Humboldt Park Health

“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: 52591 Based on document reviews, video surveillance review, and interview, for 1 of 1 patient (Pt #2) who eloped from the Emergency Department (ED), the hospital failed to activate the Code Gold (emergency response for patient elopement), as required by hospital policy. Findings include: 1. On 4/29/2026 the hospital’s policy titled “Code Gold” (Reviewed January, 2026) was reviewed. The policy requires staff to activate Code Gold via hospital’s operator for the “unauthorized departure of a patient who is incapable of adequately protecting self, and who departs the health care facility unsupervised and undetected.” The policy also indicated to notify the public safety, other staff, chief nursing officer or the house supervisor, the attending physician, and the police officer (if the patient is not found). 2. On 4/29/2026, the clinical record for Pt. #2 was reviewed. On 4/16/2026, Pt #2 presented to the hospital’s ED under police custody due to suicidal ideation. On 4/18/2026 at 4:15 PM, Pt. #2 eloped from the hospital’s ED. The clinical record did not indicate that the Code Gold was activated. 3. On 4/29/2026, the incident report for Pt. #2 was reviewed. The incident report indicated that the ED Charge Nurse notified the house supervisor and the Chicago Police regarding Pt. #2’s elopement 4. On 4/28/2026, the video surveillance footage of the hospital’s ED was reviewed. On 4/18/2026 at 4:15 PM, while using the restroom across from Pt. #2’s room (Room 11), Pt. #2 pushed the sitter who was waiting outside the restroom door. Then, Pt. #2 ran towards the main ED exit door, which was approximately 8 feet from the restroom, then Pt. #2 left the hospital vicinity. The sitter followed by three public safety officers were seen running after Pt. #2. The ED attending physician was also seen present at the time. However, the sitter and the three public safety officers were unsuccessful in stopping Pt. #2 from eloping. 5. On 4/30/2026 a approximately 11:35 AM an interview was conducted with the Chief Medical Officer (MD #1). MD #1 stated the Code Gold was not activated as required because the elopement “happened so fast and all parties required to respond were already present and involved in the pursuit.””

“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: 40079 Based on observation, document review, and interview, for 2 of 2 patients (Pt. #7 and Pt. #8) with IV (intravenous) access, the hospital failed to ensure that the IV accesses were labeled with the date and time of insertion and changed every 96 hours as required by the hospital’s policy. Findings include: 1. During an observational tour of the 4B Telemetry/Medical Surgical Unit conducted on 04/30/2026 from 10:05 AM - 11:30 AM along with the Chief Nursing Officer (E #6). The following was observed: Two patients (Pt.#7 - IV access site on the right forearm, and Pt.#8 - IV access site on right lower leg) had IV access sites that were not labeled with date and time of insertion, to indicate that the IV access was within the 96 hour policy requirement. 2. The hospital’s policy titled, “IV Therapy Guidelines” (revised 11/2025) was reviewed and required, “All catheter insertion sites will have a dressing. A transparent dressing is preferred. The dressing is changed every 96 hours (4 days).” 3. The clinical record for Pt. #7 was reviewed on 04/30/2026. Pt. #7 was admitted to the hospital on 04/18/2026 with a diagnosis of abdominal pain. Pt. #7’s IV was inserted on 04/18/2026 at 8:00 PM. The clinical record indicated that the IV site was changed on 04/30/2026 (12 days after initial insertion). 4. During the tour, the CNO (E #6) confirmed that the IV access sites for (Pt. #7 and Pt. #8) were not labeled as required. 5. On 04/30/2026 at approximately 10:40 AM, an interview was conducted with the Registered Nurse (E #13). E #13 stated that IV site dressings should be labeled with the date, time and initials of staff member to be able to determine when the IV site should be changed. IV sites should be changed every 96 hours or if there are signs of infection or infiltration (intravenous fluids leak into surrounding skin).”

