Lakeland Hospital, St Joseph

“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: 29955 Based on interview and record review, the facility failed to acknowledge and record a grievance received from a patient’s (P-1) representative in 1 of 3 grievances reviewed resulting in loss of patient rights. Findings include: On 08/07/2026 at 09:05 AM record review occurred of P-1’s medical record. P-1’s medical record revealed that on 6/15/2026 at 11:05 AM P-1 presented to the facility Emergency Room (ER) with the complaint of seizure. P-1 was a 58-year-old female with no known history of seizures. P-1’s medical history included ovarian cancer. P-1 was also actively being monitored by palliative care for a 10 cm right-sided tumor but was not receiving chemotherapy or radiation treatment. P-1 had bloodwork, an EKG (electrocardiogram - test to view electrical activity of the heart), and a CT (computed tomography) scan (a radiological test to view both bone tissue and soft tissue). On 6/15/2026 at 02:36 PM P-1 was admitted to in-patient for “seizure like activity versus convulsive syncope (loss of consciousness, fainting, or passing out)” and transferred to the Orthopedic/Neurology unit. Documentation by staff J, RN, on 06/16/2026 at 05:08 AM documented the following in P-1’s medical record: “2230 (10:30 PM) - called to patients [SIC] room by staff member, patient was on the floor- post fall protocol initiated, no deformities noted, patient stated she did hit her head but did not lose consciousness, neurological assessment perform [SIC] - no change from initial assessment. 2235 (10:35 PM) - charge nurse was notified, provider notified all enroute to bedside. Patient was assisted back into bed-patient had a two minute [SIC] episode eyes went up and to right, generalized body stiffened and minor shaking, patient at this time not able to answer questions and was “snoring”. Placed patient on her side suctions suctions [SIC][suctioned], and placed oxygen on and maintained airway. 2240 (10:40 PM) - Providers bedside see orders 2300 (11:00 PM) - IV route reestablished 2330 (11:30 PM) - patient sent with house supervisor for imaging 0030 (12:30 AM) - patient returned- will continue to monitor.” On 08/06/2026 at 03:05 PM during an interview with staff I, Nurse Manager of the Orthopedic/Neurology unit, it was revealed that P-1’s husband had not been notified of P-1’s fall at the time of the incident. Staff I stated that P-1’s husband became aware of P-1’s fall when he had arrived to visit P-1 on the morning of 06/16/2026. Staff I stated that he had been off on 06/16/2026 and was made aware that the husband was upset when he returned on 06/17/2026. Staff I stated that he went to meet with P-1’s husband. Staff I stated he was never able to connect with P-1’s husband and had called several times. Staff I was asked if there was documentation to review for the investigation. Staff I referred to an ERS (Event Reporting System) report. On 08/07/2026 at 11:55 AM a record review occurred of the facility grievance log. A grievance for P-1 was not located on the log. On 08/07/2026 at 12:08 PM an interview occurred with staff Q, Manager of Patient Relations. Staff Q was queried if a complaint had been filed by P-1’s husband or P-1. Staff Q stated there was not a complaint filed by P-1 or P-1’s husband. Staff Q was asked what the expectation was when an employee receives a concern/complaint/grievance from a patient or patient’s family member. Staff Q responded that the expectation is for an employee to follow policy and report concerns/complaints/grievances to management and/or Patient Relations. Staff Q was asked if Patient Relations was aware of P-1’s husband’s complaint and if it would be considered a grievance. Staff Q stated Patient Relations was not aware of the situation and the complaint was considered a grievance because it was not addressed at the moment. On 08/07/2026 at 02:10 PM record review occurred of the policy titled, “Patient Complaint and Grievance Resolution,” dated 09/15/2025, reference # 3195, version # 9, which revealed, “3. Definitions ... f. Grievance: A formal or informal, written or verbal complaint that is made to (Healthcare System) by a patient, companion, or any individual. Any complaint that cannot be resolved in the moment by a team member or when an appropriate team member cannot quickly be at the patient/resident’s location (i.e. member of leadership team or Patient Relations), is postponed for later resolution, is referred to other team member for later resolution, requires investigation, and/or requires further actions for resolution is considered a grievance,” and “5. Policy ...h. Grievances, i. Notification, Anyone interacting with (Healthcare System) facilities can file a grievance. Upon notification of a grievance, the complainant will be contacted by the Patient Relations department, acknowledging the grievance and outlining the plan for investigation defined in a timely manner. Patient Relations will send the grievance to the appropriate team within the organization for investigation and follow up response. Grievances will be resolved within 7 business days. If this timeframe is unable to be met, communication will be provided along with a proposed closure date.””

