Mildred Mitchell-Bateman Hospital

“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: 46199 Based on document review and interview, it was revealed the facility failed to review and resolve a patient grievance for one (1) of ten (10) patients, patient 1. This failure has the potential to negatively impact all patients receiving care at the facility. Findings include: A policy was reviewed titled “Handling of Patient Complaint / Grievances” effective date 6/13/24. The policy has a section titled “Definitions” which states, in part, “As referenced in The State Operations Manual A-0118 “A ‘patient grievance’ is a formal or informal written or verbal complaint made to the hospital by a patient or the patient’s representative, facility employee or other individual on behalf of any patient regarding the patient’s care.” The policy has a section titled “Purpose” which states, in part, “The intent is to address patient complaints and grievances regarding patient care and services in a timely and responsive manner.” A document titled “MMBH Grievance Log (April)” was reviewed. An entry dated 4/8/25 indicates that patient 1 filed the following complaint, “Patient states, ‘We need to have treatment team with all team members present, in person come to meet with us in person Zoom & remote meetings are for business, not Department of Health and Human Resources (DHHR) or hospital come to patient. [Staff 4] does not see his patients every week.” A section of this entry titled “Notes” states, “The Nurse Manager spoke with the Medical Director, who stated the meetings would always be virtual due to time and scheduling. This was explained to the patient and [he/she] was not satisfied with the response. This resolution was not satisfactory with the patient and [he/she] declined/refused to sign the grievance form. The patient wished to appeal this resolution to the Mental Health Ombudsman, who approved the complaint appeal.” An interview was conducted with staff 2 and staff 3 on 4/21/25 at 2:09 p.m. Staff 2 was asked about patient 1’s current treatment. Staff 2 stated, “We recently had a clinical case conference on [him/her]. We’ve got a game plan for [him/her] going forward, focusing on re-looking at guardianship.” Staff 2 was asked if he/she was aware of patient 1 requesting that his/her treatment team meetings be done face-to-face. Staff 2 stated, “It’s not really the standard here but if it is needed. I was not aware of a face-to-face request.” It should be noted that Staff 2 is the medical director who replied to the patients grievance. A telephone interview was conducted with staff 4 on 4/22/25 at 2:09 p.m. Staff 4 was asked if he/she was aware that patient 1 had filed a complaint asking to have treatment team meetings face-to-face rather than virtually. Staff 4 stated, “I was not aware of that.” An interview was conducted with staff 9 on 4/22/25 at 2:45 p.m. Staff 9 was asked about his/her response to a complaint from patient 1. Staff 9 stated, “We have a monthly meeting with nurse managers and [staff 2] to bring up concerns or issues that we’re having. Some patients had brought up that they didn’t like the virtual meetings because it was like talking to a machine. The response to the complaint was based on a conversation that had happened at a meeting months earlier. I guess I could’ve written the response more clearly. I think it would be wonderful to do it in person, I used to do the treatment team meetings in person.” An interview was conducted with staff 1 on 4/23/25 at 11:20 a.m. Staff 1 was asked about moving to face-to-face treatment team meetings. Staff 1 stated, “I like the idea of face-to-face. There may be times when we have eighteen (18) people, and we’ll have trouble placing them all.” Staff 1 was asked about the handling of patient 1’s complaint about this issue. Staff 1 stated, “I have already sent out an email to leadership stating that we need to do a better job of communicating when it comes to complaints.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 43434 Based on review of medical records (MR), review of facility documents and interview with staff (EMP) it was determined that the facility failed secure and monitor an open elevator shaft on an inpatient unit (A0144) and failed to complete 15 minute safety checks as ordered for one patient (A0144). This failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to the patients. The facility was notified of the IJ on 2/4/25 at 4:38 p.m. The facility submitted and implemented an acceptable plan to remove the IJ, which was verified by the State Survey Agency. The IJ was abated on 2/4/25 at 9:12 p.m. The following interventions were implemented to resolve the IJ: Face checks are to be conducted/completed every fifteen (15) minutes by licensed Staff. One (1) additional random fifteen (15) minute Face Check to be conducted/completed every hour by the Nurse Supervisor or an Administrator approved designee. Two (2) random video reviews will be conducted and two (2) random in-person safety checks will be conducted by select administrative staff during dayshift. Nursing Department policy NURe035 “Unit Face Checks/Security Checks” was revised on 01/28/25. The EMPs have had the updated education on the policy. Cross Reference: 482.13(c)(2) Patient Rights: Care in Safe Setting”

“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: 43434 Based on document review, medical record review, video observation, and EMP interviews, it was determined that nursing failed to supervise patient care (Patient 1). This failure potential to cause harm to all patients who recieve care at this facility (see tag 0395). As a result of this failure, Immediate Jeopardy (IJ) was identified, and the facility was notified on 2/4/25 at 4:38 p.m. The facility submitted and implemented an acceptable plan to remove the IJ, which was verified by the State Survey Agency. The IJ was removed on 2/4/25 at 9:12 p.m. The following interventions were implemented to resolve the IJ: Face checks are to be conducted/completed every fifteen (15) minutes by licensed EMPs. One (1) additional random fifteen (15) minute Face Check to be conducted/completed every hour by the Nurse Supervisor or an Administrator approved designee. Two (2) random video reviews will be conducted and two (2) random in-person safety checks will be conducted by administrative staff during dayshift. Nursing Department policy NURe035 “Unit Face Checks/Security Checks” was revised on 01/28/25. The EMPs have had the updated education on the policy. Cross Reference: §482.23(b)(3): A registered nurse must supervise and evaluate the nursing care for each patient.”