“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 observation, document review, and interview, it was determined, that for 4 (Pt. #2, #3, #4, and #5) of 24 patients, the hospital failed to ensure patients received care in a safe setting by failing to ensure that the patients’ room doors were kept open for adequate monitoring while the patients remained in their rooms in bed, as required for safety. Findings include: 1. On 04/11/2026 between 11:30 AM through 12:00 PM, an observational tour of the hospital’s Adult Acute Behavioral Health Unit (3-A) was conducted. During the tour staff were observed monitoring the hallway, another staff was monitoring the patients in the community room, and a Nurse (E #7) was observed conducting the safety rounds using a binder that included observation flow sheets for each patient on the census, which included the type of observation(s) for each patient. While the safety rounds were being conducted, there were two patient rooms with the doors closed, each room had two patients (Pt. #2-#5) inside. Staff (E #7) opened the doors to conduct their safety rounds, and proceeded to close the doors after the rounds were completed. 2. A policy related to maintaining patient room doors open when a patient is in their room, was requested from the hospital. The hospital did not have a policy, however based on interview the hospital follows the protocol of leaving doors open while patients are in their room, the doors should be locked while the patients are out of their room to ensure safety. 3. The clinical records for Pt. #2, #3, #4, and #5 were reviewed and indicated the following: - Pt. #2 was admitted to the hospital’s Adult Behavioral Health Unit (BHU) on 04/08/26 with chief complaint (CC) of suicidal ideation. Physician Order, 04/08/26, “Suicide Precautions.” - Pt. #3 was admitted to the hospital’s Adult BHU on 04/10/26 with a chief complaint of worsening depression and repeated suicidal ideation. Physician Order, 04/08/26, “Suicide Precautions. Ongoing.” - Pt. #4 was admitted to the hospital’s Adult BHU on 04/10/26 with a chief complaint of worsening depression and repeated suicidal ideation. Physician Order, 04/10/26, “Suicide Precautions. Ongoing.” - Pt. #5 was admitted to the hospital’s Adult BHU on 04/03/26 with a chief complaint of command auditory hallucinations. Physician Order, 04/10/26, “Elopement/Suicide Precautions. Ongoing.” 4. An interview was conducted during the tour on 04/11/2026 at approximately 11:55 AM, with the Director of Behavioral Health (E #2). E #2 was asked if the doors to patient rooms should remain closed if the patient is in their room. E #2 stated that E #2 was not sure, but that it probably should be kept open to ensure the safety of the patients. 5. An interview was conducted with a Registered Nurse (RN/E #8) on 04/13/2026 at 9:05 AM. E #8 stated that when patients are in their rooms, their doors should remain open, and if they are not in their room, the rooms will be locked. 6. An interview was conducted with the Nurse Practitioner (E #1) on 04/13/2026 at 9:25 AM. E #1 stated that for patients in the BHU, if they are in their room, the door should remain open to ensure their safety and for proper monitoring. B. Based on document review and interview, it was determined that for 4 of 5 patients’ (Pt. #2, #3, #4, and #5) records reviewed for suicide risk assessments, the hospital failed to ensure a suicide reassessment was completed as required. Findings include: 1. The hospital’s policy titled, “Suicide Risk Screening, Assessment, and Prevention” (revised 08/9/2024) was reviewed and required, “Purpose: To identify clients at risk for suicide and assess the need for further supportive services ... 3. The RN (Registered Nurse) ... b. Completes the Columbia Suicide Frequent Screen every shift or with change patient affect and/or behavior.” 2. The clinical record of Pt. #2 was reviewed on 04/11/26. Pt. #2 was admitted to the hospital’s Adult Behavioral Health Unit (BHU) on 04/08/26 with chief complaint (CC) of suicidal ideation. The clinical record included the following: -Psychiatric Evaluation, 04/09/26, “ ... Pt. #2 ... presents to the emergency department with SI (suicidal ideation) ... During evaluation, patient stated, ‘my brain is restless, I can’t sleep, I’m suicidal ... Plan: Admit for inpatient ... monitor SI closely with safety precautions.” -Physician Order, 04/08/26, “Suicide Precautions.” -Columbia Suicide Risk Assessment was not documented as being completed for 04/10/26 for the 7 PM to 7 AM shift. 3. The clinical record of Pt. #3 was reviewed on 04/11/26. Pt. #3 was admitted to the hospital’s Adult BHU on 04/10/26 with a chief complaint of worsening depression and repeated suicidal ideation. The clinical record included the following: -Psychiatric Evaluation, 04/09/26, “Pt. #3 ... with acute psychosis, increased paranoia, worsening depression, noncompliance with medications, with repeated suicidal ideation and command auditory hallucinations telling to ‘hurt myself ... C-SSRS (Columbia-Suicide Severity Rating Scale): 1. Have you ever wished you were dead: Yes 2. Have you ever actually had thoughts of killing yourself? Yes 3. Have you been thinking about how you might do this? Yes ...” -Physician Order, 04/08/26, “Suicide Precautions. Ongoing.” -Columbia Suicide Risk Assessment was not documented as being completed for 04/10/26 for the 7 PM to 7 AM shift. 