Carrollton Springs

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 33579 Based on interviews, observations, and record review, the hospital failed 14 of 14. The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. Hospital Patient #1 and Patient #2 were able to engage in a fight. Findings Include: During Interviews on 08/19/2026, starting at 12:30 PM, with hospital Staff #3, Staff #5, and Staff #6, reported that the hospital Patient ratios are 12 Patients to 1 licensed staff, and 2 behavioral health technicians. Staff #7 (therapist) was left outside alone with 14 Patients. During Observation of video footage on the date in question 08/16/2026, at 10:30 AM on 08/19/2026. Patient #1 and Patient #2 are observed on video seated at a table with other patients. Patient #1 and Patient #2 rise from the table and begin to exchange strikes. The other patients at the table are observed immediately moving towards the exit door. There is another patient who attempts to separate Patients 1 and 2 from fighting. Staff #7 is approaching and telling all other patients not involved to enter the building. Staff #5 and Staff #8 are observed running to the site of the incident. Patients 1 and 2 are separated with the use of physical restraint. Patient #2 is reported to have fainted and came back to after Staff #5 helped the patient stand. During an interview with hospital Staff #5, it was reported. Patient #2 was sent out EMS for further assessment after being choked and having her head pushed into the concrete more than two times and temporarily fainting. Staff #5 indicated the injuries noted were ligature marks around Patient #2’s neck from being choked and 3-4 red spots on top of the head. No injuries noted to Patient #1. During an interview with hospital Staff #2 on 08/19/2026, Staff # 2 reported that there were no incidents of Patient #1 being touched inappropriately by Patient #4. Staff #2 indicated that, in communication with the nursing staff, the patients were separated and instructed to not engage with one another. Patient #4 was placed on 1:1 and in a blocked room. Patient #1 and #4 indicated that they understood the instructions and did not engage with one another for the remainder of Patient #1’s hospital stay. Policy The hospital policy Patient’s Bill of Rights dated 03/2026 states that each individual has the right to exercise their legal, civil, and human rights, including constitutional rights, statutory rights, and those set out in Virginia human rights regulations, except where specifically limited by law. Individuals have the right to receive person-centered services that reflect their needs and preferences. Individuals also have the right to be protected, respected, and supported by exercising these rights, including receiving care in the least restrictive manner possible. The hospital’s Policy on Nursing Standards of Care dated 10/2025 reflected, “All patients admitted to the hospital will receive nursing care delivered in accordance with established standards of care and practice.””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 33579 Based on record review, interview, and observation, the hospital failed 1 of 1 Patient (Patient #6) by failing to ensure the Patient was kept in a Safe Setting. The Patient was pushed by an RN Staff Member through the entry door of the activity room, causing the Patient to fall, scratch, and bruise the torso on the left side. Findings Include: During Record Review on 06/18/2026, at 6:45 PM, Patient #6 wrote a complaint against hospital Staff #5, “Patient #6 wrote a grievance on 06/18/2026, stating RN #5 violently assaulted/battery caused a 16-inch injury to my torso. Staff #5 shoved Patient #6 to the floor purposely, causing Patient #6 to graze a metal object and fall to the floor.” During Record Review on 06/18/2026, Staff #1 wrote: “Patient #6 wrote a grievance letter in marker and informed Primary Staff that Patient #6 was pushed by Staff #5 when attempting to assist the patients into the group activity room during ‘Code 100,’ violence for their safety. Staff #5, responded to Code 100, and all patients not involved in ‘Code 100’ were escorted for their safety to the activity room. Patient #6 was ‘pushed’ and fell against a chair, scratching his side. Patient #6 reported the injury to the nurse. During Record Review, the hospital Interdisciplinary Progress Note 06/18/2026 at 9:00 PM, “Patient #6 approached nurse and reported having a big scratch on his left lateral side of abdomen. The scratch is approximately 12 inches long. Patient #6 reports being pushed and falling into a chair. During an interview with hospital Staff #1, it was reported that hospital Staff #5 was suspended the following morning from 06/19/2026 through July 2, 2026. Upon Staff #5’s return to work, Staff #5 was removed from the ‘Response Team.’ Staff #6 was required to complete retraining on the Physical portion of Handle with Care. Staff #5 is no longer able to work with the adolescent patients. During an interview, hospital Staff #3 reported in their written statement, ‘After reviewing the surveillance footage, it was observed that during the code response on 06/18/2026, Patient #6 was pushed by Staff #5. As a result of the push, the patient fell and struck their side against the leg of the mental chair that was being used to prop the door open.’ After review of the hospital Video footage on 07/15/2026 at 11:30 AM. Patient #6 was standing in front of the doorway of the Activity Room on Unit M4 on the evening of 06/18/55 at 6:56 PM, with Hospital Staff #5 standing directly behind him and other Response Team members beside them. Patient #6 appeared to lean back, and Staff #5 placed their hands on the lower back just above the waist of Patient #6 and pushed Patient #6 through the doorway. The video footage does not reveal if Patient #6 tripped and then fell or if the patient immediately fell into the chair, propping the door open. The video footage is clear that Patient #6 was pushed by hospital staff member #5. Policy The hospital policy Patient’s Bill of Rights dated 03/2026 states that each individual has the right to exercise their legal, civil, and human rights, including constitutional rights, statutory rights, and those set out in Virginia human rights regulations, except where specifically limited by law. Individuals have the right to receive person-centered services that reflect their needs and preferences. Individuals also have the right to be protected, respected, and supported by exercising these rights, including receiving care in the least restrictive manner possible. The hospital’s Policy on Nursing Standards of Care dated 10/2025 reflected, “All patients admitted to the hospital will receive nursing care delivered in accordance with established standards of care and practice.” The hospital Policy on Suspected Child Abuse, Neglect 03/2026, “All Lifepoint BH facilities:s Patients have the right to be free from mental, physical, sexual, and verbal abuse, neglect, and exploitation. It is the policy of this Facility to protect patients from real or perceived abuse, neglect, or exploitation from anyone, including staff members, students, volunteers, other patients, visitors, or family members. This facility mandates that, under the guidance of applicable laws, all credible allegations of abuse, exploitation, or neglect shall be reported to law enforcement. The hospital Policy on Observation 11/2025, the Nursing staff and medical providers will assess patients for risk level and make level of observation and precaution recommendations based on the risk level assessment findings and patient behavior. It is critical that patient observation levels and precautions are documented on the Close Observation Sheet and communicated to team members.”

