M Health Fairview University of MN Medical Center

“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: 40945 Based on interview and document review, the hospital failed to ensure an allegation of neglect was reported to the state agency for 1 of 1 patients (P1) reviewed. P1 used a razor to self-harm that was not detected during the initial patient search when admitted to the mental health unit. The facility took immediate action of patient search procedures to prevent further incidents of patient self-harm. Findings include: P1’s medical records indicated P1 was admitted to the facility on 2/6/26, at 4:42 a.m. with a primary diagnosis of suicide attempt, self-injurious behaviors, and laceration of upper extremity. P1’s additional diagnoses included generalized anxiety disorder and borderline personality disorder. P1 was discharged from the facility on 2/18/26. A nursing note dated 2/14/26, at 11:17 p.m. indicated at approximately 6:40 p.m. P1 approached staff with a razor blade in hand and appeared to be bleeding from bilateral forearms. A rapid response code was called. A Pediatric Surgery Consultation Note dated 2/14/26, at 10:32 p.m. indicated P1 engaged in self-injurious behavior this evening using a razor blade that she had hidden in her waistband. On exam, P1 has a 4-centimeter (cm) laceration to the lateral surface of her left upper arm, multiple superficial lacerations to the volar surface of her left forearm, and multiple superficial and deep lacerations to the volar surface of her right forearm. During an interview on 7/7/26, at 11:31 p.m. with the Chief Nursing Officer (CNO) and System Program Manager of Regulatory & Accreditation, CNO verified on 2/14/26, P1 did sustain significant injury which required laceration repair. For patient safety items such as razor blades are not permitted to be in patients’ possession. During the initial search of the patient’s body and personal belongings the razor should have been identified and locked up for patient and staff safety. Per the facility policy the incident which occurred on 2/14/26 involving P1 should have been reported per facility policy to the state agency. A facility policy titled Restricted Items and Access, Mental Health and Addiction dated 9/30/2024, indicated the policy purpose included staff to follow this list for restricted access items in mental health and addiction areas to reduce harm. “Absolutely No Access Items: Items NOT available for patient use throughout hospitalization due to serious harm. These items will be sent home, to security, or labeled and locked in a secure area on unit, depending on the item. The list included Personal razors (straight edge or electric, not supplied by hospital). A facility policy titled Mandated Reporting to the Office of the Ombudsman for Mental Health and Developmental Disabilities dated 12/3/2021, the policy statement included “It is the policy of M Health Fairview to accurately and in a timely manner report incidences of serious injury or death of a patient pursuant to applicable law”. The purpose of the policy is “To ensure compliance with the MN Statute regarding the reporting of death or serious injury to individuals receiving services for mental illness, developmental disability, chemical dependency or emotional disturbance”. The policy outlines serious injury to include “All other injuries considered serious by a physician including, but not limited to: Complication of previous injury, Complication of medical treatment and Self-injurious behavior”.”

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 40945 Based on observation, interview and document review, the hospital failed to maintain kitchen coolers and sanitation of the food preparation areas in the kitchens contributing to the hospital cockroach control problem. This had the potential to affect all patients, visitors and employees who received food provided from the kitchen. As a result, the hospital was found out of compliance with the Condition of Participation of Physical Environment at 42 CFR 482.41. A condition level deficiency was issued at A0701. See A0701for additional information.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 40945 Based on observation, interview and document review, the hospital failed to maintain kitchen coolers and sanitation of the food preparation areas in the kitchens contributing to the hospital cockroach control problem. This had the potential to affect all patients, visitors and employees who received food provided from the kitchen. Findings include: On 9/23/25, at 10:35 a.m. during a tour of the East Bank lower-level kitchen with patient nutrition manager (PNM) and operations manager for kitchen and nutritional department (OM) the following sanitation problems were observed: - The floor surfaces in food prep area were noted to have substantial amounts of dirt, grease, and food debris on the floor throughout the entire area where food is prepped. - The floor surface in the area where food is cooked was noted to have a large amount of dirt, grease, and food debris throughout the entire area where food is cooked. Including under all kitchen appliances and prep tables. - The six-burner gas range was noted to have substantial amounts of thick layer of black grease-like substance on the actual burners and on sides of stove. -The side of the oven/warmer next to the range was noted to be covered in a thick layer of grease-like substance, food debris and food/grease splatter. -A large flat top grill was noted to have a thick layer of grease down the sides and under the grill. - A total of 6 coolers in the main kitchen area were pulled out and were noted to have substantial amounts of dirt, crumbs, and food debris underneath all coolers inspected. - Underneath a stainless-steel prep table a cockroach trap was noted, approximately 20 dead roaches were on the trap as well as 2 live cockroaches. On 9/23/25, at 11:32 a.m. PNM confirmed the above noted findings. On 9/23/25, at 11:38 a.m. executive chef stated the floors in the entire kitchen area were filthy. It has been a battle between kitchen staff and environmental services staff (EVS). Kitchen staff are to be pulling up the black mats and clean under them, however that is also not being done. EVS staff are responsible to clean the floors including under the coolers, prep tables and stoves. The cleaning is not being done as instructed and the floors in the entire kitchen are filthy. Failure to maintain a clean environment, including the floors is contributing to the cockroach problem. During an interview on 9/23/25, at 11:43 kitchen staff (KS)-A stated no one is currently cleaning the kitchen floors, including under the cooler, stoves, and coolers. KS-A stated EVS is responsible for cleaning the floors in the entire kitchen are, however, this is not being completed. The floors are always filthy. Cockroaches are an ongoing problem in the kitchen. During an interview on 9/23/25, at 11:53 a.m. KS-A stated kitchen floors including under the stoves, coolers and prep tables are EVS’s job not kitchen staff. The condition you see the floors in today is how it always is. The floors are always filthy. Cockroaches are an ongoing problem in the kitchen. During an interview on 9/23/25, at 12:02 p.m. KS-C stated the kitchen floors are filthy. He does not know the last time they were cleaned. Cockroaches are a problem in the kitchen they run around on the floors and walls. On 9/23/25, at 12:12 p.m. during a tour of the East Bank upper-level kitchen with patient nutrition manager (PNM) and operations manager for kitchen and nutritional department (OM) the following sanitation problems were observed: - The floor surfaces in food prep area were noted to have substantial amounts of dirt, crumbs, and food debris on the floor throughout the entire area where food is prepped. - The floor surface in the area where food is cooked was noted to have a large amount of grease, dirt, crumbs, and food debris throughout the entire area where food is cooked. - The six-burner gas range was noted to have substantial amounts of thick layer of black grease-like substance on the actual burners and on sides of stove. -The side of the convection oven next to the range was noted to be covered in a thick layer of grease-like substance, food debris and food/grease splatter. -The large flat top grill was noted to have a thick layer of grease down the sides and under the grill. -An area where a cooler was pulled out the day prior was noted on the floor tile to have thick black grease approximately 4 feet by 4 feet in diameter of thick black grease substance. Also noted was a substantial amount of thick dust going up the wall approximately 6 feet in height. - The cooler in the pizza area of the kitchen was noted to have a temperature of 45 degrees. When the cooler door was opened a large amount of ice buildup was noted directly above food containers. Water was noted to be dripping on top of the food containers and leaking inside the actual food containers. - In the cooler there was also mushrooms which had an expiration date of 9/19, homemade salad dressing expiration date of 9/18, and chili expiration date of 9/19. On 9/23/25, at 12:30 p.m. PNM confirmed the above noted findings. During an interview on 9/23/25, at 12:31 PNM stated all the food needed to be thrown out including the expired food items. PNM stated the kitchen floors and kitchen was filthy. Temperatures for coolers need to be under 40 degrees for food safety. Temperatures above 40 degrees, expired food, and water from ice buildup in food may lead to food borne illness. All food prepared in the pizza area need to be thrown out. During an interview on 9/23/25, at 12:37 executive chef stated work orders have been submitted for EVS to clean, however the work request still has not been addressed. The grill line needed to be shut down due to the condition of the kitchen. The floors are filthy, covered with dirt, grease, food debris and dust, we are shutting the line down. During an interview on 9/23/25, at 2:21 p.m. pest control technician stated he provides pest control weekly to the East kitchen for routine pest control including spraying for cockroaches. The kitchen needs a cleaning. Grease, and food is contributing to the cockroach infestation. The facility has been educated on the fact that this species of cockroaches feed on grease and food and cleaning the floors and pulling out equipment is important. During an interview on 9/24/25, at 2:23 p.m. dietary director stated she was responsible for both East and West banks kitchens. Cockroaches in the east bank has been an ongoing concern and pest control comes weekly if not more often. She has been made aware of the issue with EVS not completing the nightly cleaning the East bank kitchens. The current condition was filthy and unacceptable. The responsibility to ensure a clean and sanitary kitchen falls on both EVS staff and kitchen staff and no one is being held accountable. Failure to ensure a clen and sanitary environment in the kitchen can lead to foodborne illnesses. Failure to maintain adequate temperatures for food storage and serving expired foods also could lead to foodborne illness for patients, staff, and visitors. Audits of cleaning logs revealed staff are not completing the tasks nor are they filling out the cleaning log and signing off. There is failure on both staff and management. During an interview on 9/24/25, at 1:20 p.m. environment services (EVS) director stated part of his duties and responsibilities is to ensure the hospital is clean in accordance with standards and guidelines. A clean environment is important to reduce the risk of infection and keep patients safe. EVS is responsible for cleaning of the kitchen. Made aware of the condition of Easts kitchens. Cleaning of the kitchens is not being properly completed or completed at all due to the volume of work. The quality of the cleaning is something that needs to be worked on. The amount of dirt and grease buildup was substantial. For us as leaders this is a learning opportunity. We need to be completing weekly checks to make sure cleaning is being completed, including pulling out all equipment. The condition of the kitchen there would be a concern for food born illness. This is not our standard of cleanliness. A training manual titled Sanitation Guidelines for Food Operations dated 6/2022, indicated the purpose of a sanitation program is to provide a clean and sanitary environment for the handling of food products. Cleaning means removing food and other types of soil from a surface. A surface could be a pot or a countertop or a can opener or a cutting board or a wall or floor. Sanitizing means reducing the number of microorganisms to safe levels. All surfaces that come in contact with food must be cleaned and then sanitized. A training manual titled Food Safety Policies and Standards dated 5/31/25, indicted all retail food establishments/food operations are required to adhere to the food safety standards described in the Sodexo Food Safety Management System Manual. The training indicated the storage contents are maintained at temperatures at or below 40°F (4°C). A cleaning schedule must be created and utilized. Identifying what is to be cleaned, frequency, and what equipment/cleaning agents to be used. The premises must be maintained free of insects, rodents, and other pests. Any recommended action by the PCO must be completed and documented. A policy and procedure manual titled Environment of Care Program dated January 2025, indicated the hospital establishes and maintains a safe, functional environment. Leader are to identify individual(s) to intervene whenever environmental conditions immediately threaten life or health, threaten to damage medical equipment or buildings, and will complete the following: manage risk, coordinate risk reduction activities in the physical environment, collect deficiency information, and disseminate summaries, actions, and results.”

