Northwest Health - Porter

“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: 14445 Based on document review and interview the hospital staff failed to ensure that a patient received completed discharge instructions, and a safe discharge (see tag 813), for 1 of 10 MRs (Medical Record) reviewed. (Patient # 6). The cumulative effect of this systemic problem resulted in the facility’s inability to ensure that safe Discharge Planning was promoted.”

“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: 14445 Based on document review and interview the nurse failed to ensure complete supervision and nursing care provided to 1 of 10 MRs (Medical Record) reviewed. (Patient # 6). Findings include: 1. Facility policy titled, “Care Management Plan for Discharge Planning”, policy number: none listed, indicated on page 1, under I. Identification of patients in need of discharge planning, A., All patients are screened by nursing services for potential discharge needs; and on page 2, under III. Discharge Plan, B. The Care Manager will develop discharge plan with input from the patient and/or caregiver, D. The Care Manager will reassess the patient’s discharge plan and any factors that may impact the patient’s continuing care needs. Last revised 12/2024. 2. Facility policy titled, “Inpatient Acute Nursing Guidelines of Patient Care”, policy number: none listed, indicated on page 7, under Interventions: Global Interventions; The nurse will perform interventions to meet the individualized needs and problems of the patient, and on page 10, under Respiratory Care Management: Maintaining oxygen delivery system: reassessment after every change to oxygen; oxygen saturation will be monitored. Last revised/approved 6/2025. 3. Review of MR for patient # 6, reflected the following: (a). Patient admitted on 4/27/2025 to 3rd floor (Progressive unit) after seen, evaluated, treated in the ED/ER (Emergency Department/Emergency Room) on evening/night of 4/26/2025 for complaints of: weakness, SOB (shortness of breath) and cough. Patient had been brought to AH # 40’s (Acute Care Hospital) - (ED/ER by ambulance/EMS (emergency medical services). Patient was discharged on 5/1/2025 to home (to address provided by patient) via transport service, with discharge instructions. (b). H&P (History & Physical) on 4/27/2025, by MD # 30 (Doctor of Medicine-MD/Hospitalist) reflected patient does have a history of chronic daily/mild dementia, but after speaking to contact, it was found that patient was brought in due to being a little more altered than usual. Patient history also included: COPD (Chronic obstructive pulmonary disease). Patient on 4 L (liters) of oxygen at home and albuterol as needed. (c). Nurse note on 4/28/2025 at 10:30 pm, reflected O2 (oxygen) at 3 L, sat (saturation) = 99%. (d). RT (Respiratory) flowsheets (during patient’s hospital stay) reflected O2 nasal cannula use: 3 L to 1 L; O2 sats = 95% to 98%. (e). Nurse flowsheet on 5/1/2025 morning, for Respiratory: reflected patient denies shortness of breath, 2 L nasal cannula. Respirations: regular and unlabored. O2 sat = 100%. (f). CM (Case Management) note on 5/1/2025 at 4:29 pm, by S # 10 (Case Management) reflected patient discharged home with no needs. CM arranged for transport service, address listed in note. (g). The MR lacked documentation - entries by nursing staff in regards to the following: 1. Any belongings that the patient had arrived with on admission (i.e. shoes). 2. Any type of footwear patient was dressed in at time of discharge. 3. For an assessment of respiratory status prior to discharge: respiration rate, oxygen saturation; with patient on room air, as patient was discharged with no supplemental oxygen for transport to home. 3. That patient was sent via transport to a different address than her/his own for discharge. 4. If the address was checked and verified as having been correct for the patient. 4. In interview on 6/18/2025 at approximately 1:50 pm, with S # 12 (Case Management), confirmed that they don’t see what belongings patient is leaving with; not part of patient dressed - shoes or no shoes for discharge; prepare for transport service arrival. That is nursing’s responsibilities. 5. In interview on 6/18/2025 at approximately 1:40 pm and at approximately 2:28 pm, with S # 10 (Case Management), confirmed the following: a. Patient # 6 did not ask for anyone to be called; family - emergency contact or FM # 1 (family member). Patient able to make a call; believe patient could have made a call. b. Address given by patient # 6. Did not double check face sheet, went with what patient said. There are times when facesheets are wrong. Did not realize patient address on facesheet was different than one patient wanted to go to. Address on facesheet could be from a previous stay. 6. In interview on 6/18/2025 at approximately 2:25 pm, with S # 11 (Case Management), confirmed - No recollection of what belongings patient # 6 had with her/him. 7. In interview on 7/9/2025 at approximately 2:37 pm, with FR # 20 (Friend) the following was indicated: a. When the patient (Patient # 6) arrived at FR # 20’s house, after discharge from AH # 40, the patient was barefoot. b. The patient (Patient # 6) was discharged to FR # 20’s house (Patient’s previous address). Patient arrived via a transport service. c. The patient (Patient # 6) has oxygen at home. Has used oxygen for the last 16 to 18 years. 8. It was determined that Patient # 6’s arrival at FR # 20’s house was not planned, and was discharged without oxygen or a respiratory assessment being completed prior to hospital discharge.”

