SSM Health St. Mary’s Hospital - Jefferson City

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 51264 Based on the recent Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individual with an emergency medical condition) survey, interview, record review and policy review, the hospital failed to meet the emergency needs of patients in accordance with acceptable standards of practice, failed to ensure protocols were consistent with nationally recognized and evidence based guidelines for the care of patients with emergency conditions, including but not limited to patients with obstetrical (relating to childbirth and the processes associated with it) emergencies, and failed to ensure that applicable staff were trained annually on the protocols. This failure led to one patient (#1) who presented to the hospital’s emergency department not being provided an appropriate medical screening examination and potential for other patients with emergency needs not being provided care consistent with nationally recognized and evidence-based guidelines. These failed practices resulted in noncompliance with 42 CFR 482.55 Condition of Participation (CoP): Emergency Services. The hospital’s ED average monthly census over the past six months was 1,932. The hospital census was 97. Please refer to A-1104, A-1115 and A-1117 for further details.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 51264 Based on the recent Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individual with an emergency medical condition) survey, interview, record review and policy review, the hospital failed to meet the emergency needs of patients in accordance with acceptable standards of practice, failed to ensure protocols were consistent with nationally recognized and evidence based guidelines for the care of patients with emergency conditions, including but not limited to patients with obstetrical (relating to childbirth and the processes associated with it) emergencies, and failed to ensure that applicable staff were trained annually on the protocols. This failure led to one patient (#1) who presented to the hospital’s emergency department not being provided an appropriate medical screening examination and potential for other patients with emergency needs not being provided care consistent with nationally recognized and evidence-based guidelines. Findings included: Review of the hospital’s policy titled, “Policy and Procedure Administration”, reviewed 11/10/25, showed all policies, procedures, and guidelines required periodic review for accuracy and currency of information. Documents were to be reviewed at least once every three years unless otherwise indicated by regulatory or accreditation requirements. Review of the hospital’s policy titled, “Procedure: Obstetrical (OB, relating to childbirth and the process associated with it) Ultrasound Protocol,” effective 09/11/15, with a last approval date of 04/03/25, showed no accredited organizations as sources for information were used. Protocols showed ultrasounds were indicated in patients who were less than 14 weeks pregnant to confirm a pregnancy inside the uterus (within a woman’s pelvis where a fetus develops and grows) and to evaluate a suspected ectopic pregnancy (a pregnancy that attaches itself outside the uterus and cannot survive). Transvaginal ultrasounds (an ultrasound where a probe is inserted into the vagina to create images of the female reproductive organs) were to be used if transabdominal (outside the body across the abdominal wall) scans were unclear or provided limited visualization with early pregnancies. Review of the hospital’s policy titled, “General Ultrasound Call Back,” with a last reviewed date of 06/29/21, showed: - The policy’s original effective date was 09/04/13, it was revised on 06/03/19 and 08/20/20 and last reviewed on 06/29/21. - References used for the policy were from the Radiographics 2008 professional journal article titled, “Abdominal Emergencies,” the American Institute of Ultrasound in Medicine (AIUM) article titled, “Practice Parameter for Documentation of an Ultrasound Examination,” from 2019 and the AIUM article titled, “Manual for Ultrasound Accreditation Preliminary reports,” from 2020, and undated policies and guidelines from internal sources. - Criteria for OB ultrasounds to rule out ectopic pregnancies included a positive urine pregnancy test within two weeks; a quantitative human chorionic Gonadotropin (hCG, a blood test that measures the precise amount of the pregnancy hormone hCG; confirms pregnancy, monitors its progression and estimates gestational age [a measure of the age of a pregnancy which is taken from the beginning of the woman’s last menstrual period and the date of delivery, full-term is defined as 39 weeks through 40 weeks and 6 days]) was confirmed to be greater than 1,500 prior to calling the technologist, unless the patient was unstable, demonstrates syncope (to faint), or had an abnormal rise or fall of quantitative hCG levels, or severe lateralizing pain; the patient is less than 16 weeks pregnant; or a transabdominal and/or transvaginal ultrasound was needed for optimal images. Review of Patient #1’s hospital based urgent care medical record dated 01/26/26 at 11:15 AM, showed: - Patient #1’s chief complaint was back pain and pregnancy problem. - At 4:15 PM, history notes indicated she had a positive pregnancy test two days prior, she was “spotting a little bit” and had lower left sided back pain. Over the past couple weeks, she has experienced left lower abdominal cramping. She had a history of miscarriage. - Her left lower back was “painful to the touch.” No abdominal or pelvic examination was noted. - Flowsheets showed her pain was in her back with a pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) score of four. - Impression notes showed her diagnoses were pregnancy of unspecified gestation age, acute left sided low back pain without sciatica (pain that radiates from the lower back to the buttocks and legs), abdominal cramping and spotting. Patient #1’s ED medical record dated 01/26/26, showed: - At 5:40 PM, a 22-year-old female arrived in the ED reporting a chief complaint at triage (process of determining the priority of a patient’s treatment based on the severity of their condition) of cramping, low pelvic discomfort for three days, and low back pain for the past four weeks. She reported she was four weeks pregnant. Her pain scale assessment score was six. - Provider history notes showed Patient #1 reported left lower back pain that worsened with movement for the past two weeks. When she went home from working as a server, the pain intermittently radiated into her left leg. She denied loss of feeling or control of her functions. She was pregnant for the third time and had given birth once. - Nine days prior, a pregnancy test resulted negative. She had some light spotting that resolved. Four days prior, a pregnancy test resulted positive. - She denied abdominal or pelvic pain, vaginal discharge, odor, or painful urination. She did report some frequency and urgency. She also denied fever or chills, nausea (a feeling of sickness with an urge to vomit) or vomiting. - Abdominal examination showed her abdomen was soft, non-distended, nontender to the touch on all quadrants. There was no rebound tenderness (pain that increases when pressure is relieved) or guarding and no suprapubic tenderness. - Physical examination of her muscles and joints showed her left lower back was tender. She had normal strength, circulation and feeling in her legs. - Orders included a blood test that measured hCG, which resulted with her quantitative pregnancy hormone level being 422.06. - Provider notes concluded, “Patient #1 did not have a fever and did not appear ill. She had a positive pregnancy test four days prior. She had one episode of light spotting on 01/17/26, otherwise had not had vaginal bleeding. She denied abdominal or pelvic pain. There were no concerning signs for damage in her lower back nerves.” - The provider recommended Patient #1 call the clinic the following day to schedule a follow up appointment for “re-evaluation and repeat quantitative hCG.” Patient #1 was advised to return if her condition became worse or new symptoms arose. - Her diagnosis was acute left sided low back pain with left sided sciatica, less than eight weeks gestation of pregnancy. - At 8:43 PM, Patient #1 was discharged. During telephone interviews on 5/11/26 and 05/13/26 at 9:20 AM and 7:45 AM, Staff H, Regulatory Director, stated that policy owners received automated renewal notifications upon policy due dates. Recently, during system changes, the hospital discovered that some policies lacked those automated notifications and were now under review. Writers and reviewers of policies could utilize learning modules, ad hoc trainings, and meetings provided by system policy managers as needed to assist with development. They ensured policies were congruent among multiple disciplines by developing documents collaboratively. Authors from all invested disciplines were to use evidence-based research and current national standards for content. Once those leaders developed, reviewed, or revised the policy, it went to senior leadership groups (the Chief Nursing Officer (CNO), the Professional Practice Council, and medical executives) for review. During a telephone interview on 5/11/26 at 9:20 AM, Staff P, System Regulatory Director, stated that policies were to be reviewed every three years unless there was a regulatory or process change. A policy board comprised of nursing, medical, regulatory, legal, corporate, and ethical staff approved documents associated with their respective fields. Content experts wrote policies and appropriate stakeholders approved them. Owners of system-wide policies were automatically notified when their policies were due for review. Local policies, specific to a particular hospital, were reviewed and authorized by their appropriate stakeholders. All clinicians who used those policies could be notified of changes through emails and learning materials online. During a telephone interview on 5/22/26 at 1:00 PM, Staff E, ED Medical Director, stated that policies were to be reviewed in quarterly ED Committee Meetings and were approved in Medical Executive Committee meetings where all department chairs were involved in the approval discussion. Protocols that were guidelines, not policies, were approved by department directors that used those protocols. Those did not have to be followed precisely, like a policy did; they had room for clinical judgment. Radiology policies and protocols that were used in the ED were helpful for their own department, but they used a different lens of patient care to develop their documents. ED policies were reviewed using American College of Emergency Physicians (ACEP) in conjunction with other representing bodies for other disciplines, such as ACOG for pregnancies. Different ED policies used appropriate discipline sources as guidance. When he received notification of changes in standard practice, from regulatory or discipline representing organizations, he notified his staff and ensured that they received that information.”

“PROTOCOLS CFR(s): Protocols must be consistent with nationally recognized and evidence-based guidelines for the care of patients with emergency conditions, including but not limited to patients with obstetrical emergencies, complications, and immediate post-delivery care. This Standard is not met as evidenced by: 51264 Based on the recent Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individual with an emergency medical condition) survey, interview, record review and policy review, the hospital failed to meet the emergency needs of patients in accordance with acceptable standards of practice, failed to ensure protocols were consistent with nationally recognized and evidence based guidelines for the care of patients with emergency conditions, including but not limited to patients with obstetrical (relating to childbirth and the processes associated with it) emergencies. This failure led to one patient (#1) who presented to the hospital’s emergency department not being provided an appropriate medical screening examination and potential for other patients with emergency needs not being provided care consistent with nationally recognized and evidence-based guidelines. Findings included: Review of the hospital’s policy titled, “Policy and Procedure Administration”, reviewed 11/10/25, showed all policies, procedures, and guidelines required periodic review for accuracy and currency of information. Documents were to be reviewed at least once every three years unless otherwise indicated by regulatory or accreditation requirements. Review of the hospital’s policy titled, “Procedure: Obstetrical (OB, relating to childbirth and the process associated with it) Ultrasound Protocol,” effective 09/11/15, with a last approval date of 04/03/25, showed no accredited organizations as sources for information were used. Protocols showed ultrasounds were indicated in patients who were less than 14 weeks pregnant to confirm a pregnancy inside the uterus (within a woman’s pelvis where a fetus develops and grows) and to evaluate a suspected ectopic pregnancy (a pregnancy that attaches itself outside the uterus and cannot survive). Transvaginal ultrasounds (an ultrasound where a probe is inserted into the vagina to create images of the female reproductive organs) were to be used if transabdominal (outside the body across the abdominal wall) scans were unclear or provided limited visualization with early pregnancies. Review of the hospital’s policy titled, “General Ultrasound Call Back,” last review date 06/29/21, showed: - References used for the policy were from the Radiographics 2008 professional journal article titled, “Abdominal Emergencies,” the American Institute of Ultrasound in Medicine (AIUM) article titled, “Practice Parameter for Documentation of an Ultrasound Examination,” from 2019 and the AIUM article titled, “Manual for Ultrasound Accreditation Preliminary reports,” from 2020, and undated policies and guidelines from internal sources. - Emergent ultrasound exams intended to aid the ordering physician in diagnosis and treatment of the patient were available for call back during the hours of 5:00 PM to 7:00 AM each night. - Ultrasound technologists were called in for emergent ED exams only if they met the appropriate criteria set by hospital leadership in consultation with the radiologists. Otherwise, the radiologist was to approve the request before paging the technologist. - Criteria for OB ultrasounds to rule out ectopic pregnancies included a positive urine pregnancy test within two weeks; a quantitative human chorionic Gonadotropin (hCG, a blood test that measures the precise amount of the pregnancy hormone hCG; confirms pregnancy, monitors its progression and estimates gestational age [a measure of the age of a pregnancy which is taken from the beginning of the woman’s last menstrual period and the date of delivery, full-term is defined as 39 weeks through 40 weeks and 6 days]) was confirmed to be greater than 1,500 prior to calling the technologist, unless the patient was unstable, demonstrates syncope (to faint), or had an abnormal rise or fall of quantitative hCG levels, or severe lateralizing pain; the patient is less than 16 weeks pregnant; or a transabdominal and/or transvaginal ultrasound was needed for optimal images. The hospital’s policy, “General Ultrasound Call Back,” did not appear consistent with nationally recognized and evidence-based guidelines for the care of patients with emergency conditions, including but not limited to patients with obstetrical emergencies such as ectopic pregnancy. Review of guidelines from the American College of Obstetricians and Gynecologists, titled “ACOG Practice Bulletin NO. 193: Tubal Ectopic Pregnancy. Obstetrics and Gynecology 131(3):p e91-e103, 03/2018. I DOI:10.1097/AOG.0000000000002560,” recommend that the minimum diagnostic evaluation of a suspected ectopic pregnancy is a transvaginal ultrasound evaluation and confirmation of pregnancy, without specifying any hCG threshold for omitting imaging, Review of the document, “American College of Emergency Physicians,” dated 02/2017, showed that ectopic pregnancies can present at almost any hCG level and that rupture has been documented at very low hCG levels. During telephone interviews on 5/11/26 and 05/13/26, at 9:20 AM and 7:45 AM, Staff H, Regulatory Director, stated that policy owners received automated renewal notifications upon policy due dates. Recently, during system changes, the hospital discovered that some policies lacked those automated notifications and were now under review. Writers and reviewers of policies could utilize learning modules, ad hoc trainings, and meetings provided by system policy managers as needed to assist with development. They ensured policies were congruent among multiple disciplines by developing documents collaboratively. Authors from all invested disciplines were to use evidence-based research and current national standards for content. Once those leaders developed, reviewed, or revised the policy, it went to senior leadership groups (the Chief Nursing Officer (CNO), the Professional Practice Council, and medical executives) for review. During a telephone interview on 5/11/26 at 9:20 AM, Staff P, System Regulatory Director, stated that policies were to be reviewed every three years unless there was a regulatory or process change. A policy board comprised of nursing, medical, regulatory, legal, corporate, and ethical staff approved documents associated with their respective fields. Content experts wrote policies and appropriate stakeholders approved them. Owners of system-wide policies were automatically notified when their policies were due for review. Local policies, specific to a particular hospital, were reviewed and authorized by their appropriate stakeholders. All clinicians who used those policies could be notified of changes through emails and learning materials online. During a telephone interview on 5/22/26 at 1:00 PM, Staff E, ED Medical Director, stated that policies were reviewed in quarterly ED Committee Meetings and were approved in Medical Executive Committee meetings where all department chairs were involved in the approval discussion. Protocols that were guidelines, not policies, were approved by department directors that used those protocols. Those did not have to be followed precisely, like a policy did; they had room for clinical judgment. Radiology policies and protocols that were used in the ED were helpful for their own department, but they used a different lens of patient care to develop their documents. ED policies were reviewed using American College of Emergency Physicians (ACEP) in conjunction with other representing bodies for other disciplines, such as ACOG for pregnancies. Different ED policies used appropriate discipline sources as guidance. When he received notification of changes in standard practice, from regulatory or discipline representing organizations, he notified his staff and ensured that they received that information.”

“STAFF TRAINING CFR(s): Applicable staff, as identified by the hospital, must be trained annually on the protocols and provisions implemented pursuant to this section. (i) The governing body must identify and document which staff must complete such training. (ii) the hospital must document in the staff personnel records that the training was successfully completed. (iii) the hospital must be able to demonstrate staff knowledge on the topics implemented pursuant to this section This Standard is not met as evidenced by: 51264 Based on the recent Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individual with an emergency medical condition) survey, interview, record review and policy review, the hospital failed to meet the emergency needs of patients in accordance with acceptable standards of practice, failed to ensure protocols were consistent with nationally recognized and evidence based guidelines for the care of patients with emergency conditions, failed to ensure staff training was based on current evidence based practices, including but not limited to patients with obstetrical (relating to childbirth and the processes associated with it) emergencies. This failure led to one patient (#1) who presented to the hospital’s emergency department not being provided an appropriate medical screening examination and potential for other patients with emergency needs not being provided care consistent with nationally recognized and evidence-based guidelines. Findings included: Review of the hospital’s policy titled, “Policy and Procedure Administration”, reviewed 11/10/25, showed all policies, procedures, and guidelines required periodic review for accuracy and currency of information. Documents were to be reviewed at least once every three years unless otherwise indicated by regulatory or accreditation requirements. During interviews on 5/11/26 and 05/13/26 at 9:20 AM and 7:45 AM, Staff H, Regulatory Director, stated that policy owners received automated renewal notifications upon policy due dates. Recently, during system changes, the hospital discovered that some policies lacked those automated notifications and were now under review. Discipline/unit leadership was responsible for disseminating the policy revisions to their staff using modes and media that worked best for their staff’s situation. If policies affected everyone, those were typically reviewed annually via learning modules.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 51264 Based on policy review, the hospital failed to provide, within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#1) of 20 Emergency Department (ED) records reviewed from 08/10/25 through 02/10/26. These failed practices had the potential to cause harm to patients who presented to the ED seeking care and who potentially had an unrecognized emergency medical condition (EMC). Findings included: Review of the hospital’s policy titled, “Emergency Medical Treatment and Labor Act (EMTALA),” revised 12/13/23, showed the hospital ensured any individual who requested emergency care received a medical screening exam (MSE) to determine the presence of an EMC. If an individual presented with an EMC, the ED provided treatment to stabilize to the extent of the hospital’s capability and capacity or provided an appropriate transfer if indicated. Capability included equipment and specialized services provided by the hospital. EMCs included conditions that showed acute (sudden onset) symptoms of sufficient severity such that absence of treatment placed an individual in serious jeopardy, serious impairment, or dysfunction of any body part. MSEs were examinations sufficiently detailed to reveal whether the patient suffered from an EMC and included medically indicated screens, tests, history and physical examinations. Stabilized meant that no material deterioration of the condition was likely, within reasonable medical probability, that resulted or occurred during a transfer/discharge. Review of the hospital’s policy titled, “Procedure: Obstetrical (OB, relating to childbirth and the process associated with it) Ultrasound Protocol,” effective 09/11/15, with a last approval date of 04/03/25, showed no accredited obstetrical organizations as sources for information were used. Protocols showed ultrasounds were indicated in patients who were less than 14 weeks pregnant to confirm a pregnancy inside the uterus (within a woman’s pelvis where a fetus develops and grows) and to evaluate a suspected ectopic pregnancy (a pregnancy that attaches itself outside the uterus and cannot survive). Transvaginal ultrasounds (an ultrasound where a probe is inserted into the vagina to create images of the female reproductive organs) were to be used if transabdominal (outside the body across the abdominal wall) scans were unclear or provided limited visualization with early pregnancies. Review of the hospital’s policy titled, “General Ultrasound Call Back,” last review date 06/29/21, showed: - The policy’s original effective date was 09/04/13, it was revised on 06/03/19 and 08/20/20 and last reviewed on 06/29/21. - References used for the policy were from the Radiographics 2008 professional journal article titled, “Abdominal Emergencies,” the American Institute of Ultrasound in Medicine (AIUM) article titled, “Practice Parameter for Documentation of an Ultrasound Examination,” from 2019 and the AIUM article titled, “Manual for Ultrasound Accreditation Preliminary reports,” from 2020, and undated policies and guidelines from internal sources. - Emergent ultrasound exams intended to aid the ordering physician in diagnosis and treatment of the patient were available for call back during the hours of 5:00 PM to 7:00 AM each night. - Ultrasound technologists were called in for emergent ED exams only if they met the appropriate criteria set by hospital leadership in consultation with the radiologists. Otherwise, the radiologist was to approve the request before paging the technologist. - Criteria for OB ultrasounds to rule out ectopic pregnancies included a positive urine pregnancy test within two weeks; a quantitative human chorionic Gonadotropin (hCG, a blood test that measures the precise amount of the pregnancy hormone hCG; confirms pregnancy, monitors its progression and estimates gestational age [a measure of the age of a pregnancy which is taken from the beginning of the woman’s last menstrual period and the date of delivery, full-term is defined as 39 weeks through 40 weeks and 6 days]) was confirmed to be greater than 1,500 prior to calling the technologist, unless the patient was unstable, demonstrates syncope (to faint), or had an abnormal rise or fall of quantitative hCG levels, or severe lateralizing pain; the patient is less than 16 weeks pregnant; or a transabdominal and/or transvaginal ultrasound was needed for optimal images. Please refer to 2406 for further details.