Borgess Medical Center

“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: 36887 Based on interview and record review, the facility failed to ensure the nursing service followed facility policy for bathing and/or hygiene care for 7 (P-1, P-3, P-5, P-7, P-8, P-9, P-10) of 8 patients reviewed resulting in unmet patient needs and the potential for adverse patient outcomes. Findings include: See Specific Tag(s): A-398 Failure to provide hygiene”

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 36887 Based on interview and record review, the facility failed to provide effective discharge instruction and planning for care following discharge for 1 (P-1) of 3 patients reviewed for discharge planning resulting in an incomprehensive plan of care following discharge and the potential for poor patient outcomes. Findings include: See Specific Tag(s): A-802 Failure to have comprehensive discharge instructions”

“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: 36887 Based on interview and record review, the facility failed to follow policy for bathing and/or hygiene care and nursing assessments for 7 (P-1, P-3, P-5, P-7, P-8, P-9, P-10) of 8 patients reviewed resulting in unmet patient needs and the potential for adverse patient outcomes. Findings include: Review of the medical record for P-1 revealed he was a 90-year-old male who was admitted to the facility 8/7/2025-8/14/2025 for lethargy and altered mental status. Review of nursing documentation regarding the activities of daily living (ADLs-basic tasks a person performs to maintain their well-being such as bathing/showering, toileting, transferring, and eating) revealed P-1 was incontinent of bladder and bowel and required moderate to maximum assistance with bathing, toileting, dressing, and repositioning. He was weak and bed-bound. Documentation of oral care, bathing, gown change, and linen change was not found. Nursing documentation was inconsistent throughout regarding patient being independent vs requiring maximum assistance and having Braden scores (a scale used to determine risk of pressure injury occurrence-the lower the score, the higher the risk of injury) documented on the initial nursing assessment on 8/7/2025 at 0351 as 12 and on 8/7/2025 at 0600 (2 hours, 9 minutes later) as 20. On 11/4/2025 at 0956, LPN (Licensed Practical Nurse) Staff K stated bathing and mouthcare were “supposed to be offered every day.” When queried why those things were not documented, she stated she does provide the care but often gets pulled into other tasks with other patients and must prioritize what needs to get done. When she does have time to document, the ADL tasks were forgotten. Review of the medical record for P-3 revealed she was a 47-year-old female who was a paraplegic and had urinary incontinence. She was admitted 10/15/2025-10/20/2025 for pneumonia and sepsis. The only instance of documented toileting was 10/20/2025 at 0538. No other hygiene documentation, oral or physical, was present. Nursing documentation was inconsistent regarding the patient being independent vs dependent for care. On 11/3/2025 at 1424, Staff D stated, “Significant opportunity to document.” Review of the medical record for P-5 revealed she was a 80-year-old female admitted 4/28/2025-5/8/2025 for a left-sided stroke. Toileting was documented being offered and/or provided; however, was inconsistent with some large gaps as follows: Admission at 1700 4/28/2025 at 2256, 4/29/2025 at 0504 (6 hours, 8 minutes later), 4/29/2025 at 0732 (2 hours, 28 minutes later), 4/30/2025 at 0714 (23 hours, 43 minutes later), 5/2/2025 at 1316 (2 days, 6 hours, 2 minutes later), 5/3/2025 at 0141 (12 hours, 25 minutes later), 5/3/2025 at 0505 (3 hours, 24 minutes later), 5/3/2025 at 1637 (11 hours, 32 minutes later), 5/3/2025 at 1800 (1 hours, 23 minutes later), 5/4/2025 at 1556 (21 hours, 56 minutes later), 5/5/2025 at 0148, (9 hours, 44 minutes later), 5/5/2025 at 0817 (6 hours, 29 minutes later), 5/5/2025 at 1034 (2 hours, 17 minutes later), 5/5/2025 at 1342 (3 hours, 8 minutes later), 5/5/2025 at 1707 (3 hours, 25 minutes later), 5/5/2025 at 2250 (5 hours, 43 minutes later), 5/6/2025 at 0841 (9 hours, 31 minutes later), 5/7/2025 at 0728 (23 hours, 47 minutes later), and 5/7/2025 at 2207 (14 hours, 39 minutes later). Nothing was found from 5/7/2025 at 2207 until the time of discharge on 5/8/2025 at 1415 (16 hours, 8 minutes later). No other hygiene documentation was found regarding oral care, bathing, change of gowns or linens. On 11/3/2025 at 1444, Staff D commented, “Definite opportunity for documenting again.” Review