Voyages Behavioral Health of Conroe

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 38015 . Based on observation, interview and record review, the facility failed to meet the Condition of Participation requirements for Patient Rights. The facility failed to ensure compliance with patient’s rights to receive care in a safe setting and to be free from abuse: A) Patients on active suicide precautions were placed in medical beds with numerous ligature risks and were only monitored every 15 minutes (refer to tag A-144); B) Three different patients in the facility had eloped from the same fence on at three different occasions; the facility did not have an effective plan to prevent past and future patient elopements (refer to tag A-144), and; C) There were hard plastic colored art markers with sharp conical points which were unmonitored and available for patients to access on all four facility units (refer to tag A-144).”

“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: 38015 Based on observation, interview and record review, the facility failed to ensure patients’ right to a safe environment, as evidenced by: A) Three suicidal patients (Patients #2, #4, & #5) being able to elope from facility in the same manner by jumping over the fence. More specifically, the facility failed to: 1. Ensure past, current, and future patients were effectively prevented from eloping from the outside courtyard patio fence; 2. Conduct and document any investigations for the three elopements, including interviewing staff involved and the patients who eloped, and reviewing video tape footage; 3. Document any existing current corrective actions taken to prevent future elopements; 4. Take and document any corrective actions towards staff involved in the elopements; 5. Document evidence of staff education/re-education; and 6. Identify the outdoor patio’s fence as an elopement risk on their facility-wide Risk Assessment. These elopements failures could have resulted in injury, permanent impairment, or death. B) The presence of unmitigated ligature risks on medical beds, representing opportunities for the potential of strangulation and asphyxiation inside the bedrooms of seven patients who were on suicide precautions. These hazards could have resulted in death or permanent impairment. These patient had orders to only be closely monitored every 15 minutes (Patient #’S 6, 7, 8, 9, 10, 11 & 12). In addition, there were 30 other patients on suicide precautions who may have wandered into these rooms when the room was unlocked and vacant. More specifically, the facility failed to protect patients from: 1. The presence of unmitigated ligature risks inside the bedrooms of seven patients who were on suicide precautions and had orders to be closely monitored only every 15 minutes. (Patient #’s 6, 7, 8, 9, 10, 11 & 12). These medical beds with steel frames contained multiple tie-off ligature points. In addition, they had long unsecured electrical cords approximately 6-7 feet long. Both the frames and electric cords represented serious asphyxiation and strangulation potential which could have resulted in death or permanent impairment for the seven patients on suicide precautions as well as the remaining 30 other patients on suicide precautions who might wander into these rooms with the medical beds; 2. Oxygen concentrator machines with electric cords approximately 5 feet in length, along with plastic nasal canola oxygen tubing several feet long connected to the machines, again representing serious asphyxiation and strangulation hazards. 3. Facility’s Medical Bed policy failed to adequately address adequate safety procedures for patients on active suicide precautions. These ligature risks could have resulted in injury, permanent impairment, or death. C) Infection Control issues: More specifically, the presence of: 1. Blood smear in seclusion room, and; 2. Overflowing trash can with dirty gloves, other patient and staff waste materials plus other trash on the floor in laundry room. D) Numerous items that could be used for self-harm or to harm others: hard plastic markers with pointed conical tips, craft paint brushes with wooden handles, wire basket, Workstation on Wheels (WOW). E) 2 of 2 seclusion rooms with beds in them that created a blind spot for the staff member standing at the door monitoring the patient. Findings included: A) ELOPEMENTS: Three patients (Patients #2, #4, & #5) being able to elope from facility in the same manner on three separate occasions by jumping over the outdoor patio fence. These elopements could have resulted in outcomes of death or permanent impairments from injuries. Review of undated facility document titled “PATIENT’S RIGHTS, RESPONSIBILITIES & GRIEVANCE”, a form which is given to all new patients on admission for their review and acknowledgement, showed that patients had the right to receive care in a safe environment. In an interview on 8/13/25 at 3:15 PM, MT#IQ stated that Patient #2 had just eloped from the facility