Stormont Vail Hospital

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 53828 Based on policy review, document review, record review, and staff interview, the hospital failed to ensure the protection and promotion of patients’ rights. This failure has the potential to adversely affect patient safety, dignity, and the quality of care. Findings Include: The hospital failed to ensure that informed consent documentation was completed in accordance with hospital policy by failing to obtain and document an informed decision signature for 3 of 26 patient records reviewed (refer to tag A-0131).”

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 53828 Based on policy review, document review, record review, and staff interview, the hospital failed to implement and maintain an effective discharge planning process. The cumulative effect of these failures has the potential to result in inadequate discharge planning to support safe transitions of care. Findings Include: 1. The hospital failed to ensure that a patient received appropriate referrals and discharge arrangements necessary to support the patient’s post-hospital medical needs in 1 of 26 patient records reviewed. (Refer to tag A-807). 2. The hospital failed to ensure that discharge planning information and education were provided, including instructions to a caregiver regarding referrals, outpatient follow-up, and the use and maintenance of medical equipment, for 1 of 26 patient records reviewed. (Refer to tag A-0808).”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 53828 Based on policy review, document review, record review, and staff interview, the hospital failed to ensure that informed consent was obtained prior to treatment or transfer in accordance with hospital policy for 3 of 26 (Patients 7, 10, and 16) patient records reviewed. This failure may result in patients not being fully informed of the risks and benefits before giving consent for procedures or transfer to another health care facility. Findings Include: Review of a hospital policy titled “Authorization and Consent” dated 05/06/25, showed that adults may provide verbal or phone acknowledgment of informed consent if they are “ ...not physically capable of signing due to physical disability or impairment ...” and the staff documents the circumstances that prevented the patient from signing. The policy also stated “ ...All consent in the healthcare setting should be ‘informed’ consent. Informed consent means that the patient’s (or surrogate’s) consent was based on receiving and understanding pertinent and meaningful information about the anticipated benefits, risks, alternatives to the proposed medical treatment and having their questions about those topics answered ...” Review of a hospital document titled “Consent to Surgical Operation or Other Procedure” showed that the informed consent the patients were asked to acknowledge stated “ ...My physician has discussed with me and I have also had the opportunity to ask questions and understand the following...” Review of a hospital policy titled “Inpatient Transfer to Equal or Higher Level of Care” dated 02/28/23 and last reviewed 02/09/26, showed that the hospital required providers to “ ...inform patient and/or family and obtain consent of the plan to transfer, and where (if known) they are going to be transferred ...” and required the patient’s primary nurse to “ ...verify informed consent with [Hospital A] Provider and complete Form 1238: Patient Request for Transfer or Refusal of Treatment ...” Patient 7 Review of Patient 7’s consent for CT-guided (non-invasive diagnostic imaging) left lung mass biopsy (tissue sample removal) and possible chest tube (flexible tube inserted to drain air and/or fluid) placement showed “verbal consent given” in place of the patient’s signature on 08/26/25 at 1:53 PM and was signed by 2 witnesses. Review of Patient 7’s medical record did not reveal any documentation of a physical disability or lack of capability to explain that verbal consent was obtained for the lung biopsy. Patient 10 Review of Patient 10’s consent for image-guided random renal (kidney) biopsy showed “Verbal Consent” in place of the patient’s signature on 12/15/25 at 10:39 AM and was signed by 2 witnesses. Review of Patient 10’s medical record did not reveal any documentation of a physical disability or lack of capability to explain that verbal consent was obtained for the renal biopsy. Patient 16 Review of Patient 16’s nursing documentation of “Transfer to Equal/Higher Level of Care” dated 11/23/25 at 9:15 AM showed that the patient was transported from Hospital A to Hospital B on 11/23/25 at 9:20 AM by ambulance. Review of Patient 16’s medical record showed that the record lacked “Form 1238: Patient Request for Transfer or Refusal of Treatment,” or any documentation of a hospital provider discussing the risks and benefits of transfer with Patient 16. Review of an electronic communication from Staff D, Regulatory Specialist, dated 06/23/26 at 4:11 PM, showed that the hospital had no signed consent for transfer for Patient 16. During an interview on 06/18/26 at 10:00 AM, Staff M, Registered Nurse (RN), stated that patients are regularly asked to acknowledge informed consent for certain interventional radiology procedures after they have been positioned for the procedure. Staff M stated that this leads to staff routinely obtaining verbal consent rather than the patient’s signature because the patient’s positioning is not conducive to signing the form. Staff M stated that obtaining verbal consent for the procedure, as was done for Patient 10, would be common because patients are positioned prone (on their abdomens) before informed consent is obtained. Staff M reported that RNs discuss planned procedures, risks, and benefits with patients if a provider has not done so before the patient completes the informed consent form. Staff M reported that some patients do not have an opportunity to visit with a provider about their procedure until after the patients have acknowledged informed consent, during the time-out (standardized pause taken for staff to verify information immediately before beginning a procedure). During an interview on 06/18/26 at 10:24 AM, Staff N, RN, stated that the nurses conduct the informed consent conversation with patients and obtain consent signatures for interventional radiology procedures with moderate sedation if the Nurse Practitioner has not already done so, and that patients can ask the provider questions immediately before starting the procedure, just before they do the time-out. Staff N stated that verbal consent is often obtained for kidney and lung biopsies due to patient positioning and confirmed that the acknowledgment of consent for the procedure Patient 10 had would have typically been verbal.”

“DISCHARGE PLANNING-EVALUATION CFR(s): §482.43(a)(2) Standard: Discharge Planning Evaluation (2)A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-hospital services, including, but not limited to hospice care services, post-hospital extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services. This Standard is not met as evidenced by: 53828 Based on policy review, record review, and interview, the hospital failed to ensure that a patient received appropriate referrals and discharge arrangements necessary to support the patient’s post-hospital medical needs for 1 of 26 patient records reviewed (Patient 12). This failure puts patients at risk of not receiving follow-up care and treatment, leading to adverse health outcomes and harm. Findings Include: Review of a Hospital Policy titled “Safe Discharge Planning - Patient Identification and Evaluation - Case Management, Social Work” dated 10/28/25 showed that “ ...When the patient is discharged, the hospital promptly provides the patient’s ... agencies, or outpatient services with necessary medical information in order to increase the likelihood of better patient outcomes after discharge ...” Patient 12 Review of Patient 12’s Case Management / Social Work Discharge Planning Evaluation dated 5/26/26 at 1:14 PM showed that the patient required assistance with bathing and ambulating (walking), and that the patient’s support system at home did not include anyone able to provide daily manual physical assistance. This evaluation also showed that a home health referral was sent by social work but was denied by the receiving agency, and that Patient 12 reported needing to include his/her spouse in choosing a different home health agency for the hospital to send the referral to. Patient 12’s medical record lacked any further documentation of the home health referral being completed. Review of Patient 12’s Discharge Summary signed by Staff R, Doctor of Osteopathy (DO), dated 05/26/26 at 2:35 PM, showed that outpatient urology follow-up was considered by Staff R, but lacked any additional documentation of discharge planning related to Patient 12 going home with a Foley catheter in place. . Review of Patient 12’s After Visit Summary dated 05/26/26 at 4:00 PM showed that no referrals or instructions for follow-up with urology or another provider related to the indwelling urinary catheter were included. Review of Patient 12’s medical records showed that the patient was discharged on 05/26/26 at 4:39 PM and readmitted on 05/29/26 at 2:54 PM. Patient 12’s readmission history and physical dated 5/29/26 at 4:36 PM noted that the patient had a Foley catheter in place. Review of Patient 12’s urine culture collected on 05/29/26 at 5:31 PM showed >100,000 CFU/mL Klebsiella pneumoniae (bacteria) and >100,000 CFU/mL Proteus mirabilis (bacteria ), requiring 11 days of treatment with levofloxacin and clindamycin (antibiotics). Review of Patient 12’s Neurosurgery Consult Note dated 5/30/26 at 12:56 PM showed that the patient’s urinary tract infection needed to be treated before the patient could have surgery. During an interview on 06/17/26 at 11:00 AM, Patient 12’s spouse reported that the patient did not receive any home health services between discharge on 05/26/26 and readmission on 05/29/26. Patient 12’s spouse denied being told that the patient would be discharged home with a Foley catheter, what home care would be required, or receiving any follow-up appointment instructions regarding the patient’s Foley catheter, either verbally or in writing. During an interview on 06/18/26 at 8:40 AM, Staff L, Registered Nurse (RN), Director of Case Management, reported that Patient 12’s Home Health referral was still pending when the patient was discharged to home and that the hospital’s transitional care team had a phone conversation with Patient 12’s spouse on 05/27/26, the day after the patient’s discharge, and advised the patient’s spouse to contact the patient’s primary care provider to have them arrange for the services. Staff L also confirmed that there was no mention of indwelling urinary catheter care, education, or supplies in Patient 12’s home health referral. Staff L confirmed that Patient 12’s home health referral from discharge on 05/26/26 remained pending at the time of the patient’s readmission on 05/29/26. During an interview on 06/22/26 at 9:30 AM, Staff R, DO, the physician who discharged Patient 12, stated that Patient 12 would have needed to follow up with a urologist about the Foley catheter within 1-2 weeks after discharge, but denied having arranged for urology follow-up because the patient was not already established with a urologist. Staff R reported preferring that the patient’s primary care arrange for the urology referral. Staff R reported that Patient 12 denied being aware that Patient 12’s home health referral had not been completed before the patient was discharged.”