of the medical record for P-7 revealed he was a 72-year-old male who was admitted 5/13/2025-6/4/2025 with cellulitis and pneumonia. Toileting was offered and/or provided; however, was inconsistent with large gaps as follows: Admitted 5/13/2025 at 0406 5/19/2025 at 1355 (6 days, 9 hours, 49 minutes later), 5/19/2025 1721 (3 hours, 26 minutes later), 5/25/2025 at 0108 (5 days, 7 hours, 49 minutes later), 5/25/2025 at 0507 (3 hours, 59 minutes later), 5/25/2025 at 0555 (48 minutes later), 5/27/2025 at 0227 (1 day, 20 hours, 32 minutes later), 5/29/2025 at 0136 (1 day, 23 hours, 51 minutes later), 5/29/2025 at 0410 (2 hours, 34 minutes later), 5/29/2025 at 0420 (10 minutes) 5/29/2025 at 0540 (1 hour, 20 minutes) 6/3/2025 at 0321 (4 days, 21 hours, 41 minutes) 6/3/2025 at 0548 (2 hours, 27 minutes) 6/3/2025 at 1251 (7 hours, 3 minutes) 6/3/2025 at 1801 (5 hours, 10 minutes) 6/3/2025 at 2200 (3 hours, 59 minutes) 6/4/2025 at 0201 (4 hours, 1 minute). The patient was discharged 6/4/2025 at 0406. Oral hygiene was documented on 5/24/2025 at 1739 and 6/4/2025 at 0012 which stated the family aided with the oral care. No other documentation was found regarding oral care, bathing, change of gowns or linens. Review of the medical record for P-8 revealed she was a 68-year-old female who was admitted 9/24/2025-10/1/2025 with a non-healing left foot ulcer. No ADL documentation was found for toileting, oral or physical hygiene, gown and linen changes. Review of the medical record for P-9 revealed she was a 79-year-old female who was admitted 9/25/2025-10/2/2025 for a stroke. Review of nursing documentation revealed P-9 had urinary incontinence. A toileting schedule was established and a care plan was developed to include peri-care with every episode of incontinence. Toileting documentation was as follows: Admission 9/25/2025 at 2000 9/28/2025 at 0527 (2 days, 9 hours, 27 minutes later), 9/28/2025 at 0600 (33 minutes later), 9/29/2025 at 2000 (14 hours later), 9/29/2025 at 2342 (3 hours, 42 minutes later), P-9 was discharged home 10/2/2025 at 1141 (2 days 11 hours, 59 minutes later). No other documentation was done regarding toileting, oral or physical hygiene, gown and linen changes. Review of case management documentation dated 9/29/2025 at 1749 revealed a recommendation for further “PT (physical therapy) for bed mobility and ambulation OT (occupational therapy) for ADL’s, transfers...” Review of the medical record for P-10 revealed he was a 56-year-old male who was admitted 8/27/2025 at 1853-9/2/2025 at 1534 for open wounds at multiple sites and osteomyelitis. Provider notes indicated P-10 had a neurogenic bladder (disconnect between the nerves to the brain that bladder is full, causing incontinence). Nursing documentation on 9/1/2025 at 2000 revealed he was a paraplegic since the 1980’s following a car accident while other documentation on 9/2/2025 at 1157 stated he was a quadriplegic and was unable to sit in a wheelchair. On 9/1/2025 at 0800 notes are present that a toileting schedule was established but failed to provide any details. No documentation was found for toileting, oral or physical hygiene, gown and linen changes. A request was made to the facility for a policy regarding provision of care for ADL’s; however, none was provided prior to exit of survey. Facility policy #17900985 titled “Nursing Assessments and Vital Signs” last revised 4/2022 states, “Ongoing Assessments: A. An ongoing assessment must be completed each shift and a focused assessment performed per policy Nursing Plan of Care for the specific body system/parts related to existing patient conditions.” Facility policy #17739689 titled “Nursing Plan of Care” last revised 5/22/2023 states, “1. The Registered Nurse is responsible for the coordination, delivery, and evaluation of care through the nursing process. The RN (registered nurse) will facilitate an interdisciplinary, collaborative approach as the patient’s plan of care is managed. A. Assessment. The RN collects comprehensive data pertinent to the healthcare consumer’s health and/or the situation. ...E. Implementation. The RN implements the identified plan. a. Coordination of care. The RN coordinates care delivery. b. Health Teaching and Health Promotion. The RN employs strategies to promote health and a safe environment...Use the Ongoing Assessment or body part-specific assessment to complete an update every shift or per department standard of care... Develop a plan to assist the patient towards the goals... Implement the identified plan and interventions. Document care provided. Document interventions implemented...””

