Nevada Regional Medical Center

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 50321 Based on interview, record review and policy review, the hospital failed to: - Ensure restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head), physical holds (to physically hold someone to purposefully restrict the movements of their arms, legs, head, etc.) and seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) were ordered by a licensed independent practitioner (LIP) responsible for the care of one current patient (#19) and four discharged patients (#14, #22, #29 and #30) of 10 restrained, physically held or secluded patient records reviewed; (A-0168) - Ensure restraint, physical hold and seclusion orders included the limb location, timeframe and clinical justification for one current patient (#19) and six discharged patients (#14, #21, #22, #24, #25 and #28) of 10 restrained, physically held or secluded patient records reviewed; (A-0168) - Ensure that the practitioner responsible for the care of the patient authenticated, dated and signed verbal or telephone restraint or physical hold orders within 24 hours for one current patient (#19) and one discharged patient (#14) of three restrained, physically held or secluded patient records reviewed with verbal or telephone orders; (A-0168) - Ensure the discontinuation or restraints, physical hold and seclusion was recorded for one current Patient (#19) and three discharged Patients (#14, #24, #25) of 10 restrained, physically held or secluded patient records reviewed; (A-0175) - Ensure appropriate ongoing monitoring and nursing documentation during the use of non-violent restraints for two discharged patients (#24 and #25) of three non-violent restrained patient records reviewed; and (A-0175) - Ensure a qualified staff member completed a face-to-face (a qualified staff members evaluation of a patient in violent restraints [medical cuffs applied to both arms and both legs to prevent someone form causing harm to themselves or others]) evaluation and contacted a physician with the results of the evaluation within one hour after violent restraints, physical holds or seclusion were initiated for one current patient (#19) and six discharged patients (#14, #21, #22, #28, #29 and #30) of seven violent restrained, physically held or secluded patient records reviewed. (A-0178) This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation (CoP): Patient’s Rights. Please refer to A-0168, A-0175 and A-0178”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 50321 Based on interview, record review and policy review, the hospital failed to: - Ensure restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head), physical holds (to physically hold someone to purposefully restrict the movements of their arms, legs, head, etc.) and seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) were ordered by a licensed independent practitioner (LIP) responsible for the care of one current patient (#19) and four discharged patients (#14, #22, #29 and #30) of 10 restrained, physically held or secluded patient records reviewed; - Ensure restraint, physical hold and seclusion orders included the limb location, timeframe and clinical justification for one current patient (#19) and six discharged patients (#14, #21, #22, #24, #25 and #28) of 10 restrained, physically held or secluded patient records reviewed; and - Ensure that the practitioner responsible for the care of the patient authenticated, dated, and signed verbal or phone restraint or physical hold orders within 24 hours for one current patient (#19) and one discharged patient (#14) of three restrained, physically held or secluded patient records reviewed with verbal or phone orders. Findings included: Review of the hospital’s policy titled, “Restraints and Seclusion,” dated 05/26/23, showed: - A physical restraint was any manual method, physical or mechanical device, material or equipment that immobilized or reduced the ability of a patient to move his or her arms, legs, body or head freely. - Seclusion was the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving. - The use of restraint or seclusion was limited to those situations for which there was adequate and appropriate clinical justification. - The policy required that a physician or other LIP responsible for the care of the patient order a restraint or seclusion prior to the application of a restraint or seclusion. In some situations, however, the need for a restraint or seclusion intervention might occur so quickly that an order could not be obtained prior to application. In those emergency application situations, the order must be obtained either during the emergency application of the restraint or seclusion, or immediately (within a few minutes) afterwards. - A protocol could not serve as a substitute for obtaining a physician or LIP order prior to the initiation of each episode of restraint or seclusion. If protocols were used that included the use of restraint or seclusion, a specific physician or LIP order was still required for each episode of restraint or seclusion use. - Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardized the immediate physical safety of the patient, a staff member or others may only be obtained and renewed for four hours for up to a total or 24 hours for adults aged 18 or older. - At the end of the time frame, if the continued use of restraint or seclusion to manage violent or self-destructive behavior was deemed necessary based on an individualized patient assessment, another order was required. - The type of restraint used should be consistent with the type of restraint ordered. - Each episode of restraint or seclusion should contain the following documentation in the patient’s medical record: a description of the patient’s behavior and interventions used; the patient’s response to the intervention used, including the rationale for continued use of the intervention; individual patient assessments and reassessments; the patient’s behavior and staff concern in regard to safety risks to the patient, staff and others that necessitated the use of restraint or seclusion and orders for restraint and seclusion. - Physician education and training on the use of restraints or seclusion included ordering requirements and requirements and timeframes for patient assessments. Review of the hospital’s policy titled, “Medical Staff Rules and Regulations,” dated 2022, showed: - Telephone or verbal orders may be taken by a practitioner, Registered Nurse (RN) or Licensed Practical Nurse (LPN). Telephone orders would only be accepted from the responsible practitioner or their designee when it was not practical for the order to be given in writing. - Only those individuals authorized by the State of Missouri to function as LIPs were authorized to write orders. - Any house staff members, who were supervised by medical staff members in carrying out their patient care responsibilities, would have orders countersigned within 24 hours. - Medical record entries that required countersignatures included any house staff, Physician Assistants (PA, a type of mid-level health care that can serve as a principal healthcare provider), Nurse Practitioners (NP, a nurse with advanced clinical education and training) or allied health professionals employed by the primary physician and any verbal or telephone orders. Review of Patient #14’s medical record showed: - On 12/19/25 at 9:15 AM, he was placed in four-point restraints (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others) for violent behaviors. A verbal order was obtained for “behavioral restraints” for two hours. A limb location or clinical justification for restraints was not included in the order. - At 12:27 PM, he was placed in a physical hold for violent behaviors. A telephone order was obtained for “behavioral restraints” for two minutes. The order was not for a physical hold. The order was not signed by a physician until 12/23/25 at 8:50 AM. - On 12/20/25 at 6:25 AM, he was placed in a physical hold for violent behaviors. A telephone order was obtained for a “physical hold.” A timeframe or clinical justification for the physical hold was not included in the order. The order was still pending to be signed by a physician when the medical record was obtained, on 01/28/26 at 11:17 AM. - On 12/21/25 at 12:24 PM, a nursing note showed he was placed in a physical hold. No order for a physical hold was included in the medical record. Review of Patient #19’s medical record showed: - On 06/04/25 at 12:07 PM, she was placed in a physical hold for violent behaviors. No order for a physical hold was included in the medical record. - At 12:21 PM, she was placed in a physical hold for violent behaviors. No order for a physical hold was included in the medical record. - At 5:45 PM, she was placed in four-point restraints for violent behaviors. No order for restraints was included in the medical record. - On 06/05/25 at 10:11 AM, she was placed in four-point restraints for violent behaviors. - At 10:16 AM, a telephone order was obtained for “four-point restraints for safety.” A timeframe or clinical justification for restraints was not included in the order. The order was not signed by a physician until 07/08/25 at 6:23 PM. - On 06/06/25 at 10:58 AM, she was placed in four-point restraints for violent behaviors. - At 11:29 AM, a telephone order was obtained for “behavioral restraints” for four hours. A limb location or clinical justification for restraints was not included in the order. The order was not signed by a physician until 07/08/25 at 6:32 PM. - On 06/10/25 at 4:29 PM, she was placed in four-point restraints for violent behaviors. - At 5:27 PM, a verbal order was obtained for “behavioral restraints” for four hours. A limb location or clinical justification for restraints was not included in the order. The order was not signed by a physician until 07/08/25 at 6:32 PM. - On 06/16/25 at 7:50 PM, she was placed in a physical hold for violent behaviors. No order for a physical hold was included in the medical record. - On 06/22/25 at 8:24 PM, she was placed in a physical hold for violent behaviors. No order for a physical hold was included in the medical record. - On 06/23/25 at 4:15 PM, she was placed in four-point restraints for violent behaviors. No order for restraints was included in the medical record. - On 06/24/25 at 9:40 AM, she was placed in four-point restraints for violent behaviors. No order for restraints was included in the medical record. - On 06/28/25 at 9:15 PM, she was placed in bilateral (left and right) ankle restraints for non-violent behavior. No order for restraints was included in the medical record. - On 07/06/25 at 8:53 PM, she was placed in four-point restraints for violent behaviors. - At 9:14 PM, a verbal order was obtained for “four-point” restraints. A timeframe or clinical justification for restraints was not included in the order. The order was still pending to be signed by a physician when the medical record was obtained, on 01/28/26 at 3:16 PM. - At 10:10 PM, a verbal order was obtained for “behavioral restraints” for one hour and nine minutes. A limb location or clinical justification for restraints was not included in the order. The order was not signed by a physician until 07/08/25 at 6:32 PM. - On 07/12/25 at 12:25 AM, she was placed in four-point restraints for violent behaviors. No order for restraints was included in the medical record. - On 07/19/25 at 11:34 PM, she was placed in a physical hold for violent behaviors. No order for a physical hold was included in the medical record. - On 07/21/25 at 12:29 AM, she was placed in four-point restraints for violent behaviors. No order for restraints was included in the medical record. - On 07/24/25 at 10:01 PM, she was placed in four-point restraints for violent behaviors. No order for restraints was included in the medical record. - On 07/26/25 at 9:49 PM, she was placed in four-point restraints for violent behaviors. No order for restraints was included in the medical record. - On 08/09/25 at 11:40 PM, she was placed in four-point restraints for violent behaviors. No order for restraints was included in the medical record. - At 10:35 PM, she was placed in four-point restraints for violent behaviors. No order for restraints was included in the medical record. - On 10/25/25 at 8:06 PM, she was placed in a physical hold for violent behaviors. - At 9:57 PM, a verbal order was obtained for a “physical hold.” A timeframe or clinical justification for a physical hold was not included in the order. The order was still pending to be signed by a physician when the medical record was obtained, on 01/28/26 at 3:16 PM. - On 11/08/25 at 9:42 PM, she was placed in four-point restraints for violent behaviors. No order for restraints was included in the medical record. - On an unknown date, she was placed in a physical hold for violent behaviors at 10:29 PM. No order for a physical hold was included in the medical record. Review of Patient #21’s medical record showed: - On 11/17/25 at 11:00 PM, she was placed in four-point restraints for violent behaviors. - At 11:21 PM, an order was obtained for the use of “hard restraints for patient safety” for two hours. - A limb location or clinical justification for restraints was not included in the order. Review of Patient #22’s medical record showed: - On 08/31/25 at 2:55 PM, he was placed in four-point restraints for violent behaviors. - At 1:16 PM, an order was obtained to “document alternative methods to restraints.” The order did not direct staff to apply restraints. - On 09/02/25 at 10:37 AM, an order was obtained for “hard restraints for patient safety” for two hours. A limb location or clinical justification for restraints was not included in the order, and was written over 24 hours after the initiation of restraints. Review of Patient #24’s medical record showed: - On 01/12/26 at 11:39 PM, an order was obtained for “soft restraints for patient safety for no more than 24 hours” located on the bilateral wrists. - A clinical justification for restraints was not included in the order. - On 01/13/26 at 12:07 AM, Certified Nursing Assistant (CNA) documentation showed restraints were applied. Review of Patient #25’s medical record showed: - On 12/19/25 at 4:52 PM, an order was obtained for “soft restraints for patient safety for no more than 24 hours” located on the bilateral hands. A clinical justification for restraints was not included in the order. - At 5:10 PM, she was placed in bilateral wrist restraints. - At 5:13 PM, an order was obtained for “soft restraints for patient safety” for 24 hours. A limb location or clinical justification for restraints was not included in the order. - At 5:16 PM, an order was obtained for “soft restraints for patient safety” for 24 hours located on the bilateral wrists. A clinical justification for restraints was not included in the order. Review of Patient #28’s medical record showed: - On 12/05/25 at 11:18 AM, she was placed in a physical hold. - At 11:39 AM, a phone order was obtained for a “physical hold” to administer medications. - A timeframe for restraints was not included in the order. Review of Patient #29’s medical record showed: - On 11/24/25 at 3:42 PM, he was placed in a physical hold for violent behaviors. - A note showed he was placed in a physical hold from 3:42 PM through 3:45 PM, then placed in seclusion at 3:45 PM. An order for a physical hold or seclusion was not included in the medical record. - On 11/25/25 at 11:59 AM, he was placed in a physical hold for violent behaviors. An order for a physical hold was not included in the medical record. Review of Patient #30’s medical record showed on 11/27/25 at 1:16 PM, she was placed in four-point restraints for violent behaviors. An order for restraints was not included in the medical record. During an interview on 01/28/26 at 4:25 PM and 01/29/26 at 9:35 AM, Staff L, Chief Nursing Officer (CNO), stated that she expected staff to obtain an order for restraints, physical holds and seclusion. Restraint orders should include the location of the restraint on the body, timeframe for the restraint and clinical justification. The restraint ordered should match what was applied to the patient. The hospital had an accreditation survey the week prior to the current onsite survey and the same opportunities were identified. The hospital was working to develop an action plan to address the opportunities. She was unaware that physicians had not signed verbal and telephone orders. She was unsure of the timeframe they were required to do so but would expect providers to follow the policy. Since the discovery of unsigned orders, the hospital had audited and found more orders that were unsigned. During concurrent record review and interview on 01/28/26 at 1:11 PM, Staff K, RN, stated that the restraints ordered on 11/08/25, for Patient #19 were ordered under a physician who had not been employed at the hospital for over eight months. That physician could not have been the one to authorize restraints at that time, and it was likely whatever physician was on-call that day. During a telephone interview on 01/29/26 at 6:30 AM, Staff N, RN, stated that if a restraint was used, a clinical justification included things like tampering with medical devices or violent behavior to self or others. She agreed that “safety” did not provide the patient behavior that led to the necessity of the restraint.