The Moses H. Cone Memorial Hospital

“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: 50318 Based on facility policy review, medical record review and staff interviews, the facility staff failed to complete a face-to-face assessment within one hour after a violent physical restraint intervention for 1 of 4 patient restraint records reviewed (Patient #2). The findings include: Review of facility policy, “Restraint and Seclusion,” effective date 10/19/2022, revealed, “... Violent or Self-Destructive Behavior Restraint or Seclusion: ... C. Ongoing assessment, care, and documentation for the patient restrained or secluded for violent or self-destructive behavior: ... 1. Assessment/Care: a. The physician or other LP [Licensed Practitioner] (or designated, trained behavioral health RN [Registered Nurse]) must see and evaluate the patient face-to-face within one hour of the initiation of restraint/seclusion ...” Closed medical record review on 02/23/2026 for Patient #2 revealed a 23-year-old presented to the ED (Emergency Department) on 12/05/2025 at 0811 for a psychiatric evaluation. Upon presentation to the ED lobby, the patient was displaying manic behavior (intense, elevated or irritable mood), aggression towards staff and security, and had pressured speech (an intense, rapid, and often unstoppable stream of speech). An IVC (involuntary commitment, a legal process that mandates individuals with severe mental illness into inpatient treatment) was initiated at 0833, and the patient was placed on a psychiatric hold in the ED. On 12/08/2025, an order for violent restraints was placed at 1035 by MD #1 for bilateral ankle and wrist restraints. The reason for restraints was listed as danger to others and danger to self. The restraints were initiated by RN #2 at 1036. The patient’s behavior was listed as “try to fight other in room 49.” The restraint order was discontinued at 1322 (total of 2 hours and 46 minutes) by MD #1. Record review failed to reveal documentation of a face-to-face evaluation within an hour by the physician or other LP. Interview on 02/25/2026 at 1058 with Accreditation Specialist #3 revealed no face-to-face documentation by a Provider. Telephone interview on 02/25/2026 at 1243 with MD #1 revealed the MD did not recall Patient #2 or their violent restraints on 12/08/2025. Interview revealed MD #1 saw the patient on rounds earlier that morning, and the patient was not aggressive at that time. MD #1 revealed they could only locate their discontinuation of the restraint order and could not find any other documentation related to Patient #2’s restraint, including a face-to-face evaluation. Interview on 02/25/2026 at 1410 with Accreditation Specialist #4 revealed RN #2 was not available for interview, did not recall Patient #2, and did not have access to the electronic medical record to review Patient #2’s record. NC00235448, NC00235154, NC00236063, NC00235183, NC00235187, NC00235098”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 34065 Based on policy review, observations, medical record review, hospital document reviews and staff and provider interviews, the hospital’s governing body failed to provide oversight and have systems in place to ensure the protection and promotion of patient’s rights to receive care in a safe environment. The findings included: 1. Hospital staff failed to provide a safe environment for 1 of 1 patients reviewed by failing to ensure systems were in place to provide a safe environment for an intentional overdose patient with Suicide Ideations (thoughts of suicide) to leave the hospital AMA (against medical advice) and failed to notify physician prior to patient departure. Cross refer to 482.13 Patient Rights Standard: Tag A 0144.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 34065 Based on policy review, medical record review, hospital documents, and staff and provider interviews, the hospital’s nursing staff failed to follow policies for nursing supervision of a patient on suicidal precautions and failed to escalate a patient’s safety concerns via the chain of command and failed to communicate to a licensed provider (LP) the patient’s intent to leave AMA (Against medical advice) for 1 of 1 records reviewed (Patient #2). The findings included: 1. The hospital failed to ensure policies were followed for Suicidal patient with an overdose and was allowed to leave AMA for 1 of 1 patients reviewed (Patient #2). Cross refer to 482.23 Nursing Standard: Tag A 0385”

“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: 41946 Based on policy review, incident report review, medical record review and physician and staff interviews, the hospital staff failed to provide a safe environment for 1 of 1 patients reviewed by failing to ensure a Licensed Provider [LP] was notified prior to allowing a patient [Patient #2] on suicidal precautions with 1:1 sitter in place, with a documented plan by multiple providers for psychiatric inpatient stabilization to sign out of the hospital AMA [against medical advice] and by failing to prevent a delay in filing involuntary commitment paperwork. The findings included: Review on 12/11/2025 [MC1.1]of the policy, Suicide Assessment and Precautions for At-Risk Patients, last approved 03/09/2023 revealed, “PURPOSE: The purpose of this policy is to promote a safe environment for patients deemed at risk for self-harm and/or suicide. This policy applies to all patients in inpatient, emergency (ED)... Special Considerations: If the patient is attempting to leave, notify the physician/extender. .. If the patient refuses to wait for the physician/extender, ask the patient to sign the Against Medical Advice (AMA) form ... unless the patient is involuntarily committed patients cannot sign AMA due to legal custody order. ..” Review on 12/11/2025 of the policy, Leaving Against Medical Advice (AMA), last approved 09/25/2024 revealed, “... PROCEDURE: 1. When a patient wants to leave the hospital AMA, nursing will: a. Encourage the patient ... to remain until the LP [MC2.1]or provider on call can discuss the risks involved in leaving AMA. b. Immediately notify the attending LP or provider on call and request a face-to-face (preferred method) or telephone discussion with the patient ... This discussion should include [MC3.1]... Notify the administrative coordinator [house nurse supervisor] ... all circumstances require a Safety Zone Portal [incident report] to be submitted immediately after occurrence... Exclusion Circumstances: patients who pose a threat to self or others cannot legally leave the hospital if certain conditions are met. Such patients would include: ... 2. Patients who are involuntarily committed may not leave. ..” Review on 12/11/2025 of the policy, Involuntary Commitment, last approved 11/09/2022 revealed, “... physicians, ... other certified healthcare professional ... who believe that a patient may injure himself/herself or others may initiate involuntary commitment ...PROCEDURE: Responsibility: Physicians, physician assistants [PA], Nurse Practitioners [NP], Nursing (staff RN’s [registered nurse], directors, clinical nurse managers, and administrative coordinators [Nursing House Supervisors] may be involved), Clinical Social Work (CSW) staff, ... Emergency Commitment: Patient presents and requires immediate hospitalization to prevent harm to self or others. ...1. Complete the appropriate Emergency Certificate form ... The form must be completed and notarized. This form is used in addition to the First Examination for Involuntary Commitment (DMH 5-72-19). ...2. The First Examination for Involuntary Commitment (DMH 5-72-19) must be attached but not require notarization. ... 5. Patient may be detained at the hospital once the forms are faxed to the Clerk of Superior Court. ...If a patient meeting any of these criteria should leave or attempt to leave, the Chain of Command - Patient Safety policy should be followed. ..” Review on 12/11/2025 of the policy, Chain of Command - Patient Safety, last approved 01/17/2025 revealed “... POLICY: ... Any team member who identifies an immediate problem regarding patient care and is unable to resolve it should escalate the issue to successively higher levels of authority (chain of command or COC) until a satisfactory resolution is achieved. All team members shall be empowered to invoke the COC in furtherance of patient safety. All team members involved in the care of the patient are responsible to ensure appropriate notification, response, and follow-up to safeguard the safety and welfare of the patient. It is the responsibility and the obligation of the executive team to support staff members to speak up when they witness or have knowledge of actions which could adversely impact patient safety. .. examples of when to initiate the COC include, ... 7. When patient expresses desire to leave against medical advice. ..” Review on 12/10/2025 of the policy, Secure Chat, last approved 06/24/2025 revealed “PURPOSE: to outline a secure platform to allow discussions between care providers regarding [named health system] patients which protects patient ePHI (electronic Protected Health Information). ... PROCEDURE: ... Prohibited: ...Secure chat messages are NOT a substitute for documentation within the legal record. ... Secure Chat is NOT to be used for critical or time sensitive messages. ...” Review on 12/11/2025 of the Incident Report for Patient #2 dated 10/27/2025 revealed the report was completed by the Mental Health Nurse Practitioner [MHNP] #1, and Administrative Coordinator [AC] #2 on 10/27/2025. Occurrence type was “...Refusal of Medical Care, Patient #2 left AMA. Harm: C Minimal harm- minimal symptoms or loss of function or injury limited to additional treatment, monitoring and/or increased length of stay.”[MC4.1] Location was at Hospital B, on [Named] Medical Unit. “...An additional Unit was providing patient care, [Named] Hospital C, When did this happen: 10/27/2025 at 1315, When did you know this happened: 10/27/2025 at 1340.” The AC #2 documented “...18-yo [year-old] female patient admitted after OD [overdose] was voluntary patient, no IVC [involuntary commitment] in place, Inpatient Psych [psychiatry] recommended BH [behavioral health] admit. Patient was medically cleared. Patient indicated to staff that she did not want to go to [Hospital C] and that she wanted to leave the hospital [Hospital B]. Per the CN [charge nurse] she reached out to Inpatient Psych to ask about IVC but before answer was received the patient signed AMA papers and left. It appears all these were happening simultaneously. The nurse caring for the patient reached out to the NP [named] via secure chat to let her know what occurred and discovered she was in process of IVC paperwork. Patient had already left at 1315. I was notified at 1340 of events when added to secure chat. The IVC paperwork arrived at 1358 for me to notarize. [Named Certified Social Worker-CSW, LCSW #5] from Transitions of Care [TOC] looped in [Named TOC Manager -TOC #4]. [Named TOC Manager and Named TOC Regional Director -TOC#6] reached out to legal who provided direction that IVC could not move forward as the patient was an adult and had left AMA. [Named LCSW #5] was asked to call for a welfare check on patient. ...” The MHNP #1 documented, “...a patient under involuntary commitment (IVC) status was permitted to leave the hospital against medical advice prior to completion of the IVC documentation. The evaluating provider determined that the patient continued to meet criteria for inpatient psychiatric hospitalization due to poor insight, emotional instability, and inconsistent reporting of overdose details. The patient’s chart indicated ingestion of approximately nine (9) 300 mg [milligram] Oxcarbazepine prescribed for seizures and can be used for bipolar disorder tablets, although she minimized the amount when questioned. She expressed limited understanding of the seriousness of her actions and fluctuated between denial and justification, stating she did not intend to die, but wanted to sleep. Despite the provider’s recommendation for involuntary commitment and clear communication of safety concerns, the nursing and supervisory staff permitted the patient to leave against medical advice (AMA). The IVC paperwork was completed by this provider and security should’ve been notified. No attempt was made to notarize or submit legal documents required to allow LEO [law enforcement officer] to search and bring patient back to the hospital. The provider was not consulted prior to the patient’s departure, and the event was reported