“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: 47061 Based on record review and interviews, the facility failed to ensure a registered nurse supervised and evaluated the nursing care of a patient, as evidenced by inconsistent and inadequate nursing skin assessments for 1 of 1 patients (Patient #1), who had sustained bruises to her upper and lower extremities, chest, right shoulder, hips, and sacrum. Findings included: [Patient #1] was a 59-year-old female admitted to the facility on 04/13/2026 for Bipolar 1 Disorder, manic, severe with psychosis and generalized anxiety disorder. Patient stated the reason for her admission was due to psychosis and paranoid thinking. The patient stated she can feel parasites in her body and crawling out of her skin. [Patient #1] stated she had been showering and bathing multiple times a day to kill the parasites. She had also been rubbing and pulling at her skin to remove the parasites. She had recently lost 30 pounds due to fear of parasites being in her food. Her husband stated this behavior had been occurring for more than a year. The patient was admitted to the facility with multiple bruises noted during the initial skin assessment. On 05/15/2026, the treatment team, physician, and husband made the decision to transfer the patient to an acute hospital for medical clearance and further evaluation. The patient was transferred and admitted to the acute hospital. Psychiatric Inpatient Progress Note completed on 04/20/2026 at 10:03 AM by Personnel #7, reflected the following, “ ...She has been quite delusional and psychotic. Patient seems to be experiencing grandiosity in addition to paranoid delusional thinking with a morbid involved. She inquired if therapist for safe as she had shared the details with the mom with him. Patient also feels that in sex a coming out of the skin. She seemed to be actively squeezing at skin to get the insect out. Patient has been repeatedly washing hands with soap and also showering multiple times in order to kill the bumps in her body. Discussed with patient about this the addition of Abilify to regimen. Patient consents ... Skin is excoriated due to repetitive showers and scratching behaviors ...” Seclusion and Restraint Clinical Assessment/Progress Note completed on 05/03/2026 at 11:05 PM by Personnel #8, reflected the following, “ ...Pt came out of her shower naked and attempted to walk out of her room. The BHT [behavioral health technician] attempted to redirect the pt [patient]. The pt put her hands around the BHT neck. Code 100 was called. Pt was escorted to the quiet room where she received Geodon 20 mg [milligrams] IM [intramuscular] in her right gluteus medius. Pt took medication willingly. After administration of med [medication] the pt became combative by kicking staff. Pt was placed in HWC [handle with care] hold the in seclusion, for continued physical and verbal aggression towards staff ...” Daily Treatment Planning Updates completed on 05/15/2026 at 7:30 AM by Personnel #9, RN, reflected the following, “The patient was combative with staff in her room. She ran into the room across the hall naked and laid on the floor and began singing Ave Maria loudly. The two male occupants in the room began to complain. This nurse had to physically remove the patient, she became combative again a code 100 was called. [Personnel #7] contact and Ativan 2mg/1ml ordered and the patient was taken to the quiet room where the medication was administered.” Nursing Shift Progress Note completed on 05/15/2026 at 9:00 AM by Personnel #9, reflected the following, “Late entry: Bruising observed to the bilateral upper extremities and upper abdomen observed in various stages of healing. No open wounds noted and the patient had no complaint of pain.” Interdisciplinary Progress Note completed on 05/15/2026 at 11:00 AM by Personnel #9, reflected the following, “The pt is crawling on the floor. Running away from staff. Pulling her hair and hitting herself.” A review of the medical record reflected numerous bruises on the patient on the day of admission on the initial skin assessment. A review of the medical record did not evidence that a skin assessment had been performed during the 7:00AM-7:00PM Shift Nursing Assessment and the 7:00PM-7:00AM Shift Nursing Assessment throughout the patient’s admission dated 04/13/2026 through 05/15/2026. There was no documentation regarding any bruising in the 12-hour Nursing Assessments. During an interview with Personnel #7, on 05/19/2026 at 9:40 AM stated the following, “When she was admitted here, she was complaining of seeing bugs under her skin. She was having both somatic and visual hallucinations. At home, she had been bathing multiple times per day to kill the bugs. She was constantly scratching and pulling at her skin because she was hallucinating that she had bugs inside of her and under her skin. I feel that is why she was heavily bruised up. She was heavily bruised up at the time of admission and the bruising continued during her admission because she continued to pull and scratch at her skin to get the bugs out of her. She was constantly pulling and pinching her skin to try to get to the bugs.” During an interview with Personnel #6 on 05/19/2026 at 11:15 AM stated the following, “I took care of [Patient #1] while she was on 1:1. She would pull at herself, rub herself, bang her legs against the bed, hit the bed with her arms and her legs. I would try to redirect her from self-harm behavior. I would use a pillow or a blanket to block her from hitting the bed. She was a very challenging patient. She would be relaxed and calm and then all the sudden her behavior flipped. She would go right into being aggressive. She would hit herself, staff and patients. She would be perfectly fine and then she would just look at you and start screaming and hitting. It would come out of nowhere.” During an interview with Personnel #1 and Personnel #4 on 05/19/2026 at 12:14 PM, both personnel acknowledged that the 12-hour nursing assessments did not evidence a skin assessment had been performed or documented to address the patient’s bruising during Patient #1’s admission.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 33579 Based on Interview, Record Review the hospital failed 1 of 1 Patient (Patient #1), by failing to ensure that nursing staff develops and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdiscipinary care plan. The hospital failed to provide a medical assessment, and document the medical assessment for Patient #1 after being physically assaulted by another Patient (Patient #2). Findings Include: During Interview with hosptial Staff #3, on 10/01/25 at 11:30 AM, ‘There is no medical record in the system showing Patient #1 was medically assessed by nursing following him being Punched and pushed to the floor by Patient #2.” During Record Review, the hospital Incident Log reflected, On 08/11/2025, at 11:11 AM, Physical Assault/Confrontation. During Record Review the hospital Incident Report reflected, “ On 08/11/2025, at 11:11 AM, in the Dayroom. Patient #2 and Patient #1, got into a physical altercation. Patient #2 was observed punching Patient #1 and shoving Patient #1 to the floor. Policy The hospital policy Patient’s Rights 04/2025, “You have the right, under the rules by, which this Hospital is licensed, to be given a copy of these rights before you are admitted to the Hospital as a patient. If you desire, a copy should also be given to the person of your choice. If a guardian has been appointed for you or you are under 18 years of age, a copy will also be given to your guardian, parent, or conservator.” The hospital Policy on Nursing Services 10/2023, “All patients admitted to the Hospital will receive nursing care delivered in accordance with established standards of care and practice.” The hospital Policy on Physician Services 03/2025, “Each Physician and/or AHP must ensure timely, adequate, professional care for his/her patients by being available, or having available an alternate Physician and/or AHP, who assumes responsibility for management of the patient. This alternate Medical Staff Member should be of a similar discipline and possess equivalent Clinical Privileges at the Hospital.””