Miramont Behavioral Health

“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: 50643 Based on record review and interview staff failed notify a medical provider and enter a safety event related to falls in 1 of 3 medical records reviewed (Patient #1), failed to update and revise the nursing care plan with appropriate interventions and goals to reflect patient’s care needs related to falls in 1 of 3 medical records reviewed (Patient #1), and failed to follow provider direction related to neurological nursing assessments following a patient fall in 1 of 3 medical records reviewed (Patient# 5) in a total sample of 10 medical records reviewed. Findings Include: A review of the facility’s policy titled, “Occurrence Reporting - Severity Classification” dated 12/2022 revealed, “... Serious injuries/events constitute... Accidents such as falls... Any facility employee of staff member who discovers, is directly involved in or is responding to an event/occurrence is to complete or direct the completion of an occurrence/incident form... The incident report is to be completed at the time of the event...” A review of the facility’s policy titled, “Edmonson Fall Reduction” dated 12/2022 revealed, “...the staff will assess and re-assess the patient’s level of risk for falls and in conjunction with the treatment team, institute appropriate interventions...the plan will be renewed annually and on as needed basis...The Edmonson Fall Risk Assessment (a tool designed to evaluate the risk of falls among psychiatric patients by analyzing various factors such as medication use, diagnosis, ambulation, nutrition, sleep patterns, and history of falls) will be completed by a Registered Nurse during the intake phase of admission... Each patient will be reassessed each shift... Documentation will be completed in the patient’s medical record. All High-Risk fall patients will have a Problem Listed for Risk and Falls on their Treatment Plan. In the event of a patient fall, with or without injury... A nurse will assess the patient... The attending physician will be promptly notified to determine the need for further evaluation... The nurse follows the physician’s treatment orders post fall... Neurological checks and vital signs as ordered or appropriate for injury... The caregiver witnessing a fall or finding a patient after an un-witnessed fall will complete an incident report and turn in to the risk manager... Patient’s fall risk will be reassess utilizing the Edmonson Fall Risk Assessment immediately after the fall, identifying appropriate interventions and needed safety devices... Patient’s Treatment Plan will be reviewed and updated...” Review of Patient #1’s medical record revealed Patient #1 had an unwitnessed fall on 10/24/2025 at 8:45 AM. Nursing assessment revealed no injury. There was no documentation that the medical staff was notified per policy. Review of the Facility Event log revealed that no event was entered for Patient #1 at the time of Patient #1’s fall on 10/24/2025 at 9:36 AM. Review of Patient #1’s medical record revealed that there was no Edmonson Psychiatric Fall Risk Assessments/Score and no updates to Patient #1’s Treatment Plan at the time of her fall on 10/24/2025 at 8:45 AM. Review of Patient #5’s medical record revealed Patient #5 had an unwitnessed fall on 11/23/2025 at 11:40 AM. Further review of Patient #5’s medical record revealed, “Nursing Order - Neuro Checks” on 11/23/2025, “Q 4 Hr... Start Time: 11/23/25 at 1:00 PM... Stop Time: 11/24/25 at 11:00 AM” A review of Patient #5’s medical record revealed no documentation that neuro checks were completed every 4 hours per facility policy and physician order. During an interview on 1/14/2026 at 11:39 AM, MD J, stated that when she is in the facility, she expects the nursing staff to call her to assess a patient who has fallen. MD J stated that when she is not on-site, she expects the nursing staff to call her to inform her of all patient falls immediately. MD J stated that when a patient hits their head during a fall, neurological checks are ordered, and the patient is almost always sent the ED for evaluation. MD J stated that it is the nursing responsibility to document RN to MD communication regarding falls and ED transfers in the patient medical record.”

“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: 50643 Based on record review and interview, the facility failed to follow policy related to patient transfers from the facility to the Emergency Department (ED) for 3 of 3 patients (Patient’s #1, #8, and #9) who were transferred to ED in a total sample of 10 medical records reviewed. Findings Include: A review of the facility’s policy titled, “Emergency Transfer” dated 8/2022 revealed, “...RN... Provides information to E.D. on the patient’s condition and interventions used... Prepares the necessary forms listed on the Hospital Transfer Checklist... Documents in Progress Notes the patient’s status, interventions and procedures done, patient’s response to interventions/procedures, report called to receiving hospital ED and ED staff receiving report, time ambulance service contacted, time ambulance arrived, and the transfer of the patient (by whom, time, and where).” A review of the facility’s RN work direction titled “Patient Transfers” (no date) revealed, “...Transfers-send the following with the patient: Get order from provider for transfer & reason. Print Face sheet. Print MAR (Medication Administration Record). Do “Nurse-to-Nurse” call with facility patient is transferring to... Do Narrative note with transfer information...” A review of Patient #1’s medical record revealed Patient #1 was transferred out of the facility to the ED on 10/24/2025 at 4:00 PM. Further review of Patient #1’s medical record revealed no documentation that the facility contacted the receiving ED regarding Patient #1’s transfer, no evidence of a Transfer Checklist or a Transfer Form, no documentation that the facility sent Patient #1’s medical records to the receiving ED, and no narrative note stating there was a transfer with reason of transfer regarding Patient #1’s transfer to ED on 10/24/2025. A review of Patient #8’s medical record revealed Patient #8 was transferred out of the facility to the ED on 10/24/2025 at 2:00 PM. Further review of Patient #8’s medical record revealed no documentation that the facility called the receiving facility, regarding Patient #8’s transfer, no evidence of a Transfer Checklist or a Transfer Form, and no documentation that the facility sent Patient #8’s medical records to the receiving facility. A review of Patient #9’s medical record revealed Patient #9 was transferred out of the facility to the ED on 10/24/2025 at 11:30 AM. Further review of Patient #9’s medical record revealed no documentation that the facility called the receiving facility regarding Patient #9’s transfer, no evidence of a Transfer Checklist or a Transfer Form, and no documentation that the facility sent Patient #9’s medical records to the receiving facility. During an interview on 1/13/2026 at 3:39 PM, CNO (Chief Nursing Officer) E stated that he expected nursing staff to document patient transfer details in a narrative note. CNO E stated that if there was not documentation, then it could be assumed the transfer work direction and policy had not been followed.”

