Smokey Point Behavioral Hospital

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 43948 . Based on interview, document review, and review of the hospital’s policies and procedures, the hospital’s governing body failed to provide effective oversight for the management of medical emergencies within the hospital. Failure to provide effective oversight of medical emergencies that occur within the hospital risks an unsafe healthcare environment for patients. Findings included: 1. Failure to develop and implement policies and procedures to guide staff during medical emergencies, including opioid overdoses places patients at risk for inappropriate care, serious injury, and death. 2. Failure to ensure that the hospital staff notify the providerof a medical emergency as soon as possible places patient at risk for inappropriate care, serious injury, and death. Cross Reference: A0093 Due to the scope and severity of deficiencies cited under 42 CFR 482.12, the Condition of Participation for Governing Body was NOT MET. .”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 43948 . Based on interview, document review, and review of the hospital’s policies and procedures, the hospital’s failed to ensure that staff provided patient care in a safe setting. Failure to provide patient care in a safe setting places the patient at risk for serious harm, injury, and death. Findings included: 1. Failure to ensure that all patient’s meet the hospital’s admission criteria. 2. Failure to develop and implement policies and procedures for staff conducting the admission skin checks. 3. Failure to develop and implement policies and procedures to guide staff in the prevention, management, and monitoring of patient with an increase risk for suicide ideation and behaviors. 4. Failure to initiate an incident report capturing all relevant events occuring at the hospital, involving patients, staff, family members, or visitors. Cross Reference: A0144 Due to the scope and severity of deficiencies cited under 42 CFR 482.13, the Condition of Participation for Patient Rights was NOT MET. .”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 43948 . Based on observation, interview, and document review, the hospital failed to provide adequate supervision and evaluation of all nursing personnel to ensure that all staff provided care in a safe setting for patients who were experiencing suicidal ideation resulting in an opioid overdose, requiring administration of opioid reversal medication (Narcan). Failure to provide patient care in a safe setting for high-risk patients requiring an increased level of monitor, or the ability to respond to urgent medical emergencies places the patient at risk for serious harm, injury, and death. Findings included: 1. Failure to ensure that staff members are adequately prepared to respond to medical emergencies, including a suspected opioid overdose and administer a lifesaving medication (Narcan). 2. Failure to document in a patient’s medical record when incidents or acute changes in a patient’s condition occur, or the interventions administered, or the patient’s response to those interventions. 3. Failure to monitor patients who have the potential to experience withdrawal symptoms and complications from opiates and alcohol detoxification. Cross Reference: A0144 1. Failure to ensure that all medications/treatments administered are ordered by a physician who is responsible for the care and treatment of the patient. Cross Reference: A0405 Due to the scope and severity of deficiencies cited under 42 CFR 482.23, the Condition of Participation for Nursing Service was NOT MET. .”

“EMERGENCY SERVICES CFR(s): 482.12(f)(2) If emergency services are not provided at the hospital, the governing body must assure that the medical staff has written policies and procedures for appraisal of emergencies, initial treatment, and referral when appropriate. This Standard is not met as evidenced by: 43948 . Item #1 - Policies and Procedures to Guide Staff During Medical Emergencies Based on interview, medical record review, and policy and procedure review, the hospital failed to develop and implement policies and procedures to guide staff during medical emergencies, including opioid overdose, for 1 of 1 medical record’s reviewed (Patient #1). Failure to develop and implement policies and procedures to guide staff during medical emergencies places the patient at risk for inappropriate care, serious injury, and death. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Medical Emergency,” policy number SP008, last reviewed 01/25, showed the following: a. In the event of a medical emergency, a code will be called to announce the nature of the emergency and the location. All available nurses and physicians are to respond. b. Any staff member coming upon a situation in which a person appears to require medical assistance should call a code blue and stay with the victim until help arrives. c. The first person who arrives, that is medically trained (nurse or physician), should institute the necessary first aid until additional help arrives. d. Qualified medical personnel at the scene should determine the need for outside emergency medical services (EMS) and then call the switchboard operator, give a brief description of the problem, and instruct them to call 911 for medical assistance. When the switchboard is not covered, the unit staff will call 911. Document review of the hospital’s policy and procedure titled, “Use of Narcan/Naloxone,” policy number NSG 600-80, last reviewed 01/25, showed the following: a. The purpose of the policy is to provide guidance on the process of administering Naloxone where an opioid overdose is suspected. b. This policy applies to any healthcare staff with training on the use of Naloxone. c. When a patient is unresponsive and/or where an opioid overdoes is suspected, the nurse will call a code blue (a hospital emergency code used to describe the critical status of a patient) and administer Naloxone/Narcan. d. If necessary, emergency medical services will be contacted immediately so that the patient may be transferred as soon as possible for evaluation and treatment at a medical hospital. e. After Naloxone is administered, additional support and/or Basic Life Support (BLS) measures may be administered while awaiting emergency medical assistance. f. The patient will be kept under continued surveillance until emergency personnel arrive. g. When a physician or provider arrives at the Code Blue, or when the on-call physician or provider is notified of the incident, the nurse will obtain the order for Naloxone and enter it into the patient’s medical record. h. The Investigator’s review of the policy and procedure found no staff guidance regarding patient monitoring after the medication administration or documentation of the incident and interventions administered in the patient’s medical record. Document review of the hospital’s policy and procedure titled, “Plan of Care,” policy number POC 100.59, last reviewed 01/25, showed that emergency psychiatric and medical services are provided by the medical staff 24 hours per day. A written plan for the management of medical and psychiatric emergencies has been developed to provide emergency services to patients requiring immediate medical evaluation for urgent conditions. 