Brentwood Meadows LLC

“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: 50584 Based on document review and interview, nursing services failed to fully complete a MSE (Medical Screening Exam) form, failed to enter a complete physician verbal order, failed to document conversations related to a patient, failed to complete a screening assessment and complete two patient identifiers prior to administration of a medication, failed to perform a pre-administration assessment, positively identify the patient with two hospital identifiers and verify the frequency of the medication order prior to administering medication to patient and failed to document the time the medication was administered and failed to complete an incident report in one instance for 1 of 20 Medical Records reviewed. (P20), The cumalative effects of these systemic problems resulted in the facility’s inability to provide nursing care in a safe manner.”

“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: 50584 Based on document review and interview nursing services failed to fully complete a MSE (Medical Screening Exam) form, failed to enter a complete physician verbal order, failed to document conversations related to a patient, failed to complete a screening assessment and complete two patient identifiers prior to administration of a medication in 1 of 20 Medical Records reviewed. (P20) 1. Facility policy titled Documentation, PolicyStat ID: 18132620, Last Reviewed: 5/2025, page 1, under Procedures: 1. Overview of Documentation: a. Documentation is to be pertinent, concise, and reflects the patient status. b. The documentation appearing in the patient’s medical record shall meet the following objectives: page 2, vi. Documentation entries will be written in a legible manner. Page 3, d. Narrative entries are to be made for any significant change in the patient’s status or treatment. Narrative statements are also used to document calls placed to physicians and therapists, as well as others involved in the patient’s care. Page 5, under errors made to the medical record will be corrected using the S.L.I.D.E method. SL-Single Line through error, I- Initials of person who is correcting the error, D-Date, E-Error. Under Any late entries in the medical record will follow the following format: 1. Date and time the note with the date and time that you are entering it, NOT the date and time of when the entry should have been made. 2. Facility policy titled Screening Assessment and/or Level of Care/Psychosocial Assessment, PolicyStat ID: 17831529, Last Reviewed: 3/2025, page 2, under Policy: 1. The Screening Assessment will be used for all assessments and should be filled out in its entirety. a. Every patient must have a Screening assessment. 2. The Screening assessment must be conducted on all patients to determine the level of care. Page 5, under Procedures: The assessment will include a demographic profile, presenting problems or needs, family history, financial resources, medical and psychiatric history, cultural factors that may impact treatment, social supports and functional status/capacity for activities of daily living and instrumental activities of daily living, and will determine whether or not the facility can provide services to address the individual’s needs, as well as the disposition. 3. Review of Verbal Counseling form filled out by A6 (CNO [Chief Nursing Officer]) for N2 (RN [Registered Nurse]) indicated on 10/26/25 P20 presented to F1 (psychiatric hospital) and was treated in the parking lot, brought into F1 for evaluation, sent to a higher level of care due to inability to appropriately evaluate P20 due to lethargy. P20 was placed in the front lobby for two hours prior to sending P20 to a higher level of care. N2 administered medication to P20 not yet evaluated, lack of appropriate documentation on the facility MSE form, missing orders and documentation of conversation with MD1 (psychiatrist) to ensure a complete medical record. Relevant company policies violated: Medication Administration, MSE, Documentation. Performance Improvement Plan: Follow proper procedure related to MSE, documentation of physician order on MSE form with detailed documentation of contact with MD1, ensure vitals are repeated and recorded on a patient that had received medication and is awaiting evaluation, notification of the Administrator on-call for deviation from normal activity (staging of law enforcement in parking lot with suicidal patient), when transferring a patient to another facility House Supervisor must call the receiving nurse and give a detailed report to ensure the facility is aware the patient is coming, and document physicians order for transfer per facility EMTALA (Emergency Medical Treatment and Labor Act) policy. Medication administration occurs only after a patient has been appropriately examined and medication history has been completed to ensure documentation of medications for interactions and allergies. 