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 47061 Based on observation, record review, and interview, the facility failed to ensure that a safe environment was provided for 1 of 10 patients (Patient #1). Although physician ordered to be on constant staff observation, Patient #1 was left alone in the bathroom for approximately 12 minutes and attempted suicide by strangulation on 11/16/2024. Findings Included: Patient #1’s Inpatient Psychiatric Evaluation completed on 11/05/2024 at 12:29 AM reflected the following, “ ...Date of Admission: 11/05/2024 ... Chief Complaint: ‘I kind of, like, already attempted this week, I took 11 tab [tablets] of Tylenol. I have angry outbursts from mother I have history of self-harm’ ...a 14-year-old female, was admitted to a recent suicide attempt by ingesting 11 Tylenol pills the previous day, which has resulted in dizziness, nausea, and weakness. She presented with a history of emotion and physical abuse. There is a pending CPS [child protective services] case going on the same matter. She said she does not want to stay with her mother in the same house and would like to go to a foster care ...Patient has feelings of depressed and low mood, helplessness, worthlessness, mid cycle waking up, anhedonia. Patient continues to have suicidal thoughts, and ideation but no plan ...She also disclosed a history of self-harm, specifically cutting, which she attributes to the various traumatic events in her life ...She also suffers from anxiety and panic attacks ...has been hospitalized for psychiatric reasons four times since September of this year, with each stay lasting about two weeks. She feels that these hospitalizations have not been helpful ...Diagnosis: Major depressive disorder severe recurrent without psychosis, Generalized anxiety disorder, Panic disorder, Post Traumatic stress disorder [PTSD], Relationship Distress with significant other ...” Interdisciplinary Progress Note completed on 11/16/2024 11:55 AM reflected the following, “At 11:55 am code 100 called, Patient requested to use the restroom according to the PCA [patient care associate] and her door was opened which took her longer time than normal, the nurse walked into room and found patient laying on the floor with pillowcase wrapped around her neck. Patient had a nosebleed and was able to respond when lifting the patient head from the ground. Pt was very tearful and stated ‘I was feeling sad and wanted to end it all.’ Patient VS [vital signs] are WNL [within normal limits] ...Mom notified, patient is now placed on a 1:1 and is currently being sent out for further observation per Dr ...” Inpatient Progress Note completed on 11/16/2024 at 11:37 AM reflected the following, “ ...Patient presented with a history of attempting self-harm by strangulation using a pillowcase ...It was noted that she experienced dizziness and a nosebleed upon waking. The patient could not recall if she hit her head during the episodes. She mentioned that staff members found her and assisted her after she fainted. She had petechiae all over her neck. When discussing her current living situation, the patient expressed mixed emotions about not returning home and the possibility of moving to a residential care, but she herself is uncertain about its necessity ...Regarding her mental state, the patient conveyed a lack of excitement about her future and could not identify any activities or goals that she looks forward to as an adult. During the session, her cognitive function was assessed by asking her to perform a serial subtraction task, which she completed with some difficulty, indicating potential issues with concentration and focus ... Physical symptoms included persistent dizziness and headaches. It was recommended that she undergo a medical evaluation, possibly including a CT [computed tomography] scan ...It was decided to keep the patient on a 1-to-1 observation for her safety and to monitor her condition closely. Further medical evaluation and continued psychiatric care were planned to ensure comprehensive care ...” Video Footage Review completed with the Director of Nursing and the Director of Quality on 11/21/2024 at 10:40 AM for the attempted suicide incident that occurred on 11/16/2024 with Patient #1: 11:39:21 Patient #1’s room door was unlocked by Personnel #6 who waited outside the patient room with the door open so Patient #1 could go to the bathroom 11:39:28 Personnel #6 left Patient #1 in her room unattended to assist another patient 11:51:52 Personnel #7 and Personnel #6 entered Patient #1’s room 11:52:20 Personnel #6 ran down the hall for assistance 11:54:00 Multiple staff members entered and exited Patient #1’s room 11:54:32 Crash cart was brought to Patient #1’s room 11:57:11 Personnel #13 [physician] entered Patient #1’s room 12:00:36 Patient #1 left patient room and ambulated to the nurse’s station in paper scrubs 12:09:35 Patient #1 stood at nurse’s station drinking a cup of fluids 12:16:28 Patient #1 sat in day room area while her head was assessed by Personnel #7 12:18:00 Patient #1 remained sitting in day room, talking with Personnel #7 and Personnel #6 12:20:00 Patient #1 appeared to be sobbing/crying, supported by staff in day room 12:24:23 Personnel #12 [physician] moved Patient #1 to a private exam room 12:31:55 Patient #1 exited private exam room and returned to day room to sit in a chair with her legs drawn up, staff remained with Patient #1 until EMS [emergency medical services] arrived for transport, Patient #1 appeared calm and to be talking to staff 1:53:15 EMS arrived and prepared Patient #1 for transport 1:56:35 Patient #1 was placed on stretcher and left day room and facility During an interview on 11/21/2024 at 10:40 AM, Personnel #4 stated the following, “ ...On 11/16/2024, [Patient #1] was changed to line-of-sight observation level. She had asked to use her restroom in her room and the PCA unlocked her door and left the door open. The PCA got distracted by another patient having a panic attack and left [Patient #1] unattended for an extended period ... We identified that the PCA had [Patient #1] on line of sight on 11/16/2024 as ordered. The PCA led [Patient #1] to her room. Another patient was in distress and the PCA left [Patient #1] alone while she was on line of sight to assist the patient in distress. Th PCA took the distressed patient to the nurse and realized that [Patient #1] had been left unattended. The nurse and the PCA returned to [Patient #1]’s room and that is when they found her in the bathroom with a pillowcase around her neck ...A corrective action plan was developed and implemented for the incident that occurred on 11/16/2024 with [Patient #1]. The DON [director of nursing] developed the corrective action plan and is currently working on the retraining of all the staff.” During an interview on 11/21/2024 at 3:03 PM, Personnel #6 stated the following, “ ...The day of the incident on 11/16, [Patient #1] asked me to go to the restroom. I took her to the restroom, and I did walk away. I told her to shut her bedroom door when she was finished. [Personnel #7] wanted to check to make sure she was ok and found [Patient #1] in the bathroom and she went into action. She told me to go get another nurse and the crash cart. I knew that [Patient #1] was on line of sight and it was completely my fault for leaving her unattended for 12 minutes. I should have stayed with her no matter what. When I saw her in the bathroom, she [Patient #1] was sitting up and talking. They didn’t have to use any ammonia or anything like that to wake her up. They didn’t use anything from the crash cart. She didn’t require any oxygen ...” During an interview on 11/21/2024 at 3:20 PM, Personnel #7 stated the following, I was the nurse assigned to [Patient #1] on 11/16/2024 with [Personnel #6]. That morning [Personnel #6] let me know there was another patient having problems and needed medication. I wanted to check that patient’s vital signs and when I got to [Patient #1]’s room, I asked [Personnel #6] why her door was open. I asked her why she wasn’t with [Patient #1], and she told me because she felt like she needed to help the other patient having a serious panic attack. I ran into [Patient #1]’s room and found her on the floor of the bathroom. She was lying on the floor. I saw that she had something on her neck which ended up being a pillowcase. As soon as I started removing it, she responded immediately. She was awake and alert and immediately started crying. She was scared that she was in trouble. She did have a small amount of bleeding from her nose. We called a code and got the crash cart, but nothing was needed. She stood up and walked out of the bathroom. [Personnel #13] did come in briefly and assessed the situation and the patient was not in distress. [Personnel #12] is the doctor that did her full assessment after the incident.” Record review of the facility policy titled “Patient Bill of Rights” dated 07/2021 reflected the following, “Basic Rights for All Patients ...You have the right to a clean and humane environment in which you are protected from harm, have privacy with regard to personal needs, and are treated with respect and dignity ...You have the right to be free from mistreatment, abuse, neglect, and exploitation ...” Record review of the facility policy titled “Levels of Observation and Precautions” dated 03/2024 reflected the following, “ ...Line of sight observation: This level of observation is very restrictive and involves continuous visual monitoring at all times ...Staff must be within visual contact of the patient at all times ...When using the ‘Special Bathing’ area of the Hospital, staff will be required to monitor the patient inside the ‘Special Bathing’ area at all times ...””