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 51264 Based on interviews, record review, and policy review, the hospital failed to provide, within its capability and capacity, an appropriate medical screening examination (MSE) to determine whether or not an emergency medical condition existed for one patient (#1) of 20 Emergency Department (ED) records reviewed from 08/10/25 through 02/10/26. These failed practices had the potential to cause harm to patients who presented to the ED seeking care and who potentially had an unrecognized emergency medical condition (EMC). These failed practices had the potential to cause harm to all patients who presented to the ED seeking care and who potentially had an unrecognized EMC. Findings included: Review of the hospital’s policy titled, “Emergency Medical Treatment and Labor Act (EMTALA),” revised 12/13/23, showed the hospital ensured any individual who requested emergency care received a medical screening exam (MSE) to determine the presence of an EMC. If an individual presented with an EMC, the ED provided treatment to stabilize to the extent of the hospital’s capability and capacity or provided an appropriate transfer if indicated. Capability included equipment and specialized services provided by the hospital. EMCs included conditions that showed acute (sudden onset) symptoms of sufficient severity such that absence of treatment placed an individual in serious jeopardy, serious impairment, or dysfunction of any body part. MSEs were examinations sufficiently detailed to reveal whether the patient suffered from an EMC and included medically indicated screens, tests, history and physical examinations. Stabilized meant that no material deterioration of the condition was likely, within reasonable medical probability, that resulted or occurred during a transfer/discharge. The hospital’s EMTALA obligation ended when a qualified medical person (QMP) made the decision that no EMC existed, even if the underlying medical condition persisted, and the patient was discharged with follow up instructions. Review of the hospital’s policy titled, “Procedure: Obstetrical (OB, relating to childbirth and the process associated with it) Ultrasound Protocol,” effective 09/11/15, with a last approval date of 04/03/25, showed no accredited obstetrical organizations as sources for information were used. Protocols showed ultrasounds were indicated in patients who were less than 14 weeks pregnant to confirm a pregnancy inside the uterus (within a woman’s pelvis where a fetus develops and grows) and to evaluate a suspected ectopic pregnancy (a pregnancy that attaches itself outside the uterus and cannot survive). Transvaginal ultrasounds (an ultrasound where a probe is inserted into the vagina to create images of the female reproductive organs) were to be used if transabdominal (outside the body across the abdominal wall) scans were unclear or provided limited visualization with early pregnancies. Review of the hospital’s policy titled, “General Ultrasound Call Back,” last review date 06/29/21, showed: - The policy’s original effective date was 09/04/13, it was revised on 06/03/19 and 08/20/20 and last reviewed on 06/29/21. - References used for the policy were from the Radiographics 2008 professional journal article titled, “Abdominal Emergencies,” the American Institute of Ultrasound in Medicine (AIUM) article titled, “Practice Parameter for Documentation of an Ultrasound Examination,” from 2019 and the AIUM article titled, “Manual for Ultrasound Accreditation Preliminary reports,” from 2020, and undated policies and guidelines from internal sources. - Emergent ultrasound exams intended to aid the ordering physician in diagnosis and treatment of the patient were available for call back during the hours of 5:00 PM to 7:00 AM each night. - Ultrasound technologists were called in for emergent ED exams only if they met the appropriate criteria set by hospital leadership in consultation with the radiologists. Otherwise, the radiologist was to approve the request before paging the technologist. - Criteria for OB ultrasounds to rule out ectopic pregnancies included a positive urine pregnancy test within two weeks; a quantitative human chorionic Gonadotropin (hCG, a blood test that measures the precise amount of the pregnancy hormone hCG; confirms pregnancy, monitors its progression and estimates gestational age [a measure of the age of a pregnancy which is taken from the beginning of the woman’s last menstrual period and the date of delivery, full-term is defined as 39 weeks through 40 weeks and 6 days]) was confirmed to be greater than 1,500 prior to calling the technologist, unless the patient was unstable, demonstrates syncope (to faint), or had an abnormal rise or fall of quantitative hCG levels, or severe lateralizing pain; the patient is less than 16 weeks pregnant; or a transabdominal and/or transvaginal ultrasound was needed for optimal images. Review of Patient #1’s hospital based urgent care medical record dated 01/26/26 at 11:15 AM, showed: - Patient #1’s chief complaint was back pain and pregnancy problem. - At 4:15 PM, history notes included she had a positive pregnancy test two days prior. She reported “spotting a little bit” and had lower left sided back pain. Over the past couple weeks, she experienced left lower abdominal cramping. She had a history of miscarriage. - On examination, her pulse was 105 (normal pulse/heartbeats for adults range from 60 to 100 per minute) without distress or difficulty breathing. Her left lower back was painful to the touch. No abdominal or pelvic examination was noted. - Flowsheets showed her pain was in her back with a pain score of four. - Impression notes showed her diagnoses were pregnancy of unspecified gestation age, acute left sided low back pain without sciatica (pain that radiates from the lower back to the buttocks and legs), abdominal cramping and spotting. - Follow up instructions included to return if her symptoms worsened or failed to improve; will refer to the ED for further evaluation and treatment; a report was called to the hospital’s ED. Patient #1’s ED medical record dated 01/26/26, showed: - At 5:40 PM, a 22-year-old female arrived in the ED reporting a chief complaint at triage of cramping, low pelvic discomfort for three days, and low back pain for the past four weeks. She reported she was four weeks pregnant. Her pulse (normal pulse/heartbeats for adults range from 60 to 100 per minute) was 117. Her pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and ten means worst possible pain) was six. - Provider history notes showed Patient #1 reported left lower back pain that worsened with movement for the past two weeks. - Nine days prior, a pregnancy test resulted negative. She had some light spotting that resolved. Four days prior, a pregnancy test resulted positive. - She denied abdominal or pelvic pain, vaginal discharge, odor, or painful urination. She did report some frequency and urgency. She also denied fever or chills, nausea (a feeling of sickness with an urge to vomit) or vomiting. - Abdominal examination showed her abdomen was soft, non-distended, nontender to the touch on all quadrants. There was no rebound tenderness (pain that increases when pressure is relieved) or guarding and no suprapubic tenderness. - Physical examination of her muscles and joints showed her left lower back was tender. She had normal strength, circulation and feeling in her legs. - Orders included a laboratory test of her urine, a complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection), a comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases or conditions), a procalcitonin (a substance produced by many types of cells in the body, often in response to bacterial infections but also in response to tissue injury), a blood type test, and a blood test that measured hCG. - Her quantitative pregnancy hormone level was 422.06. - Provider notes concluded, “Patient #1 did not have a fever and did not appear ill. She had a positive pregnancy test four days prior. She had one episode of light spotting on 01/17/26, otherwise she had not had vaginal bleeding. She denied abdominal or pelvic pain. Quantitative hCG is only 422.06. She needed to follow up with an OB/GYN. Her urine was negative for blood or signs of infection.” - The provider recommended Patient #1 call the clinic the following day to schedule a follow up appointment for “re-evaluation and repeat quantitative hCG.” Patient #1 was advised to return if her condition became worse or new symptoms arose. - Her diagnosis was acute left sided low back pain with left sided sciatica, less than eight weeks gestation of pregnancy. - At 8:43 PM, Patient #1 was discharged. Review of Patient #2’s medical record dated 09/03/26, showed she presented to the ED at four weeks gestation with pain but no bleeding and had an MSE that included ultrasound to evaluate for ectopic pregnancy. Review of Patient #5’s medical record dated 09/15/25, showed she presented to the ED at six weeks gestation with pain but no bleeding and had an MSE that included ultrasound to evaluate for ectopic pregnancy. Review of Patient #10’s medical record dated 11/12/25, showed she presented to the ED at six weeks gestation with cramping and a “small amount of blood on wiping,” and had an MSE that included an ultrasound to evaluate for ectopic pregnancy. Review of Patient #11’s medical record dated 10/05/25, showed she presented to the ED in early pregnancy of unclear gestational age with pain and spotting and had an MSE that included ultrasound to evaluate for ectopic pregnancy. Review of Patient #12’s medical record dated 10/05/25, showed she presented to the ED at six to eight weeks gestational age with pain and bleeding two days prior with an hCG of less than 1500 (499) and had an MSE that included ultrasound to evaluate for ectopic pregnancy. Review of Patient #14’s medical record dated 09/09/25, showed she presented to the ED at six weeks, six days gestation with painless blood noted while urinating and had an MSE that included ultrasound to evaluate for ectopic pregnancy. Review of Patient #15’s medical record dated 09/22/25, showed she presented to the ED in early pregnancy of unclear gestational age with pain but no bleeding with an hCG less than 1500 (268) and had an MSE that included ultrasound to evaluate for ectopic pregnancy. Review of Patient #16’s medical record dated 01/31/26, showed she presented to the ED at seven weeks gestation with pain but no bleeding and had an MSE that included ultrasound to evaluate for ectopic pregnancy. During a telephone interview on 02/18/26 at 2:35 PM, Patient #1, stated that the urgent care clinic told her they were sending her to the ED for an ultrasound to rule out an ectopic pregnancy. She did not remember if she asked the ED provider for an ultrasound or asked when it would be done. The provider stated that they would wait for laboratory results and see. She asked the person who drew her blood when the ultrasound would be. That person said they could see the note from urgent care. She did not receive the ultrasound. She used the restroom prior to leaving the ED. She saw blood and reported it to a staff member in the hallway. The staff member told the ED physician about the blood and then told the patient she needed to report the blood to her Obstetrician/Gynecologist (OB/GYN, a specialty physician focused on women’s health and delivering babies) at her follow up appointment. During a telephone interview on 02/12/26 at 1:32 PM with Staff N, ED NP and Staff E, ED Medical Director, Staff N stated that she did not recall receiving report on Patient #1 from the urgent care clinic. Patient #1 complained of back pain for two weeks that worsened after working as a server. A physical examination showed no abdominal or pelvic pain, cramping or tenderness and the patient reported spotting that resolved nine days prior. Her presentation “clinically did not call for an ultrasound”. “Patients often reported symptoms in triage that were not congruent with their complaint in the examination room. She spent much more time with the patient than triage nurses. She took time to get histories, perform physical examinations and a review of systems (ROS, a technique used by healthcare providers to review each body system through a series of questions, to determine what signs or symptoms a patient is experiencing). If Patient #1’s pregnancy-related history had been pertinent to the visit, she would have noted that. Staff E stated that patients who requested ultrasounds did not always get one if it wasn’t indicated. She was stable, had no abdominal pains or bleeding, and she was positive for pregnancy within nine days.” During an interview on 02/11/26 at 12:25 PM, Staff I, Diagnostic Medical Sonographer, stated that they could be called in to conduct ultrasounds in the ED for early pregnancies. Most often the patient presented with bleeding and pain. Transabdominal ultrasounds would be attempted first, but a transvaginal ultrasound could be completed if there was an indication for it. Sometimes the transvaginal ultrasounds were not definitive, and the patient laboratory results, dates, presentation, and the hCG results would be used to get a full picture of the patient. Serial hCG levels may be required. During a telephone interview on 02/18/26 at 10:56 AM, Staff L, ED Charge Nurse, stated that providers usually looked at notes from the ministry’s urgent care, but they had to look for it in the chart. It did not automatically appear.”

“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: 48359 Based on observation, interview and policy review, the hospital failed to: - Identify and follow isolation precautions (techniques used to prevent the spread of highly contagious or high-risk infections) for six (#1, #2, #3, #4, #5 and #10) of seven isolation patients observed; - Perform hand hygiene (washing hands with soap and water or alcohol-based hand sanitizer) when providing care for two patients (#2 and #8) of two patients observed; - Label intravenous (IV, in the vein) dressings with the initiation date and IV tubing with the initiation date and time for seven patients (#1, #6, #8, #9, #11, #12 and #13) of seven patients; observed; - Discard expired food and label food with an expiration date in the kitchen; - Ensure staff consumed food in a designated area; - Ensure refrigerators, freezers and microwaves were clean in three of five units observed; and - Properly store soiled linen. This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.42 Condition of Participation (CoP): Infection Prevention and Control and Antibiotic Stewardship. Please refer to A-0749.”

“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: 38236 Based on observation, interview and policy review, the hospital failed to: - Identify and follow isolation precautions (techniques used to prevent the spread of highly contagious or high-risk infections) for six (#1, #2, #3, #4, #5 and #10) of seven isolation patients observed; - Perform hand hygiene (washing hands with soap and water or alcohol-based hand sanitizer) when providing care for two patients (#2 and #8) of two patients observed; - Label intravenous (IV, in the vein) dressings with the initiation date and IV tubing with the initiation date and time for seven patients (#1, #6, #8, #9, #11, #12 and #13) of seven patients observed; - Discard expired food and label food with an expiration date in the kitchen; - Ensure staff consumed food in a designated area; - Ensure refrigerators, freezers and microwaves were clean in three of five units observed; and - Properly store soiled linen. Review of the hospital’s policy titled, “Isolation Precautions (techniques used to prevent the spread of highly contagious or high-risk infections),” reviewed 05/21/25, showed: - It is the responsibility of the provider, nurse and/or the Infection Preventionist to document/initiate the appropriate isolation (to separate those known or suspected to be contagious). - All personnel are responsible for complying with and enforcing isolation precautions including appropriate usage of personal protective equipment (PPE, such as gloves, gowns, goggles and masks). - Patients with a previous history of resistant microorganism (organisms, such as bacteria, too small for the naked eye) or actively infected with multi-drug-resistant organism (MDRO; bacteria resistant to many antibiotics) will be placed on the appropriate category of transmission-based precautions unless cleared by Infection Prevention. - Patient care processes should include measures to protect the patient from infection or colonization (the presence of bacteria on a body surface but not having any active illness or symptoms). - PPE will be donned and doffed per Center for Disease Control and Prevention (CDC) guidelines. - Instruct patient/family on the patient’s specific category of isolation, isolation precautions related to specific category of isolation and the expectation of adherence to isolation guidelines by patient, family and visitors. Document education in the electronic health record (EHR). - Contact (precautions used to minimize the risk of infection spreading through touching an infected person or contaminated object) plus precautions are designed for patients with diarrhea with an unknown/infectious etiology (cause) or known/suspected clostridium difficile (C-diff, a bacterium in the gastrointestinal tract that causes severe diarrhea, fever, nausea, and abdominal pain) infection. - Transportation of patients on Contact Plus precautions requires the patient to don a clean gown and perform hand hygiene prior to transportation. Review of Patient #1’s medical record dated 08/22/25, showed on 08/22/25 at 5:08 PM, a nasal swab culture (a test to identify bacteria that may cause) showed positive for Methicillin-Resistant Staphylococcus aureus (MRSA, highly contagious bacteria, that causes infections in different parts of the body and is resistant to many common antibiotics). Observation with concurrent interview on 08/25/25 at 1:40 PM, showed Patient #1’s door did not have isolation signage or PPE available. He stated that he had a wound to his right thigh. He was not aware he was on isolation and had been hospitalized for three days. Review of Patient #2’s medical record dated 08/22/25, showed on 08/23/25 at 9:34 AM, a nasal swab culture showed positive for MRSA. Observation on 08/25/25 at 2:05 PM, showed Patient #2’s door did not have isolation signage or PPE available. During an interview on 08/25/25 at 2:05 PM, Staff B, Registered Nurse (RN), stated that she did not know what kind of isolation Patient #2 was on. She agreed there was no door signage or PPE available. Review of Patient #3’s medical record dated 08/21/25, showed on 08/23/25 at 1:47 AM, a urine culture showed positive for Klebsiella pneumoniae (a type of bacteria that causes respiratory, urinary and wound infections) and extended spectrum beta-lactamase (ESBL, highly contagious bacteria, that causes infections in different parts of the body and is resistant to many common antibiotics). Observation on 08/25/25 at 2:10 PM, showed Patient #3’s door did not have isolation signage on the door. Review of patient #4’s medical record dated 08/18/25, showed on 08/19/25 at 8:37 PM, a nasal swab culture showed positive for MRSA. Observation on 08/25/25 at 2:30 PM, showed Patient #4’s door did not have isolation signage or PPE available. Review of Patient #5’s medical record dated 08/19/25, showed on 08/22/25 at 2:55 PM, an order was written for a C-diff culture. The specimen was not collected at the time of survey. Observation on 08/25/25 at 2:33 PM, showed Patient #5’s door did not have isolation signage or PPE available. Patient #5 was transferred for a computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) scan, the transport staff were not aware Patient #5 was on isolation. During an interview on 08/25/25 at 2:34 PM, Staff D, RN, stated that staff should have worn PPE when caring for Patient #5, she did not know what kind of isolation Patient #5 was on. Observation on 08/25/25 at 4:00 PM, showed Patient #10’s door did not have PPE available. During an interview on 08/26/25 at 11:00 AM, Staff Q, RN and concurrent medical record review of Patient #10’s medical record dated 08/14/25, showed the patient was placed in isolation because he had a history of MDRO infections. Staff Q stated that any patient with a history of MDRO infections were permanently flagged in the medical record and automatically placed in contact isolation for each admission. She was aware the patient was on isolation and did not know why the PPE was not available. During an interview on 08/27/25 at 1:00 PM, Staff BB, Chief Nursing Officer (CNO), stated that she expected appropriate signage and PPE supplies on the doors of isolation patients. She was surprised by the failure to provide signage, PPE and patient education. She expected staff to follow the hospital’s isolation precautions policy. During an interview on 08/27/25 at 10:40 AM, Staff W, Infection Preventionist, Staff X, Infection Prevention Regional Director and Staff Y, Infection Prevention System Director, stated that the process for identifying patient isolation was through their EHR. A patient was flagged for isolation if he/she had a history of a resistant bacteria and/or the laboratory created the notice in the EHR once a culture result was positive. The patient was expected to remain on isolation until the infection preventionist was able to review the patients EHR, if it was determined the isolation was not necessary the infection preventionist removed the flag from the EHR and notified the nurse to discontinue the isolation. Once a patient was identified for isolation the nurse placed the appropriate signage and PPE on the patient’s door. When a patient on isolation was transferred outside of their room, the staff were to don PPE prior to room entry, clean the contact surfaces on the bed, assist the patient to perform hand hygiene and donning a clean gown. The staff were then to remove their PPE prior to exiting the room with the patient. The receiving department was expected to review the EHR for potential isolation precautions prior to the patient’s arrival. They were surprised to know the survey team identified this opportunity for improvement. Their audits showed an 85 to 88 percent compliance for isolation identification and care over the previous two months. During an interview on 08/25/25 at 1:55 PM, Staff A, Three West Manager, stated that isolation identification and compliance was one of the items she was working on as a manager. Staff A was not aware of the policy expectations for transferring patients on isolation to other units/departments. Review of the hospital’s policy titled, “Hand Hygiene,” revised 07/24/24, showed SSM Health follows the Centers for Disease Control and Prevention (CDC) and the World Health Organization’s (WHO) “Five Moments for Hand Hygiene” process: - lmmediately before touching the patient and upon arrival to patient care area (Moment one); - Before a clean/aseptic procedure (Moment two); - After body fluid exposure risk (Moment three); - After touching a patient (Moment four); and - After touching a patient’s surroundings (Moment five). - Contact with patient objects (linens, equipment, furniture, etc.) is associated with hand contamination, even without having touched the patient. Observation on 08/25/25 at 2:05 PM, on Three West, showed Staff A, Three West Manager, did not perform hand hygiene prior to entering Patient #2’s room. Observation on 08/25/25 at 2:08 PM, on Three West, showed Staff B, RN, did not perform hand hygiene prior to donning gloves or entering Patient #2’s room. Observation on 08/25/25 at 3:50 PM, on Two West, showed Staff Q, RN, disconnected the IV tubing from Patient #8, placed her dirty gloved hand into her pocket, answered the phone and failed to perform hand hygiene and glove change prior to reconnecting the IV tubing. During an interview on 08/27/25 at 1:00 PM, Staff BB, CNO, stated that she expected staff to follow the policy for hand hygiene. The hospital followed the WHO guidelines for hand hygiene expectations. During an interview on 08/27/25 at 10:40 AM, Staff W, Infection Preventionist, Staff X, Infection Prevention Regional Director and Staff Y, Infection Prevention System Director, stated that they expected staff to follow the World Health Organization’s (WHO) five moments of hand hygiene. That expectation included staff performing hand hygiene prior to donning gloves and entering a patient’s room. Review of the hospital’s policy titled, “Peripheral Intravenous Catheter (IVC, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream), Management and Removal,” revised 11/19/24, directed staff to label the IV dressing with the date the dressing is applied and label the IV tubing upon initiation with the date and time. Observation on 08/25/25 at 1:40 PM, on Three West, showed Patient #1’s IV dressing was not labeled with the initiation date and the IV tubing was not labeled with the initiation date and time. Observation on 08/25/25 at 2:35 PM, on Five West, showed Patient #6’s IV dressing was not labeled with the initiation date and the IV tubing was not labeled with the initiation date and time. Observation on 08/25/25 at 3:50 PM, on Two West, showed Patient #8’s IV dressing was not labeled with the initiation date and the IV tubing was not labeled with the initiation date and time. Observation on 08/25/25 at 4:15 PM, on Two West, showed Patient #9’s IV dressing was not labeled with the initiation date. Observation on 08/26/25 at 9:30 AM, on Two West, showed Patient #11’s IV dressing was not labeled with the initiation date and the IV tubing was not labeled with the initiation date and time. Observation on 08/26/25 at 9:45 AM, on Two West, showed Patient #12’s IV dressing was not labeled with the initiation date and the IV tubing was not labeled with the initiation date and time. Observation on 08/26/25 at 9:50 AM, on Two West, showed Patient #13’s IV dressing was not labeled with the initiation date and the IV tubing was not labeled with the initiation date and time. During an interview on 08/27/25 at 1:00 PM, Staff BB, CNO, stated that she had been in the CNO role for two weeks and was not aware of the inconsistencies with IV dressing and tubing