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 50321 Based on interview, record review and policy review, the hospital failed to ensure the discontinuation of restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head), physical holds (to physically hold someone to purposefully restrict the movements of their arms, legs, head, etc.) and seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) were recorded for one current Patient (#19) and three discharged Patients (#14, #24, #25) of 10 restrained, physically held or secluded patient records reviewed and to ensure appropriate ongoing monitoring and nursing documentation during the use of non-violent restraints for two discharged patients (#24 and #25) of three non-violent restrained patient records reviewed. Findings included: Review of the hospital’s policy titled, “Restraints and Seclusion,” dated 05/26/23, showed: - A physical restraint was any manual method, physical or mechanical device, material or equipment that immobilized or reduced the ability of a patient to move his or her arms, legs, body or head freely. - Seclusion was the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving. - Monitoring meant that the patient would be seen to determine if the use of restraint or seclusion continued to be safely applied, and if there appeared to be a need for an assessment of the patient to occur. - Patients placed in restraint or seclusion for violent or self-destructive behavior should be monitored at least every 15 minutes documented by the required one to one (1:1, continuous visual contact with close physical proximity) sitter (person assigned to continuously observe a patient within close proximity, to ensure their safety). - Patients placed in restraints for safety, non-violent and non-destructive behavior should be assessed at least once an hour. - Ongoing assessment meant that the patient would be evaluated to determine the patient’s response to the restraint or seclusion, and if the patient had any care needs. The assessment should include the patient’s vital signs (VS, measurements of the body’s most basic functions), hydration, circulation, the patient’s level of distress and agitation, skin integrity, general care needs and range of motion (ROM, how far you can move or stretch a part of your body, such as a joint or a muscle). The assessment should also determine if the patient continued to require restraint or seclusion. - Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. Restraints or seclusion may only be employed while the unsafe situation (clinical justification) continued. Once the unsafe situation ended, the use of restraint or seclusion must be discontinued. - Each episode of restraint or seclusion should contain the following documentation in the patient’s medical record: any in-person medical and behavioral evaluation for restraint or seclusion used to manage violent or self-destructive behavior - including the one hour face-to-face (a qualified staff members evaluation of a patient in violent restraints [medical cuffs applied to both arms and both legs to prevent someone form causing harm to themselves or others]) evaluation for patients placed in restraint or seclusion for violent or self-destructive behavior; a description of the patient’s behavior and interventions used; the patient’s response to the intervention used, including the rationale for continued use of the intervention; individual patient assessments and reassessments; the intervals for monitoring; the patient’s behavior and staff concern in regard to safety risks to the patient, staff and others that necessitated the use of restraint or seclusion and orders for restraint and seclusion. Review of Patient #14’s medical record showed on 12/21/25 at 12:24 PM, a nursing note showed he was placed in a physical hold. There was no other documentation related to the physical hold included in the medical record. Review of Patient #19’s medical record showed: - On 06/04/25 at 5:45 PM, she was placed in four-point restraints (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others) for violent behaviors. A discontinuation time was not recorded. - On 06/05/25 at 10:11 AM, she was placed in four-point restraints for violent behaviors. A discontinuation time was not recorded. - On 06/16/25 at 7:50 PM, she was placed in a physical hold for violent behaviors. A discontinuation time was not recorded. - On 06/22/25 at 8:24 PM, she was placed in a physical hold for violent behaviors. A discontinuation time was not recorded. - On 06/24/25 at 9:40 AM, she was placed in four-point restraints for violent behaviors. A discontinuation time was not recorded. - On 06/28/25 at 9:15 PM, she was placed in non-violent bilateral ankle restraints. A note showed she was restrained for medication administration and then released. A discontinuation time was not recorded. - On 07/06/25 at 8:53 PM, she was placed in four-point restraints for violent behaviors. A discontinuation time was not recorded. - On 07/12/25 at 12:25 AM, she was placed in four-point restraints for violent behaviors. A discontinuation time was not recorded. - On 07/19/25 at 11:34 PM, she was placed in a physical hold for violent behaviors. A discontinuation time was not recorded. - On 07/21/25 at 12:29 AM, she was placed in four-point restraints for violent behaviors. A discontinuation time was not recorded. - On 07/24/25 at 10:01 PM, she was placed in four-point restraints for violent behaviors. A discontinuation time was not recorded. - On 07/26/25 at 9:49 PM, she was placed in four-point restraints for violent behaviors. A discontinuation time was not recorded. - On 08/09/25 at 11:40 PM, she was placed in four-point restraints for violent behaviors. - On 08/10/25 at 10:35 PM, she was placed in four-point restraints for violent behaviors. A discontinuation time was not recorded. - On 11/08/25 at 9:42 PM, she was placed in four-point restraints for violent behaviors. A discontinuation time was not recorded. - On an unknown date, she was placed in a physical hold for violent behaviors at 10:29 PM. A discontinuation time was not recorded. Review of Patient #24’s medical record showed: - On 01/12/26 at 11:39 PM, a telephone order was placed for bilateral wrist restraints. - On 01/13/26 at 12:07 AM, Certified Nursing Assistant (CNA) documentation showed restraints were applied. - No other restraint documentation was included in the medical record. Review of Patient #25’s medical record showed: - On 12/19/25 at 5:10 PM, she was placed in bilateral wrist restraints. - At 6:10 PM, a restraint assessment was completed. No other restraint assessments were completed, and a discontinuation time was not recorded. - On 12/20/25 at 5:35 AM, she was placed in bilateral wrist restraints. - Restraint assessments were completed hourly through 5:30 PM, however, no further assessments were documented, and a discontinuation time was not recorded. During an interview on 01/28/26 at 4:25 PM and 01/29/26 at 9:35 AM, Staff K, Chief Nursing Officer (CNO), stated that she expected staff to document ongoing monitoring of restraints according to policy. She was unsure what the time interval for non-violent restraint monitoring was. Nurses were responsible for completing ongoing restraint assessments and documenting in the patient’s medical record. She expected staff to document when restraints were discontinued. During concurrent record review and interview on 01/28/26 at 1:11 PM, Staff K, Registered Nurse (RN), stated that restraint documentation was to include hourly checks for circulation and other assessments, and should be documented on the restraint form. He was unable to locate the form in Patient #24’s medical record. During an interview on 01/29/26 at 6:30 AM, Staff O, RN, stated that restraints were documented on paper in a binder at the nurse’s station. She then clarified the document in question was the paper documentation for restraint orders, not ongoing monitoring. Sitter’s also documented restraint assessments every 15 minutes on their paper rounding sheets. She was unsure how to document any other restraint assessments, such as circulation checks, though there might have been a flow chart she was unfamiliar with. Patient #24 was placed in restraints after he was intubated (process where a healthcare provider inserts a tube through a person’s mouth or nose down into their windpipe when a person is not breathing on their own) and remained in restraints until he was transferred to an outside hospital. She did not complete any additional documentation related to the restraints.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 50321 Based on interview, record review and policy review, the hospital failed to follow their policy and ensure a qualified staff member completed a face-to-face (a qualified staff members evaluation of a patient in violent restraints [medical cuffs applied to both arms and both legs to prevent someone form causing harm to themselves or others]) evaluation and contacted a physician with the results of the evaluation within one hour after violent restraints, physical holds (to physically hold someone to purposefully restrict the movements of their arms, legs, head, etc.) or seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) were initiated for one current patient (#19) and six discharged patients (#14, #21, #22, #28, #29 and #30) of seven violent restrained, physically held or secluded patient records reviewed. Findings included: Review of the hospital’s policy titled, “Restraints and Seclusion,” dated 05/26/23, showed: - A physical restraint was any manual method, physical or mechanical device, material or equipment that immobilized or reduced the ability of a patient to move his or her arms, legs, body or head freely. - Seclusion was the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving. Seclusion would only be used for the management of violent or self-destructive behavior that jeopardized the immediate physical safety of the patient, a staff member or others. - When a restraint was used to manage violent or self-destructive behavior, a physician or other licensed independent practitioner (LIP), Registered Nurse (RN) or Physician Assistant (PA, a type of mid-level health care that can serve as a principal healthcare provider) trained in accordance with the policy must see the patient face-to-face within one hour after the initiation of the intervention. - If a patient’s violent or self-destructive behavior resolved and the restraint intervention was discontinued before the practitioner arrived to perform the face-to-face evaluation, the practitioner was still required to see the patient face-to-face and conduct the evaluation within one hour after the initiation of the intervention. - The one-hour face-to-face evaluation should include both a physical and behavioral assessment of the patient. An evaluation of the patient’s medical condition would include a complete review of systems assessment, behavioral assessment, a review and assessment of the patient’s history, drugs and medications, most recent lab results, etc., as well as to evaluate the patient’s immediate situation, the patient’s reaction to the intervention, the patient’s medical and behavioral condition and the need to continue or terminate the restraint or seclusion. - When a trained RN or PA conducted the required face-to-face evaluation, he or she must consult the attending physician or other LIP responsible for the patient’s care as soon as possible after the completion of the evaluation. The consultation should include, at a minimum, a discussion of the findings of the one-hour face-to-face evaluation, the need for other interventions or treatments and the need to continue or discontinue the use of restraint or seclusion. - The consultation must be conducted as soon as possible (i.e. within one hour of being performed unless circumstances prohibit). A consultation that was not conducted prior to the renewal of an order would not be consistent with the requirement, “as soon as possible.” - Each episode of restraint or seclusion should contain documentation in the patient’s medical record to show any in-person medical and behavioral evaluation for restraint or seclusion used to manage violent or self-destructive behavior - including the one-hour face-to-face evaluation for patients placed in restraint or seclusion for violent or self-destructive behavior. Review of Patient #14’s medical record showed: - On 12/19/25 at 9:15 AM, he was placed in a physical hold for violent behaviors. - At 10:00 AM, a face-to-face evaluation was completed. - At 12:27 PM, he was placed in four-point restraints (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others) for violent behaviors. - At 12:29 PM, a face-to-face evaluation was completed. - On 12/20/25 at 6:25 AM, he was placed in a physical hold for violent behaviors. - At 6:50 AM, a face-to-face evaluation was completed. The evaluation did not include a medical assessment, list of interventions or an evaluation of the restraints. - All face-to-face evaluations were completed by unknown staff members. - The physician was not contacted with the results of any of the face-to-face evaluations. - On 12/21/25 at 12:24 PM, a nursing note showed he was placed in a physical hold. There was no other documentation related to the physical hold, or a face-to-face assessment, included in the medical record. Review of Patient #19’s medical record showed: - On 06/04/25 at 12:07 PM, she was placed in a physical hold for violent behaviors. - At 12:21 PM, she was placed in a physical hold for violent behaviors. - At 12:40 PM, a face-to-face evaluation was completed. - At 5:45 PM, she was placed in four-point restraints for violent behaviors. - At 6:18 PM, a face-to-face evaluation was completed. - On 06/05/25 at 10:11 AM, she was placed in four-point restraints for violent behaviors. - At 11:08 AM, a face-to-face evaluation was completed. - On 06/06/25 at 10:58 AM, she was placed in four-point restraints for violent behaviors. - At 11:58 AM, a face-to-face evaluation was completed. - On 06/10/25 at 4:29 PM, she was placed in four-point restraints for violent behaviors. - At 4:45 PM, a face-to-face evaluation was completed. - On 06/16/25 at 7:50 PM, she was placed in a physical hold for violent behaviors. - At 8:20 PM, a face-to-face evaluation was completed. - On 06/22/25 at 8:24 PM, she was placed in a physical hold for violent behaviors. - At 9:24 PM, a face-to-face evaluation was completed. - On 06/23/25 at 4:15 PM, she was placed in four-point restraints for violent behaviors. - At 5:15 PM, a face-to-face evaluation was completed. - On 06/24/25 at 9:40 AM, she was placed in four-point restraints for violent behaviors. - At 10:35 AM, a face-to-face evaluation was completed. - On 07/06/25 at 8:53 PM, she was placed in four-point restraints for violent behaviors. - At 9:56 PM, a face-to-face evaluation was completed. - On 07/12/25 at 12:25 AM, she was placed in four-point restraints for violent behaviors. - At 1:25 AM, a face-to-face evaluation was completed. - On 07/19/25 at 11:34 PM, she was placed in a physical hold for violent behaviors. - At 11:55 PM, a face-to-face evaluation was completed. - On 07/21/25 at 12:29 AM, she was placed in four-point restraints for violent behaviors. - At 1:34 AM, one hour and five minutes after restraints were initiated, a face-to-face evaluation was completed. - On 07/24/25 at 10:01 PM, she was placed in four-point restraints for violent behaviors. - At 11:15 PM, one hour and 14 minutes after restraints were initiated, a face-to-face evaluation was completed. - On 07/26/25 at 9:49 PM, she was placed in four-point restraints for violent behaviors. - At 11:00 PM, one hour and 11 minutes after restraints were initiated, a face-to-face evaluation was completed. - On 08/09/25 at 11:40 PM, she was placed in four-point restraints for violent behaviors. - On 08/10/25 at 12:40 AM, a face-to-face evaluation was completed. - At 10:35 PM, she was placed in four-point restraints for violent behaviors. - At 11:35 PM, a face-to-face evaluation was completed. The review of systems and medical assessment were not completed. - On 10/25/25 at 8:06 PM, she was placed in a physical hold for violent behaviors. - At 9:26 PM, one hour and 20 minutes after restraints were initiated, a face-to-face evaluation was completed. - On 11/08/25 at 9:42 PM, she was placed in four-point restraints for violent behaviors. - At 10:42 PM, a face-to-face evaluation was completed. - On an unknown date at 10:29 PM, she was placed in a physical hold for violent behaviors. A face-to-face evaluation was not completed. - All face-to-face evaluations were completed by unknown staff members. - The physician was not contacted with the results of any of the face-to-face evaluations. Review of Patient #21’s medical record showed: - On 11/17/25 at 11:00 PM, she was placed in four-point restraints for violent behaviors. - On 11/18/25 at 12:00 AM, a face-to-face evaluation was completed - The face-to-face evaluation was completed by an unknown staff member. - The physician was not contacted with the results of the face-to-face evaluation. Review of Patient #22’s medical record showed: - On 8/31/25 at 2:55 PM, he was placed in four-point restraints for violent behaviors. - At 4:10 PM, one hour and 15 minutes after restraint initiation, a face-to-face evaluation was completed. - The face-to-face evaluation was completed by an unknown staff member. - The physician was not contacted with the results of the face-to-face evaluation. Review of Patient #28’s medical record showed: - On 12/05/25 at 11:18 AM, she was placed in a physical hold for violent behaviors. - At 12:00 PM, a face-to-face evaluation was completed. - The face-to-face evaluation was completed by an unknown staff member. - The physician was not contacted with the results of any of the face-to-face evaluations. Review of Patient #29’s medical record showed: - On 11/24/25 at 3:42 PM, he was placed in a physical hold for violent behaviors. - At 4:15 PM, a face-to-face evaluation was completed. - On 11/25/25 at 11:59 AM, he was placed in a physical hold for violent behaviors. - At 12:04 PM, a face-to-face evaluation was completed - Both face-to-face evaluations were completed by unknown staff members. - The physician was not contacted with the results of either of the face-to-face evaluations. Review of Patient #30’s medical record showed: - On 11/27/25 at 1:16 PM, she was placed in four-point restraints for violent behaviors. - At 2:00 PM, a face-to-face evaluation was completed - The face-to-face evaluation was completed by an unknown staff member. - The physician was not contacted with the results of the face-to-face evaluation. During an interview on 01/28/26 at 4:25 PM and 01/29/26 at 9:35 AM, Staff L, Chief Nursing Officer (CNO), stated that the face-to-face evaluation should identify who completed the assessment and when the physician was notified with the results. She recognized there was not a place in the electronic health record (EHR) to document that information to verify the evaluation was completed by a qualified staff member. That had been identified the week prior to the current on-site survey during a separate accreditation survey. The hospital had begun to work on an action plan to address the identified opportunities for restraint documentation. During concurrent record review and interview on 01/28/26 at 1:11 PM, Staff K, RN, stated that he was unable to see who completed the face-to-face evaluations when reviewing Patient #14, #19, #21, #22, #28, #29 and #30’s medical records. There was no way to verify the evaluations were completed by an RN or a physician. During an interview on 01/27/26 at 2:15 PM, Staff G, RN, stated that RNs completed face-to-face evaluations and should contact the physician with the results.”

