Woodland Springs

“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: 38387 Based on review of the facility policy, patient medical record, and confirmed in interview, the facility failed to uphold patient rights to make informed decision regarding his care for one of eight patients reviewed (Patient #B). Findings included: Review of the facility policy Discharge Against Medical Advice (PolicySTAT ID 201972428, origination 11/2020), it stated “the voluntary patient’s right to leave the hospital AMA is addressed in an appropriate and timely manner...If a patient requests to discharge from the Hospital, the therapist and/or nurse will try to understand why the patient is making the request and advise the patient of the AMA procedure, possible outcomes of the discharge, and the effect it can have on their recovery. A member of the treatment team (RN, Therapist or Provider) will assess the patient’s legal, physical, and mental health status, including the potential for risk of harm to self or others. The patient is given the Request for Discharge AMA form to complete and sign. A member of the treatment team (RN, Therapist or Provider) will notify the patient’s Attending Physician. If the Attending Physician declines AMA discharge: 1. The rationale for not discharging will be explained to the patient, and must include a patient’s imminent risk of harm to self or others due to a mental disorder, or that the patient has a persistent, acute, or grave mental disability....Procedures appropriate to state regulations will be followed... If the evaluating agency does not pursue an involuntary stay, and allows the AMA discharge, documentation must include that the patient is requesting discharge and does not meet criteria to be held against their will in pursuit of a hearing to order an involuntary stay.’ It is of the utmost importance for nursing and medical staff to document that a patient is requesting discharge and “does not meet criteria to be held against their will” in cases of AMA discharge. A Comprehensive Psychiatric Evaluation (CPE) must be completed prior to the patient leaving the Hospital.” Review of Patient #B medical record revealed he admitted voluntarily on 01/20/2026 for a suicide attempt (overdose). Records indicated he requested to leave AMA on 1/21/26 9:45 AM indicating “my family and I decided on more private setting and 1:1 therapy” Review of the nursing notes and/or progress notes revealed no documentation about patient’s request for AMA and any notes that require the hold for an additional 24 hours. Further review of Patient #B medical record revealed an order for 24 hour hold 1/21/26 12:45 PM. Review of the AMA documentation indicated patient rescinded his AMA request on 1/22/26 11:31 AM, 25 hours and 46 minutes after his request. In an interview with Staff #2 on 5/29/26 at 1:30 PM in the conference room confirmed the above findings.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 38387 Based on review of facility policy, EMTALA logs, patient record review, and confirmed in interviews, the facility failed to ensure a patient presenting to the hospital’s emergency department with complaints of suicidal and homicidal ideation received an appropriate medical screening examination prior to discharge in 1 (Patient # A) of 36 patient medical records reviewed. Findings include: Review of the facility policy Emergency Medical Treatment and Active Labor Act (EMTALA) (policy Stat ID 16438131, effective 12/2024), it stated “if an EMC exists and it is within the specific [facility] capacity and capability to treat the patient, the [facility] will provide stabilizing medical (including psychiatric) treatment, including inpatient hospitalization, if appropriate. The person’s stabilized condition should be documented in the medical records. A person is deemed stabilized for a psychiatric or substance use condition if the person is not in danger of harming themselves or others, they are protected from harming themselves or others, or their condition no longer presents a significant medical risk of material deterioration. If the specific [facility] does not have the capacity or capability to treat the patient’s EMC, or the patient requests transfers, the hospital will stabilize the patient’s medical condition within its capacity and capability and appropriately transfer the patient to another facility for further appropriate care. Review of the facility policy Safety Assessment (policy Stat 17392565, effective 01/2025) it stated “To provide screening of all potential patients upon entering the facility for: reason for visit, recent thoughts of self-harm or harming others, safety, vital signs baseline, special equipment use, underlining medical conditions that may need acute medical attention, and blood sugar monitoring if insulin dependent. Procedures o Upon arrival, the client will be asked to complete the Safety Assessment Form. o After completion of the Safety Assessment Form, the Vital Signs will be completed and include a Breathalyzer and Blood Glucose level if the patient is an insulin dependent diabetic... If the client answers “Yes” to any of the screening questions, the Receptionist will immediately notify the Assessment Specialist who will review the form and determine order of screening if multiple clients are present at the same time. If the client selects “I feel concerned, unsafe” to the level of safety question, the Receptionist will immediately notify the Assessment Specialist who will review the form and determine order of screening if multiple clients are present at the same time. Once screening is complete, if the client is determined to meet criteria for services, the Safety Assessment Form becomes a permanent part of the Medical Record. If the client is determined not to meet criteria for treatment, The Safety Assessment Form is scanned into a shared drive to record the screening session.” Review of the facility policy Screening Assessment and/or Level of Care/Psychosocial Assessment (PolicyStat 16376835, effective 12/2024) it stated “The Screening Assessment will be used for all assessments and should be filled out in its entirety. No section of the assessment should be left blank without explanation... Every patient must have a Screening assessment. If the patient doesn’t meet criteria for Inpatient, PHP, or IOP then the Screening assessment is staffed with a provider, signed and outpatient resources provided...The Screening and Level of Care Assessments will be conducted by the qualified medical personnel (QMP) in the Assessment Department...The assessment is completed on every patient who comes to the facility seeking services.” Review of the EMTALA logs revealed Patient #A arrived to the facility lobby on 12/11/2024 at 07:25 PM and vitals were taken at 07:30 PM with a disposition of ‘referred out’ with comments “referred out...cannot complete ADLs.” No time was indicated for assessment start or end time. A review of Patient # A’s medical records revealed: Patient # A (20-year-old male with bipolar I, autism, IDD, ADHD) arrived at the facility on 12/11/2024 at 07:25 PM with complaints of suicidal and homicidal ideation. Patient arrived via private vehicle and was accompanied by his mother (legal guardian). The patient’s mother documented the following safety assessment form on 12/11/2024 at 07:40 PM: “Are you having current thoughts to harm yourself? Yes Are you having current thoughts to harm others? Yes. Have you attempted to harm yourself within the last 24 hours? Yes Please indicate below which best applies to your level of safety at this time: I feel concerned, unsafe” No vital signs were assessed per the facility policy. Further review of the above medical record showed Patient #A was assessed only by Staff #7, a qualified medical professional with a master’s license in social work. There was no documentation that Staff #7 consulted a psychiatrist who was on call and/or the telemedicine services of other providers available to the facility 24/7. Review of Patient #A’s Personalized Treatment Recommendation revealed Staff #7 made recommendations for patient to be referred to [Facility B] and [Facility C] for “proper services for patient’s needs. If crisis occurs, please call 988, 911, or take to nearest ER.” Recommendation was signed and dated on 12/11/2024 at 11:24 PM, 3 hours 59 minutes after patient entered the facility. In an interview with Staff #5 on 02/28/2025 at 03:55 pm via Zoom she stated that the QMP (qualified medical professional) would consult with provider when doing assessments even if patient met exclusionary criteria such as autism or anyone who is unable to complete ADLs. The intake staff would then provide a list of resources who are able to accept the patient and the facility assessors would come to lobby and screen for safety. Review of all records available revealed no documentation the patient was assessed for a possible EMC nor were the family offered a transfer to another facility who had services available for the patient. There was no documentation the patient or family’s refusal to transfer to another facility for further evaluation and treatment. No documentation that the patient EMC was stabilized prior to discharge home. Surveyor requested documentation of the assessment and transfer for Patient #A on 02/27/2025 and again on 2/28/2025. None was provided by the end of the survey on 02/28/2025. key: ADL - activities of daily living EMC - emergency medical condition”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 38387 Based on video review, review of facility incident reports and patient record review, and confirmed in interview, the facility failed to promote each patient’s rights when the facility failed to: A. ensure staff followed provider’s order for patient monitoring for one of three patients reviewed (Patient #A) refer to A0144-C B. ensure each patient had the right to be free from all forms of abuse or harassment as the facility did not follow their policy related to the investigation of actual events of sexual allegations; placing all patients at risk of delayed investigations. refer to A0145 The deficient practices were identified under the following Condition of Participation §482.13 Patient’s Rights, and 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. Review of records and updated policy confirmed IJ abated on 02/20/2025 at 10:10 AM.