Mercy Behavioral Hospital

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 53243 Based on record reviews and interviews, the hospital failed to recognize and follow hospital policy for documentation of grievance. The deficient practice was evidenced by failure of the facility to recognize repetitive phone calls made by a family member requesting discharge of the patient to that family members care as a grievance for 1 (#1) of 3 total sample patients reviewed for complaints/grievances. Findings: Review of the hospital’s grievance policy and procedure titled 202: Grievance Policy and Procedure, last revised 04/2024, revealed in part: A grievance is a real or imagined wrong or other cause for complaint or protest, especially unfair treatment. It is an official statement, written or verbal, of a complaint over something believed to be wrong or unfair and the CEO/Administrator is responsible for reporting all grievances though the Committee Hierarchy. Further review of the hospital’s policy revealed in part the verbal or written patient grievance is received and logged, and the grievance investigation is launched within twenty-four (24) hours of receipt. Review of the medical record for Patient #1 revealed a multidisciplinary integrated treatment plan note dated 06/25/2026 documenting the patient’s father called 6 times during 4-hour time span morning of 06/24/2026. Further review revealed phone call restrictions were initiated as result of the repetitive phone calls as evidenced by a physician’s order on 06/24/2026 at 12:44 PM “staff will provide weekly update post txteam to father. Father may call for urgent needs only once dly between 9:30 AM and 10:00 AM.” Signed by S6MD. Review of the medical record for Patient #1 revealed in part: a multidisciplinary progress note dated 09/18/2026 at 3:15PM documenting “patient father cont to call 10-15x a day, unable to abide to the agreed once weekly update.” In interview on 06/30/2026 at 10:46 AM S2ADON confirmed she had assumed the father’s calls had been documented as a grievance and was not sure why the grievance process had not been initiated. In interview on 06/30/2026 at 11:11 AM S1DON confirmed this should have been treated as a grievance but was not.”

“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: 50453 Based on observation, record review, and interview, the hospital failed to ensure the patient’s right to receive care in a safe setting. This deficient practice was evidenced by: 1) failure of the nursing staff to ensure MHT’s were performing observations on 3 (#1-#3) of 3 (#1-#3) patients reviewed; 2) failure to ensure employees were CPR certified in 4 (S4RN, S6MHT, S7MHT, S8MHT) of 7 (S2RMQ, S4RN, S5RN, S6MHT, S7MHT, S8MHT, S9LPN) personnel files reviewed; and 3) failure to ensure employees were trained in crisis intervention in 3 (S5RN, S6MHT, S7MHT) of 7 (S2RMQ, S4RN, S5RN, S6MHT, S7MHT, S8MHT, S9LPN) personnel files reviewed. Findings: 1) Failure of the nursing staff to ensure MHT’s were performing observations on 3 (#1-#3) of 3 (#1-#3) patients reviewed. A review of hospital policy No. EOC 1.18, titled “Observation Precaution,” date originated 01/04/2021, no last date revised, revealed in part: “PURPOSE: To promote safety and ensure that the patient is being treated in the least restrictive environment that is clinically permitted. DOCUMENTATION: The charge nurse will be responsible, for assignment of staff to carry out ordered status. Staff assignments will be recorded on the MHT Team Assignment Form by the Charge RN. Charge nurse or designee will make rounds every 2 hours and sign the Observation Sheet to ensure that the MHT’s are observing their assigned patient, filling the form out correctly and not charting ahead.” Patient #1 Review of Patient #1’s medical record revealed Patient #1 was admitted on 07/15/2024 for Schizophrenia and Bipolar Disorder. Review of the Close Observation sheets for Patient #1 revealed the following: 03/07/2025 missing observation for 3:45 PM. 03/08/2025 missing RN initials for 8:00 AM-11:45 AM and 12:00PM-3:45 PM. Further review of Patient #1’s medical record failed to reveal documentation that the RN rounded on the patient every 2 hours per hospital policy. In