Poplar Bluff Regional Medical Center

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 50321 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 one patient (#2) of 23 Emergency Department (ED) records reviewed. The hospital’s average monthly census was 3,663. Findings included: Review of the hospital’s policy titled, “Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition),” dated 07/14/22, showed: - An EMC was a medical condition that manifested itself by acute (sudden onset) symptoms of sufficient severity (including severe pain, psychiatric [relating to mental illness] disturbances and/or symptoms of substance abuse) 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 impairment to bodily functions, or serious dysfunction of any bodily organ or part. - A MSE was the process required to reach, with reasonable clinical confidence, the point at which it could be determined whether or not an EMC existed. The MSE was an ongoing process, and the medical record must reflect continued monitoring based on the patient’s needs and continue until the patient was either stabilized, discharged, admitted to inpatient care, or appropriately transferred. - A patient was stable for discharge when, within reasonable clinical confidence, it was determined that the patient had reached the point where his or her continued care, to include diagnostic work-up and/or treatment, could reasonably be performed as an outpatient, provided the patient was given a plan for appropriate follow up care with the discharge instructions, or the patient required no further treatment and the treating physician had provided written documentation of his or her findings. Review of the hospital’s undated policy titled, “ED Minimum Shift Required Documentation for Nurses,” showed the administration of intravenous (IV, in the vein) pain medication required a reassessment within 30 minutes of administration. Vital signs (VS, measurements of the body’s most basic functions) should be documented in real time for every ED encounter, and more frequently if indicated per order such as the use of telemetry (remote observation of a person’s heart rhythm, using signals that are transmitted from the patient to a computer screen), an unstable status, or cardiac complaint. Review of the hospital’s policy titled, “Triage (process of determining the priority of a patient’s treatment based on the severity of their condition) Assessment of Patients by Emergency Severity Index (ESI),” dated 10/17/24, showed: - Triage involved a rapid, directed patient assessment which provided an assignment of an acuity (the severity of a patient’s illness and the level of service needed) level for each patient who arrived in the unit based on the ESI algorithm. - Based on the algorithm, an acuity level of two answered yes to the questions, “high risk situation, or confused/lethargic (weak, sluggish)/disoriented, severe pain or distress, and Danger zone VS. Parameters for VS were not included. - Severe pain or distress was determined by clinical observation and/or patient rating of greater than or equal to a pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) score of greater than or equal to seven out of 10. Please refer to A-2406 for further details.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 50321 Based on interview, record review and policy review, the hospital failed to follow its policies and procedures when they failed to provide, within its capability and capacity, an appropriate medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for one patient (#2) of 23 Emergency Department (ED) records reviewed. Findings included: Review of the hospital’s policy titled, “Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition),” dated 07/14/22, showed: - An EMC was a medical condition that manifested itself by acute (sudden onset) symptoms of sufficient severity (including severe pain, psychiatric [relating to mental illness] disturbances and/or symptoms of substance abuse) 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 impairment to bodily functions, or serious dysfunction of any bodily organ or part. - A MSE was the process required to reach, with reasonable clinical confidence, the point at which it could be determined whether or not an EMC existed. The MSE was an ongoing process, and the medical record must reflect continued monitoring based on the patient’s needs and continue until the patient was either stabilized, discharged, admitted to inpatient care, or appropriately transferred. - A patient was stable for discharge when, within reasonable clinical confidence, it was determined that the patient had reached the point where his or her continued care, to include diagnostic work-up and/or treatment, could reasonably be performed as an outpatient, provided the patient was given a plan for appropriate follow up care with the discharge instructions, or the patient required no further treatment and the treating physician had provided written documentation of his or her findings. Review of the hospital’s undated policy titled, “ED Minimum Shift Required Documentation for Nurses,” showed the administration of intravenous (IV, in the vein) pain medication required a reassessment within 30 minutes of administration. Vital signs (VS, measurements of the body’s most basic functions) should be documented in real time for every ED encounter, and more frequently if indicated per order such as the use of telemetry (remote observation of a person’s heart rhythm, using signals that are transmitted from the patient to a computer screen), an unstable status, or cardiac complaint. Review of the hospital’s policy titled, “Triage (process of determining the priority of a patient’s treatment based on the severity of their condition) Assessment of Patients by Emergency Severity Index (ESI),” dated 10/17/24, showed: - Triage involved a rapid, directed patient assessment which provided an assignment of an acuity (the severity of a patient’s illness and the level of service needed) level for each patient who arrived in the unit based on the ESI algorithm. - Based on the algorithm, an acuity level of two answered yes to the questions, “high risk situation, or confused/lethargic (weak, sluggish)/disoriented, severe pain or distress, and Danger zone VS. Parameters for VS were not included. - Severe pain or distress was determined by clinical observation and/or patient rating of greater than or equal to a pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) score of greater than or equal to seven out of 10. Review of Patient #2’s medical record, dated 06/25/25, showed: - At 9:11 AM, she arrived at the ED with a chief complaint of midline chest and abdominal pain with nausea, vomiting, and diarrhea since the previous night. - At 9:15 AM, VS were obtained, and her blood pressure (BP, normal adult blood pressure is between 90/60 and 120/80) was 169/88. No other VS were taken throughout the ED visit. Her pain scale assessment score was 10 out of 10. Her acuity level was two. - Provider documentation indicated she had presented with similar pain in the past and recently visited the ED for a motor vehicle accident (MVA). The pain felt like a burning sensation up into her chest and was mild. She was hypertensive but her other VS were stable. - Her home medications list included medication used to treat high BP. - At 12:06 PM, four milligrams (mg) of IV morphine (an opioid pain medication) was administered. No pain scale assessment or reassessment was recorded. - At 1:09 PM, four mg of IV morphine was administered. Her pain scale assessment score was four out of 10. No pain scale reassessment was recorded. - She was referred to a gastroenterologist (physician who specializes in the digestive system) for follow up and was diagnosed with acute gastritis (inflammation of the stomach) and cyclical vomiting (repeated, severe episodes of nausea and vomiting, followed by periods of complete wellness). - There were no VS orders in the medical record. - At 1:47 PM, she was discharged. During a telephone interview on 09/16/25 at 10:45 AM, Staff I, Nurse Practitioner (NP, a nurse with advanced clinical education and training), stated that he remembered caring for Patient #2 on 06/25/25. She had been vomiting which likely caused her increased BP. He was unsure how often VS were to be recorded in the medical record and he was surprised the only BP reading in the chart was 169/88. Typically, when he entered a room to see a patient he would cycle a BP reading on the monitor. If her BP remained elevated during the visit, he would have provided medications. He believed other VS sets were taken but possibly not recorded. If no other VS were taken, that would be concerning. He referred Patient #2 to a gastroenterologist only, not her primary care provider. During a telephone interview on 09/16/25 at 10:31 AM, Staff G, NP, stated that he would not treat a systolic pressure (the pressure against the artery during the heartbeat, when the heart is pushing blood out) in the 140-150’s in the ED, but would refer the patient to their primary care provider. If a systolic pressure were higher, such as 180-190’s, he would re-evaluate it and potentially provide treatment in the ED. During an interview on 09/16/25 at 12:07 PM, Staff E, ED Director, stated that VS were typically automatically taken every 15 minutes when a patient was connected to a monitor. The frequency of recorded VS would depend on the patient’s acuity. The frequency of VS for a patient with an acuity level of two would depend on their presentation. She was unsure how often VS were required and would refer to the policy. If a BP had been 169/88, she would expect a second set of VS to have been taken. She would not necessarily be concerned with a BP that high; it would be dependent on the patient’s presentation. During a telephone interview on 09/16/25 at 10:00 AM, Staff J, Registered Nurse (RN), stated that she cared for Patient #2 on 06/25/25. If a BP were 169/88, she would notify a physician. She was surprised no other VS were taken before Patient #2 was discharged. During a telephone interview on 09/16/25 at 12:26 PM, Staff H, RN, stated that VS should be rechecked after the administration of medications like morphine. If a patient had a BP of 169/88, she would have rechecked it but would not focus on it unless it were “sky high,” such as a systolic pressure of 180 or greater. Sometimes the ED was busy, and VS may not have been a priority. The monitors in the ED rooms would automatically cycle, taking a BP, every 15 minutes, but the nurse would have to validate the readings. During an interview on 09/16/25 at 9:36 AM, Staff L, RN, stated that if a BP was elevated, she would first consider the patient’s history and presentation. Secondly, she would discuss the BP with the provider. She would document in the free text section of the medical record any discussion that was made with the provider regarding abnormal VS. VS were typically repeated within one hour of discharge, but she was unsure if that was required by policy.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48359 Based on interview, record review and policy review the hospital failed to: - Ensure the safety of all patients when they failed to identify, investigate and educate all staff in response to the attempted suicide (to cause one’s own death) of one discharged patient (#49) of two safety events reviewed. - Provide one-to-one (1:1, continuous visual contact with close physical proximity) oversight for one patient (#43) of two medical records reviewed. - Follow their internal policy for every 15-minute rounding for Behavioral Health Unit (BHU) patients for one current patient (#47) and 10 discharged patients (#39, #40, #41, #42, #43, #44, #45, #46, #48 and #49) of 11 medical records reviewed. - Follow their internal policy for the frequency of completion for the 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) in the BHU for one current patient (#47) and three discharged patients (#39, #42, and #49) of 10 medical records reviewed. These failed practices resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation (CoP): Patient’s Rights.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48359 Based on interview, record review and policy review the hospital failed to: - Ensure the safety of all patients when they failed to identify, investigate and educate all staff in response to the attempted suicide (to cause one’s own death) of one discharged patient (#49) of two safety events reviewed. - Provide one-to-one (1:1, continuous visual contact with close physical proximity) oversight for one patient (#43) of two medical records reviewed. - Follow their internal policy for every 15-minute rounding for Behavioral Health Unit (BHU) patients for one current patient (#47) and 10 discharged patients (#39, #40, #41, #42, #43, #44, #45, #46, #48 and #49) of 11 medical records reviewed. - Follow their internal policy for the frequency of completion for the 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) in the BHU for one current patient (#47) and three discharged patients (#39, #42, and #49) of 10 medical records reviewed. Review of the hospital’s policy titled, “Suicide Risk Assessment and Reassessment for Behavioral Health Services, dated 12/2023 showed: - In a behavioral health setting, we generally consider that there is some level of risk for virtually every patient and have an environment and a set of practices developed with this in mind. Psychiatric (relating to mental illness) units have a primary concern with patient safety with respect to potential for injury to self or others, differing in the respect from virtually all other acute care hospital units. - For high, moderate and low risk suicide document observations every 15 minutes or more frequent as ordered. - Rounds are required to be completed within three minutes to either side of each quarter hour. - Reassess suicide risk with a reassessment tool every two hours for patients on 1:1 observation for suicide risk. - Reassess suicide risk with a reassessment tool every four hours for patients assessed at high-risk but not on 1:1 observation. - For moderate and low suicide risk reassess suicide risk with a reassessment tool at least daily. Review of the hospital’s policy titled, “Event Reporting,” dated 11/08/23, showed: - A patient safety event is an event, incident, or condition that resulted or could have resulted in harm to a patient. - Suicide is a patient safety event. - The department manager will conduct a brief/limited investigation on events which are precursor or near miss harm events. This information is critical for patient safety efforts and to prevent recurrence. - For events with no harm, the department manager will complete an investigation within 14 calendar days of the reported date. - The risk/quality department will review department supervisor/manager investigation and determine if additional investigation is needed within three business days of the reported date. - The risk/quality department will establish a small core group to determine the safety event classification and whether the event meets the definition of a serious safety event. - The risk/quality department will facilitate a Root Cause Analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred to find the root cause) when an event meets the definition of a Serious Safety Event. - The risk/quality department will complete the RCA within 45 days of event discovery. Review of the hospital’s document titled, “Event Report #1645410,” dated 03/02/24 showed: - During a 15-minute observation round, Patient #49 was found in the bathroom with a sheet around her neck. - Patient #49 stated “I’m sorry.” - A written note showed “I’m sorry.” - The department manager did not investigate. - A RCA was not completed. - The event was not reported to the Department of Health and Senior Services (DHSS). Review of Patient #49’s medical record showed: - On 03/02/24 she was a 19-year-old female admitted to the BHU for major depressive disorder (persistently low mood, decreased interest in pleasurable activities, feelings of guilt or worthlessness, lack of energy, poor concentration, appetite changes, agitation, sleep disturbances, or suicidal thoughts). - At 11:02 AM and 11:29 AM, every 15-minute rounds were completed, 27-minutes between rounds. - At 12:17 PM and 12:40 PM, every 15-minute rounds were completed, 23-minutes between rounds. - At approximately 12:30 PM, staff noticed on security camera that Patient #49 was in her bathroom, the sheets were off her bed and a piece of paper stuck out from under her door. - The patient was found in the bathroom standing in front of the mirror. - A sheet was draped over the back of her neck. - She was starting to tie the ends of the sheet together. - At 1:18 PM and 1:40 PM, every 15-minute rounds were completed, 22-minutes between