labeling. She expected staff to follow the policy for the labeling of IV dressings and tubing. During an interview on 08/27/25 at 10:40 AM, Staff W, Infection Preventionist, Staff X, Infection Prevention Regional Director and Staff Y, Infection Prevention System Director, stated that they expected staff to follow the IV policy for labeling IV dressings and tubing. IV sites and tubing were to be labeled with date and start time. The IV policy was owned and developed by the evidence-based nursing practice committee. Review of the hospital’s policy titled, “Food Safety Product Labeling and Dating Guidelines,” revised 02/08/23, showed: - Ready to eat, time/temperature control for safety (TCS) food prepared in a food establishment and held longer than the subsequent meal period must be marked to indicate the date or day by which the food is to be consumed or discarded; - Once a Non-TCS food has a documented use by date, policy requires the product to be consumed or discarded by that date; and - All managers and food employees need to be trained and understand the operation’s date marking policy and the dating/labeling system they use. Observation with concurrent interview, on 08/26/25 at 12:52 PM, in the kitchen, showed: - Expired Teriyaki Marinade in the kitchen; - Thyme leaves with an unreadable expiration date; - Expired cooked noodles in the walk-in cooler; - Expired half and half cream; - Open fries in the freezer with no label; and - Open pasta in dry storage with no label. Staff CC stated that the expired items should have been discarded, and the open items should have a use by date. During an interview on 08/27/25 at 10:40 AM, Staff W, Infection Preventionist, Staff X, Infection Prevention Regional Director and Staff Y, Infection Prevention System Director, stated that they expected all food to be labeled with expiration dates and all expired food was discarded. There was a contracted service responsible for maintaining the expiration dates of food in the kitchen. Audits were performed quarterly to assess for compliance. They were not surprised the surveyors identified expired food in the kitchen. The system had identified an opportunity for improvement and had begun a pilot program for regulatory meetings and more frequent and focused audits at other hospitals in the region. Review of the undated Occupational Safety and Health Administration (OSHA) guideline showed eating and drinking in work areas where blood or other potentially infectious materials may contaminate work surfaces, or the food itself is prohibited. Although requested, the hospital failed to provide a policy on designated staff break areas. Observation with concurrent interview on 08/26/25 at 1:32 PM, in the Family Birth Center, showed Staff Z, Scrub Technician, eating at the nurses’ station. Staff Z stated that she was not supposed to eat at the nurses’ station. During an interview on 08/27/25 at 1:00 PM, Staff BB, CNO, stated that she hoped staff had time for a 30-minute meal break and wanted staff to use a designated area. During an interview on 08/26/25 at 1:40 PM, Staff T, Family Birth Center Manager, stated that it did meet her expectations for staff to eat at the nurses’ station if there was a “potential case” in the unit. Staff T stated that there were no “expected cases” in the unit at that time. During an interview on 08/27/25 at 10:40 AM, Staff W, Infection Preventionist, Staff X, Infection Prevention Regional Director and Staff Y, Infection Prevention System Director, stated that they expected staff to follow the OSHA guidelines for staff meal breaks. The expectation was for no staff food or drink to be stored or consumed in clinical areas. Each unit had designated areas for food storage and consumption. It did not meet their expectations for a nurse manager to state that it was acceptable to consume food in the nurses’ station based on the busyness of the unit. Although requested, the hospital failed to provide a policy in regard to the cleaning of patient nourishment areas. Observation on 08/25/25 at 2:40 PM, in the Five West Patient Nourishment Room, showed a refrigerator with visible spilled and dried food on the base and a freezer with visible drips of spilled popsicle on the base. Observation on 08/26/25 at 12:45 PM, in the Three West Patient Nourishment Room, showed a dirty freezer with visible drips of spilled popsicle on the base. Observation on 08/26/25 at 1:00 PM and 1:15 PM, in the Emergency Department (ED) Patient Nourishment Areas, showed two microwaves with drips of dried food on the inside tops, sides, backs and bases. During an interview on 08/27/25 at 1:00 PM, Staff BB, CNO, stated that she expected refrigerators, freezers and microwaves were clean. She believed the food and nutrition department may be responsible for the cleaning of those items. During an interview on 08/27/25 at 10:40 AM, Staff W, Infection Preventionist, Staff X, Infection Prevention Regional Director and Staff Y, Infection Prevention System Director, stated that they expected all refrigerators, freezers and microwaves to be clean and free of food spillage. During an interview on 08/27/25 at 2:06 PM, Staff FF, Environmental Services (EVS) Director, stated that the cleaning of refrigerators and freezers was a shared responsibility between the food service and nursing staff. EVS cleaned microwaves weekly on Wednesdays. Review of the undated OSHA guideline prohibited putting soiled or contaminated linens on the floor, requiring them to be bagged and containerized to prevent contamination and infection spread. Although requested, the hospital failed to provide a policy on the storage and handling of dirty linens. During a concurrent observation and interview on 8/26/25 at 12:20 PM, in the Dirty Linen Storage Area, showed approximately 20 bags of dirty linen on the floor. Staff DD, EVS Director, stated that too many bags of dirty linen were placed down the laundry chute which caused the linen cart to break and overflow dirty linen bags on the floor. The dirty linen should not be on the floor. 48359”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 48359 Based on observation, interview, record review, video review and policy review, the Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible for management of the entire hospital including accountability for the effective oversite of staff to comply with the requirements under 42 CFR 482.13 CoP: Patient’s Rights. These failures had the potential to affect the safety of all patients. The hospital failed to: - Ensure the CEO was responsible for management of the entire hospital; (A-0057) - Follow their policy to respect the right to privacy for one discharged patient (#14) of one discharged patient reviewed; (A-0143) - Provide a Behavioral Health Unit (BHU) safe patient environment for 10 current patients (#31, #32, #33, #34, #35, #36, #37, #38, #39 and #40) of 10 current patients reviewed and one discharged patient (#14) of one discharged patient reviewed; (A-0144) - Recognize physical, emotional and verbal abuse and neglect toward one discharged patient (#14) of one discharged patient reviewed; (A-0145) - Immediately investigate, interview staff and remove staff members involved in the abuse and neglect of one discharged patient (#14) of one discharged patient reviewed; (A-0145) - Provide education to staff following an incident involving physical, emotional and verbal abuse and neglect of one discharged patient (#14) of one discharged patient reviewed; (A-0145) - Use the least restrictive intervention for one discharged patient (#14) of one discharged patient reviewed; (A-0165) - Follow their policy for therapeutic holds (treatment technique in which a violent patient is physically contained by people) for one discharged patient (#14) of one discharged patient reviewed; (A-0167) - Ensure therapeutic holds and seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) were ordered by a physician responsible for the care of the patient for one discharged patient (#14) of one discharged patient reviewed; (A-0168) - Immediately secure a physician restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) order for one discharged patient (#14) of one discharged patient reviewed; (A-0168) - Ensure restraints were discontinued at the earliest possible time for one discharged patient (#14) of one discharged patient reviewed; (A-0174) - Ensure appropriate monitoring during the use of restraints for one discharged patient (#14) of one discharged patient reviewed; (A-0175) - Ensure a one-hour face-to-face assessment (a direct, in-person evaluation by a qualified healthcare professional to assess a patient’s condition after they have been placed in restraints) was completed and accurate after violent restraint application for one discharged patient (#14) of one discharged patient reviewed; and (A-0179) - Ensure all staff members who applied restraints received training in the safe application of restraints for one discharged patient (#14) of one discharged patient reviewed. (A-0194) This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.12 Condition of Participation (CoP): Governing Body.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48359 Based on observation, interview, record review, video review and policy review, hospital failed to: - Follow their policy to respect the right to privacy for one discharged patient (#14) of one discharged patient reviewed; (A-0143) - Provide a Behavioral Health Unit (BHU) safe patient environment for 10 current patients (#31, #32, #33, #34, #35, #36, #37, #38, #39 and #40) of 10 current patients reviewed and one discharged patient (#14) of one discharged patient reviewed; (A-0144) - Recognize physical, emotional and verbal abuse and neglect toward one discharged patient (#14) of one discharged patient reviewed; (A-0145) - Immediately investigate, interview staff and remove staff members involved in the abuse and neglect of one discharged patient (#14) of one discharged patient reviewed; (A-0145) - Provide education to staff following an incident involving physical, emotional and verbal abuse and neglect of one discharged patient (#14) of one discharged patient reviewed; (A-0145) - Use the least restrictive intervention for one discharged patient (#14) of one discharged patient reviewed; (A-0165) - Follow their policy for therapeutic holds (treatment technique in which a violent patient is physically contained by people) for one discharged patient (#14) of one discharged patient reviewed; (A-0167) - Ensure therapeutic holds and seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) were ordered by a physician responsible for the care of the patient for one discharged patient (#14) of one discharged patient reviewed; (A-0168) - Immediately secure a physician restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) order for one discharged patient (#14) of one discharged patient reviewed; (A-0168) - Ensure restraints were discontinued at the earliest possible time for one discharged patient (#14) of one discharged patient reviewed; (A-0174) - Ensure appropriate monitoring during the use of restraints for one discharged patient (#14) of one discharged patient reviewed; (A-0175) - Ensure a one-hour face-to-face assessment (a direct, in-person evaluation by a qualified healthcare professional to assess a patient’s condition after they have been placed in restraints) was completed and accurate after violent restraint application for one discharged patient (#14) of one discharged patient reviewed; and (A-0179) - Ensure all staff members who applied restraints received training in the safe application of restraints for one discharged patient (#14) of one discharged patient reviewed. (A-0194) The severity and cumulative effect of this practice had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ). As of 04/15/25, the hospital provided an immediate action plan sufficient to remove the IJ when the hospital implemented corrective actions that included educating all current and oncoming nursing staff on abuse and neglect. All remaining staff were provided education prior to the start of their next shift. This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation (CoP): Patient’s Rights.”

“CHIEF EXECUTIVE OFFICER CFR(s): 482.12(b) The governing body must appoint a chief executive officer who is responsible for managing the hospital. This Standard is not met as evidenced by: 48359 Based on observation, interview, video review, medical record review and policy review, the Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible for management of the entire hospital, including accountability for the effective oversite of staff to comply with the requirements under 42 CFR 482.13 Condition of Participation (CoP): Patient’s Rights. These failures had the potential to affect the quality of care and safety of all patients. Findings included: Review of the hospital’s document titled, “Mid-Missouri Region Leadership Organizational Chart,” dated 03/2025, showed all administrative leaders reported to Staff Z, CEO. During an interview on 04/22/25 at 11:40 AM, Staff Z, CEO, stated that he had full oversight of the hospital.”

“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: 48359 Based on observation, interview, record review, video review and policy review, the hospital failed to follow their policy to respect the right to privacy for one discharged patient (#14) of one discharged patient reviewed. These failures had the potential to affect the quality of care and safety of all patients. Findings included: Review of the hospital’s policy titled “Patient Rights and Responsibilities,” dated 05/12/23, showed patients have the right to privacy regarding their treatment and care. Review of the hospital’s policy titled, “Violent Restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) Utilization” revised 08/15/24, showed patients’ right to privacy and dignity will be reasonably maintained and modesty will be preserved. Review of the hospital’s document titled, “Behavioral Health Nursing Orientation Competency Checklist,” dated 10/2024, showed customer services skills included the maintenance of patient’s privacy. Review of the hospital’s document titled, “Behavioral Health Tech Orientation Competency Checklist,” dated 10/2024, showed customer services skills included the maintenance of patient’s privacy. Record review of Patient #14’s ‘s medical record dated 03/13/25 through 03/25/25 showed: - On 03/14/25 at 8:17 AM, a 37-year-old male was admitted to the BHU for suicidal ideation (SI, thoughts of causing one’s own death). - His history included schizoaffective disorder-bipolar type (mental illness that is characterized by symptoms of mania, depression and mood disturbances), Post-Traumatic Stress Disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock), Attention Deficit Hyperactive Disorder (ADHD, characterized by problems with keeping attention to one thing and impulsive behaviors), intermittent explosive disorder (a mental and behavioral disorder characterized by explosive outbursts of anger and/or violence to the point of rage, out of proportion to the situation at hand), obsessive compulsive disorder (OCD, having a tendency toward excessive orderliness, perfectionism, and great attention to detail), rheumatoid arthritis (RA, a chronic disease that causes inflammation of the joints, resulting in painful deformity and immobility) and mild intellectual disability. - Patient #14 reported his history included physical, emotional and sexual trauma. Review of hospital’s video titled, “03.18.25, 1227, E.C.-2025-04-09 12.13.28.092, dated 03/18/25, showed at 52:30 (not actual time), Staff OO, SO and Staff C, RN enter the room. Staff C holds a urinal for the patient to pee in. Staff C does not cover the patient for privacy. The patient’s penis is exposed. Review of hospital video titled, “03.18.25, 2110, E.C.-2025-04-09 12.13.30.165”, dated 03/18/25, showed at 2:45:06 (not actual time), Staff NNN, RN, Staff PPP, RN and Staff KK, Security Officer, pulled Patient #14’s pants and diaper off for use of a bedpan. Patient #14 was fully exposed to the seclusion room camera and the hallway. During an interview on 04/21/25 at 9:00 AM and 04/22/25 at 11:40 AM, Staff Z, President, stated that he expected a patient’s privacy was protected when using the urinal in front of the seclusion room camera. During an interview on 04/23/25 at 10:00 AM, Staff A, Interim BHU Manager, stated that she expected staff to honor the privacy and dignity of patient’s during toileting by closing the door to the seclusion room. During an interview on 04/15/25 at 11:52 AM, Staff HH, Registered Nurse (RN), stated that a patient should be covered from the seclusion room camera for urinal and bedpan use. 38236”

“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: 48359 Based on observation, interview, video review, record review and policy review, the hospital failed to provide a safe patient environment on the Behavioral Health Unit (BHU) for 10 current patients (#31, #32, #33, #34, #35, #36, #37, #38, #39 and #40) of 10 current patients reviewed and one discharged patient (#14) of one discharged patient reviewed. These failures had the potential to affect the quality of care and safety of all patients. Findings included: Review of the hospital’s policy titled, “Behavioral Health Environment of Care Risk Assessment,” revised 12/27/23, showed: - The risk assessment is designed to help identify and abate suicide (to cause one’s own death) hazards in locked psychiatric (relating to mental illness) units. - It consists of criteria applicable to all rooms on the department, as well as specific criteria for areas such as bedrooms, bathrooms, seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) rooms and staff workstations. - The risk assessment will be conducted to ensure the provision of safe and secure behavioral health services on BHUs treating suicidal (SI, thoughts of causing one’s own death) patients. Review of the hospital’s document titled, “Behavioral Health Nursing Orientation Competency Checklist,” revised 10/2024, showed the patient’s environment must be evaluated for any potential ligature (anything which could be used for the purpose of hanging or strangulation) risks. If any ligature risk is identified, known or suspected, interventions must be initiated to eliminate or mitigate the risk to assure patient safety, in accordance with hospital policy. Review of the hospital’s document titled, “Behavioral Health Tech Orientation Competency Checklist,” dated 10/2024, showed behavioral health safety and situational awareness included understanding expectations for room checks. Review of the hospital’s undated and untitled document showed BHUs will conduct complete room searches every 24 hours. Employees will examine patient belongings in rooms. Record review of Patient #14’s medical record dated 03/13/25 through 03/25/25, showed: - On 03/14/25 at 8:17 AM, a 37-year-old male was admitted to the BHU for suicidal ideation (SI, thoughts of causing one’s own death). - His history included schizoaffective disorder-bipolar type (mental illness that is characterized by symptoms of mania, depression and mood disturbances), post-traumatic stress disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock), attention deficit hyperactive disorder (ADHD, characterized by problems with keeping attention to one thing and impulsive behaviors), intermittent explosive disorder (a mental and behavioral disorder characterized by explosive outbursts of anger and/or violence to the point of rage, out of proportion to the situation at hand), obsessive compulsive disorder (OCD, having a tendency toward excessive orderliness, perfectionism, and great attention to detail), rheumatoid arthritis (RA, a chronic disease that causes inflammation of the joints, resulting in painful deformity and immobility) and mild intellectual disability (ID, below average intellectual functioning which limits the ability to learn at an expected level and limits level of function in daily life). - Room visual checks were not performed on 03/14/25 at 3:46 PM, 03/15/25 at 10:24 AM and 4:35 PM, 03/16/25 at 8:27 PM, 03/20/25 at 3:37 AM and 8:55 PM, 03/21/25 at 4:28 AM, 8:35 PM, and 8:38 PM, 03/23/25 at 1:53 PM and 3:43 PM and 03/24/25 at 11:46 PM, for 13 out of 23 shifts, they were not done. - Room searches were completed on 03/16/25 at 8:27 PM and 03/20/25 at 8:55 PM, for six of 12 days, they were not done. - On 03/23/25 at 6:40 PM, Patient #14 placed a disinfectant wipe in his mouth and swallowed one to two tablespoons of shampoo in his room. Observation on 04/07/25 at 2:30 PM, in the BHU, showed patient rooms were open and easily accessible to all patients. Non-psychiatric safe toothbrushes, mouthwash, deodorant, lip balms, moisturizers, earplugs and toothpaste were in in gray bins in each occupied patient room. The day room had a gray bin filled with rigid plastic markers. Review of the hospital’s video titled, “03.18.2025 Hallway Seclusion Room,” dated 03/18/25, showed at 6:05:47 (not actual time), Staff HHH, Registered Nurse (RN), left a cellphone charging cord and backpack in the BHU hallway unattended. During an interview on 04/22/25 at 11:40 AM, Staff Z, President, stated that he expected the BHU environment to be safe. During an interview on 04/17/25 at 12:34 PM and 04/23/25 at 10:50 AM, Staff ZZ, Chief Nursing Officer (CNO), stated that she expected the BHU environment to be safe. She did not expect disinfectant wipes to be in patient rooms. The availability of toiletries in patient open rooms was “risky.” There were opportunities for improvement with the toiletries and disinfectant wipes. After review of the hospital’s video titled, “03.18.2025 Hallway Seclusion Room,” dated 03/18/25, Staff ZZ, stated that Staff HHH’s, RN, unattended backpack and phone charging cord in the hallway was a ligature risk. During an interview on 04/07/25 at 2:30 PM and 04/23/25 at 10:00 AM, Staff A, Interim BHU Manager, stated that patient rooms remained open. She expected the BHU environment to be safe, disinfectant wipes should never be accessible to the patients. During an interview on 04/14/25 at 1:25 PM, Staff CC, RN, stated that Patient #14 ingested shampoo and a had a disinfectant wipe in his mouth, which he obtained from his bathroom. During an interview on 04/14/25 at 12:30 PM, Staff BB, Patient Care Technician (PCT), stated that when Patient #14 exited his bathroom he had had a disinfectant wipe in his mouth and swallowed a small amount of shampoo. 38236”