4. The clinical record of Pt. #4 was reviewed on 04/11/26. Pt. #4 was admitted to the hospital’s Adult BHU on 04/10/26 with a chief complaint of worsening depression and repeated suicidal ideation. The clinical record included the following: -Psychiatric Evaluation, 04/10/26, “ ... Pt. #4 was admitted ... with acute psychosis, worsening depression, non-adherence with medications, with command auditory hallucinations, ‘they always want me to do something ... Current Suicide Risk Factors: Imminent risk of harm to the safety of self and others. Depression ...” -Physician Order, 04/10/26, “Suicide Precautions. Ongoing.” -Columbia Suicide Risk Assessment was not documented as being completed for 04/10/26 for the 7 PM to 7 AM shift. 5. The clinical record of Pt. #5 was reviewed on 04/11/26. Pt. #5 was admitted to the hospital’s Adult BHU on 04/03/26 with a chief complaint of command auditory hallucinations. The clinical record included the following: -Psychiatric Evaluation, 04/03/26, “ ... Pt. #5 was admitted ... with acute psychosis, noncompliance with medications, and command auditory hallucinations, ‘that are distressing causing me to feel unsafe.’ (Pt. #5) reports that upon admission to the hospital, was experiencing depression ... Current Suicide Risk Factors: Imminent risk of harm to the safety of self and others. Depression ...” -Physician Order, 04/10/26, “Elopement/Suicide Precautions. Ongoing.” -Columbia Suicide Risk Assessment was not documented as being completed for 04/08/26 7 AM to 7 PM, shift and on 04/10/26 for the 7 PM to 7 AM shift. 6. On 4/13/2026 at 8:54 AM, a telephone interview was conducted with E #8 (Registered Nurse, Day Shift 2/21/2026). E #8 stated that the RN will conduct a suicide risk assessment using the Columbia Suicide Severity Rating Scale every shift since patients in psychiatric unit can be unpredictable and have frequent changes in their behavior. 7. On 4/13/2026 at approximately 9:23 AM, an interview was conducted with E #1 (Nurse Practitioner, Psychiatry).” E #1 stated that patients will have a suicide screen using the C-SSRS and if they are stratified as a suicide risk, they will have a suicide risk assessment completed every shift by the nurse.”

“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: 39802 Based on document review and interview, the hospital failed to ensure an appropriate medical screening exam (MSE) was performed to determine if an emergency medical condition existed prior to discharge/transfer for 1 of 3 (Pt. #1) patients who presented to the emergency department (ED) in police custody [of a total ED sample of 20 patients]. Findings include: 1. The Hospital’s policy titled, “Emergency Medical Treatment and Active Labor Act (EMTALA)” (revised October 2024), was reviewed and required, “ ...Psychiatric Emergency Medical Condition: an individual with a psychiatric condition will not be treated differently than any other individual who presents to the ED with an emergency medical condition. That is, if an individual is determined by a qualified medical practitioner to be dangerous to him/herself or others by reason of mental illness, that individual would be considered to have an emergency medical condition ... With respect to psychiatric conditions, the patient is considered ‘stable’ for purpose of transfer when the patient is protected or prevent from injuring self or others (by adequate chemical or physical restraint). Stability for discharge means the patient is no longer a threat to self or others, as clinically determined ... If a patient has an emergency medical condition, the patient will receive treatment within the hospital’s capabilities until the condition is stabilized or an appropriate transfer to another facility is made ... All patients coming to the hospital requesting emergency care (or where such requests are made on their behalf) will receive an appropriate medical screening examination...” 2. The Hospital’s policy titled, “Management of Behavioral Health Patients in the Emergency Department” (revised June 2014), was reviewed and required, “ ...Initial and ongoing clinical risk assessments: ... 1. The triage nurse will determine if the patient has a primary psychiatric complaint or has active psychiatric symptoms. These patients are assigned a triage ESI [Emergency Severity Index] 2 [2 = Emergent on a scale of 1 to 5 where 1 is the most urgent and 5 is non-urgent]. 2. The primary nurse will contact the Behavioral Medicine Unit (BMU) Intake Coordinator immediately for patients that are deemed to have an active psychiatric complaint or exhibiting psychiatric symptoms to assess a patient for suicidal or homicidal ideations. The Intake Coordinator will determine the level of risk, the need for precautions and treatment plan in conjunction with the ED physician ...” The policy did not include any reference to not providing a behavioral health assessment for patients in police custody. 3. The Transferring Hospital (Hospital A) clinical record for Pt. #1 was reviewed on 01/06/2026. Pt. #1 presented to the Hospital’s ED on 12/06/2025 at 9:02 AM with a chief complaint of suicidal ideation (SI). - The Triage Assessment by ED Nurse (E#9), dated 12/06/2025 at 9:58 AM, included “ ...Mode of Arrival: EMS [emergency medical services/ambulance]. Patient arrived to the ED in police custody with reported SI. Patient is currently homeless. On assessment, patient is also complaining of worsening right-sided cramping when breathing. Endorses nasal congestion and cough. Patient was assigned male at birth but identifies as female and prefers she/her pronouns. Patient alert and answering questions. Safety maintained ...” The record indicated that Pt. #1 was placed on suicide precautions upon arrival; a 1:1 sitter was ordered and placed