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 45847 . Based on record review and interview, the hospital failed to adhere to the provider’s agreement that required a hospital to be compliant with §42 CFR 489.24, Special responsibilities of Medicare hospitals in emergency cases. . Based on documentation review and staff interviews, Facility A failed to: . A. Conduct a complete an appropriate Medical Screening Examination (MSE) for 1 of 20 patients (Patient #1) whose medical records were reviewed. Facility A failed to appropriately assess Patient #1’s hypertension (184/124), resulting in Patient #1 driving herself to seek treatment at another facility while experiencing an emergency medical condition (EMC). . B. 1. Inform the individual of the risks and benefits to the individual of the transfer/discharge for 1 of 20 patients (Patient #1) whose records were reviewed. 2. Follow its policies regarding appropriate transfers/discharges as evidenced by: a. No documented transfer attempts, such as contacting the receiving facility, documented efforts too to transfer Patient #1 to another medical facility, and no MOT was completed for Patient #1. b. No documentation of staff informing Patient #1 of the risks and benefits of leaving Facility A with an elevated blood pressure of 188/124 and Patient #1 being allowed to drive herself to a receiving hospital. c. Not obtaining a signed consent or refusal of a transfer by Patient #1. . Cross reference to Tag A2406 CFR §489.24(a) and §489.24(c). Tag A2409 CFR §489.24(e)(1). .”

“ON CALL PHYSICIANS CFR(s): 489.20(r)(2) and 489.24(j)(1-2) §489.20(r)(2) [The hospital (including both the transferring and receiving hospitals), must maintain] a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. §489.24(j)(1) Each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital’s patients who are receiving services required under this section in accordance with the resources available to the hospital, including the availability of on-call physicians. §489.24(j)(2)(i) The hospital must have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician’s control. §489.24(j)(2)(ii) The hospital must have written policies and procedures in place to provide that emergency services are available to meet the needs of patients with emergency medical conditions if it elects to permit on-call physicians to schedule elective surgery during the time that they are on call or to permit on-call physicians to have simultaneous on-call duties. This Standard is not met as evidenced by: 45847 . Based on record review and interview, Facility A failed to maintain written on-call policies and procedures in place to provide that emergency services are available to meet the needs of patients with emergency medical conditions (EMC). The physician’s duties as an on-call provider were not outlined within the policy, resulting in 1 of 20 patients whose records were reviewed not being seen for care upon presentation with an EMC. . Findings include: Document Review: The On-Call policy, last reviewed and effective as of 01/2023, outlined the on-call requirements for the “Administrator on Call”. There were no provisions for the on-call hospitalist or behavioral health responsibilities if on-call. The policy did state on page 1 of 2: “ ...A. An On-call roster will be prepared and disseminated by the Chief Executive Officer on a quarterly basis.” . And on page 2 of 2: “ ...Physician On Call Each Hospital will create a Physician On-Call Schedule. A physician will be available for consultation 24 hours per day ...” . Interviews During interviews with Staff #4 (Director of Quality) and Staff #5 (Marketing Director of Intake and Admissions) on the afternoon of 08/13/2024, Staff #4 indicated that Facility A does not have a hospitalist or mid-level professional on duty 24/7 to complete examinations or provide stabilization and there is no current policy or bylaw in place defining the duties of an on-call provider and his/her duties. .”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 45847 . Based on record review, and interview, Facility A failed to conduct a complete an appropriate Medical Screening Examination (MSE) for 1 of 20 patients (Patient #1) whose medical records were reviewed. Facility A failed to appropriately assess Patient #1’s hypertension (184/124), resulting in Patient #1 driving herself to seek treatment at another facility while experiencing an emergency medical condition (EMC). . Findings include: Policy Review Facility A’s Hospital Medical Staff Bylaws, last reviewed and effective as of 04/2024, was reviewed. The Hospital Medical Staff Bylaws was a 64-page document. The term “Qualified Medical Personnel (QMP)” was not found within the entirety of the document nor was the term “Medical Screening Examination (MSE)”. There was no written policy stance outlining who could/should respond to an emergency medical condition (EMC) or meet the needs of patients presenting to Facility A’s Emergency Department (ED) with an EMC. A pending update to the Hospital Medical Staff Bylaws was provided and reviewed. The outline was under review at the time of this investigation. The review process was planned to be completed by Friday, 08/16/2024, and implemented immediately. The definition of a “Qualified Medical Personnel (QMP)” was defined as stated on page 4 of 10 of the pending documents: “ ....B. The Governing Board shall approve, in writing, the qualified medical personnel (QMP) who may perform the medical screening examinations (MSE) for EMTALA purposes. 1. Qualified Medical Person or Personnel (QMP) means an individual, in addition to a licensed physician, who is licensed or certified and who has demonstrated current competence in the performance of MSEs, for example: i. Psychiatric Social Worker, depending on State law ii. Registered Nurse in Psychiatric Services, depending on State law iii. Psychologist iv. Physician Assistant v. Advanced Registered Nurse Practitioner ...” . Facility A’s EMTALA Policy, last reviewed and effective as of 04/2024, was reviewed and stated on page 1 of 6: “ ...To ensure (Facility A) comply with the requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA) and associated regulations. All persons presenting to a (Facility A) will be provided a medical screening examination to determine if they have an emergency medical condition. This includes persons presenting for an examination or treatment at the request of the mental health authority, sheriff’s office, or local police department ...” . And on page 3 of 6: “ ...Qualified Medical Personnel (QMP) means those individuals who are designated to perform the medical screening examination by the Hospital’s Governing Board through the Medical Staff and/or Hospital Bylaws ...” . “ ...Medical Screening Exam (MSE) includes both a general and focused assessment based on the patient’s chief complaint with the intent to determine the presence or absence of an EMC. A psychiatric MSE should include a screening assessment by a QMP and then staffed with a medical provider to determine the presence of an EMC. Triage, or the completion of a medical/psychiatric triage form alone, does not satisfy the MSE requirement ...” . Facility A’s Safety Assessment Policy, last reviewed and effective as of 01/2021, was reviewed. The Safety Assessment Policy stated on page 1 of 3: “ ...Purpose To ensure a process for timely and effective screening of clients presenting for possible admission. To ensure patients are triaged and assessed in order of Mental Health and Medical needs ...” . And on page 2 of 3: “ ...Policy To provide screening of all potential patients upon entering the facility for: reason for visit, recent thoughts of self-harm or harming others, safety, vital signs baseline, special equipment use, underlining medical conditions that may need acute medical attention, and blood sugar monitoring if insulin dependent ...” . Facility A’s On-Call policy, last reviewed and effective as of 01/2023, was reviewed. The On-Call policy shared information on the on-call requirements for the “Administrator on Call”. There were no provisions for the on-call hospitalist or behavioral health staff. The On-Call Policy stated on page 2 of 2: “ ...A physician will be available for consultation 24 hours per day ...”