Maple Heights Behavioral Health

“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: 47186 Based on document review and interview the facility refused to accept a transfer from a referring hospital of an individual who required specialized treatment within the facilities’ capabilities in 1 of 22 medical records reviewed (Patient 22). Findings included: 1. Facility did not follow their policy titled: EMTALA Compliance, PolicyStat ID: 17970669, last approved 05/2025, under Policy: It is the intent of the Hospital to provide the following services to all individuals who present to the Hospital with a request for examination and/or treatment: Within the capabilities of the hospital, further medical examination and treatment, as may be required to stabilize the medical condition. In addition, The Hospital will accept appropriate transfers of patients with emergency medical conditions from a transferring hospital if: The Hospital has the specialized capabilities not available at the transferring hospital, and The Hospital has the capability and capacity to treat the patient. 2. On 9/13/25, F2’s MR for P22 indicated patient returned to F2 by EMT (Emergency Medical Transport). On 9/13/25 at approximately 4:09 pm, F2MD1 (Doctor of Medicine) note indicated F1 had rescinded patient’s acceptance after transport had been initiated, the patient was sent back to F1 when nursing report revealed patient had bed bugs. F2MD1 note indicated P22 was in stable condition upon return. 3. In interview on 9/25/25 at approximately 2:43 pm to 2:53 pm, N2 (SW, Admissions Counselor) confirmed P22 arrived to facility by EMT on 9/13/25, and was denied entry to facility due to bedbugs. 4. In a telephone interview on 9/29/25 at approximately 11:59 am to 12:07 pm, N3 (RN, Acute Admissions) confirmed the patient did arrive at facility by EMT on 9/13/25, remained in the ambulance, was denied entry to facility because patient had bedbugs.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47186 Based on document review and interview the facility failed to obtain a provider order for restraint and/or seclusion use for 2 of 11 patient medical records reviewed (Patient 4 and Patient 5); and failed to update/revise patient’s plan of care related to restraint use for 1 of 11 medical records reviewed (Patient 4). The cumulative effect of this systemic problem resulted in the facility’s inability to ensure that Patient Rights were promoted.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 47186 Based on document review and interview the facility failed to update/revise patient’s plan of care realted to restraint use for 1 of 11 medical records reviewed (Patient 4). Findings include: 1. The facility did not follow their policy titled: Scope of Service/Provision of Patient Care Plan, Policy Number: LD 1, last revised 3/2025, under Treatment Planning: The program has an interdisciplinary approach to treatment planning. Those involved in the treatment planning process include the patient’s physician, nursing, therapists, activity therapists and mental health technicians. Dietitian and pharmacist are included as indicated. The team is responsible for development of the individualized treatment planned review and evaluation of ongoing treatment. The Interdisciplinary Treatment Plan is developed within 72 hours of admission. Treatment plans are reassessed by the team at regular intervals and revised as needed. The patient, and family when appropriate, is encouraged to participate in the treatment planning process by providing input and acknowledging agreement with the plan in writing. Patient progress in meeting the treatment plan goals is documented in the progress notes. 2. Review of P4’s MR (Medical Record) lacked documentation of patient’s care plan reviewed/revised/updated after a restraint was used on patient on 6/5/25. 3. In interview on 8/22/25 at approximately 4:00 pm, A3 (Director of Risk Management) confirmed P4’s MR lacked documenation of treatment plan reviewed/revised after a restraint was used on the patient, on 6/5/25.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 47186 Based on document review and interview the facility failed to obtain a provider order for restraint and/or seclusion use for 2 of 11 patient medical records reviewed (Patient 4 and Patient 5). 1. Facility policy titled: Restraint, No Policy Number, last revised 9/2024, under Procedure: 2. The order shall indicate the reason and maximum duration of restraint, and under Policy: 4. Restraint may only be ordered by the attending physician or covering practitioner. 2. Facility policy titled: Seclusion, No Policy Number, last revised 9/2024, under Policy: 3. Seclusion may only be ordered by a psychiatrist and only for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others after less restrictive interventions are ineffective or ruled-out, and under Procedure: 2. The order shall indicate the reason and maximum duration of the seclusion. 3. Review of P4’s MR indicated on 6/05/25 at approximately 3:02 pm to 3:19 pm, a physical restraint was initiated by staff as patient was self-harming by biting oneself intentionally causing bleeding. P4’s MR lacked an order for physical restraint use and/or duration. 4. Review of P5’s MR indicated on 6/30/25 at approximately 8:27 am staff initiated a protective restraint technique as patient attempted to elope between unit doors. P5’s MR indicated patient was restrained from 8:26 am to 8:27 am and then the patient was placed in seclusion until 10:03 am. P5’s MR lacked documentation of an order for restraint/seclusion, reason, and/or maximum duration on 6/30/25. 5. Facility Incident/Event Report dated 6/05/25 indicated P4 was restrained at approximately 3:02 pm until 3:19 pm. The report lacked documentation of provider notification and/or order for the restraint. 6. Facility Incident/Event Report dated 6/30/25 indicated P5 attempted to elope through a door between the 500 and 600 Unit. The report indicated staff used a protective restraint technique to prevent patient from leaving the unit and patient was then placed in seclusion for patient’s safety from 8:27 am until 10:03 am. The Incident/Event report lacked documentation of provider notification and/or order for restraint or seclusion. 7. In interview on 8/22/25 at approximately 4:00 pm, A3 (Director of Risk Management) confirmed MRs lacked documented physician orders for patient’s (P4) restraint on 6/5/25, and patient (P5) restraint/seclusion on 6/30/25.”

