Bronson Methodist Hospital

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to complete a 1-hour face-to-face assessment for 1 (P-10) of 1 patients reviewed for violent restraint resulting in the loss of patient rights. Findings include: Review of the medical record for P-10 revealed she was a 22-year-old female who presented to the Emergency Department (ED) 1/2/2026 for a drug overdose. On 1/2/2026 at 2356 an order was placed for 4-point violent restraint to 4 extremities for the duration of up to 4 hours. Restraint was initiated 1/3/2026 at 0000 and was discontinued 1/3/2026 at 0129. Review of the face-to-face assessment revealed it was done prior to initiation of restraint on 1/2/2026 at 2357. On 1/6/2026 at 1422, Staff C stated the events of ordering and initiating restraint, along with the physician face-to-face assessment was most likely happening all at the same time and the order of the documentation did not necessarily reflect the true picture of how the events happened. When queried as to if staff had the ability to make a late entry, Staff C confirmed that they could. The updated facility policy titled “System Nursing Policy G-02 Restraints” which had no revision or effective date present, states, “A Practitioner should perform a face-to-face assessment within one hour of the initiation of violent restraints to evaluate the patient’s situation, reaction to the restraint, medical and behavioral condition, and the need for continued restraint use.””

“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: 36887 Based on interview and record review, the facility failed to provide an appropriate medical screening exam for 1 (P-1) of 31 patients reviewed. Findings include: Review of the medical record for P-1 revealed she was a 24-year-old female who presented to the Emergency Department (ED) on 8/12/2025 at 1041 for a second visit with a chief complaint of vaginal bleeding with pain rated 10/10. She had come in 8/12/2025 at 0035 with the same complaint. She was 17 weeks, 5 days pregnant. Following labs and an ultrasound, she had been discharged home at 0546 to follow up with her OB/GYN (obstetrics/gynecology) physician. Triage notes from 8/12/2025 at 1046 stated P-1 was “...[brought in by] EMS [emergency medical services] from home for vaginal bleeding and bad pain, seen last night).” The chief complaint was updated a minute later at 1047 to reflect P-1 was 17 weeks pregnant. Vital signs were as follows: T (temperature)-97.5, HR (heart rate)-82, R (respirations)-18, BP (blood pressure)-107/57, SpO2 (oxygen saturation)-100% room air. P-1 rated her pain as 10/10 “worst pain ever.” She was placed in the waiting room. There was no assessment of onset of pain, characteristics of pain such as onset, location, quality, and description, onset of bleeding, amount of bleeding, or any characteristics of bleeding such as color and/or clotting. There was no auscultation of fetal heartrate or documentation that the physician was notified staff were unable to find a fetal heart rate. On 11/13/2025 at 0845, review of ambulance documentation revealed two forms. One was titled “5th District EMS Field Notes” dated 6/12/2025 (assumed to be misdated as there was no visit by P-1 to this facility in June 2025 and the notes indicated she was 17 weeks 6 days in gestation). Basic information regarding name, date of birth, and address was present along with meds and allergies. Some vital signs were present as well as a brief note of P-1’s gestation and that she had 2 miscarriages and 4 pregnancies. P-1 was given an ESI-3 despite clinical presentation and 10/10 pain. The second form was an electronic “Pre-hospital Care Report Summary” dated 8/12/2025 which provided much more detailed information about the EMS (emergency medical services) transportation including time of the call, arrival to patient, transport times, and arrival at the facility. The chief complaint was listed as “Abdominal Cramps.” Two sets of vital signs were obtained as follows: 1027 HR-90, R-18, BP-120/70, SpO2-98% Pain 10/10 1037 HR-98, R-16, BP-135/80, SpO2-98% Pain 4/10 The “Narrative History Text” indicated she had been to the hospital earlier that day and had an ultrasound. P-1 stated, “the cramping had not stopped and... the spotting had worsened.” Additionally, it stated, “Pt stated that the pain in her abdomen (sic) felt like cramping, similar to her contractions with her first baby...” On 11/13/2025 at 0958, Triage Nurse Staff M stated she had received a verbal report in triage from EMS of P-1 having abdominal pain and vaginal bleeding. She stated the EMS report, “Field Notes”, was usually given to the registration clerk for registration purposes and then “clipped to the chart” with name band and registration information. She stated she would have only received the field notes as the electronic “Pre-hospital Care Report Summary” was provided once the EMS staff had time to put it in. This was confirmed by ED Director Staff B and ED Manager Staff A. Staff M did not recall if she asked about bleeding and forgot to chart it, or if she had asked about it at all. She confirmed the protocol was for pregnant patients under 18 weeks gestation to be evaluated in the ED and not be sent to labor and delivery. The bottom of the report was time-stamped when sent to the facility as 8/12/2025 at 1516. Further review of the medical record ED timeline revealed that upon coming to the lobby to take the patient back to a room at 1246, they found the patient had left without being seen by a provider. There was no evidence the hospital documented education regarding leaving Against Medical Advice (AMA) or the refusal to sign AMA documents. Review of the medical record from the receiving facility dated 8/12/2025 revealed P-1 arrived at 1248 with no chief complaint on file. Physician notes stated a rapid response was called to the waiting room bathroom. Upon physician arrival, P-1 was “on the toilet holding a fetus still connected to placenta... They went to (initials of the initial facility) but will (sic) her in the waiting room too long so they came here. She started having worsening pain, she went to the bathroom and delivered the fetus.” P-1 was moved to an ED room for delivery of the placenta which occurred at 1310. Physician notes indicated a discussion with P-1 that the baby was not viable as the eyelids and nasal passages were still fused. The baby did have a heart rate of 78 and respirations of 10. Comfort measures were recommended. P-1 was transferred to the labor and delivery (L&D) department at the initial facility. Review of the medical record for L&D revealed P-1 arrived with a chief complaint of “delivered (17 wk demise).” The initial history and physical (H&P) states, “She reports she began feeling crampy yesterday morning... She was seen in the ER (emergency room) at 4 am. There she reports waiting in the waiting room in pain for multiple hours prior to being seen...They discharged her to home... she continued to be painful and that never resolved