an interview on 04/01/2025 at 10:00 AM, S2RMQ verified observation at 3:45 PM on 03/07/2025 was not completed, and on 03/08/2025 two RN initials were not completed for 8:00 AM-11:45 AM and 12:00 PM-5:45 PM. S2RMQ also verified all of the above should have been completed and they were not. S2RMQ further reported RN observation checks were to be completed every two hours per policy and the checks were not completed. Patient #2 Review of Patient #2’s medical record revealed Patient #2 was admitted on 03/23/2025 for Bipolar, Depression, and SI. On admit Patient #2 was placed on Q15 minute observations and placed on LOS on 03/25/2025. Review of the Close Observation sheets for Patient #2 revealed the following: 03/25/2025 missing RN initials for 8:00 PM 03/28/2025 missing RN initials for 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM Further review of Patient #2’s medical record failed to reveal documentation that the RN rounded on the patient every 2 hours per hospital policy. Patient #3 Review of Patient #3’s medical record revealed Patient #3 was admitted on 03/24/2025 with Bipolar, Opioid Dependence, and Stimulant Dependence. On admit Patient #3 was placed on Q15 minute observations. Review of the Close Observation sheets for Patient #2 revealed the following: 03/24/2025 missing RN initials for 8:00 PM 03/26/2025 missing RN initials for 8:00 AM Further review of Patient #3’s medical record failed to reveal documentation that the RN rounded on the patient every 2 hours per hospital policy. In an interview on 04/01/2025 at 10:08 AM, S1DON confirmed the above mentioned findings. S1DON stated the RN initials blank on the close observation sheet is for the RN to initial, verifying the MHT’s are performing their observations as ordered. S1DON also confirmed the RN did not document anywhere that they performed their rounds every 2 hours as per policy. 2) Failure to ensure employees were CPR (Cardio-Pulmonary Resuscitation) certified in 4 (S4RN, S6MHT, S7MHT, S8MHT) of 7 (S2RMQ, S4RN, S5RN, S6MHT, S7MHT, S8MHT, S9LPN) personnel files reviewed. A review of the hospital policy No. 314, titled “Medical Emergencies,” date adopted: 05/2024, revealed in part: “PROCEDURE: Nursing: In an Emergent Medical Crisis: Acts to Preserve Life: As indicated initiates, as appropriate, CPR or other intern medical treatment while other staff are directed to activate the EMS system. Staff Training: Nursing staff are certified in the BCLS, First Aid, and the Use of an AED.” A review of the provided job description for Registered Nurse revealed in part: “Duties and Expectations: Adheres to established nursing practices and standards of care.” A review of the provided job description for Mental Health Technician revealed in part: “QUALIFICATIONS: Must have valid Driver’s License, Crisis Intervention and CPR.” A review of employee personnel records S4RN, S6MHT, S7MHT, and S8MHT failed to reveal documented CPR certification. In an interview on 04/01/2025 at 9:58 AM, S3HR confirmed S4RN, S6MHT, S7MHT, and S8MHT did not have documented CPR certification in their employee files. S3HR also confirmed that all staff should have a current CPR certification in their employee files. In an interview on 04/01/2025 at 10:08 AM, S1DON confirmed that all nurses and MHT’s should have current CPR certification to provide a safe patient environment. 3) Failure to ensure employees were trained in crisis intervention in 3 (S5RN, S6MHT, S7MHT) of 7 (S2RMQ, S4RN, S5RN, S6MHT, S7MHT, S8MHT, S9LPN) personnel files reviewed. A review of employee personnel records for S5RN, S6MHT and S7MHT failed to reveal documented crisis intervention training. In an interview on 04/01/2025 at 9:58 AM, S3HR confirmed S5RN, S6MHT, and S7MHT did not have documented crisis intervention training in their employee file. S3HR stated this training is included in their PEACE training and should be done upon hire and then annually. S3HR further stated that the above mentioned employees failed to attend the last class offered for crisis intervention training. In an interview on 04/01/2025 at 10:08 AM, S1DON confirmed that all nurses and MHT’s should have current education in crisis intervention to provide a safe patient environment.”