“DIRECTOR OF DIETARY SERVICES CFR(s): 482.28(a)(1) The hospital must have a full-time employee who- (i) Serves as director of the food and dietetic services; (ii) Is responsible for daily management of the dietary services; and (iii) Is qualified by experience or training. This Standard is not met as evidenced by: 31630 Based on document review and interview, the Director of Dietary Services failed to supervise on-duty personnel (SP-4, Dietary staff member) for possible intoxication. Findings include: 1) Policy titled, “HR015-Substance-Free Workplace,” last revised, 01/2024, signed by SP-9, read under paragraph titled, “Policy” on page one of five, “...employees are required to report to work in an appropriate mental and physical condition so they may perform their jobs in a satisfactory manner...It is the Company’s policy to conduct drug testing on all prospective and current employees for purposes of pre-employment screening, post-accident investigation, random testing, and reasonable suspicion testing...” Under paragraph titled, “Reasonable Suspicion” on page three of five, read, “...A member of management may request a drug test when there is a documented ‘reasonable suspicion’ that an employee is impaired or incapable of performing assigned duties as shown by factors including: Observable phenomena, such as physical symptoms or manifestations of being under the influence of a drug or alcohol at work; Abnormal conduct or erratic behavior at work; A significant deterioration in work performance...We require two (2) or more individuals (at least one person at a supervisory level) to observe and document these types of ‘reasonable suspicion’ behaviors...The evidence of reasonable suspicion will be presented to Human Resources who will conduct any investigation deemed necessary before sending the employee to be tested...” 2) Review of three of three witness statements indicated the following: a) Statement #1, documented and signed by SP-3 (Behavioral Health Aide) on March 30, 2025 at 10:40 am, read “I found SP-4 (Dietary Staff Member) looking lost in the hall and peering through windows. I asked what she/he was looking for and she/he said Ibuprofen. She/he said she/he had some in her/his car and when I asked where her/his car was parked, she/he said she/he didn’t know. I walked with her/him back to the kitchen where SP-6 (Head Cook) was. SP-6 and I asked if she/he was okay and she/he stated yes. I told her/him she/he didn’t look well and then SP-6 offered her/him the option of going home if she/he wasn’t’ feeling well. She/he stated she/he had been throwing up on her/his way in to work. I asked if she/he would be okay to drive and she/he said yes but then said she/he was given a ride here. I asked if she/he wanted me to call her/him a transportation company and she/he said ‘no I can drive.’ Throughout entire interaction she/he appeared very disoriented and confused with delayed responses.” This statement was also signed on 3/30/25 by SP-5 (Director of Risk Management). b) Statement #2, documented and signed by SP-7 (House Supervisor) on 3/30/25 at 7:45 am, read “Writer received a message...telling me to check on the dietary aid. Writer went to cafeteria where tech stated that they were concerned that she/he was either under the influence or something was really wrong with her/him. Writer went in to talk with aid and she/he was trying to unlock one of the doors in the kitchen and could not get the key in the door knob. Writer asked her/him if she/he was ok and she/he offered me some food. I explained that I was there checking on her/him and that I did not want any food but thank you. She/he again asked if I wanted something to eat. Writer again told her/him no that I was just checking in to see if they needed anything this morning. She/he said ‘Can I get you a muffin or something else to eat’ Writer told her/him no. During conversation she/he was slurring her/his words and appeared unsteady and kept leaning on her/his elbows on the prep area.” This statement was also signed on 3/30/25 by SP-5 (Director of Risk Management). c) Statement #3, documented and signed by SP-5 (Director of Risk Management) on 3/30/25 at 11:00 am, read “SP-7 spoke to writer about concerns w/dietary staff ‘SP-4.’ SP-7 stated staff thought SP-4 intoxicated. Writer asked how they know that. SP-7 reported staff stated she/he was belligerent and either appeared to be intoxicated or ‘very ill.’ ...SP-7 stated “...SP-4 kept repeating herself/himself and not making sense...” “...Writer went to dietary. SP-4 was stuttering her/his words and her/his speech was pressure delayed. She/he asked who I was and gave her/him my name and title. She/he introduced herself/himself to me and fumbled with her/his name badge...” 3) In interview on 3/30/25 at 9:40 am with SP-3 (Health Aide), indicated the following: (i) SP-3 confirmed they authored Statement #1 above and signed/dated the document (as indicated above) and confirmed the findings. (ii) SP-3 also stated, “I am a behavioral health tech and have been here two and a half years. SP-4 is one of the cooks. I was notified by our house supervisor, SP-7, and let me know SP-4 appeared to be intoxicated and belligerent with the adolescent patients and that she/he was trying to contact the dietary manager, SP-2, and the Director of Risk, SP5.” 4) In interview on 3/30/25 at 10:10 am with SP-7 (House Supervisor), indicated the following: (i) SP-7 confirmed they authored Statement #1 above and signed/dated the document (as indicated above) and confirmed the findings. (ii) SP-7 also stated, “I am the house supervisor, RN (Registered Nurse), and I was the house supervisor on March 30, 2025. I have been here for almost 2 years... I went down to the cafeteria and saw her/him messing with the condiments counter and asked her/him if she/he was ok, she/he said she/he was fine. I could not smell anything on her/his breath, but she/he had an unsteady gait when walking around the cafeteria area...I saw SP-6 come in to work and I explained the staff member’s behavior and she/he said, she/he couldn’t smell anything on her/him. I filled out a witness statement and gave it to SP-5 that same day.” 5) In interview on 3/30/25 at 10:39 am with SP-5 (Director of Risk), indicated the following: (i) SP-5 confirmed she authored, signed, and dated a copy of the written statement that was given to the surveyor on 5/13/25 and that she/he still agreed with everything she/he documented. (ii) SP-5 also stated, “I am the Director of Risk and have been here for 20 months. SP-7 approached me and said, they had some concerns about an employee in the dietary area, named SP-4. SP-7 and SP-3 indicated, they thought she/he was under the influence of alcohol and I asked them how they came to that suspicion, SP-3 indicated, she/he was slurring her/his words and had short memory recall...I went down to dietary and spoke to SP-4, around 10:30-11:00 am...Shehe slurred her/his words a little bit...I then called the Director of Human Resources (SP-8) and let them know the staffs’ concerns and what I had observed...” 6) In interview on 3/30/25 at 10:59 am with SP-8 (HR Manager), indicated the following: “I am the Director of HR and have been here for 1 yr. I received a phone call from SP-5 in the afternoon who told me, that SP-4 wasn’t answering questions properly...I told her/him to get witness statements. I was off that day and didn’t receive the witness statements until the next day.” 7) In interview on 3/30/25 at various different interview times (see above); SP-3, SP-7, SP-5, and SP-8 all indicated through written or verbal statements that SP-4 was not in a competent state of mind and they failed to follow company policy.”