“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: 48359 Based on interview, record review, video review and policy review the hospital failed to: - Recognize physical, emotional and verbal abuse and neglect toward one discharged patient (#14) of one discharged patient reviewed; - Immediately investigate, interview staff and remove staff members involved in the abuse and neglect of one discharged patient (#14) of one discharged patient reviewed; and - Provide education to staff following an incident involving physical, emotional and verbal abuse and neglect of one discharged patient (#14) of one discharged patient reviewed. These failures had the potential to affect the quality of care and safety of all patients. Findings included: Review of the hospital’s policy titled, “Caregiver Misconduct, Patient Abuse, Neglect, Misappropriation of Property, and Harassment,” revised 11/17/23, showed: - Immediately upon observing or becoming aware of incidents of possible abuse and/or neglect, any staff must report such incidents to their immediate supervisor. If the supervisor is unavailable, the staff must contact the Nursing Supervisor or Administrator on Call. - For the protection of patients and involved personnel, patient care providers involved in patient abuse, and/or neglect must be relieved of patient care responsibilities and removed from patient care areas of the hospital during the pendency of a prompt investigation. - The Administrative Supervisor will conduct a preliminary investigation to gather pertinent information to understand the allegation further and determine escalation. - Any employee working in the patient care site who is accused of abuse and/or neglect of a patient by any source will immediately be removed from all patient care responsibilities anywhere in the hospital or patient care site, until the determination of administrative leave is made. - Risk Management and Human Resources will oversee the investigation, which should include the collecting and preserving any physical and documentary evidence; interviewing all alleged victims, witnesses, and those alleged to have committed acts of abuse; collecting other corroborating or disproving evidence; and documenting each step taken during the internal investigation. - Upon the conclusion of an investigation into patient abuse and/or neglect, a written summary of the investigation will be completed and distributed by Risk Management; for employees, a determination will be reached in conjunction with Human Resources, the Campus Executive Team, Risk, and Regulatory for appropriate corrective action up to and including termination of employment, if indicated by the investigation; and results of investigations and remedial actions will be communicated to appropriate hospital leadership, Human Resources (HR), Regulatory, appropriate medical staff leadership, and affiliated organizations. - The patient’s legal decision-maker shall be notified of each instance of reported patient caregiver misconduct/abuse, neglect, or harassment; incidents shall be reported to the appropriate regulatory agency when the ministry has reasonable cause to believe the incident meets or could meet the definition of abuse and/or neglect; the ministry will report to the appropriate regulatory and licensing agencies within seven calendar days; if the event is not reported, Risk Management must clearly document the reason for not reporting on the investigative report; and the Department of Health shall be notified of instances involving an Eligible Adult (an adult with a disability, between the ages of 18 and 59 who is unable to protect their own interests or to adequately perform or obtain services which are necessary to meet their essential human needs) patient. Review of the hospital’s policy titled, “Violent Restraint Utilization,” revised 08/15/254, showed: - Patients’ rights to privacy, freedom, dignity, comfort and autonomy will be reasonably maintained and modesty will be preserved. - Patients have the right to be free from restraints of any form that are imposed for coercion, discipline, convenience or retaliation by the staff. - Relief periods for patients in seclusion or restraints must occur, except when precluded for safety reasons (in which case the reason must be documented). Patients must be given directly supervised relief periods every two hours at which time they should be offered toileting, fluids, and/or nourishment. Relief periods must be documented. If relief periods are not given, document the reason. Review of the hospital’s undated document titled, “Module six, Healthcare Restraint Holds/Applications,” showed to never place a towel, bag or other cover over a patient’s face. Record review of Patient #14’s medical record, dated 03/13/25 through 03/25/25, showed: - On 03/14/25 at 8:17 AM, a 37-year-old male was admitted to the Behavioral Health Unit (BHU) for suicidal ideation (SI, thoughts of causing one’s own death). - His history included schizoaffective disorder-bipolar type (mental illness that is characterized by symptoms of mania, depression and mood disturbances), Post-Traumatic Stress Disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock), Attention Deficit Hyperactive Disorder (ADHD, characterized by problems with keeping attention to one thing and impulsive behaviors), intermittent explosive disorder (a mental and behavioral disorder characterized by explosive outbursts of anger and/or violence to the point of rage, out of proportion to the situation at hand), obsessive compulsive disorder (OCD, having a tendency toward excessive orderliness, perfectionism, and great attention to detail), rheumatoid arthritis (RA, a chronic disease that causes inflammation of the joints, resulting in painful deformity and immobility) and mild Intellectual disability/ Intellectual developmental disorder (ID, IDD, below average intellectual functioning which limits the ability to learn at an expected level and limits level of function in daily life). - Patient #14 had a guardian (the person appointed by a judge to manage the property and rights of another person who is considered incapable of doing so themselves). - On 03/17/25 at 1:28 PM, four-point restraints (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others) were applied and remained in place for one hour and 56 minutes. No relief periods were documented during this time and there was no documentation to indicate why the relief periods were not given. - On 03/18/25 at 12:19 AM, four-point restraints were applied and remained in place for seven hours and 58 minutes. No relief periods were documented during this time and there was no documentation to indicate why relief periods were not given. - At 12:30 PM, four-point restraints were applied and remained in place for four hours. No relief periods were documented during this time and there was no documentation to indicate why relief periods were not given. - At 9:10 PM, four-point restraints were applied and remained in place for a minimum of three hours and 10 minutes. No restraint discontinuation time was documented. No relief periods were documented during this time and there was no documentation to indicate why relief periods were not given. - On 03/19/25 at 12:53 PM, four-point restraints were applied and remained in place for 58 minutes. - On 03/22/25 at 3:10 PM, four-point restraints were applied and remained in place for one hour and 22 minutes. - On 03/23/25 at 10:00 AM, four-point restraints were applied and remained in place for one hour. - At 6:15 PM, four-point restraints were applied and remained in place for one hour and 14 minutes. Review of hospital video titled, “BWC, 03.17.2025(1),” dated 03/17/25, showed at 1:23.13 PM, Staff QQ, Security Officer (SO) and Staff WW, Security Officer Supervisor (SOS), grabbed Patient #14’s arms and pulled forward and upward. Patient #14 was pulled by his arms forward on the floor two to three feet. Review of the hospital’s video titled, “03.17.25, 1335, E.C.-2025-04-09 12.13.25.945,” dated 03/17/25, showed: - At 01:01 (not actual time), Staff FF, SO, and Staff WW, SOS, lifted Patient #14 off the floor to the bed. Patient #14 landed on the bed with his right arm twisted and pulled up behind his back at the top of the bed. - At 01:10, Staff QQ, SO, pulled Patient #14’s shirt up over his face. - At 03:25, Staff WW covered Patient #14’s mouth and nose with his hand. - At 08:17, the restraints were in place and all staff left the room. Patient #14’s right arm hung off the side of the bed, not at the mattress level. His belly and right hip were visibly exposed. - At 34:01, both arms hung off the side of the bed, not at the mattress level. Review of the hospital’s video titled, “03.18.25, 0010, E.C.-2025-04-09 12.13.25.699,” dated 03/18/25, showed: - At 06:45 (not actual time), Staff PP, Registered Nurse (RN), placed her right hand over Patient #14’s nose and mouth. - At 08:46, Patient #14’s right arm hung off the side of the bed, not at the mattress level. - At 58:19, Patient #14’s hands and feet hung off the bed, his shirt was pulled up and his abdomen was visible. - At 01:14:45, Patient #14’s arms and feet continued to hang off the bed. - At 01:43:00, Staff YY, RN, administered a medication to Patient #14 by mouth with no water, he chewed the medicine. - At 3:55:00, Patient #14 wiggled uncomfortably, and cried. - At 6:38:32, Patient #14 soiled himself with urine, he was not provided hygiene care. - At 7:25:16, the urine spot on Patient #14’s pants had dried. - At 7:27:55, Patient #14 soiled himself with urine, he was not provided hygiene care. - At 8:05:45, Staff B, RN, and Staff EE, RN, removed the restraints. Patient #14 immediately moved his arms in a circular motion and his ankles had visible deep indentations. - At 8:08:20, Patient #14 was hesitant to stand up. When he stood, the entire back side of his pants were visibly wet. - Patient #14 was improperly positioned in four-point restraints for seven hours, 56 minutes and 59 seconds. His arms and legs hung in a dependent position off the bed, and he was not on the wedge pillow to achieve a 30-degree head elevation. Review of the hospital’s video titled, “03.18.25, 1227, E.C.-2025-04-09 12.13.28.092,” dated 03/18/25, showed: - At 00:45 (not actual time), Staff QQ, SO, pulled Patient #14’s shirt over his face. - At 02:27, Staff C, RN, moved Patient #14 by pulling on his clothes. His hands and feet hung off the bed. - At 10:52, 22:45 and 27:30, staff repositioned him by pulling his clothes. - At 1:49:10, Staff B, RN, tightened the right wrist restraint. His right arm was not at the mattress level. - At 3:12:19, he cried. Review of the hospital’s video titled, “03.18.2025, 2110, E.C.-2025-04-09 12.13.30.165,” dated 03/18/25, showed: - At 00:04 (not actual time), Staff DD, SO, Staff JJJ, SO, and Staff MMM, RN, moved Patient #14 up in the bed by pulling his arms while he was restrained in 4-point restraints. The mattress moved with him and was not on the bed frame correctly. His feet hung off the bed. - At 03:56, Patient #14’s feet hung off the mattress and onto the hard bedframe. He was not on the wedge pillow to achieve a 30-degree head elevation. - At 59:10, Patient #14 attempted to move his right arm, but the restraint did not allow any movement. Review of the hospital’s video titled, “03.19.25, 1248, E.C.-2025-04-09 12.13.32.062 PM,” dated 03/19/25, showed at 05:12 (not actual time), Patient #14’s left arm hung off the bed. At 1:04:19, the restraints were removed; Patient #14’s shirt was wet from the bottom up to his shoulder blades and his pants were wet from the top down past his knees. Review of hospital’s video titled, “BWC, 03.22.2025 3:00 PM #one through #three,” dated 03/22/25, showed: - At 15:02:16, Staff MM, SO, stated, “do you have a blanket or pillowcase or something once we get him down, we can put it over his face temporarily.” Staff HH, RN, stated, “yeah, I will go grab one.” - At 15:04:00, Patient #14 stated, “what happened was my foot started hurted.” Staff UU, SO, stated, “you asked for some medication, right?” Staff HH stated, “No, he did not, because I asked him several times what he needed, and he walked away from me. So, he had multiple chances to say what he needed, and he did not.” Staff UU stated, “hasn’t your ankle been throbbing everyday by this time, wasn’t it throbbing yesterday?” - At 15:05:50, Patient #14 stated, “no! It’s not going to be just for now, it’s going to be forever.” Staff MM stated, “It’s not forever, because the last time I saw you in restraints they put you in ‘em but 15 minutes, you was out.” - At 15:07:31, staff wrestled with a pillowcase over Patient #14’s face. - At 15:08:36, Staff MM stated, “make sure you get it tight on his feet.” - At 15:15:48, Staff RR, House Supervisor (HS) stated, “Ok, so here is the deal, what we have been told last week you can file assault charges, you can have him arrested, police will pick him up and they will bring him right back here because of his mental retardation status. It is a viscous cycle.” Staff LLL, Patient Care Technician (PCT), stated, “if he assaults me, I’m calling the police. If that’s an action I can take, then I will do it.” Staff RR, HS, stated, “exercise it, exercise it.” Staff MM stated, “if you ever want to press charges, I will press charges, I will go to court, I don’t care. We can do that and bring cuffs up here right now.” Staff RR, HS, stated, “yeah it’s been going on for two weeks.” - At 15:18:50, Staff UU stated, “no shots just put him in restraints.” Staff RR stated, “yeah that’s what the doctor said, the doctors been upset because they have been giving him shots this week.” Someone stated, “they have been giving him shots like every six hours.” Staff RR stated, “but she says she didn’t give that order, so she was upset about that.” Review of the hospital’s video titled, “03.22.2025, 1500, E.C.-2025-04-09 12.13.34.075 PM,” dated 03/22/25, showed: - At 06:56 (not actual time), Staff C, RN, stood next to Patient #14 with a pillowcase in her hands. - At 07:13, Staff MM, SO, and Staff XX, SO, placed a pillowcase over Patient #14’s face. Staff UU, SO, helped hold the pillowcase. - At 10:13, Patient #14 tried to move his head. Staff XX and Staff UU held the pillowcase more firmly on Patient #14’s face, his eyes, nose and mouth were not visible. - At 13:31, Patient #14’s left arm and left foot hung off the side of the bed. Review of hospital’s video titled, “BWC,03.23.2025 10:00 AM,” dated 03/23/25, showed: - At 09:56:04 AM, Staff HH, RN, asked, “is he spitting?” Staff LL, SO, stated, “Yes.” Staff HH, stated, “Alright, well the doctor said that restraints will be justified again.” - At 10:01:41, Staff WW, SOS, stated, “don’t pull him too far, cause this strap right here is tight, tight.” - At 10:03:18, Patient #14 moaned several times, breathed hard and loud. Staff HH stated, “apparently you don’t want to go home. I told you 24 hours incident free and here we are. You were spitting and scratching people. You just scratched me.” Staff LL stated, “attempting to tear up property too.” Staff HH stated, “Yep, so I guess you don’t want to go home.” - At 10:04:44, Staff LL stated, “stop” as he covered Patient #14’s nose with his hand and placed the pillowcase over Patient #14’s mouth. Someone stated, “bring it down hard, there you go.” Staff LL stated, “lay back” as he covered Patient #14’s eyes with his hand. Staff LL covered Patient #14’s mouth and nose firmly with the pillowcase. Patient #14 moaned. Patient #14 stated, “I don’t give a fuck.” Staff LL stated, “well you’re going to have too; the world does not revolve around you buddy.” - At 10:05:43, Staff LL stated, “that’s a spit, nice try” as he rubbed the pillowcase in the patient’s face. - At 10:06:33, Staff LL stated, “let go, let go” as he pulled Patient #14’s nose up and backward with his right thumb. He then pinched Patient #14’s nose together. - At 10:07:13, Staff WW, SOS, stated, “I was lucky and didn’t get spit on that time.” Staff LL stated, “he had one locked in and I fucking rubbed his mouth all over this (pillowcase). He was foaming at the mouth, I had it prepped and ready for you Staff WW.” Review of the hospital’s video titled, “BHUSeclusion1,” dated 03/23/25, showed: - At 01:14 (not actual time), Patient #14 stood up and closed the seclusion room door. Staff LL, SO, pushed the door open with his foot and two hands; Patient #14 fell between the door and the wall. - At 03:21, Staff LL placed a pillowcase over Patient #14’s face. - At 03:42, Staff LL placed a pillowcase over Patient #14’s face. - At 09:20, Staff LL held the pillowcase covering Patient #14’s mouth and nose. - At 18:55, Staff FF, SO, placed a pillowcase over and above Patient #14’s mouth. Staff LL placed his right hand over Patient #14’s mouth and nose with the pillowcase under his hands. Staff FF held the right side of the pillowcase. - At 19:18, Staff LL, placed his right hand over Patient #14’s mouth and nose with the pillowcase under his hands. Review of hospital’s video titled, “BWC, 03.23.2025 7:00 PM #one through #seven,” dated 03/23/25, showed: - At 18:10:35, Patient #14 stated, “I still feel unsafe.” Someone stated, “You got to use your words, why do you feel unsafe?” Staff XX, SO, stated, “we are going to have to do restraints, here in a second.” - 18:19:36, Staff MM, SO, stated, “we’re going to need two people to hold his arms while someone covers his head, he won’t move his legs that much.” - At 18:53:02, Patient #14 swung at Staff BB, PCT, but did not make contact. - At 18:53:44, Staff BB, stated, “where is the pillowcase that I had?” - At 18:54:19, Staff BB laughed. Staff TT stated, “where is that pillowcase, put it over his head!” - At 18:55:52, Staff CC stated, “put it over it” and placed the pillowcase over Patient #14’s head. - At 18:56:15, Staff HH, stated, “I guess your pinky promise to me didn’t mean nothing.” Staff TT slapped Patient #14’s restrained left hand. The slap was audible. Some staff laughed. Staff TT laughed and stated, “quit doing that.” Review of the hospital’s video titled, “BHUSeclusion2,” dated 03/23/25, showed: - At 32:02 (not actual time), Patient #14 removed his shirt and placed it around his neck. Staff BB, PCT, and Staff NN, Nursing Student (NS), ripped the shirt out of Patient #14’s hands from around his neck, twisting his neck to the side. - At 38:39, Staff BB waved the pillowcase. - At 40:16, Staff CC, RN, placed a pillowcase over Patient #14’s head while the patient sat on the floor and twisted the bottom of the pillowcase to tighten it on Patient #14’s neck. Staff CC, Staff XX, SO, Staff BB and Staff MM, SO, picked Patient #14 up by his arms and legs to attempt to place him on the bed. Extra lifting and pulling was needed. Patient #14 was lifted over a wedge pillow. - At 40:51, Staff XX took over holding the pillowcase and twisted the pillowcase tighter. - At 40:57, Staff BB took the pillowcase off Patient #14’s head. Staff CC placed the pillowcase over Patient #14’s mouth and nose. - At 41:38, Staff CC continued to hold the pillowcase over Patient #14’s face. - At 43:09, Patient #14’s face continued to be covered with the pillowcase. - At 45:49, Patient #14’s right arm and right foot hung off the side of the bed, his pants were pulled down and his diaper showed. During an interview on 04/21/25 at 9:00 AM and 04/22/25 at 11:40 AM, Staff Z, President, stated that the hospital had an “incredible” opportunity to be better. He understood the organization needed to think differently regarding the definition of abuse. He agreed the staff’s actions were willful at times and a reasonable layperson would state that Patient #14 was at risk of harm. During an interview on 04/23/25 at 9:00 AM, Staff AAA, Medical Director, stated that he believed the pillowcase being placed on Patient #14’s head and face was abuse and no one would condone that kind of behavior. He also believed slapping a patient was abuse. During an interview on 04/17/25 at 12:34 PM and 04/23/25 at 10:50 AM, Staff ZZ, Chief Nursing Officer (CNO), stated that pulling Patient #14’s arms to drag him in the hallway was not an appropriate technique and could be considered abusive. Patient #14 was defiant without violence and the application of violent restraints was inappropriate and punishing. Slapping a patient was abusive and uncalled for. Unapproved hold techniques and pulling a patient’s clothing was not okay. The power struggle between Patient #14 and Staff BB, PCT, over a shirt was inappropriate and under investigation. Patient #14’s exposed abdomen and pants down was not dignified. Clinical staff were responsible to ensure the patient’s treatment was dignified. She expected the hospital to follow the policy for abuse and neglect investigations. Staff BB, PCT, and Staff LL, SO, were the only two staff members placed on leave, after the state surveyors entered the building. Leadership made the decision to allow Staff BB and Staff LL to return to patient care before the completion of the investigation due to the “magnitude” of staff involved and that their continued leave was “inequitable to the working staff”. Leadership did not follow the hospital’s policy and procedure and they were responsible to ensure quality patient care. The events were a “horrendous pill to swallow.” The hospital had a learning opportunity regarding respect, abuse and neglect. Leadership needed to re-program staff and themselves to the willful definition of abuse. The hospital needed a culture shift, adaptation in what they did and education on how to approach abuse and neglect differently. She expected staff to utilize professional standards, and this survey presented a global concern. During an interview on 04/23/25 at 10:00 AM, Staff A, Interim BHU Manager, stated that she believed at times the staff acted willfully and Patient #14 experienced abuse. Patient #14’s positioning with his hands and feet in a dependent position without his head elevated was neglectful. Staff were responsible to protect themselves from a patient’s spit. The BHU did not have access to personal protective equipment (PPE, such as gloves, gowns, goggles and masks) during these events. PPE was provided to the BHU the Thursday before the State Surveyors entered the hospital. Failure to provide Patient #14 hygiene when he soiled himself was neglectful. Covering patient #14’s face/head with a pillowcase or his shirt was distressing and abusive. Failure to provide relief periods during a prolonged restraint episodes was neglectful. Slapping a patient was abuse. Pulling a patient by his arms was abuse. She agreed the investigation fell apart in the beginning when the pillowcase placed over Patient #14’s head was not ruled abuse. During an interview on 04/08/25 at 3:45 PM, 04/09/25 at 4:35 PM, 04/15/25 at 11:15 AM and 04/17/25 at 10:28 AM, Staff T, Security Manager, stated that he had a limited knowledge of the abuse and neglect investigation process. Staff LL, SO, was placed on leave after the State Surveyors entered the hospital. Staff LL pushed the seclusion room door “a little too hard” and Patient #14 was pushed into the wall. Staff LL was brought back to work before the investigation was completed and there was no education provided before he provided patient care. He was surprised staff involved in the abuse and neglect of Patient #14 were allowed to continue to provide patient care. Any time a staff member slapped/hit a patient it was abuse. The pillowcase was “very inappropriate, physically and emotionally abusive,” should never have been used and was not protective of his dignity. Clinical staff should have ensured Patient #14’s abdomen was covered after the restraints were applied to ensure dignity. Pulling Patient #14’s arms to drag and roll him had a risk of injury and was abusive. Patient #14 should not have been dragged through the hallway with a sheet, it was not protocol or the way “we do things.” “It looked abusive from the outside.” Failure to provide relief periods was neglectful and abusive. Hospital staff made choices that looked like abuse. Intent did not have to be present for abuse. He agreed all staff had the responsibility to protect the patient. There was a lot of choices and bad decisions made in the care of Patient #14. During an interview on 04/09/25 at 8:35 AM, 12:43 PM and 04/17/25 at 2:12 PM, Staff S, Risk and Regulatory Director, stated that she was made aware the pillowcase was placed over Patient #14’s head the day after the event occurred. She only reviewed a few moments of the video, when the pillowcase was placed over Patient #14’s head, called the Ministry’s Risk Management Director, verbally discussed the pillowcase event and abuse was ruled out. When the event was initially presented to her, she reviewed the situation with a screening tool and based on the hospital’s current definition of abuse the event was ruled out for abuse. The Ministry’s Risk Management Director did not view the event video. She did not view the remainder of the restraint episodes for Patient #14. No staff were removed from patient care. She was not aware of any additional events related to Patient #14. She was responsible for the performance of a complete abuse/neglect investigation when allegations were presented. She stated that the hospital had an opportunity to review the current definition of abuse and imminent risk. Evaluation of the current abuse definition was priority. She looked to create a culture shift. The hospital “really failed a lot of people and Patient #14 was abused.” Patient #14’s eight-hour restraint episode was abuse. Failure to provide hygiene when he soiled himself twice during the restraint episode was neglect. Failure to provide relief periods was abusive and neglectful. Patient #14 experienced pain and abuse when his arms and legs were restrained and hung off the bed for hours. She expected a restrained patient’s hands and feet to be at the mattress level. A staff member slapping a patient was abuse. During an interview on 04/17/25 at 10:10 AM, Staff WW, SOS, stated that pulling Patient #14’s left arm in the hallway was abusive. Upon reflection into the event, he could have told the clinical staff to wait to restrain Patient #14 and used a medical sled to move the patient. He had no training on how to roll a patient, he pulled his arm and there was a risk of injury during the roll. No one was responsible to oversee the situation or to identify wrong actions. Oversight would be valuable. He saw a lot of opportunity for improvement with the management of Patient #14. There were some very egregious staff actions and there was a need for a lot of staff education. It was punishment when a patient was restrained after he/she showed compliance and he/she was no longer an imminent risk to self or others. He felt the hospital needed a culture change. During an interview on 04/16/25 at 12:44 PM, Staff B, Charge RN, stated that she agreed staff escalated Patient #14’s behaviors when they drug him down the hallway. The event was based on the staff’s emotions more than the patient’s care. The staff’s comment regarding, “not getting to go home”, was punishing and taunting. After review of the hospital’s video titled, “03.18.25, 0010, E.C.