2. The Investigator reviewed the medical record for Patient #1, who was admitted on 01/31/25 at 2:14 AM. The patient transferred from an acute care hospital after a suicide attempt by an intentional overdose on fentanyl two days prior. The Initial Nursing Assessment dated 01/31/25 at 2:10 PM, showed documentation that the patient reported using fentanyl in the intake department and was given Narcan prior to being transferred up to the unit. The Investigator found no evidence that staff documented the overdose incident or the Narcan administration in the intake department. 3. On 04/10/25 at 3:45 PM, during an interview with the Investigator, an intake counselor (Staff #16) stated after the patient was admitted on 01/31/25 at 2:14 AM, the patient remained in the intake department due to her refusal to comply with the mandatory skin-check before transferring to the unit. When patients refust the required skin check during intake, they norcally transfer the patient to the inpatient unit with a staff member assigned for 1:1 continuous observation. No staff was availabile for 1:1 monitoring in the inpatient unit. The patient was placed in the “bubble room,” which is a secured room adjacent to the intake department with a plexiglass wall separating the two spaces. At 6:30 AM on 01/31/25, Staff #16 reported that the patient knocked on the plexiglass wall, requesting to speak with them. The patient reported that while they were in the bathroom, they had taken an undetermined amount of fentanyl, attempting to overdose. The intake counselor notified the house nursing supervisor who came to the intake department to assess the patient. Staff #16 called the Administrator on Call (AOC), to advise them about the incident and report that the nursing house supervisor requested that the patient be transferred out for medical treatment. The AOC told Staff #16 that the hospital leadership did not want the patient to be transferred out for medical treatment and that the hospital was equipped to handle the situation. Staff #16 stated that the neither the AOC or the hospital leadership were medical or psychiatric physicians. 4. On 04/10/25 at 8:00 AM, during an interview with the Investigator, the nursing house supervisor (Staff #15) reported that when she received the call from the intake staff, she instructed Staff #16 to notify the AOC and call 911 to have the patient transportedto an acute medical care hospital. Staff #15 obtained a dose of Narcan from the emergency kit on the 2nd floor of the hospital and proceeded to the intake area. Upon her arrival, Staff #15 assessed the patient. She observed that the patient had pinpoint pupils (caused by the opioid overdose), exhibited slurred speech, had an altered level of consciousness and shallow breathing, with an oxygen saturation in the low 80’s. (oxygen saturation is a vital sign that indicates how well your blood is carrying oxygen to your tissues. Oxygen saturation under 85% can lead to hypoxia, the absence of oxygen, and hypercapnia, carbon monoxide retention, causing respiratory failure. A normal oxygen saturation is 95% to 100%). Staff #15 stated that she was unsure of any policies or procedures to guide staff when responding to opioid overdoses and Narcan administration. On 01/31/25 at 8:10 AM, the house supervisor administered one single 4 mg dose of Narcan nasal spray. 5. On 04/14/25 at 1:55 PM, during an interview with the Investigator, the Chief Nursing Officer (Staff #7) stated that he was not sure of the hospital’s protocol for responding to medical emergencies when a patient overdoses. Item #2 - Provider Notification of Medical Emergencies Based on interview, medical record review, and policy and procedure review, the hospital failed to ensure that the hospital staff notified the provider when medical emergencies occurred, for 1 of 1 medical records reviewed (Patient #1). Failure to ensure that the provider is notified when medical emergencies occur places the patient at risk for delayed and/or inappropriate treatment, serious injury, and death. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Medical Emergency,” policy number SP008, last reviewed 01/25, showed the following: a. In the event of a medical emergency, a code will be called to announce the nature of the emergency and the location. All available nurses and physicians are to respond. b. Qualified medical personnel at the scene should determine the need for outside emergency medical services (EMS) and then call 911 for medical assistance. Document review of the hospital’s policy and procedure titled, “Memorandum of Transfer,” policy number POC 100.40, last reviewed 01/25, showed the following: a. The hospital administration is responsible for the implementation of and adherence to the hospital’s transfer policy. In the cases where medical care is required which exceeds the hospital’s scope of care, the hospital has an agreement established to transfer patients to an acute care medical hospital. b. Each patient that arrives at the hospital for treatment or care will be evaluated by a physician who is present in the hospital or is evaluated by a physician on call with authorized nursing staff responsible for assessing and reporting the patient’s condition back to the physician. c. If after receiving a report on the patient’s condition from the nursing staff, the physician on call determines if an immediate transfer is medically appropriate. If appropriate, the physician will write an order for a transfer to an acute care hospital for medical evaluation and treatment. Document review of the hospital’s policy and procedure titled, “Use of Narcan/Naloxone,” policy number NSG 600-80, last reviewed 01/25, showed the following: a. When a patient is unresponsive and/or where an opioid overdoes is suspected, the nurse will call a code blue (a hospital emergency code used to describe the critical status of a patient) and administer Naloxone/Narcan. b. If necessary, emergency medical services will be contacted immediately and the patient may be transferred for evaluation and treatment at a medical hospital. c. When a physician or provider arrives at the Code Blue, or when the on-call physician or provider is notified of the incident, the nurse will obtain the order for Naloxone and enter it into the patient’s medical record. Document review of the hospital’s policy and procedure titled, “Client Intake and Assessment,” policy number POC 100.14, last reviewed 01/25, showed that for physical concerns identified during the intake process, a medical consultation is obtained from a physician. 2. The Investigator reviewed the medical record for Patient #1, who was admitted on 01/31/25 at 2:14 AM. The patient had been transferred from an acute care hospital after a suicide attempt by an intentional overdose on fentanyl a couple of days ago. The Initial Nursing Assessment dated 01/31/25 at 2:10 PM, showed that the patient reported using fentanyl in the intake department and was given Narcan prior to being transferred up to the unit. The Investigator’s review of the patient’s medical record for no evidence documenting that the provider was notified of the overdose incident that occurred in the intake department prior to her transfer to the inpatient unit, or the subsequent administration of Narcan. 