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to ensure the policy for discharge planning was followed for 1 (P-1) of 3 patients reviewed for discharge planning resulting in a deficient discharge plan and the potential for poor patient outcomes. Findings include: Review of the medical record for P-1 revealed he was a 90-year-old male who was admitted to the facility 8/7/2025-8/14/2025 for lethargy and altered mental status. P-1 was his own decision-maker. His daughter was his caregiver, listed as his emergency contact, and was documented in the medical record several times as being his contact person. He did not have an advanced directive. Provider notes dated 8/12/2025 at 1811 listed P-1’s daughter as the contact person with her phone number. The Physical Therapy (PT) assessment dated 8/12/2025 at 1147 stated the PT plans and goals were reviewed with patient and family. The discharge planning assessment dated 8/7/2025 at 1557 also indicated the presence of family members for discussion of needs following hospitalization. Review of the initial nursing assessment dated 8/7/2025 at 0351 revealed P-1 had a Braden score (risk assessment tool used to evaluate a patient’s risk of developing a pressure injury. Score 18 or higher-low risk, 15-17-moderate risk, 13 to 14-high risk, 12 or lower-very high risk) of 12. Additionally, the initial assessment also indicated there was redness to the buttock/coccyx area. Pressure injury prevention measures were added to the care plan including keeping bedding dry, without wrinkles, using a lifting sheet, and repositioning every 2-3 hours. A foam dressing was first identified in nursing documentation on 8/10/2025 at 2000 “to risk area” and a “skin abnormality-buttock/coccyx” was indicated. There was no further information provided as to the appearance, size, or staging of the abnormality. A “skin abnormality-buttock” was documented again 8/11/2025 at 2000. The documentation did not provide any information regarding dressing change, appearance, size, and/or staging of the abnormality. On 8/14/2025 at 0700, nursing documentation revealed “Wound-pressure injury, Stage II buttock; circumferential, partial thickness; dressing dry and intact.” The presence of Stage II pressure injury to the buttock was documented again 8/14/2025 at 1500 shortly before discharge. On 11/4/2025 at 1015, Registered Nurse (RN) Staff L stated a wound care consult would have been automatically triggered in the system “for a Stage II wound or higher.” Staff L was unable to recall P-1 or the situation, but stated, in general, she would contact the provider and care team prior to reaching out to the family to first develop a plan, then present it to the family. She further explained although she was the primary nurse for P-1 on the day of discharge, she would not have discharged the patient as the facility had a special team that went through the hospital processing all admissions and discharges. Report would be given to the discharge nurse as well as to case management for follow-up purposes. On 11/4/2025 at 1027, Admissions-Discharge Unit (ADU) Staff M stated the ADU RN would do a full charge review looking at orders, case management notes, care plans, consults, progress notes, the patient’s diagnosis, and past medical history. From there the discharge plan would be developed. Staff M confirmed that auto-consults would also be reviewed. Following development of the plan, the paperwork including instructional information based on the patient’s diagnosis would be printed and then presented to the patient and family. The discharging ADU RN for P-1 was unavailable for interview. On 11/4/2025 at 1111, Physician Staff O stated he was unable to recall P-1. He stated, “In general, the presence of a Stage II (pressure injury) wouldn’t necessarily delay discharge.” Further review of the medical record revealed no mention of a wound in provider notes or in provider orders. There was no documentation present that wound care saw P-1 as the auto-consult was not fulfilled prior to discharge. There was no mention of a wound found in case management notes. Review of discharge instructions revealed there was no information regarding the presence of a wound or how to care for the wound. Included were “Discharge Orders” which were for activity, diet, home care agency to include physical therapy and nursing care for debility, and durable medical equipment needs. There was no mention of wound care. Informational education included was for stroke, stroke prevention, ischemic stroke, and urinary tract infection. Part of the discharge information included the “Transition of Care Packet Procedure and Cover Form” with the discharge date of 8/14/2025 at 1530 written at the top lists the patient’s name, name of the home care agency with contact information. In the middle of the page is a list of documents that needed to be sent to the home care agency. “Wound Care Plan” was present in the list; however, was not marked. Facility policy #14961945 titled “Discharge Planning-Ascension National Case Management Policy” last revised 2/25/2022 states, “Case management associates will perform timely discharge needs assessments, which will identify patients requiring post hospital care coordination in conjunction with the interdisciplinary team’s documentation...Case management will initiate appropriate referrals to internal and external providers of care to meet identified transitions of care/discharge planning needs. All activities will be performed through input and collaboration with attending and consulting physicians, nursing staff, participating therapists, and other members of the health care team in conjunction with the patient/responsible party(s) goals. Responsible staff members will document all assessment findings and plans for continuing care in the medical record. Additional referrals to case management may be made at any time for specific needs by nursing, physicians, patients, families and others... The discharge plan is evaluated on an on-going, timely basis, revised an documented as appropriate by the entire health care team. This will ensure case management services are responsive to transitional care needs... The medical record should reflect the plan of care as discussed with the individual or individual acting on his or her behalf.” A policy was requested for the ADU; however, none was available. Documentation was provided as to the processes for discharges and admissions. Review of the facility’s undated discharge process titled “Discharging Patients” states, “To prepare a patient for discharge, you must review the following documentation: 1. Progress Notes: please read last progress note from each medical specialty/consult as well as the attending physician. Ensure that all recommendations have been addressed such as new medications, medication dose changes, etc... Review patient orders to ensure orders have been completed...””

