Mesa Springs

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 45847 . Based on record review and interview, Facility A failed to provide an explanation of the individual risks and benefits of refusing treatment for 1 of 20 patients (Patient #1) whose records were reviewed. Facility A failed to follow its policy when an explanation of the individual the risks and benefits of refusing a medical screening examination (MSE) and inpatient treatment were not documented, and there was no documentation to ensure risks and benefits were explained to Patient #1 or his guardian when he was exhibiting suicidal ideation. . RECORD REVIEWS: Record at Facility B, the sending facility: Patient #1, a 17-year-old male, arrived at Facility B’s Emergency Department (ED) on 08/10/2025 at 11:09 PM with a chief complaint of suicidal ideation and “plan to slit wrist.”. The patient was ordered to have a bedside sitter and behavioral health consult with a recommendation for inpatient psychiatric services. The patient’s mother agreed to transfer. . Notes documented by Staff #16, an ED RN, at 3:21 AM included: “... BH states that if pt leaves ER prior to mother giving consent (&/or refusing) that PD will need to be called on pt. If pt’s mother refuses for pt to go, pt allowed to leave and BH will make CPS report. BH additionally states that if pt was agreeable, he is legally allowed to sign himself into treatment facility ...” . Staff #18, the Behavioral Health Transfer Center representative, documented the following at 4:03 AM: “I have explained the following benefits of being transferred/refusing transfer to the individual: Transfer to a higher level of care for specialty and/or services not provided at this facility”. . Review of the Ambulance Trip Report from Facility B to Facility A: Incident: 587891 EMS Vehicle: 19921 EMS Unit: M222 . EMS Unit M222 arrived at Facility B at the bedside of Patient #1 on 08/11/2025, at 4:48 AM where Patient #1 was evaluated. Staff #20 documented Patient #1’s mental status as “Normal Base Line” and his neurological status as “No focal Deficits”. All vital signs and GCS, obtained at 4:48 AM, 4:59 AM, 5:23 AM, 5:33 AM, and 5:44 AM were within normal parameters. . EMS arrived with Patient #1 at Facility A on 08/11/2025, at 5:57 AM and the care of Patient #1 was transferred to Facility A staff at 5:57 AM. . Record at Facility A, the intended receiving facility: Patient #1, a 17-year-old male, presented to Facility A via EMS as a transfer from Facility B for suicidal ideation on 08/11/2025 at 6:50 AM. Patient #1 was offered vital signs and a MSE by Staff #9, and his mother refused both at 6:50 AM. . An “Interdisciplinary Progress Note” was documented by Staff #9 at 7:00 AM and included: “Mom states was told would be here for 24-72hrs. Pt supposed to be wearing boot for injured ankle but thought it would be okay for short amount of time. Did not want to for beyond that time. Refused VS, MSE, declined IP recommendations. Staffed w/[Staff # 13]. . The recommendation for inpatient admission was declined by Patient #1’s mother and signed on 08/11/2025 at 7:00 AM. . Facility A failed to follow its policy when an explanation of the individual the risks and benefits of refusing a medical screening examination (MSE) and inpatient treatment were not explained to Patient #1 when Patient #1 was exhibiting suicidal ideation. . POLICY REVIEWS: Facility A’s “Emergency Treatment and Active Labor Act (EMTALA)-Freestanding Behavioral Health Hospitals” policy, last reviewed and effective on 07/2025, was reviewed. The policy stated on page 5 of 6: “ ...The person has the right to refuse examination, treatment, or an appropriate transfer. ln such cases, the involved [Facility A] will: A. offer the individual the examination, treatment, or transfer required by EMTALA and document in the medical records the examination, treatment or transfer that was refused, B. explain to the individual the risks and benefits of the examination, treatment or transfer, and document that such risks and benefits were explained, C. take reasonable steps to obtain the individual’s written informed refusal (see Patient Treatment Consent/Request/Refusal Form); and D. if the individual refuses to sign a writing informed refusal, the Hospital will document the foregoing, including the steps it took to obtain the individual’s written informed refusal ...” . Facility A failed to follow its EMTALA Policy when an explanation of the individual the risks and benefits of refusing the examination and inpatient treatment were not documented and no evidence was found that such risks and benefits were explained to Patient #1 or his mother. . Facility A’s “SCREENING ASSESSMENT AND/OR LEVEL OF CARE/PSYCHOILOGICAL ASSESSMENT” policy, last reviewed and effective on 03/2025, was reviewed. The policy stated on page 3 of 7: “ ...4. Whenever a patient is assessed and the Level of Care Assessment is completed, but the patient is not admitted, including when a patient does not meet criteria, patient declines treatment recommendations, and/or the patient requests to return at a later date or time for treatment, the following guidelines must be adhered to: ... ...b. When the disposition of care calls for Inpatient treatment and the patient requests to leave to get personal items or make ancillary arrangements, staff should provide support within a therapeutic scope and provide assistance to the patient with respect to their needs without the patient leaving the secure area. If the patient declines immediate admission/treatment, a declination of recommended treatment form must be completed. If the patient returns for admission in less than 72 hours, a Level of Care Assessment Update may be completed and is to be attached to the full assessment. If the patient is at risk of harming self or others and declines treatment, see policy related to involuntary admissions ...” . A policy related to involuntary admissions was not provided by the facility. . INTERVIEWS: On 09/29/2025 beginning at 8:25 AM, Staff #1 was interviewed via email. Staff #1 was asked for clarification of the AMA process and involuntary admission process. Staff #1 replied, “[Patient #1] had not been admitted to the facility and/or one of our outpatient programs, so the AMA policy was not utilized to handle his declination of recommended treatment from the admission area. I have attached the policy, titled, “Screening Assessment and/or Level of Care/Psychosocial Assessment,” and section #4 outlines the process that was applied when the patient and his mother declined the treatment recommendations from the admission step and the form that was signed and completed was appropriate to this identified process.” . The indicated “Screening Assessment and/or Level of Care/Psychosocial Assessment” policy was reviewed and noted to have referred to a “policy related to involuntary admissions”. Staff #1 was asked to provide the policy. . Staff #1 replied, “We no longer have a specific and/or separate policy related to involuntary admissions, but the subject was inserted into the EMTALA policy and the section that was referenced in the Screening Assessment - Level of Care policy”. Staff #1 then referred this surveyor to the Emergency Medical Treatment and Active Labor Act (EMTALA) policy and an “Admission Registration Checklist”. The checklist made no reference to patient’s involuntarily admitted and refusing care when diagnosed with self-harming behaviors. .”

“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: 47061 Based on record review and interview, the hospital failed to ensure compliance with 42 CFR 489.20 (l) Compliance with 489.24 and 42 CFR 489.24 (e) (1)-(2) Appropriate Transfer for 1 of 20 patients [Patient #1] when they presented to the hospital on 07/23/2024 for treatment. Patient #1 did not receive an appropriate transfer to an acute care hospital. Cross refer A2409.”

“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: 47061 Based on record review and interview, the hospital failed to contact the receiving hospital to inquire about available space and obtain an acceptance for the transfer of 1 of 20 patients [Patient #1]. Findings Included: Patient #1 was initially evaluated at Hospital A. Hospital A had begun the transfer process due to their inability to accommodate Patient #1’s acuity level with their current staffing. Patient #1 signed all transfer paperwork, but the patient was denied by several facilities. Ultimately, Hospital C accepted Patient #1. Hospital A attempted to transfer the patient to Hospital C, but the patient refused transfer to Hospital C and became agitated. Patient #1 made statements that he wanted to kill Hospital A staff and himself. The Police Department was contacted, and Patient #1 was taken into custody on a detention warrant and transferred to Hospital B. Hospital A staff were aware of the transfer to Hospital B but did not complete an MOT [memorandum of transfer], send discharge paperwork or contact Hospital B regarding the transfer. Interdisciplinary Progress Note completed on 07/23/2024 at 9:35 PM reflected the following, “Conducted pt assessment at 2135-2145 pt did exhibit verbally threatening behavior and expressed SI if pt wasn’t admitted.” Interdisciplinary Progress Note completed on 07/23/2024 at 10:43 PM reflected the following, “Called 911 D/T [due to] threatening bx [behavior] towards self. Pt uncooperative w/ [with] transfer out process. Unable to contact additional IP [inpatient] facilities D/T bx.” Interdisciplinary Progress Note completed on 07/23/2024 at 11:03 PM reflected the following, “Pt’s transfer started. Hospitals [Hospital C], [Hospital D], [Hospital E], [Hospital F]. Pt signed ROI [release of information] to provide information.” Interdisciplinary Progress Note completed on 07/23/2024 at 11:37 PM reflected the following, “[Hospital C] accepted pt.” Interdisciplinary Progress Note completed on 07/23/2024 at 11:50 PM reflected the following, “Pt declined transfer to [Hospital C]. [Police Department] transported pt to [Hospital B].” A review of the medical record did not evidence that report, medical records, and/or an MOT were sent to Hospital B. During an interview on 08/22/2024 at 9:54 AM, Personnel #3 stated [Patient #1] came in and was offered a transfer out. [Patient #1] required a 1:1 and we did not have the staff. This occurred on night shift. [Patient #1] agreed to being transferred out initially. He signed the EMTALA transfer paperwork that gave us permission to look for placement. We sent out clinicals to 5 different places. [Hospital C] accepted him as a patient. The other 4 facilities declined. We ended up having to call out the police department because he became aggressive. The police officer waited while we were trying to find a place to transfer him. When our social worker went to inform him of his transfer to [Hospital C] he declined it. The police were present during this interaction. Once he declined that option, that is when the police took him into custody. We didn’t tell the police to take him, they just took custody of him based on his behavior. The police were aware of how many hospitals had already declined this patient. After reviewing the intake note, it looks like we knew he was being transferred to [Hospital B]. We did not direct the police officer to take the patient to [Hospital B]. I know we completed all the appropriate transfer paperwork and MOT for his [Hospital C] transfer, but I don’t know if we did all of that for [Hospital B]. During an interview on 08/26/2024 at 9:10 AM, Personnel #5 stated the night [Patient #1] came in he was offered a transfer. He was very agitated and aggressive, so the night supervisor was helping me. The police had already been called. He had threatened staff physically and verbally. We explained to the police that we were trying to get [Patient #1] transferred and he was ok with that at that time. [Hospital C] accepted him and when we went to take him the disposition form, he stated he did not want to go to [Hospital C]. The police made the decision to take him to [Hospital B]. I knew the patient was being transferred to [Hospital B] and I documented that [Patient #1] was being transferred to [Hospital B] by the [Police Department]. We did not call report to [Hospital B] or complete any paperwork for [Hospital B] because we did not facilitate that transfer. The police facilitated that transfer. It was more that the patient refused our treatment and refused the transfer we had arranged so the police made the decision to take him to [Hospital B]. Police Department Report completed 07/24/2024 at 2:32 PM by Officer reflected the following, “ ...Upon arrival at 2252, employee’s informed that the MAP [mental application patient] (Patient #1) was inside the locked clinic doors. I spoke to the staff inside the locked clinic doors, and immediately, MAP appeared agitated and stating that he was not going to talk to the police. The clinic staff informed me that MAP had gone in for an evaluation, and after finishing he would kill them and kill himself. Once the MAP was upset and yelled, the employees said that they could not take him which agitated the MAP due to him wanting/needing assistance. I spoke to MAP who I remembered from a past call at the same location. MAP began calming down during the situation and was able to talk to me about what was going on. MAP mentioned wanting to get assistance and getting denied. [Hospital A] staff mentioned that they had a transfer for the MAP in process and had contacted transport. I was able to be direct and inform MAP about staff waiting to see which hospital would accept. MAP was open to going anywhere needed except a couple of hospitals. [Hospital A] appeared to list the MAP as ‘aggressive’ which caused the MAP to be denied all hospitals except one. Only one hospital accepted MAP, which he decided to deny as well. MAP refused the hospital due to getting previous care at the location and ‘nothing happening’. MAP asked to be taken to [Hospital B] although he also has ‘bad experiences’ at [Hospital B]. I was able to speak to MAP and let him know that in order to make sure that he was safe, he could be transported to [Hospital B]. MAP was receptive to take a ride with me and was transported to [Hospital B] ...in order to keep him from harming himself, anyone else, and get regulated back on his medications. MAP was released to [Hospital B] staff without any incident ...” Hospital B History of Presenting Illness completed on 7/24/2024 at 2:20 AM reflected the following, “[Patient #1] ...presents under Legal Status: DW-Detention Warrant due to concern about harm to self and harm to others. Per warrant: ‘Told [Hospital A] staff that he wanted to kill them and then kill himself. Many diagnosis of Bipolar, depression, anxiety, autism, sensory overload.’ Interview Details: Patient appears agitated and wanted to sleep instead of talking to provider. After a few attempts patient agreed to talk. Pt states that he came back from Kentucky because it did not work out over there. He came there thinking that the shelter is better but it wasn’t. He came back and wanted to go to [Hospital A] to check in for a few weeks. They did not let him. When asked about his reason for going there, he states that he just want a break from the street. He wants to calm down in the inpatient unit. He likes [Hospital A] facility so he went there. However, they told him that they are out of rooms. They wanted to send him to another hospital. He was upset because he just wants the room in [Hospital A]. They called the police on him to take him to [Hospital B]. He denies SI/HI [homicidal ideation]/AVH [auditory verbal hallucinations] ... ASSESSMENT/PLAN: Patient is not a harm to himself or others. Patient is autistic and his emotion is not well regulated. He tends to get upset and threatening when he does not get what he wants. He is contracting for safety at this time. He does not meet criteria for inpatient at this time: discharge to shelter in AM ...””