3. On 04/03/25 at 11:30 AM, during an interview with the Investigator, the Clinical Director (Staff #4) stated that Patient #1 presented to the hospital at 12:15 AM on 01/31/25 and was admitted at 2:14 AM. When asked about the protocol for patients that are suspected of an overdose, Staff #4 stated that the provider should be notified about the incident, then after their assessment of the situation, the provider will make the decision to send the patient out for medical evaluation and treatment if appropriate. 4. On 04/04/25 at 1:55 PM, during an interview with the Investigator, the Chief Medical Officer (Staff #8) stated that when there is a medical emergency, such as a patient overdose, the provider (or provider on call) should be notified. The provider then will determine the appropriate care going forward, including interventions such as Narcan, and/or transfer to the medical hospital for evaluation and treatment. Staff #8 verified that the on-call provider was not notified of the overdose incident or Narcan administration for Patient #1. 5. On 04/14/25 at 10:50 AM, during an interview with the Investigator, an intake clinician (Staff #10) stated that if there is ever a medical emergency, such as an overdose, staff should call 911 and notify the house supervisor. Staff #10 stated that the nursing staff should notify the provider of the medical emergency. 6. On 04/14/25 at 1:55 PM, during an interview with the Investigator, the Chief Nursing Officer (Staff #7) stated that he assumed that the provider was notified regarding Patient #1’s overdose on 01/31/25. After reviewing the medical record with the Investigator, Staff #7 verified that the provider was not notified of the incident. .”

“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: 43948 . Item #1 - Admission and Exclusionary Criteria Based on interview, record review, and review of the hospital’s policies and procedures, the hospital failed to ensure there was an effective process in place to ensure that only patients who meet the hospital’s admission criteria were admitted to the facility, for 1 of 1 medical records reviewed (Patient #1). Failure to ensure that all patient’s meet the hospital’s admission criteria risks the inability to provide appropriate quality healthcare that meets the patient’s needs and risks the deterioration of the patient’s condition, increasing the chance for adverse health outcomes, serious injury, and death. Findings included: 1. Document review of the hospital’s document titled, “Medical Staff Rules and Regulations,” no policy number, not dated, showed the following: a. All admissions shall meet the inclusionary criteria as established by the medical staff and in accordance with the state mental health code. b. Patients that meet the exclusionary criteria are not to be admitted. The patient must be able to benefit from the program. Document review of the hospital’s policy and procedure titled, “Admission, Discharge, and Continued Stay Criteria,” policy number POC 100.50, last reviewed 01/25, showed the following: a. Criteria that will prevent the admission of a patient to hospitalization may be waived, where appropriate, only by the admitting physician with approval from the medical director. b. The exclusionary criteria preventing the admission of a patient’s acceptance for hospitalization includes: i. Oxygen saturation below 90%. ii. Patient who have overdosed with Narcan administration and/or without stable vital signs for 24 hours following the overdose. Document review of the hospital’s document titled, “Smokey Point Behavioral Hospital Intake Call Sheet,” no form number, not dated, showed the following: a. Current Medical Issues considered exclusionary - oxygen saturation below 90%. b. Overdose with Narcan administered will not be accepted for 24 hours after the Narcan administration. 2. The Investigator reviewed the medical record for Patient #1 who transferred from an acute care hospital on 01/31/25 at 12:15 AM after attempting suicidce by fentanyl overdose 2 days earlier and was admitted to the facility at 2:14 AM. 3. On 04/10/25 at 3:45 PM, during an interview with the Investigator, an intake counselor (Staff #16) stated that at approximately 6:30 AM on 01/31/25, the patient knocked on the plexiglass wall, wanting to speak with them. The patient reported that while they were in the bathroom, they had taken an undetermined amount of fentanyl, attempting to overdose. Staff #16 notified the house supervisor who came to the intake department to assess the patient. Staff #16 stated that if a patient overdoses and receives a dose of Narcan, they will have to wait 24 hours before admission. Staff #16 stated that a recent overdose with Narcan administration is one of the hospital’s exclusionary criteria. Staff #16 stated that the Intake Call Sheet lists all of the exclusionary criteria. 4. On 04/10/25 at 8:05 AM, during an interview with the Investigator, the house nursing supervisor (Staff #15) stated that after learning of Patient #1’s overdose, she went to the intake department to assessed the patient. Staff #15 stated that the patient had signs of an opioid overdose including pinpoint pupils, slurred speech, decreased level of consciousness, and shallow breathing, with an oxygen saturation in the low 80’s (normal range is between 95% and 100%). Staff #15 stated that the hospital’s exclusionary criteria was that a patient who had overdosed and been administered Narcan could not be accepted until 24 hours after the incident. Staff #15 stated that this was due to the need to monitor the patient’s vital signs for 24 hours in a medical setting. Staff #15 stated that she requested that patient be sent out for medical evaluation and treatment, however she was told by the hospital leaders, that were not medical or psychiatric physicians, that the hospital does not send patients out for overdoses. 5. On 04/14/25 at 12:55 PM, during an interview with the Investigator, the Chief Medical Officer (Staff #8) stated that he was not sure of the hospital’s protocol for exclusionary criteria for admission. Staff #8 stated that it is the provider’s decision to accept a patient for admission or send a patient out for medical evaluation and treatment. Staff #8 stated that Smokey Point Behavioral Hospital is not a medical surgical facility. Item #2 - Skin Check Based on interview, record review, and review of the hospital’s policies and procedures, the hospital failed to develop and implement clear, comprehensive policies and procedures to guide staff conducting the admission skin checks, including alternative interventions when the patient is unwilling or unable to comply, as demonstrated by 1 of 1 medical records reviewed (Patient #1). Failure to develop and implement policies and procedures for staff to follow when a patient refuses an initial skin checks places the patients at risk for inconsistent treatment and care. Findings included: 1. Document review of the hospital’s document titled, “Contraband and Valuable Search,” policy number POC 100.18, last reviewed 01/25, showed the following: a. After the patient has consented to admission and before they are escorted to the unit, the patient is to give all valuable or contraband to a family member or trusted friend. b. The intake coordinator will ask the patient if they have any additional contraband on their person. c. At this time, the intake staff will perform a pat search, and any additional contraband or