prior to leaving the ER. A few hours later pain continued to worsen and bleeding increased. She took an ambulance... where she again waited for a long time in the waiting room in labor pains, then patient ’ s mom took her to (receiving facility initials). On arrival to (receiving facility initials), she went to the bathroom, where she delivered her baby on the toilet. Baby was alive at the time of birth...” The H&P further indicated the baby was now deceased. Facility policy titled “Treatment and Active Labor Act Compliance” dated 6/7/2002 states, “Any person who comes to the hospital’s dedicated Emergency Department (ED), Labor and Delivery Department, or arrives on hospital property requesting treatment for what may be an emergency medical condition will receive a medical screening performed by a qualified provider to determine whether an emergency medical condition exists. Persons with emergency conditions will be treated and their condition stabilized without regard to ability to pay for services... Labor means the process of childbirth beginning with the latent or early phase of labor and continuing through the delivery of the placenta. A woman is considered to be in true labor unless a physician or qualified medical personnel certifies that, after a reasonable time of observation, the woman is in false labor... Medical Screening Examination is the process requiring determining, with reasonable clinical confidence, whether or not an emergency medical condition exists or a woman is in labor. This is documented in the patient’s medical record... Triage is a sorting process to determine the order in which patients will be provided a medical screening examination by a qualified medical person. Triage is not the equivalent of a medical screening examination and does not determine the presence or absence of an emergency medical condition... The medical screening consists of an assessment and any ancillary tests or focused assessment based on the patient’s chief complaint necessary to determine the presence or absence of an emergency medical condition... The medical screening examination is the process a provider must use to reach with reasonable clinical confidence whether a medical emergency does or does not exist. The medical screening must provide evaluation and stabilizing treatment within the scope of the hospital or facility’s abilities and not consider a patient’s ability to pay... If a patient waiting for medical screening decides to leave without examination the following steps should be taken...ask the patient to sign AMA form...and document in the medical record the above information and if they refuse to sign the AMA, document that on the record as well...” Facility policy titled “Triage Guidelines for the Emergency Department”, undated, states, “ (Facility name) emergency departments strive to provide emergency care that get patients to the right level of care, with the right resources, at the right time... (Facility name) will provide hospital emergency care to all patients requesting emergency care who are on hospital property... All patients who present tot he ED will receive an immediate triage assessment by a registered nurse using a reliable, five level triage scale using the ESI (emergency severity index) Algorithm.. The purpose of an immediate triage assessment is to determine the presence of an Emergency Medical Condition... All patients are guaranteed a medical screening exam (MSE) and stabilization treatment in accordance with the Emergency Medical Treatment & Active Labor Act (EMTALA). The triage assessment does not qualify as the MSE... A MSE will be performed by a provider based upon triage acuity and departmental acuity/saturation.” Facility policy titled “Guideline for Management of Obstetrical and Postpartum Patients Who Present to ED”, undated, states, “PURPOSE: Provide safe and efficient care for pregnant or recent postpartum women who present for care int he ED by determination of the best location for evaluation of these patients... All patient who present to the ED for treatment who are pregnant with a gestational age of <18 weeks will be evaluated in the ED. An attempt shall be made to auscultate fetal heart rate at 12 weeks or greater gestation as part of at least one set of maternal vital signs. Inability to hear or count fetal heart rate will be noted in the documentation and physician notified. Notification of the obstetrical provider will be based on the findings related to pregnancy or impact on fetal wellbeing, at the discretion of the ED physician.””

“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: 48030 Based on interview and record review, the facility failed to ensure that an alleged incident of patient abuse was reported and remediated for one patient (P-1) of 10 patients reviewed, resulting in possible negative outcomes for this patient. Findings include: During chart review for P-1 on 10/21/2025 at 1415 the record revealed the following entries regarding the patient’s allegation of assault: 8/2/2025 - General Medicine Note- “Subjective Patient seen examined at bedside. Overnight, patient called the police and staff. Currently she has no complaints. Ostomy output has decreased. She is feeling hungry. She is open to go home soon. She denies any fevers, chills, chest pain, shortness of breath, nausea, vomiting or abdominal pain.” 8/2/2025 at 0149 Nursing Note - 8/2 0140 “Patient called 911 on room phone. Security and police went in room to discuss with patient.” 8/2/2025 - 1033 - Nursing to provider notification - “pt is confused and urine smells strong - can we do UA? also pt accusing staff of sexual harrassement [sic] and currently hitting/throwin[sic]” 8/2/2025 - 1418 Nursing provider notification - “Evaluate patient is adamant about leaving again. She called the police to come get her.” On 10/21/2025 at 1545 an interview with the System Manager of Case Management (Staff Q) was conducted and revealed she received a phone call from the staff at the rehabilitation facility P-1 had been transferred back to upon discharge. Staff Q reported that the staff member wanted to report that P-1 had reported she was making allegations of abuse by staff that occurred during her recent admission to the facility. Staff Q explained after she ended the call with the rehabilitation facility staff member, she called the Risk Management Department to report the incident. Staff Q revealed she called the rehabilitation facility back to notify them that she had let the Risk Management Department know about the allegations. When queried if she had heard anything further about the complaint, Staff Q responded, “no”. During an interview with the staff nurse (Staff T) on 10/22/2025 at 0900 that was assigned to care for P-1 during the admission it was revealed that she remembered P-1 and that she was experiencing mental status changes during her admission. Staff T explained that she recalled trying to explain what they are doing to P-1 and she would yell at staff and