E #1 stated that E #1 wrote up a report regarding the incident with Pt #1. E #1 stated, however, there has been no follow-up communication from administration, regarding the incident. 9. On 12/24/2024 at 8:55 AM, an interview was conducted with the Nursing Supervisor (E #3). E #3 stated that E #3 was told by an ER nurse that a security officer was arrested and detained at the local police station. E #3 stated that at that point, E #3 interviewed the EMT staff that was still present in the Hospital (the staff that transported Pt #1 and alleged witness abuse to Pt #1). E #3 stated that after E #3 received this report, E #3 called the Director of Security (E #2); the Senior Vice President of Clinical Services (E #4), and the Director of Behavioral Health (E#8). E #3 stated that, regarding the incident with Pt #1, it could be classified as an abuse allegation. E #3 stated that E #3 wrote up an event summary for Pt #1. E #3 stated that, however, E #3 did not write a formal incident report and the incident was not escalated to the Risk Department. 10. On 12/24/2024 at 1:40 PM, a phone interview was conducted with the EMT (Z #2/transferred Pt #1). Z #2 stated that Pt #1 was transferred from another hospital due to behaviors. Z #2 stated that when Pt #1 was transported onto the unit (4 Main), Pt #1 was verbally aggressive, but not physically aggressive. Z #2 stated that Z #2 was able to see into the shower room, where the door was still open. Z #2 stated that Z #1 (the other EMT) and Z #2 witnessed a security guard hit Pt #1 and the patient went down to the floor. Z #2 stated that a nurse was trying to break up the encounter. Z #2 stated that after Z #1 and Z #2 left the unit, they called the Medical Control, and they were advised to call the police. B. Based on document review and interview, it was determined that for 2 of 4 (Pt #1, Pt #2) clinical records reviewed for abuse, the Hospital failed to ensure that the procedure for abuse allegations, was adhered to, by failing to remove staff upon notification of an abuse allegation. Findings include: 1. On 12/24/2024, the Hospital’s policy titled, “Abuse-Clients and/or Family Members with Grievance Regarding Physical or Sexual Abuse or Neglect” (dated 10/2024), was reviewed and indicated, “ ... If the grievance is made against the employee, the employee will be placed immediately on indefinite suspension ... pending an investigation ... Informs the patient/of his/her rights to contact the police and file a complaint ...” 2. An event summary regarding Pt #1, that was documented by the Nursing Supervisor (E #3), included. “ ...Incident Summary: [E #1] was handcuffed and arrested by [local police department] for alleged battery of a male psychiatric patient. The arrest was based on a report by an EMT [emergency medical technician] employee from [ambulance company], who claimed to have witnessed the incident. [EMT] stated that [E #1] was arguing and verbally aggressive with patient [Pt #1] while trying to get the patient to take a bath. [Nurse/E #6] reported that the patient was the aggressor and that [E #6] did not witness [E #1] assaulting the client. Response and Actions: CNO [E #4], and [E #2] were notified; ER Nurse [E #9], Receiving Nurse [E #6], and Supervisor [E #3] assessed the patient for injuries, followed by the resident doctor; No injuries were reported by the on-call resident ...” 3. The clinical record for Pt #1 was reviewed on 12/23/2024. Pt #1 was a direct admit to 4 East (Adult Male Behavioral Health) Unit on 12/9/2024. Pt #1 was discharged home on 12/15/2024. - The Initial Psychiatric Evaluation (dated 12/9/2024), documented by the Attending Psychiatrist (MD #1), included, “[Pt #1] with a longstanding history of very poorly controlled diagnosis of schizoaffective disorder [serious mental illness]. - A Nursing admission note (dated 12/10/2024 at 2:05 AM), documented by the 4 East Registered Nurse (RN/E #6), included, “Pt arrived [to] the unit at 0040 [12:40 AM] on a stretcher [accompanied] by [Hospital transporter] and security. Pt is a direct admit from [a local hospital]. Pt is involuntary admission and petitioned. Pt was taken to 4 Main [an unoccupied unit] to clean up because per report, pt has lice and bedbugs ...Per protocol with pt with bed bugs and lice, pt should shower with medicated soap ...before the pt can be admitted to the unit. Pt is violent toward staff and difficult to follow instruction to shower ...pt is aggressive and extremely violent towards others .... No physical injuries noted on pt.” 4. On 12/24/2024, the clinical record for Pt #2, was reviewed. On 12/9/2024 at approximately 12:43 PM, Pt. #2 was brought to the hospital’s ED (emergency department) due to bizarre and paranoid behavior: - At 1:10 PM, the ED nurse’s note indicated, “RN (registered nurse) called to room and security holding (Pt. #2) ... blood noted to (Pt. #2’s) bottom lip ...” The note did not indicate how Pt. #2 sustained injury to bottom lip. - At approximately 9:05 PM, Pt. #2 was admitted to the behavioral health unit. The admitting nurse’s note indicated, “ ...received on the unit ... ambulatory ... injuries mild healing stage noted on (Pt. #2’s) right nose and lip area ...” 