Medical Behavioral Hospital - Mishawaka

“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: 14445 Based on document review and interview, facility failed to keep a patient free from abuse in one instance (Patient # 6) and failed to reassess and change observation status in one instance (patient #3). Findings include: 1. Facility policy titled, Patient Rights and Responsibilities, PolicyStat ID 13517670, indicated on page 3, under PROCEDURE, have right to; 18. Receive care in a safe setting, free from verbal or physical abuse or harassment, Last revised 9/2021. 2. Review of Patient # 3’s MR (medical record) indicated the following: (a). Patient # 3; 21 y/o admitted to APH # 40 on 4/23/2025 to 300 unit (room # 305, then to room 308 on 4/25/2025, to room 303 on 5/10/2025), with diagnoses: Bipolar & Unspecified psychosis. (b). Provider admission orders included, but not limited to: Activity level: up Ad lib (up as desired), Precautions: suicide, assault, elopement, Observation level: every 15 minutes. (c). Nurse note on 5/12/2025 at 12:00 am, reflected patient was in milieu at beginning of shift. Patient was listening to music, while hanging out with other patients. Patient asked to call family. Patient took meds (medications) then went by TV (television) to watch TV. Patient was found in a resident room by staff. Patient and another female/male patient were asked what they were doing. Patient said they had sex and it was consensual. Staff took patient to his/her room. NP and supervisor were called. Patient refused and said he/she did not rape another patient. (d) MR documentation lacked a reassessment after the event and lacked increase by provider(s) for an appropriate patient’s observation status to a Level II (every 5 minutes) or Level III (1:1 Observation); related to patient # 3’s inappropriate sexual behavior towards another patient (Patient # 6). 3. Review of Patient # 6’s MR (Medical Record) indicated the following: (a). Patient # 6 admitted on 5/6/2025; with diagnoses: Bipolar Disorder. (b). Nurse note on 5/11/2025 at 11:00 pm, reflected patient was at milieu hanging out with staff and other patients at the beginning of the shift. Patient took her/his meds (medications) then went to hang out by the TV (television). Patient came to talk to nurse at nursing station, saying another patient (Patient #3) had raped her/him. 4. Review of Incident/event on 5/11/2025 on 300 unit at 10:00 pm for inappropriate behaviors for patient # 3 and patient # 6, in patient # 6’s room (the bathroom). a. BHA (Behavioral Health Associate -S # 2) found patient # 3 and patient # 6 in bathroom - Room # 306. b. Patient # 6 was laying on floor, back in shower. BHA turned on light and took patient # 3 out of room. c. Patient # 6 sent to hospital to get assessed for rape. 5. In interview on 5/15/2025 at approximately 4:15 pm, with S # 2 (Behavioral Health Associate), confirmed the following: When making rounds found patients (# 3 & # 6) in patient # 6’s room; after started looking for patient # 3; because he/she was not in his/her room or in the milieu. Found patient in patient # 6’s bathroom.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 14445 Based on document review and interview, the facility failed to ensure the patient care units were adequately staffed to provide nursing care to all patients as needed on one patient care unit. (300 unit). Findings include: 1. Facility policy titled: Clinical Staff (Nurse) Staffing Plan, no policy number, indicated on page one (1) - Section - Purpose - This policy is to establish guidelines for providing sufficient numbers and mix of staff necessary to provide multidisciplinary patient care that is consistent with the assessed needs of the population served. Last revised 09/2024. 2. The facility Staffing Grid by shift, indicated nurses work a twelve (12) hour shift and BHA’s (Behavioral Health Associate) work eight (8) hour shifts. For 2nd shift - 3:00 pm to 11:30 pm; for census of 14 or 15 patients; required staff for 2nd shift: 1 RN (Registered Nurse), 1 LPN (Licensed Practical Nurse)/RN, 2 BHA’s. 3. Review of staffing plan/data for 5/11/2025, indicated the following: On second shift staffing for 15 patients, with one patient needing a 1:1 required the following staff: 2 RNs and 3 BHAs a. On second shift - staff that worked: 2 RN’s (1 RN after 7:30 pm) and 2 BHAs; with 1 of the 2 BHAs assigned to a 1:1 observation. b. 1 BHA left for other remaining 14 patients on unit. Unit lacked 1 BHA. 4. In interview on 5/16/2025 at approximately 1:40 pm, with A # 1 (Director Quality & Risk), confirmed/ verified staffing on 5/11/2025 for 2nd shift; with 2 BHAs. One of the BHAs was on a 1:1. Staffing grid for 2 BHAs for 15 patients, and 2 BHAs for 14 patients.”