at bedside on 12/06/2025 at 9:16 AM; and Pt #1 was in police custody/CPD (Chicago Police Department) remained present in ED with Pt #1. The Nurse Practitioner (NP#1) note, date of service 12/06/2025 at 9:03 AM (signed 12/10/2025 at 11:41 PM), included the following: - History of Present Illness: “ ...Patient was brought in under CPD custody for medical clearance for assessment of SI. Patient expressed suicidal ideation and per patient has been ‘tired of this life’ and while in the custody started banging head on the metal poles. Per pt SI thoughts have been going on for 2 weeks. Has a history of SI with attempts-cutting, pills with last attempt being 3-4 months ago. Denies HI [homicidal ideation], A/V [auditory/visual] hallucinations. Patient also shares concern for productive cough that is been going on for 2.5 weeks with intermittent chills, fevers and SOB [shortness of breath]...” - Review of Systems: “Negative except for ones positive in the history of present illness. Past medical/surgical history: ...bipolar, PTSD [post traumatic stress disorder] ... Nontoxic, calm, redirectable ... The patient is awake alert and oriented ... Flat affect with suicidal ideations ...” - Medical Decision Making: “[Pt. #1] under CPD [police] custody brought in for SI evaluation ... Pt is nontoxic appearing with stable VS [vital signs], endorsing SI and ongoing productive cough. Due to pt being under custody, pt not appropriate for inpt [inpatient] psych at [this Hospital]. Pt being medically assessed for head trauma and c/f [clinical features of] pna [pneumonia/respiratory infection]. Labs, CXR [chest xray], and CT [computerized tomography scan] head ordered... Given normal imaging and grossly unremarkable labs. No indication of PNA or other underlying pulmonary process. Pt remained saturating WNL [within normal limits] on RA [room air] with no resp[iratory] distress. Pt and CPD informed pt is medically stable and cleared from a medical standpoint, but given current presentation and risk assessment, the patient to remain under observation until a full psychiatric evaluation can be completed to assess for potential hospitalization. CPD advised pt is to remain in [Hospital A] ER [emergency room] until released from custody for proper psych evaluation and placement or for pt to be taken back into jail with 1:1 supervision, SI (suicidal ideation) precautions, and cared for via jail psych facility/care. Per CPD officers, they were instructed for pt to be taken to [Hospital B] for psych holding. Pt discharged with imaging and work up. CPD informed and instructed for pt to be monitored 1:1 with SI precautions and if pt is released from custody, [Pt. #1] is to be brought to nearest ER for psych evaluation. CPD officers verbalized they understood. Pt informed of plan and also provided with SI hotline and resource. Verbalized understood and comfortable with plan. Case was discussed with [ED Physician MD#1] who agrees with treatment plan ...” - MD#1 signed off on NP#1’s above note on 12/12/2025 at 9:27 AM and included, “I agree with the assessment, management, and disposition as presented by the Resident/APP [advanced practice provider] with exceptions as documented. The care of this patient was managed by the advanced practice provider noted on this chart. I was available for consultation regarding this patient. Patient stable here and NAD [no apparent distress]. Officers requested that this patient be moved to another hospital. I spoke with ED Physician at [Hospital B] upon the patient’s arrival [to Hospital B] and gave warm handoff.” The record did not include any documentation or orders to indicate that psychiatry was consulted or whether behavioral health intake was notified of the patient’s arrival and need/request for psychiatric assessment/evaluation. Pt. #1’s disposition was set to discharge with law enforcement on 12/06/2025 at 1:37 PM, and Pt #1 was discharged with CPD via CPD vehicle transportation on 12/06/2025 at 2:08 PM. 4. Receiving Hospital (Hospital B) clinical record for Pt. #1 was reviewed on 01/08/2026. Pt. #1 arrived at Hospital’s B ED on 12/06/2025 at 2:26 PM with a chief complaint of suicidal ideation. - The History and Physical, dated 12/06/2025 at 2:38 PM, included “ ... [Pt. #1] who presents to ED with chief complaint of suicidal ideation. Patient has a plan to bang head against a wall ... to death. [Pt. #1] was in police custody and began banging head against wall in cell. [Pt. #1] says this was with the intent of killing self. [Pt. #1] says that [Pt. #1] was feeling suicidal prior to being picked up by police. Denies HI, AVH ... [Pt. #1] says has been off medications for at least a month ... Patient was seen earlier today at [Hospital A] for this but then CPD brought [Pt. #1] here. Patient had negative head CT, CXR at Hospital A. Per CPD, patient was there all morning. Spoke with attending from [Hospital A], they did a med clearance and said that patient needed to stay for psychiatric evaluation. CPD was concerned that patient would not have a room to stay in so [Pt. #1] was discharged and told [Pt. #1] could come here. Patient discharge from [Hospital A] with form by [NP#1] stating ‘due to safety concerns and needing a complete psychiatric assessment, the patient is to be continuously monitored until a full evaluation is performed to establish disposition. Patient has been monitored 1 to 1 with suicide precautions. If patient is released from custody, patient will be taken for formal psych eval at a medical hospital facility.’ - ED Physician Progress Note on 12/06/2025 at 3:07 PM included “Inpatient certificate filed. Per CPD, expected to have mittimus [judicial order] tomorrow.” - ED Nursing Note, dated 12/06/2025 at 3:20 PM, included “Pt brought to ED by CPD officers from another ER for psych evaluation. Pt is in police custody was seen in another ED since this morning and was discharged without psychiatric evaluation as pt stated [Pt. #1] having suicidal thoughts since this morning. Pt is calm and cooperative with care on arrival ... “ - Intake Coordinator Consult, dated 12/06/2025 3:20 PM, included “[Pt. #1] brought to this ED in police custody for a psychiatric evaluation and medical clearance. While the patient was in custody at the police station, the patient intentionally struck head against the wall and stated to the police that [Pt. #1] would kill self. Per CPD, they initially took the patient to [Hospital A] emergency department for clearance and the patient was assessed by [NP#1]. Per CPD, the attending physician informed them they cannot complete the psychiatric assessment and provide the appropriate care while the patient is in custody. They were instructed the police to take the patient to this emergency department for psychiatric assessment. The patient was discharged from that ED and brought here. In the ED, the patient was calm, cooperative, and alert. The patient corroborated the information provided by the police but stated that [Pt. #1] was provoked by the police as [Pt. #1] felt they were disrespectful towards [Pt. #1] [Pt. #1] intentionally hit head against the wall and stated that [Pt. #1] would kill self. [Pt. #1] added that [Pt. #1] has been depressed the past 2 weeks and has been withdrawn and isolative. [Pt. #1] could not provide a reason as to why [Pt. #1] did not seek mental health help prior to arrest. Today was the first time [Pt. #1] had left the house but was later arrested for retail theft which worsened depression. [Pt. #1] reported a history of depression and bipolar disorder. [Pt. #1] is non-compliant with medications. [Pt. #1] was adamant that [Pt. #1] was in need of psychiatric admission. ER MD assessed the patient at bedside. Plan for care is to pursue psychiatric admission. CPD made aware of the need for a Mittimus. Petition and Certificate completed and placed into the chart with copies.” ED Physician Progress note, dated 12/07/2025 at 2:15 PM, included “Per CPD, mittimus is in and patient can be discharged to police custody for mental health placement.” ED Nursing note, dated 12/07/2025 at 2:32 PM, included “Mittimus in, brought by CPD officer. [MD] aware. Pt OK for discharge with CPD officers to [Name of Behavioral Health Hospital for Prisoners].” ED Nursing note, dated 12/07/2025 at 2:44 PM, included “Copy of mittimus placed in chart. Labs/Notes given with CPD for [Name of Behavioral Health Hospital for Prisoners].” ED Discharge note, dated 12/07/2025 at 3:04 PM, included “Pt discharged in CPD custody for [Name of Behavioral Health Hospital for Prisoners]. with mittimus, ambulatory, handcuff in the front, stable and pain-free, discharge papers and transfer papers provided with pt, verbalized understanding. Pt is stable, calm and cooperative.” 5. A telephone interview was conducted with ED Physician (MD#1) on 01/06/2026 at approximately 1:30 PM. MD#1 stated that if the patient is in police custody, they will not be evaluated by the crisis worker until they are released from custody. MD#1 stated that if the patient remains in custody, they (Hospital A) cannot admit them to their inpatient psychiatric units. MD#1 stated that after the patient is medically cleared, they wait in the ED with police present until a judge is able to review their case and determine whether they are to be released or remain in custody. MD#1 stated that if they are released from police custody, then they will be evaluated by the crisis worker/intake department here (at Hospital A) and if they need inpatient psych, they will be admitted (either voluntary or petitioned/certified for involuntary admission). MD#1 stated that if they remain in custody then the patient would need to go to (Name of State Psychiatric Facility for Prisoners). MD#1 stated that the psych evaluation is done as part of the medical screening examination. MD#1 stated that the crisis/intake staff helps in the process for patients who are not in custody, but the ED provider has the ultimate decision of whether the patient should be admitted or not. MD#1 stated that if the patient in custody is non-threatening and the evaluation deems that the patient does not require inpatient services, they can be discharged into police custody. MD#1 stated that for someone that has SI, HI, or severe psychosis, they present as an immediate danger to self or others and therefore are generally kept in the ED as a safe place where they can be watched. MD#1 stated that the likely outcome is that they will require inpatient stabilization. MD#1 stated that the patient was mainly seen by NP#1 but MD#1 did check in from time to time and was updated by NP#1. MD#1 stated that Pt #1 was cleared medically but hadn’t been cleared yet from the acute psychiatric concern for SI. MD#1 stated that they explained to the officers the plan that they would have to wait until Monday for a judge to make a determination (12/06/2025 was a Saturday when courts weren’t open) and in the meantime they would watch the patient in the ER. MD#1 stated that the officers wanted to take the patient to another hospital (Hospital B) because that hospital had a special psych unit area for these patients which is something Hospital A didn’t have. MD#1 stated that the officers were pretty insistent on taking the patient. MD#1 stated that if it’s something we (Hospital) don’t have and they (officers) are insisting and the patient is stable and calm, then it sounded okay. MD#1 stated that the officers had called their sergeant or higher ups who gave them the direction to have the patient moved to Hospital B. MD#1 stated that after that they prepared the paperwork and discharged Pt #1. 