rounds. - At 2:30 PM, an order was written for 1:1 observation due to high-risk suicide. - On 03/03/24 at 4:00 PM and 6:55 PM, the CSSR was completed, 55 minutes late. - On 03/05/24 at 8:45 AM and 9:00 PM, the CSSR was completed, ten hours and 15 minutes late. - On 03/06/24 at 12:00 PM and 10:00 PM, the CSSR was completed, eight hours late. - At 10:00 PM and 03/07/24 at 8:45 AM, the CSSR was completed, eight hours and 45 minutes late. - At 4:21 PM, the 1:1 observation order was discontinued. Review of Patient #43’s medical record showed: - On 05/03/24, she was a 28-year-old female admitted to the BHU for a 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) for walking erratically down a street with very erratic movements. She appeared intoxicated and had a history of drug use. - At 10:30 PM, a provider order was written for 1:1 observation for patient safety related to fall risk. - At 10:43 PM. Staff RR, PCT was assigned the 1:1 observation and rounded every 15 minutes on 14 other patients. - On 05/04/24 at 7:03 AM through 6:45 PM, Staff LL, PCT provided 1:1 observation and rounded every 15 minutes on other patients. - On 05/04/24 at 1:18 AM and 1:42 AM, every 15-minute rounds were completed, 24-minutes between rounds. - At 3:47 AM and 4:07 AM, every 15-minute rounds were completed, 20-minutes between rounds. - At 4:24 AM and 4:44 AM, every 15-minute rounds were completed, 20-minutes between rounds. - At 7:38 PM, the 1:1 observation order was discontinued. Review of Patient # 42’s medical record showed: - On 02/19/24 at 7:59 AM an order was written for 1:1 observation due to high-risk suicide. - At 8:00 PM, the CSSR was completed, 11 hours late. - On 02/20/24 at 7:00 AM, the CSSR was completed, nine hours late. - At 10:23 PM, the CSSR was completed, 13 hours and 23 minutes late. - On 02/22/24 at 9:30 AM, the CSSR was completed, nine hours and 7 minutes late. - At 10:00 PM, the CSSR was completed, 11 hours and 30 minutes late. - On 02/23/24 at 10:00 AM, the CSSR was completed, eight hours late. - At 7:01 PM and 7:28 PM, every 15-minute rounds were completed, 27-minutes between rounds. - At 7:47 PM and 8:08 PM, every 15-minute rounds were completed, 21-minutes between rounds. - At 8:39 PM, she was transferred to the Emergency Department (ED) following a fall. Every 15-minute rounds were not performed in the ED between 10:22 PM and 11:28 PM. - At 11:28 PM, she was transferred to the BHU. - On 02/24 at 9:00 AM, the CSSR was completed, nine hours late. - At 8:00 PM, the CSSR was completed, 9 hours late. - On 02/25/24 at 8:00 AM, the CSSR was completed, ten hours late. - At 8:02 AM and 8:29 AM, every 15-minute rounds were completed, 27-minutes between rounds. - At 8:46 AM and 9:14 AM, every 15-minute rounds were completed, 28-minutes between rounds. - At 10:33 AM and 10:57 AM, every 15-minute rounds were completed, 24-minutes between rounds. - At 11:06 AM she was transferred to the ED after stuffing paper in her right ear. - At 1:41 PM, she was transferred to the BHU. Every 15-minute rounds were not completed while Patient #42 was in the ED. - At 3:35 PM, she was transferred to the ED again for stuffing paper in her right ear. - At 4:09 PM, she was transferred to the BHU. Every 15-minute rounds were not completed while Patient #42 was in the ED. - On 02/26/24 at 9:00 AM, the CSSR was completed, 11 hours late. - At 12:49 PM and 1:14 PM, every 15-minute rounds were completed, 25-minute between rounds. - At 1:19 PM and 1:42 PM, every 15-minute rounds were completed, 23-minutes between rounds. - At 2:24 PM and 2:43 PM, every 15-minute rounds were completed, 19-minutes between rounds. - On 02/26/24 at 3:05 PM, she was transferred to the ED after stuffing foam from a drinking cup and paper up her nose and in both ears. - At 6:53 PM, she was transferred to the BHU. Every 15-minute rounds were not completed while Patient #42 was in the ED. - At 8:00 PM, the CSSR was completed, nine hours late. - On 02/27/24 at 8:00 AM, the CSSR was completed, ten hours late. - At 8:13 PM, the 1:1 observation order was discontinued. Review of Patient # 39’s medical record showed: - On 03/05/21 at 3:01 PM and 3:21 PM, every 15-minute rounds were completed, 20-minutes between rounds. - At 5:02 PM and 5:26 PM, every 15-minute rounds were completed, 24-minutes between rounds. - At 6:22 PM and 6:42 PM, every 15-minute rounds were completed, 20-minute between rounds. - At 7:01 PM an order was written for 1:1 observation due to high-risk suicide. - On 03/09/24 at 2:00 PM and 8:00 PM, the CSSR was completed four hours late. - On 03/10/24 at 8:00 PM and 03/11/24 at 12:00 AM, the CSSR was completed two hours late. - At 4:00 AM and 9:00 AM, the CSSR was completed three hours late. - On 03/11/24 at 11:00 AM and 4:00 PM, the CSSR was completed, three hours late. - At 5:34 PM, the 1:1 observation order was discontinued. Review of Patient # 47’s medical record showed: - On 05/13/24 at 5:35 PM and 7:10 PM, every 15-minute rounds were completed, one hour and 35-minutes between rounds. - At 8:02 PM and 8:22 PM, every 15-minute rounds were completed, 20-minutes between rounds. - At 9:02 PM and 9:23 PM, every 15-minute rounds were completed, 21-minutes between rounds. - On 05/16/24, no CSSR was completed. Review of Patient # 40’s medical record showed: - On 04/12/24 at 7:16 PM and 7:44 PM, every 15-minute rounds were completed, 28-minutes between rounds. - At 8:16 PM and 8:42 PM, every 15-minute rounds were completed, 26-minutes between rounds. - At 8:49 PM and 9:09 PM, every 15-minute rounds were completed, 20-minutes between rounds. Review of Patient # 41’s medical record showed: - On 02/26/24 at 9:20 AM and 9:40 AM, every 15-minute rounds were completed, 20-minutes between rounds. - At 10:01 and 10:26 AM, every 15-minute rounds were completed, 25-minutes between rounds. - At 11:23 AM and 11:44 AM, every 15-minute rounds were completed, 21-minutes between rounds. Review of Patient # 44’s medical record showed: - On 05/03/24 at 10:43 PM through 05/04/24 at 6:46 AM and 7:16 PM through 7:37 PM Staff RR, PCT, provided every 15-minute rounds for Patient #44 while she was also assigned the 1:1 observation of Patient #43. - On 05/03/24 and 05/04/24, Staff RR and Staff LL, PCT, provided every-15-minute observations for Patient #44 while also providing 1:1 observation for Patient #43. - On 05/04/24 at 1:19 AM and 1:42 AM, every 15-minute rounds were completed, 23-minutes between rounds. - At 3:47 AM and 4:07 AM, every 15-minute rounds were completed, 20-minutes between rounds. - At 4:24 AM and 4:44 AM, every 15-minute rounds were completed, 20-minutes between rounds. - At 7:05 AM through 6:48 PM, Staff LL provided every 15-minute rounds for Patient #44 while she was also assigned the 1:1 observation of Patient #43. Review of Patient # 45’s medical record showed: - On 05/03/24 at 10:43 PM through 05/04/24 at 6:46 AM and 7:16 PM through 7:36 PM Staff RR, PCT, provided every 15-minute rounds for Patient #45 while she was also assigned the 1:1 observation of Patient #43. - On 05/04/24 at 7:04 AM through 6:47 PM, Staff LL, PCT, provided every 15-minute rounds for Patient #45 while she was also assigned the 1:1 observation of Patient #43. - On 05/03/24 and 05/04/24, Staff RR and Staff LL provided every-15-minute observations for Patient #45 while also providing 1:1 observation for Patient #43. - At 3:31 PM and 3:59 PM, every 15-minute rounds were completed, 28-minutes between rounds. - At 4:31 PM and 4:59 PM, every 15-minute rounds were completed, 28-minutes between rounds. - At 6:15 PM and 6:44 PM, every 15-minute rounds were completed, 29-minutes between rounds. Review of Patient # 46’s medical record showed: - On 05/03/24 at 10:43 PM through 05/04/24 at 6:46 AM and 7:16 PM through 7:36 PM Staff RR, PCT, provided every 15-minute rounds for Patient #46 while she was also assigned the 1:1 observation of Patient #43. - On 05/04/24 at 7:04 AM through 6:47 PM, Staff LL, PCT, provided every 15-minute rounds for Patient #46 while she was also assigned the 1:1 observation of Patient #43. - On 05/03/24 and 05/04/24, Staff RR and Staff LL provided every-15-minute observations for Patient #46 while also providing 1:1 observation for Patient #43. - On 05/07/24 at 2:50 AM and 3:14 AM, every 15-minute rounds were completed, 24-minutes between rounds. - At 4:09 AM and 4:29 AM, every 15-minute rounds were completed, 20-minutes between rounds. - At 5:32 AM and 5:52 AM, every 15-minute rounds were completed, 20-minutes between rounds. Review of Patient # 48’s medical record showed: - On 04/18/24 at 3:33 PM and 3:59 PM, every 15-minute rounds were completed, a 26-minutes between rounds. - At 4:50 PM and 5:14 PM, every 15-minute rounds were completed, 24-minutes between rounds. - At 6:18 PM and 6:40 PM, every 15-minute rounds were completed, 22-minutes between rounds. During a telephone interview on 05/21/24 at 11:30 AM and 05/22/24 at 12:00 PM, Staff C, CNO, stated that she was not aware of Patient #49’s suicidal gesture. She expected to be informed of all nursing and patient events. Any attempt of suicide needed to be taken seriously. She expected a RCA and staff education after “this type of event.” She expected any gesture of a suicide attempt was reported to the DHSS. She stated that she was not aware a PCT simultaneously provided 1:1 observation and performed every 15-minute rounds on other patients. A staff member with a 1:1 assignment was not to be assigned other duties. Gaps in every 15-minute rounds did not meet her expectation. Every 15-minute rounds should never be missed for a patient on a 1:1 observation status. The hospital needed to strengthen leadership rounding to achieve a consistent practice. Staff C stated that she expected staff to follow all hospital policies. During a telephone interview on 05/16/24 at 4:05 PM, 05/21/24 at 9:30 AM and 05/22/24 at 12:50 PM, Staff UU, BHU Director, stated that he considered a suicidal gesture to be a significant safety event. At the time of the event, he did not consider the significance of the “I’m sorry” note. Staff were complacent. It was unacceptable for staff to “let their guard down.” He did not follow up with the staff involved in Patient #49’s event or provide staff education. He stated that the simultaneous assignment of a 1:1 observation and every 15 rounding “should have never happened, patients were placed at risk.” He would not have asked his team “to do the impossible.” He did not perform any follow up investigation into the double assignment event. Staff UU stated that he expected every 15-minute rounds to be completed within the policy expectation of every 15-minutes with an allowance of a three-minute window. There were to be no gaps when a patient was on a 1:1 observation. There was an auditing process for every 15-minute rounds and he believed the rounding was “always done.” During a telephone interview on 05/16/24 at 4:00 PM, 05/21/24 at 8:30 AM and 05/22/24 at 12:15 PM, Staff MM, BHU Manager, stated that “sometime in early March a female patient made a gesture of suicide.” Staff MM reviewed Patient #49’s medical record for the care given after the suicide gesture. She did not investigate factors that led to Patient #49’s suicidal gesture. She did not investigate as required per the Event Reporting Policy. She stated that on the morning of 05/04/24 she was notified the fall precautions were discontinued for Patient #43 and staffing was adequate. At 7:30 AM, she received a text message from the PCT asking about her simultaneous assignment of the 1:1 and every 15-minute rounds for other patients. She told the PCT to speak with the charge nurse, she was not supposed to provide 1:1 observation and also provide every 15-minute observation of other patients. Her expectation was 1:1 observation and every 15-minute rounding were not performed by the same staff member. She was not aware the PCT who worked the night of 05/03/24 provided the 1:1 observation for Patient #43 and every 15-minute rounds for other patients. Staff MM did not speak with the charge nurse. She did not perform any follow up investigation into the double assignment event. Staff BB stated that she expected “no gaps” in every 15-minute rounding. There was no excuse for gaps when a patient was ordered a 1:1 observation. Staff MM expected the CSSR’s to be completed per the hospital policy. “A lot of education was provided about the CSSR completion expectations.” During a telephone interview on 05/22/24 at 10:45 AM, Staff BBB, Registered Nurse (RN), stated that he felt Patient #49’s action was a “gesture for attention.” That was an “expected event” in the BHU. Leadership did not debrief the event with him. During a telephone interview on 05/22/24 at 1:35 PM, Staff DDD, RN, stated that she overheard the PCT for Patient #49 call out and she went to help. She felt the event was a significant safety event. Any type of event whether a patient was seeking attention or attempted suicide was to be taken seriously. Leadership did not debrief the event for Patient #49 with her. During a telephone interview on 05/23/24 at 10:00 AM, Staff XX, PCT, stated that during her 15-minute observation rounds she found patient #43 in the bathroom, she knocked on the door, said she needed to enter and found the patient with the sheet “draped around her neck.” Leadership did not debrief the event with her. During a telephone interview on 05/22/24 at 11:30 AM, Staff CCC, BHU Intake Manager, stated that she was unaware the PCT was assigned the 1:1 observation for Patient #43 while also providing every 15-minute rounding for other patients. Staff ZZ, Charge Nurse, called Staff CCC and was told to pull the intake coordinator to cover the 1:1 observation of Patient #43 and discontinue the 1:1 observation order as soon as possible. She was unaware the licensed staff refused to be pulled to provide 1:1 observation. “This should never happen.” One to one observation and every 15-minute observations simultaneously were “impossible” for one staff member. No leadership follow up was performed in response to this double assignment event. During a telephone interview on 05/22/24 at 10:35 AM, Staff AAA, House Supervisor, stated that he did not recall Patient #43. He expected the charge nurses to escalate staffing issues to their departmental leadership when he was unable to pull staff to cover short shifts. Failure to provide 1:1 observation for Patient #43 did not meet his expectations. During a telephone interview on 05/22/24 at 10:25 AM, Staff ZZ, Charge Nurse, stated that when patient #43 was awake, she was “very high acuity.” She was a “all hands-on deck patient, a two to three staff members to one patient acuity.” She called the House Supervisor and was told there were no staff available to provide 1:1 observation for Patient #43. She called Staff CCC, BHU Intake Manager, but did not ask her to come into the hospital and help. The PCT sat outside of Patient #43’s doorway when she was not providing every15-minute rounds for the other patients. Staff ZZ had 11 patients herself. Patient #43 went to sleep around 5:00 AM. When Staff ZZ returned to work that evening, Patient #43 remained on 1:1 observation. During a telephone interview on 05/21/24 at 11:00 AM, Staff KK, Charge Nurse, stated that her understanding was the 1:1 order was “no longer in effect” for Patient #43. She told the PCT to watch Patient #43 for falls. During a telephone interview on 05/16/24 at 10:35 AM, Staff LL, PCT, stated that on 05/04/24 she was assigned the 1:1 observation of Patient #43 and also every 15-minute observations of 14 other patients. She spoke with Staff KK, Charge Nurse, and was told “it’s just until an assessment of Patient #43 was performed.” The 1:1 assignment remained in place “all day.” She called Staff MM, BHU Manager, and was told to talk to the charge nurse, and “to not call her on her day off.” Staff KK, told her to “watch the patient better.” During a telephone interview on 05/21/24 at 10:30 PM, Staff RR, PCT, stated that she reported to the charge nurse, simultaneous 1:1 observation and every 15-minute rounds on other patients was “unethical.” She stated that there was “plenty of staff” to cover the 1:1, but it required a licensed staff member to be pulled to the PCT role. She stated that “I had to do what the licensed staff said.” She spoke with other nurses and was told “we have to do what we have to do.” She was told the 1:1 observation was to be discontinued during the day. When she returned to work that night, the patient was still ordered 1:1 observation. Staff MM, BHU Manager, was aware and responded, “there was enough staff.” The House Supervisor stated that there were no sitters available at the hospital and the BHU staff had to “figure it out themselves.” She did not speak with Staff MM, because “she stands by her nurses.” She did not report the event to Staff UU, BHU Director, he would have said “you knew better.””