valuables will be given to a family member or trusted friend to take out of the hospital. Document review of the hospital’s policy and procedure titled, “Plan of Care,” policy number POC 100.59, last reviewed 01/25, showed that during the admission process, the patient and belongings will be searched for unsafe items. Document review of the hospital’s policy and procedure titled, “Unclothed Body Search (Property Search, Skin Check, Contraband Search),” policy number POC 100.92, last reviewed 01/25, showed the following: a. An unclothed body search will be conducted as clinically indicated to ensure a safe environment for all patients. b. An unclothed body search will be conducted upon admission in a private location with two staff present. c. Hospital scrubs will be offered to the patient to provide a respectful, dignified approach to the search. d. Body orifices will not be searched by unauthorized personnel. e. The unclothed body search will be conducted in the patient’s room or in the intake area. The patient will be asked to remove all clothing items and don hospital scrubs. The clothing items will be removed from the bathroom and inspected by a 2nd staff member. The nurse who is the same sex as the patient (or in line with the patient’s preference) will conduct the skin check. f. Once the patient and their clothing are determined to be free of contraband, the patient is allowed to get dressed back into their own clothing. Document review of the hospital’s policy and procedure titled, “Patient Safety Precautions,” policy number POC 114, last reviewed 06/24, showed that at the time of admission, every patient will receive an unclothed safety and health evaluation (SHE), and the results are documented in the electronic health record. The nursing staff enters the initial orders for the unclothed SHE in the electronic health record. Document review of the hospital’s policy and procedure titled, “Admission, Discharge, and Continued Stay Criteria,” policy number POC 100.5, last reviewed 01/25, showed that neither the admission criteria nor the exclusionary criteria referenced the mandatory skin check or guidance for staff when the patient refuses to cooperate with the assessment. 2. The Investigator reviewed the medical record for Patient #1, who arrived to the facility on 01/31/25 at 12:15 AM for treatment of suicidal behavior following an intentional fentanyl overdose. Documentation showed that the patient was admitted at 2:14 AM, and Patient #1 refused a skin assessment. 3. On 04/10/25 at 3:45 PM, during an interview with the Investigator, an intake counselor (Staff #16) stated that he contacted the house supervisor requesting that they perform a skin assessment for the patient. Patient #1 refused the assessment. Staff #16 stated that since the patient refused the skin check, they would need to be monitored on a 1:1 observation (the patient is assigned a constant one to one staff member within close proximity) if they were to be transferred up to the unit. Staff #16 stated that they did not have staff available on the unit for this increased staffing level. In the interim, the patient was placed in the “bubble room,” which is a secured room adjacent to the intake department with a clear plexiglass wall separating the two spaces. When asked about the hospital policy that addresses the skin check requirements or the increased level of observations after a refusal, Staff #16 stated that that was just standard practice in the hospital. 4. On 04/14/25 at 10:50 AM, during an interview with the Investigator, an intake clinician (Staff #10) stated that the mandatory skin check is performed by nursing staff. If there is not a nurse working in intake at the time, staff will call the nursing house supervisor to come to perform the assessment. During the skin check, staff are assessing the patient’s skin for wounds, scars, and injuries, while also looking for contraband. Staff #10 stated that if the patient refuses the skin check, they will be placed on 1:1 or line of sight observations. 5. On 04/14/25 at 1:35 PM, during an interview with the Investigator, the Clinical Director (Staff #2) stated that she was not aware of a “hard and fast rule” regarding the process when a patient refuses the admission skin check and was unsure of the policy that address this. Staff #2 stated that she believed that if the patient refuses to comply with the assessment during their intake process, they should have 1:1 observation on the unit. Item #3 - Monitor for Suicidal Ideation Based on interview, record review, and review of the hospital’s policies and procedures, the hospital failed to implement policies and procedures to manage and monitor patients identified with an increase safety risk for suicidal behaviors, as demonstrated by 1 of 1 medical records reviewed (Patient #1). Failure to ensure that the hospital implemented policies and procedures to guide staff in the prevention, management, and monitoring of patients with an increased risk for suicide ideation and behaviors places the patients at an increased risk for physical and psychological harm or death. Findings included: 1. Document review of the hospital’s document titled, “Levels of Observation,” policy number POC 100.43, last reviewed 08/24, showed the following: a. It is the policy of the hospital to provide a safe and secure environment for patients during their hospitalization. b. Level of observation precautions are initiated by a physician/licensed practitioner/provider or nursing staff when a patient may have an increased risk for harm to self, others, or property. c. There are four levels of observation used. The levels are designed to provide increasing intensity of observation, precaution, and oversight commensurate with the professional staff’s assessment of the patient’s conditions, symptoms and behaviors, and safety needs. d. Standard Observation (Every 15 minutes) - A staff member will directly observe and check in with the patient at least every 15 minutes and document the patient’s location at each interval. All patients at a minimum are at Standard Observations level. e. High Risk Level of Observation (Every 5 minutes) - A staff member will directly observe and check in with the patient at least every 5 minutes and document the patient’s location at each interval. Criteria for this level of observation may include patients who are classified as High Risk for Suicide. f. Line of Sight Observation/Severe High Risk for Suicide - A staff member will always keep the patient within direct line of sight and document the patient’s location at a minimum of 15-minute intervals. When patients shower, change clothes or use the bathroom, the staff will remain outside the door with the door slightly open and visually check on the patient. Criteria for this level of observation may include patients who are classified as Severe High Risk for Suicide. g. One to One (1:1) Observation/Severe Risk for Suicide - A patient is assigned a constant one to one staff member within close proximity who can provide immediate assistance to the patient. The staff member continuously assesses the patient’s location and documents at least every 15 minutes. When patients shower, change clothes, or use the bathroom, staff will remain within close proximity. Criteria for this level of observation may include patients who are