4. Review of P20 MR indicated: a. MSE (Medical Screening Exam) on 10/26/25 lacked narrative documentation of N2 placing calls to the physician on patients’ condition and obtaining orders for transfer and Ativan. b. Lacked documentation of date and time to late entries made on 10/28/25 for changes to comments, medication order, transfer order, and time change of vital sign from 1300 hours to 1400 hours. c. MSE indicated on page 2 signed by N2, MSE was performed on 10/25/25 at 1300 hours, P20 was in the parking lot of F1, not registered as a patient at 1300 hours. d. Time entered on MSE under RN (Registered Nurse) that reviewed the Safety Assessment was illegible. 5. In interview on 1/7/26 at 1100 hours with A6, he/she confirmed there was a lack of appropriate documentation on the facility MSE form, missing orders and documentation of conversation with MD1 to ensure a complete medical record for P20”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 50584 Based on document review, observation, and interview, nursing services failed to complete an incident report in one instance. (P20) 1. Facility policy titled Incident Report Protocol & Patient Safety Events, PolicyStat ID: 18088458, Last Reviewed: 5/2025, page 2, under Policy: Our culture of safety promotes reporting of patient safety incidents to continuously improve safety and minimize and/or prevent the occurrence of errors, events and system breakdowns leading to patients, staff, volunteers, visitors, and others through proactive risk management and patient safety activities. Page 3, Patient Safety Incidents must be captured via the incident reporting system. It is the responsibility of all staff to report all patient safety incidents, accidents, or injuries involving patients or visitors and to report such occurrences using the Incident Reporting system along with notifying their supervisor immediately. 2. In observation of video footage on 1/7/25 at 1300 hours with A1 (Director of Quality) from 10/26/25, indicated at 1255 hours N2 (RN [Registered Nurse]) was observed going outside of F1 (psychiatric hospital). At 1318 hours N2 observed coming in through front door lobby, at 1323 hours N2 went out front lobby doors, walked to P20s car and handed medication through the passenger side window. At 1400 hours P20 comes into lobby with N2 and the police officers, P20 placed in a chair in the lobby. N2 takes vital signs at 1403 hours and administered point of care breathalyzer to P20, at 1406 hours N2 provided P20 a drink and left the lobby. From 1406 hours through 1506 hours P20 sat in lobby chair slumped to the side with no staff member engaging with him/her. At 1532 hours A14 (Social Worker) checks on P20 in lobby, at 1506 hours N2 wakes P20 and appeared to speak to P20, P20 continues to slump and fall asleep, N2 physically touched P20 to arouse him/her. At 1543 hours A14 spoke to P20 and left lobby at 1546 hours, at 1550 hours N2 with P20 and he/she appeared to respond, 1551 hours N2 leaves lobby. At 1600 hours P20 slumped in chair with his/her head down, at 1611 hours N2 speaks with P20 and EMS arrived. At 1615 hours EMS left with P20. P20 sat in lobby from 1400 hours through 1615 hours, MSE room 2 was available at 1457 hours and MSE room 1 was available at 1506 hours for P20 to be moved from the lobby to an appropriate examination room. 3. On 10/27/25 investigative report completed by A6 (CNO [Chief Nursing Officer]), indicated video footage observed and there was no detailed documentation of the events on 10/26/25 in the parking lot. 4. Review of Incident Report log lacked incident report for P20 with detailed documentation of the events on 10/26/25 in the parking lot. 5. In interview on 1/7/26 at 1100 hours with A6, he/she confirmed there was not an incident report submitted with detailed documentation of the events that occurred involving P20 on 10/26/25.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 50584 Based on document review, observation, and interview nursing services failed to perform a pre-administration assessment, positively identify the patient with two hospital identifiers and verify the frequency of the medication order prior to administering medication to patient and failed to document the time the medication was administered in 1 of 20 Medical Records reviewed. (P20) Findings include: 1. Facility policy titled MM 05-001 Medication Administration, PolicyStat ID: 18426147, Last Reviewed: 9/2024, page 1, under Purpose, To ensure medications are administered by authorized individuals in a safe and timely manner to meet the needs of the patient. Page 6, under Medication Administration: Required pre-administration assessment: Perform a review of laboratory data and/or verification of patient condition (i.e., heart rate, blood pressure, somnolence/confusion, etc.) prior to administration and document the results in the patient’s record. Verifies the medication selected for administration based on the medication order. Page 7, Verifies there is no contradiction with respect to allergies, sensitivity, or diagnosis. Positively identify the patient before administering the medication. Check the patient’s identification with two hospital-approved identifiers (i.e., name band, date of birth, patient-specific number, photograph) and ask patient (when possible), to state his/her name. Document the exact time the medication is given. 