5. On 12/24/2024, the incident and follow-up reports for Pt. #2 was reviewed: - On 12/9/2024 at 1:15 PM, the incident report and staff interviews indicated that while in the ED, Pt. #2 sustained laceration/bruising on Pt. #2’s bottom lip while being redirected by two public safety officers (E #16 and E #17). - On 12/11/2024, Pt. #2 reported to the hospital’s Director of Behavioral Health Unit (E #8) that while in the ED (on 12/9/2024), Pt. #2 was beaten badly by the hospital’s security/safety officer. - On 12/12/2024, E #5’s (Director of Quality and Risk) letter indicated that the hospital resolved Pt. #2’s complaint/grievance. 6. On 12/24/2024, the hospital’s schedule for public safety officers E #1, E #16, and E #17, was reviewed. E #1 worked night shift on 12/9/2024; was scheduled off on 12/10/2024; and then returned to work on 12/11/2024. E #16 continued to work at the hospital from 12/9/2024 through 12/13/2024 and E #17, from 12/9/2024 through 12/10/2024. There was no documentation that the security officer were suspended following allegations of abuse. 7. On 12/24/2024 at approximately 12:06 PM, an interview was conducted with E #5 (Director of Quality/Risk). E #5 stated that on 12/9/2024, E #5 received the incident report for Pt. #2. E #5 stated that due to the nature of the incident, there was a potential for patient abuse. On 12/9/2024, E #5 was not able to speak with Pt. #2. On 12/9/2024, E #5 stated that E #5 asked the two public safety officers if they physically assaulted Pt. #2. E #5 stated that while the investigation was ongoing, E # 16 and E #17 were not suspended, pending results of the investigation. E #5 stated, “The two public safety officers should have been suspended and removed from the area of services. I did not make (Pt. #2) aware of (Pt. #2’s) right to notify the police.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(6) Orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis (PRN). This Standard is not met as evidenced by: 50411 Based on document review and interview, it was determined that for 1 of 2 (Pt #9) clinical records reviewed for restraints, the Hospital failed to ensure that a physician’s order was not written as a standing [continuous] order. Findings include: 1. On 12/23/2024, the hospital’s policy titled “Restraint/Seclusion Policy (Reviewed May 2024)” was reviewed and required “...10. Non-violent or non-self-destructive patient - The order must be time limited not to exceed twenty-four (24) hours. A new order is required when the original order expires ...Evaluation and reassessment for continued need for restraint/seclusion ... ...11. Orders for restraint or seclusion must never be written as a standing order or on an as needed basis ...” 2. The clinical record for Pt # 9 was reviewed on 12/23/2024. Pt.#9 was admitted on 10/31/2024 for violent behavior and diagnosed with aggressive behavior/schizophrenia, agitation and right lower leg cellulitis [bacterial infection of the skin’s deeper layers]. On 11/4/2024 at 7:50 AM, an order for restraints for Pt.#9 was ordered by Psychiatrist - MD#4. The order indicated a duration from 11/4/2024 7:50 AM to 11/19/2024 9:30 PM. 3. On 12/24/2024 at approximately 11:25 AM, an interview was conducted with the Executive Director of the Behavioral Medical Unit (E#8). E#8 stated that non-violent restraint orders are only good for 24 hours and should never be entered as a standing order.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 50411 Based on document review and interview, it was determined that for 1 of 2 violent restraint (Pt. #8) records reviewed, the Hospital failed to ensure that restraints were discontinued at the earliest possible time. Findings include: 1. On 12/23/2024, the hospital’s policy titled “Restraint/Seclusion Policy (Reviewed May 2024)” was reviewed and required “ ...12 ...Restraint must be discontinued as soon as the individual meets the behavioral criteria for discontinuation ...Discontinuation of restraint and seclusion - 1. A patient may be released from restraints or seclusion before the expiration of the physician’s order if, in the professional judgment of the nurse, the patient is no longer exhibiting violent or self-destructive behavior ...” 2. The clinical record of Pt.#8 indicated that Pt.#8 was admitted from [area hospital] for trying to start a fire with a diagnosis of schizoaffective disorder. On admission, Pt.#8 was anxious, irritable and impulsive. 4-point restraints every 2 hours was ordered for Pt.#8 from 10:30 PM on 12/10/2024 to 6:30 PM on 12/11/2024. The progress note by registered nurse (E#14) on 12/11/2024 at 8:30 PM, indicated that pt was removed from 4 point restraint at 8:30 PM and care provided. 3. The 24-hour restraint/seclusion flow sheet for the same period was reviewed and indicated that on 12/11/2024 at 3:15 AM to 8:00 AM - Pt.#8 behavior was marked as “S” - which indicated that the patient was sleeping and restraint may have been discontinued as required in the hospital’s policy. 4. On 12/24/2024 at approximately 11:25 AM, an interview was conducted with the Executive Director of the Behavioral Medical Unit (E#8). E#8 stated that the restraint order can be discontinued by the registered nurse if in the nurses’ professional judgment, it is safe to do so.”