“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 involve a patient’s designated decision maker in decisions of care for 1 (P-1) of 10 records reviewed, resulting in the potential for poor patient outcomes and unmet care needs. Findings include: On 6/15/2026 at 11:05 AM P-1 presented to the facility Emergency Room (ER) with the complaint of seizure. P-1 was a 58-year-old female with no known history of seizures. P-1’s medical history included ovarian cancer. P-1 was also actively being monitored by palliative care for a 10 cm right-sided tumor but was not receiving chemotherapy or radiation treatment. P-1 had bloodwork, an EKG, and a CT (computed tomography) scan (a radiological test to view both bone tissue and soft tissue). On 6/15/2026 at 14:36 P-1 was admitted to in-patient for “seizure like activity versus convulsive syncope (loss of consciousness, fainting, or passing out)” and transferred to the Orthopedic/Neurology unit. On 6/15/2026 at 08:00 PM, Staff J, registered nurse (RN) documented P-1’s fall assessment. P-1’s HDS (Hester Davis Scale) score was (22) high risk. (Hester Davis Scale - a scale using nine variables to score and project the possibility of a patient fall. The variables contained in the HDS include age, last known fall, mobility, medications, mental status, toileting needs, volume of electrolytes, communication/sensory, and behavior.) Mobility was documented as “dizziness, generalized weakness, immobilized required assist of one person.” Mental status was documented as “oriented to person and place; memory loss/confusion and requires reorienting.” On 6/15/2026 at 05:08 AM staff J documented, “2230 (10:30 PM) - called to patients [SIC] room by staff member, patient was on the floor- post fall protocol initiated, no deformities noted, patient stated she did hit her head but did not lose consciousness, neurological assessment perform [SIC] - no change from initial assessment. 2235 (10:35 PM) - charge nurse was notified, provider notified all enroute to bedside. Patient was assisted back into bed-patient had a two minute [SIC] episode eyes went up and to right, generalized body stiffened and minor shaking, patient at this time not able to answer questions and was “snoring”. Placed patient on her side suctions suctions [SIC][suctioned], and placed oxygen on and maintained airway. 2240 (10:40 PM) - Providers bedside see orders 2300 (11:00 PM) - IV route reestablished 2330 (11:30 PM) - patient sent with house supervisor for imaging 0030 (12:30 AM) - patient returned- will continue to monitor.” On 08/07/2026 at 08:15 AM an interview occurred with staff J. Staff J was asked when he contacted P-1’s family member/spouse to make them aware of P-1’s fall. Staff J explained that he did not call P-1’s family/spouse because his priority was to take care of P-1. He stated that regaining IV access for P-1 was very difficult. Staff J added that he was waiting for the CT scan results. He explained that P-1 had missed her daughter’s funeral that day and did not want to add burden to the family if the results were not critical. He explained that he had focused on caring for P-1 post-fall as the priority and filing the ERS report. He then stated he realized the next day he had missed contacting the family. Staff J stated, “I believe I filled out everything and did everything in the policy except calling the family.” On 08/07/2026 at 02:15 PM record review occurred of the policy titled, “Falls: Risk Screening, Prevention, and Post-Fall Follow-up,” dated 07/21/2024, reference # 7590, version # 8, which revealed, “C. Inpatient ...3. At the time of the fall, notify the: Charge Nurse, Hospital Supervisor/Department Leadership (if there is a reported, actual or potential injury), provider, and family/significant other.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 29955 Based on observation, interview, and record review, the facility failed to provide the Important Message from Medicare (IMM) for 2 patients (P-7 and P-8) of 4 patients reviewed for IMM, failed to provide a safe environment for one patient (P-2) of 13 patients, and failed to keep one patient (P-2) of 13 patients free from harm resulting in loss of patient rights and less than optimal outcomes. See Specific Tag: A-117 - Failure to provide the Important Message for Medicare A-144 - Failure to provide a safe environment for the patient A-145 - Failure to keep a patient free from harm”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 29955 Based on record review and interview, the facility failed to provide the Important Message from Medicare (IMM) to 2 (P-7 and P-8) of 4 patients potential loss of rights for the patient. Findings include: On 5/7/2026 at 0930 during review of P-7’s medical record staff B was unable to locate an IMM provided to P-7 at the time of admission and at the time of discharge. P-7 was hospitalized from 12/22/2025 to 1/10/2026 insurance coverage was listed as Medicare. Staff B was queried if P-7 should have received an IMM at the time of discharge and prior to discharge. Staff B stated, “Yes. I do not know who is responsible for providing the IMM’s for the Behavioral Health unit.” On 5/7/2026 at 0940 during review of P-8’s medical record staff B was unable to locate an IMM provided to P-8 at the time of admission and at the time of discharge. P-8 hospitalized from 12/14/2025 to 1/13/202 and insurance coverage was listed as Medicare and Medicaid. Staff B was queried if P-8 should have received an IMM at the time of discharge and prior to discharge. Staff B stated, “Yes. He should have an IMM.” A review of the policy, “Important Message From Medicare (IMM 1st Notice),” dated 4/7/2026, revealed, “4.1 Medicare Requirements,...4.1.5 Medicare beneficiary (or representative) must be given notification and sign the notice within two (2) calendar days of admission and up to seven (7) calendar days before admission for an elective admission. 