Hartgrove Hospital

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 36774 Based on document review, and interview 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 Pt. #1 was properly monitored by staff while receiving care at the hospital. See A 144 A. 2. The hospital failed to ensure a timely and appropriate response to a medical emergency (Code), placing the patient at risk for serious harm. See A 144 B. An immediate jeopardy began on 4/06/2026, due to the hospital’s failure to ensure appropriate supervision of Pt. #1’s care, and was idenitifed on 4/10/2026 at 42 CFR 482.13, Patient Rights. Subsequently, the hospital reported that Pt. #1 expired on 4/06/2026 at 8:15 AM. The IJ was announced on 4/10/2026 during a meeting at 4:45 PM with the Chief Executive Officer, Chief Operating Officer, Chief Medical Officer, Director of Nursing, Director, Risk and Performance Improvement, and Assistant Director of Nursing, and was not removed by survey exit date 4/10/2026 In addition, an immediate jeopardy also began on 4/06/2026, due to hospitals failure to provide proper actions or interventions were provided to Pt. #1, and was also identified on 4/10/2026 at 42 CFR 482.13, Patient Rights. The IJ was also announced on 4/10/2026 during a meeting at 4:45 PM with the Chief Executive Officer, Chief Operating Officer, Chief Medical Officer, Director of Nursing, Director, Risk and Performance Improvement, and Assistant Director of Nursing, and was also not removed by survey exit date 4/10/2026.”

“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: 36774 A. Based on document review and interview, for 1 of 1 patient’s (Pt. #1) record reviewed related to death, the hospital failed to ensure that Pt. #1 was properly monitored by staff while receiving care at the hospital. Subsequently, the hospital reported that Pt. #1 expired on 4/06/2026 at 8:15 AM. Findings include: 1. On 4/7/2026, the clinical record for Pt. #1 was reviewed. On 4/3/2026, Pt. #1 was admitted as transfer from another hospital due to suicidal ideation. The clinical record included: - On 4/3/2026, the Behavioral Health Intake Assessment indicated, “ ... Reason for Admission ... (Pt. #1) stated that (Pt. #1) recently had thoughts of hurting self, but denies current suicidal or homicidal ideation ...” - On 4/3/2026 at 11:25 AM, provider’s order was obtained to admit Pt. #1 to the unit (2 South/unit caring for patients who are higher functional with less aggressive behaviors). Additional orders included, vital signs monitoring twice per day, behavioral monitoring every-15 minutes, and placing Pt. #1 on suicide, aggressive, and elopement precautions. - On 4/3/2026 at 12:48 PM, the nurse’s admission note indicated, “ ... Advance Directives: None ... Diagnosis: Schizophrenia (type of psychiatric condition) ...” - On 4/4/2026 at 11:30 AM, E #10’s (Nurse Practitioner, Internal Medicine) history and physical note indicated, “Chief Complaint/Reason for Consultation: suicidal ideation ... Past Medical History: No problems documented .... No surgery history documented ... Home Medications: No medications documented ... Assessment and Plan: Knee pain, right. Motrin (pain medication, as needed) ...Prophylactic measure: Aspirin 81 milligrams (mg) daily (used to prevent blot clot) ... Hyperlipidemia (high cholesterol) Lipitor 80 mg (at bedtime). Hypertension (high blood pressure): Continue Amlodipine 5 mg daily (blood pressure medication) ... “ - On 4/4/2026 at 3:52 PM, E #9’s (Nurse Practitioner, Psychiatry) psychiatric evaluation indicated, “ ... (Pt. #1) admitted for suicidal ideation, stating (Pt. #1) intends to jump into traffic due to persistent chronic pain in (Pt. #1’s) right knee ... exacerbated by stress from a history of incarceration.. denies hearing voices ... Pain is significant issue ... expressing frustration over obtaining oxycodone (opiod pain medication) for knee pain ... due to inability to contract for safety ... impulsivity, and current psychiatric instability, necessitates continued inpatient admission. Reasons for ongoing hospitalization include the gravity of suicidal ideation, heightened impulsivity, complex pain management needs, anxiety management ... Assessment and Plan ... Medications: Seroquel (psychotropic medication) 600 milligrams (mg) at bedtime, initiate one time dose of Gabapentin (used for nerve pain) 300 mg , this afternoon and at bedtime today only; Hydroxyzine 25 mg (by mouth) as needed (for anxiety) ...” - On 4/5/2026 at 10:21 PM, E #1’s progress note indicated, “(Pt. #1) became agitated and threatened to assault both staff and (patient) because staff was unable to provide requested pain medication. (Pt. #1) was non-directable (would not follow commands) and (Pt. #1) became more agitated. (Pt. #1) taken to quiet room for a time out. MD (MD #2/Attending Psychiatrist) notified