Avera Mckennan Hospital & University Health Center

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 32355 Based on review of an anonymous complaint report received by the South Dakota Department of Health (SD DOH, record review, interview, policy review, and job description review, the provider failed to ensure one of eight sampled patients (5) discharge orders were reviewed for accuracy by one of one case manager (CM) (E) before being discharged from the facility and readmitted to an assisted living center (ALC) that could not provide him with the level of care that he needed, and he was re-hospitalized after two days. Findings include: 1. Review of an anonymous complaint received (time withheld due to anonymity) by the SD DOH revealed patient 5 had an increased temperature and complained of a headache and was transferred from an ALC to the local hospital’s emergency department (ED) for evaluation. Through testing and assessments, it was determined that the patient had a brain bleed and required a higher level of care. The patient was air-lifted to an acute care hospital where he was admitted for further care and treatment. After patient 5 was admitted to the acute care hospital, the director of nursing (DON) G at the ALC received physician notes from the hospital to keep her informed of the patient’s current condition. DON G had conversations with the patient’s social worker (SW) and was concerned that they would not be able to meet his needs when he was discharged from the hospital and admitted back to their facility. He required the use of a nasal gastric (NG) tube (a small tube that is placed through the nose and down into the stomach for nutritional support), a heparin drip (blood-thinning medication administered intravenously (IV), and rehabilitation therapy needs for muscle strengthening. As an ALC, they were not able to support that level of care (LOC). On 2/11/26 CM (staff who assist patients with discharge planning) E contacted DON G regarding patient 5’s status and indicated he was back to his baseline level of care before his admission and was able to be discharged back to the ALC. Again, DON G voiced her concerns that they would not be able to support his LOC needs. CM E confirmed the patient no longer had an IV heparin drip nor an NG tube for nutritional support. On 2/16/26 CM E contacted DON G, stating patient 5 was ready to return home. DON G stated she would need to have accurate documentation that the patient was fit for the ALC to safely take care of him. CM E sent the most recent documentation from the physician to DON 5 for her to review. DON G reviewed the most recent documentation and discharge notes from the physician and agreed to accept him back into the ALC. She informed CM E that they would not be able to admit him back into their facility until the next day, on 2/17/26. He was admitted back to the ALC later that afternoon (2/16/26) without DON G’s knowledge or consent. She had received a call from the ALC staff to let her know he had returned from the hospital. Upon review of his hospital discharge orders, DON G noted that he was not on any anticoagulation therapy (blood-thinning medications). She felt this was unsafe and scheduled an appointment for him to see his primary care provider (PCP) H on 2/18/26. She also noted that during his stay at the acute care hospital, he had a Preadmission Screening and Resident Review (PASRR) (an assessment completed to Identify a mental health illness and to ensure the patient was placed in the appropriate setting). The PASRR results qualified him for 100 days of care in a long-term care facility (LTC). This assessment supported her concerns about the ALC not being able to meet his care needs. On 2/18/26, patient 5 complained of a headache and was unsteady on his feet. DON G transported the patient to a sister facility, so that the hospital could review his stay at the acute care facility. He was re-admitted to the hospital just two days post-discharge from the acute care facility. Later, he was discharged from that hospital to a LTC facility for rehabilitation care and treatment. 2. Review of patient 5’s electronic medical record (EMR) from 1/26/26 through 2/16/26 revealed on 1/26/26, he was air-lifted to the facility and presented to the ED with complaints of a headache, confusion, and fever. Through assessment and testing in the ED, it was identified that he had an active brain bleed. He had a history of atrial fibrillation (irregular heartbeat) and coronary artery disease (heart condition that blocks the blood flow to the heart) with a stent (small tube inserted into the artery to improve blood flow to the heart) placement in 2021. He required the use of Warfarin (blood-thinning medication) to help regulate his heart rate and blood flow to the heart. His treatment course was complicated due to his history of alcohol consumption, smoking, community-acquired pneumonia (infection in the lungs) causing an exacerbation of his chronic obstructive pulmonary disease (COPD) (lung disease that restricts airflow), behaviors due to bipolar (mood fluctuations) diagnosis that required medication adjustments, malnutrition with NG tube placement for nutritional support, and urinary retention with a foley catheter placement (tube inserted into the bladder to assist with urine flow). His brain bleed required the use of vitamin K to reverse the blood-thinning medication that he had taken at the ALC, Abilify (an antipsychotic medication) was prescribed to help with his behaviors, bipolar disorder, and increased anxiety. From 1/26/26 through 2/4/26, he was placed on bedrest and required the use of soft wrist restraints (device used to secure a patient’s wrists to a bed frame) due to his having alcohol withdrawals and needed the restraints to prevent him from causing self-harm or pulling out any tubes, lines, or dressings that were required for medical treatment. He was combative, impulsive, and had aggressive behaviors, with the inability to follow directions from the staff. He had a history of falling and had two falls during his hospitalization. He was high risk for falling until due to his impulsive behaviors and poor safety awareness. His Warfarin was discontinued, and he was started on Eliquis (a blood-thinning medication) for replacement therapy during his hospitalization. Patient 5’s physical therapy documentation from 1/27/26 through 2/12/26 indicated physical therapy was ordered upon admission to work on strengthening muscles to return him to his baseline. Before his hospitalization, he was independent with all activities of daily living (ADL) and medication management at the ALC. Physical therapy was unable to evaluate and treat the patient until 2/2/26 due to bed rest orders. Upon initial evaluation, the patient required the assistance of two staff members to assist with bed mobility, sitting on the edge of the bed, and control of his upper part of his body. He was unable to follow verbal cues from the physical therapist. His knees buckled upon standing and required the physical therapist to support his knees while standing. With assistance, he stood for 20 seconds. By working with physical therapy, he was able to regain independence with bed mobility and transfers, and needed stand-by assistance from the staff with walking. Due to continued confusion, he had difficulties with comprehension. On 2/12/26, the physical therapist indicated that the patient would benefit from continued physical therapy with home