Hackensack Meridian Health Carrier Clinic

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 47131 Based on staff interviews, document review, and review of five of ten medical records (Patient (P)2, P3, P4, P6, and P9), it was determined that the facility failed to ensure all patients on the Adolescent Unit receive a “Welcome Packet” with written rules and patient expectations, in accordance with its “Patient Rights” policy. Findings include: Reference: Policy titled “Patient Rights” (Last revised 02/2026) states, “...Communication and Information: ...Be advised in writing of the hospital rules regarding the conduct of patients... .” Reference: Document titled, “ADOLESCENT UNIT PATIENT WELCOME PACKET” (No Date) states, “... Please be mindful to follow the listed rules in order to keep the Adolescent Unit a safe and therapeutic environment. ...Your Expectations as a Patient: ...We want you to know your applicable rights; we are here to educate you as well. ... .” During an interview conducted with Staff (S)7 on 03/19/26 at 10:37 AM, he/she stated, “ ...After the patient is assessed by a RN [Registered Nurse], the MHT [Mental Health Technician] will take the patient to his/her assigned room and review the unit ‘rules and expectations’ and provide the patient with a “Welcome Packet” folder. S7 confirmed that the patient will sign an acknowledgement form that he/she received the “Welcome Packet” folder which includes written unit rules and behavior expectations, and the signed acknowledgement form is uploaded into the patient’s electronic medical record (EMR). On 03/19/26 at 11:45 AM, during review of the electronic medical records for P2, P3, P4, P6, and P9, in the presence of S6, the following medical records lacked a signed attestation that the patient received the ‘Welcome Packet’ which included written rules and expectations of patient conduct on the unit, in accordance with the facility’s ‘Patient Rights’ policy above. P2, a 15-year-old [male/female] who was admitted to the Adolescent Unit on 12/10/25 for “MDD [Major Depressive Disorder] ... .” P3, a 17-year-old [male/female] who was admitted to the Adolescent Unit on 12/28/25 for “ ... MDD, recurrent severe, without psychosis ... .” P4, a 16-year-old [male/female] who was admitted to the Adolescent Unit on 12/12/25 for “ ...ODD [Oppositional Defiant Disorder] ... .” P6, a 17-year-old [male/female] who was admitted to the Adolescent Unit on 12/10/25 for “ ...MDD ... .” P9, a 14-year-old [male/female] who was admitted to the Adolescent Unit on 03/02/26 for “ ...Psychosis ... .” The above findings were confirmed with S6 at the time of the discovery.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 47131 Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to ensure vital signs are assessed and monitored for patients after a physical/therapeutic hold in accordance with facility policy, in one of ten medical records (Patient (P)1). Findings include: Facility policy titled, “Restraints” (Last revised 09/2025) stated, “... Operational Definitions: ... Physical Holding/Therapeutic Hold-Holding a patient in a manner that restricts the patient’s movement against the patient’s will. The duration must be only for as long as it takes to perform the procedure. ...Type of Restraints: Physical Holding/Therapeutic Hold ...Evaluation by the LP [Licensed Practitioner]: Within one hour of giving the initial order, an LP shall respond, conduct, and document a face-to-face evaluation of the patient. ... The clinical condition of the patient shall be evaluated and documented by medical or licensed nursing personnel. ... Interventions: ... The patient will be assessed for assessment/response to intervention ... Each assessment and nursing intervention should be made as follows: Every Two (2) hours: ...Vital signs ...” A review of P1’s medical record for Patient (P)1, revealed the following: P1 was a 33-year-old who was admitted to the facility on 01/05/26 from the Emergency Department with psychiatric diagnoses including schizoaffective disorder-bipolar type, auditory and tactile hallucinations, and self-harm behaviors. In a nursing note entered on 01/08/26 at 8:01 AM it stated, “ ...0729 [7:29 AM] staff attempted to escort patient to QA [Quiet Area], but [he/she] resisted walking. [He/She] then leaned forward and lowered to the ground. 0730 [7:30 AM] patient was placed in therapeutic hold to prevent harm to self and others. While in physical hold, [he/she] continued to yell and was not following verbal redirection ... Patient was assisted to standing and walked to QA2 where [he/she] continued to yell. Patient was given Ativan (a medication used to treat severe anxiety and acute agitation) 2 milligrams IM [intramuscular] at 0738 [7:38 AM] in right deltoid and appeared to tolerate it well. Face to face completed at 0738 [7:38 AM]. Doctor [name] informed nurse to give Geodon (an antipsychotic medication used to treat acute agitation) 20 milligram IM PRN [as needed] now in addition to the Ativan [he/she] received. Patient was agreeable to IM medication. 