within the last two weeks by jumping over the outside patio fence where patient go to get fresh air and to smoke. Review of facility incident report showed that on 8/2/25, Patient #2 had eloped from facility. Record review of Patient #2’s medical records showed that he had eloped from facility on 8/2/25 by jumping over the outside patio fence. He was returned back to the facility by police in handcuffs with generalized bruising on both arms, bruises on left shoulder, and redness in chest area and back. The patient, a 37-year-old male, had just been admitted to the facility on 7/29/25. Review of the patient’s Initial Psychiatric Evaluation dated 7/30/25 showed that he was admitted to the facility involuntarily due to expressing intention to hang himself with an extension cord from a tree after he killed his girlfriend. The patient was placed on suicide and “violence” precautions. In an interview on 8/14/25 at 11:15 am, RN #J stated that Patient #4 just eloped yesterday (8/13/24) from the outdoor patio fence during a smoke break. The police found and caught him, then brought him back after he had gone to HCA Conroe Hospital first. Record review of Patient #4’s medical records showed that he was a 21-year-old male admitted to the facility on 8/6/25 due to, in his own words, “suicidal tendencies” and had a history of “two prior suicide attempts by firearm”. He had active orders for suicide precautions. Physician progress notes dated 8/13/25 showed that the patient demonstrated significant psychiatric instability and continued inpatient care in a structured, secure environment was necessary. Further review of facility incident reports showed that on 9/1/24, Patient #5 had also eloped by jumping over the same outdoor patio fence. Patient #5, a 22-year-old male, had just been admitted the prior day on 8/31/24. Record review of Patient #5’s medical records showed he had a history of previously attempting suicide and was on active suicide precautions when he eloped. He was never returned to the facility. Observation on 8/14/25 at 11:00 am of facility’s outdoor courtyard patio where all three elopements took place showed there was an approximately 12-foot wooden fence barrier separating the patio to the outside of the facility into the parking lot. Inside the courtyard, perpendicular to and connecting to the fence on one side, meeting it at a corner, was the facility’s brick wall with an approximately 4-inch-wide decorative cement ledge running horizontal along the wall. This ledge overhang was approximately three feet high from the ground and met the corner at the wooden fence (i.e., it was possible for someone tall enough to use this 4 inch cement ledge as a footing to jump up and reach/grab the top of the wooden fence). In an interview at this time of observation of the courtyard, CNO Staff #I stated that the patients had eloped from this fence and from now on, to prevent further elopements, a technician will be seated by the fence. In another interview at this time of observation of the courtyard, Mental Health Technician (MHT) Staff #M stated that there is sometimes just one staff present in the courtyard watching patients outside “if there aren’t too many patients”. Record review of patients who were on elopement precautions on 8/13/25 showed there were 17 patients total on active elopement precautions. In an interview on 8/15/25 at 10:45 am, CNO Staff #I stated that there was no investigation and documentation of what had occurred with the elopements. She also stated that the elopement event occurring on 8/2/25 had been addressed in a staff meeting, but there was no documentation of a correction plan to prevent further elopements and no documentation of staff training or re-education. In addition, there was no documentation of any corrective action taken with staff who were involved with the elopements. When it was pointed out that the plan on 8/2/25 to place a chair next to the fence to prevent additional elopements was not effective, as evidenced by a third elopement from the fence taking place, Staff #I stated that it was because staff were not complying with the plan to sit by the fence. Review of the facility’s 2025 Risk Assessment document failed to identify their patio fence as a risk for patient elopement. B) UNMITIGATED LIGATURE RISKS - Beds and Oxygen Concentrators: Review of facility policy #NSG33 titled “Medical Bed Policy”, last revised 8/15/25, failed to adequately address the safety of patients on suicide precautions and to protect them from numerous ligature risks on the bed frames and from their electric cords. It only contained general information about the definitions what “ligature-resistant” and “ligature-reduced” meant per the Joint Commission. There were no specific interventions concerning level of observation and limiting access to the rooms. It only listed that safety searches would be conducted, and durable medical equipment would be removed from the rooms when not in use. Review of another