“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: 32143 Based on review and interview the facility failed 1. to have current and updated governing bylaws, unable to provide a list of all voting and non voting members of the governing board, have policies and procedures that clearly applied to the hospital in 2 of 2 (Seclusion and Restraint, Suspected Child, Adult, Disabled Person or Elderly Abuse/Neglect/Exploitation) policies reviewed. The facility failed to ; 2. provide Governing Board Meeting Minutes for the appointment of CEO. Refer to Tag A 0057 3. have contracts for 6 ( radiology group of providers, radiology facility, OPO, Echo Labs, dietician, van rental lease) contracted services provided. Refer to Tag A0083 A review of the governing bylaws, last approved on 8/23 stated the facility’s applicability was with Springstone Corporate. The bylaws stated on page 3 that the “Authority 1. Ownership. The hospital is owned by Springstone, Inc (the “owner”).” An interview was conducted with the CEO on 6/13/24 concerning the facility’s ownership. The CEO stated that Lifepoint Health Inc. had bought out the facility back in October of 2023. The CEO reported that the merger was official in March/April of 2024 but was unsure of the exact date. The CEO was asked if the facility had a DBA (doing business as). The CEO provided a form that stated, “Ownership Structure” The form revealed Lifepoint Health Inc. at the top and the facility as an LLC of Lifepoint Health. There was no further evidence that Springstone Corporate was the “owner” of the facility. The facility was unable to provide a list of all voting and non voting members of the governing board. The CEO and Quality Director was given the request in writing on 6/10/24 and also verbally asked”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 40989 Based on document review and interview the facility failed to: A. chemical restraints/emergency behavioral medications (EBM) administered Intramuscular (IM) or Intravenous (IV) for behavioral emergencies were identified and monitored as a chemical restraint in 2 (Patient #2, #4) of 2 medical records reviewed. B. ensure chemical restraints/EMBs were added to the restraint log 1 (Patient #2) of 1 medical record reviewed. C. ensure the policy and procedures addressed and gave clear instructions for the assessment and reassessment of a patient after the administration of a chemical restraint in 1 (Patient #2) of 1 medical record reviewed. D. ensure staff was educated on the administration of chemical restraints and safe monitoring after administration. E. an order was obtained from the physician, not longer than 30 minutes after the initiation of seclusion in 1 (Patient #2) of 2 (Patient #2 and #4) medical records reviewed. Refer to Tag A0160 F. orders written for restraints were not written on a PRN (as needed basis) in 1 (Patient #4) of 2 (Patient #2 and #4) medical records reviewed. Also, the facility failed to follow the facility policy titled, “Seclusion and Restraint”. Refer to Tag A0169 G. ensure the 1-hour face-to-face evaluation was completed by a different nurse than the one who initiated the restraint as required by Texas State Regulation in 1 (Patient #2) of 2 (Patient #2 and #4) medical records reviewed. Refer to Tag A0180 46435 Review of documentation, interview, and observations it was determined that, patient #16’s right to reasonable protection of personal property from theft or loss was not provided, as the patient’s belongings were not returned to him upon discharge from the facility. Findings Include: During Observations conducted of the facility on 06/13/2024 at 3:00PM. Review of the medication room in the Sunrise Unit revealed patient home medication containers are stored in the medication dispensing unit in a sealed plastic bag with patient identifiers on them. An interview was conducted with Staff #34 and Staff #35 on 06/13/2024 at 3:15PM. Staff #34 and #35 were asked what the intake process for new patients that arrive with home medications. Staff #35 states when the patient to the unit and personal belongings and personal searches are conducted if there are any additional medications are found that the intake nurse in the intake area did not find, the medication would be secured and verified by the unit nurse and they would be added to any medication that had already been received by the intake nurse logged on the personal medication sheet, secured in a bag and placed in the medication dispensing cabinet so it could be returned to patient at the time of discharge. Staff #35 states once the medication is verified by the unit nurse and they counter sign the sheet her responsibility for the medication ends because she does not have access to the medication dispensing unit. Staff #34 states as a nurse she would store the medication at admission and part of their discharge process would check the medication dispensing unit for any home medication that needed to be returned to the patient at discharge. Staff #34 and #35 stated that they have the patients sign their sheet when they come in and when they leave but sometimes things just get left behind. When staff #34 asked to look in the cabinet for patient #16 belongings they state there is none. Documents reviewed included: 1. Review of patient #16’s medical record for April 18, 2024, at 3:45PM, revealed during admission on the “Home Medication Belongings Form” there are several medications listed as being received by the facility, with the Patient signature. At time of discharge, it is noted on this sheet the patient refused to sign due to medication missing. 2. Review of the medical record for patient #16 revealed A supplemental sheet dated 04/25/2024 and signed by the patient and two RN’s (names unreadable) that indicates “Discharge Home Medications Missing at D/C on 4/25/24: Naproxen, Melatonin, Zoloft (2 Bottles), Mens daily vitamins, Buspar, and Trazadone.” But there are several other medications that were received at the same time during admission listed as returned.”

“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: 32143 Based on review and interview the facility failed to; A. have any performance improvement concerning the previous citations on 3/5/24, or any evidence of action plans or tracking performance to ensure that improvements are sustained. Refer to Tag A 0283 B.to have an ongoing reporting system for adverse patient events. Refer to Tag A0286 C. conduct any performance improvement projects. The facility failed to document what quality improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. Refer to Tag A0297”

“MEDICAL STAFF CFR(s): 482.22 The hospital must have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital. This Condition is not met as evidenced by: 32143 Based on review and interview the facility failed to; 1. to ensure periodical conduct review appraisals were conducted in 8 of 8 ( staff # 23 and staff #42 -49) provider credential files reviewed. refer to A340 2. ensure A. The provider had approved privileges from the Medical Executive Committee (MEC) and approved by the Governing Board (GB). 4 (#42, #45, #47, #48, #24) out of 8 (#23, #24, #42-44 and #47-#48) provider files reviewed. B. The provider failed to have a background check 2(#42, #47) out of 8(#23, #24, #42-44 and #47-#48) provider files reviewed. C. The provider had an application 2 (#45, #47) out of 8(#23, #24, #42-44 and #47-#48) provider files reviewed. D. The provider had peer references 3 (#45, #47, #48) out of (#23, #24, #42-44 and #47-#48 E. The Nurse Practitioner failed to have a supervising physician and/or no patient charts listed as reviewed by the physician. 2 (#24, #44) out of 2(#24, #44) files reviewed. refer to A341 3. to provide information on the official members of the medical staff voting and non-voting, and failed to ensure the that the Medical Executive Committee (MEC) was making voting decisions on provider credentialing and recredentialing in 2 (2/24 and 5/24) of 2 quarters provided. refer to A347”

“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: 32143 Based on review and interview the facility failed to A. have an approved Nurse Staffing Plan and matrix to ensure a significant number of nurses and staff were available to provide safe patient care of each nursing unit, failed to provide any data or information from nurse staffing advisory meetings to determine safe staffing, failed to ensure nurse staffng was covered during breaks and meals, and failed to protect the nurses who provided input and discussed staffing issues with regulators from retaliation. Refer to Tag A0392 B. Nursing failed to ensure a physical assessment was completed on 2 of 2 (Patient #1 and #7) patient medical records reviewed. Refer to Tag A0395”

“MEDICAL RECORD SERVICES CFR(s): 482.24 The hospital must have a medical record service that has administrative responsibility for medical records. A medical record must be maintained for every individual evaluated or treated in the hospital. This Condition is not met as evidenced by: 47892 Based on document review and interview, the facility failed to follow the Governing Body Bylaws, Medical Executive Bylaws, and the facility policy titled, “Practitioner Deficiency and Delinquency” to ensure medical records were promptly completed thirty (30) days after a patient’s discharge in 43 discharged patients whose records were reviewed. Refer to A0438.”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 28659 Based on observation, document review and interview the facility failed to ensure a clean and sanitary environment in 5 of 5 (Dietary department, Clean Supply Rooms, Washer/Dryer Rooms, Consult Rooms, Linen Storage Rooms) areas observed. Also, the Infection Control Professional (ICP) failed to follow the Infection Prevention and Control Plan/Program. Refer to Tag A0750”

“Establishment of the Emergency Program (EP) CFR(s): §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms “facility” or “facilities” in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: 47892 Based on document review and interview the facility failed to include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or an emergency. Refer to E0009.”

“CHIEF EXECUTIVE OFFICER CFR(s): 482.12(b) The governing body must appoint a chief executive officer who is responsible for managing the hospital. This Standard is not met as evidenced by: 32143 The facility failed to provide Governing Board Meeting Minutes for the appointment of CEO. A review of staff #1’s chart revealed he had a job description as the facility CEO on 7/19/23. The facility failed to have a current or updated governing bylaws. A review of the governing bylaws, last approved on 8/23 stated the facility’s applicability was with Springstone Corporate. The bylaws stated on page 3 that the “Authority 1. Ownership. The hospital is owned by Springstone, Inc (the “owner”).” An interview was conducted with the CEO on 6/13/24 concerning the facility’s ownership. The CEO stated that Lifepoint Health Inc. had bought out the facility back in October of 2023. The CEO reported that the merger was official in March/April of 2024 but was unsure of the exact date. The CEO was asked if the facility had a DBA (doing business as). The CEO provided a form that stated, “Ownership Structure” The form revealed Lifepoint Health Inc. at the top and the facility as an LLC of Lifepoint Health. There was no further evidence that Springstone Corporate was the “owner” of the facility. A review of the governing bylaws provided to the surveyor stated, “Members. The Governing Board shall be comprised of the following members: A. Voting Members: a. Chief Executive Officer (who shall serve as the Chief Executive Officer/ Chairperson of the Governing Board); b. Director of Nursing; c. Four executives of Springstone, Inc. who shall be designated at the beginning of each year. B. Participants: a. Hospital Medical Director b. Hospital Chief Financial Officer c. Hospital Quality Director ...” M. Appoint the Administrator. The Governing Board shall manage the affairs of the Hospital through the Administrator. The Administrato”