“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: 48040 Based on observation, interview, and document review, the facility failed to identify and implement discharge plans for transportation arrangements for 1 of 10 residents (P1) reviewed for discharge planning. P1, who had a documented mental health diagnosis including hallucinations and delusions resulting in cognitive impairment, was discharged without transportation to their assisted living residence. As a result, P1 went missing for approximately 24 hours before being located by law enforcement and returned to the facility. Findings include: P1’s admission Record dated 7/7/25, indicated P1’s diagnoses included schizophrenia (mental health conditions with hallucinations, delusions, eccentric speech and behavior, and diminished emotional expression and purposeful activity), suicidal ideation, and auditory hallucinations (hearing things that are not there). On 7/7/25 at 7:34 p.m., P1’s medical record indicted P1 arrived at the emergency department (ED) via emergency medical services (EMS) experiencing suicidal ideation and auditory hallucinations. P1 was a patient at an assisted living. On 7/7/25 at 7:41 p.m., P1’s medical record indicated it was appropriate for P1 to be discharged, return to the assisted living facility, and follow up with community providers for treatment, safety and medication management. On 7/7/25 at 10:38 p.m. P1’s medical record indicated nursing staff gave P1 the discharge paperwork, and he left the hospital before transportation could be arranged back to his assisted living facility (ALF), and his whereabouts were unknown. On 7/8/25 at 11:12 a.m. a medical doctor (MD)-A note indicated P1 lives in assisted living facility and recommended him to be discharged back to his group home (ALF). On 7/14/25 at 11:45 a.m., a review of the video footage outlined a registered nurse (RN)-A gave P1 discharge paperwork and his belongings, and then P1 was escorted by security officer (SO)-B who opened the exit door for him, and P1 left the ED on foot. On 7/14/25 at 3:12 p.m., Security Officer (SO)-B stated when patients get discharged, they had to show at the exit door their discharge documents with a “green sticker” marker. The SO would then open the door for them to leave. SO-B stated it is not a requirement in the ED department to ask about a transportation arrangement prior to opening the door for a discharged patient with a “green sticker”. SO-B stated he did not check with the nursing staff if P1 was ready to be discharged but assumed it was fine since he had the “green sticker”. On 7/14/25 at 3:40 p.m., RN-A stated he was P1’s nurse during his hospitalization. RN-A stated he gave the discharge instructions document to P1 with his belonging upon request. RN-A stated he called the ALF and got confirmation P1 was in their system. RN-A stated the assessor social worker (SW)-A asked him to set up a ride for P1. RN-A stated P1 left ED before he could arrange a transportation back to his assisted living facility for him. RN-A stated he did not receive education about safe discharge planning recently. On 7/15/25 at 10:20 a.m. the nurse manager at the ALF, RN-F stated P1 called the police after 24 hours of being missing on 7/8/25 and was located at a McDonald’s on Hennepin and Lake Street which was about 2.1 miles from the hospital. He was picked up from the McDonald’s and brought to Waconia and Ridgeview Hospital. RN-F stated P1 did have delusions, paranoia, and was at a high risk for personal safety when alone. RN-F stated she was afraid something could have happened to P1 when they were alone. RN-F stated P1 thought he had to walk back to the facility from the hospital. The ALF staff picked him up from the Waconia and Ridgeview Hospital and brought him back to the assisted living facility on 7/8/25 at 10:35 p.m. P1 had not sustained any physical injuries. On 7/15/25 at 11:07 a.m., SW-A stated she did the diagnostic evaluation center (DEC) assessment on P1 and called the assisted living facility to verify the address. SW-A stated she sent a message and provided an address for RN-A to set up a transport for P1. SW-A stated when she asked RN-A where he sent P1, RN-A replied P1 was gone. SW-A stated she called the attending physician (MD)-A who informed the charge nurse about a missing vulnerable adult situation. SW-A stated missing adult alert was initiated at that time and she heard overhead speaker with P1 description in the alert. On 7/15/25 at 12:06 p.m. SW-B stated SW-A sent her a message referring to a miscommunication within the ED which had let the security officer to walk out P1 to the exit door. SW-B stated there was a lack of clarity if the ED had arranged the transportation or not. SW-B stated transportation should always be arranged for patients discharging back to group homes (AL) which did not occur. On 7/15/25 at 12:21 p.m., RN-B stated when he got a call from MD-A he went to talk to RN-A who said he gave P1 his discharge paperwork and his belongings and P1 was gone when he came back. RN-B stated RN-A did not arrange transportation for P1 and should have done this--along with not giving P1 a green sticker to be released from the ED. RN-B stated if someone needs to wait for transportation they wait until transport shows up before giving to the patient the discharge document with the green sticker. RN-B stated he called SO-C to initiate a missing vulnerable adult alert and called the police who showed up at the ED to get P1’s description. RN-B stated he directed RN-A to notify the ALF and to file an incident report. RN-B stated for any patients from a group home (ALF), nursing staff must arrange the transportation for them and notify the group home about their discharges and arrival time. RN-B stated RN-A was a pool nurse and did not know the process for group home patients. RN-B stated patients from (ALF) should remained at the ED pending their transport arrangement. On 7/16/25 at 1:06 p.m., MD-A stated he spoke to the charge nurse, RN-B about P1 missing and he initiated a vulnerable adult missing alert. MD-A stated he ordered DEC assessment for P1, and a final disposition ordered for his discharge with a transportation arrangement back to his group home. MD-A stated the normal process would be to set up a ride for patients regardless of their legal guardian status from a group home (AL) so they would return safely. On 7/16/25 at 2:09 p.m. SO-C stated when he became aware of P1’s missing, he asked dispatch to initiate a missing adult alert and then reviewed the video, which showed P1 had his discharge paperwork with a green sticker, and he was let out by one of the security officers. SO-C stated the clinical staff should have communicated with the security department about P1’s need for transport back to his ALF. SO-C stated nurses should not give the discharge document with a green sticker to patients from ALF if they did not make any transportation arrangement yet. On 7/16/25 at 9:42 a.m., RN-C stated after the provider gave the discharge instructions to the patient from a group home, nursing staff should communicate with the security department for P1’s need of transportation back to the facility. RN-C stated nurses must wait for the transportation before giving the discharge document with a green sticker to the patient from (ALF). 7/16/25 at 4:02 p.m., the ED nurse manager, RN-E stated if the nursing staff were aware that P1 came from ALF, they should have set up transportation for his return to his facility. RN-E stated he did not know if RN-A was told to set up a ride for P1. RN-E stated he did not do anything to address the issue with P1’s discharge planning. RN-E stated he had not been provided any discharge planning review education when the ED staff discharge patients back to the nursing facilities. The facility Discharge Planning Policy dated 1/8/24 indicated the discharge planning is a coordinated interdisciplinary process that begins as early as possible in the patient’s treatment and results in the identification of discharge needs, development, implementation, and coordination of a discharge care plan that meets the patient needs included when needed, transportation arrangement in a timely manner.”

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 48040 Based on document review, the hospital failed to ensure a system for informing patients of their right to formulate an advanced directive at emergency department during admission for 5 of 10 patients reviewed for advanced directives. Findings include: P3’s Admission Default Flowsheet Data dated 7/7/25, indicated P3 did not have an advanced directive. P3’s flowsheet lacked evidence advance directive information was provided. P4’s Admission Default Flowsheet Data dated 7/7/25, indicated P4 did not have an advanced directive. P4’s flowsheet lacked evidence advance directive information was provided. P5’s Admission Default Flowsheet Data dated 7/7/25, indicated P5 did not have an advanced directive. P5’s flowsheet lacked evidence advance directive information was provided. P7’s Admission Default Flowsheet Data dated 7/8/25, indicated P7 did not have an advanced directive. P7’s flowsheet lacked evidence advance directive information was provided. P8’s Admission Default Flowsheet Data dated 7/10/25, indicated P7 did not have an advanced directive. P8’s flowsheet lacked evidence advance directive information was provided. On 7/14/25 at 11:45 a.m., a registered nurse (RN)-D stated admission nurses provided the advance directive notice to the patients during an admission and documented in the admission navigator but was not a requirement at the emergency department. On 7/14/25 at 11:45 a.m., RN-E (emergency department [ED] manager) stated he was unable to verify whether P3, P4, P5, P7, and/or P8 had received the required advanced directive information at the time of admission. RN-E stated advanced directives spot was in the admission tool but was not a requirement in the emergency department to offer an advanced directive information at the time of admission. On 7/14/25 at 3:20 p.m., a system program manager (SPM)-D stated there were workgroup and plan in motion to update their Advance Care Planning (ACP) and Advance Directive policy and the corresponding practice to match the regulation which required Advance Directive information should be offered to all patients presented to the emergency department but were not finalized yet. The hospital Advance Care Planning (ACP) and Advance Directives policy dated 1/20/22 and reviewed on 11/05/24 directed admission nurses to review the medical record and document the presence of an Advance Directives in the admission navigator. The policy further directed nurses to provide a health care directive information at the time of any inpatient admission and documented in the admission navigator. State Operations Manual (SOM) states Advanced Directive information should also be given to all patients presenting to the ED and must be documented in the patient’s medical record.”

