HospitalInspections.org

Based on interview, record review and policy review, the hospital failed to provide care in a safe setting when the hospital failed to:
- Ensure a thorough investigation was performed following reports of allegations of abuse and neglect for three discharged patients (#3, #7 and #8) of four abuse and neglect allegations reviewed. (A-0145)
- Provide education to staff following incidents involving abuse and neglect for four discharged patients (#3, #7 and #8) of four incidents reviewed. (A-0145)
- Follow their policy when they did not contact patient's legal guardians (a person appointed to take care of and manage the rights of a person who is considered incapable) when informed consent was required, for three discharged patients (#7, #28 and #29) of three discharged patients reviewed. (A-0131)

These failed practices resulted in the noncompliance with 42 CFR 482.13 Condition of Participation: Patient's Rights.

Please refer to A-0131 and A-0145.

Based on interview, record review and policy review, the hospital failed to follow their policy when they did not contact the parent/legal guardian (a person appointed to take care of and manage the right of a person who is considered incapable) for three patients (#7, #28 and #29) to obtain consent for new medications, to provide medical information related to an injuries and/or to inform them of potential abuse.

Findings included:

Review of the hospital's undated document titled, "Statement of Patient Rights," showed the patient and/or legal guardian had the right to be informed of general information pertaining to services received by the patient.

Review of the hospital's policy titled, "Informed Consent, Medications," dated 04/2020, showed the ordering practitioner would discuss prescribed medications with the legal guardian.

Review of the hospital's document titled, "Rules and Regulations of the Medical Staff of Centerpointe Hospital Columbia," reviewed 03/06/2025, showed practitioners should discuss the indications for and the side effects of taking or not taking prescribed medications with the patients and their families, and document the discussion in the medical record. In the event of an emergency, an informed consent does not have to be signed for a medication to be administered to prevent the patient from harming themselves or others. Once the emergency is over, informed consent was obtained.

Review of the hospital's undated document titled, "Education: Potential Injury," showed in the event of a probable or actual patient injury, staff were to notify the patient's guardian.

Review of the hospital's policy titled, "Abuse and Neglect," dated 04/2020, showed the RN will notify the designated family contact and/or legal representative of any patient who was abused.

Review of Patient #7's medical record showed:
- On 01/11/25, a 16-year-old adolescent male was admitted for disruptive mood dysregulation disorder (DMDD, condition of extreme irritability, anger, and frequent, intense temper outbursts).
- His father was listed as the legal guardian.
- On 01/13/25, from 3:20 PM through 3:25 PM, he was placed in a manual hold initiated by Staff L, BHA, after he slapped the BHA and "called him a bitch."
- At 5:59 PM, a nursing assessment documentation indicated that Patient #7 was verbally and physically aggressive. He called a staff member a "bitch" and slapped the staff member in the face. Patient #7 was immediately placed in a physical hold. Upon release he was given oral medication at the direction of the provider. A physical assessment post hold identified that he had sustained a bloody lip during the event. Patient #7 indicated that he bit his lip during the hold.
- At 6:25 PM, the patient's father was notified of the manual hold and the injury to the patient's lip.
- At 6:29 PM, during the post restraint patient debriefing, Patient #7 indicated the precipitating event for his outburst was that Staff L had been antagonizing him.
- The documentation did not indicate that Patient #7's father had been informed of any potential abuse or harassment that he may have endured leading up to, or during, the manual hold.

Review of the hospital's document titled, "Grievance Log," dated 08/2024 to 03/2025, showed on 01/13/25, Patient #7's father called and filed a complaint. He stated the patient was in an altercation with a staff member and his lip was busted. The father reported that he was not made aware of any potential assault related to the incident that occurred on 01/13/25.

Review of Patient #28's medical record showed:
- On 02/28/25, a 15-year-old male was admitted for Major Depressive Disorder (MDD, a mental health condition that causes persistently low mood and loss of interest in activities that once brought joy).
- On 03/03/25, he was involved in an altercation with another patient. As a result, a medication order for a new intramuscular (IM, within the muscle) psychotropic (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thought, feeling or behavior) medication, was obtained.
- No consent documentation indicating that a parent/guardian had consented to the administration of the psychotropic medication was found.

Review of the hospital's document titled, "Grievance 11032025," dated 03/10/25, showed Patient #28's guardian filed a grievance with the hospital due to the patient receiving a medication without their informed consent. The hospital determined that informed consent should have been obtained from his guardian, prior to the administration of the medication.