0755 [7:55 AM] patient received Geodon 20 milligrams IM for agitation in left deltoid and appeared to tolerate it well. ... Writer notified LIP [Licensed Independent Practitioner] that patient had bleeding in mouth. Patient denies any pain or discomfort at this time. Med [Medical] consult placed and medical staff notified. LIP [Licensed Independent Practitioner] reports patient can receive [his/her] AM medications now. Nursing supervisor made aware. Patient remains in QA2 [Quiet Area 2] with 1 to 1 [one-to-one] observation ... Edit: ... 1058 [10:58 AM] Patient out of the QA ... [he/she] appeared to be in better behavioral control and asked to go to [his/her] room. [He/She] was agreeable to unit expectation and able to follow simple instructions. [He/She] remains on 1:1 at this time and is visible on the unit.” A review of documentation in the Therapeutic Hold Progress Note, dated 01/08/26 at 7:59 AM by S15, stated, “ ... Face to Face Assessment: Does pt have any medical issues that need to be considered? No known factors; Patient’s subjective report leading to or remaining in Therapeutic Hold: patient trying to hit [him/her]self and injure [his/her] teeth; Physical Condition Assessment: belligerent; ...Plan to reduce Seclusion need: Continue Current Medications ...” A review of the “Rover PCT Vitals” flow sheets, P1’s vital signs was documented on 01/08/26 as, “0713 [7:13 AM] ... Temp [temperature]: 98.2F; Pulse: 75; BP [Blood Pressure]: 115/56; SpO2 [oxygen saturation]: [blank] ... 1916 [7:16 PM]: Temp 98.7F; Pulse 76; BP 128/76; SpO2 96%.” No other vital signs were documented for P1 on 01/08/26. During an interview, on 01/14/26 at 12:45 PM, S16 confirmed that when a provider completes a face-to-face evaluation, the evaluation includes a general assessment of the patient, including the patient’s mental status and updated vital signs. When asked if a patient’s vital signs should be assessed after being placed in a therapeutic hold, S16 stated, “Yes, vital signs should be reassessed.” The medical consultation note completed by S17 on 01/08/26 at 9:42 AM stated, “ ... Consult Reason: Self-inflicted facial bruising. s/p (status/post) PRT (Physical Restraint Technique) ... V.s.[Vital Signs] stable. ... Assessment/ Plan: pt denies pain or tenderness in the face, no swelling or puffiness, redness or abrasions noted, denies difficulty moving the jaw when chewing or talking. Monitor ...” The patient’s vital signs documented were noted to be from 7:13 AM, prior to the patient being placed in a therapeutic hold. P1’s medical record lacked documentation that on 01/08/26, the patient’s vital signs were reassessed every two hours while P1 was in QA2 after the patient was placed in a Physical Hold/Therapeutic Hold at 7:30 AM, until the order was discontinued at 10:58 AM. S16 confirmed these findings on 01/14/26 at 12:45 PM.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48614 Based on staff interview, review of medical records, and review of facility documents, it was determined that the facility failed to ensure: 1.) implementation of their policy on assessing elopement risk and assigning level of observation (0144); 2.) accurate documentation of Q15 (every 15 minutes) observation for all patients (0144); 3.) a comprehensive risk assessment is documented involving all courtyards (0144); 4.) the safety risk assessment and PSS3/ESS6 screening tools are completed for all patients upon admission and defined in facility policy (0144). This failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to the patients. Findings include: The facility was informed of the IJ and provided with the IJ template on January 2, 2024 at 4:20 PM. An acceptable removal plan was received on January 4, 2024, the last day of survey. The facility addressed the IJ findings by educating the Admissions Department Staff, the LIP’s [Licensed Independent Practitioners], and the inpatient unit Registered Nurses on elopement risk assessment procedures and communication to the assigned providers with patient results, provided re-education to staff on all inpatient units for courtyard procedures and protocol, as well as implementation of a Courtyard Patient Roster/Tracking Sheet to be utilized during courtyard activities (smoke breaks, fresh air breaks, and group activities). The IJ was resolved on January 4, 2024, at 11:26 AM, after the State Survey Agency verified full implementation of the removal plan through staff interviews, document review, and review of staff education.”