“DISCHARGE PLANNING EVALUATION CFR(s): The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). This Standard is not met as evidenced by: 53828 Based on policy review, document review, record review, and interview, the hospital failed to ensure that discharge planning information and education were provided, including instructions to a caregiver regarding referrals, outpatient follow-up, and the use and maintenance of medical equipment, for 1 of 26 patient records reviewed (Patient 12). This failure places the patient at risk for inadequate post-acute care, improper equipment use, and adverse health outcomes after discharge. Findings Include: Review of a Hospital Policy titled “Safe Discharge Planning - Patient Identification and Evaluation - Case Management, Social Work” dated 10/28/25 showed that “ ...All evaluations, education, and discharge- planning interventions must be documented in the patient record ... the discharge plan must include ... Whether the patient is able to provide some or all of the required post-discharge self-care, and if not, whether the patient has family or friends available who are willing and able to provide the required care at the times it would be needed and are willing to be trained by the hospital sufficiently to provide the required care ...” Review of undated hospital documents titled “Foley Catheter Care, Adult” and “Indwelling Urinary Catheter Bag Care, Adult” showed the hospital had written home care education available for distribution to patients being discharged home with an indwelling urinary catheter. Patient 12 Review of Patient 12’s medical records dated 05/25/26 at 2:13 AM showed that Patient 12 had a normal urinalysis (urine test) on 05/25/26. Patient 12’s medical record showed that a Foley (indwelling urinary catheter) was placed on 05/25/26 at 6:35 AM, and Patient 12 was discharged home on 05/26/26 at 4:39 PM. Patient 12’s nurses documented that the patient was confused on 05/25/26 at 2:14 AM, 2:30 AM, 4:30 AM, 7:00 AM, and 9:16 AM. Review of Patient 12’s “Family/Caregiver Questions” dated 05/25/26 at 7:29 PM showed that the patient’s spouse advised the hospital that Patient 12 was confused and had a caregiver. Review of Patient 12’s shift assessment dated 05/26/26 at 7:16 AM showed that the patient had impaired vision in both eyes and impaired hearing in both ears. The medical record lacked documentation of the status of Patient 12’s urinary catheter at the time of discharge or evidence of any provider follow-up instructions, home care instructions, or education regarding indwelling urinary catheters being provided to the patient or caregivers, either verbally or in writing. Patient 12’s medical record also lacked evidence of discharge education or instructions related to the patient’s home health referral. Review of Patient 12’s medical record dated 05/29/26 at 2:54 PM showed that upon readmission, Patient 12’s urine culture collected on 05/29/26 at 5:31 PM showed >100,000 CFU/mL Klebsiella pneumoniae (bacteria) and >100,000 CFU/mL Proteus mirabilis (bacteria), requiring 11 days of treatment with levofloxacin and clindamycin (antibiotics). Review of Patient 12’s Neurosurgery Consult Note dated 5/30/26 at 12:56 PM showed that the patient’s urinary tract infection needed to be treated before the patient could have surgery. During an interview on 06/17/26 at 11:00 AM, Patient 12’s spouse stated that Patient 12 was discharged home from the hospital on 05/26/26 with a Foley urinary catheter in place. Patient 12’s spouse denied that any family members or caregivers were at the hospital with Patient 12 that day and stated that the patient was transported home in a bus from the independent living facility where they live. Patient 12’s spouse denied being given any information or education related to indwelling urinary catheter care by the hospital and stated that no one at the hospital advised Patient 12’s family that a catheter would remain in place at home or why, despite Patient 12 being confused and unable to relay the information to caregivers. Patient 12’s spouse stated that the patient was confused and did not remember receiving education about caring for the Foley catheter. During an interview on 06/18/26 at 8:40 AM, Staff L, Registered Nurse (RN), Director of Case Management, stated that there was nothing related to an indwelling urinary catheter in Patient 12’s home health referral, and that the home health referral was still pending at the time of Patient 12’s discharge. Staff L reported that on 05/27/26, the day after the patient’s discharge, when Patient 12’s spouse asked the hospital’s transitional care team questions about the patient’s referrals, the team advised the spouse to contact the patient’s primary care provider for assistance. During an interview on 06/22/26 at 9:30 AM, Staff R, the Doctor of Osteopathy (DO) who discharged Patient 12, stated that Patient 12 was intentionally discharged home with a Foley catheter in place due to urinary retention. Staff R stated that the floor nurses are expected to provide education on urinary catheter care, cleaning, and emptying to patients who are going home with a catheter in, and that if the patient is confused, the nurses are also expected to communicate discharge education and instructions to the patient’s caregiver. Staff R stated that assistance with Foley care could also be included in home health orders. Staff R stated that in addition to going home with a new Foley, Patient 12 was to get physical therapy through home health services. Staff R reported believing that case management had advised Patient 12’s spouse that the patient was being discharged home, but denied being aware that the patient’s home health referral had not been completed prior to discharge. During an interview on 06/22/26 at 12:55 PM, Staff U, the RN caring for Patient 12 at the time of discharge, reported that they typically ensured that patients going home with a Foley catheter could demonstrate how to care for and drain it correctly. Staff U stated that if the patient could not understand the training, he/she would usually make efforts to train a caregiver or family member. Staff U denied providing documentation about home care education or supplies in patients’ medical records. Staff U denied discussing Patient 12’s discharge plan or education with anyone other than the patient because no caregiver was present at the hospital on the day of discharge. Staff U stated that Patient 12’s written discharge education packet was smaller than most because there was no virtual nurse that day, and they normally compile the discharge packets for patients. Staff U was unable to identify any written home care instructions regarding Foley catheters provided to Patient 12. Staff U reported having provided Foley catheter care instructions to Patient 12 and having Patient 12 demonstrate the tasks, but acknowledged that Patient 12 needed prompting on tasks and likely would have required additional repetition to retain the education. Staff U reported that Patient 12 seemed uncomfortable with going home with the Foley and asked whether it would stay in when getting into the wheelchair to leave the hospital.”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 47234 Based on policy review, document review, observation, and interview, the Hospital failed to ensure patients were informed that behavioral health care may include the use of video surveillance for 6 (Patient 1, 2, 3, 4, 5, and 6) of 6 sampled patients. This deficient practice posed a risk of violating personal privacy rights for any patient that received services at this hospital. Findings include: Review of a hospital policy titled, “Behavioral Health Inpatient Video Monitoring,” revised 09/30/2023, showed, “ ...The patient and/or guardian will be informed that video monitoring equipment is turned on to ensure patient safety while hospitalized...” Review of a hospital policy titled, “Patient Rights and Responsibilities,” revised 09/07/21, showed, “ ...[Above Named Hospital] respects, protects and promotes patient rights by: ... Respecting the patient’s rights to personal privacy ...” Review of the hospital’s admission documents/forms/consents, “Behavioral Health Services Patient Acknowledgements”, “Treatment Authorization and Related Agreements”, “Legal Rights of Patients”, “Admission as a Voluntary Patient”, and “Consent to Treatment and Acknowledgment of Notice of Privacy Practices,” failed to show that behavioral health care may include the use of video surveillance for patient monitoring. Patient 1 Review of Patient 1’s medical record showed a 47-year-old admitted on 11/28/24 at 1:43 AM with a diagnosis of Schizoaffective Disorder Bipolar Type (experiences symptoms of delusions, hallucinations, disorganized speech, grossly disorganized behavior) and Suicidal Ideation (thinking about or planning suicide). Patient 2 Review of Patient 2’s medical record showed a 56-year-old admitted on 11/15/24 at 12:18 PM with a diagnosis of Paranoid Schizophrenia (a serious mental disorder in which people interpret reality abnormally. Patient 3 Review of Patient 3’s medical record showed a 39-year-old admitted on 10/25/24 at 3:44 PM with a diagnosis of Unspecified Mood Disorder (depressive disorder can cause clinically significant distress or impairment in social, occupational or other important areas of functioning) and Unspecified Anxiety Disorder (anxiety or phobias that don’t meet the exact criteria for any other anxiety disorders but are significant enough to be distressing and disruptive). Patient 4 Review of Patient 4 medical record showed a 21-year-old admitted on 08/28/24 at 7:27 PM with a diagnosis of depression (disorder where symptoms of sadness, hopelessness, or loneliness occur frequently and impair daily living). Patient 5 Review of Patient 5’s medical record showed, a 17-year-old admitted on 12/09/24 at 7:07 PM with a diagnosis of Major Depressive Disorder, recurrent episode with psychotic features (disorder where symptoms of sadness, hopelessness, or loneliness occur frequently and impair daily living. Additions of psychotic features during these depressive episodes can include hallucinations, excess energy[mania], fear of others [paranoia] and/or magical or impaired thinking [delusions]). Patient had a history of several suicide attempts, suicidal ideation, chronic pain, depression, anxiety, substance abuse, and auditory and visual hallucinations. Review of hospital consent for treatment failed to show patient and/or guardian was informed of video monitoring while hospitalized. Patient 6 Review of Patient 6’s medical record showed a 15-year-old admitted on 09/30/24 at 7:15 PM with a diagnosis of Disruptive Mood Dysregulation Disorder (a disorder in children that causes an inappropriate response to anger). Patient 6 had a history of suicide attempts and suicidal ideation. Review of the medical records for Patients 1-6 failed to show documented evidence that any patient and/or patient representative was informed or acknowledged that video surveillance may be used during patient monitoring. An observation on 12/18/24 at 1:15 PM of the Behavioral Health Adolescent/Child nursing station showed a video monitor of a live feed in all patient rooms. During an interview on 12/18/24 at 1:15 PM, Staff W, Patient Care Technician (PCT), stated, “We video monitor in all the patient rooms at all times.” During an interview on 12/18/24 at 1:10 PM, Staff C, Director of Risk Management, confirmed that the hospital does not inform patients of possible video monitoring during their hospital stay.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 45841 Based on observation, interview, record review, and facility policy review, the facility failed to protect and promote each patient’s rights for 4 of 4 (Patients 4, 6, 7, and 8) patients reviewed for restraints. Findings Include: 1. The hospital failed to identify hand mitts as a restraint, even though the hand mitts greatly reduced the patient’s ability to use their hands and the patient would not be able to easily remove the mitts in the same manner they were applied by the staff. Specifically, this deficient practice resulted in the staff’s failure to obtain restraint orders, perform restraint assessments, and conduct the restraint monitoring required when physical restraints were utilized. (Refer to A-0161) 2. The hospital failed to ensure restraints were used only in accordance with a physician’s or other authorized licensed practitioner’s order. Specifically, this deficient practice had the likelihood of resulting in the inappropriate use of restraints. (Refer to A-0168)”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(C) A restraint does not include devices, such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets, or other methods that involve the physical holding of a patient for the purpose of conducting routine physical examinations or tests, or to protect the patient from falling out of bed, or to permit the patient to participate in activities without the risk of physical harm (this does not include a physical escort) This Standard is not met as evidenced by: 45841 Based on observation, interview, record review, and facility policy review, the facility failed to identify hand mitts as a restraint, even though the hand mitts greatly reduced the patient’s ability to use their hands and the patient would not be able to easily remove the hand mitts in the same manner they were applied by the staff for 1 (Patient 8) of 1 patient observed with hand mitts. Specifically, this deficient practice resulted in the staff’s failure to obtain restraint orders, perform restraint assessments, and conduct the restraint monitoring required when physical restraints were utilized. Findings Include: A facility policy titled, “Patient Rights and Responsibilities,” revised 09/07/21, revealed the section titled “Patient Rights” indicated “9. The right to be free from corporal punishment, restraint or seclusion of any form.” A facility policy titled, “Standard Process Description: Restraint initiation, orders and documentation,” revised 02/27/23, revealed the section titled “Common medical devices and intervention” indicated “Hand mitts would no [sic] be considered a restraint as long as the device is easily removed by a patient.” The policy also indicated, “Hand mitts that are pinned or attached to the bedding, or applied so tightly that the patient’s hand or fingers are immobilized, or if the mitts are so bulky that the patient’s ability to use their hands is greatly reduced, would be considered a restraint.” A facility policy titled, “Restraints and Seclusion Patient Care Management Policy,” revised 03/06/23, revealed the section titled “Definitions” indicated “Non-violent Behavior: behavior that threatens a patient’s safety, healing and well-being by pulling on or removing lines, tubes, and medical devices that are necessary for care of treatment.” The policy revealed the section titled “Initiating Restraints/Seclusion,” included “1. A physician order is required to initiate restraints or seclusion. EXCEPTION: during an emergency event, e.g. [exempli gratia, for example] self-extubation. In these events, the RN [registered nurse] may initiate restraints and then obtain an order immediately.” The policy revealed, “3. The physician order includes: a. Indication for restraint/seclusion b. Type of restraint c. Duration for use of restraint/seclusion.” The policy revealed, “Maximum duration for patient in restraints for non-violent restraint should not exceed 24 hours.” The policy revealed the section titled “Face to Face Assessment,” indicated “Required assessment and monitoring times vary depending on type of restraint/seclusion ordered. 