Moberly Regional Medical Center

“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: 51509 Based on observation, interview, record review and policy review, the hospital failed to: - Ensure the immediate availability of a registered nurse (RN) to supervise and administer patient care on each nursing unit; (A-0392) - Ensure patient observation forms were completed for seven discharged patients (#3, #18, #19, #20, #22, #23 and #34) of 12 patients reviewed; (A-0392) - Appropriately reposition two current patients (#4 and #5) and six discharged patients (#2, #6, #8, #10, #11 and #13) of eight patients reviewed. (A-0395) - Appropriately label all intravenous (IV, in the vein) catheter site dressings for six current patients (#27, #28, #29, #31, #32 and #36) of eight patients observed; (A-0395) - Provide a clean work surface or barrier when administering medications or performing patient care activities for six current patients (#5, #26, #27, #28, #29 and #38) of seven patients observed; (A-0395) and - Administer insulin (medication that regulates the amount of sugar in the blood) within an appropriate time frame of patients’ blood glucose (sugar that circulates in the blood and when too high or too low can be detrimental to a person’s health, normal 74 to 250) measurement for two current patients (#27 and #29) and two discharged patients (#10, and #13) of four patients reviewed. (A-0405) These failed practices resulted in a systemic failure and noncompliance with 42 CFR 482.23 Condition of Participation (CoP): Nursing Services. Please refer to A-0392, A-0395 and A-0405. 51292”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 51292 Based on interview, record review and policy review, the hospital failed to ensure the immediate availability of a registered nurse (RN) to supervise and administer patient care on each nursing unit and to ensure patient observation forms were completed for seven discharged patients (#3, #18, #19, #20, #22, #23 and #34) of 12 patients reviewed. This failed practice placed all patients admitted to the hospital at risk for their health and safety. Findings Included: Review of the hospital’s document titled, “Daily Schedule,” dated 02/2026, showed: - On 02/09/26, there was no RN assigned to the Senior Behavioral Health Unit (SBHU) for dayshift to supervise the assigned Licensed Practical Nurses (LPN). - On 02/12/26, there was no RN assigned to the SBHU for the dayshift to supervise the LPN assigned. - On 02/12/26, there was no RN assigned to the SBHU for nightshift to supervise the LPN assigned, between the hours of 2:00 AM to 7:00 AM. - On 02/16/26, there was no RN assigned to the SBHU for the dayshift to supervise the LPN assigned. - Leaving the SBHU without adequate supervision for four shifts in 02/2026. Review of the hospital’s document titled, “Daily Schedule,” dated 03/2026, showed: - On 03/05/26, there was no RN assigned to the SBHU for nightshift to supervise the LPN assigned. - On 03/08/26, there was no RN assigned to the SBHU for dayshift to supervise the LPN assigned. - On 03/11/26, there was no RN assigned to the SBHU for dayshift to supervise the LPN assigned. - On 03/12/26, there was no RN assigned to the SBHU for dayshift to supervise the LPN assigned. - On 03/20/26, there was no RN assigned to the SBHU for dayshift to supervise the LPN assigned, between the hours of 3:00 PM to 7:00PM. - On 03/21/26, there was no RN assigned to the SBHU for dayshift to supervise the LPN assigned. - On 03/22/26, there was no RN assigned to the SBHU for dayshift to supervise the LPN assigned. - On 03/26/26, there was no RN assigned to the SBHU for dayshift to supervise the LPN assigned. - Leaving the SBHU without adequate supervision for nine shifts in 03/2026. During an interview on 04/14/26 at 10:15 AM, Staff U, Chief Nursing Officer (CNO), stated that he was aware an RN needed to be assigned for each unit on every shift. Utilizing an RN on limited duty and/or the House Supervisor for an individual unit’s supervising RN, was not acceptable and did not meet that requirement. Review of the hospital’s policy titled, “Observation Levels Policy,” dated 02/16/26, showed: - The standard/routine observation for all patients on the SBHU were to be completed and documented every 15 minutes. - Line of Sight (LOS, continuous visual contact with the patient) observations required the patient was to remain in staff view at all times. A specific, in person, staff member was assigned for this level of observation; video monitoring cannot be used. If appropriate, one staff member could be assigned observation for more than one patient. Observations were to be completed and documented every 15 minutes. - One to one (1:1) observations consisted of an assigned staff member who remained within a close proximity (usually an arm’s length) of the patient at all times to ensure staff’s ability to intervene for safety if necessary. Observations were to be completed and documented every 15 minutes. Review of Patient #3’s medical record, dated 02/10/26, showed: - At 2:46 PM, a 77 year-old female was admitted to the SBHU for worsened behaviors with increased confusion due to a neurocognitive disorder (decreased mental function either in language, learning, memory, or socially; and loss of ability to do daily tasks) , and schizophrenia (serious mental disorder that affects a person’s ability to think, feel, and behave clearly). - Routine observations were ordered every 15 minutes. - On 02/20/26, between 5:30 AM and 7:00 AM, no patient observations were documented. - For 03/04/26 and 03/06/26, no patient observations forms were provided. - On 03/06/26 at 12:52 AM, Patient #3 was transferred to a higher level of care. Review of Patient #18’s medical record, dated 02/09/26, showed: - At 6:58 PM, a 63-year-old female was admitted to the SBHU on a 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to them themselves and others) due to manic (elevated or excited mood or behavior) symptoms with bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows). - Routine observations were ordered every 15 minutes. - On 2/13/26 at 8:03 PM, an order for 1:1 observation was ordered. - On 2/16/26 at 9:37 AM, the 1:1 order was decreased to LOS observation. - At 5:35 PM, the LOS order was discontinued. - At 6:06 PM, 1:1 continuous observation was ordered. - On 2/17/26 at 4:25 PM, the 1:1 order was discontinued. - On 02/20/26, no patient observations were documented between 5:00 AM and 7:00 AM. - On 3/7/26 at 2:33 PM, LOS observation was ordered while the patient was awake, with a bed alarm while in bed. - At 1:28 PM, the LOS while awake order was discontinued. - At 5:55 PM, a LOS observation level was ordered while the patient was awake. - From 02/09/26 through 03/20/26, daily patient observation forms did not distinguish whether observations were routine, LOS, or 1:1. - On 3/20/26, Patient #18’s guardian signed her out of the hospital against medical advice (AMA). Review of Patient #19’s medical record, dated 02/16/26, showed: - At 7:35 PM, a 70-year-old female was admitted from a nursing home to the SBHU on a 96-hour hold due to a neurocognitive disorder with behaviors. - There were no orders for LOS or 1:1 patient observations. - On 02/20/26, no patient observations were documented between 5:00 AM and 7:00 AM. - On 3/11/26, Patient #19 was discharged back to the nursing home. Review of Patient #20’s medical record, dated 02/17/26, showed: - At 6:48 PM, a 79-year-old female was admitted to the SBHU due to a worsened neurocognitive disorder (decreased mental function either in language, learning, memory, or socially; and loss of ability to do daily tasks) with delusions (false ideas about what is taking place or who one is). - There were no orders for LOS or 1:1 patient observations. - On 02/20/26, no patient observations were documented between 5:00 AM and 7:00 AM. - On 3/5/26, Patient #20 was discharged to a nursing home. Review of Patient #22’s medical record, dated 02/10/26, showed: - At 5:55 PM, a 62-year-old female was admitted to the SBHU for major depression (a long period of feeling worried or empty with a loss of interest in activities once enjoyed) along with neurocognitive disorder due to a known physiological condition (the condition or state of the body or bodily function) with behaviors. - Routine patient observations were ordered every 15 minutes. - On 02/20/26, no patient observations were documented between 5:00 AM and 7:00 AM. - On 3/2/26, Patient #22 discharged to a nursing home. Review of Patient #23’s medical record, dated 02/10/26, showed: - At 11:41 PM, a 69-year-old male was admitted to SBHU for a neurocognitive disorder with behaviors. - From 02/10/26 through 02/25/26, daily