was confused at times. Staff T recalled that a male patient care associate (Staff Y) needed to perform a bladder scan for urinary retention, and she explained the procedure to P-1 but when the PCA went to perform the scan, P-1 began yelling “he is raping me”. Staff T explained that she immediately went into P-1’s room and tried to explain the procedure to her again, but P-1 continued to say she was being raped, and the scan was not completed. Staff T revealed she notified the primary care provider that P-1 was yelling at staff, a 2-person “buddy” system was initiated following the incident and a sign was placed outside of her room, so that caregivers were not in her room alone. Staff T recalled she did not remember much else about the incident other that P-1 continued to yell out and her bed alarm kept going off. When queried if she notified leadership about the incident, Staff T stated, “I do not remember”. When queried if she was interviewed about the incident by her manager or anyone from Human Resources, Staff T revealed, “no”. On 10/22/2025 at 1030 an interview with the Patient Care Associate (Staff Y) was conducted and revealed that he was told in shift report from the off-going PCA that P-1 had not voided in a long time and there was concern for urinary retention, so he notified the nurse. Staff Y explained that he went in to do a bladder scan and introduced himself to P-1 and explained what the bladder scan was for and how he was going to do it and “she started screaming at me and told me to get out of the room” and he immediately left her room to notify the nurse. Staff Y added, “I never even made it past the curtain in her room.” Staff Y explained that he was later notified that P-1 called 911 from her room following this incident and reported she was sexually assaulted. Staff Y revealed, “I never even touched the patient” and added that he heard that P-1 had made the same allegations the following day about the nurse (Staff T). Staff Y said immediately following the incident he changed his assignment, so he would no longer be providing care to P-1 since she was confused, and he did not think it was a good idea to be in a room alone with her. An interview with the Internal Medicine Hospitalist (Staff Z) was conducted on 10/22/2025 at 1100. Staff Z revealed he remembered P-1 and that after reviewing her record that he evaluated her on 8/1/2025, 8/2/2025 and that she was requesting to be discharged on 8/3/2025. Staff Z explained that P-1 was alert and oriented but had a history of dementia and may have been having Sundown Syndrome (increasing confusion, restlessness, anxiety and paranoia which occurs in the late afternoon and at night) symptoms. Staff Z revealed that he did not recall P-1 telling him about an assault or that she called 911 but does know she was experiencing urinary retention and required a foley catheter insertion. Staff Z revealed P-1 did require a Zyprexa injection on 8/2/2025 for agitation and becoming combative with staff. When queried if he had previous concerns of patient assault on the unit, Staff Z explained, “this a very vulnerable unit because of the patient population and increased confusion” and he did not believe P-1 was assaulted during the admission. During an interview with the staff nurse (Staff GG) on 10/29/2025 at 0830 by phone, it was revealed she remembered P-1 and that she was not confused at the start of her shift, but her confusion increased as the day progressed. Staff GG revealed that the patient care associate (Staff Y) reported to her that P-1 refused a bladder scan and was inferring that he was trying to get under the covers with her and be inappropriate. Staff GG explained that she went into P-1’s room with another female PCA and explained the process of the bladder scan and the patient allowed her to do it. Staff GG revealed the P-1 did not report the incident with Staff Y when she was providing care for her, but she later called 911, which was the next time she heard of the incident, and she saw the police on her unit. Staff GG explained that she notified the charge nurse and that the police shared with her that they were not going to be do anything further about the complaint. Staff GG added P-1’s glucose was low and required dextrose and her potassium was also low, so she was very focused on those things. Staff GG added that when she spoke with Staff Y about the incident, he shared with her that he went to do the bladder scan, and she refused and they decided not to assign male caregivers for her moving forward. Staff GG revealed she never spoke with management human resources following the incident and did not complete an incident report. A phone interview with the Security Officer (Staff DD) was conducted on 10/29/2025 at 0800 and revealed she remembered being called up to P-1’s hospital room because she was calling 911. Staff DD explained that Security is notified if anyone uses a hospital phone to dial 911 and Security and the local police department went to speak with P-1 in her room who told them she was calling 911 so she could get a ride out of the facility. Staff DD revealed that P-1 told them that a male patient care associate (PCA) came into her room to do a bladder scan by himself, and she did not think a male should do that without a female present because he could have attempted to harm her or do sexual harm. Staff DD explained that the police asked P-1 if she was harmed and she said “no”. Staff DD explained that P-1 was notified that police could not give her a ride home at 0200. When queried if she had any other calls about P-1 or if she called 911 again, Staff DD revealed “no, we did not hear from her again”. Staff DD added, we spoke with the facility staff involved and they explained that when P-1 asked for a female PCA, the male PCA stepped out of the room and that was the end of it. Staff DD explained following the incident a report was filed and which was reviewed by the supervisor, and she never heard anything about it after that. On 10/29/2025 at 0900 an interview with the 4th floor Adult General Medicine Unit Manager (Staff HH) was conducted and revealed she found out about P-1’s allegations because of an incident report that was sent to her. Staff HH explained there was some confusion as to which unit P-1 was on when during alleged event and she had spoken with the 3rd Floor Neurovascular Unit Manager (Staff D) and reviewed the charting related to the foley insertion to determine who provided care to P-1. Staff HH explained that when she spoke with the staff members, they did not remember P-1. Staff HH added that she was at an outside function for the facility and ran into the human resource manager (who is no longer with the facility) and was talking to her about the event and was told it was handled and “was going to take care of it”. Staff HH explained she attempted to follow-up with an email to the HR manager and found that she no longer worked at the facility, and she assumed that the investigation was managed by