M Health Fairview St John’s Hospital

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 49618 Based on interview and record review, the hospital failed to follow their policy to provide care in a safe setting for one of three patients (P2) when he eloped from the hospital. P2 lacked decision making capability and was a fall risk. As a result, the hospital was found out of compliance with the Condition of Participation Patient Rights at 42 CFR 482.13. A condition level deficiency was issued at A-0115. See A-0144 for additional information.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 49618 Based on interview and record review, the hospital failed to follow their policy to provide care in a safe setting for one of three patients (P2) when he eloped from the hospital. P2 lacked decision making capability and was a fall risk. Findings include: P2’s medical records indicated P2 was admitted to the hospital on 4/3/26 with a primary diagnosis of hyperkalemia. P2’s additional diagnoses included aneurysm of arteriovenous dialysis fistula, chronic kidney disease- mineral and bone disorder, chronic pain syndrome, drug-seeking behavior, episodic mood disorder, end stage renal disease needing dialysis, homelessness, impaired mobility, learning disability, developmentally disabled, noncompliance with renal dialysis, personal history of noncompliance with medical treatment (presenting hazards to health), schizoaffective disorder (bipolar type), and weakness. P2 eloped from the hospital on 4/10/26. P2’s provider progress note dated 4/3/26 indicated P2 presented to the emergency department (ED) for placement to another facility. P2 had just been discharged from the hospital a few hours prior and the long-term care facility that he was accepted to did not allow him to use his electric wheelchair. The provider noted that P2 had hyperkalemia, needed dialysis, and needed placement at a long-term care facility. P2 was admitted to the hospital. P2’s provider progress note dated 4/3/26 indicated P2 had cognitive impairments. P2 had underlying schizophrenia but had a decline in cognition associated with ruptured aortic aneurysm and prolonged intubation in December 2024. P2 was deemed to lack medical decision-making capacity and had a court appointed guardian since December 2024. P2’s ED timeline assessments dated 4/3/26 indicated P2 was not a risk for elopement. P2 did not have any confusion at the time of the assessment. P2 had a fall risk score of two, which indicated P2 was a fall risk. A fall prevention wristband was placed on P2. P2’s progress note dated 4/4/26 indicated P2’s care plan directed staff to identify and manage fall risks. The intervention was P2’s activity would be supervised. P2’s progress note dated 4/4/26 indicated P2 required stand by supervision for bed mobility and transfers. P2’s provider progress note dated 4/6/26 indicated social worker (SW) had been following P2 for placement to a long-term care facility. This was deemed challenging due to the setting of homelessness, profound cognitive and psychiatric illness, inability to adhere to outpatient dialysis as well as follow up which contributed to overall poor prognosis and recurrent hospitalizations. P2’s progress note dated 4/6/26 indicated the provider updated her that she had just spoken with P2. P2 reported to the provider that his brother was going to bring in his electric scooter and he planned to leave the hospital. The writer called the guardian who stated the guardian had spoken to P2’s brother who reported he did not plan to bring P2’s electric scooter to him at the hospital. The provider was notified. P2’s progress note dated 4/6/26 indicated P2 stated he was frustrated and wanted to leave the hospital. P2 stated he would be leaving once his electric scooter was dropped off. The provider was notified. P2’s provider (P) progress note dated 4/7/26 indicated P2 was medically ready for discharge. P2’s provider progress note dated 4/8/26 indicated P2’s discharge was complicated by placement and behavioral issues. P2’s progress note dated 4/8/26 indicated P2’s brother brought P2’s electric scooter to the hospital. P2’s progress note dated 4/8/26 indicated P2 was independent with his electric scooter. P2’s progress note dated 4/8/26 indicated the writer notified security that P2 had left hospital grounds, crossed the street, and went to the gas station around 4:00 p.m. P2 was told earlier in the day that since he had an electric scooter that he needed to stay on hospital grounds. Law enforcement, nursing supervisor, and provider were notified. P2 returned on his own to the hospital at 4:30 p.m. while he attempted to take money out of the ATM machine in the cafeteria. P2 was escorted back to his room by nursing staff and security. P2 stated he knew that crossing the street would “be a problem” but P2 did it anyway. P2 stated he wanted to leave hospital grounds to get snacks. It was reiterated to P2 that he was not allowed to leave hospital grounds, and P2 verbalized understanding. P2’s progress note dated 4/9/26 indicated P2 used his electric scooter around the unit. P2 asked to go outside and was told that he could only go outside if he stayed in front of the hospital and could not leave any further than that. P2’s progress