health (HH) services, and required a chair alarm and items to be within his reach for fall safety. Patient 5’s case management notes indicated on 1/29/26, CM E reached out to the ALC DON G to discuss the patient’s baseline level of care status before 1/26/26. DON G informed CM E that at his baseline, he was independent with all ADLs, pleasant, and never combative. He was known to go out and drink alcohol and, at times, smoke marijuana (causes relaxation, euphoria, and altered perceptions, and impaired memory/coordination). He would need to return to this baseline before the ALC would accept him back. The ALC did not offer HH services. On 2/4/26, a fax was sent to the ALC that indicated the patient was unable to participate in the conversation and required 1:1 (staff sitting in the room continuously with the patient) staff supervision. Patient 5 was not medically ready for discharge and required a rehabilitation stay. On 2/9/26, CM E met with the patient at the bedside, and he continued to require 1:1 staff supervision. Patient 5’s medical doctor (MD) reported that the patient was stable and could be discharged from the hospital. CM E was going to start check on the facility referrals for the patient once he was off 1:1 staff supervision. On 2/10/26, CM E contacted the ALC to review patient 5’s data to see if the patient was able to return to their facility. She was going to follow up with the ALC on 2/11/26 since the patient was medically ready to be discharged from the hospital and back to the ALC. On 2/11/26, CM E spoke with DON G at the ALC regarding the patient returning to their facility because he was medically ready. DON G stated the patient was not able to return to their facility due to him receiving an intramuscular injection of Zyprexa (medication used to treat mental instability, such as bipolar disorder) and required 1:1 staff supervision on 2/8/26. CM E informed DON G that patient 5 was medically ready according to the hospital physician. Both parties argued back and forth on contacting the state ombudsman (a neutral patient and resident advocate that is associated with the state social services department). On 2/16/26, CM E faxed the physician’s progress note regarding patient 5 from that day to DON G at the ALC. At the same time, she requested the social worker (SW) to set up a ride for the patient and to update the facility and patient 5 when transportation was confirmed. This request was made before the ALC agreed to accept him back. Later that day, CM E received a call from DON G, who requested documentation to support patient 5 no longer needed a NG tube for nutritional support and did not require heparin injections at discharge. CM E followed up with the hospital physician and requested documentation to indicate that patient 5 would not need a rehabilitation stay was okay to return to the ALC. She also requested discharge orders from the physician, and they were faxed to the ALC. She received a call from DON G stating they could take the patient back if the hospital was able to find transportation. The hospital arranged for transportation to arrive at 3:00 p.m. and transfer the patient back to the ALC via taxi services. CM E documented that she contacted the family and patient 5 about his discharge status. There was no documentation to confirm that she had followed up with the ALC to let them know transportation was arranged and that the patient would arrive at their facility later that day. Patient 5’s PASRR revealed he had one completed on 1/19/26 and 2/4/26. Both PASRRs were referred to Maximus (a separate state organization that ensures appropriate placement for the patients) for further evaluation. On 2/4/26, Maximus approved the patient for 100 days of convalescent care long-term care. There was no further documentation to support that CM E had attempted to contact any LTC facilities for patient 5’s placement. Patient 5’s licensed social worker (LSW) D communication documentation indicated on 2/10/26, patient 5 was off 1:1 observation, physical therapy was working with the patient, a skilled nursing facility (LTC) was pending approval for placement, and the ALC was reviewing the patient’s status to see if they could safely re-admit him back to the facility. On 2/12/26, patient 5 was medically ready to return to the ALC, and CM E was working with the local ombudsman to coordinate his discharge from the hospital. On 2/16/26, CM E requested that transportation be arranged for the patient to be discharged from the hospital and admitted back to the ALC. LSW D requested transportation for patient 5 and notified CM E, and patient 5’s bedside registered nurse (RN) that transport was expected to arrive at 3:00 p.m. that day. There was no documentation to confirm that the ALC agreed to admit the patient back into their facility and that the ALC was notified that the hospital had arranged for patient 5 to arrive at the ALC later that same day. Patient 5’s 2/10/26 psychiatry progress note on 2/10/26 indicated “The patient is confused but not agitated this afternoon. He will wax/wane [fluctuate] in presentation and agitation.” “Today, the patient was seen, but upon entering the room, the patient was found standing next to the bed, refusing to sit back in his bed, and is not responsive to redirection despite multiple attempts by myself and nursing staff.” “Patient proceeds to become increasingly agitated and, despite multiple attempts, does not respond to verbal de-escalation and redirection.” A mental status exam revealed that patient 5 was agitated, his speech was at a high volume, and he lacked insight or understanding of his illness. His judgment was poor based on his decision-making in everyday activities, social situations, compliance, and motivation for treatment. Patient 5’s acute care violence assessment tool indicated on 2/12/26 that he remained confused, irritable, agitated, impulsive, continued to have substance intoxication withdrawal, and he remained at high risk for causing violence. On 2/15/26 and 2/16/26, he remained confused. agitated, impulsive, continued to have substance intoxication withdrawal, and he was assessed as having a moderate risk of causing violence. On 2/12/26, the hospital physician documented that the patient was medically ready to be discharged from the hospital and readmitted back to the ALC or previous level of care, and was discharged back to the ALC on 2/16/26. The hospitalist’s 2/16/26 progress note for patient 5 indicated there was a discharge discrepancy. It was initially documented that the patient was medically ready to be discharged to the ALC. But at the end of the patient’s review of his hospital stay, the hospitalist had documented that patient 5 was medically stable and ready for discharge to a post-acute rehabilitation facility for continued therapy. This documentation was electronically signed on 2/16/26 at 12:40 a.m. Patient 5’s 2/16/26 discharge summary indicated that the documentation was started at 2:18 p.m. that day before his discharge from the hospital. His anticoagulation treatment (Eliquis) was resumed for his diagnosis of atrial fibrillation and past stent placement. There was no documentation that the hospital physician ordered HH services for physical therapy for muscle strengthening. He was medically stable and discharged to the ALC. This documentation was electronically signed on 2/17/26 at 5:47 p.m., the day after he was discharged. Patient 5’s 2/16/26 discharge instructions and orders that were