“DISCHARGE PLANNING - MD REQUEST FOR PLAN CFR(s): Upon the request of a patient’s physician, the hospital must arrange for the development and initial implementation of a discharge plan for the patient. This Standard is not met as evidenced by: 48040 Based on observation, interview, and document review, the facility failed to implement discharge need for transportation arrangements for 1 of 10 residents (P1) reviewed for discharge planning. As a result, P1 went missing for approximately 24 hours before being located by law enforcement and returned to the facility. Findings include: P1’s admission Record dated 7/7/25, indicated P1’s diagnoses included schizophrenia (mental health conditions with hallucinations, delusions, eccentric speech and behavior, and diminished emotional expression and purposeful activity), suicidal ideation, and auditory hallucinations (hearing things that are not there). On 7/7/25 at 7:34 p.m., P1’s medical record indicted P1 arrived at the emergency department (ED) via emergency medical services (EMS) experiencing suicidal ideation and auditory hallucinations. P1 was a patient at an assisted living. On 7/7/25 at 7:41 p.m., P1’s medical record indicated it was appropriate for P1 to be discharged, return to the assisted living facility, and follow up with community providers for treatment, safety and medication management. On 7/14/25 at 11:45 a.m., a review of the video footage outlined a registered nurse (RN)-A gave P1 discharge paperwork and his belongings, and then P1 was escorted by security officer (SO)-B who opened the exit door for him, and P1 left the ED on foot. On 7/14/25 at 3:40 p.m., RN-A stated he was P1’s nurse during his hospitalization. RN-A stated he gave the discharge instructions document to P1 with his belonging upon request. RN-A stated he called the ALF and got confirmation P1 was in their system. RN-A stated the assessor social worker (SW)-A asked him to set up a ride for P1. RN-A stated P1 left ED before he could arrange a transportation back to his assisted living facility for him. RN-A stated he did not receive education about safe discharge planning recently. On 7/15/25 at 10:20 a.m. the nurse manager at the ALF, RN-F stated P1 called the police after 24 hours of being missing on 7/8/25 and was located at a McDonald’s on Hennepin and Lake Street which was about 2.1 miles from the hospital. He was picked up from the McDonald’s and brought to Waconia and Ridgeview Hospital. RN-F stated P1 did have delusions, paranoia, and was at a high risk for personal safety when alone. She was afraid something could have happened to P1 when they were alone. RN-F stated P1 thought he had to walk back to the facility from the hospital. The ALF staff picked him up from the Waconia and Ridgeview Hospital and brought him back to the assisted living facility on 7/8/25 at 10:35 p.m. P1 had not sustained any physical injuries. On 7/15/25 at 11:07 a.m., SW-A stated she did the diagnostic evaluation center (DEC) assessment on P1 and called the assisted living facility to verify the address. SW-A stated she sent a message and provided an address for RN-A to set up a transport for P1. SW-A stated when she asked RN-A where he sent P1, RN-A replied P1 was gone. SW-A stated she called the attending physician and a missing vulnerable adult alert was initiated. On 7/15/25 at 12:06 p.m. SW-B stated SW-A sent her a message referring to a miscommunication within the ED which had let the security officer to walk out P1 to the exit door. SW-B stated there was a lack of clarity if the ED had arranged the transportation or not. SW-B stated transportation should always be arranged for patients discharging back to group homes (AL) which did not occur. On 7/15/25 at 12:21 p.m., RN-B stated RN-A did not arrange transportation for P1 and should have done this--along with not giving P1 a green sticker to be released from the ED. RN-B stated if someone needs to wait for transportation they wait until transport shows up before giving to the patient the discharge document with the green sticker. RN-B stated any patients from a group home (ALF), nursing staff must arrange the transportation for them and notify the group home about their discharges and arrival time. RN-B stated RN-A was a pool nurse and did not know the process for group home patients. RN-B stated patients from (ALF) should remained at the ED pending their transport arrangement. On 7/16/25 at 1:06 p.m., MD-A stated he spoke to the charge nurse, RN-B about P1 missing and he initiated a vulnerable adult missing alert. MD-A stated he ordered DEC assessment for P1, and a final disposition ordered for his discharge with a transportation arrangement back to his group home. MD-A stated the normal process would be to set up a ride for patients regardless of their legal guardian status from a group home (AL) so they would return safely. The facility Discharge Planning Policy dated 1/8/24 indicated the discharge planning is a coordinated interdisciplinary process that begins as early as possible in the patient’s treatment and results in the identification of discharge needs, development, implementation, and coordination of a discharge care plan that meets the patient needs included when needed, transportation arrangement in a timely manner.”

“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: 47264 Based on observation, interview, and document review, the facility failed to ensure staff followed infection control measures for one of ten patients (P7) reviewed when staff provided direct patient care to a patient on contact precautions without using the required personal protective equipment (PPE). As a result, the hospital was found out of compliance with the Conditions of Participation Infection Prevention and Control and Antibiotic Stewardship Programs at 42 CFR 482.42. A condition level deficiency was issued at A0747. See A0749 see for additonal information.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 47264 Based on observation, interview, and document review, the facility failed to ensure staff followed infection control measures for one of ten patients (P7) reviewed when staff provided direct patient care to a patient on contact precautions without using the required personal protective equipment (PPE). Findings include: During an observation of the cardiovascular intensive care unit (CVICU) on 3/31/25 at 9:53 a.m., an isolation cart stocked with gloves, reusable gowns, surgical masks, and eye protection was sitting directly outside P7’s. The sign on the left of the doorway indicated “Contact Precautions. Everyone must clean hands before entering, and after exiting. Staff entering beyond the swing of the door must. Before entering: Put on gown. Put on gloves. Before exiting: Take off gown. Take off gloves.” The curtain was drawn, and three sets of feet could be seen around a wheelchair. When the curtain opened, three direct care staff members, including registered nurse (RN)-A, were readjusting P7 in a wheelchair at the bedside. None of the staff members were wearing reusable contact precaution gowns but all were wearing gloves. While at the entrance of P7’s room, RN-A spoke with another staff member, pulled her hospital phone out of her scrub pockets, and began a conversation over the phone. RN-A had not exited P7’s room and her gloves were not doffed. The two other staff members removed their gloves and performed hand hygiene with foaming hand sanitizer prior to leaving the room. At 9:57 a.m., RN-A exited P7’s room, with gloves on, and donned a reusable contact precaution gown, then reentered the room. RN-A hung up the phone and put it back into her pocket. At 9:59 a.m. another staff member donned a reusable gown and gloves, entered P7’s room, and then escorted P7 off the unit. RN-A doffed her reusable gown and disposed of her gloves, performed hand hygiene with foaming hand sanitizer, and then entered another patient room. P7 was a 60-year-old female who admitted directly to the medicine/surgery unit of the hospital on 3/25/25 at 10:02 a.m. for planned perioperative antibiotic treatment. P7’s relevant medical diagnoses include chronic respiratory failure, ataxia, coordination impairment, history of cerebrovascular accident, unilateral hemiparesis, obesity, nephrolithiasis, and left-sided nephrostomy tube. An order for contact isolation dated 3/25/25 indicated P7 was on continuous contact isolation. The contact order did not identify the medical indication. On 3/26/25 at 4:53 p.m., P7 underwent a urologic procedure to remove an obstructive ureteral stone, placement of a ureteral stent, and removal of the left-sided nephrostomy tube. No complications were noted. On 3/26/25 at 6:57 p.m., P7 was transferred to the post anesthesia care unit. On 3/26/25 at 9:12 p.m., P7 was transferred to the medical/surgical unit. A rapid response team note indicated on 3/26/25 at 11:05 p.m. a rapid response was initiated for a P7’s critical lab values with concerns for septic shock. The rapid response concluded on 3/27/25 at 1:50 a.m. On 3/27/25 at 1:34 a.m., P7 was transferred to the CVICU. A provider note dated 3/29/25 at 10:14 a.m. indicated cultures collected during P7’s surgery on 3/27/25 were positive for Escherichia coli extended spectrum beta lactamase (ESBL) and gram-negative bacilli. The note indicated ESBL producing organisms require contact precautions. A nursing note dated 3/30/25 at 5:45 a.m. indicated P7 had two episodes of watery stool overnight. Specimen collection and results data for C. difficile Toxin B PCR with reflex to C. difficile EIA, dated 3/30/25 at 12:57 p.m. indicated P7 was negative for C. difficile. An order for enteric precautions dated 3/30/25 at 10:10 a.m. indicated P7 was on continuous enteric isolation. A nursing note dated 3/30/25 at 2:46 p.m. indicated P7 continued to have loose stools, and a C. difficile culture was negative. During an interview on 3/26/25 9:47 a.m., RN-B stated if a patient is on enteric or contact isolation, there should be a sign outside their door and a fully stocked precaution cart. RN-B stated staff must follow the signs outside the door and don appropriate PPE prior to entering. RN-B stated staff must wash their hands after caring for a patient on enteric precautions. During an interview on 3/26/25 at 10:14 a.m., RN-C stated if a patient is on enteric precautions or specific signage directing staff, they should always wash their hands with soap and water after providing patient care. During an interview on 3/26/25 at 11:32 a.m., RN-D stated if a patient is on enteric isolation or a staff members’ hands are visibly soiled, staff must wash their hands prior to exiting the room. During an interview on 3/31/25 at 10:09 a.m., RN-A stated if a patient is on contact isolation, staff must wear gloves, a gown, and potentially eye protection if there is concern for bodily fluids splashing. RN-A stated patients who are on contact isolation are indicated by the sign on the door. RN-A stated when accessing a patient’s electronic medical record, any patient specific precautions will show on the left side of the navigator, and indications can be found by reading nursing or provider notes. RN-A stated it is the nurse’s responsibility to know why their patient may be on any precautions. RN-A stated she “forgot to put on a gown,” when she entered P7’s room. RN-A stated she entered P7’s room to speak with the patient, but while she was there, P7 requested to be transferred to her wheelchair. RN-A stated she then called for assistance from other nursing staff, and two additional direct care staff assisted with P7’s transfer without wearing reusable gowns. RN-A stated she did not know why P7 was on contact isolation or enteric isolation. During an interview on 3/31/25 at 10:28 a.m., RN-E stated it is the responsibility of the nurse to check if the precaution sign on the patient’s door matches the precautions listed in their medical record. RN-E stated if a patient’s room does not have appropriate signage, she would notify the direct care staff, place a pre-made sign on the door, and request a precaution cart be placed outside the patient’s room immediately. During an interview on 4/1/25 at 11:02 a.m., RN-F, nurse manager, stated the unit conducts contact and isolation precaution, and hand hygiene audits every month, thirty times per month monitoring their compliance rates. Every day environmental staff cleans patient rooms, nurse aid staff wipe down high touch areas in patient rooms such as keyboards and doorknobs, ect., and nurses disinfect patient equipment after use. During an interview on 4/1/25 at 2:09 p.m., the system program manager stated when the unit conducts their infection control audits if a staff is found to not adhere to infection control standards staff are given “just in time” education informing the staff of the missed protocol. The staff conducting the audit include nursing, regulatory, or the infection preventionist. In an email correspondence sent on 4/1/25 at 3:53 p.m., they system program manager stated RN-A completed annual mandatory education regarding hand hygiene and contact isolation on 2/9/25. A training titled 2025 Mandatory Annual Education Lesson 3, transmission-based precautions are used when a patient is known or suspected of having a disease which may spread to others. The training indicated contact precautions are used when caring for patients with suspected or confirmed multidrug-resistant organisms. The training indicated contact precautions include staff wear a gown and gloves when entering the room. The training indicated enteric precautions are used when caring for patients with suspected clostridium difficile. training indicated contact precautions include staff weary a gown and gloves when entering the room, and cleanse their hands with soap and water, not alcohol-based hand rub, when exiting the room. A policy titled Hand Hygiene - Hand Washing dated 10/9/24, indicated hand washing with soap and water is required when caring for patients in enteric precautions rooms.