Pine Rest Christian Mental Health Services

“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 record review and interview, the facility failed to ensure nursing staff adhered to the policies and procedures of the facility and failed to identify the medical decline of 1 (P-1) of 10 patients reviewed resulting in poor outcomes of P-1 and the potential for poor outcomes for patients with medical decline. Findings include: See Tag A-0398 Failure to ensure nursing staff adhere to policy”

“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: 29955 Based on interview and record review, the facility failed to ensure nursing and support staff adhered to the policies and procedures of the facility and failed to identify the medical decline of 1 (P-1) of 10 patients reviewed resulting in poor outcomes of P-1. Findings include: On 3/18/2026 at 1522 a review of P-1’s chart revealed she was a 59 year old female admitted involuntarily on 10/11/2025 with schizoaffective disorder, bipolar type, and medical comorbidities including diabetes and congestive heart failure. On 11/6/2025 at 1257, physician progress notes documented P-1 as, “unresponsive and hyper somnolent with a blood glucose of 34. A code blue was initiated. Vital signs included O2 saturation 89%, HR 69, BP 116/68. She was placed on 2 L nasal cannula oxygen and given two 1 mg glucagon injections.” P-1 was transferred to the local emergency department (ED) for evaluation of a possible stroke. P-1 returned to the facility on 11/7/2025. Provider notes on 11/3/2025 documented progressive weight gain (42 lbs) during P-1’s admission. Weight records showed: 193 lb (10/11/25 admission), 215 lb (10/31/25), 217 lb (11/01/25), 221 lb (11/03/25), 215 lb (11/05/25), 235 lb (11/15/25) On 11/16/25 at 1823 staff H, Registered Nurse (RN) documented, “(P-1) has been presenting this evening with bizarre and illogical presentation. Somatic complaints of feeling unsteady and feeling like she’s going to fall. (P-1) was observed throwing herself back from her walker to mimic unsteadiness. 1:1 ATC (Around the Clock) added due to high fall risk and attempting to throw self off balance. Asking staff to hold her while she walks. She has been periodically having no issues [SIC] with walking through this shift. Focused on receiving help from staff will [SIC] almost all basic tasks such as opening drinks, food trays, walking, and pushing a chair up to her to sit down. Staff will continue to monitor.” On 11/16/25 at 2213, Staff G, RN, documented, “Patient was laying in bed prone with her head laying on her pillow turned towards the door. (P-1) is alert and orientated to person. When patient was asked to tell this writer her name. Patient lifted up her head and spelled out (P-1) then laid her head back down closed her eyes and began to snore. When patient was asked how her mood has been. (P-1) opened her eyes and this writer could not make out what (P-1) response was. Patient was unable complete assessments due to cognitive impairments. (P-1) took her scheduled HS medications whole in yogurt with sips of water in between. Patient did not utilize any PRN (as needed) medications this evening. Patient needed reminders and extensive to dependant [SIC] assistance from her assigned 1:1 ATC staff for poor safety awareness and decline in function a near fall intervention. (P-1) would attempt to roll off of edge of her bed and her 1:1 assigned staff step in to prevent (P-1) from [SIC] (P-1) did not have any complaints of pain or discomfort this evening. (P-1) vitals signs taken and her heart rate was 43 when taken with vitals machine. Heart rate was 89 when taken via apical heart rate.” During an interview with staff G, RN, on 3/19/26 at 0915 she explained her assessment of P-1 stating, “She couldn’t say her name...wouldn’t say more than one or two words...needed assistance to go to the bathroom. I called the other night shift nurse to come help assess her (P-1). During shift change when I was coming on it was reported to me that she was having difficulty walking. I called medical provider to send her out.” P-1 was sent to an emergency department on 11/17/25 at 0023 via ambulance. On 3/19/26 at 0931, an interview was conducted with Staff H, RN, who explained that on 11/16/25, P-1 had “no significant changes from her normal,” but had reported that the floor felt “slanted and a little more unstable than usual.” Staff H stated that he assessed P-1 using neuro checks per stroke protocol. He also stated that he contacted the provider to report the changes. On 3/19/26 at 1311 a Root Cause Analysis (RCA) was presented by staff C, Director of Nursing for Adult Inpatient units. According to the action plan presented nursing staff were going to be scheduled for facility led training sessions. Staff C stated the plan was for all nurses to attend the mandatory first grand round session, but subsequent educational sessions offered would be optional. Staff C started to read the focused list of medications that staff would be educated on. The first three sessions were focused on psychiatric medications with no mention of diabetic medications, medical care of a declining patient, or tracking daily input and output of patients. Staff C was asked what the RCA identified...was there areas of improvement in the psychiatric care or the medical care of patients. Staff C stated that medical care was the area in need of improvement. Educational materials for the educational sessions were not available at the time of survey. On 3/19/26 at 1400 a policy titled, “Medical Decline in Hospitalized Patients, HRS 10/326,” policy #16020433, last revised 10/2024. According to the policy an explanation for the policy revealed, “Patients’ clinical condition may suddenly deteriorate without explanation while the patient remains conscious and/or verbally responsive. These sudden changes in clinical status do not warrant a code blue, however rapid clinical response is indicated. Responses to a patient’s clinical deterioration may vary depending on the body system involved and/or the potential criticality of manifest symptoms. (Facility) is not a medical facility and, therefore, responds to conditions in a less acute state in order to assure the highest level of care for our patients.” Also revealed were conditions that would trigger a “Rapid Response” for a team of medical professionals to respond to which included: Altered level of consciousness - Confusion, Delirium, Somnolent, Obtunded, Stuporous, Comatose Signs of stroke - Weakness, numbness, blurred vision, slurred speech, facial droop/drop.”