2. Review of P20 MR indicated: a. MSE (Medical Screening Exam) form on 12/26/25 indicated an order for Ativan 2 mg (milligrams) po for aggression. MSE form lacked documentation of time Ativan order was taken, frequency for medication order or time medication was given to P20. 3. Review of Pyxus log indicated Ativan 2 mg retrieved for P20 after an override at 1322 hours. 4. In observation of video footage on 1/7/25 at 1300 hours with A1 (Director of Quality) from 10/26/25, indicated at 1255 hours N2 (RN [Registered Nurse]) was observed going outside of F1. At 1318 hours N2 observed coming in through front door lobby, at 1323 hours N2 went out front lobby doors, walked to P20s car and handed medication through the passenger side window. At 1400 hours P20 comes into lobby with N2 and the police officers, P20 placed in a chair in the lobby, N2 takes vital signs. 5. In interview on 1/6/26 at 1550 hours with N2 (RN [Registered Nurse]), he/she confirmed P20 was in the parking lot when the Ativan was administered, P20 was not registered as a patient, N2 did not do any assessment, MSE or take vital signs on P20 prior to administering the Ativan. 6. In interview on 1/7/26 at 1100 hours with A6 (CNO [Chief Nursing Officer]), he/she confirmed N2 did not do a full health history on P20 to know what medication or drugs were in his/her system prior to administering the Ativan.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 50584 Based on document review, observation and interview, it was determined that 4 of 20 medical records (P6, P7, P19, and P20) reviewed of patients who presented to the hospital requesting services, the facility failed to ensure compliance with 489.24 in that the facility failed to provide a complete medical screening exam (P20) and failed to accept an appropriate transfer from a referring facility (P6, P7, and P19). Findings Include: 1. See findings cited at 42 CFR 489.24, A2406 and A2411”

“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: 50584 Based on document review, observation, and interview facility failed to provide an appropriate MSE (Medical Screening Exam) for 1 of 20 MRs (Medical Records) reviewed. (P20) Findings include: 1. Facility policy titled Emergency Medical Treatment and Active Labor Act (EMTALA)- Freestanding Behavioral Health Hospitals, PolicyStat ID: 18288143, Last Reviewed: 7/2025, page 3, under Definitions: Medical Screening Exam (MSE) is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC (Emergency Medical Condition). The MSE should include both a general and focused assessment based on the patient’s chief complaint with the intent to determine the presence or absence of an EMC. Treatment: A. A person who comes to the hospital will recieve an MSE conducted by a QMP (Qualified Medical Personnel) to determine an EMC exists. An appropriate MSE should address the presenting symptoms and comply with current policies and procedures for assessment for those presenting symptoms. C. The chart should document continued monitoring and treatment until the patient is stabilized or transferred. 2. Review of P20 MR indicated: a. MR lacked documentation of a complere MSE. 3. Review of Verbal Counseling form filled out by A6 (CNO [Chief Nursing Officer]) for N2 (RN [Registered Nurse]) indicated on 10/26/25 Medication administration occurs only after a patient has been appropriately examined and medication history has been completed to ensure documentation of medications for interactions and allergies. 4. In observation of video footage on 1/7/25 at 1300 hours with A1 from 10/26/25, indicated at 1255 hours N2 was observed going outside of F1 (psychiatric hospital) (Director of Quality), 1318 hours N2 observed coming in through front door lobby, at 1323 hours N2 went out front lobby doors, walked to P20s car and handed medication through the passenger side window. 5. In interview on 1/6/26 at 1550 hours with N2, he/she indicated on 10/26/25 there were 6 or 7 police officers in the parking lot surrounding a car. N2 recognized the car, went outside into the parking lot where P20 was located, tried to talk to P20. P20 was rocking back and forth vigorously in the passenger seat of the car, N2 tried to talk to FM1 (P20 friend) to find out what was going on, P20 had a knife and had a superficial cut to his/her neck, P20 asked for an Ativan, N2 went inside the facility and phoned the physician, received an order for Ativan. N2 confirmed P20 was in the parking lot when the Ativan was administered. P20 was not registered as a patient, N2 did not complete any assessment, MSE or take vital signs on P20 prior to administering the Ativan. 6. In interview on 1/7/26 at 1100 hours with A6 (CNO [Chief Nursing Officer]), he/she indicated on 10/26/25 police were in the parking lot talking to P20, EMS was staged knowing there was a stand-off in progress, N2 inserted him/herself in the situation. A6 confirmed N2 did not do a full health history on P20 to know what medication or drugs were in his/her system prior to administering the Ativan. P20 was not a registered patient at the time the Ativan was administered, P20 was not taken into an examination room and remained in the lobby for an extended period with no staff contact. A6 confirmed Vital signs were only taken one time after bringing P20 into the facility at 1400 hours.”

