River Oaks Hospital

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to inform patients, or when appropriate, the patient’s representative, of the patient’s rights, in advance of furnishing patient care in 2 (#2 and #4) of 5 sampled patient medical records. Findings: Review of hospital policy provided by S10CNO titled “Patients’ Rights and Restriction of Rights Function: Rights”, last reviewed 01/2023, revealed in part: “Procedure: 1. Upon admission, patient/his or her family member/or representative receives and acknowledges receipt of ‘Patient Rights’.” Patient #2 Review of medical record on 12/03/2025 between 12:04 PM-1:00 PM revealed an admit date of 10/12/2025 with ongoing admission. Review of Patient #2’s “Conditions of Admission” form dated 10/12/2025, failed to reveal signatures of patient or family member/representative confirming acknowledgment of receipt of Patient Rights. During an interview on 12/03/2025 at 12:45 PM, S3NM confirmed the “Conditions of Admission” form dated 10/12/2025, failed to reveal signatures of patient or family member/representative confirming acknowledgment of receipt of Patient Rights. Patient #4 Review of medical record on 12/01/2025 between 12:54 PM and 2:15 PM and 12/03/2025 between 10:06 AM-10:30 PM revealed an admit date of 09/19/2025 and discharge date of 09/25/2025. Review of Patient #4’s “Conditions of Admission” form dated 09/19/2025, failed to reveal signatures of patient or family member/representative confirming acknowledgment of receipt of Patient Rights. During an interview on 12/03/2025 at 10:24 AM, S3NM confirmed the “Conditions of Admission” form dated 09/19/2025, failed to signatures of patient or family member/representative confirming acknowledgment of receipt of Patient Rights.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 47397 Based on record review and interview the hospital failed to ensure 2 (#1 and #5) of 5 patients sampled participated in their treatment process. Findings: Review of hospital policy provided by S10CNO titled “Patients’ Rights and Restriction of Rights Function: Rights”, last reviewed 01/2023, revealed in part: “Procedure: 7. Patient receives education regarding his/her medication and the treatment process. Patient #1 Review of Patient #1’s medical record revealed and admit date of 09/16/2025 and discharge of 09/22/2025 with diagnoses of depression unspecified second to suicidal ideations with plan to overdose. Review of Patient #1’s Interdisciplinary Master Treatment Plan dated 09/16/2025 last entry made on 09/17/2025 failed to reveal evidence Patient #1 or her representative participated in the treatment process. During an interview on 12/03/2025 at 3:55 PM, S10CNO confirmed Patient #1’s treatment plan did not reveal evidence Patient #1 or her representative participated in the treatment process. Patient #5 Review of Patient #5’s medical record revealed, admit date of 09/29/2025, and discharge on 11/26/2025 with diagnoses of depression unspecified second to suicidal ideations with plan to overdose. Review of Patient #5’s Interdisciplinary Master Treatment Plan dated 09/30/2025 with last entry made on 10/14/2025 failed to reveal evidence Patient #5 or her representative participated in the treatment process. During an interview on 12/03/2025 at 3:55 PM, S10CNO confirmed Patient #5’s treatment plan did not reveal evidence Patient #5 or her representative participated in the treatment process.”

“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: 47397 Based on record review and interview the hospital: 1) failed to ensure the right to request or refuse treatment in 1 (#1) of 5 patient medical records sampled; and 2) failed to ensure the patient or patient representative signed a consent for treatment in 1 (#2) of 5 patient medical records sampled. Findings: Review of hospital policy provided by S10CNO titled “Patients’ Rights and Restriction of Rights Function: Rights”, last reviewed 01/2023, revealed in part: “”Policy: River Oaks recognizes and respects the rights of the patient as an individual with special needs. The staff supports the patient’s right to make decisions regarding his/her care. This includes discontinuing treatment. Procedure: 12. The organization respects the right of the individual served or surrogate decision-maker to refuse care treatment or services in accordance with law and regulation.” Review of hospital policy provided by S10CNO titled “Informed Consent Function: Rights”, last reviewed 11/2001, revealed in part: “Policy: It is the policy of River Oaks that the patient has a right to reasonably informed participation in decisions involving their health care. To the degree possible this should be based on a clear, concise explanation of his/her condition and of all proposed treatment, including any risk of mortality or serous side-effects, problems related to recuperation and probability of success. The patient will not be subjected to any procedure without his voluntary, competent and willing consent or that of his legally authorized representative. Where medically significant alternatives for care exist the patient shall be so informed. A. Informed consent for routine hospital care: 1. General Consent: Any patient registered as inpatient will sign a general consent. 2. Evidence of informed consent: i. In-patient: an admission consent form will be executed by the patient or the patients legally recognized representative as part of the hospital’s regular admission procedure.” 1) Failure to ensure the right to request or refuse treatment in 1 (#1) of 5 patient medical records sampled. Review of patient #1’s medical record revealed and admit date of 09/16/2025 and discharge of 09/22/2025 with diagnoses of depression unspecified second to suicidal ideations with plan to overdose. Review of History and Physical dated 09/17/2025 at 10:10 AM revealed the following in part: Allergies: No known allergies. Immunological Status: Received all Childhood immunizations. Physical Examination: Skin: without any significant skin lesion. Medical Problems: 1. Suicidal Ideation: PRN (as needed) medications and plan per psychiatry. Review of Daily Nurse Progress Note dated 09/17/2025 between 7:00 AM and 7:00 AM on 09/18/2025 revealed patient was not having thoughts of killing herself and was not exhibiting suicidal behavior. Review of Daily Nurse Progress Note dated 09/17/2025 at 3:20 PM revealed patient complaint of an allergic reaction to a vaccine she received before her admission at the psychiatric hospital. S7MD was notified and order was provided for one dose of ibuprofen 600 mg orally with continued monitoring. Review of Daily Nurse Progress Note dated 09/18/2025 between 7:00 AM and 7:00 AM on 09/19/2025 revealed patient was not having thoughts of killing herself and was not exhibiting suicidal behavior. Review of Daily Nurse Progress Note dated 09/18/2025 at 8:00 PM revealed patient was cooperative and denied suicidal ideations. Review of Medical Consult Form signed by S7MD dated 09/19/2025 at 10:30 AM revealed the following in part: “Patient received meningitis shot in her right arm 1 day prior to arrival at our facility. Since then she has developed mild swelling, redness at site. No fever no chills no loss of sensation or strength in right arm. No additional concerns, unsure if she has ever had a reaction before.” Assessment: Allergic Reaction. Plan: “localized based on exam. Will start scheduled Tylenol and ibuprofen for 2 day duration and monitor response. Patient ambulating without difficulty, normal appetite and activity level.” Continued review failed to reveal documentation that S7MD contacted Patient #1’s mother to inform her of this change in condition and his treatment plan. Review of Progress Notes dated 09/19/2025 at 5:55 PM revealed during mother’s visitation with Patient #1 she was concerned about her daughter’s arm and requested transfer to an emergency department for treatment. Mother wanted to know when she could be discharged. She was told the Formal Voluntary Admission was for 72 hours. S7MD was notified of mother’s request for her daughter to be transferred to an emergency department for treatment. S7MD stated he did not want to send Patient #1 to an emergency department and did not want to order what the mother suggested. (Benadryl, Pepcid, and steroids). Continued review of Patient #1’s medical record failed to reveal documented safety concerns or behaviors posing risk of harm to self or others during transport from the psychiatric hospital to an emergency department in response to the mother’s request for medical evaluation/treatment from a higher level of care. During an interview on 12/03/2025 at 3:35 PM, S17Staff stated S7MD had evaluated the reaction and his professional opinion was the patient did not need to be transferred. S17Staff indicated the transfer of a patient for medical care was costly, and if the issue could be handled at the psychiatric hospital then that is the preferred path. 2) Failure to ensure the patient or patient representative signed a consent for treatment in 1 (#2) of 5 patient medical records sampled. Review of Patient #2’s medical record on 12/03/2025 between 12:04 PM-1:00 PM revealed an admit date of 10/12/2025 with ongoing admission. Review of Patient #2’s “Conditions of Admission” form dated 10/12/2025, failed to reveal the patient or patient representative signed a consent for treatment. During an interview on 12/03/2025 at 12:45 PM, S3NM confirmed the “Conditions of Admission” form dated 10/12/2025, failed to reveal the patient or patient representative signed a consent for treatment.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 47397 Based on observation and interview the hospital failed to ensure care in a safe setting as evidenced by: 1) failure to ensure Unit ‘B’ was maintained at a temperature between 70-75 degrees Fahrenheit effecting the 21 (#R1-#R21) patients on the census; 2) failure to ensure Patient #2 did not have access to shoelaces that created a ligature risk; and 3) failure to ensure patients did not have access to contraband. Findings: Review of hospital policy provided by S10CNO titled “Patients’ Rights and Restriction of Rights Function: Rights”, last reviewed 01/2023, revealed in part: “Procedure: 4. Patient is provided reasonable access to care, in a safe environment.” 1) Failure to ensure Unit ‘B’ was maintained at a temperature between 70-75 degrees Fahrenheit effecting the 21 (#R1-#R21) patients on the census. Review of Facility Guidelines Institute 2014 edition revealed in part: Part 4 (ASHRAE 170) Patient areas (including psychiatric units) are required to maintain a temperature between 70-75 degrees Fahrenheit. During a tour of Unit ‘B’ on 12/01/2025 between 9:42 AM and 9:58 AM guided by S11DPO and S18ADON, observation revealed patients in the milieu with blankets and towels wrapped around their bodies. Observation of the wall approximately twelve feet above the common area of Unit ‘B’ revealed a large clock reading 9:57 AM with temperature gauge measuring 66 degrees Fahrenheit. Continued observation revealed HVAC system ‘C’ temperature gauge in the common area of Unit ‘B’ on the wall approximately eye level reading 64 degrees Fahrenheit. During an interview on 12/01/2025 at 10:00AM S11DPO and S18ADON confirmed the common area of Unit ‘B’ was uncomfortably cold. S11DPO and S18ADON confirmed the readings on both gauges and stated he hospital was working on the Heating,Ventilation, and Air Conditioning sytem (HVAC). During a tour of Unit ‘B’ on 12/03/2025 between 4:50 PM and 4:55 PM guided by S19CEO observation of the wall, approximately twelve feet above the common area of Unit ‘B’ revealed the temperature gauge read 69 degrees Fahrenheit and the gauge on the wall approximately eye level, reading 67 degrees Fahrenheit. There were no patients observed on Unit ‘B’. During an interview on 12/03/2025 at 4:51 PM, S19CEO stated the patients were in the cafeteria in another building, confirmed the temperatures and stated the HVAC system was currently being worked on. 2) Failure to ensure 1 (#2) of 1 pateints sampled observed did not have access to shoelaces that created a ligature risk. Review of hospital policy provide by S10CNO titled “Admission to Discharge: Personal Belongings, Valuables, Safety/Skin, & Contraband Searches” last reviewed 12/2024, revealed in part: “Contraband: Ligature: string/rope/cord longer than 8 inches.” During a tour of Unit ‘A’ on 12/01/2025 between 9:59 AM and 10:36 AM guided by S18ADON and S3NM observations revealed Patient #2’s room with a pair of tennis shoes containing shoelaces made from the strings of medical masks tied together creating a ligature risk. During an interview on 12/01/2025 at 10:15 AM, S3NM confirmed the shoelaces in Patient #2’s shoes, verified they were a ligature risk, and stated the shoelaces should be removed from his room. 3) Failure to ensure patients did not have access to contraband. Review of hospital policy provide by S10CNO titled “Admission to Discharge: Personal Belongings, Valuables, Safety/Skin, & Contraband Searches” last reviewed 12/2024, revealed in part: “Contraband/permissible Items: 1. Hygiene items and buckets will be provided to patients for use during hygiene times and secured in a locked location when not in use. 1.1 Shampoo. 1.5 Toothbrushes. Danger Risk: Any items which are sharp or containing metal.” During a tour of Unit ‘A’ on 12/01/2025 between 9:59 AM and 10:36 AM guided by S18ADON and S3NM observations revealed the following: -Patient #R22’s room contained two metal pieces that appeared to be approximately 1 inch long, rectangular shaped with sharp corners sitting on the desk. -Room ‘a’ contained a paper bag with 2 latex-like exam gloves. Continued observation revealed a box of “Maxi-Pads” on the windowsill. -Room ‘b’ bathroom contained 3 shampoo bottles and a toothbrush. During an interview on 12/01/2025 at 10:20 AM, S3NM stated she believed the two metal pieces in Patient #R22’s room were parts of zippers and should not be accessible to patients. S3NM confirmed the items in Room ‘a’ and in the bathroom of Room ‘b’ were considered contraband and should be restricted from patient access unless there use were observed by staff.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 47397 Based on record review and interview the hospital failed to perform adequate physical assessments on 1 (#4) of 5 patients sampled. Findings: Review of hospital policy provided by S10CNO titled “Assess and Reassess: Function: Nursing: Provision of Care”, last reviewed 11/2023, revealed in part: Policy: All patients admitted to River Oaks Psychiatric Hospital will have a nursing assessment completed at a minimum every shift. Procedure: Assessment will include the patient’s mental status and physical status. Findings will be documented. More frequent assessments may be needed when patient is having a physical problem and change of condition. Pain assessments are completed on all patients and are assessed by a nurse at a minimum per shift. Reassessment occurs with change in patients’ condition, physical complaint, and patient injuries. Review of Patient #4’s medical record revealed an admit date of 09/19/2025 with admit diagnoses including auditory, visual hallucinations with depression and anxiety. Patient was discharged on 09/25/2025 with diagnoses including adjustment disorder and right hand fourth digit abscess. Review of Patient #4’s nursing notes dated 09/19/2025, 09/20/2025, 09/21/2025, 09/22/2025, and 09/23/2025 failed to reveal documentation of pain or changes to skin integrity. Each note stated “No medical issues.” Nursing Progress Note dated 09/23/2025 written by S20RN, revealed Patient #4’s “mother stated she wanted her daughter to have her hand examined and if an xray is needed then do the xray. Was told by S16NP to put the patient back on the physician list for an examination. No xray done until hand is examined per mother’s request.” Review of Patient #4’s nursing note 09/24/2025 failed to reveal documentation of pain or changes to skin integrity. The note stated “No medical issues.” Review of Medical Consult Form signed by S16NP on 09/24/2025 at 12:00 PM revealed the following: “My finger is infected. patient has erythema and edema to her right ring finger, no purulent drainage. Reports it is tender to touch. Afebrile.” Physical assessment: Right ring finger with edema [swelling] and erythema [redness] no purulent [discharging pus] drainage. Plan: “Keflex [antibiotic] 500 mg twice a day for 7 days and warm water soaks twice a day.” Nursing Progress Note dated 09/25/2025 written by S20RN, revealed the following: “I asked S7MD to reexamine Patient #4’s hand this morning around 9:00 AM. He gave orders to send patient to urgent care to get her finger drained. Urgent care drained her finger and sent her with a prescription for Bactrim DS [antibiotic] 800-160 mg oral daily for 7 days. S7MD gave order to discontinue the Keflex [antibiotic] and start the Bactrim. The patient’s mother was notified she returned to the unit, her finger was drained and she would be starting Bactrim.” Review of Medical Consult Form signed by S7MD on 09/25/2025 at 9:15 AM revealed the following: “Infected Finger: patient with swelling and pain with palpation of right hand fourth digit. She started on oral antibiotic however no improvement in swelling. She remains afebrile and infection appears localized. She will benefit from incision and drainage, which we are unable to do here. Will send out for treatment to urgent care.” Review of Patient #4’s nursing note 09/25/2025 revealed patient was discharged to mother at 3:40 PM.