Sycamore Springs

“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: 49709 Based on document review and interview, the facility failed to restrict an unauthorized employee from having access to controlled substances in the automated dispensing cabinet, failed to restrict an unauthorized employee from administering controlled substances (A7, Registered Nurse [RN]) and failed to have a system in place to prevent access to controlled substances for individuals with restrictions. The cumulative effects of this systemic problem prevented the facility from providing medication administration by nursing in a safe manner.”

“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: 49709 Based on document review and interview, the facility failed to restrict an unauthorized employee from having access to controlled substances in the automated dispensing cabinet, failed to restrict an unauthorized employee from administering controlled substances (A7, Registered Nurse [RN]) and failed to have a system in place to prevent access to controlled substances for individuals with restrictions. Findings include: 1. Review of policy/procedure titled, “MM 07-001 Controlled Substances,” PolicyNo.: 17743065, last approved 03/2025; indicated under: Part III - Storage. Under Restricted Access: In the patient care area, access to controlled substances in the automated dispensing cabinets (ADC) is controlled by pharmacy. Under: Part V - Administration: Controlled substances are administered by authorized personnel to registered patients of the facility pursuant to a valid practitioner’s order. 2. Review of State Professionals Recovery Program (IPRP) RMA Nurses indicated on page 6, A7 does not have access to controlled substances through their employer. Under I. Narcotic restriction: A7 understands they have a narcotic restriction for a minimum of 6 months. Further, A7 understands the narcotics restriction requirement must be met at the same employer for the entirety of the narcotic restriction. V. Length of RMA: This RMA will remain in effect for a minimum of 5 years, signed 09/11/2023. Addendum to the RMA: C. Change in RMA with supporting rationale: removal of narcotics restriction. Participant provided two rationales for support, signed 03/20/2025. 3. MR review for P2 indicated the following: Review of electronic medication administration record (e-MAR) for 02/05/25 - 03/18/25, indicated P2 received a controlled substance medication, Lorazepam, administered by A7 on 02/28/25 at 2204 hours. 4. MR review for P5 indicated the following: Review of e-MAR for 02/05/25 - 03/18/25, indicated P5 received a controlled substance medication, Lorazepam, Benadryl and Haldol mixture, administered by A7 on 02/25/25 at 2318 hours and on 03/04/25 at 2238 hours. 5. MR review for P7 indicated the following: Review of e-MAR for 02/05/25 - 03/18/25, indicated P7 received a controlled substance medication, Lorazepam, administered by A7 on 02/28/25 at 2207 hours. 6. Interview with A2 (Director of Nursing [DON]) on 03/27/25 at approximately 11:15 a.m., confirmed A7’s name on the e-MAR indicated A7 administered Lorazepam to P2 and P7, and Lorazepam, Benadryl, and Haldol mixture to P5. 7. Interview with A2 on 03/27/25 at approximately 4:25 p.m., indicated they were aware of A7’s controlled substance agreement, and A2 confirmed A7 has e-signed they administered controlled substances to 3 out of 10 patients reviewed. A2 confirmed A7 is not supposed to do that. A2 indicated they and A7 must follow the rules from State Nursing Assistance Program (SNAP) and Recovery Monitoring Agreement (RMA). 8. Interview with A15 (RN) on 03/27/25 at approximately 4:35 p.m., confirmed whatever staff is logged into the system will be the name on the e-MAR for that patient. 9. The facility failed to have system in place to prevent access to controlled substances for individuals with restrictions.”