“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 provide, within its capability and capacity, an appropriate medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for five (# 1, #3, #13, #18, and #23) of 31 Emergency Department (ED) records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. The hospital’s average monthly ED census over the past six months was 904. Findings Included: Review of the hospital’s policy titled, “Emergency Department Scope of Services,” revised 11/21/24, showed: - An EMC was defined as a condition that is a danger to the patient and could result in a risk of dysfunction or impairment to the smallest bodily part or organ if the patient is not treated in the near future. An EMC includes, but is not limited to undiagnosed acute pain, substance abuse symptoms, and psychiatric (relating to mental illness) conditions, such as depression (extreme sadness that doesn’t go away), insomnia (difficulty falling asleep or staying asleep), suicidal/suicidal ideation (SI, thoughts of causing one’s own death) or attempt, dissociative state (mental health conditions that involve a loss of connection between thoughts, memories, feelings and identity) and inability to comprehend danger or care for self. - Initial assessments should include the chief complaint and the assignment of the Emergency Severity Index (ESI, a triage level scale used in emergency departments to rank patients by acuity, from level 1 [most urgent] to level 5 [least urgent] and vital signs (VS, measurements of the body’s most basic functions) to be completed and a pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible). Height, weight and a focused physical exam related to the chief complaint. - Reassessments for those areas of complaint should be completed after interventions performed. - Suicide risk assessment, allergies, home medications, past medical and surgical history, and infectious disease screening are to be obtained. - ED services include triage (process of determining the priority of a patient’s treatment based on the severity of their condition), initial and ongoing assessment by a Registered Nurse (RN), a MSE provides all necessary testing and on-call services withing the capability of the hospital to reach a diagnosis. - Federal law requires that all necessary definitive treatment will be administered to the patient and only maintenance care can be referred to a physician’s office. - An MSE includes monitoring of VS, pain level, stabilization and treatment of any EMC, including protection from self-harm and screening for all types of abuse. This includes the use of ancillary departments, including social services, circulation stabilization, medication administration and diagnostic imaging. - Discharge and follow up instructions should be completed with every patient. A patient who may be at reasonably at risk to deteriorate is unstable and may not be discharged. Review of the hospital’s policy titled, “Left Without Being Seen (LWBS)/Against Medical Advice (AMA)/Elopement (when a patient makes an intentional, unauthorized departure from a medical facility),” revised 08/20/2024, showed: - If multiple patients present at the same time, they are triaged including an initial assessment and information gathering. - LWBS is defined as a patient that stays long enough to speak with registration and be placed on the log but leaves before having their complaint and initial VS documented or prior to receiving an MSE to determine if an EMC exists. - If a patient leaves prior to triage, every effort should be made to determine the reason for leaving and they should be informed of the benefits for remaining, and the risks of leaving the ED. A Refusal of MSE form should be signed and witnessed by the ED staff, becoming part of the medical record. If the patient refuses to sign the form, that should be documented. - AMA is defined as a patient that refuses to consent to an MSE and withdraws their request for examination or treatment. A Release of Responsibility for Discharge form should be completed and/or refusal to sign documented, becoming part of the medical record. - Patients that are intoxicated (the condition of having physical or mental control markedly diminished by the effects of alcohol or drugs), hypoglycemic (low blood sugar), have head trauma, are in postictal (pertaining to the period follow a seizure) state, experienced a drug overdose, dementia (a loss of thinking abilities and memory), psychosis (a serious mental illness characterized by defective or lost contact with reality), or experiencing acute (sudden onset) stress are considered to lack decision making capacity and are not able to leave AMA. - For patients lacking decision making capacity, with imminent threat to life, limb, or health, immediate treatment may be rendered without consent. - Patients at risk for elopement must have measures put into place to ensure their safety. They should be visible from the nurses’ station at all times and/or have one to one care. Law enforcement should be notified if a patient elopes with intoxication, an altered mental status, or is having a behavioral health crisis. Staff should complete an incident report. Review of hospital’s policy titled, “Pain Management, Assessment and Reassessment,” revised 01/19/23, showed: - All patients should have a prompt and effective assessment and management of pain. - The RN is responsible for completing a pain assessment that includes the location, nature of pain, onset and duration, type, intensity and quality. - The appropriate pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) should be used. - Reassessments should be completed within 60 minutes of the administration of pain medication or pain intervention, and with each new complaint of pain. Review of hospital’s policy titled, “Charges and Documentation - Emergency Department,” revised 05/30/23, showed that ED staff are responsible documenting all care rendered to each patient during their ED visit. Review of hospital policy titled, “Management of the Emotional Ill Patient,” revised 11/24/24, showed: - Patients expressing SI or those that have attempted suicide, must be placed under constant surveillance by a staff member or law enforcement officer to prevent attempts to harm self. Their clothing should be removed, and they should be searched for weapons or items that could cause harm. - Patients should be assessed for thoughts of suicide, paranoia (excessive suspiciousness without adequate cause), depression, visual and/or auditory hallucinations (seeing or hearing things which are not there). If they are deemed to be suicidal, homicidal, have severe psychosis, or are agitated, a sitter will be provided. - Patients must receive psychiatric and medical screenings to determine the absence of an EMC prior to discharge. The on-call psychiatrist and ED provider must discuss all findings, including diagnostic testing, and agree on disposition of the patient, prior to discharge. If they do not agree, a face-to-face evaluation by the psychiatrist may be required. Please see the 2567 for additional information.”

“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 appropriate medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for five (# 1, #8, #13, #18, and #23) of 31 Emergency Department (ED) records reviewed. 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 Department Scope of Services,” revised 11/21/24, showed: - An EMC was defined as a condition that is a danger to the patient and could result in a risk of dysfunction or impairment to the smallest bodily part or organ if the patient is not treated in the near future. An EMC includes, but is not limited to undiagnosed acute pain, substance abuse symptoms, and psychiatric (relating to mental illness) conditions, such as depression (extreme sadness that doesn’t go away), insomnia (difficulty falling asleep or staying asleep), suicidal/suicidal ideation (SI, thoughts of causing one’s own death) or attempt, dissociative state (mental health conditions that involve a loss of connection between thoughts, memories, feelings and identity) and inability to comprehend danger or care for self. - Initial assessments should include the chief complaint and the assignment of the Emergency Severity Index (ESI, a triage level scale used in emergency departments to rank patients by acuity, from level 1 [most urgent] to level 5 [least urgent] and vital signs (VS, measurements of the body’s most basic functions) to be completed and a pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible). Height, weight and a focused physical exam related to the chief complaint. - Reassessments for those areas of complaint should be completed after interventions performed. - Suicide risk assessment, allergies, home medications, past medical and surgical history, and infectious disease screening are to be obtained. - ED services include triage (process of determining the priority of a patient’s treatment based on the severity of their condition), initial and ongoing assessment by a Registered Nurse (RN), a MSE provides all necessary testing and on-call services withing the capability of the hospital to reach a diagnosis. - Federal law requires that all necessary definitive treatment will be administered to the patient and only maintenance care can be referred to a physician’s office. - An MSE includes monitoring of VS, pain level, stabilization and treatment of any EMC, including protection from self-harm and screening for all types of abuse. This includes the use of ancillary departments, including social services, circulation stabilization, medication administration and diagnostic imaging. - Discharge and follow up instructions should be completed with every patient. A patient who may be at reasonably at risk to deteriorate is unstable and may not be discharged. Review of the hospital’s policy titled, “Left Without Being Seen (LWBS)/Against Medical Advice (AMA)/Elopement (when a patient makes an intentional, unauthorized departure from a medical facility),” revised 08/20/2024, showed: - If multiple patients present at the same time, they are triaged including an initial assessment and information gathering. - LWBS is defined as a patient that stays long enough to speak with registration and be placed on the log but leaves before having their complaint and initial VS documented or prior to receiving an MSE to determine if an EMC exists. - If a patient leaves prior to triage, every effort should be made to determine the reason for leaving and they should be informed of the benefits for remaining, and the risks of leaving the ED. A Refusal of MSE form should be signed and witnessed by the ED staff, becoming part of the medical record. If the patient refuses to sign the form, that should be documented. - AMA is defined as a patient that refuses to consent to an MSE and withdraws their request for examination or treatment. A Release of Responsibility for Discharge form should be completed and/or refusal to sign documented, becoming part of the medical record. - Patients that are intoxicated (the condition of having physical or mental control markedly diminished by the effects of alcohol or drugs), hypoglycemic (low blood sugar), have head trauma, are in postictal (pertaining to the period follow a seizure) state, experienced a drug overdose, dementia (a loss of thinking abilities and memory), psychosis (a serious mental illness characterized by defective or lost contact with reality), or experiencing acute (sudden onset) stress are considered to lack decision making capacity and are not able to leave AMA. - For patients lacking decision making capacity, with imminent threat to life, limb, or health, immediate treatment may be rendered without consent. - Patients at risk for elopement must have measures put into place to ensure their safety. They should be visible from the nurses’ station at all times and/or have one to one care. Law enforcement should be notified if a patient elopes with intoxication, an altered mental status, or is having a behavioral health crisis. Staff should complete an incident report. Review of hospital’s policy titled, “Pain Management, Assessment and Reassessment,” revised 01/19/23, showed: - All patients should have a prompt and effective assessment and management of pain. - The RN is responsible for completing a pain assessment that includes the location, nature of pain, onset and duration, type, intensity and quality. - The appropriate pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) should be used. - Reassessments should be completed within 60 minutes of the administration of pain medication or pain intervention, and with each new complaint of pain. Review of hospital’s policy titled, “Charges and Documentation - Emergency Department,” revised 05/30/23, showed that ED staff are responsible documenting all care rendered to each patient during their ED visit. Review of hospital policy titled, “Management of the Emotional Ill Patient,” revised 11/24/24, showed: - Patients expressing SI or those that have attempted suicide, must be placed under constant surveillance by a staff member or law enforcement officer to prevent attempts to harm self. Their clothing should be removed, and they should be searched for weapons or items that could cause harm. - Patients should be assessed for thoughts of suicide, paranoia (excessive suspiciousness without adequate cause), depression, visual and/or auditory hallucinations (seeing or hearing things which are not there). If they are deemed to be suicidal, homicidal, have severe psychosis, or are agitated, a sitter will be provided. - Patients must receive psychiatric and medical screenings to determine the absence of an EMC prior to discharge. The on-call psychiatrist and ED provider must discuss all findings, including diagnostic testing, and agree on disposition of the patient, prior to discharge. If they do not agree, a face-to-face evaluation by the psychiatrist may be required. Review of Patient #1’s medical record, dated 09/27/25, showed: - At 8:51 PM, a 27-year-old female presented to the ED with complaints of abdominal pain that she had tolerated for one week but had become sharp and severe that day. - Her VS were within normal limits, and she rated her pain, in her left lower abdominal quadrant, at a nine. Her pain radiated to her left lower back and side. - A physical assessment showed her abdomen was tender and non-distended. - Laboratory testing included a pregnancy test, urinalysis (a laboratory examination of a person’s urine), complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection), comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions) and a Lipase (an enzyme produced by the pancreas which the body uses to break down fats, normal is 10-99) levels. Her results were unremarkable. - At 9:26 PM, intravenous (IV, in the vein) fluids and IV Toradol (a nonsteroidal anti-inflammatory drug [NSAID] that is used to treat moderately severe pain and inflammation) were administered. - At 9:56 PM, a computed tomography (CT, a combination of x-rays [tests that create pictures of the structures inside of the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) scan of her abdomen and pelvis (area of the body below the abdomen) without contrast were completed. - At 10:01 PM, her CT results indicated prominent inflammatory changes extending through the pelvis with fullness in the right ovary. A pelvic ultrasound (a test that uses sound waves to create images of structures within the body) was recommended to assess the etiology (cause) of the pelvic inflammatory changes. The inflammatory changes could represent pelvic inflammatory disease (PID, a serious infection of a woman’s reproductive organs). The appendix (a small tube-shaped part that is joined to the intestines on the right side of the intestines) was not definitively seen however no dilated tubular structure was seen to suggest appendicitis (inflammation of an organ located in the lower right abdomen). A follow-up CT with contrast was recommended if the pelvic US did not correlate with the inflammatory changes in the pelvis which appeared centered around the uterus (within a woman’s pelvis where a fetus develops and grows). No abnormalities were seen within the kidneys. - No additional tests were ordered or performed. - No follow up pain assessments or VS were documented. - At 10:17 PM, physician documentation showed that the abdominal CT showed no acute findings, her laboratory tests were within normal limits and upon reassessment she had slept and felt much better. At 10:38 PM, she was discharged with instructions to follow-up with her primary care provider. - No prescriptions were provided. - There was no documentation that the CT results and recommendations were discussed with her. During an interview on 10/01/25 at 8:15 AM, Staff G, Quality Director, stated he was unable to locate a specific policy related to incidental findings with radiology tests. During a telephone interview on 10/08/25 at 9:30 AM, Staff K, ED Director, stated that the provider should notify the patient if there was an abnormality on their CT scan. Nursing should be aware to ensure additional testing has been completed if there was an EMC. Nursing educates the patients and assists them with the needed follow up. For patients with primary care physicians, the results would be sent to that provider. VS, including pain assessments, should be obtained according to hospital policy and based on the patient’s acuity level. They are to be obtained after any intervention, within 60 minutes of any pain medication administration, and documented, with a final set obtained prior to discharge. At times nursing prints out the VS and place a patient sticker on them to be scanned into the medical record. During a telephone interview on 10/08/25 at 10:30 AM, Staff J, Chief Nursing Officer (CNO), stated that the provider should notify patients of incidental findings and recommendations obtained from radiological (a variety of medical imaging/x-ray techniques used to diagnose or treat diseases) exams. VS, along with pain assessments, should be obtained and documented, within 60 minutes of pain medication administration, prior to discharge, and per policy. It was not acceptable for nurses to print a copy of the VS, label them, and then scan them into the medical record, unless the computer system was down. During a telephone interview on 10/08/25 at 4:30 PM, Staff C, ED Medical Director, stated that he expected the physician to discuss CT results with the patients and to document those conversations. Patient #1 should have been prescribed antibiotics and instructed to return the next day for the US if it was not obtained during her initial visit. Nursing staff should obtain and document VS and pain reassessments. During a telephone interview on 10/09/25 at 8:15 AM, Staff P, ED Physician, was unable to recall Patient #1. When provided the CT results, he stated that US testing was not available during her ED visit. US was only available Monday through Friday during the day shift hours. Any incidental findings based on CT results could be followed up as an outpatient. Patient #1 did not have signs or symptoms of PID. She had no vaginal discharge. He stated that the CT findings were reviewed with the patient. She already had an appointment and was going to follow-up with her gynecologist (a medical professional which deals with the functions and diseases specific to women and the reproductive system). The conversation was not documented in the medical record. Review of Patient #8’s medical record, dated 04/03/25, showed: - At 12:54 PM, a 69-year-old male presented to the ED with a snake bite. - He had been seen at an urgent care center but was told to go to the ED to be evaluated. His VS were obtained with a blood pressure (BP, normal adult blood pressure is between 90/60 and 120/80) of 177/82, HR of 77, T of 97.8, RR of 18, SPo2 of 99%, and a pain scale rate of three. - Documentation indicated a few small abrasions/puncture wounds in the skin from the bite. The snake was determined to be non-venomous. - His past medical history, surgical history, family history, social history and current medications were not documented. - At 1:04 PM, a tetanus injection was administered, and antibiotic ointment was applied to the puncture sites. - At 1:28 PM, he was discharged. No additional VS were documented. Review of Patient #13’s medical record, dated 05/26/25, showed: - At 9:20 AM, a 41-year-old female presented to the ED with domestic abuse and back pain radiating up to her shoulders. Her spouse had assaulted her, throwing her around the room and up against the wall. Her pain scale rating was an eight. She filed a police report. - Triage documentation indicated there was no suspected abuse. - Her past medical history, surgical history, social history and current medications were not documented. - At 9:34 AM, an IM injection of Toradol 30 mg was administered for pain. - At 10:39 AM, a CT of the lumbar and thoracic spines resulted with no acute findings. - At 11:05 AM, she was discharged with the diagnosis of myalgia (muscle aches and pain). She was instructed to follow-up with her primary care physician. - No follow-up pain assessment, discharge VS, social service referrals, or interventions or resources for domestic abuse were documented as being offered or presented. - There was no documentation within the medical record indicating that she was being discharged to a safe environment. During an interview on 10/08/25 at 9:30 AM, Staff K, ED Manager, the nurse was responsible for obtaining past medical history, surgical history, and current medications as part of triage. All patients provided care in the ED should have discharge VS completed and documented prior to discharge. All patients that present to the ED are screened for abuse. If abuse has been identified, there should be documentation that the patient was offered information related to the available resources and a referral for social services. If the patient declined those interventions, the nurse should document that they were offered but refused. Social services were available for all patients that present to the ED with abuse. During an interview on 10/08/25 at 10:30 AM, Staff J, CNO, stated that she expected nursing staff to follow hospital policy by obtaining all information including past medical history, surgical history, family history, social history, and any current medications during triage. Failure to obtain that information could trigger an EMTALA violation. That information should always be obtained. Per hospital policy, all patients being discharged from the ED should have a set of discharge VS and a pain assessment completed and documented prior to discharge. During an interview on 10/08/25 at 4:30 PM, Staff C, MD, stated past medical history, surgical history, social history and