Rogers Memorial Hospital

“DISCHARGE PLANNING EVALUATION CFR(s): The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). This Standard is not met as evidenced by: 47413 Based on record review and interview the facility staff failed to ensure that the patient and the patient’s legal guardian were informed of the discharge instructions in 1 of 10 medical records reviewed (Patient #1) in a total sample of 10 medical records reviewed. Findings Include: A review of the facility’s policy #ADM-211 titled, “Patient Rights and Responsibilities” effective 04/29/2025 revealed, “... Rights of the individual served... (and/or legal representative)... has the following rights: ... To receive information about the outcomes of the individual’s care, treatment, or services...” A review of the facility’s policy #PCS-212 titled, “Discharge Planning” effective 10/29/2025 revealed, “... Procedures... 10. Discusses plans for discharge... with the individual’s... legal guardian... 12. Provides the individual served with the discharge summary, including discharge instructions, at the time of discharge... a. At the time of discharge, patients will receive discharge instructions...” A review of Patient #1’s medical record revealed that he was admitted to Facility A on 11/29/2025 under an Emergency Detention (detention for evaluation for individuals with mental illness) for schizoaffective disorder (mental health condition combining psychotic and mood disorder symptoms). Review of Patient #1’s medical record revealed a past medical history of dementia, hypertension (high blood pressure), and medication non-compliance. Further review of Patient #1’s medical record revealed that Guardian J has been Patient #1’s guardian for a year. Patient #1 was discharged from Facility A back to Facility B on 12/19/2025 via Lyft (a transportation service Facility A uses for patient transport). A review of Patient #1’s medical record revealed, “Patient Summary Documents” on 12/19/2025 at 8:23 AM by RN (Registered Nurse) N: “... Patient has received psychoeducation and opportunities to practice healthy coping skills ...” Review of the note revealed no evidence that discharge instructions were given to Guardian J. A review of Patient #1’s medical record revealed, “Discharge Planning Documents- Nurse Completed Verbal Review with Parent/Guardian” on 12/19/2025 at 9:31 AM, and revealed no signature from Patient #1 or Guardian J or evidence that Guardian J was given information on Patient #1’s discharge instructions. A review of Patient #1’s medical record revealed, “Discharge Medication List ... The medications listed have been explained to me and I was given the opportunity to ask questions about my medications. By signing below, I acknowledge I have read and understand the medications and instructions listed” on 12/19/2025 at 9:31 AM, and revealed no signature from Patient #1 or Guardian J or evidence that Guardian J was given information about Patient #1’s discharge medication list. During an interview on 01/27/2026 at 9:45 AM with RN (Registered Nurse) F, when asked about the discharge process if a patient has a legal guardian, he stated that he reviews with medications and the safety plan with the legal guardian and the patient. During an interview on 01/27/2026 at 10:16 AM with Therapist I, she stated that if a patient has a legal guardian, the facility needs to be in communication with the guardian about discharge instructions and discharge medications. During an interview on 01/27/2026 at 2:45 PM with Compliance Specialist E, she stated that patients should be signing the discharge paperwork, and she stated she did not see a signature from Patient #1.”

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 29972 Based on record review and interview the facility staff failed to ensure that the patient’s legal guardian was informed of the discharge instructions as per policy in 1 of 10 medical records reviewed (Patient (Pt) #1); and failed to provide a safe discharge as per the treatment plan in 1 of 10 medical records reviewed (Patient (Pt) #1), in a total sample of 10 medical records reviewed. Findings Include: Facility staff failed to ensure that the patient’s legal guardian was informed of the discharge instructions as per policy. See Tag A-808. Facility staff failed to provide a safe discharge as per the treatment plan. See Tag A-813.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 29972 Based on record review and interview the facility staff failed to ensure that the patient’s legal guardian was kept informed regarding the treatment plan and discharge instructions as per policy in 1 of 10 medical records reviewed (Patient (Pt) #1), in a total sample of 10 medical records reviewed. Findings Include: Review of policy and procedure #15-008-0221 titled, “Patient Rights and Responsibilities” effective 02/01/2021 revealed, “You (Patient) or your representative (Legal Guardian) shall receive information about your illness, course of treatment and prognosis for recovery...” Review of policy and procedure #CLI-PCS-102 titled, “Treatment Planning” last reviewed 02/27/2023 revealed the following: - “The treatment plan is an ongoing reflection of the patient’s changing progress toward goals and requires updates to the treatment plan including possible changes to the IPOC (Interdisciplinary Plan of Care)...and to the Master Treatment Plan.” - “Evaluation is based, not only on team members observation about patient functioning, but on feedback from the patient/guardian/support system.” - “The Treatment Plan Signature Sheet (HIM-139) should be signed by the patient, parent/guardian.” - “If the parent/guardian if not available in person, a member of the care team will review care plan updates, document verbal consent, and sent the parent/guardian form