only after patient had already left hospital grounds. The nurse was aware that patient had been assigned a bed at [named Hospital C.] This lapse in adherence to established IVC protocols represents a serious safety and process failure. The patient had expressed suicidal behavior, poor impulse control, and emotional dysregulation, placing her at continued risk of harm to herself. Allowing her to leave prior to legal detainment and without provider clearance compromised patient safety, violated procedural standards, and exposed the facility to legal and regulatory risks. Immediate follow-up communication occurred between the psychiatric provider, supervising nurse, charge nurse, LCSW, and unit supervisor to document the event and confirm the timeline. All parties acknowledged that the patient was permitted to leave despite the active recommendation for IVC and without involvement of hospital security or completion of required documentation. AC [named] reports speaking to legal department who stated “I spoke to legal and since the pt. [patient] signed an AMA and is an adult there is not much we can do. Legal said we cannot notarize the paperwork if the patient left AMA.” [Legal was not identified on request] ...” Subsequent follow-up by facility leadership dated 10/28/2025 at 0017 by the Chief Medical Officer [CMO] revealed, “If the original intent was to place the patient on an IVC hold and we were allowing paperwork, it does not seem appropriate to let the patient leave AMA, even if they sign AMA paperwork.” ... Leadership Documentation by the Unit Nursing Director, [Registered Nurse, RN #7]... on 10/28/2025 at 1308. “This does not align fully with what the House Supervisor stated had occurred.” .... Comment: by [Named] Quality Coordinator [QMC #10] on 10/29/2025 at 2237 revealed “Suggest review of the process as my understanding is the pt would still be IVC’d and would be picked up by police, even if they left, if considered a danger to self. ...Comment by Master of Social Work [MSW #9] on 10/28/2025 at 0907 revealed, “Noted legal and TOC involved in event. Per chart review, hospitalist (admitting provider) was not notified of AMA until hours later. ...” Review of the incident report revealed no further investigation was completed beyond this report. Closed medical review on 12/10/2025 revealed Patient #2, an 18-year-old female who presented to the Hospital B emergency room on 10/25/2025 at 0007, via emergency medical services [EMS] for an overdose of (9) nine Trileptal (Oxcarbazepine) 300 mg tablets. At 0021 the Triage Nurse, ED RN #11 documented “Pt. via EMS from home after pt. took (9) 300 mg Oxcarbazepine tablets, noncommittal when asked if she was attempting to harm herself. Pt. says she ‘just wanted to go to sleep’.” At 0022 the Chief Complaint updated: “Drug Overdose.” At 0025, a Suicide Assessment and Interventions: Columbia Suicide Severity Rating Scale was completed by ED RN #11, with result of “High Risk.” At 0027, Patient #2 was assigned a Patient Acuity Score of 2-emergent. Review of the ED Provider Note dated for 10/25/2025 at 0203 revealed, Patient #2 had a “past medical history significant for depression, adjustment disorder, possible bipolar disorder... she states she ‘just wanted to sleep’ because she feels overwhelmed. She endorses being stressed and depressed. She does not endorse suicidal intent during my assessment but is noncommittal when asked if she had any intent to hurt herself at all. ...Poison Control was contacted upon arrival and recommended a 12-hour observation from time of ingestion if the medication was extended release. Patient reports taking the medication at 11 PM. ... Test/Admission - Considered: ...after she is medically cleared she will need TTS [psychiatry consult] evaluation. I discussed staying with the patient she agreed to stay voluntarily at this time. I did tell the patient that I was concerned for her mental health and that if she chose to leave I would feel [MC5.1]involuntary commitment paperwork is [sic] feel that she needs psychiatric evaluation. The patient voiced understanding. ...Final Diagnoses: Drug overdose of undetermined intent, initial encounter. ...” On 10/25/2025 at 0330, an order was placed for Suicide Precautions [SI] with 1:1 sitter by the Hospitalist, Medical Doctor [MD #13]. Review of the History and Physical dated 10/25/2025 at 0340 by MD #13 resulted in an admit to observation status, and consult to Psychiatry for Patient #2 with a principal diagnosis of “Drug overdose, intentional...” On 10/25/2025 at 1522, Patient #2 was transferred to the Medical Unit at Hospital B, with SI precautions and 1:1 Sitter. On 10/25/2025 at 1543, a face-to-face Psychiatry Consult was completed by MHNP #14, and revealed “...given the overdose, emotional instability, and limited insight, she meets criteria for inpatient psychiatric hospitalization once medically stabilized. ...Plan: ...Disposition: --We recommend inpatient psychiatric hospitalization when medically cleared. Patient is under voluntary admission status at this time; please IVC if attempts to leave hospital. ... CSSR Risk Category: High Risk...” On 10/26/2025 at 1358, Behavioral Health MD #16 documented in a Progress Note, “...Assessment[MC6.1]: Given the overdose, emotional instability, and limited insight, she meets criteria for inpatient psychiatric hospitalization once medically stabilized. ...” On 10/26/2025 at 1832, review of the Progress Note by Hospitalist, MD #15 revealed “Subjective: ..Notes she was not trying to hurt herself. States that she really only took 4 tablets of the Oxcarbazepine. She notes she was overwhelmed because her father wanted to get rid of her cat and she was unable to sleep, which is why she took extra doses of Oxcarbazepine. She states she would really like to go home. ...Assessment & Plan: medically cleared, move to psych inpatient once bed available.” On 10/27/2025 at 0857, LCSW #5 completed an initial evaluation, and documented Patient #2’s referral was sent to the Hospital C, “Expected Discharge Plan: Psychiatric Hospital...Barriers to Discharge: ...Psych Bed not available. ...” Review of the Discharge Summary, on 10/27/2025 at 1105 by Hospitalist MD #17, revealed “...UPDATE: Patient left AMA and I was not informed until several hours after she left...Discharge Patient, Behavioral Health, Discharge Disposition: 70 [refers to Psychiatric Hospital-Hospital C]-Another Health Care Institution Not Defined, Discharge Date: 10/27/2025...” A Discharge Order was placed 10/27/2025 at 11.05 by MD #17. [MC7.1]On 10/27/2025 at 1110 a Secure Chat [instant message sent via electronic medical record between clinical staff] message was sent by LCSW #5 to Administrative Coordinator [AC] #18 at Hospital C, and MHNP #1 that revealed “talked to pt. voluntary commitment for Behavioral Health [named Hospital C], she said she was cleared to discharge home.” At 1133, A Secure Chat message was sent by the Primary Care RN #19, “asking for someone to come and talk to her. If it’s OK for her to leave. Does not want to go to BH [Hospital C].” At 1159, A Secure Chat message was sent by MHNP#1 to LCSW #5, and AC #18 “IVC paperwork completed and sent to SW [social worker] for notary. Will enter the orders.” A Secure Chat message was sent at 1245 by MHNP#1 to RN #19 “I need time to enter orders.” At 1258 a Secure Chat message was sent by RN #19, to MHNP#1 “Since the pt. does not want to go, are you going to IVC her now? Her bed is ready, get over here now.” At 1300, A Secure Chat message was sent by RN #19 to MHNP#1 “Since Pt. does not want to go, AC/AD [administrative director], asking when she is leaving. Bed is ready at [named Hospital C].” At 1302 A Secure Chat message was sent by RN #19 to MHNP #1, “Pt. is asking for belongings, signing AMA.” Review of the Leaving Hospital Against Medical Advise form, revealed it was completed on 10/27/2025 at 1315, and witnessed by the Charge Nurse [CN] #3. At 1316 A Secure Chat message was sent by MHNP#1 to RN #19, “No, IVCing Pt..” A Secure Chat message was sent at 1322 by MHNP#1 to RN#19, “unable to leave.” At 1334 A Secure Chat message was sent by RN #19 to MHNP #1, “pt. D/C’d [discharged] AMA.” At 1336 A Secure Chat message was sent by MHNP#1 to RN #19, and LCSW #5 “requesting [named LCSW #5] to complete paperwork, and [Named RN #19] notify security.” At 1340 A Secure Chat message was sent by AC #2 to MHNP#1 “so the Pt. has signed AMA and left. Technically staff could not hold her.” At 1350, AC #2 sent a Secure Chat message to MHNP#1 “no notes with indications of IVC.” At 1356, A Secure Chat message was sent by AC #2 to MHNP#1 “the IVC paperwork just arrived for me to notarize. Do you still want me to sign?” At 1356 A Secure Chat message was sent by MHNP#1 to AC #2 “yes. please.” At 1414, a Secure Chat message was sent by MSW #20 [Master of Social Work], to MHNP#1 “discussed with legal, we cannot notarize paperwork if pt. AMA...will request a welfare check.” Review of a Nursing Progress Note by RN #19 on 10/27/2025 documented at 1931 but timed at 1344 revealed “Patient left AMA. Alert and oriented to person, place, time and general circumstances. Denied suicidal and/or homicidal ideations. Denies perpetual disturbances-visual or auditory hallucinations. Judgement fair and intact. Reports voluntary admission and felt that she should be allowed to discharge voluntarily as well. Medical provider and Psych NP including other staff members in the loop made aware. Mother visited unit after patient’s departure. According to Mother, patient would not intentionally hurt herself and this was the first time pt had ever done such.” A TOC Transition Note was written 10/27/2025 at 1458 but timed at 1344 revealed by LCSW #5 “CSW notified of initiating IVC at 1328. CSW collected IVC paperwork from Psych NP [named] to begin filing. CSW notified via secure chat at 1336, of pt. having signed AMA, IVC paperwork placed in shredder by [Hospital B] AC. Per TOC Supervisor, [named], LCSW and TOC Manager [named] welfare check is needed. CSW called [named county] Non-emergency EMS at 1451 to request welfare check.” Review of the Consult Note, by MHNP#1, dated 10/27/2025 at 1424, but timed at 1344 revealed on evaluation, “...limited insight into the seriousness of her situation. ...Despite reassurance and explanation of safety concerns, patient continued to minimize risk and expressed intent to leave. She did provide verbal consent for contact with her mother....Given the circumstances of the ingestion, conflicting statements, and poor judgement regarding safety, inpatient psychiatric hospitalization was recommended for further stabilization, medication review, and safety monitoring. However, prior to initiation of involuntary commitment paperwork, nursing staff permitted the patient to leave against medical advice (AMA). Patient departed prior to completion of commitment process. ...” Review revealed Patient #2 signed AMA and left the medical unit via elevator on 10/27/2025 at 1315. In summary, Patient #2 was placed on Suicidal Precautions with a 1:1 sitter on 10/25/2025 at 0330 for an intentional overdose. Record review revealed the intent to admit Patient #2 for inpatient psychiatric stabilization was evident in the medical record from 10/25/2025 through 10/27/2025 by LPs. On 10/27/2025 approximately 1105, Patient #2 was discharged from the Medical Unit by the Hospitalist/Attending, MD #17 with the intent of being voluntarily admitted to the inpatient behavioral health unit at Hospital C for psychiatric stabilization as evidenced in the Discharge Order and Discharge Summary. There was no indication clinical staff communicated with an LP via approved means prior to Patient #2 leaving the facility AMA. Further review of the medical record failed to reveal an escalation of the chain of command prior to Patient #2 leaving AMA per hospital policy by clinical staff who were aware of intent to IVC Patient #2. Licensed Clinical staff [LCSW #5, RN #19] were aware Patient #2 discussed going home instead of completing voluntary admission as planned on review of the Secure Chat Progress Note as early as 1110. [2 hours prior to Patient #2 signing AMA] The plan for ER Commitment/IVC was not ordered or documented by a LP, even though intent to IVC was evidenced in the Secure Chat Progress Note 30 minutes prior to the AMA form being signed by Patient #2. Patient #2 was allowed to leave while on Suicide Precautions, without evidence that a LP was notified per hospital policy. Request to interview Discharge MD #17, revealed they were unavailable. Telephone interview on 12/10/2025 at 1430 with RN #19 revealed they had been employed since 2007 and recalled Patient #2. The interview revealed “psych[MC8.1] had been into see the patient. I asked the [named] nurse practitioner as she left the patient’s room, was there anything I needed to know. She did not respond and left. The charge nurse [named] asked me, ‘what was the hold up, why is she here.’ The [named] nurse practitioner did not tell me anything so we didn’t know. We were waiting for the nurse practitioner to come and discharge the patient. The patient kept asking ‘when can I leave.’ I reached out to [named] nurse practitioner with psych she didn’t respond. I sent a secure chat in [named electronic medical record system] and she didn’t respond. The charge nurse [named] discharged the patient AMA while I was away. When [named] nurse Practioner got back in touch the patient had left. I was aware the patient was supposed to be admitted, but not for sure she wasn’t going home. I did not talk to the doctor. [MC9.1]..” The interview revealed RN #19 was relieved for break by CN #3, when she had returned Patient #2 had been allowed to sign AMA by charge nurse (CN#3). The interview revealed RN #19 communicated with the LP only via Secure Chat and did not call the LP or overhead page them. Telephone interview on 12/10/2025 at 1434 with the Administrative Coordinator [AC #2] for Hospital B on 10/27/2025 revealed they recalled Patient #2 and had been employed for 25 years. The interview revealed “So what I remember, I was added to the chat after the patient had signed out AMA. She was a voluntary patient and denied suicidal ideations. I was added after the fact. My involvement was after the patient had already left. The IVC paperwork was brought to me by the [named LCSW#5]... I signed and notarized the papers. Then I saw on secure chat, the transitions of care supervisor [named-MSW#20] had said ‘we can’t IVC a patient who had left AMA.’ I did shred the IVC paperwork, it had my name and seal on it, and it could not be filed according to the transitions of care supervisor. I did not reach out to my supervisor. If a patient on suicidal precautions with sitter wanted to leave AMA, a provider would be notified. I do get notified if a patient was admitted to behavioral health, however I am not involved in bed assignments.” The interview revealed escalation of the chain of command did not reach AC #2 until after Patient #2 had left AMA, and also that AC #2 did not escalate the issue to her chain of command or nursing administrator or LP. Further interview on 12/15/2025 at 1028 via Teams [a software platform that combines chat, video meetings, file sharing, and application integration into one workspace] revealed “typically I would get a phone call from a charge nurse, that a patient had signed out AMA. The expectation was for the RN to reach out to an MD, that the patient was leaving AMA. I communicate with the charge nurse by Secure Chat, or we get a phone call. I was not aware the patient was leaving AMA. I was not in the room with the patient that day. I was notified through [named TOC#6] that the nurse Practioner had indicated the paperwork should be redone, and to be e-filed. I cannot send incorrect paperwork. The address was incorrect for last known location. [named MHNP#1] indicated the address needed to be updated, so there was incorrect information on the IVC.” Interview on 12/10/2025 at 1550 with the Transitions of Care Regional Director, TOC #6 revealed, they were contacted by the [MSW #20] after Patient #2 had left AMA. The interview revealed “Our lens, the patient was no longer a patient. Signed out AMA. I did not have shared access to the Chat. I had reached out to legal, which was an hospital attorney via a phone call on Teams, and the question I asked, ‘can you go back and IVC them, even though they’ve been released from the hospital.’ The answer was ‘no, cannot IVC after the fact.’ The doctor clears the patient; it’s a physician decision. Our team was not aware of AMA.” The interview revealed TOC #6 was not aware of what was posted of their legal discussion on Secure Chat. The interview revealed, TOC #6 did not escalate the issue per Chain of Command policy. Telephone interview on 12/11/2025 at 0930 with MHNP#1 revealed these events occurred on 10/27/2025. The interview revealed “I first did an assessment [MC10.1]of the patient around 1100 in the patient’s room. There was inconsistencies from the EMS report, and medical record from what the patient had reported to me. I attempted to call Dad; I tried to call Mom. I did not let her go. I needed all the information. I determined the patient needed to be inpatient in behavioral health. In the Chat at 1159, I completed and passed the paperwork onto [named LCSW#5], but I also notified her face to face. I messaged her, ‘paperwork completed.’ And met her on the 5th floor. It was a[MC11.1] an IVC Petition and first exam, it takes 15-20 minutes to complete. I handed it off to the social worker, it was not completed[MC12.1] [meaning it was not notarized and e-filed with district court]. ..I normally place the IVC order in the record once the notarized paperwork was sent to the magistrate. We are able to hold the patient to keep them here. She had a sitter in place. I sent a Secure Chat at 1245 where I was completing IVC paperwork. The notary makes the petition valid. Once signed, the IVC paperwork should have been uploaded in the system. Once I was made aware she had left AMA, I advised nursing to contact hospital security to be brought back. We should have and can do that. The House Supervisor [named AC #2] declined. If the IVC had been completed and faxed, LEO [law enforcement officer] could have went and brought her back. Afterwards, I reported the incident to Medical Director [named], as well as the hospital attorney, as well as my attending that day, [named MD #21] and completed a Safety Zone [incident report]. Also, later that day, I contacted [named liaison RN Specialist for Behavioral Health] to see if anything else I needed to do. I do believe there is missing Secure Chat in the progress note posted by the charge nurse, not all of the messages were copied and pasted into the medical record. The goal was for this patient to be admitted voluntarily. I needed more information, because the patients account of what happened and the medical record were not the same. When I read the EMS Run Sheet, it sealed the deal. The patient had not given an accurate account of what had happened. The charge nurse that day [named CN #3] works in the holding unit for Psyche and floats and she knows and works with behavioral health patients. [MC13.1]I was not informed until the patient had already left.” The interview revealed that even though MHNP#1 instructed the paperwork to be completed and filed for the IVC, Nursing staff [AC #2] did not complete the IVC or notify security. Further telephone interview on 12/12/2025 at 0845 revealed “The intent was for this patient to go inpatient voluntarily. The information was inconsistent from the patient that day. There was a 1:1 Sitter [named] with her. I messaged her by Secure Chat to let her know, not to allow the patient to leave, she responded ‘ok’ ..” When asked who was aware of the intent to IVC Patient #2 prior to AMA, MHNP #1 replied “[Named RN #19], [Named AC #18 at Hospital C], [named Sitter #22], and [named LCSW#5]... I work on the Behavioral Health Side-Code 70[MC15.1]. I started Signed and Held admitting orders to Behavioral Health but never finished them. As for Emergency IVC, only a medical doctor can initiate an ER certificate per policy. I do an affidavit and 1st Examination which is secondary under the IVC. ..We rarely use the Emergency certificate to IVC on the floor. ..I don’t think I spoke to [named RN #19], she was aware[MC16.1], it was obvious in chat she understood. The [named CN #3] would know not to allow a patient with SI to leave, if she was relieving. ..” The interview with MHNP #1 revealed RN #19 was aware of the intent to IVC Patient #2 prior to signing out AMA, and CN #3 was aware a patient under suicidal precautions should not leave without LP notification. Telephone interview on 12/11/2025 at 1030 with CN #3 revealed they had been employed since 2013 and recalled Patient #2. The interview revealed “I did discharge the patient and notified the provider. I completed the AMA paper. I notified the hospitalist, and psyche team by secure chat in [named EMR]. I was using secure chat; it was the provider for psyche that day. She was trying to reach the patient’s Mom. She was trying to hold the patient. We were trying to deescalate. The patient did not want to wait. It was definitely a red flag. If they were going to IVC her, the provider was not there. We talked to security about it, we did not have an IVC order, they said they could not touch her. I do not recall who in security I spoke to. We cannot touch or hold a patient if they are not IVC’d. I reached out to Nursing leadership, I spoke to my AC, I don’t recall who. Said ‘we couldn’t hold if not IVC’d’. She walked out the door to the elevator. ..” When asked if this was a safe discharge, CN #3 replied “I couldn’t speak to that. We did what we needed to do, I know this has happened before. With Chat you can only see what you are included in. ..” The interview revealed CN #3 [MC17.1]copied and pasted Secure Chat into the medical record ‘when she felt she needed to do so.’ The interview revealed CN #3 could not identify what Nursing Leadership, Security, or Provider she spoke to, [MC18.1]prior to Patient #2 leaving AMA. Telephone interview on 12/11/2025 at 1210 with the MSW #20 -Transitions of Care supervisor revealed they were employed since 08/2025 and recalled the incident. The interview revealed “...[named LCSW#5] was newer and received the IVC paperwork[MC19.1]. I never had a conversation with her[MC20.1]. She had completed the 1344 TOC Note, and we told her to call and request the welfare check. No follow-up involved with this incident. We discussed it that day. I was unaware IVC paperwork had been shredded. The patient signed out prior to getting the IVC paper to her [LCSW#5] at 1315. They were notified at 1328. The patient was already gone.” Telephone interview on 12/11/2025 at 1400 with LCSW #5 revealed they had been a clinical social worker for 2 years and recalled the event with Patient #2. The interview revealed “I tried to review the voluntary admission with the patient that morning. I told the Psych NP. I sent a Secure Chat at 1100 with the nurse practitioner [named-MHNP#1]. I tried, but the patient was under the impression she was cleared to discharge home, ‘please advise.’ She responded at 1149, ‘I am here now, and will take care of it.’ I received the paperwork, I received a separate secure chat message at 1328 from the nurse practitioner, ‘Hey I’m doing an IVC, [named medical floor] dictation room, can you run grab it.’ So, I grabbed the paperwork. I went back to my desk on the 2nd floor, and I saw a separate Chat at 1336, that the patient had left at 1315. I started to upload it into the e-file system to the [named county] district court and then took it to the House Supervisor [AC #2] to get notarized. The House Supervisor told me the patient had signed out AMA, so I called my supervisor [named MSW #20]. She recommended I do a welfare check, so I called that in at 1451. An IVC takes priority, I went to start filing [e-filing] ...I did not finish, I was in the process of filing of it, that’s when I went to the house supervisor [named AC #2]. It was my first IVC actually. Once I went to get it notarized, I cancelled it. I did not make a note. There has been no further discussion or follow-up since the incident.” Telephone interview on 12/12/2025 at 0935 with Chief of Psychiatry, MD #23, revealed “with any SI patient, the provider should be notified before she left. ...I don’t think the patient should have been allowed to leave. ..They should have asked security. The intent was inpatient. The nurse should have contacted the doctor. ..The RN can communicate to the provider for guidance. We can re-evaluate, we can order medication, we have to have a plan. It’s up to the RN to get the provider there. ..This was not a safe discharge. We are all working on an appropriate discharge. A lot of considerations before the patient should go. I was not aware of this event. ..The attending MD should have been notified to come.” Teams Interview [video and audio conferencing] on 12/15/2025 at 0830 with Locums [A Physician who stands in temporarily for another Physician] Psychiatric MD #21, revealed “I didn’t see this patient or face to face with this patient per the note. [Named MHNP#1] had communicated with me about this patient early in the day. I had instructed her to call parents to see if this information from the patient was accurate. She did connect to receive collateral information, and it wasn’t safe for the patient to leave. [Named MHNP#1] later on discussed she had left AMA, we talked. The patient had left before the IVC was completed. In NC there is a lot of steps to the IVC process. I would have not allowed the patient to leave. ...We should have IVC’d out the gate. Anyone who had evaluated her could have made that decision to IVC. If the paperwork was completed accurately, the LEO could have brought her back, even if the patient did leave. ..” The interview revealed MD #24 (SAME PHYSICIAN OR DIFFERENT. SHOULD IT BE #21 OR #24?) had communicated with MHNP#1 early in the day and was following their directive to reach out to parents to clarify information surrounding the overdose event. Telephone interview on 12/12/2025 at 1235 with Sitter #22 revealed she did recall Patient #2. “ ...When the provider comes to see the patient, I wait outside in the hallway for privacy. I told the Charge Nurse the patient wanted to leave. The AC came in the room. The CN tried to send the Psych Provider a message. The RN knew she wanted to leave before lunch. The CN called the AC, and the patient signed out AMA. The patient stated she wasn’t suicidal and was feeling better. The RN asked her to stay. ..No one called security. I walked in the room and she was gone. ..I don’t know how she left, she got on the elevator ...” The interview revealed [named CN #3] and [named AC #2] were [MC22.1]both aware, Patient #2 wanted to leave AMA. The interview revealed, “the [named MHNP#1] did message me to keep the patient, but at that time, the patient had already left AMA[MC23.1]. ..” Interview on 12/12/2025 at 1315 with the Chief Medical Officer, MD #8 revealed “ ...when staff saw she was voluntary, I would have suggested an IVC the day before and then rescind if not needed. There was a delay in the clarification of the need to IVC ...There was a communication breakdown. It’s quite clear she was still at risk. ...The patient did this without Mom knowing about it, without the provider knowing about it and took advantage of the that moment and left. ..We’ve all learned from this. We can educate and keep the patient at the center. There are opportunities for all of us ...” The interview revealed the hospital would be looking at the IVC process, to include Emergency Certificate processes. The interview revealed there was a fine line with supporting patient rights and holding a patient against their will. The CMO revealed, if the intent was to IVC Patient #2, the provider should have put a brief note in the medical record, so that all staff had availability to the information, and the Hospitalist/Attending should have been notified prior to the patient leaving the hospital. Interview on 12/12/2025 at 1345 with the CNO #26 of Hospital B revealed, “ ...I would expect the RN to follow the chain of command, regarding a patient on suicide precautions, with sitter. I would expect an RN to give hand-off of what’s going on with the patient. It’s the expectation the Charge Nurse and House Supervisor would have made an MD aware before getting belongings to the patient. If the IVC paperwork was notarized, the patient can be detained before the documents are uploaded. Security can secure that patient. ...””

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 41946 Based on policy review, incident report review, medical record review, and physician and staff interviews, the facility failed to identify opportunities to promote patient safety measures, and evaluate processes for quality improvement for a reported [CR1.1] incident of a patient on suicidal precautions that was allowed to sign out against medical advice [AMA] by staff who did not follow hospital policies and failed to prevent a delay in completing involuntary commitment paperwork for 1 of 1 medical records reviewed. [Patient #2] Review on 12/16/2025 of the policy, Quality and Performance Improvement Plan, last approved 10/01/2024 revealed “...Procedure / Scope: Quality and performance improvement are priorities for the leadership of [named health system] and support a systematic, coordinated and continuous approach to the improvement and management of patient care through: ... Through ongoing review of incidents and events, to identify opportunities to improve patient safety and to implement/revise processes and procedures ...” Review on 12/11/2025 of the policy, Suicide Assessment and Precautions for At-Risk Patients, last approved 03/09/2023 revealed, “PURPOSE: The purpose of this policy is to promote a safe environment for patients deemed at risk for self-harm and/or suicide. This policy applies to all patients in inpatient, emergency (ED)... Special Considerations: If the patient is attempting to leave, notify the physician/extender. .. If the patient refuses to wait for the physician/extender, ask the patient to sign the Against Medical Advice (AMA) form ..., unless the patient is involuntarily committed patients cannot sign AMA due to legal custody order. ..” Review of the policy, Leaving Against Medical Advice (AMA), last approved 09/25/2024 revealed, “... PROCEDURE: 1. When a patient wants to leave the hospital AMA, nursing will: a. Encourage the patient ... to remain until the LP or provider on call can discuss the risks involved in leaving AMA. b. Immediately notify the attending LP or provider on call and request a face-to-face (preferred method) or telephone discussion with the patient ... This discussion should include ... Notify the administrative coordinator [house nurse supervisor] ... all circumstances require a Safety Zone Portal [incident report] to be submitted immediately after occurrence... Exclusion Circumstances: patients who pose a threat to self or others cannot legally leave the hospital if certain conditions are met. Such patients would include: ... 2. Patients who are involuntarily committed may not leave. ..” Review of the policy, Involuntary Commitment, [IVC] last approved 11/09/2022 revealed, “... physicians, ... other certified healthcare professional ... who believe that a patient may injure himself/herself or others may initiate involuntary commitment ...PROCEDURE: Responsibility: Physicians, physician assistants [PA], Nurse Practitioners [NP], Nursing (staff RN’s [registered nurse], directors, clinical nurse managers, and administrative coordinators [Nursing House Supervisors] may be involved), Clinical Social Work (CSW) staff, ... Emergency Commitment: Patient presents and requires immediate hospitalization to prevent harm to self or others. ...1. Complete the appropriate Emergency Certificate form... The form must be completed and notarized. This form is used in addition to the First Examination for Involuntary Commitment. ...2. The First Examination for Involuntary Commitment ... must be attached but not require notarization. ... 5. Patient may be detained at the hospital once the forms are faxed to the Clerk of Superior Court. ...If a patient meeting any of these criteria should leave or attempt to leave, the Chain of Command - Patient Safety policy should be followed. ..” Review of the policy, Chain of Command - Patient Safety, last approved 01/17/2025 revealed “... POLICY: ... Any team member who identifies an immediate problem regarding patient care and is unable to resolve it should escalate the issue to successively higher levels of authority (chain of command or COC) until a satisfactory resolution is achieved. All team members shall be empowered to invoke the COC in furtherance of patient safety. All team members involved in the care of the patient are responsible to ensure appropriate notification, response, and follow-up to safeguard the safety and welfare of the patient. It is the responsibility and the obligation of the executive team to support staff members to speak up when they witness or have knowledge of actions which could adversely impact patient safety. ... ... Examples of when to initiate the COC include, ... 7. When patient expresses desire to leave against medical advice. ..” Review on 12/10/2025 of the policy, Secure Chat, last approved 06/24/2025 revealed “PURPOSE: to outline a secure platform to allow discussions between care providers regarding [named health system] patients which protects patient ePHI (electronic Protected Health Information). ... PROCEDURE: ... Prohibited: ...Secure chat messages are NOT a substitute for documentation within the legal record. ... Secure Chat is NOT to be used for critical or time sensitive messages. ...” Review on 12/11/2025 of the Incident Report for Patient #2 dated 10/27/2025 revealed the report was completed by the Mental Health Nurse Practitioner [MHNP] #1, and Administrative Coordinator [AC] #2 on 10/27/2025. Occurrence type was “...Refusal of Medical Care, Patient #2 left AMA. Harm: C Minimal harm- minimal symptoms or loss of function or injury limited to additional treatment, monitoring and/or increased length” Location was at Hospital B, on [Named] Medical Unit. “...An additional Unit was providing patient care, [Named] Hospital C, When did this happen: 10/27/2025 at 1315, When did you know this happened: 10/27/2025 at 1340.” The AC #2 documented “...18-yo [year-old] female patient admitted after OD [overdose] was voluntary patient, no IVC [involuntary commitment] in place, Inpatient Psych [psychiatry] recommended BH [behavioral health] admit. Patient was medically cleared. Patient indicated to staff that she did not want to go to [Hospital C] and that she wanted to leave the hospital [Hospital B]. Per the CN [charge nurse] she reached out to Inpatient Psych to ask about IVC but before answered was received the patient signed AMA papers and left. It appears all these were happening simultaneously. The nurse caring for the patient reached out to the NP [named] via secure chat to let her know what occurred and discovered she was in process of IVC paperwork. Patient had already left at 1315. I was notified at 1340 of events when added to secure chat. The IVC paperwork arrived at 1358 for me to notarize. [Named Certified Social Worker-CSW, LCSW #5] from Transitions of Care [TOC] looped in [Named TOC Manager -TOC #4]. [Named TOC Manager and Named TOC Regional Director -TOC#6] reached out to legal who provided direction that IVC could not move forward as the patient was an adult and had left AMA. [Named LCSW #5] was asked to call for a welfare check on patient. ...” The MHNP #1 documented, “...a patient under involuntary commitment (IVC) status was permitted to leave the hospital against medical advice prior to completion of the IVC documentation. The evaluating provider determined that the patient continued to meet criteria for inpatient psychiatric hospitalization due to poor insight, emotional instability, and inconsistent reporting of overdose details. The patient’s chart indicated ingestion of approximately (9)[CR2.1]- 300 mg [milligram] Oxcarbazepine [prescribed for seizures, and bipolar disorder] t[CR3.1]ablets, although she minimized the amount when questioned. She expressed limited understanding of the seriousness of her actions and fluctuated between denial and justification, stating she did not intend to die, but wanted to sleep. Despite the provider’s recommendation for involuntary commitment and clear communication of safety concerns, the nursing and supervisory staff permitted the patient to leave against medical advice (AMA). The IVC paperwork was completed by this provider and security should’ve been notified. No attempt was made to notarize or submit legal documents required to allow LEO [law enforcement officer] to search and bring patient back to the hospital. The provider was not consulted prior to the patient’s departure, and the event was reported only after patient had already left hospital grounds. The nurse was aware that patient had been assigned a bed at [named Hospital C]. This lapse in adherence to established IVC protocols represents a serious safety and process failure. The patient had expressed suicidal behavior, poor impulse control, and emotional dysregulation, placing her at continued risk of harm to herself. Allowing her to leave prior to legal detainment and without provider clearance compromised patient safety, violated procedural standards, and