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 35028 Based on observation, interview, and record review, the facility failed to provide care in a safe setting for 2 of 5 patients (Patient A, Patient B). This was evidenced by the facility’s failure to ensure that: a. 1 of 3 patients (Patient B), a 15-year-old adolescent with an emergency medical condition, was transferred as quickly as possible to a medical facility for treatment of nonstop nausea, vomiting, and severe abdominal pain following a Tylenol overdose. Additionally, the facility failed to ensure that an accurate On-Call Schedule that outlined medical coverage was available to the nurses. b. 2 of 4 staff members, Staff #3 (Intake Assessor) and Staff #9 (Unit RN on the Adolescent Unit), were able to describe the side effects of Tylenol overdose. c. 1 of 3 patients (Patient A) were monitored per provider’s order for patient monitoring Findings were: a. Transfer of Patient B. Record review of policy 16488078, “Transfer to Another Facility (Texas Only),” last reviewed by Staff #6 (VP of Nursing) on 09/2024, showed: Transfer of Patients Who Have Emergency Medical Conditions. A. If a patient at the Hospital has an emergency medical condition that has not been stabilized ... because the Hospital does not have the appropriate equipment or personnel to correct the underlying process ..., evaluation and treatment shall be performed, and transfer shall be carried out as quickly as possible. Record review of policy 17374043, “On-Call Policy,” last reviewed by Staff #6 (VP of Nursing) on 01/2025, showed: Purpose ... To establish a process of notifying the ... Physician on Call ... Each Hospital will create a Physician On-Call Schedule. A physician will be available for consultation 24 hours per day ... to determine if presenting patients have an emergency medical condition (EMC) ... that exceeds the facility’s capacity to treat ... will be transferred via safe transport to a facility that can provide definitive treat for their EMC. Record review of the Consultation/Management and Medical Clearance for Patient B, dated 01/08/2025 at 6:48 PM by Staff #14 (DO) showed: MOT. Voluntary. Blood Pressure 115/68, Pulse 70, Respirations 16, Temperature 98.2. Recent overdose with Tylenol 20 tablets at 3:00 AM. Patient may be accepted based on clinical review. Medical clearance - Yes Record review of the Physician’s MOT Orders and Preliminary Plan of Care for Patient B, dated 01/08/2025 at 6:48 PM by Staff #14 (DO) showed: Medical consult for physical exam within 24 hours of admission. Psychiatric consult for complete admission psychiatric exam within 24 hours of admission. Record review of the Screening Assessment for Patient B, dated 01/08/2025 at 8:19 PM by Staff #3 (Intake Assessor), showed an “impulsive” suicide attempt “last night” with Tylenol and a previous suicide attempt in 2020. Record review of Nursing Admission Assessment for Patient B, dated 01/08/2025 at 9:50 PM by Staff #17 (RN-adolescent unit) showed: Pain Assessment with pain level at 7 (scale of 0-10). Constant. Abdomen. Cramping. “It’s nonstop.” “Vomiting due to OD on Tylenol.” Pain at its best = 4; at worst = 9. Nausea/vomiting. Record review of the Inpatient Therapy Note for Patient B dated 01/09/2025 at 12:32 PM by Staff #15 showed: Patient nauseous. Record review of the Inpatient Comprehensive Psychiatric Evaluation for Patient B, conducted on 01/09/2025 at 12:59 PM by Staff #8 [MD-attending], showed a 15-year-old adolescent female admitted per MOT for treatment of a Tylenol overdose. She complained of abdominal pain and nausea. She was placed on suicide precautions and line of sight observations. Diagnoses: Major depressive disorder, recurrent, severe, without psychotic features and Cannabis use disorder, mild. Problems: Chronic illness with SEVERE exacerbation, progression, or side effects of treatment. Risk: Drug therapy requiring intensive monitoring for toxicity. Record review of Medication Administration Record for Patient B showed Zofran 4mg given as a PRN by Staff 16 (RN) on 01/09/2025 at 2:34 PM. Record review of the January 2025 On-Call Schedule showed the following medical coverage: 01/08/2025, 7p-7a Staff #10 (MD) 01/09/2025, 7a-7p Staff #11 (NP) 01/09/2025. 7p-7a Staff #12 (DO) Record review of the Nursing Shift Progress Note for Patient B, dated 01/09/2025 at 3:25 PM by Staff #9 (RN - adolescent unit), showed: Patient was admitted last night after being medically cleared after a Tylenol overdose. It was reported that patient was having nauseated [sic], vomiting, and right lower abdominal pain that comes and goes. Night shift reported that they called the on-call provider, and the provider did not answer. Throughout the day, the patient continued to vomit, and have nausea and the right lower abdominal pain. Day shift nurses continued to try and call the listed on-call provider. It was then discovered that the scheduled on-call provider (Staff #11, NP) was being covered for by Staff #12, DO. Staff #12 was then notified about the situation. Patient received Zofran ordered by Staff #8 (MD) which was somewhat helpful. Patient reported increased right lower abdominal pain radiating to her back. Notified Staff #12 of the worsening of the situation. Staff #12 ordered for patient to be transferred out for medical clearance. Notified nursing supervisor Staff #13, Staff 8 (MD-attending), and [patient’s] mother. Vital Signs - Blood pressure 110/55, Heart rate 101 [Note: heart rate increased from 70 on admission to 101], Respirations 20, Temperature 100.2 [Temperature was 98.2 on admission], SpO2 98% room air ... Ambulance arrived at 5:15 PM. In an interview with Staff #9 (RN) on 02/19/2025 at 1:54 PM, she stated, after reviewing her documentation in the Nursing Shift Progress Note for Patient B dated 01/09/2025 at 3:25 PM, the following. “ She did not know how many times the night shift had attempted to call the on-call provider and not get an answer. “ She did not know when the calls were made. “ She did not know if anyone tried to reach the Administrator on Call. “ She could not remember the times that the day shift nurses tried to call the on-call provider. “ She did not know when the patient reported increased right lower abdominal pain radiating to her back. “ She should have provided the time frames within her narrative note for clarification and accuracy. Record review of the Nursing Shift Progress Note for 7pm-7 am on 01/08/2025 (beginning 7 PM on 01/08/2025 and ending at 7 AM 01/09/2025) did not document any phone calls to the on-call provider or the Administrator on-call. Record review of Physician Orders for Patient B ordered by Staff #12 (DO) on 1/9/2025 at 3:45 PM showed: Medical transfer to emergency department/hospital. Pain, nausea/vomiting (PER PARENTAL REQUEST) b. Staff’s knowledge of Tylenol overdose. Record review of “Acetaminophen Overdose” from the National Library of Medicine - MedlinePlus, updated 01/02/2023, showed: Acetaminophen (most common brand name Tylenol) is a pain medicine. Acetaminophen overdose occurs when someone takes more than the recommended amount of this medicine. Acetaminophen overdose is one of the most common poisonings. People often think that this medicine is very safe. However, it can be deadly if taken in large doses ... Taking ... 7,000 mg or more, can lead to a severe overdose problem ... Symptoms may include: Abdominal pain, upset stomach, appetite loss, coma, seizures, diarrhea, irritability, jaundice (yellow skin and whites of the eyes), nausea/vomiting, and sweating. https://medlineplus.gov/ency/article/002598.htm Record review of the “Screening Assessment” for Patient B dated 01/08/2025 at 8:19 PM by Staff #3, an Intake Assessor, showed: Suicide attempt by Tylenol “last night.” The patient denied pain. Neither the amount of Tylenol taken, nor the time of the overdose were documented. In an interview with Staff #3, an Intake Assessor, on 02/19/2025 at 11:57 AM, she stated she saw Patient B in the Intake Department. She also stated Patient B had overdosed on Tylenol. When asked if she knew what the symptoms of Tylenol overdose were, she replied she was unsure. In an interview with Staff #9, an RN on the adolescent unit, on 02/19/2025 at 1:54 PM, she stated she worked the day shift on the adolescent unit on 01/09/2025, the day Patient B was transferred to Texas Children’s Hospital. She reviewed her documentation on Patient B dated 01/09/2025 at 3:25 PM. When asked if she knew what the symptoms of Tylenol overdose were, she replied, “I really don’t know.” In an interview with Staff #4 (Medical Director) on 02/19/2025 at 1:20 PM, he stated that staff’s lack of knowledge of Tylenol overdose needed to be addressed. 