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 48359 Based on observation, interview, record review and policy review, the hospital’s Governing Body failed to ensure: - The Chief Executive Officer (CEO) provided adequate oversight when policies and procedures were not followed (A-0057); - Eligible patients were provided the Important Message from Medicare (IM, information about a patient’s right to appeal discharge) as well as obtain a patient signature within no later than two calendar days following admission (A-0117); - Staff followed their own policies and procedures for informing, retrieving, assisting with the formulation and documenting Advanced Directives (AD, a legal document where the patient can direct their medical care wishes, should the patient become unable to make their own decisions) (A-0132); - Staff followed their own policies and procedures to provide care in a safe setting due to failures to ensure one to one (1:1, continuous visual contact with close physical proximity) sitters for high risk suicidal (thoughts of causing one’s own death) patients, recognize suicidal behavior, remove unsafe signage in the Behavioral Health Unit, provide psychiatric safe rooms (a room that has been cleared of any objects a patient might use to harm themselves or others) and complete crash cart logs (A-0144); - Staff followed their own policies and procedures in regards to the neglect of patients (A-0145); - Provider orders were obtained for restraints/seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) (A-0168); - Providers received restraint training (A-0176); - Staff followed their own policies and procedures in regards to 1:1 observation for patients during episodes of simultaneous restraints and seclusion (A-0183); - Staff followed their own policies and procedures in regards to the required face to face evaluation within one hour of restraint application (A-0184); - Staff were trained in first aid related to restraints (A-0206); - Staff were provided unit specific orientation and on-going education (A-0398); - Perform hand hygiene (wash hands with soap and water or alcohol-based hand sanitizer) and glove changes during patient care for 12 patients (#27, #28, #32, #34, #35, #36, #38, #39, #40, #41, #42, and #45) of 15 patients observed (A-0749); - Prepare a clean work surface prior to performing patient care for seven patients (#27, #32, #34, #39, #40, #43, and #45) of 10 patients observed (A-0749); - Cleanse the skin surface prior to an intravenous (IV, in the vein) needle insertion for one patient (#34) of one patient observed (A-0749); - Clean the pill splitter between use for one patient (#39) of one patient observed; (A-0749) - Clean the workstation on wheels (WOW, a computer or supply and medication storage on a wheeled stand that can be moved from patient to patient) between use for four patients (#35, #38, #41, #42) of 16 patients observed (A-0749); - Discard supplies when dropped on the floor for one patient (#35) (A-0749); - Date food items that were located in patient pantry areas (A-0749); - Discard expired patient food items; and properly label food items in the patient refrigerator with patient name and open date (A-0749); - Remove expired patient care supplies from a supply storage area (A-0749); - Discharge planning was included in the Quality Assurance and Performance Improvement (QAPI, process for reporting and/or identifying adverse events, near misses or review of high risk problem prone areas for patient safety) program (A-0803); and - Discharge planning evaluations were completed to ensure appropriate arrangements for post-hospital care (A-0805). These failures had the potential to adversely affect the quality of care and safety of all patients in the hospital. The hospital census was 143.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47504 48359 Based on observation, interview, record review and policy review, the hospital failed to: - Eligible patients were provided the Important Message from Medicare (IM, information about a patient’s right to appeal discharge) as well as obtain a patient signature within no later than two calendar days following admission (A-0117); - Staff followed their own policies and procedures for informing, retrieving, assisting with the formulation and documenting Advanced Directives (AD, a legal document where the patient can direct their medical care wishes, should the patient become unable to make their own decisions) (A-0132); - Staff followed their own policies and procedures to provide care in a safe setting due to failures to ensure one to one (1:1, continuous visual contact with close physical proximity) sitters for high risk suicidal (thoughts of causing one’s own death) patients, recognize suicidal behavior, remove unsafe signage in the Behavioral Health Unit, provide psychiatric safe rooms (a room that has been cleared of any objects a patient might use to harm themselves or others) and complete crash cart logs (A-0144); - Staff followed their own policies and procedures in regard to the neglect of patients (A-0145); - Provider orders were obtained for restraints (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely)/seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) (A-0168); - Providers received restraint training (A-0176); - Staff followed their own policies and procedures in regard to 1:1 observation for patients during episodes of simultaneous restraints and seclusion (A-0183); - Staff followed their own policies and procedures in regard to the required face to face evaluation within one hour of restraint application (A-0184); and - Staff were trained in first aid related to restraints (A-0206). These failed practices resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation (CoP): Patient’s Rights. The hospital census was 143. The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ). As of 11/08/23, the hospital had provided an immediate action plan sufficient to remove the IJ when the hospital implemented corrective actions that included all current and oncoming nursing staff were education on patients leaving against medical advice (AMA). All remaining staff were educated prior to the start of their next shift. As of 11/14/23, the hospital had provided an immediate action plan sufficient to remove the IJ when the hospital implemented corrective actions that included all current and oncoming nursing staff were education on recognizing and investigating patient neglect. All remaining staff were educated prior to the start of their next shift. As of 11/15/23, the hospital had provided an immediate action plan sufficient to remove the IJ when the hospital implemented corrective actions that included all current and oncoming nursing staff were education on recognizing the necessity for and implementing high risk suicide precautions. All remaining staff were educated prior to the start of their next shift. As of 12/06/23, the hospital had provided an immediate action plan sufficient to remove the IJ when the hospital implemented corrective actions that included all current and oncoming nursing staff were education on one-to-one (1:1, continuous visual contact with close physical proximity) observation for suicidal patients. All remaining staff were educated prior to the start of their next shift. As of 12/07/23, the hospital had provided an immediate action plan sufficient to remove the IJ when the hospital implemented corrective actions that included all current and oncoming nursing staff were education on recognizing suicidal behaviors. All remaining staff were educated prior to the start of their next shift. Please refer to A-0117, A-0132, A-0144, A-0145, A-0176, A-0183, A-0184 and A-0206.”

“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: 48359 Based on observation, interview and policy review, the hospital failed to ensure that nursing staff were appropriately trained, orientated and their competency validated. The Chief Nursing Officer (CNO) failed to fulfill her responsibility to ensure that all nursing personnel had been educated regarding the hospital’s policies and procedures and adhered to them. These failures resulted in the hospital’s noncomplaince with 42 CFR 432.23 Condition of Participation: Nursing Services and resulted in the hospital’s failure to provide quality healthcare and safety. The hospital census was 143. Please refer to A-0398 for details.”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 47504 Based on observation, interview and policy review, the hospital failed to ensure infection prevention policies were followed when staff failed to: - Perform hand hygiene (wash hands with soap and water or alcohol-based hand sanitizer) and glove changes during patient care for 12 patients (#27, #28, #32, #34, #35, #36, #38, #39, #40, #41, #42, and #45) of 15 patients observed; - Prepare a clean work surface prior to performing patient care for seven patients (#27, #32, #34, #39, #40, #43, and #45) of 10 patients observed; - Cleanse the skin surface prior to an intravenous (IV, in the vein) needle insertion for one patient (#34) of one patient observed; - Clean the pill splitter between use for one patient (#39) of one patient observed; - Clean the workstation on wheels (WOW, a computer or supply and medication storage on a wheeled stand that can be moved from patient to patient) between use for four patients (#35, #38, #41, #42) of 16 patients observed; - Discard supplies when dropped on the floor for one patient (#35); - Date food items that were located in patient pantry areas; - Discard expired patient food items; and properly label food items in the patient refrigerator with patient name and open date; and - Remove expired patient care supplies from a supply storage area. The severity and cumulative effects of these systemic practices resulted in the hospital’s noncompliance with 42 CFR 482.42 Condition of Participation: Infection Prevention and Control and Antibiotic Stewardship Programs and resulted in the hospital’s failure to ensure quality healthcare and safety. The hospital census was 143. Refer to A-0749 for details. 48359”

“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 provide discharge planning evaluations to ensure appropriate arrangements for post-hospital care for five (#4, #5, #20, #22, and #23) of five Women’s Health medical records reviewed. The hospital failed to include discharge planning in the Quality Assurance and Performance Improvement (QAPI, process for reporting and/or identifying adverse events, near misses or review of high risk, problem prone areas for patient safety) process to assess its discharge planning process on a regular basis. These failed practices had the potential for adverse health consequences, medical errors during transitions of care and negative impacts on vulnerable populations upon discharge. The severity and cumulative effects of the systemic failures resulted in the hospital being out of compliance with 42 CFR 482.43 Condition of Participation (CoP): Discharge Planning. The hospital census was 143.”

“CHIEF EXECUTIVE OFFICER CFR(s): 482.12(b) The governing body must appoint a chief executive officer who is responsible for managing the hospital. This Standard is not met as evidenced by: 48359 Based on interview, record review and policy review, the Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible for the management of the entire hospital. Including accountability for the effective oversight of staff to comply with the requirements under: - 42 CFR 482.12 Condition of Participation (CoP) Governing Body; - 42 CFR 482.13 CoP: Patients Right’s; - 42 CFR 482.23 CoP: Nursing Services; - 42 CFR 482.42 CoP: Infection Prevention and Control and Antibiotic Stewardship Programs; and - 42 CFR 482.43 CoP: Discharge Planning. These continued failures had the potential to affect the quality of care and safety of all patients. The hospital census was 160. Findings included: Review of the hospital’s undated document titled, “Medical Staff Bylaws,” showed the CEO was the individual appointed by the Corporation to provide for the overall management of the Hospital. Review of the hospital’s document titled, “Poplar Bluff Regional Medical Center Organizational Chart,” date 10/30/23, showed that all administration leaders reported to Staff G, CEO. During an interview on 12/07/23 at 2:30 PM, Staff G, CEO, stated that he was fully responsible for the entire hospital.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 48359 Based on interview, record review and policy review, the hospital failed to ensure that staff provided the initial Important Message from Medicare (IMM, information about a patient’s right to appeal discharge) and ensure it was signed, dated and placed in the patient’s medical record upon admission for three patients (#16, #19, and #39) of 17 Medicare patient’s medical records reviewed. This failed practice had the potential to affect all Medicare eligible patient’s ability to be informed of their right to appeal discharge. Findings included: Review of the hospital’s policy titled, “Important Message from Medicare,” dated 11/13/2023, showed that the Registration personnel were responsible for the delivery of the IMM at or near the time of admission, but no later than two calendar days from the admission date. Review of Patient #16’s medical record showed that she was admitted to the hospital on 11/03/23 and had not received the IMM by 11/06/23. Three days after admission. Review of Patient #19’s medical record showed he was admitted to the hospital on 11/01/23 and had not received the IMM by 11/06/23. Five days after admission. Review of Patient #39’s medical record showed he was admitted to the hospital on 10/27/23 and had not received the IMM by 11/15/23. Nineteen days after admission. During an interview on 11/15/23 at 2:00 PM, Staff F, Chief Nursing Officer (CNO), stated that she expected Medicare eligible patient to receive the IMM within 24 hours of admission. During an interview on 11/16/23 at 9:30 AM, Staff M, Registration Director, stated that the Emergency Room (ER) nurse notified the Registration department when a patient was to be admitted. The Registrar then delivered and obtained signatures on the IMM. Case Management could not run a report through the electronic medical record (EMR) system that showed which patient had transitioned from observation status to in-patient status. That lack of reporting had resulted in the missed IMM’s.”