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 47397 Based on record review and interview the hospital failed to ensure a completed Nursing Care plan in 2 (#1 and #5) of 5 patient medical records sampled. Findings: Review of hospital policy provided by S10CNO titled “Patients’ Rights and Restriction of Rights Function: Rights”, last reviewed 01/2023, revealed in part: “Procedure: 8. Patient’s plan of treatment is individualized to his/her special needs and circumstances.” Patient #1 Review of Patient #1’s medical record revealed and admit date of 09/16/2025 and discharge of 09/22/2025 with diagnoses of depression unspecified second to suicidal ideations with plan to overdose. Review of Medical Consult Form signed by S7MD dated 09/19/2025 at 10:30 AM revealed the following in part: “Patient received meningitis shot in her right arm one day prior to arrival at our facility. Since then she has developed mild swelling, redness at site. No fever no chills no loss of sensation or strength in right arm. No additional concerns, unsure if she has ever had a reaction before.” Assessment: Allergic Reaction. Plan: “localized based on exam. Will start scheduled Tylenol and ibuprofen for two day duration and monitor response.” Review of Medical Consult Form signed by S7MD dated 09/19/2025 at 7:45 PM revealed the following in part: Assessment: “Allergic Reaction”. Plan: “Continue Tylenol and Ibuprofen and will start scheduled Benadryl as well.” Review of Patient #1’s Interdisciplinary Master Treatment Plan dated 09/16/2025 with last entry made on 09/17/2025 failed to reveal a medical problem related to Allergic Reaction. During an interview on 12/03/2025 at 3:55 PM, S10CNO confirmed Patient #1’s treatment plan did not include the medical problem related to Allergic Reaction and should have been included. Patient #5 Review of Patient #5’s medical record revealed, admit date of 09/29/2025, and discharge on 11/26/2025 with diagnoses of depression unspecified second to suicidal ideations with plan to overdose. Review of document titled “Hospital / Licensed Provider Abuse / Neglect Initial Report” dated 11/05/2025 at 10:00 AM revealed in part: Patient #5 alleged that another male patient touched her in the thigh/groin over the clothes while in the classroom. Following the allegation, a ten foot boundary from Patient #5 was placed on the male patient although the allegation was unsubstantiated per the hospital. Review of Patient #5’s Interdisciplinary Master Treatment Plan dated 09/30/2025 with last entry made on 10/14/2025 failed to reveal a problem related to Patient #5’s allegation of sexual assault. During an interview on 12/03/2025 at 3:55 PM, S10CNO confirmed Patient #5’s treatment plan did not include a problem related to Patient #5’s allegation of sexual assault and should have been included.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 47397 Based on record review and interview the hospital failed to ensure the registered nurse assigned nursing care of each patient on Unit ‘B’. Findings: Review of Nurse Assignment sheet on 12/01/2025 at 9:46 AM for Unit ‘B’ failed to reveal the nurse had completed the assignment sheet. During an interview on 12/01/2025 at 9:46 AM, S21RN stated the unit had been busy and she had not had the chance to complete the nursing assignment sheet. S21RN verified the assignment sheet was supposed to be completed at shift change.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 47397 Failure to ensure nursing staff adhered to all policies and procedures as evidenced by: 1) failure to submit an incident report per hospital policy and procedure related to a patient-to-staff incident where staff was injured; and 2) failure to ensure nursing staff were educated and trained per hospital policy and procedure. Findings: 1) Failure to submit an incident report per hospital policy and procedure related to a patient-to-staff incident involving staff injury. Review of hospital policy provided by S10CNO titled “IR/Incident Reporting Process” last revised 09/2023, revealed in part: “V. Procedure: B. Healthcare Facility Staff 1. Any healthcare facility employee, who discovers, is directly involved in, or responds to an incident, is to complete or direct completion of an IR/Incident Report as soon after the event as possible, but not later than the end of the shift.” Review Patient #2’s Nursing Progress Note dated 12/01/2025 at 5:00 PM revealed S22MHT reported to nurse that Patient #2 pushed her and she cut her wrist on a piece of metal on the unit. S22MHT notified the nurse supervisor and reported she was pressing charges against Patient #2. Review of Incident Log on 12/03/2025 provided as complete and dated 09/01/2025 through 12/01/2025 failed to reveal an incident report was completed related to this incident. During an interview on 12/03/2025 at 4:12 PM, S10CNO confirmed there had not been an incident report completed by staff per hospital policy and procedure as of 12/03/2025 at 4:12 PM. 2) Failure to ensure 2 (S13RN and S6MHT) of 6 nursing staff personnel files sampled were educated and trained per hospital policy and procedure. Review of hospital policy provided by S10CNO titled “Patients’ Rights and Restriction of Rights Function: Rights”, last reviewed 01/2023, revealed in part: Procedure: 6. All employees receive continued education regarding the patient’s right to privacy and confidentiality. Review of hospital policy provided by S10CNO titled “Staff Competency and Training” last revised 09/2020, revealed in part: “Purpose: to assure compliance with all laws, rules and regulations relating to federal and state health care programs. Annual Retraining: On an annual basis, each employee is required to complete the following topics: “ Fire safety and Emergency Management “ Infection control “ Risk Management including patient safety “ Corporate compliance, including requirements of the ( Agreement) “ HIPAA and Confidentiality “ Code of Conduct “ Ethics “ EMTALA “ Patient/Resident Rights “ Patient/Resident Advocacy and Grievance Process o Abuse/Neglect Identification and Reporting Clinical/Nursing Staff will receive additional training, appropriate to their position following areas: “ Management of aggressive behaviors “ Suicide risk assessment and management “ Medical necessity of admission and continued stay “ Appropriate use of involuntary commitments “ Active and individualized treatment requirements “ Physician participation and supervision in care “ Proper use and monitoring of physical and chemical restraint and seclusion(semi-annually for PRTF staff) “ Interdisciplinary patient/resident-centered treatment planning “ Documentation requirements “ Medical Equipment and Waived testing Training may be accomplished via the HealthStream platform, individual in-trainings, or in person group formats based on the topic and appropriate co demonstration. Competency Assessment On an annual basis, each employee receives a performance evaluation assessing competence related to each job role/responsibility. Any unsatisfactory rating accompanied by a plan for improvement. Additional task-specific competency assessments may be required annually for specific tasks in various department. Review of S13RN’s personnel file revealed a date of hire of 04/18/2022 as a Registered Nurse. Review of S13RN’s Performance Evaluation dated 12/15/2024 revealed a total score of two-“Requires Improvement”. Continued review revealed a Compliance score of one-“Does Not Meet Expectations”. Compliance refers to in part: “Follows and abides by facility policies, procedures, and corporate compliance program as applicable to role and responsibilities. Maintains required training.” Review of S13RN’s assigned training list revealed the following: Precautions and Prevention of High risk Behaviors: Past due on 06/17/2022 Stages of Crisis: Past due 11/20/2022 Anxiety related disorders: Past due 08/01/2023 Assessing Immediate risk to Physical Safety: Past due 08/01/2023 Avoiding Power Struggles: Past due 08/01/2023 Bipolar Disorder: Past due 08/01/2023 Developing a Crisis Prevention Plan: Past due 08/01/2023 Key Points in Crisis Management: Past due 08/01/2023 Limit Setting-Supportive Redirection: Past due 08/01/2023 Post Crisis Patient Debriefing: Past due 08/01/2023 Safety Managing Altercations: Past due 08/01/2023 Schizophrenia and Psychotic Disorders: Past due 08/01/2023 Self-Assessment Before, During, and After a Crisis: Past due 08/01/2023 Substance Use Disorders: Past due 08/01/2023 Seclusion and Restraint Training (All Staff): Past due 08/01/2023 Seclusion and Restraint Training (RN): Past due 08/01/2023 Stages of Crisis Stage 4-Tension Reduction: Past due 10/31/2025 Q3 Sept Play it safe: Past due 10/31/2025 Q3 Sept Play it safe-Metal Scraps: Past due 10/31/2025 Caring for the Cognitively Impaired for Healthcare Assistants: Past due 11/20/2025. Post Crisis Staff Debriefing: Past due 11/20/2025. During an interview on 12/03/2025 at 1:45 PM, S2HR and S23HR confirmed S13RN received a low rating on her performance evaluation partly because of non-compliance with assigned training. Review of S6MHT’s personnel file revealed a date of hire of 02/2025 as a Mental Health Technician. Review of S6MHT’s Performance Evaluation dated 10/01/2025 revealed a total score of two-“Requires Improvement”. Continued review revealed a Compliance score of one-“Does Not Meet Expectations”. Compliance refers to in part: “Follows and abides by facility policies, procedures, and corporate compliance program as applicable to role and responsibilities. Maintains required training.” Review of S6MHT’s assigned training list revealed the following: Limit Setting-Supportive Redirection: Past due 06/30/2025 Stages of Crisis-Stage 2-Defensive: Past due 06/30/2025 Substance Use Disorders: Past due 06/30/2025 Stages of Crisis-Stage 3-Loss of Control/Risk: Past due 07/31/2025 Observation round policy and procedure: Past due 09/30/2025 Safety Managing Altercations: Past due 09/30/2025 Stages of Crisis Stage 4-Tension Reduction: Past due 10/31/2025 Q3 Sept Play it safe: Past due 10/31/2025 Q3 Sept Play it safe-Metal Scraps: Past due 10/31/2025 Q3 Sept Play it safe-Nemschoff Chairs: Past due 10/31/2025 Caring for the Cognitively Impaired for Healthcare Assistants: Past due 11/20/2025. Post Crisis Staff Debriefing: Past due 11/20/2025. During an interview on 12/03/2025 at 1:58 PM, S2HR and S23HR confirmed S6MHT received a low rating on his performance evaluation partly because of non-compliance with assigned training.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 14442 Based on record review and interview, the hospital failed to ensure the patient right to receive care in a safe setting. This deficient practice is evidenced by failing to ensure hospital policy for elopement precautions was implemented for 1 (#1) of 2 (#1, #2) patients that eloped from the hospital. Findings: Review of hospital policy titled “Elopement Precautions Function: Care” Reviewed: 12/2024, Revised: 10/2024 revealed, in part: “Policy: It is the policy of River Oaks Hospital to prevent patient elopements whenever possible and to provide consistent methods of follow-up in the event that they do occur. Procedure: Elopement Precautions. All patients deemed as elopement risks should be placed on Elopement Precautions according to the severity of the risk of elopement. Patients most frequently at high risk for elopement are adolescents, chemical dependency patients and patients under involuntary admission status. The decision may be based on the following: Patient’s self-disclosure. Risk factors or warning behaviors, which may influence and/or predict elopement, can include: Patients who sign a Request for Release From Formal Voluntary Status (“72”)-if a patients signs a “72” the Physician will be notified of such and of any other elopement risks present to determine if high risk for elopement is present and/or elopement precautions are indicated, document in medical record.” Review of Patient #1’s medical record revealed the patient voluntarily admitted to the hospital on 12/25/2024 at 12:19 PM. Further review of Patient #1’s medical record revealed documentation Patient #1 verbalized a desire to leave the hospital. Review of Patient #1’s medical record revealed a signed “Request for Release Formal Voluntary Status” form dated 12/27/2024 at 8:49 AM that read, in part: “I, (Patient #1’s name) having been hospitalized at River Oaks Hospital on a formal voluntary status, now request that the Administrator release me within 72 hours.” Review of Patient #1’s medical record revealed no evidence Patient #1’s physician was notified that the patient signed a “Request for Release Formal Voluntary Status” form as indicated in hospital policy. Review of Patient #1’s medical record revealed Patient #1 eloped from the hospital on 12/27/2024 at 11:18 AM. In an interview on 01/14/2025 at 2:39 PM, S1DRM confirmed Patient #1’s medical record contained no evidence the physician was notified that the patient signed a “Request for Release Formal Voluntary Status” form. S1DRM confirmed Patient #1 eloped from the hospital on 12/27/2024 at approximately 11:18 AM.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 50453 Based on record review and interview, hosptial nursing staff failed to administer PRN medications in accordance with accepted standards of practice. This deficient practice is evidenced by failure of the nursing staff to monitor the therapeutic effects of PRN medications in 1 (#2) of 3 (#1-#3) patients reviewed. Findings: Review of hospital policy titled, “PRN Orders” missing effective date and review date, revealed in part: “PROCEDURE: F. Efficacy or PRN medication must be documented within one hour after administration.” Patient #2 Review of Patient #2’s medication administration record revealed the following PRN medications were administered: Tizanidine (Zanaflex) 4mg oral tablet four times a day PRN for Muscle Spasms: Administered on 12/25/2024 at 12:16 PM. Effectiveness evaluated at 7:13 AM on 12/26/2024. Administered on 12/26/2024 at 8:51 AM. Effectiveness evaluated at 10:38 AM on 12/26/2024. Hydroxyzine (Vistaril) 50mg oral tablet four times a day PRN for Anxiety: Administered on 12/28/2024 at 8:10 AM. Effectiveness evaluated at 2:39 PM on 12/28/2024. In an Interview on 01/14/2025 at 11:35 AM, S1DRM confirmed that the therapeutic effects of the PRN medications listed above were not re-evaluated within one hour of administration.”