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 39802 Based on document review, observation, and interview, it was determined that for 1 of 1 Emergency Department, the Hospital failed to post signage related to the rights of the individual with respect to examination and treatment for emergency medical conditions and women in labor (EMTALA-Emergency Medical Treatment and Labor Act), and whether the Hospital participates in the Medicaid program. Findings include: 1. The Hospital’s policy titled, “Emergency Room Triage Medical Screening and Registration” (revised October 2003), was reviewed and required, “Purpose: ... To comply with the Federal Emergency Medical Treatment and Active Labor Act (EMTALA)...” 2. On 8/26/2024 at 12:15 PM, an observational tour of the Emergency Department (ED) was conducted. There was no EMTALA signage posted at entrance where patients would present, waiting area, or throughout the Emergency Department. 3. An interview was conducted with the Senior Vice President of Patient Care (E#8) on 8/26/2024, at approximately 12:30 PM. E#8 stated that the signage may have been removed when they painted the walls, but E #8 could not provide a date or timeframe of when repainting may have occurred. E#8 stated that they should have signs posted in the ED regarding the patients’ rights regarding EMTALA. 4. On 8/28/2024 at 9:35 AM, another observational tour of the ED was conducted. EMTALA signage had been posted at the main entrance, waiting area, and treatment area of the ED.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 2 of 20 patients’ (Pt. #1 and Pt. #20) clinical records reviewed who presented to the ED (emergency department), the hospital failed to ensure the central log included each individual who came to the emergency department seeking assistance and the appropriate disposition for each patient. Findings include: 1. On 8/26/2024, the hospital’s policy titled, “Emergency Room Triage Medical Screening And Registration” (10/2003) was reviewed and required, “I... To comply with the Federal Emergency Medical Treatment and Active Labor Act... III. Procedures: A. Emergency cases will be directed immediately to the treatment room where triage, and registration will also take place. Upon entry, patient/family members... CFD (Local Fire Department) personnel will proceed to registration... The registrar will document this information on the ED sign in log...” 2. On 8/26/2024, the clinical record for Pt. #1 was reviewed. On 5/07/2024, Pt. #1 was brought to Hospital A’s ER (emergency room) due to suicidal ideation. Pt. #1 has past medical history that included hypertension, seizure disorder, and bipolar disorder (type of mental illness). From the ER, Pt. #1 was admitted to the 4th floor behavioral health unit with diagnoses of suicidal ideation and bipolar disorder. On 5/14/2024, Pt. #1 was discharged accompanied by the paramedics via ambulance. 3. On 8/26/2024, the paramedic run sheet for Pt #1’s discharge via ambulance was reviewed. On 5/14/2024 at 5:08 PM, the paramedic run sheet indicated, “ ... dispatched to a non-emergency hospital discharge out of (Hospital A) going to (Name of Nursing Home) ... The crew (paramedics) ... made it to 4th floor ... After (Pt. #1) was dressed, the crew moved (Pt. #1) into the ambulance ... After returning to the ambulance ... (Pt. #1) started (complaining) of pain in the left leg around (tibia and fibula/lower leg bones) ... When the crew started to unload (Pt. #1) to bring (Pt #1) into the ER ... (Pt. #1) started to have contractions and (show) signs of partial seizures ... the crew decided (that Pt. #1) was not stable for transport. After the crew notified (Hospital A’s desk attendant, the attendant) called the (ER) nurse...” 4. On 8/26/2024, the timeline of Pt. #1’s incident, completed by E #7 (Director, Behavioral Health Unit) was reviewed and indicated, “On 5/14/2024, (Pt. #1) was discharged (from Hospital A). (Pt. #1) left ... with (Name of Ambulance) at 5:05 PM ... to (Name of Nursing Home) ... (Pt. #1) was loaded into (the) ambulance ... started complaining of leg pain. EMT (emergency medical technician) assessed (Pt. #1) and could not determine a reason for the leg pain, so the decision was made to bring (Pt. #1) to (Hospital A’s ED) to be examined. As (Pt. #1) was being unloaded from the ambulance, (Pt. #1) began having seizure-like activity. EMTs went to (Hospital A’s) observation desk, where the nurse (E #3/ED RN) at the desk called ... (E #4/ED Charge Nurse)...” 5. The clinical record of Pt. #20 was reviewed on 08/27/2024. Pt. #20 presented to the ED on 05/11/2024 with a chief complaint of substance misuse/intoxication. Pt. #20 had a medical screening exam and was treated. Pt #20 was discharged to home. 6. On 8/26/2024, the hospital’s ED logs from February 2024 - July 2024 were reviewed:. - The log from 5/11/2024 lacked the correct disposition for Pt. #20, it was documented as “unknown.” - The log from 5/14/2024 did not include Pt #1 who was brought to the ED by paramedics due to concern about seizures. 7. On 8/27/2024 at approximately 3:00 PM, an interview was conducted with E #1 (Senior Vice President of Quality). E #1 stated that all patients coming into the ED should be registered on the log. E #1 stated that an appropriate disposition should have been written on the ED log for Pt. #20.”