“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 complete admission lab draw, failed to notify provider of change in patient weight, failed to notify provider of patient refusal of medications, failed to complete a nursing care plan to evaluate/address patient’s nutritional needs for 1 in 10 patients (Patient 6). The cumulative effect 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: 47186 Based on document review and interview facility staff failed to complete admission lab draw, failed to notify MD (Medical Doctor) of change in patient weight, and failed to notify MD of patient refusal of medications in 1 of 10 patient MRs (Medical Records) reviewed (Patient 6). Findings include: 1. Facility policy titled, Medication Administration And Documentation, No Policy Number, originated 12/2022, indicated under Procedure: 3. Administration. y. Document all refused drugs on the patient’s MAR. Notification of the practitioner is also to be documented in the progress note. 2. P6’s MR indicated patient refused Paliperidone (Invega ER [Emergency Release]), 3 mg (milligrams), by mouth, daily on March 20, 22, 24, and 30, 2025. The MR indicated P6 refused Divalproex Sodium, 500 mg, by mouth, twice daily on March 20, 22, 24, and 28, 2025. P6’s MR indicated patient refused Lisinopril, 5 mg, by mouth, daily on March 30, 2025. P6’s MR lacked documentation of provider notification of patient’s refusal of scheduled medications on these dates, per policy. P6’s MR indicated lab draws were ordered on 3/19/25 which included (but not limited to), Lithium Level, Valproic Acid, TSH (thyroid stimulating hormone), and CBC (complete blood count). P6’s MR lacked documentation of Lithium Level, Valproic Acid, TSH and/or CBC labs drawn, as ordered. MR lacked nursing staff’s documentation of attempts to obtain labs or patient’s refusal of labs. Review of patient 6’s MR indicated patient weight on 3/18/25 and 3/19/25 was 174 lb., and on 3/30/25 was 154 lb. MR lacked documentation of patient’s weight on 3/26/25, as ordered and lacked documentation of MD notification of weight loss. 3. In interview on 4/21/25 at approximately 4:15 pm to 4:30 pm, A1 (Director Risk & Performance Improvement) confirmed staff did not follow policy/orders regarding lab draw, weekly patient weight, and/or provider notification with missed medications regarding P6. 4. Facility Incident Report, dated 3/30/25 and initiated by A1 (Director Risk & Performance Improvement) regarding P6 indicated on patient’s admission (3/18/25) a reported history of chronic kidney disease, psychiatric treatment, hypertension, functioning deterioration, and decreased food intake was noted in patient’s MR. Facility Incident Report indicated admitting labs were ordered on 3/18/25 which included (but not limited to), lithium level, CBC (complete blood count), CMP (complete metabolic panel), and U/A (urine analysis). No indication/documentation of lab attempts/why not completed, or physician notification orders were not completed. Facility Incident Report indicated P6 with fair to good appetite throughout facility stay, but lacked intake/output of food/liquid, or percentage of meals eaten and/or skipped. Patient had a documented 20-pound weight loss from 3/18/25 to 3/30/24 with no provider/or dietician notification and no weight recorded for P6 on 3/26/25, per order. On 3/28/25, P6 with a noted decline by staff in patient’s ADL’s (activities of daily living) function despite prompting and poor food intake. Facility Incident Report indicated P6 was transported to F2 (Acute Care Facility) on 3/30/25 where patient was determined to be dehydrated, had an elevated lithium level. P6’s lithium level, while at F2, indicated 1.4 outside of the therapeutic range (therapeutic = 0.6 - 1.2, mild toxicity = 1.5 - 2.5). Facility Incident Report indicated investigative results regarding P6’s lack of care during facility stay included lack of nursing staff communication regarding patient’s change in condition, lack of meal intake/fluids/weight documentation, lack or labs drawn, as ordered, and lack of timely labs/notification to the provider.”

“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 add a nursing care plan to evaluate/address patient’s nutritional needs after patient refused to eat or drink for 1 in 10 patients (Patient 6). 1. Facility policy titled, Dietary Services, No Policy Number, last revised 3/2024, indicated under Policy: The hospital will ensure provision of patient specific nutritional services through dietary services for meal planning and assessments, processes that address diet orders and meal delivery, staff training for all processes and contract with a food service provider. Patients will receive three meals a day along with snacks and beverages to meet nutritional and hydration needs as calculated by the dietician and ordered by the practitioner. Procedure: 1. A Diet Order - will be obtained based on information provided at time of admission. 