exposed the facility to legal and regulatory risks. Immediate follow-up communication occurred between the psychiatric provider, supervising nurse, charge nurse, LCSW, and unit supervisor to document the event and confirm the timeline. All parties acknowledged that the patient was permitted to leave despite the active recommendation for IVC and without involvement of hospital security or completion of required documentation. AC [named] [CR4.1]reports speaking to legal department who stated “I spoke to legal and since the pt. [patient] signed an AMA and is an adult there is not much we can do. Legal said we cannot notarize the paperwork if the patient left AMA. ...” Subsequent follow-up by facility leadership dated 10/28/2025 at 0017 by the Chief Medical Officer [CMO] revealed, “If the original intent was to place the patient on an IVC hold and we were allowing paperwork, it does not seem appropriate to let the patient leave AMA, even if they sign AMA paperwork.” Follow-up documentation by the Unit Nursing Director, [Registered Nurse, RN #7]... on 10/28/2025 at 1308 revealed “ ... This does not align fully with what the House Supervisor stated had occurred.” Follow-up Comment: by [Named] Quality Coordinator [QMC #10] on 10/29/2025 at 2237 revealed “Suggest review of the process as my understanding is the pt would still be IVC’d and would be picked up by police, even if they left, if considered a danger to self.” Follow-up comment by a Master of Social Work [MSW #9] on 10/28/2025 at 0907 revealed, “Noted legal and TOC involved in event. Per chart review, hospitalist (admitting provider) was not notified of AMA until hours later. ...” Review of the incident report revealed no further investigation, identification of actions needed, action plan, monitoring, or education was completed beyond this report. [CR5.1] Closed medical review on 12/10/2025 revealed Patient #2, an 18-year-old female who presented to the Hospital B emergency room on 10/25/2025 at 0007, via emergency medical services [EMS] for an overdose of nine T Trilepta[CR6.1]l[prescribed for seizures and can be used for bipolar disorder[CR7.1]] 300 mg [milligram] tablets. At 0021 the Triage Nurse, ED RN #11 documented “Pt. via EMS from home after pt. took nine [CR8.1]300 mg Oxcarbazepine [generic name for Trileptal] tablets, noncommittal when asked if she was attempting to harm herself. Pt. says she ‘just wanted to go to sleep’.” At 0022 the Chief Complaint updated: “Drug Overdose [OD].” At 0025, a Suicide Assessment and Interventions: Columbia Suicide Severity Rating Scale was completed by ED RN #11, with result of “High Risk.” At 0027, Patient #2 was assigned a Patient Acuity Score of 2-emergent. Review of the ED Provider Note dated for 10/25/2025 at 0203 revealed, Patient #2 had a “past medical history significant for depression, adjustment disorder, possible bipolar disorder... she states she ‘just wanted to sleep’ because she feels overwhelmed. She endorses being stressed and depressed. She does not endorse suicidal intent during my assessment but is noncommittal when asked if she had any intent to hurt herself at all. ...Poison Control was contacted upon arrival and recommended a 12-hour observation from time of ingestion if the medication was extended release. Patient reports taking the medication at 11 PM. ... Test/Admission - Considered: ...after she is medically cleared she will need TTS [psychiatry consult] evaluation. I discussed staying with the patient she agreed to stay voluntarily at this time. I did tell the patient that I was concerned for her mental health and that if she chose to leave I would feel involuntary commitment paperwork is I feel [sic] that she needs psychiatric evaluation. The patient voiced understanding. ...Final Diagnoses: Drug overdose of undetermined intent, initial encounter. ...” On 10/25/2025 at 0330, an order was placed for Suicide Precautions [SI] with 1:1 sitter by the Hospitalist, Medical Doctor [MD #13]. Review of the History and Physical dated 10/25/2025 at 0340 by MD #13 resulted in an admit to observation status, and consult to Psychiatry for Patient #2 with a principal diagnosis of “Drug overdose, intentional...” On 10/25/2025 at 1522, Patient #2 was transferred to the Medical Unit at Hospital B, with SI precautions and 1:1 Sitter. On 10/25/2025 at 1543, a face-to-face Psychiatry Consult was completed by MHNP #14, and revealed “...given the overdose, emotional instability, and limited insight, she meets criteria for inpatient psychiatric hospitalization once medically stabilized. ...Plan: ...Disposition: --We recommend inpatient psychiatric hospitalization when medically cleared. Patient is under voluntary admission status at this time; please IVC if attempts to leave hospital. ... CSSR Risk Category: High Risk...” On 10/26/2025 at 1358, Behavioral Health MD #16 documented in a Progress Note, ...Assessment: Given the overdose, emotional instability, and limited insight, she meets criteria for inpatient psychiatric hospitalization once medically stabilized. ...” On 10/26/2025 at 1832, review of the Progress Note by Hospitalist, MD #15 revealed “Subjective: ..Notes she was not trying to hurt herself. States that she really only took 4 tablets of the Oxcarbazepine. She notes she was overwhelmed because her father wanted to get rid of her cat and she was unable to sleep, which is why she took extra doses of Oxcarbazepine. She states she would really like to go home. ...Assessment & Plan: medically cleared, move to psyche inpatient once bed available.” On 10/27/2025 at 0857, LCSW #5 completed an initial evaluation, and documented Patient #2’s referral was sent to the Hospital C, “Expected Discharge Plan: Psychiatric Hospital...Barriers to Discharge: ...Psych Bed not available. ...” Review of the Discharge Summary, on 10/27/2025 at 1105 by Hospitalist MD #17, revealed “...UPDATE: Patient left AMA and I was not informed until several hours after she left...Discharge Patient, Behavioral Health, Discharge Disposition: 70 [code for Hospital C]-Another Health Care Institution Not Defined, Discharge Date: 10/27/2025...” A Discharge Order was reviewed dated 10/27/2025 at 11.05 by MD #17, “...Discharge Disposition: 70-Another Health Care Institution Not Defined, ...Comments: Behavioral Health...” On 10/27/2025 at 1110 a Secure Chat [instant message sent via electronic medical record between clinical staff] message was sent by LCSW #5 to Administrative Coordinator [AC] #18 at Hospital C, and MHNP #1 that revealed “talked to pt. voluntary commitment for Behavioral Health [named Hospital C], she said she was cleared to discharge home.” At 1133, A Secure Chat [CR9.1]message was sent by the Primary Care RN #19, “asking for someone to come and talk to her. If it’s OK for her to leave. Does not want to go to BH [Hospital C].” At 1159, A Secure Chat [CR10.1]message was sent by MHNP#1 to LCSW #5, and AC #18 “IVC paperwork completed and sent to SW [social worker] for notary. Will enter the orders.” A Secure Chat message was sent at 1245 by MHNP#1 to RN #19 “I need time to enter orders.” At 1258 a Secure Chat message was sent by RN #19, to MHNP#1 “Since the pt. does not want to go, are you going to IVC her now? Her bed is ready, get over here now.” At 1300, A Secure Chat message was sent by RN #19 to MHNP#1 “Since Pt. does not want to go, AC/AD [administrative director], asking when she is leaving. Bed is ready at [named Hospital C].” At 1302 A Secure Chat message was sent by RN #19 to MHNP #1, “Pt. is asking for belongings, signing AMA.” Review of the Leaving Hospital Against Medical Advise form, revealed it was completed on 10/27/2025 at 1315, and witnessed by the Charge Nurse [CN] #3. At 1316 A Secure Chat [CR11.1]message was sent by MHNP#1 to RN #19, “No, IVCing Pt..” A Secure Chat message was sent at 1322 by MHNP#1 to RN#19, “unable to leave.” At 1334 A Secure Chat message was sent by RN #19 to MHNP #1, “pt. D/C’d [discharged] AMA.” At 1336 A Secure Chat message was sent by MHNP#1 to RN #19, and LCSW #5 “requesting [named LCSW #5] to complete paperwork, and [Named RN #19] notify security.” At 1340 A Secure Chat message was sent by AC #2 to MHNP#1 “so the Pt. has signed AMA and left. Technically staff could not hold her.” At 1350, AC #2 sent a Secure Chat message to MHNP#1 “no notes with indications of IVC.” At 1356, A Secure Chat [CR12.1]message was sent by AC #2 to MHNP#1 “the IVC paperwork just arrived for me to notarize. Do you still want me to sign?” At 1356 A Secure Chat message was sent by MHNP#1 to AC #2 “yes. please.” At 1414, a Secure Chat message was sent by MSW #20 [Master of Social Work], to MHNP#1 “discussed with legal, we cannot notarize paperwork if pt. AMA...will request a welfare check.” Review of a Nursing Progress Note by RN #19 on 10/27/2025 documented at 1931 but timed at 1344 revealed “Patient left AMA. Alert and oriented to person, place, time and general circumstances. Denied suicidal and/or homicidal ideations. Denies perpetual disturbances-visual or auditory hallucinations. Judgement fair and intact. Reports voluntary admission and felt that she should be allowed to discharge voluntarily as well. Medical provider and Psych NP including other staff members in the loop made aware. Mother visited unit after patient’s departure. According to Mother, patient would not intentionally hurt herself and this was the first time pt had ever done such.” A TOC Transition Note was written 10/27/2025 at 1458 but timed at 1344 revealed by LCSW #5 “CSW notified of initiating IVC at 1328. CSW collected IVC paperwork from Psych NP [named] to begin filing. CSW notified via secure chat at 1336, of pt. having signed AMA, IVC paperwork placed in shredder by [Hospital B] AC. Per TOC Supervisor, [named], LCSW and TOC Manager [named] welfare check is needed. CSW called [named county] Non-emergency EMS at 1451 to request welfare check.” Review of the Consult Note, dated 10/27/2025 at 1424, but timed at 1344 by MHNP#1 revealed “...10/27/2025: “On evaluation, ...limited insight into the seriousness of her situation. ...Despite reassurance and explanation of safety concerns, patient continued to minimize risk and expressed intent to leave. She did provide verbal consent for contact with her mother....Given the circumstances of the ingestion, conflicting statements, and poor judgement regarding safety, inpatient psychiatric hospitalization was recommended for further stabilization, medication review, and safety monitoring. However, prior to initiation of involuntary commitment paperwork, nursing staff permitted the patient to leave against medical advice (AMA). [CR13.1]Patient departed prior to completion of commitment process. ...” Review revealed Patient #2 signed AMA and left the medical unit via elevator on 10/27/2025 at 1315. In summary, Patient #2 was placed on Suicidal Precautions with a 1:1 sitter on 10/25/2025 at 0330 for an intentional overdose. Record review revealed the intent to admit Patient #2 for inpatient psychiatric stabilization was evident in the medical record from 10/25/2025 through 10/27/2025 by Licensed Providers. On 10/27/2025 approximately 1105, Patient #2 was discharged from the Medical Unit by the Hospitalist/Attending, MD #17 with the intent of being voluntarily admitted to the inpatient behavioral health unit at Hospital C for psychiatric stabilization as evidenced in the Discharge Order and Discharge Summary. Licensed Clinical staff [LCSW #5, RN #19] were aware Patient #2 discussed going home instead of completing voluntary admission as planned on review of the Secure Chat progress note as early as 1110. [2 hours prior to Patient #2 signing AMA] The plan for ER Commitment/IVC was not ordered or documented by the LP to provide notification, even though intent to IVC was evidenced in the Secure Chat Progress Note, 30 minutes prior to the AMA form being signed by Patient #2. Patient #2 was allowed to leave AMA while on Suicide Precautions, without evidence a Physician/Provider was notified following hospital policies. Further review of the medical record failed to reveal an escalation of the chain of command prior to Patient #2 leaving AMA per hospital policy by clinical staff. Clinical Staff and the LP used Secure Chat to relay critical and time-sensitive messages prohibited by policy. A Charge Nurse intentionally copied and pasted Secure Chat into the medical record prohibited by policy. And finally, facility quality staff did not identify opportunities to improve patient safety and evaluate processes for quality improvement after review of this event where many facility