“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: 50453 Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by the failure of the nursing staff to document vital signs as ordered by the physician for 1 (#3) of 3 (#1-#3) patient medical records reviewed. Findings: A review of hospital policy No. PC 11.71, titled “Vital Signs and Weights,” date originated 01/04/2021, no last date revised, revealed in part: “POLICY: All patients will have their vital signs, including pain assessment, weight and height, taken on admission. Vital signs will be taken a minimum of twice a day thereafter, unless the physician orders a more frequent schedule.” Review of Patient #3’s medical record revealed Patient #3 was admitted on 03/24/2025 with Bipolar, Opioid Dependence, and Stimulant Dependence. Patient #3 was discharged on 03/26/2025. Review of Patient #3’s admit orders initiated on 03/24/2025 at 6:45 PM revealed an order for vital signs to be obtained on admit, then BID. Review of Patient #3’s Vital Sign Graphic Flowsheet revealed vital signs were obtained the following times: 03/24/2025 at 10:00 PM 03/25/2025 at 10:00 PM Further review failed to reveal that vital signs were obtained BID as ordered by the physician. In an interview on 04/01/2025 at 10:08 AM, S1DON confirmed the above mentioned findings.”

“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, the hospital failed to administer drugs in accordance with accepted standards of practice. This deficient practice was evidenced by the failure to document the effects of an administered as needed medication in 1 (#3) of 3 (#1 - #3) patient medical records reviewed. Findings: A review of hospital policy No. 401 titled, “Medication Administration,” with a last revised date of 07/17/2024, did not reveal a procedure for the documentation of the effectiveness after an as needed medication was administered. Further the hospital was unable to produce a policy and procedure related to the documentation of the effectiveness after an as needed medication was administered. Review of Patient #3’s medical record revealed Patient #3 was admitted on 03/24/2025 with Bipolar, Opioid Dependence, and Stimulant Dependence. Review of Patient #3’s Medication Administration Record revealed the following PRN order: Clonidine 0.1 mg PO every 8 hours PRN for SBP greater than 160, DBP greater than 100 Further review of Patient #3’s MAR revealed that Patient #3 was given Clonidine 0.1mg PO on 03/24/2025 at 10:00 PM. Review of Patient #3’s Vital Sign Graphic Flowsheet revealed the following vital signs on 03/24/2025 at 10:00 PM: BP 169/99 and Pulse 68 Further review failed to reveal repeat vital signs or documentation of the effects of the as needed Clonidine. In an interview on 04/01/2025 at 10:08 AM, S1DON confirmed the above mentioned findings.”

“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: 26351 Based on record reviews and interviews, the hospital failed to be in compliance with 42 CFR §489.20 (l) of the provider’s agreement which requires hospitals comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases as evidenced by the hospital failing to ensure a medical screening examination was provided to each patient presenting to the ED to determine whether or not an emergency medical condition existed. This deficient practice was evidenced by: 1. failure to ensure a medical screening exam was performed on 1 (Patient #20) out of 20 patients (Patients #1-#20) reviewed with an emergency medical/psychiatric condition (see findings in A-2406). 2. the transferring hospital’s failure to send to the receiving facility all medical records for Patient #20 (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms and preliminary diagnosis (see findings in A-2409).”