3. A Nutritional Screen will be conducted on all admitted patients. A Dietary Consult (Nutritional Assessment) is triggered if any items on the screen are positive. Staff Training: All Registered Nurses and Behavioral Health Technicians shall receive training related to the Dietary Services processes, include assessment, ordering diets, completion of dietary forms, meal/snack delivery and patient observations. 2. P6’s MR (Medical Record) lacked Dietary Consult after patient reported refusal to eat related to paranoia of food being poisoned. P6’s MR lacked documentation of meal and/or liquid intake. P6’s MR lacked documentation of weekly weight, as ordered. P6’s MR lacked documentation of provider notification of patient’s 20 pound weight loss within 12 days. P6’s MR lacked Nursing Care Plan of Insufficient Nutrition/Hydration. P6’s MR from F2 on 3/30/25 at approximately 11:39, indicated patient presented to ED (Emergency Department) from F1 (Psychiatric Hospital) for weight loss, failure to thrive, and dehydrated., 3. In interview on 4/21/25 at approximately 4:15 pm to 4:30 pm, A1 (Director Risk & Performance Improvement) confirmed missed opportunity for dietary consult with patient reported food paranoia, no measured food/fluid intake, and no weekly weight was documented in P6’s MR.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 32952 Based on document review and interview, the facility failed to ensure nursing staff followed facility policy related to the patient’s right to be protected by the hospital as evidenced by patient elopement for 6 of 10 patient medical records (MR) reviewed. (Patients #1, 3, 4, 5, 6, and 7) Findings include: 1. Facility policy titled “PATIENT RIGHTS”, policy number #RI-001, with a revision date of 4/2024 indicated the following: PROCEDURE: Patient Rights: 1.g. Patients have the right to be protected by the Hospital from neglect; from physical, verbal and emotional abuse (including corporal punishment); and from all forms of misappropriation and/or exploitation. 2. Review of Patient #1’s medical record indicated the following: (a.) Patient #1 was voluntarily admitted to the Adult Unit on 9/11/24 at 1:15 a.m. and discharged on 10/8/24. The patient had diagnoses that included, but were not limited to, major depressive disorder, recurrent severe without psychotic features. (b.) A review of Patient #1’s BEHAVIORAL HEALTH - PATIENT OBSERVATION SHEET dated on 9/21/24 indicated that Patient #1 was on assault precautions beginning on 9/19/24 at 1:43 a.m. and elopement precautions beginning on 9/20/24 at 1:06 p.m. (c.) A review of nurse’s note for Patient #1 dated 9/22/24 at 12:52 a.m. indicated the following: At approximately 9:00 (p.m.) the pt (patient) grabbed a bracelet from one of the techs (Behavioral Health Technicians) and ran out the fire exit door at the end of the unit. We called 911 to report that the pt had eloped from the facility. The provider reached out to the directors, and they had determined that (he/she) was not a threat to (himself/herself) or others at this time, but that (he/she) was hypomanic and that they were going to discharge (him/her) AMA (Against Medical Advice). (d.) Review of an incident report for Patient #1 dated 9/21/24 reported by N20 (Registered Nurse) indicated the following: Incident Date: 9/21/24 and Incident Time: 9:00 p.m. Time of the incident is approximate. Shift: Night. Location of Incident: 400 Unit hallway/Adult Unit. Patient precautions at the time of the incident? Yes. If yes, elopement. sexually acting out. Witnesses: Staff: (N34, Behavioral Health Technician) and (N35, Behavioral Health Technician). Type of Incident: Elopement and returned greater than 30 minutes. Facts of Summary Event: (Patient #1) crowded BHT and grabbed wrist fob and opened the emergency exit door to outside the building. 3. Review of Patient #3’s medical record indicated the following: (a.) Patient #3 was voluntarily admitted to the Adult Unit on 10/4/24 at 11:45 p.m., then admitted under an EDO dated 10/7/24 and discharged on 10/12/24. The patient had diagnoses that included, but were not limited to, major depressive disorder, single episode, severe without psychotic features and adverse effect of amphetamines. (b.) A review of Patient #3’s BEHAVIORAL HEALTH - PATIENT OBSERVATION SHEET dated on 10/11/24 indicated that Patient #3 was on low suicide risk precautions beginning on 10/4/24 at 11:59 p.m. (c.) A review of nurse’s note for Patient #3 dated 10/11/24 at 7:30 p.m. indicated the following: While in the courtyard, patient grabbed a bracelet from the BHT and used that to elope. Police and emergency contact notified. (d.) A review of a nurse’s note for Patient #3 dated 10/12/24 at 9:00 a.m. indicated the following: Police have been unable to locate the patient. They have checked the areas near the facility and have not located (him/her). Emergency contact has not had any contact with (him/her) at this time. (e.) A review of an incident report for Patient #3 dated 10/11/24 reported by N25 indicated the following: Incident Date: 10/11/24 and Incident Time: 7:00 p.m. Time of the incident is approximate. Shift: Day. Location of Incident: Courtyard Adult Unit. Main Party Involved Type: Patient. Patient precautions at the time of the incident? Yes. suicide. Witnesses: Staff: (N26) BHT. Type of Incident: Elopement: Not Returned. Facts of Summary Event: All patients were outside. Patient #3 ducked and grabbed staff’s arm. After ripping off the staff’s beacon (fob), (Patient #3) ran. Staff attempted to do a hold. (Patient #3) ran through the bushes and across the highway. 