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 43080 Based on interview and document review, the facility failed to obtain a licensed provider restraint order for 1 of 5 patients (P1) prior to, or after, the initiation of a physical/manual hold (violent) restraint. Findings include: P1’s medical record identified the following emergency department (ED) nurses note, dated 11/9/24 2:45 p.m.: P1 was “very disruptive” and “frightening to the hallway patients,” as P1 paced and yelled out. Despite many attempts, P1 was not able to be directed back to her room and the yelling increased. A behavioral emergency response team and “code green” were called and continued attempts to redirect P1’s behaviors were attempted; however, response techniques were unsuccessful and P1 continued to be disruptive in the hallway. In response, staff went “hands on” and physically guided her to her room and administered intramuscular (IM) medication injections to P1. Immediately after these administrations, the manual hold on P1 was released. P1 was then directed to sit in a wheelchair, and she was transported by the code team and security to the mental health unit. P1’s ED Care Timeline identified the following: -11/9/24 at 2:20 p.m. a Violent or Self-Destructive Seclusion Restraints nurse entry indicated an order was obtained by medical doctor (MD)-A for a physical hold as P1 was “manic” and an imminent risk of harm to others. -11/9/24 at 2:23 p.m., a follow up Restraint Summary nurse entry indicated the restraint was discontinued. -11/9/24 at 2:25, a nurse entry indicated P1 was transferred out of the ED [to a mental health unit]. On 12/31/24 at 1:34 p.m., during the abbreviated medical record review process with professional practice leads (PP)-A and PP-B, P1’s restraint documentation was reviewed. P1’s medical record, physician order section, lacked evidence a violent/manual hold order was placed by a licensed provider prior to or after P1’s 11/9/24 manual hold. PP-A and PP-B acknowledged inability to locate the required order. An interview with P1 was attempted; however, was unsuccessful. When interviewed on 1/2/25 at 11:10 a.m., registered nurse (RN)-A identified she was the vice president of ED services. RN-A explained she expected a qualified provider to input a restraint order into the medical record when a patient required a manual hold for medication administration. RN-A identified she reviewed P1’s chart and was unable to identify such an order for P1. During an interview on 1/2/25 at 11:48 a.m., the ED medical director (MD)-A stated he expected all restraints required a processed order. If a manual hold was required for IM medication administration, he stated he expected the provider would evaluate the patient and the need for such treatment, at which time, if the manual hold was identified, the provider would place a restraint order in the medical record order section. At times, depending on the situation details, a verbal restraint order, would be provided. In those situations, the nurse entered the order and then the provider followed up with their attestation of the order. MD-A explained he was made aware of the lacked order concern after the survey started and indicated this was an opportunity for improvement as “one of the people involved should have caught” the lapse in the process. When interviewed on 1/2/24 at 3:06 p.m., P1’s ED provider (MD)-B stated she was required to input a restraint order into the medical record if such an intervention was required. MD-B explained this step was missed by her for P1 when the manual restraint was applied; however, she was unable to remember any specific details related to P1’s situation as a possible reason as to why this step in the “closed loop” restraint process was missed, other than this situation was “a perfect storm” for P1 being she transferred almost right away after the restraint to the mental health unit.. A Restraint or Seclusion policy, dated 3/24/24, indicated its purpose was to ensure a safe environment for both patients and staff, while protecting patient rights, dignity, privacy, and well-being. A Procedure section for Restraint for Violent/Self-Destructive Behavior, with an associated Initiation of Restraint section, directed a licensed provider (LP) ordered the restraint use. If the LP was not immediately available, the RN may initiate the restraint; however, was then expected to obtain an order as it was safe to do so, but no longer than one hour after the initiation of the restraint. The order was to contain a description of the patient actions that necessitated the intervention, a statement that the restraint was to be discontinued when criteria met, type(s) of restraint(s), and order duration (hour hours for individuals greater than or equal to 18 years of age.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) [the patient must be seen face-to-face within 1 hour after the initiation of the intervention -- ] §482.13(e)(12)(ii)To evaluate - 1. The patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. This Standard is not met as evidenced by: 43080 Based on interview and document review, the facility failed to provide a face-to-face evaluation (a physical and behavioral assessment of the patient by a qualified practitioner), within an hour of a restraint initiation, for 1 of 5 patients (P1) who were physically restrained. Findings include: P1’s medical record identified the following emergency department (ED) nurses note, dated 11/9/24 2:45 p.m.: P1 was “very disruptive” and “frightening to the hallway patients,” as P1 paced and yelled out. Despite many attempts, P1 was not able to be directed back to her room and the yelling increased. A behavioral emergency response team and “code green” were called and continued attempts to redirect P1’s behaviors were attempted; however, response techniques were unsuccessful and P1 continued to be disruptive in the hallway. In response, staff went “hands on” and physically guided her to her room and administered intramuscular medication injections to P1. Immediately after these administrations, the manual hold on P1 was released. P1 was then directed to sit in a wheelchair, and she was transported by the code team and security to the mental health unit. P1’s ED Care Timeline identified the following entries: -11/9/24 at 2:20 p.m. a Violent or Self-Destructive Seclusion Restraints entry identified a physical hold was needed as P1 was “manic” and an imminent risk of harm to others. -11/9/24 at 2:23 p.m., a follow up Restraint Summary entry identified the restraint was discontinued. -11/9/24 at 2:25, a patient transferred entry identified P1 was transferred out of the ED [to a mental health unit]. On 12/31/24 at 1:34 p.m., during the abbreviated medical record review process with professional practice leads (PP)-A and PP-B, P1’s restraint documentation was reviewed. P1’s medical record lacked evidence a one-hour face-to-face evaluation was conducted after P1’s 11/9/24 manual hold. PP-A and PP-B acknowledged inability to locate the required evaluation. An interview with P1 was attempted; however, was unsuccessful. When interviewed on 1/2/25 at 11:10 a.m., registered nurse (RN)-A identified she was the vice president of ED services. RN-A explained she expected a qualified staff to conduct the face-to-face and document the specifics of the evaluation in the medical record. These staff included the ED licensed providers and the mental health unit RNs. RN-A identified she reviewed P1’s chart and was unable to identify P1 was provided a face-to-face evaluation, either in the ED or once she arrived at the mental health unit. During an interview on 1/2/25 at 11:48 a.m., the ED medical director (MD)-A stated he expected the ED provider conducted the face-to-face evaluation within 60 minutes of the restraint, even if the restraint lasted for 60 seconds. MD-A explained he was made aware of the lacked face-to-face concern after the survey started and indicated this was an opportunity for improvement as “one of the people involved should have caught” the lapse in the process. When interviewed on 1/2/24 at 3:06 p.m., P1’s ED provider (MD)-B stated she was required to perform a one-hour face-to-face evaluation and document this process into the medical record if a restraint was utilized. MD-B explained this step was missed by her for P1 after the manual restraint was applied; however, she was unable to remember any specific details related to P1’s situation as a possible reason as to why this step in the “closed loop” restraint process was missed, other than this situation was “a perfect storm” for P1 being she transferred almost right away after the restraint to the mental health unit. A Restraint or Seclusion policy, dated 3/24/24, indicated its purpose was to ensure a safe environment for both patients and staff, while protecting patient rights, dignity, privacy, and well-being. A Procedure section for Restraint for Violent/Self-Destructive Behavior, with an associated Face to Face Assessment section, directed within one hour of the initiation of the restraint, the licensed provider (LP) or specifically trained RN, was to conduct an in-person, face-to-face assessment to assess the patient’s immediate situation, reaction to the intervention, behavioral condition, need to continue or terminate the restraint, and to perform a complete review of systems with a medical and behavioral status review.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47264 Based on observation, interview, and document review, the hospital failed to protect and promote patient rights for 6 of 15 patients (P3, P4, P5, P6, P7, P8) when a security guard restrained P3 using a taser energy weapon (TEW) a law enforcement weapon and handcuffs a law enforcement tool, and security guards abused P3, P4, P5, P6, P7, P8 by using intimidation tactics when displaying and or activating a taser energy weapon (TEW), displaying REPULS, a chemical spray, both law enforcement weapons toward patients as a de-escalation technique. As a result of these failures, the deficient practices resulted in an immediate jeopardy (IJ). The hospital was found out of compliance with Condition of Participation Patient Rights at 42 CFR 482.13. The IJ began on 5/14/24 when a security guard restrained P3 using a taser energy weapon (TEW) a law enforcement weapon and handcuffs a law enforcement tool when P3 was causing a disturbance with physical and verbal threats during a behavioral health crisis. Additionally, P3, P4, P5, P6, P7, and P8 were abused when security guards used law enforcement weapons for de-escalation. On 5/23/24 at 4:15 p.m., the hospital’s Chief Operating Officer, the VP of High Reliability, the System Program Manager of Regulatory and Accreditation, the System Clinical Educator, and the Nursing Director for the Emergency Departments were notified of the IJ. The IJ was removed on 5/30/24 at 6:00 p.m., when an acceptable removal plan was verified, it had been implemented; however, the hospital remained out of compliance with the COP of Patient’s Rights at 42 CFR 483.13. The IJ was removed on 5/30/24 at 6:00 p.m. when the hospital had submitted and implemented an acceptable removal plan. This included review of policies, providing face-to-face training to all clinical and hospital staff of proper patient de-escalation techniques and appropriate use of law enforcement weapons, re-education focused on appropriate use of force, using the least restrictive measures, and utilizing the hospital’s behavioral emergency response team resources. This was verified through observation of shift huddle training, interview, and document review. Findings include: See A-0145 The hospital failed to ensure patients right to be free from abuse in the form of intimidation for six of six patients (P3, P4, P5, P6, P7, and P8) when multiple security guards displayed their taser energy weapon (TEW), one security guard also displayed his REPULS, a chemical spray, both law enforcement weapons, at patients and patients were told to get on the ground to gain control of patient behaviors during a behavioral health crisis. See A-0154 The hospital failed to ensure a patient right to be free from restraint by use of a taser energy weapon (TEW) a law enforcement weapon and handcuffs a law enforcement tool for one of eight patients (P3) who was tased to gain behavioral compliance and handcuffed to be placed in custody during a behavioral health crisis.”