-2025-04-09 12.13.25.699,” dated 03/18/25, she stated that Patient #14 should have “definitely” been repositioned up on the wedge, he was in an unacceptable position. Patient #14’s position was abusive. She was debriefed about the pillowcase over Patient #14’s head and felt Patient #14 was physically and emotionally abused. During an interview on 04/14/25 at 1:25 PM, Staff CC, RN, stated that he did not know why the wedge was not removed when Patient #14 was lifted to the seclusion bed. He thought to remove the wedge afterwards. “Staff BB, PCT, said they were going to have to do restraints. Someone said to put it (pillowcase) over his head. No one intended to cause Patient #14 harm, we did our best to help him.” He agreed intent did not have to be present for abuse. Staff CC took cues from other more experienced staff. He would not have placed the pillowcase over Patient #14’s head if he had not been told to do so. He was most “ashamed” of the pillowcase. He did not know how to state if abuse was present as a reasonable layperson. He agreed a hand slap was physical abuse and not professional. During an interview on 04/15/24 at 8:50 AM, Staff EE, RN, stated that Patient #14’s crying indicated distress, being upset and frustrated. Patient #14 experienced emotional and physical abuse during the eight-hour restraint episode overnight. It was inappropriate and not dignified to reposition a patient by pulling his/her clothing. When she viewed the video footage and did not see imminent harm, she agreed the restraints appeared to be punishment. Ideally nursing directed the patient care, but sometimes SO’s took over. Spitting was not an indication for violent restraints. A pillowcase was never to be used to prevent spitting. A pillowcase should never be held over a patient’s mouth and/or nose or used as a hood. A patient’s shirt should never be pulled over a patient’s head. It was not “good and dignity was not maintained.” Covering a patient’s eyes caused fear, distress and emotional abuse. During an interview on 04/16/25 at 3:13 PM, Staff PP, RN, stated that she believed Patient #14’s right arm was not properly aligned when the restraint was in place on 03/18/25. The placement of his arm had a risk for injury and was abusive. She expected a patient’s hands and feet to be at the mattress level. She did not notice his arm placement at the time. She agreed that at approximately one hour and 45 minutes into the restraint episode Patient #14 was calm and a release could have been trialed. She agreed the remaining six hours Patient #14 was restrained was wrong, abusive and neglectful. She did not feel empowered to speak up for Patient #14. Patient #14 was abused, neglected and his treatment lacked dignity. She wished she had spoken up and advocated for Patient #14. During an interview on 04/14/25 at 12:30 PM, Staff BB, PCT, stated that he was “shocked” when Staff CC, RN, placed the pillowcase over Patient #14’s head. It was abusive, not safe and did not “look good.” The lift technique used to place Patient #14 on the bed did not follow his training, it was a tiny space and “we were doing anything we could do.” There was no reasoning for the lift, “we were just in the moment.” If he could go back to the situation, he would redirect Patient #14 to lay on the bed rather than lift him over the wedge to the bed. He was informed by HR Friday, after the surveyors entered the hospital on Monday, an investigation was pending, and he was placed on leave. He worked on Saturday and Sunday, he did not receive any education prior to returning to work. 38236”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(3) The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient or others from harm. This Standard is not met as evidenced by: 48359 A-0165 Based on observation, interview, record review, video review and policy review, the hospital failed to use the least restrictive intervention for one discharged patient (#14) of one discharged patient reviewed. These failures had the potential to affect the quality of care and safety of all patients. Findings included: Review of the hospital’s policy titled, “ Violent Restraints (medical cuffs applied to both arms and both legs to prevent someone form causing harm to themselves or others) Utilization,” revised 08/15/24, showed: - Patients will be protected from harm in the least restrictive environment possible with the intent to prevent, reduce and work to eliminate the use of restraints. - Prior to the use of restraints, interventions shall be considered as appropriate, except when less restrictive alternatives are not feasible and it is imminently necessary to protect the health and safety of the patient, staff or others, including but not limited to verbal de-escalation and/or redirection, diversionary activities, reality orientation, observation, decreased stimulation, altered environment, reorientation to surroundings and medication. - The physician who is responsible for the care of the patient, gives the order only when less restrictive measures have been found to be ineffective to protect the patient or others from harm. Record review of Patient #14’s’s medical record dated 03/13/25, showed: - On 03/14/25 at 8:17 AM, a 37-year-old male was admitted to the Behavioral Health Unit (BHU) for suicidal ideation (SI, thoughts of causing one’s own death). - His history included schizoaffective disorder-bipolar type (mental illness that is characterized by symptoms of mania, depression and mood disturbances), Post-Traumatic Stress Disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock), Attention Deficit Hyperactive Disorder (ADHD, characterized by problems with keeping attention to one thing and impulsive behaviors), intermittent explosive disorder (a mental and behavioral disorder characterized by explosive outbursts of anger and/or violence to the point of rage, out of proportion to the situation at hand), obsessive compulsive disorder (OCD, having a tendency toward excessive orderliness, perfectionism, and great attention to detail), rheumatoid arthritis (RA, a chronic disease that causes inflammation of the joints, resulting in painful deformity and immobility) and mild Intellectual disability/ Intellectual developmental disorder (ID, IDD, below average intellectual functioning which limits the ability to learn at an expected level and limits level of function in daily life). - On 03/16/25 at 8:50 PM, violent restraints were applied after verbal redirection, one-to-one (1:1, continuous visual contact with close physical proximity) intervention, close observation and medication administration. There were no attempted diversionary activities, reality orientation, decreased stimulation, altered environment or reorientation to surroundings. - 03/17/25 at 1:28 PM, violent restraints were applied after medication administration. There was no attempted verbal de-escalation and/or redirection, diversionary activities, reality orientation, observation, decreased stimulation or altered environment. - On 03/18/25 at 12:19 AM, violent restraints were applied after increased frequency of nursing rounds, 1:1 intervention and medication administration. There was no attempted verbal de-escalation and/or redirection, diversionary activities, reality orientation, decreased stimulation, altered environment or reorientation to surroundings. - At 12:30 PM, violent restraints were applied after medication administration. There was no attempted verbal de-escalation and/or redirection, diversionary activities, reality orientation, observation, decreased stimulation or altered environment. - At 9:10 PM, violent restraints were applied after verbal redirection, 1:1 intervention and decrease stimulation. There were no attempted diversionary activities, reality orientation, altered environment or reorientation to surroundings. - On 03/19/25 at 12:53 PM, violent restraints were applied after medication administration. There was no attempted verbal de-escalation and/or redirection, diversionary activities, reality orientation, observation, decreased stimulation or altered environment. - On 03/22/25 at 3:10 PM, violent restraints were applied after medication administration. There was no attempted verbal de-escalation and/or redirection, diversionary activities, reality orientation, observation, decreased stimulation or altered environment. - On 03/23/25 at 10:00 AM, violent restraints were applied, there was no attempted verbal de-escalation and/or redirection, diversionary activities, reality orientation, observation, decreased stimulation, altered environment or medication administration. - At 6:15 PM, violent restraints were applied after time out, close observation, 1:1 observation and verbal directions. There were no attempted diversionary activities, reality orientation, decreased stimulation, altered environment, reorientation to surroundings or medication administration. Review of the hospital’s video titled, “03.16.2025, 2050, E.C.-2025-04-09 12.13.21.794 PM,” dated 03/16/25, showed at 00:57 (not actual time), Patient #14 voluntarily entered the seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) room, laid down on the bed and allowed staff to apply four-point restraints (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others) without resistance. Review of the hospital’s video titled, “Video1,” dated 03/17/25, showed at 00:15 through 08:19 (not actual time), Patient #14 sat quietly on the hallway floor until staff attempted to drag him down the hallway by his arms. Review of the hospital’s video titled, “03.19.2025, 1248, E.C.-2025-04-09 12.13.32.062 PM,” dated 03/19/25, showed at 00:02 (not actual time), Patient #14 voluntarily entered the seclusion room and sat on the bed. Review of the hospital’s video titled, “03.22.2025, 1500, E.C.-2025-04-09 12.13.34.075 PM,” dated 03/22/25, showed at 00:02 (not actual time), voluntarily entered the seclusion room and sat on the bed. At 07:29, staff forced Patient #14 onto his back to apply four-point restraints. Patient #14 did not resist the position change or restraint application. Review of the hospital’s video titled, “BHUSeclusion1,” dated 03/23/25, showed at 00:02 (not actual time), Patient #14 voluntarily entered the seclusion room and sat down. During an interview on 04/17/25 at 12:34 PM and 04/23/25 at 10:50 AM, Staff ZZ, Chief Nursing Officer (CNO), stated that when Patient #14 voluntarily walked into the seclusion room, he was compliant, sat down on the bed and was not an imminent risk of harm to self or others. She believed the low intensity head banging was Patient #14 seeking attention and did not present as an imminent risk. The hospital had the capability to provide seclusion, and seclusion was less restrictive than violent restraints. During an interview on 04/16/25 at 12:44 PM, Staff B, Charge Registered Nurse (RN), stated that she expected as needed medications to be given prior to the applications of restraints. If a patient refused an oral medication a shot was to be administered. Seclusion was not used routinely, there was an opportunity to try seclusion for Patient #14. During an interview on 04/17/25 at 10:10 AM, Staff WW, Security Officer Supervisor (SOS), stated that when Patient #14 voluntarily walked into the seclusion room he was not an imminent risk to himself or others and did not require violent restraints. He felt the hospital needed a culture change. During an interview on 04/15/24 at 8:50 AM, Staff EE, RN, stated that after she viewed the hospital’s video titled “03.18.2025, 1227, E.C.-2025-04-09 12.13.28.092 PM,” dated 03/18/25, she believed Patient #14 did not fight and was calm; it would have been reasonable to try a less restrictive approach. As needed medications were expected to be given prior to the application of restraints in an effort to use a less restrictive method for behavior management. During an interview on 04/15/25 at 11:52 AM, Staff HH, RN, stated that seclusion was less restrictive than violent restraints. “It’s just how we have always done it.” She was unable to define seclusion. Upon review of the hospital’s video titled, “BHUSeclusion1,” dated 03/23/25, she believed Patient #14 voluntarily walked into the seclusion room, “it looked like he was waiting to see what was going to happen” and he did not appear to present an imminent risk of harm to self or others. If a patient was calm, there was no indication for violent restraints. During an interview on 04/16/25 at 10:15 AM, Staff D, RN, stated that she should have given Patient #14 a chance to “chill,” a little more time to “cool off.” Patient #14 was unpredictable. She believed more verbal de-escalation could have been tried prior to the violent restraint application. During an interview on 04/14/25 at 12:30 PM, Staff BB, Patient Care Technician (PCT), stated that Patient #14’s behavior escalated when the restraints were applied, “the restraints made things worse.” Patient #14 voluntarily regulated his behavior in the seclusion room. The best course of action would have been to remove dangerous items from the room and seclude Patient #14. He wished he had spoken up. 38236”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 48359 Based on interview, record review, video review and policy review, the hospital failed to follow their policy for therapeutic holds (treatment technique in which a violent patient is physically contained by people) for one discharged patient (#14) of one discharged patient reviewed. These failures had the potential to affect the quality of care and safety of all patients. Findings included: Review of the hospital’s policy titled, “ Violent Restraints (medical cuffs applied to both arms and both legs to prevent someone form causing harm to themselves or others) Utilization,” revised 08/15/24, showed patients will be protected from harm in the least restrictive environment possible with the intent to prevent, reduce and work to eliminate the use of restraints. Patients will be restrained by competent staff following established procedures. Review of the hospital’s undated document titled, “Module Six, Healthcare Restraint Holds/Applications,” showed: - For a supine holding position, staff hold the patient down on either side of the elbow and knee. Not on a joint! - A staff person can then apply restraints to the ankles and wrists. Keeping one-arm raised above the head reduces the individual’s ability to use their core strength and resist. - A staff person may be needed to control the individual’s head, do not turn their head. - A staff person may be needed to control the individual’s feet until restraints can be applied. - Supine hand positions hold the limbs for the application of restraints is achieved by grasping either side of the knee and either side of the elbow with both hands. - Ensure no pressure is exerted on the joints. For better leverage, lock your arms and position your shoulders directly over your hands. - Any use of force must be justified and legally warranted. - Escort technique guidelines include maintaining a 45-degree angle and proper distance, direct the individual where you want them to go, use your verbal and non-verbal skills, do not point with your finger, use your hand and maintain awareness. - The reactionary gap is four to six feet. It is the distance between an individual and an aggressor in which the ability to react is impaired due to the close proximity of the aggressor. - Do not cover or bury the patient’s face or put any pressure on the patient’s back. - Policies and procedures should be adhered to for all healthcare restraint applications/holds. Although requested the hospital failed to provide a staff required training for therapeutic holds policy. Review of the hospital’s undated document titled, “Learning Status Report,” showed: - Staff D, Registered Nurse (RN), was not AVADE (a workplace violence prevention training program focused on providing employees with the skills and knowledge to prevent, manage, and respond to violence and aggression in the workplace) level III certified; - Staff BB, RN was not AVADE level III certified; - Staff CC, Patient Care Technician (PCT), was not AVADE level III certified; - Staff VV, RN, was not AVADE level III certified; and - Staff XX, Security Officer (SO) was not AVADE level III certified. Review of the untitled hospital document dated 09/07/23, showed Staff NN, Nursing Student (NS), was not AVADE level III certified. Record review of Patient #14’s medical record dated 03/13/25 through 03/25/25, showed on 03/14/25 at 8:17 AM, a 37-year-old male was admitted to the Behavioral Health Unit (BHU), for suicidal ideation (SI, thoughts of causing one’s own death). His history included schizoaffective disorder-bipolar type (mental illness that is characterized by symptoms of mania, depression and mood disturbances), post-traumatic stress disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock), attention deficit hyperactive disorder (ADHD, characterized by problems with keeping attention to one thing and impulsive behaviors), intermittent explosive disorder (a mental and behavioral disorder characterized by explosive outbursts of anger and/or violence to the point of rage, out of proportion to the situation at hand), obsessive compulsive disorder (OCD, having a tendency toward excessive orderliness, perfectionism, and great attention to detail), rheumatoid arthritis (RA, a chronic disease that causes inflammation of the joints, resulting in painful deformity and immobility) and mild intellectual disability (ID, below average intellectual functioning which limits the ability to learn at an expected level and limits level of function in daily life). Review of the hospital’s videos titled, “03.16.2025, 2050, E.C.-2025-04-09 12.13.21.794 PM,” dated 03/16/25, “03.22.2025, 1500, E.C.-2025-04-09 12.13.34.075 PM,” dated 03/22/25 and “BHUSeclusion2,” dated 03/23/25, showed Staff XX, SO, applied holds to Patient #14. Review of the hospital’s video titled, “03.17.2025, 1335, E.C.-2025-04-09 12.13.23.945 PM,” dated 03/17/25, showed Staff VV, RN, and Staff D, RN, applied holds to Patient #14. Review of the hospital’s videos titled, “BHUSeclusion1,” dated 03/23/25 and “BHUSeclusion2,” dated 03/23/25, showed Staff BB, PCT, Staff CC, RN, and Staff NN, NS, applied holds to Patient #14. During an interview on 04/08/25 at 3:45 PM, 04/09/25 at 4:35 PM, 04/15/25 at 11:15 AM and 04/17/25 at 10:28 AM, Staff T, Security Manager, stated that staff who worked in high-risk areas including the emergency department (ED), BHU, security and one-to-one (1:1, continuous visual contact with close physical proximity) patient sitters were required to have AVADE level III training. Staff who did not complete AVADE level III training were not trained on therapeutic holds. During an interview on 04/21/25 at 9:00 AM and 04/22/25 at 11:40 AM, Staff Z, President, stated that he expected staff to have competencies and training. If an individual was not properly trained, he expected them to not be involved with holds. During an interview on 04/17/25 at 12:34 PM and 04/23/25 at 10:50 AM, Staff ZZ, Chief Nursing Officer (CNO), stated that unapproved hold techniques were not okay. She expected staff to follow their training for therapeutic hold techniques. During an interview on 04/23/25 at 10:00 AM, Staff A, Interim BHU Manager, stated that the staff’s failure to utilize proper therapeutic hold techniques had a risk for injury and could be abusive. During an interview on 04/14/25 at 1:25 PM, Staff CC, RN, stated that he attended the most basic AVADE training for self-defense, he was not taught how to apply therapeutic holds. Review of the hospital’s video titled, “03.17.25, 1335, E.C.-2025-04-09 12.13.25.945,” dated 03/17/25, showed: - At 00:40 (not actual time), Staff SS, RN, grabbed Patient #14’s right arm and twisted it to the left several times. Patient #14 began to turn to the right and Staff SS pushed his head down toward his chest. - At 01:10, Staff FF, SO, placed his lower arm and elbow into the patient’s left jaw and shoulder. - At 01:29, Staff SS placed his left knee onto Patient #14’s left leg. - At 05:29, Patient #14’s head was held forward with his chin touching his chest by Staff QQ, SO. Staff FF forcefully used his elbow to push Patient #14’s left leg down. - At 07:20, Staff QQ had Patient #14’s right wrist in a restraint, he remained laying over the top of the bed pushing his body towards Patient #14 causing Patient #14’s head to move forward/down further towards his chest. Review of the hospital’s video titled, “03.18.25, 0010, E.C.-2025-04-09 12.13.25.699,” dated 03/18/25, showed: - At 05:45 (not actual time), Staff KK, SO, and Staff FFF, SO, pulled backwards on Patient #14’s arms in an attempt to move him up in bed. - At 13:51, Staff FFF, placed his right hand on the left side of Patient #14’s head and smashed his head into the mattress. - At 20:49, Staff KK pulled Patient #14’s right arm and pulled it backward toward the bed. Staff FFF pulled his left arm backward toward the bed. Staff FFF placed his right hand over the patient’s right cheek and pushed his head into the mattress. - At 52:52, Patient #14 removed his right wrist restraint. - At 56:38, Staff KK pushed Patient #14’s right arm and shoulder against the bed. Staff KK and Staff FFF held Patient #14’s face turned to the left against bed. Review of the hospital’s video titled, “03.18.25, 1227, E.C.-2025-04-09 12.13.28.092,” dated 03/18/25, showed: - At 00:00 (not actual time), Staff QQ, SO, pulled Patient #14’s right arm out and twisted toward the bed. Patient #14 was pulled forward at the end of the bed, nearly fell off of the bed, and staff rolled him into a face-down position. - At 00:29, Staff QQ, Staff WW, Security Supervisor (SOS), Staff C, RN, and Staff CCC, PCT, turned Patient #14 to his back by twisting/pulling his arms and clothes. Staff QQ and Staff WW pulled Patient #14’s arms to move him over and up in the bed. Review of the hospital’s video titled, “03.18.2025, 2110, E.C.-2025-04-09 12.13.30.165,” dated 03/18/25, showed at 00:04 (not actual time), Staff JJJ, SO, pulled and twisted Patient #14’s left arm. Review of the hospital’s video titled, “03.19.25, 1248, E.C.-2025-04-09 12.13.32.062 PM,” dated 03/19/25, showed: - At 02:43 (not actual time), Staff WW, SOS and Staff OO, SO, pulled Patient #14 back onto the bed. Staff OO placed his elbow and arm on Patient #14’s neck and left shoulder. - At 03:38, Staff OO removed his arm from Patient #14’s neck and placed his left hand on the right side of Patient #14’s face and turned his face to the left. - At 04:34, Staff B, RN, took over the hold to Patient #14’s face. She placed two hands to apply pressure on Patient #14’s left face on to the mattress. Review of the hospital’s video titled, “03.22.2025, 1500, E.C.-2025-04-09 12.13.34.075 PM,” dated 03/22/25, showed at 07:13 (not actual time), Staff XX, SO, Staff MM, SO and Staff UU, SO, pulled Patient #14 backward to lay him down. Review of the hospital’s video titled, “BHUSeclusion1,” dated 03/23/25, showed: - At 03:02 (not actual time), Patient #14 leaned to his left. Staff LL, SO, pushed Patient #14 by his head down onto the mattress. Patient #14 was twisted at the waist with his legs off the bed and the left side of his face pushed into the mattress. - At 03:21, Staff LL placed his right knee and leg onto Patient #14’s left shoulder. - At 03:26, Staff LL removed his knee and leg from Patient #14. He continued to hold Patient #14’s face down on the mattress turned to the left. - At 03:42, Staff LL pushed Patient #14’s head down with two hands. - At 09:20, Staff LL held Patient #14’s forehead back with two hands on the mattress. - At 09:41, Staff LL pushed down on Patient #14’s inner elbow with his left thumb. Review of the hospital’s video titled, “BHUSeclusion2,” dated 03/23/25, showed at 41:38 (not actual time), Staff BB, PCT, placed his left knee and leg over the top of Patient #14’s right leg. During an interview on 04/17/25 at 12:34 PM and 04/23/25 at 10:50 AM, Staff ZZ, Chief Nursing Officer (CNO), stated that unapproved hold techniques were not okay. She expected staff to follow their training for therapeutic holds. The hospital had an education gap for staff caring for a high-risk patient population. During an interview on 04/08/25 at 3:45 PM, 04/09/25 at 4:35 PM, 04/15/25 at 11:15 AM and 04/17/25 at 10:28 AM, Staff T, Security Manager, stated that holds that involved staff knees/elbows, direct pressure on a patient’s joints and face were not approved techniques and had a risk of injury. The twisting of Patient #14’s wrist had a risk of injury. During an interview on 04/23/25 at 10:00 AM, Staff A, Interim BHU Manager, stated that the staff’s failure to utilize proper therapeutic hold techniques had a risk for injury During an interview on 04/17/25 at 9:05 AM, Staff RR, House Supervisor, stated that direct joint pressure was not an approved hold and there was risk of pain and injury. She expected staff to have the proper knowledge, skills and training. AVADE taught staff to stay back to avoid injury. During an interview on 04/16/25 at 12:44 PM, Staff B, Charge RN, stated that once the patient was restrained there was no reason to continue the holds. She believed AVADE was too self-defense focused. The safety of the patient was lost with the move from Crisis Prevention Institute (CPI, a type of training where staff learn to safely defusing violent behavior and safe physical holds to restrict a person’s movement) to AVADE. She expected to see more patient trauma related to the teaching of harmful techniques. For example, she was taught to “gouge their eyes out.” During an interview on 04/15/25 at 11:52 AM, Staff HH, RN, stated that if she had seen Staff BB, PCT, place his knee on Patient #14’s thigh she would have stepped into the hold and allowed Staff BB to reapply. During an interview on 04/14/25 at 1:25 PM, Staff CC, RN, stated he attended the most basic AVADE training for self-defense, he was not taught how to apply therapeutic holds. During an interview on 04/15/24 at 8:50 AM, Staff EE, RN, stated that direct pressure on a knee joint was inappropriate. If she had been aware of the staffs’ actions during the holding of Patient #14, she would have redirected staff to proper therapeutic hold techniques. During an interview on 04/16/25 at 10:15 AM, Staff D, RN, stated that she had never seen knees and/or elbows used as a hold technique. She was taught to hold your body weight with your hands. If she had been aware she would have made them stop. During an interview on 04/15/25 at 10:15 AM, Staff FF, SO, stated that twisting Patient #14’s arm was not a proper technique. He did not know why Patient #14’s head was pushed forward when he was lifted from the floor, that was not a trained technique and there was a risk for injury. Placing a knee on a patient’s thigh was not an approved hold technique. He did not tap any staff out because he “kept hoping to make things better.” During an interview on 04/15/25 at 11:20 AM, Staff GG, SO, stated that sitting on a patient’s chest, using an elbow into the chest and face holds were not approved techniques. During an interview on 04/16/25 at 8:40 AM, Staff KK, SO, stated that holding a patient’s head with multiple hands was not appropriate. During an interview on 04/16/25 at 9:30 AM, Staff LL, SO, stated that a face hold was not an approved technique. 38236”