and (MD #2) ordered (STAT medication) for agitation. (Pt. #1) given STAT (as soon as possible) IM (intramuscular) Zyprexa (psychotropic medication) 10 milligrams (mg) and STAT IM Benadryl (used to prevent extrapyramidal symptom/involuntary movement, may cause short-term sedation) 25 mg at (7:21 PM) in right arm. (Pt. #1) then transferred to (2 North) to better meet (Pt. #1’s) needs related to aggression and agitation ...” (On 4/5/2026 at approximately 7:36 PM, Pt. #1 was also given Tramadol 50 mg tablet [pain medication], a medication that may also cause hypotension or syncope. Recommendations include monitoring for signs of hypotension/low blood pressure). -From 4/5/2026 12:00 AM through 4/6/2026 at 11:29 AM, the behavioral monitoring sheets were reviewed. On 4/5/2026, from 7:29 PM through 9:30 PM, the monitoring sheets, no untoward issues were identified for Pt. #1. From 9:38 PM on 4/5/2026 through morning of 4/6/2026, Pt. #1 was documented as inside Pt. #1’s room, either sleeping on (Pt. #1’s) stomach, right side, or back. The monitoring sheets indicated that Pt. #1 “appears sleeping with visible respirations”. On 4/6/2026 at 8:00 AM, the monitoring sheet indicated that Pt. #1 “appears sleeping with visible respirations while laying on Pt. #1’s stomach. -The hospital’s code blue (medical emergency) documentation form dated 4/6/2026 indicated, “ ... (Pt. #1) .... At (8:13 AM) ... RN (Registered Nurse) Assessment: Patient Conscious at onset ... No. Did patient with a pulse become pulseless ... No ... Breathing Present ... No ... Circulation Present ... No ... Paramedics called ... by (E #6/RN). Paramedics arrival time: (8:26 AM) ... CPR (Cardiopulmonary Resuscitation/emergency heart-saving measure when heart stops beating) Initiated: No ... AED (Automated Emergency Defibrillator/medical device used to treat cardiac arrest by analyzing heart rhythm and delivering electric shock to restore normal function) Initiated ... No ... Physical Assessment: Neurological ... Unresponsive ... (Pt. #1) heard with breathing sounds although no pulse or breathing noted ... Mild bleeding noted on (Pt. #1’s) mouth and clothes ... (Pt. #1) attempted to arouse ... unresponsive. (Pt #1) flipped over and placed on ground ... Medical Intervention: Airway/ventilation ... Apnea ... Oxygen administered ... No ... Patient Disposition: (Pt. #1) was observed cold, and pulseless. Not breathing ... (Signed by E #7/Nurse Manager on 4/6/2026 at 12:08 PM) ...” - The clinical record lacked documentation that Pt. #1’s vital signs were monitored as ordered from 4/5/2026 through 4/6/2026. The last documentation of Pt. #1’s vital signs was 4/4/2026 at 8:30 AM with the following readings: Blood pressure: 93/56 (low blood pressure is below 90/60, high blood pressure 130/80 and above), respiratory rate of 19 (normal 12 to 20). There was no reading of Pt. #1’s pulse rate. 2. On 4/8/2026, the hospital’s policy titled, “Patient Monitoring/Observation Rounds” indicated, “ ... Scope ... Nursing ... Nursing Staff ... h. Observe patients are in their room ... when sleeping by entering the room and looking for the rise and fall of the chest, counting at least three respirations, and making sure that the patient has moved from his/her previous position ...” 3. On 4/08/2026, the drug literature for Zyprexa indicated that medication could induce orthostatic hypotension (low blood pressure) with associated dizziness, bradycardia (low heart rate), and in some patients, syncope (passing out). 4. On 4/08/2026, the drug literature for Benadryl indicated that medication could potentiate effects of central nervous system depressants, e.g., when taken concurrently. 5. On 4/09/2026, the hospital’s report to CMS (Centers for Medicare and Medicaid) titled, “Report of a Hospital Death Associated with the Use of Restraint or Seclusion,” indicated, “ ... Patient Name (Pt. #1) ... Date and Time of Death: 04/06/2026 (at) 8:15 AM ...” 6. On 4/8/2026 at approximately 10:41 AM, an interview was conducted with MD #1 (Attending Psychiatrist who responded to the Code Blue). MD #1 stated that (Pt. #1’s) arms were stiff that’s why I think (Pt. #1) must have expired (dead) for at least couple of hours. I got in at 8:00 AM, the code was called around 8:05 AM. 7. On 4/8/2026 at approximately 11:00 AM, a telephone interview was conducted with E #4 (MHS/Mental Health Specialist, 11 PM-7AM on 4/5/2026). E #4 stated that E #4 was rounding the whole time and saw that Pt. #1 was lying on the bed, with visible respirations. E #4 stated that there was nothing unusual observed on Pt. #1 and that Pt. #1 was inside the room and had no roommate. E #5 stated that nobody talked to E #4 about what happened to Pt. #1. E #4 stated, “I did not find out until I came back to work Monday night.” E #4 stated that E #4 have not heard of anything