sent with him to the ALC indicated Eliquis was not transcribed on those orders, as the discharge summary had indicated. Home health was not ordered for the patient to continue with physical therapy to help him return to his baseline level of care, where he was fully independent with all ADLs. There was no documentation to support that the interdisciplinary team (IDT) had discussed and reviewed patient 5’s barriers to returning to a facility that did not require 24-hour licensed professional care, such as a nurse. The ALC was required to have a licensed nurse in their facility once a week. The highest level of professional medical coverage at the ALC would be a registered medication aide. The patient required assistance with ambulation and further muscle strengthening through physical therapy services. His moods continued to fluctuate due to changes in his psychotropic medications during his hospitalization. The psychologist could not complete a full assessment of him on 2/12/26 due to his increased behaviors that day. He continued to have no safety awareness with impulsive behaviors, confusion, and anxiety issues. He remained at high risk for falling upon discharge from the hospital, which increased his risk for more brain bleeds. There was no communication documented that the IDT discussed his PASRR approval for LTC services for 100 days, where there would be a licensed nurse in the facility 24-hours a day and seven days a week to ensure his safety. 3. Interview and Patient Discharge or Transfer to Another Acute Care Facility policy review on 4/1/26 at 9:00 a.m. and again at 2:55 p.m. with RN CM manager C revealed a patient was assigned a social worker (SW) and CM upon admission to the hospital. The SW was responsible for completing the initial assessment of the patient, which included the patient’s prior living situation, their social history, prior level of assistance needed for ADLs, if others lived with the patient that helped with their care, and if there were any known barriers to their ability to return to their prior living situation. The information gathered was documented and shared with the patient’s medical team. Rounds (organized meetings by a healthcare team to discuss patient progress, review test results, and formulate or update a management plan) were completed daily and were to be attended by as many of the patient’s medical team as possible. Referrals to nursing homes, ALCs, home health services, or other therapy services were made based on the patient’s needs obtained by the assigned SW and medical team. The assigned CM was responsible for ensuring the patient’s needs were addressed once the SW had completed the patient’s initial admission assessment. Discharge planning began as soon as the patient was admitted to the facility. The assigned CM met with the patient and (if possible) their family members to discuss discharge preferences. If the patient had come from an ALC or a nursing home, their nursing staff would be contacted and informed of the patient’s progress and discharge plans. The goal was to have the patient return to the ALC or nursing home based on their needs. The determination of when a patient was ready for discharge was based on the patient’s needs and the recommendations of the patient’s physician. If a facility expressed safety concerns for the ability to care for the patient, most facilities would do an on-site evaluation of the patient at the hospital before accepting them back into their care. The hospital struggled with some facilities (including ALCs) not wanting to take patients back. If there were continued concerns between the receiving facility and the hospital, the ombudsman was contacted to assist. She was not aware of an instance when a patient being discharged from the hospital to the receiving facility had refused to take the patient back or had continued safety concerns for the patient. To her knowledge, the hospital did not have a policy or procedure to follow regarding the discharge of patients. They relied on experience as to what steps needed to be taken for the safe discharge of a patient. If a patient was living in an ALC before their hospitalization and that facility voiced concerns about taking the patient back, she would want to know what barriers were preventing the patient from returning to their care so those concerns could be addressed. She expected the CMs to document any conversations that took place with the receiving facility staff, especially if they opposed the patient returning to their facility. If a patient were to be discharged from the hospital, she expected all discharge orders to be reviewed and reflected within the discharge instructions. If there were missing orders within the discharge instructions, she expected that to be caught before the patient was discharged from the hospital. She was unaware that patient 5’s Eliquis order, home health services, and therapy orders were not included in his discharge instructions, but they should have been. She agreed that patient 5 had many risk factors, including a recent brain bleed, was at continued high risk for falling, had agitation, poor safety awareness, was withdrawing from alcohol and nicotine, was restrained and required 1:1 staff supervision while hospitalized, and a new antipsychotic medication was recently added. She confirmed his discharge back to the ALC was a concern. When a copy of the provider’s revised January 2024 Patient Discharge or Transfer to Another Acute Care Facility policy was reviewed by RN CM manager C, she stated it was in place before she started in her position a year ago. She did not agree with the policy, which stated that the discharge policy/procedure did not apply to patients returning to a nursing home or an ALC. 4. Interview on 4/1/26 at 10:25 a.m. with MD, ALC primary care provider H revealed she was familiar with patient 5 and was his primary care physician since he was admitted to his home at the ALC. She reviewed his discharge information from the hospital. According to the information included in his discharge summary, he required skilled nursing services. Those required services could not be provided at an ALC. She would consider those services to be over the level of care an ALC facility could provide. 5. Interview on 4/1/26 at 10:35 a.m. with LSW D revealed she had worked as an LSW at the hospital for 2 months. The SWs were responsible for completing the initial admission assessment of the patients once the SWs were assigned to them. They collected information about their past that included social history, any prior services they received, confirmed their current level of care, and any other relevant information about their prior needs. That assessment information was documented and shared with the patient’s medical team members. The SWs then passed the patient off to the CM, but were available if there were needs that could not be addressed by the assigned CM. The SWs attended the length of stay meetings to keep informed of the progress of the patient. The SW did not usually communicate with the nursing home or ALC staff; the CMs did that. The PASRR assessments were not completed by the SW staff; they were completed by the float CMs. They would check with the patients personally once a week to ensure their needs were being met. 6. Interview on 4/1/26 at 11:00 a.m. and again at 2:05 p.m. with RN CM E revealed she had worked as an RN CM for one year with the hospital. Once she was assigned to a patient, she