Review of Patient #29's medical record showed:
- On 02/28/25, a 14-year-old female was admitted for MDD.
- On 03/06/25, an influenza (highly contagious condition affecting the respiratory system) vaccine was administered to Patient #29.
- No consent documentation indicating that a parent/guardian had consented to the vaccination was found.

During an interview on 03/18/25 at 1:30 PM, Staff T, Patient Advocate, stated that the hospital substantiated that Patient #28 and #29 received medications prior to obtaining informed consent from the patient's guardian.

During an interview on 3/18/25 at 2:00 PM, Staff V, Case Manager (CM), stated that nurses were responsible for notifying guardians about medication changes. It was her understanding, if a blanket consent was signed that the guardian was agreeable to everything and was not to be bothered.

During an interview on 3/18/25 at 2:05 PM, Staff W, Clinical Services Director, stated that:
- She expected guardians to be contacted as quickly as possible after admission and again prior to discharge, at minimum, regardless of a blanket consent.
- Nurses were responsible for notifying guardians of medication changes.
- If a guardian was unable to be reached at time of discharge, the patient's discharge would be delayed until contact was made.

During an interview on 03/19/25 at 12:30 PM, Staff B, CNO, stated he found it acceptable for staff to use a blanket consent, notated by typing a period in the medication list section of the Medication Consent Form, for all medication changes. This would indicate that the parent/guardian was agreeable to all medications. His expectation was that parents/guardians be contacted, by admission staff at the time of admission, by the nurse or provider with every medication change, unless the blanket consent was signed. Then contact for medications was not necessary. Social workers should be in contact with parents/guardians daily and within 24-48 hours of a patient's discharge. Parents/guardians would be notified as soon as possible after an adolescent patient was placed in a manual hold or if the patient was injured during a manual hold. He expected staff to follow the abuse and neglect policy and to inform parents/guardians if any type of abuse towards the patient was suspected.

During an interview on 03/18/25 at 12:16 PM, Staff C, Quality Director, stated that a blanket consent was not to be used as a consent for all medications. It was consent for the general knowledge that psychotropic medications were commonly used at the facility.




50496




51509

Based on interview, record review, and policy review, the hospital failed to ensure patients were free from all forms of abuse and neglect when the hospital failed to perform thorough investigations and provide staff education related to incident reports with allegations of abuse.

Findings included:

Review of the hospital's policy titled, "Abuse and Neglect," dated 04/2020, showed:
- Staff who witness or suspect a patient has been abused, either physical or verbally, will report such abuse to the Administrator on Call (AOC), Nursing Supervisor, Risk Management Director and the Chief Nursing Officer (CNO) immediately.
- Any involved staff member shall be notified of the allegation and suspended from duty, pending results of the investigation. If the staff member is working at the time of the allegation of abuse, the department head will assign replacement staff as necessary to complete the shift.
- The RN will complete a nursing assessment of the patient who was abused to evaluate the patient's physical and mental condition to determine what further medical evaluation the patient may need.
- The RN will notify the designated family contact and/or legal representative of the patient who was abused.
- The medical record shall include documentation of examinations, treatment given and any referrals made to other care providers.
- Reports of abuse which occur while the patient is hospitalized will be thoroughly investigated by the Risk Manager or other staff as assigned by the Chief Executive Officer (CEO).

Review of the hospital's policy titled, "Patient Abuse and Neglect," dated 09/01/15, showed:
- No patient is to be mistreated or abused physically, verbally, psychologically or sexually while in the hospital's care. Any employee who is found guilty of mistreating, abusing or neglecting a patient will be subject to disciplinary action, up to and including, termination.
- Patient abuse is strictly prohibited and will not be tolerated. Examples of patient abuse include but are not limited to striking a patient; using excessive force in restraining a patient; rough handling of the patient; teasing, taunting or ridiculing a patient; speaking inappropriately with a patient and threatening a patient.
- All instances of witnessed or alleged patient abuse or neglect must be immediately reported to the Risk Manager, a department head or supervisor.
- Failure to report witnessed patient abuse may result in disciplinary action up to and including termination.

Review of the hospital's undated document titled, "Incident Reporting Policy," dated 01/01/22, showed any hospital staff member who witnessed, discovered or had direct knowledge of an incident must complete an Incident Report before the end of the shift/workday. The Supervisor would review Incident Reports for legibility, completion and date. The RM would be notified of a serious event, and the Supervisor would take the lead in investigating non-serious incidents.