facility policy, #VSS.1.06 effective 8/1/22 titled “Patient Safety”, addressed: keeping electrical cords from becoming tripping hazards and preventing them from being pinched between the bed’s side rails and bed frames; ensuring tables and cabinet drawers in patient rooms are closed after use, and; using excessive caution when moving patients on oxygen. It failed to mention bed frames and electrical cords being ligature risks. Review of facility’s Risk Assessment document for 2025 identified their medical beds as being high ligature risks. However, listed as Prevention Measures were “Justification/order from physician will be needed for patient to be placed in bed”. This preventative measure, by itself, was insufficient to ensure patient safety. In an interview on the morning of 8/13/25, CNO Staff #I stated that there were medical beds with metal frames in use and present in the facility’s 300 and 400 units. When asked how patients on suicide precautions were kept safe, Staff #I stated that patients on suicide precautions did not use the medical beds. Record review on 8/15/25 showed there were currently 37 patients on active suicide precautions. In an interview on 8/15/25 at 11:30 am, Staff #I stated there were no patients in the facility currently on 1:1 close observations; they were all on every 15 minutes close observations (‘Q 15 minute Close Observations’). Observation on 8/15/25 starting at 11:45 am of patient bedrooms, accompanied by CEO Staff #D showed the following: Room 403B: A medical bed with steel frames and long electric cord present, housing Patient #12 who was on active suicide precautions. Her level of observation was once every 15 minutes. Also present inside this room was an Oxygen concentrator machine with long plastic nasal annular tubing attached. Room 305B: A medical bed with steel frames and long electric cord present which was housing Patient #8 who was on active suicide precautions. Her level of observation was once every 15 minutes. Also present inside this room was an Oxygen concentrator machine with long plastic nasal annular tubing attached. Room 303A: A medical bed with steel frames and long electric cord present which was housing Patient #6 who was on active suicide precautions. His level of observation was once every 15 minutes. Room 304A & 304B: 304A-a medical bed with steel frames and long electric cord present which was housing Patient #7 who was on active suicide precautions. Her level of observation was once every 15 minutes. 304B- another medical bed with steel frames and long electric cord present which was housing Patient #10 who was also on active suicide precautions. Her level of observation was once every 15 minutes. Room 307B: A medical bed with steel frames and long electric cord present which was housing Patient #9 who was on active suicide precautions. His level of observation was once every 15 minutes. Room 302A: A medical bed with steel frames and long electric cord present which was housing Patient #11 who was on active suicide precautions. Her level of observation was once every 15 minutes. In an interview with Staff #D at the time of finding, he acknowledged that the medical beds posed ligature risks for patients. In addition, he stated that the oxygen machines with the electric cords and plastic tubing were safety hazards and should not have been left in the room unattended. The machines were promptly removed by staff. C) INFECTION CONTROL: Review of facility policy #VEVS.1.01 titled “Housekeeping Re Room Checklist” with effective date 8/1/22 revealed that it was designed to foster appropriate infection control for the facility environment. It showed that all spills of blood or other body fluids would be immediately cleaned and disinfected. Observation on 8/13/25 at 10:30 am of a facility’s seclusion room #343 revealed there was an approximately 3 x 2 inch reddish dried liquid smear on one of the inside room walls which appeared to be blood. In an interview with RN Staff #I at the time of findings, she stated that it appeared to be blood and was a possible infection control issue. Observation on 8/13/25 at 1:20 pm of Unit 300’s laundry room revealed there was an overflowing trash can with scattered trash on the floor, containing dirty gloves and mixed debris from patients and staff. In an interview at the time of findings, CNO Staff #I stated the trash should not be overflowing and would be cleaned right away. 35028 . D) ITEMS THAT COULD BE USED FOR SELF-HARM OR TO HARM OTHERS. Review of policy VSS.1.06, “Patient Safety,” effective 8.1.2022, showed: “Purpose and Scope. To provide guidelines concerning patient safety ... Patients can be confused and disturbed when admitted to a hospital ... General Patient Safety - As a matter of general safety, the hospital staff should ... 