tried to meet them within 24 hours of their admission to the hospital. Discharge planning was discussed right away to see what their preference was for where they would like to be discharged. If the patient was from a nursing home or an ALC, they expected the facility to readmit the patient. She reached out to the patient’s receiving facility to discuss their discharge plans. If there was resistance from the facility to taking the patient back, she checked with therapy to ensure the patient was ready to be discharged. If there were continued concerns from the receiving facility, she checked again with therapy to ensure the patient was deemed ready to discharge, and checked in with the patient and their family that they agreed with the patient’s discharge plan. They would get the ombudsman involved if necessary to resolve the situation. If the patient was back to their baseline level of care, she was trained that the patient was expected to go back to the ALC. If there was an ALC that refused to take back the patient, she would not send the patient back under those circumstances. On 2/11/26, patient 5 was deemed medically ready for discharge from the hospital. She attempted to contact the nurse at his former ALC, but was informed she was out of the facility and would not return until 2/16/26, so he remained at the hospital. On 2/16/26, the ALC nurse had requested to review patient 5’s medical records before agreeing to take him back. Those records were sent by fax to his ALC as requested. A call was received from the ALC saying they agreed to take him back if transportation was arranged. RN CM E was responsible for ensuring discharge instructions were reviewed for accuracy before discharge. She confirmed she had reviewed the physician’s discharge orders. She acknowledged that he had just had a brain bleed, was at high risk for falling, was going through withdrawal from alcohol and nicotine, was impulsive, had recently been restrained due to agitation, was getting 1:1 staff supervision due to poor safety awareness, was placed on an antipsychotic medication for mental health concerns before his discharge, and would be returning to an ALC that did not provide skilled nursing care. During her review of the discharge orders, she had failed to recognize an order for an anti-coagulant medication, and orders for home health and therapy services were not included in the discharge instructions. Home health services were not available in the area where patient 5 lived, and she had failed to document that in his medical record. She acknowledged that although home health services were not available on an outpatient basis, arrangements for needed services could have been made if he had been placed in a skilled living facility. 7. Interview on 4/1/26 at 3:30 p.m. with RN A regarding patient 5’s discharge revealed: *It was apparent that there was missed communication internally amongst the IDT on the discharge of this patient. *Even though the ALC had eventually accepted him back to their facility, it was clear that he required a higher-skilled level of care and oversight for his safety, well-being, and rehabilitation needs. *She was not aware that the LSWs had minimal involvement with the discharge process and would have expected them to be more involved to ensure proper placement occurred for the patient’s well-being. *She was not aware that the CM team did not have a policy and process in place to determine the proper placement of a patient. They should not have been relying on “what they knew or know.” *There were several staff that should have reviewed the patient’s final discharge orders to ensure they were all carried through. She agreed those missed orders for continued physical therapy, and Eloquis, were concerning and created the potential for safety concerns for the patient. 8. Review of the provider’s undated Patients’ Rights and Responsibilities pamphlet that was provided to the patients upon admission revealed that the patients were told about care alternatives when hospital care was no longer appropriate. “When medically proper and legally permitted, or on your request, you may be transferred to another facility. Avera will work with patients to address discharge planning needs. If, at any time, you or your representative sees a need for more in-depth discharge planning or you wish to review your specific discharge plans, feel free to discuss with your team.” Review of the provider’s revised January 2024 Patient Discharge or Transfer to Another Acute Care Facility revealed “Patients are discharged from the hospital or transferred to another level of care based on the patient’s assessed needs. Plans for discharge or transfer are facilitated by an interdisciplinary team, as appropriate to the patient’s needs. The discharge/transfer process does not apply to assisted living, long-term care (LTC), or skilled nursing care dispositions when being discharged from the hospital.” Review of the provider’s undated Social Worker job description revealed “The main focus of the Social Worker is to assist in meeting the psychosocial/continuum of care needs of the patient and family to ensure optimum functioning. In addition to direct care services, the Social Worker shall have duties of consultation, education, policy and program planning, performance improvement tasks, advocacy, and liaison with the community. Evaluates data gathered in terms of the medical plan of treatment, available social service programs, financial counseling, and plans a pertinent therapy program that will provide maximum benefits and safety for each patient. Works collaboratively with clinical coordinators, physicians, and other members of the care team in providing coordinated services, which facilitates continuity of care for the patient.” Review of the provider’s undated RN-Case Manager job description revealed “Collaborates with the multidisciplinary care team to bring together an established plan for patient treatments, assists with the transitions between levels of care, to promote the best possible patient outcome. The case manager facilitates efficient utilization of resources and identifies patient care needs throughout the continuum of care.” Review of the provider’s March 2023 Provider Orders policy revealed “Provider orders are used to communicate to the health care team all medical, nursing, and ancillary treatments, procedures and modalities. The goal is to provide safe, accurate and timely implementation of provider orders. The nurse or qualified ancillary staff acknowledges the electronic order confirming receipt of the order and verifying appropriate measures have been taken to ensure proper and prompt execution of the order.””