patient observation forms did not distinguish whether observations were routine, LOS, or 1:1. - On 02/12/26 at 1:53 PM, LOS observations were ordered while the patient was in the dining room and 1:1 observations while he was in his room or bathroom. - On 2/17/26 at 11:06 AM, the 1:1 order while in his room or bathroom order was discontinued. - At 3:59 PM, the LOS order while in the dining room was discontinued. - On 02/18/26 at 8:20 AM, LOS observations were ordered while awake. - On 02/20/26, no patient observations were documented between 5:00 AM and 7:00 AM. - On 02/24/26 at 3:31 PM, the LOS while awake order was discontinued. - From 02/10/26 through 02/25/26, daily patient observation forms did not distinguish whether observations were routine, LOS, or 1:1. - On 2/25/26, Patient #23 discharged to a nursing home. Review of Patient #34’s medical record, dated 12/19/25, showed: - At 2:16 PM, an 80-year-old male arrived at the Emergency Department (ED) for aggressive behavior and suicidal ideation (SI, thoughts of causing one’s own death). - At 2:20 PM, he was given a chemical restraint (a form of medical restraint in which a drug is used to restrict the freedom or movement of a patient) and placed in violent restraints (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others). - At 3:13 PM, 1:1 observation with a sitter (person assigned to continuously observe a patient within close proximity, to ensure their safety) was ordered. - At 6:27 PM, his restraint order was renewed, along with a sitter at bedside. - At 10:27 PM, his restraint order was renewed, along with a sitter at bedside. - Documentation of every 15 minutes observations ended at 5:40 PM, there were no observations documented for greater than a six-hour period. Although requested no further observation sheets were provided. During an interview on 04/10/26 at 9:30 AM, Staff X, RN, stated that all patients on SBHU were to be monitored and observations documented every 15 minutes. Staffing was an issue no matter where you worked but the hospital’s priority was the1:1 and LOS patients. They just made it work. During an interview on 04/14/26 at 10:15 AM, Staff U, Chief Nursing Officer (CNO), stated that 1:1 monitoring should have a person assigned to the patient and they should be close enough to respond to patient needs.”

“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: 51509 A-0395 Based on observation, interview, record review and policy review, the hospital failed to ensure that staff: - Appropriately repositioned two current patients (#4 and #5) and four discharged patients (#2, #6, #11 and #13) of six patients reviewed; - Appropriately labeled all intravenous (IV, in the vein) catheter site dressings for six current patients (#27, #28, #29, #31, #32 and #36) of eight patients observed; and - Provided a clean work surface or barrier when administering medications or performing patient care activities for six current patients (#5, #26, #27, #28, #29 and #38) of seven patients observed. Findings included: Review of the hospital’s policy titled, “Pressure Injury (injury to the skin and/or underlying tissue, usually over a bony area) Prevention,” dated 03/04/26, showed: - Patients at the highest risk were those Age 65 or greater, with an altered mental status (AMS, mental functioning ranging from slight confusion to coma), generalized weakness, obesity (a disorder involving excessive body fat that increases the risk of health problems), poor nutrition or cachexia (loss of weight and muscle mass due to disease), and high blood pressure. -The Wound Care RN and the provider will be consulted for all wounds (present on admission or hospital-acquired) and patients with a Braden Scale (an assessment tool for predicting the risk of bed sores or pressure ulcers; 19-23 was no risk, 15-18 was mild risk, 13-14 was moderate risk, 10-12 was high risk and 9 or less was very high risk) score equal to or less than 14. - Interventions to be initiated included repositioning every two hours(even if a therapeutic support surface was in use), ensuring active or passive range of motion (ROM, how far you can move or stretch a part of your body, such as a joint or a muscle)/mobility exercises were implemented, and applying ; moisture barrier and protective dressings per manufacturer guidelines to sacrum (triangular shaped bone above the tailbone) and coccyx (tailbone area) to prevent injuries from shearing (injury to the skin caused by friction) and friction. Review of the hospital’s policy titled, “Patient Care Documentation,” dated 03/23/26, showed the nurse is responsible for ensuring the Patient Care Record is complete and readily available to the physician. A patient’s reluctance or refusal for treatment is documented, and all communications with the physician have been charted. Review of Patient #2’s medical record, dated 12/29/25, showed: - A 74-year-old female was admitted for medication management due to increased aggression with agitation. Her past medical history included diabetes (a disease that affects how the body produces or uses blood sugar and can cause poor healing), dementia (a loss of thinking abilities and memory), incontinence (inability to control urination or bowel movements), high blood pressure and poor oral intake. - On 01/18/26, documentation indicated that she sat in a chair from 5:30 AM to 9:00 PM. She was offered bathroom breaks at 10:06 AM, 3:46 PM and 10:06 PM. There was no documentation during that time frame, indicating she had been repositioned. Her skin assessment was negative for wounds. - On 01/19/26, documentation indicated that she sat in her chair from 5:45 AM to 8:45 PM. She was offered bathroom breaks at 11:21 AM and 2:23 PM. There was no further documentation during that time frame, indicating she had been repositioned. Her skin assessment was negative for wounds. - On 01/20/26, documentation indicated she sat in a chair from 7:00 AM to 9:17 PM. She was offered bathroom breaks at 10:16 AM and 11:52 AM. There was no further documentation during that time frame, indicating she had been repositioned. Her skin assessment was negative for wounds. - On 01/21/26, documentation indicated she sat in her chair from 6:15 AM to 9:30 PM. She was offered bathroom breaks at 9:55 AM, 10:30 AM, 4:24 PM and 10:49 PM. There was no further documentation during that time frame, indicating she had been repositioned. Her skin assessment was negative for wounds. - On 01/22/26, documentation indicated she was in her chair from 6:45 AM to 9:02 PM. She was offered a bathroom break at 6:08 PM. There was no further documentation during that time frame, indicating she had been repositioned. Her skin assessment was negative for wounds. - On 01/23/26, documentation indicated she was in her chair from 6:30 AM to 8:32 PM. She was offered bathroom breaks at 2:01 PM, 4:21 PM and 8:30 PM. There was no further documentation during that time frame, indicating she had been repositioned. Her skin assessment was positive for a pressure wound to her right buttocks. Review of Patient #6’s medical record, dated 10/06/25, showed: - He was admitted for AMS. His skin assessment was negative for abnormalities, and he had a Braden score of 12. Nursing orders included repositioning every two hours to maintain skin integrity. - On 10/07/25, from 2:57 AM to 6:56 AM, no repositioning was documented. - From 10:09 AM to 2:25 PM, no repositioning was documented. - On 10/08/25, from 1:54 AM to 8:00 AM, no repositioning was documented. - At 09:40 AM, a small pressure injury on his tailbone was documented. During an interview on 03/30/26 at 2:45 PM, Patient #4 stated that she had a broken pelvis and was unable to reposition herself in bed. Staff did not offer to reposition her. During an interview on 03/30/26 at 3:00 PM, Patient #5 stated that she was too weak to reposition herself in bed. Staff did not offer to reposition her. During an interview on 04/14/26 at 10:15 AM, Staff U, Chief Nursing Officer (CNO), stated that he expected at risk patients with low Braden scores to be repositioned every two hours. Documentation stating their position, and full skin assessments should be done each shift. If the patient refused, he expected a reason for the refusal to be documented. Review of Patient #8’s medical record, dated 11/06/25, showed: -At 8:19 AM, she was admitted for a significant infection of wounds in her left lower leg which required intravenous (IV, in the vein) antibiotics. - She was non-ambulatory (not able to walk) and had a medical history of multiple sclerosis (MS, a disorder in which the immune system attacks the protective covering of the nerve cells) and muscle spasticity (a condition causing involuntary muscle stiffness, tightness