“COMPLIANCE WITH LAWS CFR(s): 482.11 Compliance with Federal, State and Local Laws This Condition is not met as evidenced by: 48061 Based on document review, observation and interview the facility failed to ensure compliance with 2001 AIA guidelines plan approval for 6 of 10 patients (P1, P2, P3, P6, P7 and P8). Findings include; 1. 440 IAC 1.5-3-8 Physical plant; maintenance and environmental services Authority: IC 12-21-2-3; IC 12-25-1-2; IC 12-25-1-4 Affected: IC 12-25 Sec. 8. (a) The private mental health institution shall be constructed, arranged, and maintained to ensure the safety of the consumer and to provide facilities for services authorized under the private mental health institution license as follows: (1) The plant operations and maintenance service, equipment maintenance, and environmental service shall meet the following requirements: (A) Be staffed to meet the scope of the services provided. (B) Be under the direction of a person or persons qualified by education, training, or experience. (2) The facility shall have a designated safety officer to assume responsibility for the safety program. (3) The facility shall have a physical plant and equipment that meet the statutory requirements and regulatory provisions of the rules of the fire prevention and building safety commission, including 675 IAC 22, Indiana fire codes, and 675 IAC 13, Indiana building codes. (b) The condition of the physical plant and the overall environment shall be developed and maintained in such a manner that the safety and well-being of consumers are assured as follows: (1) No condition in the facility or on the grounds shall be maintained that may be conducive to the harborage or breeding of: (A) insects; (B) rodents; or (C) other vermin. (2) No condition shall be created or maintained that may result in a hazard to: (A) consumers; (B) employees; or (C) the public. (3) The facility shall have a plan for emergency fuel and water supply. (4) Provision shall be made for the periodic inspection, preventive maintenance, and repair of the physical plant and equipment by qualified personnel as follows: (A) Operation, maintenance, and spare parts manuals shall be available, along with training or instruction of the appropriate personnel, in the maintenance and operation of the fixed and movable equipment. (B) Operational and maintenance control records shall be: (i) established; (ii) retained; (iii) analyzed periodically; and (iv) readily available on the premises. (C) Maintenance and repairs shall be carried out in accordance with applicable codes, rules, standards, and requirements of: (i) local jurisdictions; (ii) the fire prevention and building safety commission; and (iii) the Indiana state department of health. (5) The food service of the private mental health institution shall comply with the administrative rules of the Indiana state department of health contained in 410 IAC 7-24. (c) A facility shall comply with the following provisions regarding new construction, a renovation, or an addition to the facility: (1) The standards contained in the 2001 edition of the national “Guideline for Construction and Equipment of Private Mental Health Institution and Medical Facilities” (Guidelines) shall apply to all facilities covered by this rule, except as provided in subdivision (2). (2) Codes and rules adopted by the fire prevention and building safety commission that pertain to building requirements, fire safety, and access for individuals with disabilities shall: (A) apply to all facilities covered by this rule; and (B) take precedence over the requirements of the Guidelines on those topics. 2. The facility was plan approved utilizing the 2001 AIA guidelines which states under 11.2 General Psychiatric Nursing Unit: 11.2.A Patient Rooms: Each patient room shall meet the following standard: 11.2.A1. Maximum room capacity shall be two patients. 3. P1’s medical record was reviewed and indicated the patient was 45 y/o (year/old) admitted to H1 from 4/22/24-4/26/24. The MR documentation indicated H1 was at capacity at the time of P1’s admission and the patient was admitted to a cot 4/22/24 , room # 217, Bed C (added as 3rd patient to room). 4. P2’s medical record was reviewed and indicated the patient was 37 y/o (year/old) admitted to H1 from 4/22/24-4/27/24. the MR documentation indicated H1 was at capacity at the time of P2’s admission and the patient was admitted to a cot 4/22/24, room # 336, Bed C (added as 3rd patient to room). 5. P3’s medical record was reviewed and indicated the patient was 30 y/o (year/old) admitted to H1 from 3/6/24-3/27/24. The MR documentation indicated H1 was at capacity at the time of P3’s admission and the patient was admitted to a cot on 3/6/24, willows unit, no room number (added as 3rd patient to room). 6. P6’s medical record was reviewed and indicated the patient was 27 y/o (year/old) admitted to H1 from 1/22/24-1/27/24. The MR documentation indicated H1 was at capacity at the time of P6’s admission and the patient was admitted to a cot 1/22/24, room #217, Bed C (added as 3rd patient to room). 7. P7’s medical record was reviewed and indicated the patient was 26 y/o (year/old) admitted to H1 from 1/21/24-1/28/24. The MR documentation indicated H1 was at capacity at the time of P7’s admission and the patient was admitted to a cot 1/24/24, room #217, Bed C (added as 3rd patient to room). 8. P8’s medical record was reviewed and indicated the patient was 32 y/o (year/old) admitted to H1 from 1/3/24-1/8/24. The MR documentation indicated H1 was at capacity at the time of P8’s admission and the patient was admitted to a cot 1/3/24, room #213, Bed C (added as 3rd patient to room). 9. In an interview on 5/6/24 at approximately 2:30 pm with A1 (Quality Director) confirmed cots are for both over-flow admissions, bed blocks, and/or bed holds. Cots are not utilized for any other reasons. H1 does not currently have a policy stating three patients can be roomed together. 10. Facility tour on 5/6/24 at approximately 2:30 pm with A1 (Quality Director) this writer observed over-flow patient cots were blue plastic, canoe shaped cots/sleds, without wheels or legs, able to be placed on the floor and are able be donned with a thick foam mattress. 10. H1 facility unit blueprints indicated the patient sleeping area for each unit is 5016 square feet in total and can house up to forty-two patients. Rooms are designed with two patient beds.”