38387 c. line of sight monitoring Review of the facility policy Levels of Observation and Precautions (PolicyStat ID 14807112, effective 03/2024) it stated under Line of Sight (LOS) observation: “this level of observation is very restrictive and involves continuous visual monitoring at all times. Documention should reflect the need for continued line of sight or improvement in behaviors. Staff must be within visual contact of the patient at all times. A staff member may observe more than one patient on line of sight observation only while those patients remain in an area for scheduled activity. If a staff member is observing more than one patient and one or more of the patients go to separate areas, the staff must transfer responsibility for line of sight to other staff members so that there is continuouse observation of all patients on line of sight preautions.” Review of Patient A chart revealed she is a 51 year old female with a longstanding history of schizophrenia brought in on an emergency detainment order. She stated she was having command thoughts and would hear voices internally expressing to harm herself. Review of the chart orders revealed a LOS was ordered at her date of admission (02/09/2025). Review of the staffing sheet for 02/12/2025 revealed 2 nurses (and 1 nurse training) and three techs with a census of 23 patients. Staff #21 was assigned LOS observation for Patient A and Patient M along with Q15 rounds for six other patients. Review of the 2/12/2025 video incident with Staff #2 on 02/19/2025 at 10:40 AM revealed no tech observing Patient #A per facility policy for LOS. Patient A in room 9 also had her door closed from 9:00 PM to 9:30 PM. An interview with Staff #2 on 02/20/2025 at 1:40 PM in the conference room confirmed the above findings. She stated that there were discussions to downgrade her observation levels but nothing was documented nor ordered.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 38387 Based on review of facility policy, review of facility incident reports and patient record review, and confirmed in interview, the facility failed to ensure patients are free from all forms of abuse or neglect by failure of staff not following their policy related to the investigation of actual events of sexual allegations; placing all patients at risk of delayed investigations for one of three patients (Patient A) reviewed. Findings included: Review of the facility policy Incident Report Protocol and Patient Safety Events (PolicyStat ID 15693888, effective 04/2024) it stated “it is the responsibility of all staff to report all patient safety incidents, accidents, or injuries involving patients or visitors and to report such occurrences using the Incident Reporting System along with notifying their supervisor immediately.” Review of facility incident reports revealed an incident occurred on 2/12/25 around 9:00-09:30 PM when Patient C entered Patient A’s room (room 9) to sexually assault her in the bathroom. Patient A and Patient C were alone in the room for eleven minutes (09:16 PM to 9:27 PM). Patient D notified Staff #21 that Patient A and Patient C were in the bathroom at about 9:30 PM. After the notification, Staff #21 entered the room and found Patient C in the bathroom getting dressed and Patient A in the bedroom dressed. Review of the incident report above revealed it was reported on 2/13/25 by the Patient D, the roommate of Patient A. Patient D made the outcry to the nursing staff the following morning on 02/13/2025 at 08:30 AM. No report was made by Staff #21, who witnessed the two patients in the room. Patient A was not assessed for injuries, nor was Patient C placed in a blocked room after the incident on 2/12/2025. The facility did not follow their policy related to the investigation of actual events of sexual allegations, placing all patients at risk of delayed investigations. In an interview with Staff # 2 on 02/19/2025 at 10:50 AM in the CEO office confirmed the above findings. She stated that after the notification the following day, the facility sent Patient A for a sane exam and Patient C was placed in a room in an opposite hallway away from Patient A.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 35028 Based on observation, interviews, and record review, the facility failed to meet the Condition of Participation for Patient Rights as evidenced by: (a) Observation rounds were not performed by a PCA (Psychiatric Care Assistant) on 6 of 6 patients admitted to the Meadows Unit, a unit with the highest acuity. (Refer to A0144.) (b) The PCA did not follow the facility’s policy for Observation Rounds by making visual contact with 1 of 6 patients admitted to the Meadows Unit, a unit with the highest acuity. (Refer to A0144.) (c) The “Inpatient Risk Assessment” did not include the bedroom doors on 4 of 4 units. The doors provided a ligature point in which material can be attached over the top of the doors and used for hanging or strangulation. (Refer to A0144.) (d) Unsupervised plastic markers with conical tips that can be used as weapons were found on 3 of 4 units (3 day rooms and 1 patient bedroom). (Refer to A0144.) (e) A damaged countertop soft drink dispenser was on a cabinet in the dayroom of the adolescent unit. There were sharp edges, screws, and removable pieces that could have been used for self-harm, or as a weapon. (Refer to A0144.) (f) The PCA failed to handle soiled linen in such a manner as to minimize microbial contamination. This failure potentially exposed the PCA, other staff, and patients to a variety of microorganisms, including bacteria, viruses, fungi, and ectoparasites. (Refer to A0144.) 38387 (g) A PCA was assigned monitor two patients on line-of-sight status, as well as the 15-minute observation rounds for all odd numbered rooms along one hallway. The two patients on line-of-sight status, were not always within the PCA’s line of sight - an infraction of the facility’s policy. (Refer to A0144)”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 35028 Based on observation, record review, and interviews, the facility failed to provide a setting for vulnerable patients that protected them from potential harm. This was evidenced by the facility’s failure to ensure that: (a) The PCA (Psychiatric Care Assistant) assigned to perform observation rounds on 6 of 6 patients (Patients #C, L, M, N, O, and Patient # P) conducted the rounds at 10:00am on the Meadows Unit, a unit with the highest acuity. (b) The PCA assigned to perform the observation rounds at 10:15am for 1 of 6 patients (Patient # C) on the Meadows Unit documented that the patient was in the shower after visualizing the patient. In addition, several staff members had conflicting understandings of Policy ID # 14807112, “Levels of Observation and Precautions.” (c) The Plant Ops Director identified the patient bedroom doors on 4 of 4 units (Meadows, Cedar, Willows, and Sunrise) as being a ligature risk on the “Inpatient Risk Assessment.” (d) Patients admitted into 3 of 4 units (Cedars, Willows, and Sunrise) were in environments that were free of potentially harmful objects - unsupervised plastic markers with conical tips - objects that can be used for self-harm or as weapons. (e) Patients admitted into 1 of 4 units (Sunrise - the adolescent unit) were in an environment that was free of potentially harmful equipment - damaged countertop soft drink dispenser with sharp edges, screws, and removable pieces. (f) 1 of 4 PCAs (Staff # 9) on the Willows Unit transported contaminated linens safely from a patient ’ s room to the soiled linen room. (g) The PCA assigned to monitor 2 of 2 patients (Patient #A and Patient #B) on line-of-sight status kept the patients within visual contact at all times. Findings showed: (a) Failure to conduct rounds. In an interview with Staff #1 (CEO) on 12/18/2024 at 9:30am during the opening conference, Staff #1 stated that the Meadows Unit is an adult unit with the highest acuity and is sometimes referred to by others as the Psychiatric Intensive Care Unit. Observation on the Meadows Unit, on 12/18/2024 at 10:00am showed 6 patients on the unit (Patients #C, L, M, N, O, and Patient # P) with no visible PCA conducting the Q15 minute observation rounds. Staff #15 (PCA-3) was standing in the nurse’s station with her head down looking at papers. The Patient Observation Sheets were requested. At 10:13am, she found Staff # 11 coming onto the unit with a clip board in his hand. Staff # 15 and Staff #11 were observed reviewing the clip board, which had attached to it the Observation Rounds Sheets for the 6 patients referenced above. Review of the clipboard on 12/18/2024 at 10:15am showed Patient Observation sheets for Patients # C, L, M, N, O, and