new that needs to be implemented when monitoring patients on the unit. 8. On 4/08/2026 at approximately 11:37 AM, an interview was conducted with E #5 (MHS, 7AM-3PM on 4/6/2026). E #5 stated, “That day, I received report from (E #4/MHS). We went into the room, and I heard (Pt. #1) breathing. We looked for the rise and fall of the chest. There is no specific number of times that we count the rise and fall of the chest. I thought (Pt. #1) was just sleeping. I started the rounds around 8:00 AM. The Substance Counselor arrived and wanted to speak to (Pt. #1). The counselor did not go into the room, and (Pt. #1) was not responding. Sometimes the patient ignores people. The counselor called me and so I went into the room. I was calling (Pt. #1’s) name, tapping the wall, the bed, and then I leaned over to see to see what was going on. I saw red vomit-like substance on (Pt. #1’s) pillow. I immediately called the Charge Nurse (E #6). The charge nurse and program specialist went into the room and checked the patient. The charge nurse touched (Pt. #1), and (Pt. #1) was cold. A code (code blue) was called, and the nurse and the doctor came. I did not stay inside the room.” 9. On 4/08/2026 at approximately 1:04 PM, an interview was conducted with E #6 (Charge Nurse, 7AM-3PM on 4/6/2026). E #6 stated, “We had a shift report around 7:30 AM. I was preparing my day. Around 8:00 AM, staff member came to me saying that (Pt. #1) was not responding. I went to the room. I tried to wake (Pt. #1) up. (Pt. #1) was cold and had no pulse. I called a code blue and run to the patient to start doing CPR. The doctor (MD #1) arrived and said not to start CPR due to the fact that (Pt. #1) was pulseless and was in rigor mortis. Usually, after the shift report, the charge nurse makes rounds around 7:45 AM. I was getting to start the rounds, but my priority in the morning was to start preparing medications. I have been off since then and was back the next day.” E #6 stated that there is nothing new that staff members were made aware of regarding monitoring patients. 10. On 4/9/2026 at approximately 3:30 PM, an interview was conducted with E #8 (Director, Risk and Performance Improvement). E #8 stated that the hospital has not completed an investigation regarding Pt, #1’s death. Regarding follow-up investigation and plan, E #8 stated that the hospital is waiting to hear from the coroner’s office regarding Pt. #1’s cause of death. B. Based on document review and interview, for 1 of 2 patients’ (Pt. #1) records reviewed related to code blue/medical emergency response, the hospital failed to ensure a timely and appropriate response to a medical emergency (Code), placing the patient at risk for serious harm. Subsequently, the hospital reported that Pt. #1 expired on 4/06/2026. Findings include: 1. On 4/7/2026, the clinical record for Pt. #1 was reviewed. On 4/3/2026, Pt. #1 was admitted as transfer from another hospital due to suicidal ideation. The clinical record included: - On 4/3/2026, the Behavioral Health Intake Assessment indicated, “ ... Reason for Admission ... (Pt. #1) stated that (Pt. #1) recently had thoughts of hurting self, but denies current suicidal or homicidal ideation ...” - On 4/3/2026 at 12:48 PM, the nurse’s admission note indicated, “ ... Advance Directives: None ... Diagnosis: Schizophrenia (type of psychiatric condition) ...” - On 4/6/2026, the hospital’s code blue (medical emergency) documentation form indicated, “ ... (Pt. #1) .... At (8:13 AM) ... RN Assessment: Patient Conscious at onset ... No. Did patient with a pulse become pulseless ... No ... Breathing Present ... No ... Circulation Present ... No ... Paramedics called ... by (E #6/RN). Paramedics arrival time: (8:26 AM) ... CPR (Cardiopulmonary Resuscitation/emergency heart-saving measure when heart stops beating) Initiated: No ... AED (Automated Emergency Defibrillator/medical device used to treat cardiac arrest by analyzing heart rhythm and delivering electric shock to restore normal function) Initiated ... No ... Physical Assessment: Neurological ... Unresponsive ... (Pt. #1) heard with breathing sounds although no pulse or breathing noted ... Mild bleeding noted on (Pt. #1’s) mouth and clothes ... (Pt. #1) attempted to arouse ... unresponsive. (Pt #1) flipped over and placed on ground ... Medical Intervention: Airway/ventilation ... Apnea ... Oxygen administered ... No ... Patient Disposition: (Pt. #1) was observed cold, and pulseless. Not breathing ... (Signed by E #7/Nurse Manager on 4/6/2026 at 12:08 PM) ...” - The clinical record/progress notes lacked documentation of the following: patient care interventions, notification of the medical director, attending physician, director of nursing and risk of the code blue event. The clinical record did not include charting of the code blue incident, patient’s vital signs, symptoms, reactions, and status of the patient ...” - The clinical record also did not include documentation from the medical or psychiatric provider’s (physician or APNs) assessment, reassessment, interventions, or disposition conducted for Pt. #1, when the incident was identified that Pt. #1 was found unresponsive and had no pulse on 4/6/2026. The hospital’s rules and regulations of the medical staff indicated, “ ... 