“CONTRACTED SERVICES CFR(s): 482.12(e) The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 32143 Based on review and interview the facility failed to have contracts for 6 of 6 ( radiology group of providers, radiology facility, OPO, Echo Labs, dietician, van rental lease) contracted services provided. A review of the contract log revealed all contracts were approved on 2/15/24 by the governing board. A review of the following services rendered at the facility from outside contracted services did not have a contract. There was no contract for the physician radiology group or a radiology facility, no contract for the Organ Procurement, no contract for Echo Labs, No contract for a dietician, and no contract for the vans that are being leased to transport patients. Staff # 1 and # 3 were unable to provide the requested contracted services.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 28659 Based on record review and interview the hospital failed to ensure patients had the capacity to consent and understand the risks and benefits of psychotropic medications before signing an informed consent in 1 of 1 (Patient #4) medical record reviewed. Also, the physician must sign the informed consent for treatment with psychoactive medications within 2 working days as required by Texas Administrative Code (TAC) Rule 414.405(d). Findings: Patient #4 Patient #4 was a 27-year-old female admitted to the facility on 5/23/2024 with a diagnosis of Bipolar Disorder current episode manic with severe psychosis. A review of the Psychiatric Evaluation completed by Physician #40 on 5/24/2024 was as follows: “ ...Patient was seen with consent. The patient is a 27-year-old female who presents with mania, delusions, psychosis, and severe agitation. She has received multiple PRN (as needed) meds after admission due to aggression and acting out against staff. During the psychiatric interview, the patient has disorganized thoughts, thought blocking, and needed much encouragement to get the answers .... Pt is minimizing psychiatric symptoms, but her presentation is consistent with psychosis ... Orientation: Not oriented to person, place, and time ...” A review of the progress note dated 5/25/2024 revealed that the patient’s behavior was bizarre, distracted, and only oriented to person. The provider’s signature was illegible. A review of the progress note dated 5/26/2024 revealed the patient was guarded, loud, irritable, and only oriented to person. The provider’s signature was illegible. A review of the progress note dated 5/27/2024 failed to document if the patient was oriented to person, place, time, or situation. The provider’”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(B) [A restraint is-] (B) A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. This Standard is not met as evidenced by: 40989 Based on document review and interview the facility failed to ensure: A. chemical restraints/emergency behavioral medications (EBM) administered Intramuscular (IM) or Intravenous (IV) for behavioral emergencies were identified and monitored as a chemical restraint in 2 (Patient #2, #4) of 2 medical records reviewed. B. chemical restraints/EBMs were added to the restraint log in 1 (Patient #2) of 1 medical record reviewed. C. the policy and procedure titled, “Seclusion and Restraint” gave clear instructions for the assessment and reassessment of a patient after the administration of a chemical restraint/EBM in 1 (Patient #2) of 1 medical record reviewed. D. staff was educated on the administration of chemical restraints/EBMs and safe monitoring after administration. E. an order was obtained from the physician, not longer than 30 minutes after the initiation of seclusion in 1 (Patient #2) of 2 (Patient #2 and #4) medical records reviewed. Findings: Medical record reviews were conducted on 6/10/2024-6/12/2024 with RN Staff #31. The medical record review was as follows: Patient #2 Patient #2 was a 15-year-old female admitted to the facility on 5/28/2024 by Physician #23 with a diagnosis of Psychosis. A review of the medication orders dated 5/29/2024 at 8:30 am by Physician #23 was as follows: “Haldol (antipsychotic) 5 milligrams (mg) IM NOW and Lorazepam (sedative medication) 1 mg IM NOW for aggression/psychosis”. A review of the medication administration record (MAR) revealed 5 mg of Haldol was administered IM on 5/29/2024 at 8:38 am and 1 mg of Lorazepam was administered IM on 5/29/2024 at 8:42 am by Registered Nurse (RN) Staff #25. A review o”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(6) Orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis (PRN). This Standard is not met as evidenced by: 40989 Based on document review and interview the facility failed to ensure orders written for restraints were not written on a PRN (as needed basis) in 1 (Patient #4) of 2 (Patient #2 and #4) medical records reviewed. Also, the facility failed to follow the facility policy titled, “Seclusion and Restraint.” Findings: Patient #4 Patient #4 was a 27-year-old female admitted to the facility on 5/23/2024 with a diagnosis of Bipolar disorder with severe manic psychosis and marijuana abuse. A review of the medication order by Physician #40 dated 5/23/2024 at 3:30 pm was as follows: “Olanzapine (Zyprexa-antipsychotic medication) 10 milligrams (mg) intramuscular (IM) Q (every) 4 hours PRN for unspecified psychosis not due to a substance or known physical condition. Notes: Verified with RN Staff #41-Max Daily 30 mg”. A review of the facility policy titled, “Seclusion and Restraint,” with an effective date of 1/2024 was as follows: “ ...Purpose To provide guidelines for the use of seclusion and/or restraints at the Hospital and Clinics ... Definitions ...Emergency Medications (Texas Facilities Only) A drug or medication that has been ordered to be given “now” because it is immediately necessary to address the signs and symptoms of a patient’s mental illness and to prevent: A. Imminent probable death or substantial bodily harm to the patient because the patient: 1. is threatening or attempting to commit suicide or serious bodily harm; or 2. is behaving in a manner that indicates that the patient is unable to satisfy the patient’s need for nourishment, essential medical care, or self-protection; or B. Imminent physical harm to others because of threats, attempts, or other acts”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(13) States are free to have requirements by statute or regulation that are more restrictive than those contained in paragraph (e)(12)(i) of this section This Standard is not met as evidenced by: 40989 Based on document review and interview the facility failed to ensure the 1-hour face to face evaluation was completed by a different nurse than the one who initiated the restraint as required by Texas State Regulation in 1 (Patient #2) of 2 (Patient #2 and #4) medical records reviewed. Texas State Rule was as follows: “415.260[c][1] Face-to-face evaluation. A physician, physician assistant as provided in paragraph (3) of this subsection, or a registered nurse who is trained and has demonstrated competence in assessing medical and psychiatric stability, other than the registered nurse who initiated the use of restraint or seclusion, shall conduct a face-to-face evaluation of the individual within one hour following the initiation of restraint or seclusion to personally verify the need for restraint or seclusion”. Findings: Patient #2 A review of Patient #2’s medical record was completed on 6/12/2024 after 10:00 am with RN Staff #31. Patient #2 was a 15-year-old female admitted to the facility on 5/28/2024 with a diagnosis of Psychosis. A review of the medical record revealed Patient #2 received multiple restraints/seclusions/emergency behavior medications (EMBs) on 5/30/2024. The review of the medical record was as follows: “ ...5/30/2024-Patient #2 was placed in a physical restraint at 8:33 am and administered a chemical restraint/EBM at 8:40 am by RN Staff #29. Staff #29 documented on a progress note that Patient #2 refused the 1-hour face-to-face evaluation but failed to document a time. A review of the 1-hour face-to-face was documented by RN Staff #29 at 5:00 PM. RN Staff #29 was the same RN who initiated the restraint. Also, this was greater than 8 hours after the initiation of the restraint/E”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 32143 Based on review and interview the facility failed to have any performance improvement concerning the previous citations on 3/5/24, or any evidence of action plans or tracking performance to ensure that improvements are sustained. A review of the Quality Assessment Performance Improvement (QAPI) Meeting Minutes dated May 22, 2024 revealed there was mention of the citations from the 3/4/24 complaint survey. The minutes stated, “Regulatory Updates: On April 9, 2024, the statement of deficiencies associated with the unannounced state survey done on March 4, 2024, was received by the Director of Quality and CEO. There were (1) finding that was substantial in compliance and no deficiencies were cited but there were 4 findings had related deficiencies cited and they were included appropriate nurse staffing, emergency treatment were the hospital failed to ensure there was a documented written plan for the care of all individuals treated in the Emergency Treatment Room and no expired items were located in there, Nursing Reassessments, Emergency medication monitoring and documentation, and restraint and seclusion documentation. The plan of correction was completed and returned.” There was no performance improvement concerning the citations or any evidence of action plans or tracking performance to ensure that improvements are sustained and provide patient safety. The QAPI meeting minutes discussed an EMTALA that was cleared on the 3/5/24 visit but no other citations. An interview was conducted with Staff #3 on 6/11/24. Staff #3 was asked if she had made a plan of correction book or had addressed the citations in QAPI from the previous visit. Staff #3 was unable to answer the question and was not able to supply the surveyor with any further information.”

“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: 32143 Based on review and interview the facility Quality Assessment Performance Improvement (QAPI) program failed to have an ongoing reporting system for adverse patient events. A review of the QAPI meeting minutes dated 5/22/24 revealed there was no mention of patient adverse events or tracking of medical errors. There was no clear expectations for safety established. An interview was conducted with Staff #3 on 6/11/24. Staff #3 stated that she was following adverse reactions but had not reported it in the QAPI meeting minutes. Staff #3 had some data but had not analyzed the data or determined the root cause of the incidents.”

“QAPI PERFORMANCE IMPROVEMENT PROJECTS CFR(s): 482.21(d) As part of its quality assessment and performance improvement program, the hospital must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must be proportional to the scope and complexity of the hospital’s services and operations. (2) A hospital may, as one of its projects, develop and implement an information technology system explicitly designed to improve patient safety and quality of care. This project, in its initial stage of development, does not need to demonstrate measurable improvement in indicators related to health outcomes. (3) The hospital must document what quality improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. (4) A hospital is not required to participate in a QIO cooperative project, but its own projects are required to be of comparable effort. This Standard is not met as evidenced by: 32143 Based on review and interview the Quality Assessment Performance Improvement (QAPI) program had failed to conduct any performance improvement projects. The facility failed to document what quality improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. An interview was conducted with Staff #3 on 6/11/24. Staff #3 stated that the hospital was not participating with the QIO cooperative project. Staff #3 was unable to provide any information of any specific PI projects. The facility was tracing 6 individual tracers that fell below the 90% benchmark goal: “Discharge Planning Progress note is filled out completely and addresses all areas of DC planning and safety planning = 40%, which is a 10% decrease from March. “Initial Master Treatment Plan is completed per state required timeframe = 50%, which is a 14% decrease from March. “Discharge plan is completed in full with follow-up appointments and includes the next provider of care = 60%, which is a 33% decrease from March. “Safety plan is completed with no blanks and addresses all high-risk items and access to means identified in psychosocial assessment, treatment plan, and throughout treatment= 70%, which is a 1% decrease from March. “Weekly progress notes completed that describe the progress related to treatment goal (can be embedded into a therapy note or in a separate progress note)= 80%, which is a 6% decrease from February. “Treatment plan update completed every 7 days from admission== 80%, which is a 6% decrease from March. The facility had data but minimal analysis of the issue. There was no documentation on any quality improvement projects being conducted, the reasons for conducting these projects, and the measurable progress.”

“MEDICAL STAFF PERIODIC APPRAISALS CFR(s): 482.22(a)(1) The medical staff must periodically conduct appraisals of its members. This Standard is not met as evidenced by: 32143 Based on review and interview the facility failed to ensure periodical conduct review appraisals were conducted in 8 of 8 ( staff # 23 and staff #42 -49) provider credential files reviewed. A review of provider credential files revealed there was no periodical conduct review appraisals found. Staff # 49 confirmed on 6/12/24 there were no evaluations in the files for periodical conduct review appraisals for staff #23, 42, 43, 44, 45, 46, 46, 48, or 49).”

“MEDICAL STAFF CREDENTIALING CFR(s): 482.22(a)(2) The medical staff must examine the credentials of all eligible candidates for medical staff membership and make recommendations to the governing body on the appointment of the candidates in accordance with State law, including scope-of-practice laws, and the medical staff bylaws, rules, and regulations. A candidate who has been recommended by the medical staff and who has been appointed by the governing body is subject to all medical staff bylaws, rules, and regulations, in addition to the requirements contained in this section. This Standard is not met as evidenced by: 32143 Based on review and interview the facility failed to ensure A. The provider had approved privileges from the Medical Executive Committee (MEC) and approved by the Governing Board (GB). 4 (#42, #45, #47, #48, #24) out of 8 (#23, #24, #42-44 and #47-#48) provider files reviewed. B. The provider failed to have a background check 2(#42, #47) out of 8(#23, #24, #42-44 and #47-#48) provider files reviewed. C. The provider had an application 2 (#45, #47) out of 8(#23, #24, #42-44 and #47-#48) provider files reviewed. D. The provider had peer references 3 (#45, #47, #48) out of (#23, #24, #42-44 and #47-#48 E. The Nurse Practitioner failed to have a supervising physician and/or no patient charts listed as reviewed by the physician. 2 (#24, #44) out of 2(#24, #44) files reviewed. An interview and review of the medical providers’ credentialing files was conducted on 6/12/24 with staff #50. The following files revealed missing information from the following. Physician #42 A request for clinical privileges was in the chart for core medical privileges. The standard form had no physician signature, date, or time when requested. Another standard form stated approved for the core privileges but there was no signature on who approved the privileges, date, or time. No letter from the MEC or Governing Board approved the recertification of clinical privileges. The facility had a contract to allow the contracted telehealth company to perform credentialing functions however the facility failed to have the credential files on site for review. The contract stated, “Upon request and reasonably advanced notice, Group shall provide the company with access to Group’s credential/re-credential materials and files related to the credentialing, quality improvement, and peer review act”

“MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY CFR(s): 482.22(b)(1), (2), (3) The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. (1) The medical staff must be organized in a manner approved by the governing body. (2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy. (3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: (i) An individual doctor of medicine or osteopathy. (ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located. (iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located. This Standard is not met as evidenced by: 32143 Based on review and interview the facility failed to provide information on the official members of the medical staff voting and non-voting, and failed to ensure the that the Medical Executive Committee (MEC) was making voting decisions on provider credentialing and recredentialing in 2 (2/24 and 5/24) of 2 quarters provided. A review of the Medical Executive Committee (MEC) Minutes dated February 5th 2024 revealed staff #1 CEO and staff #5 CNO attended the MEC. A review of the minutes revealed staff #1 approved the minutes form the last meeting and approved the reappointment of the medical director and the radiology group. There was no provider that voted or approved. The meeting was adjourned by the medical director and second by staff #1. There were 5 physicians listed as attending the meeting. There was no sign in sheet that they were present nor any documentation in how they were present at the meeting. A review of the MEC minutes on 5/6/24 revealed there were 5 physicians in attendance, four corporate board members the CEO, pharmacist, Quality manager, and the minutes taken by the HR manager. There was no information on how they were present (by zoom, teams, etc.) nor was there any sign in sheet. The CEO approved staff #3 as the MEC president and staff #5 the CNO second the motion but she was not listed as an attendee of the meeting. There was no documentation that any provider voted on the medical director president. Credentialing was brought up for 5 approved appointments for medical doctors and one nurse practitioner (NP). 2 NPs were mentioned for reappointment. There was no documented evidence that they were voted on or approved by the medical staff. The surveyor requested a list of all medical staff that were members of the MEC and if they were voting o”