Patient # P. Further observation showed that the rounds for 10:00am had not been documented. In an interview with Staff #11 (PCA) on 12/18/2024 at 10:20, he stated the rounds had not been conducted for 10:00am because he had taken a bathroom break. He also said he was OJT (On the Job Training). He concluded by saying he had not handed off the Patient Observation Sheets to another staff member prior to leaving the unit and he had taken the sheets with him. In an interview with Staff #15 (PCA-3) on 12/18/2024 at 10:20, she stated that Staff #11 was working without oversight from the person responsible for his OJT training, Staff # 9 (PCA). She stated she found Staff #11 in the breakroom, sitting at a table, looking at his phone. She went on to say that any individual conducting the Q15 minute observation rounds cannot be behind on them and a hand-off to another staff member is required if a break is needed - “You need to let someone know. You cannot disappear.” She identified herself as a PCA-3, “the highest level of a PCA,” and that she was a preceptor for PCAs in training. In an interview with Staff # 10 (Human Resources Director) on 12/18/2024 at 10:20, he stated Staff # 11 should not have been assigned to the observation rounds without supervision while on OJT, adding, “He should never have had the rounds. This was his second day on the floor. He was not competent to round on the patients.” Record review of policy ID 14807112, “Levels of Observation and Precautions,” last approved 3/2024 by Staff #17 (Vice President of Nursing) showed: “Policy ... It is critical that patient observation level and precautions are documented on the Close Observation Sheet and communicated to team members. Procedures. Every 15-minute observations: This is moderately restrictive for the patient and involves monitoring every 15 minutes on the Close Observation Sheet. Staff members must complete the Close Observation Sheet by noting the patient behaviors and location codes, along with the initials of the staff member who is conducting the observation.” Record review of a Power Point presentation titled, “Milieu Management Training,” provided by Staff 14 the Nurse Educator, showed: “Timeframes for Rounding. All patients are ‘rounded’ on regularly throughout the day at least every 15 minutes.” (b) The patient in the shower. Observation on the Meadows Unit on 12/18/2024 at 10:15am, showed Staff # 11 rounding. He had 6 Observation Sheets attached to a clipboard. The door to room P-02 was closed. The patient assignment placard positioned beside the bedroom door showed that Patient # C had been assigned to that room. The water in the shower could be heard running. Though he had neither entered the bedroom nor called out to the patient, Staff # 11 went to document on the sheet before being stopped and questioned by the surveyor. In an interview with Staff # 11 on 12/18/2024 at 10:14am, he stated he was on day two of floor duty, adding that he did not make visual or verbal contact with Patient # C because she was in the shower. He stated he could not make visual contact with Patient # C since the patient was of the opposite sex. When questioned about a solution to this dilemma, he was unable to identify an alternative method of conducting this observation. With prompting, Staff # 11 asked a female PCA in the adjacent room providing a 1:1 with another patient to check on Patient # C. In an interview with Staff # 10 (Human Resources Director) on 12/18/2024 at 3:30pm, he stated Staff # 11 should not have been assigned to the observation rounds without supervision while on OJT, adding, “He should never have had the rounds. This was his second day on the floor. He was not competent to round on the patients.” In an interview with Staff # 15 (PCA-3) on 12/18/2024 at 10:20am, she stated visual or verbal contact - preferably visual - must be made with every patient every 15 minutes when conducting the observation rounds. In an interview with Staff # 14 (Nurse Educator) on 12/18/2024 at 3:40pm, he stated he teaches the PCAs how to conduct the Q15 minute rounds. He also said that he puts a new PCA with a preceptor. When informed that Staff #11, who was on OJT status, was conducting Q15 rounds alone on the Meadows Unit, he stated that this was okay because he had had the training. When Staff #14 was told that another staff member stated Staff #11 should “never have been doing the rounds,” he stated, “There’s confusion.” He concluded by saying, “If a patient is in the shower, call out the patient’s name to know if they are safe.” Record review of a Power Point presentation titled, “Milieu Management Training,” (provided by Staff 14 (Nurse Educator) not dated, showed: “Timeframes for Rounding. All patients are ‘rounded’ on regularly throughout the day at least every 15 minutes. It is vital that you visualize the patient every 15 minutes, including in the restroom.” Record review of policy ID 14807112, “Levels of Observation and Precautions,” last approved 3/2024 by Staff #17 (Vice President of Nursing) showed: “Policy ... It is critical that patient observation level and precautions are documented on the Close Observation Sheet and communicated to team members. Procedures. 1. Every 15-minute observations: ... Staff must make visual contact with the patient at least every 15 minutes. This includes when the patient is toileting and/or showering, in groups, or attending off-unit activities.” (c) Inpatient Risk Assessment. In an interview with Staff #1 (CEO) on 12/18/2024 at 9:00am, he stated the census at midnight was 88 with a capacity of 94 patients. Review of the “Inpatient Risk Assessment” showed that the document had been completed by Staff #8 (Director of Environment of Care) and revised on 3/12/2024. In an interview with Staff #8 on 12/18/2024 at 4:00pm, he stated the doors to the patient bedrooms on all four units were not listed on the “Inpatient Risk Assessment.” He also said that the doors should have been included in the assessment because the doors provide a ligature point in which material can be attached over the top of the doors and used for hanging or strangulation. He concluded by saying that because of the tie-off points at the top of the bedroom doors, patient safety can be compromised. (d) Unsupervised plastic markers. Observation of the day area on the Cedars Unit on 12/18/2024 at 10:15am showed 3 unattended plastic markers with conical tips on a table. Further observation showed that an unsupervised plastic marker with a conical tip was in bedroom A19. The patient assignment placard positioned beside the bedroom door showed that Patient # K had been assigned to that room. Further observation showed an unsupervised plastic marker with a conical tip in the dayroom of the Willows Unit. Additionally, a container of numerous plastic markers with conical tips was found on a shelf in the dayroom on the Sunrise Unit. Record review of the Inpatient Comprehensive Psychiatric Evaluation for Patient # K by Staff # 16 (Medical Director) dated 12/16/2024 at 12:04pm showed a chief complaint of “suicidal now.” This 24-year-old female had been a patient in the Intense Outpatient Program at Woodland Springs Hospital. She reported increased agitation and anger, depression, irritability, feelings of hopelessness, and suicidal ideation with a plan. In an interview with Staff # 7 (Director of Clinical Services) on 12/18/2024 at 10:20am, she stated that an unsupervised plastic marker with a conical point could potentially be used for self-harm or as a weapon. (e) Damaged countertop soft drink dispenser. Observation on the Sunrise Unit, an adolescent unit, on 12/18/2024 at 10:30am showed a damaged countertop soft drink dispenser. The front of the dispenser was missing, exposing wires, screws, sharp edges, and removable pieces. In an interview with Staff # 7 (Director of Clinical Services) on 12/18/2024 at 10:30am, she stated that a patient had damaged the countertop soft drink dispenser. She also stated that the damaged dispenser with sharp edges, screws, and removable pieces could be used for self-harm or as a weapon. She concluded by saying that the dispenser needed to be removed from the unit. At that point, Staff # 7 phoned Staff # 13 (Maintenance) and asked him to remove the damaged equipment. (f) Transport of soiled linen. Observation of Staff # 7 (PCA) on 12/18/2024 at 11:00am showed him hurrying down the hallway on the Willows Unit carrying linen from a patient’s room. The linen was visibly soiled. He was handling the soiled linen so that the linen was touching his scrubs at his front torso area. He was not wearing gloves. In an interview with Staff # 7 on 12/18/2024 at 11:05am, he stated he was not wearing gloves. He was not aware the soiled linen was touching his scrubs, but stated he knew that this was against the hospital policy. He also stated he should have brought the linen cart to the room instead of transporting the uncovered soiled linen down the hallway in his hands, adding, “I was lazy.” In an interview with Staff # 14 (Infection Control Preventionist and Nurse Educator) on 12/18/2024 at 12:37pm, he stated that staff should wear gloves when handling contaminated linen. He also stated that the PCAs may have to pick up soiled linens from a patient’s