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 47504 Based on interview, record review and policy review, the hospital failed to follow their own policies and procedures that outlined staff roles for informing, retrieving, assisting with formulation, and documenting Advance Directive (AD, a legal document where the patient can direct their medical care wishes should the patient become unable to make their own decisions) information for 18 (#1, #2, #3, #4, #6, #7, #8, #9, #10, #11, #12, #14, #16, #18, #20, #21, #39, and #40) current patients of 19 current patients and two (#20 and #21) discharged patients of four discharged patients. These failures had the potential to affect all patients who presented to the hospital seeking care. Findings included: Review of the hospital’s policy titled, “Advance Directives,” revised 07/15/2019, showed the following: - Prior to or upon admission of a patient, the Social Services Director or designee will inquire of the patient, his/her family members and/or his or her representative, about the existence of any written advance directives. Information about whether or not the patient has executed an advance directive shall be displayed prominently in the medical record. - If the patient indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. - The patient will be given the option to accept or decline the assistance, and care will not be contingent on either decision. - Social Services or Nursing staff will document in the medical record the offer to assist and the patient’s decision to accept or decline assistance. Review of Patient #1’s medical record showed that, he had not been assessed for the need to formulate and/or revise an AD. Review of Patient #2’s medical record showed that, he had not been assessed for the need to formulate and/or revise an AD. Review of Patient #3’s medical record showed that, he had not been assessed for the need to formulate and/or revise an AD. Review of Patient #4’s medical record showed that, he had not been assessed for the need to formulate and/or revise an AD. Review of Patient #6’s medical record showed that, she had not been assessed for the need to formulate and/or revise an AD. Review of Patient #7’s medical record showed that, he had not been assessed for the need to formulate and/or revise an AD. Review of Patient #8’s medical record showed that, he had not been assessed for the need to formulate and/or revise an AD. Review of Patient #9’s medical record showed that, he had not been assessed for the need to formulate and/or revise an AD. Review of Patient #10’s medical record showed that, he had not been assessed for the need to formulate and/or revise an AD. Review of Patient #11’s medical record showed that, he had not been assessed for the need to formulate and/or revise an AD. Review of Patient #12’s medical record showed that, he had not been assessed for the need to formulate and/or revise an AD. Review of Patient #14’s medical record showed that, she had not been assessed for the need to formulate and/or revise an AD. Review of Patient #16’s medical record showed that, he had not been assessed for the need to formulate and/or revise an AD. Review of Patient #18’s medical record showed that, she had not been assessed for the need to formulate and/or revise an AD. Review of Patient #20’s medical record showed that, he had not been assessed for the need to formulate and/or revise an AD. Review of Patient #21’s medical record showed that, he had not been assessed for the need to formulate and/or revise an AD. Review of Patient #38’s medical record showed that, she had not been assessed for the need to formulate and/or revise an AD. Review of Patient #39’s medical record showed that, he had not been assessed for the need to formulate and/or revise an AD. Review of Patient #40’s medical record showed that, he had not been assessed for the need to formulate and/or revise an AD. During an interview on 11/06/23 at 3:30 PM, Staff B, Assistant Chief Nursing Officer (ACNO), stated that all patients were given an admission packet that contained AD information. He stated that all patients were asked by the nurse if they had an AD and would notify case management if a patient requested information. During an interview on 11/06/23 at 4:10 PM, Staff I, Registered Nurse (RN), stated that they always asked a patient if they had an AD and if the patients requested information at that time they would notify case management. They did not ask the patient if they wanted information on AD. During an interview on 11/06/23 at 4:20 PM, Staff G, Intensive Care Unit (ICU, a unit where critically ill patients are cared for) Director, stated that there was a box that the admitting nurse had to check yes or no if a patient had an AD. There were additional questions to ask the patient if they wanted additional information or would like to speak to someone regarding AD, but the admission nurse skipped over those questions and would only make a referral if a patient asked. She stated they were supposed to answer those additional questions. During an interview on 11/15/23 at 2:30 PM, Staff F, Chief Nursing Officer (CNO), stated that nursing was to ask each patient if they would like information regarding an AD. If the patient responded yes, a referral to Case Management would be completed. During an interview on 11/15/23 at 4:30 PM, Staff ZZ, Case Management Director, stated that the hospital staff were not asking if patients would like information regarding AD. Each patient should be asked if they would like information regarding an AD. During an interview on 11/16/23 at 10:30 AM, Staff A, Risk Management and Compliance Officer, stated that staff were expected to ask each patient if they would like information regarding an AD. 48359”

“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 47504 48359 Based on observation, interview, record review and policy review, the hospital failed to: - Ensure that staff followed the suicide (to cause one’s own death) risk assessment and interventions in a non-behavioral health setting when caring for four current patients (#29, #37, #48 and #49) of five patients observed; - Recognize suicidal behavior (any action that could cause one’s own death) for two discharged patients (#50 and #51) of two patients observed; - Ensure a safe environment when 15-minute safety rounds were not completed for one current patient (#37) of four patients reviewed, and the patient eloped (when a patient makes an intentional, unauthorized departure from a medical facility) from the Emergency Department (ED); - Obtain restraint/seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) orders for one discharged patient (#50) of two patients observed; - Follow the hospital’s policies and procedures in regard to the 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) re-assessment for patients at risk for self-harm (behavior that is harmful or potentially harmful to oneself) for one current patient (#47) of two patients observed; - Ensure that all signage was secured to provide a safe environment for behavioral health patients; and - Follow the hospital’s policy and procedure for daily crash cart (mobile cart which contains emergency medical supplies and medication) checks. Findings included: Review of the hospital’s policy titled, “Suicide Risk Assessment and C-SSRS in Non-Behavioral Health Setting,” revised on 02/28/23, showed that: - Based on the severity and immediacy of the suicide risk assessed, patient safety measures and interventions will be implemented to keep patients from inflicting harm to self. - One to one (1:1, continuous visual contact with close physical proximity) observation was to be used as an intervention for high-risk suicide. Continuous observation in which staff can see the patient in clear view and staff can respond immediately to include using the toilet and bathing. - Based on the C-SSRS, all patients who have attempted to commit suicide within four weeks are considered a high risk. - High risk patients should have 1:1 observation and a safe room checklist should be completed. Review of the hospital’s document titled, “Suicide Conversion to Safe Room Check List,” revised on 10/2021, showed that: - The safe room check list should be utilized on initiation of suicide precautions and at the beginning of every shift. - Patient should be dressed in paper pants and tops or a hospital gown with no ties. - Personal items are secured, that included cell phones and charge cords. - All cords will be removed to include call bell, bed, and cell phones. - All monitor cords should be removed. - All metal silverware should be removed. - Non-break away curtains and blinds should be removed. - Trash liners should be removed. - Hand sanitizers should be removed. - Excess linen bins should be removed. - Trash cans should be removed. - Closets should be locked or empty. - High risk level of suicide should have continuous observation, secure in a ligature (anything which could be used for the purpose of hanging or strangulation) resistant room. Review of the medical record for Patient #29 on 11/14/23 showed that: - She was admitted to the Behavioral Health Unit (BHU) on 11/09/23 following a drug overdose. - She was transferred to the ED on 11/12/23 and was admitted for observation on telemetry (remote observation of a person’s heart rhythm, using signals that are transmitted from the patient to a computer screen). - Her diagnosis was major depressive disorder (a long period of feeling worried or empty with a loss of interest in activities once enjoyed) and hypotension (low blood pressure). Observation on 11/14/23 at 1:30 PM showed: - Patient #29 had been admitted to the BHU for an attempted suicide on 11/09/23. - She was wearing a regular hospital gown with ties. - There were eight electrical outlets in the room that had not been secured. - There was a large red container that was used for sharp needles hanging on the wall inside the patient room. - There was a large soap dispenser full of liquid soap in the bathroom. - There were two large bins with plastic liners utilized for linens. - There were two trash cans with plastic liners. - There was a total of seven cords that were over 18 inches long and had not been secured, one cell phone charger, one regular wall phone cord, one call light cord, one fall/monitor cord that was not utilized hanging on the wall, one cord that was plugged into the wall for the bed controls, and two call light cords in the bathroom. - A regular shower curtain that was not a break away. - A paper towel dispenser with an extra roll of paper towels sitting in the bathroom. - Regular blinds on the windows with strings. - There was not a staff member providing 1:1 constant observation. - There was a Telesitter (continuous virtual care that provided live video from the patient’s room) in the room that was utilized as 1:1 observation. Observation and concurrent interview on 11/14/23 at 2:30 PM, Staff B, Assistant Chief Nursing Officer (ACNO), stated that: - Patient #37, was in the ED triage room awaiting a transfer to an in-patient mental health facility. - He had attempted suicide by hanging himself. - In the triage room above the patient’s head were three monitor cords greater than 18 inches in length. - There was a crash cart in the triage room. - There was a red container that was utilized for sharp needles on the wall. - The supply cabinet was open and left unlocked. - There was one trash can with a liner inside the room. - The patient was in direct line of sight (LOS, continuous visual contact with the patient), but at that time the nurse was not sitting in direct LOS. No one was present watching the patient. Review of the medical record for Patient #48 showed that: - On 12/02/23 at 1:40 AM, she was admitted to the hospital with hepatic encephalopathy (a nervous system disorder brought on by severe liver disease) and major depressive disorder with recurrent severe suicidal ideations (SI, thoughts of causing one’s own death). - On 12/02/23 at 8:00 AM, her C-SSRS placed her at moderate risk for suicide. - At 8:37 AM, the patient was placed on suicide precautions and a sitter (person assigned to continuously observe a patient within close proximity, to ensure their safety) was assigned for continued observation. Observation on 12/05/23 at 9:58 AM, showed: - Patient #48 had a metal soda can that was sitting on her bedside table. - There were two call light strings in the bathroom, and the bathroom electrical outlet worked. - The shower had a removeable shower head that had a metal cord that was over 18 inches long. - There was a red container that was utilized for sharp needles on the wall. Review of the medical record for Patient #49 showed that: - On 11/30/23 at 1:34 PM, she arrived at the ED with a suicide attempt. - At 2:37 PM, her C-SSRS evaluation placed her a high risk for suicide. - At 3:11 PM, a provider order was placed for a 1:1 sitter observation. - On 12/01/23 at 6:41 PM, she was admitted to inpatient, her suicide precaution and sitter observation orders were continued to her inpatient stay. Observation of Patient #49 on 12/05/23 between 10:08 AM and 10:28 AM, showed: - The patient sitter was in the hallway and could not fully see the patient. - Patient #49 was sitting in her room on her wheel walker. - The patient was sitting between the window and the closet. - The patient’s wheel walker had two cords, one on each side, the window blind had strings on it and the television cord longer than 18 inches, was hanging down. - There was a privacy curtain in the room that was not break away. Observation and concurrent interview on 12/05/23 at 10:10 AM, Patient #49 stated that: - No one escorted her into the bathroom or when she took a shower. - In her room there was a call light cord, a phone cord, and the plug-in to the bed that were over 18 inches long. - There was a trash can with plastic liner in the bathroom and one in the patient’s room. - Eight electrical outlets in both the room and bathroom that were working. - A large soap dispenser was full of liquid soap in the bathroom. - A metal soda can was sitting on the bedside table. - A non-break away privacy curtain. - One large red container that was utilized for sharp needles was attached to the wall. During an interview on 12/05/23 at 9:58 AM, Staff X, Registered Nurse (RN), stated that Patient #48 had a history of depression (extreme sadness that does not go away) and had been admitted for SI. During an interview on 12/05/23 at 10:08 AM, Staff NN, RN, stated that Patient #49 was admitted for COVID-19 (highly contagious, and sometimes fatal, virus) and a suicide attempt. The patient was on isolation for COVID-19. Gloves, mask, face shield, and gown were required to be put on before entering the patient’s room. Review of the hospital’s policy titled, “Suicide Risk Assessment and Reassessment for Behavioral Health Services Policy, dated 09/05/22, showed that: - As behaviors can change over time, recognize the possible need to repeat and communicate results of the reassessments of SI. - Intensity is in part determined by assessing the frequency, duration and intensity of these thoughts; in addition, the presence of a plan and access to means to execute that plan enters into the assessment and determination of level of risk, and to specification of precautions. - Suicide attempt is a non-fatal, self-inflicted destructive act with explicit or inferred intent to die. Review of Patient #50’s medical record showed that: - He was a 32-year-old male, alert and oriented times four (A&O x 4, a person is oriented to person, place, time, and situation), who was admitted on 11/12/23 to the BHU for psychosis (a mental disorder characterized by a disconnection from reality.), substance abuse (misuse of alcohol and/or other drugs), and schizophrenia (serious mental disorder that affects a person’s ability to think, feel, and behave clearly). - On 11/17/23 at 10:00 AM, the C-SSRS showed a moderate suicide risk. - On 11/17/23 at 11:31 AM, it was noted that during an intervention with the patient, he took his shirt off and wrapped it around his neck and attempted to tie it while making suicidal statements. - A C-SSRS was not completed after this observed suicide attempt. His previously documente4d risk level at those times was a moderate suicide risk. - At 8:01 PM, the patient stated he was paranoid (excessive suspiciousness without adequate cause) and suicidal, he had a plan to electrocute himself in the shower. - A C-SSRS assessment was not completed after an observed suicidal statement. His previously documented risk level at that time was a low suicide risk. - On 11/19/23 at 2:00 PM, the C-SSRS showed a low suicide risk. - At 6:40 PM, there was an order given for restraints due to the patient being dangerous to self. - At 6:56 PM, he pulled the camera out of the ceiling, stood against the wall, and wrapped the cords around his neck. He was placed in restraints to prevent him from harming himself. - A C-SSRS assessment was not completed after an observed suicide attempt. His previously documented risk level at that time was a low risk for suicide. - On 11/20/23 at 2:00 AM and 7:00 AM, the C-SSRS showed a low suicide risk. - At 12:31 PM, the patient was angry, yelling, and refused to return to the unit. He was hitting himself in the head, ripped off his pants, and placed them around his neck. - At 12:44 PM, there was an order given for a physical hold due to the patient being physically aggressive toward others and dangerous to self. 