“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: 32143 Based on review and interview the facility failed to have an approved Nurse Staffing Plan and matrix to ensure a significant number of nurses and staff were available to provide safe patient care of each nursing unit, failed to provide any data or information from nurse staffing advisory meetings to determine safe staffing, failed to ensure nurse staffng was covered during breaks and meals, and failed to protect the nurses who provided input and discussed staffing issues with regulators from retaliation. A review of the Governing Board (GB) meeting minutes for 11/20/23, 2/22/24, and 5/22/24 revealed that the GB had not approved any Nurse Staffing Plan or staffing matrix. The facility was unable to provide any information on how nurse staffing was budgeted for the facility. The facility was cited in 3/24 for not conducting nurse staffing advisory meetings to determine safe staffing levels. An interview was conducted with staff # 5 Director of Nursing (DON) on 6/11/24. Staff #5 stated that she had not presented any other staffing plan for approval other than what was sent down from corporate. Staff #5 confirmed it was the policy and procedure, “Plan for the Provision of Nursing Care in Psychiatric Specialty Areas” last reviewed on 6/2023.” Staff #5 stated that since our last visit in March, she has been trying to find a comparable nursing grid from one of the other facilities in their corporation but could not find one. Staff #5 stated that they are using one that was made for an alcohol and drug rehabilitation unit and not specific for this facility and patient population. Staff #5 confirmed the grid was not developed for the facility and she was unable to provide any data or information on how this matrix had safe patient-nurse ratios to provide safe patient care. Staff #5 stated she had 28659 On the late morning of 6/11/2024, staff Registered Nurse #12, was interviewed. During the interview, staff #12 described a recent event on the unit where a female patient refused to comply with the nurse’s request and attempted to force her way into the medication room. The Staff RN stated, “I have this loud whistle and I blew it for help, but no one came to help me”. On 06/12/2024 during rounding in the adult unit, staff #12 approached this surveyor and stated, “Did you or did you not tell the CNO, staff #5, everything I spoke to you about? I spoke to you in confidence”. Staff #12 stated, “The CNO, staff #5, came to me and questioned everything I said to you yesterday”. A CMS Surveyor witnessed this line of questioning. On 06/13/2024 in the early afternoon, the CNO, staff #5, was interviewed. The CNO, staff #5, was asked to explain her scheduling process. The CNO explained the expected nurse-patient ratio for each unit. The CNO was asked, “When you prepare your schedule for staffing the units, do you consider nurse/patient care staff breaks (staff are off the unit)? Or when a patient care staff must leave the patient unit to walk to the admission area to escort a new patient to the unit, that the unit, will be short-staffed until the new patient and patient care staff return? The CNO stated, “No, I never considered that”. On 06/13/2024, during an interview, the CNO was asked, “How was the staffing grid determined? The CNO was asked to explain, what process was used to determine the staffing grid. How did nursing leadership, determine if the numbers were sufficient for a safe effective patient-staff ratio? The CNO, Staff #5, replied, “The grid we are using came from another facility of ours in another state. The facility is a chemical dependence rehabilitation and treatment facility. We kno 40989 Findings: An observation tour was conducted on 6/12/2024 at 10:30 am on the Cedars Unit. The Cedars Unit was a 12-bed inpatient unit for adults. At the time of the observation, the unit had 10 patients and one being a new admit. Patient #19 was just admitted to the facility. The nursing admission had not been completed at the time of the observation. Registered Nurse (RN) Staff #31 was the RN assigned to the unit and was training another RN. At 10:40 am, 7 patients were taken to the activity room with the activity therapist for a group Yoga session. The therapist was alone for the group activity. This left 3 patients on the unit with one nurse and one Mental Health Tech (MHT) Staff #38. Two patients were in their assigned rooms and the new patient was pacing the unit at a rapid pace. At 10:45 all patients were returned to the day room from the group activity. At 10:50 am MHT Staff #38 was called to the Sunrise Unit to assist with a behavioral emergency. MHT Staff #38 returned to the Cedars Unit at 11:13 am. While the MHT was off the unit, this left RN to monitor 10 patients alone for 23 minutes. An interview was conducted with RN Staff #31 on 6/12/2024 at 11:20 am. RN Staff #31 was asked what would happen if she had an emergency in the Dayroom area. RN Staff #31 stated, “I would call for help”. RN Staff #31 was asked how she would call for help from the dayroom if she was the only RN on the floor. RN Staff #31 confirmed she was not assigned a “walkie-talkie” to radio for help if she was not near a phone. At 11:25, six patients were taken to the activity room to continue the group session leaving 4 patients on the unit with one RN and one MHT. At 11:30 am MHT #38 left the unit again to process a urine sample for the new admit and returned to the unit at 11:43 am leaving one RN alone on t”

“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: 40989 Based on observation, document review, and interview, Nursing failed to ensure a physical assessment was completed on 2 of 2 (Patient #1 and #7) patient medical records reviewed. Findings: Patient #1 Patient #1 was a 19-year-old female admitted to the facility on 6/07/2024 with a diagnosis of Major Depressive Disorder with Psychotic Features, ADHD, and Autism Spectrum Disorder. A review of the Nursing Assessment dated 6/08/2024 at 9:12 am revealed a section of the nursing assessment document was titled, “Physical Assessment”. The physical assessment included Pain and interventions attempted, Respiratory assessment, Gastrointestinal (GI) Assessment, and COVID-19 Screening. Registered Nurse (RN) Staff #12 documented that Patient #1 had no complaints of pain, the respiratory assessment was normal, the GI assessment was normal, and no symptoms were noted during the COVID-19 screening assessment. A physical assessment is described as an inspection, palpation (feeling with the fingers or hands), percussion (tapping body parts with fingers, hands, or a small instrument), and auscultation (listening to sounds from the heart, lungs, or other organs typically with a stethoscope). An interview was conducted with RN Staff #31 on 6/11/2024 at 2:30 pm. RN Staff #31 was when was the nursing assessment completed. RN Staff #31 stated, “We do the assessments when we give the patients their medications”. RN Staff #31 was asked if a physical assessment was completed on each patient every 12 hours. RN Staff #31 stated, “We ask the patients if they have any complaints with their bowels or problems breathing or if they are coughing, and if they say yes then we will listen to their bowel sounds or lung sounds. RN Staff #31 was asked if the patient did not have any complaint”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 47892 Based on document review and interview, the facility failed to follow the Governing Body Bylaws, Medical Executive Bylaws, and the facility policy titled, “Practitioner Deficiency and Delinquency” to ensure medical records were promptly completed thirty (30) days after a patient’s discharge in 43 discharged patients. Findings: A review of document titled “Delinquent Charts as of 06/12/2024” was conducted and this document revealed that 43 patient charts were delinquent. Further review revealed 22 charts were greater than 30 days delinquent. Eight (8) charts were greater than 60 days delinquent. 13 charts were greater than 90 days delinquent. An interview was conducted with Staff #18 on 6/13/2024 at 9:30 am. Staff #18 was asked how she reported the delinquency of records. Staff #18 stated, “I report this in our daily flash meetings every morning. I report a weekly listing of all medical records that have deficiencies and notify the practitioner by email. I also report the delinquent charts to our Quality Director, Staff #3, in our quality meetings and our CEO, Staff #1. They are fully aware of all the delinquent charts”. A review of the Governing Board Bylaws with an effective date of 8/2023 stated: “ ...5. Performance Improvement Responsibilities. A ... B ... C ... D. The Governing Board charges the Medical Staff to assume a leadership role in organizational performance improvement activities designed for process measurement assessment and improvements. These monitoring and evaluation activities include, but are not limited to, medical assessment and treatment of deviations from established patterns of clinical practice. The Medical Staff must actively participate in the measurement and assessment of all patient care processes, includin”

“SCOPE OF RADIOLOGIC SERVICES CFR(s): 482.26(a) [§482.26 Condition of Participation: Radiologic Services The hospital must maintain, or have available, diagnostic radiologic services...] §482.26(a) Standard: Radiologic Services The hospital must maintain, or have available, radiologic services according to the needs of the patients. This Standard is not met as evidenced by: 32143 Based on review the facility failed to have a contract for the radiology physicians group or radiological services. A review of the contract log revealed all contracts were approved on 2/15/24 by the governing board. Radiology services rendered at the facility from outside contracted services did not have a contract. There was no contract for the physician radiology group or a radiology facility. Staff # 1 and # 3 were unable to provide the requested contracted services.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 28659 Based on observation, document review and interview the facility failed to ensure a clean and sanitary environment in 5 of 5 (Dietary department, Clean Supply Rooms, Washer/Dryer Rooms, Consult Rooms, Linen Storage Rooms) areas observed. Also, the Infection Control Professional failed to follow the Infection Prevention and Control Plan/Program. Findings: A tour of the facility was conducted on 6/10/2024 at 10:15 am with CEO Staff #1. The following was observed. Dietary Department: A tour of the dietary department was conducted on 6/10/2024 at 10:15 with Staff #1 and Food Service Manager (FSM) Staff #7. The deep fryer was observed with oil. The internal perimeter of the fryer was dotted with visible food residue. The surface of the deep well fryer had a cookie sheet resting over the oil. FSM Staff #7 stated, “The cookie sheet is what we cover the oil with. The surveyor observed the cookie sheet did not fully cover the surface of the oil. Dust particles suspended in the air had the potential to settle on the surface of the deep fryer oil contaminating the oil. The outside of the deep well fryer was coated with dried oil splash residue. Staff #1 confirmed the observations. 26 Cookie sheets were observed with heavily burned grease build-up. 12 of the cookie sheets were black on the underside of the pan making it difficult to clean and sanitize after each use. One (1) Sauté pan was observed heavily discolored on the outside. The pan’s inner surface was black. The inner base surface of the pan had been scratched showing a silver metallic surface. FSM Staff #7 confirmed the pan was not originally black but silver in color. FSM Staff #7 stated, “It can no longer be cleaned to silver”. The convection oven”

“OPO AGREEMENT CFR(s): 482.45(a)(1) Incorporate an agreement with an OPO designated under part 486 of this chapter, under which it must notify, in a timely manner, the OPO or a third party designated by the OPO of individuals whose death is imminent or who have died in the hospital. The OPO determines medical suitability for organ donation and, in the absence of alternative arrangements by the hospital, the OPO determines medical suitability for tissue and eye donation, using the definition of potential tissue and eye donor and the notification protocol developed in consultation with the tissue and eye banks identified by the hospital for this purpose; This Standard is not met as evidenced by: 32143 Based on review and interview the facility failed to have an agreement with an OPO. Review of the contract list revealed there was no contract for an OPO. Staff # 3 confirmed there was no OPO contact on 6/13/24. A review of the policy and procedure “Organ , Tissue, and Eye Procurement” stated there was attachments for Springstone Organ, Tissue & Eye Procurement Services and phone numbers. The facility was unable to provide this attachment nor a OPO contrast.”

“TISSUE AND EYE BANK AGREEMENTS CFR(s): 482.45(a)(2) Incorporate an agreement with at least one tissue bank and at least one eye bank to cooperate in the retrieval, processing, preservation, storage and distribution of tissues and eyes, as may be appropriate to assure that all usable tissues and eyes are obtained from potential donors, insofar as such an agreement does not interfere with organ procurement; This Standard is not met as evidenced by: 32143 Based on review and interview the facility failed to have an agreement with an eye or tissue bank. Review of the contract list revealed there was no contract for an eye or tissue bank. Staff # 3 confirmed there was no agreement on 6/13/24.”

“STAFF EDUCATION CFR(s): 482.45(a)(5) Ensure that the hospital works cooperatively with the designated OPO, tissue bank and eye bank in educating staff on donation issues; This Standard is not met as evidenced by: 32143 Based on review and interview the facility failed to have any staff education for designated OPO, tissue bank, eye bank or educated staff on donation issues. Review of employee files #1, #2, #5, #18, 26, #28, #31 revealed there was no staff education for for designated OPO, tissue bank, eye bank or educated staff on donation issues. The facility failed to have policy and procedure or a contract.”

“DIRECTOR OF RESPIRATORY SERVICES CFR(s): 482.57(a)(1) There must be a director of respiratory care services who is a doctor of medicine or osteopathy with the knowledge, experience and capabilities to supervise and administer the service properly. The director may serve on either a full-time or part-time basis. This Standard is not met as evidenced by: 47892 Based on document review and interview the hospital failed to ensure the Governing Body appointed a physician as the Medical Director of Respiratory Services. Findings: A review of the credential file for the physicians working at the facility revealed that the Governing Body had not appointed one of the physicians as the Medical Director of Respiratory Services. An interview was conducted on 6/12/2024 after 1:30 PM with Staff #1. Staff #1 confirmed that no physician was appointed as the director of respiratory services.”

“Neurological Examination CFR(s): When indicated, a complete neurological examination must be recorded at the time of the admission physical examination. This Standard is not met as evidenced by: 40989 Based on document review and interview the facility failed to ensure a screening neurological exam was conducted by a physician in 2 (Patient #1and #2) of 2 medical records reviewed. Findings: Patient #1 Patient #1 was admitted to the facility on 6/07/2024 by Physician #23 with a diagnosis of Major Depressive Disorder with psychotic features, Attention Deficit Hyperactivity Disorder (ADHD) by history, and Autism Spectrum Disorder by history. A review of the History and Physical dated 6/7/2024 at 12:00 pm revealed Nurse Practitioner (NP) #24 completed the neurological screening exam. There was no documented neurological examination by a physician in the medical record. Patient #2 Patient #2 was a 15-year-old female admitted to the facility by Physician #23 on 5/28/2024 with a diagnosis of Psychosis unspecified. A review of the History and Physical dated 5/29/2024 at 10:00 am revealed NP #24 completed the neurological screening exam. There was no documented neurological examination by a physician in the medical record. An interview was conducted with RN Staff #5 on 6/12/2024. RN Staff #5 confirmed the neurological exam was performed during the history and physical by NP #24 and not a physician.”