note dated 4/9/26 at 10:54 p.m. indicated P2 reported he needed to move his vehicle from his prior group home. P2 stated he planned to leave in the morning. The guardian was called to discuss this and the guardian stated P2 cannot leave the hospital. The charge registered nurse (RN) and nursing supervisor were notified. P2’s provider progress note dated 4/10/26 at 1:15 a.m. indicated provider was notified that P2 wanted to leave because his vehicle was going to be towed from his prior group home. P2’s guardian was called and guardian stated he did not want P2 to leave the hospital. Provider attempted to talk to P2, but he was sleeping. The provider discussed with the charge RN that the charge RN was going to talk to the prior group home to see if P2’s vehicle removal could be delayed. P2’s progress note dated 4/10/26 at 3:12 a.m. indicated charge RN was notified P2 wanted to leave the hospital against medical advice (AMA) in the morning to move his vehicle from his prior group home. P2’s primary RN called P2’s guardian who stated she did not want P2 to leave the hospital. The primary RN and charge RN spoke with P2 regarding the need to stay at the hospital for dialysis and a safe discharge plan. Primary RN and charge RN advocated P2 to call his guardian to make a plan. The guardian did not answer her phone. These calls had been made before 9:00 p.m. on 4/9/26. The nursing supervisor, security, and the provider were notified about the situation. The provider and the charge RN attempted to talk to P2 about the situation, but he was sleeping. P2’s progress note dated 4/10/26 at 4:58 a.m. indicated P2 stated he wanted to leave the hospital to get his vehicle that was parked at his prior group home, but the hospital had been waiting for discharge placement to a long-term care facility to meet P2’s needs. The provider, charge RN, and supervisor spoke with P2 on the previous shift. The progress note indicated staff would need to be aware and ensure P2 did not leave the hospital AMA. P2’s progress note dated 4/10/26 at 7:29 a.m. indicated P2’s guardian called the unit and stated she wanted P2 to stay in the hospital and was agreeable to a court hold if it was needed. The charge RN, primary RN, nursing supervisor, and provider were notified about what the guardian stated. P2’s progress note dated 4/10/26 at 7:50 a.m. indicated P2 was found to have left the hospital AMA between 7:40 a.m. and 7:45 a.m. that morning. The writer, charge RN, nursing supervisor, provider, leadership, and guardian were notified. P2’s provider progress note dated 4/10/26 indicated P2 left the hospital AMA. P2 was awaiting placement to a long-term care facility when he left AMA. P2’s condition at the time of discharge was stable. P2’s flow sheets indicated P2 was a high fall risk on 4/4/26 at 1:44 a.m., 4/4/26 at 8:50 a.m., 4/4/26 at 8:05 p.m., 4/5/26 at 4:15 a.m., 4/5/26 at 8:00 a.m., 4/5/26 at 3:00 p.m., 4/5/26 at 9:53 p.m., 4/6/26 at 4:15 a.m., 4/6/26 at 8:45 a.m., 4/6/26 at 4:00 p.m., 4/6/26 at 8:30 p.m., 4/7/26 at 12:05 a.m., 4/7/26 at 10:00 a.m., 4/7/26 at 4:00 p.m., 4/7/26 at 8:20 p.m., 4/8/26 at 12:35 a.m., 4/8/26 at 8:20 a.m., 4/8/26 at 6:00 p.m., 4/9/26 at 12:40 a.m., 4/9/26 at 11:00 a.m., 4/9/26 at 5:00 p.m., and 4/10/26 at 12:25 a.m.. During an email correspondence on 6/15/26 at 1:28 p.m., regulatory and accreditation specialist (RC)-A indicated staff completed an elopement risk assessment on P2 and scored no risk for elopement. During an email correspondence on 6/15/26 at 1:38 p.m., RC-A indicated the hospital no longer had camera footage of P2 eloping from the hospital due to it being over 30 days. During an interview on 6/15/26 at 2:26 p.m., P-A stated P2 told her that he was upset because he did not have his electric scooter and he liked to go for rides on his electric scooter. P2 stated he planned to have his brother bring his electric scooter to the hospital. P-A thought P2 could leave his room “once in a while” to go for a ride on his electric scooter. P-A stated before he eloped on 4/10/26 she did not think P2 was at risk of eloping despite P2 saying that he wanted to leave the hospital multiple times. P-A would tell P2 that he could not leave because the guardian would need to know he had a safe discharge. P-A stated the incident when P2 went to the gas station she did not think that was considered an elopement because he came back to the hospital to resume medical care. P-A stated P2 did not have a one-to-one sitter before or after the incident on 4/10/26. P-A stated it is not reasonable for every patient who stated they wanted to leave to be put on a one-to-one sitter. During an interview on 6/15/26 at 2:39 p.m., RN-K stated when P2 stated on 4/9/26 he wanted to leave the hospital, RN-K had a discussion with RN-J. RN-K and RN-J talked to P2 and P2 agreed to go to dialysis in the morning. RN-K stated when she called P2’s guardian on 4/9/26 and stated P2 wanted to leave the hospital, RN-K asked the guardian how she should prevent P2 from leaving. The guardian stated to RN-K that she did not know whether P2 had a vehicle or not. RN-K notified the provider. P2 was not on a one-to-one sitter during RN-K’s shift. RN-K had a discussion with RN-J about P2 being on a one-to-one sitter. RN-J stated that since