“PATIENT RIGHTS: REVIEW OF GRIEVANCES CFR(s): 482.13(a)(2) [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.] The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. This Standard is not met as evidenced by: 47413 Based on record review and interview the facility failed to follow the process outlined in the complaint/grievance policy to acknowledge and investigate 8 complaints/grievances (Patients #11, 12, 13, 14, 15, 16, 17, 18) in a total of 16 complaints/grievances reviewed. Findings Include: A review of the facility’s policy titled, “Patient/Client Grievance Complaint” last reviewed 08/2022 revealed, “... Upon receipt of the grievance, the Client Rights Specialist shall meet with the grievant or representative... identify the issue and explain the process... The Client Rights Specialist shall proceed with a full investigation of the grievance...” A review of the complaint titled, “MRN 0050221” filed by Patient #11 to the facility on 04/07/2025 revealed, “Patient did not have the correct dosage of medication.” There was no additional documentation including acknowledgment, investigation, follow up or resolution as of 05/27/2025 (date of survey). A review of the complaint titled, “MRN 0049831” filed by Patient #12 to the facility on 04/07/2025 revealed, “Negative interaction with a specific staff member.” There was no additional documentation including acknowledgment, investigation, follow up or resolution as of 05/27/2025 (date of survey). A review of the complaint titled, “MRN 0035084” filed by Patient #13 to the facility on 04/11/2025 revealed, “Negative interaction with a specific staff member.” There was no additional documentation including acknowledgment, investigation, follow up or resolution as of 05/27/2025 (date of survey). A review of the complaint titled, “MRN 0050521” filed by Patient #14 to the facility on 04/14/2025 revealed, “Unhappy with meds given and needs being met.” There was no additional documentation including acknowledgment, investigation, follow up or resolution as of 05/27/2025 (date of survey). A review of the complaint titled, “MRN 0050331” filed by Patient #15 on 04/14/2025 revealed, “Negative interaction with a specific staff member.” There was no additional documentation including acknowledgment, investigation, follow up or resolution as of 05/27/2025 (date of survey). A review of the complaint titled, “MRN 0050301” filed by Patient #16 on 04/16/2025 revealed, “Negative interaction with a specific staff member.” There was no additional documentation including acknowledgment, investigation, follow up or resolution as of 05/27/2025 (date of survey). A review of the complaint titled, “MRN 0050451” filed by Patient #17 on 04/16/2025 revealed, “Patient wished to have unit restriction removed.” There was no additional documentation including acknowledgment, investigation, follow up or resolution as of 05/27/2025 (date of survey). A review of the complaint titled, “MRN 0050151” filed by Patient #18 on 04/19/2025 revealed, “Missing belongings.” There was no additional documentation including acknowledgment, investigation, follow up or resolution as of 05/27/2025 (date of survey). During an interview on 05/27/2025 at 11:01 AM Director of Quality B stated that the policy is that the timeline is 7-30 days for complaints and grievances to be acknowledged and resolved. During an interview on 05/27/2025 at 12:00 PM when asked about the missing follow-ups on the complaints, Client Rights Specialist K stated, “I have followed-up with all patients; I have gotten behind on documenting the follow-ups.””

“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: 47413 Based on record review and interview, facility staff failed to ensure signed informed consent for psychotropic medications (used to treat mood, thoughts, behavior or perception) was obtained prior to administration for 2 of 10 patients (Patients #6, 8) in a sample of 10 records reviewed. Findings include: A review of the facility’s policy titled, “Informed Consent for Medications” last revised 08/2022 revealed, “... 5. The nurse on the unit will obtain and witness the patient’s written consent to take psychotropic medications... 6. The patient will be directed to sign the informed consent form...” A review of Patient #6’s medical record revealed the following: Patient #6 was voluntarily admitted to the facility on 03/21/2025 for alcohol detox. The medication consent form, including “Gabapentin (anti-seizure medication)” and “Lexapro (anti-depressant medication)” was signed by Patient #6 on 03/23/2025 (no time). “Administrations” revealed Patient #6 was first administered Gabapentin on 03/21/2025 (2 days before the consent was signed) and Lexapro on 03/22/2025 (1 day before the consent was signed). A review of Patient #8’s medical record revealed that Patient #8 was voluntarily admitted to the facility on 05/11/2025 for major depressive disorder. The medication consent form, including “Invega (antipsychotic medication” was signed by Patient #8 on 05/15/2025 (no time). “Administrations” revealed Patient #8 was first administered Invega on 05/13/2025 (2 days before the consent was signed) and on 05/14/2025 (1 day before the consent was signed). During an interview on 05/27/2025 at 1:31 PM Director of Quality B stated that there needs to be signed/written consent prior to psychotropic medication administration.”