Review of the hospital's undated document titled, "Checklist of Investigation Task Suggestions," showed:
- It may not be necessary, nor applicable, to do everything listed on the checklist, it would depend on the type of incident and or other factors.
- Confirm that the patient's needs are being attended to.
- Follow up with the medical/surgical hospital, family, etc. regarding the patient's condition or well-being.
- Interview all involved, or necessary parties, and complete Witness Statements as needed.
- Discuss incident with physician/practitioner.
- Gather applicable policies for review to determine if protocol has been followed and if policy or procedure revision may be warranted.
-Consider what investigative documentation might be requested for review/copy by an outside organization and prepare for response.

Review of Patient #8's medical record showed:
- On 01/15/25, a 44-year-old female was admitted on a 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) after she overdosed on prescribed medication.
- On 01/19/25 at 9:36 AM, nursing documentation indicated that her behavior, affect and mood were within normal limits. She was alert and oriented to person, place, time and situation. She reported feeling "very good."
- On 01/20/25, she reported to the house supervisor that on 01/19/25, at approximately 1:00 PM, she was inappropriately touched by a male Behavioral Health Assistant (BHA), who placed his hand down her pants and inserted his fingers into her vagina. A police report was filed, and she agreed to be transferred to a nearby hospital to be assessed by a sexual assault nurse examiner (SANE, a registered nurse or nurse practitioner who has completed specialized training to assist sexual assault victims and collect all forensic evidence and perform exams).

Review of the hospital's untitled, undated, investigation document, showed:
- On 01/20/25, Patient #8 reported that on 01/19/25, Staff MM, BHA, sexually assaulted her by digital penetration.
- The allegation was communicated to hospital leadership and Staff MM was suspended, pending the investigation.
- Staff EE, Risk Management Director, interviewed Staff MM. Staff MM denied the event had occurred but resigned following the interview.
- The hospital was unable to substantiate or unsubstantiate the allegation, due to the pending SANE examination.
- Statements from Patient #8 and Staff MM were obtained, no additional staff or possible witnesses were interviewed.
- No education was provided to staff after this incident.

Review of Patient #7's medical record showed:
- On 01/11/25, a 16-year-old male was admitted for disruptive mood dysregulation disorder (DMDD, condition of extreme irritability, anger).
- On 01/13/25 at 3:20 PM, Patient #7 hit a staff member after becoming agitated and angry. A manual hold was initiated by Staff L, BHA, and assisted by Staff M, BHA, and Staff N, BHA.
- At 5:59 PM, Staff P, RN, wrote in the shift assessment that the patient was verbally/physically aggressive. Called a staff member a "bitch" and slapped him in the face. Patient #7 was put into a manual hold and released. After the hold, the patient indicated that he had a bloody lip, He stated he bit his lip during the hold.
- At 6:25 PM, Staff P, RN, documented the patient's injury and notified his parent of the event.
- At 6:31 PM, the patient reported that he was not treated in a caring manner or with respect for his privacy and dignity. The staff member antagonized him.
- No documentation in the medical record was found regarding the immediate notification to the provider, house supervisor or unit manager regarding the injury incurred during the hold.

Review of the hospital's undated, untitled, self-reported document showed:
- On 01/13/25, Patient #7's father contacted Staff T, Patient Advocate, with concerns that Staff L, BHA, potentially used inappropriate, antagonistic language towards the patient and may have been responsible for the patient biting his lip during a manual hold. Staff T immediately notified leadership and Staff L was suspended pending investigation.
- Staff L, BHA, reported he responded to a radio-call for assistance in the gym, because the patient was cussing at the staff and calling them bitches. Staff L asked the patient to stop, but the cussing and name calling continued when they returned to the unit from the gym. Staff L asked Patient #7 to distance himself from another patient. He alleged that Patient #7 continued to escalate, called another staff member a bitch and continued to curse.
- Staff K, RN, reported witnessing Staff L talking with Patient #7 and felt Staff L was "not in control of himself." Staff K stepped in between the patient and Staff L to separate them. Staff L's body language matched that of "posturing" and his speech was "taunting." Staff K told the patient and Staff L "that's enough" and Staff L walked away from patient, into the dayroom. Staff K, RN, debriefed with the patient and felt that the situation had deflated. It was change of shift and he did not remove Staff L from the unit.
- Staff L stated that when he exited the dayroom, Patient #7 approached him asking for his phone number so they could meet up outside of the hospital to fight. Staff L engaged with the patient and the patient proceeded to call him a bitch and slap him. Staff L initiated a manual hold with assistance from Staff M, BHA, and Staff N, BHA.
- During post hold debriefing, Patient #7 reported that after the manual hold, Staff L was behind him and told him "if we were outta here I would probably kill yo ass lil kid" or "if we were outta here I'm gonna kill you you stupid little bitch." Patient #7 admitted asking Staff L for his phone number with the intention to fight him. He described Staff L's composure as "puffed out" when speaking to him and he felt cornered.
- Staff L, BHA, and Staff M, BHA, denied any knowledge of an injury to Patient #7, they did not see any blood coming from patient or his mouth.
- Staff N, BHA, witnessed Patient #7 spitting up some blood, a small amount of blood ended up on a pair of white shoes he was wearing at the time. He indicated the patient may have felt cornered, or threatened, while in the corner of the dayroom prior to striking Staff L. Staff L was posturing towards the patient. It looked like "tough guy versus tough guy."
- The hospital determined that Staff L postured towards the patient, disengaged the manual hold without a nurse present and continued to non-therapeutically engage with the patient. He was
terminated for gross misconduct.
- After the abuse allegation was substantiated, no staff education was completed related to Abuse and Neglect.

