Trustpoint Hospital

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 37530 Based on facility document review, policy review, camera footage review, medical record review, job description, observation and interview, the Governing Body failed to ensure staff followed hospital policies and patient falls and patient to patient aggressive behaviors were investigated, and adverse events were analyzed and tracked by the Quality Assurance Performance Improvement (QAPI) program to develop and implement preventative actions, and the Governing Body failed to ensure the quality of care and safety of the patients were provided with oversight and supervision of the registered nurse (RN) for 2 of 5 (Patient #1 and #5) sampled patients. The findings included: 1. Review of Hospital #2’s policy titled “Healthcare Quality Management Plan,” with an effective date of 12/2025, revealed, “ ...The purpose of the Quality Management Plan is to outline an effective system to ensuring the quality and safety of services across all settings and patient populations ...The Quality Management Plan includes provisions for quality assurance/performance improvement/quality control with the overarching concept of high reliability to support the clinical work throughout programs, facilities, and organization. The Quality Management Plan is designed to monitor the quality of health care providers to all clients served ...The primary goal of the Quality Management Plan are ...Achieving excellence in client experience of care ...Incorporating the use of evidence-based practice and research ...Ensure A consistent, safe and high quality environment that exemplifies the concept of High Reliability, evidence-based and evidence-informed practice, and compassionate. care ... FACILITY QUALITY COUNCIL ...The Quality Council ...is the steering committee for the facilities process improvement program and ensures implementation of process improvement activities through resources, training, and education. The Quality Council receives reports of process improvement activities from the department’s specific indicators, Process Improvement teams, committee as assigned, patient/family satisfactory surveys, and staff input regarding process improvement activities and assures that appropriate actions are implemented to resolve identified problems or improve existing process ...” Review of Hospital #2’s policy titled “PROCESS IMPROVEMENT PROGRAM,” dated 4/2025, revealed, “ ...The Process Improvement program is designed to provide a coordinated, objective, and systematic approach to facility wide quality assurance activities. The Program is based upon an integrated and collaborative approach of measurements-based care to increase the probability of desired patient outcomes by assessing and improving those governance managerial, clinical, and support process that most affect patients outcome ....Objectives are ...To enhance, maintain, and continually improve the quality of patient care through intra and or inter departmental services, measurements and assessments of patient care, resolution of problems, and ongoing pursuit of opportunities to improve patient care ...The Quality Care Council is the steering committee for the program and will ...establish policies and ensure implementation of process improvement activities through resources, training and education ....design, maintain, support, and document evidence of ongoing programs to systematically measure, assess and improve patient outcome and Facility performance ...” Review of Hospital #2’s policy titled “Risk Management Program,” dated 10/2024, revealed, “ ... It is the policy of [Named Hospital #2] to utilize the Risk Management Program techniques to promote safety, pro-actively focus on loss prevention, and detect hazardous events and circumstances. It must provide a systematic, multi-disciplinary approach to manage and reporting incidents of injury, damage, and loss ...The Incident Report is a risk management tool that raises awareness of potential exposure to perils that may/did cause harm. It enables the facility to manage risk, increase safety, and improving the quality of health care provided in the facility through risk control interventions and monitoring the effectiveness of the interventions and corrective action plan ...Supervisors would notify facility Risk Management of a serious incident as well as take the lead in investigation. Non-serious incidents ...When documenting incidents in the medical record, the staff would chart precisely what happened without making reference to any “errors” or that an incident report was completed ...Facility Risk Manager will collect data for statistical analysis and trending. Definition of incident report forms ...Verbal Altercation/Threats to Harm Pt/Pt [patients to patients] or Pt/Staff ...Orders Not Carried Out ...Failure to carry out a physician’s order appropriately or in any timely manner ...Falls unintentionally coming to rest on the ground, floor, or other lower levels ...Observed Fall ...Unobserved Fall ...The following examples represent the typical initial severity level, however a final level of severity may be determined after further review ...Fall with injury requiring emergency treatment are transferred to a medical hospital ...Death within 72 hours of discharge ...” Review of Hospital #2’s policy titled, “Fall Prevention,” dated 9/2024, revealed, “ ...All patients will be assessed on admission for fall risk ...the following actions should be taken ...Return bedrails to the original position ...Ensure call light is within reach ...if Patient Falls ...Immediately assess patient and take appropriate actions to protect patient ...Notify MD/LIP [Medical Doctor/Licensed Independent Practitioner] of the fall and patient’s condition ...Notification of family ...name of person contacted as well as dated and time ...Implement physicians orders ...Notify family of fall ...Notify Nurse Manager ...Documentation of actions or intervention taken to prevent further falls ...Reassess patient and document within the electronic records ...” Review of Hospital #2’s policy titled “Risk Management Incident Investigation,” dated 12/2024, revealed, “ ...It is the policy of [Named Hospital #2] to utilize investigation as a preventive tool to avoid incidents from reoccurring to improve quality of care...Gather data...conducting interviews with staff members...Risk Manager’s role is to make recommendations based on investigation findings...” Review of Hospital #2’s policy titled “Incident Reporting - Risk Management Program,” dated 10/2024, revealed, “ ...Any facility staff member who witnesses, discovers, or had direct knowledge of an incident must complete an Incident Report before end of the shift/work day [workday]...The facility Risk Manager...will notify appropriate agencies of reportable incidents...” Review of Hospital #2’s policy titled “Patient Observation,” dated 9/2024, revealed, “ ...All patients are monitored at minimum once in every 15 minutes block of time ...Remain vigilant for specific risk for patients on Special Precautions ...1:1 Observation ...1:1 is the highest level of observation and is reserved for patients who are so unpredictable that without a dedicated staff member there is a risk of patient harming self or others ...Staff who are assigned to monitoring the patient on 1:1 observation will have no other assignment ...Staff are to remain within visual range and close proximity (easy reach) of patient at all times ...All 1:1 observations will be reviewed daily ...” Review of Hospital #2’s policy titled “Vital Signs and Weight,” dated 9/2025, revealed, “ ...Vital signs will be taken at the time of admission and then as ordered by the practitioner ...Reporting of Vital Signs ...the staff member who takes the vital signs will alert the nurse immediately if they are abnormal ...If vital not taken by the nurse initially, the nurse will retake the vitals to verify results ...The nurse shall contact the practitioner immediately for additional recommendation if vitals fall within the ranges below ...BP [Blood Pressure] systolic greater than ...Adult ...180 ...” Review of Hospital #2’s policy titled “Assessment, Neurological,” dated 5/2025, revealed, “ ...Neurological assessment will be initiated when a patient has hit their head, had a change in level of consciousness, and unwitnessed fall or per practitioner order ...Results of the assessment are documented on the Neurological assessment form ...” Review of Hospital #2’s policy titled “Fall Precautions and Prevention,” dated 5/2025, revealed, “ ...Patient safety is an ongoing responsibility of all staff ...All patients admitted to the hospital will be assessed using the MORSE Falls Assessment ...each patient will be placed in a risk category ...Nursing shall place the patient on fall precautions when indicated and ensure the practitioner is notified and orders and the level of observation and precautions consistent with the assessed level of risk ...Assist and encourage patient to use the bathroom every two (2) hours and monitor for incontinence ...Use safety mats and alarms at night ...Interventions Post Fall ...Patient is assessed/reassessed after any fall. (MORSE Fall Assessment utilized for assessment and post fall assessment) ...the Medical practitioner will be contacted by the Charge Nurse to determine course of treatment after a patient has fallen ...Patient falls risk reassessed and appropriate interventions implemented ...An incident report will be completed and submitted to the Director of Risk Management/Performance Improvement after a patient has fallen ...” Review of Hospital #2’s policy titled “Management of Aggressive Behavior,” dated 12/2024, revealed, “ ...The Nurse documents the emergency situation and any treatment rendered in the patient ’ s record and in the Nursing Supervisor’s logbook, completes and Incident...notifies the House Supervisor of all action taken...” Review of Hospital #2’s “PATIENT RIGHTS & [and] RESPONSIBILITIES,” dated 12/1/2025, revealed, “ ...Right to receive care in a safe setting ...Right to be free from physical ...abuse ...” Review of Hospital #2’s undated education titled, Medical Emergencies- Change in Condition, revealed, “ ...Rapid Response systems are programs that are designed to improve the safety of hospitalized patients whose condition is deteriorating quickly ...Criteria Guidelines for Initiating the RRT [Rapid Response Team] (early warning signs) ...Acute change in level of consciousness or mental status ...Significant bleeding ...Failure to respond to medical interventions ...” Review of Hospital #2’s Director of Risk Management “Job Description” signed on 2/28/2025 at 12:26 PM, revealed, “ ...Plan, organize, direct and control all aspects of risk management activities. Ensure a safe environment for the protection of patients ...to the facility in such a manner as to comply with laws, regulations and the standards of the accrediting and approved agencies ...Investigate and analyze actual potential risks in the facility, assess liability and probability of legal action for potential notification, Implement, educate and encourage incident reporting system throughout the facility ...ensure the organization ’ s procedures and policies are being followed by all employees ...Develop implement, coordinate and facilitates the Qualiy Assurance/Process Improvement (QAPI) Program for facility ...” 2. Patient #1 was transported from home to Hospital #1’s Emergency Department (ED) via Emergency Medical Services (EMS) on 11/27/2025 at 3:01 PM, after being found unresponsive by husband. Patient #1 reportedly got into an argument with her husband and took about thirty (30) Xanax (medication used to treat anxiety) 2.5 milligrams (mg) tablets. Patient #1 was admitted for inpatient treatment at Hospital #1. The physician at Hospital #1 determined Patient #1 needed to be involuntarily admitted to a higher level of inpatient psychiatric care due to being a danger to self and others. Emergency medical services were called and Patient #1 was transferred to Hospital #2. 3. Review of Hospital #2’s medical record revealed Patient #1 was admitted on 12/1/2025 to Hospital #2 with diagnoses including Major Depressive Disorder, High Suicide Risk, Hypertension, Cerebrovascular Accident with Right Sided Hemiparesis and Wheelchair Bound. Patient #1 was assessed as a high risk for injury from falls and at risk for bleeding from being on clopidogrel 75 milligrams tablet daily. Patient #1 was placed on fall precautions with 1:1 observation (level of monitoring used for high-risk patients to ensure safety) as needed. Patient #1 was ordered metoprolol (medication used to treat high blood pressure) 25 mg by mouth twice daily. Patient #1’s blood pressure on 12/1/2025 at 8:00 PM was taken by Certified Nursing Assistant (CNA) #1 with the result of 182/93. CNA #1 documented that she notified Registered Nurse (RN) #1 of Patient #1 ’ s blood pressure being out of range. RN #1 failed to reassess Patient #1’s blood pressure or notify the provider of the blood pressure which was out of range according to the hospital policy. Review of the “INCIDENT REPORT FORM,” dated 12/1/2025 at 7:10 PM, revealed Patient #1 had an observed fall at 7:04 PM. There was no documentation the patient ’ s vital signs were assessed following the fall. The nursing notes revealed the patient became combative following the fall and was treated with Ativan which was ineffective. A second “Incident Report Form” dated 12/1/2025 at 9:30 PM revealed the patient fell and sustained a head laceration. Patient #1 was transferred by emergency medical services (EMS) and admitted to Hospital #3 with a diagnosis of subdural hematoma (serious collection of blood between the brain ’ s surface and outer covering) with an intraparenchymal hemorrhage (bleeding directly into the brain ’ s functional tissue) of the left occipital lobe. Patient #1 expired at Hospital #3 on 12/3/2025 Review of the facility’s video footage on 12/1/2025 revealed no observations of RN #1 entering Patient #1’s the room to assess the patient. 4. During an interview on 1/5/2026 at 2:00 PM, when asked if she completed a thorough investigation on Patient #1’s two falls, the Risk Manager stated, “ ...In hindsight I should have done it quicker ...I started it on Monday [12/8/2025] the day you showed up ...I did not review or document the camera footage until I reviewed it with you...I did not have time to complete a thorough investigation ...we don’t do an investigation for each fall...based on the incident report the patient was aggressive with staff, and she sustained a fall ...that was all I was aware of until I got call from the hospital [Hospital #3] a few days later [12/2/2025] ...” The Risk Manager stated that the last Quality Council Meeting was held on 12/11/2025, but Patient #1’s fall with a major injury which resulted in the Patient’s death was not discussed in the meeting. When asked why she delayed the investigation of Patient #1’s fall with a major injury, the Risk Manager stated that she had been made aware that Patient #1 had a brain bleed on the left side, but since the knot and laceration were on the right side of her head, she thought the Patient had the injury while a Patient at Hospital #1. The Risk Manager stated she wanted to look at the medical record from Hospital #1. The Risk Manager stated, “...then I thought it was a spontaneous bleed ...that was the reason for the delay in the investigation ...I did not know the severity of the fall until the patient expired and that is when I reported it to the state on 12/4/2025...” The Risk Manager was asked if she gathered any witness statements from the staff members on duty on 12/1/2025. The Risk Manager stated, “No.” During an interview on 1/5/2026 at 4:15 PM, the Chief Executive Officer (CEO) stated the Risk Manager should have completed a thorough investigation of Patient #1’s falls. The CEO stated the Risk Manager told her that she had not reported it to the state and had not begun an investigation. The CEO confirmed that the Risk Manager did not complete a thorough investigation which should have included staff statements, camera footage, and incident reports. 