and spasms due to damaged brain or spinal cord pathways). - Her Braden Scale was 12 to 13 throughout her admission, and she was not repositioned every two hours. - On 11/6/25, from 12:02 PM to 11:23 PM, no repositioning was documented. - On 11/7/25, from 8:03 AM to 4:03 PM, no repositioning was documented. - On 11/8/25, from 1:16 AM to 10:45 AM, and from 4:10 PM to 7:47 PM, no repositioning was documented. - On 11/9/25, from 7:07 PM to 11:23 PM, no repositioning was documented. - On 11/10/25, from 1:33 AM to 5:33 AM, no repositioning was documented. - From 11/06/25 to 11/10/25, there were only 10 documented repositions that showed which anatomical direction the patient faced and there was no documentation indicating the patient had refused to be repositioned. - At 4:25 PM, she discharged home with home health services. Review of the medical record for Patient #11, dated 11/12/26, showed: - A79-year-old who was admitted for a fall that resulted in a right hip fracture (a break in a bone). Her skin assessment showed she had a rash in her right groin and under her left breast (Wound #1). She had a history of atrial fibrillation (A-fib, an irregular, often rapid heart rate that commonly causes poor blood flow), high blood pressure, and left forefoot amputation (removal of an injured or diseased body part). - On 11/13/26, she had surgery on her right hip fracture. She returned to her room at 5:55 PM. Her skin assessment showed she had Wound #1 and Wound #2 (surgical incision to right hip). - On 11/14/26, from 12:00 AM to 8:00 AM, no repositioning was documented. Her skin assessment showed Wound #1 and Wound #2. - On 11/16/25, from 12:00 AM to 10:00 AM, from 12:00 PM to 4:38 PM, and from 4:38 PM to 8:00 PM, no repositioning was documented. - On 11/17/25, her skin assessment showed Wound #3 (pressure injury on her tailbone). No pictures were taken, and no new orders were documented. Review of Patient #13’s medical record, dated 01/03/26, showed: - A76-year-old, bed-bound male was admitted for diabetic ulcers (an open wound or sore usually found on the bottom of feet in people with diabetes), cellulitis (an infection of the skin) on both lower legs, pressure injuries to the sacrum, upper thighs and left lower ankle, with excoriation (referring to the skin being scraped or worn away) to most of his buttocks and upper thighs. Wound pictures were taken on admission, without any measurements. - The physician documented, he was at high risk for worsened pressure injuries due to poor tissue perfusion (the passage of blood, blood substitute, or other fluid through the blood vessels or channels of an organ or tissue). - He was to be repositioned every two hours to maintain skin integrity. Wound care orders included application of barrier cream to the buttocks and upper thighs every six hours. - On 01/03/26, from 2:00 PM to 7:19 PM, there was no documentation for repositioning. - On 01/05/26, wound care was due at 9:00 PM but not completed until 12:19 AM. - On 01/06/26, from 8:00 AM to 11:39 AM, there was no documentation for repositioning. Wound care was due at 6:00 PM but not completed until 10:34 PM. - On 01/07/26, from 3:32 AM to 9:44 AM, and between 5:02 PM to 10:05 PM, there was no documentation for repositioning. Wound care was due at 12:00 PM but not completed until 2:50 PM. - On 01/09/26, he was transferred to a nursing home facility. There was no documentation of his wound status at discharge. Review of the hospital’s policy titled, “IV Dressing Change, Site Care, Site Changes and Tubing Changes,” dated 01/2026, showed IV site dressings were to be labeled with the date, time and staff member initials as well as the size and type of IV device. Observation on 03/31/26 at 9:01 AM, showed Patient #27’s IV site was not labeled with a date, time, initials or size and type of IV device. Observation on 03/31/26 at 8:35 AM, showed Patient #28’s IV site was not labeled with a date, time, initials or size and type of IV device. Observation on 03/31/26 at 9:15 AM, showed Patient #29 had two IV sites that were not labeled with a date, time, initials or size and type of IV device. Observation on 03/31/26 at 10:30 AM, showed Patient #31’s IV site was not labeled with a date, time, initials or size and type of IV device. Observation on 03/31/25 at 10:35 AM, showed Patient #32’s IV site was not labeled with a date, time, initials or size and type of IV device. Observation on 03/31/26 at 2:40 PM, showed Patient #36’s IV site was not labeled with a date, time, initials or size and type of IV device. During an interview on 04/10/26 at 9:30 AM, Staff X, RN, stated that IV sites should be labeled with a date, time and initials. During an interview on 04/14/26 at 10:15 AM, Staff U, Chief Nursing Officer (CNO), stated that he expected all tubing and IV sites to be dated. Review of the hospital’s policy titled, “Administration of Medications,” dated 06/2025, showed that the Workstation on Wheels (WOW) should be cleaned and disinfected with a disinfectant wipe at the beginning of each shift and any time the device became soiled. The scanner should be disinfected anytime it was used in an isolation room, or the WOW would be kept in the isolation room for the duration of the patient’s hospitalization, if possible. Although requested, no other policies pertaining to a clean work surface or the use of a barrier for medication administration and patient care activities were provided. Observation on 03/30/26 at 3:00 PM, showed Staff G, RN, failed to clean her work surface and/or use a barrier prior to medication preparation and administration for Patient #5. Observation on 03/31/26 at 10:30 AM, showed Staff C, RN, failed to clean her work surface and/or use a barrier prior to medication preparation and administration for Patient #26. Observation on 03/31/26 at 9:01 AM, showed Staff M, RN, failed to clean her work surface and/or use a barrier prior to medication preparation and administration for Patient #27. Observation on 03/31/26 at 8:35 AM, showed Staff G, RN, failed to clean her work surface and/or use a barrier prior to medication preparation and administration for Patient #28. Observation on 03/31/26 at 9:15 AM, showed Staff N, RN, failed to clean her work surface and/or use a barrier prior to medication preparation and administration for Patient #29. Observation on 03/31/26 at 11:06 AM, showed Staff H, RN, failed to clean her work surface and/or use a barrier prior to obtaining a blood glucose (sugar that circulates in the blood and when too high or too low can be detrimental to a person’s health, normal 74 to 250) measurement for Patient #29 and instead placed the equipment and supplies on the patient’s bed. Observation on 03/31/26 at 11:12 AM, showed Staff M, RN, failed to clean her work surface and/or use a barrier prior to obtaining a blood glucose measurement for Patient #27 and instead placed the equipment and supplies on the patient’s bed. Observation on 03/31/26 at 2:12 PM, showed Staff N, RN, failed to clean her work surface and/or use a barrier prior to urinary catheter (a small flexible tube inserted into the bladder to provide continuous urinary drainage) care for Patient #29. Instead, supplies were placed on a bathroom sink and then transferred around the room to multiple surfaces including a patient chair and cluttered bedside table; none of which were cleansed prior to placing supplies on them. Observation on 03/31/26 at 1:50PM, showed Staff C, RN place supplies for IV insertion on the patient’s bed prior to placement for Patient # 38. During an interview on 03/31/26 at 8:35 AM, Staff G, RN, stated that WOWs were cleaned at the end of the shift and sometimes between patients. If a patient was on isolation precautions, the WOW stayed in that room. During an interview on 04/10/26 at 9:30 AM, Staff X, RN, stated that a clean work surface or barrier should be utilized for medication preparation and administration. During an interview on 04/14/26 at 10:15 AM, Staff U, CNO, stated that he expected nurses to clean the WOWs between patients and to clean their work surface prior to medication administration. 