Centerpointe Hospital of Columbia

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 50321 Based on observation, interview, record review and policy review, the hospital failed to: - Provide care in a safe setting when a staff member was found asleep on an inpatient unit while on shift; (A-0144) - Complete patient safety rounds per provider orders for 12 current patients (#20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30 and #31) and one discharged patient (#2) of 13 patient records reviewed; (A-0144) - Ensure patients were free from all forms of abuse and neglect when the hospital failed to perform an immediate and thorough investigation and provide staff education related to an incident report with an allegation of abuse; (A-0145) - Ensure restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) and seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) orders were placed and authenticated by a physician for two current patient’s (#8 and #15) of four patient records reviewed; and (A-0168) - Ensure a one-hour face-to-face assessment was completed within one hour of restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) initiation for three current patients (#8, #14 and #15) of four patient records reviewed. (A-0178) Please refer to A-0144, A-0145, A-0168 and A-0178.”

“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: 46856 Based on observation, interview, record review and policy review, the hospital failed to provide care in a safe setting when a staff member was found asleep on an inpatient unit while on shift and when staff failed to complete patient safety rounds (visualization and documentation of the safety of each patient) per provider orders for 12 current patients (#20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30 and #31) and one discharged patient (#2) of 13 patient records reviewed. Findings included: Review of the hospital’s Employee Handbook, dated 2024, showed it was the company’s expectation that employees would always conduct themselves professionally and with due regard to the facility, fellow employees and patients, and to adhere to all standards and policies set forth in the handbook and by the company. Prohibited conduct included sleeping, or the appearance thereof while working. Observation on 05/27/26 from 1:30 PM to 2:12 PM, on the Silver Lining Unit, showed Staff E, Registered Nurse (RN), sitting at a workstation on wheels (WOW, a computer or supply and medication storage on a wheeled stand, that can be moved from patient to patient) inside the treatment team room. For approximately 20 minutes, she dozed off, then roused herself, typed on her WOW’s keyboard, then dozed off again repeatedly. Then, she stood up, went into the medication room, and returned to the treatment team room with medication. She then asked Staff R, RN Manager, to cosign the medication at 2:12 PM. During an interview on 05/28/26 at 12:33 PM, Staff D, Quality Management Director, stated that it was not acceptable to sleep on the job and they were “not paying you to nap on the job.” If staff saw an employee sleeping on the job, they should report that staff member. Staff E, RN, was responsible for all the patients on the unit. During an interview on 05/28/26 at 12:33 PM, Staff T, Chief Executive Officer (CEO), stated that it was not acceptable for staff to sleep while on a shift. He expected staff to report other staff who slept on the unit. Staff E, RN, was currently suspended pending investigation. Review of the hospital’s policy titled, “Patient Observations,” dated 04/2020, showed: - In order to maintain patient safety, the hospital staff made and documented routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and/or initiated by the RN. - One to one (1:1, continuous visual contact with close physical proximity) meant one team member was assigned to one patient. The assigned team member remained close enough to intervene if the patient attempted inappropriate behavior, but at such a distance to avoid injury, at all times and maintained continuous visual observation of the patient. - Every five-minute observation meant the patient was monitored at minimum once every five-minute block of time. - Every 15-minute observation meant the patient was monitored at minimum once every 15-minute block of time. - Documentation of 1:1 observation occurred every five-minutes even though the patient was observed continuously. - In order to minimize the chance that a patient might anticipate the timing of the observation, staff were instructed to vary the order in which a patient was observed within each 15-minute period. - Documentation of observations would be completed in real time and by the person who conducted the observation. There might be times in which actual entries were delayed due to an emergency. Documentation should be made as a late entry as soon as possible with a note that indicated the reason for the delay if appropriate. - Documentation would be documented on paper during planned or unplanned downtime. Review of Patient #2’s medical record, dated 01/30/26, showed: - On 01/30/26, she was a 32-year-old female admitted for psychosis (mental illness characterized by defective or lost contact with reality) and bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows). - On 01/31/26 at 12:43 AM, an order was placed for every 5-minute safety rounds. - Between 2:41 AM and 9:16 PM, there were 20 instances when every five-minute safety rounds were not completed . - On 02/01/26, between 12:04 AM to 9:09 PM, there were 19 instances when every five-minute safety rounds were not completed. - On 02/02/26, between 2:40 AM and 11:36 PM, there were 11 instances when every-five minute safety rounds were not completed. - On 02/03/26, between 12:27 AM and 9:45 PM, there were 22 instances when every-five minute safety rounds were not completed. - On 02/04/26, between 2:42 AM and 10:25 PM, there were 16 instances when every five-minute safety rounds were not completed. - On 02/05/26, between 2:06 AM and 9:36 AM, there were 10 instances when every five-minute safety rounds were not completed. - At 12:35 PM, every five-minute safety rounds were discontinued, and an order was placed for every 15-minute safety rounds. - Between 5:35 PM and 11:36 PM, there were two instances when every 15-minute safety rounds were not completed. - On 02/06/26, between 1:35 AM and 9:44 PM, there were eight instances where every 15-minute safety rounds were not completed. Review of Patient #20’s medical record, dated 05/18/26, showed: - She was a 16-year-old admitted to the hospital for bipolar disorder. - At 10:12 PM, an order was placed for every 15-minute safety rounds. - Between 10:48 PM and 11:04 PM, there was one instance when every 15-minute safety rounds were not completed. - On 05/20/26, between 6:28 AM and 7:28 AM, there was one instance when every 15-minute safety rounds were not completed. - On 05/21/26, between 5:53 PM to 6:13 PM, there was one instance when every 15-minute safety rounds were not completed. - On 05/22/26, between 6:01 PM and 7:52 PM, there was one instance when every 15-minute safety rounds were not completed - On 05/23/26, between 8:12 PM and 11:20 PM, there were two instances when every 15-minute safety rounds were not completed. - On 05/24/26, between 5:44 PM and 6:00 PM, there was one instance when every 15-minute safety rounds were not completed. - On 05/25/26, between 2:59 PM and 9:58 PM, there were three instances when every 15-minute safety rounds were not completed. - On 05/26/26, between 4:09 AM and 5:27 PM, there were two instances when every 15-minute safety rounds were not completed. Review of Patient #21’s medical record, dated 05/24/26, showed: - She was a 17-year-old admitted to the hospital for anxiety, Post-Traumatic Stress Disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock) and depression (extreme sadness that doesn’t go away). - At 11:23 PM, an order was placed for 1:1 and every five-minute safety rounds. - Between 10:29 PM and 10:35 PM, there was one instance when every five-minute safety rounds were not completed. - On 05/25/26, between 5:41 PM and 11:54 PM, there were eight instances when every five-minute safety rounds were not completed. - On 05/26/26, between 4:21 AM and 10:04 PM, there were three instances when every five-minute safety rounds were not completed. - On 05/27/26, between 1:38 AM and 6:08 AM, there were three instances when every five-minute safety rounds were not completed. Review of Patient #22’s medical record, dated 05/19/26, showed: - He was a 15-year-old admitted to the hospital for disruptive mood dysregulation disorder (DMDD, condition of extreme irritability, anger, and frequent, intense temper outbursts) and bipolar disorder. - At 2:15 PM, an order was placed for every five-minute safety rounds. - Between 3:56 PM and 9:37 PM, there were seven instances when every five-minute safety rounds were not completed. - On 05/20/26, between 6:33 AM and 6:28 PM, there were four instances when every five-minute safety rounds were not completed. - At 7:02 PM, every 5-minute safety rounds were discontinued, and an order was placed for every 15-minute safety rounds. - On 05/21/26, between 10:16 AM and 9:15 PM, there were three instances when every 15-minute safety rounds were not completed. - On 05/22/26, between 12:31 PM and 8:55 PM, there were three instances when every 15-minute safety rounds were not completed. - On 05/23/26, between 6:14 PM and 11:22 PM, there were four instances when every 15-minute safety rounds were not completed. - On 05/24/26, between 5:55 AM and 9:10 PM, there were three instances when every 15-minute safety rounds were not completed. - On 05/25/26, between 7:32 PM and 9:53 PM, there were three instances when every 15-minute safety rounds were not completed. - On 05/26/26, between 4:11 AM and 4:46 AM, there were two instances when every 15-minute safety rounds were not completed. Review of Patient #23’s medical record, dated 05/24/26, showed: - She was a 14-year-old admitted to the hospital for suicidal ideation (SI, thoughts of causing one’s own death). - Between 5:10 PM and 9:23 PM, there were three instances when every five-minute safety rounds were not completed - On 05/25/26, between 4:00 AM and 5:31 AM, there were two instances when every five-minute safety rounds were not completed. - At 10:37 AM, every five-minute safety rounds were discontinued, and an order was placed for every 15-minute safety rounds. - Between 9:35 PM and 9:53 PM, there was one instance when every 15-minute safety rounds were not completed. - On 05/26/26, between 4:10 AM and 9:39 AM, there were two instances when every 15-minute safety rounds were not completed. Review of Patient #24’s medical record, dated 05/22/26, showed: - She was a 14-year-old admitted to the hospital for anxiety and depression. - At 3:51 AM, an order was placed for every five-minute safety rounds. - Between 8:23 AM and 1:05 PM, there were four instances when every five-minute safety rounds were not completed. - At 3:01 PM, every five-minute safety rounds were discontinued, and an order was placed for every 15-minute safety rounds. - Between 5:28 PM and 9:39 PM, there were five instances when every 15-minute safety rounds were not completed. - On 05/23/26, between 8:50 AM and 11:21 PM, there was one instance when every 15-minute safety rounds were not completed. - On 05/24/26, between 7:10 PM and 8:44 PM, there were three instances when every 15-minute safety rounds were not completed. - On 05/25/26, between 8:47 PM and 9:57 PM, there were two instances when every 15-minute safety rounds were not completed. - On 05/26/26, between 4:10 AM and 4:30 AM, there was one instance when every 15-minute safety rounds were not completed. Review of Patient #25’s medical record, dated 05/19/26, showed: - She was a 78-year-old admitted to the hospital for an altered mental status (any change in a person’s mood, behavior, psychomotor skills, and/or cognition). - At 4:42 AM, an order was placed for every 15-minute safety rounds. - On 05/20/26, between 6:27 AM and 6:57 AM, there was one instance when every 15-minute safety rounds were not completed. - On 05/21/26, between 5:37 PM to 8:34 PM, she was logged out for a medical send out. No paper rounding sheets were provided for that time. - On 05/24/26, between 4:12 AM and 10:57 PM, there were two