Risk Management and Human Resources. On 10/21/2025 at 1430 an interview with the System Director of Risk Manager (Staff O) was conducted and revealed she was familiar with P-1 and explained, “the whole team was involved with the case because it was an assault allegation”. Staff O revealed the case was initially assigned to a risk manager in the office (who is currently on leave and unavailable for interview). Staff O revealed the Risk Management Department received a voicemail from the System Director of Case Management (Staff Q) stating that she had received a phone call from the rehabilitation facility where P-1 was residing and they were reporting that P-1 had reported she was sexually assaulted by facility staff. Staff O explained that Staff Q documented that she called the rehabilitation facility to review the allegations and was told by staff at the facility that P-1 had reported multiple other episodes of false allegations at the rehabilitation facility. Staff O explained that following the phone call with the rehabilitation facility, Staff Q reviewed P-1’s record to determine the caregivers and units P-1 was admitted to. Staff O explained that Staff Q found that P-1 was retaining urine, requiring straight catheterization and foley catheter insertion. Staff O continued that Staff Q contacted the Human Resources (HR) Department On 8/12/2025 to report the facility staff that was involved in P-1’s care and begin the investigation. Staff O explained that Staff Q documented that she had spoken with a HR representative that is no longer with the facility. Staff O explains the file does not include any interviews that were conducted and that “HR probably considered it unsubstantiated and closed the file on 8/15/2025”. When queried if Staff Q documented that HR had provided any additional follow-up, Staff O explained the last note in the file was from 9/4/2025 that stated “significant discrepancies, nothing substantiated, still waiting for APS (Adult Protective Services) report” and a note dated 9/5/2025 from the previously employed HR representative revealed, the matter will be transferred to the System Director of Human Resources (Staff S). When queried if the investigation into the allegations was followed according to the facilities policy/procedure, Staff O revealed, “no this is not how this should have been handled.” On 10/22/2025 at 1130 an interview with the System Director of Human Resources and Employee Engagement (Staff S) was conducted. Staff S revealed she was not aware of the incident investigation pertaining to P-1 until 10/21/2025. Staff S explained that the Manager of Human Resources was responsible for managing the investigation, but she is no longer working at the facility. Staff S revealed she reviewed the file and the expectation would have been that there were notes on the investigation including staff interviews before it was closed, which were not found with the file. Staff S explained the file had been closed and marked as unable to substantiate. When queried if the facility followed their policy/process for incident report investigation, Staff S revealed they did not. Review of facility policy titled, “Investigation of Physical and Sexual Misconduct Allegations”, last revised 5/17/2025, section titled “Procedure, All patient or visitor complaints of misconduct by a [facility] workforce member must be immediately reported to Human Resources and/or Risk Management as well as operational leadership at the location the alleged misconduct occurred. Complaints involving employed individuals and patients, or visitors shall be investigated by Human Resources and Risk Management.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 36887 Based on observation, interview, and record review, the facility failed to properly restrain 2 (P-2, P-3) of 5 patients reviewed for restraint resulting in the loss of patient rights and the potential for poor patient outcomes. Findings include: See specific tags: A-168 Failure to have order for restraint A-179 Failure to have a documented face-to-face assessment A-185 Failure to have documented patient behavior and intervention used prior to patient restraint A-196 Failure to have ongoing restraint training for physicians”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 29955 Based on interview and record review, the facility failed to ensure intake and output was documented for 3 (P-1, P-3, and P-10) of 4 patient reviewed for documentation of intake and output, resulting in the potential for inadequate monitoring and assessment for these patients. Findings include: See specific tag: A-0392 - Failure to provide hydration and record urine output”

“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: 36887 Based on interview and record review, the facility failed to have a physician/provider order for 2 (P-2, P-3) of 5 patients reviewed for restraint resulting in the loss of patient rights, the potential for inappropriate restraint, and the potential for poor patient outcomes. Findings include: Review of the medical record for P-2 revealed she was a 37-year-old female who had presented to the Emergency Department (ED) 7/7/2025 to have a mental health evaluation. P-2 told Physician Staff FF and Social Worker Staff CC she did not want to live at home anymore and wanted to be admitted to an inpatient psychiatric unit and be gradually transitions to temporary housing and then to permanent housing. She told Staff FF “if she does not go to a psychiatric facility then she will feel suicidal.” Upon finding she did not meet admission criteria and was being discharged, P-2 refused to be discharged. P-2 was “escorted out of the department with all of her belongings by security.” On 8/7/2025 at 1130, review of the security report written by Security Officer Staff S, dated 7/7/2025 at 1548, revealed upon entering the patient room, two clinical staff members were “holding down the patient keeping her restrained to the bed.” When asked why the patient was being held down, “the staff member informed us that she had attempted to bite them after them (sic) telling the patient that she had been discharged.” On 8/11/2025 at 1951, Registered Nurse (RN) Staff X stated when she went in to discharge P-2, she became “very agitated” and “was refusing discharge.” She stated she was “caught off guard” because she thought discharge had already been discussed with P-2. P-2 then began making “vague suicidal statements” so Staff X went and got Social Worker Staff CC to come speak with P-2 again. Staff X stated Staff CC was talking with P-2 who continued making vague suicidal statements. As a result, Physician Staff FF came back into the room. On 8/11/2025 at 1402, Physician Staff FF stated P-2 was “fixated” on her housing situation and did not meet criteria for inpatient admission. When P-2 found out about the discharge, she opened drawers in the room and “grabbed some needles and attacked” him. He then stated he “side-stepped her” and “pushed her against the bed and held