4. Review of Patient #4’s medical record indicated the following: (a.) Patient #4 was voluntarily admitted to the Adult Unit on 10/30/24 at 1:52 p.m. and discharged on 11/9/24. The patient had diagnoses that included, but were not limited to, schizoaffective disorder, bipolar type. (b.) A review of Patient #4’s BEHAVIORAL HEALTH - PATIENT OBSERVATION SHEET dated on 10/11/24 indicated that Patient #4 was not on precautions at time of elopement. (c.) A review of nurse’s note for Patient #4 dated 10/31/24 at 8:01 a.m. indicated the following: Patient eloped during this shift at approximately (6:10 a.m.). Unsure if patient was injured in the process of elopement as patient did not return and kept running. (d.) A review of a nurse’s note for Patient #4 dated 10/31/24 at 10:15 a.m. indicated the following: Pt was brought back to the facility by (police) without incidence. Pt. was unharmed and was returned to the unit without further attempts to elope. (e.) A review of a psychiatric evaluation for Patient #1 dated 10/31/24 at 2:30 p.m. indicated the following: Soon after (he/she) was admitted (he/she) became verbally aggressive got into an altercation with another patient, managed to kick open the fire escape door and took off into the night. Patient #1 was eventually brought back to intake by the police after a few hours and admitted to the unit. (f.) Review of an incident report for Patient #4 dated 10/31/24 reported by N28 indicated the following: Incident Date: 10/31/24 and Incident Time: 6:05 a.m. Time of the incident is approximate. Shift: Night. Location of Incident: 400 Hallway/Adult Unit. Main Party Involved Type: Patient. Patient precautions at the time of the incident? No. Suicide -low risk. Witnesses: Staff: (N30) RN and (N40) RN. Type of Incident: Elopement: Returned greater than 30 minutes. Facts of Summary Event: Patient #4 pushed the door at approximately 6:00 a.m. (N28) RN removed (Patient #4) from that area. Soon after, another patient came out of (his/her) room yelling due to being woke up. Both patients had to be separated to prevent physical altercation. While (N28) attempted to separate, (Patient #4) sprinted to the end of the hallway and out the exit door. Police located and returned (Patient #4) at 8:06 a.m. 5. Review of Patient #5’s medical record indicated the following: (a.) Patient #5 was voluntarily admitted to the facility on 10/22/24 at 5:39 p.m. and was a current patient. The patient had diagnoses that included, but were not limited to, major depressive disorder, recurrent severe without psychotic features and generalized anxiety disorder. (b.) A review of Patient #5’s BEHAVIORAL HEALTH - PATIENT OBSERVATION SHEET dated on 11/2/24 indicated that Patient #5 was on elopement and high suicide risk precautions beginning on 10/23/24 at 3:39 a.m. (c.) A review of nurse’s note for Patient #5 dated 11/2/24 at 10:03 a.m. indicated the following: Patient and two others formulated and executed a plan to choke a staff member, take their wrist band and escape. The patient was gone from the building for approximately 10 minutes. (d.) Review of incident report dated 11/2/24 at 8:40 a.m. indicated the following: Patients #5, 6 and 7 were ordered every 15 minute observations. Patients had come back from breakfast and were escorted into the noisy activity room. (N32, Behavioral Health Technician), was in the hallway talking with a patient, (N33, Behavioral Health Technician) was in the noisy activity room with the patients, and (N22, Registered Nurse) was in the medication room, getting ready for medication pass. (Patient #5) came out of the group room and into the hallway requesting to get something out of (his/her) room. (N32), the patient (he/she) was speaking with, and (Patient #5) walked down the hallway. At this time, (Patients #6 and 7) came out of the noisy activity room and down the hallway. After (Patients #5, 6 and 7) escaped through the hallway emergency exit door, the patient, (N32) was speaking with ran to get staff (N22) and (N33). 6. Review of Patient #6’s medical record indicated the following: (a.) Patient #6 was voluntarily admitted to the facility on 10/10/24 at 9:00 p.m. and discharged on 11/4/24. The patient had diagnoses that included, but were not limited to, major depressive disorder, recurrent unspecified and generalized anxiety disorder. (b.) A review of nurse’s note for Patient #6 dated 11/2/24 at 11:53 a.m. indicated the following: Patient and two others formulated and executed a plan to choke a staff member, take their wrist band and escape. The patient was gone from the building for approximately 5 minutes. (c.) Review of incident report dated 11/2/24 at 8:40 a.m. indicated the following: Patients #5, 6 and 7 were ordered every 15 minute observations. Patients had come back from breakfast and were escorted into the noisy activity room. (N32, Behavioral Health Technician), was in the hallway talking with a patient, (N33, Behavioral Health Technician) was in the noisy activity room with the patients, and (N22, Registered Nurse) was in the medication room, getting ready for medication pass. (Patient #5) came out of the group room and into the hallway requesting to get something out of (his/her) room. (N32), the patient (he/she) was speaking with, and (Patient #5) walked down the hallway. At this time, (Patients #6 and 7) came out of the noisy activity room and down the hallway. After (Patients #5, 6 and 7) escaped through the hallway emergency exit door, the patient (N32) was speaking with ran to get staff (N22) and (N33). 