“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: 48359 Based on observation, interview, record review, video review and policy review, the hospital failed to ensure therapeutic holds (treatment technique in which a violent patient is physically contained by people) and seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) were ordered by a physician responsible for the care of the patient for one discharged patient (#14) of one discharged patient reviewed. The hospital failed to follow their policy to immediately secure a physician restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) order for one discharged patient (#14) of one discharged patient reviewed. These failures had the potential to affect the quality of care and safety of all patients. Findings included: Review of the hospital’s policy titled “Violent Restraint Utilization,” revised 08/15/24, showed: - When the nurse’s assessment indicates the patient requires restraints, the physician will be contacted for an order to restrain the patient, and the patient will then be placed in restraints. - In an emergency situation, when the physician is not immediately available, under the supervision of a registered nurse (RN) trained in the use of restraints, a trained staff member can initiate the restraint. An order must be immediately secured from a physician who is responsible for the care of the patient. - The order for restraint shall include the type of restraint, device or seclusion employed. Record review of Patient #14’s’s medical record dated 03/13/25 through 03/25/25 showed: - On 03/14/25 at 8:17 AM, a 37-year-old male was admitted to the Behavioral Health Unit (BHU) for suicidal ideation (SI, thoughts of causing one’s own death). - His history included schizoaffective disorder-bipolar type (mental illness that is characterized by symptoms of mania, depression and mood disturbances), Post-Traumatic Stress Disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock), Attention Deficit Hyperactive Disorder (ADHD, characterized by problems with keeping attention to one thing and impulsive behaviors), intermittent explosive disorder (a mental and behavioral disorder characterized by explosive outbursts of anger and/or violence to the point of rage, out of proportion to the situation at hand), obsessive compulsive disorder (OCD, having a tendency toward excessive orderliness, perfectionism, and great attention to detail), rheumatoid arthritis (RA, a chronic disease that causes inflammation of the joints, resulting in painful deformity and immobility) and mild intellectual disability (ID, below average intellectual functioning which limits the ability to learn at an expected level and limits level of function in daily life). . - On 03/17/25 at 12:23 PM, an order was written for four-point restraints (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others). There was no order for therapeutic holds or seclusion. The restraints were applied at 1:28 PM, 55 minutes prior to the order. - On 03/18/25 at 12:45 PM, an order was written for four-point restraints. There was no order for seclusion or therapeutic holds. - At 9:29 PM, an order was written for four-point restraints. There was no order for therapeutic holds. - On 03/19/25 at 2:29 PM, an order was written for violent restraints. There was no order for therapeutic holds or seclusion. The restraints were applied at 12:53 PM, 1 hour and 36 minutes prior to the order. - On 03/22/25 at 3:37 PM, an order was written for therapeutic holds and four-point restraints. The restraints were applied 27 minutes prior to the order. - On 03/23/25 at 11:34 AM, an order was written for therapeutic holds and four-point restraints. There was no order for seclusion. The restraints were applied one hour and 34 minutes prior to the order. - On 03/23/25 at 7:02 PM, an order was written for therapeutic hold and four-point restraints. The restraints were applied 47 minutes prior to the order. Review of the hospital’s video titled, “Video1,” dated 03/17/25, showed at 00:15 through 08:19 (not actual time), Patient #14 sat quietly on the hallway floor until staff attempted to drag him down the hallway by his arms to the seclusion room. The restraint application was not emergent. Review of hospital’s video titled, “03.17.25, 1335, E.C.-2025-04-09 12.13.25.945,” dated 03/17/25, showed: - At 00.01, (not actual time) Patient #14 was in the seclusion room and restraints were initiated. - Staff QQ, Security Officer (SO), Staff FF, SO, Staff WW, SO, Staff VV, RN, Staff D, RN and Staff SS placed therapeutic holds on Patient #14 while the restraints were applied. - At 03:25, all staff left the room and closed the seclusion room door, Patient #14 was secluded while in restraints. - At 1:02.41, Staff D closed the seclusion room door, Patient #14 was secluded while in restraints. - At 1:31.05, Staff D closed the seclusion room door, Patient #14 was secluded while in restraints. Review of hospital’s video titled, “03.18.25, 1227, E.C.-2025-04-09 12.13.28.092,” dated 03/18/25, showed: - At 02:27 (not actual time), Patient #14 was in the seclusion room and restraints were initiated. - Staff QQ, SO, and Staff GG, SO, placed therapeutic holds on Patient #14 while the restraints were applied. - At 27:30, Staff OO, SO, closed the seclusion room door, Patient #14 was secluded while in restraints. - At 1:49:10, Staff B, RN, closed the seclusion room door, Patient #14 was secluded while in restraints. - At 2:13:22, the seclusion room door was opened and closed, Patient #14 was secluded while in restraints. - At 2:45:52, the seclusion room door was opened and closed, Patient #14 was secluded while in restraints. - At 3:12:19, Staff MMM, RN, closed the seclusion room door, Patient #14 was secluded while in restraints. Review of hospital’s video titled, “03.18.2025, 2110, E.C.-2025-04-09 12.13.30.16,5,” dated 03/18/25, showed at 00:04 (not actual time), Patient #14 was in the seclusion room and restraints were initiated. Staff DD, SO, Staff JJJ, SO and Staff MMM, RN, placed therapeutic holds on Patient #14 while the restraints were applied. Review of hospital’s video titled, “03.19.25, 1248, E.C.-2025-04-09 12.13.32.062 PM,” dated 03/19/25, showed: - At 00:02 (not actual time), Patient #14 voluntarily entered the seclusion room and sat on the bed. The restraint application was not emergent. - At 02:43, restraints were initiated. - Staff WW, SO, Staff OO, SO and Staff B, RN, placed therapeutic holds on Patient #14 while the restraints were applied. - At 07:25, Staff C, RN, closed the seclusion room door, Patient #14 was secluded while in restraints. Review of hospital’s video titled, “03.22.2025, 1500, E.C.-2025-04-09 12.13.34.075 PM,” dated 03/22/25, showed at 00:02 (not actual time), Patient #14 voluntarily walked into the seclusion room and sat on the bed. The restraint application was not emergent. At 7:45, restraints were initiated. Review of hospital’s video titled, “BHUSeclusion1,” dated 03/23/25, showed: - At 00:02 (not actual time), Patient #14 voluntarily entered the seclusion room and sat down. The restraint application was not emergent. - At 03:02, four-point restraints were initiated. - At 10:58, staff exited the seclusion room and shut the door, Patient #14 was secluded while in restraints. Review of hospital’s video titled, “BHUSeclusion2,” dated 03/23/25, showed from 00:27 to 11:14 (not actual time), Patient #14 was calm. The restraint application was not emergent. At 39:17, restraints were initiated. During an interview on 04/23/25 at 9:00 AM, Staff AAA, Medical Director, stated that orders were needed for physical holds and seclusion in addition to violent restraints. During an interview on 04/17/25 at 12:34 PM and 04/23/25 at 10:50 AM, Staff ZZ, Chief Nursing Officer (CNO), stated that when the seclusion room door was closed, and a patient was not able to exit the room he/she was secluded, and an order should have been in place for seclusion. During an interview on 04/23/25 at 10:00 AM, Staff A, Interim BHU Manager, stated that she expected orders for therapeutic holds and seclusion. During an interview on 04/09/25 at 8:35 AM, 12:43 PM and 04/17/25 at 2:12 PM, Staff S, Risk and Regulatory Director, stated that she expected orders for therapeutic holds, restraints and seclusion. During an interview on 04/16/25 at 12:44 PM, Staff B, Charge RN, stated that she expected an order to be obtained within minutes of an emergent restraint application. The start time needed to match the order time. She expected orders for therapeutic holds and seclusion. She was disappointed the order expectations were not met. During an interview on 04/15/24 at 8:50 AM, Staff EE, RN, stated that a provider order was needed for therapeutic holds, seclusion and restraints. She expected a restraint order to be obtained as soon as the restraints were applied. 38236”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 48359 Based on interview, record review, video review and policy review, the hospital failed to ensure restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) were discontinued at the earliest possible time for one discharge patient (#14) of one discharged patient reviewed. These failures had the potential to affect the safety of all patients admitted to the hospital. Findings included: Review of the hospital’s policy titled “Violent Restraint Utilization,” revised 08/15/24, showed: - To ensure the seclusion/restraint is ended at the earliest possible time¸ evidence of resolution of behavior listed in original order must be met. - Restraints are discontinued as soon as is safely possible. - When it is determined through patient assessment that the condition(s) requiring the restraint no longer exists, the trained RN discontinues the restraints. Record review of Patient #14’s medical record dated 03/13/25 through 03/25/25 showed: - On 03/14/25 at 8:17 AM, a 37-year-old male was admitted to the BHU for suicidal ideation (SI, thoughts of causing one’s own death). - His history included schizoaffective disorder-bipolar type (mental illness that is characterized by symptoms of mania, depression and mood disturbances), Post-Traumatic Stress Disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock), Attention Deficit Hyperactive Disorder (ADHD, characterized by problems with keeping attention to one thing and impulsive behaviors), intermittent explosive disorder (a mental and behavioral disorder characterized by explosive outbursts of anger and/or violence to the point of rage, out of proportion to the situation at hand), obsessive compulsive disorder (OCD, having a tendency toward excessive orderliness, perfectionism, and great attention to detail), rheumatoid arthritis (RA, a chronic disease that causes inflammation of the joints, resulting in painful deformity and immobility) and mild Intellectual disability/ Intellectual developmental disorder (ID, IDD, below average intellectual functioning which limits the ability to learn at an expected level and limits level of function in daily life). - On 03/17/25 at 1:28 PM, four-point restraints (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others) were applied. - At 1:45 PM, his psychological status was resting. - At 2:00 PM, he was calm and resting. - At 2:15 PM, he requested to come out of restraints. - At 2:30 PM, no psychological status was documented. - At 3:17 PM, he was calm. - At 3:24 PM, he was calm, subdued, and the restraints were discontinued. He was restrained for one hour and 56 minutes. - On 03/18/25 at 12:19 AM, four-point restraints were applied. - At 2:30 AM, he was calm. - At 2:45 AM to 4:45 AM, 6:15 AM, 6:45 AM, and 8:00 AM he was calm and subdued. - At 8:17 AM, he was calm subdued, and the restraints were discontinued. He was restrained for seven hours and 58 minutes. - At 12:30 PM, four-point restraints were applied. - At 1:19 PM, 1:30 PM, 2:45 PM, 3:45 to 4:30 PM, he was calm and subdued. - At 4:30 PM, the restraints were discontinued. He was restrained for four hours. - At 9:10 PM, four-point restraints were applied. - At 9:21, 9:29 and 9:46 PM, no psychological status was documented. - At 11:20 and 11:35 PM, he was calm, tearful. - At 11:50 PM, he was calm and cooperative. - On 03/19/25 at 12:05 AM, he was calm, and stated what he would do the next time he felt angry. - At 12:20 AM, he was calm and cooperative. - At 12:30 AM, he was subdued. - There was no documented restraint discontinuation time. - On 03/19/25 at 12:53 PM, four-point restraints were applied. - At 1:20 PM, he stated he felt calm, and the medications were working. - At 1:36 PM, he smiled and talked. - At 1:48 PM, no psychological status was documented. - At 1:51 PM, the restraints were discontinued. He was restrained for 58 minutes. - On 03/22/25 at 3:10 PM, four-point restraints were applied. - At 3:40 PM, no psychological status was documented. - At 3:56 PM, he talked to staff. - At 4:06 and 4:16 PM, no psychological status was documented. - At 4:32 PM, he was subdued, and the restraints were discontinued. He was restrained for one hour and 22 minutes. Review of hospital’s video titled, “03.17.25, 1335, E.C.-2025-04-09 12.13.25.945,” dated 03/17/25, showed: - At 00.01 (not actual time), four-point restraints were initiated. - At 04:44, he got his right wrist out of the restraint. Patient #14 calmly laid on the bed. - At 21:39, Staff D, RN, Staff DDD, RN, Staff FF, Security Officer (SO), and Staff CCC, Patient Care Technician (PCT), entered the room. Staff D gave an injection in the left arm and Staff DDD gave an injection in the right arm. Patient #14 was calm. - At 34:01, Staff D, RN, entered the room and talked to the patient. Patient #14 was calm. - At 1:31.05, Staff DD, SO, walked into the room and talked to the patient. Patient #14 was calm. - At 01:47.24, the restraints were removed and he walked out of the room. Review of hospital’s video titled, “03.18.25, 0010, E.C.-2025-04-09 12.13.25.699,” dated 03/18/25, showed: - At 06:01 (not actual time), four-point restraints were initiated. - At 12:25, he talked to Staff YY, Charge Nurse (CN) who stood in the doorway. - At 20:09, he got his left wrist out of the restraint and removed an isolation mask. Patient #14 calmly sat on the bed. - At 01:14:45, Patient #14 talked with someone outside of the room. - At 2:14:46, Patient #14 was asleep. - At 3:16:20, Patient #14 was calm. - At 3:55:00, Patient #14 cried - At 4:10:50 and 5:51:32, Patient #14 was calm. - At 4:40:08 and 6:12:01, Patient #14 was asleep. - At 7:39:44 and 8:01:56, Staff GG, SO, entered in the room, talked to the patient and left the room. - At 8:03:45, Staff B, RN, entered the room and talked to the patient. - At 8:05:45, the restraints were removed. He was restrained for seven hours, 56 minutes and 59 seconds. - At 8:08:20, Patient #14 appeared hesitant to stand up. He calmly walked out of the room. Review of hospital’s video titled, “03.18.25, 1227, E.C.-2025-04-09 12.13.28.092,” dated 03/18/25, showed: - At 02:27 (not actual time), the four-point restraints were in place. - At 47:16, Patient #14 was calm. - At 47:45, Staff OO, SO, and Staff CCC, PCT, entered the room. Patient #14 was calm. - At 52:30 Staff OO, SO, and Staff C, RN, entered the room. Staff C held a urinal for the patient to pee in. Patient #14 was calm. - At 2:13:22, the door was open and closed by Staff. Patient #14 was calm. - At 2:45:52, Patient #14 cried. The seclusion room door was opened, and someone talked to the patient. - At 3:12:19, Patient #14 cried as Staff MMM, RN, talked to him. Staff MMM left and closed the door. The patient continued to cry. - At 4:00:02, the restraints were removed and he walked out of the room. Patient #14 was restrained for four hours. Review of hospital’s video titled, “03.18.2025, 2110, E.C.-2025-04-09 12.13.30.165,” dated 03/18/25, showed: - At 00:04 (not actual time), four-point restraints were initiated. - At 12:32, the room light was turned off. Patient #14 was calm. - At 20:23, Staff NNN, RN entered the room. Patient #14 was calm. - At 36:56, Patient #14 was calm. - At 42:44, Staff MMM, RN, and Staff NNN, RN, entered. Patient #14 was calm. - At 2:00:00, Patient #14 was calm. - At 2:40:55, Staff NNN, RN, Staff KK, SO, and two other staff members entered the room and changed Patient #14’s diaper. Patient #14 was directable with the hygiene. The restraints were replaced on the lower extremities. Staff left the room and turned off the light. Patient #14 remained calm. - At 3:23:14, the restraints were removed and he walked out of the room. Patient #14 was restrained for at least three hours and 1o minutes. Review of hospital’s video titled, “03.19.25, 1248, E.C.-2025-04-09 12.13.32.062 PM,” dated 03/19/25, showed: - At 02:43 (not actual time), four-point restraints were initiated. - At 18:12 to 30:40, Patient #14 was calm. - At 38:17, Staff C, RN, entered the room. Patient #14 was calm. - At 45:50, Staff D, RN, entered the room. Patient #14 was calm. - At 49:27 to 54:46, Patient #14 was calm. - At 54:47, Staff OOO, PCT, entered the room and talked to the patient. Patient #14 was calm. - From 55:16 to 1:01:34, Patient #14 was calm. - At 1:04:19, the restraints were removed - At 1:10:15, Patient #14 calmly sat in a wheelchair and was pushed out of the room. Review of hospital’s video titled, “03.22.2025, 1500, E.C.-2025-04-09 12.13.34.075 PM,” dated 03/22/25, showed: - At 04:48 (not actual time), Patient #14 was calm while restraints were placed on the bed. - At 07:13, four-point restraints were initiated. - At 30:20, Staff MM, SO, entered the room and talked to the patient. Patient #14 was calm. - At 35:16, Staff KKK, PCT, entered the room and talked to the patient. Patient #14 was calm. - At 35:42, Staff GGG, RN, entered the room. Patient #14 was calm. - At 37:13, Staff GGG and Staff KKK, PCT, entered the room. Patient #14 was calm. - At 57:42, Staff KKK entered the room appears talked to the patient and left. Patient #14 was calm. - At 58:51, Staff MM, SO, entered the room. Patient #14 was calm. - At 1:01:58, Staff UU, SO, entered the room. Patient #14 was calm. - At 1:07:44, Staff UU and Staff KKK entered the room. Patient #14 was calm - At 1:11:11, Staff UU talked to the patient. Patient #14 was calm. - At 1:12:52, Staff UU left the room. Patient #14 was calm. - At 3:31:35, the restraints were removed. - At 3:34:44, he walked out of the room. Review of hospital’s video titled, “BHUSeclusion1,” dated 03/23/25, showed: - At 03:02 (not actual time), four-point restraints were initiated. - At 19:19 to 40:40, Patient #14 was calm and talked to staff in the doorway. - At 40:46 to 56:32, Patient #14 was calm. - At 40:51, Staff CC, RN, entered the room and talked to the patient. Patient #14 responded by talking and shaking his head up and down. - At 1:08:53, Staff CC and Staff NN, Nursing Student (NS), entered the room. The patient was given an injection in the right arm. Patient #14 was calm. - At 1:24:51, Patient #14 was calm and held his arm still for a blood draw. - At 1:27:48, the restraints were removed and Patient #14 walked out of the room. During an interview on 04/15/25 at 2:50 PM, Staff JJ, Physician, stated that she could not make an assessment if Patient #14 was capable of communicating the restraint discontinuation criteria. Smiling was an indication a patient was ready to be released from restraints. During an interview on 04/17/25 at 12:34 PM and 04/23/25 at 10:50 AM, Staff ZZ, Chief Nursing Officer (CNO), stated that when Patient #14 was calm and cooperative a discontinuation of the violent restraints should have been trialed. The hospital had a learning opportunity regarding the discontinuation of restraints. During an interview on 04/22/25 at 4:03 PM, Staff III, House Supervisor, stated that when Patient #14 displayed calm and cooperative behaviors the restraints should have been discontinued. He only needed to show that he would not injure staff or patients. Patient #14 could not understand education “about the world.” He needed a break to calm. As the person in charge, he expected people to understand what their job was. “He could not believe how the staff treated Patient #14; he was a child.” Patient #14 was obviously not understanding conversation. Patient #14 tried to use actions to get his needs met. He could not express himself and was unable to express his needs. During an interview on 04/22/25 at 3:00 PM, Staff YY, RN, stated that she was the CN on the night of 03/18/25. If she was the primary nurse and Patient #14 did not display self-harm behaviors she would have removed the restraints. She had never had a patient in restraints for more than one hour. She agreed when she assisted Patient #14 with the bedpan, he was calm and compliant. She did not remove the restraints at that time because she felt it was his primary nurse’s responsibility. Staff PP, RN, did not discuss removing the restraints during the shift. As the CN she was responsible for the shift’s tasks but did not oversee all patient care. She provided support to non BHU floated staff if they asked for assistance. During an interview on 04/16/25 at 12:44 PM, Staff B, CN, stated that it was reasonable to trial a release when Patient #14 slept, cried or was subdued during the restraint episode. Behaviors were to be considered for restraint discontinuation. Staff would know quickly if the trial was successful, Patient #14 verbalized if he was at risk of harm to self or others. She was afraid Patient #14 would fall when he was released from the restraints after eight hours. 38236”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 48359 Based on interview, record review, video review and policy review, the hospital failed to ensure appropriate monitoring during the use of restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) for one discharged patient (#14) of one discharged patient reviewed. These failures had the potential to affect the quality of care and safety of all patients. Findings included: Review of the hospital’s policy titled “Violent Restraint Utilization,” revised 08/15/254, showed: - Patients will be restrained by competent staff following established procedures. - On-going assessment and monitoring at regular intervals include the physical and emotional well-being while in restraints; the maintenance of patient’s rights, dignity, comfort and safety; changes in behavior or clinical condition that may indicate the removal of the restraint or change to less restrictive method; and the proper application of the restraint and that no harm is caused. - One-to-one (1:1, continuous visual contact with close physical proximity) monitoring of patients in restraints if the patient has a condition that increases the risks to patient safety posed by the restraint such as obesity and history of abuse, which might lead to pathological fracture or other injury. - An assigned staff member who is competent and trained in accordance with this policy, must monitor the patient and document the findings at the initiation of restraint or seclusion and every 15 minutes thereafter. - Every 15-minute assessments include signs of any injury associated with the application of restraint or seclusion; circulation in the restrained extremities; the physical and psychological status and comfort, including pain; the maintenance of head of bed elevation of 30 degrees for patients restrained in the supine position; and the readiness for discontinuation of restraint or seclusion. - Every two-hour assessments include vital signs (VS, measurements of the body’s most basic functions); range of motion (ROM, how far you can move or stretch a part of your body, such as a joint or a muscle) of the restrained extremities; hygiene and elimination; and nutrition/hydration. Review of Staff PP’s, Registered Nurse (RN), personnel file showed she had no restraint training. Review of Staff HHH’s, RN, personnel file showed he had no restraint or sitter (person assigned to continuously observe a patient within close proximity, to ensure their safety) training. Record review of Patient #14’s medical record, dated 03/13/25 through 03/25/25, showed: - On 03/14/25 at 8:17 AM, a 37-year-old male was admitted to the Behavioral Health Unit (BHU) for suicidal ideation (SI, thoughts of causing one’s own death). - His history included schizoaffective disorder-bipolar type (mental illness that is characterized by symptoms of mania, depression and mood disturbances), post-traumatic stress disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock), attention deficit hyperactive disorder (ADHD, characterized by problems with keeping attention to one thing and impulsive behaviors), intermittent explosive disorder (a mental and behavioral disorder characterized by explosive outbursts of anger and/or violence to the point of rage, out of proportion to the situation at hand), obsessive compulsive disorder (OCD, having a tendency toward excessive orderliness, perfectionism, and great attention to detail), rheumatoid arthritis (RA, a chronic disease that causes inflammation of the joints, resulting in painful deformity and immobility) and mild Intellectual disability/ Intellectual developmental disorder (ID, IDD, below average intellectual functioning which limits the ability to learn at an expected level and limits level of function in daily life). - Patient #14’s body mass index (BMI, measurement of body fat based on height and weight, 40 or higher is severe obesity) was 47.78. - On 03/17/25 at 1:28 PM, four-point restraints (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others) were applied. - At 1:30 PM through 3:24 PM, Staff D, RN, documented every 15-minute rounding assessments. - On 03/18/25 at 12:19 AM, four-point restraints were applied. - At 1:15 AM through 7:00 AM, Staff PP, RN, documented every 15-minute rounding assessments. The 15-minute assessments began 56 minutes after the restraints were initiated. - At 1:46 AM through 6:30 AM, Staff PP documented every two-hour rounding assessments. - At 12:30 PM, four-point restraints were applied. - At 12:30 PM through 1:15 PM, Staff EE, RN, documented every 15-minute rounding assessments. - At 1:19 PM, Staff QQQ, RN, documented an every 15-minute rounding assessment. - At 1:30 PM through 4:30 PM, Staff EE, documented every 15-minute rounding assessments. - At 2:30 PM, Staff EE, documented every two-hour rounding assessment. - At 9:10 PM, four-point restraints were applied. - At 9:10 PM and 11:10 PM, Staff PPP, RN, documented an every 15-minute rounding assessment. - At 9:50 PM through 10:56 PM, Staff UUU, Patient Care Technician (PCT), documented every 15-minute and every two-hour rounding assessments. - At 11:20 PM through 12:20 AM, Staff NNN, RN, documented every 15-minute rounding assessments. - On 03/19/25 at 12:53 PM, four-point restraints were applied. - At 12:59 PM through 1:56 PM, an unknown staff member documented every 15-minute rounding assessments. - On 03/22/25 at 3:10 PM, four-point restraints were applied. - At 3:10 PM through 4:16 PM, Staff KKK, PCT, documented every 15-minute rounding assessments. - At 4:32 PM, Staff EE, RN, documented an every 15-minute rounding assessment. - On 03/23/25 at 10:00 AM, four-point restraints were applied. - At 10:00 AM through 11:15 AM, Staff BB, PCT, documented every 15-minute rounding assessments. - At 6:15 PM, four-point restraints were applied. - At 7:15 PM through 7:45 PM, Staff SSS, RN, documented every 15-minute rounding assessments. The 15-minute assessments began one hour after the restraints were initiated. Review of the hospital’s video titled “03.17.25, 1335, E.C.-2025-04-09 12.13.25.945” dated 03/17/25, showed no bedside assessments. Review of the hospital’s video titled, “03.18.25, 0010, E.C.