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 14445 Based on document review and interview, the hospital staff failed to ensure that a patient received completed discharge instructions, and a safe discharge, for 1 of 10 MRs (Medical Record) reviewed. (Patient # 6). Findings include: 1. Policy titled, “Inpatient Acute Nursing Guidelines of Patient Care”, policy number: none listed, indicated on page 16, under Discharge: discharge assessment will include, understanding of discharge instruction from nurse, including patient teaching. Last revised/approved 6/2025. 2. Policy titled, “Care Management Plan for Discharge Planning”, policy number: none listed, indicated on page 2, under III. Discharge Plan, B. The Care Manager will develop discharge plan with input from the patient and/or caregiver, D. The Care Manager will reassess the patient’s discharge plan and any factors that may impact the patient’s continuing care needs. Last revised 12/2024. 3. Review of MR for patient # 6, reflected the following: (a). Patient admitted on 4/27/2025 to 3rd floor (Progressive unit) after seen, evaluated, treated in the ED/ER (Emergency Department/Emergency Room) on evening/night of 4/26/2025 for complaints of: weakness, SOB (shortness of breath) and cough. (b). H&P (History & Physical) on 4/27/2025, by MD # 30 (Doctor of Medicine-MD/Hospitalist) reflected patient does have a history of chronic daily/mild dementia, but after speaking to contact, it was found that patient was brought in due to being a little more altered than usual. (c). Patient was discharged on 5/1/2025 to an address (address provided by patient), that was not the noted home address for the patient as listed on the patient’s facesheet; via transport service. (d). MR documentation lacked completed/received - signed discharge instructions by the patient. (e). The MR lacked documentation - entries by nursing staff in regards to the following: 1. That patient was sent via transport to a different address than her/his own for discharge. 2. If the address was checked and verified as having been correct for the patient. 4. In interview on 6/18/2025 at approximately 1:40 pm and at approximately 2:28 pm, with S # 10 (Case Management), confirmed the following: a. Patient # 6 did not ask for anyone to be called; family - emergency contact or FM # 1 (family member). Patient able to make a call; believe patient could have made a call. b. Address given by patient # 6. Did not double check face sheet, went with what patient said. There are times when facesheets are wrong. Did not realize patient address on facesheet was different than one patient wanted to go to. Address on facesheet could be from a previous stay. 5. In interview on 7/9/2025 at approximately 2:37 pm, with FR # 20 (Friend), the following was indicated: a. When the patient (Patient # 6) arrived at FR # 20’s house, after discharge from AH # 40, the patient was barefoot. b. Patient arrived via a transport service. 6. It was determined that the patient (Patient # 6) did not arrive at her/his residence.”

