Glenwood Behavioral Health Hospital

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 40471 Based on record review, staff interview, and policy review, the Acute Care Hospital failed to timely report an allegation of patient to patient sexual abuse. This affected one (Patient #01) of 10 patients reviewed. Findings include: Review of records for Patient #01 was admitted on 04/07/26 at 3:31 A.M. with an admitting diagnosis of unspecified psychosis not due to a substance or a known physiological condition, additional diagnoses included schizophrenia, borderline personality disorder (BPD), post traumatic stress disorder (PTSD), and self-mutilating behavior, and during her admission she was diagnosed with bipolar type one disorder. Review of Patient #01’s admission assessment documentation revealed the patient was having grandiose delusions, including belief she was pregnant despite labs that showed she was not, she owed money to people who were pursuing her for repayment and to kill her, and her ex-boyfriend was trying to harm her. Patient #01 provided inconsistent information throughout the intake process. Review of nursing notes dated 04/09/26 at 8:45 A.M. revealed Patient #01 asked Licensed Practical Nurse (LPN) G to speak in private. Patient #01 told LPN G “I believe I was sexually assaulted last night.” LPN G told Patient #01 she would write down what Patient #01 told her and have to notify her Unit Manager (UM) F of the allegation. Patient #01 stated she did not wish for UM F to be told and she wanted a rape kit done by a Sexual Assault Nurse Examiner (SANE) nurse. LPN G again stated the acute hospital’s protocol was for her to notify her supervisor. Patient #01 stated “I will not talk to the nurse manager. You will take my statement, and I will not talk to the unit manager. I only want a SANE to do my rape kit.” However, LPN G documented that she did notify UM F of the situation. Review of nursing notes dated 04/09/26 at 10:45 A.M. and 2:45 P.M. revealed Patient #01 made additional statements with details, including the assault occurred at 3:00 A.M. by two male patients she identified (Patient #02 and Patient #03), initially Patient #01 stated a female patient assaulted her, but then recanted that statement. Each time Patient #01 stated she wanted a rape kit done by a SANE nurse and she had previous SANE examinations. LPN G documented she contacted UM F, who contacted the Director of Risk Management (DRM) C. Interview on 04/14/26 at 9:50 A.M., DRM C stated she was made aware of the allegation of sexual assault on 04/09/26 at 3:30 P.M., DRM C verified she called the local authorities. Interview on 04/14/26 at 2:17 P.M., LPN G stated she contacted UM F to let her know about the allegation as well as Nurse Practitioner (NP) H to obtain orders to increase frequency of observations for Patient #01 while she remained in the acute hospital. Interview on 04/15/26 at 10:15 A.M., NP H verified LPN G contacted him on 04/09/26 about the allegation of sexual assault, he provided orders for every five minute observations of Patient #01, but he had not reported the allegation of assault to any other member of leadership, NP H stated the unit staff usually made sure it was escalated, but he was not aware if it had been at the time. Interview on 04/20/26 at 8:11 A.M., Chief Executive Officer (CEO) A stated she expected each staff member to escalate allegations of abuse immediately or as soon as possible if a situation required immediate interventions for safety. Interview on 04/20/26 at 9:54 A.M., Physician K stated the acute hospital had several methods for communications which expedited communication between leadership and providers. Physician K expected each staff member to escalate allegations of abuse immediately or as soon as possible. Interview on 04/20/26 at 11:32 A.M., UM F stated she did not recall the exact time LPN G reported the allegation of assault, but stated it was on 04/09/26 between 10:00 A.M. and 2:51 P.M., at least once by phone and once in person while UM F was on the unit. UM F notified DRM C of the allegation on 04/09/26 around 2:51 P.M. which was when LPN G called UM F again to update her on the situation. UM F was not able to state why she had not reported the allegation to DRM C sooner. Review of policy titled, “Abuse and Neglect Reporting”, dated 08/2025, revealed “It was the policy of acute hospital that any staff who witness or suspect a patient had been abused either physically or verbally will report such abuse to the appropriate authority IMMEDIATELY (their emphasis). This included patient-to-patient, staff-to-patient, or suspicion that a patient may have been at risk for verbal, mental, physical, and sexual abuse.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 28999 Based on record review, interview and policy review, the facility failed to ensure that patient and/or patient representative concerns were promptly recorded, addressed, and resolved in accordance with the provider’s policies and procedures; and failed to ensure staff obtained consent from the legal guardians of three adolescent patients prior to the administration of a medication used to treat anxiety. The affected Patients #1, #2, #3 and #6. The hospital census was 50. See A120 and A131.”