instances when every 15-minute safety rounds were not completed - On 5/25/26, between 10:27 AM and 10:57 AM, there was one instance when every 15-minute safety rounds were not completed. Review of Patient #26’s medical record, dated 05/19/26, showed: - She was a 70-year-old admitted to the hospital for SI. - At 8:22 PM, an order was placed for every 15-minute safety rounds. - Between 8:22 PM and 8:38 PM, there was one instance when every 15-minute safety rounds were not completed. - On 05/20/26, between 1:12 AM and 7:00 AM, there were two instances when every 15-minute safety rounds were not completed. - On 05/24/26, between 10:57 PM and 11:27 AM, there was one instance when every 15-minute safety rounds were not completed. Review of Patient #27’s medical record, dated 05/15/26, showed: - He was a 21-year-old admitted to the hospital for SI. - At 4:34 AM, an order was placed for every five-minute safety rounds. - Between 4:34 AM and 2:25 PM, there were seven instances when every five-minute safety rounds were not completed. - At 2:56 PM, every five-minute safety rounds were discontinued, and an order was placed for every 15-minute safety rounds. - On 05/19/26, between 4:11 PM and 4:41 PM, there was one instance when every 15-minute safety rounds were not completed. - On 05/20/26, between 6:11 AM and 7:26 AM, there was one instance when every 15-minute safety rounds were not completed. - On 05/22/26, between 1:56 AM and 2:41 PM, there were three instances when every 15-minute safety rounds were not completed. - On 05/23/26, between 4:41 AM and 5:11 AM, there was one instance when every 15-minute safety rounds were not completed. - On 05/24/26, between 4:38 AM and 5:08 AM, there was one instance when every 15-minute safety rounds were not completed. Review of Patient #28’s medical record, dated 05/21/26, showed: - He was a 53-year-old admitted to the hospital for SI. - At 6:54 PM, an order was placed for every five-minute safety rounds. - On 05/22/26, between 12:29 AM and 11:24 AM, there were 13 instances when every five-minute safety rounds were not completed. - At 11:28 AM, every five-minute safety rounds were discontinued, and an order was placed for every 15-minute safety rounds. - Between 8:29 PM and 8:59 PM, there was one instance when every 15-minute safety rounds were not completed. - On 05/26/26, between 8:59 PM and 9:29 PM, there was one instance when every 15-minute safety rounds were not completed. Review of Patient #29’s medical record, dated 05/06/26, showed: - She was a 49-year-old admitted to the hospital for SI. - At 8:55 PM, an order was placed for every five-minute safety rounds. - Between 8:55 PM and 10:11 PM, there was one instance when every five-minute safety rounds were not completed. - On 05/07/26, between 10:36 AM and 4:37 PM, there were six instances when every five-minute safety rounds were not completed. - At 5:26 PM, every five-minute safety rounds were discontinued, and an order was placed for every 15-minute safety rounds. - Between 5:22 PM and 05/08/26 at 7:27 AM, every 15-minute safety rounds were not completed. - On 05/08/26, between 2:12 PM and 7:42 PM, there were four instances when every 15-minute safety rounds were not completed. - On 05/09/26, between 8:27 PM and 8:57 PM, there was one instance when every 15-minute safety rounds were not completed. - On 05/10/26, between 8:42 AM and 6:12 PM, there were two instances when every 15-minute safety rounds were not completed. - On 05/14/26, between 2:42 AM and 8:12 PM, there were three instances when every 15-minute safety rounds were not completed. - On 05/18/26, between 2:12 AM and 2:42 AM, there was one instance when every 15-minute safety rounds were not completed. - On 05/20/26 between 12:08 AM and 7:42 AM, there were three instances when every 15-minute safety rounds were not completed. - On 05/24/26, between 8:42 AM and 8:46 PM, there were two instances when every 15-minute safety rounds were not completed. Review of Patient #30’s medical record, dated 05/14/26, showed: - He was a 37-year-old admitted to the hospital for auditory hallucination (hearing things that are not heard by others, imaginary). - At 11:39 AM, an order was placed for every 15-minute safety rounds. - Between 11:39 AM and 12:09 PM, there was one instance when every 15-minute safety rounds were not completed. - On 05/20/26, between 6:24 AM and 9:19 PM, there were three instances when every 15-minute safety rounds were not completed. - On 05/22/26, between 2:04 AM and 2:34 AM, there was one instance when every 15-minute safety rounds were not completed. - On 05/24/26, between 5:34 PM to 8:10 PM , every 15-minute safety rounds were not completed. - On 05/26/26, between 9:10 PM and 9:23 PM, there was one instance when every 15-minute safety rounds were not completed. Review of Patient #31’s medical record, dated 05/19/26, showed: - He was a 25-year-old admitted to the hospital for SI. - At 12:49 PM, an order was placed for every five-minute safety rounds. - Between 12:49 PM and 11:57 PM, there were five instances when every five-minute safety rounds were not completed. - On 05/20/26, between 12:17 AM and 11:08 AM, there were five instances when every five-minute safety rounds were not completed. During an interview on 05/28/26 at 12:33 PM, Staff D, Quality Management Director, stated that she expected staff to follow rounding orders. 50321”

“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: 46856 Based on interview, record review and policy review, the hospital failed to ensure patients were free from all forms of abuse and neglect when the hospital failed to perform an immediate and thorough investigation and provide staff education related to an incident report with an allegation of abuse. Findings included: Review of the hospital’s policy titled, “Abuse and Neglect,” dated 04/2020, showed that any staff who witness or suspect a patient has been abused either physically or verbally will report such abuse to the Administrator on Call (AOC) immediately. This includes patient-to-patient or staff-to-patient abuse or neglect. For patient-to-patient abuse, the nurse would complete a nursing assessment of the patient who was abused to evaluate the patient’s physical and mental condition to determine what further medical evaluation the patient might need. A transfer to an outlying facility might be required. The registered nurse (RN) would notify the designated family contact and/or legal representative of the patient who was abused. The medical record should include documentation of examinations, treatment given, any referrals made to other care providers and to community agencies. Staff will notify their nursing supervisor, Director of Risk Management, and Chief Nursing Officer (CNO) immediately. The supervisor will notify the authorities as needed. Reports of abuse or neglect which occur while the patient is hospitalized will be thoroughly investigated by the Risk Manager or other staff as assigned by the Chief Executive Officer (CEO). Interviews related to the investigation will be completed by the Risk Manager and/or Human Resources Director, as assigned by the CEO. Review of Patient #2’s medical record, dated 01/30/26, showed the following: - She was a 32-year-old female admitted for psychosis (mental illness characterized by defective or lost contact with reality) and bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows). - At 2:46 AM, sexually acting out (SAO, inappropriate, harmful, out of control sexual behaviors in children and adults) precautions were ordered. - At 10:00 PM, a provider order was entered for Patient #2 to not have a roommate due to sexually acting out behaviors and psychosis. - On 02/05/26 at 12:35 PM, every five-minute observations were discontinued and every 15-minute observations were ordered. - Throughout her hospitalization, nursing documented that Patient #2 was paranoid (excessive suspiciousness without adequate cause), had hallucinations (seeing or hearing things which are not there), was hyperactive, pacing, sexually inappropriate and her thought process was disorganized and tangential (a type of thought disorder in which each of a series of thoughts seems less closely related to the original thought than the one before it). She was seen drawing things in the air, exhibited attention seeking behaviors, and at times refused to wear pants or underwear and stripped herself naked. She blocked her toilet with toilet paper, paper towels, socks and underwear. - On 02/06/26 at 7:01 PM, Staff E, RN, documented that she was informed at 10:00 AM, that Patient #2 had accused another unidentified patient of sexually assaulting her either on 02/04/26 or 02/05/26. She stated that she wanted a sexual assault nurse examiner (SANE, a registered nurse or nurse practitioner who has completed specialized training to assist sexual assault victims and collect all forensic evidence and perform exams) exam. Staff E contacted Hospital B, Acute Care Hospital, and was told that the SANE nurse would not be there until 6:00 PM. Non-emergency transportation was arranged and Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) arrived to transport the patient at 5:20 PM. - At 6:12 PM, she was transferred to Hospital B. - There was not any documentation on 02/05/26 to show a nursing assessment was completed or that a physician was notified of the allegation of abuse. Review of Patient #2’s police report, dated 02/06/26, showed: - At 12:10 PM, law enforcement was dispatched to Centerpointe Hospital of Columbia in response to a sexual assault call. - On 01/31/26 at 12:43 AM, every five-minute observations were ordered. - Upon arrival, Patient #2 stated that between 01/30/26 and 02/06/26 a black male, not entirely brown, who was approximately five feet ten inches tall with white freckles wearing blue scrubs had done something to her. She said that the unknown black male asked her to “come here,” and then she was laying down on the ground in her old bedroom. She stated that something happened, as she said that the law enforcement officer observed Patient #2 cup her left hand and insert the index finger and middle finger of her right hand into the cup of her left hand, and then she quickly removed the fingers from the cup of her left hand. She repeated that hand motion several times. Patient #2 then stated that she felt a thumb, or something touched her vaginal area. She was not aware of any penetration. She stated that she did not remember if the unknown black male said anything while on top of her and she was not sure if she had on her pants or undergarments. Patient #2 had seen the unknown black male multiple times before the incident but had not seen him afterward. She stated she could identify the man that attacked her and that she had no concept of time at that moment. - She agreed to have a SANE exam done so she would have evidence to confirm if something happened to her. During the interview, Patient #2 made statements about an active shooter and suspicious activity in the crawl space in her home. - Staff S, Risk Management Director, informed law enforcement that Patient #2 frequently changed rooms and had frequently thrown away her clothing during her stay, so there was no evidence on scene to collect. Review of Patient #2’s medical record, from Hospital B, dated 02/06/26, showed she arrived on 02/06/26 and was evaluated in the emergency department (ED). The ED provider was concerned that Patient #2 was unable to make medical decisions to consent to a sexual assault exam. Patient #2 was sent to the psychiatric (relating to mental illness) unit for a psychiatric evaluation to determine if she had decision-making capacity for a potential SANE exam. She was then admitted to the psychiatric unit for a 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others). Review of the hospital’s undated investigation showed the following: - On 02/05/26, Patient #2 reported to Staff C, Chief Financial Officer (CFO), that she believed she had been sexually assaulted at the facility between 02/04/26 and 02/05/26. - On 02/06/26, Staff C reported Patient #2’s allegations to Staff S, Risk Management Director. Staff S started investigating the allegations. Per Patient #2’s interview, she was unable to provide many details about the alleged perpetrator other than he was between five feet seven inches and five feet ten inches