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). - At 12:56 PM, he was released from the restraints. - A C-SSRS assessment was not completed after an observed suicide attempt. His previously documented risk level at that time was a low suicide risk. - At 7:00 PM the C-SSRS showed a low suicide risk. During an interview on 12/06/23 at 9:35 AM, 10:40AM, and 12/07/23 at 9:51 AM, Staff FFF, BHU Manager, stated that: - On 11/19/23, Patient #50 pulled the camera out of the ceiling in the seclusion room and wrapped the cord around his neck. Staff immediately responded. - If a patient was having SI, they would do whatever they had to do to keep the patient safe. - If a patient attempted suicide, they should be put on 1:1 observation. She was not aware of the hospital policy for the two-hour re-assessment window for patient’s that were placed on a 1:1 observation status. - If a patient had a suicide attempt, the patient would be put on high-risk precautions. - The two attempts Patient #50 had, would have been considered suicide attempts. - If a patient had a suicidal gesture, it should always be taken seriously. - Staff failed to recognize suicidal behavior from Patient #50. During an interview on 12/07/23 at 10:33 AM, Staff PPP, Therapist, stated: - She was aware of the two suicide attempts he had, but she was not on the unit at the time. - Every time there was a threat of suicide, it should be taken seriously. - When Patient #50 put the shirt around his neck and wrapped the cord around his neck he should have been placed on high-risk precautions. - She felt staff could identify suicidal behaviors, but there were a few steps not taken for Patient #50. During an interview on 12/11/23 at 4:30 PM, Staff SSS, RN, stated that she believed that Patient #50 could have been suicidal. During interview on 12/12/23 at 3:31 PM, Staff TTT, Physician, stated that she felt that Patient #50 was suicidal. If a patient attempted suicide, she would expect them to be placed as high-risk precautions and be placed on 1:1 observation. During interview on 12/13/23 at 7:59 AM, Staff UUU, RN, stated that Patient #50 was a danger to himself, and others and she would consider him a high suicide risk. Review of Patient #51’s medical record showed that: - He was a 36-year-old male with a court order for a 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others), evaluation, and treatment for hyper-religious statements (a psychiatric disturbance in which a person experiences intense religious beliefs or episodes that interfere with normal function) and increased aggression (behavior that is intended to harm another individual). - He was admitted to the BHU on 11/15/23 at 10:45 PM, and was diagnosed with schizoaffective bipolar (serious mental disorder that affects a person’s ability to think, feel, and behave clearly). - Admission orders include safety observations with safety checks to be done every 15-minutes and safety precautions that showed a handwritten box checked that stated safety. - On 11/19/23 at 11:00 AM, the C-SSRS showed a low suicide risk. - On 11/19/23 at 7:00 PM, Staff RRR, RN, documented that he was a low suicide risk with no thoughts of suicide. - On 11/20/23 at 7:13 PM, a late entry was made by Staff OOO, RN, that showed on 11/19/23 at 6:35 PM, Staff QQQ, PCT, found Patient #51 standing in the doorway with a blanket wrapped around his neck hanging off the door stating he wanted to die. All items were removed from the room. - There was no documented notification of the Charge Nurse (CN), Physician or Manager of the suicide attempt on 11/19/23 or a change in his C-SSRS suicide risk assessment. - Patient #51’s C-SSRS, showed he was a low suicide risk from admission until discharge on 11/28/23. During an interview on 12/07/23 at 9:30 AM, Staff L, BHU Manager, stated that: - All patients on the BHU received every 15-minute safety rounds. - She had not been notified of the situation with Patient #51 until the following morning by the House Supervisor. Security had turned in a report for the incident. - There was no documentation in the chart at that time of the suicide attempt. - Staff OOO, RN, the assigned nurse of Patient #51, at the time of suicide attempt, was asked to put an addendum into the chart of the incident. - Patient #51 was not made a high risk for suicide and was not placed on 1:1 observation. During an interview on 12/07/23 at 10:30 AM, Staff PPP, Licensed Professional Counselor (LPC) stated that: - Patient #51 was extremely agitated (a state of feeling irritated or restless) at times and made threats to staff members. - She was aware that Patient #51 had wrapped a blanket around his neck and hung it on the door. - Patient #51 was suicidal and should have been placed on high-risk suicide precautions but was on moderate risk only and did not have a 1:1 sitter. During an interview on 12/07/23 at 11:00 AM, Staff QQQ, Patient Care Tech (PCT), stated: - She had been assigned as the PCT for Patient #51 on 11/19/23. - He could become very threatening to staff and security was called often for his behaviors. - On 11/19/23 at approximately 6:15 PM, quiet time had just been announced over the radio. Patient #51 overheard a comment made by Staff OOO, RN, about him and became upset. As he went to his room he stated, he would just kill himself. - She notified Staff OOO, RN, of the suicidal comment and Staff OOO stated, “It’s not my problem it’s the next nurse’s problem.” - She went to check on Patient #51 and found him with a blanket wrapped around his neck hanging off the door and he stated, “No one cares, I am going to kill myself.” - She engaged in a conversation and was able to remove all ligature risks from the room and then notified Staff OOO. - Patient #51 was suicidal and that all patients making statements or gestures should be on high-risk suicide precautions that included an assigned constant 1:1. - She was not aware that he was not placed on a 1:1 observation as her shift was over. - Her direct manager talked to her about the incident but no one from administration discussed this with her. During an interview on 12/07/23 at 11:30 AM, Staff BBBB, Psychiatrist and Medical Director of BHU, stated that: - Patient #51 was unpredictable and disorganized on most days. He had been threatening to staff and herself at times. - She was not notified of the suicide attempt by Patient #51 on the day of the incident. - She became aware of the suicide attempt when she was contacted by Risk Management at a later date. - She expected for the assigned RN to call the Physician with a suicide attempt at the time it happened and follow policy. - Any person who stated that they wanted to kill themselves or make a gesture in any way should be considered a high-risk suicidal patient. - She did not know what the policy was for high-risk suicide precautions and stated that “I have just started this job within the last two months, I don’t know all the policies, but I depend on the nurse to implement the precautions per policy.” During an interview on 12/12/23, Staff RRR, RN, stated that: - He was the nurse that was assigned to Patient #51 on 11/19/23 at 7:00 PM. - He had received report that Patient #51 wrapped a blanket around his neck and was hanging it on the door earlier in the day. - He did not recall if Patient #51 was on high-risk suicide precautions. He was not aware that it had just occurred at shift change until he was contacted by administration to schedule an interview with the state surveyor. - All suicidal gestures should be elevated as a high risk for suicide. - The process for any suicide gesture or attempt should include the notification to the Physician, CN, and Manager. Patients should be elevated to a high-risk for suicide, placed on a 1:1 observation and the documented in the nurses’ notes. This was not done for Patient #51. During an interview on 12/12/23 at 3:00 PM, Staff TTT, Physician, BHU, stated that: - Patient #51 had been very threatening to staff on the unit and had the potential to be both suicidal and homicidal. - She was not notified of the suicide attempt made by Patient #51 until a later date. - All patients who attempt suicide should be placed in a high-risk category and have 1:1 sitters until the patient was no longer suicidal. A nurse may elevate the patients at the time of a crisis to a higher suicidal risk, but the physician must order the lowering of a suicidal risk. During an interview on 12/18/23 at 9:00 AM, Staff AAAA, Physician, BHU, stated: - Patient #51 had an explosive behavior at times. - All suicide attempts, statements of SI and gestures should be elevated to high-risk suicide protocol. - His expectations were to be notified of any changes to a patient including suicide attempts, statements of ideation and gestures. - All high-risk suicide precautions were to include a 1:1 sitter who had constant supervision of the patient. - He was not aware that Patient #51 had not been placed on 1:1 observation. An interview request was made for Staff OOO, RN, and she was no longer employed by the hospital and the last known phone number had been disconnected. Review of the hospital’s policy titled, “Suicide Risk Assessment and C-SSRS in Non-Behavioral Health Setting,” revised on 02/28/23, showed that based on the severity and immediacy of the suicide risk assessed, patient safety measures and interventions will be implemented to keep patients from inflicting harm to self. All moderate risk patients should have every 15-minute rounding. Review of the medical record for Patient #37 on 11/14/23 showed that: - Patient #37 presented to the ED on 11/14/23 at 12:50 PM, for SI and a plan to hang himself. - He had a history of depression and multiple suicidal attempts. - He was evaluated by Staff GGGG, Physician, and was identified as a moderate risk for suicide using the C-SSRS. - At 1:14 PM, suicide precautions were ordered. - At 2:09 PM, Patient #37 had been evaluated and was awaiting transfer to the BHU for inpatient care. - At 6:45 PM, Staff CCCC, RN, was giving report and the patient was not in his room in the ED. The CN was notified that the patient was missing. - At 7:01 PM, a Code Elopement (when a patient makes an intentional, unauthorized departure from a medical facility) was called, and security was notified. - At 7:17 PM, a court order to retain Patient #37 was obtained and local law enforcement was made aware of the situation. - At 9:37 PM, Patient #37 was brought back to the ED by the local police department. - Patient #37 was then transferred to the BHU. -There were no every 15-minute safety checks completed in the ED prior to his elopement. During an interview on 12/15/23 at 2:00 PM, Staff CCCC, RN, stated that: - She was the nurse that was assigned to care for Patient #37 on 11/14/23. - He was being seen for SI and depression and was a moderate risk for suicide. - Any patient that was in the ED with a moderate risk for suicide should have a 1:1 sitter and every 15-minute safety rounds should be done. - Patient #37 was placed in the trauma room directly in front of the nurse’s station. - Every 15-minute safety rounds were not done for Patient #37. - Staff CCCC was busy with a total of four patients and was not sitting at the nurse’s station. She was not sure if anyone was sitting at the nurse’s station with constant supervision of the patient. She stated, “obviously not as he eloped.” - She was not aware that he had eloped until she was giving report to oncoming staff and his room was empty. - She could not find Patient #37 within the ED and notified security. Security saw him leave the facility. - She called a Code Elopement and called the police department to report the elopement. - A court order was obtained for a 96-hour hold. During an interview on 12/19/23 at 11:30 AM, Staff GGGG, Physician, stated that: - Patient #37 presented to the ED on 11/14/23 for SI and depression. - He was placed on a moderate risk level for suicide and was placed in the trauma room that was directly in front of the nurse’s station. - There were usually three nurses who sat at that nurse’s station, and he felt that he was placed in a direct line of sight (LOS, continuous visual contact with the patient). - He was assessed by a mental health physician and was awaiting transfer to the BHU for inpatient care. - Every 15-minute checks were not done because the patient was in LOS. - Emergency situations could leave the 1:1 patient unattended. - He did not know how the patient eloped, but that the nurses probably had an emergency, and no one saw him leave. - A Code Elopement was called, law enforcement and management were notified of the elopement. - The patient was brought back by the local police department and was unharmed. - He was transferred to BHU without further incident. Observation and concurrent interview on 11/14/23 at 2:30 PM, Staff B, ACNO, stated that Patient #37, was in the ED triage room awaiting a transfer to an in-patient mental health facility. The patient was in direct LOS, but at that time the nurse was not sitting in direct LOS. No one was present watching the patient. During an interview on 12/20/23 at 10:00 AM, Staff XXX, CN, stated that: - He was not aware that every 15-minute safety checks were not completed on Patient #37. - All patients with a moderate risk for suicide should have every 15-minute checks completed. - Although Patient #37 had been placed across from the nursing station in a direct LOS, his expectation was that every 15-minute safety checks were completed on every patient with a moderate risk of suicide no matter where they were located in the ED. - He was notified by Staff CCCC, RN, that Patient #37 had eloped. He looked in all areas of the ED and was unable to locate him. He then called a Code Elopement and alerted security. - His shift ended, and he was not aware of the outcome for finding the patient. - No one has contacted him from administration in regard to Patient #37’s elopement until a request was made by the State Surveyor. During an interview on 12/20/23 at 6:30 PM, Staff FFFF, Security Officer, stated that: - He was on duty 11/14/23 at the time of the elopement but security was up on the fifth floor when Patient #37 eloped from the ED. - He was notified of the elopement and was transporting another patient to the BHU when he saw Patient #37 walking down the street by the local hotel. - At that time Patient #37 was off hospital property and he did not stop him. - Patient #37 was brought back to the ED by law enforcement and then he transported the patient to the BHU unit. During an interview on 12/18/23 at 9:30 PM, Staff EEEE, RN, stated that: - He was assigned to complete the admission on Patient #37. - He was brought to BHU by security. - Patient #37 was being admitted for SI and depression. He was assigned a moderate risk for suicide. - All moderate risk suicidal patients should have every 15-minute safety checks. Review of the hospital’s policy titled, “Restraint and Seclusion,” dated 06/2022, showed that all restraint and seclusion require a physician order. Once restraints are removed or a patient is removed from seclusion that episode is considered ended and a new physician’s order is required for any additional episodes. Review of Patient #50’s medical record showed that: - On 11/17/23 at 7:50 AM, the patient was placed in restraints and taken to the seclusion room due to self-harm, banging head, agitated, and threatening behaviors, throwing self against exit doors, not responding to verbal interventions, and medication was ineffective. - At 7:50 AM, there was an order given for restraints and physical hold due to the patient damaging property and elopement attempt. - At 8:21 AM, the patient was released and escorted back to his room. - There was no order for seclusion. - On 11/22/23 at 1:30 PM, he attempted to tear the patient phone off the wall. Two security staff and three nursing staff physically restrained the patient and took him to the seclusion room. - At 1:36 PM, he was placed in four-point restraints. - At 2:28 PM, he was released from the restraints. - There was no order for restraints or seclusion. During an interview on 12/06/23 at 9:35 AM, 10:40AM, and 12/07/23 at 9:51 AM, Staff FFF, RN, BHU Manager, stated that if a patient was placed in a physical hold, restraints or seclusion there must be an order for it. During an interview on 12/13/23 at 7:59 AM, Staff UUU, RN, stated that there should always be an order for restraints and seclusion. During an interview on 12/14/23 at 8:57 AM, Staff VVV, RN, stated that if restraints and/or seclusion was needed, there must be an order for it, and the Physician, House Supervisor, and CN were notified. Review of the hospital’s policy titled, “Suicide Risk Assessment and C-SSRS in Non-Behavioral Health Setting,” revised on 02/28/23, showed that adolescents and adult patients who present for care and services will be screened for SI and behavior using the C-SSRS. The RN was to re-assess suicide risk and need for suicide precautions at least every shift if moderate or high risk and/or if there is an observed or stated change in behavior. Review of Patient #47’s medical record dated 11/16/23 at 12:00 PM, showed that she had an initial C-SSRS of high risk completed on 11/15/23 at 6:54 PM. No additional C-SSRS’s had been completed while the patient remained in the ED. 17 hours and six minutes had passed since the patient had a C-SSRS risk assessment completed. During an interview on 11/16/23 at 12:15 PM, Staff K, ED Director, stated that she did not know why the C-SSRS had not been assessed during the previous shift. Review of the hospital’s policy titled, “Suicide Risk Assessment and C-SSRS in Non-Behavioral Health Setting,” revised on 02/28/23, showed that a ligature risk is defined as anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation. Observation on 12/06/23 at 11:00 AM, showed one hard plastic eight inch by ten-inch sign sticky tacked to the exit door to the side hallway and two hard plastic eight inch by ten-inch signs sticky tacked to the exit doors to the back unit in the BHU. During an interview on 12/06/23 at 9:35 AM, 10:40AM, and 12/07/23 at 9:51 AM, Staff L, RN, BHU Manager, stated that hard plastic signs on the exit doors could easily be taken off, broken, and used as a weapon. Review of the hospital’s policy titled, “Checking, Restocking and Replacing Crash Carts,” dated 07/19/18, showed that crash carts are to be checked for function and integrity every day that the unit is open. Document “closed” on the daily checklist on the days the department is not open. Review of the hospital’s document titled, “Daily Crash Cart Check-off,” for the Pediatric crash cart dated 10/2023, showed no daily checks for 10/08/23, 10/09/23, 10/11/23 and 10/31/23. Review of the hospital’s document titled, “Daily Crash Cart Check-off,” for the Pediatric crash cart dated 11/2023, showed no daily check for 11/04/23. Review of the hospital’s document titled, “Daily Crash Cart Check-off,” for the ED “Front Pod” crash cart, dated 11/2023, showed no daily check for 11/04/23 and 11/05/23. Review of the hospital’s document titled, “Daily Crash Cart Check-off,” for the ED “T-Alpha” crash cart dated 11/2023, showed no daily check for 11/03/23 and 11/04/23. Review of the hospital’s document titled, “Daily Crash Cart Check-off,” for the ED “T-Bravo” crash cart dated 11/2023, showed no daily checks for 11/02/23, 11/03/23 and 11/04/23. Review of the hospital’s document titled, “Daily Crash Cart Check-off,” for the ED “T-Charlie” crash cart dated 11/2023, showed no daily check for 11/03/23 and 11/04/23. Review of the hospital’s document titled, “Daily Crash Cart Check-off,” for the ED “Station 2-Mid Pod” crash cart dated 11/2023, showed no daily check for 11/03/23 and 11/04/23. Review of the hospital’s document titled, “Daily Crash Cart Check-off,” for the ED “Station 3-Fast Track” crash cart dated 11/2023, showed no daily check for 11/03/23 and 11/04/23. During an interview on 11/15/23 at 2:00 PM, Staff F, Chief Nursing Officer (CNO), stated that crash cart logs should have been completed every day. If a unit is closed the log should have been marked “closed.” During an interview on 11/16/23 at 10:30 AM with Staff A, Risk Management and Compliance Officer, stated that crash cart logs were to be completed every day.”