6. A telephone interview was conducted with the ED Medical Director (MD#2) on 01/06/2026 at approximately 2:20 PM. MD#2 stated that if a patient arrives in police custody, they do a medical clearance, but they cannot be admitted to the psychiatric units here (at hospital) while under custody due to safety. MD#2 stated that they would keep the patient in the ED until the patient is either released from custody or the judge writes a warrant to take them to the [Name of State Behavioral Health Hospital for Prisoners]. MD#2 stated that they do a medical clearance and then do a psychiatric evaluation as part of the medical screening exam. MD#2 stated that if the patient is cleared both medically and psychologically and there is no reason to hold them, they will discharge the patient back into police custody. MD#2 stated that the patient can be discharged if they are safe. 7. An interview was conducted with Nurse Practitioner (NP#1) on 01/06/2026 at 2:41 PM. NP#1 stated that if a patient is in custody, they do not contact crisis to evaluate the patient, as the patients cannot be admitted to Hospital A. NP#1 stated that they don’t move forward with the psychiatric evaluation until the patient is cleared by the judge, otherwise, if the judge orders them to remain in custody, the patient has to go to the State psychiatric facility that takes prisoners. NP#1 stated that they typically just hold the patient in the ED while in custody, until the judge makes a determination. NP#1 stated that the courts aren’t open on the weekends. NP#1 explained to the officers that they would have to hold Pt. #1 and wait in the ED until Monday or if the officers could ensure the safety of the patient with 1:1 monitoring and suicide precautions, the patient could be taken back to jail. NP#1 stated that the officers stated that did not have the capabilities to safely manage the patient at their local precinct and had asked if Hospital A had a psych holding facility to which NP#1 replied no, they would have to wait in the ED. NP#1 stated that the officers then spoke to their higher ups who then told the officers that Hospital B had psychiatric holding. NP#1 stated that to NP#1’s knowledge, Hospital B would be doing the same thing they were doing at Hospital A. NP#1 stated that the officers requested discharge to go to Hospital B. NP#1 stated that Pt. #1 was not cleared psychiatrically, as a psychiatric assessment/evaluation was not yet completed. NP#1 stated that the patient was still SI but was medically stable. NP#1 explained to the officers that the patient could not be left alone if discharged to police custody. NP#1 stated that the officers agree to take the patient under those safety measures, and then the patient was discharged back to police custody. 8. An interview was conducted with the Crisis/Intake Worker (E#2) on 01/07/2026 at approximately 10:00 AM. E#2 stated that the crisis team evaluates all psych patients (21 and older) in the ED immediately after they are medically cleared, whether or not the patient is in custody. E#2 stated that typically the providers in the ED will notify them when a patient is ready to be evaluated. E#2 stated that the crisis/intake team has someone working 24/7. E#2 stated that when they do their evaluation, they will document a note in the patient’s medical record of their assessment and recommendations. E#2 stated that they will discuss it with the ED Provider who has the final decision on whether they think the patient needs inpatient psych admission or not. E#2 stated that if they agree that the patient doesn’t need inpatient psych, and the patient is in custody, they will discharge the patient back to jail with the police. E#2 stated that if they recommend inpatient services and the patient is still in custody, they hold the patient in the ED until the judge either orders to release the patient from custody or to remain in custody (with a Writ Mittimus) which can take up to 2-3 days. E#2 was not aware of the practice of not having intake assess a psychiatric patient in custody at Hospital A. 9. An interview was conducted with the ER Nurse (E#9) on 01/08/2026 at approximately 9:27 AM. E#9 stated that when a psych patient arrives, they (nursing) will notify the intake department pretty quickly when triage is done. E#9 stated that they typically come down right away and are available 24/7. E#9 stated that intake can come evaluate the patient even before they are medically cleared, as long as they are alert and oriented. E#9 stated that once the patient is medically cleared, they go with the directions of psych as to whether or not the patient needs to be admitted to the psych unit. E#9 stated that for patients in police custody, they wait until they receive the order from the judge to send them to [name of State psychiatric facility for prisoners] to get psychologically evaluated. In regard to Pt. #1, E#9 stated “I may have called them (Intake) to notify them about the patient [Pt #1], as that’s what I normally do. I don’t believe I documented it but I think I was told that they wouldn’t come down right away if the patient is still in custody since they can’t be admitted here.””