current medications should have been obtained and documented per hospital policy. Nursing was responsible for obtaining all the information and ensuring it was documented during the triage process. Once a physician writes orders for discharge, the nurse should obtain VS prior to discharge. Review of Patient #18’s medical record, dated 05/03/25, showed: - At 1:49 PM, a 28-year-old male presented to the ED accompanied by law enforcement with a complaint of SI. Signed affidavits (a written statement confirmed by oath, for use as evidence in court) indicated he wanted to kill himself but did not have a plan. - At 2:09 PM, VS were obtained along with laboratory tests including a CBC, CMP, acetaminophen (pain medication, also used to reduce fever) level, UA, and urine drug screen (UDS, a test that analyzes urine for the presence of certain illegal drugs and prescription medications). - At 2:30 PM, a psychiatric consult was ordered and an IV was started. - ED physician documentation stated that Patient #18 came in with a complaint of depression. He had intermittent thoughts of harming himself over the last year but had never acted on it. He was not currently having suicidal thoughts. - At 4:08 PM, his IV was removed. - At 4:19 PM, he was discharged with instructions to follow-up with his PCP and given a list of local resources. - There was no behavioral health documentation or documentation of any conversations or phone calls with the on-call psychiatrist in the medical record. - Patient #18 was not placed on one to one (1:1, continuous visual contact with close physical proximity) observation, nor was there documentation regarding a search of his person for any weapons or objects that could result in self-harm. - His VS were not obtained and documented prior to discharge. Review of a hospital document titled, “Affidavit (a written statement confirmed by oath, for use as evidence in court),” dated 05/03/25 at 1:49 PM, showed a police officer documented that Patient #18 came to the calm realization he wanted to commit suicide. Patient #18 told the officer directly that he wanted to kill himself, but did not have a plan. During an interview on 10/08/25 at 10:30 AM, Staff J, CNO, stated staff should pay attention when an affidavit was presented by law enforcement. All BH patients in the ED must have a consultation with psychiatry prior to being discharged. Psychiatric consultations always available 24 hours per day. If there was an affidavit and the physician wanted to discharge a psychiatric patient, a face-to face must be completed with the psychiatrist on call prior to the discharge. Nurses should notify the house supervisor or charge nurse if there was an issue of a patient having an affidavit and a psychiatrist not being consulted. “I reviewed that particular chart after it was requested. We failed to follow our policy for patients that present with SI. A psychiatric provider was not contacted for Patient #18 prior to being discharged.” During an interview on 10/08/25 at 4:30 PM, Staff C, ED Medical Director, stated ED physicians do not always call the on-call psychiatrist. He was not involved in hospital policy reviews but was consulted at times. He was not aware that hospital policy required a consult be done with psychiatrist prior to the discharging a patient with SI. Review of Patient’s #23 medical record, dated 05/02/25, showed: - At 6:07 PM, an 84-year-old male presented to the ED after a fall with an altered mental status. - He lived alone, had a history of dementia, was not making sense, and family was concerned that he may have mixed up his medications. - Staff Q, ED Physician, documented that Patient #23 had been seen on 04/27/25 for similar symptoms. He had been checked out a few days ago and there was no need to reevaluate him. He was alert and oriented times two (he knew who he was and where he was). - At 7:30 PM, he was discharged with instructions to follow up with his primary care provider for medication management and encouraged to be more active in his community. - There was no documentation of his current medications, or any assessments related to the fall reported during triage. During an interview on 10/08/25 at 4:30 PM, Staff C, ED Medical Director, stated that no matter how many times a patient returned to the ED for similar symptoms a complete MSE and stabilization should be performed. All obligations must be fulfilled for EMTALA. 51509”

“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: 50151 Based on interview, record review and policy review, the hospital failed to follow their policies to identify an emergency medical condition (EMC) for a potential psychiatric emergency and provide an appropriate triage process, for one patient (#5) of nine ED records reviewed for patients that presented to the ED with an emotional illness/psychiatric disturbance chief complaint from 03/31/24 through 10/03/24. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. The hospital’s average monthly ED census over the past six months was 859. Findings included: Review of the hospital’s policy titled, “Emergency Medical Treatment and Active Labor Act (EMTALA) Compliance,” dated 12/2021, showed the following: - All individuals who present to the ED are provided with an appropriate MSE to determine if an EMC exists. - The term EMC means a medical condition manifesting itself by acute symptoms including severe pain, psychiatric (relating to mental illness) disturbances and/or substance abuse. - The MSE may range from an abbreviated examination that involved brief questioning by a qualified medical person to a complex process that involved performing ancillary studies and procedures. - The MSE is an ongoing process and requires determination, within reasonable clinical confidence, that a medical emergency does or does not exist. - The process requires continued monitoring and documentation and involves more than the initial triage process. The triage process does not constitute as a MSE and only determines the order in which individuals are screened. - In the event a patient decided to voluntarily withdraw their request for examination, an appropriately trained individual from the ED staff must, offer the individual further medical examination and treatment that may be required to identify and stabilize an EMC; the patient must be educated of the risks of withdrawing their request for an MSE; and steps should be taken to secure the individuals informed written refusal of examination and/or treatment. Review of the hospital’s policy, “Management of the Emotionally Ill Patient,” dated 08/20/24, showed the following: - A patient who presented to the ED for a possible psychiatric emergency, should not be left unattended. - A patient who has expressed suicidal ideation (SI, thoughts of causing one’s own death) or who had attempted suicide, must be provided constant surveillance and attended to by a qualified staff member or law enforcement. - The patient should be assessed for thoughts of suicide, paranoia (excessive suspiciousness without adequate cause), depression (extreme sadness that doesn’t go away) and hallucinations (seeing or hearing things which are not there). - A patient with a complaint of emotional illness, should not be discharged without a psychiatric screen that showed an absence of a mental health emergency and a medical screening that showed an absence of a physical health emergency. Review of the hospital’s policy, “Emergency Department Scope of Services,” date 08/20/24, showed the following: - An EMC is any condition that is a danger to the patient or unborn fetus or has increased the risk dysfunction or impairment to a body part or organ, if the patient is not treated in the near future. EMCs included but are not limited to, undiagnosed acute pain which has impaired normal functioning; pregnancy with contractions; substance abuse symptoms; and psychiatric disturbances. Psychiatric disturbances may include severe depression, SI or suicide attempt, dissociative state (feeling disconnected from yourself and the world around you), an inability to comprehend danger or care for themselves. - When a patient arrived at the ED registration desk, the ED Registered Nurse (RN) is notified. - If the patient’s complaint was shortness of breath, chest pain, decreased level of consciousness (LOC, the state of being fully alert, aware, oriented, and responsive to the environment), bleeding or that of panic, ED RN or ED physician should be immediately notified by registration staff. - The goal from patient arrival to be triaged, is as timely as possible or within 20 minutes. - During the triage process, the ED RN completes an initial assessment and assigns an Emergency Severity Score Index (ESI, a numerical value one [most urgent] to five [least urgent] that shows priority of medical evaluations, as well as resources needed to treat patients). - A patient who is in a high-risk situation such as a psychiatric patient, a patient at risk of harm to self or others, or who is in severe pain and or distress, will be assigned an ESI level two. - Any patient identified as at risk of harm to self or others, should be provided a one to one (1:1, continuous visual contact with close physical proximity) sitter. - If all ED patient care areas were occupied by other patients and a patient presented with a condition that threatened life or limb, the ED RN and/ or the ED physician were responsible to relocate stable patient to make room for the unstable patient. Review of the hospital’s policy, “Emergency Room Registration,” dated 12/14/21, showed the following: - When a patient presented to the ED, the ED registration clerk obtained the patient’s date of birth (DOB), legal name and chief complaint. - The patient will be asked to review, initial, and sign the consent to treat. - Once all the required information is entered, the patient is then asked to have a seat in the waiting room. - If the patient’s stated chief complaint was shortness of breath, chest pain, decreased LOC, bleeding, HI/ SI, or that of panic, the ED clinical staff should be immediately alerted about the patient. If there were no clinical staff located at the nursing station, the ED registration clerk should go find a clinical staff member to be notified of the emergent patient. - An ED registration clerk should meet a patient, who has arrived via ambulance or by police escort, at the door to complete the registration process. Please refer to 2406 for further details.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 50151 Based on interview, record review and policy review, the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#5) of 27 Emergency Department (ED) records reviewed from 03/31/24 through 10/03/24. The hospital failed to follow their policies to identify an emergency medical condition (EMC) for a potential psychiatric emergency and provide an appropriate triage process, for one patient (#5) of nine ED records reviewed for patients that presented to the ED with an emotional illness/psychiatric disturbance chief complaint from 03/31/24 through 10/03/24. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. The hospital’s average monthly ED census over the past six months was 859. Findings included: Review of the hospital’s policy titled, “Emergency Medical Treatment and Active Labor Act (EMTALA) Compliance,” dated 12/2021, showed the following: - All individuals who present to the ED are provided with an appropriate MSE to determine if an EMC exists. - The term EMC means a medical condition manifesting itself by acute symptoms including severe pain, psychiatric (relating to mental illness) disturbances and/or substance abuse. - The triage process does not constitute as a MSE and only determines the order in which individuals are screened. - In the event a patient decided to voluntarily withdraw their request for examination, an appropriately trained individual from the ED staff must, offer the individual further medical examination and treatment that may be required to identify and stabilize an EMC; the patient must be educated of the risks of withdrawing their request for an MSE; and steps should be taken to secure the individuals informed written refusal of examination and/or treatment. Review of the hospital’s policy, “Management of the Emotionally Ill Patient,” dated 08/20/24, showed the following: - A patient who presented to the ED for a possible psychiatric emergency, should not be left unattended. - A patient who has expressed suicidal ideation (SI, thoughts of causing one’s own death) or who had attempted suicide, must be provided constant surveillance and attended to by a qualified staff member or law enforcement. - A patient with a complaint of emotional illness, should not be discharged without a psychiatric screen that showed an absence of a mental health emergency and a medical screening that showed an absence of a physical health emergency. Review of the hospital’s policy, “Emergency Department Scope of Services,” date 08/20/24, showed the following: - An EMC is any condition that is a danger to the patient or unborn fetus or has increased the risk dysfunction or impairment to a body part or organ, if the patient is not treated in the near future. EMCs included but are not limited to, undiagnosed acute pain which has impaired normal functioning; pregnancy with contractions; substance abuse symptoms; and psychiatric disturbances. Psychiatric disturbances may include severe depression, SI or suicide attempt, dissociative state (feeling disconnected from yourself and the world around you), an inability to comprehend danger or care for themselves. - When a patient arrived at the ED registration desk, the ED Registered Nurse (RN) is notified. - If the patient’s complaint was shortness of breath, chest pain, decreased level of consciousness (LOC, the state of being fully alert, aware, oriented, and responsive to the environment), bleeding or that of panic, ED RN or ED physician should be immediately notified by registration staff. - The goal from patient arrival to be triaged, is as timely as possible or within 20 minutes. - During the triage process, the ED RN completes an initial assessment and assigns an Emergency Severity Score Index (ESI, a numerical value one [most urgent] to five [least urgent] that shows priority of medical evaluations, as well as resources needed to treat patients). - A patient who is in a high-risk situation such as a psychiatric patient, a patient at risk of harm to self or others, or who is in severe pain and or distress, will be assigned an ESI level two. - Any patient identified as at risk of harm to self or others, should be provided a one to one (1:1, continuous visual contact with close physical proximity) sitter. - If all ED patient care areas were occupied by other patients and a patient presented with a condition that threatened life or limb, the ED RN and/or the ED physician were responsible to relocate a stable patient to make room for the unstable patient. Review of the hospital’s policy, “Emergency Room Registration,” dated 12/14/21, showed the following: - When a patient presented to the ED, the ED registration clerk obtained the patient’s date of birth (DOB), legal name and chief complaint. - The patient will be asked to review, initial, and sign the consent to treat. - Once all the required information is entered, the patient is then asked to have a seat in the waiting room. - If the patient’s stated chief complaint was shortness of breath, chest pain, decreased LOC, bleeding, HI/SI, or that of panic, the ED clinical staff should be immediately alerted about the patient. If there were no clinical staff located at the nursing station, the ED registration clerk should go find a clinical staff member to be notified of the emergent patient. Upon presentation to the ED registration desk, the registration clerk, not clinical staff, determine the immediacy of their assessment. Patients are either placed in the waiting room or they are seen by the clinical staff. Review of Patient #5’s medical record, dated 06/18/24, showed: - At 10:07 PM, she presented to the ED with police and her chief complaint was entered as self-harm/ psychiatric evaluation. - Staff N, ED Clerk, wrote on the Consent For Treatment form, “Patient was brought in as a 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others), refused to sign” in the patient signature line. - At 11:50 PM, Staff P, RN, documented that the patient left without being seen with a police officer (PO), daughter and family. - There was no additional documentation provided. Although requested, there was no police report available for Patient #5 on 06/18/24 since Patient #5 was escorted by family to the ED. During an interview on 10/02/24 at 8:30 AM, Staff J, RN, stated that the ED does not have a dedicated triage nurse. Patients were triaged when they were brought back to be placed in a room. Suicidal patients would be given an ESI of two, during the triage process. A patient with an ESI of two should not be placed in the waiting room. The ED RN should be notified of the patient with SI by ED registration when they entered the ED. When the ED rooms were full and a patient with SI presented, they worked to clear a room to get that patient into an ED room as soon as possible. The patient with SI, was monitored every 15 minutes to make sure they did not leave or self-harm, were placed in paper scrubs and searched for high-risk items. During an interview on 10/02/24 at 9:15 AM, Staff H, Chief Nursing Officer (CNO), stated that the ED registration clerks have been instructed to enter the patient’s stated chief complaint on arrival. When a patient with SI presents to the ED, the patient would be registered and the ED RN should be alerted by registration staff of the patient if they need to be seen immediately. When a patient with SI was brought into the ED by law enforcement, the patient would be placed directly into a room. Psychiatric patients were given an ESI of two so the entire department was alerted that a patient with a possible psychiatric emergency was in the department. Ideally patients were seen by someone within 20 minutes of arrival. There were times when psychiatric patients eloped (when a patient makes an intentional, unauthorized departure from a medical facility), but she believed there were safety measures in place in the ED to prevent elopement. When a patient left before they were triaged, nursing staff should attempt to stop the patient. Ideally, they had the patient sign the refusal of services form before they left. During an interview on 10/02/24 at 10:35 AM, Staff L, ED Clerk, stated that his job was to get information about why the patient presented to the ED upon their arrival. After they got the information, they put it on a log and created an encounter for the patient. If police brought a patient into the ED with SI or homicidal ideation (HI, thoughts or attempts to cause another’s death) they knew to skip the registration desk and enter through the ambulance doors. During an interview on 10/02/24 at 10:45 AM, Staff M, ED Clerk, stated that if a patient presented to the ED with a chief complaint of self-harm, she would immediately go and tell a nurse. If the ED was not busy, she would take the patient straight back to a room. She tried to keep SI and HI patients out of the waiting room. If a patient there for self-harm decided to leave before being seen by a nurse or physician, she would apologize to the patient about the wait time and then complete an event report. During an interview on 10/02/24 at 11:30 AM, Staff N, ED Clerk, stated that Patient #5 was brought in by her family through the main ED entrance. Patient #5 did not want to provide any information for registration and she was placed in the ED waiting room with the PO and family that came in with her. She noticed that the patient was walking out of the ED on the camera and thought to herself, “Why is this patient leaving?” Normally when a patient was brought in by police, they were supposed to be directly placed into a room. During an interview on 10/02/24 at 2:51 PM, Staff O, PO, stated that she received a call about an intoxicated person (Patient #5) that was having an argument with her son and who reported she had been cutting herself. It was reported that Patient #5 stated to her son, “Well, I might as well die then.” The patient’s daughter drove Patient #5 to the ED. She followed the patient and her daughter in her police car. When they arrived at the ED, registration told them that there would be a several hour wait time. The patient was not assessed by any staff and sat in the waiting room. After 45 minutes to an hour of waiting, the patient wanted to leave to go home and smoke. The patient was told by registration she was free to go. Staff O made it a point to tell registration why the patient was there just to make sure. During an interview on 10/03/24 at 9:30 AM, Staff P, RN stated that she was unable to remember Patient #5 and without any documentation, could not say if she laid eyes on her while she was in the ED on 06/18/24. Whenever law enforcement brought a patient, with SI or possible SI, into the ED, they bring them into the ED through the ambulance bay and complete the required paperwork which included an affidavit. Local law enforcement were usually good about getting the required paperwork completed. Since law enforcement did not fill out the paperwork they do for patients with SI, she questioned if the patient had SI when they presented to the ED. Registration entered the patient’s chief complaint and registered the patient. If the patient’s chief complaint was something that needed to go straight back, registration would bring the paperwork to the ED RN and notified them of the patient’s chief complaint. In the event a patient with SI presented to the ED and there were no rooms available, the patient may be sat in the waiting room with law enforcement. The law enforcement officer was allowed to be responsible for close observation while the patient waited in the waiting room. ED registration would make the call to sit the patient in the waiting room with law enforcement to observe them if the ED RN was not notified of the patient. If the law enforcement officer had to leave the hospital or was not able stay to observe the patient while in the waiting room, the law enforcement officer would have to notify ED registration. The ED nurses would need to be made aware of the situation, by registration, so they could work on getting the patient to the back so they could be closely observed. There were times when a BHU technician or a house supervisor could be pulled to sit with the patient in the ED waiting room, but the ED RN would have to be aware of the situation to coordinate resources for the patient to be observed while in the waiting room. Patients do not get triaged until they were taken back to their room. The goal to get a patient with SI triaged is within 20 to 30 minutes of arrival. If the ED RNs were not informed by registration that there was a patient with SI in the waiting room that could make the triage wait time longer. 