“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, nursing services failed to increase observation level or obtain order from provider, due to inappropriate sexual behavior in 1 instance (Patient # 3). Findings include: 1. Facility policy titled: Patient Observation, Policy Stat ID 12931622, indicated on page 1, under POLICY: patients will continue to be assessed and monitored during their treatment to ensure observation levels are appropriate, and under PROCEDURE: 2. observation levels can be increased or decreased by a provider’s order. Last revised 10/2024. 2. Review of Patient # 6’s MR (Medical Record) indicated the following: (a). Patient # 6 admitted on 5/6/2025; with diagnoses: Bipolar Disorder. (b). Nurse note on 5/11/2025 at 11:00 pm, reflected patient was at milieu hanging out with staff and other patients at the beginning of the shift. Patient took her/his meds (medications) then went to hang out by the TV (television). Patient came to talk to nurse at nursing station, saying another patient (Patient #3) had raped her/him. 3. Review of Patient # 3’s MR (medical record) indicated the following: (a). Patient # 3; 21 y/o admitted to APH # 40 on 4/23/2025 to 300 unit (room # 305, then to room 308 on 4/25/2025, to room 303 on 5/10/2025), with diagnoses: Bipolar & Unspecified psychosis. (b). Provider admission orders included, but not limited to: Activity level: up Ad lib (up as desired), Precautions: suicide, assault, elopement, Observation level: every 15 minutes. (c). Nurse note on 5/12/2025 at 12:00 am, reflected patient was in milieu at beginning of shift. Patient was listening to music, while hanging out with other patients. Patient asked to call family. Patient took meds (medications) then went by TV (television) to watch TV. Patient was found in a resident room by staff. Patient and another female/male patient were asked what they were doing. Patient said they had sex and it was consensual. Staff took patient to his/her room. NP and supervisor were called. Patient refused and said he/she did not rape another patient. (d) MR documentation lacked a reassessment after the event and lacked increase by provider(s) for an appropriate patient’s observation status to a Level II (every 5 minutes) or Level III (1:1 Observation); related to patient # 3’s inappropriate sexual behavior towards another patient (Patient # 6). 4. Review of Incident/event on 5/11/2025 on 300 unit at 10:00 pm for inappropriate behaviors for patient # 3 and patient # 6, in patient # 6’s room (the bathroom). a. BHA (Behavioral Health Associate -S # 2) found patient # 3 and patient # 6 in bathroom - Room # 306. b. Patient # 6 was laying on floor, back in shower. BHA turned on light and took patient # 3 out of room. c. Patient # 6 sent to hospital to get assessed for rape. 5. In interview on 5/15/2025 at approximately 11:50 am, with A # 1 (Director Quality & Risk), confirmed that Patient # 3 was not put on 1:1 or q (every) 5 minute checks after incident; not ordered by provider or initiated by nursing.”

“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: 14445 Based on document review and interview, the facility failed to ensure a patient was free from abuse in one instance. (Patient # 6). Findings include: 1. The hospital policy titled, Patient Rights and Responsibilities, PolicyStat ID 13517670, indicated on page 3, under PROCEDURE, have right to; 18. Receive care in a safe setting, free from verbal or physical abuse or harassment, Last revised 9/2021. 2. The hospital policy titled: Patient Observation, Policy Stat ID 12931622, indicated on page 1, under POLICY: patients will continue to be assessed and monitored during their treatment to ensure observation levels are appropriate, and under PROCEDURE: 2., observation levels can be increased or decreased by a provider’s order. Last revised 10/2024. 3. Review of Patient # 6’s MR (Medical Record) indicated the following: (a). Patient # 6 admitted on 4/3/2025 on 100 unit; diagnosis of Alzheimers disease. (b). Provider admission orders on 4/3/2025, included, but not limited to: Observation Level: Every 15 minutes. (c). Nurse note on 4/4/2025 at 1:00 pm, reflected patient noted to pace and intrusive at times. Note at 11:00 pm, patient continues to wander into other patient rooms. (d). Psychiatric progress note on 4/5/2025, by NP # 50 (Nurse Practitioner - Psychiatric) reflected patient is confused and requires redirection. (e). Nurse note on 4/7/2025 at 10:10 pm, reflected patient was in milieu wandering around when shift started, patient is alert & oriented x 1 (person) and walks independently; he/she is intrusive and will occasionally wander into other patient rooms. At around 10:00 pm, patient was heard calling from another patient’s room; upon inspection, patient was found beaten up on the face, with blood oozing by right ear and left eye; right eye was noted to be swollen. (f). Psychiatric progress note on 4/8/2025, by NP # 50 reflected nursing reports patient was involved in a physical altercation with another patient last night. Patient is confused and intrusive. (g). MR documentation lacked any increase by provider(s) for an appropriate patient’s observation status to a Level II (every 5 minutes) or Level III (1:1 Observation); related to patient # 6’s confusion, intrusiveness, wandering, and incident that occurred on 4/7/2025; that resulted in patient injury. 4. Review incident report dated 4/7/2025 at 10:15 pm indicated Patient # 6 send out to ER (Emergency Room) at AH # 60 (Acute Care Facility). Patient yelled from another patient’s room; staff in to check; patient found on floor; blood by right ear & left eye, and swelling. 5. In interview on 4/23/2025 at approximately 3:04 pm, with N # 20 (Behavioral Health Associate - staff), confirmed the following: a. Worked on 4/7/2025 & 4/8/2025, on 100 unit. b. Patient # 6 was a wanderer, needed lots of redirection; tried to go into other patient’s rooms, would have to redirect by staff. c. Was helping another BHA with a patient in room 101, that was on 1:1. Did not see patient # 6 go into patient # 5’s room right away. Heard noise; into room 107; found patient # 6 on floor near door. Patient had blood by nose and by right eye. 6. In interview on 4/23/2025 at approximately 3:30 pm (via telephone), with N # 21 (RN/Registered Nurse - staff), confirmed the following: a. Recalled incident towards beginning of shift; was getting medications ready; heard yelling; ran back. b. Found where yelling was coming from; found patient # 6 on floor by door of patient # 5’s room. Patient # 6 had bleeding on face. d. Patient # 6 was confused/wandering around.”