her” there “trying to defend myself.” She was held to the bed until security arrived. No documentation was found in the medical record regarding P-2’s actions or the subsequent physical hold including physician orders for the hold. Review of the medical record for P-3 revealed she was an 11-year-old female who was initially admitted to PICU (pediatric intensive care unit) 3/21/2025 with dehydration and hypernatremia. The initial history and physical (H&P) revealed she had a tonsillectomy and adenoidectomy (T&A) 2/20/2025 and had not been eating or drinking much over the past month. She transitioned to the general pediatric unit 3/22/2025. Review of Physician Staff RR’s progress notes dated 3/26/2025 revealed the following: “Mom reports that (P-3) was held down by nursing staff last night for med administration and that Mom walked in as they were attempting to give the trileptal (treatment of seizures)... Spoke with (Nurse Manager Staff F to ensure nursing staff is aware that this is not appropriate...” Review of physician orders revealed no orders were present for a physical hold on P-3 at any time during her admission to the facility. Review of facility policy “System Nursing Policy G-02 Restraints”, with no origination or revised dates, states, “’Restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely... Each episode of restraint or seclusion should be initiated upon i. the order of a Practitioner who is responsible for the patient...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) [the patient must be seen face-to-face within 1 hour after the initiation of the intervention -- ] §482.13(e)(12)(ii)To evaluate - 1. The patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to conduct and/or document a 1-hour face to face assessment for 2 (P-2, P-3) of 5 patients reviewed for restraint resulting in the potential for unidentified, unmet patient needs and poor patient outcomes. Findings include: Review of the medical record for P-2 revealed she was a 37-year-old female who had presented to the Emergency Department (ED) 7/7/2025 to have a mental health evaluation. P-2 told Physician Staff FF and Social Worker Staff CC she did not want to live at home anymore and wanted to be admitted to an inpatient psychiatric unit and be gradually transitioned to temporary housing and then to permanent housing. She told Staff FF “if she does not go to a psychiatric facility then she will feel suicidal.” Upon finding she did not meet admission criteria and was being discharged, P-2 refused to be discharged. P-2 was “escorted out of the department with all of her belongings by security.” On 8/7/2025 at 1130, review of the security report written by Security Officer Staff S, dated 7/7/2025 at 1548, revealed upon entering the patient room, two clinical staff members were “holding down the patient keeping her restrained to the bed.” When asked why the patient was being held down, “the staff member informed us that she had attempted to bite them after them (sic) telling the patient that she had been discharged.” On 8/11/2025 at 1951, Registered Nurse (RN) Staff X stated when she went in to discharge P-2, she became “very agitated” and “was refusing discharge.” She stated she was “caught off guard” because she thought discharge had already been discussed with P-2. P-2 then began making “vague suicidal statements” so Staff X went and got Social Worker Staff CC to come speak with P-2 again. Staff X stated Staff CC was talking with P-2 who continued making vague suicidal statements. As a result, Physician Staff FF came back into the room. On 8/11/2025 at 1402, Physician Staff FF stated P-2 was “fixated” on her housing situation and did not meet criteria for inpatient admission. When P-2 found out about the discharge, she opened drawers in the room and “grabbed some needles and attacked” him. He then stated he “side-stepped her” and “pushed her against the bed and held her” there “trying to defend myself.” She was held to the bed until security arrived. No documentation was found in the medical record regarding P-2’s actions or the subsequent physical hold including the 1-hour face-to-face assessment. Review of the medical record for P-3 revealed she was an 11-year-old female who was initially admitted to PICU (pediatric intensive care unit) 3/21/2025 with dehydration and hypernatremia. The initial history and physical (H&P) revealed she had a tonsillectomy and adenoidectomy (T&A) 2/20/2025 and had not been eating or drinking much over the past month. She transitioned to the general pediatric unit 3/22/2025. Review of Physician Staff RR’s progress notes dated 3/26/2025 revealed the following: “Mom reports that (P-3) was held down by nursing staff last night for med administration and that Mom walked in as they were attempting to give the trileptal (treatment of seizures)... Spoke with (Nurse Manager Staff F to ensure nursing staff is aware that this is not appropriate...” Further review of the medical record for P-3 revealed there were no orders for the physical hold of P-3 and no face-to-face assessment was found. Review of facility policy “System Nursing Policy G-02 Restraints” with no origination or revised dates, states, “One-hour face-to-face assessment: A Practitioner should perform a face-to-face assessment within one hour of the initiation of violent restraints to evaluate the patient’s situation, reaction to the restraint, medical and behavioral condition, and the need for continued restraint use.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(ii) [there must be documentation in the patient’s medical record of the following:] A description of the patient’s behavior and the intervention used. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to document patient behaviors and intervention used prior to restraint for 2 (P-2, P-3) of 5 patients reviewed for restraint resulting in the potential for improper use of restraint, unidentified and unmet patient needs, and poor patient outcomes. Findings include: Review of the medical record for P-2 revealed she was a 37-year-old female who had presented to the Emergency Department (ED) 7/7/2025 to have a mental health evaluation. P-2 told Physician Staff FF and Social Worker Staff CC she did not want to live at home anymore and wanted to be admitted to an inpatient psychiatric unit and be gradually transitions to temporary housing and then to permanent housing. She told Staff FF “if she does not go to a psychiatric facility then she will feel suicidal.” Upon finding she did not meet admission criteria and was being discharged, P-2 refused to be discharged. P-2 was “escorted out of the department with all of her belongings by security.” On 8/7/2025 at 1130, review of the security report written by Security Officer Staff S, dated 7/7/2025 at 1548, revealed upon entering the patient room, two clinical staff members were “holding down the patient keeping her restrained to the bed.” When asked why the patient was being held down, “the staff member informed us that she