HIM-139 for physical signature.” Review of policy and procedure #CLI-PCS-110 titled, “Aftercare/Continued Care Planning” effective date 05/01/2022 revealed the following: - “Discharge plans and final disposition will be recorded on the ‘Discharge Instructions’ form in the patient’s electronic health record. The course of treatment, improvement during treatment, prognosis, and any problems foreseen for the patient, as well as recommendations made, will be recorded by a member of the treatment team...” - “The treatment team will complete discharge instructions and review these instructions with the patient prior to or at the time of discharge. A member of the treatment team will obtain signatures verifying this review at the time of discharge.” - “The EHR (Electronic Health Record) Depart (Departure) and the Discharge Medication Reconciliation must be reviewed with the parent/guardian for signatures and a copy is provided to the patient/guardian.” Review of Pt #1’s medical records revealed Pt #1 is 37 years old admitted to the behavioral health facility under a Chapter 51 Emergency Detention (involuntary admission) on 06/12/2024 at 2:51 AM; Pt #1 was discharged home on 07/05/2024 at 3:36 PM. Review of Pt #1’s Psychiatric Evaluation dated 06/12/2024 at 2:51 PM, revealed that Pt #1 has a history of schizophrenia spectrum disorder, bipolar mood disorder, PTSD (post traumatic stress disorder), developmental delay and anxiety. Per review of Pt #1’s medical record revealed, “Letters of Guardianship” Circuit Court documents dated 08/18/2004, Family A (Pt #1’s mother) was appointed “Permanent” legal guardian as Pt #1 was deemed “incompetent” per court documents. Review of the Treatment Plan Signature Sheet (HIM-139) form revealed by “Signing this document, I have been informed of the services within the treatment plan and have participated in treatment planning and care.” The Treatment Plan Signature Sheet revealed, “To not delay necessary treatment, when a parent/guardian cannot attend...staff will obtain verbal consent from the parent or guardian to initiate immediate service and will work toward getting written consent within 10 days--this applies to minors and adults with legal guardians.” Review of Pt #1’s Treatment Plan Signature Sheet revealed Pt #1 initialed as having reviewed his/her Treatment Plan with staff on 06/13/2024, 06/20/2024, 06/24/2024, 06/28/2024, and 07/01/2024. Review of Pt #1’s Treatment Plan Signature Sheet revealed that the “Parent/Guardian” sections were not signed by Family A (guardian) to show evidence of staff reviewing the Treatment Plan updates with Family A as per policy. During interview with Director of Clinical Services D on 08/21/2024 beginning at 2:45 PM, Director D stated that the patient and patient’s legal guardian should sign the Treatment Plan as an acknowledgement and consent of the Treatment Plan. Director D confirmed that there was no documented evidence of staff updating Pt #1’s legal guardian on the Treatment Plan meetings and Family A signing as per policy. Review of Pt #1’s Patient Summary Documents revealed that Registered Nurse (RN) E discussed the Discharge Instructions with Pt #1 on 07/05/2024 beginning at 3:21 PM, and Pt #1 signed and acknowledged the Discharge Instructions on 07/05/2024 at 3:24 PM. Review of Pt #1’s Patient Summary Documents revealed the “Patient/Representative Written Consent Signature” showing the legal guardian was informed of Pt #1’s Discharge Instructions was documented as “Declined.” Interview with Family A (Legal Guardian) on 08/20/2024 beginning at 6:28 PM revealed that Pt #1 called Family A after Pt #1 was discharged. Per Family A, Pt #1 stated that he/she was discharged with no transportation. Family A stated that Pt #1 showed up to Family A’s house 3 hours after calling Family A and stated that Pt #1 took the bus home and did not have any money but the bus driver let Pt #1 ride anyway. Per Family A, the hospital did not call and inform Family A that Pt #1 was being discharged on that day. Family A stated that if Pt #1 had not called her, Family A would not have known that Pt #1 was discharged. Family A stated that Pt #1 was not discharged with medication prescription. Per interview with RN E on 08/22/2024 beginning at 9:40 AM, when asked if legal guardians are included in the review of the patient’s discharge instructions, RN E stated that he/she has never run into a situation of having to include the legal guardian with an adult patient. RN E stated that the discharge instructions are shared with the legal guardian if they are present at discharge. RN E stated that he/she was not aware that Pt #1 had a legal guardian and did not review the discharge instructions with Pt #1’s legal guardian. During interview with Director of Nursing (DON) C on 08/21/2024 beginning at 2:05 PM, while reviewing Pt #1’s medical records; DON C confirmed the findings and stated that the discharge instructions should be discussed with the patient’s legal guardian and should be signed by the legal guardian as per policy.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 29972 Based on record review and interview staff failed to implement a preventative action plan based on a comprehensive root cause analysis for all adverse events as per policy in 1 of 3 adverse events reviewed (Patient (Pt) #1), in a total sample of 3 adverse events reviewed. Findings Include: Review of policy and procedure #COM-REG-105 titled, “Incident Reporting” effective 01/01/2022 revealed the following: - “Primary Investigator Responsibilities: 1. Evaluate the incident and assist in providing support as necessary. 2. Investigate the incident and document the following within the incident report: a. who was involved in the incident? b. When did the incident occur? c. Where did the incident occur? d. What happened? e. Was policy followed? f. How can this be prevented from occurring in the future? 