policies were not followed, and Patient #2, while on SI precautions was allowed to sign out AMA. Interview on 12/12/2025 at 1230 with the Director of Quality, revealed “ ...Everything was done to follow policy. We upheld patient rights. We followed our policy. We did not do any follow-up after this event. ...” Further interview on 12/17/2025 at 0900 with the Director of Quality, and the Systems- Chief Medical Officer revealed, Director of Quality “...I am a part of the incident report review. It was appropriate to use the Secure Chat platform for bed placement, but for the AMA we should have moved away from Secure Chat. When we deviate from policy and procedures, an incident report should be filed. There was not an incident report for the Secure Chat filed, however, there was an incident report filed for the AMA for this patient. If Secure Chat comes up, we investigate per the incident. If medical staff are involved, it was referred [CR14.1]to the Medical Director of the Professional for review. Secure Chat was reviewed in the Medical Executive Committee meetings and was ongoing. The quality processes we adhere to for quality improvement are: The Joint Commission serious safety events, when we miss or have a process failure, and we do an root cause analysis [RCA-systematic problem-solving method used to find the fundamental reasons (root causes) behind an issue, rather than just treating its symptoms, to implement lasting solutions and prevent reoccurrence.] [CR15.1][CR15.2]verses a deeper dive, and every Sentinel Event [unexpected patient safety event that results in death, permanent harm, or severe temporary harm, requiring immediate investigation.] has RCA follow-up. Systems CMO “We use the CUSS model [a patient safety communication tool, Concerned, Uncomfortable/Uncertain, Safety Issue, and Stop], that includes [named Hospital C] to reevaluate applications, and to address via the chain of command. It assists us to recognize our role and support our team better.” Quality Director “...Now we will measure AMA’s and ensure notification of attending providers. Human beings want to leave quickly. A patient can refuse. A risk/benefits conversation with a provider needs to happen. If the SI policy was in place, we can and did have a sitter in place present. We are looking at processes with [named EMR] today. We audit all submitted IVC paperwork, sent to the state in a 24-time frame. This IVC was never executed. We were looking at the Emergency and 1st Exam policy; we do see an opportunity. ..We are developing focused education for Behavioral Health Providers to prevent a reoccurrence. This was a difficult incident report and would fall to the unit level for investigation. A debriefing was initiated today to the Unit Manager to review the event. ...” The interview revealed an investigation had not been identified because this incident report did not qualify as serious safety event, RCA, or sentinel event, and should have been investigated at the unit level and not system level. Telephone interview on 12/10/2025 at 1430 with RN #19 revealed they had been employed since 2007 and recalled Patient #2. The interview revealed there had been no quality improvement follow-up or education since the event. Telephone interview on 12/11/2025 at 1030 with CN #3 revealed she had been employed since 2013 and recalled Patient #2. The interview revealed there had been no quality improvement follow-up or education since the event. Telephone interview on 12/11/2025 at 0930 with MHNP#1 revealed “... I reported the incident to Medical Director [named], as well as the hospital attorney, as well as my attending that day, [named MD #21] and completed a Safety Zone [incident report]. Also, later that day, I contacted [named liaison RN Specialist for Behavioral Health] to see if anything else I needed to do. ...” The interview revealed there had been no quality improvement follow-up or education since the event. Telephone interview on 12/12/2025 at 0935 with Chief of Psychiatry for [named] health system, MD #23, revealed “...I was not aware of event...” The interview revealed there had been no quality improvement follow-up or education since the event. Interview on 12/12/2025 at 1300 with the Chief Medical Officer, MD #8 revealed “... if the intent was to IVC Patient #2, the provider [MHNP#1] should have put a brief note in the medical record, so that all staff had availability to the information. ...We’ve all learned from this. .. We can educate and keep the patient at the center. ..i Don’t think this incident created enough awareness. The implementation going forward will be to do what’s best for the patient. ..” The interview revealed the CMO was unaware if further investigation had occurred past review of the incident report. Telephone interview on 12/12/2025 at 1345 with the Chief Nursing Officer, CNO #26 revealed she was the Assistant Chief Nursing Officer at the time, and recently was promoted to Chief Nursing Officer [CNO] of Hospital B. The interview revealed the expectation was for nursing staff to follow hospital policies, ...” The interview revealed the CNO was unaware of this patient event, prior to the survey entrance. Interview on 12/15/2025 via Teams [video and audio conferencing] with the Chief Nursing Information Officer, and the Medical Information Officer revealed they do not audit Secure Chat integrity. The interview revealed “the only way we are aware of patient safety events involving Secure Chat, was through [named Quality Director] who reviewed incident reports and referred them to us [information officers], when indicated for review. ...” The interview revealed there was a not quality improvement monitoring process in place for Secure Chat, other than facility staff placing an incident report currently.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 41946 Based on of policy review, incident report review, medical record review, provider and staff interviews, the hospital nursing staff failed to follow policies for nursing supervision of a patient on suicidal precautions, failed to escalate a patient’s safety concerns via the chain of command, and failed to communicate to a licensed provider [LP] the patient’s intent to leave against medical advice [AMA] for 1 of 1 patient. [Patient #2] The findings include: Review on 12/11/2025 of the policy, Suicide Assessment and Precautions for At-Risk Patients, last approved 03/09/2023 revealed, “PURPOSE: The purpose of this policy is to promote a safe environment for patients deemed at risk for self-harm and/or suicide. This policy applies to all patients in inpatient, emergency (ED)... Special Considerations: If the patient is attempting to leave, notify the physician/extender. .. If the patient refuses to wait for the physician/extender, ask the patient to sign the Against Medical Advice (AMA) form (form number MR911042), unless the patient is involuntarily committed patients cannot sign AMA due to legal custody order. ..” Review of the policy, Leaving Against Medical Advice (AMA), last approved 09/25/2024 revealed, “... PROCEDURE: 1. When a patient wants to leave the hospital AMA, nursing will: a. Encourage the patient ... to remain until the LP or provider on call can discuss the risks involved in leaving AMA. b. Immediately notify the attending LP or provider on call and request a face-to-face (preferred method) or telephone discussion with the patient ... This discussion should include ... Notify the administrative coordinator [house nurse supervisor] ... all circumstances require a Safety Zone Portal [incident report] to be submitted immediately after occurrence... Exclusion Circumstances: patients who pose a threat to self or others cannot legally leave the hospital if certain conditions are met. Such patients would include: ... 2. Patients who are involuntarily committed may not leave. ..” Review of the policy, Chain of Command - Patient Safety, last approved 01/17/2025 revealed “... POLICY: ... Any team member who identifies an immediate problem regarding patient care and is unable to resolve it should escalate the issue to successively higher levels of authority (chain of command or COC) until a satisfactory resolution is achieved. All team members shall be empowered to invoke the COC in furtherance of patient safety. All team members involved in the care of the patient are responsible to ensure appropriate notification, response, and follow-up to safeguard the safety and welfare of the patient. It is the responsibility and the obligation of the executive team to support staff members to speak up when they witness or have knowledge of actions which could adversely impact patient safety. ... ... Examples of when to initiate the COC include, ... 7. When patient expresses desire to leave against medical advice. ..” Review on 12/11/2025 of the Incident Report for Patient #2 dated 10/27/2025 revealed the report was completed by the Mental Health Nurse Practitioner [MHNP] #1, and Administrative Coordinator [AC] #2 on 10/27/2025. ..The AC #2 documented “...18-yo [year-old] female patient admitted after OD [overdose] was voluntary patient, no IVC [involuntary commitment] in place, Inpatient Psych [psychiatry] recommended BH [behavioral health] admit. Patient was medically cleared. Patient indicated to staff that she did not want to go to [Hospital C] and that she wanted to leave the hospital [Hospital B]. Per the CN [charge nurse] she reached out to Inpatient Psych to ask about IVC but before answered was received the patient signed AMA papers and left. It appears all these were happening simultaneously. The nurse caring for the patient reached out to the NP [named] via secure chat to let her know what occurred and discovered she was in process of IVC paperwork. Patient had already left at 1315. I was notified at 1340 of events when added to secure chat. The IVC paperwork arrived at 1358 for me to notarize. ..MHNP #1 documented, “...a patient under involuntary commitment (IVC) status was permitted to leave the hospital against medical advice prior to completion of the IVC documentation. The evaluating provider determined that the patient continued to meet criteria for inpatient psychiatric hospitalization due to poor insight, emotional instability, and inconsistent reporting of overdose details. ...Despite the provider’s recommendation for involuntary commitment and clear communication of safety concerns, the nursing and supervisory staff permitted the patient to leave against medical advice (AMA). .. The provider was not consulted prior to the patient’s departure, and the event was reported only after patient had already left hospital grounds. The nurse was aware that patient had been assigned a bed at BHH. This lapse in adherence to established IVC protocols represents a serious safety and process failure. The patient had expressed suicidal behavior, poor impulse control, and emotional dysregulation, placing her at continued risk of harm to herself. Allowing her to leave prior to legal detainment and without provider clearance compromised patient safety, violated procedural standards, and exposed the facility to legal and regulatory risks. ..” Closed medical review on 12/10/2025 revealed Patient #2, an 18-year-old female who presented to the Hospital B emergency room on 10/25/2025 at 0007, via emergency medical services [EMS] for an overdose of (9) nine Trileptal 300 mg [prescribed for seizures and can be used for bipolar disorder] tablets. At 0021 the Triage Nurse, ED RN #11 documented “Pt. via EMS from home after pt. took (9) 300 mg Oxcarbazepine (Generic for Trileptal) tablets, noncommittal when asked if she was attempting to harm herself. Pt. says she ‘just wanted to go to sleep’.” At 0025, a Suicide Assessment and Interventions: Columbia Suicide Severity Rating Scale was completed by ED RN #11, with result of “High Risk.” Review of the ED Provider Note dated for 10/25/2025 at 0203 revealed, ...Poison Control was contacted upon arrival and recommended a 12-hour observation from time of ingestion if the medication was extended release. Patient reports taking the medication at 11 PM. ..Considered: ...after she is medically cleared she will need TTS [psychiatry consult/evaluation] evaluation. I discussed staying with the patient she agreed to stay voluntarily at this time. I did tell the patient that I was concerned for her mental health and that if she chose to leave I would feel involuntary commitment paperwork is I feel that she needs psychiatric evaluation. The patient voiced understanding. ...Final Diagnoses: Drug overdose