7. Review of the closed medical record revealed Patient #5 was admitted on 11/4/2025 with diagnoses including Autism Spectrum Disorder, Foreign Body in Right Ear, Hypothyroidism, Intellectual Disability, and Asthma. Patient #5 had 2 orders for 1:1 observation, but nursing staff failed to monitor Patient #5 as ordered. Patient #5 demonstrated ongoing aggressive and combative behaviors toward other patients and staff. The facility failed to document these behaviors per hospital policy and to investigate the behaviors to prevent further occurrences. Patient #5 sustained a fall on 12/16/2025 and reported she hit her head. The RN assessed Patient #5 with no apparent injuries. The facility failed to develop and implement new interventions to prevent further falls. During an interview on 1/8/2026 at 1:06 PM, the Quality Manager of Rehabilitation stated there were no incident reports for Patient #5’s aggressive behaviors on 11/26/2025 and 12/14/2025 or her fall on 12/16/2025. The Quality Manager of Rehabilitation confirmed the 1:1 observation ordered by the provider for Patient #5 were not performed as ordered. The Governing Body failed to ensure nursing staff were accountable for the care provided to Patient #1 and #5. Nursing staff failed to reassess Patient #1’s elevated blood pressure and notify the provider of the elevated blood pressure. Nursing staff failed to follow the provider’s orders for neuro checks and vital signs every hour for 6 hours after Patient #1 fell. Nursing staff failed to complete a post fall assessment and implement interventions after Patient #1 ’ s first fall. Nursing staff failed to notify the provider of Patient #1’s head injury after a fall. Nursing staff failed to provide appropriate 1:1 observation to ensure the Patient’s safety. Nursing staff failed to provide 1:1 observation for Patient #5 as ordered. Nursing staff failed to complete incident reports for Patient #5’s falls and aggressive behaviors. The Governing Body failed to ensure that the adverse events with Patient #1 and #5 were thoroughly investigated to analyze and track their causes and implement preventative actions to promote patient safety. Refer to A 0263, A 0286, A0385 and A 0395”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 37530 Based on facility document review, policy review, camera footage review, medical record review, job description, observation and interview, Hospital #2 failed to provide evidence of an effective and on-going Quality Assurance Performance Improvement (QAPI) program to track adverse events, analyzed the causes and implement preventative actions as part of the facility wide QAPI Program for 2 of 5 (Patient #1 and Patient #5) sample patients reviewed for falls and patient to patient aggressive behavior. The findings included: 1. Review of Hospital #2’s policy titled “Healthcare Quality Management Plan,” with an effective date of 12/2025, revealed, “ ...The purpose of the Quality Management Plan is to outline an effective system to ensuring the quality and safety of services across all settings and patient populations ...The Quality Management Plan is designed to monitor the quality of health care providers to all clients served ...The primary goal ...Ensure A consistent, safe and high quality environment...FACILITY QUALITY COUNCIL ...is the steering committee for the facilities process improvement program and ensures implementation of process improvement activities through resources, training, and education...” Review of Hospital #2’s policy titled “PROCESS IMPROVEMENT PROGRAM,” dated 4/2025, revealed, “ ...The Process Improvement program is designed to provide a coordinated, objective, and systematic approach to facility wide quality assurance activities ....Objectives are ...To enhance, maintain, and continually improve the quality of patient care...” Review of Hospital #2’s policy titled “Risk Management Program,” dated 10/2024, revealed, “ ...utilize the Risk Management Program techniques to promote safety, pro-actively focus on loss prevention, and detect hazardous events and circumstances ...The Incident Report is a risk management tool that raises awareness of potential exposure to perils that may/did cause harm. It enables the facility to manage risk, increase safety, and improving the quality of health care provided in the facility through risk control interventions and monitoring the effectiveness of the interventions and corrective action plan ...” Review of Hospital #2’s policy titled “Risk Management Incident Investigation,” dated 12/2024, revealed, “ ...It is the policy of [Named Hospital #2] to utilize investigation as a preventive tool to avoid incidents from reoccurring to improve quality of care...” Review of Hospital #2’s policy titled “Incident Reporting - Risk Management Program,” dated 10/2024, revealed, “ ...Any facility staff member who witnesses, discovers, or had direct knowledge of an incident must complete an Incident Report before end of the shift/work day [workday]...” Review of Hospital #2’s policy titled “Patient Observation,” dated 9/2024, revealed, “ ...All patient are monitors at minimum once in every 15 minutes block of time ...Remain vigilant for specific risk for patients on Special Precautions ...1:1 Observation ...1:1 is the highest level of observation and is reserved for patients who are so unpredictable that without a dedicated staff member there is a risk of patient harming self or others ...” Review of Hospital #2’s policy titled “Vital Signs and Weight,” dated 9/2025, revealed, “ ...Vital signs will be taken at the time of admission and then as ordered by the practitioner ...” Review of Hospital #2’s policy titled “Assessment, Neurological,” dated 5/2025, revealed, “ ...Neurological assessment will be initiated when a patient has hit their head, had a change in level of consciousness, and unwitnessed fall or per practitioner order ...” Review of Hospital #2’s policy titled “Fall Precautions and Prevention,” dated 5/2025, revealed, “ ...Patient safety is an ongoing responsibility of all staff ...All patients admitted to the hospital will be assessed using the MORSE Falls Assessment ...each patient will be placed in a risk category ...Nursing shall place the patient on fall precautions when indicated and ensure the practitioner is notified and orders and the level of observation and precautions consistent with the assessed level of risk ...” Review of Hospital #2’s policy titled “Management of Aggressive Behavior,” dated 12/2024, revealed, “ ...The Nurse documents the emergency situation and any treatment rendered in the patient’s record...” 2. Review of Hospital #2’s “PATIENT RIGHTS & [and] RESPONSIBILITIES,” dated 12/1/2025, revealed, “ ...Right to receive care in a safe setting ...Right to be free from physical ...abuse ...” Review of Hospital #2’s Director of Risk Management “Job Description” signed on 2/28/2025 at 12:26 PM, revealed, “ ...Plan, organize, direct and control all aspects of risk management activities. Ensure a safe environment for the protection of patients ... Develop implement, coordinate and facilitate the Qualiy Assurance/Process Improvement (QAPI) Program for facility ...” 3. Medical record review revealed Patient #1 was transferred as an involuntary admission form Hospital #1 to the psychiatric unit at Hospital #2 via emergency medical services (EMS) on 12/1/2025 at 6:17 PM and was admitted with diagnoses including Major Depressive Disorder and as a high risk for suicide. Patient #1 was assessed as a high risk for falls and required assistance for toileting. Patient #1’s blood pressure on admission on 12/1/2025 at 6:23 PM was 156/86. Review of nursing notes revealed Patient #1 slid out of her wheelchair onto the floor on 12/1/2025 at 7:04 PM, and staff documented no apparent injuries. There were no vital signs or assessment documented after the fall. Nursing staff called Medical Nurse Practitioner (NP) #1 and notified her of the fall. Medical NP #1 gave a verbal order for vital signs and neuro checks to be done every hour for 6 hours. The vital signs and neuro checks were not documented as completed. There was no documentation nursing staff developed and implemented interventions to prevent further falls for Patient #1 after her first fall on 12/1/2025. Review of the nursing notes revealed Patient #1’s blood pressure on 12/1/2025 at 8:00 PM was 182/93. There was no further documentation of Patient #1’s vital signs including blood pressure after 8:00 PM. There was no documentation nursing staff reassessed Patient #1’s blood pressure or notified the provider of Patient #1’s elevated blood pressure per facility policy. Review of nursing notes dated 12/1/2025 at 9:20 PM, revealed Psychiatric NP #2 was notified of Patient #1’s ongoing aggressive and combative behaviors toward staff and self-harming behaviors such as banging her head on the bed rails and walls. At approximately 9:30 PM, Patient #1 was found by RN #1 crawling on the floor of her room with a laceration to her right eye and swelling. Patient #1 was assisted back to bed. There was no post fall assessment including vital signs or neuro checks documented by nursing staff. Patient #1 began showing signs of agitation, being combative with staff and refusing care and medications. Patient #1 started banging her head and extremities on the side rails and walls of her room. Nursing staff called Psychiatric NP #2 at 9:35 PM, and got an order for Ativan (medication used to treat anxiety) 1 mg intramuscular injection which was administered on 12/1/2025 at approximately 10:10 PM. Patient #1 was placed on 1:1 observation. The certified Nursing Assistant (CNA) who was assigned to 1:1 observation notified the nurse that Patient #1 began vomiting. The nurse noted that Patient #1 had a decrease in her level of consciousness and was nonverbal. The nurse contacted Psychiatric NP #2 around 10:50 PM who ordered for Patient #1 to be sent to the ED (Emergency Department) for further evaluation. When EMS arrived at 11:11 PM, Patient #1 was unresponsive. EMS documented Patient #1’s blood pressure was 206/123 at 11:20 PM and 205/119 at 11:23 PM. EMS assess Patient #1’s level of conscious as an 8 on the Glasgow Coma Scale which indicated severe traumatic brain injury. EMS transported Patient #1 to Hospital #3. Review of Hospital #2’s video recording revealed there was no video footage viewed that showed RN #1 entering Patient #1’s room following the fall and after the Patient started exhibiting behaviors. The video footage revealed staff had closed Patient #1 alone in her room at times and provided inadequate 1:1 observation. Review of the “Discharge Summary and [Hospital #3],” dated 12/3/2025 at 3:04 PM, by Medical Doctor (MD) #1, revealed “ ...[Patient #1] was admitted to ICU [Intensive Care Unit] ...due to subdural hematoma and intraparenchymal hemorrhage and passes away during the hospital stay ...she was brought to the hospital where she was found to have right subdural hematoma with midline shift and intraparenchymal hemorrhage in the left occipital lobe she was intubated and admitted to ICU with neurosurgery consult ...and family transitioned patient to DNR [Do Not Resuscitate]/comfort care due to previous wishes of patient. She was extubated and downgraded to hospitalist services. Hospice agency was consulted ...Primary cause of death ...Traumatic right subdural hematoma and traumatic left occipital intraparenchymal hemorrhage...” 4. Patient #5 was admitted to Hospital #2 on 11/4/2025 with diagnoses including Autism Spectrum Disorder, Foreign Body in Right Ear, Hypothyroidism, Intellectual Disability, and Asthma. Patient #5 had orders for 1:1 observation after midnight on 11/13/2025 and on 11/14/2025 to begin at 10:00 AM. Nursing staff failed to provide 1:1 observation for Patient #5 as ordered. Patient #5 exhibited aggressive and combative behaviors toward other patients and staff on 11/26/2025 and 12/14/2025. Patient #5 fell on 12/16/2025 with no apparent injuries. Nursing staff reassessed Patient #5’s fall risk after her fall but documented that Patient #5 did not have any falls. Nursing staff failed to accurately reassess Patient #5’s fall risk after her fall on 12/16/2025 and failed to implement interventions to prevent further falls. Nursing staff failed to investigate and document per facility policy Patient #5’s aggressive behaviors on 11/26/2025 and 12/14/2025 and her fall on 12/16/2025. The facility failed to document and investigate the incidaents for Patient #1 and #5 and track the adverse events to implement preventative actions and maintain an effective Quality Assurance and Performance Improvement Program. Refer to A 286”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 37530 Based on policy review, facility document review, medical record review, camera footage review and interview, the hospital failed to ensure nursing services was provided with the supervision and oversight to ensure care was provided safely and appropriately for 2 of 5 (Patient #1 and #5) patients reviewed. The findings included: 1. Review of the facility ‘s policy titled, “Vital Signs and Weight,” dated 9/2025, revealed, “ ...Reporting of Vital Signs ...the staff member who takes the vital signs will alert the nurse immediately if they are abnormal ...If vitals not taken by the nurse initially, the nurse will retake the vitals to verify results ...The nurse shall contact the practitioner immediately for additional recommendation if vitals fall within the ranges below ...BP [Blood Pressure] systolic greater than ...Adult ...180 ...” Review of the facility’s policy titled, “Patient Observation,” dated 9/2024, revealed, “ ...The RN may increase the level of observation if the patient’s condition changes. The psychiatric practitioner will be contacted soon as possible for notification of the change in condition and to obtain an order for the observation level ...1:1 Observation ...1:1 is the highest level of observation and is reserved for patients who are so unpredictable that without a dedicated staff member there is a risk of patient harming self or others ...Staff who are assigned to monitoring the patient on 1:1 observation will have no other assignment ...Staff are to remain within visual range and close proximity (easy reach) of patient at all times ...Staff are to remain in the room with the patient during ...toileting ...All 1:1 observations will be reviewed daily ...” Review of the facility’s policy titled, “Fall Prevention,” dated 9/2024, revealed, “ ...All patients will be assessed on admission for fall risk ...if Patient Falls ...Immediately assess patient and take appropriate actions to protect patient ...Notify MD/LIP [Medical Doctor/Licensed Independent Practitioner] of the fall and patient ’ s condition ...Notification of family ...name of person contacted as well as dated and time ...Implement physicians orders ...Notify family of fall ...Notify Nurse Manager ...Documentation of actions or intervention taken to prevent further falls ...Reassess patient and document within the electronic records ...” Review of the facility’s policy titled, “Fall Precautions and Prevention,” dated 5/2025, revealed, “ ...Patient safety is an ongoing responsibility of all staff. In order to reduce the risk for patient injuries as a result of a fall, nursing staff will assess and re-assess the patient ’ s level of risk for falls and implement appropriate interventions ...All patients admitted to the hospital will be assessed using the MORSE Falls Assessment ...each patient will be placed in a risk category ...Nursing shall place the patient on fall precautions when indicated and ensure the practitioner is notified and orders the level of observation and precautions consistent with the assessed level of risk ...45+ [score of 45 or greater]...Severe/High) Risk for Ralls [Falls]...Use safety mats and alarms at night...1:1 or Q [every] 5 minutes observation if indicated by practitioner order or nursing judgement ...Interventions Post Fall ...Patient is assessed/reassessed after any fall. (MORSE Fall Assessment utilized for assessment and post fall assessment) ...the Medical practitioner will be contacted by the Charge Nurse to determine course of treatment after a patient has fallen ...Patient falls risk reassessed and appropriate interventions implemented... An incident report will be completed and submitted to the Director of Risk Management/Performance improvement after a patient has fallen ...” Review of the facility’s policy titled, “Assessment, Neurological,” dated 5/2025, revealed, “ ...Neurological assessment will be initiated when a patient has hit their head, had a change in level of consciousness, and unwitnessed fall or per practitioner order ...Check level of consciousness and compare to the pre-injury state (Any change in the level of consciousness should be reported to the physician immediately) ...Check vital signs ...Results of the assessment are documented on the Neurological assessment form ...” Review of the “PATIENT RIGHTS & [and] RESPONSIBILITIES,” dated 12/1/2025, revealed “ ...Right to appropriate assessment and management of your plan ...Right to receive care in a safe setting ...” Review of the undated facility’s education titled, Medical Emergencies- Change in Condition, revealed, “ ...Rapid Response systems are programs that are designed to improve the safety of hospitalized patients whose condition is deteriorating quickly ...Criteria Guidelines for Initiating the RRT [Rapid Response Team] (early warning signs) ...Acute change in level of consciousness or mental status ...Significant bleeding ...Failure to respond to medical interventions ...” 