3. Initiate any needed action plan, staff re-training, human resources involvement, care delivery process or policy changes, or treatment plan modifications. 4. Sign off on the incident report as completed.” Review of Pt #1’s medical records revealed Pt #1 is 37 years old admitted to the behavioral health facility under a Chapter 51 Emergency Detention (involuntary admission) on 06/12/2024 at 2:51 AM; Pt #1 was discharged “home” on 07/05/2024 at 3:36 PM. Review of Pt #1’s Psychiatric Evaluation dated 06/12/2024 at 2:51 PM, revealed that Pt #1 has a history of schizophrenia spectrum disorder, bipolar mood disorder, PTSD (post traumatic stress disorder), developmental delay and anxiety. Review of Pt #1’s Incident Report completed by Clinical Services Manager (CSM) I, revealed an Incident Date of 07/05/2024 and Time of Incident at 3:40 PM. Per review of the Incident Summary, “Therapist (H) communicated to first shift nurses that patient was not to be discharged until everything was set in place for the group home...At 341 (3:41 PM) (H) came to (CSM I) office and stated that the second shift nurse (RN E) just discharged (Pt #1) without checking to see if things were set. (Pt #1) did not have any medications faxed to preferred pharmacy and no ride was set up for the patient to take him to his group home. Patient is on a stipulation agreement for (Pt #1’s) emergency detention and housing was a stipulation to his agreement. Writer went to ask (RN E) if he/she got any hand off from 1st shift nurse (RN F) and he/she stated ‘No. I just saw the DC (discharge) order and discharged him...’” Per interview with Psychiatrist G on 08/21/2024 beginning at 3:40 PM, Psychiatrist G stated that he/she mistakenly put an order for Pt #1 to discharge home instead of to the group home. Psychiatrist G stated that it was a miscommunication and stated that the nurse saw the order to discharge “home” and figured it was ok to discharge. Psychiatrist G stated that the discharge orders automatically default to “home” and he/she should have changed this. Per interview with RN E on 08/22/2024 beginning at 9:37 AM, RN E stated that he/she came in as 2nd shift RN and took shift report from the first shift RN F that Pt #1 was “packed up and ready to go.” RN E stated he/she reviewed the physician order and discharged Pt #1. RN E was not aware that Pt #1 had a legal guardian and was not aware of the discharge plan to discharge to a group home with transportation. RN E stated that he/she should have coordinated with the treatment team to ensure all steps were completed prior to discharging Pt #1. Review of the Primary Investigator Summary of Pt #1’s Incident Report revealed, “(Registered Nurse E) was educated/reminded via a coaching note...” Review of Registered Nurse (RN) E’s Coaching Form signed by RN E on 07/18/2024 revealed, “Before discharging a patient, make sure that both Therapist and CTS (Care Transition Specialist) have completed their documentation. This is notated under discharge forms in Cerner-result will state ‘yes’ once their forms are complete. If there are any delays from the clinical team in completing their paperwork, please reach out to them directly to coordinate discharge. Nursing may not discharge a patient until the clinical documentation is complete.” Per review of Pt #1’s Incident Report there was no documented evidence of a comprehensive investigation, including interviewing all staff involved to determine the root cause and implementing a preventative action plan based on all contributory factors. Per interview with Director of Nursing (DON) C on 08/21/2024 beginning at 2:20 PM, DON C stated that staff determined that Pt #1’s adverse event was caused by a lack of communication by RN E and he/she was re-educated on reviewing notes and communication. DON C stated that the investigation and action plan did not address the physician’s order being inaccurate or the nursing shift report provided to RN E. Per DON C, no other staff were re-educated or provided with a coaching. If a discharge happens during shift change, DON C stated that it is not in the RN’s discharge process to review progress notes from previous days, the RN will review the physician order for discharge and rely on nursing shift report.”

“DISCHARGE PLANNING EVALUATION CFR(s): The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). This Standard is not met as evidenced by: 29972 Based on record review and interview the facility staff failed to ensure that the patient’s legal guardian was informed of the discharge instructions as per policy in 1 of 10 medical records reviewed (Patient (Pt) #1), in a total sample of 10 medical records reviewed. Findings Include: Review of policy and procedure #CLI-PCS-110 titled, “Aftercare/Continued Care Planning” effective date 05/01/2022 revealed the following: - “Discharge plans and final disposition will be recorded on the ‘Discharge Instructions’ form in the patient’s electronic health record. The course of treatment, improvement during treatment, prognosis, and any problems foreseen for the patient, as well as recommendations made, will be recorded by a member of the treatment team...” - “The treatment team will complete discharge instructions and review these instructions with the patient prior to or at the time of discharge. A member of the treatment team will obtain signatures verifying this review at the time of discharge.” - “The EHR (Electronic Health Record) Depart (Departure) and the Discharge Medication Reconciliation must be reviewed with the parent/guardian for signatures and a copy is provided to the patient/guardian.” Review of Pt #1’s medical records revealed Pt #1 is 37 years old admitted