“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, nursing services failed to obtain a provider order to increase observation level of a patient in one instance. (Patient # 6). Findings include: 1. The hospital policy titled: Patient Observation, Policy Stat ID 12931622, indicated on page 1, under POLICY: patients will continue to be assessed and monitored during their treatment to ensure observation levels are appropriate, and under PROCEDURE: 2., observation levels can be increased or decreased by a provider’s order. Last revised 10/2024. 2. Review of Patient # 6’s MR (Medical Record) indicated the following: (a). Patient # 6 admitted on 4/3/2025 on 100 unit; diagnosis of Alzheimers disease. (b). Provider admission orders on 4/3/2025, included, but not limited to: Observation Level: Every 15 minutes. (c). Nurse note on 4/4/2025 at 1:00 pm, reflected patient noted to pace and intrusive at times. Note at 11:00 pm, patient continues to wander into other patient rooms. (d). Psychiatric progress note on 4/5/2025, by NP # 50 (Nurse Practitioner - Psychiatric) reflected patient is confused and requires redirection. (e). Nurse note on 4/7/2025 at 10:10 pm, reflected patient was in milieu wandering around when shift started, patient is alert & oriented x 1 (person) and walks independently; he/she is intrusive and will occasionally wander into other patient rooms. At around 10:00 pm, patient was heard calling from another patient’s room; upon inspection, patient was found beaten up on the face, with blood oozing by right ear and left eye; right eye was noted to be swollen. (f). Psychiatric progress note on 4/8/2025, by NP # 50 reflected nursing reports patient was involved in a physical altercation with another patient last night. Patient is confused and intrusive. (g). MR documentation lacked any increase by provider(s) for an appropriate patient’s observation status to a Level II (every 5 minutes) or Level III (1:1 Observation); related to patient # 6’s confusion, intrusiveness, wandering, and incident that occurred on 4/7/2025; that resulted in patient injury. 3. Review incident report dated 4/7/2025 at 10:15 pm indicated Patient # 6 send out to ER (Emergency Room) at AH # 60 (Acute Care Facility). Patient yelled from another patient’s room; staff in to check; patient found on floor; blood by right ear & left eye, and swelling. 4. In interview on 4/23/2025 at approximately 3:04 pm, with N # 20 (Behavioral Health Associate - staff), confirmed the following: a. Worked on 4/7/2025 & 4/8/2025, on 100 unit. b. Patient # 6 was a wanderer, needed lots of redirection; tried to go into other patient’s rooms, would have to redirect by staff. c. Was helping another BHA with a patient in room 101, that was on 1:1. Did not see patient # 6 go into patient # 5’s room right away. Heard noise; into room 107; found patient # 6 on floor near door. Patient had blood by nose and by right eye. 5. In interview on 4/23/2025 at approximately 3:30 pm (via telephone), with N # 21 (RN/Registered Nurse - staff), confirmed the following: a. Recalled incident towards beginning of shift; was getting medications ready; heard yelling; ran back. b. Found where yelling was coming from; found patient # 6 on floor by door of patient # 5’s room. Patient # 6 had bleeding on face. d. Patient # 6 was confused/wandering around.”