“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: 47504 48359 Based on interview, record review and policy review, the hospital failed to follow their internal policy for reassessment and notification of leadership when a patient (#25) was allowed to discharge Against Medical Advice (AMA), and ensure the hospital’s policy was followed related to neglect for one staff member (Staff Y, Registered Nurse [RN]). Findings included: Review of the hospital’s policy titled, “Event Reporting Policy,” revised 02/28/23, showed that: - The policy was to provide guidance for communicating, reporting, investigating and acting upon a patient safety event including a near miss, precursor and serious safety events, sentinel events and serious reportable/never event. - A patient safety event is an event, incident or condition that resulted or could have resulted in harm to a patient. - A sentinel event is a patient safety event that reaches a patient and results in death. - All staff report patient safety events via the Event Reporting System (ERS). - Staff are to complete the safety investigation to identify potential root causes and corrective actions. - Document investigation findings in ERS. - Risk and Quality are to review all the events of the document. - A Root Cause Analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to find the root cause) is to be completed. Review of the hospital’s policy titled, “AMA and Elopement (when a patient makes an intentional, unauthorized departure from a medical facility) Policy,” revised 04/21/23, showed that: - When a patient indicates his/her desire to leave the facility AMA, nursing is to immediately notify the unit charge nurse and then escalate to the nursing supervisor and to the attending provider. - Based on professional discretion, if unit leadership believes the patient is alert and oriented and has the capacity to make an informed choice to leave the facility, nursing will notify the patient’s attending provider of the patient’s desire to leave AMA. - Nursing will contact next-of-kin/caregiver to discuss the situation and document the communication in the medical record and document in the ERS. - If nursing believes that the patient is not alert and oriented and/or does not have the capacity to understand the risks of leaving and the benefits of staying, the patient should be informed that an assessment will be performed to determine whether he or she has the capacity to make an informed decision to leave AMA. - Staff will notify the attending provider, unit charge nurse, and/or a Qualified Mental Health Provider (QMHP) to determine if the patient is at risk. - The patient’s durable power of attorney (DPOA, a legal document that lets a person name someone else to make decisions about their health care in case they were not able to make those decisions themselves) or caregiver will be contacted, if applicable, to determine their wishes for the patient. - If the provider determines the patient does not have capacity, and there is no DPOA or caregiver to provide direction, the patient will be placed on an involuntary hold. Although requested, the hospital failed to provide video from the date of the incident. Although requested, the hospital failed to provide investigation documents related to the incident. Review of Patient #25’s medical record showed that: - He was a 60-year-old male that presented to the Emergency Department (ED) on 10/19/23 at 1:07 PM, for altered mental status (mental functioning ranging from slight confusion to coma) with delusions (false ideas about what is taking place or who one is), confusion, and wandering around his house. - On 10/19/23 at 2:21 PM, Staff AAAA, ED Physician, documented that he had confusion, disorientation (confused and unable to think clearly), and memory problems. - On 10/19/23 at 2:25 PM, a comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions) was done and showed that his sodium (a type of electrolyte in the blood, normal range 135-145) was critical at 110, potassium (a type of electrolyte in the blood, normal range 3.5-5.2) was critical at 2.2, and chloride (a type of electrolyte in the blood, normal range 96-106) was critical at 74. - On 10/19/23 at 4:17 PM, Staff AAAA, ED Physician, documented that he was alert and oriented and could identify the year but not the month or date. - On 10/19/23 at 11:41 PM, he was admitted to the Intensive Care Unit (ICU, a unit where critically ill patients are cared for). - On 10/20/23 at 2:14 AM, an AMA form was signed by Patient #25; Staff DD, RN, signed both RN signature and witness signature. - On 10/20/23 at 3:00 AM, Staff DD, RN, documented that Patient #25 wanted to leave AMA and he had explained the risks of leaving AMA. The patient called his wife, his wife answered and stated she was on her way to pick him up. He was escorted to ED exit. - On 10/20/23 at 7:51 AM, Staff YYY, Hospitalist, made an addendum that showed the patient was alert, oriented times two, inattentive, and had poor insight and judgement. - On 10/20/23 at 8:08 AM, an addendum was made by Staff DD, RN, that documented Patient #25 wanted to leave AMA and Staff YY, Hospitalist, was notified. He documented Patient #25 was alert and oriented to self, time, situation and place. - On 10/20/23 at 8:25 AM, Staff CC, RN, wrote an addendum that showed that near midnight she talked to Patient #25, he wanted to go smoke. He was alert and oriented to self, place, situation, and time. - On 10/20/23 at 9:09 AM, Staff YY, Hospitalist, documented that at 2:05 AM, nursing staff reported that Patient #25 was no longer confused, was alert and oriented to person, place, time, and event. Patient #25 was going to leave AMA and that nursing staff talked with the patient’s wife by phone and that he would be waiting in the ED waiting room for them to pick him up. Patient #25 was escorted to the ED waiting room. At 7:27 AM, she called and spoke with Patient #25’s family and was told that they were searching for him. The family stated that there had been a fatal accident and they did not know if he was involved. Staff YY, Hospitalist, called the county coroner and was told that the patient was found to be walking a long distance away from the hospital and had been struck and killed by a vehicle. During an interview on 11/06/23 at 2:50 PM, Staff G, ICU Director, stated that: - Patients that were alert, oriented, and capable of making sound decisions were allowed to sign AMA paperwork. - All risks were identified by the nurse completing the AMA form. - Nursing staff would notify the family and would ensure that they had a safe discharge plan. - For patients who wanted to leave AMA and were not capable of making decisions for themselves, the physician would order a 72-hour medical hold. During an interview on 11/07/23 at 1:42 PM, Staff B, Assistant Chief Nursing Officer (ACNO), stated that: - He completed the investigation of the incident for Patient #25. - He interviewed all staff involved in the incident. - He reviewed the chart documentation and stated that Patient #25, had been capable of making his own decisions, was alert and oriented, and had chosen to leave AMA. - The nurse had spoken directly with the family and they were to pick the patient up in the ED waiting room. - His investigation showed the nurses did their due diligence, escalated the event, and the hospital did everything they could and it was a “terrible situation” that had occurred. - A RCA had not been done as he felt the hospital handled the situation correctly. During an interview on 11/07/23 at 3:00 PM, Staff YY, Hospitalist, stated that: - She could not cover the whole hospital and she had been extremely busy and never saw Patient #25. - On 10/20/23 she received a phone call from Staff DD, RN, who stated that Patient #25 wanted to leave AMA. He was alert and oriented and capable of making his own decisions. She could not remember the time of the call. - She had reviewed the chart and was aware that Patient #25’s lab work showed a critically low sodium and potassium but that he had received medications and his levels had improved. - She had not been aware of Patient #25’s confusion and that Staff CCC, Hospitalist, had added the confusion into the chart at a later time. - She told Staff DD, RN, to let him go AMA and that they could not hold him against his will. - She called to check on the patient and learned that the family was trying to locate the patient. - She then attempted to locate Patient #25 in the hospital and no one had seen the patient. She called security and the house supervisor. - She had been made aware of a tragic accident and called the county coroner and found out that the person had been identified as Patient #25. - She stated that the charge nurse and staff nurse had both talked to the patient and he had been capable of making his own decision to leave AMA. - No one from administration had talked to her regarding an investigation of the incident. During an interview on 11/07/23 at 3:45 PM, Staff L, RN, stated that: - She had been the assigned nurse in the ED for Patient #25. - He was alert and oriented but had subtle confusion. He talked about his dog and she had been told that he did not have a dog by the patient’s family. - She gave report to Staff DD, RN, and had made him aware that the patient was “off” and was not “with it” at times. - No one from administration had talked to her regarding an investigation of the incident. During an interview on 11/08/23 at 8:25 AM, Staff DD, RN, stated that: - He had been the nurse assigned to care for Patient #25 in the ICU on 10/19/23. - Patient #25, wanted to leave AMA, and that he was alert and oriented and capable of making his own decisions. - Patient #25 called his wife but he did not stay in the room during the conversation and did not talk to the wife. - Patient #25 told him his wife would be downstairs to pick him up. - He notified the physician and the house supervisor and stated that they were both too busy to come to the ICU to talk to the patient. He was then told to let the patient leave AMA and they could not force him to stay. - He walked him down to the ED waiting room and left him there after he signed the AMA paperwork around 3:00 AM. - On 10/20/23 at 7:15 AM, he had left the hospital following his shift and received a phone call from Staff G, ICU Director, who told him that he needed to come back to the hospital and document the phone call he had made to the physician for Patient #25’s AMA. He was not aware of the patient’s death until later in the week. - No one from administration had talked to him regarding an investigation of the incident. During an interview on 11/16/23 at 8:30 AM, Staff EEE, House Supervisor, stated that: - On 10/20/23, he received a phone call from Staff DD, RN, stating that a patient wanted to leave AMA and that two nurses had signed off on the AMA. - Staff DD, RN, stated that Patient #25 was alert and oriented to self, place, time, and situation and that he had notified the physician and family. - On 10/20/23 at 6:00 AM, he was made aware that Patient #25 was no longer in the ED waiting room. - On 10/20/23, he was unsure of the time, but was notified that the patient was missing and escalated it to Administration. It was shift change so he was not aware of Patient #25’s death until a later time. - No one from administration interviewed him as part of any investigation of the incident. During an interview on 11/20/23 at 2:40 PM, Staff AAAA, ED Physician, stated that he did remember that Patient #25 was confused, had a low sodium level, and was admitted into ICU. No one from administration had interviewed him as part of any investigation of the incident. During an interview on 11/20/23 at 3:05 PM, Staff YYY, Hospitalist, stated that: - Patient #25 was admitted to the ICU for confusion and a low sodium level on 10/19/23. - He was the hospitalist that accepted the admission and on 10/19/23 he worked from 7:00 AM until 7:00 PM. - Patient #25 was alert and oriented to self and time. He was confused and he had a difficult time following the conversation. He had poor insight and could not verbalize why he was there at the hospital. - On 10/20/23 at 7:00 AM, he returned to work and began to look for Patient #25. He was not on his rounding list. - He found out that Patient #25 had left AMA earlier that morning and was tragically killed in an accident. - He made an addendum to Patient #25’s medical record and added the physical examination. He stated that the electronic medical record (EMR) system was new and there was not a template for the physical examination and he added the information on 10/20/23 at 7:51 AM. He was aware of the patient death at the time he made the addendum. - No one from administration had contacted him regarding any investigation of the incident. Review of the hospital’s policy titled, “Alleged Patient Abuse and Patient Neglect,” dated 11/15/23, showed that: - Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness; - The hospital will strive to identifying events and occurrences that may constitute or contribute to abuse and neglect; - All allegations of abuse and/or neglect will be investigated in a thorough, timely, impartial, dignified, objective and confident manner; and - The Risk Management Director and other members of the Executive Team shall report substantiated allegations of patient abuse/neglect to the appropriate regulatory entities and/or professional licensing agency as applicable. Review of the hospital’s document titled, “Terminated for Abuse/Neglect Diversion,” dated 11/06/23, showed that Staff Y, RN, was terminated for violation of the Abuse/Neglect Policy on 12/16/22. Review of the undated hospital investigation documents showed that: - On 10/28/22, the House Supervisor emailed the Human Resources Director, stating that Staff Y, RN, had left the hospital premises during her shift. When she was found she had pin point pupils, confusion and disorientation. - On 11/05/22, Staff Y, was allowed to return to work after a fit for duty evaluation. - On 12/05/22, two physicians vocalized concerns to the Chief Nursing Officer (CNO) regarding Staff Y’s frequent absence from the ICU, being unfocused and untrustworthy in the care of her patients. - On 12/05/22, the hospital began an investigation into Staff Y for medication diversion. - On 12/07/22, the Pharmacist’s review of the Benadryl (medication used to treat itching, insomnia, and allergic reactions) administrations between the dates of 09/04/22 and 12/06/22 showed 31 doses of Benadryl had been administered. Fifty-four doses of Benadryl had been removed from the medication dispensing machine. “Many additional dispense cancels had taken place where she could have taken the vials from the machine and then cancelled the transaction.” - Staff Y continued to provide patient care in the ICU between the dates of 11/05/22 to 12/04/22. - On 12/16/22, Staff Y was terminated for neglecting patients while diverting medications. - Staff Y, was reported to the Missouri State Board of Nursing on 05/29/23, 165 days after Staff Y’s termination date. The hospital failed to report Staff Y’s substantiated neglect to the Missouri Department of Health and Senior Services. During an interview on 11/08/23 at 2:30 PM, Staff A, Risk Management and Compliance Officer, stated that a study on Benadryl addiction had been emailed to pharmacy staff and nursing leadership, no house-wide education was provided. There were no attestations for confirmation of education to pharmacists or nursing leaders. No education had been provided regarding neglect. During an interview on 11/14/23 at 1:00 PM with Staff A, Risk Management and Compliance Officer, stated that Staff Y had not been investigated for patient neglect.