2. Medical record review revealed Patient #1 was transferred as an involuntary admission from Hospital #1 to the psychiatric unit at Hospital #2 via emergency medical services (EMS) on 12/1/2025 at 6:17 PM and was admitted with diagnoses including Major Depressive Disorder and as a high risk for suicide. Patient #1 was assessed as a high risk for falls and required assistance for toileting. Patient #1’s blood pressure on admission on 12/1/2025 at 6:23 PM was 156/86. Review of nursing notes revealed Patient #1 slid out of her wheelchair onto the floor on 12/1/2025 at 7:04 PM and staff documented no apparent injuries. There were no vital signs or assessment documented after the fall. Nursing staff called Medical Nurse Practitioner (NP) #1 and notified her of the fall. Medical NP #1 gave a verbal order for vital signs and neuro checks to be done every hour for 6 hours. The vital signs and neuro checks were not documented as completed. There was no documentation nursing staff notified Patient #1’s family of the fall. There was no documentation nursing staff developed and implemented interventions to prevent further falls for Patient #1 after her first fall on 12/1/2025. Review of the nursing notes revealed Patient #1’s blood pressure on 12/1/2025 at 8:00 PM was 182/93. There was no further documentation of Patient #1’s vital signs including blood pressure after 8:00 PM. There was no documentation nursing staff notified the provider of Patient #1’s elevated blood pressure per facility policy. Review of nursing notes dated 12/1/2025 at 9:20 PM, revealed “... At 21:35 [Named Psychiatric NP #2] the oncall [on call] psych NP was notified of pts ongoing agressive [aggressive] behaviors and the fall [this was over 2 hours after the fall]. New order obtained to give patient 1 mg of ativan [Ativan] [treat anxiety] IM [Intramuscular]...While pulling up patients ativan at the nurses station patient again became even more agressive with her 1 on 1 and demanded she was going to crawl out of bed into her wheel;chair [wheelchair] and rolled herself out into the common area yelling again at staff and exhibiting combative behavior towards anyone who attempted to come near her. Staff again assisted pt back into her room at assisted pt back into her bed...” Patient #1 began showing signs of agitation, being combative with staff and refusing care and medications. Patient #1 started banging her head and extremities on the side rails and walls of her room. Nursing staff called Psychiatric NP #2 at 9:35 PM, and got an order for Ativan (medication used to treat anxiety) 1 mg intramuscular injection which was administered on 12/1/2025 at approximately 10:10 PM. Patient #1 was placed on 1:1 observation. The certified Nursing Assistant (CNA) who was assigned to 1:1 observation notified the nurse that Patient #1 began vomiting. The nurse noted that Patient #1 had a decrease in her level of consciousness and was nonverbal. The nurse contacted Psychiatric NP #2 around 10:50 PM who ordered for Patient #1 to be sent to the ED (Emergency Department) for further evaluation. When EMS arrived at 11:11 PM, Patient #1 was unresponsive. EMS documented Patient #1’s blood pressure was 206/123 at 11:20 PM and 205/119 at 11:23 PM. EMS assess Patient #1’s level of conscious as an 8 on the Glasgow Coma Scale which indicated severe traumatic brain injury. EMS transported Patient #1 to Hospital #3. Review of Hospital #2’s video recording revealed there was no video footage viewed that showed RN #1 entering Patient #1’s room following the fall and after the Patient started exhibiting behaviors. 3. Medical record review at Hospital #3 revealed Patient #1 was admitted on 12/1/2025 at 11:25 PM to Hospital #3 with diagnoses including subdural hematoma (serious collection of blood between the brain’s surface and the outer covering of the brain) and intraparenchymal hemorrhage (bleeding into the brain ’ s functional tissue). Patient #1’s family transitioned Patient #1 to comfort care, and Patient #1 died on 12/3/2025. In summary, nursing staff at Hospital #2 failed to appropriately monitor Patient #1 due to her risk of self harm and high risk for falls. Nursing staff failed to appropriately assess Patient #1 after her fall and failed to notify the Medical NP, Psychiatric NP and House Supervisor of Patient #1’s head injury after her fall. Nursing staff failed to assess Patient #1 and call the Rapid Response Team when she demonstrated a change in mental status. 4. Patient #5 was admitted to Hospital #2 on 11/4/2025 with diagnoses including Autism Spectrum Disorder, Foreign Body in Right Ear, Hypothyroidism, Intellectual Disability, and Asthma. Patient #5 had orders for 1:1 observation after midnight on 11/13/2025 and on 11/14/2025 to begin at 10:00 AM. Nursing staff failed to provide 1:1 observation for Patient #5 as ordered. Patient #5 exhibited aggressive and combative behaviors toward other patients and staff on 11/26/2025 and 12/14/2025. Patient #5 fell on 12/16/2025 with no apparent injuries. Nursing staff reassessed Patient #5’s fall risk after her fall but documented that Patient #5 did not have any falls. Nursing staff failed to accurately reassess Patient #5’s fall risk after her fall on 12/16/2025 and failed to implement interventions to prevent further falls. Nursing staff failed to investigate and document per facility policy Patient #5’s aggressive behaviors on 11/26/2025 and 12/14/2025 and her fall on 12/16/2025. Refer to A 395”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 37530 Based on policy review, facility document review, medical record review, camera footage review, medical record review, and interview, the facility failed to ensure the Quality Council Committee analyzed and monitored processes to track adverse events and implement preventative actions as part of the facility wide Quality Management Plan Program for 2 of 5 (Patient #1 and Patient #5) sample patients reviewed for falls and aggressive behaviors. The findings included: 1. Review of Hospital #2’s policy titled “Healthcare Quality Management Plan,” with an effective date of 12/2025, revealed, “ ...The purpose of the Quality Management Plan is to outline an effective system to ensuring the quality and safety of services across all settings and patient populations ...The Quality Management Plan includes provisions for quality assurance/performance improvement/quality control with the overarching concept of high reliability to support the clinical work throughout programs, facilities, and organization. The Quality Management Plan is designed to monitor the quality of health care providers to all clients served ...The primary goal of the Quality Management Plan are ...Achieving excellence in client experience of care ...Incorporating the use of evidence-based practice and research ...Ensure A consistent, safe and high quality environment that exemplifies the concept of High Reliability, evidence-based and evidence-informed practice, and compassionate. care ... FACILITY QUALITY COUNCIL ...The Quality Council ...is the steering committee for the facilities process improvement program and ensures implementation of process improvement activities through resources, training, and education. The Quality Council receives reports of process improvement activities from the department’s specific indicators, Process Improvement teams, committee as assigned, patient/family satisfactory surveys, and staff input regarding process improvement activities and assures that appropriate actions are implemented to resolve identified problems or improve existing process ...” Review of Hospital #2’s policy titled “PROCESS IMPROVEMENT PROGRAM,” dated 4/2025, revealed, “ ...The Process Improvement program is designed to provide a coordinated, objective, and systematic approach to facility wide quality assurance activities. The Program is based upon an integrated and collaborative approach of measurements-based care to increase the probability of desired patient outcomes by assessing and improving those governance managerial, clinical, and support process that most affect patients outcome ....Objectives are ...To enhance, maintain, and continually improve the quality of patient care through intra and or inter departmental services, measurements and assessments of patient care, resolution of problems, and ongoing pursuit of opportunities to improve patient care ...The Quality Care Council is the steering committee for the program and will ...establish policies and ensure implementation of process improvement activities through resources, training and education ....design, maintain, support, and document evidence of ongoing programs to systematically measure, assess and improve patient outcome and Facility performance ...” Review of Hospital #2’s policy titled “Risk Management Program,” dated 10/2024, revealed, “ ... It is the policy of [Named Hospital #2] to utilize the Risk Management Program techniques to promote safety, pro-actively focus on loss prevention, and detect hazardous events and circumstances. It must provide a systematic, multi-disciplinary approach to manage and reporting incidents of injury, damage, and loss ...The Incident Report is a risk management tool that raises awareness of potential exposure to perils that may/did cause harm. It enables the facility to manage risk, increase safety, and improving the quality of health care provided in the facility through risk control interventions and monitoring the effectiveness of the interventions and corrective action plan ...Supervisors would notify facility Risk Management of a serious incident as well as take the lead in investigation. Non-serious incidents ...When documenting incidents in the medical record, the staff would chart precisely what happened without making reference to any “errors” or that an incident report was completed ...Facility Risk Manager will collect data for statistical analysis and trending. Definition of incident report forms ...Verbal Altercation/Threats to Harm Pt/Pt [patients to patients] or Pt/Staff ...Orders Not Carried Out ...Failure to carry out a physician’s order appropriately or in any timely manner ...Falls unintentionally coming to rest on the ground, floor, or other lower levels ...Observed Fall ...Unobserved Fall ...The following examples represent the typical initial severity level, however a final level of severity may be determined after further review ...Fall with injury requiring emergency treatment are transferred to a medical hospital ...Death within 72 hours of discharge ...” Review of Hospital #2’s policy titled “Risk Management Incident Investigation,” dated 12/2024, revealed, “ ...It is the policy of [Named Hospital #2] to utilize investigation as a preventive tool to avoid incidents from reoccurring to improve quality of care...Gather data...conducting interviews with staff members...Risk Manager’s role is to make recommendations based on investigation findings...” Review of Hospital #2’s policy titled “Incident Reporting - Risk Management Program,” dated 10/2024, revealed, “ ...Any facility staff member who witnesses, discovers, or had direct knowledge of an incident must complete an Incident Report before end of the shift/work day [workday]...The facility Risk Manager...will notify appropriate agencies of reportable incidents...” Review of Hospital #2’s policy titled “Patient Observation,” dated 9/2024, revealed, “ ...All patient are monitors at minimum once in every 15 minutes block of time ...Remain vigilant for specific risk for patients on Special Precautions ...1:1 Observation ...1:1 is the highest level of observation and is reserved for patients who are so unpredictable that without a dedicated staff member there is a risk of patient harming self or others ...Staff who are assigned to monitoring the patient on 1:1 observation will have no other assignment ...Staff are to remain within visual range and close proximity (easy reach) of patient at all times ...All 1:1 observations will be reviewed daily ...” Review of Hospital #2’s policy titled “Vital Signs and Weight,” dated 9/2025, revealed, “ ...Vital signs will be taken at the time of admission and then as ordered by the practitioner ...Reporting of Vital Signs ...the staff member who takes the vital signs will alert the nurse immediately if they are abnormal ...If vital not taken by the nurse initially, the nurse will retake the vitals to verify results ...The nurse shall contact the practitioner immediately for additional recommendation if vitals fall within the ranges below ...BP [Blood Pressure] systolic greater than ...Adult ...180 ...” Review of Hospital #2’s policy titled “Assessment, Neurological,” dated 5/2025, revealed, “ ...Neurological assessment will be initiated when a patient has hit their head, had a change in level of consciousness, and unwitnessed fall or per practitioner order ...Results of the assessment are documented on the Neurological assessment form ...” Review of Hospital #2’s policy titled “Fall Precautions and Prevention,” dated 5/2025, revealed, “ ...Patient safety is an ongoing responsibility of all staff ...All patients admitted to the hospital will be assessed using the MORSE Falls Assessment ...each patient will be placed in a risk category ...Nursing shall place the patient on fall precautions when indicated and ensure the practitioner is notified and orders and the level of observation and precautions consistent with the assessed level of risk ...Assist and encourage patient to use the bathroom every two (2) hours and monitor for incontinence ...Use safety mats and alarms at night ...Interventions Post Fall ...Patient is assessed/reassessed after any fall. (MORSE Fall Assessment utilized for assessment and post fall assessment) ...the Medical practitioner will be contacted by the Charge Nurse to determine course of treatment after a patient has fallen ...Patient falls risk reassessed and appropriate interventions implemented ...An incident report will be completed and submitted to the Director of Risk Management/Performance Improvement after a patient has fallen ...” Review of Hospital #2’s policy titled “Management of Aggressive Behavior,” dated 12/2024, revealed, “ ...The Nurse documents the emergency situation and any treatment rendered in the patient ’ s record and in the Nursing Supervisor’s logbook, completes and Incident...notifies the House Supervisor of all action taken...” 