1. Non-Violent restraints a. Every two (2) hours.” During observation on 10/02/24 at 4:22 PM, Patient 8 was observed in the medical intensive care unit (MICU) with bilateral hand mitts applied. The patient was observed in bed and appeared to be sedated. The mitts were observed closed on the top. During a concurrent interview, RN 12 stated that Patient 8 had mitts on because of the patient’s impulsivity to pull at their medical devices. RN 12 stated Patient 8 could follow commands at times but at other times the patient could not. RN 12 stated that the mitts were open when Patient 8’s family was at the bedside, so the family was able to hold the patient’s hand, but, after the family left, staff closed the top of the mitts. RN 12 stated they liked to keep the mitts open when possible because Patient 8’s hands become sweaty and “smelly” when the mitts were closed. RN 12 stated they performed circulation checks every couple of hours. RN 12 stated the mitts were helpful because they were “least restrictive,” and they were “not a restraint.” Review of Patient 8’s “Hospitalist History and Physical,” dated 10/01/24, revealed Patient 8 was admitted on 10/01/24 for cardiac arrest. Review of Patient 8’s “Safety Interventions” flowsheet revealed that Patient 8 had mittens documented for the first time on 10/01/24 at 8:00 PM. Patient 8’s flowsheets revealed mitts were documented again on 10/02/24 at 8:00 AM, 10:00 AM, 12:00 PM, 12:26 PM, and 2:00 PM. Further review of Patient 8’s medical record revealed no evidence of an order for restraints, restraint documentation, or restraint assessments. During an interview on 10/02/24 at 9:32 AM, RN 3 stated that orders were needed for soft restraints, any locked restraints, or anything that required the physician to assess the patient within a certain amount of time. RN 3 stated the mitts utilized at the facility were not considered restraints. RN 3 stated the mitts slipped on the patient, and there was a closure strip at the base of the mitt because they were one-size-fits-all. RN 3 stated the mitts opened at the top and could be left open, but there was also a cover to close the top. During an interview on 10/02/24 at 2:07 PM, Clinical Simulation Educator (CSE) 11 stated that restraint classes were provided for most patient-facing staff. CSE 11 stated nurses also received education during skills class. CSE 11 stated staff were taught how to apply mitts properly and were educated on how the policy did not consider mitts restraints and did not require the same physician face-to-face as restraints. CSE 11 stated the use of mitts still needed to be documented. CSE 11 stated she believed the mitts were documented under restraints but only that the mitts were on or off. CSE 11 stated the staff education on application of mitts included how to leave two finger widths of space when securing the mitts. CSE 11 stated staff were shown how to close the top of the mitts, but the mitts did not have to be closed. CSE 11 stated she could be wrong and would follow up with someone. CSE 11 stated her manager had responded to a message and told her that staff were educated to close the tops of the mitts. During an interview on 10/02/24 at 2:09 PM, the DRM requested CSE 11 to get clarification on mitt education including the top being closed because, if they were closed, that “would be a restraint.” During an interview on 10/02/24 at 3:16 PM, CSE 11 stated the clarification for closed or open mitts was based on what was the least necessary for the patient. CSE 11 stated there was nothing in the policy that specifically stated that closed mitts were a restraint. During an interview on 10/02/24 at 4:03 PM, RN 4 stated that she had personally utilized mitts on a patient in the Emergency Department (ED). RN 4 stated the mitts she had utilized had not required an order in the past, but she did not know if that policy had changed. RN 4 stated having the mitts open or closed on the top would depend on the goal of the mitts and how they were applied. RN 4 stated, if she was at the point of putting mitts on a patient, the goal would to be to apply the mitts closed because, at that point, the patient’s safety was kept in mind, and they were applying the mitts so that the patient was prevented from pulling out any necessary medical devices. During an interview on 10/03/24 at 12:55 PM, RN 12 stated that 10/02/24 was his first day as Patient 8’s nurse. RN 12 stated Patient 8 had mitts on when he took over the patient’s care. RN 12 stated his “best guess” was that the mitts were on Patient 8 for “possibly” 12 to 16 hours prior to him taking over the patient’s care. RN 12 stated the mitts were able to come off once the patient was extubated. RN 12 stated the only alternative to the mitts would have been to use wrist restraints, but those were more restrictive. RN 12 stated there were no non-restraint alternatives to the mitts. RN 12 stated he was not qualified to say if the mitts were a restraint or not. RN 12 stated patients could not do things such as utilize the call light, use the phone, or make a call if the mitts were closed on the top. RN 12 stated, because mitts were not a restraint, they would not be documented under the restraint flowsheet and would not require a provider’s order. RN 12 stated he could not recall when mitts were determined to not be a restraint anymore.”

“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: 45841 Based on interview, record review, and facility policy review, the Hospital failed to ensure restraints were used only in accordance with a physician’s or other authorized licensed practitioner’s order for 3 of 4 (Patients 4, 6, and 7) patients reviewed for restraints. Specifically, this deficient practice had the likelihood of resulting in the inappropriate use of restraints. Findings Include: A facility policy titled, “Restraints and Seclusion Patient Care Management Policy,” revised 03/06/23, revealed the section titled, “Initiating Restraints/Seclusion,” included “1. A physician order is required to initiate restraints or seclusion. EXCEPTION: during an emergency event, e.g. [for example] self-extubation. In these events, the RN [registered nurse] may initiate restraints and then obtain an order immediately.” The policy also indicated, “3. The physician order includes: a. Indication for restraint/seclusion b. Type of restraint c. Duration for use of restraint/seclusion.” Patient 4 Review of Patient 4’s “Hospitalist History and Physical,” dated 09/01/24, revealed Patient 4 was admitted to the hospital on 09/01/24 for respiratory distress. Review of Patient 4’s “Restraint Type” flowsheet revealed Patient 4 had non-violent restraints on 09/05/24 at 2:00 PM and 4:00 PM. The record revealed the type of non-violent restraint was not documented. Review of Patient 4’s “Reason for Restraint” flowsheet, dated 09/05/24 at 2:00 PM and 4:00 PM, revealed staff documented Patient 4 was pulling at their nasogastric tube. Further review of Patient 4’s medical record did not reveal an order for restraints. During an interview on 10/01/24 at 1:34 PM, Quality Program Manager (QPM) 7 stated that they did not see reference to the non-violent restraints in medical record notes for Patient 4. QPM 7 stated that, if the patient were in mitts, there would not have needed to be an order. QPM 7 stated that the type of restraint should have been documented in the flowsheet, and it was unknown what type of restraint it was, because all that was documented was non-violent and there was no order found. Patient 6 Review of Patient 6’s “Hospitalist History and Physical,” dated 09/18/24, revealed Patient 6 was admitted on 09/17/24 for aggressive behavior. Review of Patient 6’s “Violent Behavior Restraint Adult” order, dated 09/17/24 at 11:32 PM, revealed a physical hold restraint was ordered for Patient 6 due to aggression and was continuous for three hours. Review of Patient 6’s “Four Way Locking” flowsheet revealed Patient 6 had four-way locking restraint started continuously on 09/17/24 at 11:45 PM until being discontinued on 09/18/24 at 1:30 AM. A physician’s order for Patient 6, dated 09/18/24 at 12:31 AM, indicated a 5 milligram (mg) injection of midazolam (a benzodiazepine used for sedation). The record indicated the midazolam was administered on 09/18/24 at 12:40 AM. A “Chemical Restraint” flowsheet revealed Patient 6 had a chemical restraint started on 09/18/24 at 12:40 AM and discontinued on 09/18/24 at 1:30 AM. Further review of Patient 6’s record did not reveal an order for either the chemical restraint or the four-way locking restraints and no documentation of the physical hold restraint. During an interview on 10/01/24 at 1:14 PM, Quality Program Manager (QPM) 7 stated that there was no restraint documentation for a physical hold for Patient 6. QPM 7 stated that there was no order for a chemical restraint or four-point locked restraints. QPM 7 stated that the only order was for a physical hold. QPM 7 stated that midazolam was administered at 12:40 AM, the same time as the chemical restraint was documented on the restraint flowsheet, but it did not specify in the order that the midazolam was for a chemical restraint. QPM 7 stated that the assumption could be that the nurse documented a chemical restraint for Patient 6 because that was when they medicated the patient, but there was no order for a chemical restraint. QPM 7 stated that it could have also been confusion on the provider’s part. During an interview on 10/02/24 at 4:03 PM, Registered Nurse (RN) 4 stated that four-point restraints did require an order. RN 4 stated that she was not as familiar with the policy for chemical restraints, but for a nurse to give it, the doctor would need to put the order in. RN 4 stated that she did not recall if the order for a chemical restraint specified chemical restraint or just the medication, but, if she needed to clarity, she could ask the provider. RN 4 stated that there was a spot in the record to document restraints, which was where a physical hold restraint would be documented. Patient 7 Review of Patient 7’s “ED [Emergency Department] Provider Note[s],” dated 08/16/24, revealed Patient 7 was admitted for altered mental status. Patient 7’s “ED Notes,” dated 08/17/24 at 5:45 AM, revealed Patient 7 continued to yell and kick staff. The notes revealed Patient 7 was physically held by staff members to restrain the patient from assaulting staff. The notes revealed the ED provider was at Patient 7’s bedside, and an order for four-point restraints was placed. Review of Patient 7’s “Violent Behavior Restraint Adult” order, dated 08/17/24 at 5:55 AM, revealed locking restraints were ordered for Patient 7 due to the patient being combative and violent. The record indicated the order was continuous for three hours. Review of Patient 7’s “Restraint Type” flowsheet revealed Patient 7 was placed in violent restraints on 08/17/24 at 5:50 AM. The record did not indicate what type of violent restraint was used for Patient 7. Further review of Patient 7’s record revealed there was no order for a physical hold restraint. During an interview on 10/01/24 at 1:45 PM, Quality Program Manager (QPM) 7 stated that restraint documentation for Patient 7 did not indicate what type of violent restraints the resident was placed in. QPM 7 stated tthat it appeared the nurse did not open that section of documentation. QPM 7 stated that there was no order or restraint documentation for a physical hold for Patient 7, and based on the wording of the nurse’s note they would expect to see one. QPM 7 stated that if the note had been worded that the patient had to be held for the restraints to be applied, they would not expect to see an order or documentation of a physical hold. QPM 7 stated based on the nurse’s note, “There are missing pieces.””