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 50453 Based on record review and interview, the hospital failed to ensure that all medical record entries were dated and timed by the person responsible for providing the treatment or service provided. This deficient practice is evidenced by failing to assure all pages in the medical record contained the date and time of treatment or service provided for 1 (#2) of 3 (#1-#3) records reviewed for completeness of documentation. Findings: A review of Patient #2’s medical record revealed an AMA form titled, “Release From Responsibility For Discharge” signed by the patient and witnessed by hospital staff. Further review failed to reveal a date or time the document was completed. In an interview on 01/14/2025 at 9:26 AM, S1DRM confirmed the AMA form for Patient #2 was not complete and was missing the date and time.”

“CONTENT OF RECORD: ORDERS DATED & SIGNED CFR(s): 482.24(c)(2) All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations. This Standard is not met as evidenced by: 50453 Based on record review and interview, the hospital failed to ensure all hospital orders were promptly signed, dated, and timed by the physician. This deficient practice is evidenced by verbal/telephone orders not being authenticated by the physician within the timeframe stipulated by the hospital policy for 2 (#1, #2) of 3 (#1-#3) medical records reviewed. Findings: Review of Medical Staff Bylaws, last revised 04/2024, revealed in part: “Medical Records: 6. Telephone orders of authorized physician practitioners shall be accepted and transcribed by Registered Nurses or Licensed Practical Nurses. The responsible physician practitioner shall sign such orders at the next visit, not to exceed forty-eight (48) hours.” Review of hospital policy titled “Telephone/Verbal Orders,” last reviewed 01/2024, revealed in part: “PROCEDURE: 1) The licensed nurse receiving the verbal/telephone order shall promptly enter the order into the electronic medical record, indicating the order in the following manner: Choose telephone order and the ordering physician in the drop down in the electronic record. The licensed nurse receiving the verbal/telephone order will repeat the order back to the physician to ensure accuracy of the order. The physician will authenticate orders electronically within 48 hours of the verbal/telephone order. A covering physician/LIP may authenticate the attending physician/LIP’s telephone orders.” Review of Patient #2’s medical record revealed an admission date of 12/24/2024. Review of Patient #2’s admission and medication orders revealed the orders were obtained by telephone from the physician and entered by the nurse on the following dates: 12/24/2024 at 5:10 PM 12/25/2024 at 9:30 AM 12/27/2024 at 11:40 PM 12/29/2024 at 10:23 PM 12/29/2024 at 10:24 PM Further review revealed that the physician did not authenticate the orders listed above until 01/02/2025 at 10:09 AM. In an interview on 01/14/2025 at 1:15 PM, S1DRM confirmed that the orders entered by the nurse for Patient #2 were not authenticated by the physician within 48 hours of the verbal/telephone order as per policy. Review of Patient #1’s medical record revealed an admission date of 12/26/2024. Review of Patient #1’s admission and medication orders revealed the orders were obtained by telephone from the physician and entered by the nurse on the following dates: 12/26/2024 at 12:42 PM 12/27/2024 at 6:17 AM 12/27/2024 at 6:21 AM Further review revealed that the physician did not authenticate the orders listed above. In an interview on 01/14/2025 at 1:19 PM, S1DRM confirmed that the orders entered by the nurse for Patient #1 were not authenticated by the physician within 48 hours of the verbal/telephone order as per policy.”

“Discharge Summary - Patient Condition CFR(s): [The record of each patient who has been discharged must have] a brief summary of the patient’s condition on discharge. This Standard is not met as evidenced by: 50453 Based on record review and interview, the hospital failed to ensure the discharge summary contained the relevant information about the condition of the patient on the day of discharge. This deficient practice is evidenced by the discharge summary not including an accurate description of the clinical course for 1 (#2) of 3 (#1-#3) medical records reviewed. Findings: Review of the hospital Medical Staff Bylaws, last revised 04/2024, revealed in part: “Medical Records: 8. (K) a discharge summary, entered within (30) days following discharge and including: (1) the reason for hospitalization; (2) the significant findings; (3) the course and progress of the patient with regard to each identified clinical problem; (4) the clinical course of the patient’s treatment; (5) the final assessment, including the general observations and understanding of the patient’s condition initially, during treatment and at discharge; (6) the specific appointment arrangements for further treatment, including prescribed medications and after, specific instructions to the patient and family as necessary; (7) the final primary and secondary diagnosis.” Review of Patient #2’s medical record revealed the patient was admitted on 12/24/2024 for Opiate and sedative detoxification. Review of incident report provided involving Patient #2, revealed that Patient #2 eloped from the facility on 12/30/2024 at 4:10 PM and the provider was notified of elopement. Further review of Patient #2’s medical record revealed an additional note stating the patient returned on 12/30/2024 at 5:10 PM to collect his cell phone. MD notified. Discharge AMA order obtained. Patient signed out AMA. Returned cell phone. Left agitated, yelling about MD not discharging him prior. Review of the discharge summary for Patient #2 revealed in part: 2. Safety: No major behavioral problems were reported during the hospitalization. 10. The patient tolerated medications without side effects and was successfully detoxed with no acute events. Patient was more cooperative and responded positively to redirections and limits set by the staff. The patient requested discharge and was discharged AMA. 11. On date of discharge, the patient was evaluated and patient denied withdrawal symptoms, suicidal/homicidal ideation, intention or plan and there was no evidence of manic or depressive symptoms. Patient was discharged from the hospital in stable condition. Condition at Discharge: Psychiatric Functioning to include Mental Status: The patient is felt to have improved in their psychiatric condition to the point where they may be discharged to outpatient care for follow-up at this time, having reached maximal hospital benefit. Social Functioning: The patient is felt to have improved in their level of functioning, so that they may function in an unstructured environment. Dated/timed by physician on 12/31/2024 at 9:50 AM. In an interview on 01/14/2025 at 3:27 PM, S1DRM confirmed that the discharge summary did not contain documentation that the patient eloped from the facility on 12/30/2024. S1DRM also confirmed that based on the hospital bylaws, the discharge summary did not contain all relevant information regarding the patient condition on the day of discharge.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 14442 Based on record review, observation, and interview, the hospital failed to ensure the patient right to receive care in a safe setting by failing to ensure Unit A shared patient bathroom doors were closed and locked when unoccupied. This deficient practice presented a risk for patient harm or injury by patients being able to enter adjoining patient rooms through shared bathrooms and had the potential to impact all 13 Unit A patients on census at time of survey. Findings: Review of the hospital policy and procedure titled Patient Observation Rounds, reviewed and revised on 09/2024 revealed, in part: Purpose: To ensure patient safety, as well as, to provide a process for observing and documenting patient location and behavior. Procedure: 1.4 Ensure that doors are closed/latched/locked before letting go of the door handle/walking away. MHT: Patient bathroom doors are closed and locked when unoccupied. Review of a hospital Louisiana Department of Health Abuse and Neglect report revealed, in part, an alleged patient to patient sexual assault on Unit A that occurred on 09/12/2024 when patient #1 entered patient #3’s room through a shared bathroom. Review of the report revealed a patient blocked the bathroom door from locking with toilet paper and paper towels which was not identified until after the allegation. Further review revealed staff should ensure patient bathroom doors were locked when unoccupied. Review of Patient #4’s medical record revealed patient assigned to room A. Further review revealed Patient #4 had orders for aggression and homicidal precautions. Review of Patient #5’s medical record revealed patient assigned to room B. Further review revealed Patient #5 had orders for suicide precautions. Observation of hospital Unit A on 10/22/2024 at 2:16 p.m., with S1Director Risk Management, revealed Unit A had 12 double occupancy rooms and 12 shared bathrooms. Observation of hospital Unit A on 10/22/2024 at 2:19 p.m. with S1Director Risk Management revealed patient room A and patient room B shared a bathroom. The bathroom was unoccupied at time of observation. Observation revealed room A patient bathroom door was open and not closed and locked. Further observation revealed patient room B was able to be accessed by walking through the shared bathroom. In an interview on 10/22/2024 at 2:24 p.m., S1Director Risk Management confirmed the hospital policy was to ensure that patient bathroom doors were closed and locked when unoccupied. S1Director Risk Management confirmed that if a shared patient bathroom door was not closed and locked a patient from one room could enter the adjoining patient room.”