“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: 26351 Based on 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. The deficient practice is evidenced by failure to ensure a medical screening exam was performed on 1(Patient #20) out of 20 patients (Patients #1-#20) reviewed with an emergency medical/psychiatric condition. Findings: Review of the hospital’s policy titled “301 Admissions & Exclusionary Criteria” revised 08/2023, revealed in part: Policy - It is the policy of the Hospital to assess, admit, or refer patients on a twenty-four (24) hour per day, seven (7) days per week ... Hospital admits patients 21 (twenty-one) years of age or older. Procedure - Referrals for Admission: 2.) All admissions to the facility are screened by the Admissions Department and Director of Nursing for clinical appropriateness. The on-call physician / practitioner is contacted by the admissions personnel or RN Charge Nurse, depending on the time of the referral, for admission approval and admit orders. Review of Patient #20’s medical record failed to reveal the provider evaluated, assessed or treated Patient #20’s psychiatric condition prior to transferring the patient back to Hospital A. In an interview on 07/15/2024 at 1:39 p.m. S2DON verified the hospital had 14 patients on 06/07/2024. He stated that did not include Patient #20. He verified the hospital had available beds for Patient #20. S2DON stated Patient #20 should have been wheeled on the stretcher to the seclusion room with enough staff to secure Patient #20 in restraints to get Patient #20 off the EMS stretcher. S2DON verified Patient #20 would have been safer here than being transferred back to the emergency department. After reviewing the admission criteria policy, S2DON verified that Patient #20 did meet admission criteria and did not meet any exclusionary criteria.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 36293 Based on record review and interviews, the hospital failed to provide documented evidence to indicate an appropriate transfer was provided for 1 (#20) of 17 patients discharge records reviewed out of a total sample of 20. This deficient practice was evidenced by the transferring hospital’s failure to send to the receiving facility all medical records for Patient #20 (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms and preliminary diagnosis. Findings: Review of the hospital’s policy 315 titled, “Patient Transfers” revealed in part: Policy - Patient transfers should allow for a minimum disruption in care and provide for continuity of care and treatment. Procedure 1. The physician contacts the receiving facility and obtains acceptance for admission. 2. The nurse obtains the physician’s order with clarification of specific data required to accompany the patient. 6. Notify the receiving facility of time transportation is expected to arrive with the patient. 7. Complete the Patient Transfer Form, which includes an overall assessment of the patient’s condition prior to transfer, a listing of medications and treatments to be continued at the receiving facility and a listing of the patients belongings. Copy all appropriate record evaluations, assessments, and documentation for continuum of care and secure in a sealed envelope to be given to the receiving facility. Review of Patient #20’s Medical Record revealed in part: PEC (physician emergency certificate) dated 06/07/2024 at 1:25 a.m. Dangerous to self, gravely disabled, unable and unwilling to seek voluntary admission. CEC (coroner emergency certificate) dated 06/07/2024 at 12:25 p.m. Suicidal, Dangerous to self, gravely disabled, unwilling to seek voluntary admission. Admit Orders dated 06/07/2024 at 12:00 p.m. Legal status PEC/CEC. Admission Diagnosis: blank VORB (verbal order read back) practitioner line was blank, date of order and time were blank, the nurse signature line was blank, and the licensed practitioner’s signature line was blank with no date or time. Discharge Orders are blank except for the patient’s label. Multidisciplinary Notes 06/07/2024 at 12:15 p.m. by S3RN: Patient #20 arrived via ambulance upon entering the building EMT (emergency medical technician) notified