41474”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 39840 Based on interview and record review, the hospital’s Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible for management of the entire hospital, including accountability for the effective oversite of staff to comply with the requirements under 42 CFR 482.23 Condition of Participation (CoP): Nursing Services, 42 CFR 482.13 CoP: Patient’s Rights and 42 CFR 482.43 CoP: Discharge Planning. - Recognize failures and conduct complete and thorough investigations to prevent future reoccurrences following incidents: - A blood transfusion (to administer blood into a vein) reaction for one patient (#7); - Abuse by threat of discharge for non-compliance for one Behavioral Health Unit (BHU) patient (#32); - An allegation of abuse and sexual assault for one patient (#15); - A precipitous vaginal delivery (when a baby is born within three hours of regular contractions starting) of an infant for one patient (#17); - A fall that resulted in an injury that required transfer to a higher level of care and surgical intervention to repair a broken bone for one patient (#20); - An attempted suicide (thoughts of causing one’s own death) for one patient (#23); - Ensure that the Chief Nursing Officer (CNO) provided adequate oversight and supervision of nursing personnel when the staff failed to follow their policies for assessment for three discharged patient’s (#17, #20, and #32) of three discharged patient records reviewed; - A failed referral arrangement to follow up care services for on discharged patient (#34) of one record reviewed; - Ensure that staff were trained on a periodic basis in first aid related to restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head), for three staff (H, O, and P) of four staff personnel files reviewed; - Ensure the safety of all BHU patients within a dedicated, secured, ligature-resistent and psychiatric safe patient environment for 19 current patients (#31, #33, #35, #36, #37, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, and #55) that were located in a locked BHU; and - Provide annual evaluations for three staff (H, O, and Q) of three personnel records reviewed. These failures had the potential to adversely affect the quality of care and safety of all patients in the hospital.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 39840 Based on interview, record review and policy review, the hospital failed to recognize failures and conduct complete and thorough investigations to prevent future reoccurrences following incidents: - A blood transfusion (to administer blood into a vein) reaction for one patient (#7); - An allegation of abuse and sexual assault for one patient (#15); - Abuse by threat of discharge for non-compliance for one Behavioral Health Unit (BHU) patient (#32); - A precipitous vaginal delivery (when a baby is born within three hours of regular contractions starting) of an infant for one patient (#17); - A fall that resulted in an injury that required transfer to a higher level of care and surgical intervention to repair a broken bone for one patient (#20); - An attempted suicide (thoughts of causing one’s own death) for one patient (#23) (A-0145); - The hospital failed to ensure that staff were trained in first aid related to restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) (A-206). - The hospital failed to ensure the safety of all BHU patients when they failed to provide a dedicated, secured, ligature-resistant and psychiatric safe patient environment for 19 current patients (#31, #33, #35, #36, #37, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54 and #55) that were located in a locked BHU. (A-0144) This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation: Patient’s Rights. The severity and cumulative effect of this practice had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ). As of 06/05/24, the hospital had provided an immediate action plan sufficient to remove the IJ when the hospital implemented corrective actions that included educating all current and oncoming nursing staff on blood transfusions and reactions, the abuse and neglect policy, assessment and reassessment of Obstetrics (OB, the branch of medical science concerned with childbirth and caring for and treating women in or in connection with childbirth) patients, fall prevention and interventions and the suicide precaution procedures. All remaining staff were educated prior to the start of their next shift. As of 06/25/24, the hospital had provided an immediate action plan sufficient to remove the IJ when the hospital implemented corrective actions that included educating all current and oncoming Behavioral Health Unit (BHU) staff on a psychiatric safe environment for BHU patients. Please refer to A-0144, A-0145 & A-0206. 41865”

“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 interview, record review and policy review, the hospital failed to ensure that the Chief Nursing Officer (CNO) provided adequate oversight and supervision of nursing personnel when the staff failed to follow their policies for assessment for three discharged patient’s (#17, #20 and #32) of three discharged patient records reviewed (A-0395), and provide annual evaluations for three staff (H, O, and Q) of three personnel records reviewed (A-0398). These failed practices resulted in a systemic failure and noncompliance with 42 CFR 482.23 Condition of Participation: Nursing Services. The severity and cumulative effect of this practice had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ). As of 06/05/24, the hospital had provided an immediate action plan sufficient to remove the IJ when the hospital implemented corrective actions that included educating all current and oncoming nursing staff on assessment and reassessment of Obstetrics (OB, the branch of medical science concerned with childbirth and caring for and treating women in or in connection with childbirth) patients and fall prevention. All remaining staff were educated prior to the start of their next shift. Please refer to A-0395 and A-0398”

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 48359 Based on interview, record review and policy review the hospital failed to arrange referrals to follow up care services for one discharged patient (#34) of one record reviewed. This failure had the potential to lead to unsafe discharges, in appropriate transitions of care and results in poor discharge outcomes for all patients in the hospital. The severity and cumulative effects of the systemic failure resulted in the hospital being out of compliance with 42 CFR Condition of Participation (CoP): Discharge Planning. The hospital census was 27.”

“CHIEF EXECUTIVE OFFICER CFR(s): 482.12(b) The governing body must appoint a chief executive officer who is responsible for managing the hospital. This Standard is not met as evidenced by: 39840 Based on interview and record review, the Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible for management of the entire hospital, including accountability for the effective oversite of staff to comply with the requirements under 42 CFR 482.23 Condition of Participation (CoP): Nursing Services, 42 CFR 482.13 CoP: Patient’s Rights and 42 CFR 482.43 Discharge Planning. These failures had the potential to affect the quality of care and safety of all patients. Findings included: Review of the hospital’s document titled, “Medical Staff Bylaws,” dated 03/28/22, showed that the CEO was responsible for the overall management of the hospital. Review of the hospital’s document titled, “Organizational Chart,” dated 01/30/24, showed that all administrative leaders reported to Staff R, CEO. During an interview on 06/05/24 at 11:00 AM, Staff R, CEO, stated that he was responsible for the hospital and the staff.”

“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: 39354 Based on observation, interview and policy review, the hospital failed to ensure the safety of all behavior health patients when they failed to provide a dedicated, secured, ligature (anything which could be used for the purpose of hanging or strangulation)-resistant and psychiatric (relating to mental illness) safe patient environment for 19 current patients (#31, #33, #35, #36, #37, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54 and #55) that were located in a locked Behavior Health Unit (BHU). They failed to ensure: - The day room entry door did not lock from the inside, had psychiatric safe chairs, tables and window coverings. - Patient rooms had psychiatric safe window coverings, laundry baskets, and trash cans. - Smoke detectors had psychiatric safe covers. - Patient care area furniture, electrical outlets and thermostats were secured with psychiatric safe screws and that wall pictures were mounted flush against the wall with psychiatric safe screws. Review of the hospital’s policy titled, “Providing a Safe Environment for Patients at Risk of Harm to Self or Others,” reviewed 01/2019, showed: - The purpose is to assure patients identified as being at risk of harm to self or others are cared for in a safe environment. - A ligature point is anything which could be used to attach a cord, rope or other material for the purpose of hanging or strangulation. - Each patient care area that is reasonably expected to care for a patient identified as being at risk of harm to self or others, shall have an assessment to identify environmental risks. - The hospital shall provide the appropriate level of education and training to staff regarding the identification of patients at risk to harm self or others, the identification of environmental patient safety risk factors and mitigation strategies. Review of the hospital’s document titled, “Behavioral Health Program Handbook,” dated 11/2019, showed patients have the right to receive care in a safe setting. Observation, of the BHU, on 06/24/24 between 3:02 PM and 3:40 PM and 06/25/24 between 8:45 AM and 9:48 AM, showed: - A shower room with an uncovered metal thermostat. - Room 302 contained a bottle of Nystatin powder (an anti-fungal powder) sitting on the floor and a nonfunctioning air conditioning unit, blowing hot air. - Room 303 had a nonfunctioning air conditioning unit. - Room 321 had a two-inch gap between a picture frame and the wall. - Room 322 had a hard rubber base board trim detached from the wall. - All patient rooms had door frames, hinges, beds, desks and curtain rods secured with non-psychiatric safe screws. - All patient rooms contained round plastic clothes baskets, hard plastic trash cans, hard plastic or rubber covered metal cages covering the smoke detectors, non-psychiatric safe window coverings, and curtain rods with metal brackets that were bent and pulling away from the wall. - The unit hallway had a broken telephone wall jack, a picture with a two-inch gap between the frame and the wall, and a non-psychiatric safe table and chair. - The patient day room had non-psychiatric safe chairs and tables, electrical outlets and sheet rock with non-psychiatric safe screws, vertical plastic blinds and an unsecured plastic trash can. - The day room entry door had a functioning lock with the ability to lock the door from inside the room. During an interview on 06/25/24 at 10:00 AM, Staff L, BHU Director, stated that she expected all screws on the BHU to be psychiatric safe, any wall hangings were to be secured flush to the walls and all air conditioning units were to work properly. She was not aware the entry door to the day room locked by hand from the inside. She did not know the day room and patient hallway tables and chairs were not psychiatric safe. She expected all patient care areas on the BHU to be psychiatric safe. During an interview on 06/26/24 at 10:16 AM, Staff H, Chief Nursing Officer, (CNO), stated that she expected all furniture in the BHU to be psychiatric safe. She expected all patient rooms to be psychiatric safe, without plastic laundry baskets. The smoke detector covers should be psychiatric safe. All outlets and wall jacks should be in good repair. All pencils should be accounted for. During an interview on 06/26/24 at 10:53 AM, Staff G, Quality Director, stated that all screws, smoke detectors, laundry baskets, curtains, blinds, furniture and trash cans needed to be psychiatric safe in the BHU.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 39840 Based on interview, record review and policy review, the hospital failed to recognize failures and conduct a complete and thorough investigation to prevent future reoccurrences following incidents of a blood transfusion (to administer blood into a vein) reaction for one patient (#7); an allegation of abuse and sexual assault for one patient (#15); a precipitous vaginal delivery (when a baby is born within three hours of regular contractions starting) of an infant for one patient (#17); a fall that resulted in an injury that required transfer to a higher level of care and surgical intervention to repair a broken bone for one patient (#20); an attempted suicide (to cause one’s own death) for one patient (#23); and abuse by threat of discharge for one Behavioral Health Unit (BHU) patient (#32). Findings included: Although requested the hospital failed to provide a policy that addressed how to investigate event reports. Review of Patient #7’s medical record dated 10/31/24 showed: - He was a 79-year-old male who presented to the Emergency Department (ED) after a fall at home. - His medical history included congestive heart failure (CHF, a weakness of the heart that causes it to not pump blood like it should leading to a buildup of fluid in the lungs and surrounding body tissues), atrial fibrillation (A-fib, an irregular, often rapid heart rate that commonly causes poor blood flow), high blood pressure and diabetes (a disease that affects how the body produces or uses blood sugar and can cause poor healing). - An ED provider documented that based on the patient’s blood workup he had chronic kidney disease (CKD, ongoing, gradual loss of kidney function), appeared to be acutely anemic and had a hemoglobin (Hgb, a protein in red blood cells that carries oxygen throughout the body) of seven (normal range was 13.7 grams per deciliter (g/dL) to 17.5 g/dL). - He was admitted for further evaluation and a possible blood transfusion. - On 10/31/24 at 1:39 PM, a blood administration product worksheet showed a crossmatch (tests the compatibility of the bloods of a transfusion donor and a recipient by mixing the serum of each with the red blood cells [RBC] of each other to ensure the absence a reaction) antibody (a protein produced by the body’s immune system in response to the presence of a foreign or harmful substance) screen was performed on two units of blood. The results showed both units were compatible and negative for antibodies. - At 2:09 PM, the first unit of blood began transfusing. It was completed at 5:08 PM. - Blood transfusion documentation showed stable vital signs (VS, measurements of the body’s most basic functions), clear sounds in both lungs and no signs or symptoms of a blood transfusion reaction. - At 6:05 PM, the second unit of blood began transfusing. - At 8:31 PM, the Medication Administration Record (MAR) showed he received tramadol (a narcotic-like pain reliever used to treat moderate to severe pain). - At 8:33 PM, a nursing note showed when the patient attempted to take the tramadol he choked and reported he was having difficulty breathing. Staff P, Licensed Practical Nurse (LPN), called Staff O, Registered Nurse (RN), for assistance. The head of the patient’s bed was elevated to help with his shortness of breath. The patient’s oxygen saturation (measure of how much oxygen is in blood. A normal is between 95% and 100%.) was 86%. Oxygen was provided, which brought his saturation up, where it continued to range from 90% to 93%. - At 8:37 PM, his temperature (normal degree of hot or cold of the body ranges from 97.8 to 99 degrees) was 98.4 degrees, his respiration rate (RR, normal breaths per minute for an adult at rest ranges from 12 to 20) was 21 per minute, his blood pressure (BP, normal adult blood pressure is between 90/60 and 120/80) was 186/82 and his pulse (normal pulse/heartbeats for adults range from 60 to 100 per minute) was 152 bpm. The nurse stopped the infusion and notified the physician of a possible transfusion reaction. The physician ordered Cardizem (a medication used to treat high blood pressure) for his elevated blood pressure and rapid heart rate, along with an antihistamine (a medication that helps conditions caused by too much histamine [a chemical created by your body’s immune system]) for the possible reaction. - At 10:05 PM, a nursing note indicated that he was “coughing almost continuously.” His pulse was at a “sustained rate of 150s.” The physician ordered the Cardizem to be increased and for lasix (medication used to treat water retention, swelling, and high blood pressure) to be started. - On 11/01/24 at 3:41 AM, an electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions) showed A-fib with Rapid Ventricular Response (RVR, a result of A-fib with a rapid and irregular pumping of blood through the heart) and a pulse of 148 bpm. - At 3:50 AM, a nursing note indicated the patient’s pulse suddenly dropped from over 150 bpm to 70 bpm. When the nurse entered the patient’s room, he was sitting up in bed attempting to speak but was not able to. The Cardizem was stopped but the patient’s pulse continued to drop. - At 3:53 AM, his pulse was in the upper 50s and a rapid response (a changing situation that requires more staff to address the current needs of the patient) was called. The patient had large amounts of dark sanguineous (bloody; containing blood) fluid draining from his mouth. - At 3:56 AM, the patient suffered cardiac arrest (when the heart suddenly and unexpectedly stops pumping). Advanced Cardiac Life Support (ACLS, specific life saving measures taken by certified health professionals when a patient’s heartbeat or breathing stops) was initiated and continued until 4:21 AM when the patient’s death was pronounced. Review of the hospital’s untitled, undated document regarding an event on 10/31/23, showed: - Patient #7 was having difficulty breathing from the beginning of the night shift on 10/31/23. His vitals were “unstable to begin with, his HR was in the 150s, BP around 150 systolic pressure (the pressure against the artery during the heartbeat, when the heart is pushing blood out) and oxygen saturation was above 90%.” - At 8:30 PM, the patient was given pain medication. He had difficulty swallowing, choked on the water, began to turn red in the face and was unable to cough or breathe at that time. - The on-call physician was notified and orders to stop the transfusion, administer oxygen and obtain a chest x-ray (test that creates pictures of the structures inside the body-particularly bones) were received. - The physician believed the symptoms were related to a transfusion reaction and treated like one. The blood products were stopped and the intravenous (IV, in the vein) was flushed with normal saline (a solution made of salt and water). - Staff O, RN, notified the lab about a possible transfusion reaction. A laboratory technician met Staff P, LPN, at the bedside to obtain the blood bag and tubing. They were told it was a possible transfusion reaction. - Staff P, LPN, was unaware of transfusion reaction protocol and did not follow it. - At 3:53 AM, Patient #7’s pulse dropped to 70 bpm. Upon arrival to the patient’s room, he was “spewing blood from his mouth and nose.” - At 3:55 AM, his pulse was 23 bpm. - At 3:56 AM, a code blue (emergency situation where a patient’s heart or breathing has stopped, and staff quickly respond to attempt to restore the heartbeat or breathing) was called, the patient’s time of death was documented at 4:21 AM. - On 11/01/23, the nursing supervisor documented that a possible blood transfusion reaction had occurred without a lab workup. The lab director was notified and the workup was initiated. Given the time frame since the patient had expired, no transfusion specimens were available. - A type, screen and crossmatch were repeated, using the pre-transfusion specimen. Results indicated that the patient and the blood product were compatible. - Findings were reported to the United States Food and Drug Administration (FDA) and the Professional Standards Committee regarding potential quality issues with the blood products. Documentation indicated that “it is doubtful if this is a transfusion reaction per the laboratory director and physicians involved in the case.” “Just to be complete in our diligence, we reported it to the FDA.” - Per Staff H, Chief Nursing Officer (CNO), the hospital identified education deficits in the area of transfusion reaction responses and nursing staff had been educated. Review of the hospital’s undated document titled, “Updated Policies,” showed: - Staff were to sign and date that they had read the new, updated policies that were attached. - The first attached document, titled, “Blood Administration,” was composed of screenshots from within the hospital’s electronic health record (EHR) system. It directed staff on how to obtain consent for a blood transfusion, verify the blood products, initiate the transfusion and document during the transfusion process. - A second attached policy was titled, “Blood and Blood Product Administration,” dated 01/19/23. This directed staff to refer to the “Transfusion Reaction” policy if a transfusion reaction was suspected. - The “Transfusion Reaction” policy was not attached. - The staff attestation sheets, dated 11/02/23 through 05/22/24, did not identify which departments and/or nursing units had been educated, and that not all staff had completed it. During an interview on 06/04/24 at 4:17 PM, Staff N, Clinical Educator, stated that she did not have access to the event reporting system and was unaware of any sentinel events (actual events that could or did cause patient harm) or the need for education unless she received notification from her supervisor, Staff H, CNO. She was rarely notified to educate after an event. She provided education via written, computer and face-to-face, to all RNs and LPNs, that administered blood, after the incident with Patient #7. Staff signed attestation sheets and/or sent email confirmations that they had received the education. During an interview on 06/04/24 at 2:25 PM, Staff H, CNO, stated that it was the responsibility of the nursing staff who felt there was a possible blood transfusion reaction to notify the laboratory so that the reaction workup could be started. After the laboratory was