“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: 43434 Based on document review, medical record (MR) review, video observation and staff (EMP) interviews, the facility failed to secure and monitor an open elevator shaft on an inpatient unit; and failed to complete appropriate fifteen (15) minute checks, in one (1) out of twenty-one (21) patients, (Patient 1). This failure has the potential to cause great harm and or death to any patient receiving care at the facility. Findings include: Failure to secure the elevator: A video observation was conducted on 1/30/25 at 9:10 a.m. revealed: On 01/28/25 Prior to 2:51 a.m. Patient #1 was seen wandering and calmly sitting in the common area. At 2:56 a.m., EMP 3 gets on the elevator and Patient #1 tries to get on the elevator too. EMP 3 redirected Patient #1. It should be noted there is no documentation in the medical record that this incident was reported to the charge nurse. On 01/28/25 at 3:32 a.m., Patient #1 walks over to the elevator and tries to open it, getting it open. Patient #1 looks down into the elevator and returns to the dining area. At 3:32.38, Patient #1 walks back to the right-side elevator, opens it up and steps in, the door closed behind them. There were no EMP present in the area from 3:26 a.m. to 3:34 a.m. EMP 1 and EMP 2 came out of the kitchen area at 3:34 a.m. At 3:36 a.m.; EMP 1 and EMP 2 walk toward the male hallway. They turn around and look at the elevator, then EMP 2 goes over and slides the door open looking down through the shaft; EMP 2 and EMP 1 go to close the elevator door, but you can see a gap between the elevator doors. Both EMPs walk away but come back in view at 3:37:54 a.m.; EMP 1 goes back to the elevator door; The elevator door on the left side opened and EMP 2 was seen holding the door open; EMP 1 is seen using the phone and heads to the nurse’s station; At 3:43 a.m. a chair is placed at the elevator and EMP 4 is assigned to monitor the elevator and is seen monitoring the elevator. At 3:46 a.m., EMP 2 and EMP 7 look at the elevator door and down the elevator shaft, then walk out of sight. Emp 4 is seen leaving the elevator unsecured at 3:37:34 a.m. and did not return until 3:43:39 a.m. No other employee replaced emp 4. Emp 4 is seen leaving the elevator unsecured at 4:37 a.m. and did not return until 4:39:38 a.m. No other employee replaced emp 4. Emp 4 is seen leaving the elevator unsecured at 4:37:20 a.m. and did not return. At 6:02 a.m. Emp 3 is seen at the elevator at 6:02:39 a.m. for the remainder of the shift. A review of the policy titled “Response to Elevator Emergencies and Maintenance” with an effective date of 11/20/23 states in part...Procedure: 1. The switchboard operator is to be notified at the first indication of a problem with an elevator. 2. The switchboard operator will then contact security or maintenance to determine that a problem does exist. The operator shall notify the elevator vendor for necessary repairs. 3. After confirmation of a problem with the elevator, the switchboard operator should then notify the safety director. It should be noted there is no written policy or procedure for securing the elevator doors. A review of the policy titled “Guidelines for Procedure Failure of Essential Equipment Policy” with a review date of 08/15/24, states in part; “ The Director of Maintenance is responsible for the proper and safe functioning of all equipment within the facility and the condition of that facility generally. It is there for the Director of Maintenance’s responsibility to maintain awareness of the activities within the facility. A written procedure is developed that specifies the action to be taken during the failure of essential equipment and major utility services. This procedure includes a call system for summoning essential personnel and outside assistance when required. Procedure: I. Essential equipment ...Elevators ...II. Notification: The Director of Maintenance or designee shall always be notified first when a disruption of services occurs ...In the event of a disruption of services outside of normal business hours, the Shift Supervisor shall immediately notify the Director of Maintenance or designee and the Administrator on-call ...C. Staff to Notify During Equipment failure: Switchboard Operator has list and telephone numbers of staff to notify in case of equipment failure. A review of an email dated 01/28/25 at 10:15 a.m. from emp #12 states in part; “7:18 a.m. [states emp 12’s name] on scene in building 3 [three] securing the elevator shaft and assisting emergency personnel with retrieval of the patient from the elevator shaft...7:57 a.m. directed [states emp 12’s name] to ensure that a guard was in place between the elevators on floors 2 [two], 3 [three], and 4 [four] of building 3 [three] and to shut down the elevators by tripping the power and contact the elevator company ASAP [as soon as possible]... 