Research Medical Center

“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: 49404 Based on interview, record review, video review, and policy review the hospital failed to follow its policies and procedures when they failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for two patients (#3 and #21) of 21 Emergency Department (ED) records reviewed from 07/12/25 through 01/12/26. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an Emergency Medical Condition (EMC). Findings included: Review of the hospital’s policy, titled “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) - Medical Screening Examination and Stabilization Policy,” adopted 07/18/24, showed: - An EMTALA obligation is triggered when an individual comes to a dedicated ED and requests an examination or treatment of a medical condition, or a prudent layperson observer would conclude from the individual’s appearance or behavior that the individual needs examination or treatment of a medical condition. - If a prudent layperson observer would believe that the individual is experiencing an EMC, then an appropriate MSE shall be performed. - The MSE must be completed by an individual qualified to perform such an examination to determine whether an EMC exists. - If an EMC is determined to exist, the individual will be provided necessary stabilizing treatment within the capacity and capability of the facility, or an appropriate transfer as defined and required by EMTALA. - The individual shall be continuously monitored according to the individual’s needs until it is determined whether or not the individual has an EMC, and if he or she does, until he or she is stabilized or appropriately admitted or transferred. Review of the hospital’s document titled, “Medical Staff Rules and Regulations,” date 01/24/23, showed Qualified Medical Persons (QMPs) may perform MSEs. Advance Practice Registered Nurses (RNs), Qualified Mental Health Professionals, and Physician Assistants who have demonstrated competency in the performance of MSEs, are functioning within the scope of their license, hospital policies, and have been approved by the hospital’s Governing Board, are considered to be QMPs. Patients shall be discharged only on order of the attending physician. Review of the hospital’s policy titled, “Against Medical Advice (AMA) - Leaving Against Medical Advice,” effective 12/2023, showed once a patient has decided, or made a statement to the effect, that they desire to leave the hospital AMA, hospital personnel will attempt to determine the reason for wanting to leave AMA. Their attending physician should be contacted and notified of the patient’s wishes to leave AMA. If the patient is not ready for medical discharge, hospital staff will make reasonable attempts to explain the consequences, implications, risks and benefits, and alternatives to such a decision. Please refer to A-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: 49404 Based on interview, record review, video review and policy review, the hospital failed to follow its policies and procedures when they failed to provide, within its capability and capacity, an appropriate medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for two patients (#3 and #21) of 21 Emergency Department (ED) records reviewed from 07/12/25 through 01/12/26. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. Findings included: Review of the hospital’s policy, titled “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) - Medical Screening Examination and Stabilization Policy,” adopted 07/18/24, showed: - An EMTALA obligation is triggered when an individual comes to a dedicated ED and requests an examination or treatment of a medical condition, or a prudent layperson observer would conclude from the individual’s appearance or behavior that the individual needs examination or treatment of a medical condition. - If a prudent layperson observer would believe that the individual is experiencing an EMC, then an appropriate MSE shall be performed. - The MSE must be completed by an individual qualified to perform such an examination to determine whether an EMC exists. - If an EMC is determined to exist, the individual will be provided necessary stabilizing treatment within the capacity and capability of the facility, or an appropriate transfer as defined and required by EMTALA. - The individual shall be continuously monitored according to the individual’s needs until it is determined whether or not the individual has an EMC, and if he or she does, until he or she is stabilized or appropriately admitted or transferred. Review of the hospital’s document titled, “Medical Staff Rules and Regulations,” date 01/24/23, showed Qualified Medical Persons (QMPs) may perform MSE’s. Advance Practice RNs, Qualified Mental Health Professionals, and Physician Assistants who have demonstrated competency in the performance of MSEs, are functioning within the scope of their license, hospital policies, and have been approved by the hospital’s Governing Board, are considered to be QMPs. Patients shall be discharged only on order of the attending physician. Review of the hospital’s policy titled, “Against Medical Advice (AMA) - Leaving Against Medical Advice,” effective 12/2023, showed once a patient has decided, or made a statement to the effect, that they desire to leave the hospital AMA, hospital personnel will attempt to determine the reason for wanting to leave AMA. Their attending physician should be contacted and notified of the patient’s wishes to leave AMA. If the patient is not ready for medical discharge, hospital staff will make reasonable attempts to explain the consequences, implications, risks and benefits, and alternatives to such a decision. Review of Patient #3’s ambulance report, dated 12/20/25, showed Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) responded to a call about a possible assault. Patient #3 was found sitting on the curb outside a restaurant and stated he had been assaulted with a bat. He did not have any marks on his body indicating trauma. He reported that he had walked from nearby woods without assistance and his address was listed as homeless. He provided short answers to questions, was alert, awake, and oriented times three (A&O x 3, refers to being alert and oriented to person, place and time) with a Glasgow Coma Scale (GCS, estimates coma severity. The maximum score is 15 which indicates a fully awake patient) of 15. He was transported to Research Medical Center and arrived at 5:35 AM. Review of Patient #3’s medical record, dated 12/20/25, showed: - At 5:37 AM, a 63-year-old male presented to the ED via EMS with a chief complaint of being cold. - At 5:50 AM, while in triage, he sat on the floor, refused to sit in the chair, refused to answer questions or to let the nurse obtain his vital signs (VS, measurements of the body’s most basic functions). He stated that he wanted to leave, refused to walk, and demanded that the nurse carry him outside. Security was called to the bedside. - At 5:55 AM, nursing documentation indicated he was able to answer orientation questions and had ambulated to the triage area. He then refused to allow the nurse to obtain his VS or to perform a triage assessment. He continued to request to leave, after risks of leaving were reviewed. He refused to sign the Left Prior Triage (LPT)/Left Prior Medical Screen Exam (LPMSE) form. - Disposition comments included a GCS of 15, patient ambulatory, refusing to answer triage questions or to allow the nurse to obtain VS. Stated he wanted to leave and refused to get off the floor where he was sitting. Security was called and escorted him out of the department. - No past medical history was documented. - He was not seen by a provider and no provider notification of his intent to Leave Without Being Seen (LWBS) was documented. - At 5:55 AM, he was discharged. Review of the hospital’s ED surveillance video, dated 12/20/25, showed: - At 5:35 AM, Patient #3 arrived by ambulance and was transported by stretcher by EMS staff into the ED. - At 5:36 AM, a Security Officer (SO) greeted the patient and conducted a security screening while the patient remained on the stretcher. He was wearing a winter coat, but no socks or shoes. - At 5:39 AM, two EMS staff moved him by stretcher to the triage area and assisted him from the stretcher to a chair. He immediately slumped to his side in the chair with his head over a small table in the corner. - At 5:43 AM, a nurse met him and attempted to sit him up straight. He then slid off the chair, onto the floor, hitting a small table on his way down and slumped to his side. The nurse attempted to sit him up on the floor, the patient did not appear to sit up. The nurse remained with him and made additional attempts to reposition him by pulling on his arm. He laid on the floor and would occasionally sit and lay down with his arm against another chair and the table. The nurse was able to get the patient to sit up with his back against a chair. She then pulled on the patients arm but he did not get off of the floor. The patient slumped forward with his back against the chair. The nurse appeared to continue to interact with the patient, but his head remained slumped forward and he did not appear to interact with her. The nurse walked away while the patient remained seated on the floor slumped forward. - At 5:50 AM, another nurse arrived while the patient continued to sit on the floor slumped forward. The second nurse picked up the patient’s backpack, set it on the floor near a desk, and went back to the patient. The patient leaned to the side and laid his head on a chair. The second nurse then pulled the patient’s arm in an attempt to sit him up. - At 5:54 AM, the nurse took a wheelchair to the room and was joined by three SOs. Patient #3 was lifted to the wheelchair and removed from the room, wearing his coat and no socks or shoes. - At 5:56 AM, he was transported by wheelchair out of the ED accompanied by three SOs. They took him across the parking lot to a bus stop near the hospital and laid him on a bench. Staff then returned to the hospital with the wheelchair. - At 6:00 AM, a bus drove by the bus stop bench where the patient was lying and did not stop. The patient appeared to lay on the bus stop bench for the remainder of the video. - He did not stand without assistance or walk on his own during his ED encounter. During a telephone interview on 01/13/26 at 2:50 PM, Staff S, RN, stated that: - The report she received from EMS was that Patient #3’s VS were stable. He was there due to the cold weather and had no signs of trauma. - She asked him to sit up and remove his jacket so she could take his VS and further assess him, but he refused and slid onto the floor. He was uncooperative with attempts to reposition him. - He answered orientation questions and was A&O x 4 but only responded that he was cold. He had no other complaints, did not want to see a physician, and wanted to leave. - She asked Staff U, RN, the shift’s charge nurse for assistance. Patient #3 responded to her orientation questions but refused other questions and restated his desire to leave. He was not seen by a physician. - The nurses attempted to move him back to the chair, but he wouldn’t cooperate. - He refused to sign the AMA form. - Security was called to move him out of the ED at Staff U’s direction. - She did not know if Staff U notified the physician that the patient was leaving. During an interview on 01/13/26 at 12:15 PM, Staff P, Security Director, stated that he was notified by police that Patient #3 was found dead at the bus stop on 12/20/25 at 6:44 AM. The SOs’ actions did not meet his expectations. Patient #3 should have been seen by a provider. There was opportunity for a provider to be called because Patient #3 was unable to leave the ED without staff assistance. During an interview on 01/13/26 at 1:45 PM, Staff R, SO, stated that he assisted two other SOs in transporting Patient #3 from the ED to the bus stop bench. He did not observe the patient speaking or answering questions at any time. The other two SO’s moved Patient #3 from the floor to the wheelchair and it appeared as though it required substantial effort. Patient #3 was rolled to the bus stop and assisted from the wheelchair to the bench. Patient #3 made no verbal response during their encounter but was breathing and moving his extremities. During an interview on 01/14/26 at 9:55 AM, Staff D, Interim ED Director, stated that it was her expectation that a provider would have been notified of Patient #3’s desire to LWBS. He was unable to move himself. The triage nurse appropriately notified the charge nurse, but the charge nurse should have notified a provider before facilitating his removal from the ED to the bus stop. The decision to discharge him as LWBS without notifying a provider was out of her scope of practice. Discharged patients without transportation were offered a taxi if they had an address for their destination. If they did not have a destination, they were allowed to stay in the ED waiting room until bus services resumed at 6:00 AM. Education for all staff concerning provider notification was conducted and security staff were empowered to express concerns about possibly unsafe discharges. During an interview on 01/13/26 at 11:00 AM, Staff Q, Patient Safety Manager, stated that she was notified of the incident the morning it occurred. Their investigation showed opportunities for improvement, including that a provider should have been notified. There had been sufficient time for a provider to see the patient because he was unable to leave without assistance. Education was immediately provided to clinical and non-clinical staff that all patients must receive an MSE before being discharged. If patients refused an MSE, that should be escalated to the charge nurse and then a provider. Security staff were to no longer escort patients off the hospital premises and must verify that patients were cleared to leave before escorting them out. Although