4.2.8. Emergencies: In emergency situation, any physician/APN with hospital privileges may write or give orders to serve the needs of the patient ... 4.7 Patient Death ... In the event of a patient’s death while a patient of (Name of the Hospital), the deceased shall be pronounced dead by the attending psychiatrist/APN or his/her qualified designee ... Provisional and anatomic diagnosis shall be recorded whenever possible in the medical record within 72-hours ...” 2. On 4/08/2026, the hospital’s policy, “Rapid Response/Medical Emergency Care Policy” indicated, “ ... Scope: Medical Staff, Nursing ... Procedure ... 4. If the patient is at immediate risk or arrest RN or designee will contact the operator ... to page “Code Blue (medical emergency) ... 6. Physician ... Provide medical direction to RN ... Order medications as appropriate ...7. RN ... Services as Code Blue team leader to provide appropriate medical assessment and intervention ... ensures CPR is indicated in a timely manner if indicated and carries out physician orders. Document all patient interventions on the ... code blue documentation form and in progress notes ... Notifies medical director, attending physician, director of nursing and risk manager of code blue event. RN shall notify patient family ... regarding the event and outcome of event ... 8. Nursing Supervisor. Ensure the completion of documentation in the progress notes ... In all cases, complete charting of the incident ... medication given, patient’s vital signs, symptoms, reactions, and status of the patient ...” 3. On 4/08/2026, the American Heart Association CPR Guidelines (2025) indicated, “Start CPR immediately if an adult is unresponsive and not breathing ... activate emergency response, if available, have someone bring an AED (automated external defibrillator) ...” 4. On 4/09/2026, the hospital’s report to CMS (Centers for Medicare and Medicaid) titled, “Report of a Hospital Death Associated with the Use of Restraint or Seclusion,” indicated, “ ... Patient Name (Pt. #1) ... Date and Time of Death: 04/06/2026 (at) 8:15 AM ...” 5. On 4/8/2026 at approximately 10:41 AM, an interview was conducted with MD #1 (Attending Psychiatrist who responded to the Code Blue). MD #1 stated that there were people/staff in Pt. #1’s room when MD#1 arrived. MD#1 stated that Pt. #1 was lying face down and did not seem to be breathing and there was dried pool of emesis under Pt. #1’s face. MD #1 stated that Pt. #1 was not connected to the heart monitor or vital signs machine. MD #1 also stated that there was nobody performing CPR or if oxygen was placed on Pt. #1. MD #1 stated, “We rolled (Pt. #1) and moved (Pt. #1) on the floor. Once (Pt. #1) was rolled over, (Pt. #1) was cold, had no pulse, and the extremities were stiff. Because (Pt. #1) was cold and stiff, I felt that CPR would be unlikely to provide any chance of recovery, which is what my understanding. I am not sure of (Pt. #1’s) code status (advance directives). (Pt. #1) was in rigor mortis (postmortem stiffening of muscle that typically begins 2 to 4 hours after death). (Pt. #1’s) arms were stiff that’s why I think (Pt. #1) must have expired for at least couple of hours. I got in at 8:00 AM, the code was called around 8:05 AM. Typically, when a patient is found unresponsive and with no pulse, a code blue will be called. All available staff will respond and bring the crash cart, check the vital signs, assessing for history, administer oxygen, and provide supportive techniques. Those were not done before I arrived. I had ACLS (advanced cardiac life support) certification while I was a resident, but that has expired. I am not sure if that is a requirement for me here. There was no other provider (other than the psychiatric nurse practitioner) from the hospital who were present. I don’t remember if the time when (Pt. #1) was pronounced dead was documented. I suppose I or the nurse practitioner will be the code team leader. I don’t feel that I can fully recall the protocol for a code team leader. I did not know that I was supposed to document about my assessment or examination. After the incident, I signed a form that I was present (during the code blue) with the nurse manager, I also spoke to the Risk Manager about what I saw and what happened. I was not told that there should be anything done differently. 