“Local, State, Tribal Collaboration Process CFR(s): §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: 47892 Based on document review and interview the facility failed to include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or an emergency. Findings: A review of the facility Policy titled “Emergency Operation Plan” with an effective of 11/2023 was as follows: “Policy The hospital shall test its Emergency Operation Plan during exercises and actual events. Procedure 1 ... ... 5. The Hospital, with emergency services, will conduct at least one exercise a year that includes participating in at least one community wide exercise ...” A review of the Policy titled “Needs and Vulnerabilities within the Community” with an effective date of 3/2024 was as follows: “...Purpose To communicate to our community partners our needs and vulnerabilities in the event of an emergency. Scope of policy ... Definition ... Policy The Hospital will communicate with its community partners the needs and vulnerabilities of the Hospital on an annual basis during the Emergency Operations Review and whenever its needs or vulnerabilities change ...” An interview was conducted with Staff #4 on 6/12/2024 after 2:30 pm. Staff #4 confirmed the facility failed to follow its policies titled “Emergency Operation Plan” and “Needs and Vunerabilities within the Community”. During a review of document titled “Annual Performance Evaluation-Emergency Preparedness” revised on 12/5/2022 stated: “Has the facility coordinated or joined local or state emergency organizations or validated “receiver status” with local entities: Yes.” An interview was conducted wit”

“A life safety code (LSC) full survey was conducted on site on 06/13/2024. An entrance conference was held for EOC Director on 06/13/2024 to discuss the purpose of the LSC survey, and the survey process was explained. Instructions were provided on writing plans of correction. An opportunity was provided for questions and discussion. The LSC survey was conducted under the authority of Chapter 2 of the State Operations Manual, Appendix A, Acute Care Hospitals, 42CFR482 to determine the Hospital’s compliance. An LSC exit conference was conducted on 06/13/2024 in the hospital. In attendance was the EOC Director. The preliminary findings of the survey and the next steps in the survey process were explained. An opportunity was provided for questions and discussion. Note: The CMS-2567 (Statement of Deficiencies) is an official, legal document. All information must remain unchanged except for entering the plan of correction, correction dates, and the signature space. Any discrepancy in the original deficiency citation(s) will be reported to the Dallas Regional Office (RO) for referral to the Office of the Inspector General (OIG) for possible fraud. If information is inadvertently changed by the provider/supplier, the State Survey Agency (SA) should be notified immediately.”

“Building Services - Other CFR(s): NFPA 101 Building Services - Other List in the REMARKS section any LSC Section 18.5 and 19.5 Building Services requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. This Standard is not met as evidenced by: 35321 K500 Building Services - Other Findings: The inspector observed, while accompanied by the EOC Director, during the hours of the survey from 1 pm to 5:30 pm on 06/13/2024, that there were the following issues: 1) Based on observation in main electrical room, the peel ‘n stick label for the damper was fading and needed replacement.”

“Evacuation and Relocation Plan CFR(s): NFPA 101 Evacuation and Relocation Plan There is a written plan for the protection of all patients and for their evacuation in the event of an emergency. Employees are periodically instructed and kept informed with their duties under the plan, and a copy of the plan is readily available with telephone operator or with security. The plan addresses the basic response required of staff per 18/19.7.2.1.2 and provides for all of the fire safety plan components per 18/19.2.2. 18.7.1.1 through 18.7.1.3, 18.7.2.1.2, 18.7.2.2, 18.7.2.3, 19.7.1.1 through 19.7.1.3, 19.7.2.1.2, 19.7.2.2, 19.7.2.3 This Standard is not met as evidenced by: 35321 K711 Evacuation and Relocation Plan Findings: The inspector observed, while accompanied by the EOC Director, during the hours of the survey from 1 pm to 5:30 pm on 06/13/2024, that there were the following issues: 1) Based on review of the records, facility failed to provide date when the evacuation and relocation plan was last reviewed and/or revised.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 35321 K712 Fire Drills Findings: The inspector observed, while accompanied by the EOC Director, during the hours of the survey from 1 pm to 5:30 pm on 06/13/2024, that there were the following issues: 1) Based on review of the records, facility failed to include the transmission of a fire alarm signal as part of its required fire drill.”

“Electrical Systems - Other CFR(s): NFPA 101 Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 6 (NFPA 99) This Standard is not met as evidenced by: 35321 K911 Electrical Systems - Other Findings: The inspector observed, while accompanied by the EOC Director, during the hours of the survey from 1 pm to 5:30 pm on 06/13/2024, that there were the following issues: 1) Based on observation in electrical room known as “204 electrical”, there was storage of combustible rubbish which needed to be removed from this room.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 35321 K918 Electrical Systems - Essential Electric System Maintenance and Testing Findings: The inspector observed, while accompanied by the EOC Director, during the hours of the survey from 1 pm to 5:30 pm on 06/13/2024, that there were the following issues: 1) Based on observation at the generator set location, there was a missing light bulb and cover.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 46435 Review of documentation, interview, and observations it was determined that, patient #16’s right to reasonable protection of personal property from theft or loss was not provided, as the patient’s belongings were not returned to him upon discharge from the facility. Findings Include: During Observations conducted of the facility on 06/13/2024 at 3:00PM. Review of the medication room in the Sunrise Unit revealed patient home medication containers are stored in the medication dispensing unit in a sealed plastic bag with patient identifiers on them. An interview was conducted with Staff #34 and Staff #35 on 06/13/2024 at 3:15PM. Staff #34 and #35 were asked what the intake process for new patients that arrive with home medications. Staff #35 states when the patient to the unit and personal belongings and personal searches are conducted if there are any additional medications are found that the intake nurse in the intake area did not find, the medication would be secured and verified by the unit nurse and they would be added to any medication that had already been received by the intake nurse logged on the personal medication sheet, secured in a bag and placed in the medication dispensing cabinet so it could be returned to patient at the time of discharge. Staff #35 states once the medication is verified by the unit nurse and they counter sign the sheet her responsibility for the medication ends because she does not have access to the medication dispensing unit. Staff #34 states as a nurse she would store the medication at admission and part of their discharge process would check the medication dispensing unit for any home medication that needed to be returned to the patient at discharge. Staff #34 and #35 stated that they have the patients sign their sheet when they come in and when they leave but sometimes things just get left behind. When staff #34 asked to look in the cabinet for patient #16 belongings they state there is none. Documents reviewed included: 1. Review of patient #16’s medical record for April 18, 2024, at 3:45PM, revealed during admission on the “Home Medication Belongings Form” there are several medications listed as being received by the facility, with the Patient signature. At time of discharge, it is noted on this sheet the patient refused to sign due to medication missing. 2. Review of the medical record for patient #16 revealed A supplemental sheet dated 04/25/2024 and signed by the patient and two RN’s (names unreadable) that indicates “Discharge Home Medications Missing at D/C on 4/25/24: Naproxen, Melatonin, Zoloft (2 Bottles), Mens daily vitamins, Buspar, and Trazadone.” But there are several other medications that were received at the same time during admission listed as returned.”

“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: 32143 Based on review and interview the facility failed to 1. have policies and procedures that clearly applied to the hospital in 2 of 2 (Seclusion and Restraint, Suspected Child, Adult, Disabled Person or Elderly Abuse/Neglect/Exploitation) policies reviewed. A review of the policy and procedures revealed that the policies were corporate policies and had multiple states within the policies. There was no clear understanding that the following policies had been adopted and vetted through the Governing Body for the individual facility. A review of the policy and procedure Seclusion and Restraint, Applicability Springstone Corporate last revised 1-2024. The policy gives direction for two different states North Carolina, and Texas. A review of policy and procedure Suspected Child, Adult, Disabled Person or Elderly Abuse/Neglect/Exploitation, applicability Springstone Corporate, last revised 9/2023 revealed the policy was for Washington State, North Carolina, Arizona, and Texas. A review of the Governing Board Minute Meetings dated 2/22/2024 revealed the annual review and approval of policy and procedures. An interview was conducted with staff #2 on 3/4/24. Staff #2 stated that she was not aware of the multiple states in the policy and procedures. Staff #2 stated she did not have an available list of the policies and procedures that were approved during the annual review. 2. A. ensure chemical restraints that were given or may be administered IM or IV for behavioral emergencies were identified and monitored as a chemical restraint. B. ensure the policy and procedures addressed and gave clear instructions for the assessment and reassessment of a patient after the administration of a chemical restraint. C. ensure staff was educated on the administration of chemical restraints and safe monitoring after administration. D. ensure Chemical restraints were added to the restraint log monitored through Risk and Quality in 2 of 2 (#20 and #4) charts reviewed. Refer to Tag A0160 3. ensure a physical assessment was completed on 2 of 2 (Patient #13 and #24) patients reviewed. Refer to Tag A0395 4. a. ensure safe staffing levels by providing an adequate number of Registered Nurses (RN) and Patient Care Assistants (PCA) to meet the needs of the patients safely on 4 (Meadows, Cedars, Willows, and Sunrise) of 4 patient care units. b. have an approved staffing matrix/grid for 4 (Meadows, Cedars, Willows, and Sunrise) of 4 patient care units. c. have an approved process to determine patient acuity levels to assist the staffing coordinator/house supervisor on when to increase or decrease staff to ensure patient and staff safety on 4 (Meadows, Cedars, Willows, and Sunrise) of 4 patient care units. d. ensure all staff had adequate coverage during scheduled meal and break times on 4 of 4 (Meadows, Cedars, Willows, and Sunrise) patient care units. e. ensure adequate staffing was provided to ensure patient rights were not violated in 1 of 1 (Patient #14) patient’s medical records reviewed on 1 of 1 (Willows Unit) Patient care units. f. follow its own Staffing Plan to evaluate staffing needs based on patient acuity-established criteria and anticipated admission, transfers, and discharges in 4 (Meadows, Cedars, Willows, and Sunrise) of 4 patient care units. The deficient practices were identified under the following Condition of Participation, CFR 482.62: Special Staff Requirements, were determined to pose an Immediate Jeopardy (IJ) to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possible death. Refer to Tag A1704”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 32143 Based on review and interview the facility failed to: A. ensure chemical restraints that were given or may be administered IM or IV for behavioral emergencies were identified and monitored as a chemical restraint. B. ensure the policy and procedures addressed and gave clear instructions for the assessment and reassessment of a patient after the administration of a chemical restraint. C. ensure staff was educated on the administration of chemical restraints and safe monitoring after administration. D. ensure Chemical restraints were added to the restraint log monitored through Risk and Quality in 2 of 2 (#20 and #4) charts reviewed. E. ensure an order was received from a physician during a behavioral emergency before placing a patient in seclusion in 1 (Patient #4) of 1 medical record reviewed. Refer to Tag A0160”

“Special Staff Requirements CFR(s): Condition of Participation: Special Staff Requirements for Psychiatric Hospitals The hospital must have adequate numbers of qualified professional and supportive staff to evaluate patients, formulate written, individualized comprehensive treatment plans, provide active treatment measures and engage in discharge planning. This Condition is not met as evidenced by: 40989 Based on observation, document review, and interview the hospital failed to: a. ensure safe staffing levels by providing an adequate number of Registered Nurses (RN) and Patient Care Assistants (PCA) to meet the needs of the patients safely on 4 (Meadows, Cedars, Willows, and Sunrise) of 4 patient care units. b. have an approved staffing matrix/grid for 4 (Meadows, Cedars, Willows, and Sunrise) of 4 patient care units. c. have an approved process to determine patient acuity levels to assist the staffing coordinator/house supervisor on when to increase or decrease staff to ensure patient and staff safety on 4 (Meadows, Cedars, Willows, and Sunrise) of 4 patient care units. d. ensure all staff had adequate coverage during scheduled meal and break times on 4 of 4 (Meadows, Cedars, Willows, and Sunrise) patient care units. e. ensure adequate staffing was provided to ensure patient rights were not violated in 1 of 1 (Patient #14) patient’s medical records reviewed on 1 of 1 (Willows Unit) Patient care units. f. follow its own Staffing Plan to evaluate staffing needs based on patient acuity-established criteria and anticipated admission, transfers, and discharges in 4 (Meadows, Cedars, Willows, and Sunrise) of 4 patient care units. The deficient practices were identified under the following Condition of Participation, CFR 482.62: Special Staff Requirements, were determined to pose an Immediate Jeopardy (IJ) to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possible death. Refer to Tag A1704”