2. Review of Hospital #2’s “PATIENT RIGHTS & [and] RESPONSIBILITIES,” dated 12/1/2025, revealed, “ ...Right to receive care in a safe setting ...Right to be free from physical ...abuse ...” Review of Hospital #2’s Director of Risk Management “Job Description” signed on 2/28/2025 at 12:26 PM, revealed, “ ...Plan, organize, direct and control all aspects of risk management activities. Ensure a safe environment for the protection of patients ...to the facility in such a manner as to comply with laws, regulations and the standards of the accrediting and approved agencies ...Investigate and analyze actual potential risks in the facility, assess liability and probability of legal action for potential notification, Implement, educate and encourage incident reporting system throughout the facility ...ensure the organization ’ s procedures and policies are being followed by all employees ...Develop implement, coordinate and facilitates the Qualiy Assurance/Process Improvement (QAPI) Program for facility ...” 3. Patient #1 was transported from home to Hospital #1’s Emergency Department (ED) via Emergency Medical Services (EMS) on 11/27/2025 at 3:01 PM, after being found unresponsive by husband. Patient #1 reportedly got into an argument with her husband and took about thirty (30) Xanax (medication used to treat anxiety) 2.5 milligrams (mg) tablets. Patient #1 was admitted for inpatient treatment at Hospital #1. Review of Hospital #1’s Medication Administration Record dated 11/28/2025 at 12:05 AM, revealed Patient #1 received a Lovenox (medication used to prevent the formation of blood clots) 40 mg injection. Patient #1 also received clopidogrel (medication used to prevent the formation of blood clots) 75 mg tablet by mouth on 11/29/2025 at 8:03 AM. Review of Hospital #1’s “Safety/Equipment,” dated 11/27/2025, 11/28/2025, 11/29/2025, and 11/30/2025 at 6:00 AM and 8:00 AM, revealed “ ...Fall Prevention Precautions Initiated ...Positive injury Risk Factors ...Bleeding risk ...” Review of Hospital #1’s “Consultation Note,” dated 11/29/2025, revealed, “ ...Plan ...6404 [certificate of need for involuntary commitment] ...we will continue suicide precautions and sitter in room for safety per hospital protocol and imitated treatment for acute management ...” Review of Hospital #1’s physician Progress Note dated 12/1/2025, revealed, “ ...On comprehensive assessment of patient’s current dangerousness to self and others, at present the patient is a high risk due to untreated psychiatric symptoms that significantly impair their judgement, behavior, capacity to recognize reality, and ability to cope with ordinary demands ...this patient meets criteria for psychiatric hospitalization on involuntary status ...” Review of the 6404 “FIRST CERTIFICATE OF NEED FOR EMERGENCY INVOLUNTARY ADMISSION,” dated 12/1/2025 at 1:00 PM, revealed “ ...intentional Xanax overdose ...threat to self ...suicide risk ...” 4. Patient #1 was transferred from Hospital #1 to Hospital #2 for a higher level of care on 12/1/2025 at 5:50 PM by EMS. Review of Hospital #2’s medical record revealed Patient #1 was admitted on 12/1/2025 to Hospital #2 with diagnoses including Major Depressive Disorder, High Suicide Risk, Hypertension, Cerebrovascular Accident with Right Sided Hemiparesis and Wheelchair Bound. Review of Hospital #2’s “Intake Assessment (Behavioral and Medical),” dated 12/1/2025, revealed, “ ...Patient reports that she got mad at her husband...What happened in the last 72 hours which led to the Precipitating Crisis/Chief Complaint ...Patient presented to ED [at Hospital #1] after reported SA [Suicide Attempt] via OD [overdose] ...Patient reports, “I wanted to die” & refuses to discuss further information. While admitted to hospital patient made threats of slitting her throat. Patient is not safe to D/C [discharge] at this time. 6404 [involuntary admission]...Past or present medical conditions ...Mobility Wheelchair ...Medications ...clopidogrel Oral 75 mg ...” Review of Hospital #2’s “Treatment Items,” dated 12/1/2025, revealed, Patient #1 was a risk for injury from falls related to past medical history of Cerebrovascular Accident along with foot drop. The goal while Patient #1 was hospitalized was to remain free from fall-related injuries and compliance with treatments. “...Nursing will implement fall precautions ...1:1 supervision as needed ...” Review of Hospital #2’s “Final Physician Medication Orders,” dated 12/1/2025, revealed, “ ...clopidogrel ...75 mg PO [twice daily] ...9:00 AM ...Start: 12/2/2025 9:00 AM ...Indication: DVT [deep vein thrombosis] prophylaxis ... metoprolol [medication used to treat high blood pressure] ...25 mg PO BID [twice daily] ...Start: 12/1/2025 9:00 PM ...indication: Blood Pressure ...” Review of Hospital #2’s “Nursing Assessment,” dated 12/1/2025 at 6:23 PM, revealed “ ...Arrived on unit ...12/1/2025 at 6:15 PM ...Toileting ...Assistance required ...Special Equipment ...Wheelchair ...The Morse Fall Scale ...Total Score 60 [severe high risk for falls] ...” Review of the “Observations Blood Pressure,” dated 12/1/2025 at 8:00 PM, revealed Patient #1 ’ s blood pressure was taken by Certified Nursing Assistant (CNA) #1 with a result of 182/93. CNA #1 documented that she notified Registered Nurse (RN) #1. The facility failed to reassess Patient #1’s blood pressure and notify the provider of the blood pressure which was out of range according to the hospital policy. Review of the “INCIDENT REPORT FORM,” dated 12/1/2025 at 7:10 PM, revealed, “ ...Staff Name ...[Named RN #2] ...Incident Time ...7:04 PM ...Location of Incident ...Hallway/Main Door ...Patient precautions at the time of the Incident ...Suicide ...Fall ...Observed Fall ...NOTIFICATION ... Physician/Practitioner Name [blank] ...” Review of the “Patient Notes,” dated 12/1/2025 at 7:17 PM, revealed, “...the patient was seen walking out of her wheelchair by the main door, and she fell to the floor on her bottom. She did not hit her head and had no injury. Vitals were found normal...[documented by RN #2] ...” There was no documentation that Patient #1’s vital signs were taken immediately after the fall. Review of the “Patient Notes,” dated 12/12025 at 7:20 PM (events in this note occurred after the documented time), revealed, “ ...7:20 PM Patient was assisted to her room after requesting to go to bed ...Nurse exited the room per request. Nurse waitted [waited] a few minutes and went to pts [patient] room again to see if she would take her oral meds. Upon entering patients room she was found crawling on her stomach across the room and was attempting to slid on her stomach out of her room into the common area ...Patient noted to have a knot above her right eye just above the eyebrow and blood on the right side of her head...At 9:35 PM [Named Psychiatric NP #1] the oncall [on call] psych [psychiatric] NP was notified of pts [patient’s] ongoing aggressive [aggressive] behaviors and the fall [this was 2 hours and 19 minutes after the resident had fallen]. New order obtained to give patient 1 mg [milligram] of ativan IM [intramuscular] due to pts [patient’s] refusal to take any of her oral medications...At 10:10 PM 1 mg IM Ativan was administered in the left hip as ordered ...After administration of injection pt remained on a 1 to 1 supervision due to her risk of injury to self and of fall risk. Patient remained in bed with ongoing behaviors for 40 minutes then suddenly rolled onto her side and expelled a small amount of clear vomit and stopped moving or kicking or yelling. Staff attempted to arouse patient and she was unresponsive to verbal and tactile stimuli...Nurse immediately called [Named Psychiatric NP #2] and asked if pt couuld [could] be sent to the ER [Emergency Room] for evaluation...EMS arrived and transported patient...spoke to ER [Emergency Room] nurse about patient’s condition. Per nurse she is unable to confirm dx [diagnosis] at this time due to ER status. At 1:05 am ER nurse [Named Hospital #3 staff] called stating patient is being admitted ...with a admit DX [diagnosis] of a Subdural hematoma witha [with a] Intraparenchymal hemorrhage of the left occipital lobe. [Named Nurse Practitioner [Psychiatric NP #2] the psych [psychiatric] NP andhouse [and house] supervisor notified ...Signed by [Named RN #1] ...” Review of the “INCIDENT REPORT FORM,” dated 12/1/2025 at 9:30 PM, revealed “ ...Staff [Named RN #1] ...Reported Time ...9:27 PM ...Location of Incident ...pt ’ s [patient ’ s] Room ...Patient precautions at the time of the Incident ...Suicide ...Patient Injury (unspecified) ...Unobserved Fall ...[symbol for changed] to 1:1 due to increased agitation throwing self out of bed ...Was an injury observed ...Yes ...Laceration R [right] eye & [and] knot ...Patient was assisted back to bed from w/c [wheelchair] due to ongoing aggressive behavior ...once in bed 10 minutes later staff entered & pt was crawling around on Floor. Pt noted to have a knot with laceration above R eye ...placed on 1:1 ...medical on call notified of injury, psych [psychiatric] NP [Nurse Practitioner] notified ...new order for Ativan [used to treat anxiety] 1 mg IM [intramuscular] ...given at 10:10 PM ...NOTIFICATION ...[Named RN #1] ...9:45 PM ...NP notified send to ER [Emergency Room] ...Family ...called spouse [Named Family Member #1] x [times] 3 no answer ...” Review of Hospital #2’s video recording from 12/1/2025, with the Risk Manager and the Director of Information Technology (IT) present, revealed the following: At 6:17 PM Patient #1 arrived via (by) stretcher by Emergency Medical Services (EMS). At 6:20 PM Patient #1 transferred to the wheelchair. At 6:20 PM EMS exited facility with stretcher and Patient #1 was transferred to the seclusion room by RN #2. At 6:30 PM Patient #1 exited the seclusion room in wheelchair, accompanied by RN #2, and placed at table in front of the nursing station. Patient #1 was dressed in brown shirt and blue pants with non-skid socks. At 7:07 PM Patient #1 propelled self in wheelchair towards the nursing station to the open window. Patient #1’s first fall which occurred at 7:04 PM was not seen on the video footage. Patient #1 had wheeled herself out of view of the camera. At 9:01 PM CNA #3 turned off the lights and closed the door to Patient #1 ’ s room leaving Patient #1 alone in her room with the door closed. At 9:30:48 PM RN #1 arrived at Patient #1’s door with the medication cart, opened the door, turned on the light and entered the room. At 9:31:06 PM Patient #1 was lying on her back at the doorway and appeared to be crawling on the floor. At 9:31:16 PM RN #1 moved the medication cart, and Patient #1 crawled out of the room on her back, into the halfway. Patient #1 grabbed the door frame with her left hand and pulled herself to a sitting position. At 9:35:22 PM CNA #1 and CNA #4 assisted Patient #1 off the floor. At 9:35:32 PM CNA #1 and CNA #4 assisted Patient #1 back to bed. At 9:40:10 PM CNA #2 placed a chair at the doorway outside of the room and turned off the lights. 1:1 monitoring by CNA #2 started at 9:40:17 PM (CNA #2 was not within easy reach of Patient #1 while she was at the doorway or seated in the chair outside the room). At 10:22:20 PM CNA #2 walked away to the table beside the patient room, stood by the table briefly and went back to the patient’s room (CNA #2 was not within easy reach of Patient #1 when she walked to the table outside the patient’s room or when she was seated in the chair outside the room). At 10:22:41 PM Patient #1 rolled to the middle of the common area in her wheelchair, and CNA #2 remained in front of the patient doorway (CNA #2 was not within easy reach of Patient #1 while the Patient was in the middle of the common area, and she was at the Patient’s doorway). At 10:24:40 PM CNA #2 was seated in the chair in the doorway (CNA #2 was not within easy reach of Patient #1 while she was seated in the chair outside the room). At 10:41:15 PM CNA #2 got up from the chair, turned on the lights, and entered the room with CNA #4. At 10:42:46 PM CNA #2 and CNA #4 exited the room (CNA #2 was not within easy reach of Patient #1 when she exited the room). At 10:42:51 PM CNA #2 was seated at the door in the chair with the lights on in room (CNA #2 was not within easy reach of Patient #1 while she was seated in the chair outside the room). At 10:43:46 PM CNA #2 exited the room and walked down toward the nurses ’ station (CNA #2 was not within easy reach of Patient #1 when she exited the room and walked to the nurses ’ station). At 11:11:47 PM EMS personnel (4 paramedics and 2 police officers) came down the hall with a stretcher. At 11:13:36 PM EMS exited the room with the patient on the stretcher. There was no video footage viewed that RN #1 entered the room in an attempt to conduct neuro checks or obtain vital signs as ordered. 5. Review of the ED records from Hospital #3 dated 12/1/2025 at 11:35 PM, revealed Patient #1 arrived via EMS with complaints of altered mental status. Patient #1 was diagnosed with subdural hematoma with a midline shift and intraparenchymal hemorrhage in the left occipital lobe. Patient #1 was intubated and admitted to the Intensive Care Unit (ICU) at Hospital #3. Review of the “Discharge Summary and [Hospital #3],” dated 12/3/2025 at 3:04 PM, by Medical Doctor (MD) #1, revealed “ ...[Patient #1] was admitted to ICU [Intensive Care Unit] ...due to subdural hematoma and intraparenchymal hemorrhage and passes away during the hospital stay ...Reportedly at [Named Hospital #2] the patient became combative and agitated throwing her head against the wall multiple times. She was restrained and given Ativan. She was minimally responsive, so she was brought to the hospital where she was found to have right subdural hematoma with midline shift and intraparenchymal hemorrhage in the left occipital lobe she was intubated and admitted to ICU with neurosurgery consult. Neurological exam was poor, and family transitioned patient to DNR [Do Not Resuscitate]/comfort care due to previous wishes of patient. She was extubated and downgraded to hospitalist services. Hospice agency was consulted ...Primary cause of death ...Traumatic right subdural hematoma and traumatic left occipital intraparenchymal hemorrhage...” 6. During a telephone interview on 12/8/2025 at 7:11 PM, RN #1 at Hospital #2 stated, “ ...I’m going to start from the beginning at 6:45 PM [on 12/1/2025]. She [Patient #1] was on her butt in the front of the door right at shift change ... I asked them [Named RN #2 and RN #3], “Who’s this?” This first time I’ve ever seen her, she’s a new patient ...they kind of gave me the rundown and said she was scooting along in her wheelchair and fell out of her chair ...”Did she have an injury?” ...