8:21 a.m. elevator company contacted to determine a manner to lock the elevator doors pending their inspection and repair.” A review of the document titled “Switchboard Operator Log” with a date of 01/28/25 states in part; 9:01 a.m. elevators down the rest of the day and elevator watch...09:15 a.m. walked with elevator guys. It should be noted there was no documentation about a broken elevator until 9:01 a.m. on the log. A review of a document titled “Elevator Sign in Sheet” January 2025, revealed on 01/07/25 at 5:00 a.m. the elevator company was contacted for blown fuses they arrived at 6:40 a.m. and departed at 8:00 a.m. There is no other documentation that the elevator company was contacted until 01/28/25 at 7:00 a.m. for “2nd (second) elevator shaft” arrival time 9:00 a.m. departure time 2:00 p.m. A review of a document from the facilities contracted elevator company states in part ...”When was alleged incident reported to your office(date/time): 01/28 at 7:45 a.m. [shows employee #12’s name] ...Technicians respond date/time 01/28/25 at 9:00 a.m ....Equipment involved in the alleged incident was identified please provide: Elevator/Escalator 1 & 2 ...” An interview was conducted via phone on 1/31/25, at 1:22 p.m. with EMP 3. When asked the process if the elevator is not working? They stated in part, “We contact the charge nurse, and they contact the nursing supervisor, and they contact security.” When asked if security was contacted when the staff noticed the elevator door would open? They stated, “I think the charge nurse called but I didn’t see them.” Failure to complete fifteen (15)-minute checks: A review of the policy titled, “UNIT FACE CHECKS/SECURITY CHECKS,” with a last review date of 02/14/22, was completed. The policy states in part that, “Face Checks will be done every fifteen (15) minutes on all shifts unless otherwise ordered. Face checks. And security checks will be done by the registered nurse (RN) from both outgoing and incoming shifts before or after the shift report. First and last rounds of the shift will be conducted in this manner. Unit windows and doors will be checked each time. Complete the face check sheet By using the code at the bottom of the face check sheet to indicate Where the Patient is. If any Patient cannot be accounted for, report this immediately to the charge nurse...RN or LPN, will do the spot checks hourly. They are to indicate the time that they did their spot checks at the bottom of the face check sheets... The face check person should always look for signs of life including but not limited to breathing, chest and or abdominal rises, snoring and or any kind of body movements.” A review of the MR for Patient 1 revealed they were admitted to the facility on 01/27/25 at 8:36 p.m. Patient 1 was diagnosed with unspecified schizophrenia spectrum, psychotic disorder and cannabis use disorder. The patient was transferred to the admissions unit A4. The patient had fifteen (15) minute safety checks ordered. A review of the “Elopement Risk Assessment “ Completed on 01/27/25, risk low. A review of “Face Check” documentation for Patient 1, dated 1/28/25, was completed. The Face Check documentation has a time range of 2300 (11:00 p.m.) to 06:45 a.m., The documentation reveals: 11:00 p.m., bed, respirations observed; 11:15 p.m., bed, respirations observed; 11:30 p.m., bed, respirations observed; 11:45 p.m., EMP 1 documents hall; 12:00 a.m., hall; 12:15 a.m. through 1:30 a.m., dining area; 1:45 a.m., through 2:15 a.m. hall; 2:30 a.m. through 2:45 a.m. dining area; 3:00 a.m., a diagonal line is marked across the area and illegible documentation; 3:15 a.m., through 3:30 a.m., dining area; 3:45 a.m., bedroom EMP 21 documents bedroom; 4:00 a.m., EMP 3 documents that the patient is in their bedroom; 4:15 a.m., EMP 3 documents that the patient is in their bedroom; 4:30 a.m., EMP 3 documents that the patient is in their bedroom; 4:45 a.m., EMP 3 documents that the patient’s respirations were observed; 5:00 a.m., EMP 3 documents that the patient’s respirations were observed; At 5:15 a.m., EMP 4 documents bed, respirations observed but then marks a diagonal line through it; 5:30 a.m., EMP 4 documents bed, respirations observed but then marks a diagonal line through it; 5:45 a.m., EMP 4 documents bed, respirations were observed; approximately 6:10 a.m. EMP 4 reported patient 1 missing. A review of the video showed the above specified times the employees did not enter the Patient’s room; they completed their face