5. Keep tools, ... instruments ... out of patient access.” Review of policy 07, “Patient Safety Precautions,” revision date 2.14.2024, showed: “Purpose and Scope. To promote a safe environment and decrease the possibility of harm ... Guidelines ... routine environmental checks.” Review of the census for Units 100, 200, 300, and 400 showed a census of 37 patients on August 15, 2025. Further review of physician orders for 37 of 37 patients (4, 6-12, 22-50) showed that all 37 patients were on “Suicide / Self-Harm Precautions Every Shift.” A tour of the facility was provided by Staff I (CNO) and Staff D (CEO) on 8.13.2025 beginning at 10:30am. On Units 100, 200, 300, and 400, items were found that could be used for self-harm or to harm others. “ Unit 100. A plastic tub that contained hard plastic markers with pointed conical tips and four craft paint brushes with 6-7-inch pointed wooden handles was observed on a table in the Quiet Activity Group Room on Unit 100. Staff D (CEO) stated these craft items (markers and paint brushes) could be used as weapons to harm others or to harm self. “ Unit 200. There were 50-60 hard plastic markers with pointed conical tips in a plastic tub on a table in the commons area. Staff I (CNO) did not know how many markers were in the plastic tub, adding, “The markers are not inventoried.” “ Unit 300. There were 30-40 hard plastic markers with pointed conical tips in a plastic tub on a table in the commons area. Again, Staff I (CNO) stated she did not know how many markers were in the plastic tub. “ Unit 400. There were hard plastic markers with pointed conical tips in a plastic tub on a table in the commons area. A wire basket with removable metal leaves was also found. Staff I (CNO) stated the wire basket should not be on the unit, adding, “Wire is not allowed.” Suicidal and homicidal patients had access to these unsupervised markers, craft paint brushes, and wire basket. In an interview with Staff N (MHT) on 8.13.2025 at 11:10am, the MHT stated that units 100 and 200 had a higher acuity, adding, “It can get more dangerous, scary sometimes.” In interviews with Staff I (CNO) and Staff O (MHT) on 8.13.2025 at 1:10pm and 1:15pm respectively, they both stated the hard plastic markers could be used to harm self or as a weapon to harm others. In an interview with Staff P (MHT) on 8.13.2025 at 1:40pm, the MHT stated, “The markers can be used as weapons by filing them down to a point or slamming them in a door so that a sharp piece can be broken off. The MHT also stated that staff do not count the markers. During a repeat tour of the facility on 8.14.2025 at 11:50am, the same plastic tub of 30-40 hard plastic markers with pointed conical tips was on tables in the commons area on Units 300 and 400. In an interview with Staff I (CNO), she stated that the markers had not been removed from the two units, adding, “I’m working on the process.” Unit 400 was toured on 8/14/2025 at 11:50am with Staff I (CNO). A nurse was observed outside of the nurse’s station administering medications from a Workstation on Wheels (WOW). Observation of the WOW showed that it had a screen, keyboard, and small drawers for patient medications. In several of the drawers were medications. The drawers were not locked. In an interview with Staff I (CNO) on 8/14/2025 at 11:50am, she stated that bringing the WOW onto the unit for medication passes was an acceptable practice. She also stated she had not considered that an angry patient could use the Workstation on Wheels (WOW) as a weapon. Staff I stated there had been recent violence by patients on the unit in which furniture had been turned over and a fire extinguisher had been pulled from a wall and used as a weapon. Review of video surveillance for an 8.8.2025 incident showed Patient #13 becoming noticeably more agitated - pacing and gesturing. Numerous staff attempted to verbally deescalate him. He was observed tearing up papers, kicking objects, and turning over furniture. Review of the article, “Violent Patients,” by Kristine Song, Robert B. Blankenship, and Derek J. Schaller in Stat Pearls, March 3, 2025, showed: “Violence in healthcare settings presents a growing global concern, creating significant challenges for healthcare providers and institutions ... Mitigating violence in healthcare requires a multifaceted approach that involves identifying underlying causes, implementing preventive measures ... Examination devices, sharp objects, and furniture that could be used as weapons should be removed ... According to guidelines on preventing workplace violence ... environmental changes can be implemented, including ... the removal or securing of furniture that could be used as weapons.” D) SECLUSION ROOM BLIND SPOTS. Observation of 2 of 2 seclusion rooms on 8.13.2025 at 10:30am showed a bed secured to the floor in each room. Staff M (MHT) laid on the floor on the side of the bed farthest from the door. Staff D (CEO), standing in the anteroom at the seclusion room door, was unable observe Staff M attempting to strangle himself. In an interview with Staff D (CEO) during the observation, he stated there was a blind spot in the seclusion room and could compromise patient safety.”