“PATIENT RIGHTS: TIMELY REFERRAL OF GRIEVANCES CFR(s): 482.13(a)(2) [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee.] The grievance process must include a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the appropriate Utilization and Quality Control Quality Improvement Organization. At a minimum: This Standard is not met as evidenced by: 18665 Based on record review, interview and policy review, the facility failed to ensure that patient and/or patient representative concerns were promptly recorded, addressed, and resolved in accordance with the provider’s policies and procedures. This affected one (Patient #1) patient and had the potential to affect any patient at the hospital. The hospital census was 50 patients. Findings include: Review of a nursing note dated 02/20/24 at 9:30 AM revealed that Staff F received a phone call from Patient #1’s representative about concerns they had with care and services. These concerns were reported to them by Patient #1 about their dates of service from 02/13/24 to 02/20/24. Review of the nursing documentation revealed that the patient’s representative was concerned about being given another patient’s medication by accident, that social work only contacted him once, that he/she was not contacted for information about Patient #1 for the admission process and that staff had contacted another of Patient #1’s representatives about care circumstances and to obtain consent for treatment. Review of Staff F’s documentation about the phone call and concerns revealed that Staff F phoned the facility’s patient representative and left a message on 02/20/24 at 10:42 AM and sent an electronic message by text message at 10:49 AM regarding the need for further attention to the matter. Review of the facility’s grievance log on 03/26/24 revealed that there was no documented information about the concerns of Patient #1’s representative. Review of the procedure revealed the facility had a system for logging the concern on a tracking tool, continuing the advancement of the concern to designated staff where it would be assigned to an appropriate staff person to investigate within two days. Review of the investigation process revealed tasks included patient interview, witness interview, staff interview, chart review, communication with other staff and documentation on the Patient Concern Notification Form. The process continued with the patient advocate’s review, determination for action, involvement of managers, achievement of a resolution and response to the complainant in writing, with retention of the documents within the facility’s log. Interview with Staff H on 03/26/24 at 3:31 PM revealed that all staff are trained about complaint and grievance protocols including identification of an incident for prompt and effective reporting with use of the facility’s form and investigation by appropriate staff. Interview with Staff G on 03/26/24 at 3:40 PM revealed that he/she recalled receiving a call and an electronic message about Patient #1 representative’s concern but no Patient Concern Notification Form was completed. Staff G confirmed that the facility’s process for managing grievances was not followed according to protocol. Review of the facility’s policy titled “Grievance Procedure Patient and Family”, issued February 2021, revealed that complaints that are considered grievances included situations where a patient or a patient’s representative telephoned the hospital with a complaint regarding the patient’s care or with an allegation of abuse or neglect, or failure of the hospital to comply with one or more conditions of participation, or other Centers for Medicare and Medicaid Services requirements. Review of the grievance procedure action steps revealed that staff receiving the concern from a patient or patient representative should acknowledge receipt of the grievance by documentation on the Patient Concern Notification Form with a time and date, attempt to resolve the concern at the time of receipt, document the actions taken on the Patient Concern Notification Form, and forward the Patient Concern Notification Form to the patient advocate.