checks from the patient’s door. A review of the face check documents revealed that from 3:00 a.m. through 4:00 a.m. Emp 21 completed safety checks, from 4:15 a.m. through 5:00 a.m. Emp 3 completed safety checks and from 5:00 a.m. through 6:00 a.m. Emp 4 completed safety checks. Review of video dated 01/28/25 at 3:32.38, Patient #1 walks back to the right-side elevator, opens it up and steps in, the door closed behind them. The patient was not re-seen on the unit and was found at the bottom of the elevator shaft at 6:52:39 a.m. An interview was conducted on 1/30/25, at 11:07 a.m., EMP 15 indicated that face check documentation was inaccurate noting that the Patient 1 was documented as being in bed when they were no longer on the floor. In addition, EMP 15 indicated that EMP 5 documented completing safety checks with staff when video review shows this did not occur. A telephone interview was conducted on 1/31/25, at 2:29 p.m. with EMP 5. EMP 5 stated in part, “During face checks at approximately 5:50 a.m. [EMP 4] came to the nursing station to inform [EMP 5] that [Patient 1] could not be located in their room. After doing a search of the unit, twice, I called for a code 5 [five] [Elopement.]. I’m pretty sure. I wasn’t aware I was supposed to do face checks with staff. I just sign off and make sure there’s no holes in the documentation. They’re supposed to walk into the rooms and make sure it’s the patient. I have no idea what they saw.” An interview was conducted via phone on 1/31/25, at 12:05 p.m. with EMP 2. When asked to explain safety checks and any safety checks they completed on patient 1, EMP 2 stated in part, “I did face checks, there was someone in the patient’s room. I wrote what I saw.” When asked the process if the elevator is not working? They stated in part, “We contact the charge nurse, and they contact the nursing supervisor, and they contact security.” When asked if security was contacted when the staff noticed the elevator door would open? They stated in part, [States Emp 1’s name] told the charge nurse and they said they called security.” When asked if they saw security on the unit? They stated in part; “Yea, security came up and looked at it and left. We had someone sit by the elevator and at 5:00 a.m., I went to lunch. Yea, when I got back is when we found out the patient was missing. We did two-unit searches, and the nurse called a code 5. That’s all I know. I can’t really remember anything else.” An interview was conducted via phone on 1/31/25, at 1:22 p.m. with EMP 3. When asked to explain safety checks and any safety checks they completed on Patient 1, EMP 3 stated in part, “Every hour we change assignments. The patient was in the dining area for quite a while. The patient wasn’t doing anything out of the ordinary. I don’t remember much. We are supposed to do face checks every fifteen (15) minutes. Mine would have been at 4:00 a.m. I think I found out the patient was missing around 5:45 a.m. to 6:00 a.m. not exactly sure of the time. Then I sat at the elevator until I finished my shift” An interview was conducted via phone on 1/31/25, at 11:47 a.m. with EMP 4. When asked to explain safety checks and any safety checks they completed on Patient 1, EMP 4 stated in part, “I was pulled to the unit that night. I was on a 1:1 with a patient that night, completed face checks at times, and hall walks. I think I did their 2:00 a.m. face check. I thought the patient was in room [number] and someone was in that room, but the patient was really admitted to room [number], and someone was in that bed also. Then I did the 5:30 a.m. or 6:00 a.m. face check and I notified [EMP 5] the patient was missing.” When asked how a safety check is to be completed, they stated, “We are to open the door to confirm the patient and watch them breathing.” A second interview was conducted on 2/4/25, at 3:12 p.m. with EMP 15. EMP 15 stated, “Staff on A-4 unit did not follow policies for safety checks and face checks.” An interview was conducted on 2/4/25, at 3:25 p.m. with EMP 11. EMP 11 stated, “I’m confident that the documentation was done thoroughly and in a timely manner. However, the documentation doesn’t match the reality of the situation. For a period of time, the paperwork is not accurate. Hourly initials were signed off, appropriate initials but for at least two of those occasions, the documentation could not be correct.” May it be noted; the patient opened the elevator at 3:32:38 a.m. and was not noticed to be missing until 6:10 a.m. documentation of fifteen (15) minute safety checks continued to be documented as the patient was in their bedroom. The facility was unaware the patient was in the elevator shaft during this time period.”

