Vermilion Behavioral Health Systems

“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 psychiatric hospital failed to ensure 1 (#1) of 4 (#1-#4) client medical records contained a plan of care addressing all of the patient’s medical conditions as identified problems. Findings: Review of psychiatric hospital’s policy #PC-029 titled “Treatment Planning”, last revised on 08/2025, revealed in part: “Policy: The treatment plan is the tool used by the physician and interdisciplinary treatment team to implement the physician ordered services and move th patient toward the expected outcomes and goals. Procedure: 3. the treatment plan shall include (as a minimum): a) Problems and needs relevant to admission and discharge as identified in the various assessments, expressed in behavioral and descriptive terms; d0 Problems, both physical and mental, that require therapeutic management. 4. Guidelines of the Interdisciplinary Treatment Plans: b) The Interdisciplinary Treatment Plan shall identify mental health and physical problems and specify those to be addressed during the treatment episode. The treatment plan will also identify deferred problems with rational for not addressing the deferred problem.” Review of Patient #1’s medical record revealed a 12 year-old male admitted on 08/07/2025. Review of Patient #1’s History and Physical dated 08/07/2025 revealed diagnoses included Autism. Review of Patient #1’s Treatment plan dated 08/07/2025, failed to reveal Autism addressed as a problem with interventions and goals to assist him in achieving higher level of functioning. During an interview on 09/11/2025 at 1:15 PM, S2CNO and S4RM confirmed Patient #1’s Treatment Plan failed to include Autism addressed as a problem with interventions and goals to assist him in achieving higher level of functioning.”

“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 interviews the hospital failed to ensure a registered nurse assigned the nursing care of each patient to other nursing personnel in accordance with the patient’s needs. This deficiency is evidenced by failing to ensure a Registered Nurse made all patient care assignments. Findings: Review of psychiatric hospital’s policy #NR-001 titled “Assignment of Nursing Staff” last reviewed 08/2025, revealed in part: “Policy: To assure quality nursing care and a safe patient environment, nursing personnel staffing and assignments are based on at least the following: 4. Patient care assignment is commensurate with the qualifications of each nursing staff member and the identified nursing need of the patient according to their psychiatric and medical condition. Procedures: 2. Staffing assignments will be documented on the Staffing Assignment Sheet. 4. The names of the patients assigned to the staff member will be entered in the space provided.” Review of psychiatric hospital’s documents titled “Nursing/BHA Daily Assignments” dated 09/01/2025 through 09/11/2025 failed to reveal the names of the patients assigned to a staff member. During an interview on 09/11/2025 at 11:58 AM, S4RM verified the “Nursing/BHA Daily Assignments” dated 09/01/2025 through 09/11/2025 failed to reveal the names of the patients assigned to a staff member. S4RM stated that the psychiatric hospital used technology ‘A’ for observation monitoring. The patients did not have an assigned staff member; instead, they were monitored by all nursing staff members, except for 1:1 patients who were assigned a staff member. S4RM confirmed a check mark on the “Nursing/BHA Daily Assignments” indicated the BHA had a 1:1 patient but the names of the 1:1 patients were not listed on the assignment sheet.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(14) If the face-to-face evaluation specified in paragraph (e)(12) of this section is conducted by a trained registered nurse, the trained registered nurse must consult the attending physician or other licensed practitioner who is responsible for the care of the patient as soon as possible after the completion of the 1-hour face-to-face evaluation. This Standard is not met as evidenced by: 44763 Based on record review and interview, the hospital failed to ensure the RN who performed the face-to-face evaluation after the initiation of restraints or seclusion consulted with the attending physician or other licensed practitioner as soon as possible after the evaluation for 1 (#3) of 2 (#1, #3) patient records reviewed for restraints or seclusion. Findings: Review of Patient #3’s medical record revealed in part, she had been placed in a physical restraint on 10/31/2024 at 5:32 p.m. Patient #3 was released from the physical restraint and placed in seclusion at 5:34 p.m. Patient #3 was released from seclusion at 5:50 p.m. S3RN conducted the one hour face-to-face evaluation on 10/31/2024 at 6:25 p.m. S3RN consulted with the attending provider on 10/31/2024 at 5:30 p.m. (before the one hour face-to-face evaluation was conducted) Further review failed to reveal documentation of the RN consulting with the attending provider as soon as possible after the one hour face-to-face evaluation. Review of Patient #3’s medical record revealed in part, she had been placed in a physical restraint on 11/04/2024 at 7:53 p.m. and released at 7:55 p.m. S4RN conducted the one hour face-to-face evaluation on 11/04/2024 at 8:11 p.m. S4RN consulted with the attending provider on 11/04/2024 at 7:55 p.m. (before the one hour face-to-face evaluation was conducted) Further review failed to reveal documentation of the RN consulting with the attending provider as soon as possible after the one hour face-to-face evaluation. Review of Patient #3’s medical record revealed in part, she had been placed in a physical restraint on 11/05/2024 at 8:06 p.m. Patient #3 was released from the physical restraint and placed in seclusion at 8:07 p.m. Patient #3 was released from seclusion at 8:22 p.m. S4RN conducted the one hour face-to-face evaluation on 11/05/2024 at 8:30 p.m. S4RN consulted with the attending provider on 11/05/2024 at 8:09 p.m. (before the one hour face-to-face evaluation was conducted) Further review failed to reveal documentation of the RN consulting with the attending provider as soon as possible after the one hour face-to-face evaluation. In an interview on 11/06/2024 at 2:23 p.m. S1DON and S2DRM verified there was no documentation of the RN consulting with the provider as soon as possible after the one hour face-to-face evaluation for all 3 restraint/seclusion occurrences included in Patient #3’s medical record.”