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 47234 Based on document review, record review, policy review and interview the hospital failed to ensure the emergency medical treatment and labor act (EMTALA) requirements were met by failing to provide an appropriate medical screening exam (MSE) and failing to provide stabilizing treatment for patients who presented to the emergency department seeking emergency medical care for an emergency medical condition (EMC). Failure to provide an appropriate MSE and appropriate transfer places patients at risk for unidentified emergency medical conditions resulting harm and injury up to an including death. Findings Include: Review of a document titled, “Medical Staff Rules and Regulations,” Revised 09/2023, “ ...Each member of the medical staff shall comply with these medical policies related to Emergency Medical Treatment and Labor Act (EMTALA) ... The Medical Screening Examination required by EMTALA may be conducted by a physician who is a member of the Health Center’s active or limited active Medical Staff or other qualified medical personnel ...” Review of a policy titled “Emergency Medical Treatment and Active Labor Act (EMTALA) Screening-Treatment-Transfer and On-Call Roster Policy” revised 02/28/24 showed, “ ... Stormont Vail Health (“SVH”) shall comply with federal law by providing, within its capabilities, to each person who comes to the ED an appropriate medical screening examination to determine whether the individual has an emergency medical condition and to provide necessary stabilizing treatment ... Emergency Medical Condition. An emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: ...2. Serious impairment of bodily functions; or 3. Serious dysfunction of any bodily organ or part ...Hospital Property. Hospital property includes SVH’s main buildings, the physical area immediately adjacent to main buildings, other areas and structures that are not strictly contiguous with the main buildings but are located within two hundred fifty (250) yards of the main buildings. This definition includes parking lots, sidewalks, and driveways, but excludes other areas or structures that are not part of SVH, such as physician offices, or other entities that participate separately under Medicare, or non-medical facilities. Medical Screening Examination. A medical screening examination is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether an emergency medical condition exists or whether a woman is in labor. It is more extensive than an initial triage assessment that determines the order in which individuals coming to the ED will be seen ... Stabilized. With respect to an emergency medical condition, stabilized means that (i) within reasonable clinical confidence, the emergency medical condition has been resolved; (ii) that no material deterioration of the condition is likely, within reasonable medical probability ...For purposes of an individual with a psychiatric condition, the individual is considered to be stabilized when he/she is no longer considered to be a threat to himself/herself or to others ...1. Medical Screening Examination. SVH shall provide a medical screening examination to each individual who comes to the ED. The extensiveness of the medical screening examination shall be based upon the medical judgment of the qualified medical personnel performing the medical screening examination. All ancillary services routinely available in the ED shall be made available to each individual who comes to the ED. 2. Individuals who come to a location other than SVH’s ED. Individuals who Come to hospital property at a location other than at the ED who require a medical screening examination in accordance with Section 1 above, shall be transported or escorted to the ED for a medical screening examination and stabilizing treatment as soon as possible unless it would be more appropriate in the circumstances: to provide an examination and/or treatment in another location on the hospital’s property; or to request ED personnel to come to the individual ... Individuals coming to the ED shall not be discharged without having completed a medical screening examination unless the individual or his/her legal representative refuses to consent to such examination, and the refusal is properly documented. Review of a policy titled, “Suicide Risk Reduction - ED” Dated 07/15/20 showed, “ ...Process Description: Suicide Risk Reduction Procedure for Emergency Room Patients ...Key Points 1. Patient identified as a Suicide Risk using the Columbia assessment in triage. Cycle Time 2 minutes. Reasons 1. All patients in the Emergency Room are screen for suicide risk using the Columbia ...6. Qualified staff will accompany patient from one area of the hospital to another. Cycle Time 2-3 minutes ...6. Continuous monitoring by qualified staff is required to reduce risk of harm to the patient ...” Review of a policy titled “Suicide Prevention Patient Care Management Policy” revised 04/05/23 showed “POLICY: It is the policy of Stormont Vail Health (SVH) to take steps to identify patients who are at risk for suicide and implement strategies to provide a safe and secure environment while they are in our care. Patients who have been identified at risk will have safety measures implemented to monitor their safety ...Safety Measures: ...High Risk; High Risk and violent/aggressive a. Consider psychiatric safe room assigned ... Notify Attending Physician and Charge Nurse. PATIENT EDUCATION: 1. Education the patient on the plan of care. Include family and significant others if available and ...3. Educate patient about a safety plan to help the patient after discharge and develop the plan with the patient 4. Provide mental health resources at discharge with follow up care as indicated to include the suicide hotline. REPORTABLE CONDITIONS: clinically 1. Change in level of consciousness, behavior, speech, ability to move 2. Self-inflicted injuries 3. Openly threatening to commit suicide 4. Making passive suicidal statements “When I’m gone”, statements of being a burden or feeling hopeless appropriate ...6. Sudden change in mood or behavior - sudden compliance or increased irritability/anger ...8. Isolating behaviors- refusing to talk, making dismissive statements i.e. “Whatever, I don’t care, just leave me alone, doesn’t matter” ...11. Concerns expressed by patient/family. DOCUMENTATION: 1. Complete the Columbia Suicide Severity Rating Scale according to department Protocol. ...7. The discharge safety plan will be completed for high risk patient prior to discharge. If completed on paper a copy will be scanned into the EMR and the original given to the patient. 8. Provide mental health resources and follow up appointments at discharge with as indicated to include the suicide hotline ... Review of a hospital policy titled, “Restricting a Patient’s Discharge” Review/Revised 4/10/23 showed, “ ...POLICY / PURPOSE: The purpose of this policy is to clarify the legal standards and processes that apply when attempting to restrict a patient’s discharge and to “retain” or “detain” them in order to provide healthcare services. Stormont Vail Health (SVH) strives to provide high quality care that respects the patient’s right to autonomous decision-making while effectively addressing situations that may present an imminent risk of harm to the patient or others due to a serious mental health or medical condition ... POLICY STATEMENTS: A. PREVENTING A PATIENT’S DISCHARGE 1. The preventing (“detaining”) of a patient from leaving a treatment facility constitutes a significant infringement and restriction on their freedoms. 2. Kansas statutes allow a treatment facility to “detain” a patient only in specific situations for “emergency observation” when the patient meets the statutory criteria for involuntary civil commitment for mental illness, which includes the presence of an imminent threat of harm to self or others. Consequently, detention often involves the use of restraints and /or seclusion. 3. The retention of a patient who lacks capacity but does not meet the statutory criteria for involuntary commitment for mental illness, involves various methods to encourage the patient to remain, including, persuasion, de-escalation, and redirection ...C. PATIENTS WITHOUT DECISIONAL CAPACITY 1. Involuntary Civil Commitment The involuntary civil commitment of a patient requires the following four criteria to be met. The patient: 1. must suffer from a mental disorder to the extent that they need immediate treatment; AND 2. lack the capacity to make an informed decision about their treatment (i.e. due to the patient’s mental health disorder, demonstrate that, despite conscientious efforts at explanation, the patient cannot understand the nature and effects of their hospitalization or treatment as evidenced by an inability to weigh the possible risk and benefits and to make a decision that aligns with their values); AND 3. have a treatable mental illness other than alcohol/substance abuse, anti-social personality disorder, intellectual disability, organic personality syndrome or an organic mental disorder; AND 4. pose an imminent threat that the patient is reasonably likely to cause harm to self and/or others. The legal definition of imminent threat is that which is certain, immediate and impending vs. something that might happen or might occur in the future. When a patient meets all of the above criteria and a physician desires to initiate the involuntary civil commitment process, the physician is to consult Risk Management for review and mutual approval. Appropriate planning and personnel resources will need to be arranged due to the fact that the detention period can generally take between 48-72+ hours to complete the process and transfer the patient to an appropriate mental health institution. If approved, the physician is to place a Mental Health Order in the chart to detain the patient.4 The order should generally contain or accompany an order for restraints and/or seclusion given the presence of imminent harm involving the patient. 5 The physician must then complete a written application for emergency observation of the patient pursuant to Kansas Statute 59-2954(c) ...” Review of the Kansas State Statute: 59-2954. Emergency observation and treatment; authority of treatment facility’s procedure. (a) A treatment facility may admit and detain any person for emergency observation and treatment upon an ex parte emergency custody order issued by a district court pursuant to K.S.A. 59-2958 and amendments thereto ...(c) A treatment facility may admit and detain any person presented for emergency observation and treatment upon the written application of any individual, except that a state psychiatric hospital shall not admit and detain any such person, unless a written statement from a qualified mental health professional authorizing such admission to a state psychiatric hospital has been obtained. The application shall state: ...(3) the applicant’s belief that the person may be a mentally ill person subject to involuntary commitment and because of the person’s mental illness is likely to cause harm to self or others if not immediately detained; ...” Review of a policy titled, “Visitor Occurrence Reporting” Review/Revised 05/11/23 showed, “Purpose: To support effective management of visitor accidents and incidents by assuring that such events are accurately recognized, responded to, reported, documented and evaluated to: o Assure that the immediate security, safety and information needs of visitors involved in events are met ...Definitions: Visitor Incident: Any unusual event not consistent with the routine operations of SVH that involves a visitor including, but not limited to: accidents or falls (with or without injury) ... Visitor: Any individual who is present on property owned or leased by Stormont Vail Health who is not currently registered as a patient, acting as an employee or performing assigned volunteer duties on behalf of Stormont Vail Health ...Procedure: 1. In the event of an incident that involves an accident, the highest priority is to care for the individual(s) involved ... 2. As appropriate, the individual may be offered the opportunity to be registered as a patient to receive care in the SVH ED (if emergent care is needed) ... 