4.1.6. Medicare beneficiary (or representative) must be given a second copy of the notification within two (2) calendar days, but no less than 4 hours, prior to discharge.””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to 1) immediately remove a staff member accused of sexual assault, 2) failed to maintain safe use and/or storage of cleaning equipment around 1 (P-2) of 1 psychiatric patients, and 3) failed to provide training of ancillary staff coming to work on the behavioral health unit resulting in the loss of patient rights and poor patient outcomes. Findings include: 1) Review of the medical record for P-2 revealed she was an involuntary patient on the Behavioral Health (BH) unit admitted 12/30/2025-2/25/2026 for severe depression, anxiety and suicidal ideation. Nursing documentation dated 1/8/2026 at 0706 revealed she reported an “incident” with an environment services (EVS) employee, Staff F, and was “tearful and anxious.” Further nursing documentation on 1/8/2026 at 1037 indicated P-2 was “tearful and anxious regarding an assault involving an EVS staff member.” P-2 rated her anxiety and depression as 10/10 and admitted to auditory hallucinations of self-harm/suicide. On 5/6/2026 at 1230, review of facility incident report dated 1/8/2026 indicated EVS Staff F entered P-2’s room, kissed her and sucked on her fingers. He also gave her $30 and his contact information that morning. P-2 also reported a second allegation that Staff F entered her room on 1/4/2026, had remained there over an hour, and performed oral sex on her. During interview on 5/6/2026 at 1400, Physician Staff H stated she arrived to work on 1/8/2026 at approximately 0900. BH Clinical Nurse Leader Staff FF informed her of P-2’s allegations and stated he had started to interview staff and had informed the BH Manager Staff D and Vice President (VP) Patient Care/Chief Nursing Executive Staff II. Physician Staff H stated she was immediately concerned for P-2’s safety “and everyone else’s safety” and asked where the EVS Staff F was currently. She stated Clinical Nurse Leader Staff FF told her they first had to find out if the alleged incident had occurred and if P-2 had encouraged it. Physician Staff H stated she became very angry and said, “I’m not worried about if she encouraged it. Where is he?” House Supervisor Staff JJ informed Physician Staff H that EVS Staff F had been sent over to the pediatric unit. Physician Staff H then asked if security had been contacted and was told, “No.” Physician Staff H said, “This is unacceptable.” and walked to Chief Medical Officer (CMO) Staff MM’s office and explained the situation and her concern as to where EVS Staff F was. Physician Staff H was later informed by CMO Staff MM that EVS Staff F had been located, placed on administrative leave pending investigation, and had been escorted off property on 1/8/2026 at 1030. These statements were corroborated by BH Medical Director Staff Y on 5/6/2026 at 1334 who had also arrived on the BH unit at approximately 0900 on 1/8/2026 and accompanied Staff H to the CMO’s office. Interview with House Supervisor Staff JJ was requested; however, she was unavailable. Facility policy #1370 titled “If a Physical Assault or Other Allegations of Misconduct Involving a Patient-Investigating Allegation and Notification” effective 3/25/2022 states, “Sexual misconduct or sexual assault, including but not limited to inappropriate touch, physical , verbal or sexual assault and/or any conduct of a sexual nature that is without consent... The accused employee or provider will be immediately removed from patient care.” Facility policy #24602 titled “Allegations of Sexual Assault-Investigation Policy” effective 9/24/2024 states, “...The alleged offender will be immediately removed from the care of the patient making the allegation.” This policy fails to ensure the alleged offender to be immediately removed from all patient care/care areas pending investigation. 2) On 5/6/2026 at 0947 review of video documentation revealed the following: 1/4/2026 14:07:21 Video began showing the women ’ s hallway 14:08:15 EVS Staff F entered P-2’s room 14:08:23 EVS Staff F exited room, grabbed his cleaning cart and pushed it into P-2’s room, then closed the door An interview was conducted on 5/6/2026 at 1015 with Director of EVS Staff EE who stated EVS staff are permitted to enter patient’s rooms on the BH unit, even with the patient being in the room unless otherwise instructed by BH staff. She stated the cleaning carts should not be left unattended as “patients could potentially take items off of it and harm themselves or someone else” and “should never be taken into a patient room.” 3) Review of EVS Staff F’s staff file revealed he had received education in 2025 for workplace violence, policies, compliance, safeguarding of sensitive data, workplace safety, privacy and information security, patient engagement, infection prevention and bloodborne pathogens, clinical support, and healthcare safety. On 5/6/2026 at 1015, Director of EVS Staff EE was queried during interview as to if her EVS employees received any additional training specific to working on the BH unit such as de-escalation techniques, seeing or hearing inappropriate behaviors, and/or when and what type of concerns to report to the BH staff. She stated there “used to be” training given by the BH Manager; however, to her knowledge it was not being done anymore. She said, “There is no additional training provided outside of ‘see something, say something’ and workplace violence.””

