Mayo Clinic Health System - Mankato

“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: 33925 Based on interview and document review, the hospital failed to ensure staff re-evaluated and developed a safe discharge plan for 1 of 10 patients (P4) reviewed when P4 was discharged to walk home over a mile away in unsafe weather temperatures. P4 presented to the emergency department (ED), was treated, and when transportation could not be arranged, he said he would walk home, was given a map and socks to wear as mittens. As a result, the hospital was found out of compliance with the Condition of Participation Discharge Planning at 42 CFR 482.43. A condition level deficiency was issued at A-0799. See A-0802 for additional information.”

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 33925 Based on interview and document review, the hospital failed to ensure staff re-evaluated and developed a safe discharge plan for 1 of 10 patients (P4) reviewed when P4 was discharged to walk home over a mile away in unsafe weather temperatures. P4 presented to the emergency department (ED), was treated, and when transportation could not be arranged, he said he would walk home, was given a map and socks to wear as mittens. Findings include: P4’s EMS Documentation, dated 1/19/26, identified the crew had received call from an assisted living in Mankato. EMS responded and recorded P4 as a 73-year-old male who reported a possible allergic reaction. P4 was alert and oriented on the scene and complained about a pinkish skin developing with itching. P4 was taken 1.6 miles to the hospital ED, placed in a triage bay, and report was given to the hospital staff. P4’s ED Record identified the following information: - P4 presented to the ED on 1/19/26 at 3:00 p.m. via EMS, was triaged and assigned an ESI (Emergency Score Index) of 4 (1-5 scale with 1 most unstable). - A chief complaint of itching was listed, and P4 was diagnosed with Pruritus (itchy skin). - Registered nurse (RN)-A was assigned to the patient at 3:41 p.m. - P4 was recorded as alert and oriented to person, place, and time, and was in no acute distress. - ED Disposition was set to be discharged by the physician on 1/19/26 at 5:50 p.m. P4’s ED Notes, dated 1/19/26 at 6:13 p.m., identified P4 was ready for discharge and the registered nurse (RN) attempted to locate a ride back to the assisted living campus for him. P4 had no family present with him, so P4 was given a cell phone to call his son for a ride. P4’s son was unable to be reached. The local bus route was no longer running, and the RN called the assisted living. They stated they were unable to provide P4 a ride. The RN attempted to involve a local service called “Go Go Grandparents” but were unable to do that as P4 did not have an account with the service. The note recorded, “RN encouraged patient to wait to secure a safe ride due to the cold weather, even offering to get the patient an Uber through personal account. Patient continued to state he was going to walk home and had done it before. He requested a map to help guide him and this was provided. Patient stated he would stop along the way to get something to eat and warm up midway. P4 was recorded as his own decision-maker and left the campus walking back to the assisted living campus. RN-A authored the note. P4’s ED Provider Note, dated 1/19/26, identified P4 had multiple medical conditions including anxiety, COPD, and atrial fibrillation. A section labeled, “Social Drivers of Health,” identified multiple questions which were auto populated from a previous questionnaire the patient had completed. This identified a subsection labeled, “Transportation Needs: Unknown (12/1/2025),” and outlined P4 had declined non-medical transportation issues previously. P4 was treated with Benadryl and Pepcid and his symptoms improved. P4 was discharged back home with primary care to follow-up. The note lacked any evidence that the medical doctor (MD) was contacted or updated with P4 leaving the hospital to walk home in the severe cold. A Vulnerable Adult Maltreatment Report, dated 1/22/26, identified P4 was taken to the ED on 1/19/26 for possible anesthetic reaction. P4 was then discharged back to his assisted living campus without a ride and picked up by local law enforcement when someone reported an elderly man walking in below zero temperatures. P4 was reported to be wearing slip on shoes, jeans with a t-shirt, springtime thin jacket. P4’s mustache was frozen with ice when he was found. P4 was returned to the assisted living campus, and his hands were red in color, cold to touch, and he had icicles melting off his mustache. An AccuWeather report, printed 3/2/26, identified the weather for Mankato, MN on 1/19/26. This recorded a high temperature for the day of 4 degrees (F) and a low temperature of -7 (F). On 3/2/26 at 12:28 p.m., RN-B was interviewed and explained patients coming from other healthcare facilities, like an assisted living or skilled nursing campus, do not always have all the paperwork to help them determine someone’s cognition or decision-making abilities. They rely heavily on the verbal EMS report. RN-B stated discharge planning for these patients from the ED fell mostly to the nurse assigned to them and their own “good judgement,” but there were some social workers available to help, if needed. RN-B stated arranging transportation back to the care