had attempted to bite them after them (sic) telling the patient that she had been discharged.” On 8/11/2025 at 1951, Registered Nurse (RN) Staff X stated when she went in to discharge P-2, she became “very agitated” and “was refusing discharge.” She stated she was “caught off guard” because she thought discharge had already been discussed with P-2. P-2 then began making “vague suicidal statements” so Staff X went and got Social Worker Staff CC to come speak with P-2 again. Staff X stated Staff CC was talking with P-2 who continued making vague suicidal statements. As a result, Physician Staff FF came back into the room. On 8/11/2025 at 1402, Physician Staff FF stated P-2 was “fixated” on her housing situation and did not meet criteria for inpatient admission. When P-2 found out about the discharge, she opened drawers in the room and “grabbed some needles and attacked” him. He then stated he “side-stepped her” and “pushed her against the bed and held her” there “trying to defend myself.” She was held to the bed until security arrived. No documentation was found in the medical record regarding P-2’s actions, interventions and/or de-escalation techniques used and P-2’s response to them prior to the physical hold., nor was any documentation of the physical hold present. Review of the medical record for P-3 revealed she was an 11-year-old female who was initially admitted to PICU (pediatric intensive care unit) 3/21/2025 with dehydration and hypernatremia. The initial history and physical (H&P) revealed she had a tonsillectomy and adenoidectomy (T&A) 2/20/2025 and had not been eating or drinking much over the past month. She transitioned to the general pediatric unit 3/22/2025. Review of Physician Staff RR’s progress notes dated 3/26/2025 revealed the following: “Mom reports that (P-3) was held down by nursing staff last night for med administration and that Mom walked in as they were attempting to give the trileptal (treatment of seizures)... Spoke with (Nurse Manager Staff F to ensure nursing staff is aware that this is not appropriate...” No documentation was found in the medical record regarding P-3’s actions, interventions and/or de-escalation techniques used and P-3’s response to them prior to the physical hold., nor was any documentation of the physical hold present. Review of facility policy “System Nursing Policy G-02 Restraints”, with no origination or revised dates, states, “’Restraint’ is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely...Each episode of restraint or seclusion should be initiated upon i. the order of a Practitioner who is responsible for the patient... Orders for restraint or seclusion applied to manage Violent Behavior should remain in effect until the patient’s assessed behavior or situation no longer requires restraint or seclusion... DOCUMENTATION Episodes of restraint and seclusion should be documented as indicated on currently approved assessments, flowsheets, ordering forms, and electronic health record.” The policy did not reflect what less restrictive measures were nor did it address what “documented as indicated” meant.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(1) Training intervals. Staff must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion- (i) Before performing any of the actions specified in this paragraph; (ii) As part of orientation; and (iii) Subsequently on a periodic basis consistent with hospital policy. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to provide on-going restraint training for physicians resulting in the potential for loss of patient rights, unrecognized and unmet patient needs, and poor patient outcomes for all patient requiring restraint. Findings include: Review of Physician Staff FF credentialing file on 8/12/2025 at 0917 revealed he completed the “Preventing Workplace Violence” computer based learning module 10/16/2017 during his “on-boarding”/orientation to the facility. Medical Staff Services Supervisor Staff JJ confirmed this was the most recent training at the time of discovery. Review of the “Preventing Workplace Violence” module on 8/12/2025 at 1300 revealed training regarding definitions of workplace violence, key behaviors promoted by the facility for a positive culture, promotion of a safe environment, patient rights, employee rights, warning signs, de-escalation tactics, and reporting violence to security and law enforcement. Review of facility policy “System Nursing Policy G-02 Restraints” with no origination or revised dates, revealed there was no definition or expectation present for physical hold and there was no direction provided as to how often training should occur for restraint and/or de-escalation techniques for direct care staff.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 29955 Based on interview and record review, the facility failed to ensure intake and output was documented for 3 (P-1, P-3, and P-10) of 4 patients reviewed for documentation of intake and output, resulting in the potential for inadequate monitoring and assessment for these patients. Findings include: P-1 On 8/7/2025 at 1400 record review occurred of P-1’s medical record. According to the discharge summary by staff W, hospitalist, the following was documented on 6/5/2025 at 1429: “89 y.o. (year-old) with past medical history of GERD (Gastroesophageal Reflux Disease), BPH (Benign Prostatic Hyperplasia), depression, dementia, who is being admitted to the MICU (Medical Intensive Care Unit), as a transfer from IMHS (Internal Medicine Hospital Services), following ED presentation for less than 24 hours of acute encephalopathy.” P-1 was hospitalized from 5/10/2025 to 6/5/2025 at which time P-1 expired. On 8/11/2025 at 0900 an interview was conducted with staff W, the attending physician for P-1. Staff W stated P-1 had severe dementia, protein malnutrition, cardiac concerns, and severe infection (E. Coli.). Staff W also stated that P-1 was a failure to thrive related to his advanced dementia and poor state of health. P-1’s DPOA (durable power of attorney) stated she wanted P-1 to have a NG (nasogastric) tube in order for P-1 to receive nutrition. On 8/12/2025 at 1045 a review occurred of P-1 ’ s medical record. Orders for Intake and output (I&O’s) were documented on 5/10/2025, and again on 5/12/2025. Additional orders on 5/12/2025 for water flushes of 30ml of warm water before and after medication administration were identified. The following was documentation was missing on the date noted below for P-1 ’ s intake and output: 5/16/25 0935 No intake documented 5/17/25 No intake documented No output documented 5/18/25 No intake documented No output documented 5/24/25 No intake documented No output documented 5/25/25 No intake documented No output documented 5/26/25 No intake documented No output documented 5/30/25 0957 No intake recorded 5/31/25 1732 No intake recorded 6/01/25 1531 No intake recorded 6/03/25 1101 No intake recorded P-3 On 8/7/2025 at 1400 a review occurred of P-3’s medical record. P-3 was an 11 year-old