notified, the reaction workup order could be initiated by either nursing or laboratory staff. She would only educate the staff involved in an event, not bring attention to the event in question, or point out any particular employee failure. During an interview on 06/04/24 at 4:28 PM, Staff M, Chief Operating Officer (COO), stated that only a few staff could access the event reporting system due to software restrictions. The Quality Director would check event reports daily during the staff’s safety huddles. During the huddle each event was reviewed and it was decided if follow-up was needed or not. After Patient #7’s event, it was the responsibility of the laboratory director and Staff N, Clinical Educator, to educate respective staff. The department head would be responsible for ensuring that the department received the education. Review of Patient #15’s medical record, dated 02/03/24, showed: - She was an 18-year-old female admitted from an outside hospital with a diagnosis of schizophrenia (serious mental disorder that affects a person’s ability to think, feel, and behave clearly). - She lived with her adoptive parents; had a history of molestation by her brother; and was “hearing voices to kill herself and was walking the street with scissors when her adoptive dad called the police, and they picked me up”. - Nursing documentation, dated 02/05/24 at 1:37 AM, indicated that Patient #15 had reported that a male peer was flirting with her. She was instructed to let the staff know if there were any more issues. - A psychiatric (relating to mental illness) note, dated 02/05/24 at 12:41 PM, indicated Patient #15 reported to the provider that a male peer on the unit was making her uncomfortable. The provider encouraged the patient to report the peer’s behavior to the staff. - On 02/05/24 at 12:58 PM, an order for sexual precautions was entered. - On 02/06/24 at 5:50 PM, she was discharged to home. Review of the hospital’s untitled, undated document, showed hospital staff received a telephone call from Patient #15’s mother, on 02/19/24, reporting that Patient #15 was raped by a staff member while admitted on the Behavioral Health Unit (BHU). The hospital staff called Patient #15 for additional information. Patient #15 reported that she was raped by another patient and would be filing a police report the next day. Patient #15 had reported to the provider and the nursing staff that a male patient was flirting with her and making her feel uncomfortable during her stay. On 02/20/24, the hospital staff spoke with the provider who remembered Patient #15 had reported a male patient had been following her around. However, the name of the patient was not the same patient name Patient #15 had reported to the other hospital staff. The patient was delusional (false ideas about what is taking place or who one is) and hallucinating (seeing or hearing things which are not there) throughout much of her admission. The provider reported that Patient #15 made advances towards another patient which resulted in the sexual precautions order. On 02/23/24, the hospital reached out to the local police department to extend the hospital’s cooperation and concern. A message was left with the investigating officer and a copy of the police report had been requested. Patient #15’s EHR was reviewed, staff interviews were completed, 15-minute checks were reviewed for completeness, and there was an attempt to pull the video footage. None of the staff could recall any allegations of rape or sexual contact between patients in the month of February. At that time, Patient #15’s claim was unsubstantiated until further evidence was provided. The plan was to reeducate regarding sexual precautions and to ensure that all blind spots were visually checked. During an interview on 06/04/24 at 4:17 PM, Staff N, Clinical Educator, stated that she “occasionally” provided education on the BHU. She could not recall the last time she provided education on abuse or neglect and that most of the education she provided regarding abuse was done during new-hire orientation. During an interview on 06/04/24 at 3:50 PM, Staff L, BHU Director, stated that she was on vacation during this event and was not involved in the investigation. She was unsure if any education was provided to staff during her absence. She could not recall any staff education after her return and it was not documented in her meeting minutes. During an interview on 06/04/24 at 5:10 PM, Staff O, RN, stated that she had not received any education on sexual precautions or abuse after the date Patient #15’s event occurred. During a telephone interview on 06/10/24 at 8:55 AM, Staff T, BHU RN, stated that she had not received any education on sexual precautions or abuse after the date Patient #15’s event occurred. During an interview on 06/04/24 at 2:25 PM, Staff H, CNO, stated that she was aware of a report of sexual abuse and that it had been investigated. When asked how the hospital investigated these types of events, she stated that she was unsure if there was a policy that directed staff on how to investigate; and if there was, she could not speak to how the policy stated investigations should be done. There nad been no hospital wide education related to Patient #15’s event. During an interview on 06/04/24 at 4:28 PM, Staff M, COO, stated that she helped with the investigation of Patient #15’s event. After the investigation, staff were educated on the Sexual Precautions policy and to check “hidden” areas that the video cameras did not monitor. She did not have any attestation sheets for the education and no Root Cause Analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to find the root cause) was completed. Review of Patient #17’s medical record, dated 02/19/24, showed: - She was a 23-year-old female who presented to the Obstetrics (OB, the branch of medical science concerned with childbirth and caring for and treating women in or in connection with childbirth) Department at 5:14 PM, with a chief complaint of possible rupture of membranes (a fluid-filled bag [amniotic sac] that surrounds and protects the fetus) at 9:00 AM. - She had a history of two previous live births. - There was no documentation of fetal or maternal monitoring from 5:25 PM until 7:15 PM and no documentation of fetal or maternal monitoring from 7:16 PM until 11:12 PM. - At 7:15 PM, her blood pressure was 126/98. - Fentanyl (a medication used to treat severe pain, and is a high-risk drug for theft and personal use) 100 micrograms (mcg, measure of dosage strength) intravenous push (to manually administer a dose of medication through a tube into a vein) was given at 11:10 PM and cervical dilation was seven cm. - At 11:13 PM, her blood pressure was 157/102 and pulse was 105. - At 11:30 PM, her cerrvical dilation was documented as complete. - At 11:39 PM, she delivered a male infant. - The physician arrived three minutes after the baby’s birth, the infant was vigorous and crying, with excellent respiratory effort. - At 11:45 PM, the placenta (an organ that develops in the uterus during pregnancy that provides oxygen and nutrients to the growing baby and removes waste products from the baby’s blood) was delivered spontaneously and intact. Review of the hospital’s untitled, undated document, showed: - On 02/19/24 at 9:00 PM, Patient #17 was laboring and was not noted to be on the monitor while another patient was delivering. - Staff stated Patient #17 was not in active labor and would not deliver until morning. - Patient #17 got herself up to the tub around 11:00 PM and was complaining of pain when she got out of the tub. - Staff S, RN, gave Patient #17 Fentanyl at 11:10 PM, while the patient was not on a monitor, per the physician and review of the EHR. - Patient #17 was placed on the monitor at 11:10 PM, and at 11:36 PM, the house supervisor was notified by phone of the imminent delivery by Staff S, RN, who stated “We need you here. We think this girl is about to deliver and the doctor stated she will try to get here on time.” - The house supervisor went directly to the OB unit and arrived at 11:39 PM and the baby had just delivered. - The physician arrived within another two or three minutes. Patient #17 and the baby were both stable. - The physician was concerned about the lack of monitoring and medication administration without monitoring, as well as lack of notification of the physician. The physician stated she was not even made aware that Patient #17 was laboring. The response to the situation was documented by the former Nurse Manager as: - She had spoken with Staff S, RN. It was reported that Patient #17 was not in active labor or hurting so she was not on the monitor and the plan was to let the patient sleep through the night. - Staff S had checked on Patient #17 shortly after the other patient had delivered at 8:01 PM. - At 9:30 PM, Patient #17 stated she was feeling a little something occasionally, but was not uncomfortable and was going to go to sleep. - An hour or so later, Staff S noticed that the tub was running so she went in to check on Patient #17, she indicated that she was fine. - At 11:00 PM, Patient #17 called for help to get out of the tub saying she was hurting a lot. Her cervix was dilated to seven cm. - Staff S then asked a coworker when the cut off to give fentanyl was to which the coworker responded that she did not know. Then, Staff S, RN, phoned another coworker with no immediate answer, and then another. - Staff S told the Nurse Manager that she knew she should have called the physician and admitted she was “scared of her.” - When the physician arrived, she apologized to her and knew then that she should have called her earlier. - The Nurse Manager informed Staff S that all three physicians had come to her and made it very clear they wanted the phone call and expected those phone calls. - The Nurse Manager explained to Staff S under no circumstance should nurses get called over the physicians; if there was a change in status the physicians should be called immediately. - She was concerned that Staff S gave medication to Patient #17 who was not, and had not been on the monitor. - That under no circumstances do you do anything that could disrupt the baby’s environment without knowing the baby’s wellbeing and the contraction pattern. This could be extremely detrimental. - Staff S voiced her understanding and that it was a very big learning experience for her. - The Nurse Manager felt that Staff S had come out of that having learned a lot and would be more diligent with monitoring and informing the physician in the future. Review of the hospital’s undated document titled, “Minutes for the March 8th Staff Meeting,” showed staff were instructed to contact the physician with questions about patient care. During an interview on 06/24/24 at 3:30 PM, Staff K, OB Manager, stated that she remembered hearing about the incident with Patient #17 and the former Nurse Manager had mentioned it in the 03/08/24 staff meeting. Staff were to call the physician when they had questions about a patient. She stated that she had not received any specific education about the OB policy that addressed how to monitor patients during labor. During an interview on 06/04/24, Staff M, COO, stated that the department head was delegated to provide and record education to staff. She also stated that the former Nurse Manager only documented education to the involved employee when Patient #17 was not monitored. She was not aware of any other education that had been provided to OB staff. During an interview on 06/04/24 at 2:25 PM, Staff H, CNO, stated that unit specific education was handled by the unit manager. During an interview on 06/04/24 at 4:17 PM, Staff N, Clinical Educator, stated that she did not provide education in response to an event, but mostly during orientation. Review of Patient #20’s medical record, dated 03/26/24, showed: - He was a 62-year-old male admitted to the BHU with a long history of schizophrenia. - Fall precautions were documented on 03/31/24, 04/05/24, 04/06/24, 04/07/24, and 04/08/24; however, no documentation of preventive measures were noted. - On 03/31/24, bilateral lower leg swelling was noted. The patient used a wheelchair intermittently throughout his stay. - He had lower leg cellulitis (an infection of the skin) was treated with antibiotics. - On 04/08/24 at 7:53 AM, fall precautions were ordered. - On 04/08/24, Patient #20 fell, after he stood up from his wheelchair to get his breakfast tray, sat back down, and hit his leg on the wheelchair. - He suffered a leg fracture (a break in a bone) and was transported to an outside hospital for surgical repair. Review of the hospital’s untitled, undated document showed an event, on 04/08/24 at 7:30 AM, where Patient #20 hit his leg on the wheelchair and suffered a hip fracture. He was observed in his wheelchair with spilled orange juice under his wheelchair. He could not verbalize his concerns nor discomforts. He stood up to receive his breakfast tray, became unsteady and sat back down in his wheelchair, but hit his leg on the side of the wheelchair. His legs were examined, there were no protrusions or abnormalities were noted. At 7:50 AM, he was wheeled to the nurse’s station and his left thigh was noticeably irregular. The Nurse Practitioner (NP, a nurse who has advanced clinical education and training) arrived to assess the patient. A rapid response (a changing situation that requires more staff to address the current needs of the patient) was called and ED staff arrived and assisted the patient to the stretcher. The investigation and follow up was documented and the post fall review was completed; barriers were identified were challenges communicating with the patient and his advanced age. The precipitating factors included cellulitis related pain, deconditioning related to using the wheelchair for transportation over several days, and the orange juice on the floor. It was unclear if this was spilled before or after his near fall. The treatment and resolution were the rapid response and his discharge to a higher level of care. During an interview on 06/04/24 at 3:52 PM, Staff L, BHU Director, stated that there was no education provided to her staff after Patient #20 fell. During a telephone interview on 06/06/24 at 2:23 PM, Staff U, BHU RN, stated that she did not receive any specific education after Patient #20 fell. During a telephone interview on 06/10/24 at 8:55 AM, Staff T, BHU RN, stated that she did not receive any education after Patient #20 fell. During an interview on 06/04/24 at 2:25 PM, Staff H, CNO, stated that unit specific education was handled by the unit manager. During an interview on 06/04/24 at 4:17 PM, Staff N, Clinical Educator, stated that she did not provide education in response to an event, but mostly during orientation. Review of Patient #23’s medical record, dated 02/24/24, showed: - He was a 48-year-old male who was admitted to the BHU after attempting suicide by overdosing on medication. - He had a history of substance abuse (misuse of alcohol and/or other drugs) and multiple suicide (SI, thoughts of causing one’s own death) attempts by medication overdose, hanging and walking out into traffic. - At the time of his admission he stated that he had SI, but no plan. He verbally contracted for safety, and was placed on 15-minute observation. - On 02/26/24 at 12:22 AM, a nursing note indicated he admitted to thoughts of SI and homicidal ideation (HI, thoughts or attempts to cause another’s death) but verbally contracted for safety. He reported hallucinations of “bad people hurting me.” His 15-minute observations continued. - On 2/26/24 at 2:42 PM, a nursing note showed he attempted to elope (when a patient makes an intentional, unauthorized departure from a medical facility) when he pushed past staff to get to the door. He yelled “I need help” and “help me” repeatedly. Medication was given and the patient went to his room to take a nap. - On 2/26/24 at 4:33 PM, a nursing note showed staff responded to a door alarm and found that the patient had tied a bed sheet around his neck and looped it over the door. The patient was standing on his bed and putting pressure on the sheet around his neck. The RN was able to remove the sheet from the door and the patient’s neck. He was placed on one-to-one (1:1, continuous visual contact with close physical proximity) observation and moved to a room across from the nurses’ station. Review of the hospital’s untitled, undated document showed an event on 02/26/24, where staff responded to loud door alarm to find Patient #23 had tied a bed sheet around his neck and looped it over the door. The patient was standing on the bed while leaning out putting pressure on sheet around neck. The RN jumped up on bed next to patient and was able to pull the door closer to patient and get the sheet off of the door and from around patient’s neck. The response to the situation was documented as a chart review showed staff responded promptly and the door alarm worked as designed. The patient was changed to 1:1 observation and moved closer to nursing station. During an interview on 06/04/24 at 4:17 PM, Staff N, Clinical Educator, stated that she “occasionally” provided education on the BHU. She could not recall the last time she provided education on suicide attempts or elopement and that most of the education she provided regarding those areas was done during new-hire orientation. During a telephone interview on 06/10/24 at 8:55 AM, Staff T, BHU RN, stated that she had not received any education on suicide precautions after Patient #23’s event occurred. During an interview on 06/04/24 at 2:25 PM, Staff H, CNO, stated that if a patient was admitted to the BHU after a recent suicide attempt, they would be placed on a 1:1 observation status until they could be re-evaluated. Unit specific education was handled by the unit manager. During an interview on 06/04/24 at 3:50 PM, Staff L, BHU Director, stated that she was on vacation during this event and was not involved in the investigation. She was unsure if any education was provided to staff during her absence. She could not recall any staff education after her return and it was not documented in her meeting minutes. During an interview on 06/04/24 at 4:28 PM, Staff M, COO, stated that Patient #23 had not expressed any SI prior to the event. She also stated that the department head was delegated to provide and record education to staff, however, the hospital did not educate staff after this event Review of Patient #32’s medical record, dated 06/05/24, showed: - He was a 30-year-old male with a history of bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows), Post Traumatic Stress Disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock), anxiety (a feeling of worry or fear experienced intermittently), mood disorder (when a person’s general emotional state or mood is distorted or inconsistent with their circumstances and interferes with their ability to function), and SI. - He presented to the ED accompanied by his outpatient addiction (condition of being dependent on a particular substance, thing, or activity) counselor on 06/04/24 with a chief complaint of hearing voices, seeing shadows and several manic (elevated or excited mood or behavior) episodes. - He received a psychiatric evaluation from Staff SS, Physician, who agreed to admit him voluntarily to the hospital’s BHU. - Staff SS told the patient no violent behavior would be tolerated and that the patient would need to attend group therapy and make efforts to participate in a healthy way. - He was discharged against medical advice (AMA) on 06/05/24 after vandalizing the facility and threatening harm to himself and staff. During an interview on 06/26/24 at 9:40 AM, Staff SS, Physician, stated that: - He was reluctant to admit Patient #32 based on his behavior during previous admissions. The patient had a history of non-compliance with treatment, had threatened him, other staff and his parole office. He engaged in manipulative behavior to avoid incarceration, had a propensity for violence, resisted treatment for methamphetamine (a drug with more rapid and lasting effects than amphetamine, used illegally as a stimulant) abuse, and displayed sociopathic (a person with a personality disorder manifesting itself in extreme antisocial attitudes and behavior and lack of conscience) behavior. - He was contacted by the ED to evaluate the patient for admission and after meeting with the patient and his substance abuse counselor agreed to admit him. - He discussed the patient’s behavior during his previous admission and wanted to set clear expectations for successful therapy, including refraining from violence and threats of violence. - He had a historical basis for his evaluation and had a good understanding of the patient’s behavior and demands. During an interview on 06/26/24 at10:15 AM, Staff G, Quality Director stated that the physician’s statement to Patient #32 that no violence would be tolerated was intended to set expectations for behavior. He acknowledged that the patient met the standard for admission to an inpatient psychiatric unit and that conditions for behavior placed prior to admission could potentially be considered a threat. A threat would be considered abuse. During an interview on 06/26/24 at 10:15 AM, Staff H, CNO, stated that telling a patient they would be discharged for violent behavior would be considered either setting boundaries or a threat, but therapeutic communication would have been more appropriate. 41865”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(2)(vii) [The hospital must require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following:] (vii) The use of first aid techniques and certification in the use of cardiopulmonary resuscitation, including required periodic recertification. This Standard is not met as evidenced by: 39840 Based on interview, record review and policy review, the hospital failed to ensure that staff were trained on a periodic basis in first aid related to restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head), for three staff (H, O, and P) of four staff, whose personnel files were reviewed. This failure had the potential to result in serious injury or death to patients who required restraints in the hospital. Findings included: Review of the hospital’s policy titled, “Restraint and Seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving),” dated 05/26/23, showed staff restraint training should include first aid techniques. Review of three personnel files showed no periodic restraint first aid training for the follow staff: - Staff H, Chief Nursing Officer (CNO); - Staff O, Registered Nurse (RN) Clinical Educator; and - Staff P, Licensed Practical Nurse (LPN). During an interview on 06/05/24 at 4:16 PM, Staff H, CNO, stated that restraint first aid training should be completed by all clinical staff.”