6. On 4/08/2026 at approximately 1:04 PM, an interview was conducted with E #6 (Charge Nurse, 7-3 on 4/6/2026). E #6 stated, “We had a shift report around 7:30 AM. I was preparing my day. Around 8:00 AM, staff member came to me saying that (Pt. #1) was not responding. I went to the room. I tried to wake (Pt. #1) up. (Pt. #1) was cold and had no pulse. I called a code blue and run to the patient to start doing CPR. The doctor (MD #1) arrived and said not to start CPR due to the fact that (Pt. #1) was pulseless and was in rigor mortis. E #6 stated that there is nothing new that E #6 was made aware of regarding care of patients in the unit. 7. On 4/8/2026 at approximately 1:39 PM, an interview was conducted with E #7 (2 North Nurse Manager). E #7 stated, “I completed the Code Blue form. Code Blue was called for (Pt. #1). When (E #6) was going to start compression/CPR, (MD #1) said not to start compression. (MD #1) did not pronounce or gave a time of (Pt. #1’s) time of death. When the EMS (emergency medical service) arrived, EMS started compression/CPR, connected (Pt. #1) to AED, and got an asystole (no heart rhythm).” E #7 stated that EMS left the hospital afterwards. 8. On 4/9/2026 at approximately 3:30 PM, an interview was conducted with E #8 (Director, Risk and Performance Improvement). E #8 stated that the hospital has not completed an investigation regarding Pt. #1’s death. Regarding follow-up investigation and plan, E #8 stated that the hospital is waiting to hear from the coroner’s office regarding Pt. #1’s cause of death. 34411 C. Based on document review and interview, for 5 of 5 (Pt #4, Pt #9-Pt #12) clinical records reviewed for patients on suicide precautions, the hospital failed to ensure that a daily suicide risk assessment was completed, as required per policy. Findings include: 1. The hospital’s policy titled, “Suicide and Self-Harm Prevention Plan” (dated 2/2025) was reviewed, and required, “ ...Patients at risk for suicide and/or self-injurious behaviors require intensive support, close observation, frequent re-assessment ...Reassessments of Risk: ...Daily suicide risk re-assessment will be completed by the RN [registered nurse] for all patients on suicide precautions (SP) ...” 2. The clinical records for 5 patients (Pt #4, Pt #9-Pt #12) on suicide precautions were reviewed on 4/8/2026. The following was included: - Pt #4 was admitted on 4/2/2026, with an admitting diagnosis of suicidal ideation. An admission suicide risk assessment was completed. An order was placed for suicide precautions on 4/2/2026. Pt #4’s clinical record lacked daily suicide risk reassessments from 4/3/2026-4/7/2026. - Pt #9 was admitted on 4/2/2026, with an admitting diagnosis of suicidal ideation. An admission suicide risk assessment was completed. An order was placed for suicide precautions on 4/2/2026. Pt #9’s clinical record lacked daily suicide risk reassessments from 4/3/2026-4/7/2026. - Pt #10 was admitted on 4/2/2026, with an admitting diagnosis of delusion. An admission suicide risk assessment was completed. An order was placed for suicide precautions on 4/2/2026. Pt #10’s clinical record lacked daily suicide risk reassessments from 4/3/2026-4/7/2026. - Pt #11 was admitted on 4/4/2026, with an admitting diagnosis of suicidal ideation. An admission suicide risk assessment was completed. An order was placed for suicide precautions on 4/4/2026. Pt #11’s clinical record lacked daily suicide risk reassessments from 4/5/2026-4/7/2026. - Pt #12 was admitted on 4/2/2026, with an admitting diagnosis of suicide ideation. An admission suicide risk assessment was completed. An order was placed for suicide precautions on 4/2/2026. Pt #12’s clinical record lacked daily suicide risk reassessments from 4/3/2026-4/7/2026. 3. On 4/8/2026 at approximately 10:45 AM, an interview was conducted with the RN/Director of Emergency Services (E # 25). E #25 stated that when a patient presents to the hospital, they are initially screened through the emergency services intake department. E #25 stated that an admission suicide risk assessment is done on admission. E #25 stated that the floor nurses are expected to complete daily suicide reassessments while the patient is admitted on the unit.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(B) [A restraint is-] (B) A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. This Standard is not met as evidenced by: 36774 Based on document review and interview, for 2 of 4 patients’ (Pt. #1 and Pt. #4) clinical records reviewed regarding use of restraints, the hospital failed to ensure that staff were able to identify use of drug or medication as a chemical restraint. Findings include: 1. On 4/9/2026, the hospital’s policy titled, “Restraint and Seclusion” (2/2025) was reviewed and indicated, “... Medication (Chemical Restraint): The administration of a drug or medication when it is used as a restriction to manage the patient’s behavior... and is not a a standard treatment... for the patient’s condition...” 