S3RN and mental health technician that the Patient #20 was very aggressive and combative. Patient had recently head butted the EMT in transport. S3RN called all staff for help due to the patient being in 4 point restraints and still launching his upper body off the stretcher. After attempting to calm the patient down, S1Physician was notified of patient arrival and current situation. Order was given at this time. Haldol 15 mg (milligrams) IM (intramuscular), Ativan 4 mg IM, and Benadryl 50 mg IM. Patient #20 remained on stretcher in 4 point restraint due to patient being extremely combative with EMT and staff. IM injection was given at 12:25 p.m. by nurse. We again attempted to calm patient down and waited on injection to take effect approximately 40 minutes (injection was ineffective). EMT’s could not release patient out restraints due to patient trying to flip stretcher. S1Physician notified of and updated on situation as well as S2DON. S1Physician gave orders to transfer Patient #20 to hospital A. Hospital A accepted patient and report was given to RN in ER. Patient #20 remained on stretcher with EMT’s and staff at stretcher side while we await on the arrival of another unit to transport due to extreme combative behavior. Patient left via ambulance at 2:15 p.m. in stable condition. Review of nursing note dated 06/07/2024 by S2DON. S2DON received a call regarding a combative Patient #20 who was transferred to their hospital from hospital A. The EMT staff were not able to release Patient #20 from their stretcher due to his combative behavior. S1Physician ordered an injection that was ineffective as evidenced by the EMT’s inability to release the patient from their stretcher and relinquish care to our hospital. Order received to return to hospital A to stabilize to a point of being able to have Patient #20 released from the ambulance’s stretcher taking into consideration recent overdose. Transferred to hospital A remaining combative per advanced cardiac life support unit in stable condition. Interview on 07/16/2024 at 11:33 a.m., S2DON stated Patient #20 was brought to this hospital via ambulance. He stated Patient #20 was transferred from hospital A to this hospital. He stated Patient #20 head-butted the female EMT and busted her lip. He stated Patient #20 was in soft restraints and stretcher belts in place. S2DON stated Patient #20 was not released from the soft restraints or taken off the stretcher at this hospital. He stated S1Physician was notified by phone of this incident. He stated S1Physcian ordered an as needed medication to be given to Patient #20 for aggression. He stated the as needed medication was given to Patient #20 by one of their nurses. S2DON said the medication was not effective. He stated S3RN called hospital A and spoke with a nurse in their emergency room. He stated the EMT’s also spoke to the ER physician at hospital A. He stated Patient #20 was admitted here, given the medication, and then transferred to hospital A. He stated Patient #20 was brought here by a basic ambulance and because of the medication administered, Patient #20 had to be transported in an advanced trained EMT team to hospital A. Interview on 07/16/2024 at 1:30 p.m., S3RN stated the EMT asked her if she had more staff to help with Patient #20 because he was very combative and had already head-butted the EMT and split her lip. She stated the EMT staff brought Patient #20 into the hospital via stretcher. She stated Patient #20 was very combative, trying to flip the stretcher and would try and bite when they would try and hold the gurney stable. She stated then Patient #20 would act calm. She stated EMT told her that they would not release Patient #20 from the stretcher because of him being so combative. S3RN stated that Patient #20 continued to be combative so she notified S1Physician and requested medication orders for the patient’s psychosis and violence. S1Physician gave telephone orders for Haldol, Ativan and Benadryl IM. She stated she waited over thirty minutes the patient continued to be combative with cursing and verbal threats. S3RN stated the patient seemed to become more agitated so she called