“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: 35731 Based on document review and interview, the registered nurse failed to evaluate a patient per policy in one (1) instance. (Patient # 10) Findings include: 1. The facility policy titled, Suicide Risk Assessment and Interventions Columbia Protocol in Non-Behavioral Health Setting, version eight (8), no policy number, indicated on page two (2) - section Procedure - Required Action Steps - Guidance - Determining suicide risk level can include additional information and sources other than the patient, such as Emergency Medical Services, significant others and/or other observers who report suicide ideation, intent and/or behavior. This policy was last revised on 06/08/2022. 2. Patient # 10’s MR (medical record) indicated the patient was a 24 y/o (year/old) brought into H # 2’s (Acute Care Hospital) Emergency Department (ED) by police on several dates including, but not limited to, the following: a. The Law Enforcement Statement In Support of Emergency Detention and Transport dated 01/15/2025 at 6:16 pm, indicated the patient was believed to be mentally ill due to - intellectual disability and other psychiatric disorders that substantially disturbed the individual’s thinking, feeling, or behavior and impaired the individual’s ability to function, and the person named above (patient # 10) was - dangerous to self and was in immediate need of hospitalization and treatment for the following reasons: Patient # 10 stated he/she would go in his/her room and self-harm. b. The Nurses note dated 01/15/2025 at 6:63 pm by N # 2 (Registered Nurse-RN), indicated the patient refused to answer the questions for the Columbia Suicide Risk Assessment. The patient was calculated (per the computer system) at low risk for suicide with no action interventions required. c. The Provider note dated 01/15/2025 at 7:34 pm by M # 2 (Doctor of Osteopathy-DO/Family Medicine), indicated Medical Decision Making - Patient had medical screening examination. The patient refused to cooperate with evaluation. There appears to be no acute change in his/her condition. He/she was considered safe to return to his/her group home. Patient was discharged back to H # 3 (Group Home). d. The Provider note dated 01/16/2025 at 6:45 pm by M # 2, indicated the diagnosis to be - intentional self-harm by strangulation. History of present illness - patient was found at his/her facility (H # 3) with a cord wrapped around his/her neck. The patient appeared to be hypoxic. 3. In interview on 02/27/2025 at approximately 2:50 pm with staff member A # 1 (Chief Nursing Officer-CNO), confirmed when the patient doesn’t answer and/or refuses to answer the Columbia Suicide Risk Questions the system will automatically default to low risk. 4. In interview on 02/28/2025 at approximately 3:48 pm with medical staff member M # 4 (Chief Medical Officer-CMO), confirmed he/she believed it was a communication gap with the consult from H # 4. The nurse should use her discretion to change the suicide risk assessment if and/or when necessary.”

“DISCHARGE PLANNING - EARLY IDENTIFICATION CFR(s): 482.43(a) The hospital’s discharge planning process must identify at an early stage of hospitalization those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient’s representative, or patient’s physician. This Standard is not met as evidenced by: 35731 Based on document review and interview, the facility failed to provide appropriate discharge planning evaluation for a patient who had been previously identified as suicidal in one instance. (Patient # 10) Findings include: 1. The facility policy titled, Discharge Planning and Follow Up Care, version two (2), no policy number, indicated on page one (1) - section Procedure - number two (2) - to discharge a patient, obtain the completed chart and verify that all orders and reassessments have been completed and signed. This policy was last revised on 11/25/2024. 2. The facility policy titled, Suicide Risk Assessment and Interventions Columbia Protocol in Non-Behavioral Health Setting, version eight (8), no policy number, indicated on page two (2) - section Procedure - Required Action Steps - Guidance - Determining suicide risk level can include additional information and sources other than the patient, such as Emergency Medical Services, significant others and/or other observers who report suicide ideation, intent and/or behavior. This policy was last revised on 06/08/2022. 