“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: 36774 Based on document review and interview, it was determined that for 1 of 20 patients’ (Pt. #1) clinical records reviewed for individuals seeking care in the emergency department (ED), the hospital failed to provide a medical screening examination, to determine if Pt. #1 had an emergency medical condition. Findings include: 1. On 8/26/2024, the Hospital’s Rules and Regulations of the Medical Staff (2020) was reviewed and indicated, “ ... Department of Family Medicine ... II. Scope of Services. The Department of Emergency Medicine provides emergency care to patients of all ages. Comprehensive general emergency medicine is provided by physicians with clinical privileges in the Department of Emergency Medicine. Individuals presenting to (Name of Hospital) Emergency Department will be provided with comprehensive triage to assess acuity followed by an appropriate medical screening examination within the capability of the department... The medical screening examination will be performed by a member of the medical staff qualified to work in the Emergency Department ...” 2. On 8/26/2024, the clinical record for Pt. #1 was reviewed. On 5/07/2024, Pt. #1 was brought to Hospital A’s ER (emergency room) due to suicidal ideation. Pt. #1 has past medical history that included hypertension, seizure disorder, and bipolar disorder (type of mental illness). From the ER, Pt. #1 was admitted to the 4th floor behavioral health unit with diagnoses of suicidal ideation and bipolar disorder. The clinical record included: - On 5/14/2024, the attending psychiatrist’s note indicated, “ ... (Pt. #1 is) doing relatively well ... discharge back to ... nursing home today ...” The attending psychiatrist placed an order to discharge Pt. #1 to the nursing home. Pt. #1 was discharged accompanied by the paramedics via ambulance at 5:08. Pt #1’s clinical record did not include documentation of Pt #1 returning to the 4th floor or the ED after discharge. 3. On 8/26/2024, the paramedic run sheet, dated 5/14/2024 at 5:08 PM, was reviewed and included, “ ... dispatched to a non-emergency hospital discharge out of (Hospital A) going to (Name of Nursing Home) ... The crew (paramedics) ... made it to 4th floor ... After (Pt. #1) was dressed, the crew moved (Pt. #1) into the ambulance ... After returning to the ambulance ... (Pt. #1) started (complaining) of pain in the left leg around (tibia and fibula/lower leg bones) ... When the crew started to unload (Pt. #1) to bring (Pt #1) into the ER ... (Pt. #1) started to have contractions and (show) signs of partial seizures ... the crew decided (that Pt. #1) was not stable for transport. After the crew notified (Hospital A’s desk attendant, the attendant) called the (ER) nurse. After the phone call, the crew was told to bring (Pt. #1 back to the 4th floor. After the crew brought Pt. #1) to the 4th floor, the crew was told that (Pt. #1) could not be admitted on the floor due to (Pt. #1) having a medical problem, so the nursing staff (called) the ER and after 30 minutes, all the crew heard was that they (hospital staff) were wondering if it was a real seizure. So, after waiting for around 30-45 minutes and hearing no word from (the hospital) staff, the crew was worried for (Pt. #1’s well-being) ... the crew notified (ambulance’s dispatch for medical direction of the situation) ...” Subsequently, Pt. #1 was taken to Hospital B’s ER by the paramedics. 4. On 08/26/2024, the incident report dated 5/14/2024 at 5:50 PM, completed by E #7’s (Director, Behavioral Health Unit) was reviewed and included, “On 5/14/2024, (Pt. #1) was discharged (from Hospital A). (Pt. #1) left ... with (Name of Ambulance) at 5:05 PM ... to (Name of Nursing Home) ... (Pt. #1) was loaded into (the) ambulance ... started complaining of leg pain. EMT (emergency medical technician) assessed (Pt. #1) and could not determine a reason for the leg pain, so the decision was made to bring (Pt. #1) to (Hospital A’s ED) to be examined. As (Pt. #1) was being unloaded from the ambulance, (Pt. #1) began having seizure-like activity. EMTs went to (Hospital A’s) observation desk, where the nurse (E #3/ED RN-Registered Nurse) at the desk called ... (E #4/ED Charge Nurse). After (E #3’s) phone call, the EMTs were instructed to take (Pt. #1) back to 4 South. Once the EMT and (Pt. #1) arrived (on) the 4th floor, (E #5 and E #6/4th floor RNs) told the crew (paramedics) that (Pt. #1) was discharged and needed to be seen in (the ED) for medical reasons. The 4th floor nurses, house supervisor (E #2), and ER continued to discuss and debate ... 30-45 minutes elapsed. The (Name of Ambulance) crew decided to call their Medical Direction Supervisor regarding the situation due to a concern of (Pt. #1’s) well-being and delay in care ... (Pt. #1) arrived (at Hospital B’s ED) ... at 6:48 PM ...” 