[Named RN #3] said “no ....she denies any ideation or anything like that ...she’s just upset with her husband” ...I don’t know, an hour and then maybe 40 minutes into the shift ...she’s fighting us, she’s kicking, she’s trying to crawl out of bed ...she don’t want to go to bed ...I get all her meds [medications]...and she don’t want her meds ...” When asked about Patient #1 lying on the floor as seen on the video footage, RN #1 stated she went to Patient #1 ’ s room with her medications and found her lying on the floor. RN #1 stated she saw a cut on Patient #1’s right eyebrow with swelling, but Patient #1 would not let her touch her or assess her. RN #1 stated she decided to put Patient #1 on 1:1 observation. RN #1 stated she called Psychiatric NP #2 and told her what happened, and Psychiatric NP #2 ordered 1 mg Ativan injection which she administered. RN #1 stated that after the injection, she was at the nurses’ station when a nurse or CNA told her that Patient #1 was vomiting. RN #1 stated she called Psychiatric NP #2 who ordered to send Patient #1 to the ED for further evaluation. RN #1 stated she left Patient #1 ’ s room to let EMS in the building. RN #1 stated when she got back to the room, Patient #1 was unconscious and not moving. During a telephone interview on 12/10/2025 at 8:16 AM, Medical NP #1 at Hospital #2 stated, “ ...got call from [Named Registered Nurse (RN #2)] around 7:00 PM [on 12/1/2025] ...she said the patient had a fall and slipped out of wheelchair ...I said was it witnessed? She said “yes” ...I asked if she hit her head ...she said “no” I asked if there was any deformity ...She said “no” I gave orders for neuro [neurological] checks every hour for 6 hours along with the vital signs and let me know if any changes ...I did not hear from the staff all night ...” When asked if she was aware that Patient #1 had another fall and hit her head with a laceration and hematoma and was later sent out to the Emergency Department, Medical NP #1 stated, “ ...I did not know anything about that ...I came in that morning to see her ...I did not know about that at all ...no one told me about a hematoma or head injury ...For me personally, if I have a patient I ’ m unfamiliar with ...hits their head, I want them to get imaging right away ...” When asked if she would consider a fall an emergency if the patient hit their head, was on blood thinner medication, and had a hematoma and laceration, Medical NP #1 stated, “Yes. for sure.” During an interview on 12/16/2025 at 8:48 AM, Psychiatric NP #2 at Hospital #2 stated, “ ...she [RN #1] said the patient [Patient #1] ...came in due to an overdose ...she was agitated and trying to kick staff and throw self out of bed ...she tried to give the patient her medication and she would not take anything ...she continued to be aggressive ...I gave an order for 1 mg Ativan to treat a possible benzo [Benzodiazepine use to treat anxiety] withdrawal ...then I said, with her throwing herself out of the bed, make her 1:1 [observation] ...told me that she had a fall early in the shift ...medical was notified ...I asked if they did neuro checks and she said she was refusing care at the time ...” When asked if nursing staff had informed her that Patient #1 had a laceration, a hematoma, and had been bleeding, Psychiatric NP #2 stated, “ ...I was not aware of that ...they called me at 10:00 PM or after 10:30 or around that time ...told me the patient was vomiting, and I said send her out ...” When asked if she knew whether the Rapid Response Team had been called, Psychiatric NP #2 stated, “No, there was not a rapid responsecalled ...it should have been called ...I asked the House Supervisor if she was told the patient was unconscious and she said no ...” When asked what nursing staff should do if a patient does not respond appropriately or has an altered mental status, Psychiatric NP #2 stated they should complete an assessment by checking vital signs, checking neurological status, and if necessary, initiate cardiopulmonary resuscitation. During an interview on 12/16/2025 at 7:39 PM, when asked about vital signs, RN #1 at Hospital #2 stated, “ ...if the blood pressure is out of range, we have to let the NP [Nurse Practitioner] know...the tech [technician] does them [vital signs] at the beginning of the shift. If something is going on, then we will recheck it. If we give meds [medications], we recheck the vital signs, and also if the patient refuses and gets combative, will try again later ...” When asked what type of assessment she would perform after a patient fall, RN #1 stated, “ ...I would do vital sign, neuro checks, check for wounds, check pain, monitor functional status, assess her speech ...” When asked if she should have followed Medical NP #1’s orders for vital signs and neuro checks every hour for 6 hours, RN #1 stated, “Oh yes, if she let me ...” During a telephone interview on 12/17/2025 at 10:21 AM, the House Supervisor at Hospital #2 stated, “ ...[Patient #1] was very unhappy to be there, and she had actually had a fall at shift change ...she placed herself from the wheelchair on the floor of the unit. It was witnessed ...she had no injuries ...she [Patient #1] was refusing her night time medications ...[RN #1] told me that she went ahead and put a tech with the patient [1:1 observation] because she was being so aggressive and that she was getting ready to give her an injection ...then the next call I got was that she had fallen ...she [RN #1] called the medical provider and the psychiatric provider and decided they were going to send her out mainly because at that point, she was refusing neuro assessments and vital signs ...that was the gist of it ...” When asked if RN #1 notified her that Patient #1was not responding or she couldn’t arouse her, the House Supervisor stated, “ ...No, I think the terminology she used when she called, she either said, drowsy or lethargic ...the impression I got from her was, she received an Ativan injection and was drowsy from that ...” When asked what RN #1 told her about Patient #1 ’ s status when EMS arrived, the House Supervisor stated EMS assessed her as comatose. The House Supervisor stated that the nurse should page a rapid response overhead when a patient is not responding. The House Supervisor was informed that while reviewing the video footage, RN #1 was never seen attempting to enter Patient #1 ’ s room with the blood pressure machine used on the unit to check vital signs or to conduct neuro checks. The House Supervisor stated, “ ...I was unaware of any of that ...I can’t speak to that ...but yes, that’s the first thing I would have done. Check the blood pressure and assess neuro checks ...if you’re not going in the room with the dynamap (machine used to check vital signs) or making a conscious attempt to do something ...I can ’ t say that the patient refused ...I agree ...you’re not wrong there ...” When asked if she was aware that Patient #1 had 2 falls, the House Supervisor stated, “ ...I believe I was just aware of the one fall [Patient #1’s first fall at 7:04 PM] ...” When asked if she had been informed that Patient #1 had a fall with a head injury, would she have come to Patient #1’s room to assess the situation, the House Supervisor stated, “Absolutely.” The House Supervisor confirmed she was not told about Patient #1’s second fall or her head injury at that time. During an interview on 12/17/2025 at 2:39 PM, the Chief Nursing Officer (CNO) at Hospital #2 stated that the nurse should communicate that a patient had a fall with an injury to the provider, and the nurse should document the assessment including the injury and the patient ’ s vital signs. When asked if staff should close the door to a patient ’ s room with the patient alone in the room who had been banging their head against the rails and walls and had been assessed as a high risk for falls or suicide, the CNO stated, “Absolutely not. The door needs to be open...if the door is closed, someone should be in the room with the patient...” When asked if a patient had a change in status, should the nurse assess the patient and document the assessment, the CNO stated, “...Absolutely, 100 percent...” During a telephone interview on 12/18/2025 at 12:49 PM, CNA #2 at Hospital #2 confirmed she was assigned 1:1 observation for Patient #1 on 12/1/2025. When asked if she was within easy reach of Patient #1 when she was seated in the chair at the doorway outside the room, CNA #2 stated, “...I was not...” CNA #2 stated she had not received any training on 1:1 observation for patients. When asked if she witnessed Patient #1 banging her head on the side rails or walls, CNA #2 stated, “...I did not see her. I heard her banging on something...” When asked if the patient ’ s door should be closed with the patient alone in the room, CNA #2 stated, “No”. During an interview on 1/5/2026 at 2:00 PM, when asked if she completed a thorough investigation on Patient #1 ’ s two falls, the Risk Manager stated, “ ...In high insight I should have done it quicker ...I started it on Monday [12/8/2025] the day you showed up ...I did not review or document the camera footage until I reviewed it with you ...so, no I did not ...I did not have time to complete a thorough investigation ...we don ’ t do an investigation for each fall ...we just review the incident reports to see if there are any concerns ...based on the incident report the patient was aggressive with staff, and she sustained a fall ...that was all I was aware of until I got call from the hospital [Hospital #3] a few days later [12/2/2025] ...” The Risk Manager stated that the last Quality Council Meeting was held on 12/11/2025, but Patient #1’s fall with a major injury which resulted in the Patient ’ s death was not discussed in the meeting. When asked why she delayed the investigation of Patient #1 ’ s fall with a major injury, the Risk Manager stated, “ ...On December 2 [12/2/2025] I knew she had a bleed on the left side, but the knot was on the right side, I wanted to look at her outside record prior to her coming to the facility ...my thought was she had the injury at the admitting facility [Hospital #1] ...then I thought it was a spontaneous bleed ...that was the reason for the delay in the investigation ...I did not know the severity of the fall until the patient expired and that is when I reported it to the state on 12/4/2025 ...” The Risk Manager was asked if she gathered any witness statements from the staff members on duty on 12/1/2025. The Risk Manager stated, “No.” During an interview on 1/5/2026 at 4:15 PM, the Chief Executive Officer (CEO) stated the Risk Manager should have completed a thorough investigation of Patient #1’s falls. The CEO stated she did not know that Patient #1 had a fall with a brain bleed and was admitted to the hospital in the Intensive Care Unit until she was told on the morning of 12/3/2025. The CEO stated the Risk Manager told her that she had not reported it to the state and had not begun an investigation. The CEO confirmed that the Risk Manager did not complete a thorough investigation which should have included staff statements, camera footage, and incident reports. The facility failed to ensure that a patient’s elevated blood pressure was reassessed and reported to the provider. The facility failed to complete a post fall assessment and failed to put appropriate interventions in place to prevent additional falls. The facility failed to follow provider orders for neurological check and vital sign check every hour for six hours and notify provider with any change. The facility failed to notify the medical provider after a fall with major head injury. In review of the camera footage RN #1 never tried to assess Patient #1 ’ s vital signs or neurological checks. The facility failed to put appropriate intervention in place to prevent falls [chair alarms, bed alarms, and fall mats]. Patient #1 had a second fall with major head trauma and expired in the hospital. The facility failed to thoroughly investigate and analyze these incidents to determine causes of adverse events for Patient #1. 7. Review of the closed medical record revealed Patient #5 was admitted on 11/4/2025 with diagnoses of Autism Spectrum Disorder, Foreign Body in Right Ear, Hypothyroidism, Intellectual Disability, and Asthma. Review the Orders dated 11/12/2025 at 1:08 PM by Psychiatric NP #4 revealed an order for Observation 1:1 with a start date of 11/14/2025 at 00:00 (after midnight) and a stop date of 11/14/2025 at 9:37 AM. Review of the Orders dated 11/12/2025 at 1:08 PM by Psychiatric NP #4 revealed an order for Observation 1:1 with a start date of 11/14/2025 at 10:00 AM and no stop date. Review of the “BEHAVIORAL HEALTH - PATIENT OBSERVATION SHEET” dated 11/14/2025 at 12:08 AM, revealed the Patient was on 15-minute observations. The facility failed to implement the 1:1 observation as ordered for 1:1 monitoring on after midnight (11/14/2025 at 00:00). Review of the “BEHAVIORAL HEALTH - PATIENT OBSERVATION SHEET,” dated 11/14/2025 at 10:00 AM, revealed the Patient was on 15-minute observations. The 1:1 observation was not started until 11/15/2025 at 9:41 AM (23 hours 41 minutes after the 1:1 observation was ordered to start). The facility failed to implement the 1:1 observation as ordered to start on 11/14/2025 at 10:00 AM. Review of the “Patient Notes,” dated 11/26/2025 5:00 PM, revealed “...Patient slapped and scratched another patient while in the gym [gymnasium]. Patient hit, with her hands, assigned 1:1 RBT [Registered Behavior Technician] ...attempted to take railings and base boards off the wall to hit staff ...Signed by [Named RN #5] at 11/26/2025 at 6:53 PM ...” Review of the “Patient Notes,” dated 12/14/2025 at 12:53 AM, revealed “ ...Note Coming onto shift pt [patient] had started verbally and physically attacking her 1:1 [CNA #2] ...Pt then slapped another pt on the unit ...Signed by [Named Licensed Practical Nurse [LPN] #4] at 12/14/2025 at 1:00 AM ...” Review of the “Patient Notes,” dated 12/16/2025 at 6:36 AM, revealed “ ...Pt was rowing [rolling] over her bed and didn’t realized [realize] she was almost at the edge of the bed when she slipped and fell of her bed @ [at] 6:20am ...pt reported she hit her head ...RN assess with no injury noted ...Signed by [Named RN #7] at 12/16/2025 at 6:43 AM ...” Review of the “Incident Report,” 12/16/2025, revealed “ ...Observed fall ...patient lost her balance and slipped and fell, patient was assessed, vitals were wnl [with in normal limits] no injuries ...” During an interview on 1/8/2026 at 1:06 PM, the Quality Manager of Rehabilitation stated there were no incident reports for Patient #5 ’ s aggressive behaviors on 11/26/2025 and 12/14/2025 or her fall on 12/16/2025. The Quality Manager of Rehabilitation confirmed the 1:1 observation ordered by the provider for Patient #5 were not performed as ordered. The facility failed to have appropriate safety measures in place to prevent patient to patient incidents. The facility failed to accurately complete a post fall assessment and put interventions in place to prevent future falls. The provider was not notified that Patient #5 hit her head during the fall. The facility was unable to provide incident reports, camera footage, written staff statements or an investigation of the incidents on 11/26/2025, 12/14/2025 and 12/16/2025 for Patient #5. The facility failed to track adverse events for Patient #1 and #5, analyze their causes and implement preventative actions including feedback and learning throughout the hospital to implement and maintain an effective Quality Assurance and Performance Improvement Program.