to the behavioral health facility under a Chapter 51 Emergency Detention (involuntary admission) on 06/12/2024 at 2:51 AM; Pt #1 was discharged home on 07/05/2024 at 3:36 PM. Review of Pt #1’s Psychiatric Evaluation dated 06/12/2024 at 2:51 PM, revealed that Pt #1 has a history of schizophrenia spectrum disorder, bipolar mood disorder, PTSD (post traumatic stress disorder), developmental delay and anxiety. Per review of Pt #1’s medical record revealed, “Letters of Guardianship” Circuit Court documents dated 08/18/2004, Family A (Pt #1’s mother) was appointed “Permanent” legal guardian as Pt #1 was deemed “incompetent” per court documents. Review of Pt #1’s Patient Summary Documents revealed that Registered Nurse (RN) E discussed the Discharge Instructions with Pt #1 on 07/05/2024 beginning at 3:21 PM, and Pt #1 signed and acknowledged the Discharge Instructions on 07/05/2024 at 3:24 PM. Review of Pt #1’s Patient Summary Documents revealed the “Patient/Representative Written Consent Signature” showing that the legal guardian was informed of Pt #1’s Discharge Instructions was documented as “Declined.” Interview with Family A (Legal Guardian) on 08/20/2024 beginning at 6:28 PM revealed that Pt #1 called Family A after Pt #1 was discharged. Per Family A, Pt #1 stated that he/she was discharged with no transportation. Family A stated that Pt #1 showed up to Family A’s house 3 hours after calling Family A and stated that Pt #1 took the bus home and did not have any money but the bus driver let Pt #1 ride anyway. Per Family A, the hospital did not call and inform Family A that Pt #1 was being discharged on that day. Family A stated that if Pt #1 had not called her, Family A would not have known that Pt #1 was discharged. Family A stated that Pt #1 was not discharged with medication prescription. Per interview with RN E on 08/22/2024 beginning at 9:40 AM, when asked if legal guardians are included in the review of the patient’s discharge instructions, RN E stated that he/she has never run into a situation of having to include the legal guardian with an adult patient. RN E stated that the discharge instructions are shared with the legal guardian if they are present at discharge. RN E stated that he/she was not aware that Pt #1 had a legal guardian and did not review the discharge instructions with Pt #1’s legal guardian. During interview with Director of Nursing (DON) C on 08/21/2024 beginning at 2:05 PM, while reviewing Pt #1’s medical records; DON C confirmed the findings and stated that the discharge instructions should be discussed with the patient’s legal guardian and should be signed by the legal guardian as per policy.”

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 29972 Based on record review and interview the facility failed to provide a safe discharge as per treatment plan in 1 of 10 medical records reviewed (Patient (Pt) #1), in a total sample of 10 medical records reviewed. Findings include: Review of policy and procedure #15-008-0221 titled, “Patient Rights and Responsibilities” effective 02/01/2021 revealed, “You (Patient) or your representative (Legal Guardian) shall receive information about your illness, course of treatment and prognosis for recovery...” Review of policy and procedure #CLI-PCS-110 titled, “Aftercare/Continued Care Planning” effective date 05/01/2022 revealed the following: - “Discharge plans and final disposition will be recorded on the ‘Discharge Instructions’ form in the patient’s electronic health record. The course of treatment, improvement during treatment, prognosis, and any problems foreseen for the patient, as well as recommendations made, will be recorded by a member of the treatment team...” - “Verify attending provider’s written discharge order and discharge plan.” - “The treatment team will complete discharge instructions and review these instructions with the patient prior to or at the time of discharge. A member of the treatment team will obtain signatures verifying this review at the time of discharge.” - “Discharge instructions shall contain the following: a. A complete description of arrangements with treatment and other community resources for the provision of follow-up services...c. Description of community housing/living arrangement...” - “At the time of discharge, patients will receive a patient summary of information that outlines:...b. Treatment needs that will continue at the next level of care...d. Living arrangements...” - “The EHR (electronic health record) Depart (Departure) and the Discharge Medication Reconciliation must be reviewed with the patient/guardian for signatures and a copy is provided to the patient/guardian.” Review of Pt #1’s medical records revealed Pt #1 is 37 years old admitted to the behavioral health facility under a Chapter 51 Emergency Detention (involuntary admission) on 06/12/2024 at 2:51 AM; Pt #1 was discharged “home” on 07/05/2024 at 3:36 PM. Review of Pt #1’s Psychiatric Evaluation dated 06/12/2024 at 2:51 PM, revealed that Pt #1 has a history of schizophrenia spectrum disorder, bipolar mood disorder, PTSD (post traumatic stress disorder), developmental delay and anxiety. Per review of Pt #1’s Letters of Guardianship Circuit Court documents dated 08/18/2004, Family A (Pt #1’s mother) was appointed “Permanent” legal guardian as Pt #1 was deemed “incompetent” per court documents. Review of Pt #1’s Social Worker Progress Notes completed by Social Worker (SW) H revealed the following: -06/26/2024 at 11:34 AM: “Pt reports concern that he does not have stable housing...Writer to follow up with CM (case manager).” -06/26/2024 at 12:51 PM: “Pt’s (Pt #1’s) mother (Family A) reports return to apartment is not option at this time.” -06/26/2024 at 4:58 PM: “Writer met with pt to discuss housing following d/c (discharge) from IP (inpatient)...Pt reports (Pt #1) was not aware that (Pt #1) was unable to return to former living arrangement...Pt reports anxiety surrounding unstable housing...” -06/28/2024 at 11:22 AM: “Writer provided pt with update regarding housing. (Pt #1) stated ‘I will just be homeless.’ Writer reassured pt that voicemails have been left for Family Care to assist with placement.” -07/02/2024 at 2:11 PM: “Writer received email from...Granny’s House informing writer pt has been accepted for housing.” -07/02/2024 at 4:13 PM: “Writer met with pt and informed of acceptance to Granny’s House (group home). Pt is agreeable. MD (physician) in process of completing intake paperwork...” Review of Pt #1’s Physician Progress Note completed by Psychiatrist G dated 07/05/2024 at 2:58 PM revealed, “...(Pt #1) was alerted to discharge, told that he would be going to (Pt #1’s) new group home today...Discharge orders were completed relative to (Pt #1) going to his new group home. Medications were transmitted to pharmacy electronically. SW/therapist was in the process of arranging for transportation for (Pt #1).” Review of Pt #1’s Patient Summary Documents including the Discharge and Aftercare Instructions, signed by Registered Nurse (RN) E on 07/05/2024 at 3:21 PM revealed, “(Pt #1) to discharge to Granny’s House.” Discharge Instructions were signed by the patient on 07/05/2024 at 3:24 PM. The Aftercare and Discharge Instructions were not signed indicating that staff reviewed the final treatment plan and discharge instructions with the legal Guardian (Family B) as per policy. Review of Pt #1’s Physician orders revealed that Psychiatrist G wrote an order on 07/05/2024 at 2:53 PM to discharge Pt #1 “Home”, this was inconsistent with Pt #1’s treatment plan to discharge to a group home. Review of Pt #1’s Incident Report completed by Clinical Services Manager (CSM) I, revealed an Incident Date of 07/05/2024 and Time of Incident at 3:40 PM. Per review of the Incident Summary, “Therapist (H) communicated to first shift nurses that patient was not to be discharged until everything was set in place for the group home...At 341 (3:41 PM) (H) came to (CSM I) office and stated that the second shift nurse (RN E) just discharged (Pt #1) without checking to see if things were set. (Pt #1) did not have any medications faxed to preferred pharmacy and no ride was set up for the patient to take him to his group home. Patient is on a stipulation agreement for (Pt #1’s) emergency detention and housing was a stipulation to his agreement. Writer went to ask (RN E) if he/she got any hand off from 1st shift nurse (RN F) and he/she stated ‘No. I just saw the DC (discharge) order and discharged him...’” Interview with Family A (Legal Guardian) on 08/20/2024 beginning at 6:28 PM revealed that Pt #1 called Family A after Pt #1 was discharged. Per Family A, Pt #1 stated that he/she was discharged with no transportation. Family A stated that Pt #1 showed up to Family A’s house 3 hours after calling Family A and stated that Pt #1 took the bus home and did not have any money but the bus driver let Pt #1 ride anyway. Per Family A, the hospital did not call and inform Family A that Pt #1 was being discharged on that day. Family A stated that if Pt #1 had not called her, Family A would not have known that Pt #1 was discharged. Family A stated that Pt #1 was not discharged with medication prescription. Per interview with Psychiatrist G on 08/21/2024 beginning at 3:40 PM, Psychiatrist G stated that he/she mistakenly put an order for Pt #1 to discharge home instead of to the group home. Psychiatrist G stated that it was a miscommunication and stated that the nurse seen the order for “home” and figured it was ok to discharge. Psychiatrist G stated that staff realized the mistake after Pt #1 was discharged and Psychiatrist G drove around in car looking for Pt #1 but could not locate him/her. Psychiatrist G stated that he/she assumed Pt #1 took the bus to Family A’s house. Per interview with RN E on 08/22/2024 beginning at 9:37 AM, RN E stated that the RN should print out the discharge medication list, discharge instructions, and aftercare instructions and review with the patient prior to discharge. RN E stated that he/she came in as 2nd shift RN and took shift report from the first shift RN F that Pt #1 was “packed up and ready to go.” RN E stated he/she reviewed the physician order and discharged Pt #1. RN E was not aware that Pt #1 had a legal guardian and was not aware of the discharge plan to discharge to a group home with transportation. RN E stated that he/she should have coordinated with the treatment team to ensure all steps were completed prior to discharging Pt #1.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47413 Based on observation, record review and interview facility staff failed to prevent contraband from entering the unit for 8 patients (Patients #1, 2, 5, 6, 7, 8, 10, 11) in a total of 12 adverse events reviewed involving contraband and failed to wand patient clothing per facility policy in 1 (Patient #3) of 1 patient observed. Findings Include: Facility staff failed to prevent contraband from entering the unit and failed to wand patient clothing per facility policy. See tag A-0144. Immediate Jeopardy was determined on 07/10/2024 at 11:20 AM under 42 CFR 482.13 regarding the facility’s failure to prevent contraband from entering the unit. Facility staff were notified of the Immediate Jeopardy on 07/10/2024 at 11:20 AM. The Immediate Jeopardy was removed on 07/10/2024 at 2:15 PM after the facility developed an education curriculum for all staff to complete prior to being involved in the belongings check process. The deficient practice remains at a Condition level pending evidence of ongoing sustainable and systemic implementation of corrective actions.”