“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: 47264 Based on document review and interviews, the hospital failed to ensure patients right to be free from abuse in the form of intimidation for six of six patients (P3, P4, P5, P6, P7, and P8) when multiple security guards displayed their taser energy weapon (TEW), one security guard also displayed his REPULS, a chemical spray, both law enforcement weapons, at patients and patients were told to get on the ground to gain control of patient behaviors during a behavioral health crisis. Findings include: P4 presented to the adult emergency department (ED) on 11/20/23 at 1:18 p.m. via ambulance for significant behavioral changes. P4’s diagnoses included acute psychosis, opioid dependence with opioid-induced psychotic disorder with delusions, and aggressive behavior. A security report, dated 11/24/23, indicated on 11/23/23 at 9:07 p.m. in the ED, security guard (SG)-G responded to P4’s room for a behavioral health crisis. The report indicated while in the room, P4 verbally threatened and postured towards SG-G, who responded by drawing his TEW and pointing it at P4 with verbal directives to back up. The report indicated P4 did not respond well, and SG-G indicated he pushed P4 backwards, and then drew his chemical spray to gain behavioral compliance. The report indicated P4 then complied and was secured back into his room without activation of the TEW or chemical spray. A security report dated 11/29/23, indicated on 11/26/23 at 5:55 a.m. in the ED, SG-H was assisting medical staff with de-escalating P4 when P4 made verbal threats and attempted to kick SG-H. The report indicated SG-H responded by drawing his TEW, pointing it at P4, and giving him verbal directives to get down. The report indicated P4 stopped advancing toward SG-H and in response, SG-H holstered his TEW without activation, and with the help of other staff, used a manual hold to secure P4 back into his room. The report indicated after this point, P4’s nurse made the clinical decision to seclude P4 inside his room, and the door was locked. P5 presented to the adult ED on 1/14/24 at 6:41 a.m. via ambulance for distress following a domestic disturbance. P5’s diagnoses included mild intellectual disability. A security report, dated 1/14/24, indicated on 1/14/24 at 4:49 p.m. in the ED, SG-F responded to a verbal request for help with P5 who was attempting to elope. The report indicated P5 postured multiple times and encroached on SG-F’s space, resulting in SG-F drawing his TEW and pointing it at P5. The report indicated P5 called 911 in response and medical staff were able to deescalate the situation and bring P5 back into his room. The report indicated a code 21 (behavioral emergency) was called, and SG-F removed himself as his presence was agitating P5. P6 presented to the pediatric ED on 1/10/24 at 2:13 p.m. via ambulance for detoxification of Fentanyl use. P6’s diagnoses included anxiety, depression, severe opioid dependence, and oppositional defiant disorder. A security report, dated 1/25/24, indicated on 1/24/24 at 5:12 p.m. in the behavioral ED, medical staff requested help from SG-F with P6 in the bathroom. The report indicated P6 was punching himself in the face and both security and medical staff attempted to verbally deescalate him. The report indicated P6 managed to separate himself from staff and began punching himself again. The report indicated SG-F approached P6 with the intention of initiating a manual hold to prevent further self-injurious behavior, however, P6 began advancing towards SG-F and posturing. The report indicated SG-F drew his TEW and pointed it at P6. The report indicated SG-F gave P6 multiple directives to get on the ground, and P6 eventually complied where SG-F restrained him with a manual hold. The report indicated a code 21 was called and more security staff arrived to assist but were reallocated to manage a behavioral emergency for another patient. The report indicated P6 then contracted for safety, and SG-F released him from the manual hold without further issue. P7 presented to the adult ED on 12/22/23 at 10:21 a.m. via ambulance for mental health and chemical dependency treatment. A security report, dated 1/25/24, indicated on 1/24/24 at 10:13 p.m. in the ED, SG-A assisted with a code 21 to manage P7’s behaviors. The report indicated SG-A and other security staff attempted to deescalate P7, who was posturing, making verbal threats towards others, and threatening to engage in self-injurious behavior. The report indicated P7 attempted to knee SG-A in the groin, which was unsuccessful, and P7 was given space alone in his room after an as needed psychotropic was administered. The report indicated P7 reacted violently to the mediation and began pounding on the unlocked door. The report indicated clinical staff made the decision to close P7 into his room, which doubled as a seclusion room, and initiate seclusion. The report indicated SG-A entered the room to inform P7 he was being placed into seclusion, when P7 began to charge SG-A and make verbal threats. The report indicated SG-A drew his TEW, pointed it at P7, and turned it on. The report indicated staff were able to close the door and initiate seclusion, resulting in SG-A holstering his TEW. P8 presented to the adult ED on 4/3/24 at 11:45 a.m. via private transportation from an intensive residential treatment program for significant behavioral changes. P8’s diagnoses included antisocial personality disorder, schizoaffective disorder, polysubstance abuse, and agitation. P8 was admitted to the hospital’s mental health and addiction services unit on 4/8/24 at 8:10 p.m. A security report, dated 4/4/24, indicated on 4/4/24 at approximately 11:50 p.m. in the mental health unit, SG-C responded to a code green (a silent alert sent to behavioral health RNs, psychiatric assistants, behavioral assistants, and security to address a behaviorally escalated patient) for P8’s escalating behaviors. The report indicated clinical and security staff were able to deescalate P8 and relocate him to seclusion while he made multiple verbal threats and destroyed property. The report indicated P8 was then moved to seclusion but was allowed to keep multiple personal items that were not appropriate or safe for seclusion. The report indicated on 4/4/24 at approximately 1:15 a.m., P8 was resistant to returning these items, and so security staff reentered the seclusion room with a shield and TEW drawn to retrieve those items safely. P3 presented to the pediatric ED on 5/4/24 via ambulance for suicidal ideation and agitation. P3’s diagnoses included adjustment disorder, autism spectrum disorder, attention deficit disorder, and Wolf-Parkinson-White Syndrome (long QT syndrome). P3 was socially boarding in the ED since presenting at the ED, as family refused to accept him at home due to previous aggressive behavior. A security report, indicated on 5/14/24 at 7:29 p.m., SG-A was completing security rounds in the pediatric ED when he observed disruptive behavior from P3. The report indicated P3 was walking around the unit with a wet floor sign and verbally threatening staff and was not responding to redirection from clinical staff. The report indicated security intervened and attempted to deescalate P3, which was unsuccessful. The report indicated P3 became fixated on SG-A, dropped the wet flood sign, and charged towards SG-A. The report indicated SG-A responded by pushing P3 away defensively, and when P3 looked angry, SG-A immediately stepped back and drew his TEW. The report indicated SG-A gave P3 verbal commands to get on the ground, which he slowly began to listen to and lingered on his knees. The report indicated while the TEW was still drawn, SG-A pushed P3 onto his hands and knees and multiple security staff moved to secure P3. The report indicated P3 resisted this manual hold and was given multiple directives to stop resisting or he would be tased by SG-A. The report indicated P3 continued to resist, and SG-A attempted to deploy his TEW, but noted a technical malfunction with his TEW. The report indicated SG-A then repositioned his TEW on P3’s back and activated it again, delivering a drive-stun shock to P3. P3 stopped resisting, and staff were able to place him into handcuffs. Dispatch contacted 911 and the police department was in route. Police report dated 5/14/24 indicated the police officers arrived at 9:55 p.m. and were advised P3 had been held in the ED for approximately 10 days for mental health evaluations and possible dissociative identify disorder and had exhibited 4-5 distinct personalities since arriving in the ED. P3 was causing a general disturbance by removing a metal grate from a sink was instructed to remove it which he complied, and later picked up a wet floor sign, swinging it around, was instructed to drop the sign, and did not comply. Security then retained P3 using a the taser. P3 was not taken into law enforcement custody. The police officers left the hospital at 10:01 p.m. During an interview on 5/22/24 at 10:47 a.m., SG-F stated the TEW is the most effective way to deescalate violent patients. SG-F stated the taser can be displayed or “arched,” to deescalate patients. SG-F stated arching is activating the electrical current without deploying the prongs of the TEW, which creates a loud electrical noise. SG-F stated he points the TEW at patients who are charging at him with a weapon. SG-F stated he uses his TEW when he feels his life is in danger and it is not safe to approach patients to manually restrain them. During an interview on 5/22/24 at 3:48 p.m., SG-E stated security staff are taught to withdraw their TEWs, arch them if needed, and verbally inform patients of their intent to use the weapon. SG-E stated if the behaviors do not stop and the danger becomes more imminent, they can use the TEW on patients. SG-E stated most patients become compliant when staff arch the TEW at them. During an interview on 5/23/24 at 8:30 a.m., SG-D stated security can pull the TEW, turn it on to activate the aiming lasers, activate the arching mechanism, and deploy the TEW on patients. SG-D stated the purpose of pulling the TEW is to scare the patient and make it clear security staff can hurt them. SG-D stated the TEW can be used on a patient in response to an attempted assault himself or his coworkers. During an interview on 5/23/24 at 10:13 a.m., the regional security manager stated security staff may use the TEW if they are confronted with a violent situation. The regional security manager stated security staff may use their weapons to mitigate threats to themselves or others. The regional security manager stated the use of any weapon is dependent on the scenario and the security staff’s judgement. During an interview on 5/23/24 at 10:44 a.m., the security supervisor stated TEWs, and chemical spray can be used on patients if there is a verbal threat of violence. An undated training document titled “Duty Gear,” indicated all security staff are equipped with handcuffs. Security staff may handcuff patients when medical restraints are not available. Security staff should apply medical restraints to a patient as soon as possible. Handcuffs are not a health care intervention and should not be used on patients. Handcuffs are a law enforcement tool and are not considered a use of force, but a control technique. The document indicated multiple uses of a single taser, and multiple tasers may be used on an individual to control combative behavior. Tasers may be used by security staff if other de-escalation attempts have failed. An undated training document titled “Use of Control Measures,” indicated security staff may arrest another individual if a felony has been committed, or if a person attempts or completes a public offense. A policy titled “Taser Energy Weapon,” dated 12/13/22, indicated security may draw and/or use their taser if “A dangerous or violent subject has a weapon or is aggressively advancing toward the [security staff], and the [security staff] believes that they will be assaulted.” A policy titled “Security Use of Force,” dated 2/28/23, indicated security staff are to use the least amount of force necessary to effectively gain compliance from individuals. The policy indicated security staff must act to “return all situations to therapeutic response to a behavioral emergency as soon as possible.” The policy indicated security staff may threaten the use of force to gain control over situations and avoid violence. The policy indicated security staff may “compel a subject with the threat of force to gain complain” by drawing their intermediate weapons, tasers and REPULS spray.”