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to protect 1(P-2) of 13 patients from sexual abuse and verbal harassment and failed to perform timely investigation of abuse allegatrions resulting in the loss of patient rights, increased distress, and poor patient outcomes. Findings include: Review of the medical record for P-2 revealed she was an involuntary patient on the locked Behavioral Health (BH) unit admitted 12/30/2025-2/25/2026 for severe depression, anxiety and suicidal ideation. Nursing documentation dated 1/8/2026 at 0706 and 1/8/2026 at 1037 indicated P-2 was tearful with anxiety while reporting an assault by an EVS (environmental services) Staff F. On 5/6/2026 at 1230, review of facility incident report dated 1/8/2026 indicated EVS Staff F entered P-2’s room, kissed her, sucked on her fingers, put $30 and his contact information in her shirt pocket that morning. P-2 reported a second allegation that Staff F also entered her room on 1/4/2026, had remained there over an hour, and performed oral sex on her. The incident report also included interviews with P-2 and EVS Staff F. Their recounting of events matched with the exception of who had initiated the sexual contact. On 5/6/2026 at 0947, review of video documentation was made available for the BH unit on the dates in question. Security Manager Staff QQ stated the cameras were triggered by motion sensor and there were “literally hundreds of video segments” he had to go through to obtain all of the information needed for the internal investigation. Review of the video documentation revealed the following: 1/4/2026 14:07:21 Video began showing the women’s hallway 14:08:15 EVS Staff F entered P-2’s room 14:08:23 EVS Staff F exited room, grabbed his cleaning cart, pushed it into P-2’s room, and closed the door 15:09:18 EVS Staff F exited room (1 hour and 55 seconds in room) 1/8/2026 06:48:14 Video began showing the women’s hallway 06:48:46 EVS Staff F entered P-2’s room 06:52:05 EVS Staff F exited P-2’s room (3 minutes, 19 seconds in room) Continued review of the medical record revealed safety rounds for P-2 were ordered every 15 minutes on both 1/4/2026 and 1/8/2026. Review of the rounding documentation revealed the following: 1/4/2026 1400 Patient room, own; sleeping 1416 Activity room; calm (1 minute late) 1432 Activity room; calm (1 minute late) 1443 Patient room, own; calm 1505 Patient room, own; sleeping (7 minutes late) 1/8/2026 0651 Patient room, own; sleeping 0715 Patient room, own; sleeping (11 minutes late) 0739 Hallway; tearful (9 minutes late) 0751 Patient room, own; calm 0821 Dining room; calm (15 minutes late) 0834 Dining room; calm 0854 Patient room, own; calm, lying awake (5 minutes late) 0900-1148 Patient room, own; sleeping 1214-1315 Patient room, own; calm/sitting 1332-1343 Staff office; calm Review of nursing documentation, nursing interview, and physician interview showed direct contrast to the rounding documentation. Nursing note from Registered Nurse (RN) Staff E dated 1/8/2026 at 0706 revealed P-2 was “reporting incident that occurred with environmental services member. Is tearful and anxious...” Another nursing note from RN Staff X dated 1/8/2026 at 1037 states, “Pt (patient) presents in room. Pt appears tearful and anxious... Rates anxiety and depression 10/10.” The note continues to state P-2 was expressing concerns of getting in trouble for reporting and endorsing hearing voices telling her to commit suicide. During interview on 5/6/2026 at 1122, Registered Nurse (RN) Staff BB stated she had spoken with P-2 on 1/8/2026 and described P-2 as “having a myriad of emotions. At times she was rocking herself back and forth.” During interview on 5/6/2026 at 1334, BH Medical Director Staff Y stated she had gone with Physician Staff H for support when talking with P-2 on 1/8/2026. Staff Y stated, “(P-2) was a wreck. She was someone who had trauma. She was crying, curling in bed, covers over her head and had increased guilt and self-blame. She had a trauma response, and you can’t make that up.” During interview on 5/6/2026 at 1400, Physician Staff H stated she was able to speak with P-2 mid morning of 1/8/2026. When asked to describe P-2’s demeanor, Staff H stated, “She very much had an acute stress reaction. She was curled in a fetal position on the bed with the covers up over most of her head, she was shaking and crying uncontrollably... We had to use mild to moderate sedatives.” Additionally, several assessments and interviews were also conducted with P-2 on 1/8/2026 throughout the day including police, SANE (sexual assault nurse examiner), physicians, risk, and security as well as having nursing assessments and receiving medications. During interview on 5/6/2026 at 1035, BH Manager Staff D stated he reviewed rounding documentation upon return from a one-month leave, which started 1/8/2026, and gaps had been identified in the rounding information when he reviewed and compared the rounding documentation to the video documentation. He stated the staff member doing the rounding (Staff G) on 1/4/2026 never opened the door of P-2’s room and actually visualized the patient. BH Manager Staff D also stated education was provided to all staff, including providers and EVS, during huddles and staff meetings about rounding; however, interviews with BH Staff KK and LL on 5/7/2026 at 0901 and 0948 respectively indicated they were unaware of any rounding education being provided and no changes were seen in practice on the unit. BH Manager Staff D further stated he was doing audits of rounding. A request was made for audit documentation on 5/6/2026 at 1035 but was not provided prior to exit of survey. Request was also made at that time for policy regarding safety rounding but was not provided prior to exit of survey. Office of Recipient Rights (ORR) Staff HH stated during interview on 5/6/2026 at 1550 there were delays with his involvement and subsequent investigation into the allegations involving EVS Staff F and P-2 as he was not contacted properly. Interim Manager of the BH unit, Staff BB, was unsure what could be shared with him, and he was told to wait