room, adding, “Sometimes the PCA will take the linen cart to the patient’s room.” Review of Policy 15562613, “Linen Management,” approved 4/2024 by Staff # 18 (Facilities Environment of Care Manager), states: Purpose - To establish policies and procedure for management of linen within the hospital ... Handling and Transportation of Used Linen - All used linen will be considered contaminated and handled in such a manner as to minimize microbial contamination ... Remove linen from bed by folding all four (4) sides to the center. Roll into small bundle and place in linen hamper. Avoid shaking or unnecessary motion that might cause a dispersal of organisms ... Wear appropriate protective garb ... e.g., gloves ... Keep linen hamper covered until hamper is full ... Transport closed dirty linen bag to the soiled utility room immediately.” The interview was continued with Staff # 7 (Infection Control Preventionist and Nurse Educator) on 12/18/2024 at 11:10am after he reviewed the above referenced policy, “Linen Management.” Staff #7 said that the PCA should have taken the linen hamper to the room, put the soiled linen in the linen hamper, and returned the hamper to the soiled linen room. Review “Laundry and Bedding - Guidelines for Environmental Infection Control in Healthcare Facilities” published by The Centers for Disease Control and Prevention (2003) states: “Contaminated textiles and fabrics often contain high numbers of microorganisms from body substances ... Disease transmission attributed to health-care laundry has involved contaminated fabrics that were handled inappropriately ... [and] presumably have been transmitted from contaminated textiles and fabrics to workers via (a) Direct contact or (b) Aerosols of contaminated lint generated from sorting and handling contaminated textiles ... The laundry process starts with the removal of used or contaminated textiles, fabrics, and/or clothing from the areas where such contamination occurred, including but not limited to patients’ rooms ... Handling contaminated laundry with a minimum of agitation can help prevent the generation of potentially contaminated lint aerosols in patient-care areas.” 38387 (g) Patients on line-of-sight status. Review of the facility policy Levels of Observation and Precautions (PolicyStat ID 14807112, effective 03/2024) it stated under Line of Sight (LOS) observation: “this level of observation is very restrictive and involves continuous visual monitoring at all times. Documention should reflect the need for continued line of sight or improvement in behaviors. Staff must be within visual contact of the patient at all times. A staff member may observe more than one patient on line of sight observation only while those patients remain in an area for scheduled activity If a staff member is observing more than one patient and one or more of the patients go to separate areas, the staff must transfer responsibility for line of sight to other staff members so that there is continuouse observation of all patients on line of sight preautions.” Random review of the medical records from the Meadows unit on 12/17/2024 revealed two of ten patients who had orders for a Line of sight level of observation (Patient #A, Patient #B). In an interview with Staff #9 on 12/17/2024 at 10:50 AM in Meadows unit, he stated that line of sight is checking on patients every few minutes. He stated that it was NOT necessary to have visual of patients at all times. He confirmed that he had been assigned to do Q15 rounds for all odd number rooms in the hallway and that it included both Patient #A and Patient #B. He proceeded to show the surveyor the two patient rooms one with a closed door and the other a few doors down. He acknowledged that having the door closed and the other patient down the hall, he is unable to provide constant visual monitoring at all times of both patients. In an interview with Staff #14 on 12/17/2024 at 2:50 PM in the conference room, he stated that if a PCA is assigned multiple LOS patients, he should not be assigned routine Q15 rounds.”

“A Life Safety Code (LSC) compliant was conducted at the facility on 12/13/2024. An entrance conference was conducted on the morning of 12/13/2024 with the CEO, Director of Quality, and Director of Facilities to discuss the purpose of the LSC compliant and the survey process. 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. A LSC exit conference was conducted on the afternoon of 12/13/2024, with the CEO, Director of Quality, and Director of Facilities. 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. NO DEFICIENCIES NOTED AT TIME OF SURVEY.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 33326 The facility failed to meet the Conditions of participation at Patient’s Rights, the facility failed to provide patient care in a safe environment when - (14) fourteen out of (36) thirty-six chairs, located in 6 patient dayrooms, had exposed metal railings. These railings had sharp edges, placing patients at risk of lacerations, pain and possible patient self-harm attempts. (Sunrise, Willows, and Cedars inpatient units) - The patient’s outside courtyard wall had been written on by patients at an approximately 12-foot height. The courtyards furnishings were immovable on the concrete pad; a patient would have to be lifted by another someone to reach this height, placing patients at risk of a fall/injury, back injury and possible brain concussion and death. - The patient’s outside courtyard wall had been written on by patients; the writing included racist and derogatory statements and included patient’s names and phone numbers, placing patients at risk for psychological and confidentiality concerns. (Adolescent courtyard) - While in the Pre-admission intake area, an adult female patient was allowed to touch and hug a minor male’s legs and thighs for 8 minutes without staff intervention, placing the patient at risk of psychological and sexual abuse. (Patient #3) - (1) One out of (10) ten patients, reviewed for home medication reconciliation, did not have, the guardian requested critical seizure medications reviewed for continuation at the time of admission, placing the patient at risk of seizures. (Patient #3) Cross Refer: A0142- Safe Environment A0144- Safe Setting A0145- Abuse”

“PATIENT RIGHTS: PRIVACY AND SAFETY CFR(s): 482.13(c) Patient Rights: Privacy and Safety This Standard is not met as evidenced by: 33326 Based on observations, interviews, and record reviews, the facility failed to provide a safe environment as evidenced when the patient’s outside courtyard wall had been written on by patients at an approximately 12-foot height. The courtyards furnishings were immovable on the concrete pad; a patient would have to be lifted by someone to reach this height. This practice places patients at risk of a fall, back/neck injury. Findings include: During a tour of the Sunrise patient’s outside courtyard, on the morning of 12/09/24, a high wall had been written on by patients, the writing was even with the courtyard fence railing. The courtyard had stationary furnishings bolted to a concrete pad; the furnishings were at least 2 feet away from the wall and could not have been used to write on the wall. During an interview on the morning of 12/09/24, on the Sunrise unit hallway, Staff #4, Maintenance Technician, stated the height of the fence is 12-feet high. During an interview on the morning of 12/09/24, on the Sunrise patient’s courtyard Staff#2, DON confirmed the findings and when asked how a patient could reach the wall that high, stated, “I don’t know.” When asked how the patients are supervised in the courtyard and if the courtyard cameras can be monitored by the nurses, Staff #2 stated, “No, we have 2 PCAs with the patients in the courtyard. The camera monitors are reviewed by the Quality Director.” Review of the facility provided policy, Patient Bill of Rights (effective 07/2024) reflected, “5. You have the right to be free from ...neglect.””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 33326 Based on observations, interviews, and record reviews, the facility failed to provide care in a safe environment when, (14) fourteen out of (36) thirty-six chairs, located in 6 patient dayrooms, had exposed metal railings. These railings had sharp edges, placing patients at risk of lacerations, pain and possible patient self-harm attempts. (Sunrise, Willows, and Cedars inpatient units) Findings include: Review of the facility provided policy, Patient Bill of Rights (effective 07/2024) reflected, “The Hospital is required to respect and provide for your rights in order to maintain licensure and do business in this state ...3. You have the right to a clean and humane environment in which you are protected from harm ...” Observations made on the morning of 12/09/24, during a tour of the facility’s inpatient psychiatric units revealed (14) fourteen out of (36) thirty-six chairs, located in 6 patient dayrooms, had damaged patient chairs. The chairs had a semi-soft, plastic and foam padded, armrest that had been pulled back to expose sharp metal railings. During a tour of the dayrooms, Staff #2, DON was shown the exposed rail. Staff #2 touched the rail but did no comment on the railings. During an interview on the morning of 12/09/24, on the Sunrise unit hallway, Staff #4, Maintenance Technician, confirmed the facility was aware of the damaged armrests stating, “We have more armrests on order.” On 12/09/24 at 12:55pm, Staff #1, CEO was informed of the damaged chairs and the immediate risk of suicidal patients cutting themselves. Staff#1 confirmed the findings and stated, “We have the armrests on order. Staff #1 stated in part, the facility had additional functional chairs in the out-patient area that could be used to remedy the risk.