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 37530 Based on policy review, facility document review, medical record review, camera footage review and interview, Hospital #2 failed to ensure the registered nurse (RN) provided oversight and supervision to ensure patient care was provided safely while following hospital policies and procedures for fall precautions and aggressive behaviors for 2 of 5 (Patient #1 and #5) patients reviewed. The findings included: 1. Review of Hospital #2’s policy titled, “Vital Signs and Weight,” dated 9/2025, revealed, “ ...Vital signs will be taken at the time of admission and then as ordered by the practitioner ...Reporting of Vital Signs ...the staff member who takes the vital signs will alert the nurse immediately if they are abnormal ...If vitals not taken by the nurse initially, the nurse will retake the vitals to verify results ...The nurse shall contact the practitioner immediately for additional recommendation if vitals fall within the ranges below ...BP [Blood Pressure] systolic greater than ...Adult ...180 ...” Review of Hospital #2’s policy titled, “Patient Observation,” dated 9/2024, revealed, “ ...The RN [Registered Nurse] may increase the level of observation if the patient ’ s condition changes. The psychiatric practitioner will be contacted soon as possible for notification of the change in condition and to obtain and order for the observation level ...1:1 Observation ...1:1 is the highest level of observation and is reserved for patients who are so unpredictable that without a dedicated staff member there is a risk of patient harming self or others ...Staff who are assigned to monitoring the patient on 1:1 observation will have no other assignment ...Staff are to remain within visual range and close proximity (easy reach) of patient at all times ...Staff are to remain in the room with the patient during ...toileting ...All 1:1 observations will be reviewed daily ...” Review of Hospital #2’s policy titled, “Fall Prevention,” dated 9/2024, revealed, “ ...All patients will be assessed on admission for fall risk ...the following actions should be taken ...Return bedrails to the original position ...Ensure call light is within reach ...if Patient Falls ...Immediately assess patient and take appropriate actions to protect patient ...Notify MD/LIP [Medical Doctor/Licensed Independent Practitioner] of the fall and patient ’ s condition ...Notification of family ...name of person contacted as well as dated and time ...Implement physicians orders ...Notify family of fall ...Notify Nurse Manager ...Documentation of actions or intervention taken to prevent further falls ...Reassess patient and document within the electronic records ...” Review of Hospital #2’s policy titled, “Fall Precautions and Prevention,” dated 5/2025, revealed, “ ...Patient safety is an ongoing responsibility of all staff. In order to reduce the risk for patient injuries as a result of a fall, nursing staff will assess and re-assess the patient ’ s level of risk for falls and implement appropriate interventions ...All patients admitted to the hospital will be assessed using the MORSE Falls Assessment ...each patient will be placed in a risk category ...Nursing shall place the patient on fall precautions when indicated and ensure the practitioner is notified and orders the level of observation and precautions consistent with the assessed level of risk ...45+ [score of 45 or greater]...Severe/High Risk for Ralls [Falls]...Use safety mats and alarms at night...1:1 or Q [every] 5 minutes observation if indicated by practitioner order or nursing judgement ...Interventions Post Fall ...Patient is assessed/reassessed after any fall. (MORSE Fall Assessment utilized for assessment and post fall assessment) ...the Medical practitioner will be contacted by the Charge Nurse to determine course of treatment after a patient has fallen ...Patient falls risk reassessed and appropriate interventions implemented... An incident report will be completed and submitted to the Director of Risk Management/Performance improvement after a patient has fallen ...” Review of Hospital #2’s policy titled, “Assessment, Neurological,” dated 5/2025, revealed, “ ...Neurological assessment will be initiated when a patient has hit their head, had a change in level of consciousness, and unwitnessed fall or per practitioner order ...Check level of consciousness and compare to the pre-injury state (Any change in the level of consciousness should be reported to the physician immediately) ...Check vital signs ...Results of the assessment are documented on the Neurological assessment form ...” Review of Hospital #2’s “PATIENT RIGHTS & [and] RESPONSIBILITIES,” dated 12/1/2025, revealed “ ...Right to appropriate assessment and management of your plan ...Right to receive care in a safe setting ...Right to be free from physical ...abuse ...” Review of Hospital #2’s undated education titled, Medical Emergencies- Change in Condition, revealed, “ ...Rapid Response systems are programs that are designed to improve the safety of hospitalized patients whose condition is deteriorating quickly ...Criteria Guidelines for Initiating the RRT [Rapid Response Team] (early warning signs) ...Acute change in level of consciousness or mental status ...Significant bleeding ...Failure to respond to medical interventions ...” 2. Review of the medical record for Patient #1 revealed on 11/27/2025 at 3:01 PM, the Patient was transported from home to Hospital #1’s Emergency Department (ED) via Emergency Medical Services (EMS) on 11/27/2025 at 3:01 PM, after being found unresponsive by husband. Patient #1 reportedly got into an argument with her husband and took about thirty (30) Xanax (medication used to treat anxiety) 2.5 milligrams (mg) tablets. Patient #1 was admitted for inpatient treatment at Hospital #1. Hospital #1’s Face Sheet documented the emergency contact name and telephone number of Family Member #1. Hospital #1’s ED Musculoskeletal Assessment dated 11/27/2025 revealed Patient #1 had generalized weakness, was wheelchair bound, and required 2-person assistance. Hospital #1’s Medication Administration Record dated 11/28/2025 at 12:05 AM, revealed Patient #1 received a Lovenox (medication used to prevent the formation of blood clots) 40 mg injection. Patient #1 also received clopidogrel (medication used to prevent the formation of blood clots) 75 mg tablet by mouth on 11/29/2025 at 8:03 AM. Hospital #1’s “Safety/Equipment,” dated 11/27/2025, 11/28/2025, 11/29/2025, and 11/30/2025 at 6:00 AM and 8:00 AM, revealed “ ...Fall Prevention Precautions Initiated ...Positive injury Risk Factors ...Bleeding risk ...” Review of Hospital #1’s “Consultation Note,” dated 11/29/2025, revealed, “ ...Plan ...6404 [certificate of need for involuntary commitment] ...we will continue suicide precautions and sitter in room for safety per hospital protocol and imitated treatment for acute management ...” Hospital #1’s physician Progress Note dated 12/1/2025, revealed, “ ...On comprehensive assessment of patient ’ s current dangerousness to self and others, at present the patient is a high risk due to untreated psychiatric symptoms that significantly impair their judgement, behavior, capacity to recognize reality, and ability to cope with ordinary demands ...this patient meets criteria for psychiatric hospitalization on involuntary status ...” Review of the 6404 “FIRST CERTIFICATE OF NEED FOR EMERGENCY INVOLUNTARY ADMISSION,” dated 12/1/2025 at 1:00 PM, revealed “ ...intentional Xanax overdose ...threat to self ...suicide risk ...” 3. Patient #1 was transferred from Hospital #1 to Hospital #2 via EMS on 12/1/2025 at 5:50 PM. Review of Hospital #2’s medical record revealed Patient #1 arrived from Hospital #1 on 12/1/2025 via EMS. Patient #1 was admitted to Hospital #2 with diagnoses including Major Depressive Disorder, High Suicide Risk, Hypertension, Hyperlipidemia, Cerebrovascular Accident with Right Sided Hemiparesis, and Wheelchair Bound. Review of Hospital #2’s Face Sheet, revealed the emergency contact for Patient #1 was Family Member #1. Family Member #1 ’ s name and telephone number were documented on the form. Review of Hospital #2’s “Intake Assessment (Behavioral and Medical),” dated 12/1/2025, revealed, Patient #1 reported she got mad at her husband and tried to commit suicide by overdose. “ ...Patient reports, “I wanted to die” & refuses to discuss further information. While admitted to hospital patient made threats of slitting her throat. Patient is not safe to D/C [discharge] at this time. 6404...Past or present medical conditions ...Mobility Wheelchair ...Medications ...clopidogrel [blood thinner] Oral [by mouth] 75 mg ...” Review of Hospital #2’s “Treatment Items,” dated 12/1/2025, revealed, Patient #1 was a risk for injury from falls related to past medical history of Cerebrovascular Accident along with foot drop. The goal while Patient #1 was hospitalized was to remain free from fall-related injuries and compliance with treatments. “...Nursing will implement fall precautions ...1:1 supervision as needed ...” Review of Hospital #2’s “Final Ancillary Orders,” dated 12/1/2025, revealed Patient #1 was involuntarily admitted at 5:00 PM, was a full code status, placed on suicide precautions with every 5 minute checks and was to have vital signs taken every shift. Review of Hospital #2’s physician’s orders dated 12/1/2025, revealed, clopidogrel 75 mg twice daily to start at 9:00 AM on 12/2/2025 to prevent blood clots. Patient #1 also had a physician ’ s order dated 12/1/2025 for metoprolol (medication used to treat high blood pressure) 25 mg twice daily to start on 12/1/2025 at 9:00 PM for blood pressure control. Review of Hospital #2’s “Nursing Assessment,” dated 12/1/2025 at 6:23 PM, revealed Patient #1 required a wheelchair and needed assistance with toileting. Patient #1 ’ s Morse Fall Score was 60, indicating the patient was at severe high risk for falls. Review of Hospital #2’s “Observations Blood Pressure (BP),” dated 12/1/2025 at 6:23 PM, revealed Patient #1’s BP was 156/86; at 8:00 PM BP was 182/93. Documentation revealed Certified Nursing Assistant (CNA) #1 reported Patient #1’s BPs to RN #1. There was no documentation of interventions for the elevated BP. Review of the “INCIDENT REPORT FORM,” dated 12/1/2025 at 7:10 PM, revealed Patient #1 experienced a fall observed by RN #2 at 7:04 PM in the hallway/main door. The incident report documented Patient #1 was on suicide precautions at the time of the fall. There was no documentation the physician/practitioner was notified. The incident report documented the patient’s family was not notified because “... patient does not know number nor [was the number] on record [medical record]...” Review of the Hospital #2’s “Patient Notes,” documented by RN #2 dated 12/1/2025 at 7:17 PM, revealed, “...the patient was seen walking out of her wheelchair by the main door, and she fell to the floor on her bottom....” RN #2 documented, “She [Patient #1] did not hit her head and had no injury. Vitals were found normal. She stated she got out of the wheelchair ...With assistance from staff, she returned to her wheelchair ...” There was no documentation that Patient #1’s vital signs were taken immediately after the fall. Review of the “Patient Notes,” dated 12/1/2025 at 7:20 PM (documentation in the note included events that occurred after this time), revealed “ ...7:20 PM Patient was assisted to her room after requesting to go to bed. As staff attempted to get patient into bed she became agitated and started cursing and becoming combative with staff stating she wanted them to cut off her beacon [patient tracking systems that provide real-time visibility and tracking of patients within healthcare facilities] because she was going home and repeatedly tried to climb out of bed despite staff redirection. Once in bed patient became enraged and began trying to bang her head and extremities on the side rail and was yelling ...Patient was yelling at staff to call her husband ...once in bed staff exited the room...Nurse brought pt [patient] her medications and attempted to talk with patient to help her settle into her new environment, patient began spitting at nurse, she was cursing and trying to slap the nurse and refused to take her oral medications and told nurse to ’ get the hell out of her room ’ . Nurse exited the room per request. Nurse waitted [waited] a few minutes...Upon entering patients room she [Patient #1] was found crawling on her stomach across the room and was attempting to slide on her stomach out of her room into the common area ...Patient noted to have a knot above her right eye just above the eyebrow and blood on the right side of her head. This nurse [RN #1] attempted to assess the head injury and obtain vitals but patient refused. Patient would not let staff touch her and again became combative ...This nurse [RN #1] and 2 [other] staff were able to get patient into bed but she still would not allow the nurse to visualize the area that was bleeding or appply [apply] pressure, and adamantly refused to allow nurse to obtain vital signs or assess her pupil response ...Patient denied pain when questioned and continued to try to kick and hit staff and was again trying to climb out of bed. 1 to 1 supervision was initiated and medical oncall [on call] was notified of the fall with the laceration and knot above the eye. no new orders were given. At 9:35 PM [Named Psychiatric NP #1] the oncall [on call] psych [psychiatric] NP was notified of pts [patient’s] ongoing aggressive [aggressive] behaviors and the fall [this was 2 hours and 19 minutes after the resident had fallen]. New order obtained to give patient 1 mg [milligram] of ativan IM [intramuscular] due to pts [patient’s] refusal to take any of her oral medications. Ativan order entered into pts orders by [Named Psychiatric NP #1] and verified by [Named RN #1]. While pulling up patients Ativan at the nurses station patient again became even more aggressive [aggressive] with her 1 on 1 [observation] and demanded she was going to crawl out of bed into her wheel;chair [wheelchair] and rolled herself out into the common area yelling again at staff and exhibiting combative behavvior [behavior] towards anyone who attempted to come near her. Staff again assisted pt back into her room ...back into her bed. At 10:10 PM 1 mg IM Ativan was administered in the left hip as ordered ...After administration of injection pt remained on a 1 to 1 supervision due to her risk of injury to self and of fall risk. Patient remained in bed with ongoing behaviors for 40 minutes then suddenly rolled onto her side and expelled a small amount of clear vomit and stopped moving or kicking or yelling. Staff attempted to arouse patient and she was unresponsive to verbal and tactile stimuli ...Nurse immediately called [Named Psychiatric NP #2] and asked if pt couuld [could] be sent to the ER [Emergency Room] for evaluation due to sudden change in mental status and recent fall with head injury. order obtained. Nurse called spouse 3 times with no answer. House supervisor notified of incident and transfer to ER [emergency room]. EMS arrived and transported patient off of the unit at 11:03 PM. Staff went to ER with patient due to 1 on 1 status. injury ...combative and aggressive with staff. Ativan 1 mg IM administered for agitation ...Staff report multiple attempts to throw herself to the floor, attempted to hit head against railing of bed. Patient threw herself to floor form her bed, hitting her head. Laceration above left eye [laceration was above the right eye]. Patient uncooperative with assessment. Medical notified. Patient made a 1:1 for safety. Patient then began vomiting, sent out via 911 to [Named Hospital #3] ER for evaluation...” Review of the “INCIDENT REPORT FORM,” dated 12/1/2025 at 9:30 PM (documentation in the form included events that occurred after this time), revealed “ ...Staff [Named RN #1] ...Reported Time ...9:27 PM ...Location of Incident ...pt ’ s [patient’s] Room ...Patient precautions at the time of the Incident ...Suicide ...Patient Injury (unspecified) ...Unobserved Fall ...