it was 11:00 p.m. at night, RN-K and RN-J did not think P2 would leave the hospital at that time. RN-K stated P2 had left the hospital “a day or two” prior on his electric scooter. During an interview on 6/15/26 at 3:03 p.m., SW-A stated she received a call on 4/6/26 from the provider stating P2 planned to have his brother bring his electric scooter to the hospital. SW-A spoke with the guardian who stated she had just got off the phone with P2’s brother and P2’s brother stated he did not plan to bring his electric scooter to the hospital. SW-A stated she was assisting P2 in finding placement at a long-term care facility. Most of the long-term care facilities had declined P2’s admission due to his behaviors and history of leaving facilities AMA. During an interview on 6/15/26 at 3:33 p.m., RN-M stated she was at the hospital when P2 left the hospital to go to the gas station. RN-M stated P2 had just received his electric scooter. Soon into the evening shift, P2 “disappeared” on his electric scooter. RN-M notified security while the charge RN notified law enforcement. P2 returned to the hospital and stated he had gone to the gas station. P2 was not on a one-to-one sitter before he went to the gas station and P2 was not on a one-to-one sitter when he returned to the hospital. During an email correspondence on 6/15/26 at 3:50 p.m., RC-A indicated P2 never returned to the hospital after he eloped from the hospital on 4/10/26. During an interview on 6/16/26 at 6:47 a.m., P-B stated staff had called her several times on her overnight shift on 4/9/26 through the morning of 4/10/26. Staff told P-B that P2 wanted to leave AMA. P-B attempted to talk to P2, but he was sleeping. P-B spoke with the charge RN and the charge RN stated she was going to call the prior group home to see if moving the vehicle could be delayed. P-B stated her assumption was that the charge RN was going to follow up with the prior group home, and the provider on the day shift would follow up with P2 and “do what they needed to do”. P-B stated since P2 had a guardian and he continuously stated he wanted to leave, P2 should have been put on a one-to-one sitter. During an interview on 6/16/26 at 7:58 a.m., RN-J stated while she cared for P2, P2 was confused and did not participate in cares. The night before P2 eloped on 4/10/26, RN-J and P2’s primary RN had a discussion with P2 about him wanting to leave. RN-J called the guardian and stated if the hospital needed to place P2 on a hold to prevent him from eloping, the guardian would be agreeable. P2 did not have a one-to-one sitter during her shift. RN-J stated she did not place P2 on a one-to-one sitter during her shift because P2 insisted he was leaving in the morning. P2 was agreeable to get his dialysis done in the morning. RN-J viewed no risk of elopement because of her discussion with P2 and P2 was alert and orientated. RN-J could not recall what kind of staffing and resources were available to her in order to place P2 on a one-to-one sitter. Most of the time the provider does not need to place an order for a patient to be on a one-to-one sitter, it would be up to nursing discretion. After P2’s shift, she gave the oncoming shift the report about P2. During an interview on 6/17/26 at 10:00 a.m., RN-L stated she was told on her shift that P2 had his electric scooter, and he planned to leave. RN-L stated P2 was in his room most of the night. P2 told RN-L that he planned to leave, and the provider and SW wanted to ensure he had a safe discharge. RN-L stated P2 was not on a one-to-one sitter during her shift. RN-L thought maybe P2 had not been on a one-to-one sitter because the SW was trying to find P2 long-term placement. During an interview on 6/17/26 at 10:29 a.m., RN-N stated when she started her morning shift on 4/10/26, she had just received a report from the overnight RN. The overnight RN told RN-N that P2 wanted to leave to pick up his vehicle. RN-N stated he had left the hospital a couple of days prior to going to the gas station. RN-N questioned why P2 had his electric scooter and why P2 was not on a one-to-one sitter. RN-N spoke with P2 stating he could not leave the hospital because he had dialysis that morning. RN-N told P2 that she would talk to the guardian to figure out the vehicle situation. P2 stated he planned to leave the hospital. P2 was caring for two additional critical patients. Another RN passed by RN-N in the hall and stated she had seen a patient on an electric scooter not too long before. RN-N went to P2’s room and P2 was not in his room. RN-N notified security, nursing supervisor, and guardian. RN-N stated she did not know why P2 was not on a one-to-one sitter given that he had already left the hospital once and he stated he planned to leave the hospital. The facility’s Patient Elopement policy dated 10/21/21 indicated the definition of elopement is the patient is not on a hold but lacks decisional capacity due to cognitive, emotional, or chemical impairment and wanders away, or otherwise leaves the hospital or care environment unsupervised or unnoticed prior to their scheduled discharge. If a patient is found to pose an elopement risk, providers implement precautions and interventions (including one-to-one sitters as appropriate) necessary to provide safe environment for the patient to lessen the risk of elopement. Once a patient has eloped, the charge RN would notify the patient’s provider that the patient eloped from the hospital and would work with the provider to determine decisional capacity and potential need for a hold. The hospital’s Surrogate Decision-Makers for Patients with Diminished Decision-Making Capacity dated 12/5/24 indicated if a patient has a court-appointed guardian, the guardian is the only person who may make decisions on behalf of the patient.”

“PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION CFR(s): 482.13(b)(4) The patient has the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital. This Standard is not met as evidenced by: 43080 Based on interview and document review, the hospital failed to ensure all inpatients were promptly asked after admission if they desired their personal physician to be notified of their hospital admission. As the facility followed automatic physician admission notifications via “Care Everywhere,” the patient’s right to choose this notification was not provided to them. This had the potential to affect all inpatients of the facility regarding their preferences for physician notification, and those inpatients who desired not to have their physician updated. Findings include: During an abbreviated medical record review process on 1/9/26, that started at 10:29 a.m., registered nurse (RN)-A and RN-B, when asked to present information of provider admission notifications, stated they lacked the ability to see this field, and thus were unable to display this information. During an interview on 1/9/26, at 2:02 p.m., the system program manager for regulatory and accreditation (MRA) stated the facility utilized “Care Everywhere (an integrated patient record exchange for those organizations that utilized Epic - electronic medical record system software).” She explained that when a patient was admitted, an automatic notification was uploaded into this system and thus the patient was not provided the opportunity to be asked about their choices for physician notification. MRA was unable to state how the physician was alerted once the automatic notification was sent via Care Everywhere but verbalized that any provider who utilized Epic, had access to Care Everywhere. MRA was unaware if there were providers within the Minnesota that did not utilize Epic. MRA stated Registration staff, in May of 2024, asked this question during registration; however, at some point after that, something changed, and they no longer asked it. MRA identified she was unable to find a policy that addressed admission physician notifications. During a follow-up abbreviated medical record review process on 1/9/26, that started at 2:17 p.m., clinical informaticist (CI)-A provided details related to patients being asked if they wanted family updated on their admission; however, when information was reviewed related to physician notification, P10’s chart was reviewed and the field that asked if the patient wanted their physician updated on their admission identified “No” as the chosen response. Immediately after, CI-A stated, “These questions are not relevant,” as the admission notifications went “to [the physician’s] inbox,” if the patient was a Fairview patient. During a subsequent interview on 1/9/26, at approximately 2:45 p.m., MRA stated, “Not everyone has Care Everywhere ...they have to opt into it or opt out.” This option was in the MyChart app for patients to choose. MRA was unaware how the facility knew who opted into, or out of, this process. A policy on primary physician admission notification, along with Care Everywhere, were requested; however, not provided.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 49618 Based on observation, interview, and record review, the facility failed to inform each patient of their patient rights in advance of receiving care to eight of sixteen patients (P4, P5, P6, P11, P12, P13, P14, P15) reviewed when patients was provided care through the emergency department (ED). Findings Include: During an observation on 7/9/25 at 10:28 a.m., R-C registered a patient who needed an interpreter and R-C did not obtain an interpreter. R-C offered the patient bill of rights handout, and the patient shrugged her shoulders indicating she did not know what R-C was saying. R-C indicated in the computer that the patient was offered the patient bill of rights handout. Upon medical record review on 7/9/25 at 10:58 a.m., for P4, P5, P6, P11, P12, P13, P14, and P15 the medical record indicated the question - bill of rights was offered and the box for yes and the box for no was left unchecked. P4’s medical record was reviewed. P4 was admitted to the facility on 7/7/25 when she walked into the ED by herself and was diagnosed with closed compression fracture of L2 vertebra, abdominal distension, and constipation. P4 was discharged from the ED on 7/7/25. P4’s diagnoses did not indicate cognitive impairment. P5’s medical record was reviewed. P5 was admitted to the facility on 7/8/25 when she walked into the ED by herself and was diagnosed with right sided weakness and acute nonintractable headache. P5 was discharged from the ED on 7/8/25. P4’s diagnoses did not indicate cognitive impairment. P6’s