. Facility A’s Transfer Policy, last reviewed and effective as of 12/2023, was reviewed and stated on page 3 of 10: “ ...Each patient who arrives at the Hospital shall be: 1. evaluated by a Physician who is present in the Hospital at the time the patient presents or is presented or 2. evaluated by a physician on-call who is (a) physically able to reach the patient within 30 minutes after being informed that a patient is present at the Hospital who requires immediate medical attention; or (b) accessible by direct, telephone, or radio communication within 30 minutes with a registered nurse, physician assistant or other qualified medical personnel as established by the governing body at the Hospital under orders to assess and report the patient’s condition to the physician and 3. personally examined and evaluated by the physician before an attempt to transfer is made ...” . Medical Record from Facility A The medical record for patient #1 was reviewed. The medical record revealed that Patient #1, a 47-year-old female, arrived by personal vehicle in Facility A’s lobby on 06/10/2024, at 1:56 PM. Staff #8 (Receptionist) documented of every 15-minute observations beginning on 06/10/2024, at 1:56 PM. These observations ended at 2:45 PM. The medical record contained a “Safety Assessment Form” that was completed by Patient #1, which was not co-signed by any nursing or medical staff. The “Safety Assessment Form” contained a blood pressure that was documented at 2:02 PM by Staff #8 of 170/116. There was a second blood pressure documented by Staff #8 at 2:30PM of 188/124. . There was a note, written by Staff #7 (ED RN) on 06/10/2024, at 3:00 PM stating that Patient #1’s initial blood pressure was 170/116 and her rechecked blood pressure was 188/124. The note further stated that Staff #8 referred Patient #1 to Facility B for medical clearance. . Patient #1 was documented as “referred out” and left the ED on 06/10/2024, at 2:53 PM in her private vehicle. The total time in the ED was 54 minutes. In that time a medical screening assessment (MSE) was not documented, a triage assessment was not documented, and there was no evidence contained within the record that a nurse or physician had assessed or seen Patient #1. . Emergency Department (ED) Central Log Facility A’s ED log shows that Patient #1 arrived at Facility A at 1:56 PM and was “referred out” at 2:53 PM. . Medical Record from Facility B The medical record from the receiving facility, Facility B’s, Emergency Department (ED) was reviewed. The medical record showed that Patient #1 arrived at Facility B at on 06/10/2024, at 3:08 PM with chief complaints of high blood pressure. Staff #10 (ED RN) noted “Patient states she went to go check into (Facility A) and was sent to the ED at (Facility B) for elevated BP (blood pressure)”. . A triage assessment was initiated by Staff #10 on 06/10/2024, at 3:09 PM. All screening assessments and a review of Patient #1’s past medical history and current medications were obtained. Patient #1’s height, weight and vital signs were obtained at 3:13 PM. Patient #1 had an elevated blood pressure of 184/124 and an elevated pulse rate of 113 at that time. A Medical Screening Examination (MSE) was initiated by Staff #11 (ED Physician) on 06/10/2024, at 3:19 PM. Nine more sets of vital signs were obtained during Patient #1’s time in Facility B’s ED and her final blood pressure was normal at 115/69 on 06/11/2024, at 6:15 AM. . Patient #1 received three different blood pressure medications: Clonidine 0.2mg was given orally on 06/11/2024, at 12:46 AM, 3:07 AM, and 3:25 AM. Hydralazine 10 mg was given IV on 06/10/2024, at 5:32 PM and on 06/11/2024, at 5:18 AM. Labetalol 10 mg was given IV on 06/10/2024, at 7:19 PM. . Patient #1 was discharged home on 06/11/2024, at 6:20 AM. . Interviews On the morning of 08/13/2024, during an interview with Staff #5 (Marketing Director of Intake and Admissions), it was verified that Patient #1 did not receive an medical screening examination before leaving the facility. Staff #5 verified that Patient #1 drove herself to the receiving hospital after leaving Facility A. Staff #5 also verified that the document provided was the complete medical record for Patient #1 for the date of June 10, 2024. .”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 45847 . Based on record review and interview, Facility A failed to inform the individual of the risks and benefits to the individual of the transfer/discharge for 1 of 20 patients (Patient #1) whose records were reviewed. Failed to follow its policies regarding appropriate transfers/discharges. . Findings included: Facility A’s EMTALA Policy, last reviewed and effective as of 04/2024, was reviewed and stated on page 4 of 6: “ ...Transfers A. When a patient is being transferred from a (Facility A) to another medical facility because it does not have the capacity or capability to treat the patient’s EMC, the following procedure will be followed: 1. Contact the on-call physician to initiate the Consent to Transfer EMTALA Form; 2. Call an Emergency Department able to provide appropriate care to the patient and obtain a verbal acceptance of transfer, including the name of an accepting physician; 3. Discuss transfer and risks with the patient; 4. lf the patient consents for transfer call EMS for transfer; 5. Complete and send a copy of the Consent to Transfer EMTALA Form and assessment to the receiving hospital; and 6. lf the patient refuses to be transferred and is not at imminent medical risK complete a copy of the Consent to Transfer EMTALA Form noting the patient’s refusal, and complete assessment process ... ...C. The (Facility A) will call EMS or local sheriff’s department for the patient’s transfer to receiving hospital. D. lf there is not a hospital able/willing to accept the patient for treatment and transfer, the (Facility A) must continue to provide stabilizing treatment within its capacity and capability ...” . Facility A’s Transfer Policy, last reviewed and effective as of 12/2023, was reviewed and stated on page 3 - 4 of 10: “ ...Each patient who arrives at the Hospital shall be: 4. evaluated by a Physician who is present in the Hospital at the time the patient presents or is presented or 5. evaluated by a physician on-call who is (a) physically able to reach the patient within 30 minutes after being informed that a patient is present at the Hospital who requires immediate medical attention; or (b) accessible by direct, telephone, or radio communication within 30 minutes with a registered nurse, physician assistant or other qualified medical personnel as established by the governing body at the Hospital under orders to assess and report the patient’s condition to the physician and 6. personally examined and evaluated by the physician before an attempt to transfer is made; however a. after receiving a report on the patient’s condition from the Hospital’s registered nurse, Physician Assistant or other qualified medical personnel as established by the governing body by telephone, radio or audiovisual communication, if the Physician on call determines that an immediate transfer of the patient is medically appropriate and that the time required to conduct a personal examination and evaluation of the patient will unnecessarily delay the transfer to the detriment of the patient, the Physician on call may order the transfer by telephone, radio or audiovisual communication; and b. if the on-call physician issues orders for the transfer of the patient by telephone, radio, or audiovisual communication, those orders shall be reduced to writing in the patient’s medical record, signed by the registered nurse, Physician Assistant or other qualified medical personnel as established by the governing body receiving the order, and countersigned by the Physician authorizing the transfer as soon as possible.” . Medical Record from Facility A The medical record for patient #1 was reviewed. The medical record revealed that Patient #1, a 47-year-old female, arrived by personal vehicle in Facility A’s lobby on 06/10/2024, at 1:56 PM. Staff #8 (Receptionist) documented of every 15-minute observations beginning on 06/10/2024, at 1:56 PM. These observations ended at 2:45 PM. The medical record contained a “Safety Assessment Form” that was completed by Patient #1, which was not co-signed by any nursing or medical staff. The “Safety Assessment Form” contained a blood pressure that was documented at 2:02 PM by Staff #8 of 170/116. There was a second blood pressure documented by Staff #8 at 2:30PM of 188/124. . There was a note, written by Staff #7 (ED RN) on 06/10/2024, at 3:00 PM stating that Patient #1’s initial blood pressure was 170/116 and her rechecked blood pressure was 188/124. The note further stated that Staff #8 referred Patient #1 to Facility B for medical clearance. . Patient #1 was documented as “referred out” and left the ED on 06/10/2024, at 2:53 PM in her private vehicle. The total time in the ED was 54 minutes. In that time a medical screening assessment (MSE) was not documented, a triage assessment was not documented, and there was no evidence contained within the record that a nurse or physician had assessed or seen Patient #1. . There were no documented transfer attempts and not MOT was found for Patient #1, such as contacting the receiving facility, offering to transfer Patient #1 to another medical facility, informing Patient #1 of the risks and benefits to the individual of leaving Facility A with an elevated blood pressure of 188/124 and driving herself to a receiving hospital, or having Patient #1 sign a consent or refusal of a transfer. . Emergency Department (ED) Central Log Facility A’s ED log shows that Patient #1 arrived at Facility A at 1:56 PM and was “referred out” at 2:53 PM. . Medical Record from Facility B The medical record from the receiving facility, Facility B’s, Emergency Department (ED) was reviewed. The medical record showed that Patient #1 arrived by private vehicle at Facility B at on 06/10/2024, at 3:08 PM with chief complaints of high blood pressure. Staff #10 (ED RN) noted “Patient states she went to go check into (Facility A) and was sent to the ED at (Facility B) for elevated BP (blood pressure)”. . A triage assessment was initiated by Staff #10 on 06/10/2024, at 3:09 PM. All screening assessments and a review of Patient #1’s past medical history and current medications were obtained. Patient #1’s height, weight and vital signs were obtained at 3:13 PM. Patient #1 had an elevated blood pressure of 184/124 and an elevated pulse rate of 113 at that time. A Medical Screening Examination (MSE) was initiated by Staff #11 (ED Physician) on 06/10/2024, at 3:19 PM. Nine more sets of vital signs were obtained during Patient #1’s time in Facility B’s ED and her final blood pressure was normal at 115/69 on 06/11/2024, at 6:15 AM. . Patient #1 received three different blood pressure medications: Clonidine 0.2mg was given orally on 06/11/2024, at 12:46 AM, 3:07 AM, and 3:25 AM. Hydralazine 10 mg was given IV on 06/10/2024, at 5:32 PM and on 06/11/2024, at 5:18 AM. Labetalol 10 mg was given IV on 06/10/2024, at 7:19 PM. . Patient #1 was discharged home on 06/11/2024, at 6:20 AM. There was no documentation from Facility A found within this medical record that would indicate that any records were sent to Facility B. . Interviews The above findings were verified during an interview on the morning of 08/13/2024 with Staff #5 (Marketing Director of Intake and Admissions). It was also verified that the document provided was the complete medical record for Patient #1 for the date of June 10, 2024. . In an interview on 08/13/2024 with Staff #5, the Marketing Director of Intake and Admissions, Staff #5 was asked if a transfer was offered or provided for Patient #1. Staff #5 stated that there was not, and that Patient #1 drove herself to the receiving facility (Facility B). Staff #5 further stated that anyone whose needs could not be met at Facility A and needed a higher level of care should have a transfer, but that some patients refused an EMS transfer. Staff #5 indicated that if an EMS transfer was refused, Facility A had a form for patients to fill out for refusing the EMS transfer. Staff #5 also indicated that Facility A failed to obtain a refusal of transfer for Patient #1. .”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47061 Based on observation, record review, and interview, the facility failed to protect the rights to receive care in a safe environment for 3 of 12 (Patients #1, #2, and #3) patients. 1. Patient #2 was able to obtain two syringes from the nurse’s station from an unlocked cart on 12/06/2023. One syringe was accounted for after a contraband room search on 12/07/2023. Staff was unable to account for second syringe. 2. Female Patient #1 and male Patient #2 were able to congregate unsupervised in the male patient’s room with the intent to be sexually active on 12/06/2023. Patient #1 reported that she injected methamphetamine in exchange for sex with Patient #2 on 12/06/023 while on staff close observational status. 3. Staff failed to ensure a safe, drug-free patient care environment and prevent that Patient #2 was able to hide an illegal substance on his body throughout the admission process and approximately 52 hours into his inpatient hospitalization. 4. Although on constant staff observation, Patient #3 was left staff unobserved in the bathroom on 12/15/2023 and attempted suicide by hanging. 5. After the installation of a new medication dispensing system on 12/14/2023, staff failed to follow hospital policy and ensure that all alerts for dispensing psychotropic medications were properly functioning. Within 24 hours, one patient (Patient #3) received a long-acting antipsychotic medication instead of the short-acting formula ordered to address the agitation following her suicide attempt. Cross Refer Tag A0144”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 47061 Based on observation, record review, and interview, the facility failed to ensure that a safe environment was provided for 3 of 12 (Patients #1, #2, and #3) patients. 1. Staff failed to ensure that medical supplies including sharps were secured from unauthorized patient use. While distracting the nursing staff, Patient #2 was able to take two syringes out of a medical cart on 12/07/2023 and used at least one of them for illegal substance use injection while inpatient hospitalized. 2. Staff failed to prevent two patients of the opposite sex (Patient #1 and Patient #2) to spend time in a patient room together where they reportedly used illegal drugs and had consensual intercourse. 3. Staff failed to prevent Patient #2 to bring an illegal substance into the hospital and on to the patient unit. Patient #2 was able to hide Methamphetamine undetected by staff through the admission process and approximately 52 hours into his hospitalization until 12/6/2023 when a Patient #1 reported having received and intravenously used the substance she received from Patient #2. 4. Although on constant staff observation, Patient #3 was left alone in the bathroom and attempted suicide by hanging on 12/15/2023. 5. Staff failed to ensure appropriate alarms systems to prevent medication errors were fully functioning during the transitional installation of medication dispensing systems [Pyxis System]. Patient #3 required psychotropic medication administration after an attempt to commit suicide in her inpatient bathroom; in addition to the short-acting antipsychotic medication ordered for the patient’s mental health condition at that time, Patient #3 received its long-acting formula. Findings Included: 1. Patient #2’s Inpatient Comprehensive Psychiatric Evaluation completed on 12/05/2023 at 2:08 PM reflected the following, “ ...Date of Admission: 12/04/2023 ...Chief Complaint ...4 days ago patient wanted to run into traffic has also been thinking about overdosing on pills ...Patient is 55-year-old with a prior diagnosis of paranoid schizophrenia who is presenting with worsening of mood and anxiety symptoms with increase in paranoia suicidal thoughts ...Patient also has been abusing stimulant methamphetamine ...over the last 6 months patient has been abusing amphetamines ...1 to 2 times a week ...cannabis smoking 1-2 or 3 times a week up ...Diagnoses: 1. Schizophrenia chronic paranoid type. 2. Methamphetamine use disorder severe. 3. Cannabis use disorder moderate to severe ...” During an interview on 12/20/2023 at 11:30 AM, Personnel #4 stated that “ ...We did a search of [Patient #2’s] room and found a syringe that was unused. We traced back on the cameras to figure out how he got the syringes. He stole them from an emergency cart that was located behind the nurse’s station. He distracted the nurse by asking her to get him some medication and she went to the medication room. He reached over the counter and was able to reach the syringes from an unlocked cart. The syringes have since been removed from that cart and are now locked up in the medication room. The cart has also been locked ...” 