requested, a police report and coroners’ examination were not obtained due to the active police investigation. There was no EMS report for the patient after he was found at the bus stop deceased. Although requested, all police and EMS interviews must be set up by a Union Representative and there has been no response. Review of Patient #21’s first ambulance report, dated 01/02/26, showed: - At 10:24 AM, EMS was dispatched for a patient with breathing problems. - Upon arrival EMS found Patient #21 laying in a hotel room bed and appeared to be in pain. The patient reported sharp, constant abdominal pain and rated it a 10, on a pain scale (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible). The patient denied nausea and vomiting. - Upon attempting to get VS, the patient continued to move, reporting that she couldn’t stop moving because she was in too much pain. Patient #21 then told EMS she wanted the pain to go away and proceeded to wrap cords around her neck. When EMS tried to stop her, she became combative. The crew had to pull over on the side of the road and call for fire and police assistance. - EMS advised the patient that they could give her pain medication to help her, but she had to stop fighting them so they could start an intravenous (IV, in the vein) catheter. The patient became combative again and tried to grab cords and the radio. - For the safety of everyone, the patient was placed in restraints. Versed (medication used to help patients feel relaxed or sleep before surgery or during a procedure) was administered. Review of Patient #21’s first medical record, dated 01/02/26, showed: - At 11:31 AM, she presented to the ED via EMS following a call for a complaint of abdominal pain. Per EMS, she put a blood pressure cord around her neck when she was placed in the ambulance. She was given 10mg of midazolam (medication used to help patients relax or sleep before and during surgery or medical procedures and is a high-risk drug for theft and personal use) for agitation. - Her past medical history included chronic abdominal pain, bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows), borderline personality disorder (a type of mental disorder in which a person has a rigid and unhealthy pattern of thinking, functioning and behaving), frequent psychiatric hospitalizations, and frequent suicidal (to cause one’s own death) gestures by attempted strangulation. - She was cooperative upon arrival to the ED and requested medication for abdominal pain. She denied suicidal ideation (SI, thoughts of causing one’s own death) or homicidal ideation (HI, thoughts or attempts to cause another’s death) and her suicide screening showed she was a low risk. - She had multiple prior presentations of self-harming (behavior that is harmful or potentially harmful to oneself) gestures associated with abdominal pain. - Blood was obtained and tested. Physician documentation showed suspected leukocytosis (an increased number of white blood cells in the blood, especially during an infection), due to initial agitation. - She had an elevated white blood cell (WBC, the number of white cells [infection-fighting cells] in the blood, normal range was 4.1 to 11.1) count of 13.6. - She received morphine (an opioid pain medication) for pain. - At 3:38 PM, she received a behavioral health evaluation. She was noted to be non-compliant with outpatient follow up or medications and it was determined she did not meet criteria for inpatient admission. She denied SI or HI and demanded to be discharged. Her friend was contacted and agreed to pick her up. - At 4:35 PM, she was discharged. Review of Patient #21’s second ambulance record, dated 01/02/26 at 7:54 PM, showed EMS arrived on scene to find Patient #21 sitting in her vehicle with complaints of abdominal pain, but she would not elaborate. Police handcuffed her due to past violent encounters with EMS. She was taken to the ambulance but became combative and attempted to use cords to strangle herself. Her documented symptoms included combative, violent, restless, agitated, overactive, with strange and inexplicable behavior. Review of Patient #21’s second medical record, dated 01/02/26, showed: - At 8:31 PM, she presented to the ED via EMS following a call for abdominal pain. Per EMS she put a blood pressure cord around her neck when she was placed in the ambulance and was placed in handcuffs for her safety. - Upon arrival she attempted to wrap cords around her neck and gain access to sharp objects. She was placed in restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) and given midazolam. - Physician documentation showed she was just discharged from the ED a few hours prior. She was seen for the same reasons, assessed and discharged. She frequently presents to the ED with self-harming behaviors in order to get sedating and pain medications. She would be assessed and discharged because she denied attempts to harm herself. - Her behavior de-escalated (reduced the intensity of a conflict or potentially violent situation), and she was released form restraints. - She denied SI or HI. - At 11:28 PM, she received a behavioral health evaluation and denied SI or HI. She expressed a desire to be discharged and was agreeable to transportation home by taxi. - At 11:36 PM, she was discharged. Review of the hospital’s ED surveillance video, dated 01/02/26, showed: - At 11:34 PM, Patient #21 laid on chairs in the ED waiting room. She appeared to be restless and grimaced. - At 11:36 PM, she approached the security station at the ED entrance and placed a cable attached to a computer around her neck. A SO, nurse and Patient Care Technician (PCT) were present and intervened to free her. She resisted their efforts to remove the cord. Three other SOs arrived and assisted, she was freed and escorted out the front door accompanied by three SOs. She attempted to reenter the ED but was stopped by the SOs. - At 11:37 PM, the SOs took her back to the vestibule at the ED entrance. Her shoes and belongings were returned to her and the SOs remained with her. A physician and nurse briefly observed the situation from inside the ED but had no interaction with the patient. - At 11:43 PM, her ride arrived, and she departed. Review of Patient #21’s ambulance report, dated 01/03/26, showed at 8:28 PM, showed EMS responded to Patient #21’s home for a report of a psychiatric (relating to mental illness) crisis. She was discovered by police holding a loaded gun to her head. She resisted disarmament by police. She was uncooperative and combative with EMS, requiring medication to prevent her from acts of self-harm. She was transported to the hospital’s ED. Review of Patient #21’s third medical record, dated 01/03/26, showed: - At 9:06 PM, she presented to the ED via EMS for SI. She had pointed a loaded gun to her head and had to be disarmed by police. She received sedation (to induce a state of drowsiness and relaxation) by EMS and was somnolent (sleepy, drowsy) upon arrival. - She became agitated and required continuous sedation. - Blood was obtained and showed a WBC count of 18.2, a potassium (mineral in the blood or body fluid, normal range was 3.6 to 5.2) of 3.0, and an aspartate aminotransferase (AST, an enzyme that is found mostly in the liver, normal range was 10 to 45) of 63. Physician documentation showed she had leukocytosis from her agitation. - At 11:17 PM, she was admitted to the Intensive Care Unit (ICU, a unit where critically ill patients are cared for) for monitoring while on continuous sedation, pending transfer to the hospital’s psychiatric unit when sedation could be safely discontinued. - On 01/08/26, she was transferred from the ICU to the inpatient psychiatric unit where she was treated until her discharge on 01/10/26. During an interview on 01/14/26 at 10:50 AM, Staff T, Physician, stated that: - She treated Patient #21 during her second encounter on 01/02/26. The patient’s presentation was consistent with her previous encounters. - The patient had a history of chronic abdominal pain, which she self-treated with marijuana gummies, and cannabinoid hyperemesis (recurring episodes of severe nausea, vomiting, and abdominal pain found in long-term, heavy marijuana users). She required minimal pain management for her abdominal pain and usually asked for midazolam. - She typically presented extremely agitated until she received midazolam, often receiving it from EMS enroute. - She had a history of attempting to wrap cords around her neck in the ambulance and/or when she arrived at the ED, and other self-harm gestures. - Staff T considered the patient’s behavior performative and was done as a means of receiving medication. - Upon receiving medication her behavior would de-escalate. Once her behavior was appropriate, she would participate in a behavioral health evaluation. - Patient #21 would then deny SI or HI and request to be discharged. The behavioral health evaluations determined she was not a threat to herself, or others and she did not meet criteria for admission. - On 01/03/26, her presenting circumstances were different. It started with a domestic argument that escalated and resulted in police intervening when she held a gun to her head. This escalation of behavior indicated the need for admission. - She was extremely agitated and aggressive upon arrival to the ED, which required continuous sedation. She was transferred to the ICU for sedation monitoring until her behavior permitted the discontinuation of sedation and a transfer to the hospital’s psychiatric unit. - Following her discharge from the psychiatric unit, she presented to the ED the next day for self-harming behavior. During an interview on 01/14/26 at 11:15 AM, Staff P, Security Director, stated that the SOs should have sought a re-evaluation for Patient #21 following her attempted self-harm after discharge. They should not have stopped her from voluntarily re-entering the ED after she was escorted out. During an interview on 01/14/26 at 11:30 AM, Staff A, Quality VP, stated that staff escalated the circumstances of Patient #21’s discharge to the house supervisor after it occurred, but the patient left before they could intervene. She was notified of the event that night and she immediately followed up with the physician, and initiated EMTALA education for all staff. Patient #21 should not have been permitted to leave without a re-evaluation by the physician, and staff should have escalated the incident to the supervisor before she was permitted to leave. The security supervisor present during the incident was terminated.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 39840 Based on observation, interview, record review and policy review, the hospital failed to: - Implement physician orders for two discharged patients (#34 and #65) of two reviewed; (A-0395) - Document fall risk assessments for five discharged patients (#65, #78, #80, #81, and #82) who experienced a fall during admission of six discharged patients reviewed; (A-0395) - Assess patients every two hours while in violent restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) or seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving); (A-0395) - Verify medication administration when insulin (medication that regulates the amount of sugar in the blood) was administered by scanning a bar code label on the back of an employee badge for one current patient (#83) of two insulin medication administrations observed; (A-0405) - Ensure insulin prepared from a multi-dose vial was properly labeled for two current patients (#44 and #83) of two observed; (A-0405) - Ensure insulin, a critical medication, was administered within the ordered time frame for one current patient (#44) of two observed and for 341 administrations of long-acting insulin of 1,687 administrations reviewed, and 2,875 administrations of short acting insulin of 6,835 administrations reviewed; (A-0405) and - Ensure all medications were secure on three units with medication cabinets located in the nurses’ station of four units observed. (A-0502) The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as an Immediate Jeopardy (IJ). As of 03/27/25, the hospital provided immediate action plans sufficient to remove the IJ when the hospital implemented corrective actions that included insulin administration education to all nursing staff who were qualified to administer medications. This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.23 Condition of Participation (CoP): Nursing Services. Please refer to A-0395, A-0405 and A-0502.