“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: 35731 Based on document review and interview the facility failed to ensure a patient’s wound was measured upon admission; failed to consult a wound care nurse in a timely manner; failed to obtain a urine culture in a timely manner; failed to obtain a therapeutic blood level (Depakote) test per provider order; failed to initiate skin prevention interventions (specialty bed/mattress & turning repositioning every two hours); failed to document intake in the medical record; failed to initiate treatment/care plan related to wound/skin integrity and nutrition upon admission; and failed to complete an incident report related to a new hospital acquired wound for 1 of 10 patient medical records reviewed. (Patient # 10) The cumulative 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: 35731 Based on document review and interview, the registered nurse failed to ensure a patient’s wound was measured upon admission in one (1) instance, failed to order a wound care nurse consult in a timely manner in one (1) instance, failed to collect a urine sample in a timely manner in one (1) instance, failed to obtain a physician order to collect a urine sample by strainght catheterization in one (1) instance, failed to collect a therapeutic blood test in one (1) instance, failed to initiate skin prevention interventions (specialty bed/mattress & turning repositioning every two hours), failed to ensure a ring was returned after being in the facilities safe in one (1) instance, and failed to document a patient’s intake in the medical record (MR) in one (1) instance. (Patient # 10) Findings include: 1. The facility policy titled, Physician Orders/Receipt and Notation, no policy number, indicated on page 1 - Policy - There shall be Provider’s Orders written for all medical and functional management for each patient specific to their individual needs. In circumstances when a delay in care could result in a negative patient outcome, a telephone or verbal order may be received. This policy was last revised in 09/2020. 2. The facility policy titled, Laboratory Process, PolicyStat ID 12197196, indicated on page 1 - Policy - To obtain laboratory results and place them on the cart for provider review in a timely manner. Procedure - number 1. Provider orders lab, number 4. Nurses obtains specimen for ordered tests, and number 10. Lab refusals shall be documented on the lab sheet in the patient’s medical record. This policy was last revised in 05/2021. 4. The facility policy titled, Intake & Output Monitoring, PolicyStat ID 12386133, on page 1 - Purpose - To assure that each patient receives sufficient amount of fluids based on individual needs. This policy was last revised in 09/2022. 5. The facility policy titled, Skin-Pressure Ulcer Assessment and Prevention, PolicyStat ID 12197143, on page 1 - Policy - The hospital shall ensure consistent, accurate assessment for the risk for skin breakdown is completed upon admission. Patients determined to be at risk for skin breakdown shall receive the necessary care and services to prevent skin breakdown. Procedure - Initial Assessment - Upon admission, all patients will be assessed for the risk of skin impairment using the Braden Pressure Ulcer Risk Assessment, which is part of the Nursing Admission form. The Braden Pressure Ulcer Risk Assessment is a scored scale that predicts a hospitalized patient’s risk for skin impairment. Scoring - High Risk 12 or below. The nurse will identify all applicable nursing interventions to assist in achieving the expected outcomes and goals, including but not limited to - Recording intake to ensure adequate nutrition and hydration, implementing low air loss mattress in bed, and turning and repositioning the patient at a minimum of every two (2) hours. This policy was last revised in 01/2020. 6. The facility policy titled, Management of Patient Belongings, PolicyStat ID 13950524, on page 1 - Discharge - letter c - Delivering the items to the skilled or assisted living facility, and/or referring facility of the patient. This policy was last revised in 07/2023. 7. The facility policy titled, Wound Care and Treatment, PolicyStat ID 12385988, on page 1 - Purpose - To ensure consistent, accurate identification and assessment of all wounds, and to ensure appropriate treatment is implemented timely in accordance with professional standards of practice for wound treatment. Policy - letter A - Wounds will be measured on admission (length, height, width), on page 3 - Procedure for Wound Treatment - number 1 - A treatment order will be obtained upon identification of a wound. This policy was last revised in 09/2022. 8. Review of the closed MR for patient # 10 indicated the patient was an 86 y/o (year/old) admitted to H # 2’s (Psychiatric Hospital) inpatient unit on 12/24/2024 and was discharged on 01/02/2025 to H # 3 (Long Term Care Facility). The patient’s diagnoses included, but were not limited to, unspecified dementia (confusion), multiple falls, severe depression, aggression, anxiety, and recent history of UTI (urinary tract infection). a. Patient Personal Effects Inventory dated 12/24/2025, indicated no jewelry listed/described. b. Security Patient Belongings dated 12/24/2024, indicated a gold ring was placed in the patient valuables envelope security bag, receipt number 3722769. c. Nursing Admission Assessment, no date, indicated the Braden Risk Assessment Scale was completed at time of admission - patient’s score was an eleven (11) which indicated the patient was at High Risk (12 or below). d. Nursing Admission Assessment dated 12/24/2024 at 2:31 pm, indicated the patient had redness (slight open red area) on the sacrum/coccyx area. No measurements documented. e. Daily Nursing Narrative dated 12/24/2024 at 3:00 pm, indicated patient had redness in groin area and coccyx f. Admission Orders dated 12/24/2024 at 4:00 pm, indicated urinalysis with culture & sensitivity (C&S), and Depakote level. g. Medication Administration Reconciliation dated 12/29/2024 indicated a urine sample was collected by straight catheterization. h. Provider Order dated 01/01/2025 at 7:00 pm, indicated to cleanse wound to left hand dorsal 3rd finger, and apply skin prep to 3rd/4th fingers, TARP (turn and reposition patient) while in bed to offload pressure from sacrum, cleanse wound to midline sacrum with wound cleaner and apply skin prep to peri wound, apply medihoney to wound bed and cover with optifoam dressing. i. Weekly