-2025-04-09 12.13.25.699,” dated 03/18/25, showed every 15-minute assessments were not performed. No VS, ROM, nutrition or hydration was performed while Patient #14 remained in restraints for seven hours and 58 minutes. Review of the hospital’s video titled “03.18.2025 Hallway Seclusion Room,” dated 03/18/25, showed: - At 00:57 (not actual time), Patient #14 entered the seclusion room. - At 13:48, all staff exit the room and Staff KKK, PCT, placed a chair in the hallway outside of the seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) room. Staff KKK was intermittently distracted by her cellphone and other staff members. - At 48:23, Staff KKK was relieved by Staff HHH, RN. Staff HHH was intermittently distracted by other staff members. - At 1:21:18, Staff KKK retrieved his cellphone from his pocket. - At 2:03:47, Staff KKK was relieved by Staff YY, Charge Nurse. Staff YY was intermittently distracted by her cellphone. - At 2:38:25, Staff YY was relieved by Staff HHH. Staff HHH remained continually distracted by his cellphone until 4:51:15 when he moved his chair and belongings across the hallway to plug in his cellphone charging cord. Staff HHH stood in the hallway without a full line of sight (LOS, continuous visual contact with the patient) to Patient #14 and remained continually distracted by his cellphone until he exited at 7:04:05. Review of the hospital’s video titled “03.18.25, 1227, E.C.-2025-04-09 12.13.28.092,” dated 03/18/25, showed no bedside assessments were performed. No VS, ROM, nutrition or hydration was performed while Patient #14 remained in restraints for four hours. Review of the hospital’s video titled “03.18.2025, 2110, E.C.-2025-04-09 12.13.30.165,” dated 03/18/25, showed no bedside assessments were performed. No VS, ROM, nutrition or hydration was performed while Patient #14 remained in restraints for a minimum of three hours and 10 minutes. Review of the hospital’s video titled “03.19.25, 1248, E.C.-2025-04-09 12.13.32.062 PM,” dated 03/19/25, showed no bedside assessments were performed. Review of the hospital’s video titled, “03.22.2025, 1500, E.C.-2025-04-09 12.13.34.075 PM,” dated 03/22/25, showed no bedside assessments were performed. Review of the hospital’s video titled, “BHUSeclusion1,” dated 03/23/25, showed at 56:33 (not actual time), Staff HH, RN, performed a circulation check. Staff BB, PCT, performed no bedside assessments. Review of the hospital’s video titled “BHUSeclusion2,” dated 03/23/25, showed no bedside assessments were performed. At 8:05:45 (not actual time), the ankle restraints were removed and there was a visible deep indentation on Patient #14’s skin on both ankles. During an interview on 04/21/25 at 9:00 AM and 04/22/25 at 11:40 AM, Staff Z, President, stated that he expected staff to follow the hospital’s policies and procedures. He expected a physical assessment for restrained patients. During an interview on 04/23/25 at 9:00 AM, Staff AAA, Medical Director, stated that he expected all staff to follow all of the hospital’s policies and procedures. He expected every-15 minute and two-hour assessments to include a physical assessment and was surprised those assessments were not done. He expected patients with prolonged restraint episodes to be given relief periods with ROM. During an interview on 04/17/25 at 12:34 PM and 04/23/25 at 10:50 AM, Staff ZZ, Chief Nursing Officer (CNO), stated that she expected staff to follow the hospital’s policies and procedures. She expected a hands-on assessment. She was surprised that did not happen. It was false documentation when a physical assessment was not performed and was documented. She expected and was surprised that staff did not physically attempt to obtain VS while Patient #14 was restrained. After she viewed the removal of restraints on 04/18/25 at 8:17 AM, she saw the indentation in Patient #14’s ankles and believed he had swelling and pain as a result of the failed circulation assessments and the too tight restraints. During an interview on 04/23/25 at 10:00 AM, Staff A, Interim BHU Manager, stated that she expected staff to follow all hospital policies and procedures. She expected every 15-minute and all two-hour rounds were performed with a physical assessment. She was not surprised the physical assessments were not completed once she understood the egregiousness of the staffs’ actions. During an interview on 04/09/25 at 8:35 AM, 12:43 PM and 04/17/25 at 2:12 PM, Staff S, Risk and Regulatory Director, stated that she expected staff to follow the hospital’s policies and procedures. Failure to provide relief periods with ROM was abusive and neglectful. Failure to perform a physical assessment for circulation and injury checks was neglectful. Documentation of completed assessments that did not include a physical assessment was false documentation. A sitter in the hallway without a full LOS of the restrained patient was neglectful. During an interview on 04/17/25 at 9:05 AM, Staff RR, House Supervisor, stated that she expected a hands-on assessment. She was disappointed and embarrassed the ROM was not performed while Patient #14 was restrained. During an interview on 04/16/25 at 12:44 PM, Staff B, Charge RN, stated that she expected staff to provide relief periods and ROM per policy. Circulation and injury checks required a hands-on assessment. Documentation of circulation and injury checks that were not performed was false documentation. She expected VS to be attempted and was not surprised the video did not show VS attempts. During an interview on 04/16/25 at 3:13 PM, Staff PP, RN, stated that she was assigned Patient #14, and he was her first experience with violent restraints. She stated that she did not know where to find the violent restraint policy to review. She was unsure which staff member was responsible for every 15-minute rounds, she was aware she was responsible for every two-hour rounds that included hydration, toileting and a skin assessment. She failed to recognize VS were required with every two-hour assessment. She stated that assessments required a hands-on physical assessment. During an interview on 04/23/25 at 7:51 AM, Staff HHH, RN, stated that he received no sitter training, never worked as a sitter and had never been floated to a BHU. His thought process that night was he “did not know how it went, he was along for the ride.” He had no idea what his role was or how to care for Patient #14 as his sitter. He was told not to enter the seclusion room, and he followed the Charge Nurse’s directions. He was not told to sit in the anteroom, he was able to fully view Patient #14’s body with the exception of his right arm from his post in the hallway. He agreed he was distracted by his phone. He remembered moving his chair to plug in his phone and agreed he did not have his eyes on the patient at all times. He was embarrassed and sorry he was on his phone. He felt terrible to have witnessed the care of Patient #14 once he understood Patient #14’s diagnosis and history. He “hated that he played any part in that. He did not know at the time.” He was going to take a lot from that experience. He felt he should have been educated for the special population in the BHU. The BHU patients were not normally within his scope of practice. He stated that he would never be a part of anything like that again. He would be more proactive in the future. 38236”

“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: 48359 Based on observation, interview, record review, video review and policy review, the hospital failed to ensure a one-hour face-to-face assessment (a direct, in-person evaluation by a qualified healthcare professional to assess a patient’s condition after they have been placed in restraints) was completed and accurate after violent restraints (medical cuffs applied to both arms and both legs to prevent someone form causing harm to themselves or others) application for one discharged patient (#14) of one discharged patient reviewed. These failures had the potential to affect the quality of care and safety of all patients. Findings included: Review of the hospital’s policy titled, “Violent Restraint Utilization,” revised 08/15/24,” showed: - When a restraint or seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff member or others, the patient must be seen face-to-face within one hour after the initiation of the intervention by a Registered Nurse (RN) who has obtained education, training on the face-to-face assessment and demonstrated knowledge based on the specific needs of the patient population. - The face-to-face assessment should address the patient’s immediate condition, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the restraint or seclusion. - The RN who completes the face-to-face assessment, should not be the RN initiating the restraint or seclusion event. Review of the hospital’s undated and untitled document showed: - Staff D, RN, was not face-to-face certified; - Staff QQQ, RN, was not face-to-face certified; - Staff TTT, RN, was not face-to-face certified; and - Staff RRR, RN, was not face-to-face certified. Record review of Patient #14’s medical record dated 03/13/25 through 03/25/25 showed: - On 03/14/25 at 8:17 AM, a 37-year-old male was admitted to the Behavioral Health Unit (BHU) for suicidal ideation (SI, thoughts of causing one’s own death). - His history included schizoaffective disorder-bipolar type (mental illness that is characterized by symptoms of mania, depression and mood disturbances), Post-Traumatic Stress Disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock), Attention Deficit Hyperactive Disorder (ADHD, characterized by problems with keeping attention to one thing and impulsive behaviors), intermittent explosive disorder (a mental and behavioral disorder characterized by explosive outbursts of anger and/or violence to the point of rage, out of proportion to the situation at hand), obsessive compulsive disorder (OCD, having a tendency toward excessive orderliness, perfectionism, and great attention to detail), rheumatoid arthritis (RA, a chronic disease that causes inflammation of the joints, resulting in painful deformity and immobility) and mild Intellectual disability/ Intellectual developmental disorder (ID, IDD, below average intellectual functioning which limits the ability to learn at an expected level and limits level of function in daily life). - Patient #14 reported a history of physical, emotional and sexual trauma. - On 03/16/25 at 8:50 PM, Staff B, RN, participated in the application of the violent restraints - At 8:55 PM, Staff B, completed a face-to-face assessment. - On 03/17/25 Staff D, RN, completed a face-to-face assessment. - On 03/18/25 at 12:19 AM, Staff YY, RN, completed a face-to-face assessment. The assessment was documented on 03/25/25 at 9:47 AM. The face-to-face assessment showed Patient #14 had no known history of physical or sexual abuse increasing the risk of stress and trauma. - At 1:19 PM, Staff QQQ, RN, completed a face-to-face assessment. The face-to-face assessment showed Patient #14 had no known history of physical or sexual abuse increasing the risk of stress and trauma. - At 9:10 PM, Staff MMM, RN, participated in the application of the violent restraints - At 9:46 PM, Staff MMM, completed a face-to-face assessment. The face-to-face assessment showed Patient #14 had no known history of physical or sexual abuse increasing the risk of stress and trauma. - On 03/22/25 at 3:42 PM, Staff TTT, RN, completed a face-to-face assessment. The face-to-face assessment showed Patient #14 had no known history of physical or sexual abuse increasing the risk of stress and trauma. - On 03/23/25 at 10:52 AM, Staff RRR, RN, completed a face-to-face assessment. The face-to-face assessment showed Patient #14 had no known history of physical or sexual abuse increasing the risk of stress and trauma. - On 03/23/25 at 7:10 PM, Staff SSS, RN, completed a face-to-face assessment. The face-to-face assessment showed Patient #14 had no known history of physical or sexual abuse increasing the risk of stress and trauma. Review of the hospital’s video titled, “03.17.2025, 1335, E.C.-2025-04-09 12.13.23.945 PM,” dated 03/17/25, showed Staff D, RN, participated in the application of the violent restraints to Patient #14. Review of the hospital’s video titled, “03.18.2025, 0010, E.C.-2025-04-09 12.13.25.699 PM,” dated 03/18/25, showed Staff YY, RN, participated in the application of the violent restraints to Patient #14. Review of the hospital’s video titled, “03.18.2025, 1227, E.C.-2025-04-09 12.13.28.092 PM,” dated 03/18/25, showed Staff QQQ, RN, did not enter the room to perform the face-to-face assessment for Patient #14. Review of the hospital’s video titled, “03.22.2025, 1500, E.C.-2025-04-09 12.13.34.075 PM,” dated 03/22/25, showed Staff TTT, RN, did not enter the room to perform the face-to-face assessment for Patient #14. Review of the hospital’s video titled, “BHUSeclusion1,” dated 03/23/25, showed Staff RRR, RN, did not enter the room to perform the face-to-face assessment for Patient #14. Review of the hospital’s video titled, “BHUSeclusion2,” dated 03/23/25, showed Staff SSS, RN, did not enter the room to perform the face-to-face assessment for Patient #14. During an interview on 04/21/25 at 9:00 AM and 04/22/25 at 11:40 AM, Staff Z, President, stated that he expected the face-to-face was performed by a certified RN, who was not involved in the restraint application. He expected physical assessments for the face-to-face. During an interview on 04/23/25 at 9:00 AM, Staff AAA, Medical Director, stated that he expected nurses who performed the face-to-face assessment were certified. He was not aware of the education gap with the face-to-face certifications. During an interview on 04/17/25 at 12:34 PM and 04/23/25 at 10:50 AM, Staff ZZ, Chief Nursing Officer (CNO), stated that she expected the nurse who performed a face-to-face was certified. The purpose of the face-to-face was to abate the restraint episode as soon as possible. She expected the face-to-face assessment to be purposeful and visible on the video. The staff member who performed the face-to-face was not to have been involved in the restraint application. She was surprised the face-to-face assessment was not visible in the video and was documented by the staff member who applied the restraints. She expected the face-to-face documentation to be accurate and complete. She wanted the face-to-face to show what was happening at the time of the assessment. During an interview on 04/09/25 at 8:35 AM, 12:43 PM and 04/17/25 at 2:12 PM, Staff S, Risk and Regulatory Director, stated that there was a known gap for staff face-to-face certifications. She expected the face-to-face assessment was visible on the video, performed by a certified RN who was not involved in the restraint application. She expected the patient’s past trauma to be considered and documented on the face-to-face assessment. She expected the face-to-face assessment to be an at the moment assessment. During an interview on 04/22/25 at 4:03 PM, Staff III, House Supervisor, stated that he performed the face-to-face at the time the restraints were applied to Patient #14 on 03/18/25. He assessed for proper restraint application, patient positioning on the wedge for head elevation and breathing restriction. He did not assess the need to continue the restraints, he was not aware that was required for the face-to-face assessment. During an interview on 04/16/25 at 12:44 PM, Staff B, Charge RN, stated that she expected the face-to-face to take place in the room and was not surprised the nurse who performed the assessment was the same individual involved in the restraint application. The House Supervisor could have performed the face-to-face. This worked well during the day, but not as well during the night. The face-to-face was a completely different assessment compared to the assessment of why the patient was initially restrained. She expected the nurse who performed the face-to-face was aware of and to properly document the patient’s trauma history. She expected trauma history was a consideration when the decision was made to continue/discontinue the restraints. There was no longer face-to-face training since the hospital switched to AVADE (a workplace violence prevention training program focused on providing employees with the skills and knowledge to prevent, manage, and respond to violence and aggression in the workplace) from Crisis Prevention Institute (CPI, a type of training where staff learn to safely defusing violent behavior and safe physical holds to restrict a person’s movement). She believed AVADE was too self-defense focused. The safety and dignity of the patient was lost with the move to AVADE. She expected to see more patient trauma related to the teaching of harmful techniques. For example, she was taught to “gouge their eyes out.” She expected staff to feel empowered to tap out of an escalating situation. During an interview on 04/17/25 at 9:05 AM, Staff RR, House Supervisor, stated that the face-to-face was to be performed by a nurse not involved in the restraint initiation. She expected a physical presence for the face-to-face assessment. The nurse who performed the face-to-face was to be objective and she expected the patient’s past trauma to be considered in the decision to initiate, continue and/or discontinue restraints. The explanation to continue the restraints should be distinct from the reason the restraints were initiated. She expected the nurse who performed the face-to-face to be certified.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f) Restraint or Seclusion: Staff Training Requirements. The patient has the right to safe implementation of restraint or seclusion by trained staff. This Standard is not met as evidenced by: 48359 Based on observation, interview, record review and policy review, the hospital failed to ensure all staff members involved in restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) received restraint training for one discharged patient (#14) of one discharged patient reviewed. These failures had the potential to affect the quality of care and safety of all patients. Findings included: Review of the hospital’s policy titled “Violent Restraint Utilization,” revised 08/15/24, showed education and training on the use of restraints and seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) are provided to staff members applying restraints. Review of the untitled hospital document dated 09/07/23, showed Staff NN, Nursing Student (NS), had no restraint training. Review of Staff PP’s, Registered Nurse (RN), personnel file showed she had no restraint training. Review of Staff QQ’s, Security Officer (SO), personnel file showed he had no restraint training. Review of Staff XX’s, SO, personnel file showed he had no restraint training. Review of Staff HHH’s, RN, personnel file showed he had no restraint or sitter training. Record review of Patient #14’s medical record dated 03/13/25 through 03/25/25 showed: - On 03/14/25 at 8:17 AM, a 37-year-old male admitted to the Behavioral Health Unit (BHU) for suicidal ideation (SI, thoughts of causing one’s own death). - His history included schizoaffective disorder-bipolar type (mental illness that is characterized by symptoms of mania, depression and mood disturbances), Post-Traumatic Stress Disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock), Attention Deficit Hyperactive Disorder (ADHD, characterized by problems with keeping attention to one thing and impulsive behaviors), intermittent explosive disorder (a mental and behavioral disorder characterized by explosive outbursts of anger and/or violence to the point of rage, out of proportion to the situation at hand), obsessive compulsive disorder (OCD, having a tendency toward excessive orderliness, perfectionism, and great attention to detail), rheumatoid arthritis (RA, a chronic disease that causes inflammation of the joints, resulting in painful deformity and immobility) and mild Intellectual disability/ Intellectual developmental disorder (ID, below average intellectual functioning which limits the ability to learn at an expected level and limits level of function in daily life). - Patient #14 reported a history of physical, emotional and sexual trauma. - On 03/16/25 at 8:50 PM, Staff XX, SO, was involved in restraint application. - On 03/17/25 at 7:36 PM through 03/18/25 at 8:36 AM, Staff PP, RN, was Patient #14’s primary nurse. - On 03/18/25 at 12:30 PM, Staff QQ, SO, was involved in the restraint application. - On 03/22/25 at 3:10 PM, Staff XX, SO, was involved in the restraint application. - On 03/23/25 at 10:00 AM, Staff NN, NS, was involved in the restraint application. During an interview on 04/21/25 at 9:00 AM Staff Z, President, stated that he expected staff to have restraint competencies and training. During an interview on 04/15/25 at 2:50 PM, Staff JJ, Physician, stated that she expected staff to follow the hospital’s policies, procedures and training. During an interview on 04/23/25 at 10:50 AM, Staff ZZ, Chief Nursing Officer (CNO), stated that the hospital had an education gap for staff caring for a high-risk population. Staff were set up for failure without the proper training. During an interview on 04/16/25 at 12:44 PM, Staff B, Charge RN, stated that she expected consistent training for all staff when working with a difficult patient population. There was a potential for serious injury to patients and staff without proper training. During an interview on 04/16/25 at 3:13 PM, Staff PP, RN, stated that on 03/18/25, she was assigned Patient #14, and he was her first experience with violent restraints. She stated that she did not know where to find the violent restraint policy to review. During an interview on 04/17/25 at 8:30 AM, Staff QQ, SO, stated that he felt his training had “somewhat” prepared him for managing Patient #14. He would have felt more comfortable if he had more training. 38236”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 41474 Based on interview, record review, policy review and video review, the hospital failed to ensure patients received care in a safe setting and were free from all forms of abuse, neglect or harassment when the hospital failed to: - Ensure that four-point locking restraints (medical cuffs applied to both arms and both legs to prevent someone form causing harm to themselves or others) had a quick release mechanism or that staff had immediate access to the key. (A-0144) - Ensure a thorough investigation was performed following an event report with allegations of abuse and neglect. (A-0145) - Provide education to staff following an incident involving verbal abuse. (A-0145) This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation (CoP): Patient’s Rights.”

“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: 41474 Based on observation, interviews and policy review the hospital failed to ensure patients received care in a safe setting when the hospital failed to ensure that four-point locking restraints (medical cuffs applied to both arms and both legs to prevent someone form causing harm to themselves or others) had a quick release mechanism or that staff had immediate access to the key. These failed practices had the potential to adversely affect the quality of care and safety to all patients the in the hospital. Finings included: Review of the hospital’s undated document titled, “Patient Rights and Responsibility,” showed: - Patients have the right to receive safe, quality care through the services that the ministry provides. - Patients were to not be denied appropriate care on the basis of mental disability. - Patients had the right to receive care in a safe setting, to be treated with dignity, respect, and considerate care at all times and under all circumstances. Review of the hospital’s undated policy titled, “Violent Restraint Utilization,” showed: - Patients have the right to be free from restraints of any form that are imposed for coercion, discipline, convenience or retaliation by staff. - Use of restraints will not result in injury to the patient. - Patients will be restrained by competent staff following established procedures. - Patients will be restrained when necessary to ensure safety and when the least restrictive interventions have been determined to be ineffective. Review of the hospital’s document titled, “Restraints 2024,” showed violent restraints had been applied to 24 patients in the Emergency Department (ED) from 01/01/24 through 12/09/24. Observation on 12/09/24 at 3:30 PM, in the ED, showed a set of double locking restraints in a cabinet. There was a locking mechanism for the part of the restraint that went onto the patient’s wrist and a separate locking mechanism that attached to the bed. There was no key for the restraints in the cabinet or at the nursing station. During an interview on 12/09/24 at 3:35 PM, Staff H, Registered Nurse (RN), stated that a key to the restraints should have been in the cabinet where the restraints were kept or at the nursing station. Security Officers had the key to the restraints. During an interview on 12/09/24 at 3:40 PM, Staff I, Security Officer, stated that he had a key to the restraints. If he had a patient in restraints in the ED and received a call to respond somewhere else on hospital property, he would only leave the patient in restraints if the patient had a one-to-one sitter (1:1, continuous visual contact with close physical proximity) with them. He would take the restraint key with him if he had to respond somewhere else on campus. During an interview on 12/09/24 at 3:50 PM, Staff J, RN, stated that she did not have a key to the restraints. Security Officers kept the key. Observation with concurrent interview on 12/10/24 at 10:05 PM, on the Behavioral Health Unit (BHU), showed Staff O, RN, did not have a key for the locking restraints. Staff O stated that the BHU had the same type of double locking restraints that were used in the ED. During an interview on 12/10/24 at 10:20 AM, Staff G, RN, stated that all staff on the BHU were to have a key to the double locking restraints. During an interview on 12/10/24 at 9:15 AM, Staff P, Mental Health Technician (MHT), stated that all staff members on the BHU were to have a key to the double locking restraints at all times.”