tall and had darker skin with white freckles. She consented to a SANE exam and filed a police report. Patient #2 was scheduled to be sent out to Hospital B for a SANE exam and left at 6:12 PM that evening. Hospital B staff subsequently admitted Patient #2 for psychiatric treatment. - A gap was identified in reporting the allegations and starting the investigation. - Every five-minute safety rounds were continued. - Education was provided to Staff C, regarding the mandatory reporting ladder and what that required for any further reports she may receive. - There was no documentation of any staff interviews. During an interview on 05/27/26 at 10:14 AM, Staff C, CFO, stated that she was rounding in the evening on patients and saw Patient #2 walking up and down the hallway. Patient #2 approached Staff C in the hallway and said she needed to tell her something. She disclosed that she thought she had been sexually assaulted. She did not give any additional details and said she did not know if it happened recently. Patient #2 also said, “another patient, who was wearing a shirt on backwards, was a sign.” Patient #2 “did not feel safe at that moment.” Staff C stated that she had no clinical training and was a relatively new employee, so she called Staff D, Quality Management Director, and informed her of the situation. Staff D said she was not on site and directed Staff C to notify the house supervisor. Staff C stated that she notified the house supervisor but could not remember who the house supervisor for that shift was. After that event, Staff S, Risk Management Director, gave her education and had her sign a form. At the time of the event, they did not have cameras on the unit. During an interview on 05/27/26 at 11:00 AM and 05/28/26 at 12:33 PM, Staff D, Quality Management Director, stated that she vaguely recalled the incident with Patient #2. Staff C, CFO, called Staff D and informed her of the situation with Patient #2. Staff D was not on site, so she told Staff C to tell the charge nurse or house supervisor about Patient #2’s allegations. Staff D thought she sent Staff C the house supervisor’s phone number. Staff D stated that they needed someone on site to start the investigation immediately. The next day, Staff S, Risk Management Director, followed up with Staff C and educated her about the flow tree for abuse and neglect allegations. Staff C, CFO, reported Patient #2’s allegations to Staff D and should have reported it to onsite staff or the house supervisor. There were opportunities for improvement. More documentation could have been done, and they could have interviewed more staff. During an interview on 05/28/26 at 11:35 AM, Staff S, Risk Management Director, stated that Staff C, CFO, shared that she had been doing rounds when Patient #2 shared she believed she had been sexually assaulted. Staff S told Staff C that the house supervisor and Staff S needed to be aware of the allegations. Staff S talked with Patient #2, who did not provide a lot of information and “seemed paranoid.” Staff S tried to obtain additional details, and Patient #2 shared she believed it was a patient with white freckles and dark brown or black skin. Patient #2 was “all over the place” in her description of the event. She could not recall if clothes were removed or not. Staff S contacted law enforcement and two officers arrived to speak with the patient around lunch time. Patient #2 had a high anxiety response. She said she would like to have a SANE exam. Staff S notified Staff E, RN, that Patient #2 would need to be transferred to Hospital B for a SANE exam. Patient #2 was not transferred until around 5:00 PM or 6:00 PM, and she was later admitted to Hospital B. Staff S stated that she had not spoken with Staff C prior to the morning of 02/06/25. She would have spoken with the patient right away. She usually included a timeline in her investigations but failed to do so in that investigation. She tried to ask Patient #2 if the individual was present or had been absent from the unit. They did not have any cameras at the time of the event. They utilized an electronic rounding system with ankle bands that recorded patient proximity and time for patient safety rounds. She reviewed patient rounds and patient proximity in their electronic rounding system and did not notice any issues. She looked for gaps in the patient observation rounds when reviewing an incident. She usually interviewed staff to determine if there were special circumstances for a significant gap in rounding. At the end of her investigation, there was not enough evidence to substantiate the allegations. She did not interview staff during her investigation; she normally would have interviewed staff. Staff interviews were not limited to a certain number of people; she could have interviewed anyone who had completed rounds on the patient, any behavioral health associate, the charge RN, and the patient’s roommate. Patient #2 did not have a roommate. Patient #2 “was mentally unwell.” It was difficult to determine the “accuracy of a patient’s recollection of the timeline.” Staff C signed a form with education on their regulatory ladder, mandatory reporting, and allegation timelines. No other staff were educated as a result of the event. During an interview on 05/27/26 at 11:35 AM, Staff E, RN, stated that she recalled Patient #2. She was the charge nurse on 02/06/26. Patient #2 was “psychotic at the time; her story kept changing” and it was hard to get details from her. Patient #2 had showered and needed a SANE exam. She was not the first one to whom Patient #2 reported the allegations of sexual assault. If she was the first person to whom a patient reported allegations of sexual assault, she would stay with the victim, call the house supervisor immediately and remove the accused from the unit. During an interview on 05/28/26 at 10:30 AM, Staff R, Nurse Manager, stated that she worked on 02/06/26 from 7:00 AM to 7:00 PM. Staff E, RN, might have called her and told her about the event with Patient #2. Staff C, CFO, did not report the event to Staff R. If a patient reported allegations of sexual assault by another patient, she would make sure the victim was safe, separate the patients and instruct the charge nurse to notify the medical provider, who would likely give an order to send the patient out to another hospital. If the victim could not identify a perpetrator, she would keep the patient safe, notify the medical provider, and notify administration and they could place the victim on every five-minute rounding or a one to one (1:1, continuous visual contact with close physical proximity) for safety. During an interview on 05/28/26 at 11:09 AM, Staff Q, House Supervisor, stated that he worked on 02/05/26 from 10:41 AM to 11:30 PM. He could not recall Staff C, CFO, coming to him or calling him with patient allegations of assault. If he received a report of a patient-to-patient sexual assault and the patient was unable to identify the perpetrator, he would collect witness statements; make sure the psychiatric and medical teams were aware of the assault; have the nurses complete and incident report and a progress note; and then notify risk management. Risk Management took over the investigation and notified the patient’s family/guardian. Hospital staff gave the victim the opportunity for a SANE exam and to file a police report. Staff provided written witness statements, which were collected by the house supervisor and given to Risk Management. The patient was generally transferred to a different unit for patient safety.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 50321 Based on interview, record review and policy review, the hospital failed to ensure restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) and seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) orders were placed and authenticated by a physician for two current patient’s (#8 and #15) of four patient records reviewed. Findings included: Review of the hospital’s policy titled, “Restraint,” dated 04/2020, showed: - Restraint meant the use of manual method, physical or mechanical device, material or equipment that immobilized or reduced the ability of a patient to move his arms, legs, body or head freely, or a drug or medication when used as a restriction to manage behavior or restrict freedom of movement that was not a standard treatment or dosage for the patient’s condition. - Holding a patient who was not cooperative with a medication through injection and/or an approved hold was considered a restraint. - A restraint would only be ordered by the attending physician or covering practitioner. Review of the hospital’s policy titled, “Seclusion,” dated 04/2020, showed: - Seclusion would only be ordered by a psychiatrist (physician who specializes in mental health disorders). - Seclusion was the involuntary confinement of a patient alone in a room or area from which they were physically prevented from leaving. - A trained registered nurse (RN) could initiate seclusion in the absence of a practitioner. The attending physician or covering practitioner should be contacted during the initiation of seclusion or immediately after. Review of the hospital’s Medical Staff Rules and Regulations, dated 03/06/25, showed: - Orders dictated over the telephone should be signed, dated and timed by the person who took the order and should include the name of the practitioner who gave the order. The practitioner must acknowledge that the read-back was accurate. - Authentication timelines were outlined in attachment 7.8. - Attachment 7.8 showed the authentication of orders was to be completed no later than 24 hours after the order was given. Review of Patient #8’s medical record, dated 05/08/26, showed: - At 6:15 PM, she was a nine-year-old admitted to the hospital for escalated behavioral outbursts. - On 05/20/26 at 4:02 PM, she was placed in seclusion. - At 4:05 PM, an order for seclusion, physical restraint and chemical restraint (a form of medical restraint in which a drug is used to restrict the freedom or movement of a patient) was placed by an RN. - At 4:15 PM, she was released from seclusion. - At 5:11 PM, the order was discontinued. The order was never authenticated by a physician. - On 05/21/26 at 4:38 PM, she was placed in a manual hold that was immediately released. She was then placed in seclusion. - At 4:40 PM, she received a chemical restraint. - At 5:00 PM, she was released from seclusion. - On 05/22/26 at 8:46 AM, an order for seclusion, physical restraint and chemical restraint was placed by an RN. - At 10:25 AM, the order was discontinued. The order was never authenticated by a physician. Review of Patient #15’s medical record, dated 05/20/26, showed: - At 2:52 PM, she was a 13-year-old admitted to the hospital for suicidal ideation (SI, thoughts of causing one’s own death). - On 05/21/26 at 4:37 PM, she was placed in a manual hold. - At 4:38 PM, she was placed in seclusion. - At 4:45 PM, she received a chemical restraint. - At 4:50 PM, she was released from the manual hold. - At 5:15 PM, she was released from seclusion. - On 05/22/26 at 8:22 AM, an order for seclusion, physical restraint and chemical restraint was placed by an RN. - At 8:24 AM, the order was discontinued. The order was never authenticated by a physician. During an interview on 05/28/26 at 12:33 PM, Staff T, Chief Executive Officer (CEO), and Staff D, Quality Management Director, stated that they expected staff to obtain an order for restraints and seclusion. If the order was obtained from a physician but placed by an RN, the order should be authenticated within 24 hours. The restraint orders should not have been discontinued.