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 50321 Based on interview, record review and policy review, the hospital failed to: - Implement physician orders for two discharged patients (#34 and #65) of two reviewed; - Document fall risk assessments for five discharged patients (#65, #78, #80, #81, and #82) who experienced a fall during admission of six discharged patients reviewed; and - Assess patients every two hours while in violent restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) or seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving). Findings Included: Review of the hospital’s policy titled, “Enteral Nutrition (nutrition that is delivered into the digestive system as a liquid),” revised 01/2021, showed Registered Dieticians (RDs) Nutritionists monitored the nutritional care of all patients receiving enteral nutrition. Enteral nutrition was provided to patients upon receipt of a physician order. The physician would specify for the RD to manage, specify the type of product, the rate of feeding and plan for advancement. Nurses would process enteral tube feeding orders and follow the policy regarding positioning of the patient, medication administration, clogged tubes and tolerance monitoring. Review of Patient #34’s medical record showed: - On 05/02/24, he was admitted to the hospital for stab wounds to the neck, lower chest, abdomen, and groin. - On 05/06/24, the patient’s documented weight was 76.6 kg. - On 05/23/24, a gastrostomy tube (G-tube, soft flexible tube inserted through the skin of the abdomen and into the stomach) was placed due to the patient having difficulty tolerating sufficient oral feeding. - The RD recommendation and the physician order showed the nurses were to supplement a bolus (large volume) G-tube feed of 400 milliliters (ml) if the patient ate 50% of his meal, 125 ml if he ate 75%, and 480 ml if he ate nothing. - The patient successfully removed his G-tube twice. - On 05/28/24, Patient #34 removed his G-tube. He did not receive supplemental feeding, due to the wait for verification of proper placement of the replacement G-tube. - On 05/31/24, RD documentation indicated Patient #34’s primary nurse the day before was not aware that he was receiving tube feedings and did not give any. - On 06/07/24, RD documentation requested for nursing staff to document all tube feedings to better estimate the patient’s nutritional intake. - On 06/10/24, supplemental feedings were missed again, due to the wait for verification of proper placement of a replacement G-tube. RD documentation indicated that no supplemental feedings had been documented over the past 72 hours. Sitter (person assigned to continuously observe a patient within close proximity, to ensure their safety) documentation showed no oral intake that day due to replacement of his G-tube and poor overall intake. - On 06/11/24, RD documentation indicated Patient #34’s nurse did not administer any tube feedings because she believed the feeding tube had not yet been replaced. The RD informed the nurse that the tube was in place and ready for infusions. - From 06/07/24 through 06/13/24, no oral supplements were documented. Patient #34’s G-tube was removed at night on 06/09/24 but was replaced and functional on 06/10/24. - On 06/16/24, no oral supplements were documented, and he only took in 220 ml by mouth. - On 06/17/24, progress note documentation indicated Patient #34 received a supplemental feeding of 480 ml. It could not be determined if that was a late entry. - On 06/18/24, Staff QQQQ’s, Case Manager, documentation indicated that she voiced concerns to the unit manager about Patient #34 not receiving multiple tube feedings as ordered by the physician. - On 06/19/24, his weight was 68.6 kg, a loss of 8 kg since admission. - On 06/21/24, Patient #34 was transferred to hospice care. - On 06/24/24, Patient #34 died. During a review of Patient #34’s incident reports and concurrent interview, Staff H, Quality Vice President, stated that an anonymous incident report was filed on 06/18/24 related to missed tube feedings. The report showed the patient had orders for tube feedings to supplement his oral intake. Staff V, Medical/Surgical Director, investigated this incident. Staff V’s review of Patient #34’s record indicated a missed tube feeding occurred on 06/17/24, but the feedings were resumed on 06/18/24. He concluded this was a “human factor”. During an interview on 03/26/25 at 10:22 AM, Staff QQQQ, Case Manager, stated that she had been concerned about Patient #34’s weight loss and noticed the missed tube feedings in his chart. She brought it to the attention of the nurse leaders in a multi-disciplinary meeting. During an interview on 03/26/25 at 9:20 AM, Staff V, Medical/Surgical Director, stated that he vaguely recalled the issue with Patient #34’s missed feeds. He confirmed that there were missed supplemental feedings when the patient did not eat by mouth sufficiently. During an interview on 03/26/25 at 2:30 PM, Staff IIII, Assistant Chief Nursing Officer (ACNO), stated that there were nursing errors related to Patient #34’s tube feedings. Review of the hospital’s policy titled, “Organization Wide Patient Assessment,” revised 08/2024, showed the checking of vital signs (VS, measurements of the body’s most basic functions: blood pressure [BP, normal adult blood pressure is between 90/60 and 120/80] and heart rate [HR, normal 60 to 100 per minute]) was considered a part of the assessment/reassessment process. Patient reassessment on medical/surgical and telemetry (remote observation of a person’s heart rhythm, using signals that are transmitted from the patient to a computer screen) units was to be performed every shift. Physician orders served as mechanisms for the medical staff to communicate the patient’s care, treatment needs, and continued care requirements. Although requested there was no policy related to the obtention of orthostatic VS (VS measurements of BP and HR while a patient is lying down, sitting, and then standing, to assess how the body responds to changes in position). Review of Patient #65’s medical record showed: - On 06/11/24 at 3:12 PM, a 39-year-old male was admitted to the hospital for nausea, vomiting, and generalized weakness with recurrent episodes of dizziness following a kidney transplant on 05/13/24. - At 3:26 PM, a physician order was placed to obtain orthostatic VS once per shift. - On 06/12/24 at 9:23 AM; 06/13/24 at 12:21 PM; 06/14/24 at 9:30 AM; 06/20/24 at 9:48 AM; 06/23/24 at 5:00 AM; and 06/25/24 at 12:31 PM, orthostatic VS were obtained. - On 06/17/24 at 6:03 PM, orthostatic VS were attempted, and Patient #65 experienced a fall. - On 06/20/24 at 3:18 AM, nursing documentation showed orthostatic VS could not be obtained due to Patient #65’s weakness and syncopal (to faint) episodes. - Orthostatic VS were not documented for any other nursing shift assessments. At a minimum, 26 sets of VS were missed. - On 06/27/24 at 5:04 PM, Patient #65 was discharged. During a review of Patient #65’s incident reports on 03/26/25 at 1:31 PM, Staff H, Quality Vice President, stated that nursing staff had failed to obtain orthostatic VS after Patient #65 had sustained three falls between 06/15/24 and 06/17/25. She expected nursing staff to obtain VS as ordered by the medical team. During an interview on 03/27/25 at 9:29 AM, Staff N, ACNO, stated that it was the responsibility of nursing staff to ensure physician orders were followed. If a physician ordered orthostatic VS every shift, they were to be obtained every shift. She expected nursing staff to follow physician orders as written. Review of the hospital’s policy titled, “Patient Fall Prevention Program Requirements and Performance Monitoring,” revised 02/2024, showed a patient fall was a sudden, unintentional descent, with or without sustained injury, that resulted in the patient coming to rest on the floor, on or against some other surface, on another person, or an object. All patients would be evaluated for fall potential through completion of the appropriate Fall Risk Assessment. This would occur during the admission process; initial, daily nursing assessment; at minimum once per shift; following a change in medical condition and/or level of care; and post fall. After each patient fall, the nurse would document in the post fall assessment intervention within the medical record. At a minimum, the nurse would notify the attending physician, nurse leader, and the patient’s legal representative as soon as possible. All notifications would be documented in the medical record. Review of the hospital’s undated document titled, “Event Reports,” showed Patient #65, #78, #80, #81, and #82 sustained falls with harm that required intervention or prolonged hospitalization. Patient #65 experienced two additional falls with no harm. Review of Patient #65’s medical record showed: - On 06/14/24 at 7:50 PM, a Morse Fall Risk Assessment (a method of assessing a patient’s likelihood of falling) was completed with a score of 65, high risk. A Morse Fall Risk Assessment was not completed the following shift. - On 06/15/24 at 10:12 AM, nursing documentation showed a physician was notified that Patient #65 experienced a fall. - At 10:30 AM, a post fall assessment was completed. A Morse Fall Risk Assessment was not completed. - At 1:13 PM, nursing documentation showed a physician was notified that Patient #65 experienced a fall. - At 1:30 PM, a post fall assessment was completed. A Morse Fall Risk Assessment was not completed. - At 8:30 PM, a Morse Fall Risk Assessment was completed with a score of 80, high risk. A Morse Fall Risk Assessment was not completed the following shift. - On 06/16/24 at 12:19 PM, nursing documentation showed a physician was notified that Patient #65 experienced a fall. - At 12:30 PM, a post fall assessment was completed. A Morse Fall Risk Assessment was not completed until the following shift. Review of Patient #78’s medical record showed: - On 07/30/24 at 11:22 AM, a 50-year-old male was admitted following a fall from a bicycle. - On 09/29/24 at 10:45 AM, a Morse Fall Risk Assessment was completed with a score of 80, high risk. - At 4:42 PM, nursing documentation showed a physician was notified that Patient #78 experienced a fall. No post fall assessment was completed. A Morse Fall Risk Assessment was not completed until the following shift. Review of Patient #80’s medical record showed: - On 11/24/24 at 11:13 AM, a 65-year-old male was admitted for a gastroenterology (GI, branch of medicine concerned with the structure and diseases of the stomach and intestines) workup. - On 12/11/24 at 8:00 PM, a Morse Fall Risk Assessment was completed with a score of 40, moderate risk. - At 4:20 AM, a post fall assessment was completed. A Morse Fall Risk Assessment was not completed until the following shift. - At 4:22 AM, nursing documentation showed a physician was notified that Patient #80 experienced a fall. Review of Patient #81’s medical record showed: - On 11/25/24 at 1:39 PM, a 63-year-old male was admitted for bilateral lower leg swelling. - On 11/26/24 at 9:00 AM, a Morse Fall Risk Assessment was completed with a score of 20, low risk. - At 9:18 PM, nursing documentation showed a physician was notified that Patient #81 experienced a fall. - At 10:26 PM, one hour and eight minutes later, a post fall assessment and Morse Fall Risk Assessment were completed with a score of 70, high risk. Review of Patient #82’s medical record showed: - On 08/13/24 at 12:18 AM, a 39-year-old female was admitted for burns sustained to her face, abdomen, and arms. - On 09/17/24 at 8:00 AM, a Morse Fall Risk Assessment was completed with a score of 60, high risk. - At 2:00 PM, a post fall assessment was completed. A Morse Fall Risk Assessment was not completed until the following shift. No provider notification was documented. During an interview on 03/26/25 at 2:35 PM, Staff IIII, ACNO, stated that she expected a Morse Fall Risk Assessment to be completed per policy. This included a post fall assessment and a reassessment of the Morse Fall Risk Assessment to be completed immediately after a patient fall. Over one hour or the next shift was not immediate. She expected nursing staff to notify the medical team of a patient fall and document the communication in the medical record. During an interview on 03/26/25 at 1:31 PM, Staff H, Quality Vice President, stated that patient safety had identified a failure to complete nursing assessments as a contributing factor of patient falls. Review of the hospital’s policy titled, “Patient Restraint/Seclusion,” dated 07/01/23, showed patients are assessed by a RN immediately after restraints or seclusion are initiated to assure safe application/initiation of the restraint or seclusion. An RN would assess the patient at least every two hours. The assessment would include: signs of injury associated with restraint, including circulation of affected extremities; respiratory and cardiac status; psychological state, including level of distress or agitation, mental status and cognitive functioning; needs for range of motion, exercise of limbs and systematic release of restrained limbs are being met; hydration/nutritional needs are being met; hygiene, toileting/elimination needs are being met; the patient’s rights, dignity, and safety are maintained; patient’s understanding of reasons for restraint and criteria for release from restraint; and consideration of less restrictive alternatives to restraint. Review of Patient #25’s medical record showed: - On 03/14/25, a 62-year-old male was admitted to the Research Psychiatric Center (RPC). - On 03/15/25 at 7:20 PM, he was placed in seclusion. - At 7:46 PM, a face-to-face assessment and a seclusion assessment were documented. An order was placed for seclusion. - At 9:23 PM, nursing noted that the patient had been in seclusion since the start of the shift. - At 11:57 PM, an order for seclusion was placed. - On 03/16/25 at 3:42 AM, an order for seclusion was placed. - At 6:48 AM, nursing noted that the patient remained in seclusion. - At 7:34 AM, seclusion was discontinued. There was an 11 hour and 48-minute gap with no seclusion assessment documentation. A new order was placed for seclusion. - At 7:35 AM, seclusion was restarted. - At 11:19 AM, an order was placed for seclusion. - At 11:20 AM, seclusion was discontinued. There was a three hour and 45-minute gap with no seclusion assessment documentation. - At 11:21 AM, seclusion was restarted. - At 3:58 PM, seclusion was discontinued. There was a four hour and 37-minute gap with no seclusion assessment documentation. - At 3:59 PM, an order was placed for seclusion, and seclusion was restarted. - At 7:40 PM, an order was placed for seclusion. - At 11:38 PM, an order was placed for seclusion. - On 03/17/25 at 1:50 AM, seclusion was discontinued. There was a nine hour and 51-minute gap with no seclusion assessment documentation. - At 6:55 AM, seclusion was restarted. - At 6:57 AM, an order for seclusion was placed. - At 10:08 AM, a seclusion reassessment and face-to face assessment were documented, three hours and 13 minutes after seclusion was started. - At 10:09 AM, seclusion was discontinued. - Patient #25’s Patient Monitoring Form, dated 03/16/25, showed he was in seclusion from 7:45 AM to 11:46 PM. The nurse signed the form hourly from 8:00 AM to 6:01 PM. From 7:00 PM to 11:46 PM, there were no nurse signatures. Review of Patient #89’s medical record showed: - On 02/28/25, a 36-year-old male was admitted to RPC. - On 