medical record was reviewed. P6 was admitted to the facility on 7/8/25 when she walked into the ED by herself and was diagnosed with unstable angina, chest pain, sick sinus syndrome, and bradycardia. P6 was currently admitted to the facility when chart review happened on 7/9/25. P4’s diagnoses did not indicate cognitive impairment. P11’s medical record was reviewed. P11 was admitted to the facility on 7/8/25 when he came into the ED and was discharged from the ED on 7/8/25. P4’s diagnoses did not indicate cognitive impairment. P12’s medical record was reviewed. P12 was admitted to the facility on 7/8/25 when she came into the ED and was discharged from the ED on 7/8/25. P4’s diagnoses did not indicate cognitive impairment. P13’s medical record was reviewed. P13 was admitted to the facility on 7/7/25 and was transferred to the cardiac special care unit and where he was discharged on 7/8/25. P4’s diagnoses did not indicate cognitive impairment. P14’s medical record was reviewed. P14 was admitted to the facility on 7/7/25 when he came into the ED and was discharged from the ED on 7/7/25. P4’s diagnoses did not indicate cognitive impairment. P15’s medical record was reviewed. P15 was admitted to the facility on 7/7/25 when he came into the ED and was discharged from the ED on 7/7/25. P4’s diagnoses did not indicate cognitive impairment. During an interview on 7/7/25 at 12:33 p.m., P13 stated he was not informed about his patient rights during his hospital stay, did not know about his rights as a patient, and was not offered the patient bill of rights. During an interview on 7/7/25 at 12:40 p.m., P14 stated he was not informed about his patient rights during his hospital stay, did not know about his rights as a patient, and was not offered the patient bill of rights. During an interview on 7/7/25 at 12:47 p.m., registered nurse (RN)-A stated the facility’s registration team will offer patients a patient bill of right handout when the patient is registered. During an interview on 7/7/25 at 1:17 p.m., RN- B stated patients are offered a patient bill of rights handout at check in. RN-B would also explain the patient bill of rights before any treatments are given. During an interview on 7/7/25 at 1:50 p.m., RN-C stated patients are offered the patient bill of rights handout by the facility’s registration team. During an interview on 7/7/25 at 2:03 p.m., P4 stated she was not informed about her patient rights during her hospital stay, did not know about her rights as a patient, and was not offered the patient bill of rights. During an interview on 7/8/25 at 11:52 a.m., P11 stated he was not informed about his patient rights during his hospital stay, did not know about his rights as a patient, and was not offered the patient bill of rights. During an interview on 7/8/25 at 11:55 a.m., P5 stated she was not informed about her patient rights during her hospital stay, did not know about her rights as a patient, and was not offered the patient bill of rights. During an interview on 7/8/25 at 11:59 a.m., P12 stated she was not informed about her patient rights during her hospital stay, did not know about her rights as a patient, and was not offered the patient bill of rights. During an interview on 7/8/25 at 1:59 p.m., registration (R)-A stated patients are offered the patient bill of rights handout during the registration process. The patient bill of rights is offered to every patient during registration. R-A stated she will document the patient’s response in the registration screen in the computer and there is a place in the registration notes where she would document if the patient accepted or declined the patient bill of rights handout. R-A stated there is increased registration staff turn over in the ED and registration staff are “bypassing” asking the patients if they want the patient bill of rights handout because “there are several patients and not enough staff who know how to properly register patients.” During an interview on 7/8/25 at 2:20 p.m., R-B stated she will offer patients the patient bill of rights handout during “quick registration” when the patient first walks in the door of the ED and if they can’t offer the patient bill of rights handout at that point, she will offer it during the full registration when the patient is in their ED room. There is a screen in the computer system that asks if the patient bill of rights handout was offered and the “only answer you can put is yes;” there is not another answer that registration staff can choose from. R-B stated there is several new registration staff in the ED that will answer “yes” that they offered the patient the patient bill of rights handout but not actually offering it to the patients. During an interview on 7/8/25 at 3:15 p.m., P6 stated she did not know about her rights as a patient and none of the staff offered her the patient bill of rights handout. During an observation on 7/9/25 at 9:57 a.m., R-A registered two patients and asked if the patient wanted a patient bill of rights handout. Both patients declined. During an interview on 7/9/25 at 10:04 a.m., P15 stated he did not know about his rights as a patient and none of the staff offered him the patient bill of rights handout. During an interview on 7/9/25 at 10:24 a.m., P18 stated she did not know about her rights as a patient and none of the staff offered her the patient bill of rights handout. During an interview on 7/9/25 at 10:27 a.m., P20 stated she did not know about her rights as a patient and none of the staff offered her the patient bill of rights handout. The facility’s policy “Patient Rights” dated 11/11/22 indicated during admission, patients would be offered the patient bill of rights. Documentation that the patient received or declined the patient bill of rights would be part of the medical record.