51292”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 51292 Based on observation, interview, record review and policy review, the hospital failed to administer insulin (medication that regulates the amount of sugar in the blood) within an appropriate time frame of patients’ blood glucose (BG, sugar that circulates in the blood and when too high or too low can be detrimental to a person’s health, normal 74 to 250) measurement for two current patients (#27 and #29) and two discharged patients (#10, and #13) of four patients reviewed. Findings included: Review of the hospital’s policy titled, “Administration of Medications,” dated 06/04/25 showed: - Caregivers were to be aware of medication due times through access of the electronic medication administration record (eMAR) area of the chart; - Medications were to be given within one hour before or after the scheduled dosage time; and - If a patient refused to take a medication, it would be indicated on the eMAR and/or in a care note. Any failure to give medication would be charted, regardless of cause and the physician would be notified in a timely manner. Review of Patient #10’s medical record, dated 10/14/25, showed: - On 10/18/25, seven units of sliding scale insulin was due at 12:00 PM and administered at 4:48 PM. Four hours and 48 minutes late. - On 10/18/25, three units of sliding scale insulin was due at 5:00 PM and administered at 6:42 PM. One hour and 42 minutes late. - On 10/19/25, four units of sliding scale insulin was due at 11:30 AM and administered at 1:47 PM. Two hours and 17 minutes late. - On 10//19/25, four units of sliding scale insulin was due at 4:30 PM and administered at 5:54 PM. One hour and 24 minutes late. - On 10/20/25, 10 units of Lantus (long-acting blood glucose lowering medication) was due at 9:00 AM, and administered at 5:41 PM. Eight hours and 41 minutes late. - On 10/20/25, four units of sliding scale insulin was due at 11:30 AM and administered at 5:40 PM. Six hours and 10 minutes late. Review of Patient #13’s medical record, dated 01/03/26, showed: - On 01/04/26, five units of insulin was due at 11:30 AM and administered at 2:04 PM. Two hours and 34 minutes late. - On 01/04/26, one unit of sliding scale insulin was due at 12:00 PM and administered at 2:04 PM. Two hours and four minutes late. - On 01/07/26, five units of insulin was due at 11:30 AM and administered at 1:00 PM. One hour and 30 minutes late. - On 01/07/26, two units of sliding scale insulin was due at 12:00PM and administered at 2:51 PM. Two hours and 51 minutes late. - On 01/07/26, five units of insulin was due at 4:30 PM and administered at 6:20 PM. One hour and 50 minutes late. Observation on 03/31/26 at 9:01 AM, Staff M, RN, used a BG measurement of 117, obtained at 4:49 AM, to determine the sliding scale insulin dosage for Patient #27. The BG value was obtained over four hours prior to that scheduled administration. Observation on 03/31/26 at 9:15 AM, showed Staff N, RN, used a BG measurement of 212, obtained 4:38 AM, to administered two units of sliding scale insulin to Patient #29. The BG value was obtained over four hours prior to that scheduled administration. During an interview on 03/31/26 at 11:12 AM, Staff M, RN, stated that insulin should be administered within one hour of the BG measurement. Night shift generally obtained BG measurements at 6:30 AM, but breakfast arrived at approximately 7:30 to 8:00 AM. She agreed she should have rechecked Patient #27’s BG level that morning, prior to determining the dose of insulin to be administered. During an interview on 04/14/26 at 9:10 AM, Staff N, Chief Nursing Officer (CNO), stated that he expected insulin to be given within one hour of the BG measurement or another BG measurement should be obtained. Nursing staff should document why the medication was late, as well as any unexpected outcomes or abnormalities.”

“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: 44536 Based on interview, record review, and policy review, the hospital failed to follow its policies and provide within its capability and capacity stabilizing treatment for one patient (#7) out of 25 Emergency Department (ED) records reviewed from 01/15/24 to 07/15/24. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). Findings included: Review of the hospital’s policy titled “Emergency Medical Treatment and Active Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition),” revised 11/05/23, showed: - EMTALA obligates the hospital to provide a medical screening examination (MSE), treatment and/or transfer of individuals with an EMC. If an EMC is determined to exist, the hospital must provide any necessary stabilizing treatment or arrange appropriate transfer. - An EMC is a medical condition with acute symptoms of sufficient severity (including psychiatric [related to mental illness] disturbances) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious dysfunction or impairment of a bodily part, acute psychiatric or substance abuse symptoms are revealed or the individual is expressing suicidal/suicidal ideation (SI, thoughts of causing one’s own death) or homicidal ideation (HI, thoughts or attempts to cause another’s death) that endanger themselves or others. - A MSE is the process required to reach the point where it can be determined whether or not an EMC exists. The MSE includes both a generalized assessment and a focused assessment based on the patient’s chief complaint. The MSE is ongoing and must continue until the patient is stabilized, admitted or appropriately transferred. - A stabilized EMC means no material deterioration of the condition is likely to result from transfer or discharge. The patient has reached the point where continued care could reasonably be performed as an outpatient, the patient is given a plan for appropriate follow-up care or the patient requires no further treatment and the treating physician has provided written documentation of their findings. - A psychiatric patient is considered stable when they are prevented from injuring themselves or others. - Stabilized patients are not transferred and stabilization of a patient ends the hospital’s EMTALA obligation. If a patient needs follow up care, they are discharged with instructions. Review of the hospital’s document titled, “Medical Staff Rules and Regulations,” approved 05/22/23, showed: - A patient suspected to be suicidal in intent shall be admitted to an appropriate room consistent with the patient’s medical needs. If these accommodations are not available, the patient shall be transferred, if possible, to another institution where suitable facilities are available. When transfer is not possible, the patient may be admitted to a general area of the hospital as a temporary measure, while providing all reasonable care appropriate to the situation. Appropriate restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) may be used as permitted by these Rules and Regulations and hospital policy. The patient will be afforded psychiatric consultation as necessary and appropriate. The hospital social worker can be consulted for assistance. - Any individual who presents to the ED for care shall be provided with a MSE to determine whether the individual is experiencing an EMC. - Any individual experiencing an EMC must be stabilized prior to transfer or discharge unless the patient is determined stable for discharge. - Stable for discharge is considered the patient has reached a point where continued care could reasonably be performed as an outpatient, they are provided with an appropriate follow-up plan and discharge instructions, or the patient requires no further treatment and the physician has provided written documentation of the examination findings. Although requested, the hospital could not provide a policy outlining the care of psychiatric patients in the ED. Review of the hospital’s policy titled, “Involuntary Admission (a legal process through which a person is hospitalized and treated for mental health disorders without their consent),” revised 11/16/23, showed: - Patients who are a harm to themselves or someone else, require constant supervision to remain safe and are not willing to seek treatment will be placed on an involuntary commitment to an appropriate placement. - The procedure for 96-hour detention included: patients found to have a mental disorder or at harm to themselves or others should be encouraged to seek voluntary treatment; if the patient refuses and is not considered safe to return to home, involuntary commitment should be pursued. - An affidavit (a written statement confirmed by oath, for use as evidence in court) is completed noting evidence of harm to self or others and evidence of a mental disorder or substance abuse. - If the patient is 55 or older and is believed to have a mental disorder, the Senior Mental Health unit should be contacted for possible placement on Moberly Regional Medical Center (MRMC) psychiatric unit. If the patient will be admitted to MRMC psychiatric unit, a staff member will complete an Application for Detention. If the patient was voluntary and becomes involuntary, State of Missouri Department of Mental Health forms must be completed. - If the patient will not be admitted to MRMC, affidavits must be taken to the probate judge in the county in which the patient resides. If after hours, the police or sheriff department will take the application to the probate judge. The judge will determine appropriateness and placement for the individual. Review of the hospital’s policy titled, “Post Elopement (when a patient makes an intentional, unauthorized departure from a medical facility),” revised 01/2022, showed: - In the event of a patient elopement; the charge nurse immediately notifies security, house supervisor and police. - The charge nurse completes an incident report. - Appropriate restraint may be used to detain an involuntary patient who has eloped off the unit or hospital grounds. The police may be summoned to assist in returning the patient, if necessary. - Appropriate restraint is not used to detain a voluntary patient who has eloped. - In the event a voluntary patient is assessed by the physician and found to need involuntary admission, steps are taken to seek involuntary status for the patient. - The incident necessitates a quality improvement review. See A-2407 for additional information.