S1Physician and S2DON to update them on Patient #20 continued agitation and combative behavior. She continued to state that S1Physician gave her telephone orders to transfer the patient back to hospital A’s emergency room. S3RN stated she called report to a nurse and the EMT transferred the patient into another ambulance and took him away. S3RN stated she did not complete a Resident Transfer Form to send to the receiving facility and did not complete the telephone discharge orders given by S1Physician. Interview on 07/17/2024 at 1:30 p.m., following review of Patient #20’s medical record, S2DON acknowledged the patient was transferred without discharge orders and without the required Resident Discharge Form which details: the patient demographics; name of receiving facility with date and time notified; diagnoses; vital signs; allergies; and medications.”

“CARE OF PATIENTS - ADMISSION CFR(s): 482.12(c)(2) [ ...the governing body must ensure that the following requirements are met:] Patients are admitted to the hospital only on the recommendation of a licensed practitioner permitted by the State to admit patients to a hospital. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to ensure all patients were admitted to the hospital only on the recommendation of a licensed practitioner. This deficient practice was evidenced by failing to consult a provider to make a final decision for admission or denial for 1 (#1) of 3 (#1, #2, #3) patient records reviewed. Findings: Review of the hospital’s policy titled “301 Admissions & Exclusionary Criteria” revised 08/2023, revealed in part, Referrals for Admission: 2.) All admissions to the facility are screened by the Admissions Department and Director of Nursing for clinical appropriateness. The on-call physician / practitioner is contacted by the admissions personnel or RN Charge Nurse, depending on the time of the referral, for admission approval and admit orders. Review of Patient #1’s medical record revealed an admission date of 06/07/2024. Review of the admit orders dated 06/07/2024 at 12:00 p.m. revealed the admission diagnosis was blank, the VORB practitioner line was blank, date of order and time were blank, the nurse signature line was blank, and the licensed practitioner’s signature line was blank with no date or time. Review of the close observation (Q15 Min Checks) not dated revealed in part, 12:15 p.m. admit and 2:15 p.m. discharge. There was a note at the bottom of this observation sheet stating Patient #1 was in intake room for the hour he was here. Review of the multidisciplinary note dated 06/07/2024 at 12:15 p.m. revealed in part, Patient #1 arrived via ambulance. In an interview on 07/11/2024 at 10:14 a.m. S1DON stated either himself or the charge RN accepts patients for evaluations for admission. S1DON stated if the patient meets the admission criteria, then that patient comes to the hospital for an evaluation. S1DON stated then the nursing assessment process starts. S1DON stated then the physician is contacted for admission of the patient. S1DON stated once Patient #1 arrived at this hospital that was when the psychiatrist was contacted to accept Patient #1 for admission. In a phone interview on 07/11/2024 at 1:15 p.m. S2Psych stated generally they call and run information by the staff of the hospital and they accept the patient. S2Psych stated obviously Patient #1 should not have been accepted here. S2Psych stated he was contacted about Patient #1 after Patient #1 arrived to this hospital. In an interview on 07/15/2024 at 1:39 p.m. S1DON stated Patient #1 should have been wheeled on the stretcher to the seclusion room with enough staff to secure Patient #1 in restraints to get Patient #1 off the EMS stretcher. S1DON verified Patient #1 would have been safer at Mercy Behavioral Hospital than being transferred back to Hospital ‘A’ emergency department. After reviewing the admission criteria policy, S1DON verified that Patient #1 did meet admission criteria and did not meet any exclusionary criteria. In a phone interview on 07/15/2024 at 3:10 p.m. S3UR stated she notified S1DON. S3UR stated S1DON made the decision to accept Patient #1 into this hospital.”