3. Patient # 10’s MR indicated the following: The patient was a 24 y/o (year/old) brought into H # 2’s (Acute Care Hospital) Emergency Department (ED) by police on several dates including, but not limited to, the following: a. The patient arrived to the ED on 01/14/2025 with the diagnosis of foreign body in hand, pica, and suicidal ideation. b. The Psychiatric Consult was ordered by M # 3 (Doctor of Osteopathy-DO/Emergency Medicine). c. The Case Management (CM) note dated 01/15/2025 at 7:53 am, indicated the medical record chart was further reviewed by T # 1 (Transition Care Coordinator-TCC) with the current complaint being that the patient wants to overdose. d. The CM note dated 01/15/2025 at 12:07 pm, indicated H # 3, H # 2’s charge nurse, Case Manager Director and Nurse Administration were all updated/aware, and were in agreement related to patient # 10 being discharged. e. The Provider note dated 01/15/2025 at 12:12 pm by M # 3, indicated - Calls-Consults - recommended H # 4 come and see the patient. It was felt that patient # 10 was not truly suicidal, but he/she had behavioral issues. The patient was discharged to H # 3 at 1:46 pm. f. The Law Enforcement Statement In Support of Emergency Detention and Transport dated 01/15/2025 at 6:16 pm, indicated the patient was back in the ED and was believed to be mentally ill due to - intellectual disability and other psychiatric disorders that substantially disturbed the individual’s thinking, feeling, or behavior and impaired the individual’s ability to function, and the person named above (patient # 10) was - dangerous to self and was in immediate need of hospitalization and treatment for the following reasons: Patient # 10 stated he/she would go in his/her room and self-harm. g. The Nurses note dated 01/15/2025 at 6:63 pm by N # 2 (Registered Nurse-RN), indicated the patient refused to answer the questions for the Columbia Suicide Risk Assessment. The patient was calculated (per the computer system) at low risk for suicide with no action interventions required. h. The Provider note dated 01/15/2025 at 7:34 pm by M # 2, Medical Decision Making - Patient had medical screening examination. The patient refused to cooperate with evaluation. He/she had numerous recent formal evaluations from H # 4 and was previously cleared to return to his/her group home. There appears to be no acute change in his/her condition. He/she was considered safe to return to his/her group home. Patient was discharged. i. The Triage Assessment dated 01/15/2025, signed by M # 1 on 01/16/2025 at 8:35 am on page 7, section Crisis Type - indicated suicidal, section Psychiatric Recommendations/Outcomes - M # 1 recommended that the client (patient # 10) needed to stay in the ED for the time being, and section Admission Criteria Met - indicated recent suicide attempt or gesture within seventy-two (72) hours prior to admit. j. The patient arrived to the ED on 01/16/2025 with the diagnosis of intentional self-harm by strangulation. k. The Provider note dated 01/16/2025 at 6:45 pm by M # 2, indicated the diagnosis to be - intentional self-harm by strangulation. History of present illness - patient was found at his/her facility (H # 3) with a cord wrapped around his/her neck. The patient appeared to be hypoxic. Patient was alone for approximately ten (10) to fifteen (15) minutes. Patient # 10 appeared stable on arrival to ED. He/she did not wish to answer questions at this time. 4. In interview on 02/27/2025 at approximately 2:50 pm with staff member A # 1 (Chief Nursing Officer-CNO), confirmed when the patient doesn’t answer and/or refuses to answer the Columbia Suicide Risk Questions the system will automatically default to low risk. 5. In interview on 02/28/2025 at approximately 1:45 pm with medical staff member M # 2, confirmed when patient # 10 arrived to the ED in the evening of 01/15/2025, nothing had changed from earlier in the afternoon when he/she was discharged by medical staff member M # 3. When H # 4 comes in for a psychiatric consultation first they go talk to the patient, then go into a room where they phone the psychiatrist to discuss the assessment, then they are supposed to come find us to let us know their findings. Honestly, we all thought it was just attention seeking and maybe that clouded our judgement. 6. In interview on 02/28/2025 at approximately 2:10 pm with medical staff member M # 3, confirmed he/she never spoke to anyone from H # 4 related to the psychiatric evaluation recommendations. He/she confirmed receiving a call from CM (doesn’t remember the name of person), indicating a meeting was held by CM, H # 3, patient # 10’s guardian, hospital administration who all agreed to discharge patient # 10. Everyone thought it was behavioral issues. M # 3 further confirmed that he/she thought it was the “wrong play” to discharge the patient, but “I did”. 7. In interview on 02/28/2025 at approximately 3:48 pm with medical staff member M # 4 (Chief Medical Officer-CMO), confirmed he/she believed it was a communication gap with the consults at H # 4. The nurse should use her discretion to change the suicide risk assessment if and/or when necessary.”

“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: 44532 Based on document review and interview, the registered nurse failed to ensure patient assessment and/or vital signs every 4 (four) hours, failed to provide a sitter, and failed to document 15-minute monitoring safety checks for 1 of 10 patient (P1) medical records reviewed. The cumulative effect of these systematic problems resulted in the facility’s inability to provide nursing care in a safe manner.”