“EMERGENCY SERVICES CFR(s): 482.12(f)(2) If emergency services are not provided at the hospital, the governing body must assure that the medical staff has written policies and procedures for appraisal of emergencies, initial treatment, and referral when appropriate. This Standard is not met as evidenced by: 47892 Based on document review and interview the Governing Body failed to ensure the medical staff had written policies and procedures for the care of all individuals treated in the Emergency Treatment Room. Findings: After multiple requests for the Emergency Treatment Room Policy, one was not provided. A review of the hospital’s policies revealed that there was no policy or procedure for the care of an individual treated in the Emergency Treatment Room. An interview was conducted with Staff #7 on 3/4/2024 after 1 PM. RN Staff #7 confirmed the facility did not have any policies or procedures for the Emergency Treatment room.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(B) [A restraint is-] (B) A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. This Standard is not met as evidenced by: 32143 Based on review and interview the facility failed to: A. ensure chemical restraints that were given or may be administered IM or IV for behavioral emergencies were identified and monitored as a chemical restraint. B. ensure the policy and procedures addressed and gave clear instructions for the assessment and reassessment of a patient after the administration of a chemical restraint. C. ensure staff was educated on the administration of chemical restraints and safe monitoring after administration. D. ensure Chemical restraints were added to the restraint log monitored through Risk and Quality in 2 of 2 (#20 and #4) charts reviewed. A review of patient # 20’s chart revealed he was a 17-year-old black male admitted for major depression with psychotic symptoms. He was admitted voluntarily on 2/25/24. Patient #20 was placed on precautions for Aggression and moderate suicide. Patient #20’s level of observation was every 15 minutes. A review of patient #20’s chart revealed he had a physician order for a 1:1 observation level for “psychotic, wandering, and trying to elope.” The order was written on 2/27/24 at 12:45 PM. A review of patient #20’s chart revealed there was a restraint packet in the patient’s chart. The packet was incomplete as follows. Page #1 out of 7 revealed it was an initiation of a restraint order. Staff # 10 RN documented on 2/28/24 at 18:25 (6:25 pm) “Pt ran for door when staff was exiting pt was physically restrained and escorted back to unit and punching staff.” Staff #10 RN documented that the physical hold started at 1805 (6:05 pm) and ended at 1805 (6:05 pm). Staff # 10 RN charted that a verbal physician order was received for the hold on 2/28/24 at 18:25 (6:25 pm). The bottom of the page required a name, date, and time the RN supervisor was notified and the attending physician. This information was blank. The physician did not sign the intervention restraint hold order until the next day on 12/29/24 at 12:10 pm. Page #2 out of 7 revealed Staff # 10 RN failed to chart who the face-to-face evaluator was or if the evaluation was completed within the hour. Staff # 10 RN charted that patient #20’s father was notified at 18:10 (6:10 pm). The only documented alternative intervention attempted before the restraint was documented as a “1:1 verbal interaction.” The signature for the treatment plan update was left blank. Page #3 out of 7 revealed it was for a face-to-face evaluation and it was completely blank. The page asked for the date and time of completion, what the patient’s response was to the intervention, an assessment of the immediate condition (including vital signs), a review of health systems, and a mental status/behavioral assessment. Page #4 out of 7 was completely blank. The page required medical history physical and psychological, behavioral criteria for discontinuation of restraint, and a summary of communication including the patient’s physician. Page #5 out of 7 was completed by another nurse on a different shift. The RN signed the patient debriefing on 2/29/24 at 8:20 am, 14 hours after the initiation of a physical hold restraint. There was no documentation on why the debriefing was delayed by 14 hours. Page #6 out of 7 was completely blank. The page was for a staff debriefing. There was no documentation on what staff were involved during the restraint process. Page #7 out of 7 was for monitoring activities. The RN filled out the form at 1805 for monitoring the patient during the hold but did not sign the form until 19??. The time on the form was illegible. The RN had written a different time over the original time. A review of the physician orders dated 2/28/24 at 18:25 (6:25 pm) revealed an order for Haldol 5 mg IM, Benadryl 50mg IM, and Ativan 1 mg IM once for aggression. A review of the Medication Administration Record (MAR) dated 2/28/24 revealed the medication was administered at 18:25 (6:25 pm). The order was not written as a verbal order. The physician did not sign the order until 2/29/24 at 14:47 (2:47 pm). The medication was administered to patient #20 at the same time as the documented hold. The medication was not added to the restraint packet. A separate 2-page form was found on the chart that stated, “Emergency Medications-One Hour Face to Face Evaluation.” The form stated the intervention was on 2/28/24 at 1830 and the face-to-face was done at 1930. The nurse documented, “pt took emergency medication without restraint. Haldol 5/Ativan 1/ Benadryl 50 IM.” A review of page 2 revealed that the nurse performing the face-to-face should have written a clinical summary of the intervention. There was no documentation that the nurse performing the face-to-face documented any patient evaluation factors that may have contributed to the violent or self-destructive behavior, and whether the intervention was appropriate to address the violent or self-destructive behavior. A review of the policy and procedure for Restraints and Seclusions stated, “Emergency Medications (Texas Facilities Only) A drug or medication that has been ordered to be given “now” because it is immediately necessary to address the signs and symptoms of a patient’s mental illness and to prevent: A. Imminent probable death or substantial bodily harm to the patient because the patient: 1. is threatening or attempting to commit suicide or serious bodily harm; or 2. is behaving in a manner that indicates that the patient is unable to satisfy the patient’s need for nourishment, essential medical care, or self-protection; or 8. Imminent physical harm to others because of threats, attempts, or other acts the patient makes or commits ... A review of the complete policy revealed that the policy fails to recognize emergency behavioral medication administration (EBM) as a restraint. There was no information in the policy on how to assess a patient after they have received an EBM. An interview was conducted with staff #10 RN was conducted on 3/4/24 at 3:30 pm. Staff #10 stated that he did not know of any restraint logs and that when he must give medications IM for behavioral emergencies, they are not considered restraints if the patient is willing to take them on their own. Staff #10 stated that they do not have any mechanical restraints they just hold the patient, place them in seclusion, and administer medications per physician orders. Staff #10 was asked when an EBM is administered for a behavioral emergency what was the order or protocol for assessing the patient? How soon do you go back to check the patient after the administration, how often do you assess the patient, and for how long? Staff #10 stated there was no protocol other than the face-to-face within 1 hour. Staff #10 confirmed it could be 1 hour before anyone assessed a patient after an EBM administration. Psychotropic medications such as Geodon, Haldol, and Zyprexa can cause over-sedation. These drugs have no known antidote. According to https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8037562/#:~:text=Chemical%20restraint%20use%20can%20lead,12%2C13%2C14%5D. “Chemical restraint use can lead to decrease in functional and cognitive performance, falls and fractures, excess sedation, and respiratory depression [12,13,14]. Prescribing of antipsychotics has been linked to an increased risk of stroke and mortality [15,16].” A review of patient #20’s chart revealed there was a second restraint package in his chart for Seclusion and Restraint. The package revealed he was in a physical hold from 18:15 (6:15 pm) to 18:15 (6:15 pm) on 2/28/24. The nurse had documented on the first page “pt repeatedly kicking door to courtyard. Pt physically restrained to prevent self harm”. There was no documentation that the staff used seclusion as an option before administering a chemical restraint/ EBM. Pages 3,4 and 6 of the restraint package were left blank. A review of the nurse’s notes dated 2/28/24 revealed the nurses did not perform any physical assessments on the patient for 24 hours. The notes stated the patient refused assessments at 8:24 am. There was no other attempt to assess the patient. A review of the nurse’s note for 2/29/24 revealed there was no assessment performed on the patient for over 24 hours and no further attempts were documented. Patient #20 was discharged per parents request on 2/29/24. An interview was conducted with staff # 3 and staff # 2 on 3/5/24 in the afternoon. Staff #3 confirmed that the restraint log did not include chemical restraints /EBM. Staff #2 stated that she was not aware that the chemical restraints/EBM were to be monitored on the restraint log. Staff #2 was unable to describe to the surveyor the process for chart audits for restraints. Staff #2 stated that the nurses are supposed to check them and make sure they are complete. Staff #2 was unable to bring any monitoring tools used for restraints. Staff #2 confirmed there were no protocols that she was aware of to monitor the patients after the administration of an EBM. 40989 Patient #4 A review of patient #4’s medical record revealed the following: Patient #4 was a 17-year-old male admitted to the hospital on 4/14/2023 with a diagnosis of bipolar disorder most recently depression, anxiety disorder, and Auditory Processing Disorder (a condition that makes it hard to understand speech). He was placed in the Sunrise Unit on moderate suicide precautions (SP) and Q (every) 15-minute observations. A review of patient #4’s chart revealed a document titled, “Restraint and Seclusion Initiation of Intervention/Order.” Physician #24 gave a telephone order to RN Staff #27 on 4/20/2021 for a physical restraint and emergency medication. Rationale for intervention: Danger to self and others. Type of intervention utilized: Physical Restraint and Emergency Medication ordered by Physician #24 ... Medications: 50 mg (milligrams) of Thorazine (an antipsychotic medication) intramuscular (IM) for aggression. Registered Nurse (RN) Staff #28 documented the initiation of the physical restraint started at 5:47 PM and ended at 5:50 PM ...” A review of the medication administration record (MAR) revealed RN Staff #27 administered Thorazine 50 mg IM on 4/20/2021 at 5:51 PM. A review of the progress note dated 4/20/2021 at 5:51 PM by RN Staff #27 was as follows: “ ...This RN came onto the unit to hear patient yelling **** you to a Patient Care Assistant (PCA) and a nurse on the unit. Patient was escorted off the unit. This nurse followed RN and patient to seclusion. Doctor was present and ordered emergency medication. This RN got emergency medication and gave to patient. RN then went back to unit to make sure all other patients were ok ...” A review of the document titled; “Seclusion& Restraint Monitoring Activities” was documented by RN Staff #27. RN Staff #27 documented that Patient #4 was in a physical hold on the unit beginning at 5:35 PM, transported to the seclusion room at 5:50 PM, and remained in a physical hold in the seclusion room until 6:05 PM. Patient #4 was released from the restraint/seclusion at 6:15 PM. RN Staff #27 and RN Staff #28 were former employees and were unable to interview for clarification. A review of the Close Observation Sheet dated 4/20/2021 revealed Patient #4 was on a Q-15-minute observation. The Patient Care Assistant (PCA) documented the Q-15-minute observation checks as follows: “ ... 5:30 PM Patient #4 was in the Day Room not complying and being disrespectful; 5:45 PM Patient #4 was in the Seclusion Room agitated and tearful; 6:00 PM Patient #4 was in the Seclusion Room agitated and tearful and at 6:15 PM Patient #4 was in his bedroom calm ...” There was no physician order for the Seclusion (involuntary confinement in a room where a patient is physically prevented from leaving or gives the perception that threatens the patient with physical intervention if they attempt to leave the room). Staff #3 confirmed there was no order for patient #4 to be placed in seclusion. Vital signs were documented by RN Staff #27 from 5:35 PM to 6:15 PM. The vital sign documentation read, “Unable to perform due to safety risk” from 5:35 PM to 6:10 PM. Respiration count was documented as “fast” from 5:35 PM to 6:00 PM and “regular” from 6:05 PM to 6:15 PM. There was no respiration count documented by RN Staff #27 for the entirety of the restraint/seclusion. The surveyor was unable to determine who monitored Patient #4 during seclusion and after the administration of the emergency behavioral medication because the documentation by RN Staff #27 contradicted the progress note dated 4/20/2021 at 5:51 PM. RN Staff #27 documented on 4/20/2021 that she arrived on the unit at 5:51 PM, transported the patient to seclusion, administered the emergency medications, and returned to the unit. Also, RN Staff #27 documented she monitored the patient in seclusion from 5:35 PM until 6:15 PM. A review of the hospital policy titled, “Restraint and Seclusion” Policy Stat ID 15084525, with an origination date of 1/2012 and a revised date of 1/2024 was as follows: “ ...Purpose To provide guidelines for the use of seclusion and/or restraints at the Hospital and Clinics ... Definitions ... Seclusion Any involuntary confinement of a patient alone in a room or area where he/she is physically prevented from leaving. This includes situations where a staff physically prevents the patient from leaving or gives the perception that threatens the patient with physical intervention if he/she attempts to leave the room ... Procedure Who Does What ... Practitioners/Providers/Physicians A. Provides verbal and written order (sic) for the employment of seclusion/restraint. The order is documented on the Seclusion/Restraint. 1. Order/Progress Note form and includes: a. Reason/purpose for seclusion and restraint intervention. b. Type of restriction. c. Be time limited, not to exceed: 4 hours for adults 18 and older. d. Criteria for release/termination seclusion/restraint. e. Medications ordered, if applicable ... Physician/Qualified Trained RN Conducts an in-person, face-to-face assessment of patient in seclusion/restrain within one (1) hour of initiation and documents findings on the One Hour Face-to-Face Evaluation. The face-to-face evaluation is performed even in those situations where the person is released early (prior to one hour) ... Monitoring Activities ... Safety Committee Analyzes and aggregates seclusion/restraint data and reports to the Quality Committee. The data includes, but not limited to: Shift, the length of each episode, the date and time each episode was initiated, the day of the week each episode was initiated, the type of restrictive intervention used, whether injuries were sustained by the patient or staff, age of the patient, and gender of the patient ... The Performance Improvement process and treatment plan includes information from the patient and staff debriefings in order to reduce the use of seclusion and restraints. Procedures for Emergency Medications (Texas Only) Following the administration of the Emergency Medications, the RN must complete a 1-hour face to face evaluation of the patient to continue the surveillance of the immediate situation, evaluation of the patient’s reactions to the Emergency Medication, assessment of the medical and behavioral condition of the patient, and determining the need for additional interventions ...” During an interview on 3/05/2024 with Staff #3, it was confirmed that the DON was responsible for monitoring the chemical restraints and she had not received any data to date.”