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 49618 Based on interview and record review, the facility failed to include the patient in his right to participate in the development and implementation of his care plan for one of one patient (P1) reviewed for care plans. The hospital had an unknown specialized behavioral health care plan for P1 to change into behavioral scrubs and to remove P1’s belonging from his possession that was enforced when P1 presented to the emergency department (ED) for abdominal pain and constipation. Findings include: P1 presented to the ED on 4/19/25 when he walked into the ED by himself. P1 was diagnosed with abdominal pain and constipation. P1’s prior diagnoses included anxiety, bipolar disorder, borderline personality disorder, and opioid dependence. During his ED visit there was no behavioral health concerns. P1’s triage notes indicated he did not wish to be dead in the past month, did not have suicidal thoughts in the past month, and did not have any suicidal behaviors in his lifetime. P1 was discharged from the ED on 4/19/25. P1’s nursing progress note dated 4/19/25 indicated P1 refused a security search and removal of his belongings from his person. P1’s RN and provider were updated. A letter sent to P1 on 5/2/25 indicated P1 had a special care plan that was developed for him when he came to the facility. The care plan was created to help promote healing and safe environment for P1 while keeping other patients and staff safe. The care plan indicated P1 would be roomed in ED room 7 or 8 if available; no opiates, benzos, or stimulants to be given in the ED given P1’s extensive chemical dependency issues; the ED provider would clearly state the expectations of the workup and encounter from the onset of P1’s arrival; a therapeutic search would be done by security with every visit, and if willing change into behavioral health scrubs; patient belongings “WILL” be removed, “each and every time”; P1 would remain in his room and would not wander out in the unit or stand in the doorway; P1 wouldn’t only be able to speak to his primary registered nurse (RN) and primary provider; P1 cannot ask to speak to a different RN, charge RN, or different provider; food would only be given if therapeutically appropriate; security would escort P1 out of the facility with every discharge; and the police department (PD) would be called if needed. The letter stated this care plan would apply to every ED visit. The ED Care Plan Committee would review the care plan “typically” every 18 months. The team would take into consideration changes to the care plan based on P1’s behaviors and clinical presentation. The facility’s safety reporting and patient feedback tool dated 5/2/25 indicated P1 called and left a message stating P1 was put on a care plan without warning and that he has not had any behaviors to be put on a care plan. On 5/5/25 provider (P)-A reviewed the report intake and stated P1’s care plan would be evaluated every 18 months. On 5/6/25 P-A stated he would not change the care plan or engage in further discussion or debate with P1 about the care plan. P1 liked to “look for wedges, things to argue, nitpick, and debate”. P-A stated, “continuously negotiating every little detail with P1 would be a full-time job quite frankly”. P-B stated he did not think additional or further discussion with P1 would be impactful in “our” decision on the workplace safety care plan at this time. During an interview on 7/7/25 at 9:06 a.m., P1 stated he went to the ED on 4/19/25 and the ED staff told him he had a care plan and part of that care plan was that they were going to take all his belongings. His visit to the ED on 4/19/25 did not consist of any behavioral concerns. P1 stated he went as though his care plan was degrading. P1 refused to have his belongings removed but eventually gave his belongings up due to staff repeatedly asking for his belongings. P1 stated he likes to have his phone on him while he is in the ED because it helps to calm him down. During an interview on 7/7/25 at 12:47 p.m., RN-A stated she believe P1 had a care plan in place at one point, but he had “behaved” and the care plan was removed. P1 stated he should not be on a care plan or that his care plan should have been removed when he did not have behaviors. During an interview on 7/7/25 at 1:17 p.m., RN-B stated she could not recall what interventions were on P1’s care plan but that he did have a care plan in place. RN-B stated she has not seen P1 show behaviors “in a long time”. During an interview on 7/8/25 at 11:21 a.m., RN-D stated she would not normally see the patient have their belongings removed without suicidal or homicidal thoughts if they presented to the ED