Insight Hospital and Medical Center Coldwater

“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 assess and identify an impaired patient (P-1) leading to aggressive behavior resulting in injury of two patients (P-1 and P-2). Findings include: On 3/26/2026 during review of P-1’s medical record, it was revealed that on 1/29/26 at 2118, staff O, Emergency Department (ED) physician documented P-1 as a 38-year-old male who had been brought in by the local police and the Community Mental Health (CMH) agency for paranoia and agitation. Staff O also documented that P-1 was hyperactive with pressured and tangential speech. Also documented was “Psych was without any evidence of intoxication but with paranoid and manic behavior. A petition was completed by CMH and a certification was completed by staff O. P-1 was accepted by staff P, Psychiatrist, for admission and treatment in the Behavioral Unit. On 3/27/2026 at 0825 during an interview with staff O, staff O stated that P-1 had arrived at the ED with four police officers. Staff O also stated that he was aware that P-1 had caused “significant” damage at the local shelter prior to being brought to the ED. Staff O stated that P-1 did exhibit signs of agitation verbally while he was assessing P-1. Staff O stated that he was able to calm P-1 and discovered that P-1 had used drugs the prior day. P-1 tested positive for methamphetamine, Ecstasy, and Cannabinoids. Staff O stated P-1 did not make any threats while he was in the ED. Staff O was asked if he was aware that P-1 had been violent prior to coming into the ED. Staff O stated, yes, but he felt the paranoia and agitation were psychiatric in nature. Staff O was questioned if the facility had any policies or assessment tools to use when admitting a patient exhibiting aggression, paranoia, or violence. Staff O responded that he follows the petition and certification process, and psychiatry decides whether they are going to accept the patient for admission. P-1 was admitted to Behavioral Unit on 1/30/2026. On 1/30/26 at 1201 a psychiatric evaluation was completed by staff P. Documentation under “History of Present Illness” revealed, “he (P-1) said that he was high that he was using methamphetamine for the last several days he said that he was not sleeping for [SIC] than 24 hours...He said that he had an argument with his girlfriend he felt other people were against him and may harm him he said that he went to the domestic violence shelter. He said that he was brought to the hospital.” Further document review revealed, “he gave a history of being incarcerated in MDOC (Michigan Department of Corrections) for 10 years.” P-1’s mental status examine [SIC] revealed his mood was “worried”, his affect was “irritable at times”, and his thought content was “recently been feeling others may harm him or his girlfriend had brought this [SIC] people to harm him.” P-1 was also documented as being “oriented.” Nursing admission notes by staff U, RN, dated 1/30/26 at 0340 revealed, “(P-1) was elated mostly throughout assessment and jumped topics often with laughter. He made reference to being high several times throughout assessment. He spoke of smoking meth several time a week...(P-1) would refer to paperwork and that the staff there (domestic violence shelter) was rude to him but he denies needing to live there and any abuse. (P-1) did make a comment about having several felonies and then laughed...(P-1) refused to sign paperwork at this time.” A nursing progress note by staff H, RN, on 1/30/26 at 0915 revealed, “(P-1) mentioned he was high last night, manic and paranoid due to being high. (P-1) said he was partying more than usual. He enjoys doing the drugs and he is not suicidal or homicidal...(P-1) denies anxiety or depression, not SI/HI (suicidal ideation/homicidal ideation). Denies hearing voices. He said “man I was just high. I really want to go home and take care of my dog and get back to work. I was just letting off steam.” On 1/30/26 at 1000 staff Q, Social Worker, progress note revealed, “Psychotherapy was offered to the (P-1) the pt. (patient) declined. The (P-1) stated, “I am not planning on staying here.’ (P-1) is pacing in the hallway.” At 1153, staff Q, documented, “...The (P-1) is pacing in the hallway.” On 1/30/26 at 1233, staff K, Social Worker, documented from P-1’s first treatment team meeting, “(P-1) was initially pleasant then, upon discussing that [SIC] the had been [SIC] petitioned to the unit, he became agitated, kept repeating, ‘I just want to go home, I don’t have any mental illness.’ When (staff P, psychiatrist) attempted to speak to him about his stay here, he interrupted and stated, “I just want to go home and I don’t even want an aspirin from you!’” Staff K further documented, “(P-1) was asked if he was open to entering rehab facility to address SUD (Substance Use Disorder). (P-1) declined.” Staff K later documented at 1421, “(P-1) very agitated and irritable during today’s meeting after it was discussed that he had been petitioned to the unit...” On 1/30/26 at 1345, staff Q, Social Worker, documented, “Sw (social worker) observed (P-1) arguing with nurse over his cell phone. The (P-1) did not want to show the screen while being observed for numbers.” At 1350 P-1 asked staff Q, “what do I [SIC] do get up out of here.” Staff Q explained that P-1 would have to “remain calm, cooperative, work with staff, and be observed for any side effects from his meth usage...(P-1) asked this writer ‘are you against me’ sw educated (P-1) on this writers role.” On 1/30/26 at 1602, staff R, Care Navigator, documented, “(P-1) presents as irritable, ambivalent, and guarded with a labile affect. His thought processes are paranoid and is lacking insight. His speech is loud, clear, and pressured. (P-1) appearance is very disheveled. He is exhibiting psychomotor agitation. (P-1) eye contact is fair. (P-1) denies any mental health concerns, including depression, anxiety, hallucinations, paranoia, SI and HI...does not believe he needs to be here. (P-1) reports he was high on methamphetamines and got in an argument with a female acquaintance who he says then called several men to confront him at his apartment.” Staff R also documented, “He is demanding discharge and states, “I’m going to call my mother and she will come up here and get me out of here...Inpatient substance abuse treatment is discussed and (P-1) declines reporting he is not ready to give up substances...”. On 1/30/26 at 1815, staff R, Care Navigator, documented, “Per staff reports, (P-1) assaulted three nursing staff, security guard, and another patient (P-2) with metal broom taken from staff’s hands. (P-1) then broke open fire hose cabinet and used metal nozzle to break through solarium window. NORA (Need Officer Response Assistance) and 911 called. Per reports, (P-1) then jumped onto the roof below and then jumped to the ground. (P-1) sustained injuries from jumping off the roof. He was found lying on the ground by police and taken to the ER (Emergency Room) for medical treatment. (Staff P, Psychiatrist) was notified of events and placed discharge order.” On 3/27/2026 at 1440 review of P-2 medical record revealed that P-2 was a 41-year-old male admitted to the facility on 1/23/26 for manic behavior and agitation with a history of schizophrenia, manic type. On 1/30/26 Staff H, RN, documented, “(P-2) is sitting in blue chair in hallway curled up covered with a white blanket. Patient is talking to himself.....Another patient (P-1) is ramped up too and they have been playing off each other. (P-2) was given ativan and zydis for his agitation and mood.” P-2 was attacked by P-1 on 1/30/26 causing injury. According to the Physician Assistant’s note on 1/30/26 at 1928, “41-year-old male patient presents to the emergency department for evaluation of injuries after assault. Patient was assaulted by another patient, and was hit in the head with a boom handle. He did not lose consciousness. He does have some pain and swelling to the right cheek and a [SIC] cuts on his scalp...” On 3/26/2026 at 0840 a review occurred of the Root Cause Analysis (RCA) that had been developed by the facility. Staff A, Chief Executive Officer and Chief Nursing Officer, explained that three meetings had occurred and actions had been identified to address the need for improvement. Staff A stated that a violent predictability tool had been purchased in the last week (3/17/2026) but had yet to be received to use/implemented with the electronic medical record (EMR). Staff A was then queried if any other corrective actions had been put into place that had been identified from the RCA. Staff A stated that corrective actions had been identified but not been put into place yet. The facility was not able to identify any new risk mitigation strategies for future violent patients.”