“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: 43434 Based on documentation reviews, medical record (MR) review, video observations and EMP interviews, the facility failed to complete accurate safety checks and medication reassessments on one (1) out of twenty-one (21) medical records reviewed, Patient 1. This failure has the potential to cause harm to all patient receiving care at this facility. Findings: A review of the policy titled, “UNIT FACE CHECKS/SECURITY CHECKS,” with a last review date of 02/24/22 states, in part, “Policy: Face checks will be completed every fifteen (15) minutes on all shifts unless otherwise ordered. GUIDELINES: A. Face Checks/Security Checks will be done by the Registered Nurse from both outgoing and incoming shifts BEFORE or AFTER the shift report. FIRST and LAST ROUNDS of the shift will be conducted in this manner...Licensed staff members RN or LPN will do the spot checks hourly. They are to indicate the time that they did their spot checks at the bottom of the face check sheets. Spot checks include checking the face check board for completeness and doing a visual on all Patients on the unit...... The face check person should always look for signs of life including but not limited to breathing, chest and or abdominal rises, snoring and or any kind of body movements.” A review of “Face Check” documentation for Patient 1, dated 1/28/25, was completed. The Face Check documentation has a time range of 2300 (11:00 p.m.) to 06:45 a.m., The documentation reveals: 11:00 p.m., bed, respirations observed; 11:15 p.m., bed, respirations observed; 11:30 p.m., bed, respirations observed; 11:45 p.m., EMP 1 documents hall; 12:00 a.m., hall; 12:15 a.m. through 1:30 a.m., dining area; 1:45 a.m., through 2:15 a.m. hall; 2:30 a.m. through 2:45 a.m., dining area; 3:00 a.m., a diagonal line is marked across the area and illegible documentation; 3:15 a.m., through 3:30 a.m., dining area; 3:45 a.m., bedroom EMP 21 documents bedroom; 4:00 a.m., EMP 3 documents that the patient is in their bedroom; 4:15 a.m., EMP 3 documents that the patient is in their bedroom; 4:30 a.m., EMP 3 documents that the patient is in their bedroom; 4:45 a.m., EMP 3 documents that the patient’s respirations were observed; 5:00 a.m., EMP 3 documents that the patient’s respirations were observed; At 5:15 a.m., EMP 4 documents bed, respirations observed but then marks a diagonal line through it; 5:30 a.m., EMP 4 documents bed, respirations observed but then marks a diagonal line through it; 5:45 a.m., EMP 4 documents bed, respirations were observed; approximately 6:10 a.m. EMP 4 reported patient 1 missing. Review of the Face check documentation revealed that from 3:00 a.m. through 4:00 a.m. emp 21 completed safety checks, from 4:15 a.m. through 5:00 a.m. emp 3 completed safety checks and from 5:00 a.m. through 6:00 a.m. emp 4 completed safety checks. An interview was conducted via phone on 1/31/25, at 2:29 p.m. with EMP 5. When asked when they were supposed to complete safety checks EMP 5 stated, “I wasn’t aware I was supposed to do face checks with staff. I just sign off and make sure there’s no holes in the documentation. They’re supposed to walk into the rooms and make sure it’s the patient. I have no idea what they saw.” An interview was conducted on 1/30/25, at 11:07 a.m., with EMP 15. When asked about face checks, EMP 15 stated, “The video evidence shows that the patient was no longer on the floor at the times the face checks were documented and that the patient was in their bed. Also, [staff #5] documented that safety checks were done but the video shows they were not.” A second interview was conducted on 2/4/25, at 3:12 p.m. with EMP 15. EMP 15 stated, “Staff on A-4 unit did not follow policies for safety checks and face checks.” An interview was conducted on 2/4/25, at 3:25 p.m. with EMP 11. EMP 11 stated, “I’m confident that the documentation was done thoroughly and in a timely manner. However, the documentation doesn’t match the reality of the situation. For a period of