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 33326 Based on interviews, observations, and record reviews, the facility failed to protect a patient’s rights to be free from all forms of abuse, neglect (failure to provide goods or services necessary to avoid physical harm, mental anguish or mental illness) or harassment when, 1.) The patient’s outside courtyard wall had been written on by patients; the writing included racist and derogatory statements and included patient’s names and phone numbers, placing patients at risk for psychological and confidentiality concerns. (Adolescent courtyard) 2.) While in the Pre-admission intake area, an adult female patient was allowed to touch and hug a minor male’s legs and thighs for 8 minutes without staff intervention, placing the patient at risk of psychological and sexual abuse. (Patient #3) 3.) (1) One out of (10) ten patients, reviewed for home medication reconciliation, did not have, the guardian requested critical seizure medications reviewed for continuation at the time of admission placing the patient at risk of seizures. (Patient #3) Findings include: 1.) During a tour of the Sunrise patient’s outside courtyard, on the morning of 12/09/24, a high wall had been written on by patients, the writing included racist and derogatory statements and included patient’s names and phone numbers. During an interview on the morning of 12/09/24, on the Sunrise patient’s courtyard Staff#2, DON confirmed the findings and when asked about the writings stated, “We give them space to express themselves.” When asked if the derogator words are therapeutic to a young adolescent who has not been exposed to that kind of language, Staff #2 stated, “I agree, we need to clean it up.” Review of the facility provided policy, Patient Bill of Rights (effective 07/2024) reflected, “The Hospital is required to respect and provide for your rights in order to maintain licensure and do business in this state ...3. You have the right to a clean and humane environment in which you are treated with respect and dignity.” 2.) On the morning of 12/10/24, a facility provided video, dated 9/23/24 was viewed. The video revealed a view of the first Pre-admission intake room’s back wall, looking out to the opened door, into the hallway. Video timeline: 9:07pm Patient #1, a 13-year-old-male, is observed sitting in the room’s doorway. Patient #7, a 26-year-old-female is brought into room located approximately 5 feet away, across the hall. Both doors were left open. 9:08pm Both patients are sitting on the floor, in their room’s doorways. They appear to be talking. There are no staff members in the camera’s view. 9:22pm Patient #7 moves across the hall to sit in patient #1’s doorway. Patient #7 is seen resting her chest on patient #1’s legs, touching his legs and upper thighs. There are no staff members in the camera’s view. 9:30pm Patient #7 is seen standing up and leaving the pre-admission intake area. There are no staff members in the camera’s view. During an interview, in the conference room, Staff #5, Quality Director, confirmed the video findings and stated, Patient #7 had come in wanting to be admitted for intoxication. When asked if the facility had a policy to ensure the safety of patients in the pre-admission intake area, since the patients in this area had not been assessed for their safety risk. Staff #5 said, “The staff thought she was a minor.” The facility did not provide a policy for the Safety of patients in the pre-admission intake areas. There are no staff members in the camera’s view. Review of the facility provided policy, Patient Bill of Rights (effective 07/2024) reflected, “...5. You have the right to be free from ...abuse.” 3.) Review of the facility provided policy, Medication Reconciliation, (effective 04/2024) reflected, “Purpose: To accurately and completely reconcile medications across the continuum of care for patients ...Definitions: The process includes comparing prescriber’s medication orders at the interfaces of care to the list, bringing discrepancies to the prescriber’s attention and, if appropriate, making changes to the orders ...The Admission Medication Reconciliation will be admission medication orders and will be filed in the MD Order section of the patient’s Medical Record.” During a telephone interview, on the morning of 12/10/24, minor Patient #3’s mother stated, “The facility assured me Patient #3 would get his scheduled home medications. He has been on these medications for 3 years; he can’t miss a dose. He has a seizure disorder. I even brought in his home medications for them to use. I found out they weren’t given.” Review of Patient #3’s Medication Reconciliation form dated 10/03/24 reflected Trileptal (a antiseizure medication) 600 (mg) milligram PO (by mouth) TID (three times a day) and Trileptal 150mg PO Daily were not reconciled or ordered on 10/03/24 by the initial physician’s encounter. On 10/04/24 at 3:21pm the Trileptal was ordered for Disruptive Mood dysregulation disorder. Review of Patient #3’s MAR (medication administration record) dated 10/03/24 to 10/04/24 reflected no doses of Trileptal were administered. During an interview, on the afternoon of 12/09/24, in the administrative conference room, when asked why the medications had not been reconciled on admission, Staff #9 stated, “We have asked the medication reconciliation to be completed by the admitting physician for Cardiac and anti-seizure medications. We dropped the ball. That’s not a mood dysregulation dose, that’s an anti-convulsant dose. The mom was clear it was.””

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 38387 Based on observation, record review and confirmed in interview, the facility failed to post conspicuously the required signage (per section 1867 of the Social Security Act) specifying the rights of individuals with respect to examination and treatment for emergency medical conditions (EMC) and women in labor and whether or not the hospital participated in the Medicaid program under a State plan (under Title XIX). The hospital failed to post signage in a manner that was noticeable and visible to individuals arriving to the facility via for examination and treatment. Findings included: Observation on tour conducted 10/09/2024 at 9:35 am, the facility entrance and exam rooms had no EMTALA required wall signage. At the time of observation, Staff ID #3 and #4 confirmed there was no EMTALA signage.”

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 38387 Based on review of the facility policy, EMTALA call log, transfer center logs, patient records, and interview, the facility failed to accept four (4) patients that required in-patient Psychiatric care when they had the capacity and capability to treat the patients. The facility documented the reason for not accepting the patients as ‘no appropriate bed’ despite having available beds and adequate staffing. Findings: Review of the facility policy Transfer to Another Facility (PolicyStat ID 16488078, effective 09/2024), it stated “this policy governs all transfers including those not governed by a transfer agreement and applies to transfers between hospitals licensed under the Texas Health and Safety Code, Chapters 241 and 577 as well as transfers to hospitals that are exempt from licensing...a hospital that has specialized capabilities or facilities may not refuse to accept from a a referring hospital an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual...the transfer of a patient may not be predicated upon arbitrary, capricious or unreasonable discrimination based on race, religion, national origin, age, sex/gender, physical condition, economic status, insurance status or ability to pay.” In an interview with Staff #1, he stated the facility has four different inpatient units: Meadows (high acuity psych); Cedars (adult); Willows (low acuity, substance abuse); and Sunrise (adolescents, mixed population 13-17 years old). Each unit has the following available beds: Meadows 26 beds (run usually 22 beds) Cedars 22 beds (could be flexed up to 30 beds if needed) Willows 22 beds (could be flexed to 30 beds if needed) Sunrise 26 beds In an interview with Staff #1 on 10/09/2024 at 09:35 AM in the conference room confirmed that ‘no appropriate bed’ indicated the facility had no staff and/or bed available to accept patient transfer. In a follow up interview via email with Staff #1 on 11/26/2024, he stated that ‘out of network’ meant the patient’s insurance plan does not cover hospital services. 