7. Review of Patient #7’s medical record indicated the following: (a.) Patient #7 was voluntarily admitted to the facility on 10/22/24 at 11:08 p.m. and discharged on 11/14/24. The patient had diagnoses that included, but were not limited to, major depressive disorder, recurrent, severe with psychotic symptoms and generalized anxiety disorder. (b.) A review of nurse’s note for Patient #7 dated 11/2/24 at 11:59 a.m. indicated the following: Patient and two others formulated and executed a plan to choke a staff member, take their wrist band and escape. The patient was gone from the building for approximately 5 minutes. (c.) A review of Patient #7’s BEHAVIORAL HEALTH - PATIENT OBSERVATION SHEET dated 11/3/24 indicated that Patient #7 also continued to be on fall precaution and high suicide risk precautions. The observation check sheet did not indicate that Patient #7 was on elopement precautions on 11/3/24. A review of Patient #7’s BEHAVIORAL HEALTH -PATIENT OBSERVATION SHEETS indicated that elopement precautions were added on 11/7/24 at 4:07 a.m. and discontinued on 11/7/24 at 10:26 a.m. and then added on 11/11/24 at 6:32 p.m. and were on the observation sheets for the patient until discharge on 11/14/24. (d.) Review of incident report dated 11/2/24 at 8:40 a.m. indicated the following: Patients #5, 6 and 7 were ordered every 15 minute observations. Patients had come back from breakfast and were escorted into the noisy activity room. (N32, Behavioral Health Technician), was in the hallway talking with a patient, (N33, Behavioral Health Technician) was in the noisy activity room with the patients, and (N22, Registered Nurse) was in the medication room, getting ready for medication pass. (Patient #5) came out of the group room and into the hallway requesting to get something out of (his/her) room. (N32), the patient (he/she) was speaking with, and (Patient #5) walked down the hallway. At this time, (Patients #6 and 7) came out of the noisy activity room and down the hallway. After (Patients #5, 6 and 7) escaped through the hallway emergency exit door, the patient (N32) was speaking with ran to get staff (N22) and (N33). 8. During an interview with A1 on 11/15/24 at approximately 2:00 p.m., A1 verified the medical record information for Patients #1, 3, 4, 5, 6 and 7.”

“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: 32952 Based on document review and interview, the facility failed to ensure adequate licensed nursing staff and other personnel to provide nursing care to all patients as needed. (Adult Inpatient Units and Adolescent Inpatient Unit) Findings include: 1. Facility policy titled “STAFFING PLAN FOR NURSING SERVICES”, last revised on 5/2024 indicated the following: “POLICY: The Staffing Plan for Nursing Services reflects specific service needs to meet patient care and organizational needs. GENERAL STAFFING GUIDELINES: The Staffing Plan has been developed to identify staffing needs based on the following criteria: * Acadia Safe Staffing Guidelines. * Patient population. * Average daily census. * Length of stay. * Speciality needs of patient population served/acuity. * Physical environment and available technology. * Type of patient care delivered system utilized. * Skill mix. * Competencies required. * Measurable outcomes of clinical care. Core Coverage: A. The minimum staffing needed for each skill level (RNs [Registered Nurses], LPNs [Licensed Practical Nurses], Behavioral Health Associates, others) is determined by the nurse-patient ratio guidelines and patient care needs of the population. Core coverage staffing plans should be considered guidelines. (See attached staffing grids by unit.). 2. A review of the staffing grid matrix for the Adult Inpatient Unit indicated the following: (a.) Day Shift: Census of 1 to 12 patients would require 1 RN (Registered Nurse). Census of 13 to 20 patients would require 2 RNs. Census of 1 to 10 and 13, 14, 15, 16 patients would require 1 BHT (Behavioral Health Technician). Census of 11, 12 and 17 to 20 patients would require 2 BHTs. (b.) Night Shift: Census of 1 to 20 patients would require 1 RN. Census of 1 to 14 patients would require 1 BHT. Census of 15 to 20 patients would require 2 BHTs. 3. A review of nurse staffing worksheets provided and signed by N31 on 11/14/24 for the time period of 9/21/24 through 9/22/24, 10/11/24 through 10/13/24, 10/30/24 through 11/14/24 for the Adult Inpatient Units indicated unit was short staffed for the 300 hall/Adult Unit for the following dates: (a.) On 11/2/24 for day shift, the census was 17 patients with 2 RNs and 1 BHT indicating the unit was short staffed by 1 BHT, based on the facility staffing grid/matrix. (b.) On 11/6/24 for day shift, the census was 19 patients with 1 RN and 2 BHT’s indicating the unit was short staffed by 1 RN, based on the facility staffing matrix. (c.) On 11/9/24 for day shift, the census was 17 patients with 2 RN’s and 1 BHT indicating the unit was short staffed by 1 BHT, based on the facility staffing matrix. (d.) On 11/14/24 for day shift, the census was 15 patients with 1 RN and 2 BHT’s indicating the unit was short staffed by 1 RN. based on the facility staffing matrix. 