“DISCHARGE PLANNING PROGRAM REVIEW CFR(s): The hospital must assess its discharge planning process on a regular basis. The assessment must include ongoing, periodic review of a representative sample of discharge plans, including those patients who were admitted within 30 days of a previous admission, to ensure that the plans are responsive to the patient post-discharge needs. This Standard is not met as evidenced by: 32355 Based on interview and document review, the provider failed to ensure the patient’s discharge planning process was evaluated regularly by reviewing a representative sample of discharged patients’ closed medical records to identify the effectiveness of the plan, the provider’s responsiveness to patients’ post-discharge needs, and to modify the discharge process based on identified trends by one of one case manager (CM) C. Findings include: 1. Interview on 4/1/26 at 8:00 a.m. with CM C regarding the discharge planning chart review process revealed she oversaw the patient chart reviews, but there was no process or policy in place for the staff to use as guidance. She had completed “some here and there, or as time had allowed.” She was unaware of the federal requirements and regulations that required a facility to complete periodic reviews of the patient charts and their discharge plans to ensure all their needs were met upon discharge from the hospital. Nor was she aware that patients with hospital readmissions within 30 days required chart reviews. She was in the manager role for approximately 2 years and during that timeframe, had completed a “few random reviews.” 2. Review of CM C’s patient chart reviews for appropriate discharge planning revealed that one chart review was completed for the year 2024 on October 15th. Seven patient chart reviews had been completed for the year 2025. There was not any patient chart reviews to support that the facility had a discharge planning process in place for any patients since July 2025. 3. Interview on 4/1/26 at 3:30 p.m. with the senior director for medical support services A and accreditation manager B revealed they were unaware that periodic chart reviews were a federal requirement for discharged patients. To their knowledge, there was no policy in place for that process.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 50715 Based on record review, video event review, observation, interview, and policy review the provider failed to protect patients’ rights when staff failed to: *Ensure two of two camera monitoring rooms had been paused for patients not requiring camera monitoring. *Ensure a placard (sign) was displayed in patients’ rooms with cameras notifying of the camera monitoring per provider policy. *Assess and secure potential environmental safety hazards for one of one sampled patient (3) who attempted suicide on 12/22/24 and subsequently expired on 12/25/24. *Ensure close observation with 15-minute safety checks for one of one sampled patient (3) had been performed and documented in accordance with the provider’s policy. Findings include: 1. Record review, video event review, observations, interviews, and policy review throughout the survey process revealed: *Patients’ privacy or notification of a camera monitoring was not provided for patients placed in camera monitored rooms per the provider’s policy. -Observation and interviews with staff revealed cameras in the adult unit A were always left on and no signage was placed inside the room advising the room was being monitored. *The provider’s safety risk assessment of the environment had not included an assessment of toiletry supplies. *Behavioral Health Technician (BHT) H had not performed documented 15-minute safety checks for patient 3 per the provider’s policy. -Per camera recording review, patient 3 had not been visually checked with 15-minute safety checks by BHT H from 6:39 p.m. until 7:15 p.m. on 12/22/24. -BHT H documented he performed his 15-minute safety checks on patient 3 at 6:51 p.m. and again at 7:00 p.m. on 12/22/24. Refer to A143, finding 1 and A145, finding 1.”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 46511 Based on observation, interview, and policy review the provider failed to ensure: *Camera monitoring had been paused in two of eight patient rooms (1399 and 1464) for patients who did not require camera monitoring. *A placard had been displayed in patients’ rooms with cameras notifying the patients of monitoring per the provider’s policy. Findings include: 1. Observation and interview on 1/7/25 at 11 a.m. with vice president R and nurse manager I revealed: *Unit A had two camera monitoring rooms. *Unit B had four camera monitoring rooms. *Unit C had two camera monitoring rooms. *Cameras would not have recorded when turned off. *Cameras should have been turned off by default. *Physician orders had not been required for camera use. *Nurses had determined whether cameras were to be turned on or off. *On 12/22/24, the camera for room 1464 occupied by patient 3 in unit A had been turned on. *The camera for room 1464 was not supposed to be on during that time. Interview on 1/7/25 at 11:25 a.m. with lead behavioral health tech (BHT) K revealed: *He was the lead BHT for unit A. *Cameras should have been turned off generally. *Cameras had been used when patients were asleep and when on a 1:1 (one-to-one) observation status. *He did not know why the cameras had been turned on. Interview on 1/7/25 at 11:46 with registered nurse (RN) M revealed: *She had worked as a nurse in unit A. *Cameras in unit A had been monitored for patients with suicidal ideations, self-harm risks and dementia. *Cameras in unit A had been generally turned on. *She did not know why the cameras had been turned on. Interview on 1/7/25 at 1:40 p.m. with BHT O confirmed: *She generally had worked in unit A. *Cameras had been used in unit A for patients on suicide watch and who had been at risk for falls. *Cameras had been on at all times. Interview on 1/7/25 at 2:19 p.m. with lead BHT P revealed: *He usually had worked in unit B. *Cameras had not been typically turned on. *Patients needed a medical reason to be placed in camera monitored rooms. *He had been unsure who decided if cameras were turned on or off. Interview on 1/7/25 at 4:10 p.m. with BHT B revealed: *She usually had worked in unit A. *Camera rooms had been used for violent patients and patients who had been at risk for falls. *Cameras had generally been turned on. Interview on 1/7/25 at 4:30 p.m. with RN C revealed: *She had been a nurse in unit A. *Camera use had been ordered and used differently between the hospital units. *She had heard that orders were needed to turn cameras on in other units. *Security had to be contacted to turn cameras on and off. *Sometimes cameras had been left on after they had been no longer needed. Interview on 1/8/25 at 8:20 with RN D revealed: *She had been a nurse in unit A *Cameras in unit A rooms had been turned on for weeks to months at a time. *The camera had been turned on for room 1464 on 12/22/24. *Patient 3 had stayed in room 1464 on 12/22/24. *She was unsure why the camera had been turned on for this room. *Security had to be called to have cameras turned off. *No specific person had been assigned to contact security to turn off cameras. *There should have been a sign posted in rooms with cameras when they had been turned on. *She had thought an order was required to use a camera for patient monitoring. Interview on 1/8/25 at 8:57 a.m. with psychiatrist E revealed: *She had never ordered a camera to be on for monitoring. *She had thought it was up to the nurses to determine if camera monitoring was necessary. Observation and interview on 1/8/25 at 9:15 a.m. with nurse manager I at unit A revealed: *Room 1465 had the camera turned on and had been occupied by a patient. *Camera monitoring had not been needed for this patient. *There was no placard posted in room 1465 that indicated camera monitoring. *She had been unable to locate any placards for camera use in unit A. Observation and interview on 1/8/25 at 9:25 a.m. with nurse manager I at unit B revealed: *Room 1399 had the camera turned on. *Room 1399 had a patient staying in it. *There was no placard posted in room 1399 that indicated camera monitoring. *There had not been any