“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: 44763 Based on record reviews and interviews, the hospital failed to ensure patients received care in a safe setting. This deficient practice was evidenced by: 1.) failing to accompany a discharged patient to his/her car as per hospital policy and allowing the patient to walk to a nearby gas station to wait on a ride for 1 (#2) of 3 (#1, #2, #3) patient records reviewed; and 2.) failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality of care for psychiatric patients for ligature risks and safety risks. Findings: 1.) Failing to accompany a discharged patient to his/her car as per hospital policy and allowing the patient to walk to a nearby gas station to wait on a ride for 1 (#2) of 3 (#1, #2, #3) patient records reviewed. Review of the hospital’s policy titled “311 Patient Discharges” revised 06/2024, revealed in part, the patient must be accompanied by a nursing staff member or a designee to his/her car. Review of Patient #2’s medical record revealed an admission and discharge date of 06/07/2024. Review of the physician’s orders revealed an order dated 06/07/2024 at 2:30 p.m. Per S2Psych Okay to discharge patient once job is confirmed telephone order read back S2Psych / S4RN. Further review of Patient #2’s medical record revealed a nurse’s note dated 06/07/2024 at 5:00 p.m. Job confirmed and patient signed non SI contract. S2Psych notified. Patient requested to walk and meet his ride at the gas station. Patient discharged at 5:50 p.m. In an interview on 07/11/2024 at 10:55 a.m. S4RN stated Patient #2 called his ride to come get him. S4RN stated Patient #2 told her he didn’t want to wait on his ride. S4RN stated she told Patient #2 that he could walk to the gas station to wait for his ride. In an interview on 07/15/2024 at 2:10 p.m. S1DON verified Patient #2 was not accompanied by a hospital staff member and was allowed to walk to a nearby gas station. 2.) Failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality of care for psychiatric patients for ligature risks and safety risks. Review of the hospital’s policy titled “908 Contraband & Restricted Articles” revised 06/2024, revealed in part, To ensure a safe environment and to provide a monitoring system for patients who are utilizing sharps or items designated as contraband. Items considered to be restricted: Knives (all types); Glass, mirrors and metal picture frames; Plastics (plastic garbage bags & plastic utensils); Ceramics, pottery, cosmetics with sharp attachments; Scissors, razor blades, nail files, metal combs; Coat hangers; Personal hairdryers, curling irons; Electric razors with cord attachments; Tape players with recording devices and record players; All medications; Other potentially sharp objects; Lighters, matches; Cameras; Clothing items deemed potentially dangerous such as belts, cords, and long shoelaces; Cell phones Observation on 07/10/2024 at 10:15 a.m. - 11:13 a.m. of the inpatient unit accompanied by S1DON revealed the following: Room ‘g’: there was a plastic spoon on the nightstand Room ‘b’: there was a plastic cracker packaging on the nightstand In an interview during the observation S1DON verified the above stated findings. S1DON stated the above stated items should not be in patient rooms.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to ensure the use of restraints was in accordance with the order of a physician or other licensed independent practitioner who was responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This deficient practice was evidenced by failing to obtain a physician’s order for the use of restraints for 1 (#1) of 3 (#1, #2, #3) patients reviewed. Findings: Review of Patient #1’s medical record revealed an admission date of 06/07/2024. Review of the multidisciplinary note dated 06/07/2024 at 12:15 p.m. revealed in part, S4RN called all staff for help due to the patient being in 4 point restraints and still launching his upper body off the stretcher. After attempting to calm the patient down, S2Psych was notified of patient arrival and current situation. PRN orders was given at this time. Haldol 15mg IM, Ativan 4mg IM, and Benadryl 50mg IM. Patient #1 remained on stretcher in 4 point restraint due to patient being extremely combative with EMT and staff. IM injection was given at 12:25 p.m. by LPN. We again attempted to calm patient down and waited on injection to take effect approximately 40 minutes (injection was ineffective). EMTs could not release patient out restraints due to patient trying to flip stretcher. In an interview on 07/10/2024 at 12:27 p.m. S1DON stated Patient #1 was in soft restraints and stretcher belts were in place upon arrival. S1DON stated Patient #1 was not released from the soft restraints or taken off the stretcher at this hospital. In an interview on 07/11/2024 at 10:31 a.m. S4RN stated EMS asked her if she had more staff to help with Patient #1. S4RN stated EMS told her that Patient #1 was very combative and had already head-butted the EMT girl. S4RN stated EMS brought Patient #1 into the hospital via stretcher. S4RN stated Patient #1 was very combative, trying to flip the stretcher. S4RN stated Patient #1 was in 4 point restraints. In an interview on 07/15/2024 at 1:39 p.m. S1DON verified there was no documentation of an order for restraints in Patient #1’s medical record.”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 44763 Based on record reviews and interview, the hospital failed to ensure medical records contained accurate information related to patient name and date of birth for 1 (#2) of 3 (#1, #2, #3) patients reviewed. Findings: Review of the hospital’s policy titled “1102 Authentication of Medical Records” revised 06/2024, revealed in part, It is the responsibility of the Coordinator of the Health Information Management Department to assure authenticity and integrity of the medical record of discharged patients within 30 days post-discharge. Medical records are completed within 30 days post-discharge and that medical records are accurate for clients assessed, cared for, treated, or served. Review of Patient #2’s medical record revealed an admission date of 06/07/2024 and a discharge date of 06/07/2024. Review of the face sheet revealed Patient #2’s date of birth was 09/20/2000. Further review revealed the patient labels that were on majority of the pages of Patient #2’s medical record revealed Patient #2’s date of birth as 06/26/1992. Review of Patient #2’s psychiatric evaluation dated 06/07/2024 revealed Patient #2’s last name was incorrect. Further review revealed Patient #2’s date of birth as 09/01/2000. In an interview on 07/10/2024 at 3:21 p.m. S1DON verified Patient #2’s name and date of birth was correct on the face sheet. S1DON verified Patient #2’s date of birth was incorrect on the patient labels that were on majority of the pages of Patient #2’s medical record. S1DON verified Patient #2’s last name and date of birth were incorrect on Patient #2’s psychiatric evaluation.”