2. On 4/9/2026, the clinical record for Pt. #1 was reviewed. On 4/3/2026, Pt. #1 was admitted as transfer from another hospital due to suicidal ideation. The clinical record included: - On 4/5/2026 at 10:21 PM, E #1’s progress note indicated, “(Pt. #1) became agitated and threatened to assault both staff and (patient) because staff was unable to provide requested pain medication. (Pt. #1) was non-directable (would not follow commands) and (Pt. #1) became more agitated. (Pt. #1) taken to quiet room for a time out. MD (MD #2/Attending Psychiatrist) notified and (MD #2) ordered (STAT medication) for agitation. (Pt. #1) given STAT (as soon as possible) IM (intramuscular) Zyprexa (Olanzapine/psychotropic medication) 10 milligrams (mg) and STAT IM Benadryl 25 mg at (7:21 PM) in right arm. (Pt. #1) then transferred to (2 North) to better meet (Pt. #1’s) needs related to aggression and agitation ...” -The clinical record did not indicate that Pt. #1 voluntarily accepted the medication. 3. On 4/9/2026, the clinical record for Pt. #4 was reviewed. Pt. 4 was admitted to the hospital on 4/02/2026 due to suicidal ideation. On 4/06/2026, the clinical record indicated, “(Pt. #4) was escorted to the quiet room and was placed on supine physical hold... continuous to try hurting self... given Zyprexa PRN (intramuscular) while (on) hold...” The restriction of rights on 4/06/2026 did not indicate that Pt. # received emergency forced medication. 4. On 4/9/2026, the hospital’s document titled, “CMS (Centers for Medicare and Medicaid Services). Report of a Hospital Death Associated With the Use of Restraint or Seclusion” (dated 4/06/2026) was reviewed and indicated, “Date and time death was reported to CMS must be documented in the patient’s medical record. One option for documentation can be to download ... or print this page to file in the medical record... (Pt. #1)...Date and Time of Death: 4/06/2026 8:15 AM. Date/Time Form Submitted: 4/6/2026 5:57 PM...” 5. On On 4/07/2026 and 4/08/2026, interviews were conducted with E #12 (Interim Nurse Manager, 2 South/Nursing Supervisor) at approximately 3:05 PM. E #1 stated E #1 administered Olanzapine and Benadryl for Pt. #1 because Pt. #1 was threatening to both staff and patient. E #1 stated that the medication was not used as form of chemical restraint. 6. On 4/07/2026 at approximately 4:27 PM, an interview was conducted with E #1 (Registered Nurse). E #1 stated, “(Pt. #1) was highly irritable, non-directable, and psychotic which went on for a while. (Pt. #1) started threatening staff, peers, and stated will jump to the nurse’s station. We took (Pt. #1) to the quiet room and gave Zyprexa (Olanzapine) and Benadryl intramuscular injection. There was a large number of people. (E #12) was there, who administered the medication. We gave the medication because (Pt. #1) was a danger to self and others. (Pt. #1) stayed in the quiet room for about 10 to 15 minutes...” E #1 stated that Olanzapine and Benadryl were not used for Pt. #1 as a form of chemical restraint. 7. On 4/08/2026 at approximately 2:27 PM, an interview was conducted with MD #2 (Attending Psychiatrist/On-call). MD #2 stated that the Olanzapine and Benadryl were ordered as “emergency medications” because Pt. #1 was aggressive and threatening to hurt staff. MD #2 stated that Olanzapine and Benadryl was not part of Pt. #1’s medication regimen. 8. On 4/09/2026 at approximately 11:53 AM, an interview was conducted with E #8 (Director, Risk and Performance Improvement). E #8 stated that the CMS form was submitted for Pt. #1. E #8 stated that it is possible that the report was made to CMS due to use of chemical restraint because Pt. #1 was given Olanzapine and Benadryl (on 4/5/2026). On 4/10/2026 at approximately 11:00 AM, E #8 stated that Pt. #1 voluntarily accepted Olanzapine and Benadryl. However, E #8 was unable to provide documentation that Pt. #1 voluntarily accepted the medication.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 36774 Based on document review and interview, for 1 of 4 patients’ (Pt. #1) clinical records reviewed regarding use of restraints, the hospital failed to ensure notice of restriction of rights was provided to Pt. #1 Findings include: 1. On 4/7/2026, the clinical record for Pt. #1 was reviewed. On 4/3/2026, Pt. #1 was admitted as transfer from another hospital due to suicidal ideation. The clinical record included: - On 4/5/2026 at 10:21 PM, E #1’s (Registered Nurse) progress note indicated, “(Pt. #1) became agitated and threatened to assault both staff and (patient) because staff was unable to provide requested pain medication. (Pt. #1) was non-directable (would not follow commands) and (Pt. #1) became more agitated. (Pt. #1) taken to quiet room for a time out. MD (MD #2/Attending Psychiatrist) notified and (MD #2) ordered (STAT medication) for agitation. (Pt. #1) given STAT (as soon as possible) IM (intramuscular) Zyprexa (Olanzapine/psychotropic medication) 10 milligrams (mg) and STAT IM Benadryl.” The clinical record did not indicate that Pt. #1 voluntarily accepted the medication. The record also did not include restriction of rights notice was provided to Pt. #1. 