“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: 44532 Based on document and interview, the facility failed to ensure care in a safe setting in one instance for 1 of 10 patient (P1) medical records reviewed. Findings include: 1. Facility policy titled “Patient Rights Policy”, revision date: 03/07/2022. Patient Rights: Personal privacy and safety. 2. Facility policy titled “Suicide Risk Assessment and Interventions Columbia Protocol in Non-Behavioral Health Setting”, revision date: 06/08/2022, indicated All adolescent and adult patients who present for care will be screened for suicide ideation and behavior using the Columbia Protocol (Columbia-Suicide Severity Rating Scale (C-SSRS). On page 6, Table 1: Patient Safety Measures and Interventions Based on Screening Responses, Level of Risk: High- Initiate continuous observation (1:1 or in dedicated, secured, ligature resistant area or room), - RN to notify MD and MD to order Mental Health Professional face-to-face consult before leaves the area/unit, - All staff to use communication/de-escalation techniques, - If family/significant other with patient: Nurse to provide “Support Person Education”, RN to Re-assess suicidal risk and need for suicidal precautions if there is an observed or stated change in behavior. Registered Nurse observe patient every 15 minutes and utilize the Frequent Observation Flow Sheet. 3. MR indicated P1 was admitted to the facility on 01/10/2025 at 1532 hours for suicidal ideation. MR indicated Notice of “Patient Rights and Responsibilities”, was signed by P1 on 01/10/2025 at 1650 hours which included but not limited to patient have the right to an environment that is safe, preserves dignity and contributes to a positive self -image. Columbia-Suicide Severity Rating Scale (C-SSRS) was completed on 01/10/2025 at 1705 hours on P1, indicated patient level of risk is high. MR lacked documentation of completed 15-minute checks and having a sitter at bedside while a patient at the facility. Nurse Note dated 01/11/2025 at 1618 hours written by N1 (Registered Nurse) indicated security guard and ER tech notified nurse that patient in room ED11 was blue. Patient found on the floor, not breathing, cool to the touch, and mottled, no pulse was detected, MD1 notified. P1 was pronounced expired at this time by MD1 (Emergency Room Medical Doctor) on 01/11/2025 at 1625 hours. 4. In interview on 01/23/2025 at approximately 1430 hours, with A1 (Chief Nursing Officer, CNO), confirmed the patient (P1) did not have a sitter at the bedside and 15 minute checks were not completed for P1. 5. In phone interview with N1 (Registered Nurse) on 01/27/2025 at 1030 hours verified that P1 did not have a sitter assigned on 01/11/2025 and should have.”

“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: 44532 Based on document review and interview, nursing services failed to assess patient and/or vital signs every 4 (four) hours, failed to document 15-minute monitoring safety checks, and failed to provide a sitter at the bedside for 1 of 10 patient (P1) medical records reviewed. Findings include: 1. Facility policy titled “ED Assessment and Reassessment”, revision date 09/24/2024. To provide guidelines for standardizing the frequency of assessing and reassessing of patients that present in the emergency department including patients triaged and in the ED waiting area. Vital signs will be recorded every four hours or at a minimum on admission and at time of discharge and as needed by the patients condition. 2. Facility policy titled “Suicide Risk Assessment and Interventions Columbia Protocol in Non-Behavioral Health Setting”, revision date: 06/08/2022, indicated All adolescent and adult patients who present for care will be screened for suicide ideation and behavior using the Columbia Protocol (Columbia-Suicide Severity Rating Scale (C-SSRS). On page 6, Table 1: Patient Safety Measures and Interventions Based on Screening Responses, Level of Risk: High- Initiate continuous observation (1:1 or in dedicated, secured, ligature resistant area or room), - RN to notify MD and MD to order Mental Health Professional face-to-face consult before leaves the area/unit, - All staff to use communication/de-escalation techniques, - If family/significant other with patient: Nurse to provide “Support Person Education”, RN to Re-assess suicidal risk and need for suicidal precautions if there is an observed or stated change in behavior. Registered Nurse observe patient every 15 minutes and utilize the Frequent Observation Flow Sheet. 3. Review of P1 medical record indicated: a. Patient was admitted to the facility on 01/10/2025 for suicidal ideation. Columbia-Suicide Severity Rating Scale (C-SSRS) was completed on P1 indicated patient to be at a high risk for suicide. MR lacked documentation of completed 15-minute checks and lacked documentation of sitter at bedside while a patient at facility. b. Initial Medical Screen dated 01/10/2025 at 1620 hours indicated P1 was assessed by the triage nurse vital signs: pulse 84 bpm (beats per minute) (normal range 60-100 bpm), respiratory rate 16 brpm (breaths per minute) (normal range 10-21 brpm), blood pressure 165/97 mmHg (millimeters of mercury) (normal range systolic 95-120 and diastolic 59-81). MR lacked documentation that P1 had vital signs rechecked during his/her time in the Emergency Department or re-assessed by a registered nurse for any changes in medical or psychiatric conditions. 4. Interview with A1 (Chief Nursing Officer) on 01/23/2025 at approximately 1400 hours, confirmed that P1 medical record lacked documentation of patient re-assessment and/or vital signs being repeated, lacked documentation of having a sitter at the bedside, and lacked 15-minute monitoring of the patient safety checks for the duration P1 was in the ED. 5. In phone interview with N1 (Registered Nurse) on 01/27/2025 at 1030 hours verified that P1 did not have a sitter assigned on 01/11/2025 and should have.”