placards available for use in this unit. Interview with nurse manager I on 1/8/25 at 11:55 a.m. revealed: *Her expectation was that cameras should have been turned off generally. *Signage should have been posted in the rooms while monitoring had taken place. Interview with security officer J on 1/8/25 at 2:30 p.m. revealed: *Unit A likely had cameras on more than units B and C. *Staff had to call security to turn cameras on and off. *Cameras had been turned on for room 1464 on 12/22/24. *Patient 3 had been staying in room 1464 on 12/22/24. Review of the provider’s 1/25 Video/Audio Surveillance policy revealed: *”Cameras may be used if it is determined that the patient residing in the camera room merits an additional monitoring tool.” *”If it is determined by staff a camera is to be on, contact the on duty Security Officer to have it activated.” *”An order is not necessary for camera use.” *”The patient will be told verbally the camera is recording and a placard approved for this purpose must be placed in the patient’s room advising that the room is being monitored. The placard will be displayed in the patient room.” *”Once surveillance is no longer required, unit staff will contact the on duty Security Officer to have the camera shut off, and the placard removed at that time.” Review of the provider’s placard for camera monitoring notification revealed “For your safety, your room is monitored by a security camera.” Review of the provider’s undated Rights and Responsibilities booklet revealed: *”7. Patient Needs: -Privacy: You have the right to every consideration of privacy. All parts of your medical care, examination and treatment will be conducted so as to protect your privacy.””

“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: 50715 Based on record review, video event review, observation, interview, and policy review the provider failed to protect a patient from neglect by not providing the services necessary to avoid the physical harm of one of one sampled patient (3) who attempted suicide and subsequently expired, including not having: *Ensure close observation with 15-minute safety checks for one of one sampled patient (3) had been performed and documented in accordance with the provider’s policy. *Include an evaluation of toiletry supplies in their safety risk assessment of the environment. *Assess and secure potential environmental safety hazards for one of one sampled patient (3) that attempted suicide and subsequently expired. Findings include: 1. Review of patient 3’s electronic medical record (EMR) revealed: *He had been voluntarily admitted on 12/15/24 for worsening psychosis with deterioration in functioning. *His 12/15/24 history and physical indicated he had denied any suicidal ideations or homicidal ideations. *He had been placed on the adult unit C. *His treatment plan had included 15-minute checks and suicide precautions. *On 12/21/24, he had been found in the day room with just his underwear on. *On 12/22/24 around 11:00 a.m. due to his increase in paranoia, confusion, anxiety, irritableness, and hostile statements, orders from psychiatrist E were to transfer him to adult unit A. *On 12/22/24 at 2:19 p.m. a progress note indicated psychiatrist E had documented patient 3: -“Can be intrusive with peers, poor boundaries. -Has hallucinations and has delusions. -Has no suicidal ideation and has no homicidal ideation.” *His 12/22/24 behavioral care plan indicated he had transferred to adult unit A on 12/22/24 around 5:00 p.m. to a room equipped with camera monitoring due to it being close to the nurse’s station. -He did not require a room with camera monitoring. *Behavioral Health Technician (BHT) H had documented his 15-minute patient safety checks for patient 3 as follows: -5:01 p.m. location was dining room (DR) behavior was calm. -5:15 p.m. location was DR, behavior was calm. -5:30 p.m. location was DR, behavior was calm. -5:44 p.m. location was day room (DYR), behavior was calm. -6:06 p.m. location was patient room (PR), behavior was calm. -6:20 p.m. location was DYR, behavior was calm. -6:28 p.m. location was DYR, behavior was calm. -6:38 p.m. location was DYR, behavior was calm. -6:51 p.m. location was DYR, behavior was calm. -7:00 p.m. location was DYR, behavior was calm. *A nurse’s note written by registered nurse (RN) C on 12/22/24 at 9:02 p.m. indicated patient 3 had been found in his room unresponsive during BHT F’s 15-minute safety checks for the patient at approximately 7:13 p.m. -No pulse had been identified; CPR had been initiated. -He had been rushed to the adjoining hospital’s emergency department (ED). -RN C had been notified by security the patient had drank a deodorant bottle and forced it down his throat at approximately 6:43 p.m. -RN C notified the staff at the heart hospital of deodorant bottle in his throat. *Patient 3 expired on 12/25/24 related to a global anoxic injury (brain injury characterized by a widespread lack of oxygen to the brain). Review of video footage of the suicide attempt of patient 3 on 12/22/24 revealed at: *6:32 p.m., he entered his room and laid on the bed. *6:36 p.m., he got out of the bed, turned on the light and began to go through his personal belongings. *6:37 p.m., he had closed the door to his room and was carrying two bottles of unknown liquids and personal deodorant. -He drank one of those two bottles of unknown liquid. *6:38 p.m., he put his fingers down his throat and began to cough and gag. *6:39 p.m., he got out of bed and went to the sink. -BHT H entered patient 3’s room to perform the 15-minute safety check. -BHT H had documented at 6:38 p.m. that patient 3 had been in the DYR and his behavior was calm. *6:40 p.m., he drank another bottle of an unknown substance and began to attempt to force a bottle down his throat and was unsuccessful. *6:42 p.m., he tried to force the same bottle down his throat a second time and was again unsuccessful. *6:43 p.m., he lubricated the bottle with an unknown substance from another bottle, laid back down on the bed and began to use his hands in a forceful manner to push the bottle down his throat. *6:44 p.m., his arms were extended out from his body. *6:46 p.m., he had used his hands to plug his nose. *6:48 p.m., he began to turn blue and ceased to move. *6:49 p.m., He exhibited agonal breathing (not getting enough oxygen and gasping for air). *6:51 p.m., BHT H had walked outside of his room with an iPad in his hand. -BHT H had not opened his door to perform a visual safety check of patient 3. -BHT H documented that at 6:51 p.m., patient 3 had been in the DYR, and his behavior was calm. *6:55 p.m., BHT H walked back up to the nurse’s station and had gone into the DR. *6:59 p.m.; BHT H left the DR and walked to the DYR. *7:00 p.m., BHT H was at the nurse’s station with the iPad, walked past patient 3’s room and down through the DYR. -BHT H again had not opened patient 3’s room door to perform a visual safety check. -BHT H documented that at 7:00 p.m., patient 3 had been in the DYR, and his behavior was calm. *7:02 p.m., BHT H was back at the nurse’s station. *7:15 p.m., BHT F opened patient 3’s room door. She: -Continued to knock on his door and appeared to not have gotten a response from him. -Visually checked on him by walking into his room and approaching his bed. -Walked back out to the nurse’s station and approached BHT B. *At 7:16 p.m. BHT F and BHT B entered patient 3’s room and they: -Assessed patient 3 and checked for signs of breathing. -Alerted