03/01/25 at 9:35 PM, he was placed in seclusion and an order entered. - At 9:37 PM, nursing documented that seclusion was discontinued, and four-point restraints (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others) were applied. An order was placed for four-point restraints. - At 9:38 PM, nursing documented that his restraints were assessed. - On 03/02/25 at 1:48 AM, an order for four-point restraints was placed. - At 5:44 AM, an order for four-point restraints was placed. - At 7:40 AM, nursing documented that restraints were discontinued. There was a ten hour and two-minute gap with no restraint assessment documentation. - Patient #89’s Patient Monitoring Form, dated 03/01/25 and 03/02/25, showed the nurse initialed the form every one hour and fifteen minutes, from 03/01/25 at 9:45 PM to 03/02/25 at 7:36 AM, while Patient #89 was in restraints. There was no additional documentation regarding circulation, toileting or alternatives attempted. During an interview on 03/26/25 at 12:20 PM, Staff HHHH, RPC House Supervisor, stated that if a patient was let out of seclusion for one minute and then placed back in seclusion, a new order was needed. During an interview on 03/26/25 at 12:00 PM, Staff BBB, VP of Operations and RPC ACNO, stated that for violent restraint or seclusion documentation, there was no option for continuation documentation. The only options available for documenting violent restraints or seclusion were to start, restart, and discontinue. Staff had to document that restraints or seclusion were discontinued, and then document that restraint or seclusion was restarted. If it was restarted, there was no need for a face-to-face assessment. Her expectation was for staff to document every two hours while a patient was in physical violent restraints, and every four hours for patients in seclusion. During an interview at 03/27/25 10:00 AM, Staff IIII, ACNO, stated that the hospital’s policy was for nursing to assess patients in restraints or seclusion every two hours. During an interview on 03/27/25 at 11:50 AM, Staff YYYY, Quality Manager, stated that nursing documented every two hours on the Patient Monitoring Form while a patient was in restraints or seclusion. During an interview on 03/27/25 at 12:12 AM, Staff IIII, ACNO, stated that the Patient Monitoring Form documentation every two hours did not meet her expectation for nursing restraint or seclusion documentation every two hours. 46856 49489”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 50321 Based on observation, interview, record review and policy review, the hospital failed to: - Verify medication administration when insulin (medication that regulates the amount of sugar in the blood) was administered by scanning a bar code label on the back of an employee badge for one current patient (#83) of two insulin medication administrations observed; - Ensure insulin prepared from a multi-dose vial was properly labeled for two current patients (#44 and #83) of two observed; and - Ensure insulin, a critical medication, was administered within the ordered time frame for one current patient (#44) of two observed, for 341 administrations of long-acting insulin of 1,687 administrations reviewed, and 2,875 administrations of short acting insulin of 6,835 administrations reviewed. These failures had the potential of affecting all patients that required insulin. Late administration and failing to label insulins could cause harm or have a significant, negative impact on all patients receiving insulin. Findings included: Review of the hospital’s policy titled, “Medication Administration,” revised 02/2024, showed a work around was the intentional or purposeful use of a function or process which would result in the bypass of critical functions of the systems intended to promote patient safety. The verification for correct medication, dosage, route and time was accomplished by comparing the label on the medication, scanning the medication bar code and the patient’s armband. The steps in the administration process included the verification that the medication selected matched the medication label and the scanning of all medications. Review of the hospital’s undated policy titled, “Addendum One,” showed patient specific vials should be labeled and stored in the patient specific medication bins. Observation on 03/25/25 at 9:31 AM, showed: - Staff XXX, Registered Nurse (RN), removed insulin from the automatic dispensing machine (ADM). She withdrew lantus (long-acting blood-glucose-lowering medication) and Lispro (a short-acting insulin) into separate syringes from multi-dose vials. She returned the insulin vials to the ADM, closed the door and laid the two syringes down on the counter beside the ADM without affixing a barcode label. She then withdrew a pre-filled syringe of Lovenox (a medication used to help prevent the formation of blood clots) and laid it down next to the two unlabeled syringes. - Staff XXX stated “I guess I need to put labels on them with you observing me” and proceeded to reopen the ADM. She became confused with which syringe was lantus and which syringe was Lispro. She was comparing dosages of insulin and trying to label them appropriately, decided to discard them. She then re-withdrew the insulin and labeled the syringes with the appropriate labels located in the bin of the ADM for each insulin type. - At 9:31 AM, Staff XXX entered Patient #44’s room and administered the insulin. She stated, “I am late giving this today. I just got busy.” She did not re-check Patient #44’s blood sugar at that time. Review of Patient # 44’s medical record showed on 03/25/25 at 9:31 AM, Staff XXX, RN, administered 30 units of lantus and 20 units of Lispro. Observation on 03/26/25 at 11:24 AM, showed: - Staff TTTT, RN, removed insulin from the ADM, withdrew the insulin into a syringe from a multi-dose vial and returned the vial to the ADM. A roll of orange labels was in the ADM bin, next to the insulin. - Staff TTTT entered Patient #83’s room, scanned his identification bracelet, returned to the computer and scanned a barcode taped on the backside of her employee badge to complete the medication administration documentation. She did not scan the barcode on the insulin vial. - Two different types of insulin barcodes were taped on the backside of Staff TTTT’s employee badge. Review of Patient #83’s medical record, showed on 03/26/25 at 11:26 AM, Staff TTTT, RN, administered three units of insulin. During an interview on 03/26/25 at 2:35 PM, Staff IIII, Assistant Chief Nursing Officer (ACNO), stated that it was not appropriate for nursing staff to scan a barcode label located on the back of their employee badge. Insulin was to be labeled at the time of preparation when withdrawn from a multi-dose vial. The label attached during preparation should be used for scanning during medication administration. She expected staff to use the labels available in the ADM. The orange labels located in the bin next to the insulin, within the ADM, were the correct labels. Each label contains the correct barcode for that insulin. Labels should be used during the preparation and administration of insulin. There was no shortage of labels. During an interview on 03/26/25 at 11:31 AM, Staff UU, Nurse Manager (NM), stated that her expectation was to label insulin syringes only if staff were to administer more than one type of insulin, or prepare insulin for more than one patient at a time. She was aware staff were using barcode labels located on the backside of their employee badges and that was her expectation for staff. She stated there was no policy related to the labeling of insulin syringes. During an interview on 03/26/25 at 11:30 AM, Staff TTTT, RN, stated that she was not expected to label insulin syringes if she only gave one type of insulin to one patient at a time. Currently, there was a shortage of insulin labels with a barcode so the work around was to use a label on the backside of her employee badge. Review of the hospital’s policy titled, “Medication Administration,” revised 02/2024, showed time critical medications are medications that should be given within 30 minutes of their scheduled times. Early or late administration could cause harm or have significant, negative impact on the intended effects. Lispro insulin should be administered at 8:00 AM and 5:00 PM if ordered two times per day and administered at 8:00 AM, 12:00 PM and 5:00 PM if ordered three times per day. Other insulins should be administered at breakfast 7:30 AM, lunch at 11:30 AM, and dinner at 4:30 PM. Addendum One identifies that insulin is a high risk and high alert medication. Observation on 03/25/25 at 9:31 AM, showed Staff XXX, RN, enter Patient #44’s room and administer insulin at 9:31 AM. She stated “I am late giving this today. I just got busy.” She did not re-check Patient #44’s blood sugar, his last documented blood sugar was at 7:00 AM. During an interview on 03/26/25 at 9:00 AM, Staff UUU, NM, stated the Patient Care Technician (PCT) normally checked blood sugars around 7:00 AM. All floors use multi-dose vials of insulin. Each of the nurses have their own preferred way of drawing up insulins and administering them. Some nurses place their insulin syringes in a baggie and place a label on the baggie. All syringes and baggies should have a label attached to them. The labels are in the bins next to the multi-dose insulin vials in every ADM. Critical medication administrations were not monitored. An application on the charge nurse phone alerts when a nurse is late administering a medication. During an interview on 03/26/25 at 2:35 PM, Staff IIII, ACNO, stated that it was not appropriate for nursing staff to administer insulins late or to use a blood sugar that was obtained at two hours before the administration. She expects the nursing staff to re-check a blood sugar if they were obtained over an hour before administering the insulin. During an interview on 03/27/25 at 9:15 AM and 11:30 AM, Staff WWWW, Pharmacy Director, stated the administrations of critical timed medication insulins were not routinely monitored. Insulins should be administered within 30 minutes of the scheduled administration times. She reviewed an untitled, handwritten document labeled with Lantus (long-acting) and stated that out of 1,687 administrations reviewed, from 02/12/25 to 03/27/25, 62 of the administrations were greater than 120 minutes late. 279 administrations were greater than 60 minutes late. She reviewed a second untitled, handwritten document labeled Humalog (short-acting) insulin and stated that out of a total of 6,835 administrations reviewed, from 02/12/25 to 03/27/25, 2,245 were administered greater than 60 minutes late and 630 administrations were administered greater than 120 minutes late. The overall totals of short-acting insulin administrations that were late was 2,875 out of 6,835. The overall totals of long-acting insulin administrations that were late was 341 out of 1,685. 47504”

“SECURE STORAGE CFR(s): 482.25(b)(2)(i) §482.25(b)(2)(i) - All drugs and biologicals must be kept in a secure area, and locked when appropriate. This Standard is not met as evidenced by: 50321 Based on observation, interview and policy review, the hospital failed to ensure all medications were secure on three units with medication cabinets located in the nurses’ station of four units observed. This failure had the potential to allow unauthorized access of medications by personnel, visitors, and patients. Findings included: Review of the hospital’s policy titled, “Storage of Medications,” revised 08/2024, showed lockable medication carts, automated dispensing cabinets (ADCs), and drawers were used to store medications. These storage areas/units would be locked when unattended. Observation with concurrent interview on 03/24/25 at 3:28 PM, on the Progressive Care Unit (PCU), showed a cabinet in the center of the nurses’ station. The cabinet doors were visibly ajar with the doorknob lock turned to the right with no staff present. Upon stepping toward the cabinet Staff M, Nurse Manager (NM), was seen twisting the doorknob lock counterclockwise while attempting to close the doors. She then moved the numbered dial locking mechanism on the doorknob lock to lock the cabinet. Staff M stated that the cabinet was locked, and it contained patient medications in plastic bins labeled with room numbers. Observation on 03/25/25 at 9:16 AM, on the PCU, showed the doors to the cabinet with patient medications were open with no staff present. The cabinet contained patient medications in plastic bins labeled with room numbers. Observation on 03/25/25 at 2:47 PM, on the fourth-floor central telemetry (remote observation of a person’s heart rhythm, using signals that are transmitted from the patient to a computer screen) unit, showed a cabinet in the center of the nurses’ station. The cabinet doors were open with no staff present. The cabinet contained patient medications in plastic bins labeled with room numbers. Observation with concurrent interview on 03/25/25 at 2:50 PM, on the fourth-floor north telemetry unit, showed a cabinet in the center of the nurses’ station with no staff present. The doorknob lock was turned to the right. Staff OO, Nursing Director, opened the cabinet door without turning the doorknob lock or moving the numbered dial locking mechanism on the doorknob lock. Staff OO stated that the cabinet door was not locked. The cabinet contained patient medications in plastic bins labeled with room numbers. During an interview on 03/26/25 at 2:35 PM, Staff IIII, Assistant Chief Nursing Officer (ACNO), stated that she expected cabinets containing patient medications located in the center of the nurses’ stations to be locked. The cabinets not located behind locked doors could be accessible to the any person who walked on the unit. During an interview on 03/24/25 at 3:10 PM, Staff L, Registered Nurse (RN), stated that the patient medication cabinet located in the middle of the nurses’ station on the PCU was not kept locked.”