5. On 8/26/2024, the clinical record for Pt. #1 at Hospital B was reviewed. On 5/14/2024 at 6:42 PM, Pt. #1 arrived at Hospital B’s ED. The clinical record included: - On 5/14/2024, the ED provider’s note indicated, “ ... (Pt. #1 with past medical history of) depression ... seizure disorder ... presents with shaking ... History provided by BLS (basic life support/ambulance) crew and (Pt. #1). (Pt. #1) is a difficult historian. (Pt. #1) was reportedly being transferred via ambulance from an inpatient psychiatric facility to the nursing home ... when (Pt. #1) had an episode of shaking. EMS crew described the activity more like an absence seizure (no convulsion) ... Assessment and Plan ... Will get basic labs (laboratory test) and lactic acid to evaluate ... whether (Pt. #1) had ... a true seizure ... concern for syncope... Higher concern for psychogenic non-epileptic seizures (seizure due to psychological distress) ...” - On 5/15/2024, the ED physician’s notes indicated, “(Pt. #1) with ... questionable seizure disorder ... presents with upper extremity shaking and chest pain ... On arrival (at) the ED, noted to be tachycardic (heart rates to the 110s/normal 60-100). Blood pressure was 147/107 (normal range is 90-120/60-80). Pt. #1’s oxygen level was normal) ... on room air. Initial (laboratory tests) were notable for lactic acid (acid caused by cell breakdown/stress) of 5.9 (normal level is less than 2), which subsequently down trended to 2.9 after 3 (liters) of fluid resuscitation ... Neurology was consulted in the ED due to concerns about the upper extremity tremors. The tremor was noted to be distractible and suppressible. Neurology recommended no further neurologic inpatient workup. (Pt. #1) was then admitted to the medicine service for alternative tremor workup and tachycardia ... Assessment and Plan ... Upper Extremity Shaking ... likely represents dystonia/catatonia (neurological movement disorder) ... EEG during shaking showed no epileptiform activity (spike waves associated with epilepsy) ... Plan: 4-6 hours EEG ... Stop ... serotogenic agents (antidepressant medication); psychiatry consult for evaluation of possible dystonia/catatonia ... Lactic acidosis (high lactic acid level) (is) likely (due to) hypovolemia (low body fluid volume)... Plan: Fluid resuscitation. Sinus Tachycardia (Fast Heart Rate) ... will fluid resuscitate ...” - On 5/16/2024, the attending physician note indicated, “ ... I ... examined (Pt. #1) on 5/16/2024 ... The risk associated with (Pt. #1’s) management today was high... concern for seizure yesterday with IVF (intravenous fluid) resuscitation also, but now more dystonia...” Pt. #1 stayed at Hospital B for two days, and required assessment, monitoring, diagnostic testing, including psychiatric and medical consultation. 6. On 8/26/2024 at approximately 2:06 PM, an interview was conducted with E #7 (Director, Behavioral Health Unit). E #7 stated, “(On 5/14/2024, E #5/4th Floor RN) called and told me that (Pt. #1) was discharged accompanied by paramedics to the nursing home. The paramedics brought (Pt. #1) to the ED due to a change in medical condition. The paramedics were instructed to take (Pt. #1) back to the 4th floor.” 7. On 8/27/2024 at approximately 9:19 AM, a telephone interview was conducted with E #2 (Nursing Supervisor). E #2 stated, “I received a phone call from (E #6/4th Floor RN). (E #4) told me that (Pt. #1) was picked up by the paramedics. While in the ambulance, (Pt. #1) had a seizure. The paramedics took (Pt. #1) to the ED and reported to (E #3/ED RN) that (Pt. #1) had a seizure... (E #4) did not notify the ED doctor about the incident.” 8. On 8/27/2024, at approximately 9:49 AM, a telephone interview was conducted with E #3 (ED RN). E #3 stated, “I was at the desk then. The paramedics brought the patient to the ED because the patient had a seizure. I called (E #4/ED Charge Nurse), who told me to tell the paramedics to take the patient back to the 4th floor.” 9. On 08/27/2024, at approximately 10:00 AM, a telephone interview was conducted with E #4 (ED Charge Nurse). E #4 said, “That day, I was at the back of the ER. (E #3) called me and said paramedics were transporting a patient. The paramedics thought that the patient was going to have a seizure and did not feel comfortable transferring the patient. (E #3) told me the patient was not having a seizure.” E #4 stated that E #3 did not tell the full story. So, E #4 instructed E #3 to tell the paramedics to take the patient back to the 4th floor.” 10. On 8/27/2024 at approximately 11:59 AM, an interview was conducted with E #8 (Senior Vice President of Patient Care). E #8 stated that Pt. #1 should have been seen in the ED and provided a medical screening examination. 11. On 8/27/2024 at approximately 12:28 PM, an interview was conducted with MD #1 (ED Attending Physician). MD #1 stated that any patient entering the ED should receive a full assessment and medical screening examination by a physician to determine if a patient has an emergency medical condition. MD #1 stated that the ED assessment and medical screening exam should be documented in the clinical record.”

“PATIENT RIGHTS: REVIEW OF GRIEVANCES CFR(s): 482.13(a)(2) [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.] The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 1 of 2 grievances (Pt. #9) reviewed, the hospital failed to ensure that the complaint/grievance was resolved. Findings include: 1. On 6/14/2024, the hospital’s policy titled, “Resolution of Patient Complaints and Grievances” (6/2023) was reviewed and required, “I... This policy establishes a mechanism and procedures to respond, review and resolve patient grievances... E... Grievance: A written or verbal complaint by a patient or a patient’s representative regarding the patient’s care... F... 3. Reviews the grievance and reviewer responses... 5. Maintains documentation of the steps taken to investigate the grievance process...” 2. On 6/14/2024, the hospital’s complaints and grievance logs from January 2024 through June 14, 2024, were reviewed. On 5/10/2024, the log indicated that Pt. #9’s caregiver/representative had a grievance regarding the care received from the hospital. Pt. #1 was admitted to the hospital on 5/4/2024 due to aggressive behavior. There was no documentation regarding resolution of the grievance. 3. On 6/14/2024 at approximately 2:00 PM, findings were discussed with E #13 (Senior Vice President Of Quality and Compliance. E #13 stated that there should be documentation regarding resolution of the complaint/grievance.”