venues had been a challenge for several years as there was no local taxi service anymore in the area adding, “Everyone knows this is a problem.” RN-B stated assessing someone’s transportation needs or choice is done verbally and if a person from the assisted living was their own decision-maker, then they would attempt to arrange a ride for them as best able but ultimately, if they wanted to leave, they’d be allowed to leave the ED on their own. On 3/2/26 at 1:53 p.m., RN-A was interviewed and verified they were the nurse assigned to care for P4 when he presented to the ED on 1/19/26. RN-A recalled the patient interaction and explained he was set for discharge when they discovered he had no transportation back to the assisted living. P4 thought his son could help, but was unable, and the last bus pick-up for the day had already passed. RN-A offered another service called, “Go Go Grandparents,” but P4 did not have an account for it. They reached out to the health unit coordinator (HUC) but, again, all bus or other services were closed or done for the day. RN-A stated P4 then seemed to feel bad about “being a burden” and stated he would just walk back on his own as he had done it before. RN-A told P4 it was cold outside, and he had no mittens, but P4 persisted. A map was printed and RN-A offered P4 some socks to use on his hands for mittens. P4 then left the ED. Awhile later, RN-A received a telephone call from the assisted living, and they were upset explaining P4 had been picked up by local police and brought back to their campus. RN-A stated they were glad P4 was found by the police as they recalled it was “a very, very cold day.” RN-A explained the situation still was upsetting to them and wished more transportation options were available in the after-hours. They used to be able to contact EMS or the local police for these issues, however, they had been told not to anymore by hospital leadership. RN-A did not recall speaking with the MD who cared for P4 about the transportation issue, either. RN-A stated the hospital leadership talked with them about this incident, but more so just expressed they had reviewed the documentation and did not know what else could have been done. RN-A stated that, in hindsight, they should have just not allowed P4 to leave the ED given the weather conditions outside until a transportation option was found. RN-A added, “I could have been empowered to do that.” When interviewed on 3/2/26 at 2:42 p.m., RN-C stated they had worked in the ED for several years and explained there were several options for transportation, if needed. These included AMV, but they stop with rides at 5:00 p.m., and “Fair Ride” which was possibly available 24/7 but RN-C was not sure. RN-C verified using EMS or local police for a ride was “not an option” per leadership and verified either the nurse assigned or the HUC would be responsible for arranging the transportation for the patient. RN-C stated if a person were their own decision-maker and wanted to leave the ED despite it being unsafe outside, which would be “a hard one” to navigate. RN-C stated they would attempt to call family for a ride or maybe an Uber after checking with the charge nurse for options. RN-C stated they would not allow them to leave if it was unsafe. RN-C recalled hearing about an incident at the hospital a few months prior where someone had left and was “in the cold for hours” as a result, however, there had been no new practices or re-education done with staff they could recall about how to address the situation in the future. RN-C added, “Not that I know of anyway.” On 3/2/26 3:13 p.m., a group interview was held with nurse administrator (NA)-A, clinical nurse specialist (CNS)-A, NA-B, accreditation specialist (AS)-A, and NA-C. CNS-A explained using EMS or local police for transportation was not an option unless it was “a special circumstance,” and acknowledged that after-hours transportation options can be “kinda limited.” The ED had a nurse and social worker who could help arrange transportation, too, but some services like AMV stop service and are not after-hours. CNS-A explained they have done education with staff on situations where someone is not allowed to leave the ED, such as a risk to themselves or others, but had not done education for a weather-related scenario like this incident. In this case, the nurse attempted to get P4 to stay but he wanted to leave so it was a “more gray area.” CNS-A acknowledge that a telephone report to the local police when P4 left would have likely been appropriate just so they were aware of a potential unsafe situation adding such notification was “not out of the ordinary.” There is always an option to just house someone in the ED for a while, too, pending space available. CNS-A stated if this scenario happened again, the nurses would be expected to go through all their options for transport but then contact local police if the person left the campus. CNS-A stated they felt some education on this incident would be helpful for the staff. NA-A verified there was no safety report completed for this event, either, nor had the incident gone to the hospital’ safety committee for review. NA-A added they had reached out to the hospital legal department about this incident but had never heard back from them. When interviewed on 3/3/26 at 8:55 a.m., MD-A verified they were the physician assigned to