Review of Patient #3's medical record showed:
- On 01/07/25, a 15-year-old female was admitted for suicidal/suicidal ideation (SI, thoughts of causing one's own death) and self-injurious behavior after cutting her thighs and arms.
- Her admission assessment indicated two separate sutures to her left arm after cutting herself with a pencil sharpener blade.
- Admission orders included line of sight (LOS, continuous visual contact with the patient) observation and to keep a dressing over her stitches due to her to picking at them.

Review of the hospital's undated, untitled, self-reported document showed:
- On 01/15/25, Staff R, BHA, neglected to remain with Patient #3 during a 1:1 observation while the patient was in the bathroom. Patient #3 was able to dig at and exacerbate her self-harm wound. Staff R was suspended pending an investigation.
- Staff R, BHA, admitted that she sat outside the bathroom while keeping an eye on the patient's feet from underneath the magnetic bathroom door, but did not enter.
- During a telephone interview Staff R detailed that Patient #3 had been in a group during hygiene time. So, she accompanied Patient #3 to the bathroom and stood outside the door. When asked if the patient was left alone at any point, Staff R stated no. She remembered the patient came out of the bathroom without the bandage that had been on her arm. She asked Patient #3 why she removed the bandage and was told that she "wanted to take it off" and that she was "getting my bandage changed anyway." Staff R informed the patient that she was not to take the bandage off herself. She was to present at the nurse's station and a nurse would remove it for her.
- Patient #3 was assessed by nursing staff and did not require any outside medical treatment.
- Staff R was terminated from her position.
- No education was provided to staff after this incident.

During a telephone interview on 03/19/25 at 10:10 AM, Staff EE, Risk Management Director, stated that when an incident occurred, all staff working on the unit the day the incident occurred would be interviewed or asked to provide a witness statement. After Patient #8's incident which occurred on 01/20/25, the patient and Staff MM, BHA, were interviewed. She attempted to contact Patient #8's roommate but was unable to get in contact with her. No other staff or patients were interviewed. The hospital unable to determine if Patient #8's allegation of sexual assault occurred. A SANE examination was pending. She became aware of the event regarding Patient #7 the day after his father contacted Staff T, Patient Advocate. She expected staff to follow policy and immediately report employees who displayed antagonistic behavior, used inappropriate language with a patient or if a patient sustained an injury during a hold. They should fill out an incident report. Staff should also report inappropriate handling of a patient by a staff member during a physical hold. Staff who found themselves escalated in a situation should remove themselves, or if they are asked by other staff members to remove themselves, they should follow policy and remove themselves immediately. They should not continue to engage with the patient. Once an investigation has been initiated, the process takes about two weeks to complete. Interviews need to be completed, along with employee retraining. All abuse and neglect events should be investigated. The hospital does not have a specific policy regarding the investigation process, but they can refer to an investigation task checklist. Appropriate education should be provided to all staff members after incidents have been reported, investigated and substantiated.

During an interview on 03/19/24 at 12:16 PM, Staff B, CNO, stated that he expected the staff to follow the abuse and neglect policy. Staff who witnessed alleged abuse should immediately report it. Staff who were involved in an incident were expected to complete an incident report and report any injuries a patient may have incurred. For abuse or neglect allegations related to a staff member, he expected that staff member to be immediately removed from patient care. He expected every staff member who was present when an incident occurred to be interviewed.

During an interview on 03/19/25 at 9:10 AM, Staff A, CEO, stated that the retraining of all staff was not completed for every incident. Staff members involved in incidents would receive education. The hospital receives incident reports daily and it would be unrealistic for the hospital to educate all staff members after every report. Town hall meetings were completed monthly and would include education regarding abuse and neglect. All staff members participate in mandatory quarterly hands-on abuse and neglect training.