“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 observation, interview, and record review, the facility failed to ensure nursing staff implemented fall safety interventions for fall prevention for 5 of 11 patients (P-1, P-4, P-5, P-7, and P-9) resulting in harm to 1 patient (P-1) and the potential for harm for all patients served by the facility who are at risk for falls. Findings include: See Specific Tag: A-0392”

“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 observation, interview, and record review, the facility failed to ensure nursing staff implemented fall safety interventions for fall prevention for 5 of 11 patients (P-1, P-4, P-5, P-7, and P-9) and failed to develop an action plan for a significant fall with injury resulting in harm to 1 patient (P-1) and the potential for harm for all patients served by the facility who are at risk for falls. Findings include: P-1 Record review of P-1 medical record occurred on 7/15/2025 at 1400. P-1 was admitted to the facility on 5/13/2025 after sustaining a fall at home. According to documentation P-1 sustained a fall on 5/13/2025 between 1045 and 1120 on the Cardiac/Neuro/Medical/Surgical Unit (3 North). P-1 was assessed by the rapid response team and a CT (computed tomography) scan was ordered. Review of the physician’s note dated 5/13/2025 at 1446 revealed, “....I was notified at 1308 that patient had an unwitnessed fall in her room while attempting to walk to her door. No head injury, LOC (loss of consciousness), or other injury per patient. RRT (Rapid Response Team) was called. Systolic BP was noted to be in the 170s per RRT team. Stat CT Head showing acute subdural hematoma along the tentorium cerebelli bilaterally, left more than right. Left-sided SDH (subdural hematoma) with maximum width 1.3 cm, with mass effect and subfalcine herniation with 0.9 cm midline shift to the right. Right-sided SDH measuring 0.5 cm in width. No skull fracture. ICU (Intensive Care Unit) and Neurosurgery were notified, and Aspirin and Plavix were held by RRT team.” P-1 SDH failed to resolve and a craniotomy was performed on 5/31/2025. P-1 was discharged to a long-term care facility for rehabilitation on 6/16/2025. On 7/15/2025 at 1300 an interview occurred with staff C, the Manager of Risk Management. Staff C provided the RCA information, and she highlighted identified causes related to the adverse event. Staff C shared that the causes identified included incorrect communication between staff, and lack of ensuring that fall precautions were implemented and activated. Staff C further stated that the bed alarm had not been engaged to alarm when the P-1 was out of bed without assistance. P-9 On 7/16/2025 at 1040 a tour was conducted of the 8 Northwest unit. An interview was conducted with P-9’s family member. P-9’s family member stated that P-9 was hospitalized after a fall at home. The TIPS whiteboard (a TIPS whiteboard is a communication tool used to communicate between staff, patients, and family members about the specific risk for falls for a patient) revealed the section titled “History of Falls” had not been marked. On 7/16/2025 at 1055, staff M confirmed the TIPS whiteboard was incorrect and should have been marked to indicate P-9 had a history of falls. P-5 On 7/16/2025 at 1135 during a tour of the 4 North medical/surgical unit - room 446, the TIPS whiteboard had a date of 07/14 (2025). The TIPS whiteboard had not been updated since 7/14/2025 (2 days). P-5 TIPS whiteboard noted that P-5 was a increased of fall related to “May forget or choose not to call.” P-4 On 7/16/2025 at 1138 during a tour of the 4 North medical/surgical unit - room 442, the TIPS whiteboard had a date of 07/8 (2025). The TIPS whiteboard had not been updated since 7/8/2025 (8 days). P-4 TIPS whiteboard noted that P-4 was a increased of fall related to “history of falls, medication side effects, unsteady walk, and may forget or choose not to call.” P-7 On 7/16/2025 at 1149 during a tour of the 4 North medical/surgical unit - room 430, the TIPS whiteboard had a date of 07/15 (2025). The TIPS whiteboard had not been updated since 7/15/2025. P-7 TIPS whiteboard noted that P-7 was a increased fall risk related to “Medication Side Effects and IV Pole or Equipment.” On 7/16/2025 at 1200 an interview occurred with staff M, the Director of Nursing of the inpatient floors 3N, 4N, and 8NW that had been toured. Staff M was queried how often TIPS boards were to be updated. Staff M replied, “with every shift and throughout the day....” On 7/16/2025 at 1345 staff C, Manager of Risk Management, was interviewed a second time. Staff C was asked if an action plan had been established with the completion of the RCA for P-1. Staff C responded, “it is a loose action plan ...” Staff C was asked who would oversee the action plan. Staff C stated that she thought that Quality and Nursing were in charge of the action plan. On 7/16/2025 at 1645 an interview occurred with staff L, the Director of Quality. Staff L was queried about an action plan. Staff L stated an action plan had not been formally established. Staff L stated that due to change in ownership and leadership fall tracers had been stopped at the facility. Staff L further stated that the Lead of the Fall Committee had been absent since the end of May 2025. Staff L stated the last Fall Committee meeting had been held on 6/10/2025, and the fall tracers had been stopped on 5/31/2025 by the direction of the national corporate office.”