P4 on 1/19/26. MD-A recalled the patient as alert and oriented but only “vaguely” remembered the case. MD-A stated the nurses were responsible for arranging post-care transportation. MD-A did not recall anyone speaking with them about this incident or P4’s lack of transportation on 1/19/26. If they had, MD-A stated he would have requested P4 not leave and remain in the ED. MD-A stated there were open rooms available that night most likely and he could have just remained in the ED until the morning. MD-A added, “That’s the usual protocol I think.” MD-A reiterated if they had been told P4 wanted to walk back to his assisted living in severe cold weather, it would not have been allowed adding, “I would have intervened.” MD-A expressed weather like that is a safety risk and the hospital was responsible for his care adding, “He’s [our] patient.” A hospital Transportation Services for Established Mayo Patients policy, dated 2/2025, identified it applied to employees when offering or arranging free local transportation services, however, it did not apply to the emergency department of inpatient transfers to other hospitals. The policy outlined free local transportation would be offered to established patients without regard to payer source if they met clinical criteria and had no reasonable means of transportation. A hospital Care Management Transportation Assistance Guideline policy, dated 2/2025, identified guidance on when Mayo Clinic funds could be used for transport. It included tree-style options to be considered prior, including family or volunteer service. If those are exhausted then care management could obtain approval from leadership to pay the cost of transport. The policy included several insurance-covered providers who could be contacted. A hospital Discharge Planning Policy, dated 11/2021, identified it applied to all personnel involved in direct patient care when participating in hospital discharge planning. It outlined that all patients would be assessed for continuing care needs throughout the episode of care and a discharge plan would be developed with the patient. The policy directed, “The discharge plan must be reassessed if factors arise that may affect continuing care needs or the appropriateness of the plan.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) Unless superseded by State law that is more restrictive-- (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1-hour for children under 9 years of age; This Standard is not met as evidenced by: 47264 Based on interview and document review, the hospital failed to renew an order for non-violent restraints for one of two patients (P3) reviewed per hospital policy. P3’s last order for non-violent restraints was placed on 7/2/24 at 1:54 p.m., not renewed at 24 hours, the order was discontinued on 7/3/24 at 8:00 p.m. Findings include: P3 presented to the hospital emergency department (ED) on 6/19/24 at 7:53 a.m. via ambulance from his long-term care facility for shortness of breath. P3’s medical diagnoses included dementia, chronic obstructive pulmonary disease (COPD), failure to thrive, and severe protein calorie malnutrition. On 6/19/24 at 12:40 p.m. P3 was admitted to an inpatient unit and transferred out of the ED. On 6/19/24 at 5:55 p.m., the hospital received P3’s Provider Orders for Life-Sustaining Treatment (POLST) from his long-term care facility. P3’s POLST, dated 7/1/22, indicated P3 wanted full treatment and resuscitation in the event of a medical emergency. P3’s code status at the hospital remained full code, in accordance with his POLST. On 6/20/24 at 11:36 a.m., a rapid response was called for P3 and P3 was intubated for airway protection. On 6/20/24 at 12:30 p.m., P3 was transferred to the intensive care unit (ICU) for increased level of care. An order placed on 6/20/24 at 2:11 p.m. indicated P3 was placed in non-violent restraints for interference with medical devices. The order stated it was valid for 24 hours from the time of placement. An order placed on 6/21/24 at 12:49 p.m. indicated P3 was placed in non-violent restraints for interference with medical devices. The order stated it was valid for 24 hours from the time of placement. An order placed on 6/22/24 at 11:03 a.m. indicated P3 was placed in non-violent restraints for interference with medical devices. The order stated it was valid for 24 hours from the time of placement. An order placed on 6/23/24 at 10:57 a.m. indicated P3 was placed in non-violent restraints for interference with medical devices. The order stated it was valid for 24 hours from the time of placement. A nursing note on 6/23/24 indicated P3 was extubated at approximately 11:40 a.m. An order placed on 6/27/24 at 6:23 p.m. indicated P3 began receiving enteral tube feedings via nasogastric (NG) tube continuously. A shift event note indicated on 7/1/23 at approximately 7/1/24 at 10:30 p.m. a code was called for altered breathing for P3. Cardiopulmonary Resuscitation was performed and successful. An order placed on 7/2/24 at 1:54 p.m. indicated P3 was placed in non-violent restraints for interference with medical devices. The order stated it was valid for 24 hours from the time of placement. An order placed on 7/2/24 at 6:20 p.m. indicated P3 was intubated for airway protection in the setting of acute respiratory failure. Flow sheet documentation on 7/2/24 at 8:00 p.m. and 10:00 p.m. indicated