9. Nothing in this policy is intended to override SVH responsibilities to provide Emergency Medical Screening Exams for individuals presenting for emergency medical care. (See SVH Policy: Emergency Medical Treatment and Labor Act (EMTALA) Screening, Treatment, Transfer and On-Call Roster). The hospital failed to ensure an appropriate medical screening examination (MSE) to determine if an emergency medical condition (EMC) exists was completed for 4 of 21 patients (Patient 1, 12, 19, and 21) who presented to the emergency department (ED) seeking emergency medical care. (Refer to tag A2406) The hospital failed to provide stabilizing treatment for 4 of 21 patients (Patient 1, 12, 19, and 21) who presented to the emergency department seeking emergency medical care. (Refer to tag A2407)”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 47234 Based on record review, policy review, document review and interview the hospital failed to provide an appropriate medical screening examination (MSE) to determine if an emergency medical condition (EMC) exists for 4 of 21 patients (Patient 1, 12, 19 and 21) who presented to the emergency department (ED) seeking emergency medical care. The hospital’s failure to ensure an appropriate MSE has the potential for patients to be discharged with an unidentified EMC which delays necessary stabilizing treatment and may lead to deterioration of the person’s condition, including harm and death. Findings Include: Patient 1 Review of Patient 1’s medical record dated 05/07/24 at 5:00 AM “ ...Service(s) being requested: Client came to door asking for help. Client stated he went to crisis as he is suicidal and not safe, client shared that he had overdosed on Saturday and friends used Narcan and he overdosed on Sunday and friends used CPR [Cardiopulmonary Resuscitation]. Non-emergency ambulance called for clients welfare and will be taken to [Above Named Hospital] for evaluation. Client stated he really needs detox and treatment ....” Review of Patient 1’s “Prehospital Care Report” incident date/time 05/07/24 at 5:31 AM showed “Found ambulatory at scene of mental health facility. Staff stated that he had been released from prison last Friday and has been taking meth (methamphetamine), cocaine, fentanyl, alcohol and weed since then; Patient overdosed on Saturday and Sunday ... patient is very lethargic and stated he would like to commit suicide by a fentanyl overdose ...patient report was given and received by hospital RN ...” Review of Patient 1’s, medical record showed, a 36-year-old who presented to the Emergency Department (ED) on 05/07/24 at 6:11 AM by ambulance. Patient 1 was triaged at an Emergency Severity Index (ESI) 2 (Patients are very ill and at high risk. The need for care is immediate and an appropriate bed needs to be found). His chief complaint was “Pt [Patient] reports to ed [Emergency Department] with complaints of recent drug use. States he took heroin and fentanyl within the last two hours. Pt [Patient] states he was trying to commit suicide by using drugs ...” He has a history of anxiety, asthma, bipolar disorder, depression, intravenous drug abuse and Obsessive Compulsive Disorder presented with substance abuse relapse and suicidal ideation. . Review of “Columbia Suicide Severity Rating Scale (C-SSRS)” dated 05/07/24 at 6:17 AM, showed, “1. In the past month, have you wished you were dead or wished you could go to sleep and not wake up? Yes; 2. In the past month, have you actually had any thoughts of killing yourself? Yes; 3. Have you been thinking about how you might do this? Yes. 4. Have you had these thoughts and had some intention of acting on them? Yes. 5. Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? Yes 6. Have you ever done anything, started to do anything, or prepared to do anything to end your life? Yes; 6a. Was this within the past three months? Yes. Risk of Suicide High Risk.” Review of Patient 1’s “ED Notes” dated 05/07/24 at 7:25 AM, written by Staff O, License Master Social Worker, LMSW showed “ ...Suicide Risk/C-SSRS ...Risk of Suicide: High Risk ...Risk Factor Assessment; Suicidal and Self-Injurious Behavior: Actual suicide attempt; Describe preparatory acts: Overdose; Suicidal Ideation (Most Severe in Past Month): Suicidal intent with specific plan (2 days ago); Activating Events (Recent): Pending incarceration or homelessness; Treatment History: Not receiving treatment; Clinical Status (Recent): Highly impulsive behavior, Substance abuse or dependence ... Does the patient need a safety plan completed before discharge? Yes Pt eloped prior to safety plan completion ...Symptoms; Mood/Pt Behaviors: Irritable; Judgment: Impaired; Compliant with Prescribed Medication Regime?: Not on medication; Psychiatric Treatment History; Current Psychiatrist and/or therapist?: No..” During an interview on 05/31/24 at 9:13 AM, Staff O, LMSW, stated that, patients who are able to keep themselves safe receive a safety plan. [Patient 1] had a suicidal attempt couple days prior; he had needles falling out of his socks and kept saying that they were insulin needles. Then he started saying he wanted to leave, calling the doctor names, and subsequently, he left against medical advice. He was denying being currently suicidal at the moment I met with him. Since he was being verbally abusive, he was escorted out by security. Review of Patient 1’s “MDM [Medical Decision Making]” dated 05/07/24 at 7:04 AM, showed that, ...Here after heroin use over the last several days. Patient reports he was kicked out of rehab housing. Attempted to go to [Community Mental Health Center] but they did not have bed for him so went up here. Patient sleepy here but arouses to voice. Remains uncooperative. Additional needles found on patient in his pockets and socks. Vital signs otherwise stable. No oxygen requirement. Discussion of potential discharge led the patient to become agitated, belligerent, yelling, and cursing at staff members. Security involved. Patient demanding his syringes be given back to him. Encouraged drug cessation. Resources were provided. Patient left with security. During an interview on 05/29/24 at 11:28 AM, Staff H, MD (Doctor of Medicine), stated, “ ...Looks like he was on, or using drugs the last couple of days and either he left or was dismissed ...” Staff H, MD, shown charting that Patient 1 was high risk for suicide and trying to commit suicide with drugs stated, “it’s tricky.” Review of Patient 1’s “ED Notes” dated 05/07/24 at 8:50 AM, showed, “Pt becomes verbally aggressive/abusive to staff when being woke up. Pt states he will leave. Security notified and pt escorted to door ...” Review of “Discharge Instructions - Encounter Notes” on 05/07/24 at 8:52 AM, showed, “Avoid further drug use, follow up on resources provided.” Even though security staff escorted Patient 1 out of the ED, review of an entry titled, “ED Disposition” dated 05/07/24 at 8:57 AM, showed, “Eloped”. Review of Patient 1’s medical record on 05/31/24 at 9:28 AM, Staff A, RN, Director of the Emergency Department, stated that Patient 1’s disposition was incorrect and it should not be elopement since patient left with security. Review of Patient 1’s medical record failed to show that the hospital provided an adequate MSE to determine whether he had an EMC. He did not receive a medical screening examination that addressed his complaint of suicidal ideation or sufficient to determine the presence or absence of an emergency medical condition. Review of Patient 1’s [Community Behavioral Health Center] medical record dated 05/07/24 at 10:21 AM showed “ ...Client is struggling with depression and wanting to die/kill himself ...” One hour and 24 minutes after being discharged out of ED from [Above Named Hospital]. Patient 12 Review of Patient 12’s medical record showed, a 48-year-old male, presented to the Emergency Department (ED) on 05/17/24 at 1:02 PM by police transportation. Patient 12 was triaged at 1:49 PM with an Emergency Severity Index (ESI) 2 (Patients are very ill and at high risk. The need for care is immediate and an appropriate bed needs to be found.) His chief complaint was suicidal and homicidal ideation. Review of Patient 12’s “ED Triage Notes” dated 05/17/24 at 1:41 PM, written by Staff G, Registered Nurse (RN) showed, “Pt [sic] arrived with [Police Department] officer who reports that pt [sic] had called and was stating he was suicidal. Pt [sic] has abrasion to left wrist that was self-inflicted. Pt [sic] is here mumbling, and then in raised voice talking about killing someone; someone “on internet.” Pt initially pacing around the waiting room. Now sitting and calm. P/w/d [pink/warm/dry]. Eupneic [normal respirations], GCS 14 [Glasgow Coma Scale indicating mild dysfunction. A normal GCS score, indicating full neurological health, is 15].” Review of Patient 12’s “ED Triage Notes” dated 05/17/24 at 1:50 PM, written by Staff G, RN showed, “Pt [sic] wants to kill wants to kill someone named [name] who we [sic] met on the internet because he disrespected him. Pt [sic] oriented x 4. Pt [sic] seems to be preoccupied with Trump winning the election and Microsoft stock winning. Pt [sic] intoxicated, reports drinking 1/2 pint today. Pt [sic] newly homeless after getting into a fight with his neighbor.” Review of Patient 12’s “Columbia Suicide Severity Rating Scale (is a suicidal ideation and behavior rating scale)” dated 05/17/24 at 1:52 PM, showed, “...Risk of Suicide High Risk ...” Review of Patient 12’s “ED Notes” dated 05/17/24 at 2:36 PM, written by Staff EE, RN showed, “This RN attempts to locate patient in ED waiting room, as ED room is ready for patient. Upon looking for patient in ED waiting areas, unable to locate. Registrar reports patient left the ED. [Police Department] contacted at 1435 [2:35 PM] for welfare check, sent to voicemail, message left to return call to [phone number] in concern to welfare check needed. [Police Department] returns call at 1540 [3:40 PM], reports they will attempt to contact patient for welfare check.” During an interview on 05/29/24 at 11:44 AM, Staff G, RN stated that she works triage a lot and it is not uncommon to have a 45-to-50-minute wait before a patient is triaged. Staff G went on to state that if a patient comes in and they’re suicidal or homicidal or both and cannot be placed in a room they are put in the front lobby. Staff G stated, “I did not feel the patient met the criteria for room 13 [suicide precautions room] ...The Police Department to my knowledge does not follow up so we do not know if they actually done the welfare check ...” Patient 12 presented with a complaint of suicidal/homicidal ideation and was at risk for self harm/harm to others. He needed placement in a safe and monitored environment in the ED. However, the nurse decided that he did not meet the criteria for room 13. He was in need of a medical screening examination (MSE) to determine whether he had any other medical conditions contributing to his current psychiatric condition. It appeared that he needed a psychiatric evaluation and possible inpatient admission. Instead, Patient 12 left the ED waiting room and did not receive any medical interventions. During an interview on 05/29/24 at 11:27 AM, Staff H, Doctor of Medicine (MD) stated, “ ...we will not hold a patient at this facility, we were told by the attorney general we cannot hold the patient regardless if they are suicidal or homicidal ...” During an interview on 05/30/24 at 3:13 PM, Staff AA, RN stated that we don’t notify security if we place a patient in the waiting room that is suicidal or homicidal due to confidentiality. Patient 19 Review of Patient 19’s medical record showed, a 22-year-old, presented to the ED on 10/29/23 at 1:56 PM by private vehicle with mother, and two other family members. Patient 19 was triaged at an ESI 2. Review of Patient 19’s “ED Triage Notes” showed, “Pt [Patient] to triage accompanied by mother seeking inpatient tx [treatment] for pt [sic] who is manic (showing wild, apparently deranged, excitement and energy). Per mother, pt [sic] took LSD (Lysergic acid diethylamide a potent hallucinogen drug that alters person perception of reality) previous Tuesday and has had suicidal tendencies since that time. Pt [sic] refused to let RN [registered nurse] place ID [identification] bracelet at this time as she states, “ I died last Tuesday”. Pt [sic] not answering additional questions at this time.” Review of Patient 19’s “ED Triage Notes” dated 10/29/23 at 2:02 PM, showed, “Pt [sic] delayed in answering questions in triage. Pt [sic] states she knows where she is and “her worst fears have come true.” Review of Patient 19’s “Columbia Suicide Severity Rating Scale” dated 10/29/23 at 2:06 PM, “...Risk of Suicide High Risk ...” Review of Patient 19’s “ED Provider Notes” dated 10/29/23 at 2:23 PM, showed, “Chief Complaint; Patient presents with Altered Mental Status ...Physical Exam ... Neurological: Mental Status: She is alert. ...Psychiatric: Comments: Patient agitated ... Medical Decision Making: 21-year-old female here today with parent and concern for manic behavior. Patient has a history of bipolar apparently. Parent also relating that patient took LSD several days ago. Patient speaking loudly in an agitated manner. She is approaching hitting room occupants including other patients and their family members. She occasionally is shouting and raising her voice. She does not appear to be physically aggressive. No evidence of trauma. She is speaking clearly without difficulty. Her movement is purposeful. Does not appear to be any focal or unilateral neurological deficits. Patient does not appear to be short of breath. She has good muscle tone. Patient was offered multiple times to be taken to a room for evaluation and treatment. Patient not responding to questions. After a brief moment of being somewhat calm she began to get agitated again. Again she declined to answer or respond to multiple offers of being roomed, evaluated, and treated. Given the lack of cooperation, patient was then discharged. She was escorted from the waiting room by security. Parent is with patient. Nothing in patient interaction indicating that patient does not have capacity to make her own decisions. Discussed at length with parent that we could not force patient to be evaluated ...” During an interview on 05/29/24 at 2:01 PM, Staff P, Advanced Practice Registered Nurse (APRN), stated, “ ...We don’t do MSE’s in the