“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: 44763 Based on record reviews and interviews, the hospital failed to ensure that all orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner for 2 (#1, #2) of 3 (#1, #2, #3) patient records reviewed. Findings: Review of the hospital’s Medical Staff Bylaws & Rules and Regulations revealed in part, all orders for treatment shall be in writing. A verbal order shall be considered to be in writing if dictated to a licensed professional nurse functioning within his sphere of competency and signed by the responsible practitioner. The appropriately authorized person receiving dictation shall sign all orders dictated over the telephone with the name of the Practitioner dictating per his approval. The responsible Practitioner shall authenticate such orders within ten (10) days, and failure to do so shall be brought to the attention of the Medical Executive Committee for appropriate action. Review of the hospital’s policy titled “402 Medication & Treatment Orders” adopted date 05/2024, revealed in part, Verbal/Telephone Orders: The prescribing practitioner must date, time, and authenticate the verbal order within ten (10) days as designated by state law. Patient #1 Review of Patient #1’s medical record revealed an admission date of 06/07/2024. Review of the admit orders dated 06/07/2024 at 12:00 p.m. revealed the admit orders were not signed by the licensed practitioner. Further review of Patient #1’s medical record revealed an order for Haldol 15mg IM, Ativan 4mg IM, Benadryl 50mg IM Q4h PRN for agitation/psychosis telephone order read back S2Psych / S4RN. This order was not signed by S2Psych. In an interview on 07/10/2024 at 1:40 p.m. S1DON verified the telephone order for the PRN medication that was administered to Patient #1 was not signed by the physician. In an interview on 07/10/2024 at 1:58 p.m. S1DON verified the physician has 10 days to sign orders. In an interview on 07/15/2024 at 1:39 p.m. S1DON verified there were no documented signatures on the admission orders. Patient #2 Review of Patient #2’s medical record revealed an admission date of 06/07/2024. Review of the admit orders dated 06/07/2024 1:30 p.m. revealed the admit orders were not signed by the licensed practitioner. Further review of Patient #2’s medical record revealed an order dated 06/07/2024 at 1:50 p.m. New Admit with OPC/FVA hx of bipolar. This order was not signed by the licensed practitioner. Order dated 06/07/2024 at 2:30 p.m. Per S2Psych Okay to discharge patient once job is confirmed. Telephone order read back S2Psych / S4RN. This order was not signed by S2Psych. In an interview on 07/10/2024 at 3:21 p.m. S1DON verified the physician orders in Patient #2’s medical record were not signed by the physician.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 44763 Based on observation and interview, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients, staff, and visitors. Findings: Observation on 07/10/2024 at 10:15 a.m. - 11:13 a.m. of the inpatient unit accompanied by S1DON revealed the following: Dayroom A: there were 4 floor tiles broken in the middle of the room Male Shower Room: there were 2 tiles missing from the baseboard Room ‘f’: there was peeling paint on the wall near the head of the patient bed In an interview during the observation S1DON verified the above stated findings.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 44763 Based on observation, record review, and interview, the infection control officer failed to ensure the hospital’s system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel was implemented. This deficient practice was evidenced by failing to maintain a sanitary environment. Findings: Review of the hospital’s policy titled “515 Environmental Services” revised 06/2024, revealed in part, To control the spread of infection within the hospital, the hospital will maintain a thoroughly clean and safe environment. All patient and non-patient rooms shall be thoroughly cleaned and disinfected, keeping in mind Standard Precautions and Infection Control. Observation on 07/10/2024 at 10:15 a.m. - 11:13 a.m. of the inpatient unit accompanied by S1DON revealed the following: Dayroom A: there was popcorn on the floor next to a chair and other debris in multiple areas on the floor Dayroom B: there was a wet puddle of liquid on the table and the floor and debris in multiple areas on the floor Room ‘a’: small area of liquid on the floor Room ‘b’: multiple rust areas and rusted screws to the cover of the air conditioner Room ‘c’: there was a dead bug located under the patient mattress of side B and a live bug located under the patient mattress of side A Room “d’: rust areas to the cover of the air conditioner Room ‘e’: rust areas to the cover of the air conditioner Room ‘f’: there was a dead bug located under the patient mattress of side B In an interview during the observation S1DON verified the above stated findings.”

“Provisional or Admitting Diagnosis CFR(s): A provisional or admitting diagnosis must be made on every patient at the time of admission, and must include the diagnosis of intercurrent diseases as well as the psychiatric diagnosis. This Standard is not met as evidenced by: 44763 Based on record review and interview, the hospital failed to ensure an admitting diagnosis was made on every patient at the time of admission, and include the diagnosis of intercurrent diseases as well as the psychiatric diagnosis. This deficient practice was evidenced by failing to document an admitting diagnosis on every patient at the time of admission for 1 (#1) of 3 (#1, #2, #3) patients reviewed. Findings: Review of Patient #1’s medical record revealed an admission date of 06/07/2024. Review of the admit orders dated 06/07/2024 at 12:00 p.m. failed to reveal an admission diagnosis. In an interview on 07/10/2024 at 1:40 p.m. S1DON verified the admission diagnosis on the admission orders was blank. S1DON stated “they did not put one.””