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 50321 Based on interview, record review and policy review, the hospital failed to ensure a one-hour face-to-face assessment was completed within one hour of restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) initiation for three current patients (#8, #14 and #15) of four patient records reviewed. Findings included: Review of the hospital’s policy titled, “Restraint,” dated 04/2020, showed a practitioner or trained nurse should conduct an in-person evaluation of the patient within one hour of initiation of restraint to assess physical and psychological status. Review of Patient #8’s medical record, dated 05/08/26, showed: - At 6:15 PM, she was a nine-year-old admitted to the hospital for escalated behavioral outbursts. - On 05/20/26 at 4:50 PM, she was placed in a restraint. - A face-to-face assessment was completed; however, a time was not recorded. Review of Patient #14’s medical record, dated 05/23/26, showed: - At 12:30 PM, she was a 39-year-old admitted to the hospital after a suicide (to cause one’s own death) attempt via overdose. - At 1:00 PM, she was placed in a restraint. - A face-to-face assessment was completed; however, a time was not recorded. - On 05/25/26 at 3:27 PM, she was placed in a restraint. - At 7:00 PM, a face-to-face assessment was completed, three hours and 33 minutes after the restraint was initiated. Review of Patient #15’s medical record, dated 05/20/26, showed: - At 2:52 PM, she was a 13-year-old admitted to the hospital for suicidal ideation (SI, thoughts of causing one’s own death). - On 05/23/26 at 1:58 PM, she was placed in a restraint. - At 3:15 PM, a one-hour face-to-face assessment was completed, one hour and 17 minutes after the restraint was initiated. During an interview on 05/28/26 at 12:33 PM, Staff T, Chief Executive Officer (CEO), and Staff D, Quality Management Director, stated that they expected the one-hour face-to-face assessment to be completed within one hour of restraint initiation.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 41865 Based on interview, record review and policy review, the hospital failed to provide care in a safe setting when the hospital failed to: - Ensure a thorough investigation was performed following reports of allegations of abuse and neglect for three discharged patients (#3, #7 and #8) of four abuse and neglect allegations reviewed. (A-0145) - Provide education to staff following incidents involving abuse and neglect for four discharged patients (#3, #7 and #8) of four incidents reviewed. (A-0145) - Follow their policy when they did not contact patient’s legal guardians (a person appointed to take care of and manage the rights of a person who is considered incapable) when informed consent was required, for three discharged patients (#7, #28 and #29) of three discharged patients reviewed. (A-0131) These failed practices resulted in the noncompliance with 42 CFR 482.13 Condition of Participation: Patient’s Rights. Please refer to A-0131 and A-0145.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 50151 Based on interview, record review and policy review, the hospital failed to follow their policy when they did not contact the parent/legal guardian (a person appointed to take care of and manage the right of a person who is considered incapable) for three patients (#7, #28 and #29) to obtain consent for new medications, to provide medical information related to an injuries and/or to inform them of potential abuse. Findings included: Review of the hospital’s undated document titled, “Statement of Patient Rights,” showed the patient and/or legal guardian had the right to be informed of general information pertaining to services received by the patient. Review of the hospital’s policy titled, “Informed Consent, Medications,” dated 04/2020, showed the ordering practitioner would discuss prescribed medications with the legal guardian. Review of the hospital’s document titled, “Rules and Regulations of the Medical Staff of Centerpointe Hospital Columbia,” reviewed 03/06/2025, showed practitioners should discuss the indications for and the side effects of taking or not taking prescribed medications with the patients and their families, and document the discussion in the medical record. In the event of an emergency, an informed consent does not have to be signed for a medication to be administered to prevent the patient from harming themselves or others. Once the emergency is over, informed consent was obtained. Review of the hospital’s undated document titled, “Education: Potential Injury,” showed in the event of a probable or actual patient injury, staff were to notify the patient’s guardian. Review of the hospital’s policy titled, “Abuse and Neglect,” dated 04/2020, showed the RN will notify the designated family contact and/or legal representative of any patient who was abused. Review of Patient #7’s medical record showed: - On 01/11/25, a 16-year-old adolescent male was admitted for disruptive mood dysregulation disorder (DMDD, condition of extreme irritability, anger, and frequent, intense temper outbursts). - His father was listed as the legal guardian. - On 01/13/25, from 3:20 PM through 3:25 PM, he was placed in a manual hold initiated by Staff L, BHA, after he slapped the BHA and “called him a bitch.” - At 5:59 PM, a nursing assessment documentation indicated that Patient #7 was verbally and physically aggressive. He called a staff member a “bitch” and slapped the staff member in the face. Patient #7 was immediately placed in a physical hold. Upon release he was given oral medication at the direction of the provider. A physical assessment post hold identified that he had sustained a bloody lip during the event. Patient #7 indicated that he bit his lip during the hold. - At 6:25 PM, the patient’s father was notified of the manual hold and the injury to the patient’s lip. - At 6:29 PM, during the post restraint patient debriefing, Patient #7 indicated the precipitating event for his outburst was that Staff L had been antagonizing him. - The documentation did not indicate that Patient #7’s father had been informed of any potential abuse or harassment that he may have endured leading up to, or during, the manual hold. Review of the hospital’s document titled, “Grievance Log,” dated 08/2024 to 03/2025, showed on 01/13/25, Patient #7’s father called and filed a complaint. He stated the patient was in an altercation with a staff member and his lip was busted. The father reported that he was not made aware of any potential assault related to the incident that occurred on 01/13/25. Review of Patient #28’s medical record showed: - On 02/28/25, a 15-year-old male was admitted for Major Depressive Disorder (MDD, a mental health condition that causes persistently low mood and loss of interest in activities that once brought joy). - On 03/03/25, he was involved in an altercation with another patient. As a result, a medication order for a new intramuscular (IM, within the muscle) psychotropic (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thought, feeling or behavior) medication, was obtained. - No consent documentation indicating that a parent/guardian had consented to the administration of the psychotropic medication was found. Review of the hospital’s document titled, “Grievance 11032025,” dated 03/10/25, showed Patient #28’s guardian filed a grievance with the hospital due to the patient receiving a medication without their informed consent. The hospital determined that informed consent should have been obtained from his guardian, prior to the administration of the medication. Review of Patient #29’s medical record showed: - On 02/28/25, a 14-year-old female was admitted for MDD. - On 03/06/25, an influenza (highly contagious condition affecting the respiratory system) vaccine was administered to Patient #29. - No consent documentation indicating that a parent/guardian had consented to the vaccination was found. During an interview on 03/18/25 at 1:30 PM, Staff T, Patient Advocate, stated that the hospital substantiated that Patient #28 and #29 received medications prior to obtaining informed consent from the patient’s guardian. During an interview on 3/18/25 at 2:00 PM, Staff V, Case Manager (CM), stated that nurses were responsible for notifying guardians about medication changes. It was her understanding, if a blanket consent was signed that the guardian was agreeable to everything and was not to be bothered. During an interview on 3/18/25 at 2:05 PM, Staff W, Clinical Services Director, stated that: - She expected guardians to be contacted as quickly as possible after admission and again prior to discharge, at minimum, regardless of a blanket consent. - Nurses were responsible for notifying guardians of medication changes. - If a guardian was unable to be reached at time of discharge, the patient’s discharge would be delayed until contact was made. During an interview on 03/19/25 at 12:30 PM, Staff B, CNO, stated he found it acceptable for staff to use a blanket consent, notated by typing a period in the medication list section of the Medication Consent Form, for all medication changes. This would indicate that the parent/guardian was agreeable to all medications. His expectation was that parents/guardians be contacted, by admission staff at the time of admission, by the nurse or provider with every medication change, unless the blanket consent was signed. Then contact for medications was not necessary. Social workers should be in contact with parents/guardians daily and within 24-48 hours of a patient’s discharge. Parents/guardians would be notified as soon as possible after an adolescent patient was placed in a manual hold or if the patient was injured during a manual hold. He expected staff to follow the abuse and neglect policy and to inform parents/guardians if any type of abuse towards the patient was suspected. During an interview on 03/18/25 at 12:16 PM, Staff C, Quality Director, stated that a blanket consent was not to be used as a consent for all medications. It was consent for the general knowledge that psychotropic medications were commonly used at the facility. 50496 51509”

“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: 41865 Based on interview, record review, and policy review, the hospital failed to ensure patients were free from all forms of abuse and neglect when the hospital failed to perform thorough investigations and provide staff education related to incident reports with allegations of abuse. Findings included: Review of the hospital’s policy titled, “Abuse and Neglect,” dated 04/2020, showed: - Staff who witness or suspect a patient has been abused, either physical or verbally, will report such abuse to the Administrator on Call (AOC), Nursing Supervisor, Risk Management Director and the Chief Nursing Officer (CNO) immediately. - Any involved staff member shall be notified of the allegation and suspended from duty, pending results of the investigation. If the staff member is working at the time of the allegation of abuse, the department head will assign replacement staff as necessary to complete the shift. - The RN will complete a nursing assessment of the patient who was abused to evaluate the patient’s physical and mental condition to determine what further medical evaluation the patient may need. - The RN will notify the designated family contact and/or legal representative of the patient who was abused. - The medical record shall include documentation of examinations, treatment given and any referrals made to other care providers. - Reports of abuse which occur while the patient is hospitalized will be thoroughly investigated by the Risk Manager or other staff as assigned by the Chief Executive Officer (CEO). Review of the hospital’s policy titled, “Patient Abuse and Neglect,” dated 09/01/15, showed: - No patient is to be mistreated or abused physically, verbally, psychologically or sexually while in the hospital’s care. Any employee who is found guilty of mistreating, abusing or neglecting a patient will be subject to disciplinary action, up to and including, termination. - Patient abuse is strictly prohibited and will not be tolerated. Examples of patient abuse include but are not limited to striking a patient; using excessive force in restraining a patient; rough handling of the patient; teasing, taunting or ridiculing a patient; speaking inappropriately with a patient and threatening a patient. - All instances of witnessed or alleged patient abuse or neglect must be immediately reported to the Risk Manager, a department head or supervisor. - Failure to report witnessed patient abuse may result in disciplinary action up to and including termination. Review of the hospital’s undated document titled, “Incident Reporting Policy,” dated 01/01/22, showed any hospital staff member who witnessed, discovered or had direct knowledge of an incident must complete an Incident Report before the end of the shift/workday. The Supervisor would review Incident Reports for