“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: 47413 Based on observation, record review and interview facility staff failed to prevent contraband from entering the unit in 8 (Patients #1, 2, 5, 6, 7, 8, 10, 11) in a total of 12 adverse events reviewed involving contraband and failed to wand patient clothing per facility policy in 1 (Patient #3) of 1 patients observed. Findings Include: A review of the facility’s policy titled, “Patient Rights and Responsibilities” effective 02/01/2021 revealed, “ ... The following are your rights as a voluntary patient in a mental health facility: ... Your surroundings must be kept safe and clean ...” A review of the facility’s policy titled, “Searches of Person, Belongings & Environment” last reviewed 04/10/2023 revealed, “ ... The purpose of this policy is to provide a safe environment for all patients ... and to establish clear guidelines in searching, storing, or disposing of potentially harmful items ... Personal Search: Inpatient: A search of the patient’s person, including the patient’s pockets, patting the individual’s body, an examination of patient’s shoes and hat, and if suspicion indicated, a visual inspection of the patient’s mouth ... Belongings Search- (Admission): Before entering the facility, a search of person (patient) and belongings shall be completed by the staff member admitting and orienting the patient to the facility ... Until the belongings search is complete, the patient should not be left unattended with belongings ... The patient is to be present whenever possible during a search of personal belongings ... All cell phones are to be placed in storage (off unit) ...” A review of the facility’s document titled, “Standard Work Sheet; Purpose: Check in belongings, ensure safety and eliminate prohibited/restricted items, secure patient valuables” last updated 03/05/2024 revealed, “... Staff will use metal detector to wand clothing and items the patient identifies to be brought onto the unit...” A review of the facility’s document titled, “Prohibited items- Inpatient and Residential Levels of Care” last revised 04/10/2023 revealed, “Prohibited belongings or possessions are strictly banned by law and/or [facility name] for the safety of all patients ... The prohibited items on this list apply to all patients ...” The facility’s document revealed the following items were listed as prohibited: “Illegal substances; E-cigs/Vape and other smokeless cigarettes; Cellphones; Straight razors; Craft kits with sharp items; Shoes with shoelaces.” A review of the facility’s adverse event reports from 03/01/2024 through 07/09/2024 revealed the following incidents regarding contraband found on the inpatient units: On 03/04/2024 Patient #1 brought cocaine (illegal street drug) onto the unit. Patient #1 was voluntarily admitted on 03/04/2024 for relapse of alcohol and cocaine use. On 03/04/2024, Patient #1 was found with cocaine on the unit. The cocaine was confiscated per facility policy and there was no known clinical outcome to Patient #1 or other patients present on the unit identified. On 03/04/2024, Patient #2 brought a razor blade onto the unit. Patient #2 was voluntarily admitted on 03/04/2024 for anxiety, depression, and suicidal ideation. On 03/04/2024, Patient #2 was found with a razor blade on the unit. The razor blade was confiscated per facility policy and Patient #2 cut his/her right forearm with the razor blade as a result. On 04/15/2024, Patient #5 was found with a vape pen on the unit. Patient #5 was voluntarily admitted on 04/07/2024 for suicidal ideation. On 04/15/2024, Patient #5 was found with a vape pen on the unit. The vape pen was confiscated per facility policy and there was no known clinical outcome to Patient #5 or other patients present on the unit identified. On 04/21/2024, Patient #6 brought a baggie with a large amount of ecstasy (illegal street drug) onto the unit. Patient #6 was voluntarily admitted on 04/20/2024 for anxiety and depression. On 04/21/2024, Patient #6 was found with a baggie with a large amount of ecstasy on the unit. The ecstasy was confiscated per facility policy and there was no known clinical outcome to Patient #6 or other patients present on the unit identified. On 05/13/2024, Patient #10’s cellphone was found on the unit. Patient #10 was voluntarily admitted on 05/13/2024 for suicidal ideation and cocaine use. On 05/13/2024, Patient #10 was found with his/her cellphone on the unit. The cellphone was confiscated per facility policy and there was no known clinical outcome to Patient #10 or other patients present on the unit identified. On 05/24/2024, Patient #7’s clothes with a hypodermic needle were found in the dryer. Patient #7 was voluntarily admitted on 05/20/2024 for anxiety, depression, and suicidal ideation. On 05/24/2024, staff found a hypodermic needle in the dryer with Patient #7’s clothing. The needle was confiscated per facility policy and there was no known clinical outcome to Patient #7 or other patients present on the unit identified. On 06/25/2024, Patient #8’s vape pen was found on the unit. Patient #8 was voluntarily admitted on 06/19/2024 for mania (a state of mind where an individual experiences intense moods, delusions, and hyperactivity) and psychosis. On 06/25/2024, Patient #8 was found with a vape pen on the unit that s/he “found it outside in a bush.” The vape pen was confiscated per facility policy and there was no known clinical outcome to Patient #8 or other patients present on the unit identified. On 07/06/2024, an empty patient room (previously Patient #11 - unknown name) had 2 shoestring laces laying on top of the cabinet in the room. No known clinical outcome for any of the patients present on the unit identified. During an observation on 07/09/2024 beginning at 11:16 AM of the facility’s belongings check process in the belonging check room, MHT (Mental Health Technician) W was observed going through patient belongings with Patient #3. MHT W did not wand Patient #3’s clothing items. An interview was conducted on 07/09/2024 at 10:54 AM with RN H. RN H stated that facility staff receive education on contraband during orientation. RN H stated that updates to policies, procedures, or education is “just a lot of word of mouth around here.” When asked about belongings checks, RN H stated, “When I first started, everyone was in charge of belongings checks. Then it went to just a certain group of people who was in charge of the checks. Now it is back to everyone can do the belongings checks. I think it worked better when a specific group was in charge of the checks.” When asked about the belongings check and skin check process, RN H stated, “Sometimes the nurse will do the skin check on the patient and then the tech will go through the patient belongings afterwards. Patients could easily grab something.” An interview was conducted on 07/09/2024 at 11:09 AM with VP of Compliance B. When asked to explain the belongings check and skin check process, VP of Compliance B stated that the preferred process would be that the patient belongings are reviewed in the belongings room with the patient or 2 staff members and after the belongings check, the patient will go through their skin check in the hybrid room. An interview was conducted on 07/09/2024 at 12:04 PM with MHT K. When asked about the belongings check process, MHT K stated, “Sometimes the patients might have had a skin check prior to getting their belongings searched.” An interview was conducted on 07/09/2024 at 12:06 PM with RN L. When asked about education regarding contraband and belongings search, RN L stated that it is part of their annual trainings. When asked about contraband on the units, RN L stated, “I have recently seen vapes and cellphones making it back.” During an interview on 07/09/2024 at 1:26 PM with DON (Director of Nursing) D when asked about how s/he ensures that staff receive re-education and updates on adverse events such as contraband being brought onto the unit by patients, DON D stated, “I have weekly Teams meetings where I will post updates and documents for staff to review; the expectation is that all staff join, but they are not required to join. There is no certain time frame after the meetings are completed that staff need to review the meeting minutes. Staff are not required to sign anything showing that they joined the meeting or reviewed the updates.” During an interview on 07/10/2024 at 1:55 PM with Talent Development Onboarding Specialist O, when asked if patient belongings such as clothes need to be wanded during the belongings check, Talent Development Onboarding Specialist O stated, “Yes, staff should be wanding. It is part of our standard workflow.””