Skin Assessment dated 01/01/2025, indicated the patient had two (2) areas of concern. Number one (1) - pressure sore on third finger was open, drainage, area red, moist and foul odor, length 2.5 cm (centimeters) x width 1 cm. Number two (2) - open pressure ulcer, red, moist, coccyx with no measurements. j. Daily Nursing Narrative dated 01/01/2025 at 6:30 pm, by wound care, indicated wound noted to midline sacrum, measures 4.6 cm x 0.7 cm x 0.1 cm. k. Patient Observation Rounds dated 01/01/2025 from 7:00 pm until 01/02/2025 at 12:55 pm, indicated the patient was in his/her room, and lacking any documentation the patient was being turned every two (2) hours (8 times). l. Daily Nursing Narrative dated 01/01/2025 at 8:40 pm, indicated patient resting quietly in his/her bed for all evening/night so far. m. Labcorp patient report - Urine Culture - date collected 12/29/2024 - date received 12/29/2024 - date reported 01/03/2025, indicated the urine culture was abnormal resulting Citrobacter Koseri - greater than 100,000 colony forming units per mL (milliliter), and Proteus Mirabilis - greater than 100,000 colony forming units per mL of urine. Cefazolin (Antibiotic) recommended. n. The MR lacked appropriate documentation related to the patient being discharged with his/her ring from the safe. o. The MR lacked documented oral intake data. Measurements in cc’s (cubic centimeters) per policy. p. The MR lacked a Depakote level which should have been collected per provider order. q. The MR lacked initial measurements for the sacrum/coccyx wound discovered on admission and lacked an order for wound nurse consultation upon admission. r. The MR lacked documentation the patient was on any kind of specialty bed. 9. In interview on 02/21/2025 at approximately 11:30 am with administrative staff member A # 2 (Licensed Practical Nurse-LPN/Chief Executive Officer-CEO), confirmed patient # 10’s belongings bag was signed out from the safe and taken to the unit on 01/02/2025 at 9:04 am, but was unsure where the bag went. 10. In interview on 02/21/2025 at approximately 11:45 am with staff member M # 1 (Maintenance/Security), confirmed he/she removed the security bag from the safe, walked it to the 200 unit, told an employee, and left it at the unit. 11. In interview on 02/21/2025 at approximately 1:30 pm with administrative staff member A # 1 (Registered Nurse-RN/Director of Nursing-DON), confirmed if the patient was turned every two (2) hours it should be documented in the medical record. If the patient refused a straight catheter (techniques used to collect a urine sample), it should be documented in the patient’s medical record. 12. In interview on 02/21/2025 at approximately 2:20 pm with administrative staff member A # 2, confirmed that after reviewing the video camera footage, it appeared that M # 1 notified B # 1 (Behavioral Health Assistant-BHA) that the patient’s belongings security bag was on the rack. He/she placed the security bag on the rack. A # 2 was unable to confirm where the security bag went. The footage doesn’t show anything. I checked the unit and was unable to locate the security bag. B # 1 has been terminated since then. 13. In interview on 02/21/2025 at approximately 3:20 pm with staff member B # 4 (BHA) confirmed he/she was hired at H # 2 in 02/2025, and was taught to sign the Patient Belongings sheet upon discharge to ensure all patient belongings were sent with the patient. 14. In interview on 02/21/2025 at approximately 4:10 pm with administrative staff member A # 2, confirmed the nurse should have collected the urine for the urinalysis/urine culture within twenty-four (24) hours, and notified the physician to get an order for straight catheterized if necessary. The medical record lacked an order for the patient to have a straight catheterization. The medical record showed an order for a specialty mattress but lacked documentation that the patient had a specialty mattress. At 4:40 pm, further confirmed the initial admission skin assessment indicated the patient had a sacrum/coccyx area which was red and slightly open (wound), but lacked a wound nurse consult within twenty-four (24) hours.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 35731 Based on document review and interview the registered nurse failed to ensure the patient’s treatment plan was initiated upon admission related to skin integrity/wound care in one (1) instance. (Patient # 10) Findings include: 1. The hospital policy titled, Patient Treatment Plan, PolicyStat ID 12386362, indicated on page two (2) - Procedure - Preliminary Treatment Plan: Upon admission, the nurse shall initiate the Interdisciplinary Treatment Plan for the patient’s identified nursing care needs as part of the admission assessment. This policy was last revised in 09/2022. 2. The hospital policy titled, Skin Assessment, PolicyStat ID 12385990, indicated on page one (1) - Assessment - number two (2) - letter f - number 1. If a skin condition, wound, pressure ulcer is noted, the wound should be assessed by the nurse and documented on the skin/wound form, and page two (2) - number 3 - Provide any necessary pressure relieving measures. This policy was last revised in 09/2022. 3. The hospital policy titled, Wound Care and Treatment, PolicyStat ID 12385988, indicated on page one (1) - Purpose - to ensure consistent, accurate identification and assessment of all wounds, and to ensure appropriate treatment is implemented timely in accordance with professional standards of practice for wound treatment. This policy was last revised in 09/2022. 4. Review of Patient # 10’s medical record indicated the following: a. Nursing Admission Assessment dated 12/24/2024 at 2:31 pm, indicated on page one (1) - Public Health History & Status - Integumentary - redness (slight open red area) to sacrum/coccyx area. The medical record lacked any initial measurements, and/or initial skin/wound assessment discharge plan within twenty-four (24) hours. b. Providers Orders dated 01/01/2025 at 7:00 pm by N # 1 (Nurse Practitioner-NP), indicated cleanse wound to midline sacrum (4.6 centimeters-cm x 0.7 cm x 0.1 cm) with wound cleanser and pat dry. Apply Medihoney to wound bed and cover with optifoam dressing. 5. In interview on 02/21/2025 at approximately 4:20 pm with administrative staff member A # 2 (Licensed Practical Nurse-LPN/Chief Executive Officer-CEO), confirmed the nurse should have initiated the skin/wound treatment plan within twenty-four (24) hours of admission.”