legibility, completion and date. The RM would be notified of a serious event, and the Supervisor would take the lead in investigating non-serious incidents. Review of the hospital’s undated document titled, “Checklist of Investigation Task Suggestions,” showed: - It may not be necessary, nor applicable, to do everything listed on the checklist, it would depend on the type of incident and or other factors. - Confirm that the patient’s needs are being attended to. - Follow up with the medical/surgical hospital, family, etc. regarding the patient’s condition or well-being. - Interview all involved, or necessary parties, and complete Witness Statements as needed. - Discuss incident with physician/practitioner. - Gather applicable policies for review to determine if protocol has been followed and if policy or procedure revision may be warranted. -Consider what investigative documentation might be requested for review/copy by an outside organization and prepare for response. Review of Patient #8’s medical record showed: - On 01/15/25, a 44-year-old female was admitted on a 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) after she overdosed on prescribed medication. - On 01/19/25 at 9:36 AM, nursing documentation indicated that her behavior, affect and mood were within normal limits. She was alert and oriented to person, place, time and situation. She reported feeling “very good.” - On 01/20/25, she reported to the house supervisor that on 01/19/25, at approximately 1:00 PM, she was inappropriately touched by a male Behavioral Health Assistant (BHA), who placed his hand down her pants and inserted his fingers into her vagina. A police report was filed, and she agreed to be transferred to a nearby hospital to be assessed by a sexual assault nurse examiner (SANE, a registered nurse or nurse practitioner who has completed specialized training to assist sexual assault victims and collect all forensic evidence and perform exams). Review of the hospital’s untitled, undated, investigation document, showed: - On 01/20/25, Patient #8 reported that on 01/19/25, Staff MM, BHA, sexually assaulted her by digital penetration. - The allegation was communicated to hospital leadership and Staff MM was suspended, pending the investigation. - Staff EE, Risk Management Director, interviewed Staff MM. Staff MM denied the event had occurred but resigned following the interview. - The hospital was unable to substantiate or unsubstantiate the allegation, due to the pending SANE examination. - Statements from Patient #8 and Staff MM were obtained, no additional staff or possible witnesses were interviewed. - No education was provided to staff after this incident. Review of Patient #7’s medical record showed: - On 01/11/25, a 16-year-old male was admitted for disruptive mood dysregulation disorder (DMDD, condition of extreme irritability, anger). - On 01/13/25 at 3:20 PM, Patient #7 hit a staff member after becoming agitated and angry. A manual hold was initiated by Staff L, BHA, and assisted by Staff M, BHA, and Staff N, BHA. - At 5:59 PM, Staff P, RN, wrote in the shift assessment that the patient was verbally/physically aggressive. Called a staff member a “bitch” and slapped him in the face. Patient #7 was put into a manual hold and released. After the hold, the patient indicated that he had a bloody lip, He stated he bit his lip during the hold. - At 6:25 PM, Staff P, RN, documented the patient’s injury and notified his parent of the event. - At 6:31 PM, the patient reported that he was not treated in a caring manner or with respect for his privacy and dignity. The staff member antagonized him. - No documentation in the medical record was found regarding the immediate notification to the provider, house supervisor or unit manager regarding the injury incurred during the hold. Review of the hospital’s undated, untitled, self-reported document showed: - On 01/13/25, Patient #7’s father contacted Staff T, Patient Advocate, with concerns that Staff L, BHA, potentially used inappropriate, antagonistic language towards the patient and may have been responsible for the patient biting his lip during a manual hold. Staff T immediately notified leadership and Staff L was suspended pending investigation. - Staff L, BHA, reported he responded to a radio-call for assistance in the gym, because the patient was cussing at the staff and calling them bitches. Staff L asked the patient to stop, but the cussing and name calling continued when they returned to the unit from the gym. Staff L asked Patient #7 to distance himself from another patient. He alleged that Patient #7 continued to escalate, called another staff member a bitch and continued to curse. - Staff K, RN, reported witnessing Staff L talking with Patient #7 and felt Staff L was “not in control of himself.” Staff K stepped in between the patient and Staff L to separate them. Staff L’s body language matched that of “posturing” and his speech was “taunting.” Staff K told the patient and Staff L “that’s enough” and Staff L walked away from patient, into the dayroom. Staff K, RN, debriefed with the patient and felt that the situation had deflated. It was change of shift and he did not remove Staff L from the unit. - Staff L stated that when he exited the dayroom, Patient #7 approached him asking for his phone number so they could meet up outside of the hospital to fight. Staff L engaged with the patient and the patient proceeded to call him a bitch and slap him. Staff L initiated a manual hold with assistance from Staff M, BHA, and Staff N, BHA. - During post hold debriefing, Patient #7 reported that after the manual hold, Staff L was behind him and told him “if we were outta here I would probably kill yo ass lil kid” or “if we were outta here I’m gonna kill you you stupid little bitch.” Patient #7 admitted asking Staff L for his phone number with the intention to fight him. He described Staff L’s composure as “puffed out” when speaking to him and he felt cornered. - Staff L, BHA, and Staff M, BHA, denied any knowledge of an injury to Patient #7, they did not see any blood coming from patient or his mouth. - Staff N, BHA, witnessed Patient #7 spitting up some blood, a small amount of blood ended up on a pair of white shoes he was wearing at the time. He indicated the patient may have felt cornered, or threatened, while in the corner of the dayroom prior to striking Staff L. Staff L was posturing towards the patient. It looked like “tough guy versus tough guy.” - The hospital determined that Staff L postured towards the patient, disengaged the manual hold without a nurse present and continued to non-therapeutically engage with the patient. He was terminated for gross misconduct. - After the abuse allegation was substantiated, no staff education was completed related to Abuse and Neglect. Review of Patient #3’s medical record showed: - On 01/07/25, a 15-year-old female was admitted for suicidal/suicidal ideation (SI, thoughts of causing one’s own death) and self-injurious behavior after cutting her thighs and arms. - Her admission assessment indicated two separate sutures to her left arm after cutting herself with a pencil sharpener blade. - Admission orders included line of sight (LOS, continuous visual contact with the patient) observation and to keep a dressing over her stitches due to her to picking at them. Review of the hospital’s undated, untitled, self-reported document showed: - On 01/15/25, Staff R, BHA, neglected to remain with Patient #3 during a 1:1 observation while the patient was in the bathroom. Patient #3 was able to dig at and exacerbate her self-harm wound. Staff R was suspended pending an investigation. - Staff R, BHA, admitted that she sat outside the bathroom while keeping an eye on the patient’s feet from underneath the magnetic bathroom door, but did not enter. - During a telephone interview Staff R detailed that Patient #3 had been in a group during hygiene time. So, she accompanied Patient #3 to the bathroom and stood outside the door. When asked if the patient was left alone at any point, Staff R stated no. She remembered the patient came out of the bathroom without the bandage that had been on her arm. She asked Patient #3 why she removed the bandage and was told that she “wanted to take it off” and that she was “getting my bandage changed anyway.” Staff R informed the patient that she was not to take the bandage off herself. She was to present at the nurse’s station and a nurse would remove it for her. - Patient #3 was assessed by nursing staff and did not require any outside medical treatment. - Staff R was terminated from her position. - No education was provided to staff after this incident. During a telephone interview on 03/19/25 at 10:10 AM, Staff EE, Risk Management Director, stated that when an incident occurred, all staff working on the unit the day the incident occurred would be interviewed or asked to provide a witness statement. After Patient #8’s incident which occurred on 01/20/25, the patient and Staff MM, BHA, were interviewed. She attempted to contact Patient #8’s roommate but was unable to get in contact with her. No other staff or patients were interviewed. The hospital unable to determine if Patient #8’s allegation of sexual assault occurred. A SANE examination was pending. She became aware of the event regarding Patient #7 the day after his father contacted Staff T, Patient Advocate. She expected staff to follow policy and immediately report employees who displayed antagonistic behavior, used inappropriate language with a patient or if a patient sustained an injury during a hold. They should fill out an incident report. Staff should also report inappropriate handling of a patient by a staff member during a physical hold. Staff who found themselves escalated in a situation should remove themselves, or if they are asked by other staff members to remove themselves, they should follow policy and remove themselves immediately. They should not continue to engage with the patient. Once an investigation has been initiated, the process takes about two weeks to complete. Interviews need to be completed, along with employee retraining. All abuse and neglect events should be investigated. The hospital does not have a specific policy regarding the investigation process, but they can refer to an investigation task checklist. Appropriate education should be provided to all staff members after incidents have been reported, investigated and substantiated. During an interview on 03/19/24 at 12:16 PM, Staff B, CNO, stated that he expected the staff to follow the abuse and neglect policy. Staff who witnessed alleged abuse should immediately report it. Staff who were involved in an incident were expected to complete an incident report and report any injuries a patient may have incurred. For abuse or neglect allegations related to a staff member, he expected that staff member to be immediately removed from patient care. He expected every staff member who was present when an incident occurred to be interviewed. During an interview on 03/19/25 at 9:10 AM, Staff A, CEO, stated that the retraining of all staff was not completed for every incident. Staff members involved in incidents would receive education. The hospital receives incident reports daily and it would be unrealistic for the hospital to educate all staff members after every report. Town hall meetings were completed monthly and would include education regarding abuse and neglect. All staff members participate in mandatory quarterly hands-on abuse and neglect training. 50151 50496 51292”