female who presented to the Emergency Room on 3/21/2025 with her mother. P-3’s mother reported that P-3 had “minimal intake for the past three weeks,” and was “refusing to swallow any liquids or food due to pain.” Mom also reported giving pain meds without much relief. Physical exam revealed she would not speak or answer questions. Mucous membranes were dry with “healing eschar to bilateral tonsillar beds. No bleeding.” Lab work was done and revealed P-3 was hypernatremic (high sodium blood level) and dehydrated. Pediatric Hospitalist (staff RR) was consulted, and “recommended admission to the PICU (pediatric intensive care unit) given patient ’ s significant hypernatremia.” P-3 was admitted to the PICU in stable condition. Orders for strict intake and output were written by staff RR. On 3/21/2025 at 1418 staff EEE , pediatric intensivist documented “Since being discharged from ED 3/19 mom reports her daughter continues to not eat and drink,” and under “GU” (genitourinary) “strict I&O’s.” On 3/22/2025 at 1537 staff FFF, physician, documented under “GU”...”strict I&O’s. “On 3/23/2025 at 0644 staff RR, pediatric intensivist documented the following, “Discussed possibility of NG placement but will hold on this for now as I’d like to encourage PO intake if possible. If necessary, this will be challenging due to (P-3’s) anxiety and may worsen her pain as well as worsen any oral aversion. On 3/24/2025 at 0659 staff GGG, documented under “GU - strict I&O’s.” On 3/25/2025 at 0653 staff GGG, documented under “GU - strict I&O’s.” On 3/26/2025 at 0652 staff RR documented under “GU - strict I&O’s.” On 3/27/2025 at 0740 staff HHH, pediatrician, documented, “Strict recording of I/O’s - still on IVFs (intravenous fluids) due to mild AKI (acute kidney injury), will not adjust today but hope to work towards decreasing dependence on IVFs in the next 1-2 days.” On 3/28/2025 at 1107 staff III, physician, documented under “GU - strict I&O’s.” On 8/12/2025 at 1030, a review occurred of P-3’s medical record for documented hydration/nutrition/fluids intake and fluid output (I&O’s). The following was documented for P-3’s intake and output: 3/21/25 1601 No output documented 3/22/25 2255 No output documented 3/23/25 No intake documented 3/25/25 No intake documented No output documented 3/26/25 No intake documented No output documented 3/27/25 No intake documented No output documented 3/28/25 No intake documented No output documented 3/29/25 No intake documented No output documented P-10 On 8/12/2025 at 1000 a review occurred of P-10’s medical record. P-10 was a 25-year-old male hospitalized from 5/2/2025 to 5/10/2025. P-10 was described in the medical record as, “a 25 y.o. male admitted 5/2/25 for Streptococcus agalactiae bacteremia and worsening thrombocytopenia. CT of the left knee completed showing small effusion and expected postsurgical changes without evidence of osteomyelitis or abscess. He had a recent admit 3/28/25 with a L tibial plateau fx (fracture) after a dirt bike accident s/p (status post) L tibial external fixator application 3/29/25 with removal of External Fixation and ORIF (open reduction and Internal fixation - a surgical procedure used to treat severe bone fracture or dislocations) of L (left) Tibial Plateau 4/2/25. PMH (past medical history): CF (cystic fibrosis),DM (diabetes mellitus), (and) pancreatic insufficiency.” On 8/12/2025 at 1015 physician progress notes were reviewed. On 5/2/2025 at 0918, staff JJJ, physician, documented, “No intake or output data in the 24 hours ending 05/02/25 2321.” On 5/3/2025 at 1254, staff KKK, documented, “No intake/output data recorded.” On 5/6/2025 at 1649, staff LLL, physician, documented, “No intake/output data recorded.” On 8/12/2025 at 1025 a review occurred of P-10’s medical record for documented hydration/nutrition/fluids intake and fluid output (I & O). The following was documented for P-10’s intake and output: 5/4/2025 No output documented 5/5/2025 No output documented 5/6/2025 No intake documented No output documented 5/7/2025 No intake documented 5/8/2025 No intake documented No output documented On 8/12/2025 at 1100 an interview was conducted with staff B, Manager Patient Safety and Quality. Staff B was asked if intake and output is required to be recorded. Staff B replied, “What goes in and out must be recorded.” On 8/12/2025 at 1130 a review occurred of the policy titled, “Nursing Documentation of Assessment & Care Procedure,” no date provided. According to the policy, “Nursing Physical Assessment ... #6. The RN can delegate data collection for certain aspects of physical assessments and reassessments to non-licensed staff. Non-licensed staff may gather data re: TPR, B/P, weight, height, I&O, bedside testing results, point of care testing, pain score, etc., consistent with defined roles and competencies. Non-licensed staff will document data they collect. The RN will assess the results of all data gathered by non-licensed staff”...#7. A nurse may enter “No change from MY previous X assessment unless otherwise noted” for documentation of unchanged assessment findings from his/her own documentation within a 12 hour time period with the exception of vital signs, I&O volumes...””

“ORGANIZATION OF EMERGENCY SERVICES CFR(s): 482.55(a)(1) [If emergency services are provided at the hospital --] (1) The services must be organized under the direction of a qualified member of the medical staff. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to have only one medical director for the Emergency Department resulting in the potential for being uninformed of issues within the department, varying opinions on how to lead the department, and the potential for poor patient outcomes for all patients served by the Emergency Department. Findings include: On 8/10/2025 at 1512, System Manager of Accreditation Staff A was queried as to who the Emergency Department (ED) medical director was to which he replied, “We have two ED medical directors - (Physician Staff Z) and (Physician Staff Y).” When asked why there were two, Staff A stated, “It’s a pretty big ED.” On 8/11/2025 at 1009, Physician Staff Y stated he has been the co-ED medical director for the past 12-14 years, ever since coming to the facility. On 8/11/2025 at 1147, Physician Staff Z agreed she was the co-medical director of the ED. On 8/12/2025 at 1315, review of the contract titled “Agreement for Medical Director of Trauma and Emergency Center Between [facility initials] and [name of emergency services provider group], PC” signed on varying dates between 5/12/2023-5/15/2023 revealed the following: “Appointment and Duties. [Facility name] hereby appoints CORPORATION’s physicians, [Physician Staff Z] and [Physician Staff Y] to serve as the Medical Director of Trauma and Emergency Center (“Medical Director), performing the functions described in the attached Exhibit A (the “Services”). CORPORATION shall cause the Medical Director to perform the Services required pursuant to this Agreement as CORPORATION’s agent.””