“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: 48061 Based on document review and interview, nursing staff failed to complete documentation of the Over-Capacity Emergency Admissions Checklist for 10 of 10 medical records reviewed. (P1, P2, P3, P4, P5, P6, P7, P8, P9, and P10) Findings Include: 1. The facility policy titled, “Wait List & Over Capacity Admission Policy for IP, PHP, & IOP”, PolicyStat ID 15562647, last revised 05/2024, indicated under Procedures: Those Assessed as Required Inpatient Services: When patients are assessed and the Psychiatric Medical Provider determines the patient requires inpatient admission to the Hospital and there is not an inpatient bed available, the Assessment Department will begin to locate alternative placement for the patient. However, if the alternative arrangements cannot be secured for the patient, the patient shall be admitted to the hospital utilizing the Over-Capacity Emergency Admissions Checklist. This process is as follows: 1. Documentation reflecting capacity status of the Hospital at time of decision. 2. Documentation reflecting efforts to accommodate patient with local option. 3. Documentation reflecting the On-Call Psychiatric Medical Provider recommends or agrees that the patient’s condition warrants admission despite the limited capacity at the Hospital. 4. Documentation that the Director of Nursing or designee is notified to discuss census and acuity to determine need for additional staffing. 5. Documentation that the patient will be accommodated in a manner that will ensure safety, privacy, access to bathroom facilities and all other essentials including a comfortable, safe bed option. 6. Documentation reflecting that the AOC or designee has spoken with the patient/and or family to explain the situation and obtains their understanding and approval. This should include: a. that the arrangement states that the patient will not occupy a patient room for the night, b. the details of the patient’s accommodation, c. assurance that all patient safety and privacy rights will be in compliance throughout the accommodation time, d. both patient and or guardian/family will have access to AOC/Patient Advocate for questions or concerns. 7. Documentation that the Hospital CEO or their designee has been notified and agrees to alternative accommodation. Upon completion of all above steps, the patient may be admitted to the Facility. Recommended that status be reevaluated every shift in attempt to move patient to common accommodations as quickly and safely as possible. 2. Review of P1’s medical record (MR) indicated he/she was admitted to H1 on 4/22/24, H1 was at capacity at the time of P1’s admission, H1 staff attempted but were unable to place P1 at three other locations. P1’s MR lacked a completed Over-Capacity Emergency Admissions Checklist prior to admission. 3. Review of P2’s MR indicated he/she was admitted to H1 on 4/22/24. H1 was at capacity at the time of P2’s admission, P2 rejected H1’s staff notification of finding other placement him/her. P2 requested to remain at H1. P2’s MR lacked a completed Over-Capacity Emergency Admissions Checklist prior to admission. 4. Review of P3’s MR indicated he/she was admitted to H1 on 3/6/24, H1 was at capacity at the time of P3’s admission. P3’s MR lacked documentation of H1 staff attempting to place the patient at another facility and/or a completed Over-Capacity Emergency Admissions Checklist prior to admission. 5. Review of P4’s MR indicated he/she was admitted to H1 on 3/2/24. H1 was at capacity at the time of P4’s admission. P4’s MR lacked documentation of H1 staff attempting to place the patient at another facility and/or a completed Over-Capacity Emergency Admissions Checklist prior to admission. 6. Review of P5’s MR indicated he/she was admitted to H1 on 2/21/24. H1 was at capacity at the time of P5’s admission. P5’s MR lacked documentation of H1 staff attempting to place the patient at another facility and/or a completed Over-Capacity Emergency Admissions Checklist prior to admission. 7. Review of P6’s MR indicated he/she was admitted to H1 on 1/22/24. H1 was at capacity at the time of P6’s admission. P6’s MR lacked documentation of H1 staff attempting to place the patient at another facility and/or a completed Over-Capacity Emergency Admissions Checklist prior to admission. 8. Review of P7’s MR indicated he/she was admitted to H1 on 1/24/24. H1 was at capacity at the time of P7’s admission. H1 staff attempted but were unable to place P7 at two other locations. P7’s MR lacked a completed Over-Capacity Emergency Admissions Checklist prior to admission. 9. Review of P8’s MR indicated he/she was admitted to H1 on 1/16/24. H1 was at capacity at the time of P8’s admission. H1 staff attempted but were unable to place P8 at two other locations. P8’s MR lacked a completed Over-Capacity Emergency Admissions Checklist prior to admission. 