“PATIENT RIGHTS: PRIVACY AND SAFETY CFR(s): 482.13(c) Patient Rights: Privacy and Safety This Standard is not met as evidenced by: 35731 Based on document review and interview the facility failed to honor a patient’s right (patient # 10) related to visitation and ensure patient safety (patient # 11) in two (2) of eleven (11) medical records (MR’s) reviewed. Findings include: 1. The facility policy titled, Patient Rights Policy, no policy number, indicated patients’ rights include, but are not limited to, the right to participate in the plan of care, reasonable responses to reasonable requests for service, and personal privacy and safety. Patients’ rights also apply to persons who may have responsibility for healthcare decisions on behalf of the patient. This policy was last reviewed/revised on 03/07/2022. 2. The facility policy titled, Adoption of Newborn Policy, no policy number, indicated a patient had full rights until the termination papers were signed. If termination papers, Biological Parental Consent to Release Newborn to Adoptive Parents, Adoption Agency or Private Adoption Attorney Representative, while natural mother and infant are still hospitalized, then any issues relating to the infant must be approved by the adoption agency/attorney thereafter. This policy was last reviewed/revised on 03/08/2022. 3. Review of the Board of Trustee Bylaws, dated January 2024, indicated the local governing authority appointed by the Corporation to provide for the overall management of the hospital. The purpose shall be to provide services to best serve the needs of patients. 4. Review of Patient # 10’s MR indicated the following: a. Hospital Adoption Plan, dated 09/04/2024, indicated patient # 10 would be giving permission to G # 1 (Adoption Support Center) adoptive parents to provide care for the baby (patient # 11), make medical decisions, and receive medical information pertaining to the baby (patient # 11). Patient # 10 indicated would like the baby (patient # 11) moved to the adoptive parent’s room immediately and would like the baby (patient # 11) identification band to be given to the adoptive mother. b. Verification of Birth Facts, dated 10/12/2024, signed by patient # 10, indicated that she had been given the option to complete a voluntary paternity affidavit while hospitalized following the birth of her child, that the paternity affidavit had been fully explained to her, and she did not choose to complete a paternity affidavit. c. Authorization for Treatment of Newborn, dated 10/12/2024, signed by patient # 10 and C # 2 (Licensed Social Worker) at approximately 10:57 am, indicated patient # 10 delegated authority to G # 1 to make all decisions and to obtain necessary health care on behalf of the child (Patient # 11). d. Indiana Department of Child Services (DCS) Hospital Release Authorization, dated 10/12/2024, indicated DCS did not authorize release until TBD (to be determined) due to ongoing DCS investigation. e. Statement of Child Placing Agency Placing Child in Care and Custody of Adopting Parents, dated 10/12/2024, indicated patient # 10 released and relinquished infant baby (patient # 11) to the care, custody and control of G # 1, a licensed child-placing agency in the State, for the purpose of adoption and consented to the adoption of the child by G # 1 adoptive parents. R # 1 (Notary Public/Representative) as a representative of G # 1, place the child in the care and custody of the adoptive parents in anticipation of the child’s adoption and pending the finalization of the adoption. R # 1 authorized the adoptive parents to consent to any medical or other professional care and treatment for the child’s health and welfare. f. Relinquishment of Child, to Child Placing Agency, Consent to Adoption and Waiver of Notice Regarding Adoption Proceedings, dated 10/12/2024, indicated Patient # 10 deposed the following: She was the biological mother of infant baby (patient # 11), the child was conceived out of wedlock, the paternity of the child had not been established, she released and relinquished the child to the care, custody and control of G # 1 for the purpose of adoption and desire that the child be placed in the care and custody of the adopting parents pending the adoption. Patient # 10, C # 2, and R # 1 (Notary Public/Representative) signed. 