“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 1 of 5 patients’ (Pt. #1) clinical record reviewed, the hospital failed to ensure that the patient’s representative/caregiver was provided information regarding Pt. #1’s treatment plan, including the disposition of care. Findings include: 1. On 11/13/2024, the clinical record for Pt. #1 was reviewed. On 5/27/2024, Pt. #1 was brought to the hospital’s ED (emergency department) due to shortness of breath. The clinical record included: - On 5/27/2024 at 1:53 AM, the ED physician’s note indicated, “(Pt. #1) with dementia (memory problem) with known history of COPD (chronic obstructive pulmonary disease/respiratory illness), very poor historian..” At 3:27 AM, the ED nurse’s note included name of two daughter’s as contacts for Pt. #1. - On 5/27/2024 at 11:48 AM, E #7’s (Telemetry RN) progress note indicated, “ ... (At 9:00 AM), received (Pt. #1) from ER (emergency room) via cart ... alert and oriented to self ... unaware of day date, or time ... (Pt. #1) came to (the) ER with increased (shortness of breath) ... (E #2/Nurse Practitioner/Hospitalist) notified, no new orders received ...” - On 5/28/2024 at 12:58 PM, E #2’s (Nurse Practitioner/Hospitalist) progress note indicated, “ ... (Pt. #1) seen and assessed at bedside this morning. Oriented to self and place, but not date. ...Denies any medical complaints at this time including headache, cough, (shortness of breath), (chest pain) ... abdominal pain ... O2 sat (oxygen saturation) 100% on 3 liter’s nasal cannula (NC) ... Exam ... Awake, (no acute distress), on NC at 3 Liters ... Assessment and Plan... Diet ...(Disposition)... “ At 3:08 PM, E #2 placed an order to discharge Pt. #1. There was no documentation regarding discussion of Pt. #1’s treatment/care plan with Pt. #1 or Pt. #1’s daughter. 2. On 11/13/2024, the hospital’s policy titled, “Patient’s Rights and Responsibilities” (October 2021), was reviewed and included, “... Information: The patient has the right to obtain from the practitioner responsible for coordinating their care complete and current information concerning their diagnosis... treatment, and any known prognosis...” 3. On 11/13/2024 at approximately 10:00 AM, an interview was conducted with E #2 (Hospitalist/Nurse Practitioner). E #2 stated that E #2 was the practitioner coordinating the care for Pt. #1. E #2 stated that Pt. #1 had memory issue and the daughters were the caregivers and contacts. E #2 stated that with Pt #1’s condition, there should have been a documentation regarding discussion of the treatment plan, including the disposition, with the patient’s daughter.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 1 of 2 patient care units (4B/Telemetry) staffing schedules/assignments reviewed, the hospital failed to ensure that adequate number of registered nurses and/or personnel were available to meet patient care needs. This can potentially affect the delivery of safe patient care on the unit. Findings include: 1. On 11/13//2024, the hospital’s staffing policy titled, “Acuity Levels and Patient Classification” (dated September 2022) was reviewed and included, “... Procedures... 7. The Charge Nurse assigns patients based on patient acuity, competency of the staff, and available personnel...” 2. On 11/13/2024, the staffing assignments/records for 4 B/Telemetry Unit were reviewed for May 27, 2024, May 28, 2024, November 11, 2024, and November 12, 2024. The records indicated the following: - 05/27/2024, Day Shift (7:00 AM through 7:00 PM), short of one RN/Registered Nurse; - 05/27/2024 Night Shift (7:00 PM through 7:00 AM), short of two RNs and one CNA (Certified Nurse Assistant); - 05/28/2024, Day Shift, short of one RN and one CNA; - 05/28/2024, Night Shift, short of one RN; -11/11/22024, Night Shift, short of two RNs; -11/12/2024, Day Shift, short of two RNs and one CNA. 3. On 11/13/2024 at approximately 2:00 PM, findings were discussed with E #11 (Nurse Manager). E#11 confirmed that based on the unit’s grid and acuity level, the unit was short staffed on the above dates because of call-offs. E #11 stated that the hospital uses agency but could not get anyone. 4. At approximately 12:15 PM, interviews were conducted with Pt #11 and Pt. #12. Pt. #11 and Pt. #12 stated that it takes a while before staff respond to call lights. Pt. #12 stated, “I have been here and came back from surgery and nobody has been here.””