4. A review of nurse staffing worksheets provided and signed by N31 on 11/14/24 for the time period of 9/21/24 through 9/22/24, 10/11/24 through 10/13/24, 10/30/24 through 11/14/24 for the Adult Inpatient Units indicated unit was short staffed for the 400 hall/Adult Unit for the following dates: (a.) On 11/5/24 for day shift, the census was 15 patients with 1 RN and 2 BHT’s indicating the unit was short staffed by 1 RN, based on the facility staffing matrix. (b.) On 11/6/24 for day shift, the census was 17 patients with 1 RN and 2 BHT’s indicating the unit was short staffed by 1 RN, based on the facility staffing matrix. 5. A review of the staffing grid matrix for the Adolescent Inpatient Unit indicated the following: (a.) Day Shift: Census of 1 to 12 patients would require 1 RN. Census of 13 to 20 patients would require 2 RNs. Census of 1 to 9 patients would require 1 BHT. Census of 10 to 17 patients would require 2 BHTs. Census of 18 to 20 patients would require 3 BHTs. (b.) Night Shift: Census of 1 to 19 patients would require 1 RN. Census of 20 patients would require 2 RNs. Census of 1 to 11 patients would require 1 BHT. Census of 12 to 20 patients would require 2 BHTs. 6. A review of nurse staffing worksheets/assignment logs for the time period of 11/1/24 through 11/14/24 for the Adolescent Inpatient Unit indicated unit was short staffed for the 600 hall/Adult Unit for the following dates: (a.) On 11/3/24 for night shift, the census was 11 patients with 1 RN and 1 BHT indicating the unit was staffed at minimum and lacked an additional staff member to monitor the emergency exit door on the hall. (b.) On 11/5/24 for day shift, the census was 11 patients with 1 RN and 2 BHT’s indicating the unit was staffed at a minimum and lacked an additional staff member to monitor the emergency exit door on the hall. (c.) On 11/6/24 for day shift, the census was 14 patients with 1 RN and 3 BHT’s indicating the unit was short staffed by 1 RN, based on the facility staffing matrix. (d.) On 11/7/24 for day shift, the census was 13 patients with 1 RN and 3 BHT’s indicating the unit was short staffed by 1 RN, based on the facility staffing matrix. 7. During an interview with N31 (Registered Nurse/Chief Nursing Officer) on 11/14/24 beginning at 3:00 p.m., N31 verified the nurse staffing for the Adolescent Unit and Adult Units.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 32952 Based on document review and interview, the facility failed to ensure contracted nursing staff failed to obtain de-escalation and restraint certification for 2 of 16 personnel files reviewed. (N29, Registered Nurse/Agency and N34, Behavioral Health Technician/Agency) Findings include: 1. Facility policy titled “RN [Registered Nurse] Job Description” last revised on 1/1/2020 indicated the following: PURPOSE STATEMENT: “Responsible for providing professional nursing care to patients with a positive, empathetic, and professional attitude to foster a supportive and therapeutic environment. Recognize that patient safety is a top priority. LICENSES/DESIGNATIONS/CERTIFICATIONS: CPR [cardiopulmonary resuscitation] and de-escalation and restraint certification required (training available upon hire and offered by facility.)” 2. Facility policy titled “Behavioral Health Technician Associate III Job Description” last revised on 1/1/2020 indicated the following: PURPOSE STATEMENT: “Responsible for providing personal care services to patients at the facility under the direction of clinical or nursing leadership. ESSENTIAL FUNCTIONS: Applies de-escalation techniques to help manage patient’s emotions, behavior and participate in treatment and assist with seclusion and restraint when necessary. LICENSES/DESIGNATIONS/CERTIFICATIONS: CPR and de-escalation and restraint certification required (training available upon hire and offered by facility.)” 3. A review of personnel file for N29 (Registered Nurse/Agency)’s personnel file lacked documentation of general/department specific orientation, patient rights, Handle with Care, seclusion/restraint and elopement education/training. 4. A review of personnel file for N34 (Behavioral Health Technician/Agency)’s personnel file lacked documentation of patient rights, Handle with Care, seclusion/restraint and elopement education/training. 5. During an interview with A3 (Human Resources Director) on 11/14/24 beginning at 1:00 p.m., A3 verifed the personnel file information for N29 and N34.”