of undetermined intent, initial encounter. ...” On 10/25/2025 at 0330, an order was placed for Suicide Precautions [SI] with 1:1 sitter by the Hospitalist, Medical Doctor [MD #13]. Review of the History and Physical dated 10/25/2025 at 0340 by MD #13 resulted in an admit to observation status, and consult to Psychiatry for Patient #2 with a principal diagnosis of “Drug overdose, intentional...” On 10/25/2025 at 1522, Patient #2 was transferred to the Medical Unit at Hospital B, with SI precautions and 1:1 Sitter. On 10/25/2025 at 1543, a face-to-face Psychiatry Consult was completed by MHNP #14, and revealed “...given the overdose, emotional instability, and limited insight, she meets criteria for inpatient psychiatric hospitalization once medically stabilized. ...Plan: ...Disposition: --We recommend inpatient psychiatric hospitalization when medically cleared. Patient is under voluntary admission status at this time; please IVC if attempts to leave hospital. ... CSSR Risk Category: High Risk...” On 10/26/2025 at 1358, Behavioral Health MD #16 documented in a Progress Note, ...Assessment: Given the overdose, emotional instability, and limited insight, she meets criteria for inpatient psychiatric hospitalization once medically stabilized. ...” On 10/26/2025 at 1832, review of the Progress Note by Hospitalist, MD #15 revealed “...Assessment & Plan: medically cleared, move to psyche inpatient once bed available.” On 10/27/2025 at 0857, LCSW #5 completed an initial evaluation, and documented Patient #2’s referral was sent to the Hospital C, “Expected Discharge Plan: Psychiatric Hospital...Barriers to Discharge: ...Psych Bed not available. ...” Review of the Discharge Summary, on 10/27/2025 at 1105 by Hospitalist MD #17, revealed “...UPDATE: Patient left AMA and I was not informed until several hours after she left...Discharge Patient, Behavioral Health, Discharge Disposition: 70-Another Health Care Institution Not Defined, Discharge Date: 10/27/2025...” A Discharge Order was reviewed dated 10/27/2025 at 11.05 by MD #17, “...Discharge Disposition: 70-Another Health Care Institution Not Defined, ...Comments: Behavioral Health...” On 10/27/2025 at 1110 a Secure Chat [instant message sent via electronic medical record between clinical staff] message was sent by LCSW #5 to Administrative Coordinator [AC] #18 at Hospital C, and MHNP #1 that revealed “talked to pt. voluntary commitment for Behavioral Health [named Hospital C], she said she was cleared to discharge home.” At 1133, A Secure Chat message was sent by the Primary Care RN #19, “asking for someone to come and talk to her. If it’s OK for her to leave. Does not want to go to BH [Hospital C].” At 1159, A Secure Chat message was sent by MHNP#1 to LCSW #5, and AC #18 “IVC paperwork completed and sent to SW [social worker] for notary. Will enter the orders.” At 1231, 10/27/2025 RN #19 acknowledged the discharge orders with stated intent to admit to behavioral health, Hospital C. A Secure Chat message was sent at 1245 by MHNP#1 to RN #19 “I need time to enter orders.” At 1258 a Secure Chat message was sent by RN #19, to MHNP#1 “Since the pt. does not want to go, are you going to IVC her now? Her bed is ready, get over here now.” At 1300, A Secure Chat message was sent by RN #19 to MHNP#1 “Since Pt. does not want to go, AC/AD [administrative director], asking when she is leaving. Bed is ready at [named Hospital C].” At 1302 A Secure Chat message was sent by RN #19 to MHNP #1, “Pt. is asking for belongings, signing AMA.” Review of the Leaving Hospital Against Medical Advise form, revealed it was completed on 10/27/2025 at 1315, and witnessed by the Charge Nurse [CN] #3. At 1316 A Secure Chat message was sent by MHNP#1 to RN #19, “No, IVCing Pt..” A Secure Chat message was sent at 1322 by MHNP#1 to RN#19, “unable to leave.” At 1334 A Secure Chat message was sent by RN #19 to MHNP #1, “pt. D/C’d [discharged] AMA.” Review of a Nursing Progress Note by RN #19 on 10/27/2025 documented at 1931 but timed at 1344 revealed “Patient left AMA. Alert and oriented to person, place, time and general circumstances. Denied suicidal and/or homicidal ideations. Denies perpetual disturbances-visual or auditory hallucinations. Judgement fair and intact. Reports voluntary admission and felt that she should be allowed to discharge voluntarily as well. Medical provider and Psych NP including other staff members in the loop made aware. Mother visited unit after patient’s departure. According to Mother, patient would not intentionally hurt herself and this was the first time pt had ever done such.” Review of the Consult Note, dated 10/27/2025 at 1424, but timed at 1344 by MHNP#1 revealed “...10/27/2025: “On evaluation, ...limited insight into the seriousness of her situation. ...Despite reassurance and explanation of safety concerns, patient continued to minimize risk and expressed intent to leave. She did provide verbal consent for contact with her mother....Given the circumstances of the ingestion, conflicting statements, and poor judgement regarding safety, inpatient psychiatric hospitalization was recommended for further stabilization, medication review, and safety monitoring. However, prior to initiation of involuntary commitment paperwork, nursing staff permitted the patient to leave against medical advice (AMA). Patient departed prior to completion of commitment process. ...” Review revealed Patient #2 signed AMA and left the medical unit via elevator on 10/27/2025 at 1315. Review of the medical record failed to reveal an RN communicated with a LP prior to allowing Patient #2 to sign and leave AMA at 1315. Further review failed to reveal documentation of this patient safety issue being escalated above the RN and CN via the nursing chain of command for guidance prior to the patient leaving AMA. Telephone interview on 12/10/2025 at 1430 with RN #19 revealed they had been employed since 2007 and recalled Patient #2. The interview revealed “psyche had been into see the patient. I asked the [named] nurse practitioner as she left the patient’s room, was there anything I needed to know. She did not respond and left. The charge nurse [named] asked me, ‘what was the hold up, why is she here.’ The [named] nurse Practioner did not tell me anything so we didn’t know. We were waiting for the nurse Practioner to come and discharge the patient. The patient kept asking ‘when can I leave.’ I reached out to [named] nurse Practioner with psyche, she didn’t respond. I sent a secure chat in [named electronic medical record system] and she didn’t respond. The charge nurse [named] discharged the patient AMA while I was away. When [named] nurse Practioner got back in touch the patient had left. I was aware the patient was supposed to be admitted, but not for sure she wasn’t going home. I did not talk to the doctor. ..” The interview revealed RN #19 was relieved for break by CN #3, when she had returned Patient #2 had been allowed to sign AMA by charge nurse (CN#3). Telephone interview on 12/10/2025 at 1434 with the Administrative Coordinator [AC #2] for Hospital B on 10/27/2025 revealed they recalled Patient #2 and had been employed for 25 years. The interview revealed “So what I remember, I was added to the chat after the patient had signed out AMA. She was a voluntary patient and denied suicidal ideations. I was added after the fact. My involvement was after the patient had already left. ... I did not reach out to my supervisor. If a patient on suicidal precautions with sitter wanted to leave AMA, a provider would be notified. I do get notified if a patient was admitted to behavioral health, however I am not involved in bed assignments.” The interview revealed escalation of the chain of command was not initiated by AC#2. Further interview on 12/15/2025 at 1028 via Teams [a software platform that combines chat, video meetings, file sharing, and application integration into one workspace] revealed “typically I would get a phone call from a charge nurse, that a patient had signed out AMA. The expectation was for the RN to reach out to an MD, that the patient was leaving AMA. I communicate with the charge nurse by Secure Chat, or we get a phone call. I was not aware the patient was leaving AMA. I was not in the room with the patient that day.” The interview revealed AC#2 was not notified prior to Patient #2 signing out AMA. Telephone interview on 12/11/2025 at 1030 with CN #3 revealed she had been employed since 2013 and recalled Patient #2. The interview revealed “I did discharge the patient and notified the provider. I completed the AMA paper. I notified the hospitalist, and psyche team by secure chat in [named EMR]. I was using secure chat; it was the provider for psyche that day. She was trying to reach the patient’s Mom. She was trying to hold the patient. We were trying to deescalate. The patient did not want to wait. It was definitely a red flag. If they were going to IVC her, the provider was not there. We talked to security about it, we did not have an IVC order, they said they could not touch her. I do not recall who in security I spoke to. We cannot touch or hold a patient if they are not IVC’d. I reached out to Nursing leadership, I spoke to my AC, I don’t recall who. Said ‘we couldn’t hold if not IVC’d’. She walked out the door to the elevator. ..” When asked if this was a safe discharge, CN #3 replied “I couldn’t speak to that. We did what we needed to do, I know this has happened before. With Chat you can only see what you are included in. ..” The interview revealed CN #2 could not identify what Nursing Leadership, Security, or Licensed Provider she was able to reach prior to allowing Patient #2 to leave AMA. Telephone interview on 12/12/2025 at 0935 with Chief of Psychiatry for [named] health system, MD #23, revealed “with any SI patient, the provider should be notified before she left. ...I don’t think the patient should have been allowed to leave. They should have asked security. The intent was inpatient. The nurse should have contacted the doctor. The RN can communicate to the provider for guidance. We can re-evaluate, we can order medication, we have to have a plan. It’s up to the RN to get the provider there. ..This was not a safe discharge. We are all working on an appropriate discharge. A lot of considerations before the patient should go. I was not aware of this event. ..The attending MD should have been notified to come.” Telephone interview on 12/12/2025 at 1235 with Sitter #22 revealed she did recall Patient #2. “ ...When the provider comes to see the patient, I wait outside in the hallway for privacy. I told the Charge Nurse the patient wanted to leave. The AC came in the room. The CN tried to send the Psych Provider a message. The RN knew she wanted to leave before lunch. The CN called the AC, and the patient signed out AMA. The patient stated she wasn’t suicidal and was feeling better. The RN asked her to stay. ..No one called security. I walked in the room and she was gone. ..I don’t know how she left, she got on the elevator ...” The interview revealed [named CN #3] and [named AC #2] were [MC1.1]both aware, Patient #2 wanted to leave AMA. The interview revealed, “the [named MHNP#1] did message me to keep the patient, but at that time, the patient had already left AMA[MC2.1]. ..” Telephone interview on 12/12/2025 at 1345 with the Chief Nursing Officer, CNO #26 revealed, “ ...I would expect the RN to follow the chain of command, regarding a patient on suicide precautions, with sitter. I would expect an RN to give hand-off of what’s going on with the patient. It’s the expectation the Charge Nurse and House Supervisor would have made an MD aware before getting belongings to the patient. If the IVC paperwork was notarized, the patient can be detained before the documents are uploaded. Security can secure that patient. ...” NC00234362”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 41946 Based on policy review, incident report review, medical record review, physician and staff interviews, the facility failed to maintain an accurate medical record for 1 of 1 medical records reviewed. [Patient #2]. Review on 12/10/2025 of the policy, Secure Chat, last approved 06/24/2025 revealed “PURPOSE: to outline a secure platform to allow discussions between care providers regarding [named health system] patients which protects patient ePHI (electronic Protected Health Information). ... PROCEDURE: ... Prohibited: Do not use the copy and paste functionality to reproduce a Secure Chat message to paste into any medical record documentation. Secure chat messages are