“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: 48614 Based on review of medical records, staff interviews, facility documents, and tour of the facility inpatient units and courtyards, it was determined that the facility failed to ensure 1.) implementation of their policy on assessing elopement risk and assigning level of observation; 2.) accurate documentation of Q15 (every 15 minutes) observation for all patients; 3.) a comprehensive risk assessment is documented involving all courtyards; 4.) the safety risk assessment and PSS3/ESS6 screening tools are completed for all patients upon admission and defined in facility policy. Findings include: 1. On 12/28/23, review of the medical record of Patient 1 (P1) revealed the following: On 12/20/23 at 21:51 [9:52 PM], upon admission, Staff 28 (S28), the Associate Counselor, determined at screening that the P1 has a history of elopement, documenting, “Runaway behaviors from home and facility.” The medical record lacked documentation that an LIP (licensed independent practitioner) received a verbal agreement from the patient for elopement risk, and the patient was placed on Q15 observation. On 01/02/2024 at 1:37 PM, S10 (Assistant Vice President of Nursing) verified that there was no documented acknowledgement from an LIP of the patient’s elopement assessment, or of communication from S28 to the LIP for P1’s history of elopement. S10 confirmed that there was no documented treatment plan or care plan addressing P1’s history of elopement. S10 indicated that P1’s level of observation was a standard level of every 15 minutes, and stated, “per facility ‘Observation Status and Special Precautions Policy’, the patient should have been on every five minute checks at minimum.” Facility policy titled, “Observation Status and Special Precautions” stated, “every 5-minute checks” will be done for patients at risk for elopement, even if they “verbalized agreement with current treatment plan and denies intent to elope.” 2. On 1/2/24, during the review of the surveillance footage of the incident, P1 was observed eloping from the APA courtyard at 9:55 PM. A tree located near the fence in the APA courtyard was involved at the point of elopement. Upon review of the facility document titled, “Carrier Clinic Q15 min Patient and Environmental Observation Form,” it was documented that the patient was “calm” and “on unit” at 10PM, 10:15PM, 10:30PM, 10:45PM, and 11PM. Upon interview at approximately 1:37 PM, S2, the Assistant Vice President of Risk, verified that the facility video recordings were accurate, and that P1, as of 9:55 PM on 12/25/2023, was no longer on the APA Unit. 3. On 01/02/2024 at 11:30 AM, S2 provided documentation of a risk assessment from 12/26/23, following P1’s elopement from the APA courtyard. The risk assessment identified the trees as high risk. S2 provided documentation of a risk assessment completed on 6/12/23, following a patient elopement from another courtyard using a tree. The tree was removed as a mitigation plan, but no risk assessment was provided for other courtyard areas, including the APA courtyard. S2 stated that following P1’s elopement, all APA staff received re-education prior to their next working shift on this unit, but that only the staff on the APA unit received the education. S2 confirmed that staff members can float and work on other units, including patient observers. 4. On 12/28/23, upon review of safety risk assessments documented for Patient 2 (P2), P3, P4, P5, P6, P7, and P10, the following was revealed: -P2, admitting diagnosis paranoid schizophrenia, was assessed on 12/21/23 at 2:41 PM and documented as a “moderate risk level.” Provider order written on 12/21/23 at 2:47 PM indicated the patient was placed on every (q) 5-minute safety checks. -P3, admitting diagnosis manic depression and schizoaffective disorder, was assessed on 12/17/23 at 3:38 PM and a complete safety risk assessment was not conducted. Provider order written on 12/17/23 at 3:45 PM indicated the patient was placed on q15-minute safety checks. -P4, admitting diagnosis schizophrenia, was assessed on 12/20/23 at 4:00 AM and documented as “unable to complete.” Upon request, S2 was unable to provide a safety risk assessment that was done at admission. Provider order written on 12/19/23 at 8:53 PM indicated the patient was placed on q5-minute safety checks. -P5, admitting diagnosis schizophrenia with passive suicidal thoughts, was assessed on 12/24/23 at 7:33 PM and documented as a “moderate risk level.” Upon request, S2 was unable to provide a safety