“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: 35028 . Based on observation, interview, and record review, the facility failed to ensure that there was an adequate number of RNs on 1 of 2 units as evidenced by one RN functioning as the (1) house supervisor, (2) charge nurse on Unit 100, (3) medication nurse on Unit 100, and (4) charge nurse on Unit 200 during the 7am to 7pm shift on August 8, 2025 - a unit with a high acuity. This failure resulted in an RN not being readily available, thus creating an unsafe environment for patients and staff. Additionally, the facility failed to take into consideration the acuity of the patients in the development of the written staffing schedule. Findings were: Review of the “2025 Nurse Staffing Plan,” reviewed 3.31.2025, showed: “The Nursing Services Department ... supports the provision of patient care in a safe, cost-effective manner ... determined by the budgetary process ... The plan will establish adequate numbers of registered nurses (RNs), licensed vocational nurses (LVNs), and other personnel to provide nursing care to all patients. The plan will ensure that RN coverage will be immediately available to assist and supervise patient care and respond to emergencies.” Review of the “Daily Staffing Assignments” dated 8.8.2025 showed that Staff J functioned as (1) the House Supervisor, (2) 100 Hall Charge RN, (3) 100 Hall Medication Nurse, and (4) 200 Hall Charge Nurse during all or portions of the 7am-7pm shift. A breakdown of the “Daily Staffing Assignments” showed: House Supervisor: Staff J (RN) 100 Hall Charge RN: Staff J (House Supervisor) 100 Hall Medication Nurse: Staff EE (LVN) 7am-12pm, then Staff J (House Supervisor) 12pm-7pm 200 Hall Charge RN: Staff CC (RN) 7am-3pm, then Staff J (House Supervisor) 3pm-7pm 100 Hall Tech: No MHT assigned. 200 Hall Tech: Staff GG (MHT) In an interview with Staff J (RN-House Supervisor) on 8.13.2025 at 11:32am, she stated she worked on 8.8.2025 as the House Supervisor, 100 Hall Charge RN, 100 Hall Medication Nurse, and 200 Hall Charge Nurse during all or portions of the 7am-7pm shift, adding that when fulfilling the role as the House Supervisor and the Charge Nurse on a unit, she has had to leave the unit to function as the House Supervisor. “I tell the nurse on the other unit to watch my patients.” Review of the “2025 Nurse Staffing Plan,” reviewed 3.31.2025, showed: “The Nursing Services Department ... supports the provision of patient care in a safe, cost-effective manner ... determined by the budgetary process ... The plan will establish adequate numbers of registered nurses (RNs), licensed vocational nurses (LVNs), and other personnel to provide nursing care to all patients. The plan will ensure that RN coverage will be immediately available to assist and supervise patient care and respond to emergencies. Patient care assignments will take into consideration: a. Number of patients b. Characteristics of patients, including intensity of the patient’s emotional, mental, and medical needs ... e. Anticipated admissions, discharges, and transfers per shift ... A staffing plan for each unit ... is established as a guide for staffing on a particular unit. A staffing grid is designed to provide guidance for daily staffing needs based on census. This staffing guide serves as a tool and will be adjusted accordingly to meet the patient’s needs.” Further review of the attached ‘Staffing Matrix by Unit Census AM Shift’ showed: Census 1 - 10: 1 RN and 1 MHT. Census 11 - 12: 1 RN and 2 MHTs. Census 13 - 16: 1 RN, 1 LVN, 2 MHTs.” Of note, there was no discussion in the staffing plan of how the characteristics of patients, including intensity of the patient’s emotional, mental, and medical needs would be factored along with the census to determine the staffing pattern. In an interview with Staff F (Quality Director) on 8.14.2025 at 2:55pm, she stated that the “Staffing Matrix by Unit Census” is the tool used to determine staffing, adding that there was no acuity tool used to assist in determining adequate staffing. In an interview with Staff LL (RN) 8.14.2025 at 11:25am, the RN stated that on 8.8.2025 the CNO was on PTO (paid time off). “There should have been a second MHT on Unit 100. Staffing is a problem. An MHT was sent to the emergency room with a broken wrist on the 8th [August]. The acuity was high. Agency is not allowed. We have been short enough to need an agency nurse.” In an interview with Staff N (MHT) on 8.13.2025 at 11:20am, the MHT stated, “We work a lot of times short staffed.” The MHT also stated that another MHT had gotten