until after the law enforcement investigation was complete; however, was not notified when they were done. ORR Staff HH stated he was unable to interview P-2 until 2/10/2026. Following his investigation, ORR Staff HH substantiated the loss of patient rights and stated P-2’s “narrative was consistent” and the interaction between P-2 and EVS Staff F was “at the very least inappropriate contact.” Continued review of the 1/8/2026 incident report revealed P-2 began asking questions about the investigation by the facility and police. A phone call was set up with the detective on 2/9/2026. The incident report contained an email from Physician Staff H dated 2/19/2026 at 1244 which was sent to ORR Staff HH, ORR Staff TT, Risk Manager Staff DD, BH Medical Director Staff Y, and BH Manager Staff D. The email contained information regarding the call with the detective on 2/9/2026 stating the detective “verbally berated (P-2)” and told her the incident was consensual. Social Worker Staff UU, who had been sitting with P-2 during the call, confirmed P-2’s report to the physician stating the detective had been “verbally inappropriate.” Physician Staff H wrote that P-2’s mental health “acutely deteriorated. She had an acute stress reaction with very severe depression and anxiety, and we had to medicate and place her on a 1:1 sitter for her safety and well-being.” Physician Staff H spoke of P-2 currently recovering from the phone incident and asking questions such as, “If I’m an involuntary patient on this unit, and he was an employee, why was he allowed to be in my room for over an hour, and everyone can just say because they determine it was consensual?” Physician H documented in the medical record on 2/10/2026 at 1148 P-2 had “significant events of acute anxiety and depression, after receiving upsetting news regarding her incident investigation... had to be placed on 1:1 for concerns for self-harm and suicide... (P-2) is experiencing uncontrollable sobbing and rocking back and forth.” On 2/12/2026 at 1019, Staff documented discussion with P-2 regarding the phone call with detective. She stated P-2 was “sobbing and (stated) to me, ‘you (sic) don’t know how aggressive he was... I had to push him off of me.’” P-2 was also asking how the detective came to his determination that it was “okay for a hospital employee to come into her room and do that.” Another piece of information found in the 1/8/2026 incident report 2/19/2026 email was that P-2 had also reported an “incident of verbal harassment from a technician who was her 1:1 sitter.” The 2/11/2026 incident report regarding verbal harassment was obtained and reviewed on 5/7/2026 at 1330. The patient as well as an anonymous provider reported BH Technician Staff GG told P-2 if she had pulled her pants down for EVS Staff F then the contact between them was consensual then followed with, “It wasn’t like you got raped or anything.” The provider reported P-2 was “now in a full state of anxiety and panic” and was expressing suicidal ideation. The provider further stated, “... this is just pure harassment of a patient that is leading to severely negative outcomes...” During interview with Physician Staff H on 5/6/2026 at 1400, she stated, “Between the assault, the detective, and (BH Technician Staff GG), the trauma was increased and it prolonged her stay.” She said she started making comments in huddles that we were “going to believe (P-2) until it could be proven otherwise.” Physician Staff H denied having been interviewed by police or risk management regarding P-2’s behaviors and statements following the sexual assault. She said P-2’s statements and reactions “consistently described non-consensual, unwanted sexual activity.” Review of EVS Staff F’s employee file revealed he had passed all background checks. He was terminated 1/15/2026. Review of BH Technician Staff GG’s staff file revealed she had passed all background checks. Request was made on 5/7/2026 at 0900 for disciplinary files; however, they were not provided prior to exit of survey. During conversation with Physician Staff H on 5/6/2026 at 1400, Physician Staff H stated human resources had given BH Technician Staff GG “ a 1 to 2-week suspension, she had to do some (education) modules and was okay to return to work. She’s upstairs on the unit right now.” Further review of the staff file revealed BH Technician Staff GG had done four modules on 3/6/2026 (3 weeks and 2 days later following the harassment incident) including: “Person Centered Planning”, “Creating a Culture of Trauma-Informed Care”, “Foundations of Unconscious Bias”, and “Recipient Rights for Mental Health Recipients.” During the entrance conference on 5/5/2026 at 1100, a request was made for the root cause analysis (RCA) related to the incident. On 5/6/2026 at 1204, a file titled “Root Cause Analysis 1-8-2026,” dated 5/6/2026, with a report date of 1/8/2026 (the date of the incident) was provided for review. During the review, the document was found to be incomplete as it did not include the staff involved in the RCA, the RCA process, meeting information such as the committee members, the action plan, or the review of plans. The RCA also did not include those overseeing the action plans. On 5/7/2026 at 0940, a second request was made for the RCA. Clincial Regulatory Specialist Staff A stated that the RCA had been requested and the document that was provided was only a summary, not the official RCA. By the end of survey, an official RCA had not been provided for review. Facility policy #1370 titled “If a Physical Assault or Other Allegations of Misconduct Involving a Patient-Investigating Allegation and Notification” effective 3/25/2022 states, “Sexual misconduct or sexual assault, including but not limited to inappropriate touch, physical , verbal or sexual assault and/or any conduct of a sexual nature that is without consent... The accused employee or provider will be immediately removed from patient care...” The policy fails to address when the investigation should occur or provide guidance for timely notification to the hospital leadership and/or staff/physicians immediately