“DISCHARGE PLANNING-EVALUATION CFR(s): §482.43(a)(2) Standard: Discharge Planning Evaluation (2)A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-hospital services, including, but not limited to hospice care services, post-hospital extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services. This Standard is not met as evidenced by: 49489 Based on interviews, record review and policy review the hospital failed to provide a discharge plan that ensured safe, appropriate arrangements for post-hospital care for one patient (#11) out of five patients reviewed. This failed practice had the potential to cause poor health outcomes for all discharged patients. Findings included: Review of the hospital’s policy titled, “Discharge Planning,” dated 04/2020, showed all patients would have a discharge plan developed and implemented prior to their discharge. The discharge plan would include timely and direct communication with, and transfer of, information to other programs, agencies, or individuals that would be providing ongoing care. Discharge needs to be considered included: aftercare services and arrangements; family relationships; physical and psychiatric needs; housing needs and/or placement issues; accessibility to community resources; personal support systems; and transportation problems related to aftercare treatment. Components of the discharge care plan included: where the patient would live following discharge; with whom they would live and in what circumstances; the level of care which the patient would be discharged such as intensive, outpatient, or residential etc.; referrals to self-help groups; support groups or other community resources. Review of the hospital’s policy titled, “Discharge Criteria,” dated 10/2020, showed patients were ready for discharge if they met the following criteria: reduction of life-threatening or endangering symptoms to within safe limits; ability to meet basic life and health needs; adequate post-discharge living arrangements; and constant or close observation were no longer required. Review of Patient #11’s medical record showed: - On 08/08/24, she was admitted for suicidal ideation (SI, thoughts of causing one’s own death) related to her living condition. She had a plan to overdose on pills or hang herself. - Her past medical history included depression, anxiety, asthma (a chronic lung disease which makes breathing difficult), bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows), schizophrenia (serious mental disorder that affects a person’s ability to think, feel, and behave clearly), substance abuse (a complex condition where there is uncontrolled use of a substance despite harmful consequence), a seizure disorder (sudden, uncontrolled electrical disturbance in the brain which cause changes in behavior, movements and/or in levels of consciousness), and intellectual disability (below average intellectual functioning which limits the ability to learn at an expected level and limits level of function in daily life). - She had been noncompliant with her home medications for several days prior to her admission. - Staff DD, Social Worker (SW), met with the patient who expressed a desire to discharge to a residential care facility (RCF, a nonmedical facility that provides a home-like environment for individuals who are unable to live independently, but do not require 24-hour nursing care). - Staff DD’s documentation indicated she had pursued local psychiatric (pertaining to mental illness) treatment resources and sent referrals to various treatment programs. - On 08/14/24, Staff DD documented the patient was calling out of state treatment programs but then two nurses informed her that the patient no longer wanted to go to a treatment program. Staff DD reinforced that a treatment program would be best due to her history of substance abuse. Patient #11 expressed a desire to go to West Plains, Missouri. Staff DD documented that she arranged for the patient to go to Catholic Charities for housing and then she could attend her appointment at an outpatient treatment center the following week. - On 08/15/25, discharge documentation indicated Patient #11 was discharged to the outpatient treatment center. Her medications were called-in to a pharmacy in Van Buren, MO. - Follow-up treatment for addiction was scheduled with the outpatient treatment center on 08/20/24. During an interview on 03/19/25 at 11:10 AM, Staff DD, SW, stated that she remembered Patient #11. She needed a treatment center but did not want to go anywhere near her family members. Patient #11 specifically asked to go to West Plains, Missouri without explaining why or if she had any contacts in that area. Staff DD was unaware of that city until Patient #11 asked about it. She was able to arrange an appointment with an outpatient treatment center for 08/20/25. The outpatient treatment center advised her that when Patient #11 arrived at her outpatient appointment, they would be able to transfer her to an inpatient bed. Staff DD had to figure out where Patient #11 could stay after discharge until her appointment. She contacted Catholic Charities and they agreed to assist with finding temporary housing for the patient until her appointment. Staff DD stated that she failed to document these conversations and arrangements. At the time, she was still very new to her job and had not been adequately trained. She felt pressured to arrange discharges immediately when the physician said the patient was ready so they could open beds faster. She didn’t realize at that time that she could advocate to delay discharge to allow her to make safer arrangements. During an interview on 03/19/25 at 9:25 AM, Staff CC, Psychiatrist, stated that Patient #11 needed an RCF because of her intellectual disability and history of substance abuse. She was unlikely to be safe in a setting where she could walk out at any time. During an interview on 03/18/25 at 3:00 PM, Staff X, Chief Operating Officer, Hospital B, stated that she was formerly employed at Centerpointe Columbia, and often managed concerns related to discharge planning. She did not recall being involved with the concerns the complainant raised about Patient #11. She stated that Catholic Charities would occasionally be contacted regarding a patient’s discharge plan to assist with utilities, but they would never be used for housing or shelter needs.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48359 Based on observation, interview and policy review the hospital failed to: - Follow their policy for the investigation of abuse and neglect and perform a timely and thorough investigation to accurately determine whether abuse had occurred for one current patient (#6) and one discharged patient (#12) of three allegations of abuse reviewed. (A-0145) - Immediately remove two staff members from patient care after allegations of abuse were reported for one current patient (#6) and one discharged patient (#31) of three allegations of abuse reviewed. (A-0145) - Ensure linen cabinets were locked and secure from patient access. (A-0144) - Ensure all personal hygiene items were locked and secure from patient access. (A-0144) - Ensure a metal door-jam frame lock was secured. (A-0144) - Ensure a fire extinguisher was attached to the wall and secure from patient access. (A-0144) - Ensure physician orders were followed for every five-minute rounding for one current patient (#24) of one patient reviewed. (A-0144) - Ensure a unit specific orientation was completed for four staff members (M, N, BB and UU) of seven staff members reviewed. (A-0144) These failed practices resulted in the noncompliance with 42 CFR 482.13 Condition of Participation: Patient’s Rights. Please refer to A-0144 and A-0145”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 39354 Based on observation, interview, record review and policy review, the hospital failed to: - Ensure linen cabinets, that contained items of contraband (items that are illegal, forbidden, or that can be used to harm self or others), were locked and secure from patient access on three of three units observed. - Ensure contraband items were monitored and accounted for on one unit of three units observed. - Ensure a 10-pound fire extinguisher was secured from patient access, on one of three units observed. - Ensure a metal door-jam frame lock was secured on one unit of three units observed. - Ensure physician ordered, every five-minute checks were completed on one patient (#24) of five patients reviewed. - Ensure unit specific orientation was completed for four staff members (M, N, BB and UU) of seven staff members reviewed. Findings included: Review of the hospital’s policy titled, “Rights and Responsibilities of Individuals, Contraband,” dated 04/2020, showed staff will consider any item deemed to be unsafe to be contraband. Review of the hospital’s document titled, “Adult Unit Guidelines,” dated 02/2019, showed patients were informed: “personal hygiene-the locked cabinet with your belongings will be unlocked with staff supervision only. Personal hygiene, including showering, shampooing and cleaning teeth are expected to be completed at this time. Erasers or pencils with erasers are not allowed on the unit. The staff reserves the right to deny any item not on this list if it jeopardizes safety.” Review of the undated hospital document titled, “Contraband Guide,” showed general items not allowed were items with strings or straps, any items with metal or glass, sharp objects, alcohol, drugs, medication or paraphernalia, plastic bags, or chemicals. Review of the hospital’s policy titled, “Provision of care, treatment and services: observations, patient,” dated 04/2020, showed the following: - To maintain patient health and safety, the hospital staff encourage patients to practice daily safety and documented routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the Registered Nurse (RN). - Level of observation can be increased by the RN any time there was a concern but only a psychiatric (relating to mental illness) practitioner may decrease the level. - The psychiatric practitioner will order one of three levels of observation at the time of admission and as the patient’s condition warranted a change: Every 15-minute checks, every five-minute checks or one to one (1:1, continuous visual contact with close physical proximity). - The psychiatric practitioner may also order a precaution level of observation for suicide (to cause one’s own death). - Every 15-minute checks: all patients are monitored at minimum once every 15-minute block of time. - Every 5-minute checks: patients are placed on every 5-minute checks if their behavior was unpredictable and there was potential risk for harm to self or others, yet the behavior was not at the point requiring constant 1:1 observation. Review of the hospital’s policy titled, “Safety management, environmental risk assessment,” dated 04/2018, showed it was the hospital’s policy to conduct a risk assessment of the physical environment to evaluate hazards and develop protective measures associated with various tasks performed in each area within the hospital. The “pro-active risk assessment” was used to evaluate the risks in the environment of care and establish the appropriate controls or measures to limit the impact on the ability of the organization to perform clinical and business activities. Review of the hospital document titled “Pro-Active risk assessment,” dated 07/20/24 through 07/25/24, showed no documentation of locked cabinets, secured fire extinguishers, metal door-jam closures or personal hygiene items. Review of the hospital document titled “Behavioral Health Assistant (BHA) environmental rounds,” dated 04/08/24 through 04/16/24, showed no shift documentation of checks for locked cabinets, secured fire extinguishers, metal door-jam closures or personal hygiene items for all three units (adolescent, adult, and silver linings [geriatric unit]). Review of the hospital’s policy titled, “Suicide Precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm),” dated 04/2020, showed the psychiatric practitioner shall order observation and precautions consistent with the assessed level of risk. Suicide risk, level of observation and/or placement on SP will be communicated to all staff. SP may include removing items that are the focus of self-harm or plan for suicide, limit linens and belongings and increased contraband checks. Review of the hospital’s document titled, “Incident Report Form,” dated 02/06/24, showed on 02/06/24 at 6:35 PM, Patient #20 reported to staff that she felt suicidal and swallowed two pencils. Review of the hospital’s document titled, “Incident Investigation Report,” dated 02/08/24, showed: - Patient #20 reported to staff she felt suicidal and swallowed two pencils. The patient obtained them when she used a pencil to fill out menus for the kitchen. She was transferred to Hospital B for evaluation and treatment. - Patient #20’s history included multiple hospitalizations for ingestion of foreign bodies and pica (compulsive eating of material that may or may not be food). - During a previous admission to Centerpointe Hospital of Columbia she swallowed