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 44536 Based on interview, record review, and policy review, the hospital failed to provide within its capability and capacity, stabilizing treatment for one patient (#7) out of 25 Emergency Department (ED) records reviewed from 01/15/24 to 07/15/24. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). Findings included: Review of the hospital’s policy titled, “Emergency Medical Treatment and Active Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an EMC),” revised 11/05/23, showed: - EMTALA obligates the hospital to provide a medical screening examination (MSE), treatment and/or transfer of individuals with an EMC. If an EMC is determined to exist, the hospital must provide any necessary stabilizing treatment or arrange appropriate transfer. - An EMC is a medical condition with acute symptoms of sufficient severity (including psychiatric [related to mental illness] disturbances) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious dysfunction or impairment of a bodily part, acute psychiatric or substance abuse symptoms are revealed or the individual is expressing suicidal ideation (SI, thoughts of causing one’s own death) or homicidal ideation (HI, thoughts or attempts to cause another’s death) that endanger themselves or others. - A MSE is the process required to reach the point where it can be determined whether or not an EMC exists. The MSE includes both a generalized assessment and a focused assessment based on the patient’s chief complaint. The MSE is ongoing and must continue until the patient is stabilized, admitted or appropriately transferred. - A stabilized EMC means no material deterioration of the condition is likely to result from transfer or discharge. The patient has reached the point where continued care could reasonably be performed as an outpatient, the patient is given a plan for appropriate follow-up care or the patient requires no further treatment and the treating physician has provided written documentation of their findings. - A patient is stable for transfer if the treating physician has determined the patient is expected to leave the hospital and be received at a second facility with no material deterioration in their medical condition and believes the receiving facility has the capability to manage the patient’s medical condition and any foreseeable complication of that condition. A psychiatric patient is considered stable when they are prevented from injuring themselves or others. - Stabilized patients are not transferred and stabilization of a patient ends the hospital’s EMTALA obligation. If a patient requires follow up care, they are discharged with instructions. Transfer to another medical facility by appropriate means may occur after stabilization if the individual requires specialized treatment not available at the hospital and another hospital has the capability of specialized care and space to treat the patient or if a stabilized individual requests transfer to the hospital of their choice. Review of the hospital’s document titled, “Medical Staff Rules and Regulations,” approved 05/22/23, showed: - A patient suspected to be suicidal in intent shall be admitted to an appropriate room consistent with the patient’s medical needs. If these accommodations are not available, the patient shall be transferred, if possible, to another institution where suitable facilities are available. A suicidal patient in the ED will not be transferred absent an appropriate MSE, stabilization, and certification per the hospital’s EMTALA policy. When transfer is not possible, the patient may be admitted to a general area of the hospital as a temporary measure, while providing all reasonable care appropriate to the situation. Appropriate restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) may be used as permitted by these Rules and Regulations and hospital policy. The patient will be afforded psychiatric consultation as necessary and appropriate. The hospital social worker can be consulted for assistance. - Any individual who presents to the ED for care shall be provided with a MSE to determine whether the individual is experiencing an EMC. - Any individual experiencing an EMC must be stabilized prior to transfer or discharge unless the patient is determined stable for discharge. - Stable for discharge is considered the patient has reached a point where continued care could reasonably be performed as an outpatient, they are provided with an appropriate follow-up plan and discharge instructions, or the patient requires no further treatment and the physician has provided written documentation of the examination findings. Although requested, the hospital did not provide a policy outlining the care of psychiatric patients in the ED. Review of the hospital’s policy titled, “Involuntary Admission (a legal process through which a person is hospitalized and treated for mental health disorders without their consent),” revised 11/16/23, showed: - Patients who are a harm to themselves or someone else, require constant supervision to remain safe and are not willing to seek treatment will be placed on an involuntary commitment to an appropriate placement. - The procedure for 96-hour detention included: patients found to have a mental disorder or at harm to themselves or others should be encouraged to seek voluntary treatment; if the patient refuses and is not considered safe to return to home, involuntary commitment should be pursued. - An affidavit (a written statement confirmed by oath, for use as evidence in court) is completed noting evidence of harm to self or others and evidence of a mental disorder or substance abuse. - If the patient is age 55 or older and is believed to have a mental disorder, the Senior Mental Health unit should be contacted for possible placement on Moberly Regional Medical Center (MRMC) psychiatric unit. If the patient will be admitted to the MRMC psychiatric unit, a staff member will complete an Application for Detention. If the patient was voluntary and becomes involuntary, State of Missouri Department of Mental Health forms must be completed. - If the patient will not be admitted to MRMC, affidavits must be taken to the probate judge in the county in which the patient resides. If after hours, the police or sheriff department will take the application to the probate judge. The judge will determine appropriateness and placement for the individual. Review of the hospital’s policy titled, “Post Elopement (when a patient makes an intentional, unauthorized departure from a medical facility),” revised 01/2022, showed: - In the event of a patient elopement; the charge nurse immediately notifies security, house supervisor and police. - The charge nurse completes an incident report. - Appropriate restraint may be used to detain an involuntary patient who has eloped off the unit or hospital grounds. The police may be summoned to assist in returning the patient, if necessary. - Appropriate restraint is not used to detain a voluntary patient who has eloped. - In the event a voluntary patient is assessed by the physician and found to need involuntary admission, steps are taken to seek involuntary status for the patient. - The incident necessitates a quality improvement review. Review of the medical record for Patient #7 on 06/02/24 at 10:15 PM showed: - She was a 56-year-old female brought to the ED by ambulance with complaints of anxiety (a feeling of fear or worry experienced intermittently). - At 10:35 PM, Staff M, Registered Nurse (RN), documented the patient reported she was having chest pain and a panic attack (specific periods of sudden onset of intense