“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: 47892 Based on observation, document review, and interview, Nursing failed to ensure a physical assessment was completed on 2 of 2 (Patient #13 and #24) patients reviewed. Findings: An observation was conducted on the Cedars Unit on 3/05/2024 after 9:00 AM. This surveyor observed RN Staff #4 passing medications and completing an assessment through a small window in the medication room. The medication room has a small window with an opening at the bottom so the nurse can pass medications through and talk with the patient. The 12-hour shift assessment was completed by asking the patient questions and documenting the patient’s answers on the hospital’s assessment sheet titled, “7:00 AM-7:00 PM Nursing Assessment”. A review of the document titled, “7:00 AM-7:00 PM Nursing Assessment” revealed it was a 2-page document. On page 2 of the document, it required a physical assessment for Pain, interventions attempted for pain, Respiratory, GI (Gastrointestinal), and COVID-19 Screen. On the Respiratory assessment, there are boxes to check for: “Normal, Wheezing, Congested, Sore throat, Labored, Cough, Short of breath, and If on O2(oxygen), list liter and O2 sat”. On the GI assessment, there are boxes to check for: “Normal, Constipation, Diarrhea, and Nausea”. RN Staff #4 was observed asking 2 of 2 (Patients #13 and #24) patients if they were experiencing any symptoms related to the Respiratory and GI systems. RN Staff #4 never used a stethoscope (a medical device to listen to sounds generated internally by the heart, lungs, and intestinal tract) to listen to Patient #13 and #24’s lungs or intestinal tract. RN Staff #4 failed to take vital signs (blood pressure, heart rate, respiratory rate, and oxygen level) during her assessment. There were no vital signs documented on the 7:00 AM to 7:00 PM assessment. RN Staff #4 confirmed the vital signs were taken by the Patient Care Assistant (PCA) and posted at the nurse’s station. RN Staff #4 did not take the vital sign document into the medication room while she completed her physical assessment to ensure that the patient’s vital signs were within normal range before giving any medications to 2 of 2 (Patients #13 and #24) patients observed. A physical assessment is described as an inspection, palpation (feeling with the fingers or hands), percussion (tapping body parts with fingers, hands, or a small instrument), and auscultation (listening to sounds from the heart, lungs, or other organs typically with a stethoscope). An interview was conducted on 3/5/2024 after 11:00 AM with RN Staff #4. RN Staff #4 was asked if the nursing staff always completed the 12-hour assessments through the medication window. RN Staff #4 stated “Yes”. RN Staff #4 was asked if they ever touched the patient during the 12-hour assessments or listened to the patient’s lungs or bowel sounds. RN Staff #4 stated, “Only if the patient complains of any symptoms”. RN Staff #4 was asked how they assess patients with known medical conditions. RN Staff #4 stated, “If the patient is complaining of any symptoms, they would do more to assess the patient”. RN Staff #4 again confirmed all shift assessments were completed during the administration of medications. This surveyor was unable to determine how and when a shift assessment was completed if the patient refused to take medications and refused to come to the medication window. A review of the facility policy titled, “Shift Nursing Assessment/Reassessment”, PolicyStatID 14314198 with a last revised date of 5/2018 and an expiration date of 9/2024 was as follows: “ ...Purpose To provide a concise record of physical and psychological interventions and assessments. Policy The Shift Nursing Assessment will be completed on all patients for each shift of the day. Procedure ... B. The RN will complete the required assessment each shift ....”. The policy failed to have clear guidance on what was required by the RN during the “required assessment”. RN Staff #4 confirmed the nursing assessments were completed through the medication window and there was not a physical assessment completed on patients unless the patient had a complaint or previous medical history.”