8/16/2024 Patient #H 49 yo male presents with lacerations to top of head after hitting head into picture frame; denies any attempt at self harm; SI, HI; reported that patient hearing voices and trying to harm himself- medically cleared on 08/16/24 (2:45 AM). Review of the call log had a denial of ‘no appropriate bed’ with deflection noted as ‘out of network’ Patient #K 40 yo female who is paranoid reporting that there are people following her who want to kill her with an EDO on 8/16/24 (04:34 AM). Patient is hearing voices telling her to kill herself. She stated she would use a knife to kill herself. Patient stated she is currently suicidal with a plan to cut herself in the throat with a knife. Review of the transfer center call log had a denial of ‘no appropriate bed’ with deflection noted as ‘out of network’. However, review of the call log and review of patient records, Patient #J a 34 yo female for suicidal ideation was accepted on 08/16/2024 at 06:25 AM and admitted on 08/17/2024. Per the administrator (Staff #5) staffing ratio was 1:12 nurse to patient; 1:12 PCA to patient. Review of the staffing sheets provided revealed the following census and staff for 8/16/2024: Meadows- 21 beds (day: 2 nurses, 3 PCA) 24 beds (night: 2 nurses, 3 PCA - 1 PCA 1:1) Cedars - 20 beds (day: 2 nurses, 2 PCA) 19 beds(night: 2 nurses, 2 PCA) Sunrise - 9 beds (day: 1 nurse, 3 PCA - 2 PCA 1:1) 11 beds (night: 1 nurse, 3 PCA - 2 PCA 1:1) Willows - 21 beds (day: 2 nurses, 2 PCA) 21 beds (night: 2 nurses, 2 PCA) Review of the census for 8/16/2024 provided revealed the following census for 8/16/2024 with the following new admits for that day. Meadows: 24 beds; four new admits at 12:44 PM; 6:08 PM; 8:27 PM; and 11:12 PM Cedars: 19 beds; one new admit at 5:33 PM Sunrise: 11 beds; one new admit at 3:41 PM Willows: 20 beds; two new admits at 4:55 PM and 4:02 PM 09/01/2024 Patient #B 52 yo female who needs hospitalization due to suicide attempt by OD on ambien on 09/01/24 (11:56 AM). Review of the call record log had a denial of ‘no appropriate bed’ with deflection noted as ‘out of network’ However, review of the call log and patient chart, Patient #C (53 yo female) for suicide attempt by OD on several medication was accepted on 09/01/2024 at 12:33 PM and admitted as an inpatient on 09/02/2024. Review of the staffing sheets revealed the following: Meadows - 21 beds (day: 2 nurses, 3 PCA - 1 PCA 1:1) Cedars - 18 beds (day: 2 nurses, 2 PCA); 17 beds (night: 2 nurses, 2 PCA) Sunrise - 23 beds (day: 2 nurses, 5 PCA - 4 PCA 1:1) 24 beds (nurse: 2 nurses, 4 PCA - 3 PCA 1:1) Willows - 19 beds (day: 2 nurses, 2 PCA) 20 beds (night: 2 nurses, 2 PCA) Review of the census for 09/01/2024 provided revealed the following census for 09/01/2024 with the following new admits for that day. Meadows: 20 beds; no new admits Cedars: 16 beds; no new admits Sunrise: 24 beds; two new admits at 8:46 AM and 4:48 PM Willows: 20 beds; two new admits at 12:33 AM and 12:26 PM 09/10/2024 Patient #D 38 yo female with worsening hallucinations; threatening statements online to hurt others on 09/10/24 (3:19 PM). Review of the call record log had a denial of ‘no appropriate bed’ with deflection noted as ‘out of network’ However, Patient #X 29 yo female with suicidal ideation was accepted 09/10/24 at 5:53 PM and admitted on 09/10/2024. Review of the staffing sheets revealed the following: Meadows - 21 beds (day: 3 nurses, 2 PCA); 22 beds (night: 2 nurses, 4 PCA - 1 PCA 1:1, 1 LOS) Cedars - 19 beds (day: 2 nurses, 2 PCA); 21 beds (night: 2 nurses, 2 PCA) Sunrise - 21 beds (night: 2 nurses, 4 PCA - 1 PCA 1:1, 1 LOS) Willows - 16 beds (day: 2 nurses, 2 PCA); 18 beds (night: 2 nurses, 2 PCA) Review of the census for 09/10/2024 provided revealed the following census for 09/10/2024 with the following new admits for that day. Meadows: 22 beds; three new admits at 2:19 PM, 7:02 PM, and 9:17 PM Cedars: 21 beds; two new admits at 12:49 PM and 3:48 PM Sunrise: 21 beds; eight new admits at 7:03 AM, 1:39 PM, 1:41 PM, 2:08 PM, 3:31 PM, 5:58 PM, 7:11 PM, 7:40 PM, Willows: 18 beds; two new admits at 10:13 PM and 10:35 PM In an interview with Staff #7 on 10/10/2024 at 2:30 PM via phone, he stated that he reviewed patient charts and would recommend to the facility intake to accept patient transfer. He DOES NOT deny transfer unless the patient does not meet their admission criteria. In an interview with Staff #5 on 10/10/2024 at 3:10 PM, she confirmed that the transfer center does not make the determination for denied transfers. The intake department constantly has to monitor the bed availability throughout the day so it is up to the facility to determine the bed availability. She stated that her or Staff #1 were responsible for determining if the facility could accept the patient.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 38015 Based on record review and interview, the facility failed to ensure the rights of 2 of 2 patients (Patient #1 & #2) to be free of potential abuse and neglect as shown by: A. Staff not closely monitoring patients on Sexually Acting Out (SAO) Precautions via Line-of-Sight per physician orders (Patient #1), allowing opportunity for a male and female patient to be in a bathroom together, and B. Nursing staff not monitoring PCA assignments, allowing a male Patient Care Technician (PCA-Staff #A) to perform 1-to-1 monitoring for a female patient on Sexually Acting Out Precautions (SAO-Patient #1). Findings included: Review of facility policy titled “Sexually Acting Out (SAO)”, #13572466, last revised 12/2019 stated that Sexual Precautions are defined as intensified levels of staff awareness and attention to patient safety/security related to sexual acting out behaviors. SAO Precautions are physician orders and include Line-of-sight (LOS) and 1:1 (one-to-one) monitoring. Review of another facility policy titled “Levels of Observation and Precautions”, # 13048351, last revised 2/2023 showed that LOS observation is very restrictive and involves continuous monitoring of the patient at all times by staff; staff must be within visual contact with the patient at all times. 1-to-1 Observation is the most restrictive; staff must be within arms-length reach to the patient at all times, including during toileting and/or showering to continuously monitor patient behavior. Record review of Patient #1’s clinical progress notes showed the following: Patient #1 had a physician’s order for LOS observation. On 12/14/23, the patient went into a common bathroom in the facility’s adolescent unit’s seclusion room that staff had been allowing patients to use. It was then brought to the attention of staff who were supposed to be monitoring the patient that a peer, Patient #2 had been in the bathroom with Patient #1 together at the same time. Facility investigation revealed that the two patients were in the bathroom together for approximately 20 minutes and Patient #1 was not being properly monitored via LOS by PCA-Staff #J. Video review showed both patients sneaking into the same bathroom. Patient #2 reported they were touching each other over clothes and Patient #1 reported that sexual intercourse had occurred. Both patients were subsequently treated prophylactically for sexually transmitted infection. In an interview on the afternoon of 12/19/23, DQ-Staff #C stated that Staff #J was not following her assignment and the event should not have been allowed to occur. Further record review of Patient #1’s clinical chart showed that due to the event occurring 12/14/23, she was placed on 1-to-1 close observation monitoring by her physician due to sexually acting out. On 12/16/23, a male PCA (Patient Care Assistant technician)-Staff #A, who was not assigned to care for the patient for 1-to-1 monitoring, switched assignments with female PCA-Staff #K to care for the patient from 12:00 am to 2:00 am. Later in the morning at approximately 7:30 am, Patient #1 reported to PCA staff on duty that during the night, PCA-Staff #A showed her a pornographic video on his cellphone of himself having sex with a woman. Patient #1 then stated that they both had oral sex and intercourse together and that PCA-Staff #A requested she shower afterwards. Patient #1’s roommate, Patient #11, during interview with facility staff investigating incident, stated she heard PCA-Staff #A ask Patient #1 if she wanted to watch a video. In addition, Patient #11 stated she overheard PCA-Staff #A argue with other PCA staff during that night, insisting that he should be the person doing the 1-to-1 monitoring of Patient #1. Patient #11 also reported that the patient had showered in the early evening then again, in the early morning. Video review showed PCA-Staff #A, while performing 1-to-1 monitoring for Patient #1 during 12:00 am to 2:00 am on 12/16/23, visualized him coming to the patient’s door several times from inside the bedroom, looking back and forth down the adolescent halls and nurse’s station, then re-entering Patient#1’s bedroom. Record review of the patient’s written statement describing the event on 12/16/23 included graphic details of sexual interaction with PCA-Staff #A and included a written telephone number. Review of PCA-Staff #A’s HR files showed that the telephone number submitted by the patient in her written statement matched his phone number. In an interview on 12/20/23 at 2:00 pm, Staff #C stated that nursing staff should have been monitoring the PCA assignments and having the male PCA care for the patient in this case should nave have been allowed to occur.”