“INTEGRATION OF EMERGENCY SERVICES CFR(s): 482.55(a)(2) [If emergency services are provided at the hospital --] (2) The services must be integrated with other departments of the hospital. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to provide timely specialized admission/transfer for 3 (#23, 24, 25) of 11 patients reviewed for psychiatric admission and/or transfer resulting in the delay of specialized services and the potential for poor patient outcomes. Findings include: During the initial tour of the facility on 8/27/2024 at 0920, the Behavioral Health (BH) annex (a locked unit for behavioral health patients in the ED) was toured. Accreditation Specialist Staff E stated the staff in the annex were currently under behavioral health management. On 8/27/2024 at 0959, Confidential Informant #1 stated annex staff were being told by Behavioral Health (BH) Director Staff N and BH Manager Staff O to hold patients in the Emergency Department (ED) up to 24 hours or until given permission by Staff N or Staff O to send packets to outside facilities, even if there were no beds currently available. Confidential Informant #1 stated, “I don’t think it’s good patient care to wait 24 hours to place a patient when there are external beds available.” On 8/28/2024 at 1002, Confidential Informant #2 stated 1N management “has to give permission to look outside of the hospital for a bed. It could be hours or days. We will be written up if the process is not followed.” Review of the medical record for P-23 revealed he was a 38-year-old male who presented to the ED 8/11/2024 at 0042 with a chief complaint of feeling possessed. His wife reported he had increased aggression both verbally and physically. He was evaluated by the screener (a social worker, licensed counselor, or psychiatrist that conducts a mental health evaluation) 8/11/2024 from 1630-1800. The findings were discussed with the ED physician 8/11/2024 at 1700. In an addendum on the BH evaluation dated 8/11/2024 at 1808, documentation states, “This screener did explain that 1 North (1N) currently does not have any beds ...” On 8/11/2024 at 1956, another addendum to the BH evaluation states, “ ...this patient was accepted to 1N by (Physician Staff Q) pending bed availability.” A final addendum to the BH evaluation dated 8/12/2024 at 0943 states, “Accepted to (outside psychiatric facility).” P-23 was transferred to the outside facility 8/12/2024 at 2205. On 8/28/2024 at 1640 review of the BH Facility Placement Log revealed the reason for transfer of P-23 stated, “Accepted by 1N doctor-Per management okay to send out due to length of stay in ED.” In an email dated 8/28/2024 at 1118, Confidential Informant #2 stated, “Patient (#23) was screened in the ED on 8/11 and accepted to 1N on 8/11. However, a bed was never available (sic) and the patient had to then be sent to an external hospital on 8/12 at 2200 after 1N management gave approval to send the patient out.” Review of the medical record for P-24 revealed he was a 32-year-old male who presented to the ED on 8/10/2024 at 1259 with a chief complaint of suicidal ideation. He was also experiencing visual and auditory hallucinations. P-24 was evaluated by the screener on 8/10/2024 from 1700-1845 who documented medical clearance had been achieved. He was accepted as an admit to 1N by Physician Staff Q on 8/12/2024 at 1001. P-24 was admitted to the unit on 8/12/2024 at 1158. No documentation is present on the BH Facility Placement Log regarding the long wait. Confidential Informant #2 stated via email dated 8/28/2024 at 1118, “Patient (#24) was screened in the ED on 8/10 and accepted to 1N on 8/10. However, no beds were available (sic) and the patient had to wait for admission to 1N until 8/12.” Review of the medical record for P-25 revealed he was a 34-year-old male who presented to the ED on 8/3/2024 at 0933 for hearing voices and had been petitioned by the police. BH evaluation was performed by the screener 8/3/2024 from 1600-1930. In an addendum to the BH evaluation on 8/3/2024 at 2035, it states, “ ...patient is accepted to 1N ... There are no available beds on 1N at this time. A packet was created in the event it needs to be sent out ...” The patient was admitted to 1N 8/5/2024 at 1544. No documentation is present on the BH Facility Placement Log regarding the long wait. Confidential Informant #2 stated via email on 8/28/2024 at 1118, “Patient (#25) was accepted to 1N on 8/3. Patient was not admitted to 1N until 8/5 at 1545.” Review of the medical record for P-26 revealed he was a 20-year-old male who presented to the ED on 7/24/2024 at 0038 with a chief complaint of suicidal and homicidal ideation. He was petitioned and the physician signed a clinical certification. BH evaluation performed by the screener was done 7/24/2024 from 0340-0346. Medical clearance was achieved 7/24/2024 at 0628. An addendum to the BH evaluation on 7/25/2024 at 0951 indicated P-26 was accepted for admission on 1N. No documentation is present in the BH Facility Placement Log regarding the long wait. Confidential Informant #2 stated via email on 8/28/2024 at 1118, “Patient was accepted to 1N on 7/24. 1N was full on 7/24 and ED screeners were told by 1N management that the patient would need to wait in the ED until he could be admitted to 1N on 7/25.” On 8/28/2024 at 1127, Confidential Informant #1 provided an email regarding the transfer of P-22 from BH Director Staff N dated 7/24/2024 at 0932 that states, “I need to know why the guideline wasn’t followed where the patient packets aren’t sent anywhere for 24 hours to allow 1N docs to determine if they will accept and 1N to determine when. Being full is not a reason to bypass the 24 hour (sic) process ...” On 8/28/2024 at 1314, BH Director Staff N stated a “disconnect” had been discovered earlier this year in which psychiatric patients in the ED were all being sent out to outside facilities when there were beds available in house. A process was developed which included input from “1N management, providers, and ED leadership” to have patients wait up to 24 hours in the ED for placement in house prior to sending out packets to outside facilities even if there were no beds currently available. “We will not hold a patient if we don’t foresee a discharge within 