“LICENSURE OF PERSONNEL CFR(s): 482.11(c) The hospital must assure that personnel are licensed or meet other applicable standards that are required by State or local laws. This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to ensure that social workers had a valid unincumbered license. This is evidenced by failure to ensure social workers performing medical screening examinations on patients with emergency medical/psychiatric conditions had a valid unincumbered license verified by the hospital in 10 (S27PLPC, S30LPC, S31PLPC-S39PLPC, S40LPC, S41LPCS, S42LPC, and S43LPC) of 10 (S27PLPC, S30LPC, S31PLPC-S39PLPC, S40LPC, S41LPCS, S42LPC, and S43LPC) intake social workers reviewed for appropriate licensing credentials. Findings: A review of the personnel files of S27PLPC, S30LPC, S31PLPC-S39PLPC, S40LPC, S41LPCS, S42LPC, and S43LPC failed to reveal current unincumbered license verification. In an interview on 08/26/24 at 3:00 p.m., S2HR confirmed that license validity had not been verified in the following 10 social workers: S27PLPC, S30LPC, S31PLPC-S39PLPC, S40LPC, S41LPCS, S42LPC, and S43LPC.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 47397 Based on record review, and interview, the hospital failed to ensure care in a safe setting. This deficient practice is evidenced by failure of the hospital to ensure non-licensed intake personnel did not have convictions that bar employment in healthcare facilities in the State of Louisiana in 1 (S35REC) of 5 (S34REC, S35REC, S36REC, S37CS, and S44CS) unlicensed intake personnel files reviewed. Findings: A Review of memo HHS 24-S-12 updated 12/18/2023 regarding Criminal Convictions that Bar Employment of Unlicensed Persons or Ambulance Personnel revealed in part, “It is the responsibility of all employers that employ non-licensed persons or ambulance personnel to know which convictions bar employment. Louisiana Revised Statute 40:1203.3 covers criminal convictions that bar an employer from hiring a non-licensed person or ambulance personnel. Those criminal convictions are listed in the following table, in part: . . . R.S.40:966... A review of S35REC’s personnel file revealed hire date: 10/11/2021. Further review revealed a Background Report dated 05/12/2023 with an arrest date, 01/14/2019 in Hammond, Louisiana. Charge: R.S. 40:966. Further review failed to reveal a disposition pertaining to Charge: R.S. 40:966. In an interview on 08/27/24 at 11:31 a.m., S2HR confirmed the hospital failed to obtain the details of the disposition pertaining to Charge R.S. 40:966 before hiring S35REC.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 47397 Based on record review and interview the hospital failed to ensure the policy and procedure governing medical care in the Emergency Intake process were followed as evidenced by failure to ensure intake counselors performing medical screening examinations on patients with emergency medical/psychiatric conditions obtained admission orders from a qualified provider before diagnosing, admitting into computer and assigning Patient #10 a room number. Findings: A review of psychiatric hospital policy titled “Plan for the Provision of Care, Function: Leadership”, revised 05/2024, revealed in part: 5.2 Admission process:....Upon receipt of physician’s orders and signed consent for treatment, the patient meeting admission criteria will be admitted to the appropriate unit/program ... A review of the EMTALA Log dated 08/22/2024 at 11:20 a.m. revealed Patient #10. Continued review revealed Patient #10 arrived by car, a 16 year old female, accompanied by mother with a complaint of psych. The EMTALA log revealed Patient #10’s condition was considered a Medical/Psychiatric Emergency. Further review revealed Patient #10’s EMTALA disposition was at 1:30 p.m. as an admission. Observations of intake process on 08/22/24 from 11:17 a.m. through 1:00 p.m. revealed the following: 11:17 a.m.-12:03 p.m. S17MSW completed the intake process. 12:06 p.m. S17MSW announces to mother that she is going to get admit orders from S54MD. In an interview on 08/22/24 at 12:08 p.m., S17MSW stated “We are admitting her for suicidal ideations, I will call the nurse on the adolescent unit and get admit orders”. 12:18 p.m. S17MSW begins admitting the patient into the computer. 12:20 p.m. S17MSW reviews call sheet and admits Patient #10 to room ‘b’ to S54MD. S17MSW states “Patient is now admitted”. 11:17 a.m.-12:20 p.m. S17MSW failed to contact a physician, nurse or other provider for admission orders. In an interview on 08/22/24 at 12:20 p.m., S17MSW confirmed she had not spoken with nurse or physician. 12:21 p.m. observation of room ‘c’ reveals large computerized admit board. The admit board reveals Patient #10 was admitted. 12:31 p.m. medication for aripiprazole and olanzapine entered onto SBAR. UDS negative entered. Then S15MSW sends SBAR to nurse on unit through a computer messaging system. 12:47 p.m. S17MSW received admit orders for Patientg #10 from S54MD. In an interview on 08/22/24 at 12:47 p.m., S17MSW confirmed she had just received admit orders from S54MD. A review of Patient #10’s Standardized Intake Assessment dated 08/22/2024, completed at 12:03 p.m. revealed in part, S17MSW performed the medical screening. Documentation revealed blood pressure of 113/58, temperature 96.5, and pulse 95 with respirations 18. The triage was signed by S17MSW as assessor at 12:47 a.m. S17MSW indicated S54MD was notified of higher risk on 08/22/2024 at 12:47 p.m. A review of Patient #10’s Psychiatric SBAR-Intake to Unit Patient Report Worksheet form dated 08/22/2024 at an undocumented time revealed the form was completed by S17MSW. The assessment on the form revealed Patient #10 was diagnosed with Eczema. Further review failed to reveal S17MSW documented receiving admission orders from S54MD. Continued review failed to reveal a signature of the receiving nurse or a time the SBAR was submitted to the unit. A review of physician order sheet revealed admit orders per telephone on 08/22/2024 at 4:17 p.m. by from S69RN from S54MD. In an interview on 08/22/24 at 3:48 p.m. S9RMPI stated Patient #10 should not have been admitted until after the physician and nurse were spoken to and had provided admit orders per hospital policy.”

“EMERGENCY SERVICES PERSONNEL CFR(s): 482.55(b) Personnel This Standard is not met as evidenced by: 47397 Based on interview and record review the hospital failed to ensure all emergency services personnel requirements were met by failing to ensure effective EMTALA training for 6 (S12SW, S16RNAD, S23MHA, S29RSW, S30LPC and S37CS) of 18 (S8REC, S10RN, S11RN, S12SW, S15MHT, S16RNAD, S17MSW, S20CSW, S23MHA, S27PLPC, S29RSW, S30LPC, S34REC, S35REC, S36REC, S37CS, S44CS, S46ADOA) intake staff reviewed; Review of hospital’s policy titled “Staff Competency and Training”, approved 04/2024, revealed in part: Orientation...Hospital-wide orientation will include at least the following elements ...EMTALA. Annual Retraining. On an annual basis, each employee is required to complete refresher training on the following topics ...EMTALA. S12SW A review of S12SW’s personnel file revealed date of hire: 05/22/2002. Further review failed to reveal S12SW underwent EMTALA training. S16RNAD A review of S16RNAD’s personnel file revealed date of hire: 10/09/2023. Further review failed to reveal S16RNAD underwent EMTALA training. In an interview on 08/27/24 at 1:38 p.m., S16RNAD stated she did not know the meaning of the acronym “EMTALA”. S16RNAD reported she was unable to state how EMTALA defines an emergency medical/psychiatric condition. S23MHA A review of S23MHA’s personnel file revealed date of hire: 06/05/2023. Further review failed to reveal S29RSW underwent EMTALA training. S29RSW A review of S29RSW’s personnel file revealed date of hire: 10/04/2016. Further review failed to reveal S29RSW underwent EMTALA training. S30LPC A review of S30LPC’s personnel file revealed date of hire: 01/03/2023. Further review failed to reveal S30LPC underwent EMTALA training. S37CS A review of S37CS’s personnel file revealed date of hire: 07/08/2024. Further review failed to reveal S37CS underwent EMTALA training. In an interview on 08/27/24 at 11:25 a.m. S1EDU confirmed the above findings. In an interview on 08/27/24 at 1:36 p.m., S8REC reported she was unable to state what the acronymn “EMTALA” means, “You will have to ask admissions”. S8REC confirmed she completed the EMTALA course and completed the test but could not remember the information that was presented in the course and on the test. In an interview on 08/27/24 at 1:42 p.m., S18MSW reported she was unable to state what the acronymn “EMTALA” means, “something about a log?” S18MSW confirmed she was unable to state how EMTALA defines an emergency medical/psychiatric condition.”

“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: 48051 Based on observation, record review and interview, the hospital failed to ensure compliance with the requirements of CFR 489.24 as evidenced by failure to ensure all patients who presented with an emergency medical/psychiatric condition received an appropriate medical screening exam performed by qualified medical persons on 20 (#1 - #20) of 20 (#1 - #20) patients with a psychiatric/medical emergency reviewed (see findings tag A-2406).”

“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: 47397 Based on observation, record review and interview, the psychiatric hospital failed to ensure all patients who presented with an emergency Medical/Psychiatric condition received an appropriate medical screening exam. This deficient practice is evidenced by failure to ensure intake staff were qualified medical persons performing medical screening examinations on 20 (#1-#20) of 20 (#1-#20) patients reviewed with emergency medical/psychiatric conditions. Findings: Observation of sign in hospital lobby revealed the following, in part: ...If you have a medical emergency or are in labor, you have the right to receive, within the capabilities of this hospital’s staff and facilities: An appropriate Medical Screening Examination ... A review of psychiatric hospital policy titled “Plan for the Provision of Care, Function: Leadership”, revised 05/2024, revealed in part: ...Refer to Stoplight (Exclusionary Criteria) sheet for admission restrictions that exist which would prevent the proper utilization of services within the hospital or prevent patients from receiving the most appropriate care for their type and degree of illness .... Patient #1 A review of the EMTALA Log dated 06/26/2024 at 6:03 p.m. revealed Patient #1 arrived by car with a complaint of chemical dependency and Patient #1’s condition was considered a Medical/Psychiatric Emergency with a disposition for Medical Clearance per ambulance at 8:15 p.m. A review of Patient #1’s Standardized Intake Assessment dated 06/26/2024 revealed in part, S25MCSW performed the medical screening at 6:27 p.m. Patient #1’s medical condition included sweating, blood pressure 89/68, and heart rate 109. The assessment revealed S25MCSW described the patient’s current mental status as “lethargic, momentarily alert, than unresponsive” and indicated in multiple assessment questions unable to assess due to the patient being lethargic. S25MCSW documented in the additional comments, “referred MOT (Memorandum of Transfer) for low BP and LOC”. S49MD (Psychiatrist) was notified via phone of the patient’s higher risk and assessment review on 06/26/2024 without a time indicated. . The triage was signed by S25MCSW as the assessor on 06/26/2024 without a time indicated. The patient was transferred to unkown facility. A review of the EMTALA Log dated 06/27/2024 at 11:45 a.m. revealed Patient #1’s return to this facility by car with a complaint of chemical dependency. The EMTALA Log revealed Patient #1’s condition was considered a Medical/Psychiatric Emergency with a disposition for admission at 2:00 p.m. A review of Patient #1’s Standardized Intake Assessment - Reassessment Within 72-Hours dated 06/27/2024 revealed in part, the original assessment was completed on 06/26/2204 and S27PLPC (Provisional Licensed Professional Counselor) signed as the Assessor on 06/27/2024 at 12:22 p.m. S27PLPC documented Patient #1 was sent out for medical clearance (on 06/26/24) because of low blood pressure and changes in level of consciousness. Further documentation revealed the patient was “lethargic during assessment” and Current Mental Status included poor eye contact, slurred speech and lethargic. The Standardized Intake Assessment - Reassessment Within 72-Hours did not include a medical screening. S27PLPC indicated S47MD (Psychiatry) was notified of the patient’s higher risk on 06/27/2024 at 12:35 p.m. A MOT dated 06/27/2024 at 12:46 p.m. revealed in part, S27PLPC completed the form and indicated, “Pt is lethargic in admissions lobby. Per doctors order, pt is requesting to get sent to ER due to heavy sedation, lethargy and drug overdose.” S47MD was listed as the consulting physician. The medical record did not reveal documentation as to why the patient was not transferred at that time. Patient #1 was admitted to Unit “i” at 2:00 p.m. A review of a nursing note by S50RN dated 06/27/2024 at 3:25 p.m. revealed in part, patient arrived to the Unit “i” via escort by S16RNAD at 2:20 p.m. Patient was alert, oriented x 2, sedated and confused. Patient was confused and unable to answer questions. S50RN documented, “Patient stated that she had Xanax after she left the hospital last night.” S51MD assessed the patient and ordered the patient to be transferred for medical clearance. The patient was transferred to Hospital “A” on 06/27/2024 without a time indicated. In an interview on 08/26/2024 at 11:11 am S16RNAD confirmed the above mentioned findings. In an interview on 08/27/2024 at 3:30 p.m. S9RMPI confirmed the above mentioned findings. Patient #2 A review of the EMTALA Log dated 05/07/2024 at 6:34 p.m. revealed Patient #2 arrived by car with a complaint of chemical dependency and Patient #2’s condition was considered a Medical/Psychiatric Emergency with a disposition for, “pt (patient) had to be medically cleared referred to urgent care” at 8:00 p.m. Further, the EMTALA Log revealed the departure mode as, “Ped” (the