“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: 36774 Based on document review and interview, it was determined that for 5 of 5 patients’ (Pt. #1, Pt. #2, Pt. #3, Pt. #4, and Pt. #5) clinical records reviewed regarding informed consent, the hospital failed to ensure that the psychotropic drug consent was completed, as required. Findings include: 1. On 6/14//2024, the hospital’s policy titled, “Patient Rights” (June 2024) was reviewed and required, “... II... Privacy and Confidentiality. To be informed of the... treatment options, including potential risks, benefits...” 2. On 6/14/2024, the hospital’s document titled, Psychotropic Medication Notice and Consent Form” (undated) was reviewed and included, “(Names of different psychotropic medication)... The Physician/designee and I discussed 1. The nature of my condition; 2. My physician’s reasons for prescribing the medication... 4. Reasonable alternative treatments... 6. The common side effects...I have received the information about the psychotropic medication by means of: [Check those that apply]...” 3. On 6/14/2024, the clinical record for Pt. #1 was reviewed. Pt. #1 was admitted on 5/21/2024 due to schizoaffective disorder and aggressive behavior. The medication administration record (MAR), indicated that Pt. #1 received Lorazepam and Haldol (psychotropic medications) on 5/21/2024 and 5/22/2024. However, the psychotropic consent form was completed on 5/29/2024 (day of Pt. #1’s discharge). 4. On 6/14/2024, the clinical record for Pt. #2 was reviewed. Pt. #2 was admitted on 6/12/2024 due to acute psychosis (deviation from reality). The MAR indicated that Pt. #2 was given Lexapro and Haldol (psychotropic medications) on 6/12/2023 and 6/13/2024. However, the psychotropic consent form was incomplete, i.e., Lexapro and Haldol were not checked.. The form also did not indicate that Pt. #2 gave consent for the administration of Lexapro and Haldol. 5. On 6/14/2024, the clinical record for Pt #3 was reviewed. Pt. #3 was admitted on 6/11/2024 due to bipolar disorder (type of mental illness). The MAR indicated that Pt. #3 was given Depakote (psychotropic medication) on 6/12/2024 and 6/14/2024. However, the psychotropic consent form was incomplete, i.e., Depakote was not checked. The form also did not indicate that Pt. #3 gave consent for the administration of Depakote. 6. On 6/14/2024, the clinical record for Pt #4 was reviewed. Pt. #4 was admitted on 6/12/2024 due to bipolar disorder. The MAR indicated that Pt. #4 was given Depakote and Lithium Carbonate (psychotropic medications) on 6/13/2024. However, the psychotropic consent form was incomplete, i.e., Depakote and Lithium were not checked. The form also did not indicate that Pt. #4 gave consent for the administration of Depakote and Lithium. 7. On 6/14/2024, the clinical record for Pt. #5 was reviewed. Pt. #5 was admitted on 6/12/2024 due to major depressive disorder. The MAR indicated that Pt. #5 was given Lexapro on 6/13/2024. However, the psychotropic consent form was incomplete, i.e., Lexapro was not checked. 8. On 6/14/2024 at approximately 10:30 AM, findings were discussed with E #5 (Director of Behavioral Medicine). E #5 stated that the psychotropic medication consent form for the above patients were incomplete. E #5 stated that the form should indicate the name(s) of the psychotropic medication and if the patient gave consent for the administration of the medication/s. E #5 added that the form should be completed prior to administration of the medication.”

“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: 40079 A. Based on document review and interview, it was determined that the hospital failed to ensure that video surveillance is maintained for at least 30 days for review to conduct a thorough investigation of any safety or security incident. This has the potential to affect current or future safety events that require an investigation. Findings include: 1. The hospital’s policy titled, “Camera use/Reviewing of Footage” (revised 2023) was reviewed and included, “Storage and Retention Requirements Video surveillance data must be maintained on a secure server dedicated to video surveillance and saved for at least 30 days before deletion ...” 2. On 06/13/2024, the hospital provided a “Public Safety Report” dated 05/21/24 at 10:15 AM, and included, “Type of incident: Code Gray (security assistance required) ... (Name of Pt. #1) ... Location 4-E (4-east adult male behavioral health unit) Patient (Pt. #1) above time and date, (Public Safety Officer, PSO/E/#1) was standing on 4E when (Pt. #1) walked past (E #1) swing hitting (E #1). Nursing called a code gray, (Pt. #1) was put in restraints, medicated by nursing staff.” 3. On 06/13/2024, video footage of 4-East for 05/21/2024-05/22/2024, was requested. There was no video footage available for review. 4. An interview was conducted with the Director of Security (E #3) on 06/13/24 at 11:45 AM. E #3 stated that E #3, the Vice President of Nursing (E #4) reviewed video footage of an incident that occurred on 05/21/24, that involved (Pt. #1) punching a Public Safety Officer (PSO/E #1). E #3 stated that the video footage was not saved, their surveillance system does not have the capability to save footage unless E #3 saves the video if an incident is reported. E #3 stated that the video surveillance system saves footage for about 7 days, before it is overridden by new footage. E #3 stated that the footage was reviewed due to (E #1) being hit, and to ensure that all staff responded appropriately to the code gray. E #3 did not save the footage since there was no wrongdoing by staff. B. Based on document review and interview, it was determined that for 1 of 5 records (Pt. #1) reviewed for safety rounding, the hospital failed to ensure that safety rounding was completed and documented in the clinical record. Findings include: 1. The Hospital’s policy titled, “Precautions” (revised 05/2022), was reviewed and required, “...Patient’s on 1:1(one to one) ... are under constant visual surveillance at all times ... The RN (registered nurse) will ... ensure that the precautions are maintained as ordered ... b. Precaution sheets are completed in their entirety for all patients on precautions on the Behavioral Units.” 2. On 06/13/2024, the clinical record of Pt.#1 was reviewed. Pt.#1 was admitted to the hospital’s adult male behavioral health unit with a diagnosis of schizoaffective disorder on 05/21/2-24 at 12:45 AM and was discharged on 05/29/24 at 4:05 PM. The clinical record included the following: -Physician’s order dated 05/21/2024, “1:1 Observation Precaution” -Precaution and Rounding Sheets from 05/20/2024 at 11:00 PM through 05/29/2024 at 6:45 AM, were reviewed. The clinical record lacked the Precaution and Rounding Sheets for 05/23/2024, 05/25/2024, and 05/29/2024 from 7:00 AM to 2:00 PM. 3. An interview was conducted with the Director of Behavior Health Unit (BHU/E #5) on 06/14/24 a 11:20 AM. E #5 stated that E #5 could not find the Precaution and Rounding sheets for (Pt. #1) for 5/23/24, 5/25/24 and 5/29/24. E #5 stated that E #5 checked the assignment schedules for these dates and staff was assigned for 1:1 observation, and thinks that the flow sheets were misplaced before they were scanned into the clinical record.