NOT a substitute for documentation within the legal record. ... Secure Chat is NOT to be used for critical or time sensitive messages. ...” Review on 12/11/2025 of the Incident Report for Patient #2 dated 10/27/2025 revealed the report was completed by the Mental Health Nurse Practitioner [MHNP] #1, and Administrative Coordinator [AC] #2 on 10/27/2025. ...When did this happen: 10/27/2025 at 1315...The AC #2 documented “...18-yo [year-old] female patient admitted after OD [overdose] was voluntary patient, no IVC [involuntary commitment] in place, Inpatient Psych [psychiatry] recommended BH [behavioral health] admit. Patient was medically cleared. Patient indicated to staff that she did not want to go to [Hospital C] and that she wanted to leave the hospital [Hospital B]. Per the CN [charge nurse] she reached out to Inpatient Psych to ask about IVC but before answered was received the patient signed AMA {against medical advice] papers and left. It appears all these were happening simultaneously. The nurse caring for the patient reached out to the NP [named] via secure chat to let her know what occurred and discovered she was in process of IVC paperwork. Patient had already left at 1315...” The incident report review revealed Secure Chat was utilized by nursing staff to relay critical information to a LP [licensed provider] that a suicidal patient with intention of admission to behavioral health was asking to leave AMA.] Closed medical review on 12/10/2025 revealed Patient #2, an 18-year-old female who presented to the Hospital B emergency room on 10/25/2025 at 0007, via emergency medical services [EMS] for an overdose of (9) nine Trileptal 300 mg [prescribed for seizures and can be used for bipolar disorder] tablets. At 0022 the Chief Complaint updated: “Drug Overdose.” At 0025, a Suicide Assessment and Interventions: Columbia Suicide Severity Rating Scale was completed by ED RN #11, with result of “High Risk.” On 10/25/2025 at 0330, an order was placed for Suicide Precautions [SI] with 1:1 sitter by the Hospitalist, Medical Doctor [MD #13]. Review of the History and Physical dated 10/25/2025 at 0340 by MD #13 resulted in an admit to observation status, and consult to Psychiatry for Patient #2 with a principal diagnosis of “Drug overdose, intentional...” On 10/25/2025 at 1522, Patient #2 was transferred to the Medical Unit at Hospital B, with SI precautions and 1:1 Sitter. On 10/25/2025 at 1543, a face-to-face Psychiatry Consult was completed by MHNP #14, and revealed “...given the overdose, emotional instability, and limited insight, she meets criteria for inpatient psychiatric hospitalization once medically stabilized. ...Plan: ...Disposition: --We recommend inpatient psychiatric hospitalization when medically cleared. Patient is under voluntary admission status at this time; please IVC if attempts to leave hospital. ... CSSR Risk Category: High Risk...” On 10/26/2025 at 1832, review of the Progress Note by Hospitalist, MD #15 revealed. ...Assessment & Plan: medically cleared, move to psych inpatient once bed available.” Review of the Discharge Summary, on 10/27/2025 at 1105 by Hospitalist MD #17, revealed “...UPDATE: Patient left AMA and I was not informed until several hours after she left...Discharge Patient, Behavioral Health, Discharge Disposition: 70-Another Health Care Institution Not Defined, Discharge Date: 10/27/2025...” On 10/27/2025 at 1110 a Secure Chat [instant message sent via electronic medical record between clinical staff] message was sent by LCSW #5 to Administrative Coordinator [AC] #18 at Hospital C, and MHNP #1 that revealed “talked to pt. voluntary commitment for Behavioral Health [named Hospital C], she said she was cleared to discharge home.” At 1133, A Secure Chat message was sent by the Primary Care RN #19, “asking for someone to come and talk to her. If it’s OK for her to leave. Does not want to go to BH [Hospital C].” At 1159, A Secure Chat message was sent by MHNP#1 to LCSW #5, and AC #18 “IVC paperwork completed and sent to SW [social worker] for notary. Will enter the orders.” A Secure Chat message was sent at 1245 by MHNP#1 to RN #19 “I need time to enter orders.” At 1258 a Secure Chat message was sent by RN #19, to MHNP#1 “Since the pt. does not want to go, are you going to IVC her now? Her bed is ready, get over here now.” At 1300, A Secure Chat message was sent by RN #19 to MHNP#1 “Since Pt. does not want to go, AC/AD [administrative director], asking when she is leaving. Bed is ready at [named Hospital C].” At 1302 A Secure Chat message was sent by RN #19 to MHNP #1, “Pt. is asking for belongings, signing AMA.” Review of the Leaving Hospital Against Medical Advise form, revealed it was completed on 10/27/2025 at 1315, and witnessed by the Charge Nurse [CN] #3. At 1316 A Secure Chat message was sent by MHNP#1 to RN #19, “No, IVCing Pt..” A Secure Chat message was sent at 1322 by MHNP#1 to RN#19, “unable to leave.” At 1334 A Secure Chat message was sent by RN #19 to MHNP #1, “pt. D/C’d [discharged] AMA.” At 1336 A Secure Chat message was sent by MHNP#1 to RN #19, and LCSW #5 “requesting [named LCSW #5] to complete paperwork, and [Named RN #19] notify security.” At 1340 A Secure Chat message was sent by AC #2 to MHNP#1 “so the Pt. has signed AMA and left. Technically staff could not hold her.” At 1350, AC #2 sent a Secure Chat message to MHNP#1 “no notes with indications of IVC.” At 1356, A Secure Chat message was sent by AC #2 to MHNP#1 “the IVC paperwork just arrived for me to notarize. Do you still want me to sign?” At 1356 A Secure Chat message was sent by MHNP#1 to AC #2 “yes. please.” At 1414, a Secure Chat message was sent by MSW #20 [Master of Social Work], to MHNP#1 “discussed with legal, we cannot notarize paperwork if pt. AMA...will request a welfare check.” Review of a Nursing Progress Note by RN #19 on 10/27/2025 documented at 1931 but timed at 1344 revealed “Patient left AMA. ...CSW collected IVC paperwork from Psych NP [named] to begin filing. CSW notified via secure chat at 1336, of pt. having signed AMA, IVC paperwork placed in shredder by [Hospital B] AC. ...” Review of the Nursing Progress Note, by CN #3 dated 10/27/2025, electronically signed at 1547, but timed for 1344 revealed a series of Secure Chats spanning from 1110 through 1315 on 10/27/2025 that included critical and time-sensitive information of communication between clinical staff regarding Patient #2’s discharge disposition, intent to IVC, and AMA. Review of the Psych Consult Note, dated 10/27/2025 at 1424, but timed at 1344 by MHNP#1 revealed “...10/27/2025: “... However, prior to initiation of involuntary commitment paperwork, nursing staff permitted the patient to leave against medical advice (AMA). Patient departed prior to completion of commitment process. ...” Review revealed Patient #2 signed AMA and left the medical unit via elevator on 10/27/2025 at 1315. In summary, nursing staff supervising the care and safety of Patient #2 used Secure Chat on 10/27/2025 for 2 hours to relay critical, and time sensitive information to notify a LP the Patient’s intent to leave AMA, and did not communicate via approved means, allowing Patient #2 to sign out AMA and leave. An LP utilized Secure Chat to relay the intent to IVC Patient #2 to nursing and clinical staff and did not document in the electronic medical record or communicate by approved means in a timely manner. A Charge Nurse copied and pasted Secure Chat communications, into a Nursing Progress Note against hospital policy. These events allowed Patient #2, while on suicidal precautions with 1:1 sitter at the bedside, who was discharged to be admitted to the inpatient Behavioral Health for psychiatric stabilization following an intentional overdose to leave the hospital AMA. Telephone interview on 12/10/2025 at 1430 with RN #19 revealed they had been employed since 2007 and recalled Patient #2. “...We were waiting for the nurse practitioner to come and discharge the patient. The patient kept asking ‘when can I leave.’ I reached out to [named] nurse practitioner with psych, ... I sent a secure chat in [named electronic medical record system] and she didn’t respond. The charge nurse [named] discharged the patient AMA while I was away. When [named] nurse practitioner got back in touch the patient had left. I was aware the patient was supposed to be admitted, but not for sure she wasn’t going home. I did not talk to a doctor. ..” The interview revealed RN #19 utilized Secure Chat to relay critical message and time sensitive information, regarding Patient #2. Telephone interview on 12/11/2025 at 1030 with CN #3 revealed she had been employed since 2013 and recalled Patient #2. The interview revealed “... I notified the hospitalist, and psych team by secure chat in [named EMR]. I was using secure chat; it was the provider for psych that day. ...She was trying to hold the patient. ...With Chat you can only see what you are included in. ..” The interview revealed CN #2 copied and pasted Secure Chat into the medical record ‘when she felt she needed to do so. ’ ...” The interview revealed CN #2 did not document in the medical record critical information related to communicating with an LP, Security, or Nursing Leadership prior to allowing Patient #2 to leave AMA, while suicidal precautions were in place with intent to admit to behavioral health for inpatient psychiatric stabilization following an intentional overdose. Telephone interview on 12/11/2025 at 0930 with MHNP#1 revealed “...I determined the patient needed to be inpatient in behavioral health. In the Chat at 1159, I completed and passed the paperwork onto [named LCSW#5], but I also notified her face to face. I messaged her, ‘paperwork completed.’ And met her on the 5th floor. It was a IVC Petition and first exam, it takes 15-20 minutes to complete. I handed it off to the social worker, it was not completed. ..I normally place the IVC order in the record once the notarized paperwork was sent to the magistrate. We are able to hold the patient to keep them here. She had a sitter in place. I sent a Secure Chat at 1245 where I was completing IVC paperwork. The notary makes the petition valid. Once signed, the IVC paperwork should have been uploaded in the system. Once I was made aware she had left AMA, I advised nursing [via secure chat] to contact hospital security to be brought back. We should have and can do that. The House Supervisor [named AC #2] declined. If the IVC had been completed and faxed, LEO [law enforcement officer] could have went and brought her back. ...I do believe there is missing Secure Chat in the progress note posted by the charge nurse, not all of the messages were copied and pasted into the medical record. ...I was not informed until the patient had already left.” Further telephone interview on 12/12/2025 at 0845 revealed “...There was a 1:1 Sitter [named] with her. I messaged her by Secure Chat to let her know, not to allow the patient to leave, she responded ‘ok’ . ..I don’t think I spoke to [named RN #19], she was aware, it was obvious in chat she understood. ..” The interview revealed the MHNP #1 used Secure Chat to relay critical and time sensitive messages to clinical nursing staff regarding, the intent to IVC a patient. Interview on 12/12/2025 at 1315 with the Chief Medical Officer, MD #08 revealed “... if the intent was to IVC Patient #2, the provider [MHNP#1] should have put a brief note in the medical record, so that all staff had availability to the information. ...” Telephone interview on 12/12/2025 at 1345 with the Chief Nursing Officer, CNO #26 revealed she was the Assistant Chief Nursing Officer at the time, and recently was promoted to Chief Nursing Officer [CNO] of Hospital B. The interview revealed the expectation was for nursing staff to follow hospital policies, ...” The interview revealed nursing staff should document critical patient information timely in the medical record. Interview on 12/16/2025 at 1200 via Teams with the Chief Nursing Information Officer, and the Medical Information Officer revealed “...It’s against policy to use secure chat for critical information. Currently, we do not have hospital issued cell phones for all clinical staff in order to extend Secure Chat to a hospital issued phone. ...We do not use Secure Chat for emergency situations. ...” The interview revealed nursing staff need to have access to a desktop with the electronic medical record system in order to receive and reply to Secure Chat messages. NC00234362; NC00230661; NC00232466; NC00228825; NC00228578; NC00228992; NC00233578; and NC00230273”