facility was unable to verify the meaning of this type of departure mode). A review of the medical record revealed the patient was given a Referral Recommendations and Crisis Safety Plan dated 05/07/2024. The form revealed in part: Referral Recommendations: 1. Clinic “D” ... and 2. Hospital “C” ... it was further noted at the top of the form, “for medical clearance of a prior injury”. A review of the EMTALA Log dated 05/07/2024 at 11:49 p.m. revealed Patient #2’ return to the facility by car with a complaint of chemical dependency. The EMTALA Log revealed Patient #2’s condition was considered a Medical/Psychiatric Emergency with a disposition for admission to the facility on 05/08/2024 at 1:45 a.m. A review of Patient #2’s Standardized Intake Assessment dated 05/08/2024 revealed in part, S57IC completed the medical screening on 05/08/2024 at 12:03 a.m. S57IC indicated S54MD was notify of the patient’s higher risk on 05/07/2024 at 7:21 p.m. Of note, this time frame would have been during Patient #2’s original encounter at the facility mentioned above (approximately 5 hours earlier). Further, S57IC documented the completion of the triage on 05/07/2024 at 7:21 p.m. (approximately 5 hours earlier). The assessment does not indicate the provider’s notification of higher risk at this second encounter. The assessment was signed by S57IC as the Assessor on 05/08/2024 at 12:57 a.m. and indicated the Assessment was reviewed with S54MD via phone at this same time. The Intake Assessment did not reveal the reason the patient was in need of medical clearance at the original encounter or if the patient had received a medical clearance prior to returning to this facility. In an interview on 08/26/2024 at 11:15 a.m. S16RNAD confirmed the above mentioned findings. In an interview on 08/27/2024 at 3:30 p.m. S9RMPI confirmed the above mentioned findings. Patient #3 A review of the EMTALA Log dated 07/12/2024 at 6:45 p.m. revealed Patient #3 arrived by car with a complaint of chemical dependency. The EMTALA Log revealed Patient #3’s condition was considered a Medical/Psychiatric Emergency with a disposition for admission at 10:00 p.m. A review of Patient #3’s Standardized Intake Assessment dated 07/12/2024 revealed in part, S17MSW completed the medical screening on 07/12/2024 at 8:21 p.m. S17MSW indicated on the medical screening that Patient #3 had history of diabetes and had the following symptoms cramping, sweating, nausea, diarrhea, and tremors. S17MSW signed indicated the triage was completed on 07/12/2024 without a time indicated and as the assessor on 07/12/2024 at 8:45 p.m. S17MSW indicated S59MD (Psychiatrist) was notified via phone of the patient’s higher risk and for assessment review on 07/12/2024 at 9:51 p.m. Patient #3 was admitted to Unit “j” at 10:00 p.m. The Nursing Admission Assessment dated 07/12/2024 at 9:50 p.m. revealed a blood glucose of 483 mg/dl. A nursing note on the Nursing Admission Assessment by S60RN revealed S3NP was contacted regarding the blood glucose and orders were received to transfer the patient to the emergency room. The note indicated the patient was transferred to Hospital “A” at 11:20 p.m. A review of Stoplight (Exclusionary Criteria) sheet for admission restrictions form approved by S48MD and S63MD, updated on 08/09/2024, revealed, in part: Yellow Zone: Require review by S48MD (Medical). 16. Diabetes (all types) - S48MD must be contacted for blood glucose less than 45 or blood glucose greater than 400. In an interview on 08/27/2024 at 3:30 p.m. S9RMPI confirmed the above mentioned findings. Patient #4 A review of the EMTALA Log dated 08/11/2024 at 8:15 p.m. revealed Patient #4 arrived by car with a complaint of chemical dependency. The EMTALA Log revealed Patient #4’s condition was considered a Medical/Psychiatric Emergency with a disposition for admission on 08/12/2024 at 2:55 a.m. A review of Patient #4’s Standardized Intake Assessment dated 08/11/2024 revealed in part, S25MSP completed the medical screening on 08/12/2024 at 12:29 a.m. S25MSP indicated on the medical screening that Patient #4 had a history of seizures with the last occurring 1 year. S25MSP signed indicating the triage was completed on 08/12/2024 at 12:42 a.m. and as the assessor on 08/12/2024 at 2:40 a.m. S25MSP indicated S51MD (Psychiatrist) was notified via phone of the patient’s higher risks and for assessment review on 08/12/2024 at 2:40 a.m.. Patient #4 was admitted to Unit “i” at 2:55 a.m. A review of a MOT initiated on 08/12/2024 at 9:47 a.m. revealed a transfer to emergency department (no hospital indicated on form) for seizure activity. In an interview on 08/27/2024 at 3:30 p.m. S9RMPI confirmed the above mentioned findings. Patient #5 A review of the EMTALA Log dated 08/16/2024 at 7:00 a.m. revealed Patient #5 arrived by ambulance with a complaint of “detox”. The EMTALA Log revealed Patient #5’s condition was considered a Medical/Psychiatric Emergency with a disposition for admission on 08/16/2024 at 1:00 p.m. A review of Patient #5’s Standardized Intake Assessment dated 08/16/2024 revealed in part, S17MSW completed the medical screening on 08/16/2024 without a time indicated. S17MSW documented the patient’s presenting problem as intentional overdose and has history of self-harm; current withdrawal symptoms at sweats, nausea/vomiting, cramps, fever, tremors, anxiety, and cravings; current mental status as disheveled and confused. The patient reported the last use of heroin was on 08/14/2024. S17MSW signed indicating the triage was completed on 08/16/2024 without a time indicated and as the assessor on 08/16/2024 at 8:38 a.m. S17MSW indicated S54MD (Psychiatrist) was notified via phone of the patient’s higher risk and assessment review on 08/16/2024 at 11:55 a.m. Patient #5 was admitted to Unit “i” on at 1:00 p.m. A review of the Nursing Admission Assessment dated 08/16/2024 at 3:00 p.m. revealed an initial heart rate of 94. Current withdrawal symptoms included diaphoresis, nausea, tremors and anxiety. Patient #5’s heart rate decreased to 39, a time was not indicated of this taking place. MOT dated 08/16/2024 at 6:20 p.m. revealed a transfer to the emergency department (no hospital indicated on form) related to low heart rate, no provider noted on the MOT. In an interview on 08/27/2024 at 3:30 p.m. S9RMPI confirmed the above mentioned findings. Patient #6 A review of the EMTALA Log dated 08/20/2024 at 10:40 a.m. revealed Patient #6 arrived by car with a complaint of chemical dependency. The EMTALA Log revealed Patient #6’s condition was considered a Medical/Psychiatric Emergency with a disposition for admission on 08/20/2024 at 12:45 p.m. A review of Patient #6’s Standardized Intake Assessment dated 08/20/2024 revealed in part, S19RSW completed the medical screening on 08/20/2024 at 11:11 a.m. S19RSW indicated on the medical screening that Patient #6 had a history of diabetes, scar on stomach and current active symptoms of cramping, nausea, tremors and body pain at a level of 10 on pain scale. Presenting Problem was described as detox from heroin, fentanyl, cocaine, and mojo. S19RSW signed indicating the triage was completed on 08/20/2024 at 11:23 a.m. and as the assessor 11:49 a.m. S19RSW indicated S63MD (Psychiatrist/Medical Director) was notified via phone on 08/20/2024 at 11:19 a.m. of the patient’s higher risks on 08/20/2024 at 11:19 a.m. and for assessment review at 11:49 a.m. Patient #6 was admitted to this Unit “i” on 08/16/2024 at 12:45 p.m. A review of the Medical History and Physical Examination - Male (H and P) completed by S48MD on 08/20/2024 at 2:45 p.m. revealed in part, Item 8. Medical Problems: #3. pseudoseizure - patient with abnormal movements, no loss of consciousness or postictal state. Suspected the patient was having withdrawal symptoms. Recommended transfer for emergency evaluation and EMS contacted. The patient was transferred to Hospital “A”. In an interview on 08/27/2024 at 3:30 p.m. S9RMPI confirmed the above mentioned findings. Patient #7 A review of the EMTALA Log dated 03/05/2024 at 12:27 a.m. revealed Patient #7 arrived by car with a complaint of chemical dependency. The EMTALA Log revealed Patient #7’s condition was considered a Medical/Psychiatric Emergency with a disposition for admission to Unit “g” at 4:35 a.m. A review of Patient #7’s Standardized Intake Assessment dated 03/05/2024 revealed in part, S43LPC completed the medical screening on 03/05/2024 at 3:23 a.m. S43LPC indicated on the medical screening that Patient #7 had a history of anxiety, depression and leg pain at a level of 8 on pain scale. Vital signs indicated a heart rate of 123 (out of range per facility protocol). Presenting Problem was documented as patient presents wanting to detox from opiates and she indicated she had a wound on her right leg. S43LPC signed indicating the triage was completed on 03/05/2024 at 3:28 a.m. and as the assessor at 4:10 a.m. S43LPC indicated S49MD (Psychiatrist) was notified via phone on of the patient’s higher risk and for assessment review 03/05/2024 at 4:10 a.m. Patient #7 was admitted to Unit “g” on 03/05/2024 at 4:35 a.m. A review of Stoplight (Exclusionary Criteria) sheet for admission restrictions form approved by S48MD and S63MD, updated on 08/09/2024, revealed, in part: revealed: Yellow Zone: Require review by S48MD (Medical). 10. Adult: Vital Signs out of normal parameters (Norm Adult ... HR: 50-110 ...). The History and Physical Examination - Female was completed by S67APRN on 03/05/2024 at 6:00 p.m. revealed in part, a large wound on the right thigh. Further review of the medical record revealed an Authorization to Bill Clinic “D” and dated 03/05/2024. This form also included hand written notes by a Physician Assistant (unable to identify name) at Clinic “D” and dated 03/05/2024 at 7:20 p.m.. The note revealed the treatment performed on Patient #7, medication being prescribed and it was co-signed by S48MD(Hospital F’s Internal Medicine/Medicine Services) on 03/06/2024 at 3:45 p.m. Patient #7 was escorted by an MHT (mental health tech) to Clinic “D” which is located within walking distance of this facility. There was no documentation of the mode transfer - ambulatory or via wheelchair. In an interview on 08/27/2024 at 3:30 p.m. S9RMPI confirmed the above mentioned findings. Patient #8 A review of the EMTALA Log dated 03/05/2024 at 2:05 a.m. revealed Patient #8 arrived by ambulance with a complaint of a psych condition. The EMTALA Log revealed Patient #8’s condition was not considered a Medical/Psychiatric Emergency. Further review revealed Patient #8’s EMTALA disposition was admission at 2:19 a.m. A review of Patient #8’s Standardized Intake Assessment - Direct Admissions revealed in part, S43LPC signed as the assessor on 03/05/2024 at 3:00 a.m. Presenting Problem was documented as patient exhibiting psychosis, mania, erratic behaviors and agitated. S43LPC indicated S49MD (psychiatry) was notified via phone of the patient’s higher risks 03/05/2024 at 2:10 a.m. and for assessment review at 3:10 a.m. Patient #8 was admitted to Unit “j” on 03/05/2024 at 2:19 a.m. The Standardized Intake Assessment - Direct Admissions form does not include a medical screening section. Patient #8 was listed on this facility’s EMTALA Log with no indication the patient was a direct admit. In an interview on 08/27/2024 at 3:30 p.m. S9RMPI confirmed the above mentioned findings. Patient #9 A review of the EMTALA Log dated 04/29/2024 at 12:30 p.m. revealed Patient #9 arrived by car with a complaint of psychiatric condition. The EMTALA Log revealed Patient #9’s condition was considered a Medical/Psychiatric Emergency with a disposition for admission at 4:29 p.m. A review of Patient #9’s Standardized Intake Assessment dated 04/29/2024 revealed in part, S20CSW completed the medical screening on 04/29/2024 at 1:31 p.m. S20CSW indicated on the medical screening that Patient # 9 had a history of asthma, hypertension, seizures with the most recent as January and current active withdrawal symptom of tremors. Presenting Problem was documented as patient presents wanting to detox from fentanyl and depression. Patient #9 reported his last use of cocaine, marijuana and methamphetamine was in the last 24 hours. S20CSW signed indicating the triage was completed on 04/29/2024 at 1:34 p.m. and as the assessor at 3:43 p.m. S20CSW indicated a provider (no name listed) was notified via phone of the patient’s higher risk on 04/29/2024 at 3:24 p.m.and the assessment was reviewed with S47MD (psychiatry) at 3:43 p.m. The patient was admitted to the facility at 4:29 p.m. A MOT dated 04/27/2024 at no time indicated revealed Patient #9 being transferred for chest pain of a 10. Also the patient received an injection of Vivitrol. The patient was transferred to Hospital “A” without a time indicated. In an interview on 08/27/2024 at 3:30 p.m. S9RMPI confirmed the above mentioned findings. Patient #10 A review of Patient #10’s Standardized Intake Assessment dated 08/22/2024, completed at 12:03 p.m. revealed in part, S17MSW performed the medical screening. Documentation revealed blood pressure of 113/58, temperature 96.5, and pulse 95 with respirations 18. The triage was signed by S17MSW as assessor at 12:47 a.m. S17MSW specified S54MD was notified of higher risk on 08/22/2024 at 12:47 p.m. The form failed to show an indication for the higher risk notification. A review of Patient #10’s Psychiatric SBAR-Intake to Unit Patient Report Worksheet form dated 08/22/2024 with no time documented revealed the form was completed by S17MSW. Eczema was written in the Initial Medical/Acute Medical section. Patient #11 A review of the EMTALA Log dated 07/29/2024 at 10:15 a.m. revealed Patient #11 arrived by car with a complaint of chemical dependency. The EMTALA log revealed Patient #11’s condition was considered a Medical/Psychiatric Emergency with a disposition at 12:00 p.m. as an admission. A review of Patient #11’s Standardized Intake Assessment dated 07/29/2024, completed at 10:35 p.m. revealed in part, S17MSW performed the medical screening. Further review failed to reveal medicine service was notified. A review of Patient #11’s Psychiatric SBAR-Intake to Unit Patient Report Worksheet form dated 07/29/2024 at an unknown time revealed the form was completed and revealed Patient #11 was diagnosed with Opioid dependence with withdrawal by S17MSW. Patient #11 presented to detox off opiates, fentanyl 2-20 bags daily, last used 07/29/2024 at 4:00 a.m. Cocaine 8 ball weekly last use 07/29/2024 at 8:30 a.m. Patient #11 presented with withdrawal symptoms tremors, sweating, nausea, and cramping. UDS positive for fentanyl and cocaine. Further review failed to reveal S17MSW had obtained admit orders from the provider. Continued review failed to reveal a signature of the receiving nurse or a time the form was submitted to the unit. A review of Stoplight (Exclusionary Criteria) sheet for admission form approved by S48MD and S63MD, updated on 08/09/2024, revealed, in part: Yellow Zone: Requires review by S48MD (Medical). 