2. On 4/9/2026, the hospital’s policy titled, “Restraint and Seclusion” (2/2025) was reviewed and indicated, “... Medication (Chemical Restraint): The administration of a drug or medication when it is used as a restriction to manage the patient’s behavior... and is not a a standard treatment... for the patient’s condition... 6.0... Restriction of rights notice is completed for every restraint/seclusion episode and concurrent administration of involuntary medication...” 3. On 4/07/2026 at approximately 4:27 PM, an interview was conducted with E #1. E #1 stated, “(Pt. #1) was highly irritable, non-directable, and psychotic which went on for a while. (Pt. #1) started threatening staff, peers, and stated will jump to the nurse’s station. We took (Pt. #1) to the quiet room and gave Zyprexa (Olanzapine) and Benadryl intramuscular injection. There was a large number of people. (E #12) was there, who administered the medication. We gave the medication because (Pt. #1) was a danger to self and others. (Pt. #1) stayed in the quiet room for about 10 to 15 minutes...” 4. On 4/08/2026 at approximately 2:27 PM, an interview was conducted with MD #2 (Attending Psychiatrist/On-call). MD #2 stated that the Olanzapine and Benadryl were ordered as “emergency medications” because Pt. #1 was aggressive and threatening to hurt staff. MD #2 stated that Olanzapine and Benadryl was not part of Pt. #1’s medication regimen. 5. On 4/09/2026 at approximately 11:53 AM, an interview was conducted with E #8 (Director, Risk and Performance Improvement). E #8 stated that it is possible that the report was made to CMS due to use of chemical restraint because Pt. #1 was given Olanzapine and Benadryl (on 4/5/2026). On 4/10/2026 at approximately 11:00 AM, E #8 stated that Pt. #1 voluntarily accepted Olanzapine and Benadryl. However, E #8 was unable to provide documentation that Pt. #1 voluntarily accepted the medication.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 36774 Based on document review and interview, for 1 of 4 patients’ (Pt. #1) clinical records reviewed regarding use of restraints, the hospital failed to ensure documentation of monitoring was completed. Findings include: 1. On 4/9/2026, the hospital’s policy titled, “Restraint and Seclusion” (2/2025) was reviewed and indicated, “... Medication (Chemical Restraint): The administration of a drug or medication when it is used as a restriction to manage the patient’s behavior... and is not a standard treatment... for the patient’s condition... 5.0 Monitoring of patient’s in restraints... 5.1 Assigned staff conducts 15 minute... patient observation on the Restraint/Seclusion/Physical Flowsheet that includes the following... Obtains vital signs at initiation and termination of restraint...” 2. On 4/07/2026, the clinical record for Pt. #1 was reviewed. On 4/3/2026, Pt. #1 was admitted as transfer from another hospital due to suicidal ideation. The clinical record included: - On 4/5/2026 at 10:21 PM, E #1’s progress note indicated, “(Pt. #1) became agitated and threatened to assault both staff and (patient) because staff was unable to provide requested pain medication. (Pt. #1) was non-directable (would not follow commands) and (Pt. #1) became more agitated. (Pt. #1) taken to quiet room for a time out. MD (MD #2/Attending Psychiatrist) notified and (MD #2) ordered (STAT medication) for agitation. (Pt. #1) given STAT (as soon as possible) IM (intramuscular) Zyprexa (Olanzapine/psychotropic medication) 10 milligrams (mg) and STAT IM Benadryl.” The clinical record did not indicate that Pt. #1 voluntarily accepted the medication. The record also did not indicate that vital signs were obtained. 3. On 4/08/2026 at approximately 2:27 PM, an interview was conducted with MD #2 (Attending Psychiatrist/On-call). MD #2 stated that the Olanzapine and Benadryl were ordered as “emergency medications” because Pt. #1 was aggressive and threatening to hurt staff. MD #2 stated that Olanzapine and Benadryl was not part of Pt. #1’s medication regimen. 