2. Patient #1’s Inpatient Comprehensive Psychiatric Evaluation completed on 12/01/2023 at 2:17 PM reflected the following, “ ...Date of Admission: 11/30/2023 ...patient is a 35-year-old female with history of bipolar disorder and polysubstance use disorder ...Patient reports history of hatred towards men due to history of abuse physically emotionally and sexually. Patient has a history of self-harm by scratching cutting trying to find a vein to inject methamphetamines in ...substances usage primarily methamphetamines ...cocaine ...benzodiazepines ...Patient had stated in intake ‘I am bipolar I am meth addict’ ...Diagnoses: 1. Bipolar disorder most recent episode mixed severe with psychosis. 2. Sedative hypnotic use disorder severe. 3. Methamphetamine disorder severe ...” Patient #2’s Inpatient Comprehensive Psychiatric Evaluation completed on 12/05/2023 at 2:08 PM reflected the following, “ ...Patient is 55-year-old with a prior diagnosis of paranoid schizophrenia ...Patient also has been abusing stimulant methamphetamine ...over the last 6 months patient has been abusing amphetamines ...1 to 2 times a week ...cannabis smoking 1-2 or 3 times a week up ...Diagnoses: 1. Schizophrenia chronic paranoid type. 2. Methamphetamine use disorder severe. 3. Cannabis use disorder moderate to severe ...” During an interview on 12/20/2023 at 3:49 PM, Personnel #7 stated that “I remember [Patient #1] and [Patient #2]. On 12/6, I had conversations with them regarding boundaries. I walked in on them in [Patient #2]’s room together. When I entered the room, [Patient #2] had [Patient #1] by the hand and was leading her into the bathroom. I came in at the right time and I stopped them. I let her know that her behavior was not acceptable, and she couldn’t be in another patient’s rooms...” Record review of the facility policy titled “Patient Bill of Rights” dated 01/2021 reflected the following, “Basic Rights for All Patients ...You have the right to a clean and humane environment in which you are protected from harm ...” 3. Patient #2’s Inpatient Comprehensive Psychiatric Evaluation completed on 12/05/2023 at 2:08 PM reflected the following, “ ...Patient is 55-year-old with a prior diagnosis of paranoid schizophrenia ...Patient also has been abusing stimulant methamphetamine ...over the last 6 months patient has been abusing amphetamines ...1 to 2 times a week ...cannabis smoking 1-2 or 3 times a week up ...Diagnoses: 1. Schizophrenia chronic paranoid type. 2. Methamphetamine use disorder severe. 3. Cannabis use disorder moderate to severe ...” Facility staff provided a screenshot of treatment team note completed on 12/07/2023 at 4:02 PM by Personnel #8 reflected the following, “[Patient #1]-During the completion of the Safety Plan, pt [patient] reported to therapist that she had used meth [methamphetamine] yesterday while on the unit ...Pt then stated that she received Meth from [Patient #2]. Pt stated that between 2 and 3 pm on 12/6/23 [Patient #2] grabbed two needles from the Nurses station and that the cameras would have seen it. Pt then stated it was at 5 pm yesterday when her and the other pt used the Meth IV consensual. This is when pt provided two versions of the next allegations. Pt first made the allegations that she was offered meth in return for sexual favors. Pt then stated she was forced to take Meth IV and then Raped in the shower ...” Witness Statement written on 12/08/2023, untimed, by Personnel #18 reflected the following, “On Wednesday December 6th PT [Patient #1] stated to me that she traded sex with another male pt for drugs (ICE) [methamphetamine]. PT [Patient #1] also stated she and the male PT had been planning it for a few days and she could have stuck herself instead of him doing it.” 4. Patient #3’s Inpatient Comprehensive Psychiatric Evaluation completed on 12/12/2023 at 11:29 AM reflected the following, “ ...Date of Admission: 12/11/2023 ...Chief Complaint: I bought a gun 5 days ago ...patient is a 27-year-old single, adult, Indian American female ...She reported buying a gun 5 days ago with an intent to use it on herself. This has triggered her admission. Patient reports that her 1st mental health contact was at the age of 13. Since then she has been hospitalized over 15 times in inpatient psychiatric setting. She also reports 5 suicide attempts in the past in terms of attempting to strangle herself/hang herself or even overdose ...Diagnoses: major depressive disorder recurrent severe without psychosis, rule out bipolar disorder mixed, PTSD (post-traumatic stress disorder), generalized anxiety disorder, rule out borderline personality disorder, panic disorder, history of sedative hypnotic dependence and alcohol use disorder binge type in remission, victim of trauma, single, inability to advance herself in life due to significant mental health issues, severe impairment in functionality ...” Patient #3’s 7:00PM-7:00AM Shift Nursing Assessment completed on 12/15/2023 at 7:00 AM reflected that Patient #3 was on line of site observation for previous suicide attempts in the hospital, but denied any homicidal or suicidal ideation. Patient refused suicide assessment and would not contract for safety. Patient’s mood and affect were described to be flat, angry, and irritable with high levels of anxiety (8 out of 10) and depression (10 out of 10). Patient #3’s Interdisciplinary Progress Note completed on 12/15/2023 at 12:45 PM reflected the following, “[Patient #3] was found in restroom with makeshift noose (made of bra/pants) around her neck this afternoon. Patient was responsive and showed no s/s of injury ...Patient was transported from bathroom to seclusion room in order to de-escalate situation and administer emergency medication safely and privately ...” Patient #3’s 7:00PM-7:00AM Shift Nursing Assessment completed on 12/16/2023 at 5:00 AM reflected that Patient #3 refused nursing and suicide assessment reporting that she could not think. Patient was withdrawn from peers and isolative to her bedroom. During an interview on 12/20/2023 at 9:20 AM, Personnel #1 stated “ ...Last Friday, [Patient #3] had tied paper scrubs around her neck while she was in the bathroom. She was originally on a 1:1, but the doctor downgraded her to a line of sight. The PCA allowed the patient to shut the door. The PCA stood right outside the bathroom door, but she wasn’t watching her ...the patient was taking too long and then [Personnel #15] immediately called a code ...used shears to remove the paper scrubs from her neck ...” During an interview via telephone on 12/20/2023 at 8:05 PM, Personnel #15 stated the following, “I remember [Patient #3] and the incident that happened with her. She was on ‘line of sight’ observation, so I wasn’t supposed to let her out of my sight. She asked to go to the restroom, so I went into the room with her. She asked for scrubs, so I got her some paper scrubs. She then said she was going to shower. I realized she was in the shower for too long and when I opened the curtain, she had made a noose with the paper scrubs. I called a code ...” Record review of the facility policy titled “Levels of Observation and Precautions” dated 02/2023 reflected the following, “ ...Line of sight observation: This level of observation is very restrictive and involves continuous visual monitoring at all times ...Staff must be within visual contact of the patient at all times ...When using the ‘Special Bathing’ area of the Hospital, staff will be required to monitor the patient inside the ‘Special Bathing’ area at all times ...” 