7. Abscesses present on the body consult S48MD. A review of Memorandum of Transfer dated 07/29/2024 at 2:00 p.m., revealed in part, patient walked across the street with a staff member to Clinic D for evaluation with incision and drainage of abrasions on body. Signed by S3NP at 1:50 p.m. A review of Patient #11’s Progress Note dated 07/29/2024 (no time) from Clinic D revealed patient presented with complaints of possible abscess to the Left upper arm. IVDU heroin, last used prior to coming to psychiatric hospital today. Patient was somnolent but arousable. Wound was 3.5 cm round, eschar with multiple areas of surrounding induration. Assessments revealed in part, cutaneous abscess of left upper limb. Incision and Drainage performed, anaerobic and aerobic cultures collected at 07/29/2024 at 5:03 p.m. with aerobic culture indicating staphylococcus aureus. Patient started on sulfamethoxazole-trimethoprim tablet, 800 mg-160 mg, 1 every 12 hours for 10 days. Follow-up in 2-3 days. Patient #12 A review of the EMTALA Log dated 07/23/2024 at 12:45 a.m. revealed Patient #12 arrived by car with a chemical dependency. The EMTALA log revealed Patient #12’s condition was considered a Medical/Psychiatric Emergency with a disposition at 3:25 a.m. as an admission. A review of Patient #12’s Standardized Intake Assessment dated 07/23/2024, completed at 1:45 a.m., revealed in part, S22LPC performed the medical screening. Vital signs reveal blood pressure 132/92, temperature 98.9, pulse 113, and respiration 18. Medical issues included no spleen, no gallbladder, no pancreas, diabetes, PTSD, hypertension, seizures last 4 months. Review of medications revealed patient was taking Apixaban (Eliquis). The triage was signed by S22LPC as assessor at 2:55 a.m. S22LPC indicated S54MD (Psychiatrist) was notified on 07/23/2024 at 2:50 a.m. Further review failed to reveal medicine service was notified. A review of Stoplight (Exclusionary Criteria) sheet for admission form approved by S48MD and S63MD, updated on 08/09/2024, revealed criteria for admission acceptance. Further review, revealed, in part: Yellow Zone: Require review by S48MD (Medical). 8 ....Seizure disorders ... 9. Oral blood thinner medication ... 10. Adult: vital signs out of normal parameters (Norm Adult ...HR: 50-110). 16. Diabetes (all types) ... A review of Memorandum of Transfer dated 07/23/2024 at 11:30 a.m., revealed in part, Patient #12 sent by Ambulance to undocumented hospital. Further review revealed the nature of the emergency was PE and right leg numbness. A review of Patient #12’s medical records from Hospital C revealed a provider note dated 07/23/2024 at 3:08 p.m. Patient #12 was sent to the ED from a psychiatric facility for evaluation and medical clearance for chronic right foot numbness. The note stated the numbness was chronic and he was discharged back to sending hospital. Patient #13 A review of the EMTALA Log dated 06/30/2024 at 4:05 p.m. revealed Patient #13 arrived by car with a complaint of eating disorder. The EMTALA log revealed Patient #13’s condition was considered a Medical/Psychiatric Emergency with a disposition for admission at 4:55 p.m. A review of Patient #13’s Standardized Intake Assessment dated 06/30/2024, completed at 4:13 p.m., revealed in part, S21PLPC performed the medical screening. Vital signs reveal blood pressure 141/84, temperature 96.4, pulse 87, and respiration 17. Medical issues included shoulder pain and leg pain. Clotting history and pulmonary embolism. Date and time of provider’s notification for higher risk was 06/30/2024 at 5:20 p.m. The provider notified was S65NP (Psychiatrist). Continued review revealed Xarelto 20 mg 1 tab daily with food under “Medications” section. Further review failed to reveal medicine service was notified. The triage was signed by S21PLPC as assessor and Patient #13 was admitted on 06/30/2024 at 5:20 p.m. A review of hospital admission criteria form approved by S48MD and S63MD, updated on 08/09/2024, revealed Stoplight (Exclusionary Criteria) sheet for admission. Further review, revealed, in part: Yellow Zone: Require review by S48MD (Medical). 9. Oral blood thinner medication ... A review of Patient #13’s Nursing Admission Assessment dated 06/30/2024 revealed patient arrived on unit at 6:00 p.m. Further review revealed Patient #13 stated he was currently monitoring his left lung PE because he could feel pain with deep breathing. Physician was notified and orders received to send to ER for medical clearance. A review of telephone order dated 06/30/2024 at 7:50 p.m. revealed S48MD ordered to send to Hospital “B” for evaluation of current left lung PE and left clavicle fracture related to motor vehicle accident in 03/2024. A review of Patient #13’s medical records failed to reveal a MOT. A review of Patient #13’s medical records from Hospital “B” revealed an After Visit Summary dated 06/30/2024 at 10:22 p.m. Further review revealed instructions stating patient was medically cleared from having a current pulmonary embolism. Instructed to continue taking Xarelto and follow-up with primary care doctor. Patient #14 A review of the EMTALA Log dated 06/15/2024 at 3:20 a.m. revealed Patient #14 arrived by ambulance with a complaint of psych. The EMTALA log revealed Patient #14’s condition was considered a Medical/Psychiatric Emergency with disposition at 5:57 a.m. for admission. A review of Patient #14’s Standardized Intake Assessment dated 06/14/2024, completed at 11:10 p.m., revealed in part, S25MSP performed the medical screening. Vital signs reveal blood pressure 152/67, temperature 97.6, pulse 87, and respiration 16. Medical issues included hypertension, bipolar, and kidney injury. Continued review revealed the rest of the assessment was not completed due to the inability to assess as patient had hearing problems and possible vision problems. Date and time of provider’s notification for higher risk was 06/14/2024 at 11:10 p.m. The provider notified was S56NP (Psychiatric NP). Further review failed to reveal medicine service was notified. The triage was signed by S25MSP as assessor 06/14/2024 at 11:10 p.m. Of note, the patient did not present to the hospital until 06/15/2024 at 3:20 a.m. according to the EMTALA log. A review of Patient #14’s SBAR-intake to Unit Patient Report Worksheet dated 06/14/2024 at 10:00 p.m. revealed vital signs of blood pressure 159/82, temperature 97.8, pulse 91, and respiration 20. Further review revealed the patient ETA to unit was 12:00 a.m. The form indicated orders needed to be obtained. A review of Stoplight (Exclusionary Criteria) sheet for admission approved by S48MD and S63MD, updated on 08/09/2024, revealed criteria for admission acceptance. Further review, revealed, in part: Yellow Zone: Require review by S48MD (Medical). 19. ...Kidney injury. A review of Memorandum of Transfer dated 06/15/2024 at 10:30 a.m., revealed in part, Patient #14 sent by ambulance to Hospital “C”. Further review revealed the nature of the emergency was altered mental status. Continued review revealed the signature of Qualified Medical Personnel as S58RN but failed to reveal a physician’s signature. A review of Patient #14’s medical records from Hospital “C” revealed a provider note dated 06/15/2024 at 11:31 a.m. Patient with altered mental status with reported facial droop and aphasia with unknown time of LKN. Per EMS, patient had been altered since she arrived at River Oaks Hospital over 12 hours ago, however, River Oaks Hospital did not activate EMS until 10:30 a.m. Patient was admitted for positive troponin, chest x-ray with edema, possible component of heart failure. Patient #15 A review of the EMTALA Log dated 07/23/2024 at 5:12 p.m. revealed Patient #15 arrived by car with a complaint of chemical dependency. The EMTALA log revealed Patient #15’s condition was considered a Medical/Psychiatric Emergency with disposition at 7:45 p.m. for admission. A review of Patient #15’s Standardized Intake Assessment dated 07/23/2024, dated 5:50 p.m., revealed in part, S19RSW performed the medical screening. Vital signs reveal blood pressure 120/58, temperature 99.4, pulse 135, and respiration 22. Medical issues included seizures (most recent 12/2023) and sleep apnea. Patient seeking alcohol detoxification. Assessment was reviewed over the phone by S63MD at 6:27 p.m. with a provisional diagnosis of ETOH withdrawal. Continued review failed to reveal S63MD physically assessed Patient #15 before admit. The triage was signed by S19RSW as assessor 07/23/2024 at 6:27 p.m. A review of Patient #15’s SBAR-intake to Unit Patient Report Worksheet dated 07/22/2024 at 6:18 p.m. although vital signs were taken at 5:50 p.m. Vital signs reveal blood pressure 120/58, temperature 99.4, pulse 135, and respiration 22. Patient was admitted to the detox unit. Form completed at 6:23 p.m. by S19RSW 10:31 p.m. A review of nursing progress notes dated 07/23/2024 at 6:45 p.m. revealed SBAR was received and physician contacted and notified of heart rate 135. Orders to begin ETOH protocol with phenobarbital were taken. Patient #15 arrived on unit at 7:53 p.m., nursing administered phenobarbital and multi vitamin. A review of Psychiatric Evaluation dated 07/24/2024 at 8:48 a.m. revealed Patient #15 had a history of seizures, esophageal varices and pancreatitis. The provider was called to the bedside of Patient #15 at 8:15 a.m. and found the patient with hematemesis, tachycardia and hypotension. Patient sent to ER. A review of hospital form titled “Code Blue R.N. Documentation” dated 07/24/2024 at 8:30 a.m. revealed the following: Patient vomiting blood. Patient conscious with a pulse. Paramedics called at 8:25 a.m. and arrived at 8:40 a.m. No AED initiated. Vital signs at 8:30 a.m. Blood pressure 70/33, pulse 137; 8:30 a.m. Blood pressure 67/36 pulse 130; 8:33 a.m. Blood pressure 65/31, pulse 133; 8:40 a.m. Blood pressure 70/33, pulse 133. Pain in shoulders and arms. Medical intervention O2 per mask with oxygen saturation of 100% at 8:35 a.m. ordered by S51MD. A review of Stoplight (Exclusionary Criteria) sheet for admission approved by S48MD and S63MD, updated on 08/09/2024, revealed, in part: Yellow Zone: Require review by S48MD (Medical). 8 ....Seizure Disorder. 10. Adult: vital signs out of normal parameters (Norm Adult ...HR: 50-110). A review of Memorandum of Transfer dated 07/24/2024 at 8:37 a.m., revealed in part, Patient #15 transferred out of psychiatric hospital to Hospital “A” due to loss of blood. Further review failed to reveal a physician’s signature. A review of Patient #15’s medical records from Hospital A revealed Patient #15 arrived at the ED on 07/24/2024 at 9:05 a.m. and admitted at this time with a diagnosis of alcoholic cirrhosis, tachycardia, hypotension, gastrointestinal hemorrhage, hematemesis, and nausea. Final medical diagnoses: alcoholic cirrhosis, esophageal varices with bleeding, shock, acute pancreatitis, acute kidney failure, coagulation defect, alcoholic cardiomyopathy, systolic heart failure, portal hypertension, acute anemia, hypo-osmolality and hyponatremia, alkalosis, and thrombocytopenia A provider note dated 07/24/2024 at 9:29 a.m. revealed Patient #15 presented to ED with hematemesis that had happened in the past. Patient stated he started with headaches and lightheadedness on 07/23/2024. On the morning of 07/24/2024 Patient #15 stated he became nauseous and began vomiting blood. Hemoglobin was 4.8 and hematocrit 16.6. Patient was bleeding from rectum and received 2 units PRBC per rapid infuser. Patient #15 was admitted to ICU and transfused 6 units of PRBCs, 1 unit fresh frozen plasma and 1-unit platelets. Underwent EGD with banding. Given antibiotics. Hepatology consulted and said he was not a liver transplant candidate. Palliative Medicine was consulted. He was not a candidate for trans-jugular intrahepatic portosystemic shunt. He as extubated on 07/26/2024. He was transferred from critical care on 07/27/2024 and discharged home on 07/28/2024. In an interview on 8/22/24 4:05 p.m., S9RMPI stated Patient #15 should have been screened/assessed by a qualified medical person. The hospital realized the patient should have been sent to ER due to heart rate. It was because of this case that the Stoplight (Exclusionary Criteria) sheet for admission form was updated on 08/09/2024. Patient #16 A review of the EMTALA Log dated 08/24/2024 at 6:15 p.m. revealed Patient #16 arrived by car with a complaint of chemical dependency. The EMTALA log revealed Patient #16’s condition was considered a Medical/Psychiatric Emergency with a disposition at 9:31 p.m. for admission. A review of Patient #16’s Standardized Intake Assessment dated 08/24/2024, completed at 7:21 p.m., revealed in part, S25MSP performed the medical screening. Vital signs reveal blood pressure 116/63, temperature 98.3, pulse 117, and respiration 18. Medical issues Diabetes on insulin. Continued review failed to reveal a blood glucose measurement. Date and time of provider’s notification for higher risk was 08/24/2024 at 8:45 p.m. The provider notified was S63MD. The triage was signed by S25MSP as assessor 08/24/2024 at 8:45 p.m. A review of hospital admissions criteria form approved by S48MD and S63MD, updated on 08/09/2024, revealed criteria for admission acceptance. Further review, revealed, in part: Yellow Zone: Require review by S48MD (Medical). 10. Adult: vital signs out of normal parameters (Norm Adult ...HR: 50-110). 