“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 record review and interview, the facility failed to follow policy for obtaining verbal consent for 2 of 2 (P-1, P-2) sampled patients. Findings include: On 1/27/2025 at 1400 during record review of P-1 medical record it was revealed the verification of verbal consent obtained on P-1’s visit on 12/12/2024 contained one witness. On 1/27/2025 at 1530 during record review of P-2 medical record it was revealed the verification of verbal consent obtained on P-2’s visit on 3/15/2024 contained one witness. On 1/28/2025 at 1000 an interview was conducted with Registrar staff G, who was asked if two witnesses were required for verbal consents for general consent taken over the phone. Staff G stated, “Only one witness is required for verbal consent since the form changed a while back.” Staff G brought the form up to view on her computer monitor to show one witness line on the electronic form. On 1/28/2025 at 1025 an interview was conducted with staff K, the manager of registration. Staff K was queried if she was aware staff were only obtaining one witness signature rather than two witnesses when taking verbal consents over the phone. Staff K stated, “I was not aware of only one witness being used when obtaining verbal consents until today, but I understand the confusion due to the change in the form.” On 1/28/2025 at 1300 record review occurred of the policy titled, “Obtaining consent for Treatment,” policy # CP-22.25, dated 9/15/2021. According to the policy it reads under the subtitle, “verbal consent, b. Two ProMedica employees (excluding volunteers) witness the patient or the patient’s legally authorized representative providing legal consent.””

“CONTENT OF RECORD: CONSULTATIVE RECORDS CFR(s): 482.24(c)(4)(iii) [All records must document the following, as appropriate:] Results of all consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient. This Standard is not met as evidenced by: 29955 Based on record review and interview, the facility failed to ensure the medical record for one (P-1) of four psychiatric patients reviewed contained the Community Mental Health (CMH) assessment and safety plan in the medical record, resulting in the inability for all healthcare professionals involved in the patient’s care to access vital mental health information. Findings include: On 1/27/2025 at 1500 during record review of P-1’s medical record it was revealed the CMH assessment and safety plan from P-1’s 12/12/2024 ED visit was not available. On 1/27/2025 at 1520 an interview occurred with staff B, Intensive Care Unit and Emergency Department manager. Staff B was queried if a copy of P-1’s CMH assessment and safety plan should be in the patient record. Staff B stated the record should be available for access, and she would make an inquiry to find the assessment and safety plan. On 1/28/2025 at 0910, staff B provided a copy of P-1’s CMH assessment and safety plan. Staff B stated that the assessment and safety plan had not been sent to the facility for the patient record. On 1/28/2025 at 1100 a review of the contract between CMH and the facility, dated 10/10/2023, on page 2, under the subtitle, “II. Coordination of Care,...D. (CMH) and (facility) agree to jointly develop the process of timely referrals, how best to track referrals back and forth, how to effectively manage any care transitions, how to coordinate the transfer of health and medication information, and any medical notes regarding diagnosis, treatment, prescriptions, and specific follow up care.””