“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: 47504 Based on interview, record review and policy review, the hospital failed to follow its policies and provide within its capability and capacity, an appropriate medical screening examination (MSE) and stabilization for one patient (#1) of 26 Emergency Department (ED) records reviewed from 04/01/23 through 04/30/23 and 01/08/24 through 07/07/24. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). Findings included: Review of the hospital’s policy titled, “Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an EMC) Definitions and Requirements,” revised 07/01/24, showed the hospital’s ED must provide to any individual, including any stage of development, who comes to the ED an appropriate Medical Screening Examination (MSE). A MSE would be completed within its capability and determine if an EMC exists. A MSE is the process required to reach with reasonable clinical confidence whether or not an EMC exists. If an EMC is determined to exist, the hospital must provide either further medical examination and any necessary stabilizing treatment within the capabilities of the staff and facilities available at the hospital or provide an appropriate transfer to another medical facility. An EMC exists if there is a medical condition manifesting itself by acute symptoms of sufficient severity including psychiatric (relating to mental illness) disturbances such that the absence of immediate medical attention could reasonably be expected to result in acute psychiatric symptoms that are manifested and if the individual is determined to be a danger to self or to others. To stabilize means to provide medical treatment of the condition to assure within reasonable medical probability, that no deterioration of the condition is likely to result from or occur if discharged or transferred. Review of the hospital’s policy titled, “Behavioral Health (BH) Admission and Exclusionary Criteria,” reviewed on 03/2021, showed that all patients admitted to the BH Unit must meet at least one of the admission criteria that included a patient having physically aggressive threats or actions that pose an imminent risk of harm to self or others due to a treatable primary psychiatric condition and patient needs exceed an outpatient level of care for a treatable psychiatric condition. Review of the hospital’s policy “Organization Wide Patient Assessment,” reviewed on 04/2024, showed that each patient is assessed by the appropriate disciplines beginning with admission/pre-admission and progressing through discharge. Initial assessments are completed according to unit-specific parameters and reassessments are performed when there is a significant change in the patient’s condition. Re-assessments from the physician in the ED are done as needed and patients with acute emotional illness are ongoing until a transfer is done to an appropriate psychiatric treatment center as deemed necessary. Please refer to 2407 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: 47504 Based on interview, record review, and policy review, the hospital failed to provide, within its capability and capacity, an ongoing assessment and reassessment of a medical screening exam (MSE) sufficient to determine the presence of an Emergency Medical Condition (EMC) for one patient (#1) of 26 Emergency Department (ED) records reviewed from 04/01/23 through 04/30/23 and 01/08/24 through 07/07/24, when they were discharged with an unstable medical condition. Findings included: Review of the hospital’s policy titled, “Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an EMC) Definitions and Requirements,” revised 07/01/24, showed the hospital’s ED must provide to any individual, including any stage of development, who comes to the ED an appropriate Medical Screening Examination (MSE). A MSE would be completed within its capability and determine if an EMC exists. A MSE is the process required to reach with reasonable clinical confidence whether or not an EMC exists. Review of the hospital’s policy “Organization Wide Patient Assessment,” reviewed on 04/2024, showed each patient is assessed by the appropriate disciplines beginning with admission/pre-admission and progressing through discharge. Initial assessments are completed according to unit-specific parameters and reassessments are performed when there is a significant change in the patient’s condition. Re-assessments from the physician in the ED are done as needed and patients with acute emotional illness are ongoing until a transfer is done to an appropriate psychiatric treatment center as deemed necessary. Review of Patient #1’s medical record dated 04/18/23 through 04/19/23, showed the following: - She presented to the ED on 04/18/23 at 2:41 PM, via police, for an angry outburst at her day program and threatened to harm herself. - She received a mental health evaluation and did not meet criteria for an inpatient admission to the Behavioral Health Unit (BHU). The physician documented that Patient #1’s actions were attention seeking and behavioral. The provider did not feel that medication changes would benefit the patient. Physicians did not feel that Patient #1 was an imminent threat to herself or others and was to follow up with her outpatient providers. Her host family was not comfortable with her returning home that night, so the hospital agreed to let the patient stay until the morning of 04/19/23. - On 04/19/23 at 12:15 AM, Patient #1 became escalated, grabbed a tongue depressor through the nursing station window and broke it in half, threatened staff, banged on the windows, and tried to get through the locked doors. She required sedation medications intramuscularly (IM, in the muscle). There was no documentation of a mental health evaluation following the incident. - Fifteen-minute rounding sheets showed Patient #1 remained in a hallway bed throughout her ED visit and was not admitted to the hospital. - Patient #1 was discharged with her host mother on 04/19/23 at 5:30 PM. - Patient #1 did not receive a second mental health assessment after her outburst in the ED requiring sedation medication; a change of condition and as part of her MSE to determine the presence of an EMC. Review of a document from Facility B, Police Department (PD), showed four officers responded to a 911 call on 04/18/23 at 1:46 PM for a possible armed assault. Patient #1 had a knife. She had been at the day center and had been cutting herself with a plastic fork. Her guardian (the person appointed by a judge to manage the property and rights of another person who is considered incapable of doing so themselves) did not feel safe transporting her to the ED and requested help from the PD. She was de-escalated and transported to Research Medical Hospital ED for an evaluation. Review of an email dated 07/10/24 at 1:31 PM titled, “Notes on [Patient #1],” showed the following: - On 04/18/23 at 7:24 PM, a Behavioral Health Assessment (BHA) was completed and discharge was recommended. The host mother did not feel comfortable returning home with the patient without her husband present and Staff Y, ED Physician, agreed to keep Patient #1 overnight. - On 04/19/23 at 12:38 AM, Staff Y called and reported to the crisis stabilization unit that Patient #1 was very aggressive and required IM sedation. Staff Y reported that Patient #1’s aggression and agitation was not normally at this level when the patient presented to the ED. The patient was making gestures to staff swiping her thumb across her throat. During an interview on 07/09/24 at 4:00 PM, Staff CC, ED Physician, stated that Patient #1 was attention seeking and did not have a status change. He felt that it was ok to proceed with the discharge plan. Although requested, interviews were not provided for Staff X, CM; Staff Y, ED Physician; Staff Z, ED Physician; Staff AA, RN; Staff BB, RN; and Staff LL, Patient Care Technician, PCT. At the time of the patient’s initial presentation, she had an appropriate MSE. However, the patient’s behavior escalated and Patient #1 required sedative medications. She did not receive a new MSE following a change in condition on 04/19/23 at 12:15 AM in the ED. Patient #1 was discharged.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 47504 Based on interview, record review, and policy review, the hospital failed to ensure that an emergency medical condition (EMC) was stabilized for one patient (#1) of 26 Emergency Department (ED) records reviewed from 04/01/23 through 04/30/23 and 01/08/24 through 07/07/24, when they were discharged with an unstable medical condition. Findings included: Review of the hospital’s policy titled, “Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an EMC) Definitions and Requirements,” revised 07/01/24, showed the hospital’s ED must provide to any individual, including any stage of development, who comes to the ED an appropriate Medical Screening Examination (MSE). A MSE would be completed within its capability and determine if an EMC exists. A MSE is the process required to reach with reasonable clinical confidence whether or not an EMC exists. If an EMC is determined to exist, the hospital must provide either further medical examination and any necessary stabilizing treatment within the capabilities of the staff and facilities available at the hospital or provide an appropriate transfer to another medical facility. An EMC exists if there is a medical condition manifesting itself by acute symptoms of sufficient severity including psychiatric (relating to mental illness) disturbances such that the absence of immediate medical attention could reasonably be expected to result in acute psychiatric symptoms that are manifested and if the individual is determined to be a danger to self or to others. To stabilize means to provide medical treatment of the condition to assure within reasonable medical probability, that no deterioration of the condition is likely to result from or occur if discharged or transferred. Review of the hospital’s policy titled, “Behavioral Health (BH) Admission and Exclusionary Criteria,” reviewed on 03/2021, showed that all patients admitted to the BH Unit must meet at least one of the admission criteria that included a patient having physically aggressive threats or actions that pose an imminent risk of harm to self or others due to a treatable primary psychiatric condition and patient needs exceed an outpatient level of care for a treatable psychiatric condition. Review of the hospital’s policy “Organization Wide Patient Assessment,” reviewed on 04/2024, showed that each patient is assessed by the appropriate disciplines beginning with admission/pre-admission and progressing through discharge. Initial assessments are completed according to unit-specific parameters and reassessments are performed when there is a significant change in the patient’s condition. Re-assessments from the physician in the ED are done as needed and patients with acute emotional illness are ongoing until a transfer is done to an appropriate psychiatric treatment center as deemed necessary. Review of Patient #1’s medical record dated 04/18/23 through 04/19/23, showed the following: - She presented to the ED on 04/18/23 at 2:41 PM, via police, for an angry outburst at her day program and threatened to harm herself. - She received a mental health evaluation and did not meet criteria for an inpatient admission to the Behavioral Health Unit (BHU). The physician documented that Patient #1’s actions were attention seeking and behavioral. The provider did not feel that medication changes would benefit the patient. Physicians did not feel that Patient #1 was an imminent threat to herself or others and was to follow up with her outpatient providers. Her host family was not comfortable with her returning home that night, so the hospital agreed to let the patient stay until the morning of 04/19/23. - On 04/19/23 at 12:15 AM, Patient #1 became escalated, grabbed a tongue depressor through the nursing station window and broke it in half, threatened staff, banged on the windows and tried to get through the locked doors. She required sedation medications intramuscularly (IM, in the muscle). There was no documentation of a mental health evaluation following the incident. - Fifteen minute rounding sheets showed Patient #1 remained in a hallway bed throughout her ED visit and was not admitted to the hospital. - Patient #1 was discharged with her host mother on 04/19/23 at 5:30 PM. Review of a document from Facility B, Police Department (PD), showed four officers responded to a 911 call on 04/18/23 at 1:46 PM for a possible armed assault. Patient #1 had a knife. She had been at the day center and had been cutting herself with a plastic fork. Her guardian did not feel safe transporting her to the ED and requested help from the PD. She was calmed down and was transported to Research Medical Hospital ED for an evaluation. Early in the patient’s ED visit it was determined that she did not meet criteria for the BHU because she had just been discharged from there. It was noted in the ED record that she “exhibited attention seeking behaviors.” Her foster mother did not feel safe having her return home. The patient had an outburst in the ED that required sedation with haloperidol and midazolam because she could not be verbally de-escalated. Despite the patient’s aggressive behavior at the daycare and again in the ED, she was not stabilized prior to discharge. Review of Patient #1’s medical record dated 04/19/23 through 04/23/23, showed the following: - Patient #1 presented to the ED on 04/19/23 at 9:08 PM, via police, for running away toward traffic from her group home manager. The police were called to get the patient back to the ED. - Physician documentation showed Patient #1 paced around the ED, slammed a book shut and an affidavit (a written statement confirmed by oath, for use as evidence in court) was completed. - On 04/20/23 at 07:29 AM, a mental health assessment was completed by Staff V, Social Worker (SW) and showed Staff CC, ED