24 hours.” On 8/28/2024 at 1334, BH Manager Staff O stated the process was for the screener to go to the unit and evaluate the patient and once the need for admission was determined, call the physician to admit. If there were no beds and it was safe, the patient was kept in the ED annex for 24 hours. If a bed was not available within 24 hours, then packets could be sent to outside facilities seeking patient placement. When queried as to if this was a delay in the patient’s treatment, Staff O stated, “We don’t see this as a delay in care.” She further stated the patient was receiving treatment in the ED in the form of vital sign monitoring, safety monitoring, and medication administration. She admitted therapies were unavailable as well as sessions with the psychiatrist regarding their psychiatric concerns. On 8/28/2024 at 1504, Psychiatrist Staff Q stated she had heard about the admission process that was put into place in February 2024 but she was not part of the development of it. She stated if the patient was waiting in the ED and it was known there was no bed available, it was considered a delay in treatment because treatment could begin elsewhere. She stated she worked mostly with the geriatric patients. “The (geriatric) patients need interaction and need to be able to move around. Treatment should be as soon as possible. ED is not the place for that. It needs to be in the least restrictive setting. This practice goes against the Michigan Mental Health Code.” Staff Q was queried as to if the patient were considered stable after being medically cleared in the ED and having the BH evaluation to which she stated they were not stable because they had not yet received treatment. Michigan Mental Health Code 330.1708 states, “Suitable services; treatment enviornment; setting; rights. Sec.708. (1) A recipient shall receive mental health services suited to his or her condition. (2) Mental health services shall be provided in a safe, sanitary, and humane treatment environment. (3) Mental health services shall be offered in the least restrictive setting that is appropriate and available. (4) A recipient has the right to be treated with dignity and respect.” On 8/28/2024 at 1512, ED Medical Director Staff P stated he had voiced concerns about delays to the former ED nursing director. He stated obtaining a bed for the psychiatric patient was a “balancing act” as admission was preferable, and it was unknown how long it might take to get an outside facility to accept. “If we are pretty sure there are no beds available for a certain amount of time, we need to be careful not to hang onto that (patient).” Facility policy #10835619 titled “Admission and Transfer of Emergency Psychiatric Patients” effective 10/2022 states, “It is the policy of [facility name] to provide an appropriate Medical Screening Examination (“MSE”) and stabilizing treatment within its capabilities and capacity and appropriate transfer of all individuals who come to [facility name] Emergency Department seeking evaluation and/or treatment for a psychiatric or mental health condition. 2. It is the policy of [facility name] to comply with EMTALA and Policy - Screening, Stabilization and Transfer of Emergency Patients (EMTALA) in the examination, treatment, admission, and transfer of all individuals who come to [facility name] Emergency Department seeking evaluation and/or treatment for a psychiatric or mental health condition...The MHS [mental health screener] will discuss the case with the Emergency Department physician attending the patient who will review and approve the disposition. As determined to be appropriate by the MHS or Emergency Department physician, the psychiatrist on-call may be consulted to review the case and, if appropriate, examine the patient. A MSE under this Policy shall be conducted by the emergency department physician, the attending physician, or an MHS in consultation with the emergency department or attending physician to determine if an EMC [emergency medical condition] exists. 3. If the emergency department physician or attending physician determines that an EMC exists, the individual shall be provided stabilizing treatment within [facility name] capabilities and capacity or an appropriate transfer in accordance with Screening, Stabilization and Transfer of Emergency Patients (EMTALA) Policy... If [facility name] does not have the capability or capacity to treat the patient’s emergency medical condition, the patient may be transferred to an appropriate facility...” Facility process titled “Admission from ED to 1N” dated 8/7/2024 states, “ED screener completes screen and determines need for inpatient placement...ED Screener calls the admitting doctor for acceptance or denial for next available bed. If no current available bed, screener to escalate to 1N supervisor or manager on call for after hours. Once accepted, ED Screener to call 1N for screener report. BA (Business associate-unit clerk) will get ED Screener report and gather appropriate packet and notify 1N Charge RN of potential admission. 1N Charge RN will determine admission time with coordination of Nursing Supervisor/Manager on call. If admission time is greater than 24 hours, decision to hold will be escalated to leadership for 1N and ED (on call for after hours) 1N Charge RN or designee will notify admitting unit of admission day/time. ED Nurse gives report to 1N Nursing ED calls for Transport Patient Transported and Admitted to 1N””

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to provide a medical screening exam for 2 (#22,26) of 26 patients reviewed and failed to provide appropriate transfer for 5 (#4, 10, 11, 22, 23) of 5 patients reviewed for transfer resulting in the potential for unrecognized, unmet patient needs and the potential for poor patient outcomes. Findings include: See Specific Tags: A-2406 Failure to provide a medical screening exam A-2409 Failure to provide appropriate transfer”