nursing staff to activate the emergency response system (EMS). *At 7:16 p.m. BHT H began Cardiopulmonary Resuscitation (CPR) on patient 3. *At 7:17 p.m., patient 3 was transferred to a gurney (wheeled stretcher). *At 7:18 p.m., patient 3 was transferred from the adult unit A to the adjoining hospital’s ED. Observation and interview on 1/7/25 at 11:10 a.m. on Adult Unit A with nurse manager I and Vice President (VP) R in the intake room revealed: *Toiletry products had been placed in yellow bins labeled with the patient’s room number. *Toiletry items in the bins included: -Shampoo -Conditioner -Toothbrush -Toothpaste -Lotion -Deodorant -Mouthwash -Chapstick -Combs/Brushes/Picks -Hygiene products from home *Nurse manager I and VP R confirmed this process was implemented after the event on 12/22/24 of patient 3’s attempted suicide and subsequent death. *VP R confirmed an event like this had never happened there before and he had reached out to other facilities and had reviewed literature for best practices to implement. *Nurse manager I and VP R confirmed toiletry items had not been considered contraband prior to the above event but were now considered a form of contraband on adult unit A. *VP R confirmed they are “constantly” reviewing this new process and best practices to determine if that process needed to be implemented throughout the other inpatient units. -VP R confirmed the patients placed on adult unit A were at the highest risk for self-harm and aggressive behaviors. *Nurse manager I confirmed patients were to ask staff for their hygiene products and staff were to provide the patients with their items. The expectation was for patients to return all of their toiletry products to staff. *There had not been a formal check in or check out documentation process created. -Nurse manager I confirmed staff were expected to communicate with one another which patients had been given their toiletry items and when those items were returned. -It was the expectation the staff member who gave out the toiletry items to patients would ensure the items had been returned. -She agreed a more formal check in and check out documentation process would hold staff accountable to ensure items were brought back timely and accounted for. Interview on 1/7/25 at 11:25 a.m. with lead behavioral health technician (BHT) K revealed: *Every four hours a new BHT was assigned to perform safety checks on patients with the use of an iPad program called ObserveSmart. *All patients were to wear a beacon (tracking device) either on their wrist or ankle for staff to perform their safety checks. *To complete a patient observation, staff must have been in range (distance set by administration) of the patient’s beacon. *Staff had the option to complete a “forced” observation (patient not wearing a beacon or patient is out of range) to complete the safety checks. -He confirmed if staff had over 5% of forced checks, ObserveSmart would notify management. -He confirmed staff still needed to observe the patient. *The expectation for staff was to visually look at the patient by opening the door. *He confirmed toiletry items were to be checked out to patients and not kept in their rooms, but there had been no log to document who or what time a patient’s toiletry items were checked in or returned. Observation and interview on 1/7/25 at 12:10 p.m. with BHT N revealed he: *Had been assigned as the 4-hour safety check staff. *Used the iPad to perform the 15-minute safety checks. *Confirmed if the patient’s door was closed, the expectation would have been to open the door and lay eyes on the patient. *If a green light appeared next to a patient’s name on the iPad, that meant it had “paired” with a patient’s beacon and did not mean staff did not have to check on the patient. -The expectation had always been to visualize the patient. Interview on 1/7/25 at 1:40 p.m. with BHT O revealed: *Staff use an iPad program to perform 8-minute and 15-minute safety checks. *She confirmed staff are to visualize the patient with every check. *She stated, “If the patient is sleeping, you must watch for respirations.” *Staff should not use the forced entry to document safety checks. *She confirmed depending on the connectivity with the patients’ beacons to the iPad, you could have more than one patient’s green light on at a time to complete documentation on. -Confirmed staff still needed to visualize each patient. *She confirmed toiletry items needed to be checked out and checked back in by staff, but there had been no log created to ensure staff accountability of that process. Interview on 1/7/25 at 4:05 p.m. with BHT B revealed she: *Confirmed when performing safety checks, eyes are to be on the patient. *Stated, “We watch for their chest to rise and fall, and also take note of their emotional state.” *Had been educated on the expectation to open the patient’s door to check on them. *Had been working the night of 12/22/24 on adult unit A. *Had been alerted by BHT F around 7:13 p.m. to go look at patient 3 due to concerns about the patient’s condition. *Had gone into patient 3’s room and he was blue and dusky in color and not responding. *Had yelled for the RN to call a code. Interview on 1/7/25 at 4:30 p.m. with RN C revealed she: *Had been assigned as the resource RN on adult unit A on 12/22/24. *Confirmed that at 7:13 p.m. she heard RN G yell to call a code for patient 3. *Ran into patient 3’s room and began CPR. *Helped assist in the transfer of patient 3 to the heart hospital emergency department for continued care. *Called security to check the camera for patient 3’s room *Was told by security it had appeared patient 3 had forced a lotion bottle down his throat at 6:43 p.m. *Was unsure if BHT H had performed patient 3’s 15-min safety checks. *Expected BHT’s to check patients every 15 minutes by: -Visually laying eyes on the patient. -Checking for respirations. Interview on 1/8/25 at 8:18 a.m. with RN D revealed: *On 12/22/25, she had worked from 7:00 a.m. to 7:00 p.m. on adult unit A. *She had received the transfer report from the adult unit C nurse about patient 3. *Patient 3 had transferred over to adult unit A around 5:00 p.m. -She and BHT H were handing out patient dinner trays in the DR which had included patient 3. *At 7:00 p.m. she had given a handoff report to RN G. *She clocked out at 7:06 p.m. *At 7:23 p.m. she had received a call from RN G regarding patient 3’s status. *She drove back to the hospital and replaced RN G at the adjoining hospital’s ED. *She had been informed that they pulled a deodorant bottle out of patient 3’s throat. *She remained with patient 3 until he transferred to the hospital’s main hospital. *She confirmed that after the event, all patient toiletries had to be checked out. -Stated, “I do not feel this is going well, this has never happened before, we are taking away their dignity.” -Confirmed a log would be helpful to know what’s being checked out and by whom. *Confirmed the expectation for BHT’s when performing the 15-minute safety checks would have been to visualize the patient. Interview on 1/8/25 at 8:55 a.m. with psychiatrist E revealed: *She had been treating patient 3’s psychosis (mental disorder characterized by a disconnection from reality). *Patient 3 had been having episodes of impulsiveness and would have been a better fit in adult unit A. *Patient 3 had not expressed any suicidal ideations. *Patient 3 had orders for 15-minute safety checks. *Her expectation would have been for staff to look