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 2 of 3 patients’ (Pt. #6 and Pt. #7) clinical records reviewed regarding use of violent and/or self-destructive restraints or seclusion, the hospital failed to ensure that the care plan was modified to reflect use of restraint or seclusion as an intervention. Findings include: 1. On 6/14/2024, the clinical record of Pt. #6 was reviewed. Pt. #6 was admitted on 5/03/2024 due to disorganized thoughts and delusion (deviation from reality). On 5/4/2024 from 6:45 PM through 8:45 PM, Pt. #6 was placed in seclusion due to aggression and combative behavior. The clinical record lacked documentation that the care plan was modified to reflect the use of seclusion as an intervention. 2. On 6/14/2024, the clinical record of Pt. #7 was reviewed. Pt. #7 was admitted on 5/23/2024 due to agitation. On 5/26/2024 from 2:45 PM trough 4:45 PM, Pt. #7 was placed in violent restraints (four point) due to aggressive behavior. The clinical record lacked documentation that the care plan was modified to reflect the use of restraint as an intervention. 3. On 6/14/2024, the hospital’s policy titled, “Restraint/Seclusion Policy” (5/2024) was reviewed and included, “I... To provide guidelines for the safe and effective use of restraints and/or seclusion in situations where appropriate to prevent or minimize harm to self or others...” The policy did not include modification of care plan regarding use of restraint or seclusion. 4. On 6/14/2024 at approximately 1:00 PM, findings were discussed with E #5 (Director of Behavioral Medicine). E #5 confirmed that the care plan was not modified. E #5 stated that the care plan should reflect use of restraint and seclusion as intervention.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 40079 Based on document review and interview, it was determined that for 1 of 3 clinical records reviewed (Pt.# 1) regarding use of violent and/or self-destructive restraint, the hospital failed to ensure the physicians’ orders for restraints were complete. Findings include: 1. The hospital’s policy titled, “Restraint/Seclusion” (revised 05/2024) was reviewed and required, “4. Use of restraint or seclusion must be in accordance with the order of a physician ... 5. In an emergency, a nurse ... may initiate the use of restraint prior to obtaining an MD order ...” 2. On 06/13/2024, the clinical record of Pt.#1 was reviewed. Pt.#1 was admitted to the hospital’s adult male behavioral health unit on 5/21/24 at 12:45 AM with a diagnosis of schizoaffective disorder (mental condition with hallucinations, delusions, anxiety). The clinical record included a physician’s phone order dated 05/21/2024 at 10:30 AM, “Restraint/Seclusion ... Aggressive behavior threatens safety of others, Attacking sitter and security guard.” The order lacked the physician’s signature. 3. An interview was conducted with a Registered Nurse (RN-E #8) on 06/14/24 at 10:25 AM. E #8 stated that on 05/21/24, (Pt. #1) had to be restrained due to (Pt. #1) attacked staff (Public Safety Officer/E #1 and Constant Observer/E #2). E #8 stated that a physician order is obtained by the RN for any type of restraint or seclusion, the physician will then sign off on the order. E #8 confirmed that for (Pt. #1) the physician order was not signed.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 1 of 3 patients’ (Pt. #6) clinical records reviewed regarding use of restraints or seclusion, the hospital failed to ensure that a face-to face evaluation within 1-hour after initiation of seclusion was completed. Findings include: 1. On 6/14/2024, the hospital’s policy titled, “Restraint/Seclusion Policy” (5/2024) was reviewed and required, “... III... Seclusion: The involuntary confinement of a patient alone in a room or are from which the patient is physically prevented from leaving... IV... 7. Within one (1) hour of restraint/seclusion application for the management of violent or self-destructive behavior, the trained practitioner... must conduct a face-to-face evaluation...” 2. On 6/14/2024, the clinical record of Pt. #6 was reviewed. Pt. #6 was admitted on 5/03/2024 due to disorganized thoughts and delusion (deviation from reality). On 5/4/2024 from 6:45 PM through 8:45 PM, Pt. #6 was placed in seclusion due to aggressive and combative behavior. The clinical record lacked documentation that a face-to-face evaluation was completed. 3. On 6/14/2024 at approximately 1:00 PM, findings were discussed with E #5 (Director of Behavioral Medicine). E #5 confirmed that the clinical record did not include a face-to-face evaluation within one hour after initiation of seclusion. E #5 stated that one hour face to face evaluation is only completed for patients placed in violent restraints.”

“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: 36774 Based on document review and interview, it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.43, Discharge Planning. Findings include: 1. The hospital failed to demonstrate periodic assessment of the discharge planning process, including review of patients admitted within 30 days of previous admission were conducted. See A-803. 2. The hospital failed to ensure that the psychosocial assessments were completed as part of the discharge planning evaluation, as required. See A-805. 3. The hospital failed to ensure that the discharge planning evaluation was discussed with the patient’s state guardian. See A-808.”

“DISCHARGE PLANNING PROGRAM REVIEW CFR(s): The hospital must assess its discharge planning process on a regular basis. The assessment must include ongoing, periodic review of a representative sample of discharge plans, including those patients who were admitted within 30 days of a previous admission, to ensure that the plans are responsive to the patient post-discharge needs. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that the hospital failed to demonstrate periodic assessment of the discharge planning process, including review of patients admitted within 30 days of previous admission were conducted. This potentially affect the discharge planning needs and outcomes for any patient in the hospital. Findings include: 1. On 3/27/2024, the hospital’s policy titled, “Discharge Planning” (revised on 1/2015) was reviewed and included, “ ... IV. Procedures ... 10. Assessment of multiple admissions which includes an evaluation of whether readmissions were potentially due to problems in discharge planning or the implementation of discharge plans ...” 2. On 3/27/2024 at approximately 10:30 AM, any documentation, meeting minutes, or data collected to indicate that the hospital conducted periodic review of the discharge planning program was requested. No available information was provided. 3. On 3/27/2024 at approximately 11:30 AM, E #2 (Clinical Director, Behavioral Health Unit) and E #6 (System Vice President for Quality and Regulatory Compliance) could not provide any documentation, meeting minutes, or data collected to indicate that the hospital conducted periodic review of the hospital’s discharge planning program. E #6 stated that there is no meeting minutes or documentation available.”