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 28999 Based on record review, interview and policy review, the facility failed to ensure staff obtained consent from the legal guardians of three adolescent patients prior to the administration of a medication used to treat anxiety. The affected Patients #2, #3, #6. The hospital census was 50. Findings include: 1. Review of the medical record of Patient #2, a 14 year old, revealed the patient was transferred to the facility from an outside hospital on 02/01/24 at 5:40 PM with suicidal ideations. The patient had a plan to commit suicide by cutting her wrists. According to a psychiatric physician’s history and physical, the patient had a history of suicide attempts, multiple hospitalizations, and outpatient treatment. The patient was diagnosed with major depressive disorder. A certified nurse practitioner (CNP) ordered for the patient to be medicated with Vistaril (a medication used as a sedative to treat anxiety and tension) 25 milligrams (mg) by mouth every six hours as needed for anxiety and insomnia. A nurse’s annotation at 9:35 PM stated the patient’s mother did not consent for the patient to be medicated with Vistaril stating that the patient had taken 10 mg of the medication previously and 25 mg “is too much.” The medication reconciliation order form listed Vistaril. The CNP placed an “X” in the box under the heading “do not order” indicating that Vistaril not be ordered while the patient was in the hospital. Despite the mother’s refusal to consent to the patient being medicated with Vistaril and the CNP not ordering Vistaril, review of the Medication Administration Record (MAR) listed Vistaril 25 mg to be given by mouth every six hours as needed for anxiety. Review of the MAR revealed the patient was medicated with Vistaril 25 mg by mouth on 02/02/24 at 9:00 AM and on 02/03/24 at 4:40 PM. 2. Review of the medical record of Patient #3, a 15 year old, revealed the patient was transferred to the facility from a group home on 01/23/24 at 6:31 AM after a suicidal attempt. The patient had five hospitalizations for mental treatment in the past three months. The psychiatric physician’s history and physical revealed the patient had choked and cut himself. The patient endorsed hopelessness and helplessness during an interview on admission. The patient was diagnosed with bipolar disorder without psychotic features and generalized anxiety disorder. Vistaril 25 mg by mouth every six hours as needed for anxiety and insomnia was ordered by a CNP. Although medication consent for other psychiatric medications was noted in the medical record, there was no consent signed by a guardian/parent permitting staff to medicate the patient with Vistaril. Review of the MAR revealed the patient was medicated with Vistaril on 02/01/24 at 4:00 PM, 02/02/24 at 9:00 AM, 02/03/24 at 9:00 AM, and 02/03/24 at 4:40 PM for anxiety. 3. Review of the medical record of Patient #6, a 17 year old, revealed the patient was transferred to the facility from an outside hospital on 01/12/24 at 2:51 PM after running away from home causing the patient’s adoptive mother to file a missing person’s report. The patient returned home after three days, however, her adoptive mother described her as aggressive and threatening when she returned. The patient allegedly held her adoptive mother by the neck and threw a bottle at her. The CNP ordered Vistaril 50 mg by mouth every six hours as needed for anxiety. A nurse’s note stated the patient’s adoptive mother/guardian would get back with staff with a decision on whether or not she could be medicated with the medication used for anxiety. A psychiatric physician’s progress note on 01/15/24 at 10:50 AM stated the patient’s mother refused to approve PO (by mouth) medications. Despite the guardian’s refusal to consent to the administration of Vistaril, according to the MAR, the patient was medicated with Vistaril 50 mg by mouth on 01/18/24 at 9:00 PM. During an interview on 03/28/24 at 3:45 PM, Staff D, Chief Nursing Officer was asked to review the medical records of Patient #2, Patient #3, and Patient #6 to locate medication consent forms signed by the legal representatives of the adolescent patients. After reviewing the medical records, Staff D was unable to locate documentation informed consent was obtained prior administration of the medication used to treat anxiety. It was further confirmed that informed consent must be obtained from the legal representatives of adolescent patients prior to the administration of medication. The facility policy titled “Informed Consent, Medications”, issued April 2020, documented patients who have psychotropic medications ordered will be informed of the benefits and risks involved in taking prescribed medications. Informed consent will be obtained prior to administering the medication. The ordering practitioner will discuss with the patient and/or legal representative at the time the medication is ordered. Informed consent may be documented on a medication consent form. Discussion of informed consent may be documented in a progress note.”