[symbol for changed] to 1:1 due to increased agitation throwing self out of bed ...Was an injury observed ...Yes ...Laceration R [right] eye & knot ...Patient was assisted back to bed from w/c [wheelchair] due to ongoing aggressive behavior ...once in bed 10 minutes later staff entered & pt was crawling around on Floor. Pt noted to have a knot with laceration above R eye ...refused vital, refused wound care ...placed on 1:1 [observation] ...medical on call notified of injury, psych [psychiatric] NP [Psychiatric NP #1] notified ...new order for Ativan [used to treat anxiety] 1 mg IM ...given at 10:10 PM ...NOTIFICATION ...[Named RN #1] ...9:45 PM ...NP notified send to ER [Emergency Room] ...Family ...called spouse [Named Family Member #1] x [times] 3 no answer ...” Review of the “Final Ancillary Orders,” dated 12/1/2025, revealed, “ ...1 to 1 Observation ...Start Time ...12/1/2025 at 10:00 PM ...Neuro [neurological] Checks ...Start Time ...12/1/2025 at 11:00 PM ...[this was after Patient #1 had been transferred to Hospital #3]” Review of the “Leave of Absence,” dated 12/1/2025 at 11:32 PM (documentation in the note included events that occurred after this time), revealed “ ...pt had an unobserved Fall in her room. Staff entered patients room & she was crawling Along the Floor heading toward her room exit door ...pt had a visible knot above her R eyebrow and small Laceration on her R forehead that had a lg [large] amount of bleeding ...Findings ...admitted to [Named Hospital #3] with a Dx [diagnosis] of a Subdural hematoma and a 4 mm [millimeter] parenchymal Hemorrhage in Left Occipital Lobe ...” Review of Psychiatric NP #2 note dated 12/2/2025 at 12:25 AM, revealed, “ ...Note 9:37 PM Received a call from nursing reporting patient is agitated and unable to be redirected. Nursing reports patient had a fall earlier in the shift, medical provider had been notified. Patient continues to attempt to throw herself out of the bed. Ativan [used to treat anxiety disorders and agitation] 1 mg [milligram] IM [intramuscular] ordered for acute agitation. Patient made 1:1 for safety. 10:35 PM nursing contacted this provider reporting the patient is vomiting. Gave an order to send the patient to [Named Hospital #3] for eval [evaluation]...” Review of Hospital #2’s video recording from 12/1/2025, with the Risk Manager and the Director of Information Technology (IT) present, revealed the following: At 6:17 PM Patient #1 arrived via (by) stretcher by Emergency Medical Services (EMS). At 6:20 PM Patient #1 transferred to the wheelchair. At 6:20 PM EMS exited facility with stretcher and Patient #1 was transferred to the seclusion room by RN #2. At 6:30 PM Patient #1 exited the seclusion room in wheelchair, accompanied by RN #2, and placed at table in front of the nursing station. Patient #1 was dressed in brown shirt and blue pants with non-skid socks. At 7:07 PM Patient #1 propelled self in wheelchair towards the nursing station to the open window. Patient #1 ’ s first fall which occurred at 7:04 PM was not seen on the video footage. Patient #1 had wheeled herself out of view of the camera. At 7:08 PM Patient #1 attempted to get up out of wheelchair at the nursing station. At 7:13:17 PM Patient #1 was wheeled in her wheelchair from the hallway toward nursing station by RN #1. At 7:38 PM Patient #1 moved back and forth in her wheelchair in front of the nursing station. At 8:26 PM Certified Nursing Assistant (CNA) #1 wheeled the patient from the common area to her room, and CNA #4 followed and entered the patient’s room. At 8:29:05 PM CNA #1 and CNA #4 exited the room and turned off the lights. At 9:01 PM CNA #3 turned off the lights and closed the door to Patient #1’s room leaving Patient #1 alone in her room with the door closed. At 9:30:48 PM RN #1 arrived at Patient #1’s door with the medication cart, opened the door, turned on the light and entered the room. At 9:31:06 PM Patient #1 was lying on her back at the doorway and appeared to be crawling on the floor. At 9:31:16 PM RN #1 moved the medication cart, and Patient #1 crawled out of the room on her back, into the halfway. Patient #1 grabbed the door frame with her left hand and pulled herself to a sitting position. At 9:33:20 PM RN #1 turned toward Patient #1 lying on the floor and the patient hands went up towards the nurse standing in the doorway. RN #1 bent down to the patient, and the patient was sitting on her buttocks. At 9:35:22 PM CNA #1 and CNA #4 assisted Patient #1 off the floor. At 9:35:32 PM CNA #1 and CNA #4 assist Patient #1 back to bed. At 9:40:10 PM CNA #2 placed a chair at the doorway outside of the room and turned off the lights. 1:1 monitoring by CNA #2 started at 9:40:17 PM (CNA #2 was not within easy reach of Patient #1 while she was at the doorway or seated in the chair outside the room). At 10:22:20 PM CNA #2 walked away to the table beside the patient room, stood by the table briefly and went back to the patient’s room (CNA #2 was not within easy reach of Patient #1 when she walked to the table outside the patient’s room or when she was seated in the chair outside the room). At 10:22:32 PM Patient #1 was at the doorway in her wheelchair with CNA #2 at her side. At 10:22:41 PM Patient #1 rolled to the middle of the common area, and CNA #2 remained in front of the patient doorway (CNA #2 was not within easy reach of Patient #1 while the Patient was in the middle of the common area, and she was at the Patient’s doorway). At 10:23:06 PM Licensed Practical Nurse (LPN) #1, LPN #2, CNA #1, and CNA #2 approached Patient #1 in her wheelchair. CNA #1 pushed Patient #1 back to her room with the assistance of CNA #2 and LPN #2. At 10:24:40 PM CNA #2 was seated in the chair in the doorway (CNA #2 was not within easy reach of Patient #1 while she was seated in the chair outside the room). At 10:41:15 PM CNA #2 got up from the chair, turned on the lights, and entered the room with CNA #4. At 10:42:46 PM CNA #2 and CNA #4 exited the room (CNA #2 was not within easy reach of Patient #1 when she exited the room). At 10:42:51 PM CNA #2 was seated at the door in the chair with the lights on in room (CNA #2 was not within easy reach of Patient #1 while she was seated in the chair outside the room). At 10:43:09 PM CNA #3 entered the patient’s room. At 10:43:14 PM CNA #2 entered the patient’s room. At 10:43:17 PM CNA #4 entered the patient’s room. At 10:43:46 PM CNA #2 exited the room and walked down toward the nurses’ station (CNA #2 was not within easy reach of Patient #1 when she exited the room and walked to the nurses’ station). At 10:45:46 PM CNA #2 walked down the hallway to the patient ’ s room with towels in hand. At 10:46:29 PM CNA #4 left the patient’s room down the hall toward the nursing station. CNA #4 came back down the hallway with a mop in her hand and entered the patient ’ s room. At 11:11:47 PM EMS personnel (4 paramedics and 2 police officers) came down the hall with a stretcher. At 11:13:36 PM EMS exited the room with the patient on the stretcher. There was no video footage viewed that RN #1 entered the room in an attempt to conduct neuro checks or obtain vital signs. 4. Review of the “EMS (Emergency Medical Services) Run Sheet,” dated 12/1/2025, revealed, “ ...Call Received 12/1/2025 at 10:53 PM ...On Scene 12/1/2025 at 11:00 PM ...Primary Impression ...Altered Mental Status ...Secondary Impression ...Injury to Head ...Mechanism of Injury Blunt ...Trauma ...Head ...Swelling ...Vitals Calculations ...11:20 PM ...BP ...206/123 ...11:23 PM ...205/119 ...GCS [Glasgow Coma Scale - tool used to assess patient ’ s level of consciousness] ...11:08 ...8 [3 to 8 indicates severe traumatic brain injury] ...11:10 PM ...8 ...11:23 PM ...8 ...Narrative ...RN [RN #1] reported the pt [pt] was in the memory care unit and had been throwing herself out of bed onto the floor and had been banging her head against the wall at around 9:30 PM. For the pt ’ s [patient ’ s] safety the pt had been subdued in the bed and administered 1 mg of Ativan at 10:10 PM this evening. Pt was being monitored by staff and they reported they notice a hematoma on her R [right] eyebrow. Pt does take Plavix [clopidogrel] and the facility NP [Nurse Practitioner] wanted the pt evaluated at the ED [emergency department]. Crew found ...female supine in her bed w [with]/ a wet towel across her forehead ...Head ...Hematoma and small laceration noted to the R eyebrow, Bleeding controlled ...Pupils sluggish, left at 2 mm [millimeters]/right at 3 mm ...Upper extremities ...R arm contracture L [left] arm hematoma on forearm ...Pt was hypertensive ...” 5. Review of the ED records from Hospital #3 dated 12/1/2025 at 11:35 PM, revealed Patient #1 arrived via EMS with complaints of altered mental status. Patient #1 was diagnosed with subdural hematoma with a midline shift and intraparenchymal in the left occipital lobe. Patient #1 was intubated and admitted to the Intensive Care Unit (ICU) at Hospital #3. Review of the “Discharge Summary and [Hospital #3],” dated 12/3/2025 at 3:04 PM, by Medical Doctor (MD) #1, revealed “ ...[Patient #1] was admitted to ICU [Intensive Care Unit] ...due to subdural hematoma and intraparenchymal hemorrhage and passes away during the hospital stay ...Reportedly at [Named Hospital #2] the patient became combative and agitated throwing her head against the wall multiple times. She was restrained and given Ativan. She was minimally responsive, so she was brought to the hospital where she was found to have right subdural hematoma with midline shift and intraparenchymal hemorrhage in the left occipital lobe she was intubated and admitted to ICU with neurosurgery consult. Neurological exam was poor, and family transitioned patient to DNR [Do Not Resuscitate]/comfort care due to previous wishes of patient. She was extubated and downgraded to hospitalist services. Hospice agency was consulted ...Primary cause of death ...Traumatic right subdural hematoma and traumatic left occipital intraparenchymal hemorrhage ...Secondary cause of death ...Depression, history of stroke, COPD [Chronic Obstructive Pulmonary Disease] ...” 6. During a telephone interview on 12/8/2025 at 7:11 PM, RN #1 at Hospital #2 stated, “ ...I’m going to start from the beginning at 6:45 PM [on 12/1/2025]. She [Patient #1] was on her butt in the front of the door right at shift change ... I asked them [Named RN #2 and RN #3], “Who’s this?” This first time I’ve ever seen her, she’s a new patient ...they kind of gave me the rundown and said she was scooting along in her wheelchair and fell out of her chair ...”Did she have an injury?” ...[Named RN #3] said “no ....she denies any ideation or anything like that ...she’s just upset with her husband” ...I don’t know, an hour and then maybe 40 minutes into the shift, the patient asked if she could go and lay down ...so they [Certified Nursing Assistant [CNA] #1 and CNA #3] escorted her to her room in her wheelchair ...said she’s fighting us, she’s kicking, she’s trying to crawl out of bed ...she don’t want to go to bed ...I get all her meds [medications]...and she don’t want her meds ...she was still trying to crawl out of the bed, just being very upset ...” When asked about Patient #1 lying on the floor as seen on the video footage, RN #1 stated she went to Patient #1 ’ s room with her medications and found her lying on the floor. RN #1 stated she saw a cut on Patient #1 ’ s right eyebrow with swelling, but Patient #1 would not let her touch her or assess her. RN #1 stated she decided to put Patient #1 on 1:1 observation. RN #1 stated she called Psychiatric NP #2 and told her what happened, and Psychiatric NP #2 ordered 1 mg Ativan injection which she administered. RN #1 stated that after the injection, she was at the nurses ’ station when a nurse or CNA told her that Patient #1 was vomiting. RN #1 stated she called Psychiatric NP #2 who ordered to send Patient #1 to the ED for further evaluation. RN #1 stated she left Patient #1 ’ s room to let EMS in the building. RN #1 stated when she got back to the room, Patient #1 was unconscious and not moving. During a telephone interview on 12/10/2025 at 8:16 AM, Medical NP #1 at Hospital #2 stated, “ ...I actually remember situation very well. So, I was on call [on 12/1/2025] and got call from [Named Registered Nurse (RN #2)] around 7:00 PM ...she said the patient had a fall and slipped out of wheelchair ...I said was it witnessed? She said “yes” ...I asked if she hit her head ...she said “no” I asked if there was any deformity ...She said “no” I gave orders for neuro [neurological] checks every hour for 6 hours along with the vital signs and let me know if any changes. She said ok ...I wrote her [Patient #1] name down so on the next day I would go to see her ...I did not hear from the staff all night ...” When asked if she was aware that Patient #1 had another fall and hit her head with a laceration and hematoma and was later sent out to the Emergency Department, Medical NP #1 stated, “ ...I did not know anything about that ...I came in that morning to see her ...I did not know about that at all ...no one told me about a hematoma or head injury ...For me personally, if I have a patient I ’ m unfamiliar with ...hits their head, I want them to get imaging right away ...” When asked if she would consider a fall an emergency if the patient hit their head, was on blood thinner medication, and had a hematoma and laceration, Medical NP #1 stated, “Yes. for sure.” During an interview on 12/16/2025 at 7:39 PM, when asked about Patient #1’s second fall on 12/1/2025 at approximately 9:30 PM, RN #1 at Hospital #2 stated she went to Patient #1’s room to give her medications, and when she found the Patient crawling across the floor. RN #1 stated she saw a thin line of blood on the floor at the foot of the bed, and Patient #1 had some blood in her hair. RN #1 stated she did not go into the room following Patient #1’s fall but was later told that there was blood in the bathroom. RN #1 stated the Patient had a nick and a bump on her head after the fall, but she denied any pain and did not have any loss of consciousness. RN #1 confirmed the fall was unwitnessed. RN #1 stated she called Psychiatric NP #1 and told her that Patient #1 had fallen. RN #1 stated she could not remember any orders from Psychiatric NP #1. RN #1 stated she put the Patient on 1:1 observation after the fall. RN #1 stated that later, a CNA reported that Patient #1 had spit up, and she called Psychiatric NP #1 who ordered for the Patient to be sent out to the ED. RN #1 stated the Patient’s eyes were open, but she had no movement and was not talking. RN #1 stated she left the room, with the CNA still in the room, to meet the EMS personnel and direct them to Patient #1’s room. RN #1 stated when she got back to Patient #1’s room with EMS, Patient #1 was not responding. During an interview on 12/16/2025 at 7:39 PM, when asked about vital signs, RN #1 at Hospital #2 stated, “ ...if the blood pressure is out of range, we have to let the NP [Nurse Practitioner] know...the tech [technician] does them [vital signs] at the beginning of the shift. If something is going on, then we will recheck it. If we give meds [medications], we recheck the vital signs, and also if the patient refuses and gets combative, will try again later ...” When asked what type of assessment she would perform after a patient fall, RN #1 stated, “ ...I would do vital sign, neuro checks, check for wounds, check pain, monitor functional status, assess her speech ...” When asked if she should have followed Medical NP #1’s orders for vital signs and neuro checks every hour for 6 hours, RN #1 stated, “Oh yes, if she let me ...” During an interview on 12/16/2025 at 8:48 AM, Psychiatric NP #2 at Hospital #2 stated, “ ...she [RN #1] said the patient [Patient #1] had a new admit ...came in due to an overdose ...she was agitated and trying to kick staff and throw self out of bed ...she tried to give the patient her medication and she would not take anything ...she continued to be aggressive ...I gave an order for 1 mg Ativan to treat a possible benzo [Benzodiazepine use to treat anxiety] withdrawal ...then I said, with her throwing herself out of the bed, make her 1:1 [observation] ...told me that she had a fall early in the shift ...medical was notified ...I asked if they did neuro checks and she said she was refusing care at the time ...” When asked if nursing staff had informed her that Patient #1 had a laceration, a hematoma, and had been bleeding, Psychiatric NP #2 stated, “ ...I was not aware of that ...they called me at 10:00 PM or after 10:30 or around that time ...told me the patient was vomiting, and I said send her out ...” When asked if she knew whether the Rapid Response Team had been called, Psychiatric NP #2 stated, “No, there was not a rapid response called ...it should have been called ...I asked the House Supervisor if she was told the patient was unconscious and she said no ...” When asked what nursing staff should do if a patient does not respond appropriately or has an altered mental status, Psychiatric NP #2 stated they should complete an assessment by checking vital signs, checking neurological status, and if necessary, initiate cardiopulmonary resuscitation. During an interview on 12/16/2025 at 9:13 AM, CNA #1 at Hospital #2 stated, “ ...She [Resident #1] was my patient ...I heard she fell at shift change and she was still at the nursing station ...she said she wanted to go to bed...and I took her to the bed ...next thing I know heard something go “boom boom”...