classified as Severe High Risk for Suicide. Document review of the hospital’s policy and procedure titled, “Patient Safety Precautions,” policy number POC 100.114, last reviewed 06/24, showed the following: a. It is the policy of the hospital to provide a safe and secure environment for patients during their hospitalization. b. During an emergency situation and in the absence of the physician/provider’s order, the nurse may initiate precautions and will notify the physician/provider to obtain a telephone order as soon as possible and document in the clinical record the rationale. c. High Risk for Suicide/Suicide Precautions/Severe High Risk - Suicide precautions is an intervention used for any patient who has active suicidal ideation (plan, intent, and means). d. Interventions for patients on suicide precautions include an initial, unclothed safety and health evaluation on admission to ensure safety measures. Document review of the hospital’s policy and procedure titled, “Patient Rights,” policy number PR010, last reviewed 01/25, showed that the patient’s rights include the right to receive care in a safe setting. 2. The Investigator reviewed the medical record for Patient #1, who was admitted on 01/31/25 at 2:14 AM. The patient had been transferred from an acute care hospital after a suicide attempt by an intentional overdose on fentanyl 2 days ago. The medical record review showed the following: a. On the Intake Assessment dated 01/31/25 at 2:12 AM, an intake clinician documented that the patient reported current suicidal ideation with a plan to overdose. The patient had a history of multiple suicide attempts. Staff documented when the patient was assessed for their risk for suicidal ideation with intent, the patient’s score was 17, indicating a high-risk for suicide. The intake clinician recommended that the patient be placed on suicide precautions. Staff documented that the intake assessment was reviewed with the provider on call, and the provider accepted the patient at 2:14 AM, placing the patient on suicide precautions. b. A review of the provider’s order showed that on 01/31/25 at 4:47 AM, an order to admit the patient and to place the patient on Q5 (every 5 minute) observations, was entered into the electronic health record by nursing staff. The provider electronically signed the orders on 01/31/24 at 6:24 AM. On 01/31/25 at 11:00 AM, nursing staff entered an order into the electronic health record for the patient adding suicide precautions. The provider authenticated the order at 12:01 PM. c. Patient #1 transferred to the inpatient unit at 9:15 AM. The Investigator found no evidence that staff implemented high suicide risk precautions, including Q5 or 1:1 observations between 2:14 AM and 9:15 AM. 3. On 04/10/25 at 3:45 PM, during an interview with the Investigator, an intake counselor (Staff #16) stated that the patient remained in the intake department between 2:14 AM to 9:10 AM because of the skin check refusal. Once the patient is transferred to the unit, they will be on 1:1 observation until a skin check is completed. Staff #16 stated at the time of Patient #1’s admission, nursing staff reported that that the unit did not have the staff required to perform 1:1 observation for Patient #1, so the patient stayed in the intake department. Staff #16 stated that at approximately 6:30 AM on 01/31/25, the patient knocked on the plexiglass wall, requesting to speak with them. The patient reported that while they were in the bathroom unsupervised, they had taken an undetermined amount of fentanyl, attempting to overdose. The intake counselor notified the house nursing supervisor who came to the intake department to assess the patient. 4. On 04/03/25 at 2:30 PM, during an interview with the Investigator, the Chief Nursing Officer (Staff #7) stated that the patient was placed on 1:1 monitoring after the overdose. The nursing house supervisor stayed with the patient until she was taken up to the unit. Staff #7 verified that the patient was not on 1:1 monitoring prior to the overdose. 5. On 04/14/25 at 10:50 AM, during an interview with the Investigator, an intake counselor (Staff #10) stated that when a patient is the intake department and 1:1 observation is required, the intake staff will stay with the patient. Staff #10 stated that she was unsure of the process for the night shift, since they have less staff available. 6. On 04/14/25 at 1:35 PM, during an interview with the Investigator, the Director of Performance Improvement (Staff #2) stated that when a patient refuses to allow a skin check, 1:1 observation is required, so that patient will be taken to the unit. The expectation is that the intake staff will monitor the patient by 1:1 observation until the patient is transferred to the unit. Item #4 - Incident Reporting Based on interview, medical record review, and policy and procedure review, the hospital failed to ensure that the staff consistently completed incident reports for all qualifying events, to be forwarded for internal and external review, for 1 of 1 qualifying events (Patient #1). Failure to complete an incident report capturing all relevant events occurring at the hospital, involving patients, staff, family members, or visitors, creates barriers to patient safety and ongoing performance improvement, and places the patient at risk for inappropriate care, patient harm, serious injury, and death. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Incident Reporting,” policy number RM014, last reviewed 01/25, showed the following: a. All unexpected and undesirable occurrences causing difficulty or problems which involve a patient, family member, visitor, or employee are to be documented on an Incident Report Form immediately after the occurrence. b. The form is to be signed and sent directly to the immediate supervisor or department manager. c. Any necessary follow-up is to be documented on the incident report. d. The Incident Report is divided by seriousness of the incident, which sections that identify the incident as Class I, Class II, Class III, and Class IV. Class I incidents result in no serious harm to the patient, visitor, or staff. Class II incidents result in some harm, such as suicide attempts off premise. Class III incidents are those that result in serious harm to a patient, or staff that require immediate medical attention. Class IV incidents result in death or permanent loss of function. e. Incident Reports are divided into two categories: An incident and a critical incident. i. An incident is any occurrence that impacts the health, safety, and welfare or lifestyle choice of a patient, including a minor injury, a medication error, or a behavior or situation that is not a critical incident. ii. A critical incident is the alleged, suspected, or actual occurrence of an incident of abuse, neglect, or exploitation, serious medication errors, death, homicide or ideation, a missing person, or other action or event that the provider determines may result in harm to the participant. Document review of the hospital’s policy and procedure titled, “Governing Body Bylaws and Constitution,” policy number ADM006, last reviewed 01/25, showed that the Governing Board is ultimately accountable for the quality of patient care, treatment, and services. The Governing Board ensures the safety of patients, staff, and others. The Governing Board has oversight to ensure an ongoing program for performance improvement and risk management at the hospital. Document review of the hospital’s policy and procedure titled, “Use of Narcan/Naloxone,” policy number NSG 600-80, last reviewed 01/25, showed that the purpose of the policy was to provide guidance on the process of administering Naloxone where an opioid overdose is suspected. The policy does not contain guidance for staff to initiate an Incident Report after an incident of patient overdose or the administration of Narcan. 