“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: 35731 Based on document review and interview the facility failed to ensure an incident report was completed for a new hospital acquired wound in one (1) instance. (Patient # 10) Findings include: 1. The hospital policy titled, Incident Reports, PolicyStat ID 13033981, indicated on page one (1) - Purpose - it is the policy of the hospital to support a culture of shared accountability for the identification, reporting and management of patient events that may impact the quality of care provided. An incident is defined as: any event which is not consistent with the routine operation of the hospital and that adversely affects or threatens to affect the well-being of the patients. This policy was last revised on 01/2023. 2. Review of patient # 10’s medical record indicated the following: a. Provider Order dated 01/01/2025 at 10:50 am, indicated a new wound consultation for right third (3rd) and fourth (4th) fingers. b. Daily Nursing Narrative dated 01/01/2025 at 5:47 pm, indicated patient had a pressure sore to third finger which was open with serous drainage and foul odor. c. Medical record initial skin assessment lacked documentation related to finger wounds. 3. In interview on 02/21/2025 at approximately 11:30 am by administrative staff member A # 1 (Registered Nurse-RN/Director of Nursing-DON), indicated there were no incident reports completed for patient # 10’s hand wound.”

“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: 47186 Based on document review and interview facility staff failed to measure wounds after wounds/skin breakdown noted on admission; failed to evaluate patient’s nutritional needs after patient refused to eat or drink; failed to documented Intake/Output; failed to complete admission lab draw; and failed to develop a nursing care plan to evaluate/address patient’s nutritional needs after patient refused to eat or drink for 1 in 10 patients. (Patient #8) The cumulative effects of these systemic problems resulted in the facility’s inability to provide nursing care in a safe manner.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 47186 Based on document review and interview, facility failed to ensure patient’s Power of Attorney (POA) was updated/involved in patient plan of care with patient’s medication change/administered, per facility policy and standards of practice for 1 of 10 patients (Patient # 8). Findings Include: 1. Review of hospital policy titled “Patient Rights and Responsibilities”, PolicyStat ID 13517670, last approved 04/2023: indicated under Procedure: You have the right to receive information about your health status, course of treatment, prospects for recovery and outcomes of care, including unanticipated outcomes, in terms you can understand, tailored to the patient’s age and language; have your family and/or agent, when appropriate, be informed of your care, including unanticipated outcomes, in order to participate in current and future decisions affecting your care and to participate in the development and implementation of your plan of care. During hospitalization information concerning your condition, medication, treatment, and discharge plans may be shared with your personal friends and family through your designated spokesperson. Your designated spokesperson will be responsible to update friends and family members as desired to protect your privacy. If you have a Power of Attorney, that person will be the designated spokesperson, if appropriate. 2. Review of patient 8’s MR indicated a designated POA based on patient’s medical diagnosis and inability to make medical decisions regarding his/her care. MR for patient 8 indicated at approximately 9:30 pm, 10/05/24, the following medications were administered to patient: Ativan, 0.5 mg, IM and Haldol 2.5 mg, IM, as ordered, to calm patient. MR lacked documentation of P8’s POA notification for change in medication ordered/administered. 3. Incident Report Log dated 10/05/24 at approximately 9:30 pm, indicated N2 (Registered Nurse [RN]) received a telephone order from MD5 (Nurse Practitioner [NP]) to administer a one time injection of Ativan, 0.5 mg, IM (intramuscularly) and Haldol 2.5 mg, IM, to calm patient 8. 4. In Interview on 10/21/24 at approximately 10:05 am to 10:12 am, N2 confirmed an order was received/administered to patient 8 intramuscularly of Ativan and Haldol to help patient calm down. N2 did not recall if patient’s POA was notified.”