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 41127 Based on record review and interview, the facility failed to immediately re-educate all staff on appropriate and inappropriate de-escalation techniques following an incident that occurred with 1 of 1 patient (Patient #1) in a total of 1 facility-submitted Misconduct Report reviewed. Findings Include: A review of the entity-submitted Misconduct Incident Report (MIR) on 03/28/2024 revealed an incident that occurred on 03/20/2024 involving several staff members [Registered Nurse (RN) A, RN B, and Mental Health Technician (MHT) C)] who used their feet to push and scoot Patient #1 off the elevator and down the hallway towards the unit after Patient #1 refused to walk. A review of Patient #1’s medical record revealed Patient #1 was a 10-year-old who was voluntarily admitted to the facility on 03/15/2024 for combative and aggressive behavior and was discharged to home on 03/22/2024. Patient #1 had a diagnosis of ADHD (Attention Deficit Hyperactivity Disorder). Chief complaint for admission is documented as, “[Patient #1] says is here “because of anger issues.” A review of the “Incident Report” dated 03/20/2024 (no time) completed by Director of Nursing (DON) D revealed, “Unit staff reported to me during staff debriefing that staff used their feet to pull, push, and scoot the patient onto an off the elevator.” Documentation of actions taken included: 03/21/2024-video reviewed. 03/21/2024-A review with compliance, Human Resources, Chief Operating Officer, and Patient Safety occurred. 03/21/2024- Employees observed placed on paid leave until investigation is completed...” During an interview on 04/24/2024 at 9:40 AM MHT C stated on 03/20/2024 s/he was asked to help with Patient #1 who was trying to fight with another patient. MHT C stated 2 nurses went down to the cafeteria to assist Patient #1 back to the unit. Patient #1 was very agitated, refusing to get off the elevator, and started rolling around on the floor in the elevator. Patient #1 did eventually walk off the elevator and once in the hallway laid on the floor. Patient #1 was using his/her head to run into the shins of the staff and was banging his/her head on the wall. MHT C stated the two nurses used their legs to guide Patient #1 forward down the hall toward the unit. During an interview on 04/24/2024 at 11:25 AM Vice President (VP) of Compliance M stated as part of the investigation the video of the incident with Patient #1 was reviewed on 03/21/2024 by patient safety staff. VP of Compliance M stated the staff did not report the use of their legs/feet to scoot Patient #1 out of the elevator in the incident report. When the video was reviewed by Patient Safety Staff, it was determined the involved staff used a practice that was not a technique the staff is trained to use. During an interview on 04/25/2024 at 12:20 PM Director of Nursing (DON) D stated s/he had concerns with the maneuver staff used to get Patient #1 on and off the elevator and the use of the feet/legs to force the patient off the elevator and down the hall was a technique that was not taught in CPI (Crisis Prevention Institute) training (crisis intervention and de-escalation skills that reduce challenging behaviors). DON D stated that when RN A, RN B and MHT C were asked about the technique they used with their legs to “scoot the patient off the elevator” they stated that was a “technique that was taught in previous training.” DON D stated this was not a technique that is used or taught currently in crisis intervention or de-escalation skills for patients who are exhibiting challenging behaviors. DON D stated RN A and RN B voluntarily terminated their employment while the staff was on suspension during investigation of the incident with Patient #1. MHT C was informed that NCI (Nonviolent Crisis Intervention) training needed to be completed prior to returning to work. A review of attendance sheet titled, “Nonviolent Crisis Intervention Refresher Training” dated 04/17/2024 at 8:00 AM-12:00 PM revealed MHT C was included in the roster, as well as signature by MHT C. There was no evidence found that all facility staff were re-educated on appropriate de-escalation techniques immediately following the incident.”