“DISCHARGE PLANNING TIMELY EVALUATION CFR(s): Any discharge planning evaluation must be made in a timely basis to ensure the appropriate arrangements for post-hospital care will be made before discharge and to avoid unnecessary delays in discharge. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 4 of 8 patients’ (Pt. #1, Pt.# 2, Pt. #4, and Pt. #6) clinical records reviewed for discharge planning on the behavioral health unit, the hospital failed to ensure that the psychosocial assessments were completed as part of the discharge planning evaluation, as required. Findings include: 1. On 3/26/2024, the hospital’s policy titled, “Psychosocial Completion Guidelines” (10/2018) was reviewed and included, “... Policy: 1. All patients who are hospitalized on the Behavioral Medicine Units will have a Psychosocial Assessment completed within 48 hours of admission...” 2. On 3/26/2024, the clinical record for Pt. #1 was reviewed. On 11/17/2023, Pt. #1 was admitted to the hospital’s behavioral health unit for bizarre and paranoid behavior. The required psychosocial assessment was not completed for Pt. #1. 3. On 3/26/2024, the clinical record for Pt. #2 was reviewed. On 3/19/2024, Pt. #2 was admitted to the hospital’s behavioral health unit with a diagnosis of schizoaffective disorder. As of 3/26/2024 (seven days after admission), the required psychosocial assessment was not completed. 4. On 3/26/2024, the clinical record for Pt. #4 was reviewed. On 3/22/2024, Pt. #4 was admitted to the hospital’s behavioral health unit with a diagnosis of schizoaffective disorder. As of 3/26/2024 (four days after admission), the required psychosocial assessment was not completed. 5. On 3/26/2024, the clinical record for Pt. #6 was reviewed. On 3/21/2024, Pt. #6 was admitted to the behavioral health unit with a diagnosis of schizoaffective disorder. As of 3/26/2024 (five days after admission), the required psychosocial assessment was not completed. 6. On 3/26/2024 at approximately 11:30 AM, findings were discussed with E #2 (Clinical Director, Behavioral Health Unit). E #2 oversees the discharge planning for the hospital’s behavioral health unit. E #2 stated that the required psychosocial assessments as part of the discharge planning evaluation were not completed for the above patients.”

“DISCHARGE PLANNING EVALUATION CFR(s): The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). This Standard is not met as evidenced by: 48264 Based on document review and interview, it was determined that for 2 of 2 patients’ (Pt. #1 and Pt. #5) clinical records reviewed for discharge planning with state guardians, the hospital failed to ensure that the discharge planning evaluation was discussed with the patient’s state guardian. Findings include: 1. On 3/26/2024, the hospital’s policy titled, “Discharge Planning” (1/2015) was reviewed and included, “ ...IV. Procedures: A. Department Staff identify patients for discharge planning intervention through Department high risk screening and assessment which are completed within 1 working day of the patient’s admission ...B. Department Staff conducts a discharge planning assessment ...that includes ...a discussion or meeting with the family, surrogate decision maker, members of the Treatment Team and facilities/agencies that have previously provided care to the patient ...Department Staff gather the following information ...to determine a patient’s need for discharge services: ...4. Decision Making Capacity, i.e., ...Power of Attorney ...Guardianship etc. ...”. 2. On 3/26/2024, the hospital’s policy titled, “Patient Rights” (12/2022) was reviewed and included, “ ...Privacy and Confidentiality: ...Intake staff (nurses, physicians, Social Workers etc.) must notify any Power of Attorney (POA) or Guardian of admission, prior to transfer, or discharge ...”. 3. On 3/26/2024, the clinical record of Pt. #1 for the following hospitalization dates were reviewed: - On 11/11/2023, Pt. #1 was admitted due to bizarre, paranoid behavior. The clinical record indicated that Pt. #1 had a state guardian. On 11/16/2023, Pt. #1 was discharged to another facility for residential placement. - On 11/17/2023, Pt. #1 was admitted due to bizarre, paranoid behavior. On 11/16/2023, Pt. #1 discharged home with (Pt. #1’s) brother. - On 12/24/2023, Pt. #1 was admitted due to schizoaffective disorder (mental disorder of abnormal thought processes and unstable mood). On 1/01/2024, Pt. #1 was discharged home with (Pt. #1’s) brother. - The clinical record for Pt. #1’s hospital encounters included documentation that Pt. #1 had a state guardian. However, the clinical record did not include documentation that the state guardian participated, nor follow-ups were made to discuss the discharge planning evaluation. 4. On 3/26/2024, the clinical record for Pt. #5 was reviewed. On 3/18/2024, Pt. #5 was admitted due to bizarre and paranoid behavior. The clinical record indicated that Pt. #5 had a state guardian. On 3/25/2024, Pt. #5 was discharged to a nursing facility. The clinical record did not include notification and follow-up with state guardian regarding the plan and results of discharge planning evaluation. 5. On 3/26/2024 at approximately 1:18 PM, an interview with the Clinical Director of Behavioral Health (E #2) was conducted. E #2 stated that a patient’s legal/state guardian, POA and or Emergency Contact person should be included in the patient’s discharge plan and then notified of patient’s discharge disposition.”