at the patient when performing safety checks. *Confirmed patients were no longer allowed to keep their toiletry products. - She thought the process had been going “ok”. Interview on 1/8/25 at 11:55 a.m. with nurse manager I revealed: *Her expectations regarding BHT’s performing 15-minute safety checks were: -Staff were to always have eyes on patients. -BHT’s were to be out in the DYR and not behind the nurse’s station. -When performing the 15-minute safety checks, the BHT’s sole responsibility would have been to check on patients. -BHTs had been trained to check for breathing and to visualize the patient’s hands and head. Interview on 1/8/24 at 2:22 p.m. with security J revealed: *On 12/22/24, he came to work at 6:00 p.m. *Prior to the beginning of his shift, he had received a debrief of any events that had occurred that day. *At 7:15 p.m. he had responded to the medical emergency on adult unit A and assisted the nursing staff. *He had realized patient 3’s room had a camera in it and placed a call to another security officer to pull up the camera footage. *He had verified from the camera footage that patient 3 had forced a bottle down his throat at 6:43 p.m. *He called up to the floor to notify the nursing staff of what he had visualized on the camera footage. *He stated, “I have never heard of something like this before.” Interview on 1/8/25 at 3:10 p.m. with RN G revealed: *On 12/22/24, her shift was from 7:00 p.m. to 7:00 a.m. *She had received a report from RN D. *She had been in the medication room when the BHT’s called a code. *She had gone to patient 3’s room and staff had been performing CPR. *She had gone with patient 3 to the hospital ED. *She confirmed all toiletry items needed to be checked out and checked back in. -She stated, “Whoever gives items out is responsible to ensure items come back.” -She confirmed a log would be helpful. Interview on 1/8/24 at 3:30 p.m. with BHT F revealed: *On 12/22/24, her shift began at 3:00 p.m. on adult unit A. -From 3:00 p.m. to 7:00 p.m. she had been assigned to be on a 1:1 observation with a patient. *At 7:00 p.m. when she had received a report from BHT H, he had confirmed he would complete the 7:00 p.m. 15-minute safety checks for all patients on adult unit A. -At 7:00 p.m. BHT H documented the 15-minute safety check for patient 3. *At 7:13 p.m., she had started the 15-minute safety checks. -Patient 3 was the first patient she needed to check on. *At 7:15 p.m. she opened patient 3’s room door and: -His face was blue. -His eyes were slightly open. -She had called his name and continued to knock on door. -She went back out to the nurse’s station to get another BHT to check on him. -BHT B visualized patient 3 and had yelled to call a code. *BHT F ran to get the gurney and crash cart. *She had stated, “The blue color of the patient is what alerted me. I did not see his chest rise.” *She confirmed the expectation for 15-minute safety checks would have been to: -Open the patient’s room door. -Put eyes on the patient. -Observe for respirations. -Observe for movement. Interview and review of the toiletries check in and check out process and education plan on 1/8/25 at 3:45 p.m. with vice president R, clinical educator S, and clinical manager I revealed: *”Toiletries for each patient will be checked out and checked in each time a patient is given their toiletry(ies). *Toiletries include hospital supplied items and/or patient personal products that are checked by intake staff prior to admission on the unit. *Patients will be given their supplies as requested. *Prior to a patient receiving their toiletry bin item(s), the staff member will check out each item for a maximum of 30 minutes and will document on the checkout sheet. *The staff member who checked out the item is responsible for ensuring the item(s) is checked back in within 30 minutes. *Patients are not allowed to check in or check out toiletries 30 minutes prior to the end of each shift. *Room checks will be done 4 times a day throughout the day.” *All staff assigned to unit A would be educated beginning at 4:00 p.m. on 1/8/25 and prior to the beginning of their shift. *Clinical manager I confirmed the resource RN will monitor the checkout sheet logbook to ensure compliance with the check out, check in process. Review of the provider’s January 2025 Safety Precautions Level System policy revealed: *”Close Observation Check: -An in person visual observation of a patient at an ordered interval, actively observing behavior, mood, physical wellbeing (observing respiration), and environment. *All patients on suicide precautions are to be on 8-minute checks, 15-minute checks, line-of-sight, or 1:1. *15 Minute Observations. This level of observation may be implemented for any of the following reasons: -The patient is potentially suicidal, self-destructive, or present with moderate risk of self-harm. -The patient is a higher fall risk. -The patient is confused and/or risk for wandering. -The patient has the potential to be violent/aggressive to others. *The patient shall be observed by staff throughout the day and night every 15 minutes, with documentation of checks on the ObservSmart application.” Review of the provider’s January 2024 Safety Measures for the Adult Programs policy revealed: *”Patient observation checks are to be made regularly according to the appropriate close observation status. *A patient on suicide precautions will not have access to shoelaces, strings, belts, sweatshirts with hoods, or other personal items posing a risk for self-harm. *Any object which patient may use to harm himself/herself or others will not be available to patient when he/she is not attended by staff.” Review of the provider’s November 2023 B.3 Contraband policy revealed: *Hospital provided toiletry products not listed as contraband items for adult unit A were: -Shampoo -Conditioner -Toothbrush -Toothpaste -Lotion -Deodorant -Mouthwash -Chapstick -Combs/Brushes/Picks Review of the provider’s undated 2024 Suicide Screening Education revealed: *”Observer responsibilities: -Maintain constant observation of the patient -Document observations every 15 minutes on safety check flowsheet or Meditech intervention -Report changes in patient’s condition or behaviors to Primary RN or Resource RN. -Be alert to contraband -Primary responsibility is to constantly watch/observe the patient. *Close Observation -Observer must complete an assessment of the patient’s safety at minimum of every 15 minutes in addition to 8 minutes and line of sight checks. *15-minute safety checks include assessment of: -Environment -Patient’s physical and emotional well-being -Patient’s needs.” Review of the provider’s Patient’s Rights and Responsibilities booklet revealed: *”7. Patient Needs: -Security: You have the right to have all care and treatments provided to you in a safe and secure area, free from neglect and abuse.” Review of the provider’s December 2024 Mental Health Environment checklist revealed: *No evaluation of toiletry supplies throughout the various environments. Review of provider’s job description for a Behavioral Health Technician revealed: *”Implements suicide precautions as needed. *Assess changes in patient’s condition/behavior and notified RN. *Maintains accurate and concise records, documenting promptly all pertinent information in the patient’s EMR. *Comply with safety principles, laws, regulations, and standards associated with, but not limited to CMS, The Joint Commission, DHHS, and OSHA if applicable.””