2. The Investigator reviewed the medical record for Patient #1, who was admitted on 01/31/25 at 2:14 AM. The patient was transferred to the inpatient unit at 9:15 AM. 3. On 04/10/25 at 3:45 PM, during an interview with the Investigator, an intake counselor (Staff #16) stated that the patient remained in the intake department between 2:14 AM to 9:10 AM because of the skin check refusal. Once the patient is transferred to the unit, they will be on 1:1 observation until a skin check is completed. Staff #16 stated that at approximately 6:30 AM on 01/31/25, the patient knocked on the plexiglass wall, reporting that while they were in the bathroom unsupervised, they had taken an undetermined amount of fentanyl, attempting to overdose. The intake counselor notified the house nursing supervisor who came to the intake department to assess the patient. 4. On 04/10/25 at 8:05 AM, during an interview with the Investigator, the house nursing supervisor (Staff #15) stated that after learning of Patient #1’s overdose, she went to the intake department to assessed the patient. Staff #15 stated that the patient had signs of an opioid overdose including pinpoint pupils, slurred speech, decreased level of consciousness, and shallow breathing, with an oxygen saturation in the low 80’s (normal range is between 95% and 100%). Staff #15 stated that due to the patient’s clinically deteriorating status, the nursing staff administered an opioid reversal medication, Narcan at 8:10 AM. 5. The Investigators’ review of hospital documents found not evidence of an Incident Report for the 01/31/25 suicide attempt, overdose, or life-saving medication administration. 6. On 04/03/25 at 2:30 PM, during an interview with the Investigator, the Chief Nursing Officer (Staff #7) stated that there should be an Incident Report for any overdose or suicide attempt. Staff #7 verified that there was no Incident Report created the events for Patient #1 that occurred in the intake department on 01/31/25. 7. On 04/03/25 at 11:30 AM, during an interview with the Investigator, the Clinical Director (Staff #4) stated that after learning of the incident that occurred on 01/31/25 involving Patient #1, she looked for an incident report, but did not locate one. Staff #4 stated that an incident report was not created when the missing report was discovered. .”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 43948 . Item #1 - Staff Naloxone/Narcan Training Based on interviews, document reviews, and policy reviews, the hospital failed to ensure that all staff received the appropriate orientation and annual training for their specific duties and responsibilities, including clear guidance on the administration of Narcan (a medication used to treat patients suspected of an opioid overdose) for 4 of 4 staff reviewed (Staff #3, #10, #15, and #16). Failure to ensure that staff members are adequately prepared to respond to medical emergencies, including a suspected opioid overdose, and administer a lifesaving medication (Narcan), places the patient at risk for serious injury, serious harm, and death. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Use of Narcan/Naloxone,” policy number NSG 600-80, last reviewed 01/25, showed the following: a. The purpose of the policy is to provide guidance on the process of administering Naloxone where an opioid overdose is suspected. b. This policy applies to all healthcare staff with training on the use of Naloxone where an opioid overdose is suspected. c. Intake, reception, and nursing staff will receive education on opioid overdose symptoms and response during New Employee Orientation (NEO) and yearly thereafter. 2. The Investigator made three requests, on 04/03/25, 04/09/25, and 04/14/25, for the hospital’s Narcan/Naloxone training curriculum and competency attestations mentioned in the policy titled, “Use of Narcan/Naloxone.” The hospital staff did not provide the requested training or attestations. 3. A review of the NEO curriculum for nursing staff, clinical services staff, and intake staff showed that curriculum did not include training for Narcan/Naloxone. 4. A record review of personnel files showed that 4 of 4 personnel files did not contain documentation in their position description training, NEO training, or annual training for how to respond to a potential opioid overdose or the administration of Narcan/Naloxone (Staff #3, #10, #15, and #16). 5. On 04/09/25 at 12:10 PM, during an interview with the Investigator, the Director of Performance Improvement (Staff #2) stated that the hospital was currently training, and once the clinical educator was available, they would provide the requested Naloxone/Narcan training curriculum. 6. On 04/09/25 at 1:25 PM, during an interview with the Investigator, an RN (Staff #14) stated that she has worked at the hospital for 8 years and thinks she may have received Narcan training once while attending the hospital’s first aid course. Staff #14 did not remember receiving Narcan training during their annual training. 7. On 04/14/25 at 1:55 PM, during an interview with the Investigator, the Chief Nursing Officer (CNO) (Staff #7) stated that the hospital did not currently have training curriculum or competencies to guide the staff’s response to a potential opioid overdose and the administration of Naloxone/Narcan. Item #2 - Documentation of Overdose Incident and Naloxone Administration Based on interview, record review, and review of the hospital’s policies and procedures, the hospital failed to ensure that staff documented patient safety incidents, including the change in a patient’s condition, the interventions implemented, and the patient’s response to the interventions, as demonstrated by 1 of 1 medical record’s reviewed (Patient #1). Failure to document when incidents or acute changes in a patient’s condition occur, the interventions administered, or the patient’s response to those interventions, risks negative health outcomes, delays the administration of life-saving interventions, and places the patients at an increased risk for physical harm or death. Reference: National Institute of Health (NIH) - National Institute of Drug Abuse Naloxone is a medicine that rapidly reverses an opioid overdose. It is an opioid antagonist. This means that it attaches to the opioid receptors and reverses and blocks the effects of other opioids. Naloxone works to reverse opioid overdoes in the body for only 30 to 90 minutes. But many opioids remain in the body longer than that. Because of this, it is possible for a person to still experience the effects of an overdose after a dose of Naloxone wears off. People who are given Naloxone should be observed constantly until emergency care arrives. They should be monitored for another 2 hours after the last dose of Naloxone is given to make sure breathing