P3 continued in non-violent bilateral wrist restraints due to continued behavior of pulling on life-sustaining lines and tubes. Flowsheet documentation on 7/3/24 at 12:00 a.m., 2:00 a.m., 4:00 a.m., 6:00 a.m., 8:00 a.m., 10:00 a.m., 12:00 p.m., 2:00 p.m., 4:00 p.m., and 6:00 p.m. indicated P3 continued in non-violent restraints due to continued behavior of pulling on life-sustaining lines and tubes. An order for a palliative care consultation was placed on 7/3/24 at 3:42 p.m. with P3’s guardian due to P3’s consistent refusal and resistance to treatments. Flowsheet documentation at 7/3/24 at 8:00 p.m. indicated P3’s nonviolent left and right wrist restraints were discontinued by nursing staff. On 7/5/24 at 2:34, an advanced care planning meeting was held with P3, P3’s guardian, his family, and the physician. P3 was transferred to comfort cares and his medical code status was changed to allow for natural death. Flowsheet documentation on 7/3/24 at 8:00 p.m. indicated P3’s nonviolent restraints were discontinued after release criteria was met. On 7/5/24, P3 was transitioned to comfort cares. A respiratory therapy note on 7/5/24 at 4:04 p.m. indicated P3 was extubated for comfort cares. An inpatient expiration summary on 7/6/24 at 1:48 a.m. indicated P3’s time of death was 1:02 a.m. P3’s preliminary cause of death was indicated as natural. During an interview on 8/7/24 at 1:52 p.m., registered nurse (RN)-A stated orders for nonviolent restraints need to be placed by the provider within an hour of application, and only lasts for 24 hours. During an interview on 8/7/24 at 2:21 p.m., RN-B stated orders for bilateral wrist restraints are renewed at least every 24 hours. During an interview on 8/7/24 at 2:41 p.m., RN-C stated orders for nonviolent restraints should be renewed every 24 hours by a provider and this is stated in the hospital’s policy. During clinical record review on 8/8/24 at approximately 2:00 p.m., the informatics nurse specialist, informatics clinical specialist, the clinical nurse specialist manager, the clinical nurse specialist, and the nurse administrator stated they could not identify an order renewal for the nonviolent restraints continued on P3 after 7/3/24 at 1:54 p.m. A hospital policy titled “Restraint or Seclusion,” dated 3/9/23 indicated an authorized provider must evaluate the need for continued non-violent restraints and renew the order every 24 hours.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 34083 Based on interview and document review, the facility failed to follow their grievance policy and procedure including investigation and providing a written response to a patient in response to a grievance and report a grievance of suspected maltreatment immediately to the State Agency for 1 of 10 patients (P6) who voiced a grievance to the facility of abuse. Findings include: Review of P6’s 12/19/23 at 6:06 p.m., emergency record identified she was brought to the Emergency Department (ED) due to increased concern for safety at home with suicidal ideation with a plan for self-harm. She was assessed and placed on a 72 hour hold to facilitate acute psychiatric placement. Psychiatry was consulted on 12/21/23 and petitioned for Civil Commitment with the County. P6 had diagnosis of Bipolar I depressed, anxiety disorder, obsessive compulsive disorder, borderline personality disorder, self-injurious behaviors, post-traumatic stress disorder and major depressive disorder. The ED record documented attempts for acute care placement which were unsuccessful and P6 was housed in the ED pending placement. Review of the timeline provided by registered nurse (RN)-A identified the sequence of the reported events on: 1) 12/29/23: During rounds of the ED department was notified by the charge nurse of an alleged abuse by an (unidentified) male technician against P6 during the overnight hours of December 28, 2023. Law enforcement had not been notified prior to the report and interviewed P6 on the morning of December 29, 2023. Immediate changes to P6’s Behavioral Safety Plan included: 2 staff members in attendance during interactions and placed on video camera monitoring. 2) 12/31/23, an email was sent to RN-A (nurse manager) informing that P6 alleged a Behavioral health nurse, “patted her inappropriately” while assisting with a shower and drying her off. 3) 1/2/24, RN-A received email dated as sent December 31, 2023, that P6 alleged that she was “patted inappropriately” when assisted with drying following a shower. RN-A reached out to the compliance department for assistance on next steps to take regarding the allegations. 4) 1/3/24, Mayo Clinic Health System Clinical Coordination Council approved Immediate Response to Allegations of Abuse of a Patient by Mayo Clinic personnel Procedure-Mayo Health System. 