“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: 47186 Based on document review and interview facility staff failed to measure wounds after wounds/skin breakdown noted on admission; failed to evaluate patient’s nutritional needs after patient refused to eat or drink; failed to documented Intake/Output; and failed to complete admission lab draw, for 1 of 10 patient medical records reviewed. (Patient 8) Findings include: 1. Facility policy titled, Wound Care and Treatment, PolicyStat ID: 12385988, last revised 09/2022, indicated under Policy: A. Wounds will be measured on admission (length, height, width). 1. Additional measurements may be made by the Wound Care Nurse or designee. This includes pressure-related and non-pressure related wounds. C. A Wound Care Nurse, through a contracted service or on-staff, shall provide all needed wound care services including treatment and documentation of progress or regress. E. The registered dietitian will provide a nutritional screening and interventions deemed necessary to promote healing. 2. Facility policy titled, Skin-Pressure Ulcer Assessment and Prevention, PolicyStat ID: 12197143, last revised 1/2020, indicated under Procedure: Initial Assessment: Upon admission, all patients will be assessed for the risk of skin impairment using the Braden Pressure Ulcer Risk Assessment, which is part of the Nursing Admission Database form. The Braden Pressure Ulcer Risk Assessment is a scored scale that predicts a hospitalized patient’s risk for skin impairment. Scoring: Moderate risk: 13 - 14. For any patient scoring as a moderate or high risk, the nurse will initiate the Nursing Care Plan - Impaired Skin Integrity. The nurse will identify all factors that contribute to the patient’s risk for impaired skin integrity, including: decreased sensory perception, decreased mobility, decreased activity, poor nutrition , mechanical factors (i.e., shearing forces, pressure, restraints), altered circulation, sensation, incontinence. The nurse will identify all applicable nursing interventions to assist in achieving the expected outcomes and goals, including but not limited to :recording intake to ensure adequate nutrition and hydration, referring to dietitian for a nutritional assessment, implementing low air loss mattress in bed. All Patients: Patients with Moderate Risk and/or a Stage I Pressure Ulcer will receive all interventions listed above, in addition to: the patient will be turned and repositioned (or cued to do so) at a minimum of every two hours, avoiding positioning patient on the affected side, if possible. Notify the dietitian to evaluate the patient’s nutritional intake and review corresponding labs. 3. Review of patient 8’s MR lacked documentation of: wound measurements on admission to bruise on back of left hand and wrist, scabbed wounds to lower left leg, bruise to upper right thigh, pressure injury to left inner great toe, wound to left outer ankle, skin tear to right inner upper thigh, bruise to right lower/outer forearm; low air loss mattress placement on patient’s bed; patient turned/repositioned or cued to turn every 2 hours; consult for wound care nurse; completed admitting lab draw, per provider order; and/or referral to dietician for nutritional screening and interventions necessary to promote healing per policy. 4. In interview on 10/17/24 at approximately 9:26 am to 9:48 am, N5 (Registered Nurse [RN]) confirmed no wound measurements were taken of P8’s skin abnormalities on admission. 5. In interview on 10/21/24 at approximately 10:05 am to 10:12 am, N2 (RN) indicated he/she was assigned P8 on 3-nights (10/05/24 - 10/07/24) and that patient was not on a low air loss mattress. 6. In interview on 10/17/24 at approximately 10:03 am to 10:40 am, A1 (Quality, Risk & Compliance) confirmed no measurements/photos were taken of P8’s skin abnormalities, per policy, on 10/04/24. A1 confirmed wound care nurse consult was not initiated, per policy, as facility no longer had a wound care nurse. A1 confirmed a Nursing Plan of Care for Skin Integrity was not initiated on P8 based on patient’s skin condition or Braden scoring, per policy.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 47186 Based on document review and interview facility staff failed to develop a nursing care plan to evaluate/address patient’s nutritional needs after patient refused to eat or drink for 1 in 10 patients (Patient #8). 1. Facility policy titled, Skin-Pressure Ulcer Assessment and Prevention, PolicyStat ID: 12197143, last revised 1/2020, indicated under Procedure: Initial Assessment: Upon admission, all patients will be assessed for the risk of skin impairment using the Braden Pressure Ulcer Risk Assessment, which is part of the Nursing Admission Database form. The Braden Pressure Ulcer Risk Assessment is a scored scale that predicts a hospitalized patient’s risk for skin impairment. Scoring: Moderate risk: 13 - 14. For any patient scoring as a moderate or high risk, the nurse will initiate the Nursing Care Plan - Impaired Skin Integrity. The nurse will identify all factors that contribute to the patient’s risk for impaired skin integrity, including: decreased sensory perception, decreased mobility, decreased activity, poor nutrition , mechanical factors (i.e., shearing forces, pressure, restraints), altered circulation, sensation, incontinence. The nurse will identify all applicable nursing interventions to assist in achieving the expected outcomes and goals, including but not limited to :recording intake to ensure adequate nutrition and hydration, referring to dietitian for a nutritional assessment, implementing low air loss mattress in bed. All Patients: Patients with Moderate Risk and/or a Stage I Pressure Ulcer will receive all interventions listed above, in addition to: the patient will be turned and repositioned (or cued to do so) at a minimum of every two hours, avoiding positioning patient on the affected side, if possible. Notify the dietitian to evaluate the patient’s nutritional intake and review corresponding labs. 2. P8’s MR indicated on admission assessment a bruise on back of left hand and wrist, scabbed wounds to lower left leg, bruise to upper right thigh, pressure injury to left inner great toe, wound to left outer ankle, skin tear to right inner upper thigh, bruise to right lower/outer forearm. MR indicated on assessment a Moderate Braden Score of 13 (where 15 = low). MR lacked Nursing Care Plan for Impaired Skin Integrity and Insufficient Nutrition. 3. In interview on 10/17/24 at approximately 9:26 am to 9:48 am, N5 (Registered Nurse [RN]) confirmed no Nursing Care Plan for P8 was initiated for Impaired Skin Integrity or Insufficient Nutrition. 4. In interview on 10/17/24 at approximately 10:03 am to 10:40 am, A1 (Quality, Risk & Compliance) confirmed a Nursing Plan of Care for Skin Integrity was not initiated on P8 based on patient’s skin condition or Braden scoring, per policy.”