time, the paperwork is not accurate.” A review of the policy titled “Medication Administration,” dated 12/20/24, The policy states in part, “ ...Evaluating effectiveness: RN must cosign the PRN [as needed] note in CareVue [electronic medical record] and add an addendum documenting the effectiveness of the medication. Medication Nurse: must document the effectiveness in BCMA [Bateman Charting Medication Administration] as follows: evaluating effectiveness is to be completed within 60 minutes of oral and 30 minutes of an IM administration. Is to be assessed, evaluated by asking the Patient if the medication alleviated the symptoms and or documenting behavioral changes. A review of a document titled “Bateman PRN (as needed medication) Nursing Note” dated 01/28/25 at 3:45 a.m. by EMP 5. PRN (as needed) was: Effective. It should be noted this assessment could not be completed due to the patient eloping at 3:32 a.m.”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 43434 Based on document review, medical record review, video review, and EMP interview it was determined the hospital failed to ensure the medical record was accurate in one (1) of twenty-one (21) medical records reviewed, patient 1. This failure has the potential to adversely affect all patients receiving care in the hospital. Findings include: A review of policy titled “Medical Records Charting Guidelines,” dated 6/21/24, was completed. The policy states in part that, POLICY: All personnel will use charting guidelines to record information in the medical record to assure an accurate and complete medical record...” A review of “Face Check” documentation for Patient 1, dated 1/28/25, was completed. The Face Check documentation has a time range of 2300 (11:00 p.m.) to 06:45 a.m., dining area; 3:45 a.m., bedroom EMP 21 documents bedroom; 4:00 a.m., EMP 3 documents that the patient is in their bedroom; 4:15 a.m., EMP 3 documents that the patient is in their bedroom; 4:30 a.m., EMP 3 documents that the patient is in their bedroom; 4:45 a.m., EMP 3 documents that the patient’s respirations were observed; 5:00 a.m., EMP 3 documents that the patient’s respirations were observed; At 5:15 a.m., EMP 4 documents bed, respirations observed but then marks a diagonal line through it; 5:30 a.m., EMP 4 documents bed, respirations observed but then marks a diagonal line through it; 5:45 a.m., EMP 4 documents bed, respirations were observed; approximately 6:10 a.m. EMP 4 reported patient 1 missing. A review of a document titled “Bateman [hospitals abbreviated name] PRN (as needed medication) Nursing Note” dated 01/28/25 at 3:45 a.m. by EMP 5. PRN (as needed) was: Effective. It should be noted this assessment could not be completed due to the patient eloping at 3:32 a.m. A video review dated 01/28/25 at 3:32 a.m., Patient #1, walks over to the elevator and tries to open it, getting it open. The patient looks down into the elevator and returns to the dining area. A video review dated 01/28/25 at 3:32.38, Patient #1, walks back to the right-side elevator, opens it up and steps in, the door closed behind them. An interview was conducted on 1/30/25, at 11:07 a.m., with EMP 15. When asked about face checks, EMP 15 stated, “The video evidence shows that the patient was no longer on the floor at the times the face checks were documented and that the patient was in their bed. Also, [EMP 5] documented that safety checks were done but the video shows they were not.” A second interview was conducted on 2/4/25, at 3:12 p.m. with EMP 15. EMP 15 stated, “Staff (EMP) on A-4 unit did not follow policies for safety checks and face checks.” An interview was conducted on 2/4/25, at 3:25 p.m. with EMP 11. EMP 11 stated, “I’m confident that the documentation was done thoroughly and in a timely manner. However, the documentation doesn’t match the reality of the situation. For a period of time, the paperwork is not accurate. Hourly initials were signed off, appropriate initials but for at least two of those occasions, the documentation could not be correct.””