waiting room but if a patient is being uncooperative or not answering questions, it’s difficult to see if they are alert and orientated. If unable to get history from patient, we would try to get history from family. Safety would be our number one concern. My guidelines are that we are not to physically force any patient into a room per the hospital policy. The attorney general came and told us that we can’t force people to be treated against their will. The social worker does the heavy lifting on the patients to see if they need to be admitted...” Review of “Discharge Instructions - Encounter Notes” dated 10/29/23 at 2:33 PM, showed, “Follow up with your doctor in two days. Return to the emergency room as needed.” Review of “ED Notes” dated 10/29/23 at 2:35 PM, showed, “Pt [Patient] escorted out with the assistance of security. Unable to provide discharge instructions.” Review of “ED Notes” dated 10/29/23 at 2:45 PM, written by Staff Y, LMSW (Licensed Master Social Worker) showed, “Patient brought to ED by her mother. ED SW [Social Worker] contacted by triage nurse that patient was agitated and screaming in the ED lobby. ED SW went to lobby and patient had been taken to the parking lot by security due to her disruptive behavior in the lobby. ED SW went to the parking where patient was with her mother and two friends. Also present was security officers and charge nurse. Patient was making statements such as, “I have been saved.” And “God is with me.” Patient’s mother had paperwork stating she is patient’s legal guardian. ED provider had seen patient earlier and patient refused to be roomed for assessment. Patient was discharged and told if she returned, [Local Police Department] would be called for criminal trespass by security. Recommendation was for patient to go to [Community Behavioral Health Care 1]. Patient left with her mother and two friends. ED social worker left a message on the [Community Behavioral Health Care 1] Crisis Intake message line of patient being brought by her mother.” Review of document titled “IN THE DISTRICT COURT OF SHAWNEE COUNTY, KANSAS DIVISION 12” electronically filled 2022, Dec, 08 AM 11:46, showed, “LETTERS OF GUARDIANSHIP; [Patient 19’s Mother], having been appointed and qualified of [Patient 19], an adult with an impairment in need of a guardian, is granted Letter of Guardianship with full power and authority as provided by law, including all powers and duties of a guardian set out in K.S.A. 59-3075 and 59-3077. IT IS SO ORDERED ...Honorable [Judge 1], District Judge ...” During an interview on 05/30/24 at 12:30 PM, Staff Y, LMSW, stated, “...The patient was psychotic she had not been taking medication screaming, “I’m god” and “I have been saved” they were instructed to come to ED for involuntary hold by EMS. [Hospital 1] would not put a hold on her, she was out in the parking lot because of her disruptive behavior and was told she could not come back because of disruptive behavior. The mother had paperwork in her hand, but I did not look at paperwork she was holding. I don’t know why she wasn’t let back in; we do let other patients that are disruptive stay all the time...” Review of hospital document titled “Patient Relations” dated 01/02/24 at 10:53 AM, showed, “ ...Patient name: [Patient 19] ...Admission Date: Oct 29, 2023, 1:56 PM ...Narrative description: Patient mother has submitted survey feedback regarding daughter care that she received [sic] from her visit in the ER on 10/29/2023: ...I am [Patient 19’s mother] the mother and guardian for [Patient 19]. I know my daughter’s condition Bipolar I Manic is complicated. I showed up in the ER told the front desk people that ...I have guardianship paperwork ... Once she was in your ER ... the doctor came in the waiting room and said no he wouldn’t help her. She was pushed out of the door by 3 security officers, and 2 to 3 nurse staff. Then they shoved her in my car and didn’t give us any direction on what we should do ... “Doctor didn’t even ask me about her condition just that he would not treat her ...” During an interview on 05/30/24 at 2:51 PM, Patient 19’s mother (F1) stated that the hospital kicked us out before Patient 19 was seen for being manic and trying to hurt herself. She stated that she had guardianship paperwork and asked if there was a room to put her in because while the nurses were questioning, she started to grab at staff and all the hospital things. She stated that the staff said no and told her that she would need to wait in the waiting room. F1 stated that she told staff that it was not going to be good to have her in the waiting room ... F1 stated that Patient 19 started screaming at the top of her lungs and messing with other people not 2 seconds later. She stated the doctor came in and said that they could not treat her, and they need to go to the Community Behavioral Health Care 1. F1 stated that they were thrown out and it took six people to pick her up and throw her out of the hospital. She stated that the hospital told her is she came back it would be trespassing. F1 stated that a lady cop said that she was trying to be nice, but that Patient 19 just couldn’t come there anymore. F1 stated that she then drove to a hospital in Kansas City on 10/29/24, and Patient 19 was admitted. During an interview on 05/30/24 at 3:44 PM, Staff T, Security Guard stated “I was approached by her mother, she had exhausted all of her resources and was looking for help. The patient was very agitated and mother stated she would respond to gentle talking. The doctor asked in waiting room if she wanted help and would not respond to doctor. The patient would yell and verbally attack her mother. She was asked to leave and wouldn’t leave, then she threw herself on the ground, so I put her in a body wrap to keep harming herself. I told her that she still needed to get help after I put her in the car.” During an interview on 05/30/24 at 12:09 PM, Staff U, Armed Security, stated that Patient 19 was having a mental health crisis. Her mom had wanted her to stay and be treated. The patient was talking loudly and having abnormal conversations with other waiting room patients and throwing herself on the ground. Staff U spoke to the mother about patient options which is jail with law enforcement or hospitals. Staff U went on to state that for mental health patients they will be asked to leave, be arrested and released. Then return to the hospital to get help and get trespassed again so it’s a circle, due to a lack funding and we tend to pass them around.” During an interview on 05/31/24 at 9:28 AM Staff A, RN Director of Emergency Department, stated that, if a patient states that they want to harm self or others, the doctor would decide if the patient had capacity if they did not have capacity. Then doctor would do ex parte order to hold the patient. If provided with guardianship paperwork we would copy paperwork and put into the chart ...” Review of Patient 19’s medical record came into the ED demonstrating psychiatric symptoms and behaviors. She needed placement in the ED in a safe and monitored environment. Patient 19 needed a psychiatric evaluation and, if necessary, inpatient psychiatric admission/treatment. Patient 19 needed an MSE to determine if she had any other current medical conditions contributing to her psychiatric condition. Instead, the hospital did not provide any stabilizing treatment/medical interventions for Patient 19. The hospital failed to provide Patient 19 an MSE for a condition manifesting itself by acute psychiatric disturbances and/or symptoms of substance abuse. Further review of the medical record failed to show F1 was allowed to make medical decisions for Patient 19 as her legal guardian. Review of Patient 19’s hospital 3 medical recorded dated 10/29/23 at 3:31 PM, 56 minutes after being dismissed from hospital 1, showed Patient 19 presented to the ED in Kansas City with bipolar mood disorder type 1 (Period of abnormally elevated or irritable mood and high energy, accompanied by abnormal behavior that disrupts life) with psychotic symptoms (experiencing delusions, hallucinations or confused and disturbed thoughts). Patient 21 Review of a document titled, “EMS Patient Care Report” showed, Patient 21, a 45-year-old male with Altered Level of Consciousness and Chest Pain Suspected Cardiac on 05/15/24 at 5:35 PM. Review of a document titled, “EMS Patient Care Report” showed, “[Ambulance Service] dispatched for a sick at a skilled nursing facility non-emergent. [Ambulance Service] went en route as [Ambulance Service] was passing by sidewalk in front of [Hospital 1] ambulance bay as a small group of bystanders and law enforcement officers were frantically waving [Ambulance Service] down to stop as there was an unconscious male lying on the side walk. [Ambulance Service] pulled over and diverted to that call. Bystanders reported that they found the patient like this, unknown when or how he fell. Patient had emesis noted on the ground next to his mouth. Airway patient and breathing adequately. Patient woke to painful stimulation. Patient reported that he had chest pain and was attempting to get to [Hospital 1]. Patient also reported that he has a history of seizures. [Ambulance Service] and fire crew assisted patient onto cot via sheet lift and secured with all seatbelts. Secured in ambulance. Vital signs on scene were stable. IV attempt made on scene. Patient denied any injuries or pain other than pain in his chest. Patient refused aspirin as he felt like he could not take it. [Ambulance Service] went enroute to hospital. Patient became more alert en route but remained confused. Vital signs remained stable with no further changes in assessment findings. Diverted from [Hospital 1] to [Hospital 2] ...” Review of a document titled, “Incident Report” dated 05/15/24 at 5:30 PM showed, “ ...At around 1730 [5:30 PM] hours on the above date, [Staff CC, Security] was dispatched to the area of 10th and Washburn on a man down. As [Staff CC] was entering the area, [Staff CC] was advised that the subject was on the sidewalk near the southern [sic] lower helipad. On scene, there were two unkknown [sic] employees and a bystander trying to assist. [Staff CC] noted that male subject was on his left side, vomiting. One of the unknown employees was a medical staff member. Sternum rubs were given with little response from the subject. [Staff CC] began to search the subject and found two long knives and a expandable baton [sic]. [The Ambulance Service] was dispatched. A [Police Department] officer arrived and assisted with trying to obtain the subject’s name. The medical staff employee found an alert bracelet that stated that he had heart issues. [Ambulance Service] arrive, along with [Fire Department] and they took over care of the patient. [Staff CC] alerted the ER officers that this subject was on the way there and that he had weapons on his person. The weapons were placed in the subjects backpack. [Staff CC] cleared at this time ...” During an interview on 05/29/24 at 5:17 PM, Staff V, Paramedic, stated, “this is a very odd case because the patient was on the sidewalk closest to [Hospital 1] ...the patient was right there by the fence of the helicopter pad ...[The Ambulance Service] happened to be driving by and see everyone flagging [The Ambulance Service] down ...when [The Ambulance Service] arrived [Hospital 1] security and a woman in scrubs were attending to [Patient 21] ...called to give a radio report to [Hospital 1] but [Hospital 1] said divert we told [Hospital 1] [Patient 21] was trying to get into their Emergency Department and [Hospital 1] stated again please divert ...” During an interview on 05/30/24 at 4:31 PM, Staff CC, Security, stated that there was a man down on the sidewalk by the lower helicopter pad with vomit on the ground laying on his left side and [Hospital 1] dispatch called [The Ambulance Service]. Staff CC went on to state, “...I heard on the radio that [The Ambulance Service] got rerouted to [Hospital 2] even though they were literally right there at the ambulance bay ...” During an interview on 05/31/24 at 9:28 AM, Staff A, RN Director of Emergency Department, stated, “ ...if you are on our property and need medical attention, we would see you regardless if on diversion ...” The hospital failed to provide an MSE to Patient 21 who was on hospital property and whose appearance or behavior showed a need for an examination or treatment to determine whether he had an emergency medical condition. Patient 21 was found down next to the ambulance bay with decreased responsiveness and later complaining of chest pain. Patient 21 did not receive an MSE from the hospital. The hospital failed to do a history and physical, an EKG, any labs, or any imaging studies to determine whether the patient had an EMC. Since Patient 19 did not receive an appropriate MSE, they could not determine whether the patient needed any cardiac stabilizing treatments like aspirin, cardiac consultation, cardiac catheterization, and/or hospitalization. Instead, the hospital did not provide any stabilizing treatment/medical interventions for Patient 21 and he subsequently received care at Hospital 2.