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(11) Physician and other licensed independent practitioner training requirements must be specified in hospital policy. At a minimum, physicians and other licensed practitioners authorized to order restraint or seclusion by hospital policy in accordance with State law must have a working knowledge of hospital policy regarding the use of restraint or seclusion. This Standard is not met as evidenced by: 47504 Based on interview, record review and policy review, the hospital failed to ensure all physicians and other licensed practitioners (LP’s) who ordered restraints (any manual method, physical or mechanical device, material, or equipment that immobilized or reduces the ability of a patient to move his or hers arms, legs, body or head freely) and seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving), completed the required training. The hospital also failed to put a policy into place regarding restraint and seclusion training requirements for physicians and LP’s. These failures had the potential to adversely affect all patients placed in restraints. Findings included: Review of the hospital’s undated document titled, “Medical Staff Bylaws of Poplar Bluff Regional Medical Center,” showed all medical staff members shall abide by federal law and all hospital policies pertaining to restraints and seclusion. Review of the hospital’s policy titled, “Restraint and Seclusion,” revised 06/2022, showed that staff who have direct patient contact will have ongoing education and training in the proper and safe use of seclusion and restraint. Licensed staff will be educated and trained in the safe use of seclusion and restraint as well as techniques and alternatives to handle the symptoms, behaviors and situations that are treated using restraint or seclusion. Even though requested, the hospital failed to provide training requirements on restraint/seclusion for physicians and a copy of training completion. During an interview on 11/16/23 at 10:00 AM, Staff BBB, Nurse Educator, stated that he was not aware of physician training for restraints. During an interview on 11/16/23 at 10:15 AM, Staff C, Chief Quality Officer (CQO), stated that physicians had not received training on restraints.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(15) All requirements specified under this paragraph are applicable to the simultaneous use of restraint and seclusion. Simultaneous restraint and seclusion use is only permitted if the patient is continually monitored- o Face-to-face by an assigned, trained staff member; or o By trained staff using both video and audio equipment. This monitoring must be in close proximity to the patient. This Standard is not met as evidenced by: 39354 48359 Based on interview, record review and policy review, the hospital failed to ensure a one-to-one (1:1, continuous visual contact with close physical proximity) sitter was available for one patient (#50) of one patient reviewed that had a restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head)/seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) episode. This had the potential to affect all patients that had episodes of behavioral restraint/seclusion. Findings included: Review of the hospital’s policy titled, “Restraint and Seclusion,” dated 02/19/10, showed that restraint and seclusion can be used simultaneously only if constantly monitored face to face by a trained and specifically assigned staff member. A patient in restraint or seclusion is monitored through continuous in person observation by an assigned staff member who is competent and trained to do so. Review of the hospital’s policy titled, “Patient Sitters for Behavior Health Purposes,” dated 06/01/17, showed that the primary nurse is to document in the medical record that a sitter was assigned and observing the patient. Review of the hospital’s document titled, “Event Report,” dated 11/19/23, showed: - At 4:30 PM, Patient #50 was shouting and threatening staff, damaging property, and engaged in aggressive (behavior that is intended to harm another individual) behavior. - He was put in a physical hold and placed in a seclusion room. - At 6:38 PM, the patient tore down the camera from the ceiling and attempted to wrap the cord around his neck. The patient was unsuccessful in self-harm. - At 6:40 PM, the patient 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). - At 8:13 PM, the patient was removed from the four-point restraints. Review of Patient #50’s medical record showed that: - He was a 32-year-old male, alert and oriented times four (A&O x 4, a person is oriented to person, place, time, and situation), who was admitted on 11/12/23 to the Behavioral Health Unit (BHU) for psychosis (a mental disorder characterized by a disconnection from reality), substance abuse, and schizophrenia (serious mental disorder that affects a person’s ability to think, feel, and behave clearly). - He had a history of mental health issues. - On 11/17/23 at 7:50 AM, the patient was placed in restraints due to self-harm, banging his head, agitation, and threatening behaviors, throwing self against the exit doors, not responding to verbal interventions, and medication was ineffective. - At 7:50 AM, there was an order given for restraints and physical hold due to the patient damaging property and elopement (when a patient makes an intentional, unauthorized departure from a medical facility) attempt. - At 8:21 AM, the patient was released and escorted back to his room. - There was no 1:1 observation. - On 11/18/23 at 11:25 AM, the patient walked down the hall past the nurse’s station and began to shout. When staff approached him, he became angrier, threw himself against the exit door, tore his shirt off, slapped himself in the face, and pounded his chest. As the doctor approached, he began to say racial slurs and verbal threats toward the doctor. He charged at the doctor, and then threw himself against the exit door. The patient was taken into a physical hold and walked to the seclusion room. - At 11:40 AM, the patient was placed in seclusion due to an immediate risk of violence. - At 12:25 PM, the patient was released. - There was no documentation of 1:1 observation. - At 5:13 PM, the patient was marching up and down the halls banging on the walls and various objects. The patient tore his shirt off and threw it. Security took the patient into a physical hold and walked him to seclusion due to the immediate threat to others. - At 5:25 PM, the patient was released from seclusion. - There was no 1:1 observation. - On 11/20/23 at 12:31 PM, the patient was angry, yelling, and refused to return to the unit. He was hitting himself in the head, ripped off his pants, and placed them around his neck. The patient was placed in a physical hold and taken to the seclusion room. - At 12:44 PM, he was placed in four-point restraints. - At 12:56 PM, he was released from the restraints. - There was no 1:1 observation. - On 11/22/23 at 1:30 PM, he attempted to tear the patient phone off the wall. Two security staff and three nursing staff physically restrained the patient and took him to the seclusion room. - At 1:36 PM, he was placed in four-point restraints. - At 2:28 PM, he was released from the restraints. - There was no 1:1 observation. - On 11/23/23 at 1:15 PM, there was an order given for restraints and a physical hold due to the patient being physically aggressive toward others, dangerous to self, dangerous/threatening to other patients or staff, and he broke the fire alarm and attempted to break the phone. - There was no documentation in the medical record. - There was no documentation of the house supervisor or the BHU manager notification. - There was no face-to-face assessment or 1:1 observation documentation. During interviews on 12/06/23 at 9:35 AM and 10:40 AM and on 12/07/23 at 9:51 AM, Staff FFF, Registered Nurse (RN), BHU Manager, stated that: - There was video in all patient rooms and in the patient common area. - There was no audio with the video. - Patient technicians do every 15-minute checks on all the patients. - If a patient was placed on 1:1, it needed to be documented in the chart. During an interview on 12/13/23 at 7:59 AM, Staff UUU, RN, stated that she recalled Patient #50. Patient #50 was very quick tempered and had a lot of angry outbursts. Patient #50 was a danger to himself and others and would consider him high risk. Patient #50 was totally out of control. All patients are on 15-minute checks. If a patient goes into seclusion, they are to be 1:1. There was a paper form that was filled out for the face to face, and it was kept with the restraint and seclusion physician order.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(i) When restraint or seclusion is used, there must be documentation in the patient’s medical record of the following: The 1-hour face-to-face medical and behavioral evaluation if restraint or seclusion is used to manage violent or self-destructive behavior. This Standard is not met as evidenced by: 39354 48359 Based on interview, record review and policy review, the hospital failed to conduct a one hour face-to-face assessment, that included a medical/physical assessment, after a restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head)/seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) episode for one patient (#50) of one patient reviewed. This had the potential to affect all patients that had episodes of behavioral restraint/seclusion. Findings included: Review of the hospital’s policy titled, “Restraint and Seclusion,” dated 06/20/22, showed that within one hour of the initiation of restraint and seclusion a face-to-face evaluation and assessment must be completed. Review of Patient #50’s medical record showed that: - He was a 32-year-old male, alert and oriented times four (A&O x 4, a person is oriented to person, place, time, and situation), who was admitted on 11/12/23 to the Behavioral Health Unit (BHU) for psychosis (a mental disorder characterized by a disconnection from reality.), substance (misuse of alcohol and/or other drugs) abuse, and schizophrenia (serious mental disorder that affects a person’s ability to think, feel, and behave clearly). - On 11/17/23 at 7:50 AM, the patient was placed in restraints due to self-harm, banging head, agitated and threatening behaviors, throwing self against the exit doors, not responding to verbal interventions, and medication was ineffective. - At 7:50 AM, there was an order given for restraints and physical hold due to the patient damaging property and elopement (when a patient makes an intentional, unauthorized departure from a medical facililty) attempt. - At 8:21 AM, the patient was released and escorted back to his room. - There was no face-to-face assessment. - On 11/18/23 at 5:13 PM, the patient was marching up and down the halls banging on the walls and various objects. The patient tore his shirt off and threw it. Security took the patient into a physical hold and walked him to seclusion due to the immediate threat to others. - At 5:25 PM, the patient was released from seclusion. - There was no face-to-face assessment. - On 11/19/23 at 4:44 PM, the patient was pulling on the exit signs and shouting. He went to the door, banged on it, and demanded to be released. He began to shout insults, profanities, and threatened staff. He went to the exit doors and pulled the metal bar off the door. He became an immediate threat to himself and others. - At 4:39 PM, he was taken into a physical hold by staff, and carried to the seclusion room. - At 6:27 PM, the nurse attempted to speak with the patient regarding release from seclusion. He continued making threats, pounded on the door and walls. He was considered a high risk of harm to others at that time and was not released. At that time, it was deemed inadvisable to open the door due to his very high risk of agitation and threats. - At 6:56 PM, he pulled the camera out of the ceiling, stood against the wall, and wrapped the cords around his neck. He was placed in restraints to prevent him from harming himself. - There was no face-to-face assessment. - On 11/20/23 at 12:31 PM, the patient was angry, yelling, and refused to return to the unit. He was hitting himself in the head, ripped off his pants, and placed them around his neck. The patient was placed in a physical hold and taken to the seclusion room. - At 12:44 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 other). - At 12:56 PM, he was released from the restraints. - There was no face-to-face assessment. - On 11/22/23 at 1:30 PM, he attempted to tear the patient phone off the wall. Two security staff and three nursing staff physically restrained the patient and took him to the seclusion room. - At 1:36 PM, he was placed in four-point restraints. - At 2:28 PM, he was released from the restraints. - There was no face-to-face assessment. - On 11/23/23 at 1:15 PM, there was an order given for restraints and a physical hold due to the patient being physically aggressive toward others, dangerous to self, dangerous/threatening to other patients or staff, and he broke the fire alarm and attempted to break the phone. There was no documentation in regard to the initiation of restraints in the patient medical record. - There was no face-to-face assessment. During an interview on 12/12/23 at 3:31 PM, Staff TTT, Physician, stated that she recalled Patient #50. She did not think a face-to-face within one hour was required anymore. During an interview on 12/06/23 at 9:35 AM, 10:40AM, and on 12/07/23 at 9:51 AM, Staff FFF, Registered Nurse (RN), BHU Manager, stated that if a patient was one-to-one (1:1, continuous visual contact with close physical proximity), the doctor would perform a face-to-face evaluation. When a patient was placed in restraints, the nurse that was not involved in the direct care of the patient would perform the face-to-face with the patient. During an interview on 12/13/23 at 7:59 AM, Staff UUU, RN, stated that she recalled Patient #50. A face to face was to be done within an hour. There was a paper form that was filled out for the face to face, and it was kept with the restraint and seclusion physician order.”

“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: 47504 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, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely), for all staff. 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),” revised 06/2022, showed that staff who have direct patient contact will have ongoing education and training in the proper and safe use of seclusion and restraint. Licensed staff would be educated and trained in the safe use of seclusion and restraint as well as techniques and alternatives to handle the symptoms, behaviors, and situations that are treated using restraint or seclusion. Although requested, the hospital failed to provide training requirements and a copy of training completion on restraint/seclusion medical first aid for staff and physicians. Review of the hospital’s restraint log showed that violent and/or non-violent restraints were utilized on patients 139 times for the previous six months. During an interview on 11/16/23 at 10:00 AM, Staff BBB, Nurse Educator, stated that first aid training for restraint/seclusion was not included in their education requirements. During an interview on 11/16/23 at 10:15 AM, Staff C, Chief Quality Officer (CQO), stated that first aid training for restraint/seclusion was not included in their education requirements.”