Physician, and Staff Y, ED Physician, both requested a recommendation for placement into a BHU as there was a concern for Patient #1’s safety. Staff V recommended placement into a BHU. - On 04/21/23 at 5:54 AM, physician documentation showed Patient #1 continued to meet criteria for placement on the BHU, but there continued to be no available beds. - On 04/21/23 at 6:21 AM, physician documentation showed a mental health assessment was completed and the patient met criteria for placement in the BHU, due to repeated agitation and the host mother felt the patient was unsafe to return home. However, there were no available beds, so Patient #1 remained in the ED in a hallway bed in the psychiatric pod waiting for placement on the BHU. - On 04/21/23 at 12:58 PM, Staff EE, Psychiatrist (physician who specializes in mental health disorders), documented a clinical note following a conversation with Staff Y, which showed Patient #1 did not appear to be a candidate for inpatient psychiatric treatment. He adjusted her medications and recommended outpatient treatment. - On 04/22/23 at 6:06 PM, physician documentation showed a urine test was completed, Patient #1 had a urinary tract infection and antibiotics were started. - On 04/23/23 at 7:54 AM, nursing documentation showed Patient #1 walked to the pod door with a blanket wrapped around her and over her head. Staff asked the patient if she needed to use the restroom or assistance, Patient #1 turned and walked toward the staff and stated she needed food because she was six months pregnant and she needed to leave. The patient got into the staff member’s personal space and refused to back away. Patient #1 grabbed toward the staff member’s groin area and continued to advance, yelling “stop raping her”, then struck the staff member on the arms and upper body. Patient #1 was directed back to her bed and security was called for assistance. There was no sedation or physical restraints used to prevent the patient from harming others. - On 04/23/23 at 7:57 AM, physician documentation showed a repeat mental health evaluation was completed and discharge was recommended at that time. Staff were reaching out to the guardian to inform her of the discharge from the ED. - On 04/23/23 at 1:41 PM, nursing documentation showed Patient #1 hit, spit and smeared it on the window, and attempted to break a badge reader. - On 04/23/23 at 2:26 PM, nursing documentation showed Patient #1 ripped skin off her right second finger and smeared blood on the window and door. There was no sedation or physical restraints used to prevent the patient from harming herself. - On 04/23/23 at 3:11 PM, nursing documentation showed Patient #1 pressed the lockdown and emergency buttons, paced the hall, yelled and banged on the windows and tried to open doors. She stood on her cot and attempted to pull down the exit sign and attempted to pull equipment off the walls. Patient #1 was redirected back to her bed multiple times and security and off duty police were called. The guardian was called to pick up the patient. - On 04/23/23 at 3:24 PM, case management (CM) notes showed nursing staff informed her that the police would be called on Patient #1’s guardian if they did not pick up the patient in the next one to two hours. They would have the patient arrested due to aggression against ED staff and destroying property. The guardian was called and she refused to give consent for the patient to be discharged due to no one being at home; but reported if the ED staff wanted to call the police, she understood. The host mother spoke with the guardian and reported that she did not feel safe having Patient #1 in her home due to her behavior in the ED. - On 04/23/23 at 3:28 PM, physician documentation showed Patient #1 began having anxiety about going back to her group home and was given medications for anxiety. - Patient #1 was discharged from the ED on 04/23/23 at 9:34 PM. Review of Patient #1’s medical record from Hospital B, dated 04/24/23, showed Patient #1 presented to the ED, via police with agitation and combativeness. Patient #1 ran from her home and police found her running on a busy interstate ramp, she was restrained and taken to Hospital B. She was placed in four-point restraints at Hospital B and required sedative medications. She had a mental health assessment and on 04/25/23 was admitted to the BHU at Hospital C for being a danger to herself and others. Review of Patient #1’s medical record from Hospital C, dated 04/25/23, showed Patient #1 was admitted 04/25/23 through 05/04/23 as a voluntary admission for work-up and management of erratic behavior. Review of an email dated 07/10/24 at 1:31 PM titled, “Notes on [Patient #1],” showed the following: - On 04/18/23 at 7:24 PM, a Behavioral Health Assessment (BHA) was completed and discharge was recommended. The host mother did not feel comfortable returning home without her husband present and Staff Y, ED Physician, agreed to keep Patient #1 overnight. - On 04/19/23 at 12:38 AM, Staff Y called and reported to the crisis stabilization unit that Patient #1 was very aggressive and required IM sedation. Staff Y reported that Patient #1’s aggression and agitation was not normally at this level when the patient presented to the ED. The patient was making gestures to staff swiping her neck across her throat. - On 04/19/23 at 8:06 PM, it was noted that the ED attempted to discharge Patient #1. Patient #1 refused to get in the car and ran to a parking garage. A call was made to the police, she was apprehended and brought back to the ED. Patient #1 was sedated with Versed (medication used to help patients feel relaxed or sleep) 5 mg and Haldol (medication used to treat mental disorders by decreasing excitement of the brain) 5mg due to aggression. Staff Y wanted the patient admitted but did not want another BHA completed. - On 04/20/23 at 06:33 AM, Staff CC, ED Physician, called and stated that Patient #1 needed a BHA. Staff CC was informed that Staff Y had not wanted a new BHA done because the plan was to have her admitted if she returned. Staff CC stated he wanted the patient assessed because it would be impossible to place the patient with a BHA that stated discharge. - Twelve BHU’s were contacted for placement and a blast email (act of sending a single email message to a large email list simultaneously) was sent requesting placement. - On 4/21/23 at 11:25 AM, Staff EE, Psychiatrist, was not willing to accept Patient #1 to the BHU she had been recently discharged from and stated that there was no psychiatric benefit for her being admitted. Staff Y requested to speak with Staff EE to discuss Patient #1. - On 04/21/23 at 1:43 PM, the crisis stabilization unit called Staff Y and stated that Staff EE documented he would not be accepting Patient #1 back in the BHU. Staff Y stated they were not comfortable discharging the patient. Staff Y requested that the transfer center continue placement efforts. Staff Y stated that if Patient #1 did well with medication and does not continue to have behaviors that required prn medications, they would consider discharge. - On 04/22/23 at 6:13 PM, Staff Z, ED Physician, ordered a psychiatric evaluation for discharge. - On 04/22/23 at 8:10 PM, Patient #1’s case was closed as the psychiatric evaluation recommended discharge. Review of an undated document titled, “Behavioral Health Assessment,” showed on 04/20/23 at 7:29 AM, Staff V, SW, documented that self-harm, aggressive behavior, and eloping from the ED was the behavior resulting in a 911 call for Patient #1. Documentation showed Staff CC, ED Physician, and Staff Y, ED Physician, were both requesting admission of Patient #1 due to a concern for patient safety as a result of her aggressive behavior, self-harm and her recent elopement from the ED. She denied suicidal ideation (SI, thoughts of causing one’s own death)/ homicidal ideation (HI, thoughts or attempts to cause another’s death) thoughts. Staff V did discuss the assessment with the guardian and documented the guardian reported they did not feel safe for Patient #1 to return to her home. The guardian filled out an affidavit attesting to her concerns of patient safety. Psychiatric admission would be pursued per request from guardian, Staff CC and Staff Y. The recommendation of patient disposition was to admit the patient and was discussed with Staff CC. Review of the document titled, “Affidavit in support of Application for detention, evaluation and treatment rehabilitation,” dated 04/24/23 showed Patient #1 was trying to walk out of the door at home and became aggressive. She took off and headed towards the highway. Patient #1 had been discharged from Research Medical Center (RMC). She had put holes in the walls and was fighting with staff and was told she could not return to RMC. The police had been called and during the attempt to apprehend Patient #1, she spit on the officers and attempted to break the windows on the police car. Review of the document titled, “Affidavit in support of Application for detention, evaluation and treatment rehabilitation, dated 04/24/23 showed the police had been dispatched and found Patient #1 on a busy intersection. She was handcuffed and put in the patrol car. Patient #1 attempted to kick out the rear window, yelled racial slurs and spit. She was transported to Hospital B per request of guardian. During an interview on 07/09/24 at 4:00 PM, Staff CC, ED Physician, stated that Patient #1 was attention seeking and her behavior was congruent behavior with previous admissions. She remained stable at her baseline behavior and was cleared by a psychiatrist for discharge. Staff CC stated that he felt that discharge was appropriate. During an interview on 07/10/24 at 11:00 AM, Staff V, SW, stated that she worked as a counselor doing crisis stabilization. She did mental health assessments for patients who presented to the ED for a mental health evaluation. She did perform a mental health assessment on 04/20/23 for Patient #1. She recommended admission to a BHU. Staff V stated that Patient #1 was a danger to self and to others based on her behaviors. The intake unit would then try to find placement for patients requiring in-patient care. If there was a delay in finding inpatient care, the ED would typically order a psychiatrist to assess the patient. The psychiatrist could then usually clear the patient for discharge. Staff V stated that Patient #1 “was definitely a threat to self and others and needed to be placed in an inpatient BHU.” During an interview on 07/16/24 at 11:21 AM, Staff W, RN, stated that he was involved in an incident with Patient #1 on 04/22/23 at 6:55 AM when she put a blanket over her head and told Staff W that she was six months pregnant and needed some food so she could leave. She was asked to back away from Staff W’s personal space and she refused. Patient #1 got aggressive, swinging hard at Staff W and attempting to make contact with the groin area. A panic button was pushed and Patient #1 was held until security arrived. Staff W stated that when a behavioral health patient had an extended stay in the ED, they should show a major improvement in order to be discharged. Staff W stated that at times, if they were unable to find placement for a BHU, they would do a psychiatry telehealth visit to get an order for discharge. “She was clearly mentally disturbed and not mentally stable.” During a phone interview on 07/17/24 at 8:10 AM, Staff GG, RN, stated that it was typical if there was a patient awaiting placement into an inpatient BHU and they were having trouble finding placement, the physicians made a referral for psychiatry telehealth for an assessment to see if they could discharge the patient. The telehealth psychiatrist reviewed the history and talked to the patient. If a patient answers “no” to SI/HI questions, they would often make a medication adjustment and discharge the patient for outpatient care. During a phone interview on 07/17/24 at 3:19 PM, Staff FF, Psychiatrist, stated that he does psychiatric telehealth assessments. He stated that Staff Z, ED Physician, ordered a mental health assessment for Patient #1. Staff FF stated that Patient #1 had been in the ED several days and was awaiting placement for BHU inpatient care, but they were having problems finding placement. The ED would typically order a psychiatric mental health assessment to see if they could get an order for a therapeutic discharge if they were unable to find placement. He stated that he did an assessment on Patient #1 and that she denied having any SI/HI thoughts and was having behavioral issues. He increased her medications and ordered a therapeutic discharge. He stated that he did not speak with the ED physician but did review her medical record prior to his assessment. During a phone interview on 07/18/24 at 2:50 PM, Staff EE, Psychiatrist, stated that he received a phone call from Staff Z, ED Physician asking a favor. He stated that Patient #1 had been in the ED and that Staff Z would like him to write a note and discharge the patient. Staff EE stated that he never saw the patient in the ED and typically does not see patients in the ED. He did write the note based on her recent inpatient visit with him on 04/17/23. She had been discharged from the BHU of an acute hospital and he felt that it wasn’t benefiting her. Staff EE stated that her behaviors were getting worse but that it could have been because of the ED setting, but he did not see or talk to the patient at that time. For an acute mental health crisis, the patient needed inpatient psychiatric treatment to protect her from harming herself or others. When the patient’s behavior in the ED escalated to the point that she was harming herself and others, physical restraints and/or sedation was needed and not provided. Although requested, interviews were not provided for Staff X, CM; Staff Y, ED Physician; Staff Z, ED Physician; Staff AA, RN; Staff BB, RN; Staff JJ, RN; and Staff LL, Patient Care Technician (PCT).”