a battery and was sent to an outside hospital for treatment. - At Hospital B an esophagogastroduodenoscopy (EGD, procedure in which a thin scope with a light and camera at its tip is used to look inside the organs of the upper digestive tract) was completed and six pencils were removed from the patient. - Corrective action included continuation of re-iterating the importance of the patient form when presenting patients to physicians discussed with the intake department. Review of Patient #20’s medical record dated 02/05/24 through 02/06/24, showed: - She was a 29-year-old female, transferred from an outside medical facility on 02/05/24 at 1:04 PM, for depression and suicidal ideation (SI). - She had a past medical history of several abdominal surgeries due to foreign body ingestion. - Safety precautions included every 5-minute checks throughout her hospitalization. - Physician documentation on 02/06/24, showed Patient #20 was transferred by ambulance to a medical facility after she swallowed two pencils. Observation on 04/17/24 at 10:30 AM, on the Adult 2 Unit, showed Patient #27 was in the hallway with one pencil in his possession. Patient #13 was in the hallway, standing on his hands, with his feet propped against a door and two pencils in his possession. Observation with concurrent interview on 04/17/24 at 10:25 AM, on the Adult 2 Unit, showed no pencils were signed out for use by patients on 04/17/24. Staff OO, BHA, stated that staff were to make sure patients given a pencil were written on the sign out sheet daily. When the pencils were returned their names were to be marked on the list. The sheet was used to track the pencils so staff could ensure all were accounted for. Review of Patient #13’s medical record showed: - He was a 28-year-old male, admitted on 03/23/24 for hearing voices and seeing things that were not there. - Upon his admission he reported hearing voices that told him to rape, molest and hurt others. - On 04/17/24 safety precautions included every 15-minute checks. Review of Patient #27’s medical record showed: - He was a 62-year-old male, admitted on 03/31/24 for increased confusion and aggression. - At his residential facility he made several threats to harm staff and had been aggressive toward other patients and staff. During his transfer he made homicidal (thoughts or attempts to cause another’s death) threats towards transport staff. - On 04/17/24 safety precautions included every 5-minute checks and assault precautions (AP, measures to alert staff of a patient’s potential to become violent with others). Observation with concurrent interview on 04/15/24 at 2:20 PM, on the Adolescent Inpatient Unit, showed one unlocked cabinet containing multiple items of contraband that included two full sized bottles of shampoo and conditioner, five towels and paper cups with liquid in them. Staff C, Unit Manager, stated that the cabinet containing contraband items should have been locked and not accessible to patients. Observation on 04/15/24 at 2:20 PM, on the Adult 1 Unit, showed an unlocked cabinet contained two small shampoo bottles, two small lotion bottles, four hand towels, and two personal clothing items. Observation on 04/15/24 at 2:25 PM, on the Adult 2 Unit, showed an unlocked, patient hallway cabinet, that contained six small bottles of hair conditioner, four small bottles of shampoo, two small bottles of mouth wash, one toothbrush, one small tube of toothpaste, one container of deodorant, four wash cloths, and four towels. Observation on 04/16/24 at 9:00 AM, on the Adult 2 Unit hallway, showed an unlocked patient cabinet by patient room 407, that contained one pillow, towels, sheets, and an unsecured fire extinguisher. Observation on 04/16/24 at 9:03 AM, on the Adult 2 Unit, showed the door-jam frame lock was not secured for patient room 400. The frame lock could be pulled down, leaving a three-inch-long by two-inch-wide piece of metal exposed. Observation on 04/16/24 at 9:13 AM, on the Adult 2 Unit, showed on the bathroom counter in patient room 305, a container of deodorant, a small bottle of mouth wash, a small bottle of hair conditioner and a small bottle of shampoo. During an interview on 04/15/24 at 2:20 PM, Staff H, RN, stated that cabinet doors were to stay locked at all times. During an interview on 04/15/24 at 2:27 PM, Staff I, RN Nurse Manager, stated that all hallway cabinets were to be locked. They were unlocked for shower time only and were not to be left open. During an interview on 04/16/24 at 9:02 AM, Staff I, stated that she did not know how long the patient hallway cabinet had been unlocked. The cabinets were checked the previous week and they were locked at that time. Review of Patient #24’s medical record from 04/12/24 through 04/16/24 showed: - He was a 52-year-old male, alert and oriented times four (A&O x 4, a person is oriented to person, place, time and situation), admitted on 04/12/24 with SI and a plan to jump off of a bridge. - He had a history of depression (extreme sadness that doesn’t go away). - His 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), dated 04/12/24 showed, he had current suicidal thoughts with a specific plan and was determined to be a high suicidal risk. - Physician orders, dated 04/12/24, showed the patient was placed on SP, and every five-minute checks through 04/16/24, when he was placed on every 15-minute checks. - Patient observation report documentation dated 04/12/24 through 04/16/24, showed the patient was on every five-minute checks from 04/12/24 at 6:55 PM through 04/13/24 at 11:44 AM. There was no every five-minute documentation for two days, 11 hours, and 45 minutes before the physician order changed from every five-minute checks to every 15-minute checks. During an interview on 04/16/24 at 1:33 PM and 04/18/24 at 8:35 AM, Staff B, Director of Quality Management (DQM), stated that there were no physician orders for Patient #24 to be changed from every five-minute checks to every 15 minute checks and the patient should have stayed on every five minute checks until an order to change was received. The hallway cabinets were always to be locked. Patients should not have access to the fire extinguisher. The fire extinguisher should be secured and locked unless needed. The fire extinguisher was considered a security risk. Personal hygiene items should not be left in patient rooms. Room checks were completed every shift. She expected the door-jam frame lock to always be secured, as it was a ligature risk. If a patient had an order for every five-minute checks, the patient remained on every five-minute checks until an order was received for every 15-minute checks. A high-risk suicide patient on the floor with unlocked cabinets and an unsecured fire extinguisher placed patients at risk of harm. During an interview on 04/16/24 at 4:11 PM, Staff QQ, BHA, stated that when a patient was on five-minute checks, they were to stay on five-minute checks until an order was received to change to every 15-minute checks. The hallway cabinets were to be locked at all times. If personal hygiene items were found in a patient room, they were to be taken out and locked up. Room checks were done every shift. During an interview on 04/16/24 at 4:34 PM, Staff RR, RN, stated that when a patient was on five-minute checks, they should have stayed on five-minute checks until an order was received to change to every 15-minute checks. If a high suicide patient was on every five-minute checks, they should have stayed on every five-minute checks until an order to change was received. The hallway cabinets were to be locked at all times. Linens were not to be in the cabinet with the fire extinguisher. She expected the fire extinguisher cabinet and the linens cabinet to be locked at all times. She expected the metal door-jam frame to be secured. The fire extinguisher and the metal door-jam frame lock could have been used as a weapon. During an interview on 04/16/24 at 4:45 PM, Staff SS, RN, stated that when a patient was on five-minute checks, they were to stay on five-minute checks until an order was received to change to every 15-minute checks. If a high suicide patient was on every five-minute checks, they were to stay on every five-minute checks until an order to change it was received. The hallway cabinets were to always be locked. Linens were not supposed to be in the cabinet with the fire extinguisher. She expected the fire extinguisher cabinet, and the linens cabinet were to always be locked. She expected the metal door-jam frame to always be secured. The fire extinguisher and the metal door-jam frame lock could have been used as a weapon. During an interview on 04/17/24 at 4:11 PM, Staff TT, BHA, stated that when a patient was on five-minute checks, they were to stay on five-minute checks until an order was received to change to every 15-minute checks. The hallway cabinets were to always be locked. If personal hygiene items were found in a patient room, they were to be taken out and locked up. Room checks were done every shift. Review of Staff BB’s, Agency RN, personnel file, showed a hire date of 01/30/24 and a termination date of 03/22/24. There was no unit specific orientation completed. Review of Staff M’s, BHA, personnel file showed a hire date of 01/30/23 with no documentation of a unit specific orientation. Review of Staff N’s, BHA, personnel file showed a hire date of 12/11/23 with no documentation of a unit specific orientation. Review of Staff UU’s, BHA, personnel file showed a hire date of 12/11/23 and a termination date of 04/11/23. There was no unit specific orientation completed. During an interview on 04/17/24 at 10:20 AM, 11:20 AM and 04/18/24 at 10:15 AM and 12:05 PM, Staff GG, CNO, stated that all staff were expected to complete a unit specific orientation. She was unaware Staff BB, did not complete a unit specific orientation. 41474 48359 49489”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 48359 Based on interview, record review and policy review, the hospital failed to follow their internal policy for investigation of abuse and neglect and perform a timely and thorough investigation to accurately determine whether abuse had occurred for one current patient (#6) and one discharged patient (#12) of three allegations of abuse reviewed. The hospital failed to immediately remove two staff members from patient care after allegations of abuse were reported for one current patient (#6) and one discharged patient (#31) of three allegations of abuse reviewed. These failed practices placed all patients admitted to the hospital at increased risk for their safety. Findings included: Review of the hospital’s policy titled, “Abuse and Neglect,” dated 04/2020 showed: - Staff who witness or suspect the patient has been abused either physical or verbally will immediately report such abuse to the Administrator on Call (AOC), Nursing Supervisor, Director of Risk Management and the Chief Nursing Officer (CNO). - The staff member shall be notified of the allegation and suspended from duty, pending results of the investigation. - If the staff member is working at the time of the allegation of abuse, the department head will assign replacement staff as necessary to complete the shift. Review of the hospital’s undated document titled, “Incident MO00233351,” showed: - On 03/17/24 at 11:00 AM, Staff CC, Licensed Practical Nurse (LPN), notified Staff DD, House Supervisor, of the abuse allegation against Staff BB, Agency Registered Nurse (RN), from Patient #6. - At 10:00 PM, 11 hours later, the abuse allegation was escalated to the Quality Management Director, Chief Executive Officer (CEO), Unit Manager and AOC. - On 03/18/24 at 10:50 AM, 23 hours and 50 minutes later, Patient #6 was interviewed. - Staff DD, House Supervisor, erroneously believed the investigation process could not proceed until an incident report was filed. Due to this, Staff BB, was not immediately sent home and the notification process was not immediately begun. Review of the hospital’s document titled, “Witness Statement,” dated 03/17/24 showed: - Staff CC, LPN, stated that Patient #6 was in the seclusion room, (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) standing by the door. - Staff BB, Agency RN, was trying to redirect the patient. The patient was tearful and yelling. - Staff BB was closing the seclusion room door and pushed