risk assessment that was done at admission. Provider order written 12/23/23 at 9:56 PM indicates the patient was placed on q5-minute safety checks. On 12/23/23 at 9:51 PM, P5 had a “positive screen” for his/her suicide screening status. A secondary screening titled “ED-Safe Secondary Screener (ESS-6)” was not conducted. S10, AVP of Nursing, confirmed that a secondary suicide screening was not conducted on 01/02/24 at 3:40 PM. A progress note was written by a registered nurse on 12/24/23 at 12:16 PM that stated the patient “ ...contracts for safety.” -P6, admitting diagnosis bipolar disorder with depression, was assessed on 12/16/23 at 4:35 AM and documented as “moderate risk level”. Provider order written 12/16/23 at 5:12 AM indicates the patient was placed on q15-minute safety checks. -P7, admitting diagnosis major depressive disorder with psychotic features, was assessed on 12/20/23 at 4:20 PM and had a “positive screen” for his/her suicide screening status. The secondary screening, ESS-6, recommended the level of intervention as “current level”. The chart failed to reveal what the “current level” was. A provider order written on 12/20/23 at 4:07 PM indicates the patient was placed on q15-minute safety checks. An interview was conducted with S14 that indicated he/she would have placed the patient on q5-minute checks given the positive screen and the patient’s past history. -P8, admitting diagnosis bipolar disorder, was assessed 12/24/23 at 12:53 PM and documented as “moderate risk level”. Provider order written 12/24/23 at 12:58 PM indicates the patient was placed on q15-minute safety checks. -P10, admitting diagnosis schizoaffective disorder depressive type, had an initial psychiatric assessment conducted on 12/18/23 at 9:33 AM. The physician wrote, “Patient agreed to stay safe ...” An interview was conducted with S14, the Psychiatric Nurse Practitioner, on 01/02/24 at 11:35 AM concerning the “Safety Risk Assessment,” S14 stated that, “low risk indicates a q15 minute check, moderate risk indicates a q5 minute check, and high risk indicates a 1:1.” S14 confirmed that safety risk assessments are conducted on every patient at admission and throughout his/her inpatient stay and this helps to guide the level of observation needed for the patient. Upon request, S2 provided the facility policy titled, “Observation Status and Special Precautions” for review. Upon review of the policy, the policy lacked definition of the frequency of observation in relation to the safety risk assessment risk levels. Upon request, S2 was unable to provide a policy regarding the safety risk assessment. During an interview with S14 on 01/02/24 at 11:30 AM, the process of admitting a patient with suicidal thoughts was reviewed. S14 stated the patient has multiple safety screenings, including the “ ...PHQ9 [which is] done first and then safety risk assessment, and suicide assessment”. S14 explained these safety assessments in conjunction with an initial full patient assessment help to determine the level of patient observation. Per S14, an additional factor is whether the patient is able to “contract for safety” which, “is not signed but is documented in the note.” During an interview with S1, the Vice President of Patient Care Services, he/she stated, “we do not use contracts for safety.” A review of the facility’s policy titled, “Observation Status and Special Precautions” stated patients are placed on 1:1 observance if the patient, “ ...is unable or unwilling to verbalize that they will NOT attempt to harm themselves” or observed every 5 minutes if the patient “may verbalize uncertainty in ability to maintain personal safety but is agreeable with utilizing coping skills or reaching out to staff if additional support is needed.” The facility failed to ensure implementation of their suicide screenings in conjunction with contracting for safety in their policies and procedures to provide a safe environment for the patient. 49174”

“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: 49174 Based on medical record review and staff interviews, it was determined that the facility failed to ensure an accurate written discharge disposition in the medical record for one of 10 medical records reviewed (#1). Findings include: On 12/28/23, review of Patient 1’s (P1) medical record revealed his/her discharge disposition as “home” despite P1 having eloped on 12/25/23. Upon review with Staff 10 (S10), AVP of Nursing, concerning the documented discharge disposition, S10 stated, “I don’t know why it says that. [He/she] eloped.””