his wrist fractured because of short staffing. My biggest concern is safety.” In an interview with Staff P (MHT) on 8.13.2025 at 1:50pm, the MHT stated, “Several days ago [MHT later confirmed the date to be 8.8.2025], a patient picked up a chair and threw it. He broke a door. Later that day, Staff T (MHT) was sent to the emergency room after being sprayed by a patient with the fire extinguisher. He saturated the unit. The fire alarm went off. The staff member with the patients in the smoke area could not help because the gate unlocked when the fire alarm went off.” Staff P concluded by saying, “Acuity doesn’t play into staffing.” In an interview with Staff Q (MHT) on 8.13.2025 at 2:05pm, the MHT stated that on 8.8.2025, he was working on Unit 100 with Staff J (House Supervisor) when he was injured by Patient #3, adding that Patient #3 had been agitated and aggressive that day. He also stated he was the only male MHT in the hospital on the 7am-7pm shift. Staff Q also stated that Patient #3 had “punched out the plexiglass in the seclusion room door, threatening to “beat all staff on the unit.” Patient #3 also “threw a chair, flipped a table, and tore a metal soap dispenser off the wall.” An emergency code was called when Patient #3 became out of control. There was “me and four women” to conduct the emergency code. It was during this emergency code that Patient #3 “landed on my harm and twisted it inward.” He stated, “Two to three days earlier, it took three men [Staff Q, Staff M, and Staff P] to hold Patient #3 for an emergency medication.” He concluded by saying, “This 6-foot 2-3-inch patient warranted extra staff.” Observation of Staff Q (MHT) on 8.13.2025 at 2:05pm showed he had cast on his right arm. In an interview with Staff B (DPO) on 8.14.2025 at 12:30pm, he stated he was one of the Crisis Prevention Intervention (CPI) instructors. When questioned about the safety of having only one male MHT in the hospital with the remainder of the MHTs being female, he stated, “I’ve met girls who could handle this.” As noted in the previous interviews, this was not the sentiments of the female and male MHTs. Review of video surveillance for the 8.8.2025 incident involving Patient #3 was conducted on 8/14/2025 at 1:00pm with Staff B (DPO) and another surveyor. The incident started around 3:54pm. Staff Q (MHT) was observed talking with Patient #3. The patient’s behavior became noticeably more agitated as evidenced by pacing and gesturing. Numerous staff attempted to verbally deescalate the patient. By 3:59, the patient was seen tearing up papers, kicking objects and turning over furniture. At 4:02pm, he kicked Staff Q (MHT). The patient and staff members moved in front of the nurse’s station which was in a blind spot not recorded by the camera. [Staff Q (MHT) stated that it was at this point in front of the nurse’s station that he was injured by Patient #3.] At 4:03pm, the patient was escorted to the seclusion room. At 4:05pm, the patient knocked out the window of the seclusion room and attempted to reach out to grab staff members. At 5:03pm, he was administered oral medication and released from seclusion at 5:16pm.”

“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: 43549 Based on review of the facility policy, record review and interview, the facility failed to ensure that a Registered Nurse assessed a patient, based on the patient’s needs, but at least every12 hours after the initial comprehensive nursing assessment in 1 (#A) of 1 sampled patient records with skin issues. Findings include: Review on 06/25/2024 of the facility’s current policy titled Nursing Documentation Standards Dated 8/1/22 revealed the following information: “ Each patient is reassessed by the nurse every shift. The reassessments are completed on a daily nursing assessment/ progress note. Significant patient changes are documented in the multidisciplinary progress notes with appropriate clinician notification.” Record review of patient (#A) admitted on 03/04/24 discharged 03/29/24 had diagnoses of depression, hypertension, diabetes, stage 2 bilateral heal ulcers and chronic lower extremity lymphedema. Reason for admitting was suicidal ideation due to pain in her legs. Daily Nursing Assessments for patient (#A) from the day after admission 03/05/24 through discharged 03/29/24 revealed that no daily assessment or other nursing note assessed, described the lymphedema. There was mention of it in the nursing notes. When Interviewed 06/25/23 at 14:50 the Director of Quality Management confirmed the findings and stated, “There’s nothing I can say”.”