16. Diabetes (All Types)- S48MD must be contacted for blood glucose less than 45 or blood glucose greater than 400. A review of Nursing Admit Assessment dated 08/24/24 at 10:30 p.m., revealed Patient #16’s accucheck read 381. Heart rate 118 prior to and upon arrival. A review of Patient #16’s physician orders revealed a telephone order for admit by S63MD on 08/24/2024 at 10:03 p.m. A review of Memorandum of Transfer dated 08/26/2024 at 9:18 a.m., revealed in part, Patient #16 transferred out of psychiatric hospital by ambulance to ER due to the required medical services not available. Blood glucose level 590. A review of Patient #16’s medical records from Hospital A revealed After Visit Summary dated 08/26/2024 at 2:48 p.m. Patient was administered Insulin regular human and fluids at 12:37 p.m. Instructions included changes to his insulin lispro and levemir. Patient was transported back to Hospital E. Patient #17 A review of the EMTALA Log dated 08/22/2024 at 6:46 p.m. revealed Patient #17 arrived by ambulance with a complaint of psych. The EMTALA log revealed Patient #17’s condition was considered a Medical/Psychiatric Emergency with a disposition at 10:19 p.m. for admission. A review of Patient #17’s Standardized Intake Assessment dated 08/22/2024, completed at 9:00 p.m., revealed in part, S23MHA performed the medical screening. Vital signs reveal blood pressure 113/55, temperature 97.8, pulse 79, and respiration 18. Medical issues included Alcohol Use Disorder, Liver Cirrhosis, and Hepatic Encephalopathy. Allergies, “None” and “Yes” was left blank. Continued review revealed patient was admitted to ICU multiple times for GI bleed and other medial issues. Date and time of provider’s notification for higher risk was 08/22/2024 at 9:00 p.m. The provider notified was S54MD (Psychiatry). Further review failed to reveal medicine service was notified. The triage was signed by S23MHA as assessor 08/22/2024 at 9:00 p.m. A review of Patient #17’s SBAR-intake to Unit Patient Report Worksheet dated 08/22/2024 at 4:40 p.m. revealed vital signs were taken at 3:00 p.m. Blood pressure 110/62, temperature 98.5, pulse 98, SpO2 98%and respiration 17. The form stated that the patient with mild weakness and is easily directable. Medically cleared for psych admission. S16RNAD indicated she spoke with S48MD who stated okay to admit. Form was submitted 10:31 p.m. The form failed to reveal S48MD assessed the patient. Review of History and Physical dated 08/23/2024 at 5:00 a.m. revealed medical problems included positive ESBL. Review of physician orders dated 08/22/2024 at 11:30 p.m. revealed level of observation: Contact ESBL. A review of hospital admission criteria form approved by S48MD and S63MD, updated on 08/09/2024, revealed criteria for admission acceptance. Further review, revealed, in part: Red Zone: Cannot be treated at the Psychiatric Hospital. 5. Infectious Disease Requiring Isolation ....18. Encephalopathy. A review of Memorandum of Transfer dated 08/24/2024 at 9:18 a.m., revealed in part, Patient #17 transferred out of psychiatric hospital by ambulance to ER due to the required medical services not available. Continued review revealed the signature of Qualified Medical Personnel as S64RN. Further review failed to reveal a physician’s signature. A review of Patient #17’s medical records from Hospital A revealed Patient #17 arrived at the ED on 08/24/2024 at 10:03 a.m. and admitted on 08/24/2024 at 1:52 p.m. with a diagnosis of liver failure. A provider note dated 08/24/2024 at 10:09 a.m. revealed the patient with a history of liver cirrhosis, esophageal varices with bleeding and banding, hepatic encephalopathy. Patient #17 was complaining of abdominal pain and distention for 2 days. Vomited on 08/23/2024. Patient was admitted to Hospital A earlier in the month in shock requiring pressors, with GI bleed requiring 3 bands placed to esophageal varices. He was transfused. Developed ESBL E coli pneumonia. Required treatment for hepatic encephalopathy. Patient was discharged home where he would attend a church based program he has been treated for alcohol dependence. In an interview on 08/27/24 at 3:50 p.m., S48MD stated he assessed Patient #17 in the front lobby of the hospital and considered him stable. He did not know Patient #17 had been recently treated for ESBL. He was unaware that Patient #17 completed a course of antibiotics in a hospital for ESBL the day before admit to this hospital. He did not know of his diagnosis of hepatic encephalopathy. S48MD stated did not know Patient #17 was admitted. He did not get all of the information for this patient. S48MD confirmed he did not see the information from Hospital A before admission. Patient #18 A review of the EMTALA Log dated 06/18/2024 at 4:46 p.m. revealed Patient #18 was 11 years old and arrived by car with a psych complaint. The EMTALA log revealed Patient #18’s condition was considered a non-emergent. with a disposition at 7:32 p.m. for referral departure by ambulance. Review of certified medical records provided by hospital as complete, revealed page 1 of 9 of the Standardized Intake Assessment dated 06/18/2024 at 5:17 p.m. Vital signs obtained Blood pressure 109/73, temperature 97.0, pulse 81, and respirations 17. Further review revealed S26MSW completed the medical screen at 5:15 p.m. A review of Memorandum of Transfer dated 06/18/2024 at 5:50 p.m., revealed in part, Patient #18’s birthday as 11/25/2002 and that she was 11 years old. Sent to Hospital ‘G’. The documentation fails to reveal mode of transport. Further review revealed nature of transfer, “Patient is 11 year old presenting for homicidal ideations towards family via knives. Hospital ‘F’ currently not admitting under 12 years old. Continued review revealed the signature of Qualified Medical Personnel as S26MSW. Further review failed to reveal a physician’s signature. Review of Patient #18’s medical records from Hospital ‘G’ revealed patient arrived on 06/18/2024 at 7:59 p.m. via ambulance. ED provider revealed patient has intellectual disability and is on medications she is complaint. Patient was having violent thoughts against her family. Patient was not PEC’s at Hospital ‘F’. Patient was seen by pediatric emergency medicine found to be stable was discharged on 06/18/2024 at 10:32 p.m. Patient #19 A review of the EMTALA Log dated 02/02/2024 at 3:25 a.m. revealed Patient #19 arrived by ambulance with a psych complaint. The EMTALA log revealed Patient #19’s condition was considered a Medical/Psychiatric with dispositio at 4:42 a.m. for admission. A review of Patient #19’s Standardized Intake Assessment dated 02/02/2024, completed at 4:32 a.m., revealed in part, S43LPC performed the medical screening. Further review failed to reveal documented blood pressure, temperature, pulse, and respirations. Medical issues included Tardive Dyskinesia, ADHD, HTN, and Asthma. The triage was signed by S43LPC as clinician at 4:32 a.m. S43LPC indicated S52MD (Psychiatrist) was notified of higher risk on 02/02/2024 at 4:32 a.m. Further review failed to reveal medicine service was notified. A review of Patient #19’s Nursing Admission Assessment dated 02/02/2024 at 5:00 a.m., revealed nurse was unable to assess patient due to Tardive Dyskinesia. A review of hospital admission criteria form approved by S48MD and S63MD, updated on 08/09/2024, revealed criteria for admission acceptance. Further review, revealed, in part: Yellow Zone: Require review by S48MD (Medical). 8 ....Severe neurological deficits ... A review of Memorandum of Transfer dated 02/02/2024 at 11:20 a.m., revealed in part, Patient #19 sent by EMS to Hospital E. Further review revealed the nature of the emergency was medical evaluation of EPS/Tardive Dyskinesia. Continued review revealed the signature of Qualified Medical Personnel as S53RN. Further review failed to reveal a physician’s signature. A review of Patient #19’s medical records from Hospital E revealed a provider note dated 02/02/2024 at 1:53 p.m. Patient #19 was sent for psychological evaluation and tardive dyskinesia. Further review revealed the history of present illness, which stated the nurse from the sending hospital reported Patient #19’s jaw appeared to be locked. They were worried about worsening tardive dyskinesia and gave him a dose of Ativan about 3 hours prior. They reported the inability to give him some of his home medications as they are on non-formulary. They thought that his prescription medications were at Hospital E’s pharmacy. The provider documented confusion on whether Patient #19 was fully medically cleared prior to transport as they report he was missing information. Patient was found to have CK greater than 1000 and given 2 liters of fluids. Given Benadryl for jaw locking. Patient #19 was medically cleared and discharged back to sending hospital. Patient #20 A review of the EMTALA Log dated 02/15/2024 at 12:20 a.m. revealed Patient #20 arrived by police with a psych complaint. The EMTALA log revealed Patient #20’s condition was considered a Medical/Psychiatric Emergency with disposition at 3:38 a.m. for admission. A review of Patient #20’s Standardized Intake Assessment dated 02/15/2024, completed at 2:35 a.m., revealed in part, S43LPC performed the medical screening. Further review revealed documented blood pressure 137/67, temperature 97.1, pulse 67, and respirations 19. Medical issues included triple bypass in 2022, CVA in 2022 with memory issues and limited motor skills. The triage was signed by S43LPC as clinician at 2:32 a.m. S43LPC indicated S54MD (Psychiatrist) was notified of higher risk on 02/15/2024 at 2:32 a.m. Further review failed to reveal medicine service was notified. A review of hospital admission criteria form approved by S48MD and S63MD, updated on 08/09/2024, revealed criteria for referral acceptance. Further review, revealed, in part: Yellow Zone: Require review by S48MD (Medical). 6. ...CHF, History of Stroke ... A review of Memorandum of Transfer dated 02/15/2024 at 10:30 p.m., revealed in part, Patient #20 sent by Ambulance to Hospital B. Blood pressure was 188/104, pulse 78 and respirations 18. Further review revealed the nature of the emergency was medical evaluation and treatment of hypertension with chest pain. Continued review revealed the signature of Qualified Medical Personnel as S62RN. Further review failed to reveal a physician’s signature. A review of Patient #20’s medical records from Hospital B revealed an ED provider note dated 02/15/2024 at 11:04 p.m. Patient #20 with a history of NSTEMI, CABG, CVA with residual left-sided weakness presented to ED with chest pain for 45 minutes. Patient stated he had severe 10/10 anterior chest pain. Stated he was supposed to take aspirin and Plavix for history of CVA but does not. Was provided full-dose aspirin and nitroglycerin EN route. Stated the nitroglycerin significantly improved his chest pain to a 2/10 in severity. In an interview on 08/22/2024 at 1:59 p.m., S9RMPI stated a registered nurse (RN) has training and the medical knowledge necessary in order to identify the need for medical clearance before admit. S9RMPI reported that administration has prevented an RN from coming into the intake process. S9RMPI stated the RN supervisor should be doing medical screens in place of the non-medical social workers. S9RMPI reported sometimes the RN heard about a patient in intake and came to triage after admission and recognized the patient was not medially cleared for admission and was transferred for medical clearance. S9RMPI proposed a plan that the nurse triage the patient first then completes the medical screen then prioritizes the patient by medical acuity. In an interview on 08/22/24 at 3:30 p.m., S9RMPI stated patients should have medical clearance before admission. In an interview on 08/22/2024 at 3:38 p.m., S9RMPI verified that the Stop Light is a form used by the intake counselors to screen appropriate admissions. According to the Stop Light admissions criteria form, Patients #1, #3, #4, #7, #11, #12, 14, #15, #16, #17, #19, #20 should not have been admitted before medical clearance. In an interview on 08/26/24 at 11:50 p.m., S9RMPI reported referrals are determined by intake counselors and call specialists looking at referral packets. The nonclinical staff are reviewing the medical history and determining the appropriateness of admit. The nonclinical staff are filling out the SBAR that includes a MSE. S9RPMI stated the hospital does not yet have a completed policy addressing MSEs and walk-ins but in process. S9RMPI reported they know that they should have an RN doing the medical screening exam. S9RMPI stated she could not find evidence that the process of intake included the internist notification during the medical screening exam. S9RPMI had a meeting on Friday 08/23/2024 with S33DON, S16RNAD and S61CEO. Made changes on Friday. Policy is not completed and is in process. Trying to create the ability to prioritize the medical screening. In an interview on 08/27/24 at 3:50 p.m., S48MD confirmed he and his nurse practitioners are considered “medicine services”. S48MD reported that medicine services complete the history and physicals as well as ensure medical stabilization and address medical issues once admitted. S48MD stated he did not do medical clearances unless asked to do so through the messaging system and sometimes they will come see the patient in intake. They do not medically clear patients without obvious issues that would impede treatment. S48MD reported if the patient has no symptoms, the medicine service does not medically clear because the hospital does not have the resources to medical clear. Lab services takes several days and the hospital does not have the equipment to complete medical clearance exams. 