[Patient #1] was banging her head on the rail ...I started doing something else ...the next thing she was lying on the floor on her back ...we trying to talk to her and that ’ s when she had the injury to her head ...it was like a slit and swollen. It did not get bigger till afterwards ...after that, the 1:1 [CNA #2] said she was throwing up and she was foaming at the mouth with white spit ...we told the nurse [RN #1] ...” When asked what RN #1 did when she came to Patient #1’s room, CNA #1 stated, “ ...she came down to the room ...I can ’ t recall what she did ...then she went to the nursing station ...” During a telephone interview on 12/17/2025 at 10:21 AM, the House Supervisor at Hospital #2 stated, “ ...We [she and RN #1] had a conversation earlier in the shift that the patient [Patient #1] was very unhappy to be there, and she had actually had a fall at shift change ...she placed herself from the wheelchair on the floor of the unit. It was witnessed ...she had no injuries ...so that was the first conversation ...second conversation was that she was refusing her night time medications ...the nurse [RN #1] told me that she went ahead and put a tech with the patient [1:1 observation] because she was being so aggressive and that she was getting ready to give her an injection ...then the next call I got was that she had fallen ...she [RN #1] called the medical provider and the psychiatric provider and decided they were going to send her out mainly because at that point, she was refusing neuro assessments and vital signs ...that was the gist of it ...” When asked what the nurse should do when a patient refuses vital signs and neuro checks after a fall, the House Supervisor stated, “ ...I would call the provider and tell them ...you ordered neuro checks and vital sign and I’m unable to do them ...how would you like to proceed ...” When asked if RN #1 notified her that Patient #1 was not responding or she couldn’t arouse her, the House Supervisor stated, “ ...No, I think the terminology she used when she called, she either said, drowsy or lethargic ...the impression I got from her was, she received an Ativan injection and was drowsy from that ...” When asked what RN #1 told her about Patient #1 ’ s status when EMS arrived, the House Supervisor stated EMS assessed her as comatose. The House Supervisor stated that the nurse should page a rapid response overhead when a patient is not responding. The House Supervisor was informed that while reviewing the video footage, RN #1 was never seen attempting to enter Patient #1 ’ s room with the blood pressure machine used on the unit to check vital signs or to conduct neuro checks. The House Supervisor stated, “ ...I was unaware of any of that ...I can ’ t speak to that ...but yes, that’s the first thing I would have done. Check the blood pressure and assess neuro checks ...if you’re not going in the room with the dynamap (machine used to check vital signs) or making a conscious attempt to do something ...I can ’ t say that the patient refused ...I agree ...you’re not wrong there ...” When asked if she was aware that Patient #1 had 2 falls, the House Supervisor stated, “ ...I believe I was just aware of the one fall [Patient #1 ’ s first fall at 7:04 PM] ...” When asked if she had been informed that Patient #1 had a fall with a head injury, would she have come to Patient #1 ’ s room to assess the situation, the House Supervisor stated, “Absolutely.” The House Supervisor confirmed she was not told about Patient #1 ’ s second fall or her head injury at that time. During an interview on 12/17/2025 at 2:39 PM, the Chief Nursing Officer (CNO) at Hospital #2 stated that the nurse should communicate that a patient had a fall with an injury to the provider, and the nurse should document the assessment including the injury and the patient ’ s vital signs. When asked if staff should close the door to a patient ’ s room with the patient alone in the room who had been banging their head against the rails and walls and had been assessed as a high risk for falls or suicide, the CNO stated, “Absolutely not. The door needs to be open...if the door is closed, someone should be in the room with the patient...” When asked if a patient had a change in status, should the nurse assess the patient and document the assessment, the CNO stated, “...Absolutely, 100 percent...” During a telephone interview on 12/17/2025 at 6:01 PM, when asked about when the staff should close the door to a patient ’ s room, CNA #3 at Hospital #2 stated, “ ...we have to keep their door open when they’re [patient] in there [patient ’ s room]...we have to keep it shut when they’re out ...” During a telephone interview on 12/18/2025 at 9:13 AM, when asked if she received a call from the nursing staff related to Patient #1 ’ s fall on 12/1/2025 at 7:04 PM. Medical NP #1 at Hospital #2 stated, “ ...Yes, I talked to [Named RN #2]. She was the charge nurse ...I told her to do neuro checks Q 1 hour with vitals for 6 hours and let me know if there were any changes ...” When asked if staff members should have followed her orders for neuro checks and vital signs every hour for 6 hours, Medical NP #1 stated, “Yes.” When asked if patients who were at a high risk for falls should have appropriate interventions in place, Medical NP #1 stated, “ ...Yes, everyone on the senior unit are at a high risk for falls and are closely monitored ...” During an interview on 12/18/2025 at 10:36 AM, when asked if she had taken Patient #1 ’ s vital signs after the fall on 12/1/2025, RN #2 at Hospital #2 stated, “ ...No, I thought someone on the team took the vital signs ...” When asked why there was no documentation on the incident report the provider or the family was notified, RN #2 stated that the telephone number for Patient #1 ’ s family provided by Patient #1 was incorrect. RN #2 stated she received an envelope from Hospital #1 when Patient #1 arrived at Hospital #2, but she did not check the documents for Patient #1 ’ s family telephone number. When asked about notifying the Medical Nurse Practitioner (NP) about Patient #1 ’ s fall, RN #2 stated, “I don ’ t remember any orders [from the Medical NP].” When asked what interventions should be put in place for a patient who was a high risk for falls, RN #2 stated, “ ...wheelchair alarm, in some cases a safety belt, bed alarms, 3 rails up, educate the patient to call for help, wheelchair next to the bed, and they should be assisted to the bathroom ...” During a telephone interview on 12/18/2025 at 12:14 PM, when asked what the nursing staff should do when a patient fell and sustained a head injury, the Medical Director at Hospital #2 stated the nursing staff should notify the Nurse Practitioner of the fall and the injury, try to assess neuro checks and look for any change in the patient’s neurological status. The Medical Director stated the standard of care would not be to send the patient out without a change in the clinical picture. During a telephone interview on 12/18/2025 at 12:49 PM, CNA #2 at Hospital #2 confirmed she was assigned 1:1 observation for Patient #1 on 12/1/2025. When asked if she was within easy reach of Patient #1 when she was seated in the chair at the doorway outside the room, CNA #2 stated, “...I was not...” CNA #2 stated she had not received any training on 1:1 observation for patients. When asked if she witnessed Patient #1 banging her head on the side rails or walls, CNA #2 stated, “...I did not see her. I heard her banging on something...” When asked if the patient ’ s door should be closed with the patient alone in the room, CNA #2 stated, “No”. CNA #2 stated she never saw anyone come to Patient #1’s room and attempt to take vital signs or conduct neuro checks while she was assigned to 1:1 observation with the Patient. During a telephone interview on 12/18/2025 at 9:13 PM, when asked if nursing staff had called to inform her that Patient #1 had a second fall with a laceration and hematoma to her left eye, Medical NP #1 stated, “ ...when they called me I did not get any additional information ...I did not know anything about the second fall ...I never received a second call for this patient ...” Nursing staff failed to provide appropriate monitoring of Patient #1 when the staff closed the door and left the Patient alone in her room. Nursing staff failed to put interventions such as fall mats and bed alarms per hospital policy for Patient #1 who was assessed as a severe risk for falls. Nursing staff failed to provide appropriate 1:1 observation for Patient #1 when the CNA was not within easy reach of the Patient and when the CNA could not observe the Patient. Nursing staff failed to assess Patient #1 after her second fall when she sustained a head injury. Nursing staff failed to notify the Medical NP of Patient #1 ’ s second fall and failed to notify the Psychiatric NP and House Supervisor of the head injury sustained by Patient #1. Nursing staff failed to call the Rapid Response Team per the hospital ’ s education when Patient #1 had an acute change in her level of consciousness or mental status. Nursing staff failed to follow facility policy and notify Patient #1’s family of the fall that occurred on 12/1/2025 at 7:04 PM. Nursing staff failed to document the Medical NP was notified of Patient #1 ’ s fall. Nursing staff failed to document and follow Medical NP #1’s orders for neuro checks and vital signs every hour following Patient #1 ’ s fall. Nursing staff failed to develop and implement new interventions to prevent further falls for Patient #1. Nursing staff failed to assess Patient #1’s vital signs and complete a post fall assessment after the fall. Nursing staff failed to notify the practitioner and reassess Patient #1’s blood pressure that was out of range when it was taken on 12/1/2025 at 8:00 PM according to the vital signs and weight policy. 7. Review of the medical record revealed Patient #5 was admitted on 11/4/2025 with diagnoses including Autism Spectrum Disorder, Foreign Body in Right Ear, Hypothyroidism, Intellectual Disability, and Asthma. Review of the “Nursing Assessment,” dated 11/4/2025, revealed “ ...Morse Fall Assessment ...Total Score 0 ...” Review of the “Psychiatry Progress Note,” dated 11/12/2025, revealed “ ...Patient reportedly ate a snack this morning and ECT [Electroconvulsive Therapy - medical treatment involving a brief, controlled electrical seizure under anesthesia to reset brain chemistry to treat severe mental illnesses] was therefore canceled. She will be 1:1 staffing after midnight on 11/13/2025 to maintain NPO [nothing by mouth] status for ECT ...Patient behaviors continue to require seclusion and IM [intramuscular] medication for aggression/agitation ...” Review the Orders dated 11/12/2025 at 1:08 PM by Psychiatric NP #4 revealed an order for Observation 1:1 with a start date of 11/14/2025 at 00:00 (after midnight) and a stop date of 11/14/2025 at 9:37 AM. Review of the Orders dated 11/12/2025 at 1:08 PM by Psychiatric NP #4 revealed an order for Observation 1:1 with a start date of 11/14/2025 at 10:00 AM and no stop date. Review of the “BEHAVIORAL HEALTH - PATIENT OBSERVATION SHEET” dated 11/14/2025 at 12:08 AM, revealed the Patient was on 15-minute observations. The facility failed to implement the 1:1 observation as ordered for 1:1 monitoring after midnight. Review of the “BEHAVIORAL HEALTH - PATIENT OBSERVATION SHEET,” dated 11/14/2025 at 10:00 AM, revealed the Patient was on 15-minute observations. The 1:1 observation was not started until 11/15/2025 at 9:41 AM (23 hours 41 minutes after the 1:1 observation was ordered to start). The facility failed to implement the 1:1 observation as ordered. Review of the “Patient Notes” dated 11/26/2025 at 5:00 PM, revealed, “ ...Note Patient slapped and scratched another patient while in the gym. Patient hit, with her hands, assigned 1:1 RBT [Registered Behavior Technician] and threw her pork chop at the 1:1 RBT. Patient attempted to take railings and base boards off the wall to hit staff ...” Review of the “Patient Notes” dated 12/14/2025 at 12:53 AM, revealed “ ...Coming onto shift pt had started verbally and physically attacking her 1:1 ...Pt started being verbally and physically combative and aggressive towards staff, kicking, spitting, hitting ...Pt then slapped another pt on the unit ...” Review of the “Patient Notes” dated 12/16/2025 at 6:36 AM, revealed, “ ...Pt was rowing [rolling] over her bed and didn’t realized [realize] she was almost at the edge of the bed when she slipped and fell of [off] her bed @ 6:20 am ...pt reported she hit her head ...RN assessed with no injury noted ...” Review of the “Incident Report” dated 12/16/2025, revealed, “ ...Observed fall ...patient lost her balance and slipped and fell, patient was assessed, vitals were wnl [with in normal limits] no injuries ...” Review of the Morse Fall Reassessment,” dated 12/16/2025, reveled, “ ...The Morse Fall Scale uses six different patient risk factors that gives an indication of the patient’ probability of falling by assigning a numerical score. The total possible scoring on the scale is 125 ...0 - 24: Low risk ...25 - 44: Moderate risk -- requires Falls Prevention treatment plan implementation ...45 and higher: High risk -- requires Falls Prevention treatment plan implementation ...History of Falling...0...Total Score 0 ...” During an interview on 1/8/2026 at 10:58 AM, when asked if the staff should have followed the order for the 1:1 observation for Patient #5 after midnight on 11/13/2025 and 1:1 observation on 11/14/2025 starting at 10:00 AM, the Quality Manager of Rehabilitation stated, “Yes.” The Quality Manager of Rehabilitation stated there were no incident reports or investigations for Patient #5 attacking another patient and staff on 11/26/2025, attacking staff on 12/14/2025, or Patient #5 ’ s fall on 12/16/2025. Nursing staff failed to accurately reassess Patient #5’s fall risk after her fall on 12/16/2025. Nursing staff failed to investigate and document per facility policy Patient #5’s aggressive behaviors on 11/26/2025 and 12/14/2025 and her fall on 12/16/2025. Nursing staff failed to develop and implement interventions to prevent further falls after Patient #5’s fall on 12/16/2025. Nursing staff failed to follow orders for 1:1 observation on 11/13/2025 after midnight and on 11/14/2025 at 10:00 AM.”