4. On 4/09/2026 at approximately 11:53 AM, an interview was conducted with E #8 (Director, Risk and Performance Improvement). E #8 stated that it is possible that the report was made to CMS due to use of chemical restraint because Pt. #1 was given Olanzapine and Benadryl (on 4/5/2026). On 4/10/2026 at approximately 11:00 AM, E #8 stated that Pt. #1 voluntarily accepted Olanzapine and Benadryl. However, E #8 was unable to provide documentation that Pt. #1 voluntarily accepted 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 Based on document review and interview it was determined that for 1 of 1 patient (Pt. #1) clinical record reviewed for an allegation of abuse, the hospital failed to ensure that patient was offered to have a sexual examination after a report of being inappropriately touched by a peer. Findings include: 1. The hospital’s polity titled, “Sexual Allegation, Aggression and Sexual Victimization: Prevention Response and Notification Plan” (revised 02/2023) was reviewed and required, “Sexual Allegations: Patient reports/alleges ... Sexual Misconduct: Verbal and/or physical contact of a sexual nature regarded as offensive or provocative; intentional touching without consent ... fondling/touching and other direct or through clothing another person’s genitals, breast, groin, thighs, or buttocks ... Action Steps: 5. Response to Sexual Allegation: ... Offer patient transport to the ER (emergency room) for rape/trauma evaluation for cases involving any sexual allegation of touching genital/anal area ... If patient refused ER, RN (Registered Nurse) will document refusal in the medical record and promptly contact medical physician by phone to examine the patient as soon as possible no longer than 24 hours of notification.” 2. On 3/28/26, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted to the hospital on 09/20/25 and dishcarged on 10/03/25 The clinical record included the following: -Initial Psychiatric Evaluation dated 09/21/25 at 4:39 PM, “(Pt. #1) who was admitted due to SI (Suicidal Ideation) with plan. Presenting symptoms include severe anxiety with excessive worrying, restlessness, mood liability, and depressive symptoms characterized by hopelessness, fatigue, and poor sleep.” -Psychiatric Progress Note (MD #1) dated 09/30/25 at 3:05 PM, “(Pt. #1) was initially seen in the hallway. (Pt. #1) reports that (Pt. #1) is not doing good because of yesterday (09/29/25) says someone touched (Pt. #1) and that was going on for a few days. (Pt. #1) did not tell anyone because (Pt. #1) was scared. (Pt. #1) reported this to staff and is meeting with several staff members about it today.” -Multidisciplinary Progress Note (RN/E #13) dated 09/30/25 at 3:32 PM, “(Pt. #1) reported to staff RN (E #13) of being touched inappropriately by a male peer (Pt. #8) during the past few days. Patient reported was scared to speak with staff. Peers (Pt. #1 and Pt. #8) were separated, (Pt. #1) denies current pain or discomfort. Medical consult entered post injury, and Midas (hospital’s incident/event reporting system) completed.” The nursing note did not indicate that the patient was offered transport to an ER for rape/trauma evaluation, and/or if the patient refused. -Medical Consult dated 09/30/25 at 3:32 PM, “Pain Assessment: Denies; Review of Systems: (all within normal limits); Physical Examination: ... Negative for dryness or diaphoresis. Detailed exam of skin does not show any evidence of bruising, skin breach, lacerations, erythema, eyes, nose, ears, and genitalia show no evidence of injury. Psychosocial: The patient is in a good mood, no anxiety.” The medical consult note did not include documentation that the patient was offered transportation to the ER for rape/trauma evaluation. 3. An Incident Report dated 09/30/25 for (Pt. #1) and (Pt. #8) was reviewed and included the following: “Date of incident 09/29/25; Incident reported: 09/30/25; (Pt. #1) reported a male peer (Pt. #8) touched (Pt. #1) inappropriately on buttock over clothes several days ago while in the hallway and in the dayroom but unclear of what date or time. (Pt. #1) was also reported the male peer making inappropriate statements to (Pt. #1). ‘I didn’t tell nobody because was scared’ per (Pt.#1) ... (Pt. #8) accused of touching (Pt. #1) inappropriately ... (Pt. #8) denies the incident taking place; (Pt. #1) unable to recall what day it happened. Staff notified treatment team.” 4. An interview was conducted with the Nurse Supervisor (E #5) on 03/30/26 at 5:20 PM. E #5 stated that for allegations of abuse involving peer to peer or staff to peer the process is to interview the patient making the allegation, we notify the social worker, risk management, the medical director, guardian if any. We ask the patient if they want to go out for rape kit and offer an advocate. 5. Interviews were conducted with the Director of Nursing (E #10) and Assistant Director of Nursing (E #11) on 03/30/26. E #10 and E #11 confirmed that for (Pt. #1) there was no documentation in the clinical record to indicate that (Pt. #1) was offered a sexual assault examination after an allegation of being inappropriately touched by a peer on the buttocks and vaginal area.”