Patient #6 from the doorway hard enough for her to hit the wall and fall to the ground, approximately four feet. - The patient was not physically aggressive at the time. Review of the hospitals document titled “Timesheet,” dated 03/17/24 through 03/18/24, showed on 03/17/24, Staff BB, Agency RN, worked from 6:55 AM through 7:39 PM. Review of Patient #6’s medical record showed on 02/13/24, she was a 19-year-old female on a 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) for physical aggression. Her psychiatric (relating to mental illness) diagnosis was bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows) with psychotic features (characterized by defective or lost contact with reality), rule out paranoid schizophrenia (a mental illness that involves mistaken beliefs that one or more people are plotting against them or their loved ones), rule out attention deficit/hyperactive disorder (ADHD, characterized by problems with keeping attention to one thing and impulsive behaviors) and rule out Impulse Control disorder (failure to resist an urge or temptation). During an interview on 04/17/24 at 8:35 AM, Staff B, Quality Management Director, stated that she expected Staff DD, House Supervisor, was aware of the requirement to immediately remove staff and collect witness statements. The investigation for Patient #6’s allegation of abuse began approximately 24 hours after the alleged abuse was reported. During a telephone interview on 04/16/24 at 3:43 PM, Staff DD, House Supervisor, stated that she was notified of the abuse allegation by Staff CC, LPN. Staff DD did not communicate the event to leadership, she did not remove Staff BB from patient care and she did not initiate an investigation. During an interview on 04/17/24 at 3:05 PM, Staff I, Nurse Manager, stated that she was surprised and unaware that Staff BB was not immediately removed from care and the allegation was not immediately escalated. During a telephone interview on 04/17/24 at 11:00 AM, Staff HH, Physician, stated that pushing a patient was abuse and the staff member was immediately removed from patient care. Review of the hospital’s undated document titled, “Incident MO00233321,” showed on 03/15/24 at 10:30 AM, Staff YY, Behavioral Health Aide (BHA), notified Staff ZZ, House Supervisor of an abuse allegation against Staff UU, BHA, for Patient #31. Staff UU, was not immediately removed from the schedule pending investigation. He finished his shift on 03/15/24 and part of a shift on 03/16/24 before relieved of duty pending an investigation of alleged abuse. Review of the hospitals undated, untitled document showed: - On 3/15/24, 10:00 AM, Patient #31 slammed her door and attempted to lock herself in by standing behind the door. - Staff UU, BHA, and Staff YY, BHA, wedged the door open to explain the door was not allowed closed. - The patient continued to try and close the door. - She stopped trying to close the door and she was yelling “get out.” - She attempted one more time to close the door and Staff UU gave her a five second warning to move or he would forcibly move her. - The patient did not move, Staff UU picked her up off the floor and proceeded to throw/toss her on the bed. - Afterwards, Staff UU stated, “That was aggressive, but I don’t care.” Review of the hospitals document titled “Timesheet,” dated 03/15/24 through 03/17/24, showed on 03/15/24, Staff UU, BHA, worked from 7:04 AM through 7:31 PM. On 03/16/24 Staff UU, began work at 7:08 AM. Review of Patient #31’s medical record showed on 03/02/24, she was a 25-year-old female with a history of bipolar disorder and Post-Traumatic Stress Disorder (PTSD, a condition of persistent mental and emotional stress occurring because of injury or severe psychological shock). During an interview on 04/17/24 at 3:05 PM, Staff I, Nurse Manager, stated that “Quality made the decision not to send Staff, UU, BHA, home” after the allegation of abuse against Patient #31. During an interview on 04/17/24 at 8:35 AM, Staff B, Quality Management Director, stated that she did not send Staff UU, BHA, home and was “on the wrong side of safety.” She did not want to create “staffing holes.” Staff A, CEO, corrected the situation and sent Staff UU home the following day. On 03/16/24 during the afternoon, Staff DD, House Supervisor, walked Staff UU out of the hospital pending completion of the investigation. Review of the hospital’s document titled, “Interview,” dated 04/02/24, showed: - On 04/02/24, a nursing supervisor reported a sexual assault allegation by Patient #12 to Staff Q, Patient Advocate, and Staff WW, Risk Management Director. - Patient #12 reported Patient #18 was present during the incident. - Patient #12 reported she did not know who assaulted her but there was spit on her vagina when she wiped and she asked a nurse for a rape kit. Review of the hospital’s document titled, “Interview,” dated 04/03/24, showed: - Staff N, BHA, was sitting in another hall for a one to one (1:1, continuous visual contact with close physical proximity) patient when Patient #12 yelled out she had been raped and needed a rape kit. - He stated that Patient #12 said a gentleman had gone into her room and touched her, but she did not know who. - When asked if the incident was reported to other staff or a RN, he stated that he was unsure; and he asked Staff WW, Risk Management Director, who he should report incidents like this to overnight. He was told all staff were responsible to report any incident to their supervisor. Review of the hospital’s document titled, “Interview,” dated 04/02/24, showed: - Staff VV, BHA, stated that Patient #12 reported someone touched her while she was sleeping and it smelled. - She did not see anyone go into Patient #12’s room. - She stated Patient #12 requested a rape kit from the nurse. - After Patient #12 reported the incident, she and Staff PP, BHA, reported the incident to the patient’s nurse. Review of the hospital’s document titled, “Interview,” dated 04/03/24, showed Staff PP, BHA, stated Patient #12 insisted someone had raped her and accused Staff N, BHA. She then reported the incident to the nurse and stated that Patient #12 had requested a rape kit. Review of the hospital’s undated document titled, “Incident Report,” showed: - On 03/30/24, Patient #12 reported to Staff PP, BHA, someone entered her room, she smelled a “man’s breath,” someone “came” on her and she alleged Staff N, BHA, raped her. - Staff PP, BHA, reported the alleged sexual assault to Staff P, RN. - Staff P, RN, reported the sexual assault allegation to Staff HH, Physician. - On 04/02/24, Patient #12 requested to speak with Staff Q, Patient Advocate, to report the inappropriate sexual contact. - Staff WW, Risk Management Director, notified Staff GG, CNO and Staff B, Quality Management Director, of the allegation. - On 04/02/24 Staff Z, Physician, offered to transfer Patient #12 to Facility B for a sexual assault forensic exam (SANE, a RN or nurse practitioner who has completed specialized training to assist sexual assault victims and collect all forensic evidence and perform exams), she accepted. - Patient #12, Patient #18, Staff N, BHA, and Staff PP, BHA, were interviewed, but Staff P, RN, could not be reached to interview. - Patient #12 could not directly specify who allegedly assaulted her when interviewed by Staff WW, Risk Management Director. - The allegation was ruled unsubstantiated. - Opportunities for improvement were identified as an extended lapse in time of report to Staff WW, Risk Management Director, after the initial allegation was made to the Physician and House Supervisor. Review of Patient #12’s medical record showed: - On 03/15/24, she was a 29-year-old female with schizophrenia, non-adherent to medication, had delusions (false ideas about what is taking place or who one is) she was poisoned. She exhibited flight of ideas (jumping from one topic to the next, common with mania [a period of time when a person cannot sleep for days, feels elevated and is easily distracted]), pressured speech (rapid, compulsive talking, a classic symptom of bipolar disorder) on examination, paranoia (excessive suspiciousness without adequate cause) and reported auditory hallucination (hearing things that are not heard by others, imaginary). - On 03/30/24 at 6:56 AM, Patient #12 requested a rape kit and stated she had been raped. Staff P, RN, called Staff HH, Physician, and notified Staff AA, House Supervisor. - At 4:30 PM, staff reported to Staff HH Patient #12 alleged that someone raped her, nursing was noted to be investigating. During a telephone interview on 04/16/24 at 5:00 PM, Staff HH, Physician, stated that on 03/30/24 during rounds he was informed by the nursing staff that Patient #12 had reported an allegation of sexual assault, and it appeared to be a dream or delusion. He spoke with Patient #12 in the presence of a nurse to investigate the alleged abuse. Patient #12 would not elaborate about the claim and was apprehensive. He directed nursing staff to call the medical treatment team for a recommendation. He expected nursing staff to inform him of allegations of abuse and sexual assault. He was expected to speak with patients who alleged abuse and referred to medical for guidance on needed exams. During an interview on 04/18/24 at 10:12 AM, Staff WW, Director of Risk Management, stated that on 04/02/24, she was made aware of Patient #12’s sexual assault allegation after she was asked to file a grievance. The investigation into the sexual assault allegation began on 04/02/24, three days after the abuse allegation was reported. She spoke to Staff Z, Physician, who offered a SANE on 04/02/24, but she was not aware he had also been informed of Patient #12’s sexual assault allegation on 03/30/24. She felt the investigation was a “mess” and the information she provided was “conflicting, confusing and insufficient.” During an interview on 04/16/24 at 12:28 PM, Staff Z, Physician, stated that on 03/30/24 he was consulted by a nurse about Patient #12’s allegation of sexual assault. He expected to be notified each time there was an allegation of sexual assault. During an interview on 04/18/24 at 9:49 AM, Staff XX, Physician’s Assistant (PA, a type of mid-level health care provider that can diagnose illnesses, develop and manage treatment plans, prescribe medications, and may serve as a principal healthcare provider), stated that on 03/30/24, Patient #12 reported that someone had gone into her room the night prior and inappropriately touched her. She reported this to nursing staff immediately. She offered Patient #12 a SANE, but she declined. She expected staff to inform her when a patient reported sexual assault. During a telephone interview on 04/16/24 at 1:27 PM, Staff AA, House Supervisor, stated that she did not receive a report from nursing staff that Patient #12 alleged sexual assault, only that she had been delusional and paranoid. She expected notification by staff immediately if a patient reported sexual assault. During a telephone interview on 04/16/24 at 9:14 AM, Staff P, RN, stated that she notified Staff AA, House Supervisor, and Staff HH, Physician, about Patient #12’s sexual assault allegation. If a patient reported abuse or neglect, the expectation was to notify the House Supervisor and Physician. During an interview on 04/17/24 at 10:20 AM and 11:20 AM, Staff GG, CNO, stated that she expected staff members accused of abuse were immediately sent home. She expected an investigation to begin immediately upon the report of abuse. The House Supervisor would begin interviews. She agreed the investigation of Patient #12’s sexual assault allegation was not thorough and was poorly done. She expected the House Supervisor to report the incident to herself and the Risk Manager. During an interview on 04/17/24 at 8:35 AM, Staff B, Quality Management Director, stated that she expected an allegation of abuse was immediately reported to the AOC, Quality Manager, Risk Manager and CEO. A staff member with an allegation of abuse were to be sent home immediately. She would have done more to investigate Patient #12’s allegation. She agreed that immediate education for supervisors was necessary. During an interview on 04/17/24 at 3:05 PM, Staff I, Nurse Manager, stated that staff members accused of abuse were to be immediately removed from patient care until an investigation was completed.”