involved with the patient’s care. Facility policy #24602 titled “Allegations of Sexual Assault-Investigation Policy” effective 9/24/2024 states, “...The alleged offender will be immediately removed from the care of the patient making the allegation.” This policy fails to ensure the alleged offender to be immediately removed from all patient care/care areas pending investigation. Facility policy #29527 titled “Behavioral Health-Recipient Rights-Complaints and Investigations Appeal Process” effective 9/17/2025 states, “Purpose To ensure the safeguarding of all recipients’ rights within the context of the total treatment environment. To protect these rights, and to respond to complaints received by recipients or by other individuals/agencies on behalf of recipients, an Office of Recipient Rights (ORR) as defined in Section 7 of Public Act 258 of the Michigan Mental Health Code shall be established... An investigation will be immediately initiated in cases involving alleged abuse, neglect, serious injury, or death of a patient, including all deaths by suicide or unknown cause, when a rights violation is apparent or suspected whether there is a complaint filed.””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 45246 Based on observation, interview and record review, the facility failed to ensure nursing staff kept expired medications separate from medications ready to use and secured medications when not under immediate supervision, resulting in possible negative outcomes to patients receiving care in a facility and unsafe medication storage. Findings include: On 5/05/26 at approximately 1250 intensive care unit medication storage room was observed. Medications and supplies were spot checked for expiration dates. There was a 5% Dextrose solution 1000 ml bag stored on the shelf with other bags ready for patients’ use. This bag expired on 12/2025. There was a 0.9 % NaCl (Sodium chloride) fluid 100 ml bag stored on a shelf with other ready-to-use solutions. This bag expired on 01/2026. Facility Chief nursing officer, Staff N, acknowledged findings at the time of discovery and confirmed that expired medications and supplies should not be stored with current stock in use. When asked who is responsible for checking expired medications and supplies and removing them timely, Staff N stated that it was responsibility of the staff nurses. On 5/05/26 at approximately 1340, during the tour of facility’s peri-operative areas, a block cart (a supply cart used by clinical staff to perform anesthetic procedures prior to surgeries) was observed in a hallway next to the patient’s room. Cart was unlocked and unattended by clinical staff. The top drawer had a 0.5 % Sensorcaine (a local anesthetic used to numb specific areas of the body during surgery, labor, dental procedures, and other medical interventions) vial, opened and half full. Vial was not dated and timed when it was opened. Further, there was a 0.5 mg Flumazenil (medication used to reverse the effects of benzodiazepine sedatives) vial and 0.4 mg/ml Naloxone (an opioid antagonist used to reverse or reduce the effects of opioids, particularly in cases of overdose) vial. Both vials were unopened and stored in a top door of the block cart. Facility’s operative services nurse manager, Staff L was present during the tour and acknowledged findings at the time of discovery. Staff L was asked if the cart was usually unlocked with medications stored in it. She stated that block cart should be locked if left unattended by staff. On 5/07/26 at 1035, during interview with facility’s Vice President and Patient Care Services Chief Nurse Executive, Staff II, she was asked if her expectation was that all clinical staff and registered nurses follow facility’s policies and procedures. She stated “yes”. Facility’s policy “Storage and Security of Medications and Medication Related Items”, effective 7/21/24, was requested and reviewed. Policy revealed: “1. Purpose: To outline the process for specifying what constitutes appropriate storage and security for all medications, not limited to controlled substances or nonprescription medications. C. Storage locations 1. Appropriate storage locations include: a. Secured areas such as the pharmacy department and medication room locations. b. Locked medication drawers, cabinets, mounted locked box, or refrigerators. c. Automated dispensing machines (ADM). 2. Inappropriate storage locations or situations include: a. Leaving medications at the bedside or unlocked or unsecured storage area. D. Expired, damaged, or contaminated medications are to be stored separately from stock medications to be administered to patients.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 29955 Based on observation, interview, and record review the facility failed to obtain an order for restraints for one of five patients (P-1), failed to document restraint use for one of five patients (P-1), and failed to assess a patient during restraint use for one of five patients (P-1), and failed to provide restraint training for one of four employees (staff Q) resulting in the improper use of restraints. Findings include: The facility failed to ensure restraint orders, assessments, documentation occurred for a patient in restraint and failed to ensure all staff were trained in restraint use. See specific tag A-0154.”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 29955 Based on interview and record review, the facility staff failed to test all endoscopes used in procedures for 485 patients from 9/29/2023 through 10/17/2023 resulting in the potential for the spread of infectious disease. Findings include: A-0776 - Facility personnel failed to test endoscopes according to policy for the processing of endoscopes.”