“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: 36774 A. Based on document review and interview, it was determined that for 1 of 5 patients’ (Pt. #1) clinical records reviewed regarding assessment, the hospital failed to ensure that a fall risk assessment was conducted, as required. Findings include: 1. On 11/13/2024, the hospital’s policy titled, “Fall Prevention Program, Adult” (April 2024) was reviewed and included, “... Procedures... A. Inpatient Assessment using Morse Fall Scale... Upon admission...” 2. On 11/13/2024, the clinical record for Pt. #1 was reviewed. On 5/27/2024, Pt. #1 was brought to the hospital’s ED (emergency department) due to shortness of breath. On 5/27/2024 at 9:00 AM, Pt. #1 was admitted to the telemetry unit with a diagnosis of COPD (chronic obstructive pulmonary disease). There was no fall risk assessment completed for Pt. #1 upon admission to the unit. 3. On 11/13/2024 at approximately 2:00 PM, findings were discussed with E #12 (Vice President of Quality). E #12 stated that there was no fall risk assessment performed during Pt. #1’s admission to the unit. E #12 stated that a fall risk assessment should have been completed. B. Based on document review and interview, it was determined that for 1 of 2 patient care units (4B Telemetry) reviewed for hourly rounding, the hospital failed to ensure that the documentation of hourly rounding was performed. Findings include: 1 On 11/13/2024, the hourly monitoring logs for 4B Telemetry Unit for 11/12/2024, was reviewed. The logs did not include documentation of hourly rounding at 8:00 AM; 10:00 AM; and 11:00 AM for Room 427 Bed 1 and 2; Room 429 Bed 1 and 2; Room 433 Bed 1 and 2; and Room 435 Bed 1. 2. On 11/13/2024, the hospital’s document regarding “Purposeful Hourly Rounding” (undated) was reviewed. The document included, “Definition: A structured process where nurses or staff check on patients at regular intervals to address key needs... Hourly Rounding Log... Documentation of Hourly Rounding: Keep accurate records of each round...” 3. On 11/13/2024 at approximately 11:30 AM, an interview was conducted with E #11 (4B Telemetry Unit Manager). E #11 stated that the nurses and nursing assistant alternately make hourly rounds on each patient. E #11 stated that documentation of the rounding is completed on the log posted by the patient’s door. E #11 stated that documentation on the log should be completed when hourly rounding was made. 4. On 11/13/2024 at approximately 12:15 PM, interviews were conducted with Pt. #12. When asked about the staff making rounds, Pt. #12 stated that sometimes, nobody comes for three hours.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 1 of 5 patients’ (Pt. #1) clinical records reviewed for nursing care plan, the hospital failed to ensure that an individualized plan of care was developed based on Pt. #1’s needs. Findings include: 1. On 11/12/2024, the hospital’s policy titled, “Interdisciplinary Plan of Care” (March 2022) was reviewed and included, “... Definition... an individualized plan of care that is formulated... with the patient outcomes in mind and is based on... patient’s needs and goals... Procedure: 1. The plan of care is initiated during the admission process based on the assessed needs of the patient...” 2. On 11/13/2024, the clinical record for Pt. #1 was reviewed. On 5/27/2024, Pt. #1 was brought to the hospital’s ED (emergency department) due to shortness of breath. The clinical record included: - On 5/27/2024 at 1:53 AM, the ED physician’s note indicated, “(Pt. #1) with dementia with known history of COPD (chronic obstructive pulmonary disease/respiratory illness), very poor historian according to the daughter, (Pt #1) removed ... oxygen at home... Assessment and Plan: Acute Exacerbation of COPD with Asthma ... oxygen ...” - On 5/27/2024 at 5:28 AM, MD #1’s (Hospitalist) progress note indicated, “ ... (Pt. #1) ... on 3 (L/liters) nasal cannula/NC, dementia, (hypertension/high blood pressure) ... arrived in the ED ... for shortness of breath ... began at 1:00 AM this morning ... found unattached to ... oxygen ... done multiple times due to (Pt. #1’s) dementia, per (Pt. #1’s daughter). (Pt. #1) began becoming hypoxic and was unable to catch ... breath, before arriving to the hospital... Will admit to telemetry ... as inpatient ...” - On 5/27/2024 at 11:48 AM, E #7’s (Telemetry RN) progress note indicated, “ ... (At 9:00 AM), received (Pt. #1) from ER (emergency rom) via cart ... alert and oriented to self ... unaware of day date, or time ... (Pt. #1) came to (the) ER with increased (shortness of breath) ...” From 5/27/2024 through 5/28/2024, there was no nursing care plan developed for Pt. #1’s respiratory need/problem, including behavior of removing oxygen. 3. On 11/13/2024 at approximately 2:00 PM, findings were discussed with E #11 (4B Telemetry Nurse Manager). E #11 stated that there should have been nursing care plan developed to address Pt. #1’s respiratory needs and behavior of removing the oxygen.”