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 50584 Based on document review and interview facility failed to accept an appropriate transfer from a referring facility in 3 of 20 Medical Records reviewed. (P6, P7, P19) Findings include: 1. Facility policy titled Emergency Medical Treatment and Active Labor Act (EMTALA)- Freestanding Behavioral Health Hospitals, PolicyStat ID: 18288143, Last Reviewed: 7/2025, page 6, under Receiving a Request for Transfer: A. If a Hospital receives a request to transfer a patient with an unstable psychiatric EMC (Emergency Medical Condition), and if the Hospital has the capacity and capability to treat the patient, then the Hospital has am obligation to accept the patient regardless of the patient’s insurance status. 2. On 12/9/25 transfer log for incoming referrals indicated: a. On 12/9/25 at 1916 hours a referral indicated P19 was referred to F1 (psychiatric hospital) for a suicide attempt by setting him/herself on fire due to voices in his/her head telling him/her to do it. Diagnosis: Manic Bipolar. P19 was deflected due to mental health capacity. Review of census log indicated F1 was not at full capacity. b. On 12/9/25 at 1943 hours a referral to F1 for P6 for presenting to another facility for suicidal and homicidal ideation towards his/her neighbor. P6 felt his/her neighbor was trying to kick him/her out of his/her home. In the past P6 tried to end his/her life consuming an abundance of alcohol. Diagnosis: Suicidal ideation, positive mental health, major depressive disorder, substance use disorder. P6 was deflected due to mental health capacity. Review of census log indicated F1 was not at full capacity. c. On 12/9/25 at 2024 hours a referral for P7 indicated P7 presented to another facility with suicidal ideation with a plan to jump off the bridge, depression worse, P7 had been off his/her medications for a month. Diagnosis: Borderline bipolar, PTSD (Post Traumatic Stress Disorder), depression. P7 was deflected by F1 due to mental health capacity. Review of census log indicated F1 was not at full capacity. 3. Review of census log indicated F1 was not at full capacity on 12/9/25 from 1900 hours through 2100 hours. 4. On 12/9/25 Teams chat at 1720 hours indicated A8 (transfer center) sent a group chat requesting bed availability, A4 (Lead Assessment Specialist) confirmed F1 had plenty of beds available. 5. In interview on 1/6/25 at 1210 hours with A3 (Director of Intake), he/she indicated in a meeting with corporate employees, A3 and A7 (CEO [Chief Medical Officer]), were told the facility needed to deflect mental health patients and only admit chemical dependency patients to meet certain numbers by the end of the year. The transfer center was also given the directive and were told to deflect patients due to staffing or capacity, even if they weren’t at full capacity. A3 and A7 also had a meeting with the transfer center and told them the focus needed to be on chemical dependency patients and not to admit mental health patients. 6. In interview on 1/6/25 at 1220 hours with N1(Assessment Specialist-RN [Registered Nurse]), he/she confirmed on 12/9/25 the transfer center deflected three patients for the reason of capacity when the facility had the capacity and capability to admit the patients. (P6, P7 and P19) 7. In interview on 1/7/25 at 1115 hours with A7 he/she confirmed there were patients deflected over a 24-hour period, it was reported to corporate by a staff member, and F1 went back to admitting mental health patients. A7 confirmed that F1 did have the capacity and capability to care for the patients that were deflected on 12/9/25 and confirmed the transfer center called him/her on 12/9/25 and he/she told the transfer center not to admit P6.”