“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 a medical screening exam to 2 (P-22, 26) of 26 patients reviewed resulting in the potential for unmet patient needs and poor patient outcomes. Findings include: Review of the medical record of P-22 revealed she was a 27-year-old female who presented to the Emergency Department (ED) on 7/23/2024 at 0114 with a chief complaint of umbilical abdominal pain with nausea and vomiting for the past 3 days. She was given an ESI (emergency severity index-tool used to determine the acuity of the patient) of 3. The behavioral health indicators in triage indicated P-22 had suicidal ideation and she wished she were dead or could go to sleep and never wake up. She denied thoughts of how to kill herself or preparing to end her life. The suicide risk score indicated she was low risk for suicide. Orders were found for suicide precautions and suicidal discharge instructions. Discharge disposition indicated P-22 left without being seen. The discharge summary where physician documentation would normally be, it was written, “Patient eloped prior to Dr. exam.” Time of discharge was 0146. Incidentally, P-22 returned to the ED 7/23/2024 at 1235 with abdominal pain with nausea and vomiting and suicidal ideation. The behavioral health evaluation dated 7/23/2024 at 1626 stated, “Per the patient she attempted to drown herself in the tub this morning.” P-22 received a petition and clinical certificate and was transferred to an outside psychiatric hospital. Review of the medical record of P-26 revealed he was a 20-year-old male who presented to the ED on 7/23/2024 at 2105 with a chief complaint of suicidal ideation and homicidal ideation. He stated his plan was to jump from a building, and he wanted to “harm his father.” He was triaged at 2124 and placed in the ED waiting room. Review of triage documentation revealed the CSSRS (Columbia Suicide Severity Rating Scale-used to determine risk of suicide) evaluation placed P-26 at high risk for suicide. The VAAC (Violence Aggression Assessment Checklist-used to determine risk for violence) evaluation indicated he was low risk for violence. P-26 did have a past psychiatric history of being bipolar (mood swings), ADHD (Attention Deficit Hyperactivity Disorder-chronic condition including attention difficulty, hyperactivity, and impulsiveness), and depression. It was noted he had been off of his medications for the past three months. Further documentation of ED disposition by the same triage nurse on 7/23/2024 at 2340 stated, “Condition at Discharge: Stable Discharge To: LWBS (left without being seen).” The discharge summary where physician documentation would normally be, it was written, “Patient eloped prior to Dr exam.” Incidentally, P-26 returned to the ED 7/24/2024 at 0038 for suicidal and homicidal ideation. He received a petition and clinical certificate and was admitted to the in-patient psychiatric unit. On 8/28/2024 at 1431, ED Manager Staff A was queried as to what her expectations were regarding a suicidal patient coming in through triage. She stated their practice and her expectation was that someone either sit with the patient or the patient would be brought back to the (ED) room immediately following triage. On 8/28/2024 at 1512, ED Medical Director Staff P stated “a suicidal patient is considered an ESI-2. We try to get them into a room as quickly as possible.” He described the process of the provider quickly evaluating to decide if placement was needed in the main ED for medical clearance or if the patient could be sent to the behavioral health annex (locked psychiatric area of the ED). Review of facility policy #12972721 titled “(facility name redacted) Michigan Emergency Medical Treatment & Active Labor Act (EMTALA) Policy” effective 1/12/2023 states, “Definitions...Emergency Medical Condition - A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: 1. Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or the unborn child) in serious jeopardy... Medical Screening Examination (MSE) - The process required to reach with reasonable clinical confidence the point at which it can be determined whether an Emergency Medical Condition exists. The Medical Screening Examination must be the same Medical Screening Examination that the Hospital would perform on any individual coming to the Hospital’s emergency department with those signs and symptoms, regardless of the individual’s ability to pay for medical care... Qualified Medical Person or Personnel (QMP) - An individual in addition to a licensed physician who is license or certified and who has demonstrated current competence in the performance of Medical Screening Examinations, for example: 1. Registered Nurse in Perinatal Services 2. Psychiatric Social Worker 3. Registered Nurse in Psychiatric Services 4. Psychologist 5. Physician Assistant 6 Advanced Registered Nurse Practitioner 7. Certified Registered Nurse Midwife... Any patient who comes to the Hospital’s Dedicated Emergency Department and requests or has a request made on his or her behalf for emergency examination and treatment or for who a Prudent Layperson Standard would indicate, on the basis of the individual’s appearance or behavior, requires examination or treatment for a medical condition, will be provided an appropriate Screening Examination within the capabilities of the Dedicated Emergency Department including ancillary services routinely available to the emergency department to determine whether an Emergency Medical Condition exists regardless of their ability to pay for medical care...Patients who come to a Dedicated Emergency Department requesting service will receive a triage exam. If the triage exam detects a possible Emergency Medical Condition that needs immediate attention, the patient will be immediately brought to the examining area where the Medical Screening Examination will continue by a physician or Qualified Medical Person. b. The triage exam initiates a Medical Screening Examination, but does not constitute a Medical Screening Examination in and of itself. The Medical Screening Examination extends until the point that the Qualified Medical Person or physician determines that an Emergency medical Condition Does not exist... When an individual presents with psychiatric symptoms, the Medical Screening Exam should include an assessment of suicide or homicide attempt or risk, orientation, or assaultive behavior that indicates danger to self or others. When the Hospital determines that an individual poses a danger to self or others, this is considered an Emergency Medical Condition.””