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 29955 Based on observation, interview, and record review the facility failed to obtain orders for restraint use for one of five patients (P-1), failed to document restraint use for one of five patients (P-1), failed to assess for one of five patients (P-1) during restraint use, and failed to ensure one of four staff members (staff Q) received restraint training resulting in the potential for less than optimal outcomes for a patient in restraints. Findings include: A record review of P-1’s electronic medical record occurred on 2/7/2024 at 1300. The review failed to identify orders for restraint and failed to reflect documentation by nursing staff referencing restraint use. A review of the facility’s complaint and grievance log from 8/1/2023 to 2/7/2024 was conducted on 2/7/2024 at 1400. During review of the log the patient of concern (P-1) was identified on the log with a grievance filed on 11/6/2023. The grievance stated P-1’s spouse and daughters filed a grievance regarding the use of restraint for P-1, and P-1 being held down during the night of 11/3/2023. Through the investigation of the grievance filed with the facility, staff M the unit manager was able to determine mitts were placed on the patient but “not tied” therefore the mitts had not been considered a restraint. Further documentation stated the patient “managed to bite them off” and that the nurse, staff Q “tried to replace the mitts,” but was unsuccessful. Staff M was unable to establish P-1 was held down by 3-4 employees. Documentation of findings by staff M stated that a transfer of P-1 from a cart to his bed which involved 3 employees. On 2/8/2024 at 1000, a tour of the post-surgical unit occurred. Observation of P-10 in restraints no concerns were identified. On 2/8/2024 at 1010, while on tour staff were queried about restraint orders and restraint use. Staff were also queried if not tying restraints negated the need for a restraint order. Staff interviewed were able to explain the need for a restraint order, the proper use of restraints, and when restraints use were to be discontinued. No concerns were noted during the interviews. Staff Q was no longer employed by the facility. On 2/8/2024 at 1025, an interview was conducted with staff M, the unit manager. Staff M was asked to explain her investigation findings. Staff M stated that on 11/9/2023 she had a conversation with staff Q, the nurse caring for P-1 on the night of 11/3/2023. Staff M stated that staff Q had explained P-1 had been pulling at his feeding tube and IV (intravenous catheter) line. According to staff M it was also revealed during her interview with staff Q that the staff member thought because she had not tied the mitts that it was not considered a restraint, so no order was received from the physician and no documentation occurred. Staff M was then asked what had been done to ensure staff were aware of the proper use of restraints including the need for an order, proper application of restraints, documentation of restraint use, and discontinuation of restraints. Staff M stated after doing her investigation the daily unit huddles both for day shift and night shift included review of restraints including need for an order, proper application of restraints, proper documentation of restraint use including assessments, and when to discontinue restraints. Staff M stated the topic was covered over a week at both daily huddles to ensure all staff were aware of the information shared. Staff M was then queried what was done to ensure staff Q was educated about the errors that were identified through her investigation of the incident. Staff M stated staff Q had been a contracted traveling nurse and her contract had been terminated. On 2/8/2024 at 1300, a review of employee files was conducted to specifically identify restraint use training. When reviewing the file of staff Q the facility could not produce documentation of restraint training as part of the onboarding of contracted traveling nurses. The facility was unable to produce documentation prior to the end of survey. Review occurred of the policy titled, “Restraints: Care of the Patient in Restraints,” dated 5/31/2022, policy #8168, version 10 on 2/8/2024 at 1410. According to the policy it states, “IV. Use of Restraints, A. Ordering requirements, 1. Non-violent Restraints, letter D, it states, “In emergent situations, when the need for intervention occurs so quickly that an order cannot be obtained prior to application of physical restraints, an RN may initiate physical restraint based on assessment of the patient. The RN will notify the Provider within minutes of restraint application once the patient is safe and obtain the appropriate order. The assessment and restraint intervention must be documented by the RN.” The policy further states, “2. Non-violent Restraint: Assessment and Documentation, a. On initiation and discontinuation, the RN will document that the restraint used is the least restrictive restraint intervention and that it was applied properly and safely.” The policy addresses staff education and use of restraints by stating, “V. Staff Education in the Use of Restraints, A. Direct patient care staff who provide care for patients in restraint will be educated, and able to demonstrate competency in the use of restraints: 1. as part of the orientation process, 2. prior to participating in the use of restraint, 3. on a periodic basis thereafter, B. Direct patient care staff will be educated and able to demonstrate competency in the following areas as appropriate to their role and responsibility: 1. Strategies to identify staff and patient behaviors, events and environment factors that may trigger restraint, 2. Use of non-physical intervention skills, 3. Choosing the least restrictive intervention based on an individual assessment, 4. Safe application of restraint (all types) including how to respond to distress, 5. Identification of behavioral changes that indicate restraint is no longer necessary, 6. Monitoring the physical and psychological well-being of the patient (e.g., respiratory and circulatory status, skin integrity, vital signs); and 7. Certification/recertification in cardiopulmonary resuscitation (CPR) C. Education will be: 1. Provided by qualified individuals as evidenced by education, training, and experience in techniques used to address patient behaviors, 2. Specific to patient population needs, 3. Documented in staff education records.””