5. During an interview on 12/20/2023 at 1:20 PM, Personnel #5 stated “I was not aware of a medication error that occurred on 12/15 with [Patient #3]...We just had our Pyxis swap out on 12/14; we finished the process Thursday of last week. We have a pop-up warning in the Pyxis system that comes up to remind the nurse that there are two kinds of Haldol-short acting and long acting. Those pop-up warnings have not been installed in the new Pyxis machines. I haven’t had a chance to get them installed. There normally would have been a pop-up verifying that she wanted a long-acting Haldol. I still need to add all the medication warnings in the Pyxis system ...I will get those pop-ups installed and get all my labels in place for the look alike, sound alike medications. We are working on it, but I will get that moved to the top.” During a phone interview on 12/20/2023 at 7:12 PM, Personnel #16 stated “ ...I had never administered emergency medications ...I pulled the medications and I only got one vial of the Haldol 5 mg. [Personnel #19] told me that I needed two vials because the order was for 10 mg. When I got back in the Pyxis I typed in “Hal” and then I picked the first Haldol that showed up on the screen. It was not the regular Haldol, it was Haldol Decanoate. I just grabbed that one and we tried to draw it up. We couldn’t draw up the entire vial. The patient ended up getting Haldol 5 mg [short acting] from the first vial and only a small amount from the second vial with Haldol Decanoate 50 mg [long acting]. When we were doing our paperwork afterwards, [Personnel #19] realized what had happened. We told the doctor, and he ordered Cogentin. She slept for most of the shift after the emergency medication, but I didn’t notice any adverse reactions.” During an interview on 12/21/2023 at 9:34 AM, Personnel #5 stated “I put in all the high alert medication alerts, but I still need to test it to see if I did everything right. The new Pyxis and the old Pyxis machines were supposed to be cloned. That is why I thought all the safety mechanisms were in place. I didn’t know until yesterday that they had not been installed ... I have stickers that say long-acting and short-acting, but we are switching units, so I haven’t placed those stickers yet. If I place those on the cubies [cubicles] and then we move units then I will have to throw those cubies away so I’m waiting to place stickers until we move units...” During a tour of the Cedar Unit with Personnel #5 and Personnel #1 on 12/21/2023 at 9:30 AM, the medication removal was simulated for Haldol Decanoate, Invega, and Depakote ER from the Pyxis The high alert stickers were not found on the cubies or on the vials for those psychotropic medications. During an interview on 12/21/2023 at 12:24 PM, Personnel #1 stated “we are moving units next week, but the stickers should have been placed for the high alert medications regardless of having to throw away the cubies.” The facility policy titled “Pyxis MedStation-Policy and Procedure” dated 06/2022 reflected the following, “ ...Procedures are designed to provide safe and accurate provision of medication, secure storage, accurate accountability for controlled substances and other drugs, accurate patient billing, and compliance with State and Federal regulations ...High alert medications will require a phone call to the on-call pharmacist for verification that the dosage form/strength is correct. A prompt will appear on the screen if verification is necessary ...” The facility policy titled “High Risk Medication, Look Alike/Sound Alike Medications and Overrides” dated 05/2023 reflected the following, “ ...High Alert Medications-drug/s which are involved in a higher percentage of medication incidences and/or sentinel and significant events, or that carry an increased risk for error, abuse, injury, or other adverse outcome ...Medication storage bins in the Pharmacy may also be labeled with such cautionary statements as, ‘Caution: Sounds like ...’ or ‘Look Alike/Sound Alike’ or other cautionary labels as deemed appropriate by the Director of Pharmacy ...””

“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: 47061 Based on record review and interview, the facility failed to ensure that a registered nurse supervised and evaluated the nursing care for 1 of 3 patients (Patient #1). Patient #1 did not receive an assessment following reports on 12/06/2023 of sexually inappropriate behavior and intravenous [IV] drug use while inpatient at the facility. Findings Included: Record review of Patient #1’s medical record did not evidence any progress notes, nursing notes, or therapy notes related to the patient’s report of sexually inappropriate behavior or IV methamphetamine use during her inpatient admission. Facility staff provided a screenshot of a treatment team note completed on 12/07/2023 at 4:02 PM by Personnel #8 that reflected the following, “[Patient #1]-During the completion of the Safety Plan, pt [patient] reported to therapist that she had used meth [methamphetamine] yesterday while on the unit ...Pt then stated that she received Meth from [Patient #2]. Pt stated that between 2 and 3 pm on 12/6/23 [Patient #2] grabbed two needles from the Nurses station and that the cameras would have seen it. Pt then stated it was at 5 pm yesterday when her and the other pt used the Meth IV consensual. This is when pt provided two versions of the next allegations. Pt first made the allegations that she was offered meth in return for sexual favors. Pt then stated she was forced to take Meth IV and then Raped in the shower ...” Review of male Patient #2’s medical record reflected an Interdisciplinary Progress Note completed on 12/07/2023 at 5:00 PM that “A female pt report to staff that she had done meth with pt during afternoon on 12/6/23. The female pt stated that [Patient #2] had obtained two syringes from the nurses station and used them to take meth intravenously on the unit. The female pt reported that the meth was supplied by [Patient #2] ...” Patient #2’s Inpatient Progress Note completed on 12/08/2023 at 1:46 PM reflected the following, “ ...I discussed with patient concerns regarding another female peer making allegations that patient had boundary violations and had also given patient drugs while on the unit ... Patient was very non chalant when discussed about concerns of these boundaries ...” During an interview on 12/20/2023 at 11:30 AM, Personnel #4 stated that Patient #1 “reported to a PCA [patient care associate] that another patient ran into her room with a syringe and stabbed her twice in the AC [antecubital] and then ran out of her room ...We found out that she had obtained drugs and a syringe from another patient and shot up. The patient she received the drugs from had brought the drugs into the facility in his rectum ...We did a search of his room and found a syringe that was unused. We traced back on the cameras to figure out how he got the syringes. He stole them from an emergency cart that was located behind the nurse’s station. He distracted the nurse by asking her to get him some medication and she went to the medication room. He reached over the counter and was able to reach the syringes from an unlocked cart. The syringes have since been removed from that cart and are now locked up in the medication room. The cart has also been locked. The story was that the two patients met up a couple days prior to the incident and he asked her if she wanted some of his drugs. We saw on the video that she looked out for him while he passed her the drugs. We saw him drop the drugs on the floor when he walked past her, and she picked them up. There was a report that she had sex with the patient in exchange for the drugs. She said it was consensual, but we never saw any evidence of it. We did see them go away together, but it was less than five minutes. She went into his room, and we figure that is when they were shooting up. A PCA walked in on them, and they were fully clothed. The PCA immediately separated them. On her way out she apologized for planning everything. She spoke with a PCA during a smoke break on the day of her discharge and told her that the sex was consensual. The incident happened late on 12/6 and [Patient #1] was discharged early on 12/7...” During an interview on 12/20/2023 at 12:00 PM, Personnel #3 stated that Patient #1 “does not have any documentation in her medical record regarding the meth incident or the inappropriate sexual behavior. There are no progress notes, nursing notes, or therapy notes that speak to the events. The therapist did not document the family session or the safety plan in the medical record.” During an interview on 12/20/2023 at 3:49 PM, Personnel #7 stated that “I remember [Patient #1] and [Patient #2]. On 12/6, I had conversations with them regarding boundaries. I walked in on them in [Patient #2]’s room together. When I entered the room, [Patient #2] had [Patient #1] by the hand and was leading her into the bathroom. I came in at the right time and I stopped them. I let her know that her behavior was not acceptable, and she couldn’t be in another patient’s rooms...They both apologized, and she went to her room and didn’t come back out for the rest of the night. I did not see them doing drugs or having sex. She wasn’t fighting him when he was holding her hand. They were both fully clothed. I reported it to my nurse and [Patient #1] was moved to another unit later in the day.” Witness Statement written on 12/08/2023, untimed, by Personnel #18 reflected the following, “On Wednesday December 6th PT [Patient #1] stated to me that she traded sex with another male pt for drugs (ICE) [methamphetamine]. PT [Patient #1] also stated she and the male PT had been planning it for a few days ...””