“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: 47264 Based on document review and interviews, the hospital failed to ensure a patients right to be free from restraint by use of a taser energy weapon (TEW) a law enforcement weapon and handcuffs a law enforcement tool for one of eight patients (P3) who was tased to gain behavioral compliance and handcuffed to be placed in custody during a behavioral health crisis. Findings include: P3 presented to the hospital’s pediatric emergency department (PED) on 5/4/24 at 6:47 p.m. via ambulance for the suicidal ideation and agitation. P3’s diagnoses included adjustment disorder, autism spectrum disorder, attention deficit disorder, and Wolf-Parkinson-White Syndrome (long QT syndrome). P3 was transferred to the behavioral emergency center on 5/5/24 at 4:49 p.m. A social work note, dated 5/6/24, indicated P3’s family refused to allow P3 back into the home due to his violent and unsafe behaviors. The note indicated the plan for P3 would be to continue looking for alternative placement for P3. The note indicated P3 began socially boarding in the PED until appropriate placement could be found. P3 was transferred back to the PED on 5/7/24 at 5:49 p.m. A nursing date, dated 5/11/24, indicated P3 had a good rapport with SG-B. A social work note, dated 5/13/24, indicated P3 was appropriate for inpatient mental health treatment, and was no longer considered a social boarder. The note indicated staff were seeking appropriate inpatient placement. A nursing note, dated 5/14/24 at 2:46 p.m., indicated P3 had achieved placement at a pediatric mental health hospital, and would transfer there at a later date. A security report written by security guard (SG)-A, dated 5/14/24, indicated SG-A was completing routine rounds in the PED when he observed P3 walking around with a plastic wet floor sign and not listening to clinical staff directives to return the object and SG-A then called for more security staff. Registered nurse (RN)-A made multiple attempts to deescalate P3, but P3 felt staff had wrongfully confiscated his personal affects following negative behavior. P3 continued to walk around with the sign and held it up to mimic a gun. The report detailed P3’s similar behavior from an earlier point in the shift when P3 had obtained a metal sink grate and was resistant to giving it back to staff, indicating P3 showed a habit of obtaining objects “that could be used as weapons.” SG-A recognized P3 from another behavioral crisis he had previously and noted P3 had previously become fixed on SG-A, resulting in seclusion for the safety of others. SG-A believed P3 was a “a behaviorally unstable person” and felt the floor sign could be used as a weapon, which “was not going to be a chance we could take”.” SG-A felt verbal threats of violence precede physical violence, and this logic led him to separate P3 from others who were not involved in his care. SG-A then “corralled” P3 into a section of the PED, and instructed RN-A to call for a code 21. The report indicated SG-B began to verbally deescalate P3, until P3 recognized SG-A from the previous interactions and began to aggressively walk towards him. SG-A attempted to give verbal commands to stop and to drop the sign. P3 then dropped the sign, but continued to walk towards SG-A, and SG-A felt P3 “was about to make good on his threats” of violence. The report indicated SG-A used a two-handed defensive hand-check to P3’s upper chest to propel him backwards. P3 angry, and in response, SG-A “Immediately and almost without hesitation” stepped backwards, pulled his taser from his belt, “armed it, and pointed it at [P3] while giving him verbal commands to get on the ground.” P3 slowly went to the ground and hesitated on his knees. SG-A then pushed P3 down further, and other security staff attempted to bring him to the ground entirely. P3 began to resist, and SG-A told P3 he would tase him if he did not stop resisting. P3 continued to resist, and in response, SG-A placed the taser against P3’s right shoulder blade and tried to fire his taser. The taser made a low electrical sound, but did not result in any response from P3, so SG-A moved the taser to P3’s lower back and fired it again. The report indicated this second use of the taser “did work in taking the fight from [P3],” and P3 stopped resisting. P3 was then placed in handcuffs and the provider gave medical clearance to discharge P3 to the juvenile detention center but it was later decided to move P3 to the adult ED instead. P3 told security staff that his multiple personalities had been controlling him throughout the incident. The report indicated a police report was filed and this “should satisfy CMS requirements for contacting the police when a law enforcement tool is used on a patient.” A police report dated 5/14/24, indicated hospital staff contacted local law enforcement at 7:34 p.m. to inform them P3 had assaulted a security guard and was being restrained in the hallway of the PED. The police report indicated P3 had been swinging a sign around on the unit and P3 had charged security staff without the sign. P3 was told he would be tased if he continued not to comply and “security restrained him using the drive stun feature of the taser.” Hospital staff told the police officer P3’s family refuses to have him in the home, and the police advised the hospital to have a Child Protective Services report made for neglect of the child’s needs. The police report indicated P3 needed placement in a secure in-patient setting, but there were none available at this time. A nursing note written by RN-A, dated 5/14/24 at 7:48 p.m., indicated P3 had transferred to a PED bed for milieu management. P3 was walking around with a plastic “wet floor” sign and would not return the sign to staff, knocking it against the unit walls and railings, and security was on the unit for rounding and intervened, calling for additional security on their radio. The behavioral emergency response team (BERT) was contacted, but unavailable due to another behavioral health emergency in the hospital. The note indicated a code 21 was in the process of being called when P3 charged security staff and swinging the plastic sign. P3 kept hold of the sign and was told if he did not drop the sign, he would be tased. P3 did not comply with these directives. P3 then charged security staff again, and security responded by tasing him, which brought him to the ground, and then security staff placed him in handcuffs. Hallways video footage from 5/14/24 at 7:28 p.m. was reviewed with the security training manager on 5/22/24. In the video, SG-A can be seen walking around the unit and completing his rounds. P3 was ambulating in the hallways as well with their one-to-one staff assignment, psychiatric assistant (PA)-A. P3 picked up a wet floor sign and began to walk around with it over his head and at his sides. P3 walked in front of the nurse’s station near other clinical staff and patients before continuing down the hall. RN-A can be seen with PA-A attempting to verbally deescalate P3 and retrieve the sign. P3 held the sign out towards them with a jerking motion, mimicking a gun. SG-B can be seen entering the unit and engaging in conversation with P3, at which point RN-A and PA-A disengage completely and move back to the nurses’ station. Multiple security staff can be seen entering the unit and watching from a distance. P3 then looked at SG-A, who appeared to be giving verbal directives at this time. P3 dropped the sign and quickly walks towards SG-A. SG-A raises both hands and firmly pushes P3 back and away, and immediately raised his taser and turns it on. P3 slowly raises his hands and gets onto his knees where he hesitates. SG-A then walked behind P3 and uses his left hand to push P3 down between the shoulder blades, knocking him onto his hands and knees. SG-B and SG-C attempt to initiate a manual hold of P3 on the ground, however, he immediately began to resist. SG-A and SG-D also assist in the manual hold, with the taser still drawn. The group of security guards struggle for a few moments as P3 moves from his knees to his feet, then back to his knees. SG-E also attempted to assist in the manual hold at this time. SG-A can be seen moving his taser into P3’s upper right shoulder blade and holding it there for a moment before moving it to his lower back, at which point the taser goes out of view. Shortly afterwards, P3 stopped resisting and SG-A, SG-B, SG-C, SG-D, and SG-E have P3 in a prone five-person manual hold. While in the prone position, handcuffs were applied to P3 by SG-C. P3 was then sat up by a security guard and is sat on the ground handcuffed while security staff stood around him. Shortly afterwards, the BERT staff arrived and then left without speaking to the patient. SG-A’s body camera footage from 5/14/24 at 7:32 p.m. was reviewed with the security training manager on 5/22/24. In the audio and video, SG-A was heard giving verbal directives to “get down on the ground.” P3 held his hands up and slowly complied, lower himself to his knees and hesitating. SG-A responded by walking behind P3 and firmly pushing him between his shoulder blades to knock him onto his hands and knees. SG-B and SG-C then attempted to initiate a manual hold on P3 while SG-A also attempted to assist. The camera footage went dark during this time period and P3 can be heard shouting at the security guards while SG-A verbalized his intent to use his taser on P3 if he did not stop resisting. It was unclear at what point P3 was tased and the handcuffs were applied based on the body camera footage. Eventually, the camera footage showed P3 sitting upright with his hands secured with handcuffs behind his back. P3 was crying and asking what had happened, and saying they did not mean to do anything, it was their other personality, [“Name”].” SG-A then said “You are going to juvenile. You can’t threaten people, that doesn’t work for us.” BERT staff then entered the unit and attempted to assess P3, however, SG-A grabbed their staff by the arm and pushed them away, informing them this patient was in custody and should not be seen. At 7:52 p.m., P3 was taken to the adult ED by security in a wheelchair and the handcuffs were removed. During an interview on 5/22/24 at 10:52 a.m., SG-F stated all security staff have access to handcuffs, chemical spray, and a taser. SG-F stated the taser can be pointed and “arched” at patients as a warning. SG-F stated arching the taser creates a loud electrical sound but does not deploy the electrifying probes. SG-F stated this sound is used to warn the patient they are not “kidding around”. SG-F stated he has displayed his