“IC PROFESSIONAL ADHERENCE TO POLICIES CFR(s): [The infection preventionist(s)/infection control professional(s) is responsible for:] (v) The prevention and control of HAIs, including auditing of adherence to infection prevention and control policies and procedures by hospital personnel. This Standard is not met as evidenced by: 29955 Based on interview and record review the facility staff failed to test all endoscopes used in procedures for 485 patients from 9/29/2023 through 10/17/2023 resulting in the potential for the spread of infectious disease. Findings include: On 2/7/2024 at 1205, an interview took place with staff H, the nurse manager of the Sterile Processing Department (SPD). Staff H was queried if endoscopes were processed with ATP (Adenosine Triphosphate - ATP testing is used to assess the cleanliness of a surface and the effectiveness of cleaning procedures. ATP testing is not a test of sterility, but of organic contamination. ATP testing is a fast and accurate way to monitor and maintain cleaning standards). Staff H stated that in September 2023 there was a shortage of ATP test strips at the facility. Staff H stated that the facility had borrowed ATP test strips from the other hospital (child facility). Staff H stated it was then discovered there was a back order for the ATP test strips. Staff H was then asked to provide testing logs for endoscopes for the weeks when ATP test strips were not available. On 2/7/2024 at 1445 an interview occurred with staff I, the lead sterile processing technician. Staff I was queried about the ATP testing of endoscopes and the availability of ATP test supplies. Staff I stated that ATP strips were not available in late September (2023) and that visual inspections were used until RESI testing strips (RESI testing is designed to perform rapid, sensitive (>1?g) and cost-effective residual protein testing. Provides you with a simple, practical and easy-to-interpret protein detection method.) were provided as a back-up to the ATP strips. Staff I stated that there had always been a supply of ATP testing strips in the refrigerator upstairs (Endoscopy unit). Staff I was queried if a supply inventory was kept for critical supplies for the processing of the endoscopes. Staff I stated that a previous manager had not kept a tracking system of supplies and that it was assumed all supplies had ample supply. Staff I was asked what type of testing occurred during the time of not having the ATP strips. Staff I stated only visual inspection of the scopes occurred. On 2/8/2024 at 0840, an interview was conducted with staff H, the nurse manager of SPD and staff L, the Director of SPD. Staff H was asked the time period that scopes were not ATP tested. Staff H stated from 9/29/2023 through 10/17/2023. Staff H was then asked when the Infection Control Preventionist (staff K) was notified. Staff H stated staff K was notified on 10/17/2023. Staff H stated she was not aware that staff K needed to be notified. On 2/8/2024 at 0900 an interview occurred with staff K, the facility Infection Control Preventionist. Staff K was queried about her knowledge of the lack of ATP testing for endoscopes in the SPD. Staff K stated that she was unaware that the SPD had not been testing endoscopes. She stated that her first knowledge of the lack of testing was on 10/17/2024. Staff K was asked what was done when she became aware of this information. Staff K stated she immediately met with the nurse manager and director of the SPD. She added that she immediately started gathering information for all procedures conducted with scopes not ATP tested including the patient names, procedures, and scopes used. She stated that she also let the nurse manager, staff H, and director, staff L, know that a backup test should be used if the ATP test strips were on back order. Staff K stated the SPD then reached out to the other facility (child facility) to find out what testing they were using in lieu of ATP testing. Staff K stated the SPD acquired RESI tests to replace ATP testing. Staff K was then asked if she knew how many patients and how many procedures were conducted without any test after cleaning and before disinfection. Staff K later provided information that 485 patients and 487 procedures were conducted with scopes that had not been tested by ATP or RESI testing. On 2/8/2024 at 0925, a request was made for the policies for endoscope cleaning and ATP testing. On 2/8/2024 at 1440, a review occurred of the policy titled, “Flexible Endoscope Reprocessing,” policy # 6300-957, dated 6/01/2022. According to the policy it states under section 5.25, “Procedure for visual inspection: ...Endoscopes shall be evaluated with a cleaning verification test called ATP. Follow the ATP manufacturer’s IFU (instructions for use) for specific instructions.” Further policy review included the policy titled, “Flexible Endoscope ATP Quality Testing,” policy #6300-111, dated 5/2019. According to policy it states, “Procedure: 3. Frequency of testing: Because flexible endoscope reprocessing has a small margin of safety & given that the risk of pathogen transmission is high, we will monitor endoscopes as follows: ...Endoscopes types with high risk of pathogen transmission (e.g. duodenoscopes, EUS-endoscopic ultrasound scopes, bronchoscopes) shall be monitored after each manual cleaning cycle.” According to the AORN article titled, “Guideline Essentials: Flexible Endoscopes. AORN (Association of Operating Registered Nurses). Accessed April 26, 2023.” (https://www.aorn.org/guidelines-resources/guidelines-for-perioperative-practice/guideline-essentials/processing-flexible-endoscopes.) “Because contamination is not always visible, AORN provides a conditional recommendation for assessing cleanliness through use of at least one of following tests: protein, hemoglobin, carbohydrate, and ATP.””