“ORGANIZATION OF NURSING SERVICES CFR(s): 482.23(a) The hospital must have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The director of the nursing service must be a licensed registered nurse. He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. This Standard is not met as evidenced by: 44431 Based on record review and interview, the facility failed to develop policy to ensure that the Director of Nursing (DON) has a valid Wisconsin license in 1 of 1 DON position descriptions reviewed. Findings include: Review of facility document entitled “Job Description Director of Nursing Inpatient,” last revised 09/06/2023 revealed, “The Director of Nurses.....will manage department staff ...manage care of patients ranging in age from 4 to geriatric and will be expected to function clinically on an inpatient unit, if necessary, and/or assist with patient care issues as they arise...assume the manager role on the inpatient units in a clinical capacity as needed..6. Assist with development and maintenance of policies and procedures with the Vice President of Nursing.” Review of facility DON (Director of Nurses) job description education/training requirements revealed no criteria for Wisconsin state licensure or that any registered nurse license was required. Review of memo announcement informing staff of Staff D starting at the facility in the official role as the new DON is dated 10/12/2023 at 2:29 PM. Review of DON D’s personnel file found that DON D held a current Registered Nurse license from another state (non-compact state) and a Wisconsin Registered Nurse License was obtained on 11/14/2023. DON D did not hold a valid nursing license to practice in Wisconsin in the period from 10/12/2023 to 11/14/2023. In an interview with Vice President M on 4/25/24 at 10:25 AM when asked about the training Staff D received and if they provided care prior to orientation being completed, M stated, “Staff D had 30 days of shadowing with our previous DON and had an additional 30 days of training with the DON. We have found no evidence of Staff D providing care before receiving their Wisconsin Nursing License, but they were licensed in the state of Illinois. Although DON D now holds a current Wisconsin nursing license, there is no evidence that the facility has updated their policy or the DON Job Description to require a valid Wisconsin nursing license at the time of appointment to the DON role.”

“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: 44431 Based on record review and interview the facility failed to clearly define, communicate and provide training on the expectation of how ADL (Activities of Daily Living) are provided to patients by the MHTs (Mental Health Technicians) in 1 of 1 Employee Orientation Process reviewed. Findings Include: Review of facility policy titled, “New Employee Orientation (NEO),” effective date of 01/01/2022 revealed, “Purpose: To assure each employee has a thorough understanding of [Facility Name] policies, services, and philosophy, as well as the duties of their job....In order to assure successful completion of the orientation period, each employee will be oriented to all facets of his/her job and working conditions based on the job description....Orientation to working conditions and specific aspects of the job will be conducted by the manager or an individual appointed by the department manager on an “on-the-job” basis.....Clinical employees will continue orientation to complete Patient Care Orientation (PCO)...[Facility Name] Practical Skills are provided during orientation, role-specific onboarding, and on the job training.” Review of facility document titled, “Inpatient Mental Health Technician (MHT) Initial Competency Checklist,” revealed under patient care tasks, no competencies or return demonstration required specific to ADLs. Review of Nursing Services Orientation for MHTs, titled, “ADL’s (Activities of Daily Living) Roles Activity,” no date, revealed, “This activity is designed to understand what surrounding ADLS an MHT is expected to support....In the hospital setting, ADLs, or Activities of daily living, encompass the essential tasks patients need assistance with to maintain their well-being and facilitate their recovery process...Personal Hygiene: Assisting patients with bathing, grooming, and oral care to promote cleanliness and prevent infections....Dressing and undressing: Helping patients put on and take off clothing as needed, considering any medical devices or equipment they may require...Mobility assistance: Supporting patient with walking, transferring from bed to chair, or using mobility aids to prevent muscle atrophy and maintain mobility...Toileting: Helping patients with using the toilet and maintaining continence, addressing any issues related to mobility or medical conditions...Basic household (patient room) tasks...this may involve ensuring the patient’s immediate environment is clean and comfortable...In our setting, nurses and MHTs work together to assist patients with these ADLs as part of their comprehensive plan.” Review of the Facility document titled, “Mental Health Technician job description,” revealed, “The Mental Health Technician functions as an active part of the treatment team, providing continuous patient care....Job Duties and Responsibilities: 1. Assist patients with performing activities of daily living. 2. Assists in direct patient care in group or one-to-one setting.” Review of Personnel files for MHTs C, G and H revealed completed nursing services orientation but no specific training or competency assessment relating to the performance of ADLs. In interviews conducted with MHTs Staff G and H between 04/23/2024 and 04/25/2024, both stated there is no clear expectation on what is expected of MHTs when assisting patient who require assistance with ADLs and what that means. Review of email sent to all facility MHTs from Staff D on 03/07/2024 at 11:37 revealed, “We are committed to accepting patients in a psychiatric/behavioral crisis at our facility. Our decision to accept a patient is based on specific criteria and hospital required standards....A patient in psychiatric/behavioral crisis may also need assistance with activities of daily living or have other needs that may be unfamiliar to some. Once a patient is accepted, it becomes our collective responsibility to prioritize their safety, well being, and ensuring that their needs are met. We are dedicated to providing a therapeutic, clean and supportive environment for all patients under our care....I have attached the job description for all to review.” In an interview with Staff D on 04/25/2024 at 12:20 PM, when asked if staff are expected to provide patient care without being trained or certified, Staff D stated, “We try to assign a CNA (Certified Nursing Assistant) to all the patients that need assistance with ADLs. We don’t require our MHTs to be CNAs. We do accept patients that have a need for assistance with ADLs but this is more on the adult unit. MHTs would assist nurses and do what they are comfortable to do, but we don’t have a specific training/competency for ADLs. We don’t take patients that require total care with ADLs.””