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 38387 Based on random review of patient charts from September 2023 to December 2023 and confirmed in interview, the facility failed to accurately complete, date, and time the physician inpatient progress notes for one of five patient charts reviewed (Patient #D). Findings included: In review of Patient #D chart, the inpatient progress note for 10/31/2023 were dictated and transcribed by Staff #20 on 11/01/2023 at 15:56 hours and electronically signed by the same Staff #20 on 11/01/2023 at 16:11 hours. In review of Patient #D chart, the inpatient progress note for 11/01/2023 were dictated and transcribed by Staff #21 on 12/08/2023 at 12:02 hours and electronically signed by the same Staff #21 on 12/08/2023 at 12:02 hours. The time and date of each entry (orders, reports, notes, etc.) must be accurately documented. Timing establishes when an order was given, when an activity happened or when an activity is to take place. Timing and dating entries is necessary for patient safety and quality of care. In an interview with Staff #19 on 12/08/2023 at 1:05 PM in the conference room she could not explain the discrepancies in the date and time. She stated that the providers dictate in real time when they perform their assessments. She stated that maybe they document their assessments and dictate at another time, but she was unaware if those notes are kept.”

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 38387 Based on review of the facility policy, random review of patient records from September to December 2023, and confirmed in interview, the facility failed to document the progress note to decrease or discontinue the level of observation for two of five patients (Patient #D, #E) reviewed and failed to reassess the need for increased level of observation for one of five patients (Patient #E) reviewed. The hospital failed to document the necessary information needed to monitor the patient’s condition. Findings included: In review of the facility policy Levels of Observation and Precautions (PolicyStat ID 13048351, effective 02/2023), it stated: “Purpose To ensure there is clear differentiation between patients’ needs when different levels of risk are present. The levels of observation and precautions are identified based on the risk assessment as well as by patient behavior... The nursing staff and medical providers will assess patients for risk level and make level of observation and precaution recommendation based on the risk level assessment findings and patient behavior. It is critical that patient observation level and precautions are documented on the Close Observation sheet and communicated to team members. During the course of treatment, any clinical professional may determine an increase in observation and/or the additions of a precaution is warranted and clinically necessary. The charge nurse and the provider are notified when an increase in level of observations and/or precaution is indicated. Orders should be obtained for increased observation and/or precautions as noted above. A provider’s order is required to decrease or discontinue a level of observation or precaution. A progress note by the provider accompanies the order with the rationale for decreasing or discontinuing the level observation or precaution.” Patient #D In review of the Patient #D chart, the inpatient progress notes for 10/31/2023, Staff #20 documented “patient attempted to elope from the hospital last night and transferred to higher acuity unit...remains a danger to himself and others due to his psychotic symptoms behavior and paranoia. Lacks insight and judgment. Inability to contract for safety. Continue 1:1 supervision for safety.” Review of patient orders on 10/31/2023 revealed a decrease in observation to Q15 ordered. No documentation was provided for the rationale for decreasing the level of observation. In review of the inpatient progress note for 11/01/2023, Staff #21 documented “limited response and remains at high risk still very high elopement risk still at risk to intrusive only act upon others.” In review of the inpatient progress note for 11/02/2023, Staff #22 documented “it was reported that patient was packing up all his belongings saying that he has been trapped, will be gone for a long time, and will finally be free. Patient was transferred from Willows after attempting to elope. He still has no insight and poor judgment ... Limited response and remains at risk.” In review of the inpatient progress note for 11/03/2023, Staff #22 documented “patient has become rather irritated and vocalizing more agitation. Has become threatening and posturing towards staff. Has absolutely no insight into his symptoms and need for hospitalization. Due to his aggression and verbalizing desire to elope he has received order for no visitation for 24 hours. Needs frequent redirection.” In review of the inpatient progress note for 11/04/2023, Staff #21 documented “the patient after our visit attempted to elope by breaking out the window in the break room. He indicated that he had not been taking his medicines that he had been cheeking most of them as he feels he does not treatment nor does he need medication.” Review of the patient orders on 11/4/2023 revealed an order for an increase in observation to 1:1 soon after his elopement. An interview with Staff #2 on 12/08/2023 at 1:15 PM in the conference room confirmed the above findings. She presumed the reason Patient #D had a downgrade in observation level was because of his transfer to the higher acuity unit, but she was unable to provide documentation. Patient #E In review of the inpatient progress notes on 12/01/2023, Staff # 23 documented “patient is alert and oriented x4, mood good, affect engaging, eye contact good, speech rate volume tone prosody within normal limits, thought process logical and goal directed, thought content no suicidal ideation, no homicidal ideation, no auditory hallucination, no visual hallucination, fair judgment and developing insight ... Continue precautions and observations.” In review of the inpatient progress notes on 12/02/2023, Staff #23 documented “patient is alert and oriented x4, mood depressed, affect labile, eye contact good, speech rate volume tone prosody within normal limits, thought process logical and goal directed, thought content no suicidal ideation, no homicidal ideation, no auditory hallucination, no visual hallucination, poor judgment and poor insight... Continue precautions and observations.” Review of the provider orders on 12/02/2023 revealed an increase of observation for a 1:1 level of observation ordered by Staff #23. No documentation was available for review for the need for the increased level of observation. In review of the inpatient progress notes on 12/03/2023, Staff #23 documented “patient is alert and oriented x4, mood depressed, affect labile, eye contact poor, speech rate volume tone prosody low and slow, thought process logical and goal directed, thought content positive suicidal ideation, no homicidal ideation, positive auditory hallucination, no visual hallucination, poor judgment and poor insight ... Continue precautions and observations.” Review of the provider orders on 12/03/2023 revealed a 1:1 level of observation ordered by Staff #23. No documentation was available for review for the continued need for the increased level of observation. In review of the inpatient progress notes on 12/04/2023, Staff #23 documented “patient is alert and oriented x4, mood depressed, affect labile, eye contact poor, speech rate volume tone prosody low and slow, thought process logical and goal directed, thought content positive suicidal ideation, no homicidal ideation, positive auditory hallucination, no visual hallucination, poor judgment and poor insight ... Continue precautions and observations.” Review of the provider orders on 12/04/2023 revealed a 1:1 level of observation ordered by Staff #23. No documentation was available for review for the continued need for the increased level of observation. In review of the inpatient progress notes on 12/05/2023, Staff #23 documented “patient is alert and oriented x4, mood depressed, affect labile, eye contact poor, speech rate volume tone prosody pressured, thought process logical and goal directed, thought content positive suicidal ideation, no homicidal ideation, positive auditory hallucination, no visual hallucination, poor judgment, and poor insight ... Continue precautions and observations.” Review of the provider orders on 12/05/2023 revealed a 1:1 level of observation ordered by Staff #23. No documentation was available for review for the continued need for the increased level of observation. In review of the inpatient progress notes on 12/06/2023, Staff #23 documented “patient is alert and oriented x4, mood depressed, affect labile, eye contact poor, speech rate volume tone prosody pressured, thought process logical and goal directed, thought content positive suicidal ideation, no homicidal ideation, positive auditory hallucination, no visual hallucination, poor judgment and poor insight ... Continue precautions and observations.” Review of the provider orders on 12/06/2023 revealed a 1:1 level of observation ordered by Staff #23. No documentation was available for review for the continued need for the increased level of observation. In review of the inpatient progress notes on 12/07/2023, Staff #23 documented “patient is alert and oriented x4, mood depressed, affect labile, eye contact poor, speech rate volume tone prosody pressured, thought process logical and goal directed, thought content positive suicidal ideation, no homicidal ideation, positive auditory hallucination, no visual hallucination, poor judgment and poor insight ... Continue precautions and observations.” Review of the provider’s orders for 12/08/2023 revealed a decrease in level of observation to a line of sight ordered by Staff #23 with no documentation as to the rationale. An interview with Staff #2 on 12/08/2023 at 1:15 PM in the conference room confirmed the above findings. She stated that she discussed with Staff #23 regarding Patient #E and the reason for her increased precautions. She acknowledged that it would be ‘best’ if the providers documented the rationale for the change in observation levels, but it is not currently monitored.”