“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: 39840 Based on interview, record review and policy review, the staff failed to follow their policies for assessment for three discharged patients (#17, #20, and #32) of three discharged patient records reviewed. This failure had the potential to place all patients at risk for their safety. Findings included: 1. Review of the hospital’s policy titled, “Labor Responsibilities,” dated 01/16/23, directed staff to evaluate labor at regular intervals and assess and record vital signs (VS, measurements of the body’s most basic functions) and fetal monitor patterns every 15 to 30 minutes during the active phase of labor which was defined as four centimeters (cm) dilation or greater. Review of Patient #17’s medical record, dated 02/19/24, showed: - She was a 23-year-old female who presented to the Obstetrics (OB, the branch of medical science concerned with childbirth and caring for and treating women in or in connection with childbirth) Department at 5:14 PM, with a chief complaint of possible rupture of membranes (a fluid-filled bag [amniotic sac] that surrounds and protects the fetus) at 9:00 AM. - She had a history of two previous live births. - There was no documentation of fetal or maternal monitoring from 5:25 PM until 7:15 PM and no documentation of fetal or maternal monitoring from 7:16 PM until 11:12 PM. - At 7:15 PM, her blood pressure (BP, normal between 90/60 and 120/80) was 126/98. - Fentanyl (a medication used to treat severe pain) 100 micrograms (mcg, measure of dosage strength) intravenous push (to manually administer a dose of medication through a tube into a vein) was given at 11:10 PM and cervical dilation was seven cm. - At 11:13 PM, her blood pressure was 157/102 and pulse (normal 60 to 100 per minute) was 105. - Cervical dilation was documented as complete at 11:30 PM. - She delivered a male infant at 11:39 PM. - The physician arrived three minutes after the time of the baby’s birth and the infant was vigorous and crying with excellent respiratory effort. - The placenta (an organ that develops in the uterus during pregnancy that provides oxygen and nutrients to the growing baby and removes waste products from the baby’s blood) was delivered spontaneously and intact and 11:45 PM. During a telephone interview on 06/06/24 at 3:58 PM, Staff S, OB Registered Nurse (RN), stated that she cared for Patient #17 and gave her Fentanyl when she was not on a monitor. She also stated that the baby should have been monitored. During an interview on 06/04/24 at 3:30 PM, Staff K, OB Nurse Manager, stated that pain medication should not be given without the patient being monitored. During a telephone interview on 06/10/24 at 11:58 AM, Staff W, OB Physician, stated that she would expect to receive a call if there were a change in a patient’s condition. She would also expect for patient’s to be monitored when medications were needed. During an interview on 06/05/24 at 4:16 PM, Staff H, Chief Nursing Officer (CNO), stated that she would have expected all OB patients to be monitored when pain medications were given. 2. Review of the hospital’s undated policy titled, “Observations and Precautions,” showed: - Fall precautions were defined as increased awareness of a patient condition that required a higher level of care due to an assessed high risk for injury due to falling; - Any patient felt to be at risk for falls would have preventive measures implemented as indicated; and - Preventive measures may include, but were not limited to, move the patient closer to the nurse’s station; apply a fall risk band; clear the pathway to the bathroom; assistive devices for ambulation within easy reach; frequent patient checks with toileting every two hours; frequent reorientation and reeducation on safety needs; and diversionary activities. Review of Patient #20’s medical record dated 03/26/24 showed: - He was a 62-year-old male admitted to the Behavioral Health Unit (BHU) with a long history of schizophrenia (serious mental disorder that affects a person’s ability to think, feel, and behave clearly). - Fall precautions were documented on 03/31/24, 04/05/24, 04/06/24, 04/07/24, and 04/08/24; however, no documentation of preventive measures or interventions were noted. - Bilateral lower leg swelling was noted on 03/31/24 and the patient used a wheelchair intermittently throughout his stay. - Lower leg cellulitis (an infection of the skin) was treated with antibiotics. - Fall precautions were ordered on 04/08/24 at 7:53 AM. - He fell on 04/08/24 after he stood up from his wheelchair to get his breakfast tray and sat back down, when he hit his leg on the wheelchair. - He suffered a leg fracture (a break in a bone) and was transported to an outside hospital for surgical repair. During a telephone interview on 06/06/24 at 2:23 PM, Staff U, BHU RN, stated that she had cared for Patient #20 and when he was admitted, he was able to walk. She stated that his legs were swollen and he used a wheelchair at times. She stated that she was not sure who allowed Patient #20 to have a wheelchair. He would be in and out of it throughout her shifts. She stated that she had heard that Patient #20 possibly tripped on one of the footrests of the wheelchair and he hit the arm rest with his hip when he sat back down in the wheelchair. She stated that wheelchairs on a psychiatric (relating to mental illness) unit were dangerous. During a telephone interview on 06/10/24 at 8:55 AM, Staff T, BHU RN, stated that any patient on fall precautions should have a yellow bracelet and a sign on their door. She stated that specific fall interventions were not documented in the medical record and patients were supposed to be close to the nurses’ station. She stated that Patient #20 was never close to the nurses’ station because he always wanted to be in the same room when he was in the hospital and that room was down the hall. She also stated that, at times, there would be lots of patients in wheelchairs. During an interview on 06/05/24 at 3:52 PM, Staff L, BHU Director, stated that there was no video available in the area where Patient #20 fell. Patient #20 was very independent, he stood up to get his own tray and he fell. She was sure one of her staff had witnessed the fall. During an interview on 06/05/24 at 4:16 PM, Staff H, CNO, stated that Patient #20’s fall was witnessed and she would expect staff to follow the hospital’s policies. 3. Review of the hospital’s policy titled “Suicide Risk Assessment,” dated 06/2021, showed an initial suicide risk assessment should be performed on every patient admitted to identify individuals at risk for suicide and to obtain clinical information relevant to their treatment. Ongoing assessments should be conducted to identify changes in the acute factors during their hospitalization. These assessments should be documented, including the initial risk assessment, the self-harm questions asked by the RN each shift, and the patient’s self-report completed twice daily. Review of the hospital’s policy titled “Assessment/Re-assessment Documentation,” dated 06/2021, showed the patient’s condition would be reassessed as the patient’s condition/situation warrants. Review of the hospital’s policy titled “Providing a Safe Environment for Patients at Risk of Harm to Self or Others,” dated 01/2019, showed assessment/re-assessment must be completed on any patient seen in a psychiatric care setting. Patients identified as being at risk must be re-assessed at least daily in an inpatient setting. Review of Patient #32’s medical record showed: - He was a 30-year-old male with a history of bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows), Post Traumatic Stress Disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock), anxiety (a feeling of worry or fear experienced intermittently), mood disorder (when a person’s general emotional state or mood is distorted or inconsistent with their circumstances and interferes with their ability to function) and suicidal ideation (SI, thoughts of causing one’s own death) who presented to the emergency department (ED) accompanied by his outpatient addiction (condition of being dependent on a particular substance, thing, or activity) counselor on 06/04/24 with a chief complaint of hearing voices, seeing shadows and several manic (elevated or excited mood or behavior) episodes. - He received a psychiatric evaluation from Staff SS, Physician, who agreed to admit him voluntarily to the hospital’s BHU. - On 06/05/24 at approximately 7:20 PM, Patient #32 asked Staff TT, RN, if he missed lunch. He was informed dinner had already been served and was offered food. The patient was unhappy with the food choices and having to wait for the food to be delivered. He punched a hole in the wall, yelled he wanted to leave against medical advice (AMA) and refused to return to his room. - At 7:30 PM he was given Benadryl (a medication that that helps conditions caused by too much histamine [a chemical created by the body’s immune system]), Haldol (a medication used to treat mental disorders by decreasing excitement of the brain) and Ativan (a medication used to treat anxiety or sleep difficulty) by mouth per his request for something to help calm down. - Staff TT called Staff SS and received an order to discharge the patient. - The patient was informed of the discharge order, became angry, refused to leave, demanded a transfer to another hospital and threatened suicide. He threatened staff with a pencil and repeatedly hit his head on the window in his room. - Staff SS was contacted again and ordered staff to request the police remove the patient from the hospital. - Additional staff were summoned to provide support. Upon their arrival the patient changed clothes, sat alone in the hall and said he would return with a firearm. - The police arrived, spoke with the patient and he accompanied them to the hospital’s entrance at 7:55 PM. His belongings were returned. He refused to sign the hospital’s AMA form. - Patient #32 did not receive a psychiatric re-assessment before he left the hospital after he threatened suicide. During a telephone interview on 06/25/24 at 7:00 PM, Staff TT, RN, stated that: - She was patient #32’s nurse the evening of 06/05/24. - The patient woke up at approximately 7:20 PM and was upset that he slept through dinner and demanded something to eat. He was offered sandwiches and other snacks but was upset by the food choices and while staff retrieved food from the kitchen, he punched a hole in the wall outside of his room and yelled he wanted to leave. - She called Staff SS, Physician, and he ordered the patient to be discharged. - She informed the patient he was to be discharged, he became angry, he threatening to “blow my brains out,” asked to be transferred to another facility and refused to leave. - He refused to leave his room, threatened staff with a pencil and repetitively hit the window in his room with his shoulder and head. - She notified the physician of the patient’s behavior and refusal to leave, he instructed her to request the police remove the patient from the hospital. - The patient changed his mind multiple times about leaving and began complying with staff requests when additional staff arrived. - The police arrived and had a calm conversation with the patient and agreed to give him a ride home. - She stated that she did not attempt to re-assess the patient because attempts to engage him provoked additional outbursts. During a telephone interview on 06/25/24 at 3:55 PM, Staff GG, House Supervisor, stated that: - She was summoned to the BHU on the evening of 06/05/24 because of a combative patient and arrived after the patient returned to his room. - The police arrived and spoke with the patient. She heard the police ask the patient several times about his intention of harm to himself or others and the patient stated that he was mad and just saying things and wanted to leave. - She was unaware of the patient’s previous statement about harming himself or threats to staff. - She thought the patient was aware that he could stay and encouraged him to return the ED if he needed help. - She stated that the patient did not receive a psychiatric re-assessment. During an interview on 06/26/24 at 9:40 AM, Staff SS, Physician, stated that: - He felt discharge was appropriate for the patient because he was admitted voluntarily and felt treatment would be ineffective due to the patient’s non-compliance with therapy. - He stated that he was aware of the patient’s violent outburst but was unaware of the patient’s statements about harming himself and others. - He agreed that a psychiatric re-assessment would have been appropriate had he known about those statements. An involuntary hold also would have been considered. During an interview on 06/26/24 at 10:15 AM, Staff G, Quality Director, stated that: - A patient admitted voluntarily should be re-assessed before leaving AMA. - He would have expected Patient #32 was re-assessed before he was allowed to leave AMA. - The physician should have been made aware of the patient’s statements about harming himself and staff. - He expected that a patient receiving psychiatric medications would be re-assessed to document their affect. During an interview on 06/26/24 at 10:15 AM, Staff H, CNO, stated that: - If a patient expressed SI or homicidal ideation (HI, thoughts or attempts to cause another’s death) after wanting to leave AMA, she expected documentation of a psychiatric re-assessment. - An involuntary hold, if appropriate, was a physician decision - If the patient changed their mind and wanted to stay, they would stay. During an interview on 06/26/24 at 9:20 AM, Staff L, Nurse Manager, stated that psychiatric patients who wished to leave AMA should receive a psychiatric re-assessment to evaluate the safety of their discharge. During an interview on 06/26/24 at 9:05 AM, Staff QQ, Charge RN, stated that when patient’s condition deteriorates, they can be held involuntarily if an affidavit (a written statement confirmed by oath, for use as evidence in court) describing the need has been completed and the physician orders the patient held. Patients with a change in condition or a new expression of SI or HI were re-assessed and the physician notified. 41865 49404”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 39840 Based on interview and record review, the hospital failed to provide annual evaluations for three staff (H, O, and Q) of three personnel records reviewed. Findings included: Although requested, the hospital failed to provide a policy that addressed performance evaluations. Review of personnel records showed no evaluations for Staff H, Chief Nursing Officer (CNO); Staff O, Registered Nurse; and Staff Q, Licensed Practical Nurse. During an interview on 06/05/24 at 1:20 PM, Staff V, Human Resources Generalist, stated that there were no annual evaluations for any staff at the hospital. During an interview on 06/05/24 at 4:16 PM, Staff H, CNO, stated that annual evaluations need to be performed and they had not done them.”