10. Review of P9’s MR indicated he/she was admitted to H1 on 12/6/23. H1 was at capacity at the time of P9’s admission. P9’s MR lacked documentation of H1 staff attempting to place the patient at another facility and/or a completed Over-Capacity Emergency Admissions Checklist prior to admission. 11. Review of P10’s MR indicated he/she was admitted to H1 on 12/5/23. H1 was at capacity at the time of P10’s admission. H1 staff attempted but were unable to place P10 at two other locations. P10 declined to be sent out for medical clearance required by another facility to facilitate alternative placement. P10’s MR lacked a completed Over-Capacity Emergency Admissions Checklist prior to admission. 12. In an interview on 5/6/24 at approximately 3:00 pm with staff member A2 (Chief Executive Officer) confirmed Over-Capacity Emergency Admission Checklists were not completed per facility policy and should have been.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 48061 Based on document review, observation, and interview the facility failed to keep patients free from abuse or harassment for 2 of 10 medical records reviewed. (P1 & P2) Findings Include: 1. The facility policy titled, “Suspected Child, Adult, Disabled Person or Elderly Abuse/Neglect/Exploitation”, PolicyStat ID 14414852, last revised 09/2023, indicated employees shall not subject a patient to any sort of abuse, neglect, or exploitation. 2. The facility policy titled, “Patient Bill of Rights”, PolicyStat ID 14373415, last revised 10/2023, indicated patient’s have the right to be free from physical and or emotional abuse by any member of the staff. 3. P2’s medical record was reviewed and indicated Seclusion & Restraint documentation dated 9/11/23 for P2 indicated the restraint started at 8:33 pm and ended 8:35 pm. The patient was pacing the unit, yelling at staff and peers, threw a large coffee carafe at a PCA hitting him/her in the lower back, patient stuffed napkins down his/her throat, patient elbowed a plexiglass shadowbox dislodging the glass, attempted to bite PCA staff member. 4. Human Resources investigation documentation dated 9/14/23 by A3; On 9/14/23 A3 (Senior Human Resources Business Partner) spoke with PCA 1(Patient Care Assistant) regarding the incident between him/her and P1. PCA 1 stated that P1 attacked him/her without reason. During the altercation the staff members glasses were broken causing cuts on his/her face. PCA 1 reported he/she and P1 fell during the altercation causing the staff member an injury to his/her right leg. 5. Human Resources investigation documentation dated 9/15/23 indicated and A3 reviewed the 9/11/23 video footage. This video footage confirmed that PCA 1 held P2 against the wall with his/her hand on the patient’s neck an additionally placed his/her gloved hand over the patient’s mouth and nose for approximately 42 seconds. 6. Observation of video surveillance for incident on 9/14/23, between P1 and PCA 1, conducted on 2/9/24 at approximately 10:00 am with A2 (Director of Quality) confirmed P1 approached PCA 1 in an attempt to harm her and at the same time PCA 10 (Patient Care Assistant) intervened placing an arm between the patient and PCA 1. Video footage shows that PCA 1 did not back away or use appropriate CPI (Crisis Prevention Institute) training. The patient and the staff member in what appeared to be an active fight. PCA 10 continued to try and stop the altercation. The video showed PCA 1 putting his/her arm around P1’s neck and in doing so P1, PCA 1 and PCA 10 all fell to the ground. Once PCA 11 (Patient Care Assistant) arrived along with other staff members, P1 and PCA 1 were successfully separated. 7. Observation of video surveillance for incident on 9/11/23, between P2 and PCA 1, was conducted on 2/9/24 at approximately 1:00 pm with A2 (Director of Quality) confirmed that PCA 1 held P2 against the wall with his/her hand on the patient’s neck an additionally placed his/her gloved hand over the patient’s mouth and nose for approximately 42 seconds. PCA 1’s actions were inappropriate and did not meet CPI training 8. In interview on 2/9/24 at approximately 11:20 am with PCA 10 (Patient Care Assistant) indicated on 9/14/23 while in the cafeteria he/she told P1 to place his/her cup in the window, P1 was upset over the length of meal time (30 minutes), P1 did not say anything after that but charged at PCA 1, he/she put an arm between the patient and the staff member, the patient swung at the staff member over his/her arm, he/she was unsure when PCA 1 started hitting back, the patient and staff member had each other by the hair at one point then they went down to the floor, PCA 10 tried to break the two apart, PCA 11 came in and broke the two apart. PCA 10 indicated he/she hadn’t seen PCA 1 be aggressive prior to this altercation. 