“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: 29955 Based on interview and record review, the facility failed to obtain consent from a responsible party for 1 (P-4) of 10 patients reviewed and failed to identify the person giving consent for treatment in 3 (P-5, P-7, and P-9) of 10 pediatric patients resulting in the potential for uninformed and invalid consent. Findings include: On 10/8/2024 at 1520 during document review it was revealed that P-4, a 16-year-old female was brought to the Emergency Room (ER) via ambulance for suicidal attempt on 7/10/2024. P-4 general consent indicated under patient signature, “verbal consent from patient - suicidal.” On 10/9/2024 at 1000 during document review it was revealed that P-5, was a 15-year-old female brought to the (ER) for sinus tachycardia and viral pharyngitis on 8/12/2024. P-5 general consent was signed but failed to indicate the relationship to the patient. On 10/9/2024 at 1015 during document review it was revealed that P-7, was a 3-year-old female brought to the (ER) for lethargy and altered mental status on 8/7/2024. P-7 general consent was signed but failed to indicate the relationship to the patient. On 10/9/2024 at 1020 during document review it was revealed that P-9, was a 17-year-old male brought to the (ER) for nausea, vomiting, and diarrhea on 8/6/2024. P-9 general consent was signed but failed to indicate the relationship to the patient. On 10/9/2024 at 1025 during an interview with the Director of Registration, “Staff N”, was queried about the consent for P-4 a minor patient. Staff N agreed that P-4 was a minor and could not give consent for herself. Staff N was then queried about the lack of documentation of relationship with P-5, P-7, and P-9. Staff N responded, “There is a glitch within the computer system that if a consent is signed after the patient had been brought back in the ED that the relationship could not be added due to the computer program.””

“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: 29955 Based on interview and record review, the facility failed to protect the safety of 2 (P-4 and P-9) of 3 minor patients reviewed by failing to contact Child Protective Services (CPS), resulting in the potential for poor patient outcomes including death. Findings include: On 10/8/2024 at 1530 during document review of P-4 medical record it was revealed that P-4 was a 16-year-old female brought to the facility ED via ambulance on 7/10/2024 for suicidal ideation after being found sitting on railroad tracks. P-4 was accompanied by her parent who became upset with facility staff after being asked not to lie in the patient’s bed. P-4 left the ED with the parent. According to the physician’s documentation on 7/10/2024 for P-4 the following was documented under Psychiatric, “Clearly is suicidal and admits she was sitting on the tracks trying to get hit by a train.” ED Provider Note under Medical Decision Making, “The patient is a 16 y.o. (year-old) female who presented with suicidal ideation. She admits to sitting on the train tracks in an attempt to get hit by a train. She denies taking any medication at home in an attempt to harm herself ...I spoke with social work who will plan to speak with the patient.” The provider’s discharge note read, “I (staff O) spoke with social work (staff P) after they spoke with the patient and mom. Mom was mad at ED staff after she was asked by nursing staff why she was using the bed and daughter was not. Mom says that she cannot get comfortable in the chair due to health problems. It sounds like the daughter tries to please mom. She needs mental health help, but mom says this is an embarrassment. Mom walked out of the ED with daughter. Social work will likely contact CPS. There was not enough in terms of signs of physical abuse to say that mom cannot make a decision that I don’t agree with as she is still the patient’s legal guardian. Patient was discharged from hospital as AMA (against medical advise)/eloped at 0550.” On 10/8/2024 at 1600 an interview was conducted with the Director of Social Work (staff M) for the facility. Staff M was queried about the physician’s note referencing that the social worker would contact CPS for the parent leaving with the minor patient prior to having a mental health screening. Staff M stated that she had reviewed P-4 medical record and had been in touch with the social worker (staff P) working in the ED on that day. Staff M stated staff P had stated she had forgot to contact CPS and had failed to document in the patient’s (P-4) medical record. Staff M was then asked when staff P had forgot that she had not contacted CPS. Staff M stated, “Today.” On 10/9/2024 at 0930 an interview was conducted with staff P, social worker. Staff P was queried if she was aware that P-4 had left with her mother prior to being discharged. Staff P stated she was aware that P-4 had left with her mother. Staff P was asked if she evaluated P-4. Staff P stated, “Yes.” Staff P was then queried if she was supposed to contact CPS. Staff P stated, “Yes.” Staff P stated she had not documented her assessment nor had she contacted CPS. On 10/9/2024 at 0945 during record review of P-7 medical record it was revealed that P-7 was a 15-year-old female brought to the ED on 5/12/2024 for overdose of THC (Tetrahydrocannabinol compound - It is the principal psychoactive constituent of cannabis) gummies. P-7 had consumed 19 THC gummies at her home residence. There was no documentation demonstrating that P-7’s parents were reported to CPS. On 10/9/2024 at 1020, an interview occurred with staff M, the Director of Social Work. Staff M was queried if P-7 parents should have been reported to CPS for P-7 overdose of THC gummies which where not secured in the parent’s home. Staff M stated, “Yes.” On 10/9/2024 at 1050, a document review occurred of the policy titled, “System Nursing Q-25 Child Protection Law - Basic Duties and Responsibilities Policy,” date not provided. According to the policy it reads under the subtitle, “What must be reported...3. What Must Be Reported: a. Reasonable cause is a concept that seeks to impose an objective standard in evaluating facts. Reasonable cause is present when a hypothetical person of reasonable prudence would, in assessing the facts, suspect that child abuse and/or child neglect is occurring.” The policy further states, “c. Child neglect is harm or threatened harm to a child’s health or welfare by a person responsible for the child’s health or welfare which occurs through either negligent treatment, including the failure to provide adequate food, clothing, shelter, or medical care, or placing a child at an unreasonable risk by the failure to eliminate that risk.””