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 43676 Based on observation and video review, the facility did not provide a safe setting by leaving the unsecured elevator doors unattended. This failure has the potential to affect all patients receiving care at the hospital. Findings include: A video observation was conducted on 1/30/25 at 9:10 a.m. revealed: On 01/28/25: Emp 4 is seen leaving the elevator unsecured at 3:37:34 a.m., and did not return until 3:43:39 a.m., No other employee replaced emp 4. Emp 4 is seen leaving the elevator unsecured at 4:37 a.m., and did not return until 4:39:38 a.m., No other employee replaced emp 4. Emp 4 is seen leaving the elevator unsecured at 4:37:20 a.m., and did not return. Emp 3 is seen at the elevator at 6:02:39 a.m., for the remainder of the shift. A review of the policy titled “Response to Elevator Emergencies and Maintenance” with an effective date of 11/20/23 states in part...Procedure: 1. The switchboard operator is to be notified at the first indication of a problem with an elevator. 2. The switchboard operator will then contact security or maintenance to determine that a problem does exist. The operator shall notify the elevator vendor for necessary repairs. 3. After confirmation of a problem with the elevator, the switchboard operator should then notify the safety director. It should be noted there is no written policy or procedure for securing the elevator doors. A review of the policy titled “Guidelines for Procedure Failure of Essential Equipment Policy” with a review date of 08/15/24, states in part; “ The Director of Maintenance is responsible for the proper and safe functioning of all equipment within the facility and the condition of that facility generally. It is there for the Director of Maintenance’s responsibility to maintain awareness of the activities within the facility. A written procedure is developed that specifies the action to be taken during the failure of essential equipment and major utility services. This procedure includes a call system for summoning essential personnel and outside assistance when required. Procedure: I. Essential equipment ...Elevators ...II. Notification: The Director of Maintenance or designee shall always be notified first when a disruption of services occurs ...In the event of a disruption of services outside of normal business hours, the Shift Supervisor shall immediately notify the Director of Maintenance or designee and the Administrator on-call ...C. Staff to Notify During Equipment failure: Switchboard Operator has list and telephone numbers of staff to notify in case of equipment failure. A review of the document titled “Switchboard Operator Log” with a date of 01/28/25 states in part; 9:01 a.m. elevators down the rest of the day and elevator watch...09:15 a.m. walked with elevator guys. It should be noted there was no documentation about a broken elevator until 9:01 a.m. on the log. A review of a document titled “Elevator Sign in Sheet” January 2025, revealed on 01/07/25 at 5:00 a.m. the elevator company was contacted for blown fuses they arrived at 6:40 a.m. and departed at 8:00 a.m. There is no other documentation that the elevator company was contacted until 01/28/25 at 7:00 a.m. for “2nd (second) elevator shaft” arrival time 9:00 a.m. departure time 2:00 p.m. A review of a document from the facilities contracted elevator company states in part ...”When was alleged incident reported to your office(date/time): 01/28 at 7:45 a.m. [shows employee #12’s name] ...Technicians respond date/time 01/28/25 at 9:00 a.m ....Equipment involved in the alleged incident was identified please provide: Elevator/Escalator 1 & 2 ...” A review of an email dated 01/28/25 at 10:15 a.m. from emp #12 states in part; “7:18 a.m., [states Emp 12’s name] on scene in bulding 3 [three] securing the elevator shaft and assisting emergency personnel with retrieval of the patient from the elevator shaft...7:57 a.m., directed [states emp 12’s name] to ensure that a guard was in place between the elevators on floors 2 [two], 3 [three], and 4 [four] of building 3 [three] and to shut down the elevators by tripping the power and contact the elevator company ASAP [as soon as possible]... 8:21 a.m. elevator company contacted to determine a manner to lock the elevator doors pending their inspection and repair.” An interview was conducted via phone on 1/31/25, at 11:47 a.m. with EMP 4. When asked why they left the elevator after being assigned to sit and monitor the elevator? They stated in part, “I had to do my assigned safety checks.” An interview was conducted via phone on 1/31/25, at 1:22 p.m. with EMP 3. When asked the process if the elevator is not working? They stated in part, “We contact the charge nurse, and they contact the nursing supervisor, and they contact security.” When asked if security was contacted when the staff noticed the elevator door would open? They stated, “I think the charge nurse called but we I didn’t see them.””