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 47234 Based on record review, document review and interview the hospital failed to provide stabilizing treatment for 4 of 21 sampled patients (Patient 1, 12, 19, and 21) who presented to the emergency department seeking emergency medical care. Failure to provide stabilizing treatment has the potential to place patients at risk for deterioration of the emergency medical condition (EMC) causing harm or injury up to and including death. Patient 1 Review of Patient 1’s medical record dated 05/07/24 at 5:00 AM “ ...Service(s) being requested: Client came to door asking for help. Client stated he went to crisis as he is suicidal and not safe, client shared that he had overdosed on Saturday and friends used Narcan and he overdosed on Sunday and friends used CPR [Cardiopulmonary Resuscitation]. Non-emergency ambulance called for clients welfare and will be taken to [Above Named Hospital] for evaluation. Client stated he really needs detox and treatment ....” Review of Patient 1’s “Prehospital Care Report” incident date/time 05/07/24 at 5:31 AM showed “Found ambulatory at scene of mental health facility. Staff stated that he had been released from prison last Friday and has been taking meth (methamphetamine), cocaine, fentanyl, alcohol and weed since then; Patient overdosed on Saturday and Sunday ... patient is very lethargic and stated he would like to commit suicide by a fentanyl overdose ...patient report was given and received by hospital RN ...” Review of Patient 1’s, medical record showed, a 36-year-old who presented to the Emergency Department (ED) on 05/07/24 at 6:11 AM by ambulance. Patient 1 was triaged at an Emergency Severity Index (ESI) 2 (Patients are very ill and at high risk. The need for care is immediate and an appropriate bed needs to be found). His chief complaint was “Pt [Patient] reports to ed [Emergency Department] with complaints of recent drug use. States he took heroin and fentanyl within the last two hours. Pt [Patient] states he was trying to commit suicide by using drugs ...” Review of “Columbia Suicide Severity Rating Scale (C-SSRS)” dated 05/07/24 at 6:17 AM, showed, “1. In the past month, have you wished you were dead or wished you could go to sleep and not wake up? Yes; 2. In the past month, have you actually had any thoughts of killing yourself? Yes; 3. Have you been thinking about how you might do this? Yes. 4. Have you had these thoughts and had some intention of acting on them? Yes. 5. Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? Yes 6. Have you ever done anything, started to do anything, or prepared to do anything to end your life? Yes; 6a. Was this within the past three months? Yes. Risk of Suicide High Risk.” Review of Patient 1’s “ED Notes” dated 05/07/24 at 7:25 AM, written by Staff O, License Master Social Worker, LMSW showed “ ...Suicide Risk/C-SSRS ...Risk of Suicide: High Risk ...Risk Factor Assessment; Suicidal and Self-Injurious Behavior: Actual suicide attempt; Describe preparatory acts: Overdose; Suicidal Ideation (Most Severe in Past Month): Suicidal intent with specific plan (2 days ago); Activating Events (Recent): Pending incarceration or homelessness; Treatment History: Not receiving treatment; Clinical Status (Recent): Highly impulsive behavior, Substance abuse or dependence ... Does the patient need a safety plan completed before discharge? Yes Pt eloped prior to safety plan completion ...Symptoms; Mood/Pt Behaviors: Irritable; Judgment: Impaired; Compliant with Prescribed Medication Regime?: Not on medication; Psychiatric Treatment History; Current Psychiatrist and/or therapist?: No..” During an interview on 05/31/24 at 9:13 AM, Staff O, LMSW, stated that, Patients that are able to keep themselves safe receive a safety plan. [Patient 1] had a suicidal attempt couple days prior; he had needles falling out of his socks and kept saying that they were insulin needles. Then he started saying he wanted to leave, calling the doctor names, and subsequently. he left against medical advice. He was denying being currently suicidal at the moment I met with him. Since he was being verbally abusive, he was escorted out by security. Review of Patient 1’s “MDM [Medical Decision Making]” dated 05/07/24 at 7:04 AM, showed that, ...Here after heroin use over the last several days. Patient reports he was kicked out of rehab housing. Attempted to go to [Community Mental Health Center] but they did not have bed for him so went up here. Patient sleepy here but arouses to voice. Remains uncooperative. Additional needles found on patient in his pockets and socks. Vital signs otherwise stable. No oxygen requirement. Discussion of potential discharge led the patient to become agitated, belligerent, yelling, and cursing at staff members. Security involved. Patient demanding his syringes be given back to him. Encouraged drug cessation. Resources were provided. Patient left with security. During an interview on 05/29/24 at 11:28 AM, Staff H, MD (Doctor of Medicine), stated, “ ...Looks like he was on, or using drugs the last couple of days and either he left or was dismissed ...” Staff H, MD, shown charting that Patient 1 was high risk for suicide and trying to commit suicide with drugs stated, “it’s tricky.” Review of Patient 1’s “ED Notes” dated 05/07/24 at 8:50 AM, showed, “Pt becomes verbally aggressive/abusive to staff when being woke up. Pt states he will leave. Security notified and pt escorted to door ...” Review of “Discharge Instructions - Encounter Notes” on 05/07/24 at 8:52 AM, showed, “Avoid further drug use, follow up on resources provided.” Even though security staff escorted Patient 1 out of the ED, review of an entry titled, “ED Disposition,” dated 05/07/24 at 8:57 AM, showed, “Eloped”. Review of Patient 1’s medical record on 05/31/24 at 9:28 AM, Staff A, RN, Director of the Emergency Department, stated that Patient 1’s disposition was incorrect and it should not be elopement since patient left with security. Review of Patient 1’s medical record failed to show that the hospital provided stabilizing treatment to Patient 1 within reasonable clinical confidence that his medical condition was resolved or that he was no longer considered to be a threat to himself or others, or he had a safety plan or written instruction of resources available to him. Review of Patient 1’s [Community Behavioral Health Center] medical record dated 05/07/24 at 10:21 AM showed “ ...Client is struggling with depression and wanting to die/kill himself ...” One hour and 24 minutes after being discharged out of ED from [Above Named Hospital]. Patient 1 returned to the ED on 05/14/24 at 12:22 AM with chief complaint of cellulitis (infection) to lower extremity (leg) with history of injecting fentanyl to this area and discharged at 1:03 AM with a prescription for an antibiotic on the same date. Although Patient 1 denied suicidal ideation during this visit on 05/14/24, review of Patient 1’s [Community Behavioral Health Cente [1] medical record on 05/14/24 at 6:15 AM “ ...4:13 AM ...client facedown passed out in shower with water running, face in 4-5 inches of water ...the client was pronounced dead @ 4:44 AM ...” Patient was pronounced dead 3 hours and 41 minutes after discharged from emergency room. Patient 12 Review of Patient 12’s medical record showed, a 48-year-old male, presented to the Emergency Department (ED) on 05/17/24 at 1:02 PM by police transportation. Patient 12 was triaged at 1:49 PM with an Emergency Severity Index (ESI) 2 (Patients are very ill and at high risk. The need for care is immediate and an appropriate bed needs to be found.) His chief complaint was suicidal and homicidal ideation. Review of Patient 12’s “ED Triage Notes” dated 05/17/24 at 1:41 PM, written by Staff G, Registered Nurse (RN) showed, “Pt [sic] arrived with [Police Department] officer who reports that pt [sic] had called and was stating he was suicidal. Pt [sic] has abrasion to left wrist that was self-inflicted. Pt [sic] is here mumbling, and then in raised voice talking about killing someone; someone “on internet.” Pt initially pacing around the waiting room. Now sitting and calm. P/w/d [pink/warm/dry]. Eupneic [normal respirations], GCS 14 [Glasgow Coma Scale indicating mild dysfunction. A normal GCS score, indicating full neurological health, is 15].” Review of Patient 12’s “ED Triage Notes” dated 05/17/24 at 1:50 PM, written by Staff G, RN showed, “Pt [sic] wants to kill wants to kill someone named [name] who we [sic] met on the internet because he disrespected him. Pt [sic] oriented x 4. Pt [sic] seems to be preoccupied with Trump winning the election and Microsoft stock winning. Pt [sic] intoxicated, reports drinking 1/2 pint today. Pt [sic] newly homeless after getting into a fight with his neighbor.” Review of Patient 12’s “Columbia Suicide Severity Rating Scale (is a suicidal ideation and behavior rating scale)” dated 05/17/24 at 1:52 PM, showed, “...Risk of Suicide High Risk ...” Review of Patient 12’s “ED Notes” dated 05/17/24 at 2:36 PM, written by Staff EE, RN showed, “This RN attempts to locate patient in ED waiting room, as ED room is ready for patient. Upon looking for patient in ED waiting areas, unable to locate. Registrar reports patient left the ED. [Police Department] contacted at 1435 [2:35 PM] for welfare check, sent to voicemail, message left to return call to [phone number] in concern to welfare check needed. [Police Department] returns call at 1540 [3:40 PM], reports they will attempt to contact patient for welfare check.” Patient 12 presented with a complaint of suicidal/homicidal ideation and was at risk for self harm/harm to others. He needed placement in a safe and monitored environment. He was in need of a medical screening examination (MSE) to determine whether he had any other medical conditions contributing to his current psychiatric symptoms/condition. It appeared that he needed a psychiatric evaluation and possible inpatient admission. Instead, Patient 12 left the ED waiting room and did not receive any medical interventions. During an interview on 05/29/24 at 11:44 AM, Staff G, RN stated that she works triage a lot and it is not uncommon to have a 45-to-50-minute wait before a patient is triaged. Staff G went on to state that if a patient comes in and they’re suicidal or homicidal or both and cannot be placed in a room they are put in the front lobby. Staff G stated, “I did not feel the patient met the criteria for room 13 [suicide precautions room] ...The Police Department to my knowledge does not follow up so we do not know if they actually done the welfare check ...” During an interview on 05/29/24 at 11:27 AM, Staff H, Doctor of Medicine (MD) stated, “ ...we will not hold a patient at this facility, we were told by the attorney general we cannot hold the patient regardless if they are suicidal or homicidal ...” During an interview on 05/30/24 at 3:13 PM, Staff AA, RN stated that we don’t notify security if we place a patient in the waiting room that is suicidal or homicidal due to confidentiality. Patient 19 Review of Patient 19’s medical record showed, a 22-year-old, presented to the ED on 10/29/23 at 1:56 PM by private vehicle with mother, and two other family members. Patient 19 was triaged at an ESI 2. Review of Patient 19’s “ED Triage Notes” showed, “Pt [Patient] to triage accompanied by mother seeking inpatient tx [treatment] for pt [sic] who is manic (showing wild, apparently deranged, excitement and energy). Per mother, pt [sic] took LSD (Lysergic acid diethylamide a potent hallucinogen drug that alters person perception of reality) previous Tuesday and has had suicidal tendencies since that time. Pt [sic] refused to let RN [registered nurse] place ID [identification] bracelet at this time as she states, “ I died last Tuesday”. Pt [sic] not answering additional questions at this time.” Review of Patient 19’s “ED Triage Notes” dated 10/29/23 at 2:02 PM, showed, “Pt [sic] delayed in answering questions in triage. Pt [sic] states she knows where she is and “her worst fears have come true.” Review of Patient 19’s “Columbia Suicide Severity Rating Scale” dated 10/29/23 at 2:06 PM, “...Risk of Suicide High Risk ...” Review of Patient 19’s “ED Provider Notes” dated 10/29/23 at 2:23 PM, showed, “Chief Complaint; Patient presents with Altered Mental Status ...Physical Exam ... Neurological: Mental Status: She is alert. ...Psychiatric: Comments: Patient agitated ... Medical Decision Making: 21-year-old female here today with parent and concern for manic behavior. Patient has a history of bipolar apparently. Parent also relating that patient took LSD several days ago. Patient speaking loudly in an agitated manner. She is approaching hitting room occupants including other patients and their family members. She occasionally is shouting and raising her voice. She does not appear to be physically aggressive. No evidence of trauma. She is speaking clearly without difficulty. Her movement is purposeful. Does not appear to be any focal or unilateral neurological deficits. Patient does not appear to be short of breath. She has good muscle tone. Patient was offered multiple times to be taken to a room for evaluation and treatment. Patient not responding to questions. After a brief moment of being somewhat calm she began to get agitated again. Again she declined to answer or respond to multiple offers of being roomed, evaluated, and treated. Given the lack of cooperation, patient was then discharged. She was escorted from the waiting room by security. Parent is with