taser and arched it at a patient when they had charged him with a weapon, or it was not possible to approach the patient with just his hands. SG-F stated he has used his handcuffs on a patient for a citizen’s arrest. During an interview on 5/22/24 at 11:14 a.m., the security training manager stated when a taser is pulled from the security staff’s belt, the body worn camera is automatically activated. There are two ways to use the taser: to deploy the taser probes, or as a stun weapon by using a drive stun. The security manager stated to deploy the taser, the taser is turned on, which activates lights and laser guides. The taser probes need to be at least 12 inches apart to achieve neuromuscular incapacitation, which causes an individual’s muscles to lock up, incapable of moving. If used as a stun weapon by utilizing the drive stun, the probes are not ejected from the taser and the taser creates localized pain at the contact site. The security manager stated the second time SG-A used the taser on P3 was when the drive stun was delivered and P3 likely felt intense localized pain that lasted until the taser was removed. The security manager stated the only contact in the videos between P3 and SG-A prior to the manual holds were when SG-A pushed P3 away. The security manager stated handcuffs were applied to P3 because staff wanted local law enforcement to arrest P3 for assaulting SG-A. The security manager stated she was unsure when this assault occurred and did not see any assault on the footage reviewed. The security training manager stated security can complete a citizen’s arrest on a patient if a crime is committed and local law enforcement is called. During an interview on 5/22/24 at 3:48 p.m., SG-E stated if a patient is not complying and the situation is imminent, they are allowed to take out their taser and arch it to gain behavioral compliance and then restrain the patients as needed. SG-E stated tasers can be taken out and arched at patients as a warning to settle them down and encourage compliance. SG-E stated handcuffs may be used on a patient when they have assaulted someone or destroyed property or equipment. SG-E stated P3 did not assault SG-A. SG-E stated SG-A told him P3 had assaulted a nurse in another room, and that is why P3 was being put in handcuffs. SG-E stated the threat of someone assaulting security justifies the use of a law enforcement weapon on a patient. SG-E stated P3 was clearly in conflict with themselves, switching back and forth between personalities, and actively having a mental health crisis. During an interview on 5/22/24 at 4:03 p.m., SG-A stated on 5/14/24, he was in the PED completing his rounds as a security staff when he noticed P3 walking around with a sign and making low level threats. SG-A stated he radioed to their dispatch center and requested more security staff. SG-A stated after that, SG-B and P3 were talking down the hall when P3 saw SG-A. SG-A stated when P3 saw him, he changed instantly and was focused on SG-A like he had in a previous, unrelated encounter. SG-A stated P3 charged towards him, and SG-A responded with a defensive hand check to create space. SG-A stated P3 then became very angry, and SG-A pulled out his taser, giving verbal commands to get on the ground. SG-A stated P3 started getting down onto the ground, and SG-A pushed him between the shoulder blades because he was going “too slowly.” SG-A stated P3 then began to resist, and it took multiple security staff to get him back to his knees. SG-A stated he tased P3 in his upper right shoulder and when it didn’t create neuromuscular incapacitation, he moved the taser to achieve a distance greater than 12 inches apart and fired again. SG-A stated it was effective and P3 immediately stopped resisting, allowing them to have an effective five person hold on P3. SG-A stated he used the taser to get P3 into custody, handcuffs were applied because he used a law enforcement tool, which was the taser. SG-A stated he wanted to maintain control of the scene and ensure the safety of others on the unit. During an interview on 5/23/24 at 8:30 a.m., SG-D stated security can use either their law enforcement weapons on a patient if it’s a one-to-one scenario, if there’s attempted assault, if the patient is bigger or stronger than you, or if the patient is in control of the situation. SG-D stated security staff can use the taser on a patient if they are making verbal or physical threats. SG-D stated a taser can be pointed at a patient, activated to engage the lasers, and arched to scare the patient. SG-D stated the intention is to warn the patient they are serious, and this can hurt them. SG-D stated when he tried to place P3 in a manual hold, P3 was resistive, and staff were giving multiple verbal directives. SG-D stated P3 fought back until the taser was used, at which point there was no more resistance. SG-D stated SG-A told him to arrest P3 for the attempted assault of SG-A. SG-D stated handcuffs were placed on P3 for the attempted assault of SG-A. SG-D stated any time a law enforcement weapon is used, it is considered a law enforcement action that requires police response. SG-D stated the decision a crime was committed is made by the police. During an interview on 5/23/24 at 10:05 a.m., medical doctor (MD)-A stated the hospital is struggling to place social boarding patients, and they tend to be aggressive. MD-A stated P3 had escalated multiple times before in the PED and had been manageable with verbal de-escalation and psychotropic PRN medications. MD-A stated if a patient is a danger to others, staff can implement violent restraints in order to ensure safety on the unit. MD-A stated she was unsure how a taser could impact the elongated QT complex of a patient with preexisting conditions. During an interview on 5/23/24 at 10:13 a.m., the regional security manager stated the threat of violence is grounds for use of law enforcement weapons on patients. The regional security manager stated whether a taser or chemical spray is used on an individual is dependent on the security staff’s judgement at that time. The security manager stated he was part of the use of force reviewed and felt the hospital’s processes were followed and there was no wrongdoing on the hospital’s part. During an interview on 5/23/24 at 10:44 a.m., the security supervisor stated no individual corrective action was taken with SG-A following this incident. The security supervisor stated no policies or procedures have been revised related to this incident. The security supervisor stated self-defense and the threat of violence are justification to use either the taser or the chemical spray on patients. During an interview on 5/23/24 at 12:23 p.m., the Chief Nursing Officer (CNO) stated the incident on 5/14/24 was reviewed in multiple stages and teams, including herself, the VP of Operations, a mental health advanced practice registered nurse (APRN), patient safety specialists, security, and clinical staff. The CNO stated P3 was placed into handcuffs for the immediate safety for the entire unit. The CNO stated their interdisciplinary team felt they could not have maintained safety of the unit in any other way. CNO stated she did not know why the hospital five-point restraint was not used and would have to review the video again. During an interview on 5/23/24 at 1:25 p.m., RN-A stated the PED has violent restraints (four- or five-point restraint) to use on patient, and they are used as a last resort. RN-A stated she had worked with P3 on 5/14/23 and the days leading up to it where he had multiple behavioral escalations, requiring staff intervention and seclusion. RN-A stated P3 had picked up the floor sign and was holding it like a guitar and refusing to give it back to staff. RN-A stated she offered PRN medications to P3, but he also refused. RN-A stated she tried to call the BERT team, but they were busy with another patient on a separate unit. RN-A stated she could hear P3 escalating and was about to call a code green but decided to call a code 21. RN-A stated before the code 21 team could arrive, she heard a security staff state “I am going to tase you.” RN-A stated she was only able to see part of the event because she was on the phone trying to get a hold of resources. RN-A stated she felt these security interventions were appropriate because P3 was “bigger than the staff,” and they were worried he could hurt someone. An undated training document titled “Duty Gear,” indicated all security staff are equipped with handcuffs. The document indicated security staff may handcuff patients when medical restraints are not available. The document indicated security staff should apply medical restraints to a patient as soon as possible. The document indicated handcuffs are not a health care intervention and should not be used on patients. The document indicated handcuffs are a law enforcement tool and are not considered a use of force, but a control technique. The document indicated multiple uses of a single taser, and multiple tasers may be used on an individual to control combative behavior. The document indicated tasers may be used by security staff if other de-escalation attempts have failed. An undated training document titled “Use of Control Measures,” indicated security staff may arrest another individual if a felony has been committed, or if a person attempts or completes a public offense. A policy titled “Taser Energy Weapon,” dated 12/13/22, indicated security may draw and/or use their taser if “A dangerous or violent subject has a weapon or is aggressively advancing toward the [security staff], and the [security staff] believes that they will be assaulted.” A policy titled “Security Use of Force,” dated 2/28/23, indicated security staff are to use the least amount of force necessary to effectively gain compliance from individuals. The policy indicated security staff must act to “return all situations to therapeutic response to a behavioral emergency as soon as possible.” The policy indicated security staff may threaten the use of force to gain control over situations and avoid violence. The policy indicated security staff may “compel a subject with the threat of force to gain compliance” by drawing their intermediate weapons, tasers and REPULS spray. A hospital policy titled, “Handcuffs,” dated 8/8/23, indicated any time an individual is handcuffed in a citizen’s arrest by security staff, the individual must be transferred into local law enforcement custody. The policy indicated patients may be placed in handcuffs as a healthcare intervention when immediate restraint is necessary, and no other appropriate restraints are available.”