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 41865 Based on interview, record review and policy review the hospital failed to: - Timely and urgently educate staff following a patient elopement (when a patient makes an intentional, unauthorized departure from a medical facility) and an attempted suicide (to cause one’s own death) for two discharged patients (#45 and #46) of two medical records reviewed. (A-144) - Follow their internal policy for prompt reporting of an attempted suicide for one discharged patient (#45) of two medical records reviewed. (A-144) - Follow observation orders for one discharged patient (#47) of two discharged medical records reviewed. (A-144) - Obtain a consent for treatment for eight patients (#11, #12, #13, #15, #29, #30, #31 and #32) of eight patients reviewed. (A-117) - Provide the Important Message from Medicare (IMM, information about a patient’s right to appeal discharge) for five patients (#12, #13, #14, #30 and #31) of 16 patients reviewed. (A-117) These failed practices resulted in the noncompliance with 42 CFR 482.13 Condition of Participation: Patient’s Rights. Please refer to A-0117 and A-0144”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 47504 Based on interview and record review, the hospital failed to ensure that patients on the inpatient Rehabilitation Unit (Rehab, an inpatient area staffed and medically supervised in the care and treatment of the physical restorative needs of patients) had a consent for treatment for eight current patients (#11, #12, #13, #15, #29, #30, #31 and #32) out of eight patients reviewed and failed to ensure that patients received the Important Message from Medicare (IMM, information about a patient’s right to appeal discharge) for five current patients (#12, #13, #14, #30, and #31) of 16 patients reviewed. Findings Included: Review of hospital document titled, “Procedure for Registration Forms and Signatures,” dated 12/31/18, showed: - The Patient Access Department obtains signatures on all registration forms, from the patient or legally authorized individual, prior to or during the registration process. - The Condition of Admission and Consent is obtained for all types of registrations including inpatient. - The consent form is signed upon registration and in conjunction with the physician’s order that encompasses the entire episode of care. - A consent is indexed to each account within the episode of care. - If a patient was a Medicare or Managed Medicare inpatient, it is required that the Important Message from Medicare be issued within two days of the inpatient admission. Review of Patient #11’s medical record, admitted 04/25/24, showed no completed Condition of Admission and Consent. Review of Patient #12’s medical record, admitted 04/29/24, showed no completed Condition of Admission and Consent and no IMM notification. Review of Patient #13’s medical record, admitted 04/26/24, showed no completed Condition of Admission and Consent and no IMM notification. Review of Patient #14’s medical record, admitted 05/01/24, showed no completed Condition of Admission and Consent and no IMM notification. Review of Patient #15’s medical record, admitted 04/11/24, showed no completed Condition of Admission and Consent. Review of Patient #29’s medical record, admitted 04/18/24, showed no completed Condition of Admission and Consent. Review of Patient #30’s medical record, admitted 05/02/24, showed no completed Condition of Admission and Consent and no IMM notification. Review of Patient #31’s medical record, admitted 04/26/24, showed no completed Condition of Admission and Consent and no IMM notification. Review of Patient #32’s medical record, admitted 04/30/24, showed no completed Condition of Admission and Consent. During an interview on 05/06/24 at 3:00 PM, Staff S, Inpatient Rehab Manager, stated that patients were discharged from the hospital and then admitted for inpatient rehabilitation. The nurses sent a form “Notice of Arrival” to admissions to notify them that the patient had arrived on the rehab unit. A copy of the consents arrived from the previous admission and an updated sticker was put on that copy of the consent. Registration did not come to the rehab unit to get new forms signed, they used the old forms, including the IMM. During an interview on 05/08/24 at 9:15 AM, Staff TT, Patient Access Director, stated that patients admitted to the rehabilitation unit should have new consents. Original admission paperwork could not be used. The Patient Access Department should have obtained new signatures and this had not been done. Staff re-used signed admission forms and placed a new sticker on it. All patients should receive new documents including the IMM. During an interview on 05/07/2024 at 10:30 AM, Staff U, Patient Access Assistant Director, stated that they didn’t obtain new consents for the rehab admission or give patients a new IMM. “We just use the same paperwork that was obtained from the previous admission.” During an interview on 05/07/24 at 2:15 PM, Staff LL, Chief Nursing Officer (CNO), stated that it was in the policy that all patients that had been discharged and then admitted to the inpatient rehabilitation unit were required to have all new consents and paperwork completed for the current admission and that previous admission paperwork and consents could not be used. A new IMM must be given to patients.”

“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: 47504 Based on interview, record review and policy review the hospital failed to: - Timely and urgently educate staff following a patient elopement (when a patient makes an intentional, unauthorized departure from a medical facility) and an attempted suicide (to cause one’s own death) for two discharged patients (#45 and #46) of two medical records reviewed; - Follow their internal policy for prompt reporting of an attempted suicide for one discharged patient (#45) of two medical records reviewed; and - Follow observation orders for one discharged patient (#47) of two discharged medical records reviewed. Findings included: 1.Review of the hospital’s undated document titled “Root Cause Analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to find the root cause) and Action Plan Framework RF #7597 - Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) Elopement,” showed: - Patient #46 was a 21-year-old who arrived on 04/20/24 at 1:04 AM, via EMS, after ingesting 20 fentanyl (a medication used to treat severe pain and was a high-risk drug for theft and personal use) laced pills. - At 1:07 AM, he was deemed a high suicide risk, placed on one to one (1:1, continuous visual contact with close physical proximity) observation, and required an inpatient psychiatric (relating to mental illness) admission. - At 12:30 PM, he attempted to elope but was stopped by security staff. - At 5:07 PM, he was strapped to a gurney by two EMS crew with four buckles and was taken out to the ambulance bay. - At 5:08 PM, Patient #46 released the buckles, apologized to EMS crew, jumped off of the gurney, and fled the area. - At 5:09 PM, EMS crew returned to the Emergency Department (ED) and notified staff that Patient #46 had eloped. - A briefing was completed on 04/22/24 related to the elopement of Patient #46. - A signed attestation was to be completed by all staff in the ED by 05/10/24. - A meeting was held on 04/23/24 to develop a new policy for the discharge of high elopement risk patients and was to be completed by 05/10/24. Review of the hospital’s document titled “Transfer Process for Behavioral Health Patients,” dated 05/2024, showed it would not be in effect until 05/10/2024. A huddle was to take place before the discharge of a high elopement risk patient with the Clinical Nurse Coordinator (CNC), staff, security supervisor, providers, and EMS crew. Review of the hospital’s documents titled “Registered Nurse (RN) Group” and “Tech/Medic/Safety Group,” dated 05/01/24, and “Research Medical Center Emergency Services Huddle,” dated 04/26/24, showed a huddle must occur prior to the transfer of a high elopement risk patient with the CNC, staff, security supervisor, providers, and EMS crew. High elopement risk patients were to be escorted out with security and a safety coordinator. Review of Patient #46’s medical record showed: - He was a 21-year-old who arrived at the hospital on 04/20/24, at 1:04 AM, after intentionally ingesting 20 fentanyl pills in an attempt to harm himself. - At 5:41 AM, he was evaluated, deemed involuntary (a legal process through which a person is hospitalized and treated for mental health disorders without their consent) and required an inpatient psychiatric admission. - At 12:30 PM, he attempted to elope but was stopped by security and placed in a room instead of a hallway stretcher. - At 5:07 PM, EMS placed him on a stretcher to prepare for transport to an inpatient psychiatric facility. - At 5:09 PM, EMS returned and notified security that the patient had eloped. During interviews on 05/06/24 at 1:45 PM, and 05/07/24 at 1:32 PM, Staff C, ED Director, stated that following the elopement a new policy required a huddle with the nurse, charge nurse, patient safety coordinator, and security for any patient deemed an elopement risk. There was no assessment criteria to deem a patient as an elopement risk, it was based on nursing judgement. Education after the elopement event started immediately; however, it was not documented. The first documented occurrence for the education was in a pre-shift huddle on 04/26/24. He acknowledged this showed a delay in the education of staff following the elopement of Patient #46. Staff did not sign an attestation. During an interview on 05/06/24 at 11:45 AM, Staff LL, Chief Nursing Officer (CNO), stated that typically more documentation related to education following an incident was completed and she was unsure why that was not done following the elopement of Patient #46. She agreed house-wide education should have been done because a similar incident could occur outside of the ED. During an interview on 05/08/24 at 11:45 AM, Staff YY, Quality Vice President, stated that house-wide education for all staff would occur related to restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) removal and the safe transfer of behavioral health patients. A roster with staff signatures would be obtained at the time of the education. She acknowledged that no documentation of the education provided to staff was obtained, as stated in the plan of correction provided to the State of Missouri in the self-report. During an interview on 05/06/24 at 3:05 PM, Staff PP, Patient Safety Manager, stated that she knew more documentation of the education provided to staff after the elopement of Patient #46 was required and that education was not completed urgently. During interviews on 05/06/24 at 2:45 PM, and 05/07/24 at 2:45 PM, Staff H, Nurse Manager, stated that education following the elopement event started immediately via an electronic messaging system and in-person huddles. She acknowledged the first written documentation regarding the education was dated 04/26/24 and that no other written records related to education were documented before this date. She stated that did show a delay in educating staff regarding the elopement of Patient #46. Review of the hospital’s undated document titled “RCA and Action Plan Framework, IR #7651 - Suicide Attempt,” showed: - Patient #45 arrived 04/23/24, at 6:57 PM, from a long-term care facility with a chief complaint of attacking staff at the facility. - At 7:10 PM, violent restraints were applied due to violent, self-destructive behavior and aggression towards staff. - At 7:53 PM, the restraints were removed from the patient and placed at the foot of the bed; - On 04/24/24 at 1:10 AM, a monitor tech observed the patient grabbing the restraints and wrapping them around her neck. The monitor tech alerted the medic. The medic and monitor tech removed the restraint from around her neck and patient was observed as slightly cyanotic (blue to purplish discoloration of the skin due to low oxygen presence in the blood.) - At 1:11 AM, a call was placed over the radio for staff assist. - At 1:25 AM, violent restraints were applied due to violent, self-destructive behavior and aggression towards staff. - At 1:25 AM, the physician noted suicide attempt by strangulation using restraint strap. She was cyanotic with ligature (anything which could be used for the purpose of hanging or strangulation) marks to her neck. Overall suicide risk was high. - At 4:06 AM, the restraints were removed from patient and removed from the room. - The investigation showed that synthetic restraints were left on the bed. - Ligature risks, that were not essential for patient care, were not removed from the room after use of the intervention was discontinued. - Safety huddle messages began on 04/26/24. - Education was to be completed by 04/30/24; which included rounding by the charge nurse during the shift and a check of patients in restraints or recently removed restraints to ensure proper room set up for a suicide safe (a room that has been cleared of any objects a patient might use to harm themselves or others) environment. Review of hospital document titled, “Serious Safety Event (SSE) Identification, Notification and Management,” dated 04/01/24, showed: - An event may be considered a SSE if it is a preventable adverse patient event, is indicative of a serious gap in safety systems, policies, or processes and directly increases risk of future occurrence of an SSE. - When a SSE has occurred, the supervisor would immediately notify patient safety/risk management. - Patient Safety/Risk Management would notify executive leaders and other key individuals, as appropriate and initiate an internal response within 60 minutes of discovery of the event. Review of the hospital’s undated document titled, “Pre-shift Huddle Agenda,” showed when working in Pod 3 or with Suicidal Ideation (SI) patients, staff are not to pre-load the bed with restraints. Restraints should only remain at the bedside when actively in use on the