“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 Registered Nurse failed to follow the P&P (Policy & Procedure) related to Patient Personal Care for bathing offered daily; in the patients MR (Medical Record), for 3 of 10 MR’s reviewed. (Patients # 5, # 6, & # 8). Findings include: 1. Review of hospital policy titled: “Patient Personal Care”, Policy Stat ID 12197137; indicated Bathing/showers will be offered daily; All patients shall be encouraged or assisted in grooming daily or more often as needed. Last revised 1/2020. 2. Review of Patient # 5 MR, indicated the following: A. Patient admitted to APH # 40 (Acute Psychiatric Hospital) on 2/29/2024. B. MR lacked documentation in daily flowsheets and/or daily notes for ADL’s (activities of daily living) - hygiene care/bathing, offered or completed or refused, for the following days: 3/1/2024, 3/2/2024 and 3/3/2024. 3. Review of Patient # 6 MR, indicated the following: A. Patient admitted to APH # 40 on 9/15/2023. B. MR lacked documentation in daily flowsheets and/or daily notes for hygiene care/bathing, offered or completed or refused, for the following days/timeframes: September 2023: 9/16/2023 - 9/20/2023; 9/24/2023 - 9/28/2023; October 2023: 10/4/2023 - 10/14/2023; 10/18/2023 - 10/20/2023; 10/25/2023 - 10/28/2023 November 2023: 11/4/2023 - 11/13/2023; 11/23/2023 - 11/27/2023 December 2023: 12/7/2023 - 12/12/2023; 12/23/2023 - 12/31/2023 January 2024: 1/12/2024 - 1/14/2024; 1/21/2024 - 1/31/2024 February 2024: 2/1/2024 - 2/6/2024; 2/8/2024 - 2/11/2024; 2/16/2024 - 2/20/2024 4. Review of Patient # 8 MR, indicated the following: A. Patient admitted to APH # 40 on 2/4/2024. B. MR lacked documentation in daily flowsheets and/or daily notes for hygiene care/bathing, offered or completed or refused, for the following days: 2/8/2024, 2/11/2024 and 2/12/2024. 5. In interview on 3/5/2024 at approximately 10:40 am, and at approximately 4:25 pm, with A # 3 (Quality/Risk), confirmed/verified the following: A. That hygiene documentation is to be charted on flowsheet in MR; for daily completed, or chart if patient refused. B. That the above noted MRs lacked hygiene documentation. 6. In interview on 3/5/2024 at approximately 12:45 pm, while on tour; with N # 1 (RN {Registered Nurse} - Staff Nurse), confirmed BHAs (Behavioral Health Associate) responsibility to document hygiene; nurse reviews for completeness of documentation on flowsheet.”

“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 nursing staff failed to ensure discharge instructions and medication list were provided to the patient for 1 of 11 MRs (medical record) reviewed. (Patient # 8). Findings include: 1. Review of established hospital policy titled: “Patient Discharge-AMA” (Against Medical Advice), Policy Stat ID 13916075, indicated under Procedure, page 2, 8. “The prescriber will evaluate medications and provide prescriptions. If the provider declines to provide prescriptions to the patient the provider will document the rationale”. Last revised 6/2023. 2. Review of established hospital policy titled: “Patient Education about Discharge Medications”, Policy Stat ID 10009376, indicated on page 1, under Policy “The patient shall receive appropriate education about medications provided at discharge.” and under Procedure, “Documentation of education regarding discharge medications shall be recorded.” Last revised 12/2021. 3. Review of Patient # 8 MR, indicated the following: A. Patient admitted to APH # 40 (Acute Psychiatric Hospital) on 12/29/2023. B. Patient signed out; left AMA on 1/2/2024 at 10:45 am. C. MR lacked documentation for the following: 1. Discharge instructions. 2. A discharge medication list and education. D. MR lacked documentation by Social service staff, Nursing staff, and provider in regards to why above not provided to patient on 1/2/2024. 4. In interview with A # 3 (Quality/Risk) on 2/5/2024 at approximately 10:45 am, and on 2/6/2024 at approximately 12:15 pm, the following was confirmed: A. Patients receive medication list; prescriptions called in to pharmacy; discharge instructions; even if sign out AMA; unless Doctor documents for none to be received/given. B. Confirmed/verified MR for patient # 8 MR lacked part of discharge plan document, lacked medication list and education for discharge. Discharge summary lacked documentation of discharge instructions and lacked documentation of medication list.”