“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: 48359 Based on observation, interview and policy review, the hospital failed to ensure that four nursing staff (Staff HHH, OOO, RRR, and FFF) of four nursing staff personnel files reviewed, were orientated and verified competency in the patient care they provided; and that the Chief Nursing Officer (CNO) fulfilled her responsibility to ensure that all nursing personnel had been educated regarding the hospital’s policies and procedures and adhered to them. This failure could place all patients at risk for their safety. The hospital census was 143. Findings included: Review of the hospital’s document titled, “Department Orientation and Initial Competency Assessment (DOICA),” dated 02/13/16, showed the initial competency was to be completed within 90 days of hire. Complete the first two pages within seven days. The orientee is to complete the self-assessment regarding experience. The observer is to document the method of assessment and signs his/her name after each observation. Review of the hospital’s document titled, “New Hire Competency,” dated 02/04/21, showed a newly hired employee would be evaluated during weeks one, two, four, six, eight, 10 and 12 of orientation. Although requested the hospital did not provide a policy related to nursing orientation and on-going education. Review of the personnel file for Staff HHH, Registered Nurse (RN), showed that there was no unit specific orientation competency or assessment of competency completed. Review of the personnel file for Staff OOO, RN, showed that her hire date was 06/14/21. The first two pages of the DOICA were completed on 10/14/21, 134 days after her hire date. There was no self-assessment documented on the DOICA form. The New Hire Competency was documented in week one on 10/14/21, there was no documentation of competency for weeks two, four, six, eight, ten or twelve. The General Nursing and Behavioral Health competencies were completed on 11/01/23, 2 years and 140 days after her hire date. Review of the personnel file for Staff RRR, RN, showed that his hire date was 11/04/19. The first two pages of his DOICA were completed in 12/2019, 31 days after his hire date. There was no self-assessment documented on the DOICA form. The New Hire Competency was documented in week one on 02/04/20, there was no documentation of competency for weeks two, four, six, eight, ten or twelve. Review of the personnel file for Staff FFF, Behavioral Health Nurse Manager, showed that her hire date was 08/09/21. There was no DOICA form. The New Hire Competency was documented in week one on 12/28/21, there was no documentation of competency for weeks two, four, six, eight, ten or twelve. During an interview on 12/11/23 at 4:30 PM, Staff Y, RN, stated that she has worked for the Behavioral Health Unit for four months. She had one day of orientation. She did not feel like that was enough orientation. She would benefit from more training. During an interview on 12/07/23 at 9:50 AM, Staff FFF, Behavioral Health Nurse Manager, stated that the behavioral health staff need education specifically related to the “big picture” of behavioral health. During an interview on 12/07/23 at 10:30 AM, Staff V, Licensed Practical Therapist, stated that staff would benefit from additional training/education. During an interview on 12/07/23 at 1:30 PM, Staff H, CNO, stated that there was no unit specific orientation competency for the Behavioral Health Unit. She expected each unit to have a unit specific orientation checklist. She expected all staff to be educated. During an interview on 12/07/23 at 2:30 PM, Staff G, Chief Executive Officer, stated that the hospital needed to connect the why to their educational efforts. The hospital’s education process needed to be consistent and ensure validation of competency.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 47504 Based on observation, interview and policy review, the hospital failed to: - Perform hand hygiene (wash hands with soap and water or alcohol-based hand sanitizer) and glove changes during patient care for 12 patients (#27, #28, #32, #34, #35, #36, #38, #39, #40, #41, #42, and #45) of 15 patients observed; - Prepare a clean work surface prior to performing patient care for seven patients (#27, #32, #34, #39, #40, #43, and #45) of 10 patients observed; - Cleanse the skin surface prior to an intravenous (IV, in the vein) needle insertion for one patient (#34) of one patient observed; - Clean the pill splitter between use for one patient (#39) of one patient observed; - Clean the workstation on wheels (WOW, a computer or supply and medication storage on a wheeled stand that can be moved from patient to patient) between use for four patients (#35, #38, #41, #42) of 16 patients observed; - Discard supplies when dropped on the floor for one patient (#35); - Date food items that were located in patient pantry areas; - Discard expired patient food items; and properly label food items in the patient refrigerator with patient name and open date; and - Remove expired patient care supplies from a supply storage area. Findings included: Review of the hospital’s policy titled, “Hand Hygiene,” dated 01/03/22, directed staff to perform hand hygiene: - Upon entering a patient’s room, and before any patient contact; - After touching wounds or any body surface likely to contain body fluids or microorganisms (organisms, such as bacteria, too small for the naked eyes); - After contact with inanimate environmental sources; - After contact with all patients and equipment; - Prior to departing patient rooms; - Between patients; and - When changing gloves. Observation on 11/14/23 at 11:30, showed Staff AA, Registered Nurse (RN), failed to perform hand hygiene between glove changes during urinary catheter care, medication administration and when she exited the patient room when providing care for Patient #27. Observation on 11/14/23 at 12:00 PM, showed Staff AA, RN, failed to perform hand hygiene before entering the room and with glove changes during medication administration for Patient #28. Observation on 11/13/23 at 3:15 PM, showed Staff FF, RN, failed to perform hand hygiene in between glove changes when providing care for Patient #32. Observation on 11/14/23 at 9:50 AM, showed Staff W, RN, failed to perform hand hygiene between glove changes when providing care for Patient #34. Observation on 11/14/23 at 10:20 AM, showed Staff RR, RN, failed to perform hand hygiene between glove changes when providing care for Patient #35. Observation on 11/14/23 at 10:40 AM, showed Staff RR, RN, failed to perform hand hygiene between glove changes when providing care for Patient #36. Observation on 11/15/23 at 8:30 AM, showed Staff SS, RN, failed to perform glove changes and hand hygiene during a urinary catheter removal and providing eating assistance, for Patient #38. Observation on 11/15/23 at 8:50 AM, showed Staff V, Infection Control Director, failed to perform hand hygiene before entering and exiting Patient #39’s room. Observation on 11/15/23 at 9:05 AM, showed Staff TT, RN, failed to perform hand hygiene between glove changes during medication administration for Patient #40. Observation on 11/15/23 at 9:15 AM, showed Staff WW, RN, failed to do hand hygiene between glove changes when providing care for Patient #41. Observation on 11/15/23 at 9:30 AM, showed Staff XX, RN, failed to perform hand hygiene and glove changes when he retrieved a pen from his pocket and failed to perform hand hygiene between glove changes while caring for Patient #42. Observation on 11/15/23 at 9:00 AM, showed Staff VV, RN, failed to perform hand hygiene and glove changes when she retrieved a pen and camera from her pocket while caring for Patient #45. Although requested, the hospital failed to provide a policy regarding the preparation of a clean surface prior to patient care. Observation on 11/14/23 at 11:30 AM, showed Staff AA, RN, failed to prepare a clean work surface prior to medication administration for Patient #27. Observation on 11/13/23 at 3:15 PM, showed Staff FF, RN, failed to clean the surface of the bedside table prior to laying supplies on the table, and failed to use a barrier when he laid catheter supplies on the bed when providing care for Patient #32. Observation on 11/14/23 at 9:50 AM, showed Staff W, RN, failed to clean the surface of the bedside table prior to placing supplies on it when providing care for Patient #34. Observation on 11/15/23 at 8:45 AM, Showed Staff TT, RN, failed to prepare a clean work surface prior to medication administration for Patient #39. Observation on 11/15/23 at 9:05 AM, showed Staff TT, RN, failed to prepare a clean work surface prior to medication administration for Patient #40. Observation on 11/15/23 at 11:00 AM, showed Staff XX, RN, failed to clean the surface of the bedside table prior to laying supplies down when providing care for Patient #43. Observation on 11/15/23 at 9:00 AM, showed Staff VV, RN, failed to clean the work surface following wound care and then placed Patient #45’s drinking cup on the dirty surface. Review of the hospital’s policy titled, “Vascular Lines Policies and Procedures,” dated 06/2023, showed peripheral vascular access devices were to be inserted using standard precautions and a no touch aseptic technique (process that is intended to minimize contamination from pathogens). The skin was not to be palpated after cleansing unless sterile gloves were worn. The insertion site should be cleansed with an antiseptic solution for at least 30 seconds, then allowed to dry completely before inserting the IV needle. Observation on 11/14/23 at 9:50 AM, showed Staff W, RN, failed to cleanse the skin surface prior to an IV needle insertion for Patient #34. Review of the hospital’s policy titled, “Cleaning, Disinfection, Sterilization and Storage of Patient Care Equipment,” dated 01/03/22, showed that the cleaning and disinfection of hard surfaces and equipment shall be done between each patient. Observation on 11/15/23 at 8:45 AM, showed Staff TT, RN, failed to clean the inside of the pill splitter after use when preparing medications for Patient #39. Observation on 11/15/23 at 1:00 PM, showed Staff UU, RN, failed to clean the surface of the WOW prior to placing supplies on top of the WOW when providing care for Patient #35. Observation on 11/15/23 at 8:30 AM, showed Staff SS, RN, failed to clean the WOW keyboard after medication administration and prior to exiting the patient room, while providing care for Patient #38. Observation on 11/15/23 at 9:15 AM, showed Staff WW, RN, failed to prepare a clean work surface on a WOW when providing care for Patient #41. Observation on 11/15/23 at 9:30 AM, showed Staff XX, RN, failed to clean the surface of the WOW prior to a medication administration for Patient #42. Observation on 11/15/23 at 1:15 PM, showed Staff UU, RN, failed to discard supplies after she dropped a syringe of saline on the floor and then picked it up and used it when providing care for Patient #35. Review of the hospital’s policy titled, “Nursing Unit Stock,” dated 01/2023, directed staff to: - Place items such as salt, pepper and sugar into individual zipper bags or small containers; - Complete an orange label for each type of item and place the label on the outside of the zipper bag or plastic container; - When restocking pantries, do not refill original zipper bag or plastic container, simply place a new bag or container in the pantry area and throw away the existing bag or remove the orange label from the plastic container after cleaning, reuse for another item; - Place only food for patient use in the refrigerator; - Discard all expired products; and - Nursing is to label products with a date and time when an item is opened. Observation on 11/06/23 at 3:45 PM, showed the patient nutrition pantry on the Intensive Care Unit (ICU, a unit where critically ill patients are cared for) contained individual packages of peanut butter, graham crackers, crackers, salt, creamer, sugar and sweetener in plastic bins without expiration dates. There was one opened package of cheese slices that was not labeled with a patient name, opened date, or expiration date. There was one frozen dinner with only initials in the freezer that was not labeled with a patient name. Observation on 11/07/23 at 10:00 AM, showed the patient nutrition pantry on the fifth floor contained individual packages of salt, creamer, sugar, sweetener, peanut butter, and crackers in plastic bins without expiration labels. Observation on 11/07/23 at 10:30 AM, showed the patient nutrition pantry on the sixth floor contained individual packages of salt, creamer, sugar, sweetener, peanut butter, and crackers in plastic bins without expiration labels, individual packages of sugar and sweetener in zipper bags without expiration labels, one multi-use bottle of chicken broth powder without an open date and time label, and one expired high protein shake. Observation on 11/07/23 at 10:45 AM, showed 13 expired IV start needles in the medication room cabinet. During an interview on 11/06/23 at 4:00 PM, Staff G, ICU Director, stated that all food in the patient nutrition refrigerator should be properly labeled with the patient’s name, open date, and expiration dates. She stated that the frozen meal in the freezer appeared to be an employee’s, based on the initials on the outside of the box. During an interview on 11/15/23 at 2:00 PM, Staff F, Staff V, Infection Control Director, stated that a clean surface should have been prepared prior to medication administration and patient care. She stated that the skin should have been prepped with alcohol prior to IV starts. She expected the WOW keyboard to be cleaned after each patient use. Staff were not to reach into their pockets with dirty gloves/hands. The inside of pill splitters were to be cleaned to remove any medication residue after each use. Supplies that were dropped on the floor were to be discarded. All ancillary staff were expected to follow the hand hygiene policy. Hand hygiene was to be performed before entering and exiting patient rooms, with glove changes and when moving from a dirty area to a clean area. Patient care supplies were to be inventoried for expiration dates twice yearly and with every use. Food supplies without open/expiration dates were to be discarded. During an interview on 11/16/23 at 10:30 AM, Staff A, Risk Management and Compliance Officer, stated that she expected staff to prepare a clean work surface prior to medication administration and patient care. All food items were to be dated with open and expiration dates. All expired supplies were to be discarded. 48359”

“DISCHARGE PLANNING PROGRAM REVIEW CFR(s): The hospital must assess its discharge planning process on a regular basis. The assessment must include ongoing, periodic review of a representative sample of discharge plans, including those patients who were admitted within 30 days of a previous admission, to ensure that the plans are responsive to the patient post-discharge needs. This Standard is not met as evidenced by: 48359 Based on interview, record review and policy review, the hospital failed to include discharge planning in the Quality Assurance and Performance Improvement (QAPI, process for reporting and/or identifying adverse events, near misses or review of high risk, problem prone areas for patient safety) process to assess its discharge planning process on a regular basis. This failed practice had the potential to result in medical errors during transitions of care and impact negatively on vulnerable populations. Findings included: Review of the hospital’s policy titled, “QAPI Plan,” dated 01/03/23, showed that performance improvement is the ongoing analysis and adaptation of processes to increase the probability of achieving desired outcomes to meet the needs of patients and other customers. Poplar Bluff Regional Medical Center’s plan for performance includes a systematic approach to planning, designing, measuring, assessing and continuously improving processes and outcomes to ensure safe patient care. Review of the hospital’s untitled and undated document, showed there were no current metric dashboards related to the following measures managing discharge planning: - Timeliness of identifying patients in need of discharge planning; - Quality and timeliness of implementing discharge evaluations and plans; - Appropriateness of these discharge plans; and - Effective implementation of discharge plans. During an interview on 11/15/23 at 2:00 PM, Staff F, Chief Nursing Officer (CNO), stated that there should be QAPI for discharge planning. During an interview on 11/15/23 at 4:30 PM, Staff ZZ, Case Management Director, stated that she did not report any metric outcomes to the hospital’s QAPI committee. During an interview on 11/16/23 at 10:30 AM, Staff A, Risk Management and Compliance Officer, stated that the hospital did not have QAPI for discharge planning.”

“DISCHARGE PLANNING TIMELY EVALUATION CFR(s): Any discharge planning evaluation must be made in a timely basis to ensure the appropriate arrangements for post-hospital care will be made before discharge and to avoid unnecessary delays in discharge. This Standard is not met as evidenced by: 48359 Based on interview, record review and policy review, the hospital failed to provide discharge planning evaluation to ensure appropriate arrangements for post-hospital care for five (#4, #5, #20, #22, and #23) of five Women’s Health medical records reviewed. This failed practice had the potential for adverse health consequences upon discharge. Findings included: Review of the hospital’s policy titled, “Case Management Plan for Discharge Planning,” dated 06/30/20, showed that: - All patients are screened by nursing services for potential discharge needs upon admission or placement in observation. - The Case Manager will screen all acute care patients, with the possible exception of maternity and normal newborn cases for potential discharge planning needs, utilizing the High-Risk Screening tool. This screen will take place during the initial clinical review for medical necessity and will be in conjunction with the initial screening completed by nursing in the admission assessment process. -The Case Manager or Social Worker will develop the discharge plan with input from the patient and/or caregiver, and the healthcare team. They will discuss options available for post-hospital care services, if indicated. The discharge plan will also reflect the recommendations of the physician and healthcare team members involved in the patient’s care, treatment and services, as appropriate. - The discharge plan will be documented in the patient’s medical record to provide guidance to the healthcare team in preparing the patient for discharge. Review of Patient #4’s medical record, showed that there was no discharge needs assessment upon admission. Review of Patient #5’s medical record, showed that there was no discharge needs assessment upon admission. Review of Patient #20’s medical record, showed that there was no discharge needs assessment upon admission. Review of Patient #22’s medical record, showed that there was no discharge needs assessment upon admission. Review of Patient #23’s medical record, showed that there was no discharge needs assessment upon admission. During an interview on 11/06/23 at 4:00 PM, Staff Q, Registered Nurse (RN), stated that she “did not know” how patient’s discharge needs were assessed. The nurses “just ask them if they needed anything.” During an interview on 11/15/23 at 2:00 PM, Staff F, Chief Nursing Officer (CNO), stated that there needed to be a Social Worker assigned to Women’s Health. Discharge planning support should be provided to all populations. During an interview on 11/15/23 at 2:45 PM, Staff P, Women’s Health Nurse Director, stated that High Risk assessment for discharge planning were not a “hard stop” in the electronic medical record (EMR). Nursing would bypass items that were not hard stops. Case Management was only made aware of patient needs if the nurse was able to identify needs and then notified Case Management. The Women’s Health Department needed to stop waiting until discharge to assess for discharge planning needs. Discharge needs were to be identified upon admission. During an interview on 11/15/23 at 4:30 PM, Staff ZZ, Case Management Director, stated that there was no High Risk Screening for discharge planning in the obstetrical, nursery, gynecologic, and pediatric units. Social Work/Case Management involvement was dependent upon written consults. The discharge planning process needed to be updated to encompass all patient care areas. The Case Management department had a “learning curve” in order to adequately meet women’s discharge needs.”