apprehension, fearfulness, or terror, often associated with feelings of impending doom) and called for an ambulance. - At 10:47 PM, Staff V, ED Physician, documented the patient denied currently having chest pain or shortness of breath. The patient took clonazepam (medication used to treat anxiety) for anxiety and felt her current symptoms were related to her uncontrolled anxiety. - Staff V completed a physical examination including assessment of heart, lungs and psychiatric. The electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions) was negative for acute coronary concerns and the patient refused to proceed with laboratory tests. The ED physician discussed the risks and benefits of not proceeding with the testing. The patient was deemed competent to make her own decisions. She continued to refuse laboratory testing and was discharged Against Medical Advice (AMA). - At 10:50 PM, Patient #7 signed a completed AMA form. Review of the medical record for Patient #7 on 06/02/24 at 11:42 PM showed: - She was a 56-year-old female with complaint of paranoia (excessive suspiciousness without adequate cause) and confusion. - At 11:49 PM, Staff M, RN, documented Patient #7 was seen in the ED approximately one hour before this presentation with complaint of anxiety and chest pain. She left AMA. Patient #7 now reported “I want to go to [Hospital B] Psych Ward. I’m confused.” - At 11:53 PM, Staff M documented a Columbia Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person’s risk to self-inflicted harm and desire to end one’s life) Assessment for Patient #7. The patient denied wishing she was dead and denied any thoughts of killing herself. Her assessed suicide risk was low. - At 11:59 PM, Staff V, ED Physician, documented Patient #7 was sitting in the ED waiting room and felt like she heard people talking about her. The patient reported she heard voices threatening her. Patient #7 requested to go to Hospital B’s Psychiatric Unit. She did not want to be admitted to MRMC’s senior behavioral health unit (BHU) because she did not “trust” the hospital. Patient #7 reported she had attempted suicide in the past and currently had thoughts of harming herself by cutting her wrists. - On 06/03/24 at 12:02 AM, Staff V documented an examination of Patient #7 which was normal other than slow response to questioning, flat affect, irritable mood and thoughts of suicide. The patient reported her plan for suicide was cutting. Patient #7’s judgement and insight was assessed as impaired with delusions (false ideas about what is taking place or who one is) and auditory hallucination (hearing things that are not heard by others, imaginary). - At 12:06 AM, Staff V documented differential diagnoses considered were psychosis (a serious mental illness characterized by defective or lost contact with reality), volume depletion, drug use, hypoglycemia (low blood sugar) and paranoia. - At 12:10 AM, Staff V documented an attempted blood draw was not successful and Patient #7 refused further attempts. Staff V talked with Patient #7 and told her before she could talk with a psychiatrist to approve a transfer, she had to have results of the laboratory tests. Patient #7 told Staff V she did not trust her and did not believe the tests were necessary. Staff V explained to Patient #7 that because she had reported a plan to harm herself and had previously attempted suicide, a 96-hour involuntary hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) would be initiated to keep Patient #7 in the ED until test results were obtained. - Patient #7 walked out of the ED and the discharge disposition was recorded as “Eloped.” Discharge diagnoses were listed as suicidal ideations and delusional disorders. Staff V’s documentation included “Due to staffing and safety issues, we were not able to prevent her from leaving.” The local police department was notified. Review of the hospital’s undated, incomplete document included in Patient #7’s medical record titled, “Order for 96 Hour Detention, Evaluation and Treatment and Warrant,” showed: - An outline of procedures for completing 96-hour detention paperwork and showed the county required a completed and notarized 96 Hour Detention, Evaluation and Treatment form, a completed and notarized affidavit in support of 96-hour hold, completed list of witnesses, and a completed confidential case filing information form. Contact information was included with the instructions on how to process the application during normal business hours and after hours. - Staff V started the application for submission to the probate court for 96-hour hold including documentation of Patient #7’s statements of auditory hallucinations, persecutorial (when someone believes a person or group wants to hurt them despite the lack of proof) delusions, admission to suicidal ideation with a plan to cut herself and had had previous suicide attempts that required psychiatric admission. The application was not completed, signed, notarized, nor submitted. - Staff V initiated an affidavit which showed Patient #7 presented to the ED for confusion, delusions and requested to be sent to Hospital B. The patient reported she believed she hallucinated while in the waiting room, denied drug use, reported current suicidal thoughts of cutting herself and had a history of suicidal actions and subsequent hospitalization. Patient #7 exhibited paranoia about hospital staff. The affidavit was not signed, notarized, nor submitted. - A form titled, “List of Witnesses” was started with Staff V’s name and contact information included. The form was not completed, signed, nor submitted. Review of Patient #7’s medical record from Hospital B dated 06/03/24 showed: - Patient #7 was a 56-year-old female with a history of schizophrenia (serious mental disorder that affects a person’s ability to think, feel, and behave clearly). - She was brought to the hospital by ambulance with reports of suicidal ideation, auditory and visual hallucinations (seeing things which are not there), and a plan to cut herself. - At 2:53 AM, she was evaluated for medical clearance, was cleared of medical concerns before laboratory results and transferred for psychiatric evaluation. - At 3:55 AM, psychiatry notes showed Patient #7 presented voluntarily with a chief complaint of erratic behavior (behaving in a wild and unpredictable manner). Patient #7 stated “I’m suicidal.” She exhibited paranoid tendencies about the staff trying to hurt her. The patient was reluctant to answer questions, verbalized paranoid comments and ultimately became agitated (a state of feeling irritated or restless). The evaluation was hindered due to the patient’s paranoid delusions and disorganized behavior. It was determined Patient #7 was at risk of imminent harm to herself or others and required further evaluation. - The medical record contained paperwork titled, “Application for 96-hour Imminent Harm Admission,” and she was placed on 96-Hour Hold for further psychiatric observation. - Initial diagnoses were listed as unspecified schizophrenia, rule-out schizoaffective disorder, bipolar type (mental illness that is characterized by symptoms of mania, depression and mood disturbances) and rule-out substance induced psychosis (a serious mental illness characterized by defective or lost contact with reality, caused by taking or stopping a drug). Although requested, the hospital did not provide incident reports or security events regarding Patient #7’s elopement from the ED on 06/02/24. During a telephone interview on 07/26/24 at 1:00 PM, Staff V, ED Physician, stated that Patient #7 initially presented to the hospital on 06/02/24 with complaint of panic attack and chest discomfort. The patient did not report any intent to harm herself during that ED visit. Staff V attempted to do an appropriate work-up to rule-out a heart attack or other cardiac-related issue. The patient refused laboratory work, repeated back to Staff V that she understood the risks associated with leaving before her evaluation was complete, signed an AMA form and left the treatment area. Patient #7 never left the hospital and sat in the ED waiting area after signing the AMA form. Staff V stated that about 45 minutes later, Patient #7 told the registration clerk she needed to be seen in the ED again. The patient was screened by nursing and told the nurse and the physician that she wanted to go to Hospital B for psychiatric care. During the provider’s assessment, Patient #7 reported that she heard people talk about harming her or “get rid of her.” With more detailed questioning, Patient #7 told her that she had thought of harming herself using a knife and she knew where she could get one. Staff V discussed with the patient that