patient. Nothing in patient interaction indicating that patient does not have capacity to make her own decisions. Discussed at length with parent that we could not force patient to be evaluated ...” During an interview on 05/29/24 at 2:01 PM, Staff P, Advanced Practice Registered Nurse (APRN), stated, “ ...We don’t do MSE’s in the waiting room but if a patient is being uncooperative or not answering questions, it’s difficult to see if they are alert and orientated. If unable to get history from patient, we would try to get history from family. Safety would be our number one concern. My guidelines are that we are not to physically force any patient into a room per the hospital policy. The attorney general came and told us that we can’t force people to be treated against their will. The social worker does the heavy lifting on the patients to see if they need to be admitted...” Review of “Discharge Instructions - Encounter Notes” dated 10/29/23 at 2:33 PM, showed, “Follow up with your doctor in two days. Return to the emergency room as needed.” Review of “ED Notes” dated 10/29/23 at 2:35 PM, showed, “Pt [Patient] escorted out with the assistance of security. Unable to provide discharge instructions.” Review of “ED Notes” dated 10/29/23 at 2:45 PM, written by Staff Y, LMSW (Licensed Master Social Worker) showed, “Patient brought to ED by her mother. ED SW [Social Worker] contacted by triage nurse that patient was agitated and screaming in the ED lobby. ED SW went to lobby and patient had been taken to the parking lot by security due to her disruptive behavior in the lobby. ED SW went to the parking where patient was with her mother and two friends. Also present was security officers and charge nurse. Patient was making statements such as, “I have been saved.” And “God is with me.” Patient’s mother had paperwork stating she is patient’s legal guardian. ED provider had seen patient earlier and patient refused to be roomed for assessment. Patient was discharged and told if she returned, [Local Police Department] would be called for criminal trespass by security. Recommendation was for patient to go to [Community Behavioral Health Care 1]. Patient left with her mother and two friends. ED social worker left a message on the [Community Behavioral Health Care 1] Crisis Intake message line of patient being brought by her mother.” Review of document titled “IN THE DISTRICT COURT OF SHAWNEE COUNTY, KANSAS DIVISION 12” electronically filled 2022, Dec, 08 AM 11:46, showed, “LETTERS OF GUARDIANSHIP; [Patient 19’s Mother], having been appointed and qualified of [Patient 19], an adult with an impairment in need of a guardian, is granted Letter of Guardianship with full power and authority as provided by law, including all powers and duties of a guardian set out in K.S.A. 59-3075 and 59-3077. IT IS SO ORDERED ...Honorable [Judge 1], District Judge ...” During an interview on 05/30/24 at 12:30 PM, Staff Y, LMSW, stated, “...The patient was psychotic she had not been taking medication screaming, “I’m god” and “I have been saved” they were instructed to come to ED for involuntary hold by EMS. [Hospital 1] would not put a hold on her, she was out in the parking lot because of her disruptive behavior and was told she could not come back because of disruptive behavior. The mother had paperwork in her hand, but I did not look at paperwork she was holding. I don’t know why she wasn’t let back in; we do let other patients that are disruptive stay all the time...” Review of hospital document titled “Patient Relations” dated 01/02/24 at 10:53 AM, showed, “ ...Patient name: [Patient 19] ...Admission Date: Oct 29, 2023, 1:56 PM ...Narrative description: Patient mother has submitted survey feedback regarding daughter care that she received [sic] from her visit in the ER on 10/29/2023: ...I am [Patient 19’s mother] the mother and guardian for [Patient 19]. I know my daughter’s condition Bipolar I Manic is complicated. I showed up in the ER told the front desk people that ...I have guardianship paperwork ... Once she was in your ER ... the doctor came in the waiting room and said no he wouldn’t help her. She was pushed out of the door by 3 security officers, and 2 to 3 nurse staff. Then they shoved her in my car and didn’t give us any direction on what we should do ... “Doctor didn’t even ask me about her condition just that he would not treat her ...” During an interview on 05/30/24 at 2:51 PM, Patient 19’s mother (F1) stated that the hospital kicked us out before Patient 19 was seen for being manic and trying to hurt herself. She stated that she had guardianship paperwork and asked if there was a room to put her in because while the nurses were questioning, he she stared to grab at staff and all the hospital things. She stated that the staff said no and told her that she would need to wait in the waiting room. F1 stated that she told staff that it was not going to be good to have her in the waiting room ... F1 stated that Patient 19 started screaming at the top of her lungs and messing with other people not 2 seconds later. She stated the doctor came in and said that they could not treat her, and they need to go to the Community Behavioral Health Care 1. F1 stated that they were thrown out and it took six people to pick her up and throw her out of the hospital. She stated that the hospital told her is she came back it would be trespassing. F1 stated that a lady cop said that she was trying to be nice, but that Patient 19 just couldn’t come there anymore. F1 stated that she then drove to a hospital in Kansas City on 10/29/24, and Patient 19 was admitted. Patient 19 came into the ED demonstrating psychiatric symptoms and behaviors. She needed placement in the ED in a safe and monitored environment. Patient 19 needed a psychiatric evaluation and, if necessary, inpatient psychiatric admission/treatment. Patient 19 needed an MSE to determine if she had any other current medical conditions contributing to her psychiatric symptoms/condition. Instead, the hospital did not provide any stabilizing treatment/medical interventions for Patient 19. During an interview on 05/30/24 at 3:44 PM, Staff T, Security Guard stated “I was approached by her mother, she had exhausted all of her resources and was looking for help. The patient was very agitated and mother stated she would respond to gentle talking. The doctor asked in waiting room if she wanted help and would not respond to doctor. The patient would yell and verbally attack her mother. She was asked to leave and wouldn’t leave, then she threw herself on the ground, so I put her in a body wrap to keep harming herself. I told her that she still needed to get help after I put her in the car.” During an interview on 05/30/24 at 12:09 PM, Staff U, Armed Security, stated that Patient 19 was having a mental health crisis. Her mom had wanted her to stay and be treated. The patient was talking loudly and having abnormal conversations with other waiting room patients and throwing herself on the ground. Staff U spoke to the mother about patient options which is jail with law enforcement or hospitals. Staff U went on to state that for mental health patients they will be asked to leave, be arrested and released. Then return to the hospital to get help and get trespassed again so it’s a circle, due to a lack funding and we tend to pass them around.” During an interview on 05/31/24 at 9:28 AM Staff A, RN Director of Emergency Department, stated that, if a patient states that they want to harm self or others, the doctor would decide if the patient had capacity if they did not have capacity. Then doctor would do ex parte order to hold the patient. If provided with guardianship paperwork we would copy paperwork and put into the chart ...” Review of medical record failed to show that patient received emergency medical examination for a medical condition manifesting itself by acute psychiatric disturbances and/or symptoms of substance abuse, or no longer considered to be a threat to himself/herself or others. Further review of the medical record failed to show F1 was allowed to make medical decisions for Patient 19 as her legal guardian. Review of Patient 19’s Hospital 3 medical recorded dated 10/29/23 at 3:31 PM, 56 minutes after being dismissed from Hospital 1, showed Patient 19 presented to ED with bipolar mood disorder type 1 (Period of abnormally elevated or irritable mood and high energy, accompanied by abnormal behavior that disrupts life) with psychotic symptoms (experiencing delusions, hallucinations or confused and disturbed thoughts). Patient 21 Review of a document titled, “EMS Patient Care Report” showed, Patient 21, a 45-year-old male with Altered Level of Consciousness and Chest Pain Suspected Cardiac on 05/15/24 at 5:35 PM. Review of a document titled, “EMS Patient Care Report” showed, “[Ambulance Service] dispatched for a sick at a skilled nursing facility non-emergent. [Ambulance Service] went enroute as [Ambulance Service] was passing by sidewalk in front of [Hospital 1] ambulance bay as a small group of bystanders and law enforcement officers were frantically waving [Ambulance Service] down to stop as there was an unconscious male lying on the side walk. [Ambulance Service] pulled over and diverted to that call. Bystanders reported that they found the patient like this, unknown when or how he fell. Patient had emesis noted on the ground next to his mouth. Airway patient and breathing adequately. Patient woke to painful stimulation. Patient reported that he had chest pain and was attempting to get to [Hospital 1]. Patient also reported that he has a history of seizures. [Ambulance Service] and fire crew assisted patient onto cot via sheet lift and secured with all seatbelts. Secured in ambulance. Vital signs on scene were stable. IV attempt made on scene. Patient denied any injuries or pain other than pain in his chest. Patient refused aspirin as he felt like he could not take it. [Ambulance Service] went enroute to hospital. Patient became more alert enroute but remained confused. Vital signs remained stable with no further changes in assessment findings. Diverted from [Hospital 1] to [Hospital 2] ...” Review of a document titled, “Incident Report” dated 05/15/24 at 5:30 PM showed, “ ...At around 1730 [5:30 PM] hours on the above date, [Staff CC, Security] was dispatched to the area of 10th and Washburn on a man down. As [Staff CC] was entering the area, [Staff CC] was advised that the subject was on the sidewalk near the southren [sic] lower helipad. On scene, there were two unkknown [sic] employees and a bystander trying to assist. [Staff CC] noted that male subject was on his left side, vomiting. One of the unknown employees was a medical staff member. Sternum rubs were given with little response from the subject. [Staff CC] began to search the subject and found two long knives and a expandable baton [sic]. [The Ambulance Service] was dispatched. A [Police Department] officer arrived and assisted with trying to obtain the subjects name. The medical staff employee found an alert bracelet that stated that he had heart issues. [Ambulance Service] arrive, along with [Fire Department] and they took over care of the patient. [Staff CC] alerted the ER officers that this subject was on the way there and that he had weapons on his person. The weapons were placed in the subjects backpack. [Staff CC] cleared at this time ...” During an interview on 05/29/24 at 5:17 PM, Staff V, Paramedic, stated, “this is a very odd case because the patient was on the sidewalk closest to [Hospital 1] ...the patient was right there by the fence of the helicopter pad ...[The Ambulance Service] happened to be driving by and see everyone flagging [The Ambulance Service] down ...when [The Ambulance Service] arrived [Hospital 1] security and a woman in scrubs were attending to [Patient 21] ...called to give a radio report to [Hospital 1] but [Hospital 1] said divert we told [Hospital 1] [Patient 21] was trying to get into their Emergency Department and [Hospital 1] stated again please divert ...” During an interview on 05/30/24 at 4:31 PM, Staff CC, Security, stated that there was a man down on the sidewalk by the lower helicopter pad with vomit on the ground laying on his left side and [Hospital 1] dispatch called [The Ambulance Service]. Staff CC went on to state, “...I heard on the radio that [The Ambulance Service] got rerouted to [Hospital 2] even though they were literally right there at the ambulance bay ...” During an interview on 05/31/24 at 9:28 AM, Staff A, RN Director of Emergency Department, stated, “ ...if you are on our property and need medical attention, we would see you regardless if on diversion ...” Patient 21 was found down next to the ambulance bay with decreased responsiveness and later complaining of chest pain. Patient 21 did not receive an MSE from the hospital. The hospital failed to do a history and physical, an EKG, any labs, or any imaging studies to determine whether the patient had an EMC. Since Patient 19 did not recieve an appropriate MSE, they could not determine whether the patient needed any cardiac stabilizing treatments like aspirin, cardiac consultation, cardiac catheterization, and/or hospitalization. Instead, the hospital did not provide any stabilizing treatment/medical interventions for Patient 21 and so he was taken to Hospital 2 by ambulance.”