48051”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 48051 Based on record review and interview, the hospital failed to ensure the patient /patient representative’s right to participate in the development and implementation of his or her plan of care was met. This deficient practice was evidenced by failure to ensure the patient /patient representative was included in the development and implementation of the patient’s plan of care for 2 (#2, #4) of 4 (#1- #4) patient medical records reviewed for care plan development and implementation. Findings: Review of the hospital’s policy titled, “Interdisciplinary Patient-Centered Care Planning”, Revised: 04/2024, revealed in part: Policy: It is the policy of the hospital to provide therapeutic services based upon a patient-centered, individualized treatment plan. The treatment team, led by the attending psychiatrist, works with the patient and family/representative to collaboratively identify the patient’s assessed needs to be addressed during treatment and develop appropriate goals and interventions. Procedure: Developing the Treatment Plan: 5.The patient/family and/or representative is to sign the treatment plan to indicate their agreement with and participation in development of the plan. If the patient refuses to sign or is unwilling to sign, that will be documented. A medical record review for patient participation in the development and implementation of patient’s treatment plan of care revealed: Patient #2 was admitted 06/27/2024 and the Interdisciplinary Master Treatment Plan was dated 06/30/2024. The last page of the treatment plan revealed in part, an area to indicate patient participation (with the options to be selected by checking a box next to the following: Contributed to goals/plan, Aware of plan, Unable to participate due to clinical reasons, Refused to participate, Refused to sign, and/or Unable to Sign), an area to document the patient’s stated goal and an area for the patient’s signature and date acknowledging the following statement, “This treatment plan has been presented and reviewed with me in language that I understand. I had the opportunity to ask questions.” There was no documentation to patient participation, patient’s stated goal, or the signature of the patient to indicate the involvement with the treatment plan. Patient #4 was admitted 07/11/2024 and the Interdisciplinary Master Treatment Plan was dated 07/14/2024. The last page of the treatment plan revealed in part, an area to indicate patient participation (with the options to be selected by checking a box next to the following: Contributed to goals/plan, Aware of plan, Unable to participate due to clinical reasons, Refused to participate, Refused to sign, and/or Unable to Sign), an area to document the patient’s stated goal and an area for the patient’s signature and date acknowledging the following statement, “This treatment plan has been presented and reviewed with me in language that I understand. I had the opportunity to ask questions.” There was no documentation to patient participation, patient’s stated goal, or the signature of the patient to indicate the involvement with the treatment plan. In an interview on 08/20/2024 at 3:45 p.m. S9RMPI confirmed the above mentioned findings.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48051 Based on observation and interview, the hospital failed to provide care in a safe setting. This deficient practice was evidenced by toiletry items remaining in the presence of patients when not in use. Findings: A review of facility policy, “Admission to Discharge: Personal Belongings, Valuables, Safety/Skin, & Contraband Searches” last revised: 03/2024, revealed in part: Policy: 7.0 Certain items that are considered unsafe for patients to have will be classified as contraband ...all patients and family member will be advised at the time of admissions of the facility’s policy on contraband. Procedure: Categories of controlled items: Contraband: ... prohibited or unauthorized items. Any item that poses a safety risk may be considered contraband or if an item poses a safety risk or interferes with the rights of others. Monitored: Items may be used by patients under the direct supervision of staff members. Items are monitored by staff and kept in a safe place on the unit when not in use. Excessive amount of any monitored item will not be permitted. Restricted: Item that may be checked out by patients for short periods of time. Restricted items will be kept in a safe place on the unit not accessible to patients when not in use. Excessive amounts of any restricted item will not be permitted. Section Contraband/Permissible Items: 1. Personal hygiene items will be provided by the hospital including: Hygiene items and buckets will be provided to patients during hygiene times, 1.1 Shampoo, 1.2 Conditioner, 1.3 Body Wash, 1.4 Deodorant, 1.5 Toothbrush. Observations during a tour of the facility on 08/19/2024 from 10:15 a.m. to 12:15 p.m. revealed toiletry items in Patient #R1’s restroom and Room “a” restroom. Toiletry items available included: Patient #R1 restroom: 2 tan toothbrushes, 2 tubes of Freshmint Toothpaste, 4 McKesson Shampoo/Body Wash - 8 ounce bottles; and Room “a”: 1 McKesson Shampoo/Body Wash - 8 ounce bottle and 1 black hair brush. These items would be considered contraband and pose a safety risk when not in use. In an interview on 08/19/2024 at 10:35 a.m. Patient #R1 confirmed his current room assignment and restroom. He further confirmed the toiletry items in his restroom were not his possessions and he had returned his toiletry items after use. In an interview on 08/19/2024 and present during the tour, S10CNO and S11DirPO confirmed the above mentioned findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(2)(ii) [The hospital must require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following:] (ii) The use of nonphysical intervention skills. This Standard is not met as evidenced by: 47397 Based on record review and interview, the hospital failed to ensure the hospital’s direct care staff were educated, trained and demonstrated knowledge on the use of nonphysical intervention skills as evidenced by 1 (#S6MHT) of 2 (S6MHT, and S7MHT) direct care staff sampled for nonphysical intervention skills training failing to have documented evidence of nonviolent behavior training. Findings: Review of hospital’s policy titled “Staff Competency and Training”, approved 04/2024, revealed in part: Orientation...Clinical/Nursing Staff will receive additional training, apprpopriate to their positions, in at least the following areas: Management of aggresive behaviors. Annual Retraining:...Management of aggresive behaviors. Review of daily staffing report for 08/11/2024, 08/14/2024, 08/15/2024, 08/19/2024, and 08/20/2024 revealed S6MHT was staffed as an mental health techinician for Unit A. Further review revealed on 08/16/2024 and 08/18/2024, S6MHT was staffed as an mental health techinician on Unit B. Continued review revealed on 08/10/2024, S6MHT was staffed as an mental health techinician on Unit C. Review of S6MHT’s personnel record revealed a date of hire of 8/07/2024. Further review failed to reveal evidence S6MHT was educated and trained and that she demonstrated knowledge on the use of nonphysical intervention skills. In an interview on 08/21/2024 at 1:26 p.m., S1EDU verified there was no documented evidence of S6MHT’s education, training and demonstratration of the knowledge on the use of nonphysical intervention skills. In an interview on 08/21/2024 at 2:15 p.m., S9RMPI verified S6MHT is currently on the schedule.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 47397 48051 Based on record review and interview, the hospital failed to have a registered nurse (RN) supervise and evaluate the nursing care for each patient. This deficient practice is evidenced by 1 (#2 and #R2) of 5 (#1-#4, and #R2) patient medical records reviewed lacking an initial nursing admission assessment. Findings: A review of facility policy, “Assess and Reassess FUNCTION: Nursing: Provision of Care” last revised 12/2023, revealed in part: POLICY: All patients admitted to the hospital will have a Nursing Assessment completed on admission within 8 hours. PROCEDURE: Nursing assessment will be completed within 8 hours of their admission. If the patient refuses the assessment or is unable to participate in the assessment process, the RN/LPN will document this in the daily nursing progress note and/or on the assessment. Continued attempts to complete the assessment will be documented on the form at minimum of every day. A review of Patient #2’s medical records revealed an admission on 06/27/2024 at 12:40 p.m. A nursing note on the Nursing Admission Assessment from 06/27/2024 at 3:25 p.m. revealed in part, “Pt AAO x 2, drowsy, sedated and confused. Pt unable to answer questions, unable to assess the patient.” The Nursing Admission Assessment had an area on the bottom of page #1 that revealed, “If unable to complete full Assessment, document ongoing efforts to complete: RN must complete all objective aspects of assessment, including narrative of patient presentation/behaviors/condition.” This area included Attempt #1, Attempt #2 and Attempt #3 for the nurse to document the date, time, and reason for being unable to complete an assessment. This area had no documentation in the blanks. A review of all nursing notes during the course of the patient’s admission did not reveal any documentation related to an attempt to perform an initial nursing admission assessment. A review of Patient #R2 medical records revealed an admission on 06/15/2024 at 4:45 a.m. Continued review revealed #R2’s 10 page Nursing Admission Assessent with the following information indicated on the form: Page 1: Gender: female Method of Arrival: Wheelchair Source of information: Patient Preferred language: English Primary thnicity: non-hispanic or Lation Height: 4’11” and weight: 120 lbs. Skin assessment: “T” located on shoulders, legs, and back. Pages 2-10: blank. In an interview on 08/20/2024 at 2:35 p.m., S9RMPI confirmed the above mentioned findings.”

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 44495 Based on record review and interview, the hospital failed to ensure grievances were resolved according to the hospital policies. The deficient practice is evidenced by failure of the hospital to provide a letter describing the steps taken to investigate the patient’s claims for 1(#3) of 1 reviewed allegations of sexual assault that occurred in the hospital. Findings: Review the provided hospital policy “Grievances: Patient & Family; The Role of the Patient Advocate,” revised 10/2023, revealed in part, “For the purposes of this policy, a “patient grievance” is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient’s representative regarding the patient’s care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the facility’s compliance with the CMS Hospital Conditions of Participation (CoP), or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR Section 489. . . . All verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with CMS requirements are considered grievances for the purposes of these requirement.” Further review revealed, “10. Once the issue has been resolved, the staff person responsible for investigating and resolving the grievance will provide a written response with seven (7) days of the grievance complaint being received.” Review of the Occurrence Log revealed on 04/26/2024 Patient #2 kissed Patient #3 on the cheek. An investigation which included camera review and interviews was performed. The investigation revealed Patient #3 was shocked by the incident and “traumatized” because she was not expecting the kiss. Review of the binder with the closed grievances failed to reveal a letter was sent to Patient #3 or her parents. In interview on 06/03/2024 at 10:25 a.m., S5Adv verified the parents of Patient #3 were not sent a letter. S5Adv verified she was given a copy of the investigation and was aware she needed to send a letter, but failed to do so.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 44495 Based on record review and interview, the hospital failed to provide care in a safe setting. The deficient practice is evidenced by failure to perform withdrawal assessments as ordered for 1 (#1) of 1 patient with ordered withdrawal assessments. Findings: Review of the policies “Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-AR)” revised 09/2021, and “Clinical Opiate Withdrawal Scale (COWS)” revised 07/2018, revealed neither policy had guidelines for allowance of early or late performance of the assessment. Review of the medical record for Patient #1 revealed the patient was admitted on 05/07/2024 with a diagnosis of opioid dependence with withdrawal and alcohol abuse. Review of the physician’s orders revealed, “CIWA AR Scale; Every 4 hours for Detox; Notify provider if above 15; Start 05/08/2024 at 2:00 p.m.” and “COWS Scale- Opiate Withdrawal Scale; Every 4 hours while awake; Start 05/08/2024 at 5:00 a.m.” Review of the medical records revealed on 05/08/ 2024 the CIWA was performed at 1:22 a.m., 7:01 a.m., 10:17 a.m., 2:08 p.m., 5:37 p.m., and 10:00 p.m. Further review revealed the COWS Scale was performed on 05/09/2024 at 4:08 a.m., 8:35 a.m., 12:05 p.m., 5:22 p.m., and 9:56 p.m. In interview on 05/30/2024 at 3:00 p.m., S3DON verified the assessments were not every 4 hours. S3DON stated the hospital policy allowed them to be performed within a range before or after the scheduled time for each assessment. In interview on 06/03/2024 at 10:00 a.m., S2DRM verified the policy did not address guidelines for the allowance of early or late assessments and therefore should have been performed every 4 hours.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 44495 Based on observation and interview, the hospital failed to ensure the registered nurse supervised the care of each patient. The deficient practice is evidenced by failure to the nurse review and sign the observation sheet for 1 (#2) of 5 (#1-#5) reviewed medical records. Findings: Review of the hospital policy “Observation Rounds,” revised 04/2024, revealed in part, “PROCEDURE: Charge Nurse: . . . D. Reviews and signs patient observation forms, at least twice per shift for accuracy (2) two times for eight hour shift and (3) times for twelve hour shifts.” Review of the Patient Observation record for Patient #2 revealed on 04/26/2024 the registered nurse failed to review and sign the record during the 11:00 a.m. - 3:00 p.m. shift and the 3:00 p.m. - 7:00 p.m. shift. In interview on 5/30/2024 at 1:05 p.m., S2DRM verified the nurse did not supervise the patient’s care according to the hospital’s policy.”