with abdominal pain and constipation. Removing the patient’s belongings would not typically be protocol. The removal of patient belongings is at the discretion of the primary nurse. If the patient is abusing their phone by calling emergency services while they are receiving emergency care or if the patient is talking to others who are “ramping” him up, she would remove the patient’s belongings. RN-D was unsure why she asked P1 to remove his belongings during his ED visit on 4/19/25. During an interview on 7/8/25 at 11:29 a.m., RN-E stated security would do a search and remove belongings if the provider deemed the patient to be a harm to themselves or others. It would not be protocol for a patient to come in the ED for abdominal pain and constipation and have a security search done and patient belongings removed. RN-E was unable to recall P1’s ED visit from 4/19/25. During an interview on 7/8/25 at 1:00 p.m., P-A stated patients would have a care plan when patients have an increased number of visits for the same concern. When a patient has a care plan, interdisciplinary team (IDT) will meet once a month, care plans would be reviewed, and P-A would take notes on each patient’s facility visits during that month. P-A stated if the patient comes to the ED for a concern and it is not related to the concern that the care plan was used for, then staff are not expected to use the care plan. Providers and clinical staff have access to implement the care plan. If the patient came to the ED for a concern, providers and clinical staff have the authority to implement or not implement the care plan. P-A stated P1’s care plan was started on 4/18/24 and is up for review in October of 2025. P1’s care plan was “mostly” about behavioral stuff such as firing his nurses, wanting a different provider, and going to the nurses station frequently through his ED visits. The last 20 ED visits for P1 have been “exclusively” about gastrointestinal (GI) concerns. P1’s care plan interventions about removing his belongings and changing into behavioral health scrubs was pertaining to behavioral health concerns. If P1 is coming in for GI concerns and does not pertain to any behavioral health concerns, it would not be a priority to implement the care plan. P-A stated pertaining to P1’s ED visit on 4/19/25, P1 should have not been asked to do a security therapeutic search of have his belongings taken from him. An interview was attempted with security (S)-A on 7/9/25 at 9:05 a.m. and 1:13 p.m. with no success. An interview was attempted with S-B on 7/9/25 at 9:06 a.m. and 1:14 p.m. with no success. The facility’s” Interdisciplinary Plan of Care” policy dated 12/20/23 indicated a patient’s plan of care is based on the patient’s goals and the time frames, settings, and services required to meet those goals. The patient’s plan of care would be prioritized based on clinical assessment and patient’s health concerns. As patient care needs are identified, it is the responsibility of the health care team, in partnership with the patient and family, to prioritize the care and services delivered so that the patient’s most urgent needs are met.”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 49618 Based on observation and interview, the facility failed to provide personal privacy and dignity for six of ten patients (P3, P4, P5, P6, P7, and P15) when the patients were receiving care in hallway beds in the emergency department (ED). Findings include: P3 was admitted to the facility on 4/25/23 when she came to the ED via emergency medical services (EMS) and was diagnosed with cough and hypoxia (low oxygen). P3 was admitted to the facility and was discharged on 4/27/23. P3’s diagnoses consisted of mild dementia. P4 was admitted to the facility on 7/7/25 when she walked into the ED by herself and was diagnosed with closed compression fracture of L2 vertebra, abdominal distension, and constipation. P4 was discharged from the ED on 7/7/25. P4’s diagnoses did not indicate cognitive impairment. P5 was admitted to the facility on 7/8/25 when she walked into the ED by herself and was diagnosed with right sided weakness and acute non-intractable headache. P5 was discharged from the ED on 7/8/25. P5’s diagnoses did not indicate cognitive impairment. P6 was admitted to the facility on 7/8/25 when she walked into the ED by herself and was diagnosed with unstable angina, chest pain, sick sinus syndrome, and bradycardia. P6 was currently admitted to the facility on 7/9/25. P6’s diagnoses did not indicate cognitive impairment. P7 was admitted to the facility on 7/9/25 when she walked into the ED by herself and diagnosed with umbilical hernia without obstruction. P7 was discharged from the ED on 7/9/25. P15 was admitted to the facility on 7/7/25 when he came into the ED and was discharged from the ED on 7/7/25. P15’s diagnoses did not indicate cognitive impairment. During an interview on 7/7/25 at 9:15 a.m. with family member (FM)-A, FM-A stated P3 was lying in a hallway bed close to the ambulance bay. Whenever the ambulance bay would open, she would get a “blast” of cold air. P3 had a blanket that had a large hole in it, so P3 felt cold throughout her admission. P3 would complain of the loud noises, and she was trying to cover herself up with the