“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: 51264 Based on interview, record review, digital video records and policy review, the hospital failed to ensure patients were free from all forms of abuse, neglect or harassment when the hospital failed to ensure a thorough investigation was performed following an event report with allegations of abuse and provide education to staff related to abuse and neglect. These failed practices had the potential to adversely affect the quality of care and safety of all patients in the hospital. Findings included: Review of the hospital’s undated document titled, “Patient Rights and Responsibility,” showed: - Patients had the right to receive safe, quality care through the services that the ministry provides. - Patients had the right to receive appropriate and compassionate care at all times and under all circumstances. - Patients were to not be denied appropriate care on the basis of mental disability. - Patients had the right to receive care in a safe setting, to be treated with dignity, respect and considerate care at all times and under all circumstances. - Patients had the right to be free from all forms of abuse or harassment. - The hospital expects all patients and visitors to follow the code of conduct while at the hospital. Examples of violent, threatening, or aggressive action include but are not limited to intimidating, harassing, unwanted physical touching, or making verbal or written threats to hospital team members or other patients. Review of the hospital’s policy titled, “Caregiver Misconduct,” revised 11/17/23, showed: - Caregiver misconduct means abuse, neglect, misappropriation of a patient’s property or harassment of a patient. - Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, mental anguish or death. This includes staff neglect or indifference to the infliction of injury or intimidation of one patient by another. - An eligible adult is an adult with a disability, between the ages of 18 and 59 who is unable to protect their own interests or adequately perform or obtain services which are necessary to meet their essential human needs. - Harassment is repeated, knowing and purposeful conduct that alarms or causes distress to another and serves no legitimate purpose. - Immediately upon observing or becoming aware of incidents of possible abuse, neglect and harassment in the health care setting, any staff must report such incidents to their immediate supervisor. - The staff who observes or becomes aware of an incident must complete an event report in the event reporting system. - When a determination of the individual involved cannot be made based on available information, risk management and human resources (HR) should be contacted to discuss how to best protect patients while the investigation occurs. - For the protection of patients and involved personnel, patient care providers involved in patient abuse, neglect or harassment must be relieved of patient care responsibilities and removed from patient care areas of the hospital during the pendency of a prompt investigation. - Matters requiring relief of patient care responsibilities due to patient abuse, neglect and harassment of patients will be addressed by the hospital’s Chief Medical Officer (CMO) in a manner consistent with this policy and as otherwise required by the hospital Medical Staff Bylaws. - All incidents of possible caregiver abuse should be initiated within one business day of identification and be given high priority by those individuals needed to participate in the investigation. - Risk management and HR will oversee the investigation, the investigation should include collecting and preserving any physical and documentary evidence; interview alleged victims, witnesses and if deemed appropriate, those alleged to have committed acts of abuse; collect other corroborating or disproving evidence; include other regulatory authorities; document each step taken during the internal investigation. - Upon the conclusion of an investigation into patient abuse, neglect or harassment a written summary of the investigation will be completed and distributed, as indicated, by risk management; and results of investigations and remedial actions will be communicated to appropriate hospital leadership, HR, regulatory, appropriate medical staff, leadership, and affiliated organizations. - Following an investigation, incidents shall be reported to the appropriate regulatory agency when the ministry has reasonable cause to believe there is sufficient evidence or another regulatory authority could obtain the evidence, to show the alleged incident occurred, and reasonable cause to believe the incident meets, or could meet the definition of abuse, neglect or misappropriation. Review of the hospital’s undated document titled, “Abuse Allegations for 2024,” showed there were two allegations of abuse investigated for 2024. On 05/21/24 at 11:15 PM, in the Emergency Department (ED), there was an allegation of abuse by a security officer on Patient #21. The Investigation was completed and unsubstantiated. The other abuse allegation was unrelated to the event on 05/21/24. Review of the hospital’s document titled, “Event by Patient 5212024,” dated 05/21/24, showed on 05/21/24 Patient #21 had a fall in the ED. An event description showed the patient attempted to elope (when a patient makes an intentional, unauthorized departure from a medical facility) and ran through the ED. The patient was first contacted by security and the patient fell backwards to the ground, landing on his left elbow. The patient was then helped to his feet and he began to run through the ED once again. Attempting to stop the patient, security grabbed for the patient and in doing so, fell to the ground landing on his chest and right arm. The patient was then successfully stopped by security and placed back in his room. There was no identification of who completed the event report. Review of ED video surveillance for 05/21/24, from multiple views without time stamps, showed Staff CC, Security Officer, and Staff Z, Security Officer, were outside of Patient #21’s room when the patient walked into the hallway. Patient #21 ran in the opposite direction and the officers ran after him. After chasing him down the hallways and around the nurses station, Staff CC lowered his shoulder and the patient ran into him. Patient #21 fell backwards hitting his elbow on the floor. Three staff members in scrubs, and one physician, were present. Staff Z was behind Staff CC. They assisted Patient #21 up, off the floor, and he began to run again in the opposite direction. Staff Z ran after him, followed by Staff CC. After running around the nurses’ station, Staff Z tried to reach for the patient and fell on his chest and shoulders. Staff CC continued to run after the patient. Staff Z got up from the floor and began walking in the direction they were running. Both officers caught up with the patient from different directions, grabbed the patient by the arms and escorted him back to his room. Staff BB, Security Officer, arrived and walked ahead of them to the patient’s room. Staff BB entered first, followed by Staff CC and Staff Z with Patient #21, and then nursing staff. The entire event lasted approximately one minute and 50 seconds. Six staff in scrubs and three security officers were seen in the video recordings of the event. Review of body camera video footage from Staff CC, Security Officer, for 05/21/24 at 11:05:08 PM, showed the events that took place after Patient #21 and Staff Z, Security Officer, fell. Footage began just before apprehension of Patient #21 and included escorting him back to his room, where a verbal exchange occurred. - At 23:05:33, Staff Z grabbed the patient’s left arm and stated, “I’m gonna whoop your ass”. Staff CC grabbed the patient’s right arm and they began walking the patient back to his room. Patient #21 said, “I’m sorry. I’m sorry, I’ll go back to my room” while they walked. - At 23:05:49, an unidentified voice stated, “you’re going to jail”. Staff BB, ahead of them, entered the patient’s room followed by the escorted patient. - At 23:05:57, the patient’s bed jingled as Staff Z sat him on the bed. Nursing asked the patient why he ran and he replied, “I’m sorry, they’re in my head; the government.” Staff CC told nursing staff that he knocked Patient #21 down. Nursing staff said the patient may have hit his head. - At 23:06:21, Staff BB walked over to Staff Z and asked him a question. Staff Z, glanced down at his chest, then told him that he fell and pointed to the place in the hallway. Staff BB stepped outside the room. Nursing staff asked Staff Z if he was okay. - At 23:06:27, Staff Z, still in the room, pointed his finger at the patient and stated, “I’m gonna tell you something,” (body cam was turned so audio became jumbled for a moment), “running again tonight, I’m gonna lose my job. I’m gonna beat your ass.” - At 23:06:35, Staff BB went back to the doorway and directed Staff Z out of the room. Staff Z continued to say on his way out, “I’ll tell you what, hurt my damn arm.” Staff CC said that Staff Z needed to be checked out and nursing encouraged him. - At 23:18:23, Staff CC told another officer that he had to stay and write a report. The other officer then told Staff CC that he should check with Staff BB first as he might write the report. Review of the hospital’s undated document titled “Investigation,” showed: - On 05/21/24, Patient #21 was on a 96-hour hold (court-ordered evaluation by behavioral specialist to determine if a person is safe to themselves and others). He left his room and ran in the ED stating he needed to get out of there. Security stopped the patient, he fell backwards to the floor and fractured his right elbow. - The hospital’s abuse policy defined abuse as, “The willful infliction of injury, unreasonable confinement, intimidation, coercion, financial exploitation, or punishment, with resulting physical harm, pain, fear, or mental anguish. This includes staff neglect or indifference to the infliction of injury or intimidation of one patient by another.” - The section titled, “Situation,” showed a 38-year-old male who presented via law enforcement for a 96-hour evaluation. The patient was disorganized, paranoid (excessive suspiciousness without adequate cause) and noncompliant with his behavioral health care. Affidavit (a written statement confirmed by oath, for use as evidence in court) reports showed that on 05/18/24, the patient called police paranoid that the government was out to get him, additionally he locked his wife out of the home. The patient had a history of schizophrenia (serious mental disorder that affects a person’s ability to think, feel, and behave clearly) and questionable compliance with his medications. He was evaluated and it was determined that he needed inpatient psychiatric treatment. 11 hours after his ED admission, the patient left his room and stated he needed to get out of there and ran through the ED, which was full of patients. - Staff listed as witnesses of Patient #21’s fall included Staff JJ, ED Technician; Staff KK, Registered Nurse (RN); and Staff Y, RN. - In the section titled, “Statements obtained from the alleged,” showed unable to obtain because of paranoia. Post fall the patient stated, “I am sorry, it’s the government’s fault.” - The investigation included a medical record review, video review and staff interviews. - During an interview on 05/23/24 at 7:00 AM, Staff JJ, ED Technician, stated that she heard someone yell there was a runner, she moved out of the way because she didn’t know what to do. She saw security officers and the patient running around the circle. Staff CC, Security officer, ran into the patient and the patient fell backwards and was stopped. - During an interview on 05/23/24 at 7:15 AM, Staff Y, RN, stated that she was with another patient when she heard someone shout there was a runner. She stepped out of the other room and heard Patient #21 hit the floor. Staff CC had physically stopped the patient. She heard security officers yell at the patient to get up, that was when he ran again. There was a lot of verbal escalation between security officers, especially Staff Z, and Patient #21. She tried to de-escalate the situation. Staff Z was very verbal, she and Staff BB, Security Officer, tried to calm down Staff Z. Staff BB grabbed Staff Z and told him to get out of the room. Staff Y felt she could have re-directed the patient verbally. - During an interview on 05/23/24 at 8:00 AM, Staff KK, RN, stated she had been walking in the hallway when she heard someone say there was a runner. She saw a patient in paper scrubs, she knew that meant it was a behavioral health patient, so she immediately went into a room eight or nine. She did not know how the patient ended up falling to the ground. She stayed in the other room during the event because she was concerned about safety. She ended up going into Patient #21’s room to make sure other people were there. - During an interview on 05/23/24 at 12:35 PM, Staff CC, Security Officer, stated that staff had trouble keeping Patient #21 in his room. The patient had been re-directed five or six times. The patient left his room several times and stated he needed to leave. At one point Staff CC had the nurse intervene. Staff CC stated that he got a small briefing on patients, but it was usually rushed. He had his back to Patient #21’s room and was giving report to Staff Z, Security Officer, when the patient left his room. That was when Staff CC and Staff Z took off after the patient. Patient #21 made two laps around the nurses’ station. Staff CC and Patient #21 both turned a corner, he went into the patient with his left shoulder and his other arm was back and to his side. The patient was bigger than him. He used what he was taught in Awareness-Vigilance-Avoidance-Defense-Escape (AVADE, a program that teaches people how to prevent, avoid, de-escalate, and reduce risk of violence in the workplace) training. After the patient fell, he tried to help him up. The patient then ran again, a technician tried to stop the patient, but when they realized he wasn’t stopping they moved out of the way. After the patient fell, he went around the circle again, then Staff Z fell and Staff CC continued to pursue the patient. - The findings of the investigation showed the “Determination of Abuse (physical allegation only)”, reviewed by the Campus Executive Team, Risk, HR, and the Manager of Security, that abuse or neglect did not occur or that the findings were inconclusive, the manager and the HR Director would determine whether other actions were needed. No letter was sent to the alleged person because it was non-applicable. It was determined that physical force was necessary to stop the patient from running. The patient was on 96-hour-hold and he was a risk to himself and others. The techniques used to stop him were appropriate. The activity did not rise to the level of abuse because it did result in physical injury but did not meet all of the criteria of abuse as defined in the abuse policy. - Recommendations included coaching security staff to immediately turn on the body camera. Security officers used the correct AVADE stance except for the officers closed fist so they recommended a review of AVADE stance for Staff CC. The three nursing staff interviewed indicated they did not feel comfortable attempting to stop the patient, were uncertain of how to stop the patient and felt comfortable leaving it up the security officers. It was recommended that those three employees attend AVADE training. A care team review of the patient’s record was recommended to determine if he could have benefited from medications due to his anxiety and his pacing in his room and into the hallway. Review of the hospital’s document titled, “HR Investigation Summary,” dated 05/21/24, showed: - The “Complaint” section indicated there was verbal escalation towards a patient in the emergency room. - The “Investigation” section included various investigation teams had interviewed multiple staff to discuss the event that occurred in the ED. - The interview on 05/23/24 at 07:15 AM, with Staff Y, RN, was included in the HR investigation. - On 05/23/24, Staff BB, Security Officer, was interviewed and stated that he was in a different area when the event began. A nurse asked him to respond. He saw the patient being escorted by Staff CC and Staff Z to his room. He did not see Patient #21 or Staff Z fall. He found Staff Z’s body camera in the bathroom, it appeared to have come off during his fall. When he arrived at the patient’s room, he saw Staff CC and Staff Z at the door. Staff Z looked at the patient and stated, “If you do that shit again, I’m going to whoop your ass, I may lose my job.” Staff BB had to remove Staff Z from the patient’s room. After that, the patient stayed in his room and Staff BB stayed with the patient for around 10 minutes. - On 05/24/24 at 12:35 PM, Staff CC, Security Officer, was interviewed and stated that he and Officer Z took the patient back to his room and returned him to bed. Staff Z had fallen during the event and he was very upset. At one point, Staff Z pointed at the patient and said, “I’m going to mess you up.” Staff BB then removed him from the room and he went to be checked out. - On 05/24/24 at 8:30 AM, Staff Z, Security Officer, was interviewed and stated that he was getting report from Staff CC when the patient asked if he could use the restroom. After exiting the restroom, the patient began to run down the hallway. Staff Z yelled that they had a runner, he and Staff CC ran after him. They cut through a nursing area when the patient collided with Staff CC and fell. They helped him up and he ran again. Staff Z was in the lead and thought he could grab the patient, but fell hitting his right shoulder hard on the floor. He got up and continued the pursuit with Staff CC. Finally, the officers caught up with the patient and escorted him to his room. Nursing staff then took over and Staff Z went to get checked out. He stated that Staff BB was also in the room and told Staff Z to leave because he was mad and needed to calm down. Staff Z stated that he told Staff BB that he was going to beat the patient but did not say anything to the patient. Staff Z said he told the patient that he wasn’t going to have any more running. Staff Z went on to say that he did not know that Staff CC’s body camera was on and did not remember stating that he may lose his job, or telling the patient he would whoop his ass. Staff Z said that he should have walked away. - On 05/24/24 at 11:45 AM, Staff II, ED Technician, was interview and stated that she could tell the Security Officers were aggravated with the patient but wasn’t sure what was said. She said Staff Z and Staff CC were there and Staff BB came later. She could not recall if any officers were asked to be removed from the room. She said Staff Z was very upset, said some words that could have been threatening, could have been cuss words, but she wasn’t sure what they were exactly. She stated they could use more training on how to redirect a patient in that situation. - The “Findings” section showed the investigating teams used interviews with staff present during the event and unnamed video camera footage to substantiate the claim of verbal escalation. Staff Z would receive a Final Corrective action and attend de-escalation training. The Security Manager was able to discuss the need for a de-escalation training requirement for Staff Z with their training curriculum provider. They currently did not have one but could develop one. The training would likely last two or three hours. - The document was prepared by the HR Partner and HR Manager. Review of the hospital’s undated document titled, “Competencies 2024,” showed that Staff Z, Security Officer, received level two AVADE training on 02/19/24, and AVADE de-escalation training on 07/19/24 and 11/18/24. He completed abuse and neglect training on 11/17/24; harassment in the workplace on 11/18/24; and non-violent and inclusive language on 11/17/24. Review of the hospital’s document titled, “Work Schedule,” dated 05/2024 through 08/2024, showed that Staff Z, Security Officer, returned to work on 05/31/24 on light duty. Review of Patient #21’s medical record dated 05/21/24 through 06/17/24, showed: - He was a 38-year-old male who presented to the ED at 12:27 PM, with law enforcement for a 96-hour-hold evaluation due to concern about worsening psychosis (mental illness characterized by defective or lost contact with reality) and his ability to care for himself. - Affidavit reports dated 05/18/24 showed he called the police paranoid that the government was out to get him and he locked his wife out of the home. - His past medical history included bipolar disorder with depression (characterized by clear changes in mood, energy, and activity levels with periods of extremely sad or hopeless behavior), back pain, high blood pressure, schizophrenia, medication non-compliance and obesity. - A psychiatric assessment indicated he was inattentive, withdrawn, paranoid, delusional (false ideas about what is taking place or who one is), with suicidal ideation (SI, thoughts of causing one’s own death). He was impulsive (to act with little or no forethought or consideration of the consequences) and inappropriate. - On 05/21/24 at 2:32 PM, the patient tried to elope from the ED. - On 05/21/24 at 4:30 PM, the plan was to follow through on the 96-hour evaluation with an accepting psychiatric facility. - On 05/21/24 at 11:15 PM, nursing documentation showed that Patient #21 attempted to run out of the ED, security chased the patient and attempted to stop him by the door. Security made contact with him and he fell to the floor, landing on his left elbow. The patient was helped to his feet and he attempted to run again. The patient was then stopped by security staff and directed back to his room. The patient stated, “I’m sorry, it’s the government’s fault.” He repeatedly talked about the government and the Federal Bureau of Investigation (FBI) with paranoid statements. - Physician documentation showed Patient #21 walked to the bathroom and at that point he started running around the ED to try and leave. He appeared to be paranoid and was talking about the FBI and Central Intelligence Agency (CIA) trying to control him and he needed to leave. While trying to be brought back to his room by security staff the patient fell. Staff were unsure how he landed; he did not lose consciousness. He had no bruising and denied tenderness to his scalp. He had tenderness to his right elbow joint with some mild swelling, the skin was intact. An x-ray (test that creates pictures of the structures inside the body-particularly bones) of the right elbow was ordered. He was given an intramuscular (IM) injection. - On 06/17/24, the discharge summary showed Patient #21 was admitted to the behavioral health unit (BHU) for a 96-hour-hold initially, but then placed on a 21-day hold. His medications were adjusted. He was initially noncompliant with medications but became compliant at least a week prior to his discharge. He showed overall improvement, was able to develop a safety plan and his sleeping improved. He denied any paranoia regarding his wife and reported he felt good. During an interview of 12/16/24 at 9:45 AM, Staff Y, RN, stated that Patient #21 had been assigned to her on 05/21/24. She was in another patient’s room when he tried to elope. She heard the patient hit the ground when he fell. He got up and ran again. Security Officers chased him and one of the security officers fell onto the floor. Things got heated with Staff Z, Security Officer, after he fell. Staff Z was standing in the doorway of Patient #21’s room and told Patient #21, he was going to “beat his ass.” That was when she said they needed to get Staff Z out of the room. She felt that what the officer said was verbal abuse because it was a threat. She did not think Staff Z was really going to hurt the patient, he was just injured and embarrassed from falling. She told Security Officers that Patient #21 was psychotic, scared and not in his right mind. Patient #21 was never a threat and didn’t want to hurt anyone. She reported the verbal abuse to HR during her interview. She felt that the patient could have been verbally de-escalated. She did not remember if she completed an event report related to the incident. During a telephone interview on 12/16/24 at 9:30 AM, Staff A, Regulatory Director, stated that Staff CC, Security Officer, did not activate his body camera footage until after Patient #21 fell so she did not watch the body camera footage for her investigation. Staff D, Regional President, had seen the body camera footage. Staff A was only involved in the investigation related to the patient’s fall since the patient fractured his elbow. Inappropriate conduct went to HR to be investigated and she was not a part of that. Security Officers were appropriate with the physical contact that resulted in an injury to the patient. The only aspect identified in her investigation was related to the AVADE stance, everything else was done according to AVADE. She did not interview Staff Z, Security Officer, because he was not able to be interviewed since he was out on workman’s compensation due to the injuries he sustained in the incident. During an interview on 12/11/24 at 11:40 AM, Staff X, Security Manager, stated that Staff Z, Security Officer, said something like, “If you try to run again, I’m going to fuck you up,” to Patient #21 but it was after the incident was over. He expected better of his security officers. Staff Z was off work after the incident and did not return to work until 05/31/24, on light duty. When he returned to work, he was on modified duty and not in patient care areas, he sat at the visitor entrance desk, in plain clothes and counted people when they entered the hospital. The visitor entrance was for the public and had nothing to do with patients. Patients would only use the visitors entrance if they were lost. Staff Z completed de-escalation training on 07/19/24. During a telephone interview on 12/16/24 at 12:45 PM, Staff Z, Security Officer, stated that he did not remember when he went back to work or when he did de-escalation training. When he returned to work he sat at the visitors desk and counted patients and visitors that entered the hospital. He had not done anything wrong to Patient #21. He did not remember when, but he did his de-escalation training with Staff X and it was a verbal discussion. During a telephone interview on 12/16/24 at 7:45 AM, Staff BB, Security Officer, stated that he was one of the officers that escorted Patient #21 back to his room. He heard Staff Z tell Patient #21 something along the lines of, “If you do that again, I am going to fuck you up.” He never felt that Staff Z would actually hurt the patient, he was just hurt and embarrassed and took it out on the patient and said something he didn’t mean. Staff immediately pulled Staff Z from the patient care area. He reported what was said through the chain of command. HR did call him about the incident. He did not know if Risk Management was involved in the investigation. He did not remember if he completed an event report, but thought that he and Staff CC, Security Officer completed one. During a telephone interview on 12/18/24 at 8:00 AM, Staff CC, Security Officer, stated that during shift change, when Staff Z was giving him report, Patient #21 tried to run from the ED. He and Staff Z attempted to stop the patient from leaving and the patient fell. When the patient got up he attempted to run again, that was when Staff Z fell to the ground. He received education related to his stance according to AVADE a few days after the incident. What Staff Z told the patient was not what he would tell a patient, but Staff Z would not have hurt the patient, he just didn’t want the patient to run again. Patient #21 knew what he was doing, he was able to answer questions and listen. The patient was responsive to the nursing staff and could follow their instructions, so the patient was aware of what he was doing. Staff CC stated that he completed an event report following the incident. When he spoke with Staff A, Regulatory Director, he reported to her that what Staff Z said to Patient #21 was profane and inappropriate. During an interview on 12/12/24 at 9:38 AM, Staff AA, Patient Safety Specialist and HR Partner, stated that she received a report of an employee injury after a fall in the ED and that the event escalated. Staff Z’s, Security Officer, behavior got out of control and staff were upset about his behavior. She spoke to all staff members involved in the incident to determine if it was substantiated or not. She made sure the staff member wasn’t working until she was able to determine what kind of behavior they were dealing with. Based off of interviews and body camera footage they were able to substantiate the allegation for inappropriate behavior. Staff Z, Security Officer, was given a level three corrective action, which meant that if he did one more thing wrong, he would be terminated. Staff Z was off work due to injuries sustained in the incident. If an employee was out on leave of absence, they had seven days to complete corrective action after their first day back to work. If Staff Z had been on medical restrictions or did not have access to a computer, he may not have been able to do his recommended education and that was fine. During an interview on 12/11/24 at 3:45 PM, Staff A, Regulatory Director, Staff D, Regional President, and Staff C, CNO, stated they did not feel that the incident met the definition of abuse or verbal abuse.”