she felt she was high-risk for SI and needed psychiatric treatment. Staff V explained that the ED would need to perform certain lab tests before they could transfer Patient #7 to Hospital B. The patient agreed to blood work, but the attempt to draw was unsuccessful and the patient then refused further blood draws. Staff V stated that the transfer centers for the psychiatric facilities in their area required that complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection), COVID-19 (highly contagious, and sometimes fatal, virus) and a drug screen at a minimum were complete before they would entertain any discussion regarding transfer of a patient for further evaluation. Staff V told Patient #7 she would be bound to get a 96-hour hold from the judge to keep the patient for the necessary testing and transfer. Patient #7 refused further testing and walked out of the ED. Patient #7 was never left alone after she reported SI to Staff V, but ED staff had not had an opportunity to begin one to one (1:1, continuous visual contact with close physical proximity) observation or placement in the psychiatric safe room (a room that has been cleared of any objects a patient might use to harm themselves or others). Staff V stated that Patient #7’s behaviors were not considered dangerous or combative. The ED had the capability to administer a chemical restraint (a form of medical restraint in which a drug is used to restrict the freedom or movement of a patient) and access to some psychiatric stabilization medications. The ED was fully staffed to competently care for the volume of its patients; but the number of staff was not enough to safely physically restrain patients, combative or not. It was felt that the risk of harm to Patient #7 or to hospital staff trying to physically restrain her for a chemical restraint were greater than the risk of Patient #7 actually harming herself. The police were notified and 96-hour hold paperwork was started, but not completed. Staff V stated that she could not have forwarded a 96-hour hold request to the judge for approval until an accepting destination had agreed to take the patient and required lab testing completed. Staff V stated that if the police found Patient #7, their process for a 96-hour hold was different and they could take the patient directly to a psychiatric ED for evaluation without necessary labs and referral. Staff V stated that the BHU within the hospital also had the same laboratory requirements before an intake representative would discuss if a patient was appropriate for inpatient care. Staff V stated that the hospital had social workers available during weekday daytime hours that could complete “Imminent Harm” paperwork. Otherwise after a nurse did an initial screening for SI/HI, the provider in the ED performed mental health evaluations (MHE) and determined if transfer was pursued. During a telephone interview on 07/22/24 at 8:00 AM, Staff M, RN, stated that she remembered the events that occurred with Patient #7 on 06/02/24. The patient did not report to her during triage or her assessment that she was suicidal, but she told the ED physician that she was suicidal. The physician told Staff M and she called the house supervisor to get a sitter for 1:1 observation. Staff M stated that she heard the physician discuss the 96-hour hold and the patient left the ED within three minutes following that conversation; before 1:1 or the 96-hour hold paperwork were completed. Security and the police were called, but she did not believe that the patient was returned to the ED that night. The protocol for a patient who presented with SI/HI was to get a sitter and start 96-hour hold paperwork, if needed. If an active SI/HI patient eloped or was violent, staff would not put themselves in danger. They would call security and the police. During an interview on 07/17/24 at 11:45 AM, Staff I, ED Physician/ED Medical Director, stated that Hospital B did require certain labs and radiology testing before they would accept a patient for psychiatric transfer. Providers sometimes called the on-call provider if they had concerns that the patient would not meet admission criteria for the hospital’s own BHU before running tests on patients aged 55 and older. The hospital’s BHU would not accept patients with a urine drug screen result positive for illicit drugs. With regards to Patient #7’s visit and elopement on 06/02/24, he felt it was appropriate to initiate a 96-hour hold on a patient who had expressed SI. He reviewed Patient #7’s medical record and the documented statement regarding not enough staff and safety concerns as reason not to deter the patient from elopement. He had not discussed this patient nor this visit with Staff V, ED Physician; but wondered if Staff V considered inquiring for assistance from other ED providers on-call if the census or acuity within the ED was overwhelming at the time and if additional presence may have been beneficial. During an interview on 07/15/24 at 11:15 AM and 07/17/24 at 8:35 AM Staff E, ED Director, stated that the hospital did not have access to telehealth (remote delivery of healthcare services while the health care provider is at a separate location, including exams and consultations, through video and telephone communication) services for psychiatry. The hospital had a BHU that could admit eligible patients over the age of 55. If a patient in the ED was above age 55, the ED provider would decide if consultation with the psychiatrist on-call for the BHU was warranted. Nurses from the BHU could come to the ED and perform a MHE on a patient older than 55 as well; but this was rarely utilized. The hospital’s BHU staff could also complete “Imminent Harm” paperwork. Affidavits could be completed by any staff and nurses could start the application process for 96-hour hold request form, but the provider had to sign the form before it was forwarded through the court system. ED providers often consulted with providers at Hospital B regarding potential transfer of psychiatric patients. Admission to the hospital’s BHU would only occur after required lab and radiology (a variety of medical imaging/x-ray techniques used to diagnose or treat diseases) testing was complete. Transfer to another facility before the labs and other diagnostic tests were completed could be accomplished; but it was “frowned upon.” The ED had a psych safe room and a patient deemed as high-risk after CSSR was placed in the room with a 1:1 observer. If a high-risk patient attempted to elope the ED, nurses were encouraged to de-escalate the patient with verbal techniques but told not to put themselves in a harmful situation to physically detain a patient. The house supervisor and security were notified, but security was limited as to their capability to put “hands on” patients as well. A physician might decide to chemically restrain a patient and security might be involved in that process. Sometimes local law enforcement was requested as a “presence of force.” If a high-risk patient did elope the ED, law enforcement was notified, and they brought the patient back to the ED until the MSE was completed and a transfer was arranged. In the case of Patient #7’s visit on 06/02/24, she was not placed in the psych safe room and 1:1 observation had not begun because her CSSR in triage was determined low-risk. Patient #7 then told the provider she was suicidal and left the ED almost immediately after, before high-risk measures were implemented. During a telephone interview on 11/23/24 at 11:00 AM, Staff T, House Supervisor, stated that she was the house supervisor on duty on 06/02/24 when Patient #7 eloped from the ED. When a high-risk patient eloped the ED, she and security were notified. Security searched the immediate hospital premises and if they were unable to locate the patient, security called the police for assistance. When 96-hour hold paperwork was needed, the provider and ED nursing staff completed the paperwork. She did not fill out an event form when a patient eloped the ED, but she notified the administrator-on-call (AOC) if she felt that the situation warranted due to a patient at-risk. She did not recall notifying the AOC on 06/02/24. During a telephone interview on 11/23/24 at 12:00 PM, Staff U, Security Officer, stated that he was the security officer on duty on 06/02/24. He was unsure if he was notified that Patient #7 eloped on 06/02/24. Security was trained to not chase an individual that was attempting to elope. Sometimes they were asked to come to the ED as a “show of force” for someone who was “out of control”; but most times they do no put hands on a patient and instead called police. He was very familiar with Patient #7 because she was known