does not slow or stop. Findings included: 1. Document review of the hospital’s document titled, “Assessment and Reassessment by Registered Nurse (RN),” policy number NSG 100.1, last reviewed 01/25, showed the following: a. It is the policy of the hospital to provide quality patient care by reassessing the patient’s needs whenever changes in status occur. The RN shall reassess whenever the patient’s needs or status changes. b. The RN shall reassess the patient when medication is changed, or the patient reports any side effects to medication. c. Prior to the administration of any PRN (as needed) medication, the evaluation for need is documented. d. Documentation of the PRN medication effectiveness is required again within 1 hour of administration. e. If the patient is identified to have a physical complaint such as a new physical condition warranting closer assessment, the nurse will reassess the patient and monitor for worsening until improvement is identified. Document review of the hospital’s policy and procedure titled, “Medication Administration,” policy number MM 100.25, last reviewed 01/25, showed that PRN medications will only be given as prescribed by the provider. The policy does not address the administration of medications given in emergent situations, such as Narcan/Naloxone. The policy does not address the monitoring of the patient’s response to the medication or documentation in the patient’s clinical record. Document review of the hospital’s policy and procedure titled, “Use of Narcan/Naloxone,” policy number NSG 600-80, last reviewed 01/25, showed that policy was to provide guidance on the process of administering Naloxone when an opioid overdose is suspected. The policy does not provide staff guidance for any monitoring requirements, such as vital signs, after the medication is administered. The policy does not address documentation requirements in the patient’s clinical record regarding the overdose incident, the medication administration, the patient’s response to the medication, or the patient’s vital signs. Document review of the hospital’s policy and procedure titled, “Medical Emergency,” policy number SP 008, last reviewed 01/25, showed that policy was to provide guidance in the event of a medical emergency. The policy does not address documentation requirements in the patient’s clinical record regarding the patient’s status or change in condition, any medication interventions, the patient’s response to the interventions, or the patient’s vital signs. 2. The Investigator reviewed the medical record for Patient #1, who was admitted on 01/31/25 at 2:14 AM. On the Initial Nursing Assessment dated 01/31/25 at 2:10 PM, staff documented that the patient reported using fentanyl in the intake department and was given Narcan prior to being transferred up to the unit. 3. The Investigator found no evidence of documentation showing Patient #1’s overdose incident or that the patient received Narcan in the intake department. 4. The review of the medical record found that the intake staff documented the patient’s vital signs on 01/31/25 at 6:33 AM and after the patient was transferred to the unit, nursing staff documented the vitals at 9:47 AM. The Investigator found no evidence that staff monitored or assessed the patient’s vital signed between 6:33 AM and 9:47 AM. 5. On 04/10/25 at 3:45 PM, during an interview with the Investigator, an intake counselor (Staff #16) stated that the patient remained in the intake department due to her refusal to comply with the mandatory skin-check prior to her transfer to the unit. Intake staff placed the patient in the “bubble room,” which is a secured room adjacent to the intake department with a plexiglass wall separating the two spaces. At approximately 6:30 AM, the patient reported they had taken an undetermined amount of fentanyl, attempting to overdose. Staff #16 observed that the patient was crying and experiencing shallow breathing. The intake counselor notified the house supervisor who came to the intake department to assess the patient. Staff #16 stated that the house supervisor took the rolling vitals machine into the room and stayed in the room with the patient. The house supervisor was still in the room with the patient when he left at approximately 7:30 AM. 6. On 04/10/25 at 8:00 AM, during an interview with the Investigator, the house nursing supervisor (Staff #15) reported that when she received the call from the intake staff, she obtained a dose of Narcan/Naloxone from the emergency kit on the 2nd floor of the hospital and proceeded to the intake area. Upon her arrival, Staff #15 assessed the patient. She observed that the patient had signs and symptoms of opioid overdose, including pinpoint pupile, slurred speech, a decreased level of consciousness, low blood pressure, and shallow breathing, with an oxygen saturation in the low 80’s (normal oxygen saturation is 95% to 100%). Staff #15 stated that she did not have a method to records the patient’s vital signs, other than a cell phone, at the time of her assessments. Staff #15 stated that the patient continued to exhibit an altered level of consciousness with low oxygen saturation levels, and at 8:10 AM she administered a single 4 mg dose of Narcan/Naloxone nasal spray. Staff #15 stated that she stayed with the patient and continued to monitor the patient’s response to the medication administration and the vital signs. At 9:10 AM, one hour after the Narcan administration, vital signs were stable and the patient was transferred to the unit. Staff #15 stated that she recorded the patient’s vitals on the cell phone and later sent the information to the Chief Nursing Officer. Staff #15 stated that she reported the overdose incident and the Narcan/Naloxone administration to the receiving nurse on the unit. Staff #15 requested that the receiving nurse notify the provider of the incident during treatment team and continue to monitor the patients’ vitals every 5 minutes for one hour, every 30 minutes for 2 hours, and every 4 hours for the next 24 hours. 7. On 04/03/25 at 2:30 PM, during an interview with the Investigator, the Chief Nursing Officer (Staff #7) stated that the house supervisor may have sent Patient #1 vitals to his phone, but he was unable to locate that text message. Staff #7 verified that the overdose incident, the medication administration, and the monitoring of the patient’s vitals signs were not entered into the clinical record. Item #3 - Monitoring and Management of Withdrawal Symptoms and Complications Based on interview, record review, and review of the hospital’s policies and procedures, the hospital failed to ensure that patients assessed with the potential for opiate or alcohol withdrawal were monitored for withdrawal symptoms and complications, as demonstrated by 1 of 1 medical records reviewed (Patient #1). Failure to monitor patients who have the potential to experience withdrawal symptoms and complications from opiates and alcohol detoxification places the patients at an increased risk for physical harm or death. Findings included: 1. Document review of the hospital’s document titled, “Detox Protocols - COWS (Clinical Opiate Withdrawal Scale) & CIWA (Clinical Institute Withdrawal Assessment),” policy number MM 100.5, last reviewed 01/25, showed the following: a. It is the policy of the hospital to provide safe and