“DISCHARGE PLANNING - EARLY IDENTIFICATION CFR(s): 482.43(a) The hospital’s discharge planning process must identify at an early stage of hospitalization those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient’s representative, or patient’s physician. This Standard is not met as evidenced by: 43549 Based on record review and interview, the facility failed to provide an effective discharge planning program that facilitates the provision of follow-up care for 2 of 2 discharged patients reviewed (A and B) who did not have complete discharge information. Patient A was senior citizen admitted for aggression with diagnoses of bipolar disorder a with brief psychotic disorder was discharged 10/19/23. The record documented the patient was not allowed to move back into the home she shared prior to discharge and alternates including long term care were explored. Social Worker (#17) note 10/19/24 at 10:20 am to the patient’s family, inquired about two different discharge addresses provided to clarify which was correct, transportation to home, obtaining medications, living alone or not and obtaining food/ groceries. Discharge Summary by Psychiatric Nurse Practitioner #18 on 10/19/23 at 3:15 pm “Discharge Plan & Disposition” checked boxes reading: Outpatient patients, symptoms can be appropriately managed in a community setting through outside counseling and/or medication management. X- Return to Home X- Needs a Private Psychiatrist 7 discharge medications were listed including psychiatric and other medications. X- Medication risks, benefits, and options have been reviewed with the patient. x- Discharge information has been communicated to the patient. Discharge follow-up plans/recommendations: Patient to follow-up with outpatient psychiatrist for further mental health needs. Follow-up care for identified medical problems: patient to follow-up with primary care physician for future medical needs. Discharge plan does not include information needed for a safe discharge including: the address patient is going to, name of a psychiatrist to follow up with or an appointment for further care, if medication prescriptions were provided or called into a pharmacy. There was no evidence of patient receipt of complete discharge instructions. Patient B was a wheelchair bound (some days bed bound) patient admitted 3/6/24 for polyneuropathy, suicidal ideation with diagnoses of major depressive disorder severe with psychotic features, anxiety disorder, diabetes (on sliding scale insulin), hypertension, chronic lower limb lymphedema and stage 2 bilateral heal ulcers. She lived alone at home with intermittent family assist visits and home health 2-3 hours daily. The patient did not want to discharge and appealed to stay longer stating she was alone at home and wanted home care 8 or more hours daily and interaction with others like she had in the facility. The patient appealed a pending discharge 3/18/24 to Kepro Quality Improvement Organization/ Humana/ Medicare Administrator Contractor Novitas which agreed with her appeal. Patient was discharged to home 3/29/24. Discharge Summary 3/29/24 at 8:20 pm by #16 a Doctor of Osteopathy with Psychiatric Certification “Discharge Plan & Disposition” checked boxes reading: Outpatient patients, symptoms can be appropriately managed in a community setting through outside counseling and/or medication management. X- Return to Home X- Outpatient therapy at (left blank) 13 discharge medications were listed including psychiatric and other medications. Did not include insulin order. X- Medication risks, benefits, and options have been reviewed with the patient. x- Discharge information has been communicated to the patient. Discharge follow-up plans/recommendations: Patient to follow-up with outpatient psychiatrist for further mental health needs. Follow-up care for identified medical problems: patient to follow-up with primary care physician for future medical needs. Discharge plan does not include information needed for a safe discharge including: the address patient is going to, name of a psychiatrist to follow up with or an appointment for further care, if medication prescriptions were provided or called into a pharmacy, diabetic medication and blood sugar monitoring, dietary recommendations, wound care/ treatment how/supplies/ by whom. There was no evidence of patient receipt of complete discharge instructions. When interviewed 6/26/24 at 1:00 pm Dr. ##16 a Doctor of Osteopathy with Psychiatric Certification stated she thought the medical doctor was responsible for the medical part of the discharge information. When interviewed 6/26/24 at 12:10 Medical Doctor #19 stated he is not routinely informed, prior to discharge of medically followed patients. When interviewed 6/26/24 at 2:20 pm #2 Director of Quality Management confirmed the discharge plans did not include the afore mentioned information.”

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 37322 Based on record review and interview, the hospital failed to produce training records for education on communication as specified in the grievance letter of two patients (ID #B,N) of three grievance letters reviewed. Findings Include: Record review of the facility policy “Patient Complaint and Grievance Process” dated 08/91/2022 stated: I. The patient will be provided with written notice of the final results of the complaint and grievance process. Record review of the grievance letter sent by the Director of Quality (staff ID #3) to patient (ID#N) on 12/22/2023 stated the facility “re-educated the leadership team and staff on the importance of overall communication in addressing families concerns as well as communicating the role they have in providing care”. Record review of the grievance letter sent by the Director of Quality (staff ID #3) to patient (ID#B) on 01/22/2024 stated “we re-educated staff on the importance of overall communication and addressing concerns and communicating in a timely manner”. Interview on 02/16/2023 between 3:15 pm and 3:30 pm with both staff (ID#3, 2) revealed there were no training records regarding communication for staff or leadership for the months of December 2023 and January 2024. Interview on 02/16/2023 at 3:15 pm with the Director of Quality (staff ID#3) who stated, “we could have done a better job with education”. Interview on 02/16/2023 at 3:15 pm with the CNO (staff ID#2) who stated “I do not have any training records on communication for December, or January.”