to wander the halls and property of the hospital after she had been seen in the ED. When security approached her to leave, she wanted them to call police because she was “scared to go outside.” She had never been violent toward him. Staff U stated that Patient #7 was well-known in the community for walking around and when people tried to help her, she often said “the hospital just wants to do brain surgery on me.” No one had ever asked him to complete an affidavit about her statements of seeing people who were not there or hearing voices of individuals that were not present. During a telephone interview on 07/31/24 at 11:00 AM, Staff X, Police Officer Facility D, stated that just after midnight on 06/03/24 he was notified by the hospital that Patient #7 had eloped from the ED. He spoke with the physician regarding concerns for the patient. A short time after leaving the ED, he responded with another officer to a call that someone was attempting to enter homes without permission and Patient #7 was apprehended. Patient #7 reported to officers that she wanted to go to Hospital B for a psychiatric evaluation. Patient #7 did not necessarily appear to be experiencing a “psychiatric emergency” at that time and never reported SI or HI; but he had had frequent previous encounters when she appeared to be responding to hallucinations or was felt to be altered by recent drug use. The decision to take the patient to Hospital B rather than MRMC was made by his supervisor; but “Why would we take her back when they just let her leave?” The police department experienced frequent elopements from MRMC, but most of the time it was individuals who requested narcotics from the ED or were heavily intoxicated and then just “left” when they wanted to. During a telephone interview on 07/23/24 at 9:00 AM, Staff R, ED Physician, stated that the hospital’s BHU providers have seen patients in the ED in the past, but they are not “on-call” to perform MHEs. Staff R stated that other facilities will not consider admission of a psychiatric patient in transfer unless all labs and radiologic tests have been completed. If a patient refused testing, the provider would not be able to proceed with a transfer for admission. Staff R stated that a 96-hour hold would be initiated by a provider when the patient exhibited SI, HI, active psychosis, acts of self-harm, or when they were unable to care for themselves related to a mental illness. She was familiar with Patient #7 from previous ED encounters. When asked if Patient #7 was felt capable of making appropriate decisions and caring for herself, Staff R stated that “It depends on the day. Some days I feel she would benefit from a mental health evaluation.” During a telephone interview on 07/30/24 at 7:30 AM, Staff W, ED Physician, stated that the providing physician performed the MHE in the ED. Before any outside facilities would discuss placement of a patient with psychiatric concerns, providers must provide lab results. He was unaware that they were required before 96-hour hold paperwork could be completed. Staff W stated that during other encounters with Patient #7, she had come to the ED usually by EMS, was screened for the presence of a medical problem and did not want further evaluation or tests. There were other conditions in which a patient could be detained for 96-hour hold other than SI or HI; but though she often appeared to be responding to internal stimuli or voices, he did not consider Patient #7 a danger to herself or to others. During a telephone interview on 07/22/24 at 5:20 PM, Staff Q, Paramedic from Facility C, stated that she had encountered Patient #7 multiple times in transport to the ED. Patient #7 often presented with paranoid ideas and appeared to be hallucinating. Staff Q stated that she was never approached by hospital staff to write an affidavit in support of a 96-hour hold for Patient #7. She was very concerned about Patient #7’s ability to care for herself and considered submitting a hotline for Patient #7’s well-being. During a telephone interview on 07/18/24 at 1:30 PM, Staff L, RN, stated that Patient #7 was seen frequently in the ED for anxiety. She was seen, treated, released, and ED staff obtained a taxi pass to take her home. Patients who presented with SI received a suicide risk assessment and if the suicide risk was determined as high-risk, the patient was placed in 1:1 observation. If a patient was high-risk and attempted to elope; security, the house supervisor and the police were notified. Staff L stated that a 96-hour hold was utilized when a patient was not willing or did not possess the capacity to make decisions regarding their own well-being. A nurse could write an affidavit in support of a 96-hour hold, but the provider had to initiate the process and sign the request. The police took the completed form to the county judge, approval was returned via fax to the hospital and the patient was either admitted to their hospital or transferred to another. Other hospitals wanted all preadmission labs and typically a chest x-ray completed before a transfer was completed for a patient with psychiatric complaints. During an interview on 07/15/24 at 11:50 AM, Staff G, RN, stated that patients with a psychiatric emergency were sometimes placed in a regular ED room until a psychiatric diagnosis was obtained and a suicide risk completed. High-risk suicidal patients were moved to the psych safe room, if appropriate and available, and placed on 1:1 observation. The ED used their own Patient Care Technician for 1:1 observation until the house supervisor provided a sitter from elsewhere in the hospital. High-risk psychiatric patients deemed to have SI/HI on suicide screening were also changed into scrubs, their clothing and belongings secured, and every 15-minute checks were documented. If a patient was potentially going to be admitted to the hospital’s psychiatric unit, one of the BHU nurses and/or the psychiatrist might do a MHE on the patient. If the patient was not likely appropriate for admission and not SI/HI, the ED physician performed the MHE. During an interview on 07/16/24 at 1:00 PM, Staff H, RN, stated that patients with a high-risk rating on their suicide screening were encouraged to stay and security was notified if the patient attempted to leave the ED. However, if the hospital did not have a 96-hour hold on the patient, they could not physically detain the patient or prevent their departure. ED staff called law enforcement to have them secure a patient once the patient was determined incompetent. During a telephone interview on 07/23/24 at 10:00 AM, Staff S, RN, stated that a patient who reported SI would have a CSSR completed, changed into scrubs and placed in the psychiatric safe room. If the CSSR revealed high-risk, the psych safe room had a camera for observation and 1:1 observation would be started. If a high-risk patient attempted to elope, staff called security, the house supervisor, and the police. A 96-hour hold should probably be completed after an elopement of a patient with high-risk CSSR, as without it the police may not bring the patient back to the ED. The ED physician performed most of the MHEs as the hospital’s psychiatric unit staff will only see those patients who are 55 years old and older. Otherwise, the ED physician may contact a psychiatric or mental health provider at Hospital B and engage in discussions regarding a patient via telephone or e-mail. The standard practice in the ED was to ensure that labs and radiology tests were completed prior to transfer of any psychiatric-related patient. Review of the documents titled, “Moberly Police Department, Incident #2406-0097 and #2406-0098,” dated 06/03/24 showed Staff X, Police Officer Facility D, responded to the hospital at 12:10 AM after being informed of a suicidal subject in the ED. Staff X spoke with Staff V, ED Physician, who reported that Patient #7 had made statements of self-harm and wanted to go to Hospital B. Staff V began 96-hour hold paperwork, but Patient #7 left before the form was completed. Staff X documented contact with Patient #7 in response to a different call for trespassing and Patient #7 was ultimately transferred to Hospital B’s psychiatric services via Facility C ambulance. Review of the document titled, “Run-Number 24-2033,” dated 06/03/24 showed Facility C sent an ambulance at 1:59 AM for a 56-year-old female with suicidal ideation. The female was found to be Patient #7 and accompanied by law enforcement. Law enforcement reported to the Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) Patient #7 appeared under the influence of an unknown substance, had SI and was hearing things. The patient was transported to Hospital B.”