5. Patient # 11’s MR indicated the following: a. Date of Birth 10/11/2024. b. Case Management notes, dated 10/12/2024, no initial time, by C # 2, indicated patient # 10 appointed G # 1 to make decisions for patient # 11 while she was an inpatient at the hospital with R # 1 being G # 1’s representative. All paperwork was completed in full. C # 2 was present and signed as witness for G # 1 paperwork of Relinquishment of child to the child placement agency (G # 1). Documents notarized. CPS (Child Protective Services) cannot state the birth father needs supervised visits because they are not taking custody. Due to the situation “C # 2 and Registered Nurse feel it would be appropriate to still have birth father remain supervised by his case manager”. R # 1 indicated F # 1 (Father) had 15 days to file through the court for paternity and to his/her knowledge that had not happened. C # 2 spoke with patient # 10 who indicated she did not want to make any decisions for patient # 11 and appointed G # 1 to make all decisions for patient # 11 while he/she was in the hospital. At 4:26 pm C # 2 was notified F # 1 was here with one of the workers from the drug rehabilitation with him. At that time patient # 11 was taken to a different room for F # 1 to visit. At 5:03 pm, C # 2 was notified the adoptive parents were very upset, and C # 2 explained that the birth father had the right to see patient # 11 while he/she was here. The adoptive parent stated that G # 1 had decision making power and doesn’t want F # 1 to see the patient, it was a safety risk, and their lawyers advised them that F # 1 was out of the time frame to establish paternity. c. Consent for Circumcision, dated 10/12/2025 at 11:25 am, indicated R # 1 who was the representative for G # 1, signed the consent form. d. Birth Parental Consent to Release Newborn to Adopting Parents, Adoption Agency or Private Adoption Attorney Representative (Newborn Chart), dated 10/12/2024 at 10:47 am, indicated to discharge the newborn (patient # 11) to the custody of G # 1. The form was signed by patient # 10 and C # 2. The form was notarized by R # 1. e. Discharge of Newborn to Adopting Parents Child Protective Services (CPS), Adoption Agency, or Private Adoption Attorney Representative (Newborn Chart), dated 10/12/2024 at 10:50 am, indicated patient # 10 was aware the acknowledged male newborn would be discharged to the representative of G # 1. The form was signed by patient # 10 and notarized by R # 1. 6. In interview on 01/22/2025 at approximately 9:45 am with staff member C # 1, confirmed we only go by legal paperwork. Most of the time the adoption plan is sent from the attorney and if we do not have the paperwork, we contact the attorney and/or DCS. The birth mother can choose who she wants to let see the baby. 7. In interview on 01/22/2025 at approximately 10:00 am with staff member A # 7 (Director Women & Children’s Department), confirmed the babies stay in the birth mothers’ room or we have a room for the adoptive parents to be with the baby. On 01/23/2025 at approximately 1:50 pm with staff member A # 7, confirmed he/she had called DCS on 10/12/2024 and spoke with D # 1 who indicated they do not have that authority to make that decision related to visitation. 8. In interview on 01/22/2025 at approximately 4:20 pm with staff member N # 2, confirmed he/she was told that the night before CPS decided to allow F # 1 to visit the baby. Patient # 11 was taken out of the adoptive parents room and taken to another room to allow F # 1 to visit along with his Case Worker for almost an hour. 9. In interview on 01/23/2025 at approximately 10:40 am with D # 1 (Family Case Manager - Department of Child Services), confirmed he/she had nothing to do with the decision to allow F # 1 to visit patient # 11 in the hospital. According to DCS he failed to meet the deadline for paternity and F # 1 was only the alleged father. 10. In interview on 01/23/2025 at approximately 2:20 pm with staff member N # 1 (Clinical Manager Obstetrics/Pediatrics/Neonatal Intensive Care Unit), confirmed patient # 10 gave one of patient # 11’s identification bands to the adoptive mother. R # 1 signed consent for patient # 11 to be circumcised. 11. In interview on 01/23/2025 at approximately 3:15 pm with staff member C # 2, confirmed he/she was directed by C # 1 to allow F # 1 to visit patient # 11. We did not get a copy of the Case Worker’s identification who was with F # 1.”