9. In interview on 2/9/24 at approximately 12:37 pm with PCA 11 (Patient Care Assistant) indicated he/she was the first to respond to the altercation in the cafeteria on 9/14/23, PCA 1 had the patient by the hair and had to be told numerous times to let the patient go, felt PCA 1 was aggressive/overreacted during codes using too much force, and would rarely use deescalating training before doing a physical hold, PCA 1’s mood affected his/her care and was known to work a lot of hours, and felt the event from 9/14/23 was a fight because PCA 1 could have backed down/away and did not. 10. In interview on 2/12/24 at approximately 2:10 pm with PCA 3 (Patient Care Assistant) indicated during the hold/restraint on 9/11/23 with P2, PCA 1 had his/her hand on the patient’s face, did not do the incident report but did report the hold and report the details of the hold to N1 at the end of the shift”

“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: 48061 Based on document review and interview, the facility failed to ensure an incident report was filed by the end of shift for 2 of 10 patients. (P1 & P2) Findings include: 1. The facility policy titled, “Incident Report Protocol & Patient Safety Events”, PolicyStat ID 14854330, last revised 01/2024, indicated incident reports are to be filled out for any patient safety incident. The incident Report should be filled out as soon as practicable after the incident has occurred. Optimally, Incident Reports must be completed at the time of the event and appropriate notification of the supervisor immediately, but no later than the end of shift. 2. On 9/12/23 at 7:57 am A2 (Quality Director) created an incident report for a restraint/hold on P2 that occurred on 9/11/23. There was no incident report filed on 9/14/23 for P1 grabbing another patient’s finger and bending it backwards. 3. In interview on 2/12/24 at approximately 2:30 pm with A2 (Quality Director) confirmed the incident report for the 9/11/23 event with P2 was filed on 9/12/23 at 7:57 am by him/her and not by staff whom took part in or witnessed the incident and an incident report was not filed for incident involving P1 grabbing a peers finger backwards and should have been.”

“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: 48061 Based on document reviewed and interview, the facility failed to ensure patient safety when employing 1 of 1 agency staff. (PCA 1) Findings include: 1. The facility policy titled, “Background and Credit Check Policy”, PolicyStat ID 12583330, last revised 11/2022, indicated when evaluating a criminal record, Human Resources will consider: (1) the nature and gravity of the offense(s); (2) the time that has passed since the offense(s) and/or completion of the sentence(s); and (3) the nature of the job held or sought. Factors that will be considered include: The facts and circumstances surrounding the offense or conduct; The number of offenses for which the candidate was convicted; Evidence that the candidate performed the same type of work, post-conviction, with the same or a different employer, with no known incidents of criminal conduct; The length and consistency of employment history before and after the offense; Rehabilitation efforts(e.g., education and training; certificate of good conduct); Employment or character references and other information regarding fitness for the particular position; 2. Review of personnel file for PCA 1 (Patient Care Assistant) indicated the following: PCA 1 held a suspended Indiana Registered Nurse License at the time of hire to F1(Psychiatric Hospital); license was suspended by B3 (Licensing Agency) on 6/21/16 for knowingly violating a rule regulating the nursing profession. On 3/13/2019 B3 concluded that he/she failed to comply with the terms of the conditions set on 10/19/2016 and his/her nursing license was placed on INDEFINITE SUSPENSION until he/she completed AT LEAST SIX (6) MONTHS OF FULL, CONTINUOUS AND COMPLETE COMPLIANCE with an ISNAP (Recovery Program) RMA(Recovery Monitoring Agreement) and followed all therapy recommendations for his/her substance abuse and/or mental health evaluation, which included individual therapy. 3. Incident of patient abuse occurred between PCA 1 and P1 on 9/14/23. 4. In interview on 2/12/24 at approximately 1:10 pm with A3 (Senior Human Resource Business Partner) indicated he/she verified that initial hiring documentation had information related to PCA 1’s suspended nursing license. PCA 1’s court documents related to his/her suspended license were added to the staff members file during a monthly audit much later after hire and cannot remember the month they were added. A3 confirmed that PCA 1’s termination was not reported to B3.”