“Psych Eval - Within 60 Hours CFR(s): [Each patient must receive a psychiatric evaluation that must--] Be completed within 60 hours of admission; This Standard is not met as evidenced by: 49174 Based on medical record review and staff interviews, it was determined the facility failed to provide the patient with a full psychiatric evaluation within 60 hours of admission, in one of ten medical records reviewed (#9). Findings include: On 12/28/23, review of P9’s medical record revealed the following: On 12/15/23 at 6:31 PM, P9 was admitted to the facility. An “Attending Assessment Note” was documented by psychiatry on 12/18/2023 at 7:28 PM, approximately 73 hours after admission. Upon interview, on 1/2/24 at 11:30 AM, Staff 14 (S14), the Psychiatric Nurse Practitioner, stated, “a patient should be evaluated by an APN [Advanced Nurse Practitioner] or MD [Medical Doctor] upon admission for stabilization and getting [the patient] to the unit. This evaluation is called an ‘Access Assessment’ and must be completed within 24 hours. The full assessment is done by the patient’s primary psychiatrist and that note is called the ‘Attending Assessment Note’.” S2, the Assistant VP of Risk, confirmed this information on 1/2/24 at 10:50 AM, and stated, “there are two psychiatric assessments. The first one is the initial psych and that is done on admission and the [second assessment is the] full medical assessment [which] has to be done within 60 hours.” When the Attending Assessment Note was presented to S10, the AVP of Nursing, he/she confirmed that the evaluation was done late, and stated, “that’s what I have.” The facility was unable to provide documentated evidence that a full psychiatric examination was completed within 60 hours of admission.”

“Treatment Plan CFR(s): Standard Treatment Plan Each patient must have an individualized, comprehensive treatment plan based on an inventory of the patient’s strengths and disabilities. This Standard is not met as evidenced by: 49174 Based on medical record review, staff interview, and review of facility policies and procedures, it was determined that the facility failed to provide an individualized, comprehensive treatment plan, in accordance with facility policy, in three of 10 medical records reviewed (#1, #9, and #10). Findings include: On 12/28/23, a review of Patient 1 (P1), P9, and P10’s medical records revealed the following: On 12/20/23 at 8:00 PM, P1 was admitted with a diagnosis of manic-depressive disorder. The medical record lacked a treatment of care plan for the patient. On 1/2/24 at 1:47 PM, a request was made to Staff 10 (S10), the AVP of Nursing, for P1’s treatment of care plan. S10 was unable to provide the treatment of care plan and stated, “we don’t have one for [him/her].” On 12/15/23 at 6:31 PM, P9 was admitted with a diagnosis of bipolar disorder manic with psychotic features. P9’s treatment of care plan was never finalized and was left in “draft” format. On 01/02/24 at 3:15 PM, S10 confirmed that the treatment of care plan was still in “draft” format. On 12/15/23 at 11:39 PM, P10 was admitted with a diagnosis of schizoaffective disorder, depressive type. P10’s treatment of care plan was finalized on 12/22/23. On 01/02/24 at 03:25 PM, S10 confirmed there was a delay in finalizing the treatment of care plan. Facility policy titled, “Medical Staff Documentation” last approved 03/21, was reviewed and stated, “...a master treatment plan is done within 72 hours of admission by the multidisciplinary team involved in the assessment and treatment of the patient.” The facility was unable to provide evidence that P1, P9 and P10’s treatment of care plan was completed and finalized within 72 hours post admission, in accordance with facility policy.”