50151




50496




51292

Based on interviews, record review and policy review the hospital failed to provide a discharge plan that ensured safe, appropriate arrangements for post-hospital care for one patient (#11) out of five patients reviewed. This failed practice had the potential to cause poor health outcomes for all discharged patients.

Findings included:

Review of the hospital's policy titled, "Discharge Planning," dated 04/2020, showed all patients would have a discharge plan developed and implemented prior to their discharge. The discharge plan would include timely and direct communication with, and transfer of, information to other programs, agencies, or individuals that would be providing ongoing care. Discharge needs to be considered included: aftercare services and arrangements; family relationships; physical and psychiatric needs; housing needs and/or placement issues; accessibility to community resources; personal support systems; and transportation problems related to aftercare treatment. Components of the discharge care plan included: where the patient would live following discharge; with whom they would live and in what circumstances; the level of care which the patient would be discharged such as intensive, outpatient, or residential etc.; referrals to self-help groups; support groups or other community resources.

Review of the hospital's policy titled, "Discharge Criteria," dated 10/2020, showed patients were ready for discharge if they met the following criteria: reduction of life-threatening or endangering symptoms to within safe limits; ability to meet basic life and health needs; adequate post-discharge living arrangements; and constant or close observation were no longer required.

Review of Patient #11's medical record showed:
- On 08/08/24, she was admitted for suicidal ideation (SI, thoughts of causing one's own death) related to her living condition. She had a plan to overdose on pills or hang herself.
- Her past medical history included depression, anxiety, asthma (a chronic lung disease which makes breathing difficult), bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows), schizophrenia (serious mental disorder that affects a person's ability to think, feel, and behave clearly), substance abuse (a complex condition where there is uncontrolled use of a substance despite harmful consequence), a seizure disorder (sudden, uncontrolled electrical disturbance in the brain which cause changes in behavior, movements and/or in levels of consciousness), and intellectual disability (below average intellectual functioning which limits the ability to learn at an expected level and limits level of function in daily life).
- She had been noncompliant with her home medications for several days prior to her admission.
- Staff DD, Social Worker (SW), met with the patient who expressed a desire to discharge to a residential care facility (RCF, a nonmedical facility that provides a home-like environment for individuals who are unable to live independently, but do not require 24-hour nursing care).
- Staff DD's documentation indicated she had pursued local psychiatric (pertaining to mental illness) treatment resources and sent referrals to various treatment programs.
- On 08/14/24, Staff DD documented the patient was calling out of state treatment programs but then two nurses informed her that the patient no longer wanted to go to a treatment program. Staff DD reinforced that a treatment program would be best due to her history of substance abuse. Patient #11 expressed a desire to go to West Plains, Missouri. Staff DD documented that she arranged for the patient to go to Catholic Charities for housing and then she could attend her appointment at an outpatient treatment center the following week.
- On 08/15/25, discharge documentation indicated Patient #11 was discharged to the outpatient treatment center. Her medications were called-in to a pharmacy in Van Buren, MO.
- Follow-up treatment for addiction was scheduled with the outpatient treatment center on 08/20/24.

During an interview on 03/19/25 at 11:10 AM, Staff DD, SW, stated that she remembered Patient #11. She needed a treatment center but did not want to go anywhere near her family members. Patient #11 specifically asked to go to West Plains, Missouri without explaining why or if she had any contacts in that area. Staff DD was unaware of that city until Patient #11 asked about it. She was able to arrange an appointment with an outpatient treatment center for 08/20/25. The outpatient treatment center advised her that when Patient #11 arrived at her outpatient appointment, they would be able to transfer her to an inpatient bed. Staff DD had to figure out where Patient #11 could stay after discharge until her appointment. She contacted Catholic Charities and they agreed to assist with finding temporary housing for the patient until her appointment. Staff DD stated that she failed to document these conversations and arrangements. At the time, she was still very new to her job and had not been adequately trained. She felt pressured to arrange discharges immediately when the physician said the patient was ready so they could open beds faster. She didn't realize at that time that she could advocate to delay discharge to allow her to make safer arrangements.

During an interview on 03/19/25 at 9:25 AM, Staff CC, Psychiatrist, stated that Patient #11 needed an RCF because of her intellectual disability and history of substance abuse. She was unlikely to be safe in a setting where she could walk out at any time.

During an interview on 03/18/25 at 3:00 PM, Staff X, Chief Operating Officer, Hospital B, stated that she was formerly employed at Centerpointe Columbia, and often managed concerns related to discharge planning. She did not recall being involved with the concerns the complainant raised about Patient #11. She stated that Catholic Charities would occasionally be contacted regarding a patient's discharge plan to assist with utilities, but they would never be used for housing or shelter needs.