patient. Restraints are single use and straps may be cut to decrease excess strap length. Review of the hospital’s document titled, “Emergency Services Huddle,” dated 05/03/24 showed restraints were not to be left in the room and must be removed once the patient is taken out of the restraint. Restraints were for single patient use, and excess slack should be cut off to prevent any ligature risks. Review of hospital’s document titled, “Attestation Program Tracking Form, maintaining a psych safe environment in the Emergency Department,” showed a list of handwritten names with no signatures, dated 04/29/24 through 05/07/24. Review of Patient #45’s medical record showed: - She was a 48-year-old female who was transferred to the ED on 04/23/24 from a long-term facility for aggressive behavior towards staff. - She had been brought in with physical restraints applied and when staff attempted to remove them, she became combative, and restraints were re-applied on 04/23/24 at 7:10 PM. - Restraints were removed and a face-to-face evaluation by the physician was done on 04/23/24 at 8:05 PM. - On 04/24/24 at 1:10 AM, she wrapped a restraint around her neck in a suicidal gesture. - Ligature marks were noted on the neck and the patient became combative when staff attempted to remove the restraint from around her neck, the restraints were reapplied and the patient was sedated. - Restraints were removed at 4:10 AM and she was placed on high risk for suicide. During an interview on 05/08/24 at 9:00 AM, Staff VV, Monitor Tech, stated that she noticed on the video monitor that Patient #45 used the restraints that were left at the bedside and attempted to strangle herself. She stated that she immediately called for help and went to Patient #45’s room as staff attempted to remove the restraints from around her neck. During an interview on 05/07/24 at 2:30 PM, Staff MM, Medic, stated that she was called to Patient #45’s room for an attempted suicide after the patient attempted to strangle herself with the restraints that were left at the bedside. She stated that the patient had been previously restrained, and staff left the restraints at the bedside. She stated that the restraints were long and definitely a ligature risk. During an interview on 05/08/24 at 8:50 AM, Staff UU, Charge RN, stated he was called to Pod 3 for additional staff support on 04/24/24 at 1:00 AM. Patient #45 had used restraints left at the bedside in an attempt to strangle herself. She had ligature marks on her neck. He immediately removed everything that was a safety risk from her room. He did not notify the house supervisor of the event. He notified Administration at the Charge Nurse Meeting at 7:30 AM. He participated in safety huddles during his next scheduled shift. During an interview on 05/08/24 at 10:30 AM, Staff YY, Quality Vice President, stated that the charge nurse did not report the event to the house supervisor. She stated that once the house supervisor was notified, they would notify the administrator on call. Administration was not aware of the event until 6:30 AM, five hours following the event. She stated that it was policy to immediately notify the house supervisor. During an interview on 05/07/24 at 1:45 PM, Staff C, ED Director, stated that he was notified of the event on 04/24/24 at 6:30 AM. He reviewed the documentation of education that was submitted associated with the self-report to the State of Missouri and stated that “this was not appropriate education for the suicide attempt.” During an interview on 05/07/24 at 2:15 PM, Staff LL, CNO, stated that the education submitted for the self-report “was not appropriate” and that she expected additional education to have been done. She stated that her expectation of the charge nurse was to immediately notify the house supervisor of any events of self-harm or suicide attempt. The house supervisor would then notify the administrator on-call. During an interview on 05/07/24 at 2:45 PM, Staff H, ED Manager, stated that the education that was submitted for the self-report was “not appropriate” and stated that they started education immediately in huddles but did not get attestations of the education. He stated he was not aware of the event until the Charge Nurse Meeting the morning of 04/24/24 at 7:00 AM. During an interview on 05/07/24 at 3:15 PM, Staff PP, Patient Safety Manager, stated that she could not make the units submit education. She submitted the education that was given to her for the self-report. She stated that the education she submitted for the self-report was not adequate. Review of the hospital’s policy titled, “Behavioral Health: Levels of Observation,” dated 10/2022, showed: - One to one observation was ordered on a patient who is at immediate risk of harm to self and/or others (unable to make an alternative plan for safety and actively seeking ways to harm self and/or others). - Line of sight (LOS, continuous visual contact with the patient) patient was to remain within visual contact of a staff member. Staff were to always monitor the patient to ensure safety, while maintaining the patient’s privacy as much as possible. - Patients who no longer meet criteria for elevated observation levels must have a physician order to discontinue LOS or 1:1 observation. - Fifteen-minute checks, on admission, safety checks will be conducted in a random manner on all patients to maintain a secure and safe environment a minimum of every 15-minutes unless more intensive monitoring is ordered. - The RN may place a patient on 1:1 observation, but only a physician may discontinue this level. - Nursing staff will document in the progress note that 1:1 status is being maintained, criteria for continued 1:1 observation, or progress made in transitioning to a lesser level of observation. - Patient location and behavior shall be documented every 15 minutes in addition to documentation in the progress note. - The physician will document the assessment and criteria the patient meets for 1:1 status in the physician’s progress notes daily. Review of Patient #47’s medical record showed: - He was a 30-year-old male with a history of schizophrenia (serious mental disorder that affects a person’s ability to think, feel, and behave clearly) who presented to the ED on 10/12/23 with auditory hallucinations (hearing things that are not heard by others, imaginary) and homicidal ideations (HI, thoughts or attempts to cause another’s death). Prior to arrival at the ED, he told his guardian (the person appointed by a judge to manage the property and rights of another person who is considered incapable of doing so themselves) he needed to go to the hospital, he was hearing voices. Without warning, he attacked his guardian with a kitchen knife. After the ED provider’s evaluation, he assaulted a police officer and chased a nurse practitioner (NP, a nurse who has advanced clinical education and training). - He was admitted to the Behavioral Health Unit (BHU), placed on every 15-minute checks and no roommate. - On 10/13/23, he attacked a peer by hitting him multiple times in the face with a closed fist. His plan of care showed increased chance of harming self or others. - On 10/19/23, he attempted to swing at a peer. - On 10/24/23, he punched a peer during shift change. - On 11/01/23, he entered the dayroom, immediately approached the back of a peer and attempted to choke/strangle them. - On 11/07/23, he punched a peer in the back of the head four or five times with closed fists. - On 11/08/23, his mental status exam was positive for HI. An order was written to restrict him to the unit. - On 11/11/23, he was reported to have been aggressive with a female staff member without warning. - On 11/23/23, a peer came to the nurses’ station window and stated that Patient #47 punched him in the face and ran back to his room. - On 11/30/23, he attempted to choke a peer. - On 12/01/23, his plan of care showed he failed to follow measures to prevent injury, danger or loss. - On 12/06/23, he had a physical altercation with a peer. - On 12/13/23, he randomly choked a peer. - On 12/14/23, he was on the back of a staff member with his arms around their neck choking them. He later came out of his room and lunged at staff trying to punch them. - On 12/15/23, he hit a peer in the back of the head. When he was approached by a RN, he attacked the RN. He then headbutted a staff member. - On 12/26/23, he was involved in altercation with Patient #48. He had a small laceration above the left side of his lip. Later he walked to a peer that was not looking at him and struck him with a closed fist in the face. The observation orders were changed to LOS, while out of his room. - On 12/26/23, 12/27/23, 12/28/23, 12/30/23, 01/07/24, 01/08/24, 02/09/24 and 03/02/24, he refused to discuss SI and/or HI. - On 12/27/23, 12/28/23 and 12/30/23 his observation did not follow the LOS order, he was on 1:1 observation. - On 12/29/23, his observation did not follow the LOS order, he was on every 15-minute checks. - On 12/30/23, the provider progress note (PPN) showed precautions every 15-minutes checks. - On 12/31/23 through 01/17/24, his observation did not follow the LOS order, he was on 1:1 observation. - On 01/01/24 and 01/03/24, the PPN showed precautions every 15-minutes. - On 01/04/24, he charged at a Mental Health Technician (MHT). The PPN showed precautions every 15-minute checks. - On 01/07/24, the PPN showed precautions 1:1. - On 01/16/24, the PPN showed precautions LOS during the day and 1:1 at night. - On 01/22/24, an order was placed to restrict him to the unit. - On 01/23/24, the PPN showed precautions 1:1. - On 01/24/24 through 01/26/24, his observation did not follow the LOS order, he was on every 15-minute checks. - On 01/29/24, he punched another male patient. - On 02/01/24, he had a witnessed fall. He jumped up and charged at a MHT and the intervening RN. Twenty minutes later he jumped out of bed and charged at the MHT. Later he attempted to swing at and bite the medical provider. When released from a therapeutic hold (treatment technique in which a violent patient is physically contained by people), he attempted to charge at the staff. After he was released from seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving), he charged through the seclusion room door and attempted to attack the MHT. Later the patient ran out of his room, put his hands around a staff member’s neck and started choking him. His observation did not follow the LOS order, he was on every 15-minute checks. - On 02/05/24, the PPN showed precautions LOS and 1:1 when out of room. His observation did not follow the LOS order, he was on every 15-minute checks. - On 02/06/24, he ran out of his room, put his hands around a staff member’s neck and started choking him. His observation order was changed to 1:1. - On 02/09/24, he grabbed the 1:1 observer’s neck. When other staff arrived, he continued to strike, kick and lunge at them. Later staff attempted to offer dinner, the patient threw the food and lunged at the RN. - On 02/10/24, he randomly, completely unprovoked, lunged at the 1:1 staff member. - On 02/16/24, he advanced towards the 1:1 observer and was de-escalated. While debriefing he again lunged at the MHT. - On 02/18/24, he banged his head against the bathroom door. The RN attempted to assess him, he lunged at the RN, put his hands around the RN’s neck and began to squeeze. - On 02/19/24, he sexually assaulted the 1:1 MHT by grabbing her breast and butt. - On 02/22/24, he got into a physical altercation with a peer. Later he charged at and attempted to hit his 1:1 observer. - On 02/26/24, he charged at a male peer. - On 02/27/24, he charged at a male peer. When talking to the RN he grabbed the RN and had his arm around her neck and took her down to her knees and onto the ground. Later he charged at a female RN in the hallway. An observation order for 1:1 was written with room door closed while the patient was in the room. Continue every 15-minute checks. Staff were not to enter his room alone at any time. - On 03/03/24, he charged at and hit a peer in the hallway. - On 03/07/24, he grabbed a nurse walking down the hallway and began to choke him. He later exited his room and attacked a MHT. Later he ran out of his room towards a nurse with his hands up in a double hand choke stance. He contacted the nurse’s neck with both hands. - On 03/11/24, his observation did not follow the 1:1 order, he was on every 15-minute checks. - On 03/22/24, he voluntarily walked to the quiet area and, unprovoked, he hit a male peer three times in the face. - On 03/27/24, he was discharged into police custody. During a telephone interview on 05/08/24 at 10:00 AM, Staff XX, Physician, stated that a provider order was required to change a patient’s level of observation. Patient #47 was mostly observed by LOS or 1:1. With increased violence he was placed on 1:1 observation. His activity was restricted because of his behavior. Any modification in his activity required a provider order. Review of Patient #47’s medical record showed inconsistent documentation. During an interview on 05/27/24 at 2:10 PM and 05/28/24 at 9:00 AM, Staff LL, CNO, stated that a physician order was required for LOS and 1:1 observation. Every 15-minute rounding was a standard in the BHU. The hospital did not have a policy for the management of patient to peer and/or staff abuse. During an interview on 05/07/24 at 3:07 PM, Staff QQ, Assistant CNO, stated that a provider order was required for 1:1 observation. Extra staff members were assigned to 1:1 observation of Patient #47 without a provider order for 1:1 observation. During an interview on 05/07/24 at 3:25 PM, Staff RR, Nurse Manager, stated that a provider order was required for 1:1 observation. During a telephone interview on 05/07/24 at 5:30 PM, Staff SS, Licensed Practical Nurse (LPN), stated that observation orders change per the provider orders. Staff followed the current observation order; observation frequency was shared in report. Patient #47 was “completely unpredictable.” 48359”