“DISCHARGE PLANNING EVALUATION CFR(s): The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). This Standard is not met as evidenced by: 48359 Based on interview, record review and policy review the hospital failed to arrange referrals to follow up care services for one discharged patient (#34) of one record reviewed. Findings included: Review of the hospital’s policy titled, “Home Health and Hospice Referrals,” dated 06/2021, showed: - The Social Worker (SW, provides services intended to aid the disadvantaged, distressed, or vulnerable person) will provide the patient (or responsible party representing the patient) with a current copy of the list of those Home Health (medical care delivered in a patient’s home) agencies located in the service area of the patient’s choice. - The SW will inform the patient or responsible party of his or her right to choose the Home Health agency, educating them about Home Health services. - The SW will provide the patient with a Confirmation of Receipt of Providers List form for the patient to sign, verifying his/her choice of agencies. This form will become a part of the permanent record. - The agency of the patient’s or responsible party’s choice will then be notified by the SW with the referral. Review of the hospital’s policy titled, “Referrals to Community Resources,” dated 06/2021, showed: - Referrals to outside agencies will be made through the SW department. - The SW will consult with the physician and nursing staff as indicated and serve as a liaison between the patient and the community agency. - The patient/responsible party will be offered the appropriate list of agencies to meet his/her discharge needs with the appropriate explanation and will be given the choice of which agency he/she prefers. - The patient/responsible party will be asked to sign the Confirmation of Receipt of Providers List. Review of the hospital’s policy titled, “Referral to Social Services (SS),” dated 06/2021, showed: - Referrals will be accepted from physicians, nurses, allied health professionals (health professionals other than nurses or physicians), community, patient/social support system and Case Managers (CMs, coordinates and provides services to people who face complex challenges). - Referrals may be made verbally, by order in the patient’s chart or in writing and routed to the SW. The SW will follow up. - High risk factors/triggers for the SW include access problems at home, new diagnoses, uncontrolled and/or noncompliance with diabetes (a disease that affects how the body produces or uses blood sugar and can cause poor healing), inability to perform Activities of Daily Living (ADL, daily self-care activities, such as bathing, dressing and eating), dependent and living at home, inadequate or no known social support system and/or no insurance/financial difficulties. Review of the hospital’s policy titled, “Discharge Planning,” dated 11/2021, showed: - The purpose of the policy was to assure the discharge planning process and the discharge plan are consistent with the patient’s goals for care and his or her treatment preferences. To ensure an effective transition of the patient from the hospital to post (after) discharge care, as well as reduce the factors leading to preventable hospital readmissions. - If the discharge plan for a patient involves the need for post-acute care providers, Nevada Regional Medical Center (NRMC) shall provide a list of post-acute care providers that are available to the patient and that serve the geograpic area in which the patient resides. - NRMC shall document in the patient’s medical record that the list was presented to the patient or to the individual acting on the patient’s behalf. - NRMC shall assist patient, their families or the patient’s representative in selecting a post-acute care provider by using and sharing data. - NRMC shall arrange for the initial implementation of the discharge plan. This includes arranging referrals to rehabillitation (the action of restoring someone to health or normal life through training and therapy) hospitals, long-term care hospitals, long term care facilities, home health and pertinent community resources that may be able to assist with financial, transportation, meal preparation or other post-discharge needs. - Staff shall document in the patient’s medical record the arrangement made for initial implementation of the discharge plan, including materials provided to the patient or the patient’s informal caregiver or representative. Review of the hospital’s policy titled, “Discharging of a Patient,” dated 06/19/23, showed: - Discharge is often a time when things get rushed and items are often missed or neglected. - Extreme care should be taken to ensure this process takes place efficiently and effectively. - Discharge planning is to begin at the time of the patient’s admission, paying particular attention to the appropriate destination that meets the needs of the patient. - Arrangements for continuing care and referrals should have taken place prior to the time the patient is dismissed. - More vulnerable groups of patients include people with learning disabilities, those with complex healthcare issues and limited resources. Review of the hospital’s undated and untitled document showed: - On 05/08/24, Patient #34’s family made a grievance with Staff G, Quality Director. - On 05/30/24, Patient #34’s medical record was requested from Hospital C, a local acute care hospital. - On 06/11/24, a peer review of Patient #34’s medial record showed on 03/01/24 he was admitted to the hospital. On 03/07/24 he was discharged. He was to have a follow up appointment in three to five days, which he did not complete. On 03/17/24, he was at Hospital B’s Emergency Department (ED), a local acute care hospital. On 03/27/24, Patient #34 died at Hospital C, an acute care hospital. The peer review showed no quality-of-care issues were identified. His length of stay was appropriate and therapeutic, his post discharge plan was implemented and appropriate with outpatient oral antibiotics and a follow up appointment. - On 06/21/24, a closure letter was sent to the complainant. Review of Patient #34’s medical record showed: - On 03/01/24, he was a 43-year-old male admitted to the Intensive Care Unit (ICU, a unit where critically ill patients are cared for) with diabetic ketoacidosis (DKA, a life-threatening condition affecting people with diabetes; occurs when the body breaks down fat too fast causing the blood to become acidic) and noncompliance with diabetes management. - On 03/02/24 at 9:59 AM, the patient’s family tried to apply for a “medical card” so the patient could get supplies. The physician planned to keep the patient in the hospital until 03/04/24 to consult with the SW and “hopefully” get free supplies including a glucometer (used to measure the amount of glucose [sugar] in blood at patient bedside) and insulin (medication that regulates the amount of sugar in the blood).” - On 03/03/24 at 8:35 AM, the patient needed “a lot” of assistance the following day if there was “any possibility” of going home and getting equipment set up including a glucometer and insulin through the SW. - On 03/04/24 at 9:55 AM, the patient’s psychological (how the mind works and affects behavior) assessment showed possible abnormal mood or affect (the expression of emotion or feelings displayed to others). The patient was “largely noncompliant” and needed a SW, physical therapy (PT, focuses on range of motion and decreasing pain after an injury or illness) and CM consults. - At 12:16 PM, a SW note showed the patient was noncompliant with diabetes management “most likely related to his lack of insurance.” The patient had difficulty with “word finding.” He had no source of income. He reported he was “quite debilitated.” He had significant impaired mobility, his “legs felt like noodles.” There were five steps to get into his home. The patient’s brother reported that two weeks prior, he physically assisted the patient in and out of a car. The arrangement for follow-up care to include a glucometer and medications was challenging due to the lack of insurance. - At 1:47 PM, the SW provided the patient and his brother with a Medicaid application form. The staff member for the referral agency, to assesses for Medicaid acceptance, was out of the office. - At 5:44 PM, the SW reviewed the Medicaid application with the patient and his brother. - At 6:45 PM, an occupational therapy (OT, focuses on the use of fine motor and cognitive skills to perform tasks required in daily life) consult showed the patient was noncompliant with his home medications and had an altered mental status (mental functioning ranging from slight confusion to coma). The brother stated that, on 03/03/24, the patient tried to get into bed after walking to the bathroom, his legs gave out and he required assistance. The patient stated he had no money or insurance. The patient tolerated standing for approximately 60 seconds, his heart rate (the number of times the heart beats within a certain time period, normal pulse/heartbeats for adults range from 60 to 100 per minute) increased to 120 beats per minute and he was told to sit down. His arms and legs were weak. He had swelling in both legs, was at a high risk for falls, confused, had poor core strength and chronic (long term, on-going) low back pain. He had decreased safety and functional mobility with a decreased ability to perform ADLs. His was able to sit upright without support for 30 seconds and then required support due to fatigue (weakness or tiredness). He had a good rehabilitation potential. His short-term goals were to stand for two to three minutes, require moderate assistance with dressing himself and stand-by assistance for movement from one place to another. His two-week goals were to stand for five-plus minutes, require minimal assistance to perform ADL’s and to be discharged with appropriate therapy referrals. - At 9:07 PM, a nutrition consult showed he was noncompliant with his diabetes management, he had not taken his diabetic medication in two years. He would benefit from significant diabetes education in an outpatient setting. The patient stated that his brother assisted him to a car due to extreme weakness. - On 03/05/24, he developed pneumonia (infection in the lungs). He continued PT and OT for potential placement. - At 7:05 AM, a PT consult showed he would benefit from skilled PT interventions. He had a good potential for rehabilitation. The patient stated that he had a functional decline and agreed treatment was necessary to return to his previous level of function. His PT plan was to be seen daily, five times a week for two weeks for skilled therapeutic interventions to address his ADL limitations. - At 3:55 PM, the Medicaid application was submitted to the referral agency and feedback was to be provided at the referral agency staff member’s earliest convenience. - On 03/06/24 at 9:41 AM, A CM consult continued for placement rehabilitation versus home health versus medication, he did not have insurance or the ability to pay. - On 03/07/24 at 11:12 AM, he became much weaker. His situation was complicated by not having insurance, the hospital tried to find placement. The decision was made for the patient to go home with family support. - At 11:13 AM, the discharge instructions showed Patient #34 was to follow up with his primary care physician in three to five days. - On 03/07/24 at 2:00 PM, he was discharged to home with a caregiver. - At 5:16 PM, a local pharmacist called to report the patient’s mother was at the pharmacy “preparing” to pick up the patient’s medications and supplies. The patient wanted to follow-up with Staff II, MD. - Staff II was not in his office the week following Patient #34’s discharge. - There were no Confirmation of Receipt for home health, rehabilitation or community resource referrals in the medical record. - There was no follow up appointment scheduled for Patient #34. Review of Patient #34’s Hospital B medical record showed: - On 03/24/24 at 4:45 AM, Patient #34 was at Hospital B’s ED for altered mental status. - EMS reported he had sinus tachycardia (an increased heart rate that exceeds 100 beats per minute [bpm]) and was given cardioversion (a medical procedure to restore the heartbeat to normal rhythm; using either electricity or drugs) enroute to the hospital. - Hospital B completed a head computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body), a head and neck computed tomography angiography (CTA, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones], computer and intravenous [IV, in the vein] injection of substance to produce detailed images of blood vessels and tissues in the body), lumbar puncture (procedure of taking fluid from the spine in the lower back through a hollow needle) and chest x-ray. - The CT scans were within normal limits. The chest x-ray showed left side pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest due to poor pumping by the heart). - His white blood cell count (WBC, the number of white cells [infection-fighting cells] in the blood, normal is 4,500 to 11,000) was 25,000. - He was transferred to Hospital C with pneumonia, sepsis (life threatening condition when the body’s response to infection injures its own tissues and organs) with associated encephalopathy (damage or disease that affects the brain) and ventricular tachycardia. Review of Patient #34’s Hospital C medical record showed: - On 03/24/24, Patient #34 was transferred from Hospital B with pneumonia and severe sepsis for a higher level of care. - He had a fever of 102 degrees Fahrenheit. - His chest x-ray showed pneumonia. - On 03/26/24 at 11:36 AM, the impression was “probably catecholamine (a type of hormone with increased production during episodes of stress such as surgery, sepsis or traumatic injury) induced acute (sudden onset) cardiomyopathy (a disease in which the heart muscle weakens and becomes enlarged making it hard to deliver blood to the rest of the body).” - He had a cardiac catheterization (a procedure where a long, thin tube is inserted in a large blood vessel that leads to the heart to diagnose or treat certain heart conditions) with a stent placement (a tiny tube placed into an artery or a vein, to hold the structure open). - At 1:01 PM, he developed cardiac arrest (when the heart suddenly and unexpectedly stops pumping). A code blue (emergency situation where a patient’s heart or breathing has stopped, and staff quickly respond to attempt to restore the heartbeat or breathing) was performed and return of spontaneous circulation (ROSC, resumption of a sustained heart rate) was achieved. - On 03/27/24 at 10:02 PM he developed cardiac arrest. A second code blue was initiated. - At 10:55 PM, Patient #34 died of acute respiratory failure (condition in which not enough oxygen passes from the lungs into the blood). During an interview on 06/25/24 at 1:45 PM, Staff HH, SW, stated that she assisted Patient #34’s family with a Medicaid application. She stated that a Medicaid application allowed for retroactive insurance coverage for up to 90 days. She considered using the hospital’s SW Special Needs Program to assist Patient #34 with his medications. She did not confirm that Patient #34’s family obtained his discharge prescriptions. No referrals for follow up care services were completed for Patient #34. Referrals were to be documented in the medical record. During an interview on 06/26/24 at 8:25 AM, Staff II, MD, stated that Patient #34 was “weaker” upon his admission to the hospital. He was able to walk in the room without assistance. The patient’s brother stated that the patient was weak and the family needed support with caring for Patient #34. The patient’s parents stated that they were capable of caring for Patient #34. Staff II spoke with CM about a home health or rehabilitation referral during the patient’s hospital stay. He did not know what CM did in regard to the requested referrals. Staff II was informed the patient’s mother was able to fill his discharge prescriptions. The patient had a follow up appointment at his office two weeks after his discharge, maybe on 03/19/24. The patient walked into his office, his insulin needs decreased and he was started on oral diabetes medication. Staff II provided a lot of education to the patient and his family. He felt the patient was safe to discharge to home with a “loving family.” During a telephone interview on 06/26/24 at 10:45 AM, Staff NN, MD, stated that he notified the SW when a referral to follow up care services was needed. He expected the SW to place referrals as he requested. He expected referrals to follow up with care agencies regardless of the patient’s insurance status. He “pushed towards placement,” for Patient #34, because the patient was noncompliant. He did not remember other details for Patient #34. During an interview on 06/26/24 at 10:15 AM, Staff H, Chief Nursing Officer (CNO), stated that she expected discharge planning efforts to be documented in the medical record. Initially an order was placed for therapies to perform an asessment and make recommendations for follow up care services that focused on the patient’s potential. Paperwork for referrals was completed and faxed to the needed service. She expected efforts to be made with requested referrals and those efforts were to be documented in the medical record. She expected a summary of the work being done for discharge planning to be documented in the medical record. During an interview on 06/26/24 at 10:55 AM, Staff G, Quality Director, stated that referrals to follow up care services for Patient #34 were not completed as requested by the provider. The agencies would have declined Patient #34 because of his “self-pay situation.” The patient applied for Medicaid and requested retroactive coverage. He could not explain why the referrals were not completed. The hospital needed to do their “due diligence” with post discharge care needs. The SW was responsible to address the post discharge care needs for Patient #34. There was no follow up with the family to ensure the discharge medications were obtained. The failed follow up care service referrals were not identified during the hospital’s grievance investigation. During an interview on 06/26/24 at 11:35 AM, Staff W, SW Supervisor, stated that the patient’s “self-pay” status caused limitations for available follow up care services. She expected referral to agencies “within reason.” A referral could have been made to the Emergency Room Enhancement Program (ERE, a program to decrease barriers to healthcare for indivuals in crisis by addressing their immediate needs). A Medicaid application was completed and reviewed by a company that assessed for Medicaid application acceptance. The Medicaid coverage was approved “a few days after the patient died.” She agreed there was a need for continued process improvement. She wanted the hospital to make every effort to do their due diligence with discharge planning. During a telephone interview on 06/26/24 at 12:30 PM, Staff KK, PT, stated that he was consulted to perform an assessment of Patient #34 and made recommendations for needed follow up care services. During the initial assessment, Patient #34 was able to ambulate independently and he recommended a swing bed (Medicare program in which a patient can receive acute care, then if needed, skilled nursing care in the same facility) placement upon discharge. The patient’s condition declined and a nursing home placement was recommended for Patient #34. Patient #34 “could not take care of himself.” During an interview on 06/26/24, at 8:50 AM, Staff P, Licensed Practical Nurse (LPN), stated that she remembered Patient #34, but did not care for him directly. She recalled that he appeared to have trouble taking care of himself and required the help of his mother and brother. His brother was very active in his care and was present for education. His brother often went to the nurses’ station to discuss Patient #34’s care. She was not present for his discharge. During an interview on 06/26/24, at 8:57 AM, Staff D, RN, stated that he recalled instances that involved referring a patient to the in-house medication fund and the utilization of local resources to assist patients in retrieving medications at discharge. He stated that to discharge a patient home with family, he needed to ensure both parties were capable and willing to participate in the care plan. The family member responsible for the patient’s care needed to come to the bedside and receive adequate education. A patient may require a delayed discharge to ensure the family was well prepared for the patient to have a safe discharge. 50321”