supportive detoxification that will promote human functioning and personal growth. b. When indicated by a patient’s clinical history and presentation, upon admission or anytime thereafter, providers will order the use of appropriate withdrawal protocols in order to monitor the progress and severity of the patient’s withdrawal process and prevent or manage possible complications. c. When a patient has been chronically using opiates and presents in withdrawal or is expected to be in withdrawal in the near future, the provider will, at their discretion, order the use of COWS to monitor the severity of the withdrawal symptoms. Document review of the hospital’s policy and procedure titled, “Use of Narcan/Naloxone,” policy number NSG 600-80, last reviewed 01/25, showed that policy was to provide guidance on the process of administering Naloxone where an opioid overdose is suspected. The policy did not provide staff guidance for any monitoring requirements, including monitoring for opioid withdrawal by utilizing the COWS to monitor the severity of the withdrawal. The Investigator requested a hospital policy and procedure for patient overdoses. On 04/14/25 at 11:30 AM, the Director of Performance Improvement (Staff #2) stated that the hospital did not have a policy to address staff actions during a suspected overdose. 2. The Investigator reviewed the medical record for Patient #1, who was admitted on 01/31/25 at 2:14 AM. The patient had been transferred from an acute care hospital after a suicide attempt by an intentional overdose on fentanyl a couple of days ago. The medical record review showed the following: a. On the Intake Assessment dated 01/31/25 at 2:12 AM, an intake clinician documented that the patient reported daily substance abuse, including fentanyl, methamphetamines, and cocaine. The patient reported current suicidal ideation with a plan to overdose. The intake clinician documented that the patient was currently experiencing opiate/fentanyl withdrawal. In addition, the intake clinician documented that the patient met the criteria for the following diagnosis: Opioid dependence with withdrawals. The intake staff documented that the patient met the criteria for inpatient psychiatric/substance use treatment due to the severe deterioration in the level of functioning requiring a medically monitored detoxification process. b. A review of the provider’s orders showed that on 01/31/25 at 4:47 AM, the patient was admitted to the unit, however the Investigator found no evidence that the patient was placed on withdrawal protocols. 3. On 01/31/25 at 11:00 AM, nursing staff entered an order adding COWS monitoring every 6 hours. The provider authenticated the order at 12:01 PM. And while the intake clinician had documented that the patient was currently experiencing opiate withdrawals, the medical record did not contain an order to monitor the patient for withdrawal symptoms or complications between 2:14 AM on 01/31/25 until 11:00 AM. 4. On 04/14/25 at 1:55 PM, during an interview with the Investigator, the Chief Nursing Officer (Staff #7) stated that based on the information obtained by the intake clinician during intake screening, Patient #1 should have been on COWS monitoring. If there was not a nurse working in intake at that time, nursing staff should have been pulled from the floor to perform the assessments. .”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 43948 . Based on interview, medical record review, and policy review, the hospital failed to ensure that staff obtained an order from the physician for the administration of all medications, including emergency medication such as Naloxone/Narcan, for 1 of 1 medical records reviewed (Patient #1). Failure to ensure that all medications/treatments administered are ordered by a physician who is responsible for the care and treatment of the patient places the patient at risk for inappropriate care, serious injury, and death. Findings included: 1. Document review of the hospital’s document titled, “Smokey Point Medical Staff Rules and Regulations,” not dated, showed the following: a. All orders are given by a member of the medical staff and authenticated within 72 hours. b. Only the physician or the nurse practitioner can order medications. Document review of the hospital’s policy and procedure titled, “Use of Narcan/Naloxone,” policy number NSG 600-80, last reviewed 01/25, showed the following: a. The purpose of the policy is to provide guidance on the process of administering Naloxone where an opioid overdose is suspected. b. When a patient is unresponsive and/or where an opioid overdoes is suspected, the nurse will call a code blue (a hospital emergency code used to describe the critical status of a patient) and administer Naloxone/Narcan. c. When a physician or provider arrives at the code blue, or when the on-call physician or provider is notified of the incident, the nurse will obtain the order for Naloxone and enter it into the patient’s medical record. 2. The Investigator reviewed the medical record for Patient #1, was admitted on 01/31/25 at 2:14 AM. 3. On 04/10/25 at 3:45 PM, during an interview with the Investigator, an intake counselor (Staff #16) stated after the patient was admitted on 01/31/25 at 2:14 AM, the patient remained in the intake department due to her refusal to comply with the mandatory skin-check prior to her transfer to the unit. Intake staff placed the patient in the “bubble room,” which is a secured room adjacent to the intake department with a plexiglass wall separating the two spaces. At approximately 6:30 AM on 01/31/25, Staff #14 reported that the patient knocked on the plexiglass wall, requesting to speak with them. The patient reported that while they were in the bathroom unsupervised, they had taken an undetermined amount of fentanyl, attempting to overdose. The intake counselor notified the house supervisor who came to the intake department to assess the patient and monitor her status. At 8:10 AM on 01/31/25, the house supervisor administered one single 4 mg dose of Narcan/Naloxone spray. 4. A review of the patient’s medical record showed that staff failed to obtain an order from the provider for the Narcan/Naloxone that was administered in response to the patient’s overdose. 4. On 04/04/25 at 1:55 PM, during an interview with the Investigator, the Chief Medical Officer (Staff #8) stated that there should always be an order for any medication that is administered, including when Narcan is administered during medical emergencies. Staff #8 stated that there is always a provider available 24/7, including a psychiatric provider and a medical provider. The on-call provider should have been contacted, and an order obtained for the administration of the Narcan/Naloxone. 5. On 04/14/25 at 1:55 PM, during an interview with the Investigator, the Chief Nursing Officer (Staff #7) stated that he was not sure of the hospital’s protocol for responding to medical emergencies when a patient overdoses. Staff #7 stated that he was not aware that the hospital had a policy and procedure for these incidents. Staff #7 verified that Patient #1’s medical record did not contain an order for Narcan/Naloxone. Staff #7 stated that based on his nursing experience, the provider should have been notified immediately to report the incident and obtain an order for the reversal medication. .”