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 43676 Based on observation and staff interview, the facility failed to ensure the facility was maintained to ensure an acceptable level of safety and quality. This deficient practice could affect all patients, staff, and visitors in the area(s) referenced. Facility census 86. Findings included: 1. Observation on 11/18/24 between the hours of 12:10 p.m. and 1:05 p.m.,observed in the tunnel between buildings 2 and 3 were 2 locations where wet floor signs and blankets laying in the floor. The two areas noted was in the bottom corner of the wall on the same side of the elevator in building 2 and up at the top of the tunnel where the tunnel connects to building 3. 2. Interview on 11/18/24 at approximately 2:10 p.m., interview conducted with Employee # 8. I asked the employee if they are aware of any roof or ceiling leaks? Employee replied “ Maybe the one out in the hallway. It only does that when it rains really hard.” 3. Interview on 11/18/24 at approximately 2:50 p.m., interview conducted with Employee # 75. I asked the employee if they are aware of any roof or ceiling leaks? The employee replied “Down in the tunnel, it’s been leaking on and off when it rains really hard. The issue is where the tunnel connects to each building below ground.” Asked the employee how long they have been aware of the leak. Employee replied “Oh my, its been that way ever since I’ve been here and I’ve almost been here 13 or 14 years now”. 4. Observation on 11/19/24 at between the hours of 9:15 a.m. and 10:15 a.m. in the basement tunnel between buildings 2 near the elevator had blankets on the floor and in the corner it was observed that the blanket was wet. 5. Interview with the Maintenance Director verified these findings at the time of discovery. The findings were also acknowledged by the Chief Executive Officer at the exit interview on 11/19/24 at approximately 11:30 a.m.”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 46199 Based on medical record review, document review and staff interviews, it was determined that the governing body failed to ensure the medical staff was accountable for the quality of care in (1) one out of (10) ten patients, Patient #2. This failure has the potential to negatively impact all patients receiving care at the facility. Findings include: A medical record review was conducted for patient #2. The patient was involuntarily admitted to the facility on 11/12/23. The record contains an entry titled “Nursing Progress Note (Free Text)” entered on 5/25/24 at 3:32p.m. by Emp #12 which states, “Patient requested to speak with this writer. [Patient #2] stated [Patient #2] wants to switch providers.” It should be noted there is no documentation in the medical record that the provider discussed a transfer of care to another hospital provider with the patient. An email was reviewed dated 5/28/24 at 10:41a.m. sent by Emp #8, this email was sent to Emp #11, Emp # 9 and two other employees. The email states, in part, “Can we re-educate about these types of notes being placed in the chart? This is more of a direct conversation or an email etc. [Patient #2] was absolutely fine talking with us this morning. This is just one example- but these chart messages from staff or patients to us makes our chart look terrible and that we are not communicating which is not the case.” The email contains a segment from Patient #2 ’ s chart indicating [Patient #2 ’ ] wanting to change providers. A document was reviewed titled “Employee Acknowledgement Form” [EAF] which states, “I acknowledge and have been made aware of notifying the attending when a patient wants a new doctor, via email. DO NOT put a note in the patients ’ chart stating the patient wants a new doctor. Failure to comply may result in progressive discipline. I have read and understand these terms.” May it be noted that this document has a Name, Signature and Date lines. The document itself is not dated. A document was reviewed titled “Mildred Mitchell-Bateman Hospital Governing Body Bylaws” signed 10/21/21. A section of this document titled “Glossary” states, in part, “Chief Executive Officer (CEO): The hospital ’ s Chief Executive Officer who is qualified by education and experience, who is hired by the Secretary of the Department of Health and Human Resources and represents the Governing Body, acting as its agent in the overall, daily administrative operations and management of Mildred Mitchell-Bateman Hospital.” The document contains a section titled “Section VI.02 Authority and Duties” which states, in part, “(a) The Corporation shall empower the Chief Executive Officer to be responsible for the Hospital ’ s management. The specific authority and duties of the Chief Executive Officer shall be the following ...(xiv) To cooperate with the Medical Staff and with those concerned with rendering professional services, to the end that quality care will be rendered to the patients.” A document was reviewed titled “Medical Staff Bylaws, Rules, and Regulations” adopted and approved 4/25/23. This document has a section titled “Article II Medical Records” which states, in part, “2.1 Preparation/Completion of Medical Records. The Patient’s Provider shall be responsible for the preparation of a complete and legible medical record for each patient. Its contents shall be pertinent and current ...The record shall also contain a written plan of care, treatment and services appropriate to the patient’s needs, identifying the patient’s needs, goals, timeframes, settings, and services required to meet the patient’s needs.” An interview was conducted with Emp #1 on 6/26/24 at 4:20p.m. Emp #1 was shown an email authored by Emp #8 on 5/28/24 at 10:41a.m. and the EAF. Emp #1 stated, “This is the first time I ‘ve seen these.” Emp #1 was asked about the EAF and Emp #1 stated, “This has to be changed. It needs a few more sentences.” Emp #1 was asked why they were not included in the email from Emp #8. Emp #1 stated, “I’ll need to talk to [Emp #8] about that.””