5) 1/4/24, the incident was reported to Office of Risk Management (ORM) for investigation. Interview on 1/4/24 at 2:38 p.m., with the licensed social worker (LSW) reported she had performed the initial social assessment when P6 came to the ED on 12/19/23. P6’s admission was due to a mental health issues and suicidal ideation. On 1/3/24 she had spoken with P6 who informed her she had “Rights”, she wanted to speak with the Ombudsman and that she had contacted law enforcement because an unidentified ED staff member had “sexually assaulted” her. P6 was not able to identify when the incident had occurred or who the staff member was. The LSW followed up with the nurse supervisor who was going to speak with P6. Immediately following the reported incident P6’s plan of care was revised for two staff members in attendance for all personal care, and security was stationed outside the room, as a precaution. The LSW was unaware of any additional information about the alleged incident but stated P6’s room was located across from the nursing station to allow for staff to monitor her. Interview on 1/4/23 at 3:07 p.m., with physician (MD)-A reported P6 was housed in the main ED due to her need for oxygen. She was non-compliant and voiced multiple complaints that staff were not taking care of her. P6 would have behaviors of yelling and screaming for assistance when the ED was very busy, and staff could not immediately respond to her requests. He recalled one incident when the ED was very busy and P6 was in the doorway of her room yelling that she saw someone (several male technicians were across the hall), through the glass of her room, and claimed one of them had assaulted her. She did not know who the alleged person was and was not able to identify anyone. MD-A identified he was not able to recall the date of the incident, but reported P6 was not able to identify anyone or when the alleged assault had taken place. He stated he had been very busy with activity in the ED and had not responded to the allegation, but thought administration was aware and looking into the incident. Attempted interview on 1/4/24 at 3:55 p.m. with P6 who voiced multiple complaints of mistreatment by the facility. She referenced incidents that had occurred from August 2022 and October 2023, and the reason she had been brought to the hospital, due to not wanting to live anymore. She stated while she had been in the ED she had been “sexually assaulted”, and that she had been “patted” inappropriately when being assisted with a shower. P6 was not able to identify the alleged staff or the date/time the incident took place. She questioned who was calling and from where, then voiced she wished she had realized who she was talking to as she thought this surveyors agency (State Agency) was the agency that had put her in the hospital in the first place and hung up the phone. Interview on 1/4/23 at 4:42 p.m., with registered nurse (RN)-A identified when she was notified on 12/29/23 of P6’s alleged sexual assault she ensured safety measures were in place. Law enforcement had been notified of the allegation, however, she was unsure if the State Agency had been. She identified that security was also present outside P6’s room when staff were in attendance and her room was across from the nurse’s station and within the line of sight. RN-A denied knowledge of the Grievance and abuse policies and no reports were completed since P6 was not able to identify anyone. Following receipt of the email alleging the second incident she had thought the nurse was just helping P6 dry off but had reached out to Compliance for direction. RN-A confirmed she had not received any further direction, and no additional documentation or reporting was completed. Interview on 1/4/24 at 4:50 a.m. with the Accreditation Specialist identified she was not certain of a policy in place, but reported the organization was currently working on a policy/procedure and it was currently in committee approval. She confirmed the alleged incident had not been reported tot he State Agency, and no further investigation had taken place. After the survey, and email was received identifying the facility had an Abuse and the Grievance policy. The incident had been referred to The Office of Risk Management for further investigation and their recommendations would be followed according to facility policy. Review of the 12/27/23, patient Complaint and Grievance Procedure identified an application was available to all personnel who received a concern or complaint involving the Mayo Clinic or it’s personnel. Prompt service was to be provided and if the issue is not able to be resolved, the patient was to be provided contact information for the Office of Patient Experience. If a concern or grievance was not able to be promptly resolved by staff present, it was to become a Grievance subject to The Joint Commission (TJC) and the Centers of Medicare and Medicaid Services (CMS) Conditions of Participation (CoP’s). A Grievance was defined as any concern expressed by a patient regarding care provided, allegations of abuse, neglect, patient harm, or breach of restricted information or the hospital’s compliance or a concern that was not promptly resolved by the department staff. Review of the July 3, 2023, Mandated Reporting of Abuse, Neglect, or Exploitation of Vulnerable Adult Policy identified the purpose to ensure appropriate handling and reporting of suspected cases of abuse, neglect, or exploitation of vulnerable adults in accordance with state law. All personnel must report the suspected maltreatment to the State Agency as outlined in the policy. Information of an alleged incident involving a Mayo clinic associated person must be communicated immediately to the appropriate Unit/Department Manager/House Supervisor and Administrator of the department in addition to the legal department. The Legal department reviews the information/allegation and provides guidance on investigation and reporting requirements.”