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to indicate staffing and equipment resources required during transfer for 5 (P-4, 10, 11, 22, 23) of 5 patients reviewed for transfer resulting in the potential for unrecognized, unmet patient needs and poor patient outcomes. Findings include: Review of the medical record for P-4 revealed she was a 54-year-old female who presented to the Emergency Department (ED) on 7/3/2024 at 1506 after being petitioned by police for paranoia. Following her medical and behavioral health (BH) evaluations, it was determined the patient needed to be transferred to an outside psychiatric hospital. Review of the transfer documentation revealed there was no indication present of what staff or equipment resources were needed for the transfer. Review of the medical record for P-10 revealed she was a 69-year-old female who presented to the ED on 7/10/2024 at 0142 with a chief complaint that read “D/C (discharge) to inpatient and then they realized they didn’t have a bed so they sent her back waiting (sic) for placement.” A review was conducted of her previous visit which started on 7/6/2024 at 1651 when she had presented to the ED in police custody in “CRISIS” and “suicidal.” P-10 was medically cleared and had her BH evaluation on 7/7/2024 at 1730. On 7/7/2024 at 2039, packets were sent to multiple outside psychiatric hospitals seeking admission placement. She was accepted to a psychiatric hospital in Indiana. Review of the transfer documentation revealed there was no indication present of what staff or equipment resources were needed for the transfer. Further review of P-10’s medical record indicated the medical clearance was rescinded on 7/8/2024 at 1030 as some lab values came back abnormal and needed to be addressed. The transfer was cancelled at that time. Medical clearance was reinstated 7/9/2024. The transfer process was started again, and the patient was accepted 7/9/2024 at 0911 at another psychiatric facility (same hospital system as the original accepting hospital) in Indiana. It was noted the transfer document was also re-done and still did not include staff or resources needed for the transfer. Review of the medical record for P-11 revealed she was a 50-year-old female who presented to the ED 7/10/2024 at 0910 with a chief complaint of suicidal ideation without a plan. Following medical clearance and a mental health screening, it was determined she would be transferred to an outside psychiatric facility. Review of transfer documentation revealed there was no indication present of what staff or equipment resources were needed for the transfer. Review of the medical record for P-22 revealed she was a 27-year-old female who presented to the ED on 7/23/2024 at 1235 with a chief complaint of abdominal pain with nausea and vomiting and suicidal ideation. Following medical clearance and mental health screening, it was determined she would be transferred to an outside psychiatric facility. Review of transfer documentation revealed there was no indication present of what staff or equipment resources were needed for the transfer. Review of the medical record for P-23 revealed he was a 38-year-old male who presented to the ED on 8/11/2024 at 0042 with a chief complaint of feeling possessed. Following medical clearance and mental health screening, it was determined he would be transferred to an outside psychiatric facility. Review of transfer documentation revealed there was no indication present of what staff or equipment resources were needed for the transfer. On 8/28/2024 at 1512, ED Medical Director Staff P stated the provider was to complete the risks/benefits of transfer, the accepting physician, the hospital to which the patient was being transferred and sign the transfer form. Other staff would finish filling out the form. Facility policy #12972721 titled “(facility name redacted) Michigan Emergency Medical Treatment & Active Labor Act (EMTALA) Policy” effective 1/12/2023 states, “An appropriate transfer is a transfer in which...The transfer is completed through the appropriate medical personnel and utilizing the appropriate equipment for the patient... The physician or Qualified Medical Person shall complete the “TRANSFER FORM” prior to transfer.””