“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: 48040 Based on interview and document review, the hospital failed to ensure patients were given medications per physician orders for 2 of 2 patients (P1, P2) on the inpatient psychiatry unit when registered nurse (RN-A) did not follow physician orders and gave P1 and P2 medications to “knock them out.” This had the potential to affect all patients receiving medications from RN-A. The failure resulted in an Immediate Jeopardy (IJ). As a result, the hospital was found out of compliance with the Condition of Participation of Nursing Services at 42 CFR 482.23. A condition-level deficiency was issued. See A-0405.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 48040 Based on interview and document review, the hospital failed to ensure patients were given medications per physician orders for 2 of 2 patients (P1, P2) on the inpatient psychiatry unit when registered nurse (RN-A) did not follow physician orders and gave P1 and P2 medications to “knock them out.” This had the potential to affect all patients receiving medications from RN-A. The failure resulted in an Immediate Jeopardy (IJ). The IJ began on 11/19/23, when RN-A failed to follow facility practice/policy and administered multiple as needed psychotropic medications and other medications at one time outside of the physician order parameters which caused sedation and resulted in P1 and P2 being sedated. The Vice President (VP) Chief Nursing Officer (CNO), System Director of Regulatory & Accreditation, and two System Program Manager in Regulatory & Accreditation were notified of the IJ findings on 12/7/23, at 12:00 p.m. The IJ was removed on 12/8/23, at 1:35 p.m. after verification of an acceptable removal plan, but a condition level deficiency was issued. Findings include: P1 Admission record indicated P1 admitted to the hospital on 11/19/23 with diagnoses that included bipolar disorder, most recent episode manic, severe with psychotic behavior. P1’s Physician Orders dated 11/19/23 included: -haloperidol (Haldol, an antipsychotic medication) 5 milligrams (mg) by mouth (po) every 8 hours as needed (PRN). Administration instructions: Emergency use for agitation. -lorazepam (Ativan, an antianxiety medication) 2 mg po every 8 hours PRN. Administration (Admin) instructions: Emergency use for agitation. -diphenhydramine (Benadryl, an antihistamine medication) 50 mg po every 8 hours PRN. Administration instructions: Emergency use for agitation. The Physician Order directed to GIVE HALOPERIDOL, LORAZEPAM and DIPHENHYDRAMINE AT THE SAME TIME. -hydroxyzine (Atarax, an antihistamine medication) 25 mg po every 4 hours PRN. Admin instructions: Administer only if there is no other oral medication ordered prn for anxiety. Consider discontinuing if another PRN is ordered for anxiety. -olanzapine (Zyprexa, an antipsychotic medication) 10 mg po 3 times daily PRN. Admin instructions: Not to exceed 30 mg in 24 hours. Doses should be at least 2 hours apart. Olanzapine to be used first line for agitation, unless otherwise specified. On 11/19/23, at 8:05 a.m. P1’s medication administration record (MAR) indicated the following medications were given by RN-A: diphenhydramine 50 mg po, haloperidol 5 mg po, lorazepam 2 mg po, olanzapine 10 mg po, and hydroxyzine 25 mg po. At 1:58 p.m. a progress note written by RN-A indicated P1 was agitated, animated and hyper-verbal that morning. P2’s Admission Record indicated R2 admitted to the hospital on 10/27/23, with diagnoses included schizophrenia, schizoaffective disorder, chronic with acute exacerbation, depression, and suicidal ideation. P2’s Physician Orders dated 11/19/23 included: -alprazolam (Xanax, an antianxiety medication)1 mg po 2 times daily PRN for anxiety. -chlorpromazine (Thorazine, an antipsychotic medication) 25-50 mg po 3 times daily PRN. -hydroxyzine (Atarax) 50 mg po every 4 hours PRN. Admin Instructions: Administer only if there is no other oral medication ordered prn for anxiety. Consider discontinuing if another PRN is ordered for anxiety. -lorazepam (Ativan) 0.25 mg po 1 time daily PRN. On 11/19/23 at 8:09 a.m., P2’s MAR indicated chlorpromazine 50 mg po, hydroxyzine 50 mg po and lorazepam 0.25 mg po were given at the same time by registered nurse (RN)-A. At 11:33 a.m. a progress note written by RN-A indicated he gave P2 PRN thorazine for auditory hallucinations, and PRN ativan and hydroxyzine for increasing anxiety. On 12/5/23 at 9:53 a.m., RN-F stated the provider would set up the time and the parameters for PRN medications. RN-F stated nurses in the inpatient psychiatry units were expected to take a set of vital signs and assess patients prior to medicating patients with PRN medications. On 12/5/23 at 10:00 a.m., the nurse manager, RN-D stated on 11/19/23 at approximately 11:24 a.m. RN-B notified her via text that RN-A had intentionally over medicated P1. RN-D stated she instructed RN-B to call the hospitalist if further guidance was needed, and to file an internal incident report. RN-D stated RN-A was allowed to finish his day shift, as well as an afternoon shift which included providing care to patients, including medication administration. RN-D stated the facility reviewed P1 and P2’s MAR for 11/19/23, but did not look other days P1 and P2 may have been given incorrect medications by RN-A, nor did they look at any other patients who may have been given incorrect medications by RN-A. On 12/5/23 at 1:17 p.m. RN-B stated on 11/19/23 during shift report handoff, RN-A was informed P1 had been administered Ativan 2 mg at 7:07 a.m. RN-B stated after receiving report RN-A stated, “I wished I could give a B52 (a medication combination of Ativan, Benadryl, and Haldol) to P1.” RN-B stated later that shift, RN-A told him he had intentionally over-medicated P1. RN-B stated RN-A had stated he was “two for two” for knocking out patients that shift. RN-B stated he had observed P1 on 11/19/23 at approximately 7:30 a.m., and P1 did not have any behaviors. RN-B stated he had assessed P1 at approximately 9:00 a.m. and at that time, P1 appeared overly sedated. RN-B stated the Pyxis (automated medication cart) would not let you double medication at close intervals unless you canceled a previous medication administration record. RN-B stated RN-A did cancel a previous medication administration record in order to give P1 Ativan 2 mg again. On 12/5/23 at 2:13 p.m., nurse practitioner (NP)-A stated a week and half prior to the incident on 11/19/23, she raised a concern over how RN-A was administering PRN Ativan and Thorazine at the same time to P2, even though P2 already had scheduled medications to keep him calm. NP-A stated when she confronted RN-A he seemed receptive to the correction. On 12/5/23 at 3:50 p.m., the pharmacy manager (PM)-A stated she expected nurses to follow medication orders as given by the clinicians to prevent misuse or medication errors. PM-A acknowledged there would be a risk of respiratory distress/sedation if Ativan 2mg, Haldol 5 mg, Benadryl 50 mg, Hydroxyzine 25mg, and Zyprexa 10 mg were given all at the same time, as had happened with P1. On 12/5/23 at 4:11 p.m., the psychiatric unit director of nursing (DON) stated RN-A had been coached previously about medication administration included the parameters and the frequencies. The DON stated it was not the hospital process to give olanzapine and hydroxyzine along with Ativan, Haldol and Benadryl. The DON stated there was no system in place to prevent further occurrence; they trained their nurses and trusted them to follow physicians’ orders. On 12/6/23 at 10:00 a.m., RN-C stated on 11/19/23 at 7:07 a.m. she gave P1 Ativan 2mg, documented that in the MAR, and gave a verbal report to RN-A. RN-C stated when she came back to work at 3:00 p.m., she realized her documentation on P1’s Ativan was modified to “not given” by RN-A. RN-C stated she notified RN-D via email to address the issue. On 12/6/23 at 4:16 p.m., the CNO stated the hospital completed an investigation, and determined RN-A intentionally did not follow physician’s orders for P1 and P2 related to medication administration. The CNO also stated RN-A did not monitor vital signals on P1 and P2 which placed both patients at a safety risk. The hospital investigation dated 11/29/23 indicated: For P1: The provider order includes for Ativan ‘This drug may cause significant respiratory depression. Monitor respiratory status and vital signs carefully for 1 hour after each dose’. Vital signs were not completed. And no patient assessments were completed. This was verified by the flowsheet and video surveillance. This patient was non-responsive and mumbling when the provider tried to assess him. Vital signs are ordered every shift. For P2: The first line treatment for anxiety was hydroxyzine, RN-A administered Ativan. During the investigative interview RN-A reported the patient said hydroxyzine was not effective, but this was administered anyway. This patient also received lisinopril which can reduce heart rate and blood pressure. Vitals were not obtained before administering this medication. There were no vital signs taken until 6:53 p.m. It is standard/best practice to obtain vitals before administering blood pressure medications. Vital signs are ordered every shift. Several of RN-A’s coworkers reported he verbalized intentionally overmedicating patients stating, “You guys, I’m intentionally overmedicating my patients today; I’m going to say I found a pill on the floor, I’m two for two in knocking them out.” The facility Medication Administration policy reviewed 11/22/22 directed its purpose is to ensure the safe and effective management of medications throughout administration and monitoring processes, as well as meet regulatory compliance and adherence to established best practice standards. The policy directed nurses to assess and document vital signs prior to and/or after medication administration as appropriate to the medication or based on parameters within the order or protocol. The IJ was removed on 12/8/23, at 1:35 p.m. after the following actions were completed: The medication administration policy was reviewed. A mandatory education of current policies and processes around PRN medication administration including justification of use for appropriate indications and stacking of medications was provided to all nursing staff who administer psychoactive medication. This was to be completed prior to the start of their next shift, any staff on leave were required to complete prior to their first shift. The DON reviewed all medication administration records for those patients assigned to RN-A on 11/19/23 to ensure no other patients were overmedicated. This was verified through staff interview and document review.”