blanket because she only had a gown on. During an interview on 7/7/25 at 2:03 p.m., P4 was observed in a hallway bed in the ED. During the interview, P4 stated she did not feel as though her care was private. P4 needed to use the bathroom, and a staff member asked her if she could use the bed pain in the middle of the hallway on her bed. P4 could not recall the name of the staff member who asked her that. P4 stated she told the staff member that she would never use a bed pan in the hallway and that she would like to go to a closed bathroom. During an interview on 7/8/25 at 11:04 a.m., ED director (EDD)-A stated she would expect the same level of care for patients in the hallway that patients in ED rooms would get. EDD-A stated when a patient is in a hallway bed and needed to use the bathroom, she would expect staff to either walk them to the bathroom or use assistive devices such as a walker, cane, or wheelchair to escort the patient to the bathroom. EDD-A stated it would be a challenge to provide a patient dignity, confidentiality, and privacy for a patient to use a bed pan in the hallway. If patients are in a bed in the hallway, EDD-A would expect staff to have lower toned conversations when they are providing care to obtain patient’s privacy. During an interview on 7/8/25 at 11:55 a.m., P5 was observed in a hallway bed in the ED. During the interview, P5 stated she “absolutely” did not feel as though her care is private while in the hallway. P5 did not have pants or a bra on and was only in a gown. P5 felt vulnerable being in the hallway surrounded by people. During an interview on 7/8/25 at 3:15 p.m., P6 was observed in a hallway bed in the ED. During the interview, P6 stated when she needed to use the bathroom, RN-G asked if P6 could use the bed pan in the hallway. RN-G stated the bathroom closest to P6 was in use and that she would have to use the bed pan. P6 felt very uncomfortable doing this. During an interview on 7/9/25 at 7:43 a.m., supervisor (S)-A stated she would expect the same level of care for patients in the hallway that patients in ED rooms would get. She would expect staff to preserve patient’s dignity while in the hallway. S-A stated that some patients would “have” to use a bed pan while in the hallway and that it is an expectation that privacy is maintained while putting the bed pan in and taking the bed pan out. S-A stated it would be “horrible” for a patient to use a bed pain while in the hallway. S-A stated she would “never” want a patient to defecate or urinate while they are surrounded by EMS staff, facility staff, other patients, or visitors. Privacy is maintained for patients in the hallway by having conversations quietly with the patients and some providers will bring patients or family members to a different room to have a private conversation with them. During an interview on 7/9/25 at 9:23 a.m., RN-G stated she asked P6 if she could use the bed pan in the hallway because P6 had a low heart rate and was concerned about P6 falling. RN-G stated if a patient is in the hallway using a bed pan, she did not “think” it preserves the patient’s dignity but “didn’t know what else to do”. During an interview on 7/9/25 at 10:06 a.m., P16 was observed in a hallway bed in the ED. P16 stated she did not feel as though she had privacy being out in the hallway on a bed. During an interview on 7/9/25 at 10:10 a.m., P7 was observed in a hallway bed in the ED. P7 stated she did not feel as though her care was private because everyone was hearing the conversations she was having with the provider. P7 felt as though her dignity was not being preserved. Email Correspondence dated 7/10/25 at 11:20 a.m. indicated on 7/7/25 the ED was in contingency surge plan at 7:00 a.m., 12:00 p.m., 4:00 p.m. and was in crisis surge plan at 8:00 p.m. On 7/8/25 the ED was in crisis surge plan at 7:00 a.m., 12:00 p.m., and 4:00 p.m. The ED was in contingency surge plan at 8:00 p.m. On 7/9/25 the ED was at contingency surge plan at 7:00 a.m., crisis surge plan at 12:00 p.m., and contingency surge plan at 4:00 p.m. The facility’s “Confidentiality of Health Information” policy dated 2/2/22 indicated it is recommended adding curtains, screens, cubical, dividers, shields, or similar barriers to open areas where oral communications often occur between providers and patients. The facility’s “Surge Plan” policy dated 4/21/25 indicated if the ED was at a contingency stage, it meant the space, staff, and supplies used are not consistent with daily practices, but provide care to a standard that is functionally equivalent to usually patient care practices. If the ED were at the contingency stage, the ED staff would utilize inpatient hallway bed space while patient rooms are being cleaned to facility movement of patients out of the ED and the ED staff would open hallway assignments to patients. If the ED was at a crisis capacity stage, it meant the need to manage increase patient care volume would otherwise severely challenge or exceed the existing structure, a large influx of patients into the ED, and adaptive spaces, staff, and supplies are not consistent with usual standards of care, but provide sufficiency of care. When the ED is at a crisis capacity stage, ED staff would initiate all open hallway assignments.”