“Adequate Staffing CFR(s): There must be adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide the nursing care necessary under each patient’s active treatment program. This Standard is not met as evidenced by: 40989 Based on observation, document review, and interview the hospital failed to: a. ensure safe staffing levels by providing an adequate number of Registered Nurses (RN) and Patient Care Assistants (PCA) to meet the needs of the patients safely on 4 of 4 (Meadows, Cedars, Willows, and Sunrise) patient care units. b. have an approved staffing matrix/grid for 4 of 4 (Meadows, Cedars, Willows, and Sunrise) patient care units. c. have an approved process to determine patient acuity levels to assist the staffing coordinator/house supervisor on when to increase or decrease staff to ensure patient and staff safety on 4 of 4 (Meadows, Cedars, Willows, and Sunrise) patient care units. d. ensure all staff had adequate coverage during scheduled meal and break times on 4 of 4 (Meadows, Cedars, Willows, and Sunrise) patient care units. e. ensure adequate staffing was provided to ensure patient rights were not violated in 1 of 1 (Patient #14) patient’s medical records reviewed on 1 of 1 (Willows Unit) Patient care units. f. follow its own Staffing Plan to evaluate staffing needs based on patient acuity-established criteria and anticipated admission, transfers, and discharges in 4 of 4 (Meadows, Cedars, Willows, and Sunrise) patient care units. The deficient practices were identified under the following Condition of Participation, CFR 482.62: Special Staff Requirements, were determined to pose an Immediate Jeopardy (IJ) to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possible death. Findings: An observation tour was conducted on 3/04/2024 at 9:10 AM with Staff #1. Staff #1 confirmed the current patient census was 64. The hospital was divided into 4 units. The Willows Unit was an adolescent female unit with 12 patient beds. The current patient census was 7. The Cedars Unit was an adult unit with 12 patient beds. The current patient census was 11. The Willows Unit and the Cedars Unit shared a medication room. The Meadows unit was an adult unit with 24 patient beds. The current patient census was 23. The Sunrise Unit was an adolescent unit with 24 patient beds. The current patient census was 23. An interview was conducted with RN Staff #1 and RN Staff #2 on 3/05/2024 at 10:30 AM. RN Staff #2 was asked how she determined the staffing needs for each unit. She replied, “I look at the patient census and decide how many staff are needed for each unit.” RN Staff #2 was asked if the units were staffed based on patient acuity. The question went unanswered by Staff #1 and RN Staff #2. Staff #1 was asked to provide the patient acuity tool that was used to determine the number of staff needed for each unit to ensure quality care for patients and patient and staff safety. After multiple requests for an acuity tool, one was not presented for review. During an interview on 3/05/2024 after 9:00 AM, Staff #1 confirmed the facility did not have an acuity tool to assist in determining the nurse staffing needs to ensure patients were cared for appropriately and safely on 4 (Willows, Meadows, Cedars, and Sunrise) of 4 patient care units. RN Staff #2 was asked to provide a staffing matrix/grid to align with the facility policy titled, “Plan for the Provision of Nursing Care in Psychiatric Specialty Areas”. RN Staff #2 provided a grid and stated, “This is what I have been using since the second week of January.” RN Staff #2 was asked if the staffing matrix/grid had been approved by the Governing Body. She confirmed the staffing matrix/grid had not been approved by the Medical Staff, Governing Body, or the Nursing Staffing Committee. Further review of the document provided by RN Staff #2 revealed the staffing matrix/grid belonged to another hospital and had not been approved by the hospital’s Governing Body. A review of the current unapproved staffing matrix/grid being used by RN Staff #2 to staff 4 of 4 (Meadows, Cedars, Willows, and Sunrise) patient care units was divided into two shifts, 7:00 AM-7:00 PM and 7:00 PM-7:00 AM. On 3/05/2024, RN Staff #2 confirmed that the matrix/grid being used required only 1 RN and two PCAs for 12 patients and did not take into consideration the patient’s age or acuity of the patients. An interview was conducted with Staff #20 on 3/05/2024 at 11:30 AM. Staff #20 was asked how the nurse staffing was scheduled. She stated, “Well, I let them know who is available and put them on the schedule. I usually get this done a couple of weeks in advance. Then the house supervisors decide what unit they will work on. If they don’t need all the staff scheduled due to discharges or if they need more staff, then the house supervisors or the Director of Nurses (DON) are responsible for that. I will assist in scheduling PRN (as needed) employees if needed.” This surveyor was informed of three separate incidents that occurred in the Willows Unit. 1. Patient #14 was forced to sleep on the floor of the dayroom for 4 nights because she was on a line-of-sight observation with only 1 PCA scheduled. The leadership failed to increase the nurse staffing from 3/01/2024 to 3/04/2024 to safely monitor patients as ordered by the physician and not restrict Patient #14’s patient rights. 2. Physician #24 was attacked by a patient in the unlocked nurse’s station when the RN left her alone on the unit with a patient on 2/03/2024. 3. Patient #16 restrained the RN on the unit to allow two patients to have a physical altercation on 2/03/2024. Further review was as follows: 1. A review of Patient #14’s medical record revealed she was a 14-year-old female admitted on 2/26/2024 with a diagnosis of Disruptive mood dysregulation disorder and Major depressive disorder with psychotic features. She was experiencing visual hallucinations. She was placed on a line of sight (LOS) observation, sexually acting out (SAO) precautions (perpetrator), suicide precautions (SP), and required to be placed in a blocked room (could not have a roommate) for her safety and the safety of other patients. A Review of the Close Observation documents dated 3/1/2024-3/04/2024 revealed Patient #14 was sleeping on the dayroom floor for 4 (3/1/2024-3/04/2024) of 4 nights reviewed. An interview was conducted with PCA Staff #15 on 3/04/2024 at 3:00 PM. PCA Staff #15 was asked why Patient #14 slept on the floor in the day room. PCA Staff #15 stated, “Her mattress was brought to the dayroom, and she was sleeping on the floor so that we could monitor her. She was on a line-of-sight observation and there was not enough staff to monitor her while she was in her room. She’s been doing that since Friday”. RN Staff #14 confirmed Patient #14 had slept in the dayroom because there was not enough staff to monitor her at the level of observation ordered by the physician. An interview was conducted with Patient #14 on 3/04/2024 after 12:00 PM. Patient #14 was asked if she was sleeping in her room during the night. She stated, “No, I have to sleep out here so they can watch me”. A review of the Night shift (7:00 PM to 7:00 AM) staffing schedules and assignment sheets dated 3/1/2024 through 3/04/2023 for the Willows unit was as follows: “ ...3/01/2024-Patient Census was 9. 1 RN and 1 PCA were scheduled. Patient #14 was on a LOS observation and the remaining 8 patients were on Q (every) 15-minute observations. There were 8 patients on moderate suicide precautions (SP), 1 patient on low SP, 5 patients on sexually acting out (SAO) precautions (1 perpetrator and 2 victims), 2 patients on elopement precautions (EP), 3 patients on aggression precautions, 1 patient on fall precautions, and 1 patient on seizure precautions. 3/02/2024- Patient Census was 8. 1 RN and 1 PCA were scheduled. Patient #14 was on a LOS observation and the remaining 7 patients’ observation levels were not documented. There were 8 patients on moderate SP, 4 patients on SAO precautions (1 perpetrator and 1 victim), 1 patient on EP, 2 patients on aggression precautions, 1 patient on fall precautions, and 1 patient on seizure precautions. 3/03/2024- Patient Census was 7. 1 RN and 1 PCA were scheduled. Patient #14 was on a LOS observation and the remaining 6 patients’ observation levels were not documented. There were 4 patients on moderate SP, 3 patients on low SP, 3 patients on SAO precautions (1 perpetrator), and 4 patients on aggression precautions. 3/04/2024- Patient Census was 7. 1 RN and 1 PCA were scheduled. Patient #14 was on a LOS observation and the remaining 6 patients’ observation levels were not documented. There were 2 patients on moderate SP, 5 patients on low SP, 3 patients on SAO precautions (1 perpetrator), and 4 patients on aggression precautions ...” During an interview with Physician #17 on 3/05/2024 at 10:45 AM it was confirmed that Patient #14 was sleeping in the day room on a mattress because there was not enough staff to monitor her on a line of sight if she slept in her room. Physician #17 stated, “The patient had to remain on LOS observations for her safety and the safety of the other patients”. The nurse staffing for 3/1/2024 through 3/4/2024 on the Willows Unit was inadequate and violated Patient #14’s rights by forcing her to sleep in a day room on a mattress because the facility failed to increase the staffing to allow her to have a private place to sleep and continue to be monitored at a safe level as ordered by Physician #17. 2. A review of the incident report dated 2/03/2024 revealed Patient #19 was left alone on the Willows Unit while Physician #24 was working in the nurse’s station. Patient #19 walked into an unlocked nurse’s station and attacked Physician #24. Patient #19 placed her hands around Physician #24’s neck and began to strangle her. A review of the progress note dated 2/03/2024 at 11:49 AM by RN Staff #24 was as follows: “ ...Pt met with psychiatrist and was placed on LOS due to reporting HI (Homicidal ideation) thoughts of hurting people and unable to plan for safety at this time. Physician #24 gave verbal orders for new medications to be given. Pt. stayed back from lunch while peers went to the cafeteria. Pt sitting in dayroom, appears anxious. Pt declined to utilize any coping skills/activities offered by this RN such as drawing, coloring, journaling. Pt declined to eat when lunch tray was brought to unit. Physician #24 was sitting in nurses station working. This RN briefly stepped into med room to ask Cedars RN to verify orders, while in the med room, heard Physician #24 calling for help. Found Pt behind nurses station with arms around Physician #24’s neck attempting to choke/strangle her. At 11:46 hands on patient to make her release Physician #24, restrained by this RN and code 100 called. Pt struggling against restraint hold, additional staff came to unit and assisted with restraint and transfer to seclusion room ...11:54 AM Zyprexa (antipsychotic medication) IM (intramuscular) given for agitation ...At 12:15 PM pt sitting quietly, able to walk back to unit. Pt placed on 1:1 for safety ...” A review of the Staff assignment sheet dated 2/03/2024 for the 7:00 AM-7:00 PM shift revealed the patient census was 12. Two patients were on a LOS observation. There were no precautions documented on the staffing assignment sheet for 12 of 12 patients. There were no observation levels documented on the staffing assignment sheet for 10 of 12 patients on the unit. There was no documented increase in the nurse staffing on the Willows Unit after Patient #19 was increased to a 1:1 observation. This left 1 PCA to monitor 12 patients. One patient was on a LOS observation and one patient was on a 1:1 observation. There was no documentation that patients were monitored per physician orders for safety. This placed all patients and staff at risk of serious harm. An interview was conducted with RN Staff #21 on 3/05/2024 after 10:00 AM. RN Staff #21 was asked if the Willows Unit increased its staffing after Patient #19 was placed on a 1:1 after attacking Physician #24. RN Staff #21 stated, “I’m sure someone went over to the unit. A PCA was probably pulled from another unit to go over and help. They did have someone assigned to the patient on the night shift but I can’t tell about the day shift because there is nothing written on the assignment sheet. We can ask for all the help we need but never get it. The staffing is horrible here and it is very unsafe. The RNs and the PCAs do the best they can but it is just not safe.”. 3. A review of the incident report dated 2/06/2024 revealed Patient #16 placed RN Staff #22 in a restraint to allow two patients to have a physical altercation on the Willows Unit. A review of the medical record for Patient #16 revealed the patient was on moderate suicide precautions, aggression precautions, sexually acting out precautions, fall precautions, and seizure precautions. She was also experiencing auditory hallucinations. A review of the progress note dated 2/06/2024 at 2100 (9:00 PM) documented by RN Staff #22 was as follows; “ ...A patient was attempting to attack another patient on the Willows Unit at approximately 1820 (6:20 PM). This RN was standing between the two patients in an attempt to stop the attack when Patient #16 put this nurse into a restraint by placing the front of her body directly against the back of this RN’s body and tightly wrapping her arms around this RNs body to significantly limit this RNs movement. It is noted that Patient #14 is double the weight of this RN. It is further noted that restraint of this RN resulted in another patient being attacked ...” A review of the Staffing assignment sheets dated 2/06/2024 for 7:00 AM-7:00 PM and 7:00 PM-7:00 AM revealed the following: “ ...7:00 AM-7:00 PM. The patient census was 10. 1 RN and 2 PCAs were scheduled. At the beginning of the shift, there was 1 patient on a 1:1 observation and 2 patients on LOS observation, 6 patients were on aggression precautions, 10 patients were on Suicide Precautions, 4 patients on SAO precautions, 1 patient on seizure precautions, and 2 patients on fall precautions. 7:00 PM-7:00 AM The patient census was 10. 1 RN and 1 PCA were scheduled. There were 2 patients on a LOS observation that were assigned to 2 different rooms, 5 patients were on aggression precautions, 10 patients were on SP, 3 patients were on SAO precautions, 1 patient was on seizure precautions, and 2 patients were on fall precautions ...” One PCA would not be able to monitor two patients on a LOS that were assigned to different rooms. The RN would not be able to monitor a patient on LOS while working as the only RN on the unit and completing other assigned duties such as medication passes, physician orders, and shift assessments. A review of the progress note dated 2/06/2024 at 8:55 PM by RN Staff #23 was as follows: “ ...While doing rounds PCA noted patient on the floor on the right side of her bed with a pair of underwear around her neck attempting to strangle herself ...” Patient #14 was on LOS observations and was able to attempt self-strangulation in her room because there was not enough staff to ensure her safety. There were two patients on a LOS and only one PCA available. The RN documented that while the PCA was doing rounds the patient was noted on the floor on the right side of her bed with a pair of underwear around her neck attempting to strangle herself. RN Staff #21 confirmed Patient #16 should have always been in a staff member’s LOS as ordered by the physician and she was not. The inadequate staffing and monitoring by the hospital allowed Patient #16 to be alone in her room and attempt self-strangulation. Confidential interviews were conducted on 3/04/2024 and 3/05/2024 between 9:00 AM and 5:00 PM. Staff members were asked if the nurse staffing levels were safe. Multiple staff members (RN #4, #10, #14, #18, #21, #22, PCA Staff #11, #12, #15, and #19,) confirmed the nurse staffing levels were inadequate and difficult to work in. The staff stated they did not feel safe and could not provide the quality of care that patients deserved. RN Staff #4, #10, #14, #18, #21, #22, PCA Staff #11, #12, #15, and #19 were asked if they were relieved by another staff member for their scheduled lunch breaks. RN Staff #4, #14, #18, and PCA Staff #15 confirmed if they were working on a 12-bed unit they just ate at the desk or in the med room. The RNs and PCAs stated they used to have a float RN and a float PCA but that was taken away from them recently. RN Staff #4, #14, #18, and PCA Staff #15 confirmed if there were two nurses on the unit, they were expected to relieve each other for lunch and that left only 1 RN responsible for up to 24 patients. RN Staff #4, #10, #14, #18, #21, #22, PCA Staff #11, #12, #15, and #19 were asked if the hospital automatically deducted daily lunch breaks. Staff stated that at the end of the day when they clocked out, the time clock would ask if they had taken a lunch break and you had to answer yes or no. RN Staff #4, #10, #14, #18, #21, #22, PCA Staff #11, #12, #15, and #19 staff said it’s best that you say you did, or you have to fill out a missed lunch sheet and get “ridiculed” for it. RN Staff #4, #21, #22, PCA Staff #15, and #19 confirmed they could fill out a missed lunch form but they get asked why they didn’t take a lunch and if we tell them there was no one to relieve us, the Director of Nurses (DON) tells us we are stealing from the company and just being lazy. The RN staff was asked if the house supervisor could relieve them for lunch. RN Staff#18 stated, “Sometimes she would but she was also doing all the treatment team meetings, and if someone called in or didn’t show up, she would have to work on the floor”. RN Staff #4, #14, #21 and PCA Staff #15, and #19 confirmed that if they informed the Chief Executive Officer (CEO) or DON that there was not enough staff to relieve staff for scheduled lunch breaks, the CEO just said that the hospital had a nursing budget and they had to stay within that budget. That’s all we hear is budget, budget, budget regardless of what is needed on the patient units. RN Staff #4, #14, #21, PCA Staff #15, and #19 informed this surveyor they had to leave the unit for a restroom break because there was no staff restroom on any patient care unit in the hospital. RN Staff #4 stated, “We just called one of the nurses on another unit and let them know we are going to the restroom”. RN Staff #4 confirmed that on the units with 12 patients that would leave only one PCA to monitor all 12 patients. RN Staff #4, #14, and #18 were asked what duties the RN was required to do on a scheduled shift. The nursing staff confirmed they were responsible for all medication passes, discharges, admissions, shift assessments, taking physician orders, assisting the physician when needed during patient visits on the unit, and playing the role of the unit secretary because there was not one assigned to each unit. A review of the facility policy titled, “Plan for the Provision of Nursing Care in Psychiatric Specialty Areas”, PolicyStat ID 13812300, revised 6/2023 was as follows: “ ...Policy: The Hospital will provide outstanding psychiatric nursing care in response to individual needs of patients who have a mental disorder and/or substance use disorder as outlined in the most current DSM. In support of this mission, the nursing department is dedicated to providing quality person-centered care to all patients. Licensed nurses at the Hospital function as interdependent members of the multidisciplinary treatment team ... Staffing Plan Guidelines: A. There shall be a sufficient number of qualified and competent Registered Nurses and PCAs on each unit to provide patients with nursing services that require the judgment and specialized skills of the competent nursing staff. Nursing staffing shall also be sufficient to promptly recognize untoward changes in a patient’s condition and to intervene appropriately utilizing nursing, medical, or Hospital staff. In striving to ensure optimal, achievable, quality nursing care and a safe patient environment, nursing staffing and patient assignment shall be based upon identified minimum staffing requirements by the unit and the following: * 1. A Registered Nurse plans, delegates, supervises, and evaluates the nursing care of each patient on a 24-hour basis. Licensed nurses may provide nursing care within the scope of the State Nurse Practice Act. This may include gathering data, such as vital signs, giving medications, and/or evaluating treatment effects. * 2. A Registered Nurse makes a patient assessment before delegating appropriate aspects of nursing care to other competent members of the healthcare team and includes considerations that minimize the risk of the transfer of infections and accidental contamination; the patient care assignment is commensurate with the qualifications and competence of each nursing staff member, the identified needs of the patient, and the prescribed medical plan. * 3. A PCA can assist the RN with delegated tasks such as obtaining vital signs, assisting with personal care and hygiene of the patient, assisting with meals, providing patient supervision and monitoring the patient on their individual prescribed level of observation, can conduct educational groups, provide supervision of visitation, ln some cases when competent may assist in obtaining phlebotomy and lab specimens, assist with checking in patient belongings, and ensuring the unit is safe and free from contraband. (This list may not be all inclusive). * 4. Responsibility for nursing care related duties is retained by the Hospital Nursing Department when nursing students or nursing personnel from outside agencies are providing patient care within a patient care unit. * 5. Adequate staffing for nursing personnel to participate in educational programs, performance improvement activities, and other activities that foster professionalism and innovation in nursing is provided... B. The Nursing Department shall define, implement, and maintain a system for determining patient requirements for nursing care on the basis of demonstrated patient needs, appropriate nursing intervention, and priority for care. This acuity staffing system shall be based upon objective assessment tools that qualify the number of nursing staffing members needed to fulfill patient needs on each unit. The Assessment Coordinator utilizes input from the Chief Executive Officer, the unit charge nurses, or designee prior to admission placement decisions so that patient care needs can be coordinated with available resources. C. Individualized, goal-directed nursing care is provided to all patients through use of the nursing process. D. The Nursing Department uses findings from performance improvement activities and feedback from clients to assist in the evaluation of patient care provided. Findings shall be used to compare actual client outcomes with defined standards of care and practice. If staffing is adequate, both in terms of the number and qualifications of staff, correlation between actual health outcomes and standards should be positive. Procedure: A. Master staffing plans for the units are on file in the facility. The unit has a master/core staffing grid that identifies the size of the unit, skills mix utilized on the unit, and minimum number of staff that will be assigned when any patients are present. Plans include permanently assigned staff and per diem employees. B. Staffing is based upon patient census, acuity, and relevant treatment needs. C. Staffing includes a mixture of RNs, LPNs and PCAs D. Staffing schedules are planned by the Nurse Manager or their designee for a two week period that coincides with each pay period. E. Based on census and patient acuity, the needs of each unit are evaluated collaboratively on a shift or partial shift basis between the House Supervisor RN, the nurse manager, and DON to provide optimal patient care that is fiscally sound. Staffing adjustments, which may include additional staff, cancellation of staff, or reassignment of staff, are made by the House Supervisor, Nurse Manager or his/her designee. Schedules are updated as necessary. 12-hour staffing schedules are posted on each unit. Patients will be divided into units based on specific treatment needs in order to deliver the most appropriate care. Master copies of all schedules, daily staffing sheets and acuity reports are kept digitally for a period of three (3) years. F. Variance between projected needs and actual staffing are described, acknowledged, and justified according to census and acuity. G. It is necessary, at times, to reassign nursing personnel, on a daily or temporary basis, in order to meet patient care needs. NO NURSING STAFF WILL BE ASSIGNED SPECIFIC TASKS FOR WHICH HE/SHE HAS NOT DEMONSTRATED COMPETENCY. H. All staff are to contact the Scheduler or House Supervisor during the day or the charge nurse/house supervisor after hours when unable to work an assigned shift. All calls are to be made (3) hours prior to start of the shift. In the event that a patient care unit has few or no patients assigned to that unit, nursing staff may be canceled or reassigned. When staff cancellation is necessary, the nursing staff is notified (2) hours before the beginning of the shift for which they were scheduled to work .... Sample Unit Staffing Description: Skills Mix: Registered Nurses, Licensed Practical Nurses and Patient Care Associates provide nursing care. Core Staffing: Staff is adjusted according to patient census, safety concerns, and acuity levels. Staffing grids will be adjusted based on specific state regulatory requirements ...” A review of the staffing assignment sheets was conducted with RN Staff #2, Staff #20, and RN Staff #21 on 3/04/2024 and 3/05/2024 for 4 (Willows, Meadows, Cedars, and Sunrise) of 4 patient care units. This surveyor was unable to determine if 4 (Willows, Meadows, Cedars, and Sunrise) of 4 patient care units were staffed adequately and safely because the facility failed to have an approved staffing matrix/grid or an acuity tool to assist in determining the minimum number of staff required to safely provide the care ordered by the physicians. The nurse staffing assignment sheets did not consistently address patient room assignments, patient acuity, such as special monitoring, special visitations, observation levels, or the additional staff needed for hall monitoring on the adolescent unit. The potential for additional staffing shortages existed when these situations were factored in but could not be determined based on the information provided on the nurse staffing sheets. An interview was conducted with RN Staff #2 on 3/05/2024 at 9:20 AM. RN Staff #2 was asked if she felt like the nurse staffing was adequate and safe for the patients and staff. RN Staff #2 replied, “If you are only here for complaints why are you looking at staffing”. Again, RN Staff # 2 was asked if the nurse staffing was adequate and safe for the patients and the staff. RN Staff #2 did not answer the question and exited the room. On 3/05/2024 after 2:00 PM, CEO Staff #1 and DON, RN Staff #2 confirmed the facility did not use Licensed Vocational Nurses (LVN). Also, the CEO confirmed the facility did not have an approved staffing matrix/grid or acuity tool to assist in determining the minimum numbers of RNs and PCAs to ensure that all patients received quality care and all staff and patients were safe on 4 (Meadows, Cedars, Willows, and Sunrise) of 4 patient care units.”